Professor Avan Aihie Sayer, University of Newcastle – Written evidence (INQ0019)

Questions

Scientific basis

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.)?

• Significant progress has been made in understanding the epidemiology of ageing, but much work remains to be done. It is clear that lifestyle and environment are important factors across the lifecourse that influence the ageing trajectory, and as modifiable factors, these are key to understand in depth if we are to design appropriate interventions at different stages of life to prolong healthspan and compress morbidity.

• Insights from the biology of ageing (for instance the role of oxidative stress, inflammation and hormonal changes) are now starting to come together into models of ageing that can inform the development of interventions. An example would be using drugs to modulate the impact of excessive oxidative stress across multiple organ systems including muscles, kidneys and heart, to protect against multiple diseases. Such approaches are now starting to be tested in clinical trials. This work in translational ageing research is critical to ensure that insights into the basic biology of ageing have a positive impact on health and wellbeing for people as they age.

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?

• The scientific basis for public health advice about healthy lifestyles as a way to increase health span is strong. For example, recent analyses conducted for the Global Burden of Disease project have addressed the impact of lifestyle factors on morbidity and mortality across large data sets from national as well as international settings. This work has shown clearly that lifestyle factors (obesity, poor diet, physical inactivity, alcohol and smoking) are leading causes of years of life lost. As these are potentially modifiable influences on health, they are key to effective preventive public health strategies and current advice.

a. What are the practical impediments for this advice being acted on?

• Health behaviours are socially patterned, such that ‘healthier’ lifestyles are far more common among more affluent, educated sectors of the population and less common among disadvantaged groups. These differences are central to the current inequalities in health in the UK. Although the challenges of changing heath behaviours are widely recognised, much health advice is still targeted at the individual, with emphasis put on individual responsibility. As there may be relatively greater engagement from more advantaged groups with such health promotion strategies, these initiatives may even act to widen health inequalities. To achieve the ambition of increasing healthy years of life, while narrowing the gap between the richest and poorest members of society, much greater focus is needed on ‘top-down’ structural and policy considerations. In terms of practical impediments, an individual’s environment across the lifecourse is key: making healthy lifestyle choices in unhealthy, unsupportive environments is unlikely to be successful or sustainable.

b. Are there examples of good practice in the UK/devolved nations, or elsewhere?

• There are excellent examples of upstream policy interventions in the UK that have been effective in achieving change in lifestyle factors that are linked to poor health. Notable successes include the introduction of smoke-free legislation (England, 2007), reducing exposure to second-hand cigarette smoke, and Public Health England’s current Reduction and Reformulation Programme, working with industry to reduce the level of salt and free sugars in processed foods. In addition there are many important local examples of good practice, particularly where environments have been changed to make them ‘age-friendly’ https://www.who.int/ageing/projects/age_friendly_cities_network/en/. These include structural changes to neighbourhoods of older adults that improve ‘walkability’ - promoting opportunity for physical activity, increasing access to shops and services that support independent living, as well as enhancing social interaction.

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

• The lead time for novel agents to be tested in trials, to reach the marketplace, and then to have time to impact on the health of older people at scale is long, and it is unlikely that such interventions starting clinical trials now will have a significant impact by 2035. Nevertheless, investment in this area of translational research will be vital for longer-term benefit beyond the 2035 horizon.

• The pathway from laboratory to clinic for existing drugs that can be repurposed is shorter however, and it is possible that such agents, if shown to be effective in trials, could contribute to the Government’s aim of five more years of healthy and independent life by 2035. Repurposing existing medications provides the quickest route to generating drug interventions with benefit across multiple conditions as discussed below.

• Effective treatment of multimorbidities requires interventions that treat more than one disease. The existing paradigm of treatment, where each individual disease is treated with multiple medications, has led to polypharmacy – and the use of multiple medications is associated with harms. In the short term, effective treatment of multimorbidities is likely to come from non-drug interventions, particularly the effective delivery of exercise and nutritional interventions as described above. Schemes to reduce polypharmacy may also provide improvements in health and wellbeing; such schemes are already being delivered at scale in some areas of the UK, although high-quality evidence of net benefit to health, function and quality of life for older people from polypharmacy reduction is currently lacking.

These are priority areas of research at the NIHR Newcastle Biomedical Research Centre (https://www.newcastlebrc.nihr.ac.uk/).

4. How complete is the understanding of behavioural determinants and social determinants of health in old age, and of demographic differences?

• Understanding behaviours is a focus of research at the Newcastle University Institute for Ageing (https://www.ncl.ac.uk/ageing/) and the NIHR Policy Research Unit in Behavioural Science at Newcastle University (https://research.ncl.ac.uk/behscipru/).

Technologies & Industrial strategy

Questions 5. – 10.

• The UK’s National Innovation Centre for Ageing, at Newcastle University (https://www.ncl.ac.uk/nica/), leads on technological and other innovations for ageing societies.

Healthier ageing

11. How feasible is the Government’s aim to provide five more years of health and independence in old age by 2035?

• This is an ambitious aim. However, much has been achieved in understanding influences on health in older age, and gains in healthy life years are achievable. It will require a translational approach to take research findings into real-life settings, needing appropriate investment as well as integration of health promotion strategies across the lifecourse.

a. What strategies will be needed to achieve the Government’s aim?

• Investment in translational ageing research to ensure that insights from discovery science are tested rigorously in clinical trials and that effective therapies can be delivered in practical ways via healthcare, social care, public health and public policy structures

• Effective lifecourse strategies – recognising the impact of health across the lifespan as well as what features of health may become more important in older age such as maintaining physical function, cognitive function and independence

• Population-level approaches to support health across the lifecourse, including investment in age-friendly environments and other strategies to encourage social engagement and interaction with older people

Questions 12. – 13. Inequalities in health in older age is a focus of research at the Newcastle University Institute for Ageing (https://www.ncl.ac.uk/ageing/)

17 September 2019