Secrets of Women’s Healthy Ageing: Living Better, Living Longer

By Cassandra Szoeke

Secrets of Women's Healthy Ageing draws on the findings of a unique study that has focused on the health of more than four hundred women in their mid-to-late lives. Over the past thirty years a team of international investigators has compiled a remarkable amount of data, aiming to raise awareness of modifiable risk factors in women’s health.

Their findings cover brain, heart and gut health, diet, sleep, exercise, and the benefits of socialising. But importantly, they highlight how the results relate directly to women's wellbeing. In Secrets of Women's Healthy Ageing Cassandra Szoeke shares the wisdom revealed by this comprehensive study, showing how to promote overall wellness and providing the key ingredients for living a long and healthy life.

• Language: English
• Publisher: Melbourne University Publishing Ltd
• Release date: Aug 31, 2021
• ISBN: 9780522877243

Book preview

Professor Cassandra Szoeke is the principal investigator of the Women’s Healthy Ageing Project, the longest ongoing study of women’s health in Australia. She is a general physician, consultant neurologist and multi-award-winning clinical researcher. She has published more than two hundred articles in medical journals and has held many significant academic positions in universities and institutions locally and internationally.

She has worked in both the public and private health systems in Australia, including being a board director appointed by the state health minister. She has worked for government organisations including the Department of Health and the Commonwealth Science Industry and Research Organisation, where she was theme leader and then clinical consultant in the Preventive Health Flagship. She is currently director of the Healthy Ageing Program in the Centre for Medical Research and Professor of Medicine in the Faculty of Medicine, Dentistry and Health Sciences at the University of Melbourne.

Professor Szoeke is a fellow of the Royal Australasian College of Physicians and associate fellow of the Australasian Institute of Digital Health. She sits on the council of the Australian Medical Association, is director of the Asia–Pacific node of the International Women’s Brain Project and is appointed by the Department of Health to sit on the Victorian Medical Panel. Recognised internationally for her contributions to healthy ageing research, she holds the Australian clinical representative role in the worldwide Alzheimer’s Disease Initiative and the Global Burden of Disease Study, and is chief medical officer for the Australian Healthy Ageing Organisation.

MELBOURNE UNIVERSITY PRESS

An imprint of Melbourne University Publishing Limited

Level 1,715 Swanston Street, Carlton,Victoria 3053, Australia

[e-mail]

www.mup.com.au

First published 2021

Reprinted 2021

Text © Cassandra Szoeke, 2021

Illustrations © Lilian Darmono, 2021

Design and typography © Melbourne University Publishing Limited, 2021

This book is copyright. Apart from any use permitted under the Copyright Act 1968 and subsequent amendments, no part may be reproduced, stored in a retrieval system or transmitted by any means or process whatsoever without the prior written permission of the publishers.

Every attempt has been made to locate the copyright holders for material quoted in this book. Any person or organisation that may have been overlooked or misattributed may contact the publisher.

Cover design by Sandy Cull

Cover image by Stocksy and Alamy

Typeset by Megan Ellis

Printed in Australia by McPherson’s Printing Group

9780522877236 (paperback)

9780522877243 (ebook)

For my daughters, and all daughters

CONTENTS

Prologue: Beyond ‘Bikini Health’

1 Introduction: Living Longer, Living Better

2 Brain: Health From the Head Down

3 Move: Activity for Vitality

4 Nutrition: Fuel for the Body

5 Bone: Our Structural Foundation

6 Mood: Stress and Distress

7 Connection: We Are Better Together

8 Hormones: Hormone Therapy—a Knowledge Frontier

9 Adaptation: Intrinsic Ability and Resilience

10 Future Health: What Comes Next?

Sex—Men, Women and Differences: An Epilogue

Notes

Acknowledgements

Women’s Healthy Ageing Project Scientific

Advisory Panel

Index

PROLOGUE

BEYOND ‘BIKINI HEALTH’

The women at the heart of this story come from all walks of life. When we first met them, many were married—some happily, some not. Some were dealing with the tumult of divorce. Some were single, some shared their lives with other women. Some, not all, were in paid work. Those caring for children or ailing parents could have told you their work was never-ending. Some lived in suburban homes with sports timetables stuck to the fridge; in apartments with freezers stocked with Lean Cuisine; or on new estates at the city’s fringes, where the mortgages were as big as the houses. What they had in common was this: they were all at home when the phone call came, and when it counted, they all said ‘yes’.

It was 1990, a year of big ballads and bigger social changes. Sinéad O’Connor was dominating charts worldwide with her hit ‘Nothing Compares 2 U’. Nelson Mandela was freshly released from prison and the Berlin Wall was being dismantled. In Australia, employees of the Roy Morgan market research company were hitting the phones, randomly dialling hundreds of households across the country’s second-biggest city, Melbourne. Their mission: to find women aged 45 to 55 willing to answer detailed and intimate questions to provide University of Melbourne researchers with a wide-frame snapshot of women’s health in this phase of life.

Of 2000 women who took the call and agreed to be surveyed, 779 were still having their periods and more than 400 would go on to say ‘yes’ to a second, far more demanding request. What these women had in common was an exceptional commitment to furthering medical knowledge of women’s health in midlife and beyond. They embarked on what was to be a five-year program, starting in 1991, to take part in face-to-face interviews about everything from the food they ate to their sex lives, and to travel to the university every year for a series of specialised medical tests, physical and psychological. Five years grew into three decades. Some women moved away, could no longer take part, or, sadly, succumbed to illness. Yet even today hundreds have continued to volunteer their time, blood, bodies and innermost thoughts for what has become the groundbreaking Women’s Healthy Ageing Project, the study that forms the foundation for this book.

In my working life as a researcher, I have learnt that when we talk about ‘women’s health’, people often expect to hear about reproductive health or ‘bikini health’—that is, matters relating only to areas of the body covered by a bikini. This study, the one to which so many women have given so many years, has been run by doctors whose primary interest is the brain. That is why this book is not about so-called bikini health but more about ‘burkini health’—women’s overall health and wellbeing from midlife onwards.

The three decades of research on which this book is based have been led from the head down, from the body’s central control-and-command centre—the brain. The inaugural principal investigator and current chair of the project’s Science Advisory Board, Professor Lorraine Dennerstein AO, is a psychiatrist and was awarded the gold medal for outstanding contributions to sexology and sexual health by the World Association for Sexology in Montreal, Canada in 2005. I am a neurologist. Together with the study participants, research teams and a host of international researchers and collaborators, we have explored the secrets to women’s healthy ageing.

In this book we are interested in women’s overall health, not just reproductive health.

The project has become a landmark study, collecting information from the decades of life that lead to later-life diseases, whilst also including the details about menopausal transition. We now understand that the three decades before the age of 70 (at least from age 45 onwards) are the ones during which chronic diseases slowly develop, well before they lead to any changes significant enough to lead to a diagnosis. For example, we were involved in the 2013 reportin the medical journal The Lancet that showed that the hallmark for dementia—deposits of amyloid, a type of protein, in the brain—occurs three decades before first diagnosis. We also know it takes several decades for changes to blood vessels to result in heart attacksor strokes. The chronic diseases of ageing get their name from the fact they take many decades to evolve.

The good news? This means we have several decades in which we can prevent disease. Thanks to our project’s study design and its wonderful participants, who have been incredible in sharing their tips and experiences across 30 years, we now know much more about these key decades and their role in chronic disease development in women. Our participants have shown us the things you do in your forties, fifties and sixties that will help your health when you are over 70.

Once arteries are blocked or brain cells are dead, there is only so much we can do to help. To this day, we have no disease-modifying therapy once you get dementia, and as anyone who has had heart bypass surgery will tell you, it is no walk in the park. But you know what is a walk in the park? Yes, a walk in the park. Our study has taught us that exercising intensively when we can find the time or motivation is not nearly as good as taking a daily walk over 30 years. If there is one single thing you can do to benefit your overall health, it’s walk in the park! We will talk more about that in this book’s third chapter, ‘Move’.

ABOUT THE STUDY

The Women’s Healthy Ageing Project began in 1990 under the name Melbourne Women’s Midlife Health Project. It was to be a special kind of research, a ‘longitudinal prospective’ investigation into health over the menopausal transition for five years. Instead of taking a snapshot of health today, or comparing health today with what can be recalled from the distant past, this study embarked on a plan to see the participating women every year, and take detailed measures and make validated assessments moving forward (‘prospective’) over a long time (‘longitudinal’). The study’s first discovery was that this transition didn’t take just a neat five years and so it was extended, and extended again and again, providing important information about women’s health from midlife into late life. The project has become the longest ongoing study of its kind in Australia. It has followed up many hundreds of pre-menopausal women from the age of 45 through the menopausal period and into the early ageing process, with participants now aged 75–85.

The type of research we do is called ‘observational’. This is different from ‘clinical trials’ or ‘intervention studies’, where a group of people get something and are compared with a group that does not. Observational studies are the scientific equivalent of what we all do when we observe what is going on around us and see the consequences of the different choices people make. Once when I used this example in a public lecture, an audience member asked if my research was like watching reality TV. If it were, you would need to picture more than 400 amazing female characters, appearing in more than 30 seasons and still going strong. This is as scientifically impressive as it would be to TV executives—and, just like on TV, entirely due to the incredible stars of the show and their commitment to improving health for women everywhere by sharing their stories.

If this were a TV show, I would watch every episode. These women have shared so many aspects of their lives with researchers: health, social and emotional, and in many cases, their deepest, darkest secrets. For this reason, no individual will be identified in this book; we have research tools for qualitative analysis that allow us to theme responses and create generic advice and information. All the information we collected over all 30 years has been entirely de-identified.

Although they were initially asked to be part of this journey for just five years, 90 per cent of the original group of women decided to continue these contributions indefinitely. So it was that several hundred women connected in a common cause to share their knowledge and, through this, help create a better health system for women of the future. This was no trivial contribution. They undertook several hours of detailed neuropsychological testing. Some of the tests, designed by expert researchers (keen on examining the most subtle deficits), escalated in difficulty until even Einstein would find them impossible—the test subjects were, understandably, sometimes exasperated.

‘Oh my God, those tests. The better you do, the harder it gets. I remember being asked to read back these digits. It started OK: Sixty-two, the researcher says. Sixty-two, I respond. The number climbs to 837, and I respond. But each time you respond correctly they add another digit—I mean, it became impossible. Then, when you just cannot repeat back the long digit sequence, they stop. Exhausted, you take a breath and they say, OK, now we will do it again. This time I want you to reverse the digits I call out and repeat them to me backwards, so 62 would be 26—ready? I don’t think anyone could be ready for that!’

It did not stop there. Our participants underwent blood tests and X-rays, brain and bone scans, and painstakingly completed detailed daily menstrual diaries across an entire year. This is the degree of passion that these several hundred women brought to their commitment to improve your health.

Such devotion and commitment attracted others. Several hundred researchers and health professionals from a broad range of disciplines have come from all over the world to join their call for better health for women and a better understanding of women’s health. In just the last decade more than 60 health professionals have completed higher-degree studies in ageing with the Healthy Ageing Program, which is building a workforce of people committed to delivering the best ageing experience possible. All these researchers’ knowledge and findings have contributed to this book.

The Australian women’s commitment to participating in the study was seen internationally. People on the other side of the world read about them and decided to do similar studies. Each of these sister studies brought something wonderful to the vision of women’s health. Some were funded to include several thousand women; others were able to include sub-studies for minority populations and examine local differences in care.

Even so, our study remains rare in the level of detail it collects, biologically, mentally and emotionally. It is also one of very few worldwide to continue for decades, and into the years after participants reached menopause. Because so few studies have managed to continue beyond menopause, keeping up detailed physical, biomarker and clinical information, we often all come together in a global effort to draw data from many countries, informing new guidelines in women’s health and defining the stages of menopause. Our researchers and their counterparts around the world contribute to national, international and global work as we combine datasets to answer the big questions in health. Although we are few, we are crucial because women now spend a third of their lives in postmenopause. Even fewer studies have hormone and menstrual data from midlife. When we came together to better define this third of women’s lives, it emerged that the postmenopause appears to have at least three stages, each with substages. We are only just beginning to understand the post menopause.

Such collaboration also allowed us to explore questions about differences by country in women’s experiences and health. This work has shown that—over and above differences in socioeconomic status—women in different countries really did experience their health journeys differently, highlighting the importance of culture in our experiences of health and wellbeing.

Our participants were aged 45–55 at the start of the project’s first phase in 1990. A new phase has begun with the start of each decade since. We are now in the project’s fourth phase. The women who are continuing to share their secrets were aged 75–85 in the project’s thirtieth year, 2020. Although there are now other larger studies internationally, the Australian women came together first. Therefore, these amazing women remain internationally crucial because they reach each age band five to 10 years earlier than those in studies elsewhere in the world. When we share information about their experiences, it can help international researchers fine-tune their own programs before their participants reach that age.

The several hundred women and many researchers who devote their time to our project are committed to sharing their knowledge. This book is an extension of their work on this to date. It is about all their stories, reflecting not just participants’ contributions but also those of researchers and health professionals, locally and internationally, who have been inspired by the participants’ willingness to step up and tackle some of the hardest questions in women’s health. The Australian women have joined with other cohorts of women around the world to collate information that has led to cross-country comparison studies and global health work.

Because the information the women provided was so detailed, it challenges the status quo of clinical practice. The women and researchers whose stories make up this book are trailblazers in the field of healthy ageing. The women’s contribution has been unique, in telling us not just about their illnesses and moods but also revealing details about their sex lives, relationships and identifying what is causing them hassles. They have demonstrated how all these things are connected—how you cannot fix one without addressing the other. They have shown us how diseases interact and overlap. They have helped us see how connected our environment is to our health and quality of life. Their stories and measures grouped together have a message worth hearing and heeding.

Experts in different fields have contributed equally to this study, as have our participants. We think this is a major reason for its longevity and success: incorporating the opinions and issues of importance to everyone, including the women who were in the study. A key element has been the inclusion of a broad range of disciplines—psychologists to nutritionists, social scientists to medical specialists—with equal contributions to the study development and data analysis from the outset. This inclusive culture has continued throughout the life of the study, with the dataset made available at first to all areas of the University of Melbourne and, since the 2000s, more widely for international collaboration through an online de-identified database, the Biogrid Network.

Although the project was initially led by a consortium of chief investigators, since 2013 it has been governed by a scientific advisory committee. Three investigators from the original 1990s study joined this advisory team, including Professor John Hopper AO, who was the original statistician back in 1990, and with Professor Henry Burger AO as inaugural chair. At the time of writing, the advisory board chair is Professor Dennerstein. This board has significantly contributed to the breadth of the study, with the addition of geriatrics experts broadening its scope over the past decade of follow-up as the women of the study are now all aged over 70.

We are indebted to our participants, who have shared all their healthy ageing secrets with us and the world.

WHAT THE STUDY MEASURED