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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