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Enhancing Healthy Aging

As life span increases, individual behavior will have important ramifications for healthy aging, both physically and cognitively. Technological innovations and new approaches to health care can also facilitate healthy aging across a diverse society.

STRATEGIES FOR HEALTH PROMOTION

Robert N. Butler

International Longevity Center, New York


Despite all the advances in medicine and public health, life expectancy in the United States may decline from such factors as obesity, diabetes, smoking, and alcohol abuse as well as poor health care coverage. Noting that the United States has fallen from 11th to 42nd in world rankings of life expectancy in recent years, Butler cautioned, “We may reach a point where our grandchildren have lower life expectancy than we have.”

Butler called for a broad strategy of health promotion. The essential elements are already well known. The grand challenge is getting people to do them. As no more than 25 percent of health and longevity depends on genes, the other 75 percent is up to people themselves. Butler identified seven steps in a public health campaign to promote healthy aging. The first four concern physical health, encouraging people to (1) remain physically active, (2) change their diets by reducing caloric intake and adding fruits and vegetables, (3) moderate their use of alcohol, and (4) cease



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3 Enhancing Healthy Aging A s life span increases, individual behavior will have important ramifications for healthy aging, both physically and cognitively. Technological innovations and new approaches to health care can also facilitate healthy aging across a diverse society. STRATEGIES FOR HEALTH PROMOTION Robert N. Butler International Longeity Center, New York Despite all the advances in medicine and public health, life expectancy in the United States may decline from such factors as obesity, diabetes, smoking, and alcohol abuse as well as poor health care coverage. Noting that the United States has fallen from 11th to 42nd in world rankings of life expectancy in recent years, Butler cautioned, “We may reach a point where our grandchildren have lower life expectancy than we have.” Butler called for a broad strategy of health promotion. The essential elements are already well known. The grand challenge is getting people to do them. As no more than 25 percent of health and longevity depends on genes, the other 75 percent is up to people themselves. Butler identified seven steps in a public health campaign to promote healthy aging. The first four concern physical health, encouraging people to (1) remain physi- cally active, (2) change their diets by reducing caloric intake and adding fruits and vegetables, (3) moderate their use of alcohol, and (4) cease 

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 GRAND CHALLENGES OF OUR AGING SOCIETY tobacco use. The other steps foster cognitive health: (5) building and maintaining support systems and close friendships, (6) managing stress, and (7) continuing to seek meaning and maintain a sense of purpose. With greater longevity and improvements in both physical and cogni - tive health, people can and should work longer. This will have a positive impact on individuals’ health and will reduce Social Security costs. Older persons can also volunteer, providing services to others. What else can be done? Butler mentioned several public policy strate- gies: tax soda, tax alcohol, and further regulate tobacco. He also advocated universal health insurance and a national walking movement, established through joint efforts of government, private foundations, corporations, and lobby groups to encourage people to walk together, using pedometers to monitor performance and get feedback. A movement that establishes walking as a fun, frequent, and shared practice could have an immense impact on healthy aging. Butler closed his remarks with an emphasis on the value of taking a life-course perspective to health promotion. Considering a range of healthy behaviors, preventive care, and physical and cognitive exercise, Butler declared, “It is never too late to start and always too soon to stop.” OBESITY AMONG OLDER PEOPLE Gordon L. Jensen Department of Nutritional Sciences Pennsylania State Uniersity One specific risk to healthy aging is the recent rise in obesity among older people. In the United States, there has been a tremendous increase in the prevalence of obesity among people in their 60s and 70s. In this age range, a third or more of both men and women are now obese, meeting the threshold definition of a body mass index of 30 or greater. While some excess weight in older people may be positive, providing a metabolic reserve, obesity to this extent has adverse consequences. It is often accompanied by the gamut of serious medical comorbidities. It also has profound functional implications, particularly for mobility. In addi- tion to loss of mobility, obesity is also a predictor of many other forms of functional decline: joint disease, chronic disease, chronic proinflammatory state, decline in muscle mass, sedentary lifestyle, homebound status, and restrictions in activities of daily living. These build on each other, as the physical inactivity of a sedentary lifestyle leads to more substantial loss of muscle mass, further restricting mobility.

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 ENHANCING HEALTHY AGING Obesity in older people thus has a tremendous impact on their qual - ity of life, capacity to live independently, and psychosocial health. It also has a great economic impact on the health care system, as body mass that is either very high or very low is associated with increased health care expenditures. An obese Medicare recipient costs approximately $1,500 more per year than one of healthy weight. That figure does not cover indirect costs of lost productivity. A study of diet quality among community-dwelling older adults gen- erated several observations. Nutrient deficiencies are relatively common among older obese people. Due to poor diet quality, they are overnour- ished and undernourished at the same time. Obese older women are less likely than men to meet nutrient requirements and to have healthy eating habits. Women living alone were most apt to have a high body mass index and poor diet quality. Strategies for prevention and treatment of obesity among older peo- ple are needed. However, research on which interventions are relevant for older obese people in particular is lacking. Pilot studies involving prudent diet, behavior modification, physical activity, and pedometers are showing positive results. It is not clear whether they will translate into long-term sustained benefits. More aggressive bariatric surgery (surgi - cal modification of the gastrointestinal tract to promote weight loss and maintenance of a more healthy weight) is now being offered to the “young old.” As this is a potentially life-threatening surgical intervention, the need to develop other interventions and to intervene earlier is clearly very great. Devising effective interventions for obese individuals in childhood and midadulthood has also proved difficult. Jensen identified these priorities for research on obesity and aging: • hat is the significance of sarcopenic obesity (obesity with associ - W ated muscle loss), especially for functional decline? • What should weight recommendations for older people be? • hat warrants intervention and what should those interventions W be? • hat are the proper protocols for caring for older people with W obesity in transitional care, chronic care, and community-based settings? • ow should poor diet quality and micronutrient deficiencies be H handled?

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 GRAND CHALLENGES OF OUR AGING SOCIETY EXERCISE AND COGNITION Arthur Kramer Biomedical Imaging Center Uniersity of Illinois at Urbana-Champaign Exercise encompasses not only physical activity but also intellectual engagement, social interaction, and aspects of diet. In cognitive health and in physical health, exercising more is the route to healthy aging. These issues have been informed by molecular and cellular studies of nonhuman animals, prospective observational epidemiological studies, and human randomized clinical trials. Much is known about the molecu - lar and cellular underpinning of exercise. Positive impacts of exercise include increases in neurotrophins, enhanced synaptogenesis (formation of new synapses), enhanced angiogenesis (formation of new blood ves - sels), increased production of various neurotransmitters, reduced meta amyloid protein, and enhanced learning and memory. More work needs to be done, particularly regarding the interaction of different factors that act as moderators and mediators. Exercise to build and maintain cognitive health is important across the life span. The increase in the numbers of sedentary children is of grave concern for their well-being now and in the future. Sedentary older adults should not consider themselves too old to start. According to current research, there is no point of no return with regard to the benefits of exer- cise for cognition and brain health. Even older persons with Parkinson’s disease, multiple sclerosis, and early Alzheimer’s disease benefit from exercise. Genetic moderators also play a role in the relationship between exer- cise and cognition. More research is needed on the interaction of different alleles that are linked to different aspects of cognition. Various genes can also affect the dopamine system, influencing a person’s experience of and pleasure from exercise. Another area of research concerns the interaction of exercise and other lifestyle choices on cognition and the brain. Multimodal interven - tions appear most promising. These incorporate physical activity, intel - lectual engagement, emotional control, social interaction, and meaning. The interaction of exercise and diet on cognitive health is also beginning to be studied. From a public health perspective, how can exercise be encouraged so as to stimulate and maintain cognitive health? Exercise can be built into all environments for living, working, and playing. Exercise can be an element in the design of transportation, workplaces, schools, parks, rec - reational facilities, urban environments, and so forth. “There is more to be known, certainly,” Kramer concluded, “but we know enough to suggest

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 ENHANCING HEALTHY AGING that exercise and physical activity have positive effects both on reduction of disease in the long term and on memory, cognition, decision making, intentional processes, and brain health even in the short term and even independent of disease reduction—of course, also in concert with disease reduction. But if we cannot get people to do what we know is good for them, it is kind of a moot point from a public health perspective.” RACIAL DISPARITIES AND COMMuNICATION M. Chris Gibbons Urban Health Institute and Schools of Medicine and Public Health Johns Hopkins Uniersity Consumers increasingly are using information technology to acquire the necessary tools and information in order to promote their own healthy aging. In addition, the rising desire to age in place generates a growing home health care sector. If there is also a rising prevalence of chronic dis - eases, then care for such diseases will increasingly be provided by family members, community members, and other types of health care workers outside a hospital or health care setting. In such situations, nonmedical factors will have greater importance. Sociobehavioral factors are increas - ingly recognized as important determinants of healthy aging and health care outcomes. The line between biological and sociobehavioral factors is not sharp. Disease causation in general and health disparities in particular result from the complex interaction of many factors that simultaneously and often cooperatively act across more than one level. Thus it is not pos- sible to characterize health, disease, aging, or disparity at only one level of analysis, and interventions, too, should act on many levels. Transdis - ciplinary research that truly integrates sociobehavioral, environmental, and biomolecular research on health, aging, disparities, and intervention is necessary. Currently, more research is being performed and a higher level of con- sensus exists among researchers regarding prevalence of chronic disease, increasing longevity, and rising health care costs. Regarding intractable health care disparities, more research is being performed and a higher level of consensus exists at the epidemiological level. However, regard - ing what to do about these health care disparities, less research is being performed and a lower level of consensus exists among researchers. A promising initiative for intervening in health care disparities will come from information and communication technologies. Just as advances in these technologies helped propel a revolution in molecular biology and clinical sciences, the same revolution is needed in the behavioral and

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0 GRAND CHALLENGES OF OUR AGING SOCIETY population sciences. Health care interventions based on information tech- nology will provide a more robust and comprehensive characterization of the process of healthy aging and the pathogenesis of disparities. These approaches also offer significant promise for the promotion of healthy aging and the reduction of disparities. In discussions of health care and information technology, what generally comes to mind is electronic medi- cal records, e-consultations, telemedicine, remote monitoring, intelligent devices, and sensor technology. These tend to be designed for and used by physicians and other health care professionals. However, this repre- sents only a very limited part of the spectrum. The use of technologies by consumers has the potential for even greater impact than those used by professionals. These include a range of platforms, including cell phones, Web 2.0/3.0, health gaming, population health technologies, consumer health informatics, and programmed evidence-based processes. Technologies used by consumers will need careful attention to design so that patients and caregivers are empowered to do what is necessary toward the goal of improving clinical outcomes. Reducing health care disparities requires not just increasing access to technology, but rather redesigning it. The underserved and minorities do not use information technologies in the same way as the general population. Without attention to design, information technology could even increase health care dis- parities. Gibbons advocated user-centered design to attend to the needs, wants, and limitations of the end-users. Human-computer interaction and usability testing should also be addressed in the development of informa- tion technologies. Culturally informed design that attends to the needs of minorities, immigrants, or low-literacy groups is also an essential part of the process. The relevant end-users of these information technologies are not only patients but also a range of caregivers, including family members, friends, neighbors, home health care workers, and community health workers. Consumer use includes a variety of tasks, such as calendaring (e.g., keep- ing track of appointments, scheduling tasks), decision support, open and distance learning, and radio frequency identification devices for tracking and constant monitoring. With well-designed information technologies, health risks can be managed before they become diseases, and patients can receive an intervention without going to the hospital. Intervention delivery can occur via a variety of formats (e.g., Web, game console, tele - vision, cell phone, personal digital assistant). Interventions can be deliv - ered when and where they are needed. Connections can be maintained regardless of location, facilitating aging in place, ongoing social networks and personal independence. Information and communication technologies have great potential to improve outcomes across the continuum of health care. Possible areas of

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 ENHANCING HEALTHY AGING impact include harm reduction, prevention/wellness, screening, diagno - sis, medical treatment, self-care, and survivorship. By making information accessible in the form in which it is needed, information technologies can help make health care proactive rather than reactive. The efficacy of tra- ditional interventions could also be enhanced via technological adjuncts to treatment or care. The current challenge, Gibbons concluded, is not just what doctors and hospitals need in order to do a better job, but what patients and care - givers need “in order to do the things we want them to do better over time to improve clinical outcomes.” And the best approach is information technologies that are used and owned by patients or immediate caregivers and that do not depend on a physician or practitioner. Gibbons posed three critical questions: 1. What is the role of human factors (how humans behave physically and psychologically in relation to environments, products, and ser- vices) on the use of information and communication technologies among seniors? 2. What is the role and impact of designs that take account of the characteristics of the end-users on seniors’ use of technology? 3. What is the role and impact of using computer science in combina- tion with health information among seniors?

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