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 yearit 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 groupstackling 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 datethe 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 healthto
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 levelwill provide
greater understanding of personal risk and the motivation for
positive action.
(c) Improved practical information for healthcare
professionalswill 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
150 Coronary Heart Disease Statistics. British Heart
Foundation Statistics Database 2003. Back
151
Stamler J (1986) Findings of the Multiple Risk Factor Intervention
Trial. JAMA 254, 2823-8. Back
152
Kannel WB (1990) Contribution of the Framingham Heart Study to
preventative cardiology. J Am Coll Cardiol 15, 206-11. Back
153
British Heart Foundation, Press Release, 4 June 2004. Back
154
Law MR et al By how much and how quickly does reduction in serum
cholesterol concentration lower the risk of ischaemic heart disease?
BMJ 308, 363-6. Back
155
Health Development Agency, "Relative Contributions of changes
in risk factors and treatment to the reduction in coronary heart
disease mortality", January 2005. Back
156
Coronary Heart Disease Statistics. British Heart Foundation Statistics
Database 2003. Back
157
Cholesterol UK surveys conducted by Communicate Research and
ICM published in 2004-available on request. Back
158
Flora pro.activ penetration research, Frank Research Ltd, April
2004. Back
159
Simon Broome Register Group BMJ 1991;303:893-6. Back
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