Heart to heart

disease is expensive in both human and economic terms, yet much can be done to
help prevent it. The workplace offers tremendous opportunities for education
and prevention, where the OH nurse can play a pivotal role, by Paula Hunt

Deaths from coronary heart disease in the UK are declining, but prevalence
rates remain among the highest in the world. It is still the most common cause
of premature death and in total causes around 125,000 deaths a year.1 Although
rates are falling among all social groups, rates among male manual workers,
such as builders and cleaners, are considerably higher than for male non-manual
workers, including doctors and lawyers. The gap is widening further because the
death rate is falling more slowly in the manual group.

Coronary heart disease costs the UK healthcare system about £1.6bn annually
(1996). However, the far greater financial burden of CHD falls on the workplace
because of loss through death, days lost through employee illness and from the
informal care of people with the disease. In 1996, such "production
losses" were estimated to have cost the UK economy £8.5bn.

Yet the workplace offers tremendous opportunities for health promotion and
CHD prevention. Because people spend a significant proportion of their day at
work, networking with colleagues and dining in workplace restaurants, the main
risk factors for CHD; raised blood cholesterol, low physical activity,
hypertension, smoking, poor diet and obesity, can all be addressed there,
through heart health initiatives.

Assessing risk

A reduction in the different risk factors for coronary heart disease would
have a considerable impact on its overall prevalence and the costs associated
with the disease. The National Heart Forum2 has estimated the impact of
changing the main modifiable CHD risk factors. As summarised in Table 1 (on
p18), realistic improvements in these risk factors could result in an overall
30 per cent reduction in CHD.

The most common single risk factor in CHD is raised blood cholesterol, which
is present in 46 per cent of cases. Physical inactivity is present in 37 per
cent of CHD patients and obesity in 6 per cent. And the overall prevalence of
those classed as overweight or obese in the population is increasing

Assessing CHD risk and developing accessible support programmes that
encourage lifestyle changes, are considerable challenges, but the rewards could
be excellent. Almost without exception, evidence has shown that lowering blood
cholesterol reduces the risk of CHD.3 Indeed, a 10 per cent reduction in blood
cholesterol at the age of 40 years has been shown to reduce the risk of CHD by
approximately 50 per cent.4

Dietary changes

It is difficult to estimate the exact proportion of CHD that is due to an
unhealthy diet.

However, the underlying cause of elevated serum cholesterol is, for the vast
majority of individuals, an excess of dietary fatty acids,5 especially
saturated fat. Achieving a healthy diet, which is low in fat and rich in fruit
and vegetables remains elusive to many in the UK.

The Balance of Good Health (see Figure 1, opposite) shows the proportions of
foods we should eat from the five different food groups to reduce risk from
CHD. Motivational help is also an important element in any attempt at dietary
change,6 and there are many educational resources that expand on heart health
dietary messages, and are suitable for use with clients in the occupational
health setting (Table 2).

Keeping fatty and sugary foods to a minimum is a clear message about eating
for good health, but within this food group, some foods are distinctly better
than others. This is especially true for fats and oils. The now
well-established message that saturated fatty acids are the ‘baddies’, while
polyunsaturated and monounsaturated fatty acids are the ‘goodies’ remains true.
The message about keeping overall (total) fat intake low – to less than 35 per
cent of total energy – also holds good.

Recent evidence, however, has shown the clear beneficial effect of plant
sterols and stanols – naturally occurring substances found in vegetable
oils.7,8 The consumption of normal daily quantities of plant sterol or
stanol-enriched spreads, milks and yoghurts (eg, Flora Pro.activ9) as part of a
healthy diet has been shown to reduce low density lipoprotein cholesterol by an
average of 10 per cent to 15 per cent within three weeks, without affecting
serum tricglycerides or high density lipoprotein cholesterol. The use of such
cholesterol-lowering foods is even recommended in the USA’s National
Cholesterol Education Program.

Table 3 is a guide to the ever-increasing range of fat spreads on the
supermarket shelf. Clients are best advised to check labels for nutrition
information, and to keep abreast of new products.

Heart health initiatives

Statistics show that men access the primary healthcare system far less
frequently than women, particularly during their working years. The
occupational health service therefore has unique access to men who work and is
well placed to assess and alert them to any possible risk of CHD.

Although the nurse/client relationship in a one-to-one consultation may be
the most personalised starting point for CHD prevention, the whole working
environment can be geared up to make healthy lifestyles more achievable. For example,
the catering contract might specify that three different undressed salads and
at least two cooked vegetables must always be provided in the dining room,
along with a choice of skimmed milk, fresh fruit and free drinking water.
Portion packs of cholesterol-lowering spreads are also very helpful. Health
promotion messages could feature in well-used places such as the stairways,
lifts, toilets and staff rooms. Gyms, shower rooms and lockers for joggers can
be provided, along with well-positioned bicycle racks for those choosing to
cycle to work. This encourages physical activity and helps resolve a common
problem of limited car-parking space.


The workplace is a prime site for heart health initiatives. The main risk
factors for CHD are raised blood cholesterol, low physical activity,
hypertension, smoking, poor diet and obesity. It is likely that a significant
proportion of the workforce will have one, if not more of these risk factors.
Through health assessment, those at risk of coronary heart disease can be
identified and referred on to their GP where necessary. The benefits for
companies and organisations, of supporting employees at risk of ill-health are
clear – a fitter, happier and healthier workforce.


1. British Heart Foundation (2000) British Heart Foundation Statistics

2. National Heart Forum (in press) Coronary heart disease. Estimating the
impact of changes in risk factors. Stationery Office: London.

3. Department of Health (2000) National service framework for coronary heart
disease. DOH:London.

4. Law MR, Wald NJ, Thompson SG (1994) By how much and how quickly does
reduction in serum cholesterol concentration lower risk of ischaemic heart
disease? BMJ; 308: 367-373.

5. Phillips C, Belsey J, Shindler J (2000) Flora pro.activ: a clinical and
financial impact analysis. Journal of Medical Economics; 3: 61-76.

6. Hunt P, Pearson D (2001) Motivating change. Nursing Standard, Sept

7. Hendriks et al (1999) Spreads enriched with three different levels of
vegetable oil sterols and the degree of cholesterol lowering in
normocholesterolaemic and mildly hypercholesterolaemic subjects. European
Journal of Clinical Nutrition 53: 319-327.

8. Weststrate JA et al (1998) Plant sterol-enriched margarines and reduction
of plasma total and LDL cholesterol concentrations in normocholesterolaemic and
mildly hypercholesterolaemic subjects. European Journal of Clinical Nutrition,
52: 334-343.

9. Law M (2000) Plant sterol and stanol margarines and health. BMJ, 320:861-864.

10. Bond M, Irving L (2000) The WaistWatchers evaluation report. North
Derbyshire NHS Health Authority. Unpublished report available from project
co-ordinator, Paul Boshell at Chesterfield PCT. Tel. 01246 231255 ext. 4286

Paula Hunt is an independent consultant nutritionist and state registered

Table 1 Effect of reducing risk factors for CHD

Risk factor                   Most likely
change                                          Reduction in CHD(per cent)

Blood cholesterol          All with levels <6.5 mmol/l                                11
Physical inactivity          All light and
sedentary become moderate           10
Blood pressure             50 per cent with levels <140/90                        6
Smoking                       Prevalence of 24 per cent                                 0.5
Obesity            6 per cent men, 8 per
cent women with BMI >30          3
Total                                                                                                    30

Source: National Heart Forum (in

Table 2. Educational resources

– Cut the saturated fat from your
diet. British Heart Foundation (2002) Tel.020-7935 0185 or visit www.bhf.org.uk

– So you want to lose weight… for good. British Heart Foundation (2001) Tel.020-7935
0185 or visit www.bhf.org.uk

– Eating to manage your cholesterol (other CHD risk factor leaflets also
available). The Flora Project. Careline Tel. 0800 389 8193

– Healthy eating for a healthy heart: patient information.
Nursing Standard (2002) Vol 16: 25. Photocopiable leaflet

– Healthy Eating made simpler: patient information. Nursing
Standard (2002) Vol 16: 21 Photocopiable leaflet

Table 3. Spreading fats: a rank

Sterol-enriched low fat spreads

Especially for those with raised blood cholesterol or at risk
of heart disease

Low fat spreads

Choose those with the least saturated fat. Spreads with mainly
polyunsaturated or monounsaturated fats are both fine

Fat spreads and soft margarines

The total fat content varies widely. Unlike spreads, all
margarines, by definition are as high in fat as butter, but some will be mainly
polyunsaturated or monounsaturated fat. Fat spreads are slightly lower in total
fat but may be highly saturated

Butter and hard margarines

Butter is high in saturated fat. Hard margarines may be based
on vegetable oil, but they are hydrogenated to make them solid. This makes them
high in trans-fatty acids, which behave like saturated fatty acids in the body

Tackling heart health – a case study

The WaistWatchers programme is a good example of best practice in action.
Run by Chesterfield Primary Care Trust, the eight-week educational programme
focuses on men working in the manual ‘blue collar’ sector, which is a high-risk
group that is traditionally difficult to target with any effectiveness.

The WaistWatchers scheme focuses on men aged 30 years to 60
years, with a high waist to hip ratio (>0.9) known as central (apple-shaped)
obesity. Recognising the importance of cholesterol management for people with
this kind of obesity, the WaistWatcher scheme aims to reduce CHD risk factors
and drive weight loss.

The course is run by a link person, usually an occupational
health nurse, and focuses on adopting a healthy lifestyle. It includes weekly
sessions on different risk factors, including the role of diet, alcohol and
healthy eating, along with a weekly physical activity session. The ethos is about
small realistic changes that the men will find achievable. A slightly
competitive, team element, between companies, is built into the course.

Risk factors such as hypertension and raised body mass index
are identified and men are referred to their GPs, who may then test their
cholesterol level as part of an overall assessment. Results of the scheme to
date have been encouraging.10 Of the 71 participants completing the programme,
76 per cent had lost weight, 83 per cent had reduced their waist measurement,
44 per cent said they had reduced the amount of fat in their diet, half were
more physically active and half said they drank less alcohol. Other benefits
reported were a clearer understanding about how to improve diet, feelings of
better health and well-being and improved fitness and self-esteem.

Lillian Bryant, OH nurse at Sappa Profiles Ltd says:"I
think you get the most success with men by targeting them in the workplace. Men
seem to find it difficult to seek out support on their own. They need to have a
good link person to coax and keep them going. Some of the men are really quite
heavy, but they enjoy the WaistWatchers programme and look forward to the
weekly sessions. After the programme has stopped, many join gyms or go
swimming, so they remain active.

"Of course you have to handle it carefully with the
company. There are lots of incentives. With the WaistWatchers programme
employees get fitter and have fewer weight-related problems, so are more likely
to be doing their job properly. Also, there’s less absenteeism."

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