Thirty years ago the UK government made wearing a seat belt in the front of a car compulsory. The legislation, twinned with a high profile campaign, is estimated to have saved 50,000 lives in its first two decades.
This same approach to shifting social norms through education and legislation should be rolled out for the prevention of cardiovascular disease (CVD), according to Dr Mike Rayner, director of the British Heart Foundation’s Health Promotion Research Group.
Lifestyle choices to do with smoking, drinking, eating and exercise significantly increase the risk of developing CVD. As such, CVD is a highly preventable disease. Yet Dr Rayner—interviewed for a new EIU report on CVD—believes the biggest misconception today about CVD prevention is still the extent to which people are free to choose their lifestyle: “People are subjected to all forms of persuasion on the part of those trying to make money out of them,” he says.
After campaigning for two decades for traffic-light labelling on food, he was amazed when it was taken up voluntarily by UK supermarkets earlier this year. Even so, it is not the best of possible schemes. In fact, in Dr Rayner's view, the UK’s approach to preferring voluntary initiatives from industry has come to the end of its shelf life.
Now he is calling for, among other things, a tax on fatty foods, tighter regulation of the promotion of these foods, and market intervention in the price of cigarettes and alcohol; although slow progress so far means he is not optimistic about any of these measure being implemented any time soon.
Dr Rayner’s journey up to this point—where legislation is a must—has been a long one long: he originally protested against anti-smoking bans because he believed they encroached on people’s freedoms, before becoming a convert. Still, legislation is no panacea, nor does he advocate new regulation in all instances.
No single action—from education to changing prices on alcohol to marketing restrictions on unhealthy foods—will address the CVD burden, he says. The extent of the problem requires a series of initiatives, coordinated across multiple levels (as set out in the recent EIU report on CVD).
Meanwhile, what is appropriate for rich world countries like the UK is not necessarily the solution for lower income countries where local circumstances and cultures can be much different. (In Afghanistan, for instance, receiving 60 lashes for selling alcohol under current laws is probably a much more effective “prevention initiative” than setting minimum unit prices.)
But whatever approach is taken, Mr Rayner believes the result should be sustainable—for everyone. This means factoring depleted fish stocks into any drive to get people to eat less red meat, or considering the job losses which would inevitably follow on from a blanket ban on fizzy drinks.
Prevention, persuasion and psychology
CVD prevention at population level, such as a "fat tax" or smoking ban, relies heavily on regulation. This is its greatest strength – it can compel healthy behaviour (or seat belt wearing) – but also its greatest potential weakness. It inevitably involves some degree of coercion, which runs the risk of paternalism.
It need not involve regulation, however. The same human flaws that are exploited by the food industry to persuade us to buy certain items at the check-out can also be used to persuade us to act in the interests of our own health. The current UK government is attempting to turn psychological weakness into an advantage outside of the legislative framework.
Its Behavioural Insights Team, commonly referred to as the “nudge unit”, is designed to seek “intelligent ways” to support and enable people to make better choices, using insights from behavioural science and medicine instead of increased rulemaking. Many of these goals overlap with CVD prevention, from smoking cessation to encouraging kids to eat healthier foods and walk to school more often. Early successes have brought them to the attention of the Obama administration in the US.
Besides the difficulties of making positive lifestyle changes, non-adherence to treatment is another significant obstacle to effective CVD prevention. Even after suffering a CVD incident, some patients forget to take their medication; other patients opt not to complete a course of treatment for other reasons, ranging from concerns about costs, the inconvenience involved with travel, to feelings of despondency caused by depression and anxiety. At its most anodyne, individuals frequently stop taking drugs prescribed for prevention after they feel better and think themselves cured.
This is part of a much wider medical problem: in the rich world adherence to treatment for all diseases is around 50%. Recognising the commercial opportunities here, private enterprise is looking to play a greater role. Earlier this year a US company called WellDoc launched a smartphone product aimed at giving type 2 diabetics better management of their treatment, through tailoured advice and motivational coaching. In the UK, meanwhile, a start-up called Impact Health is developing a similar health psychology smartphone product to increase adherence to treatment among sufferers of Crohn’s disease.
CVD patients stand to benefit from such development in medical technology, although they may have to wait a little while yet. Impact Health’s online platform requires patients to have a smartphone. For this reason the start-up is targeting Crohn’s first and not CVD. As David Knull, one of its directors, explains, the profile of the average sufferer is generally around 30 years old—far younger than the average CVD patient, and much more likely to have a smartphone.
Download the EIU report here
The views and opinions expressed in this article are those of the authors and do not necessarily reflect the views of The Economist Intelligence Unit Limited (EIU) or any other member of The Economist Group. The Economist Group (including the EIU) cannot accept any responsibility or liability for reliance by any person on this article or any of the information, opinions or conclusions set out in the article.
