Infection, inflammation, height, and longevity Eileen M. Crimmins* and Caleb E. Finch Andrus Gerontology Center, College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA 90089-0191 Edited by Kenneth W. Wachter, University of California, Berkeley, CA, and approved November 15, 2005 (received for review February 21, 2005) Using historical data from cohorts born before the 20th century in four northern European countries, we show that increasing lon- gevity and declining mortality in the elderly occurred among the same birth cohorts that experienced a reduction in mortality at younger ages. Concurrently, these cohorts also experienced in- creasing adult height. We hypothesize that both the decline in old-age mortality and the increase in height were promoted by the reduced burden of infections and inflammation. Thus, early growth and cardiovascular diseases of old age may share infectious and inflammatory causes rooted in the external environment. aging ͉ vascular disease ͉ mortality ͉ historical cohorts ife expectancy has doubled during the last 250 years from Lpreindustrial norms of 35–40 years (1, 2). Although all ages have benefited, the increases among the elderly began many decades after the increases at younger ages (3). We have Fig. 1. Model linking infectious exposure at earlier ages and external hypothesized that the historical increase in life expectancy at the environment to inflammation, height, organ damage, morbidity, and mor- older ages was due in part to life-long reduction in exposure to tality at older ages. Barker (10) and Fogel (11) emphasize dietary influences on chronic inflammation (4). It is well known that the survivors of growth͞development as a central mechanism. birth cohorts with lowered early age mortality due to infections experienced lower mortality throughout adult life (5–8), a relationship we have characterized as the ‘‘cohort morbidity conditions as a cause of mortality at old age; however, at this time phenotype’’ (4). Others have proposed that mortality at young approximately half of mortality in old age was ascribed to and old age is linked by improvements in nutrition and a unknown causes (13, 14). Where cause of death recording is not reduction in organ damage due to infections (9,10). We add the complete, Preston concludes deaths from unknown causes at reduction in lifelong exposure to inflammation to these expla- older ages are most likely to be cardiovascular (14). When life nations and develop in more detail the physiological mechanisms expectancy increases from 40 to 70 years, reductions in cardio- linking lifetime exposure to infections and late life health vascular disease are as important in total mortality decline as the outcomes. We also consider inflammation as a possible link combination of tuberculosis and all other infectious and parasitic between childhood mortality and adult height (11). conditions (14). Furthermore, Fogel showed that cardiovascular We argue that the demographic and economic revolutions disease was twice as prevalent among older Army veterans born beginning Ͼ200 years ago were accompanied by a physiological before 1845 vs. veterans born in the early 20th century (10). revolution, which occurred long before the benefits of modern The early mortality or medical records do not give any specific medicine. The historical reduction in inflammation was an evidence for the prominence of atherosclerosis, which is the internal manifestation of the physiological revolution, which was main cause of contemporary heart attacks and strokes. However, also indexed by the historical increases in height. We propose a a significant literature indicates that atherosclerosis was an general model in which the reduction in lifelong levels of ancient human condition and was common before the 20th infections and inflammation reduced and delayed the athero- century. For instance, autopsies of Egyptian mummies found sclerotic process and mortality due to heart disease and allowed atherosclerotic plaques in a majority of this sample (16͞24) (15, increased height (Fig. 1). This heuristic model emphasizes the 16). As early as 1858, Virchow concluded that ‘‘an inflammation pathway from decreases in infection through reductions in of the arterial coat was the starting point of the so-called inflammation but recognizes that other potential links include atheromatous degeneration’’ (17). improvements in diet and nutrition and reductions in direct In highly infectious environments, children are exposed to organ damage. Thus, our model considers a broader set of high inflammation levels, which promote the process of athero- pathophysiological mechanisms linking health across the life genesis even without exposure to high-fat diets. Infections and course than presented heretofore. inflammatory responses (18, 19) are recognized risk factors in Extensive debate over the causes of the historical mortality atherogenesis, a lifelong process that begins in utero (20). In decline has not resolved the relative roles of improved public Norway, infant mortality rates, a proxy for exposure to infections health, vaccines, income, and nutrition (1, 12). However, all of among survivors, correlated strongly with arteriosclerotic deaths these factors would have reduced exposure to, resistance to, or 40–69 years later for cohorts born from 1896–1925 (21). Con- consequences of infections. The role we hypothesize for inflam- mation considers the importance of heart disease as a historical cause of old-age mortality. Only recently have causes of death at Conflict of interest statement: No conflicts declared. old ages been reliably recorded; however, under reasonable This paper was submitted directly (Track II) to the PNAS office. interpretations of 19th century terminology, historical cause-of- Abbreviations: CRP, C-reactive protein; LDL, low-density lipoprotein; qn, probability of death data indicate substantial cardiovascular mortality. In the dying at age n. earliest cause-of-death records for England and Sweden, the *To whom correspondence should be addressed. E-mail: [email protected]. recorded cardiovascular deaths were comparable to infectious © 2005 by The National Academy of Sciences of the USA 498–503 ͉ PNAS ͉ January 10, 2006 ͉ vol. 103 ͉ no. 2 www.pnas.org͞cgi͞doi͞10.1073͞pnas.0501470103 Downloaded by guest on September 25, 2021 Fig. 2. Mortality of birth cohorts at ages 1 and 70 in Sweden (1751–1899) (a), France (1806–1899) (b), Switzerland (1871–1899) (c), and England (1841–1899) (d) with deviation from maximum cohort height at age 20–21 up to 1899 (measured in millimeters on right axis). temporary populations with high mortality from infectious con- Evidence of Cohort Mortality Links at Young and Old Ages ditions have elevated circulating levels of ‘‘acute phase’’ inflam- Cohort and period mortality data are available from varying matory proteins, e.g., blood levels of C-reactive protein (CRP), dates: Sweden since 1751, France since 1806, England since 1841, IL-6, and fibrinogen. Elevations at even moderate levels are risk and Switzerland since 1876. Mortality data are from the Human factors for heart attack and stroke (22). These inflammatory Mortality Database (www.mortality.org͞Public͞main.html) sup- markers are typically elevated during infections, e.g., diarrhea, plemented by data for France (27). Inclusion in this database is HIV, malaria, tuberculosis and other parasites, and periodontal limited to countries where death registration and census data are disease (4, 23–25). virtually complete; to facilitate comparisons across time and To further explore the cohort morbidity hypothesis (4), we place, similar techniques are used in constructing the data series. examine statistical associations between early and later mortality Because even the best historical data are liable to underregis- for cohorts born up to 1900 in Sweden, England, France, and tration and age uncertainties, particularly at the youngest and Switzerland. We hypothesize that historical trends in mortality at oldest ages, much of our analysis is limited to those under 75 younger and older ages will be similar within cohorts. We also years of age. We examine childhood mortality at all ages, because compare trends in childhood and middle-age mortality within infant mortality is usually the last age to achieve complete cohorts. We expect these trends to be less similar to childhood registration. mortality because people in middle age do not die from the At the initial dates for our analyses, cohort life expectancy at chronic diseases developed through exposure to inflammation. birth was low: 34 years in Sweden, 38 years in France, 42 years We focus exclusively on cohorts born before the 20th century, in England, and 45 years in Switzerland. For the 1899 cohort, life when levels of infection were high, but before smoking, a major expectancy had increased to 55 years in Sweden, 56 years in inflammatory stimulus, became popular. Most importantly, Switzerland, 53 years in England, and 50 years in France. These these cohorts entered adulthood before general childhood im- low life expectancies imply that all of these cohorts were exposed SOCIAL SCIENCES munizations and before antibiotics. The inflammatory mecha- to highly prevalent infections. nisms that we describe can only work when mortality from Mortality at ages 1 and 70 of successive cohorts by year of birth infection is high; once childhood infection is low, it can no longer up to 1899 show the strong link within cohorts of childhood and be a factor