We all know that it would be a good idea to eat more fresh fruit and veg and to cut down on Domino’s Pizza and KFC. Yet faced with a choice between a delicious piece of cake or a raw carrot, our good intentions often go unfulfilled.
How then are we, as a nation, to reach the ambitious but important target of five additional years of healthy life by 2035, as set out by the government? That’s where The Health of the Nation – a Strategy for Healthier Longer Lives comes in. This new report, published by the All Party Parliamentary Group last week begins to explore this conundrum. It is largely agreed that we need to see a substantial shift towards prevention if we are to achieve this ‘healthier lives’ target, but where exactly should the government focus efforts for greatest impact?
One thing is clear; behavioural risk factors represent the largest opportunity to reduce the health burden across the population. Yet it can be argued that recent governments have failed to prioritise prevention and behavioural interventions. There are a number of high impact, traditional public health measures that are well discussed elsewhere, but in this post we focus on three key areas: 1) smoking, 2) diet, and 3) stress, purpose and relationships.
Why these three? Modelling suggests that these three factors contribute most to years of lost healthy life expectancy. We estimate that 2-4 additional years of healthy life expectancy are lost through poor diet, 1-2 years due to smoking and 0.5-2.5 related to stress, purpose and relationships.
Addressing these risk factors could also help to reduce health inequalities. The heaviest drinking, smoking and mental health issues are highly concentrated in the most vulnerable sections of society, with tobacco exposure being three times higher in the most deprived quintile compared to the least. The impact of this is stark. Between rich and poor, there is an 8 year gap in life expectancy, and an 18 year gap in years lived in good health.
So what do we think the government should do to tackle these issues?
We should focus on ideas that will have the largest impact for the smallest effort, considering not only cost (behavioural interventions are often highly cost effective, costing well below the average £13,000 each quality-adjusted life year (QALY) is estimated to cost the NHS) but also political capital. The idea is to change environments in which we live in order to offer easy, healthier choices. Here are just a few of our ideas:
1. Tackle smoking
There is a massive and well-documented negative impact of smoking, and smoking is increasingly concentrated amongst those in lower income groups, and those with mental health problems, so reducing it will also substantially reduce health inequalities. Some of the most effective ideas are around harm reduction, for example encouraging smokers to switch to e-cigarettes which are estimated to be 95% safer than smoking tobacco.
This means that if all smokers switched it could save over 2 million disability-adjusted life years (DALYs) per year. Clinicians playing a greater role in recommending e-cigarettes as a safer alternative could help smokers to switch. Other key ideas are around expanding (or at the least maintaining) smoking cessation interventions – the ‘no brainer’ of the public health world – and potentially even committing to banning conventional cigarettes altogether by 2030.
2. Improve diet
Willpower alone is an ineffective way of achieving mass change in diet; evolution has led to us finding sweet and fatty foods hard to resist (that raw carrot stands no chance against the slice of cake). At the same time, markets have evolved to give us exactly what our revealed behaviour says we want. Against this background, by far our best strategy is to reshape our food environment.
For example, the government should use pricing to change producer behaviour, following the UK’s added-sugar levy which has resulted in sugar levels falling by 28% with no loss in sales, primarily through reformulation of existing products. Restricting the marketing of unhealthy foods through the introduction of a 9pm junk food watershed could also improve diet, and has been estimated to result in a net present value of over £2 billion.
3. Reduce stress and create a stronger sense of purpose & relationships
Chronic stress (such as at work); lack of purposeful activity (such as unemployment); and social isolation, have substantial health impacts. Social isolation, for example, has been estimated to have around the same impact on health as smoking 15 cigarettes a day (around a decade of HLE lost). Despite this, there has been far less attention applied to addressing these factors.
Some promising ideas are to expand and support social prescribing: rather than prescribe a pill for a patient who is overweight or unhappy, why not instead prescribe a physical or social activity. Another idea would be to support people to stay in the labour market for longer, given work is a major source of meaning, challenge and social support for many people. This could be through moving defaults away from automatic retirement at a given age; financial incentives for delaying retirement; late-career retraining; and Japanese-style later life work cooperatives.
If you want to read more about the ideas above, or any of our other ideas to help people live healthy lives, download the full report here.