Coronary heart disease statistics

2010 edition

Peter Scarborough, Prachi Bhatnagar, Kremlin Wickramasinghe, Kate Smolina, Colin Mitchell and Mike Rayner

British Heart Foundation Health Promotion Research Group

Department of Public Health, University of Oxford

British Heart Foundation Statistics Database www.heartstats.org 1 Contents

Page Foreword 7 Introduction 8 Summary 9 Glossary 11 Chapter 1 Mortality 14 Targets Table/Figure CVD mortality targets Table 1.1 17 Tracking English CVD target Figure 1.1a 18 Tracking English CVD inequalities target Figure 1.1b 18 Tracking Scottish CHD target Figure 1.1c 19 Tracking Welsh CHD target Figure 1.1d 19 Tracking Welsh inequalities CHD target Figure 1.1e 20 Deaths by cause Numbers of deaths by age and sex, UK Table 1.2 21 Numbers of deaths by sex and country of the UK Table 1.3 22 Male deaths by cause, all ages Figure 1.3a 23 Female deaths by cause, all ages Figure 1.3b 23 Male deaths by cause, under 75 Figure 1.3c 24 Female deaths by cause, under 75 Figure 1.3d 24 Excess winter mortality Excess winter CVD mortality, England and Wales Table 1.4 25 Time and geographical trends Age-specific CHD time trends, UK Table 1.5, Figure 1.5a, b 26-27 CHD time trends, by Government Office Region Table 1.6 28 Premature CHD death rates, by local authority Table 1.7, Figure 1.7a,b 29-35 Socio-economic differences CVD, CHD, stroke by socioeconomic status, England and Wales Table 1.8 36 CHD by socioeconomic status, England and Wales Figure 1.8 36 British Heart CHD by deprivation quintile, Great Britain Table 1.9, Figure 1.9a,b 37-38 Foundation Statistics Database www.heartstats.org 2 International differences Time trends in CHD death rates, Europe Table 1.10a,b 39-40 CHD death rates, selected European countries Figure 1.10a 41 Changes in CHD deaths rates over 10 years, selected European countries Figure 1.10b 41 Chapter 2 Morbidity 42 Incidence Myocardial infarction, England and Scotland Table 2.1, Figure 2.1 46 Stroke, England and Scotland Table 2.2, Figure 2.2 47 Angina, UK Table 2.3 48 Heart Failure, UK Table 2.4 48 Case-fatality Myocardial infarction, England and Scotland Table 2.5 49 Stroke, England and Scotland Table 2.6 49 Prevalence CHD, stroke, myocardial infarction, angina, England Table 2.7 50 CHD, stroke, myocardial infarction, angina, Scotland Table 2.8 50 Any heart condition, stroke, myocardial infarction, angina, heart failure, Wales Table 2.9 51 Stroke, myocardial infarction, angina, Northern Ireland Table 2.10 51 Myocardial infarction, stroke, angina, UK Figure 2.10a,b,c 52-53 Angina, UK Table 2.11 54 Heart failure, UK Table 2.12 54 CHD, stroke, hypertension by health authority, UK Table 2.13 55 CVD over time, by age and sex, Great Britain Table 2.14, Figure 2.14 56-57 Chapter 3 Treatment 58 Prescriptions for CVD Time trends, England Table 3.1, Figure 3.1 62-63 Revascularisations Time trends in CABGs, PCIs, UK Table 3.2, Figure 3.2 64 Inpatient episodes Main diagnosis, England and Scotland Table 3.3 65 Main diagnosis, England Figure 3.3a,b 66 Main diagnosis, Scotland Figure 3.3c,d 67

British Heart Foundation Statistics Database www.heartstats.org 3 Hospital discharges Time trends in hospital discharges for CVD, Europe Table 3.4 68 Time trends in hospital discharges for CHD, Europe Table 3.5, Figure 3.5 69-70 Time trends in hospital discharges for stroke, Europe Table 3.6, Figure 3.6 71-72 Smoking cessation Time trends in use of nicotine replacement therapy, England, Scotland and Northern Ireland Table 3.7 73 Ambulance services Time trends in responses to emergency calls within eight minutes, England Table 3.8 74 Treatment after a heart attack Time trends in thrombolytic treatment and use of secondary prevention medication, England and Wales Table 3.9 74 Chapter 4 Behavioural risk factors 75 Smoking Time trends in smoking prevalence, Great Britain Table 4.1, Figure 4.1 80-81 Time trends in smoking prevalence, Northern Ireland Table 4.2 82 Prevalence by region, UK Table 4.3 83 Prevalence by socioeconomic status, Great Britain and Northern Ireland Table 4.4, Figure 4.4a,b 84-85 Prevalence by ethnic group, England Table 4.5 86 Time trends in prevalence of smoking in young people, England, Scotland, Wales, Northern Ireland Table 4.6 87 Prevalence of tobacco use, the World Table 4.7 88 Diet Time trends in consumption of fat, salt, sugar, fibre, fruit and vegetables, Great Britain Table 4.8 89 Time trends in consumption of selected foods, UK Table 4.9, Figure 4.9,a,b,c 90-92 Quality of diet, UK Table 4.10 93 Consumption of salt, Great Britain Table 4.11 93 Consumption of fat, salt, sugar, fibre, fruit and vegetables, by Government Office Region Table 4.12 94 Consumption of fat, salt, sugar, fibre, fruit and vegetables, by income quintile, UK Table 4.13 95 Consumption of fat, salt, sugar, fibre, fruit and vegetables, by ethnic group, UK Table 4.14 96 Consumption of fruit and vegetables in children, England Table 4.15 97 British Heart Total energy available from fat and availability of fruit Foundation and vegetables, Europe Table 4.16 98 Statistics Database www.heartstats.org 4 Physical inactivity Trends in prevalence, England, Scotland, Wales Table 4.17 98 Prevalence, England, Scotland, Wales and Northern Ireland Table 4.18 99 Prevalence by strategic health authority, England Table 4.19 100 Prevalence by income quintile, England Table 4.20, Figure 4.20 101 Prevalence by ethnic group, England Table 4.21 102 Time trends in children’s physical activity levels, England Table 4.22 102 Prevalence by country, European Union Table 4.23, Figure 4.23 103-104 Alcohol Consumption by sex and age, Great Britain Table 4.24, Figure 4.24 105 Time trends in heavy drinking, Great Britain Table 4.25, Figure 4.25 106-107 Time trends in consumption by children, England Table 4.26 108 Time trends in consumption by children, Scotland Table 4.27 109 Heavy drinking by country or region, Great Britain Table 4.28, Figure 4.28a,b 110-111 Consumption by socioeconomic status, Great Britain Table 4.29, Figure 4.29 112-113 Consumption by ethnic group, England Table 4.30 114 Frequency of heavy drinking by country, European Union Table 4.31, Figure 4.31 114-115 Chapter 5 Medical risk factors 116 Blood pressure Definition and recommendation for treatment Table 5.1 123 Time trends in prevalence of hypertension, England Table 5.2, Figure 5.2a,b 124-125 Blood pressure levels, England Table 5.3, Figure 5.3 126 Blood pressure levels, Scotland Table 5.4 127 Prevalence of hypertension, Wales Table 5.5 127 Blood pressure levels by Government Office Region, England Table 5.6 128 Blood pressure levels by income, England Table 5.7 128 Blood pressure levels by ethnic group, England Table 5.8 129 Prevalence of hypertension by country, Europe Table 5.9 129 Cholesterol Recommendations and target Table 5.10 131 Time trends in cholesterol levels, England Table 5.11, Figure 5.11 132 Prevalence of low HDL-cholesterol, England Table 5.12 133 Prevalence of total cholesterol and low HDL-cholesterol by region, England and Scotland Table 5.13 133 Prevalence of total cholesterol and low HDL-cholesterol by income, England Table 5.14 134 Prevalence of total cholesterol and low HDL-cholesterol by ethnic group, England Table 5.15 134 British Heart Foundation Statistics Database www.heartstats.org 5 Obesity Targets, UK Table 5.16 135 BMI by sex and age, England Table 5.17, Figure 5.17 136 Prevalence of raised waist circumference, England Table 5.18 137 Overweight and obesity in children, England Table 5.19 137 Underweight, healthy weight, overweight and obese school children, England Table 5.20 138 Time trends in prevalence of obesity, England Table 5.21, Figure 5.21 139 Time trends in prevalence of overweight and obesity in children, England and Scotland Table 5.22, Figure 5.22 140 BMI by Government Office Region, England Table 5.23 141 BMI by income, England Table 5.24 141 Raised waist circumference by income, England Table 5.25 142 BMI, waist-hip ratio and waist circumference by ethnic group, England Table 5.26, Figure 5.26a,b 142-143 Prevalence of overweight and obese children, the World Table 5.27 144 Diabetes Prevalence of diagnosed diabetes, England Table 5.28 145 Prevalence of diagnosed diabetes, Scotland Table 5.29 145 Prevalence of diagnosed diabetes, Wales Table 5.30 145 Prevalence of diagnosed diabetes, Northern Ireland Table 5.31 146 Time trends in the prevalence of diagnosed diabetes, country of the UK Table 5.32, Figure 5.32a,b 146-147 Prevalence of diagnosed diabetes by Government Office Region, England Table 5.33 148 Prevalence of diagnosed diabetes by income, England Table 5.34 148 Prevalence of diagnosed diabetes by ethnic group, England Table 5.35, Figure 5.35 149 Prevalence of diabetes by country, Europe Table 5.36 150 Chapter 6 Economic costs 151 Health care costs CHD, CVD, stroke, UK Table 6.1, Figure 6.1a,b,c 153-154 Total costs CHD, CVD, stroke, UK Table 6.2 155 International differences in costs CHD, CVD, stroke by EU country, Europe Table 6.3 156

British Heart Foundation Statistics Database www.heartstats.org 6 Foreword

This new edition of Coronary Heart Disease Statistics documents areas in the fight against coronary heart disease in which we have come a long way, where we still have a long way to go, and where we have barely made an impact.

The successes should be celebrated. Mortality rates from coronary heart disease continue to fall. The first edition of this series of publications reported 175,793 deaths from coronary heart disease in the UK in 1988 – the equivalent figure reported here for 2008 is 88,236. This fall in deaths is due to a combination of increased public understanding of risk factors for coronary heart disease, government policies aimed at helping people achieve healthy lifestyles and improved treatment for coronary heart disease aimed both at treating the condition once it has presented and preventing the condition before presentation. The BHF can take pride in the knowledge that many of the beneficial changes that have taken place in the prevention and treatment of coronary heart disease in recent decades have resulted directly from BHF- funded research. But the number of deaths from coronary heart disease is still shockingly high. Over 12,500 people under the age of 65 in the UK died from coronary heart disease in 2008. That’s about 35 people every day, many of whom did not live long enough to enjoy their retirement or experience their grandchildren growing up.

We still have a long way to go in preparing for the extra resources that will be required in the future to cope with an older population and the increased levels of coronary heart disease that will accompany this demographic change. The fact that people are living longer in the UK – and surviving longer after being diagnosed with coronary heart disease – is a success story, but the implications for health resources must be appropriately planned. Statistics in this publication suggest that we already spend about £3.3 billion pounds a year on health care costs for CHD, and this amount will only increase in a population where the number of people living with coronary heart disease is increasing.

And the social gradient in coronary heart disease that is described throughout this publication still stubbornly remains, despite much effort to remove it. This gradient is clearly demonstrated by comparisons of adults of working age in England and Wales, where women in manual employment are five times as likely to die from coronary heart disease as women in higher managerial and professional employment, and men in manual employment are three times as likely to die as men in higher managerial and professional employment. Disturbingly, evidence presented in this publication suggests that the relative difference between coronary heart disease mortality rates in the most deprived and most affluent areas of Great Britain has barely changed since the mid 1990s, and may have slightly increased.

As generations of politicians, researchers and charities have found, there is no magic bullet that will remove these social inequalities. Instead, we must continue the good work of tackling the causes of coronary heart disease in all individuals and all communities, whether these causes are genetic, behavioural, social, cultural or economic.

Professor Peter Weissberg Medical Director, British Heart Foundation British Heart Foundation Statistics Database www.heartstats.org 7 Introduction

This is the seventeenth edition of Coronary Heart Disease Statistics published by the British Heart Foundation. The series of publications began twenty years ago, aiming to document the burden of coronary heart disease (CHD) in the United Kingdom. Since then the publication has expanded to include information on other cardiovascular conditions including stroke and heart failure and dedicated sections on cardiovascular risk factors.

Coronary Heart Disease Statistics is designed for health professionals, medical researchers and anyone with an interest in CHD. It is a compendium of the latest statistics drawn from a variety of sources including national statistics, hospital episode statistics, national and international surveys and peer- reviewed journal articles. Most of the information that appears in the compendium has been previously published elsewhere, but there are a number of tables and figures that are new to this publication (for example: CHD mortality rates by local authority in the UK; estimates of the incidence of heart attack, stroke, heart failure and angina).

The compendium is divided into six chapters. Chapter one describes social, ethnic and geographic patterns in mortality from cardiovascular diseases. Chapter two describes the morbidity burden of cardiovascular diseases in the UK, focusing on estimates of incidence, prevalence and case fatality. Chapter three describes treatment levels for cardiovascular diseases. Chapter four details the prevalence of behavioural risk factors for CHD (smoking, poor diet, physical inactivity and alcohol consumption), describing differences in prevalence by social group, ethnicity, geographic region and describing the burden amongst children. Chapter five details the prevalence of medical risk factors for CHD (raised blood pressure, raised cholesterol, overweight and obesity, diabetes), describing differences in prevalence by social group, ethnicity and geographic region. Chapter six provides estimates of the economic costs of cardiovascular diseases to the UK economy and health systems. Wherever possible, the situation in the UK is contrasted with international data.

Each chapter contains a set of tables and figures to illustrate key points and a brief review of the data presented. Where appropriate, public health targets for England, Wales, Scotland and Northern Ireland are also presented.

All of the tables and figures in the compendium are also available from the British Heart Foundation’s www.heartstats.org website. This website aims to be the most comprehensive and up-to-date source of statistics on cardiovascular disease in the UK. The website is updated on an ongoing basis and contains a wider range of tables and figures than is available in the Coronary Heart Disease Statistics series of publications. Further copies of this publication can be downloaded from the website, as well as copies of recent supplements to the Coronary Heart Disease Statistics series, including:

n Ethnic Differences in Cardiovascular Disease (2010)

n Stroke Statistics (2009)

n European Cardiovascular Disease Statistics (2008) British Heart Foundation n Regional and Social Differences in Coronary Heart Disease (2008) Statistics Database n www.heartstats.org Diet, Physical Activity and Obesity (2006) 8 Summary n Heart and circulatory disease is the UK’s biggest killer. n In 2008, over 191,000 died from heart and circulatory disease in the UK including 88,000 deaths from CHD and a further 43,000 from strokes. n CVD caused more than 50,000 premature deaths in the UK. More than one in four deaths in men before the age of 75 and one in five deaths in women before the age of 75 is from CVD. n In recent years CHD death rates have been falling more slowly in younger age groups. n Death rates from CHD are highest in Scotland and North of England, and lowest in the South of England. n Death rates from CVD have been falling in the UK at one of the fastest rates in Europe. But death rates in the UK still remain relatively high compared to some Western European Countries. n There are around 124,000 heart attacks in the United Kingdom every year. n In England and Scotland stroke incidence rates are about 25% higher in males than females. n In 2009 incidence of angina was highest in Scotland and incidence of heart failure was highest in Northern Ireland while England had the lowest rate for both conditions. n In 2008 around 266 million prescriptions were issued for CVDs in England. n Over 80,000 PCIs are now carried out every year in the UK, more than three times as many as a decade ago. n The annual number of inpatient episodes for CVD has increased to 422,000 in England, 49,000 in Scotland and 27,000 in Wales. n The prevalence of smoking is higher in Scotland and Northern Ireland (both 24%) compared to England and Wales (both 21%). n Only around a third of men and women currently consume the recommended five portions of fruits and vegetables per day in Britain. n Only around one in five boys and girls aged 5 to 15 consume five or more portions of fruits and vegetables per day. n Self reported physical activity levels are highest among men in Scotland, as 45% meeting recommended levels compared to 33% in Northern Ireland, 38% in Wales and 39% in England. British Heart Foundation Statistics Database www.heartstats.org 9 n More than a third of men and nearly a third of women regularly exceed the government recommended level of alcohol intake.

n Men and women in higher social classes are more likely to exceed government levels for recommended alcohol intake than men and women in the lower social classes.

n Around one in three adults in England and Scotland are hypertensive and nearly half of them are not receiving treatments.

n Around six in ten adults in England have blood cholesterol levels of 5mmol/l or above.

n More than a quarter of adults in England are obese.

n Around 30% of boys and girls aged 2-15 in England and Scotland are overweight or obese.

n The prevalence of diabetes in the UK is around 4% among females and 6% among males.

n CVD is estimated to cost the UK economy around £30bn a year.

British Heart Foundation Statistics Database www.heartstats.org 10 Glossary

This section provides a definition for some of the terms used throughoutCoronary heart disease statistics 2010 edition.

Age standardised rate – a measure of the rate that a population would experience if it had a standard age structure. It is useful to present rates as age standardised as it allows for comparisons between populations with very different age structures.

Angina – the most common form of coronary heart disease. It is characterised by a heaviness or tightness in the centre of the chest which may spread to the arms, neck, jaw, face, back or stomach. Angina occurs when the arteries become so narrow that not enough oxygen-containing blood can reach the heart when its demands are high, such as during exercise.

Angioplasty – a technique to widen a narrowed or obstructed blood vessel by inflating tightly folded balloons that have been passed into the narrowed location via a catheter. This technique squashes the fatty tissue that has caused the narrowing, hence widening the artery.

Atherosclerosis – a disease characterised by chronic inflammation in the artery walls. The disease is commonly referred to as ‘hardening’ or ‘furring’ of the arteries.

Body Mass Index (BMI) – a formula relating body weight to height to assess whether a person is overweight. BMI is calculated by dividing a person’s weight (in kilograms) by their height (in metres) squared. Adults with a BMI of 25-30 are considered to be overweight. Those with a BMI of over 30 are considered obese.

British National Formulary (BNF) – a publication that provides key information on the selection, prescribing, dispensing and administration of all medicines that are generally prescribed in the UK.

Cardiovascular disease (CVD) – the collective term for all diseases affecting the circulatory system (heart, arteries, blood vessels).

Cerebrovascular disease – the collective term for all diseases affecting blood vessels that supply the brain. Technically, stroke (and the many subtypes of stroke) is a subset of cerebrovascular disease, but the two terms are often used interchangeably.

Coronary Artery Bypass Graft (CABG) – an operation to bypass a narrowed section of a coronary artery and improve the blood supply to the heart.

Coronary Heart Disease (CHD) – the collective term for diseases that occur when the walls of the coronary arteries become narrowed by a gradual build-up of fatty material called atheroma. The two main forms of CHD are heart attack (also known as myocardial infarction) and angina.

British Heart Foundation Statistics Database www.heartstats.org 11 Diabetes – a disease caused by a lack of insulin (type 1) or an increased resistance of the body to insulin (type 2). Diabetes is characterised by high blood glucose levels. The resulting chronic high blood glucose levels (hyperglycaemia) are associated with long-term damage, dysfunction and failure of various organs, especially the eyes, kidneys, nerves, heart and blood vessels.

HDL (High Density Lipoprotein) cholesterol – the fraction of cholesterol that removes cholesterol (via the liver) from the blood. Low levels of HDL-cholesterol are associated with an increased risk of atherosclerosis.

Heart attack – the condition caused by a blockage of one of the coronary arteries when the heart is starved of oxygen. A heart attack usually causes severe pain in the centre of the chest. The pain lasts for more than fifteen minutes, and may last for many hours. The pain usually feels like a heaviness or tightness which may also spread to the arms, neck, jaw, face, back or stomach. There may also be sweating, light-headedness, nausea or shortness of breath. Sometimes a heart attack can be ‘silent’ and produce little discomfort.

Heart failure – a clinical syndrome which occurs when the heart is unable to pump enough blood to meet the demands of the body. It occurs because the heart is damaged or overworked. Some people with moderate heart failure may have very few symptoms. People with moderate or severe heart failure suffer from a number of problems, including shortness of breath, general tiredness and swelling of the feet and ankles.

Hospital Inpatient Episodes – Periods of continuous admitted patient care under the same consultant.

Incidence – a measure of morbidity based on the number of new episodes of an illness arising in a population over a defined time period.

International Classification of Disease (ICD) – a coding system published by the World Health Organization that provides an internationally recognised method of coding diseases in order to categorise mortality and morbidity statistics. The ICD is revised approximately every ten years. The tenth and most recent revision (ICD-10) was introduced in 2000. Change between revisions can result in discontinuities in mortality and morbidity trends, such as the move from ICD-9 to ICD-10 which resulted in an artificial increase in the number of reported stroke incidents and mortalities.

LDL (Low Density Lipoprotein) cholesterol – the more harmful fraction of cholesterol which carries cholesterol from the liver to the cells of the body and causes atherosclerosis.

Myocardial infarction (MI) – see heart attack.

National Statistics Socio-Economic Classification (NS-SEC) – a statistical classification based on occupation and details of employment status.

Non-Milk Extrinsic Sugars (NMES) – generally added sugars that are not integrally present in the cells of food like fruit and vegetables, and that are not naturally present in milk.

British Heart Non-Starch Polysaccharides (NSP) – complex carbohydrates that are the major part of dietary fibre and Foundation can be measured more precisely than total dietary fibre. Statistics Database www.heartstats.org 12 Office of Population, Censuses and Surveys Classification of Surgical Operations and Procedures 4th Revision (OPCS-4) – a classification system for surgical operations and procedures conducted in the National Health Service.

Percutaneous Coronary Intervention (PCI) – see angioplasty.

Prevalence – a measure of morbidity based on the current level of a disease in the population at any particular time.

Primary prevention – interventions aimed at reducing the risk of disease before the disease has presented. Primary prevention interventions are usually aimed at populations, such as regulation of tobacco advertising.

Secondary prevention – interventions aimed at reducing the risk of disease recurrence after the disease has initially presented. Secondary prevention interventions are therefore targeted at individuals already at high-risk of disease.

Stent – a short tube of expandable mesh which is inserted at the part of the artery that is to be widened by coronary angioplasty. It helps to keep the artery open and prevent re-narrowing.

Stroke – the consequence of an interruption to the flow of blood to the brain. A stroke can vary in severity from a passing weakness or tingling of a limb to a profound paralysis, coma and death.

Waist Circumference (WC) – a measure of central obesity, where fat is concentrated in the abdomen. For men, central obesity is defined as a waist circumference greater than 102cm. For women, central obesity is defined as a waist circumference of greater than 88cm.

Waist to Hip Ratio (WHR) – a measure of central obesity, where fat is concentrated mainly in the abdomen. For men, central obesity is defined as a WHR of 0.95 or over. For women, central obesity is defined as a WHR of 0.85 or over.

For a more comprehensive glossary, please visit www.heartstats.org

British Heart Foundation Statistics Database www.heartstats.org 13 1. Mortality

This chapter reports on mortality from cardiovascular disease (CVD) and coronary heart disease (CHD) in the UK. CVD and CHD mortality in the context of mortality from other chronic conditions are presented, as well as seasonal and temporal trends in CHD mortality. Regional, socioeconomic, and international differences are also described. Where possible, the latest data from routinely collected, national datasets have been used.

Public health targets Recent trends indicate that the Our Healthier Nation target to reduce the death rate from CHD, stroke and related diseases in people under 75 years in England by at least two fifths by 2010 will be met – in 2007, the figure was already below the target rate. Data also indicate that the Scottish target for reduction in CVD death rates may be met by 2010, and that the Welsh target for a reduction in CHD deaths by 2012 has already been surpassed (Table 1.1 and Figures 1.1a, 1.1c and 1.1d).

Progress towards the CVD inequalities target in England is also steady. If this continues, the target to reduce the inequalities gap in premature death rates from CVD between the areas with the worst health and deprivation indicators and the population as a whole by 40%, by 2010, will also be met. Premature CHD mortality, for those living in the 15% most deprived areas of Scotland has declined over recent years in accordance with their aim. The Welsh target aims for a more rapid improvement of CHD mortality in the most deprived groups – while CHD mortality has declined overall in Wales, the decline appears to be at a similar rate in both the most and least deprived groups (Figures 1.1b and 1.1e).

Total mortality Diseases of the heart and circulatory system (cardiovascular disease or CVD) are the main cause of death in the UK and account for almost 191,000 deaths each year - one in three of all deaths. The main forms of CVD are CHD and stroke. Almost half (46%) of all deaths from CVD are from CHD and nearly a quarter (23%) are from stroke (Table 1.2).

CHD by itself is the most common cause of death in the UK. In 2008, around one in five male deaths one in eight female deaths were from the disease – a total of around 88,000 deaths. Stroke caused over 43,000 deaths in the UK, and there were a further 60,000 deaths from other circulatory diseases (Table 1.3 and Figures 1.3a and 1.3b).

Premature mortality CVD is one of the main causes of premature death in the UK (death before the age of 75). 28% of premature deaths in men and 20% of premature deaths in women were from CVD in 2008. CVD caused almost 50,000 premature deaths in the UK in 2008 (Table 1.3 and Figures 1.3c and 1.3d).

CHD, by itself, is the most common cause of premature death in the UK. About one fifth (18%) of premature deaths in men and one in ten (9%) premature deaths in women were from CHD, which caused British Heart over 28,000 premature deaths in the UK in 2008 (Table 1.3 and Figures 1.3c and 1.3d). Foundation Statistics Database www.heartstats.org 14 Excess winter mortality There is a pattern of excess winter cardiovascular mortality in the UK. In 2007/08, almost 9,000 more people died of CVD in the winter months compared to the summer months. This amounts to about 16% more male deaths and 17% more female deaths. Excess winter mortality tends to increase with age (Table 1.4)1.

Recent trends in death rates in the UK Death rates from CVD have been falling in the UK since the early 1970s. For people under 75 years, death rates have fallen by 44% in the last ten years (Figure 1.1c).

In recent years, CHD death rates have been falling more slowly in younger age groups and fastest in those aged 55 and over. For example, between 1998 and 2008 there was a 49% fall in the CHD death rate for men aged 55 to 64 in the UK, compared to a 26% fall in men aged 35 to 44 years. In women, there was a 55% fall in those aged 55 to 64 years and the rate in those aged 35 to 44 years barely changed. There is some evidence that these rates are beginning to level off in younger age groups2 (Table 1.5 and Figures 1.5a and 1.5b).

A recent study aimed to explain the decline in mortality from CHD over the last two decades of the twentieth century in Britain. Combining and analysing data on uptake and effectiveness of cardiologic treatments and risk factor trends, the authors examined how much of the decline in CHD mortality in England and Wales between 1981 and 2000 could be attributed to medical and surgical treatments and how much to changes in cardiovascular risk factors. They concluded that more than half (58%) of the CHD mortality decline in Britain during the 1980s and 1990s was attributable to reductions in major risk factors, principally smoking. Treatments to individuals, including secondary prevention, explained the remaining two-fifths (42%) of the mortality decline3.

National and regional differences Death rates from CHD are highest in Scotland and the North of England, lowest in the South of England, and intermediate in Wales and Northern Ireland. The premature death rate for men living in Scotland is 63% higher than in the South West of England and 100% higher for women. For more than 25 years these rates have been consistently highest in Scotland (Table 1.6).

Maps of CHD mortality by local authority in the UK demonstrate this North-South gradient and show that the highest mortality rates are also concentrated in urban areas (Table 1.7 and Figures 1.7a and 1.7b).

Socioeconomic differences Socioeconomic differences in health can be measured using individual-level and area-level measures of socioeconomic status. Individual-level measures define socioeconomic status on the basis of an individual’s occupation, income, wealth, education or a combination of these factors. Area-level measures define socioeconomic status on the basis of where an individual lives and tend to be based on a ‘deprivation index’ – a score for an area that is constructed using data on an area’s population, resources, geographical features or a combination of these factors. Estimates of social differences in health are often based on area-level measures because deprivation indices are freely available and only require limited knowledge about individuals. However it should be remembered that not all people who live in affluent areas are British Heart themselves affluent, and vice versa. Foundation Statistics Database www.heartstats.org 15 Using individual-level measures, death rates in 2001/03 from CVD, CHD and stroke were all highest in the lowest socioeconomic group and lowest in the highest socioeconomic group, with a clear gradient across the social groups. This inequality was more striking in women than men, with the CHD death rate in female workers with routine jobs five times higher than those with managerial or professional jobs (Table 1.8 and Figure 1.8).

The England target for CVD inequalities measures absolute inequalities in CVD mortality using area-level measures of deprivation. This looks at the absolute difference in death rates between the most deprived groups and the rest of the population. Using this absolute measurement, inequalities in CVD mortality are declining, as the difference in the rate of deaths between these two groups is reducing. An alternative way of measuring inequality is to look at relative inequalities between the most and least deprived areas. When using the relative measure, Great Britain demonstrates a strong positive relationship between CHD mortality rates and increasing level of deprivation. This relationship has persisted over the past 14 years, and shows little sign of improvement. While deaths from CHD have declined overall, there appears to have been no narrowing of the relative difference between the most deprived and the least deprived (Table 1.9 and Figures 1.9a and 1.9b).

International differences The death rate from CVD has been falling in the UK at one of the fastest rates in Europe. The death rate for men fell by 38% between 1996 and 2006 in the UK, with only Ireland , Norway and Austria having a larger decrease in men over this time. The decline in female CVD mortality tells a similar story. CVD mortality is declining across most of Europe, with the exception of some Eastern European countries. Between 1996 and 2006, Russia and Ukraine both experienced an increase in CVD mortality, most notably for men. In the Ukraine, for example, death rates rose by 7% in men.

Despite the decline in death rates from CVD in the UK, rates are still relatively high compared to other Western European countries, at 305 per 100,000 CHD deaths in men in 2003. Only Ireland and Germany had a higher rate than the UK in the same year. In countries of Eastern and Central Europe, where death rates have been rising rapidly recently, the death rates were generally higher than in the UK, with Russia and Ukraine having the highest CVD mortality in Europe for both men and women (Tables 1.10a and 1.10b and Figures 1.10a and 1.10b).

1. Excess winter deaths are calculated by subtracting the actual number of deaths in winter (usually December to March), from the number of deaths which would have been expected for this period, calculated on the basis of the actual number of deaths occurring in the surrounding non-winter months. It is postulated that excess winter mortality is partially preventable through improvements to cold damp housing – see Olsen N (2001) Prescribing warmer, healthier homes. BMJ, 322: 748-749. British Heart 2. Allender S, Scarborough P, O’Flaherty M, Capewell S (2008). 20th century CHD morality in England and Wales: population trends in CHD Foundation risk factors and coronary death. BMC Public Health 8: 148. Statistics Database www.heartstats.org 3. Unal B, Critchley JA, Capewell S (2004). Explaining the decline in coronary heart disease mortality in England and Wales between 1981 and 2000. Circulation, 109: 1101-1107. 16 Table 1.1 Cardiovascular disease mortality targets for the United Kingdom

England1,2 CVD – Target To reduce the death rate from CHD, stroke and related diseases in people under 75 years by at least two fifths by 2010 – saving up to 200,000 lives in total. CVD – Inequalities target To reduce the inequalities gap in death rates from CHD, stroke and related diseases between the fifth of areas with the worst health and deprivation indicators and the population as a whole in people under 75 years by 40% by 2010.

Wales3 CHD – To reduce CHD mortality in 65-74 year olds from 600 per Health outcome target 100,000 in 2002 to 400 per 100,000 in 2012. CHD – To improve CHD mortality in all groups and at the same time Health inequality target aim for a more rapid improvement in the most deprived groups.

Scotland4 CHD – Target To reduce mortality rates from CHD among people under 75 years by 60% between 1995 and 2010, from the 1995 baseline of 124.6 to 49.8 per 100,000 population (standardised to the European Standard Population). CHD – Inequalities target To reduce the death rate from CHD of those aged under 75 years living in the most deprived 15% of areas in Scotland. Reduce mortality from CHD among the under 75s in deprived areas.

Northern Ireland No target set.

1. Department of Health (1999) Our Healthier Nation. DH: London. 2. Department of Health (2004) National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/06 and 2007/08. DH: London. British Heart 3. Welsh Assembly Government (2008) See Chief Medical Officer Wales website http://wales.gov.uk/topics/health/research/research/gain/targets/ Foundation health-gain (Accessed June 2010). Statistics Database 4. Scottish Executive (2008). Spending Review 2007, Scottish Government. The Scottish Executive: http://www.scotland.gov.uk/ Publications/2007/11/30090722/34 and http://www.scotland.gov.uk/Publications/2004/12/20325/47433 (Accessed June 2010) www.heartstats.org 17 Figure 1.1a Tracking the English CVD mortality target: Age-standardised death rates per 100,000 from CVD, under 75s, 1970 to 2007, England

300

250

200

150

100 Target for 2010

50

0 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Figure 1.1b Tracking the English CVD inequality target: Absolute gap in age-standardised death rates per 100,000 from CVD, under 75s, 1996 to 2007, England

40

35

30 100,000 population 25 Target for 2010

20

15

10

5

0 Absolute gap in CVD death rates pe r 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

British Heart Foundation Statistics Database www.heartstats.org 18 Figure 1.1c Tracking the Scottish CHD mortality target: Age-standardised death rates per 100,000 from CHD, under 75s, 1995 to 2008, Scotland

140

120

100

80

60 Target for 2010

40

20

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Figure 1.1d Tracking the Welsh CHD mortality target: Age-standardised death rates per 100,000 from CHD, adults aged 65 to 74, Wales

700

600

500

Target for 2012 400

300

200

100

0 2001 2002 2003 2004 2005 2006 2007

British Heart Foundation Statistics Database www.heartstats.org 19 Figure 1.1e Tracking the Welsh CHD inequalties target: Age-standardised death rates per 100,000 from CHD, all ages, 2001 to 2007, Wales

250

Least deprived 20%

Most deprived 20% 200 Wales total

150

100

50

0 2001 2002 2003 2004 2005 2006 2007

British Heart Foundation Statistics Database www.heartstats.org 20 Table 1.2 Deaths by cause, sex and age, 2008, United Kingdom

All ages Under 35 35-44 45-54 55-64 65-74 75+ All causes Men 276,725 9,011 7,519 14,420 31,406 55,445 158,924 Women 302,952 4,878 4,446 9,680 21,060 39,496 223,392 Total 579,677 13,889 11,965 24,100 52,466 94,941 382,316 All diseases of the Men 91,645 547 1,482 4,214 9,431 17,785 58,186 circulatory system Women 99,212 295 593 1,535 3,794 10,026 82,969 (I00-I99) Total 190,857 842 2,075 5,749 13,225 27,811 141,155 Coronary heart disease Men 49,665 118 787 2,739 6,317 10,889 28,815 (I20-I25) Women 38,571 23 192 590 1,742 4,861 31,163 Total 88,236 141 979 3,329 8,059 15,750 59,978 Stroke Men 20,357 113 223 570 1,244 3,004 15,203 (I60-I69) Women 22,785 84 183 463 949 2,413 18,693 Total 43,142 197 406 1,033 2,193 5,417 33,896 Other diseases of the Men 21,623 316 472 905 1,870 3,892 14,168 circulatory system Women 37,856 188 218 482 1,103 2,752 33,113 (I00-I19, I26-I59, I70-I99) Total 59,479 504 690 1,387 2,973 6,644 47,281 Diabetes Men 3,107 64 73 131 301 627 1,911 (E10-E14) Women 3,348 29 44 117 152 451 2,555 Total 6,455 93 117 248 453 1,078 4,466 Cancer Men 83,360 695 1,180 4,053 12,949 22,760 41,723 (C00-D48) Women 77,064 664 1,745 4,694 11,191 17,551 41,219 Total 160,424 1,359 2,925 8,747 24,140 40,311 82,942 Colo-rectal cancer Men 8,777 34 114 427 1,364 2,445 4,393 (C18-C21) Women 7,523 28 107 343 902 1,552 4,591 Total 16,300 62 221 770 2,266 3,997 8,984 Lung cancer Men 19,912 11 138 851 3,429 6,302 9,181 (C33, C34) Women 15,421 9 134 786 2,567 4,325 7,600 Total 35,333 20 272 1,637 5,996 10,627 16,781 Breast cancer Men 69 0 3 2 12 14 38 (C50) Women 12,072 82 623 1,333 2,152 2,392 5,490 Total 12,141 82 626 1,335 2,164 2,406 5,528 Other cancers Men 54,602 650 925 2,773 8,144 13,999 28,111 (C00-C17, C22-C32, Women 42,048 545 881 2,232 5,570 9,282 23,538 C35-C49, C51-D48) Total 96,650 1,195 1,806 5,005 13,714 23,281 51,649 Respiratory disease Men 37,021 252 263 682 2,530 6,336 26,958 (J00-J99) Women 44,269 209 235 556 1,912 4,903 36,454 Total 81,290 461 498 1,238 4,442 11,239 63,412 Injuries and poisoning Men 13,012 3,616 2,244 1,810 1,412 1,042 2,888 (V01-Y98) Women 8,161 1,015 629 700 587 609 4,621 Total 21,173 4,631 2,873 2,510 1,999 1,651 7,509 All other causes Men 48,580 3,837 2,277 3,530 4,783 6,895 27,258 Women 70,898 2,666 1,200 2,078 3,424 5,956 55,574 Total 119,478 6,503 3,477 5,608 8,207 12,851 82,832

Notes: ICD-10 codes in parentheses.

Source: England and Wales, Office for National Statistics (2010) Deaths registered by cause, sex and age. www.statistics.gov.uk (accessed April 2010). Scotland, General Register Office (2010) Registrar General Annual Report. GRO: Edinburgh. Northern Ireland, Statistics and Research Agency (2008) Registrar General Annual Report. NISRA: Belfast.

British Heart Foundation Statistics Database www.heartstats.org 21 Table 1.3 All deaths and deaths under 75 by cause and sex, 2008, England, Wales, Scotland, Northern Ireland and United Kingdom

All ages Under 75 England Wales Scotland Northern United England Wales Scotland Northern United Ireland Kingdom Ireland Kingdom All causes Men 227,613 15,401 26,504 7,207 276,725 94,880 6,459 13,096 3,366 117,801 Women 249,411 16,665 29,196 7,680 302,952 63,947 4,475 8,909 2,229 79,560 Total 477,024 32,066 55,700 14,887 579,677 158,827 10,934 22,005 5,595 197,361 All diseases of the Men 75,584 5,262 8,497 2,302 91,645 26,988 1,886 3,702 883 33,459 circulatory system Women 81,683 5,709 9,352 2,468 99,212 12,910 948 1,913 472 16,243 (I00-I99) Total 157,267 10,971 17,849 4,770 190,857 39,898 2,834 5,615 1,355 49,702 Coronary heart disease Men 40,532 2,930 4,852 1,351 49,665 16,737 1,167 2,375 571 20,850 (I20-I25) Women 31,265 2,258 3,989 1,059 38,571 5,812 421 958 217 7,408 Total 71,797 5,188 8,841 2,410 88,236 22,549 1,588 3,333 788 28,258 Stroke Men 16,710 1,095 2,051 501 20,357 4,061 295 667 131 5,154 (I60-I69) Women 16,748 1,893 3,316 828 22,785 3,206 248 511 127 4,092 Total 33,458 2,988 5,367 1,329 43,142 7,267 543 1,178 258 9,246 Other diseases of the Men 18,342 1,237 1,594 450 21,623 6,190 424 660 181 7,455 circulatory system Women 33,670 1,558 2,047 581 37,856 3,892 279 444 128 4,743 (I00-I19, I26-I59, I70-I99) Total 52,012 2,795 3,641 1,031 59,479 10,082 703 1,104 309 12,198 Diabetes Men 2,483 166 372 86 3,107 916 61 183 36 1,196 (E10-E14) Women 2,683 209 361 95 3,348 594 47 131 21 793 Total 5,166 375 733 181 6,455 1,510 108 314 57 1,989 Cancer Men 69,392 4,713 7,841 1,814 83,360 34,112 2,364 4,319 842 41,637 (C00-D48) Women 63,255 4,183 7,684 1,942 77,064 29,228 1,963 3,679 975 35,845 Total 132,647 8,896 15,525 3,756 160,424 63,340 4,327 7,998 1,817 77,482 Colo-rectal cancer Men 7,197 499 839 242 8,777 3,538 247 468 131 4,384 (C18-C21) Women 6,161 418 746 198 7,523 2,352 159 336 85 2,932 Total 13,358 917 1,585 440 16,300 5,890 406 804 216 7,316 Lung cancer Men 16,063 1,170 2,114 565 19,912 8,529 631 1,236 335 10,731 (C33,C34) Women 12,231 862 1,966 362 15,421 6,136 448 1,044 193 7,821 Total 28,294 2,032 4,080 927 35,333 14,665 1,079 2,280 528 18,552 Breast cancer Men 57 5 7 0 69 22 3 4 0 31 (C50) Women 10,090 627 1,043 312 12,072 5,199 327 570 186 6,582 Total 10,147 632 1,050 312 12141 5,221 330 574 186 6,613 Other cancers Men 46,075 3,039 4,881 1,007 54,602 22,023 1,483 2,611 376 26,491 (C00-C17, C22-C32, Women 34,773 2,276 3,929 1,070 42,048 15,541 1,027 1,729 511 18,510 C35-C49, C51-D48) Total 80,848 5,315 8,810 2,077 96,650 37,564 2,510 4,340 887 45,001 Respiratory disease Men 30,748 2,053 3,276 944 37,021 8,231 525 1,027 280 10,063 (J00-J99) Women 36,558 2,392 4,167 1,152 44,269 6,211 487 909 208 7,815 Total 67,306 4,445 7,443 2,096 81,290 14,442 1,012 1,936 488 17,878 Injuries and poisoning Men 10,468 674 1,412 577 13,012 7,955 524 1,150 495 10,124 (V01-Y98) Women 6,542 483 849 287 8,161 2,778 189 407 166 3,540 Total 16,891 1,157 2,261 864 21,173 10,733 713 1,557 661 13,664 All other causes Men 39,057 2,533 5,106 1,484 48,580 16,678 1,099 2,715 830 21,322 Women 58,690 3,689 6,783 1,736 70,898 12,226 782 1,870 387 15,324 Total 97,747 6,222 11,889 3,220 119,478 28,904 1,881 4,585 1,217 36,646

Notes: ICD-10 codes in parentheses.

Source: England and Wales, Office for National Statistics (2010) Deaths registered by cause, sex and age. www.statistics.gov.uk (accessed April 2010). Scotland, General Register Office (2010) Registrar General Annual Report. GRO: Edinburgh. Northern Ireland, Statistics and Research Agency (2008) Registrar General Annual Report. NISRA: Belfast.

British Heart Foundation Statistics Database www.heartstats.org 22 Figure 1.3a Deaths by cause, men, 2008 United Kingdom

Respiratory disease 13%

Injuries and poisoning 5% Other cancers 20%

All other causes 18%

Lung cancer 7%

Colo-rectal cancer 3% Diabetes 1%

Stroke Other CVD 7% 8% Coronary heart disease 18%

Figure 1.3b Deaths by cause, women, 2008 United Kingdom

Respiratory disease 15% Injuries and poisoning 3%

Other cancers 14%

All other causes 23% Breast cancer 4%

Lung cancer 5%

Colo-rectal cancer 2% Diabetes 1%

Stroke Other CVD 8% 12% Coronary heart disease 13%

British Heart Foundation Statistics Database www.heartstats.org 23 Figure 1.3c Deaths by cause, men under 75, 2008, United Kingdom

Respiratory disease 9%

Injuries and poisoning Other cancers 22% 9%

All other causes 18% Lung cancer 9%

Colo-rectal cancer 4% Diabetes 1%

Stroke Other CVD 4% 6% Coronary heart disease 18%

Figure 1.3d Deaths by cause, women under 75, 2008, United Kingdom

Respiratory disease 10% Other cancers 23% Injuries and poisoning 5% Breast cancer 8%

All other causes 19% Lung cancer 10%

Colo-rectal cancer 4% Diabetes 1%

Stroke Other CVD 5% 6% Coronary heart disease 9%

British Heart Foundation Statistics Database www.heartstats.org 24 Table 1.4 Excess winter cardiovascular disease mortality, men and women, England and Wales, 2007/08

Men Women Excess winter Excess winter Excess winter Excess winter mortality mortality index mortality mortality index 0-64 520 11.9 260 15.3 65-74 670 13.6 390 14.3 75-84 1,400 15.1 1,500 17.1 85 + 1,450 20.6 2,560 17.9 All ages 4,040 15.8 4,700 17.1

Notes: Excess winter mortality calculation: winter deaths - average non-winter deaths. Excess winter mortality index calculation: (Excess winter mortality/average non-winter deaths) * 100.

Source: Brock A (2008). Excess winter mortality in England and Wales 2007/08 (provisional) and 2006/07 (final). Health Statistics Quarterly; 40: 66-76.

British Heart Foundation Statistics Database www.heartstats.org 25 Table 1.5 Age-specific death rates per 100,000 population from CHD by sex, 1968 to 2008, United Kingdom

35–44 45–54 55–64 65–74 MEN WOMEN MEN WOMEN MEN WOMEN MEN WOMEN 1968 65 11 253 46 714 198 1,639 726 1969 63 11 262 47 728 202 1,660 731 1970 65 11 267 46 727 204 1,631 704 1971 69 10 280 50 724 200 1,634 698 1972 69 11 297 54 759 218 1,718 739 1973 66 11 296 56 755 220 1,692 731 1974 68 12 298 55 758 226 1,696 725 1975 63 11 298 54 742 215 1,684 717 1976 60 12 279 55 752 220 1,687 721 1977 61 11 281 53 732 209 1,678 714 1978 62 11 288 55 754 216 1,705 725 1979 57 9 286 57 749 215 1,665 706 1980 56 9 270 50 733 215 1,621 688 1981 53 9 260 49 702 203 1,601 692 1982 47 8 245 48 696 206 1,588 688 1983 46 7 242 46 705 213 1,618 692 1984 42 7 227 45 696 213 1,591 695 1985 43 7 221 43 687 213 1,601 702 1986 42 6 217 40 662 204 1,529 681 1987 41 6 201 39 638 201 1,489 661 1988 37 6 188 36 610 191 1,441 639 1989 37 6 170 32 567 180 1,373 627 1990 37 6 159 33 536 179 1,352 594 1991 34 6 153 30 512 169 1,312 593 1992 32 6 142 28 490 155 1,274 571 1993 29 5 136 26 478 147 1,266 567 1994 27 5 118 24 427 131 1,173 520 1995 26 5 117 24 408 124 1,133 498 1996 25 5 112 22 384 119 1,073 465 1997 23 5 107 21 361 110 983 434 1998 23 4 103 22 343 104 952 420 1999 22 5 97 20 317 94 902 387 2000 19 5 92 20 291 84 823 347 2001 20 4 93 19 271 79 763 328 2002 21 4 89 19 250 72 707 304 2003 19 5 85 18 238 66 660 275 2004 19 4 81 16 219 57 599 250 2005 19 4 73 16 204 54 558 225 2006 18 4 72 15 194 52 500 207 2007 17 4 69 15 188 49 471 187 2008 17 4 67 14 175 47 443 179

Source: 1968 to 1999: World Health Organization (2002) www3.who.int/whosis (accessed June 2010). From 2000: Office for National Statistics (personal communication).

British Heart Foundation Statistics Database www.heartstats.org 26 Figure 1.5a Age-specific death rates from CHD, men, 1968 to 2008, United Kingdom, plotted as a percentage of the rate in 1968

140

120

100

80 35–44 45–54 55–64 65–74 60

40 CHD mortality % of 1968 rate

20

0 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Figure 1.5b Age-specific death rates from CHD, women, 1968 to 2008, United Kingdom, plotted as a percentage of the rate in 1968

140

120

100

35–44 80 45–54 55–64 65–74

60

40 CHD mortality % of 1968 rate

20

0 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 British Heart Foundation Statistics Database www.heartstats.org 27 22 28 21 14 21 14 15 20 21 23 22 22 19 20 65 81 65 50 62 47 49 63 60 72 69 70 59 61 23 30 23 15 20 15 14 20 20 26 22 26 19 21 74 89 69 52 64 51 53 68 63 76 70 75 62 65 27 33 25 16 19 17 17 22 22 27 25 30 21 22 76 88 75 54 66 53 57 70 64 84 76 78 66 69 28 35 27 18 22 17 18 24 25 29 27 29 23 24 80 98 82 57 73 58 60 78 71 88 79 86 71 74 30 37 32 18 25 20 20 26 27 32 28 33 25 27 89 83 65 77 63 65 82 78 96 81 94 77 80 101 30 41 33 23 28 21 22 32 29 33 30 38 28 30 90 95 67 87 69 69 90 87 92 83 87 112 101 103 36 44 36 23 29 24 23 32 34 39 35 39 30 32 99 75 91 70 73 97 92 98 88 92 113 104 106 106 38 45 39 25 32 24 26 36 33 41 38 40 32 35 80 92 77 81 92 94 98 105 120 109 104 115 109 114 41 50 40 26 34 26 27 35 35 43 40 46 34 36 88 80 87 115 133 113 103 108 101 121 111 122 100 104 46 54 41 30 36 29 29 42 39 48 41 52 37 39 91 91 93 133 146 128 106 119 110 128 117 130 108 112 49 59 45 31 37 30 34 44 45 55 46 57 41 43 93 95 139 153 128 101 113 121 119 141 133 149 116 120 53 63 50 32 38 31 33 47 44 53 51 61 42 45 149 160 135 103 114 100 100 131 120 144 134 155 120 136 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 South West London South East East West Midlands West East Midlands North West Yorkshire and Humberside Yorkshire North East South West London South East East West Midlands West East Midlands North West Yorkshire and Humberside Yorkshire North East Northern Ireland Scotland Wales England United Kingdom WOMEN AGED 35-74 Northern Ireland Scotland Wales England United Kingdom 58 64 52 35 37 35 51 46 59 53 62 46 48 155 171 146 112 115 110 142 129 155 143 155 129 134 70 74 58 40 41 39 53 48 66 58 73 50 55 175 188 158 126 125 124 147 138 172 157 173 141 149 77 84 65 45 48 43 62 59 77 71 81 58 62 201 211 174 141 140 133 171 162 190 181 206 160 168 81 93 71 52 49 46 67 65 82 80 90 63 67 222 221 197 153 147 141 191 177 212 201 215 173 181 96 76 52 53 48 74 69 89 84 96 67 72 101 259 247 215 169 161 154 200 196 237 225 238 190 199 95 83 61 59 56 77 77 94 87 97 72 77 101 277 267 231 192 177 176 221 205 248 243 248 207 216 94 86 63 60 58 80 79 97 94 75 79 105 102 275 274 238 197 188 193 227 218 259 245 265 217 226 84 58 60 57 77 74 94 90 73 79 104 113 101 262 279 245 200 193 177 229 225 264 251 259 220 228 94 63 62 62 77 76 97 88 75 80 105 111 100 303 283 267 218 207 199 230 231 268 257 273 230 240

MEN AGED 35-74 90 68 64 67 81 78 94 79 93 107 118 101 108 300 302 289 225 214 212 239 246 281 277 282 241 266 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 Age-standardised death rates from CHD per 100,000 population by country and Standard Region, 1978 Region, Standard and country by population 100,000 per CHD from rates death Age-standardised to 1996, and by country Government Office Region, 1997 2008, United Kingdom ICD-9 codes 410-414 for pre-2001 data, ICD-10 I20-25 thereafter. Age-standardised using the European Standard Population. Government Office Regions replaced regions in England 1997. Pre 1997: Office for Population Censuses and Surveys (1994) Mortality Statistics 1992, DH5 series, HMSO: London previous ed itions; Office for National Statistics 1993-1996 figures, personal communication. Office for National Statistics, personal communication. 1997-2008: England and Wales: Scotland and Northern Ireland: raw data from the General Register Office for Scotland, Ireland Statistics R esearch Agency. British Heart South West South East East Anglia West Midlands West East Midlands North West Yorkshire and Humberside Yorkshire North South West South East East Anglia West Midlands West East Midlands North West Yorkshire and Humberside Yorkshire North Northern Ireland Scotland Wales

England WOMEN AGED 35-74 United Kingdom Northern Ireland Scotland Wales

England MEN AGED 35-74 United Kingdom Foundation 1.6 Table Notes: Source: Statistics Database www.heartstats.org 28 Table 1.7 Numbers of deaths and age-standardised death rates from CHD for men and women under 75 by local authority, 2006/08, United Kingdom

Men Women Men Women Map Code Local authority Age Age Map Code Local authority Age Age reference Number of standardised Number of standardised reference Number of standardised Number of standardised deaths death rate/ deaths death rate/ deaths death rate/ deaths death rate/ 2006-2008 100,000 2006-2008 100,000 2006-2008 100,000 2006-2008 100,000 ENGLAND 51,769 62.81 17,988 19.69 68 31UB Blaby 86 52.10 27 14.38 A North East 3,265 74.50 1,289 26.35 69 31UC Charnwood 150 57.23 47 17.16 1 00CH Gateshead 274 83.13 90 24.23 70 31UD Harborough 79 52.06 19 11.97 2 00CJ Newcastle upon Tyne 311 80.53 132 30.56 71 31UE Hinckley and Bosworth 93 47.58 32 15.54 3 00CK North Tyneside 263 79.19 92 24.74 72 31UG Melton 47 52.25 14 14.66 4 00CL South Tyneside 189 73.69 100 33.56 73 31UH North West Leicestershire 120 74.51 44 26.37 5 00CM Sunderland 338 71.67 158 29.63 74 31UJ Oadby and Wigston 44 47.76 18 14.92 6 00EB Hartlepool 110 70.32 48 27.19 75 32UB Boston 74 64.47 23 19.51 7 00EC Middlesbrough 174 84.00 69 29.22 76 32UC East Lindsey 187 57.46 61 17.25 8 00EE Redcar and Cleveland 172 66.70 86 31.08 77 32UD Lincoln 93 74.68 42 30.13 9 00EF Stockton-on-Tees 210 67.82 84 24.77 78 32UE North Kesteven 110 53.21 31 13.68 10 00EH Darlington 125 73.54 42 21.90 79 32UF South Holland 100 56.96 48 24.11 11 00EJ County Durham 678 75.10 267 26.68 80 32UG South Kesteven 133 55.80 37 14.07 12 00EM Northumberland 421 69.69 121 18.70 81 32UH West Lindsey 100 56.28 38 20.55 82 34UB Corby 67 77.29 25 25.82 B Yorkshire & Humberside 6,112 72.39 2,172 23.24 83 34UC Daventry 70 52.14 16 11.62 13 00CC Barnsley 324 83.49 142 33.93 84 34UD East Northamptonshire 57 39.17 23 15.48 14 00CE Doncaster 367 74.22 134 24.45 85 34UE Kettering 72 49.08 20 12.56 15 00CF Rotherham 329 75.04 120 25.21 86 34UF Northampton 173 59.69 66 21.03 16 00CG Sheffield 585 71.99 202 21.59 87 34UG South Northamptonshire 80 52.62 28 18.11 17 00CX Bradford 595 86.70 200 25.52 88 34UH Wellingborough 74 58.37 26 19.35 18 00CY Calderdale 227 70.87 66 19.09 89 37UB Ashfield 149 73.51 55 25.85 19 00CZ Kirklees 460 73.87 177 26.32 90 37UC Bassetlaw 138 66.50 44 19.39 20 00DA Leeds 797 73.62 270 22.38 91 37UD Broxtowe 111 57.84 41 19.28 21 00DB Wakefield 404 74.15 143 23.77 92 37UE Gedling 119 57.83 44 19.62 22 00FA Kingston upon Hull, City of 334 88.25 134 33.27 93 37UF Mansfield 127 74.99 54 28.83 23 00FB East Riding of Yorkshire 392 57.29 132 18.10 94 37UG Newark and Sherwood 116 55.70 47 20.96 24 00FC North East Lincolnshire 233 85.36 69 22.14 95 37UJ Rushcliffe 82 43.72 23 10.99 25 00FD North Lincolnshire 211 73.04 72 22.18 26 00FF York 170 56.75 54 15.35 E West Midlands 5,905 67.40 2,013 20.73 27 36UB Craven 64 57.25 23 17.58 96 00CN Birmingham 1,131 86.09 402 27.32 28 36UC Hambleton 93 52.37 29 14.20 97 00CQ Coventry 318 73.03 101 20.96 29 36UD Harrogate 163 57.87 70 22.56 98 00CR Dudley 329 59.50 112 18.24 30 36UE Richmondshire 60 71.18 18 17.29 99 00CS Sandwell 450 101.86 167 33.10 31 36UF Ryedale 61 52.94 21 16.64 100 00CT Solihull 214 61.65 67 16.21 32 36UG Scarborough 153 69.49 65 25.82 101 00CU Walsall 372 87.83 112 23.54 33 36UH Selby 90 62.75 31 21.41 102 00CW Wolverhampton 275 74.39 92 21.90 103 00GA Herefordshire, County of 201 54.55 63 15.71 C North West 9,009 77.87 3,291 25.46 104 00GF Telford and Wrekin 195 75.71 59 20.97 34 00BL Bolton 346 81.83 130 28.69 105 00GG Shropshire 313 54.69 115 18.31 35 00BM Bury 229 76.57 95 28.26 106 00GL Stoke-on-Trent 292 76.67 107 25.53 36 00BN Manchester 548 105.95 215 38.45 107 41UB Cannock Chase 108 69.19 46 27.13 37 00BP Oldham 345 102.65 127 34.26 108 41UC East Staffordshire 120 64.92 52 25.07 38 00BQ Rochdale 292 92.58 129 37.52 109 41UD Lichfield 102 51.36 36 17.18 39 00BR Salford 307 90.44 117 31.71 110 41UE Newcastle-under-Lyme 130 59.13 41 16.74 40 00BS Stockport 335 69.73 116 21.23 111 41UF South Staffordshire 103 46.91 37 15.86 41 00BT Tameside 334 96.71 144 37.90 112 41UG Stafford 112 47.40 38 14.28 42 00BU Trafford 232 70.09 77 20.04 113 41UH Staffordshire Moorlands 108 54.75 41 18.78 43 00BW Wigan 469 88.00 173 30.12 114 41UK Tamworth 94 78.32 25 20.40 44 00BX Knowsley 221 96.91 111 39.73 115 44UB North Warwickshire 69 58.71 24 19.65 45 00BY Liverpool 600 92.77 222 30.45 116 44UC Nuneaton and Bedworth 143 69.87 37 16.35 46 00BZ St. Helens 265 84.89 113 32.22 117 44UD Rugby 69 43.27 23 13.32 47 00CA Sefton 349 70.01 140 23.11 118 44UE Stratford-on-Avon 115 47.62 30 11.12 48 00CB Wirral 374 69.68 125 19.22 119 44UF Warwick 105 48.20 26 10.57 49 00EQ Cheshire East 402 60.65 116 16.05 120 47UB Bromsgrove 92 52.05 29 15.14 50 00ET Halton 166 87.42 61 28.56 121 47UC Malvern Hills 66 41.25 23 13.35 51 00EU Warrington 278 85.34 100 27.94 122 47UD Redditch 88 70.83 28 22.03 52 00EW Cheshire West and Chester 350 60.46 108 16.34 123 47UE Worcester 93 64.24 37 23.09 53 00EX Blackburn with Darwen 208 106.81 83 38.37 124 47UF Wychavon 98 42.62 43 16.76 54 00EY Blackpool 240 92.77 69 23.37 55 16UB Allerdale 122 66.82 44 21.74 F East of England 5,091 53.12 1,644 15.47 56 16UC Barrow-in-Furness 82 61.83 28 20.03 125 00JA Peterborough 197 82.31 52 19.67 57 16UD Carlisle 121 65.50 46 21.21 126 00KA Luton 195 73.11 63 23.93 58 16UE Copeland 95 70.41 40 28.12 127 00KB Bedford 134 54.78 48 17.85 59 16UF Eden 64 58.05 22 19.00 128 00KC Central Bedfordshire 215 52.91 72 16.42 60 16UG South Lakeland 101 45.82 35 14.52 129 00KF Southend-on-Sea 139 53.15 60 19.97 61 30UD Burnley 123 86.39 44 28.26 130 00KG Thurrock 118 54.76 33 13.56 62 30UE Chorley 141 75.17 25 12.68 131 12UB Cambridge 70 53.79 23 15.07 63 30UF Fylde 82 54.45 24 12.47 132 12UC East Cambridgeshire 68 47.86 29 19.20 64 30UG Hyndburn 113 86.18 44 29.90 133 12UD Fenland 103 55.90 45 24.03 65 30UH Lancaster 168 73.02 66 24.63 134 12UE Huntingdonshire 136 48.57 33 11.44 66 30UJ Pendle 133 90.16 31 19.13 135 12UG South Cambridgeshire 98 42.38 40 16.29 67 30UK Preston 131 66.20 51 23.96 136 22UB Basildon 150 57.46 57 18.83 68 30UL Ribble Valley 61 53.98 14 11.24 137 22UC Braintree 129 54.21 47 19.02 69 30UM Rossendale 81 74.49 38 33.70 138 22UD Brentwood 67 53.22 25 17.48 70 30UN South Ribble 113 58.76 30 14.78 139 22UE Castle Point 87 49.37 22 10.47 71 30UP West Lancashire 121 57.74 50 22.39 140 22UF Chelmsford 115 42.55 36 11.98 72 30UQ Wyre 157 71.40 55 19.93 141 22UG Colchester 130 49.29 35 12.20 73 47UG Wyre Forest 110 55.03 33 15.89 142 22UH Epping Forest 116 55.32 42 18.65 143 22UJ Harlow 70 63.35 28 19.59 D East Midlands 4,693 62.93 1,667 20.73 144 22UK Maldon 57 43.94 15 11.41 74 00FK Derby 271 74.26 96 24.97 145 22UL Rochford 67 43.42 19 10.88 75 00FN Leicester 372 102.09 145 36.62 146 22UN Tendring 218 70.69 69 19.51 58 00FP Rutland 24 31.45 10 11.74 147 22UQ Uttlesford 52 40.86 12 8.69 59 00FY Nottingham 285 83.06 100 26.94 148 26UB Broxbourne 76 52.38 31 19.04 60 17UB Amber Valley 151 69.82 54 22.88 149 26UC Dacorum 108 48.96 34 13.80 61 17UC Bolsover 105 77.46 46 30.76 150 26UD East Hertfordshire 94 44.53 21 9.32 British Heart 62 17UD Chesterfield 115 65.81 37 18.88 151 26UE Hertsmere 76 51.92 22 13.35 63 17UF Derbyshire Dales 89 59.38 25 16.52 152 26UF North Hertfordshire 103 51.52 43 19.38 Foundation 64 17UG Erewash 116 61.02 43 20.40 153 26UG St Albans 90 45.04 33 14.88 65 17UH High Peak 98 60.63 39 23.81 154 26UH Stevenage 82 72.48 32 22.66 Statistics Database 66 17UJ North East Derbyshire 116 57.41 43 20.45 155 26UJ Three Rivers 66 47.50 14 8.65 www.heartstats.org 67 17UK South Derbyshire 100 65.84 36 22.74 156 26UK Watford 75 67.26 17 14.43 29 Men Women Men Women Map Code Local authority Age Age Map Code Local authority Age Age reference Number of standardised Number of standardised reference Number of standardised Number of standardised deaths death rate/ deaths death rate/ deaths death rate/ deaths death rate/ 2006-2008 100,000 2006-2008 100,000 2006-2008 100,000 2006-2008 100,000 157 26UL Welwyn Hatfield 84 54.89 32 17.22 255 00AS Hillingdon 234 67.54 81 20.55 158 33UB Breckland 127 48.36 33 11.61 256 00AT Hounslow 189 67.71 60 20.34 159 33UC Broadland 95 37.03 23 7.70 257 00AU Islington 191 100.95 63 30.23 160 33UD Great Yarmouth 110 60.71 41 18.97 258 00AW Kensington and Chelsea 79 34.81 32 11.77 161 33UE King’s Lynn and West Norfolk 167 54.94 51 15.32 259 00AX Kingston upon Thames 95 47.78 33 15.05 162 33UF North Norfolk 137 57.71 28 9.95 260 00AY Lambeth 215 83.28 59 20.09 163 33UG Norwich 132 76.01 40 20.41 261 00AZ Lewisham 230 84.97 83 26.81 164 33UH South Norfolk 97 39.36 25 9.10 262 00BA Merton 98 40.59 34 12.73 165 42UB Babergh 79 46.06 23 12.56 263 00BB Newham 233 93.79 82 32.65 166 42UC Forest Heath 54 59.25 17 17.41 264 00BC Redbridge 177 51.77 90 24.50 167 42UD Ipswich 91 50.31 46 22.14 265 00BD Richmond upon Thames 107 44.88 36 13.66 168 42UE Mid Suffolk 101 53.99 33 17.06 266 00BE Southwark 180 67.50 65 22.13 169 42UF St Edmundsbury 82 43.82 24 11.63 267 00BF Sutton 110 42.77 56 18.68 170 42UG Suffolk Coastal 121 49.01 27 9.08 268 00BG Tower Hamlets 213 116.09 58 30.97 171 42UH Waveney 113 49.24 49 17.59 269 00BH Waltham Forest 201 77.01 80 28.34 270 00BJ Wandsworth 136 50.69 69 22.36 G South East 6,950 50.84 2,299 15.14 271 00BK Westminster 120 44.95 38 12.35 172 00LC Medway 287 73.65 101 23.94 173 00MA Bracknell Forest 81 52.53 21 12.86 H South West 4,840 52.05 1,557 15.26 174 00MB West Berkshire 107 43.72 23 9.10 272 00HA Bath and North East Somerset 123 43.15 33 10.07 175 00MC Reading 139 77.39 53 27.75 273 00HB Bristol, City of 369 68.99 122 21.42 176 00MD Slough 137 87.25 42 27.44 274 00HC North Somerset 162 42.60 57 13.41 177 00ME Windsor and Maidenhead 97 44.27 36 14.22 275 00HD South Gloucestershire 198 46.02 69 15.15 178 00MF Wokingham 114 47.85 35 13.22 276 00HE Cornwall 632 59.91 191 16.56 179 00MG Milton Keynes 227 74.39 80 25.82 277 00HG Plymouth 294 76.17 91 20.61 180 00ML Brighton and Hove 231 67.39 63 16.60 278 00HH Torbay 149 57.73 55 19.54 181 00MR Portsmouth 217 82.85 68 23.82 279 00HN Bournemouth 125 47.57 47 16.48 182 00MS Southampton 220 72.57 81 25.90 280 00HP Poole 115 45.43 36 12.97 183 00MW Isle of Wight 136 47.34 45 14.83 281 00HX Swindon 158 55.97 56 17.89 184 11UB Aylesbury Vale 121 43.19 47 16.32 282 00HY Wiltshire 386 48.52 137 16.11 185 11UC Chiltern 73 44.41 27 14.38 283 15UH Isles of Scilly 2 36.67 0 0.00 186 11UE South Bucks 58 51.22 18 14.50 284 18UB East Devon 133 45.38 36 11.60 187 11UF Wycombe 131 50.12 38 13.29 285 18UC Exeter 109 65.00 36 19.13 188 21UC Eastbourne 84 48.61 20 8.85 286 18UD Mid Devon 81 55.60 17 11.56 189 21UD Hastings 85 57.70 26 16.44 287 18UE North Devon 116 64.01 32 16.08 190 21UF Lewes 59 31.11 25 11.47 288 18UG South Hams 86 49.17 22 11.77 191 21UG Rother 95 49.92 31 14.30 289 18UH Teignbridge 139 55.42 56 20.11 192 21UH Wealden 119 41.43 37 10.59 290 18UK Torridge 65 46.85 22 15.43 193 24UB Basingstoke and Deane 123 48.19 44 16.72 291 18UL West Devon 64 59.03 16 13.38 194 24UC East Hampshire 89 44.70 29 13.27 292 19UC Christchurch 40 40.34 13 10.53 195 24UD Eastleigh 93 47.43 25 12.10 293 19UD East Dorset 74 36.19 15 6.63 196 24UE Fareham 76 37.74 22 9.16 294 19UE North Dorset 44 33.48 22 15.57 197 24UF Gosport 70 54.15 27 17.53 295 19UG Purbeck 31 32.13 16 13.49 198 24UG Hart 68 46.89 18 11.62 296 19UH West Dorset 74 34.63 13 5.20 199 24UH Havant 116 54.68 45 19.17 297 19UJ Weymouth and Portland 59 47.54 20 14.91 200 24UJ New Forest 137 38.65 43 10.48 298 23UB Cheltenham 84 48.77 20 10.69 201 24UL Rushmoor 58 48.28 14 10.53 299 23UC Cotswold 70 42.82 26 14.20 202 24UN Test Valley 87 43.14 30 14.15 300 23UD Forest of Dean 98 58.91 32 18.39 203 24UP Winchester 84 43.73 32 15.27 301 23UE Gloucester 117 67.03 34 18.22 204 29UB Ashford 98 51.35 29 14.19 302 23UF Stroud 106 51.41 49 21.53 205 29UC Canterbury 129 52.70 50 17.69 303 23UG Tewkesbury 63 42.03 22 12.75 206 29UD Dartford 74 53.68 21 13.94 304 40UB Mendip 74 37.56 15 7.36 207 29UE Dover 111 56.14 47 20.72 305 40UC Sedgemoor 118 53.69 39 16.78 208 29UG Gravesham 77 46.59 36 19.68 306 40UD South Somerset 141 45.13 41 12.09 209 29UH Maidstone 127 50.63 54 19.79 307 40UE Taunton Deane 100 51.84 38 17.73 210 29UK Sevenoaks 66 32.83 32 14.10 308 40UF West Somerset 41 45.17 11 11.70 211 29UL Shepway 115 60.79 38 18.05 212 29UM Swale 144 63.52 42 17.22 WALES 3,688 70.07 1,338 22.95 213 29UN Thanet 143 60.06 58 20.56 309 00NA Isle of Anglesey 99 68.59 25 16.51 214 29UP Tonbridge and Malling 97 48.73 27 11.91 310 00NC Gwynedd 143 65.42 46 19.33 215 29UQ Tunbridge Wells 75 43.33 28 14.42 311 00NE Conwy 159 68.96 49 18.83 216 38UB Cherwell 97 45.02 22 9.55 312 00NG Denbighshire 125 66.31 35 16.38 217 38UC Oxford 94 59.09 19 11.56 313 00NJ Flintshire 170 63.40 68 23.24 218 38UD South Oxfordshire 114 51.84 38 15.66 314 00NL Wrexham 169 73.27 62 24.55 219 38UE Vale of White Horse 83 40.49 18 8.22 315 00NN Powys 149 54.34 50 17.26 220 38UF West Oxfordshire 86 48.93 22 11.62 316 00NQ Ceredigion 65 44.01 27 17.10 221 43UB Elmbridge 81 40.82 30 13.17 317 00NS Pembrokeshire 139 58.24 52 19.38 222 43UC Epsom and Ewell 41 36.17 12 9.46 318 00NU Carmarthenshire 233 64.62 94 24.69 223 43UD Guildford 89 44.81 33 14.27 319 00NX Swansea 279 71.99 90 20.91 224 43UE Mole Valley 68 43.70 25 14.29 320 00NZ Neath Port Talbot 195 79.46 73 26.61 225 43UF Reigate and Banstead 79 37.21 24 10.33 321 00PB Bridgend 164 69.67 58 22.29 226 43UG Runnymede 69 54.06 23 15.98 322 00PD The Vale of Glamorgan 116 54.55 40 16.35 227 43UH Spelthorne 88 57.49 23 13.12 323 00PF Rhondda, Cynon, Taff 346 88.03 155 35.82 228 43UJ Surrey Heath 70 51.11 16 10.92 324 00PH Merthyr Tydfil 102 106.21 42 39.84 229 43UK Tandridge 59 42.16 17 11.10 325 00PK Caerphilly 268 93.86 91 27.40 230 43UL Waverley 66 31.77 24 10.03 326 00PL Blaenau Gwent 141 113.46 50 37.13 231 43UM Woking 56 41.45 15 9.60 327 00PM Torfaen 117 73.82 36 20.90 232 45UB Adur 54 48.50 30 21.80 328 00PP Monmouthshire 92 52.82 31 17.73 233 45UC Arun 156 51.78 49 13.17 329 00PR Newport 163 71.88 62 23.92 234 45UD Chichester 99 45.04 28 10.59 330 00PT Cardiff 254 60.25 102 21.13 235 45UE Crawley 74 54.40 25 16.20 236 45UF Horsham 91 40.10 22 8.75 SCOTLAND 7,447 86.59 3,074 30.73 237 45UG Mid Sussex 68 30.86 27 10.51 238 45UH Worthing 93 55.41 49 24.77 331 00QA Aberdeen City 252 77.62 95 25.20 332 00QB Aberdeenshire 261 60.05 90 20.01 London 5904 64.36 2056 19.91 333 00QC Angus 137 64.28 61 26.47 239 00AA City of London 6 45.02 1 9.09 334 00QD Argyll & Bute 143 76.46 48 22.70 240 00AB Barking and Dagenham 165 85.08 64 28.38 335 00QE Scottish Borders 150 69.61 59 23.07 241 00AC Barnet 234 53.16 60 11.79 336 00QF Clackmannanshire 72 83.84 26 26.82 242 00AD Bexley 203 58.58 70 17.59 337 00QG West Dunbartonshire 181 124.40 82 44.65 243 00AE Brent 223 66.33 84 21.99 338 00QH Dumfries & Galloway 222 70.96 90 25.80 244 00AF Bromley 204 44.26 76 13.47 339 00QJ Dundee City 233 102.21 84 29.44 245 00AG Camden 170 74.70 58 22.47 340 00QK East Ayrshire 219 102.71 91 37.44 246 00AH Croydon 258 55.81 68 13.23 341 00QL East Dunbartonshire 95 50.71 35 15.18 247 00AJ Ealing 310 81.53 96 23.34 342 00QM East Lothian 119 73.40 41 21.03 248 00AK Enfield 218 56.92 77 17.75 343 00QN East Renfrewshire 94 63.62 36 19.33 British Heart 249 00AL Greenwich 225 85.62 75 25.01 344 00QP Edinburgh City 556 85.60 216 28.74 250 00AM Hackney 194 95.16 69 31.41 345 00QQ Falkirk 216 84.92 103 35.55 Foundation 251 00AN Hammersmith and Fulham 106 58.64 42 20.75 346 00QR Fife 492 78.83 208 29.20 252 00AP Haringey 187 79.76 52 19.22 347 00QS Glasgow City 1,013 128.96 435 45.61 Statistics Database 253 00AQ Harrow 156 51.05 56 15.51 348 00QT Highland 293 70.73 106 22.77 254 00AR Havering 237 64.07 89 19.52 349 00QU Inverclyde 149 109.12 68 39.79 www.heartstats.org 350 00QW Midlothian 101 74.92 53 34.04 30 Men Women Map Code Local authority Age Age reference Number of standardised Number of standardised deaths death rate/ deaths death rate/ 2006-2008 100,000 2006-2008 100,000 351 00QX Moray 102 63.93 35 19.01 352 00QY North Ayrshire 222 91.98 115 38.94 353 00QZ North Lanarkshire 548 107.58 260 42.52 354 00RA Orkney Islands 41 98.63 6 13.03 355 00RB Perth & Kinross 164 60.65 77 25.21 356 00RC Renfrewshire 267 95.12 133 38.90 357 00RD Shetland Islands 21 52.74 12 29.98 358 00RE South Ayrshire 191 88.79 74 28.88 359 00RF South Lanarkshire 474 92.40 178 29.28 360 00RG Stirling 122 80.63 35 19.54 361 00RH West Lothian 243 93.39 106 36.94 362 00RJ Eilean Siar 54 102.37 16 31.03

NORTHERN IRELAND 1,850 72.01 702 24.30 363 95A Derry 118 85.73 39 25.20 364 95B Limavady 38 85.52 14 30.31 365 95C Coleraine 63 66.65 17 16.97 366 95D Ballymoney 34 79.06 11 22.02 367 95E Moyle 19 63.89 6 20.00 368 95F Larne 43 77.17 10 15.57 369 95G Ballymena 63 63.42 29 25.48 370 95H Magherafelt 32 56.02 19 30.99 371 95I Cookstown 40 82.83 16 31.96 372 95J Strabane 45 77.37 15 23.74 373 95K Omagh 47 66.89 21 28.56 374 95L Fermanagh 61 63.93 16 15.46 375 95M Dungannon 50 68.57 22 28.13 376 95N Craigavon 116 92.92 28 19.97 377 95O Armagh 61 72.20 20 22.59 378 95P Newry & Mourne 96 74.06 29 20.11 379 95Q Banbridge 43 65.77 23 32.70 380 95R Down 66 65.95 37 33.96 381 95S Lisburn 96 59.93 40 22.01 382 95T Antrim 49 66.91 14 18.16 383 95U Newtownabbey 90 70.57 27 18.57 384 95V Carrickfergus 40 63.92 22 30.32 385 95W North Down 76 55.81 21 13.71 386 95X Ards 85 64.15 33 23.02 387 95Y Castlereagh 52 50.12 20 16.02 388 95Z Belfast 327 90.11 153 34.35

Notes: ICD-10 codes I20-I25; directly standardised using the European Standard Population. The age-adjusted death rate per 100,000 is an annual rate. The numbers of deaths 2006-2008 is the total number of deaths over the three year period.

Source: England and Wales: rates calculated in partnership with the Office for National Statistics. Scotland: rates calculated in partnership with the General Register Office for Scotland. Northern Ireland: rates calculated in partnership with Northern Ireland Statistics and Research Agency.

British Heart Foundation Statistics Database www.heartstats.org 31 Key to local authorities, England and Wales

London

British Heart Foundation Statistics Database www.heartstats.org 32 Key to local authorities, Scotland and Northern Ireland

British Heart Foundation Statistics Database www.heartstats.org 33 Figure 1.7a Age-standardised death rates per 100,000, for men under 75 by local authority, 2006/08, United Kingdom

<46 47 to <55 56 to <66 66 to <77 >77

London

British Heart Foundation Statistics Database www.heartstats.org Contains Ordnance Survey data © Crown copyright and database right 2010 34 Figure 1.7b Age-standardised death rates per 100,000, for women under 75 by local authority, 2006/08, United Kingdom

<12 12 to <17 17 to <21 21 to <27 >27

London

British Heart Foundation Statistics Database Contains Ordnance Survey data © Crown copyright and database right 2010 www.heartstats.org 35 Table 1.8 Cardiovascular disease mortality rates by socioeconomic status and sex, 2001-03, England and Wales

CVD CHD Stroke Men Women Men Women Men Women High managerial and professional 61 13 41 5 8 5 Lower managerial and professional 84 19 56 7 12 7 Intermediate 90 19 60 7 12 7 Small employers and own account workers 100 27 66 10 15 9 Lower supervisory and technical 125 34 86 15 17 11 Semi-routine 158 35 107 15 23 11 Routine 172 51 119 24 23 14 Rate ratio 2.8 3.8 2.9 5.0 2.9 3.0

Notes: Rates are directly age-standardised to the European Standard Population, and presented per 100,000. Socioeconomic status categories defined by National Statistics Socio Economic Classification (NS-SEC). Age range for men is 25 to 64. Age range for women is 25 to 59. Rate ratio compares the ‘routine’ and ‘high managerial and professional’ categories.

Source: Langford A, Johnson B (2009). Social inequalities in female mortality by region and by selected causes of death, England and Wales, 2001–03. Health Statistics Quarterly; 44: 7-26 White C, Edgar G and Siegler V (2008). Social inequalities in male mortality for selected causes of death by the National Statistics Socio- economic Classification, England and Wales, 2001–03. Health Statistics Quarterly; 38: 34-46

Figure 1.8 CHD mortality rates by socioeconomic status, 2001/03, England and Wales

140 Men Women 120

100

100,000 80

60

Mortality rate pe r 40

20

0 High managerial Lower managerial Intermediate Small employers Lower supervisory Semi-routine Routine and professional and professional and own account and technical workers

British Heart Foundation Statistics Database www.heartstats.org 36 Table 1.9 Trends in CHD mortality by deprivation quintile, 1994 to 2008, Great Britain

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Men, all ages Quintile 1 222 211 207 193 186 172 164 152 146 138 128 122 110 104 98 Quintile 2 240 233 223 209 199 191 181 167 164 154 146 131 122 116 105 Quintile 3 255 249 239 221 213 210 191 184 178 170 154 143 133 125 118 Quintile 4 276 272 259 248 236 226 210 203 192 182 171 157 145 140 131 Quintile 5 296 292 280 268 256 240 231 221 208 203 183 173 162 156 142 Ratio 1.3 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.5 1.4 1.4 1.5 1.5 1.5

Women, all ages Quintile 1 105 98 96 92 86 82 74 72 67 66 60 55 52 47 44 Quintile 2 112 107 103 100 98 89 85 80 76 75 67 61 56 53 50 Quintile 3 119 117 115 104 103 95 91 85 85 81 71 69 63 59 55 Quintile 4 134 129 123 115 116 104 101 97 94 88 80 76 70 67 61 Quintile 5 146 140 132 130 124 119 108 105 101 96 89 84 76 72 69 Ratio 1.4 1.4 1.4 1.4 1.4 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.5 1.6

Men, under 75 Quintile 1 113 104 101 93 91 81 79 71 66 60 58 53 48 46 44 Quintile 2 124 121 114 105 98 94 88 79 76 69 66 58 56 52 48 Quintile 3 137 133 127 116 110 107 97 92 85 81 74 69 64 60 57 Quintile 4 156 151 142 134 128 123 109 104 97 91 85 79 72 69 68 Quintile 5 172 170 162 156 146 135 129 122 115 113 99 95 89 85 81 Ratio 1.5 1.6 1.6 1.7 1.6 1.7 1.6 1.7 1.7 1.9 1.7 1.8 1.8 1.9 1.8

Women, under 75 Quintile 1 37 34 33 31 28 26 23 22 20 18 16 15 15 12 12 Quintile 2 41 39 37 36 35 30 29 26 23 24 19 19 16 16 15 Quintile 3 47 45 44 39 40 36 33 31 30 27 22 23 20 18 17 Quintile 4 58 55 51 47 48 40 40 36 35 30 27 25 24 23 21 Quintile 5 66 63 59 59 54 52 47 45 42 39 37 33 31 28 28 Ratio 1.8 1.8 1.8 1.9 1.9 2.0 2.1 2.1 2.1 2.1 2.3 2.1 2.1 2.3 2.3

Notes: Quintile 1 is the least deprived and quintile 5 is the most deprived. Ratio refers to quintile 5 compared to quintile 1. Deprivation measured using the Carstairs index for local authorities.

Source: Office for National Statistics (2010). Personal communication. General Register Office for Scotland (2010). Personal communication.

British Heart Foundation Statistics Database www.heartstats.org 37 Figure 1.9a CHD mortality rates by deprivation quintile, men, 1994 to 2008, Great Britain

200 Quintile 1 Quintile 2 180 Quintile 3 Quintile 4 160 Quintile 5

140

120

100

80 CHD mortality rate

60

40

20

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Figure 1.9b CHD mortality rates by deprivation quintile, women, 1994 to 2008, Great Britain

70 Quintile 1 Quintile 2 Quintile 3 60 Quintile 4 Quintile 5

50

40

30 CHD mortality rate

20

10

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 38 Table 1.10a Age-standardised death rates per 100,000 population from coronary heart disease, 1980 to 2008, WHO European region

MEN 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Albania 121 171 115 143 168 156 Armenia 389 463 533 435 480 480 491 Austria 229 240 221 212 183 176 175 162 152 147 145 142 131 Azerbaijan 481 524 576 543 492 515 481 352 Belarus 594 459 578 618 653 677 678 631 694 606 Belgium 196 171 129 127 104 Bosnia and Herzegovina 126 144 Bulgaria 233 296 288 306 247 244 254 240 225 219 203 Croatia 137 124 236 261 214 210 242 198 220 208 205 Cyprus 115 122 112 122 Czech Republic 410 439 439 355 256 253 243 238 220 231 223 239 227 Denmark 383 345 293 227 154 155 134 127 119 107 98 Estonia 686 608 594 468 488 460 445 414 388 376 350 330 Finland 434 427 359 304 255 237 234 222 211 203 201 193 182 France 112 112 91 81 76 72 70 68 64 62 57 55 Georgia 491 488 654 392 360 Germany 225 217 177 170 166 162 149 145 136 Greece 122 130 136 130 124 124 121 126 124 112 108 106 96 Hungary 318 333 332 345 302 299 293 309 309 347 319 303 289 Iceland 341 304 233 225 166 160 171 167 171 128 129 138 134 Ireland 387 399 339 307 234 213 203 180 174 159 148 155 144 Israel 272 231 188 194 128 116 109 110 95 92 89 96 Italy 179 149 135 127 106 102 102 106 89 86 Kazakhstan 437 422 582 589 576 594 615 512 525 510 511 475 Kyrgyzstan 396 355 428 437 422 454 476 428 476 501 Latvia 641 641 549 603 465 450 436 419 436 433 410 440 Lithuania 591 560 534 417 463 473 480 459 491 476 467 449 Luxembourg 200 223 163 142 124 108 112 134 114 94 107 Malta 518 260 280 215 228 204 190 189 173 199 194 162 153 Netherlands 258 248 194 164 125 117 109 106 93 87 80 73 Norway 309 317 278 224 164 160 155 138 126 115 104 103 Poland 173 174 194 168 205 194 182 181 170 164 160 151 Portugal 131 118 114 98 86 84 88 83 79 Republic of Moldova 677 426 607 700 676 718 704 662 710 639 582 550 Romania 184 230 241 311 283 282 295 290 277 273 269 255 248 Russian Federation 540 531 458 559 544 551 573 612 579 594 556 San Marino 57 20 34 Serbia 168 162 161 164 157 178 169 154 155 Slovakia 322 310 432 387 367 367 362 369 351 338 Slovenia 186 161 156 148 147 130 140 115 117 99 97 Spain 115 114 106 103 95 92 90 90 83 82 Sweden 405 354 270 230 176 171 167 161 147 144 137 130 Switzerland 184 174 163 157 129 118 113 112 101 103 98 93 Tajikistan 283 332 358 304 291 331 315 304 284 TFYR Macedonia 146 150 155 156 151 Turkmenistan 497 565 648 Ukraine 630 427 623 663 656 697 711 707 738 713 United Kingdom 380 367 309 260 200 191 182 174 161 150 138 132 Uzbekistan 475 472 559 521 473 467 453 431 454 European Region 331 331 293 326 303 297 301 307 289 292 278 275 273 EU 228 225 209 194 166 160 156 153 144 140 133 129 127

Source: European Health for All database (HFA-DB). http://data.euro.who.int/hfadb/ (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 39 Table 1.10b Age-standardised death rates per 100,000 population from coronary heart disease, 1980 to 2008, WHO European region

WOMEN 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Albania 53 90 61 78 94 90 Armenia 291 307 348 316 288 314 312 Austria 103 110 109 108 95 93 99 96 89 86 81 77 73 Azerbaijan 288 302 339 355 336 350 328 207 Belarus 378 262 287 321 339 333 325 307 13 276 Belgium 81 75 55 56 47 Bosnia and Herzegovina 62 68 Bulgaria 142 201 180 175 149 145 150 138 127 117 104 Croatia 52 44 146 158 125 121 147 121 130 124 120 Cyprus 47 51 49 52 Czech Republic 219 224 220 192 137 136 134 132 123 138 129 146 137 Denmark 187 166 148 116 79 79 71 66 59 55 52 Estonia 397 334 309 259 240 240 233 203 192 183 170 163 Finland 171 172 158 141 120 114 115 108 97 97 90 91 88 France 48 48 39 33 30 30 28 28 25 24 22 21 Georgia 313 308 387 308 261 Germany 107 108 92 89 89 88 81 77 72 Greece 45 53 61 58 56 56 56 59 57 49 48 47 41 Hungary 162 167 171 179 173 173 171 178 180 201 185 172 166 Iceland 143 147 118 97 90 70 78 71 66 63 68 49 61 Ireland 182 182 157 145 111 102 101 91 85 77 71 80 68 Israel 169 151 118 124 71 66 62 62 54 55 52 51 Italy 90 69 63 61 52 50 50 55 45 44 Kazakhstan 268 239 319 294 322 333 345 277 286 279 280 264 Kyrgyzstan 264 213 262 277 276 318 324 302 327 347 Latvia 377 370 293 288 233 218 207 212 206 199 196 211 Lithuania 379 340 318 240 266 261 257 260 267 263 255 240 Luxembourg 98 95 68 55 50 53 51 58 50 44 53 Malta 334 151 189 147 130 125 117 118 99 111 103 86 85 Netherlands 108 101 82 71 56 52 50 47 43 39 35 33 Norway 128 122 116 94 79 73 71 66 60 52 53 50 Poland 60 55 65 61 96 91 85 85 80 79 76 70 Portugal 65 57 59 50 45 43 44 46 39 Republic of Moldova 528 313 424 499 486 517 517 470 502 448 425 408 Romania 126 163 168 197 187 184 188 182 175 174 169 158 151 Russian Federation 314 315 251 272 268 269 280 294 280 285 280 San Marino 31 18 10 Serbia 93 92 100 98 95 107 103 94 91 Slovakia 185 169 240 220 234 232 229 236 221 219 Slovenia 89 95 81 75 68 62 63 58 54 45 44 Spain 51 50 48 46 41 40 39 39 37 36 Sweden 194 158 120 102 83 82 80 77 71 67 68 64 Switzerland 73 70 71 71 65 60 59 57 51 50 47 45 Tajikistan 205 230 254 219 204 229 182 186 173 TFYR Macedonia 71 74 72 75 79 Turkmenistan 324 376 426 Ukraine 422 253 370 405 400 408 421 409 425 416 United Kingdom 164 167 145 123 94 91 87 83 76 71 65 61 Uzbekistan 333 317 417 394 357 351 330 312 321 European Region 183 186 156 172 164 161 163 164 154 151 148 148 147 EU 108 107 101 95 84 82 80 79 74 72 68 66 65

Source: European Health for All database (HFA-DB). http://data.euro.who.int/hfadb/ (Accessed June 2010.)

British Heart Foundation Statistics Database www.heartstats.org 40 Figure 1.10a Death rates per 100,000 from CHD by sex, all ages, 2003, selected countries

Ukraine Kazakhstan Russian Federation Lithuania Uzbekistan Estonia Latvia Slovakia Hungary Czech Republic Finland Poland Ireland United Kingdom Men Austria Women Germany Sweden Slovenia Norway Denmark Greece Switzerland Israel Netherlands Italy Spain Portugal France

-600 -400 -200 0 200 400 600 800

Figure 1.10b Changes in death rates from CHD by sex, 1996 to 2006, selected countries

Denmark Norway Netherlands Ireland United Kingdom Israel Sweden Slovenia Germany Switzerland Estonia Men France Women Finland Czech Republic Austria Italy Lithuania Latvia Greece Kazakhstan Hungary Poland Russian Federation Ukraine Kyrgyzstan -60 -50 -40 -30 -20 -10 0 10 20 30 40 Percentage decrease Percentage increase

British Heart Foundation Statistics Database www.heartstats.org 41 2. Morbidity

This chapter reports on country-level estimates of incidence, case fatality and prevalence of the following conditions: myocardial infarction (heart attack), stroke, angina and heart failure. Additional estimates for coronary heart disease (CHD) and cardiovascular disease (CVD) are provided where possible. Measuring the morbidity of a disease is much more complicated than counting the number of deaths that have occurred due to a disease. For example, people may be suffering from a disease and not be aware of it or the exact time of onset of disease may not be known. As such, the estimates provided in this chapter should be treated with more caution than those from chapter one, yet they represent the best available estimates of the morbidity from CHD for countries within the UK. The estimates provided in this chapter are drawn from a number of different data sources, including samples of GP registers, hospital episode and mortality statistics and national survey data, each of which have their own strengths and limitations.

Incidence Incidence of myocardial infarction has decreased in a number of developed countries during the past three decades, including the UK, driven by favourable changes in risk factors. The most recent estimates of incidence of myocardial infarction in the UK are based on national-level data from linked hospital and mortality statistics, and they suggest that in Scotland the incidence rate of myocardial infarction has decreased by about 25% between 2000 and 2009 in both men and women (Table 2.1).

In general, incidence of myocardial infarction increases sharply with age. Incidence is also higher in men than in women but the difference between sexes decreases with increasing age1. For the years in which comparison can be made (2005 to 2007), incidence of myocardial infarction appears to be between 20% and 35% higher in Scotland compared to England for both men and women, suggesting a considerable North-South gradient in the UK (Table 2.1 and Figure 2.1).

Using the most recent data available from Scotland and England, we estimate that there are around 62,000 heart attacks in English men and 39,000 in English women every year, and 8,000 heart attacks in Scottish men and 5,000 in Scottish women every year. If the rates of heart attack in Wales and Northern Ireland were comparable to that in England, then there would be approximately 124,000 heart attacks in the UK every year (Table 2.1 and Figure 2.1).

Similarly to rates of myocardial infarction, incidence of stroke has decreased in many developed countries during the past three decades, including the UK. On average around the world, stroke occurs around 30% more often in men than in women but the difference between sexes decreases with increasing age2. Data from the South London Stroke Register suggest that stroke incidence decreased by 18% in men and by 24% in women from 1995/96 to 2003/043, while the Oxford Vascular Study reported a 40% reduction in stroke incidence over the past two decades4,5. Recent national-level data from England and Scotland also show that stroke incidence rates are around 25% higher in men than in women and increase with age. They also show that the incidence of stroke is higher in Scotland than in England, but the difference is not as large as for myocardial infarction (Table 2.2 and Figure 2.2).

British Heart Foundation Using the most recent data available from Scotland and England, we estimate that there are around 57,000 Statistics Database strokes in English men and 68,000 in English women every year, and 6,500 strokes in Scottish men and www.heartstats.org 8,000 in Scottish women every year. Despite higher incidence rates in men than in women, there are a 42 greater number of events in women because women tend to live longer than men. If the rates of stroke in Wales and Northern Ireland were comparable to that in England, then there would be approximately 152,000 strokes in the UK every year (Table 2.2).

Estimates of the incidence of angina and heart failure can be provided from representative samples of GP registries. The General Practice Research Database (GPRD) contains anonymised records from such a sample in England, Wales, Scotland and Northern Ireland. GPRD data suggest that in 2009 the incidence rate of angina was the highest in Scotland and lowest in England for both men and women. Overall in the UK, incidence rates were 75% higher in men compared to women. Incidence rates generally increase with age, and are highest in the 65-74 age group in both men and women. Using these incidence rates, we estimate there are nearly 28,000 new cases of angina in the UK every year (Table 2.3).

Data from the GPRD were used to provide the most recent estimates of occurrence of heart failure in the UK. In 2009, incidence of heart failure was highest in Northern Ireland and lowest in England for both men and women. Overall in the UK, incidence rates of heart failure were about 60% higher in men compared to women. Incidence of heart failure increased with age and was highest in adults over 75 years. Using these incidence rates, we estimate there are over 27,000 new cases of heart failure in the UK every year (Table 2.4).

Case fatality Estimates of case fatality for stroke and myocardial infarction that are included in this publication only include those who reach hospital alive, and hence do not include sudden out-of-hospital deaths from either condition. In England, around 11% of men and 15% of women who were admitted to hospital with myocardial infarction in 2006 had died within 30 days. Case fatality rates in Scotland in 2008 were higher, with 12% of men and 19% of women admitted with myocardial infarction dying within 30 days (Table 2.5).

Case fatality from myocardial infarction increases with age and is higher in women than in men. However, this gender difference is largely a reflection of the different age distribution of the female patient population, with more elderly women surviving to be admitted for myocardial infarction compared to elderly men (Table 2.5).

Case fatality rates for stroke are higher than for myocardial infarction, but are measured over a different time period (60 days rather than 30 days). In England, estimates based on linked hospital and mortality data show that about 17% of men and 25% of women admitted to hospital for stroke in 2006 died within 60 days. In Scotland, similar analyses show that 19% of men and 25% of women admitted to hospital for stroke in 2008 died within 60 days (Table 2.6).

In both England and Scotland, case fatality rates for myocardial infarction and stroke were substantially lower in individuals under 75 years of age compared to the rate in all age groups (Tables 2.5 and 2.6).

Prevalence The prevalence of cardiovascular conditions such as myocardial infarction, stroke and angina increases with age and is higher in men than in women. The most recent national survey data suggests that in comparison with the rest of the UK, the prevalence of previous myocardial infarction is highest in Wales, British Heart whilst the prevalence of angina is highest in Northern Ireland. However, the differences between countries Foundation Statistics Database are not very large (Tables 2.7 to 2.10 and Figures 2.10a, b and c). www.heartstats.org 43 Age- and sex-specific prevalence estimates from national surveys allow us to estimate the number of people living in the UK who have previously had a myocardial infarction or stroke, or are currently suffering from angina or coronary heart disease. Using these figures, we estimate that there are around 1 million men and nearly 500,000 women who have had a myocardial infarction, giving a total of over 1.5 million people. Over 900,000 of these people are under the age of 75.

Using similar methods we estimate that nearly 600,000 men and women each in the UK have had a stroke, giving a total of nearly 1.2 million people. Around 600,000 of these people are less than 75 years of age.

The prevalence of the chronic condition angina is higher than for the acute conditions of myocardial infarction and stroke – the prevalence of angina is around 5% in men and 4% in women in the UK. There are around 1.2 million men and over 900,000 women in the UK suffering from angina, giving a total of nearly 2.1 million people. Over 1.2 million of these people are under the age of 75.

The prevalence of CHD (which includes angina and myocardial infarction but not stroke or heart failure) in the UK increases with age and is higher in men than in women. There are over 1.6 million men in the UK with CHD and over 1 million women, giving a total of nearly 2.7 million people. Nearly 1.6 million of these people are less than 75 years of age (Tables 2.7 and 2.8).

The GPRD can also be used to estimate the prevalence of angina and heart failure within the UK. Estimates for the prevalence of angina using the GPRD data are lower than estimates provided by national survey data. For example, the prevalence of angina in English men aged 75 and over is estimated as 16% using GPRD data but 23% using the Health Survey for England 2006. However, the prevalence rates of heart failure estimated by GPRD data and national survey data appear closer – in Welsh men aged 75 and over, the prevalence is estimated as 13% using GPRD data and 9% using the Welsh Health Survey. These discrepancies illustrate the difficulties in interpreting morbidity data (Tables 2.11 and 2.12).

However, the estimates derived from national survey data of the number of people in the UK who have CHD or have had a stroke (given above) are broadly supported by results from the Quality Outcomes Framework. This framework became part of general practice contracts in 2004, and rewards GPs for keeping up-to-date records of the number of patients within their practices who are suffering from certain conditions. Data from the Quality Outcomes Framework suggest that in 2008/09 there were around 2.3 million people suffering from CHD and 1.1 million people suffering from stroke. The prevalence of CHD was higher in Scotland (4.4%), Wales (4.2%) and Northern Ireland (4.1%) than in England (3.5%). Prevalence rates were also higher in the North of England than in the South. Prevalence rates for stroke follow a similar geographic pattern. Prevalence rates for CHD show a wide variation, with lowest rates in London (2.2%) and highest rates in the Western Isles of Scotland (6.1%). However, these rates have not been adjusted to account for differences in the age structure of populations, and so differences in rates should be treated with caution (Table 2.13).

Temporal trends in the prevalence of CHD and CVD can be estimated using data from national health surveys. The Health Survey for England series suggest that between 1994 and 2006 the prevalence of CHD increased from 6.0% to 6.5% in men and remained stable for women (from 4.1% in 1994 to 4.0% in 2006). An increase in the prevalence of CVD (defined here as either CHD or stroke) was also obtained in the Health Survey for England, increasing from 7.1% to 8.1% in men and from 5.2% to 5.6% in British Heart women between 1994 and 2006. These increases were found in the majority of age groups in both men Foundation Statistics Database and women, with the most consistent increase in trend found in the oldest age group (75 years and over)6. www.heartstats.org 44 Age-specific prevalence rates for CVD have been measured since 1988 in the General Household Survey series. They suggest that, for men aged 45 and over, prevalence of CVD increased between 1988 and the mid-2000s, and may have been falling slightly since then. For women, prevalence rates in these age groups certainly peaked in the early to mid 2000s and have declined since. Prevalence rates in the older age groups are still higher than they were at the end of the 1980s. For men aged 65-74, prevalence rates peaked in 2003, when they were 40% higher than in 1988 – equivalent rates in 2008 are 26% higher than in 1988. For women aged 65-74, prevalence rates in 2003 were 30% higher than in 1988, but rates in 2008 are very similar to 1988 rates (Table 2.14 and Figure 2.14).

1. Age-specific rates have been calculated but are not presented in this publication. 2. Appelros P, Stegmayr B, Terent A (2009). Sex differences in stroke epidemiology. A systematic review. Stroke, 40; 1082-1090. 3. Heuschmann P, Grieve A, Toschke A, Rudd A, Wolfe C (2008). Ethnic group disparities in 10-year trends in stroke incidence and vascular risk factors: The South London Stroke Register (SLSR). Stroke, 39: 2204-2210. 4. Rothwell P, Coull A, Giles M, Howard S, Silver L, Bull L, Gutnikov S, Edwards P, Mant D, Sackley C, Farmer A, Sandercock P, Dennis M, Warlow C, Bamford J, Anslow P (2004). Change in stroke incidence, mortality, case-fatality, severity and risk factors in Oxfordshire, UK, from 1981 to 2004 (Oxford Vascular Study). Lancet, 363 (9425): 1925-1933. British Heart 5. Scarborough P, Peto V, Bhatnagar P, Kaur A, Leal J, Luengo-Fernandez R, Gray A, Rayner M, Allender S (2009). Stroke Statistics. British Foundation Heart Foundation & The Stroke Association: London. Statistics Database 6. Joint Health Surveys Unit (2007). Health Survey for England 2006. The Information Centre: Leeds. www.heartstats.org 45 Table 2.1 Incidence of myocardial infarction by age and sex, 2000 to 2009, Scotland and 2005 to 2007, England

Incidence rate per 100,000 SCOTLAND 2000 2005 2006 2007 2008 2009 Number of events (most recent year) MEN Under 75 242 190 175 172 179 183 5,026 All ages 334 275 252 245 248 255 7,971 WOMEN Under 75 90 71 66 62 61 67 2,087 All ages 152 127 118 107 109 113 5,330

ENGLAND MEN Under 75 152 148 143 38,150 All ages 222 212 205 62,233 WOMEN Under 75 50 48 46 13,345 All ages 93 88 84 38,650

Notes: Incident cases include all mortalities and hospital admissions for myocardial infarction (ICD-10 I21-22) with no previous hospital admission for the same condition in the previous 30 days. Incident cases potentially include misdiagnoses and further investigation of earlier myocardial infarctions. Rates are age-standardised to the European Standard Population. Estimates for England are provisional, and may be updated in future publications.

Source: Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford (2010) Personal communication. Information Services Division Scotland (2010) Personal communication.

Figure 2.1 Incidence of myocardial infarction by age and sex, 2007, England and Scotland

300

Scotland 250 England

200

150

100

50 Age-standardised incidence rate per 100,000 rate incidence Age-standardised

0 Men Women Men Women ALL AGES UNDER 75s

British Heart Foundation Statistics Database www.heartstats.org 46 Table 2.2 Incidence of stroke by age and sex, 2000 to 2009, Scotland and 2005 to 2007, England

Incidence rate per 100,000 SCOTLAND 2000 2005 2006 2007 2008 2009 Number of events (most recent year) MEN Under 75 163 133 128 124 127 122 3,409 All ages 277 227 216 208 209 202 6,532 WOMEN Under 75 108 94 86 84 84 87 2,673 All ages 208 180 169 159 162 160 7,830

ENGLAND MEN Under 75 105 101 99 26,835 All ages 193 184 178 57,488 WOMEN Under 75 71 68 66 19,047 All ages 152 144 139 68,457

Notes: Incident cases include all mortalities and hospital admissions for stroke (ICD-10 I60-69) with no previous hospital admission for the same condition in the previous 60 days. Incident cases potentially include misdiagnoses and further investigation of earlier strokes. Rates are age-standardised to the European Standard Population. Estimates for England are provisional, and may be updated in future publications.

Source: Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford (2010) Personal communication. Information Services Division Scotland (2010) Personal communication.

Figure 2.2 Incidence of stroke by age and sex, 2007, England and Scotland

250

200 Scotland England

150

100

50 Age-standardised incidence rate per 100,000

0 Men Women Men Women All ages Under 75s

British Heart Foundation Statistics Database www.heartstats.org 47 Table 2.3 Incidence of angina by sex and age, 2009, England, Scotland, Wales and Northern Ireland

Incidence rate per 100,000 England Scotland Wales Northern Ireland United Kingdom MEN 0-44 3.6 5.9 6.1 3.3 3.9 45-54 54.0 85.3 104.2 82.6 60.5 55-64 150.3 212.6 159.2 165.5 156.3 65-74 193.6 329.2 298.3 330.7 215.4 75+ 121.1 226.1 216.8 162.8 136.7 All ages 44.8 71.2 65.6 61.5 48.7

WOMEN 0-44 1.4 4.9 0.5 3.0 1.7 45-54 30.4 44.0 52.0 44.1 33.3 55-64 67.9 163.3 116.2 49.4 78.6 65-74 127.8 187.3 177.8 135.4 136.6 75+ 91.9 125.7 161.9 96.8 99.9 All ages 25.2 45.4 39.3 26.9 28.0

Number of cases: MEN 1,855 277 259 71 2,462 WOMEN 1,253 188 190 39 1,670

Notes: Estimates are based on records from a sample of general practices in each of the constituent countries of the United Kingdom. Incidence rates are provided per 100,000 person years, as opposed to per 100,000 persons per year. These two denominators are broadly comparable provided that mortality rates in the groups are reasonably low. Estimates for all ages are age-standardised to the European Standard Population.

Source: General Practice Research Database (2010) Personal communication. This table is based on data from the General Practice Research Database, 2010. Copyright and database rights over the data belong to the Crown. The interpretation and conclusions contained in this report are those of the authors alone.

Table 2.4 Incidence of heart failure by sex and age, 2009, England, Scotland, Wales and Northern Ireland

Incidence rate per 100,000 England Scotland Wales Northern Ireland United Kingdom MEN 0-44 2.0 3.5 3.3 3.3 2.3 45-54 19.2 38.5 14.8 22.5 20.6 55-64 72.3 104.7 89.9 95.7 76.8 65-74 179.3 172.7 246.6 351.8 188.4 75+ 326.0 303.0 331.5 441.9 327.6 All ages 37.5 43.4 44.6 58.1 39.1

WOMEN 0-44 1.2 2.9 1.6 1.5 1.4 45-54 9.1 11.0 0.0 7.3 8.6 55-64 31.7 31.2 29.5 39.2 31.7 65-74 102.9 188.5 135.6 119.2 112.7 75+ 256.2 302.2 277.3 381.8 264.1 All ages 23.0 32.1 24.9 29.9 24.0

Number of cases: MEN 2,134 202 233 90 2,659 WOMEN 1,853 206 197 78 2,334

Notes: Estimates are based on records from a sample of general practices in each of the constituent countries of the United Kingdom. Incidence rates are provided per 100,000 person years, as opposed to per 100,000 persons per year. These two denominators are broadly comparable provided that mortality rates in the groups are reasonably low. Estimates for all ages are age-standardised to the European Standard Population. British Heart Foundation Source: General Practice Research Database (2010) Personal communication. This table is based on data from the General Practice Research Statistics Database Database, 2010. Copyright and database rights over the data belong to the Crown. The interpretation and conclusions contained in this report are those of the authors alone. www.heartstats.org 48 Table 2.5 Case fatality rates of those admitted to hospital for myocardial infarction by age and sex, 2008 Scotland and 2006 England

SCOTLAND ENGLAND Under 30 days Under 30 days % % MEN MEN Under 75 6.2 Under 75 5.3 All ages 12.0 All ages 10.6 WOMEN WOMEN Under 75 8.2 Under 75 7.4 All ages 18.7 All ages 15.1

Number of events: MEN MEN Under 75 236 Under 75 1,255 All ages 651 All ages 4,014 WOMEN WOMEN Under 75 118 Under 75 657 All ages 626 All ages 3,716

Notes: Incident cases include all hospital admissions for myocardial infarction (ICD-10 I21-22) with no previous admission for the same condition in the previous 30 days. All mortalities from any cause are included in the numerator. Estimates for England are provisional, and may be updated in future publications.

Source: Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford (2010) Personal communication. Information Services Division Scotland (2010) Personal communication.

Table 2.6 Case fatality rates of those admitted to hospital for stroke by age and sex, 2008, Scotland and 2006, England

SCOTLAND ENGLAND Under 60 days Under 60 days % % MEN MEN Under 75 12.8 Under 75 10.3 All ages 18.7 All ages 17.1 WOMEN WOMEN Under 75 14.6 Under 75 13.1 All ages 25.2 All ages 24.7

Number of events: MEN MEN Under 75 406 Under 75 2,404 All ages 1,009 All ages 7,615 WOMEN WOMEN Under 75 349 Under 75 2,188 All ages 1,463 All ages 12,119

Notes: Incident cases include all hospital admissions for stroke (ICD-10 I60-69) with no previous admission for the same condition in the previous 60 days. All mortalities from any cause are included in the numerator. Estimates for England are provisional, and may be updated in future publications.

Source: Unit of Health-Care Epidemiology, Department of Public Health, University of Oxford (2010) Personal communication. Information Services Division Scotland (2010) Personal communication. British Heart Foundation Statistics Database www.heartstats.org 49 Table 2.7 Prevalence of CHD, stroke, myocardial infarction and angina by age and sex, 2006, England

Having ever been diagnosed with: CHD Stroke Myocardial Angina CVD Unweighted infarction base % % % % % MEN 16-24 0.1 0.0 0.0 0.1 3.2 650 25-34 0.2 0.0 0.2 0.1 4.7 862 35-44 0.6 0.5 0.6 0.3 5.6 1,183 45-54 3.6 1.2 2.1 2.4 10.9 1,050 55-64 10.6 3.0 6.3 8.0 18.5 1,126 65-74 20.8 7.1 14.4 14.2 34.1 437 75+ 28.6 13.1 16.6 22.7 44.4 317 All ages 6.5 2.4 4.1 4.8 13.6 5,625

WOMEN 16-24 0.1 0.2 0.0 0.1 4.5 794 25-34 0.1 0.1 0.0 0.1 5.7 1,148 35-44 0.3 0.4 0.1 0.2 7.8 1,494 45-54 1.3 0.9 0.7 1.2 10.3 1,279 55-64 3.5 2.3 1.6 3.2 15.2 1,269 65-74 10.0 4.2 3.3 8.3 21.2 470 75+ 19.3 10.7 9.1 15.9 36.9 471 All ages 4.0 2.2 1.7 3.3 13.0 6,925

Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with each of the conditions by a doctor.

Source: Joint Health Surveys Unit (2008). Health Survey for England 2006: Cardiovascular disease and risk factors. The Information Centre: Leeds.

Table 2.8 Prevalence of CHD, stroke, myocardial infarction and angina by age and sex, 2008, Scotland

Having ever been diagnosed with: CHD Stroke Myocardial Angina CVD Unweighted infarction base % % % % % MEN 16-24 0.0 0.0 0.0 0.0 4.9 246 25-34 0.0 0.0 0.0 0.0 5.9 317 35-44 0.5 1.3 0.2 0.4 6.8 462 45-54 3.0 0.8 1.7 2.3 10.3 534 55-64 13.1 3.3 7.6 9.3 22.0 525 65-74 21.9 5.8 13.4 14.4 35.8 453 75+ 26.8 13.6 15.5 20.4 45.0 303 All ages 6.9 2.5 4.0 4.9 15.1 2,840

WOMEN 16-24 0.0 0.0 0.0 0.0 6.4 333 25-34 0.0 0.0 0.0 0.0 5.7 450 35-44 1.1 0.6 0.5 0.9 8.8 648 45-54 2.4 1.9 1.3 1.6 12.9 632 55-64 7.4 3.2 2.3 6.4 18.9 631 65-74 15.9 7.1 6.7 13.0 30.9 514 75+ 20.2 10.4 9.8 16.7 35.5 410 All ages 5.6 2.8 2.4 4.6 15.5 3,618

Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with each British Heart of the conditions by a doctor. Foundation Source: Scottish Centre for Social Research (2009). Scottish Health Survey 2008. The Scottish Government: Edinburgh. Statistics Database www.heartstats.org 50 Table 2.9 Prevalence of any heart condition, stroke, myocardial infarction, angina and heart failure by age and sex, 2008, Wales

Having ever been diagnosed with: Currently being treated for: Myocardial Stroke Angina Heart Any heart Unweighted infarction Failure condition base % % % % % MEN 16-24 0 0 0 0 1 697 25-34 0 0 0 0 1 658 35-44 1 0 0 0 2 953 45-54 3 1 1 1 4 972 55-64 8 4 6 2 15 1,136 65-74 16 8 14 4 29 899 75+ 24 12 20 9 42 605 All ages 6 3 4 2 10 5,920

WOMEN 16-24 0 0 0 0 0 780 25-34 0 0 0 0 1 822 35-44 0 1 0 0 1 1,162 45-54 1 1 2 0 4 1,078 55-64 2 2 4 1 8 1,257 65-74 6 4 10 2 19 951 75+ 10 10 19 6 34 816 All ages 2 2 4 1 8 6,866

Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with heart attack or stroke, and whether they are currently being treated for angina, heart failure or other heart conditions by a doctor. Prevalence of ‘any heart condition’ includes heart failure and is hence not comparable with estimates of the prevalence of coronary heart disease.

Source: Welsh Assembly Government (2009). Welsh Health Survey 2008. Welsh Assembly Government: Cardiff.

Table 2.10 Prevalence of stroke, myocardial infarction and angina by age and sex, 2005/06, Northern Ireland

Having ever been diagnosed with: Stroke Myocardial infarction Angina Unweighted base % % % MEN 16-24 0 0 1 153 25-34 1 1 0 278 35-44 0 0 0 344 45-54 1 5 5 305 55-64 2 11 13 275 65-74 6 16 20 236 75+ 12 18 24 152 All ages 2 5 6 1,743

WOMEN 16-24 0 0 0 254 25-34 0 0 0 428 35-44 0 0 0 501 45-54 1 0 4 417 55-64 2 2 2 334 65-74 3 6 15 312 75+ 6 11 24 251 All ages 1 2 5 2,497

Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with each of the conditions by a doctor.

Source: Central Survey Unit (2007). Northern Ireland Health and Wellbeing Survey 2005/06. Northern Ireland Statistics and Research Agency: British Heart Belfast. Foundation Statistics Database www.heartstats.org 51 Figure 2.10a Prevalence of myocardial infarction by sex and country, latest available year, United Kingdom

7

6

5

England, 2006 4 Scotland, 2008 Wales, 2008 Northern Ireland, 2005/06 3 Prevalence (%)

2

1

0 Men Women

Figure 2.10b Prevalence of stroke by sex and country, latest available year, United Kingdom

5

England, 2006 Scotland, 2008 Wales, 2008 4 Northern Ireland, 2005/06

3

Prevalence (%) 2

1

0 Men Women

British Heart Foundation Statistics Database www.heartstats.org 52 Figure 2.10c Prevalence of angina by sex and country, latest available year, United Kingdom

8

7 England, 2006 Scotland, 2008 Wales, 2008 6 Northern Ireland, 2005/06

5

4

Prevalence (%) 3

2

1

0 Men Women

British Heart Foundation Statistics Database www.heartstats.org 53 Table 2.11 Prevalence of angina by sex and age, 2009, England, Scotland, Wales and Northern Ireland

Prevalence (%) England Scotland Wales Northern Ireland United Kingdom MEN 0-44 0.1 0.0 0.0 0.0 0.1 45-54 1.0 1.2 1.0 1.2 1.0 55-64 4.0 4.8 4.8 5.1 4.1 65-74 9.7 12.0 11.8 13.0 10.1 75+ 16.4 18.5 17.8 20.8 16.8 All ages 2.0 2.3 2.2 2.5 2.0

WOMEN 0-44 0.1 0.0 0.0 0.0 0.1 45-54 0.6 0.7 0.6 0.6 0.6 55-64 2.0 3.1 2.7 2.3 2.1 65-74 5.7 8.5 7.2 7.9 6.1 75+ 11.5 14.0 13.1 15.8 11.9 All ages 1.2 1.6 1.4 1.5 1.3

Number of cases: MEN 112,787 11,520 12,265 4,076 40,648 WOMEN 91,917 10,309 10,382 3,693 116,301

Notes: Estimates are based on records from a sample of general practices in each of the constituent countries of the United Kingdom. Estimates for all ages are age-standardised to the European Standard Population.

Source: General Practice Research Database (2010) Personal communication. This table is based on data from the General Practice Research Database, 2010. Copyright and database rights over the data belong to the Crown. The interpretation and conclusions contained in this report are those of the authors alone.

Table 2.12 Prevalence of heart failure by sex and age, 2009, England, Scotland, Wales and Northern Ireland

Prevalence rate (%) England Scotland Wales Northern Ireland United Kingdom MEN 0-44 0.0 0.0 0.0 0.1 0.0 45-54 0.2 0.3 0.2 0.2 0.2 55-64 0.9 1.3 1.1 1.1 0.9 65-74 3.1 4.3 3.5 4.0 3.2 75+ 13.7 13.6 13.3 15.3 13.7 All ages 0.9 1.0 1.0 1.1 0.9

WOMEN 0-44 0.0 0.0 0.0 0.0 0.0 45-54 0.1 0.1 0.1 0.1 0.1 55-64 0.4 0.5 0.5 0.5 0.4 65-74 1.6 2.5 1.9 2.4 1.8 75+ 12.5 12.2 12.6 13.6 12.5 All ages 0.7 0.8 0.7 0.8 0.7

Number of cases: MEN 67,721 6,166 6,697 2,197 82,781 WOMEN 77,511 6,676 7,803 2,608 94,598

Notes: Estimates are based on records from a sample of general practices in each of the constituent countries of the United Kingdom. Estimates for all ages are age-standardised to the European Standard Population.

British Heart Source: General Practice Research Database (2010) Personal communication. This table is based on data from the General Practice Research Foundation Database, 2010. Copyright and database rights over the data belong to the Crown. The interpretation and conclusions contained in this Statistics Database report are those of the authors alone. www.heartstats.org 54 Table 2.13 Prevalence of coronary heart disease, stroke and hypertension by health authority, 2008/09, England, Scotland, Wales and Northern Ireland

Registered GP CHD Stroke Hypertension patients Register Register Register count Prevalence count Prevalence count Prevalence United Kingdom 64,677,888 2,330,277 3.6% 1,104,279 1.7% 8,535,216 13.2% England 54,310,660 1,886,406 3.5% 901,323 1.7% 7,132,856 13.1% North East 2,661,901 126,356 4.7% 57,205 2.1% 395,886 14.9% North West 7,318,925 304,954 4.2% 135,270 1.8% 987,061 13.5% Yorkshire and the Humber 5,416,151 224,326 4.1% 102,515 1.9% 721,605 13.3% East Midlands 4,568,408 169,267 3.7% 78,843 1.7% 623,524 13.6% West Midlands 5,758,803 203,504 3.5% 98,675 1.7% 812,836 14.1% East of England 5,933,784 197,135 3.3% 95,134 1.6% 793,057 13.4% London 8,462,084 189,988 2.2% 88,348 1.0% 915,531 10.8% South East 4,525,385 149,464 3.3% 76,906 1.7% 606,980 13.4% South Central 4,271,353 126,355 3.0% 64,042 1.5% 520,009 12.2% South West 5,393,866 195,057 3.6% 104,385 1.9% 756,367 14.0%

Scotland 5,367,651 237,868 4.4% 108,637 2.0% 707,749 13.2% Ayrshire & Arran 388,169 20,924 5.4% 8,975 2.3% 56,411 14.5% Borders 115,908 5,753 5.0% 2,795 2.4% 16,209 14.0% Dumfries & Galloway 155,343 8,282 5.3% 3,648 2.3% 23,264 15.0% Fife 373,201 16,439 4.4% 7,636 2.0% 51,442 13.8% Forth Valley 299,919 14,405 4.8% 5,912 2.0% 40,064 13.4% Grampian 486,176 19,607 4.0% 8,502 1.7% 61,515 12.7% Greater Glasgow & Clyde 1,306,295 56,948 4.4% 26,094 2.0% 163,715 12.5% Highland 321,561 14,526 4.5% 7,199 2.2% 46,345 14.4% Lanarkshire 590,103 27,419 4.6% 11,620 2.0% 77,820 13.2% Lothian 845,379 30,951 3.7% 15,385 1.8% 100,286 11.9% Orkney 20,263 857 4.2% 336 1.7% 3,175 15.7% Shetland 22,327 812 3.6% 333 1.5% 3,423 15.3% Tayside 415,376 19,261 4.6% 9,554 2.3% 58,995 14.2% Western Isles 27,631 1,684 6.1% 648 2.3% 5,085 18.4%

Wales 3,147,550 130,725 4.2% 63,256 2.0% 469,518 14.9% North Wales 699,536 30,512 4.4% 14,119 2.0% 106,257 15.2% Mid and West Wales 1,063,104 46,820 4.4% 23,538 2.2% 162,718 15.3% South East Wales 1,384,910 53,393 3.9% 25,599 1.8% 200,543 14.5%

Northern Ireland 1,852,027 75,278 4.1% 31,063 1.7% 225,093 12.2% Eastern 726,617 31,150 4.3% 13,166 1.8% 89,339 12.3% Northern 437,980 18,943 4.3% 7,666 1.8% 56,751 13.0% Southern 372,607 13,784 3.7% 5,607 1.5% 42,869 11.5% Western 314,823 11,401 3.6% 4,624 1.5% 36,134 11.5%

Notes: England – Copyright © Health and Social Care Information Centre 2009. Stroke refers to stroke and transient ischaemic attack. Prevalence (unadjusted) = (number on disease register / registered GP patients ) * 100%. Prevalence estimates for Shetland and Orkney are relatively unstable, due to their being based on a smaller number of patients.

Source: England – Information Centre QOF achievement data 2008/09. Wales – StatsWales. QOF 2008/09 achievement data. Scotland – ISD Scotland. QOF achievement data 2008/09 Northern Ireland – Department of Health, Social Services and Public Safety. QOF achievement data at health and social services board level.

British Heart Foundation Statistics Database www.heartstats.org 55 Table 2.14 Prevalence of cardiovascular disease by age and sex, 1988 to 2008, Great Britain

Prevalence (%) All ages 16-44 45-64 65-74 75+ MEN 1988 7.3 1.7 14.3 24.7 22.3 1989 6.9 1.2 13.3 25.9 22.1 1994 9.3 1.6 13.8 24.6 23.6 1995 9.3 1.2 12.9 27.2 23.8 1996 9.9 1.4 14.1 26.8 24.9 1998 11.3 1.9 15.5 28.1 31.0 2000 10.7 1.8 13.7 29.0 30.8 2001 11.0 2.2 15.0 31.3 33.3 2002 11.9 1.7 15.2 33.0 39.8 2003 11.3 1.7 14.7 34.5 31.7 2004 11.1 1.4 14.6 29.5 37.3 2005 11.4 1.5 16.7 28.8 32.9 2006 11.5 2.3 12.8 29.0 33.3 2007 10.9 1.0 14.7 32.0 33.8 2008 11.1 1.4 15.6 31.2 31.1

Prevalence (%) All ages 16-44 45-64 65-74 75+ WOMEN 1988 7.7 1.7 10.8 22.8 26.5 1989 7.7 2.2 11.5 22.0 26.8 1994 9.2 1.7 10.6 23.9 25.1 1995 8.7 1.3 9.7 19.7 29.2 1996 9.5 1.5 12.4 22.4 25.4 1998 9.9 1.3 10.6 26.8 29.9 2000 10.4 1.8 11.7 26.2 30.6 2001 10.2 1.5 11.5 25.2 32.2 2002 11.9 1.9 12.9 29.1 37.9 2003 10.9 2.2 11.8 29.7 30.3 2004 11.0 1.7 13.2 26.6 31.9 2005 10.8 2.0 12.3 26.0 31.3 2006 11.5 2.3 12.8 29.0 33.3 2007 9.7 1.8 11.0 23.9 27.7 2008 9.4 1.2 9.9 23.0 32.5

Notes: From 2000 data are weighted for non-response. See source for details.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/ Product.asp?vlnk=5756 (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 56 Figure 2.14 Prevalence of cardiovascular disease by age, 1988 to 2008, Great Britain

45

16-44 40 45-64 65-74 35 75+

30

25 Prevalence (%) 20

15

10

5

0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 57 3. Treatment

This chapter reports on different methods of treatment for cardiovascular disease (CVD), with a focus on treatments for coronary heart disease (CHD). The chapter includes tables and figures on the number of prescriptions, operations and hospital episodes for CVD in the UK, with temporal trends and comparisons with other countries in Europe where possible. The chapter also includes a discussion of the impact of the National Service Framework for Coronary Heart Disease1, which was introduced in 2000 and covered different aspects of treatment for CHD within the NHS over a ten year period finishing in 2010. An assessment of staffing levels and rehabilitation for CHD is also provided.

Prescriptions The rapid increase in the number of prescriptions for the treatment and prevention of CVD that began in the late 1980s shows no signs of slowing. In 2008, around 266 million prescriptions were issued for CVD in England, nearly five times as many as issued in 1986, and an increase of 6% from the number of prescriptions in 2007 (Table 3.1).

Since 1990, the number of prescriptions for antiplatelet drugs has increased steadily, and there are now over 38 million prescriptions for antiplatelet drugs in England every year. The increase in the number of prescriptions of lipid lowering drugs was slow until the late 1990s, but since then has been very rapid. The number of prescriptions for lipid lowering drugs is more than fifteen times higher than a decade ago (Table 3.1 and Figure 3.1).

The cost of prescriptions for antihypertensive therapy increased by approximately £10 million between 2006 and 2007, to just over £510 million2. However, the cost of prescriptions for circulatory diseases may not increase at the same rate as the increase in the number of prescriptions, since when commonly used drugs come out of patent they can be replaced by cheaper generic drugs (Figure 3.1).

Operations The total number of operations carried out to treat CHD is increasing. The number of percutaneous coronary interventions (PCIs) carried out in the UK in 2008 is more than three times higher than a decade earlier; over 80,000 procedures are now carried out annually in the UK. But the amount of coronary artery bypass graft (CABG) surgery reached a plateau in the late 1990s, driven by more widespread use of less invasive procedures (e.g. stents). Currently around 25,000 CABG procedures are carried out in the UK each year (Table 3.2 and Figure 3.2).

Rates of CABG and PCI vary substantially across the UK. Maps of coronary revascularisation rates for men and women by local authority in England in 2002 show a greater than six fold difference between the lowest and highest rates3. More recently, rates of operations for CHD have been shown to vary greatly around England for both men and women, with high operation rates found in urban and metropolitan areas, and in rural areas in the North and South West of England4.

British Heart Inpatient hospital episodes Foundation Overall, there were around 422,000 inpatient episodes of CHD in National Health Service hospitals in Statistics Database www.heartstats.org 2008/09 in England, and a further 49,000 in Scotland and 27,000 in Wales. These represent 4% of all 58 inpatient episodes in men and 1.6% in women in England (5% and 2% for men and women respectively in Scotland). The number of inpatient episodes of CHD has increased by 12% in the last eight years5 (Table 3.3 and Figures 3.3a, 3.3b, 3.3c and 3.3d).

Medical risk factors for CHD, such as diabetes and obesity, also result in a sizeable burden to the National Health Service. In 2008/09 there were around 80,000 inpatient episodes of diabetes, and over 8,000 of obesity in England (Table 3.3).

Staffing levels In 2002, a report on the provision of services for patients with heart disease in the UK claimed there was a shortage of all types of health care professionals involved in cardiovascular care6. However, since then the numbers of consultant cardiologists and cardiothoracic surgeons have increased considerably. As of September 2009, there were 897 cardiologists working in England7. In 2005, there were 78 in Scotland, 43 in Wales and 25 in Northern Ireland (which equates to around 15 per million in each population). This level of staffing was 50% higher than in 19998.

Rehabilitation The National Audit of Cardiac Rehabilitation monitors access to cardiac rehabilitation around the UK. Its most recent report in 20089 found that in 2006/07 only 47% of heart attack and revascularisation patients started a cardiac rehabilitation programme. The audit team also found large geographical inequalities in access to cardiac rehabilitation – for example, the percentage of elective angioplasty patients that started a rehabilitation programme ranged from 10% to 46% in different Strategic Health Authorities in England. Similar geographical differences were found in Scotland and Wales.

International differences Country-level rates of hospitalisation for CVD are dependent upon a number of factors including prevalence of disease, service provision, primary care referrals practice etc. Therefore, international comparisons of hospitalisation rates for CVD should be made with caution.

Rates of hospitalisations for CVD vary considerably across Europe. For example, the hospitalisation rate in Belarus is four times higher than in Portugal. In general, high hospitalisation rates for CVD, CHD and stroke are found in Eastern European and Scandinavian countries (Tables 3.4, 3.5 and 3.6).

Within Europe, there is an East-West divide in temporal trends for hospitalisation for CVD. Rates in some Eastern European and former Soviet countries have increased rapidly since 1995, whereas rates in Western European countries have remained relatively stable. For example, the rate of hospitalisations for CHD in Ukraine has nearly trebled since 1995, whereas the United Kingdom rate has changed little over this time period (Tables 3.4, 3.5 and 3.6, and Figures 3.5 and 3.6).

National Service Framework for Coronary Heart Disease The National Service Framework (NSF) outlined a series of priorities, milestones and goals to be achieved to improve service quality, tackle variations in care and reduce the number of deaths from CHD over the ten-year period 2000-2010. Although the time period for the NSF is now completed, the most recent data that are available for this publication are from 2009, therefore we are not yet able to give a final British Heart picture of the impact of the NSF. However, it is clear that there have been some impressive successes Foundation in implementing the programme outlined in the NSF. For example, three immediate priorities were Statistics Database www.heartstats.org 59 achieved quickly: the introduction of specialist smoking cessation clinics by health authorities to help 150,000 people quit smoking; the setting up of 50 rapid-access chest pain clinics to assess people with new symptoms for angina within two weeks of referral; and the reduction of call-to-needle times for thrombolysis for heart attacks, by improving ambulance response times and increasing the proportion of accident and emergency (A&E) departments able to provide thrombolysis. By 2008/09, over 600,000 people in England attended NHS smoking cessation services, and of these, 50% reported that they were not smoking four weeks after their quit date (Table 3.7)10. By June 2001, there were 150 rapid-access chest pain clinics open across England11. And by 2004/05, only the South East Coast missed the target of 75% of category A (immediately life threatening) calls responded to within eight minutes12 in comparison to only 3 of 32 ambulance services achieving this target in 2000/01. From 2008/09, the measurement for response time was changed but across England, 74% of emergency and urgent calls were responded to in less than eight minutes. In comparison, the Scottish Ambulance Service reported that they responded to 75% of emergency calls within eight minutes in 2009/1013 (Table 3.8).

Further targets that were achieved by the NSF regarded treatment for CHD once patients arrived at hospital. These included targets to increase to 75% the proportion of heart attack patients receiving thrombolysis within 30 minutes of arriving at hospital; to improve the use of effective medicines after heart attack so that 80 to 90% of people discharged from hospital following a heart attack are prescribed aspirin, beta-blockers and statins; and to increase the total number of revascularisation procedures by 3,000. As discussed earlier, the number of revascularisation procedures carried out in the UK is still increasing – in 2008 there were nearly 45,000 more revascularisation procedures in the UK than in 2000. The National Audit of Myocardial Infarction Project (MINAP) has monitored the achievement of the other two targets. MINAP data show that by April 2002, 59% of eligible heart attack patients were receiving thrombolysis within 30 minutes of arriving in hospital. By 2008/09, the level had risen to 83% in England and 73% in Wales. MINAP data further show that in 2008/09, at least 93% of people discharged from hospital following a heart attack in England were prescribed secondary prevention medicine (Table 3.9)14.

The NSF also outlined the importance of cardiac rehabilitation. It set an overall goal that in every hospital over 85% of people discharged with a primary diagnosis of heart attack or after coronary revascularisation should be offered cardiac rehabilitation. However, as discussed earlier, the rate of CHD patients actually starting cardiac rehabilitation programmes is still much lower than this level (47% in 2006/07)9.

The Department of Health have monitored the implementation of the NSF for CHD, and periodically report on its findings. The most recent report in 2009 highlighted improvements in waiting time for CABGs: in April 2002, there were 7,558 people waiting for a CABG and 4,364 of them had been waiting three months or more; by December 2008, this had fallen to 1,670 people waiting and only six people had been waiting longer than three months15. However, the review acknowledged that many things have changed since 2000 and identified several areas to be focussed on, such as preventing vascular disease and not just treating it, removing inequalities of access, and ensuring that those with chronic vascular conditions who require long-term and end-of-life care get the same level and quality of services that those with acute conditions are currently receiving.

British Heart Foundation Statistics Database www.heartstats.org 60 1. Department of Health (2000). National Service Framework for Coronary Heart Disease. The Stationery Office: London. 2. Office for National Statistics (2008). Prescription cost analysis. The Information Centre: London, and previous editions. 3. Otreba P, Rayner M, Hill A, Goldacre M (2003) An atlas of coronary heart disease mortality, hospital admissions and coronary revascularisations in South East England. SEPHO: Oxford. This publication contains maps of CHD mortality, hospital admissions and coronary revascularisations by local authority across England as well as the South East Region. See www.heartstats.org/chd_atlas 4. Scarborough P, Allender S, Peto V, Rayner M (2008). Regional and social differences in Coronary Heart Disease 2008. British Heart Foundation: London. This publication contains maps of mortality, morbidity and treatment rates for coronary heart disease, and local estimates of the prevalence of behavioural risk factors for CHD. See www.heartstats.org/publications. 5. In 2000/2001, the number of inpatient episodes for CHD was 378,532 in National Health Service hospitals in England. See Table 3.5 in Petersen S, Peto V and Rayner M (2003) Coronary heart disease statistics. British Heart Foundation: London. 6. Hall R, More R, Camm J et al (2002). Fifth report on the provision of services for patients with heart disease. Heart; 88 (Suppl III): iii1-iii59. 7. Office for National Statistics (2010). Medical and Dental Workforce Census 2009. The Information Centre: Leeds. 8. Boon N, Norell M, Hall J, Jennings K, Penny L, Wilson C, Chambers J, Weston R (2006). National variations in the provision of cardiac services in the United Kingdom. Heart; 92: 873-878. 9. National Audit of Cardiac Rehabilitation (2008). Annual Statistical Report 2008. British Heart Foundation: London. 10. Four week self-reported quit rates only give an indication of the true short-term quit rates achieved by smoking cessation services. In 2003/04, carbon monoxide (CO) validation was offered to clients of smoking cessation services as a tool to aid smoking cessation. Around 70% of those who reported having successfully quit smoking at the 4-week follow-up had the level of carbon monoxide in their bloodstream measured. In 88% of cases this test confirmed they were not smoking at 4-weeks. Longer term success rates are currently unknown. 11. Department of Health Heart Team, personal communication. 12. Department of Health Statistical Bulletin (2005) Ambulance services, England: 2004-2005. Department of Health: London. 13. Scottish Ambulance Service (2010). How we are performing. http://www.scottishambulance.com/AboutUs/HowWeArePerforming.aspx (accessed July 2010). 14. For more results from the MINAP project, including hospital level data, see Royal College of Physicians (2007) How the NHS Manage Heart Attacks. Sixth Public Report of the Myocardial Infarction National Audit Project. Royal College of Physicians: London. Also available at British Heart www.rcplondon.ac.uk/pubs. Foundation 15. Department of Health (2009). The Coronary Heart Disease National service framework report. Building on excellence, maintaining progress. Statistics Database Progress report for 2008. Department of Health: London. www.heartstats.org 61 0 8 358 7,991 1,226 4,149 52,190 38,124 39,100 57,823 27,634 37,536 0 6 352 7,309 1,247 4,141 47,412 35,382 37,214 53,634 26,810 37,355 0 5 327 6,790 1,265 4,126 42,098 32,779 34,707 47,742 27,378 37,582 0 4 311 6,294 1,292 4,103 35,568 30,218 32,309 42,865 27,460 37,619 0 4 310 5,871 1,325 4,088 29,444 27,356 30,715 38,580 26,361 36,546 0 3 300 5,389 1,343 4,043 22,655 24,428 29,156 33,788 24,336 34,432 0 2 289 4,975 1,338 4,029 17,604 21,601 27,994 29,591 22,439 32,185 1 2 282 4,609 1,292 4,031 13,523 18,891 26,814 25,047 20,439 30,203 1 3 267 4,152 1,214 3,983 10,331 16,552 25,394 21,075 18,321 27,738

7 840 3,138 9,002 2,609 3,871 21,971 12,125 14,375 23,106

19 532 1,066 3,619 1,356 6,431 3,822 16,718 14,282 22,195

6 247 900 334 1,058 4,424 3,722 10,314 12,525 21,996

15 295 281 629 232 1981 1986 1991 1996 2000 2001 2002 2003 2004 2005 2006 2007 2008 5,156 4,912 9,827 4,243 46,267 55,526 70,041 91,044 129,030 145,134 162,046 179,872 200,598 218,043 234,798 250,862 266,138 20,678 Prescriptions used in the prevention and treatment of cardiovascular disease, 1981 to 2008, England

British Heart

Foundation and items on based are 1991 from Figures only. contractors appliance and pharmacists community by dispensed prescriptions 200 in 1 of sample a on and fees on based are 1990 to up Figures onwards. 1991 from data with consistent not are 1990 to up data The cover all prescriptions dispensed by community pharmacists, appliance contractors, dispensing doctors and submitt ed prescribing for items personally administered. British National Formulary (BNF) codes in parentheses. Office for National Statistics (2009). Prescription cost analysis 2008. The Information Centre: Leeds, and previous editions. Statistics Database www.heartstats.org All prescriptions for disease of the circulatory system Local sclerosants (2.13) Lipid-lowering drugs (2.12) Anti-fibrinolytic drugs and haemostatics (2.11) Antiplatelet drugs (2.9) Anticoagulants and protamine (2.8) Sympathomimetics (2.7) Nitrates, calcium blockers and potassium activators (2.6) Antihypertensive therapy (2.5) Beta-adrenoreceptor blocking drugs (2.4) Anti-arrhythmic drugs (2.3) Diuretics (2.2) Table 3.1 Table Prescriptions (thousands) Notes: Source: Digoxin and other positive inotropic drugs (2.1) 62 Figure 3.1 Prescriptions used in the prevention and treatment of CVD, selected BNF paragraphs, 1981 to 2008, England

70,000

60,000 Anti-arrhythmic drugs Antiplatelet drugs Antihypertensive therapy 50,000 Lipid lowering drugs

40,000

30,000 Number of prescriptions (000s)

20,000

10,000

0 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 63 Table 3.2 Number of CABGs and PCIs, 1977 to 2008, United Kingdom

Coronary artery Percutaneous coronary bypass surgery (CABG) interventions (PCI) 1977 2,297 1978 2,653 1979 2,918 1980 4,057 1981 5,130 1982 6,008 1983 8,332 1984 9,433 1985 10,667 1986 10,767 1987 11,521 1988* 11,113 1989 12,648 1990 14,431 1991 15,659 9,933 1992 19,241 11,575 1993 21,031 12,937 1994 22,056 14,624 1995 22,475 17,344 1996 22,160 20,511 1997 25,639 22,902 1998 25,083 24,899 1999 24,733 28,133 2000 25,127 33,256 2001 24,663 38,992 2002 25,277 44,913 2003 25,461 53,261 2004 25,160 62,780 2005 23,412 70,142 2006 23,623 73,692 2007 25,372 77,373 2008 22,846 80,331

Notes: Data are not available for PCIs until after 1990. * One centre did not make a return this year. Operations performed within the private sector are not included.

Source: British Cardiovascular Intervention Society (2009). Personal communication. The Society for Cardiothoracic Surgery in Great Britain & Ireland (2009) http://www.scts.org (accessed June 2010).

Figure 3.2 Number of coronary artery bypass operations and percutaneous coronary interventions per year, 1980 to 2008, United Kingdom

90,000

80,000 Coronary artery bypass operations Percutaneous coronary interventions 70,000

60,000

50,000

40,000

Number of procedures per year 30,000

20,000 British Heart 10,000 Foundation

Statistics Database 0 www.heartstats.org 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 64 Table 3.3 Inpatient episodes by main diagnosis and sex, National Health Service hospitals, 2008/09, England, Scotland and Wales

ENGLAND SCOTLAND WALES Men Women Men Women Men Women All diagnoses 7,145,742 9,086,837 656,837 735,320 402,707 505,134 All diseases of the circulatory system (I00-I99) 741,384 580,911 81,519 64,889 46,544 37,543 Coronary heart disease (I20-I25) 274,163 148,171 31,884 17,620 17,614 9,726 Angina pectoris (I20) 67,219 48,846 7,164 5,469 4,011 3,069 Acute myocardial infarction (I21) 65,060 41,119 12,301 7,169 4,118 2,773 Other coronary heart disease 141,884 58,206 12,419 4,982 9,485 3,884 Heart failure (I50) 54,503 52,305 6,131 5,360 4,151 3,791 Stroke (I60-I69) 91,363 98,738 10,612 11,321 5,995 6,829 Diabetes (E10-E14) 45,096 35,163 3,410 3,267 2,515 2,052 Obesity (E66) 2,234 6,217 148 330 48 94 All cancer (C00-D48) 806,474 843,204 88,967 108,040 39,123 35,972 Colo-rectal cancer (C18-C21) 92,004 63,978 12,240 9,983 3,167 2,354 Lung cancer (C33-C34) 58,265 43,712 10,397 9,271 3,039 2,403 Breast cancer (C50) 917 169,956 145 26,930 14 4,064 Bladder cancer (C67) 68,811 21,002 3,697 1,705 3,522 1,118 All diseases of the nervous system (G00-G99) 163,470 184,744 14,754 17,861 168 150 All diseases of the respiratory system (J00-J99) 538,632 521,091 54,223 57,715 37,141 36,541 All diseases of the digestive system (K00-K93) 904,694 943,368 87,587 94,085 52,760 55,651 All diseases of the genitourinary system (N00-N99) 403,129 612,582 34,913 54,376 24,911 36,630 Injury and poisoning (S00-T98) 542,533 525,605 61,423 55,777 34,015 32,351 All other diagnoses 2,998,096 4,833,952 229,893 278,980 110366 228139

Notes: Finished consultant episodes; ordinary admissions and day cases combined. Pregnancy cases are not included. ICD-10 codes in parentheses.

Source: Department of Health (2009) Hospital Episode Statistics 2008/09. www.hesonline.nhs.uk (accessed May 2010). Information Services Division Scotland (2009) Main diagnosis discharges from hospital 2007/08. www.isdscotland.org (accessed May 2010). Health Solutions Wales (2009) Primary Diagnosis - 2008/09.www.infoandstats.wales.nhs.uk (accessed Aug 2010).

British Heart Foundation Statistics Database www.heartstats.org 65 Figure 3.3a Inpatient episodes by main diagnosis, men, National Health Service hospitals, 2008/09, England

Genitourinary disease 6% Injuries and poisoning 8% Digestive system disese 13%

Cancer 11%

Respiratory 8%

Nervous system disease 2%

Other CVD 5% All other causes 42% Stroke 1% Coronary heart disease 4%

Figure 3.3b Inpatient episodes by main diagnosis, women, National Health Service hospitals, 2008/09, England

Injuries and poisoning 6%

Genitourinary disease 7%

Digestive system disese 10%

Cancer 9%

Respiratory 6%

Nervous system disease 2% Other CVD 4% All other causes 53% Stroke 1% Coronary heart disease 2%

British Heart Foundation Statistics Database www.heartstats.org 66 Figure 3.3c Inpatient episodes by main diagnosis, men, National Health Service hospitals, 2008/09, Scotland

Genitourinary disease 5%

Digestive system disese 13% Injuries and poisoning 9%

Cancer 14%

Respiratory 8%

Nervous system disease 2%

Other CVD 6% All other causes 36% Stroke 2% Coronary heart disease 5%

Figure 3.3d Inpatient episodes by main diagnosis, women, National Health Service hospitals, 2008/09, Scotland

Genitourinary disease 7%

Digestive system disese 13% Injuries and poisoning 8%

Cancer 15%

Respiratory 8%

Nervous system disease 2%

Other CVD 5% All other causes 38% Stroke 2% Coronary heart disease 2%

British Heart Foundation Statistics Database www.heartstats.org 67 Table 3.4 Rates of hospital discharges from CVD, 1980 to 2008, Europe

Age-standardised rate per 100,000 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Albania 417 540 520 614 665 646 623 668 719 705 Andorra 586 610 799 799 729 727 677 683 753 Armenia 1,092 1,236 1,225 762 639 599 676 786 833 931 972 1,035 1,142 Austria 3,253 3,589 4,074 3,938 4,036 4,009 4,061 4,062 3,804 Azerbaijan 1,481 595 472 484 515 541 570 572 625 641 672 Belarus 3,415 4,577 4,749 5,049 5,226 5,309 5,165 5,374 5,599 5,750 Belgium 2,235 2,377 2,352 2,324 2,275 2,303 2,227 2,168 Bosnia and Herzegovina 964 905 Bulgaria 1,451 1,790 1,779 1,774 1,869 2,013 2,292 2,600 2,911 2,840 3,035 3,180 3,331 Croatia 1,136 1,265 1,232 1,760 1,692 1,730 1,781 1,798 1,850 1,947 1,876 1,904 Cyprus 607 690 809 549 818 927 837 820 840 738 757 3,372 Czech Republic 3,051 3,379 3,431 3,495 3,592 3,635 3,743 3,368 3,254 3,151 Denmark 2,292 2,201 2,543 2,546 2,574 2,514 2,558 2,559 2,560 2,469 2,423 Estonia 2,338 2,664 3,239 3,237 3,168 3,309 3,387 3,360 3,372 Finland 3,293 3,858 3,785 3,654 3,646 3,662 3,670 3,121 3,033 2,913 France 2,263 2,260 2,254 2,218 2,233 2,269 2,228 Georgia 1,642 543 451 412 520 531 635 632 762 837 975 Germany 2,955 3,267 3,305 3,300 3,237 3,125 3,320 3,373 Greece 1,191 1,404 1,593 2,010 2,309 2,432 Hungary 3,171 4,239 4,039 4,248 4,448 4,949 4,977 4,368 3,856 3,863 Iceland 1,935 1,863 1,919 1,878 1,819 1,710 1,480 Ireland 1,440 1,466 1,540 1,486 1,496 1,444 1,316 1,241 1,201 1,180 Israel 1,754 2,241 2,076 2,072 1,996 1,894 Italy 2,128 2,349 2,582 2,572 2,552 2,444 Kazakhstan 1,597 1,207 1,314 1,389 1,519 1,638 1,785 1,805 1,856 1,817 1,899 Kyrgyzstan 1,158 1,217 1,257 903 1,041 1,036 975 1,000 1,004 1,130 1,257 1,385 1,326 Latvia 1,898 2,423 2,445 2,598 3,144 3,137 3,175 3,289 3,399 3,636 3,816 3,900 3,893 Lithuania 1,978 2,628 2,687 3,201 4,102 4,164 4,231 4,369 4,483 4,570 4,471 4,555 4,783 Luxembourg 2,612 2,364 2,439 2,433 2,407 2,249 2,172 Macedonia, TFYR 759 1,184 1,267 1,398 1,424 1,266 1,477 1,556 1,430 Malta 666 665 592 741 835 727 751 656 942 Moldova 1,316 1,626 1,727 1,580 1,315 1,311 1,558 1,983 2,032 2,023 2,100 2,153 2,300 Montenegro 1,059 1,249 1,325 1,448 1,585 1,759 1,733 1,636 1,710 1,670 Netherlands 1,420 1,589 1,409 1,374 1,416 1,456 1,549 1,577 1,580 Norway 2,194 2,349 2,366 2,388 2,500 2,480 2,469 2,495 2,418 2,452 Poland 1,344 1,530 1,814 2,052 2,880 2,931 2,906 2,550 Portugal 944 1,125 1,164 1,213 1,221 1,248 1,240 1,194 1,332 1,388 Romania 1,784 1,914 1,737 2,024 2,422 2,741 2,965 2,798 2,882 3,159 2,826 3,057 Russian Federation 2,226 2,255 2,763 3,020 3,020 3,108 3,267 3,414 3,479 Serbia 1,590 1,571 1,691 1,798 1,796 1,823 1,932 2,094 Slovakia 2,534 2,443 2,569 2,539 2,501 2,564 2,679 2,683 2,463 Slovenia 1,286 1,391 1,424 1,560 1,685 1,738 1,718 1,745 1,792 1,960 1,940 1,918 Spain 780 1,108 1,374 1,387 1,406 1,413 1,344 1,362 Sweden 2,796 2,996 2,639 2,585 2,538 2,505 2,481 2,458 2,455 2,441 Switzerland 1,879 1,800 1,829 1,884 Tajikistan 939 653 533 561 622 678 735 771 879 Turkey 270 390 531 896 909 962 1,051 1,153 1,220 996 1,183 1,180 Turkmenistan 821 1,385 1,249 1,368 Ukraine 2,119 2,601 2,792 2,568 2,612 2,791 2,964 3,105 3,280 3,462 3,586 3,677 3,771 United Kingdom 1,471 1,448 1,462 1,452 1,292 Uzbekistan 1,217 959 1,059 1,178 1,234 1,269 1,394 1,444 1,552 European average 2,088 2,187 2,430 2,516 2,554 2,575 2,634 2,661 2,708 2,703 2,722 EU 1,977 2,194 2,411 2,435 2,463 2,444 2,458 2,394 2,418 2,386

Notes: Blank cells indicate that insufficient data were available for an estimate.

Source: World Health Organization (2010). European Health for all statistical database.

British Heart Foundation Statistics Database www.heartstats.org 68 Table 3.5 Rates of hospital discharges from CHD, 1980 to 2007, Europe

Age-standardised rate per 100,000 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Albania 121 157 146 172 191 195 187 188 204 196 Andorra 126 142 186 156 120 149 150 179 Armenia 334 437 521 318 282 258 288 324 350 382 411 434 469 Austria 785 917 924 960 981 992 1,035 1,032 1,050 990 Azerbaijan 499 201 154 162 155 166 184 175 182 186 214 Belarus 1,635 2,212 2,296 2,278 2,452 2,541 2,569 2,641 2,720 2,713 Belgium 689 742 720 716 711 721 682 660 632 Bosnia and Herzegovina 181 139 Bulgaria 460 524 545 553 542 542 489 579 663 721 854 932 1,017 Croatia 295 334 309 495 457 458 490 491 503 486 458 469 Cyprus 223 293 339 222 332 360 293 248 269 279 194 257 Czech Republic 1,223 1,041 1,107 1,058 1,097 1,062 983 905 851 776 Denmark 700 684 790 803 844 817 831 823 766 731 684 Estonia 936 990 1,117 1,094 1,035 1,038 1,047 998 1,090 1,002 Finland 1,153 1,369 1,160 1,140 1,128 1,138 1,091 923 865 791 France 497 505 510 513 514 505 514 497 Georgia 680 194 193 186 236 263 307 333 404 399 483 Germany 947 1,060 1,011 1,003 1,083 1,042 977 958 933 Greece 296 412 521 722 777 829 867 872 921 936 Hungary 961 1,113 943 879 895 903 875 856 788 808 Iceland 790 724 763 769 738 639 704 576 571 Ireland 477 457 485 493 478 455 422 418 392 374 Israel 834 1,045 911 898 850 784 677 636 580 519 Italy 493 520 600 593 606 599 606 582 570 Kazakhstan 522 436 419 519 521 552 583 606 533 547 684 Kyrgyzstan 324 321 365 156 322 324 307 328 357 385 364 394 497 Latvia 849 1,094 1,163 1,166 1,263 1,278 1,269 1,342 1,339 1,381 1,456 1,453 1,472 Lithuania 1,283 1,327 1,526 1,415 1,371 1,374 1,387 1,388 1,397 1,311 1,306 1,308 Luxembourg 819 868 907 931 856 738 689 606 Macedonia, TFYR 141 321 480 573 623 658 617 680 605 Malta 184 204 185 260 304 271 238 188 288 Moldova 508 689 665 562 419 373 444 571 578 547 588 592 656 Montenegro 342 398 458 488 559 595 541 555 521 Netherlands 546 614 526 512 523 524 555 541 529 527 Norway 890 876 944 938 981 971 952 981 972 952 Poland 332 397 541 598 958 889 915 778 742 Portugal 225 277 274 285 283 285 276 254 328 339 Romania 637 752 809 848 723 649 473 492 364 367 Russian Federation 888 936 1,103 1,168 1,178 1,201 1,258 1,313 1,330 Serbia 373 423 400 460 486 490 507 570 629 Slovakia 1,089 955 954 917 874 861 884 835 737 Slovenia 309 313 349 347 366 381 394 401 392 411 433 417 397 Spain 102 164 202 278 363 361 365 362 356 338 333 326 Sweden 868 959 905 912 878 856 820 786 766 745 Switzerland 567 535 540 551 538 520 Tajikistan 174 122 136 169 176 195 217 249 Turkey 38 56 99 144 206 216 239 277 289 348 454 534 524 Turkmenistan 269 37 28 27 Ukraine 614 719 728 665 1,197 1,284 1,380 1,450 1,555 1,646 1,712 1,761 1,821 United Kingdom 547 541 545 503 499 483 464 452 Uzbekistan 321 300 347 392 398 444 443 472 588 236 European average 669 710 816 835 844 864 880 875 880 873 867 EU 581 656 712 708 711 722 708 662 654 633

Notes: Blank cells indicate that insufficient data were available for an estimate.

Source: World Health Organization (2010) European health for all statistical database.

British Heart Foundation Statistics Database www.heartstats.org 69 Figure 3.5 Rates of hospital discharge for CHD, 1980 to 2008, selected European countries

2,000

1,800 Ukraine

1,600 Latvia 1,400

1,200

1,000 Greece

800

600

Hospital discharges per 100,000 United Kingdom

400 Spain 200

0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 70 Table 3.6 Rates of hospital discharges from stroke, 1980 to 2008, Europe

Age-standardised rate per 100,000 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 Albania 45 80 82 80 91 91 94 108 124 130 Andorra 107 123 113 101 117 106 107 84 Armenia 101 128 194 132 130 129 147 163 161 172 162 177 187 Austria 646 680 847 639 654 617 629 577 570 559 Azerbaijan 113 53 45 48 53 48 52 52 62 65 71 Belarus 569 896 912 949 1,037 1,083 1,063 1,092 1,143 1,154 Belgium 362 394 394 391 377 378 371 363 358 Bosnia and Herzegovina 131 119 Bulgaria 134 268 293 323 426 468 586 666 717 592 616 615 622 Croatia 233 297 281 411 394 396 392 383 409 437 415 411 Cyprus 116 131 143 89 140 149 137 146 149 120 126 157 Czech Republic 558 619 625 633 631 626 615 601 572 543 Denmark 430 394 452 435 424 411 404 384 373 364 356 Estonia 380 497 502 499 536 570 608 619 613 639 Finland 681 820 658 661 645 646 633 561 564 550 France 216 214 215 213 218 222 223 218 Georgia 193 58 74 72 79 80 93 98 102 132 142 Germany 487 462 464 462 542 512 497 506 511 Greece 230 256 274 330 404 424 438 434 415 448 Hungary 598 832 845 969 1,082 1,204 1,271 1,214 1,051 1,053 Iceland 244 237 228 206 254 206 207 180 149 Ireland 234 250 258 251 247 252 171 169 165 165 Israel 203 295 302 299 290 291 290 285 246 237 Italy 394 436 489 494 503 491 485 475 470 Kazakhstan 176 169 210 234 278 293 321 351 355 362 377 Kyrgyzstan 91 107 145 124 153 155 142 142 145 174 188 229 236 Latvia 282 383 445 542 638 669 695 713 732 795 838 852 838 Lithuania 408 512 671 780 825 912 956 1,013 1,055 1,068 1,079 1,170 Luxembourg 233 184 164 164 173 167 165 168 Macedonia, TFYR 121 199 218 240 224 237 224 237 247 Malta 79 77 65 73 61 54 71 58 68 Moldova, Republic of 181 230 293 270 271 247 328 418 429 475 518 540 543 Montenegro 163 160 174 195 201 197 197 183 192 Netherlands 175 194 185 186 193 201 213 225 229 226 Norway 382 320 321 328 353 345 342 345 331 331 Poland 130 159 191 232 370 418 422 355 344 Portugal 287 336 345 350 338 336 327 308 305 310 Romania 280 328 404 442 461 516 523 669 629 580 Russian Federation 370 458 595 653 668 684 720 760 769 Serbia 338 360 362 380 400 431 420 410 419 Slovakia 491 452 473 475 465 473 518 514 458 Slovenia 219 268 249 255 230 230 222 225 228 228 235 226 218 Spain 89 107 112 176 213 221 224 228 227 223 228 230 Sweden 613 617 446 418 422 417 418 417 410 397 Switzerland 214 212 207 211 224 213 Tajikistan 109 31 38 44 52 42 47 56 65 Turkey 27 50 71 106 148 158 166 184 202 145 96 100 100 Turkmenistan 82 169 153 183 Ukraine 244 358 486 467 540 585 629 671 723 770 798 828 857 United Kingdom 213 218 227 225 209 208 205 Uzbekistan 112 79 94 99 102 105 116 117 116 127 European average 342 378 426 444 458 477 489 498 508 503 504 EU 318 350 370 375 385 402 406 394 400 391

Notes: Blank cells indicate that insufficient data were available for an estimate.

Source: World Health Organization (2010) European Health for all statistical database. (Accessed April 2010).

British Heart Foundation Statistics Database www.heartstats.org 71 Figure 3.6 Rates of hospital discharges from stroke, 1980 to 2008, selected European countries

900 Latvia

800

Ukraine 700

600

500 Greece 400

300 Hospital discharges per 100,000 Spain 200 United Kingdom

100

0 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 72 38% 50% 50,121 671,259 51% 38% 52% 21,476 44,019 680,289

52% 53% 13,795 600,410

47% 55% 8,702 602,820

51% 56% 7,369 529,567

57% 361,224

53% 234,858

53% 227,335

49% 132,500

39% 14,600 1999/00 2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09 Outcome at 4 weeks in people using National Health Service smoking cessation smoking Service Health National using people in weeks 4 at Outcome services, 1999/00 to 2007/08, England, Scotland and Northern Ireland

British Heart

A client is counted as having successfully quit smoking at the 4 week follow-up if he/she has not smoked at all since two weeks after the quit date. Scottish data are based on the calendar years 2007 and 2008. Health and Social Care Information Centre (2009) Statistics on NHS stop smoking services in England, April 2008 to March 2009. Centre: Leeds previous editions. Galbraith L, Heeley C (2009) NHS smoking cessation service statistics (Scotland) 1st January to 31st December 2008. Scottish Pu blic Health Observatory: Edinburgh, and previous editions. Northern Ireland Statistics & Research Agency (2008) on smoking cessation services in Ireland: 2007/08. Dep artment of Health, Social Services and Public Safety: Belfast. Foundation Statistics Database www.heartstats.org follow-up (self report) % who had successfully quit at 4 week follow-up (self report) IRELAND NORTHERN number setting a quit date Total % who had successfully quit at 4 week follow-up (self report) SCOTLAND number setting a quit date Total % who had successfully quit at 4 week ENGLAND number setting a quit date Total Table 3.7 Table Notes: Source: 73 Table 3.8 Responses to emergency calls within eight minutes by ambulance service, 2004/05 to 2008/09, England

Emergency calls Emergency and urgent calls 2004/05 2005/06 2006/07 2007/08 2008/09 % % % % % Ambulance service North East 77.3 75.2 76.3 78.5 75.7 North West 76.7 74.3 72.7 75.6 74.3 Yorkshire 75.1 72.7 72.4 73.5 69.4 East Midlands 75.8 75.1 75.9 79.5 76.0 West Midlands 79.4 77.9 77.2 80.9 75.4 East of England 76.3 76.6 75.2 75.0 74.6 London 76.6 75.1 75.2 78.9 75.5 South East Coast 74.8 76.0 75.1 77.2 75.2 South Central 76.2 76.0 73.8 75.1 72.6 Great Western 72.7 74.0 72.8 72.2 68.4 South Western 75.7 75.9 74.1 78.9 78.0 Isle of Wight 77.2 75.7 78.0 81.7 77.0 England 76.2 75.3 74.6 77.1 74.3

Notes: From 2007/08 urgent calls are included (previous years relate to emergency calls only). From 2008/09 the starting point for response time measurement was changed - comparisons with earlier years should be treated with caution.

Source: Office for National Statistics(2007) Ambulance services, England:2008-09.The Information Centre: Leeds.

Table 3.9 Thrombolytic treatment, use of aspirins, beta blockers and statins after a heart attack, 2004/05 to 2008/09, England and Wales

Percentage of patients having thrombolytic treatment within 30 mins of arrival at hospital 2004/05 2005/06 2006/07 2007/08 2008/09 % % % % % Target 75 75 75 75 75 England National Average 84 83 84 84 83 Wales National Average 70 74 70 67 73

Percentage of patients having thrombolytic treatment within 60 mins of calling for help 2004/05 2005/06 2006/07 2007/08 2008/09 % % % % % Target 58 68 68 68 68 England National Average 54 58 64 71 72 Wales National Average 28 30 41 49 48

Percentage of patients discharged on secondary prevention medication 2008/09 Aspirin Beta blockers Statins % % % Target 80 80 80 England National Average 98 93 97 Wales National Average 98 96 96

Notes: Data are from the MINAP project, based at the Royal College of Physicians. For more details of the project see www.rcplondon.ac.uk/ index.asp

Source: Royal College of Physicians (2008) Myocardial Infarction National Audit Project. How the NHS manages heart attacks. Eigth public report 2009. UCL: London, and previous editions. British Heart Foundation Statistics Database www.heartstats.org 74 4. Behavioural risk factors

This chapter reports on the prevalence of behavioural risk factors for coronary heart disease (CHD), including sections on smoking, poor diet, physical inactivity and alcohol consumption. Patterns in the prevalence of each of these risk factors by age, sex, socio-economic status, geographic region and ethnicity are explored. Prevalence rates in the United Kingdom are compared against rates found in other countries. Temporal trends in the prevalence of these risk factors are also reported.

Smoking Smoking increases the risk of CHD. The long-term risk of smoking to individuals has been demonstrated by a 50-year cohort study of British doctors. This study found that CHD mortality was around 60% higher in smokers (and 80% higher in heavy smokers) compared to non-smokers. After observing smokers and non-smokers over a 50 year period, the study concluded that “about half of all regular smokers will eventually be killed by their habit”1.

In Great Britain, 21% of adults smoke cigarettes. The younger age groups tend to have a higher prevalence, with men aged 20 to 34 and women aged 16 to 24 having the highest prevalence of smoking. The lowest prevalence is found in those aged over 60. In Northern Ireland, smoking prevalence is at 24%, with the highest rates being found in those aged 20 to 24. This is particularly true for men, with 52% of this age group reporting being a smoker in 2008/09. Smoking has been declining since the 1970s and 1980s in both Great Britain and Northern Ireland. All countries of the United Kingdom now have a ban on smoking in public places and it is hoped that this will aid in reducing the prevalence rate of smoking amongst young people (Tables 4.1 and 4.2, and Figure 4.1).

There is little variation in smoking rates by region of England, however rates are marginally higher in the North compared to the South. Scotland and Northern Ireland both have the highest rates at 24%, compared to England and Wales at 21% (Table 4.3).

Smoking is socially patterned, with the prevalence lower in the professional groups compared to the routine and manual groups. In Great Britain in 2008, 29% of those in the routine and manual group smoked, compared to 14% of those in managerial and professional group. While there is an overall gradient of this kind in Northern Ireland, the trend across the social groups is not as smooth. The gradient in men is slightly steeper, compared to women (Table 4.4 and Figures 4.4a and 4.4b).

Smoking rates vary noticeably between ethnic groups in the UK. In 2004, 40% of Bangladeshi men smoked, compared to 21% of Black African and Chinese men. With the exception of Black Caribbean women, the prevalence of smoking among the ethnic minority women was low, with only 2% of Bangladeshi women and 10% of Black African women smoking. Chewing tobacco is more common in British Heart the Bangladeshi community and 16% of Bangladeshi women consume tobacco in this way2 (Table 4.5). Foundation Statistics Database www.heartstats.org 75 In 2008, 5% of boys and 8% of girls in England, aged 11 to 15 regularly smoked cigarettes. The latest data from Wales, Scotland and Northern Ireland all show a higher prevalence of smoking in girls than in boys. Since the early 1980s, there has been a decline in smoking amongst young people in England, Scotland and Northern Ireland. In Wales the prevalence has remained the same in boys and increased in girls (Table 4.6).

Data from the World Health Organization’s (WHO) Global Burden of Disease study show that smoking prevalence in men in the UK is well below the average for the European region (26% compared to 45%). For women the prevalence is comparable. The most recent data from the WHO show that smoking prevalence for men ranges from 70% in the Russian Federation to 9% in Ethiopia. In women the prevalence ranges from 0.2% in Algeria to 54% in Nauru (Table 4.7).

Poor diet A poor diet increases the risk of chronic diseases, particularly CVD and cancer. Diet affects CVD in a variety of ways. An energy imbalance, where more energy is taken in than expended can result in weight gain and obesity. High saturated fat raises cholesterol levels, high salt intake can raise blood pressure, and low intakes of fibre, fruit and vegetables can lead to a greater susceptibility to CVD.

The National Food Survey, and more recently the Family Food Survey, allows us to examine trends in diet over time. Overall intake of calories, fat and saturated fat has decreased since the 1970s. This trend is accompanied by a decrease in sugar and salt intake, and an increase in fibre and fruit and vegetable intake (Table 4.8).

This change in pattern may in part be due to a change in the type of foods purchased. Since the 1940s purchase of lard and butter has dramatically reduced, while the purchase of reduced fat spreads has doubled. Similarly, the purchase of whole milk has gradually been replaced with skimmed milks, reducing the fat and saturated fat content of the diet (Table 4.9 and Figures 4.9a, 4.9b and 4.9c).

The latest National Diet and Nutrition Survey provides an estimate of the quality of the diet for adults in Britain. The results suggest that in 2008/09, the percentage of food energy obtained from fat met dietary recommendations, however targets for percentage of food energy coming from saturated fat and non- milk extrinsic sugars are not being met. Average intake of fibre is too low (at 14g per day compared to a recommendation of 18g per day), and only around a third of both men and women currently consume the recommended five portions of fruit and vegetables a day (Table 4.10).

The best estimates of salt intake levels are provided by analysis of urine samples. In 2006, urinary analyses were conducted for samples of the adult population in England, Scotland and Wales, and the results suggest that average salt intake in Britain was above the target of 6g per day. Average consumption in men was between 9g per day in Wales and 10g per day in England and Scotland. Consumption levels in women were lower – the average consumption of salt in Welsh women was 7g per day (Table 4.11).

Consumption of fat, saturated fat, and non-milk extrinsic sugars is fairly similar around the UK, with the exception of the South East which has slightly lower consumption of all these. There is minimal variation of fibre and fruit and vegetable consumption. Calories (kcal) consumption does vary considerably, with people in the North East, North West and London consuming the least amount of calories. People in British Heart Foundation the South West consume the most (Table 4.12). Statistics Database www.heartstats.org 76 The Family Food Survey provides consumption by income quintile. A gradient can be observed in the consumption of fat, saturated fat, total sugars and non-milk extrinsic sugars, with those in the lower income groups consuming more of these than those on a higher income (Table 4.13 and Figure 4.13).

Differences in consumption by ethnic group are also apparent. In 2008, the White ethnic group had the highest intake of saturated fat, both absolutely and as a percentage of total energy (15%). The lowest intake of saturated fat as a percentage of total energy was in the Black and Black British group, at 11%. Salt consumption also varied considerably, with South Asians consuming 3.6 grams and the White group consuming 3 grams more at 6.6g per day3 (Table 4.14).

In 2008, the Health Survey for England estimated that 19% of boys and 20% of girls aged 5 to 15, were consuming 5 or more portions of fruit and vegetables a day – the recommended daily amount. This is compared to 11% for both groups in 2001. (Table 4.15).

Data from the WHO for 2003 show that the availability of fruit and vegetables was generally higher in Southern European countries, as compared to Northern, Western, Central and Eastern European countries. The proportion of energy available from fat varied widely, ranging from 14% in Azerbaijan to 42% in France. The proportion of energy available from fat in the UK was higher than the European average, at 35% compared to 32% (Table 4.16).

Physical inactivity People who are physically active are at lower risk of CHD. To produce the maximum benefit, exercise needs to be regular and aerobic. This should involve the use of the major large muscle groups steadily and rhythmically, so the heart rate and breathing increase significantly. The recommended level for adults is 30 minutes of physical activity on at least 5 days a week4. For children aged 5 to 18 the recommendation is to participate in physical activity of at least moderate intensity for one hour a day5.

Physical activity levels in England and Scotland have increased over the past decade, but remained stable in Wales. Despite this increase, physical activity levels in the UK still remain relatively low. Men in Scotland exercise the most, with 45% exercising above the recommended levels. However in Northern Ireland the percentage meeting the recommended levels is just 33%. The percentage of women meeting the recommended levels is even lower, at 33% in Scotland and 22% in Wales. There is also a considerable difference by age, with those aged 65 and above consistently achieving the recommended amount the least. The highest levels tend to be found in those aged under 45 (Tables 4.17 and 4.18).

In 2008, the Health Survey for England had a focus on physical activity6. Physical activity levels are normally self-reported, however for this report a sub-sample was selected to use accelerometers to objectively measure their physical activity levels. Based on the accelerometry data, only 6% of men and 4% women met the government’s recommended levels of physical activity in comparison to the self- reported levels of 39% for men and 29% for women, suggesting that physical activity levels are often over-reported. Despite its limitations, self-report is the most commonly used method of assessment and is therefore still reported on in this chapter.

There is some variation in those meeting the recommended levels by region of England, although it is not marked. In men, the lowest percentage is found in the North East and the highest in South Central. British Heart For women, the lowest is in the West Midlands and the highest is also in South Central (Table 4.19 and Foundation Figure 4.19). Statistics Database www.heartstats.org 77 The Health Survey for England 2008 shows a substantial difference in physical activity levels by equivalised household income quintile. There were a higher percentage of men and women meeting the recommended levels in the highest income quintiles compared to the lowest. The gradient is stronger in men with 42% compared to 31%, but 34% compared to 26% in women (Table 4.20).

Compared with the general population in 2004, Indian, Pakistani, Bangladeshi and Chinese men and women were less likely to meet physical activity recommendations. Of the men, Bangladeshi and Pakistani men had the lowest prevalence of meeting the recommendations (26% and 28%). This pattern was also true of the women from these groups, at 11% and 14% respectively. Irish men and Black Caribbean women had the highest prevalence of meeting the recommendation (Table 4.21).

The number of English children aged 2 to 15 meeting the recommended level of physical activity marginally increased from 66% in 2002 to 68% in 2007 meeting the recommendations. In 2007 72% of boys and 63% of girls met the recommended levels of physical activity for children (Table 4.22).

European levels of regular physical activity (defined as exercising at least five times a week) range from 3% in Bulgaria to 23% in Ireland. The UK is among the higher levels in Europe (14%) and is above the EU average of 9% (Table 4.23 and Figure 4.23).

Alcohol consumption While moderate alcohol consumption (one or two drinks a day) does not increase the risk of CVD. The World Health Report 2002 estimated that 2% of CHD and almost 5% of stroke in men in developed countries was due to alcohol. However, the impact of alcohol consumption in women in developed countries was estimated to be positive – if no alcohol were consumed, there would have been a 3% increase in CHD and a 16% increase in stroke7.

The most recent Government advice is that regular consumption of between three and four units a day for men, and between two and three units a day for women will not lead to significant health risk8. Consuming over these levels is not advised. The benchmark for heavy drinking is set at more than eight units in one day for a man and more than six units in one day for a woman.

In Great Britain in 2008 more than a third of men (37%) and nearly three in ten women (29%) regularly exceeded the Government’s recommended level of alcohol intake. 21% of men and 14% of women exceeded the Government definition of heavy drinking – in both instances the highest rate of alcohol consumption was found in the 16 to 24 age group, and levels decreased with age (Table 4.24 and Figure 4.24).

Since 1998 the General Household Survey has measured the prevalence of heavy drinking in Great Britain. Consistently over this time period, 16 to 24 year olds were the most likely group to drink heavily, and men were more likely than women to drink heavily. However, the prevalence of heavy drinking in 16 to 24 year olds has decreased over the last ten years. In men, the prevalence has decreased from 39% to 30% between 1998 and 2008 – a fall of nearly 25% (Table 4.25 and Figure 4.25).

The prevalence of drinking alcohol in people aged under 16 also seems to be in decline from a peak in the mid 1990s. In England, alcohol consumption in 11 to 15 year old boys fell from 27% in 1996 to only 18% in 2008, and from 26% to 17% in girls of the same age. A similar pattern is found in Scotland, British Heart Foundation where prevalence of alcohol consumption in 15 year old boys fell from 48% to 31% between 1996 and Statistics Database 2008, and from 46% to 31% in girls of the same age. Alcohol consumption levels in girls and boys of www.heartstats.org the same age seem to be higher in England than in Scotland (Tables 4.26 and 4.27). 78 Within Great Britain, there is considerable geographic variation in the prevalence of heavy drinking. For both men and women, the highest prevalence rates are found in the North of England, with 29% of men in Yorkshire and the Humber regularly drinking more than eight units on the heaviest drinking day in 2008, compared to only 16% in Wales. For women, the lowest prevalence rate was found in Wales, West Midlands and East England (11%) and the highest rate was found in Yorkshire and the Humber (21%) (Table 4.28 and Figures 4.28a and 4.28b).

The socio-economic gradient in exceeding drinking recommendations and heavy drinking in Great Britain is contrary to patterns in other behavioural risk factors. In 2008, for both men and women, the highest rate of both heavy drinking and exceeding recommendations was found in the managerial and professional social class; 17% of women in the managerial and professional social class regularly drink heavily compared to only 12% of women in the routine and manual social class. This gradient was even steeper for exceeding recommendations in alcohol consumption (Table 4.29 and Figure 4.29).

The amount of alcohol consumed on a regular basis varies dramatically by ethnic group. Drinking any alcohol at all is rare in the Pakistani and Bangladeshi ethnic groups, and abstention from alcohol is far more common in the Indian, Black and Chinese ethnic groups than in the general population. In England in 2004, a quarter of men (25%) and 14% of women regularly drink heavily – the equivalent levels are much lower for the Black Caribbean, Black African, Indian, Pakistani, Bangladeshi and Chinese ethnic groups. Only the Irish ethnic group had a higher prevalence rate for heavy drinking (Table 4.30).

In 2009, more people in the United Kingdom reported drinking heavily (34%) than the average level for the 27 member states of the European Union (29%). The highest reported rate was in Ireland (44%). In general, countries in Eastern Europe had lower reported rates than in the rest of Europe (e.g. Latvia 11%, Poland 19%) (Table 4.31).

1. Doll R, Peto R, Boreham J, Sutherland I (2004) Mortality in relation to smoking: 50 years’ observations on male British doctors. BMJ; 328: 1519-27. 2. Department of Health (2005) Health Survey for England 2004. The Health of Minority Ethnic Groups - headline tables. NHS Health and Social Care Information Centre. 3. This is likely to be an underestimate of salt consumption, as it does not include salt added during cooking or at the table. 4. Department of Health (2004) At least five a week: evidence on the impact of physical activity and its relationship to health. Department of Health: London. 5. Department of Health (2005) Choosing Activity: a physical activity action plan. Department of Health: London. 6. Department of Health (2010) Health Survey for England 2008. The Stationery Office: London. British Heart 7. World Health Organization (2002). The World Health Report 2002. Reducing Risks, Promoting Healthy Life. World Health Organization: Foundation Geneva. Statistics Database 8. Department of Health (1995) Sensible drinking. The report of an inter-departmental working group. Department of Health: London. See also www.heartstats.org www.nhs.uk/LiveWell/Alcohol (accessed June 2010). 79 % 13 22 24 27 30 22 12 20 23 25 31 26 13 23 24 30 29 18 7,930 6,700 14,630 % 12 21 24 26 31 21 12 21 23 23 30 20 13 22 25 29 32 22 8,380 7,240 15,620 % 12 22 25 30 31 20 12 22 25 26 29 20 13 23 26 33 33 20 9,005 7,677 16,682 % 14 24 27 31 32 24 13 23 26 29 30 26 14 25 29 34 34 23 21,665 11,627 10,038 % 14 24 29 31 32 24 14 22 28 28 29 25 15 26 31 35 36 23 8,029 6,868 14,897 % 15 25 30 34 36 26 14 23 28 31 34 25 16 26 32 38 38 27 9,327 8,097 17,424 % 15 26 28 34 38 25 14 24 27 33 38 29 17 27 29 36 37 22 7,951 6,837 14,788 % 17 26 29 34 37 28 17 25 28 31 35 31 16 26 31 38 40 25 8,299 7,055 15,354 % 16 27 29 35 35 29 15 28 27 32 35 28 16 27 31 39 35 30 7,496 6,593 14,089 % 16 27 30 35 40 31 16 27 28 33 39 31 16 27 32 37 42 30 7,830 6,579 14,409 % 18 27 30 36 39 29 19 26 30 34 36 32 18 28 30 38 43 26 8,501 7,172 15,673 % 17 27 30 32 39 27 17 26 28 30 38 27 18 27 31 34 40 28 9,108 7,642 16,750 % 20 29 31 34 38 27 19 29 30 34 37 25 21 28 32 34 39 29 9,764 8,417 18,181 % 21 29 34 35 38 30 20 29 33 34 39 32 24 28 34 36 38 28 9,445 8,106 17,551 % 23 33 36 36 37 28 21 34 35 35 37 28 26 33 37 37 37 28 8,673 18,795 10,122 % 25 35 36 36 39 30 22 35 34 35 38 30 29 35 37 37 41 30 8,874 19,178 10,304 % 26 39 37 38 38 31 23 39 36 36 36 32 30 39 39 40 40 29 9,788 8,417 18,205 % 27 41 39 38 40 30 23 40 38 37 40 30 33 42 40 40 41 31 9,199 19,840 10,641 % 29 45 44 45 42 32 24 44 43 44 40 32 36 47 45 47 44 32 22,554 12,100 10,454 % 30 45 45 45 44 34 24 42 43 42 43 33 38 48 48 48 45 35 22,636 12,156 10,480 % 31 47 47 46 46 37 24 46 45 43 45 34 40 49 50 48 47 39 23,442 12,554 10,888 % 34 51 52 51 48 40 26 48 49 46 44 38 44 53 55 56 52 42 9,852 21,332 11,480 Cigarette smoking by sex and age, 1972 to 2008, Great Britain % 46 45 42 40 39 35 34 33 32 30 28 27 28 27 27 27 26 26 25 24 22 21 21 34 50 51 52 51 41 41 41 38 37 37 33 32 31 30 29 28 26 28 26 25 26 25 24 23 23 21 20 21 25 47 48 49 48 39 52 51 46 45 42 38 36 35 33 31 29 28 29 28 29 28 27 28 26 25 23 22 22 47 54 55 56 55 43 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 22,494 12,143 10,351

British Heart

Foundation From 2000 data are weighted for non-response. Pre-2000 unweighted. The effect of weighting on smoking appears sli ght: it increased the overall prevalence in by one percentage point, from 26% to 27%. (accessed June 2010). Office for National Statistics (2009) General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/Product.asp?vlnk=5756 Statistics Database www.heartstats.org All ages Unweighted base 60+ 50-59 35-49 25-34 20-24 TOTAL 16-19 All ages Unweighted base 60+ 50-59 35-49 25-34 20-24 WOMEN 16-19 All ages Unweighted base 60+ 50-59 35-49 25-34 20-24 MEN 16-19

Table 4.1 Table Notes: Source: 80 Figure 4.1 Prevalence of smoking by sex, 1972 to 2008, Great Britain

60

50

Men 40 Women

30

20 Prevalence of smoking (%)

10

0 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

British Heart Foundation Statistics Database www.heartstats.org 81 Table 4.2 Cigarette smoking by sex and age, 1983 to 2008-09, Northern Ireland

1983 1990-91 1992-93 1994-95 1996-97 1998-99 2000-01 2002-03 2004-05 2006-07 2007-08 2008-09 % % % % % % % % % % % % MEN 16-19 31 24 24 20 23 15 23 33 19 13 18 17 20-24 46 39 40 37 39 36 26 32 32 37 20 52 25-34 42 40 34 34 39 37 30 32 37 38 33 38 35-49 45 38 34 32 34 30 33 26 33 29 32 27 50-59 41 34 32 30 33 29 26 27 29 28 25 25 60+ 30 24 23 22 21 20 16 18 16 13 12 16 All ages 39 33 31 29 31 28 26 27 27 25 23 26 Base 2,498 2,629 2,475 2,323 2,074 1,916 1,811 2,454 1,710 1,500 1,465 1,296

WOMEN 16-19 19 27 24 27 23 24 27 28 19 31 12 13 20-24 39 31 32 35 30 39 34 35 38 33 35 34 25-34 41 40 33 35 37 37 34 33 34 30 29 28 35-49 33 37 36 32 32 35 32 29 30 30 28 27 50-59 32 31 27 25 24 28 26 28 25 27 24 26 60+ 16 21 20 17 17 17 17 13 13 15 13 13 All ages 29 31 29 27 27 29 28 26 25 26 23 23 Base 3,077 3,216 3,097 3,059 2,727 2,654 2,591 2,722 2,328 2,175 1,938 1,855

TOTAL 16-19 25 26 24 24 23 20 26 31 19 24 15 15 20-24 42 34 35 36 34 38 31 33 35 35 29 40 25-34 42 40 33 35 37 37 33 32 35 33 31 32 35-49 39 37 35 32 33 33 32 27 31 30 30 27 50-59 36 32 30 27 28 28 26 27 27 28 24 26 60+ 22 22 21 19 19 18 17 16 15 14 13 14 All ages 33 32 30 28 29 29 27 26 26 25 23 24 Base 5,575 5,845 5,572 5,382 4,801 4,570 4,402 5,176 4,038 3,675 3,403 3,151

Source: Northern Ireland Statistics and Research Agency (2010). Continous Household Survey 2008/09. NISRA: Belfast.

British Heart Foundation Statistics Database www.heartstats.org 82 Table 4.3 Cigarette smoking by sex and region, 2008, United Kingdom

MEN WOMEN TOTAL % % % England 21 20 21 North East 17 23 21 North West 25 22 23 Yorkshire and the Humber 24 25 25 East Midlands 20 19 20 West Midlands 21 19 20 East of England 20 18 19 London 21 18 19 South East 21 18 20 South West 21 22 21 Wales 20 21 21 Scotland 23 24 24 Northern Ireland 26 23 24

Base England 5,720 6,770 12,490 North East 290 360 640 North West 770 920 1,690 Yorkshire and the Humber 620 750 1,370 East Midlands 580 650 1,220 West Midlands 620 740 1,360 East of England 710 790 1,500 London 530 680 1,210 South East 960 1,120 2,080 South West 640 780 1,420 Wales 390 450 830 Scotland 590 720 1,310 Northern Ireland 1,296 1,855 3,151

Notes: Data are for adults aged 16 and over.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/ Product.asp?vlnk=5756 (accessed June 2010). Northern Ireland Statistics and research Agency (2010). Continous Household Survey 2008/09. NISRA: Belfast.

British Heart Foundation Statistics Database www.heartstats.org 83 Table 4.4 Cigarette smoking by sex and socioeconomic status, 2008, Great Britain and Northern Ireland

MEN WOMEN TOTAL % % % GREAT BRITAIN Managerial and professional 14 14 14 Intermediate 22 21 21 Routine and manual 30 27 29 Total 22 21 21

NORTHERN IRELAND Professional 7 8 7 Employer, manager 20 19 20 Intermediate non-manual 18 15 16 Junior non manual 32 22 24 Skilled manual 27 23 26 Semi-skilled manual 37 32 34 Unskilled manual 49 25 34 No SEG, ref etc,armed forces 25 24 24 Total 26 23 24

Bases: GREAT BRITAIN Managerial and professional 2,970 3,290 6,260 Intermediate 1,200 1,490 2,690 Routine and manual 2,280 2,730 5,000 Total 6,680 7,890 14,580 NORTHERN IRELAND Professional 88 49 137 Employer, manager 155 99 254 Intermediate non-manual 200 366 566 Junior non manual 101 454 555 Skilled manual 424 141 565 Semi-skilled manual 151 386 537 Unskilled manual 72 112 184 No SEG, ref etc,armed forces 105 248 353 Total 1,296 1,855 3,151

Notes: Adults aged 16 and over. Great Britain: Respondents whose household reference person was a full time student, had an inadequately described occupation, had never worked or was long-term unemployed are not shown as separate categories but are included in the total. Socio-economic classification is based on the current or last job of the household reference person. Northern Ireland: SEG refers to socio-economic group.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/Product.asp?vlnk=5756 (accessed June 2010). Northern Ireland Statistics and Research Agency (2010). Continuous Household Survey 2008/09. NISRA: Belfast.

British Heart Foundation Statistics Database www.heartstats.org 84 Figure 4.4a Smoking prevalence by sex and socioeconomic group, 2008, Great Britain

35

30

Men 25 Women

20

15

Smoking prevaelce (%) 10

5

0 Managerial and professional Intermediate Routine and manual

Figure 4.4b Smoking prevalence by sex and socioeconomic group, 2008, Northern Ireland

60

50 Men Women

40

30

20 Smoking prevalence (%)

10

0 Professional Employer, Intermediate Junior Skilled manual Semi-skilled Unskilled manager non-manual non manual manual manual

British Heart Foundation Statistics Database www.heartstats.org 85 Table 4.5 Cigarette smoking by sex, age and ethnic group, 2004, England

MEN WOMEN 16-34 35-54 55+ All ages 16-34 35-54 55+ All ages % % % % % % % % Black Caribbean 27 34 12 25 44 21 5 24 Black African 21 20 25 21 15 6 2 10 Indian 18 22 19 20 8 4 3 5 Pakistani 28 34 18 29 5 7 5 Bangladeshi 35 49 29 40 1 4 3 2 Chinese 25 21 9 21 12 5 4 8 Irish 46 26 25 30 35 26 21 26 General population 32 26 14 24 28 26 15 23

Bases (unweighted): Black Caribbean 114 165 124 403 186 289 162 637 Black African 172 169 38 379 224 189 44 457 Indian 199 230 118 547 237 274 119 630 Pakistani 213 145 65 423 268 164 65 497 Bangladeshi 198 149 49 396 287 117 49 453 Chinese 170 117 58 345 145 176 51 372 Irish 114 194 188 496 147 275 231 653 General population 721 973 1,161 2,855 895 1,374 1,536 3,805

Notes: General population data is from 2003. Blank cells indicate too few respondents for accurate estimate.

Source: Joint Health Surveys Unit (2005) Health Survey for England 2004. The Health of Minority Ethnic Groups. Department of Health: London.

British Heart Foundation Statistics Database www.heartstats.org 86 8 9 5 10 8 5 8 7 10 11 7 10 9 9 7 10 13 16 7 11 8 9 11 14 16 11 8 11 8 9 10 16 12 16 10 10 8 10 9 17 13 12 11 10 16 14 15 14 12 11 8 13 13 13 11 10 9 13 13 10 10 10 8 9 13 12 12 12 11 11 9 8 7 11 9 9 7 12 14 13 12 10 17 13 16 13 12 14

Regular cigarette smoking in young people aged 11 to 15, by sex, 1982 to 2008, England, 2008, to 1982 sex, by 15, to 11 aged people young in smoking cigarette Regular and Northern Ireland Scotland, Wales % % % % % % % % % % % % % % % % % % % % 14 11 15 11 1982 1983 1984 1986 1988 1990 1992 1994 1996 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart

In Scotland, rates are for children aged 12-15 up to 1999, and 13-15 from 2000. Department of Health (2010) Smoking, drinking and drug use among young people in England 2008: Headline Figures. Assembly Government “Healtheschool” website (2003) www.healtheschool.org.uk/smoking/smoking_data.htm Welsh personal communication. Statistics for Wales: National Assembly for Wales, National Centre for Social Research and the Foundation Educational (2001). Smoking, drinking & drug use a mong young people in Scotland 2000. The Stationery Office: Edinburgh. Child and Adolescent Health Research Unit, The University of Edinburgh (2008). Scottish Lifestyle Substance Use Survey (Salsus) 2008, previous surveys. Stationery Office: Department of Health and Social Security Northern Ireland (1991) Smoking Drinking Amongst 11-15 year olds in Irela nd 1990. DHSS NI: Belfast Behaviour and Attitiudes Survey . Person’s Northern Ireland Statistics and Research Agency (2002) Young See: www.csu.nisra.gov.uk/archive/surveys/ypbas/results/ypbas%20bulletin.pdf Foundation Statistics Database www.heartstats.org Northern Ireland Wales Scotland Northern Ireland GIRLS England Scotland Wales BOYS England Table 4.6 Table Notes: Sources: 87 Table 4.7 Current tobacco use by sex, 2006, all available countries, the World WHO member states MEN WOMEN WHO member states MEN WOMEN % % % % African Region 18 3 Western Pacific Region 57 5 Algeria 29 0 Australia 22 19 Benin 18 2 China 60 4 Burkina Faso 21 10 Fiji 22 4 Cameroon 12 2 Japan 42 13 Cape Verde 16 5 Laos 64 15 Chad 15 2 Malaysia 53 3 Comoros 27 12 Marshall Islands 36 6 Congo 11 1 Micronesia 30 18 Côte d’Ivoire 14 2 Mongolia 46 7 DR of Congo 13 2 Nauru 48 54 Eritrea 16 1 New Zealand 22 20 Ethiopia 9 1 Palau 38 9 Gambia 29 3 Philippines 53 12 Ghana 10 1 Republic of Korea 53 6 Kenya 26 2 Samoa 59 23 Liberia 13 Singapore 36 6 Malawi 21 5 Tonga 62 15 Mali 18 3 Vanuatu 50 7 Mauritania 34 5 Viet Nam 44 2 Mauritius 34 1 Mozambique 21 3 European Region 45 24 Namibia 24 10 Albania 43 4 Nigeria 12 1 Andorra 36 28 Sao Tome and Principe 22 10 Armenia 61 3 Senegal 19 1 Austria 47 41 Seychelles 32 6 Azerbaijan 1 South Africa 30 9 Belarus 64 22 Sudan 28 3 Belgium 33 24 Swaziland 23 3 Bosnia and Herzegovina 49 35 Tuvalu 54 21 Bulgaria 49 38 Uganda 19 4 Croatia 39 29 Tanzania 24 4 Czech Republic 35 27 Zambia 21 5 Denmark 35 30 Zimbabwe 33 4 Estonia 48 25 Finland 33 23 Region of the Americas 27 17 France 36 27 Argentina 35 26 Georgia 57 6 Barbados 18 3 Germany 37 26 Belize 25 3 Greece 63 39 Bolivia 34 29 Hungary 45 35 Brazil 19 12 Iceland 29 24 Canada 24 18 Ireland 34 28 Chile 42 34 Israel 31 19 Cook Islands 42 34 Italy 34 20 Costa Rica 26 7 Kazakhstan 43 9 Cuba 43 29 Kyrgyzstan 46 2 Dominican Republic 17 13 Latvia 53 24 Ecuador 23 6 Lithuania 50 22 Guatemala 24 4 Luxembourg 39 30 Honduras 3 Malta 32 21 Jamaica 21 9 Netherlands 33 28 Mexico 36 12 Norway 31 30 Paraguay 33 15 Poland 30 38 Saint Lucia 28 12 Portugal 34 16 Saint Vincent and the Grenadines 19 6 Republic of Moldova 45 5 Suriname 17 3 Romania 46 24 United States of America 25 19 Russian Federation 70 28 Uruguay 39 29 Serbia 40 27 Venezuela 32 27 Slovakia 41 20 Slovenia 32 21 South-East Asia Region 39 5 Spain 37 27 Bangladesh 47 4 Sweden 17 23 Cambodia 49 7 Switzerland 33 23 North Korea 58 Turkey 51 20 India 33 4 Ukraine 65 24 Indonesia 62 5 United Kingdom 26 24 Maldives 45 12 Uzbekistan 23 3 Myanmar 43 15 Nepal 36 28 Eastern Mediterranean Region 32 4 Pakistan 35 7 Bahrain 22 3 Sri Lanka 32 2 Egypt 28 1 Thailand 43 2 Iran 30 5 Iraq 30 3 Jordan 61 10 Kuwait 37 4 Lebanon 31 7 Morocco 30 0 Oman 21 1 Saudi Arabia 23 4 Syrian Arab Republic 43 Tunisia 58 7 United Arab Emirates 25 3 Yemen 29 6

Global 411 89

Notes: Tobacco smoking includes cigarettes, cigars, pipes or any other smoked tobacco products. Current smoking includes both daily and non- daily or occasional smoking. Smoking prevalence data are sourced from surveys conducted in countries in different years. To obtain smoking prevalence estimates for 2006, trend information is used either to project into the future for countries with data older than 2006 or to backtrack for countries British Heart with data later than 2006. This is achieved by incorporating trend information from all available surveys for each country. For countries Foundation without historical data, trend information from the respective sub-region in which they fall is used. Prevalence is age-standardised to the Statistics Database WHO standard population. www.heartstats.org Source: World Health Organization. Global Health Observatory http://apps.who.int/ghodata/# (Accessed June 2010) 88 76 83 6.1 2.5 8.5 117 13.3 14.4 14.7 32.3 37.9 2,317 2,028 76 84 6.2 2.5 8.6 119 13.4 14.2 14.7 32.6 37.7 2,421 2,052 77 85 6.5 2.6 8.7 121 13.8 13.9 14.5 33.4 36.9 2,454 2,074 79 85 6.9 2.7 8.8 123 13.8 14.2 14.4 33.4 36.7 2,448 2,082 80 83 6.8 2.7 8.6 123 13.2 14.7 14.5 32.9 36.7 2,274 2,048 82 85 6.9 2.7 8.7 124 13.1 14.7 14.6 33.6 36.7 2,269 2,077 82 85 7.0 2.8 8.8 124 13.5 14.7 14.4 33.7 36.6 2,306 2,099 81 86 7.2 2.9 8.8 122 13.3 14.5 14.6 33.9 36.9 2,248 2,089 88 86 7.3 2.9 9.0 131 13.9 15.3 14.5 34.6 36.1 2,381 2,152 87 89 7.0 2.8 9.0 129 12.8 15.2 14.9 35.5 37.4 2,254 2,143 - - - - 94 6.8 2.7 8.6 16.3 37.2 40.9 2,164 2,058 - - - - 7.0 2.8 9.3 102 17.5 43.0 41.6 2,018 2,208 ------112 18.1 49.1 41.3 10.3 2,059 2,439 ------112 19.3 53.4 40.4 10.4 1975 1980 1985 1990 1995 2000 2001 2002 2003 2004 2005 2006 2007 2008 1,818 2,489 Consumption of total fat, saturated fat, salt, sugar, 1975 to 2008, Great Britain fibrevegetables, adults aged 16 and over, and fruit and Data pre-1996 are unadjusted National Food Survey data. 2001/02 data onwards are Expenditure and Food Survey data. 1996 to 2000 data are adjusted estimates from the National Food National the from estimates adjusted are data 2000 to 1996 data. Survey Food and Expenditure are onwards data 2001/02 data. Survey Food National unadjusted are pre-1996 Data Because Survey. of the discontinuity between datasets, these trends need to be interpreted with caution. Consumption assumed from purchase data, and applies to food consumed in household only. the Office for National Statistics (2010). Family Food in 2008. The Stationery Office: London and previous editions. Department for Environment, Food and Rural Affairs (2003). National Survey 2000. The Stationery Office: London previ ous editions. Purchase per person week Purchase Fruit and vegetables (excluding potatoes) (g) Salt (g) Sodium (g) Non-starch polysaccharide fibre (g) Non-milk extrinsic sugars (% total energy) Non-milk extrinsic sugars (g) Total sugars (g) Total Saturated fat (% total energy) Saturated fat (g) Fat (% total energy) Fat (g) Energy (kJ) Table 4.8 Table Consumption per person day, total diet (i.e. including alcohol) Notes: Source: Energy (kcal)

British Heart Foundation Statistics Database www.heartstats.org 89 Table 4.9 Consumption of selected foods, adults aged 16 and over, 1942 to 2008, United Kingdom

1942 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2005 2006 2007 2008 Litres per person per week Liquid wholemilk 1.98 2.34 2.72 2.73 2.75 2.76 2.63 2.71 2.37 1.90 1.24 0.82 0.68 0.48 0.49 0.43 0.42 Skimmed milks 0.01 0.02 0.25 0.73 1.12 1.16 1.17 1.14 1.15 1.15 Yoghurt 0.03 0.06 0.08 0.11 0.15 0.16 0.20 0.20 0.20 0.20 Total milk and cream 2.14 2.52 2.94 2.89 2.92 2.95 2.89 2.98 2.68 2.41 2.23 2.24 2.16 2.03 2.02 2.00 2.00 Number per person per week Eggs 1.4 3.0 3.5 4.2 4.6 4.8 4.7 3.8 3.4 2.9 2.0 1.7 1.6 1.6 2.0 2.0 2.0

Grams per person per week Natural cheese 70 75 81 92 99 103 103 105 98 97 104 103 106 99 Processed cheese 10 11 10 10 8 6 7 9 10 12 12 13 12 12 Total cheese 101 71 72 80 86 91 102 107 110 111 113 108 109 116 116 119 111 Oranges and other citrus fruits 75 93 108 124 122 142 143 153 119 136 136 137 151 145 148 131 Apples and pears 201 190 230 231 234 219 260 235 249 233 235 226 229 223 205 Bananas 37 83 96 101 85 85 91 83 130 184 214 225 226 230 219 Total fresh fruit 197 318 409 457 522 533 543 511 608 540 624 693 765 856 855 855 790 Fruit juice (ml) 7 8 14 19 17 42 97 165 225 272 332 350 366 340 325 Other fruit 97 156 162 173 163 185 152 120 113 103 92 86 92 86 84 Total fruit 197 318 513 621 698 725 723 738 857 825 962 1,068 1,189 1,292 1,313 1,281 1,199

Fresh green vegetables 438 517 392 415 430 407 372 341 366 287 287 233 246 235 221 224 203 Other fresh vegetables 450 442 433 415 427 406 394 405 466 461 475 486 506 567 566 566 557 Total fresh vegetables (excludes potatoes) 888 959 825 830 857 813 766 746 832 748 762 719 752 802 787 790 760

All processed vegetables (includes frozen & canned) 136 188 214 224 260 304 382 506 554 625 638 697 671 567 609 594 599 Fresh potatoes 1,877 1,863 1,759 1,698 1,588 1,509 1,470 1,257 1,176 1,175 1,008 810 727 587 565 537 535

Bread 1,718 1,752 1,637 1,563 1,289 1,151 1,080 1,029 949 947 859 818 782 701 692 677 659 Flour 181 176 206 243 192 173 161 156 169 121 95 60 69 60 54 54 63 Cakes, buns and pastries 190 158 179 191 161 173 153 141 146 173 187 168 165 159 153 Biscuits (includes crispbreads) 74 82 104 145 161 165 163 211 205 198 199 181 189 165 165 163 170 Breakfast cereals 23 26 40 48 51 56 78 82 94 109 121 127 135 135 135 130 130 Total cereals (excludes breads) 593 672 678 706 711 729 711 649 655 638 692 775 846 865 861 858 858 Bread and cereal products 2,310 2,424 2,315 2,269 2,000 1,880 1,791 1,678 1,604 1,585 1,551 1,593 1,628 1,566 1,553 1,535 1,517

Sugar 238 259 287 500 503 498 480 394 392 294 211 169 130 94 92 92 93 Preserves 140 155 179 116 91 85 73 76 63 58 52 43 37 35 34 33 34

Tea 61 79 79 74 73 66 62 53 46 42 36 33 30 30 30 Coffee 6 10 11 12 16 19 20 21 19 18 16 17 16 17 17 Total beverages 77 100 101 98 102 103 99 90 84 74 70 57 55 56 55

Fresh white fish 89 90 67 64 50 37 32 28 24 20 15 19 20 17 16 Fresh fatty fish 16 11 9 7 6 5 7 7 8 10 11 18 18 18 15 Shell fish 3 3 3 2 1 2 3 4 5 6 6 12 13 14 13 Takeaway fish 29 23 24 28 29 18 20 16 15 14 7 10 10 10 9 Total fish and fish products 187 261 188 169 166 164 152 128 137 140 147 147 144 167 170 165 161

Salt 26 25 28 25 32 27 15 13 9 11 8 9 9 Butter 56 61 129 127 161 173 170 147 106 74 42 34 37 38 40 41 40 Margarine 118 119 112 133 104 86 81 78 115 113 96 43 22 20 18 19 22 Low fat spreads 14 27 27 22 16 13 12 11 Reduced fat spreads 20 48 50 39 43 41 40 Lard 50 43 56 62 58 60 63 62 57 45 25 14 7 4 4 3 3 Total fats 245 245 329 337 339 336 339 315 324 293 265 227 193 183 184 181 184

Beef and veal 230 179 228 265 248 229 221 215 208 167 134 109 113 120 128 126 111 Mutton and lamb 150 173 154 186 188 167 149 119 128 92 82 54 54 53 54 55 45 Pork 11 40 9 66 57 79 80 79 118 98 84 71 68 52 55 54 55 Bacon and ham 112 100 128 172 175 179 177 137 145 132 115 111 109 112 111 109 108 Poultry 10 14 50 100 143 160 170 177 204 217 235 260 255 251 250 Sausages 113 110 114 99 103 106 106 99 100 92 74 68 66 64 65 65 62 Total meat and meat products 746 746 846 976 1,017 1,066 1,121 1,055 1,160 1,069 999 986 1,014 1,046 1,042 1,029 998

Soft drinks, low calorie (ml) 504 516 442 534 508 490 Soft drinks, not low calorie (ml) 1,150 1,184 1,276 1,273 1,178 1,192 Total soft drinks (ml) 1,654 1,699 1,718 1,807 1,686 1,682

Chocolate bars 87 113 84 84 88 88 Confectionery 125 151 123 123 129 131

Notes: Figures differ from actual food and drink consumption for a number of reasons e.g. food may be discarded during food preparation (e.g. vegetable peelings), food may be left on the plate at the end of a meal or food may become inedible before it can be consumed and is therefore thrown away. Data for 1942 to 1970 from non-adjusted National Food Survey (GB only). Data for 1975 to 1995 from adjusted National Food Survey (GB only). Data for 1996 British Heart to 2000 from adjusted National Food Survey (UK). Data for 2005 onwards from Expenditure and Food Survey (UK). Because of the discontinuity between datasets, Foundation these trends need to be interpreted with caution. Statistics Database Source: Office for National Statistics (2010) Family Food in 2008. The Stationery Office: London and previous editions. www.heartstats.org Department for Environment, Food and Rural Affairs (2001) National Food Survey 2000. The Stationery Office: London, and previous editions. 90 Figure 4.9a Consumption of fats, adults aged 16 and over, 1942 to 2008, United Kingdom

400

350

300

250

Total fats 200

150

100 Low and reduced fat spreads Consumption per person week (g)

50 Butter

Margarine 0 1942 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2008

Figure 4.9b Consumption of milk and milk products, adults aged 16 and over, 1942 to 2008, United Kingdom

3.5

3.0

2.5

2.0 Total milk and cream

1.5

1.0 Skimmed milks

0.5

Consumption per person week (litres) Liquid wholemilk

0.0 1942 1945 1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000 2008

British Heart Foundation Statistics Database www.heartstats.org 91 Figure 4.9c Consumption of fresh fruit and vegetables, adults aged 16 and over, 1942 to 2008, United Kingdom

1000

900 Total fresh vegetables, excluding potatoes 800

700

600

500 Total fresh fruit excluding fruit juice

400

300 Fruit juice 200 Consumption per person week (g) 100

0 1942 1950 1960 1970 1980 1990 2000 2008

British Heart Foundation Statistics Database www.heartstats.org 92 Table 4.10 Quality of diet by sex, 2008/09, United Kingdom

MEN WOMEN TOTAL TARGET Percentage of food energy, total fat 35.5 34.7 35.1 <35% Percentage of food energy, saturated fat 13.0 12.6 12.8 <11% Percentage of food energy, trans fatty acids 0.8 0.8 0.8 <2% Percentage of food energy, non-milk extrinsic sugars 13 12.1 12.5 <11% Mean grams per day of non-starch polysaccharide (fibre) 15.1 13.0 14.0 >18g Mean daily number of portions of fruit and vegetables consumed 4.4 4.4 4.4 >5 portions % eating recommended 5 or more portions a day 37.4 33.3 35.3

Base 181 253 434

Notes: Adults aged 19 to 64. Data are weighted for non-response. 2008/09 is the first year of a rolling three-year programme, therefore these estimates are based on low numbers and should be treated with caution. Target refers to the dietary reference values set by the Department of Health, which are the current reccommendations for consumption levels in the UK.

Source: Bates B, Lennox A, Swan G. The National Diet and Nutrition Survey: Headline results from year 1 of the rolling programme 2008/09. Department of Health and Food Standards Agency: London.

Table 4.11 Consumption of salt, adults aged 16 and over, 2000/01, Great Britain, and 2006, England, Scotland and Wales

MEN WOMEN 19-24 25-34 35-49 50-64 All ages 19-24 25-34 35-49 50-64 All ages Great Britain, 2000/01 Mean salt consumption (g/day) 11.0 11.4 11.1 10.5 11.0 9.1 8.7 8.0 7.5 8.1 % exceeding recommended daily consumption 98 80 87 82 85 83 71 69 62 69 Base 62 152 170 183 567 60 129 203 187 580

England, 2006 Mean salt consumption (g/day) 11.0 9.9 10.1 10.2 10.2 7.0 8.8 7.9 6.8 7.7 % exceeding recommended daily consumption 100 85 88 89 89 85 84 72 57 70 Base 13 20 67 88 188 6 43 99 112 262

Scotland, 2006 Mean salt consumption (g/day) 12.0 9.7 11.3 9.6 10.6 7.5 8.1 7.7 7.2 7.6 % exceeding recommended daily consumption 100 78 87 81 85 47 71 63 68 65 Base 5 18 76 96 195 7 22 105 113 247

Wales, 2006 Mean salt consumption (g/day) 12.4 9.4 9.0 8.6 9.4 6.3 7.8 6.8 6.4 6.8 % exceeding recommended daily consumption 89 83 80 81 82 56 64 60 48 57 Base 6 19 64 66 155 6 38 89 119 252

Notes: The recommended daily consumption of salt for both men and women is 6g per day or less. The 2006 estimates should be viewed with caution due to poor survey response rates. Salt consumption based on 24 hour urine collection.

Source; Office for National Statistics (2003) The National Diet and Nutrition Survey: adults aged 19 to 64 years. The Stationery Office: London. Joint Health Surveys Unit (2006) An assessment of dietary sodium levels among adults (aged 19-64) in the general population, based on analysis of dietary sodium in 24 hour urine samples. Food Standards Agency: London. Joint Health Surveys Unit (2007) A survey of 24 hour and spot urinary sodium and potassium excretion in a representative sample of the Scottish population. Food Standards Agency: London. Joint Health Surveys Unit (2007) An assessment of dietary sodium levels among adults (aged 19-64) in the general population in Wales, based on analysis of dietary sodium in 24 hour urine samples. Food Standards Agency: London.

British Heart Foundation Statistics Database www.heartstats.org 93 78 85 6.6 120 2.65 13.6 14.1 14.6 33.4 37.1 1,756 1,979 2,108 Ireland 81 85 6.6 123 2.64 13.0 14.9 15.1 34.1 37.6 1,583 2,135 2,085

79 86 6.6 855 124 2.63 14.0 14.4 14.9 34.0 37.8 2,442 2,108

76 84 6.2 119 2.50 13.5 14.3 14.7 32.6 37.9 2,436 2,043 14,437

82 89 6.6 129 2.66 14.7 14.6 15.1 35.1 38.1 1,584 2,715 2,155

78 87 6.5 122 2.58 14.0 14.4 15.1 34.1 38.6 2,534 2,624 2,084

66 79 5.3 107 2.10 13.2 13.0 13.7 28.8 37.7 1,544 2,682 1,934

78 85 6.4 121 2.55 13.7 14.5 15.0 33.5 38.1 1,671 2,511 2,066 81 85 6.3 122 2.53 13.5 14.9 14.7 33.1 37.5 1,513 2,276 2,084 80 85 6.4 125 2.57 13.9 14.8 14.7 33.2 37.8 1,361 2,436 2,082 76 85 6.4 119 2.58 13.3 14.3 14.9 33.2 38.0 1,566 2,245 2,056 Humber and The Midlands Midlands 73 80 6.3 113 2.52 12.5 14.2 14.6 31.1 37.4 1,891 2,108 1,970

71 81 6.3 773 111 2.53 12.6 13.9 15.0 32.0 37.7 2,045 1,973 North East North West Yorkshire East West East London South East South West England Wales Scotland Northern Consumption of total fat, saturated fat, salt, fibresugar, and fruit and vegetables,Region, 2006/08 by Government Office

British Heart

Foundation Data are weighted for non-response. Consumption is assumed from purchase data, and applies to food consumed in the household only. Adults aged 16 and over. Office for National Statistics (2010) Family Food in 2008. The Stationery Office: London. Statistics Database www.heartstats.org Base Purchase per person week Purchase Fruit and vegetables (excluding potatoes) (g) Salt (g) Sodium (g) Non-starch polysaccharide fibre (g) Non-milk extrinsic sugars (% total energy) Non-milk extrinsic sugars (g) Total sugars (g) Total Saturated fat (% total energy) Saturated fat (g) Fat (% total energy) Fat (g) Energy (kcal)

total diet (i.e. including alcohol) Table 4.12 Table Consumption per person day, Notes: Source: 94 Table 4.13 Consumption of total fat, saturated fat, salt, sugar, fibre and fruit and vegetables, by income quintile, 2006/08, United Kingdom

Consumption per person per day, Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5 total diet (i.e. including alcohol) (lowest income) (highest income) Energy (kcal) 2,174 2,128 2,063 2,014 1,947 Fat (g) 91 88 85 82 79 Fat (% total energy) 38.2 38.1 37.8 37.5 37.6 Saturated fat (g) 35.3 34.5 32.8 31.8 30.9 Saturated fat (% total energy) 14.9 14.9 14.7 14.6 14.7 Total sugars (g) 129 127 121 116 111 Non-milk extrinsic sugars (g) 84 82 78 74 69 Non-milk extrinsic sugars (% total energy) 14.8 14.8 14.6 14.3 13.7 Non-starch polysaccharide fibre (g) 13.7 13.6 13.4 13.4 13.5 Sodium (g) 2.60 2.55 2.54 2.51 2.43 Salt (g) 6.5 6.4 6.4 6.3 6.1 Purchase per person per week Fruit and vegetables (excluding potatoes) (g) 2,202 2,331 2,285 2,371 2,651

Notes: Adults aged 16 and over. Consumption is assumed from purchase data, and applies to food consumed in the household only.

Source: Office for National Statistics (2010) Family Food in 2008. The Stationery Office: London.

Figure 4.13 Consumption of fruit and vegetables by income quintile, 2006/08, UK

3,000

2,500

2,000

1,500 Grams per day

1,000

500

0 Lowest Quintile Quintile 2 Quintile 3 Quintile 4 Highest Quintile

British Heart Foundation Statistics Database www.heartstats.org 95 Table 4.14 Consumption of total fat, saturated fat, salt, sugar, fibre and fruit and vegetables, by ethnic group, 2006/08, United Kingdom

Consumption per person per day, Asian & Asian Black & Black Chinese & Mixed White total diet (i.e. including alcohol) British British Other Energy (kcal) 1,951 1,677 1,728 1,560 2,079 Fat (g) 77 67 73 66 85 Fat (% total energy) 35.8 36.4 38.2 38.5 38.0 Saturated fat (g) 26.1 20.7 24.3 23.4 33.8 Saturated fat (% total energy) 12.1 11.2 12.8 13.7 15.0 Total sugars (g) 100 98 94 89 122 Non-milk extrinsic sugars (g) 61 66 57 58 78 Non-milk extrinsic sugars (% total energy) 11.7 14.8 12.5 14.2 14.5 Non-starch polysaccharide fibre (g) 13.1 10.7 11.6 10.2 13.7 Sodium (g) 1.43 1.52 1.66 1.83 2.63 Salt (g) 3.6 3.8 4.2 4.6 6.6 Purchase per person per week Fruit and vegetables (excluding potatoes) (g) 2,351 2,263 2,638 1,967 2,419

Notes: Adults aged 16 and over. Consumption is assumed from purchase data, and applies to food consumed in the household only.

Source: Office for National Statistics (2010) Family Food in 2008. The Stationery Office: London.

British Heart Foundation Statistics Database www.heartstats.org 96 Table 4.15 Consumption of fruit and vegetables by sex and age, children aged 5 to 15, 2001 to 2008, England

MALES AGE (YEARS) 5 6 7 8 9 10 11 12 13 14 15 Total % consuming 5 or more 2001 9.2 11.3 8.6 8.4 10.9 12.7 11.6 7.0 13.3 14.5 18.1 11.4 portions per day 2002 11.7 9.5 9.8 9.7 9.3 10.1 12.1 14.7 11.6 14.5 14.3 11.5 2003 9.3 4.2 10.8 5.7 10.8 14.4 9.9 10.2 8.8 10.8 11.2 9.6 2004 8.9 9.6 7.9 7.1 14.4 10.2 13.0 19.7 18.5 7.6 22.8 12.7 2005 17.7 18.4 18.3 13.6 22.6 21.2 6.7 20.3 21.9 16.3 13.5 17.4 2006 23.0 20.0 20.0 17.0 18.0 18.0 15.0 20.0 21.0 16.0 19.0 19.0 2007 21.0 25.1 17.1 21.7 26.0 18.3 18.9 19.4 23.3 18.2 19.2 20.7 2008 18.0 19.5 17.7 18.7 18.4 18.1 21.7 17.3 18.9 21.2 15.4 18.7 Unweighted base 2001 139 137 128 138 143 127 143 144 144 124 131 1,498 2002 287 304 336 317 296 331 322 299 290 309 275 3,367 2003 105 130 122 119 110 128 110 128 117 116 116 1,301 2004 56 63 52 61 63 61 43 61 59 52 50 621 2005 89 83 89 102 115 84 97 96 87 86 80 1,010 2006 253 208 247 182 265 244 222 231 231 239 214 2,536 2007 222 235 221 257 222 244 240 235 266 281 246 2,670 2008 224 233 215 235 235 248 239 237 258 275 242 2,640

FEMALES AGE (YEARS) 5 6 7 8 9 10 11 12 13 14 15 Total % consuming 5 or more 2001 8.3 7.9 7.1 12.2 9.0 11.6 14.2 12.8 11.8 9.1 13.4 10.7 portions per day 2002 11.4 8.6 13.0 10.6 9.5 11.1 13.1 12.9 11.4 15.3 14.4 11.9 2003 13.1 11.4 5.8 13.7 5.5 5.6 12.3 15.7 11.6 18.9 15.0 11.7 2004 10.0 9.0 2.0 17.9 9.0 18.9 6.0 18.8 19.0 6.3 11.7 12.2 2005 23.6 16.4 10.3 20.8 17.1 12.4 17.3 23.2 14.8 9.8 18.8 16.8 2006 19.0 19.0 20.0 19.0 24.0 20.0 21.0 23.0 20.0 25.0 27.0 22.0 2007 18.7 20.1 24.9 20.8 19.2 23.4 24.5 20.6 21.1 21.3 20.7 21.4 2008 13.7 12.4 18.8 22.6 25.1 22.0 16.0 23.6 25.3 20.8 21.1 20.3 Unweighted base 2001 147 125 146 154 146 160 149 128 132 131 142 1,560 2002 301 296 298 300 300 281 310 304 296 280 270 3,236 2003 123 112 118 118 126 128 122 128 128 127 112 1,342 2004 39 48 44 66 35 52 45 57 53 56 56 552 2005 95 102 93 75 89 97 108 99 81 94 95 1,027 2006 217 229 263 241 233 224 247 221 234 210 217 2,536 2007 214 218 219 226 232 236 226 225 249 255 241 2,541 2008 212 203 227 223 227 239 226 224 245 260 228 2,514

Notes: Data are weighted for child selection, but not for non-response. Comparisons over time should be made with caution, due to the relatively low sample size in 2004.

Source: Joint Health Surveys Unit (2010) Health Survey for England 2008. Updating of trend tables. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 97 Table 4.16 Total energy available from fat and availability of fruit and vegetables by country, 2003, Europe

% energy fruit and veg % energy fruit and veg from fat per person from fat per person per year (kg) per year (kg) Albania 27.1 264.4 Lithuania 27.9 168.5 Armenia 19.6 237.6 Luxembourg 40.3 199.5 Austria 38.8 227.6 FYR Macedonia 29.6 235.7 Azerbaijan 14.0 192.0 Malta 28.1 243.1 Belarus 29.5 155.0 Netherlands 36.0 255.5 Belgium 40.3 199.5 Norway 37.2 190.7 Bosnia and Herzegovina 18.0 225.3 Poland 29.8 147.9 Bulgaria 30.1 190.1 Portugal 34.2 297.2 Croatia 28.7 199.8 Republic of Moldova 18.4 153.9 Cyprus 36.3 278.5 Romania 26.3 244.3 Czech Republic 31.2 151.4 Russia 24.7 144.8 Denmark 35.9 248.7 Serbia 39.5 224.2 Estonia 27.4 174.4 Slovakia 33.5 129.7 Finland 36.2 162.6 Slovenia 32.4 215.4 France 41.8 238.4 Spain 41.2 256.0 Georgia 18.1 142.4 Sweden 35.5 193.6 Germany 36.7 203.7 Switzerland 40.1 201.1 Greece 35.6 422.7 Tajikistan 19.1 84.5 Hungary * 38.0 176.3 Turkey 24.7 338.1 Iceland * 36.2 167.7 Turkmenistan 23.0 136.1 Ireland * 32.6 182.9 Ukraine 24.1 152.4 Israel * 34.1 336.4 United Kingdom 35.1 207.4 Italy 38.2 309.3 Uzbekistan 25.0 146.4 Kazakhstan 25.9 146.8 Kyrgyzstan 15.6 158.4 Europe average 31.9 233.2 Latvia 33.1 153.2 EU average 36.3 232.5

Notes: * data for these countries are for 2002. Fruit and vegetables do not include potatoes. Amount available refers to fruit and vegetables produced nationally, plus imports, minus exports.

Source: World Health Organization (2008). European Health for All statistical database. www.euro.who.int/hfadb (accessed June 2010).

Table 4.17 Prevalence of physical activity by sex and country, 1997 to 2009, England, Scotland and Wales

Meeting government 1997 1998 2003 2004 2006 2007 2008 2009 recommendations % % % % % % % % MEN England 32 34 36 37 40 42 Wales 36 36 38 36 38 36 Scotland 40 42 46

WOMEN England 21 21 24 25 28 31 Wales 22 23 25 23 22 23 Scotland 29 32 35

Bases MEN England 3,882 7,182 7,177 3,256 6,845 7,314 Wales 7,486 7,437 6,691 6,418 6,119 7,412 Scotland 3,934 3,269 7,614 2,533

WOMEN England 4,671 8,705 7,611 3,436 7,300 7,678 Wales 8,812 8,598 7,499 7,194 8,606 Scotland 888 4,034 3,209 British Heart Foundation Notes: Data are for adults aged 16 and over in England and Wales, adults aged 16 to 64 in Scotland. Statistics Database Source: Department of Health (2010) Health Survey for England 2008. The Stationery Office: London. www.heartstats.org Scottish Health Executive (2010) The Scottish Health Survey 2008: Results. Scottish Executive: Edinburgh. Welsh Assembly Government (2010) Welsh Health Survey 2009. Welsh Assembly: Cardiff. 98 Table 4.18 Physical activity level by sex and age, England 2008, Scotland 2008, Wales 2008 and Northern Ireland 2005/06

Summary physical All ages 16–24 25–34 35–44 45–54 55–64 65–74 75+ activity level % % % % % % % % ENGLAND MEN High (above recommended level) 39 53 49 44 41 32 20 9 Medium 31 30 32 33 34 31 33 23 Low 30 16 19 23 25 37 47 68 Base 7,305 1,133 1,210 1,411 1,204 1,084 724 538

WOMEN High (above recommended level) 29 35 36 34 32 28 17 6 Medium 34 33 39 39 35 34 30 16 Low 38 32 25 28 33 37 53 78 Base 7,660 1,088 1,212 1,428 1,230 1,119 798 785

SCOTLAND MEN High (above recommended level) 45 58 63 53 43 37 21 13 Medium 27 29 25 29 30 23 27 21 Low 28 13 12 18 27 40 51 66 Base 2,837 245 317 459 534 525 453 304

WOMEN High (above recommended level) 33 42 42 43 37 29 20 4 Medium 34 33 37 37 36 35 33 17 Low 33 25 21 20 27 35 46 78 Base 3,615 334 451 647 631 631 515 406

WALES MEN High (above recommended level) 38 48 50 41 41 33 25 15 Medium 25 28 26 27 24 22 23 19 Low 31 17 17 24 30 40 46 61 Base 5,972 696 661 952 980 1,147 922 614

WOMEN High (above recommended level) 22 28 23 27 27 21 17 7 Medium 34 39 43 37 35 33 27 16 Low 37 23 22 27 31 39 49 75 Base 7,073 772 831 1,176 1,109 1,318 1,010 857

NORTHERN IRELAND MEN High (above recommended level) 33 33 40 39 29 28 26 17 Below recommended 67 67 60 61 71 72 74 83 Base 1,747 153 287 346 305 276 237 152

WOMEN High (above recommended level) 28 26 35 35 33 26 20 11 Below recommended 72 74 65 65 67 74 80 89 Base 2,498 254 428 501 417 335 312 251

Notes: High = 30 minutes or more on at least 5 days a week (above recommended level). Medium = 30 minutes or more on 1 to 4 days a week. Low = lower level of activity. British Heart Foundation Source: Department of Health (2010) Health Survey for England 2008. The Stationery Office: London. Statistics Database Scottish Health Executive (2009) The Scottish Health Survey 2008: Results. The Scottish Executive: Eginburgh National Assembly for Wales (2009) Welsh Health Survey 2008. Welsh Assembly: Cardiff www.heartstats.org Northern Ireland Statistics and Research Agency (2007) Northern Ireland Health and Social Wellbeing Survey 2005/06: Topline results. NISRA: Belfast 99 Table 4.19 Physical activity levels by strategic health authority and sex, 2008, England

Strategic Health Authority Summary physical North North Yorkshire & East West East London South South South activity level East West the Humber Midlands Midlands England East Central West % % % % % % % % % % MEN High 35 40 41 37 37 38 41 38 43 42 Medium 33 30 29 35 33 31 29 34 32 30 Low 33 30 31 29 30 31 30 28 25 28 Base 429 965 714 637 676 820 755 532 527 682

WOMEN High 27 29 26 27 25 28 30 33 30 32 Medium 33 34 34 33 32 37 32 35 33 32 Low 40 37 40 40 43 35 37 32 37 36 Base 523 1,193 906 795 877 939 927 674 620 863

Notes: High activity level = 30 minutes or more on at least 5 days a week. Medium = 30 minutes or more on 1 to 4 days a week. Low = lower levels of activity. Results presented for prevalence in a standardised population only. Adults aged 16 and over.

Source: Department of Health (2010) Health Survey for England 2008. The Stationery Office: London.

British Heart Foundation Statistics Database www.heartstats.org 100 Table 4.20 Physical activity by sex and income quintile, 2008, England

Equivalised household income quintile Highest 2nd 3rd 4th Lowest % % % % % MEN High 42 41 42 39 31 Medium 35 37 29 28 23 Low 23 23 29 33 46 Base 1,329 1,180 1,041 1,046 854

WOMEN High 34 28 28 27 26 Medium 37 38 34 32 29 Low 28 35 38 41 45 Base 1,313 1,285 1,310 1,397 1,274

Notes: Data are weighted for non-response. High = 30 minutes or more on at least 5 days a week (above recommended level). Medium = 30 minutes or more on 1 to 4 days a week. Low = lower level of activity. Adults aged 16 and over.

Source: Department of Health (2010) Health Survey for England 2008. The Stationery Office: London.

Figure 4.20 Percentage meeting physical activity recommendations by sex and income quintile, 2008, England

45

40

Men 35 Women

30

25

20 Percentage

15

10

5

0 Highest Quintile 2nd 3rd 4th Lowest Quintile

British Heart Foundation Statistics Database www.heartstats.org 101 Table 4.21 Physical activity by sex and ethnic group, 2004, England

General Black Black Indian Pakistani Bangladeshi Chinese Irish population Caribbean African MEN % % % % % % % % High 37 37 35 30 28 26 30 39 Medium 31 29 30 26 21 23 32 28 Low 32 34 35 44 51 51 38 33 Unweighted base 2,873 409 386 549 429 408 348 497

WOMEN % % % % % % % % High 25 31 29 23 14 11 17 29 Medium 36 30 28 32 34 21 36 38 Low 39 39 43 45 52 68 47 33 Unweighted base 3,818 648 467 634 508 477 375 656

Notes: High = 30 minutes or more physical activity on at least 5 days a week (recommended level). Medium = 30 minutes or more on 1 to 4 days a week. Low = lower level of activity. Adults aged 16 and over. Data are weighted for-non-response.

Source: Department of Health (2005) Health Survey for England 2004. The Stationery Office: London.

Table 4.22 Children’s physical activity levels, by sex, ages 2 to 15, 2002 to 2007, England

2002 2006 2007 % % % BOYS Meets recommendations 70 70 72 Some activity 13 15 13 Low activity 16 15 15 Bases 4,139 3,219 2,912

GIRLS Meets recommendations 61 59 63 Some activity 16 19 18 Low activity 22 22 19 Bases 3,996 3,040 2,767

ALL CHILDREN Meets recommendations 66 65 68 Some activity 15 17 15 Low activity 19 18 17 Bases 8,136 6,258 5,679

Notes: Meets recommendations: 60 minutes or more on all 7 days. Some activity: 30-59 minutes on all 7 days. Low activity: lower level of activity. Based on the assumption that all activity was of at least moderate intensity, this group represents those who met the physical activity recommendations for at least an hour of at least moderate intensity activity a day. Data are weighted for non-response.

Source: Joint Health Surveys Unit (2010). Health Survey for England 2008. Updating of trend tables. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 102 Table 4.23 Physical activity levels by country, 2009, EU

Regularly With Some regularity Seldom Never Don’t know % % % % % Austria 5 33 33 29 0 Belgium 16 34 22 28 0 Bulgaria 3 10 28 58 1 Cyprus 16 25 13 46 0 Czech Republic 5 23 25 37 0 Denmark 15 49 18 18 0 Estonia 7 27 25 41 0 Finland 17 55 21 7 0 France 13 35 18 34 0 Germany 9 40 20 31 0 Greece 3 15 15 37 0 Hungary 5 18 24 53 0 Ireland 23 35 15 26 1 Italy 3 26 16 55 0 Latvia 8 19 29 44 0 Lithuania 14 22 20 44 0 Luxembourg 12 39 17 32 0 Malta 17 31 14 38 0 Netherlands 5 51 16 28 0 Poland 6 19 24 49 2 Portugal 9 24 11 55 1 Romania 8 13 28 19 2 Slovakia 5 25 35 35 0 Slovenia 13 39 26 22 0 Spain 12 27 19 42 0 Sweden 22 50 22 6 0 United Kingdom 14 32 22 32 0 EU 9 31 21 39 0

Notes: “Regularly” means the respondent exercises at least 5 times a week. “With some regularity” means 3 to 4 or 1 to 2 times a week. “Seldom” means 1 to 3 times a month or less often. Adults aged 15 and over.

Source: European Comission (2010). Eurobarometer 72.3: Sport and Physical Activity. Special Barometer 334. TNS Opinion & Social: Belgium.

British Heart Foundation Statistics Database www.heartstats.org 103

Ireland Ireland

Sweden Sweden

Malta Malta

Finland Finland

Cyprus Cyprus

Belgium Belgium

Denmark Denmark

United Kingdom Kingdom United

Lithuania Lithuania

Slovenia Slovenia

France France

Spain Spain

Luxembourg Luxembourg

Portugal Portugal

Germany Germany

Romania Romania

Latvia Latvia

Estonia Estonia

Poland Poland

The Netherlands Netherlands The

Slovakia Slovakia

Hungary Hungary

Czech Republic Republic Czech

Austria Austria

Italy Italy

Percentage of adults who exercise regularly, 2009, Europe Percentage of adults who exercise regularly,

Greece Greece British Heart Bulgaria Foundation Statistics Database

5 0 www.heartstats.org 25 20 15 % 10 Figure 4.23 104 Table 4.24 Alcohol consumption by sex and age, 2008, Great Britain

All ages 16-24 25-44 45-64 65+ % % % % % MEN Number of days of drinking last week None 30 37 28 26 34 5 or more 19 6 14 24 27 Maximum daily amount Exceeded recommended amount (4 units +) 37 42 42 41 21 Heavy drinking (8 units +) 21 30 27 21 7 Unweighted base 6,720 640 1,940 2,440 1,710

WOMEN Number of days of drinking last week None 45 48 41 40 57 5 or more 11 2 9 15 15 Maximum daily amount Exceeded recommended amount (3 units +) 29 36 37 32 10 Heavy drinking (6 units +) 14 24 20 13 2 Unweighted base 7,960 700 2,510 2,800 1,960

Notes: Alcohol consumption levels are based on the number of units of alcohol consumed on the heaviest day during the previous week, the “maximum daily amount”.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/ Product.asp?vlnk=5756 (accessed June 2010).

Figure 4.24 Percentage exceeding daily benchmarks for alcohol consumption by sex and age, 2008, Great Britain

45

40 Men Women 35

30

25

20

15

10

5

% exceeding daily benchmarks for alcohol consumption 0 16-24 25-44 45-64 65+ 16-24 25-44 45-64 65+ Exceeding recommended daily benchmark Exceeding benchmark for heavy drinking Note: Recommended daily benchmark is 4 units for men and 3 units for women. Benchmark for heavy drinking is 8 units for men and 6 units for women.

British Heart Foundation Statistics Database www.heartstats.org 105 Table 4.25 Heavy drinking and drinking over recommended levels by sex and age, 1998 to 2006, Great Britain

Maximum daily alcohol 1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 consumption % % % % % % % % % % MEN Exceeded recommended amount (4 units +) 16-24 52 50 50 49 51 47 42 42 44 42 25-44 48 45 49 46 47 48 42 48 48 41 45-64 37 38 37 38 41 37 35 42 44 40 65+ 16 16 18 16 19 20 16 21 23 21 All ages 39 39 40 38 40 39 35 40 41 37 Heavy drinking (8 units +) 16-24 39 37 37 35 37 32 30 30 32 30 25-44 29 27 30 28 30 31 25 31 31 26 45-64 17 17 17 18 20 18 16 21 24 21 65+ 4 5 5 5 6 7 4 7 8 7 All ages 22 21 22 21 23 22 19 23 24 21 Unweighted base 6,561 6,598 7,054 6,828 8,087 6,862 10,028 7,674 7,230 6,720

1998 2000 2001 2002 2003 2004 2005 2006 2007 2008 % % % % % % % % % % WOMEN Exceeded recommended amount (3 units +) 16-24 42 42 40 42 40 39 36 39 40 37 25-44 28 31 31 31 30 28 26 40 43 38 45-64 17 19 19 19 20 20 18 35 36 35 65+ 4 4 5 5 4 5 4 14 14 13 All ages 21 23 23 23 23 22 20 33 34 32 Heavy drinking (6 units +) 16-24 24 27 27 28 26 24 22 25 24 23 25-44 11 13 14 13 13 13 11 21 22 20 45-64 5 5 5 5 5 6 4 12 13 13 65+ 1 1 1 1 1 1 1 2 3 2 All ages 8 10 10 10 9 9 8 15 15 14 Unweighted base 7,821 7,491 8,299 7,942 9,304 8,012 11,617 9,013 8,380 7,950

Notes: Alcohol consumption levels are based on the number of units of alcohol consumed on the heaviest day during the previous week. Methods for estimating the number of units of alcohol consumed were updated in 2006. Estimates since 2006 are not directly comparable with estimates from before 2006.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/ Product.asp?vlnk=5756 (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 106 Figure 4.25 Heavy drinking and drinking over recommended levels in young adults aged 16-24, 1998 to 2008, Great Britain

60

50

40

30 Percentage

20

Men – exceeding recommended levels

Men – heavy drinking 10 Women – exceeding recommended levels

Women – heavy drinking

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Note: Estimates in 2006, 2007 and 2008 are not directly comparable with pre-2006 estimates due to changes in the methods used to estimate the number of units consumed.

British Heart Foundation Statistics Database www.heartstats.org 107 Table 4.26 Alcohol consumption in children by sex and age, 1988 to 2008, England

Individuals who reported drinking alcohol at some point in the previous week 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 % % % % % % % % % % % BOYS 11 years 7 8 8 8 7 4 5 7 5 5 3 12 years 12 9 13 10 12 14 11 12 11 8 6 13 years 20 17 15 22 27 16 18 20 17 16 15 14 years 25 32 32 34 37 28 34 34 32 29 24 15 years 45 42 49 52 50 48 51 49 44 40 38 All ages 24 22 24 26 27 23 25 25 23 21 18

GIRLS 11 years 4 4 5 4 6 2 5 4 3 2 2 12 years 7 6 7 9 9 6 9 9 9 7 4 13 years 11 19 11 16 22 14 19 21 19 15 13 14 years 19 32 25 26 35 29 31 34 33 30 25 15 years 36 39 40 48 55 40 45 45 46 41 37 All ages 17 20 17 22 26 18 23 23 23 20 17

Bases Boys 11 years 227 309 284 266 269 285 612 866 861 600 621 12 years 279 340 335 307 296 336 740 1,003 1,024 818 769 13 years 312 312 351 304 275 293 737 1,035 1,007 765 756 14 years 306 300 310 306 297 597 750 950 977 805 756 15 years 348 358 366 326 295 745 796 1,107 1,078 869 896 All ages 1,473 1,623 1,652 1,509 1,432 2,256 3,635 4,961 4,947 3,857 3,798

Girls 11 years 225 289 304 231 266 291 564 798 820 636 612 12 years 312 277 354 304 272 365 681 978 923 829 759 13 years 296 290 333 326 277 383 696 935 941 826 718 14 years 311 298 298 309 285 657 691 946 917 767 746 15 years 374 302 317 341 291 666 764 1,012 1,024 978 845 All ages 1,518 1,459 1,614 1,511 1,391 2,362 3,396 4,669 4,625 4,036 3,680

Notes: Sample is drawn from children in years 7-11 in secondary schools in England. For 2008, the sample was drawn from 268 secondary schools including schools from both the maintained and non-maintained education sectors.

Source: National Centre for Social Research (2009) Smoking, drinking and drug use among young people in England in 2008. The Information Centre: Leeds, and previous editions.

British Heart Foundation Statistics Database www.heartstats.org 108 Table 4.27 Alcohol consumption in children by sex and age, 1990 to 2008, Scotland

Individuals who reported drinking alcohol at some point in the previous week 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 % % % % % % % % % % BOYS 13 years 10 14 18 21 19 19 23 20 13 11 15 years 30 35 37 48 39 42 47 40 35 31

GIRLS 13 years 10 12 13 18 15 20 23 20 15 12 15 years 25 28 35 46 35 37 46 46 37 31

Bases Boys 13 years 301 380 358 303 369 621 1,429 1,787 5,790 2,604 15 years 251 218 250 220 424 424 2,489 1,668 5,622 2,269

Girls 13 years 324 343 348 309 389 555 1,481 1,730 5,805 2,665 15 years 219 216 252 175 402 391 2,424 1,745 5,439 2,320

Notes: Sample is drawn from children in years S2 and S4 in secondary schools in Scotland. For 2008, the sample was drawn from 377 secondary schools including schools from both the maintained and non-maintained education sectors.

Source: Office for National Statistics (2009) Scottish schools adolescent lifestyle and substance use survey (SALSUS) national report. Smoking, drinking and drug use among 13 and 15 year olds in Scotland in 2008. NHS Scotland: Edinburgh.

British Heart Foundation Statistics Database www.heartstats.org 109 Table 4.28 Heavy drinking and drinking over recommended levels by sex and country or region, 2008, Great Britain

Maximum daily amount Exceeded recommended Heavy drinking Unweighted amount base (4 units +) (8 units +) % % MEN North East 40 20 290 North West 42 26 770 Yorkshire and the Humber 43 29 630 East Midlands 39 19 580 West Midlands 35 19 620 East of England 38 21 710 London 32 20 540 South East 36 21 960 South West 37 21 640 England 38 22 5,740 Wales 35 16 390 Scotland 34 19 600 Great Britain 37 21 6,720

Exceeded recommended Heavy drinking Unweighted amount base (3 units +) (6 units +) % % WOMEN North East 33 16 360 North West 36 19 920 Yorkshire and the Humber 36 21 750 East Midlands 30 13 640 West Midlands 26 11 740 East of England 26 11 790 London 23 12 680 South East 30 14 1,120 South West 28 15 780 England 29 15 6,780 Wales 26 11 450 Scotland 29 13 720 Great Britain 29 14 7,950

Notes: Alcohol consumption levels are based on the number of units of alcohol consumed on the heaviest day during the previous week, the “maximum daily amount”. Data are weighted for non-response. Estimates are for adults aged 16and over.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/ Product.asp?vlnk=5756 (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 110 Figure 4.28a Heavy drinking by country or region, men, 2008, Great Britain

Heavy drinking (8 units +) on heaviest drinking day in previous week

28% or more 24% to 27% 20% to 23% 19% or less

Figure 4.28b Heavy drinking by country or region, women, 2008, Great Britain

Heavy drinking (8 units +) on heaviest drinking day in previous week

19% or more 16% to 18% 13% to 15% 12% or less

British Heart Foundation Statistics Database www.heartstats.org 111 Table 4.29 Alcohol consumption by sex and socio-economic classification, 2008, Great Britain

Maximum daily amount Exceeded recommended Heavy drinking Unweighted amount base (4 units +) (8 units +) % % MEN Managerial and professional 41 23 2,980 Large employers and higher managerial 44 26 520 Higher professional 40 22 740 Lower managerial and professional 41 23 1,720 Intermediate 35 19 1,200 Intermediate 34 17 480 Small employers and own account 36 21 720 Routine and manual 34 20 2,280 Lower supervisory and technical 36 21 780 Semi routine 32 19 720 Routine 34 20 780 Total 37 21 6,590

Exceeded recommended Heavy drinking Unweighted amount base (3 units +) (6 units +) % % WOMEN Managerial and professional 35 17 3,310 Large employers and higher managerial 38 18 530 Higher professional 34 15 710 Lower managerial and professional 35 17 2,070 Intermediate 27 14 1,510 Intermediate 27 14 800 Small employers and own account 27 13 710 Routine and manual 24 12 2,730 Lower supervisory and technical 28 14 780 Semi routine 23 11 1,070 Routine 21 10 880 Total 29 14 7,740

Notes: Alcohol consumption levels are based on the number of units of alcohol consumed on the heaviest drinking day during the previous week, the “maximum daily amount”. Data are weighted for non-response. Estimates are for adults aged 16 and over.

Source: Office for National Statistics (2009). General Lifestyle Survey 2008. Results published online at www.statistics.gov.uk/STATBASE/ Product.asp?vlnk=5756 (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 112 Figure 4.29 Heavy drinking and drinking over recommended levels by sex and socio-economic classification, 2008, Great Britain

45

40

35 Men Women 30

25

20 Percentage

15

10

5

0 Managerial and Intermediate Routine and manual Managerial and Intermediate Routine and manual professional professional Drinking over recommended levels (3 / 4 units +) Heavy drinking (6 / 8 units +) on heaviest on heaviest drinking day in previous week drinking day in previous week

British Heart Foundation Statistics Database www.heartstats.org 113 Table 4.30 Alcohol consumption by sex and ethnic group, 2004, England

Alcohol consumed on the General Black Black Indian Pakistani Bangladeshi Chinese Irish heaviest drinking day population Caribbean African % % % % % % % % MEN None 24 40 62 53 93 99 52 20 Under 2 units 13 12 8 11 1 0 14 10 Up to 4 units 55 72 83 77 96 99 81 44 More than 4, up to 8 units 20 16 10 13 1 0 9 25 More than 8 units 25 12 7 9 3 0 10 32 % exceeding 4 units 45 28 17 22 4 1 19 56 Unweighted base 2,829 397 369 531 416 395 337 490

WOMEN None 39 53 74 79 97 99 68 33 Under 2 units 18 17 11 8 1 0 15 18 Up to 3 units 70 81 92 92 98 99 88 64 More than 3, up to 6 units 16 12 5 4 0 0 8 20 More than 6 units 14 6 2 4 1 0 4 16 % exceeding 3 units 30 18 7 8 1 1 12 36 Unweighted base 3,745 618 446 618 495 448 364 642

Notes: Data are weighted for non-response. Estimates are for adults aged 16 and over. Source: Joint Health Surveys Unit (2005) Health Survey for England 2004. The Information Centre: Leeds.

Table 4.31 Frequency of heavy drinking by country, 2009, European Union

Individuals who reported drinking 5 or more drinks on one occasion at least once a week in the last 12 months % % Austria 36 Latvia 11 Belgium 28 Lithuania 18 Bulgaria 18 Luxembourg 14 Cyprus 26 Malta 26 Czech Republic 24 Netherlands 23 Denmark 22 Poland 19 Estonia 18 Portugal 28 Finland 22 Romania 39 France 20 Slovakia 17 Germany 36 Slovenia 18 Greece 34 Spain 34 Hungary 24 Sweden 13 Ireland 44 United Kingdom 34 Italy 30 European Union 29

Notes: Survey conducted in October 2009. Individuals were interviewed in their home using their native language. Approximately 1,000 interviews were conducted in each member state, with the exception of Germany (2,000), United Kingdom (1,300) and Luxembourg (600).

Source: TNS Opinion & Social (2010) Eurobarometer 72.3 EU citizens’ attitudes towards alcohol. European Commission: Brussels.

British Heart Foundation Statistics Database www.heartstats.org 114

Ireland

Romania

Germany

Austria

United Kingdom United

Spain

Greece

Italy

Union

European

Portugal

Belgium

Malta

Cyprus

Hungary

Republic

Czech

Netherlands

Finland

Denmark

France

Poland

Slovenia

Lithuania

Estonia

Bulgaria

Slovakia

Luxembourg Sweden

Individuals reporting heavy 2009, drinking European at least once a week in the last 12 months by country, Union Latvia

British Heart Foundation 5 0 50 45 40 35 30 25 20 15 10 Statistics Database

Percentage Percentage www.heartstats.org Figure 4.31 115 5. Medical risk factors

This chapter reports on the prevalence of medical risk factors for coronary heart disease (CHD), including sections on blood pressure, blood cholesterol, overweight and obesity, and diabetes. Patterns in the prevalence of each of these risk factors by age, sex, socioeconomic status, geographic region and ethnicity are explored. Prevalence rates in the UK are compared against rates found in other countries. Where possible, temporal trends in the prevalence of these risk factors are reported.

Blood Pressure

Risk of CHD is directly related to higher levels of both systolic and diastolic blood pressure. Meta- analysis of prospective data on over one million adults has shown that for adults aged 40 to 69 years, each 20mmHg increase in usual systolic blood pressure, or 10mmHg increase in usual diastolic blood pressure, doubles the risk of death from CHD1. At older ages the increase in risk of death from CHD is smaller, around 50% increase for every 20mmHg increase in usual systolic or 10mmHg increase in diastolic blood pressure in adults aged 80 to 89 years. Both drug treatment and lifestyle changes – particularly weight loss, increase in physical activity, and a reduction in salt and alcohol intake – can effectively lower blood pressure.

The World Health Report 2002 estimates that around 11% of all disease burden in developed countries is caused by raised blood pressure, and that over 50% of CHD and almost 75% of stroke in developed countries is due to systolic blood pressure levels in excess of 115mmHg2.

More recently, the INTERHEART study estimated that 22% of heart attacks in Western Europe and 25% of heart attacks in Central and Eastern Europe were due to a history of high blood pressure, and that those with a history of hypertension were at just under twice the risk of a heart attack compared to those with no history of hypertension3.

The 2006 National Institute of Health and Clinical Excellence (NICE) guidelines recommended persistent high blood pressure of 160/100 mmHg (or 140/90 mmHg with higher CVD risk) as the threshold for offering drug treatments, and that optimal blood pressure treatment targets are 140/90 mmHg4 (Table 5.1).

Rates of hypertension have dropped slightly in England since 1998, for both men and women at all ages. The largest decreases have occurred at older ages. For example, 73% of women aged 65 to 74 had hypertension in 1998 compared to 62% in 2008 (Table 5.2 and Figure 5.2).

In 2008, 32% of men and 29% of women in England had hypertension (defined here as a systolic blood pressure of 140mmHg or over, or a diastolic blood pressure of 90mmHg or over) or were being treated British Heart for hypertension. Around half (53%) of men and 41% of women with hypertension were not receiving Foundation treatment. Of those that were treated, around half remained hypertensive (Table 5.3). Statistics Database www.heartstats.org 116 The prevalence of hypertension increases with age in both sexes. For example, only 2% of women aged 16 to 24 are hypertensive, compared to 41% aged 55 to 64 and 62% aged 65 to 74 (Table 5.3 and Figure 5.3).

Data from the Scottish Health Survey suggest that the prevalence of high blood pressure is similar in England and Scotland. In 2008, 32% of English men and 29% of English women were hypertensive compared to 34% of Scottish men and 31% of Scottish women5 (Table 5.4).

Data from Wales and Northern Ireland are not comparable with those for England and Scotland, as they are not based on direct blood pressure measurements. The Welsh Health Survey 2008 showed that 18% of men and 20% of women reported being treated for raised blood pressure (Table 5.5).

For men in England, the lowest levels of hypertension are found in the West Midlands (27%), and the highest levels are found in the East Midlands and Yorkshire and the Humber (36%). For women, the lowest levels are found in the London, South East, South Central and South West (25%) and the highest levels are found in the North East (33%) (Table 5.6).

The prevalence of hypertension in men does not seem to vary by income quintile. In 2006, the prevalence was around 30% for each quintile. This is not the case for women where the prevalence of high blood pressure in the lowest income quintile is a third higher than in the highest income quintile (Table 5.7).

Data from the Health Survey for England show that in 2004 the proportion of Bangladeshi men with high blood pressure was half that of the general population; in Pakistani and Chinese men the proportion was two thirds that of the general population. Pakistani and Chinese women were half as likely to have high blood pressure compared to women in the general population. The prevalence of untreated hypertension was lower among Pakistani, Bangladeshi and Chinese men and Indian, Pakistani, Bangladeshi and Chinese women than in the general population6 (Table 5.8).

In 2006, the European Commission surveyed representative samples within each of the 27 member states of the European Union, and found that the prevalence of self-reported hypertension ranged from 11% in Ireland to 28% in Bulgaria. The prevalence in the UK was 19% (Table 5.9).

Blood Cholesterol Risk of CHD is directly related to blood cholesterol levels. Blood cholesterol levels can be reduced by drugs, physical activity and by dietary changes, in particular a reduction in the consumption of saturated fat.

Research from the World Health Organization highlights the importance of raised blood cholesterol as a risk factor for CHD. The World Health Report 2002 estimates that around 8% of all disease burden in developed countries is caused by raised blood cholesterol, and that over 60% of CHD and around 40% of ischaemic stroke in developed countries is due to total blood cholesterol levels in excess of 3.8mmol/l2.

More recently the INTERHEART case-control study estimated that 45% of heart attacks in Western Europe and 35% of heart attacks in Central and Eastern Europe are due to abnormal blood lipids, and that those with abnormal lipids are at over three times the risk of a heart attack compared to those with normal lipids3. British Heart Foundation Different guidelines give slightly different advice for managing high levels of blood cholesterol Statistics Database (hyperlipidaemia)7,8. A joint publication by a series of UK cardiovascular societies in 2005 suggests that www.heartstats.org 117 a threshold of 4.0mmol/l should be used to monitor treatment in individuals with CVD or at high risk of CVD. However, the National Institute of Health and Clinical Excellence recommends retaining the threshold of 5.0mmol/l for tracking levels of raised cholesterol, since many individuals will be unable to sustain a cholesterol level lower than 4.0mmol/l (Table 5.10).

High-density lipoprotein cholesterol (HDL-cholesterol) is the fraction of cholesterol that removes cholesterol (via the liver) from the blood. Low levels of HDL-cholesterol are associated with an increased risk of CHD and a worse prognosis after a heart attack. Guidelines on HDL-cholesterol generally recommend treatment for those with concentrations below 1.0mmol/l (Table 5.10).

The mean blood cholesterol level for men aged 16 and over in England in 2008 was 5.2mmol/l and for women 5.4mmol/l. Around 58% of men and 61% women had blood cholesterol levels of 5.0mmol/l and above9. In Scotland, the mean blood cholesterol level in 2008 was 5.2mmol/l for men and 5.3mmol/l for women, and proportion of people with levels of 5.0mmol/l and above continues to reduce with 57% of men and 58% of women aged 16 to 6410 (Table 5.11 and Figure 5.11).

The prevalence of raised cholesterol increases with age in both men and women until the mid 50s. In 2008, the proportion of men with cholesterol levels of 5.0mmol/l or above was 25% in those aged 16 to 24 compared to around 76% in those aged 45 to 54. The proportion of women aged 16 to 24 with cholesterol levels of 5.0mmol/l or above was 36% compared to 83% in those aged 55 to 64, and slightly lower in those over 65 years (Table 5.11 and Figure 5.11).

The mean HDL-cholesterol level for those aged 16 and over in England in 2008 for women was 1.6mmol/l, and 1.3mmol/l for men9. Overall, about 7% of men and 2% of women had HDL-cholesterol levels of less than 1.0mmol/l in England. In 2008, about 18% of men and 6% of women had HDL-cholesterol levels of less than 1.0mmol/l in Scotland11 (Table 5.12).

The prevalence of low HDL-cholesterol showed less age-related variation, with no clear pattern. Rates of low HDL-cholesterol are much higher in men than women – over five times higher overall. The greatest difference being in the 65-74 group in which the rate of low HDL-cholesterol was 1.1% for women and 8.8% for men (Table 5.12).

In both England and Scotland, the prevalence of raised total cholesterol fell between 1994 and 2008 for both men and women. In England, the prevalence of raised total cholesterol in men decreased in all age groups between 2003 and 2008 with the largest decrease in the 75 and over group which experienced a 24% drop. Similarly for women, the over 75 group also experienced the biggest reduction (16%). The prevalence of raised total cholesterol in women deceased for all age groups except for the 16-24 group which was slightly higher than in 2003. In older age groups (55 and older in men and 65 and older in women) the prevalence of raised total cholesterol has fallen steadily over the past decade (Table 5.11)10.

In 2008, the proportion of people with total cholesterol levels of 5mmol/l and over ranged between 54% and 64% for different regions of England for men, and between 56% and 68% for women. London had the lowest prevalence of raised cholesterol for men (52%) and North East had the lowest for women (56%). South Central had the highest prevalence in men (64%) but the East Midlands had the highest prevalence for women (68%) (Table 5.13).

British Heart Foundation Total blood cholesterol levels show little socioeconomic variation in either sex. However, low HDL- Statistics Database cholesterol levels vary with income; those with higher incomes are less likely to have levels of HDL- www.heartstats.org cholesterol below 1.0mmol/l (Tables 5.14). 118 In 2004, the prevalence of blood cholesterol levels of 5.0mmol/l and above, was lower in all ethnic minority groups than the general population, with the exception of the Irish. The highest rates of HDL-cholesterol below 1.0mmol/l for both sexes were found in the Indian, Pakistani and Bangladeshi communities. One fifth of Bangladeshi and Pakistani men had HDL-cholesterol levels of less than 1.0mmol/l compared to 6% of men in the general population. In contrast, Black African men and Black Caribbean women and Chinese women had a relatively low prevalence of low HDL-cholesterol (Table 5.15).

Overweight and Obesity Overweight and obesity increase the risk of CHD. As well as being an independent risk factor, obesity is also a major risk factor for high blood pressure, raised blood cholesterol, diabetes and impaired glucose tolerance14. The adverse effects of excess weight are more pronounced when fat is concentrated in the abdomen. This is known as central or abdominal obesity and is assessed using the waist to hip ratio or waist circumference15.

The World Health Report 2002 estimated that over 7% of all disease burden in developed countries was caused by raised body mass index (BMI), and that around a third of CHD and ischaemic stroke and almost 60% of hypertensive disease in developed countries was due to overweight2.

More recently, the INTERHEART case-control study estimated that 63% of heart attacks in Western Europe and 28% of heart attacks in Central and Eastern Europe were due to abdominal obesity (a high waist to hip ratio), and those with abdominal obesity were at over twice the risk of a heart attack compared to those without3. This study also found that abdominal obesity was a much more significant risk factor for heart attack than BMI.

In 2004, an obesity target for children in England was introduced by the Department of Health to halt the year-on-year rise in obesity in children under 11 by 2010. A more general aim to address the increasing rates of obesity in the population was also put forward. In Scotland a target was set to reduce the rate of increase in the proportion of children with their Body Mass Index outside a healthy range by 2018 and in Northern Ireland a target was to halt the rise in obesity in the general population by March 2010. There are currently no targets for overweight and obesity in Wales (Table 5.16).

In England in 2008, around 42% of men and 32% of women were overweight (a BMI of 25-30 kg/m2), and an additional 25% of men and 28% of women were obese (a BMI of more than 30 kg/m2). Central obesity was also common among adults in England. In 2008, data show that around 34% of men and 44% of women had central obesity (Tables 5.17 and 5.18).

Overweight and obesity increases with age. In 2008, about 33% of men and 35% of women aged 16 to 24 were overweight or obese compared to 85% of men and 75% of women aged 65 to 74. The prevalence of central obesity also increased with age, especially in men. About 9% of men and 23% of women aged 16 to 24 had central obesity compared to 51% of men and 62% of women aged 65 to 74 (Tables 5.17 and 5.18 and Figure 5.17).

The classification of overweight and obesity in children and adolescents is more problematic than in adults. Constant changes in body composition during growth mean that the relationship between BMI and adiposity during childhood is age-dependent, and further complicated by race and gender. There British Heart is no clear agreement on the best way to define overweight and obesity in children. The International Foundation Obesity Taskforce (IOTF) has developed a new international classification based on age and sex-specific Statistics Database www.heartstats.org 119 BMI cut-off points. UK data is sometimes reported using the National BMI percentile classification where children are classified as overweight or obese using the 85th and 95th percentiles as cut points. These two methods of classification result in different estimates of childhood overweight and obesity16.

The National BMI classification has been used in the 2008 Health Survey for England. This survey found just less than a third of boys (31%) and girls (29%) in England aged 2 to 15 years were either overweight or obese17. The National Child Measurement Programme found that 23% of reception class and 32% of year 6 children were either overweight or obese (Tables 5.19 and 5.20)

Overweight and obesity are increasing rapidly. In England, the percentage of men aged 16 and over who are obese rose from 14% in 1994 to 25% in 2008, and for women who are obese, from 19% in 1994 to 28% in 2008. The increase in obesity was particularly marked among men aged 45 to 74, approximately doubling between 1994 and 2008 (Table 5.21 and Figure 5.21).

The high levels of overweight and obesity among children are likely to exacerbate the trend towards overweight and obesity in the adult population, since compared to thin children, obese children have a high risk of becoming overweight adults18. Between 1995 and 2008 the prevalence of obesity among English boys increased from 11% to 17% and from 12% to 15% among English girls, and overweight (including obesity) increased from 24% to 31% in boys and 25% to 29% in girls over the same time period. Less data are available for trends in overweight (including obesity) in Scotland, but estimates suggest a similar increase in the prevalence of overweight in boys – from 28% in 1998 to 36% in 2008. Over the same time period the prevalence of overweight in girls in both England and Scotland has remained reasonably stable (Table 5.22 and Figure 5.22).

In England in 2008, about two thirds of men were overweight or obese with very little variation by Government Office Region. The highest prevalence was found in the South West and North West (68%) and the lowest in London (63%). For women, the prevalence of overweight and obesity was lower than men, with the highest prevalence in East and West Midlands (60%) and the lowest in London (53%). Recent evidence suggests that rates of obesity among women are rising faster in the North than the South of England. This pattern is not observed in men, where rates appear to be rising uniformly across England19 (Table 5.23).

Among women, obesity rates vary considerably by household income. In 2008, 31% of women from the lowest quintile of household income were obese compared to 20% in the highest quintile. Much less variation was found in men. In both men and women, the prevalence of central obesity was higher among households with lower income. In 2008, 35% of men and 51% of women from the lowest quintile of household income had a raised waist to hip ratio compared to 32% of men and 37% of women in the highest quintile. Much less variation was found in men (Tables 5.24 and 5.25).

Levels of general and abdominal obesity vary with ethnicity in both men and women in England. Because individuals from different ethnic groups tend to store fat in different places of the body and therefore have different body shapes, it is useful to compare measurements generated by the different techniques when considering ethnic differences in obesity. Using the Body Mass Index (BMI) method, in 2004 the prevalence of obesity in men was substantially lower in the South Asian community, and also in Chinese men than in the general population. Using this definition as few as 6% of Chinese and Bangladeshi men British Heart were defined as obese, compared to 23% of men in the general population aged 16 and over. Similarly, Foundation Statistics Database the prevalence of obesity in Bangladeshi and Chinese women was lower than the general population when www.heartstats.org measured by BMI, although the difference was not as substantial. However, this difference is entirely 120 removed when the Waist-to-Hip Ratio (WHR) method is used – using this technique the prevalence of obesity in Bangladeshi men is similar to that of men in the general population (around one in three men), and the prevalence of obesity in Bangladeshi women is higher than that of women in the general population. Ethnic differences in obesity measured using Waist Circumference (WC) are similar to those found using the WHR method, with a few exceptions. For example, using WHR the prevalence of obesity in Indian men (38%) is more than double the prevalence in Black African men (16%) – however, the prevalence of obesity in these ethnic groups using the WC method is very similar (around one in five men in both ethnic groups) (Table 5.26 and Figures 5.26a and 5.26b).

Data from the WHO SuRF Report2 suggest that the prevalence of adult overweight and obesity in the UK is among the highest in Europe. In 2006, the International Obesity TaskForce collated data on overweight and obesity in children worldwide. Caution should be used in interpreting these data as the studies used different age groups and different definitions of overweight and obesity. For boys, the countries with overweight (including obesity) levels of 30% or more were Canada (33%), Mexico (31%), USA (35%), Kuwait (30%), Spain (35%) and New Zealand (30%). For girls, the countries were Mexico (32%), USA (36%), Bahrain (42%), Kuwait (32%), Spain (32%), Italy (34%), Portugal (34%), Australia (30%) and New Zealand (30%). Ethiopia, Mali, Senegal and Nepal had very low levels of under 1% for both boys and girls (Table 5.27).

Diabetes There are two categories of diabetes: type 1 and type 220. Diabetes substantially increases the risk of CHD. Men with non-insulin dependent (Type 2) diabetes have a two to fourfold greater annual risk of CHD, with an even higher (three to fivefold) risk in women with Type 2 diabetes21. The INTERHEART case-control study estimated that 15% of heart attacks in Western Europe are due to diagnosed diabetes, and that people with diagnosed diabetes are at three times the risk of a heart attack compared to those without22.

The prevalence of diabetes increases with age and is higher in men than in women. The prevalence of diabetes in men is around 6% and in women is around 4%, although these rates vary around the UK. The prevalence of diabetes is highest in Wales, where 7% of men and 6% of women have been diagnosed with the disease. Most diagnosed cases of diabetes are type 2 diabetes – around 90% of diagnosed diabetes in England were type 2 in 2006 (Tables 5.28, 5.29, 5.30 and 5.31).

Not all diabetes is diagnosed. The Health Survey for England in 2003 measured blood glucose levels of all respondents aged over 35 and found that 3.1% of men and 1.5% of women had undiagnosed diabetes4.

The prevalence of diabetes has been measured sporadically since the early 1990s in a number of national health surveys in England, Wales, Scotland and Northern Ireland. Comparing the results of these surveys suggests that prevalence of diabetes has been increasing since the early 1990s and is still on the increase. In England, male and female prevalence rates have more than doubled since 1991. In Scotland, male and female rates have increased dramatically between 2003 and 2008 – by 40% for male rates (Table 5.32 and Figure 5.32).

There is substantial geographic variation in the prevalence of diabetes in the UK. As mentioned earlier, prevalence in Wales is higher than in Scotland, England and Northern Ireland. Within England, both British Heart male and female prevalence rates are generally lower in the South of England, with the exception of Foundation Statistics Database www.heartstats.org 121 London. Female prevalence rates in Yorkshire and the Humber (5.4%) are more than double rates in the South West (2.6%) (Table 5.33).

For women, the prevalence of diabetes appears to be socially patterned. The Health Survey for England in 2006 showed that the prevalence of diabetes in women in the lowest quintile of income (6.3%) was far higher than for women in the highest quintile of income (1.3%). The pattern was not as clear for men (Table 5.34).

The prevalence of diabetes varies dramatically by ethnic group within the UK. In 2004, the prevalence of diabetes among some ethnic minority groups in England was much higher than in the general population. In Black Caribbean and Indian men, the prevalence of diagnosed diabetes was more than twice that found in the general population, in contrast the prevalence in Chinese and Irish men were lower than the general population. The prevalence for Black Caribbean and Pakistani women was two and a half times that of the general population. In contrast, the prevalence of diabetes in Black African and Irish women was substantially lower than in the general population (Table 5.35 and Figure 5.35).

There is some variation in the prevalence of diabetes by country in Europe. In 2006, a survey of the 27 European Union member states (and also Croatia) found that national diabetes prevalence rates range from 3% to 8%, but mostly tend to be between 4% and 7%. There does not appear to be a consistent geographic pattern to these prevalence rates – for example, countries in Eastern Europe displayed both high prevalence rates (7% in Hungary) and low prevalence rates (3% in Latvia) (Table 5.36).

1. Prospective Studies Collaboration (2002) Age-specific relevance of usual blood pressure to vascular mortality: a meta analysis of individual data for one million adults in 61 prospective studies. The Lancet; 360: 1903-1913. 2. World Health Organization (2002) The World Health Report 2002. Reducing Risks, Promoting Healthy Life. World Health Organization: Geneva. 3. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, McQueen M, Budaj A, Pais P, Varigo J, Lisheng A, on behalf of the INTERHEART Study Investigators (2004) Effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the INTERHEART Study): case-control study. The Lancet; 364: 937-952. 4. National Institute for Health and Clinical Excellence (2006) Hypertension: Management of hypertension in adults in primary care. NICE: London. 5. The Scottish Health Survey (SHS) uses the same methods as the Health Survey for England. 6. See Table 7.3, page 32 in The Health of Minority Ethnic Groups - headline tables (2005) Health Survey for England 2004. NHS Health and Social Care Information Centre. 7. Institute for Health and Clinical Excellence (2008) Lipid modification. NICE: London. 8. Department of Health (2000) National Service Framework for Coronary Heart Disease. DH: London. 9. Joint Health Surveys Unit (2009) Health Survey for England 2008. Physical activity and fitness. The Information Centre: Leeds. 10. The reporting trends in raised cholesterol levels in England are complicated due to different weighting of results in the 2003 and later surveys. 11. Scottish Executive (2010) The Scottish Health Survey 2008. Personal communication. 12. Blane D, Hart C, Davey Smith G (1996). Association of cardiovascular disease risk factors with socioeconomic position during childhood and during adulthood. BMJ, 313: 1434-8. 13. Brunner E, Shipley M, Blane D (1999). When does cardiovascular risk start? Past and present socioeconomic circumstances and risk factors in adulthood. Journal of Epidemiology and Community Health, 53; 757-64. 14. World Health Organization (2000) Obesity – preventing and managing the global epidemic. Report of a WHO Consultation on Obesity. World Health Organization: Geneva. 15. Central obesity is commonly defined as a waist-hip ratio of 0.95 and over in men and 0.85 and over in women. Raised waist circumference is defined as a waist measurement greater than 102cm for men and greater than 88cm for women. 16. For details of the International classification system see Department of Health (2003) Health Survey for England 2002. The Stationery Office: London. Because of differences in definition and measurement, direct comparison of adult (Table 11.2) and childhood (Table 11.6) tables in this chapter is inappropriate. 17. Overweight and obesity estimates derived using the alternative National BMI percentiles classification showed no marked sex differences whereas the International classification may under-estimate obesity prevalence among boys. 18. Serdula M, Ivery D, Coates R, Freedman D, Williamson D and Byers T (1993) Do obese children become obese adults? A review of the literature. Prev Med 22:167-177. British Heart 19. Scarborough P, Allender S (2008). The North - South gap in overweight and obesity in England. British Journal of Nutrition, 100; 677-684. Foundation 20. See glossary for definition. Statistics Database 21. Garcia MJ, McNamara PM, Gordon T, Kannell WB (1974). Morbidity and mortality in the Framingham population. Sixteen year follow up. Diabetes; 23: 105-111. www.heartstats.org 22. Joint Health Surveys Unit (2004) Health Survey for England 2003. The Stationery Office: London. 122 Table 5.1 Blood pressure recommendations and hypertension definition for the United Kingdom

Recommendations

Systolic blood pressure – general population No greater than 140mmHg

Systolic blood pressure – diabetes or chronic No greater than 130mmHg renal failure sufferers

Diastolic blood pressure – general population No greater than 85mmHg

Diastolic blood pressure – diabetes or No greater than 80mmHg chronic renal failure sufferers

Hypertension

Definition Systolic blood pressure greater than or equal to 140mmHg, and / or diastolic blood pressure greater than or equal to 90mmHg

Threshold for drug treatment Sustained levels of systolic blood pressure greater than or equal to 160mmHg, and / or diastolic blood pressure greater than or equal to 100mmHg

British Heart Sources: Williams B, Poulter NR, Brown MJ et al (2004). Guidelines for management of hypertension: report of the fourth working party of the Foundation British Hypertension Society 2004-BHS IV. Journal of Human Hypertension. 18; 139-185. Statistics Database National Institute for Health and Clinical Excellence (2006). Hypertension: Management of hypertension in adults in primary care. www.heartstats.org NICE: London. 123 Table 5.2 Prevalence of high blood pressure by sex and age, 1998 to 2008, England

1998 2000 2001 2002 2003 2005 2006 2007 2008 % % % % % % % % % MEN All ages 41 40 41 37 38 39 39 31 32 16-24 16 12 20 14 11 9 10 8 7 25-34 21 21 18 17 13 17 18 13 13 35-44 26 27 23 24 21 26 18 15 18 45-54 42 41 41 36 37 33 35 33 33 55-64 60 54 58 53 53 53 51 50 52 65-74 70 70 68 62 65 64 63 63 62 75 and over 73 65 70 71 67 69 68 62 68 Base: All ages 5,401 2,552 4,840 2,161 4,108 1,916 3,924 2,021 4,350 16-24 594 260 516 947 370 185 335 285 657 25-34 984 424 711 308 557 243 473 329 697 35-44 981 510 917 445 806 312 715 380 827 45-54 981 429 877 348 699 351 663 340 697 55-64 766 378 786 335 736 367 739 316 672 65-74 665 323 660 287 577 264 592 218 462 75 and over 430 228 373 184 363 194 407 154 338

WOMEN All ages 33 33 35 34 32 29 31 29 29 16-24 4 4 5 4 2 1 1 1 2 25-34 7 6 7 6 5 4 3 6 5 35-44 13 10 12 12 10 10 10 12 13 45-54 31 31 34 33 24 23 26 26 25 55-64 52 52 54 52 47 42 42 43 41 65-74 73 75 74 70 68 62 66 61 62 75 and over 78 81 79 79 77 73 73 74 73 Base: All ages 6,483 3,046 5,813 2,668 5,075 2,392 4,838 2,090 4,507 16-24 692 268 582 1,145 479 216 411 262 604 25-34 1,142 516 896 380 715 325 602 326 661 35-44 1,190 621 1,144 554 994 429 965 387 827 45-54 1,164 562 1,056 440 837 453 810 330 742 55-64 896 419 866 408 889 431 870 318 689 65-74 751 366 716 324 617 298 638 235 496 75 and over 648 294 553 274 544 240 542 230 488

Notes: Informants were classified as having high blood pressure if their systolic blood pressure was 140mmHg or over or their diastolic blood pressure was 90mmHg or over, or they were taking medicine prescribed for blood pressure. All data are presented unweighted for analysis of trends. The measurement of blood pressure in the Health Survey for England series changed in 2003.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. Adult trend tables. www.ic.nhs.uk (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 124 Figure 5.2a Prevalence of high blood pressure, by age, men aged 16 and over, 1998 to 2008, England

80

70

60

50 75 and over 65-74 55-64 40 45-54 35-44 25-34 30 16-24

20 Prevalence of high blood pressure (%)

10

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Figure 5.2b Prevalence of high blood pressure, by age, women aged 16 and over, 1998 to 2008, England

90

80

70

60 75 and over 65-74 50 55-64 45-54 40 35-44 25-34 16-24 30

20 Prevalence of high blood pressure (%) 10

0 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 125 Table 5.3 Blood pressure levels by sex and age, 2008, England

Blood pressure level All ages 16–24 25–34 35–44 45–54 55–64 65–74 75+ % % % % % % % % MEN Normotensive untreated 68 93 87 82 67 48 38 32 Normotensive treated 8 0 1 7 16 22 25 Hypertensive treated 6 0 3 5 11 17 20 Hypertensive untreated 17 7 12 14 20 26 23 23 All with high blood pressure 32 7 13 18 33 52 62 68 Unweighted base 4,350 657 697 827 697 672 462 338

WOMEN Normotensive untreated 71 98 95 87 75 59 38 27 Normotensive treated 9 0 3 7 14 21 27 Hypertensive treated 7 0 2 4 9 19 23 Hypertensive untreated 12 2 5 9 14 18 22 23 All with high blood pressure 29 2 5 13 25 41 62 73 Unweighted base 4,507 604 661 827 742 689 496 488

Notes: Informants were classified as having high blood pressure if their systolic blood pressure was 140mmHg or over or their diastolic blood pressure was 90mmHg or over, or they were taking medicine affecting blood pressure. “Treated” means taking medication prescribed for high blood pressure. Data are weighted for non response.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

Figure 5.3 Prevalence of high blood pressure by sex and age, adults aged 16 and over, 2008, England

80

70

60

50

40 Men Women 30

20 % with high blood pressure 10

0 16–24 25–34 35–44 45–54 55–64 65–74 75+ Age group

British Heart Foundation Statistics Database www.heartstats.org 126 Table 5.4 Blood pressure levels by sex, 2003, 2008, Scotland

Blood pressure level 2003 2008 % % Men Normotensive 67.0 66.1 Hypertensive controlled 5.9 8.6 Hypertensive uncontrolled 6.3 5.3 Hypertensive untreated 20.7 20.1 All with high blood pressure 33.0 33.9

Women Normotensive 67.3 68.6 Hypertensive controlled 7.2 9.0 Hypertensive uncontrolled 9.0 7.7 Hypertensive untreated 16.6 14.6 All with high blood pressure 32.7 31.4

Bases (unweighted): Men 1,933 486 Women 2,538 593

Notes: Respondents were considered hypertensive if their systolic blood pressure was 140 mmHg or over or their diastolic blood pressure was 90 mmHg or over or they were taking medicine prescribed for high blood pressure. Adults aged 16 and over. Data are weighted for non- response.

Source: Scottish Executive (2010). Scottish Health Survey. Personal communication.

Table 5.5 Prevalence of high blood pressure by sex and age, 2008, Wales

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75+ % % % % % % % % MEN 18 2 6 16 34 46 50 Base: 5,920 697 658 953 972 1,136 899 605

WOMEN 20 1 1 4 15 31 49 59 Base: 6,866 780 822 1,162 1,078 1,257 951 816

Notes: Data refer to adults who are currently being treated for high blood pressure, and are not based upon blood pressure measurments. Because of differences in data collection techniques, these results are incomparable with prevalence estimates for England and Scotland collected by the Health Survey series.

Source: Welsh Assembly Government (2009) Welsh Health Survey 2008. Welsh Assembly: Cardiff.

British Heart Foundation Statistics Database www.heartstats.org 127 Table 5.6 Blood pressure levels by sex and Government Office Region, 2008, England

Yorkshire North North and the East West East London South South South East West Humber Midlands Midlands of England East Central West % % % % % % % % % % MEN Normotensive untreated 70 71 64 64 73 68 72 69 70 69 Normotensive treated 7 6 7 7 9 8 11 9 8 7 Hypertensive treated 7 5 8 8 5 6 5 7 7 5 Hypertensive untreated 16 18 20 21 13 19 12 15 15 19 All with high blood pressure 30 29 36 36 27 32 28 31 30 31 Unweighted base 294 530 428 425 396 468 417 338 323 422

WOMEN Normotensive untreated 67 70 71 69 70 70 75 75 75 75 Normotensive treated 11 7 9 9 11 10 11 8 8 7 Hypertensive treated 7 7 8 8 6 8 7 4 7 7 Hypertensive untreated 14 16 12 14 13 12 7 12 10 12 All with high blood pressure 33 30 29 31 30 30 25 25 25 25 Unweighted base 340 681 542 508 479 536 511 437 397 505

Notes: Data are weighted for non response. Informants were classified as having high blood pressure if their systolic blood pressure was 140mmHg or over or their diastolic blood pressure was 90mmHg or over, or they were taking medicine affecting blood pressure. “Treated” means taking medication prescribed for high blood pressure. Adults aged 16 and over.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

Table 5.7 Blood pressure levels by sex and equivalised household income, 2006, England

Highest 2nd 3rd 4th Lowest Blood pressure level % % % % % MEN Normotensive untreated 70 72 68 70 69 Normotensive treated 6 4 7 6 8 Hypertensive treated 5 7 6 6 6 Hypertensive untreated 18 17 18 17 17 All with high blood pressure 30 28 32 30 31 Unweighted base 801 742 694 582 461

WOMEN Normotensive untreated 77 75 73 71 70 Normotensive treated 8 6 7 9 9 Hypertensive treated 5 6 7 8 6 Hypertensive untreated 10 13 13 12 15 All with high blood pressure 23 25 27 29 30 Unweighted base 791 854 873 855 650

Notes: Equivalised household income is a measure that takes account of all individuals within a household that are dependent upon the income. Data are weighted for non response. Adults aged 16 and over.

Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 128 Table 5.8 Prevalence of high blood pressure by sex and ethnic group, 2004, England

General Black Black Indian Pakistani Bangladeshi Chinese Irish population Caribbean African High blood pressure % % % % % % % % MEN 32 38 25 33 20 16 20 36 Unweighted base 4,108 155 123 265 162 99 153 240

WOMEN 29 32 19 18 15 19 16 29 Unweighted base 5,075 243 154 320 207 144 166 328

Notes: Adults aged 16 and over with a valid blood pressure reading and data on medication. Informants were classified as having high blood pressure if their systolic blood pressure was 140mmHg or over or their diastolic blood pressure was 90mmHg or over, or they were taking medication for high blood pressure. Comparative data for the general population are not available for 2004 so data have been taken from 2003 survey.

Source: Department of Health (2005) Health Survey for England 2004. The Health of Minority Ethnic Groups. The Stationery Office: London.

Table 5.9 Prevalence of hypertension by country, 2006, Europe

% Base % Base Austria 19 1,013 Italy 17 1,005 Belgium 20 1,012 Latvia 22 1,031 Bulgaria 28 1,027 Lithuania 27 1,016 Croatia 22 1,000 Luxembourg 14 500 Cyprus (Republic) 17 506 Malta 20 500 Cyprus (Turkish Cypriot Community) 17 500 Netherlands 19 1,069 Czech Rep 21 1,072 Poland 22 1,000 Denmark 18 1,060 Portugal 21 1,006 Estonia 21 1,011 Romania 21 1,026 Finland 20 1,030 Slovakia 25 1,180 France 17 1,022 Slovenia 21 1,039 Germany 20 1,551 Spain 14 1,026 Greece 17 1,000 Sweden 17 1,006 Hungary 27 1,001 United Kingdom 19 1,375 Ireland 11 1,000 EU 24 25,031

Notes:Survey conducted between October and November 2006. Individuals were interviewed in their home using their native language. Estimates based on self-report of having hypertension.

Source: TNS Opinion & Social (2007). Special Eurobarometer - Health in the European Union. European Commission: Brussels.

British Heart Foundation Statistics Database www.heartstats.org 129

Bulgaria Bulgaria

Lithuania Lithuania

Hungary Hungary

Slovakia Slovakia

Poland Poland

Latvia Latvia

Croatia Croatia

Slovenia Slovenia

Romania Romania

Portugal Portugal

Estonia Estonia

Czech Rep Rep Czech

Malta Malta

Germany Germany

Finland Finland

Belgium Belgium

United Kingdom Kingdom United

Netherlands Netherlands

Austria Austria

Denmark Denmark

Sweden Sweden

Italy Italy

Greece Greece

France France

urkish Cypriot Community) Community) Cypriot urkish T ( Cyprus

Cyprus (Republic) (Republic) Cyprus Spain Spain

Prevalence of hypertension by country, 2006, Europe Prevalence of hypertension by country, Luxembourg Luxembourg Ireland Ireland British Heart Foundation 5 0 Statistics Database 30 25 20 15 10

www.heartstats.org (%) hypertension of Prevalence Figure 5.9 130 Table 5.10 Cholesterol recommendations for the United Kingdom

UNITED KINGDOM

Total cholesterol1 <4.0mmol/l in individuals with established cardiovascular disease, diabetes, or at high risk of developing cardiovascular disease.

HDL cholesterol2 ≥ 1mmol/l in individuals with established cardiovascular disease, and those at high risk of the disease.

Target3 An ‘audit’ level of total cholesterol of 5 mmol/l should be used to assess progress in people with CVD, in recognition that more than a half of patients will not achieve a total cholesterol of less than 4 mmol/l or an LDL cholesterol of less than 2 mmol/l.

Notes: The original recommendation for total cholesterol levels of less than 5mmol/l for individuals with cardiovascular disease, diabetes, or at high risk of developing cardiovascular disease, originally set in 1998 by the Joint British Societies is retained for audit purposes.

Source: 1. British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, The Stroke Association (2005). JBS2: Joint British Societies’ guidelines on prevention of cardiovascular diseases in clinical practices. Heart. 91 British Heart (suppl V): v1-v52. Foundation 2. Sacks FM, for the expert group on HDL-cholesterol (2002). The role of high density lipoprotein (HDL) cholesterol on the prevention Statistics Database of coronary heart disease; Expert group recommendations. American Journal of Cardiology. 90: 139-143. www.heartstats.org 3. National Institute for Health and Clinical Excellence (2008) Lipid modification. NICE: London. 131 Table 5.11 Total cholesterol levels by sex and age, 1994 to 2008, England

≥5.0mmol/l total cholesterol All ages 16–24 25–34 35–44 45–54 55–64 65–74 75+ % % % % % % % % MEN 1994 75 32 61 82 88 90 87 79 1998 66 23 50 70 78 81 76 72 2003 unweighted 70 28 60 77 82 81 69 63 2003 weighted 66 26 60 77 81 80 67 64 2006 57 20 53 68 74 73 54 47 2008 58 25 52 74 76 70 53 39

WOMEN 1994 77 44 57 70 82 95 97 93 1998 67 27 44 59 74 88 91 89 2003 unweighted 71 34 50 62 78 88 87 82 2003 weighted 66 31 55 69 79 84 77 75 2006 61 31 42 58 78 84 76 67 2008 61 36 42 56 76 83 75 66

Unweighted base (2008): Men 3,349 295 418 613 597 675 440 311 Women 3,925 276 501 741 730 781 489 407

Notes: Data from 1994 to 1998 are unweighted data, for 2003 weighted and unweighted data is shown, for 2006 only weighted data are presented.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds, and previous editions.

Figure 5.11 Percentage of adults with blood cholesterol levels of 5.0mmol/l and over, 2008, England

90

80 Men Women

70

60

50 % 40

30

20

10

0 16–24 25–34 35–44 45–54 55–64 65–74 75+

British Heart Foundation Statistics Database www.heartstats.org 132 Table 5.12 Low HDL cholesterol by sex and age, 2008, England

≤1.0mmol/l total HDL cholesterol All ages 16–24 25–34 35–44 45–54 55–64 65–74 75+ % % % % % % % % MEN 7.2 4.8 7.4 7.5 7.6 7.6 8.8 6.9 WOMEN 1.7 3.4 2.1 1.1 1.6 1.0 1.1 1.4 Unweighted base Men 3,349 295 418 613 597 675 440 311 Women 3,924 276 501 741 730 780 489 407

Notes: Data are weighted for non response.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. Physical activity and fitness. The Information Centre: Leeds.

Table 5.13 Total cholesterol levels and low HDL cholesterol levels by sex, Government Office Region, and country, 2008, England and Scotland

Scotland North North Yorkshire East West East London South South South East West and the Midlands Midlands England East Central West Humber % % % % % % % % % % % MEN ≥ 5.0mmol/l total cholesterol 57 57 57 58 58 58 54 52 62 64 59 ≤ 1.0mmol/l HDL cholesterol 18.3 7.9 7.3 4.6 7.8 7.3 8.5 7.6 9.0 4.7 7.4

WOMEN ≥ 5.0mmol/l total cholesterol 58 56 60 61 68 61 61 57 65 61 64 ≤ 1.0mmol/l HDL cholesterol 5.5 3.1 2.0 1.6 1.2 1.5 1.6 2.5 0.7 1.5 0.4

Unweighted base: Men 341 242 476 375 307 318 366 368 299 249 349 Women 344 260 558 448 353 402 374 409 380 299 441

Notes: Data are weighted for non-response, and estimates are age-standardised to account for differing age structures. Adults aged 16 and over. Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. Physical activity and fitness. The Information Centre: Leeds. Scottish Executive (2010). Scottish Health Survey 2008.Personal communication.

British Heart Foundation Statistics Database www.heartstats.org 133 Table 5.14 Total cholesterol levels and low HDL cholesterol by sex and equivalised household income, 2006, England

Equivalised household income quintile Highest 2nd 3rd 4th Lowest MEN Mean HDL cholesterol 1.4 1.4 1.3 1.3 1.3 % < 1.0 mmol/l HDL cholesterol 7.6 5.6 10.6 11.0 14.4 Mean total cholesterol 5.3 5.4 5.2 5.3 5.2 % ≥ 5.0 mmol/l total cholesterol 59 60 57 58 53

WOMEN Mean HDL cholesterol 1.7 1.6 1.6 1.5 1.5 % < 1.0 mmol/l HDL cholesterol 0.5 1.1 1.6 2.3 4.2 Mean total cholesterol 5.5 5.4 5.5 5.3 5.4 % ≥ 5.0 mmol/l total cholesterol 64 60 64 58 64

Unweighted base: Men 720 697 605 488 376 Women 708 724 732 731 515

Notes: “Data are weighted for non response and age-standardised. Adults aged 16 and over. For method of age-standardisation see source.”

Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds.

Table 5.15 Total cholesterol and low HDL cholesterol by sex and ethnic group, 2004, England

General Black Black Indian Pakistani Bangladeshi Chinese Irish population Carribean African (2003) % % % % % % % % MEN ≥ 5.0mmol/l total cholesterol 66 51 55 60 55 60 60 67 ≤ 1.0mmol/l HDL cholesterol 6 4 2 11 20 20 8 5

WOMEN ≥ 5.0mmol/l total cholesterol 67 56 44 53 53 55 52 67 ≤ 1.0mmol/l HDL cholesterol 2 1 3 4 6 8 1 2

Unweighted base: Men 3,814 137 103 234 137 87 101 244 Women 4,460 195 118 256 143 98 108 300

Notes: Data are weighted for non-response and age-standardised. For method of age-standardisation see source. Adults aged 16 and over.

Source: Department of Health (2006) Health Survey for England 2004. The Health of Minortiy Ethnic Groups. The Stationery Office: London.

British Heart Foundation Statistics Database www.heartstats.org 134 Table 5.16 Obesity targets for the United Kingdom

England1 Children To halt the year-on-year rise in obesity among children under 11 by 2010 in the context of a broader strategy to tackle obesity in the population as a whole.

Scotland2 Children Reduce the rate of increase in the proportion of children with their Body Mass Index outside a healthy range by 2018.

Wales No target set.

Northern Ireland3 To halt the rise in obesity by March 2010.

Source: 1. Department of Health (2004) National Standards, Local Action: Health and Social Care Standards and Planning Framework 2005/06 British Heart and 2007/08. DH: London. PSA Target 3. Foundation 2. The Scottish Government (2007). National Indicators. The Scottish Government: Edinburgh Statistics Database 3. Northern Ireland Audit Office (2009). Obesity and Type 2 Diabetes in Northern Ireland. NIAO: Belfast. www.heartstats.org 135 Table 5.17 Body mass index by sex and age, 2008, England

All ages 16–24 25–34 35–44 45–54 55–64 65–74 75+ % % % % % % % % MEN BMI (kg/m2) Less than 18.5 2 7 1 1 0 0 0 0 18.5 to less than 25 33 60 41 27 25 21 17 28 25 to less than 30 42 25 41 46 44 44 50 49 30 to less than 40 24 8 18 26 31 34 33 23 40 or more 1 0 1 2 1 2 2 0 All 30 or more (obese) 25 8 19 28 32 36 35 23 Unweighted base 6,385 1,029 1,068 1,243 1,059 968 610 409

WOMEN BMI (kg/m2) Less than 18.5 2 5 2 2 1 1 1 2 18.5 to less than 25 41 60 53 42 35 31 27 32 25 to less than 30 32 20 27 31 35 38 38 40 30 to less than 40 25 14 19 25 29 31 33 26 40 or more 3 1 3 4 3 3 4 1 All 30 or more (obese) 28 15 22 29 32 34 37 27 Unweighted base 6,450 935 1,020 1,241 1,057 985 663 549

Notes: Adults with a valid height and weight measurement. Data are weighted for non-response.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

Figure 5.17 Prevalence of overwight and obesity, by sex and age, 2008, England

90

Men 80 Women

70

60

50

40 Prevalence (%)

30

20

10

0 16–24 25–34 35–44 45–54 55–64 65–74 75+

British Heart Foundation Statistics Database www.heartstats.org 136 Table 5.18 Mean waist circumference and percentage with raised waist circumference by sex and age, 2008, England

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75+ % % % % % % % % MEN Mean waist circumference (cm) 97 85 93 99 100 103 104 102 % raised waist circumference 34 9 19 33 40 51 51 48 Base 5,077 789 838 986 845 755 496 368

WOMEN Mean waist circumference (cm) 87 80 83 87 89 92 93 92 % raised waist circumference 44 23 31 39 49 56 62 61 Base 5,188 738 781 971 850 784 546 518

Notes: Raised waist circumference: greater than 102 cm in men and greater than 88 cm in women.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

Table 5.19 Prevalence of overweight and obesity in children by sex and age, 2008, England

AGE (years) 2 to 10 11 to 15 Total BOYS Overweight 14 16 15 Obese 14 21 17 Total overweight and obese 28 36 31 Base 1,762 1,117 2,880

GIRLS Overweight 13 16 14 Obese 13 18 15 Total overweight and obese 26 34 29 Unweighted base 1,701 1,039 2,740

Notes: Overweight is defined as≥ 85th UK National BMI percentile; obese is defined as≥ 95th UK National BMI percentile.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 137 Table 5.20 Prevalence of underweight, healthy weight, overweight and obese children, by school year and sex, 2008/09, England

Underweight Healthy Weight Overweight Obese Base RECEPTION % % % % Boys 1.2 74.8 13.8 10.2 259,008 Girls 0.8 77.7 12.6 8.9 247,161 Both 1.0 76.2 13.2 9.6 506,169

YEAR 6 Boys 1.1 64.5 14.4 20.0 256,338 Girls 1.6 67.7 14.2 16.5 241,342 Both 1.3 66.1 14.3 18.3 497,680

Notes: Definitions based on UK national BMI reference charts.

Source: Department of Health Cross-Government Obesity Unit (2009). Lifestyle Statistics / National Child Measurement Programme 2008/09. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 138 Table 5.21 Prevalence of obesity by sex and age, 1994 to 2008, England

BMI >30kg/m2 All ages 16–24 25–34 35–44 45–54 55–64 65–74 75+ % % % % % % % % MEN 1994 14 6 10 16 18 18 18 16 1998 18 5 17 18 22 24 22 16 2003 unweighted 24 9 19 26 29 28 30 21 2003 weighted 23 9 19 26 29 28 30 21 2006 25 10 22 27 30 36 32 18 2008 25 8 19 28 32 36 35 23

WOMEN 1994 19 9 14 19 19 28 27 17 1998 22 12 18 24 26 31 31 22 2003 unweighted 26 15 22 26 31 30 33 27 2003 weighted 26 15 21 26 31 31 33 27 2006 29 13 20 27 30 33 39 29 2008 28 15 22 29 32 34 37 27

Unweighted base (2008): Men 6,385 1,029 1,068 1,243 1,059 968 610 409 Women 6,450 935 1,020 1,241 1,057 985 663 549

Notes: Data from 1994 to 1998 are unweighted data, for 2003 weighted and unweighted data is shown, for 2006 only weighted data are presented.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds, and previous editions.

Figure 5.21 Prevalence of obesity by sex, adults aged 16 and over, 1994 to 2008, England

35

Men 30 Women

25

20

15

10

Obesity (% including morbid obesity) 5

0 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 139 Table 5.22 Prevalence of overweight and obesity in children aged 2 to 15 by sex, 1995 to 2008, England and Scotland

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 % % % % % % % % % % % % % % ENGLAND BOYS Overweight 13 14 13 15 14 12 15 14 15 14 16 13 14 15 Obese 11 12 13 13 16 14 15 17 17 19 18 17 17 17 Overweight including obese 24 26 26 28 31 27 31 31 32 33 34 31 31 31 Unweighted base 1,918 2,132 3,063 1,981 977 877 1,653 3,745 1,452 624 1,102 2,822 2,885 2,880

GIRLS Overweight 13 12 13 14 14 13 15 14 15 17 13 14 14 14 Obese 12 12 12 14 14 14 14 17 16 18 18 15 16 15 Overweight including obese 25 24 26 27 27 27 30 31 31 35 31 29 31 29 Unweighted base 1,901 2,014 3,069 1,872 950 841 1,699 3,636 1,393 8,228 1,091 2,670 2,792 2,740

SCOTLAND BOYS Overweight including obese 28 32 36 Unweighted base 1,742 1,172 637

GIRLS Overweight including obese 28 29 27 Unweighted base 1,675 1,191 630

Notes: Children were defined as overweight or obese using the 85th and 95th percentiles of the UK reference curves (known as the National BMI percentile classification). For English data, 2003 - 2008 estimates have been weighted for non-response. All of the Scottish estimates are weighted for non-response.

Source: Joint Health Surveys Unit (2009). Health Survey for England 2008. The Information Centre: Leeds. Scottish Centre for Social Research (2009). Scottish Health Survey 2008. The Scottish Government: Edinburgh.

Figure 5.22 Prevalence of obese children aged 2 to 15, by sex, 1995 to 2008, England

20

18

16

14

12

10

8 Obesity (%) Boys 6 Girls

4

2

0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

British Heart Foundation Statistics Database www.heartstats.org 140 Table 5.23 Body mass index by sex and Government Office Region, 2008, England

Government Office Region BMI <25 BMI ≥25 < 30 BMI ≥30 BMI ≥25 Normal Overweight Obese Overweight Unweighted including obese bases % % % % MEN North East 34 41 25 66 363 North West 31 45 24 68 828 Yorkshire and the Humber 34 40 26 66 607 East Midlands 34 45 21 67 561 West Midlands 33 41 26 67 595 East of England 35 43 22 64 700 London 37 39 23 63 670 South East 33 42 25 67 459 South Central 34 40 25 65 451 South West 32 41 27 68 619

WOMEN North East 41 30 29 59 416 North West 44 32 25 56 1,003 Yorkshire and the Humber 41 34 26 59 772 East Midlands 39 35 25 60 680 West Midlands 40 32 28 60 738 East of England 42 33 24 58 764 London 47 30 23 53 759 South East 46 29 25 54 571 South Central 42 32 25 57 518 South West 42 34 23 57 762

Notes: Adults aged 16 and over. Data are weighted for non-response.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. Cardiovascular disease and risk factors. The Information Centre: Leeds.

Table 5.24 Body mass index by sex and equivalised household income quintile, 2008, England

Equivalised household income quintile Highest 2nd 3rd 4th Lowest Body mass index (kg/m2) % % % % % MEN BMI < 25: Normal 33 33 31 33 33 BMI ≥ 25 < 30: Overweight 42 45 42 39 42 BMI ≥ 30: Obese 24 21 25 27 22 BMI ≥ 25: Overweight including obese 66 66 67 65 65 Unweighted bases 1,200 1,077 926 893 730

WOMEN BMI < 25: Normal 46 42 40 37 36 BMI ≥ 25 < 30: Overweight 32 31 35 32 30 BMI ≥ 30: Obese 20 26 24 29 31 BMI ≥ 25: Overweight including obese 52 56 59 61 62 Unweighted bases 1,139 1,136 1,134 1,206 1,065

Notes: Adults aged 16 and over. Data are weighted for non-response.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 141 Table 5.25 Raised waist circumference by sex and equivalised household income quintile, 2008, England

Equivalised household income quintile Highest 2nd 3rd 4th Lowest Raised waist circumference % % % % % MEN 32 30 36 35 35 Unweighted bases 659 875 777 741 598

WOMEN 37 44 46 49 51 Unweighted bases 927 948 973 990 877

Notes: Adults aged 16 and over. Data are weighted for non-response.

Source: Joint Health Surveys Unit (2009) Health Survey for England 2008. The Information Centre: Leeds.

Table 5.26 Body mass index, waist-hip ratio and waist circumference by ethnic group and sex, 2004, England

Black Black Indian Pakistani Bangladeshi Chinese Irish General Caribbean African population MEN Mean Body Mass Index (BMI) 27.1 26.4 25.8 25.9 24.7 24.1 27.2 27.1 Percentage with BMI of 30 kg/m2 and over 25 17 14 15 6 6 25 23 Mean waist-hip ratio 0.90 0.87 0.92 0.92 0.91 0.87 0.93 0.92 Percentage with waist-hip ratio 0.95 and over 25 16 38 36 32 17 36 33 Mean waist circumference 92.5 90.6 93.0 95.0 88.7 86.8 97.3 96.5 Percentage with waist circumference 102cm and over 22 19 20 30 12 8 33 31

WOMEN Mean Body Mass Index (BMI) 28.0 28.8 26.2 27.1 25.7 23.2 26.7 26.8 Percentage with BMI of 30 kg/m2 and over 32 38 20 28 17 8 21 23 Mean waist-hip ratio 0.83 0.81 0.82 0.84 0.85 0.81 0.83 0.82 Percentage with waist-hip ratio 0.85 and over 37 32 30 39 50 22 37 30 Mean waist circumference 88.4 90.2 83.9 87.7 85.7 77.6 87.4 86.4 Percentage with waist circumference 88cm and over 47 53 38 48 43 16 43 41 Bases (unweighted) Men 209 156 310 197 138 182 311 5,397 Women 314 200 345 224 171 185 405 5,554

Notes: Adults aged 16 and over. Data are weighted for non-response.

Source: Joint Health Surveys Unit (2005) Health Survey for England 2004. The Health of Minority Ethnic Groups. Department of Health: London.

British Heart Foundation Statistics Database www.heartstats.org 142 Figure 5.26a Body mass index, waist-hip ratio and waist circumference by ethnic group, men, 2004, England

40

35

30 BMI of 30 kg/m2 and over 25 Waist-hip ratio 0.95 and 20 over

Waist circumference 102cm Percentage 15 and over

10

5

0 Black Black Indian Pakistani Bangladeshi Chinese Irish General Caribbean African population

Figure 5.26b Body mass index, waist-hip ratio and waist circumference by ethnic group, women, 2004, England

60

50

40 BMI of 30 kg/m2 and over

30 Waist-hip ratio 0.85 and over Percentage Waist circumference 88cm 20 and over

10

0 Black Black Indian Pakistani Bangladeshi Chinese Irish General Caribbean African population

British Heart Foundation Statistics Database www.heartstats.org 143 Table 5.27 Prevalence of overweight and obese children by sex, WHO Region and country, latest available year, the World

Overweight (including obesity) Year of Survey Age Range Boys Girls Definition Years (inclusive) WHO Africa Region Algeria 2006 6-10 10.3 8.7 IOTF Ethiopia 1987-1995 5-17 0.1 0.4 IOTF Mali 1993 5-17 0.2 0.5 IOTF Senegal 1992 5-17 0.1 0.7 IOTF Seychelles 2004/5 9-15 16.5 21.0 IOTF South Africa 2001-4 6-13 14 17.9 IOTF Zimbabwe 1990-4 5-17 1.7 2.4 IOTF WHO Americas Region Bolivia (urban) 2003 14-17 15.6 27.5 IOTF Brazil 2002 7-10 23.0 21.1 IOTF Canada 2004 12-17 32.3 25.8 IOTF Chile 2002 6 28.6 27.1 IOTF Mexico 2006 5-17 30.5 31.5 IOTF Trinidad & Tobago 1999 5,6,9 & 10 8.1 8.8 IOTF USA 2003/4 6-17 35.1 36.0 IOTF Venezuela 1976-82 10 & 15 21.1 17.2 IOTF WHO Eastern Mediterranean Region Bahrain 2000 12-17 29.9 42.4 IOTF Iran 1995 6 24.7 26.8 IOTF Kuwait 1999-2000 10-14 30.0 31.8 85/95th centile Lebanon 1996 5-17 23.4 19.7 IOTF Qatar 2003 12-17 16.7 19.4 IOTF Saudi Arabia 2002 5-17 16.7 19.4 IOTF UAE 1998/9 4-18 24.8 27.2 IOTF WHO European Region Austria 2003 8-12 22.5 16.7 90/97th centile Belgium 1998-9 5-15 27.3 26.7 85/95th centile Bulgaria 1998 7-17 18.9 16.1 IOTF Cyprus 1999-2000 6-17 25.4 22.6 IOTF Czech Republic 2005 6-17 24.6 16.8 IOTF Denmark 1996/7 6-16 14.1 15.3 IOTF England 2007 5-17 22.7 26.6 IOTF Estonia(Self report) 2001/2 13 &15 19.4 9.0 IOTF Finland (self report) 1999 12,14&16 17.2 10.1 IOTF France 2006 11-17 21.6 16.5 IOTF Germany 2003/6 5-17 20.4 20.0 IOTF Greece 2003 13-17 27.7 16.1 IOTF Hungary 1993-4 10 & 15 17.8 15.9 IOTF Iceland 1998 9 22.0 25.5 IOTF Ireland(Northern) 2005 2-15 27.0 26.0 IOTF Italy 2006 8-9 32.8 34.0 IOTF Malta 2007 5-6 25.6 27.8 IOTF Netherlands 2003 5-16 14.7 18.0 IOTF Norway 2003-6 5-15 12.9 14.7 IOTF Poland 2001 7-9 13.6 14.7 IOTF Portugal 2002/3 7-9 29.5 34.3 IOTF Russian Federation 1992 5-17 24.2 19.7 IOTF Slovakia 1995-99 11-17 9.8 8.2 IOTF Slovenia 2007 6-19 29.4 24.1 IOTF Spain 2000/2 13-14 35.0 32.0 IOTF Sweden 2001 6-11 17.6 27.4 IOTF Switzerland 2007 6-13 16.7 13.1 IOTF Turkey 2001 12-17 11.4 10.3 IOTF WHO South East Asia Region India 2002 5-17boys, 5-15 girls 12.9 8.2 IOTF Korea 2003 7-17 16.1 9.9 IOTF Nepal 1997 5-17 0.0 0.0 IOTF Sri Lanka 2003 10-15 1.7 2.7 IOTF Thailand 1997 5-15 21.1 12.6 IOTF WHO Western Pacific Region Australia 2007 9-13 25.0 30.0 IOTF China 2002 7-17 5.9 4.5 IOTF Japan 1996-2000 6-14 16.2 14.3 IOTF New Zealand 2000 11&12 30.0 30.0 IOTF Singapore 1993 10 & 15 20.4 14.6 IOTF Taiwan 2001 6-18 26.8 16.5 IOTF

Notes: Definition refers to the definition of overweight used for the results. IOTF refers to the International Obesity Task Force definition.

Source: International Obesity TaskForce (2010). http://www.iotf.org/database/documents/GlobalChildhoodOverweightMay2010.pdf (accessed June 2010).

British Heart Foundation Statistics Database www.heartstats.org 144 Table 5.28 Prevalence of diagnosed diabetes by sex and age, 2006, England

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75+ % % % % % % % % MEN Type 1 Diabetes 0.5 0.6 0.9 0.6 0.2 0.4 0.2 0.0 Type 2 Diabetes 5.1 0.2 0.3 1.8 5.8 8.1 15.4 13.5 Types 1 and 2 combined 5.6 0.8 1.2 2.4 6.0 8.5 15.7 13.5 Unweighted base 5,625 650 862 1,183 1,050 1,126 437 317

WOMEN Type 1 Diabetes 0.5 0.6 0.6 0.4 1.3 0.2 0.0 0.4 Type 2 Diabetes 3.7 0.3 0.5 0.8 2.3 5.9 10.4 10.4 Types 1 and 2 combined 4.2 0.9 1.2 1.2 3.6 6.0 10.4 10.6 Unweighted base 6,923 794 1,148 1,494 1,279 1,268 470 470

Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with diabetes by a doctor.

Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds.

Table 5.29 Prevalence of diagnosed diabetes by sex and age, 2008, Scotland

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75+ % % % % % % % % MEN Types 1 and 2 combined 5.3 0.8 0.3 0.5 4.1 11.1 13.2 16.1 Unweighted base 2,841 246 317 462 534 525 453 304

WOMEN Types 1 and 2 combined 4.1 1.7 1.5 2.6 2.7 5.5 8.4 9.1 Unweighted base 3,622 334 451 648 632 631 516 410

Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with diabetes by a doctor.

Source: Scottish Centre for Social Research (2009) Scottish Health Survey 2008. The Scottish Government: Edinburgh.

Table 5.30 Prevalence of diagnosed diabetes by sex and age, 2008, Wales

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75+ % % % % % % % % MEN Types 1 and 2 combined 7 0 2 2 7 11 16 19 Unweighted base 6,119 714 670 966 1,000 1,177 945 647

WOMEN Types 1 and 2 combined 6 0 0 1 5 7 14 16 Unweighted base 7,194 793 838 1,188 1,126 1,334 1,029 886 British Heart Notes: Prevalence rates are weighted for non-response. Respondents were prompted to recall whether they had ever been diagnosed with Foundation diabetes by a doctor. Statistics Database Source: Welsh Assembly Government (2009) Welsh Health Survey 2008. Welsh Assembly: Cardiff. www.heartstats.org 145 Table 5.31 Prevalence of diagnosed diabetes by sex and age, 2005/06, Northern Ireland

All ages 16-24 25-34 35-44 45-54 55-64 65-74 75+ % % % % % % % % MEN Types 1 and 2 combined 4 0 0 1 5 8 8 14 Unweighted base 1,743 153 278 344 305 275 236 152

WOMEN Types 1 and 2 combined 4 0 1 1 2 5 11 10 Unweighted base 2,497 254 428 501 417 334 312 251

Notes: Respondents were prompted to recall whether they had ever been diagnosed with diabetes by a doctor.

Source: Central Survey Unit (2007) Northern Ireland Health and Wellbeing Survey 2005/06. Northern Ireland Statistics and Research Agency: Belfast.

Table 5.32 Prevalence of diagnosed diabetes by sex and country, 1991 to 2009, United Kingdom

1991 1993 1994 1998 2001 2003 2004 2005 2006 2007 2008 2009 Unweighted base % % % % % % % % % % % % (latest year) MEN England 2 3 2.9 3.3 4.3 5.6 6,854 Scotland 3.8 5.3 2,841 Wales 5 6 7 6 7 7 7,412 Northern Ireland 4 4 1,743

WOMEN England 2 2 1.9 2.5 3.4 4.2 7,307 Scotland 3.7 4.1 3,622 Wales 5 4 5 6 6 6 8,606 Northern Ireland 2 4 2,497

Notes: Estimates are reported to the appropriate level of accuracy - one decimal place where possible, no decimal places when not. Estimates are based on self-report of being diagnosed for diabetes by a doctor. Methods are broadly comparable across studies, but small differences may affect comparability. For example, some, but not all, of the estimates are weighted for non-response. All estimates are for adults aged 16 and over. See source for details.

Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds, and previous editions. Scottish Centre for Social Research (2009) Scottish Health Survey 2008. The Scottish Government: Edinburgh, and previous editions. Welsh Assembly Government (2009) Welsh Health Survey 2008. Welsh Assembly: Cardiff, and previous editions. Central Survey Unit (2007) Northern Ireland Health and Wellbeing Survey 2005/06. Northern Ireland Statistics and Research Agency: Belfast, and previous editions.

British Heart Foundation Statistics Database www.heartstats.org 146 Figure 5.32a Prevalence of diagnosed diabetes by country, men, 1991 to 2009, United Kingdom

8

7

England 6 Scotland

Wales 5 Northern Ireland

4

Prevalence (%) 3

2

1

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

Figure 5.32b Prevalence of diagnosed diabetes by country, women, 1991 to 2009, United Kingdom

7

6

5 England Scotland Wales 4 Northern Ireland

3 Prevalence (%)

2

1

0 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

British Heart Foundation Statistics Database www.heartstats.org 147 Table 5.33 Prevalence of diagnosed diabetes by sex and Government Office Region, 2006, England

North North Yorkshire East West East London South South East West and the Midlands Midlands England East West Humber % % % % % % % % % MEN 5.2 6.5 6.3 4.6 5.8 5.4 6.0 4.7 4.9 Unweighted base 298 847 570 548 576 651 678 929 528

WOMEN 4.8 4.3 5.4 4.1 5.4 4.2 4.3 3.9 2.6 Unweighted base 389 1,030 732 692 748 740 763 1,135 696

Notes: Estimates are based on self-report of being diagnosed with diabetes by a doctor. Adults aged 16 and over. Estimates are age-standardised and have been weighted for non-response. Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds.

Table 5.34 Prevalence of diagnosed diabetes by sex and household income, 2006, England

Equivalised household income quintile Highest 2nd 3rd 4th Lowest % % % % % MEN 6.8 4.2 5.6 6.1 7.0 Unweighted base 1,151 1,084 912 758 672

WOMEN 1.3 3.3 3.0 5.8 6.3 Unweighted base 1,179 1,210 1,148 1,124 965

Notes: Estimates are based on self-report of being diagnosed with diabetes by a doctor. Adults aged 16 and over. Estimates are age-standardised and have been weighted for non-response.

Source: Joint Health Surveys Unit (2008) Health Survey for England 2006. Cardiovascular disease and risk factors. The Information Centre: Leeds.

British Heart Foundation Statistics Database www.heartstats.org 148 Table 5.35 Prevalence of diagnosed diabetes by sex and ethnic group, 2004, England

General Black Black Indian Pakistani Bangladeshi Chinese Irish population Caribbean African % % % % % % % % MEN Type 1 0.6 0.5 0.7 0.9 0.2 0.3 Type 2 3.8 9.5 4.3 9.2 7.3 8.0 3.4 3.6 Types 1 and 2 combined 4.3 10.0 5.0 10.1 7.3 8.2 3.8 3.6 Unweighted base 6,602 414 390 550 433 411 348 497

WOMEN Type 1 0.3 0.8 0.1 0.2 0.6 0.3 Type 2 3.1 7.6 2.0 5.9 8.4 4.5 3.3 2.0 Types 1 and 2 combined 3.4 8.4 2.1 5.9 8.6 5.2 3.3 2.3 Unweighted base 8,234 653 469 634 508 478 375 656

Notes: Numbers may not add exactly due to rounding. Estimates are based on self-report of being diagnosed with diabetes by a doctor. Adults aged 16 and over. Estimates are age-standardised and have been weighted for non-response. General population data taken from Health Survey for England 2003.

Source: Joint Health Surveys Unit (2005) Health Survey for England 2004. The Information Centre: Leeds.

Figure 5.35 Prevalence of diagnosed diabetes by ethnic group, 2004, England

12

10

Men Women 8

6

4 Prevalence of diabetes (%)

2

0 General Black Carribean Black African Indian Pakistani Bangladeshi Chinese Irish population (2003)

British Heart Foundation Statistics Database www.heartstats.org 149 Table 5.36 Prevalence of diabetes by country, 2006, Europe

% Base % Base Austria 7 1,013 Italy 5 1,005 Belgium 5 1,012 Latvia 3 1,031 Bulgaria 4 1,027 Lithuania 4 1,016 Croatia 6 1,000 Luxembourg 5 500 Cyprus (Republic) 7 506 Malta 6 500 Cyprus (Turkish Cypriot Community) 12 500 Netherlands 5 1,069 Czech Republic 8 1,072 Poland 5 1,000 Denmark 6 1,060 Portugal 8 1,006 Estonia 4 1,011 Romania 4 1,026 Finland 7 1,030 Slovakia 5 1,180 France 5 1,022 Slovenia 6 1,039 Germany 6 1,551 Spain 6 1,026 Greece 6 1,000 Sweden 4 1,006 Hungary 7 1,001 United Kingdom 6 1,375 Ireland 3 1,000 EU* 6 25,031

Notes: *EU refers to the 25 member states in 2006 (i.e. it does not include Bulgaria and Romania who joined in 2007, and Croatia which is not currently a member state). Survey conducted between October and November 2006. Individuals were interviewed in their home using their native language. Estimates based on self-report of having diabetes.

Source: TNS Opinion & Social (2007) Special Eurobarometer - Health in the European Union. European Commission: Brussels.

British Heart Foundation Statistics Database www.heartstats.org 150 6. Economic costs

As well as human costs, both cardiovascular disease (CVD) and coronary heart disease (CHD) have major economic consequences for the United Kingdom.

Health care costs CVD cost the health care system in the UK around £14.4 billion in 20061,2. This represents a cost per capita of just under £250. The cost of hospital care for people who have CVD accounts for about 72% of these costs, whereas 20% of the cost is due to drugs (Table 6.1 and Figure 6.1a).

CHD cost the health care system in the UK around £3.2 billion in 20061,2 and stroke cost approximately the same amount. This represents a cost per capita of just over £50 for each condition. The cost of hospital care for people who have CHD accounts for about 73% of these costs. The hospital costs for stroke account for 94% of the total health care costs (Table 6.1 and Figures 6.1b and 6.1c).

Non-health care costs Looking only at the health care costs of CVD grossly underestimates the total cost of CVD in the UK. Production losses from death and illness in those of working age and from the informal care of people with the disease contribute greatly to the overall financial burden.

In 2006, production losses due to mortality and morbidity associated with CVD cost the UK over £8.2 billion, with around 55% of this cost due to death and 45% due to illness in those of working age. The cost of informal care for people with CVD in the UK was over £8.0 billion3 in 2006 (Table 6.2).

In 2006, production losses due to mortality and morbidity associated with CHD cost the UK over £3.9 billion, with around 65% of this cost due to death and 35% due to illness in those of working age. The cost of informal care for people with CHD in the UK was around £1.8 billion3 in 2006. In contrast two thirds of the production losses for stroke were due to illnesses in those of working age, and the cost of informal care (£2.9 billion) was far higher than for CHD (Table 6.2).

Total costs Overall CVD is estimated to cost the UK economy £30.7 billion a year. Of the total cost of CVD to the UK, around 47% is due to direct health care costs, 27% to productivity losses, and 26% to the informal care of people with CVD (Table 6.2).

Overall CHD is estimated to cost the UK economy nearly £9.0 billion a year. Of the total cost of CHD to the UK, around 36% is due to direct health care costs, 43% to productivity losses, and 21% to the British Heart informal care of people with CHD (Table 6.2). Foundation Statistics Database www.heartstats.org 151 International differences Table 6.3 shows the relative costs of cardiovascular related diseases for the 27 member states of the European Union for 2006. The cost per capita of CVD is highest in Germany (€413) and lowest in Romania (€34). The cost in the UK (€313) is higher than the average for the European Union (€223) (Table 6.3 and Figure 6.3).

1. The estimates for this chapter are from a cost of illness study by researchers at the Health Economics Research Centre, Department of Public Health, University of Oxford. Details of the methods and data used can be found at www.heartstats.org/eucosts. British Heart 2. This estimate does not include the money spent on non-clinical activities concerned with the primary prevention of CVD and CHD, for Foundation example, public anti-smoking campaigns, nutrition education etc. However, the cost of drugs prescribed in primary care for both primary and Statistics Database secondary prevention is included. www.heartstats.org 3. The cost of informal care is equivalent to the opportunity costs of unpaid care. It is a measure of the amount of money that carers forgo to provide unpaid care for their spouse, friend or relative living with CVD. For more details on the methods used see www.heartstats.org/eucosts 152 Table 6.1 Health care costs of CVD, CHD and stroke, 2006, United Kingdom

CVD CHD Stroke £ million % of total £ million % of total £ million % of total Primary care 835 5.8 135 4.1 57 1.8 Outpatient care 297 2.1 104 3.2 37 1.2 Accident and emergency care 67 0.5 23 0.7 11 0.3 Inpatient care 10,363 72.1 2,369 72.9 2,967 93.5 Medications 2,811 19.6 618 19.0 100 3.2 Total health care costs 14,373 100.0 3,248 100.0 3,172 100.0 Cost per capita £238 £54 £52

Notes: Original estimates were made in Euros, and have been converted using: €1 = 76p, the approximate exchange rate in early 2008 when estimates were calculated.

Source: Allender S, Scarborough P, Peto V, Rayner M, Leal J, Luengo-Fernandez R and Gray A (2008) European cardiovascular disease statistics. European Heart Network: Brussels.

Figure 6.1a Health care costs of CVD, 2006, United Kingdom

Primary care 6% Outpatient care 2% Accident and emergency care 0.5% Medications 20%

Inpatient care 72%

British Heart Foundation Statistics Database www.heartstats.org 153 Figure 6.1b Health care costs of CHD, 2006, United Kingdom

Primary care 4% Outpatient care 3% Accident and emergency care 1% Medications 19%

Inpatient care 73%

Figure 6.1c Health care costs of stroke, 2006, United Kingdom

Primary care 2% Medications 3% Outpatient care 1% Accident and emergency care 0.3%

Inpatient care 94%

British Heart Foundation Statistics Database www.heartstats.org 154 Table 6.2 Total costs of CVD, CHD and stroke, 2006, United Kingdom

CVD CHD Stroke £ million % of total £ million % of total £ million % of total Health care costs 14,373 46.9 3,248 36.1 3,172 38.2 Production losses due to mortality 4,417 14.4 2,454 27.3 771 8.6 Production losses due to morbidity 3,839 12.5 1,443 16.0 1,443 16.0 Informal care 8,041 26.2 1,852 20.6 2,908 32.3 Total 30,669 100.0 8,998 100.0 8,295 100.0

Notes: Original estimates were made in Euros, and have been converted using: €1 = 76p, the approximate exchange rate in early 2008 when estimates were calculated.

Source: Allender S, Scarborough P, Peto V, Rayner M, Leal J, Luengo-Fernandez R and Gray A (2008) European cardiovascular disease statistics. European Heart Network: Brussels.

Table 6.3 Health care costs of CVD, CHD and stroke by EU country, 2006, Europe

CVD CHD Stroke Cost per % of total Cost per % of total Cost per % of total capita health capita health capita health Country (€) expenditure (€) expenditure (€) expenditure Austria 198 6 43 1 35 1 Belgium 193 6 46 1 27 1 Bulgaria 35 14 6 2 7 3 Cyprus 59 5 18 2 7 1 Czech Republic 107 13 25 3 16 2 Denmark 182 5 44 1 37 1 Estonia 77 15 22 4 14 3 Finland 237 10 52 2 65 3 France 207 7 32 1 23 1 Germany 413 14 96 3 58 2 Greece 173 10 46 3 44 2 Hungary 75 10 15 2 10 1 Ireland 183 6 46 1 26 1 Italy 235 10 45 2 45 2 Latvia 47 9 13 3 8 2 Lithuania 59 13 14 3 14 3 Luxembourg 252 5 60 1 24 0 Malta 72 6 18 2 5 0 Netherlands 271 9 73 2 78 3 Poland 74 17 18 4 10 2 Portugal 151 10 33 2 27 2 Romania 34 15 6 3 6 2 Slovakia 74 13 21 4 11 2 Slovenia 91 7 19 1 12 1 Spain 130 7 31 2 17 1 Sweden 308 10 62 2 52 2 UK 313 12 71 3 69 3 Total EU 223 10 49 2 38 2

Notes: For details of methods and sources used, see www.heartstats.org/eucosts

Source: Allender S, Scarborough P, Peto V, Rayner M, Leal J, Luengo-Fernandez R and Gray A (2008) European cardiovascular disease statistics. British Heart European Heart Network: Brussels. Foundation Statistics Database www.heartstats.org 155

Poland Poland

Romania Romania

Estonia Estonia

Germany Germany

Bulgaria Bulgaria

Slovakia Slovakia

Lithuania Lithuania

Republic Republic

Czech Czech

UK UK

Sweden Sweden

Portugal Portugal

Italy Italy

Hungary Hungary

Greece Greece

Finland Finland

Netherlands Netherlands

Latvia Latvia

Spain Spain

Slovenia Slovenia

France France

Malta Malta

Ireland Ireland

Belgium Belgium Austria Austria

CHD CVD Stroke Luxembourg Luxembourg

Health care costs of CVD, CHD and stroke as a proportion of total health care expenditure, by 2006, Europe EU country, Denmark Denmark Cyprus Cyprus British Heart Foundation 8 6 4 2 0

Statistics Database 18 16 14 12 10

www.heartstats.org expenditure care health total of % Figure 6.3 156