If healthy ageing is the end point, how do we get there?
By: Julie Byles
Prevention is key to healthy ageing: preventing disease, limiting long-term impairment, and supporting people to live healthier lives for longer. However, translating the acknowledged importance of prevention into sustained action can be challenging. The ILC Global Alliance accepts this challenge and supports the ILC-UK in their mission to reshape the discourse around prevention, and the importance of preventative activities and interventions across the life course.
At the ILC Global Alliance, we see ageing and longevity as the opportunity to live life to its full potential. Longevity is not just about a long life, but it is also about a good life. So, if healthy ageing is the end point, how do we get there?
Health in older age starts with health in younger life
The process of healthy ageing starts even before conception. Healthy mums, healthy dads; healthy ovum, healthy sperm. Health development continues in utero, with maximum growth of the foetus, and minimal cellular and genetic damage. Then throughout life we need to do all we can to build strong bodies and minds, and to minimise damage. Good nutrition, exercise for strength and balance, education, healthy behaviours, limiting risks, management of disease, and support for disability in later years. Wellbeing in older age also depends on the dynamic interaction between the intrinsic capacity of the individual, the influence of physical and social environments, and the availability of supports for those with greater needs. Consequently, people will enter older age already on different paths with different levels of capacity, different threats to their health, and different levels of intrinsic reserve. They will also have different social positions and personal resources, which will further affect how people are able to adapt to change and be supported in their older age.
So when talking about prevention in an ageing world, we are not only talking about preventing disease from occurring. We are also talking about the development of strength and resilience. We are also talking about the management of disease. We are also talking about environments that allow people to be supported, even when their intrinsic capacity is compromised.
Where do we start?
From a health systems perspective, there is a great incentive to prevent disease through improving health behaviours at a population level, and through screening and early intervention. While many disease risks may be viewed as the responsibilities of individuals to change their behaviours, governments also have a responsibility to create health-promoting policy and environments. For instance, through the influence of public health groups and effective government policy, Australia has seen great success in reducing rates of smoking. These effects are dramatically evident in the Australian Longitudinal Study on Women’s Health (ALSWH), where the youngest cohort of women (born 1989-95) are half as likely to smoke as the previous generation (born 1973-78), and they were less likely to smoke than their mothers (born 1946-51). Moreover, even if the young women took up smoking when young, they gave up smoking as they aged through their 20s to their 40s. If this trend continues, from 2015 to 2035, the prevalence of smokers among Australian women aged 20-90 is predicted to decrease from approximately 10 per cent to 3 per cent. The consequence of this decrease in smoking should be a decrease in healthcare costs attributable to smoking, providing other risks don’t take over.
One risk that is rising among younger generations is the risk of overweight and obesity. In Australia, we have seen a massive increase in weight across successive birth cohorts. We all know that we put on weight as we get older, but we are seeing women gain this weight earlier and earlier in the life course. Women born between 1989-95 are twice as likely to be obese than those born between 1973-78 were at the same age, with 13% obese and 32% overweight by their mid-20s. The prevalence of overweight and obesity among these young women is increasing by 1 percentage point each year.
This increase in weight is playing out in the prevalence of disease, with more asthma, more hypertension and heart disease, more diabetes, more cancer, more back pain, more arthritis, more foot problems, more incontinence. If you gain weight earlier, and you are overweight for longer, the risk of developing multiple diseases increases.
While the prevention of overweight and obesity may be simplified to a message of “eat better, and exercise more”, this message also requires reflection on the barriers to these healthy behaviours, and consideration of how weight fits in relation to women’s overall physical and mental health and within the context of their lives. In ALSWH, we have found weight gain to be associated with adverse childhood events, having less education, having no paid job, and with working full time, with lower perceived social class, stress, being depressed, violent relationships, having children, and going through menopause, as well as inactivity and sitting, and not following the national dietary guidelines including adequate fruit and vegetables and good variety. Just telling people to exercise and eat better ignores the complexity of the factors that promote obesity, and is not likely to be effective across the population. We also need to pay attention to the social circumstances, and to the broader social, physical and economic environment.
Prevention is not just about preventing disease
Absence of disease is a major criterion for successful ageing, and this would be a public health ideal. But it is practically unachievable at a population level. Even when we know the risk factors for disease, and with the best and most effective primary prevention to eliminate these risk factors, people will still get cancer, people will still get diabetes, people will still develop hypertension, people will still have stroke, people will still develop dementia. We need to also have secondary prevention to improve early detection and treatment, and we need to also have tertiary prevention to improve outcomes for people who have multiple diseases in later life. These approaches to prevention can include vaccinations including those in earlier adult life, such as those to prevent cervical cancer, or in later life such as influenza, pneumococcal and herpes zoster vaccinations. Prevention can include screening for cancers, detection and treatment of hypertension, and management of other risk factors such as lipid profiles. Prevention can also include management of chronic conditions such as diabetes, where the maintenance of glucose control can greatly modify the risk of damage to kidneys, eyes, and blood vessels. There is often a long window of opportunity to manage chronic conditions and to reduce their progression and their effects on body systems and intrinsic capacities. However, this is often a lost window of opportunity, with delays in diagnosis, delays in treatment, poor monitoring, and treatment inertia. Better health care systems can focus on improving access to screening, and on minimising delays in diagnosis and treatment in anticipation of better health outcomes and reduced need for health care in later life.
Extending prevention through later life
There is great potential for even very old people to maintain their capacities, to regain strengths and abilities, and to prevent future loss and decline. Even when people’s intrinsic capacities are greatly diminished and compromised, there is much that can be done to support their wellbeing, and to achieve the World Health Organization’s goal of healthy ageing … being maintenance of older people’s ability to be and do the things they have reason to value. Viewed in this way, social care may be seen as the long tail of prevention, with prevention extending from first cell, to last breath.
Keys to a life course approach to prevention
The key to prevention is equity. A healthy start to life begins with everyone having good access to nutrition, immunisation, education, healthcare, and safe housing.
The key to prevention is being proactive. With active policies to create health-promoting environments that enable people to engage in healthy behaviours, to access good healthcare, and to manage their conditions well.
The key to prevention is being responsive: making positive changes to deal with each health challenge, to mitigate the effects, and to prevent progression and complications.
The key to prevention is resilience: helping people to build the resources to be strong in the face of adversity.
The key to prevention is reablement: helping people to regain abilities to do the things they choose to do even when they have lost some intrinsic capacity; and preventing the next loss of ability.
The key to prevention is care: Supporting people to have quality of life, independence and autonomy right to the very last stages of life.
As ILC Global Alliance ambassador, Baroness Sally Greengross, says:
“If we don’t get prevention right, ageing stops being a triumph, and becomes a problem”
Prof Julie Byles
Head of International Longevity Centre - Australia
Professor Julie Byles BMed PhD FAAHMS, is Global Innovations Chair in Responsive Transitions in Health and Ageing, Director of the Research Centre for Generational Health and Ageing, and a Director of the Australian Longitudinal Study on Women’s Health (www.alswh.org.au). As a Fellow and Life Member of the Australian Association of Gerontology, Professor Byles’ research interests in ageing include the role of health services, preventive activities, and treatments in maintaining quality of life for older people. Professor Byles is also Head of the International Longevity Centre – Australia, and Chair of the International Association of Gerontology (Asia Oceania) Social Research and Planning sub-committee.
Professor Byles full profile: https://www.newcastle.edu.au/profile/julie-byles