Healthy Ageing – Adding Years to Life and Life to Years.

Death is inevitable, but the life of protracted ill-health is not.

Introduction

The world is undergoing a huge age shift. In this day and age, most people can expect to live into their sixties and beyond. According to the data from the World Population Ageing 2017 (Highlights) and the World Population Ageing 2019 (Highlights) of the United Nations, Department of Economic and Social Affairs, the number of people aged 60 years and older will increase from 1 billion in 2019 to 1.4 billion by 2030, an increase of 34%; by 2050, the global population of older people will have more than doubled, to 2.1 billion. The number of people above age 80 years is growing even faster than the number above age 65. In 1990, there were just 54 million people aged 80 or over in the world, a number that nearly tripled to 143 million in 2019. Globally, the number of persons aged 80 or over is projected to nearly triple again to 426 million in 2050 and to increase further to 881 million in 2100. The global number of centenarians is projected to increase 10-fold between 2010 and 2050. This shift in the distribution of the population towards older age is known as population ageing.

What is ageing?

Ageing is a complex, multifactorial biological process shared by all living organisms. It is manifested by a gradual decline of normal physiological functions in a time-dependent manner. Organismal ageing holds significant importance for human health because it increases susceptibility to many diseases, including cancer, metabolic disorders such as diabetes, cardiovascular disorders, and neurodegenerative diseases. As people get older, a wide variety of molecular and cellular damage accrues over time, resulting in a gradual decrease in functional reserve (also known as physiological reserve) of the body’s organ systems, which in turn increases vulnerability to many diseases and other adverse events, and ultimately death.

Although these physiological and homeostatic changes are largely inevitable, they are neither linear (something that follows an expected order or sequence) nor consistent (always happening or behaving similarly) and are only loosely associated with a person’s chronological age (the number of years a person has lived since birth). Simplistically stated, the extent of these age-related changes will vary significantly among individuals at any particular chronological age.  Therefore, biological or physiological age differs from the chronological age depending on the health status of an individual. While genetic factors play an important role, a wide range of environmental and behavioural factors such as diet, exercise, exposure to microorganisms, pollutants and ionising radiations have a significant influence on the process of ageing; gender too plays an important role, and in general, women outlive men by a few years. This explains why two people of the same age may differ markedly in terms of both physical appearance and physiological state; a phenomenon termed as the diversity in older age. Beyond the biological losses, ageing is also associated with other life transitions such as retirement, shifts in roles and social positions, and death of friends, spouse, and other close relationships.

Social implications of population ageing

Population ageing is a powerful and transforming demographic force. Ageing is accompanied by other broad social trends that will affect the lives of older people; major factors being globalization, urbanization and industrialization. As life expectancy increases, so do the odds of multiple generations within a family being alive at the same time. However, although the number of surviving generations in a family may have increased, today these generations are more likely than in the past to live separately, as due to increasing globalization and urbanization more and more younger generations migrate to areas of growth, leaving behind older family members. Also, due to falling fertility rates globally, there will be fewer children in families, which in itself will lead to less potential care and support for older people from their families in the future. Indeed, in many countries, the proportion of older people living alone is rising dramatically. For example, in some European countries, more than 40% of women aged 65 and older now live alone.

The number of people of working age (25 to 64 years) per person aged 65 years or over is known as the potential support ratio (PSR). According to the UN’s WPP-2019, in 2019, sub-Saharan Africa has 11.7 persons aged 25 to 64 for each person aged 65 or over. This ratio is 10.2 for Oceania, 8.3 for Northern Africa and Western Asia, 8.0 for Central and Southern Asia, 5.8 for Latin America and the Caribbean, 5.0 for Eastern and South-Eastern Asia, 3.3 for Australia and New Zealand, and 3.0 for Europe and Northern America. At 1.8, Japan in 2019 has the lowest potential support ratio of all countries or areas with at least 90000 inhabitants. An additional 29 other countries or areas, mostly in Europe and the Caribbean have potential support ratios below three. By 2050, 48 countries, mostly in Europe, Northern America, Eastern Asia or South-Eastern Asia, are expected to have potential support ratios below two. With declining support from families, society will need better information and tools to ensure the well-being of the world’s growing number of older citizens and take necessary measures to promote healthy ageing.

Is population ageing beneficial?

These extra years of life and demographic shifts have profound implications for individuals, their families and the societies they live in. A longer life offers unprecedented opportunities and has the potential to have a fundamental impact on the way we live our lives and the things we aspire for. These additional years can be gainfully employed to pursue new activities such as further education, a new career or any unfulfilled ‘dreams’. In addition to self-enrichment, elderly people can also contribute to their families and communities in many ways; for example, through longer working life. This can be summed up in the saying “70 is the new 60”. Besides, families and communities stand to gain from their wealth of wisdom and rich experience. However, the extent of the opportunities available to us, as we age, and the extent of the contributions we can make, heavily depend on one key characteristic: our health.

If people continue to enjoy good health in these extra years of life and if they are living in a supportive environment, their ability to do things they value will be boundless. On the other hand, if these added years of life are marked by poor physical and mental health, the implications, for both the older individuals and families/societies, will be much more adverse; the demands for health care and social care will be significantly greater, and older people will be more limited in the social contributions they can make. In light of this, as both the proportion of older people and length of life increases throughout the world, a pertinent question to answer is whether more of the extra years being added are accompanied by a longer period of good health, a sustained sense of well-being, and extended periods of social engagement and productivity or is it associated with more illness, disability and dependency? How will ageing affect health care and social costs? Unfortunately, data from various studies indicate that although there have been improvements in lifespan, the same advances have not been made in healthspan, meaning thereby that the extra years of life are lived under poor health. This highlights the need for focussing on healthy ageing.

What is Healthy Ageing?

As will be discussed subsequently, while ageing presents challenges to society, it also creates many opportunities – for individuals as well as society. However, whether the longer life would result in a greater opportunity to contribute to society or end up being a burden for individuals, their families and society as a whole will be determined by one single factor – health in these extra years of life. Healthy ageing and its associated concepts (e.g. successful ageing, positive ageing, ageing well, ageing productively) have been developed over the years as a response to population ageing.

In 2015, the World Health Organisation released the ‘World Report on Ageing and Health’. This report considers the health of older people in a more holistic sense, one that is based on life-course and functional perspectives. The report defines ‘Healthy Ageing’ as ‘the process of developing and maintaining the functional ability that enables well-being in older age.’

Functional ability comprises the health-related attributes that enable people to be and to do ‘what they have reason to value’.  It refers to people’s abilities to:

• meet their basic needs to ensure an adequate standard of living;
• learn, grow and make decisions
• be mobile
• build and maintain relationships
• contribute to society

It is made up of the intrinsic capacity (IC) of the individual, relevant environmental characteristics and the interaction between the individuals and these characteristics.

Intrinsic capacity is the composite of all the physical and mental capacities of an individual.  Itcomprises all the physical and mental capacities that a person can draw on, including a person’s locomotor capacity (physical movement), sensory capacity (vision and hearing), vitality (energy and balance), cognition, and psychological capacity. These capacities are interrelated and contribute to functional ability. For example, hearing helps people to communicate, maintain autonomy, and sustain mental health and cognition. Significant declines are closely related to care dependence in older age.   

Environments are where people live and conduct their lives and comprise all of the factors in the extrinsic world that form the context of an individual’s life. Environments shape what older people with a given level of intrinsic capacity can be and do. These include the home, community and broader society and relate to products, equipment and technology that facilitate older people’s capacities and abilities; the natural or built environment; emotional support, assistance and relationships provided by other people and animals; attitudes since these influence behaviour – both negatively and positively; and services, systems and policies that may (or may not) contribute to enhanced functioning at older ages. 

It is important to emphasise here that the World Health Organisation’s landmark report on ageing and health, referred to above, set out a framework for healthy ageing that made it clear that health and wellbeing in later life are not just about maintaining physical and mental health but is also about creating an environment that enables us to live our lives to the full. In a new UN-wide initiative, on 14^th Dec 2020, the United Nations General Assembly declared 2021-2030 the Decade of Healthy Ageing, in an effort to galvanize international action to improve the lives of older people, their families and communities.

Optimizing “functional ability” is the goal of the Decade of Healthy Ageing. The vision is a world in which all people can live long and healthy lives. Healthy Ageing spans the life-course and is relevant to everyone, not just those who are currently free of disease. Importantly, shifting the focus of monitoring on functional ability favours a biopsychosocial person-centred approach that does not classify the health of a population on the basis of the presence or absence of disease, but on the basis of a level of functioning that is “being and doing what persons have reason to value in the context in which they live”.  Practically, individuals can have chronic conditions, but if they live within an enabling environment, then they can be able to do what they value. Almost all determinants of healthy ageing can be improved by policies aimed at different levels (household, communities, regional, national or global). 

According to the Baseline report for the Decade of Healthy Ageing, released by the World Health Organisation, on 17^th Dec 2020, at least 14% of all people aged 60 years and over – more than 142 million people – are currently unable to meet all their basic daily needs that are necessary for a life of meaning and dignity – i.e. within their environments, they cannot dress themselves, get and take their own medication or manage their own money, bills or finances. The concept of healthy ageing has been depicted nicely and concisely in a video by the Canadian Heart & Stroke Foundation.

Physiological changes associated with ageing

Ageing is an inevitable and extremely complex, multifactorial process characterised by the progressive degeneration of organ systems and tissues. These underlying changes have an adverse impact on functioning in older people.

Some of the underlying physiological changes which impact the intrinsic capacity/functional health in older people are as under:

1. Reduction of Physiological reserve

As has been highlighted above, at the biological level ageing is characterised by a gradual, lifelong accumulation of molecular and cellular damage, resulting in progressive degeneration of organ systems and tissues. This leads to a decline in and loss of functional reserve of the body’s systems (cardiovascular, respiratory, renal, gastrointestinal, hepatobiliary [having to do with the liver, bile ducts and/or gall bladder], endocrine, immune and stress responses, and the nervous system).

2. Impairment of musculoskeletal and movement function

(a) Age-related changes in the skeletal muscle mass and strength

The ageing process, even in the absence of chronic disease, is associated with a progressive and generalised loss of muscle mass and function (termed as sarcopenia) and appears to occur even in relatively weight stable healthy individuals. It is accompanied by loss of muscle strength, which is often greater than what can be accounted for by the loss of muscle mass. 

(b) Age-related changes in bones

Ageing is also associated with significant changes in bones and joints; with age, bone mass or density, tends to fall, particularly among postmenopausal women. This thinning of bone mass is known as osteopenia. This can progress to a point where the loss of bone mass is much more pronounced, significantly increasing the risk of fractures; this condition is known as osteoporosis. Fractures in the elderly have serious implications for disability, reduced quality of life and mortality. A few years back, a new syndrome, osteosarcopenic obesity syndrome, involving the triad of bone, muscle and adipose tissue impairment has been identified.

(c) Age-related changes in articular cartilage

With age, articular cartilage undergoes significant structural, molecular, cellular and mechanical changes, increasing its vulnerability to degeneration. As cartilage erodes and fluid around the joint decreases, the joint becomes more rigid and fragile. These age-related changes in the articular cartilage that increase the risk of articular cartilage degeneration, are critical factors in the development of the clinical syndrome of osteoarthritis.

These and other age-related declines ultimately impact broader musculoskeletal function and movement. These are reflected in a decrease in various musculoskeletal and movement functions such as grip strength, gait speed etc, which are powerful predictors of future outcomes in older age.

3. Age-related changes in body composition

In addition to the loss of muscle and bone mass discussed above, an important change accompanying ageing is increasing body fatness.

(a) Increased body fatness

In general, with advancing age, the lean body mass components such as skeletal muscle, bone mass and body water decrease, while total body fat increases. This progressive increase in body fat normally peaks at about 65 years in men and later in women, after which body fatness appears to stabilise.

(b) Redistribution of body fat

Advancing age results in a redistribution of fat depots, despite stable or decreasing overall fat, with adipose storage sites changing from subcutaneous locations to more harmful ectopic locations. In particular, intramuscular adipose tissue (IMAT) may be of specific interest in the context of sarcopenia and frailty.

4. Sensory function

Age-related sensory impairment is a slow and gradual process, which affects multiple modalities including vision, hearing, smell, taste and touch. Of these, loss of hearing and vision has far wider consequences.

5. Cognitive functions

Cognitive impairment is when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life. Cognitive impairment ranges from mild to severe. With mild impairment, people may begin to notice changes in cognitive functions, but still be able to do their everyday activities. Severe levels of impairment can lead to losing the ability to understand the meaning or importance of something and the ability to talk or write, resulting in the inability to live independently.

6. Immune function

One of the well-documented physiological declines of immense importance in response to stress or damage, which impacts negatively on the health span of individuals, is the decline in function of the immune system. This age-associated immune dysfunction is referred to as “immune senescence”. However, as immune function declines with age, the immune dysfunction in the elderly manifests as:

• Decreased resistance to infections.
• Lower vaccination efficacy.
• Decreased immune surveillance (immune surveillance is a theory that the immune system patrols the body not only to recognise and destroy invading pathogens but also host cells that become cancerous).
• The increased onset of malignancies.
• Increased inflammation.
• Autoimmune activation. 

Ageing is associated with a sort of paradox: a state of increased autoimmunity and inflammation coexistent with a state of immunodeficiency. This chronic low-grade inflammatory state, known as “inflammaging”, is a significant risk factor for morbidity and mortality in older people and has been linked to a broad range of deleterious health outcomes, including sarcopenia, frailty and atherosclerosis.

Health conditions encountered in older age

Age increases the risk of many health disorders, and these can have significant impacts on intrinsic capacity beyond the trends described above under physiological changes associated with ageing. With increasing age, numerous underlying changes occur and the risk of chronic diseases rises. By age 60, the major burdens of disability and death arise from age-related losses in hearing, seeing and moving, and lifestyle diseases, including heart disease, stroke, chronic respiratory disorders, cancer and dementia. According to the data from the WHO’s Global health estimates published in the year 2013, the greatest burden of disability is estimated to come from sensory impairments (mainly hearing and vision loss; particularly in low- and lower-middle-income countries), back and neck pain, chronic obstructive pulmonary disease (particularly in low- and lower-middle-income countries), depressive disorders, falls, diabetes, dementia (particularly in high-income countries) and osteoarthritis. The important disorders that kill older people and deprive them of potential years of life include ischemic heart disease, stroke and chronic obstructive pulmonary disease.

The burden from these conditions is far greater in low- and middle-income countries than in high-income countries. Combined data for disability and death shows that all over the world, the overwhelming disease burden in older age comes from lifestyle diseases. Furthermore, as people age, they are more likely to experience several conditions at the same time, a phenomenon known as multimorbidity. Older age is also characterised by the emergence of several complex health states that tend to occur only later in life and that do not fall into discrete disease categories. These are commonly called geriatric syndromes. They are often the consequence of multiple factors and include frailty, urinary incontinence, falls, delirium and pressure ulcers. Geriatric syndromes appear to be better predictors of death than the presence or number of specific diseases.

Sarcopenia

The term sarcopenia is derived from the Greek words ‘sarx’ meaning flesh plus ‘penia’ meaning loss. Thus, sarcopenia translates loosely as muscle deficiency.

Sarcopenia is a skeletal muscle disorder characterised by progressive and generalised loss of muscle mass and function (defined by muscle strength, muscle power or physical performance) and is associated with an increased likelihood of various health outcomes. Sarcopenia is a major contributor to the risk of physical frailty, functional decline, poor health-related quality of life and premature death in older people. “There may be no single feature of age-related decline that could more dramatically affect ambulation, mobility, calorie intake, and overall nutrient intake and status, independence, breathing etc”.

Ramifications of losing muscle mass and strength

The loss of muscle mass with ageing is increasingly recognised as having important consequences in old age because it may be associated with weakness, disability, and morbidity. The consequences of sarcopenia include decreased strength, metabolic rate and maximal oxygen consumption. The decrement in strength following the loss of muscle mass is very obvious. The implications of the loss of muscle strength include functional impairment (e.g. slow walking speed, poor balance) and in severe cases, physical disabilities (e.g. difficulty performing activities of daily living, increased risk of falls).

Physical limitation is important because of its relationship with the ability to live independently and overall quality of life.

Geriatric syndromes

As has been discussed above, significant losses in IC predispose to the risk of experiencing an array of complex health states, commonly known as geriatric syndromes. Geriatric syndromes refer to multifactorial (involving or dependent on many factors, especially genetic or environmental factors) health conditions that occur when the accumulated effects of impairments in multiple organ systems render [an older] person vulnerable to situational challenges (i.e. situation-specific stressors [an activity, event or other stimuli that causes stress] or situational risk factors – the host, behavioural, or environmental factors present that may increase the likelihood of an adverse outcome).

A defining feature of geriatric syndromes is that multiple risk factors contribute to their aetiology (i.e. causation). In other words, multiple underlying factors, involving multiple organ systems, tend to contribute to and define geriatric syndromes. Usage of the term “syndrome” emphasises these multiple causations. The symptoms are assumed to result not solely from discrete diseases but also accumulated impairments in multiple organ systems and develop when the accumulated effects of these impairments in multiple domains compromise compensatory ability. There is still some debate as to which conditions may be considered geriatric syndromes, but they are likely to include frailty, falls, urinary incontinence, delirium, immobility, and pressure ulcers.

Often, the main presenting complaint may not represent the specific pathological condition underlying it. In some cases, the two processes may involve distinct and distant organs, with no connection between the underlying pathological condition and the resulting clinical symptoms. For example, an older person may present with acute cognitive decline or delirium, but these clinical symptoms may be a consequence of underlying causes as diverse as an infection or electrolyte disturbance. Similarly, a fall may be a consequence of many underlying characteristics, including drug interactions, environmental factors and muscle weakness.

Although heterogeneous, geriatric syndromes share many common factors. They are highly prevalent in older adults, especially frail older people and their effect on the quality of life and disability is substantial. They appear to be better predictors of survival than the presence or number of specific diseases. In brief, as will be discussed in subsequent sections on individual geriatric syndromes, these are core contributors to late-life disability. Furthermore, although each geriatric syndrome is distinct they share risk factors. The common risk factors identified consistently across all geriatric syndromes include:

• older age;
• functional impairment;
• cognitive impairment
• impaired mobility

Shared risk factors across all geriatric syndromes suggest the likelihood of shared basic mechanisms in the causation of various geriatric syndromes, including the overarching geriatric syndrome of frailty. Three of these four risk factors (i.e. other than age) are amenable to interventions and this raises the possibility of a unified approach to prevention of these geriatric syndromes, along with their associated poor long-term outcomes.

1. Frailty – the Overarching Geriatric Syndrome

Population ageing worldwide, as discussed in the preceding sections, is rapidly accelerating. Although this is a testament to the progress seen in society in general and healthcare in particular, it creates additional challenges for the health and social care system. In general, we tend to develop more health problems and become frailer as we age. The increase in life expectancy allows chronic diseases to develop while physical and cognitive functions decline, which predisposes older people to disability or dependency. However, the primary challenge to the healthcare system is not ageing per se but the association between ageing and frailty.

Frailty is a unique physiological syndrome, that develops as a consequence of the cumulative decline in multiple physiological systems over a life span. It is prevalent in all countries and is a leading contributor to functional decline and early mortality in older adults. It is considered a major public health problem in the older population. As discussed in the preceding sections, as people get older, a wide variety of molecular and cellular damage accrues over time, resulting in a gradual decrease in physiological reserve (also known as functional reserve) of the body’s organ systems, which in turn increases vulnerability to many diseases and other adverse events, and ultimately death.  While physiological systems do lose some of their homeostatic reserves at advanced ages, there is an inherent reserve buffer (for example, the brain contains more neurons and skeletal muscle more myocytes than are required for survival), suggested to be around 30%, which an individual can lose and still function well. Frailty is thought to result when this threshold is surpassed in multiple physiological systems – so much so that the homeostatic physiological safety net essential for the maintenance of reserves and resilience is compromised and repair mechanisms cannot maintain system homeostasis.

As a result even a relatively minor stressor event (e.g., a new drug; ‘minor’ infection; or ‘minor’ surgery) results in a dramatic and disproportionate change in health state: from independent to dependent; mobile to immobile; postural stability to falling; lucid to delirious. This oscillation in health state observed in frail older people has been referred to as “unstable disability.” Unstable disability occurs when function fluctuates with minor external events. Small precipitants, such as a change in drug therapy, cold weather or an attack of urinary tract infection, produce such a deterioration in performance that independence is threatened.

2. Falls

Falls may present as collapse, legs gave way, found lying on the floor. Gait and balance impairments are core features of frailty and are important risk factors for falls. A so-called “hot” fall may be related to a minor illness that reduces postural balance below a critical threshold necessary to maintain gate integrity, or in older adults, it could be even a manifestation of an underlying serious illness. For example, a frail older adult with bacterial pneumonia may present with falls, and may not have the typical cough, fever or elevation in white blood cell count that are commonly associated with pneumonia in younger adults.

Spontaneous falls occur in more severe frailty as a result of severe impairment in vital postural systems such as vision, balance and strength, which makes navigation unsafe in even undemanding environments. Spontaneous falls are typically repeated, giving rise to the psychological reaction of “fear of further falls”; as a result, the person may develop severely impaired mobility.

Falls are among the most common and serious problems facing elderly persons. Falling is associated with considerable mortality, morbidity, reduced functioning and premature hospitalisation. Falls generally result from an interaction of multiple and diverse risk factors and situations, many of which can be corrected. Frequently older people are not aware of their risk of falling and neither recognise risk factors nor report these issues to their physicians. Consequently, opportunities for the prevention of falling are often overlooked with risks becoming evident only after injury and disability have already occurred.

3. Urinary incontinence

Urinary incontinence is the involuntary loss of urine associated with urgency or with effort, physical exertion, sneezing or coughing. Urinary incontinence is a troubling and one of the most common disorders among geriatric patients and leads to social or hygienic problems. Its prevalence increases with age and incidence is much higher in women than men in all age groups. The impact of urinary incontinence can be profound on the quality of life of both older people and caregivers. Urinary incontinence has been associated with depression, care dependence and institutionalisation of older people and it increases strain and burden on caregivers.

4. Delirium

Delirium (sometimes called acute confusion or ‘muddledness’) is a mental disturbance of relatively short duration, characterised by rapid onset of fluctuating confusion and impaired awareness and cognition precipitated by an underlying condition or event, in vulnerable persons. Delirium is frequently described using terms like altered mental status, acute confusional state, sundowning, encephalopathy, and acute organic brain syndrome. Delirium is a serious complication for older adults because an episode of delirium can initiate a cascade of deleterious clinical events, including prolonged hospitalization, loss of functional independence, reduced cognitive function and death. Though often related to a reduction in the integrity of the brain function, an older person presenting with confusion may not have a neurologic problem but rather an infection.

5. Immobility

Mobility impairment is common in frailty and near-universal when frailty is severe (as measured by an FI-CGA score > ~0.4). It often presents as a sudden change in mobility, ‘gone off legs’ or ‘stuck in toilet.’ The concept of ‘off legs’ usually refers to elderly patients, who were previously mobile and active, with a sudden deterioration. An acute illness, for example, chest infection, urinary tract infection, myocardial infarction, stroke or even spinal cord compression due to infection could all manifest themselves in a patient with frailty as a sudden change in mobility.

6. Pressure ulcers

Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure, sufficient to impair its blood supply. They are also known as pressure sores, bedsores, and decubitus ulcers. Pressure ulcers have important consequences both for patients and for the healthcare system. They can lead to severe or intolerable pain, are prone to infection, and are associated with high mortality rates.

Diversity in older age

The common use of calendar age (chronological age) to mark the threshold of old age assumes equivalence of chronological age with biological age. However, it is generally accepted that these two are not necessarily synonymous. As the evidence shows, the loss of ability typically associated with ageing is only loosely related to a person’s chronological age. There is no ‘typical’ older person. WHO’s ‘World Report on Ageing and Health’, referred to above,  states – “Diversity is a hallmark of older age. It means that some 80-year-olds will have levels of both physical and mental capacities similar to that of many 20-year-olds.” It also highlights the fact that many other people will experience significant declines in capacity at much younger ages. Some 60- or 70-year-olds will require help from others to undertake basic activities.

Chronological or biological age – which is the culprit?

To begin with, there are many misconceptions about ageing, and many confuse chronological and biological age. While chronological age is the number of years that a person has been alive since his birth; it’s a simple passage of time; on the other hand, biological age is by and large a subjective concept and in simpler words can be said to be the ‘perceived age’; i.e. how old your body seems.

As highlighted above, diversity is the hallmark of older age. However, the diversity seen in older age is not random. It is not by mere chance that most age-related chronic diseases and disabilities appear with advancing age independently of the genetic or environmental endowment of the individual. While ageing is a passive, stochastic and inevitable phenomenon that occurs to all individuals of a species, disease occurs to only a proportion of them.  The reason is simple: while not a disease itself, the biological process of ageing is by far the greatest risk factor for all age-related chronic diseases and health conditions. Therefore, there is a need to better understand the biology driving the ageing process.

The chronological age cannot be manipulated, but we know that physiological fitness, an important parameter of perceived age, can be affected at all ages by simply adopting healthy lifestyles encompassing regular exercise, healthy diet and smoking cessation. And it is also well established that our lifestyles have an important bearing on the appearance of age-related chronic diseases and health conditions. Thus, it is not “age” (the passage of time) but “ageing” (the process) that can be manipulated.

However, despite enough scientific evidence that ageing is the major risk factor for age-related chronic diseases and health conditions, the concept has not been adequately exploited in medicine because ageing is often seen as “inevitable” and synonymous with chronological age. There is now enough scientific evidence that indicates that the process of biological ageing is malleable, and more importantly, when ageing is delayed, so are age-related chronic diseases and health conditions.

As highlighted above, ageing is malleable and can be delayed by adopting moderate lifestyle changes, including diet and exercise. Besides, over the last few decades, scientific knowledge and understanding about the basic molecular and cellular mechanisms that control the ageing process has advanced dramatically. There is a growing body of evidence that ageing is driven by interconnected biological factors we call ‘hallmarks’ or ‘pillars’ of ageing. It is believed that disrupting these hallmarks – which cover everything from the stability of our genes to ways our cells communicate – can contribute to chronic diseases and frailty, making a better understanding of how they work so important. At the same time, it has been suggested that targeting these age-related mechanisms directly can help delay ageing and prevent or even reverse geriatric syndromes, age-related chronic diseases and decline in resilience. 

The way forward

However, despite this seemingly doomsday scenario, poor health does not have to be the dominant and limiting feature of older age; there is still a beacon of hope as measures are available to promote healthy ageing. Though everyone has to die of something, death does not need to be slow, painful, or premature. Death is inevitable, but the life of protracted ill-health is not. As discussed above, although the physiological and homeostatic changes associated with ageing are largely inevitable, they are neither linear nor consistent. Also, as discussed under ‘diversity in older age’, this diversity is not random. Apart from the genetic factors, the environment (both the physical and social environments) and behaviours of the individual strongly influence these changes, and consequently, how we age, offering opportunity for public health interventions.

Other health problems can be effectively managed, particularly if they are detected early enough. The health spectrum has been viewed as promoting preventive treatment, which improves well-being before an individual presents with signs or symptoms of illness. Galen (130 – 205 AD), the physician to Roman emperor, Marcus Aurelius, and a great teacher and author stated about health: “Since both in importance and time, health precedes disease, so we ought to consider first how health may be preserved, and then how one may best cure diseases.”

Healthy Ageing – a Journey from Womb-to-Tomb

According to the WHO, ageing is a course of the biological reality that starts at conception and ends with death. These underlying changes have an adverse impact on functioning in older people. To date, emerging animal and clinical studies are beginning to elucidate how poor nutrition in utero or during the first two years of life influences disease risk later in life. A feature article titled ‘Developmental origins of health and disease: current knowledge and potential mechanisms’ published in the journal Nutrition Reviews in Dec 2017 highlighted that nutrition during gestation has profound and lasting effects on body size and body fat distribution, as well as on the development of metabolically active tissues, contributing to metabolic disorders. Furthermore, based on a review of several studies the article highlighted that “most studies that used data from famine and longitudinal cohorts have found that poor nutrition and/or growth during the ‘first 1000 days’ are risk factors for many chronic diseases later in life.”

Though a detailed discussion on the developmental origins of health and disease (DOHaD) is beyond the scope of this post, the overarching argument of the conceptual paradigm and the research field of DOHaD is that the state of health and risk from disease in later childhood and adult life is significantly affected by environmental factors acting during the preconceptional, prenatal, and/or early postnatal periods. In his book, Mothers, Babies and Health in Later Life (Mothers, Babies and Health in Later Life, 2^nd edn. Churchill Livingstone, Edinburgh) DJP Barker suggested that adverse environmental influences in utero and during infancy permanently change the body’s structure, physiology, and metabolism, increasing susceptibility to disease in later life.

Key stages of life course affecting health and well being

1. Before birth

(a) Preconception

Poor maternal health has long-lasting effects as young mothers pass poor health onto their babies. Interventions to break intergenerational cycles of ill-health, gender inequality, and poverty are particularly important. There is an increasing amount of evidence supporting the need to target the preconception period to prevent future NCD risk in offspring. Centre for global development. Start with a girl: a new agenda for global health highlighted that by investing in adolescent girl’s health and well being, you are investing in the health and well-being of the generations to come. Same views have been highlighted in the International Federation of Gynaecology and Obstetrics (FIGO) practice guidelines titled “The International Federation of Gynecology and Obstetrics (FIGO) recommendations on adolescent, preconception, and maternal nutrition: “Think Nutrition First” published in the International Journal of Gynecology and Obstetrics in Oct 2015. The guidelines highlighted that adolescent, preconception, and maternal nutrition represent a major public health issue that affects not only the health of adolescents and women but also that of future generations. FIGO recommended that maternal nutrition should be part of a life-course approach that views perinatal health within the context of women’s overall health. This can provide potential benefits to the health of the next generation – achieved by adopting healthy habits prior to conception.

(b) Fetal development

The way that a fetus obtains and allocates nutrition resources has profound consequences for its lifelong health. A review article titled ‘Resource allocation in utero and health in later life’ published in the journal Placenta in Nov 2012, showed that challenged by limited resources the baby allocates resources according to a hierarchy of priorities. Research based on the DOHaD has shown that multiple developmental factors operate from preconception through early life to affect the risk for later NCDs. According to Kuh, Diana & Smith, G.D. (2004). The life course and adult chronic disease: An historical perspective with particular reference to coronary heart disease. A Life Course Approach to Chronic Disease Epidemiology, the possibilities of preventing NCDs by achieving optimal fetal development are now increasing, as early programming is now thought to be important in the aetiology of obesity, type 2 diabetes and cardiovascular diseases.

The impact of early life on long-term outcomes through its effects on physiological processes is accepted in the life course perspective, highlighting the potential for early intervention to reduce disease risk or severity.

2. Pregnancy

As discussed above, healthy lifestyle behaviours such as healthy weight management, healthy diet, physical activity, and avoidance of risky behaviours such as smoking and alcohol consumption should ideally be emphasised in the preconception stage. However, the pregnancy period presents another opportunity for intervention as women may be particularly receptive to changing their health behaviours at this time.

Evidence suggests that maternal obesity has a significant influence on the long term health of the offspring. The review article titled ‘Influence of maternal obesity on the long-term health of the offspring’, published in the journal The Lancet Diabetes and Endocrinology in Jan 2017, highlighted that in addition to immediate implications for pregnancy complications, increasing evidence implicates maternal obesity as a major determinant of offspring health during childhood and later adult life. Observational studies have provided evidence for associations between maternal obesity and an increase in their offspring’s risk of obesity, coronary heart disease, stroke, type 2 diabetes, and asthma. Emerging evidence suggests that maternal obesity could be associated with poorer cognition in offspring and an increased risk of neurodevelopmental disorders, including cerebral palsy. Preliminary evidence suggests potential implications for immune and infectious disease-related outcomes.

The authors also discussed the potential mechanisms acting in the mother, through which maternal obesity and excess nutrient supply increase risk for future metabolic disease. Pre-pregnancy obesity predisposes the mother to gestational diabetes, hypertension and pre-eclampsia, which can affect the placental function and fetal energy metabolism. Additionally, obesity in pregnancy is associated with complex neuroendocrine, metabolic, immune, and inflammatory changes, which probably affect fetal hormonal exposure and nutrient supply. The authors also highlighted the profound public health implications of maternal obesity due to its lifelong consequences for offspring. More than 60% of women are either overweight or obese at conception in the USA and the prevalence of overweight and obesity in women of childbearing age is increasing worldwide, which will increase the population of children exposed to an obese intrauterine environment and thus perpetuate the cycle of increasing obesity and chronic disease burden. Importantly the study highlighted that the offspring of women who are obese and lose weight before pregnancy have a reduced risk of obesity.

The adverse outcomes on the offspring from maternal diabetes in pregnancy are substantially documented. A study titled ‘Intrauterine exposure to diabetes conveys risks or type 2 diabetes and obesity: a study of discordant sibships’ published in the journal Diabetes in Dec 2000 concluded that – intrauterine exposure to diabetes per se conveys a high risk for the development of diabetes and obesity in offspring in excess of the risk attributable to genetic factors alone. A review article titled ‘Maternal Diabetes in Pregnancy: Early and Long-Term Outcomes in the Offspring and the Concept of “Metabolic Memory”, published in the Journal of Diabetes Research in Nov 2011, reported impacts of maternal diabetes on the early and long-term health of the offspring. The study highlighted that the main adverse outcome on progenies from a pregnancy complicated with maternal diabetes appears to be macrosomia, as it is commonly known that intrauterine exposure to hyperglycemia increases the risk and programs the offspring to develop diabetes and/or obesity in adulthood. This “fetal programming”, due to intrauterine diabetic milieu, is termed as ‘metabolic memory’. In gestational diabetes as well as in macrosomia, the complications include metabolic abnormalities, degraded antioxidant status, disrupted immune system and potential metabolic syndrome in adult offspring.

A systematic review and meta-analysis titled ‘Major congenital malformations in women with gestational diabetes mellitus: a systematic review and meta-analysis published in the journal Diabetes Metabolism Research and Reviews in Mar 2012, performed a systematic review (and meta-analysis) of major congenital malformations in women with gestational diabetes versus a reference population. The study found a slightly higher risk of major congenital malformations in women with gestational diabetes than in the reference group.

Obesity and diabetes in pregnancy have independent and additive effects on obstetric complications, and both require proper management.

A WHO report titled ‘Tobacco control to improve child health and development: thematic brief’, issued in March 2021 states that exposure of unborn children to maternal smoking or second-hand smoke is linked to birth defects, stillbirths, preterm births and infant deaths. Maternal smoking during pregnancy is linked to a doubling of the risk of sudden infant death and birth defects, while exposure to second-hand smoke during pregnancy is linked to a 23% increased risk of stillbirth and 13% increase risk of congenital malformations. Even use of smokeless tobacco during pregnancy increases the risk of stillbirth, preterm birth or having a low-birth-weight baby. Emerging evidence suggests that smoking during pregnancy can have an impact across generations; for example grandchildren of women who smoke during pregnancy are at increased risk of asthma.

A clinical report titled ‘Fetal Alcohol Spectrum Disorders’ published in the journal Pediatrics in Nov 2015, highlighted that prenatal exposure to alcohol can damage the developing fetus and is the leading preventable cause of birth defects and intellectual and neurodevelopmental disabilities. Fetal alcohol spectrum disorder (FASD) is the general term that encompasses the range of adverse effects associated with prenatal alcohol exposure. Neurocognitive and behavioural problems resulting from prenatal alcohol exposure are lifelong. Alcohol-related birth defects and developmental disabilities are completely preventable when pregnant women abstain from alcohol use.

3. Infancy and childhood

During infancy (birth to one year) and early childhood, children attain many important developmental milestones relating to their physical as well as social and emotional development. This includes establishing healthy patterns of eating and activity, besides developing a capacity for self-regulation, language and cognitive development and wider learning skills. As discussed, lower birth weight – including shorter gestation and being small for gestational age – and low socioeconomic status are associated with higher infant mortality and poorer long-term health and educational outcomes in childhood. Early nutrition, i.e. during gestation and the first 2 years of life – the first 1000 days – sets the stage for lifelong health. Nutrition quality and quantity in this period can influence the risk of developing diseases that constitute today’s epidemic.

On the other hand, child overweight is a rising issue in both high-income as well as LMICs. It has been associated with growing up in an obesogenic environment, in which population changes in physical activity and diet are the main drivers. World Health Organization. Report of the Commission on ending childhood obesity – 2016 highlighted that parental feeding practices and control over eating affect children’s early eating patterns and risk of childhood obesity. Parental levels of physical activity and sedentary behaviour have also been shown to predict levels of activity in their children. As discussed weight gain at such an early age puts children at increased risk of ongoing overweight and obesity and of developing physical health problems such as diabetes, coronary heart disease and early osteoarthritis in later life.

4. Adolescence

Adolescence is a significant transition point for young people; childhood and adolescence are periods when behaviours associated with non-communicable disease risk are adopted. A white paper titled ‘Healthy Lives, Healthy People: our strategy for public health in England’, highlighted that the teenage years are a crucial time for health and well being in later life. Half of lifetime mental illness (excluding dementia) starts by the age of 14. More than eight out of 10 adults who have ever smoked regularly started smoking before 19, and one study found that 8 in 10 obese teenagers went on to be obese as adults.

5. Adulthood

Individuals entering adulthood bring with them risks for their later health that have been acquired during fetal life, childhood and adolescence, as discussed above. Besides as discussed, the socioeconomic environment has an important influence on adult health, as well as health behaviours. The white paper, ‘Healthy Lives, Healthy People’ referred to above highlights that individuals from more disadvantaged backgrounds are more likely to smoke, have an unhealthy diet and be less physically active by not participating in regular sports activities than those from more affluent backgrounds.

Employment and occupational health is an important aspect of adulthood. WHO report titled ‘Global Health Risk – Mortality and burden of disease attributable to selected major risks’ posted in Dec 2009, is a comprehensive assessment of leading risks to global health. Major occupational risk factors include exposure to carcinogens, airborne particulate matter, ergonomic stressors, noise and child sex abuse. These numerous hazards which people face at work may result in injuries, cancer, hearing loss, and respiratory, musculoskeletal, cardiovascular, reproductive, neurological, skin and mental disorders. In addition, there is increasing evidence from industrialised countries to link coronary heart disease and depression with work-related stress.

On the other hand white paper titled ‘The Importance of a Life Course Approach to Health: Chronic Disease Risk from Preconception through Adolescence and Adulthood’ referred to above, highlights that unemployment is also associated with several elevated health risks such as increased rates of limiting long-term illness, mental illness and cardiovascular disease and an increase in overall mortality, and in particular with suicide. Smoking, alcoholism and substance abuse or other risk factors in this age group that are of concern.

6. Ageing

People worldwide are living longer. Today most people can expect to live into their 60s and beyond. Every country in the world is experiencing growth in both the size and proportion of older persons in the population. Ageing is a complex, multifactorial biological process shared by all living organisms. It is manifested by a gradual decline of normal physiological functions in a time-dependent manner. Organismal ageing holds significant importance for human health because it increases susceptibility to many diseases, including cancer, metabolic disorders such as diabetes, cardiovascular disorders, and neurodegenerative diseases. Besides older age is also characterised by the emergence of several complex health states commonly called geriatric syndromes.

A life course approach to healthy ageing

As discussed in the preceding sections, the process of human ageing commences as early as conception with the inheritance of a specific genome, and it continues until death. In other words, it’s a journey from womb to tomb. However, the way we age is not set in stone. As discussed under ‘diversity in older age’, diversity is a hallmark of older age; we are not all destined to frailty and ill health. We all age differently because of an interplay between a variety of factors. Biologically we are different; we are born into, grow and live in diverse physical and social environments. It all contributes to the way we age.

Some of the factors that influence the way we age are things that we can control ourselves, such as diet and exercise. Therefore, by changing our lifestyle, we can positively influence the way that we age. Many of the factors that influence it act across life. So, whatever your age, it’s never too late to do something to promote good health in later life. A guest editorial titled ‘A Life Course Approach to Healthy Aging, Frailty, and Capability’, published in The Journals of Gerontology. Series A, Biological Sciences and Medical Sciences in Jul 2007 highlighted that the rate and manner in which individuals age can be significantly influenced by extrinsic factors at multiple points throughout life, thereby promoting healthy ageing.

Healthy ageing is about more than dodging disease and avoiding frailty. As defined by WHO, healthy ageing is the process of developing and maintaining the functional ability that enables well-being in older age. It’s about how we feel and how we function, physically and mentally, throughout our lives. It’s about being able to carry out tasks of everyday living, and enjoying a purposeful and fulfilling life. In short, healthy ageing is about keeping moving, keeping thinking and keeping your spirits up.

Life course model of healthy ageing

Previous research on ageing mostly focused on influences operating in later life. However as discussed in the preceding sections there is considerable variation in age-related diseases between individuals of a similar age, which may be linked to early life processes. The life course model of ageing suggests that starting in early life, various body systems attain peak capacity in early adulthood; this peak capacity depends partly on developmental processes and early environmental influences. This is followed by maintenance through to midlife, and decline from midlife onwards. The rate of decline in function for a particular organ or system depends not only on contemporary influences but also on the level of peak function attained earlier in life, which in turn depends partly on developmental processes and early environmental influences. The life course model of ageing indicates that differences in both exposure and response underlie the variation in rates of ageing between systems in the same individual and between individuals.

The life course model of ageing is also relevant to clinical practice. A study titled ‘Assessment of a large panel of candidate biomarkers of ageing in the Newcastle 85+ study’, published in the journal Mechanisms of Ageing and Development in Oct 2011 suggested that the life-course model of ageing may provide an opportunity to identify individuals at risk of accelerated ageing early in the life course, using early biomarkers of such risk. Identification of biomarkers of ageing and health status will not only lead to more robust evidence to facilitate the development and targeting of interventions to improve health and avert high-cost dependency but will also aid investigations of the links between ageing and disease. The theoretical basis and mechanistic observations underlying the DOHaD concept suggest that a much broader focus on the life course is needed than has previously been given by the medical and public health communities and policymakers if the prevalence of various lifestyle- and age-related health conditions is to be reduced.

The indisputable importance of a life-course approach for dealing with the present-day challenge of non-communicable diseases has been formally endorsed in the 2011 Political Declaration by the United Nations (United Nations General Assembly [2012]. Resolution adopted by the General Assembly. 66/2. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases). Similarly, the World Health Organization Commission for ending childhood obesity, which was tasked with tackling the growing global problems and consequences of child and adolescent obesity has recognised the indispensable contribution of life course concepts in its report (World Health Organization (WHO) (2014). Report of the first meeting of the ad-hoc working group on science and evidence for ending childhood obesity. Geneva, Switzerland; WHO).

Factors influencing healthy ageing

Healthy ageing is a challenge. Many varied factors influence the way we age. These factors operate at different levels ranging from the societal and individual right down to the level of body systems and cells. These factors do not act in isolation, but instead are influenced by and interact with each other. Identification of factors that influence ageing can facilitate identification of those at risk of poor health, and designing interventions to help them, boosting prospects of longer, healthier lives. Key stages of the life course affecting health and well-being have been discussed in the preceding sections. Some of the key factors operating in these stages which have an impact on the way we age will be discussed here briefly.

1. The environment during fetal and early postnatal life

As discussed under the preceding sections, environmental influences during intrauterine and early postnatal life are associated with alterations in form and function across a range of systems, which establish predisposition to age-related system decline and consequent diseases later in life.

2. Lifestyle factors

Maintaining healthy behaviours throughout life, particularly eating a balanced diet, engaging in regular physical activity and refraining from addictive substance use, such as alcohol and tobacco use, all contribute to reducing the risk of non-communicable diseases, improving physical and mental capacity and delaying care dependency. A study titled ‘Dietary quality, lifestyle factors and healthy aging in Europe: the SENECA study’, published in the journal Age and Ageing in Jul 2003, concluded that a healthy lifestyle at older ages is positively related to reduced mortality risk and a delay in the deterioration in health status. Furthermore, a lifestyle characterised by non-smoking, physical activity, and a high-quality diet contributes to healthy ageing.

We cannot change the environment we experienced during the fetal and early postnatal life and may feel powerless to influence our social and economic position, but lifestyle factors are one thing that, with motivation, we can all change, and in the process increase our chances of healthy ageing. Furthermore, it offers a cheaper, more accessible and more realistic way to influence the way we age.

3. Social connectedness

Social connection is broadly defined as a subjective sense of having close and positive relationships with others. It is key to healthy ageing. Friendships and social relationships are part of the fabric of life, but there is evidence to suggest that these relationships can positively influence the way you age. They are vital to extending life, getting under our skin to buffer health and wellbeing, and building resilience in the face of various challenges we encounter. Moreover, these relationships appear to matter more as we age, when our vulnerability to ill health increases.

Longitudinal studies provide the first source of evidence of the curative potential of social connectedness. Studies have shown that being more socially connected reduces the risk of mortality, memory decline, and depression. Studies have also shown that active engagement in one’s social network is more important for health than network size or diversity. One study reported that while the rate of cognitive decline was reduced by 39 per cent in older people who had a large number of networks, there was a much bigger reduction (of 91 per cent) among those who were highly engaged in those networks. Evidence also suggests that group-based social ties (e.g., with family, friends, community and interest groups) appear to be more protective of cognitive health as we age than our relationships with significant others. A brochure titled ‘A life course approach to healthy aging. How to keep moving, keep thinking, and keep your spirits up’, highlighted that lack of social relationships is a major risk factor for ill-health, on a par with the effects of smoking, inactivity and obesity. It further noted that besides influencing health and longevity, social relationships can also help maintain cognitive capabilities. People who are socially engaged are likely to have a slower rate of decline in perceptual speed, in lower risk of cognitive decline and are less likely to develop dementia.

4. Sociodemographic characteristics

Sociodemographic characteristics such as age, ethnicity, sex, marital status, and socioeconomic status have had a strong influence on healthy ageing over time.

5. Socioeconomic status

It’s an uncomfortable truth, but the way we age is influenced considerably by our social and economic circumstances. The most privileged among us can be expected to live longer, healthier lives than those from more disadvantaged backgrounds. Various life course studies document these inequalities and show us that social and economic factors influence the ageing process from very early stages in life. Though how socioeconomic circumstances influence the ageing process is unclear, it likely impacts the ageing process through its effects on childhood infection, early life nutrition, exposure to environmental pollutants, lifestyles, psychological responses, and the development of chronic diseases. Socioeconomic effects build across life, with better or poorer circumstances at any point influencing the way we age.

6. Physical and social environments

Physical and social environments, including homes neighbourhoods and communities, can affect health directly or through barriers or incentives that affect opportunities, decisions and health behaviours. Supportive physical and social environments also enable people to do what is important to them, despite losses in capacity. The availability of safe and accessible public buildings and transport, and places that are easy to walk around, are examples of supportive environments that promote healthy ageing.

7. Psychosocial factors

The study titled ‘Psychosocial factors for influencing healthy aging in adults in Korea’, published in the journal Health and Quality of Life Outcomes in Mar 2015, examined the psychosocial factors which influence healthy aging. The study showed that healthy aging was significantly influenced by depression, participation in leisure activities, perceived health status, ego integrity, self-achievement, and self-esteem (in that order). This finding means that not only physical health, but also mental health is very important to healthy ageing and the life of old people.

Lifestyle strategies to take control of your health

Lifestyle medicine is an evidence-based approach to preventing, treating and even reversing the diseases by replacing unhealthy behaviours with positive ones – such as eating healthfully, being physically active, managing stress, avoiding risky substance use, adequate sleep and having a strong support system. Six lifestyle strategies to improve health will be discussed here briefly. However, you will find a detailed description of these in my upcoming book on lifestyle- and age-related diseases and healthy ageing.

1. Healthful eating for healthy ageing

One of the best-kept secrets in health care is that “something as simple as food on your plate can truly be medicine.” Good nutrition is important, no matter what your age. Besides providing you energy and helping you to control your weight, it also helps prevent some diseases, such as heart disease, type 2 diabetes, certain cancers, high blood pressure and osteoporosis. In my post titled ‘Food as Medicine: Healthful Eating for Healthy Living’, I have discussed in detail, the role of healthy diets in both preventive and therapeutic medicine.

2. Regular physical activity for healthy ageing

Exercise is medicine that can prevent or treat many disabling or fatal diseases. Exercise is becoming more widely used to prevent and treat the diseases that are most prevalent in today’s society: coronary artery disease, stroke, hypertension, diabetes, arthritis, osteoporosis, cancer, and chronic obstructive pulmonary disease. The health rewards of exercise extend far beyond its benefits for specific diseases. Exercise enhances self-image, elevates mood, reduces stress, improves appearance, increases energy, and gives the feeling of well-being (probably by stimulating the release of endorphins). Furthermore, it reinforces other positive lifestyle changes, such as healthier eating habits and smoking cessation. It also stimulates creative thinking. Most importantly, the ability of exercise to restore function to organs, muscles, joints and bones is not shared by drugs or surgery. Paradoxically, conventional medical practice favours physical rest and inactivity during recovery from illness.

In my post titled ‘Health Benefits of Exercise: a grossly underutilized therapy’, I have discussed at length why exercise is now aptly being recognised as medicine. However, when we think of ‘medicine’ we often think of a drug, something to be taken by mouth or injection. Although not ‘taken’ but done, an exercise prescription is much like a drug prescription. In my post ‘Exercise Prescription for Optimum Health Benefits’, I have discussed the various principles of exercise prescription. However, when it comes to exercise, all three components of physical fitness namely cardiorespiratory or aerobic endurance, muscular fitness, and flexibility are equally important. In my post ‘Aerobic Exercise Prescription for Optimum Health Benefits’ and ‘Weight Training Program Design for Optimum Health’, I have discussed exercise prescription guidelines specifically for aerobic and strength training respectively.

3. Stress management for healthy ageing

Stress is such a highly subjective phenomenon that it defies definition. The most commonly accepted definition of stress (mainly attributed to Richard S Lazarus) is that: “Stress is a condition or feeling experienced when a person perceives that demands exceed the personal and social resources the individual is able to mobilise.” Our bodies are well equipped to handle stress in small doses, but when that stress becomes long-term or chronic, it can have serious effects on your body. Stress affects all systems of the body including the musculoskeletal, respiratory, cardiovascular, endocrine, gastrointestinal, nervous, and reproductive systems. Chronic psychological stress appears to accelerate biological ageing, and oxidative damage is an important potential mediator of this process. There are very many proven skills that can be used to manage stress. These help us to remain calm and effective in high-pressure situations and help us avoid the problems of long term stress. These skills fall into the following main groups:

(a) Action-oriented skills

In which we seek to confront the problem causing the stress, changing the environment or the situation. These approaches work best where you have some control. If we do, then these approaches are some of the most satisfying and rewarding ways of managing stress.

(b) Emotionally-oriented skills

In which we do not have the power to change the situation, but we can manage stress by changing our interpretation of the situation and the way we feel about it.

LIFE IS 10%
WHAT HAPPENS TO ME
AND 90%
OF HOW I REACT TO IT.
                                                 

Charles Swindoll

“It is not stress that kills us, it is our reaction to it.” – Hans Selye

I have a CHOICE:
Not only do I have the power to choose my actions, but I also have the power to choose my thoughts and my moods. When an upsetting event occurs I select my response. Will it be anger and irritation, or will it be acceptance and forgiveness?
I can simply accept what is in my environment (things are what they are) and change my attitude.

(c) Acceptance-oriented skills

Where something has happened over which we have no power and no emotional control, and where our focus is on surviving the stress. Sometimes, we have so little power in a situation that all we can do to survive it. This is the case, for example, when loved ones die. In these situations, often the first stage of coping with the stress is to accept one’s lack of power. The well-known serenity prayer has been used by anybody feeling beaten down by life, to provide solace:

“God,
 grant me the Serenity
 to accept the things I cannot change;
Courage to change the things I can;
and Wisdom to know the difference.”

Other stress management strategies include – lifestyle and time management skills, effective communication, good sleep, exercise, yogic meditation, traditional therapies (massage, acupressure acupuncture), new age therapies (sound therapy, music therapy, autogenic training for stress, biofeedback, creative visualization), naturopathy (aromatherapy, bach flower therapy, colour therapy).

4. Improve your sleep for healthy ageing

Sleep is just as important for your overall health as doing regular exercise, eating a healthy diet, and taking care of your mental and emotional needs. In fact, your quality of sleep is a key factor in healthy ageing. An ongoing lack of sleep or poor-quality sleep increases your risk of health problems such as cardiovascular disease, high blood pressure, diabetes, depression and obesity. They are also linked to memory problems, forgetfulness, and more falls or accidents. Though the need for sleep varies with age, however, in general aim for 7-9 hours of sleep each night.

Here are some tips to help:

• Go to bed and wake up at the same time every day, even on weekends.
• Find ways to relax before bedtime each night.
• Avoid distractions such as cell phones, computers, and televisions in your bedroom.
• Don’t eat large meals, or drink caffeine or alcohol late in the day.
• Exercise at a regular time each day, but not within 3 hours of your bedtime.
• Avoid long naps (over 30 minutes) in the late afternoon or evening.
• Keep your bedroom at a comfortable temperature, and as quiet as possible.
• Use low lighting in the evenings and as you prepare for bed.
• Remember – alcohol won’t help you sleep. Even small amounts make it harder to stay asleep.

5. Form and maintain relationships to promote healthy ageing

As highlighted above, social connectedness is key to healthy ageing. There are broadly four approaches that can be used to promote social connectedness.

Approaches to enhance social connections

(a) Intergenerational – An intergenerational program is an approach that enhances the social connection between the younger and older generations by facilitating partnerships in the search for wellbeing. The older generation can provide wisdom, values, skills, attention, and affection for the young while the younger generation can provide more up-to-date skills and knowledge as well as attention and affection to the old.

(b) Age-friendly community – This approach primarily targets older adults who are living at home in neighbourhoods or communities. An “ageing-friendly” community can help to promote the psychosocial well-being of older adults by providing infrastructures that support and maintain meaningful social connections throughout one’s life span.

(c) Community-based group physical activity – As highlighted above, physical activity is well recognised as a significant factor in maintaining good health. Besides providing health benefits, participation in group physical activities provides an opportunity to socialise, be actively involved with the community, make friends, and be with peers.

(d) Technology – This approach may be useful for people who live in areas where there are limited social support services. Existing research indicates that the implementation of technology helped improve some dimensions of social connections for older adults who lived at home by providing virtual social support and networks.

6. Avoid risky substance use to promote healthy ageing

Substance abuse refers to a set of related conditions associated with the consumption of mind- and behaviour-altering substances that have negative behavioural and health outcomes. Substance abuse has a major impact on individuals, families and communities. The effects of substance abuse are cumulative, significantly contributing to costly social, physical, mental, and public health problems.

High-risk substance use prevention:

Research has improved our understanding of factors that help buffer people from a variety of risky behaviours, including substance use. These are known as ‘protective factors’. Some protective factors for high-risk substance use include:

• Parental or family engagement
• Family support
• Parental disapproval of substance use.
• Parental monitoring
• School connectedness

Positive behaviours that improve health include cessation of tobacco use and limiting the intake of alcohol.

Conclusion

Most of the health problems encountered in older age, including the lifestyle- as well as age-related diseases, such as sarcopenia and frailty, are largely preventable by engaging in healthy behaviours. In fact, even in very advanced years, physical activities and good nutrition have been shown to have powerful benefits for health and well-being. In the Chinese system of medicine, “the great doctor is one who treats not someone who is already ill but someone not yet ill.” Therefore, one must strive for holistic health. By getting to the root cause(s) of illness, holistic health approach goes beyond merely eliminating symptoms. By adopting the principles of holistic health, you can enjoy better health, have increased energy, greater enthusiasm, an enhanced sense of well-being and a greater sense of joy; it can help find purpose and meaning to life and promotes inner calmness. This can be achieved by exercising your ‘power of choice’: choose wellness-oriented lifestyles, positive thoughts and attitudes, love and compassion, time to be quiet and reflect, forgive and let go. Holistic health is a way of life – Choose well to live well. Life is NOT merely living BUT living in health.