Extra Time: 10 Lessons for an Ageing Society - How to Live Longer and Live Better

Do the cyclists keep going because they are unusually healthy, or are they healthy because they cycle? Lazarus believes it’s the latter. What we see in the cyclists, he insists, ‘is true biological ageing, free from the problems caused by inactivity’.

If you wanted to see what true biological ageing might look like, you could charter a boat. In Ikaria, a beautiful Greek island off the west coast of Turkey, one in three inhabitants live into their nineties and dementia is rare. Ikarian men don’t get cancer or heart disease very often, and when they do, it develops eight to ten years later than in Americans. Ikarians also report considerably less depression.

Their life is very much an outdoor one – it’s said to be hard to get through a day in Ikaria without walking up 20 hills – and that might just have something to do with it.

Ikaria is one of the Blue Zones (see here (#ulink_7508f133-520a-58f0-a6f1-388cddfc6d75)), where people live exceptionally long lives in good health. There doesn’t seem to be any genetic singularity; the secret is lifestyle. There has been much talk about the plant-based diets eaten in Blue Zones and far less focus on exercise. But whether in Sardinia, Okinawa or the other Blue Zones, it’s clear that these hearty, long-lived people lead very active outdoor lives.

This is not ‘exercise’ in a gym, pumping iron to music videos. It’s movement built into daily life, to do tasks that the rest of us have replaced with cars, robot-vacuum cleaners and other devices. We have saved ourselves hours by not fetching water, chopping wood or tending our vegetables. But has it lost us our agility? Activity maintains muscle mass, reduces stress by connecting our primitive brain to its old hunter-gathering functions and improves immunity by triggering a cascade of chemical signals in the body. Whenever we take the lift rather than the stairs, or drive rather than walk, we may be losing more than we realise.

Until now I’ve thought of endurance athletes as freakish, as having either a genetic predisposition or a crazy obsession to compete. But now I wonder. Stunning results have been seen in an otherwise normal group of American septuagenarians who started running when it became fashionable during the 1970s, and stayed hooked. Over the next 50 years some went on jogging, others took up cycling or swimming or working out, but they did it regularly – and as a hobby, not to compete.

To the amazement of the researchers, the muscle strength of these seventy-somethings was almost indistinguishable from 25-year-olds, with as many capillaries and enzymes. Their aerobic capacity was 40 per cent higher than people of their age who were not regular exercisers. The researchers at Ball State University, Indiana, concluded this made both the men and the women biologically 30 years younger than their chronological age.

It’s impossible to overstate the importance of this finding: it suggests there is hope for us all.

Younger Next Year?

In terms of fitness, human beings keep pushing the boundaries of what is thought possible. The ‘Masters’ sporting events are a kind of amateur Olympics for those aged between 35 and 100. These regularly generate headlines about extraordinary feats – like in 2016, when Japanese athlete Hiroo Tanaka ran the 100 metres in 15.19 seconds. Tanaka’s time was nowhere near the Jamaican Usain Bolt’s world record-setting run of 9.58 seconds in the final of the 2009 World Athletics Championships in Berlin. But Bolt was 23, Tanaka was 85.

Masters athletes don’t just sustain performance to advanced ages, they have also been improving constantly over time. Their athletic performance has improved ‘significantly and progressively’ in the past 40 years. And the greatest magnitude of improvements has been made by the oldest swimmers and runners, who are over 75.

This suggests that we may be only in the foothills of understanding the ‘Young-Old’. One of the Holy Grails for serious sportspeople – the maximal rate of oxygen consumption or VO2 max – declines at half the rate in Masters athletes as it does in their sedentary peers.

One explanation is that regular aerobic exercise brings more oxygen to the muscles. The more we do, the more our heart and circulation respond, to get oxygen round the body.

Intensive working out doesn’t massively extend life. Olympians gain only 3 extra years over normal folk on average, according to a century of Games records.

But they do gain a significant health advantage. This is greatest for cyclists and rowers, apparently; but even playing lower-intensity sports like golf can be positive. Commenting on the research, Professors Adrian Bauman of Sydney University and Steven Blair of South Carolina University stressed we don’t all have to be Olympic athletes to reap the benefits of exercise and win a ‘personal gold medal’. They urged governments to do far more to improve physical activity.

We don’t all have to run marathons. Above a certain level of athleticism, you can’t advance your health, only your performance. ‘Think back over 40,000 years of evolution,’ says Norman Lazarus. ‘We had to be fit to hunt. But you wouldn’t chase an animal for 15 miles – that wouldn’t be worth it, just to get, say, a pound of steak. You’d stop after a mile and keep tracking.’

That’s a relief. I don’t enjoy running – I can only sustain it with friends, shuffling through corny hits on my headphones. But Lazarus does make me wonder how many of us modern office workers would have the stamina to track our prey for miles, if we were suddenly transported to a desert plain. Nervously, I ask whether he thinks I am doing enough. I do British Military Fitness twice a week in my local park, cycle to meetings if I can and play a slow game of tennis once a week. I don’t mention that I achieve this only on good weeks. ‘Perfect,’ he beams, as if I have made it into a club. ‘Do what you enjoy.’ He pauses. ‘But’ – he fixes me with a glare – ‘your goals do need to be sufficiently ambitious.’

Ambition is frankly what most of us lack. When I started researching this book, I thought I was pretty fit. Now, I realise with horror that I’ve slumped into a rather comfy regime. My tennis game is doubles, not singles, and includes gossip and cappuccino. I’ve dropped into the slow group at Military Fitness. I don’t work up a sweat as often as I used to. And what many experts seem to believe, though few dare to put it so crudely, is that sweat is the measure which really matters.

Ambitious is also what our health systems are not. Older people are so often told: ‘don’t overdo it’. Yet from the age of 50, muscle and bone mass start to decline by around 2 per cent a year.

We should be doubling down on strength training and aerobic fitness from that age. Instead, we spend an awful lot of time sitting down: something we are now told is as dangerous as smoking.

Don’t Just Sit There – Do Something

The idea that sitting is as dangerous as smoking sounds absurd, but evidence from all over the world, from Norway to Canada, suggests a lack of low-level physical activity is cumulatively crippling. It puts us at much greater risk of getting the same nasty diseases which exercise can help to prevent.

That doesn’t mean it’s your fault if you get cancer: I abhor the invidious trend which implies that people who fall sick didn’t do enough sit-ups or eat enough broccoli. But so compelling is the evidence, I predict that in 20 years’ time it will seem as foolish not to exercise every day as it does now to keep smoking.

We’ve known that sedentary occupations were dangerous since 1953, when J. N. Norris and colleagues reported in The Lancet that London bus drivers were more likely to suffer heart disease than London bus conductors.

This was a brilliantly elegant piece of research. The two groups of staff worked the same hours, breathed the same air and hailed from similar backgrounds. The main difference was that the drivers were sitting down all day, the conductors were moving around taking tickets and chatting to people. Without knowing it, the conductors had chosen a far healthier job.

Sitting down for more than an hour at a time sharply decreases the enzyme LPL, which burns body fat and produces good cholesterol.

It can also weaken leg and hip muscles, which makes older people more likely to fall. A weekend workout will not erase the effect of prolonged hours sitting in our cars, at our desks or at a screen. In the US and UK, only a quarter of us are apparently moving around enough during the working day, and in Australia, only a third. Older adults have the lowest levels of physical activity, with only 7 per cent of Brits achieving the recommended minimum of five times a week.

It’s not easy to improve, especially if you earn your living driving a truck or typing. Fitbits may help: people who take 10,000 steps a day apparently have lower blood pressure, more stable glucose levels and better moods than those who don’t.

There’s no special magic to the 10,000 target – it apparently derives from the first pedometers sold by a Japanese company in the 1960s, which were called manpo-kei, or ‘10,000-step meter’. Some people think 15,000 steps better resemble the daily distances covered by the average Ikarian or Okinawan, but the point is to keep trying, every day.

Could What We Think of as ‘Ageing’ Actually Be Lack of Fitness?

‘We have a muddled concept of ageing,’ says Sir Muir Gray, Clinical Advisor to Public Health England, former Chief of Knowledge for the NHS, and author of the wonderfully named book Sod 70! ‘Society perceives disease, loss of fitness, dependency, dementia and frailty as inevitable,’ he says. ‘But they are not.’

With a shock of white hair at 73, and a wiry energy, Gray clearly has no intention of slowing down. He arrives sporting a pair of black Nike trainers and announces in his rasping Scottish brogue that he has walked to our meeting – I dare not ask how far since it may put me to shame. Gray is passionately convinced that we confuse the effects of true ageing with what is mainly a loss of fitness, caused by far too little activity. ‘People with long-term conditions and those who experience pain,’ he says, ‘often mistakenly believe that exercise will make things worse, rather than understanding that the more conditions you have, the more you need to improve the four aspects of fitness: strength, stamina, suppleness and skill.’ Some doctors prescribe exercise – for osteoarthritis, for example – but not for many other conditions.

Gray believes we could save billions if we made it normal to expect people of all ages to be active. ‘Almost every week, there are headlines about the rising cost of health and social care,’ he explains. ‘The blame is usually placed on the rising numbers of older people, as if the requirement for social care was an unavoidable consequence of ageing. But exercise can reduce the need for social care.’ In 2017, he and colleagues calculated that the UK could save several billions a year from ‘even modest improvements in fitness’ to stop older people crossing the line from independence to dependence: needing carers or going into a home.

Unless we are rigorous about keeping active, natural decline will be accelerated by unnatural stiffness, extra loss of muscle tone and immunity, and hardening of the arteries. Gray calls this the ‘fitness gap’, which opens up between how able we are and how able we could be. This starts, imperceptibly, in our thirties. By our sixties, we may find we cannot do the basic things we want to do: run for a bus or climb the stairs, for example. If we don’t heed the warnings, we may end up crossing the line into dependency.

The fitness gap can be narrowed, Gray argues, from any age. Even 90-year-olds can improve their strength with relatively small amounts of exercise.

Three months of balance and gait training, and mild weight-bearing exercises, can reduce falls – which are responsible for five times as many hospitalisations among the over-65s as any other injury. They can make the difference between whether someone remains independent, or crosses the line into dependency on others.

In the UK, 10 per cent of ambulances are called out for older people who have fallen over.

Half of those who fracture a hip subsequently become reliant on others. Yet physical activity can halve the risk of falls.

It also strengthens muscle and bone density, making fractures less likely.

From a cost–benefit point of view, let alone a humanitarian standpoint, we should be investing in such programmes in every community.

A little bit of imagination would go a long way here. One company, MIRA Rehab, is using gaming software to improve balance in people aged 3 to 102. In one game, you play a piano by sitting down or standing up: each movement sounds a different key. One stroke victim was so keen to play the whole tune, says MIRA’s founder Cosmin Mihaiu, that he managed to sit down and stand up more times than his therapist had imagined possible. A trial has found statistically significant improvements in balance and pain among people who played the games 3 times a week for 12 weeks.

Yet many 90-year-olds who want to exercise come up against the prevailing attitude that exercise is for young people and that older people should relax. We give people pills to stave off pain rather than prescribe exercise which might resolve it. In England, everyone over 60 gets prescription medicines for free. Ontario, Canada, has just followed suit by eliminating the cost of prescription drugs for many senior citizens.

But gym memberships aren’t free, nor is physiotherapy. Instead of encouraging people to take responsibility for their own health, helping them to understand their bodies and strengthen their muscles, we are making it easiest to pop a pill. That sends the wrong message.

If we were serious about keeping people from crossing the line to dependency, we would put huge effort not only into preventing falls, but also delaying the onset of dementia. Much of the focus has been on finding a cure, which as yet shows no signs of success. But if we could delay onset in individuals by only five years, we would reduce the number of cases by a third. That’s because dementia is a disease which usually hits late in life.

The 2,500 Welshmen Who Showed How to Stave Off Dementia

In 1979, an eager young scientist called Peter Elwood trudged up and down the streets of Caerphilly, a valley town in South Wales, knocking on doors. He and his team asked every man between the ages of 45 and 59 if they would let themselves be poked, prodded and interviewed by medics every five years to track their health.

They must have been very persuasive because they got 90 per cent of the candidates – 2,500 Welshmen – to agree.

Caerphilly is set in stunning countryside and is home to one of the greatest medieval castles in Europe, but it’s not a rich area. Elwood picked it, unromantically, because there was a high incidence of heart disease.

Elwood had been a part of the team which proved that aspirin could protect against heart disease and he was hoping to find a test which would show who would benefit from aspirin most. He failed to do that, but over the next 35 years of the study he discovered something with even greater ramifications.

When I first read about the Caerphilly Cohort Study, it blew me away. I couldn’t believe that I’d never heard of it before. For it suggests that making simple lifestyle changes can dramatically lower the risk of cancer, diabetes, heart attack, stroke and even dementia.