Osteoporosis – And Who Is At Risk

What is osteoporosis?

Osteoporosis is a bone-thinning condition but it is by no means new.  The Romans were referring to non-healing hip fractures and other similar-sounding conditions in the 6th century.  By the early 19th century, physicians were concerned about the ‘spongy’ texture of bones in old age, even before they were able to see them on X-ray.

Osteoporosis is a silent insidious disease linked to hormonal changes at the time of the menopause.  Inevitably as we age there will be some bodily changes, such as the natural thinning of the bones in both men and women’s skeletons and weaker muscles less able to support the bones. Changes may also occur in the joints with arthritis, rheumatism and backpack being painful reminders of the passing years.

Today osteoporosis is regarded in many cases as a preventable disease although there is still a great deal we don’t know about it.  Despite its association with ageing and the menopause, the condition can also affect younger women and men.  Although more cases are being diagnosed, it doesn’t necessary follow that osteoporosis is on the increase bu that more of us are living longer, and so the chance of osteoporosis increases with longevity and the condition is more recognisable as osteoporosis by doctors who are fully aware of the effects of bone thinning.  Other reasons why many women present with osteoporosis include excessive dieting, poor nutrition, sedentary lifestyles and lack of exercise and young women who miss or have irregular periods or suffer from anorexia. A study of young women suffering from anorexia and missing periods for a year showed 77% has spinal bone loss caused by poor nutrition, weight loss and loss of ovarian function.   Young women athletes who train excessively are at risk if they become underweight and their periods stop. They can lose 5% of bone density in a year.

Lets’ bone up on the facts

  • Bone consists of the compound calcium phosphate embedded in collagen fibres. The calcium gives strength and hardness, the fibres make for flexibility.
  • Bone itself is not dead, but a living tissue full of little cavities looking not unlike a honeycomb
  • Bone changes constantly with new bone repairing and replacing old bone throughout our lifetime
  • Bone is liable to fracture, however the skeleton does replace itself every 7 –10 years
  • Bone mass decreases gradually and naturally in both women and men after the age of 35
  • Genetic inheritance and other factors also contribute to bone loss in some people
  • Fast bone losers will have lost as much as 30% of bone within ten years of the menopause (average age 51)
  • A woman who has an early menopause (before 45 years old) can experience bone loss even earlier (she will have been without bone-protective oestrogen for a longer period of her life.)
  • For the same reason fast bone loss can also be expected after a premature menopause (possibly brought about by hysterectomy).
  • The likelihood of fast bone loss is even greater if one or both ovaries were removed at the time (oophorectomy).

Your weight a 1 year of age could predict bone strength in adult life.  In a study of 230 women whose weight at a year old was traced from old medical records it was found that those underweight infants did not develop as strong skeletons in adulthood as those who were bigger infants.

 There are two types of bone: trabecular and cortical. 

  • A woman will lose about 50% of trabecular bone and 35% of cortical bone in her lifetime.
  • Trabecular bone is most likely to be lost in the 10 years or so around the menopause.
  • Cortical bone is associated with slower, gradual bone loss later in life.
  • The forearms and spinal column are made up largely of trabecular bone, and fractures in these areas are a sign of post-menopausal osteoporosis.
  • Hip and shoulder bones are both cortical and trabecular (fractures here are associated with later ageing.)

Taking the oral contraceptive pill over a long period may protect against bone loss because the hormones they contain may stimulate a substance called calcitonin that inhibits bone breakdown.  Bone tissue is continually replacing itself, most rapidly in the young and more moderately in adulthood.  Peak bone mass is reached during the early 20s, and after that, if you want to look at it pessimistically, things begin to go downhill.  In women, bone loss at around the age of 30 is up to 1% a year, in men the rate is slower.  This gradual loss of bone density is common to everyone and part of the ageing process.  But in some women, the loss accelerates to between 2% and 3% a year at the onset of the menopause, and by the age of 70, a third of bone mineral mass can have disappeared.  You can see the results in the skinny ankles and so-called ‘dowager’s hump’ or stoop of some elderly women.  That stoop is the result of what are known as crush fractures in the spine.

Overweight women gain some protection from the disease because  greater body weight puts more stress on her bones and after the menopause her excess fat will store more estrogen in the fat cells.  Something  larger ladies can smile about?

What happens at the time of the menopause?

Menopause is a normal stage in a woman’s life.  It isn’t an illness although some women do have very real problems at this time and need help.  Other women sail through the mid life changes with ease.   It can be divided into three stages:

Perimenopause

  • Signifies the transitional stage, a gradual process
  • Ovaries produce less and less oestrogen.
  • Can be 3 to 5 years, until the final cessation of the periods at menopause which for most women is between the ages of 45 and 55
  • Average age of menopause being 51 years of age. (But recent research indicates that the menopause is occurring at an increasingly younger age.)

Menopause

  • Menopause signifies a woman’s last menstrual period
  • Her ovaries finally cease to function
  • Her menstrual periods stop
  • Reproduction comes to an end.

Postmenopause

  • Signifies the many years of a woman’s life left after her last menstrual period and monthly bleed. (Possibly another 1/3rd of her life)

The hormonal fluctuations during the time of the menopause can cause physiological changes which effect metabolism and emotions.

This hormonal imbalance caused by the natural drop in oestrogen levels can result in symptoms such as:

  • Hot flushes
  • Irritability
  • Anxiety
  • Poor concentration.

A natural drop in levels of hormone oestrogen at the menopause triggers an accelerated loss of calcium from the bone.  One of the mysteries surrounding osteoporosis is that though all women lose oestrogen at the menopause, not all of them suffer bone loss.  There are certain risk factors that make some women more vulnerable than others. The increased loss occurs at whatever age the menopause takes place, either naturally around the age of 51,or unnaturally through removal of the womb and ovaries for medical reasons at an earlier age.

The earlier the menopause the earlier the risk of thinning bones. On average women who smoke experience menopause 3 years earlier and if you live with a smoker (even though you don’t smoke) you too are at a disadvantage.

Who is most at risk of osteoporosis?

According to the National Osteoporosis Society the risk factors are:

  • Heavy drinking and smoking
  • Heavy caffeine intake
  • Slight build, low weight
  • Early menopause before the age of 45
  • Family history of osteoporosis, especially in close female relatives, (i.e. mother or grandmother)
  • Lack of exercise
  • Prolonged bed rest or immobility
  • Fair skin
  • Lack of sufficient calcium in diet throughout life
  • High protein diet (which increases calcium loss)
  • Vitamin D deficiency (which reduces body’s ability to utilise calcium)
  • Long course cortisone or thyroid treatment
  • Women who have over dieted especially anorexia or bulimia sufferers)
  • Women who over-exercise such as marathon runners (periods diminish or disappear)

Studies in the US show that black women have stronger, thicker, larger bones than white.  Black women also tend to lose bone more slowly  and lose less calcium in their urine than white women.  Both black and white men lose bone and calcium in similar amounts.

What are the effects of bone loss?

There may be nothing noticeable at first.  It’s what happens in the long run that counts.  A typical sign is the broken wrist, a Colles fracture (which I experienced when I fell ice-skating – ouch)  You know the scenario: the person slips and falls on an outstretched hand.  Her average age will be 60, and I use the word ‘she’ advisedly, because it happens much more often to women than to men.

Fracture of the femur, the thighbone is another indicator.  It can happen through quite a minor fall.  The incidence rises with increased age in both men and women, but again its women who are statistically more prone to these injuries.

And then there are fractures of the vertebrae, or spine that become more frequent from the age of 50, again primarily in women.  These can cause loss of height through a concave or wedging effect of the weakened bones, or the spinal column may collapse because the bones are actually crushed.  One estimate suggests that about 60% of elderly women will experience wedging of bones in the spine.

Keep your  black coffee intake down.  An American study shows that drinking more than 2 cups a day reduces bone density, though coffe drinkers who also drank at least one glass of milk a day lost less bone than those who did not.

Hip fractures increase after the age of 70, and are the most serious of the four types of fracture connected with osteoporosis.  While the other kinds may cause pain they rarely need much medical care.  But hip fractures are associated with hospitalisation, permanent disability and death in old age. In the UK in 2004 we’re talking in terms of 300,000 cases of osteoporosis every year resulting in 70,000 hip fractures, 40,000 Colles fractures, and 40,000 fractures of the spine. And then there’s the financial burden, some £1.7 billion a year cost to the NHS.  Not to mention the cost in human misery and pain.   Some 14,000 people will die as a result of fractures.  And, yet again I say, some osteoporosis is preventable.

All fall down?

Fractures follow falls.  Even a minor impact can lead to a fracture when bones reach a certain stage of brittleness.  Why do people fall down more as they get older?  For a number of reasons, some medical:

  • They could be on a course of drug treatment that makes them drowsy or lose balance (tranquillisers for instance.)
  • They may suffer from muscular weakness through illness or lack of exercise.
  • Vision may not be as keen so there is a danger of tripping over (where lighting is not too good, for instance in a hall or on stairs).
  • Blackouts or fainting due to a physical condition.

A minimum of 2 or 3 units of alcohol a day (preferably less) will not affect bones directly.  But women who drink excessive amounts of alcohol may stumle and fall!

Prevention is better than cure

Not everyone has the opportunity, or the positive determinations to regain full mobility after an accident as I did.   But women with fragile bones have a lot to lose; both their physical independence and quality of life are at risk. Many accidents leading to nasty falls occur around the house, so be aware of potential hazards:

  • loose rugs
  • slippery floors
  • spilt liquids
  • Snake like flexes.

I find my visiting grandchildren, and other people’s pets are often the cause of “accidents just waiting to happen!”  Objects get moved from their familiar spots, toys get left in unexpected places as their bored little owners abandon treasured possessions in the most inconvenient places! Accidents in my kitchen are best avoided by keeping things in more accessible places, it’s too easy to lose one’s balance and tumble off the kitchen steps.  For people suffering from osteoporosis, handrails and non-slip mats in bathrooms can stop nasty falls on slippery surfaces, which could have such devastating consequences.

And cold weather can take it’s toll.  One study of elderly women admitted to hospital with fractures showed there was a mid winter peak.  But they weren’t slipping on icy pavements, most of the accidents took place indoors.  It was noted a large proportion of the women were thin, possibly suffering from poor nutrition which triggered low body temperatures, hypothermia and subsequent lack of co-ordination.

Strong bones

Osteoporosis, a debilitating condition caused by the loss of bone mineral, makes the bone susceptible to fracture, especially at the hip, wrist and spine. It is most common in menopausal women as the decline in oestrogen levels leads to an increase in the normal rat of mineral loss from bone.

You can help prevent osteoporosis eating a varied diet rich in vitamins and minerals, by consuming less caffeine and alcohol and by exercising.

Are you at risk?
Height and weight…….
Statistics show that tall women are more likely to develop osteoporosis. If you’re tall, pay extra attention to the things you can do to minimise your risk of developing osteoporosis.
If you are too thin, you could run and increased risk of developing osteoporosis. An overactive thyroid gland could be causing your lack of bodyweight. In addition, you don’t have sufficient adipose (fat) you will be less likely to produce oestrogen from this source.

Carrying a slight amount excess weight can actually push calcium into your bones. It is not helpful to be considerably overweight, however, as excess weight will put great pressure on your bones. If you do decide to lose weight, be careful. Research suggests that after the menopause it is better to stay the weigh you are that to go on a sudden weight-loss programme and lose more than 10 per cent of your body weight, which can double you risk of getting osteoporosis

Exercise
Lack of exercise is a significant risk factor in the development of osteoporosis. If you sit and do nothing, calcium tends to leave your bones; if you run, calcium tends to enter your bones. The critical factor is that exercise should be more weight-bearing, such as walking, running or push-ups. The more you use your bones to make demands on them, the stronger they become. It is a great way to energise you body and becoming fitter and stronger all over.

Diet – what your bones need
Calcium
This mineral is a major component of the structure of bones. You lose some calcium everyday, mainly in your urine, and it is vital that this is replaced. A daily dose of 1,000 mg is recommended, with an increase to 1,500 mg close to and thereafter the menopause. Make sure you diet supplies a large amount of calcium. You can also help this by making some positive changes and consider taking a calcium supplement, if necessary.
Phosphorus

Calcium’s ‘partner’ in bones is phosphorus. The ideal would provide them in equal amounts, but the Western diet unusually contains an excess of phosphorus. A high phosphorus intake can remove calcium from bones and can also lead to reduced vitamin D activity and hence the absorption of calcium from the digestive system.
Meat, grains and protein-rich foods in general are rich in phosphorus, so reduce your intake of these foods to the minimum that will provide adequate protein. Most fruits and vegetables have a good balance of calcium and phosphorus. Avoid carbonated drinks.

Magnesium
About 70 per cent of the body’s magnesium is stored in the bones, where it replaces some of the calcium and has an important influence on bone structure. People with osteoporosis often have a deficiency of magnesium. Many medications prescribed for osteoporosis contains calcium and vitamin D but little or no magnesium, even though some people may need it more urgently that calcium.

Other essential minerals
In addition to those listed above, make sure that you are supplying your body with adequate levels of manganese, zinc, copper, silica and boron.

Vitamin A
Also known as retinol, vitamin A stimulates the production of progesterone, thought to be more useful than oestrogen in the prevention of osteoporosis. It is found in eggs and meat, especially liver. Carotenes, the precursors of vitamin A, are available from orange, red or green plant foods, such as carrots, beetroot, and leafy green vegetables.

Vitamins B6 and B12 and Folic Acid
These B vitamins help minimise levels of homocysteine. The effect can be enhanced by taking a supplements by taking a supplement with as much as 5 mg folic acid (ask PAUL C if this is still ok to rec). This is a safe dose, but it should be always taken in combination with vitamin B12.

Vitamin C
Vitamin C is essential for healthy collagen and increases the production of progesterone. It is usually found in combination with other bioflavonoid in foods such as oranges, strawberries, tomatoes and green vegetables. If choosing a supplement, look for one that contains vitamin C in calcium form (calcium ascorbate) in combination with bioflavonoids.

Vitamin D
By promoting calcium absorption from the intestinal tract vitamin D helps to maintain normal levels of blood calcium. An adequate intake of vitamin D will, for most people, make a big difference to calcium levels.

Vitamin K
The vitamin encourages calcium deposition in the bones. Many post-menopausal women stop calcium in urine whey they take vitamin K. Leafy vegetables are the richest sources. Because it is fat soluble, vitamin K should be eaten or taken with some form of fat. Another form, vitamin K2, is produced by bacteria and other microrganisms in the digestive tract. For most healthy people, this is a major source of vitamin K. Vitamin K is not stored in the body, and so is less likely to be toxic in high doses. A recommended does in 10 mg a day, but up to 50 mg has been used without any adverse effects.

Other risk factors to consider
– excess alcohol
– excess caffeine
– carbonated drinks
– smoking
– excess salt
– Prescription medication, such as sleeping pills and steroids. They are particularly harmful and can have an adverse effect on the bones. If you are taking these, speak to your doctor or a qualified practitioner about supplements you can take for bone support or natural alternatives to help reduce the medication. Look into natural alternatives to sleeping pills or steroids.

Hints for health
Eat a varied diet throughout your life as osteoporosis can start before the menopause. For strong bones, make sure your diet is especially rich in vitamins D and K, calcium and magnesium.

Recipe for strong bones
Fruit and nut crumble.
Serves 6
Preparation time 15 minutes plus soaking time
Cooking time 35-40 minutes
This can be enjoyed for an energising and wholesome breakfast, after dinner for a healthy desert or delicious midday snack.

Dried fruit such as apricots and prunes add to the iron content of the diet. Absorption of iron is by vitamin C, but inhibited by a number of factors including drinking tea. This delicious recipe contains natural foods that provide essential minerals for bone support.

6 oz dried apricots
4 oz dried pitted prunes
4 oz dried figs
2 0z dried apples
1 pint of apple juice
3 ½ oz of wholewheat /rye/spelt flour
2 oz margarine
2 oz brown unrefined sugar sifted (you can find this at local health food store)
2 oz hazelnuts chopped
To serve and garnish
Low fat yogurt – natural or soya
Rosemary springs

1. Place the dried fruits in a bowl with the apple juice and leave overnight to soak. Transfer to a saucepan and simmer for 10-15 minutes, until softened. Turn into an ovenproof dish.
2. Sift the flour into a bowl and rub in the margarine until the mixture resembles breadcrumbs.
3. Stir in the sugar, reserving a little to serve, and the hazelnuts, then sprinkle the crumble over the fruit (sugar does not need to be added to this recipe if you are trying to avoid)
4. Bake in a preheated oven at 200oC (400oF), Gas mark 6 for 25-30 minutes.
5. Serve with a low fat yogurt, if you liked, sprinkled with the reserved sugar and garnish with rosemary.

Essential Books for Public Health Professionals Working in Healthcare

 

How To Talk About Books You Have Not Read 

How To Talk About Books You Have Not Read is a wonderful book by Pierre Bayard. The book can be read at two different levels as many books can. On one level it is a humorous book, a little like the book by Stephen Potter called One-Up-Manship, which has advice on how to impress people with one’s literary credentials even though one has never read the classics. Pierre Bayard, however, makes a very serious point – that no one will ever read all the books that they need to read or could read in their particular topic. It is far more important to know about a book and its core message, preferably in the author’s own words, and to understand how that book fits into the culture and relates to other books and concepts then not to know that a book existed.

The table below presents the Top Ten Books that are essential reading in this topic area. You can see all 10 books in the bulleted list below. 

For each book there is the full reference, the ‘Distilled Message’ (the essence of the book in the author’s own words) and ‘Why Is This Book Important?’ (the relevance of the book and other related titles or key terminology to note). 

  • Public Health, Ethics, and Equity 
  • Stewardship.  Choosing Service over Self-Interest..
  • A Public Enemy.
  • Social Determinants of Health.
  • The Politics of BSE.
  • Realistic Evaluation.
  • The Strategy of Preventive Medicine.
  • Organizational Culture and Leadership 
  • The Spirit Level.  Why More Equal Societies Almost Always Do Better.
  • Effectiveness and efficiency. Random reflections on health services.  
  • ·Public Health, Ethics, and Equity.  

Sudihr Anand, Fabienne Peter and Amartya Sen. (2004)  Oxford University Press 

Distilled message  “ …it has been our aim to launch a wide investigation of the ethical issues underlying inequalities in health. In order to examine health equity from a variety of perspectives …contributions centre on 5 themes

1. What is health equity?
2. Health equity and its relation to social justice
3. Health inequalities and responsibilities for health
4. Ethical issues in health evaluation and prioritization
5. Anthropological perspectives on health equity”

Why is this book important? The scope of Public Health is difficult to define.  If we focus on health promotion for example then the obvious focus of public health effort might appear to be on cigarette smoking and the modern diet.  However it is obvious that bringing about change in these risk factors is not simply a matter of giving people clear unbiased information, important though that is.  It is necessary to tackle the social determinants of health, the social factors that lead to smoking or a bad diet or any other risk factor.  As far as the social determinants are concerned it is again possible to consider these in different levels of depth.  An economic approach focuses on deprivation and inequality but many people feel that this is still too narrow and taking what is being called the human rights approach it is necessary to have a perspective of justice and that if the word justice in the world or any country in the health of not only the poorest people but also the whole population would be better.  This obviously raises ethical issues for public health professionals.  Is it right for them to have a salary that is much greater than the poorest people in society or even of the lowest people in a health service.  

In this book the authors start by looking at inequalities of health but they move from inequality and objective variable to equity.

Equity and its opposite inequity are still confused by many with equality and inequality.

Inequality is an objectively defined judgment, for example health inequalities such as variation in mortality rates, or health service inequalities, such as variation in the provision of services to different populations. There may be equality in the provision of health services, which is not equitable, if one population has greater need than the others. Similarly there may be unequal distribution of resources that is in the interest of equity in the higher amount of money per head, allocated to a population with high levels of deprivation and need, because it has been decided to do this in the interests of equity.

  • Stewardship.  Choosing Service over Self-Interest.  

Peter Block  (1993) Berrett-Koehler, (p.xx)

Distilled message “Stewardship is to hold something in trust for another.  Stewardship is defined in this book as the choice to preside over the orderly distribution of power.  This means giving people at the bottom and the boundaries of the organization choice over how to serve a customer, a citizen, a community.  It is the willingness to be accountable for the well-being of the larger organization by operating in service, rather than in control, of those around us.  Stated simply, it is accountability without control or compliance.”
Why is this book important? The term “steward” is an old-fashioned term encountered in Tolkien, for example, and the Shorter Oxford English Dictionary has many examples of the word “steward”, usually someone who is accountable to a king or a lord, responsible for management and order of an estate or a manor house.  More recently, however, the word has come to have a different meaning and a fourth dimension.

Of central importance is the book by Peter Block entitled Stewardship, subtitled Choosing Service over Self-Interest.   This could, of course, simply be a definition of altruism and Block writes about stewardship being “to hold something in trust for another”.   

However, a new meaning of the word “stewardship” is emerging and stewardship is something which, in a book called Permaculture, subtitled Principles and Pathways beyond Sustainability, addresses the question, “Will the resource be in better shape after my stewardship?”.   This relates to what is sometimes called intergenerational equity or environmental sustainability – we have to look after the planet for future generations.   It is our duty as stewards.

Increasingly the word “stewardship” is being used in healthcare with an appeal to the clinicians to think of themselves  not only as people who use resources but as the stewards of the resources.

  • A Public Enemy 

Henrik Ibsen  (1964)  Penguin Books, (p.219)

Distilled message “The fact is that the strongest man in the world is the man who stands alone.”
Why is this book

important

The Enemy of the People is the only play about a public health professional.  The hero and, he is a hero, is the head of public health in a small Norwegian Spa town.  He is an admired and respected person in the town, until he says that the waters, the waters on which the town’s wealth is based, are unsafe.

The political pressure on him grows, but subtle and direct and a good modern depiction of the oppositions, and hostility, he faced is the early scenes of Jaws when the coastguard is trying to convince the Town Council that they have a problem that requires action.

  • Social Determinants of Health.  

Michael Marmot and Richard G. Wilkinson  (1999)  Oxford University Press, (p.232-233)

Distilled message
  • Income support.
  • Policies should focus on reducing the proportion of children born into and living in poverty.
  • Policies should aim to reduce inequalities in income and wealth within populations.
  • Policies to ensure access to educational, training, and employment opportunities.
  • Barriers to access to health and social services should be removed.
  • Adequate follow-up support is needed for those leaving institutional care.
  • Housing policies should aim to provide enough affordable housing of reasonable standard.
  • Employment policies should aim to preserve and create jobs…Improving the health of migrants.”
Why is this book

Important

Michael Marmot has led the intellectual analysis of the social determinants of health and led the campaign for the social determinants to be recognised for the importance that they have.  The approach is a little narrower than the approach of, for example Amartya Sen.  They certainly argue in favour of social justice but argue that much can be done practically by tackling problems like bad housing and low income.

It is also certainly important to try to tackle cigarette smoking and alcohol abuse, as they are the two major causes of disease directly but success will only be achieved if success of social determinants of health is also tackled.

  • The Politics of BSE.   

Richard Packer  (2006)  Palgrave MacMillan, (p.5)

Distilled message  “The word ‘politics’ covers a host of matters from major issues of elevated principle to minor matters of interest to a few individuals only.  This is because politics is a reflection of human nature, which while sometimes aspiring to the heavens is often concerned mainly with self.  Accordingly, sometimes this book moves suddenly between the large and lofty and the small and rather grubby.  I make no apology; it would not be an accurate account without both dimensions. 
Why is this book important? This is one of a number of books that give insight into the relationship between politicians, officials and scientists written by the vet who was at the heart of the BSE drama.  The relationships are subtle and not always understood by Public Health professionals.

Other books that give useful insight include:

  • Creating Public Value by Mark Moore
  • Administrative Behaviour by Herbert Simon
  • Any of the novels of CP Snow particular Corridors of Power and The New Men.
  • Realistic Evaluation.  

Ray Pawson & Nick Tilley   (1997)  Sage, (p.215-219)

Distilled message  “The New Rules of Realistic Evaluation…

Rule 1: generative causation…

Rule 2: ontological depth…

Rule 3: Mechanisms…

Rule 4: Contexts…

Rule 5: Outcomes…

Rule 6: CMO configurations…

Rule 7: Teacher-learner processes…

Rule 8: Open Systems”

Why is this book important? Clinical practice and the evidence base of clinical practice have been dominated by two research methods in the last 50 years – the randomised controlled trial and the systematic review.  

These methods have a part to play in Public Health also but in the field of public policy a new paradigm is emerging led largely by the work of Ray Pawson. 

 

Ray Pawson argues that when one is evaluating complex interventions the reductionist method of the randomised controlled trial and the systematic review with meta analysis has its limitations.  The method proposed by Pawson and Tilley can be briefly summarised by saying it is observation, intervention, and repeat observation.

This book is of great relevance and should be used more by people working in public health who need to innovate and evaluate.  That they have no control group should not put them off. The other key book by Ray Pawson is called Evidence Based Policy and it is his critique of the relevance of the systematic review that is currently used in clinical research.

Both books are important books for public health professionals.

  • The Strategy of Preventive Medicine.  

Geoffrey Rose  (1992)  Oxford University Press, (p.14)

Distilled message The following chapters will explore the principles and ramifications of both the  high risk and the population strategies of prevention and their respective strengths and limitations. Finally, the conclusion will be that preventive medicine must embrace both, but, of the two, power resides with the population strategy
the strategy of preventive medicine
Why is this book

important?

Geoffrey Rose is one of the giants of Public Health in the last decade of the 20th Century.  His book The Strategy of Preventive Medicine brought together very elegantly the high risk approach and the population approach.  He pointed out that many events would occur mostly in low risk people, because there are so many more of them even though each individual is at low risk and that it was necessary to complement and supplement the high risk approach to the population approach.  

For example, we are probably in a muddle that he would disapprove of at present.  We are identifying lots of individuals at low risk of coronary heart disease but we have not yet identified the individuals at very high risk, people with familial hypercholesterolemia.  Furthermore because so much of our effort is going on people with lower risk we are not trying to shift the whole population curve.  

The need to do this was further emphasised by George Davey Smith in the International Journal of Epidemiology.(1)  At one time it was hoped the human genome project would allow us to identify all the individuals at high risk by identifying all those with a particular genome type.  Unfortunately this does not seem to be possible and, for many years to come it will not be possible to identify people at very high risk using biomarkers other than the ones we know about already.  

Thus we still need to adopt the principles advanced by Geoffrey Rose.  We need to deal with individuals with very high risk and seek to shift the risk profile of the whole population.

  • Davey Smith J (2011) Int J Epidemiology 40:537-562.  Epidemiology; epigenetics and the ‘Glossary Prospect:  embracing randomness in population health research and practice.
  • Organizational Culture and Leadership. (3rd Edition)  

Edgar H. Schein  (2004)  Jossey-Bass, (p.17)

Distilled message “The culture of a group can now be defined as a pattern of shared basic assumptions that was learned by a group as it solved is problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think, and feel in relation to those problems.
Why is this book

important

An organisation can be said to consist of a structure, systems and a culture.  Health services change structure all the time and increasingly focus on systems but still retain the same culture.  The culture of an organization is defined in almost as many ways as team leadership, perhaps not surprisingly as the two terms are interwoven with one of the key responsibilities of the leader being to shape the culture of their organisation.

The culture of an organisation is the set of beliefs and assumptions that influence how people feel and behave. A large organisation can have many different cultures, pediatric departments have a different culture from trauma departments and within one hospital neighbouring wards can have very different cultures even though both are doing the same job.

 
  • The Spirit Level.  Why More Equal Societies Almost Always Do Better. 

Richard Wilkinson & Kate Pickett  (2009) Penguin, (P.264.265)

Distilled message “After several decades in which we have lived with the oppressive sense that there is no alternative to the social and environmental failure of modern societies, we can now regain the sense of optimism which comes from knowing that the problems can be solved.  We know that greater equality will help us rein in consumerism and ease the introduction of policies to tackle global warming.  We can see how the development of modern technology makes profit-making institutions appear increasingly anti-social as they find themselves threatened by the rapidly expanding potential for public good which new technology offers.  We are on the verge of creating a qualitatively better and more truly sociable society for all.”
Why is this book

Important

The simple message here is that societies that are more equal, using a measure called the Gini ratio, are better for everybody, including the rich.

In the 19th Century it was enlightened self interest that led to the development to the Public Health Revolution.  The rich realised that they could get cholera just like the poor and this was an important driver of change.  Richard Wilkinson, Michael Marmot and their colleagues are hoping that this awakening will occur in England, holding up Norway as a role model.

Here is their definition of the Gini co-efficient.

“There are lots of ways of measuring income inequality and they are all so closely related to each other that it doesn’t usually make much difference which you use. Instead of the top and bottom 20 per cent, we could compare the top and bottom 10 or 30 percent. Or we could have looked at the proportion of all incomes which go to the poorer half of the population. Typically, the poorest half of the population get something like 20 or 25 per cent of all incomes and the richest half get the remaining 75 or 80 per cent. Other more sophisticated measures include one called the Gini coefficient. It measures inequality across the whole society rather than simply comparing the extremes. If all income went to one person (maximum inequality) and everyone else got nothing, the Gini coefficient would be equal to 1. If income was shared equally and everyone got exactly the same (perfect equality), the Gini would equal 0. The lower its value, the more equal a society is. The most common values tend to be between 0.3 and 0.5.” 

Source: Wilkinson, R,., Pickett, K.  (2010) The Spirit Level. Why Equality is Better for Everyone.  Penguin Books (p.118).

  • Effectiveness and efficiency. Random reflections on health services

Cochrane, A.L.  (1971)  The Nuffield Provincial Hospitals Trust.

Distilled message “There are two preliminary steps which are essential before this cost/benefit approach becomes a practical possibility, and it is with these two steps that I am chiefly concerned.  The first is, of course, to measure the effect of a particular medical action in altering the natural history of a particular disease for the better.  Since the introduction of the randomized controlled trial (RCT) our knowledge in this sphere has greatly increased but is still sadly limited.  It is in this sense that I use the word ‘effective’ in this book, and I use it in relation to research results. As opposed to the results obtained when a therapy is applied in routine clinical practice in a defined community.” (p2)
Why is this book

Important

Effectiveness and efficiency

This book, published in 1972, changed the paradigm in healthcare from one in which the only concern was that the care should be free and that the doctor’s experience was the only criterion for deciding whether or not a treatment was right. Its influence flourished in the 1980’s when it paved the way for the Cochrane Collaboration and Evidence Based Medicine

In the last three decades of the 20th century, health service payers and managers were appropriately preoccupied with effectiveness and efficiency and only services that did more good than harm, at reasonable cost, were considered for funding. However, of developed countries, only the United Kingdom faced serious resource constraints in the 1980s and was forced to think about opportunity costs rather than simply taking new interventions that had a favourable result from cost-benefit or cost-effectiveness analyses.  Since then, every other major developed economy, which is committed to offering healthcare to its whole population, has had to face up to limits placed on healthcare spending.  In Germany, Japan, and Italy, for example, evidence-based decision-making has become much more explicit. The United States remains an exception but President Obama is determined to end that.

It was in the United Kingdom, therefore, that the response to the work of Archie Cochrane was most enthusiastic.

‘He lived and died, a severe porphyric, who smoked too much, without the consolation of a wife, a religious belief, or a merit award, but he didn’t do too badly.’

These were the words of Archie Cochrane when he wrote his own obituary for the British Medical Journal. As befits the man, they were ironic, clear, accurate, and understated.   Few people had more influence on healthcare in the last fifty years of the 20th century than Archie Cochrane; firstly, by his insistence on the importance of the randomised controlled trial; secondly, by his challenge to the medical and research establishments that they should organise all of their knowledge properly, leading to the creation of the Cochrane Collaboration; and thirdly, by the publication of his Random Reflections on Health Services with the title Effectiveness and Efficiency. This small book, published in 1972, was ahead of its time in that it captured and predicted 20th century healthcare’s focus on effectiveness and efficiency.

The era of effectiveness

‘All effective treatments must be free.’

This, wrote Cochrane, was the device his banner carried at a Communist rally in the 1930s, written after considerable thought but making no impact on the communists on the march. But it did make an impact on Cochrane, who remained obsessed with the need for treatments to be demonstrated to be effective and then, if they were, for those treatments to be made available through a National Health Service. For Cochrane it was clear that the single best method for demonstrating the effectiveness of a treatment was the randomised controlled clinical trial and he promoted the importance of the trial with commitment, energy, intelligence, and a considerable degree of cunning throughout the rest of his professional career.   As a result, the term ‘effectiveness’ entered the general vocabulary not only of the research worker but of all those who manage and pay for healthcare.

 

 

Essential Terms for Public Health Professionals working in Healthcare

Language creates reality, it does not describe it.  That is one of the principles that has emerged from anthropology, linguistics and philosophy from authors as diverse as Ludwig Wittgenstein, John Searle and Benjamin Lee Whorf. Confusion about language and the meaning of the terms being used is one of the main causes of arguments, fruitless arguments, which disappear if everyone shares the same understanding of the terms being used.

Public Health professionals use a language that is rich in terms and which have no universally agreed definition; terms such as social justice or sustainability.  There are other terms where there is an agreed meaning, usually more technical scientific terms such as meta-analysis.  One of the reasons why public health professionals do not have a strong corporate culture is because no attempt has been made to develop a common core of concepts, and terms relating to these concepts, with the objective that everyone practising as a public health professional would use the term and concept with the same meaning.

A project has been designed to develop such a common core.  There are of course dictionaries of public health, notably by John Last and by Professor Williams in Swansea, but within the concept of a dictionary there is a glossary, a subset of terms of vital importance for everyone in the community of practice to use.  It could also be argued that if such a set of terms were identified and the meanings agreed, that they should be taught to new practitioners at an early stage in their induction to the profession.

A project was sponsored to stimulate discussion on core terms and common meanings and the first set of 10 terms represented here are a basis for discussion. For each term there is a bottom line drawn from one of the sources cited and a short commentary.

  • Culture: Culture is the set of important understandings (often unstated) that members of a community share in common.
  • Emergence: Much coming from little.
  • Equity: Equity is a subjective judgment of unfairness.
  • Health Promotion: Health promotion is the process of enabling people to increase control over, and to improve, their health.
  • Health Protection: “Health protection comprises legal or fiscal controls, other regulations and policies, and voluntary codes of practice, aimed at … the prevention of ill-health.
  •  Justice: To ask whether a society is just is to ask how it distributes the things we prize – income and wealth, duties and rights, powers and opportunities, offices and honours.
  • Risk: “The chance that something (good or bad) will happen.”
  • Sustainability: “Protecting resources from one generation to the next.”
  • System: A set of activities with a common set of objectives with an annual report
  • Value: “…value is expressed as what we gain relative to what we give up – the benefit relative to the cost.”

Population-based Healthcare

What is Population-based Healthcare?

Population healthcare focuses primarily on populations defined by a common need which may be a symptom such as breathlessness, a condition such as arthritis or a common characteristic such as frailty in old age, not on institutions, or specialties or technologies. Its aim is to maximise value and equity for those populations and the individuals within them.

The population healthcare methodology involves a collaborative working of multidisciplinary stakeholders to determine appropriate outcome measures for various systems, and getting populations reporting on these on an annual basis. Atrial Fibrillation, falls and fragility fractures, homelessness, chronic pelvic pain are some of the first set of systems being developed, and it is anticipated that this method will be used across all the 30 programmes and 100 recognised systems.

The first twenty of these programmes are based on the International Classification of Diseases (ICD), arranged in order of programme budget expenditure.

Each of the twenty condition focussed programmes has a large number of rare diseases as well as the common problems.

Where appropriate, major symptoms are associated with one relevant programme, although more than one specialty may be involved with a particular symptom such as breathlessness.

The remaining ten programmes focus on populations defined by a common characteristic such as age or having more than one problem.

Glossary: Population and Personalised Care

This Glossary is about Population and Personalised Care the latter being  a style of clinical and general management which always considers the patients’ perspective as the most important and is committed to increasing patient Engagement, Empowerment or Involvement, which may be regarded as synonyms. Personalised care is an element of patient centred care and is the other side of the coin from population care. This is a diffuse and fast moving field with language evolving at a rapid rate. Here are the key terms and concepts.

  • Value “What is gained relative to what we give up – the benefit relative to the cost but not only to the direct cost, which is the efficiency of a service, but the Opportunity Cost, or the Opportunity Lost to put it another way and there are three dimensions to value in healthcare
    • o Allocative value, determined by how the assets are distributed to different sub groups in the population
    • o Technical value, determined by how well resources are used for all the people in need in the population
    • o Personalised value, determined by how well the decisions relate to the values of each individual

Waste is any activity in a process that consumes resources without adding value for the patient

Cost effectiveness

The relationship between the cost of an intervention and its impact.

Optimality;

Optimality is reached when resources or productivity create maximal benefit with the least harm. Beyond optimality there is overuse.

Programme Budgeting and Marginal Analysis;

The fundamental idea behind programme budgeting is decision making based on explicit criteria related to the wellbeing of the whole population, as opposed to decision making by compromise among various institutional, parochial, or other vested interests. Marginal Analysis consists of starting with a particular mix of services and analyzing changes in that mix. If resources can be shifted to produce greater benefit then this should be done.

Opportunity Cost;

The value of the next best alternative forgone as a result of the decision made.

Equity;

Equity is a subjective judgment of unfairness.

  • System – A set of activities with a common set of objectives with an annual report.
  • o Network – If a system is a set of activities with a common set of objectives, the network is the set of organizations and individuals that deliver the systems.
  • o Pathway – The actual care process of care experienced by each individual patient/client; also described as maps that define best practice.
  • o Quality -The degree to which a service meets preset standards of goodness in the delivery of the system’s objectives.
  • Culture – “Culture is the shared assumptions of a group that is has learned in coping with external tasks and dealing with internal relationships. Akey cultural issue is the development of a culture of stewardship.
  • Population healthcare –the design and delivery of the care with a primary focus on the population in need, not the healthcare institutions, where the populations in need are defined not bureaucratically but by the optimum population size for high value care for individuals and the group in need Population medicine or population clinical practice – a style of practise in which the clinician feels, and is given responsibility for, all of the people in the population in need whether or not they have been referred
  • Personalised Care or Personalised Medicine  –  the tailoring of care to take into account each individual’ s unique  needs, preferences and values. The term has become popularised recently to describe clinical decision making in the era of the genome but another term for clinical decision making incorporating genomic information is
    • o Stratified Medicine – decision making based on the patients degree of risk, including risk suggested by genomics and based on the long standing practice of risk stratification of elderly people based on social and medical, but not genomic characteristics
    • o Precision Medicine decision making taking into account genomic information either in diagnosis – ‘molecular diagnostics’ –or choice of drug treatment –‘pharmacogenomics’.
  • Principal and Agent – legally the patient is the principal, the clinician the agent, even if there is no money involved. Some people feel the shift in the balance of power occurred with the founding of the NHS when the patient was not charged for consulting the GP. The pendulum swung further because of
    • o Information Asymmetry – the fact that the clinician has, until the advent of the Internet much more technical knowledge
    • o Trust – Faith in another to perform a task that is not in the other’s interest
    • o Autonomy – Freedom to make decisions or act without reference to others
    • o Informed Consent – Consent to treatment given with full understanding of the magnitude and probabilities of the good and adverse outcomes
  • Empathy – In his book on Emotional Intelligence Daniel Goldman identifies three types of empathy – cognitive empathy is the ability to understand what another person is thinking   Emotional empathy is the ability to feel what another person is feeling. Empathic concern is the ability to sense what another person needs for you.
  • Evidence and Value based decision making – Decision making that ensures the patient is fully informed about the strength of evidence about the probability and magnitude of both risks and benefits of the options being considered and that the patient has been helped to reflect on, clarify and express their preferences based on the value they place on the possible benefit, the possible harm and on the risk they are taking.
    • o Health Literacy – The cognitive and social skills which determine the motivation and ability of individuals to gain access to, understand and use information. The term Statistical literacy – the ability to understand and communicate probabilities which is shared by both patients and clinicians, sometimes called risk literacy is increasingly used
    • o Framing –  the conscious or unconscious presentation of data in ways that influence their interpretation and decision making
    • o Shared Decision Making – is a style of decision making in which clinicians and patients are both involved
    • o Preference Sensitive Decision Making – is a style of decision making in which the patient’s preferences are explicitly elicited, to avoid
    • o Silent Misdiagnosis – namely failure to diagnose accurately the patient’s values and preferences even though their disease has been correctly diagnosed
    • o Informed Consent
    • o Patient Decision Aids – a tool to support the patient during decision making, particularly before and after the face to face consultation and they are increasingly  delivered using digital means variously called eHealth, mHealth, digital health or Telemedicine which may be regarded as synonyms
  • Patient defined and reported outcomes are objective measures using validated tools

subjective measures of outcome, including the degree to which the treatment addressed the problem that was bothering the patient most, rather than their diagnosis and the patient’s experience.

Necessary, Appropriate, Inappropriate or Futile Classification of interventions based on the probabilities of benefit and harm

Burden of Treatment – the impact of the process of care on the affected individual and their carers

Benefits of Walking

Evidence of Benefit

We monitor the evidence base for the benefits and harms of walking and funded two comprehensive reviews which are reproduced below. In 2012 William Buckland, the Director of the National Campaign for Walking produced a report for Public Health England and the Ramblers which reinforced the strength of the evidence base – the evidence is very strong that the benefits are considerable and the risks negligible

HEALTH BENEFITS OF WALKING – THE EVIDENCE BASE                                Prepared by Nick Cavill and Charlie Foster
For the National Campaign for Walking funded by the Department of Health, NHS London and Knowledge Into Action
Version Author Date  Comment
1.0 Charlie Foster & Nick Cavill 25/6/2008  
2.0 Charlie Foster & Nick Cavill 21/2/2009 2 papers by Allender added
       

HEALTH BENEFITS OF WALKING – THE EVIDENCE BASE                                                                     “Walking is the nearest activity to perfect exercise”. Professor J Morris and Dr Adrianne Hardman, 1997[i] 

 1. Introduction

There is now overwhelming evidence about the associations between regular physical activity and a reduction in risk of death, and risk of major diseases like CVD, stroke and diabetes. It contributes to well being and is essential for good health. The considerable evidence base for the links between physical activity and health were reported in the Chief Medical Officer’s (CMO) report[ii].

In many studies, walking is merged with other activities to generate an overall composite measure of physical activity. As walking is one of the most common types of physical activity, we could refer to the evidence that links total physical activity to health outcomes assume that it can be extrapolated to walking. However, there is now sufficient evidence on the independent benefits of walking to health outcomes.

In this report we therefore do not rely solely on evidence about the relationship between physical activity and health and apply that to walking. Wherever possible, we rely on evidence that specifically links walking and health outcomes.

2. The impact of walking on fitness, strength, flexibility and stability of joints

Walking gently stresses the body’s key systems (heart and lungs, muscles, joints and circulation). This stress leads to the body adapting to accommodate the increased demands on it – i.e. becoming fitter. Walking stresses the body at a level that is considered very beneficial to overall health and fitness but is within the reach and ability of all adults and children.

It is important to remember that walking at 3 mph uses up only 30% of the maximum energy consumption of a person aged 25. But, as this decreases by 10% a decade, a person aged 75 walking at the same speed uses up 60% of his / her maximum energy. This principle is central to walking advice or prescription.

Brisk walking can improve cardiovascular fitness[iii]. Even 10-minute brisk walks can increase fitness. One study reported that women walking continuously for 30 minutes on 5 days a week had almost identical increases in fitness as women who split their 30 minutes into three 10-minute walks[iv]. Some younger men and most other adults would improve their fitness if they took up regular brisk walking[v].

We have estimated that encouraging the adult population to walk at 3 mph instead of their slower usual pace would be sufficient to improve their levels of cardiovascular fitness. This message would be appropriate for approximately 6.3 million English adults or 23% of all adults aged 16-74 years (using data from the 1990 National Fitness Survey[vi]. Figure 6 illustrates this.

Figure 6: Average levels of fitness for both genders at different age groups with the reach of brisk walking and its potential impact on improving fitness

Brisk walking would improve fitness for these adults

As muscle strength declines with aging, regular brisk walking can maintain functional capacity and muscle strength. For both men and women there is a strong relationship between stronger muscle strength and brisker preferred walking speed[vii].

Walking and other physical activities can increase joint range of motion, particularly for older adults. Stronger muscles, joints and general flexibility developed and maintained by walking can reduce the likelihood of fallsii. The risks of injury by participating in walking are extremely small[viii].

 3. Mortality and walking

Walking more can bring substantial benefit to health. This benefit is quantified by comparing the risk of specific diseases between people who walk with people who don’t walk. There is a clear dose-response relationship between walking and all-cause mortality[ix]. A physical activity energy expenditure of 500-1,000 kcals per week (about 6-12 miles of walking for an average-weight individual, compatible with the current physical activity recommendations for adults) reduces the risk of premature death by 20-30%ii.

From a public health perspective, helping people to move from a low level of walking to increasing walking levels will produce the greatest reduction in risk. These considerable health benefits hold for both women and men and are evident even up to the age of 80 years. The reduction in relative risk of mortality for adults walking more than 12.4 miles per week compared to adults who walked less than 3 miles per week is 16%[x].

Regular walking across the life course (from childhood to old age) will reduce risk of disease and pre-mature deathi. Figure 7 shows the difference in risk between an active / regular walker and less active / non-walker. The top line (unhealthy non-walker) shows the negative and cumulative effects of inactivity, low fitness and a higher risk of premature illness across the life course.

 

4. Prevention of diseases and risk factors for disease

Walking reduces the risk of many diseases.

The benefits of physical activity can be gained from activities that can be incorporated into everyday life, such as regular brisk walking…Physical activity does not need to be vigorous to confer protectioniv

 

Figure 8: Schematic representation of the dose-response relationship between walking and physical activity level and risk of diseaseii

Walking and recovery from illness

Walking is now commonly recommended by doctors as part of recovery from illness or post operative. For example using walking as an exercise therapy can improve long term conditions such as for people with peripheral vascular disease[xi].

 5. Long-term conditions

There are 15 million people in England with a long-term condition[xii]. These conditions account for 80% of the NHS Budget, 80% of GP workload and 60% of hospital inpatient activity. Those over 75 years of age make up 7.6% of the population. 75% of these have a long-term condition.

The main long-term conditions seen in primary care respond to physical activity both in prevention and treatment. These are outlined below:

Coronary Heart Disease

  • CHD causes over 101,000 deaths per year, one in five deaths in men and one in six deaths in women. It causes 20% and 11% of premature deaths in men and women respectively.
  • There are 2.6 million people living with CHD (i.e. angina, MI) in the UK.
  • The total cost of CHD to the economy is £7.9 billion, with 45% due to direct healthcare costs, 40% in productivity losses and 16% due to the costs of informal care.[xiii]

The cost of ischaemic heart disease to the NHS due to physical inactivity has been estimated at 23% of a total spend of £2.3 billion[xiv]. The Foresight report [xv] estimates direct NHS costs of CHD in 2007 to be £3.9 billion, suggesting the total NHS cost of CHD due to physical inactivity to be just over £1 billion.

The effect of walking on CHD is as follows[xvi]:

  • Increased maximal oxygen consumption
  • Relief of angina symptoms
  • Increased heart rate variability
  • Reduces Blood Pressure
  • Reduces body fat
  • Increases fibrinolysis
  • Increases levels of HDL
  • Improves glucose-insulin dynamics.
  • Improved psychological wellbeing
  • Protection from triggering an MI from vigorous activity >6 METS

For a healthy, young or middle-aged person, walking at a ‘normal’ to ‘brisk’ walking pace is enough to reduce the risk of cardiovascular disease and to improve risk factors for cardiovascular diseaseii.

Walking more than four hours per week reduces the risk of hospitalisation for cardiovascular disease by 30% compared to walking less than one hour per week[xvii]. The incidence of CHD is halved by walking over 1.5 miles a day in men compared to men who walked less distance per day[xviii]. Women who walked for exercise for about hours per week enjoyed a 35% reduction in their risk of CHD events compared to women who walked infrequently[xix].

Brisk walking of more than 3.5 hours a week may slow an atheroma, and walking five hours a week may slowly reverse its formation[xx].

Regular brisk risk walking reduces diastolic blood pressure but appears to have no effect on systolic blood pressureii.

Brisk walking for 8-15 miles per week for 6-9 months can increase good cholesterol levels (HDL) and reduce triglyceride levels in the blood[xxi]. Regular stair climbing has been reported to cause increases in HDL cholesterol, and a reduced ratio of total cholesterol to HDL cholesterol[xxii].

Heart Failure

  • There are about 900,000 people with heart failure in the UK, with a steep increase in age from 1% in those under 65 to 15% of those over 85[xxiii].
  • The total cost of treating heart failure in the NHS is £628.6 million, with the 86,000 hospital admissions accounting for over 60% of these costs[xxiv].
  • There are over 7.6 million GP consultations every year for heart failure, costing £103 million[xxv].

Most of the symptoms of heart failure are due to poor perfusion in the peripheral muscles secondary to limited cardiac output. Exercise limitation is usually from leg weakness due to lactate accumulation, leading to shortness of breath because of resulting acidosis. Regular walking therefore improves the peripheral muscle metabolism more than it affects the cardiac output. Regular walking as part of a rehabilitation programme significantly enhances quality of life, helps to retain independence and reduces hospital admissions.

Stroke

  • There are 68,400 strokes each year in the UK, causing 55,000 deaths and costing the NHS £1.36 billion.
  • Patients who have had a stroke are usually highly de-conditioned, with half the average VO2 maximum.

After a stroke regular walking can increase self-selected walking speed, reduce dependence on external aids (so maintaining independence), and reduce fatigue.

One study reported a decreased risk for stroke across increasing categories of walking pace in women[xxvi].

Most patients who have had a stroke will be encouraged to walk through their physiotherapy-led rehabilitation. There appears to be less structured walking programme for stroke patients. NICE will publish guidelines on stroke rehabilitation in 2009

Diabetes

  • There are 2.2 million people with diabetes in England (4.48% of the population) [xxvii]
  • This will increase to 3.6 million by 2025 (64% increase)
  • Half this increase is from the rise in obesity.

The effects of walking on diabetes include:

  • Improvement in blood sugar control
  • Improved insulin sensitivity
  • Reduction in body fat
  • Cardiovascular protection
  • Stress reduction (Stress can disrupt diabetes control by increasing counter-regulatory hormones, ketones and free fatty acids)
  • Prevention of diabetes in those at high risk[xxviii].

Walking and cycling levels are also associated with reduced risk of type 2 diabetes: those who walk or cycle more are less likely to get type 2 diabetes[xxix]. Walking and other changes can be a better option for helping to manage diabetes in some patients than drugs. The lifestyle changes in diet and increases in daily walking were found to be more effective in reducing the incidence of type 2 diabetes than treatment with the drug metformin (58% versus 31% reduction in risk)[xxx].

Chronic Obstructive Pulmonary Disease (COPD)

  • 900,000 people have a diagnosis of COPD, with half as many again living with COPD without a diagnosis.[xxxi]
  • There are 109,000 COPD admissions, contributing to one million bed days costing the NHS £600 million, with a total cost to the NHS of about £1 billion.
  • COPD causes 24 million lost working days per year.

COPD patients who undertake more walking halve their risk of being admitted as an emergency admission.[xxxii] NICE guidance requires that all COPD patients who can walk attend Pulmonary Rehabilitation (PR). Patients in PR are recommended to walk regularly but there are only isolated schemes that link with organised walking groups. Regular exercise in groups reduces breathlessness and anxiety and increases confidence and independence.

Depression and Anxiety

  • Every day, 25,000 people see their GP with a psychological problem.
  • 7% of the population suffer from Depression and Anxiety at any one time.
  • In 2005, 27.7 million antidepressant prescriptions were written in England, costing £338 million.
  • The cost of depression in lost economic output is £12 billion a year[xxxiii].
  • There is doubt whether most anti depressants are any better than Placebo.[xxxiv]

The Chief Medical Officer states that ‘Physical activity is effective in the treatment of clinical depression and can be as successful as psychotherapy or medication’ii.

NICE recommends that patients with mild depression follow a structured and supervised exercise programme of up to three sessions per week of moderate duration (45 minutes to one hour) for between 10 and 12 weeks. Walking might contribute to this type of regime[xxxv].

Walking can improve self-esteem, relieve symptoms of depression and anxiety, and improve mood[xxxvi]. There is an inverse relationship between daily walking and the reporting of depressive symptoms[xxxvii]. Shorter bouts (10-15 minutes) of brisk walking can induce significant positive changes in mood.

Osteoarthritis

  • Osteoarthritis of the knee and hip is the single most important cause of disability in retirement years, affecting up to 25% of those over 65.
  • The annual cost of treatment to the NHS is £675 million.
  • There are 36 million days lost due to osteoarthritis, costing the economy £3.2 billion in lost earnings.

Regular walking to build up the quadriceps muscles and help reduce weight is the cornerstone of both preventing and reducing symptoms of osteoarthritis of the hip and knee. Three 40-minute walks a week may help to halt the progression of knee osteoarthritis[xxxviii]. Regular walking and other moderate physical activities may be associated with a lower risk of subsequent osteoarthritis, especially among women.[xxxix]

Ironically, most GPs we spoke to said that the most frequent reason why overweight patients with osteoarthritis of the knee could not walk more was because of pain.

Obesity

  • 24% of the population is obese and by 2050 60% of males and 50% of females will be obese.
  • In men, 18% of social class I and 28% in social class V are obese.
  • In women 10% of social class I and 25% in social class V are obese.
  • The current NHS cost is £1 billion with a projection of £6.5 billion in 2050.
  • The wider cost of obesity is £7 billion, rising to £45.5 billion in 2050.

Obesity is associated with diabetes, hypertension, asthma, osteoarthritis, depression and hyperlipidaemia. All of these are independently improved by regular walking.

Walking uses up about 100kCal per mile regardless of pace. Abdominal weight gain has been reported to be less than peripheral gain for women who walked >4 hours a week than women who walk less than 2 hours.

Below two hours a week walking there appears to be no weight loss.

Walking one hour a day for five days a week at 50-70% VO2 max can promote regional fat loss in the abdominal sites[xl]. This is critical in reducing the risk of diabetes and coronary heart disease. Overall weight may change little as lean body mass increases with exercise. Brisk walking reduces BMI and body weight,and also reduces body compositionii.

Any walking will help children and young adults to maintain energy balance[xli]. Any consistent movement of body weight by regular walking or stair-climbing will contribute to energy expenditure and may help with weight management.

Obesity is the single most common reason for GPs to refer patients for walking schemes and exercise referral schemes.

Walking and Cancer

Fewer studies have examined this relationship compared to other diseases, and the majority has only looked at physical activity rather than walking alone. However there is evidence that physical inactivity is associated with increased risk of colonic, breast (postmenopausal) and endometrium cancer. A faster reported walking pace was associated with a reduced risk of colorectal cancer in men compared to men with a slower walking pace than others[xlii].

6. Walking and children’s health

The Chief Medical Officer has pointed out that there is a strong justification for encouraging young people to be physically active. Physical activity provides an important vehicle for play and recreation, learning physical and social skills,

developing creative intelligence and stimulating growth and fitness.

However, there is relatively little direct evidence (compared with adults) linking physical inactivity in children with childhood health outcomes. The chronic diseases described above require long incubation periods, and children and adolescents very rarely have lifestyle-related diseases such as hypertension, diabetes, osteoporosis or cardiovascular disease.

Promotion of physical activity and walking in childhood does have strong justification however. It:

  • Promotes healthy growth and development of the musculoskeletal and cardio-respiratory systems
  • Helps maintain energy balance and hence healthy weight
  • Lowers risk of hypertension and high cholesterol
  • Generates opportunities for social interaction, achievement and mental well-being.

Walking is an excellent activity for all of these benefits. In addition, it may be that walking patterns track better into adulthood than do sport and leisure pursuits.

7. Economic value of walking

There is currently no economic evaluation of walking.

WHO has recently published guidance on including health effects in economic appraisals of transport interventions[xliii]. This was designed primarily to help transport economists estimate the mortality (and therefore economic) benefits of interventions that increased walking and cycling (such as new footpaths, policies or programmes). The rationale for this work is that 35% of all energy demand is from transport and 80% of this is in road transport. The transport sector is projected to be responsible for 90% of the increase in CO2 emissions until 2010.

The WHO guidance covered walking and cycling but the subsequent Excel model focused only on cycling. WHO is now proposing to extend this model to include walking to provide a practical tool that can be used at local, national and international level to make the case for walking.

This represents an opportunity to strengthen the approach taken to provide an economic appraisal and provide a strong, evidence-based arguments to advocate walking to key policy-makers.

[i] Hardman AE, Morris JN. Walking to health. British Journal of Sports Medicine 1998 Jun;32(2):184

[ii] Department of Health (2004). At least five a week: a report from the Chief Medical Officer. London, Department of Health.

[iii] Murphy MH, Nevill AM, Murtagh EM, Holder RL. The effect of walking on fitness, fatness and resting blood pressure: a meta-analysis of randomized, controlled trials. Preventive Medicine 2007; 44:377-385.

[iv] M Murphy and A E Hardman 1998, ‘Training effects of short and long bouts of brisk walking in sedentary women’ in Medicine and Science in Sports and Exercise 30:1:152-7

[v] Killoran AJ, Fentem P, Caspersen C. Moving on: an international perspectives on promoting physical activity. London: Health Education Authority, 1994.

[vi] Sports Council, Health Education Authority, 1992. Allied Dunbar national fitness survey. Health Education Authority, London.

[vii] American College of Sports Medicine. Exercise and Physical Activity for Older Adults. Medicine & Science in Sports & Exercise 1998. http://www.acsm.org/Content/NavigationMenu/Research/Roundtables_Specialty_Conf/PastRoundtables/Exercise_for_Older_Adults.htm

[viii] Sandolin J, Santavirta, Lattila R, Vuolle P, Sarna S. Sport injuries in a large urban population: Occurrence and epidemiological aspects. International Journal of Sports Medicine 1988; 9:61-66.

[ix] Lee IM, Skerrett PJ. Physical activity and all cause mortality: what is the dose-response relation? Medicine and Science in Sports and Exercise 2001; 33: S459-S471; discussion S493-S494.

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[xi] Gardner AW, Poehlman ET. Exercise rehabilitation programs for the treatment of claudication pain. A meta-analysis. Journal of the American Medical Association 1995; 274: 975-980.

[xii] Our Health, Our Care, Our Say (2006) Department of Health

[xiii] Allender S, Peto V, Scarborough P,  Kaur A, Rayner M. Coronary heart disease statistics 2008. London: British Heart Foundation, 2008.

[xiv]Allender S, Foster C, Scarborough P, Rayner M. The burden of physical activity related ill health in the UK. Journal of Epidemiology and Community Health 2007; 61:344-348.

[xv] Tackling Obesities: Future Choices – Modelling Future trends in obesity & their impact on Health. A Foresight report for Government Office for Science.

[xvi] ACSM’s Exercise management for persons with chronic diseases and disabilities. Durstine JL Moore GE 2002.

[xvii] LaCroix AZ, Leveille SG, hecht JA, Grothaus LC, Wagner EH. Does walking decrease the risk of cardiovascular disease hospitalizations and death in older adults? Journal of American Geriatric Society 1996; 44: 113-120.

[xviii] Hakim AA, Curb JD, Petrovitch H, Rodriguez BL, Yano K, Ross GW, White LR, Abbott RD. Effects of walking on cornary heart disease in elderly men: The Honolulu Hart Program. Circulation 1999;100:9-13.

[xix] Manson JE, Hu FB, Rich-Edwards JW, Colditz GA, Stampfer MJ, Willet WC, Speizer FE, Hennekens CH. A prospective study of walking as compared with vigorous exercise in the prevention of coronary heart disease in women. New England Journal of Medicine 1999; 341:650-658.

[xx] Hambrecht R, Niebauer J, Marburger C, Grunze M, Kalberer B, Hauer K, Schlierf G, Kubler W, Schuler G. (1993) Various intensities of leisure time physical activity in patients with coronary artery disease: effects on cardiorespiratory fitness and progression of coronary atherosclerotic lesions. J Am Coll Cardiol; 22 (2):478-9.

[xxi] Dishman RK, Washburn RA, Heath GW. Physical activity epidemiology. Champaign, Human Kinetics 2004.

[xxii] Boreham CA, Wallace WF, Nevill A. Training effects of accumulated daily stair-climbing exercise in previously sedentary young women. Preventive Medicine 2000; 30: 277- 281.

[xxiii] Ellis C, Gnani S and Majeed A (2001) Prevalence and management of heart failure in general Practice in England and Wales 1994-1998. Health Statistics Quarterly 11: 17-24.

[xxiv] DH (2002) Hospital Episode Statistics 2000-2001

[xxv] Gnani S et al (2001) Health Statistics Quarterly; Netten et al (1999) PSSRU, University of Kent.

[xxvi] Hu FB, Stampfer MJ, Colditz GA, Ascherio A, Rexrode KM, Willett WC, et al. Physical activity and risk of stroke in women. Journal of the American Medical Association 2000; 283: 2961-2967.

[xxvii] Yorkshire and Humber PHO. Diabetes – key facts, Yorkshire and Humber PHO, 2005.

[xxviii] ACSM’s Exercise Management for persons with Chronic Diseases and disabilities. Human Kinetics 2002.

[xxix] Hu FB, Sigal RJ, Rich-Edwards JW, Colditz GA, Solomon CG, Willett WC, et al. Walking compared with vigorous physical activity and risk of type 2 diabetes in women. Journal of the American Medical Association 1999; 282: 1433-1439.

[xxx] Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention of metformin. New England Journal of Medicine 2002; 346: 393- 403.

[xxxi] NICE Guidelines on COPD management. Thorax 2004;59(suppl 1); 1-232.

[xxxii] Garcia-Aymerich J, Farrer E, et al Risk factors of readmission to hospital for a COPD exacerbation: A Prospective Study. Thorax 2003;58:100-105.

[xxxiii] LSE The Depression Report The Centre for Economic Performance’s Mental Health Policy Group June 2006

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[xxxv] NICE. Depression, NICE Guideline, Second Consultation. London: NHS, 2003, p19, 21.

[xxxvi] See MIND at http://www.mind.org.uk/Information/Booklets/Mind+guide+to/Mindguidetophysicalactivity.htm

[xxxvii] Mobily, K. E., L. M. Rubenstein, J. H. Lemke, M. W. O’Hara, and R. B. WALLACE. Walking and depression in a cohort of older adults: the Iowa 65+ rural health study. J. Aging Physiol. Activ. 4:119-135, 1996

[xxxviii] Ettinger Jr WH, Burns R, Messier SP, Applegate W, Rejeski WJ, Morgan T, et al. A randomized trial comparing aerobic exercise and resistance exercise with a health education program in older adults with knee osteoarthritis. The Fitness Arthritis and Seniors Trial (FAST). Journal of the American Medical Association 1997; 277: 25-31.

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[xl] ACSM Exercise Management for persons with chronic diseases and disabilities Ch 23

[xli] The Health of Children and Young People 2003. Chapter 4: Physical Activity

[xlii] Davey Smith G, Shipley M, Batty G et al. Physical activity and cause-specific mortality in the Whitehall study. Public Health 2000;114:308-315.

[xliii] Cavill N, Kahlmeier S, Rutter H, Racioppi F, Oja P. (2008) Economic assessment of Transport Infrastructure and Policies: Methodological guidance on the economic appraisal of Health effects related to Walking and cycling. Rome. World health organization. Http://www.euro.who.int/transport/policy/20070503_1

About Ageing

There are only two phases of life, the phase of growth and development and the phase of ageing and functional decline which is at present untreatable but there is great interest, and considerable investment, in the search for what would have been called an Elixir of Life but is now called Regenerative Medicine

It is important to appreciate just how serious people are about this mission. The key term is Regenerative Medicine and particularly in the USA where big powerful research centres, like the SENS Research Foundation in Mountain View, California, based on their belief that ‘ a world free of age-related disease is possible’ and new companies. The Financial Times (FT) on its front page on the 5th of September 2014 that Arthur Levinson, who developed Genentech, the company that was the first to use the knowledge locked in the human genome to create new  drugs, had resigned from the board of Roche, which had bought Genentech. The reason was to devote himself to this mission. The ‘ 64 year old’, as the FT pointed out, who is also chairman of Apple, will head the mission started by Google, also based in Mountain View to extend healthy life. The new company he will lead is called Calico, short for California Life Company, not only has the firepower of Google behind it but  will also benefit from a huge investment from another drug giant called Abbvie