4 / Healthy Ageing After 45: What Is Actually Worth Measuring and Checking?

We have spent the first three articles looking at what happens to muscle, bone and physical capacity as we age, how to start building strength and how to progressively train the body rather than simply exercise it. Now we need to answer the final question: how do you know how well you are actually aging?

This is where I want to move away from the idea that healthy aging can be measured by your weight, your appearance or one impressive blood test. A woman can have perfectly respectable laboratory results and still be losing muscle, developing osteoporosis or becoming progressively less physically capable. Equally, a woman can be strong and active while quietly developing hypertension, insulin resistance or cardiovascular risk that she cannot feel.

Healthy ageing needs both perspectives. We need to know what is happening inside the body and what the body is actually capable of doing.

Start with blood pressure because you cannot feel hypertension

Blood pressure is one of the simplest measurements we have, yet it tells us something enormously important about cardiovascular health.

Persistently elevated blood pressure damages blood vessels and increases the risk of heart disease, stroke, kidney disease and cognitive decline. The difficulty is that hypertension frequently causes no obvious symptoms.

This is why “I feel perfectly healthy” is not a substitute for measuring it.

A single elevated reading does not automatically mean you have hypertension. Blood pressure varies with stress, activity, caffeine, illness and even the circumstances in which it is measured. Repeated measurements, including properly performed home readings when appropriate, can give a much more useful picture.

If you own a monitor, make sure the cuff fits correctly, sit quietly beforehand, support your arm and take measurements under reasonably consistent conditions. A measurement is only useful if it is reasonably accurate.

Know how well your body is handling glucose

Glucose regulation becomes increasingly important as we age because insulin resistance and type 2 diabetes affect far more than blood sugar.

Fasting glucose and HbA1c are useful starting markers. Fasting glucose shows what is happening at one point in time, while HbA1c reflects average glucose exposure over roughly the previous two to three months.

In selected cases, fasting insulin can add information about the amount of insulin the body is producing to maintain glucose control, particularly when the wider clinical picture suggests insulin resistance. But fasting insulin is not required to diagnose diabetes and should not be interpreted as an isolated “metabolic health score.”

Waist circumference, blood pressure, triglycerides, HDL cholesterol, family history, previous gestational diabetes, PCOS and changes in body composition can all contribute to the wider metabolic picture.

The important point is to identify deterioration before years of abnormal glucose regulation have produced complications.

Your lipid profile deserves more than a glance at total cholesterol

A standard lipid profile usually includes total cholesterol, LDL cholesterol, HDL cholesterol and triglycerides. These measurements contribute to cardiovascular risk assessment, but total cholesterol alone is a very crude way of deciding whether your lipid profile is concerning.

Apolipoprotein B, or ApoB, can provide additional information because each atherogenic lipoprotein particle carries one ApoB molecule. ApoB therefore gives us an estimate of the number of potentially atherogenic particles circulating in the blood.

Another marker worth knowing about is lipoprotein(a), or Lp(a). Lp(a) is largely genetically determined and elevated levels are associated with increased cardiovascular risk. Because levels are relatively stable throughout life, many current guidelines and expert groups support measuring Lp(a) at least once in adulthood to identify people with genetically elevated levels.

These numbers still need context. Cardiovascular risk is influenced by age, blood pressure, smoking, diabetes, kidney disease, family history and many other factors.

The aim is not to chase a perfect cholesterol number. It is to understand your overall cardiovascular risk and modify what can realistically be modified.

Basic blood tests can identify problems that undermine physical capacity

If you are unexpectedly tired, weak or struggling to progress despite appropriate training, it may be worth looking beyond the training programme.

A full blood count can identify anaemia and other abnormalities. Ferritin and iron studies may be useful when iron deficiency is suspected, particularly in perimenopause if periods remain heavy.

Vitamin B12 and folate can be relevant depending on symptoms, diet, medication and medical history. TSH with appropriate thyroid testing becomes important when symptoms suggest thyroid dysfunction.

Renal function, electrolytes and liver markers are also part of a broader health assessment where appropriate. Kidney health becomes particularly relevant when considering medications, cardiovascular risk and some supplements.

These are not “longevity markers.” They are ordinary medical tests that can identify genuine problems capable of affecting how you feel and function.

Sometimes boring medicine is very useful medicine.

Vitamin D matters, particularly when we are thinking about bone

Vitamin D plays an important role in calcium absorption, bone metabolism and muscle function. Deficiency can therefore be relevant when assessing bone health and fracture risk.

The blood test used is 25-hydroxyvitamin D.

Whether everyone needs repeated vitamin D testing depends on individual circumstances and local medical guidance. Risk of deficiency, bone disease, limited sun exposure, certain medical conditions and medications can make testing more relevant.

If deficiency is identified, correct it appropriately. But there is no benefit in assuming that pushing vitamin D progressively higher creates progressively stronger bones.

Bone needs adequate vitamin D. It also needs calcium, protein, mechanical loading and the wider hormonal and nutritional environment required for normal remodelling.

Bone density deserves particular attention after menopause

Bone is one of the areas where menopause itself makes a substantial difference.

Declining estrogen accelerates bone turnover and can lead to significant loss of bone mineral density around and after menopause. This is why assessing fracture risk becomes increasingly important.

A DXA scan, or dual-energy X-ray absorptiometry, measures bone mineral density, usually at the hip and lumbar spine. It is the standard investigation used to diagnose osteoporosis and assess bone health in appropriate people.

DXA results in postmenopausal women are commonly reported using a T-score, which compares your bone mineral density with that of a healthy young adult reference population.

A T-score of −1.0 or above is generally considered normal. Between −1.0 and −2.5 indicates low bone mass, often called osteopenia, while −2.5 or lower is consistent with osteoporosis in the appropriate clinical setting.

But bone density is not the same thing as fracture risk.

Osteopenia does not automatically mean you will fracture

This distinction is important because women can become understandably frightened when they see the word osteopenia on a report.

A T-score tells us about bone mineral density. Fracture risk depends on much more, including age, previous fractures, family history, smoking, alcohol, glucocorticoid use, body weight, certain medical conditions and the likelihood of falling.

This is where tools such as FRAX can be useful. FRAX estimates the ten-year probability of major osteoporotic and hip fractures using several clinical risk factors, with or without bone-density information depending on the situation.

There are limitations, and it is not appropriate for every circumstance, but it reinforces an important principle: we treat the woman and her fracture risk, not simply one number on a scan.

Know when a DXA scan is appropriate

Not every 45-year-old woman needs a bone-density scan simply because she has entered perimenopause.

Routine screening recommendations vary somewhat between countries, but bone-density testing becomes particularly relevant with increasing age and earlier when risk factors are present.

These can include a previous fragility fracture, prolonged glucocorticoid treatment, very low body weight, premature or early menopause, certain endocrine or gastrointestinal diseases, strong family history and other conditions or medications that increase osteoporosis risk.

If you have significant risk factors, don't wait until an arbitrary birthday to discuss bone health.

And if you have already had a low-trauma fracture, that information itself can be extremely important even before looking at the DXA result.

Healthy Ageing After 45: Why Body Composition Tells Us More Than Body Weight

The bathroom scale tells you the combined weight of everything in your body.

It cannot tell you how much is muscle, fat, bone or water.

This becomes increasingly important with age because a woman can remain at approximately the same body weight while gradually losing muscle and gaining fat. The scale may therefore appear reassuring while body composition and metabolic health are moving in the wrong direction.

Waist circumference is one simple measurement that can provide useful information about central adiposity and cardiometabolic risk.

DXA can also estimate fat mass and lean mass in addition to bone density, although body-composition analysis is not necessary for everyone and should not become another expensive measurement women feel obliged to repeat constantly.

The question is whether the measurement changes what you do.

If it doesn't, collecting more data isn't necessarily improving your health.

Muscle mass alone is not enough

This is where healthy-ageing assessment becomes much more interesting.

For years, sarcopenia was discussed primarily as a loss of muscle mass. We now understand that muscle strength and physical performance are enormously important, and low strength can be clinically significant even before severe muscle loss becomes obvious.

This means we should not only ask how much muscle you have.

We should ask what that muscle can do.

And some of the most informative ways of answering that question require no blood test at all.

Grip strength is a simple marker of overall strength

Grip strength can be measured using a handheld device called a dynamometer.

It sounds almost too simple to be medically interesting, but low grip strength has repeatedly been associated with disability, poorer health outcomes and mortality. It is therefore often used as a practical marker of overall muscular strength.

That does not mean squeezing a hand gripper prevents cardiovascular disease.

Grip strength is useful partly because it reflects broader physical capacity.

If grip strength is unexpectedly low, particularly alongside other signs of weakness or loss of function, it gives us a reason to look more closely at muscle, nutrition, activity and overall health.

But you do not need to own a dynamometer to begin thinking about functional strength. If jars have become harder to open, shopping bags feel heavier than they used to or you increasingly avoid lifting things, those observations are information too.

The chair-rise test tells us something your blood tests cannot

Try standing from a chair without using your arms.

Then sit down and repeat it several times.

This simple movement requires leg strength, balance and coordination. Standardised versions, such as the five-times sit-to-stand test or timed chair-stand tests, are used clinically to assess physical function.

Again, the point is not to become obsessed with achieving a perfect score.

The important question is whether basic movements that should be relatively easy are becoming progressively harder.

Difficulty rising from a chair can be an early sign that lower-body strength and function deserve attention long before somebody would describe themselves as frail.

Walking speed is surprisingly powerful information

How quickly someone walks under normal conditions can provide information about overall physical function.

Walking requires the cardiovascular system, nervous system, muscles, joints, balance and coordination to work together. Slower gait speed in older adults is associated with poorer health outcomes and loss of independence.

You do not need to start timing every trip to the supermarket.

But notice your capacity. Are you beginning to struggle to keep pace with people your own age? Do you avoid hills? Has your usual walking route become significantly harder? Do you need more frequent rests?

Changes in everyday performance can sometimes reveal declining physical reserve before a laboratory marker changes.

Can you get down to the floor and back up?

This is another wonderfully practical assessment.

Getting down to the floor and returning to standing requires leg and trunk strength, mobility, balance and coordination. It also happens to be a skill that becomes very important if you ever fall.

If you can do it comfortably, keep practising.

If you cannot, don't simply accept it as something that happens with age. Identify what is limiting you. Is it knee pain? Hip mobility? Leg strength? Balance? Fear?

Those limitations can often be worked on.

The goal is not to perform an elegant yoga transition. The goal is to maintain the physical options that allow you to manage your own body.

Balance deserves to be measured before you start falling

Falls are a major cause of injury and loss of independence in older adults, and fracture risk becomes particularly concerning when poor balance meets osteoporosis.

A simple single-leg stand can give a rough indication of balance, although formal assessment can be considerably more sophisticated.

If you cannot stand safely on one leg for more than a brief moment, repeatedly need support or have noticed increasing unsteadiness, don't wait for a fall to make balance a priority.

Vision, inner-ear function, peripheral neuropathy, medications, muscle weakness, neurological conditions and blood-pressure problems can all contribute to impaired balance.

This is another situation where the answer is not always simply “do more balance exercises.”

A significant change in balance deserves an explanation.

Cardiorespiratory fitness can be assessed too

Laboratory measurement of VO2 max provides a direct assessment of maximal cardiorespiratory fitness, but most women do not need sophisticated exercise testing simply to know whether their cardiovascular fitness needs work.

Submaximal exercise tests, walking tests and wearable-device estimates can provide varying levels of information, while everyday performance remains useful too.

Can you walk briskly without excessive breathlessness? Climb stairs? Hike uphill? Sustain moderate exercise comfortably?

If you are becoming progressively more breathless with activities that were previously easy, do not automatically assume you are simply getting older or unfit.

Unexplained or disproportionate exercise intolerance can also occur with anaemia, cardiovascular disease, lung disease and other medical conditions.

A decline in capacity deserves attention when it does not make sense.

Frailty is about reserve, not age

A woman can be 75 and physically robust. Another can be considerably younger and already have very little physiological reserve.

Frailty assessment looks at vulnerability rather than simply chronological age. Depending on the method used, clinicians may consider strength, walking speed, physical activity, exhaustion, weight loss, medical conditions and ability to perform everyday tasks.

One particularly important sign is unintentional weight loss.

If you are losing weight without trying, particularly alongside weakness, reduced appetite, fatigue or declining physical function, that is not a healthy-ageing victory because the scale is moving down.

It needs investigation.

Loss of body weight in later life can include substantial loss of muscle, and unexplained weight loss can also be a sign of underlying disease.

Know which changes should not be dismissed as ageing

Ageing changes physical capacity, but “you're getting older” should not become an explanation for every new symptom.

Rapid loss of strength, unexplained weight loss, repeated falls, a fragility fracture, persistent severe fatigue, significant balance changes, new neurological symptoms, chest pain or disproportionate breathlessness during exercise deserve proper medical assessment.

Likewise, persistent muscle weakness may sometimes reflect neurological, endocrine, inflammatory, nutritional or medication-related problems rather than simply inadequate training.

Healthy ageing is not about trying to exercise your way through every symptom.

It is knowing the difference between a capacity that needs training and a change that needs investigating.

So what would I actually keep an eye on?

You do not need a dashboard containing 70 longevity biomarkers.

Know your blood pressure, glucose status and cardiovascular risk profile. Have appropriate routine blood tests according to your health, symptoms and medications. Understand your bone-health risk and have bone-density assessment when indicated. Know whether you are maintaining muscle rather than focusing exclusively on body weight.

Then measure life.

Can you lift more than you could six months ago? Can you comfortably get off the floor? Carry your shopping? Walk briskly? Climb stairs? Balance confidently? Are you maintaining or improving your cardiovascular fitness?

Those questions tell us whether the work you are doing is translating into physical reserve.

And that is ultimately what we are trying to build.

What I want you to take away from this series

Healthy ageing cannot be reduced to a blood test, body weight or biological-age score. The numbers matter, but function matters just as much. Blood pressure, glucose regulation, cardiovascular risk and bone density can reveal problems you cannot feel, while strength, balance, walking capacity and everyday function tell us whether your body remains capable of doing what life requires.

The goal after 45 is not to fight ageing. It is to arrive at each decade with as much muscle, bone, cardiovascular fitness, metabolic health and physical independence as possible. Build reserve while you have plenty of it, measure the things that can genuinely change your decisions and investigate unexpected decline rather than accepting it as inevitable.

Because ultimately, the most meaningful measure of healthy ageing is not how young your body looks.

It is how much life your body still allows you to live.

You can explore more articles, free and paid resources, my book and programmes in the Healthy Ageing & Strength section of Feel Good Menopause.