The Physiological Society – Written evidence (INQ0066)

Introduction

The Physiological Society brings together over 4000 scientists from over 60 countries. Since its foundation in 1876, its Members have made significant contributions to our knowledge of biological systems and the treatment of disease. We promote physiology and support those working in the field by organising world-class scientific meetings, offering grants for research, collaboration and international travel, and by publishing the latest developments in our leading scientific journals including The Journal of Physiology.

The Physiological Society is pleased to note that the Committee’s inquiry is considering human ageing as a whole, rather than focusing on the management of individual diseases, given the commonality that underpins the mechanism of much pathophysiology. In recognition of the value of physiology in meeting the Government’s ‘Healthy Ageing’ Grand Challenge mission as part of the Industrial Strategy, The Physiological Society has worked alongside an Expert Group and over 60 experts in the field of ageing research and policy to examine physiology’s role in meeting the Government’s target of ‘people enjoying five more years of healthy, independent living by 2035 while narrowing the gap between the experience of the richest and the poorest’. While our final report, Growing Older, Better is yet to be published, this response builds on the report’s evidence base and key conclusions

Our membership includes scientists researching the causes and mechanisms of ageing and potential treatment interventions to blunt and/or reverse ageing processes. Building a better scientific understanding of ageing processes is the most likely way to identify successful treatments for blunting or managing the negative effects of ageing. As such, we are best positioned to answer questions 1-4, 11 and 12 in the Committee’s call for evidence.

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.)?

Ageing is not a disease. The physiology of ageing is a heterogeneous process, with individuals ageing differently depending on their genetic background, environmental exposures and other factors. Importantly, we do not know the relative roles of genetics, epigenetics, lifestyle, environment in dictating the rate of ageing processes, particularly in humans. Recognising the whole system reality of ageing therefore, underpins a successful approach to healthy ageing. Ageing is however, a significant risk factor in almost all diseases and adverse health events. Similarly, physiology as a discipline is not disease-specific but it pervades all aspects of ageing and progression into pathophysiology. A dysregulation of physiology if not rectified can lead to pathophysiology and ultimately disease. This remains a significant barrier to developing interventions to retain intrinsic capacity.

One of the main contributions physiological research can make to discussions around optimum healthy ageing is ultimately to underpin epidemiological insight with mechanistic science and understand how best to maintain homeostasis (optimal function) throughout life and promote better lifelong health. These mechanistic studies need to be performed in humans – the best model of human ageing! Ultimately, the purpose of physiological research into ageing is focused on ensuring that as many people as possible follow the optimal trajectory of physical capacity and ageing as noted by the World Health Organization[1]  and ensure that physiological research is focused on supporting those whose ageing trajectories are not currently optimised. As the Science Advice for Policy by European Academies (SAPEA) notes in its recent report Transforming the future of ageing, ‘Functional ageing is the best possible approach to address ageing across the life course, knowing the importance of acquiring the most important functional abilities at a young age and preserving them during the whole life. This approach can support the policy objective for citizens to live healthier as well as longer.’[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? a. What are the practical impediments for this advice being acted on? b. Are there examples of good practice in the UK/devolved nations, or elsewhere?

Physiological research is essential to support future lifelong health policies by promoting credible and targeted evidence to fill gaps in public health messaging. Some experts that were engaged as part of the evidence building for Growing Older, Better expressed concern that arbitrary targets (such as the amount of exercise achieved per week or the number of steps per day) may act as a barrier to participation for some members of society if they are considered unattainable (owing to age or baseline functional capacity). It is crucial therefore, that physiological evidence is used as the basis of personalised plans, to develop exercise regimes or appropriate diet plans.

Societal misconceptions of ageing, are also a practical impediment to advice. These include ideas that there are certain conditions or behaviours which are part of ageing (e.g. aching joints or reduction in social interaction) or are no longer appropriate for people as they get older (e.g., long-distance cycling), and what we mean by ageing, and the factors that contribute to it, is undoubtedly complex.

There has been a welcome shift in the public conversation around mental health and wellbeing and this is something that demonstrates how an integrative, physiological approach can support whole-system approaches throughout life. Similarly, Alzheimer’s Research UK have noted that further physiological research is crucial to understanding the function of the brain and the mechanisms in diseases like Alzheimer’s that underpin the progression of dementia.

2. 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:
1. Treatments based on new approaches e.g. senolytics, epigenetic therapy

Despite major funding investment, we are yet to see a significant impact on ageing from drug interventions. In reality, lifestyle (including behaviour) change is likely to be the best route to approach the Government’s target of 5 more healthy years by 2035.  It is important to recognise that it is lifestyle change that will impact on the myriad of molecular and cellular events driving ageing, and therefore positive changes to lifestyle are likely to be most effective in achieving healthy ageing.

2. Drug repositioning
3. Treatment of co-morbidities and polypharmacy

Decline in quality of life as we age is likely to reflect the combination of multiple health conditions and therefore the interplay between conditions can be significant. While there is growing recognition of the importance of multimorbidities, there is the challenge that many of the UK’s health systems have been set up on a condition by condition basis. Health problems are understood by the public as being independent of one another and they underestimate the extent to which they have agency of their own healthspan. The evidence basis around policy interventions that support multiple conditions is starting to develop, The Physiological Society would like see more regular contact between public health organisations, local authorities, charities and physiologists to better communicate the causal relationship between declining physiological function, declining healthspan and multimorbidity.

4. Diagnostics, particularly early diagnostics for ageing-related diseases
5. Biomarkers for diagnostics and for monitoring effectiveness of treatments

As ageing is not a disease, there has been a frustration among physiologists that there is a lack of consensus on reliable biomarkers of healthy ageing that are consistent across different cell and tissue types as they age, which are also inexpensive and easy to monitor[3]. Physiologists with a focus on ageing feel that in order to support an integrative approach to ageing across different aspects of physiology, a group of biomarkers would need to be established that is rigorously evidenced, recognises the diversity of effect of ageing within different cells and how they are monitored and is sufficiently inexpensive to be replicated across long-term studies as necessary.

The Physiological Society will encourage a dialogue between physiologists and other researchers in emerging research on biomarkers to ensure biomarkers are rigorous and easily replicable in large-scale studies. Any biomarker will only be as good as the quality of the physiological measurement that the biomarker is purportedly predicting.

6. Personalised medicine for ageing-related diseases and multi-morbidities

We view personalised medicine as an approach that uses information from an individual’s genome, combined with other clinical and diagnostic information, to determine someone’s risk of developing disease; detect illness earlier; and, determine the most effective interventions to help improve our health from pharmacological approaches to lifestyle choices or effective diet and exercise plans.

While personalised medicine is an important part of the Government’s health strategy, it currently has insufficient focus on physiology and the benefits it can offer the healthy ageing process. Physiology has an important role in to play in ensuring the success of technological advancements such as UK Biobank and Genomics England. A personalised medicine approach will only be as successful as the physiological phenotyping of these patients, i.e. relating genome differences to physiological differences. Knowing the genome alone is not enough – the potential is in applying it to physiological differences between these individuals, which will identify susceptibility to ageing processes, and predict response to, ill health and disease.

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

There are significant gaps in public, clinical and policymakers’ understanding of the physiological evidence that can help people live longer and healthier lives. The Physiological Society believes that physiological insight is essential to support the development of relevant and impactful interventions – whether public awareness raising, activities and initiatives for individual behaviour change or broader national government interventions.

At the same time, this evidence-based approach must be combined with a reframing of the public’s perception of ‘normal ageing’ to support extended healthy life expectancy (or ‘healthspan’). We have found professional concern that the public often perceives ageing and loss of function as inevitable. For example, public perceptions that dementia is an inevitable part of ageing are a serious barrier to the risk reducing benefits of physiological interventions, such as diet and exercise. We also know the public don’t make the link between their heart health and their brain health, so we need to use all relevant insight from physiological research to develop clearer public messaging. This perception of ageing can prevent people from making positive changes to their lifestyle to maintain or improve function in later life or can lead to cessation of positive behaviour, such as physical activity. This further decreases function and speeds up the process of ageing.

One of the benefits of an improved understanding of the insight of physiology into ageing, would be a move away from disease-specific motivation towards a more integrative approach to lifelong health. As can be seen from examples such as the work of the Royal Osteoporosis Society on their consensus statement Strong, Steady and Straight, part of the recovery process of a fracture is ensuring that other systems in the body are sufficiently well-maintained to compensate for the loss of bone strength[4]. Shifting perceptions away from limiting people’s activity, unless there is robust physiological evidence, should be welcomed as a starting point for a ‘something is better than nothing’ approach to lifelong health that is inclusive regardless of age or current physiological function. This has application throughout the body and this presents an opportunity to leverage existing public interest to improve the quality of lifelong health dialogue with the public.

Healthier ageing

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?

With the creation of UK Research and Innovation (UKRI) and the Government’s commitment to increase research and development (R&D) spend to 2.4% by 2027, there is an excellent opportunity to review how funders establish priorities for their funding calls and the extent to which physiology research projects are funded and understood as critical to multidisciplinary responses to healthy ageing.

While The Physiological Society welcomes the Government’s funding for a healthy ageing agenda, we are concerned that the Government is too focused on responding reactively to ageing, rather than being proactive in challenging the causes of ageing and the ageing process itself. We believe that this means the Government, health service and associated public bodies will not make the step change we need to see in their response to this ageing challenge. As Figure 4 shows, in order to meet the 2035 target, the average healthy life expectancy will have to increase by nearly six months every year between now and 2035 and we do not believe that this can be achieved exclusively through managing pathophysiology and its symptoms as they manifest. An ambitious target for healthy ageing requires an ambitious response and we believe that this can only be achieved by placing physiology at the heart of this response.

The fragmentation of commissioning between local and national government in England for various aspects of lifelong health, encourages a siloed approach to policy making. This has the potential to create barriers that will make it difficult to achieve healthy ageing targets. Structural barriers between commissioning organisations, separate budgets and differing organisational priorities make it much more difficult to implement broad, ambitious projects that may have the most potential to improve health outcomes. Initiatives such as Scotland’s integration joint boards (IJBs) to which the NHS board and local authority both delegate the planning, governance and resourcing of existing responsibilities, give a clear responsibility to one actor in the system to deliver a more integrated system, a Chief Officer[5]. While these Chief Officers face similar barriers to integration as the English system, there is at least recognition that the integration requires an actor that is recognised as being responsible for driving change in a complex environment that is still heavily dependent on trust and goodwill between local stakeholders.

b. What policies would be required, and what are their potential costs and benefits?

The Government should deliver joined-up policymaking that incentivises the most beneficial decisions to be made at the right point within the system. There is a tension between local government’s responsibility for public health and leisure activities and the ‘savings’ accrued to the nationally-commissioned health service from healthier ageing and this is leading to reluctance among policymakers to invest in preventative services

At a national level, there is also the risk that individual departments focus on different priorities within the ‘healthy ageing’ agenda to the detriment of maintaining or improving function in later life.

The Physiological Society welcomes the Government’s mission-led strategic thinking within the context of increasing investment in R&D to 2.4% of GDP by 2027. Physiology is central to understanding the processes that are fundamental to the ‘ageing society’ priority that has been identified by the Government.

In order to achieve this, the basic research pipeline needs to be maintained to ensure that the Government can meet the objectives set out within the Industrial Strategy Challenge Fund (ISCF). Translational businesses and technologies that are attractive from an investment perspective do not exist in a vacuum and pure research is able to develop ideas and solutions for problems that have not as yet been identified by national governments. Investment in research should therefore look to representatives from across the whole research spectrum to ensure a balance.

c. Which organisations need to be involved?

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?

Throughout evidence-gathering for The Physiological Society’s report Growing Older, Better, experts have regularly noted the correlation between socio-economic status and health and wellbeing indicators. As the Office for National Statistics data shows, for women aged over 65, the top 10% most affluent in society will live over twice as long in good health as women from the bottom decile. At the same time, both life expectancy and healthy life expectancy increase as the levels of affluence increase[6]. The Society’s independent survey results corroborate the strong correlation between affluence and improved health outcomes. Those from low-income backgrounds were less likely to feel sufficiently informed to improve their general health[7] and those from lower socio-economic backgrounds were over twice as likely to say that there was no tangible benefit that would encourage them to make healthier lifestyle choices[8]. At the same time, those from low income groups[9] are less likely to be confident that any change they make to their lifestyle is likely to have a positive impact on their health in later life. This is undoubtedly a key challenge to meeting overall improvements in population-wide health, and therefore will need to be addressed in any healthy ageing policy agenda.

20 September 2019