Health | State of Ageing in 2020
People are living longer in poor health than in the past and progress on life expectancy is stalling.
The State of Ageing in 2020 is an online report with multiple chapters, capturing a snapshot of ageing today and considering our future prospects. Below, you can get further detail by clicking on the 'Analysis' buttons and you can hover over graphs to access the data.
Extending the number of years we spend living in good health as we age is central to maximising our enjoyment of later life
And, while many people do enjoy good health well into their old age, there are stark inequalities.
The state of the nation’s health has been brought into sharp focus by the coronavirus pandemic: over 90% of deaths from COVID-19 have been in people with at least one pre-existing health condition, most commonly diabetes, chronic lung disease, chronic kidney disease and cardiovascular disease. Excess weight is also associated with an increased risk of a positive test, hospitalisation, higher levels of treatment and death as a result of COVID-19, leading the UK government to announce a raft of measures to reduce obesity.
Those conditions associated with serious outcomes in people with COVID-19 are among the typical age-related conditions that develop slowly – often from mid-life onwards – and that have no cure. Moreover, many people have several of these chronic conditions simultaneously. They impair people’s ability to carry out normal day-to-day activities (for example, due to problems with mobility, dexterity, sight, hearing and physical coordination)
- Overall life expectancy is increasing – albeit more slowly than in the recent past. But disability-free life expectancy among women is falling.
- The wealthiest people have almost twice as many years of disability-free life ahead of them at age 65 as the poorest.
- One in four people aged 55-64 are physically inactive, meaning they do less than 30 minutes of physical activity a week. This proportion increases with age and is higher among people living in the most deprived neighbourhoods.
- Overall, rates of smoking are falling. But the proportion of adults drinking at higher or increased risk of harm peaks among people in their 50s and 60s.
- The proportion of people with a weight status that classes them as overweight or obese has increased over time in every age group over 45.
What needs to happen:
- Concerted action from across government to:
- reverse trends in stalling life expectancy and rising amounts of time spent living with disability in later life
- address growing health inequalities. This means tackling the wider determinants of health as well as action across the life course to ensure that everybody has the same opportunities to achieve a good education, good work, financial security, a decent home, and to develop and maintain connections to family, friends and a supportive wider community. It also means ensuring that health and social care services as we age are timely, appropriate and accessible to the whole population, irrespective of wealth or geographical location.
- Strong, coordinated action to address some of the main behavioural risk factors that cause disability in mid to later life. This includes:
- Physical activity: Supporting more people in mid- and later-life to be physically active by investing invest in cost-effective strength and balance programmes; promoting active travel by investing in walking and cycling infrastructure; promoting behaviour change interventions that tackle barriers specific to people in mid- and later-life; and encouraging a more age-positive and inclusive offer from the fitness and leisure sector.
- Overweight and obesity: Helping people to manage their weight and reduce levels of obesity by holding the food industry to account for meeting targets to reduce sugar and overall calories from everyday foods; introducing calorie labelling in all out-of-home outlets; restricting advertising of foods high in fat, sugar and salt; and creating healthier retail environments.
- Alcohol: Implementing minimum unit pricing and a rise in the alcohol duty to address the availability of cheap alcohol; mandating clear alcohol product labelling; and increasing investment to provide advice and treatment for people drinking at harmful levels.
- Smoking: Implementing the Smokefree Action Coalition’s roadmap for change to deliver the government’s ambition for England to be smoke-free by 2030.
How much of our lives do we spend in ill health?
Compared with men, women spend a smaller proportion of their longer lives free of disability
- On average, a girl born today in England can expect to live three-quarters of her 83.2 years of life free of disability¹ (her disability-free life expectancy [DFLE]) and a quarter with disability.
- A boy born today in England, with a life expectancy at birth of 79.6 years can expect 79.0% to be lived free of disability and 21.0% with disability.
- But for a woman at the age of 65, just less than half (46.2%) of her remaining 21.2 years will be free of disability.
- A 65-year-old man can expect a little more than half (52.4%) of his remaining 18.9 years to be free of disability.
But progress on life expectancy has stalled and disability-free life expectancy for women is falling
- Following historically large increases in life expectancy between 2001 and 2011, improvements in life expectancy have slowed over the last decade:
- Between 2001 and 2011, life expectancy at birth increased by 3.1 years for men, and 2.4 years for women in England. Since 2011, there have been further increases of 0.8 years and 0.6 years respectively.
- Disability-free life expectancy is actually decreasing – particularly among women.
- DLFE at birth for boys has fallen slightly from 63.3 years to 62.9 years over the ten-year period to 2016-18.
- And the number of years that a baby boy can expect to live with disability has increased by more than two years – from 14.6 to 16.7 years.
- Among women, DFLE at birth has fallen from 64.5 to 61.9 and the number of years lived with disability has increased from 17.5 to 21.3 years.
Stalling improvements to life expectancy is not unique to the UK – although the UK’s slowdown has been more pronounced than in other European countries. There has been much debate about the causes: contributing factors include slowing improvement in mortality rates for stroke and cardiovascular disease, and some bad flu seasons. Austerity has also been widely cited as a factor. Direct causals link are not clear – and this pattern is not visible across Europe – although there is a correlation in the UK between mounting pressure on public services and the slowdown in improvements. Inequalities are clearly key: the poorest have seen the rate of increase in life expectancy slow most dramatically and life expectancy has actually dropped for the poorest women.
We are living a longer portion of our lives with disability
- The proportion of life spent with disability has increased for both men and women:
- While males at birth could expect to live 18.7% of their lives with disability over the 2006-08 period, this had increased to 21.0% by 2016-18.
- For females at birth, the proportion of life spent with disability increased from 21.3% to 25.6% over the ten-year period to 2016-18.
This expansion of years spent with illness and conditions that impair our ability to carry out day-to-day tasks is deeply troubling. And with reported delays in diagnosis and treatment of many health conditions as a result of the pandemic, there is a risk of a further reduction in disability-free life expectancy over the coming years. The government’s commitment to action on obesity is a welcome step to improve our health but we need comprehensive and radical action across a whole range of areas, to halt the trend in disability-free life expectancy and reverse it.
People living in the wealthiest areas have almost twice as many years of disability-free life ahead of them at age 65 as those in the poorest
- People who live in the wealthiest areas (by Index of Multiple Deprivation decile) have almost twice as many years of disability-free life ahead of them at age 65 as those in the poorest (6.2 and 6.4 years in the poorest areas for men and women, respectively, compared with 12.2 for men and women in the richest areas).
- That means that at the age of 65, men in the poorest tenth of the country can expect to spend 39% of their remaining life free of disability, compared to 58% for the those in the wealthiest. The corresponding proportions for women are 35% and 53%, respectively.
The least wealthy people in society can expect not only to live a shorter life but also to spend more of that shorter life with a limiting long-term illness than wealthier people.
This is caused by the accumulation of all the circumstances of our lives. Poverty and financial insecurity, employment, our homes and the places we live, all affect physical and mental health directly, and affect behaviours like being physically active, smoking, having a poor diet and drinking too much.
With a greater burden of ill health in the poorest in society, it is the poorest who will suffer most from the delays in diagnosis and treatment of health conditions that have resulted from the pandemic. Hence, the coming years may bring not only a further reduction in disability-free life expectancy overall, but a larger gap between the richest and poorest.
People living in the South of England have a longer life expectancy and disability-free life expectancy than people living in the North
- As well as the major disparity in life expectancy and disability-free life expectancy by levels of wealth shown above, we see a pronounced disparity by geography across England, with a clear North-South divide.
- Looking at men and women together, disability-free live expectancy for 65-69 year olds ranges from 8.3 years in the North East to 11 years in the South East.
- The proportion of remaining life spent without disability between the ages of 65-69 mirrors this exactly: this ranges from 44% in the North East to 53% in the South East.
- Disparities in life expectancy become even starker at a smaller geographical level:
- In England, over the 2016-2018 period, the lowest disability-free life expectancy for girls in England at birth was 53 years in Blackpool and the highest was 69.5 in Waltham Forest.
- The lowest disability-free life expectancy for boys in England at birth was 52.8 in Blackpool and the highest was 69.4 in Wandsworth.
There is large geographic variation in the proportion of people with three or more long-term conditions
- Almost a quarter (21%) of 50-64 year olds (2.23 million people) across England have one long-term health condition and 15% (1.6 million people) have three.²
- Consistent with the geographic variation in disability-free life expectancy, we see pronounced variation in the proportion of people with those long-term conditions that cause disability.
- Across the country, the proportion of people aged 50-64 with one long-term health condition ranges from 17% in Inner London to 27% in Herefordshire, Worcestershire and Warwickshire (2019 data; not shown).
- The proportion of 50-64 year olds with three or more conditions is lower, with the smallest proportion (8%) in Cheshire and the highest (22%) in Tees Valley and Durham (see map on right).
- Of the ten regions in which more than 15% of people aged 50-64 have three or more long-term conditions (2019), only two (Cornwall and Inner London) are in the South (map on right).
- Besides the North-South differences seen here, there is also variation between rural and urban areas and between those that are coastal and those that are inland. Ten of the 20 local authorities in England and Wales with the highest proportion of people in poor health are coastal: Neath Port Talbot, Blackpool, Bridgend, Sunderland, Barrow-in-Furness, Carmarthenshire, East Lindsey, South Tyneside, County Durham and Hartlepool.
A number of factors have been identified as accounting for the observed differences in the health of people living in different parts of the country. These include environmental factors (including working conditions), educational and lifestyle factors and infrastructure challenges (many villages and small towns lack frequent and reliable public transport and high-speed internet). The impact of de-industrialisation has also been mooted as a factor: one study has shown that areas in the North that have experienced a strong transition away from employment in physically demanding occupations have particularly low levels of physical activity. All, however, are ultimately linked to other socioeconomic factors including levels of wealth: poorer places are simply less healthy.
Regardless of the cause, the data demonstrates the importance of local approaches to health prevention that address the specific issues faced by people in a local area.
Musculoskeletal disorders cause the most years spent in poor health for people aged 50 and over
- Musculoskeletal disorders (osteoarthritis, rheumatoid arthritis and other conditions that affect the muscles, joints and skeleton) are the most common long-term, chronic conditions amongst adults in England.
- They account for 30% of years lost to disability in people aged 50-69 and for 22% in people aged 70 and over. This is the largest cause of disability in both age groups.
- Sense organ disease (principally hearing and sight) account for 6% of years lost to disability for people aged 50-69. This increases to 12% in people aged 70 and over, the second largest cause of disability in this older age group.
Conditions of the musculoskeletal system are more common in women than men at every age
- Conditions of the musculoskeletal system are more common in women than men at every age.
- They are present in one in five women aged 45-54, increasing to almost half (47%) of women aged 85 or over. In contrast, they are present in under a third of men in this age group.
The data demonstrates that age is a risk factor for developing conditions of the musculoskeletal system. For women, in particular, mid-life is a critical period for safeguarding musculoskeletal health through early action to address lifestyle factors. Menopause – which has a detrimental effect on bone, cartilage and muscle mass – causes the higher prevalence seen in women than in men. However, the risk is further exacerbated by health behaviours, notably smoking and alcohol consumption, both of which can weaken bones.
The poorest women aged 50 and over are four times more likely to suffer from depression than the wealthiest. For men, its five-fold. This pattern plays out across all common disorders
- For every common long-term chronic condition, there is huge variation by wealth with a much higher prevalence in the poorest compared with the richest fifth of the population.
- The biggest gap between the richest and poorest men and women aged 50 and over is for depression, which occurs in 8% of women and 4% of men in the top wealth quintile and 28% of women and 19% of men in the bottom wealth quintile (assessed using the eight-item version of the Centre for Epidemiologic Study Depression scale and not a clinical diagnosis of depression).
- In all wealth groups, the condition with the highest prevalence is arthritis: it is present in almost two in five of the poorest fifth of the population aged 50 and over and in more than a quarter (28%) of the wealthiest fifth (men and women combined).
Although genetics, and – for women - events such as menopause, play a part in the advent of many of the chronic conditions that people in all wealth groups experience from midlife onwards, a host of modifiable risk factors – notably, smoking, diet, alcohol consumption and physical activity – are extremely important. The role of these external risk factors on the development of health conditions has led the World Health Organisation to state that ‘the major causes of chronic diseases are known, and if these risk factors were eliminated, at least 80% of all heart disease, stroke and type 2 diabetes would be prevented; over 40% of cancer would be prevented’.
Behavioural risk factors for disease and disability
The proportion of people who are physically inactive increases sharply with age
- More than three in five people (62%) aged 55-64 are ‘active’ (that is, they do 150 minutes or more of moderate activity or 75 minutes of vigorous activity per week).
- This drops just a little (to 59%) among people aged 65-74.
Physical activity can help to prevent and delay many diseases and conditions that affect us as we age. We know, for example, that inactive people are at increased risk of developing a painful musculoskeletal condition and that excess weight increases the risk of back pain or of developing osteoarthritis and other musculoskeletal conditions. We also know that regular physical activity reduces the risk of hip and knee osteoarthritis pain by 6%; of depression by up to 30%; and of falls by 76%.
Physical activity also helps us maintain functional ability, independence and quality of life as we grow older. But the time and ability we have to be physically active is not equally distributed across the population.
People in the poorest neighbourhoods are more than twice as likely to be physically inactive as people in the wealthiest
- Like other risk factors for poor health, physical inactivity is strongly associated with socio-economic status.
- Whereas fewer than one in five (18%) people aged 55-74 who live in the least deprived 10% of neighbourhoods are inactive, this proportion increases steadily with level of deprivation, reaching more than two in five (41%) in the most deprived. That is, people in this age group in the poorest neighbourhoods are more than twice as likely to be physically inactive as those in the wealthiest.
Levels of physical activity differ by ethnicity
- Of people aged 55-74, Non-British White people are the ethnic group most likely to be active (66%) and least likely to be inactive (23%) while people of South Asian origin are least likely to be active (49%) and most likely to be inactive (38%).
There are a host of factors that impact a person’s ability to be physically active: these include poor body image, lack of confidence, being uncomfortable in gym environments, and not knowing other people who exercise.
Older adults most often report poor health as their primary barrier, although they also mention fear of falling or injury, symptoms of depression and lack of time. Crime and fear of crime, area degradation, lack of green infrastructure, noise and air pollution, cluttered pavements and non-inclusive design are also barriers that prevent people from being more physically active. Many of these factors may be of greater relevance for people of minority ethnic backgrounds because they are more likely to be living in disadvantaged areas, partially explaining their lower participation in physical activity.
People in Cumbria and North Yorkshire are most active in mid-life
- The areas in which 70% or more of 55-74 year olds are active are found across the country, but five of them – Eden, South Lakeland, Craven, Richmondshire and Harrogate – are clustered together in Cumbria and North Yorkshire.
- The local authority with the lowest proportion of active 55-74 year olds (41%) is Luton and the one with the highest is Craven, where almost three-quarters of people (74%) are active.
Smoking and poor diet are the top behavioural risk factors for years lost to disability
- Among people aged 50-69 in England, smoking, unhealthy diet and alcohol use are the top three behavioural risk factors that give rise to the chronic health conditions that in turn cause disability. This ranking is unchanged since 2007.
More than eight in ten men and six in ten women aged 55- 64 are overweight or obese
- Of all risk factors across the three categories of behavioural, metabolic and environmental, or occupational, high body mass index (a metabolic risk factor) is the top risk factor for years lost to disability in 50-69 year olds in England.
- Rates of overweight or obesity are high in every age group:
- Prevalence rates peak in 55-64 year olds, in which more than 80% of men and 66% of women aged 55-64 have a weight classed as overweight or obese.
- But even among 25-34 year olds, this is the case for more than half of people.
The proportion of people whose weight classes them as overweight or obese has increased over time in every age group over 45
- The number of people who are classed as overweight or obese has increased in every age group over the last 30 years.
- The largest increase since 1993 (from 58% to 71%) is among people aged 75 and over.
Obesity is a major risk factor for many conditions which contribute to disability in later life: type 2 diabetes, coronary heart disease, stroke and some types of cancer, such as breast and bowel cancer, as well as associated mental health problems. Obesity has also been identified as a significant risk factor for more severe forms of COVID-19, making the obesity public health crisis even more urgent.
Almost half of the poorest men and women have a weight classed as obese, compared to just one-fifth of the richest
- The proportion of people who have a weight classed as overweight or obese is strongly correlated with wealth: almost half of men and women aged 50 and over in the lowest wealth quintile compared to one-fifth in the highest.
- The increase in the proportion of people living with obesity that has occurred over the last 30 years has happened mainly among the poorest men: since 2008-09, the prevalence of obesity among men aged 50 and over in the poorest fifth of the population has increased from 34% to 47%. In contrast, that of men in the wealthiest fifth of the population remained at 23% over the same period.
The poorest people, with the greatest burden of health challenges, are also being exposed to those environments most likely to cause obesity: there is a clear correlation between the availability of fast food outlets and increasing level of area deprivation. The government’s plan to ban junk food ads before the 9pm watershed is laudable, but its impact will be limited if we are surrounded by junk food outlets wherever we go in our neighbourhoods. A recent article by a number of prominent academics said that targeting individuals with weight loss programmes without changing the environments in which they take place, was like ‘treating people for cholera then sending them back to communities supplied with contaminated water’. We need to ensure that we live in places that enable us to live healthy lives.
One fifth of men aged 50-59 years still smoke
- Smoking dramatically increases the chances of developing lung cancer, heart disease and stroke and is the cause of nine in ten deaths related to chronic obstructive pulmonary disease (COPD).
- Smokers and people with COPD were more likely to develop severe complications from COVID-19 and to die from infections than patients who did not smoke or have COPD.
- Although smoking rates have declined significantly across the population and tend to drop with age, about one-fifth of men and 14% of women aged 50-59 still smoke.
- High smoking rates among younger people are a cause for concern when it comes to ageing well: one-quarter of 25-34 year old men smoke, the highest smoking rate in any age group, male or female.
As with other measures of health, smoking rates vary across the country
- Smoking rates among people aged 55-64 range from 12% in the South East to 16% in the East Midlands.
- Among people aged 65 and over, smoking rates range from 6% in the South East to 9% in the North West.
The poorer you are, the more likely you are to smoke
- Smoking rates are highly associated with wealth: more than a quarter of men aged 50 and over (29%) in the lowest wealth quintile smoke, compared with just 4% in the highest.
- Smoking rates in the wealthiest quintile of the population have declined over time: rates among the wealthiest men and women aged 50 and over have halved from one in ten (10% and 11%, respectively) in 2002-03 to one in 20 (4% and 5%, respectively) in 2018-19.
- There has also been a large decrease in smoking rates among women aged 50 and over in the poorest quintile of the population – from 31% in 2002-03 to 18% in 2018-19.
- However, smoking rates for men aged 50 and over in the poorest quintile of the population decreased by just five percentage points over that 16-year period – from 34% in 2002-03 to 29% in 2018-19. That means that almost one third of the poorest men still smoke.
Levels of smoking highest among Black men and women
- Almost a quarter (22%) of Black men and one in five (18%) Black women are smokers, higher than for White or Asian men or women.
- With smoking such an important risk factor for health outcomes, it is essential that smoking levels among ethnic minorities reduce so as to help mitigate widespread health inequalities.
Some smokers say cigarettes help them to relax, so it may be that there are higher rates of smoking among people with less money, as it helps to cope with stress caused by factors such as debt or poor housing conditions. In addition, people from lower socioeconomic groups who smoke are less likely to succeed in their attempts to stop smoking, even although, on average, all people who smoke make similar numbers of attempts to stop each year. This is because they face additional barriers, including stress related to material hardship that has contributed to their smoking habits in the first place, as well as the higher rates of smoking among others in their immediate circles. These socioeconomic patterns in smoking may intersect with the patterns by race.
Of course, the financial cost of a smoking habit only exacerbates hardship: analysis of UK government data carried out for Action on Smoking and Health suggested that quitting smoking would lift more than 447,000 households out of poverty.
Men aged 55-64 are most likely to drink at levels that put them at increased or high risk
- Alcohol use is the behavioural risk factor that leads to the third highest number of years lost to disability among people aged 50-69 in England.
- Risky levels of alcohol consumption are highest among men and women aged 55-64:
- The proportion of males aged 16 and over who drink at levels that put them at increased or high risk (more than 14 units per week) ranges from more than one in five (22%) 16-24 year olds to almost two in five (39%) 55-64 year olds.
- Among women, the proportion ranges from one in ten 25-34 year olds and over 75s to almost one in five (19%) 55-64 year olds.
Harmful alcohol use peaks in the 50s and 60s. In the ten years from 2008-2009 to 2018-2019, alcohol treatment services saw an overall 3% drop in adults being newly treated for alcohol misuse. However, among adults age 50-64, there was actually a 45% increase in people newly receiving alcohol treatment. For people aged 65 and over, the increase was even more dramatic – numbers nearly doubled for this age group.
Heavy drinking is highest among White men
- Three times as many White men aged 50-69 have heavy alcohol use as Black men (15% compared with 5%) although there is little difference between Black and White women (8% and 7%, respectively).
The wealthiest are the most likely to be regular drinkers. However, regular drinking is not the same as unsafe or binge drinking: among all people aged 16 and over, more than a quarter (26%) of those in the two least deprived quintiles are at increased risk due to their alcohol consumption compared with 14% in the two most deprived quintiles. Thus, in what has been termed the alcohol harm paradox, ‘the burden of alcohol harm falls more heavily on individuals from lower socioeconomic backgrounds’.
While some health behaviour trends look slightly positive – such as declines in rates of smoking – the broader outlook for our ability to age in good health and free of disability is not good. If trends in disability-free life expectancy continue to worsen, future generations will age with many more years in poor health than those before them. Action on healthy ageing means action on poverty, social exclusion and health inequalities.
¹ Disability-free life expectancy (DFLE) estimates years of life free from any persistent condition that reduces your ability to carry out your usual day-to-day activities. These conditions could include arthritis, hearing or vision impairment or mental health issues.
² Office for National Statistics analysis of Annual Population Survey data 2019. Created on 17/8/2020 by Office for National Statistics.