   |  | | Addressing aging at conception | By Mike Magee, MD
Geriatrician Jean-Pierre Michel and colleagues recently said: "Based on current demographic forecasts and age-incidence patterns of major age-related diseases, the prospects of greatly increased prevalence of major age-related frailty and disability can...induce despair." Michel and colleagues added that "...emerging indications, informed by recent scientific advances, suggest that some of the more daunting challenges might be met by a preventive life-course perspective that extends from conception through extreme old age."1
What they are suggesting, echoed in diverse corners -- from the American Association of Retired Persons to my own concepts of multi-generational home-centered health care and lifespan planning records -- is quite revolutionary.2,3,4 It proposes that we no longer need to be hostages of the disease process, reacting late and seeking miracles or being grateful if we are able to hold a disease at bay. Instead proponents believe that, at least for a segment of the population, it may be possible, if one begins to plan and act at conception, to avoid some diseases all together.
Let's take a look at frailty. It is a syndrome of progressive disability brought on by the gradual lifelong accumulation of molecular and cellular damage. Such damage presents itself as "anorexia, weakness, chronic exhaustion, inactivity, and impaired capacity to withstand any kind of stress."1 When one becomes frail, the gait slows, balance is impaired, weight loss is evident, and bones and muscles are fragile. As a result malnutrition, depression, social isolation, and heavy use of medications are familiar companions. Lives of inactivity, boredom and despair are interrupted by episodes of traumatic fractures, wandering confusion, adverse drug interactions, pressure ulcers and infections, and frequent hospital visits.5,6
The number of people who end up this way is pretty scary. In the United States, your current possibility of dying without disability after age 80 is less then 1 in 4, and that includes people who seem to be just fine at age 65. Scale those numbers up worldwide, and the problem becomes truly daunting. Our global population is currently 6.5 billion, headed for 9.1 billion by 2050. The greatest population growth will be seen in the 50 currently least-developed nations, where numbers will double by 2050. As the numbers explode, the citizens will age so that by 2050 at least 25% of the world’s population will be over 60. By then, absent major changes, we will need to manage approximately 5 million hip fractures per year and will be challenged to care for approximately 40 million citizens who are disabled and dependent, with the cognitive disorders of dementia and Alzheimer's.1,7
Is there any way out? Experts say yes, but not with business as usual. They say that "tomorrow's old are already born," and that many of the features associated with age-based frailty are treatable and potentially preventable if we dial back health planning and intervention to conception. Let's look at frailty fractures in the aged due to osteoporosis as an example. Bone mass reaches its peak between ages 16 and 18 with determinants including nutrition, exercise, behaviors like smoking, and genetics all contributing to early outcomes. Miss those early years as a woman and the chances are overwhelming that you will be in the ranks of approximately half of the women at age 50 with silent under-mineralized bones. If so, your chances of a frailty fracture later in life are close to certain. But the seeds for that calamity were laid many, many decades ago.1,8
This reverse timeline for osteoporosis is not the exception in chronic diseases, but rather the rule. The same phenomenon exists for heart attack, stroke, vision and hearing impairment, and cognitive disorders like dementia and Alzheimers.9,10 We have tended to segment health care into periods of life, but are now beginning to wake up to the fact that disease and disability are cumulative, and build over a lifetime. This insight means that we need to focus heavily on the early years, especially with nurturing, nutrition, exercise, healthy behaviors, lowering stress and limiting social isolation. In the case of cardiovascular and neurologic disability, researchers are now looking at the correlations between late disease incidence and early indicators such as birth weight, degree of early nurturing with flesh-to-flesh contact, growth rates, adolescent activity, educational achievement and others.11,12 In many ways, the scourge of childhood obesity, related to our fundamentally unhealthy American diet, and the subsequent appearance of type 2 diabetes in very young Americans, has been a wake-up call.13
This is not to suggest that aging is avoidable or that frailty will disappear as a reality for some as they age.14 It is simply to say that this does not need to be the destination for 3 out of 4 of us over the age of 80. Frailty, as we are learning, is malleable. And, as the experts say, "...it is vital that strategies are urgently developed to attempt to prevent frailty and reduce its effect on health care costs and quality of life ...(recognizing that) early experiences of health and well being may greatly influence the last decades of life."
References:
1. Michel JP, Newton JL, Kirkwood TBL. Medical Challenges of Improving the Quality of a Longer Life. JAMA. February 13, 2008; 299 (6), 688-690.
2. Ad Campaigns Show AARP's Committment to All Generations. AARP.
3. Magee M. Home-Centered Health Care: The Populist Transformation of the American Health Care System. Spencer Books, 2007, NY, NY.
4. Magee M. Health Records of the Future. Health Politics. 2006.
5. Fried LP et al. Frailty in older adults:evidence for a phenotype. J Gerontol Biol Sci Med Sci. 2001, 56 (3): M146-M156.
6. Hubert HB et al. Lifestyle habits and compression of morbidity. J Gerontol Biol Sci Med Sci. 2002; 57(6):M347-M351
7. Robine JM, MichelJP. Looking forward to a general theory on population aging. J Gerontol Biol Sci Med Sci. 2004; 59(6):M590-M596.
8. Rizzoli R, Bonjour JP. Detreminants of peak bone mass and mechanisms of bone loss. Osteoporosis Int. 1999;9(suppl.2)S17-S23.
9. Weir RA, McMurray JJ. Epidemiology of heart failure and left ventricular dysfunction after acute myocardial infarction. Curr Heart Fail Rep.2006;3(4):175-180.
10. Stuck AE et al. Risk factors for functional status decline in community living elderly people:a systematic literature review. Soc Sci Med.1999;48(4):445-469.
11. Ben-Shlomo Y, Kuh D. A life course approach to chronic disease epidemiology:conceptual models, empirical challenges, and interdisciplinary perspectives. Int J Epidemiol. 2002;31(2).285-293.
12. Murray GK et al. Infant developmental milestones and subsequent cognitive function. Ann.Neurol.2007;62(2):128-136.
13. Magee M. Exercise and Childhood Obesity. Health Politics. 2003.
14. National Commission for Quality Long Term Care. From Isolation to Integration. 2007.
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