1. Social and Behavioral Factors
Predicting Healthy Aging: the
Roles of Socioeconomic Status
and Physical Activity
Jack M. Guralnik, M.D., Ph.D.
Laboratory of Epidemiology,
Demography and Biometry
National Institute on Aging, NIH

3. Death Rates (Per 100,000) for Six Leading Causes
of Death, Age 65+, U.S.
Percent
Change
1980-
1980 1990 2004 2004
Heart Disease 2,629 2,092 1,537 -41.6
Cancer 1,052 1,142 1,112 +5.7
Stroke 669 449 376 -43.8
COPD 179 245 303 69.3
Diabetes 107 120 155 44.9
Pneumonia/ 214 258 152 -29.0
Influenza
Source: National Vital Statistics System Rates age-adjusted using 2000 standard population

4. Probability of Dying Between Age 45 and 65
Comparing Men in Manual versus Non-Manual Occupations
Absolute manual vs. non-
Country Probability of dying (%) manual difference
National Non-manual Manual
population classes classes
Finland 24.0 18.9 28.8 9.8
Sweden 16.4 14.1 19.7 5.6
Norway 18.0 15.7 20.9 5.2
Denmark 21.0 19.1 25.4 6.3
England/Wales 20.3 16.5 24.0 7.5
Ireland 23.1 21.0 29.1 8.1
France 21.3 16.2 27.6 11.5
Switzerland 16.7 14.5 19.5 5.0
Italy 20.8 18.5 24.6 6.0
Spain 18.1 15.2 21.1 5.8
Portugal 21.0 16.4 22.5 6.1
Source: Kunst et al. Soc Sci Med 1998;46:1459-76.

5. Probability of Dying Between Ages 15 and 59

6. Mortality and Education in Men Aged 45–90 years in Matlab, Bangladesh
1982–98
Hurt et al. J Epidemiol Community Health 2004;58:315-320.

7. Educational Inequalities* for Major Causes of Death in Men
Europe, 1990 – 1997
≥45 year ≥75 years
Rate ratio Rate difference† Rate ratio Rate difference†
IHD 1.3 148 1.1 312
CVD 1.3 78 1.2 264
Lung cancer 1.7 106 1.4 168
COPD 2.0 95 1.8 335
Total mortality 1.3 796 1.2 2127
* Pre-primary, primary, lower secondary vs. upper secondary and post-secondary
†
Difference in deaths per 100,000 population.
Source: Huisman et al. Lancet 2005; 365:493-500.

9. Life Expectancy
The average number of years of remaining life for
an individual who is a specific age
Active Life Expectancy
The average number of years of remaining life
which is disability-free for an individual who is a
specific age
Disabled Life Expectancy
The average number of years of remaining life
with disability for an individual who is a
specific age

10. TRANSITIONS TO CONSIDER WHEN
COMPUTING ACTIVE LIFE EXPECTANCY
BASELINE STATUS AT ONE YEAR
REMAIN DISABILITY-FREE
INITIALLY DISABILITY-FREE DISABLED
DIE
REMAIN DISABLED
INITIALLY DISABLED NON- DISABLED
DIE

11. Total Life Expectancy, Active Life Expectancy
and Disabled Life Expectancy
Piedmont Health Survey of the Elderly; Women, Age 65
Total Life
Expectancy
White Women
Low Education 15.2 2.6 17.8
High Education 18.0 3.0 21.0
Black Women
Low Education 15.6 2.7 18.3
High Education 19.5 3.3 22.8
0 5 10 15 20 25
Active life expectancy Disabled life expectancy
Source: Guralnik, et al. New Engl J Med 1993;329:110.

12. Americans who had not graduated from high school had a death
rate two to three times higher than those who had graduated from
college. This gap in mortality between the relatively advantaged
and the disadvantaged is very large -- larger than the gap due to
many other well-known risk factors, including cigarette smoking,
and it has been growing wider.
Marcia Angell, NEJM 1993:329:126-127

13. Proportion Surviving from Age 26 to 54 Years by Father’s
Social Class in 4271 Persons Born in March 1946
(Total Deaths = 201)
1
0.99
Proportion alive
0.98
Non-manual
0.97
0.96
0.95
Manual
0.94
0.93
26 30 34 38 42 44 48 52
Age
Kuh et al, BMJ 2002

14. Low and High Function at Age 53
British 1946 Cohort Study
• Aggregation of standardized scores on three tests
– Grip strength
– Single leg stand for up to 30 seconds
– Time to rise from chair 10 times
• Low function defined as lowest 10% of aggregate
score
• High function defined as highest 10% of aggregate
score

15. Distribution of Summary Performance Score
8
6
Percent
4
2
0
.5 1 1.5 2 2.5 3
Sum of continuous test scores

16. Figure 2. Self-Report of Disability and Falls in Persons with Poor, Middle,
and High Performance. Weighted to adjust for sampling.
Difficulty walking 1/4
mile
Difficulty walking up
and down stairs
Difficulty gripping
Performance at age 53
Falls or poor balance Poor
Middle
1-2 fall past year High
3+ falls past year
0
0 10 20 30 40 50 60
Percent

17. Relative Risk (95% CI) for Poor and High Function at Age 53
According to Childhood Social Factors
British 1946 Cohort Study
2.0
High High
Relative Risk (95%CI)
1.5
Function Function
1.0
.5
Poor Poor
Function Function
0
Adjusted for Sex Adjusted for Sex and Adulthood risk factors
(smoking, exercise, BMI, Alcohol intake)
Father’s Occupation (Manual vs. Non-manual)
. Mother’s Education (Primary vs. Secondary)

18. Percent of Participants with Poor and High Function According to Mother’s
Education and Father’s Occupation when Participant was Age 4.
Weighted to adjust for sampling
18 18
Poor function High function
16 16
14 14
12 12
Percent
10 10
8 8
6 6
4 4
2 2
0 0
Primary Secondary Primary Secondary
Mother’s Education Mother’s Education
Father’s Occupation Manual Non-manual

19. Gait Speed (400-m) According to Education Level,
Age Group, and Gender
InChianti Study
1.6
1.4
1.2
Gait Speed (m/s)
1
Years of
0.8 Education
<= 5 years
0.6
> 5 years
0.4
0.2
0
65-74 75-84 85 + 65-74 75-84 85 +
Age Group
Men Women

20. Mean Walking Speed (95% Confidence Intervals) by
Employment Grade and Sex
Adjusted for Age and Ethnicity
Whitehall II Study
1.5
trend P<0.001 both sexes
Walking speed (m/s)
1.4
1.3 Men
1.2 Women
1.1
1
Admin 1 Admin 2 SEO HEO EO Clerical
Last known employment grade
Brunner et al. J Gerontol Med Sci 2009;64:1082-9.

21. We are all wearing out but poor
people wear out faster than rich
people.
How can we modify health
disparities?

22. Physical Activity and Disability in
Older Persons:
Moving From Observational
Studies to Clinical Trials of
Disability Prevention

23. Risk Factors for Disability
• Low physical activity
• Smoking
• High and low body mass index, weight
loss
• Heavy and no alcohol consumption
• High medication use
• Poor self-rated health
• Reduced social contacts
Source: Stuck et al., Soc Sci Med 1999;48:445-469

24. DHHS Physical Activity Guidelines
Advisory Committee Report, 2008
Functional Health Chapter
Review of observational studies:
• Active mid-life and older individuals have
approximately a 30% lower risk of developing
moderate or severe functional limitations or role
limitations compared with inactive individuals.
• Results strongly consistent across studies
• No large RCTs and data cannot prove causality of
effect
http://www.health.gov/PAguidelines/Report/Default.aspx

25. Maintaining Mobility in Late Life
Established Populations for the Epidemiologic
Study of the Elderly (EPESE)
Study Design
Maintained
mobility
3847 (53%)
Loss mobility
Four annual 2526 (35%)
Baseline followups
Mobility
10,048
7227 (72%) Died - no
screened
mobility loss in
prior interviews
608 (8%)
Mobility-related Missing data
disability 246 (3%)
2821 (28%)
Source: Guralnik et al. Am J Epidemiol 1993;137:845-857

26. Physical Activity and Incident Mobility Loss
1.5
Men
Women
1.0
Relative Risk
of Loss of
Mobility**
0.5
0.0
Low High
Physical Activity*
*Summary measure including walking, gardening, and vigorous activity.
**Adjusted for age, number of chronic conditions, body mass index, smoking and alcohol consumption.
Source: LaCroix et al. Am J Epidemiol 1993;137:858-869.

27. Change in SPPB Score Over One Year
by Baseline Walking Category
Women’s Health and Aging Study
Mean change in summary
P=.001 P=.023 P=.012
performance score
0 Walkers
-0.2 Non-walkers
-0.4
-0.6
-0.8
Model 1 Model 2 Model 3
Source: Simonsick et al. J Am Geriatr Soc 2005;53:198-203.

28. Could the Evidence for the Benefits of Exercise
be Overstated by Longitudinal Studies?
• Other habits of exercising older adults may be operative
(Confounding)
• Good health permissive of exercise
(Reverse Causality)
• Reporting bias
(Non-differential misclassification)
• Data don’t directly address the public health intervention
under consideration
(Continuation versus Initiation)
Source: Kritchevsky 2009

29. Why is a clinical trial needed to demonstrate
that exercise prevents disability?
• Can improve impairments such as weakness and
poor balance
• These impairments have been shown in
observational studies to predict disability
• However, it is unknown whether treating impairments
will lead to prevention of disability
- Underlying condition that caused muscle
weakness may also go on to cause disability, even
if muscle strength improved by intervention

30. Lifestyle Interventions and
Independence For Elders
A Randomized Clinical Trial of Exercise to
Prevent Mobility Disability in Non-
disabled Older Persons with Functional
Limitations

31. Potential public health impact is high:
• Discrete, easily understood outcome
(walking 400 meters)
• Intervention that is practical and
potentially cost effective
• Supports evidence based medicine for
physicians to prescribe this intervention

32. Why a mobility intervention?
• Mobility a fundamental component of:
- Self-care – ADL’s
- IADL’s
- Independence in the community
• Focused intervention with clear endpoint
• Practical to power study compared to less
common endpoints

33. Older people who maintain mobility:
• Remain in the community
• Have lower rates of subsequent morbidity
and mortality
• Have higher quality of life
• Have lower health care costs and utilization
• Can walk for exercise

34. Overview of Study Design – LIFE-P
• Multicenter single-blind pilot RCT
– Pittsburgh, Wake Forest,
Cooper Institute, Stanford
• Physical exercise vs. successful aging health
education program
• 400 non-disabled, community-dwelling
sedentary persons age 70-89 years who are at
risk of disability
• Follow-up: one to two years
• Outcome: Short Physical Performance Battery
(SPPB) Score

35. Short Physical Performance Battery
Timed standing balance (up to 10 seconds)
Side-by-side stand
Semi-tandem stand
Tandem stand
Timed 4-meter walk
Timed multiple (5) chair rises

36. Disability Status at Four Years According to Baseline Summary
Performance Score Among Those Non-Disabled at Baseline
Iowa EPESE
100
80 Non-
disabled
Mobility
60 Disability
Percent
ADL
40 Disability
20
0
4 5 6 7 8 9 10 11 12
Summary Performance Score
Source: Guralnik et al. N Engl J Med 1995;332:556-561.

37. Age and Sex-Adjusted Proportion of Participants Unable to Complete 400 Meter
Walk at 3-Year Follow-Up by Baseline SPPB Score
InChianti Study
Unable to walk 400m after three years (%)
90
80
70
60 p for trend <0.001
50
40
30
20
10
0
<7 8 9 10 11 12
Baseline SPPB Score
n 18 18 40 47 126 284
Source: Vasunilashorn et al. J Gerontol Med Sci, 2009;64:223-9 .

38. LIFE Study Goals vs. Actual Enrollment
All Clinics
Enrollment
Recruitment
%
(Frequency) Goal
SPPB Score <= 7 41.5% ( 176) 40%
Ethnic Minorities 25.2% ( 107) 25%
Men 31.1% ( 132) 30%

39. Physical activity intervention
Center-based in a group setting with a
systematic transition to home-based exercise
I. Aerobic (walking)
II.Strength (lower extremities)
III.Balance
IV.Flexibility stretching
V.Behavioral counseling (group
and telephone)

40. Aerobic
Wake Forest U. Winston Salem, NC
Come – Walk with us!

41. Aerobic
Stanford U. Palo Alto, Ca
BP check
Outdoor walking
Taking a break during the walk

42. Doing her favorite ankle
weight exercises
Strength
Ankle weight exercises

43. LIFE-P SPPB score
10
9 8.7
8.5
Score P<0.001
8
8.0
7.9
7.5
7
Physical activity
Successful aging
6
0 6 mo 12 mo
Means estimated from repeated measures ANCOVA
adjusted for gender, field center and baseline values
J Gerontol Biol Sci Med Sci 2006;61:1157

44. Percent of participants who improved by >1
point, did not change, or declined by >1 point in
the SPPB score from baseline to 6 and 12 mos.
6 month 12 month
P=0.004 P=0.03
100%
SPPB change
80% vs. baseline
102 100
133 128
60% Improve >=1
point
40% 44 33
No change
34
31
20%
56 60
35 42 Decline >=1
0% point
PA SA PA SA
NNT for improvement = 6 at 6 mos and 9 at 12 mos
NNT for preventing decline = 10 at 6 and 12 mos
J Gerontol Biol Sci Med Sci 2006;61:1157

45. Conclusions
• Compared to SA, PA improved the SPPB
score and 400 m walk speed
• Consistency among major subgroups
• Minimal loss to follow-up
• Excellent safety record
• An intervention that improves the SPPB
performance may also offer benefit on more
distal health outcomes, such as mobility
disability

46. Definition of a successful pilot
• Recruitment of 400 participants in 9 months
• Sufficient outcome rates in the control group
• Implementation of the intervention
• Adherence to intervention after 1 year >70%
• No safety concerns from DSMB
• Favorable trends in multiple outcomes
• Loss to follow-up <2%

47. Cumulative hazard of time until major mobility
disability and until major mobility disability or death
Time until major mobility Time until major mobility
disability disability or death
Cumulative Hazard
0.3 0.3
Cumulative Hazard
0.2 0.2
0.1 0.1
0.0 0.0
0.0 0.5 1.0 0.0 0.5 1.0
Years since randomization
J Gerontol Biol Sci Med Sci 2006;61:1157

48. Overview of Study Design – Definitive Trial
• Multicenter single-blind pilot RCT
– 8 sites across U.S.
• Physical exercise vs. successful aging health
education program
• 1,600 non-disabled, community-dwelling
sedentary persons age 70-89 years who are at
risk of disability
• Follow-up: 3 years
• Outcome: Loss of ability to walk 400 m

49. 2008 Physical Activity Guidelines
for Americans: All Adults
• Avoid Inactivity
• Do a medium amount of aerobic
physical activity
– 150 min moderate-intensity
– 75 min vigorous intensity
• More exercise will have more
benefit
• Do muscle strengthening 2 days /
week
www.health.gov/paguidelines

50. 2008 Physical Activity Guidelines
for Americans: Older Adults
• If at high fall risk, do balance
training
• Monitor level of effort using
relative intensity
• Be as active as abilities and
conditions allow
• Understand how chronic
conditions affect ability to be
active
www.health.gov/paguidelines