The Miracle Pill

by Peter Walker

  Speaking from his clinic in Rio, Araujo tells me that when he started to use the test he discovered it also, indirectly, measured other risk factors: ‘We perceived that if you ask someone to sit on the floor and rise from the floor, we are evaluating at the same time several things, including body composition. Because if you are overweight, you have problems sitting normally on the floor and even more problems with rising from the floor.’53

  Araujo’s clinic has an easily searchable YouTube video54 showing how the test should be done. But be warned, it can be addictive. If you give the instructions to a child they will inevitably drop lightly to the floor, and rise again without apparent effort – indeed, it is seen as a worry if someone under eighteen cannot manage this manoeuvre with the full ten points. But as people age, the various infirmities begin to take effect.

  For example, I like to think I can manage a safe ten, although a particularly strict marker might occasionally dock me half a point for lack of grace on the descent. But even while I manage this, the sit–rise test betrays where my score is likely to decline with age. As someone who cycles a fair bit, I have fairly strong legs for my weight, particularly in the quadriceps, the large muscles at the front of your thighs which you also use a lot to stand up. Sadly, also like a lot of people who ride a bike, I also don’t stretch nearly enough, and the flexibility in my legs and hips is gradually diminishing. I can still rise from the floor without support, but I’m aware that this is largely the power in my legs overcoming the lack of movement. It’s a trick I won’t be able to pull off forever, unless I start working on my flexibility. I have been warned.

  Araujo argues that his creation is more effective than the chair test, in part because it gauges so many elements, but also because it avoids any equipment skewing the results, for example differing relative heights of people and the chair they use. “We found one way to have a sort of a simple score that everybody can understand,’ Araujo says. ‘As a physician, many times my patients would come to me and say, “Doctor, what do these lab results mean?” This tells them.’

  There is, however, more to it than a score out of ten. Araujo devised the test in the late 1990s, just to use with his older patients. But some years later a visiting US academic suggested Araujo compare the score with mortality records. He worked with postgraduate students to do this, and they found a striking link – the lower someone’s sit–rise score, the more likely they were to die. ‘Those who have a score of zero to two or three – they have really bad chances of surviving compared to those who have eight to ten,’ he says.

  The first tranche of results found that among the 200 or so people who scored zero in the test, meaning they needed help to sit or stand, the death rate was 4.3 per cent a year on average, odds as bad as some forms of cancer. In contrast, of the 480 of his patients who scored from eight to ten, only four died over the eight-year study period, despite being aged between forty and eighty.55 ‘These are just ordinary people. We’re not looking for anyone from the circus or anything,’ Araujo says. His oldest-ever scorer of a ten was aged seventy-three. Araujo, who is sixty-four but a keen runner, manages 8.5, shedding half a point for a wobble on the way down, and a full point for using one hand to rise. This still puts him in the 90th score percentile for his age group, he tells me proudly.

  Growing your brain

  Physical prowess is only half the battle when it comes to vibrant, independent ageing. Dementia, notably Alzheimer’s, is one of the most common reasons for older people needing outside care. The idea that activity could not just slow this decline, but to an extent rewind it, has obvious individual benefits. On a population-wide level, however, the implications are astounding. Amid fast-ageing populations, there are an estimated 10 million new cases of dementia worldwide every year.56 In the UK there are currently 850,000 people living with dementia, with the total cost of care exceeding £30 billion.57 By 2040, both figures are forecast to have doubled. Tackling this alone would seem sufficient justification for just about any government to start intervening to make lifetime physical activity more common.

  If prompted, most people probably know that mental stimulation, particularly into older age, is known to reduce the risk of dementia and other forms of cognitive decline. But the fact that this is also true of physical activity remains far less understood, despite several decades of studies on the subject. Research in this area has rocketed with the advent of brain-scanning technologies which allow scientists to not just test the changes prompted by physical exertion, but observe them.

  Kirk Erickson, who has led a series of these studies, is clear about the weight of evidence. ‘We can be very confident that greater amounts of physical activity reduce your risk of developing Alzheimer’s. That is something I am wholeheartedly confident of saying,’ he tells me. ‘I would also say that the evidence is very strong that engaging in moderate amounts of physical activity is beneficial for brain cognitive function.’58

  The latter area is one of the most fascinating areas of current research. Among studies Erickson has led includes ones which used randomised trials to show aerobic exercise both improved memory and actually increased the size of the hippocampus, a part of the brain connected to both memory and the mental complex tasks known as executive functions.59

  Erickson explains what these are: ‘For an example, your ability right now to selectively attend to what I’m saying and ignore distracting information, that’s considered a component of executive function. Your ability to maintain items in working memory for short periods of time, and work on that material, that’s also considered executive function. Your ability to switch between doing different tasks, between, you know, typing an email, and then jumping in and finishing up a document and then jumping back, maybe in a work environment, that’s also executive function.’

  Such tasks, of course, are central to maintaining an independent life. ‘Absolutely,’ Erickson says. ‘Unfortunately it’s one of the areas of cognitive function that shows some early losses. So if we’re able to improve executive function with modest amounts of regular physical activity, that is very important.’ Regular activity has been shown to at least mitigate such losses, but can even prompt improvements – up to a certain point. Erickson adds: ‘One caveat is that it is a moderate-sized effect, which means that you’re not going to be jumping several IQ points just by doing exercise.’

  This effect is, of course, particularly beneficial for people at risk of dementia, which is generally characterised by memory loss and a decline in higher cognitive abilities. One study took a group of older people in Australia who had the beginnings of memory problems but had not reached the threshold for Alzheimer’s. Half were randomly allocated a six-month regime of physical activity, with the others given a programme of education on ageing. At the end of this period the physical group showed some improvements on the scale to test for Alzheimer’s, while the others saw a clearly measurable decline.60 As with many elements of physical activity in older age, the key appears to be to do at least something physical, and perhaps worrying less about whether it is sufficiently strenuous or specialised. For example, in the just-mentioned Alzheimer’s research, the most common type of activity for the group who saw the improvement was simply walking.

  This is still a relatively new area, and Erickson says that when he began doing studies he faced widespread scepticism that something so simple, and without the need for any drugs, could be effective in combating dementia. ‘In recent years I think the tide is changing,’ he says. ‘We’re now at a point where the wealth of data that we have can no longer really be ignored. And then there’s the cost of pharmaceuticals and the failure of pharmaceuticals to really prevent and treat many neurologic conditions. When I go to meetings, sometimes pharmaceutical representatives will stand up and discuss the failures of their trials, and they’ll even be in favour of more work being done examining the impact of these types of behavioural modifications.’

  This is a hugely powerful idea, and one that again ties in
with the conceit of this book’s title. In being active, at any age, we might not be literally ingesting a tablet, but its effect on our bodies is to help them create a bespoke internal cocktail that can reduce the risk of disease, improve our strength, endurance, balance and power, not to mention even increase the size and function of our brain. It’s perhaps no wonder the pharmaceutical companies are starting to realise they can’t compete.

  Next steps:

  If you have children, even if it does feel like they are always sprinting around at home, think about how active they actually are, and whether they are meeting the hour-a-day recommended movement – or three hours a day for younger children. And if you are older, don’t forget the importance of balance, as well as strength and aerobic fitness, for healthy ageing.

  9 The Power of Social Engineering

  It is shortly after 9am, the temperature is −13°C, and a light snow is falling. Even though I am heavily wrapped in several layers of clothing, including long johns, a thick skiing jacket and two hats, my teeth have begun to chatter. But in front of me, on a school playground covered in several weeks’ worth of thickly encrusted snow, something fairly unlikely is happening: several dozen children are cycling around.

  I am in Joensuu, a small city in northeast Finland, about 250 miles from Helsinki and only a few dozen miles from the Russian border, which has the slightly niche claim of being one of the winter cycling capitals of the world. Despite undeniably brutal winters – on the February evening when I arrive on the train from Helsinki, Finland’s capital city, it is −16°C, and the mercury never goes above −6°C when I am there – about 20 per cent of all journeys in the city are made by bike.1 This is a year-round average and in winter the figure does understandably fall somewhat. Even so, during my visit, cyclists are still a routine sight, crunching serenely along the cycle paths, or at least what I presume are cycle paths hidden underneath the several inches of flattened snow.

  If you set aside the weather, Joensuu has several advantages for cycling, including that it is almost entirely flat. It is also geographically compact, with about three quarters of the 80,000 population living within a gentle twenty-minute bike ride of the centre. Many locals are young, with about 10 per cent being students. Finally, much of the city is new – as recently as the 1950s the population was only 7,000 – and so the streets are wide, with plenty of space for cycle lanes.

  But its friendliness for year-round cycling is no accident. As Juha-Pekka Vartiainen, who is in charge of road infrastructure for the city council, tells me: ‘There’s a long tradition of cycling here. But we also have a long tradition of planning for cycling.’2 This includes many years of constructing safe bike routes away from the motor traffic, whether entirely separated lanes or the shared use of a wide pavement. As Vartiainen points out, bike lanes simply painted onto the road will not work in a city where they would be invisible below the snow for several months a year. The bike routes are also, like the roads, ploughed after every new snowfall. Rather than scraping back to the tarmac, the ploughs smooth the snow flat, adding grooves for extra traction. This might sound counterintuitive, but as long as the temperature remains below freezing, it creates a remarkably grippy surface, and the bulk of Joensuu’s cyclists ride with normal tyres, not the metal-studded winter type seen in many other similarly freezing cities.

  But there is another, hugely important, factor in play. This is not just a regional quirk; year-round physical activity, and the many ways to create it, is a major priority of Finland’s national government. In the case of the primary school I visit, about a quarter of pupils cycle year-round, teachers tell me. Admittedly, their numbers are probably greater than normal on this particular morning. An instructor from Helsinki has arrived, and he is leading the students through snow-cycle training and a series of games, including an obstacle course and a contest in which two teams try to move a cardboard box by cycling past and hitting it with snowballs.

  This is the opening event of something called the Winter Cycling Congress, which brings together politicians, officials and experts to share information on year-round riding. Pitching up in a different chilly location every year, the Congress is a proudly low-budget event, run by a committee of volunteers and reliant on host cities to provide a venue. But this time, things are a bit more lavish than normal. As well as a generous event space, inside a vast, wood-built indoor sports arena adjoining one of the city’s universities, there are tours, excursions, and a drinks reception at Joensuu’s art gallery, hosted by the mayor. Finland’s central government has underwritten most costs, including the flights and accommodation for many attendees and media, me among them. Why? It is because physical activity is something the country takes very, very seriously, and it would like the world to know about this.

  A couple of days before arriving in Joensuu I head to Finland’s 1920s parliament building, an austere, classical-meets-modernist stone structure which looms across the centre of Helsinki. I am meeting Krista Kiuru, Finland’s minister for family affairs and social services, whose brief covers preventative health. She is, incidentally, among a majority of female ministers in a government led by Sanna Marin, who was just thirty-four when she became prime minister.

  Kiuru makes a fascinating argument for why the Finnish government is so keen on pushing everyday physical activity: as with the country’s famously excellent and much-studied education system, she says, it is not just of obvious benefit to citizens but can act as an international beacon for a small and not hugely powerful country of just over 5 million people.

  ‘It’s a basic value here in Finland that we encourage our citizens to be active in life. It is kind of a way to see that if Finland’s people can be active, then we can be better as a nation,’ Kiuru tells me during our lengthy chat in parliament, a conversation periodically interrupted by aides reminding her, in vain, that she is running late for her next engagement.

  ‘We’re not rich in natural resources. There’s no oil. But what we can do is similar to what we have done with schools, which is a very well-known product around the world. It is the same here. When we talk about the health system, we’re talking about the equal right to have good services. We encourage everyone to be active, to be as healthy as possible. It’s the same way we’re encouraging the pupils in the schools to do their best, to be as good as their potential.’3

  This is inspiring stuff. And there is little doubt that by most international standards, Finland is generally a success story when it comes to an active population. In the awkwardly named Eurobarometer surveys, huge EU-wide polls on many areas of life across the member states, Finland routinely has the highest proportion of people who say they take part in at least some sport or exercise, currently at 87 per cent. The UK equivalent is 63 per cent, which is actually above average – at the bottom sits Bulgaria, where fewer than a third of people ever do any formal exercise. Finland is also near the top for the EU rankings for non-sport physical activity, although it is beaten by the Netherlands and Denmark, both helped by their very high levels of everyday cycling.4

  The Dutch and Danish levels of bike use are, of course, a product of decades of central government-led policy and spending decisions to boost active travel. This is the sort of thing which to many British politicians’ eyes would cross into the territory of social engineering. But it is worth remembering that much of the impetus for these changes came from the public. We saw earlier that the transport revolution in the Netherlands was sparked by the Stop de Kindermoord (Stop the Child Murders) road safety mass protests of the 1970s. Copenhagen saw similar scenes later in that decade and into the 1980s, pushing authorities into action.

  In contrast, the transformation of Finland’s public health was even more dramatic, but was also a notably top-down, almost paternalistic enterprise, led by scientists and researchers who enlisted the help of politicians to persuade an initially sceptical public of the need for change. As an example of societal reform it is particularly resonant now, when the bar for public to
lerance of interventionist public health measures has perhaps been reset to a higher level with the extraordinary global government-led response to coronavirus. In the coming months, many ministers and mayors will look to the handful of countries which have managed to transform their national public health outcomes to see how it was done. If they use Finland as an example, a vital part of the story is where it all began.

  The war on cholesterol

  I am approaching the end of my very long chat with Pukka Peska, the Finnish doctor who is one of the true pioneers of modern public health, when a question occurs: how many early deaths does he think the programme he devised and led has saved? Peska says that he and some colleagues had once sat down to calculate this. They eventually worked out that if mortality rates had stayed the same as they were when he began his work in the early 1970s, over the next thirty years alone there would have been an additional 250,000 deaths among people aged under seventy-five. This is not, it should be added, a calculation taking in all of Finland, just one region of it, and not an especially populous one at that. It is, I tell him with some understatement, not bad going for a career achievement. Peska laughs. ‘This is public health,’ he says. ‘Of course, when I became involved, I believed that we could have results, but never, ever could I believe that the chronic disease epidemic would change so dramatically.’5

  There is an important point to make here. The disease epidemic Peska was trying to curb was the same foe as faced by Dr Jerry Morris: cardiovascular disease, and in particular fatal heart attacks. But Peska was not, at least initially, seeking to change the health odds via physical activity. His first targets were diet and tobacco. However, as an example of turning a population away from habits which were killing them young, Peska’s work has enormous relevance for modern efforts to promote movement. Amid the admittedly specialist world of public health programmes tackling the diseases of lifestyle, his example is perhaps the most celebrated and influential of all.