Medical Research Council (MRC) Unit and Institute of Healthy Ageing (IHA), University College London – Written evidence (INQ0007)
Compiled by Professor Nishi Chaturvedi, Professor David Gems and Professor Linda Partridge
1. How complete is the scientific understanding of the biological processes of ageing and their epidemiologies (including the relative roles of genetics, epigenetics, lifestyle, environment, etc.)?
- Common cellular hallmarks of ageing, which include genomic instability, cell senescence, disordered nutrient signalling, mitochondrial and stem cell dysfunction and altered cellular communication have wide support from animal studies. The role of these mechanisms in human ageing is less well documented, but they clearly play a role in the aetiology of multiple age-related diseases. The big opportunity here is to intervene in the processes of ageing to prevent multiple age-related diseases and multimorbidity, rather than treating these diseases one at a time and as they arise. The current Balkanisation of the medical specialities works against realisation of this opportunity.
- Marked socioeconomic differences in longevity and healthy life expectancy highlight the important role of modifiable lifestyle factors (smoking, physical activity, diet), and environment on ageing and diseases of ageing and the potential for general improvement. Direct evidence, quantifying the role of each, the optimal timing of interventions, and the role of individual differences in response, is less clear.
2. How firm is the scientific basis for public health advice about healthy lifestyles as a way to increase health span, including physical health and mental health?
- Observational data across the life course clearly indicate that healthy lifestyles are associated with longer life and health span. They also indicate the importance of the whole life course, i.e. optimising early-life reserve (e.g. cognitive, exercise capacity, respiratory function), maintenance of reserve in mid-life, and promoting resilience in later life to enhance healthy ageing. This contrasts with the current focus on older age alone as the target for interventions, and early prevention is a missed opportunity.
- Gold standard trial evidence, focussed on interventions in older age, is limited and conflicting, as a consequence of small sample size. Limited by a focus on short term mental and physical health outcomes, rather than longer term effects, and on treatment of well-established disease, rather than prevention.
a. What are the practical impediments for this advice being acted on?
- Hard to make persistent changes in healthy lifestyle once habits are entrenched in late youth/early adulthood.
- Adverse impact of commercial interests acting against the public health interest (e.g. smoking, alcohol, diet).
- Lack of effective mechanisms to ensure costs of harms are factored into the price of consumer products, with the consequence that unhealthy choices are often cheaper.
b. Are there examples of good practice in the UK/devolved nations, or elsewhere?
- UK smoking policy, particularly since 2007.
- UK government policy and Food Standards Agency actions on dietary salt intake over the period 2004-8.
- UK Soft Drinks Industry Levy.
- Ageing Well in Wales.
3. Which developments in biomedical science are anticipated in the coming years, in time to contribute to the Government’s aim of five more years of healthy and independent life by 2035?
Research areas may include:
- Treatments based on new approaches e.g. senolytics, epigenetic therapy.
- Drug repositioning.
- Treatment of co-morbidities and polypharmacy.
- Diagnostics, particularly early diagnostics for ageing-related diseases.
- Biomarkers for diagnostics and for monitoring effectiveness of treatments.
- Personalised medicine for ageing-related diseases and multi-morbidities.
- Trials of established drugs, e.g. metformin, with composite healthy ageing outcomes, have been proposed in the US, but not yet started. Indication expansion of licenced drugs that are clearly geroprotective in animals, such as sirolimus, have started for specific conditions such as the poor response of elders to immunisation against influenza, and these trials are likely to be extended to other conditions, such as dementia.
- Senolytics are at a very early stage of drug development, and are likely to be used initially for improvement of quality of organs for transplant and, locally applied, for osteoarthritis.
- Active search for other drugs to reposition, using in silico, genetic and chemical screens.
- The importance of the ageing systemic (blood and lymph) environment is being increasingly recognised and analysed experimentally, and is likely to yield new approaches in the medium future.
- Multiple biomarkers of the progress of ageing and risk of age-related diseases are being developed, including methylation clock, changes in gene expression and levels of metabolites.
- Observational life course data suggests that treatment of co-morbidity needs to start earlier, and possibly be more aggressive, to fully impact on downstream target organ damage. Trial data to support this however is limited.
- No evidence as yet that early diagnosis will result in preservation of function and enhancement of lifespan.
- Personalised medicine a myth – suggests we can tell that a certain individual is destined for a certain outcome – AND that a particular drug/intervention will reduce the risk of that outcome in that same individual. Stratified medicine much discussed, (i.e. identify groups of people at high risk, or who particularly stand to benefit), but no clear successes yet.
4. How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?
- Pretty strong evidence that differences in lifespan by socioeconomic status, ethnicity and geographic region are at least in part due to health behaviours and environment, acting across the whole of life; however, understanding of the pathways responsible for social determinants of health is incomplete.
- The current focus on individually targeted exhortations to change behaviour has limited potential for success – population level (government) policy is a far more effective tool, e.g. smoking legislation.
5. What technologies will be needed to facilitate treatments for ageing and ageing-related diseases, and what is their current state of readiness?
- Drug delivery devices, for existing or future treatments.
- Technologies for monitoring conditions and providing personalised medical advice.
- Technologies for monitoring healthy living e.g. fitness, diet, etc.
- Technologies for disease monitoring and providing advice advanced, but patchy – varies by provider.
6. What technologies will be needed to help people to live independently for longer, with better health and wellbeing? What is the current state of readiness of these technologies, and what should be done to help older people to engage with them?
- Digital communications for services, social interactions, etc.
- Devices, machines, etc. for daily living in the home.
- Transport, infrastructure, services, etc. for involvement in community.
- Accessible public spaces.
- Smart homes.
7. How can technology be used to improve mental health and reduce loneliness for older people?
8. What are the barriers to the development and implementation of these various technologies (considered in questions 5-7)?
a. What is needed to help overcome these barriers?
- The government budget directed to older people is based in Work and Pensions. Policy efforts for older people would mainly result in benefits to the NHS and local authority social services. This creates a situation where expenditure in one government department does not benefit that department.
b. To what extent do socio-economic factors affect access to, and acceptance of, scientific advice and use of technology by older people and those who care for them?
9. What opportunities are there for industry in the development of new technologies to help increase health span? In which areas of medical research and technology development does the UK excel?
- The UK science base in biomedicine of ageing is quite strong, but very unlike the US in that it does not produce start-ups. Nearly all of the exploitation of the fundamental discoveries about mechanisms of ageing is happening in the US.
10. What more is required for the UK to benefit from commercialisation of its discoveries and inventions relating to healthy ageing, as envisioned by the Government’s Industrial Strategy?
- Probably get the tech transfer and venture capital people in closer touch with the scientists, who in the UK scientific culture tend not to spot the opportunities.
11. How feasible is the Government’s aim to provide five more years of health and independence in old age by 2035?
a. What strategies will be needed to achieve the Government’s aim?
- Policies to enhance health across the whole of life. This includes investment in education in early life, improved interventions to prevent and treat ill health in mid-life, and maintenance of physical, cognitive and social function in later life.
b. What policies would be required, and what are their potential costs and benefits?
c. Which organisations need to be involved?
- This is a government responsibility and it is a cross-departmental issue.
d. Who should lead the work?
12. To what extent are inequalities in healthy ageing, as well as differences in acceptance of technologies, a barrier to achieving the aims of the Government’s Ageing Society Grand Challenge?
a. To what extent could achieving the Government’s aim of five more years of healthy and independent life exacerbate, or reduce, these inequalities?
- Individual-based interventions likely to benefit the most affluent/educated, because they are the most likely to take up what is offered, and hence likely widen inequalities in older age.
13. What would be the implications of a paradigm shift to people leading healthier lives for longer, and spending less time suffering ill health?
- Economic impacts.
- Time spent in work as opposed to in retirement.
- Provision of activities and services for active older people.
20 August 2019