September 1, 2012
Michael O’Shea – ‘obesity timebomb’(click to enlarge)Michael O’Shea admits that the cardiology services and heart health landscape in Ireland was fairly bleak when he took over as CEO of the Irish Heart Foundation in 2000.
Now, as he retires from the post, Michael believes that some important progress has been made but, as ever, there is much more to do. Particularly worrying, he believes, is our growing obesity epidemic, the lack of political will out there to tackle the vested interests that are contributing to this, and the damage the chronic disease ‘timebomb’ could cause to our health service and to society.
Looking back to the period when he started in the top job at the IHF, Michael says great hope was held out at the time for the successful implementation of the then recently-launched cardiovascular strategy.
“Major improvements were certainly needed. For example, cardiovascular rehabilitation was practically non-existent at the time, our cardiovascular disease mortality rates were high – at around 44% of all deaths, our consultant cardiologist manpower was the lowest in Europe per million of population, and outpatient waiting lists were long.”
Michael points out that around €60 million was invested in making some of the improvements recommended in the strategy. He says the Foundation was instrumental in pressing for the implementation of the recommendations.
“Five years after the launch of the strategy, practically all hospitals had a proper rehab facility. We got many additional consultants by around 2003 and that made a difference – however, consultant manpower has not increased since then and that is clearly an issue for the future.
“While we have also seen a decrease in the proportion of deaths due to cardiovascular disease down to 34%, we continue to have a high prevalence of heart disease in the population, due to our high risk-factor profile.”
Michael says the statistics here are of concern: “The Slán survey in 2007 showed that 60% of over-45s had raised blood pressure, and 60% of these were not on medication, while 70% of those on meds do not have their blood pressure controlled to below 140 over 90. This survey also showed us that many people have more than one major risk factor: in the over-45s, 48% had high blood pressure and high cholesterol; 24% had a BMI over 30 and high cholesterol; and 22% had a BMI over 30 and high blood pressure
“The more recent 2010 cardiovascular strategy published two years ago said there should be an emphasis on controlling blood pressure in primary care and this should be considered in the context of a new GP contract. This obviously begs the question as to when this contract, which has been talked about for years, will finally be implemented. There has been talk about using practice nurses more in this area – that they would have a remit to deal with patients coming through the system – this would be very welcome, but why can’t we just get on with it and implement it?
“Then we have the ‘timebomb’ of obesity. I would estimate that our obesity rate is increasing by 1% per annum among all age groups. Latest estimates are that 24% of the population is obese and a further 37% is overweight, according to a recent study by the Irish Universities Nutrition Alliance. So, in all, you have 61% of the population with a weight problem – nearly two in every three of our population is either overweight or obese.”
This, of course, is a huge issue for our health service and our society, Michael believes.
“It has major ramifications for our future management of chronic disease, from heart conditions and stroke, to cancers and osteoarthritis, and across the whole range of diseases. What is worrying is that the Government Obesity Taskforce report of 2005 had 90 recommendations, but very few have been implemented.”
In addition, Michael points out, there has been little sign of the cardiovascular policy document of 2010 being implemented.
“It’s all pretty frustrating. Prevention is probably the biggest tool in our armoury to do something about what is coming down the line in terms of chronic disease. In cardiovascular disease, the implementation of the European Society of Cardiology guidelines on prevention is supposed to be prioritised in primary care, but we have seen little action on this.”
A major preoccupation of Michael’s has been smoking and its direct link to cardiovascular disease. He is remaining on the board of ASH Ireland after his retirement.
“Twenty nine per cent of our population continues to smoke. The smoking ban was successful in protecting workers but it did not have a knock-on effect on smoking rates in general. The Foundation has for some time been calling on the Government to introduce a national tobacco control strategy. We should remember that around 5,200 Irish people are dying each year from tobacco-related illnesses.”
This strategy, Michael says, would have three elements – higher taxation; adequate controls on tobacco smuggling and adequate funding for smoking cessation programmes.
“Government policy on taxing tobacco has been intermittent, and in recent years there have been very small increases in excise duty. What we really need is a sharp shock – a major hike in the duty on tobacco.”
He does not buy the ‘higher taxation means more smuggling’ argument.
“The tobacco industry has been busy in the corridors of power persuading Government that if it puts up excise duty on tobacco, smuggling will simply grow out of all proportion. We have always rejected this – putting up the price is shown to be the single most important aspect of any tobacco control strategy.
“If you put in adequate controls against smuggling and you impose high enough penalties for this you will deal with the smuggling issue. Our penalties for smuggling are very inadequate and need to be increased.”
Michael says there should therefore be a two-pronged approach – clamping down properly on smuggling and imposing big increases in excise duty.
He points out that while the price of a pack of cigarettes in Ireland is very high compared to other countries, the Government’s take from this is, in fact, relatively low internationally.
“Every time the Government fails to increase taxes on tobacco, the industry tends to hike the price anyway, and the industry here is taking a bigger slice of the price than in other counties.”
Michael said a good example of the two-pronged approach working well has been in Australia.
“The Government there increased the price of a pack of cigarettes by 25% in 2011 and in the following months 1.2 million smokers made a serious attempt to quit – of these, 300,000 succeeded. At the same time the Australian government has kept a lid on smuggling – the rate is 5% over there and around 24% here.”
Michael says he would give some credit to the current Health Minister Dr James Reilly for his support for tobacco tax increases and his plans to ban smoking in cars with children.
“However, he badly needs the wider support of the cabinet with these proposals, and I don’t think he is getting that support at the moment. The same would go for plans on a ‘fat tax’ and on taxing sugary drinks. I think the Minister’s heart is in the right place but he needs the support of Government with any initiatives in this area.”
Michael says as a nation, our poor diet is a huge cause for concern.
“The Slán survey from 2007 showed that 37% of our energy as a population comes from fat. These is simply too much fat in our diet – 82% of people over 45 have high cholesterol. Again, you have vested interests involved here in the form of the food industry. It lobbies extensively against having to reformulate food products towards a more healthy diet regime. Calorie counting in restaurants would obviously be a big step forward – anything that will better inform the consumer has to be a good thing.
“But we also need to look at having a ‘traffic light’ system on the labelling of food products. Consumers should be able to see at a glance what is healthy or unhealthy. At the moment it is far too complex for the consumer to interpret the nutritional information on packaging. Fat, sugar and salt content should be colour-coded. The food industry has opposed this.”
Overall, Michael believes the food, drink and tobacco industries have far too much influence on Government when it comes to implementing public health measures. “New lobbying legislation may help in this regard but, as things stand, I believe these industries have too much influence in the corridors of power.”
While the issue of maintaining employment and potential job losses as a result of increased regulation is frequently cited, Michael says that is essentially a short-term view.
“There are serious economic issues at stake here, in terms of what it will ultimately cost the Exchequer and the economy down the line in terms of treating more acute and chronic illness in high-tech hospitals as a result of failing to tackle poor lifestyle and diet. Improving the health of the nation will ultimately benefit the economy.”
But in calling for increased regulation in this area are you not just restricting freedom and creating a ‘nanny state’?
“I would argue that we need more regulation because at the moment it is very difficult for the punter to make the healthier choice, even if he or she wants to. Regulation has given us seat belts in cars for our safety, but very few people would call that the ‘nanny state’ getting too involved in people’s lives,” he said.
“What is wrong with imposing regulations on the food industry to get it to formulate healthier products so that the population can make an informed choice? Voluntary measures have been shown not to work.”
Michael believes that using education and health promotion to improve lifestyle and diet is beneficial, but challenging in the current obesogenic environment.
“At every hand’s turn there is widespread availability of energy-dense foods, often at the eye level of children, in retail outlets so they can pester their parents to buy them. We are up against a very co-ordinated and sophisticated marketing mix to entice children to get their parents to purchase these foods. And then these foods sold in fast-food restaurants or other outlets are relatively cheap. It’s no wonder really that two-thirds of the population is overweight or obese.”
What about the argument that regulating for healthier food options, for example fat taxes or sugary drink taxes, will hit the less well-off the hardest? Michael believes that a co-ordinated Government approach is needed, for example increasing taxes on energy-dense foods could be offset by decreasing the cost of public transport or fruit etc. “The obesity taskforce in 2005 addressed such issues but implementation of the recommendations has been largely ignored.
“Ultimately, I fear that society and Government may only take action when we can no long afford to treat chronic illness resulting from our obesity epidemic.”
Looking back on his time in the Heart Foundation, which spans 22 years, Michael believes one of the organisation’s major achievements has been in the area of stroke. Its stroke audit of 2007 pointed the way toward establishing dedicated stroke units in practically all of the major acute hospitals.
“Following our lobbying campaign in recent years to improve stroke services and the FAST programme aimed at getting the public to recognise stroke signs, 80% more people are now accessing the acute hospital system for stroke care, and 60% more people are arriving in time to receive thrombolysis.”
Other highlights, Michael believes, have been the introduction of the workplace smoking ban in 2004, in which the IHF played a key lobbying role, the introduction of the Heartwatch secondary prevention programme in primary care (which has unfortunately been stymied in its development) and the widespread health promotion initiatives the Foundation has launched, including school and workplace programmes.
Michael believes another priority for the future should be developing comprehensive nationwide data on heart disease, in terms of prevalence, treatments, investigations, outcomes etc.
“Also, you have the lack of an unique patient identifier and poor integration between our acute and primary care systems. We need a ‘smart card’ that will record all your health details – what drugs you are on etc. – so that patients can journey seamlessly from one part of the health system to the next.
“Currently, you have the situation where there are elderly ladies with a list of the many meds they are on scribbled on the back of an envelope. I can go into a golf club in France, produce a membership card from Ireland with all my details on it, and sign up to play there. Why can’t we have the same with healthcare?”