May is
National Stroke Awareness Month in the UK. The Stroke Association and NHS official data
show that the number of middle aged people suffering a stroke increased
dramatically last year. In England, men aged 40 to 54 saw a rise of 46% over
the last fifteen years, from the year 2000 to now. That’s 4,260 men in 2000 to
6,221 last year. Women of the same age saw a 30% rise, and for all those aged
20-64, there was a 25% increase. So the message seems to be that people of
working age are experiencing strokes, and that strokes are happening at younger
ages. The reasons put forward for these rises – at least in the popular media and by the government –
are obesity and sedentary lifestyles. The Stroke Association is quite right to
point out the dangers of strokes, and to publish information so that people can
educate themselves about risks and lifestyle. However, there is perhaps more to
the statistics and more to the discussion of causes that needs to be
interrogated.
Firstly,
the overall incidence of stroke has actually fallen over the 20 years from 1990
to 2010, (from 141.97 per 100,000 to 115.50 per 100,000) and the number of UK
deaths fell, from 87,974 in 1990 to 40,282 in 2013. A number of factors
contributed here – the decline in smoking, the development of clot-busting
drugs and also the changes in emergency treatment, which meant that more stroke
sufferers received speedy attention. However, there does seem to be a rise in
the last few years among those below the age usually considered as ‘elderly’,
that is, amongst the middle-aged, still-working groups in their forties and
fifties. Why?
A
Department of Health spokesperson commenting on the statistics this month said,
“Strokes can have a devastating impact on people and their families. Adopting a
healthier lifestyle, like plenty of exercise and eating the right food, is
really important to reduce the risk of stroke.” The Stroke Association’s
website has four categories giving advice to people wanting to change their
lifestyles to reduce stroke – the usual four suspects of Diet and Nutrition, Physical
Activity, Smoking, Alcohol.
The
high profile stroke of the English broadcaster and journalist, Andrew Marr, has
highlighted the fact that, as his wife the journalist Jackie Ashley wrote
recently, “Even super fit gym bunnies have strokes”. Not surprisingly, she has embarked on
something of a crusade to point out to the public the predictors of stroke, and
how simple it can be to keep a check on the obvious precursor, high blood
pressure. For well and fit people, such as Andrew Marr, there might be no
reason to check blood pressure. In his case, the stroke seemed to be brought on
by attempting a new approach to very high intensity exercise. Jackie Ashley
comments at the end of her article “But with just a little more public
awareness, the figures for strokes among working-age people could be going down
by 50%, rather than up.”
With
respect to both these journalists, their experience is not typical, and it
arguably would take a lot more than “just a little more public awareness” to
reduce strokes.
To say
that stroke and other circulatory diseases can be halted purely by ‘behaviour
change’ or lifestyles, is utterly victim blaming. ‘Lifestyles’ play a role of
course, if by lifestyle we mean the freely chosen ways we decide to live our
lives. Everyone makes choices within the broader or narrower range available to
them. But there are wider factors over which people have little control. For
example, there has been research available for years that shows that noise
pollution raises blood pressure and is linked to heart disease. Those living
near airports have raised blood pressure in response to aircraft noises, even
when they
are asleep. The HYENA study of six large European airports in 2008 found this
(Jarup et al 2008), and follow up studies reported in the BMJ in 2013 found the
same. The British Study (Hansell et al 2013) found that people living near
Heathrow had significantly higher rates of stroke, and in the USA, Gan et al (2013)
showed higher admission rates for heart problems for anyone living near a major
airport. Studies from the occupational
health field show similar elevated risk for those working in noisy
environments; a study in Occupational and
Environmental Medicine,
for example in 2010 show rates of heart problems, hypertension and angina two
to three times higher than those who work in quieter settings.
Noise
is merely one of the reasons why blood pressure might be elevated. Salt
consumption is certainly another well-known contributor to high blood pressure.
We know that simple steps like making the holes smaller on saltshakers can
reduce salt consumption, and many people do know about these messages. But – we
also know that the food industry has a major role to play – and isn’t keeping
its side of the bargain. In 2012, the food industry and supermarkets agreed
voluntary pledges to act to reduce the amount of calories consumed in the UK,
mainly to combat obesity, but also to make eating healthier. A study commission
by the government, carried out by the London School of Hygiene and Tropical
Medicine, which reported recently, (Knai 2015), shows that the ‘responsibility
deal’, where food producers voluntarily make their food healthier, such as by
reducing salt, has not worked. The authors conclude, “The current nature and
formulation of the responsibility deal food pledges is such that pledge
implementation is unlikely to have much effect on nutrition-related health in
England”. The are glaring absences from the voluntary deal, such as there being
no focus on sugar intake, (an obvious contributor to obesity, and thus to
elevated blood pressure) and the actions of the food industry have been to
focus on education and information, all of which, as the study points out, “may
have limited effect. It is well established that interventions which improve
information and awareness of health issues or risks do not necessarily
translate into positive behavior change.” Indeed. The damning summary of the
failure of the ‘responsibility deal’ led to Barbara Gallani, director of
regulation, science and health at the Food and Drink Federation saying that the
responsibility deal “is the most ambitious and inclusive framework for
voluntary action on public health the UK has ever seen.”
When
the Journal of Public Health published its March 2015 edition, full of articles
about the ongoing effects of poverty and inequality on health, the Guardian
reported it by interviewing a man from Newcastle on Tyne whose weekly income
fell from £72 a week to £47 as a result of the bedroom tax. (This tax, for
those unfamiliar with it, was introduced for those living in social housing who
had an ‘unused’ bedroom, as an incentive for people to move to smaller houses).
All he ate was sausage rolls and he reportedly said, “I can’t sleep at night. I
regularly see my doctor, I suffer from depression.” He is a 56 year old
unemployed warehouse worker, and is just one of those reporting increased
stress, anxiety, hunger, poor diet and depression as a result of the bedroom
tax. Others reported needing ‘blood pressure tablets’.
Copeland
et al’s (2015) study shows very clearly how economic recessions affect the
poorer north east of the UK more than other parts of the country, whilst De Agostini
et al’s study, published in November 2014, patently makes the point that we
were ‘not all in it together’, and that certain parts of the country – the
poorer ones – were disproportionately affected by the Coalition government’s
tax-benefit policy changes. Schreker and Milne’s editorial to the Journal of Public
Health March 2015 edition provides an overview of some of this literature, as
well as suggesting a manifesto for improving public health inequalities.
This
week, the Guardian has another headline – “Thousands plunged into poverty by
benefit cap.” The Guardian claims to have seen an internal memo which shows
that due to the limit introduced in April 2013, on what benefits families will
be able to claim in a year, another 40,000 children will be placed on or below
the official poverty line, unless their parents can find extra work. This is on
top of the 50,000 children already in this position. The memo says, “Around
40,000 more…children might, in the absence of any behavior change, find
themselves in poverty as a result of a reduction in the cap to £23,000. If
these families respond to the cap by making behavior change, for example,
moving into work, they are likely to see themselves and their children move out
of relative poverty.” (Reported in The Guardian 30.05.15 p1). So, here’s
another explicit statement that poverty is caused by improper behaviours, and
that all that’s needed is behavior change.
The
Department of Work and Pensions’ own figures showed that in the 22 months of
the new cap, only 11% of households that were just below the cap moved into
work. Their own qualitative study into the effects of the cap showed that most
capped tenants struggled to afford basic necessities, went without food, and
used loan sharks. A quarter was under threat of eviction as they had run up
rent arrears. How is it possible to maintain normal blood pressure under these
threatening socioeconomic conditions?
If
people living in these stressful conditions were to visit their GP, what would
that GP do? The GP might take the patient’s blood pressure and what then?
Some
other opinions expressed recently have also cast doubt even on Jackie Ashley’s
suggestion above, that people need to get checked more regularly. Capewell et
al suggest that the NHS Health Checks are a waste of resources. They write
that:
“We briefly review here the evidence that
the NHS Health Checks (NHSHC) programme represents an ineffective strategy and
is currently wasting scarce resources.
The NHSHC programme invites everyone in
England aged 40–74 without cardiovascular disease (CVD) for a check every 5
years. The NHSHC website advertises that health checks can
•
prevent
heart disease, diabetes, kidney disease stroke and dementia,
•
provide
support and advice to help individuals manage and reduce their risk of future
disease.1
However,
the NHSHC programme fails to achieve both of these primary objectives.
Furthermore, it relies on weak concepts, denies strong scientific
counter-evidence and ignores persistent implementation issues.”
This
medical solution to keeping people healthy doesn’t appear to be preventing the
main causes of mortality and morbidity. Strokes of course do happen to people
of all social classes but the emphasis on ‘behaviour change’ and the failure to
take into account the social gradient in the incidence of stroke, the failure
to look at socioeconomic factors that are implicated in their cause, plus the failure
to curb the food industry, means that the rates making the headlines in this
Stroke Awareness month, of younger people having strokes, are only likely to
get worse.
Capewell, S. McCartney,
M., Holland, W., (2015) Invited Debate: NHS Health checks – a naked Emperor? Journal of Public Health, 37 (2): 187-192.
doi: 10.1093/pubmed/fdv063
Copeland, A., Kasim, A.,
Bambra, C. (2015) Grim up North or
Northern grit? Recessions and the English spatial health divide (1991–2010) Journal of Public Health 37 (1): 34-39. doi: 10.1093/pubmed/fdu019 First
published online: March 18, 2014
De Agostini,
P., Hills, J., and Sutherland, H. (2014) Were we really all in it together? The distributional effects of the UK
Coalition government's tax-benefit policy changes. Working
Paper 10 November 2014. Available from: http://sticerd.lse.ac.uk/dps/case/spcc/wp10.pdf
Gan WQ, Davies HW, Demers
PA, et al. Exposure to occupational noise and cardiovascular disease in the
United States: the National Health and Nutrition Examination Survey 1999-2004.
Occup Environ Med 2010; DOI:10.1136/oem.2010.055269
Hansell AH, Blangiardo M,
Fortunato L, et al. Aircraft noise and cardiovascular disease near Heathrow
airport in London: Small area study. BMJ 2013; 347: DOI:10.1136/bmj.f5432.
Jarup L, Babisch W,
Houthuijs D, et al. Hypertension and exposure to noise near airports: the HYENA
study. Environ Health Perspect. 2008 Mar;116(3):329-33. doi: 10.1289/ehp.10775.
Knai, C., Pettigrew, M., Durand, M et al (2015) Has a public–private
partnership resulted in action on healthier diets in England? An analysis of
the Public Health Responsibility Deal food pledge. Food Policy, 54, July,
Pages 1–10
Schreker, T., and Milne,
E. (2015) Health and politics for
2015 and beyond. Journal of Public Health, 37 (1): 1-2.
doi: 10.1093/pubmed/fdu112 First
published online: January 7, 2015
