Best Targets, Biggest Hurdles in Europe's War on CVD

Shelley Wood

April 18, 2013

ROME, ITALY — European researchers are looking back and looking ahead trying to predict how cardiovascular disease rates in the past and present will change in the coming years, and just what strategies might deliver the most bang for their buck.

As Dr Melanie Nichols (University of Oxford, UK) showed in one of the first presentations here at EuroPrevent 2013 , CHD has declined across Europe in recent years, according to the most recent European statistics. That decline has been steepest since 1990 in the UK, compared with a more gradual decline in France (where rates were much lower at baseline). Large drops in Eastern European countries since the mid-2000s have led to a "narrowing of the gap" between countries in Eastern and Western Europe.

Still, the total economic cost of CVD per year to the EU, including healthcare costs as well as costs of medication, informal care, plus lost opportunity and productivity costs, are spiking at more than €196 billion per year.

"We need to think about this in the context of the cost of prevention, [which is typically much lower]," Nichols noted. "It can be difficult for policy makers to see value in spending money on those things when there are more votes to be won in opening a new hospital . . . Particularly in heart disease, where trends have been heading downward, it's important to note that the costs aren't dropping at the same time."

And putting those numbers in context, session moderator Dr Susanne Logstrup (European Heart Network, Brussels, BE) pointed out that €196 billion "is more than the annual budget of the European Union."

Taxation and Subsidies for the Bad and the Good

In a second presentation, Dr Helen Bromley (University of Liverpool, UK) presented research aimed at identifying the most effective--and cost-effective--CVD-prevention strategies. Noting that past efforts to curb smoking and encourage physical activity have been reasonably effective and well-supported by government policies, she and her colleagues chose to look at public-health nutrition policies. "We felt this was an area with not much going on," she said.

For the purposes of their analysis, they focused on salt, saturated fats and trans fats, added sugar, and fruit and vegetable consumption.

They then categorized national public-health strategies according to four Ps--price, product, place, promotion--and interviewed policy makers as to what they felt would be the most effective strategies.

"What was clear from the nearly 70 interviews is that there is . . . support for taxation and regulatory approaches, which were seen as most effective policies." These, however, are difficult to implement, so information, education, and communication campaigns are seen as "politically most achievable."

She also gave a shout-out to countries that have managed to make strides with policies that encourage healthy eating and discourage unhealthy foods (ie, through subsidies and taxes) or that have taken initiatives to legislate food additives or substitutes, for example salt or trans fats.

"There is a lot of variety across countries in terms of policy development and implementation, partly due to capacity and partly due to political will," she said. "The good news is that all the EuroHeart countries were doing something, and some were doing it better than others."

Standouts include Portugal, Finland, Iceland, Slovenia, and England, she added.

Pushing Back on Industry

Looking to the future, Dr Simon Capewell (University of Liverpool) presented two scenarios of what CVD rates in Europe might look like in 2030, based on "modest" success in curtailing unhealthy habits and in an "ideal" scenario. In the modest scenario (in which smoking was reduced by 5%, physical inactivity by 2%, dietary salt by 10%, and dietary saturated fat by 2%), reductions in smoking and saturated fats would be predicted to have the biggest impact.

In an "ideal" scenario, Europeans would cut smoking rates by 15%, physical inactivity by 5%, dietary salt by 30%, and saturated fats by 3%. These are "distinctly feasible," he said, noting that different countries had managed to institute one or more of these successfully.

In the more ambitious scenario, "we see that smoking and saturated-fat reductions are very powerful, but also meaningful are the number of lives saved from salt reduction and increased physical activity," Capewell said.

In the discussion following the presentations, audience members and presenters alike highlighted the need for policy makers to play a bigger role but also decried the powerful industry lobbies they are up against.

"The story we've seen with tobacco, we are now seeing with cholesterol, with salt, with taking toxic trans fats out of the food chain," Capewell summed up. "In each situation there is a large body of science, there are a large number of people represented in a democratically elected government [who want change]. But unfortunately there is also an industry that makes money out of selling toxic proceeds, and that industry has had a long time to make friends with politicians and make donations to political parties."

It took 50 years after tobacco was first conclusively linked to lung cancer before regulations were enacted in many parts of the world, due to successful tactics by the tobacco industry, Capewell noted. "We are seeing the exact same behavior with alcohol, junk food, and big sugary drinks."

To heartwire , he pointed out that most policy makers are on the same page as to how risk factors should be tackled on a populationwide basis. "The WHO has looked at this, so has the United Nations, and most national governments all agree: You start with tobacco control, you then think about healthy food and in particular reducing salt and saturated fats and eliminating trans fats and on the good side promoting fruit and vegetables. So in Europe we have subsidy scheme [for fruit and vegetables] and that's the next place to start."

A comment from an audience member clearly gave speakers pause for thought, however, when he hazarded the guess that the member countries of the European Union are not actually producing enough fruit and vegetables to satisfy the recommendations being set forth by the experts.

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