The Miracle Pill

by Peter Walker

  This, as much as anything, is the choice we make by confining children to brief, supervised trips to playgrounds, or otherwise cocooning them inside vehicles, and quietening them at school desks. Such things become habituated into adulthood. This is not to blame parents, or teachers. As with every discussion of everyday activity, the one about the increasingly passive, inert, regularised nature of modern childhoods cannot be seen outside the physical and educational environment in which they take place. But when it comes to future health, or even the chance to appreciate the everyday bliss of regular exertion, our children are being badly let down.

  Ageing as a project

  One of the overriding themes of this book has been the idea that for physical activity to truly stick in the mass of people’s lives, it has to be integrated, or incidental, to use the public health term – part of someone’s daily routine, not a hard-to-schedule leisure activity. And yet, as research for this chapter, I find myself in a local gym, being led through an introductory session of stretches, squats and assorted weightlifting. What’s going on?

  This is the moment where I introduce the one slight exception to the part-of-everyday-life mantra: staying active in older age. Of course, there are people in their sixties, seventies or older who acquire their daily dose of movement as they go about their business, for example cycling and walking around, or gardening. But for many people, this simply does not happen, not least because regular active travel is often tied to a commute. However, one advantage enjoyed by many older people is more time. That is why many experts on activity and ageing advise people to, in effect, see healthy ageing as a project – not a job, but certainly important enough to set aside time for every week. When people retire, they need to construct a new schedule for their days based around something other than the workplace. As part of this, the guidance goes, why not include some formal exercise?

  This advice is not, however, getting across. If mass inactivity in children heralds a looming health crisis for the future, among the ever-growing population of older people worldwide this emergency has well and truly arrived. The UK has some of the most thorough age-based statistics for inactivity, and they make for alarming reading. Across all ages, 62 per cent of adults meet the minimum activity recommendations, and as you might expect, is it higher in young people, reaching 72 per cent for the under-35s. But the decline with age is steep. For people in their mid-fifties, 57 per cent are sufficiently active, and by sixty-five this falls to 55 per cent. Among those seventy-five plus, fewer than a third manage the minimum, and over half are totally inactive.31 It is a similar pattern for sedentariness, with official estimates saying those aged sixty-five and over spend an average of ten hours sitting down each day.32

  There is an extent to which your reaction might be: well, so what? Older people do become more infirm, and have less energy. Many people, if they think of a grandparent, will conjure up a mental image of someone sitting in an overstuffed armchair with a cup of tea. If someone is retired, don’t they deserve a bit of a rest?

  It’s not that simple. In modern terms, sixty-five is now simply not that old. UK life expectancy from birth is over eighty,33 and there are around 600,000 people aged ninety or older, a population which grows every year.34 But as we saw in Chapter 4, the gap between life expectancy and the age when the average person suffers some sort of impairment is now almost twenty-one years for women, and over sixteen years for men.35 Medical advances are helping to extend life expectancy across the globe, but these extra years come at a cost. Some studies have suggested that, for the average person in a country like the UK or US, 40 per cent of any additional time gained will simply be spent in a care home.36 This is not something countries can afford. But just as importantly, it’s really not something anyone as an individual wants to go through.

  This crisis is approaching on two fronts. People are becoming immobile and sedentary at increasingly younger ages, meaning they are ever more likely to arrive in their sixties or seventies already struggling with one or more of the conditions linked to inactivity, most notably type 2 diabetes or poor cardiovascular function. But also, as people get older they tend to move even less, exacerbating existing conditions.

  Part of this is down to a lack of aerobic exertion. Activity guidelines for older people are the same as for other adults – at a minimum, they should aim for 150 minutes of moderate activity a week, or half that amount if it is vigorous.37 But as people age the other, often-neglected aspect of the activity guidelines becomes increasingly vital – muscle strengthening. The gradual wastage of muscle mass as someone gets older, known as sarcopenia, can significantly affect their ability to live independently. Older people can lose up to 40 per cent of their muscle mass.38 However, this is by no means inevitable, and is likely to be a consequence of long-term lack of use as much as advancing years. In fact, so strong are similarities between the changes associated with inactivity and those seen with ageing, notably muscle wastage, that some researchers have theorised that to an extent we are mistaking the former for the latter, and that much age-related decline is simply down to long-term bodily underuse.

  Numerous studies have shown that weight-based training can improve not just strength, but also balance, making falls less likely. It can also help slow down reductions in bone density, another key factor for a thriving older age. It has additionally been shown to help with arthritis, the often crippling condition of joint pain and inflammation, which affects around one in five Britons from middle age and onwards.39 Thus, more or less every activity advice for older people now generally recommends some sort of strength training at least twice a week, with the US guidelines in particular saying these should ‘involve all major muscle groups’.40 Along with this is advice to work on balance and flexibility. The official NHS guidelines list examples of strength exercises as carrying heavy shopping bags, or vigorous gardening chores such as digging.41

  However, not everyone lives within walking distance of the shops, or has a garden. This is where strength-based formal exercise can come in. It can involve something as simple as press-ups and sit-ups, or activities which combine strength and flexibility, for example yoga and Pilates. Another option is to go to a gym. For all that these can remain intimidating places, an increasing number have tried to become more welcoming for older people, and have staff and equipment which make resistance training very different from the stereotype of sweaty, bulky men clanging iron weights.

  And so it was I found myself in my local gym. I am still some way off both retirement and the full onset of potential muscle wastage, but I put myself forward as a sort of underaged guinea pig, asking the local gym if they could imagine I was a sixty-plus customer and demonstrate to me the sort of regime I would be put through. In the basement of a local library, the gym is run by a non-profit social enterprise called Better, who operate a series of leisure centres across London. They have a particular specialism in what they call active ageing, and organise an annual ‘Over-55s Olympics’, in which various gyms in the chain compete against each other.

  Alistair Imbeah, the hugely enthusiastic and reassuring instructor who takes me for my example session, tells me he works with a lot of older gym-goers, both individually and in classes. My most abiding impression is that if, as he claims, mine is the sort of routine most sixty-pluses would expect, his customers must be a pretty fit bunch. Imbeah leads me through an initial callisthenics-based workout of planks and squats which leaves even my cycling-trained legs feeling it by the end.

  But the most eye-opening part is when we move onto the weights. The room does have the usual array of resistance machines and shiny metal barbells racked in ascending size. But he uses softer, much less intimidating weights, mainly soft and padded, which wouldn’t hurt too much if you dropped them on your foot. These include weighted pouches without handles, which are designed to also help improve hand grip, another area which often deteriorates with age. It’s challenging, and I ache a bit the next day, but no one could realistically call it
intimidating.

  Never too late

  For all that some people do embrace gym-going or other forms of activity and exercise in later life, there are plenty who quietly conclude that after decades of immobility, there might not be much point. This could not be more wrong. There is, seemingly, never an age point at which regular exertion does not bring benefits. Countless studies have shown that, even among notably old-age test subjects, programmes of aerobic or resistance activities, or both, coupled with balance and flexibility work, can not just slow the gradual decline caused by the advancing years but reverse it, making continued independent living all the more likely.

  At the more unusual end of this, some people take up activity in middle age or beyond, and suddenly find they are actually very good at it. As we saw in Chapter 3, Ralph Paffenbarger only started running well into his forties, but before too long was completing marathons in under three hours. Perhaps my favourite example of a late-starter is John Keston, a relatively little-known English actor and singer who settled in the US after appearing on Broadway with the Royal Shakespeare Company. While he never achieved much fame on the stage, he did make something of a name for his extraordinary late-life athletic achievements. In his mid-fifties, and with no sporting experience to speak of, Keston decided to try a couple of fun runs to combat high blood pressure. He turned out to be not only an excellent runner, but one seemingly undaunted by age. At seventy he missed out by less than a minute on becoming the first-ever runner from that age group to beat three hours in a marathon, and set dozens of veterans records.42 Last heard of, three years ago, aged ninety-two, he was still running four times a week, covering several miles at a time.43

  The good news is that you don’t have to be running marathons, let alone in under or close to three hours, to feel the health benefits of latter-age activity. It’s worth remembering that in terms of exertion, moderate and vigorous are relative terms, and as you age the amount needed to push your body into the magic zone beyond three METs necessarily becomes less. As we saw in Chapter 2 with the health gains acquired by the American over-seventies from even a few thousand fairly sedate daily steps, there is emerging evidence that in older age relatively tiny amounts of movement can do a lot of good.

  And this is not just about physical welfare. It is also true for what many activity experts consider perhaps the most exciting and fast-moving area of activity research: the mounting evidence that regular movement can ward off Alzheimer’s and other forms of dementia, as well as giving an overall boost to cognitive function. Some studies have even shown that it can reverse the shrinking of the brain that otherwise happens as we age.

  Kirk Erickson, a professor of psychology at the University of Pittsburgh and one of the world’s foremost experts in how activity can help the ageing brain, tells me: ‘We think that starting earlier in life is probably better, as is the way for most things. But that doesn’t mean it’s ever too late to start. And that’s an important message. Some people that come into my studies say, “Well, I’ve never exercised in my life, it’s probably too late for me.” And I like to tell them that it’s never too late. It’s a shame that sometimes people start thinking that they’re on an inevitable trajectory, and there’s nothing they can do.’44

  One thing that is abundantly clear from dozens of studies is that the more active and fit someone is in older age, the better their chances of living even longer. We have already seen that activity has been shown to seemingly slow the ageing process by limiting the shortening of telomeres, the end-caps for our chromosomes. The study we saw before estimated the benefit at around nine years. Others have gone higher – one UK research paper said the most inactive of a group who had their telomere length measured ‘may be biologically older by ten years compared with more active subjects’.45

  One US study that examined the fitness of more than 4,000 sixty-pluses found, a dozen years later, that those in the upper 40 per cent of tested fitness were around half as likely to have died as those in the bottom 20 per cent.46 An even longer-term study, over twenty-one years, found that 15 per cent of older members from a California running club died over that period, against 34 per cent of same-age non-runners. Even more strikingly, when age-related disability was measured, while it took the non-runners just 2.6 years on average to start finding some everyday tasks difficult, for the runners it was 8.7 years.47 It’s worth remembering that this is about lifelong fitness, not just a previous history of activity – exertion must be maintained and regular for its benefits to be felt.

  A decline in independent living can take many forms, and can be mental as well as physical. One UK study which tried to project the future scope of so-called multi-morbidity – the prevalence of a series of chronic conditions in one person – found that in 2015, more than half of Britons aged sixty-five and over had two or more conditions from a list including arthritis and high blood pressure – the two most common – as well as diabetes, cancer and dementia. By 2025 this proportion was expected to increase to almost two thirds.48

  Another crucial factor is bone strength, particularly for women, whose bone density diminishes after the menopause. Osteoporosis, the chronic condition caused by low bone density, is one of the major causes of impairment, and often death, in older people, causing an estimated 9 million fractures a year worldwide. Osteoporosis groups say the condition affects 10 per cent of women in their sixties, 20 per cent of those in their seventies, and 40 per cent of those in their eighties.49

  But while, as we saw earlier, a considerable proportion of bone density is laid down in youth, it is once again never too late to start. Numerous studies have shown that activity can halt or even reverse the age-related decay of bones, and make fractures less likely. Part of the picture is also preventing falls in the first place, which is a function also of strength and balance, hence the importance of muscular training.

  Professor David Buchner from the University of Illinois is one of the world’s best-known experts on inactivity science. He spent nine years in charge of physical activity for the US Centers for Disease Control and Prevention, and chaired the group that wrote the American government’s first official guidelines on the subject. Much of his recent work has been connected to how strength-based activity and balance exercises can prevent falls in older people.

  ‘It is amazing,’ he says. ‘I mean, an older adult can reduce the risk of a fracture by 40 per cent by doing these balance exercises and lumbar strength training. We’re not talking training Olympic athletes here, we’re talking about fairly modest, moderate amounts of physical activity on a regular basis. And it has that level of effect on older adults.’50

  Scores out of ten

  Because healthy ageing takes in so many elements – aerobic fitness, muscular strength, balance, flexibility, a lack of chronic impairment – it can sometimes be hard to measure without medical expertise. But there are shortcuts. Perhaps the best-known is usually called the sit–stand test, otherwise known as the chair test. Largely assessing muscular power and endurance, as well as elements of balance, this begins with the subject sitting upright on a straight-backed, non-padded chair without arm rests, with their feet flat on the floor and arms folded with the hands on each opposite shoulder. They must then rise, unaided, to a full stand and sit down again as many times as possible within thirty seconds.

  Men aged sixty to sixty-four should be able to manage around fourteen, and women twelve, with the recommended minimum gradually decreasing as people age more. Below-average scores have been linked in studies with a greater likelihood of death, as well as more chance of falling.51

  There are other tests which studies have shown to be good indicators of longevity, for example grip strength. Another gauge, demonstrated by a 2014 UK study and more recently popularised by Michael Mosley, the TV doctor and media sage on better ageing, is whether or not someone can stand on one foot for thirty seconds with their eyes closed.52 This is based on the importance of balance as we get older, and the connection between poor bal
ance and possible later dementia.

  Perhaps the most thorough and ingenious, if less well known, is a distant variant of the chair test devised by a Brazilian doctor called Claudio Gil Araujo, who runs a clinic in Rio and has focused on sports and exercise since the 1970s. Araujo says he became fascinated with the idea of discovering a tell-all test for older patients after noting that some of them, for example runners, were aerobically fit but had poor flexibility, or limited all-body muscular strength.

  With the help of his wife, who has a doctorate in physical education, Araujo devised what is called the sit–rise test. This is marginally more complex to explain than the chair test, but even easier to do at home. All it needs is a flat, non-slippery space of about two metres square. The person being tested stands in the middle of this, barefoot, and wearing clothing that won’t restrict their movements. They are then given the deceptively simple instruction: ‘Without worrying about the speed of movement, try to sit and then to rise from the floor, using the minimum support that you believe is needed.’

  The aim is to do this without using your hands, either on the floor or on a knee. It’s permitted to cross your legs if you want, but you cannot then rise by using the sides of your feet as a lever – they must be flat as you stand up. You are then scored out of ten, five each for the sit and the rise. A point is taken off for any support used, with half a point deducted for unsteadiness or loss of balance.

  It sounds straightforward, and in many ways it is. But the beauty of the sit–rise test is the number of elements it examines in one go. To score a ten you need not just good flexibility and balance, but also both strength and power in your muscles. These are different traits. Strength is simply the ability of your body to produce enough force to move something, whether your own body or an external object; power is about producing the greatest amount of force in the shortest possible time, and is seen as particularly important for healthy ageing.