Aging Redefined

Columbia Mailman School is guiding a global quest to enhance health as the world’s population ages—and transforming how we think about aging in the process.

December 12, 2022

People don’t generally think of getting older as a sunny topic. But when Dean Linda P. Fried, MD, MPH, talks about the subject of aging in her book-lined office, just a few days after the release of the National Academy of Medicine’s Global Roadmap for Healthy Longevity, she brims over with enthusiasm. “It’s quite extraordinary what public health has done,” says Fried, who co-chaired the commission that created the report and played a key role in shaping its vision. “Public health is already responsible for 70% of the opportunity for health,” says Fried. “And our investments in prevention have created longer life spans—people around the globe have almost double the life expectancy they had in 1900.”

Longevity, however, isn’t enough. Fried is even more passionate about the possibility of healthy longevity—not just extending the life span but also extending the health span. “For the first time in human history, it’s not only possible to live longer, but to live longer with health,” she says. “The challenge now is to make the next-stage investments to fully realize the opportunity this creates, to democratize healthy longevity so that it is available not just to those with the most resources, but to everyone.”

The National Academy of Medicine’s road map looks ahead to 2050, laying out the means and conditions for older people to stay healthy, engaged, and productive, and to lead meaningful lives. This healthy longevity, the National Academy of Medicine’s International Commission points out, won’t just benefit older people, but will also help societies as a whole to thrive.

Fried has already begun to harness the formidable resources of Columbia Mailman School and the Robert N. Butler Columbia Aging Center to take the lead on accomplishing the report’s recommendations. “Health doesn’t just come from medical care,” she says. “It’s not enough to change one sector of society; we’ll need to change every sector in service of promoting longer, healthier lives.” It’s a tall order, but it doesn’t deter Fried: “The evidence is strong that by 2050, we can create healthy longer lives around the world.”

From Frailty to force

To realize that vision, Fried is working intently on launching and expanding programs at Columbia Mailman School and at the Butler Center, which was founded as part of the legacy of Robert N. Butler, MD ’53, pioneering gerontologist and former president and CEO of the International Longevity Center-USA. Fried is hiring faculty and pulling together a dream team of experts that stretches across the university, the medical center, and the globe. Along with the School’s current work—on the biology of aging, on the impact of inequities on health span, on infrastructure and policy, on attitudes about aging, and on what we can learn from cultures around the world—Fried and the School are laser-focused on ushering in a new paradigm. “Medicine and public health have always studied the negative—disease and disability,” says Fried, who trained as a geriatrician and is known for her seminal work on frailty. “But what we don’t have is a definition of health.”

Now, she says, the science is ready, and it’s largely coming out of the School and the Butler Center. “Nearly a year ago, we launched an interdisciplinary program with faculty in Columbia Mailman School, the medical school, and beyond, to study not just the downsides of aging but also the upsides of health. It’s going gangbusters,” says Fried. “To my knowledge, we have the first formal program in the science of healthy longevity in the world,” she says. “If we can add health to longer lives, older people can stay engaged, contribute, work, volunteer, and be creative in unimagined ways.”

Science suggests that if older people can stay healthy, they will put the immense talents and assets they accrue over life to good use. “As we age, we gain knowledge and expertise, along with the intellectual and cognitive abilities to decide if something matters. We can bring these powers to bear to come up with critical solutions to problems of import,” says Fried. She says that the largely untapped human capital of older people—which only grows as more older people remain healthy—will create a third demographic dividend, one that flies in the face of the Reagan-era economic perspective that tends to see seniors or anyone in need as a potential societal burden.

Of course, not everyone views a rapidly aging population as a shining opportunity. Some scientists and economists fear the graying of the globe the way experts once feared the scourge of overpopulation in the 1970s. And there is reason to worry, if society and government aren’t propelled by good public health science to do their part to help people live long lives with good health. “People are waking up and smelling the demographics,” says John W. Rowe, MD, Julius B. Richmond Professor of Health Policy and Aging in the Department of Health Policy and Management and Butler Center faculty member. By 2030, 1 in 6 people in the world will be 60 years or older, according to the World Health Organization. By 2050, the number of people aged 80 years or older is expected to reach 426 million, triple the number of octogenarians in 2020. Some who don’t share Fried’s optimism worry that besides overtaxing our healthcare system, this “gray tsunami” will sweep away resources for younger generations. They point to a popular theory of economics known as the “lump of labor,” which maintains that there are only a certain number of jobs out there, and that older people holding on to these jobs will deprive younger workers of opportunities.

But what if this negative narrative is just plain wrong? In fact, the lump of labor theory has been disproven; when older people are working and are active consumers, that creates more jobs for young people. “We have to get rid of the assumption that aging is only about illness and dependency. That’s not based on evidence. Science has debunked that old narrative, but our society is still living by it, and missing unprecedented opportunities that can come if only we redesign society for longer, healthier lives,” says Fried.

A rising Tide

Rowe is one of those doing the debunking. He co-leads, with Fried, the interdisciplinary program examining how society can age positively and thrive, identifying opportunities for older people to, say, volunteer or participate in the workforce past retirement age if they desire. “Seventy is the new fifty!” says Rowe. “These days, people in the sixty to seventy age range are not frail; they’re fit, they’ve learned a lot, and there’s clear evidence that they have a lot to contribute.”

Fried points out that if older people want to work but can’t get jobs, which is all too common, “that’s a lose-lose proposition. We have to retrain older workers so they can keep up with changes in the workplace. We also need to create a broad range of roles for older adults that align with their goals, to create a better future.”

Rowe agrees, and points to problems in many European countries, where there are fewer and fewer workers and a growing population of retirees. “That can make it difficult to produce all the necessary goods and services,” he says. “But if you increase the workforce by creating more jobs for older adults, the entire workforce benefits—the tide lifts all ships.” Case in point: Research has shown that intergenerational teams are more productive and innovative than single-generation teams. “And evidence from factories in Europe suggests that mixed-age teams perform better than young teams—they may not be as quick, but the quality is higher and there are fewer errors,” says Rowe. “A study in a European factory that builds small trucks found that there were fewer accidents when the line included older, more experienced workers.” Perhaps even more surprising, a World Economic Forum, AARP, and Organisation for Economic Co-operation and Development study finds that investing in a multigenerational workforce will raise gross domestic product per capita by almost 19% within three decades.

The benefits go far beyond the bottom line. “Studies have shown that older people are more prosocial,” says Fried. “They care deeply about future generations, helping others, and leaving a legacy of a better world. We’ve never had that before at this scale. It’s pretty exciting and offers immense opportunities for society.” Those opportunities will only come to fruition if we adopt strategies that ensure the core institutions in our society—work, volunteering, retirement, healthcare, public health, education—are redesigned to support the population we will have in the future. Says Rowe, “It’s not just about turning society into a huge old-age home.”

In his role as chair of the MacArthur Foundation-supported Research Network on an Aging Society, which is based at the Butler Center, Rowe and a group of 14 scholars from the U.S. and Europe (including Fried) are developing an index that measures which cities, states, and countries are doing the best for their aging populations. (If you’re curious, Norway and Sweden rank first; the U.S. second.) “The index measures well-being in five domains,” says Rowe. These are productivity (participation in the workforce and volunteering); well-being (health status and life expectancy without disability); cohesion between generations; security (support for retirement and physical safety); and equity (which measures gaps between the haves and have-nots). One advantage of this index is that it’s possible to follow up over time and see how countries are doing as they implement new policies. “We’ve shared our results with the World Bank, the European Commission, and other global organizations. That’s just one example of the impact that the Butler Center is having,” says Rowe.

Aging Across cultures

Like Rowe’s research, the work of Kavita Sivaramakrishnan, PhD, associate professor of Sociomedical Sciences, stretches beyond U.S. borders. The Butler Center program she leads on global aging and health encompasses attitudes about aging and how older people are faring around the world, particularly in the global South (South Asia, Southeast Asia, the Arab countries, and sub-Saharan Africa). “I’m interested in the value and meaning of aging across cultures,” says Sivaramakrishnan, whose latest book is As the World Ages: Rethinking a Demographic Crisis. “I want to know if it’s possible to think beyond binaries—that youth equals productivity and old equals panic. As a historian who is doing work in South Africa and Asia, my goal is to look at how families and communities come up with solutions and begin to cope.”

Sivaramakrishnan’s work isn’t just about numbers. “Numbers can make me cranky,” she says. “They don’t tell the whole story. Human behavior is not so predictable. There can be misery in old age and there can also be resilience. But you can’t just expect people to stand up on their own feet with no support.” Sadly, that’s too often the case. The reluctance to increase support to elders tends to be justified financially, says Sivaramakrishnan. But the numbers ignore the often-invisible contributions older adults make in terms of sharing their pensions with the younger generation (something she has studied in South Africa) or providing care for grandchildren when parents are at work.

Some elders take on longer-term responsibilities when family members migrate to other countries for work opportunities and leave their children behind. That’s something Sivaramakrishnan herself experienced when, as a young widow, she moved from India to Boston for a job at Harvard and, for a time, left her daughter with her parents. “We pretend that kind of thing doesn’t happen in America, but throughout COVID-19, we’ve seen families migrate to be with grandparents to get more help with their children. Too often, those contributions are ignored,” she says.

Sivaramakrishnan is bringing them to light, working with nongovernmental organizations such as HelpAge International to study how well local, community-based solutions are working in aging societies. “I’ve interviewed older people in Chennai, India, who have lost a partner or whose children have migrated, and who benefited from home visits from local nonprofits,” she says. “There are effective ways of filling in older people’s lost social ties and gaps. We want to show examples of interventions that have worked on a small scale.” Those smaller but effective solutions can be translated into bigger policy changes. “Investing in the life course is not about seeing aging as a single event, or of decline and frailty. We need to look at aging as regenerative, as plastic, as something we can mold if we make the right investments at a broad, structural level, at a societal level, and on a community level,” says Sivaramakrishnan.

The Biology of resilience

Researchers at Columbia Mailman School are also spearheading a new, similarly plastic way of looking at biological aging, not as something that happens only in the third phase of life but as a process that starts from adolescence (or earlier). “A major focus of our research is biopsychosocial factors related to healthy aging—exposure to poverty, discrimination, educational barriers, and other adversities—that increase stress and produce health inequities,” says Allison Aiello, PhD, professor of Epidemiology, who started at the School on May 1 and who is developing a program on biosocial aging at the Butler Center. She is deputy director of Add Health (the National Longitudinal Study of Adolescent to Adult Health), a longitudinal study of more than 20,000 7th to 12th graders launched in 1994. “Gathering information about exposures that occur early in the life course is key to understanding what contributes to healthy aging,” she says.

A 2021 report by the Alzheimer’s Association found that 6.2 million Americans aged 65 years or older are living with dementia, a number that, without intervention, could grow to 13.8 million by 2060. In the Add Health study, Aiello is focusing on measuring risk factors for decline in cognitive function that begin as far back as middle school. Children who grow up in poverty end up developing more diseases and die younger than people with more socioeconomic advantages. “This study will allow us to understand better which factors delay early changes in cognitive function and provide insights on ways to intervene,” she says. For instance, in a 2017 study co-authored by Aiello, researchers found that low socioeconomic status across the life course was associated with immunological aging. “When you trace impacts from early to later life, including factors such as access to housing or education, you can better see how changing some of these levers through policy and intervention may reduce the risk of Alzheimer’s Disease in later life.” Aiello was drawn to the School and the Butler Center because she is an interdisciplinary thinker. “There is a lot of interaction across disciplinary areas; everyone shares a strong drive to understand healthy aging and all the complex processes that go into it. It is an exciting time to be at Columbia, given the many initiatives supporting aging research and health equity,” she says.

algorithms and aging

Just as exciting is the research of Daniel Belsky, PhD, on developing biomarkers to track how well (or poorly) someone is aging. These measurements of aging will make it possible to evaluate the impacts of various interventions over time. “We’re using clinical laboratory data, genomic data, and machine-learning tools to develop algorithms that summarize individual differences in aging—and we hope to deploy these algorithms in other studies and randomized controlled trials,” Belsky explains.

Like Aiello, Belsky, an assistant professor of Epidemiology who came to the School in 2019, was drawn to its unique approach to the science of aging. “We study biological aging across the full life-course, including young, midlife, and older adults—and we've even begun to explore whether it’s occurring in children,” says Belsky. Obviously, we all begin getting older from birth onward. What’s different about this research, says Belsky, is that “we can measure how the processes of aging progress more rapidly in some individuals. Early differences in the pace of aging may connect the environment we grow up in with our health across the lifespan.”

Exactly how these factors speed up or slow down aging is still a mystery. “But by following people over time and taking repeated physiological measurements including immune markers and blood chemistry, we can begin to see how people are aging differently,” says Belsky, who is also keen to discover whether it’s possible to modify a person’s aging trajectory for the better. “We're analyzing epigenetic data from trials to see if it's possible to slow the pace of aging. One trial focuses on restricting calories in non-obese adults. Calorie restriction has long been known to slow aging,” says Belsky. Another set of trials that Belsky is working on with Peter Muennig, MD, MPH ’98, a professor of Health Policy and Management, is focusing on poverty, including measuring the effects on aging of benefits like an earned income tax credit, helping people find and maintain employment, and social mobility. Their colleague at the Butler Center, Adina Zeki Al Hazzouri, PhD, assistant professor of Epidemiology, focuses on how social and cardiovascular exposures across the life course influence Alzheimer's disease and other dementias, and related health outcomes in old age.

The good news: “It’s now possible to say that if we do this thing, we can change the aging trajectory in this way, which will save Medicare X billions of dollars,” says Belsky. “We’ll be able to show how an intervention that may look costly will end up generating savings, opening up a new range of possibilities for public health interventions with at-risk populations.”

More engagement, Better health

Interventions that occur later in life can also change the aging trajectory, dramatically and for the better. One intervention that yields a wealth of positive results for older people is volunteering. “It’s good for the brain and the body,” says Rowe. A 2018 study he co-authored found that retired people who began volunteering at a low level had a 34% decrease in disability over time. “And we published one paper that showed that volunteering after age 65 was as beneficial to health as smoking cessation.”

Fried is a pioneer in studying the health benefits of volunteering and developing novel models that make it easier for older adults to give back in high-impact ways. In the early ’90s, she created and launched Experience Corps, which brought older volunteers to public elementary schools for 10 to 15 hours a week to support the success of all children. Not only did the kids benefit, but brain scans of the older volunteers also showed improvements in neural activity. “That got the attention of a lot of people,” says Rowe, and, indeed, the program has now expanded nationally. Fried is, characteristically, optimistic that this kind of work will also get the world’s attention. “We will have the science to guide public health and clinical care and social services so that people flourish at all ages, including into the oldest ages. Every generation has a role to play,” she says.

But first, it’s essential to get the truth about what older people can do out there. “Honestly, right now, the biggest barrier is that we’ve got the wrong story about aging,” says Fried. “If we stay with that story, all the disaster scenarios that people predict could come true. But if we build a society for longer lives with health, there will be a huge return on our investment.”

Paula Derrow has worked and written for national magazines, nonprofits, and academic institutions. She specializes in health and psychology.

Welcome, New Faculty

As the Robert N. Butler Columbia Aging Center works to transform the science around health with longevity, new members are joining the team.

Alan A. Cohen, PhD, associate professor of Environmental Health Sciences, came to the Butler Center in September. “I’ve studied aging by looking at our bodies as complex systems, versus the traditional approach, which has been to look at molecules, cells, and organs one at a time,” he says. This work will be helpful as the team creates a scientific definition of health that is more holistic than the current disease-specific approach to aging.

Yuan S. Zhang, PhD, will arrive in the Spring of 2023 as an assistant professor of Sociomedical Sciences. Her work to date has focused on understanding biosocial processes that influence the health and well-being of older adults. “I explore how life-course factors shape opportunities for older adults to lead healthy, active, independent, and engaged lives, with an emphasis on low- and middle-income countries,” she explains.

The two join Allison Aiello, PhD, another new hire (read about her work on page 17) at a key time. “It’s exciting to be a part of the energy behind the growth in the Center with incredibly bright colleagues,” says Cohen.