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.
Avoidable Waste in research
It’s always a pleasure to listen to Sir Ian Chalmers but the topic of choice at SAPCprimary care conference is to irresistible to not blog about.
Most of you reading this blog will be involved in doing or reporting research: it seems you may be wasting a lot of resources. If you aren't involved in research then you may want to know, why does so much effort go to waste?
If you are an epidemiologist then the four questions you would want to ask are published some time ago by Austin Bradford Hill
1. Why did you start?
2. What did you do?
3. What answer did you get?
4. What does it mean?
If you can’t answer these questions about the research you are doing then it seems you should go back to the drawing board.
Part of the solution is to create better questions, relevant to patients, and developed by patients. You may be surprised that a resource to make uncertainties explicit and to help prioritise new research is actually available. It is called DUETs. It has been established to ‘ publish uncertainties about the effects of treatment which cannot currently be answered by referring to reliable up-to-date systematic reviews of existing research evidence’.
I am continually frustrated with the amount of guff published in the media about the latest ‘dramatic health cure’, Yet an imitative like DUETS never gets a jot of news space. However, this initiative is unlikely to away, and at some time in the future it is likely it will pervade all aspects of research.
The key take home messages are: there is substantial avoidable waste, research should address known uncertainties and engagement of patients and the public is essential.