Population-Based Prevention and Success

• The population-based strategy is critically important to reduce the overall incidence of CVD since it aims reduce the factors at the population level through lifestyle and environmental changes that affect the whole population without requiring medical examination of individuals.

• Population based observational studies in Finland, Norway, Mauritius, Poland and the US reported substantial reduction in cholesterol levels and coronary artery disease (CAD) mortality, following the introduction of fiscal policies which reduced animal fat and increased vegetable fat consumption.^{1, 2}

• Finland: In response to extremely high CAD mortality rates, the North Karelia Project was introduced in Finland in 1972. Significant improvements in the population’s health were observed within 5 years, and were still evident today, nearly 40 years later. Dietary changes in consumption of saturated fat from animal sources e.g. use of butter on bread fell from over 80% in 1972 to around 18% in 1992; mean population serum cholesterol fell by 16% (40 mg/dl) over the same time period. By 2005, CAD mortality in men and women had declined by 80%.

• Poland: Mortality due to CAD fell 40% in Poland from  1990 to 2002 (decrease of 3% per year), reversing the previous steady rises (increase of 6% per year).³ Changes in dietary patterns resulting in a decrease in the consumption of saturated fatty acids (19%) and an increase in the intake of polyunsaturated fatty acids (32%) along with increased consumption of fresh fruits and vegetables were credited with this spectacular decline in CAD in Poland. Subsidies for dairy and meat products were cut in the late 1980s leading to price rises in meat, milk, and butter, compounded by increased availability of cheaper rapeseed and soya bean based margarines. The resulting replacement of dietary saturated fats with polyunsaturated fats was the only marked change in CAD risk factors which convincingly explained the fall.^{1, 3-5}

• Mauritius: In Mauritius, total cholesterol levels in the population fell by 32 mg/dl between 1987 and 1992. This followed an intervention by the government in 1987, to change the composition of the commonly used cooking oil from mostly palm oil (high in saturated fatty acids) to soya bean oil exclusively. Estimated intakes of saturated fats decreased by 4% of energy intake while intakes of polyunsaturated fats increased by 6%, and were mirrored in changes in serum phospholipids. The measured changes in population total blood cholesterol levels reflected predictions using the Keys equations on the changes in dietary fat intakes.⁶

• Norway: Norway was one of the first countries to successfully merge agriculture and health interests into effective nutrition policy which reduced chronic diseases especially heart diseases. Between 1975 and 1993 dietary saturated fat consumption reduced by 18% of energy intake, leading to a reduction in blood cholesterol of 10% in the general population and decreasing CAD mortality by 50% among middle-aged men. This followed the introduction of a Norwegian nutrition and food policy which focused on influencing production and consumption of food products. These interventions included: Subsidizing production and prices of healthier foods e.g. more whole grains, vegetables, low-fat milk; raising prices of sugar and butter; regulations to promote provision of healthy foods by retailers, institutions and street vendors; provision of consumer food price subsidies to encourage healthier food intake; education and information for professionals and the public.

• Despite a doubling of diabetes and obesity over the past thirty years, the US has achieved a 70% reduction in age standardized death rate from heart disease primarily through reduction in three risk factors─ high cholesterol, high blood pressure, and smoking.⁷  (see Heart Disease in the US) 

• Agriculture policy reform: Excess consumption of saturated fat resulting from agricultural overproduction is estimated to have contributed to 9,000 deaths from CAD each year in the European Union (EU). Despite a number of reforms, the majority of the EU budget still supports the production of beef and dairy products. Much less is spent on healthier produce such as fruit, vegetables and whole grains. 

• Banning trans fats: Several countries including Denmark and Switzerland and many cities in the US have taken steps to ban and/or label trans fats in food. Some UK food manufacturers have removed trans fats from their own products. However, the majority of supermarkets that sell imported products are currently not covered by any active UK trans fat reduction policies.

• Policy changes that encourage and support farmers to switch production from animal fat to healthy foods would have a profound effect on the cholesterol levels and heart disease rates not only in Europe but in all other countries including India.

• There is an urgent need to set targets for saturated fat reductions by food industry, as they have successfully done with salt in many countries. Massive education campaign is needed to reduce the saturated fat intake to <7% of the daily energy intake in India as is done in the US for several years.⁸

Sources

1. Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991 [see comments]. Bmj. 1998;316(7137):1047-1051.

2. Uusitalo U, Feskens EJ, Tuomilehto J, et al. Fall in total cholesterol concentration over five years in association with changes in fatty acid composition of cooking oil in Mauritius: cross sectional survey. Bmj. Oct 26 1996;313(7064):1044-1046.

3. Zatonski WA, Willett W. Changes in dietary fat and declining coronary heart disease in Poland: population based study. Bmj. Jul 23 2005;331(7510):187-188.

4.Szostak W B, Sekula W, Figurska K. Reduction of cardiovascular mortality in Poland and changes in dietary patterns. Kardiol Pol. Mar 2003;58(3):173-181; discussion 180-171.

5. Fall in coronary deaths in Poland may be linked to lower meat and butter intake. BMJ. Apr 4 1998;316(7137):b.

6. Keys A. Diet and the epidemiology of coronary heart disease. J Am Med Assoc. Aug 24 1957;164(17):1912-1919.

7. Ford ES, Ajani UA, Croft JB, et al. Explaining the decrease in U.S. deaths from coronary disease, 1980-2000. N Engl J Med. Jun 7 2007;356(23):2388-2398.

8. Lloyd-Jones D. M., Hong Y, Labarthe D, et al. Defining and setting national goals for cardiovascular health promotion and disease reduction: the American Heart Association’s strategic Impact Goal through 2020 and beyond. Circulation. Feb 2 2010;121(4):586-613.