ANMJ Featured Story

CHRONIC CRISIS Burden of chronic disease on preventable deaths

Thursday 24th May, 2018

Despite being a wealthy, developed country, Australia’s levels of chronic disease, amongst its population, is  soaring, devastating millions of lives, and potentially crippling the health system. Yet a great deal of this disease burden is preventable. Jessica Gadd investigates what lifestyle changes can significantly reduce the chance of developing chronic diseases, and what nurses are doing to assist in disease prevention.

A quick health check for our nation reveals a few disturbing truths. According to the Australian Institute of Health and Welfare, half of us have at least one long-term, ‘chronic’ or ‘non-communicable’ disease, such as cancer, obstructive pulmonary disease, diabetes, or a mental health disorder.

One quarter of Australians, have two or more chronic diseases – the most common combination being cardiovascular disease and arthritis. Moreover, around seven in 10 deaths (73%) in Australia are due to chronic disease.

In addition to the obvious, devastating effects, these diseases have on individuals and their families, many of them have the potential to stretch Australia’s health system beyond its capacity.

Diabetes, for example, is increasing at such a rate that Diabetes Australia has labelled the disease as a silent pandemic. They state it is ‘the biggest challenge confronting Australia’s health system’, with 280 Australians being diagnosed with the disease every day. That’s one diagnosis every five minutes, adding up to a total of around 1.7 million people with diabetes. This includes all types of diagnosed diabetes (1.2 million known and registered) as well as silent, undiagnosed type 2 diabetes (up to 500,000 estimated). As a consequence Diabetes costs the healthcare system an estimated 14.5 billion every year.

Grouped together, chronic conditions are responsible for around three quarters of Australia’s total ‘burden of disease’ – a set of statistical techniques used to measure the impact that diseases, health conditions, injuries and various health risk factors have on the population.

Yet most concerning is that chronic diseases are responsible for the shortening of lives. According to the Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011, released by the Australian Institute of Health and Welfare, Australians lost a staggering 4.5 million years to premature death or living with illness.

AUSTRALIA'S TOP HEALTH CONCERNS AND RISK FACTORS

In Australia, the leading causes of death in 2016 were ischaemic heart disease, dementia (including Alzheimer’s disease), cerebrovascular diseases, cancer of the trachea, bronchus and lung, and chronic lower respiratory diseases.

The greatest public health burdens were cancer, cardiovascular disease, mental and substance abuse disorders, and musculoskeletal conditions and injuries, which accounted for 66% of the total burden of disease in Australia.

“Unquestionably, health in Australia and premature mortality is dominated by the non-communicable diseases,” says University of Melbourne Laureate Professor Alan Lopez, co-author of the Global Burden of Disease Study.

This study is the world’s most com-prehensive observational epidemiological study, describing and examining mortality, morbidity injuries and risk factors, and enabling an understanding of global health challenges.

Professor Lopez says the rise of chronic disease in Australia is part of a worldwide trend.

“The key thing to note is that the global epidemiological environment, as measured by the burden of disease, suggests that the main causes of health loss in the world today are not measles, diarrhoea and pneumonia, as important as they are, but non-communicable diseases like stroke, cancer and ischaemic heart disease.”

What is more, one third of this chronic disease, including cardiovascular disease, stroke, dementia and some cancers is preventable.

While this might seem a staggering claim to some, it is backed up by numerous studies, including the Global Burden of Disease Study, which has found many chronic diseases have avoidable risk factors, most commonly: smoking, alcohol, obesity, poor diet and a lack of exercise.

The Australian Institute of Health and Welfare estimates that 31% of Australia’s burden of disease could have been prevented, by reducing exposure to modifiable risk factors such as these.

“Let’s look at cancer, for example,” says Professor Lopez. “If you take populations of people who smoke and people who don’t smoke, and you follow them through, then of the deaths from cancer in those populations, about one-third of them will be due to smoking. You can calculate that epidemiologically. So, using these fractions as a frame of reference, we can legitimately say that one third of these cancer deaths are preventable – because you don’t need to smoke.”

OBESITY – A GROWING PROBLEM

Smoking and alcohol consumption are the leading disease risk factors, but obesity, having tripled in the past 30 years, is not far behind them. Obesity is estimated by the Grattan Institute to cost Australia more than $5 billion a year in welfare expenditure, healthcare costs and lost income taxes.

“Obesity is a big issue in Australia,” says Professor Lopez. “It’s not clear that it’s leading to massive premature mortality in itself, but it is certainly leading to various illnesses like diabetes and some of the cancers, and many of the musculoskeletal conditions are directly related to people being obese.”

Professor Lopez says, despite the clear health hazard presented by obesity, it’s been difficult to find population-level interventions that work in reducing levels of excess body fat and obesity in the Australian population.

“There’s possibly reasons for this relating to the promotion of sugar in the population and the fast food industry,” Professor Lopez says.

“So, there’s definitely still a big agenda there for prevention in Australia around diet, around better food choices and also to be aware that it’s not all about exercise. I’m sure the fast food industry would like us to think ‘Oh I’ll just exercise more’ – well, you need to exercise an awful lot just to burn off one ice cream.”

MAKE THE HEALTHY CHOICE THE EASY CHOICE

This sentiment is echoed by Public Health Association Australia CEO and former ACT Health Minister Michael Moore AM, who argues providing information to help people make healthier choices is an important step towards solving the obesity crisis. He says there are two obvious ways to do this – either by restricting junk food marketing to children, or at least matching it with an equal amount of healthy message advertising.

“The government is really reluctant to interfere with that kind of marketing, but the reality is that if they want people to make reasonable and informed decisions, then they should be hearing messages from both sides. None of us want taxpayers’ money spent on the latter, so the government has a responsibility to enact that kind of restriction, which doesn’t cost very much money, and is therefore not a budget issue.’

A 2017 report from Deakin University revealed that ‘big food’ lobbyists have significant influence on Australia’s health policies, swaying public policy decisions with political donations – and by emphasising the importance of the big food industry’s economic contribution. Moore says that for this reason, transparency of political donations is critical.

“I think that if we want to see a healthier society we really need, in the broadest possible way, to look at our democracy. A healthy democracy equals a healthy society,” Mr Moore says. “For example, just look at how industry has had an influence around the sugar tax. We do have to keep in mind that one of the big influences on this government is the rural sector, and we have seen a small number of electorates in Queensland, in particular, that are really dependent on sugar.”

Calls to introduce a sugar tax on sugary drinks in Australia, which would work in much the same way as the tax on cigarettes, have repeatedly met with political resistance.

A press release from Health Minister Greg Hunt in February 2018 states: “Obesity and poor diets are complex public health issues with multiple contributing factors, requiring a community-wide approach as well as behaviour change by individuals. We do not support a new tax on sugar to address this issue.”

Yet a tax on sugary beverages has been successful in reducing sales of sugary drinks in around 20 countries. Mexico, for example, introduced such a tax in January 2014, and saw sugary drink sales drop by 6% by the end of the year, and a further 6% in 2015. 

“Picture a family and grandparents sitting around a table, and the child spooning eight teaspoons of sugar into its cup of tea,” Mr Moore says. “Just imagine the frowns on the adults’ faces, and yet every time we give a child a can of soft drink, they’re getting at least that much sugar. But when it’s in a can nobody frowns. And then we wonder why our kids are becoming obese!”

Mr Moore is encouraged by recent government announcements regarding a new focus on preventative health, but he points out that at just 1.6%, Australia’s spending on preventative health has a long way to go to catch up to countries such as New Zealand and Canada. These nations devote about 6% of their health budgets to prevention, and reap the results in terms of lower overall health costs per capita than Australia.

PREVENTION IS BETTER THAN CURE

The good news is avoiding these risk factors increases your chances for good health and avoiding chronic disease. It can also prolong your life – significantly.

According to a recent American study published in US journal, Circulation, 50 year olds who avoid these risk factors and keep healthy habits, maintaining a moderate level of exercise, healthy body-mass index and healthy diet, and avoiding cigarettes and too much alcohol – typically live 12 to 14 years longer than 50 year olds who don’t.

Rosemary Calder, Director of Victoria University’s Australian Public Health Policy Collaboration, argues that Australia needs to make a substantial shift, turning the focus from treatment of disease to the prevention of it.

“Most chronic diseases are related to our national lifestyle, the way in which we live and work, and they have, in many ways, the same capability of being prevented and or minimised as we’ve discovered in infectious diseases,” Ms Calder says.

“We no longer have hospitals overwhelmed by infections, because we have built early intervention strategies such as improved sanitation and vaccination programs. We haven’t taken the same logic to chronic disease and yet the evidence is very strong that prevention and early intervention works. We haven’t yet seen chronic disease as a critical health policy issue requiring the same approach to prevention.”

The difference with chronic disease is that the impacts are gradual, and it doesn’t have the same, immediate impact, Ms Calder says. “I think that is why we are complacent about this issue. But, we also know that people with multiple chronic diseases are more likely to die earlier than others, by a significant margin, and that ought to be a matter of national concern.”

Ms Calder considers one solution is for general practices to become genuine primary healthcare providers, with practice nurses, dietitians, and social workers being able to provide health management including diet and physical activity related interventions.

This model is slowly being adopted by general practices, particularly by practice nurses. In 2008 the Australian Health and Welfare Institute reported there were around 10,000 practice nurses working in 60% of Australia’s general practices.

Practice nurse Jackie Eyles says that the bulk of her day-to-day work is around health promotion, chronic disease management, and emotional and mental health support. She says that the biggest barrier to making lifestyle change is often motivation, as well as financial concerns – such as the cost of medical appointments, gym memberships, and a perception that healthy food costs more.

“I think that people have an awareness of risk factors, to a certain extent, and often that’s the reason why they’re presenting, because they want to make changes, but they don’t know how,” Jackie says.

“People often struggle to stay motivated because of the cost involved, so a big part of my role is coming up with ideas that might support better healthy choices within their friendship groups that don’t necessarily have to cost money, such as going for a walk with friends, rather than meeting them at a bar or a café.”

Jackie says making healthy lifestyle choices can be complex.

“I’m in a small rural community where the focus is on red meat and dairy because it all has an impact on farming and local incomes. So if people decide to go dairy free, or reduce their red meat intake, then often there’s the view that you’re not supporting that community’s, or your family’s way of life. And there’s the flow on effect from that. If people pack up and go, then we lose health services; if we lose numbers at the school, then we lose teachers, and so on.”

Jackie says it often takes an illness in a friend, family member or prominent community member to alert people to the importance of their own health. “I see that immediately, because someone will get sick, and then other members of the community start coming in to say: ‘I’m a bit worried about this, because I’ve also been a regular at the pub for 30 years’, or whatever the relevant lifestyle choice might be.”

BLAMING THE INDIVIDUAL IS NOT THE ANSWER

But Jackie is cautious about using the term ‘lifestyle disease’, because it shifts the focus to the individual, which can have negative effects on people’s self-esteem and mental health thus compounding the problem and discouraging positive outcomes.

“As a practice nurse, I want to help improve the patient’s life – to have an open conversation about that person’s wellbeing as a whole, so they’re able to be on the planet longer, to make better health choices, and be part of that positive lifestyle change.”

Rosemary Calder would also like to see a shift away from blaming individuals.

“We have this attitude in Australia, which gets too much airplay, that it’s your choice; it’s your fault. But if you’re a mum on a low income, and you don’t have access to a car, unfortunately you will find that fast food is cheaper and more accessible for you than chicken and fresh vegetables. You can get it delivered. You possibly could live in a small flat, so there is nowhere for your children to exercise, either.

“Now, that is not a choice that’s made. It’s not a fault. It’s not a failure – it’s a problem that we as a nation should be concerned about, because that’s all leading to preventable chronic disease. And preventable chronic disease is everybody’s business.’

In 2016 the Australian Health Policy Collaboration released Getting Australia’s Health on Track, a report that outlined a series of 10 priority policy actions designed to reduce preventable illness and disability in the population. The organisation says that failure to address this issue will result in ongoing increases in the burden on health services, with soaring hospital admissions for conditions with preventable causes.

“I’m not arguing for new money, I’m arguing for a better use of existing money,” Ms Calder says. “The proposals outlined in this report are all affordable, feasible, and implementable now. And if taken together, like a prescription, they would start to make a significant difference to the nation’s health.

“Particularly for the vulnerable populations – that’s the 10 million Australians who have income and socioeconomic status in the lower 40%. It’s in that part of our community for whom chronic disease has its worst impact. For the most recent four-year period, that 40% experienced 49,000 more deaths from chronic disease than the wealthiest 40% of Australians. Now that’s an awful road toll.”

ANTI-SMOKING – A PREVENTATIVE HEALTH SUCCESSS STORY

Ms Calder sees Australia’s road safety and smoking campaigns in the 1970s and 1980s as examples of really effective preventative health campaigns. She says that, had we not addressed those two major issues when we did, Australia’s health landscape would look very different today.

“People were dying from tobacco-related cancers and people were dying from road trauma, and the health professionals whose business was to repair the carnage could see that it had to stop.

“So public health strategies, initiated by concerned clinicians, started addressing both those areas, and Australia’s measures were really effective – they led the way, worldwide. If that hadn’t have happened our hospital system these days would be absolutely dominated by rehabilitation hospitals, and our social welfare would be dominated by disability support.”

Both Professor Lopez and Michael Moore agree, citing also taxation, restrictions around smoking in public spaces, and the introduction of plain packaging as successful tobacco prevention strategies.

“The Australian government uses Global Burden of Disease data to monitor program impact in key areas of population health, including tobacco control,’ says Professor Lopez. “

In men in the 1970s and1980s, tobacco was the cause of about one in three deaths in middle age. Because of the immense tobacco control efforts in Australia, that fraction has declined dramatically, and it’s probably now under one in 10 deaths in middle age.

“But in Australia, we can’t take our eye off tobacco – we haven’t won that one yet. It’s still a significant cause of disease burden at around 10–12%. In other words – the Australian population would be 10–12% healthier if no one had ever smoked in Australia. But we can certainly say that those bold public policy anti-smoking interventions are now paying off and saving thousands of lives”

 

To read more articles from ANMJ, view the full journal online at issuu.com/australiannursingfederation/docs/anmj_june_2018_issuu