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Ageing: Science, Technology and Healthy Living Contents

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Chapter 4: Lifestyle and environmental influences on healthy ageing

203.Lifestyle and environmental factors affect physical, cognitive and mental health as humans age. The main risk factors (and protective factors) for age-related diseases are well-known and form the basis of public health advice about healthy lifestyles—for example the importance of a nutritious diet. Evidence for these links comes partly from longitudinal cohort studies that show correlations between risk factors and health at a population level. For example, there is a correlation between clustering of risk factors and poor health affecting people living in areas of high deprivation, in particular people from ethnic minorities.346 There is also some evidence from biomedical studies, although these are largely carried out in animal models with few long-term intervention studies in humans. Understanding of the links between lifestyle and environmental factors and health has increased significantly in recent years. However, we heard that research has focused mainly on how these factors affect the risk of age-related diseases, and more work is required to understand links to the underlying biological processes of ageing.

Sources of evidence

204.Cohort studies are the main source of information on which factors influence health during life, including in old age. Cohort studies monitor groups (cohorts) of people over a period of years in order to determine correlations between risk factors and health outcomes. For example, birth cohort studies—such as the 1946 National Birth Cohort—follow groups of people who were born in the same year and monitor their lifestyle and health throughout their lives.

205.The UK has a wide range of cohort studies, that are valued highly by the research community.347 As well as results from each study, further findings can be obtained by combining information from different studies, and some comparisons can be made with studies from other countries.348

206.We heard that cohort studies need long-term funding in order to gather meaningful data. However, we were told that long-term funding is not available and that researchers have to apply for new funding periodically. Professor Nazroo explained: “we have to bid for renewal every four years—so for every two waves of data collection. Obviously, if we fail, the study ends.”349

207.In addition to cohort studies, we heard there is a need for more intervention studies, which test whether relationships between lifestyle factors and health are causal, rather than just correlative. The Academy of Medical Sciences told us: “There is an urgent need for more studies using objective measures, particularly of sleep and physical activity.”350 The UK Biobank is likely to be a valuable resource for such studies; it gathers health data and biological samples, which are useful for studies of mechanisms that underpin links seen in cohort studies.351

208.As discussed in Chapter 3, research into ageing as a process, rather than individual age-related diseases, faces challenges because it does not fit neatly into established frameworks for medical research and clinical trials. Some witnesses suggested that part of the solution could be to use changes to the hallmarks of ageing as biomarkers in studies of lifestyle and environmental influences. They gave examples, noting that these are comparatively new areas of study that require more research: epigenetic changes caused by smoking;352 telomere shortening and senescence caused by stress;353 and inflammation caused by physical inactivity, stress, and aspects of diet, nutrition and the microbiome.354

Influences on health outcomes

Lifestyle and behavioural factors

209.We heard that the most significant risk factors affecting health outcomes in middle and older age are smoking, poor nutrition, obesity, insufficient physical activity and excessive alcohol consumption.355 These risk factors (with the exception of smoking) have become more prevalent over recent decades,356 which is associated with worsening health outcomes in the general population.357

210.There is consensus from cohort study data that lifestyle factors are strongly linked to lifespan and mortality. Unhealthy lifestyle factors also reduce healthy life expectancy, by increasing the likelihood of developing age-related diseases or bringing forward the age of onset of diseases (or both). The Self-Care Academic Research Unit (SCARU) at Imperial College London explained: “up to 80% of heart disease, stroke and type-2 diabetes and over a third of cancers could be prevented by eliminating shared risk factors including tobacco use, unhealthy diet, physical inactivity and the harmful use of alcohol.”358 The Newcastle University Institute for Ageing told us that, of three lifestyle factors assessed, “obesity is most strongly associated with spending more years of life with disability, with years lived with disability [after] age 55 differing by 2.8 years according to BMI”. The other two factors assessed, smoking and alcohol consumption, increased years lived with disability after age 55 by 0.2 years and 1.6 years respectively.359

211.Conversely, healthy lifestyle behaviours, and positive lifestyle changes made at any stage in life, can increase healthy life expectancy. The Healthy Ageing Research Group at the University of Manchester wrote: “healthy lifestyle behaviours … mitigate many long-term conditions (diabetes, heart disease, respiratory disease), even when positive changes are adopted in later life.”360

212.Links have been identified between lifestyle factors and cognitive and mental health. A report on the findings of the Lothian Birth Cohort studies361 noted: “An individual’s cognitive trajectory is the result of a combination of shared influences with the rest of the body.”362 Analysis of data from this study found that there is no “silver bullet” for protecting cognitive function in old age, but a number of protective factors can give “marginal gains”.363 For example, there is clear evidence that cognitive function is harmed by smoking, loneliness and social isolation, and is aided by maintaining physical activity into older age.364

Environmental factors and local situations

213.Health throughout the life-course can be affected by people’s environment, where ‘environment’ has several aspects. People can be harmed directly, for example by pollution. Public Health England stated in a 2019 report that “poor air quality is the largest environmental risk to public health in the UK” because it “reduces life expectancy, mainly due to cardiovascular and respiratory causes and from lung cancer.” It added that the impacts “extend beyond the cardiopulmonary system to affect many other organs, increasing the risk of disease that begins from conception and persists across the life course”.365

214.There is growing evidence that air pollution harms health in old age, including cognitive health.366 Professor Cox wrote that pollution increases “premature onset of [age-related diseases]”.367 Professor Jane Raymond, Professor of Visual Cognition at the University of Birmingham, said: “High levels of air pollution are associated with high levels of Alzheimer’s disease in many cities … whether it is causal is another question but it is related to inflammation, which affects the hippocampus, which affects memory, which affects cognitive health.”368

215.The built environment affects health throughout the life-course. Poor quality housing contributes to ill health, for example dampness and poor air quality are associated with respiratory illnesses, and cold is associated with hypothermia.369 As discussed in Chapter 5, housing that is ill-suited to life in old age can affect health, including by restricting independence.

216.Health throughout the life-course can be affected by local amenities and services. The Institute of Health Research and Innovation at the University of the Highlands and Islands said that the presence of “health promoting environments such as shops that stock fresh foods, and leisure services such as swimming pools and sports centres, has a direct influence on a region’s health span.”370 Several witnesses spoke of the importance of making exercise enjoyable at school and of providing affordable exercise facilities for adults.371 In order to encourage uptake of healthy food, we heard of the value of introducing children to cooking at school and at home.372

Health inequalities

217.Cohort studies show clustering of health issues associated with deprivation, such that people in the most deprived groups are more likely than those in the least deprived groups to suffer from health problems in older age, to have reduced life expectancy and to have reduced healthy life expectancy. For example, women aged 50 and over in the poorest quintile are three times more likely to have type 2 diabetes and four times more likely to have chronic heart disease as those in the richest quintile.373 Men aged 50 and over in the poorest quintile are twice as likely to have type 2 diabetes and three times more likely to have chronic heart disease as those in the richest quintile.374 Professor Whitty told us that males in the least deprived decile can expect to live almost 10 years longer than those in the most deprived decile, and listed the conditions that contribute to that difference:

“Heart disease is the biggest [contributor] at 1.49 years; then lung cancer at 0.93; then chronic lower respiratory conditions at 0.92. All of those are very strongly driven by smoking, to be clear. Then there is cirrhosis at 0.57—I think everyone knows that that is a combination of alcohol and obesity; then pneumonia and influenza, which is a mixed bag, although smoking also contributes; then stroke—back to smoking again.”375

218.As well as facing clustering of risk factors, people living in deprivation face greater barriers to adopting changes in behaviour that can protect against ill health. This includes limited access to information376 and lack of facilities and funds to act upon advice. Professor Marmot told us:

“a health education strategy in general increases inequalities. If you simply tell people what constitutes a healthy life, the people who read the Times and the Guardian or whatever will pick it up, and those who do not, will not. That is not just because they are tuned in to information … If you give good advice on what constitutes healthy food, people down at the bottom cannot follow that advice because they do not have enough money to do it.”377

219.Levels of deprivation are higher amongst ethnic minorities, which contributes to health inequalities.378 Professor Nazroo said that “ethnic inequalities in later life in terms of health and other outcomes are dramatic. The health of a 40 year-old Pakistani or Bangladeshi person is equivalent to that of a 70 or 80 year-old white British person.” However, he noted that disadvantage is “not consistent across different ethnic groups”. He also observed that the fact that differences amongst ethnic groups increase as people get older is likely the effect of an “accumulation” of disadvantage.379 However, he told us that there is a “huge gap” in data in the UK on health and wellbeing outcomes for older people in ethnic minorities, because “particularly [in] the early birth cohorts, there were very few ethnic minority people to be sampled.”380

220.The UK has the opportunity to be a leader in understanding the impacts of lifestyle on health, using its well-established cohort studies in conjunction with its expertise in emerging areas of biomedical research. To achieve this, it is important that longitudinal cohort studies are provided with longer-term funding that gives greater security to these studies. It is also important that cohort studies recruit sufficient numbers of people from different ethnicities and socioeconomic groups to better understand health inequalities in older adults and how these may be resolved in the longer term.

Evidence base for lifestyle risk factors

Smoking and excessive alcohol consumption

221.It is well-established that smoking is harmful to health, contributing to numerous diseases that reduce healthy life expectancy and life expectancy.381 Smoking is particularly prevalent in groups with higher levels of deprivation, where it tends to be clustered with other harmful lifestyle and environmental factors. Professor Whitty explained: “There is a huge disparity in smoking rates, which drives at least some of, and probably a large part of, the difference between these [groups]”.382

222.We heard that smoking can cause harm via genetic and epigenetic changes which accelerate the processes of ageing. Professor Melzer said that smoking “greatly increases the number of DNA mutations and the amount of damage to DNA”.383 Dr Bell said: “Smoking, which we know has a major impact on the epigenome, also impacts on ageing”.384

223.It is well-established that excessive alcohol consumption is harmful to health, contributing to high blood pressure, stroke, liver disease, various forms of cancer, cognitive impairment and mental health disorders. The Newcastle University Institute for Ageing wrote that alcohol reduces disability-free healthy life expectancy after age 55 on average by 1.6 years and reduces overall life expectancy on average by 3.1 years.385 There is some evidence that alcohol is becoming a less common risk in younger generations, with Professor Richards noting that “the prevalence of hazardous drinking has been falling, particularly in younger people, but not among older people”.386

224.The impacts of smoking and excessive alcohol consumption upon ageing—and the potential for ill health and disability in old age—may be an important issue for some people when considering their behaviours and so could be an effective part of public health messaging.

Diet, nutrition and obesity

225.There is long-standing evidence that health is affected by dietary factors, both the quantity of food and its nutritional quality. In particular, poor diet can lead to obesity and can contribute to increased risk of specific age-related diseases, such as high blood pressure, type 2 diabetes, cardiovascular disease and certain types of cancer.387 Diet and nutrition can affect the health of the brain and lead to cognitive harm, for example via strokes, and there is some evidence of a link to the risk of developing dementia.388

226.There is evidence that the dietary needs of people change as they age, but there is limited knowledge of the nutritional requirements of older people. Professor John Mathers, Professor of Human Nutrition at the University of Newcastle, explained: “Part of the problem is the complexity of the nutritional needs of older people, because that greater age is usually associated with a greater likelihood of people having multiple conditions—diseases of one kind or another, combined with the use of a whole range of drugs.”389

227.Ruthe Isden of Age UK told us that malnutrition is more common than obesity for older people, noting that “there are around 1.6 million older people who are malnourished or at risk of malnutrition”.390 This high prevalence of malnutrition is partly because the smaller appetite of older people391 makes it harder for them to obtain the necessary range of nutritional content, for example protein to retain muscle mass.392

228.Recently there has been increased focus on whether dietary factors also influence the underlying biological processes of ageing, including the impact of obesity. Obesity significantly increases the low-level inflammation experienced with age (‘inflammaging’)393 and might contribute to enhanced cellular senescence.394 As discussed in Chapter 3, calorie consumption appears to be linked to the ageing process, but some witnesses cautioned against overinterpreting the results seen in animal interventional studies.395

229.There is evidence that the gut microbiome (discussed in Chapter 3) is modified by what is consumed, with impacts on health. Professor Mathers said: “Many of the substances that we ingest influence the microbiome” and “probably dominant in older people are the drugs we use”.396 Dr Marina Ezcurra, Lecturer in Molecular Biosciences at the University of Kent told us: “the Mediterranean diet is associated with a larger microbial diversity and an increase in beneficial species … meat rich diets result in increases of bacterial species [which] promote cardiovascular disease, inflammation and inflammatory bowel disease.” She added that some studies suggest that processed foods have a negative effect on the gut microbiome.397

230.Eating a balanced diet and maintaining a healthy body weight into old age are key to healthy ageing. Dietary advice has to reflect the nutritional needs of older people and the diversity of those needs.

Physical activity and inactivity

231.Physical activity improves various aspects of health throughout humans’ lives. Being physically active improves cardiovascular health and musculoskeletal mass and strength, helps to manage body weight, and affects the likelihood of diseases such as diabetes and hypertension.398

232.Physical activity can help slow the process of ageing. In youth, when bodies more readily build bone and muscle, it provides a strong basis or ‘reserve’;399 in middle age it helps to retain more of that strong basis and slow the natural decline so that old age is reached in the best condition;400 and in old age it helps to protect against the illnesses and accidents that are common at that stage of life.401

233.Physical activity improves health for people in old age. The University of Birmingham’s Centre for Musculoskeletal Ageing Research told us that there is “strong evidence to support the benefits of physical activity for physical and mental health in older adults”.402 Physical activity covers a spectrum, from light activity and the tasks of daily life to vigorous exercise.403 Studies show that changing from being sedentary to moderately active brings significant health benefits, even though the individual might still be in relatively poor health.404 Physical activity helps people retain physiological function. Professor Stephen Harridge from King’s College London wrote in the Physiological Society’s report Growing Older, Better that “highly active older people show levels of physiological function that are far superior to those of inactive people”.405

234.We heard that physical activity brings benefits for cognitive function and mental health as well as for physical health. Age UK told us that “risk and protective factors for cognitive and brain health are similar to those for physical health”.406 However, the mechanisms that link physical activity and cognitive and mental health are not well understood.407

235.Levels of physical activity tend to decline during adulthood,408 partly due to behavioural changes and partly due to reduced ability. In the Physiological Society’s report, Growing Older, Better, Professor Harridge wrote that, as humans age, “Our muscles get smaller and weaker, our hearts pump less blood and our ability to perform simple tasks of everyday living are progressively reduced. We know this to be due to an ageing process, because it is evident even in the most vigorously active master athletes whose performances decline as they get older.”409

236.There is evidence that physical activities tailored to the abilities of different groups of older people have benefits for health, for example reducing the risk of type 2 diabetes and mitigating some effects of rheumatoid arthritis.410 However, it is difficult to determine the exact contribution that physical exercise makes to health, and by what mechanisms. Professor Alun Hughes of University College London said that “there is limited evidence from what would be regarded as gold-standard interventional clinical trial data”. It is therefore difficult to provide tailored advice to people about exactly what types and amounts of physical activity they should undertake at different ages. Professor Paul Greenhaff, Professor of Muscle Metabolism at the University of Nottingham, explained: “we do not know the dose response to exercise; we do not know the frequency; we do not know how quickly the effects of exercise disappear in terms of muscle metabolic health”.411

237.There is increasing recognition that being sedentary can in itself have adverse health effects. Professor Greenhaff explained: “When you are inactive, muscle protein synthesis falls and insulin resistance in muscle develops.”412 We heard from the Centre for Musculoskeletal Ageing Research at the University of Birmingham that recent research has shown that “acute periods of sitting time induce significant increases in blood pressure in older adults.”413

238.However, there is limited evidence on the how sedentary behaviour causes harm or on how to mitigate its effects.414 The Centre for Musculoskeletal Ageing Research at the University of Birmingham wrote: “There is a relative paucity of (sedentary behaviour) research in older adults, and in particular frail older adults … we do not know the threshold of activity required to ameliorate the adverse effects of sedentary time which limits the advice we can give to older adults and those who care for them.”415

239.The benefits of physical activity are a cornerstone of public health advice, but a more detailed understanding of its positive effects—and the negative effects of sedentary time—could allow the development of advice that is more targeted. This is important throughout the life-course, including for older adults who have lower levels of physical activity.

Cognitive function and psychological stress

240.Cognitive function is affected by an individual’s health and behaviours, and can itself affect health.416 We heard that cognitive activity is protective of cognitive ability, in a similar way that physical activity is protective of physical ability. Dr Ritchie of King’s College London explained that ‘cognitive reserve’ can protect against general cognitive decline with age,417 saying that, if someone starts with a higher level of cognitive reserve, they can in principle “decline for a longer period of time [before] getting to the point where there is functional impairment”.418 Professor Barbara Sahakian, Professor of Clinical Neuropsychology at the University of Cambridge, told us that cognitive reserve can mitigate the progression of neurological damage, such as that caused by Alzheimer’s. 419

241.Several witnesses emphasised the role of education in improving cognitive ability, including school-age education420 and training and education in adulthood.421 Professor Richards highlighted the links between education and health inequalities: “Educational gradients are observed in a wide variety of health-related outcomes, so any educational policy is likely to have profound impacts on health and wealth.”422

242.We were told about factors that can contribute to cognitive decline. Professor Foster explained that “as sleep changes with age, we see a correlation with declining cognitive abilities”, but said that it is not clear “the extent to which this is correlation or causation”.423 Action on Hearing Loss told us that “if left untreated, hearing loss is associated with cognitive decline/dementia”.424

243.Psychological stresses can affect health and how well people age. Professor Cox told us that “chronic low-grade stress” is a significant factor in poor health and appears to contribute to underlying processes of ageing, such as inflammation.425 Stress-related inflammation has been linked to how the brain operates, and to mental health conditions such as depression and anxiety.426 Professor Raymond said that inflammation in different parts of the brain could explain impacts on specific cognitive functions such as learning and motivation, and could explain mental fatigue.427

244.This apparent effect of stress on the ageing process might be linked to the immune system. Professor Raymond explained that stress can trigger a response from the immune system, and that the immune system tends to malfunction as humans age, such that stress can cause neural inflammation in old age.428 The problem is exacerbated by the fact that stress harms the immune system, as the British Society of Immunology wrote:

“prolonged or chronic psychological stress can have a deleterious effect on the function of the human immune system … it is especially common in elderly individuals and, furthermore, prolonged stress has been found to cause premature and accelerated ageing of the immune system.”429

245.Cognitive ability and psychological stresses are key aspects of health throughout the life-course, but they also influence general health and might affect the underlying processes of ageing. Cognitive activities—including education, training and good-quality employment—and reduced stress are means of improving health in later life.

246.The factors that contribute to healthy life expectancy are well known, and form the basis of healthy ageing advice, namely: not smoking, avoiding excessive alcohol consumption, eating a balanced and nutritious diet, maintaining a healthy body weight, and being physically active. There is also evidence of the role of cognitive activity and reduced stress in healthy ageing.

247.Despite the evidence linking behaviours throughout the life-course to health in old age, the potential gains from healthy behaviours are not being fully achieved. Different aspects of the evidence could potentially have an impact upon people’s behaviours, for example: the fact that healthy lifestyles can reduce the time spent with disability in old age; and the discovery that behaviours can modify underlying processes of ageing.

248.We recommend that organisations with responsibility for healthy ageing advice incorporate findings about the benefits of healthy behaviours that may have a larger impact upon people’s behaviour than existing messaging. The benefits of building up good levels of physical fitness and cognitive reserve should be promoted, particularly to people in disadvantaged groups that suffer the worst health.

249.There is a need to better understand the scientific basis of the mechanisms by which lifestyle factors affect ageing. There is also a need to understand how requirements change in old age in order to develop advice covering, for example: the nutritional needs of older people; the benefits of physical activity for cognitive health; and the impacts of sedentary time.

250.We recommend that UK Research and Innovation and the National Institute for Health Research ensure that they support interventional studies to establish the mechanisms by which lifestyle and environmental factors affect health in old age, in order to improve advice for healthy ageing.

Public health interventions

251.The aim of public health advice for healthy ageing should be to encourage changes in behaviour that reduce risks and slow the rate of ageing. As noted in the evidence set out above, the basic tenets of healthy lifestyles are well-established; the challenge is to design interventions that lead to beneficial behaviour changes. In order to achieve the greatest health benefits, interventions should be designed to assist those living in deprivation and who suffer the worst health.

252.We were told about interventions that have been successful in bringing about healthy behaviour change. For example, Public Health England’s ‘toolkit’ of smoking cessation interventions highlights that the most effective methods are ‘face–to-face group support with pharmacotherapy’ and ‘face-to-face individual support with pharmacotherapy’.430 A 2019 study suggested that the NHS Health Check is an effective intervention, finding that “people who take up a health check generally have lower risk factor values than controls and are more likely to receive risk factor interventions.”431

Integrated messages and a life-course approach

253.We heard that it is best to address the range of different lifestyle risk factors together. For example, Professor Hughes said, “guidance on lifestyle needs to be integrated across all the risk factors and not focus on just one”.432 However, public health messages currently can be fragmented. Imperial College London’s Self-Care Academic Research Unit wrote that there is not a “common framework of understanding of what is involved in following a healthy lifestyle”, and explained that “many public health programmes have a ‘vertical’ approach to tackling single issues (e.g. tobacco smoking or physical exercise)” which “contrasts the holistic approach of considering the self-carer as a whole person.”433

254.A life-course approach to healthy ageing was a regular theme in the evidence, emphasising that healthy behaviours at all ages contribute to slower rates of ageing. The MRC Unit and Institute of Healthy Ageing at University College London noted that observational data indicate the importance of “optimising early-life reserve (e.g. cognitive, exercise capacity, respiratory function), maintenance of reserve in mid-life, and promoting resilience in later life to enhance healthy ageing.”434

255.A life-course approach is being encouraged in England. In 2019, Public Health England published a resource for public health professionals and the NHS on a life-course approach to preventing poor health. It states:

“unlike a disease-oriented approach, which focuses on interventions for a single condition often at a single life stage, a life course approach considers the critical stages, transitions, and settings where large differences can be made in promoting or restoring health and wellbeing.”435

256.There are advantages to adopting healthy lifestyles earlier in life. Professor Mathers said, “From a public health perspective, starting early would clearly have bigger advantages”, noting that “there is a law of diminishing returns. The later you start, the less you can gain from it.”436 We heard that habits, such as physical activity, are easier to establish earlier in life, as they become engrained and are easier to maintain if circumstances become more challenging later in life.437 We heard differing views on whether young people tend to engage with the issue of healthy ageing.438

257.We heard from several witnesses that one way of implementing a life-course approach to healthy ageing is to focus on key transition points in life, such as childhood development, puberty, starting a family, menopause, approaching retirement or becoming a carer.439 For the transition points from middle age onwards it was suggested that health services or employers might intervene to have conversations about healthy lifestyles, including through initiatives such as the NHS Health Check.440 However, we were told that take-up of the NHS Health Check is variable, and that people in lower socio-economic groups who have most to gain are least likely to engage with these types of initiatives.441

258.Encouraging healthy behaviour changes at certain transition points (for example retirement) requires input from policy domains other than public health. To help people remain healthy into old age, Professor Nazroo said that consideration should be given to “retirement policies, and later-life work where it is rewarding and engaging … volunteering and other types of activities that give them return and reward.”442 He discussed the merits of “investments in education and educational opportunities for people in their 50s and older”.443 Dr Alison Giles of the Centre for Ageing Better told us that there is insufficient focus on this age group:

“There is a bit of a gap in policy on the age group 50 to 70 … We need to be thinking of people who are still in work but have probably become carers, who may have the onset of long-term conditions. What can we put in place for those people to keep them in work and fulfilled and engaged, rather than waiting until they get to that older age and into real difficulty?”444

259.It was emphasised that a life-course approach to healthy ageing must not forget those who are already in old age. Age UK told us that “the majority of public health guidelines aim to promote healthy behaviours in children and working adults, with older people often being overlooked.”445

260.Public Health England’s advocacy for a life-course approach to healthy ageing is to be commended. Early uptake and adherence to a healthy lifestyle may continue into mid- and later life, but it is never too late to benefit from an improved lifestyle. Interventions tend to be more successful if they are designed with an understanding of what motivates people at different ages and the transition points at which they are more likely to act on public health advice.

Motivations for, and barriers to, behaviour change

Positive messaging

261.Advice about healthy ageing it is more likely to be accepted and acted on if people have positive expectations of the level of health that can be maintained in old age. Age UK said: “[people] tend to believe that age-related conditions are inevitable or that your health in later life is dependent on your genes. Such beliefs can be a barrier to taking action. People may be aware that there are things they can do to maintain aspects of health, but find it difficult to ‘convert’ this to action.”446 The Physiological Society explained that people may feel that certain conditions or behaviours are a normal part of ageing (such as aching joints or a reduction in social interaction) and so might not seek help or support, or that certain activities, such as cycling, are no longer appropriate as they age.447

262.The Government told us that it recognised the importance of positive societal attitudes towards ageing:

“Social attitudes in relation to ageing need to change. By thinking that ageing will be a negative process, people may have a more pessimistic view of their own future and expect to face difficulties in their daily lives and relationships as they age. This then manifests itself as stress, depression and anxiety.”448

263.Similarly, we heard that public health advice is more likely to be acted on if the message is positive and resonates with people’s interests and ambitions, rather than focusing on fear of poor health.449 Professor Peter Gore, Professor of Practice in Ageing and Vitality at Newcastle University, told us that researchers have found “articulating ageing in terms of maintaining personal independence to be much more effective.”450 Dr Nyman explained that “there is a theory about the psychology of ageing which suggests that, as we get older, we tend to prioritise activities that we enjoy”.451 Conversely, focusing on negative issues can be counterproductive by deterring people from helpful interventions. For example, Dr Nyman said: “there is a stigma around falls. People do not want to accept the label of being at risk of falls, so they distance themselves from falls prevention interventions”.452

Tailoring advice

264.Public health advice and interventions—including those for healthy ageing—can be provided to the population as a whole, or they can be tailored to groups and individuals. The Physiological Society said that non-tailored advice could be a deterrent for some people who are in old age or have physical limitations: “arbitrary targets (such as the amount of exercise achieved per week or the number of steps per day) may act as a barrier to participation for some members of society if they are considered unattainable (owing to age or baseline functional capacity)”.453

265.The Institute of Health Research and Innovation at the University of the Highlands and Islands thought that a ‘personalised healthcare’ approach—”in contrast to the current ‘one-size-fits-all’ model of healthy ageing”—will be important “when considering the diverse geographical, cultural, and socio-economic contexts of an ageing society”.454 Professor Gore gave the example of the LIFE study, a tailored approach which “intervened with people at the point of losing the ability to walk 400 yards”. The study found that “group and individual exercises were dramatically more effective—delaying further decline for at least 2.6 years longer than general public health advice”.455

266.One aspect of personalised healthcare is ‘social prescribing’. The Government describes this thus: “Social prescribing—sometimes referred to as community referral—is a means of enabling GPs, nurses and other health and care professionals to refer people to a range of local, non-clinical services.”456 It is an attempt to improve health outcomes and reduce costs to public services. It was welcomed in evidence, but with questions about resources. Age UK wrote: “While social prescribing is a very welcome move forward, primary care providers need relevant activities and services to which they can prescribe patients.”457

267.Not all witnesses agreed that tailored advice is necessarily effective. The British Academy wrote:

“There is a risk of a continued waste of resources on downstream behavioural interventions (targeting individuals) which are consistently shown to be less effective and more likely to generate inequalities than upstream interventions (e.g. targeting whole workplaces, communities, or the whole population).”458

268.We heard that focusing on individuals risks failing to help those most in need and hence increasing health inequalities. Professor Sayer told us: “Health behaviours are socially patterned, such that ‘healthier’ lifestyles are far more common among more affluent, educated sectors of the population and less common among disadvantaged groups”. Because much health advice is currently targeted at individuals, with an emphasis on individual responsibility, “these initiatives may even act to widen health inequalities.”459

269.Witness discussed barriers to uptake of public health advice in general, which can apply to advice for healthy ageing. Elaine Rashbrook said that “about 40% of people in England find it quite difficult to understand health messaging and language”.460 There was concern that some healthcare professionals do not understand how to communicate the concept of healthy ageing to deprived communities461 and that messaging can be inaccessible to disadvantaged groups.462 We were given several examples of where messaging was more effective because it was developed with involvement from communities and people for whom it was intended.463

270.A balanced approach to public health advice can help to achieve healthy ageing, with general messages provided to the whole population and tailored advice for groups with specific needs—in particular, disadvantaged groups who suffer from the worst health.

Responsibility for public health in England

271.It was clear from our evidence that public health advice for healthy ageing requires involvement from national government, local government and their agencies.464 The current allocation of responsibilities for public health in England was set out in the Health and Social Care Act 2012.465 The Secretary of State retained overall responsibility for improving health. National public health functions were delegated to Public Health England (PHE), which was created following the Act. Local authorities were given responsibility for improving the health of their local populations and for public health services.

272.Some witnesses were concerned about this division of public health responsibilities and its effect on efforts to develop public health advice, including for healthy ageing. For example, the Physiological Society wrote:

“The fragmentation of commissioning between local and national government in England for various aspects of lifelong health, encourages a siloed approach to policy making. This has the potential to create barriers that will make it difficult to achieve healthy ageing targets. Structural barriers between commissioning organisations, separate budgets and differing organisational priorities make it much more difficult to implement broad, ambitious projects that may have the most potential to improve health outcomes.”466

273.We heard about barriers to communicating expertise in the sector, and how these barriers can impair policy development. Birmingham Health Partners were concerned about “a lack of clinicians who work in ageing” in Public Health England.467 The Imperial College London Self-Care Academic Research Unit was concerned about the number of organisations trying to inform policy:

“With over 40–50 different stakeholders, each with their own agenda and interpretation of how to encourage healthy lifestyles, there is a real tendency to overlook other constituencies. This creates a silo effect which is inevitably duplicative, certainly confusing to the self-carer, and ultimately impedes the efforts of policymakers.”468

274.In August 2020, after we had taken evidence for this inquiry, the Government announced the creation of the National Institute for Health Protection. This new public body will bring together functions undertaken by several organisations including Public Health England. We have not examined the merits of these changes, which were made without consultation. It is not yet clear where responsibility for public health objectives—such as managing obesity—will sit in the new structure and whether the changes will assist with the task of encouraging and facilitating healthy ageing.

275.We recommend that the Government clearly defines the roles and responsibilities for healthy ageing among national and local government and their agencies. The creation of the National Institute for Health Protection should be used as an opportunity to revitalise work to promote healthy ageing across the life-course, including by improving coordination across the sector and drawing on the best information for developing public health advice.

Government policies

276.Central government policies can have a significant impact on health throughout the life-course. Dr Giles stated: “The biggest impact that we can have on public health is through central government regulations.”469

277.We heard from several witnesses that regulation and fiscal measures can be effective at disincentivising unhealthy behaviours and establishing an atmosphere conducive to healthy lifestyles. They cited examples of effective regulatory interventions to tackle behaviours associated with unhealthy ageing, including: the smoking ban;470 reductions in dietary salt intake;471 the levy on sugar in soft drinks;472 and minimum alcohol pricing in Scotland.473

278.Alternatives to regulatory changes include ‘nudge’ interventions. This approach has been defined as an intervention which “alters people’s behaviour in a predictable way without forbidding any options or significantly changing their economic incentives.”474 However, Dr Giles said that nudge approaches were insufficient.475 This Committee analysed the effectiveness of nudge theory in its 2011 report Behaviour Change, concluding that:

“non-regulatory or regulatory measures used in isolation are often not likely to be effective and that usually the most effective means of changing behaviour at a population level is to use a range of policy tools, both regulatory and non-regulatory.”476

279.If the Government is to introduce strong regulatory policies to contribute to healthy ageing, this will necessitate change in certain industries—including the food, drinks and tobacco industries—which have incentives that do not align with healthy ageing. The MRC Unit and Institute of Healthy Ageing at University College London said there is a “Lack of effective mechanisms to ensure costs of harms are factored into the price of consumer products, with the consequence that unhealthy choices are often cheaper.”477

Local public health service funding

280.Spending has fallen on local public health services aimed at preventable ill health, including lifestyle factors that affect how well people age. The King’s Fund reported in 2020 that local government public health reforms in 2012 coincided with cuts to local government funding and spending on public health services.478 The British Geriatrics Society and Royal College of Physicians referred to “the considerable budget reductions that [public health] services have had to work within over the last few years.”479

281.These funding cuts have affected services that promote healthy living across the life-course. Councillor Ian Hudspeth of the Local Government Association supported the life-course approach to preventing illness, but told us that local authorities’ funding was more likely to be cut on discretionary services—such as those which promote good health in younger people—than on services that local authorities are statutorily obliged to provide.480

282.We heard that funding cuts have affected services that support health in old age. Age UK said that “care packages can only focus on the essentials such as meals and toileting, without any time for help with mobility”, which prevents some older people from accessing services.481 Age UK also told us that:

“There is significant variation across the country in the availability of services to stay well … These services are frequently provided by the voluntary sector, but deprived areas tend to have fewer such organisations operating in their communities.”482

283.Reduced spending on public health to promote healthy ageing is counterproductive, because prevention is better (and cheaper) than treatment. Age UK argued that supporting healthy lifestyles “can produce financial savings: preventative activities through the public health grant are up to four times more cost-effective than NHS spending.”483 However, efforts to achieve this overall gain are undermined by conflicting financial incentives of individual organisations, as the Physiological Society wrote:

“There is a tension between local government’s responsibility for public health and leisure activities and the ‘savings’ accrued to the nationally-commissioned health service from healthier ageing and this is leading to reluctance among policymakers to invest in preventative services.”484

284.We recommend that the Government implement a concerted and coordinated set of national policies to support healthy ageing, including: regulatory and fiscal measures, actively to encourage people to adopt lifestyles that support healthy ageing; increasing the reach of the NHS Health Check to those in disadvantaged groups who will benefit the most; and working with local authorities on the funding of local services, housing and infrastructure to encourage and facilitate healthier living across the life-course, including the necessary services to maintain health and independence in old age.

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