This document discusses a study analyzing trends in multiple unhealthy lifestyle behaviors in England over time. The study found: 1) Overall improvements from 2003 to 2008, with a 20% drop in people exhibiting 3-4 risky behaviors, however 70% still had 2+ risks. 2) Most improvements came from higher socioeconomic groups, while risks increased in poorer groups, widening inequalities. 3) Addressing individual behaviors may not be sufficient - an integrated approach targeting people's overall lifestyles is needed, along with more targeted policies to reduce health inequalities.

1. Clustering of unhealthy behaviours
over time: implications for policy
and practice
David Buck and Francesca Frosini
The King’s Fund

2. The number of multiple lifestyles has
increasing impact on health
Source: EPIC-Norfolk cancer studies
...but more on mortality than reported quality of life.

3. Research, policy and practice questions
What has been happening over time?
– How has the distribution of multiple risk factors changed?
– Have multiple risk factors been polarising between socio-economic groups?
What might this mean for policy?
– Looking beyond single issue behaviour strategies
– Design of incentives and guidance such as public health tariffs, Quality
Outcomes Framework, the Public Health Outcomes Framework and NICE
public health guidance
What might this mean for practice?
– Are we wasting resources and increasing resistance by hitting the same
people with separate interventions and messages?
– Joint Strategic Needs Assessments, joint strategies, how to reap the health
premium cost-effectively, role of health and wellbeing board partners?

4. What we did
Cross-sectional analysis of the Health Survey for England
2003 and 2008
– Adult sample (>=16), 14,607 individuals in 2003 and 14,912 in 2008
– Four key risk factors: smoking, alcohol consumption, fruit and
vegetable consumption and physical activity levels
– Based on whether meeting government guidelines
Analysis of
– Changes in prevalence over time
– Whether changes in prevalence are related to socio-economic position,
education, gender or age

5. We found real improvements over time
Consistent with movements ‘down ladder’
– Shedding three and four risky behaviours, maintaining one and two
– Overall about a 20% drop in three+ behaviours for men and women
– But, 70% of the population still have at least two risky behaviours

6. Within this there are 16 possible risk factor
combinations
Combinations of risk factors in 2003, by gender
Note: S=Smoking; D=Drinking; F= Fruit & Vegetable; P=Physical activity; 0 = no risk factors

7. We found significant changes over time in
some of these combinations...
Change in prevalence of combinations of multiple lifestyle risk factors
between 2003 and 2008 by gender
Percentage point change in prevalence btw 2003 -2008 4.0
3.0
2.0
*
1.0
**
* *
**
0.0
** * ** *
**
-1.0
Men
-2.0
Women
-3.0
-4.0
SdFp
Sdfp
SdfP
sDfP
SdFP
sDFP
sDfp
sDFp
sdfP
sdFP
sdFp
SDFp
SDfp
SDfP
SDFP
Combinations of lifestyle risk factors
Note: S=Smoking; D=Drinking; F= Fruit&Vegetable; P=Physical activity; Capital letters= presence of risk factor;
* = significant change

8. ...but improvements come from some sectors
of the population and not others
Change in prevalence of multiple lifestyle risk factors between 2003 and 2008
for men in professionals and unskilled manual households
110
100
4 * 4 * 4
90
80 3 * 3 * 3
70
60
50
2 2
2
40
30
20
* 1 *
10 1 1 *
0 0 * 0 * 0
2003 - All pop 2008 - All pop 2003 - 2008 - 2003- 2008
Professionals Professionals Unskilled Unskilled

9. A public health success story with a worrying
twist
A real improvement in multiple health behaviours
– In 2003, about one in three of us weren’t adhering to government
guidelines on three or four of the behaviours – this had dropped to
about one in four of us by 2008
Most of the improvement came from higher socio-economic
and educated groups
– Poorer groups saw little improvement, widening relative inequalities, ie,
people with no qualifications were more than five times as likely as
those with higher education to engage in all four unhealthy behaviours
in 2008, compared to three times as likely in 2003
‘Improving the health of the poorest fastest’?
– Putting this right will be required if one of the coalition’s own criteria for
the success of its reforms is to be met

10. Implications for policy
Single behaviour approaches are necessary, but are they
sufficient?
– An approach based on people as well as ‘issues’
– Case for more targeted public health policies
– Little current integration between public health and inequalities policy
Public health and NHS reform
– Multiple behaviours in the Public Health Outcomes Framework,
informing the health premium, Quality Outcomes Framework and
design of behaviour tariffs?
– Research and guidance on multiple behaviour change from NIHR, PHE
and NICE

11. Implications for practice
Health and wellbeing boards
– Most local areas undertake similar surveys, re-analysis on these lines
will tell them what:
• they need to prioritise in their Joint Health and Wellbeing Strategy
• local authorities should take into account in their new public health
role
• the NHS should prioritise as it rolls out ‘Every Contact Counts’
Services
– The development of wellness services
– Role of health trainers and community health champions
– Training for staff delivering interventions

12. But, we need to know more
Pushing the analysis further
– Correlation with other behaviours and mental health
– Longitudinal analysis, to assess the impact of life events
– Understanding role of social capital, norms and networks
In order to intervene successfully we need to know
– If having multiple risks makes behaviour change easier or harder?
– Is it more effective to tackle risks in sequence or in tandem?
– From a population health perspective, should there be a focus on one
risk rather than another?
– How cost effective are different approaches to multiple risk from a
commissioner’s perspective?