There is massive evidence that a healthy lifestyle, especially involvement in active exercise, reduces the risk of cardiovascular disease, diabetes type 2, and obesity (Taylor et al., Reference Taylor, Cable, Faulkner, Hillsdon, Narici and van der Bij2004). There is less strong but nevertheless good evidence that it reduces the risk of depression in the older adult population (Strawbridge et al., Reference Strawbridge, Deleger, Roberts and Kaplan2002). The evidence that it reduces the risk of Alzheimer's disease is contestable (Rolland et al., Reference Rolland, van Kan and Vellas2008), but if it reduces vascular disease there can be no argument that it must reduce the risk of vascular dementia.
It is over 60 years since Morris showed that bus drivers had a distinctly higher rate of heart disease than bus conductors who ran up and down the stairs of London buses as part of their job (Morris et al., Reference Morris, Heady, Raffle, Roberts and Parks1953). So it is surprising that it is only in very recent times that a report of the Chief Medical Officer (CMO) of England and Wales has advocated the need for a new public health drive to improve the lifestyle of older people in the UK (Department of Health, 2011). In the same year as this statement from the CMO was published, further initiatives were embarked upon.
The Centre for Social Justice is a policy unit founded by the current Secretary of State for Work and Pensions, Ian Duncan Smith. Its report “The Forgotten Age” (Centre for Social Justice, 2010) pointed to the need for a healthier lifestyle to improve the quality of life of disadvantaged older people. Following the publication of this report, the Department of Work and Pensions, in collaboration with Age UK, launched the Age Action Alliance (2011), an ambitious, multisectoral approach to combat the disadvantages experienced by older people. The Alliance is an independent association of organizations across the whole of civil society. Its members are drawn from older people's groups from around the whole country, national and local voluntary organizations, government departments, and the private sector (including the fitness industry, football league, British Gas, and Microsoft). To date, over 200 organizations have joined. As the first national initiative of its kind, Alliance members aim to work together to improve the lives of the most disadvantaged older people and reduce preventable ill health in people in this age group by improving their lifestyle. Older people themselves are the driving force in the work of the Alliance.
A high proportion of older people, especially those from socially disadvantaged groups, do not take the levels of physical exercise recommended to maintain health (Scottish Government, 2004). There is a variety of reasons why this is the case. They include health problems (including physical disability), poor access to exercise facilities, inertia, lack of interest, lack of confidence, fear of over-doing it, hostile environment, and cost constraints. A study of civil servants showed that they did more exercise in their leisure time when retired than they did when they were working (Mein et al., Reference Mein, Shipley, Hillsdon, Ellison and Marmot2005). But those employed in low grades in the civil service did much less exercise than those in higher grades. Civil servants are, in large part, a socially privileged group. It is highly likely that socially disadvantaged people employed in manual occupations will do even less physical exercise in retirement than sedentary civil servants. Further, after retirement, the amount of physical exercise taken by the older population reduces markedly with age, especially after the age of 75 (Scottish Government, 2004).
Once those in employment have lost the habit of going to work as a result of retirement, many do not develop habits of taking exercise. They lead a life which is not only sedentary but also socially isolated. Unsurprisingly, they have high rates of depressive disorders (McDougall et al., Reference McDougall2007). It is well recognized that in getting the long-term unemployed back to work, it is essential to re-establish a habit of getting up in the morning and appearing at work on time. To achieve similar habits in the long-term retired and sedentary section of the population without the incentive of the monetary rewards that accompany paid employment is quite a challenge.
The initial work of this Alliance has been taken forward by several working groups, commissioned by a steering group. There are older people representatives on all groups. One of these groups, which I chair, is focused on public health and active lifestyles. The group took as its theme the “Five Ways to Wellbeing” that emerged from research conducted by the New Economics Forum, commissioned by Foresight (National Economics Forum, 2008). To achieve “Five Ways,” an individual needs to connect, take notice, be active, learn, and give.
The group decided that it would identify already existing programs, which support this theme. Programs were expected to meet a set of criteria before they could be recommended. They should promote and deliver improved physical and/or mental health and well-being. They should be sustainable, community based, have been subject to rigorous, peer-reviewed evaluation, and provide value for money. They should have been tried and tested in a variety of geographical locations.
Only a small number of programs we considered, met these standards. Of these, perhaps the program most nearly achieving the criteria we set was the fit as fiddle portfolio developed by Age UK (2012). The fit as a fiddle portfolio was set up in October 2007 with support from the Big Lottery Fund as part of its well-being program. The program aims to reach disadvantaged people living in communities who have not previously had access to services that actively improve their physical health and mental well-being. By 2011, 4,500 people had been trained as “volunteer buddies” or activity organizers. These supported individuals participating in the program. Most were prepared to continue taking part in activities once funding was no longer available, thus demonstrating the program's sustainability. Included within the program are activities that address loneliness and isolation, obesity, diet, cooking and nutrition, general well-being, intergenerational activity as well as support for carers.
The fit as a fiddle program has already been taken up by as many as a quarter of a million people in the UK. The range of activities is considerable, ranging from Abseiling to Zumba. Many people in their eighties have participated with, to date, the oldest participant being 105 years old. Over 450 organizations have already incorporated fit as a fiddle into their activities, including 99 local Age UKs. The approach empowers older people and communities to take ownership of their health and well-being. It relies on volunteers, ambassadors, and partner organizations to provide the “reach,” and the momentum to sustain activities. The interventions are tailor-made and built on the assumption that everyone, from the most active to the most frail, can do something to improve their health, well-being, and independence.
A small number of other programs have also been identified as fulfilling some or most of the criteria. Most notable of these is the “Active in Age” positive aging program run by the Beth Johnson Foundation (2012). The aim of this project is to deliver accredited training to volunteers so that they can deliver exercise programs to groups of older people in a variety of settings. All these programs have been accredited and are available for purchase. Impact assessments, performed annually, show that they are multifunctional and apart from providing physical activity those taking part in them have become part of a social network. In this way, they have been involved in reducing loneliness and improving health and well-being.
It is the intention of the working group to ask the members of the Alliance to agree to the principles of the Five Ways to Wellbeing and to ask them to demonstrate how they will achieve these principles over a specified period of time. The programs identified are only examples of how these principles can be achieved and members of the Alliance will be encouraged to engage flexibly by using other approaches if these meet the same criteria. Members will be particularly encouraged to join with other organizations to achieve desirable results.
Changing the lifestyle, attitudes, and behavior, particularly of older people and even more of older disadvantaged people, is a major challenge. Providing activities on a weekly basis is one way in which programs like fit as a fiddle have been shown to be very effective; multiple testimonials from people who have been involved demonstrate their efficacy. But there is a long way to go before such programs are available in every locality in the UK and the rest of the world.
Approaches to date have been focused on group rather than individual activity because the evidence is that group activity helps to reduce social isolation – perhaps the greatest problem for older people in our society today. However, recent studies highlight the fact that it is equally important to encourage people to increase the amount they walk in their everyday lives (Ken Fox, Opal Project, personal communication).
Promoting an active lifestyle remains the most effective way society can encourage for physical and mental well-being, while at the same time reduce loneliness and social isolation. The Alliance, through its members, and with the active participation of older people, could well be a powerful stimulus to the achievement of this objective. Those working in countries that do not already have a similar network of organizations might consider whether they should follow suit.
Conflict of interest
None.
