Clustering of unhealthy behaviours over time: Implications for policy and practice

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People’s lifestyles – whether they smoke, how much they drink, what they eat, whether they take regular exercise – affect their health and mortality. It is well known that each of these lifestyle risk factors is unequally distributed in the population.

Less is known about how these behaviours co-occur or cluster in the population and about how these patterns of multiple lifestyle risk have been evolving over time. This paper considers this in the context of the English population and sets out the implications for public health policy and practice that flow from the findings.

It reviews the current evidence on multiple lifestyle risks and analyses data from the Health Survey for England on the distribution of these risks in the adult population and how this is changing over time.

Key points

  • The overall proportion of the English population that engages in three or four unhealthy behaviours has declined significantly, from around 33 per cent of the population in 2003, to 25 per cent in 2008.
  • These reductions have been seen mainly among those in higher socio-economic and educational groups: people with no qualifications were more than five times as likely as those with higher education to engage in all four poor behaviours in 2008, compared with only three times as likely in 2003.
  • The health of the overall population will improve as a result of the decline in these behaviours, but the poorest and those with least education will benefit least, leading to widening inequalities and avoidable pressure on the NHS.

Policy implications

More effective ways must be found to help people in lower socio-economic groups and those with the least education to improve their health behaviours.

This requires a more holistic approach to policy and practice, addressing lifestyles that encompass multiple rather than individual unhealthy behaviours.

In addition, behaviour change should be linked more closely to inequalities policy and be focused more directly on improving the health of the poorest.

More research and better use of the data already available is key. In particular, it would be helpful to know whether it is easier or harder to change the behaviour of those with multiple risks, whether it is more effective to tackle the risks in sequence or in tandem, what the most cost-effective approaches are and what we can learn from other areas of care.

Download the appendices: Clustering of unhealthy behaviours over time

Summary presentation

David Buck introduces the key findings of our paper, Clustering of unhealthy behaviours over time: implications for policy and practice, examining the impact multiple lifestyles has on health and how four key risky behaviours – smoking, excessive drinking, poor diet and lack of exercise – cluster in the English population and how that is changing over time.


Rick Harris

Managing Director,
Customer Faithful
Comment date
31 January 2013
Very interesting report, and the findings around healthy lifestyle correlating with income and education are stark.
I particularly like the integrated healthcare model at the end of the document - joined up thinking!
A couple of omissions though - why is there not a copy of the Health Survey England questions within the document? It would be much easier to get a feel for how healthy lifestyle is defined if this was included, especially as my experience of public surveys is that they offer a rather narrow definition and don't allow sufficient space for open-ended definitions by citizens themselves.
Second - I'm not clear from this report the degree to which people with comorbidities have been able to participate in the survey. This is a huge issue particularly for elderly people of course. Perhaps I have missed how this has been accounted for ?

John Wilcox

Public Health Development Manager,
NHS Nottingham City
Comment date
29 October 2012
Very interesting and useful analysis. In Nottingham City, the majority of which is in the 20% most deprived nationally, we commission a telephone based adult behaviour change service which offers support to adults with one or more lifestyle risk factors. Your analysis supports the need for such a service and will inform our commissioning. We also work with the local authority on a survey where we can look at multiple risk factors. I've also experienced your observations about government policies on inequalties and individual risk factors not being joined up.

Paul Southon

Public Health Development Manager,
Comment date
28 August 2012
When trying to understand what prevents people living healthy lives it is essential that we don’t put all the emphasis on the lifestyle choices of the individual. People can only make choices from what is available to them. These are constrained throughout life by the social determinants of health – poverty, education, environment, employment etc.

Someone born into a deprived inner city with limited access to good education and employment, poor access to healthy food and limited opportunities for physical activity has a very different menu of choices to someone born into a more affluent area.

The Marmot Review and the work of the Institute for Health Equity must form the framework for future public health approaches, tackling lifestyle without tackling the social determinants will only result in failure.

“Choice is meaningless without the opportunity to exercise it.”

Julie Ann Racino

Freelance Writer,
Comment date
25 August 2012
I'd be a whole lot happier if government and researchers first identified with the public a range of different kinds of lifestyles that are supported by the government. A good public discussion might do us all good! Government is moving in the US, since 911, toward more and more policing of our streets and our homes.

I'd also appreciate if government includes in healthy lifestyles to aspire to (i.e., what government wants to do to reduce health care costs) opportunities for better employment, housing, arts and culture, and widened interests. And surprise, surprise, that also reduces governmental costs.

Sarah Cowling

HealthWORKS Newcastle
Comment date
23 August 2012
Thanks David and Francesca for this excellent report which highlights everything we know from the grass roots delivery front and will be of great help in arguing our case for a change in public health policy and practice.

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