It's never too early to start looking after your heart. It's never too late, either. February marks national heart month, so it's a good time to reflect on what the research can tell us about how to stay "heart healthy".
Coronary heart disease (CHD) was the biggest cause of death in England, accounting for nearly 60,000 of the total 466,800 deaths in 2012 (about one in seven deaths in men and one in ten deaths in women). And it's the top cause of death for people under the age of 75. Most of the risk of heart attack is down to a few risk factors that are potentially modifiable: in other words, we can do something about them - as individuals and as a population. These factors include smoking, obesity, a poor diet, high cholesterol and blood pressure, as well as physical inactivity.
The good news is that the death rate from heart disease has fallen dramatically since the 1980s, and in England, in the under-75s, it's down by 40% over the past decade. There are a number of reasons why we think this has happened, but it's a complex picture, which shifts over time. So for example, it's been calculated that the biggest single contribution to the reduction in heart deaths during the 1980s and 1990s was the fall in smoking (other important influences were improved management of cholesterol and blood pressure as well as improved cardiological treatments).
But for more recent falls in CHD mortality, other things seem to have had more of an impact: medical therapies, for instance, with the increased uptake of drugs such as statins and ACE inhibitors, as well as improved blood pressure in the general population - thought to be linked to falling intakes of salt. Even more recent evidence suggests that England's 2007 smoking ban has also had an impact on reducing heart attacks.
The history matters because it can help us to understand how we can focus our actions to save the most lives in the future. And this is where the bad news comes in. There's added pressure to act because there are trends underway now that risk undermining future improvements in heart disease.
Some of this is beyond our control - such as an ageing population. But there are things that can be done about the rise in diabetes and the high rates of obesity and excess weight, whichexperts warn could erode the health gains we're aiming for in heart disease.
The earlier we start, the better, because it's easier to protect our hearts in later life if we develop healthy lifestyles that reduce the risks of cardiovascular disease - the family of diseases that affect the heart and blood vessels that make up our circulatory system.
That's one of the reasons why preventing, and tackling, obesity in childhood is so important. In England, 18.9% of 10 to 11-year-olds were classified as obese in 2012-13, according to data from the National Child Measurement Programme. That's a bit better than the previous year, but still higher than in 2006-07.
One of the worrying things about childhood obesity is the way it can persist into adulthood. And we know that obesity in adulthood is harmful in many ways. First, it increases the risk of cardiovascular disease. Second, it also increases the risks of high blood pressure, raised cholesterol and diabetes, which are also, in themselves, risk factors for cardiovascular disease.
There are no short-cuts or silver bullets. We need to support children to eat a healthier, balanced diet (currently less than one in five in the UK eats the recommended portions of fruit and vegetables every day), both in and out of school. We need to encourage families to make those small improvements to their diets, which add up over time.
We also have to get more kids moving, more often and for longer, especially girls, who are less likely than boys to be active. The graph below shows how wide that gap becomes in teenage years.
Source: Joint Health Surveys Unit (2010). Health Survey for England 2008: Physical activity and fitness. The Information Centre: Leeds.
As our children grow into teenagers, there are some new challenges to add to the existing ones of diet and exercise. The good news is there's been a fall in the percentage of teenagers who say they've consumed alcohol in the previous week. Teenage smoking is down as well. It's hard to overstate how crucial this is: about two thirds of adult smokers report they took up smoking before the age of 18. So we have to maintain the momentum of positive trends.
And when these teenagers become adults, how can we do an even better job of protecting them from cardiovascular disease? Health campaigns can help people to change unhealthy lifestyles, and now there's the potential to harness the power of social media and technologies, from smartphones to apps, to make change both fun and relevant. Last year's Stoptober (Public Health England's smoking cessation campaign) was a big success with 250,000 registrations and almost 50,000 new fans on social media.
Individuals can only do so much, though, if they live and work in unhealthy environments. That's why PHE argues that these broad influences also have to be addressed, from how we plan our towns and our transport system, to how employers promote staff health and how our national diet can be improved - by reducing salt in the manufacture of foods, for example.
But there's also an extra challenge: many people - millions in fact - may be at increased risk for cardiovascular disease and not even know it, let alone be in a position to do something about it. For example, there are over 5m people in England who it's thought have undiagnosed hypertension - around 40% of the total expected number. It's estimated there are more than 3m adults with Type 2 diabetes in England, of which around 500,000 have not been diagnosed. These are people who are at greater risk than the general population of developing heart failure, heart attack, stroke and chronic kidney disease.
That's why PHE is leading the NHS Health Check programme, which flags up risks such as high blood pressure and cholesterol as well as lifestyle risks - such as alcohol, poor diet, obesity - in a systematic and co-ordinated way for 15m adults between the ages of 40 and 74. Early estimates suggest the programme could detect at least 20,000 cases of diabetes or kidney disease earlier and could prevent 1,600 heart attacks and strokes, on average per year. It's also why PHE, together with partners, will publish an action plan for preventing, detecting and controlling high blood pressure, and is developing a new health campaign.
Programmes need good intelligence, and PHE's national cardiovascular intelligence network provides the resources - from data to emerging evidence - that help local public health leaders to understand the health profile of their communities and target their efforts accordingly.
These are ambitious programmes; not just because they are aiming to improve the country's record on preventable diseases but because they're also targeting inequalities. As the chart below shows, the death rate from cardiovascular disease is higher the more deprived you are, especially if you're a man. Improving the country's cardiovascular health should help to narrow this gap.
Mortality rate from the big killers across deprivation quintile
Source: Office of National Statistics, Under-75 DSRs per 100,000 population
But what if you're not in middle age? What if you look at the laundry list of behaviours and medical conditions and wonder what you can still do, in your 70s and beyond, to improve your chances of overall health - including cardiovascular health? The evidence is still emerging, but a recent study has found that being physically active, for example, is associated with improved healthy ageing.
In other words, the influences on cardiovascular health are wide-ranging. In fact, they may start far earlier than one would imagine: a recent paper has reminded us just how early by suggesting that early fetal life may be critical period for cardiovascular health later on; and they appear to extend right through to our last decade. A healthy heart is an investment in our wellbeing, and it's the work of a lifetime.