The Director of Public Health             Annual Report 2015/16

Healthy

Behaviours

Why are healthy behaviours important for Healthy Ageing?

Smoking, drinking too much alcohol, not exercising enough, not eating a healthy diet, being overweight and engaging in unprotected sex can all have a negative effect on our physical and mental health. The effects of unhealthy behaviours can accumulate over our lives and particularly impact in older age. Maintaining healthy behaviours throughout our lives reduces our risk of developing long term health conditions and cancer, keeps us mentally well and can protect us against accidental injury such as broken bones from falls and some infectious diseases.

 

Healthy behaviours can also reduce the risk of exacerbations of long term health problems including heart disease, stroke, respiratory disease, diabetes and mental health problems. They can help reduce the severity of symptoms of health problems such as pain and reduced mobility, for example from musculoskeletal disorders; and make the side effects of some treatments and medications easier to manage (e.g. cancer treatment). There is also good evidence that being in older age is not too late to change to healthy behaviours. Stopping smoking, being a healthy weight and becoming physically active can keep us well in older age.

 

Although many people live healthy lives and ensure that they exercise regularly, eat and drink sensibly and don’t smoke, lots of people find it difficult to live a healthy lifestyle. We have already explored in the previous two sections how social support and healthy environments can make healthier behaviours easier, however there are also a number of barriers that make them difficult to adopt. Evidence tells us that the overwhelming majority of people know what behaviours are healthy and unhealthy, however many people do not have the practical skills, resources or support they need to stop smoking, be active, eat well, drink sensibly and practice safe sex. Many people, particularly those who live in more deprived areas, engage in multiple unhealthy behaviours, and we know that barriers to engaging in healthy behaviours are the same, whatever the healthy behaviour is. These include having a low income, living in communities where unhealthy behaviours are normalised, inability to access support and low levels of mental and physical wellbeing. Traditionally, support with healthy lifestyles has focused on individual behaviours such as stop smoking services and exercise referral schemes, however evidence now indicates that a more integrated approach is needed, particularly to support those living in more deprived areas who are more likely to engage in more than one unhealthy behaviour(1).

 

Older people can make an important contribution to promoting healthy behaviours in their community. Peer led approaches in which older people volunteer as Ageing Well champions can increase the likelihood that healthy behaviours will be sustained(2). Intergenerational health and wellbeing programmes in which the different generations share their practical skills have also been successful in sustaining healthy behaviours and strengthening communities. Examples include older people sharing cooking, gardening and ballroom dancing skills with younger people, while younger people share IT and social media skills with older people to help them access support with ageing well(3).

Older people in Dudley when asked about healthy behaviours identified what was important to them and this is captured in the word cloud below:

Never smoked

 

Ever smoked

Figure 1: The proportion of people aged under 65 and 65 and over who have smoked in Dudley

Source: Dudley health Survey 2014

What is the position in Dudley?

Stopping smoking

Smoking is the single most important behavioural cause of poor health in older people. It is estimated that the overall cost of smoking to the Dudley economy is £17 million a year(4). This comprises a combination of costs of medical treatment to treat smoking related disease, social care cost and the cost of people taking days off as a result of smoking related illnesses. Smoking contributes to a wide range of diseases, including cancer, respiratory disease, heart disease and stroke, vascular dementia and is associated with cognitive decline and Alzheimer’s disease.

A reason given by older people for continuing to smoke is that they feel the damage has already been done and that stopping would not provide any benefits, however the evidence is clear that there are benefits of stopping smoking at any age(5). On average, people who continue to smoke over the age of 60, die 5 years earlier than non-smokers. Older people also report a lack of knowledge of the local support and services available to help people stop smoking.

A greater proportion of people aged 65 years and over said they had smoked (52%) compared with people aged under 65 years (48%). In England approximately 41% of people aged under 65 have smoked and 48% of people over 65 have smoked(6).

84%

5%

6%

4%

Figure 2: Of people aged 65 and over who stated that they had smoked

Source:  Dudley health Survey 2014, images modified from a Kings Fund presentation

The overwhelming majority of people aged 65 years and over in Dudley who have ever smoked have now quit (84%). Sixteen per cent of people aged 65 smoke which indicates that around 5,000 people aged 65 and over are still smoking in Dudley, almost 1,500 of them smoke over 20 cigarettes a day. Of people in this age group who are still smoking, only 30% of them said that they did not want to quit smoking. Applying this percentage to the estimate of the number of possible smokers suggests that 3,500 people aged 65 and over would be receptive to support with stopping smoking.

Being physically active

Being physically active has multiple benefits including improved physical fitness, improving  social connectedness, reducing the risks of falls, helping people to maintain their independence and reducing use of support services. Older people should do at least 150 minutes of moderate intensity aerobic exercise per week to maintain their health(7).

Figure 3: Some of the benefits of physical activity

A review of research into physical activity levels in older adults showed that the proportion meeting recommended levels ranged widely from 2.4-83.0%(8). Physical activity appears to decline progressively with age with a significantly smaller proportion of people aged 80 years or older taking part in regular physical activity compared to those aged 60-64 years. Older women are less likely than older men to be physically active and walking is the most common form of physical activity for older people.

 

In Dudley, the proportion of people who do enough physical activity also declines with age, with the largest drop off occurring after the age of 75.  Sixty nine percent of males and just under 52% of females reported getting enough exercise. This declined further in the 75 plus age group with 48% of males getting sufficient exercise and 27% of females. Although the data in the 2014 Dudley Health Survey suggests that people are doing greater amounts of exercise, the results are not comparable to previous surveys because of differences in the way the data was collected.

 

Based on Dudley Health Survey 2014, 60% of Dudley residents aged 65 and over perform no moderate physical activity and 71% of residents aged 65 and over perform no vigorous physical activity.

Case Study

Physical activity in Dudley - Tandrusti Project and The Healthy Walks Programme

 

 

 

 

 

 

 

 

 

 

Sensible drinking

Excessive drinking of alcohol is a major cause of early death and disability in older people living in the West Midlands(9). Alcohol has been linked with an increased risk of a number of cancers, cardiovascular and respiratory conditions and falls. Alcohol misuse has also been shown to increase the risk of financial abuse to older people(10).

On average older people drink less than younger people over the course of a week, however older people drink more frequently(11). Nationally a quarter of men aged over 65 years drink more than the recommended daily allowance. Patterns of drinking in Dudley are consistent with the national picture with 72% of people under the age of 65 drinking alcohol compared with 53% of people aged 65 and over. Despite people aged 65 and over being less likely to drink they consume alcohol more frequently than younger age groups. Persistent drinking on consecutive days, especially when drinking over the recommended limit, is known to cause harm to health. A number of reasons may explain higher levels of alcohol use in older people including bereavement, retirement, boredom, loneliness, homelessness and depression(12).

The number of people in Dudley who think their level of drinking is harmful to their health also decreases with age. This perception may be correct but this may also be a result of people not fully understanding harmful levels of alcohol use. The emphasis on the harms of binge drinking may have taken attention away from the risks of drinking everyday without a break and exceeding the recommended weekly limits.

Sexual Health

A study of the rates of sexually transmitted infections (STIs) in older people in the west midlands found that rates doubled between 1996 and 2003(13). This trend is likely to have increased further since that date. Proportionally the increase is larger in older age groups than it is in the younger age groups.

There are indications that as older people become newly single due to divorce or widowhood and start dating again, some do not use contraception to protect themselves from sexually transmitted infections, and this accounts for the increase in infection rates(14). Research with older people has found that women who have gone through the menopause often do not see the need for protection because they can no longer get pregnant, while older adult men believe condom use can worsen erectile dysfunction.

Research from sexual health clinics shows that a significantly higher proportion of older adults infected with STI and HIV are diagnosed late and older people have reported a lack of knowledge about how to access support with sexual health issues. Sexual health clinics and services tend to be set up to target and cater for younger age groups. It is now becoming recognised that there is a substantial gap in the provision of sexual health for older people especially around sexual health promotion and age related sexual health problems(13).

There may also be unmet specific sexual health needs among the population of older lesbians, gay men and bisexuals. Although there is now broad societal and legal support for this group, the majority of older people will have lived a large part of their lives in times when there was a less liberal attitude to homosexuality, which may lead them to be cautious of mainstream services(15).

The rate of sexually transmitted infections among older Dudley residents is still very small compared to younger age groups. Similarly, the number of sexual health screens which check whether someone has an STI, undertaken in Dudley residents aged 65 and over years shows that numbers are small compared to younger age groups, although they are higher in men than women. Rates do not reflect the increasing rates of infection regionally and nationally. Sexual health services therefore need to ensure they are marketed to older people and that they are accessible and appropriate for people from older age groups.

Healthy Eating

As people age their energy requirements decline, this is mostly due to a decrease in lean body mass, a reduction in metabolism and because older people tend to be less active than younger people. There is some evidence to suggest that requirements for some nutrients increases whilst for others the need decreases as people age(16).

Depending on the environment they live in older people can be both vulnerable to malnutrition and over eating. Older people living in institutions have been demonstrated to be particularly vulnerable to malnutrition, whilst older people living independently have been linked with overeating(17).

Most of the health benefits of healthy eating will not have been noticeable from day to day but a chronic poor diet throughout life has been shown to adversely affect life expectancy as well as impacting on a range of conditions. A poor diet is estimated to be the third leading risk factor for premature death and ill health in the West Midlands, contributing to the risk of heart disease, stroke, diabetes, chronic kidney disease and a range of cancers(9). As well as mitigating these long-term conditions, eating a varied and balanced diet is known to have a range of benefits.

Healthy eating can increase bone density, protecting older people from osteoporosis, reducing the risk and making them less vulnerable to the negative health consequences of falls. Two of the most important nutrients for bone health are calcium and vitamin D17. Calcium is a major building-block of bone tissue and vitamin D helps the body to absorb calcium. There are a number of other foods, nutrients and vitamins that help to prevent osteoporosis and contribute to bone, muscle and joint health, including protein, fruits and vegetables, and other vitamins and minerals.

Figure 4: Benefits of eating a varied and nutritionally balanced diet

Source: Adnrea Fajardo, The Noun Project and subsequently modified by

the Department of Public Health, Dudley Council

28% of people aged 65 and over eat 5 portions of fruit or vegetables a day based on information collected in the 2014 Dudley Health Survey, this is a higher proportion than those aged under 65 (25%) however the difference is not statistically significant. 62% of people aged 65 and over eat at least 3 portions of fruit and vegetable a day. A higher proportion of older people eat more fruit and vegetable than people aged under 65 however the differences are not statistically significant.

What more should be done?

Peer led approaches to supporting healthy behaviours can be particularly effective in supporting people to take on healthy behaviours over the long term.

In Dudley, there are already a small number of older people who are volunteer health champions, however a sustained effort should be made to identify and recruit more older people as health champions, as part of the healthy ageing programme. Work is currently underway to map the community assets in Dudley and this will include people, groups, clubs and services that can support healthy behaviours and enable people who need support with changing their lifestyle to be connected to the things already in their communities that can help. Examples include sports clubs welcoming older novices to use their facilities and older people leading local walks.

In Dudley, work is currently underway to design and commission an integrated adult wellness service which will support people to lead healthy lifestyles. This will move away from the traditional service model which supports people with individual health behaviours (e.g. stop smoking service, exercise referral scheme), and will support people to set healthy behaviour goals and provide tailored support which will include whichever combination of healthy behaviours is required. This service needs to be targeted at those who can benefit most, including those with long term health conditions whose risk of relapse and exacerbation can be reduced by engaging in healthy behaviour and those who have been identified as at risk of developing a long term condition through the NHS Health Check. As the majority of people in these groups will be older people it is important that older people are involved in the design of the service to ensure that it is age friendly.

Specialist behaviour change support and services such as sexual health services, substance misuse services and weight management services will still be required for those who need additional support, and these need to be appropriate for older people. This is particularly an issue for sexual health services which have traditionally been focused on younger people.

Physical activity, sensible drinking, healthy eating and healthy weight interventions need to be integrated into falls prevention services alongside housing measures referred to in the Age Friendly environments section.

Older people often look to health professionals to support them change unhealthy behaviours. The role of health and care services is therefore critical and developing GP practices, pharmacies, opticians, hospitals and residential care as health promoting settings in which every possible contact with a patient is used to promote healthy behaviours should be a priority. It will also be important to have clear pathways from health and care services to the support available for older people to have a healthy lifestyle available in the community and services. This will be developed further in the next section of the report which focuses on high quality support services.

Key messages

  • People who live in deprived areas are more likely to engage in more than one unhealthy behaviour.
  • The barriers to living a healthy lifestyle are largely the same irrespective of the particular behaviour.
  • Peer led interventions to support healthy behaviour can increase the risk of positive behaviour change being sustained.
  • Smoking remains the most significant behavioural risk factor for poor health among older people and stopping smoking is beneficial at any age.
  • Quit rates among older people are high in Dudley and almost two-thirds (or 3,300) of older people who still smoke would like to quit.
  • Older people should do at least 150 minutes of moderate intensity exercise (or 75 minutes of vigorous exercise) each week to maintain their health, but only 69% of males and just under 52% of females achieve that.
  • Participation in specific structured exercise programmes targeted at older people can reduce falls and improve mental health in older people; increasing health, wellbeing and independence.
  • Excessive alcohol consumption is an important risk factor for a number of health problems among older people including circulatory disease, cancer, falls and mental and behavioural disorders.
  • Alcohol problems in older people are often not recognised and social isolation may increase the risk of alcohol misuse in older people.
  • Alcohol misuse increases the risk of financial abuse to older people.
  • Sexually transmitted infections among older people have doubled between 1993-2003.
  • There are indications that sexual health services and sexual health messages have not focused adequately on the needs of older people.
  • Not eating a healthy diet contributes to the risk of heart disease, stroke, diabetes, chronic kidney disease, a range of cancers and poor bone health.
  • A higher proportion of Dudley residents aged 65 and over eat 5 portions of fruit and vegetables a day than younger age groups however only 28% of older people manage to eat the recommended amount.

Recommendations

  1. Using intelligence from the community asset mapping that is currently underway in Dudley: 1) identify opportunities to use the skills and assets of older people to promote healthy behaviours in their community among people of all ages; 2) identify and recruit more older people as health champions and support them to promote healthy lifestyles; and 3) support voluntary and community groups that promote healthy living (e.g. sports clubs) to be welcoming and accessible to older people.
  2. As part of the planned healthy ageing programme, develop and target messages at older people in Dudley about the benefits of changing unhealthy behaviours in older age and the support available to overcome the barriers to healthy behaviours that older people in particular face.
  3. Involve older people in the design and delivery of the planned integrated adult wellness service (One You Dudley) which will support adults of all ages to change unhealthy behaviours, to ensure that it is acceptable, accessible and appropriate to older people in Dudley.
  4. Continue to develop and roll out health promoting health and care settings across the borough and ensure that supporting healthy behaviours in older people is incorporated into work to ‘make every contact count’.
  5. Health and care professionals and others who work with older people should be trained to identify the more hidden unhealthy behaviours such as alcohol misuse and unprotected sex, and sensitively signpost older people to support to change their behaviour.

References

  1. Buck, D. and Frosini, F., 2012. Clustering of unhealthy behaviours over time. The King’s Fund.
  2. Coull, A.J., Taylor, V.H., Elton, R., Murdoch, P.S. and Hargreaves, A.D., 2004. A randomised controlled trial of senior Lay Health Mentoring in older people with ischaemic heart disease: The Braveheart Project. Age and ageing, 33(4), pp.348-354.
  3. Springate, I., Atkinson, M. and Martin, K., 2008. Intergenerational Practice: A Review of the Literature. LGA Research Report F/SR262. National Foundation for Educational Research. The Mere, Upton Park, Slough, Berkshire, SL1 2DQ, UK.
  4. NICE (2016) Tobacco return on investment tool. Available at: https://www.nice.org.uk/about/what-we-do/into-practice/return-on-investment-tools/tobacco-return-on-investment-tool (Accessed: 20 September 2016).
  5. Kerr, S., Watson, H., Tolson, D., Lough, M. and Brown, M., 2006. Smoking after the age of 65 years: a qualitative exploration of older current and former smokers’ views on smoking, stopping smoking, and smoking cessation resources and services. Health & social care in the community, 14(6), pp.572-582.
  6. Health survey for England, 2014 [NS] (2015) Available at: http://digital.nhs.uk/catalogue/PUB19295 (Accessed: 20 September 2016).
  7. Organisation, W.H., 2010. Global recommendations on physical activity for health. World Health Organisation.
  8. Sun, F., Norman, I.J. and While, A.E., 2013. Physical activity in older people: a systematic review. BMC public health, 13(1), p.1.
  9. Newton, J.N., Briggs, A.D., Murray, C.J., Dicker, D., Foreman, K.J., Wang, H., Naghavi, M., Forouzanfar, M.H., Ohno, S.L., Barber, R.M. and Vos, T., 2015. Changes in health in England with analysis by English region and areas of deprivation: findings of the Global Burden of Disease Study 2013.
  10. Sullivan, M.P., Gilhooly, M., Victor, C., Gilhooly, K., Wadd, S. and Ellender, N., 2014. Use as abuse: a feasibility study of alcohol-related elder abuse.
  11. Statistics, O.F.N. (2013) General lifestyle survey: 2011. Available at: http://www.ons.gov.uk/peoplepopulationandcommunity/personalandhouseholdfinances/incomeandwealth/compendium/generallifestylesurvey/2013-03-07 (Accessed: 20 September 2016).
  12. Royal College of Psychiatrists, 2011. Our invisible addicts: First report of the Older Persons' Substance Misuse Working Group of the Royal College of Psychiatrists. Royal College of Psychiatrists.
  13. Bodley-Tickell, A.T., Olowokure, B., Bhaduri, S., White, D.J., Ward, D., Ross, J.D., Smith, G., Duggal, H.V. and Goold, P., 2008. Trends in sexually transmitted infections (other than HIV) in older people: analysis of data from an enhanced surveillance system. Sexually transmitted infections, 84(4), pp.312-317.
  14. Mercer, C.H., Tanton, C., Prah, P., Erens, B., Sonnenberg, P., Clifton, S., Macdowall, W., Lewis, R., Field, N., Datta, J. and Copas, A.J., 2013. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal). The Lancet, 382(9907), pp.1781-1794.
  15. Family Planning Association, F.P.A.(f. (2011) Older People. Available at: http://www.fpa.org.uk/sites/default/files/older-people-policy-statement.pdf (Accessed: 20 September 2016).
  16. World Health Organization, 2002. Keep fit for life: meeting the nutritional needs of older persons.
  17. 2016, B.N.F. (2016) Older adults - British nutrition foundation. Available at: https://www.nutrition.org.uk/nutritionscience/life/older-adults.html (Accessed: 20 September 2016).

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