Improving men's health

Probably the single most significant risk factor for long-term morbidity and premature mortality is not smoking, but simply being a man. One in five men will die before he reaches his 65th birthday. So what can general practice nurses do to tackle this ‘gender deficit’?

Advances in healthcare and treatment options mean that life expectancy is increasing – but not for everyone: women – generally speaking – live longer than men, not just in the UK but throughout the developed world. The most recent data show that this gender gap is 5.3 years.¹ There has been considerable research into the reasons for this discrepancy, not least into an apparent reluctance by men to seek medical help or advice and why this is the case. Practice nurses are at the forefront of health promotion but face a formidable task in tackling the issues, given that the consultation rate for men is 32% lower than it is for women.² This article will look at what issues lead to an earlier death in men and how nurses can improve men’s uptake of services in general practice in the hope that eventually this will have an impact on the gender deficit in mortality rates.

WHAT BARRIERS MUST WE OVERCOME?

In the UK, some 90% of interactions between patients and the NHS happen in general practice but despite the wide range of services on offer in the average practice, many of which are provided by practice nurses, men have far fewer contacts with their GP than women do. A survey on behalf of the Blue Ribbon Foundation – a charity which supports men’s health initiatives – found that not only had one in five men not visited a doctor or other healthcare professional in the last 12 months, but 6% would not do so even if they experienced chest pain. Only 14% of men questioned said they were happy to go ‘to the doctor’s’ if necessary, but more tellingly, a third would only see their GP if their partner made them go, or ‘if they really had to.’³

ISCHAEMIC HEART DISEASE AND CHD

Ischaemic heart disease was the leading cause of death for males in 2013, and accounted for 15.4% of male deaths in that year.⁴ The prevalence of heart disease in general practice is higher among men in all age groups, with the widest gap between women and men seen on those aged between the ages of 45–64 and those aged 65–74.⁵ Not only are men more reluctant to consult, but there is evidence that men are less likely than women to recognise any symptoms they may be experiencing and – even more worryingly – are less likely to recognise the need for emergency treatment.⁶ This helps to explain why men are more likely to die from CHD prematurely and, if they have a sudden cardiac event, to die.⁵

Men have higher mortality rates than women for both CHD and stroke – the male CHD mortality rate is 147 per 100,000 men, compared with 69 per 100,000 for women.⁵

Perhaps most concerning is the fact that many of the risk factors for CHD are modifiable which means that if they were tackled the risk of an early death could be reduced. It is usually the case that several risk factors for CHD coexist in the same individual. Identifying – and modifying – these risks in men is essential if premature morbidity and mortality are to be reduced and outcomes improved.

Hyperlipidaemia

Hyperlipidaemia is generally found opportunistically during routine screening or investigation for other conditions. Raised lipid levels are entirely asymptomatic (although treatment may not be).

Although NICE urges us to aim for reductions in ‘non-HDL’ when treating dyslipidaemia, laboratories generally report on total cholesterol levels, triglyceride levels and high density lipoprotein cholesterol (HDL-C) values. Higher levels of HDL-C are protective against CHD and conversely, lower values are associated with an increased risk. Again men fare worse than women: HDL levels are higher in women than in men from young adulthood until post-menopause, when the cardioprotective effects of oestrogen diminish.⁷ Triglyceride levels are also significant, as even in those with a high HDL-C level, raised triglyceride values are associated with an increased risk of ischaemic events, despite the protection that high HDL-C is thought to confer.⁸ The association between dyslpidaemia and CHD, cardiac events and stroke is well-established and dose-related – the higher the cholesterol level, the greater the risk. The presence of other risk factors such as hypertension, diabetes and smoking exacerbates the risk of cardiac events.

Up to half the difference in CHD mortality between men and women can be explained by modifiable factors, particularly HDL-C levels (and smoking).⁵

HYPERTENSION

Hypertension is one of the most common disorders in the UK and its monitoring and management is an important part of the role for many practice nurses. It seldom if ever causes symptoms, and is therefore sometimes described as the silent killer because of the damage it causes to organs and arteries over time, fuelling the development of coronary heart disease potentially leading to fatal outcomes. Current estimates suggest that nearly 30 per cent of adults in the UK have hypertension, of whom up to half are not receiving treatment.⁹ As well as increasing the risk of coronary heart disease, hypertension is also known to be linked to the development of a number of other diseases, including stroke, heart failure, peripheral vascular disease, vision problems and chronic kidney disease – all of which have an impact on quality of life.

In general practice, more men than women are known to have hypertension but more women than men have treated hypertension both overall and in all age groups apart from those aged 35-44 where the rates are virtually the same. The gap is highest in those over the age of 75 years.⁵

DIABETES

The number of people diagnosed with diabetes in the UK has risen dramatically in recent years and is expected to exceed 5 million by 2025.10 Of those with a confirmed diagnosis men have higher rates than women, with 6% in the 45-54 age range compared with 3.6% of women, rising to 13.5% in the over 75s compared with 10.6% of women.¹¹

It is estimated that 56% of those diagnosed with diabetes are male. Men over 50 are nearly twice as likely to have undiagnosed type 2 diabetes than their female counterparts. Black African and South Asian men are more likely than women from both these groups to have been diagnosed.

SMOKING AND ALCOHOL USE

Even though smoking prevalence is declining, more than 8 million people in England alone continue to smoke. And although there is some evidence to suggest the gap between men and women is closing, in 2013, 22% of men and 17% of women smoke, and men smoke more cigarettes daily than their female counterparts.¹² On average, men smoke two cigarettes a day more than women, and more men than women smoke hand-rolled tobacco. Death rates attributable to smoking in men are shown in Table 1.

Men are more likely than women to drink alcohol, and to drink at hazardous levels. A fifth of men drink more than 8 units of alcohol on at least one day in the week, and 31% of men who drink, drink more than twice the recommended amounts (21 units per week for men, 14 for women). Of those admitted to hospital for alcohol-related disease or injuries, 65% were men.

DIET

Men consume a higher intake of saturated fat than women,¹³ and only 22% of men eat the recommended five portions of fruit and vegetables on a daily basis.¹⁴ Among younger men (aged 16-24) only 15% of men achieved recommended fruit and vegetable intakes.

Men eat an average of 50g of processed meat a day (twice as much as women) and last month (October) this level was described by the World Health Organization as carcinogenic – increasing the risk of developing colorectal cancer by 18%.

OBESITY

Obesity is very near if not at the top of the healthcare agenda because of the adverse effects on health that it brings, not least because of its association with diabetes. In 2005 two thirds (67%) of men in England and Wales were overweight or obese compared with just over half (57%)of women.¹³ Men tend to accumulate fat around the abdomen and excess abdominal fat (central obesity) has a direct link to increased blood pressure, higher levels of LDL and increased risk of heart disease and stroke.¹³ Central obesity is a cardinal feature of the collection of characteristics and biochemical markers that comprise the metabolic syndrome, which includes insulin resistance, high blood pressure and dyslipidaemia, and which is a precursor of type 2 diabetes. Obesity is also now strongly linked with a significantly greater risk of developing several cancers notably colorectal cancer, oesophageal and kidney cancers, all of which are more common in males than females.¹⁵

PHSYICAL ACTIVITY

There is some evidence to suggest that those who have enjoyed exercise in their early years are more likely to continue to remain active in their adult life, but gaining weight may reduce participation in physical activity due to embarrassment, feelings of stigma and difficulties in actually participating due to lack of fitness5. Living a sedentary life with minimal physical activity is a major contributory factor in precipitating a number of diseases including – but not limited to – peripheral vascular disease, non alcoholic fatty liver disease, colon cancer, diverticulitis and deep vein thrombosis.¹⁷

However, this is one area where men outperform women. In England in 2012, 67% of men met Government recommendations for physical activity, compared with 55% of women – although these self-reported claims may be a serious overstatement. Men in lower socio-economic groups and men from Indian, Pakistani, Bangladeshi and Chines ethnic groups are less likely to achieve targets for physical activity.

HOW CAN PRACTICE NURSES HELP

In order to tackle the issues surrounding men’s reluctance to seek medical advice it may help to understand some of the contributory factors. There have been several studies to find out why men appear reluctant to seek help. Some of the reasons – and possible solutions – are shown in Table 2. Offering services outside of working hours, making the surgery environment less off putting (because men feel the surroundings are more geared towards females) by displaying more leaflets and posters specific to men’s health and targeting men’s health problems may make a difference. Advertising websites which deal with men’s health issues may be encourage men to use them as a starting point, and prompt them to see a doctor if necessary. Other options outside of the usual scope of general practice might include offering more screening at places of work, in leisure centres or at football grounds.

CONCLUSION

It is clear that men are reluctant attendees for screening and healthcare, placing them at risk of preventable diseases. Although life expectancy for both men and women has increased there is still a gender gap, and much work needs be done to address the difference in life span which persists between men and women. Changing attitudes and lifestyle is difficult and practice nurses face a tough challenge but with continued efforts and perseverance, small changes may gradually start to have an impact and – eventually – achieve results.

REFERENCES

1. Gorman BK, and Read. JG. Why men die younger than women. Geriatrics and Aging. 2007;10(3):182-191.

2. Wang Y, Hunt K, Nazareth I, et al. Do men consult less than women? An analysis of routinely collected UK general practice data. BMJ Open 2013;3:e003320 http://bmjopen.bmj.com/content/3/8/e003320.full

3. Daily Mail reporter. One in five men has ‘not visited a doctor in the last year’ (and 6% still wouldn’t even if they had chest pains). http://www.dailymail.co.uk/health/article-1365977/One-men-visited-doctor-year-wouldnt-chest-pains.html

4. Office for National Statistics. What are the top causes of death by age and gender? Available at: http://visual.ons.gov.uk/what-are-the-top-causes-of-death-by-age-and-gender/

5. Department of Health. The gender and access to health services study. Available at: https://www.menshealthforum.org.uk/sites/default/files/pdf/gender_and_access_to_health_services_study_2008.pdf

6. Greenlund K, Keenan N, Giles W, et al. Public recognition of major signs and symptoms of heart attack: seventeen states and the US Virgin Islands, 2001. Am Heart J 2004;147:1010–6.

7. Brown SA, Hutchinson R, Morrisett J, et al. Plasma lipid, lipoprotein cholesterol, and apoprotein distributions in selected US communities. The Atherosclerosis Risk in Communities (ARIC) Study. Arterioscler Thromb 1993;13:1139-1158.

8. Jeppesen J, Ole Hein H, Suaducani P, et al. Triglyceride concentration and ischaemic heart disease: An Eight-Year Follow-up in the Copenhagen Male Study. Circulation 1998;97:1029-1036.

9. British Heart Foundation. Cardiovascular disease statistics: Headline statistics. https://www.bhf.org.https://www.bhf.org.uk/research/heart-statistics

10. Diabetes UK. Facts and stats. https://www.diabetes.org.uk/Documents/Position%20statements/Facts%20and%20stats%20June%202015.pdf

11. The Information Centre (2008). Health Survey for England 2006 www.ic.nhs.uk/webfiles/publications/HSE06/HSE%2006%20report%20VOL%201%20v2.pdf

12. Men’s Health Forum. Key data: Alcohol and smoking. https://www.menshealthforum.org.uk/key-data-alcohol-and-smoking

13. Mens Health Forum. Hazardous waist: Tackling the epidemic of excess waist in men.

https://www.menshealthforum.org.uk/sites/default/files/pdf/gender_and_access_to_health_services_study_2008.pdf

14. Department of Health. Health Survey for England 2003. http://webarchive.nationalarchives.gov.uk/+/www.dh.gov.uk/en/publicationsandstatistics/publications/publicationsstatistics/dh_4098712

15. Key et al Allen NE, Spencer EA, et al. The effect of diet on the risk of cancer. Lancet. 2002;360:861-8.

16. Health and Social Care Information Centre. Statistics on smoking England-2014. http://www.hscic.gov.uk/article/2021/Website-Search?productid=15530&q=statistics+on+smoking&sort=Relevance&size=10&page=1&area=both#top

17. Booth FW, Roberts CK, Laye MJ. Lack of exercise is a major cause of chronic diseases. Compr Physiol. 2012; 2(2):1143-211.

18. Banks I. No man’s land: men, illness, and the NHS. BMJ 2001;323(7320): 1058–1060.