Source: https://www.ncbi.nlm.nih.gov/pubmed/23071150

How to Increase NAD+: The Molecule of Youth (and the danger of low NAD+)

NAD+ has many important roles for health, including stimulating anti-aging activities of Sirtuins and the DNA damage repair enzymes.

High NAD+ is necessary for healthy metabolism and mitochondria. In addition, low NAD+ can contribute to fatigue and several diseases. Read this post to learn more about NAD+ and factors that increase or decrease it.

Contents

Introduction: What is NAD+?

The chemical structures of NAD and NAD+.
The chemical structures of NAD and NAD+.

Nicotinamide adenine dinucleotide (NAD) is a coenzyme found in all living cells which consists of two nucleotides (adenine and nicotinamide).

NAD exists in two forms: NAD+ and NADH respectively. NADH contains 2 more electrons than NAD+.

Production of NAD+

NAD+ and the Electron Transport Chain in the Mitochondria

This 2-minute video demonstrates the process of oxidative phosphorylation, which converts NADH into NAD+, which generates 3 ATP molecules for each NADH used.

When our cells break down carbohydrates and fat for energy, the energy is stored by creating ATP and NADH. The energy stored in the 2 more electrons of NADH can then be converted to ATP via a process called “oxidative phosphorylation” or “cellular respiration” in the mitochondria.

In the presence of food abundance or when our bodies break down (metabolize) more carbohydrates and fats, NADH levels increase, while NAD+ levels decrease.

When electrons go through your mitochondrial electron chain, energy is produced. NADH is the most significant carrier of these electrons and it becomes NAD+ when it gives away those electrons. The body gets energy from food via electrons contained in that food.

When you have the ingredients to use those electrons, you will feel vital and healthy and when you don’t have the proper inputs you will be sick and weak.

The cell uses levels of NAD+ to know if we need to increase metabolism or energy utilization because relatively higher levels of NAD+ means we’ve been using electrons up.

NAD+ Synthesis

Different pathways that produce NAD+, source: https://www.ncbi.nlm.nih.gov/pubmed/24988458

Different pathways that produce and break down NAD+, source: https://www.ncbi.nlm.nih.gov/pubmed/24988458

The following are precursors (raw materials) from which NAD+ can be produced:

Generally, supplementation with NAD+ precursors in the salvage pathways, i.e. NR and NMN, is more effective at increasing cellular levels of NAD+ than those in the de novo pathway because the enzyme NAMPT is a rate-limiting step (bottleneck) in NAD+ production (R, R2).

Not every cell is capable of converting every one of the above precursors at all times because these precursors also have other roles in the cells (R, R2). The following biochemical conversion or pathways happen in these cells:

  • Tryptophan into NAD+: liver, neuronal, and immune cells
  • Nicotinamide into nicotinic acid: gut bacteria
  • Nicotinic acid (B3) into NAD+: Liver, kidney, heart, and intestinal cells
  • Salvage pathway: heart and skeletal muscles

NAMPT activity may be reduced by circadian rhythm misregulation and inflammation, and increased by exercise (R, R2R3).

Therefore, supporting each of these pathways may increase NAD+ specifically in these tissues or organs than others, and depending on factors like stress levels, inflammation, and circadian rhythm entrainment

The Roles of NAD+

NAD+ as a Coenzyme that Stimulates Enzyme Activity

NAD+ is a coenzyme that activates enzymes that catalyze redox reactions (electron transfer) in the body. These enzymes include Sirtuins, poly-ADP-ribose polymerases (PARPs), and CD38 (R). These enzymes that use NAD+ also break down NAD+.

Typically, increased activity of other enzymes that use NAD+ can reduce available NAD+. This reduced levels of NAD+ can inhibit Sirtuins (R).

NAD+ Activates Sirtuins

Sirtuin enzymes turn off certain genes that promote aging, such as those involved in inflammation, fat synthesis and storage, and blood sugar management (R).

Humans have 7 different Sirtuin enzymes, but Sirt1 and Sirt3 are of interest in this post. Read this post to learn more about Sirtuins.

Sirtuins are enzymes that use NAD+ to pluck off acetyl groups (deacetylate) from proteins to modify them (R).

The more NAD+ levels increase, the more active Sirtuins are (on the other hand, Nicotinamide blocks Sirt1 activity) (R).

Source: https://www.ncbi.nlm.nih.gov/pubmed/23071150Source: https://www.ncbi.nlm.nih.gov/pubmed/23071150

Sirt1, when activated by NAD+, then activates:

  • PGC-1alpha (R), which stimulates mitochondrial biogenesis (creation of new mitochondria) and increased fatty acid oxidation
  • FOXO1 (R), part of the insulin signaling pathway. FOXO1 activation reduces adipogenesis (production of new fat cells) by inhibiting PPAR-gamma
  • p53, a tumor-suppressor (anti-cancer) gene that prevents cells with DNA damage from growing into cancers
  • SREBP1c, which controls blood sugar, fatty acid, and fat production in response to insulin. It also controls cholesterol levels.
  • PPAR-gamma, which increases insulin sensitivity and insulin secretion (R). It is an inflammatory gene (R).
  • Genes that control circadian rhythm (R, R2)

Sirt3, when activated by NAD+, which leads these changes in the mitochondria (R):

  • Activation of SOD2, a mitochondrial antioxidant enzyme
  • Activation of Mitochondria enzymes responsible for breaking down fatty acid and carbohydrate for energy in, including LCAD, SDH, and AceCS2.
  • Deactivation of HIF-1alpha, a protein that is produced when oxygen is low.

NAD+ Activates PARP, an Enzyme That Repairs Damaged DNA

NAD+ is needed for PARP (Poly ADP ribose polymerase) activity. PARP is an enzyme that repairs DNA in response to damage or cellular stress (R).

PARP activity correlates with maximum lifespan across 13 mammalian species.  For example, humans have 5X times the PARP activity as rats. People who live to 100 also have higher PARP activity (R).

When there is a significant amount of DNA damage in the cell, inhibiting PARP can cause the cells to undergo apoptosis. Therefore PARP inhibitors are being tested as anti-cancer therapy (R).

Mice without PARP have increased NAD+, Sirt1 activity and experience some metabolic benefits (R).

Harmful Effects of Low NAD+

1) Low NAD+ Means Aging

In mitochondria of young people, NADH can readily donate its electrons to generate NAD+. During the aging process, increased DNA damage reduces NAD+, leading to reduced SIRT1 activity and reduced mitochondrial function (R).

Therefore, NAD+ levels decline with age and oxidative stress over time (R).

The more NAD+ levels increase, the more SIRT1 is active (on the other hand, Nicotinamide blocks SIRT1 activity) (R).

Low NAD+ reduces Sirt1 activity, which ages the body.

In addition, during aging, the decline in function of genes that control circadian rhythm can reduce NAD+ levels (R).

In turn, SIRT1 also plays a massive role in circadian gene expression, which again plays a huge role in all of our cells (R, R2).

2) Low NAD+ Can Suffocate the Cells (Hypoxia)

When you have low oxygen (hypoxia), your mitochondria don’t work as well and for good reason. Oxygen needs to be there to accept electrons in the mitochondria. When you have low oxygen, it can’t accept electrons, so your body wants to slow mitochondrial function down.

When you have low oxygen, your body responds by slowing the conversion of NADH to NAD+ (less oxidation). Therefore, you have a buildup of NADH and a relative reduction of NAD+.

Low NAD+ is called “pseudohypoxia” because the body sets in motion some of the same responses to low NAD+ that’s caused by low oxygen, even if you have adequate oxygen levels (R, R2).

Having low oxygen in your cells also results in higher NADH and lower NAD+.  Low NAD+ decreases SIRT1, which then causes higher Hypoxia Inducible Factor (R).

3) Low NAD+ Increases Sunburn and Skin Cancer

NAD+ and NADH protect you from damaging/burning your skin in the sun and skin cancer (R, R2).  NAD+ absorbs mainly the UVB spectrum and NADH absorbs mainly UVA spectrum (R).

People who I would suspect to have low NAD+ levels tend to burn easily from the sun. This indicates low MSH and/or low NAD+.

4) Low NAD+ is Associated with Fatigue

Fatigue, low physical and mental energy are also signs of lower NAD+/SIRT1.

Levels of NAD+ largely control the “redox potential” because NAD+ has the ability to acquire electrons.

The higher the redox potential of the cell, the better the mitochondria work and the more it can fight infections and function the way a cell is supposed to function.

Supplementation of NADH, NAD+ or its cofactors helps with chronic fatigue syndrome and fibromyalgia (R, R2).

5) Low NAD+ May Worsen Weight Gain and Metabolic Syndrome

NAD+ activation of Sirtuins clearly turn on genes that improve metabolism, help with weight loss, and reduce LDL cholesterol. In addition, niacin and other NAD+ precursors are being tested as treatments for cardiovascular disease.

In a mouse study, supplementation with nicotinamide riboside (a precursor of NAD+) can protect against diet-induced obesity (R). These animals can also better burn fat, burn more calories, and become more insulin sensitive.

Sirtuins improve glucose levels and glucose homeostasis by increasing insulin levels (R).

Metabolic syndrome is strongly linked to depression. This low Sirtuin activity, together with lowered NAD+ from inflammation, and lowered tryptophan availability, may worsen the depression (R).

6) Low NAD+ May Worsen Cardiovascular Diseases

The heart muscles heavily uses the mitochondria, and the mitochondria activity requires Sirt3 (R).

NAD+ Depletion, typically caused by DNA damage in failing hearts, can accelerate heart failure in experimental animals (R).

NAD+ levels also drop in the case of ischemia-reperfusion injury (damage to the heart from lack of blood flow) (R).

Ways to increase NAD+ and activate Sirtuins have therefore been proposed as treatments or supplemental treatments for heart diseases (R, R2).

7) Low NAD+ May Contribute to Multiple Sclerosis (MS)

During chronic nervous system inflammation, activation of Th1-derived cytokines by CD38 (an enzyme that uses NAD+) can reduce available NAD+ outside the cells (R). Overall, in MS patients, NAD+ increases in the immune system and decreases in the nervous system (R).

In MS patients, NAD+ increases in the immune system but neurons are NAD+ deficient (R). In addition, MS patients have less serum tryptophan available to make more NAD+ inside neurons (R).

NAD+ deficient neurons are more vulnerable to degeneration like in MS (R).

In animal models of MS, NAD+ levels are elevated in the CNS because of the changes in the immune system (R).

Increasing NAD+ by supplementation with NAD+ precursors or fasting can help with MS in animals (R), but administration of tryptophan seems to increase numbers of lymphocytes and making MS worse (R, R2).

Other Roles of NAD+

8) NAD+ Increases Cellular Antioxidants

NAD+ increases activities of SOD2 through Sirt3 (R).

9) NAD+ Increases Metabolism Along with Thyroid Hormones

NAD+ controls metabolism (along with hormones like T3) and lower levels of NAD+ and T3 will make you feel cold.  In frog cells, NAD+ increases free T3 (R).

10) NAD+ Helps with Brain Function

The brain has a high energy demand, so neurons contain a lot of mitochondria. Mitochondria dysfunction also contributes to many mental health and neurodegenerative diseases.

Treatment with NADH also improves cognitive function of Alzheimer’s disease patients (R).

NADH has been used to treat Parkinson’s Disease as NADH may increase the bioavailability of levodopa, the medication for Parkinson’s (R, R2).

In a mouse model of Alzheimer’s disease, increasing NAD+ by supplementing with nicotinamide riboside restores cognitive function by increasing PGC-1alpha levels (R).

In rats, NAD+ administration through the nose may decrease brain damage from oxygen deprivation (e.g. due to stroke) (R).

This is also why a lot of my clients claim to do better with niacin/nicotinamide in the short term: because it increases NAD+ (R).

My clients often claim to do better with amphetamine usage as well in the short term.  Amphetamines use up energy, ATP and also deplete dopamine in certain parts of the brain (striatum in rats) (R).

When rats were given niacinamide to increase NAD+ levels, the negative changes caused by amphetamines were reduced (R).

So we see that lower levels of NAD+ will decrease brain energy and dopamine, and people will start to need stimulants to keep up.

11) NAD+ Helps Balance Immune Function and Reduce Inflammation

Sick people often have chronic infections that they can’t get rid of and chronic inflammation.

Increasing NAD+ in animal models reverses autoimmune disease through various means, which demonstrates that low NAD+ is one cause of a deregulated immune system and why autoimmune conditions often coexist with chronic fatigue and brain fog.

NAD+ reverses autoimmunity by increasing an anti-inflammatory variety of Th1 and Th17 cells (which are usually bad, but NAD+ changes them to increase TGF-b and IL-10) (R).

What we see is that we can make generalizations about the immune system, but nuance is often critical.  So NAD+ levels can turn Th1 dominance from being bad to being good (R).

SIRT1/NAD+ is important for the immune system to clear pathogens in part via MHC II activation. Hypoxia or low oxygen prevents MHC II from activating by decreasing SIRT1 activity (oxidized LDL also decreased SIRT1 in macrophages) (R).

NAMPT, which makes NAD+, also increases MHC II activation. However, by activating other Sirtuins, it reduces pro-inflammatory cytokines and regulates the immune system (R).

NAD+ (and by extension SIRT1) seems like one of those molecules that creates an optimal and balanced environment for your immune system to fight infections, while also dampening inflammation.

Factors that Increase NAD+

Factors that make the mitochondria more efficient and activates Sirtuins typically increase NAD+, including fasting, caloric restriction, and ketosis.

1) Fasting or Caloric Restriction Increases NAD+

Your body senses the ratio of NAD+ and NADH and if you have low NAD+ relative to NADH, it’s a signal that you have an excess of energy either by ingesting too much energy/calories or expending too little energy. It can also be a signal for too little oxygen.

When you have high NAD+ levels, it means you likely have been using your energy up and have a negative energy balance – you’re expending more calories than you’re consuming.

When the cells have more carbohydrate to burn, this results in an accumulation of NADH. Carbohydrate and nutrient depletion allows NADH to get used up so that NAD+ build up. Therefore, fasting and caloric restriction results in higher NAD+ and Sirtuin activation (R).

2) Ketosis/Beta-Hydroxybutyrate Increases NAD+

Fat-burning states such as in ketosis can increase NAD+ (R).

3) Exercise Increases NAD+

Energy stress created by exercise cause the cells to burn NADH for energy, thus generating more NAD+ (R). NAMPT levels also increase with exercise (R).

4) Having More Body Fat Increases NAD+

Being fat of having more adipose tissue can increase NAMPT enzyme levels and leads to higher levels of systemic and hypothalamic NAD+ levels (R). Although being overweight has a bunch of negative health consequences, having higher NAD+ levels is a benefit, which may be one reason why thin people often do worse with chronic health issues.

5) Saunas and Heat shock.

Saunas are also considered a panacea and have been a part of every historical culture.  We think it’s because we’re sweating out toxins, and that might have something to do with it, but saunas and heat shocks also increase NAD+ levels (R).

Since infrared also increases SIRT1 (R), infrared Saunas are ideal (the one I have).

6) Fermented Foods and Kombucha

Fermented foods and beverages such as kombucha contain NAD+, which is one reason why it energizes me. Fermentation uses NADH to produce lactate, and the byproduct is NAD+ (R).

7) Fructose

Fructose can increase Sirt1 function and activate the enzyme that converts NADH to NAD+ in the mitochondria (R)

8) AMPK Activation

– AMPK increases SIRT1 activity by increasing cellular NAD+levels (increases NAMPT (R)) (R). SIRT1 activation also stimulates fatty acid oxidation and indirectly activates AMPK (R).

9) NAD+ Intermediates

Supplementation with NAD+ intermediates readily increases cellular and mitochondrial NAD+, and reverse many aging or disease processes associated with low NAD+ (R, R2)

  • Niacinamide– low doses (R).
  • Tryptophan and Aspartic acid are a fuel for NAD+ (R), but we usually get enough dietary amino acids if you eat adequate protein.
  • Nicotinamide Riboside (NR) (R)
  • Nicotinamide Mononucleotide (NMN) (R)

Although NR and NMN have been shown to be a great strategy to mitigate aging, their efficacy in humans still need to be further tested.

Dosage:

Mice NR and NMN doses are around 400 – 500 mg/kg per day, which are really high for human use (R).

10) Supplements

Factors that Decrease NAD+

1) Chronic Inflammation

The relationship between circadian rhythm and NAD+ levels, and one of the ways that chronic inflammation can affect NAD+ levels. Source: https://www.ncbi.nlm.nih.gov/pubmed/24786309The relationship between circadian rhythm and NAD+ levels, and some of the ways that chronic inflammation can affect NAD+ levels. Source: https://www.ncbi.nlm.nih.gov/pubmed/24786309

Chronic inflammation reduces NAD+ levels by inhibiting the NAMPT enzyme and circadian rhythm genes (R).

2) Disrupted Circadian Rhythm

The circadian clock genes BMAL1 and CLOCK control the production of the NAMPT enzyme which is the final step in the production of NAD+ (R).

The ebb and flow of cellular production due to circadian rhythm will result in the ebb and flow of NAD+ levels.

With aging, there will be lessor of this ebb and flow, which may explain why NAD+ declines with age.

Because NAMPT is involved in the conversion of nicotinamide to NAD+, in the presence of inflammation or disrupted circadian rhythm, it is more effective to increase NAD+ by supplementation with other NAD+ precursors that don’t require NAMPT, such as nicotinamide riboside or nicotinamide mononucleotide.

3) DNA Damage (PARP Activation)

Massive amounts of DNA damage means that more PARP molecules will be at work on damaged DNA and use up the NAD+. This decline in NAD+ can reduce Sirtuin activity (R).

4) Reduced Sirtuin Activity

Although NAD+ controls Sirtuin activity, there are many ways low Sirtuin levels can decrease NAD+ levels, including:

  • Sirtuin controls circadian rhythm (R), so low sirtuin levels may disrupt the circadian ebb and flow and thus reduce NAD+ levels.
  • Reduced sirtuin activity can reduce mitochondrial function through PGC-1alpha and several other mitochondrial enzymes.

5) Overeating

Having low oxygen in your cells also results in higher NADH and lower NAD+. Low NAD+ decreases SIRT1, which then causes higher Hypoxia Inducible Factor (R).

6) High Blood Sugar and Insulin Levels

Having high blood sugar levels results in higher NADH and lower NAD+ (R). Insulin also increases the NADH/NAD+ ratio (R).

7) Alcohol

The CFS sufferers that I coach do very poorly with alcohol since alcohol decreases NAD+ (R, R2).

Alcohol has many negative effects, but they don’t explain how fast people start to feel worse from it. NAD+ explains the almost instant effects.

Genes that Affect NAD+ Levels (SelfDecode)

NAMPT Produces NAD+ from Other Precursors

If you are not producing the enzyme NAMPT as well, you may be more susceptible to low NAD+ from other lifestyle factors. Also, if you have these SNPs, you may need to supplement more nicotinamide riboside to get the effects.

  1. RS1319501
  2. RS9770242

NAD(+) level decrease in aged mice and humans, which is a result of lower NAMPT (R).

PPAR-alpha Stimulates Conversion of Tryptophan to NAD+

PPARs, especially PPAR-alpha, stimulate the conversion of Tryptophan to NAD+ (R).

SNPs inside of PPAR-alpha

  1. RS135551
  2. RS1800206
  3. RS4253623
  4. RS4253655
  5. RS4253728
  6. RS4253772
  7. RS4823613
  8. RS9615264

ACMSD Converts Tryptophan to KYN

ACMSD converts tryptophan to quinolinic acid and kynurenine before conversion to NAD+ (R)

  1. RS10198552
  2. RS4954192
  3. RS6430538
  4. RS6430553
  5. RS6710823

NADH: ubiquinone oxidoreductase (Complex I) Converts NADH to NAD+

These are genes that make enzymes which convert NADH to NAD+ in the mitochondria.

  1. RS11548670 (NDUFS1)
  2. RS1156044 (NDUFV2)
  3. RS11663316 (NDUFV2)
  4. RS12457810 (NDUFV2)
  5. RS7407664 (NDUFV2)
  6. RS7637404 (NDUFV2)
  7. RS906807 (NDUFV2)
  8. RS1142530 (NDUFS7)
  9. RS11666067 (NDUFS7)
  10. RS7258846 (NDUFS7)

SelfDecode has these genes and SNPs. If you would like to learn about your SNPs, get a 23andme DNA test and upload your raw data to SelfDecode.

Caveats and Negative Effects of NAD+

The Big Picture – Increasing NAD+ in People with Fatigue

When people deal with fatigue both from hypoglycemia and low NAD+, fasting to increase NAD+ is not a good idea because not eating will also make you tired from hypoglycemia.

Blood sugar (from eating) dose-dependently worsens (increases) your NADH/NAD+ ratio in the same way as low oxygen. When you combine excess carbs/sugar and low oxygen, you start getting fatigued and have low energy.

This is one of the most significant reasons why sugar/carbs make people with health issues feel worse.

In fact, you might feel worse after eating anything because eating decreases NAD+ levels and fasting increases it.  This is especially true in a high fat+/high sugar diet (R).

Fasting, calorie restriction, and interval exercise help people because they all raise NAD+ levels (R).  There are other reasons why these help, but increasing NAD+ is perhaps the most significant reason.

Some people do worse in the short term from fasting because skipping meals cause hypoglycemia. When I was in a bad state, I’d feel like crap if I skipped meals. And then I’d eat a meal and crash because there weren’t enough energy-related molecules (ATP levels) in my lateral hypothalamus from fasting, which shuts orexin down.

Although exercise increases NAD+, people who have chronic issues can also do worse from exercise because exercise can be inflammatory and cause oxidative stress – but this is only a problem if your system can’t buffer it. Each person needs to find the right dosage for them.

Low NAD+ May Stop Cancer Growth

Most cancer cells rely on carbohydrates as energy sources. In addition, these cells also have a lot of DNA damage, which means that PARPs are activated. Therefore, cancer cells typically have low NAD+, but low NAD+ actually slows cancer growth. This is counterintuitive because NAD+ can shift metabolism towards fat burning.

Inhibiting NAMPT can reduce NAD+ levels, which can (R):

  • reduce cancer growth
  • sensitize the cancer cells to chemotherapy
  • increases apoptosis
  • inhibits glycolysis (carbohydrate burning for energy)

The use of NAD+ precursors therefore may not be beneficial in cancer patients, but this depends on the type and metabolic properties of the tumors (R).

NR Supplementation May Lower Exercise Performance

In mice, NR supplementation worsens exercise performance. They had a lower physical performance compared to the control group (R).

“The NR group showed a tendency towards worse physical performance by 35% compared to the control group at the final 10% load (P = 0.071)”(R).

Comments

  1. Ev

    This sounds like a creating a gradient or ratio of Nadh to nad plus based on your personal needs and genetics. Is there a rule that you always have to have a greater nad plus level to be maximal or efficient.

  2. Tons of good information on here!! I work with The NAD Treatment Center in San Diego, and they are using NAD to detox addicts along with other chronic conditions. Supplementing with stabilized NADH and NAD precursors can be effective depending on the situation, but it just doesn’t compare IV NAD.

  3. Sam

    Hi Joe,

    from your references on Malic Acid, it states:”Malate supplementation did not extend the lifespan of long-lived eat-2 mutant worms, a model of dietary restriction.”

    What do you take from it?

      • gotcha, thanks. If I can follow up – what would be your recommendation on how to go about testing NAD+? been wanting to check nad levels for sometime now, no luck so far.

        • Nattha Wannissorn

          There is no way to test it directly because their levels are different in various parts of the brain. It’s very tricky unless you want to use radioactive stuff. If you run an organic acids test (e.g. with Genova), you might be able to see how well the mitochondria is functioning from the metabolites and that’s a good surrogate marker for NAD+ levels in combination with the symptoms.

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