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BARELY a week passes without the publication of a think piece about our rapidly ageing population and what we should be doing about it. The problems are real and the concern is legitimate, but we rarely talk about one of the key drivers, which is the good news story of our astonishing success at keeping middle-aged people alive over the past few decades.
A Research Letter published in the MJA lays out our achievements in this area, looking at mortality among middle-aged Australians from 1960 to 2010. The difference in life expectancy between those two years is stark. In 1960, just 54% of men and 72% of women survived to the age of 70 years; five decades later, the respective figures were 82% and 89%.
This huge increase in survival is mostly down to vastly fewer people dying prematurely of heart disease and, to a lesser extent, to a reduction in cancer-related deaths among the middle-aged. In 1960, 29% of men and 16% of women died of cardiovascular disease before the age of 70 years, compared with just 5% of men and 2% of women in 2010. That represents an 85% decline in men and an 88% decline in women dying prematurely due to heart disease.
“It’s what one expert has called a ‘poorly understood triumph’,” says Professor Emily Banks, who is Scientific Director of the Sax Institute’s 45 and Up Study, the largest ongoing study into healthy ageing in the southern hemisphere. “The improvement in cardiovascular disease is medicine’s single biggest advance of the past 50 years, and it’s driven this extraordinary drop in mortality rates. And there are very few countries doing better than Australia.”
She says that the decline in mortality among the middle-aged is mostly due to a number of incremental advances over time, rather than any specific breakthrough.
“We like to think in terms of silver bullets and we think of science as a series of breakthroughs, but actually it’s largely about incremental change. The problem is that it’s very hard to create a compelling narrative out of what Atul Gawande calls ‘the heroism of incremental care’.”
Those incremental changes that have taken place over the half century include a focus on areas such as tobacco control, high blood pressure, high cholesterol and diabetes.
“We’ve found targeting these things has been beneficial in middle-aged people, and they’re just as likely to be beneficial in older people too. With smoking cessation, for example, we’ve found the absolute benefit is just as strong, if not stronger, in older people.”
Of course, this astounding success in slashing middle-aged mortality rates has a huge demographic impact, driving up the proportion of older people in the population. Old age brings its own problems. Rates of chronic disease are much higher in this population and the focus is increasingly switching to keeping older people well and fit for as long as possible.
“The big issues for older people are problems with mobility and cognitive impairment. They are the two things that get in the way of leading a full life,” says Robert Cumming, Professor of Epidemiology and Geriatric Medicine at the University of Sydney.
“There’s been a lot of research over many years on falls prevention, and I think in Australia we punch well above our weight in this area. It’s been clearly shown that exercise programs with an emphasis on balance, such as tai chi, can prevent a lot of falls. But another big cause of mobility problems is osteoarthritis, and in my opinion we’re really not doing enough research on this. It’s a bit of a forgotten area.”
But the major focus of research in geriatric medicine over the past couple of decades has been dementia, and there the results are mixed. Big Pharma has poured billions into targeted drug treatments for this disease, which have all proven unsuccessful. On the other hand, some advances are being made around prevention.
“I don’t feel optimistic at all that we’re about to have a treatment for dementia,” Professor Cumming says. “But in terms of prevention, there’s good evidence that high blood pressure in midlife is associated with dementia. So the better we can control hypertension in people in their 40s and 50s, the less dementia we’ll have. Exercise, too, has been shown to be good for your brain. The one single thing older people should be doing is keep active.”
He says there is some indication from studies in Denmark and the UK that the age-specific rate of dementia may be in decline.
“The average risk of developing dementia for an 85-year-old does seem to be dropping a bit. As there are many more 85-year-olds than in previous decades, the absolute numbers are still going up, but maybe not as fast.”
Professor Banks points to an ongoing trial in Australia aimed at targeting risk factors for dementia. The Maintain Your Brain trial is randomly allocating over 8000 people from the 45 and Up cohort to either usual care or to an intensive regimen targeting factors such as physical inactivity, cognitive inactivity, depression, anxiety, obesity and overweight.
She says that the trial will offer a clearer picture of what factors to target in middle and older age and how they affect risk of dementia.
Professor Cumming says that in the absence of any treatment for the disease, the aim is to delay dementia to the point that most people die before they get it.
“If we can push average [age] at onset back to 90 years, for example, or even 100 years, then that would make an enormous difference.”
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Absolutely agree Geoff Mitchell, the research findings call for prevention of various chronic diseases, aged at 57 myself, I’m not arguing against that! However, along with prevention and control is the vital importance of raising the quality of end-of-life care. We need health institutions and professionals who are prepared for the rising numbers of Australians who die each year in hospitals, aged care facilities and homes. We will all die.
Philip – I wouldn’t wait for the trial to be done. There’s enough anecdotal evidence out there. I have numerous bowel cancer patients who have done this and they’re all off their medication. It’s something everyone should be doing long-term irrespective of weight or diabetes status. Anybody who is eating the standard western fair ie way too much refined carbs and way too often will have a degree of IR. Some clinicians are using LCHF but in my view this is more complicated than straight IF and eating Med-type cuisine which as you say requires no special diet. It’s not a diet – it’s a lifestyle change and really not that hard at all.
Feel free to look at nysteia.com which I have put together and urge your patients to do the same.
Reversing Insulin Resistance doesn’t seem all that hard and no special diet seems to be required. My most spectacular example is a 140kg type 2 diabetic on maximal insulin and oral therapy still way out of control. He got scared enough to do something about it. Over a year and a half he went down to 80kg and came off all antidiabetic medications, HBA1c in the normal range. he said “I’ve discovered the secret to weight loss, doc-eat less”. I have several patients who have done this and all should now probably be classified as “diabetes in remission”. I am sure if they put the weight back on their HbA1c will rise again. I would be interested in a study of true type 2 diabetics who lose weight down to the middle of the normal range, to see how many still require medication for their diabetes. Anyone know if it has been done?
This poorly understood triumph of medicine is truly spectacular, and we should be very proud of this. However, what we are starting to see is that prevention and control of major causes of death actually defers the inevitable. What is left to die of is multi morbidity, frailty, and dementia.
The total numbers in Australia who will die each year is heading to an increase of 250% in the next 50 years or so. Most of these will suffer years of disability struggling to manage to live normally. It is impossible to overstate the cost of adequate care for these people.
While we seek to continue the triumph, it is imperative that we investigate how to provide care that ensures that those saved from early death and disability, get the same level of funding and attention and skill in their last days as that afforded to obvious and spectacular conditions.
The underlying problem with excess lipodeposition (call it obesity if you like but this is merely an artificial construct defined by a BMI above 30) is the development of insulin resistance (IR) and the latter is due to the pancreas being forced to produce too much insulin. Insulin is produced everytime carbohydrate is ingested and IR determines whether it enters the cells or gets converted to triglycerides and stored as adipose tissue. That’s exactly what the human body has evolved to do. To get rid of IR and regain insulin sensitivity you simply reverse this process. Any weight loss method – be that a calorie restricted diet, small meals, surgery or exercise alone – will fail in the long-term unless IR is addressed (and this is supported not only by the scientific evidence but also the experience of millions who have tried them and failed). From a practical perspective there is only one way to achieve this – intermittent fasting and eliminating refined carbohydrate. Insulin levels are zero for most of the day. The latter is not another fad diet – it is a life-style change based on human evolution. Cardiovascular exercise is extremely important for optimal health but you will not exercise the weight off because it does not address IR. Best exemplified by the Biggest Loser
No evidence yet for declining LE for Australians aged less than age 93-94 (ABS data). Reduction in mortality rates of middle-aged persons has slowed but not reversed with respect all-cause, cardiovascular or diabetes. Overweight or obese persons can greatly reduce health risks with moderate exercise= ‘fat and fit’ ( American Diabetic Association). The causes of obesity, and its management are much more complex than nutrition alone. Meanwhile the many hundreds of thousands of surviving Australians stand as a grateful tribute to recent advances in understanding, and reducing risk factors and in treatment of acute and established cardiovascular conditions.
All of these incremental advances in healthcare are very laudable. But this good work, and the billions spent, is about to be spectacularly reversed by the ill-health associated with obesity. Already we are starting to see a decline in life expectancy in western societies. So patting ourselves on the back might be a tad premature. And until doctors, and any health professional involved in nutrition, understands the cause of obesity this reversal will continue.