SECOND OPINION:We need agreed policies on cardiovascular health, writes JACKY JONES
CARDIOVASCULAR HEALTH is back in the news and is still the leading cause of premature death in Ireland. The European Society of Cardiology (ESC) estimates that cardiovascular disease (CVD) causes nearly two million early deaths (under 75 years) in Europe every year.
The World Health Statistics 2012 report shows the risk factors for heart disease are still high blood pressure, tobacco use, physical activity, and being overweight or obese. The Institute of Public Health (IPH) estimates that more than 62 per cent of Irish adults over 45 years of age have high blood pressure (hypertension). A third of a million people have received a clinical diagnosis, and nearly 600,000 have undiagnosed hypertension.
Experts disagree about the most effective way to influence risk factors. Two new papers published by the ESC advocate different approaches. The first recommends helping individuals maintain healthy lifestyles and reduce their risk factor levels, while the second recommends changing everyone’s health habits by legislation and fiscal policy. The ESC has produced guidelines on preventing CVD which explain how to use the new SCORE risk-estimation chart in clinical practice. This chart allocates a score from 0 to 26, based on age, sex, smoking habits, systolic blood pressure, and total cholesterol, to estimate the risk of having a fatal cardiovascular event within 10 years.
A non-smoking man aged 40 with normal blood pressure and low cholesterol scores 0, whereas a 65-year-old male smoker with high blood pressure and high cholesterol scores 26. On the other hand, a 65-year-old male non-smoker with normal blood pressure and low cholesterol scores 2, and a 40-year-old male smoker with high blood pressure and cholesterol also scores 2. The overall score decides whether the patient receives medication as well as help to change their health behaviour.
The individual approach to CVD prevention has several drawbacks. Two-thirds of clinicians rely on intuitive assessments and do not use methods, such as SCORE, which assess all risk factors. This means that interventions are inconsistent: some patients receive pills and others do not. Another problem is that cognitive behavioural strategies must be used by clinicians to encourage the necessary behaviour changes. This involves helping patients design their own detailed lifestyle modification plan and includes asking direct questions such as: “Are you prepared to quit [smoking] now?” Doctors often don’t have the extra 20 minutes needed, so they resort to easier but ineffective advice-giving. Even after receiving appropriate help most patients do not adopt healthy lifestyles. Only a third become physically active and 18 per cent achieve a healthy waist circumference of less than half their height.
The second ESC paper argues that individualised interventions are insufficient, and the most cost-effective approach is to bring about population level changes through taxation, environmental changes and legislation. Population approaches, such as Ireland’s tobacco legislation, tend to work quickly and cost less than clinical services. New agricultural policies are needed, taxes on fat and sugar products, subsidies for fruit and vegetables, and less salt in processed foods. Alcohol intake can be reduced by taxation and advertising regulation. These population level changes can halve CVD premature mortality rates.
Neither ESC paper refers to the influence of the social determinants of health on CVD, such as poverty and low educational attainment. A recent paper published by the Department of Public Health at HSE West shows that farmers are five times more likely, and agricultural workers seven times more likely, to die from any cause of death than salaried employees. Most deaths in the farming population are caused by CVD.
In the meantime, Ireland can choose between three different approaches to the prevention of CVD: reduce poverty and improve educational attainment in low-income groups, invest in population level changes such as public transport, or invest in individual interventions by clinicians. None of these interventions are mutually exclusive and it would be great if we could afford them all. The recession means policy makers need to choose wisely.
Dr Jacky Jones is a former regional manager of health promotion with the HSE