Healthier ageingBMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e1214 (Published 12 March 2012) Cite this as: BMJ 2012;344:e1214
- Phyo Kyaw Myint, clinical senior lecturer in ageing and stroke medicine12,
- Ailsa A Welch, senior lecturer in nutritional epidemiology1
- 1Norwich Medical School, University of East Anglia, Norwich Research Park, Norwich NR4 7TJ, UK
- 2Academic Department of Medicine for the Elderly, Norfolk and Norwich University Hospital, Norwich NR4 7UY
- Correspondence to: P K Myint
Ageing affects people in different ways, with a wide variation in age related physical and mental functioning
Healthier ageing is achievable through modifying some lifestyle factors—such as stopping smoking, being more physically active, and eating a balanced diet
For healthier ageing, eat mainly nutrient dense foods that are rich in vitamins and minerals and low in fats and sugar
Balancing energy intake and expenditure is important for maintaining healthy weight
Preventing chronic diseases may promote healthier ageing through better physical and mental health
Ageing is associated with a gradual decline in physical functioning with or without mental frailty. The ageing process is intrinsically complex, being driven by multiple causal mechanisms.1 2 Genome instability, telomere damage, mitochondrial dysfunction, and inflammation are established mechanisms of ageing.w1 w2 Age related changes in body composition include a relative increase in fat tissue and a gradual decline in muscle mass. Not everyone ages in the same way, however, and the term biological age is loosely used to indicate how well someone has aged in terms of the degree of decline in their physical functioning and their ability to meet physiological demands.3 4
Ageing is determined by complex interactions between biological, environmental, socioeconomic, and cultural factors,w3 some of which are beyond the control of individuals. Factors that may contribute to the ageing process, such as poor nutrition,w4 physical inactivity, smoking, and psychosocial characteristics (such as stress),w5 may be modifiable. These factors are associated with the development of chronic diseases that are, in themselves, associated with physical and mental frailty and could be tackled at an individual level throughout life. Considerable geographic variation in the prevalence of major chronic diseases among older people suggests that chronic diseases are not an inevitable part of ageing.5
Although we acknowledge that there is an increasing need to recognise the long term care requirement of ageing populations, we consider that efforts should be made to promote healthier lifestyles as a way to age more healthily, given the large and increasing body of mainly observational evidence suggesting that healthier ageing is achievable through lifestyle modification.
What is healthy ageing?
Healthy ageing in older age could be considered to be “being free of any chronic disabling conditions and the prevalent conditions of older age; having the ability to be content or enjoy life; and being able to perform desired physical, mental and social activities without any limitations.” Therefore, healthy ageing is largely commensurate with a quality of life that is related to good health.6 The age related changes that occur with chronological age vary considerably,w6 which suggests that it may be possible to attenuate the functional decline associated with rising chronological age by modifying biological age.6 w7
How might healthier ageing be achieved?
Healthier ageing is really aimed at the compression of morbidity in older age.7 Therefore, the ideal goal should be to maintain physical independence and biological reserve and enjoy psychosocial wellbeing well into older age. Many healthy lifestyle behaviours are positively associated not only with better physical and mental functional health (indicators of biological ageing) but also with longevity, reduced risk of chronic diseases, and more quality adjusted life years.8 9 10 w8-w13 For individuals, the aim of adopting healthy behaviours is to prevent chronic disease and preserve physical and mental function.
Prevention of chronic disease
Although ageing is not the sole cause of chronic disease, older age is strongly associated with many chronic diseases, such as arthritis, cardiovascular disease, and dementia. Because chronic diseases are associated with reduced physical function and poor quality of life, measures aimed at preventing chronic diseases (such as taking regular physical exercise, not smoking, and eating a healthy, balanced diet throughout life) are important basic steps towards healthier ageing.6 Prospective epidemiological studies have shown that positive health behaviours are associated with reduced all cause mortality and cardiovascular disease, higher life expectancy, and greater health and wellbeing in older age.8 9 w1 w14 w15
Table 1⇓ outlines the chronic health conditions common in older adults, the risk factors that have been shown to be associated with them, and lifestyle modifications for which evidence suggests that these conditions can be prevented.
Smoking is an established risk factor for many chronic conditions, including ischaemic heart disease, stroke, chronic obstructive pulmonary disease, and dementia, and avoidance of smoking is associated with a low incidence of these conditions.w16 w17 Smoking cessation has been associated with reduced mortality even after a major event such as a stroke.w18
Ensuring a healthy diet
Because chronic diseases including diabetes, cardiovascular disease, cancer, osteoporosis,w19-w22 and obesity are associated with dietary factors, a balanced diet is advisable (table 2⇓). Although a balanced diet is achievable for most people, surveys of the UK population show that recommendations for food and nutrient consumption are largely not met for fruit and vegetables, oily fish, red and processed meat, sugars, saturated fat, fibre, salt, alcohol, and some vitamins and mineralsw20; only those for percentage total fat and energy intake are met. Therefore, there is still a great need to encourage people to eat a balanced, healthy diet.
The current UK, American, and international dietary recommendations for eating a healthy balanced diet (table 2⇑)11 12 w20 w21 w23-w25 represent current knowledge and consensus opinion. These guidelines can be met by following the “eatwell plate” model of healthy eating13 and by eating different food types in the correct proportions (figure⇓). People who do not eat fish or fish oils should be encouraged to consume rich sources of the plant based n-3 polyunsaturated fatty acid α-linolenic acid (walnuts, flaxseeds, hempseeds, and their oils, plus rapeseed (canola) oil) because the evidence suggests potential benefits in people who do not eat fish.14 w26
Maintaining regular physical activity
A low level of physical activity is associated with higher incidence of chronic diseases and chronic disabling conditions.w13 w27 w28 Exercise seems to modify the gene-environment interactions for intermediate risk factors such as obesity, as having a physically active lifestyle seems to reduce the likelihood of obesity in those with a genetic predisposition to obesity.w29 w30 Physical activity has also been associated with better bone density and greater muscle mass and confers positive effects on mental health and wellbeing.w29
The health departments of each constituent country of the United Kingdom recommend that all adults, including adults aged 65 years or older, should take a minimum of 30 minutes moderate activity at least five times a week or in those who are regularly active at moderate intensity a minimum of 75 minutes of moderate to vigorous intensity activity spread across the week.15 The box outlines suggestions for how older adults might meet these recommended levels of exercise.16
Tips for older adults on how to achieve a physically active lifestyle
The recommended levels of activity can be achieved either by doing all the daily activity in one session or through shorter bouts of 10 minutes or more16
Activity can be activities of everyday life (such as climbing stairs or brisk walking) or participation in more structured exercise or sport16
Taking part in varying types of physical activity is probably best because although most types of physical activity have beneficial effects on health, these health effects differ
Older people (65 years and over) should take particular care to keep moving and retain their mobility
Specific activities that promote improved strength, coordination, and balance are beneficial for older people16
Multiple lifestyle interventions
Comparatively few intervention studies have examined the effects of lifestyle interventions on multiple risk factors; most have looked at outcomes related to the prevention of cardiovascular disease, and only a few were primary prevention studies.17 w31 w32 Nevertheless, owing to the complex interaction between lifestyle behaviours, the ageing process, and age related diseases, intervention-level evidence on healthy ageing is limited.
Ways to stave off frailty and functional decline
Sarcopenia and falls
Sarcopenia is age related loss of muscle mass and strength that is thought to be a fundamental component of frailty18 and is associated with falls among older adults. Lean muscle mass is lost at a rate of about 1% a year after age 50 years, with mechanisms being unclear.19 Suggested mechanisms include the greater rate of breakdown than synthesis of muscle proteins, neurodegenerative processes, reduced production of anabolic and sex hormones, dysregulation of cytokine secretion, and the blunting of the positive effects of exercise in older age.18 w33 Because inadequate nutrition and a sedentary lifestyle have been associated with sarcopenia, a physically active lifestyle and a balanced diet are important in avoiding falls in later life.18 w34
Preventing cognitive decline and mental frailty
Evidence from UK surveys shows that the trajectory for functional mental health (unlike for physical health) improves from a young age to middle and early older age but then starts to decline (in those aged over 75 years).6 20 However, the extent of the decline varies with the individual. Furthermore, the prevalence of dementia increases sharply from about 2% of those aged 65-69 years to about 25% of those older than 85 years in Western populations.w35 Established risk factors for dementia include current smoking, physical inactivity, and chronic medical conditions.w36 Therefore, the recommended lifestyle interventions to prevent dementia include regular physical activity and avoidance of smoking.w37 Physical activity is also effective in preventing and treating depression in older adults.21
Are vitamin supplements needed?
Adopting a diet high in nutrient dense foods and low in fat and sugar is the best way to achieve a healthy intake of vitamins and minerals; supplements are not routinely necessary. However, some population groups, including those not able to eat a full range of foods, may need vitamin supplements. As many as 15% of individuals in the UK are estimated to have low serum concentrations of 25-hydroxyvitamin D and 80% have concentrations considered to be suboptimal.w38 Adequate levels of vitamin D are essential for good bone health, and low serum concentration of 25-hydroxyvitamin D has been associated with osteomalacia and osteoporosis; falls in adults; and more recently with higher rates of other chronic diseases.w39 Vitamin D supplementation is associated with a reduced risk of falls.22 Dietary sources of vitamin D are limited mainly to animal products such as oily fish and to fortified margarines. Although exposure to sunlight is the major source of vitamin D, many adults avoid sun exposure as it has been associated with an increased risk of skin cancer.w38 Recent consensus recommendations from cancer, heart, diabetes, osteoporosis, and dermatological societies recommend about 10 minutes of sun exposure once or twice a day (depending on skin type), without sunscreen and taking care not to burn.23 In the UK effective production of vitamin D from skin occurs between May and September. Vitamin D supplementation may be needed where neither diet nor sunlight exposure is adequate.w20
Which is more important for healthier ageing—physical activity or healthy diet?
Because basal metabolic rate declines with age, even in physically active people,24 maintaining a balance between energy intake and expenditure is important throughout life especially as the potential for physical activity to potentiate weight loss reduces with age. Furthermore, the amount of physical activity to achieve weight loss is considerable without taking into account energy intake. What the ideal range of body mass index is for older adults, is not clear, especially for the oldest old people. Whereas being underweight in older age is known to be associated with poor health outcomes,25 the associations with overweight and obesity in older age are less clear. On the basis of the available evidence, both physical activity and a healthy diet seem to be needed for healthier ageing.
When to start taking steps for achieving healthier ageing
Ageing could be said to begin at the very beginning of life and to accelerate after age 30. Many chronic diseases are asymptomatic in their early stages, and the biological underpinnings of functional decline may begin before older age. Therefore, acting on the principle that it is “never too early to start,” minimising risk factors throughout one’s life is prudent. As shown by large prospective population based studies, adherence to a healthy lifestyle in middle age reduces the risk of mortality and cardiovascular events,8 w15 which suggests that it is also “never too late to start.”
Future research into ageing should ideally focus on establishing causal links between lifestyle factors and the ageing process through well conducted intervention studies and on how an individual can best maintain physiological reserve as he or she ages. Currently, healthier ageing seems achievable, at least in part, by adopting behaviours that have been associated with a reduced risk of developing chronic diseases and with better long term functional ability.
Cite this as: BMJ 2012;344:e1214
Contributors: Both authors contributed equally to writing the paper. PKM is the guarantor.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; externally peer reviewed.