What is healthy aging in the 21st century? ⫺4 1 Rudi GJ Westendorp

What is healthy aging in the 21st century?1⫺4
Rudi GJ Westendorp
KEY WORDS
Aging, morbidity, mortality, proinflammatory
response, antiinflammatory response, disposable soma, evolution,
genetics, life span, longevity, genome, Darwinian fitness, early survival, environment, TNF-␣, IL-10
INTRODUCTION
Editor’s Note: This article is based on the Keynote Address
at the Living Well to 100 Conference held at Tufts University.
The author was specifically asked to review the current issues
influencing healthy aging and future directions to set the tone
and context for the emerging science on nutrition and genetics
as presented in the remaining session. As such, this article
should be viewed as laying the practical foundation for the
science presented.
In the years to come, addressing the cumulative damage associated with aging will be one of the biggest challenges faced by
industrialized countries. Since the industrial revolution in the
middle of the 19th century, average female life expectancy has
increased in Western societies from 앒45 y to currently 쏜80 y,
which corresponds to an increase of 2.3 y per decade (1). Life
expectancy has also risen for men, although more slowly; over
the years, the gap between females and males has extended from
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2 to 6 y (1). The increase in life expectancy since 1850 is a straight
line, and there are no indications that life expectancy is leveling
off (Figure 1), despite the estimates of the United Nations, who
predicted the rate of increase to plateau (2).
The curve for Japan provides a key to what drives life expectancy. No other country has seen such a dramatic increase in life
span. From 1900 until the Second World War, life expectancy in
Japan lagged behind other countries by as much as 30 y. At that
time, Japan was an economically poor, agricultural society.
Since World War II, Japan has experienced unprecedented economic and social development and now has the highest life expectancy in the world. Although debate exists as to the specific
elements involved, wealth and an affluent environment correlate
closely with life expectancy. Improvements in sanitation, education, nutrition, and medicine afforded by increased wealth are
positive indicators of long-term health and decreased early mortality for entire populations.
LONGER WELL OR POORLY LONGER?
The increase in average life span observed in all developed
countries is accompanied by an incremental burden of ageassociated diseases. The expectation is that scientific advances
will prevent disease from occurring or, if disease does strike, will
protect us from permanent damage. Over the last 20 y, the United
Kingdom has gained about 4 y in both female and male life
expectancy, but only 2 y in healthy female life expectancy (3).
The overall increase is far greater than that for healthy living, and
this contradicts recent thinking. In 1980, Fries (4) published the
concept of compression of mortality and morbidity, on the basis
of survival curves. Juxtaposing curves from 1900 and 1980, it
appeared that the curve became rectangular with increasing survival to higher age (Figure 2).
Projecting the same curve forward in time, it was expected to
become even more rectangular, to a point where individuals all
survive to a similar age. Mortality would be compressed into a
shorter period; individuals born around the same time would die
over the same 5–15-y period instead of being threatened over the
1
From the Department of Gerontology and Geriatrics, Leiden University
Medical Center, Leiden, Netherlands.
2
Presented at the conference “Living Well to 100: Nutrition, Genetics,
Inflammation,” held in Boston, MA, November 15–16, 2004.
3
Supported by Netherlands Medical Research Council (NWO) 014-91006, 940-38-044, 014-90-002, 014-93-009, and Ministry of Economic Affairs IGE01014A.
4
Reprints not available. Address correspondence to RGJ Westendorp,
Leiden University Medical Center, Albinusdreef 2, 2333 ZA Leiden, Netherlands. E-mail: [email protected].
Am J Clin Nutr 2006;83(suppl):404S–9S. Printed in USA. © 2006 American Society for Nutrition
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ABSTRACT
In the coming years, human aging will be one of the biggest challenges faced by industrialized countries. The average life expectancy
is continuously increasing and we may be faced with spending more
years in poor health. Because aging is a relatively modern phenomenon, we lack knowledge for a proper understanding of this process.
Current biological thinking emphasizes that organisms are encoded
for early survival and reproduction, humans not excluded. Aging is
not programmed nor is it inevitable. Life span is the result of the
interactions between genes and the environment in which we live. In
the original habitat, genes encoding early survival and reproduction
were optimized in an everlasting attempt to increase fitness and
prevent the species from extinction. Aging is best explained as a cost
of optimizing fitness because investments in body maintenance and
repair cannot be maximized. The environment also determines how
a gene influencing life span is expressed over a lifetime. When the
conditions in which we live significantly improve, mortality decreases, evolutionary pressures for early survival and reproduction
relax, and further resources can be invested in body maintenance and
repair, which increases both average life expectancy and maximum
life span. Increasing our understanding of the aging process and
applying available interventions will help to protect and preserve
healthy aging.
Am J Clin Nutr 2006;83(suppl):404S–9S.
HEALTHY AGING
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lifetime. And, as Fries concluded, because there is no mortality
without disease, compression of mortality also implies compression of morbidity; individual suffering before death would also
be limited to those 5–15 y.
The difficulty with this concept is that it assumes a fixed
maximum human life span. It became clear in the 1980s that this
is not the case. The concept also fails to consider the effects on
survival of the extreme environmental change that occurred during the 80 y between data sets, therefore assuming that survival
was independent of environmental factors.
When we examine age at death in Sweden over the last 140 y,
we notice a steep increase over the last 40 –50 y. Examination of
trends in the improvement of survival show that the tendency of
the survival curve to become rectangular existed only for the
period between 1860 and 1950. From then on, there was a parallel
shift of the curve to the right (5; Figure 3).
FIGURE 2. The increasingly rectangular survival curve (4). Reprinted
with permission from reference 4. Copyright 2005 Massachusetts Medical
Society. All rights reserved.
In 2000, using the same data sets, Wilmoth et al (6) further
calculated that the rise in the maximum age at death in Sweden
from the 1860s to the 1990s was due primarily to reductions in
mortality at older ages. Of the total increase, 72.5% was attributable to decreased mortality above the age of 70 y. The increasing size of successive birth cohorts and decreased mortality below the age of 70 y accounted for the balance. It is known that a
reduction in old-age mortality has been a primary factor behind
population aging and the proliferation of centenarians during
recent decades. Wilmoth et al also showed that the mortality
decline above the age of 70 y has been the main cause of a gradual
increase in maximum achieved life span over more than a century. Only a minor part of this increase is due to the larger size of
recent cohorts, which are defined either as numbers of children
born each year or numbers of survivors to old age. It appears that,
although the maximum age has increased more slowly than the
average, the entire distribution of age at death has been shifting
upward for more than a century in industrialized countries.
Current biological thinking emphasizes that organisms are
encoded for early survival and reproduction to prevent the species from extinction. Humans are unlikely to be excluded from
this evolutionary program. In contrast with the strict control over
the first one-half of (human) life history, aging is not programmed. Because a mortality program is absent, aging is not
inevitable (7). The rightward shift of the survival curves and
analyses of changes in mortality patterns from the last half century are in line with the basic idea that there is no biological limit
to life. Therefore, compression of mortality and morbidity is not
valid either. It may even be, because we still suffer from disease
in middle age, that there is actually a decompression of morbidity, as the trend in the United Kingdom suggests. Analysis of
death registries in the Netherlands corroborates the UK findings.
A rightward shift in survival curves occurred from the 1950s
onward (8). Over the past decade in the Netherlands, comparing
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FIGURE 1. Recorded female life expectancy from 1840 to the present (1). The dashed lines denote projections of female life expectancy in Japan as published
by the United Nations (UN) in 1986, 1999, and 2001, respectively. Adapted with permission from reference 1. Copyright 2005 AAAS.
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WESTENDORP
1989 to 2000, average life expectancy increased by 2 y accompanied by an increase in the number of years with disease, hence,
decompression of morbidity. Under current conditions, we are
going to live longer with more years spent in poor health (9).
THE KNOWLEDGE SHADOW
On further improvement of our environmental conditions,
with a continuous increase in average life expectancy and no
biologically determined limit, the question becomes one of
disease-related morbidity. How do we optimize an increasingly
aging population’s health such that we don’t simply spend more
years in misery before we die? The answer lies in a thorough
understanding of the aging process and how available interventions may be applied to protect and preserve health.
Of immediate concern for health of the ever-increasing numbers of elderly is our constrained knowledge domain. The bulk of
medical research has been invested in early development, adulthood, and middle age. Scientific and medical advances in the past
century targeted prevention and control of diseases that threatened survival through the “prime” years, and these represent
enormous contributions to the quality of life we now enjoy in
youth and middle age. While this was happening, however, we
were not investing in our understanding of the natural consequence of this, ie, a growing elderly and aging population. Data
from Sweden and the Netherlands show that 앒80 –90% of deaths
now occur after the age of 75 y. The problem is that deaths at this
age are actually occurring in a “knowledge shadow.”
WHY WE AGE: THE DISPOSABLE SOMA THEORY
The process that underlies the likelihood of disease and death
in old age is considered to occur through the accumulation of
environmentally influenced molecular and cellular damage.
Host response mechanisms responsible for the maintenance and
repair of somatic cells and tissues are limited because they occur
at a cost of investments in early survival and reproduction (10).
Accumulated molecular and cellular damage causes cellular and
tissue dysfunction that, in the organism as a whole, will lead to
disease, disability, and death (11). As we age and accumulate
“scars” of incomplete repair, we become brittle, more susceptible
to disease, frail, and thus more likely to die. In humans, such
degenerative processes were seldom seen within the age ranges
commonly experienced until improvements in survival extended
the average life span. In the “original” environment, under adverse conditions, there was no advantage in investing in higher
levels of maintenance than were required to keep the body in
good condition for as long as it needed to reproduce an offspring
that had a reasonable chance of remaining alive. As a result,
Darwinian fitness has biased the population genome we carry
toward early development and reproductive effort. The theory of
disposable soma suggests that if the finite metabolic resources
are used for somatic repair, eg, to extend healthy age, then an
earlier fitness attribute, ie, reproduction, must be killed to compensate. This has proven to be the case in Drosophila and Caenorhabditis elegans (11).
An illustration of the disposable soma theory in humans is
shown in Figure 4, in which death age versus reproductive
patterns in a closed and environmentally uniform society, ie, the
British aristocracy, is plotted (12, 13). Reproductive success was
low in women who died young and increased with increasing age
at death to late middle-age. From then on, however, it declined
again in women who survived to 욷80 y. This was most pronounced in the period before 1700 when living conditions were
relatively poor and life expectancy was 앒40 y. The trade-off is
unlikely to have been an intended effect: family planning, either
to control family size or to promote maternal longevity, was not
in practice at the time. Apparently, women with more durable
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FIGURE 3. Survival curves in Sweden over the last 140 y. Examination of trends in survival improvement shows that the tendency of the survival curve
to become rectangular exists only for the period between 1860 and 1950. Afterward, there is only a parallel shift of the curve to the right. Reprinted from reference
5 with permission from Elsevier.
HEALTHY AGING
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the new objective of late survival (14). Late in life, a proinflammatory response mode has been associated with high body mass
index, cholesterol, lipids, and risk of cardiovascular disease,
stroke, and dementia (17).
REGULATION OF THE INFLAMMATORY HOST
RESPONSE
somas (greater investment in maintenance and repair) lived
longer at the cost of reproductive success. After 1700, life expectancy of the aristocracy rapidly increased as a result of improved environmental conditions. The trade-off became less pronounced, likely because the evolutionary constraints in
investments in fertility and somatic durability were relaxed.
HOW WE GROW OLD
In an affluent environment, when extrinsic mortality has
greatly diminished and the likelihood of becoming old momentously increased, the genes that have been selected for fitness,
and thus early expression, continue to be expressed in old age.
The effects of this expression may well be detrimental, because
an evolutionary mechanism to get rid of the late-acting deleterious effects of these genes is absent. An example of this is the
positive selection for a proinflammatory response mode to combat infection under adverse conditions, which improves early
survival and fitness (14). Inflammation, on the other hand, is
inferred in the pathogenesis of several age-associated diseases
(15).
In those parts of Africa where neither the environment nor the
average life span has improved compared with that in industrialized countries, and where our genotype had its origin, the first
objective is early survival. How to resist infection and stay alive
long enough to reproduce is paramount, and the genotype is
supportive. This represents a positive selection for the proinflammatory response, because this will improve the chance of survival from infection (16). That same genotype has been transported to the United States and Europe where, in affluent and
nurturing environments, the organism is no longer threatened by
infection. Rather, it is allowed to become very old, and continued
expression of the early survival and fitness genes runs counter to
ORIGINAL GENES IN A NEW ENVIRONMENT
Currently, we have a fairly solid understanding of the evolutionary mechanisms that make us age and also allow us to survive
in such disparate environments as Greenland and the Sahara.
Darwinian fitness constantly shapes the genome to better adapt
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FIGURE 4. Progeny number for married British aristocratic women as a
function of age at death for those born before 1700 and between 1700 and
1875, respectively (12, 13). Reproductive success was low in women who
died young. For both cohorts, reproductive success increased with increasing
age at death until late middle-age, during which it declined again in women
who survived to 욷80 y. Reprinted from reference 13 with permission.
Cytokines, which are the signaling peptides of various cells of
the immune system, are important regulators of the type of host
response the organism will produce. Compounds such as the
proinflammatory cytokine tumor necrosis factor ␣ (TNF-␣) mediate the inflammatory response to fight infection. Regulatory
signals such as interleukin 10 (IL-10) switch off the inflammatory response to reduce collateral damage.
Aging is associated with chronic, low-grade inflammatory
activity; systemic chronic inflammation has been found to be
related to mortality risk from all causes in older persons (18).
Age-related diseases such as Alzheimer disease, atherosclerosis,
diabetes mellitus, sarcopenia, and osteoporosis are initiated or
worsened by systemic inflammation, which suggests the critical
importance of unregulated systemic inflammation in old age
(18 –20). Accordingly, proinflammatory cytokines are believed
to play a pathogenetic role in age-related diseases, and genetic
variations located within the promoter regions of these genes
have been shown to influence the susceptibility to age-related
diseases by increasing gene transcription and therefore cytokine
production (20, 21).
Conversely, genetic variations determining increased production of IL-10 or decreased production of TNF-␣ have been shown
to be associated with healthy aging, which suggests a role for the
control of the proinflammatory mode in older age (22). Predetermination of inflammatory or antiinflammatory mode is genetically controlled and is likely a result of Darwinian fitness pressure. Humans have been programmed for a proinflammatory
response mode sufficient to survive long enough to reproduce
without too high a risk of death from infection (Figure 5).
However, when we invest more heavily in the proinflammatory mode, we sacrifice fertility, because successful pregnancy
requires an antiinflammatory phenotype (23). The investment in
proinflammatory mode by our natural genome, then, must have
a limit. If it moves too far to the right, the fitness cost in reproductive capability discourages survival of the species. This concept may explain why British aristocrats who lived longer were
less likely to reproduce. Their innate proinflammatory immune
system favored resistance to infection. At the same time, it prevented pregnancy from proceeding, a trade-off that became more
pronounced under poor environmental conditions. It also explains why a genotype associated with impaired fertility persisted despite its obvious disadvantage with respect to evolutionary fitness. Selection for resistance to infection was traded
against selection for fertility, which resulted in a compromise
that was optimal for the fitness of the species in the particular
environment.
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WESTENDORP
the organism to its habitat. Our mounting life span is determined
by genes that were originally selected for survival in an adverse
environment and are now expressed under completely new affluent environmental conditions. This may result in different,
sometimes opposing biological effects. For instance, the Drosophila melanogaster gene chico encodes an insulin receptor
substrate that functions in the insulin/insulin-like growth factor
(IGF) signaling pathway. Fruit flies with a chico mutation have
reduced insulin signaling and a longer life span when the adults
are fed a concentrated food diet mimicking affluent environmental conditions (24). This coincides with evidence that reduced
insulin signaling is associated with longevity in a variety of
species. Recently, we found evidence that reduced insulin signaling is also associated with longevity in humans (25).
The chico mutant, however, shows a shorter life span than
wild-type flies when kept under diluted, natural food conditions
(26). This interaction between genes and environment had remained unnoticed under standard affluent laboratory conditions.
The lower survival probabilities under low food conditions explain, from an evolutionary point of view, that the chico mutant
did not emerge in the natural habitat but only under experimental
affluent conditions. It also explains why humans were selected
for insulin sensitivity, improving handling of scarce food and
survival probabilities (27). Now it appears that high insulin signaling under affluent environmental conditions is suboptimal
(25) but was never optimized to match a surplus of food.
ENVIRONMENTAL IMPRINTING
An open issue in aging research is the extent to which responses to the environment during development can influence
variability in the life span in animals and the health profile of the
elderly in human populations. Both affluence and adversity in
human societies have profound effects on survivorship curves,
and some of this effect may be traceable to effects in utero or in
infancy. Data from human observational studies suggest that a
pregnant woman’s diet affects not only the health of her children
but also that of her grandchildren (28). The idea, known as the
Barker Hypothesis, links diet in very early life to disruptions in
glucose-insulin metabolism in later life and has attracted much
attention, as well as some controversy, in medical circles.
One crucial mechanism by which animals can respond in an
adaptive manner to adverse conditions, for example in nutrition
or infection, during development is phenotypic plasticity, which
describes the ability of a genotype to express different phenotypes in response to different environments. However, phenotypic plasticity is only rarely considered by evolutionary biologists or by biogerontologists studying model organisms such as
C. elegans or Drosophila. Recently, we started a discussion of
adaptive plasticity in animals, asking what such a phenomenon
may reveal that is relevant to the rate of aging in animals and in
humans, and to gather the evidence that environmentally mediated events taking place very early in life may determine the
biological status of an individual at the end of life (29).
The biological mechanisms underlying this heritable, epigenetic information have yet to be understood. The findings, however, corroborate findings concerning the regulation of life span
in ants and honey bees. Secretion of larvae juvenile hormone
(corresponding to thyroid hormones in humans) is fooddependent. Should it be stimulated at a critical time in development, the larvae develop into diploid queens with a prolonged life
span. In the absence of this food-triggered hormonal signal, the
same larvae will develop into haploid workers with a short life
span (30). This signaling by the environment to invest particular
attributes in the new organism is an example of early environmental programming. Applied in humans, and given our much
longer average life span relative to ants and honey bees, depending on early environmental programming of food, a life history of
100 y could only be an average. There is enormous potential
plasticity in our life history, but we have not yet identified the
signals controlling it.
CONCLUSIONS
Aging is under environmental and genetic control, but it is not
programmed nor is it inevitable. As evolutionary pressures for
early survival and reproduction decrease, more metabolic resources can be invested in soma maintenance and repair, which
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FIGURE 5. How proinflammatory responses that are beneficial because they increase the probability of surviving fatal infections are traded off against
antiinflammatory immune responses that allow pregnancies to proceed (14). This results in a compromise that is optimal for the fitness of the species in a specific
environment. Reprinted from reference 14 with permission.
HEALTHY AGING
increases both average life expectancy and maximum life span.
Aging is best explained as the balance between investments in
fitness and investments in body maintenance: if investment in
body maintenance is not optimal, aging occurs. Increasing our
understanding of the aging process and applying available interventions will greatly enhance healthy aging.
The author had no conflicts of interest to report.
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