Diet-the Cinderella risk factor
Working in cardiology, it is sometimes hard to keep up with the stream of high-tech gadgets, new drugs and treatment technologies which are constantly changing diagnosis and treatment of cardiovascular disease (CVD). For example, cardiovascular drugs (such as those against cholesterol and lipid disorders, and antithrombotic agents) account for the majority of blockbuster pharmaceuticals.
There is no question that CVD is common, causing more than 150 000 deaths annually in the UK alone, with annual costs in excess of £30 billion. That is why there have been massive, coordinated efforts to focus on every aspect of heart disease treatment and prevention.
However, we tend to focus on the expensive, labour-intensive, training-intensive strategies. For example, primary angioplasty is an invasive procedure to open up blockages in the blood supply to the heart immediately after a heart attack. It requires training of all staff, 24/7 cover and the necessary equipment and post-procedural care. A conservative analysis estimated the cost of a primary angioplasty in usual working hours to be £5176 with an extra £245 if undertaken out of hours. The authors of this study estimated that angioplasty added £4520 for each quality-adjusted life year (QALY) gained. Expensive stuff when you are providing this service to the whole population.
Are there cheaper, lower-hanging fruit? Of course there are, but no drug companies or vested interests are pushing them. Of the neglected risk factors with most public health impact, diet is the Cinderella at the Cardiovascular Ball. In this week’s BMJ, an economic model of CVD in the UK shows yet more evidence for Geoffrey Rose’s population strategy to disease. The authors give us three poignant take-home messages from the study. First, a 5% reduction in mean cholesterol or blood pressure in the population would save the UK at least £80-100 million. Second, legislation to reduce salt intake by 3 g/day (and we are currently having 8.5g/day on average) would prevent 30 000 cardiovascular events and save £40m a year. Third and perhaps most interestingly, legislation to reduce intake of industrial trans fatty acid by approximately 0.5% of total energy content may add 570 000 life years, saving £230million a year. NICE has been pushing for a dietary ban of trans-fats for some time.
Nobody is saying we don’t need the latest and best evidence-based tools and therapies for CVD prevention, but these numbers are hard to argue with. As I finish a night shift, I am going to forego my greasy fry-up for a bowl of muesli after reading this.
Trimming the fat- complicated devices will not solve a simple problem
After Christmas and in the run-up to Lent, people are often thinking about New Year’s resolutions and what to give up. One of the most common excesses that people want to address is food. This is the most common time of year to start new diets, exercise regimes and gym memberships, and yet obesity, particularly in childhood, is on the rise. The direct cost of overweight and obesity to the NHS has been estimated at over £3 billion. Inequalities in obesity have been identified between North and South, between men and women, and between social classes, and these inequalities seem to be worse for childhood obesity.
With the big public health problems of our age, whether smoking and high blood pressure, or diabetes and obesity, there are health inequalities, but there are also cheap, simple, population-wide interventions which can save thousands, if not millions, of lives. In the case of childhood obesity, it is not rocket science- healthier diet, less processed food, more exercise, and there are signs that the childhood obesity epidemic is levelling off. However, there is a constant push by device companies and drug companies to offer more complicated solutions which will produce big profits for them in these disease areas, because they affect so many people in the population.
This week’s BMJ includes a randomised controlled trial of a novel computerised device, the Mandometer, which provides feedback to participants during meals to slow down speed of eating and reduce total food intake. The trial ran for 12 months comparing the Mandometer with standard lifestyle modification advice and included 106 obese people aged 9 to 17 years. The Mandometer group had a BMI 0.24 units lower than the group receiving standard care. Not only does this seem a paltry difference in BMI; two of the study authors own 60% of the company which produces Mandometer, and so it is unsurprising that they found a positive effect for their device. It is hard to envisage a world where this device is going to be widely used or where it is going to make any difference to childhood obesity. If widely used, such devices will at best only increase the socioeconomic inequalities which already exist in childhood obesity. Surely the simple, population-wide policies of encouraging more exercise and better diet should be promoted instead?