Cardiovascular disease: The case for doing more on illness prevention, rather than just treatment

“Lifestyle changes” are buzz words in conversations around prevention of chronic illness. There can’t be many people who are unaware of the mantras to eat less, move more, drink alcohol responsibly if you must drink, and don’t touch cigarettes.

It suits the State and commercial interests to play up personal responsibility for making the “right” choices and mask the lack of support for – if not downright sabotaging of – healthier options. But a conference on Tuesday, November 14th , entitled Rethinking Chronic Disease Prevention in the 21st Century, is highlighting the benefits of population-wide strategies.

Hosted by the Irish Heart Foundation (IHF), the focus is on cardiovascular disease (CVD), which is the second leading cause of death in this country after cancer. But in recognition of how tackling the risk factors for heart conditions and strokes overlaps with preventing other illnesses, such as cancer and dementia, the IHF is joining with other health charities and organisations to launch the Irish Health Promotion Alliance at the conference in Dublin.

One in four deaths in Ireland is due to CVD and it is estimated that 80 per cent of premature heart disease and stroke is preventable. The case for doing more on illness prevention, rather than concentrating resources on the very costly, treatment end of the health spectrum, is laid out in a 158-page report produced for the IHF by the School of Public Health in University College Cork.

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“It’s not sustainable to focus on those already ill,” warn the authors, Prof Ivan Perry and Kerrie Gallagher in this IHF position paper entitled Primary Prevention of Cardiovascular Disease – Best Practices and Lessons for Ireland. “We struggle to achieve an appropriate balance between the immediate short-term imperatives of clinical care and the longer-term opportunities to prevent suffering and premature death and reduce health care costs through prevention.”

With our growing and ageing population, there needs to be more emphasis on keeping people well for as long as possible, if the (ill) health services are not to be further overwhelmed. Cardiovascular disease is estimated to cost the State €1.7 billion a year, almost half of which are direct health care costs.

“There is a huge opportunity here to take pressure off the health service and to improve people’s quality of life at an individual level – it’s win, win,” says the IHF’s director of health promotion, Janis Morrissey, talking to The Irish Times ahead of the conference.

The five core risk factors for cardiovascular disease are:

1. Smoking
2. Physical inactivity
3. Poor diet
4. Obesity
5. Excessive alcohol consumption

Yes, individuals are able, in theory at least, to moderate those risks for themselves, Morrissey acknowledges, “but the vast majority of our health behaviour is influenced by the world around us: the marketing we are exposed to, the environment we live in”.

Health inequalities are entwined with socio-economic status. For instance, from a dietary aspect, we may know we should eat five portions of fruit and veg a day, but it’s not all about the knowledge, she points out. It’s do you have access to those? Can you afford them? Have you got cooking skills – or even the facilities to cook?

It’s not enough, argues Morrissey, to tell people what to do, through State-funded health promotions. “There is a responsibility of government to create a world where people can be healthy and at the moment that is not the world that we live in.”

Granted there has been a lot of talk and good intentions in the past decade. The Healthy Ireland framework that was first produced in 2013 is praised by the IHF report as “a broad, comprehensive and inspiring vision for the promotion of health and wellbeing and the prevention of disease and premature mortality in Ireland”.

[ Heart disease: What is it - and what does the future hold with improving treatments? ]

But is it living up to its promise?

“There remains a significant gap between the rhetoric of prevention and practice, particularly when policy proposals require significant supporting investment and/or face opposition from commercial interests,” say the report authors. Reducing the salt content in food products such as breads, margarines and cereals has been discussed for years here, yet Australia has already shown how mandating such a measure is associated with large improvements in population health and cost-saving for the health sector.

“We know voluntary codes don’t work,” says Morrissey. “It needs to be mandatory to have a health impact. It needs to be public health led not industry led.”

The key messages for policymakers from today’s conference “are around implementation and bravery. There are lots of great policies there.” What’s lacking, she contends, is the political willpower to follow through in areas that are more challenging but where the greatest rewards can be gained.

Take the Obesity Policy and Action Plan for Ireland 2016-2025, one of the Government’s flagship public health programmes under the Healthy Ireland framework. An independent evaluation at the midway point rated just 10 per cent (six out of 60) of its actions with high levels of implementation and only 23 per cent as having achieved high levels of progress. Despite the Department of Health’s clear commitment to the plan, the IHF report says “these findings are a cause of concern and highlight the capacity deficits in Ireland’s public health infrastructure”.

Almost 20 years ago we saw an outstanding example of a population-wide initiative for the good of public health, pushed through against fierce opposition from business, including the then mighty vintners. On March 29th, 2004, Ireland became the first country in the world to implement legislation creating smoke-free enclosed workplaces that included bars and restaurants. The current Tánaiste, Micheál Martin, can take credit as the health minister who saw it over the line, although there had been years of concerted effort by others, including department official Tom Power behind the scenes and high-profile anti-smoking campaigner Prof Luke Clancy.

“It’s a great example that we are all familiar with,” says Morrissey. It’s a measure that is applicable no matter what part of the country and whatever income bracket you are in. The health of all of us has benefitted from smoke-free environments ever since. (Although right now the Government is being urged to introduce policies targeted at curbing vaping, to stop the reversal of some of these health gains.)

A tax on sugar-sweetened drinks was introduced here in 2018 but its impact is yet to be evaluated, five years later. While a study to do this has just been commissioned by the Government, “the reticence in moving this forward is very disappointing”, she comments. “We need to evaluate all of our policies – that is not just good practice but forms the basis of understanding other opportunities for subsidies and taxes in other areas.”

Yet, for politicians, the slow-burn measures of health disease prevention are never as urgent as trying to douse media flames around overcrowded hospitals and long waiting lists. “We won’t see the benefits in the short term and this makes it more challenging, in terms of election cycles, to make those changes,” agrees Morrissey. But the Irish Heart Foundation is calling on politicians “to take that leap of faith and understand the legacy they can leave as policymakers by being brave and implementing what needs to be done”.

The IHF is advocating nine areas of action, within which there are 39 recommendations.

The nine areas are:

1. Political leadership: To address the broad range of social, political, commercial and environmental determinants of health. A new cardiovascular health policy is also needed to replace the one for 2010-2019, which is four years out of date and was never evaluated.
2. Prevention targets and population health monitoring: Ambitious targets are needed for reductions in deaths, incidence and prevalence of cardiovascular disease, along with investment in tracking protective behaviours against the five core risk factors, to evaluate the effects of policy.
3. Investment in public health infrastructure: There’s an urgent need for more resources to enable the health system to understand, protect and promote the health and wellbeing of the population, as well as to plan for our future health and social care needs.
4. Promotion of health and wellbeing through taxation and legislation: Various measures are suggested here to tackle the link between ultra-processed foods and a rising prevalence of obesity.
5. Addressing the key risk factors of poor diet, physical inactivity and obesity: Recommendations for system-wide prioritisation and policy-level interventions include a revised national food pyramid, designed to promote both human and planetary health, inspired by the Harvard healthy eating pyramid.
6. Tobacco control: While Ireland has been a global leader in tobacco control, “we are failing to keep pace with the changing product landscape of innovative and novel tobacco and nicotine products”, the report warns. “The use of e-cigarettes has increased in adolescents and during pregnancy”.
7. Air quality: There are an estimated 1,300 premature deaths in Ireland every year due to particulate matters, ie a mixture of solids and liquid droplets in the air. The health co-benefits in working towards greenhouse gas emission reduction targets are clear.
8. Policy alignment on climate action and public health: Potential health gains due to climate action include beneficial effects on diet, the food environment, public transport, access to green spaces, air quality and home insulation.
9. Clinical interventions: Data on levels of awareness, treatment and control of high blood pressure are now more than 10 years old and need updating. Other recommendations here include exploration of involving pharmacies in screening and management of CVD risk factors.

Irish Heart Foundation report

“Nanny state” is a popular jibe against public health measures, especially among vested interests who believe their profitability is at risk.

“It’s a rhetorical device by corporations and media to frame public health policies such as sugar taxes or warning labels on alcohol products as manifestations of an overreaching state seeking to limit individual choice and freedom,” comments a new Irish Heart Foundation (IHF) report. In addressing how to prevent cardiovascular disease, “there is a need to explicitly acknowledge the power of corporations and the largely unseen means by which corporate power is exerted in society”.

How we frame problems and solutions matters because it determines whether we build or erode political will to take meaningful action

—  Grant Ennis, author and researcher

The report is being launched Tuesday, November 14th at a conference in Dublin on Rethinking Chronic Disease Prevention in the 21st Century, where one session will be dedicated to the commercial determinants of health.

“We don’t talk enough in Ireland about how health policy is formed, what voices are listened to and whose carry weight,” says IHF director of health promotion Janis Morrissey. There needs to be more transparency over lobbying when issues such as marketing regulations, taxes and subsidies are proposed for health reasons.

Corporations are manipulating our politics, so our politics are better for profit, says Grant Ennis, a public health researcher and author of Dark PR: How Corporate Disinformation Harms Our Health and the Environment, who will speak at the conference. “They are also manipulating our discourse so we don’t see health as political; we don’t see health as something caused by the policies around us.” Industry-friendly policies cause worldwide problems. Corporations use “nine devious frames” to distract attention from how they’re benefitting and to undermine political will, he argues in his book, which focuses on how these play out in the realms of diabetes and obesity, road accidents and global warming.

“How we frame problems and solutions matters because it determines whether we build or erode political will to take meaningful action.” Focusing on individual responsibility and victim blaming “undermines citizens’ will for political action and reduces the likelihood of meaningful change”.

Advocating “healthy choices”, for instance, is meaningless in a toxic food environment. “There isn’t a choice – you’ve got the food around you that you’ve got around you.” Ultra processed food is ubiquitous and cheap.

Only a few things are proven to work in relation to preventing the rise of diabetes related to obesity, he tells The Irish Times ahead of the conference. “They are changing the price, changing the proximity and changing the temporality, eg setting a minimum age for purchase of cigarettes or alcohol, or not allowing fast-food outlets to operate near schools during school hours.”

Ennis, a lecturer at Monash University in Melbourne, contends there is no real evidence to show that the “information environment”, eg food labelling and public health campaigns, actually change people’s behaviour, as opposed to their intentions. Meanwhile, off stage, the State is lobbied by commercial interests of all sorts to create an environment that is unhealthy.

With marketing being tax deductible here, Irish taxpayers are financing corporations to run advertising campaigns to influence the public, he points out. “You are subsidising the propaganda that is manipulating you – it’s pretty perverse.” It’s also allowing them to sell their products at a lower price.

To those who cry “nanny state” against public health measures, he says, “we already have a diabolical, evil nanny – and the nanny has rigged our politics in ways that are creating ill-health”. Yet, there is “virtue signalling” by food and drink companies in funding health initiatives, such as education campaigns and sports programmes, to distract, perhaps, from their less benign influence on the nation’s wellbeing.

Ennis highlights how Coca-Cola, for instance, gave the Irish Nutrition and Dietetic Institute (INDI) €23,800 in funding between 2010 and 2013. The INDI office confirms it had “a relationship for a brief period around the Diet Coke brand a decade ago”. But when the organisation restructured in 2013, “a decision was taken, using National Healthy Eating Guidelines as our standard, that we would not have relationships with companies who manufacture products that are high in salt, sugar and fat”. It receives no funding now from corporate food and beverage sponsors.