Approximately twenty years ago, developed countries, including the Czech Republic, saw a stalling in the until-then significant drop in cardiovascular disorders, and the situation has not changed considerably. We have to search for innovative approaches to prevention, declared Reuven Zimlichman, Director of the Institute for Cardiovascular Research, Sackler Faculty of Medicine, Tel-Aviv University, at the international panel of the Zdravotnický deník Permanent Conference on Czech Healthcare. Harm reduction will continue to play a larger and larger role in prevention policies, whether pertaining to smoking, obesity, exercise, or diet. Both experts and politicians have to play an integral role in this effort.
Approximately twenty years ago, developed countries, including the Czech Republic, saw a stalling in the until-then significant drop in circulatory system disorders, and the situation has not changed considerably. “If we wish to achieve a further decrease in numbers, we have to search for innovative approaches to prevention,” declared Reuven Zimlichman, Director of the Institute for Cardiovascular Research, Sackler Faculty of Medicine, Tel-Aviv University, at the international panel of the Zdravotnický deník Permanent Conference on Czech Healthcare.
According to him, the principle of harm reduction when it comes to addictive behaviour should play an increasingly greater role in prevention policies. “We have to take advantage of all the possibilities that this approach offers. We have to try to forestall the harm of cigarettes, alcohol, bad diet, or insufficient exercise to the maximum degree. This can save many lives,” Zimlichman claimed.
He also believes that governments have to play a highly extensive role in these efforts. “Governments should put together special teams of experts that will evaluate substitutional therapy and will be able to prove that these alternatives are better than the original addiction itself. We need to have an open mind and apply the principle of harm reduction anywhere possible,” he appealed. And added: “And, we have to teach children and young adults how to lead a healthy lifestyle. Old people are rather reluctant to change their lifestyles.”
Limiting of just one single risk factor already helps
To date, experts have identified approximately 200 risk factors for developing cardiovascular diseases, which remain the greatest killer in the Czech Republic. However, there are “only” about twenty of the most significant factors. According to Zimlichman, they can be divided into three categories depending to what degree they can be prevented and whether they are treatable. “Among those factors that can be changed, or at least we think so, are smoking, obesity, diet, stress, excessive alcohol intake, and lack of exercise. There are patients that can quit smoking, improve their diet, and lose weight. But on the other hand, there are also those who are not able to,” Zimlichman explained.
Those risk factors that we cannot avoid include, for example, age, gender, family history, or ethnicity. And finally, we have factors that also contribute to the progression of illness but can be treated: the better we are able to do so, the less grave the disease. Here experts place, for example, hypertension, high blood cholesterol levels, heart arrhythmia, or diabetes. “The more risk factors one patient has, the greater the risk (the graver the disease). If just one single risk factor is taken care of, it greatly affects the entire risk of developing cardiovascular disease,” he specified.
When it comes to cardiovascular diseases being the cause of death, according to Zimlichman, we should fear hypertension the most, then smoking and high blood sugar levels. A lack of exercise, being overweight or obese, or high cholesterol levels have a somewhat smaller influence.
We have to search for innovative solutions
As already mentioned above, until 2000, practically all developed countries witnessed a gradual decline in cases of cardiovascular diseases. Since then, however, the curves have been stagnating. In 2016, the World Health Organisation (WHO) published a list of recommended strategies that should reduce this health burden by a quarter before 2025. Despite this, no fundamental improvement can be seen since then.
“If we are to continue at this speed, the question remains whether we shall ever achieve a better result,” Zimlichman speculated. “If we want our curves fall again, we must find another solution, a novel approach. The graphs clearly show this. Of course, we must continue in the efforts we are already familiar with and that we are able to explain and teach patients, but our success rates are limited here. If we want an overall improvement, we have to begin doing new things,” professor added.
If you cannot quit, then try less at least
According to Zimlichman, we have to simply begin to accept that people make bad decisions even if it has a negative impact on their health. “They continue to overeat and eat chocolate, even if they have diabetes. Patients with chronic obstructive pulmonary disease continue to smoke, and those with ischemic heart disease continue to lead sedentary lifestyles and have unhealthy diets,” he listed the weaknesses of not just his patients.
He believes that doctors should find a compromise between a patient’s behaviour and their freedom to decide on their own lives and expert recommendations in terms of lifestyles, habits, and treatments. “And this is not always successful,” he stated. The answer lies in the principle of harm reduction when it comes to human health. This principle is successfully applied in a range of fields: “With regards to unhealthy diets, we use statins, stents, or an antiaggregant. We protect ourselves from sun rays with filters. We satisfy our cravings for sugar with sugar substitutes. We protect ourselves from sexually transmitted diseases by using condoms or getting vaccinated,” he delineated.
Zimlichman explained that rather than focusing on the harmful behaviour itself, the principle of harm reduction focuses on the result of this harmful behaviour. “In other words, if you cannot quit, then try less at least. If you cannot stop taking illegal drugs, then prevent overdosing and spread of infections,” he specified.
In regard to what was said, it is no surprise that this opinion is considered somewhat controversial. Such behaviour also bears negative aspects – it can be illegal, or immoral at the very least. “But people who do not want to change, or who are not able to, exist. It is in such situations that harm reduction can be beneficial in terms of chronic diseases that are caused,” Zimlichman explained.
The cruel reality
He also believes that the same approach be applied in the case of smoking. “Yes, the best thing to do is quit but estimates show that worldwide, about a billion people will continue to smoke in the near future. If we tell them that they should quit smoking and they do not quit, do we leave them to their fate? Or do we come up with something that will improve their chances?” he asked rhetorically.
As already mentioned, smoking is one of the most significant risk factors in the development of cardiovascular diseases, which can be avoided, however. “In comparison to non-smokers, the risk of myocardial infarction is six times higher in those women and three times higher in those men who smoke at least twenty cigarettes daily. If the patient in question quits smoking after their heart attack, the risk of its recurrence within one year is lowered by one half, and in two years, they will be on the same level as non-smokers,” Zimlichman pointed out.
Despite this clear evidence, the reality remains cruel. Studies show that 49 percent of smokers with damage to their coronary arteries do not quit their bad habit even after being diagnosed. This is also true for the 57 percent of those who survive a heart attack and for the 72 percent of patients with peripheral artery disease.
Therefore, to Zimlichman it makes sense to reduce the harm of smoking with the help of alternatives to conventional cigarettes, which significantly lower the risk of developing a disease. “If we convince a patient to use one of the alternatives in which there is no combustion, their chances greatly increase,” he stated.
In some countries, these alternatives have already been established as a permanent component of prevention policies, such as in Great Britain, where Public Health England (PHE) already considers electronic cigarettes as a tool for quitting, or the US Food and Drug Administration (FDA). According to FDA, some tobacco products (based on oral and heated tobacco) are modified risk tobacco products for consumers, and their producers can sell these products with this information on the US market. Sweden, which is the only country in the EU where smokers can use oral, smoke-free, tobacco called snus, has recorded the lowest smoking rate in the EU and the lowest lung cancer death rate, as well as other smoking-related diseases.
“We already have sufficient evidence that these alternatives can help. However, it is slow going and people have a low level of awareness of them. If they are talked about more, people will also begin to better understand them,” Zimlichman believes.
We have to remedy the last 50 years of human development
We can come to similar conclusions in the cases of being overweight or obese along with the lack of exercise. Although Zimlichman concedes that there is no scientific evidence available that proves that the losing of weight among older obese people leads to lowering their death rate, it is still true that obesity increases the risk of hypertension, high blood cholesterol levels, or diabetes. On the contrary, losing weight means a greater level of physical activity for patients, and thus a lower dependency on others and also a higher quality of life. Then, especially for older people who exercise less, more exercise then offers, for example, improved blood pressure, a lower blood sugar and lipid level, improved neurocognitive functions, and again, a higher quality of life and lower dependency on others.
There is room for harm reduction as well. In terms of obesity, it is bariatric surgery, despite its rather limited success rate. Not all patients are willing to undergo surgery for fear of complications. Furthermore, when treating diabetes, we know modern therapies such as GLP-1 agonists or the Ozempic or Victoza medications. Food labelling can also help. “In Israel, we have special stickers that label food with a high sugar content, or that are high in calories and fat. They are supposed to help parents avoid buying food for their children that is not healthy,” Zimlichman described.
“As for exercise, the WHO recommends 150 minutes of moderate-intensity exercise each week. However, we must convince patients to exercise at least ten minutes a day. If you exchange your sedentary lifestyle for any type of exercise at any intensity, you will always achieve significant health improvement. Whether it be the overall flexibility of the body, balance, or increased self-esteem,” professor added, according to whom simple walking – the faster, the better – already helps.
Furthermore, with a lack of exercise, one is greatly at risk for developing muscle loss disease (sarcopenia). This worsens with age and leads to immobility. In this regard, Zimlichman believes that we must focus on children and young adults. Studies show that they have less physical activity, which can lead to health complications in the future.
“During the last two and a half million years, we as people became erect, lost weight, and became more active. In the last fifty years, however, something has happened – we slouch, we are getting fatter, and we are increasingly lazy. We must change something to rectify this development,” Professor Reuven Zimlichman concluded.
Helena Sedláčková
