Chief Medical Officer's Report Part 2: The Health of the Nation

Health Improvement:

Premature mortality

Premature mortality has reduced substantially in recent years, down 38% since 1994. There have been particularly large falls in early deaths due to heart disease (71%) and stroke (69%) over the last 2 decades, while premature deaths due to cancer - the leading cause of death - have reduced by 28% over the same period. However, around 20,000 people in Scotland still died before the age of 75 in 2014.

Death rates (<75y) per 100,000 population by selected causes, Scotland 1994-2014

There is a clear association between excess mortality and mental wellbeing. A recent population-based historical cohort study found that the average reduction in lifespan in those previously hospitalised for mental disorder compared with the general population is 17 years. People with eating disorders (39-year reduction) and 'complicated' personality disorders (27.5-year reduction) were worst affected.

The Scottish Government's Long term Monitoring of Health Inequalities Headline Indicators Report shows that the absolute gap in premature mortality between the most and least deprived deciles has continued to reduce since 2002. However, in 2013 premature mortality relative rates were 3.2 times higher in the most deprived areas than in the least deprived areas, compared to 2.7 times higher in 1997.

All-cause mortality (<75y) by deprivation, Scotland 1997-2013
(European Age-Standardised Rates per 100,000)

Co-morbidity

Co-morbidity is the concurrent existence of 2 or more health conditions in the same individual. The clinical consequences of co-morbidity on outcomes for people and for health and care systems are widely acknowledged. For example, the challenges associated with delivering effective, safe and person-centred treatment, care and support in the context of health and care systems and guidelines that are largely structured around single diseases.

The World Health Organisation (WHO) considers mental wellbeing to be fundamental to their definition of health. Mental disorders often co-exist with other diseases, including cancers and cardiovascular disease, and risk factors such as obesity, excessive alcohol consumption, and low levels of physical activity, are common to both mental disorders and other non-communicable diseases.

The Scottish Health Survey (SHeS) shows that 46% of adults (aged 16 and over) had at least one long-term condition. This figure was comprised of 31% who had one or more limiting conditions, and 15% with only non-limiting conditions. Of those with at least one limiting physical condition, just over a quarter (26%) showed signs of the presence of a psychiatric disorder. Conversely, almost half (48%) of those showing signs of a psychiatric disorder also had a limiting physical condition.

Co-morbidity in Scotland, 2012-14

Obesity and Diet

Obesity occurs when energy intake from food and drink consumption is greater than energy requirements of the body's metabolism over a prolonged period, resulting in the accumulation of excess body fat. It is responsible for about 5% of deaths a year worldwide, and its global economic impact amounts to roughly $2 trillion annually, or 2.8% of global GDP or nearly equivalent to the global impact of smoking.

Obesity can reduce people's overall quality of life, create a strain on health services and lead to illness and premature death due to its association with serious chronic conditions such as type 2 diabetes, cardiovascular disease (including hypertension and stroke), and a range of cancers. Severely obese people have been found to be 3 times more than those of healthy weight to need social care and obesity is linked to infertility in women and impotency in men. In addition, some mental health problems such as depression, bipolar disorder and anxiety are associated with obesity, although the direction of causality is uncertain. While additional longitudinal data is required to fully understand drivers, research suggests that overweight and obese children are at greater risk than children of healthy weight to become obese adults, and have a higher risk of morbidity, disability and premature mortality in adulthood.

The Scottish Health Survey 2014 found that almost two-thirds of adults (65%) in Scotland were overweight or obese (Body Mass Index (BMI) > 25), with 28% classified as obese (BMI > 30). In addition, around one in six (17%) of children were at risk of obesity, with a further 14% at risk of overweight. There has been a significant increase in the proportion of adults aged 16 to 64 categorised as obese, from 17% in 1995 to 27% in 2014, although the level has remained fairly constant since 2008. Women have higher rates of obesity than men (29% compared to 26% in 2014) with obesity rates highest in areas of greater deprivation. This pattern is particularly marked among women in the most deprived quintile in 2014 having obesity rates 16 percentage points higher than women in the least deprived quintile.

Obesity rates (adults) by gender and deprivation, Scotland 2003-2014

Poor diet continues to be a major driver of the obesity epidemic. Food Standards Scotland published their latest review of progress against the Scottish Dietary Goals (SDGs) in April 2015. It reported there was little progress towards meeting the goals over the period 2001 to 2012. This was apparent across all deprivation groups. In 2014, the SHeS found only one in five adults (20%) and one in seven (14%) children met the recommendation of at least 5 portions of fruit and vegetables a day, while around one in ten adults and children consumed no fruit or vegetables. The SHeS 2014 also demonstrated an increase in daily consumption of sweets / chocolates and of non-diet soft drinks among the most deprived quintile. As shown below, at least daily consumption of non-diet soft drinks by women living in the most deprived areas has increased by 10 percentage points in just 6 years and is now 2.5 times higher than women living in the least deprived areas.

Consumption (once or more per day) of non-diet soft drink, by area deprivation and sex, Scotland 2008-2014

The Scottish Government and COSLA published the Prevention of Obesity Route Map in February 2010. The Route Map makes a long-term commitment (over 20 years) to tackling overweight and obesity, to help achieve a healthier Scotland and contribute towards sustainable economic growth. The Programme for Government 2015/16 contains a commitment to update the Route Map, including an aim to identify and adopt new actions.

The Supporting Healthy Choices (SHC) framework outlines the Scottish Government and the Food Standards Scotland ambition to work collaboratively with partners to improve Scotland's diet and tackle health inequalities. Rebalancing our diet, and that of our children, is a responsibility shared between individuals, communities, industry and Government. The food and drink environment has enormous potential to encourage and influence healthier choices, across the whole food journey from advertising and in-situ marketing to reformulation and provision of healthier products. This SHC framework is centred on rebalancing the Scottish diet using four core principles:

• put children's health first in food-related decisions
• rebalance promotional activities to significantly shift the balance towards healthier choices
• support consumers and communities with education and information
• formulate healthier products and menus across retail and out of home catering

Physical activity

There is strong scientific evidence that sufficient, regular physical activity is beneficial for the health of body and mind. Physical activity improves the health of the heart; skeletal muscles; bones; blood; immune system and nervous system; and reduces the risk of over twenty five chronic health conditions, including coronary heart disease, stroke, type 2 diabetes, cancer, obesity, mental health problems and musculoskeletal problems. Physical activity improves psychological wellbeing; self-perception and self-esteem; and mood and sleep quality. There is also evidence it can help prevent or delay the onset of functional limitations, improve functional ability, and reduce falls, as well as contributing to the maintenance of cognitive function and delaying the onset of cognitive decline associated with ageing. Increasing physical activity in older adults is therefore an important way to improve healthy life expectancy.

In contrast, physical inactivity shortens life expectancy. The most recent global estimate is that inactivity is responsible for 9% of global mortality, or 5.3 million of the 57 million deaths that occurred worldwide in 2008, making inactivity the fourth leading cause of global mortality.

In 2014, 63% of adults in Scotland met the guidelines on moderate or vigorous physical activity (MVPA) of at least 150 minutes of moderate, or 75 minutes' vigorous activity, or an equivalent combination of the two, per week. This figure has not changed significantly in the 2012-2014 period. Men are more likely to meet the physical activity guidelines than women (68% v 59% in 2014). Activity levels are significantly associated with age, with adherence in 2014 highest among adults aged 25-34 (79%), and steadily declining with increasing age, with the lowest proportion found among adults aged 75 and over (26%).

About a fifth (22%) of the adult population were inactive in 2014 - doing less than 30 minutes of moderate activity (or 15 minutes of vigorous activity) per week. The trend has also been stable in recent years. The groups most at risk of being physically inactive in Scotland are: those with a disability and/or long-standing poor health; older age groups; women, teenage girls and ethnic minorities (particularly of South Asian origin).

UK guidelines on physical activity also state that adults should carry out activities that strengthen muscles on at least 2 days per week. Adherence to the muscle strengthening guidelines is lower than adherence to the guideline on MVPA. Only a quarter of adults in Scotland (26%) met the recommendations for both MVPA (150 minutes) and muscle strengthening (2 days per week) in 2014.

As shown, 76% of children aged 2-15 met the physical activity guidelines of being active for at least 60 minutes per day in 2014, an increase from 71% in 2008. However, the Scottish Health Survey also finds that, while the gender gap between boys and girls physical activity has narrowed since 2008, teenage girls activity levels remain markedly lower than teenage boys.

Physical Activity among young people, Scotland 2014

As with other population health challenges like diet and obesity, addressing physical inactivity is complex and requires multiple actions and interventions across a range of sectors including education, transport and environment and health. Scotland's Physical Activity Implementation Plan sets out a range of actions being delivered with partners in environment, workplace settings, healthcare settings, education settings and sport and active recreation. These actions contribute to the long term outcomes sought for sport and physical activity in Scotland as articulated in the Active Scotland Outcomes Framework (see below), developed collectively with national and local partners through the National Strategic Group for Sport and Physical Activity (NSG) and published in 2014. A suite of indicators is used to measure and report on progress which includes measures of both opportunity and outcome.

This info graphic was developed from the UK Chief Medical Officers' 2011 Physical Activity Guidelines. It is designed for use by healthcare professionals but has been well received by many others and shared widely using social media.

Alcohol

Scotland's relationship with alcohol continues to be a challenging one. While the most recent data paints a mixed picture: consumption relatively stable, alcohol-related deaths up for the second year running, hospital admissions continuing to fall, the scale of the problem remains clear. Alcohol sales data show that adults in 2014 Scotland drink almost a fifth more than our counterparts in England and Wales (fuelling higher levels of harm), rates of alcohol-related hospital admission are 4 times higher than they were in the early 1980s and we have the highest rate of alcohol liver disease and cirrhosis in Western Europe. And it is those living in our poorest communities that are hit hardest. Mortality rates among those living in the 10% most deprived communities are around 8 times higher than rates in the least deprived areas of Scotland.

Alcohol-related deaths by deprivation decile, Scotland 2014

However, one potentially important development is the increasing number of people who are choosing not to drink. SHeS 2014 shows an increasing proportion of both men and women abstaining from alcohol over the last decade, with 14% of men and 18% of women now non-drinkers. Non-drinking is most common among those aged 75 and over but is prevalent across all age groups, with, for example, 13% of 16 to 24 years being abstinent. The highest rates of non-drinking are found among those living in the 20% most deprived areas of Scotland, with 1 in 5 reporting not drinking alcohol.

The Scottish Government's Framework for Action includes over 40 measures to reduce the damaging impact of excessive alcohol consumption. During 2014-15, almost 100,000 alcohol brief interventions were delivered to assist individual cut down on their drinking, while the target of ensuring that over 90% of clients wait no longer than 3 weeks from referral received to appropriate drug or alcohol treatment that supports their recovery continues to be exceeded each quarter. The UK CMOs' new consultation on guidelines for lower risk alcohol consumption were launched in January 2016. The main recommendations are that men and women are advised not to regularly drink more than 14 units a week; to spread drinking over three or more days if drinking as much as 14 units a week and there is no safe amount of alcohol that can be drunk during pregnancy.

Tobacco

The World Health Organisation considers tobacco to be one of the biggest public health threats the world has ever faced, killing nearly 6 million people a year worldwide. Smoking is the leading preventable cause of ill-health and premature death in Scotland, with half of all regular cigarette smokers estimated to die prematurely as a result of smoking. Smoking is associated with around a fifth of all deaths, and around 128,000 hospital admissions, per year in Scotland. This places considerable pressures on NHS services with annual costs potentially exceeding £0.5 billon.

The Scottish Household Survey 2014 found that adult smoking prevalence was 20%, a drop from 23% in 2013. This is the sharpest year-to-year decline in smoking rates over the duration of the time series. The decline in 2014 brings smoking prevalence in line with our projections towards the 2034 policy target (smoking prevalence of 5% or less by 2034). However, as with many other lifestyle factors significant inequalities remain: in the 20% most deprived areas 34% of adults smoke, compared to 9% in the least deprived areas.

Smoking prevalence: 1999-2014 and Projected smoking prevalence towards 2034 target

Figures from the SHeS 2014 showed that 11% of children are exposed to others' smoke in the home. We have set a target of a reduction to 6% (from the 2013 baseline of 12%) by 2020 and have run the Take it Right Outside social marketing campaign to help make parents aware of the dangers of smoking in the home and in cars. Exposure to second hand smoke will also be tacked via the Smoking Prohibition (Children in Motor Vehicles) (Scotland) Bill which bans smoking in cars when an under-18 is present. The Bill was passed by Parliament in December 2015 and is expected to come into force later this year.

The Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill reaffirms our commitment to tobacco control with further measures to limit its availability to under-18s, the introduction of the Challenge 25 age verification policy, and a new offence of smoking within a designated perimeter around buildings on NHS hospital grounds. In addition, working alongside the UK government, we will be one of the first countries to introduce standardised packaging on tobacco products to further reduce their visibility and their appeal.

Substance use among young people

New analyses of Scottish Schools Adolescent Lifestyle and Substance Use Survey (SALSUS) data found that levels of multiple substance use (that is the regular use of more than one substance - tobacco, alcohol, drugs) has fallen substantially over time and is at an all-time low (data published in 2014 showed that individual use was also the lowest recorded). Among 13 year olds the use of 2 or more substances has decreased from 5% in 1998 to 1% in 2013 and, as shown, among 15 year olds from 23% to 8%.

Multiple substance use among 15 year olds, Scotland 1998-2013

Many different aspects of pupils' lifestyles were found to be associated with higher levels of multiple substance use. However, 2 key risk factors emerged:

• Disengagement with school (increased levels of exclusion and truanting were strongly associated with the use of 2 or more substances).
• Lower supervision and structure in leisure time activities (a greater number of evenings spent out with friends, more time spent 'hanging out in the street', lower levels of club/group membership and lower parental knowledge of activities were associated with the use of 2 or more substances).

Electronic Cigarettes (e-cigarettes)

Electronic cigarettes continue to attract much interest and debate in academic, public health and media circles. A major challenge has been the lack of good quality evidence on the prevalence of e-cigarette use and the profile of users. Data availability is beginning to improve, however. For the first time the SHeS 2014 asked about e-cigarette use. It found that around 1 in 20 adults in Scotland are current users with a further 10% reporting that they have used e-cigarettes in the past. As with tobacco use, e-cigarette use is much higher in the most deprived areas of Scotland: 22% of adults in the most deprived areas use or have used e-cigarettes compared with 8% in the least deprived. Of current smokers, half reported ever using e-cigarettes, including 15% currently using. E-cigarette use among ex-smokers is relatively low, at 7%. At present, studies have consistently shown very low levels of experimentation in non-smokers (0.1-3.8%).

Adult use of electronic cigarettes, Scotland 2014

SALSUS 2013 provides good quality data on use among Scotland's young people. It found that pupils who had tried smoking, used to smoke or are current smokers were more likely to have tried e-cigarettes. Seventeen percent of 15 year olds and 7% of 13 year olds reported ever trying or using e-cigarettes, with 6% of regular and 2% of occasional smokers using them at least weekly. Around 4% who had never smoked had ever used them, with the vast majority of these trying them once or a few times.

The Scottish Government has aimed to strike a balance on electronic cigarettes between the opportunity they provide in terms of harm reduction as a method used to stop smoking tobacco and managing unknown risks. It is particularly important to protect children. Concerns have been raised that experimentation with e-cigarettes may lead to nicotine addiction or act as a gateway to tobacco smoking with sophisticated marketing by the tobacco industry. The Health (Tobacco, Nicotine etc. and Care) (Scotland) Bill will introduce a minimum age of 18 for their purchase, require that retailers be registered centrally to sell e-cigs, will ban sales from vending machines and will prohibit most forms of domestic advertising of e-cigarettes. When implemented the European Union Tobacco Product Directive (TPD) will introduce regulations on e-cigarette safety, contents and marketing (alongside other controls on tobacco, including an end of selling cigarettes in packs of 10). Further research evidence is emerging all the time and Scottish Government will monitor these studies very carefully.

Cancer

In 2014, 15,746 people in Scotland died from cancer (excluding non-melanoma skin cancers). As shown below, age-standardised cancer mortality rates have decreased by 20% since 1989, with a greater fall in males than in females (24% and 13% decrease, respectively). Cancers of the lung (4,117), colorectum (1,525), breast (976), prostate (906) and oesophagus (850) were responsible for more than half of the deaths from cancer in Scotland in 2014.

Cancer mortality rates, Scotland 1989-2014 (excluding non-melanoma skin cancer) European Age Standardised Rate (EASR) per 100,000 population

Significant patterns exist when examining cancer mortality by deprivation. The Scottish Government's recent Long-term Monitoring of Health Inequalities report shows that while cancer mortality rates (aged <75) have fallen in both the least and most deprived areas over the last 15 years, there has been a slight widening in the inequality gap (as measured by the relative index of inequality).

One of the keys to improving cancer mortality rates is early diagnosis, and the Scottish Government has invested £39 million in our Detect Cancer Early programme. The key aim of which is to encourage people, regardless of their personal circumstances, who have any unusual or persistent changes to their body, to visit their GP. Revised referral guidelines also assist GPs in spotting symptoms of cancer sooner and ensuring that patients who require urgent attention are quickly assessed by a specialist. We also continue to invest in advanced treatment techniques to provide Scottish patients with access to the best treatments possible. Our new Cancer Plan, due to be published this year, will provide an opportunity to build on existing programmes to ensure that the diagnostic and treatment services meet the needs of the Scottish population.

Mental health

Mental health is one of the top public health challenges as measured by prevalence, burden of disease and disability, with around 1 in 3 people estimated to be affected by mental illness in any one year. Mental health problems cover a continuum from symptoms at a sub-clinical threshold which interfere with emotional, cognitive or social function, to severe clinically diagnosed mental illnesses. Examples include common mental health problems such as depression and anxiety, and severe and enduring mental health problems such as schizophrenia.

The Scottish Health Survey finds that the mean score on the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) has been steady (at around 50.0) between 2008 and 2014. The proportion of adults in Scotland who have a below average WEMWBS score has remained at 15% between 2008-9 and 2012-13. In 2012-13, 26% of adults in the most deprived areas had a below average WEMWBS score, compared to 6% of adults in the least deprived areas. The inequality gap has widened in recent years.

The Mental Health Strategy for Scotland: 2012-2015 sets out the Scottish Government's key commitments in relation to improving the nation's mental health and wellbeing and for ensuring improved services and outcomes for individuals and communities. The strategy includes 36 commitments, 7 key themes and 4 key change areas it adheres to in achieving these priorities. The strategy promotes safe, effective and person-centred health and care. In addition to focussing on improved service delivery it emphasises actions that individuals and communities can take to maintain and improve their own health. We anticipate the next strategy will be produced after the May 2016 election, subject to the administration's priorities.

In January 2016, First Minister Nicola Sturgeon announced that more than £54m will be made available to improve access to mental health services. This additional investment will help improve access to psychological therapies for all ages including for children and adolescents' mental health services.

Suicide

There has been a 17.8% reduction in the suicide rate in Scotland over the period 2000-04 to 2010-2014, with the number of deaths by suicide in Scotland in 2014 the lowest in a single year since 1977. In 2010-14, the suicide rate was more than 3 times higher in the 10% most deprived areas compared to the 10% least deprived areas. However, over the last decade the gap between rates in the most and least deprived areas has narrowed.

Suicide rates, Scotland 1994-2014, European Age Standardised Rate (EASR) per 100,000 population

The Suicide Prevention Strategy for 2013-16 sets out a range of commitments designed to continue the downward trend in suicide rates which we had already seen in the previous 10 years. The commitments are based on emerging evidence about suicide and its prevention.