Great strides have been made in reducing death rates from cardiovascular disease, says Susanne Løgstrup, Director of the European Heart Network (EHN), but more needs to be done.
IN 2017, the European Heart Network, (EHN) celebrated its 25th anniversary. Since its inception, death rates from cardiovascular disease have more than halved in Europe, a decline which has been sharp and consistent in most Northern and Western European countries in both women and men. In Central and Eastern European countries, the decline has been less consistent with the data showing sharp peaks and troughs, however. Yet, since around 2000/2005, death rates from heart disease and stroke have also been falling in the Central and Eastern European regions.
Nevertheless, the rate of decline varies tremendously among countries. For example, within the EU, the mortality rate in men as a result of heart disease has declined by 13% in the Czech Republic compared to 57% in The Netherlands since 2003 (until the latest available year). Furthermore, the mortality burden of CVD in women ranges from 25% in Denmark to 70% in Bulgaria.
Explaining the fall in cardiovascular disease death rates
Research in many countries using the so-called ‘IMPACT’ model explains the fall in mortality from (coronary) heart disease to a very large degree. The conclusions are that approximately 50% of the fall in death rates is explained by population-wide improvements in risk (e.g. less hypertension and lower smoking rates) and 50% is explained by treatment and secondary prevention (e.g. AMI treatments and statins). The research also shows systematically that the decline in mortality from heart disease could have been higher had it not been for adverse trends in obesity and diabetes.
According to the World Health Organization Regional Office for Europe (WHO Euro), 80% of premature deaths from cardiovascular disease can be avoided by controlling three main behavioural risk factors:
Indeed, the greatest societal gain will be obtained by achieving a small reduction in risk factors across the population (prevention paradox), i.e. shifting the ‘risk curve’ to the left.4
Taking all of this into consideration, over the past 25 years EHN has had a strong focus on effecting policy change at an EU level. If we can achieve the adoption of effective policies at this level, we will be able to reduce the risk factors of a population of over 500 million people. This will then lead to a reduction in the total number of people at risk of CVD, and thus also help to address the stark inequalities between European populations.
Working on the policies that can make a difference
The Maastricht Treaty, which entered into force in November 1993, introduced for the first time explicit provisions on public health. Following the Maastricht Treaty, a number of high-level political statements on cardiovascular disease have been adopted; notably in 2004, the Council Conclusions on promoting heart health, and in 2007 the European Parliament Resolution on action to tackle cardiovascular disease. EHN was actively involved in the development of these documents and continues to promote an EU approach to tackling cardiovascular disease.
Specifically with respect to policies on tobacco and unhealthy diets, EHN has engaged actively with the EU institutions and colleagues from other organisations working in public health and tobacco control. In the past 25 years, a number of directives and regulations have been forthcoming.
On tobacco, EHN takes its cue from the international Framework Convention on Tobacco Control (FCTC), which was adopted by the World Health Assembly in May 2003. The FCTC is an evidence-base treaty that reaffirms the right of all people to the highest standard of health.
The EU adopted its first tobacco products directive in 2001. Following the adoption of the FCTC and recognising that it was no longer in tune with developments around the world, the EU adopted a new directive in 2014. This directive became applicable throughout the EU in May 2016. Whilst we welcomed the new directive, we were disappointed that it did not go as far as to mandate plain packaging across the EU; this was left up to the member states. Today, six EU member states have adopted laws at the national level introducing plain packaging; not all laws have yet entered into force.
Together with its alliance partners, EHN has also worked for the adoption of the EU directive banning the cross-border advertising of tobacco products, which stalled for years in the Council but was finally adopted in 2003. And we will be tuned into the revision of the 2011 EU directive on excise duties on tobacco, which is foreseen for next year.
It is important that prices for tobacco products are high across the EU with little price differences between the member states and no price differences between tobacco products that are essentially the same, e.g. manufactured cigarettes and so-called roll-your-own tobacco.
Unhealthy foods and diet
A cardiovascular health-promoting diet means a shift towards a more plant-based diet. It includes vegetables, fruit and berries in abundance. Whole grain products, nuts and seeds, fish, pulses, and low-fat dairy products are also important, as are tropical vegetable oils in modest amounts.
The adoption of the first EU School Fruit Scheme in 2009 was a very welcome policy and one that EHN had actively pursued. It looks to be strengthened in the EU’s new Common Agricultural Policy (CAP).
EHN had also called for the regulation of health and nutrition claims in the EU and welcomed the adoption of the relevant regulation in 2006 and, particularly, the article that stipulated that claims could only be made on food products that met a certain nutrient profile. This means that only foods in the healthier category can make claims. We very much regret, though, that these profiles have not yet been set, as this allows all foods, even those high in salt, for example, to make claims.
As people in Europe consume a great deal of processed foods, EHN has similarly advocated for mandatory nutrition declaration. This was adopted as part of the 2011 regulation on food information to consumers (FIC) and became applicable across the EU at the end of 2016. However, this declaration, mostly placed on the back of a pack, is not always easy to understand, and thus EHN was disappointed that the FIC did not mandate a front-of-pack labelling that would indicate, in particular, levels of saturated fat, salt and sugar in these highly processed food products by allocating traffic-light colours to indicate high, medium and low content. Currently, there is a great deal of development in terms of front-of-pack labelling, as many countries have recognised that this measure has the potential to help people choose healthier options.
We believe that a tremendous step forward for heart health in the European Union is imminent. This may emerge in the form of the adoption of an EU regulation setting a maximum limit of industrially produced trans fatty acids (2g per 100g of fat). The draft regulation was adopted by the European Commission in early October 2018. Again, this is a piece of regulation for which EHN has continuously advocated for, over a long period of time.
In conclusion, EHN has been at the forefront of advocating for policies in the EU that can support behavioural change on a population level, and there have been many gains – of course, we would often have liked to see more ambitious policies, but with 28 member states and industrial interests that mostly do not align with cardiovascular health interests, compromises are to be expected.
The challenges for the future
The fact that great strides have been made in reducing deaths from cardiovascular disease should not be mistaken for a sign that ‘the job is done’. In Europe, close to 4 million people die from CVD every year, accounting for 45% of all deaths – of these, more than 1.8 million deaths occur in the EU, accounting for 37% of all deaths.
Furthermore, of a European population of about 740 million people, more than 85 million live with CVD. Of these, almost 49 million people live in the EU (the EU population is close to 510 million). Essentially, most people are affected by cardiovascular disease – be it as a patient or as a carer.
CVD also imposes a significant economic burden on society; it is estimated to cost the EU economy €210bn a year, where €111bn (53%) is due to direct health care costs; €54bn (26%) is due to productivity losses, and €45bn (21%) to the informal care of people with CVD.
As stated by WHO Europe, 80% of premature deaths from CVD can be avoided by controlling three main behavioural risk factors: tobacco, unhealthy diet and physical inactivity. In the EU, average life expectancy is 81 years, yet 436,000 people die from CVD before the age of 75, thus prematurely. One may, therefore, conclude that almost 350,000 lives could be saved annually if more effort were put into prevention.
It is worth noting that while in the EU average life expectancy is 81 years, average healthy life expectancy is only about 62 years. Therefore, close to 20 years are lived in ill health – many of which as the consequence of a heart attack or a stroke or heart failure. We must therefore strive to put more health into Europeans’ long life expectancy.
Looking forward to the next 25 years of action, EHN will continue to have a strong focus on shaping EU policy in favour of cardiovascular health. It is clear that a solid intervention push in an area that covers around 500 million people has a high prevention potential. Our strategy, however, is not limited to population-level prevention, we also work with our members on strengthening the positioning of people living with cardiovascular diseases and reinforcing cardiovascular research.
We hope to contribute an article to SciTech Europa Quarterly on the strategic CVD research agenda in the near future.
2 Simon Capewell et al NEJM 2007 356 2388 updated www.nejm.org/doi/full/10.1056/NEJMsa053935#t=abstract
4 Rose G.; Br Med J (Clin Res Ed). 1981 Jun 6;282(6279):1847-51
European Heart Network (EHN)