Most people may not have heard of the Framingham Heart Study. But large public health studies that have carried out in-depth analyzes of more than 15,000 people for 77 years are the source of many of the ideas we now have about healthier aging. This was the inspiration for the creation of the first checklist for assessing cardiovascular disease risk, and our current understanding of how to reduce cardiovascular disease can be traced directly from its results.
Although the Framingham Heart Study initially focused solely on heart health and covered most of the residents of the former mill town on the outskirts of Boston throughout their lives, it now provides information on the brain, liver and many other organs.
As part of TIME's series of interviews with leaders in the field of longevity, we spoke with epidemiologist Dr. Donald Lloyd-Jones, the current study leader and a professor at the Chobanian and Avedisian School of Medicine at Boston University, about the study and what it tells us about aging well.
This interview has been condensed and edited for clarity.
What is the Framingham Heart Study?
This is the longest running community-based study in the world. Its origins lie in the search for the root causes of cardiovascular disease, especially heart attacks and strokes. In 1948, the people who designed the study recruited about a third of the population of Framingham, Massachusetts, which is about 20 miles west of Boston. They really wanted to understand what caused the emerging epidemic of cardiovascular disease after World War II.
It was already a leading cause of death, but it was very clear that it was increasing, and it was not entirely clear why this was happening. There have been some very good hypotheses suggesting that diet and cigarette smoking may be linked, but this has never been systematically or consistently proven.
They began to realize that it would be beneficial to include families in this study: that cardiovascular disease is not just a man's disease, and that there may be some familial component. They haven't even discovered DNA yet. It took decades to think about genetics.
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They saw all the participants every two years and did a full physical examination, took blood, measured height and weight, and the like. They asked: what are they doing? What were their health habits? A really deep dive into what was available at the time.
By the early 1960s, they had a strong signal that blood cholesterol levels were closely related to the risk of cardiovascular disease. Blood pressure was particularly strongly associated with cardiovascular disease risk and smoking. Quite quickly after that, they saw that body weight was associated, that sedentary lifestyle and certain aspects of diet were associated.
So Framingham was really a study that mapped what we now think of as the traditional risk factors for cardiovascular disease.
What happened next?
They enrolled over 5,000 more people who were descendants of the original participants and the spouses of those descendants. So we're starting to discover genetic connections, as well as environmental connections—the shared environment between spouses. It took decades before we realized these things were important, but there were guesses and they were smart enough to listen to these signals. Thus, cohorts of offspring are examined approximately every four years, in addition to the first cohort being examined again every two years. This continued throughout the 1970s, 80s and 90s.
We are beginning to better understand not only total cholesterol, but also the subcomponents of cholesterol. We're starting to better understand that your systolic blood pressure is actually more dangerous to you than your diastolic blood pressure. Certain types of dietary factors and certain types of physical activity were better.
Fast forward a few more decades: in 2002, the third generation of related individuals registered in Framingham. Along the way, the city of Framingham changed quite a bit. Originally, back in 1948, Framingham was a city primarily populated by people of European descent. It was a factory town, so there was a wide socioeconomic stratification, but it was fairly homogeneous in terms of race and ethnicity—almost exclusively white. But by the 90s and 2000s, there were a lot of people of Asian descent; Many Brazilians have settled in Framingham, making it a much more diverse community.
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In total, we follow six different groups of people, each with some connection to Framingham. And now there is technology that can completely sequence someone's DNA and understand modifications to that DNA, called epigenetics. We can collect data about what their cells are actually transcribing. We can collect data from proteomics, metabolomics, microbiomics, and there are new technologies that will help us look inside the body non-invasively and see the development of diseases in the cardiovascular system, brain and kidneys.
There has been a huge explosion in how we can characterize people. And Framingham has truly always been a leader in understanding the aging process of every organ system in the body. Yes, we're still the Framingham Heart Study, but we have just as much activity in brain health across the lifespan, and we also have a lot of activity focused on bone health, kidney health, lung health, liver health—you name it—because these people are so well studied throughout their lives.
What can people do to reduce their risk of aging diseases?
The American Heart Association has a good way of putting it all together called the Essential 8 of Life. It is a platform through which people can measure their cardiovascular health today. It's also associated with really positive health outcomes over time, and that's influenced by the Framingham Heart Study.
The eight ingredients won't surprise you, but they're all effective. All of them can be changed, and these are all the things that people can do today to improve their cardiovascular health, which has been shown to reduce the risk of developing Alzheimer's disease, all forms of cardiovascular disease, even cancer, arthritis, all the things that we worry about as chronic diseases of aging. If you focus on your cardiovascular health, you'll benefit from all of these things at once.
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So what are the eight components? These include eating a healthy diet, participating in physical activity, avoiding all forms of nicotine exposure (combustible cigarettes as well as other forms of nicotine exposure as they are also toxic), healthy sleep, healthy weight, healthy blood pressure, healthy blood sugar levels and healthy blood lipids.
No surprises, but here's what it's about: How can we optimize your health today to extend not only your lifespan, but your healthspan—that is, not just the years of your life, but the life in your years?
Can we move the date of your illness much later—much closer to the time of your death—so that you have more healthy years, not just more years, period?
It seems that we as a society are not necessarily doing what science suggests. Why is this?
The truth is that although we have known this for 60 years, we still do a poor job of implementing it in public health policy and clinical practice. It's a pretty simple message, but we don't design our society, our environment, our neighborhoods, or our food supply to optimize these things.
You can take this information and make changes. Great story: in the early 70s, Finland had the highest mortality rate from coronary heart disease in the world, and quite a significant one. They took the information from Framingham and said, “You know what, let's do a study where we take a county with a particularly high rate of coronary disease deaths and just make some changes in public health.” We are going to make changes to the smoking policy. We're going to help people quit smoking. We are going to stop subsidizing meat and start subsidizing fruits and vegetables in our food supply.
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Immediately, rates of coronary heart disease began to decline, and these strategies were soon being implemented throughout the country. After 30 years, the mortality rate from coronary disease had dropped by 84%, and suddenly Finland had the lowest mortality rate from coronary disease in the world – so the transition from the latter to the former.
In the United States, we saw about a 70% decline in cardiovascular disease mortality between 1968 and 2010 because we improved clinical indicators and did some public health things.
Unfortunately, I think that although we have made really great progress, the obesity epidemic has begun to seriously increase the burden of cardiovascular disease. Since obesity leads to higher blood pressure, higher blood sugar, poorer cholesterol levels—everything else—it's becoming something of a perfect storm. Since 2011, we have seen these improvements in mortality rates stabilize and perhaps even reverse somewhat, which is unfortunate. We understand everything we need to know about preventing cardiovascular disease. By implementing this, we will expand the possibilities for healthy aging.
What does the future hold for the Framingham Heart Study?
Well, you may have heard that funding science is a little difficult these days. But I hope we continue to represent the city of Framingham. I think there can be real value in having our fourth and fifth generations in the program as well.
The more we studied the life course of all these chronic diseases, the more we realized that every time we are diagnosed, the horse is already partially, if not completely, out of the barn. Therefore, we need to start doing prevention much earlier in life.
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I'll leave you with something hopeful. In another community-based study—sort of a descendant of the Framingham Heart Study—when they looked at how long people lived without heart disease, they found that lifestyle wins out. Even people with high-risk genes, if they have good lifestyle habits, live on average 12 years longer than people with good genes but poor lifestyle habits. Moreover, they live an average of 19 years longer without cardiovascular disease.
They not only extended their lives; they significantly extended their health span.
Genetics is not destiny. We can actually bend this curve and people can achieve more by sticking to these healthy lifestyle options. A lot of this is actually under our control. But we need help: we need help in the form of food. We need help in the form of good public health policies to ensure we are not exposed to indoor air contaminated by cigarette smoke. We need safe streets to go outside and be physically active. We really need to be able to buy fruits and vegetables.
In many ways, it is the policy that lays the groundwork. But much is also under our control.
This article is part of TIME Longevity, an editorial platform dedicated to exploring how and why people live longer and what this means for individuals, institutions and the future of society. See other articles on this topic. Click here.
