By Shiva Raj Mishra, Brisbane
16 May 17
Last week I had a chat with a friend who has been hypertensive since his youth. Luckily, with tremendous efforts, he has lately tamed his hypertension – especially by changing his lifestyle.
I asked him what made him hypertensive. He uttered four words: salt, sugar, alcohol and tobacco. This reminded me of my graduate school journal papers and I questioned myself if there was sufficient evidence to accuse these four usual suspects, which I shall call SSAT, for causing greater risk of chronic diseases like hypertension. Some believe that there is a lack of evidence on whether the so-called risk factors that actually elevate risk of hypertension exist. But we all know having no evidence is not an excuse. It may be killing you slowly while you are not awake.
As the global burden of hypertension is increasing, there is worldwide attention to addressing this challenging public health problem. Globally, this “silent killer” causes nearly 10 million deaths every year. And for many, it aggravates the risk of premature mortality way more than any other diseases do. It is a major risk factor for heart attack, kidney diseases and stroke.
Hypertension in Nepal is an emerging health priority. Many researches have shown that hypertension affects nearly a third of the country’s population. The burden has nearly doubled in the past ten years. A study on 2500 people in western Nepal which was conducted by Nepal Development Society showed that 28% of those who were screened for blood pressure were hypertensive. The 2017 Nepal Demographic Health Survey covering nearly 14,000 people who participated in the voluntary blood pressure measurement showed 17% women and 23% men aged 15 and above have hypertension. The burden increases with an increase in age, with the highest burden shown in older age groups. In the lowest age group (15-19 years), 2.5% of men and 2.9 % of women were hypertensive. While there is a slow progression of hypertension with age, a high burden of hypertension among youths is particularly worrisome. Still, we don’t have any evidence on other cardiovascular diseases but their burden can be expected to be substantially high given the high burden of hypertension.
Many of us come across people using excessive sugar and salt in their daily diet and yet live a hypertension-free life. This sometimes deters our motivation to reduce risk factors like SSAT. However, what we don’t take into account is the fact that susceptibility to disease is different from people to people. Furthermore, the latency of the disease (time from exposure to the development of disease) makes the whole exposure-risk equation different among individuals – some getting the disease early on while some at a later stage in life. The genetics we are born with also changes this equation. Seeing your parents have diabetes might make you feel weak as well but more than genetics, environment and the kind of food we expose ourselves to plays a bigger role in causing such diseases. Therefore, our lifestyle needs to be modified in order to control such risk factors. It is unfortunate that most of us aren’t able to do so.
Most public health professionals know the famous story of John Snow tackling the cholera epidemic of London in the 1850s. However, we are failing to appreciate the morale of what Snow did. Can we be John Snow in Nepal’s context or we just wait until hypertension establishes itself as a serious public health challenge in the country?
As Snow pulled out the Broad Street Pump significantly reducing cholera deaths in London, we need to pull off the NCD (non communicable disease) risk factors and the environment which makes people more prone to NCDs by limiting the intake of sugar and junk food. The bigger junk food companies will not be so happy but they are better off investing their capital in health-promoting industries – rather than sell junk at school canteens. It is not so surprising that today noodles are given as snacks to the children. Our consumption behaviour affects children. Will we be able to make the right personal choice and cut down consumption of junk food is another question. We eradicated smallpox which once used to be the leading killer of newborns. And many other diseases like polio and tetanus are on the way for eradication. We have been able to go this far due to a high political commitment and a determination to solve it from the roots.
Similarly, the biggest threat to human health at present and the precursor for too many chronic diseases is hypertension and it should be addressed with the population-based approach. Putting choice on individuals to decide noodles over greens won’t be much help to attain this objective because we sometimes do not have control over our choices. People are blinded by the false messages in the news that junk food is okay to eat. Even putting scholarships like “………gyanodaya” to children and prizes by some noodles companies in the past have tried enormously to create a false notion that they do care about the health of their consumers. What can we do then? First thing to do would be to tax SSAT which is a potential solution to changing the mass consumption behaviour. Mexico, Chile, Hungary, France have has already implemented this. UK and South Africa recently announced that they will introduce some forms of stringent taxes on sugary drinks. In some other countries like Australia, a modelling study in the past has shown that the country can save up to A$609 over the life time among the individuals aged >=20 years in 2010. So far studies accounted tax measures alone on sugary drinks, the effect of introducing simultaneous taxes in SSAT and subsidies in healthy foods would be enormous, and is an area for future study. A previous study showed combined effect of taxes on unhealthy food (salt, saturated fat, sugar and sugar-sweetened beverages) and subsidies in healthy food (fruits and veg) would be nearly A$3.4 billion to the health sector. Further clear food labelling on junks is getting momentum in countries like Australia using the front-of-pack nutrition labelling which is estimated to contribute a cost saving of A$81 million to the health sector.
Taxation not only enlarges the basket of money that can potentially be spent for chronic disease care, it also works as a negative incentive to pursue healthy consumption behaviour. The decision to live healthy or unhealthy is ours. But if people are not willing to adopt a healthy lifestyle then the government should step in to do what is needed for a healthy living. For that to happen, we need our government (Government of Nepal) to show us both carrot and stick. Taxation is certainly the ‘stick’ but there are not enough ‘carrots’ under the current circumstances. There should be subsidies on fruits, vegetables, dairy products and even health-promoting equipment like bicycles, various sports gears and gym membership.
Finally, the matter is simple. Be active and reduce consumption of sugar, salt, alcohol and tobacco and eat plenty of fruits and vegetables. Doing this you will definitely move a step forward for a non-communicable disease-free life.
The author is a cardiovascular epidemiologist affiliated with The Nepal Development Society and a PhD student in Statistical-epidemiology at The University of Queensland, Australia. He can be reached at firstname.lastname@example.org; Twitter: @SRajTweets (The writer is solely responsible for opinions expressed in this article.)