Health in Scotland 2007

health in Scotland 2007

Annual Report of the Chief Medical Officer contents

Foreword 1

Chapter 1 Coronary heart disease and stroke: Reducing amenable mortality 2

Chapter 2 Cancer: Reducing amenable mortality 14

Chapter 3 Liver disease: Reducing amenable mortality 22

Chapter 4 Risk factors and their impact on disease in Scotland 28

References 34

Acknowledgements 36

ISBN: 978-0-7559-5839-9

The Scottish Government St Andrew’s House Edinburgh EH1 3DG

Produced for the Scottish Government by RR Donnelley B57023 11/08

This document is available in alternative formats on request

Published by the Scottish Government, November, 2008

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100% of this document is printed on recycled paper and is 100% recyclable Foreword foreword

Last year, my annual report our poor health is inevitable and we emphasised the importance of the early should not accept it as so. years of life in building a solid foundation for good mental and The final chapter suggests “5 habits physical health in adulthood. Since that for health”. By adopting these habits report was published, many tragedies we can add significantly to the number have been reported in the media in of years we live and improve the which babies and young children have quality of those years. been abused, injured and killed. At the same time, evidence has continued to The most worrying trend reported is accumulate that children born into and the significant increase in mortality raised in chaotic circumstances are associated with consumption of more likely to be unemployed, have alcohol. Scotland must change its criminal records, abuse alcohol and attitudes to this drug. The evidence drugs and, in their turn, be violent to that mortality from alcoholic liver their own children. The need to create a disease can fall rapidly when a society more nurturing and supportive reduces consumption is strong. environment for our children remains, France achieved enormous in my view, the most pressing public improvements very quickly. We must health issue in our society. do the same. In some parts of Scotland premature death from This years report looks at how we can alcoholic liver disease is now higher reduce the scourge of early death in than that from heart attacks and we Scottish adults. The big killers are, of must act quickly to improve matters. course, heart disease, stroke, cancer and alcoholic liver disease. The report The damage done to the length and details the trends in incidence and quality of life in Scotland by the major mortality from these diseases. It killers has, as already pointed out, contains some good news and reports many of its origins in childhood. We some worrying trends. The key need to confine our efforts to support message is that, in many respects, parents and children. We must, in Scotland’s health is changing for the addition, help people at greatest risk better and, by working together, of ill health make the choices that will citizens of Scotland can accelerate the improve their mental and physical rate of improvement. Nothing about wellbeing.

1 1

Coronary heart disease and stroke: Reducing amenable mortality Chapter 1: Coronary heart disease and stroke: Reducing amenable mortality

Introduction and 2003 to a fall of 0.5% between The fall in mortality from stroke has 2003 and 2006. There was also a been more consistent. Mortality from Over the past 10 years Scotland has small increase in mortality rates in stroke in the under 75s has fallen seen a steady fall in the mortality young men between 2005 and 2006. substantially from 37 deaths per rates of the cardiovascular diseases Recent evidence suggests that the 100,000 in 1995 to 20 deaths per (CVD) of coronary heart disease (CHD) risk of developing heart disease is 100,000 in 2006 (Figure 2). If this trend and stroke. Figure 1 shows the increasing in younger men between continues, the 2010 target of a 50% progress made between 1995 and the ages of 35 and 55. This adverse reduction in mortality in this age group 2006 towards the 2010 target of a trend reflects what is happening in should be met. However, the 60% reduction in CHD deaths in those other parts of the world, including continuing increase in the proportion aged less than 75. England, Wales and the USA. It is of older people in the Scottish Although Scotland remains on course probable that unfavourable trends in population will mean the number of to meet this target, it is a matter of cardiovascular risk factors such as people of all ages in Scotland suffering concern that the rate of decline in CHD obesity and associated diabetes are a stroke will continue to increase mortality for men and women aged now beginning to impact on CHD unless the incidence of stroke in the 35-54 years shows recent significant mortality. This highlights a pressing over 75s is reduced. levelling off. Specifically, the average need to tackle the challenge of annual percentage fall in the rate in increasing obesity in the Scottish men changed from 6% between 1986 population.

Figure 1: Mortality rates in Scotland from 1995 to 2006 for coronary heart disease for ages under 75

200 180 160 140 120 100 80 60

e per 100,000 Population 40

Rat 20 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Males (MEASR) Both Sexes (BEASR) Females trend to target (FTREND) Females (FEASR) Males trend to target (MTREND) Both Sexes trend to target (BTREND)

Source: GRO(S)

3 Health in Scotland 2007

Figure 2: Mortality rates in Scotland from 1995 to 2006 for stroke for ages under 75

e per 100,000 Population 10 Rat 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Males (MEASR) Both Sexes (BEASR) Females trend to target (FTREND) Females (FEASR) Males trend to target (MTREND) Both Sexes trend to target (BTREND)

Source: GRO(S)

Behind these population trends there future adult disease, and to support Impact of Health is also a worrying gap in cardiovascular individual behaviours that promote Improvement Measures health between the more affluent and good physical and mental health and The Scottish Government is funding the more deprived people of Scotland. wellbeing. The report of the £56 million to support implementation See Figures 3 and 4. Ministerial Task Force on Health of the recently published policy Inequalities Equally Well2 published Healthy Eating, Active Living: An What more could be done to in June 2008 demonstrates the Action Plan to Improve Diet, Increase accelerate the current overall decline Scottish Government’s commitment Activity and Tackle Obesity3. It is also in CVD mortality and narrow the gap to tackling health inequalities. building on Scotland’s historic 2005 which persists between mortality rates Current health improvement policies legislation banning smoking in in rich and poor communities? aim to change the average behaviour enclosed public places and in May of the Scottish population by 2008 published a smoking prevention The recent Better Health, Better Care focussing on reducing poverty, Action Plan Scotland’s Future is Smoke action plan1 emphasises the crucial encouraging healthy lifestyles, Free. This has radical new proposals need to reduce the significant including taking more exercise and such as substantially reducing the widening health inequalities in eating more fruit and vegetables availability, affordability and Scotland. Current differences in life while reducing intake of salt, attractiveness of cigarettes to young expectancy and health in Scotland, saturated fats and alcohol. people and further reduce the number with people in the most affluent areas Increasingly health improvement of people exposed to tobacco smoke. of the country living several years policies are also targeting those Improving the pattern in the longer than those in the most deprived populations that are at greatest risk population of blood pressure, blood areas need to be tackled. The Scottish of future ill health and often least fats, diet, smoking and physical Government is working to break the able to access health improvement activity by even a small proportion will link between early life adversity and support. have a big impact on the numbers in the overall population having heart attacks and strokes. Table 1 illustrates the potential reduction in incidence of major cardiovascular events in the 10 years following treatment of middle aged men who are identified as high risk. 4 Chapter 1: Coronary heart disease and stroke: Reducing amenable mortality

Figure 3: Coronary heart disease standardised mortality ratios by SIMD deprivation decile, 2002-2006

250

200 lity Ratio 150

100 Standardised Mo rta 50

0 1 2345678910 SIMD Deprivation Decile

All Ages Ages under 65 Ages 65 and over

Source: ISD Scotland; GRO(S)

Figure 4: Cerebrovascular disease standardised mortality ratios, by SIMD deprivation decile, 2002-2006

200

180

160

140 lity Ratio 120

100

Standardised Mo rta 40

0 12345678910 SIMD Deprivation Decile

All Ages Ages under 65 Ages 65 and over

Source: ISD Scotland; GRO(S)

5 Health in Scotland 2007

Table 1: Potential reduction in incidence of major cardiovascular events in subsequent 10 years by treatment of middle-aged men identified as at high risk

Basis of high risk Treatment Reduction in individual relative risk

High cholesterol Statin 30%

High blood pressure BP lowering drug 22%

High cholesterol Combined treatment 68%

High blood pressure Combined treatment 68%

Reduction in population incidence by treating those at greatest risk

Top 10% Top 20% Top 30%

High cholesterol Statin 6% 9% 12%

High blood pressure BP lowering drug 6% 8% 10%

High cholesterol Combined treatment 13% 21% 28%

High blood pressure Combined treatment 18% 25% 31%

(Combined treatment: Statin, BP lowering drug and aspirin)

Based on Table 18.8: Stroke: practical management. 3rd Edition. Warlow C et al. Blackwell 2008. ISBN 978-1-4051-2766-04.

GPs and other professionals providing Lanarkshire, Tayside and Lothian NHS established “Framingham” risk score day-to-day services can Board areas. A second wave will begin developed from research into opportunistically identify individuals shortly in NHS Grampian, NHS cardiovascular disease in the with modifiable risk factors and Ayrshire and Arran, and NHS Fife. population of Framingham, USA, over provide medical treatment and offer A related programme, Well North, in a period of many years. The new lifestyle support to reduce future risk the north of Scotland aims to widen ASSIGN calculator measures risk on of major cardiovascular events. It is the reach of anticipatory care to the basis of key factors for each also possible to systematically screen remote and rural areas. The learning individual such as age, sex, blood populations known to be at higher points from the evaluation of these pressure, smoking history, and blood risk. This approach underpins the Keep first programmes have been shared fats. ASSIGN also includes a measure Well Programmes which provides widely across Scotland. of social deprivation – the Scottish anticipatory care for those at higher Index of Multiple Deprivation (SIMD) – risk of CHD and diabetes. The It is essential within Keep Well that as well as family history. This means programmes invite 45-64 year olds GPs and others are able to estimate an that for the first time Scottish people within deprived communities to attend individual’s future risk of CVD. The will be able to have a full assessment a health check and offer those found Keep Well pilot in south Glasgow is of CHD risk, taking account of the to be at higher risk medical treatment now assessing the impact of a new influence of both deprivation and and support to tackle smoking, poor risk-factor calculator, “ASSIGN”, family history (which also acts as a physical activity and other health developed as part of the SIGN proxy for ethnic background). Those related behaviour. The first wave of (Scottish Intercollegiate Guideline assessed by ASSIGN as having more Keep Well programmes are working in Network) guideline 97: Risk Estimation than 20% risk of CVD over 10 years Community Health Partnerships in and the Prevention of CVD5 published should be offered lifestyle support such Greater Glasgow and Clyde, in 2007. ASSIGN6 is based on the well- as smoking cessation and dietary

6 Chapter 1: Coronary heart disease and stroke: Reducing amenable mortality advice and be considered for treatment population it has been estimated that A “Resource Impact Assessment”7 of with fat-lowering drugs (statins) and 70% of deaths attributed to stroke the recent CVD SIGN Guidelines blood thinning drugs (such as aspirin). could be avoided. estimated the potential number of We know from previous surveys that lives saved over 5 years by approximately one-third of people over An important cause of stroke is atrial implementing the guidelines. Table 3 the age of 40 in Scotland will be in this fibrillation (a type of irregular heart shows the estimated impact through risk category. The number eligible for beat) which leads to the development reducing smoking rates, prescribing drug treatment and health of blood clots in the heart which then statins in high-risk patients and better improvement support is likely to travel to the brain to cause strokes. uptake of healthy eating. Health increase through the use of ASSIGN, Identifying those over 40 years of age professionals and other staff in and the expected reduction in CVD risk who have atrial fibrillation and primary health care and hospital in that population should reduce future treating them with antithrombotic services will be integral to delivering death and disability from CHD and (anti- clotting) treatments such as this reduction in CVD risk in the stroke. warfarin or aspirin could further Scottish population. The estimated reduce the number of strokes by number of lives that would be saved in Strategies such as Keep Well by about 7%. This equates to 960 fewer Scotland over 5 years by the targeting sections of the population at strokes per year in Scotland. Of these implementation of the SIGN greatest risk could reduce the average 960 people, 320 would have died and Guidelines is nearly 3,500. blood pressure of middle-aged men 320 left with significant disability. leading to a potential 16% reduction of Table 2 illustrates the estimated the incidence of stroke in Scotland. If effect of treating this group on the all main risk factors were optimally number of strokes occurring in reduced in the whole Scottish Scotland.

Table 2: Estimated reduction in the incidence of strokes in Scotland following treatment with antithrombotic drugs of those aged 40+ with atrial fibrillation (AF)

% of over 40s with AF Number of over 40s with AF Strokes avoided each year (% all strokes in Scotland)

2.3% 60,074 961 (7%)

Based on Table 18.9: Stroke: practical management. 3rd Edition. Warlow C et al. Blackwell 2008. ISBN 978-1-4051-2766-04.

Table 3: Estimated lives years saved in Scotland over 5 years by full implementation of primary prevention element of CVD SIGN Guidelines

Smoking 106

Statin prescription in high-risk patients 2,678

Healthy eating 611

Total 3,394

Source: SIGN Impact Assessment7

7 Health in Scotland 2007

Impact of clinical treatment and interventions ‘ It is now widely accepted that Stroke patients with strokes admitted Even if the person has had a stroke, ’ there is still significant scope to to dedicated hospital Stroke reduce the subsequent risk of death and disability. An increasing number of Units have better survival and interventions are becoming widely available to reduce mortality, improve recovery than those treated on survival and enable recovery after a stroke. Interventions can also reduce general wards. The NHSQiS the risk of future strokes and other 2004 clinical standards for vascular events. Table 4 illustrates the estimated impact on acute stroke in Stroke Services include the the Scottish population in a number of these interventions. requirement that at least 70% of patients with a stroke admitted to hospital should be cared for in a stroke unit within the first day of admission.

Table 4: Estimated effect of interventions for acute stroke on (a) death and (b) death or dependency in the 11,626 patients estimated to have a stroke each year in the Scottish population

Numbers in target population Number of stroke deaths avoided Intervention (% of all 11,626 strokes) (% of all stroke deaths avoided)

Admit to Stroke Unit 9,301 (80%) 556/3601 (15%)

Treatable with aspirin 9,882 (85%) 77/2675 (3%)

Number of deaths or dependency avoided

Treatable with thrombolysis 1,163 (10%) 123/6379 (2%)

Based on Table 18.2: Stroke: practical management. 3rd Edition. Warlow C et al. Blackwell 2008. ISBN 978-1-4051-2766-04.

8 Chapter 1: Coronary heart disease and stroke: Reducing amenable mortality

It is now widely accepted that patients to hospital should be cared for in a shows steady progress towards this with strokes admitted to dedicated stroke unit within the first day of target from 2005 to 2007. When the hospital Stroke Units have better admission. Over 10,000 people are 70% target is achieved, deaths from survival and recovery than those admitted to hospital for stroke each stroke should have fallen 12% treated on general wards. The 2004 year in Scotland meaning that over compared to the early 1990s when clinical standards for Stroke Services8 7,000 patients should be admitted to a care in a stroke unit was the include the requirement that at least stroke unit annually. The recent exception. 70% of patients with a stroke admitted Scottish Stroke Care Audit9 (Table 5)

Table 5: Percentage of patients with stroke admitted to a Stroke unit in Scotland at any time and within first day of admission

2005 2007 Change

No. of stroke patients 7,409 7,954 +545

Admitted to any Stroke Unit during admission

Percentage 72 77 +5%

Admitted to a Stroke Unit within 1 day of admission – NHSQiS Standard 70%

Percentage 51 56 +5%

Source: Scottish Stroke Care Audit 2008 National Report9

9 Health in Scotland 2007

Table 6 summarises the potential Coronary Heart Disease period. It also links the associated impact on recurrent stroke of (CHD) costs of implementation to show costs secondary prevention of stroke by use per year of life gained (YLG). Five SIGN Cardiovascular Guidelines of antithrombotics, reduction of blood Implementing the SIGN (93-97)10 published in 2007 cover: pressure, lowering blood cholesterol recommendations would, over a 5-year and carotid endarterectomy (surgical I Risk Estimation and Prevention period, prevent an estimated 7,200 removal of blood clots). I Acute Coronary Syndrome (heart premature CVD deaths and avoid over attacks) 27,000 major vascular events such as

Providing thrombolysis (clot-busting) I Cardiac Arrhythmias in CHD heart attacks and strokes. This is treatment for all stroke patients who equivalent to a 9% reduction in both I Management of Chronic Heart might benefit has been identified by the current CVD mortality rate and CVD Failure the National Advisory Committee for event rate. As a direct result I Management of Stable Angina. Stroke (NACS) as a development NHSScotland could potentially release priority for stroke services in Scotland. The Guidelines created a new over 60,000 bed days, costing some While trials of thrombolysis in stroke landmark in evidence-based £20 million annually, for alternative have not shown statistically significant management of these conditions, but uses. The costs per Year of Life Gained reduction in deaths there is strong also highlighted gaps in current range across the guidelines from evidence that thrombolysis reduces service provision and therefore £3,700 for heart failure nurses to disability preventing long-term potential unmet need. For this reason, £190,000 for all secondary prevention. disability in 1 in 10 patients. SIGN developed the Resource Impact The resource impact assessment Assessment referred to earlier. This estimates that providing statins to assessment will help NHS Boards plan asymptomatic individuals at high risk for the phased implementation of the of CVD provides about 37% of the Guidelines. Table 7 summarises the mortality benefit and 30% of the potential clinical benefits including the potential clinical and related resource number of lives saved over a 5-year released.

‘ Implementing the SIGN ’ recommendations would, over a 5-year period, prevent an estimated 7,200 premature CVD deaths and avoid over 27,000 major vascular events such as heart attacks and strokes. This is equivalent to a 9% reduction in both the current CVD mortality rate and CVD event rate.

10 Chapter 1: Coronary heart disease and stroke: Reducing amenable mortality

Table 6: Estimated impact of interventions to prevent recurrent strokes on the estimated 11,626 strokes occurring annually in the Scottish population

Intervention Number of strokes avoided % of all strokes in Scotland

Aspirin 926 (8%)

Statins to reduce cholesterol 854 (7%)

Drugs to reduce blood pressure 751 (6%)

Dipyrimadole + aspirin 432 (4%)

Anticoagulants 376 (3%)

Carotid endarterectomy 21 (0.2%)

Based on Table 18.4: Stroke: practical management. 3rd Edition. Warlow C et al. Blackwell 2008. ISBN 978-1-4051-2766-04.

11 Health in Scotland 2007 £4,000 £6,500 £5,300 £11,000 £10,000 £10,000 £13,000 £15,000 £68,000 £23,000 £43,000 £120,000 £147,000 gained Cost per year of life £4 £6 £3 £12 £14 £19 £17 £16 £67 £26 £22 £99 £30 £90 £120 £129 £358 (£ millions) Costs over 5 years 64 65 99 50 611 718 106 782 950 960 448 275 230 1,557 7,254 3,395 2,678 Lives saved over 5 years (NSTEMI) Recommendations Secondary prevention total Smoking Statins Diet Heart failure nurses Drugs (combined) Hypertension drugs Treatment of heart attacks (STEMI) Aspirin Primary prevention total Implantable cardiac defibrillators Cardiac resynchronisation therapy Heart failure total Anti-thrombotic (clot-busting) drugs Statins Group Treatment of acute heart attack Total Heart failure Treatment of high blood pressure Primary prevention Secondary prevention Table 7: Impact of SIGN Guidelines Implementation Based on impact assessment of SIGNSTEMI Guidelines = (some ST figures elevation are myocardial combined infarction NSTEMI and = rounded for non simplification) ST elevation myocardial infarction

12 Chapter 1: Coronary heart disease and stroke: Reducing amenable mortality

NHS Boards are working together Conclusion which will be published shortly, through the three Regional Planning reaffirms the position of CHD and The health improvement measures groups to address some of the stroke as national clinical priorities. It and interventions described above identified gaps in interventional seeks to respond to a number of have the potential to save up to 10,000 services. Examples of regional challenges, not least to respond to lives from cardiovascular disease each provision of new services include new developments in evidence year in Scotland, if optimally applied. cardiac resynchronisation therapy reflected in the SIGN Guidelines, and (CRT) (which helps patients with heart to accelerate the downward trend in failure) across Scotland. An Inter- The revised Coronary Heart Disease amenable mortality from CVD Regional planning group is now and Stroke Strategy for Scotland, observed in Scotland over many years. working to ensure optimal reperfusion therapy across Scotland for myocardial infarction (heart attacks due to blood clots in the coronary The health improvement arteries). These treatments include ‘ primary PCI (removing the clot by use measures and interventions of a small catheter inserted into the ’ arteries in the neck) or thrombolysis described above have the (“clot busting” by drug treatment). Other gaps in present service potential to save up to 10,000 provision will undoubtedly need to be addressed in due course to ensure full lives from cardiovascular implementation of the SIGN disease each year in Scotland, Guidelines and the subsequent reduction in death and disability from if optimally applied. CHD and stroke in Scotland.

13 2

Cancer: Reducing amenable mortality Chapter 2: Cancer: Reducing amenable mortality

Introduction Table 1, alongside projected average the 20th century, who took up annual numbers of cases and deaths smoking in large numbers during and Better Cancer Care was published by for the periods 2016-2020 and 2015- after the First World War (Figure 1). the Scottish Government in October 2019, respectively. In the past, 2008. It sets out opportunities for mortality rates from cancer in Scotland Demonstration of the harmful effects of reducing Scotland’s cancer burden. In have been high compared to many smoking in the early 1950s led to addition, BCC highlights advances in other countries. decreases in smoking rates and the early detection of cancer through subsequent decreases in lung cancer screening and improved diagnosis and mortality rates in men from around 1980 treatment. It also described a series of Lung cancer onwards. Women tended to take up actions to support people living with Some 4,500 people in Scotland smoking in large numbers about and beyond cancer. develop lung cancer each year. An estimated 90% of these lung cancers 20 years after men, and although the rate of smoking has generally been In this chapter, I consider the are caused by smoking. The delay lower in women, decreases in smoking prospects for reducing mortality from between first exposure to tobacco and rates were slower to materialise. the four main types of cancer in development of lung cancer is usually Consequently, although mortality rates Scotland: lung cancer, colorectal measured in decades; as a result, from lung cancer have always been cancer, female breast cancer, and current patterns of lung cancer are lower in women than men, rates prostate cancer. Discounting non- driven mainly by historic trends in the continued to increase over time and melanoma skin cancers, which usually prevalence of smoking. The prognosis only showed signs of reaching a plateau have an excellent prognosis (over of lung cancer is usually poor (the during the mid-late 1990s (Figure 2). 8,000 new cases annually with 72 average survival from diagnosis is less deaths in 2007) these four cancers than 6 months); therefore, trends in comprise 54% of all newly diagnosed age-standardised mortality rates Although the ideal is never to start cancers and almost 50% of all deaths provide a reasonable approximation to smoking in the first place, a recent from cancer).11 The numbers of newly the population’s risk of developing the comprehensive review of evidence by diagnosed cases of lung, colorectal, disease. Mortality rates from lung the International Agency for Research female breast, and prostate cancers cancer in men increased to a peak in on Cancer has highlighted the during 2005, and the numbers of the late 1970s particularly among substantial reduction in risk that can 12 deaths during 2007 are shown in those born around the beginning of be achieved by stopping smoking.

Table 1: Lung, Colorectal, Female breast, and Prostate cancer: numbers of newly diagnosed cases during 2005; average annual projected numbers of cases during 2016-2020; numbers of deaths during 2007; average annual projected numbers of deaths during 2015-2019.

Cancer Numbers of newly diagnosed cases Numbers of deaths

2005 2016-2020* 2007 2015-2019*

Lung 4,543 4,304 4,115 3,708

Colorectal 3,412 5,116 1,539 1,575

Female breast 3,998 4,886 1,062 1,021

Prostate 2,420 3,207 793 1,249

* Projected average annual numbers, assuming current trends remain unchanged

15 Health in Scotland 2007

For example, smokers who succeed in emergence of spiral computerised cancer), anaesthetic techniques and quitting by the age of 30 years tomography (CT) scanning and, with post operative care. The introduction eventually reduce their risk of lung rapid developments in the field of of adjuvant chemotherapy for patients cancer by around 90% compared to a molecular biology, the possibility that with more advanced disease has also continuing smoker, and the benefits suitable biomarkers of lung cancer may had an impact. Radiotherapy begin to emerge within 5 to 9 years of be identified and screening tests (especially pre-operatively) can quitting. This scientific evidence developed. However, before any improve local control of disease in supports the Scottish Government’s screening programme for lung cancer some patients with rectal cancer. current emphasis on helping people to can be adopted, it will be essential to While clinical audit shows that many of quit their smoking habit. demonstrate, in the context of a well- the standards for colorectal cancer conducted randomised controlled trial, care are being achieved in Scotland, As rates of smoking continue to that the benefits (in terms of reducing the prospect of cure is highest for decrease, the relative importance of mortality) outweigh the risks (which patients with localised disease, other risk factors will increase, include needless investigation of, and making early detection a priority. reinforcing the need to minimise even surgical resection of, benign exposure to other carcinogens (cancer lesions). Randomised controlled trials carried producing substances) in industrial out in USA, Denmark, and Nottingham and environmental settings. A recent For patients presenting with disease have shown that annual or biennial review of evidence by the World that cannot be cured, chemotherapy screening with a faecal occult blood Cancer Research Fund has also and radiotherapy can play a part in test (FOBT) can reduce mortality from suggested that a diet rich in fruit extending life and in disease palliation colorectal cancer. A subsequent pilot probably reduces the risk of lung alongside more general palliative care study based in Fife, Grampian, and cancer.13 interventions. Tayside NHS Boards established that a national screening programme for Although primary prevention offers the colorectal cancer was feasible. From greatest hope for reducing the impact Colorectal cancer May 2007 a national screening of lung cancer in the medium to long Some 3,500 people in Scotland programme began with the first term, it is important to strive to develop colorectal cancer each year. invitations to 50-74 year olds in improve survival, and improve Trends in mortality rates of colorectal Tayside, Grampian and Fife to symptom control and quality of life cancer for males and females are participate in the new screening among the many people still included in Figures 1 and 2, programme. Other NHS Boards will diagnosed with the disease. While a respectively. The main risk factors for follow with the last rollout planned for very small proportion of patients can colorectal cancer are high levels of 2009. Once bowel screening is be cured by radical radiotherapy, cure consumption of red and processed established, mortality from bowel is most likely to be achieved by meat, high levels of alcohol cancer should decrease by around surgical removal of small tumours that consumption (especially in men), and 16%, preventing approximately 150 have not grown and spread within the body fatness.13 Protective factors premature deaths per year. lung or elsewhere in the body. include a diet rich in fibre and vegetables, and regular physical Research in Scotland has also Unfortunately, the majority of patients activity (which can reduce the risk of increased understanding of the present with tumours that are too colon cancer substantially).13 Since genetic basis of colorectal cancer and advanced for surgery (or they may be trends in these risk and protective in future may lead to improvements in unfit for surgery due to other adverse factors over recent decades have not identifying those most at risk of effects of smoking on their general been favourable, the gradual developing colorectal cancer and health). This unsatisfactory situation reduction in colorectal cancer hence enable better targeting of has prompted an interest in early mortality rates reflects improved prevention, screening, and detection by screening. Despite a series survival. This improvement is mainly treatment.14 of negative clinical trials of screening due to advances in preparation of for lung cancer in the 1970s, interest patients before surgery, surgical has been rekindled in this field with the techniques (particularly for rectal

16 Chapter 2: Cancer: Reducing amenable mortality

Figure 1: Annual age-standardised mortality rates from lung, colorectal and prostate cancers, males, Scotland, 1968-2007

140

120

100

Lung Colorectal e per 100,000 Prostate Rat

0 1968 1971 1974 19771980198319861989 1992 1995 1998 2001 2004 2007

Year of death (registration)

Source: GRO(S)

17 Health in Scotland 2007

Figure 2: Annual age-standardised mortality rates from lung, breast and colorectal cancers, females, Scotland, 1968-2007

140

120

100

e per,00 0 100 Lung

Rat Colorectal Breast

0 1968 1971 1974 19771980198319861989 1992 1995 1998 2001 2004 2007 Year of death (registration)

Source: GRO(S)

18 Chapter 2: Cancer: Reducing amenable mortality

Female breast cancer related cancers among women.16 risk is probably reduced by a diet Other potential avenues for reducing containing lycopene (as found in Some 4,000 women in Scotland mortality from breast cancer include tomatoes, for example), and selenium develop breast cancer each year. Risk future developments and refinements (as found in fish, wholegrain, and factors for breast cancer include in breast screening, and the rapidly wheatgerm, for example).13 Due to genetic susceptibility, and increasing understanding of the remaining uncertainties about the reproductive factors that are not molecular mechanisms of breast precise role of diet in the aetiology of readily amenable to change, such as cancer, which is already leading to prostate cancer, the prospects for early onset of menstruation, nulliparity tailoring of some novel therapies.17 primary prevention are limited at (having had no births), older age at present. birth of first child, and late menopause. Potentially more Prostate cancer Limited prospects for primary modifiable factors include alcohol Some 2,500 men in Scotland develop prevention have led to considerable intake, body fatness (a risk factor for prostate cancer each year. Trends in interest in the possibility of screening post-menopausal breast cancer), use mortality rates of prostate cancer are for prostate cancer by widespread of hormone replacement therapy, and included in Figure 1. The causes of application of the prostate-specific use of oral contraceptives. Protective prostate cancer are poorly antigen (PSA) test. A major challenge factors include breast feeding, and understood. The risk of disease presented by prostate cancer is that probably physical activity, the latter increases with age, and is higher only a proportion of tumours are being especially relevant to post- among men with a family history of aggressive and life-threatening – more menopausal breast cancer. prostate cancer (and possibly some men die with prostate cancer than die other types of cancer), and among from prostate cancer. If screening were The trend in mortality rates from men of African descent. A recent to mainly identify slow-growing female breast cancer is shown in review of evidence by the World tumours with no impact on life Figure 2. The increase in breast cancer Cancer Research Fund suggested that expectancy, it would be unlikely to mortality until 1989 is consistent with diets high in calcium probably increase have a major impact on mortality from increases in incidence most likely the risk of prostate cancer, whereas prostate cancer. However, in the Tyrol driven by changes in reproductive factors. The more recent decrease in mortality is due to better survival, reflecting improvements in therapy, including better quality surgery and The more recent decrease in radiotherapy, and the use of systemic ‘ adjuvant therapy. The Scottish Breast mortality is due to better Screening Programme also contributes ’ to the reduction in mortality from survival, reflecting breast cancer.15 improvements in therapy, Chemoprevention (taking drugs to prevent the development of cancer) is including better quality surgery currently being researched in women at genetically high risk of breast and radiotherapy, and the use cancer, but otherwise, the future of systemic adjuvant therapy. prospects for primary prevention of breast cancer are limited to addressing The Scottish Breast Screening the modifiable risk factors, such as alcohol intake and body fatness. Programme also contributes to Although the magnitude of excess risk of breast cancer due to alcohol is not the reduction in mortality from very large, the high incidence of breast cancer means that alcohol is breast cancer. responsible for more cases of breast cancer than any other type of alcohol

19 Health in Scotland 2007

region of Austria, where treatment is controlled trials in mainland Europe important to identify those men whose freely available to all patients, and and the United States. cancers are most likely to progress. where PSA testing is widespread, While the microscopic features of there has been a reduction in The variable biological behaviour of tumours can help distinguish between prostate cancer mortality different prostate cancers poses those that are slow-growing and those significantly greater than the difficulties for selecting the most that are aggressive, research is reduction in the rest of Austria.18 It is appropriate treatment. The main currently focused on identifying not clear whether this has occurred options for cure of localised tumours specific characteristics of those because of screening and early are radical prostatectomy (surgical tumours that are most likely to detection, or due to more effective removal of the prostate), external progress and warrant intensive treatment (or both). However, the beam radiotherapy, or brachytherapy treatment. The explanation for the balance of benefits and risks of (implantation of small radioactive recent slight decrease in mortality screening for prostate cancer “seeds” into the prostate gland). from prostate cancer in Scotland is remains unclear, and any decision to However, because potential side unclear, but seems more likely to be implement an organised programme effects of treatment, such as due to better application of of population screening must await incontinence and impotence, can established treatments than to early the results of ongoing randomised substantially reduce quality of life, it is detection through PSA testing.

‘ Although rates of mortality from ’ cancer in Scotland have historically been high compared to many other countries, recent trends provide some grounds for optimism. Progress in reducing mortality may be accelerated by uniform application of existing knowledge, as well as new knowledge emerging from research.

20 Chapter 2: Cancer: Reducing amenable mortality

Summary emerging from research. In the long prevention interventions and term, smoking cessation is likely to reductions in cancer incidence, Although rates of mortality from deliver the greatest reductions in coupled with projected increases in cancer in Scotland have historically incidence of and mortality from cancer numbers of cases simply due to ageing been high compared to many other in Scotland, but tackling other risk of the population, mean that effective countries, recent trends provide some factors such as alcohol consumption, screening (where appropriate), grounds for optimism. Progress in poor diet, body fatness, and physical treatment, and palliative care must reducing mortality may be accelerated inactivity will potentially also have a remain priorities for the NHS in by uniform application of existing substantial impact. However, the Scotland. knowledge, as well as new knowledge inevitable time lag between primary

21 3

Liver disease: Reducing amenable mortality Chapter 3: Liver disease: Reducing amenable mortality

Chronic Liver Disease which include cirrhosis but exclude irreversible damage (cirrhosis). Causes Scotland has one of the fastest growing primary liver cancer. of death from cirrhosis include Chronic Liver Disease (CLD) mortality development of liver failure, brain rates in the world at a time when rates The liver is the largest organ in the damage (encephalopathy), in most of Western Europe are body and is responsible for many catastrophic internal bleeding falling19,20 (Figure 1). Deaths from CLD important functions such as (oesophageal varices) and also now account for 1 in 50 of all Scottish processing nutrients, production of primary liver cancer. Most cases of deaths21. These rising rates also essential proteins and removal of hepatocellular carcinoma, the contrast with falling mortality rates in toxins. CLD is characterised by commonest primary liver cancer, occur recent years from the major diseases in scarring and destruction of the liver in patients with cirrhosis. In Scotland Scotland (Coronary Heart Disease, tissue. Early changes, such as “fatty there was a 52% increase in incidence Cerebrovascular Disease and Cancer)22. liver” can progress via inflammation of primary liver cancer between 1987 23 CLD includes a range of conditions (hepatitis) and scarring (fibrosis) to and 2006 (from 178 to 345 cancers) .

Figure 1: Death rates per 100,000 population (age/sex-standardised, using European Standard Population)

1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007

Chronic Liver Disease Alcoholic Liver Disease

23 Health in Scotland 2007

There are a variety of risk factors and actually be due to alcohol use32,33. In During 2006, estimates suggested diseases that cause chronic liver other words, the overwhelming majority approximately 50,000 people in disease. The three commonest risk of deaths from CLD in Scotland are due Scotland are infected with Hepatitis C factors for CLD are excessive alcohol to alcohol. (about 1% of the population). Of consumption; blood borne viruses, in these, three-quarters (37,500) had particular Hepatitis B and C, and Blood Borne Viruses become chronically infected, the obesity. Metabolic disease majority of whom (34,300) will have, (e.g. haemochromatosis, which causes Hepatitis C at some time in the past, injected a build up of iron in the liver) and auto- The virus that causes Hepatitis C was drugs into their bodies. Less than 40% immune disease, e.g. primary biliary first identified in 1989. It is highly of those chronically-infected will have cirrhosis, are relatively rare accounting infectious and is transmitted through had their infection diagnosed. Only for less than 2% of all chronic liver blood borne routes, principally by 1 in 5 (8,000) chronically-infected disease deaths in 200724. The sharing of injecting drug use equipment individuals had ever been in specialist incidence and mortality rates of these but also via blood transfusion (prior to care and only 1 in 20 (2,000) had metabolic liver diseases appear to instigation of testing of blood donors in received a course of antiviral therapy. have changed little in recent time25,26. 1991) and, rarely, by sexual activity and It was also estimated that, at the end mother to child transmission. of 2006, just over 2,000 Hepatitis C Alcohol infected persons in Scotland were Diagnosis of Hepatitis C is confirmed by living with cirrhosis and 1,000-1,500 Alcohol is a potentially toxic and a blood test. Treatment with anti-viral Injecting Drug Users (IDUs) were addictive substance. It is rapidly therapy achieves sustained viral becoming infected annually34,37. absorbed by the body where it is clearance in 50-60% of instances34. The proportion of liver-related deaths detoxified by the liver. A rise in the There is currently no vaccination for that occurred in HCV-diagnosed average population consumption of Hepatitis C. One-fifth of those infected individuals increased from 2.8% alcohol is closely related to an with the virus recover (1995-1997) to 4.2% (2004-2006)38. increase in mortality from CLD27. spontaneously35,36 whilst of the This is likely to be due to high rates of Additional risk factors include gender remainder who develop chronic infection in the 1970s and 80s. (women are more susceptible), a Hepatitis C infection, 5-15% will genetic predisposition and concurrent develop cirrhosis over the next liver disease. 20 years36.

Alcohol consumption in the UK has more than doubled over the past 28 Alcohol consumption in the UK 50 years . In Scotland, at least 40% of ‘ men and 33% of women are drinking over twice the daily recommended has more than doubled over 29 ’ limits . Enough alcohol is sold each year in Scotland to allow every adult the past 50 years. In Scotland, over 16 to exceed weekly limits30. at least 40% of men and 33% Population consumption rises as alcohol becomes more affordable and of women are drinking over available, both of which have occurred in Scotland in recent years1. twice the daily recommended

Eighty-five per cent of deaths from CLD limits. Enough alcohol is sold in 2007 in Scotland were due to Alcoholic Liver Disease (ALD), a rise each year in Scotland to allow from 37% in 197931. Deaths from ALD have been driving the rapid rise in CLD every adult over 16 to exceed death rates in Scotland in recent years (Figure 1). As many as two-thirds of weekly limits. deaths from CLD which are not currently attributed to alcohol may

24 Chapter 3: Liver disease: Reducing amenable mortality

Hepatitis B The Hepatitis B virus is highly It was estimated, in 2003, that infectious and is transmitted through ‘ blood and bodily fluids by unprotected 22% of men and 24% women sex; sharing of injecting drug ’ equipment and from mother to child (nearly 1 in 4) of the Scottish transmission Less than 10% develop chronic infection which in turn can population were obese result in CLD. In the UK it has a lower prevalence than Hepatitis C, with 1 in (BMI >30). Furthermore, the 1,000 people thought to be infected. This contrasts with other parts of the trends in obesity are very world where up to 1 in 10 people are infected39,40. worrying with a 46% rise

In Scotland there were 475 new between 1995 and 2003. reports of Hepatitis B in 2007, up from 375 in 200641. Prevalence is higher in certain ethnic groups. A vaccine against Hepatitis B is available, uptake of which has increased in recent years42. As with Hepatitis C, there is effective drug treatment for established chronic infection. Scotland has the highest level of varices; radiological treatment of small obesity in the western world, second liver tumours and corticosteroids for The proportion of CLD deaths due to only to the United States. It was severe alcoholic hepatitis but these Hepatitis B in Scotland cannot be estimated, in 2003, that 22% of men have a limited effect on mortality determined from routine mortality and 24% women (nearly 1 in 4) of the overall. Surgical intervention through data. Scottish population were obese liver transplantation offers a life-saving (BMI >30). Furthermore, the trends in treatment with survival figures of 75% Obesity obesity are very worrying with a 46% at 5 years49. Approximately 60 patients Non-alcoholic fatty liver disease rise between 1995 and 2003. Obesity per year receive liver transplants in (NAFLD) is a disease of the liver is also commoner in children and 18% Scotland, ALD being the commonest characterised by fatty infiltration with of boys and 14% of girls age 2-15 are reason. These only save a small or without inflammation (non-alcohol obese46. proportion of deaths from ALD as many steatohepatitis or NASH). Previously fail to stop drinking, normally a pre- thought to be benign, it can progress Deaths from NAFLD have risen in requisite for surgery. Liver to fibrosis and cirrhosis in 15-20% of Scotland from 3 in 1979 to 40 in transplantation is costly and is limited patients. It can also result in liver 200747. by the number of donor organs. cancer. Development of NASH and Scotland has one of the lowest organ fibrosis is associated with obesity, Treatment of Chronic Liver donation rates in Europe and at type 2 diabetes, hypertension and Disease present 1 in 4 patients listed for liver high triglycerides25,26. In European Liver disease is often symptomless or transplant die before an organ and US studies, NAFLD affects 3-30% ‘silent’ and freqently does not present becomes available. The commitment of the population, depending on until irreversible. Mortality rates after by the Scottish Government to fully whether blood tests or liver scans are hospital admission are high and have fund the recommendations of the UK the screening test43,44,45. Hospital shown little improvement in the past Organ Donation Task Force, which will admissions for NAFLD in England and 30 years48. Medical interventions can introduce measures aiming to increase Wales have risen in the past prevent or treat complications such as the donation rate by 50% over the next 10 years26. screening and treating oesophageal 5 years, is welcome.

25 Health in Scotland 2007

Action to Reduce Mortality proportionate to the scale of the and alcohol) with consequential from CLD problem. Two other epidemics, of worsening of their disease50. Hepatitis C and obesity, unless tackled Action on Alcohol now will further increase deaths from Tackling health inequalities is a top Although treatment of established CLD CLD. Each will necessitate tailored priority in improving the health of can save lives, public health policies approaches but these should be multi- Scotland51. Those in disadvantaged are the most effective way to reverse faceted, encompassing preventative, communities are 16 times more likely the upward trend of deaths from CLD. harm reduction and early intervention to die from CLD than those in more An epidemic of alcohol misuse is measures as well as treatment and affluent areas and this gap has been driving the current rise in CLD support. It should also be recognised widening over the past 20 years52 mortality. This needs to be urgently that those with CLD may be exposed (Figure 2). addressed and with a response to multiple risk factors (e.g. Hepatitis C

Figure 2: Deprivation and Chronic Liver Disease

Male mortality rate for chronic liver disease per 100 000 population, 1980-2002

90 1980-82 80 1991-92 2000-02 70 60 50 40 30 20 10 Deaths per 100,000 popul ati on 0 1234567 Deprivation category

Female mortality rate for chronic liver disease per 100 000 population, 1980-2002 1980-82 90 1991-92 80 2000-02 70

Deaths per 100,000 popul ati on 10

0 1234567

Deprivation category

Source: Leyland et al., 2007

26 Chapter 3: Liver disease: Reducing amenable mortality

The exact reasons as to why Scotland reduce the spread of infection through whole population but with emphasis in particular has experienced such a injecting behaviours (such as needle on the early years and those at rapid increase in ALD since the early exchange) and encouragement and increased risk of health inequalities. 90s is not entirely clear. One notable support for safe sex are essential. A new national target has been set to difference from the rest of the UK is Given the large number of people reduce the rate of increase in the that Scottish licensing laws were infected with Hepatitis C but not yet proportion of children that are liberalised in 1976. Another factor is identified, it is vital that screening and overweight by 2018. This is supported demonstrated in a recent analysis of testing are implemented with by the delivery of healthy weight sales figures which has shown that, in treatment and support of those newly interventions by Health Boards to the past 3 years, adults in Scotland diagnosed with Hepatitis C. This action overweight children between drank nearly 2 litres more pure alcohol will reduce the future level of death ages 5-15. per person per year than people in and disability due to Hepatitis C in England and Wales. It is known what Scotland. Phase II of the Hepatitis C Summary works in policy terms. The most Action Plan was published in 2008 Scotland is experiencing one of the effective alcohol policy includes funded by £43 million over the next fastest growing rates of chronic liver measures directed at the population three years34. Although prevalence of disease mortality in the world. Recent as a whole as well as targeted Hepatitis B in Scotland is currently rises are predominantly due to interventions for those at risk54. This low, increasing immigration from areas alcohol misuse. Urgent and radical approach has been set out by the with higher prevalence will need action is needed and is being taken to Scottish Government in the recent careful consideration as to whether address this. But two other consultation Changing Scotland’s universal vaccination should be epidemics, that of Hepatitis C and Relationship with Alcohol with the implemented. obesity, unless similarly tackled will express aim of reducing the alcohol add further to the burden of CLD in consumption of the overall Action on Non-alcoholic Fatty future years and increase health population19. It includes measures to Liver Disease inequalities. Treatment of CLD is tackle price and availability as well as Healthy Eating, Active Living was costly and of limited impact on detection and intervention for those published in June 2008. It is an action mortality overall. About one thousand consuming alcohol at hazardous plan to improve diet, encourage people a year die from CLD in levels. These have been shown to be greater physical activity and help Scotland. Most of these deaths are the most effective in reducing alcohol tackle obesity with an additional preventable. Without urgent action related harm55,56,57. The Scottish £40 million over the next 3 years59. there will be many more. Government is already investing some Interventions are aimed across the £100 million over the next 3 years in an ongoing nationwide programme to deliver screening and brief interventions for those drinking excessively. The Government will Scotland is experiencing one publish its next steps on tackling ‘ of the fastest growing rates of alcohol misuse early next year. ’ chronic liver disease mortality Action on Viral Hepatitis Hepatitis B and C share similar in the world. Recent rises are transmission routes so there will be interventions common to both. The predominantly due to alcohol commonest route is through injecting drug use. Efforts to reduce drug use in misuse. Urgent and radical general must continue as well as encouragement of drug users into action is needed and is being treatment and support. The recently published drug strategy sets out the taken to address this. government’s renewed focus and action58. Harm reduction initiatives to

27 4

Risk factors and their impact on disease in Scotland Chapter 4: Risk factors and their impact on disease in Scotland

Dispersing myths on the successful ways of tackling the roots coronary heart disease (CHD)5 and road to better health and realities of drug misuse. 10% of strokes63. There would also be reductions in chronic lung disease and The earlier chapters of this report have The people of Scotland, with the a range of other conditions that can set out some of the biggest health necessary help and support from damage quality of life, including challenges facing Scotland – cancer, national and local government, the blindness, sexual impotence and gum coronary heart disease, stroke and NHS, community and voluntary disease. Moreover thousands of liver disease. They are all in a state of organisations, and businesses and children would be spared damage to flux. Rates of some cancers are falling, employers, can achieve better health their development and health from while other cancers are increasing. by changing how we think and what their mothers’ smoking during Deaths from coronary heart disease we do, learning from successes and pregnancy and parents’ smoking in the and stroke are decreasing – but still evidence drawn from Scotland and home. not as fast as we would like. Trends in elsewhere. mortality from alcohol-related liver Such population figures reflect the disease are rising fast and have put very real benefits that individuals Scotland and one of its increasingly Myth 2 could gain through healthier lifestyles. favoured pastimes in a frighteningly Even if we can change the way we Smokers who quit can enormously harsh light on the international stage. live, it won’t make any real difference reduce their risk of dying from The number of people known to have to our health. smoking-related diseases. The earlier liver disease as a result of Hepatitis C On the contrary, it would make a the better, but even late is better than infection has been growing steadily. massive difference. For example, it has never. been estimated that smoking is In looking at what we can all do to responsible for over 13,000 deaths a Average number of years of life reverse the bad trends and speed up year in Scotland – nearly 1 in 4 of all gained by stopping smoking at the good ones, it is helpful to identify deaths62. If we could make smoking differing ages:65 and dispel some “Scottish myths”. disappear from Scotland we would, in time, rid ourselves of an estimated I Age 30 10 years gained Myth 1 84% of cases of lung cancer, 68%, I Age 40 9 years gained 37% and 26% of cases of cancers of I Age 50 6 years gained Scotland has always been an the gullet, bladder and stomach unhealthy place and always will be. I Age 60 3 years gained respectively4, 19% of cases of You can’t change the way we are. The fact that some health trends are getting better and others worse shows that Scotland’s health can and does change. This can be seen, for If we could make smoking instance, from the continuing decline ‘ in smoking rates among both men and disappear from Scotland we women and from signs that more of us ’ are becoming more physically would, in time, rid ourselves of active60. We can also take heart from the example of other countries such an estimated 84% of cases of as France and Italy where alcohol consumption has been decreasing lung cancer, 68%, 37% and steadily over the past 20 years and, 26% of cases of cancers of the no surprise, so have rates of alcohol- related liver disease61. If other gullet, bladder and stomach countries can do it, so can Scotland. Drug injecting rates have risen steeply respectively, 19% of cases of over the past 30 years, but what goes up can also come down – and will coronary heart disease (CHD) come down if we can find more and 10% of strokes.

29 Health in Scotland 2007

Experts on cancer, heart disease and People who build into their lives at Recommended weekly upper obesity are now very much in least 30 minutes of moderately limits for alcohol agreement about the “ideal diet” intense physical activity at least five I Men: 21 units which if broadly followed by most times a week, as well as feeling the Equivalent to about 7 pints of 5% people could prevent a wide range of benefits to their mental and physical strength lager, or just over 2 bottles cancers in Scotland and much of the wellbeing, can expect to benefit from of 13.5% strength wine. CHD, and would give us a fighting lower risks of heart disease, diabetes I Women: 14 units chance of keeping our waistlines in and some cancers, including bowel Equivalent to less than 1.5 bottles check66,67,68 (see below). By changing and breast cancer. Weight control also of 13.5% strength wine, or fourteen our eating habits, and using statin becomes easier. If that type and level 25ml measures of 40% strength medication where advisable to do so, of physical activity is not feasible for a vodka or other spirits. we could reduce levels of blood given individual, for example due to cholesterol in the population such that physical disability, there may still be Some 50,000 people in Scotland are we could expect to reduce cases of ways of living more actively that now chronically infected with Hepatitis CHD by over two-fifths62. Once again, promote health and wellbeing. C, mainly as a result of injecting heroin this population figure reflects real or other drugs. The country faces a differences that individuals can make If we in Scotland overcame our dual challenge: preventing further new to their own health prospects: for national tendency to drink more infections and preventing the virus instance, researchers have found that alcohol than is good for us, we would from causing severe liver disease, reducing the level of “bad” cholesterol see the same rapid falls in the including cirrhosis and cancer, among in the blood by even a relatively small mortality from alcoholic liver disease those who are already infected. amount lowers an individual’s 5-year that France has seen and would see Tackling the first requires a range of relative risk of a major cardiovascular many other benefits to health, measures aimed at reducing the event by about 20%69. If nobody had everyday life and the social fabric of sharing of drug injecting equipment. high blood pressure, an estimated Scotland. If you keep within the These include education campaigns 13% cases of CHD64 and an even recommended limits for sensible about the dangers of injecting drugs, higher percentage of strokes could be drinking, and avoid binge drinking, needle exchange services and drug prevented. you are less likely to suffer other acute misuse treatment programmes. harmful effects of alcohol, have an Meeting the second challenge needs the availability of high quality The ‘ideal diet’ accident, be assaulted, or cause harm to others. diagnostic and treatment services. I Eat at least five portions of a variety of non-starchy vegetables and fruits every day

I Eat relatively unprocessed cereals and/or pulses at every meal 5 habits for health ‘ I I Consume only small amounts of Avoid smoking tobacco refined starchy food and other ’ I energy dense and “fast foods”, Eat something close to the snacks and confectionery

I Avoid sugary drinks ideal diet I Eat at least two portions of fish a I Be physically active on most week, one of which should be oily I Eat no more that 500g (18oz) of red days or processed meat a week. I Keep within the The evidence is now very clear that regular moderate physical activity is of recommended limits for great benefit for all-round health. drinking alcohol I Never inject drugs

30 Chapter 4: Risk factors and their impact on disease in Scotland

Myth 3 published in 2008, spans actions Myth 4 For a lot of people there’s no point in ranging from tackling poverty and When it comes to health problems giving up smoking, eating more increasing employment, through there must be simple single healthily, taking more exercise or improving physical environments and solutions, if only we could find them. cutting down on the booze – because transport. It also seeks to engage with We certainly have mounting evidence it’s all to do with disadvantage and people and target services to help that a number of specific interventions deprivation. them to have the awareness, can help individuals and the Socioeconomic factors have a crucial motivation, skills, opportunities, population to achieve better health. bearing on health, as seen in support and confidence they need to For example, immunisation has been Scotland’s many health inequalities. make a big difference to their own and shown to protect successive Improving people’s life circumstances, their families’ health and health generations against a range of opportunities and environments are prospects. Achieving such a difference potentially life-threatening or vital to Scotland’s health improvement can be helped by adopting, disabling infections. Modern-day action. At the same time, though, maintaining and fostering the 5 habits developments in medications have research in Scotland has shown, for for health shown below. greatly enhanced health professionals’ example, that the death rates of non- 5 habits for health ability to reduce high blood pressure, smokers in the least well-off areas are reduce blood cholesterol, help people I Avoid smoking tobacco lower than those of smokers in the stop smoking, and cut the risk of most affluent. In a large study of I Eat something close to the ideal cardiovascular disease. middle aged people from Renfrew and diet Paisley, followed up for 28 years, I Be physically active on most days Such things have important parts to female non-smokers did the best of I Keep within the recommended play, but one of the main pieces of all, with surprisingly little difference in limits for drinking alcohol evidence in the field of health the death rates between the most and improvement is that complex I Never inject drugs least affluent non-smoking women70. problems need comprehensive action. While smoking rates have certainly Concerns are often expressed that In the area of smoking, for example, it been coming down faster among more making healthier choices costs money is now widely accepted that success affluent people, targeting and tailoring and is a challenge for people with low needs a wide-ranging package that of smoking cessation services is incomes. On the other hand healthier includes policies relating to the helping many less well off people to choices in a number of key areas can promotion, sale and price of tobacco quit. free up money.The average cost of products; control of smoking in public tobacco leaves the average smoker places; education in schools and other The really important point here is that some £30 per week less well off. settings including through mass we are not in an “either or” situation. Similarly, the cost of drinking alcohol media; and support for smoking Socioeconomic factors affect health, above the weekly sensible levels eats cessation through healthcare both by influencing “lifestyle” and substantially into weekly income. Some professionals and smoking cessation through increasingly understood more physical activities such as walking and services. The Scottish Government has direct biological pathways. Both sets simple exercises have no cost and recognised that the same wide- of mechanisms need to be addressed. increasingly local authorities are ranging approach is needed if we are In addition, action specifically focused providing free access to sports facilities to reverse the upward trend in alcohol- on smoking, diet, physical activity and such as swimming pools and gyms to related harm, by consulting on a bold alcohol needs to be part of the overall people with lower income across age package of measures aimed at mix of actions to increase wellbeing groups. Many community projects reducing overall alcohol consumption, and reduce cancer, cardiovascular across Scotland also support people to including action on the pricing, disease and liver disease across the gain the skills and confidence to prepare promotion and accessibility of alcohol. whole population. That is why the enjoyable well-balanced meals reducing As well as inviting individuals to think report of the Ministerial Task Force on dependency on relatively expensive and again about the place of alcohol in Health Inequalities, Equally Well, often less healthy ready meals.

31 Health in Scotland 2007

their lives, the amount they drink and played by local authorities. trend in levels of overweight and the pattern of their drinking, the One of the greatest challenges for us obesity across the whole population. actions set out reflect social in Scotland, and in many other (See Figure 1.) responsibility issues facing the alcohol countries, now and in the decades industry, and the important parts to be ahead is to address the ever-upward

Figure 1: Obesity prevalance in men and women in Scotland 1995-2003

Obesity prevalence in men in Scotland 1995-2003 30 25 20 BMI >30 cent 15 WC > 102cm Per 10 5 0 1995 1998 2003

Obesity prevalence in women in Scotland 1995-2003

40 35 30 25 cent 20 BMI >30 Per 15 WC > 88cm 10 5 0 1995 1998 2003

Source: Scottish Health Survey

32 Chapter 4: Risk factors and their impact on disease in Scotland

In Scotland by 2003, 22% of men and tempting offers of sugar and fat-laden are to move towards ways of eating 24% of women were obese and rates drinks, snacks and meals in that research clearly shows are best of central obesity (measured by waist supermarkets, restaurants and fast- for us and which is also compatible circumference) were even higher. food outlets, in petrol stations, on the with food for all and a sustainable A further 42% of men and 32% of street, and even on the train. The physical environment. women were overweight. For boys and so-called “obesogenic environment” in girls, 18% of boys and 13.8% of girls which we live is added to by the fact These are just some examples. In a aged 2-15 years were obese. There is that one effect of the creeping nutshell, if we want better health for an association between obesity and increase in the average weight of the everyone, we should be aiming for a deprivation. This is stronger in women population has been an effect on what Scotland where culture, policies, than men and is also seen in school- people think of as a “normal” and strategies, programmes and activities aged children. It has been estimated healthy weight. The average child or on the ground are pointing as far as that one-fifth of cases of obesity in adult of some 30 years ago would now possible in the same direction – Scotland is associated with be considered thin and the average towards better health and greater deprivation71. Most of us are eating adult today would have been thought equality in health. Developments in more than we need, and it is showing to be overweight three decades ago. recent years, and public support for in our expanding waistlines and rising Both adults and children have also these, suggest that Scotland is more rates of diabetes. We are all ultimately become more sedentary in their day- ready than ever to achieve the responsible for what we eat, but it can to-day living. We are also beginning to necessary common purpose and be difficult to know what one is eating, realise the huge environmental cost of united effort – that we may well be at a how that fits with the “ideal diet”, and the way we produce our food, “tipping point”72 where a little more how to make real changes for the transport much of it over huge push will yield an unstoppable better. In any case we are, at every distances, sell it in wasteful momentum for population health turn, being encouraged to eat too packaging, then put about a third in improvement. much of the wrong foods, with the bin. Big changes are needed if we

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35 Health in Scotland 2007 Acknowledgements

Roger Black Editors Editor's Assistants David Brewster Jennifer Armstrong Lisa Brandeschi Martin Dennis Malcolm McWhirter Diane Davis John Dewar Helen Sandilands Frank Dixon David Goldberg Lesley Graham Laurence Gruer Grahame Howard Aileen Keel Gavin MacColl Alistair MacGilchrist Paul MacIntyre Robert Milroy Janet Murray Katharine Sharpe Bob Steele Emma Stevens Andrew Tannahill Linda Thomson Annalena Winslow

This document is also available on the Scottish Government website: www.scotland.gov.uk

RR Donnelley B57023 11/08

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