Lifestyle is the key

Life expectancy for Australians is higher now than at any time in our history. We are very lucky on the world stage because both our females and males have life expectancies that are in the top handful among all countries. However, it costs a lot of money to make it to where we are on this league table.

The Commonwealth Government spends more than $50 billion on health care each year and it is growing at a rate that is unsustainable. Additionally, looking at the life expectancy figures is not really telling us the whole story. The key statistic is the length of life we have that is free from significant disease and disability. These years are called disability-free years.

The gap between disability-free years and life expectancy, a gap where people require care, is now increasing. The economic burden to maintain this gap is all the more worrying in that demographic shifts will mean that it is borne by a diminishing proportion of young workers. There will also be a critical shortage of these workers to care for the ageing disabled.

We are living longer on average but almost all of the gains in the last two to three decades have been additional years we live with chronic illness and disability.

In Australia and around the developed world, there have been rapid increases in the prevalence of chronic diseases, for example, diabetes, excess fatness and high blood pressure. Diabetes prevalence reached over one million in Australia in 2001 and is predicted to be over three million in 20 years. Overweight and obesity trends are very rapidly increasing particularly among young adults, adolescents and children. Almost two-thirds of all adults are overweight. About 30 per cent of those less than 18 years are overweight but this figure is likely to mirror those of adults within the next couple of generations.

When these trends are combined with decreasing levels of physical activity in the lives of most people then it is clear the prognosis for disability-free years is poor.

What are we doing about this situation?

In the world of the quick fix many people and institutions, such as the health care system itself, are looking to address the symptoms the easiest and often the quickest way possible. For example, much of the current gains in life expectancy are bought at the cost of greater access to surgical and pharmaceutical health care treatments. It is a short-term option that may artificially prolong life but it fails to reduce the gap between life expectancy and disability-free years. These are being used to treat risk factors for a range of cardiovascular, metabolic and respiratory diseases.

Trends in the use of anti-hypertensives, lipid-lowering drugs, and anti-coagulants show they are being employed more and more, often pre-emptively. Studies have shown people are more likely to try to reduce risk factors if there is a pharmacological solution available and less likely if a behavioural solution is required. The attitude is to not worry about the impact of a poor diet if medication to help lower high cholesterol will do the trick.

There is no question that surgical treatments such as bypass grafts, angioplasty and stenting are important and help reduce the mortality of coronary heart disease. The number of operations in these areas increased from about 15,000 to almost 60,000 per year during the decade up to 2000. The fact that initial heart attack rates increased during the same time, much of it due to poor diets, smoking and sedentary lifestyles, is often overlooked.

Then there is liposuction and gastric banding that try to prevent the obese from becoming the super-obese. The super-obese are those who weigh over 250kg. Until the 20th century these body weights were virtually unheard of. Many super-obese over 400kg have now been reliably recorded. There is a legitimate argument that these procedures save the community even more expense down-stream when these patients are bedridden and require intensive care. This is probably true but there are still the upfront medical costs that need to be covered by the finite resources of our health care budget.

Collectively, these pharmaceutical and surgical treatments are expensive. This is why less that 1 per cent of the $50 billion health care budget is left to spend on health promotion - preventive health care. There is nothing left in the pot to work with at this end of the continuum. Once the health care system is established and funded to focus on treatments then it is extremely difficult to realign funding models to place greater emphasis on promoting healthy lifestyles. A few hundred million here or there is simply not enough: too little, too late.

On an individual level there is also evidence to show many people want an instant fix. Changing behaviours, even when they improve the quality of life, are difficult to effect.

More and more people are using “corrective or cosmetic” surgery to overcome symptoms of an over-indulgent lifestyle. This demonstrates the immediacy of our thinking and actions. If a person can’t work out in a gym, backyard, or even regularly walk, or they simply can’t be bothered then there are implants available for greater looking pectoral or gluteal muscles. Throw in a breast augmentation and a tummy tuck for good measure.

Ever wondered why diet books and weight loss products are a multi-billion dollar industry in Australia alone? Excess fatness is the most important risk factor for diabetes yet people can’t seem to help themselves or the public purse. When there is either a faster option or an expectation that the system will eventually take care of me - “I can have my cake and eat it, or two”.

The trouble with all of these treatments, pharmaceutical, surgical or otherwise, is that the benefits are typically one-dimensional. If you take statins then, sure, it helps to reduce blood lipids and fatty plaques but this is also a benefit of regular physical activity. However, with an active lifestyle you also get the return of a larger and stronger heart, more capillaries to carry oxygen in the heart and skeletal muscles, more elastic blood vessels that are less likely to rupture to cause strokes and heart attacks, better control of body weight and blood pressure, stronger bones and muscles to reduce the chance of osteoporosis and falls as we age, and the list goes on and on.

Where to from here?

Almost nothing changes in terms of behaviours unless there are inducements or penalties, or both, in place. Take smoking for example. Three decades ago when the prevalence rate in Australia was around 40 per cent who would have predicted this to fall to less than 20 per cent today? No one, and it wouldn’t have happened if it wasn’t for legislation to add taxes; to prevent advertising through most avenues; to restrict the sale to minors and in how it is sold on site; the illustrations on packaging the damage that is done to health, and so on. Educational campaigns may have been useful, although it is difficult to tell, but clearly the big-stick approach changed behaviour.

Educational campaigns have been run in Australia promoting more physical activity and how good it is for one’s health. Follow up surveys reveal more than 90 per cent of the population know it is good for them and what they need to do. Repeat state and national physical activity surveys also show the rate of sufficiently active adults has flat-lined at about 50 per cent of the adult population. People report a “lack of time” as the single most important reason for not achieving adequate levels of physical activity. Dig a little deeper and you find that (despite what they say) those who are most likely to reach a sufficient level of activity are those with the least amount of leisure time. Those least likely to be active are those with the most leisure time. We also know that for each additional hour of leisure time we get, about 50 minutes is spent on screen-based entertainment.

The answer is not a simple one. For some people there are more important day-to-day struggles with mortgages, children, work commitments and on and on. Should anything be more important than your own health or the health of the broader community?

Let’s make a greater effort to both reconstruct the health care system to more adequately “front-load” the spending model and address the inequalities of health and disability. This will only work if, as part of the model, there is also a greater emphasis on rewarding lifestyle choices that reduce the national burden of disease and disability.