Metcalf et al, in their article in this issue of the Journal on changes to cardiovascular risk factors,1 provide us with a rich database of changes in traditional risk factors from 1982 in a European population in Auckland. Regrettably, however, there are no comparative data for Māori or for individuals >74 years of age—the two groups in which the greatest morbidity and mortality due to cardiovascular disease (e.g. heart attack and stroke) resides.2,3

Clearly these data are of immense value and it is important that they be followed up with further reports. Furthermore, across New Zealand, similar data on rural communities as well as diverse socioeconomic and ethnic groups are needed—e.g. Pacific people (mostly of Samoan, Tongan, Niuean, or Cook Islands origin) and Indians from the Indian subcontinent.

There is lots of good news. The systolic blood pressures fell and more patients with hypertension were treated. Cholesterol levels fell, HDL cholesterol levels rose, and more patients were on statins. Pleasingly there were increases in the number of young people reporting leisure-time physical activity.

However there is also bad news in relation to smoking, obesity, and diabetes, which is concerning. Previous documented smoking trends over time have halted and it is notable, for example, that men aged 35–44 years have had no change in smoking rates (with 19% still smoking since 1986), and in women and men in other age groups (apart from 67–74 year olds) there has been little change from 1993–1994.

Smoking regulations have proven to be very effective and we can do more. For instance, a recent Italian study showed a significant reduction in the numbers of admissions with heart attacks from a 5-month period before an introduction of a ban on smoking in all indoor public places compared to admissions 5 months after the ban.4 This equates to an 11% reduction in heart attacks by this simple measure to reduce passive smoking. The rate of fall in smoking rates levelling off, as shown by data from the Auckland study, calls for stronger measures to be taken in New Zealand—e.g. banning the sale of duty free cigarettes and completely banning smoking in public places.

This is a long way from the current situation in New Zealand, and such an approach may appear draconian to many, but it may not appear so in the future. Even today, in the small Himalayan country of Bhutan, tobacco smoking and the sale of tobacco are completely banned.

The Auckland study’s report on increasing obesity and diabetes trends are alarming; overall, since 1982, men increased their body mass index (BMI) by 6% and women by 9%. Indeed, approximately a quarter of men aged 45–54 years and women 55–74 years are now obese (BMI>30). And the percentage of individuals that are overweight (BMI>25) or obese is now 71% for men and 57% for women.

Self-reported diabetes rates have more than doubled in men (2.1% to 4.5%) and gone up by 92% (2.5% to 4.8%) in women since the 1986 survey. These increases in obesity and diabetes may explain the worrying trends for increasing rates of cardiovascular disease that are now being seen in New Zealand.5

The ratio of waist circumference to height is a strong predictor of intra-abdominal fat,6 and abdominal obesity is regarded as being a better predictor than overall obesity for the risk of cardiovascular disease and type 2 diabetes.7 Unfortunately waist circumference measurements were not measured in the current study and nor were risk factors reported in individuals under the age of 35 years.

If we are really going to do something about prevention, we need to know what is going on in younger New Zealanders. Recent studies in US children and adolescents aged 2–19 years8 have shown increases in waist circumference from 1999–2004 of 3.7 cm in both sexes. There has also been an increase in abdominal obesity (defined as >90th percentile value in 2000–2002) by 65.4% in boys (10.5% to 17.4%) and 69.4% in girls (10.5% to 17.8%). Intuitively, although we don’t have the information, we can assume this is also happening in New Zealand.

The current report also makes little of socioeconomic status. It is well known that socioeconomic status affects cardiovascular health.9 Although the comparative populations in the Auckland study had the same median socioeconomic status score of 3 [on a scale of 1 (poorest) to 10 (richest)], it is possible that there have been dramatic changes within socioeconomic groups—e.g. cardiovascular risk improved in higher socioeconomic groups and become worse in lower socioeconomic groups. It would be interesting to see further analysis of these data, which could help targeting of prevention programs to groups likely to benefit most.

The findings from this study by Metcalf et al are striking and require urgent action. It is imperative that a public health approach is taken to modify the effects of the current obesity epidemic.

The use of prominent athletes to promote salads and healthy foods in fast food outlets, which also sell high fat and high calorie foods, will of course result in customers bypassing the salad bar and consuming the non-cardioprotective foods. Such brand endorsement by national icons is very reminiscent of the previous use of All Blacks and Olympic gold medallists in the 1960s to promote the sale of cigarettes.

The athletes should not be blamed, but this advertising should stop. There should be restrictions on the availability of high sugar and high fat foods in schools and also restrictions on advertising promoting obesogenic diets. Action is needed now.

Author information: Harvey D White, Professor and Director of Cardiovascular Research, Green Lane Cardiovascular Service, Auckland City Hospital, Auckland

Correspondence: Professor Harvey D White, Director of Cardiovascular Research, Greenlane Cardiovascular Service, Auckland City Hospital, Auckland 1030. Fax: (09) 630 9915; email: harveyw@adhb.govt.nz

Acknowledgements: I thank Charlene Nell for her excellent secretarial help.