Cardiovascular disease prevention

Reduce population-level consumption of salt. To achieve this, the evidence suggests that the following are among the measures that should be considered.

Accelerate the reduction in salt intake among the population. Aim for a maximum intake of 6 g per day per adult by 2015 and 3 g by 2025.

Ensure children's salt intake does not exceed age-appropriate guidelines (these guidelines should be based on up-to-date assessments of the available scientific evidence).

Promote the benefits of a reduction in the population's salt intake to the European Union (EU). Introduce national legislation if necessary.

Ensure national policy on salt in England is not weakened by less effective action in other parts of the EU.

Ensure food producers and caterers continue to reduce the salt content of commonly consumed foods (including bread, meat products, cheese, soups and breakfast cereals). This can be achieved by progressively changing recipes, products and manufacturing and production methods.

Establish the principle that children under 11 should consume substantially less salt than adults. (This is based on advice from the Scientific Advisory Committee on Nutrition.)

Support the Food Standards Agency so that it can continue to promote, and take the lead on, the development of EU-wide salt targets for processed foods.

Establish an independent system for monitoring national salt levels in commonly consumed foods.

Ensure low-salt products are sold more cheaply than their higher salt equivalents.

Clearly label products which are naturally high in salt and cannot meaningfully be reformulated. Use the Food Standards Agency-approved traffic light system. The labels should also state that these products should only be consumed occasionally.

Discourage the use of potassium and other substitutes to replace salt. The aim of avoiding potassium substitution is twofold: to help consumers' readjust their perception of 'saltiness' and to avoid additives which may have other effects on health.

Promote best practice in relation to the reduction of salt consumption, as exemplified in these recommendations, to the wider EU.

Reduce population-level consumption of saturated fat. To achieve this, the evidence suggests that the following are among the measures that should be considered.

Encourage manufacturers, caterers and producers to reduce substantially the amount of saturated fat in all food products. If necessary, consider supportive legislation. Ensure no manufacturer, caterer or producer is at an unfair advantage as a result.

Create the conditions whereby products containing lower levels of saturated fat are sold more cheaply than high saturated fat products. Consider legislation and fiscal levers if necessary.

Create favourable conditions for industry and agriculture to produce dairy products for human consumption that are low in saturated fat.

Continue to promote semi-skimmed milk for children aged over 2 years. This is in line with the American Heart Association's 2005 dietary recommendations for children and adolescents.

Ensure all groups in the population are protected from the harmful effects of IPTFAs. To achieve this, the evidence suggests that the following are among the measures that should be considered.

Eliminate the use of IPTFAs for human consumption.

In line with other EU countries (specifically, Denmark and Austria), introduce legislation to ensure that IPTFA levels do not exceed 2% in the fats and oils used in food manufacturing and cooking.

Direct the bodies responsible for national surveys to measure and report on consumption of IPTFAs by different population subgroups, rather than only by mean consumption across the population as a whole.

Establish guidelines for local authorities to monitor independently IPTFA levels in the restaurant, fast-food and home food trades using existing statutory powers (in relation to trading standards or environmental health).

Create and sustain local and national conditions which support a reduction in the amount of IPTFAs in foods, while ensuring levels of saturated fat are not increased. Encourage the use of vegetable oils high in polyunsaturated and monounsaturated fatty acids to replace oils containing IPTFAs. Saturated fats should not be used as an IPTFA substitute.

Develop UK-validated guidelines and information for the food service sector and local government on removing IPTFAs from the food preparation process. This will support UK-wide implementation of any legislation produced on IPTFAs.

Develop a comprehensive, agreed set of principles for food and beverage marketing aimed at children and young people. This could be similar to the 'Sydney principles' (Swinburn et al. 2008). They should be based on a child's right to a healthy diet.

Extend TV advertising scheduling restrictions on food and drink high in fat, salt or sugar (as determined by the Food Standards Agency's nutrient profile) up to 9pm.

Develop equivalent standards, supported by legislation, to restrict the marketing, advertising and promotion of food and drink high in fat, salt or sugar via all non-broadcast media. This includes manufacturers' websites, use of the Internet generally, mobile phones and other new technologies.

Ensure restrictions for non-broadcast media on advertising, marketing and promotion of food and drink high in fat, salt or sugar are underpinned by the Food Standards Agency nutrient profiling system.

Encourage best practice for all meetings, including lobbying, between the food and drink industry and government (and government agencies). This includes full disclosure of interests by all parties. It also involves a requirement that information provided by the food and drink, catering and agriculture industries is available for the general public and is auditable.

Ensure the Food Standards Agency's integrated front-of-pack labelling system is rapidly implemented.

Ensure labelling regulations in England are not adversely influenced by EU regulation.

Establish the Food Standards Agency's single, integrated, front-of-pack traffic light colour-coded system as the national standard for food and drink products sold in England. This includes the simple, traffic light, colour-coding visual icon and text which indicates whether food or drink contains a 'high', 'medium' or 'low' level of salt, fat or sugar. It also includes text to indicate the product's percentage contribution to the guideline daily amount (GDA) from each category.

Consider using legislation to ensure universal implementation of the Food Standards Agency's front-of-pack traffic light labelling system.

Develop and implement nutritional labelling for use on shelves or packaging for bread, cakes, meat and dairy products displayed in a loose or unwrapped state or packed on the premises. The labelling should be consistent with the Food Standards Agency's traffic light labelling system.

Ensure food and drink labelling is consistent in format and content. In particular, it should refer to salt (as opposed to sodium), the content per 100 g and use kcals as the measure of energy.

Continue to support the Food Standards Agency in providing clear information about healthy eating.

Ensure the UK continues to set the standard of best practice by pursuing exemption from potentially less effective EU food labelling regulations when appropriate.

Ensure government policy is assessed for its impact on CVD.

Ensure any such assessments are adequately incorporated into the policy making process.

To achieve this, the following are among the measures that should be considered.

Assess (in line with the Cabinet Office requirement) all public policy and programmes for the potential impact (positive and negative) on CVD and other related chronic diseases. In addition, assess the potential impact on health inequalities. Assessments should be carried out using health and policy impact assessment and other similar, existing tools.

Monitor the outcomes of policy and programmes after the assessment and use them to follow up and amend future plans.

Make health impact assessment mandatory in specific scenarios. (Note that strategic environmental assessment, environmental impact assessment and regulatory impact assessment are already mandatory in certain contexts.)

Ensure promoting health and reducing disease is made an explicit part of the CAP's 'public goods' so that European money promotes the wellbeing of EU citizens. The scope of what are regarded as 'European public goods' in the EU is broader than the strict definition of a 'public good' used by some economists.

Ensure CAP spending takes adequate account of its potential impact on CVD risk factors and is used in a way that optimises the public health outcomes.

To achieve this, the following are among the measures that should be considered.

Negotiate at EU and national level to ensure the CAP takes account of public health issues. Health benefits should be an explicit, legitimate outcome of CAP spending. This can be achieved through formal recognition of health as a 'public good'.

Progressively phase out payments under 'pillar one' so that all payments fall under 'pillar two'. This will allow for better protection of health, climate and the environment. It will also improve and stimulate economic growth.

Encourage the principle that future 'pillar two' funds should reward or encourage the production of highly nutritious foods such as fruit, vegetables, whole grains and leaner meats.

Negotiate to ensure the European Commission's impact assessment procedure takes cardiovascular health and other health issues into account. (Impact assessment is part of the European Commission's strategic planning and programming cycle.)

Ensure government funding supports physically active modes of travel.

To achieve this, the evidence suggests that the following are among the measures that should be considered.

Ensure guidance for local transport plans supports physically active travel. This can be achieved by allocating a percentage of the integrated block allocation fund to schemes which support walking and cycling as modes of transport.

Create an environment and incentives which promote physical activity, including physically active travel to and at work.

Consider and address factors which discourage physical activity, including physically active travel to and at work. An example of the latter is subsidised parking.

Ensure publicly funded food and drink provision contributes to a healthy, balanced diet and the prevention of CVD.

Ensure public sector catering practice offers a good example of what can be done to promote a healthy, balanced diet.

To achieve this, the evidence suggests that the following are among the measures that should be considered.

Ensure all publicly funded catering departments meet Food Standards Agency-approved dietary guidelines. This includes catering in schools, hospitals and public sector work canteens.

Assess the effectiveness of the government's healthier food mark pilot. If successful, develop a timetable to implement it on a permanent basis.

Encourage local planning authorities to restrict planning permission for take-aways and other food retail outlets in specific areas (for example, within walking distance of schools). Help them implement existing planning policy guidance in line with public health objectives. (See also recommendation 12.)

Review and amend 'classes of use' orders for England to address disease prevention via the concentration of outlets in a given area. These orders are set out in the Town and Country Planning (Use Classes) Order 1987 and subsequent amendments.

Ensure data on CVD prevention is available for scrutiny by the public health community as a whole.

Ensure new econometric data (including pooled consumer purchasing data) are rapidly made available by industry for monitoring and analysis by independent agencies.

Use population surveys (including Public Health England's National Diet and Nutrition Survey [NDNS] and the Low income diet and nutrition survey [LIDNS]) and data from all relevant sources to monitor intake of nutrients for all population groups. (Sources include: the Food Standards Agency, Department of Health, Department for Environment, Food and Rural Affairs, Office for National Statistics, the Public Health Observatories, academic and other researchers.)

Monitor the intake of salt, trans fatty acids, saturated fatty acids and mono and polyunsaturated fatty acids among different population groups and report the findings for those groups.

Support the National diet and nutrition survey and the Low income diet and nutrition survey.

Ensure the CVD module (including lipid profile measures) routinely appears in the NHS Digital's Health surveys for England.

Develop an international public health information system (resembling GLOBALink) for CVD prevention and use it to ensure widespread dissemination of these data.

The population that falls within a local authority, primary care trust (PCT) area or across combined PCT and local authority areas or within a particular region of the country.

city region partnerships

government regional offices

local authorities

local strategic partnerships

non-governmental organisations, including charities and community groups

PCTs

strategic health authorities.

Ensure a CVD prevention programme comprises intense, multi-component interventions.

Ensure it takes into account issues identified in recommendations 1 to 12.

Ensure it includes initiatives aimed at the whole population (such as local policy and regulatory initiatives) which complement existing programmes aimed at individuals at high risk of CVD.

Ensure it is sustainable for a minimum of 5 years.

Ensure appropriate time and resources are allocated for all stages, including planning and evaluation.

Gain a good understanding of the prevalence and incidence of CVD in the community. Find out about any previous CVD prevention initiatives that have been run (including any positive or negative experiences).

Consider how existing policies relating to food, tobacco control and physical activity, including those developed by the local authority, may impact on the prevalence of CVD locally.

Gauge the community's level of knowledge of, and beliefs about, CVD risk factors. This includes beliefs that smoking is the only solace in life for people with little money, or that only people who have a lot of money eat salad.

Gauge how confident people in the community are that they can change their behaviour to reduce the risks of CVD (see NICE's guideline on behaviour change: general approaches).

Identify groups of the population who are disproportionately affected by CVD and develop strategies with them to address their needs.

Take into account the community's exposure to risk factors (factors currently facing adults and those emerging for children and younger people).

Develop a population-based approach.

Ensure a 'programme theory' is developed and used to underpin the programme (Pawson 2001). This should cover the reasons why particular actions are expected to have particular outcomes.

Ensure the programme helps address local area agreement targets and acts as a local incentive to help meet the government's programme for world class commissioning in the NHS. Also ensure it tackles health inequalities.

Link the programme with existing strategies for targeting people at particularly high risk of CVD and take account of ongoing, accredited screening activities by GPs and other healthcare professionals. This includes the NHS Health Checks programme.

Work closely with regional and local authorities and other organisations to promote policies which are likely to encourage healthier eating, tobacco control and increased physical activity. Policies may cover spatial planning, transport, food retailing and procurement. Organisations that may get involved could include statutory, public sector and civil society groups (examples of the latter are charities, clubs, self-help and community groups).

When developing CVD programmes, take account of relevant recommendations in NICE's guidelines on tobacco, walking and cycling, physical activity: brief advice for adults in primary care, exercise referral schemes to promote physical activity, behaviour change: general approaches, physical activity and the environment, community engagement: improving health and wellbeing and reducing health inequalities, maternal and child nutrition, physical activity in the workplace, cardiovascular disease: identifying and supporting people most at risk of dying early, physical activity for children and young people and obesity prevention.

Only develop, plan and implement a strategic, integrated media campaign as part of a wider package of interventions to address CVD risk factors. Media campaigns should be based on an acknowledged theoretical framework.

Ensure the programme lasts a minimum of 5 years (while subject to annual evaluation reports) to maximise its potential impact.

Produce a long-term plan, and gain political commitment, for funding to ensure the programme has adequate resources and is sustainable beyond the end of the research or evaluation period.

Ensure the programme is adequately staffed. Avoid adding CVD prevention to the workload of existing staff without relieving them of other tasks.

Ensure volunteers are an additional (rather than a core) resource and that their training and support is adequately resourced.

Ensure steps are taken to retain staff.

Where staff are recruited from the local community ensure, as far as possible, that they reflect the local culture and ethnic mix.

Ensure there are effective links with other existing and relevant community initiatives.

Act as leader and governor of CVD prevention. Identify and articulate local community needs and aspirations and how these may impact on the community's risk of CVD. Reconcile these needs and aspirations or arbitrate on them to help prevent CVD (see the Department for Communities and Local Government's 2008 statutory guidance on creating strong, safe and prosperous communities).

Identify senior figures within PCTs and local authorities as champions for CVD prevention.

Identify people to lead the CVD programme, including members of the local community. Identify in advance, and provide for, the training and other needs of these potential leaders.

Develop systems within local strategic partnerships and other subregional or regional partnerships for agreeing shared priorities with other organisations involved in CVD prevention. Ensure senior staff are involved, as appropriate.

Establish baseline measures before the CVD programme begins. These should include lifestyle and other factors that influence cardiovascular risk, as well as figures on CVD prevalence and mortality. The establishment of such measures should be budgeted for as part of the programme.

Ensure evaluation is built in (in line with NICE's guideline on behaviour change: general approaches). It should include the policies and activities of partner organisations which are likely to influence CVD prevalence.

Ensure appropriate methods (using multiple approaches and measures) are used to evaluate the programme's processes, outcomes and measures or indicators. Evaluation should include determining how acceptable the programme is to the local community or the groups targeted.

Ensure the results of evaluation are freely available and shared with partner organisations. Use the findings to inform future activities.

Children and young people aged under 16 years.

Parents and carers of children and young people under the age of 16.

Local authorities (providers of cultural and leisure services).

Schools (governors and teachers).

Catering staff.

Nursery nurses and workers in pre-school day care settings such as nurseries.

Managers of children's centres.

Help children and young people to have a healthy diet and lifestyle. This includes helping them to develop positive, life-long habits in relation to food. This can be achieved by ensuring the messages conveyed about food, the food and drink available, and where it is consumed, is conducive to a healthy diet. (For more details, see NICE's guidelines on maternal and child nutrition and physical activity for children and young people).

When public money is used to procure food and drink in venues outside the direct control of the public sector, ensure those venues provide a range of affordable healthier options (including from vending machines). Ideally, the healthier options should be cheaper than the less healthy alternatives. For instance, carbonated or sweetened drinks should not be the only options and fruit and water should be available at an affordable price. (Examples of when public money is used in this way include school visits to museums, sports centres, cinemas and fun parks.)

Encourage venues frequented by children and young people and supported by public money to resist sponsorship or product placement from companies associated with foods high in fat, sugar or salt. (This includes fun parks and museums.)

Organisations in the public sector should avoid sponsorship from companies associated with foods high in fat, sugar or salt.

Anyone who eats food provided by public sector organisations.

Education authorities.

Government departments and agencies.

Local authorities.

NHS organisations.

Prison services.

The armed forces.

The emergency services.

Ensure all food procured by, and provided for, people working in the public sector and all food provided for people who use public services:

does not contain industrially produced trans fatty acids (IPTFAs).

Everyone.

Local authorities.

PCTs.

Ensure the physical environment encourages people to be physically active (see NICE's guideline on physical activity and the environment). Implement changes where necessary. This includes prioritising the needs of pedestrians and cyclists over motorists when developing or redeveloping highways. It also includes developing and implementing public sector workplace travel plans that incorporate physical activity (see NICE's guideline on physical activity in the workplace). Encourage and support employers in other sectors to do the same.

Ensure the need for children and young people to be physically active is addressed (see NICE's guideline on physical activity for children and young people). This includes providing adequate play spaces and opportunities for formal and informal physical activity.

Audit bye-laws and amend those that prohibit physical activity in public spaces (such as those that prohibit ball games).

Consider offering free swimming to parents and carers who accompany children aged under 5 years to swimming facilities.

Apportion part of the local transport plan (LTP) block allocation to promote walking, cycling and other forms of travel that involve physical activity. The proportion allocated should be in line with growth targets for the use of these modes of transport.

Ensure cycle tracks created under the Cycle Tracks Act 1984 are part of the definitive map (the legal record of public rights of way).

Align all 'planning gain' agreements with the promotion of heart health to ensure there is funding to support physically active travel. (For example, Section 106 agreements are sometimes used to bring development in line with the government's sustainable development objectives).

Everyone.

Local policy makers.

PCTs.

Regional and local government.

Use a variety of methods to assess the potential impact (positive and negative) that all local and regional policies and plans may have on rates of CVD and related chronic diseases. Take account of any potential impact on health inequalities.

Identify those policies and plans that are likely to have a significant impact on CVD rates. This can be achieved by using screening questions that cover the social, economic and environmental determinants of CVD.

Monitor the outcomes following an assessment and use this to follow up and amend plans.

Identify where expertise is required to carry out assessments and where this is available locally.

Identify the training and support needs of staff involved in carrying out assessments and provide the necessary resources.

Everyone but particularly those who frequently use these food outlets.

People eating snacks and meals provided by public sector services.

Caterers.

Chartered Institute of Environmental Health (CIEH).

Local authorities.

Providers of hygiene training.

The food and farming network (Feast).

Ensure the links between nutrition and health are an integral part of training for catering managers. In particular, they should be made aware of the adverse effect that frying practices and the use of salt, industrial trans fats and saturated fats can have on health.

Ensure they are aware of the healthy alternatives to frying and to using salt and sugar excessively, based on the NHS eatwell guide.

The PDG considers that all the recommended measures are cost effective.

See the recommendations for research and gaps in the evidence.