Cardiovascular Disease (CVDs) and Non-Communicable Diseases

Cardiovascular Disease (CVDs) and Non-Communicable Diseases
The emergence of CVD and other NCD's is a major global health
challenge. Control of the dual burden of CVD and other NCD's are primarily
through effective health promotion interventions aimed at reducing the four
common behavioural risk factors (tobacco use, unhealthy diet, low physical
activity and excess consumption of alcohol). Critically discuss examples
and relevant literature, how these behaviours can be improved using
structural interventions (e.g., taxes on unhealthy products, reformulation
of manufactured food, shaping urban environments to encourage physical
activity).
The Use of Structural Interventions in Improving Predisposing Behaviours
for Non-Communicable Diseases
(A Critical Analysis of Available Evidence)
Introduction
The rapid increase in the prevalence of Non-communicable disease in
every region of the world is possibly the most important public health
problem of the 21st Century. Non-Communicable Diseases (NCDs), mainly
cardiovascular diseases, diabetes, cancers and chronic respiratory diseases
are the leading cause of death and disability globally accounting for 63%
of the 57 million deaths in 2008 (WHO, 2010). The 2010 WHO Global Report on
Non-Communicable Diseases projects over a 15% increase in the mortality and
morbidity from NCDs in the coming decade, especially in low and middle
income countries where the impact of NCDS is currently the highest,
accounting for 80% of global mortality from NCDs (Galambos, Sturchio, &
Whitehead, 2013). Numerous studies show that tobacco use, physical
inactivity, excessive intake of alcohol and unhealthy diet are the main
preventable behavioural lifestyles that put individuals at risk of NCDS
(Desvarieux et al., 2012). Therefore interventions that address these four
risk factors (tobacco use, physical inactivity, excessive intake of alcohol
and unhealthy diet, have the potential to significantly reduce the burden
of NCDs (Beaglehole et al., 2011).
Over the years, focus on improving these lifestyle factors aiming at
reducing NCDs have moved from health promotion interventions that leave
decision making solely to the individual, to more structural population
wide interventions like taxes on unhealthy products, reformulation of
manufactured food, reshaping urban environments to encourage physical
activity (McQueen, 2013). This essay aims to describe how these risky
behaviours are being improved using structural interventions.
Why Structural Interventions?
According to Sommer and Parker (2013), structural interventions refer
to interventions that aim to alter the context within which health is
produced by modifying the social, environmental economic and political
source of public health problems that determines individual, community and
societal outcomes. Its uses an indirect approach in influencing risk of
disease. Rather than merely providing individuals withinformation to make
informed choices about their health like most traditional health promotion
interventions, structural interventions acknowledge that most risky
behaviours occur as a result of the individual's immediate environment and
tries to shape the environment in such a way to reduce risk (McQueen,
2013). Structural interventions are not aimed directly at the risky
behaviour but larger conditions within which these risky behaviours are
embedded, and usually take the form of legislation, economic incentives,
etc (Sommer & Parker, 2013).
Tobacco use, physical inactivity, excessive intake of alcohol and
unhealthy diet are behavioural lifestyle habits that are influenced by
forces outside the control of individuals (McQueen, 2013) which is
difficult to improve through the use of information led health promotion
strategies alone and usually fail to produce long term outcomes (Galambos,
Sturchio, & Whitehead, 2013). Hence the need to alter the environment that
fuel or influence these risky behaviours, a large body of evidence support
the notion that providing health information alone does not lead to the
desired change in behaviour (Sommer & Parker, 2013)
Additionally, structural interventions are very cost effective, but
require strong political will/enforcement, and multi-sectoral partnerships.
As a consequence, these interventions selected for pressing attention need
to satisfy a rigorous, evidence based criteria; a considerableoutcome on
health (lessening of theuntimely deaths and disabilities); sturdyfacts for
cost efficiency; reduced costs of execution; and the political and
fiscalpracticability for scale-up (McQueen, 2013). There are
numerousprobable intercessions for Non-Communicable Diseases.Nonetheless,
the most robust obtainableproof for the efficiency and outcome of
interventions is to reduce the pervasiveness of the main risk aspects via
population-wide approaches that are directed at all and sundry, and to
aimat treatment of individuals who are at a higher risk of contracting Non-
Communicable Diseases, especially cardiovascular conditions (Galambos,
Sturchio, & Whitehead, 2013). Not all intercessions are cost effectual or
inexpensivewith regards to equity and resources; the practicability of
execution and scale-up of intercessions in everynation must, therefore, be
reflected on (Galambos, Sturchio, & Whitehead, 2013).
Evidence for Using Structural Interventions in Improving:
Unhealthy Diets
Unhealthy diets have been acknowledged as some of the key sources of
NCDs. For examples, some cardiovascular diseases such as stroke,
hypertension and left-ventricular hypertrophy have been linked directly to
poor diets such as too much ingestion of dietary salt and the intake of
unhealthy or saturated fats. While observing the effects of dietary salt
intake on cardiovascular activities, Bochud et al. (p.530) observed that
experts have brought forth stronger evidence linking dietary salt intake to
cardiovascular conditions that have resulted in morbidity and mortality,
and as such have called for the reduction of salt intake to 5g per day. The
reduction of salt intake is meant to curb the unprecedented increase in
cardiovascular diseases throughout the world. In a bid to control the
intake of dietary salt, the WHO(2010) has proposed structural interventions
that have been widely adopted by countries such as New Zealand, France and
Japan among others (Bochud et al p. 531). While it is not possible to
control individual intake of diet salt and unhealthy and saturated fats,
one of the interventions that has been propped up by the World Health
Organization (2012) is the behavior change. Behavior change on diets is
mainly attainable through teaching the populace on the effects of poor
diets and also through individual and societal assessment of diets
ingested.
A notable example of places where structural interventions have led
to reduced mortality rates includes Japan and Finland (Desvarieux et al.,
2012). According to Desvarieux et al. (2012), in Finland, both societal and
national interventions that were directed at changing behaviors led to the
lessening of coronary related deaths by almost 85 percent in addition to
the decrease in all-cause deaths.Desvrieux (2012), further observes that
exclusive of Finland and Japan, there is no up to date data from nations
that have employed population-based structural interventions to reduce
dietary salt ingestion like the United Kingdom that gave a pointer that
they were moving from the initial 10g per day to the recommended 5g per
day.
However, it is important to observe that, In Finland, while the
decrease (-96%) was much greater in the younger generations (35-44 years),
the reduction was also considerable in the older age groups too. That is,
the reduction was -69 percent among individuals of 65-79 years, the immense
reduction indicated that it was never too late for prevention and change
(Desvarieux et al., 2012).
With regards to the intake of other unhealthy diets such as saturated
fats and meats, one of the structural interventions that have been proposed
by experts is the reduction of subsidies that are placed on such foods by
the different governments. The reduction of subsidies is likely to result
in the increase in the prices of such food stuffs thereby making them
unaffordable to many people. As a consequence, individuals will be forced
to reconsider other available but cheaper food options which will, in
effect, result in reduction in the intake of saturated fats and meats.
Consequently, this is likely to increase the number of healthy individuals.
A good example of where the removal of subsidies on unhealthy foods has
been effective in reducing NCDs that are associated with such foods is in
Poland. According to Desvarieux, after the removal of the subsidy on
extremely saturated fats and meats by the Polish government and the
subsequent promotion of the inclusion of vegetables in diets, the mortality
rates that were linked to coronary heart diseases were cut down by 25
percent within a period of 5 years, even though there was no perceptible
advancement in the polish health care system (Desvarieux et al., 2012).
Other notable structural interventions that can be effectively
employed in the reduction of the consumption of unhealthy diets are the
increase of taxes on such foods. The increase in taxes will have a similar
effect are the reduction of subsidies in that they will increases the
prices of such foods thereby making them inaccessible to many people.
However, despite the above stated interventions on the consumption of
unhealthy diets being successful in given countries, equal success rates
may not be realized among certain spheres of the populace, for instance,
wealthier individuals and families. Wealthier individuals may still have
access to the unhealthy diets despite the increase in taxes and the
reduction in subsidies. Thus they will still be able to consume unhealthy
diets. As a consequence, the most successful structural intervention that
can be applied and success realized equally throughout the population
remains education and the assessment of individual diets.
Low Physical Activity
The World Health Organization observes that apart from being the
number one cause of death universally, CVDs killed approximately 17.3
million individuals during the year 2008. Of these deaths, nearly 7.3
million were as a result of coronary heart conditions while 6.2 million
deaths were attributable to stroke (WHO Media centre , 2013). The report
further opines that both the mid-income and low-income nations were
disproportionally affected by the conditions as more than 80 percent of CVD
related deaths happened took place in these countries and the rates of
deaths in men and women were equal (WHO Media centre , 2013). The report
further projects that the number of individuals who are likely to succumb
to CVDs, stroke and heart conditions, will increase to approximately 23.3
million people by the year 2030 while CVDs will remain to be the sole
leading cause of death globally (WHO Media centre , 2013).
Alwan et al. (2010) draw a direct link between coronary heart
conditions, diabetes and stroke and physical inactivity. Alwan et al.
(2010) opine that there is also a close response association for both
diabetes and cardiovascular with risk reductions that occur regularly at a
degree of 150 minutes every week. Evidence also indicates that taking part
in 30 to 60 minutes of physical activity every day considerably lowers the
risk of colon and breast cancers (Oxford Health Alliance Programme, 2014).
A number of structural interventions aimed at the promotion of physical
activities that comprise the best buy have been proposed. For instance, the
promotion of physical activity alongside the ingestion of healthy diet
through the use of media has been observed as a more cost-effective,
inexpensive and exceedingly practicable alternative (Alwan et al., 2010).
The WHO assembly (2004) endorsed Global Strategy on Diet, Physical Activity
and Health and the subsequent Action Plan for the Global Strategy for the
Prevention and Control of Non-Communicable Diseases 2008–2013 (Alwan et al,
2010). These are some of the universal structural interventions meant to
push the member states towards the execution of the outlined programs and
actions with the objective of amplifying the levels of physical activities
amongst the world populaces. The structural interventions require children
and young adults (5-17 years) to take part in a one hour in intensive
physical activity each day. On the other hand, adults (18-65 years) are
required to involve in 75 to 150 minutes of intensive physical activities
each day (Alwan et al, 2010).
Other structural interventions that are prone to boost physical
activities amongst the populace includes ensuring execution of policies
that ensure sports, walking and cycling are accessible and safe in order to
promote physical activities (Oxford Health Alliance Programme, 2014). The
effectiveness of physical activities was demonstrated in both the United
States and Cuba during the 1991-1995 economic crises (Desvarieux et al.,
2012). The economic crisis led to amplified physical activities (walking)
because of the fuel shortage by between 30-60 percent. In effect, the
increased physical activity in the two nations resulted in 14% to 7%
decrease in obesity and a further reduction in coronary related deaths in a
year and a 39% reduction by the year 2002 (Desvarieux et al., 2012).
Lastly, another remarkable structural intervention that may be useful
in ensuring increased physical activities within populations is through
urban reshaping. This involves the construction of sidewalks in towns and
cities to ensure that pedestrians have paths that they can use to access
the urban centres. Likewise, by-laws are also effective in ensuring
increased physical activities within urban settings. For instance, laws
that do not allow people to drive to town on given days will increase
physical activities among population as people will be forced to walk and
use bicycles to access cities (Oxford Health Alliance Programme, 2014).
However, despite the benefits that can be attained from involvement
in vigorous physical activities, the advantages can only be attained if the
individual is willing to take part in the activities (Oxford Health
Alliance Programme, 2014). This is because taking part in such activities
is considered as a behavior that individuals are required to learn.
Attaining the desired outcome may, therefore, require that the above
recommended structural interventions are conducted in school or work based
environments in which it is compulsory for individuals to take part. This
may lead to development of the habit of taking part in routine physical
activity. Nevertheless, the best structural intervention with regards to
low physical activities is to reach out to the populations and teach them
the negative effects of low physical activity through the media (Oxford
Health Alliance Programme, 2014).
Excessive Consumption of Alcohol
According to Statistics (2014), over 2.5 million the annual global
deaths are attributable tothe unwarranted and detrimental consumption of
alcohol. England and Wales reports over 5000 alcohol related deaths
annually (Statistics, 2014). Unwarranted alcohol use is, therefore, a key
source of avoidable premature death that gave an explanation for nearly
1.4% of the total deaths registered in England and Wales during the year
2012(Statistics, 2014).
In relation to the unwarranted use of alcohol, Alwan et al. (2010)
assert that efficient structural interventions for alcohol related liver
conditions; cancers and other CVDs should be aimed at the diverse patterns
and levels of alcohol use.

Well-known proof of efficiency and cost-effectiveness of the structural
interventions to decrease the detrimental consumption of alcohol comprising
instances from nations like Mexico, Russia, Brazil, Viet Nam and China have
propped up the execution of the following effective structural
interventions(Alwan et al., 2010):
A widely acknowledged structural intervention that may be employed in
curbing excessive use of alcohol is the increase in taxes levied on the
alcoholic beverages. The increase in taxes will, in effect, lead to the
increment in prices of the alcoholic beverages. As a consequence, the
increment will ensure lower consumption of alcohol among the user as they
will not be able to afford more alcohol as before (Alwan et al., 2010).
Another notable structural intervention that can be successfully applied in
order to regulate and decrease the unwarranted consumption of alcohol is
the regulation of the availability and accessibility of alcoholic drinks
including the recommended purchase age limit. The structural intervention
has been widely used internationally and as been successful in decreasing
alcohol consumptions among the underage (Alwan et al., 2010).
Nevertheless, one of the key setbacks of the wide population-founded
structural interventions stated above is due to their lack of ability to
distinguish between people whose consumption of alcohol is linked with
detrimental results and those whose consumption arenot(International Center
for Alcohol Policies, 2014). Thus, by their nature, these interventions
tackle the lowest general denominator and are short of the flexibility to
act in response to the requirements of groups and individuals whose
drinking may be predominantly problematical (International Center for
Alcohol Policies, 2014).
Also, another disadvantage of the aforementioned structural
interventions is that they may neither be uniformly cultural significant
nor apposite in every setting. This is because the interventions have
normally failed to consider the important role that is played by alcohol in
various communities throughout the globe and the rationale that alcohol
consumption is strongly embedded into the foundation of the normal social
life in numerous communities (International Center for Alcohol Policies,
2014). That is to say, every part of the globe has its own distinctiverange
of viewpoints, approaches, and customs around alcohol consumption and the
perceptions on thesuitable place within the daily life. Therefore, a one-
size-fits-all intervention may not be applicable in each setting as
theefficiency is likely to fluctuate (International Center for Alcohol
Policies, 2014).
Tobacco Use
According to WHO (2010), more that 6 million universal deaths are
attributable to the use of tobacco that includes both smoking and exposure
to tobacco smoke. The statistics further observes that this rate is
anticipated to amplify by an extra 1.5 million cases in the year 2020
unlesseffectual interventions and approaches are put in place in order to
curtailthe increase. (WHO, 2010).It is approximated that smoking is
responsible for 71 percent of deaths from lung cancer, 42 percent of all
persistent respiratory conditions and 10 percent of the CVDs (WHO 2010).
While close to 1.2 billion people in the world are smokers, a higher
percentage of this people are found in both middle and low income
economies.
Beaglehole et al, observe that precedence for urgent action aimed at
realizing the proposed universal goal of a world that is free from tobacco
and in which less than 5 percent of the populace consumes tobacco by the
year 2040 (2011). By implementing 4 of the proposed strategies found in the
Framework on Tobacco Control (FCTC), above 5.5 million deaths are likely to
be prevented over a period of 10 years. The reduction in mortality rates
resulting from tobacco use will mainly affect middle-income nations and a
total of 23 low-income nations that are experience an increased burden of
Non Communicable Diseases (Beaglehole et al. 2011).
Notable structural interventions that have been put in place to
prevent and reduce tobacco use throughout the world includes the placing of
warning signs on tobacco packets with the objective of warning users of the
consequences of smoking (Hammond et al., 2006). Sommer and Parker (2013)
observe that even though this structural intervention has been successfully
applied, there is still a need to ensure that smokers are aware of the
dangers that smoking poses to them and people around them.
A study on the "effectiveness of cigarette warning labels in
informing smokers about the risks of smoking", carried out in four nations
(Canada, USA, Australia and United Kingdom) disclosed that although it
isfrequently presumed and repeatedly asserted by the tobacco industry that
tobacco users are sufficiently informed on the risks that smoking poses to
them, this notion is false (McQueen, 2013). The outcomes of the study
indicated that there were considerable gaps in the comprehension of the
smoking risks. That is to say, most of the smokers indicated that heart
conditions and lung cancers were attributable to smoking while a quarter of
the smokers (interviewees) did not deem the vice as a major cause of
strokes. Still, slightly above half the number of smokers interviewed
deemed smoking as a cause of impotence. Lastly, the study disclosedthat the
knowledge of the harmful constituents of tobacco among the users was
incongruously low (Hammond et al., 2006).
Another remarkable structural intervention that has been frequently
used to curtail the use of tobacco is the increase of taxes on tobacco
products. According to Hammond et al. (2006), increases in taxes normally
produceas a minimum proportionate increase in cigarette price, which, in
turn, diminishes cigarette use. Hammond et al. (2006) further assertsthat
approximates of price elasticity of demand for tobacco in the United
Statescharacteristicallyvary between 0.3 and 0.5. This implies that a 10
percent increase in the prices of cigarettes will in turn result in a 3-5
percent decrease in demand for cigarettes for every adult smoker. The
addictive nature of smoking, therefore, implies that the long-
standingreactions to undeviatingincrease in prices will be almost twofold
as large as short-term impacts.
Even thoughapproximationsdiffer, numerous researches have pointed out
that both the youth and the young adults are more responsive to price
compared to the adultsmokers. As such,a 10 percentrise in tobacco prices
would diminish the number of youthful tobacco users by virtually 7 percent
and thestandardamount smoked by over 6 percent.Elevated prices will,
therefore, negatively impact theheadway to established smoking. Hammond et
al. (2006) also observe that prices have sturdyoutcomes on the smoker of
18–24 years, the age bracket in whichsmoking lifestylefrequently
becomesresolutely established.
Clean indoor air laws are also structural interventions that have
been executed successfully in a bid to reduce tobacco use. The laws are
mainly meant to ban smoking in a varietyof public places that include
public parks, restaurants, transport systems, bars, and private offices
(Hammond et al., 2006). The purpose of clean indoor air laws is to make
sure that smoking is viewed as less strikingthrough thereductionof smoking
opportunities by holding up the social standards against tobacco use. The
execution of the clean indoor air laws has been aggravated by
considerableproof of the harms resulting from tobacco smoke (ETS) to the
nonsmokers.
According to Hammond et al. (2006), widespread clear indoor air laws
have been connected with reduced rates of tobacco use within the United
States. Researches have disclosed that 5-20 percent reducedper
persontobacco use in states with wide-ranging clean indoor air laws.
Hammond et al. (2006) additionally note that fewer researches have looked
atthe pervasiveness and termination rates, and that states with widespread
clean air laws have recorded a 10 percent lower incidence rates compared to
other states. This is in concurrence to the study conducted by Emont et al
that noted 12 percent increased rates of previousto current tobacco users
and Moskowitz's revelation of 38 percent increased 6-month termination
rates in regions that had stronger worksite laws.
However, despite the gains made through structural interventions such
as clean indoor air laws and price increments, many smokers are still not
aware of the danger smoking pose to them and people around them. As a
result, teaching as a structural intervention should be implemented in
order to create awareness on the risks of smoking. Furthermore, in
concurrence to the above statement, Macqueen (2013) opines that the degree
to which tobacco users comprehend the enormity of the health risks has a
sturdy effect on their smoking attitude. That is, smokers who recognize
greater health risks as a consequence of smoking are more prone to intend
to relinquish and to renounce smoking effectively. Lastly, Hammond et al.
(2006) note that the health risks that are associated with smoking are also
the most widespreadinspiration to give upthat is cited by present and
pastsmokers. It is also the best indicator of long-standingself-
restraintamongstgrounds for quitting.
Conclusion

Reducing the universal burden of NCDs will necessitate a whole-of-society
reaction at the international, national, and personal levels. There is a
need for formation of a matrix of NCD partnerships that is linked through
World Health Organization and other United Nations and bilateral agencies,
NGOs, private sectors and foundations (Galambos, Sturchio, & Whitehead,
2013).
The United Nations meeting can generate some degree of international
commitment to this novel charge; nonetheless, member countries will also
berequired to commit to establishing and strengthening countrywide plans
that are aptly financed and executed. Focusmust, therefore, be concentrated
on avoidance across the lifespan and reallocateavailable resources towards
the support of superior quality and healthy lifestyles, and timelydetection
and management of the risk aspects and symptoms as opposed to last minute
treatment of chronic illnesses (Sommer & Parker, 2013).
The United Nations High-level Meeting on Non-communicable Diseases
is, therefore, only the initialstage in what must be a lasting and
progressingassociationbetweennumerous partakers to enhanceuniversal health.
The next stages necessitate theexecution of the proposed structural
interventions, investment in ground-breakingstudies on preventative health
approaches, advancements in examination, concurrence on targets, and
establishment ofpractical timelines. This key public health challenge can
be efficiently tackled in order to save millions of upcoming lives
(Galambos, Sturchio, & Whitehead, 2013). It, therefore, calls for timely
response and involvement in universal NCD associations for deterrence and
promotion of personal and professional cost-effective strategies that are
practical (Sommer & Parker, 2013).

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