During my last holiday in Spain, we visited old friends close to Madrid. Unfortunately, my 1-year-old son had to spend two nights in hospital. It turned out to be nothing life-threatening, and medical care was good, so my worries were soon tempered. However, on the first morning in hospital, my concerns shifted from the health of my son to the health of the Spanish population. While I expected the hospital to serve a nutritious breakfast, they actually gave the children chocolate milk and Maria biscuits. I was quite amazed. Did they not know about the “breakfast guidelines”, suggesting a meal with whole grains, fruit and a skimmed dairy product? I soon learned from my friend that sweet cakes are in fact a staple breakfast for many Spanish. I figured that a nation that starts the day with so much sugar is probably not very healthy.

(Healthy) life expectancy compared

I started thinking about other Spanish living habits, such as their late bed-time and regular wine consumption. I assumed these habits would affect their life expectancy, and so, once home, I started searching for numbers to compare Dutch and Spanish (healthy) life expectancy. I was again surprised:

The Spanish have a slightly higher average life expectancy than the Dutch: 83.4 versus 81.8. Even more surprisingly, their healthy life expectancy is much higher, especially for women: Spanish women versus Dutch women: 66.5 vs 57.8; Spanish men versus Dutch men: 65.9 vs 62.8.

What can explain this gap in healthy life expectancy?

European measurements

Since 2004 the same method for calculating healthy life expectancy has been used all over Europe. Still, comparing healthy life expectancy between countries calls for caution. The method that defines whether a person is in good health is based on the subjective question: “For at least the past six months, to what extent have you been limited because of a health problem in activities people usually do? Severely limited; limited, but not severely; not limited at all”. After translation into the local language, this question might be interpreted slightly different across countries. Also, local culture might influence what is labelled as “activities people usually do”, and what counts as “severely limited”. Indeed, a study that compared how this general question related to more specific questions about daily activities (essential, such as feeding oneself, versus instrumental, such as preparing the meal) found subtle differences between countries. However, a difference between Spain and the Netherlands of ~3 years for men and ~9 years for women can hardly be explained by Dutch people (especially women) complaining more (the Dutch are indeed good at complaining, but not that good).

Lifestyle

So I compared lifestyle differences between the Netherlands and Spain that might relate to the discrepancy in healthy life expectancy. Of course, one can’t exclude every possible contributing factor, but for the obvious ones that I (and people I discussed this with) thought of, I found no major differences between the two countries (see the list below). Also, the difference doesn’t seem to be explained by environmental factors, such as air pollution (depending on measurement) or amount of sunlight (Sweden ranks highest in healthy life expectancy, making sunlight unlikely to be the defining difference). The only difference that stood out, and that many people mentioned as a possible explanation when I asked their view on this, was stress. Dutch people suffer more from work-related stress than Spaniards. Of course, stress alone cannot cause such a big difference in healthy life expectancy (and why would women suffer more from stress, for instance?), but it might be part of the explanation.

Contributing to a healthy generation

As part of my work, I am involved in a think tank set up by the Vereniging Samenwerkende Gezondheidsfondsen to devise a program for a healthier next generation. One of the core elements of the program is to increase resilience among young people, so that it’s easier for them to make healthy lifestyle decisions (healthy diet, enough sleep and relaxation, no substance use (or abuse), healthy social relations, and enough physical activity). Of course, avoiding substance abuse and taking care of your body is always a good choice. However, my search into healthy life expectancy made me wonder whether such a broad factor as resilience might actually be more important than the individual healthy choices one makes during the day. For example, being more resilient could make you less susceptible to harmful stress. Resilient people can probably allow themselves some treats, but without overindulging. Having a cookie for breakfast doesn’t mean you should eat cookies all day: finding a balance between health and (unhealthy) fun is easier when you’re more resilient.

No recipe for a long healthy life

Although the Dutch Nutrition Center prescribes whole grains and a skimmed dairy product for breakfast, apparently many Spaniards thrive on their starting the day with cookies and chocolate milk. For them, this is a habit that is probably balanced throughout the rest of the day. It is clear that the full answer to why the Spanish live so much longer, healthier lives than the Dutch is still unknown. Yet, living a (happy) healthy life may well be more about finding out what gives us mental energy: maintaining a good balance and being resilient is healthier than stressing, for example over the details of our lifestyle choices.