EUGLOREH project
THE STATUS OF HEALTH IN THE EUROPEAN UNION:
TOWARDS A HEALTHIER EUROPE

FULL REPORT

PART II - HEALTH CONDITIONS

9. MAIN HEALTH ISSUES AND TRENDS FOR DIFFERENT AGE AND GENDER POPULATION GROUPS

9.3. Adults

9.3.1 General health conditions

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9.3. Adults

 

9.3.1 General health conditions

 

For information and data concerning violence and other gender issues not dealt with in this Chapter see Chapter 9.5.

 

 

9.3.1.1. Introduction

 

For men who survive up to 60 years of age, the gap in life expectancy, as compared to women, is much smaller than at birth. During early childhood, there are closer death rates between boys and girls. However, as we move into the 15+ age group, a more gendered picture emerges. In the 15-64 age bracket, with the predominant causes of death being cardiovascular diseases, cancer, accidents, violence, suicide and alcohol, the overall rate is much higher in men (White & Holmes, 2006). Apart from very few male specific health risks in early and middle age (i.e. testicular cancer characterized by a very low death rate), the majority of the excess deaths in men to account for this male to female life expectancy gap occurs in conditions that should affect men and women equally.

 

The key biological differences have been identified between males and females (Wizemann & Pardue, 2001) as follows:

 

·          the sex chromosomes;

·          immune response;

·          symptoms, type and onset of cardiovascular disease;

·          response to toxins;

·          brain organisation; and

·          the experience of pain.

 

The above listed differences can only partially account for men’s increased susceptibility to diseases and death. Neither can these biological differences explain the large country by country variations seen in men’s health or the effect of socio-economic factors within a country (White & Holmes, 2006). It can be argued that the most significant determinants of the shorter life expectancy in men are most certainly not biological, but socio-cultural and behavioural in origin and, therefore, amenable to change.

 

An overview of the conditions affecting differentially the health status of men and women is provided in chapter 9.5.

 

As compared to women, men have a reduced life expectancy coupled with significant variations between countries and among men of different socio-economic status. Moreover, men have an increased risk of cardiovascular disease, cancer, suicide, addiction to smoking and alcohol, and overweight and obesity.

 

Despite these higher levels of morbidity and premature mortality in men, as compared to women, underlying motivations have not received much attention so far. It is to find research work focused on men and their health much before the mid 1990’s. This dearth of evidence is further reflected in the fact there has only been one study made on the status of men’s health across Europe (White & Cash, 2003) and there have been to date no calls from the EU for research intended to clarify why man’s health is so much more at risk than women’s health.

 

Even some male specific diseases are still seen to be lacking a firm research and policy base. For instance, the incidence of prostate cancer is increasing due to an ageing population, but there is still some uncertainly over the best form of diagnosis and treatment. For instance, erectile dysfunction is much more widespread than previously thought and is now seen as a sentinel marker for early stages of cardio-vascular disease and a part of the metabolic syndrome. Testicular cancer incidence is increasing rapidly and still takes a small but significant number of deaths when it is considered against almost a 98% cure rate if caught early enough.

 

On the other hand, moving to women’s specific health problems, menopause is a normal physiologic event but it is often associated to health complaints, a decrease in quality of life and an increase in the risk for illnesses such as osteoporosis and coronary heart disease (CHD). Studies of menopause are numerous but largely recent. Menopause is a time in a woman’s life when the primary healthcare provider should assess a woman’s health and her need for health promotion and disease prevention measures.

 

Menopause is defined as the permanent cessation of menstruation resulting from the loss of ovarian follicular activity. Natural menopause is recognized to have occurred after 12 consecutive months of amenorrhea for which there is no other obvious pathologic or physiologic cause. At present, it can be recognized only retrospectively. Endocrine changes will have begun years earlier. Changes in serum concentrations of follicle-stimulating hormone (FSH) and oestradiol are maximal in the year of the final menstrual period (FMP). FSH elevation, while a harbinger of menopause, is a poor predictor of age at menopause; the clinician cannot draw any conclusions about the timing of an individual woman’s menopause on the basis of the presence or degree of FSH elevation. The endocrine changes of menopause do not include any acute decrease in androgens. After menopause, oestrone, rather than the more potent oestradiol, is the major circulating oestrogen. It is produced primarily by peripheral aromatization of androgens, so that fat cells become the major source of endogenous oestrogen after menopause.

 

There is considerable individual and radical/ethnic variation in age at natural menopause, in climacteric signs and symptoms, and in what may be considered menopause-related sequelae. There is a lack of consensus as to whether changes in health occurring during the climacteric or presenting later in life are attributable to menopause and reduced ovarian function or to ageing. Estimates of the median age of menopause range from 45 to 55 years worldwide. Understanding of the factors that influence age at menopause is limited. Familial or hereditary factors appear to be the most predictive. Of other variables studied, the most consistent relation is for cigarette smoking, which advances menopause by 1 to 2 years. The timing of menopause may substantially influence subsequent morbidity and mortality. Although many clinically relevant questions remain unanswered, women seeking advice about menopause currently have more options and better interventions for healthy menopausal years than ever before.

 

9.3.1.2. Data sources

 

Sources for this report are predominantly taken from work produced by the European Union, the World Health Organization (WHO), and NGOs working in specific health fields, supported by excerpts taken from academic reports and articles. The majority of the academic articles report research done in specific areas of condition or disease. Most of these studies are quantitative, but some serve to supply qualitative back-up to the more statistical information. Specific gender-disaggregated information becomes more and more common. However, even when data is presented broken down by sex, there is rarely comment on the gendered nature of much of the disease presented.  There have been just two reports that have explicitly looked at women and health on a European scale and there has been no EU funded report on men’s health.  To date the only study that has looked at men’s health across Europe was commissioned by the European Men’s Health Forum (White & Cash 2003).

 

There are also difficulties around  the comparability of data, as European boundaries change, and differing indicators may be used in various areas. Organisations such as Eurostat and WHO have been working supra-nationally to bring together common frameworks, and are developing commonly agreed and tested indicators which produce comparable data. Even so, it has proven immensely complicated to reach a consensus on common instruments for measuring health status in different languages and in different cultural settings, in order to produce results that can be compared within, and across, countries of the EU  (De Smedt, 2004).

 

This section is also based on the International Position Paper on “Women’s Health and Menopause: a comprehensive approach”. NIH Publication n. 02-3284 (July 2002). Specific data bases utilised in this chapter also include WHOSIS, GLOBOCAN, EUROSTAT and the results of the EURODEP Programme as well as the World Bank’s “Burden of Diseases Study”.

 

Determining the prevalence of certain diseases and conditions is difficult. Studies on prevalence often have to rely on either self reports of a diagnosis or extracting data from general practitioners or hospital records. These methods are limited because they omit cases of undiagnosed conditions and the criteria used by healthcare professionals in making diagnoses can vary. Tackling cases of under reporting and improving the collection and collation of data across national and Community systems needs to become a priority focus area.

 

 

9.3.1.3. Data description and analysis

 

Premature death is frequent in middle age: two in ten women and four in ten men die before becoming 65 years old. In the EU, premature mortality (or mortality before the age of 65) is due mainly to cardiovascular diseases, cancer and injury and poisoning (Table 9.3.1.1). For men who survive up to 60 years, the gap in life expectancy, as compared to women, is much smaller than at birth.

 

Table 9.3.1.1 Premature mortality by selected causes of deaths in EU, 2005

 

Accidents and injuries

 

In the 15-64 age group men have four times the rate of death as a result of accidents as compared to women (see Chapter on Accidents), with the majority of these being related to transport. In the 0-19 age range, the rate of death in males as a result of transport accidents is 2.4 times higher than that of females (Niederlaender, 2006). This greater risk of road traffic accidents continues at all ages.

 

Every year, about 5,500 people are killed in the workplace across the European Union, with another 4.5 million accidents resulting in more than 3 daysabsence from work (amounting to around 146 million working days lost) (European Commission, 2003). These accidents are estimated to cost the EU about 20 billion Euro. Men have more accidents than women, young workers (18-24 yrs) have a much higher accident incidence rate than other age groups, but older workers (55-64 yrs) have more fatal accidents. Most injuries occur in the upper extremities of the body. (European Agency for Health and Safety at Work, 2007). Injuries per 100 000 are particularly high in Luxembourg , followed by Slovenia and Belgium. The lowest rate of injuries in the workplace are reported in Romania, Bulgaria and Latvia (WHO HFA-DB, 2006).

 

Mental health, psychiatric and neurological disorders.

 

The European Commission (European Commission 2004a) found that between 15% and 20% of adults suffered some form of mental health problem ranging from mild forms of depression through to complex psychiatric disorders.

 

Depression. Apart from specifically female conditions such as the experience of mental health problems related to childbearing, there are clear and consistent differences in the patterns of mental health experienced by men and women. Depression and depression-related problems account for more than 7% of all estimated ill-health and premature mortality in Europe with women twice as susceptible as men (European Commission, 2004b). The impact on the EU economy of mental ill health is estimated to be equivalent to a reduction of 3% to 4% of total GDP (Gabriel and Liimatainen, 2000). The EURODEP Programme explored geographical variation of depression in older people, risk factors, detection, treatment and preliminary evidence showed higher proportions of depression in women than in men in almost all studies.

 

The burden of depression includes a higher burden on social security systems and brings a loss of quality of life for those affected and their families, a loss of productivity for firms, and an increased risk of unemployment for individuals. The World Bank’s Burden of Diseases Study, judged depression in women as the leading cause of disease burden worldwide.

 

Some countries support people with even quite severe mental health problems in paid employment, though in most countries economic inactivity remains the norm. It is estimated that only around 15% of working-age people with long-term mental health problems are working, a lower number than any other group of disabled people. Unemployment, a lack of adequate housing and social networks may result in people becoming seriously isolated and excluded from society (Mental Health Europe).

 

Some Member States also endeavour to protect the rights of individuals with mental health problems. Countries such as Italy and the UK have moved care into community settings, giving individuals a better chance to access integrated services while using inpatient beds in general hospitals for short term treatment. There are still many countries which continue to incarcerate people for long periods. Care homes or ‘asylumsaccommodate large numbers of people in some Eastern European countries, but also in Belgium and the Netherlands (Knapp, 2007).

 

Women are at greater risk of experiencing domestic abuse than men, leading to high rates of depression and anxiety, symptoms of post-traumatic stress, and subsequent difficulty in establishing and maintaining relationships. Women living in poverty and women from minority groups are at heightened risk for victimization by violence . Similarly, women living on a low income for an extended period of time can experience stress, difficulty in a personal and family relationships, and can be left feeling isolated and depressed. Individuals most at risk of social isolation and anxiety are female lone parents and retired women living alone (Myers et al, 2005). Women’s social roles as primary carers for children and/or other dependants can result in ‘role overload’, where women undertake both employment and household/childrearing responsibilities. This contributes to social isolation and further impacts on mental health.

 

Women are more likely to approach their primary care physician for help. Doctors are more likely to diagnose depression in women compared to men, even when they have similar scores on standardised measures of depression, or present identical symptoms. Women are more likely to be prescribed mood altering psychotropic drugs. Men are more likely to seek specialist mental healthcare and are the principal users of inpatient care. (Austbury, 2002; Hallström, 2001).

 

There is a suggestion that men suffering from emotional and mental health problems display different symptoms and are therefore less likely to be identified with the current models for depression (Branney & White, 2008, Brownhill et al, 2005). The idea of a male depressive syndrome, which is characterised by a tendency to externalise rather than internalise symptoms has been reported in the European Mental Health Report (2004) and helps explain why men show a greater tendency to substance abuse, anti-social behaviour and self harm (White, 2006). This is coupled with the problem that men are less likely than women to seek professional help to address and discuss their depressive symptoms (Möller-Leimkühler, 2002).

 

Schizophrenia. In the EU schizophrenia has a prevalence of about 1%, equivalent to some 3.7 million people (European Commission 2003). The disease usually first affects young adults. Three-quarters of them continue to experience symptoms throughout their lives, needing constant treatment. This creates distress for families and places a huge burden on healthcare resources. More data on this condition are not readily available.

 

Epilepsy. The prevalence of epilepsy in the EU varies between 3 and 6 per 1 000 inhabitants. In a 2003 report, the European Commission suggested that although data was limited, there were indications that the incidence and mortality of epilepsy were declining. This trend may change in the expanded EU. The estimated number of people in Europe with active epilepsy is 0.9 million children and adolescents (prevalence 4.55.0 per 1000), 1.9 million aged 2064 (prevalence about 6 per 1000) and 0.6 million aged 65 or older (prevalence about 7 per 1000). Approximately 2030% of the epilepsy population have more than one seizure per month (Forsgren et al, 2005).

 

Suicide. As suicide has important negative cultural, religious, social and legal connotations, death certification practices from various countries must be compared with extreme caution. Across the European Union, some 58 000 citizens each year commit suicide, a number that is greater than the annual death toll from road accidents. Suicide is an important contributor to life years lost when it occurs among young people. Lithuania has the highest rate for males at 50-54 years of age (121.1) and at 15-19 (25.9). The rates are consistently lower for females across the lifespan, while in Greece figures for both sexes are low in all age groups (EUROSTAT). Suicide rates are generally higher among men than among women, but rates of suicide attempts are higher among women (EIWH, 2006). Depression is the main cause of suicide. The World Bank has found depression in women to be the fourth leading cause of disease burden in developing countries.

 

Cancer

 

Cancer, largely associated to tobacco smoking, causes 35% of all deaths before the age of 65. There are overall more men registered with cancer than women. When breast cancer and the gender-specific cancers are excluded, men develop cancer earlier and die earlier (lower survival) from the majority of cancer types than women. It is also noted that men also have lower survival rates for cancer (Verdecchia et al, 2007). Although it has been presumed that the causes of men’s increased risk are lifestyle related, this is not always the case and what is emerging is that there are many complex reasons for this excess (Wilkins, 2007). Lung/bronchus cancer is the most common cause of cancer death in men and the third most common in women, whereas colorectal cancer is the third most common cause of cancer death and the second for women.

 

Prevalence, incidence, mortality and survival data of different cancer types are described in Chapter 5.3.

 

Circulatory diseases

 

Cardiovascular diseases are the main group of causes of death, causing about 2 million deaths a year in the EU. These diseases tend to develop at a later age (about ten years) in women than in man as women are protected against heart diseases before menopause by oestrogen. The main circulatory diseases are ischemic heart disease, responsible of about half of deaths, and stroke, responsible for about one third of deaths from circulatory diseases.

 

Prevalence, incidence, mortality and morbidity data of cardiovascular diseases are described in Chapter 5.2.

 

A man with metabolic syndrome can be 4 times more likely to suffer from cardiovascular disease (European Men’s Health Forum, 2005). CVD tends to affect women about ten years later than men, as women are protected against heart disease before menopause by oestroegen. However, a woman who has a stroke or a heart attackespecially when older – is more likely to die than a man. Studies have indicated that women also have a higher rate of repeated attacks and heart failure, which in turn leads to increased morbidity (European Heart Network, 2005). Research data suggested that fewer women than men with suspected acute heart attack symptoms are referred for non-invasive tests, and fewer women than men who test positive for heart disease are recommended for further testing and treatment (Arber, 2006).

 

Because CVD tends to develop at a later age in women than in men, women are more likely to have complicating co-morbidities, such as hypertension and diabetes mellitus, which contribute to poorer short-term outcomes after coronary events or revascularization. Reasons for gender differences are thought to include greater prevalence of other risk factors such as obesity, stress and hypertension in diabetic women (European Heart Network, 2006). Hormonal balance associated to premenstrual, post-partum and menopausal changes can also affect the vulnerability to stress and depression.

 

In a study on patterns of mortality, White and Holmes found that deaths as a result of cardiovascular disease among men increased from the 15-24 age group (median 3.9 per 100 000 population), to the 25-34 age group (11.2 per 100 000 population), followed by a near fourfold increase in the median death rate in the 35-44 age group (39.2 per 100 000 population) (White and Homes, 2006). A similar pattern was seen among women from the 36 countries reviewed, with the median death rate increasing from 2.1 to 4.6 to 16.0 per 100 000 population across the increasing age ranges. There are striking inter-country differences among men: in Europe, per 100 000 population, Sweden had less than 21 deaths whereas Latvia had 169.9 deaths in the 35-44 age group. Analysis of cardiovascular diseases highlighted the main reported causes of death in men aged 15-34 as deaths due to pulmonary embolism, heart failure, rhythm disorders, alcoholic cardio-myopathy and sudden cardiac death.

 

Most cardiovascular related deaths in the young are as a result of congenital disorders, with a rapid rise between the ages of 25-34 and 35-44 in the rate of death from conditions related to ischemic conditions in the vasculature (White and Holmes, 2006).

 

The main circulatory diseases are ischemic heart disease (which comprises half of the deaths from circulatory diseases) and stroke (one third of deaths from circulatory disease). Evidence is growing that lowering blood cholesterol levels and treating severe hypertension can reduce the incidence of major heart attacks in women with heart disease and improve survival in older patients (European Heart Network, 2005). The prevalence of hypertension in Member States appears to be around 20% (European Commission, 2003). Hypertension is both a disease in itself and a determinant of other circulatory diseases such as circulatory diseases and renal failure.

 

Ischemic heart disease. Ischemic heart disease, in addition to being the main single cause of circulatory disease-associated mortality, is the single main cause of death before the age of 65 (European Commission, 2003). For both sexes of all ages, mortality in most in EU27 Member States is decreasing, although there is a significantly steady increase in Hungary and Lithuania, and to a lesser extent in Malta for males and the Czech Republic for females. Mortalities in the recent accession States except Poland and Slovenia are 2-3 times higher than the EU27 average (WHO HFA-DB, 2006).

 

Stroke. Stroke is an important cause of disablement in the EU, particularly at older ages. While mortality under the age of 65 for stroke is decreasing for both sexes in all Member States, those of Denmark, Greece, the Netherlands and the United Kingdom are increasing. Portugal has the highest mortality for both men and women, while Dutch males and French women have the lowest mortality respectively (European Commission, 2003).

 

Peripheral vascular disease. Peripheral vascular disease occurs quite commonly in women, and, as in all atherothrombotic CVD, incidence increases with age in women. Smoking is the most prevalent risk factor as peripheral vascular disease carries with it an increased risk for CHD, which is not gender dependant.

 

Venous thromboembolism. Modifiable risk factors for venous thrombo-embolism include the presence of haemostatic disorders, immobilization, and probably also obesity. Although most cases of venous thrombosis are not fatal, death from pulmonary embolism can occur, and post-thrombotic syndrome occurs in as many as one-fourth of patients with deep venous thrombosis. Venous thromboembolism remains a major cause of morbidity and mortality after gynaecologic surgery.

 

Abdominal aortic aneurysm. Abdominal aortic aneurism causes approximately 7 000 deaths per year in men and women in England and Wales. With a greater prevalence in men, the condition is easily diagnosed by ultrasound scan and treatment has a high success rate. Ministers in England have announced that a screening programme for men aged 65 will be implemented in England over the next five years.

 

Diabetes

 

For both men and women, the proportion of people with diabetes increases with age, but in addition with the link to the metabolic syndrome the numbers are also rising as a result of a growing number of men and women with abdominal obesity. Diabetes mellitus is a principal determinant of circulatory diseases and renal failure. In 2005, more than 25 million people in the EU were estimated to be living with diabetes. The average prevalence rate is 7.5% among adults aged 20 or over. In Germany the prevalence of people with diabetes under medical treatment grew by 43% from 1988 to 2001. The number of cases of diabetes is expected to increase by 21% in the European Region in the next 20 years according to the World Health Organisation (WHO), and by 16% across the European Union according to the IDF Atlas. This increase will be largely driven by the growing prevalence of Type 2 diabetes. Obesity-associated adult onset diabetes is seen to be occurring more frequently at younger ages (FEND and IDF, 2005). There is reason to believe that differences in coding practices may explain some of the differences observed in reported rates in France and Greece (European Commission, 2003). The Netherlands report one of the lowest prevalence rates of diabetes (3.7%) and the lowest healthcare diabetes costs (2.5% of total healthcare budget) among all EU Member States. Nevertheless, it has recently developed a national plan for improved diabetes care focusing on a multidisciplinary approach (FEND/IDF Europe, 2005). Women with diabetes may have a higher coronary heart diseases (CHD) mortality than men with diabetes. Of subjects receiving medical care for the disease, women had poorer control of blood pressure and a significantly higher mean systolic blood pressure compared to men (Duggirala et al, 2005). Researches have found that, for people at high risk, lifestyle change is more effective than drug treatment in reducing the incidence of diabetes. However, for socioeconomic, educational and empowerment reasons lifestyle change can be an unobtainable goal for many women.

 

Overweight and obesity

 

Overweight and obesity cause one million deaths a year in the WHO European Region; it is estimated that there will be 150 million obese adults (about 20% of the population) by the year 2010. Thus, obesity has been identified as a ‘global epidemic’ by the WHO and of such significance that it is now seen as a greater threat to health than that posed by smoking (WHO, 2003).

 

The Obesity in Europe report from the International Obesity Task Force (IOTF 2002) states very clearly that the problem of overweight and obesity is a societal one and not the fault of the individual, with the main causes being:

1.         An increased abundance of ‘energy densefoods and drinks which promote excessivecalorieconsumption and support a ubiquitoussnackingculture. New evidence highlights the ready evasion of appetite control by these foods, drinks and their frequency of consumption. This leads to a pervasivepassive over-consumption’ of energy.

2.         The systematic public and commercial developments which restrict opportunities for physical activities - leading to an almost sedentary lifestyle (IOTF, 2002).

 

The main concern is that fat deposited intra abdominally is not an inert substance. Instead it has its own endocrine function that creates fat toxins which can lead to fat related cancers, such as cancer of the breast, endometrium, prostate, testis, bowel, liver, kidney, oesophagus and pancreas. It also leads to a higher risk of developing hypertension, hyperlipidaemia and diabetes as a result of the metabolic syndrome (Haslam 2007). Obesity can also lead to erectile dysfunction, increased risk of dementia and sleep apnoea.

 

Though reports have identified that the problem of obesity is an issue for men, with a distinction being drawn between the problem of ‘android obesity and the ‘less problematic gynoid fat distribution” (WHO, 2000, p.6), and with the recognition that men have on average twice the amount of abdominal fat than is generally found in pre-menopausal women, the Global Strategy lists gender as one factor to be taken into consideration but that is as far as mention to gender goes. Though the 2002 WHO European report (WHO, 2002) also states that men are at ‘specific risk’ (p.35) there are few initiatives across Europe that are addressing the problem of male overweight and obesity.

 

Communicable diseases

 

Hepatitis C. In Western Europe the prevalence of chronic infection is low, but there is a notable North-South gradient in infection patterns, with an infection rate of 0.1% in the Northern Member States to more than 1% in the Mediterranean Member States. Prior to EU enlargement, Hepatitis C was responsible for 30% of liver transplants in Europe (European Commission, 2003). The two main transmission modes in Western Europe are blood transfusion and intravenous drug, while in Eastern Europe they are iatrogenic transmission and intravenous drug use. The public health impact is now becoming visible in the most affected communities, particularly among blood recipients and, more recently, intravenous drug users (IDUs) with an HIV co-infection.

 

HIV/AIDS. Although most new cases of HIV/AIDS reported in the EU since 1989 have been amongst intravenous drug users, while a growing proportion is associated with immigration and travel abroad. Data do not allow firm estimates of trends in terms of infection with HIV (rather than AIDS) (European Commission, 2003), but 24,184 newly diagnosed cases of HIV were recorded in the 23 EU countries for which data was reported in 2004 (excluding Italy and Spain). This represents a rate of 68 HIV infections per million population. Over a third of cases (36%) were females. For biological and social reasons, women are more vulnerable to HIV infection than men. Thirteen per cent of cases were young people between 15-24 years of age (EuroHIV, 2006). In many societies, it is the unequal economic, social and cultural status of women that puts them at a greater risk of infection. Those who lack adequate access to prevention or economic security, or who are involved in coercive or abusive relationships often cannot negotiate abstinence or the use of a condom. Women are becoming infected with HIV/AIDS at significantly younger ages than men. While both young girls and boys engage in consensual sex, girls are more likely than boys to be uninformed about HIV, to be coerced or raped, or enticed into sex by someone older, stronger or richer. Increased incidence of HIV/AIDS in young women has also led to an increase in the transmission of the virus from mother to child. Effective prevention programmes need to address HIV/AIDS both as a public health issue, and as a symptom of underlying gender inequality (Brown, 2003). UNAIDS has observed that men and women living with AIDS, when treated equally, show no difference in survival rates (UNAIDS et al, 2004).

 

Sexually Transmitted Infections . Sexually transmitted infections remain an important problem in the Europe Union. Women are more vulnerable to STIs biologically, culturally and socio-economically. Their lower social position in many societies gives them less power in sexual relationships and therefore a high risk of acquiring an infection. The gender stereotypes that accompany this lack of power ensure a greater stigma is attached to becoming infected, which may influence the treatment and severity of the health repercussions from such an infection.

Neisseria gonorrhoea remains one of the most common sexually transmitted infections. The incidence rate of syphilis is low and seems to be decreasing. There has been a marginal increase in Austria, Germany, Hungary, Malta and the Netherlands, and a more significant increase in Slovenia and the UK (WHO, 2006). In November 2006, the UK Health Protection Agency (HPA) recorded a dramatic increase in the number of cases, ranging from 137 in 1996 to 3 000 in 2005 (HPA, 2006). Trends in fluctuation are difficult to establish, as many countries have very low reporting rates. Gonorrhea and syphilis have a current incidence respectively 4.5. and 4.4. times higher in men than women. Up to 80% of women and 10% of men affected by gonorrhea are asymptomatic. If left untreated, gonorrhoea can cause chronic pelvic inflammatory disease, infertility and ectopic pregnancy. Those infected also face a greater risk of transmitting or becoming infected with the AIDS virus. Since the mid 1990s, an increase in the cases of gonorrhoea has been observed in some countries. England and Wales, for example, experienced a 35% increase in male cases and a 32% rise in female cases between 1995-97 (WHO, 2001). The health consequences of the human papilloma virus (HPV) are often hidden and can occur years after infection. HPV produces genital warts which are suspected of causing the cellular changes that can lead to cervical cancer, though they are commonly regarded as being of low risk with regard to malignancy (Fenton and Lowndes, 2004). Nevertheless, about 70 percent of cervical cancer shows evidence of HPV infection (Madeleine et al, 1997). Few EU countries routinely collect surveillance data on infection with genital warts. A vaccine for HPV has become recently available and several EU Member States are now starting vaccination campaigns.

 

Disability

 

Data on disability are usually limited and not comparable and so fail to reflect the true situation in the EU. It appears that most Member State populations have close to 12% disability. There is a suggestion that life expectancy without disability is either stagnating (United Kingdom) or increasing (Germany and France). Some sources, which link population health surveys with other health data estimating the prevalence/incidence of several conditions, suggest that increased life expectancy does not bring an increase in the time spent with severe handicap or severe disability (European Commission, 2003).

 

Menopause

 

Climateric. The climacteric3 is sometimes, but not always associated, with symptoms. There is debate as to whether the termsymptoms” should be used when referring to events of the climacteric. This term is used here to refer to those bodily perceptions presented as complaints by the individual woman. Conflicting findings are available as to the causes of symptoms in midlife inherent in menopause as well as specific issues pertaining to the measurement of symptoms. A number of studies suggests that symptom experience is likely to be worse when women have undergone surgical menopause.

 

Individual women may view menopause as negative and troublesome or positive and liberating. Importantly, the knowledge base on menopause is narrow in that most studies have been carried out on white women of Northern European ancestry; relatively little is known about the range of climacteric experiences in women of other racial/ethnic groups. Cross-cultural comparisons demonstrate that reported symptoms can vary significantly among countries and among ethnic groups within countries in type (e.g., vasomotor and psychological) and in the degree of distress caused. Difficulties in integrating findings from cross-cultural studies stem from a number of limitations.

 

In North America and Europe, most women have at least some menopausal hot flushes; these have been described in a limited number of studies in a variety of other cultures. The prevalence varies widely. There is consensus about the marked temporal relation of vasomotor symptoms to the climacteric. They begin to increase in the menopausal transition, and may remain increased for several years. A number of studies have shown a statistical relation between hot flushes and night sweats, and some show a relation between those vasomotor symptoms and insomnia. The mechanism of menopausal flushing remains unclear. Core body temperature elevations precede the menopausal hot flush and serve as one trigger of the heat loss phenomenon, but what is responsible for the core temperature elevation remains uncertain.

 

The physiological role of oestrogen and oestrogen receptors are fundamental in menopause. Multiple population-based studies imply a decrease in female sexual function associated to the midlife years, while there is growing evidence that the decrease reflects hormonal changes of the menopausal transition rather than increasing age. Hormonal change is only one of the many factors that affect sexual function. Other factors include the presence of a sexual partner, partner’s age and health, length of the relationship, feelings toward the partner, level of past sexual function, social class, educational level, experience of physical or psychological ill health, stressors, employment, personality factors and negative attitudes towards menopause. Declining sexual function is common but not universal with ageing. There may be an additional decrement associated to the menopausal transition.

 

In clinical trials, mastalgia has been related to oestrogen and progestin concentrations. Mastalgia that is related to the menstrual period often resolves with menopause.

 

Experimental, clinical and epidemiological data support an important role for reproductive hormones in the aetiology of some human cancers, including breast, endometrium and ovary. Whereas for common adult cancers, such as lung and colon cancers, incidence rises continuously and progressively with age, the slope of increase slows around the time of menopause for most hormone-dependent cancers. Worldwide, breast cancer is by far the most frequent invasive cancer in women and the leading cause of cancer death in women, accounting for more than 300 000 deaths each year, while cancer of the corpus uteri adds other 40 000. The effect of menopausal therapies on the risk for cancer is a rather critical issue.

 

Osteoporosis. Osteoporosis is a major public health problem through its association with fracture. One in three women and one in eight men over the age of 50 are affected by enhanced bone fragility and an increased fracture risk. Across Europe, some 19 million people are considered to suffer from osteoporosis. There are substantial differences in the descriptive epidemiology of limb fracture per region and gender. Amongst women, the incidence of hip, humerus and distal forearm fracture increases with age, with incidence rates higher in Scandinavia than in other European regions. Two group of postmenopausal women are at risk of fracture: (a) those with osteoporosis who have not yet had a fracture and who, if they remain untreated are at risk due to the progressive nature of the diseases and (b) those women with osteoporosis who have already had a fracture and are at high risk of further fractures. The incidence of hip, humerus and distal forearm fracture increases with age. Incidence rates are higher amongst women in Scandinavia than in other European regions. Moreover, osteoporosis affects a large proportion of the population of elderly women throughout the world. More women than men are affected. The overall lifetime risk for fractures in women in the United States and most European countries is from 30 to 40 percent, but there is clear variability across cultures. Worldwide for women and men, about 1.26 million hip fractures occur each year, a number expected to double by 2025.Rates of osteoporosis and related bone fractures increase with age. Low bone mass at menopause can be due to insufficient bone acquisition during growth or bone loss during adulthood. Ovarian failure heralds dramatic changes in skeletal homeostasis. Bone loss accelerates for a few years after natural menopause or ophorectomy, and continues at a lower rate for the remainder of life. The mechanism of how loss of estrogen at menopause contributes significantly to skeletal bone loss is not completely understood. Postmenopause bone loss may be exacerbated by low levels of physical activity and poor nutrition, especially low calcium intake. Severe bone loss and fractures are not natural consequences of ageing and can be prevented or substantially delayed. Osteoporosis may have no obvious symptoms. The main method for diagnosing osteoporosis is the evaluation of the skeleton by using a non-invasive measurement of bone mineral density (BMD). Fracture risk is the most important determinant in patient selection for treatment or intervention for osteoporosis, although bone density is only one of many risk factors that contribute to the risk for fracture. Although there has been major progress in the methods for assessing the risk of osteoporotic fracture, identifying individuals at greatest need for treatment still remains a problem. There is a limited diagnosis of osteoporosis in Europe. Despite the availability of effective methods for detecting bone loss, many people are not routinely assessed for osteoporosis and may not receive treatment to prevent further loss of bone mass or fractures until the disease worsens.

 

Though more women than men develop osteoporosis, men appear to be at a much greater risk than what previously thought, with both primary and secondary sources of osteoporosis contributing to the problem. Men, tend to have larger accrual of bone mass during puberty; as a consequence, men tend to suffer bone fractures approximately 10 years later in life than their female counterparts. Men's clinical condition at that age has usually also deteriorated, however, with an increase in morbidity and mortality associated to fractures and their (surgical) treatment being considerably greater than in women. A recent review made for the American College of Physicians noted that the one year mortality rate for men following hip fracture is twice that of women (Qaseem et al 2008). Following first fracture, the risk of the second is the same as for women.

 

As already noted, even though there are more older women than men falling, men have a higher mortality as a result of falls. The problem of osteoporosis is not only an age related condition in men with the condition found in men undergoing glucocorticoid steroid treatment for lung disease (Lim & Fitzpatrick, 2004); the treatment of prostate cancer, which for many men involves androgen ablation therapy, has a marked effect on oestrogen levels (Lee et al, 2005). The significance of osteoporosis in men is that, as it tends to be seen as a problem of older women, it is often misdiagnosed and under-treated leading to more severe forms of the disease.

 

Once a fracture has occurred, the risk of future fracture is at least doubled within one year. Adequate nutrition – in particular, but not exclusively, from the intake of calcium and vitamin D – and adequate physical activity are requisite preventive efforts against osteoporosis throughout life. Avoidance of tobacco use and moderation in alcohol intake are obvious. A decade ago estrogen and injectable calcitonin were the only available pharmacologic therapies for menopausal women and men with osteoporosis. Now there are new bone-specific drugs and broad-spectrum drugs that combat osteoporosis and have potentially beneficial effects on other organ systems. The same goes for calcitonin delivered as an intranasal spray.

 

Oral bone loss. Oral bone, like the rest of the skeleton, comprises both trabecular and cortical bone and undergoes formation and resorption throughout the lifespan. When oral bone loss exceeds gain, it manifests as either loss of tooth-anchoring support or a diminution of the remaining ridge in areas of partial or complete tooth loss. The prevalence of oral bone loss is significant among adult populations worldwide and increases with age for both sexes. Oral bone loss and attendant tooth loss are associated to estrogen deficiency and osteoporosis. As a consequence, women’s experiences with postmenopausal osteopenia may affect the need and outcome of a variety of periodontal and prosthetic procedures, including guided tissue regeneration and tooth implantation. Furthermore, it is possible that oral examination and radiographic findings may be useful signs of extraoral bone diminution. Non pharmacologic approaches to preserving oral bone include smoking cessation and oral hygiene self-care behaviours, such as brushing and flossing; professional dental services, including oral examination, tooth scaling and polishing. Calcium and vitamin D supplementation and pharmacologic therapies for osteoporosis may yield positive oral bone effects.

 

Uterine bleeding. Different patterns of uterine bleeding can be confusing when they occur in older women, and physicians must be alert towards the possibility of genital tract pathology. Endometrial bleeding can be linked to endometrial pathology (atrophy, polyps, submucosal leiomyoma, hyperplasia, adenocarcinoma) or to general pathology, dysfunctional conditions, or drugs. Dysfunctional uterine bleeding is common between 40 and 50 years of age. The associated endometrial histology is highly variable. In some patients with bleeding, the endometrial histologic findings appear out of phase with endocrine events. In many, the endometrium will be hyperplastic and may be secretory until the year before menopause. In postmenopausal women, endometrial atrophy is the most common histologic finding.

 

Lower genital and urinary tract atrophy. The epithelium of the inner layer of the vagina undergoes progressive loss of cells during menopause due to oestrogen depletion. Estrogen-dependent secretions decrease, leading to vaginal dryness and, in some women, vaginitis, vaginimus, and dispareunia. Loss of glycogen-producing cells, a consequence of vaginal and urethral atrophy, causes a decreased production of lactic acid and an environment that favours vaginal and urethral infection. It is important to identify and treat patients with recurrent infections to prevent significant morbidity, which includes the risk of renal impairment.

 

Pelvic floor and urinary incontinence. All four functional layers of the urethraepithelium, connective tissue, vascular tissue, and muscle – are affected by oestrogen status. Estrogen deficiency causes atrophic changes of the urethral epithelium and of the submucosa. Urinary incontinence (UI) is defined by the International Continence Society as involuntary loss of urine that is objectively demonstrable and is a social or hygienic problem. The relationship between menopause and UI is unknown and not well studied. Limited data are available to support the hypothesis that menopause is a major risk factor for incontinence, especially for stress and urge incontinence.

 

The full extent of incontinence in men is unknown but is less common in younger men though of a greater incidence in older men than previously thought (Boyle et al 2003). The causes are mainly due to either prostate problems or the side effects of surgery for prostate problems.

 

Brain function, mental health, and eye. The CNS and eye are among the many tissues thought to be affected by hormonal changes around the time of menopause. In the brain and eye, as in other target organ systems, oestrogen interacts with specific intranuclear receptors and putative membrane receptors to regulate intracellular processes. Memory and other cognitive abilities change over time during adult life. Changes that represent usual or normal accompaniments of ageing are not viewed as pathologic. Modest cognitive decrements initially detectable in middle age are accentuated at elderly age. Many studies suggest that sex hormones influence brain function throughout life, but there is little evidence that menopause per se initiates cognitive deterioration, while serum estrogen concentrations in postmenopausal women do not appear to be closely related to cognitive skills. Increasing age is often accompanied by visual acuity loss among older people, that affects women more often than men. Some observational studies suggest the potential relevance of estrogens in eye disease.

 

 

Erectile Dysfunction

 

Erectile dysfunction (ED) describes ‘an inability of the male to achieve an erect penis as part of the overall multifaceted process of male sexual function.’ (NIH consensus development panel, 1992). Whilst there is little consensus over the actual numbers of men who do suffer from ED, it has been shown that ED is strongly associated with age, with incidence rates increasing within older populations. Braun et al., (2000) found a 2.3% incidence rate in men aged 30-39, 9.5% aged 40-49, 15.7% aged 50-59, 34.4% aged 60-69 and 53.4% aged 70-79. When linking data with United Nations estimates of rise, the proportion of males aged 65 or over from 4.2% in 1995 to 9.5% in 2025. The most commonly used data source linked to the topic of erectile dysfunction has been the Massachusetts Male Ageing Study (MMAS). From this data source it has been predicted that that 152 million men suffer from erectile dysfunction worldwide with a prediction that the number of sufferers will double by 2025 (Aytac et al. 1999).

 

The impact of ED on sufferers can be severe. Effects include depressive symptoms such as loss of self esteem and feelings of inadequacy but also may have negative effects on a man’s interaction with others, particularly partners, potentially causing relationship problems.

 

Historical explanations for ED have concentrated on the psychological or spiritual origins of the condition, from which a great deal of the stigmatising thought regarding ED originates (Shah 2002). Evidence indicates that most ED is multifactorial in origin, with organic factors and psychogenic factors likely to contribute to the development of the condition. However, organic factors are the most common reasons for the development of ED, with 80% of cases believed to have a physical grounding, with for example diabetes, neurological problems, urological surgical and many prescription and recreational drugs implicated. Moreover, it has been estimated that between 50 and 70% of ED can be attributed to vascular disease, with the penile arteries being smaller than the coronary arteries, the development of vascular problems is picked up first through ED, leading to a very effective early warning system for coronary artery disease (Jackson & Padley, 2008).

 

Androgen Deficiency in ageing males (andropause). While menopause in women is a well defined process with a clear starting point, in men the same process of reduced steroid production occurs gradually and often without clinical and biochemical signs of deficiency. In most men, androgen deficiency is a slow and progressive process and thus the acronyms ADAM or PADAM (androgen or partial androgen deficiency of ageing males) have been used to better describe the physiological reduction of androgen secretion occurring in elderly men. More recently, Late Onset Hypogonadism (LOH) has been introduced as a new definition of the consequence of the declining androgen production, while Symptomatic Late Onset Hypogonadism (SLOH) has been suggested as a more precise term for those conditions in which pathological changes requiring replacement therapy occur.

 

While androgen deficiency refers to the total production of androgen steroids, in practice the assessment of testosterone, serum concentration is the most important parameter for defining hypogonadism. The importance of this phenomenon derives from the fact that, as an average, there is a progressive 1% decline of testosterone serum concentration levels per year from young adulthood and that the elderly population is progressively increasing, especially in European countries. This decline is highly influenced by health status. The presence of co-morbidity, such as hypertension, obesity, metabolic syndrome or abuse habits, such as smoking or alcohol, greatly affect the decline of testosterone towards lower levels. Considering the population ageing trend in the EU, it is clear that a significant number of people throughout Europe are likely to have symptoms of LOH. Taking into consideration both the decrease in androgen production and an increase in the older population, data show that in the EU 25 4.5million people >65 years and 3.5 million people >80 are affected by LOH. This significant incidence of the older population creates social and economic dysfunctions and requires specific attention and policies.

 

Concern arises also for the medical aspects of ageing. This is a process that affects all organs and systems. The symptoms related to testosterone deficit can affect three different areas: somatic, sexual and psychological.

 

The main aspects of the somatic area are related to change in body composition, such as a decrease in lean mass and an increase in fat mass (particularly the abdominal adiposity), a parallel reduction of muscle strength, a decline in bone mineral density and changes in carbohydrate and lipid metabolism. These findings are rather common in elderly people with androgens playing to a variable extent an important role in the pathogenesis of these alterations although no strict correlation has been found between testosterone and body composition parameters.

 

Sexual complaints are also common and represent, according to several studies, the main reason for consulting a doctor. It is well established that testosterone deficiency may severely affect erectile function. However, the vascular element of this function is often altered in the elderly. These peripheral effects are accompanied by “centralchanges, such as a reduction in libido, erotic fantasies and spontaneous erections. The psychological aspects include a broad spectrum of symptoms, from a generic loss of energy to depression, from frailty to decreased cognitive function, from sleep disturbance to poor concentration.

 

Currently, there is no universal consensus on the hormonal and clinical criteria that should be used to identify those older men who are candidates for androgen therapy. Various guidelines have been published in recent years on this aspect. The American Endocrine Society Clinical Practice Guidelines (2006) suggest a repeated level < 300 ng/dl (or 10.4 nmol/L) of total testosterone as the cut off for androgen deficiency, provided that a reduction of the total concentration due to altered Sex Hormone Binding Globulin (SHBG) levels are excluded. The presence of symptoms of hypogonadism, associated to biochemical deficit, is required for initiating Androgen Replacement Treatment (ART). In case of unclear results, the testosterone levels can be measured using the equilibrium dialysis method; in this case the cut off is 5 ng/dl (50 pg/ml)(0.17 nmol/L).

 

In a joint statement of three Scientific Societies - the International Society of Andrology (ISA), the International Society for the Study of Ageing Male (ISSAM) and the European Association of Urology (EAU) - a cut off of 230 ng/dL (8 nmol/L) of total testosterone is recommended for those who require ART. When the serum level is > 346 ng/dL (12 nmol/L) ART is not necessary, while when the levels are between 230 and 346 ng/dL ART is optional and should be individualised. The three levels of free testosterone are respectively: < 180 pmol/L (52 pg/ml), between 180 and 250 pmol/L (72 pg/ml) and > 250 pmol/L (52 pg/ml).

 

A complete diagnostic workup is mandatory before taking into consideration an ART. Present and previous diseases and drugs taken should then be considered. General blood chemistry and specific hormonal assessment should be performed. Bone and erectile function may require specific evaluation by densitometry and Doppler ultrasounds, respectively. Prostate status should be assessed by PSA analysis and digital examination and, in case of doubt, by transrectal ultrasounds.

 

Other disorders

 

In part because they live longer than men, women are more likely to be affected by sub-chronic disabling conditions as musculoskeletal disorders, arthritis and fibromyalgia. These conditions not only limit function, but over time they may be life-threatening. Each of these disorders is characterised by a long trajectory of increasing impairment. More research is needed to determine whether specific gender-related factors contribute to the increased incidence of these illnesses in women.

 

Musculoskeletal Disorders. Musculoskeletal disorders affect an increasing proportion of the population, with various degrees of impact on disability and quality of life which result in a significant number of physician visits, work absence and medication use. A Swedish study has found that the highest incidence and duration of sickness absence is for women in male dominated occupations. For both genders the lowest cumulative incidence and duration occurred in gender-integrated occupations.

 

Arthritis . More than 100 million European citizens have arthritis/rheumatism. It is estimated that rheumatoid arthritis affects between 0.5 and 1.0% of the adult population worldwide (Kvien, 2004). As the disease increases in prevalence with age and affects more women than men, older age and female gender would appear to be risk factors. It has been argued that it is difficult to compare the burden of the disease in European countries because of the varying ways in which results are presented (Hunsche et al, 2001). More research and standardised methodologies applied in the analyses are required in order to better understand the burden of this illness.

 

Fibromyalgia. Fibromyalgia syndrome, a widespread musculoskeletal pain and fatigue disorder for which the cause is still unknown, leads to pain in the soft fibrous tissues of the body: the muscles, ligaments, and tendons. Women are more frequently affected (75-80% of cases) than men. The disease has significant repercussions on everyday life, such as sexual difficulties, inability to work and disability. Its prevalence in the wider European region is estimated to be between 0.1 and 3.3% in women between 20 and 49 years of age, and according to one Norwegian study it can reach an incidence rate as high as 8. to 10.5%.

 

9.3.1.4. Risk factors

 

The main risk factors for adults are summarized in Table 9.1c.

 

Table 9.1c. Main risk factors for adults

Major modifiable risk factors for atherosclerotic CHD are similar in women and men and include dyslipidemia, hypertension, diabetes mellitus, cigarette smoking, inadequate physical activity, and obesity (especially abdominal obesity). The atherogenic risk profile of older women is appreciably more adverse than that of younger women, although it is uncertain whether age or hormone status is the primary determinant of the evolution of the adverse risk profile. Large randomized, placebo-controlled clinical trials have shown that beta-blockers, aspirin, 3-hydroxy-3-methylglutaryl-coenzyme A (HMG-CoA) reductase inhibitors (statins), and angiotensin-converting enzyme (ACE) inhibitors reduce risk for CHD events in women as well as in men. For some of these therapies, the evidence derives largely from secondary prevention trials; in general, therapies that work in secondary prevention will work in primary prevention as well. Treatment effects appear to be similar in women and men. For example, meta-analysis of data from several major lipid-lowering statin trials showed a 29-percent reduction in risk for major CHD events in women, similar to the 31-percent reduction observed in men. At present, prevention of CHD should rely on identifying and treating the classic risk factors, such as dyslipidemia, hypertension, diabetes mellitus, smoking, obesity, and sedentary lifestyle. Vigilant management of risk for CHD in women is imperative. Despite similar stroke rates, women are more likely than men to die of stroke. The main risk factors for stroke are not gender dependant. Although strokes are more closely related to hypertension (which is probably their most important risk factor) than to hypercholesterolemia, HMG-CoA reductase inhibitors (statins) reduce risk for stroke, as do antihypertensive medications.

 

Smoking is a primary cause of lung cancer, although pollution and exposure to certain gases/chemicals may also be influential

 

Alcohol. The Charter establishing the European Alcohol and Health Forum notes that 7.5% of ill-health and premature death is a consequence of harmful and hazardous alcohol consumption and that alcohol contributes to about 25% of mortality in young men (as compared to 10% in women). It has been noted that a significant proportion of the cardiovascular deaths in Eastern European countries are a consequence of sudden cardiac death as a result of excess alcohol consumption (Britton & McKee, 2000). Alcohol exacerbates financial difficulties, childcare problems, infidelity or other family stressors, and creates tension and conflict between partners. Risk factors for breast cancer in women may include regular use of alcohol (especially if combined with hormone replacement therapy (Beral, 2003), and higher body mass index (BMI) in early adulthood (Michels et al, 2006)

 

Current EU environments favour obesity. There is an abundance of food in Europe that, while energy-rich, is often poor in nutrients. Food portion sizes are growing, though people with sedentary lifestyles actually need less energy. Social and economic pressures can mean that both work and leisure hours offer decreasing opportunities for physical activity.  It is also interesting to note the relationship across Europe between availability of fruit and vegetables at national level, and the prevalence of ischaemic heart disease (Fig.9.T1.4).

 

Figure 9.T1.4. Relationship between per capita availability of fruits and vegetables and age-standardized death rates from ischaemic heart disease in the European Region before age 65, per 100.000 population.

 

 

 



Source: Pomerleau et al, 2003: p. 455

 

Levels of physical activity vary across the EU member states, but in general southern countries of the EU15 have lower levels of physical activity than Northern and Western countries. Physical inactivity is defined as less than 2.5 hours per week of moderate exercise or 1 hour per week of vigorous exercise. The World Health Report 2002 estimates that over 3% of all disease burden, over 20% of CHD, and 10% of stroke in developed countries is caused by physical inactivity.

 

Ill health increases steadily with decreasing educational level. People with low levels of education are more likely to suffer chronic health problems and resulting disability than more educated patients. Numerous studies demonstrate that life expectancy and ‘positive health experiencesincrease for those with higher levels of education. For example, people with low levels of education have an increased risk of premature death and circulatory disease.

 

References cited in this table are listed in Chapter 9.3.1

 

 

 

9.3.1.5. Control tools and policies

 

Control tools and policies are provided for specific diseases in Chapter 5 and for specific health determinants in Chapter 10. For issues concerning health services see Chapter 11.

 

9.3.1.6. Future developments

 

Key stakeholders including dedicated non-governmental organizations and several EU Governments have and continue to support investments in research and practice development.

 

EU Member States have signed up to processes which will enhance disease prevention and responses to health threats. They have also agreed to foster co-operation between health systems. The implementation of this strand may be more difficult – not due to lack of will, but because systems are often not compatible, and because the costs involved in overhauling data collection methods to a European standard are too daunting for Statesresources. Assured implementation requires a shift in organisational culture and in finance allocation at State level. There are several strata to the changes which need to occur: in systems of research and data collection, in planning, agenda setting and policymaking, and in implementation and evaluation. Interventions are needed to support Member States in making the administrative changes which add value to their services, while bringing those services to a measurable common European standard.

 

Likewise, attention must be given to the imbedding of gender equity into policy and planning. Under the Lisbon Agenda, this seems assured, but again supports are needed to allow institutes operating below State level to sign up to implementation, as the financial and human resource costs of change can overstretch fragile budgets.

 

Special attention needs to be paid to enhancing statistical methodology and classifications and breaking down barriers in research. The process of gender and health impact assessments of all research, planning and policy documents must be adhered to, right down to local level. In this way, good quality research and health services will be obtained at European level.

 

As life expectancy continues to increase, a challenge for the future will be to maintain and improve the quality of life in women as they age through a better management of menopausal symptoms and health risks associated with menopause. Despite exciting new research in the field of menopause, including the availability of more choices for intervention and major breakthroughs in the understanding of effects, much work remains to be done in terms of research and practical implementation of its results. The increasing number of postmenopausal women and their increasing longevity highlight the importance of women’s health and well-being.

 

9.3.1.7. References

 

Arber S, McKinlay J, Adams A, et al, (2006): Patient characteristics and inequalities in doctorsdiagnostic and management strategies relating to CHD: A video-simulation experiment. Social Science & Medicine 62 103115

 

Association of European Cancer Leagues (2005): Cancer in EuropeFacts and Figures. January http://www.europeancancerleagues.org/ecl/Modules/_Content/FileAttach/cancer%20in%20europe.pdf (Article online, accessed 11.07.07

 

Aus G, Bergdahl S, Lodding P, Lilja H, Hugosson J (2007): Prostate Cancer Screening Decreases the Absolute Risk of Being Diagnosed with Advanced Prostate CancerResults from a Prospective, Population-Based Randomized Controlled Trial Eur Urol 51: 659-664

 

Austbury J: (2002): Mental HealthGender Bias, Social Position, and Depression’, in: Engendering International Health: The Challenge of Equity. (Edited by Sen. George GA and Östlin P). MITPress, Cambridge

 

Aytac, I., McKinlay, J. & Krane, R. (1999) The likely worldwide increase in erectile dysfunction between 1995 and 2025 and some possible policy consequences. British Journal of Urology. 84(1): p. 50-56.

 

Beral V (2003): Breast cancer and hormone-replacement therapy in the Million Women Study. The Lancet; 362; 9382; 419-427.

 

Boyle, P. Robertson, C. Mazzeha, C. Keech. M. Hobbs, F.D.R. Fourcade R. Kiemeney , L, Lee C. and the UrEpik Study Group (2003) The prevalence of male urinary incontinence in four centres: the UREPIK study. BJU International 92. 943947

 

Branney, P White, AK (2008) Big boys dont cry: depression and men. Advances in Psychiatric Treatment 14: 256-262

 

Braun, M., Wassner, G Klotz, T Reifenrath, B Mathers, M Engleman, U (2000) Epidemiology of erectile dysfunction: results of the 'Cologne Male Survey'. International Journal of Impotence Research. 12(6): p. 305-311.

 

British Heart Foundation: Heartstats http://www.heartstats.org/datapage.asp?id=4695 (Article online, accessed 06.07.07)

 

Britton A McKee M (2000): The relation between alcohol and cardiovascular disease in Eastern Europe: explaining the paradox. Journal of Epidemiology & Community Health. 54(5): 328-332

 

Brown H (2003): Women's Lack of Control Over STI Risks Drives Microbicide Search. Population Reference Bureau. http://www.prb.org/Articles/2003/WomensLackofControlOverSTIRisksDrivesMicrobicideSearch.aspx (Article online, accessed 07.07)

 

Brownhill S, Wilhelm K, Barclay L & Schmied V (2005): 'Big build': hidden depression in men. Australian and New Zealand Journal of Psychiatry, 39: p. 921 - 931.

 

De Smedt M (2004): Towards A Common Framework To Measure Health Status. Eurostat/European Commission

 

Doyal LA (1998): Draft Framework for Designing National Health Policies with an Integrated Gender Perspective: Mainstreaming the Gender Perspective into the Health Sector (UN doc. EGM/Health/1998/Report). Presented at the UN DAW Expert Group Meeting on Women and Health, Tunisia, 28 September to 2 October 1998

 

European Commission (2004a): The State of Mental Health in the European Union. Health & Consumer Protection Directorate General, European Commission.

 

EuroHIV (2006) : HIV/AIDS Surveillance in Europe. Mid-year report 2005. Saint-Maurice: Institut de veille sanitaire, No. 72. p 6

 

European Agency for Health and Safety at Work (2007): http://osha.europa.eu/good_practice/risks/accident_prevention/intro1.php (Article online, accessed 08.07)

 

European Commission (2003): The Health Status of the European UnionNarrowing the Health Gap. Luxembourg

 

European Commission (2004b): Expert ReportActions against depression. Improving mental and well-being by combating the adverse health, social and economic consequences of depression’. Luxembourg

 

European Commission (2006): Report on Equality between Women and Men. Brussels

 

European Community/Europe Against Cancer (2003): European Code Against Cancer, Version 3. http://www.cancercode.org/ (Article online, accessed 01.07)

 

European Heart Network/European Health Management Association/Bristol-Myers Squibb (2005); A healthy heart for European women. www.ehnheart.org (Article online, accessed 02.07)

 

European Prostate Cancer Coalition: http://www.cancerworld.org/cancerworld/home.aspx?id_sito=4&id_stato=1 (Article online, accessed 07.07)

 

Eurostat (2007): Europe in figures: Eurostat yearbook 2006-07. Luxembourg: Office for Official Publications of the European Communities.

 

Falzon D and Belghiti F (2007): Tuberculosis – still a concern for all countries in Europe. Eurosurveillance weekly 12, on-line article available at http://www.eurosurveillance.org/ew/2007/070322.asp#1 (accessed 18.07.07)

 

FEND/IDF Europe (2005): Diabetes - The Policy Puzzle: Towards Benchmarking in the EU 25. Available at http://www.idf.org/webdata/docs/idf-europe/DiabetesReport2005.pdf (Article online, accessed 07.07)

 

Fenton K A and Lowndes C M (2004): Recent trends in the epidemiology of sexually transmitted infections in the European Union. Sex. Transm. Inf. 80;255-263; doi:10.1136/sti.2004.009415

 

Forsgren L, Beghi E, Õun A, Sillanpää M (2005): The epidemiology of epilepsy in Europe – a systematic review. European Journal of Neurology, Volume 12Number 4, April 2005 , pp. 245-253(9)

 

Gabriel P, Liimatainen M-R (2000): Mental health in the workplace: Introduction. International Labour Office, Geneva

 

Glei DA, Bruzzone S Caselli G (2005): Effects of war losses on mortality estimates for Italy: a first attempt Demographic Research 13(15), pp 363-388

 

Haslam, D (2007) The causes of male obesity and associated health problems IN White, A & Pettifer, M (eds) Hazardous Waist: tackling male weight problems. Radcliffe Publishing, Oxford.

 

HPA (2006): http://www.hpa.org.uk/publications/2006/hiv_sti_2006/keypoints.htm (Article online,accessed 12.06)

 

International Obesity Task Force (2002) Obesity in Europe: the case for action. European Association for the Study of Obesity, London.

 

Jackson, G; Padley, S (2008) Erectile dysfunction and silent coronary artery disease: abnormal computed tomography coronary angiogram in the presence of normal exercise ECGs. International journal of clinical practice, 62(6):973-6

 

Lee H, McGovern K, Finkelstein JS & Smith MR (2005): Changes in bone mineral density and body composition during initial and long term gonadotropin-releasing hormone agonist treatment for prostate carcinoma. Cancer 104(8): 1633-1637

 

Lim LS, Fitzpatrick RD (2004): Osteoporosis in Men. In Kirby, R.S Carson, CC, Kirby, MG & Farah, RN, (Editors), Men's Health 2nd Ed. London: Taylor & Francis.

 

Madeleine MM et al, (1997): Co-factors with human papillomavirus in a population-based study of vulvar cancer. J Natl Cancer Inst, 1997. 89(20): p. 1516-23

 

Makino M, Tsuboi K, Dennerstein L (2004); Prevalence of eating disorders: a comparison of Western and non-Western countries. Medscape General Medicine; 6: 3: 49.

 

Men and Gender Equality Policy. Helsinki (2006): 112 pp. (Publications of the Ministry of Social Affairs and Health, Finland, ISSN 1236-2050, 2007:2) ISBN 978-952-00-2269-3 (paperback) ISBN 978-952-00-2270-9 (PDF)

 

Mental Health Europe (MHE): http://www.mentalhealth-socialinclusion.org/good-practices.html (Article online, accessed 07.07)

 

Michels KB, Terry KL and Willett WC (2006): Longitudinal Study on the Role of Body Size in Premenopausal Breast Cancer. Archives of Internal Medicine, 166: 23952402. Cited by Cancer Help UK (http://www.cancerhelp.org.uk/)

 

Middle C, Johnson A, Alderdice F, Petty T, Macfarlane A (1996): Birthweight and health and development at the age of 7 years. Child Care, Health & Development; 22(1): 55-71

 

Möller-Leimkühler AM (2002): Barriers to help-seeking by men: a review of sociocultural and clinical literature with particular reference to depression. Journal of Affective Disorders, 71(1-3):1-9.

 

NIH Consensus Development Program (1992) Impotence: National Institutes of Health Consensus Development Conference Statement. Available from: http://consensus.nih.gov/1992/1992Impotence091html.htm

 

Niederlaender E (2006): Causes of death in the EU. Statistics in focus, Population And Social Conditions 10/2006

 

Plümper T, Neumayer E (2006): The unequal burden of war: the effect of armed conflict on the gender gap in life expectancy. International Organisation 60: 723-754.

 

Qaseem, A Snow, V Shekelle, P Hopkins Jr R. Forciea, MA Owens, DK (2008). "Screening for Osteoporosis in Men: A Clinical Practice Guideline from the American College of Physicians." Annals of Internal Medicine 148(9): 680-W137.

 

Shah, J., (2002) Erectile dysfunction through the ages. British Journal of Urology. 90: p. 433-441.

 

UNAIDS, UNFPA, and UNIFEM (2004): Women and HIV/AIDS Confronting the Crisis. Geneva and New York. www.unfpa.org/hiv/women/report/ (Article online, accessed 07.07)

 

Verdecchia, A., S. Francisci, et al. (2007). "Recent cancer survival in Europe: a 2000-02 period analysis of EUROCARE-4 data." The Lancet Oncology 8(9): 784-796.

 

Verlato G, Calabrese R, De Marco R (2002): (Abstract) Correlation between asthma and climate in the European Community Respiratory Health Survey. Archives of environmental health. Jan-Feb;57(1):48-52.

 

White AK (2006): Men and mental wellbeing: encouraging gender sensitivity. Mental Health Review Journal, 11(4), 3-6.

 

White AK , Cash K (2003): The state of men’s health across 17 European Countries. Brussels, The European Men’s Health Forum ISBN 1898883947

 

White AK, Holmes M, (2006): Patterns of mortality across 44 Countries among men and women aged 15-44. Journal of Men’s Health & Gender 3(2): 139-151

 

WHO (2000) Obesity: preventing and managing the global epidemic. The World Health Organisation, Geneva.

 

WHO (2001): Global Prevalence And Incidence Of Selected Curable Sexually Transmitted Infections. Geneva.

 

WHO (2002): Suicide Prevention in Europe. WHO Regional Office for Europe. Copenhagen

 

WHO (2003) Controlling the global obesity epidemic http://www.who.int/nutrition/topics/obesity/en/ (accessed April 2006)

 

WHO (2006): European Charter on counteracting obesity November 2006 http://www.euro.who.int/PressRoom/pressnotes/20070220_1 (Article online, accessed 07.07)

 

WHO (2006): European Ministerial Conference on Counteracting Obesity: November 2006 http://www.euro.who.int/Document/NUT/ObesityConf_10things_Eng.pdf (Article online, accessed 07.07)

 

WHO HFA-DB (2006): Health for All Database: http://data.euro.who.int/hfadb/ (Article online, accessed 30.01.08)

 

WHO Regional Office for Europe & European Commission (2002): Health status overview for countries of central and Eastern Europe that are candidates for accession to the European Union. European Communities & WHO July 2002

 

WHO/GENACIS (2005): Alcohol, gender and drinking problems: perspectives from low and middle income countries. World Health Organization

 

Wilkins D (2007): Report on the Expert Symposium on Men and Cancer. The Men’s Health Forum: London,

 

Wizemann TM, Pardue ML (2001): Exploring the biological contributions to human health: does sex matter? Washington, D.C.: Institute of Medicine.

 

9.3.1.8. Acronyms

 

ADAM

Androgen Deficiency of Ageing Males

AIDS

Acquired immunodeficiency syndrome

ART

Androgen Replacement Therapy

BMD

Bone Mineral Density

BMI

Body Mass Index

CHD

Coronary Hearth Disease

DG-SANCO

Director General for Health and Consumer Affairs

ED

Erectile Dysfunction

EU

European Union

EUROCARE

European cancer registries study on cancer patientssurvival and care

Euro-REVES

International Network on Health Expectancy and the Disability Process project

GIA

Gender Impact Assessment

GP

General Practitioner (Doctor)

HIA

Health impact Assessment

HIV

Human immunodeficiency virus infections

HPV

Human papilloma virus

IDF Atlas

International Diabetes Federation Atlas

IDUs

Injecting drug users

LOH

Late Onset Hypogonadism

MDG

Millennium Development Goals (WHO)

MMR

Maternal mortality rate

MOMS

European Concerted Action on Mothers' Mortality and Severe Morbidity

NGO

Non-governmental organisation

PADAM

Partial Androgen Deficiency of Aging Males

SHBG

Sex Hormone Binding Globulin

SLOH

Symptomatic Late Onset Hypogonadism

STI

Sexually transmitted infection

UNAIDS

The Joint United Nation Programme on HIV/AIDS

WHO

World Health Organization