Heart to heart
Heart disease is expensive in both human and economic terms, yet much can be done to help prevent it. The workplace offers tremendous opportunities for education and prevention, where the OH nurse can play a pivotal role.
Deaths from coronary heart disease in the UK are declining, but prevalence rates remain among the highest in the world. It is still the most common cause of premature death and in total causes around 125,000 deaths a year.1 Although rates are falling among all social groups, rates among male manual workers, such as builders and cleaners, are considerably higher than for male non-manual workers, including doctors and lawyers. The gap is widening further because the death rate is falling more slowly in the manual group.
Coronary heart disease costs the UK healthcare system about £1.6bn annually (1996). However, the far greater financial burden of CHD falls on the workplace because of loss through death, days lost through employee illness and from the informal care of people with the disease. In 1996, such "production losses" were estimated to have cost the UK economy £8.5bn.
Yet the workplace offers tremendous opportunities for health promotion and CHD prevention. Because people spend a significant proportion of their day at work, networking with colleagues and dining in workplace restaurants, the main risk factors for CHD; raised blood cholesterol, low physical activity, hypertension, smoking, poor diet and obesity, can all be addressed there, through heart health initiatives.
Assessing risk
A reduction in the different risk factors for coronary heart disease would have a considerable impact on its overall prevalence and the costs associated with the disease. The National Heart Forum2 has estimated the impact of changing the main modifiable CHD risk factors. As summarised in Table 1 , realistic improvements in these risk factors could result in an overall 30 per cent reduction in CHD.
The most common single risk factor in CHD is raised blood cholesterol, which is present in 46 per cent of cases. Physical inactivity is present in 37 per cent of CHD patients and obesity in 6 per cent. And the overall prevalence of those classed as overweight or obese in the population is increasing dramatically.
Assessing CHD risk and developing accessible support programmes that encourage lifestyle changes, are considerable challenges, but the rewards could be excellent. Almost without exception, evidence has shown that lowering blood cholesterol reduces the risk of CHD.3 Indeed, a 10 per cent reduction in blood cholesterol at the age of 40 years has been shown to reduce the risk of CHD by approximately 50 per cent.4
Dietary changes
It is difficult to estimate the exact proportion of CHD that is due to an unhealthy diet.
However, the underlying cause of elevated serum cholesterol is, for the vast majority of individuals, an excess of dietary fatty acids,5 especially saturated fat. Achieving a healthy diet, which is low in fat and rich in fruit and vegetables remains elusive to many in the UK.
The Balance of Good Health (see Figure 1, opposite) shows the proportions of foods we should eat from the five different food groups to reduce risk from CHD. Motivational help is also an important element in any attempt at dietary change,6 and there are many educational resources that expand on heart health dietary messages, and are suitable for use with clients in the occupational health setting (Table 2 ).
Keeping fatty and sugary foods to a minimum is a clear message about eating for good health, but within this food group, some foods are distinctly better than others. This is especially true for fats and oils. The now well-established message that saturated fatty acids are the 'baddies', while polyunsaturated and monounsaturated fatty acids are the 'goodies' remains true. The message about keeping overall (total) fat intake low - to less than 35 per cent of total energy - also holds good.
Recent evidence, however, has shown the clear beneficial effect of plant sterols and stanols - naturally occurring substances found in vegetable oils.7, 8 The consumption of normal daily quantities of plant sterol or stanol-enriched spreads, milks and yoghurts (eg, Flora Pro.activ9 ) as part of a healthy diet has been shown to reduce low density lipoprotein cholesterol by an average of 10 per cent to 15 per cent within three weeks, without affecting serum tricglycerides or high density lipoprotein cholesterol. The use of such cholesterol-lowering foods is even recommended in the USA's National Cholesterol Education Program.
Table 3 is a guide to the ever-increasing range of fat spreads on the supermarket shelf. Clients are best advised to check labels for nutrition information, and to keep abreast of new products.
Heart health initiatives
Statistics show that men access the primary healthcare system far less frequently than women, particularly during their working years. The occupational health service therefore has unique access to men who work and is well placed to assess and alert them to any possible risk of CHD.
Although the nurse/client relationship in a one-to-one consultation may be the most personalised starting point for CHD prevention, the whole working environment can be geared up to make healthy lifestyles more achievable. For example, the catering contract might specify that three different undressed salads and at least two cooked vegetables must always be provided in the dining room, along with a choice of skimmed milk, fresh fruit and free drinking water. Portion packs of cholesterol-lowering spreads are also very helpful. Health promotion messages could feature in well-used places such as the stairways, lifts, toilets and staff rooms. Gyms, shower rooms and lockers for joggers can be provided, along with well-positioned bicycle racks for those choosing to cycle to work. This encourages physical activity and helps resolve a common problem of limited car-parking space.
Summary
The workplace is a prime site for heart health initiatives. The main risk factors for CHD are raised blood cholesterol, low physical activity, hypertension, smoking, poor diet and obesity. It is likely that a significant proportion of the workforce will have one, if not more of these risk factors. Through health assessment, those at risk of coronary heart disease can be identified and referred on to their GP where necessary. The benefits for companies and organisations, of supporting employees at risk of ill-health are clear - a fitter, happier and healthier workforce.
Paula Hunt is an independent consultant nutritionist and state registered
dietician
Table 1. Effect of reducing risk factors for CHD
Risk factor |
Most likely change |
Reduction in CHD(per cent) |
Blood cholesterol |
All with levels <6.5 mmol/l |
11 |
Physical inactivity |
All light and sedentary become moderate |
10 |
Blood pressure |
50 per cent with levels <140/90 |
6 |
Smoking |
Prevalence of 24 per cent |
0.5 |
Obesity |
6 per cent men, 8 per cent women with BMI >30 |
3 |
Total |
|
30 |
- So you want to lose weight… for good. British Heart Foundation (2001)
- Eating to manage your cholesterol (other CHD risk factor leaflets also
available). The Flora Project. Careline Tel. 0800 389 8193
GO AHEAD
ADVISED
CHOOSE CAREFULLY
AVOID
Tackling heart health - a case study
The WaistWatchers programme is a good example of best practice in action.
Run by Chesterfield Primary Care Trust, the eight-week educational programme
focuses on men working in the manual 'blue collar' sector, which is a high-risk
group that is traditionally difficult to target with any effectiveness.
References
1. British Heart Foundation (2000) British Heart Foundation Statistics Database.
2. National Heart Forum (in press) Coronary heart disease. Estimating the impact of changes in risk factors. Stationery Office: London.
3. Department of Health (2000) National service framework for coronary heart disease. DOH:London.
4. Law MR, Wald NJ, Thompson SG (1994) By how much and how quickly does reduction in serum cholesterol concentration lower risk of ischaemic heart disease? BMJ; 308: 367-373.
5. Phillips C, Belsey J, Shindler J (2000) Flora pro.activ: a clinical and financial impact analysis. Journal of Medical Economics; 3: 61-76.
6. Hunt P, Pearson D (2001) Motivating change. Nursing Standard, Sept 26:16,2,45-52.
7. Hendriks et al (1999) Spreads enriched with three different levels of vegetable oil sterols and the degree of cholesterol lowering in normocholesterolaemic and mildly hypercholesterolaemic subjects. European Journal of Clinical Nutrition 53: 319-327.
8. Weststrate JA et al (1998) Plant sterol-enriched margarines and reduction of plasma total and LDL cholesterol concentrations in normocholesterolaemic and mildly hypercholesterolaemic subjects. European Journal of Clinical Nutrition, 52: 334-343.
9. Law M (2000) Plant sterol and stanol margarines and health. BMJ, 320:861-864.
10. Bond M, Irving L (2000) The WaistWatchers evaluation report. North Derbyshire NHS Health Authority. Unpublished report available from project co-ordinator, Paul Boshell at Chesterfield PCT. Tel. 01246 231255 ext. 4286.