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 hard 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
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 days’ absence 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).
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 ‘asylums’ accommodate 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 4.5–5.0 per 1000),
1.9 million aged 20–64 (prevalence about 6 per 1000) and 0.6 million aged 65 or
older (prevalence about 7 per 1000). Approximately 20–30% 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, 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.
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 attack – especially 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 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 dense’ foods and drinks which promote excessive ‘calorie’
consumption and support a ubiquitous ‘snacking’ culture. New evidence highlights
the ready evasion of appetite control by these foods, drinks and their
frequency of consumption. This leads to a pervasive ‘passive 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.
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.
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).
Climateric. The climacteric3 is
sometimes, but not always associated, with symptoms. There is debate as to
whether the term “symptoms” 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 urethra – epithelium, 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 “central” changes, 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.
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 experiences’ increase
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 States’
resources. 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.
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9.3.1.8. Acronyms
