Louise Lafortune, Sarah Kelly, Steven Martin, Isla Kuhn, Andy Cowan, Carol Brayne
Despite a wealth of evidence on the association between low physical activity, smoking, alcohol consumption, diet, and ill health in later life, an alarming proportion of the adult population continues to engage in these unhealthy behaviours. Embedded in a wider social, economic, and organisational context, these four behavioural risk factors contribute to close to half of the burden of illness in developed countries (WHO 2002). We know that these risks, which often co-occur or cluster, are unequally distributed in the population, and that the processes leading to ill health start in midlife (Newman et al. 2011; Singh-Manoux et al. 2011; Wills et al. 2011). A comprehensive public health strategy aimed at preventing chronic diseases, frailty, disability, and dementia would thus support a range of interventions across the life cycle to increase the uptake and maintenance of healthy behaviours. Along those lines, most public health guidelines provide general and specific recommendations to promote healthy behaviours in children, adults, and to some extent older people. However, very few recommendations exist to date for adults in midlife. Finding effective ways to change people’s behaviours is a challenging task without a good understanding as to why people engage in unhealthy behaviours, or do not undertake unhealthy ones. This segment of the population is highly heterogeneous and individuals that make up this segment are likely to share some of the same issues and challenges when it comes to changing or maintaining behaviours. To effectively “reach” that population and have it engage in health promotion initiatives, interventions need to be tailored to – or at least consider – their specific needs and circumstances. Also, a key theme that emerges from the evidence looking at population’s health from a life course perspective is that long-term chronic conditions, age related disability, and to some extent frailty and dementia are highly heterogeneous and the potential for inequalities in health outcomes is considerable, compounding those arising from poverty, social and environmental factors. For instance, over the past 5 years, the greatest reduction in the number of people displaying 4 behavioural risk factors (consumption of alcohol, smoking, lack of physical activity and poor diet) has been among those in higher socioeconomic and more highly educated groups (Buck 2012). To address this issue, a good understanding of cultural, ethnic, and geographic differences (in how people view and interpret health risks and health behaviours) is necessary to understand the breadth of barriers and facilitators which may be present in these communities; and how much they can vary within and between them. In that context, the Department of Health (DH) has asked National Institute for Health and Care Excellence (NICE) to produce public health guidance on preventive approaches to be adopted in mid-life to delay the onset of disability, dementia and frailty in later life (NICE Guidance consultation). Three evidence reviews and an economic model underpin the guidance. Researchers working in the Dementia, Frailty and End of Life theme of CLAHRC EoE were asked to work with NICE to develop the evidence reviews.
The overarching research question for the suite of reviews is which primary prevention approaches to be adopted in mid-life are most effective and cost-effective to prevent and delay the onset of disability, dementia, frailty, and other non-communicable chronic conditions in later-life. A core aim of this suit of evidence reviews is to identify prevention approaches that are tailored to midlife populations, highlighting those that have the greatest potential to maintain well-being in later life and avoid or reduce health inequalities. The specific questions addressed by the reviews are as follows:
- Review 1 – What are the key issues for people in midlife that prevent or limit, or which help or motivate them to take up and maintain healthy behaviours, and to what extent do they have an effect? How does this differ for subpopulations, for example by ethnicity, socioeconomic status or gender?
- Review 2: What behavioural risk factors in midlife are associated with successful ageing and the primary prevention or delay of disability, dementia, frailty, and non-communicable chronic conditions? How strong are the associations and how does this vary for different subpopulations?
- Review 3: What are the most effective and cost-effective midlife interventions for increasing the uptake and maintenance of healthy behaviours? To what extent do the different health behaviours prevent or delay disability and frailty related to modifiable behavioural risk factors? To what extent do the different health behaviours prevent or delay dementia? To what extent do the different health behaviours prevent or delay non-communicable chronic conditions?
The scope and specific inclusion criteria vary considerably across the three reviews. However, a number of methodological aspects are common to all three reviews. The population covered by the reviews includes adults aged 40 to 64 years and adults aged 39 and younger from disadvantaged populations. The review does not cover people with and treated for pre-existing conditions (i.e. dementia, frailty, disability, non-communicable chronic conditions) nor does it cover the treatment (i.e. drugs, dietary supplements), diagnostic and care and management of these conditions. We conducted a thorough search of the scientific and grey literature to identify systematic reviews and primary qualitative and quantitative studies published in English since 2000 that reported data pertaining to each questions. The title and abstract of identified references were screened independently by two reviewers. Primary studies that met the inclusion criteria (as described above) were assessed for quality using available tools from NICE (CPH methods manual). For systematic reviews the AMSTAR tool was used to assess quality by one reviewer and data was extracted using piloted data extraction tools. A minimum of 10% of the included studies were fully double assessed for quality. Quality assessment was conducted for all studies included in this review. No studies were excluded on the basis of quality. For review 2, we synthesised the qualitative data thematically where themes emerged and descriptively otherwise. For review 2, quantitative evidence from cohort studies is synthesised descriptively by behavioural risk, for a range of late life outcomes (review 2); for review 3, quantitative evidence from primary studies and systematic reviews is synthesised thematically (e.g. by behavioural risk factors, subpopulations) where themes emerged and descriptively otherwise. The data was not amenable for meta-analysis. Data specific to health inequalities and vulnerable communities was extracted and findings are summarised separately where data is available. Studies conducted in the UK were prioritised in the synthesis of data and in the applicability statements. For each key issue or factor of interest an evidence statement was generated which provides an aggregated summary of all of the relevant studies. Applicability ratings (i.e. directly applicable, partially applicable or not applicable) are proposed for each evidence statement to judge how similar the population(s), setting(s), intervention(s) and outcome(s) of the included studies are to those outlined in the review question.
Findings for individual reviews are very complex and will be presented in a review specific summary shortly. Until then, the complete reports are available at the link below (i.e. link to NICE guidance consultation).
The reviews serve as supporting documentation to the draft NICE PH guideline on mid-life approaches to prevent or delay the onset of disability, dementia and frailty in later life, which is out for public consultation until 5th September (NICE Guidance consultation). The research team is now busy writing the peer-review publications and research summaries for public health practitioners and other stakeholders working towards improving the health of older people. It is hoped that the combined outputs will provide an evidence base that addresses key areas of concern for government and society – how to optimise health and well-being in later life; how to tackle at a population level increasing health and social care demand; and how to change policy and practice through better use of research.
For more information, please contact Dr Louise Lafortune at firstname.lastname@example.org.
References and publications:
- Kelly S, Martin S, Kuhn I, Cowan A, BrayneC, Lafortune L. Barriers and Facilitators to the Uptake and Maintenance of Healthy Behaviours by
People at Mid-Life: A Rapid Systematic Review. PLoS ONE. 2016; 11(1):e0145074. doi:10.1371/journal.pone.0145074 download a pdf
- Lafortune L, Martin S, Kelly S, Kuhn I, Remes O, Cowan A, et al. Behavioural Risk Factors in Mid-Life Associated with Successful Ageing, Disability, Dementia and Frailty in Later Life: A Rapid Systematic Review. PLoS ONE. 2016; 11(2): e0144405. doi:10.1371/journal.pone.0144405 download a pdf
- NICE guidance: https://www.nice.org.uk/guidance/ng16