Editor's Note: Commentary based on Jacob ME, Yee LM, Diehr PH, et al. Can a healthy lifestyle compress the disabled period in older adults? J Am Geriatr Soc 2016;64:1952-61. For accompanying article summary, please see the associated Expert Analysis.

Improved health in the United States has resulted in greater longevity, raising concerns about increased disabilities in an increasingly aging population. Disabled older adults have poorer quality of life and health outcomes, including frequent hospital and nursing home admissions, as well as increased risk of mortality. Disabilities in older adults contribute to higher Medicare costs and family and societal burden. Most importantly, disability leads to poorer quality of life. Surveys indicate that older persons frequently fear severe, prolonged disability and dependence more than death.

Fries defined successful aging as the "compression of morbidity (time between the onset of disease and death)". Almost all older adults prefer to minimize time spent in the disability period and desire to age productively. This depends largely on delaying chronic diseases, which in turn can be significantly impacted by lifestyle and health behaviors.

Jacob et al. found in this large, well-characterized community-based sample of 5,248 older adults (mean age of 73) that the healthiest lifestyle (nonsmoker, regular exercise, better-quality diet, and healthy weight) was associated with longer duration of life that was consistent across age groups, sex, and race. Importantly, healthy behaviors were also associated with fewer disabled years at the end of life. Overall, older adults with the healthiest lifestyle could expect to spend about 1.7 fewer years disabled compared to their counterparts who did not follow healthy lifestyles. In particular, obesity (BMI ≥ 30.0 kg/m2) was associated with a significantly lower proportion of able years (7.3% fewer) than normal BMI. Every 25 blocks walked in a week was associated with slightly longer able-bodied years. A limitation of the current study is the subjectivity of the self-reported data on disability and health behaviors. In addition, health behaviors were assessed at baseline, and behavior patterns could have changed over time, influencing the outcomes.

These findings are supported by a prior study in Taiwan in 2011 that included over 3,000 men and women over the age of 60 and demonstrated that people who practiced at least one of four healthy behaviors (regular exercise, nonsmoker, light to moderate alcohol consumption [no more than one alcoholic beverage every other day], and sleeping six to eight hours per night) were less likely to become disabled. Moreover, the more healthy behaviors people practiced, the less likely they were to become disabled.¹

In conclusion, an unhealthy lifestyle, even later in life, predicts future disability and mortality, suggesting that maintaining healthy lifestyle behaviors may help compress morbidity near the end of life. The finding that obesity is associated with an expansion of the disability period has important implications in the context of rising obesity rates in the older adult population. Adiposity-induced inflammation has wide-ranging adverse effects, including endothelial dysfunction, capillary rarefaction, and mitochondrial dysfunction in both the cardiac and systemic vascular beds.² Furthermore, aging is a systemic process affecting all organ systems and associated with significant alterations in body composition. Typically, fat mass increases with age and peaks around age 60–75 years.³ Obese persons tend to be less physically active; conversely, a sedentary lifestyle is an important risk factor for obesity. These results caution that the increasing obesity levels of older Americans could herald a disability epidemic. By advocating healthy lifestyles, including regular exercise, a prudent diet, maintaining a desirable weight, and avoidance of tobacco products, we have an opportunity to reduce the public health burden attributable to disability as more adults reach advanced age.

References

1. Liao WC, Li CR, Lin YC, et al. Healthy behaviors and onset of functional disability in older adults: results of a national longitudinal study. J Am Geriatr Soc 2011;59:200-6.
2. Kitzman DW, Shah SJ. The HFpEF obesity phenotype: the elephant in the room. J Am Coll Cardiol 2016;68:200-3.
3. Ding J, Kritchevsky SB, Newman AB, et al. Effects of birth cohort and age on body composition in a sample of community-based elderly. Am J Clin Nutr 2007;85:405-10.

Keywords: Geriatrics, Secondary Prevention

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