Patients must take more responsibility for their health

A conference to mark the inauguration of the National Institute for Preventive Cardiology (NIPC) was held recently in Galway.

The NIPC is has been established by the heart and stroke charity Croi and is affiliated to NUI Galway. Its aim is to substantially develop and continue Croi’s work in preventive cardiology through developing research, education and training and service initiatives.

Prof Barry Franklin, the keynote speaker at the conference, stressed that there is now unequivocal data that if people can prevent risk factors in the first place, the likelihood of a person ever developing CVD is very low.

He cited a study by Don Lloyd Jones of Northwestern University in the US, which looked at the Framingham database.

Focusing on people at age 50, he looked at how many of those people had no major risk factors for CVD and followed that cohort over the following 30 years. 

His basic conclusion was that if a person can get to the age of 50 without any risk factors such as hypertension or high cholesterol, the likelihood of that person ever developing CVD is around 5-8%. In addition, these people can expect an additional lifespan of 30 to 40 years.

Preventing risk factors occurring

Prof Franklin, director of preventive cardiology and cardiac rehabilitation at the William Beaumont Hospital in Detroit, focused on key points relating to cardiac rehabilitation and primary and secondary prevention.

He stressed the need not only to effectively treat risk factors but to prevent them from occurring in the first place.

This, he claimed, was a far more effective and a less expensive strategy than health systems concentrating on costly cardiac interventions and treatments.

Prof Franklin said health professionals need to become champions of achieving healthy lifestyle overhauls in their patients. 

“We need to arm people with behavioural change strategies that can be implemented in their everyday environments.”

He emphasised the importance of a healthy diet (for example a Mediterranean-type diet), regular physical activity and not smoking.

Excessive emphasis on medical clearance

An important point, he stressed, was that there is excessive emphasis on people getting medical clearance for exercise programmes. He said just because someone is starting an exercise programme does not necessarily mean that they have to visit the doctor beforehand.

If someone had no symptoms there was nothing to prevent them starting with a moderate amount of exercise and gradually increasing it. He said the least fit people tended to get the most benefit from an exercise programme, and it was important to ‘get people moving’ as it was unlikely to have deleterious effects.

The US Preventive Services Taskforce found that screening for exercise testing had no value in low-risk asymptomatic adults.

Prof Franklin stressed that there was a big difference between training for peak performance and running marathons and exercising to improve your health and longevity. He said people with mild coronary disease who do excessive exercise do not necessarily get more benefit than those who are inactive. And one can overdose on exercise in the same way as one can on medication.

Cut down on meat, white bread and salt

Quitting smoking after a major heart attack, he said, can reduce the likelihood of future events by around 40%.

On diet, Prof Franklin said a reduction in meat consumption, both processed and unprocessed, was important. He also stressed the importance of avoiding white bread and excessive salt.

He quoted the US cardiologist William C Roberts, who said: “we fatten our cows and pigs, kill them, eat them and then they kill us.”

With healthcare costs becoming unsustainable, and doctors’ time at a premium, Prof Franklin said he believed there was going to be an increasing emphasis on the patient taking responsibility in preventing and managing heart disease, moving to a more proactive healthcare model.

The emphasis would be on checking our blood pressure and getting yearly health checks and other self-management initiatives, to help prevent the development of chronic disease and disability. 

Prof Franklin also said there would be an increasing emphasis on allied health professionals working with physicians to implement and operate prevention programmes.

Fatness – the pandemic

Greg Whyte, professor in applied sport and exercise science at Liverpool John Moores University, told the conference we are living in an obesogenic environment, with fatness becoming a worldwide pandemic.

He said both UK and Irish data showed that one-in-five children enters primary education overweight or obese, and the tendency is for children to gradually increase their weight while in primary education. In Ireland, 20% of 7-11-year-olds and 19% of teenagers are overweight or obese.

By the age of 11 in England, 35% of children are overweight or obese – in Northern Ireland the figure is even higher, with 40% of children leaving primary school either obese or overweight.

This, said Prof Whyte, is of itself a problem, but in addition, 80% of those children will become obese adults. 

He said obesity itself is not the main problem, it is what lies underneath – the impact of obesity on metabolic disease, including a huge rise in type two diabetes in children and increased incidence of cardiovascular disease and cancer.

Increasing mental health issues

Prof Whyte also highlighted the concomitant increase in mental health issues, such as low self-esteem and depression, associated with obesity and overweight, now being seen at an increasingly younger age. He also highlighted the link between deprivation and obesity. Prof Whyte said he believed obesity was largely driven by the food industry. However, the issue was not just related to what we eat but the calories we are burning.

Physical inactivity is one of the major public health issues of the 20^th century. One-quarter of English people are doing less than 30 minutes of exercise per week, and the more deprived the population the more inactive it tends to be. 

Sixty-three per cent of English people do not reach the WHO guidelines for physical activity for health. And the consequences of this inactivity put the greatest cost onto health services. The annual cost of inactivity to the UK is £8.2 billion, and inactivity carries the same risk for CVD as smoking, Prof Whyte said.

Stressing the need for a drive to promote physical activity in the population, he said there was a need for exercise prescription. 

“Any activity, no matter how small, is better than sitting still.”

Changing people’s behaviour

A major problem, however, is changing people’s behaviour and this is the critical barrier to improving population health. This can be achieved in changes in policy and legislation, changes to the built environment and changes driven by local communities.

The bottom line is for health services to focus on prevention of obesity through changes in eating habits and exercise. 

This is an economic, as well as a healthcare imperative, as health systems, faced with an increasingly fat and ageing population, will simply not be able to afford to treat the consequences of obesity, Prof Whyte said.