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Vintage Advantage - October 2009
It is strange how many people, especially men, look after their cars better than themselves. They understand that regular car maintenance will make the difference between costly repairs and a trouble-free life. They would not dream of putting the wrong fuel in the tank or the wrong oil in the engine, still less missing a service. But when it comes to their own bodies, they think they can eat and drink anything, and in any amount, without any consequences. And they proudly boast that they are never “really ill”. This is, perhaps, why so many heart attack patients say, on arrival at A&E, “I can’t understand it, I never go to the doctor”, blissfully unaware of the irony!
There has been a vast amount of research looking for ways to avoid the common hazards of old age, especially cardiovascular diseases, cancers and pulmonary disease. Unfortunately, much of this research can only produce indirect, or circumstantial, evidence, and many of the research tools available are too inaccurate to be entirely relied upon. But the general thrust of the results obtained so far confirms that it is better to keep healthy throughout adult life, rather than wait until the consequences of inactivity and over indulgence are only too apparent.
Even before a baby is born, there are influences that alter weight at birth, and this seems to have an effect on disease risk much later in life. So, a baby who is born small, but full term, will tend to die younger than a normal weight baby (Barker 1998) At present, it is not clear whether the mother’s diet is the main determinant of birth weight. An alternative possibility, for which there is some evidence (Singhal and Lucas 2004) is that the damage is done by trying to “feed up” a small baby too much in a desire to make them “catch up” with their heavier and taller peers. This may prove to be one of many examples of “common sense” and well-intentioned interventions that turn out to be counter-productive (Wells 2009). There is no substitute for reliable evidence, even when something appears obvious.
Further effects on adult health may be traced back to early infancy. Children who are fed too much in their youngest years tend to become fatter, either immediately or later in adolescence. Particular suspicion is falling on too much protein as well as simply too many calories at this age (Rolland–Cachera et al. 2006). This may predict adult obesity as the number of fat cells is set very early in life (Spalding et al. 2007).
Three aspects of childhood and adolescence are thought to be particularly important to later health. The first is physical activity habits, which tend to be set early in life, and to be strongly influenced by parental example (Sallis et al. 2000). The second is dietary habits, especially when these lead to obesity. The likelihood of being obese as an adult is greater the later in development an individual is obese (Whitaker et al. 1997).
A gleaming radiator grill?
The third childhood habit that will impact health throughout life is looking after the teeth. Nowadays, more and more people are keeping all their teeth all their lives, something that was virtually unknown fifty years ago. There are particular problems with the teeth in elderly people as a result of the unfortunate tendency of so many common drugs to cause reduced saliva flow. Saliva is the great unsung hero of tooth health, without it we would all loose our teeth very young. Saliva provides a protection for the teeth, helping to neutralize and wash away the acids produced when any carbohydrate (sugar or starch) is eaten. It also delivers the essential minerals needed to replace the tooth enamel etched away by these acids. When saliva flow is reduced, the teeth are at greater risk of erosion or decay.
Fortunately, the evidence is now clear that the teeth can be kept healthy throughout life by a few simple habits. The most important of these is regular brushing with fluoride toothpaste. Fluoride toothpaste was introduced into the UK in about 1976. The improvement in children’s teeth that can be traced to that date is truly dramatic (Cottrell 2005). Indeed many children today avoid fillings altogether.
The significance of healthy teeth in childhood for trouble free dentition in old age is not difficult to see. Most of the teeth that will remain with us until we die are already busily chomping away by the age of twelve. Better by far to look after them than face repeated (and expensive) attempts at repair, with the risk that some, or all, of the teeth will eventually be lost.
A further hazard for older teeth is the tendency of the gums to recede with age (hence the expression “long in the tooth”). As well as making the teeth look longer, this can expose areas of softer dentine just above the gum margin, and below the hard enamel that protects the crown of the teeth. Dentine normally forms the inner core of the teeth and is particularly vulnerable to decay when exposed in this way.
Tooth brushing is also important, as the teeth get older, in order to keep the gums healthy, by avoiding a build up of food debris or bacteria where the teeth meet the gums. Infections arising at the junction of teeth and gums are a common cause of pain and tooth loss in older people. But because of the exposed areas of soft dentine, which can be damaged by over-vigorous brushing, the emphasis should be on regular brushing twice a day (not more) rather than an occasional blitz.
The second foundation for healthy teeth all life-long is dietary habits. The key factor here is to allow the saliva a chance! Every time we eat or drink anything that contains carbohydrates, we expose the teeth enamel to some acid. Most eating occasions include carbohydrates in some form. The carbohydrates are metabolized by bacteria that reside on the teeth surfaces (however clean they may feel) to produce acids. And these acids will nibble away at the teeth. The reason we do not all lose our teeth very young is because saliva repairs the damage, given a chance. This needs some time. If we eat and drink too frequently, the repair process is overwhelmed by the rate of mineral removal and a cavity will form. Small cavities can repair naturally, given a period of respite for the salivary re-mineralization to work. But if damage continues, a larger cavity will result that can only be prevented from progressing to destroy the tooth by a filling from a dentist. So, avoiding eating or drinking too frequently is a core habit that will help to protect the teeth.
Nothing makes a person look old more than a bad set of teeth. And problems with the teeth are thought to be responsible for limiting the variety of foods many older people will eat, with a resulting restriction of their nutrient intake. It is silly to waste the opportunity by neglecting some simple habits of personal maintenance and diet. It is also a question of personal economics. The cost of the increasingly complex and expensive restorations needed to save teeth that are badly damaged is a financial burden many retired people would rather do without.
What about the engine?
Keeping the heart and circulatory system healthy into old age is one of the clearest examples of the importance of starting young. The habits of diet and especially exercise that will make all the difference to an active retirement are laid down early. Parental example is a key influence affecting children’s eating habits (Brown and Ogden 2004) and liking for exercise (Sallis et al. 2000). In adult life, regular exercise and the avoidance of obesity, coupled with a diet that delivers all the nutrients the body needs, will give the best chance of avoiding an unscheduled visit to the most hectic department in any hospital. Recent evidence points to a much greater importance of exercise than previously thought (Myers et al. 2002). There is now clear evidence that a healthy diet can influence blood cholesterol (Yu Poth et al. 1999) and blood pressure (Sacks et al. 2001) two other key predictors of heart attack and stroke. The fats found in oily fish seem to be especially protective (Bucher et al. 2002), along with the avoidance of too much saturated fat (Ascherio 2002) and eating plenty of fruit and vegetables (Dauchet et al. 2006).
And the bodywork?
Doting car owners lavish most care on the external surface of their “pride and joy”. They keep the bodywork clean and apply cosmetics in the form of wax polish and occasional touch-up paint. Scratches and corrosion are sternly and promptly dealt with. Similarly, we all try to keep the appearance of our skin clean and we will touch up its appearance if we feel it is needed. The skin is a very obvious indicator of age but the main causes of the changes in the skin seen in older people seem to be related to external influences rather than diet. Cumulative damage is caused by exposure to Ultra Violet rays (usually from the sun) and from cigarette smoking. There is little evidence that these can be ameliorated by diet or oral supplements. Of course, some severe nutritional deficiencies cause damage to the skin but these are highly uncommon in the developed world. Avoidance of excessive sun exposure and smoking are the best current advice. However, since most people get the majority of their vitamin D from sunlight exposure of the skin, a balance must be struck between enough sun exposure (especially in the housebound elderly) and too much. A simple rule of thumb is to enjoy the outdoors while avoiding sun burn (British Nutrition Foundation 2009).
What about the chassis?
The body’s rigid framework is, of course, the skeleton. Contrary to popular belief, the bones are not inert but a dynamic and living part of the body that require constant maintenance. Inadequate intake of the right foods, and especially inactivity, can lead to a weakening of the structure of the bones called osteoporosis (Prentice 2004).
Both men and women are prone to develop osteoporosis, which can lead to fractures, especially if muscle weakness from inactivity compromises balance and stability. Breakages can often involve the hip, with a surprisingly high risk of fatal consequences. Skeletal strength is a particularly good example of the influence of early life on a health outcome many years later. This is because the bones get stronger up to about thirty years of age and then gradually lose their strength. In women, this decline in bone strength accelerates after the menopause (although HRT will slow down the loss). This is why osteoporosis and fractures are more commonly seen in elderly women than men.
A key to strong bones in later life is to take advantage of the opportunity to maximise their strength when young. There are three main factors that influence the development of bone strength during adolescence and early adult life. These are regular exercise (especially load-bearing activities), coupled with an adequate dietary intake of calcium–rich foods, and exposure to sunlight to provide the vitamin D needed for the body to make use of the calcium.
Once the period of peak bone strength has past, around forty years of age, the decline in strength can be slowed considerably by regular exercise (aerobics or jogging are better than swimming, as they are load-bearing). There is limited evidence for an influence of diet at this stage but it seems reasonable to continue to ensure an adequate calcium intake (Shea et al. 2002). Those people who do not drink milk (the fat content does not matter as far as calcium content is concerned), or eat cheese or other dairy products (except butter), or who choose wholemeal bread rather than white bread (which is fortified with calcium) need to make an effort to find enough calcium from other foods. Food labels will help, or alternatively a suitable supplement pill may be the only answer (Shea et al. 2002).
What about fuel selection?
Moderation and variety are the key issues when it comes to the vexed question of dietary habits, however old fashioned and unimaginative these may sound. Moderation both in food calorie intake and alcohol consumption will help avoid the potential for obesity and the other complications. Both are, unfortunately, common among the retired population today. Obesity is associated with a range of risks, especially diabetes, and the consequences of being obese may not be easily reversed (Harrington et al. 2009). Moderate alcohol consumption seems to be protective against cardiovascular disease but excessive consumption leads to liver and brain damage. Binge drinking, at any age, carries a risk of stroke, quite apart from anti-social behaviour, which is not exclusively a problem confined to the young (Marmot 2001).
Diabetes is increasingly common among overweight and inactive middle aged and older people. The evidence available suggests that the onset of diabetes may be avoided by regular moderate exercise (such as walking), coupled with a diet low in saturated fat and high in fibre (American Diabetes Association 2002). The old-fashioned idea that sugar causes diabetes has long been abandoned along with the equally outdated idea that those with the condition should avoid all sugar (American Diabetes Association 2002).
Many older people have a diminished quality of life because of impaired mobility and flexibility. Despite much research, there is little evidence that dietary habits appreciably influence the underlying causes of the stiffness and pain that is so common (British Nutrition Foundation 2009). But one habit that has a beneficial effect is physical activity (Ettinger 1998). It used to be thought that it was a bad thing to start being more active in later life. But it is now clear that activity is good, and if you did not find time to be active during your working life, then retirement is a great time to start (Christmas and Anderson 2000). Tailored exercise has been shown to improve mobility and stability, lung function (Bean et al. 2004) and brain work (Colcombe and Kramer 2003). Being physically fit, which is the result of regular exercise, is also a good way to avoid heart attack and stroke (Blair and Church 2004) and seems to be a more powerful influence on the risk of these life threatening events than blood cholesterol, blood pressure or even age (Myers et al. 2002).
Maintaining your pride and joy
What is the secret of a vintage special? How do you maintain a good looking exterior and smooth running mechanisms inside? There are numerous research areas still being explored. Only in some areas is there better evidence, but much of this is still not beyond reasonable doubt.
In the meantime, it may be prudent to concentrate our efforts on some reasonable advice, based on the available evidence, but with no absolute guarantees.
- Keep active and reasonably fit all your life. Even if you haven’t been active in the past it will probably improve your chances of dodging certain conditions a little longer if you make the effort to start. If nothing else, try walking as much as you can fit into your routine. By way of incentive, it is worth reporting that one recent study observed an appreciable improvement in survival among people who made the effort to become more physically active as late as 80 years of age (Stessman et al. 2009)!
- Avoid becoming too overweight. Eat only what you need and cut down a little if your weight is creeping up (Hill 2006). Do not use food as a reward (especially for children) and do not fight your children to eat as much as you think they should.
- Being too thin is as much a risk as being too fat (Flegal et al. 2005).
- Do not use body weight as an excuse to keep smoking. Not smoking is one of the best things you can do for your health (Doll et al. 2004).If you drink alcohol, drink moderately. Heavy sessions carry a risk of stroke, even among young people. If you persistently drink more than you think afterwards you should have, seek specialist help (Fiellin et al. 2000). Regular heavy drinking may damage your health permanently.
- Eat plenty of fruit and vegetables and regular amounts of fish, and avoid too much saturated fat and salt.
- The experts are still arguing about fibre, functional foods, probiotics, prebiotics and a range of other issues. Best to wait till they make up their minds!
It is not possible to say with certainty what everyone should do if they want to have the health advantage when they are vintage characters themselves. This contemporary advice may not amount to a racing certainty but it is surely a good bet!
References
- American Diabetes Association (2002) Evidence-Based Nutrition Principles and Recommendations for the Treatment and Prevention of Diabetes and Related Complications. Diabetes Care 25(1):202-212.
- Ascherio A (2002) Epidemiological studies on dietary fats and coronary heart disease. The American Journal of Medicine 113: 9-12.
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- Blair SN, Church TS (2004) The fitness, obesity and health equation: is physical activity the common denominator. Journal of the American Medical Association 292:1232-1234.
- British Nutrition Foundation (2009) Healthy Ageing. The role of nutrition and lifestyle. (edited by S Stanner, R Thompson, J L Buttriss) British Nutrition Foundation, London.
- Brown R, Ogden J (2004) Children's eating attitudes and behaviour: a study of the modelling and control theories of parental influence. Health Education Research 19: 261-271.
- Bucher HC, Hengstler P, Schindler C, Meier G (2002) N-3 polyunsaturated fatty acids and coronary heart disease: a meta-analysis of randomized controlled trials. American Journal of Medicine. 112: 298-304.
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- Colcombe S, Kramer AF (2003) Fitness effects on the cognitive function of older adults: a meta-analytic study. Psychological Science 14: 125-130.
- Cottrell RC "Dental disease - Aetiology and Epidemiology". Encyclopedia of Human Nutrition (Caballero B, Allen L, Prentice A eds) Elsevier, Amsterdam. 2005.
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- Sallis JF, Prochaska JJ, Taylor WC (2000) A review of correlates of physical activity of children and adolescents. Medicine and Science in Sports and Exercise 32: 963-975.
- Shea B, Wells G, Cranney A etal, (2002) Meta-analysis of calcium supplementation for the prevention of post-menopausal osteoporosis. Endocrine Reviews 23: 552-559.
- Singhal A, Lucas A (2004) Early origins of cardiovascular disease: is there a unifying hypothesis. The Lancet 363: 1642-1645.
- Spalding K, Arner E, Westermark P et al. (2007) Dynamics of fat cell turnover in humans. Nature 453: 783-787.
- Stessman J, Hammerman-Rosenberg R, Cohen A et al. (2009) Physical activity, function, and longevity among the very old. Archives of Internal Medicine 169 : 1476-1483.
- Wells JCK (2009) Historical cohort studies and the early origins of disease hypothesis: making sense of the evidence. Proceedings of the Nutrition Society 68: 179-188.
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- Yu Poth et al (1999) Effects of the National Cholesterol Education Programs Step I and Step II dietary intervention programs on cardiovascular disease risk factors: a meta-analysis. American Journal of Clinical Nutrition 69:632-646.
