Are we, as human beings, actually traversing some valley of random health disaster in our late 40s, 50s and 60s? And if so, what lies ahead? And is there anything we can do about it?Marc Tran / Stocksy United

 

You’re in Your 40s and Suddenly People You Know Are Dying. What’s Going on?

By Amanda Hooton

 

Until my 40s, I had not had a single close friend of my generation die. Does this make me lucky? Perhaps. But I suspect – and the stats would back me up here – I am somewhere close to normal. One wonderful boy at high school died by suicide; a kind cousin I knew only slightly died in a car accident when we were in our early 20s. Both events were tragic, but they didn’t involve people I was directly connected to. When I was young, my friends and contemporaries were, like me, essentially immortal. Right?

Wrong. In the past five years, as I’ve moved through my 40s, I have lost people I knew – really knew – and loved. People who lived nearby; people I worked with; close friends. And I’m not the only one. The awful fact appears to be that, everywhere you look, people in midlife – in their 40s and 50s – are being lost to us. Over Christmas and New Year alone, popular former doctor and  Victorian liberal Katie Allen passed away at 59 ; respected  Melbourne university chancellor Emma Johnston died at 52 ; and much-loved journalist Tim Stoney died at 58. And, at least for me, the same feeling accompanies all these deaths: the sense of a valuable person, gone long before their time.

In this context, I’m increasingly conscious that being here post-50 feels a bit like dumb luck; good fortune to be thankful for, rather than something to simply expect. Are we, as human beings, actually traversing some valley of random health disasters in our late 40s, 50s and 60s? And if so, I have two questions. What lies ahead? And is there anything we can do about it?

Distinguished Professor Emily Banks, AM, head of the Centre of Epidemiology for Policy and Practice at the National Centre for Epidemiology and Population Health at ANU, has red hair and an infectious enthusiasm for graphs. “Sergey has done a lot of really beautiful graphs about what creates the lived experience of ill health around us,” she says over Zoom, nodding at her split screen. ANU demographer and, evidently, master-of-graphs Dr Sergey Timonin smiles modestly.

The obvious graph for midlife health is, surprise, one that depicts human death rate: age on the horizontal axis, death rate on the vertical. It’s an exponential curve, which those of us who became armchair epidemiologists during COVID-19 should recognize: shaped like a ski jump, with a long flat stretch at the start, then curving smoothly, and ever more steeply, upwards.

Until our 40s, life is basically happening on the long, flat bit of this graph. “We’re just going along in our lives,” explains Banks. “And then, as we get into ­middle age, and as the line of the graph begins to curve, we start to notice our own health problems, and the health problems around us. I know when I hit my 40s, I started to have increasing numbers of friends with serious illnesses. I had friends who died of brain cancer, pancreatic cancer, people who had heart attacks. My first boyfriend, who I’d hold hands with when I was 13, died of lung cancer in his early 50s. Those kinds of things start to happen to you.”

Yes, I say, that’s exactly what’s happened to me. Banks nods. “And that’s because for all this early time period, human mortality looks like it’s really, really flat. But actually, because it’s exponential, it’s going from one in a million, to two in a million, to four, eight, 16. For a long time, you’re only aware of deaths as isolated events, because initially the numbers are very small. But at a certain point, you’re doubling a number that’s quite big, and it becomes noticeable.”

In number terms, according to figures from the Australian Bureau of Statistics, the rate of annual ­all-cause mortality in the Australian population in 2024 was about 73 people per 100,000 between the ages of 25 and 44. Between 45-64, however, it’s 350 per 100,000. That’s almost a five-fold increase.

Importantly, it’s still not a big number. “At the population level, let’s not alarm everybody,” says Professor Gita Mishra, an epidemiologist at the University of Queensland’s School of Public Health. “In terms of absolute risk, the number is still very small.”

It doesn’t feel small, though, when it’s happening around you, to people you care about. Emily Banks nods. “What it feels like to live it – and we saw this with COVID – is something new and frightening: more people we know are dying. And when new things like that happen, we tend to make them bigger in our minds. And we start to think ‘that could happen to me’.”

This is a normal human reaction: indeed, it’s part of the rich tapestry of unconscious cognitive processes that help – and sometimes hinder – our interpretation of the world. Processes like confirmation bias (our tendency to scour for evidence that supports our particular pet theory, while busily ignoring any contradictory information); and selective attention (giving our pattern-finder brains instructions to ignore most things and focus minutely on a specific search for particular information). Both these mechanisms inform the Baader-Meinhof phenomenon, a process in which it seems as if a certain event, object or idea is occurring more frequently than it actually is.

This doesn’t negate our “everyone is suddenly dying” feeling; but it does help explain it. Exponential increase is simply the way “natural human lifespan operates”, explains Timonin. This is not to say we haven’t influenced our own mortality at all over the centuries. “Of course we’ve had massive changes in life expectancy,” says Timonin: “People today live much longer than in Victorian times; half of all children once died before the age of five, many women died in childbirth. So, the age at which the curve begins can change. But the overall shape of the curve does not.”

So, we might think we’re being suddenly targeted by some malign fate once we hit our mid-40s. But really, it’s just math.

One of the (admittedly many) uneasy but also ­ultimately hopeful details about the risk of death in middle age is that a lot of it can actually be avoided.

When we’re young, the top causes of death are ­usually sudden, and almost always have an external cause: car accidents, accidental drug overdoses. (Two more complex killers of young people are suicide, which has both external and internal, physiological factors; and, for young women, breast cancer.) As we age into midlife, however, from 45-64, things change dramatically. Accidental deaths are no longer the biggest danger. For women, breast cancer becomes the top cause of death, and is joined by lung cancer and coronary heart disease (which includes events such as heart attack). For men, coronary heart disease is number one, followed by lung cancer and suicide.

The crucial detail for both genders is that almost all these deaths are the result of chronic disease. Chronic disease is disease that takes a long time to develop, and is strongly influenced by simple details of our lifestyle: what we eat and drink, and how much exercise we do. These details are what epidemiologists call behavioral “modifiable risk factors”.

If this story came accompanied by a band, there would be a thrilling trumpet fanfare at this point, to announce the arrival of a major character onto the stage. Modifiable risk factors have a huge impact on premature death. Firstly, they can have a massive impact on disease. And secondly, they’re – well – modifiable. Which means we can alter them. Which in turn means we can meaningfully lower our risk of death: we can potentially avoid the sweeping scythe of midlife mortality. In their most basic, layman’s form, the five biggest modifiable risk factors are: tobacco use, physical inactivity, poor diet, overweight and obesity, and alcohol use.

Importantly, this is not to say that anyone’s life is reducible to statistics or that anyone is to blame for dying in midlife because they didn’t live a perfectly healthy lifestyle. A perfect life is, by definition, beyond all of us. Disease makes no moral judgment, and nor should we. As Emily Banks puts it, “It rains on the just and unjust alike.”

So. With that in mind, let’s modify some risk. Take lung cancer, for example: a top three cause of death for both men and women between 45 and 64. According to Cancer Australia, as much as 90 per cent of lung cancer in men and 65 per cent in women is estimated to be a direct result of tobacco smoking. (Other types have nothing to do with smoking and can affect people who have never smoked a single cigarette.) “Smoking is one of the most dangerous things we do,” says Emily Banks. “It plays a major role in the top five causes of death in humans overall – ­ischemic heart disease, dementia, lung cancer, stroke, and chronic obstructive pulmonary disease.” Yet people almost universally underestimate the risk ­associated with it. “Even if you’re a so-called light smoker – three to five cigarettes a day – your risk of dying from lung cancer is nine-fold that of someone who has never smoked.”

Stop smoking and virtually eliminate your chances of contracting lung cancer: this is the perfect example of a modifiable risk factor. Brilliantly straight­forward, extraordinarily effective. So why don’t we all take action immediately? Welcome to one of the great questions of humanity: why do we so reliably fail to do the things we know are good for us?

Take another example: exercise. Of course, we’d feel better if we exercised! We know this! Yet a full third of Australian adults do not reach recommended levels of aerobic exercise a week (150 minutes or more on at least five days) and a massive 80 per cent of us don’t do our two muscle strengthening sessions. Dr Rachel Dear is a medical oncologist and senior staff specialist at St Vincent’s Hospital Sydney. In her opinion, “Exercise is the number one thing you can do: it’s the wonder drug we’ve all been searching for. We have studies showing it reduces your risk of [breast ­cancer] recurrence by 50 per cent – that’s as good as adjuvant chemotherapy.” Dear, who has a lovely cheerful voice, sighs. “But of course, the number of people who don’t do it is huge. It’s too hot, it’s too cold, they don’t have time. And we can get the same dopamine hit from lying on the couch scrolling Instagram as we can from bench pressing 40 kilograms. And so a lot of people choose Instagram.”

Moving on to diet. Our sofa-scrolling high, alas, is not always accompanied by a healthful snack of broccoli florets and carrot soldiers. Eating more healthily may be an almost universal goal, yet seven out of 10 Australians do not eat the recommended quantity of vegetables each day (five kinds, half to a cup of each if cooked). Unhealthy eating, especially in these days of ultra-processed food, leads to its own risks – such as bowel cancer, type 2 diabetes, high cholesterol and heart disease – and it also means that, even when we do get off the couch, few of us are fitting into the jeans we were wearing back in our immortal 20s and 30s.

Which leads us to obesity. Six out of 10 Australians are over their healthy BMI figure. And being overweight and obese contributes to, among other things, type 2 diabetes, heart disease, stroke, high blood pressure, high cholesterol, fatty liver disease and ­endometrial, breast and colon cancers.

At this point, if you feel like you could use a stiff drink, think again. The final modifiable health risk is alcohol. It’s now acknowledged that, far from low levels being somehow “safe” – I clung for years to those claims about antioxidants in red wine – alcohol is, as the World Health Organization stated in 2023, “a toxic, psychoactive, and dependence-producing ­substance and has been classified as a Group 1 ­carcinogen by the International Agency for Research on Cancer … [a] group which also includes asbestos, radiation and tobacco”. And yet, according to the AIHW, almost 70 per cent of Australian adults – 14 million people – consumed alcohol in 2022-23, and more than a quarter exceeded the alcohol guidelines.

Written down in black and white, perhaps, the changes we need to make seem ridiculously obvious. And yet we don’t make them. Indeed, we continue to take risks with our health we would never countenance in other parts of our lives. Why?

Part of the problem is experience. Until our 40s (or even 50s), most of us have never had to worry about making any of these (let’s face it, unbelievably unappealing) lifestyle changes ever before. We’ve eaten badly and drunk too much and lain on the damn couch for 30 years, with no observable ill-effects. Why should things suddenly be different now?

The answer to this question involves one of the great challenges of middle age. “What we need to ­acknowledge, even just intuitively, is that when you stop being a ‘young’ person, even if you don’t feel any different [my italics], you lose a lot of the physiological resilience you’ve had up to this point,” says Professor Hassan Vally, an epidemiologist at Deakin University. “The ageing process involves a decline in all of the physiological activities of the body. Basically, everything gets worse. You’re in a – hopefully slow – decline, but you are in a decline. There’s no getting around it. Everything from lung function to glucose tolerance – every process that your body performs – slowly but surely gets less efficient, more prone to error, less robust. That’s just what ageing is.”

Our reluctance to accept this single, incontrover­tible fact is a source of great middle-aged woe. After all, we often feel just as immortal at 45 as we did at 25. But whatever talisman we cling to – the red Ferrari, the Botox, the coconut mouthwash (if you are long­evity guru David Sinclair) – we are not now that which we once were. We are, in fact, beginning to reap in health terms what we’ve sown in lifestyle choices for the previous 30 years. And – sadly for us – just because we haven’t noticed the damage we’ve done doesn’t mean it hasn’t happened.

“The fact is, it’s not like you’re a perfect physical specimen up to midlife and then suddenly everything collapses,” says Vally bluntly. “Damage has been occurring all along. But it’s often around midlife that it can actually begin to show in diagnosable chronic disease. It’s a question of accumulation. If someone eats really shitty food in their 20s and you go and look into their hearts, you can see the beginnings of the formation of plaques: it’s starting to happen. And over time, it just builds and builds, until it gets to a critical point and you either have a heart attack, or you get diagnosed with cardiovascular disease.” Ergo, potential illness and death in midlife.

But it’s not all bad news. The great upside of all this is that as soon as you begin to alter your life, things improve – sometimes extraordinarily quickly. Within 20 minutes of finishing a cigarette, your elevated heart rate and blood pressure begin to drop. Your body begins to process an unhealthy meal within a few hours. You clear the ethanol from an alcoholic drink out of your system in about an hour. Of course, you’ve got to then not have another cigarette, croissant or martini an hour later – and significant change does take time.

But it’s never too little – “It’s all about ­putting as few risk marbles in your disease jar as you can,” says Mishra – or too late. “If you’re a smoker, quitting at any age brings huge benefit,” says Banks. “And if you can stop by 45, you avoid 90 per cent of the excess risk.” Vally agrees. “The human body is amazing. If you do the right things at any age, it can have an effect.”

Of course, not all access to healthy lifestyle choices is created equal. UNSW Scientia Professor Kaarin Anstey is director of the UNSW Ageing Futures Institute. “There is an equity issue, where people with more resources have more capability and more access to healthy food and exercise,” she says. Ironically enough, we have created a world specifically designed for our maximum wellbeing, in which achieving that wellbeing is actually far harder and more expensive – in time, energy, and money – than any other way of living your life.

But even so. Some things are possible. “What we can all be doing,” regardless of our circumstances, says Banks, “is looking at this 40s, 50s, 60s time as a great chance to make some changes. When you get to 50, there’s free breast cancer screening, free bowel cancer screening, a free health check which looks at blood pressure, cholesterol.” And if there are issues, says Mishra, “in many cases, if you’ve tried to make lifestyle changes and you can’t get there, safe, effective medications are available.” -  The Age