« Previous | Contents | Next »
Listen
Chapter 6 Lifestyle
Health Inequalities
The health of the people of Scotland is improving: life expectancy is higher and there are fewer deaths from cancer, stroke and heart disease. However, the health gap between the most and least affluent is widening and people living in deprived areas have a significantly shorter life expectancy than those in more affluent areas. This health gap exists not only in Scotland but throughout the UK, Europe and beyond.
Scotland's multi-agency approach to health improvement has recently been endorsed by the World Health Organization, who are keen to explore how similar countries across Europe can learn from the Scottish experience. The Scottish policy is to improve health for all and to reduce the health gap. Action to deliver this policy is based in Community Health Partnerships
and Community Planning Partnerships. The targets to be achieved by 2008 are challenging - a 15% increase in the rate of health improvement for deprived populations, as measured by reductions in:
- premature mortality from coronary heart disease and cancer (under 75s)
- smoking in adults and during pregnancy
- teenage pregnancy (13-15 year olds)
- suicide rates among young people (10-24 year olds)
The Executive's wider anti-poverty and community regeneration strategy, Closing the Opportunity Gap, recognises that economic growth and tackling poverty and disadvantage go together. Improving the health of people in deprived areas is one of its six objectives.
Delivering for Health ( 1) introduces the concept of anticipatory care as an effective health service response to tackling health inequalities in Scotland. This approach will be piloted in areas with high levels of deprivation from 2006/07. The Prevention 2010 Programme is an important part of the work to tackle health inequalities and complements a range of other activities which are taking place at local and national level.
Prevention 2010 is a preventative medicine approach which will be delivered through NHS Primary Care in Community Health Partnerships ( CHPs) to those at greatest risk of disease in deprived communities. Aimed at people aged 45-64, the focus will be on cardiovascular disease and its main risk factors, especially high blood pressure, cholesterol levels, smoking, diabetes and obesity. It will identify people at particular risk of preventable ill health, and provide access to a range of appropriate services and treatments. It will also ensure that those with existing disease are having their conditions properly monitored and managed.
Up to £25m has been identified for the pilot projects, to be situated in five of the most deprived areas in Scotland: two in Greater Glasgow; and one each in Lothian, Lanarkshire and Tayside. This sum includes additional resources for primary care at local level and national support for risk assessment, workforce development, evaluation, learning and dissemination. An additional £2m for smoking cessation services in 2006 is also being linked to the Prevention 2010 pilot projects.
Tobacco Control
Smoke-free Scotland
The first action plan designed specifically for controlling the impact on Scotland of tobacco, A Breath of Fresh Air for Scotland ( 2), was launched in January 2004. Action taken forward under the Plan during 2004 made 2005 a very special year for tobacco control.
There has been a major shift in the public perception of smoking and, on 30 June 2005, the Scottish Parliament passed the Smoking, Health and Social Care (Scotland) Act 2005. This is arguably the most important piece of public health legislation for a generation and introduces from 26 March 2006 a comprehensive set of restrictions on smoking in public places and in the workplace.
The impact of smoking on Scotland's health has long been recognised and has already been referred to in Chapter 4. It kills 13,000 Scots each year, the average smoker losing at least 10 years of life. An estimated 1,000 people who have never smoked die each year as a result of inhaling other people's smoke. Given the clear evidence that smoking restrictions reduce smoking prevalence, the legislation offers a tremendous opportunity to transform Scotland's public health.
The anticipated reduction in tobacco consumption can bring real and tangible gains for the NHS in Scotland. However, it was recognised that the legislation alone was not enough and a major challenge for the NHS in Scotland during 2005 was to work with a range of agencies to ensure the smooth introduction of the ban.
The Scottish Executive put in place a major national communication and marketing strategy. Its aims were to raise public awareness of the law and of the health risks posed by second-hand smoke in order to achieve better compliance and to give clear guidance to assist operators of smoke-free premises. It included updated guidance published in December 2005 ( 3) for the NHS and Local Authorities, developed jointly by the Scottish Executive, NHS Health Scotland, ASH Scotland and Healthy Working Lives. Work continues with COSLA and the representative bodies of Environmental Health Officers to agree and monitor enforcement protocols.
As part of the Scottish Executive's wider health improvement drive, progress was made on the implementation of the tobacco action plan. There was an increased focus on helping people to stop smoking by delivering effective cessation support and discouraging people from starting to smoke. Action in 2005 included introducing test purchasing to improve enforcement of laws prohibiting the sale of cigarettes to under 16s, reviewing education and prevention measures, and enhancing smoking-cessation services.
Tobacco test purchasing
Enforcement of the laws which prohibit the sale of cigarettes to under 16s was strengthened in February 2005: the Lord Advocate announced a change in prosecution policy to allow evidence gained through test purchasing exercises involving underage youngsters to form the basis of a prosecution case. This move was welcomed by the Society of Chief Officers of Trading Standards in Scotland who are working through COSLA to extend test purchasing arrangements across Scotland.
Smoking Prevention Working Group
A short-life expert group was set up by the Scottish Executive to take forward the commitments within A Breath of Fresh Air for Scotland ( 4) relating to smoking prevention and education activity nationally and locally. In addition to making recommendations to Ministers to assist the development of a new integrated smoking prevention strategy, the group will also make recommendations in relation to the age of purchase of tobacco products. It met for the first time in August 2005 and is expected to report by autumn 2006.
Smoking cessation
In 2005, significant new resources amounting to £4m per annum were made available for smoking cessation services. The Scottish Executive announced further funding in 2006-2007 and 2007-2008, resulting in record levels of funding for cessation services of £11m nationally by 2007-2008. NHS Boards have been encouraged to give priority to delivering services in 2006 and performance management arrangements were put in place to ensure these services are delivering the appropriate outcomes.
Alcohol
The word alcohol is usually assumed to refer to ethanol, produced by the fermentation of fruits, grains, vegetables and plants. Over thousands of years humans have shown considerable ingenuity in producing alcohol from almost whatever fermentable material is around. The relatively simple nature of the chemical processes and equipment required mean that the production of alcohol is widespread. It has become associated in most cultures with many aspects of life including religious ceremony, times of celebration and consolation, social interaction and is often a part of everyday life.
Societies vary geographically and over time in their approach to alcohol, from complete prohibition to relatively liberal availability, but most countries impose a series of restrictions on alcohol, such as controlling the means of its production (particularly spirits), limiting the age at which people can purchase and consume alcohol and imposing rules on the way in which alcohol is sold and the extent to which it may be advertised.
Alcohol consumption
There is little doubt that alcohol consumption is continuing to increase across Scotland and that the health and social harms associated with this trend are positioning alcohol alongside obesity as the top public health concerns facing Scotland.
Alcohol is estimated to have been 54% more affordable in 2003 than in 1980 because of increased disposable income (Alcohol Statistics England 2004). Between 1980 and 2004 the number of liquor licences in force in Scotland increased by 23% and the "superpub" (which can accommodate 300 to 400 people under one licence) has emerged. Off-sales have grown steadily with an increase of 25% in off-sales licences between 1980 and 2004 (Liquor Licensing in Scotland 1999-2004).
Short-term effects of alcohol
Although the majority of people in Scotland enjoy alcohol without causing harm to themselves or to others, alcohol continues to cause both short and longer term health problems. Excessive drinking is increasingly common and is often associated with a range of antisocial behaviours and risks to public health.
Alcohol is attractive to many people because of the short-term social disinhibition it produces, helping them to relax and enjoy company. However, while acknowledging the positive effects of alcohol, it is important also to recognise the harmful effects of problem drinking and, in particular, the need to reduce this in children and young people. Short-term harmful effects associated with a bout of excessive drinking include acute intoxication, injuries, assault and violence.
Longer-term effects
Long-term physical damage caused by alcohol can include liver disease, pancreatic disease and heart disease. Mental health problems associated with the cumulative effects of excessive consumption can include depression, anxiety, suicide and risk-taking behaviours, as well as exacerbating personality disorders and serious mental health disorders. In addition, the small percentage of the population who are physically addicted to alcohol may suffer specific psychological and psychiatric effects including those due to withdrawal. They may also suffer neurological consequences due to nutritional deficiency.
Alcohol-related disease
In 2004-2005, over 31,000 people were admitted to a general hospital with an alcohol related diagnosis, representing 4% of all general hospital admissions that year. Alcohol problems occur in all social groups, but there are clear links with inequality: people from deprived areas are five and a half times more likely than those in more affluent areas to be admitted to hospital with an alcohol related diagnosis.
There was a 52% increase between 1997-1998 and 2004-2005 in the number of people discharged with a diagnosis of alcohol related liver disease. In 2001-2002 almost one in six people discharged from psychiatric units had an alcohol-related diagnosis. (Alcohol Statistics Scotland 2005.)
Figure 6.1: Admissions due to alcohol-related liver disease in Scotland 1997-2005 (provisional)
Source: ISD Scotland
The effects on the gastrointestinal, cardiovascular and neurological systems are relatively well understood and acknowledged. However, less frequently acknowledged are the contributions that alcohol makes to:
- accidents
- house fires
- domestic violence and partner abuse
- child neglect and child abuse
- relationship difficulties
- Fetal Alcohol Syndrome.
Examples of the scale of some less often acknowledged effects in young people are shown in Figure 6.2.
Figure 6.2: Sizing the problem: social harm.
Source: SALSUS data for 2002
Government suggested limits
Based on epidemiological evidence, the Government's suggested weekly maximum limits for alcohol consumption are 21 units for men and 14 units for women. The most recent statistics available for Scotland suggest that 29% of men and 17% of women aged between 16 and 64 are exceeding these suggested weekly limits, as shown in Figure 6.3 ( 5).
Figure 6.3: Alcohol Consumption: adults
Source: Scottish Health Survey
It would be wrong to suggest that alcohol-related problems are limited to those who are physically addicted or to young people who drink too much on Friday and Saturday nights. The statistics confirm that the overuse of alcohol by Scottish men and women is widespread and the likelihood of adverse consequences is increasing. Figure 6.4 shows the marked increase in deaths from alcoholic liver cirrhosis over recent decades and Figure 6.5 shows that the death rates are much higher in lower socioeconomic groups.
Figure 6.4: Sizing the problem: alcohol-related deaths
Figure 6.5: Sizing the problem: deprivation and alcohol
Source: ISD Scotland based on GROS data
What would make a difference?
A study of international alcohol policy carried out at the University of Dundee ( 6) suggests that there is a very broad diversity of policy initiatives currently being tried to reduce the adverse effects of alcohol over-consumption. The World Health Organization ( 7) recognises the "existence of a wide range of alcohol policies" and that these "policies are enforced and combined differently in different countries to meet the needs of that particular country". They resolved at the World Health Assembly in 2005 to continue to work on "reducing the negative health and social consequences of the harmful use of alcohol".
Factors that appear to make a difference include price supply, minimum age of purchase and market restraint. Price and consumption are closely linked and the UK Treasury estimates that "price elasticity" for most drinks categories approximates to 1.0. In other words for every percentage rise in price there is the same percentage fall in consumption. Historical and international examples of the effect of price include those in Russia and former socialist countries where fluctuations in price and availability have given rise to fluctuations in consumption and harm. It is possible that the temporary marked decrease in life expectancy suffered by a number of post-Soviet countries ( 8) may have been related to changes in alcohol availability, price and consumption. This is shown in Figure 6.6. In most Western countries price is largely determined by taxation policy as such a large percentage of the cost of alcohol, particularly spirits, is actually tax rather than production and marketing costs. Fiscal policy thus has a marked effect on alcohol consumption.
The availability of supply also affects consumption. Many countries restrict its marketing in terms of who may sell it, when it may be sold or both. An increasing trend in the UK has been the way in which alcohol, particularly wine and beer, is sold by big supermarket chains in a way which is indistinguishable in many instances from other supermarket produce. Unlike the sale of tobacco which takes place in a separate sales area, alcohol is marketed from a normal supermarket aisle and may be associated with specific price incentives to encourage large volume purchasing.
Figure 6.6: Male life expectancy in the Baltic states and the EU
Administrations tend to restrict access to alcohol by setting lower age limits upon its purchase and consumption. Generally these age limits are 18 but in some parts of the USA and elsewhere they may be 21. Higher age limits seem at least to reduce the incidence of alcohol-related road traffic accidents and injury in young people ( 9).
The attitude which countries take to alcohol and children is interesting. In some southern European states the culture is fairly widespread of introducing relatively young children to small amounts of alcohol when eating at home or in a restaurant. This is coupled with their cultural intolerance of drunkenness. Many see such an approach as being pragmatic and helpful in assisting young people to understand appropriate use of alcohol.
Other cultures differ fundamentally. The Scandinavian approach sees alcohol-free childhood as optimal. Not only does this involve a robust attempt to enforce minimum drinking ages but also extends to seeking to separate children, particularly young children, from alcohol and alcohol marketing throughout their childhood and adolescence. This has impact in terms of the type of events that alcohol producers and retailers can support. It would be of interest to evaluate the natural experiment created by this policy diversity.
Finally, patterns of alcohol consumption may be controlled by market restraint through control of advertising. In the UK spirits are advertised both on television and in cinemas. In France a total ban on alcohol advertising has now been relaxed to allow the marketing of wine. Countries vary in their approach to the sponsorship of sporting events by the alcohol industry, although currently most allow this to occur.
Scotland's policy approach
Scotland's approach has been multifaceted and seeks to draw on best international experience. The Licensing (Scotland) Act 2005 is very important in terms of its presumption against 24-hour opening and its curtailment of promotions that could be seen as encouraging binge drinking.
Epidemiological and policy analysis evidence will be reviewed as it accumulates. High level political and policy commitment exists in seeking to reduce the harm suffered by Scots from excessive alcohol consumption, in line with the WHO commitment ( 10). It is accepted that this is a challenging task and that progress towards reducing the harms associated with the excessive consumption of alcohol has not been as great as with, for example, smoking, physical activity and healthy eating. There is now clearer understanding of the scale of the problem and the types of interventions that may be effective. The introduction of the new licensing law is particularly welcome and signals a clear intent to tackle this difficult area robustly. The updated Plan for Action will maintain the momentum needed in working towards halting the significant health and social harms caused by excessive consumption behaviours.
Obesity
"Sudden death is more common in those who are naturally fat than in the lean" Hippocrates 400 BC
"Thin today - fatter tomorrow" has been the state of the UK population for the last 30 years. It is a worldwide problem that has reached pandemic proportions ( 11) mainly affecting the industrialised nations, in particular those countries who have enveloped the free market economy (Figure 6.7).
Figure 6.7: Index of economic freedom and obesity rates by country
The English and Scottish Health Surveys of 2003 ( 12,13) reported that the mean weight of both populations is within the overweight classification (which is a Body Mass Index ( BMI) of over 25 but under 30 kg/m 2). In Scotland 65.4% of men and 59.7% of women are now either overweight or obese ( BMI greater than 30 kg/m 2). Levels of obesity in women (26%) in Scotland are higher than in women in England (23.4%).
It is essential to investigate the change in distribution of body fat in the Scottish population, in particular changes in central obesity, also known as visceral obesity. This is the deposition of body fat around the internal abdominal organs, as determined by the surrogate marker of waist circumference which correlates more closely with cardiovascular disease risk than does BMI. Between 1995 and 2003 there has been a marked increase from 14.4% to 25.3% of men and from 19.4% to 34.3% of women who have a waist circumference measuring over 102cm (men) or over 88cm (women).
These data do not take into account the recent decision by an expert panel of the International Diabetes Federation to redefine the limits for increased waist circumference reducing these to >94cm for men and >80cm for women. Using these new definitions would impact dramatically on the prevalence of increased waist circumference in the Scottish population and hence on the perceived enhanced risk of cardiovascular disease and the development of type II diabetes mellitus.
The distribution of obesity within the population is more prevalent in those sectors already at increased risk of cardiovascular and other health problems - those in the lowest two socioeconomic groups. Deprivation in the industrialised nations is more closely associated with the obese while the converse is true in the developing world.
Increasing prevalence of obesity in the population has a major impact on healthcare resources through increased incidence of obesity-related disease, including:
- type II diabetes mellitus
- cardiovascular disease
- cancer
- mental ill health
- mechanical impact on joints.
As a direct consequence of the increasing weight of the population, the prevalence of type II diabetes mellitus, with all its health consequences, is rising at an alarming rate. By 2023, if current increases in obesity prevalence continue, then the rises expected in obesity-related disease will be dramatic ( 14) and are illustrated in Figure 6.8.
Figure 6.8 A dramatic rise in diseases linked to obesity is expected by 2023
Source: Choosing Health, Department of Health 2004
The direct costs of obesity to the Scottish healthcare system was estimated by Andrew Walker in his report The Cost of Doing Nothing ( 15) to be £170 million, based on obesity prevalence rates in 1998. Recent data from the Department of Health in England ( 16) indicate dramatically rising costs with figures now in excess of £1 billion in 2002, representing approximately 2.6% of the net NHS expenditure.
"Corpulence is not only a disease in its own right but a harbinger of others" Hippocrates 400 BC
The Counterweight Programme is an evidence-based weight management programme in Primary Care and will be piloted in deprived areas in Scotland as part of Prevention 2010 ( 17). The programme has demonstrated the increased costs of drug prescribing in every BNF class of drugs for the obese compared with their non-obese counterparts ( 18) especially drugs used in the treatment of cardiovascular disease, diabetes and dyslipidaemia. The obese population, who make up 23% of the total population, accounted for almost 40% of the total drug spend.
It is essential that strategies are put in place to stem the ongoing rise in obesity within the population especially in children and adolescents where the rise in obesity rates has been even more dramatic ( 19,20). In the past, an indirect approach has been taken to tackling obesity by dealing with the its consequences, such as cardiovascular disease and type II diabetes. This did not address the root problem which is the obesogenic environment of the latter half of the 20th century.
The current obesity pandemic is a result of complex interactions between man and his rapidly changing environment over the last 30 to 40 years. They involve individuals' and society's changing attitude to the environment while having the genetic makeup designed to put weight on during periods of plenty and use this excess during periods of famine. Current genetic makeup is not geared to cope with the obesogenic environment of the 21st century.
If there is to be any impact on the relentless increase in obesity prevalence within the Scottish population it is essential that a more holistic approach is taken. Simple solutions do not work in solving complex societal and environmental problems and more complex strategies will have to be constructed. It must be a combined effort, involving the Scottish Executive, NHSScotland, public services, the food and leisure industries and the people themselves, to change attitudes and the approach to the current environment.
Over the last 30 years, there have been changes in how we live our lives. Many jobs involving manual labour have been replaced by more sedentary occupations. Increasing car ownership and accessibility of transport systems have reduced the need to walk in order to get from A to B. The use of mechanised equipment and labour saving domestic appliances have displaced physically arduous tasks and for many people leisure time activities are dominated by inactive pursuits including watching television, playing video games and using home computers.
Parents' perceptions of dangers faced by children as they travel to and from school have increased, leading to a reduction in the number of children who walk or cycle to school. Environments that promote and foster playing are increasingly under threat. There is, however, some evidence that things are beginning to improve. Trend data from the 2003 Scottish Health Survey suggest that physical activity is beginning to increase and Scotland has a national physical activity strategy running programmes in schools, community, work places and care homes. Efforts are also being made to create environments which encourage physical activity.
Despite the foregoing discussions on the complexity of the obesity problem and its solution, it is clearly for Governments worldwide to take a lead in attempting to stem the tide. It remains well recognised that individuals still place a great deal of trust and belief in their family doctor. Primary Care has an important role to play in tackling obesity in the population. The Counterweight Programme ( www.counterweight.org) aims to attain a 5 to 10% loss in body weight and subsequent weight maintenance.
A 10% loss in body weight produces a 30% reduction in visceral fat, thus reducing cardiovascular risk, improving insulin sensitivity and reducing the likelihood of metabolic syndrome. Such small losses in body weight are associated with a fall of 6.1 mmHg systolic and 3.6 mmHg diastolic blood pressure and improvements in abnormal fat levels in the blood ( 21).
The cost of doing nothing to tackle obesity will be great. We will see:
- increased population co-morbidities
- increased prevalence of type II diabetes mellitus
- increased disability
- reduction in workforce availability
- decreased life expectancy.
We need to work together with the food, transport and leisure industries to effect a change in our eating and physical activity habits. If we continue as we are, the prevalence of obesity in the population will continue to increase. Ultimately, this will see the return of children dying before their parents. Life expectancy will reduce rather than continuing its present steady increase.
« Previous | Contents | Next »