We are making very slow progress on implementing optimal CVD prevention policies in Ireland, according to Maureen Mulvihill, head of health promotion with the Irish Heart Foundation.

The past decade has seen many recommendations and initiatives, and a welcome downward trend in CVD mortality, but with the obesity epidemic set to have a serious knock-on effect on CVD and other chronic conditions, more urgent actions are needed, she told Professional Diabetes and Cardiology Review.

“In terms of obesity, I believe the Obesity Taskforce report 10 years ago was a good document that mapped out a lot of areas for action. However, some of the feedback on the implementation of this report has been that there were too many recommendations, and some confusion and uncertainty about which areas to prioritise. We welcome the fact that a new obesity policy is due to be published, but there are always challenges in putting recommendations into practice. 

“There are very good reports from Ireland and internationally which map out clear recommendations. However, there is always the problem that governments tasked with implementing such recommendations are short-term. Most policies and actions are long-term and can be difficult to implement, and governments are often reluctant to tackle the more painful issues.”

Ms Mulvihill believes there is a need for an independent body to be established that would continually drive policy on CVD prevention, obesity etc, acting in a similar way to the National Cancer Control Programme. 

“While, we don’t have an official position on this, the Irish Heart Foundation would stress the benefits of having such an independent group to drive policy.

“When you look at the success of Finland in tackling CVD, this has mainly been driven by having relevant independent State-appointed bodies who help to drive forward consistent and sustainable  policy.”

Ms Mulvihill says a key issue in effectively implementing CVD prevention is funding, or the lack of it. 

“The HSE has had huge cuts in staffing. I would have a concern in terms of implementing any new obesity policy, and the recent Healthy Ireland Government plan, that a lot of people will be expected to take on more in terms of workload.

“An example would be under the recent workplace initiative aimed at promoting better health among staff in public bodies.  This is positive, but it will quickly be seen as a very cynical move unless some resources are given to support these workplaces in introducing health and wellbeing policies. The IHF already provides such support to companies and organisations, but some of the actions planned, like health checks for staff, are quite expensive to roll out.”

Ms Mulvihill points out that while there is frustration at the slow progress of implementing effective prevention measures, there have been a number of positives in recent years. 

“Overall in terms of CVD, developments around tobacco control have been very positive. This government and previous governments have been proactive in terms of the workplace smoking ban, plain packaging etc, and smoking rates have dropped over the past decade, although it is still quite high in lower socio-economic groups.

“We would hope too that the new legislation imposing controls on the sale and marketing of alcohol will have an impact on sales and consumption and could also impact on the obesity issue, as excessive alcohol consumption has a direct impact on weight.”

A very important development, says Ms Mulvihill, will be the promised publication of a physical activity plan. This was recommended in the Healthy Ireland policy document published in 2013.

“The Healthy Ireland document is impressive and positive in terms of aspirations but it can be difficult to identify some of the specific tangibles that are happening or in train to happen. The physical activity plan, however, is one of the more tangible areas of action in the document.”

Combating childhood obesity

In order to combat childhood obesity, Ms Mulvihill stresses that taxation of sugar-sweetened drinks should be a priority. 

“We had estimated conservatively an income level from this tax of around E50m.

“We are suggesting that if there is this level of income coming in, then surely there is an opportunity to reinvest some of this income into promoting healthier lifestyles and combating obesity. Specifically in relation to childhood obesity, we have recently asked the government to consider a ‘Children’s Future Health Fund’. This aims to provide a healthier future for all Irish children, but particularly for disadvantaged children who are disproportionately affected by obesity, food poverty, smoking and alcohol misuse.

“We have one of the highest levels of child obesity in Europe; our children are drinking alcohol from a younger age and are drinking more than ever before; and we have children taking up smoking at lower ages than in other EU countries.”

Ms Mulvihill says the IHF believes a Children’s Future Health Fund, with a resource of for example E30 million, perhaps raised from the sugary drinks tax could help fund schemes to enable children in low income families to afford healthier foods.

“The provision of healthier food in schools should be prioritised, particularly at second level, with all schools implementing a policy of providing healthy food as the norm. Food should not be permitted to be brought into the school if it’s not healthy and there should be no sales of unhealthy foods in vending machines.

“A concern is that there are caterers currently supplying schools with meals and snacks, but there are no standards imposed for these foods. We discovered that many schools are providing through caterers a high proportion of deep fried food, paninis, pizzas, chips, etc. Schools should also, we believe, be free of any marketing of junk foods.

But will a sugary drinks tax help reduce consumption?

“Well, Mexico imposed a 10% tax on sugary drinks and research showed that this led to a reduction by 6% in purchases of these drinks. Of particular interest is that the greatest reduction in sugary drinks was among low income groups.”

The IHF, Ms Mulvihill says, feels that families in lower income groups should be supported to make healthier food and drink choices, as many of them would be suffering from food poverty and are not  able to afford healthier options.

“We must tackle this issue as a public health matter, and not design policies that suit the food industry per se, who are ultimately looking after their profits and their shareholders, not public health. Otherwise we will never move forward.

“To quote Margaret Chan, head of the WHO, we are not just contending with ‘Big Tobacco’ any more in terms of promoting public health but also ‘Big Food’, ‘Big Soda’, and ‘Big Alcohol’. All of these industries fear regulation and protect themselves by trying to dictate the parameters of such regulation.

“These industries will raise concerns on job losses, but research shows that job losses need not be great by regulating food and drink marketing and taxation in line with public health. The jobs may move elsewhere in the economy.

“In any case, food and drink manufacturers have other products they can fall back on if consumption of their less healthy products is reduced.”

Resourcing practical initiatives

The IHF is asking the government to commit to resourcing some practical initiatives that will work, Ms Mulvihill says.

“We have been very involved at EU level for lobbying for ‘traffic light’ food labelling. It should be made easier for consumers to identify healthier choices. There is no at-a-glance nutritional labelling, for example, on sweet fizzy drinks – if you can see at a glance on the label that it is high in sugar that will help people make better choices.

“We really need to see a greater tightening up in the whole area of marketing of foods. While we have the broadcasting code for children restricting advertising up to 6pm, advertising should be restricted up to 9pm, as more children watch TV, such as family programmes, after 6pm.

“We recently published a report outlining how the cost of obesity is set to quadruple (see cover story on page 12) and in that context it behoves government to take immediate action as otherwise there will be long-term, painful consequences for everybody. 

“We welcome the fact that the government is to introduce a physical activity plan. A particular area of concern would be the fall-off in exercise levels in young people, particularly girls, as they hit teenage years.  We believe the school curricula could be refocused to try and encourage physical activity among girls still at school in terms of PE participation and in engaging with them about the type of exercise activity that appeals to them.

“Again, the challenges in physical activity tend to be concentrated in low income areas, where there is a lack of facilities, and we haven’t addressed this adequately in terms of the availability of affordable public facilities – leisure centres, gyms, etc. There are some such excellent facilities around the country, but they need to be strategically located in areas of greatest need.”

And lack of physical activity extends of course to adults, Ms Mulvihill points out. 

“Our recent report, Farmers have hearts, showed that it might be perceived that farmers have an outdoor, and therefore an active life, but we still found that one-third of this group reported not being physically active on five days a week – the recommended minimum level of activity for adults. So again there are challenges there.”

In terms of health professionals trying to get the healthy lifestyle message across to patients, this has to be put across in a language the patient understands and adequate time given to help the patient understand, she stresses.

“If the patient is being told, for example, they have high blood pressure and they need to comply with medication, as well as lose weight, that can be a lot of information to take on board at one visit.

“I would not claim that doctors, practice nurses and other professionals are not communicating the message. It’s often a question of having the time to impart the right messages and ensuring understanding. The question is whether the GP surgery, for example, is the best environment for the support needed. And I would feel that perhaps what we lack is an adequate network of referral centres for health and wellbeing, where people can go and do short courses to help them on the road to a healthier life.”

Ms Mulvihill says an area that is fraught with confusion and misinformation is nutrition. 

“While most people are informed nowadays about the need for physical activity, many would not be sure about what represents the optimal diet.

“I’ve been working in the health promotion area for 25 years and am still waiting for a national nutrition policy. I think as a society we tend to shirk away from addressing the complexities of good nutrition, because that will require policies to change food choices and to make healthier choices accessible for all.

“In reality, following a healthy diet is far from simple, particularly in a society that is increasingly sedentary and where the aggressive marketing of processed and junk foods and ‘fad’ diets is so predominant.

“You have the whole concept of a healthy diet and weight loss, and the fact that this is now a massive industry. You often see advertising promoting ‘good’ or ‘perfect nutrition’ but what it really often is, is just marketing of a dietary supplement. There is a lot of heavy marketing here, and a lot of complexity and confusion among the public as a result.”

Part of the confusion is, Ms Mulvihill believes, even where people are opting for healthy food choices, other factors like portion size, the amount of alcohol consumed or the amount of sugary drinks consumed affect the nutritional and calorie balance. 

“So that even where people are working hard to make healthier food choices you still have all these added temptations, and the concept that a regular ‘treat’ is ok, whereas 50 years ago a treat was a very occasional thing or not even an option. 

“Ultimately it is not just about giving people the right information but about creating that environment where the healthier choice is the easier choice.”