It is one of Scotland’s biggest killers and despite it affecting people individually, it is nonetheless being discussed in terms of reaching epidemic proportions.

Medical professionals, patients’ groups, public service providers and pharmaceutical representatives gathered at Holyrood magazine’s Health Briefing earlier this month to discuss Scotland’s efforts to fight heart disease.

Attendees were particularly interested to hear from Scottish public health minister Michael Matheson MSP, who was there to outline the Government’s plans to tackle the disease.

Opening the conference, Matheson began by offering optimism and realism in equal measure.

“It would be fair to say that in the last 14 years we have made significant progress in addressing mortality rates that are caused by heart disease; but even though we have made significant It would be fair to say we have made significant progress in this area in recent years in reducing the number of people in Scotland who do smoke, and also we brought in legislation that will help, I believe, to create some of the cultural shift we need.

“Alcohol remains a major problem within our society, and it contributes to many other diseases. We have taken forward the Alcohol Framework, which has 40-odd different elements to it in order to deal with this issue. We also have the Alcohol Act, which came into play just this weekend, and we have the new licensing regime in place. We know one of the key drivers to alcohol consumption is affordability. As a government, we are determined to take action on that and that is why we’ve given a clear commitment to bringing forward a minimum pricing bill in this Parliament at the earliest opportunity.

“Obesity is a very significant challenge for the health agenda here in Scotland. I personally believe that it requires a real shift in culture and in thinking. In the last 12 years, much of the debate in Parliament has focused on the idea that we just need to get people more physically active. Yes, that is part of it; but if you look at the obesity route map, you can see there is a very complex picture that will require a multi-sectoral approach to dealing with the issue effectively.

If we as a government and as a country are determined to do that then we must make sure we put in place the right measures.” Returning to the subject of prevention, Matheson highlighted the influence of the fiscal context of heart disease care, with a major push needed at a time of constrained budgets. “In the present financial climate, all of these things are going to be increasingly difficult for us to create the change that we believe is necessary. Even within that, I do believe we can continue to make progress on it,” he said.

Matheson was followed at the podium by Sally Haw, Professor of Public and Population Health at the University of Stirling. Echoing Matheson’s comments, she praised Scotland’s anti-smoking strategy as “perhaps one of the most comprehensive in the developed world”, but offered a bleaker assessment of attempts to tackle obesity.

“One particular success has been the introduction of the smoking ban, and I think politicians showed great courage across all countries in promoting a comprehensive ban rather than just a partial ban. We’ve been able to implement a comprehensive evaluation which has shown that there has been not only a reduction in exposure among bar workers but a 40 per cent reduction in exposure at a population level.” Haw highlighted a 17 per cent reduction in heart attack admissions in the year following the ban, compared with only four per cent in England, before a similar ban was introduced there. “We are also able to show that 67 per cent of the admissions prevented were amongst nonsmokers, so we do believe we can attribute this dramatic health gain in the population to the smoking ban,” she added.

Haw cautioned that the rate of decline in smoking was levelling out, and that some specific communities had been resistant to the anti-smoking message, with smoking rates of upwards of 50 per cent. Nonetheless, her overall assessment was upbeat.

However, Haw’s analysis of the outlook for dealing with obesity – which she termed “the elephant in the room” – was far less optimistic.

“A paper published in The Lancet a month or so ago estimated that by 2020 about two thirds of the English population would be overweight or obese, and this is a significant risk factor for CHD. There is nothing to suggest that the same isn’t true for Scotland, and it may be even worse.

“The trajectory of obesity presents challenges, I think, of a magnitude we’ve only just begun to realise. I think we can learn a lot from the approaches to tobacco control and apply these in addressing the issue of obesity,” Haw concluded.

Offering both a political view from the opposition as Labour’s shadow public health spokesman, and speaking as a former medical practitioner, Dr Richard Simpson shared his fellow panel members’ views on the varying levels of progress on the different risk factors.

He also suggested some further measures he felt the Government could take, and sounded a note of caution on analysing the effects of minimum alcohol pricing.

“We clearly made good progress on smoking, but we need to make further progress that is going to have to be highly focused. We are going to have to look at the situation with children, whether smoking in cars is something that should be addressed. We need to look at the question of specific groups, for example, people with enduring mental health problems,” Simpson said.

“Inevitably now, we are going to have minimum unit pricing [for alcohol]. I would just make a very strong appeal that we actually evaluate this properly before we sell it to the rest of the world. If we are going to sell this to the rest of the world as being something that is valid, it has to be properly evaluated – that is, not just a before and after study: it should be a randomised control trial.” Like speakers before him, Simpson singled out obesity as the biggest challenge facing Scotland’s health system in combating heart disease. He argued for strong government intervention, calling for taxation of salt, saturated fats and sugary drinks, and for an outright ban on transfat.

“I think we actually in Scotland have a very good programme with Counterweight, which I hope will continue to be funded in December when the funding runs out. I think that is critical. It is something innovative and it seems to be working well, but I would like to see us go beyond that. I think we need to go beyond the nudge process of introducing children to vegetables and fruit, which we’ve been doing by trying to change people’s habits in primary one, two and three.

“I think that we need to look at trans-fats.

Eighty per cent have been removed from manufacturing; we should get rid of the remaining 20 per cent. I tried a member’s bill but it wasn’t backed in the last Parliament. The WHO is now calling for a ban on trans-fats – let’s get on with it and close that door, end that chapter.

“We also need to look at salt, and I think we need to be much stronger on that. We need to look at saturated fats, which Denmark is now taxing. It is not just a question of labelling; it is a question of taxing.

“Sugary drinks, which France is now taxing and we drink a lot more of in Scotland; we need to think about regulation and legislation where it is within our powers, and some of it may not be, to try and do more than simply nudge – because I don’t think a nudge will be enough.” Simpson ended his address by calling for health planners to embrace new treatments, and to look at tailoring their approach towards specific groups.

Kate Sutherland, Co-chair, Scottish Heart and Arterial Disease Risk Prevention (SHARP) discussed the work of the charity, whose members include medical professionals involved in identifying the problems associated with heart disease. Their meetings “stimulate active debate and, importantly, an exchange of ideas regarding prevention, identification and management of cardiovascular disease,” Sutherland said, adding: “Even within the profession, this education needs to be continually reinforced.” There is an increasing number of people living with heart disease in Scotland, with around five per cent of the population affected, David Clark, chief executive of Chest, Heart and Stroke Scotland (CHSS) said.

While Scotland has had considerable success in reducing mortality from heart disease, he argued we have been less successful in reducing the number of incidences.

It can be a “disabling disease” so people who have heart disease need “advice, information and support,” he said.

CHSS supports wider access to cardiac rehabilitation programmes that Clark said can encourage individuals to make vital lifestyle changes – such as looking at ways to reduce stress, improve diet and become more physically active.

“Heart disease doesn’t just affect individuals but also their family and friends. It is very important that we do what we can to prevent heart disease in the future. But we must not lose sight of the importance of supporting those affected today.” The statements from members of the panel were followed by questions from the floor, with a lively debate chaired by health journalist Penny Taylor. Unsurprisingly, given the focus on the need to develop new ways of dealing with obesity, the first question came from a practising physiotherapist on the subject of diet.

“Physiotherapists have in the past dealt with other areas around childhood obesity and one of the things we noticed is that in – and it’s not often you get to use a statistic of 100 per cent – but in 100 per cent of cases where parents were concerned about their child’s weight, the child was already obese. Now, that suggests to me that there is a shortage of access to good advice from when children start taking solids as to dietary advice and in fact, if you trawl the internet you won’t find a great deal of evidence of how many grams of pasta or rice you should be giving a child,” he said.

Matheson agreed that health policy needed to move beyond encouraging physical activity, and into improving diets. “I think educating parents is one thing, but it is also making education stick. Part of the problem is, I think, there are confusing messages about what is healthy when you pick up a particular product.

I am particularly keen for us to make progress in looking at how we can address the issue of labelling of food to be much clearer.

“If you do educate people about what is a healthy portion size and what a balanced diet should include then you need to make it easier for them to understand the products they are picking up and how that fits into that particular framework,” Matheson said.

The public health minister added that he was “not persuaded” by the approach being taken by the UK Government of making much of the regulation around dietary advice on food voluntary, and leaving the matter to industry to resolve.

Haw highlighted the need for early intervention in a child’s diet, including looking at parents’ diets before a child is born.

“One issue is about breastfeeding. Scotland has the most appalling breastfeeding rates; it is across all socioeconomic groups, and a lot more can be done to really support breast feeding,” she said.

“Secondly, the child’s diet is often dependent on the adult’s diet. We can influence children’s diets most by influencing adult diets. This is about working with the industry using both carrots and sticks. I think there is opportunity to regulate to control, but also incentivise the promotion of healthy products too.” Responding to Haw’s point about breastfeeding, Simpson cautioned about taking what he called the “Daily Mail approach”, and suggested that often the simplest remedies were the most effective. “When Dundee had the worst breastfeeding rates, they switched that round by having an incentive scheme with vouchers for Asda,” he said. Simpson also claimed that height and weight charts for children, while now out of vogue, were useful and should be reintroduced.

Asked how the Government would try to reduce obesity, Matheson said: “It is a massive challenge, but it is not a challenge that necessarily just sits within the health directorate.

It is an important part of it but it goes across departmental boundaries.

“There were some findings recently that found that the own-brand supermarket products have reduced their salt levels very significantly, but the branded products haven’t. We have to look at what further action we can take in order to address that with the industry,” Matheson added.

Simpson called for a reintroduction of home economics classes in schools, so that children could re-learn cooking skills. “If Scots returned to having porridge in the morning made with oats, it would probably do more for the heart disease problem than anything else,” he said.

Simpson also welcomed the decision by the Scottish Parliament restaurant that it would begin to print calorie values on its menus, and argued that the approach should be extended across Scotland, particularly to takeaways.

Martin Coombes, representing AstraZeneca, who sponsored the event, requested an assurance that tackling heart disease will remain a priority area for government, and also asked about the implementation of best-practice guidelines in times of fiscal restraint.

“We’ve mentioned best practice and the national guidance that is available: SIGN guidelines, clinical standards, and the SMC advice that is issued,” he said. “We’ve seen under current economic conditions and the austerity measures that, sometimes affordability becomes a barrier in some cases to full implementation of the guidance. What can we expect from NHS boards in terms of the implementation of some of that guidance, particularly in terms of timescales?” “The approach we have to take has to be an evidence-based approach,” responded Matheson.

“We shouldn’t just do things for the sake of doing it because it sounds like that is the right thing to do. That is where I’m really keen to make sure that we act with a good evidence base in the approach that we take.

“Some of the things that were in the heart and stroke strategy have got a good evidence base that can actually make a real difference for people preventing heart disease and stroke occurring, and also for those post-disease to be able to get the support. There is a need to make sure that we continue to drive that strategy forward; as a government, it is a priority and it will form a key part of our preventive spend approach in this area.” Matheson said that health boards are in “no doubt” about the need to make sure patients receive the best quality of care they can receive, and added that they are expected to “adhere to and implement” the Government’s Quality Strategy in the way they take forward services at a local level.

“As a government we will hold the boards to account on that particular issue as well,” Matheson said.

The event on which this report has been based was initiated and funded by AstraZeneca. The selection of speakers and the views they expressed were independent of AstraZeneca.

progress, that progress to date is still not enough.

The levels of mortality in Scotland which are as a result of heart disease are still some of the highest in Western Europe. We know that those who live in the most deprived communities very often have some of the most marked risk factors in their lifestyles in contributing towards heart disease.” Matheson was the first, but by no means the last, to name the three risk factors for heart disease that became the dominant themes of the day’s discussion: alcohol, smoking and obesity.

“When you combine these factors together, they create a real difference in the mortality rate between those in the least deprived communities and those in the most deprived communities.

If you live in a more deprived community, you are four and a half times more likely to die from heart disease as a result of these risk factors. So tackling heart disease, and inequalities go along with this, must remain a key priority for any government that is intending to address this particular issue.” The minister highlighted how tackling heart disease risk factors went beyond solely the medical sphere, calling for a “change of lifestyle and a cultural shift in our attitude in a range of different areas”. Matheson also made clear the necessity of preventative action in this area of medicine. “Anticipatory care has a key part to play in taking this agenda forward. Our key programme in anticipatory care is the Keep Well project which so far has touched 113,000 people who have had Keep Well checks.” Laying out the Government’s agenda on each of the three risk factors, Matheson was candid on the varied levels of government action and success.

“Smoking is an area where we have a national strategy in place, and we will be bringing forward a new strategy which will focus very closely on prevention and cessation of smoking.