NICE Guidelines for testing and treatment of cholesterol in the UK were launched in July 2014. They have generated a lot of press interest as the threshold for who should be offered treatment has been reduced- meaning more people may be offered treatment. At the Metabolic Clinic we advocate individual and personalised assessment and treatment for individuals who will will benefit from this. In certain situations Dr Datta recommends further tests such as blood vessel scanning (carotid intima-media thickness) or CT coronary calcium scoring. However, its the discussion you have with an expert and your subsequent understanding of your own ‘heart risk’ which is more important than any test. We are happy to take clinical enquiries via e mail.
New Guidance on Vitamin D from Cardiff and Vale University Health Board
Dr Datta is lead author for Guidance on Vitamin D, published in November 2013 by Cardiff and Vale Univeristy Health Board. This document provides guidance on who would benefit from having their Vitamin D levels measured and potentially require treatment
Major concerns have been raised about the lack of progress in cutting smoking rates in Wales after new figures revealed nearly a quarter of adults still smoke.
The Welsh Health Survey 2012, published on Thursday, found 23% of people said they indulged in the habit – representing just a 1% drop since the introduction of the smoking ban in 2007.
Health campaigners have branded the statistics “desperately disappointing” after the survey showed Wales’ smoking rate had remained static since 2010, and had fallen by only 3% since 2003-2004.
They also called into question the work of the Welsh Government in its attempts to meet its target to reduce smoking prevalence to 16% by 2020.
Chris Mulholland, head of British Lung Foundation Wales, said: “These figures are desperately disappointing and there’s no denying we’ve lost ground on the battle to improve the health of the nation.
“We really have to call in to question the effectiveness of the tobacco control initiative, and the commitment to meeting these targets.
“What these results show is that work done to date, to raise awareness of the dangers of tobacco, is not working. If the Welsh Government are serious about reducing smoking levels, they will take the positive step to introduce a ban on smoking in cars where children are present as soon possible, so that we can protect the health of future generations.”
Elen de Lacy, chief executive of Action and Smoking and Health (ASH) in Wales, said: “It is disappointing to see that prevalence rates remain stagnant at 23% in Wales.
“The Welsh Government has set an ambitious target of 16% smoking prevalence by 2020 and it is hard to see how we are going to reach this target if things remain the same in Wales.
“We need to be investing in comprehensive quit smoking campaigns, delivering more flexible cessation services and tackling illicit tobacco in our communities.
“We also need to take bold steps to prevent young people from starting to smoke, like introducing standardised packaging for cigarettes across the whole of the UK.”
The survey also painted a stark picture of the health of the nation, with the number of overweight or obese adults in Wales increasing for the first time for five years.
Just 29% reported being physically active on five or more days in the past week, and 33% reported eating five or more portions of fruit and vegetables the previous day.
More than a third (34%) of children were classified as overweight or obese – a slight fall from 35% in 2011 – but the number classed as obese remained at 19%.
Mike Nutt, a weight loss surgeon at Spire Cardiff Hospital, said: “Unfortunately these figures are not a surprise. I do not think it is down to ignorance any more.
“The people I see know that their diet is terrible and that they are eating too much. The problem is you can take a horse to water but you can’t make it drink, people do not have the willpower.
“I am expecting to see more people coming through my door in the next few years as this is a trend that is continuing across the Western world. The education side of things could take years to start to come through.”
Professor John Williams, senior Royal College of Physicians officer for Wales, said a more “joined up” approach was needed.
He said: “It is disappointing that the number of overweight and obese adults has risen this year. I hope this is the wake-up call we need.
“Clinicians see the devastating impact of the obesity epidemic every day and we know that there is no easy fix.
“We need to use every available tool to change the way we live, which is why we have asked the Welsh Government to take a more joined up approach looking at everything from active travel to public health legislation.”
Dr Dev Datta, who specialises in the medical management of obesity, said: “It’s not one person or organisation’s responsibility to try and fix this. If you try to approach obesity in that sort of way then we are not going to be successful.
“All of us have a responsibility for our own health, and we cannot get away from that but some of us do that more than others. Companies involved in marketing food and drink also need to take responsibility to make things easier for people to make healthier choices.
“People in national and local government also need to play a role – if it’s easier to do things like cycle to work, more people would do it.
“And as the final part, those in medical care also have a responsibility to their patients. All these need to be brought together to be successful.”
The survey also found that 34% of adults reported that their day-to-day activities were limited because of a health problem or disability, including 16% who were limited “a lot”.
Meanwhile, 20% of adults reported fair or poor general health, while the same number reported currently being treated for high blood pressure, 14% said they were being treated for a respiratory illness, 12% for arthritis, 11% for a mental illness, 9% for a heart condition, and 7% for diabetes.
More than two in five (42%) reported drinking above the guidelines on at least one day in the past week, including 26% who reported drinking more than twice the daily guidelines.
A Welsh Government spokesman said Public Health Wales had submitted a review of health improvement programmes to the Chief Medical Officer, Dr Ruth Hussey, who will be making recommendations to Health Minister Mark Drakeford.
The spokesman said more work needed to be done to reduce the rate of smoking in Wales, adding: “While we have been making good progress in reducing smoking among young people, we need to do more to increase the number of adults successfully quitting smoking.
“Our Tobacco Control Action Plan sets challenging targets of no more than 20% of adults smoking by 2016 and 16% by 2020 and incorporates action to improve the delivery smoking cessation provision.
“There is compelling evidence that the most effective approach to tobacco control is a comprehensive strategy combining legislation, high taxation, regulation of advertising and sales, restrictions on smoking in public places, and a tailored range of awareness, education and cessation initiatives.
“If we are to change attitudes and smoking behaviour in order to meet our targets of then we all need to work together to promote a positive smoke-free approach.”
Speaking about obesity the spokesman added: “While the latest figures for children are more encouraging, after a number of years of stability we have seen a small rise in the rate of overweight and obesity amongst adults this year.
“The Welsh Government will continue to support national initiatives that aim to tackle these statistics.”
Suzanne Sheppard is painfully aware of the devastation heart disease can wreak. Her father, Christopher Rogers, died of a massive heart attack in 1988 when he was 41 and she was 15. His father had also died unusually young – at 54 – and, again, of what doctors call a myocardial infarction.
Heart trouble can be brutally genetic, sometimes cutting lives short in generation after generation of the same family. So it is with Sheppard, who is the third generation of her family at risk of dying early. The 40-year-old has familial hypercholesterolaemia (FH), the inherited cardiac condition that killed her father and grandfather and causes one person a day in the UK to have a heart attack. FH sufferers develop dangerously high levels of bad cholesterol in their blood at an early age. If either parent has the condition, children have a 50/50 chance of developing it.
Sheppard’s father’s FH was not diagnosed while he was alive. But because she is based in Cardiff, she at least knows she has the condition, as the NHS in Wales is tracking down everyone affected to give them statins that will significantly reduce their risk of dying.
Doctors and nurses there use a system called “cascade testing”, which means that, once someone with FH has been identified, every member of their family is offered a blood test. “It’s a lifesaver because if you’re not identified and treated you’re at extremely high risk of having a heart attack and potentially dropping down dead. That’s what happened to my dad,” said Sheppard. Scotland and Northern Ireland also use cascade testing. England does not.
Now top doctors and heart charities are urging the NHS and ministers to introduce the system UK-wide. They say the move is urgent as only one in eight of the 120,000 people in the UK with FH have been identified. That means there are about 100,000 cardiac timebombs.
Often the first sign of FH is a 40- or 50-something having a heart attack, 30% of which are fatal. While statins do not cure the condition completely, they make a coronary seizure much less likely. Identifying all the hidden 100,000 would save more than 1,000 lives, doctors say.
“Comprehensive cascade testing has been successfully trialled in Walesand must urgently be adopted throughout the UK,” said Steve Humphries, professor of cardiovascular genetics at University College London. He said England’s failure to follow the 2008 recommendation from the National Institute for Health and Clinical Excellence (Nice) to screen entire families amounted to “a great missed opportunity”.
Relying on GPs to spot patients with high levels of harmful LDL cholesterol and refer them to an NHS lipid clinic for testing, which should identify their FH, is inadequate, according to Humphries.
He said: “The best way to limit the damage caused by coronary heart disease is to identify those at risk as early as possible. The greatest opportunity for such disease prevention lies in diagnosing and treating people with FH and screening their families.”
Humphries estimates that 101 cardiovascular deaths will be avoided for every 10,000 FH patients aged 30 to 86 treated with high intensity statins to reduce their level of LDL cholesterol.
One in 500 people has FH. It is caused by a flaw in any of three genes (LDL-receptor, ApoB or PCSK9) – what doctors call “a spelling mistake” in their genetic make-up. It means that by the age of 60 more than 50% of men and 30% of women with FH will have developed heart disease.
“So if we tested 500 members of the general population we would find one person with it. But if we tested an FH patient we’d find that about half their siblings and children have it. Cascade screening is an effective way of finding FH patients and thus saving lives. This is preventive medicine,” added Humphries.
He recently met Professor Huon Gray, the government’s heart tsar, to try to persuade him to get the NHS in England to start testing, and believes the coalition’s forthcoming cardiovascular strategy is the ideal opportunity to finally introduce it.
The British Heart Foundation (BHF) and Heart UK, a charity that raises awareness about problems linked to cholesterol, are also lobbying for it. “When FH is undiagnosed and untreated, whole families can needlessly suffer long-term ill-health and premature death from heart disease. With effective, affordable means of diagnosing and treating FH readily available, this cycle of early deaths must be stopped,” said Jules Payne, Heart UK’s chief executive. The condition, though frequently fatal, is being ignored, Payne claims.
When Wales introduced cascade screening in autumn 2010 it had 97 known FH patients. Since then it has identified 372 others from testing 1,141 people. They are equally split between men and women and the youngest so far has been just eight.
“Once we’ve identified a new FH patient from the testing, we then offer the test to other family members. That’s when the cascade starts. We do it with siblings, parents and children and then it’s cascaded from them,” said Dr Dev Datta, a consultant in metabolic medicine and medical adviser to the Wales FH cascade testing service.
“Once you get a positive you continue testing across the generations within that family tree,”
Given the 50/50 risk of passing on FH, each patient usually has two or three close relatives with it too.
Professor Peter Weissberg, the BHF’s medical director, said: “Cascade screening should be a priority for the NHS in England, which should be doing what Wales is doing. In England at the moment the risk is that patients go on and have heart attacks if they’re not identified as being at risk, and some of those people will die. That situation is wholly avoidable. These are people who won’t die today or tomorrow but they might in 15 or 20 years’ time. We are trying to do something now that will stop people dying then.”
Weissberg is worried that none of the three major new bodies or sets of bodies created by the NHS shake-up that comes into force in April – the NHS commissioning board; local councils, who will start to be in charge of public health; or the 211 GP-led clinical commissioning groups – has so far taken responsibility for cascade testing, and so it will not happen.
Gray declined to say if he supported the calls for cascade testing. “FH is being considered as part of the development of the cardiovascular outcomes strategy, but I can’t say much beyond that because priorities for inclusion have not been agreed,” he said.
A spokeswoman for the NHS commissioning board was similarly noncommittal.
Back in Cardiff, Sheppard, who works as a paralegal, takes her statins – two blue tablets three times a day – and contemplates the day when her Lego-obsessed, taekwondo-practising six-year-old son, Cameron, has his blood test too. “That won’t be until he’s 10, because you don’t start getting statins until that age. He has a 50/50 chance of having FH.
“But I’m not overly concerned because I know that because we’ve got cascade screening so he will be tested early and treated if necessary, and the medication is good. That’s given me peace of mind,” she said.
Cameron may yet become the fourth generation of the family to have it. “It’s great that the NHS is going out there and actively looking for people with this condition.
“I’ve seen how the death of a loved one at such a young age devastates families and can rob them of a husband, father, mother – anyone.
“Medical science means that many of these deaths are totally avoidable as there’s no reason why anyone identified and put on statins at an early age can’t lead a long and healthy life, just like every other member of the general public. England should definitely follow Wales’s lead and do this.”