Heart Disease

HL Deb 25 July 1984 vol 455 cc363-89

8.38 p.m.

Lord Rea

rose to ask Her Majesty's Government what is their response to the recent authoritative report entitled Coronary Heart Disease Prevention—Plans for Action and the report of the Committee on Medical Aspects of Food Policy on Diet and Cardiovascular Disease.

The noble Lord said: My Lords, while I am most grateful for the opportunity to put the Question which is on the Order Paper to Her Majesty's Government, I make no apology for so doing. Practically everybody in your Lordships' House either already suffers from some form of this disease, or will suffer or die from it, or has a close relative or friend who has been attacked by coronary heart disease, or some other manifestation of atherosclerosis, which is the underlying process. While it is a disease which affects people mainly in the latter half of life, it often strikes while the victim is intellectually and physically active and is playing a useful role in society.

There are 30,000 deaths per annum in this country of men under the age of 65, as has already been mentioned in another place by the Member for Thanet. In this session, as we all know, Front-Benchers of all three main parties in your Lordships' House have been struck down suddenly. All too often in another place, bye-elections are caused by the death of a sitting Member from coronary heart disease. Of 17 recent deaths of Members of Parliament of which I have information, eight—that is nearly 50 per cent. —died from heart disease.

I am asking the Question now because the two reports mentioned offer suggestions about how we can tackle the origins of what is manifestly the main public health problem of the industrialised world. These suggestions invite Government action of a very practical nature based on stringent scientific evidence. The purpose of the Question is to give the Government a further opportunity to respond to the suggestions in these two reports perhaps in more detail than it did in another place in the early hours of the 17th July.

The first report, Coronary Heart Disease Prevention—Plans for Action, was published in May. It is the report of a conference in Canterbury held in September last year under distinguished auspices. Its sponsors were the Health Education Council, the Department of Health, the British Cardiac Society and the Coronary Prevention Group. Many other bodies agreed to be co-sponsors, including the Royal Colleges of Physicians of London, Edinburgh and Glasgow, the Royal College of General Practitioners, the Royal College of Nursing, the British Medical Association and the TUC, as well as other national bodies with relevant interests. The report of the Committee on Medical Aspects of Food Policy on Diet and Cardiovascular Disease (COMA) gives the deliberations and recommendations of a distinguished group of doctors and scientists appointed by the Department of Health to a sub-committee of COMA at the end of 1981. The committee took into account over 600 published papers. The report makes it clear that there is now sufficient evidence to recommend distinct changes in our national diet which should help to reduce the prevalence of coronary heart disease.

Many of the recommendations of the COMA report had already been made by the National Advisory Committee on Nutrition Education (NACNE) in their proposals for nutritional guidelines for health education in Britain. Although this report was ready at the end of 1981, it was only published by the Health Education Council in a form available to the public in September 1983.

Before going on to ask the noble Earl the Minister specific questions arising from the reports, I think it would be appropriate to give a brief account of the development of the understanding of the cases of coronary heart disease. This, of course, underlies any recommendations for prevention. When discussing coronary heart disease, it should be understood that the basic pathological process is atherosclerosis—the deposition in and gradual blockage of arteries by a fibrous, fatty change in their walls. This is a generalised process affecting most arteries in the body. The coronary arteries are especially vulnerable, being quite narrow and supplying the heart which depends on their integrity. Narrowing of their bore leads to an insufficient blood supply to the heart muscle which can cause angina if they are not fully blocked, or an infarction (that is death of part of the heart muscle) if they become completely blocked, usually by a thrombus or blood clot at a previously damaged point in the artery. But the process also affects other vital parts of the body; for instance the arteries supplying the brain. If they become narrow or partially blocked, mental processes may become slowed, memory is impaired perhaps earlier than it would be, and dementia may set in more quickly. If the arteries are blocked by a thrombus, a stroke may result, or a weakened artery may burst and lead to cerebral haemorrhage. This is much more common of course in people who are also suffering from high blood pressure. Once symptoms occur, treatment can help, and amazing feats of open heart surgery are now carried out every day, but the underlying process cannot be reversed. This is the main reason which has led to widespread interest in preventing the disease from developing in the first place.

It was in the United States of America in the 1940s that coronary heart disease first reached alarming proportions. Prior to Roosevelt's "New Deal" in the 1939–1945 war it had been relatively uncommon and restricted mainly to the more prosperous sections of the community. It rapidly spread down the social scale as affluence increased, machines gradually took over manual labour and it became the norm to travel by car and have centrally heated homes. At the same time—and for the first time—nutrition became adequate for nearly all the population with the result that there was widespread over-nutrition. This also coincided with the peak of the new habit of smoking cigarettes. As long as 40 years ago far-sighted scientists in the United States began to look at the causes of this modern epidemic.

The work started by these pioneers spread throughout the world and involved intensive epidemiological research comparing the experience of countries from Japan to East Africa and from Finland to Australia. This has been accompanied by a virtual explosion in research into lipid metabolism, looking into the biochemistry underlying atherosclerosis and its relation to nutrition and a range of life-styles and habits.

As much as 25 years ago leading figures in public health in the United States felt that they had sufficient understanding of the causes of the problem to recommend certain action to be taken by the American people, and the movement towards the reduction of animal fat in the diet began. I have recently seen a book published in 1964 entitled Fat Boy Go Unsaturated. At the same time the importance of smoking in the causation of the disease began to be understood. A succession of reports in the United States influenced the public to make considerable changes in their life-styles, particularly their dietary patterns. Over the past 20 years there has been a marked switch in the type of fat consumed in the average American home, as well as some reduction in smoking and an increase in leisure time physical activities.

At the same time high blood pressure was recognised to be an important risk factor in the development of atherosclerosis and vigorous attacks were made on this problem. Health checks have become almost overdone in America. Some other countries with a severe atherosclerosis problem picked up the message from the United States and also took action—in particular, Australia, New Zealand and later some European countries, notably Belgium and Finland. About 10 years after the institution of this movement in these countries the coronary heart disease mortality began to fall measurably.

In this country the peak mortality from coronary heart disease in men aged 35–65 was not reached until the mid-sixties, some 15–20 years after the United States. Now, in the early 'eighties, we are just beginning to see a decline, but it is very slight and scarcely evident in Scotland or Northern Ireland, which have the highest rates in the world. Finland, having taken steps (having previously led the world in this grim table) is now showing a rapid decline in coronary heart disease mortality following vigorous public education, particularly in Eastern Karelia (where the mortality rate was the worst) in the early 'seventies. Other countries such as the Eastern European bloc are still on a rising phase of CHD mortality as affluence arrived there some 15 years later than it did in Western Europe. Steps to alter the lifestyles which are thought to underlie atherosclerosis have not yet been adopted there on a general scale. Even today I read that some of the EEC butter mountain is being shipped to the USSR—possibly a move in the cold war, I do not know!

The more experienced the scientific worker is in atherosclerosis research, the more convinced he is that dietary factors play a basic role in the deposition of these fatty plaques in the walls of arteries. In Japan where the two other main risk factors (high blood pressure and smoking) are widely prevalent, there is yet a very low level of coronary heart disease. In Japan blood cholesterol levels are low. The diet contains very little fat and a high ratio of polyunsaturated to saturated fatty acids. In Crete the cholesterol level and coronary heart disease are also low. But there, there is a high fat intake—but it is mostly olive oil, which is low in saturated fatty acids and high in the polyunsaturated fatty acids derived from fish, fruit and vegetables.

At this point I had better diverge for a word about polyunsaturated fatty acids. This is a fraction of fat which performs important physiological functions —for instance in cell walls—and it discourages blood clotting in the arteries, among other useful things. It appears to discourage atherosclerosis when taken in the right proportion in the diet. Worries that cancer might be caused by polyunsaturates have been shown to be unfounded. If any noble Lords wish to talk to me about this after, I shall be pleased to give them experimental details.

All these findings were taken into account by the WHO expert committee on the prevention of coronary heart disease, whose work was published in 1982. This report states, and I think it is worth quoting: The underlying atherosclerotic process leading to mass coronary heart disease begins in youth, along with the appearance of its major risk characteristics—elevated blood pressure and blood cholesterol—and associated risky behaviour, including smoking. Preventive measures should be introduced in childhood to avert the development of these coronary heart disease precursors". Studies in East Africa by Professor Michael Crawford have shown that blood cholesterol levels start to rise in European children from the age of five onwards compared with African children who go on eating their traditional diet. The implications of this for the school meals service are obvious, as well as in the health education of parents. The disturbing article about school meals in yesterday's issue of the Guardian emphasises this point. Cost-cutting in the school meals service is a very shortsighted policy.

The WHO report suggested that Governments should prepare action plans towards the prevention of coronary heart disease. The Canterbury report is really an answer to a suggestion of the WHO committee. It is brimming over with recommendations covering a wide field. Its nutritional recommendations are really the same as those of NACNE. Those on smoking are the recommendations of the Royal College of Physicians' Report on Smoking or Health. Counting sub-headings, there are 129 recommendations. The COMA report, restricting itself to nutritional advice, still offers 37 detailed suggestions.

Obviously it is impossible to describe all of these recommendations or for the Minister to give the Government's position on all of them. When asking my specific questions, I am hoping to catch the general drift of the recommendations of the two reports.

The Canterbury report wishes to see a recognition of the importance of the problem of coronary heart disease by the Government and the establishment of a national strategy for coronary heart disease prevention, possibly as part of a new general policy for health promotion. An example of this strategy is the United States' programme "Healthy People" launched in 1979 with specific measurable objectives to be achieved by 1990. We could do likewise. Would the department be prepared to undertake a programme such as that?

Along with a national strategy, a new standing committee in the Department of Health is suggested to review economic and other policies which have a bearing on health. This committee should establish improved working relations with other departments. A health seat on the National Economic Development Council—NEDDY—is suggested to ensure that the health consequences of economic policies are fully considered.

These are all ways in which the important recommendations made by the COMA report on dietary change could be implemented, since the Ministry of Agriculture, Fisheries and Food, the Department of Trade and Industry, and the Department of Education and Science are all involved. Even the Foreign Office is involved where the common agricultural policy is concerned. The COMA report recommends the establishment of joint machinery for an on-going review and lists several advantages of having such a body—including continuity, the evolution of a coherent policy as opposed to periodic recommendations, and greater public awareness of its importance. They say that an evolving policy can also facilitate public education and change on the part of all sections of the food industry.

The COMA report's actual recommendations regarding dietary change are very similar to the short-term goals of NACNE for the 1980s, although they go a little further than these on fat but hold back when compared with NACNE on sugar and salt. In particular, COMA recommend the reduction of total fat by 16 per cent.—from 42 per cent. of the calories in the diet to 35 per cent.—and that fats should contain a higher proportion of those useful unsaturated fatty acids. They think that the unsaturated group should be increased by 15 per cent. If there is no change in the ratio between saturated and polysaturated, the COMA report believes that percentage of total fat should be decreased even more, by 25 per cent. instead of 16 per cent. This will have considerable repercussions for the dairy industry and other aspects of agriculture, particularly meat production—for instance, in the percentage of fat in carcass meat. I believe we shall all be relieved that the report makes no recommendations with regard to alcohol, except for the avoidance of excessive drinking.

The NACNE report is a little more specific on this point, taking into account that there is a U-shaped relationship between alcohol intake and mortality. There seems to be some reduction in atherosclerosis in those who drink moderately compared to those who drink no alcohol and those who drink a lot. This provides some comfort to many of us!

The COMA report makes no specific recommendations for a reduction in salt or sugar, which the NACNE report does—although COMA recommends that there should be no increase in salt or sugar in manufactured foods. This could be aided by appropriate food labelling recommendations. The COMA report is very clear in its labelling recommendations for producers, manufacturers and distributors of food containing fat. The report states in paragraph 2.4.1: The percentage by weight of fat and of saturated, polyunsaturated and trans fatty acids in butter, margarine, cooking fat and edible oils should be printed on the container or wrapping in which they are sold. Consideration should be given to providing … simple labelling codes to enable the general public to distinguish easily between fats and oils with low or high contents of saturated fatty acids". The Canterbury report suggests a so-called "traffic light" system, which is used in some other countries, to help the consumer. They also suggest that the fat content of meats, milk and cream, cheese, cakes and biscuits should be stated on the label.

I am sorry that no specific recommendations are made in the report for labelling the content of sugar and salt in various processed foods. Unless this is done it is very difficult for consumers to make simple and rapid choices if they seek to purchase foods which are low in sugar or salt content. I hope that the content of these substances will be included among the Government's recommendations for labelling.

The NACNE report and the Canterbury report are clear that salt reduction on a community-wide basis would have a beneficial effect on reducing the incidence of high blood pressure, which is an important causative factor in coronary heart disease.

Sugar contributes indirectly to coronary heart disease by contributing to obesity, which is often associated with diabetes or a tendency to diabetes. Diabetics have increased coronary heart disease and atherosclerosis and so do borderline "prediabetics"—those who do not have blood sugar levels quite high enough for them to be diagnosed as diabetics. I hope that this aspect will be further reviewed.

Before leaving the nutritional recommendations of COMA I must ask two questions relating to the specific recommendations. First, recommendation 2.6.3 states, Consideration should be given to ways and means of encouraging the production of leaner carcases in sheep, cattle and pigs (for example by adjustments to the operation of the carcase grading systems)". At present a carcase has to have 25 per cent. fat in order to qualify for the intervention price subsidy. I think we should aim towards reversing that situation and be offering subsidies for the leaner carcases and not the fatter ones. Recommendation 2.6.4 states that, Consideration should be given to ways and means of removing from the common agricultural policy those elements of it which may discourage individuals and families from implementing the recommendations on dietary change". I shall be very interested to hear the Government's views on that recommendation!

However, all of these changes, which have marked implications for agriculture and the food industry, are delicate matters and must be approached with obvious tact. They need not necessarily harm agriculture or the food industry. Voluntary agreements and codes of practice are better—if strictly adhered to, that is—than legislation imposed on an unwilling industry, because the industry is then much more likely to be opposed and the policy will be circumvented in various subtle ways.

At this point I should like to leave the food question and turn, briefly, to three other points. First, I shall refer to smoking. This is terribly important, but we had a debate on the subject in your Lordships' House very recently. I can only plead that the Government should recognise that our present voluntary agreements with the tobacco industry are not satisfactory; I have in mind, for instance, the widespread publicity for the tobacco industry that goes with sports sponsorship and the inadequate health warnings on cigarette packets. Let us take as an example carbon monoxide, which is known to play a major part in coronary heart disease and atherosclerosis. It is not mentioned on the packet, although Government publications give the carbon monoxide output of each brand of cigarette. It is clear that the manufacturers are afraid to indicate that their product contains a known poison. I can only plead with the Government, for the umpteenth time, to introduce legislation to control cigarette advertising. It has been shown that the Medicines Act can be used quite simply for this purpose.

The identification and control of hypertension is something which should be done mostly in general practice. The department could mount a programme aimed to help doctors to set up systems to do this. An imaginative series of suggestions as to how primary health care can play a part in coronary heart disease prevention forms part of the Canterbury report; but this requires a central initiative. I very much hope that the DHSS will provide it. Many general practitioners are anxious to help. The Royal College of General Practitioners has already produced a monograph on coronary heart disease prevention.

There is only a small section on exercise promotion in the part of the Canterbury report that deals with health education. I do not think quite enough emphasis has been put on this. Exercise reduces blood cholesterol and hypertension, both known risk factors in coronary heart disease. Careful thought needs to be given to ways to increase exercise, not only during leisure time, but also on the way to work, and perhaps at work. Cycling, for instance, is a socially useful form of exercise which could be greatly encouraged. The Cycle Tracks Bill, which has recently gone through your Lordships' House, will help, but more investment and central aid could be given to projects which make cycling safer. I come down to your Lordships' House on a bicycle quite often, weather permitting, but although it may stop my coronary arteries furring up, I risk sudden death under a bus on the way!;

There is great need to increase sport facilities. I should like to see a far greater proportion of the population of this country playing football, rather than watching it on a Saturday afternoon. It is much better to let off tensions in vigorous sporting activity than by indulging in hooliganism. Again, this is something where a central initiative could play a major part.

This is such a major topic that it has been possible for me only to skirt round it. What we should realise is that we now, at last, have a consensus on how to tackle the problem. In the field of nutrition, the COMA report, preceded as it was by the NACNE report and the WHO report on the prevention of coronary heart disease, has shown us the way forward. The COMA report is only a first step in how our diet should be changing in a world where back-breaking physical labour is no longer the norm.

The history of nutrition and disease in man has gone through four main phases. Our physiological pattern evolved in the days when man was mainly a hunter and gatherer; calories were short, meat was an occasional luxury, and most of our diet came from vegetables, fruit, cereals and roots. Even after the establishment of agriculture the great majority of the population scarcely had enough calories and very little meat. Infectious disease was rife and, along with it, malnutrition. With the establishment of improved agriculture and the industrial revolution there was a rise in prosperity. Nutrition began to improve in the last century and, as a result, infectious diseases began to become less common, even before the antibiotic era. But it was not until the mid-twentieth century that whole populations went into credit, as it were, in calories and fat. Now infectious diseases are of secondary importance and we are faced with the diseases of affluence which affect us mainly in the latter half of our lives.

The recommendations of these reports, if followed, will help to prevent not only coronary heart disease and the other diseases caused by atherosclerosis, but other conditions, such as bronchitis, emphysema, carcinoma of the lung, and possibly carcinoma of the bowel and breast, and will help reduce obesity, which is far too prevalent. I hope that the Government will earn the gratitude of ourselves, but more particularly of our children and our children's children—for it is they who are most likely to benefit—by acting vigorously on the recommendations contained in these two reports.

9.7 p.m.

Lord Colwyn

My Lords, as a fellow cyclist I must congratulate the noble Lord, Lord Rea, on the clear way he introduced our debate this evening and also on the timing of his Unstarred Question, following so closely the COMA report on the medical aspects of food policy and also the report from the Canterbury meeting. In view of the serious amount of cardiovascular disease in the United Kingdom, I must also stress the vital importance of the need for further research and for publicity to be given to the recommendations of these reports. I must also express admiration for the work of the Coronary Prevention Group and urge the Government to support them in every possible way.

Of course, I endorse the findings of the report, but I find myself this evening in a difficult position in that, although I am by no means an expert on the subject, I have studied the relationship between diet, stress and disease—or dis-ease, as I prefer to call it—for some years, and I do not believe that it is quite as simple as diet, exercise and smoking. I think the report has some omissions whereby the prevention of heart disease may be even simpler than is now thought, and I should briefly like to offer an explanation of my views.

I think your Lordships' House is probably the only place in the world where a non-expert can command so much attention. But if I achieve one goal this evening—that of persuading my noble friend the Minister to go to his advisers or to the Medical Research Council to try to find out whether the things I say are unfounded, or perhaps have some basis for further investigation—I shall have achieved the aim of my intervention.

Random ageing events result in cumulative damage which occurs in a sporadic fashion. This damage, which is caused by, for example, ultra-violet light, X-rays and free radicles—those are the chemically reactive entities produced in the body, particularly by the abnormal oxidation of fats and aldehydes—is usually coped with by the normal repair mechanisms within the body. Here we have a vital factor that I believe is widely misunderstood, for I am of the opinion that the deposition of cholesterol in our artery walls, and, for example, the abnormal cellular division that causes cancer, are all normal occurrences throughout life, and that it is the action of our immune system, comprising the thymus gland, several types of white blood cell, bone marrow, spleen, lymph nodes and ducts, and a variety of protein and polypeptide chemical weapons, which make the necessary day-to-day repairs.

However, these repair systems are not perfect, and the rate of repair declines relative to the rate of damage, partly because of planned ageing events and partly because of the incomplete repair, which can lead to further damage. There are two basic classes of ageing mechanism: random damage and genetically programmed obsolescence. Most people die of random age-related damage, such as cancer escaping control by a deteriorating immune system, or from a coronary thrombosis from an arterial blood clot caused by inhibition of the formation of one's natural clot-preventing hormone PGI2 or prostacyclin, by organic peroxides produced by free radicles. If those random damage events were eliminated or perfectly repaired, one could lead a healthy life to the end of one's genetically determined life span—probably 110 to 120 years, at which time the ageing clocks, particularly those situated in the brain, would start to shut off some of one's vital systems.

Maximum possible life span seems to be determined by programmed ageing, whereas average life span is determined by random ageing damage. I repeat that it is our immune system which protects us from the enemies all around and within us. As we age, our immune system's ability to protect us deteriorates seriously. In fact, most of us die because our immune system fails to protect us from cancer, atherosclerosis or infectious diseases. However, using the right nutrients we can improve the performance of our immune system, whatever our age. The most important of these are vitamins A, C and E, the minerals zinc and selenium, hormones, drugs and even complex techniques such as T-cell cloning.

What I am trying to say is that atherosclerosis, which, as we have heard this evening, kills thousands each year, can be slowed down or even reversed by using correct nutrients, which can help prevent the formation of peroxidised fats in the body. These peroxidised fats, since they are mutagens and carcinogens, are able to initiate plaque formation. Polyunsaturated fats and cholesterol are particularly likely to be converted into these carcinogenic peroxidised fats because they are very susceptible to oxidation. These peroxidised fats are also immune system suppressants which prevent the desirable destruction and removal of plaque tissue.

When a cholesterol deposit forms in the lining of one's arteries, specialised white blood cells approach the deposit and ingest it. In doing so, those white cells, which produce a variety of oxygen-related free radicles whenever they eat something, cause the cholesterol and other fats to become oxidised. It is known that within the bounds of normal diet the cholesterol content of the diet does not determine the serum cholesterol content.

The body can manufacture about 1.5 grammes a day of cholesterol. In fact, if dietary cholesterol is reduced, the body, via a feed-back mechanism, increases its manufacture of cholesterol in about 40 per cent. of people. Low cholesterol diets alone may therefore be ineffective in reducing serum cholesterol. Further, there is little evidence that high serum cholesterol levels themselves cause heart disease. It is known that oxidised cholesterol is a mutagen and plaque tumour initiator. These oxidised cholesterol and peroxidised polyunsaturated fats also enhance plaque formation by preventing the synthesis of prostacyclin in blood vessel walls, which prevents the plaque build up.

In March 1981, Trends in Pharmacological Sciences reported that small doses of a synthetic prostacyclin substance may be all that is required as a prophylactic in vascular disease. Vitamin B6 deficiency can cause free radicle damage to our arteries. As an example, smokers who do have an elevated risk for cardiovascular disease typically have low vitamin B6 levels in their serum. Women on oral contraceptives, who also have a higher cardiovascular risk, typically have lower serum levels of B6.

Excess of sugar can contribute to development of atherosclerosis. Sucrose stimulates release of insulin, which is required to utilise the sugar. The insulin remains in the blood stream and can cause cholesterol and other lipids in the blood to be deposited in arterial walls. Diabetics, who control their problems with insulin, often develop serious cardiovascular complications, whereas diabetics who control their blood sugar levels by careful dietary means do not generally develop these complications.

An association has been discovered between heart disease and drinking soft water. Minerals, especially selenium and zinc, which are removed in the softening process are required by the body as parts of the antioxidant enzymes glutathione peroxidase and superoxide dismutase which are essential to maintain disease-free arteries.

I am very suspicious of the widely held view that there were relatively few heart attacks until the start of this century. It is true that heart attacks are more common today than they were several decades ago, but perhaps not for the reasons many people believe. Dr. Broda Barnes from the USA has offered a theory by showing that during World War II the incidence of heart attacks decreased in Europe. It was thought at the time to be due to the lack of availability of cholesterol foods. However, the real reason was probably that tuberculosis had increased in incidence more than heart attacks had decreased and patients were being killed by tuberculosis before they could die from a heart attack. Post-mortems on TB victims revealed coronary artery disease was double the prewar level. Later when antibiotics were available deaths from TB dropped and heart attacks rose.

It would appear that the individual susceptible to any infectious disease is highly vulnerable to atherosclerosis. As we know atherosclerosis occurs partly as a result of a T-cell immune system failure, this comparison is very appropriate.

Dr. Barnes found that patients with too little output of thyroid hormone were particularly susceptible to heart attacks. Adequate thyroid hormone is required for proper function of the immune system. There are simple basic tests for thyroid hormone activity which should be standard medical practice in the prevention of heart disease. I am sorry to have been a little technical this evening, but I have tried to show that the causes of coronary heart disease may be even more basic and preventable than the report perhaps implies.

May I conclude by asking the Government to give a little more thought to the answer I received to a Written Question on 4th July when I asked, among other things, whether any research was being carried out into the development of techniques using EDTA for the treatment of the effects of atherosclerosis. EDTA is Ethylene-diamine tetra acetic acid—that is a difficult one, no doubt, for Hansard at this time of night.

Lord Graham of Edmonton

Say it again.

Lord Colwyn

EDTA is Ethylene-diamine tetra acetic acid. It is a good long word.

I was informed by the Medical Research Council that they considered the use of EDTA to be totally unsafe and that there was no further work being developed in that field. In some parts of the world, particularly Germany, New Zealand and the USA, hundreds of thousands of treatments have been given for the removal of the atherosclerotic plaque without any harmful results. There were some difficulties with over-dosage in the early 'sixties but now, even with patients who are quite ill, the treatment has dramatic beneficial effects. I hope the Government and the Medical Research Council are aware of the work of Bruce Halstead and others in the USA on the use of this technique, for I predict that when their work is recognised in this country there will be a saving to the National Health Service of many millions of pounds each year.

In fact, the answer to another Written Question has indicated that the probable cost of open heart surgery this year will be in the region of £22 million within the National Health Service. I would have thought that a saving of £20 million or so would be a very attractive proposition to the Government and well worth some further work on the use of EDTA, which is cheap and effective and would require no long waiting lists.

Health care and treatment is at an exciting crossroads in the mid-1980s. Those of us who believe that attitudes must change both within the professions and among the public urge the Government to widen the scope of their mandate for research and encourage the alternatives to orthodox medicine. I was delighted to read a quotation from His Royal Highness the Prince of Wales, who said: The relationship between mind and body and mind and spirit is vital to the health and welfare of people all over the country—individuals who could learn much about the possibility of preventing their own illnesses simply through a different attitude to existence".

I am personally involved at the moment with a group of dentists in setting up a British Dental Society for Clinical Nutrition, which we hope will teach dentists who see their patients once or twice a year—not just when they are ill—to offer advice on nutrition and supplements to diet. We are what we eat or what we put into ourselves. That is the secret to good health and the vital weapon for prevention.

9.21 p.m.

Lord Prys-Davies

My Lords, I am a cyclist but I am not an expert. My interest in this field is that of a layman who is concerned at the magnitude of the challenge presented by heart disease. I am sure that all noble Lords are grateful to my noble friend Lord Rea for bringing this important subject before the House. We are grateful to him for his skilled and informative survey of the background to the report which he has discussed and for having brought this problem into sharp focus. I shall be interested—as I am sure, will many people outside the Chamber—to hear the Minister's reply to the questions that my noble friend has posed.

I should like to go back to 1976 when my interest was first aroused in this challenge. It was in 1976 that the health departments of England, Wales, Scotland and Northern Ireland published an interesting consultative document on preventive medicine. It was called Prevention and Health: Everybody's Business. The purpose of the document was to arouse interest and to invite comments. I do not know to what extent DHSS policies were modified or new policies initiated in the light of the comments received on the 1976 report. I mention that because I propose to return to it at a later stage.

Within the 96 pages of the 1976 consultative document, three pages and no more were devoted to coronary heart disease. It was then stated that there was, a lack of agreement on the degree of effectiveness of preventive measures". The document was very brave. It went on to agree that cigarette smokers who gave up the habit would subsequently run a lower risk of heart attacks.

The basic view reflected in the 1976 document and certainly in the three pages devoted to coronary disease was that it is the individual who must take the major responsibility for his own health. That was the basic theme of the document. In most situations, that is true. But if the individual is to discharge that responsibility, then a very high priority must be given to health education. But, accepting the view that the individual is responsible for his health, nevertheless, for some, particularly the young—and we are so advised in the Canterbury Report and by my noble friend Lord Rea—the seeds of coronary heart disease may be sown in childhood. So for some, including young people, the responsibility must be elsewhere.

In certain specific situations, such as coronary disease, which, as we have been told, claims a quarter of all deaths—I think it is a third of all deaths between the ages of 35 and 64—the individual and social consequences of the disease are so serious that vigorous preventive measures on the part of the Government are imperative. This is required not only for humanitarian reasons—to relieve human suffering —but in order to release more health resources for the treatment of other illnesses. We are told that at any one time 7,000 NHS beds are occupied by heart disease patients. We require this also in order to protect industry from the loss of millions of working days per annum.

This leads me to the two reports to which my noble friend Lord Rea has tonight drawn the attention of the House. I do not propose to deal with the COMA Report except to say that obviously we welcome it. There may be blemishes in the Canterbury Report; there may be gaps in that report; but I welcome it wholeheartedly. The value of this report is without doubt. The duty for the Government of the day to take seriously preventive health, the duty to take detailed and specific measures in pursuit of the prevention of heart disease, was never stated more plainly in our country. The report surveys the whole field. It sets out an impressive list of specific actions which should be undertaken; again, my noble friend Lord Rea has referred to a number of those recommendations. I think it would have been helpful if the 130 recommendations—I think there are 130—had been placed in a ranking order; but that is a very minor criticism.

We are told that the Ministry of Agriculture and Food can make a major contribution; we agree with that. We are told that the Department of Education and Science can do more to promote improved health education; we agree with that. And we are told that the CBI and the trade unions can do more to promote the health of staff and members; again, we agree. The report addresses itself to the role of the EEC in the development of food policy. But some of us would wish also to see the EEC examining and recommending methods of reducing consumption of tobacco, which is a major cause of coronary heart disease. We would wish to see the EEC, right across the board in Europe, developing health educational policies. I am conscious also of the significance of the work undertaken by the Welsh Heart Programme—a pilot programme for a region of the United Kingdom—and the lessons to be applied in other parts of the country.

The report is realistic. There is nothing woolly about it. But having surveyed the scene, having referred to the role of the ministries and the EEC, the authors conclude that the central role, the vital role—those are their words—in promoting an effective prevention policy must be undertaken by the DHSS and its agents, the regional boards and the district health authorities. The role of the DHSS is basic to the programme. I am sure that the authors of the report are correct in emphasising this central role of the department.

The one point that I would wish to emphasis tonight is that changes are also required within the machinery of the DHSS if we are to advance along the lines and within the time-scale recommended in the report. I think that that is a fair point to make. Hitherto, the DHSS has concentrated on meeting the requirements of acute medicine. That is understandable, because it can bring immediate relief to the patient. It has concentrated on bringing the major specialities within reach of our people wherever they live. We are grateful for that. To a lesser extent, and thanks to the powerful intervention of the late Richard Crossman in 1978–79, it has also during the past 15 years put in a great effort to improve the service for the elderly, the mentally ill and the mentally handicapped.

However, it has not undertaken a similar effort to promote the contribution which prevention can make towards a solution of our health problems. I should have thought that this is one reason why the total number of deaths from heart disease in Britain has remained at the present high level for the past 20 years, claiming a quarter of the deaths, while during the same period, as we have heard this evening, there has been a marked decline in the number of deaths from heart disease in the United States of America, where the death rate has fallen by 26 per cent. since 1968; and Canada, Australia and new Zealand are showing the same trend.

The DHSS has therefore a vital role to play, a leading role to play, in bringing about the desired changes by the development of a co-ordinated programme. The Canterbury Report calls for the setting up within the department of a standing committee drawing on the resources of a number of departments which are named in the report. Such a committee would strive to ensure that the numerous departments would not be pursuing conflicting ends where their policies would converge. I believe that there is also a need to build within the department a special unit responsible to a deputy secretary to hammer out policies, to implement those policies and to monitor their progress towards the agreed targets. I feel that inadequate attention may have been given by the authors to the difficulties offered by the interests, the pressures, which over the years are inherent in most large-scale organisations. Nevertheless, I trust that the Ministers at the DHSS will do everything in their power to ensure that the department rises to the challenge.

Meanwhile, we offer handsome praise to the small voluntary organisations such as the Coronary Prevention Group, the British Cardiac Society and others for having shown to the department and to the country the way forward. Most of us are probably potential patients, and we are indebted to my noble friend Lord Rea for having brought the contribution of these societies so sharply into focus. I hope that the department will rise to the challenge, and will do so with the minimum of delay.

9.35 p.m.

Baroness Cox

My Lords, I should like to join others in thanking the noble Lord, Lord Rea, for giving us an opportunity to discuss this subject this evening; a subject which, as he has shown, is of the utmost importance for our nation's health. The point has already been made that coronary heart disease is the number one killer in our country at the present time. It causes the deaths of more than 150,000 people every year or, in other words, of one person every three to four minutes, and of one man in 11 before he reaches the age of 65.

Such deaths are particularly tragic because they are, to a considerable extent, avoidable. That is shown by the achievements of the other industrialised societies which have achieved major reductions in the numbers of people dying from coronary heart disease—the United States, Australia, New Zealand, Belgium, Canada, and Norway, to name but a few. Now the United Kingdom features among the top countries in world rankings for deaths from coronary heart disease, with Scotland and Northern Ireland faring worse than England and Wales. It is therefore a matter of great urgency that we should consider what action we can take to avoid this unnecessary suffering and all the costs which it incurs.

The human costs are of course incalculable; the grief of bereavement for those who lose a loved one, and the impairment of quality of life for those for whom the disease is not lethal but whose health is seriously impaired. And there are other costs, particularly the economic costs arising from absence from work, and the costs of expensive high technology medical treatment. If preventive measures can be implemented which are successful in reducing the numbers of people afflicted, that would help to reduce incalculable suffering. It would contribute to a healthier workforce, and it would save precious health service resources.

Therefore, I should like to put forward a number of suggestions which I hope are constructive. Some are pleas for an extension of work which is already under way in some places; others refer to policies adopted by other countries but not, to date, here, at least to my knowledge. Most of these suggestions will focus primarily upon attempts to improve the quality of diet.

I recognise, of course, that the predisposing factors for coronary heart disease are numerous and interrelated. However, organisations such as ASH are already doing valiant work in their campaign to discourage smoking, and discussion of the significance of diet is particularly timely in view of the recent publication of the COMA report to which reference has already been made.

My first suggestion concerns district health authority policies. About 30 district health authorities, from Blackpool to Brent, now have some kind of policy on food and health. My own district health authority of Brent published its report in 1982 recommending, inter alia, changes in hospital menus including increases in the proportion of wholemeal bread and flour and of fibre rich breakfast cereals, and a reduction of total fat intake, especially saturated fats, together with other reductions in sugar and salt.

In one hospital the catering officer pointed out that such changes would be costly. However, the sister in charge of the geriatric unit pointed out that the money saved by reduction in laxatives more than compensated for the extra costs incurred for the catering officer. Moreover, and most important, the patients themselves have appreciated the change in diet—even those elderly patients who might perhaps have been expected to resist change to their life-long dietary habits.

My second suggestion concerns health education in schools. Positive attitudes towards healthy food need to be developed as early in life as possible. Therefore, surely, schools should be used to instil relevant knowledge and to encourage good eating habits. Much is already being done; but much more could be done both within curricula in such subjects as home economics and in specific health education projects. One problem here is that some of the existing syllabuses for CSE, GCE 0-level and City and Guilds examinations encourage an unhealthy diet with emphasis on skills in making dishes with high fat content such as creamy sauces. Some thought therefore needs to be given to changing these curricula and helping staff who were trained under the old dispensation to adjust to new syllabuses which promote healthier diets. Perhaps in-service teaching courses might be helpful, drawing on the resources both of the district health education service and of the local education advisory service.

Also, in schools changes in food provided for school meals need to be accepted similar to those that have been adopted in some hospitals to which I have already referred.

The third issue I should like to raise for consideration concerns the provision of information to the public about the contents of food. It is no use making people aware of the kinds of food they should be eating or avoiding and not giving them enough information to enable them to make informed choice. Hence the importance of labelling food with information which is both accurate and easily understood. For example, in addition to the excerpt already quoted by the noble Lord, Lord Rea, for foods such as butter, margarine and cooking fats from the COMA report, that report also recommends: Information … should be provided, wherever practicable, for all other foods with a fat content of more than 10 per cent. by weight, or which are major contributors to fat intake. If the foods are sold in prepacked form, the information should be printed on the package wherever possible. If the foods are not sold prepacked the information should be displayed prominently at retail outlets. The foods in this category are mainly meats and meat products, milk and cream, cheese, and cakes and biscuits. Equally, caterers should provide similar information in appropriate ways.". This issue of labelling foods with helpful and easily comprehensible information is most important. Other countries have gone much further than we have; for example, reference has been made to Scandinavia where some foods have symbols like traffic lights with red for danger. I must admit that I would personally welcome something like this for when I look at the contents of food and the packages which contain it, I often do not know how to interpret the information given.

I give one example to illustrate this point. I am very fond of yoghourt and recently I have discovered a firm which offers a wide range of different yoghourts from low fat to so-called "rich and creamy". I must admit that I could become addicted to the latter, but I note that whereas the fat content of the low fat yoghourt is less than 2.5 per cent., that of the so-called rich and creamy is 7 per cent. But I do not know how to interpret that information. Obviously the latter has nearly three times the fat content of the former; but is it still relatively low compared with single or double cream or dangerously high? I do not know how to interpret that information provided, and I suspect that many members of the public are in the same predicament. Therefore I suggest that the Government might give some serious consideration not only to ensuring that accurate information is provided but also to recommending that some easily understood symbols are used so that the public can more easily choose a healthy diet.

The fourth topic I should like briefly to mention is the use of the mass media. I hope very much that the mass media will increase their role in providing consistent information about a healthy diet, because initiatives which have already been taken have proved the public's interest and receptivity. For example, when Woodrow Wyatt wrote a piece entitled The Diet That Kills in the News of the World, 10,000 people sent 50p and a stamped addressed envelope in order to obtain a copy of the Guide to Healthy Eating produced by the Coronary Prevention Group.

The final topic I should like to raise concerns the role of the primary health care team. A number of helpful suggestions are spelt out in the book, Coronary Heart Disease Prevention: Plans for Action. Clearly, all the members of primary health care teams are in a good position to provide health education; although there may be some difficulty in so far as many have received little in the way of training for this purpose because professional education has tended to concentrate on disease management rather than health promotion. Therefore, consideration should be given to ways in which both basic and post-basic education for health care professionals can equip them to fulfil this part of their responsibility more effectively.

I have one final suggestion. The Canterbury Report rightly emphasises the importance of screening in order to identify individuals at risk. It is well known that high blood pressure is one predisposing factor to coronary heart disease. Therefore, routine checks could help to pick up people at risk and offer them prophylactic treatment. This could be cheaply and efficiently provided by community nurses who might hold regular clinics to which people could come for a quick check up: and the nurses, naturally, would refer patients with hypertension to their general practitioners for treatment. This could be an economic and easy way of providing an important service which would combine convenience for both patients and professional staff.

My Lords, perhaps I may conclude by reiterating my appreciation of the timeliness of this debate. The recent reports to which reference has been made have shown the urgency of the situation in this country where our mortality and morbidity rate compares so badly with those of other nations. If other countries can achieve major reductions, why cannot we? Now is the time for Goverment as well as the professional bodies to take initiatives to reduce this source of human suffering. One example would be to increase support for the excellent work of bodies such as the Coronary Prevention Group at the Central Middlesex Hospital.

There is the additional incentive that the adoption of prevention would not only reduce human tragedy of such enormous proportions, but would also be cost effective It would result in a reduction of the demand on high-cost, staff-intensive resources in the health service and free them for other purposes. Rarely can there be a case so unequivocable in its appeal, combining humanitarian and economic advantage. I look forward to hearing how the Government intend to build on the good work which has already been done in order to help to bring improvements to the United Kingdom comparable to those which have been achieved elsewhere.

Earl Kitchener

My Lords, only the Government, either by the DHSS or through bodies dependent upon the Government such as the Health Education Council, have the resources and authority to publish the best advice on diet. As time goes on, no doubt better information will become available but it is six years since the working party set up by Sir Keith Joseph reported that there was an urgent need for simple and accurate information on nutrition. I hope that the discussions stimulated by the 1983 Report of the National Advisory Committee on Nutrition Education and by the two reports that we are discussing this evening will crystallise into practical recommendations. The second of these committees actually constructed diets but did not publish them lest they should be taken as recommendations which, they say, are needed but should be made by other bodies.

Our instinctive choices of food have been evolved to enable us to distinguish between, for example, ripe and unripe fruit; but that does not help us with food which has been through many manufacturing processes. This is where informative labelling, on which much has been done and which involves little interference by the law, is valuable. Apart from any legal requirement, the man who can put "no added sugar" on the label has a good chance of attracting at least my custom.

I regret that I shall have to leave shortly, but I shall of course read with interest the Minister's reply to this interesting debate.

9.50 p.m.

Lord Ennals

My Lords, I should like, with other noble Lords, to thank my noble friend Lord Rea very sincerely for enabling us to have this debate and for so much expertise which came from the noble Lord, Lord Colwyn, and the noble Baroness, Lady Cox, as well as from those of us laymen who threw in such good advice as we possibly could. I was delighted to see that the noble Baroness lists among her hobbies hill walking, and she will note that I list among mine camping, which implies the same. I shall state my own personal interests first. I do not smoke. As a result of the wisdom of my wife and the advice of the Coronary Prevention Group, at home we have only skimmed milk, wholemeal bread, no sugar, salt substitute and fibre-rich carbohydrates. I do not get enough exercise and thus I am marginally overweight. Both my parents lived well into their 90s, and so I reckon I have another 30 years or more in your Lordships' House, but I could he proved wrong.

When I was Secretary of State for the Social Services from 1976 to 1979 it was frankly impossible to get an agreed conclusion from the panel of the Committee on Medical Aspects of Food. The reason why my noble friend Lord Prys-Davies needed to complain because there were only three pages in Prevention and Health, published in 1976, was that they simply did not agree. It was not through any lack of trying on behalf of successive Secretaries of State, and certainly no layman can say "This is what ought to be done: this is what the experts say", when the experts say different things.

Thus, I warmly welcome the clarity and unanimity of the COMA report, as well as the great wisdom in advance of it from the Coronary Prevention Group to whom tribute has already been paid. Certainly, coronary heart disease today places an enormous burden on the nation in both human and economic terms. The Parliamentary Under-Secretary of State for Health and Social Security, Mr. John Patten, speaking in the Adjournment Debate in another place on 16th July. reminded us that in 1982, the most recent year for which we have figures, coronary heart disease claimed over 155,000 lives in England and Wales, and that is regardless of Northern Ireland and Scotland. Coronary heart disease is the commonest cause of death among the middle-aged, and also it causes the loss of about 30 million working days a year in England alone. It has been said by my noble friend that about 7,000 National Health Service beds are at any one time occupied by patients suffering from this condition or various forms of it, at enormous cost.

As the report says in paragraph 3.1.5, the United Kingdom has not yet experienced the dramatic declines in mortality from coronary heart disease enjoyed by a number of other countries. I would quote the United States, Canada, Australia, New Zealand, Belgium, Finland. As a result, the United Kingdom's position in comparison with other countries is increasingly conspicuous. In a world ranking of mortality from coronary heart disease in 1978, countries of the United Kindom occupied three of the top five positions for men and two of the top five positions for women. I wish the same could apply at the Olympics, but I cannot guarantee that.

We have the problem that an increasing proportion of victims are, of course, not the old aged, but those under the age of 65. Many of them are in their 40s and 50s and it is simply not good enough for the sceptics to say, as some do, "Well, you've got to die of something". That is true—one has to die of something; none of us is going to live for ever—but there is no reason why we should die of conditions which we ourselves can prevent. Smoking is a very obvious example, and diet is another obvious example. We largely have control over what we eat, provided that we know what it is that we eat. That is why the noble Baroness's point about labelling is so important.

We have had to wait a long time for a set of clear conclusions and detailed recommendations. No Government can base policy on "hunches". They have to have it written down with clear conclusions—and now the Government have this. We have a series of positive proposals, and we certainly must do everything in our power—Government, individuals and organisations in which we may be involved—to assist in carrying through these recommendations.

The conference in Canterbury in September 1983, which has been referred to by several speakers, was convened by the Coronary Prevention Group, again, with the very important role of considering practical ways in which the World Health Organisation's recommendations on the prevention of coronary heart disease could be rapidly implemented in the United Kingdom. They reached the conclusion that a national strategy for the prevention of coronary heart disease should now be established. That is absolutely right. All the organisations involved need to get together with various Government departments and state the objectives and targets which are sought by various organisations and the interest groups that influence, directly or indirectly, the major risk factors.

In addition to policy statements, specific programmes will need to be developed for smoking control, healthy nutrition and exercise promotion; and, following careful economic assessment, sufficient resources will need to be made available. And when we say that, we realise that prevention is in fact cheaper than cure. The document which was referred to by my noble friend Lord Prys-Davies in a sense began the series on prevention, and it pointed out that the responsibility lay on individuals themselves.

The noble Baroness referred to the fact that many health authorities already have very practical policies. Some of them were undertaken well before the COMA report came in. They took advantage of the NACNE report, and certainly my noble friend's references to Brent were, I think, absolutely fascinating. I hope we can have placed in the Library the report of the Brent Health Authority about the way in which they have gone about their task, to the great satisfaction of patients, of administrators and of those who control the money bags, because they can do more with their money.

We also have to look at the role of the Department of Education, because, as has rightly been said, this is a matter where problems start in school. One of the welcome aspects of the COMA report is that it has gone beyond general conclusions. It gives clear, quantitative guidelines for the level of total fat in our diet, and that is what was needed. Generalisations are not enough. They have spelt it out and have said what is reasonable in total fat and what reductions we need to make in terms of saturated fat. To help the general public achieve the desired target, the report recommends: One way of doing so would be by partial substitution of polyunsaturated fats for some saturated fats. COMA's call for clear labelling of the type and amount of fat in food products is absolutely vital to help people make an informed choice. Their recommendation that manufacturers should make efforts to introduce low-fat alternative products is welcomed.

There is no doubt that the Government will have to involve themselves in very intensive discussions with the food industry, not in order to create antagonism there, because we are all going to continue to need to eat. There is not going to be a collapse of the food industry; but there does have to be an adjustment in the food industry, not only in the food they produce but in the information they give us about what they expect us to buy. I hope there will be increasing consciousness among the public and among parents, so that instead of just taking what is cheapest, what looks best or what has the best packaging, we will actually work out our diet and buy the things that we know are needed for us as individuals.

Also, we must surely support COMA's recommendation that there should be a substantial increase in fibre-rich carbohydrates to compensate for the reduced fat intake, and that this should not involve any increase in the levels of salt or sugar. The report therefore places particular emphasis on the responsibility of food manufacturers to review their current processing practices. These recommendations are broadly in line with those set out in the report by the National Advisory Committee on Nutrition Education, which was published in September 1973.

COMA also highlights a new recognition by the Government's experts of the need to deal with the population as a whole—all of us, all who buy, all who eat, all who plan, all who educate, and not just a selected sub-group which they deem to be especially at risk. In fact, we are all at risk. The fact that my parents lived to a ripe old age does not mean that I will live to a ripe old age. If all my good habits are thrown away in riotous living with booze and smoking, I shall be in trouble. But it will not happen.

We now have before us an excellent set of guidelines for a healthy lifestyle for every one of us, including your Lordships, and so we owe a very great debt of gratitude to the panel for being so specific. It is not a document for the public. It certainly makes recommendations to the public, but not in a way that they would understand, because it is not popularised. That has to be done through the Health Education Council and through publicly prepared material being made available. It gives advice to GPs, to those responsible for health education, to producers, manufacturers and distributors of food and drink, to caterers and, of course, to the Government and the National Health Service itself.

Perhaps most importantly, as I have already mentioned—after achieving a public awareness of what is healthy and what is unhealthy in our diet, which will be a very difficult business—I have a great fear. I have always said to Governments that they have constantly to step up their campaign against smoking. The fact is that the message takes years to get home. But it is a tragic fact that smoking is very largely a working-class habit, shared by Government Whips. The working-class, Government Whips in your Lordships' House, and nurses are some of the main culprits. It may be that it is the same, too, in terms of coronary heart disease. The fish and chips factor, the packaged food factor, is all part of the failure to recognise what is good for us and what is not good for us. So we shall have to involve ourselves.

My final point is that we need to have a campaign. We really must have a national, centrally organised, vigorous and energetic campaign to achieve changes. I happen in the last couple of weeks to have been involved in two little successes in campaigning for health. One was to persuade the Government to require child-resistant closures for a range of highly poisonous household substances. I had to campaign for that for two years and set up a working party, but finally the Government have agreed. They are a sensible Government in that one respect. Secondly, I have persuaded the EEC to extend its school milk subsidies to fluoride milk for dental health. I was able to announce this on Monday. Until now, they have refused to do so. I believe that this will improve dental health. The noble Lord, Lord Colwyn, is shaking his head. Perhaps he does not want dental health to be improved, because he will have fewer customers. That is a possibility, but I cannot believe that it is really in his mind.

In a sense, we have to fight a battle, as we did with seat belts. I do not mean that we will have to make diets compulsory. But it took years and years to get the seat belt law through, and it was achieved only as a result of vigorous campaigning. So there is no doubt that we need to have an intensive and sustained campaign to secure the implementation of the COMA report and for this we must, inevitably, look to the Government for leadership.

10.5 p.m.

The Earl of Caithness

My Lords, we welcome the report entitled Coronary' Heart Disease Prevention—Plans for Action, otherwise known as the Canterbury Report. It is an important source of information about ways of implementing advice expected to reduce the risk of coronary heart disease. As we have heard, this disease is a major cause of deaths in the United Kingdom—deaths which can be prevented.

Obviously it is highly desirable that there should be increasing public awareness and discussion of the ways in which the risk of coronary heart disease can be diminished. It is not the least of the Canterbury report's merits that it has stimulated public discussion about the risks and the remedies, and will continue to do so, thereby assisting the Government's own efforts for the prevention of heart disease and of ill-health in general.

Prevention is a primary object of the Government's policies. I can confirm, in particular to the noble Lord, Lord Prys-Davies, that we take this matter very, very seriously. Care in Action, our handbook of policies and priorities for the health and social services, makes this, and the need for the promotion of good health, absolutely clear. Apart from encouraging and supporting preventive action by health authorities and the Health Education Council, the Government act directly to foster health education and prevention and to provide information and scientific evidence on health education and preventive matters.

There is evidence to suggest that lifestyles which include smoking, unwise drinking and eating habits, and lack of exercise can increase the risk of various ailments, including coronary heart disease. In 1981, as a preventive measure we published the Prevention and Health series booklets, referred to by the noble Lord, Lord Prys-Davies. These included Avoiding Heart Attacks and Drinking Sensibly, and in 1982 we issued a fourth impression of an earlier booklet in the same series, Eating for Health.

The noble Lord, Lord Rea, to whom we owe a debt of gratitude for introducing this debate, mentioned cigarette smoking as an important cause of coronary heart disease, particularly at younger ages. The Royal College of Physicians in their recent report Health or Smoking attribute 20 per cent. of all coronary heart disease deaths to smoking. This report was discussed at length in your Lordships' House on 13th June, and my noble friend Lord Glenarthur then made clear the Government's position. I would recap on part of what my noble friend said by stressing that the Government and the Health Education Council continue to draw attention to the link between smoking and heart disease at every opportunity, using publications such as Avoiding Heart Attacks and the council's booklet Beating Heart Disease which both advise about the dangers of smoking. I would mention that the large budget tax increase is just one example of where direct Government action has taken place.

The Government are also concentrating particularly on discouraging children from taking up or continuing this habit. We have sent a leaflet to all schools. Furthermore, we have announced guidelines agreed with the retail associations and designed to cut down on the sales of cigarettes to children. The Health Education Council, which is funded by the Government, last year spent £700,000 out of its budget of over £9 million on an anti-smoking campaign directed at young people. The noble Lord, Lord Ennals, will be pleased to hear that in February of this year we gave the HEC an additional £500,000 for its anti-smoking activities. In this, and other work, the council co-operates with the media, using newspaper, TV and cinema advertising. For example, the council produced a booklet for use with a recent radio series and a recent TV series by the BBC. This lists foods showing the proportion of fat in each and offers practical advice on life styles.

The HEC's other campaigns continue to highlight the dangers and risk factors of coronary heart disease. The council's impressive Look After Yourself campaign on eating, drinking and taking exercise sensibly stresses, among other things, the value of a sensible diet. The free campaign booklet includes a simple diet guide which is reinforced by distributing weight charts to the public and through district health authorities and local authorities.

The council continues to develop its efforts in these fields and is considering an extension of the successful campaigns. All this is reinforced by the work done by health authority health education units—as mentioned by my noble friend Lady Cox—community doctors, dieticians, health visitors, teachers and many others, not least of all the nurses. I will certainly ask the Brent Authority to make available a copy of its report so that I can place it in the library.

These are just a few examples of the Government's commitment. The history of the Canterbury report itself provides another example of that commitment. The report was based on the proceedings of a workshop conference on the prevention of Coronary Heart Disease held in Canterbury last September. The conference was sponsored jointly by the Health Education Council, the British Cardiac Society, the Coronary Prevention Group, the DHSS and the other United Kingdom health departments. A wide range of other professional bodies also agreed to be cosponsors. The report was published in April and launched at a conference attended by the Government's chief medical officer, who welcomed it. The noble Lords, Lord Rea, Lord Prys-Davies and Lord Ennals, asked me what was the Government's reaction to the number one suggestion. I reply by saying that there is general agreement that the problem needs planned action and not impulse reactions from time to time. It is for that reason that we are giving the report to the Royal College of Physicians who are to convene a meeting soon to discuss the way forward. I am pleased to be able to report that the Department of Health will be represented at that meeting. We will then, without any further delay, see what we can do to take the matter a stage further.

In particular. the noble Lord. Lord Prys-Davies, suggested that there ought to be a sub-department within the Department of Health. I am glad to tell him that there is already such a group; we have already done that; we have beaten him to it. There is a small group within the DHSS responsible for taking an overview and linking with other Government departments, and I know that they will be taking note of the points raised tonight.

I turn now to the second part of the Question of the noble Lord, Lord Rea, which raises the issue of the link between diet and cardiovascular disease. On Thursday 12th July, the Government published the report on the relationship of diet to cardiovascular disease which was presented last month—15th June—to the Chief Medical Officer's Committee on the Medical Aspects of Food Policy (COMA), by an expert panel set up by COMA and which in 1982 began to review all the latest available scientific evidence on diet and heart disease. The Government are committed to increasing the amount of scientific knowledge on nutrition, diet and health and making the most up-to-date scientific information on these matters widely available in an easily understood form so that people can decide for themselves what they should eat in order to reduce the risk of illnesses that may be related to unwise eating habits.

The COMA Panel report on the significance of the relationship between nutrition and cardiovascular disease is based on the available scientific evidence. This includes the evidence and research findings produced in the course of the 10 years since an earlier COMA panel reported on diet and coronary heart disease in 1974. The Government do look to COMA for independent scientific advice on diet and health and the effects of unwise eating habits—for example too much fat or salt. Many theories about these matters are being advanced and we have to recognise that medical and scientific knowledge about the relationship between diet and health is incomplete. For that reason I do agree with the noble Lord, Lord Ennals, and I am sure that the entire House agrees, the government policy must be based on sound advice rather than unsubstantiated theories. It is for that reason that we have been awaiting the COMA report before attempting to develop our initiatives in the very complex field of diet and health. The COMA panel itself acknowledges that the evidence about the effects of fat in the diet falls short of proof. But nevertheless the panel concludes that it is more likely than not that the incidence of coronary heart disease will be reduced, or the age of onset delayed, if we reduce certain fats in our diet.

The report was welcomed on behalf of the Government not only by my right honourable friend the Secretary of State, but also by my right honourable friend the Minister for Agriculture, Fisheries and Food. My right honourable friend the Secretary of State has announced that the Government are giving this report to the British Nutrition Foundation and to the Health Education Council, with a request that they ask their Joint Advisory Committee on Nutrition Education—known as JACNE—to turn the scientific evidence in the report into practical guidance on a sensible, healthy diet for families throughout the United Kingdom. The Government also want to discuss with the relevant medical bodies how best to take forward the report's recommendations about special dietary advice for people most at risk.

Although this Government have, quite rightly, played an important role, much of the responsibility for a healthy lifestyle must rest with the individual. Government action must centre on making available advice about the effects of diet on health and information about what is in the foods that we buy.

The noble Lord, Lord Rea, and my noble friend Lady Cox asked what advice the Government are giving with regard to school meals. The Government, on the advice of COMA, have commissioned a survey on the diets of school children. We expect to have some preliminary results in the next few months and appropriate advice will be forthcoming in the light of these findings.

We hope that JACNE, under the chairmanship of Dr. John Garrow, an expert in obesity, who is a member of COMA and who was recently appointed to membership of the HEC by my right honourable friend the Secretary of State, will soon start to translate the scientific advice in the report of the COMA panel into suitable messages for the public, for those working in the NHS, and for all those concerned in this field. In other words, as the noble Lord, Lord Ennals, said, he will popularise it, because the report is fairly full of scientific detail and formulae.

For the Government's part, the United Kingdom health departments and the agriculture and food departments have already set up a working party with the food industry to study the feasibility and practicality of fat-content labelling of all foods. I take the point of my noble friend Lady Cox that we want to make this as intelligible as possible. With regard to the effect on farmers, if there is to be a change in the diet of people in this country, from my knowledge of farmers, I should say that this is a challenge to which they would readily respond and they would not see it as a hindrance to their work.

The noble Lord, Lord Rea, asked what specific action the Government will take on the production of leaner carcases and on common agricultural policy. It is too early to be specific, but the Government are confident of full co-operation from both the food and agricultural industries in the consultations that will be needed. I hope that noble Lord will bear in mind that we have 10 members of the EEC, and such consultations may take a little longer than would getting our own house in order. A number of other points were raised. The noble Lord, Lord Rea, asked also whether the Government will take the initiative with GPs in establishing programmes to detect hypertension. There are a number of interesting initiatives already under way. For example, in Oxford a health visitor is employed by the health authority to visit GPs and help them develop such a service. The forthcoming Green Paper on primary health care will have projects of this kind in mind.

I take the point of my noble friend Lady Cox about community nurses. At the moment, a lot of work is being done by general practitioners but unfortunately people generally are not aware that they may have high blood pressure. However, when they visit their GPs, there is an opportunity for them to take a test at that time.

In conclusion, I should like to thank the noble Lord, Lord Rea, for raising this important subject. I should like to thank all noble Lords who took part, and although it may be wrong to single out my noble friend Lord Colwyn, I will do so. He was far too modest. He has much experience and a great knowledge of his subject. I will put his very detailed speech in front of experts far more knowledgeable in this subject than I am. I can tell him that I have just received confirmation that EDTA does have harmful effects, so I am sure that this point will be looked at very carefully tomorrow.

I believe that I have said enough to show that the Government are deeply committed to prevention policies and their implementation. We want to ensure that every health authority plays its part and the regional review system which we instituted recently includes looking closely at local prevention policies and goals. Therefore, we welcome the Canterbury report and everything that assists the campaign to reduce the risk of coronary heart disease and ill-health in general. We also welcome the COMA report and look forward to receiving the results of the extensive consultations we are making and the resulting practical guidance for a healthy diet. With the help of these and good response from individuals, we look forward to a continued improvement on the current position.