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The Evening Public Lecture
Article Type: The Evening Public Lecture From: Quality in Ageing and Older Adults, Volume 13, Issue 3
Healthy behaviours and prophylactic drugs in promoting healthy and active ageing
Enormous efforts are made in many countries to promote what have become known as the five healthy behaviours (non-smoking, a “healthy” diet, a low BMI, regular physical activity and drinking alcohol within recommended limits). Many surveys have collected data on the uptake of these behaviours, and occasional trials have assessed the effects of various strategies on their uptake within a community. Very few studies, however, have estimated the value of a healthy lifestyle in terms of reductions in disease or an increase in wellbeing. The 30-year Caerphilly cohort study in Wales gives opportunity for just such an evaluation.
The good news is that a healthy lifestyle, based on the adoption of four or five of the healthy behaviours, is highly effective and lead to a reduction of up to around one half in the incidence of diabetes, vascular disease and death from any cause. For diabetes, a low BMI (under 25 is usually advised) is associated with around a 60 per cent reduction in the development of type 2 diabetes. Apart from non-smoking, however, the healthy behaviours appear to be associated with much less benefit in cancer and, in the Caerphilly cohort, the reductions, other than from non-smoking, were not significant.
The bad news is that the degree of uptake of a healthy life style is deplorable. While around 8 per cent follow four of the healthy behaviours, only 1 per cent of people appear to follow a truly “healthy lifestyle” based on all five of the healthy behaviours. This is less than the uptake reported from several studies in the USA, in which 3-4 per cent of people reported that they followed all five behaviours – but even these uptakes of only a few people in every hundred are discouraging. The “prevention paradox” as formulated by the epidemiologist Geoffrey Rose helps in the understanding of the situation: “A preventive measure which brings much benefit to the population will offer little to each participating individual” (Rose, 1981). That is: the adoption of healthy lifestyles throughout a community will lead to large overall reductions in the population rates of disease and deaths, but the benefit to each individual will be small and relates to a possible event in the future – an event that may not actually occur – and all for a large and continuing effort to follow a somewhat demanding lifestyle.
At present only a few drugs have been adequately evaluated in the prevention of disease and the preservation of health. Aspirin is one, statins another and some weight-losing drugs can be considered to be prophylactic. It is almost inevitable, however, that many more prophylactic drugs will be developed for use in healthy people – after all, the market for such drugs is almost unlimited. Unfortunately, every drug has undesirable side effects and aspirin and statins are no exception. Even at low dose, aspirin increases the risk of bleeding and the risk-benefit balance in people with no evidence of vascular disease is debatable. Recent evidence of a substantial reduction in cancer is, however, relevant to an overall evaluation of aspirin in the preservation of health and survival. Doubts also arise in relation to prophylaxis by statins. While necrosis of muscle is a very rare complication, muscle pain and weakness are not uncommon with statin use and the possibility of an increased risk of diabetes in subjects taking high doses has also been raised. Nevertheless, already in the UK, around 30 per cent of people aged over 50 take aspirin daily and about a third of people aged over 40 take a statin regularly.
A less obvious, but most important effect of disease prevention by drugs is, however, that while the man in the street has a responsibility to do all he can to preserve his own health, the simple expedient of “a tablet a day” may be accepted by many as an easy alternate to a healthy lifestyle. It is most important therefore that discussions are widely – and urgently – promoted on how prophylactic drugs can best be handled within public health and within clinical practice – and within the context of the full range of healthy behaviours.
No effort should be spared to preach, teach and “nudge” people into a more healthy lifestyle. The persuasive power in attempting to achieve this would undoubtedly be enhanced if hard evidence of benefit, in terms of the actual reductions of disease and death that can be achieved by a truly healthy lifestyle, were more widely understood and publicised.
Peter ElwoodCardiff University School of Medicine, UK.
Rose, G. (1981), “Strategy of prevention: lessons from cardiovascular disease”, British Medical Journal, Vol. 282, pp. 1847–51