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.16 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.17 Half of those who fracture a hip subsequently become reliant on others. Yet physical activity can halve the risk of falls.18 It also strengthens muscle and bone density, making fractures less likely.19 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.20
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.21 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.22
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.23 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.
The researchers took blood samples, weighed each man and asked five simple questions. Was he a non-smoker? Did he take exercise, or walk, for at least 30 minutes a day, five days a week? Did his diet include at least three portions of fruit and vegetables a day and no more than 30 per cent fat? Did he drink less than four units of alcohol a day? And did he have a healthy body weight (a BMI of 18 to 25)?
Over the next 35 years, men who consistently answered yes to four or five of those questions had a staggeringly better quality of life than those who didn’t.24 They suffered 70 per cent less from diabetes, had 60 per cent fewer heart attacks and strokes, 35 per cent less cancer25 and were 60 per cent less likely to experience cognitive impairment or dementia. Elwood called this last finding ‘the real gold dust’. Even those in the healthiest groups who did get dementia got it later: its onset was delayed by six to seven years.
Remember, these results were achieved with relatively minimal change. The team wasn’t asking people to become cycling fanatics, only to start walking and cut down drinking and smoking. They even lowered the diet criteria from five vegetables or fruit a day to three after they were advised that there was no hope of getting anyone in South Wales to eat five!
‘From the results in Caerphilly,’ Elwood has said, ‘we can make a very strong challenge that if every person was urged to take up one extra healthy behaviour, and if only half did so, we’d see 12 per cent less diabetes, 6 per cent fewer heart attacks and strokes and 13 per cent less people with dementia. There would be savings in the NHS of millions.’
Those savings, however, have never materialised. Relatively few men in Elwood’s study managed to stick to four of the healthy behaviours. Thirty-five years later, looking back on his life’s work, Elwood reflected that behaviours in that part of Wales had changed little.26 ‘We have found that living a healthy lifestyle is better than any pill,’ he said in 2013. But ‘people are not motivated’.
This must change. For Elwood’s findings on dementia have been reinforced by subsequent studies. In 2017, the Lancet Commission on Dementia stated, ‘there is evidence that an important fraction of dementia is preventable’ through tackling diabetes, obesity, high blood pressure, physical inactivity and smoking.27
Food as Medicine
In 2017, the Finnish Geriatric Intervention Study to Prevent Cognitive Impairment and Disability (which has the marvellous acronym FINGER)28 reported even more encouraging findings about the effects of lifestyle changes on the brain. Researchers recruited 1,260 people aged between 60 and 77, who were judged to be at increased risk of dementia. Half received regular health advice, the other half a comprehensive programme of healthy eating, strength training, aerobic exercise and brain training (which we will look at in Chapter 6). After two years, those who had eaten better, got more active and trained their brains scored 25 per cent better in memory and mental tests than the first group. Even more incredibly, they experienced an 83 per cent improvement in executive functioning and 150 per cent increase in mental processing speed. Intriguingly, these improvements occurred regardless of gender, education level, socioeconomic status, blood pressure or cholesterol levels.
Diet was a key part of FINGER. At the start of the study, participants deemed to be overweight were advised to lose between 5 and 10 per cent of their body weight by reducing the number of calories they consumed. Next, they were instructed to eat lots of fruit and vegetables, to consume fish at least twice a week, to choose wholegrain cereal products over refined ones and to use vegetable margarine or rapeseed oil instead of butter. They were also asked to limit their sugar intake to a maximum of 50g per day and to limit rich dairy and meat foods.
This kind of ‘Nordic’ or ‘Mediterranean’ style diet broadly reflects the plant-based, high-fibre food consumed in the Blue Zones. These diets are achievable