House of Commons - Health - Written Evidence

Select Committee on Health Written Evidence

Memorandum by Cholesterol UK (WP 85)

SUMMARY

1. Cholesterol UK welcomes the Government's White Paper on Public Health. There is a great need for improvements in the health of our nation, and it is right that the Government should take a lead in driving, encouraging, and supporting the changes that organisations as well as individuals need to make.

2. Coronary heart disease (CHD) is the nation's biggest killer. In turn, raised cholesterol is the single greatest risk factor for CHD. Importantly most people can help lower and manage their cholesterol through changes to their diet and lifestyle. Cholesterol has been undervalued as a focus of attention in public health and has not been given clear priority alongside other heart health risk factors in this White Paper.

3. Cholesterol UK calls for a greater focus on adults, who will be new heart patients in the short and medium term. We also call for clearer targets and systems of accountability than are presently set out in order to ensure the public health strategies are given adequate funding and priority at a local level.

4. Cholesterol UK calls for three specific actions to be included in the Government's strategy. Increased awareness of the dangers of unhealthy levels of cholesterol; greater access to heart health check-ups, including cholesterol tests to motivate individuals to improve heart health; and the development of practical guidelines for healthcare professionals to help individuals adopt a healthier diet and lifestyle, drawing on the latest Joint British Societies' Guidelines 2 on Prevention of Coronary Heart Disease in Clinical Practice.

EVIDENCE BASE FOR CHOLESTEROL

5. Every year in the UK 125,000 people die from CHD. It is the nation's biggest killer. Of the risk factors linked to CHD, cholesterol is its single greatest risk factor. Statistics show that raised blood cholesterol is a factor in nearly half of all CHD cases (47%)[150], greater than smoking, blood pressure, or lack of exercise. Studies show that the relationship between CHD and cholesterol is continuous, and that as levels of cholesterol decrease, heart health risk continuously decreases alongside it[151][152]. Despite the declining number of deaths from heart attacks, the number known to be living with CHD is increasing as a proportion of the population every year—it now stands at 12%, up from 7% only 15 years ago[153].

6. Raised cholesterol is also a major risk factor in the 110,000 strokes suffered every year in the UK. Diabetes and obesity also significantly increase the risk of CHD and stroke.

7. Most people can help lower and manage their cholesterol through changes to their diet and lifestyle. Studies have shown that a 10% reduction in cholesterol (achievable by changes in diet and lifestyle) in a 40-year-old male would lead to a 54% reduction in CHD[154]. The Health Development Agency recently published a report stating that "reducing cholesterol levels by even a small amount would prevent approximately 25,000 fewer deaths each year. This is quite possible".[155] Even those individuals with a family history of high cholesterol levels can improve their health outcomes through diet and lifestyle changes.

8. Against the existing guidelines recommendation of a healthy level of cholesterol (less than 5mmol/l) 70% of UK adults over 35 have raised cholesterol[156]. This statistic will become much worse because the Joint British Societies' Guidelines will be updated in 2005 with a new lower recommended level of healthy cholesterol of less than 4mmol/l. Yet only 5% of the population and, even more worryingly, only 4% of GPs recognise cholesterol to be the major risk factor for CHD[157]. Most think that smoking is the greatest risk factor.

9. CHD costs the UK economy over £7 billion every year. Heart disease and cholesterol levels are also highest in the lower socio-economic groups—tackling CHD and cholesterol is part of addressing health inequalities.

GENERAL COMMENT ON GOVERNMENT WHITE PAPER

10. Through the National Service Framework for CHD, the Government has placed great emphasis on lowering cholesterol as part of secondary prevention strategies for those with a high risk of CHD or those who have already had a coronary event. It has also often trumpeted the benefits of this through lives saved. However, a focus on lowering cholesterol in the wider population through diet and lifestyle change as part of primary prevention has been undervalued to date—the focus has been on reducing smoking, salt intake and increasing fruit and vegetable consumption. All of these are very welcome, but Cholesterol UK is disappointed that the White Paper has not been taken as an opportunity to prioritise cholesterol alongside other major risk factors for CHD and stroke.

11. Cholesterol UK believes that the White Paper prioritises action on children at the expense of adults. We believe this is short-sighted. Children are, of course, enormously important. However, the current adult population are the patients of tomorrow, next year and next decade. They are the people that must be reached if the current increases in heart disease are to be stemmed and if the financially crippling Wanless scenario is to be avoided.

12. Cholesterol UK has concerns over the ability of the Government to ensure implementation of the many good actions in the White Paper. The Paper states that the Government will issue a "technical note" to the NHS reinforcing the priorities of this White Paper. This is not enough. If there is no clear accountability structure for implementation of the White Paper then we fear it will not receive the local funding and the priority it needs. The expected Delivery Plan for the White Paper must set clear targets for healthcare organisations and others to ensure action.

13. The White Paper also states that the new contract for primary medical care "offers enormous potential," (pp 126). GPs and their team are vital to successful public health strategies, and a clearer commitment to drive action through this new contract must be given.

SPECIFIC ACTIONS

14. The White Paper makes many unspecific commitments which require further detail. Cholesterol UK wishes to see three specific actions developed from these commitments. These concern awareness campaigns, greater access to testing, and more information for health professionals.

15. These three have been selected because they fit into a complementary whole of knowledge, empowerment and support. An awareness of risk factors and what can be done to reduce them (awareness campaigns), linked to an understanding of personal risk levels (testing) and the motivation for action it provides, together with better information for health professionals to support the individual in making and continuing the right changes to diet and lifestyle for their needs.

Awareness Campaigns

16. Cholesterol UK agrees with the White Paper which states that people need information in order to make informed choices. In Chapter Two it pledges to fund specific campaigns through third party organisations. The Government has already funded large scale campaigns against smoking and on the dangers of too much salt in the diet. Cholesterol UK calls for a consumer awareness campaign to highlight the dangers of a high saturated fat diet, its link to cholesterol and heart health, and ways to lower cholesterol through diet and lifestyle. A Cholesterol UK survey in 2004 showed that only 5% of the population know that cholesterol is the major risk factor for CHD, and also showed a clear lack of understanding of a healthy diet. Recent industry focus group research[158] has shown the need to clarify for the population that a diet high in saturated fat not only makes it likely that you will put on weight but that it also clogs arteries.

17. Such a campaign has already received wide support. An Early Day Motion supported by Cholesterol UK and the Stroke Association calling for such a campaign was one of the more popular EDMs of the 2003-04 session. It was supported by 163 MPs of all parties including several current and previous members of the Health Committee: Doug Naysmith, Paul Burstow, Patsy Calton, John Austin, Keith Bradley, David Amess, Simon Burns and Siobhan McDonagh.

18. The White Paper makes no commitment on the subject of forthcoming campaigns. A commitment for a campaign against the single greatest risk factor for heart disease is needed. Cholesterol UK suggests that such a campaign could be led by a charity or by the Food Standards Agency.

Greater Access to Testing

19. An understanding of personal risk is a strong motivator for action. In the absence of knowledge, too often we like to think that "we're all right". In particular people with high cholesterol may experience no outward symptoms or signs. A study amongst people with family history of high cholesterol shows that understanding of their condition resulted in significant heart healthy choices in diet and lifestyle. Through managing their cholesterol levels with diet and lifestyle changes and increased physical activity, the patients substantially reduced their risk of death from gastro-intestinal cancers[159].

20. It is currently difficult to obtain a heart health check-up on the NHS. One can easily obtain such a service privately, either through a health insurance plan or by purchasing tests at pharmacies. But such payments exacerbate health inequalities. Cholesterol UK calls for easy access to heart health check-ups including testing of cholesterol, blood pressure, blood sugar, and body mass index or waist circumference measurement. These tests should be free (or only a nominal cost). They should not be established as an added responsibility for GPs. Pharmacies could be a venue, but to provide full access and to motivate hard-to-reach groups who would benefit from testing, innovative community outreach schemes run through PCTs and partnerships should also be rolled out.

21. The White Paper discusses screening on page 127 but makes no commitment to an extension of screening. Cholesterol UK is interested to see what the "health stock take" offered by health trainers will become, and also awaits further information on the "personal health guides". However, both of these schemes will only be available in deprived areas to begin with. Cholesterol UK believes there should be a commitment to offer health check-ups for all those who wish to use them. The Government is rightly concerned to avoid the extension of health inequalities in uptake of screening. However, this is not a reason to deny access to all. The experience of Boots the Chemists, whose free cholesterol tests have been vastly oversubscribed, shows the massive unmet demand for information by the public. (It is worth noting that the Boots test is a test for "total cholesterol" rather than a breakdown of "good" and "bad" cholesterol. The detailed breakdown test is preferred as it gives a more comprehensive picture of an individual's heart health).

22. Both the Conservative Party and the Liberal Democrats have pledged to give greater access to testing (including cholesterol) as part of their public health plans.

More Information for Primary Care Health Professionals

23. Cholesterol UK welcomes the many measures to provide greater training for health professionals in public health. In particular we are concerned to see that primary care health professionals (including GPs, practice nurses and pharmacists) are equipped to fully advise patients on diet and lifestyle choices. Many have made the effort to train and equip themselves. But many have not. This change would be incentivised through inclusion in the relevant contracts. In addition, appropriate evidence based information is key.

24. In particular, there is a range of guidelines, but little consensus amongst primary care health professionals on which guidelines to use. Many are secondary care focused, due to the nature of their compilation, rather than appropriate for primary prevention for the majority of individuals presenting in primary care. In addition, many require a level of detailed nutritional understanding uncommon amongst primary care professionals. As the public and non-high risk individuals increasingly seek advice from general practitioners, practice nurses, occupational and community based nurses, pharmacists, as well as dietitians and nutritionists, it is important to have guidelines and information for healthcare professionals which provide consistently simple, practical, and user friendly advice.

25. The new Joint British Societies Guidelines on Prevention of Coronary Heart Disease in Clinical Practice and the current British Hypertension Society's Guidelines for the Management of Hypertension (2004) provide an opportunity for a simple condensed version of the primary prevention sections to be developed and circulated to relevant primary care professionals, providing the latest evidence based information in accessible form. This could be developed independently with Government funding and distributed through NHS organisations.

CONCLUSION

26. Cholesterol UK recommends the following three actions in order to provide the necessary knowledge, empowerment and support to improving public health through:

(a) Awareness campaigns, including a public awareness campaign on saturated fat and heart health—to provide improved understanding of cholesterol and risk factors for ill health and what can be done to reduce them.

(b) Accessible health check-ups, including cholesterol tests, at a national and local level—will provide greater understanding of personal risk and the motivation for positive action.

(c) Improved practical information for healthcare professionals—will support the individual in making and continuing to make the right changes to diet and lifestyle for their needs.

27. These recommendations should not work in isolation but be part of an integrated approach to implementing the many positive steps outlined in the Public Health White Paper.

CHOLESTEROL UK

28. Cholesterol UK is an active advocacy coalition of two leading heart patient support charities: H\E\A\R\T UK and the British Cardiac Patients Association. It was established in 2002 and campaigns for policy change to achieve a greater focus on high cholesterol as a dangerous risk of heart disease and stroke in the wider population, and greater awareness of ways to decrease and manage cholesterol levels through diet and lifestyle changes.

February 2005