Public Health England – Supplementary written evidence (INQ0091)

Evidence from Public Health England following Elaine Rashbrook, Consultant Specialist, Life Course evidence session on Tuesday, 28 January 2020

About Public Health England

Public Health England exists to protect and improve the nation’s health and wellbeing, and reduce health inequalities. We do this through world-leading science, research, knowledge and intelligence, advocacy, partnerships and the delivery of specialist public health services. We are an executive agency of the Department of Health and Social Care, and a distinct delivery organisation with operational autonomy. We provide government, local government, the NHS, Parliament, industry and the public with evidence-based professional, scientific and delivery expertise and support.

1. Introduction

1.1.    Public Health England (PHE) outlines below written evidence about healthy ageing on the following topics:

• Importance of the preconception period and foetal health for lifelong diseases and health outcomes in the context of inequalities
• Effect of popular/fad diets and exercise on the public discourse about healthy living
• Data on the trends in physical activity and how this compares with other countries
• Data on alcohol and smoking benchmarked against other countries
• PHE’s predictive prevention programme

1.2.    Further data are also provided on trends in life expectancy and healthy life expectancy and attached as Annex.

2. The Importance of Preconception and Foetal Health

2.1       There is evidence that health outcomes and the likelihood of developing lifelong diseases are associated with exposure to a range of factors during both preconception and foetal growth. Risk factors include: alcohol, diet, mental health, obesity, smoking, and drug misuse.

2.2       Exposure to these risk factors is not distributed equally throughout society, with infants born to more deprived parents likely to have increased exposure.[1] There are also differences in exposure due to parental age and ethnicity, explained below.

Alcohol

2.3       Alcohol is a teratogen, meaning that it can cause birth defects or complications during pregnancy.[2]

2.4       The severity and nature of harm are linked to the amount of alcohol consumed and the developmental stage of the foetus at the time.

2.5       Foetal alcohol spectrum disorder (FASD) is an umbrella term for a group of conditions that can occur following an alcohol exposed pregnancy.

2.6       The neurodevelopmental deficits associated with FASD are complex but well established.[3] The most common disabilities include problems with attention, executive function, spatial working memory, mathematics, communication, and adaptive behaviour. Other problems may include: abnormal facial appearance (shorter distance between the eyes, an indistinct cleft on the upper lip, and/or thin upper lips); short height; low body weight; small head size; and problems with hearing or seeing.[4] It is estimated that 3.2% of babies born in the United Kingdom (UK) are affected by FASD[5].

2.7       A review of the evidence about prenatal alcohol exposure for the UK Chief Medical Officers concluded that at consumption levels of one to two units per day, there are increased risks of low birth weight, preterm birth and being small for gestational age, which rises with rising consumption.[6]

2.8       Estimates show that one in every 67 women worldwide who consumed alcohol during pregnancy would deliver a child with FAS (the most extreme end of the FASD spectrum)[7].

2.9       In 2017 local maternity systems in England recorded information about the alcohol consumption of 379,600 of women, representing 56.9% of all records.[8] Of those, 10,995 pregnant women reported drinking more than one unit a week at booking[9], of whom 480 reported drinking 15 or more units a week. Analysis by PHE shows that women living in more deprived areas were more likely to report alcohol use at booking than the least deprived (Figure 1).

Figure 1: Alcohol use, mothers drinking more than one unit per week, by decile of deprivation of mother’s residence, maternity booking appointments January to December 2017

Notes:

1. Figure only shows the mothers to be who report drinking not all mothers

2. The evidence on how much consumption is linked to FASD is complex. Risks of low birth weight, preterm birth, and being small for gestational age may all be increased in mothers drinking above 1-2 units/day during pregnancy.

3. Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities, https://www.gov.uk/government/publications/preconception-care-making-the-case

Poor Diet

2.10  Inadequate food intake, low maternal weight and micronutrient deficiency (especially of folate) are linked to low birthweight[10].

2.11  Folic acid is important for the development of a healthy foetus, as it can significantly reduce the risk of neural tube defects (NTDs), such as spina bifida.

2.12  The proportion of women in England taking folic acid supplements before pregnancy fell from 35% in 1999-2001 to 31% in 2011.[11]

2.13  The most recent data (2019) indicates that for women whose folic acid supplement use is known, 28.2% of women took a folic acid supplement before pregnancy.[12]

2.14  Folic acid supplement use early in pregnancy varies by level of deprivation (Figure 2). A higher proportion of women in the least deprived areas took folic acid supplements in early pregnancy than those in the most deprived.

Figure 2: Known folic acid supplement use at maternal booking by decile of deprivation of mother’s residence, maternity booking appointments January to December 2017 (folic acid supplement use by proportion of total in decile)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

2.15  Folic acid supplement use in preparation for pregnancy also varies by ethnicity (Figure 3). 34.4% of women of Chinese ethnicity took folic acid supplements in preparation for pregnancy (the highest percentage), and 17.6% of women of black ethnicity (the lowest).

Figure 3: Known folic acid supplement use at booking by ethnicity of mother, maternity booking appointments January to December 2017 (folic acid supplement use by proportion of total in ethnic group).

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

Mental Health

2.16  Mental health problems in pregnancy and the first year after birth are experienced by up to 20% of women[13] and up to 10% of fathers suffer from postnatal depression.[14]

2.17  If untreated, maternal mental illness during the perinatal period can adversely affect: infant cognitive, emotional and behavioural outcomes; maternal-infant bonding and quality of parenting.[15]

2.18  Vulnerable populations include mothers living in deprived areas or on low-incomes, teenage mothers, women in some black, Asian and minority ethnic communities, women with a pre-existing psychiatric diagnosis and new mothers with an increased risk of depression.[16]

Obesity

2.19  Maternal obesity is one of several influences that appear to underlie the foetal or pre-conceptional origins of later risk of non-communicable diseases (NCDs).

2.20  Obese women have lower fertility rates and greater risk of early miscarriage, and the oocytes and early embryos of obese mothers show an increased incidence of metabolic and developmental abnormalities.[17]

2.21  Research shows an intergenerational effect with higher risks for children whose parents are obese or overweight.[18]

2.22  49% of all women in early pregnancy in England with a known body mass index are overweight or obese.[19] This proportion increases with age to 55.4% in women aged 40 or over (Figure 4).

2.23  The proportion of women who are overweight or obese in early pregnancy increases as level of deprivation increases, and the proportion of women of healthy weight decreases (Figure 5).

Figure 4: Known maternal Body Mass Index (BMI) by age of mother, maternity booking appointments January to December 2017 (BMI category by proportion of total in age range)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

2.24  The highest proportion of women who were overweight or obese in early pregnancy were of Black ethnicity (66.6%).

Figure 5: Known maternal BMI at booking by decile of deprivation of mother’s residence, maternity booking appointments January to December 2017 (BMI category by proportion of total in decile)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

2.25  The Scientific Advisory Committee on Nutrition (SACN) reviewed the scientific evidence relating to the role of nutrition during pregnancy, infancy and childhood, including growth and development during fetal life and up to the age of five years, on the development of chronic disease in later life[20]. Evidence identified in the review suggested that there were later health consequences of receiving too much or not enough of certain nutrients during fetal and infant life. Evidence also suggested that obesity during pregnancy was associated with a number of adverse outcomes. SACN is due to start a risk assessment on nutrition and maternal health in 2020.

Smoking

2.26  Smoking during pregnancy is one of the main modifiable risk factors of pregnancy-related complications, and the largest preventable cause of premature birth and low birth weight.

2.27  Smoking during pregnancy can lead a range of poor pregnancy outcomes, many of which can have long term implications for the baby including: foetal growth restriction, placental abruption, preterm labour and delivery and low birth weight.[21] In addition, it is associated with an increase in disorders and long-term conditions such as respiratory infections, bronchiolitis, meningitis, asthma, obesity and cognitive deficits.

2.28  Smoking may increase the risk of congenital abnormalities, cleft lip, gastric conditions and limb defects.[22] [23] There is also an increased risk of certain cardiac malformations, all of which can have long term implications for life chances and opportunities across the life course.[24]

2.29  10.8% of women in England are still recorded as smoking at the time of delivery and in some areas of England this rises to 28%.[25] Smoking increases the risk of stillbirth, complications in pregnancy, low birthweight, and of the child developing other conditions in later life.

2.30  Rates of smoking in pregnancy differ across groups with mothers aged 20 or under, six times more likely than those aged 35 and over to have smoked throughout pregnancy.[26] Pregnant women are also more likely to smoke if they are less educated, live in rented accommodation and are single or have a partner that smokes.[27]

2.31  Rates of smoking in pregnancy are 24.7% in the least deprived and 4.1% in the most deprived groups.

Figure 6: Known smoking status at booking by age of mother, maternity booking appointments January to December 2017 (smoking status by proportion of total in age range)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

Figure 7: Known smoking status at booking by decile of deprivation of mother’s residence, maternity booking appointments January to December 2017 (smoking status by proportion of total in decile)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

Figure 8: Known smoking status at booking by ethnicity of mother, maternity booking appointments January to December 2017 (smoking status by proportion of total in ethnic group)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

2.32  Women of white ethnicity are the most likely to be smokers at booking (15.9%).

2.33  Babies born to mothers who smoke are significantly more likely to become smokers themselves, increasing their risk of a range of health conditions and perpetuating the cycle of inequalities.[28]

Drug Misuse

2.34  The short-term risks to the child of prenatal drug exposure are relatively well-established, including, for example, clinical and neonatal complications. The effects of different drugs of misuse (using illegal drugs or misusing legal drugs) during pregnancy are broadly similar and are largely non-drug specific. Intra-uterine growth retardation and pre-term deliveries contribute to increased rates of low birth-weight and increased perinatal mortality rate.[29]

2.35  The extent to which these short-term risks lead to long-term negative consequences persisting into childhood, adolescence and adulthood is less well-established.

2.36  In 2017 local maternity systems in England recorded information about the drug consumption of 470,415 of women at booking, representing 70.5% of all records.[30] Around 5,500 women (1.2%) reported that they were currently misusing illicit drugs, solvents or medicines.

2.37  Analysis by PHE shows that pregnant women living in more deprived areas were more likely to report drug use at booking (2.5% of those reporting misusing illicit drugs, solvents, or medicines compared with 0.5% amongst the least deprived) (Figure 9).

Figure 9: Known substance use, mothers currently using or who have previously used, by deprivation decile, maternity booking appointments January to December 2017 (substance use by proportion of total in deprivation decile)

Source: Health of women before and during pregnancy: health behaviours, risk factors and inequalities. Public Health England (2019)

3. Popular (fad) diets and exercise, and public discourse

3.1       Some ‘fad’ diets (such as cutting out whole food groups) risk damaging long-term health. A healthy balanced diet, based on fruit and vegetables and higher fibre starchy carbohydrates, as illustrated by the national food model, the Eatwell Guide, can reduce the risk of chronic diseases. Media reporting of diets not supported by robust evidence may confuse the public about what is best for our health and encourage unhealthy choices. This was explored in a blog from PHE’s Chief Nutritionist, which highlighted that sensationalist headlines can make the public question well considered advisory messages. It concluded that what is required is advice that reflects the best available evidence, reported and interpreted accurately in helpful and meaningful terms, which has been the cornerstone of the approach that Public Health England looks to deliver[31].

3.2       The Eatwell Guide sets out what most of us should aim to eat to maintain long-term health and minimise the risk of serious illnesses such as heart disease, type 2 diabetes, and some cancers. This advice is underpinned by comprehensive reviews of the scientific evidence. It was refreshed in 2016 following Scientific Advisory Committee on Nutrition’s (SACN) review of the evidence on carbohydrates and health, to ensure it reflected the most up-to-date science.

3.3       PHE’s social marketing campaign, Change4Life, aims to help families make healthier choices (such as eating healthier food and moving more). PHE is working with industry to reduce sugar and calories in food.

4. Predictive Prevention

Rationale for the programme

4.1       As set out in Prevention Is Better Than Cure [32], predictive prevention involves the careful, targeted and consensual use of data to provide digitally-enabled health improvement interventions, in a way people are most likely to engage with and act on. It also stated a commitment for PHE to: “bring together and coordinate a range of experts to build, evaluate and model predictive prevention at scale”[33]

4.2       In addition, the July 2019 Prevention Green Paper announced that PHE would "work together with NHS X and other partners across the public health system, academia, industry and the voluntary sector to build a portfolio of new innovative projects that will help us evaluate and model Predictive Prevention at scale”.

4.3       Recent advances in digital approaches and behavioural sciences create opportunities to tailor public health interventions to people’s needs, social circumstances and environment. The potential of these innovations is to build, evaluate and model interventions that personalise public engagement at scale, delivering better outcomes at lower marginal cost.

4.4       In addition, we know that preventable risk factors are a key determinant in health inequalities. Population based approaches do not always reach everyone, particularly those most at risk, or in hard to reach populations. A comprehensive suite of interventions will be explored, including a more focussed approach, which will support better targeting of cohorts.

4.5       PHE is working closely with NHSX to develop the programme, taking a system-wide approach to delivery; our focus will be on prevention and public health principles.

4.6       To deliver the programme we will:

• use user-centric design approaches to create new digital products and services that support people to identify and reduce risks to their health
• conduct and publish evaluations of products and services and engage with external research to establish and expand the evidence base on what works
• develop and apply models of ‘dynamic consent’ that ensure that people understand and retain control over how their personal information is used
• draw on the latest behavioural science to develop approaches to communicating personal health risks that motivate people to act and adopt healthy behaviours.

Data and accountability

4.7       Most of predictive prevention’s aims are partially or wholly reliant on using new and existing data to achieve better healthcare outcomes. When using this data, PHE and NHSX will consider:

• public and policy concerns about security and inappropriate use of data, while respecting and protecting individual privacy
• technical and logistical issues surrounding data infrastructure and interoperability
• how we might develop an ethical and accountable approach to use of data that not only complies with data regulations but also builds public trust
• how predictive prevention can enable organisational adaptation of a robust data governance framework
• how we can partner across the health system to ensure a consistent approach to data.

5. Trends in physical activity

5.1       Data from Health Survey for England show that the proportion of adults aged 19 and over meeting the Chief Medical Officer’s aerobic activity guidelines in 2016 was 62%, which is similar to the proportion in 2012 (61%). Therefore, the proportion of adults aged 19 and over not meeting the guidelines was also similar in 2012 (39%) and 2016 (38%)[34].

5.2       Global estimates on levels of physical activity in adults were published by researchers from the World Health Organization (WHO) in 2018. The UK prevalence of insufficient physical activity was estimated at 35.9% (Figure 10); data are not available for England, Scotland, Wales and Northern Ireland separately. Portugal (43.4%) had the highest estimated rate of insufficient physical activity among 18 peer countries[35], with Finland (16.6%) estimated to have the lowest rate.[36]

5.3       Insufficient physical activity is defined in both data sources as not doing at least 150 minutes of moderate-intensity, or 75 minutes of vigorous-intensity physical activity per week, or any equivalent combination of the two.

Figure 10: Prevalence of insufficient physical activity by country, 2016

Source: Guthold R, Stevens GA, Riley LM, Bull FC. Worldwide trends in insufficient physical activity from 2001 to 2016: a pooled analysis of 358 population-based surveys with 1·9 million participants. Lancet Glob Health 2018; published online September 4. http://dx.doi.org/10.1016/S2214-109X(18)30357-7

6. Trends in smoking prevalence

6.1       Data from the Annual Population Survey shows that smoking prevalence among adults in England was 14.4% in 2018. It has declined from a prevalence of 19.8% in 2011[37].

6.2       Figure 11 shows trends in the prevalence of exposure to smoking[38] for England and selected peer countries[39] using data from the Global Burden of Disease (GBD) Study. The three peer countries with the highest exposure values and the three countries with the lowest exposure values at the first and last time points (which may not be the same) are included, together with England.

• Prevalence of smoking in England is relatively low compared with other countries - exposure in 2016 was measured at 20.4% compared with the highest exposure in Greece of 32.5% and the lowest in Sweden at 12.2%
• All countries included have seen a reduction in exposure to smoking prevalence since 1990, except for Portugal which has remained level
• The largest reduction has been seen in Denmark with a 20.0 percentage point reduction in exposure between 1990 and 2016 (from 43.4% to 23.4%). In comparison, England has seen an 11.3 percentage point reduction in exposure.

6.3       Figure 12 shows trends in the estimated death rate due to smoking from the GBD study for the same countries.

• There have been significant reductions in death rates due to smoking since 1990 in all countries selected. England has made significant progress over the period, with the rate reducing from 173 per 100,000 population to 65 per 100,000
• The latest data for 2017 shows death rates due to smoking among the peer countries ranged from 45 per 100,000 in Finland to 105 per 100,000 in Scotland and are generally in line with levels of exposure.

Figure 11: Trends in prevalence of exposure to smoking by country, all ages, 1990 to 2016

Source: Global Burden of Disease Study 2016 (GBD 2016) Results.

Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018.

Figure 12: Age-standardised death rate due to smoking, by country, 1990 to 2017

Source: Global Burden of Disease Study 2017 (GBD 2017) Results.

Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018.

Available from http://ghdx.healthdata.org/gbd-results-tool. (Accessed 06/02/2020)

7. Trends in alcohol consumption

7.1       Data from the Health Survey for England shows that 22% of adults were drinking at increased or high-risk levels[40] in 2018. This is slightly lower than the value in 2011 (26%)[41].

7.2       Figure 13 shows trends in the prevalence of exposure to alcohol[42] for England and selected peer countries[43] using data from the Global Burden of Disease (GBD) Study. The three peer countries with the highest exposure values and the three countries with the lowest exposure values at the first and last time points (which may not be the same) are included, together with England.

• The prevalence of exposure to alcohol in England has changed little over the past five years or since 1990, and in 2016 was 14.6%. This puts England’s exposure to alcohol in the lowest quartile for both Europe and the 22 peer countries
• The trends by country are mixed with some peer countries showing reductions in alcohol exposure over the past five years and since 1990, while others have seen increases in exposure or no overall change over the same period. In most cases the increases observed are small, however, Luxembourg is the key outlier and shows a significant increase over time.

7.3       Figure 14 shows trends in the estimated death rate due to alcohol in the GBD Study for the same countries.

• By country, the death rate per 100,000 population due to alcohol generally increases with the level of alcohol exposure. The peer countries with the highest exposure to alcohol also have the highest death rates due to alcohol.

Figure 13: Trends in prevalence of exposure to alcohol, by country, all ages, 1990 to 2016

Source: Global Burden of Disease Study 2016 (GBD 2016) Results.

Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018.

Figure 14: Age-standardised rate of deaths due to alcohol per 100,000 by country, 1990 to 2017

Source: Global Burden of Disease Study 2017 (GBD 2017) Results.[44]

Seattle, United States: Institute for Health Metrics and Evaluation (IHME), 2018.

Available from http://ghdx.healthdata.org/gbd-results-tool. (Accessed 06/02/2020)

24 February 2020

Annex - Further data on trends in life expectancy and healthy life expectancy

8.1       Tables 1 and 2 show life expectancy and healthy life expectancy for the top 10 countries in the world, and for the United Kingdom for males and females in 2016. Comparable data are not available for England separately.

8.2       The World Health Organization reported that male life expectancy in 2016 was highest in Switzerland at 81.2 years. This was 1.5 years more than male life expectancy in the UK (79.7 years), which was ranked 16th by WHO.

8.3       Using the WHO definition of healthy life expectancy, Singapore had the highest level for males in 2016 at 74.7 years. This was 3.8 years more than for males in the UK (70.9 years), which was ranked 19th.

8.4       Japan had the highest female life expectancy in 2016 (87.1 years). This was 3.9 years more than for females in the UK (83.2 years), which was ranked 25th.

8.5       As for males, Singapore had the highest healthy life expectancy for females (77.6 years). This was 4.7 years more than for females in the UK (72.9 years), which was ranked 26th.

8.6       Several of the GBD peer countries with low insufficient physical activity, low alcohol or low smoking exposure are included in the top 10 including Australia, Iceland, Norway and Sweden. However, Spain and France are in the top 10 for female life expectancy and have high alcohol exposure. France also has high smoking exposure. Italy is in the top 10 for male and female life expectancy and has a high level of insufficient physical activity.

Table 1. Top 10 countries for male life expectancy and healthy life expectancy in 2016

Source: World Health Organization, https://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends/en/

Table 2. Top 10 countries for female life expectancy and healthy life expectancy in 2016

Source: World Health Organization

https://www.who.int/gho/mortality_burden_disease/life_tables/situation_trends/en/