Print This PostThere have recently been exciting developments in identifying biomarkers of dementias that could be used to detect conditions before symptoms develop. We are also progressing in understanding the genetic basis of dementias. This is obviously fantastic and full of hope for bringing us closer to preventing or curing dementia in the future. But I am a little concerned about the proposed future applications of this research – namely screening tests delivered in your GP practice or even through your smartwatch.
Let me explain… it’s not that I think this kind of individual-level intervention, to help identify people at risk of a disease and prompt them to take preventative action, is without merit. But there are serious drawbacks that we need to consider before we place too much emphasis on the individual.
First, lets look at an existing individual-level screening and prevention intervention. The NHS Health Check programme aims to detect adults at risk of cardiovascular disorders and type 2 diabetes. Adults between 40 and 74 years old are invited to attend a Health Check at their GP practice where they complete a series of measurements and answer questions on their medical history and ‘lifestyle behaviours’ (diet, physical activity, smoking etc.). The Q-risk calculators are used to provide individuals with their risk scores for developing the disorders in the next 10 years. People identified as being at high risk should then be offered information and support to help them adopt healthier behaviours, as well as medication, such as statins, if appropriate. Sounds good in theory but the programme has poor uptake – about 40% last year – particularly among people known to be at greater risk of chronic disease. So it isn’t helping to reduce health inequities. While there is evidence that Health Checks successfully identify cases of cardiovascular disorders and type 2 diabetes, there is no good quality evidence that it is also helpful in preventing people from developing these conditions – that is, although people might be told they are at risk, it doesn’t look like they go on to change their behaviours and reduce their risk.
This leads us on to individual-level behavioural support. Researchers (including me) and public health practitioners have developed thousands of interventions to help people quit smoking, reduce their alcohol intake, eat a healthier diet and become more active. Some show really good effects but the majority, particularly for diet and activity, bring about at best modest changes that are not sustained in the long-term. Couple this with the fact that local authorities’ budgets seem to face ever more drastic cuts, meaning behavioural support services get the chop, and we can see that individual-level interventions are not going to bring about the change we need to prevent chronic disorders, including dementias.
Focusing on the individual also brings a risk of increasing stigma – there is an implicit message that your health is in your control, so if you are inactive, overweight, smoke and drink and become ill, then that’s your fault. But this ignores the wider determinants of health, most of which we don’t have much control over – living in poverty, having highly stressful jobs, facing discrimination are just some of the things that will impact on our physical and cognitive ability to control our diets and activity. That’s to say nothing of the silent risk factor of pollution. Societal blame and stigma are counter-productive, making people more likely to engage in unhealthy or risky behaviours.
Don’t get me wrong, I’m not saying that there isn’t a place for individual-level preventive interventions – there absolutely is and it’s important to inform people about their health and support those who are able to make changes. But what I’m disheartened by is the lack of emphasis on upstream, population level change that we need to be advocating for. Reducing poverty and pollution, heavily taxing foods with precious little nutritional value and subsidising more nutritious foods, increasing the amount of safe, accessible green spaces for people in cities will all make individual level changes so much easier and result in greater health equity.
I recognise that population-level approaches are more challenging for researchers to investigate and politically difficult to implement. The current research funding system is set up to favour RCTs but this means there is a dearth of population-level evidence for policy makers to draw on. So, this is a plea to all of us in the dementia research community, to venture outside of our comfort zone of proposing more individual-level interventions, and instead advocate more for the population level changes we need to see to prevent dementia.
Dr Lis Grey
Author
Dr Lis Grey is an NIHR / Alzheimer’s Society Dem Comm Research Fellow at University of Bristol and NIHR ARC West. Her interest lie in understanding how people with neurodegenerative disorders experience health and care services, and developing ways to improve services and support people to live well with these conditions. Lis is also passionate about working to improve research culture, and away from her work, a passionate gardner overly-ambitious baker.
Dr Yvonne Couch
Emily Spencer
Dementia Researcher
Rebecca Williams
Yasmin Bonsu