Download - The env dimension report

the environmental dimensionof malta’s ill-health

and action to prevent obesity, diabetes, cardiovascular disease

and dementia

the environmental dimension of malta’s ill-health


and dementia

Report Published by The Today Public Policy Institute

Lead Author: George Debono

Presented to the Prime Minister, December 2015

The Today Public Policy Institute is an autonomous, not-for-profit, non-governmental organisation. Its mission is to promote wide understanding of strategic issues of national importance and to help in the development and implementation of sound public policies. In pursuit of this mission, it sponsors or initiates research on specific national problems, encourages solutions to those problems and facilitates public debate on them. It is not affiliated to any political party or movement.

Its Board is made up of the following individuals: Martin Scicluna (Director General),Michael Bonello, Sina Bugeja, Stephen Calleya, Juanito Camilleri, Petra Caruana Dingli, John Cassar White, George Debono, Mark Anthony Falzon, Michael Frendo, Martin Galea, Joseph Sammut, Joseph V. Tabone, Patrick Tabone, Clare Vassallo, John Vassallo and Joseph F.X. Zahra.

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The Environmental Dimension of Malta’s Ill-Health and Action to Prevent Obesity, Diabetes, Cardiovascular Disease and Dementia

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and dementia

CONTENTS

Preface ........................................................................................................................................................................9

PART 1: BAckGRounD – why AcTIon Is essenTIAL ..................................................................11

PART 2: The ReLevAnce of PRevenTIon To DemenTIA .........................................................15

PART 3: oveRvIew of heALTh DomAIns: PRevenTIve soLuTIons ................................20

PART 4: BRIef oveRvIew of The cosTs of ILL heALTh ...........................................................26

Conclusions ...........................................................................................................................................................29

Recommendation ...............................................................................................................................................29

Annex A: Terminology and Clinical Notes ..................................................................................................30

References ..............................................................................................................................................................36

TPPI List of Published Reports ........................................................................................................................39

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preface

“…I thought of a rather cruel trick I once played on a wasp. He was sucking jam on my plate, and I cut him in half. He paid no attention, merely went on with his meal,

while a tiny stream of jam trickled out of his severed œsophagus. Only when he tried to fly away did he grasp the dreadful thing that had happened to him…”

George Orwell. Notes on the Way

1. Introduction

There is no better way to set the scene for this report than with a much needed reality check as provided by statistics which show that Malta comes out worst in almost every health-related index.

2. Physical exercise

- Malta is the least physically active country in the world with 71.9 percent of Maltese peoplequalifyingasinactive.(1)

- Maltese children are the least physically active in the EU. Only one in four (26 %) of Maltese children is physically active.(2)

- Hours spent watching television by Maltese children are among the highest in the EU. Nearlyhalf (42.7%)ofMaltesechildrenwatch television for threeormorehoursonweekdays.(2)

3. overweight, obesity, Diabetes

- Malta has one of the highest obesiy rates in the EU (22.3%) second only to Ireland (23%)andtheUnitedKingdom(24.5%).ThisrateisfarinexcessofSwitzerland(8.1%)and Italy (9.9%)(2)

- 58%ofMalteseadultsareoverweightand22%areobese.ThisfigureisfarhigherthantheEuropeanaverageandsecondonlytotheUK(24%).(2)

- Maltese children and adolescents have the highest overall prevalence of overweight and obesity in the EU and one of the highest prevalences of childhood obesity in the worldwith25.4%beingpre-obeseorobeseand7.9%beingfranklyobese.(3,4)

- Malta has the highest prevalence in Type II Diabetes in the EU; 10% of the Maltese population has Type II diabetes mellitus as compared to 2% to 3% of our European neighbours. (3,4)

4. Active mobility

- Malta has the lowest rate of bicycle use in the EU. Only 0.3 - 1% of people in Malta cycle regularly.

- Malta has the highest rate of people who never ride a bicycle - 93 %. - Malta is rated as the worst and most dangerous country for cycling and cycling tourism

in the EU.(6)


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5. Alcohol

- Malta is among the countries in the EU that have the highest binge drinking rates; this includes our 15- and 16-year-olds.(7)

most obese, Laziest and most car-dependent

6. These statistics show that, when it comes to healthy lifestyles and physical exercise, Malta is one of the fattest, laziest and most car-dependent nations on the planet.

7. Our legendary physical laziness(8,9) and high rates of both obesity and diabetes are witness to the failure of successive government administrations and health authorities to recognise that encouraging a healthy physically active lifestyle on a nationwide basis is a good investment.

8. There are many environmental factors that impinge our lifestyle and on our health, not only have these been neglected by our road and urban planners; our living and transport environment has been systematically degraded to the extent that people are not inclined to opt for active mobility options but use their car as default transport even for short journeys.

9. If nothing is done to encourage regular physical exercise, this will cast a long shadow on Malta’s future health.

10. That we are consistently at the bottom in every league speaks volumes on the incompetence of our Government health administrations in matters of preventive medicine and encouraging healthy lifestyles.

11. Governance should be strengthened towards health.

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part 1background – why action is essential

‘And now let doctors quit the centre stageTo usher in the prophylactic age’

From: ‘Superfluous Doctors’ in: Poems from a Prisoner of War Camp. AL Cochrane 1942

An Ounce of prevention

Today we are in need of a new perspective, one which focuses on prevention and public health, rather than disease and morbidity. An ounce of prevention is definitely worth the effort. So many dollars are being

spent on finding a cure, and there may actually be a simpler solution. Disease presents itself at a later stage, symptoms evolve rather slowly for most chronic diseases. If we inculcated good health habits, practices,

exercise, healthy diet and stress relief, we could be saving millions in the long run. There are several diseases in the spotlight for example dementia, and while there may not be adequate methods to treat it fully, it can

certainly be delayed in onset by adding exercise, to your routine and preventing hypertension and other co-morbid conditions. We are trying our best to find a cure, but it would be even better if the individual was aware and alert to the possibility for the disease and thus take active steps in preventing the disease onset itself. For example, regular exercise, and quitting smoking can reduce the disease burden. This can in turn

help focus efforts on finding a cure for diseases whose etiology still remains a mystery to us.

We are in the era where doctors need to provide counseling, for smoking cessation, alcohol cut -down, and encouraging adequate exercise and stress relief. Counseling thus becomes a very important part of the doctors visit. We need to ensure that sufficient time is allotted to this part of the visit so that if the patient is

seeking help in any of these measures, he /she can be guided appropriately and sound medical advice can be provided when it is needed the most.

Through the Looking Glass: A Viewpoint on Public Health: An Ounce of prevention. Avni Desai, MD, Public/Community Health, Medscape, Apr 9, 2013

“Our human brains are wired to see what is happening right in front of us right now. We are not very good at seeing things that are not obvious, that happen incrementally,

or that occur over large areas or in other parts of the world.”(Eric S. Chivian , Director, Centre for Health and the Global Environment (CHGE), Harvard Medical School.)

Changing population demographics that have resulted from longer life-spans have been described as a “silver tsunami” which points to the high healthcare costs of our ageing population which makes it

important to develop an adopt practical approaches to keeping older adults healthy.(Jeste, DV, Promoting successful ageing through integrated care. Editorial, BMJ 2011;343:d6808)

Do it, don’t waste time talking about it. (Joanna Wardlaw, University of Edinburgh and Lothian NHS)

general

12. Health behaviour interventions remain the cornerstone of chronic disease prevention.

13. As implied by the title, the focus of this report is on environmental factors that encourage incorporation of healthy lifestyles into everyday life.


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14. There seems to be little appreciation of the importance and economic benefit of maintaining good health by appropriate preventive lifestyle measures aimed at reducing non-communicable disease such as heart disease, obesity, type 2 diabetes and a host of other conditions.

15. Policy and strategy documents issued by health and other government authorities tend to dwell mostly on surveillance or treatment of established disease. This has resulted in health approaches that remain unduly disease-orientated to the detriment of prevention.

16. If nothing is done now, the contribution of Malta high rates of obesity, type 2 diabetes and other disorders to future costs of ill-health will continue to escalate. Added to this is the impending threat from dementia as our population ages.

17. The literature continues to reinforce the view that the most important lifestyle factor of all is regular physical exercise and that exercise should be part of everybodys’ daily routine. Even small amounts of daily activity, as walking just for a few minutes, can help to improve fitness and reduce the burden of obesity and diabetes, both of which have a very high prevalence in Malta.

18. In addition to regular exercise, lifestyle factors include a healthy diet, maintaining a healthy bodyweight, avoidance of excessive alcohol consumption, total abstinence from smoking and social integration.

19. To the forgoing might be added a more challenging school education and encouragement of continued mental activity or “intellectual enrichment” into middle age and beyond, which may help to preserve cognitive activity and vitality in old age.

20. Besidesimprovingqualityoflife,alife-longhealthylifestylereducesthelikelihoodoftheaged becoming a burden to society. This has come to be called ‘healthy’ or ‘successful’ aging. The ultimate aim of healthy ageing is defined as “old age free of any chronic disabling conditions and the prevalent conditions of older age; having the ability to be content or enjoy life; and being able to perform desired physical, mental and social activities without any limitations.”

21. Encouraging healthy lifestyles as a public health preventive measure needs to be given the priority it deserves. Since our living (urban) physical environment can significantly influence an individual’s lifestyle, this is an element that needs attention.

about this report

22. This report is a detailed up-to-date review of recent scientific studies on modifiable lifestyle factors that influence health with particular reference to obesity, type 2diabetes and dementia. Health prevention is directed at so-called non-communicable disease which can be defined as wholly or partly preventable disease which is largely the result of unhealthy lifestyles and/or adverse environmental factors. Such non-communicable disease include cardiovascular diseases (like heart attacks and stroke), cancers, respiratory diseases (including cancer due to tobacco), diabetes and obesity (now classified as a disease).

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23. Recent evidence suggests that a healthy lifestyle can delay the onset of dementia and dementia can now be added as a candidate for preventive measures. Prevention thus offers the possibility of withstanding the ravages of brain damage caused by Alzheimers disease2 and remaining dementia-free and intellectually functional for as long as possible. Dementia therefore features prominently in this report.

24. Though meant for the general reader, this report is based on extensive review of recent scientific evidence. It is abundantly referenced and the purpose of the scientific data reviews is to provide a research tool to allow policy makers to draw their own conclusions.

25. The report discusses possible public health preventive measures as reflected in thirteen health domains which impinge on peoples’ health in Malta. These are physical exercise, obesity, type 2 diabetes, cardiovascular health, the transport environment, air pollution, the living (urban) environment, for lifestyle improvement, cognitive enrichment , social engagement and integration, depression, diet and nutrition, alcohol consumption, tobacco smoking.

technical supplements

26. For ease of reading and reference, these domains have been grouped as follows into six separate technical booklets aimed at doctors, health specialists and those responsible for Malta’s transport and urban environment policies. Each of the domain sections can be read as an independent stand-alone essay and will be made available to medical officers and specialists accordingly.

supplement I Physical exercise and health

supplement II obesity and Type 2 Diabetes

supplement III heart and Blood vessels - Vascular Disease - Hypertension - Dementia

supplement Iv mental wellbeing - Cognitive enrichment - Social engagement and integration - Depression

supplement v Diet, food and Drink - Diet and nutrition - Alcohol consumption - Tobacco smoking

supplement vI health Aspects of Transport and the urban environment - Transport – The Living Environment - Pollution

terminology and clinical notes

27. A glossary of relevant terms is attached at Annex A to this report. Since dementia features prominently in this report, it is relevant to put this disease into clear context by adding a brief outline of the clinical features and causation of dementia and cognitive decline as an attachment to this report. This will enable the general reader to gain a fuller understanding of this report and its supplements.


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in summary

28. Many of the factors contributing to ill-health are determined by our environment and way of life.

29. Lifestyles have become unhealthy. Western societies are largely vulnerable due to advances in technology, wide car ownership, increase in sedentary behaviour (both at work and leisure) and abundance of attractive inexpensive energy-dense food. This has resulted in an unprecedented epidemic of unfitness, obesity and type 2 diabetes which has partially cancelled out the benefits from advances in medicine and the decrease in tobacco smoking.

30. The deterioration in healthy behaviour is especially evident in three Western countries, the UK, USA and Malta which share the common factor of undue car-dependence for mobility or its negative correlate, the absence of so-called ‘active mobility’ by public transport, walking or bicycle, all of which, as will be shown, can introduce the important element of regular daily exercise into peoples’ daily routine.

31. Malta seems to have been particularly affected by this unhealthy behaviour change. Epidemiologic studies have shown that Malta has the lowest national level of physical activity in the world and one of the highest obesity rates in Europe, second only to the UK. Our incidence of Type 2 diabetes is also one of the highest in Europe. Both obesity and type 2 diabetes are responsible for substantial health costs.

32. Anexpectedconsequenceofageingpopulationswillbeanincreaseintheprevalenceof dementia. This will be responsible for huge social and economic burdens in time to come. Any measure that might reduce the prevalence of dementia, even if only by a few percentage points, could represent considerable savings.

33. Strictlyspeaking,Alzheimer’sdisease,whichisthemostfrequentcauseofdementia,isnot preventable but it now seems possible to delay the appearance of the symptoms of dementia by appropriate health measures. In this way it can be expected that the period of disability and institutional dependency will be shortened.

34. On the other hand, dementia due to blood vessel disease, so-called ‘vascular dementia’ should be largely preventable by appropriate lifestyle measures.

35. The possibility of preventing dementia has now started to attract interest and recent evidence that certain healthy lifestyle measures may lower the future prevalence and burden of dementia as populations age is reviewed in some detail.

36. Though much of the scientific evidence on the potential for prevention of dementia is not yet conclusive, some countries are now instituting pro-active preventive measures aimed at the possibility of reducing the future impact of dementia. The World Health Organisation and the European Commission are also making recommendations aimed at reducing the prevalence of dementia.

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part 2the relevance of prevention to dementia

37. There is gathering interest in the prevention of dementia.

38. New evidence suggests that people who have lived a physically and mentally active life are less prone to develop symptoms of dementia. This evidence is reviewed in detail in this report.

39. The evidence is sufficiently persuasive to justify promotion of a number of lifestyle measures which might protect against dementia. Such measures have the potential to reduce the health costs of nursing care and treatment of dementia ptients by up to one third. Based on today’s cost this represents savings of up to 30M€ annually and yet more in the future as our population ages and increases the potential for dementia.

40. Given this evidence, one may well ask why preventive campaigns and strategies have not been implemented. Apart from the indifference of health authorities to the value of public health preventive measures, there is a tendency to adopt a ‘wait and see’ attitude and to compensate for inaction by conducting surveys in order to be seen as doing something. This often happens even when the need for action is obvious.

to what extent can dementia be reduced by lifestyle adjustment?

41. In 2010 Barnes et al(2) carried out an analysis of the results of available published meta-analyses and systematic reviews of the evidence on lifestyle risk factors for cognitive decline, Alzheimer’s disease and other forms of dementia. The object was to collate available evidence on the effect of risk factor reduction on the prevalence of dementia and to arrive at an estimate of the impact based on ‘population attributable risk’ (PAR).

42. The overall result of this analysis suggested that reduction or elimination of seven specific risk factors (physical inactivity, type 2 diabetes, midlife hypertension, midlife obesity, depression, smoking, and low educational attainment) had a potential for reducing the prevalence of dementia by approximately one half. Calculation of PAR was considered of relevance for guidance on public health intervention strategies that are likely to result decrease of the burden of this disease.

43. A subsequent similar analysis by Norton et al (2014)(3) of data from published meta-analyses concluded that the estimate by Barnes et al of relative risk (PAR) attributable to modifiable factors failed to take into account the overlapping effect of some of the risk factors so that the estimated benefits of risk factor modulation were greater than might be the case. In other words, the seven risk factors are not independent of each other; for instance, three of the risk factors, diabetes, hypertension and obesity, share a srong common link to physical inactivity. This more rigorous re-analysis by Norton et al resulted in a downward adjustment of the combined PAR to a lower level of about 30% as applicable to the USA, Europe, and the UK.


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44. This more realistic estimate of preventive potential of lifestyle and other interventions suggests that modulation of these seven risk factors can potentially mitigate the impact of dementia by one third. This could represent a substantial saving in future health costs of dementia. These savings would be additional to the overall saving in public health costs accruing from reduction of obesity, diabetes, cardiovascular and other disease. This has been aptly described as a ‘win-win situation’.(4)

45. The findings of Norton et al (2014)(3) were matched by the findings of a major long-term study(5) which monitored five healthy behaviours (regular exercise, non-smoking, maintaining a healthy bodyweight, ‘healthy’ diet and low alcohol intake) in 2,235 men over a 35-year period. The study was the longest of its kind to probe the influence of lifestyle factors in chronic disease. It confirmed that healthy lifestyles are associated with increased disease-free survival and preservation of cognitive function. Subjects who consistently engaged in four or five healthy behaviours showed a 60 per cent reduction in cognitive decline and dementia, with exercise being the strongest mitigating factor. There was a 70 per cent reduction in occurrence of diabetes, heart disease and stroke compared to controls.

46. Another well-conducted study in 1433 people without mild cognitive impairmentor dementia at baseline(6) concluded that a healthy diet rich in fruit and vegetable consumption, increasing crystallised intelligence and elimination of depression and diabetes are likely to have the largest impact on reducing the prevalence of dementia, outweighing even the effect of the known principal genetic risk factors. The authors suggested that, although the results only provide a crude estimate of impact on incidence and though causal relations could not be concluded with certainty, the study suggested that the findings should inform on priorities to guide public health programmes.

47. As will be discussed separately in some detail, prevention of type 2 diabetes mellitus alone can be expected to exert a significant impact on prevalence of dementia. Diabetes is now found in almost every population and epidemiological evidence suggests that without effective prevention and control programmes, the prevalence of diabetes will continue to increase globally.(7 )

how might lifestyle improvement prevent dementia?

48. The benefits of diverse lifestyle measures which have been shown to prevent dementia are believed to become manifest along two important pathways. The first is reduction in the number of cases of vascular dementia cases as a result of decreased cardiovascular disease. The second is from increased cognitive reserve. While reduction of cardiovascular disease can prevent the occurrence of dementia, the second of these pathways can be expected to result in a delay in appearance of the symptoms of dementia in patients, even in the presence of progressive brain pathology.

49. Thus, although the net effect of preventive measures can only be expected to result only in a small reduction in incidence (ie number) of new dementia cases, shortening of the duration of symptoms can be expected to result in a reduction in the prevalence of manifest dementia at any given point in time.

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50. The decrease in prevalence of dementia is therefore explained as follows: While the symptoms of dementia are delayed, death due to the physical brain changes is not delayed. In other words, the underlying brain pathology continues to progress unabated but the symptoms occur later in individuals who have lived a healthy active life. The net effect of a delay in expression of dementia symptoms is that the duration of the terminal symptomatic phase where patients become dependent on nursing care will be reduced.(3)

51. Attention was drawn by Van Gool (2006)(10) to the importance of postponing the onset of dementia symptoms on the duration of the phase of symptomatic dementia. He also highlighted the reduction in burden for families and health caregivers and the substantial economic and other gains that shortening the symptomatic period may bring with it.

52. This is illustrated in the following diagram:

Curves Depicting Severity of Dementia Depending on Age

The solid line gives an estimate of trajectory in the absence of any preventive measures. Broken lines illustrate the potential benefit of (A) postponing and shortening the episode with dementia,

(B) delaying dementia while reaching a higher age, or (C) preventing dementia. (Van Gool 2006.)

53. The potential social and economic benefit from such a delay in onset of dementia symptoms is considerable. It is estimated that delaying symptoms by one year would reduce the total worldwide number of cases of Alzheimer’s disease in people aged over 60 years in 2050 by 11%.(11,12) Though the economic benefit could be partly offset by the expected future increase in population age, the potential cost saving from preventive measures will not be influenced. To this is added the additional bonus of promotion of healthier old age in general.(13)

the evidence – is it credible?

54. Evidence of a link between the various risk factors and cognitive function or dementia has been received with varying degrees of acceptance.

55. In the USA the evidence continues to be regarded with scepticism. A National Institute of Health (NIH) State-of-the-Science Conference Statement on Preventing Alzheimer’s Disease and Cognitive Decline(18) agreed that extensive research over the past 20 years has provided important insights on the nature of Alzheimer’s disease and cognitive decline but cautioned that, since highly reliable consensus-based diagnostic criteria for cognitive decline, mild cognitive impairment, and Alzheimer’s disease were lacking, there


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remained important and formidable challenges in conducting research on these diseases. Firm conclusions, particularly in the area of prevention, could therefore not be drawn on the association of any modifiable risk factor with cognitive decline or Alzheimer’s disease. On this basis public health preventive measures were not being considered.

56. Another review originating in the USA was also dismissive of the evidence(19) and concluded that few potentially beneficial factors were identified from the evidence on riskfactorsassociatedwithcognitivedeclineandthattheoverallqualityoftheevidencewas low.

57. Similarly, a statement paper on the vascular contributions to cognitive impairment and dementia published jointly by the American Heart Association, the American Stroke Association and the American Alzheimers Association in 2011(20) omitted reference to much of the available recent evidence and dwelt instead on nosological criteria for the establishment of research programs ‘so as to be to be better positioned to guide clinicians’. The authors conceded that “lifestyle factors may be risk factors for vascular cognitive impairment but that gaps in our knowledge about the role of such factors should be bridged by additional well-designed epidemiological studies, harmonization of how lifestyle activity is defined - and clinical trials”. The main conclusion was that, based on current evidence, smoking cessation, moderation of alcohol intake and increase in physical activity were considered ‘reasonable’ preventive measures.

58. On the other hand, in its report, “Cognitive Aging: Progress in Understanding and Opportunities for Action”, the USA Institute of Medicine (IOM) recommends that older adults take action to combat the gradual decline in cognitive function that occurs naturally with age.(22) The IOM report puts physical exercise and reduction of cardiovascular disease risk factors, diabetes and smoking at the top of the list of preventive measures.

59. The recently published results (Brayne et al, 2015) of an epidemiological review of changes in dementia prevalence in some European city populations (Sweden, Netherlands, UK and Spain) showed possible reductions in overall dementia occurrence between today and 20 years ago.(23) A significant reduction in overall prevalence of dementia was only observed in the UK. The lack of an expected increase in the prevalence of dementia parallel to increasing population age over the intervening 20-30years was attributed to ‘earlier population-level health investments’ such as improved education and living conditions, and better prevention and treatment of vascular and chronic conditions. This evidence was regarded as indicative that attention to optimum health early in life might benefit cognitive health late in life. These findings add strength to the importance of public health measures aimed at reducing the risk of dementia which still remains a critical health and social care threat as populations get older. The threat will be amplified in the absence of lifestyle imrovements at a national level.

60. In spite of abiding scepticism in the USA, it can be said that the majority of published studies - as reviewed in this report - identify the risk factors with acceptable clarity. Studies which were deemed to be of sufficient scientific rigour were subjected to systematic reviews or meta-analyses. The meta-analyses largely supported the conclusions of the individual studies; this adds to the power of the findings. These meta-analyses are reviewed in the corresponding Supplement to this report.

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should preventive measures be implemented?

61. Waiting for further confirmation of available evidence will take too long. As stated in a recent McKinsey report:(21) “We should experiment with solutions and try them out rather than waiting for perfect proof of what works, especially in the many areas where interventions are low risk. We have enough knowledge to be taking more action than we are currently taking.”

62. Though the evidence of protection against dementia by a number of healthy lifestyle factors reviewed in this report is mostly derived from observational studies, it is sufficiently indicative to be of public health significance. Waiting for confirmatory evidence before acting could delay action for years or even decades while awaiting the results of further large-scale prospective trials. Such prevarication will result in loss of precious time. The possibility that modulation of lifestyle factors directed at decreasing vascular disease, which is an important contributory factor in the causation of dementia also constitutes important grounds for taking steps.

63. Some countries regard the current evidence as sufficient grounds for introduction of public health measures. For instance, the Alzheimer Australia National Preventative Health Task Force categorically considers the evidence sufficiently robust to constitute an overriding reason for including dementia within a national preventative health strategy.(25) It is of the opinion that there is a regrettable limited awareness, not only in the community but also among health professionals, that lifestyle behaviours may directly affect the risk of dementia. National strategies aimed at maximizing successful physical and mental healthy aging of the population are easily attainable. Not only will these contribute to savings in overall health care costs from improved general health in the population - they might also bestow an added bonus of saving in costs from reduction in the need for dementia care. The possibility that modulation of lifestyle factors directed at decreasing vascular disease, which is itself an important contributory factor in the causation of dementia, also constitutes important grounds for taking steps.

64. The UK has only recently started to consider preventive action.(24) It is now proposed to launch a publicity campaign aimed at making people aware that a healthy lifestyle can lower the risk of developing dementia. Doug Brown, the director of research and developmentattheAlzheimerSociety,isquotedassayingthatthereisenoughevidenceto show that it is possible and reduce the prevalence of dementia by one third by delaying the average age of onset of dementia by five years and that public health authorities should be made aware of this.

65. It is also a given that old people are better placed to be useful to society if they are in good health and that it is of fundamental economical and health significance that older people enjoy good health in order not to become a burden on society as they age.

66. While susceptibility to dementia is partly determined by immutable factors as age or genetic risk factors, there is good evidence that modulation of risk factors may postpone the clinical expression of dementia or even avert the occurrence of dementia altogether. Even if the evidence for a link between certain of these risk factors is not yet sufficiently proven to justify consensus for policy making, there is no reason why public health prevention strategies should be delayed.


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67. The message is, therefore, that there is too much to lose by waiting for conclusive scientific evidence and that there is much to be gained by using the present evidence as incentive for instituting public health approaches across the life course. Such measures will combat physical unfitness, obesity and diabetes, all of which are risk factors for much other disease; not only will public health measures promote healthier old age, they stand to offer offer a possible bonus of risk reduction of dementia.

the extent of the dementia problem

68. Alzheimer’s disease and other types of dementia are devastating conditions that significantlyincreasehealthcarecostsandinfluencethequalityoflifeofthoseafflictedand their caregivers.

69. It was estimated by Ferri et al (2005) that 25 million people worldwide have some form ofdementiasuchasAlzheimer’sdisease.4.6millionnewcasesoccureveryyear-oronenew case every 7 seconds. This means that there will be double the number of cases by 2025.(14) The Global Burden of Disease Study (GBD) suggests that by 2020 dementia and other neurodegenerative diseases will be the eighth largest source of economic disease burden in developed countries.(15,16,17)

part 3overview of health domains:

preventive solutions

physical exercise

70. Review of the scientific literature suggests that increasing physical exercise at a population level is possibly the most important and urgent need. This applies particularly to Malta.

71. Physical exercise has been described as the ‘best buy’ in terms of health promotion. In terms of reduction in health costs, the long-term economic return from a nationwide higher level of physical activity has been shown to exceed the initial investment. The major benefits from physical exercise are prevention of obesity and diabetes and increased (cardiovascular) fitness; there is also strong evidence that regular physical activity exerts a protective effect against dementia.

72. In the absence of an environment which enables people to build physical exercise into their daily routine, attempts at persuading people to take more exercise are unlikely to succeed.

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obesity

73. Obesity and type 2 diabetes are Malta’s major health scourges. These two disorders are expensive to the state but are largely preventable. Over half of cases of type 2 diabetes can be avoided by prevention of obesity and regular physical exercise.

74. Obesity has been a very misunderstood disorder. A bewildering volume of conflicting dietary information generated by bogus experts and the food and soft drink industry resulted in misleading nutritional orthodoxies which defined faulty dietary approaches for four decades. It also diverted interest from the importance of physical exercise. This exacerbated the recent surge of obesity.

75. Another cause of the skewed approach to obesity is that dietary measures are easy, low-cost, highly visible, easily attainable public health targets. It is, so to speak, “low-hanging fruit” for health authorities and, as such, much beloved of health professionals because it is a conspicuous activity which gives a reassuring feeling that “something is being done”. This is witnessed by our expenditure on generating obesity statistics and obtaining foodstuff consumption profiles to tell us what we already know. Such surveys have to date omitted assessment of cardiovascular fitness or physical exercise levels which are equally,ormore,importantcriteria.

76. Confusion also resulted from poorly designed studies which failed to distinguish between overweight but healthy people and the unhealthy obese who are morbidly obese. This resulted in undue preoccupation with weight loss and dieting while ignoring all else.

77. Attitudes to overweight and obesity have changed. Obesity is now recognised as an exceedingly complex and sometimes paradoxical condition. While there is little dispute that prevention of obesity should be the overall primary aim and that weight reduction is imperative in certain circumstances, there are reasons which render inadvisable a blanket emphasis on weight loss in simple overweight or uncomplicated obesity.

78. It is also often the case that weight loss is unattainable. Undue concentration on weight reduction in such subjects is liable to result in an unhealthy preoccupation with body image and negative reinforcement to health advice.

79. Recent findings suggest that physical fitness, rather than ideal weight, is the more important factor for health and well-being. The health benefits of regular physical activity have been shown to exceed those of weight reduction in simple overweight or in subjects with uncomplicated mild-to-moderate obesity. In other words, it is possible to be overweight but be physically fit and greater health gains can be achieved through improving physical fitness even in the absence of weight loss.

80. It is therefore makes more sense in the majority of cases to allow people to remain satisfied with their bodies provided they improve their physical fitness, even if they fail to lose weight.

81. It is now recognised that intentional weight loss can be harmful in certain circumstances. Recent observations have also yielded paradoxical results which indicate that obesity may be beneficial in some situations. One puzzling observation was that overweight people


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have greater chances of surviving after heart attacks. Another paradoxical observation is that obesity in old people might be protective against dementia. Both these further argue against undue pre-occupation with weight reduction, especially in the elderly.

82. Thus, while primary prevention of obesity from childhood onwards remains paramount, dealing with obesity solely or predominantly by weight reduction is now considered as too simplistic and may occasionally be harmful.

83. Obesity should therefore no longer be regarded as a simple matter of weight reduction by calorie restriction. Physical fitness should be the primary aim of preventive public health policies and a key element is to create conditions which will help to people to keep physically fit and not become obese in the first place.

type 2 diabetes

84. Diabetes is expensive for everyone. In addition to health expenses for management of diabetic patients, there is the added cost of treatment of the many complications of diabetes so that the economical benefit of reducing the incidence of diabetes can be enormous.

85. The key risk factors of type 2 diabetes are lack of exercise, unhealthy diet (especially sugar and refined carbohydrate) and obesity. At least half of cases of diabetes are preventable by lifestyle modification aimed at increasing the amount of regular physical exercise and improving diet.

86. Diabetes is now starting to be seen in children; as in adults, this phenomenon is ascribable to three major risk factors: faulty diet, childhood obesity and physical inactivity.

87. A large body of literature demonstrates that regular physical activity can increase insulin sensitivity and improve other components of the metabolic syndrome which predispose to diabetes.

88. Physical activity has been shown to be highly effective in preventing diabetes; the protective effect is especially pronounced in persons at the highest risk for the disease. Diabetes is three to four times more likely to occur in people who don’t exercise and exercise appears to be as good as drug treatment in preventing development type 2 diabetes in subjects with pre-diabetes. This points to the importance of life style changes aimed at preventing diabetes rather than later treatment of established diabetes with expensive drugs.

89. Diabetes may intensify age-related decrease in cognitive function and there is considerable evidence that type 2 diabetes predisposes to dementia. The latter is of great significance.

90. While the dietary aspect of diabetes is receiving attention, our strategies aimed at promotingphysicalexerciseremainfeebleandinadequate.Theyhavebeenunsuccessfulin encouraging people to take more exercise.

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cardiovascular health

91. Heart and blood vessel disease (cardiovascular disease) is a major cause of disability and death, most commonly from heart attacks and stroke. The case against vascular disease is now very strong and the potential for preventing dementia through avoidance of vascular disease is undisputed. This adds to the importance of prevention of cardiovascular disease.

92. It is universally acknowledged that cardiovascular disease can be prevented by engaging in first-line primary preventive lifestyle measures of regular physical exercise, eating a healthy diet, limiting alcohol intake, not smoking and avoiding overweight or obesity. These measures overlap with prevention strategies against a large number of other avoidable diseases, especially obesity and diabetes.

93. Blood vessel disease which predominantly affects the brain (cerebrovascular disease) is the secondmostcommoncauseofcognitiveimpairmentandaccountsforaboutaquartertoa third of cases of dementia – so called ‘vascular dementia’. Both cerebrovascular disease and vascular dementia are therefore theoretically preventable conditions.

transport environment

94. Malta’s transport remains unhealthy and dysfunctional with undue reliance on private car transport. It is probably the major determinant of Malta’s ill-health.

95. The most successful way to encourage people to exercise is by promoting so-called ‘active mobility’ (sometimes called ‘healthy mobility’) since this is the most readily available and means for introducing physical exercise into daily routines. Active mobility is represented by three transport options: using public transport, walking or cycling.

96. Most modern countries are now promoting active mobility and discouraging private car use, especially in the urban environment. This step includes substantial investment in creating environmental conditions and amenities to enable and encourage active mobility.

an enabling urban environment

97. Encouraging regular physical exercise at a national level by every possible means is essential. Provision of an environment that prompts (or obliges) people to engage in regular, daily physical activity needs to be given priority.

98. Attempts at persuading people to take more exercise are unlikely to succeed in the absence of an enabling environment which encourages and facilitates active mobility. An enabling environment includes as a minimum: safe and attractive ‘walkable’ streets which encourage both walking and bicycle use for short trips and an efficient public transport system.

99. Children need the right living environment conditions to exercise when not at school. This appliesequallytoadults,namelythat,giventherightenvironment,adultswillexercisemore.


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100. Some initiatives have been introduced as, for instance, increasing physical training time at schools, but this is not enough. Provision of, or subsidising access to, facilities as sports fields, gyms, fitness centres does not go far enough since only the motivated and only those who have the time and money will benefit from these.

101. We live in an ageing world. It is estimated that people aged over 60 years will have doubled over the coming three to four decades. It is therefore of economical and health significance that older people enjoy good health in order to remain useful to society and not to become a burden to society. The World Health Organization recommends the development of ‘age friendly environments’ which promote ‘healthy ageing’ by optimising opportunities for healthy exercise and participation in the community in order to enhance qualityoflifeaspeopleage.

nutrition

102. As with obesity, there has been a shift in attitudes to nutrition. Many previously held beliefs and orthodoxies have now been radically revised. This applies in particular to whatconstitutesa‘healthydiet’.Theearlierorthodoxy,datingbackabout40years,thatsaturated fat consumption constituted a risk factor for cardiovascular disease, was based on flawed evidence. This, and other misguided schools of thought were largely instigated by the food and beverage industry.

103. Overall, the so-called ‘Mediterranean diet’ is now recommended. This diet includes fish, vegetable oils and olive oil as the primary source of fat, non-starchy vegetables, low glycemic index fruits, occasional red meat and poultry accompanied by a low to moderate intake of red wine coupled with avoidance of high energy-dense carbohydrates as pastries, sugary sweet desserts and dishes made out of refined flour.

104. Though we live on an island in the Mediterrnean Sea, we do not consume a Mediterranean diet owing to westernising influences. This trend needs to be corrected.

105. In the context of dementia prevention, the consensus seems to be that a ‘brain healthy’ diet is one that consists largely of vegetable and fish.

cognitive enrichment and dementia

106. The term ‘cognitive enrichment’ refers to exposure to intellectual stimulation over lifetime. Limited evidence suggests that a more challenging scholastic education and mental activity continued into mid-life and beyond may delay the onset of dementia by increasing cognitive reserve.

107. For this reason WHO now recommends addition of the “healthy brain” dimension of encouraging mental activity along with social integration and engagement to healthy lifestyle recommendations.

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social engagement and dementia

108. An environment which enables and encourages social integration may possibly delay the onset of dementia.

109. Many people, especially the old can become isolated. Preliminary evidence suggests that this may increase susceptibility to dementia whereas those who remain socially ‘connected’ are less exposed to developing dementia. Activities that contribute to ‘social integration’ embrace a wide range of social interactions such as social engagement, marital status and family closeness in addition to participation in cultural activities as attending theatre performances, concerts, art exhibitions, going to museums etc. To this is added the possibility of remaining gainfully employed after retirement.

alcohol

110. Excessive alcohol consumption is now recognised as a contributory causative factor in dementia. There is some evidence that binge drinking predisposes to cognitive decline anddementiainoldage.Thefrequencyofbingedrinkinginouryoungdeservesattention.

tobacco smoking

111. Smoking was originally considered a protective factor for dementia but this was the result of biased reporting encouraged by the Tobacco lobby. New evidence strongly suggests the contrary. Tobacco smoking is now regarded as a risk factor for dementia.

depression

112. Depression is suspected of predisposing to dementia but there is as yet no clear evidence of this. Recognition and treatment of depression is a standard recommendation.

pollution

113. Pollution remains a major problem which continues to be ignored in Malta and its potential for harm remains underestimated and neglected. Intense pollution from fossil-fuel combustion by our heavy traffic is particularly associated with negative effects on cardiovascular health in addition to cancer, respiratory disease and a host of other harms. There is evidence, as yet preliminary, that pollution may predispose to cognitive decline.


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part 4brief overview of the costs of ill health

malta’s health costs

114. Malta has the lowest national level of physical activity in the world and the highest frequencyofobesityandtype2diabetesinEurope.Thesethreehealthdomainsaloneare responsible for substantial health costs alongside other potentially preventable non-communicable disease which impose increasing costs on society. To these can be added the costs of future ill-health from childhood obesity and, as our population ages, an increase in the incidence dementia.

physical inactivity

115. The health costs of treating the consequences of physical inactivity across the EU areestimatedat€80.4billionperyear.Thiscostislargelyrepresentedbyexcesscasesofcoronaryand other heart disease, stroke, overweight, type II diabetes, colorectal and breast cancer.

116. Physical inactivity is estimated to have cost the UK National Health Service over £9 billion in 2007. Malta and the UK share close similarities in regard to obesity and physical inactivity rates; extrapolated to Malta, the annual cost of physical inactivity would amount to €100 million.

117. A report by the UK Academy of Medicine (see main text) concluded that savings to the NHSfromexercisewere“incalculable”.Itspecificallyquotestheexampleoftype2diabeteswhich could be prevented if people did just 30 minutes of physical activity five times a week, saving the state billions of pounds.

transport

118. The time needed for commuting to work by car continues to rise in all countries. The costs from ill-health due to passive (private car) transport are exacerbated by the waste of time and extra fuel due to traffic congestion.

119. The health benefits of active mobility by public transport, on foot or by bicycle are now acknowledged. Interventions aimed at promoting walking and cycling are being introduced in most countries, including the USA and UK which had initially lagged behind.

120. ThecostsofMalta’sdysfunctionaltransportfor2012wereestimatedat€274millionbythe UOM Institute for Climate Change and Sustainable Development. This was largely accounted for by traffic congestion (€118million) and accidents (€83million). Healthrelated costs, not specifically included in the report, could partly be attributed to air pollution the costs of which were calculated at €83.9 million and noise (€11million).Healthcostsarisingoutoflackofexercise(consequentonpredominantcar-dependencefor commuting) did not feature in this report.

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121. Though there are no figures to indicate the health gains and savings from active mobility (by public transport, walking or bicycle), it has been shown that schemes based solely on enabling shorter motor vehicle travelling times do not deliver value for money, while transport schemes which facilitate active transport can deliver value for money many times greater than the investment. About 60% of the benefit comes from health savings due to increased physical fitness and 20% from traffic congestion relief and decrease in pollution. Other benefits are derived from fewer traffic accidents and improved ambience.

122. A World Health Organisation Health Economic Assessment Tool (HEAT) indicated that the return on investing in encouraging cycling can be expected to be around five times the amount invested. If the expected decrease in the risk of cardiovascular disease and obesity are included, walking and cycling can yield a benefit/investment ratio as high as 19:1. Health improvement from bicycle commuting also results in lower all-cause sickness absence from work.

123. Figures are not available for the health costs of the unfavourable transport situation in Malta but it is a reasonable assumption that it must be adding substantially to our health costs.

type 2 diabetes

124. Malta’s annual health expenses for diabetes were estimated at €65 million by the International Diabetes Federation.

obesity

125. Globally,thecostsofobesityareestimatedataround2trilliondollarsor2.8%ofglobalGDP.This almost equals the combinedcostsof armedviolence,wars and terrorism.AMcKinsey Global Institute institute report stated that a systemic, sustained portfolio of initiatives aimed at reversing obesity delivered at scale could save the UK National Health Service about $1.2 billion a year. Extrapolated to Malta this would represent a saving of about €90 million.

126. ThecostofobesitytotheMaltesehealthservicewasestimatedat€19.5millionfor2008and likely to rise to between €27 million and €35 million in 2020 if no action is taken.

dementia

127. ThetotalcostofcaringforpeoplewithdementiainEU27in2008wasestimatedataround€170 billion.

128. The overall costs of dementia care in Malta are estimated at between €63 million and €96 million annually.

129. Recent evidence suggests that health costs of nursing care and treatment of dementia can be reduced by up to one third by appropriate lifestyle modulation.


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130. Based on today’s costs, this could represent savings of up to €30 million annually. These savings would be additional to the overall saving in public health costs accruing from simultaneous reduction of obesity, diabetes, cardiovascular and other disease. This has been referred to as a ‘win-win situation’.

the urban street environment

131. The hidden costs of adverse social consequences of our degraded urban and streetenvironment are difficult to calculate. They are likely to add to the costs due to physical inactivity.

cognitive enrichment

132. Keeping people mentally active may delay the appearance of dementia symptoms. Promotion of continuing education, literacy and mental activity into mid-life and beyond may result in people dying from some other cause before they develop cognitive decline. Costsofdementiacarewillbereducedandqualityoflifeimproved.

potential savings

133. The cost of doing nothing are incalculable.

134. The three reference disorders under consideration in this report are obesity, type 2 diabetes and dementia. Obesity and type 2 diabetes are eminently preventable. Since they are very prevalent in Malta, interventions which reduce their frequency can beexpectedtohaveahighahighimpactandbecost-effective.Thisprobablyappliesequallyto dementia. Even small decreases in these three diseases will translate to large positive health impacts at the population level.

135. Exercise is the thread that unites most preventive health measures. It is hailed as a ‘miracle cure’, ‘best buy treatment’ and a ‘wonder drug and increasingly recognised as the pivotal factor for reducing non-communicable disease including excess coronary and other heart disease, stroke, colorectal, breast and other cancers in addition to obesity, type 2 diabetes and dementia.

136. Transport is a key determinant of health in Malta; improvement in public transport and inducing a trend to active mobility alongside improvement of the urban environment to encourage walking and bicycle use must be put high on the agenda. Exercise is also vital for growing children.

137. The other pivotal intervention is dietary modification (with particular attention to reduction of sugar and refined carbohydrate) and prevention of dementia adds ‘mind measures’ which include more rigorous school education, attending to social well-being and other measures as discussed in the supplements to this report.

138. Obesity, type 2 diabetes and dementia are estimated to cost annually around €20 million,

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€65 million and €70 million, respectively. These costs will be partially subsumed into the theoretical extrapolated overall figure of €100 million attributable to lack of physical exercise owing to an overlapping benefit for all these from improved physical activity.

139. Combining all these health costs yields a ballpark figure of potential health costs of between €150 million and €200 million for three disorders which can be reduced by appropriate interventions. A 50% reduction of obesity and diabetes is feasible with well implemented interventions. As discussed in this paper, it is probable that the prevalence of dementia can be decreased by 20%.

140. Assuming successful health interventions a conservative estimate of savings in health costscouldbebetween€40millionand€60million.

conclusions

141. Public Health policies tend to under-estimate the value of preventive measures and concentrate more on screening, surveillance and medical treatment of established disease. The importance of addressing the causes and not just the symptoms which might have been avoided in the first place is insufficiently recognised.

142. A generally healthy lifestyle which includes regular physical exercise, healthy diet, avoidanceofsmokingandlimitingalcoholconsumptionto3-4unitsperday,playsamajor role in the prevention of cardiovascular disease, stroke, hypertension, diabetes, obesity and other diseases. The additional possibility of reduction of dementia through lifestyle intervention needs to be taken seriously.

143. Encouraging healthy lifestyles needs to be approached in a holistic manner. Piecemeal interventions are insufficient. As things now stand there are few co-ordinated and effective nation-wide policies in place.

144. Delivering change requires more than good intentions. Effective measures require apopulation-based, multisectoral, multidisciplinary, and culturally relevant approach. Such interventions will need to cut across many public policy areas, especially health, social welfare, education and, not least, road design and transport. Preventive measures should also be broadbased inasmuch as they should be family-centred on home lives and extend to the living environment.

recommendation

145. It is recommended that the Government of Malta, its health environment specialists and themedicalprofession should takenoteof the conclusions inparagraphs141 to 144above.


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annex a

terminology and clinical notes

1. For the purposes of this report the word “environment” is used in its widest possible sense. It includes the “built environment” in the form of all buildings and space, created or modified by people, that forms the physical characteristics in which a community lives. It also includes what can be called the ‘transport environment’.

2. Other commonly used terms such as ‘pedestrian-friendly’ roads, and ‘age-friendly’ and ‘obesogenic’ environments are self-explanatory. An ‘obesogenic environment’ is an environment that promotes weight gain by discouraging physical exercise and facilitating access to unhealthy food.

3. Mobility options such as walking, bicycling, and use of public transport are referred to interchangeably as ‘active transport’ or ‘active mobility’ - as opposed to passive travelling in a private motor car.

4. To these one might add the ‘social environment’. This includes access to factors that contribute to “social engagement”. These have been defined as ‘the actual set of links of all kinds between individuals’. This can be summed up as “staying connected”. Social engagement includes a complex web of factors such as marital status, close friends, social support and others in addition to participation in cultural or group activities, or even remaining gainfully employed after retirement.

5. The term “dementia” is used throughout this report to refer to the severe cognitive deficit which accompanies Alzheimer’s disease, vascular dementia and other neurodegenerative diseases that ultimately result in the common final symptom pathway referred to as ‘dementia’.

6. The term dementia is therefore used as a blanket term in place of diagnostic terms such as ‘Alzheimer’s disease’, or ‘vascular dementia’. Using the blanket term “dementia” is valid for the purposes of this report because preventive measures are mostly directed at postponing the appearance (or ‘clinical expression’) of the symptom of dementia while not necessarily slowing the underlying brain disease or actual brain pathology. Preventive measures may reduce the number of cases of dementia which are caused by blood vessel disease (‘vascular dementia’).

7. Scientific evidence of the effect of preventive lifestyle measures on cognitive decline is also reviewed in some detail because prior cognitive decline may accelerate the ultimate emergenceofdementiasymptomsinpeopleafflictedwithAlzheimer’sdiseaseandotherbrain disorders which are typified by terminal dementia.

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obesity: body mass index

8. Body mass index (BMI) is a commonly used rating scale for evaluating the degree of overweight or obesity. A BMI of 25 or more is considered overweight; a BMI of 30 or higher is considered obese.

9. BMI is now starting to be regarded as a too blunt a research tool because it does not distinguish between overweight due to increased muscle mass in healthy individuals and overweight due to excess fat. It distinguishes even less between individuals who are benignly obese and those who have ‘visceral’ or central obesity which is the more dangerous form of obesity.

10. The UK National Institute of Health and Care Excellence (NICE) now suggests that waist-to-height ratio is a more realistic criterion of risk than BMI.

11. Failure to distinguish between the different patterns of obesity (‘visceral’or generalised, etc) and the context in which it occurs in epidemeological and other studies has resulted in conflicting results. This is becoming more relevant in the light of greater importance being attached to physical fitness rather than attainment of ideal body weight.

visceral obesity

12. The term visceral obesity defines excessive fat accumulation around the digestive organs in the abdominal cavity.

13. It is now recognised that body shape and the regional distribution of fat is more important for health than the total amount of skin (subcutaneous) body fat. The terms ‘central’ or ‘abdominal’ obesity, or ‘belly fat’ are often used instead of visceral fat but these don’t necessarily specifically differentiate between true visceral fat and subcutaneous fat accumulation around the abdomen and the upper part of the body.

14. It is now generally agreed that visceral fat is more damaging to health than skin (subcutaneous) body fat and that it plays a key role in the causation of the negative health effects of overweight and obesity which include diabetes, lipid disorders , hypertension, cardiovascular disease and many other diseases.

metabolic syndrome

15. Metabolic syndrome is a variant of severe obesity in which a particular combination of abnormalities occurs in the same individual. The metabolic syndrome is characterised by marked visceral obesity and the presence of other metabolic abnormalities including, in particular, insulin resistance with raised fasting plasma glucose over the normal concentration of 5.6 mmol/L or existing, previously diagnosed, type 2 diabetes. Other abnormalities are raised triglycerides and reduced high density (or ‘good’) cholesterol.


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type 1 diabetes

16. Type 1 diabetes (‘insulin-dependent diabetes’, ‘juvenile diabetes’) usually occurs at a young age.

17. There is another uncommon form of type 2 diabetes which occurs mostly in elderly males which is not usually associated with obesity or overweight.

18. Both these forms of diabetes are not preventable.

type 2 diabetes

19. The most commonly occurring form of diabete is Type 2 diabetes, or ‘maturity onset diabetes’;itaccountsfor80–90percentofalldiabeticpeople.Itislargelypreventable.

20. Type 2 Diabetes occurs most often in overweight adults who are physically inactive, especially those with visceral obesity.

21. Type 2 diabetes is now starting to be seen in obese children, especially those with a family history of type 2 diabetes.

alzheimer’s disease, vascular dementia and other dementias

22. Dementia is the blanket term used to describe severe cognitive disability caused by a number of brain disorders that typically occur in the elderly.

23. Alzheimer’s disease (AD) and Lewy body dementia are the most common diseases that result indementia.Theseaccount forhalf to threequartersofcasesofdementia.Lesscommon causes of dementia are neurodegenerative disorders as Creutzfeldt–Jakob disease, fronto-temporal dementia (Pick’s disease), posterior cortical atrophy (PCA) and, rarely, Parkinsons disease.

24. Blood vessel disease (cerebrovascular disease) is the second most common cause of acquiredcognitiveimpairmentwhichmayleadtodementia.Vasculardiseaseaccountsforaboutaquartertoathirdofcasesofdementiaandthisisgenerallyreferredtoas‘vascular’or‘multi-infarct dementia’. Dementia due to vascular disease can progress from mild cognitive impairment (‘vascular cognitive impairment’) to the full-blown manifestations of dementia – or ‘vascular dementia’ in its various forms. A clinically useful tool for distinguishing vascular dementia from Alzheimer disease is the Hachinski Ischemic Score.(21)

25. Dementia can also be non-specific. This is regarded as an extremely exaggerated form of senile loss of mental agility and cognitive decline.

26. More than one type of dementia may co-exist in the same person and the vascular element is often superimposed on neurodegenerative or other dementias and may be responsible for intensifying the dementia.

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27. The brain changes of Alzheimer’s disease are characterised by deposits of abnormal proteins called beta-amyloid in the brain. These are often referred to as neurofibrillary tanglesandsenileplaques.ThebrainabnormalityofLewybodydementiaischaracterizedby the presence of clumps of abnormal protein (or so-called Lewy bodies) in neurons.

28. Certain genetic traits have been associated with higher incidences of Alzheimer’s disease, though the exact role of these still is unclear; the most important of these is the presence of the APOE (apolipoprotein E) gene which may facilitate the harmful transportation of damaging lipids into neurons.

29. The ultimate fundamental cause of dementia is progressive loss of functioning brain cells. The end result is loss of mental ability severe enough to interfere with normal activities of daily living. The loss of mental function in Alzheimer’s disease is typically dominated by impairment of memory which initially affects short- and medium-term memory but becomes globalised with progression of the dementia. This is accompanied by loss of mental agility and capacity to reason, decide or plan. Affected patients eventually become incapable of looking after themselves and they may start to behave unpredictably or erratically. The symptoms may be accompanied by depression, apathy, disruptive behaviour or psychosis.

30. The pattern of symptoms varies between the different types of brain disease. For instance the clinical picture may be initially dominated by greater loss of attention span and executive functioning than memory loss, but these distinctions become academic as the disease progresses and reaches an end-stage of total dependence on intensive nursing care which imposes huge financial and social costs on loved ones, family and state.

31. There is as yet no curative pharmacologic treatment for dementia. Preventive measures which can mitigate or delay appearance of symptoms or prevent the disease altogether are therefore of great value.

32. An important feature of dementia is the interplay between the characteristic brain changes of Alzheimer’s disease and blood vessel (cerebrovascular) disease. Alzheimer’s diseaseandvasculardisease frequentlyco-exist,especially inolderdementiapatients.This overlapping between specific conditions (as Alzheimers’s disease, Lewy body disease, etc) and vascular disease is important because combination of the two pathologies intensifies the expression of dementia symptoms, this is of relevance to general lifestyle preventive measures aimed at diminishing vascular disease.(6-11)

33. Dementia results from a combination of pathologies so that very few subjects with dementiabeyondtheageof80yearshave‘pure’Alzheinersdiseaseorvasculardementia.Since dementia is due to many different factors, it has been suggested that dementia terminology should be reviewed and less emphasis put on Alzheimer’s pathology as the sole cause.(24)


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prevalence of dementia and economic costs

34. Dementia is now considered a major societal issue and a priority by all nations. It is a devastatingchronicdiseasethat increaseshealthcarecostsanddisrupts thequalityoflifeof thoseafflictedandtheircare-givers. It isamajorcontributor toyears livedwithdisability in the aged, exceeding those of cardiovascular disease and malignant disease.

35. In the absence of preventive measures, the number of cases of dementia worldwide can be expected to more than triple from the current 30 million to 106 million by 2050 as a result of ageing of populations (12,13) or even higher according to a later estimate - 131 million with a new case occurring every 3 seconds.(22)

36. InEuropecasesofdementiaarepredictedtodoublefromabout8milliontoabout16millionin2040.(14) However, recent findings from a Framingham Heart Study suggest that fewer people in high-income countries, including the United States and Europe are falling victim to dementia. The suggested reason for this is that the higher standard of living with higher education levels and more aggressive treatment of cardiovascular disease and diabetes may be serving as a preventive measure against the dementiain todays old age cohort.(15) Another estimate(23) also suggests that the increase in dementia might be lower than anticipated owing to improved education and living conditions, and better prevention and treatment of vascular and chronic conditions.

37. As in most countries, Malta’s population is expected to age as a result of increased lifespan.Theproportionofpeopleaged65yearsormorewillincreaseto28%ofthetotalgeneral population by the year 2050. The ratio of working population to people aged 65 years or more will decrease correspondingly from 2.2 to 5.2.(16) The number of people with dementiawasestimatedat5,198in2010.BasedonEuroCodEprojections(17) this number is expected to rise to close to 10,000 persons, or 2.3% of the total Maltese population, by 2030.(18)

38. Thetotalcostofcaringforpeoplewithdementia inEU27 in2008wasestimatedtobe€160 billion of which 56% were costs of informal care. The corresponding costs for the whole of Europe is €167 billion and €177 billion for the whole Europe(19) The overall costs of dementia care in Malta are estimated at between €63 million and €96 million annually.(20)

cognitive decline

39. Mild cognitive decline or impairment is the term used to describe unexplained memory impairment or other mild intellectual deficit in older adults.

40. In most cases it can be considered as a stand-alone disorder and part of the aging process. This form of cognitive decline is not debilitating but it is a source of worry to the sufferer. Such cognitive decline can be transient and many affected people can revert back to a previous unimpaired state.(1)

41. In cases where the cognitive decline is caused by blood vessel disease, it is termed ‘vascular mild cognitive impairment’.(2,3) Though not necessarily ‘abnormal’, it can be a precursor to dementia in about 15% of such individuals.(4,5)

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42. Identifying mild cognitive impairment is important because it may provide an opportunity for pro-active measures to minimise cognitive decline and offer a chance of offset the onset of dementia; this is especially the case with vascular cognitive impairment.

43. Many observational studies referred to in this report use cognitive decline as a measure of effectiveness of preventive measures for dementia. As explained earlier, the findings of such studies are relevant to dementia prevention per se.


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references

Preface

1. Hallal P C, Andersen L B, Bull F C, Guthold R, Haskell W, Ekelund U, for the Lancet Physical Activity Series WorkingGroup;Globalphysicalactivitylevels:surveillanceprogress,pitfalls,andprospects.Lancet2012;380:247–57.)

2. OECD Health Data, 2010, Eurostat Statistics Database; WHO Global Infobase

3. Janssen I, Katzmarzyk PT, Boyce WF, Vereecken C, Mulvihill C, Roberts C, Currie C, Pickett W; Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationshipswithphysical activity and dietary patterns and The Health Behaviour in School-Aged Children Obesity Working Group*Obesity reviews (2005) 6, 123–132.

4. DecelisA,JagoR,FoxKR.Physicalactivity,screentimeandobesitystatusinanationallyrepresentativesampleof Maltese youth with international comparisons, BMC Public Health 2014, 14:664

5. Townsend Rocchiccioli J , O’Donoghue CR, Buttigieg S. Diabetes in Malta: Current Findings and Future Trends. Medical Journal Volume 17 Issue 01 March 2005

6. ECF-cycling-barometer-2013-technical-document. http://www.ecf.com/wp-content/uploads/pdf.

7. European School Survey Project on Alcohol and Other Drugs (ESPAD, 2011)

8. http://www.forbes.com/pictures/eihg45gjhg/malta-4/ http://urbanpeek.com/2012/08/02/top-20-worlds-laziest-countries/

Parts 1 and 2: Background – why Action is essential and The Relevance of Prevention to Dementia

1. Nutrition figures for 20,000 food items tallied for obesity census, Sunday times 22 February, 2015

2. Barnes DE, Yaff e K. The projected effect of risk factor reduction on Alzheimer’s disease prevalence. Lancet Neurol2011;10:819-28

3. Norton S, Fiona E Matthews, Deborah E Barnes, Kristine Yaffe, Carol Brayne. Potential for primary prevention ofAlzheimer’sdisease:ananalysisofpopulation-baseddata.TheLancetNeurology,Volume13,Issue8,Pages788-794,August2014

4. http://www.cam.ac.uk/research/news/one-in-three-cases-of-alzheimers-worldwide-potentially-preventable-new-estimate-suggests

5. Elwood P, Galante J, Pickering J, Palmer S, Bayer A, et al. (2013) Healthy Lifestyles Reduce the Incidence of Chronic Diseases and Dementia: Evidence from the Caerphilly Cohort Study. PLoS ONE 8(12): e81877.doi:10.1371/journal.pone.0081877

6. Ritchie K, Carrière I, Ritchie CW, Berr C, Artero S, Ancelin M-L. Designing prevention programmes to reduce incidenceofdementia:prospectivecohortstudyofmodifiableriskfactors.:BMJ2010;341:c3885

7. International Diabetes Federation. Diabetes Atlas. 3rd edn. Brussels: International Diabetes Federation, 2006

8. SperlingRA,AisenPS,BeckettLA,BennettDA,CraftS,etal. (2011)Towarddefiningthepreclinicalstagesof Alzheimer’s disease: recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimers Dement 7: 280-292 S1552-5260(11)00099-9 [pii];10.1016/j.jalz.2011.03.003............

9. Alexopoulos P, Richter-Schmidinger T, Horn M, Maus S, Reichel M, et al. (2011) Hippocampal volume differences betweenhealthyyoungapolipoproteinEe2ande4carriers.JournalofAlzheimersDisease26:207-210.

10. VanGoolWA (2006) CanWe Prevent, Delay, or Shorten the Course of Dementia? PLoSMed 3(10): e430.doi:10.1371/journal.pmed.0030430

11. Brookmeyer R, Johnson E, Ziegler-Graham K, Arrighi HM. Forecasting the global burden of Alzheimer’s disease. AlzheimersDement2007;3:186-91

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12. McGee MA, Brayne C. Exploring the impact of prevalence and mortality on incidence of dementia in the oldestold:thesensitivityofadeterministicapproach.Neuroepidemiology2001;20:221-24

13. Jagger C, Matthews R, Lindesay J, Robinson T, Croft P, Brayne C. The effect of dementia trends and treatments on longevity and disability: a simulation model based on the MRC Cognitive Function and Ageing Study (MRC CFAS).AgeAgeing2009;38:319-25;discussion251

14. FerriCP,PrinceM,BrayneC,BrodatyH,FratiglioniL,GanguliM,etal.,forAlzheimer’sDiseaseInternational.Global prevalence of dementia: a Delphi consensus study. Lancet 2005;366:2112

15. Menken M, Munat TL, Toole JF. The global burden of disease study: implications for neurology. Arch Neurol. 2000;57:418-420.

16. JormAF,KortenAE,HendersonAS.Theprevalenceofdementia:Aquantitativeintegrationoftheliterature.ActaPsychiatScand.1987;76:465-479.

17. Canadian Study of Health and Aging Working Group. The incidence of dementia in Canada. Neurology. 2001;55:66-73

18. DaviglusML,BellCC,BerrettiniW,BowenPE,ConnollyES,CoxNJ,Dunbar-JacobJM,GranieriEC,HuntG,McGarry K, Patel D, Potosky AL, Sanders-Bush E, Silberberg D, Trevisan M. National Institutes of Health State-of-the-Science Conference Statement: Preventing Alzheimer’s Disease and Cognitive Decline. NIH Consens StateSciStatements.2010oApr26-28;27(4):1-3

19. Plassman B L, Williams JW,. Burke JR, Holsinger T, Benjamin S. Systematic review: factors associated with risk forandpossiblepreventionofcognitivedeclineinlaterlife.AnnInternMed.2010Aug3;153(3):182-93.

20. Gorelick PB et al. Vascular Contributions to Cognitive Impairment and Dementia; A Statement for Healthcare ProfessionalsFromtheAmericanHeartAssociation/AmericanStrokeAssociation.Stroke.2011Sep;42(9):2672-713.

21. Overcoming obesity: An initial economic analysis, Discussion paper. The McKinsey Global Institute. November 2014

22. Take Action to Promote Brain Health: IOM Report. April 2015. http://www.medscape.com/viewarticle/843108?src=wnl_edit_tpal, http://www.iom.edu/~/media/Files/Report%20Files/2015/Cognitive_aging/Cognitive%20Aging%20report%20brief.pdf

23. Wu YT, Fratiglioni L, Matthews FE Lobo A, Breteler MMB, Skoog I, Brayne C. Dementia in western Europe: epidemiological evidence and implications for policy making. Lancet Neurology: Published Online: 20 August 2015 )

24. Eatwellandexercisetostaveoffdementia.SundayTimes,UK,20September2015

25. NationalPreventativeHealthTaskforceAlzheimer’sAustraliaSubmissionNovember2008

Terminology and clinical notes

1. Molinuevo JL, Valls-Pedret C, Rami L: From mild cognitive impairment toprodromal Alzheimer disease: A nosologicalevolution.EurGeriatrMed2010,1(3):146-154.O’

2. Brien JT, Erkinjuntti T, Reisberg B, Roman G, Sawada T, Pantoni L, Bowler JV, Ballard C, DeCarli C, Gorelick PB, RockwoodK,BurnsA,GauthierS,DeKoskyST.Vascularcognitiveimpairment.LancetNeurol.2003;2:89-98.

3. 3 Sachdev PS, Chen X, Brodaty H, Thompson C, Altendorf A, Wen W. The determinants and longitudinal course of post-stroke mild cognitive impairment. J Int Neuropsychol Soc.)

4. RosenbergPB,JohnstonD,LykestosCG:Aclinicalappraochtomildcognitive impairment.AmJPsychiatr2006,163(11):1884-189

5. Chertkow H, Nasreddine Z, Joanette Y, Drolet V, Kirk J, Massoud F, Belleville S, Bergman H: Mild cognitive impairment and cognitive impairment, no dementia: Part A, concept and diagnosis. Alzheimers Dement 2007,3(4):266-282.)

6. Diaz-RuizC,WangJ,Ksiezak-RedingH,HoL,QianX,HumalaN,ThomasS,Martinez-MartinP,PasinettiGM.Role of Hypertension in Aggravating Abeta Neuropathology of AD Type and Tau-Mediated Motor Impairment. CardiovascPsychiatryNeurol.2009;2009:107286.

7. Esiri MM, Nagy Z, Smith MZ, Barnetson L, Smith AD. Cerebrovascular disease and threshold for dementia in theearlystagesofAlzheimer’sdisease.Lancet.1999;354(9182):919-20


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8. SnowdonDA,GrainerLH,MortimerJA,RileyKP,GrainerPA,MarkesberyWR.BraininfarctionandtheclinicalexpressionofAlzheimerdisease:theNunStudy.JAMA.1997;277:813-817.

9. Schneider JA, Wilson RS, Bienias JL, Evans DA, Bennett DA. Cerebral infarctions and the likelihood of dementia fromAlzheimerdiseasepathology.Neurology.2004;62:1148-1155.

10. Schneider JA, Arvanitakis Z, Bang W, Bennett DA. Mixed brain pathologies account for most dementia cases incommunity-dwellingolderpersons.Neurology.2007;69:2197-2204.

11. White L, Small BJ, Petrovitch H, Ross GW, Masaki K, Abbott RD, Hardman J, Davis D, Nelson J, Markesbery W. Recent clinical pathologic research on the causes of dementia in late life: update from the Honolulu-Asia AgingStudy.JGeriatrPsychiatryNeurol.2005Dec;18(4):224-7.

12. Norton S, Matthews FE, Brayne C. A commentary on studies presenting projections of the future prevalence of dementia. BMC Public Health 2013; 13:

13. Ferri CP, Prince M, Brayne C, et al. Global prevalence of dementia: a Delphi consensus study. Lancet 2005; 366: 2112-17.

14. BrookmeyerR,JohnsonE,Ziegler-GrahamK,ArrighiHM.ForecastingtheglobalburdenofAlzheimer’sdisease.AlzheimersDement2007;3:186-91.

15. Alzheimer’sAssociationInternationalConference(AAIC)2014.Abstracts42984and42865.PresentedJuly15,2014.

16. AbelaS,MamoJ,AquilinaC,ScerriC.EstimatedprevalenceofdementiaintheMalteseIslands.MaltaMedicalJournal Volume 19 Issue 02 June 2007)

17. http://www.alzheimer-europe.org/Alzheimer-Europe/Our-work/Completed-projects/2006-2008-EuroCoDe

18. ScerriA,ScerriC.DementiainMalta:newprevalenceestimatesandprojectedtrends.MaltaMedicalJournal,2012: 3; 21

19. Anders Wimo, Linus Jönsson, Anders Gustavsson, Cost of illness and burden of dementia - The base option. Karolinska Institutet, Alzheimer Europe

20. Times of Malta, May 29, 2012).

21. Hachinski VC, Iliff LD, Zilhka E, et al. Cerebral blood flow in dementia. Arch Neurol. 1975;32:632-637.

22. World Alzheimer’s Report 2015: Global Impact of Dementia. http://www.medscape.com/viewarticle/850147?src=wnl_edit_tpal&uac=149019BY

23. Wu YT, Fratiglioni L, Matthews FE Lobo A, Breteler MMB, Skoog I, Brayne C. Dementia in western Europe: epidemiological evidence and implications for policy making. Lancet Neurology: Published Online: 20 August 2015

24. FotuhiMVladimirHachinskiV,WhitehousePJ.Changingperspectivesregardinglate-lifedementia.NatureReviewsNeurology5,649-658(December2009)

some relevant articles published in local press

http://www.independent.com.mt/articles/2012-10-30/letters/reducing-the-impact-of-dementia-298319892/

http://www.timesofmalta.com/articles/view/20120604/letters/Urban-environment-and-dementia.422663

http://www.timesofmalta.com/articles/view/20081213/letters/the-streets-and-squares-as-social-space.237005

http://www.timesofmalta.com/articles/view/20130214/letters/Planned-supermarket-outside-Xewkija.457545

http://www.timesofmalta.com/articles/view/20140406/opinion/Urban-design-and-health.513739

list of published reports

To date, The Today Public Policy Institute has published the following reports:

• TheEnvironmentalDeficit:TheReformofMEPAandOtherRegulatoryAuthorities(LeadAuthor:MartinScicluna)–April2008

• TowardsaLowCarbonSociety:TheNation’sHealth,EnergySecurityandFossilFuels(LeadAuthor:GeorgeDebono)–June2008

• Managing the Challenges of Irregular Immigration to Malta (Lead Authors:StephenCalleyaandDerekLutterbeck)–November2008

• ForWorse,ForBetter:Re-marriageAfterLegalSeparation(LeadAuthor:MartinScicluna) – June 2009

• TheSustainabilityofMalta’sSocialSecuritySystem:AGlimpseatMalta’sWelfareState and Suggestions for a Radical Change of Policy (Lead Authors: Joseph FX Zahra,SinaBugeja,JosephSammutandJacquesSciberras)–July2009

• IntotheFuture:Socio-EconomicorSecurityChallengesforMalta–November2011

• AStrategyforAddressingtheNation’sPriorities–April2012

• HealthyMobilityinSliema:ACaseStudy(LeadAuthor:GeorgeDebono)-June2012

• SameSex:SameCivilEntitlements(LeadAuthor:MartinScicluna)-May2013

• 10Years in theUnion:Malta’s EUStory (LeadAuthor: PatrickTabone)– June2014

• AReviewoftheConstitutionofMaltaatFifty:RectificationorRedesign?(LeadAuthors:MichaelFrendoandMartinScicluna)–September2014

• Confronting the Challenge: Innovation in the Regulation of Broadcasting inMalta(LeadAuthors:PetraCaruanaDingliandClareVassallo)–November2014

• WhyMalta’sNationalWaterPlanRequiresanAnalyticalPolicyFramework(LeadAuthors: Lee Roberts, Marco Cremona and Gordon Knox) – April 2015

All the reports may be down-loaded on the TPPI website (www.tppi.org.mt).