Chapter 4: Risk factors and their impact on disease in Scotland
Dispersing myths on the road to better health
The earlier chapters of this report have set out some of the biggest health challenges facing Scotland - cancer, coronary heart disease, stroke and liver disease. They are all in a state of flux. Rates of some cancers are falling, while other cancers are increasing. Deaths from coronary heart disease and stroke are decreasing - but still not as fast as we would like. Trends in mortality from alcohol-related liver disease are rising fast and have put Scotland and one of its increasingly favoured pastimes in a frighteningly harsh light on the international stage. The number of people known to have liver disease as a result of Hepatitis C infection has been growing steadily.
In looking at what we can all do to reverse the bad trends and speed up the good ones, it is helpful to identify and dispel some "Scottish myths".
Myth 1
Scotland has always been an unhealthy place and always will be. You can't change the way we are.
The fact that some health trends are getting better and others worse shows that Scotland's health can and does change. This can be seen, for instance, from the continuing decline in smoking rates among both men and women and from signs that more of us are becoming more physically active 60. We can also take heart from the example of other countries such as France and Italy where alcohol consumption has been decreasing steadily over the past 20 years and, no surprise, so have rates of alcohol-related liver disease 61. If other countries can do it, so can Scotland. Drug injecting rates have risen steeply over the past 30 years, but what goes up can also come down - and will come down if we can find more successful ways of tackling the roots and realities of drug misuse.
The people of Scotland, with the necessary help and support from national and local government, the NHS, community and voluntary organisations, and businesses and employers, can achieve better health by changing how we think and what we do, learning from successes and evidence drawn from Scotland and elsewhere.
Myth 2
Even if we can change the way we live, it won't make any real difference to our health.
On the contrary, it would make a massive difference. For example, it has been estimated that smoking is responsible for over 13,000 deaths a year in Scotland - nearly 1 in 4 of all deaths 62. If we could make smoking disappear from Scotland we would, in time, rid ourselves of an estimated 84% of cases of lung cancer, 68%, 37% and 26% of cases of cancers of the gullet, bladder and stomach respectively 4, 19% of cases of coronary heart disease ( CHD) 5 and 10% of strokes 63. There would also be reductions in chronic lung disease and a range of other conditions that can damage quality of life, including blindness, sexual impotence and gum disease. Moreover thousands of children would be spared damage to their development and health from their mothers' smoking during pregnancy and parents' smoking in the home.
'If we could make smoking disappear from Scotland we would, in time, rid ourselves of an estimated 84% of cases of lung cancer, 68%, 37% and 26% of cases of cancers of the gullet, bladder and stomach respectively, 19% of cases of coronary heart disease ( CHD) and 10% of strokes.'
Such population figures reflect the very real benefits that individuals could gain through healthier lifestyles. Smokers who quit can enormously reduce their risk of dying from smoking-related diseases. The earlier the better, but even late is better than never.
Average number of years of life gained by stopping smoking at differing ages:65
- Age 30 - 10 years gained
- Age 40 - 9 years gained
- Age 50 - 6 years gained
- Age 60 - 3 years gained
Experts on cancer, heart disease and obesity are now very much in agreement about the "ideal diet" which if broadly followed by most people could prevent a wide range of cancers in Scotland and much of the CHD, and would give us a fighting chance of keeping our waistlines in check 66,67,68 (see below). By changing our eating habits, and using statin medication where advisable to do so, we could reduce levels of blood cholesterol in the population such that we could expect to reduce cases of CHD by over two-fifths 62. Once again, this population figure reflects real differences that individuals can make to their own health prospects: for instance, researchers have found that reducing the level of "bad" cholesterol in the blood by even a relatively small amount lowers an individual's 5-year relative risk of a major cardiovascular event by about 20% 69. If nobody had high blood pressure, an estimated 13% cases of CHD64 and an even higher percentage of strokes could be prevented.
The 'ideal diet'
- Eat at least five portions of a variety of non-starchy vegetables and fruits every day
- Eat relatively unprocessed cereals and/or pulses at every meal
- Consume only small amounts of refined starchy food and other energy dense and "fast foods", snacks and confectionery
- Avoid sugary drinks
- Eat at least two portions of fish a week, one of which should be oily
- Eat no more that 500g (18oz) of red or processed meat a week.
The evidence is now very clear that regular moderate physical activity is of great benefit for all-round health. People who build into their lives at least 30 minutes of moderately intense physical activity at least five times a week, as well as feeling the benefits to their mental and physical wellbeing, can expect to benefit from lower risks of heart disease, diabetes and some cancers, including bowel and breast cancer. Weight control also becomes easier. If that type and level of physical activity is not feasible for a given individual, for example due to physical disability, there may still be ways of living more actively that promote health and wellbeing.
If we in Scotland overcame our national tendency to drink more alcohol than is good for us, we would see the same rapid falls in the mortality from alcoholic liver disease that France has seen and would see many other benefits to health, everyday life and the social fabric of Scotland. If you keep within the recommended limits for sensible drinking, and avoid binge drinking, you are less likely to suffer other acute harmful effects of alcohol, have an accident, be assaulted, or cause harm to others.
Recommended weekly upper limits for alcohol
Equivalent to about 7 pints of 5% strength lager, or just over 2 bottles of 13.5% strength wine.
Equivalent to less than 1.5 bottles of 13.5% strength wine, or fourteen 25ml measures of 40% strength vodka or other spirits.
Some 50,000 people in Scotland are now chronically infected with Hepatitis C, mainly as a result of injecting heroin or other drugs. The country faces a dual challenge: preventing further new infections and preventing the virus from causing severe liver disease, including cirrhosis and cancer, among those who are already infected. Tackling the first requires a range of measures aimed at reducing the sharing of drug injecting equipment. These include education campaigns about the dangers of injecting drugs, needle exchange services and drug misuse treatment programmes. Meeting the second challenge needs the availability of high quality diagnostic and treatment services.
Myth 3
For a lot of people there's no point in giving up smoking, eating more healthily, taking more exercise or cutting down on the booze - because it's all to do with disadvantage and deprivation.
Socioeconomic factors have a crucial bearing on health, as seen in Scotland's many health inequalities. Improving people's life circumstances, opportunities and environments are vital to Scotland's health improvement action. At the same time, though, research in Scotland has shown, for example, that the death rates of non-smokers in the least well-off areas are lower than those of smokers in the most affluent. In a large study of middle aged people from Renfrew and Paisley, followed up for 28 years, female non-smokers did the best of all, with surprisingly little difference in the death rates between the most and least affluent non-smoking women 70. While smoking rates have certainly been coming down faster among more affluent people, targeting and tailoring of smoking cessation services is helping many less well off people to quit.
The really important point here is that we are not in an "either or" situation. Socioeconomic factors affect health, both by influencing "lifestyle" and through increasingly understood more direct biological pathways. Both sets of mechanisms need to be addressed. In addition, action specifically focused on smoking, diet, physical activity and alcohol needs to be part of the overall mix of actions to increase wellbeing and reduce cancer, cardiovascular disease and liver disease across the whole population. That is why the report of the Ministerial Task Force on Health Inequalities, Equally Well, published in 2008, spans actions ranging from tackling poverty and increasing employment, through improving physical environments and transport. It also seeks to engage with people and target services to help them to have the awareness, motivation, skills, opportunities, support and confidence they need to make a big difference to their own and their families' health and health prospects. Achieving such a difference can be helped by adopting, maintaining and fostering the 5 habits for health shown below.
5 habits for health
- Avoid smoking tobacco
- Eat something close to the ideal diet
- Be physically active on most days
- Keep within the recommended limits for drinking alcohol
- Never inject drugs
Concerns are often expressed that making healthier choices costs money and is a challenge for people with low incomes. On the other hand healthier choices in a number of key areas can free up money. The average cost of tobacco leaves the average smoker some £30 per week less well off. Similarly, the cost of drinking alcohol above the weekly sensible levels eats substantially into weekly income. Some physical activities such as walking and simple exercises have no cost and increasingly local authorities are providing free access to sports facilities such as swimming pools and gyms to people with lower income across age groups. Many community projects across Scotland also support people to gain the skills and confidence to prepare enjoyable well-balanced meals reducing dependency on relatively expensive and often less healthy ready meals.
'5 habits for health
- Avoid smoking tobacco
- Eat something close to the ideal diet
- Be physically active on most days
- Keep within the recommended limits for drinking alcohol
- Never inject drugs'
Myth 4
When it comes to health problems there must be simple single solutions, if only we could find them.
We certainly have mounting evidence that a number of specific interventions can help individuals and the population to achieve better health. For example, immunisation has been shown to protect successive generations against a range of potentially life-threatening or disabling infections. Modern-day developments in medications have greatly enhanced health professionals' ability to reduce high blood pressure, reduce blood cholesterol, help people stop smoking, and cut the risk of cardiovascular disease.
Such things have important parts to play, but one of the main pieces of evidence in the field of health improvement is that complex problems need comprehensive action. In the area of smoking, for example, it is now widely accepted that success needs a wide-ranging package that includes policies relating to the promotion, sale and price of tobacco products; control of smoking in public places; education in schools and other settings including through mass media; and support for smoking cessation through healthcare professionals and smoking cessation services. The Scottish Government has recognised that the same wide-ranging approach is needed if we are to reverse the upward trend in alcohol-related harm, by consulting on a bold package of measures aimed at reducing overall alcohol consumption, including action on the pricing, promotion and accessibility of alcohol. As well as inviting individuals to think again about the place of alcohol in their lives, the amount they drink and the pattern of their drinking, the actions set out reflect social responsibility issues facing the alcohol industry, and the important parts to be played by local authorities.
One of the greatest challenges for us in Scotland, and in many other countries, now and in the decades ahead is to address the ever-upward trend in levels of overweight and obesity across the whole population. (See Figure 1.)
Figure 1: Obesity prevalance in men and women in Scotland 1995-2003
Source: Scottish Health Survey
In Scotland by 2003, 22% of men and 24% of women were obese and rates of central obesity (measured by waist circumference) were even higher. A further 42% of men and 32% of women were overweight. For boys and girls, 18% of boys and 13.8% of girls aged 2-15 years were obese. There is an association between obesity and deprivation. This is stronger in women than men and is also seen in school-aged children. It has been estimated that one-fifth of cases of obesity in Scotland is associated with deprivation 71. Most of us are eating more than we need, and it is showing in our expanding waistlines and rising rates of diabetes. We are all ultimately responsible for what we eat, but it can be difficult to know what one is eating, how that fits with the "ideal diet", and how to make real changes for the better. In any case we are, at every turn, being encouraged to eat too much of the wrong foods, with tempting offers of sugar and fat-laden drinks, snacks and meals in supermarkets, restaurants and fast-food outlets, in petrol stations, on the street, and even on the train. The so-called "obesogenic environment" in which we live is added to by the fact that one effect of the creeping increase in the average weight of the population has been an effect on what people think of as a "normal" and healthy weight. The average child or adult of some 30 years ago would now be considered thin and the average adult today would have been thought to be overweight three decades ago. Both adults and children have also become more sedentary in their day-to-day living. We are also beginning to realise the huge environmental cost of the way we produce our food, transport much of it over huge distances, sell it in wasteful packaging, then put about a third in the bin. Big changes are needed if we are to move towards ways of eating that research clearly shows are best for us and which is also compatible with food for all and a sustainable physical environment.
These are just some examples. In a nutshell, if we want better health for everyone, we should be aiming for a Scotland where culture, policies, strategies, programmes and activities on the ground are pointing as far as possible in the same direction - towards better health and greater equality in health. Developments in recent years, and public support for these, suggest that Scotland is more ready than ever to achieve the necessary common purpose and united effort - that we may well be at a "tipping point" 72 where a little more push will yield an unstoppable momentum for population health improvement.