Because the grandparental and parental generations’ conditions don’t develop until quite late in life, the grandchild may become sick before any of its elders have started displaying symptoms. This will make it difficult for a clinician to recognise that a genetic disease is present in the family, and this is compounded by the different symptoms found in the most severely and least severely affected individuals.
This strange pattern, where the oldest generation has different and milder symptoms that develop later in life than those found in the youngest generation, is rather similar to the inheritance pattern we saw in Chapter 1 for myotonic dystrophy. This is a very unusual genetic phenomenon and it is striking that in the two most clear-cut examples of this, the effect is ultimately caused by a change in length of a stretch of junk DNA.
One obvious question is why some tissues are more susceptible to short telomeres than others. This isn’t altogether clear, but some interesting models are emerging. It’s likely that tissues where there is a lot of proliferation will be susceptible to defects that lead to shorter telomeres. The classic example is the blood stem cell population, as described earlier in this chapter. If these cells have difficulties maintaining the length of their telomeres then eventually the stem cell population will run out.
That seems like a possible explanation for aplastic anaemia but it won’t work for pulmonary fibrosis. Lung tissue replicates quite slowly, yet pulmonary fibrosis is common in people with telomere defects. It’s possible that in lung cells the effects of shortened telomeres operate in tandem with other factors that affect the genome and cell function. These take time to develop, so lung symptoms typically develop later than ones that are caused by problems with the blood stem cells.
Our lungs are exposed to potentially damaging chemicals with every breath we take, so perhaps it’s not surprising that they struggle to tolerate the burden of defective telomeres. One of the most common sources of dangerous inhaled chemicals is tobacco. The global impact of smoking tobacco on human health is huge. The World Health Organization estimates that nearly 6 million people die every year as a consequence of smoking, over half a million of them from the effects of second-hand smoke.{68}
Researchers examined the effects of cigarette smoke experimentally. They genetically manipulated mice so that some of them had short telomeres and then exposed various mice to cigarette smoke.{69} The results are shown in Figure 5.2. Essentially, the only mice that developed pulmonary fibrosis were those that had short telomeres and were exposed to cigarette smoke.
Figure 5.2 A genetic defect and an environmental challenge are required to produce pulmonary fibrosis in mice. Mice with shortened telomeres don’t develop fibrosis, and nor do mice exposed to cigarette smoke. But mice with the double insult of shortened telomeres and exposure to cigarette smoke do develop the condition.
Cigarette smoking is not the only factor that affects human health, of course, although not smoking is probably the single smartest thing you can do for yourself. But the major factor that affects human health in wealthy countries is age itself. This wasn’t always the case. But it has been true since we made giant medical, pharmacological, social and technological progress in combating what used to kill us early: all those old-fashioned things like infectious diseases, early childhood mortality and malnutrition.
Getting old is now the major risk factor for development of chronic conditions. That’s a big problem when we realise that by 2025 there are likely to be over 1.2 billion people above the age of 60 worldwide.{70} Cancer rates rise dramatically over the age of 40. If you live to 80, there’s an even chance you will develop some type of cancer. If you are over 65 and you’re an American, there’s about the same chance you will have cardiovascular disease.{71} There’s plenty more statistics that paint a similarly bleak portrait, but why depress ourselves? Oh what the heck, one last one: the Royal College of Psychiatrists in the UK has stated that about 3 per cent of over-65s have clinical depression and one in six has symptoms of milder depression that are noticed by others.{72}
Yet we all know that two individuals of the same chronological age may be very different in their health. Steve Jobs, the co-founder of Apple, died from cancer at the age of 56. Fauja Singh ran his first marathon at the age of 89, and his last at the age of 101 (no, it wasn’t the same one). There’s a lot we don’t know about what controls longevity — it is almost always a combination of genetics, environment and sheer luck. But what we do know is that simply counting how many years someone has been alive only gives you a very partial picture.
We are starting to realise that telomeres may be quite a sophisticated molecular clock. The rate of telomere shortening can be influenced by environmental factors. This means we may be able to use them as markers not of simple chronology, but of healthy years. The data are rather preliminary and not always consistent. This is partly because measuring telomeres in a consistent way is challenging, as described earlier, and we usually measure them in cells that we can access easily. These are typically the white blood cells, and they may not always be the most relevant cell type to examine. But despite these caveats, some intriguing data are emerging.
Let’s go back to our old enemy, tobacco. One study analysed the length of telomeres in the white blood cells of over 1,000 women. They found that the telomeres were shorter in those who smoked, with an increased rate of loss of about 18 per cent for every year of smoking. They calculated that smoking 20 cigarettes a day for 40 years was equivalent to losing almost seven and a half years of telomere life.{73}
A 2003 study looking at mortality rates in the over-60s claimed that the people with the shortest telomeres had the highest mortality rates.{74} This was mainly driven by cardiovascular mortality and the findings have been supported by a later, larger study in a different elderly population.{75} A study in a group of centenarians from the Ashkenazi Jewish community found that longer telomeres were associated with fewer symptoms of the diseases of ageing, and with better cognitive function than that found in people of a similar advanced age but with shorter telomeres.{76}
Sometimes we forget that it’s not just physical factors that affect health and longevity. Chronic psychological stress can be very harmful for an individual, with negative impacts on multiple systems including their cardiovascular health and their immune responses.{77} Individuals who suffer chronic psychological stress tend to die younger than less stressed individuals. A study of women aged between 20 and 50 showed that those in the chronically stressed group had shorter telomeres than the unstressed women. This was calculated to equate to about ten years of life.{78}
In the great pantheon of global human health problems that are eminently avoidable but having terrible impact, obesity seems to be on a mission to duke it out with smoking. Turning again to the World Health Organization we learn that nearly 3 million adults die each year because of being obese or overweight. Nearly a quarter of the burden of heart disease is attributable to people being overweight or obese. For type 2 diabetes, the contribution of obesity is even worse (almost half of all cases are caused by being overweight) and it’s also true for a significant proportion of cancers (between 7 and 41 per cent).{79} The economic and social costs of this global epidemic are frightening.