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“NICE” population approach, a model for European cardiovascular prevention?

The European Society of Cardiology (ESC) has welcomed the publication of the National Institute for Health and Clinical Excellence (NICE) public health guidance on prevention of cardiovascular disease (CVD) at the population level in UK.

The ESC believes the guidance – setting out a range of evidence-based recommendations for effective action to help reduce CVD levels and make it easier to enable individuals to make healthy choices – also delivers important messages for the rest of Europe. 

“This is an extremely strong document that clearly underlines how much can be gained from society by introducing legislative changes protecting the content of diets. The document brings together information in a readily accessible format that politicians can use to act upon,” says ESC spokesman Lars Rydén, from the Karolinska Institute (Sweden).

“Within the ESC we accept NICE as one of the main sources of reference for clinical decision making in cardiology,” says ESC spokesman Joep Perk, from Linnaeus University (Sweden). “Currently even if individuals try to eat healthy diets there are issues out of their control, such as the salt content in bread, that have an adverse effect on their cardiovascular health. This document details the legislative changes that could be introduced to protect them.”

The NICE guidance, which focuses mainly on food production and its influence on the nation’s diet, aims to change the cardiovascular risk factors faced by the UK population through regulation, legislation, subsidy and taxation or by rearranging the physical layout of communities. Previously the UK has focused on individual interventions, an approach which identifies and treats people at higher risk. Physical inactivity, smoking and excessive alcohol consumption are also covered to a lesser extent in the NICE document.

Simon Capewell, an ESC spokesperson from the University of Liverpool (UK), who is also Vice Chair of the NICE Guidance Development Group, says, “There was a feeling that dietary interventions have been largely neglected, yet have a big potential to deliver CVD benefits. The guidance shows how by introducing simple changes at the population level huge gains could be made in reducing the death toll from cardiovascular disease. This is no longer an optional discussion, but an issue that governments and the rest of society have to confront.”

The intention of the document, says Capewell, is to get the evidence for change firmly into the public arena “The idea is to kick start a debate, and persuade politicians to set both short term and long term goals for change,” he says.

Key evidence outlined in the NICE document includes:

Reducing mean salt intakes by 3 g per day for adults (to achieve a target of 6 g daily) would in the UK lead to around 14–20,000 fewer annual deaths from CVD each year. Reducing salt added during the manufacturing process is considered especially important since this is estimated to represent 70 to 90% of the population’s total salt intake.

Evidence suggests that reducing saturated fat intakes from 14% to 7 % of energy intake (to reach the levels seen in Japan) might prevent up to 30,000 CVD deaths annually.

If industrially-produced trans fats were banned (as successfully done in Denmark) would 4,500 and 7000 lives might be saved annually.

The guidance also considers the evidence for wider policy actions, such as extending restrictions on TV advertising for foods high in saturated fats, salt and sugar, making healthy food alternatives cheaper than junk food, establishing traffic light food labelling systems and giving local authorities powers to limit fast food outlets. The document places particular emphasis on the importance of taking action to prevent the elevation of CVD risk factors among children. “It’s well known that CVD commences in child-hood, making this aspect of the report of vital importance for future generations,” says Perk.

The NICE document indicates how introducing such changes would rapidly become self financing. Reducing population cardiovascular risk by even 1% would generate discounted savings of approximately £260 million per year. The good news, adds Capewell, is that introducing such changes can deliver rapid results. 
“In Eastern Europe when food subsidies for animal fats were abolished in the 1990s death rates from CVD dropped by one quarter within five years,” he says.

“You have only to look at the recent tobacco battles – where banning smoking in public places rapidly decreased the amount of acute coronary syndromes by 17% – to take inspiration and see how enormously effective political action can be,” says Rydén.

For maximum impact, adds Rydén, CVD needs to be tackled at both the European wide level and on an individual country basis. “Ideally each European country needs to bespoke the NICE evidence to their own situation, but the fact that few other European countries have NICE type organisations may make the process problematic,” he says.

Published on: June 25, 2010

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