Health | State of Ageing in 2020

And, while many people do enjoy good health well into their old age, there are stark inequalities.

The state of the nation’s health has been brought into sharp focus by the coronavirus pandemic: over 90% of deaths from COVID-19 have been in people with at least one pre-existing health condition, most commonly diabetes, chronic lung disease, chronic kidney disease and cardiovascular disease. Excess weight is also associated with an increased risk of a positive test, hospitalisation, higher levels of treatment and death as a result of COVID-19, leading the UK government to announce a raft of measures to reduce obesity.

Those conditions associated with serious outcomes in people with COVID-19 are among the typical age-related conditions that develop slowly – often from mid-life onwards – and that have no cure. Moreover, many people have several of these chronic conditions simultaneously. They impair people’s ability to carry out normal day-to-day activities (for example, due to problems with mobility, dexterity, sight, hearing and physical coordination) and have a significant impact on quality of life.

These issues are not inevitable. There is much we can do, as individuals and as a society, to minimise the burden of ill health that compromises the quality of our later lives and that has put many of us in particular danger from COVID-19.

• Overall life expectancy is increasing – albeit more slowly than in the recent past. But disability-free life expectancy among women is falling.
• The wealthiest people have almost twice as many years of disability-free life ahead of them at age 65 as the poorest.
• One in four people aged 55-64 are physically inactive, meaning they do less than 30 minutes of physical activity a week. This proportion increases with age and is higher among people living in the most deprived neighbourhoods.
• Overall, rates of smoking are falling. But the proportion of adults drinking at higher or increased risk of harm peaks among people in their 50s and 60s.
• The proportion of people with a weight status that classes them as overweight or obese has increased over time in every age group over 45.

Stalling improvements to life expectancy is not unique to the UK – although the UK’s slowdown has been more pronounced than in other European countries. There has been much debate about the causes: contributing factors include slowing improvement in mortality rates for stroke and cardiovascular disease, and some bad flu seasons. Austerity has also been widely cited as a factor. Direct causals link are not clear – and this pattern is not visible across Europe – although there is a correlation in the UK between mounting pressure on public services and the slowdown in improvements. Inequalities are clearly key: the poorest have seen the rate of increase in life expectancy slow most dramatically and life expectancy has actually dropped for the poorest women.

This expansion of years spent with illness and conditions that impair our ability to carry out day-to-day tasks is deeply troubling. And with reported delays in diagnosis and treatment of many health conditions as a result of the pandemic, there is a risk of a further reduction in disability-free life expectancy over the coming years. The government’s commitment to action on obesity is a welcome step to improve our health but we need comprehensive and radical action across a whole range of areas, to halt the trend in disability-free life expectancy and reverse it.  

The least wealthy people in society can expect not only to live a shorter life but also to spend more of that shorter life with a limiting long-term illness than wealthier people.

This is caused by the accumulation of all the circumstances of our lives. Poverty and financial insecurity, employment, our homes and the places we live, all affect physical and mental health directly, and affect behaviours like being physically active, smoking, having a poor diet and drinking too much.

With a greater burden of ill health in the poorest in society, it is the poorest who will suffer most from the delays in diagnosis and treatment of health conditions that have resulted from the pandemic. Hence, the coming years may bring not only a further reduction in disability-free life expectancy overall, but a larger gap between the richest and poorest.

A number of factors have been identified as accounting for the observed differences in the health of people living in different parts of the country. These include environmental factors (including working conditions), educational and lifestyle factors and infrastructure challenges (many villages and small towns lack frequent and reliable public transport and high-speed internet). The impact of de-industrialisation has also been mooted as a factor: one study has shown that areas in the North that have experienced a strong transition away from employment in physically demanding occupations have particularly low levels of physical activity. All, however, are ultimately linked to other socioeconomic factors including levels of wealth: poorer places are simply less healthy.

Regardless of the cause, the data demonstrates the importance of local approaches to health prevention that address the specific issues faced by people in a local area.

The data demonstrates that age is a risk factor for developing conditions of the musculoskeletal system. For women, in particular, mid-life is a critical period for safeguarding musculoskeletal health through early action to address lifestyle factors. Menopause – which has a detrimental effect on bone, cartilage and muscle mass – causes the higher prevalence seen in women than in men. However, the risk is further exacerbated by health behaviours, notably smoking and alcohol consumption, both of which can weaken bones.

Although genetics, and – for women - events such as menopause, play a part in the advent of many of the chronic conditions that people in all wealth groups experience from midlife onwards, a host of modifiable risk factors – notably, smoking, diet, alcohol consumption and physical activity –  are extremely important. The role of these external risk factors on the development of health conditions has led the World Health Organisation to state that, ‘the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented’.

Physical activity can help to prevent and delay many diseases and conditions that affect us as we age. We know, for example, that inactive people are at increased risk of developing a painful musculoskeletal condition and that excess weight increases the risk of back pain or of developing osteoarthritis and other musculoskeletal conditions. We also know that regular physical activity reduces the risk of hip and knee osteoarthritis pain by 6%; of depression by up to 30%; and of falls by 76%.

Physical activity also helps us maintain functional ability, independence and quality of life as we grow older. But the time and ability we have to be physically active is not equally distributed across the population.

There are a host of factors that impact a person’s ability to be physically active: these include poor body image, lack of confidence, being uncomfortable in gym environments, and not knowing other people who exercise.

Older adults most often report poor health as their primary barrier, although they also mention fear of falling or injury, symptoms of depression and lack of time. Crime and fear of crime, area degradation, lack of green infrastructure, noise and air pollution, cluttered pavements and non-inclusive design are also barriers that prevent people from being more physically active. Many of these factors may be of greater relevance for people of minority ethnic backgrounds because they are more likely to be living in disadvantaged areas, partially explaining their lower participation in physical activity.

Obesity is a major risk factor for many conditions which contribute to disability in later life: type 2 diabetes, coronary heart disease, stroke and some types of cancer, such as breast and bowel cancer, as well as associated mental health problems. Obesity has also been identified as a significant risk factor for more severe forms of COVID-19, making the obesity public health crisis even more urgent.

The poorest people, with the greatest burden of health challenges, are also being exposed to those environments most likely to cause obesity: there is a clear correlation between the availability of fast food outlets and increasing level of area deprivation. The government’s plan to ban junk food ads before the 9pm watershed is laudable, but its impact will be limited if we are surrounded by junk food outlets wherever we go in our neighbourhoods. A recent article by a number of prominent academics said that targeting individuals with weight loss programmes without changing the environments in which they take place, was like ‘treating people for cholera then sending them back to communities supplied with contaminated water’. We need to ensure that we live in places that enable us to live healthy lives.

Some smokers say cigarettes help them to relax, so it may be that there are higher rates of smoking among people with less money, as it helps to cope with stress caused by factors such as debt or poor housing conditions. In addition, people from lower socioeconomic groups who smoke are less likely to succeed in their attempts to stop smoking, even although, on average, all people who smoke make similar numbers of attempts to stop each year. This is because they face additional barriers, including stress related to material hardship that has contributed to their smoking habits in the first place, as well as the higher rates of smoking among others in their immediate circles. These socioeconomic patterns in smoking may intersect with the patterns by race.

Of course, the financial cost of a smoking habit only exacerbates hardship: analysis of UK government data carried out for Action on Smoking and Health suggested that quitting smoking would lift more than 447,000 households out of poverty.

Harmful alcohol use peaks in the 50s and 60s. In the ten years from 2008-2009 to 2018-2019, alcohol treatment services saw an overall 3% drop in adults being newly treated for alcohol misuse. However, among adults age 50-64, there was actually a 45% increase in people newly receiving alcohol treatment. For people aged 65 and over, the increase was even more dramatic – numbers nearly doubled for this age group.

The wealthiest are the most likely to be regular drinkers. However, regular drinking is not the same as unsafe or binge drinking: among all people aged 16 and over, more than a quarter (26%) of those in the two least deprived quintiles are at increased risk due to their alcohol consumption compared with 14% in the two most deprived quintiles. Thus, in what has been termed the alcohol harm paradox, ‘the burden of alcohol harm falls more heavily on individuals from lower socioeconomic backgrounds’.

While some health behaviour trends look slightly positive – such as declines in rates of smoking – the broader outlook for our ability to age in good health and free of disability is not good. If trends in disability-free life expectancy continue to worsen, future generations will age with many more years in poor health than those before them. Action on healthy ageing means action on poverty, social exclusion and health inequalities.

¹ Disability-free life expectancy (DFLE) estimates years of life free from any persistent condition that reduces your ability to carry out your usual day-to-day activities. These conditions could include arthritis, hearing or vision impairment or mental health issues.

² Office for National Statistics analysis of Annual Population Survey data 2019. Created on 17/8/2020 by Office for National Statistics.