20.3 Health Habits and Age

Each person’s routines and habits, from childhood on, powerfully affect every disease and chronic condition. This is particularly true for problems associated with aging—from arthritis to varicose veins—that may first appear after age 50 but begin decades before. In fact, some adult conditions are affected by maternal health when the adult was an embryo (Haas et al., 2013).

Virtually every fatal disease becomes more common with every decade of adulthood. Cancer is a classic example (see chart). However, most cancers are related to lifestyle behaviors that increase allostatic load every year. Although genes make a person more vulnerable to specific cancers, environment always makes a difference, with about one-third of cancer deaths connected to smoking, another one-third to diet, and the final one-third to various toxins. We now examine adult habits, with the goal of understanding which habits contribute to or diminish ongoing vitality.

Drug Abuse

As described in Chapter 17, drug abuse, especially of illegal drugs, decreases markedly over adulthood—usually before age 25 and almost always by age 40. Of the illegal drugs, marijuana use is slowest to decline. In the United States, about 11 percent of 25- to 34-year-olds still smoke it (National Center for Health Statistics, 2013). As it becomes legal in several states, rates rise.

Although illegal drug use declines in adulthood, abuse of prescribed medication increases. One reason is that such drugs are first given to reduce pain, insomnia, or psychological distress, and adults do not realize when they become addicted. However, in the United States, by far the addictive drugs most often abused are the two legal ones, sold to any adult at hundreds of thousands of stores—tobacco and alcohol.

At risk in Bangalore A man puffs on a bidi, a flavored cigarette. He is at risk of being among the 1 million Indians who die each year of smoking-related causes.

AP PHOTO/AIJAZ RAHI

Death rates for lung cancer (the leading cause of cancer deaths in North America) reflect smoking patterns of years earlier. About 70 percent of the lung cancer deaths worldwide, and 90 percent in industrialized nations, are caused by cigarettes (Ezzati & Riboli, 2012). Because North American men have been quitting for decades, the rate of lung cancer deaths for males has declined significantly since 1980, and the lung cancer–related death rate among 45- to 64-year-old males is now far lower than it is for older adults. In 2010, the median age for diagnosis of lung cancer was 70 years (National Cancer Institute, 2013). Rates for adult men continue to decline.

Relatively few women smoked in the first half of the twentieth century, but then their smoking increased and only recently has it declined. Consequently, in the United States, during the same years that male lung cancer deaths declined, the rates for females increased. Fifty years ago, more women died from the “female cancers” (breast, uterine, or ovarian) than from lung cancer; by contrast in 2010, almost twice as many adult women died from lung cancer as from the combined total of those other three (National Center for Health Statistics, 2013).

Fortunately, cigarette smoking has been declining over the past decade in North America (the United States, Canada, and Mexico) for every age and gender group. In 1970, one-half of U.S. adult men and one-third of women smoked, but by 2010 only 22 percent of men and 18 percent of women did, with almost as many adult former smokers as current smokers. It is not yet time for celebration, however, because “cigarette smoking remains the leading cause of preventable morbidity and mortality in the United States” (MMWR, 2013, p. 81).

North American projections suggest a brighter future. Women are following the male pattern of quitting, and many offices, homes, and public places are now smoke-free. The percentage of adult smokers seems to be stuck at about 20 percent over the past decade, with much lower rates after age 65 (see Figure 20.2, p. 588). It is not known if that is because many adults quit in late middle age or because most of the heaviest smokers have died.

Older and Wiser Everyone can see the obvious good news here: In the United States (not worldwide), far fewer people of any age are smoking than in 1965. But look closely with a developmental perspective: More than half of the people now over age 65 were smokers when they were young adults. Cigarettes are said to be as addictive as heroin, and quit-rates increase with every year of adulthood. Thus, this figure shows that about one hundred thousand Americans have kicked a powerful, destructive habit.

Source: National Center for Health Statistics, 2012.
Source: National Center for Health Statistics, 2013.

Worldwide trends are less encouraging. Almost half the adults in Germany, Denmark, Poland, Holland, Switzerland, and Spain are smokers. In developing nations, rates of smoking are rising, especially among women. The World Health Organization calls tobacco “the single largest preventable cause of death and chronic disease in the world today” (Blas & Kurup, 2010, p. 199). One billion smoking-related deaths are projected to occur in the world between 2010 and 2050.

The harm from cigarettes is dose-related: Each puff, each day, each breath of secondhand smoke makes cancer, heart disease, strokes, and emphysema more likely. No such linear harm results from drinking alcohol. In fact, alcohol can be beneficial: People who drink wine, beer, or spirits in moderation—never more than two drinks a day—live longer than abstainers. Drinking more than that is harmful.

The primary reason for the benefit is that alcohol reduces coronary heart disease and strokes. It increases HDL (high-density lipoprotein), the “good” form of cholesterol, and reduces LDL (low-density lipoprotein), the “bad” cholesterol that causes clogged arteries and blood clots. An occasional drink may also lower blood pressure and glucose (Klatsky, 2009).

However, moderation is impossible for some people, and lack of moderation is dangerous. Alcoholics find it easier to abstain than to have one, and only one, drink a day. Binge drinking increases the risk of strokes and high blood pressure.

Furthermore, alcohol abuse destroys brain cells; contributes to osteoporosis; decreases fertility; and accompanies many suicides, homicides, and accidents—while wreaking havoc in many families. It is implicated in 60 diseases, not only liver damage but also cancer of the breast, stomach, and throat.

There are stark international variations in alcohol abuse. It is rare in Muslim nations where alcohol is illegal, but it causes about half the deaths of Russian men under the age of 60 (Leon et al., 2007). For U.S. adults, binge drinking is dangerous and common: About 32 percent of people 25 to 44 years of age and 18 percent of those between 45 and 64 had five or more drinks on a single occasion in the past year (National Center for Health Statistics, 2013). The U.S. had 88,000 alcohol-related deaths between 2006 and 2010 (MMWR, March 14, 2014)

From 1980 to 2010 in the United States, various laws and community practices cut in half the rate of motor vehicle deaths caused by drunk drivers. In many nations, the risk of accidental death because of drinking is more common among younger adults, but the ongoing harm to families is more prevalent when an alcoholic is middle-aged (Blas & Kurup, 2010).

In general, low-income nations have more abstainers, more abusers, and fewer moderate drinkers than more affluent nations (Blas & Kurup, 2010). In poor nations, prevention and treatment strategies for alcohol abuse have not been established, regulation is rare, and laws have not caught up with abuse (Bollyky, 2012). Thus, alcohol becomes particularly lethal as national income falls.

Nutrition

Metabolism decreases by one-third between ages 20 and 60, and digestion become less efficient. To stay the same weight, adults need to eat less and move more as they age. Further, since overall calories must decline, more fruits and vegetables and fewer sweets and fats must be consumed each year. That is not what happens.

In the United States, adults now gain an average of one to two pounds each year, much more than prior generations did. Over the 40 years of adulthood, that adds 40 to 80 pounds. As a result, two-thirds of U.S. adults are overweight, defined as a body mass index (BMI) of 25 or more. Indeed, almost one-third of all U.S. men and more than one-third of all U.S. women age 25 to 65 are obese (with a BMI over 30), with 12 percent of those men and 20 percent of those women morbidly obese (with a BMI over 40) (National Center for Health Statistics, 2013). [Lifespan Link: BMI was explained in Chapter 17.]

If BMI numbers seem abstract, picture a person who is 5 feet, 8 inches tall. If that person weighs 150 pounds, BMI is about 23, a normal weight. If he or she weighs 200 pounds, the BMI is 30, which makes that person obese. If he or she weighs more than 260 pounds, the BMI is over 40, making that person morbidly obese.

If you spend most of your time among 20-year-old college students, you may be unaware of the prevalence of obesity because people in their 20s have lower rates of obesity than those in their 40s or 50s. Further, those who are obese are less likely to go out, so you do not see them as often as you see the thinner ones.

Half a billion people worldwide are obese. Rates seem to have reached a plateau in the United States, but many developing nations are reporting rapidly increasing rates (see Visualizing Development, page 590). This is particularly true in Africa and Asia, where malnutrition once was the most prevalent nutritional problem; now obesity is (World Health Organization, 2013).

A recent meta-analysis found that mortality rates by age for adults who were somewhat overweight were lower than the rates for people who were thinner, a conclusion that comforted many portly adults (Flegal et al., 2013). However, BMI of 25 or 26 may be okay, but no research finds that obesity is healthy. Excess body fat increases the risk of almost every chronic disease.

One example is diabetes, which is rapidly becoming more common and causes eye, heart, and foot problems as well as early death. Although diabetes is partly genetic, the genetic tendency is exacerbated by excess fat. The United States is the world leader in both obesity and diabetes.

The consequences of obesity are psychological as well as physical, since adults who are obese are targets of scorn and prejudice. They are less likely to be chosen as marriage partners, as employees, and even as friends. The stigma endured by fat people leads them to avoid medical checkups, to eat more, and to exercise less—with the result that their health is far more impaired than the mere fact of their weight would predict (Puhl & Heuer, 2010).

VISUALIZING DEVELOPMENT

Adult Overweight Around the Globe

A century ago, being overweight was a sign of affluence, as the poor were less likely to enjoy a calorie-rich diet and more likely to be engaged in physical labor. Today, that link is less clear. Overweight—defined as having a body mass index (BMI) over 25—is common across socioeconomic groups and across borders, and obesity (a BMI over 30) is a growing health threat worldwide.

OVERWEIGHT AND GDP

International cutoff weights for overweight and obesity are set at various levels. These numbers show proportions of adults whose BMI is over 25.

SOURCES: WORLD HEALTH ORGANIZATION (2013); WORLD BANK (2013).

OBESITY IN THE UNITED STATES

While common wisdom holds that overweight and obesity correlate with income, recent data suggests that culture and gender may play a bigger role. Obesity tends to be less prevalent among wealthy American women; for men, the patterns are less consistent.

SOURCE: PEW RESEARCH CENTER (2013).
SOURCES & CREDITS LISTED ON P. SC-1

Perhaps the goal for people whose health is damaged by their weight should be to lose enough pounds to protect their health rather than to reach normal weight. The culture’s emphasis on an ideal BMI, particularly in women, may encourage unhealthy dieting and then eating disorders, including overeating (Shai & Stampfer, 2009). This may explain why more women than men are of healthy weight (they care more) or obese (they give up if they can’t stay thin).

Healthy eating and good health care are important for all adults, whether or not they are overweight. Indeed, some people may be genetically destined to be outside the boundaries of normal weight. In the United States, Asian American adults have significantly lower rates of obesity (11 percent) and African Americans higher rates (48 percent). It is possible that the BMI cutoffs should be altered for these groups. It is also possible that weight is an important factor in the higher rates of premature death among African Americans.

The relationship between culture and obesity is crucial, although not completely understood. For instance, scientists collected many biophysiological measures (including weight, height, blood pressure, and cholesterol and glucose levels) on 5,000 adults, half of them with Inuit ancestry and half with European forebears, all living in the far Northwest of North America. Although the Inuit tended to have higher BMIs, their weight-related health risk was significantly lower than that of the Europeans. Centuries of adaptation to the Arctic may have produced body fat as insulation, without creating the mortality risk usually associated with excess fat (Young et al., 2007).

In another study, adaption to national conditions lowered the health risk. In Cuba from 1991 to 1995, a national economic crisis led to less meat and more exercise, resulting not only in an average weight loss of 14 pounds but also a decrease in the incidence of diabetes and heart disease. When the crisis was over, people regained the weight and the diabetes rate doubled (Franco et al., 2013).

Obviously, we should not rely on genes or hope for an economic crisis. However, many people do not seem able to control their eating before it becomes dangerous. For the morbidly obese, bariatric surgery may be the best option.

About 200,000 United States residents undergo gastric bypass or gastric banding surgery to lose weight each year. The rate of complications is quite high, with about 2 percent dying during or soon after the operation, and about 10 percent needing additional surgery.

Over time, however, surgery that reduces obesity saves lives because morbid obesity is a serious risk to survival (Adams et al., 2012; Schauer et al., 2010). The greatest benefits seem to occur for people with diabetes: 70 percent find that their diabetes disappears, usually not to return (Arterburn et al., 2013).

Cocaine or Coffee Cake? Could this be as dangerous as shooting up in a crack house? Few people are troubled by an overweight office worker drinking coffee and munching cake made with white flour, butter, and sugar. Yet more adult deaths occur because millions snack unhealthily than because thousands are addicted to cocaine. It is far easier to criticize people with bad habits than it is to change our own behavior.

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Why is obesity so prevalent in the United States? In previous chapters we noted two culprits, advertising and peer pressure; here we focus more specifically on what people eat.

The typical U.S. family consumes more meat and fat and less fiber than people in other parts of the world. For example, the Chinese traditionally ate many vegetables mixed with small bits of meat or fish; in general, they did not have a weight problem. Some blame the recent weight increase in China on the new taste for American food.

One specific culprit in weight gain may be sugar, either sucrose or fructose (added to many packaged foods and beverages through corn syrup). A study that reduced sugar in foods found that people lost weight, and another study in 175 nations found a correlation between national sugar consumption and diabetes (Te Morenga et al, 2013; Basu et al., 2013).

Scientists and physicians agree that nutrition is a factor in almost every adult ailment. Although some specifics have not yet been proven (sugar may not be the worst villain), a healthy diet is undoubtedly protective for every adult. Common in Greece and Italy is the so-called Mediterranean diet, which is high in fiber, fish, and olive oil. This diet has been proven to protect against heart disease without adding weight (Estruch et al., 2013). Unfortunately, though, almost no one eats as well as they should.

Inactivity

Hope It Helps Ideally, this is part of her daily exercise routine, and no one will complain about a fire hazard. More likely, though, her back hurts from hunching over her desk in an uncomfortable chair, her supervisor questions her undignified behavior, and no one in the adjoining cubicles asks to borrow her ball. Social norms make exercise difficult.

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Regular physical activity at every stage of life protects against serious illness even if a person has other undesirable health habits such as smoking and overeating. Exercise reduces blood pressure; strengthens the heart and lungs; and makes depression, osteoporosis, heart disease, arthritis, and even some cancers less likely. Health benefits from exercise are substantial for men and women, old and young, former sports stars and those who never joined a team (Aldwin & Gilmer, 2013).

By contrast, sitting for long hours correlates with almost every unhealthy condition, especially heart disease and diabetes, both of which carry additional health hazards beyond the disease itself. Even a little movement—gardening, light housework, walking up the stairs or to the bus—helps.

As explained in Chapter 17, walking briskly for at least 30 minutes a day, five days a week, is a reasonable goal. More intense exercise (e.g., swimming, jogging, bicycling) and muscle strengthening workouts are ideal. It is possible to exercise too much, but almost no adult does. In fact, one study that used objective assessment of adult movement (electronic monitors) found that fewer than 5 percent of adults in the United States and England get even 30 minutes per day of exercise (Weiler & Stamatakis, 2010). (Self-reports put the number at about 30 percent, not 5 percent; see Figure 20.3.)

Older and Lazier Exercise is important at every age, but increasingly so as people get older. Why do people who need it most move the least?

Source: National Center for Health Statistics, 2012a.

The close connection between exercise and both physical and mental health is well known, as is the influence of family, friends, and neighborhoods. Exercise-friendly communities have lower rates of obesity, hypertension, and depression (Lee et al., 2009). Neighborhoods high in walkability (paths, sidewalks, etc.) reduce time spent driving and watching television (Kozo et al., 2012). This relationship between the surroundings, exercise, and health is causal, not merely correlational: People who are more active and fit have stronger immune systems, so they resist disease. Moreover, they feel energetic, which itself increases good health habits.

Many social scientists seek to encourage exercise and other good health habits among adults. Maintaining a healthy habit lifelong is the hardest part, as the following explains.

Just Give Me the Usual Even bad habits feel comfortable—that’s what makes them habits.

BRUCE ERIC KAPLAN/THE NEW YORKER COLLECTION/CARTOONBANK.COM