Download Preventative Health Care

Preventative Health Care
By: Raymond Lengel, MSN, FNP-BC, RN
Purpose: The purpose of the educational program is to present a summary of
how prevention can improve health care. The impact of preventative health care
on the quality and quantity of life will be discussed. Interventions to improve
preventative health care will be discussed to help the individual health care
provider improve their practice. The course will utilize Healthy People 2010 as a
framework to discuss quality preventative health care practices.
Objectives
1. Discuss the impact chronic disease has on the American health care
system as well as individual patients
2. List three benefits of preventative health care
3. Discuss the impact physical inactivity, poor nutrition and smoking have on
health
4. List the two major goals of Healthy People 2010
5. Discuss three lifestyle interventions that will reduce the risk of chronic
disease
6. List 10 areas of focus of Healthy People 2010
7. List three interventions to reduce the incidence of musculoskeletal
diseases such as arthritis and osteoporosis
8. Discuss the different screening tests for cancers
9. List three interventions to reduce the incidence of chronic kidney disease
10. Discuss steps to reduce the incidence of diabetes
11. List five diseases attributed to the environment
12. Discuss two goals of Healthy People 2010 for family planning
13. List three strategies to reduce the impact of food borne illness
14. List five risk factors for cardiovascular disease
15. Discuss three strategies to reduce the incidence of sexually transmitted
diseases
16. Discuss the impact of immunization on infectious diseases
17. Discuss strategies to reduce violence
18. Compare and contrast methods to reduce the impact of depression and
anxiety
19. Discuss the impact obesity has on health
20. List three strategies to improve occupational safety and health
21. Discuss the role of the health care provider in improving oral health
22. Discuss the development of a physical activity and fitness program
23. Discuss the impact of respiratory diseases on the health of America
24. Discuss the impact of toxic substances such as tobacco and alcohol on
health
Outline
I.
Introduction
II.
Risk factors
III.
Preventative health care
IV.
Healthy people 2010
V.
Access to quality health services
VI.
Arthritis, osteoporosis and chronic back conditions
VII.
Cancer
VIII.
Chronic kidney disease
IX.
Diabetes
X.
Disability and secondary conditions
XI.
Education and community-based programs
XII.
Environmental health
XIII.
Family planning
XIV.
Food safety
XV.
Health communication
XVI.
Cardiovascular disease

Coronary Heart Disease

Heart Failure

Stroke

Peripheral Vascular Disease
XVII. Human Immunodeficiency Virus
XVIII. Immunization and infectious diseases
XIX.
Injury and violence prevention
XX.
Maternal, infant and child health
XXI.
Medical product safety
XXII. Mental health and mental disorders

Depression

Eating Disorders

Schizophrenia

Eating Disorder
XXIII. Nutrition and weight control
XXIV. Occupational safety and health
XXV. Oral health
XXVI. Physical activity and fitness
XXVII. Public health infrastructures
XXVIII.
Respiratory diseases

Asthma

Chronic obstructive pulmonary disease
XXIX. Sexually transmitted diseases
XXX. Substance abuse
XXXI. Tobacco use
XXXII. Vision and hearing
XXXIII.
Conclusion
Life expectancy significantly increased from the beginning to the end of the
20th century, partly due to the improvement in the prevention and treatment of
infectious diseases. Improvement in sanitation such as improved drinking water
and waste disposal were other large factors contributing to the increased life
expectancy.
If humans are going to continue to see this increase in life expectancy, the
21rst century is going to need to improve the prevention and treatment of chronic
disease. Preventative health care, when practiced properly, has the potential to
save billions of dollars, increase quality of life, improve work productivity and
extend life.
American health care is focused on acute care, with individuals spending
most of the health care time managing acute problem instead of working to
improve health through preventative health care. Preventative health care
involves effort by both individuals and the health care system as a whole. Health
care consumers must assume the responsibility for eating well, exercising, not
using toxic substances and maintaining a healthy weight. The health care
system must make resources and information available to individuals to practice
good preventative health. This synchronized effort has the potential to reduce
the impact of chronic disease and enhance quality of life.
Each year 1.7 million Americans die from chronic disease which is
approximately 70% of all deaths1. Heart disease, stroke, cancer, chronic
obstructive pulmonary disease and diabetes are 5 of the 6 leading causes of
death2. Controlling these five diseases – which can all be accomplished by good
preventative health care - has the potential to significantly improve morbidity and
mortality.
Quality of life is significantly affected by chronic disease. It can cause
physical or mental disability or even lead to a financial ruin. Chronic disease
causes restrictions in activity for ten percent of Americans1. Preventative health
care and preventative health practices can reduce this disability.
Quantity of life, simply defined, is how long one lives. While quantity of life is
a sought-after goal it does not mean much without quality of life. Most individuals
would choose to live 10 more years doing activities that they enjoyed, such as
travelling, dining out, and playing with family and friends instead of living 20 more
years if they were confined to a bed.
Risk Factors
Certain risk factors put individuals at risk for chronic disease that are
modifiable with good preventative health care. For many diseases there are risk
factors that are not modifiable such as age, gender and genetics. The focus of
this course will be to look at risk factors that are modifiable. Obesity, tobacco
use and physical inactivity are three activities that significantly increase the risk
of chronic disease.
Certain risk factors pop up regularly for a number of diseases. Controlling
these risk factors have the potential to significantly reduce the impact of the most
common chronic diseases and therefore has the greatest impact on health and
quality of life.
Risk factors that are most important to target are smoking, obesity, poor diet
and physical inactivity. Each year at least 4.9 million people die from tobacco
use, 1.9 million die from physical inactivity, 2.6 million die due to excess weight
and 2.7 million die form eating inadequate amounts of fruits and vegetables3.
Preventative Health Care
Preventative health care is a joint effort between the health care provider and
patient. Health care providers are responsible for making recommendations,
providing counseling, performing screenings and sometimes recommending or
prescribing chemoprophylaxis. Health care consumers must practice a healthy
lifestyle that includes exercise, healthy diet and avoiding toxic substances.
Preventative practices are classified as primary, secondary or tertiary.
Primary prevention removes or decreases risk factors before the onset of
disease. Receiving immunizations is one method of primary prevention.
Secondary prevention involves looking for disease early, when diseases are in
their early stages. Typically at this stage, disease is treated more easily. An
example of secondary prevention is routine cervical Papanicolaou screening.
Tertiary prevention limits established disease such as someone participating in a
cardiac rehabilitation program after being diagnosed with established coronary
artery disease.
Lifestyle interventions which will be discussed below in much more detail are
activities that individual patients need to take responsibility for, such as living a
physically active lifestyle, eating a good diet and avoiding toxic substances.
These measures increase the chances of living a long and healthy life.
Immunizations – another component to preventative health care - are the best
measure to reduce the incidence of infectious disease. The routine use of
immunizations in children has significantly reduced, and in some cases
practically eliminated, diseases such as measles, mumps, rubella, and
poliomyelitis.
Preventable adult infectious diseases are not as well controlled. Many cases
of pneumonia and influenza occur in unimmunized adults. Vaccination against
influenza and pneumonia will not eliminate the disease, but it should significantly
reduce their impact. Healthy People 2010 (HP2010) – a governmental program
that looks to reduce the impact of disease and improve health - has set a goal
that 90% of high-risk adults over the age of 65 should receive vaccination with
the pneumococcal and influenza vaccine. In 2006, only 64% of this population
received vaccination with the influenza vaccine within the last year and 57% ever
received vaccination by the pneumococcal vaccine4.
Screenings identify common diseases and their use is scattered throughout the
HP2010 goals. Examples of screenings include: hypertension screening and
cancer screenings for breast, cervix and colon cancer.
Counseling behaviors – another important aspect of preventative health care includes providing the health care consumer with information in the form of
literature or teaching to improve health. Common areas of counseling are:
smoking cessation, physical activity and diet changes.
Since health care consumers see primary care providers most frequently,
they are typically the ones responsible for the majority of counseling. The busy
primary care provider often does not have time to provide counseling so they
often need to develop a plan to disseminate information to their patients. Using
brief teaching at multiple visits, having follow up appointments to focus on
preventative health care, providing literature are all ways to get information to
health care consumers. A helpful strategy is to have experts in the community
that can help with counseling. It is not possible to teach the diabetic patient all
they need to know about a diabetic diet in a 15 minute office visit. Each health
care provider should have a list of recourse to help with counseling that they can
refer patients out to. Recourses that the clinician should be aware of include:

Registered dietitian

Social worker

Physical therapist

Occupational therapist

Speech therapist

Exercise physiologist

Smoking cessation specialist

Psychologist

Cardiac rehabilitation program

Pulmonary rehabilitation program

Stress management program

Diabetic education
Healthy People 2010
Healthy People 2010 is a government program - preceded by Healthy People
2000, Healthy People and the 1979 Surgeon General's Report – that is meant to
improve health care. It is a nationwide program that is attempting to promote
health and prevent disease. It has 467 objectives broken down into 28 problem
area.
The two major goals of HP2010 are to:

Increase the life expectancy of Americans

Reduce the health disparity of Americans
The remainder of this course will look at each of the 28 problem areas and
discuss some of the objectives under each problem area. Information about
disease process and risk factors under each problem area will be discussed.
HP2010 was designed to improve the health of all Americans. The program
looks to increase years of healthy life by improving care of chronic disease and
improving care of those with mental and physical impairments. In addition it
looks to promote healthy behaviors by increasing physical activity, improving
nutrition, reducing tobacco and substance abuse, reducing the number of
unintentional injuries and improving sexual health. HP2010 strives to protect
health by improving environmental and occupational health. It also looks to
improve treatment and prevention of infectious disease and enhance food and
drug safety. An improved health care system will improve the health of our
nation and HP 2010 wants to improve access to health and dental care as well
as maternal, infant and child health care and family planning.
HP2010 wants to strengthen the community by improving the public health
infrastructure, reducing violent and abusive behavior and educating the
community.
The objectives of HP 2010 are broken up into focus areas which revolved
around increasing life expectancy of Americans and reducing health disparity of
Americans.
Ten leading health indicators are used by the organization to evaluate the
health of the nation. The ten indicators are: access to health care, environmental
quality, immunizations, injury and violence, mental health, overweight and
obesity, physical activity, responsible sexual behavior, substance abuse and
tobacco use5.
The next section of this course will look at each of the 28 focus areas. It will
discuss some of the problems that are being tracked and will include data about
how well Americans are doing in regard to these goals. Understanding some of
the diseases that are trying to be prevented will be highlighted. It will also
provide strategies for each health care provider to help with improving these
goals. Some problem areas will be looked at extensively, while others will be
touched on briefly. Those topics that are applicable to the day-to-day practice of
the practicing clinician will be looked at more closely, while the ones that
evaluate health care policies and have a lot of goals related to changes that need
to be made at the governmental or organizational level will not be looked at as
closely.
Access to Quality Health Services
Quality health care is made up of three dimensions: structure, process and
outcome6. Structure is the basic make up of health care providers and health
care facilities. For example, is the health care provider competent?
The process of medical care looks at if the right things get done in the right
way. For example, was the patient with congestive heart failure treated in the
correct manner?
Outcome is a reflection of the result of health care. It looks at such questions
as: Was disease cured? Was disease prevented?
HP2010 is attempting to improve access to quality health services including:
people having health insurance, patients getting health counseling, patients
having a regular primary care provider and having access to emergency care and
access to long term care.
Health care providers need to know what to do and have time to do it in order
for preventative medicine to be practiced appropriately. There are multiple
barriers to patients having access to quality health care. A major barrier is the
lack of primary care providers as many physicians are opting to enter better
paying specialty fields instead of primary care specialties.
With fewer primary care providers (PCP) it takes more time for patients to get
into see their PCP. Because PCPs have limited time, focus is often based on
acute care issues and prevention is at times pushed to the background.
Lack of health insurance is another factor that contributes to inadequate
health care including preventative services. Approximately, 45 million American
are uninsured. Among those that are insured, many are experiencing increasing
premiums, co-payments and limited choices. Premiums for health insurance
have increased by 87% since 2000 which is significant versus an 18% increase
in inflation and a 20% increase in wages7.
What are statistics showing us? HP2010 has set a goal for all Americans
under the age of 65 to have health insurance. The baseline level (in 1997) of
insurance rates was 83 percent and as of 2006 there has been no change 4.
Counseling is a critical part to quality health care, but it is often lacking.
Health care providers are very busy and often need to take shortcuts just to get
through the day. One area that often gets cut short is counseling. Less than half
of patients receive counseling about diet and exercise, while only 66 percent
receive tobacco cessation counseling. Counseling behaviors fall slightly below
the goal set by HP20104.
Receiving health care consistently is an important part of getting good health
care. Without consistent care, patients are at risk for receiving fragmented health
care services. Fragmented health care services have the potential to result in an
increase risk of getting duplicate health care services or duplicate medication
prescriptions. In addition, it can lead to an increased risk of missing certain
aspects of care. Those who have multiple practitioners following their care have
the potential for one doctor to assume that another doctor already ran a certain
test. In 2006, 83% of adults had a source of ongoing care. The goal for 2010 is
96%4.
Some physician’s offices have wait times of over a couple months to see the
doctor for an initial visit. Delays or difficulty getting health care is another problem
that plagued 12% of health care consumers in 19964. Fortunately, most offices
are able to get established patients in for an acute visit more rapidly. Acute visits
that are not able to be seen at the doctor’s office that day can be taken care of at
an emergency room, urgent clinic or retail clinic.
Because of the difficulty getting in to see health care providers, many patients
neglect preventative health care so they do not have to be hassled by another
doctor’s appointment.
Because of busy schedules some health care providers
do not give preventative medicine enough time in their practice.
Without access to quality health care, the role of prevention is limited.
Individuals are still able to exercise, eat well, not smoke, but they will miss out on
many preventative services. A nation that practices good preventative health
care needs to have a health care system that is high in both quality and
accessibility.
The individual practitioner is limited in his or her role in what can be done to
improve access to care as many of the issues are system issues, but there are
certain things that can be done.

Encourage patients to be responsible for their own health care. Teach
them to track their own health care, know when they had certain tests,
maintain records of those tests and know when the next test is due.

Encourage patients to know their medications and carry a list of
medications with them to all health care appointments.

Encourage patients to have a primary care provider, who they visit
regularly, who coordinates all of their health care.

Teach patients to understand the health care system and how to navigate
the system.
Arthritis, Osteoporosis and Chronic Back Conditions
Arthritis, osteoporosis and chronic back problems are three common
conditions that lead to major problems for many Americans and cost the health
care system a lot of money. This section will provide an overview of these
conditions with a focus on how preventative health care can help manage them.
These conditions lead to activity limitation and disability in many, especially the
older population.
Osteoarthritis (OA) is a common cause of disability. The Arthritis Foundation
approximates that in 2006, 46 million or almost one in five adults are affected by
arthritis or another chronic joint symptom at a cost of 128 billion dollars to the
American economy8.
Joint pain, in arthritics, was experienced by 5.6 percent of the population in
2002 with a target goal of 5.3 percent by 2010. In addition, activity was limited in
37 percent of patients in 2006 with a goal of 33% by 2010. Osteoarthritis
affected 10 percent of the population between the years of 1988-1994. A goal of
8% has been set by 20104.
Osteoarthritis is associated with joint deterioration and abnormal bone
formation. As the disease progresses the cartilage wears out and bone starts to
rub on bone, leading to pain, disability and decreased quality of life.
Osteoarthritis and rheumatoid arthritis are the two most common forms of
arthritis with OA being more common in the older adult while rheumatoid arthritis
is associated with systemic symptoms such as fatigue, fever, anorexia, nerve
damage and increased size of the spleen and lymph nodes. Gout, lupus,
scleroderma and fibromyalgia are other diseases that can affect the joints.
Severe joint disease is associated with many complications including
immobility. Immobility can lead to increased stiffness, deconditioning,
hypertension, hyperglycemia and weight gain.
One of the major factors associated with arthritis is a reduction in quality of life
as pain and immobility can dominate. The lack of physical activity that stems
from the immobility increases the risk of many fatal diseases such as diabetes,
dyslipidemia, hypertension and heart disease.
Causes of Arthritis
Many factors lead to OA, the most preventable type of arthritis. Older age
increases the risk of OA. Females have higher incidence of OA with almost two
times the incidence in people over 659. Obesity is a strong risk factor due to the
excess stress that extra body weight puts on the weight bearing joints.
Repetitive stresses - such stresses put on the joints by runners or assembly line
workers - increase the risk of arthritis. Weak muscles in the legs also contribute
to osteoarthritis. Trauma plays a significant role in the development of OA – as
those with a history of trauma near a joint or a broken bone near a joint are at
increased risk for osteoarthritis. While no specific genetic marker is known in OA
there is a family connection.
Defective cartilage or poorly structured joints
commonly runs in families and can increase the risk of osteoarthritis.
Table 1: Risk Factors for Osteoarthritis9
1. Obesity
2. Age
3. Heredity
4. Trauma
5. Repetitive stress such as those who have played a lot of sports
6. Occupations that have a lot of repetitive movements e.g. assembly line workers,
carpet installers
Signs and Symptoms
The hallmark symptom of OA is pain.
Typical OA pain is worse with
movement and improves with rest.
Pain at night is common, especially as the
disease progresses, and is usually worse after a more active day. Osteoarthritis
commonly affects the weight bearing joints, such as knees and hips, but other
joints commonly affected include the fingers and neck. Stiffness after prolonged
rest is common with this disease. For example, getting out of bed in the morning
or getting up after watching a movie.
Examination may reveal crepitus, reduced range of motion, swollen joint(s) or
pain with movement.
Table 2: Signs and Symptoms of Osteoarthritis
1. Pain in the joints that is worse with movement, improves with rest
2. Common joints: Knees, hips, fingers, neck and spine
3. Usually only one to a few joints
4. Stiffness after prolonged rest
5. Crepitus
6. Decreased range of motion in affected joints
7. Swollen joints
Diagnosis
The diagnosis of osteoarthritis is often made with a history and physical exam.
If in doubt an X-ray is ordered. Joint pain and x-ray changes consistent with OA
and one of the following – age greater than 50, crepitus on physical exam or
stiffness greater than 30 minutes after getting up – are diagnostic of OA.
Laboratory tests do not diagnose OA but rule out any other disease
processes. If there is fluid in the joint, it may be aspirated. This procedure can
help relieve some of the pressure associated with the excess fluid. The fluid is
typically examined under a microscope to help rule out any other diseases that
mimic arthritis.
Treatment
Treatment of osteoarthritis focuses on pain control and maintaining function.
In the near future there may be treatments available to reverse or even cure the
disease process, but at present symptom control is the only option. Treatments
focus on medications and non-medication means to control the pain and
minimize disability.
Non-drug treatment is recommended for first line management as it bypasses
the negative effects drugs have on the body.
Non-drug treatments include:
exercise, nutrition, physical and occupational therapy, heat and cold treatments,
ultrasound, weight loss, magnets and patient education.
Table 3: Treatment for OA
1. Control pain and preserve function
2. Weight loss if indicated
3. Strengthening the muscles
4. Physical/occupational therapy
5. Ice/heat
6. Medicines
to
control
pain:
acetaminophen,
non-steroidal
inflammatory medications and narcotics
7. Topical treatments such as capsaicin and lidoderm patches
8. Joint injections with steroids and artificial joint fluid [Synvisc (Hylan)]
anti-
9. Alternative treatments: Glucosamine, Chondroitin, and SAMe
10. Surgery if symptoms are severe
Prevention
Prevention of OA requires a life long effort. Risk factor avoidance is an
important part to preventing the disease. Maintaining a healthy weight
throughout life is a primary step and maybe the most important. Extra body
weight amplifies the strain on weight bearing joints exponentially. Regular
exercise assists in preserving the muscles and joints and should lessen the risk
of OA. Activities that are associated with a lot of trauma should be avoided such
as contact sports and repetitive running.
Osteoporosis
Osteoporosis is a very common condition after the age of 50 affecting 10
million Americans. Osteopenia - which an abnormal thinning of the bone, but not
as severe as osteoporosis - affects 34 million people10. Those with osteopenia
are at high risk for the going on to develop osteoporosis. These two conditions
cost the American health care system 17 billion dollar annually10.
Osteoporosis is characterized by thin, porous bones. Patients are often
unaware that they are afflicted with the disease – making it a silent disease –
which is one reason screening is so important. The initial presentation is
sometimes a fracture after a minor stress or a fall.
Detecting and preventing this disease is critical because fractures can have
devastating effects on quality of life. Like OA, immobility may result from a
fracture, which sets the body up for many other complications. Many of the
chronic diseases discussed in this course - heart disease, stroke and diabetes –
are more likely to develop in those who are immobile. Fracture can lead to
lifelong disability, sometimes requiring nursing home placement. Some are
never able to walk again while others can walk only with the aid of walking
devices such as a cane or walker.
Any bone in the body can fracture, but in those with osteoporosis the hip,
back and wrist are the most common sites of fracture. Vertebral fractures can
lead to chronic back pain, kyphosis, height loss and death. Constipation, weight
loss and abdominal pain are increased with lumbar fractures while thoracic
fractures can lead to restrictive lung disease.
Certain risk factors reduce bone mass, with most individuals achieving peak
bone mass between the ages of 25 and 30. Prevention of osteoporosis involves
reducing risk factors for the disease. Some risk factors are modifiable and others
are not. It is important to identify risk factors so counseling can ensue and risk
minimized.
The greatest risk factor is age – often during the sixth decade bone loss is
accelerated. Other factors associated with osteoporosis include: genetics,
hormonal imbalance, poor nutrition and decreased physical activity.
Table 4: Risk Factors for Osteoporosis
Non-modifiable risk factors

Personal history of fracture beyond age 50

Female gender

Family history of fracture or osteoporosis

Caucasian or Asian race

Increased age and post-menopausal status
Somewhat modifiable or modifiable risk factors.

Certain diseases: multiple myeloma, inflammatory bowel disease,
depression and stroke

Low, lifetime intake of calcium and/or vitamin D

Cigarette smoking

Low body weight

Excessive phosphorus/protein in the diet

Amenorrhea

History of eating disorders

Physical inactivity

Alcohol abuse

Certain medications: glucocorticoid steroids, proton pump inhibitors,
excessive thyroid hormones, lithium, long-term heparin, certain
anticonvulsants, some diuretics (furosemide [lasix]) and certain
immunosuppressants.
Diagnosis
The best method to screen for osteoporosis is the duel-energy x-ray
absorptiometry (DEXA) scan which measures bone mineral density.
Screening for osteoporosis should be carried out on all women over 65 and
women 60 and older at high risk for an osteoporotic fracture11. Those who meet
criteria for osteoporosis on screening should be treated with alendronate,
risedronate or raloxifene12.
Routine screening for osteoporosis in men is recommended after the age of
7013. None-the-less, testing for the disease may occur earlier if the male had a
previous fracture, if he is taking a medication known to thin the bones, or has a
strong family history of male osteoporosis.
The DEXA scan provides a T-score, which compares bone density to a 25-30
year-old. The average score is 0, which indicates a normal bone density of a 2530 year-old. If the reading is between +1.0 and -1.0 the test is considered normal.
Scores above 0 indicate a higher bone density. When the reading is below 0 the
patient has lower than average bone density when compared to a 25-30 year old.
Osteopenia is diagnosed when a score is between -1.0 and -2.4. Readings less
than or equal to -2.5 are diagnosed with osteoporosis.
Table 5: Criteria for Screening for Osteoporosis10 11 13 14
 Any woman over the age of 65
 Postmenopausal women under 65 with one or more risk factor
 Male over the age of 70
 Postmenopausal women with any fracture
 Vertebral abnormality in a postmenopausal woman
 Follow-up on the treatment of osteoporosis
 Primary hyperparathyroidism
 Those on long-term glucocorticoid steroids
Prevention
Health care consumers need to be educated about the risk factors for
osteoporosis and what can be done to modify those risk factors.
Diet significantly affects the skeletal system. Calcium and vitamin D are the
two primary nutrients responsible for maximizing bone strength.
Supplementation is often needed to meet nutritional requirements. Sun exposure
also helps the body get vitamin D, as the skin and body can change sunlight into
vitamin D. Caution should be used as too much exposure to the sun will
increase the risk of skin cancer and sun damage. Obtaining at least 1000 to 1500
mg of calcium and 600-1000 IU of vitamin D is recommended 10 12 13 15.
Exercise – particularly weight bearing and weight training - is vital in the
treatment and prevention of osteoporosis. Weight bearing exercises include
walking and jogging. Non-weight bearing exercises such as swimming or biking,
while good for over all health, is not as effective for maintaining bone strength.
Weight training improves bone strength. Upper body weight training builds
the bone strength in the upper body, which is usually not addressed with many
aerobic exercises.
Lifestyles that promote good bone health should be encouraged in children,
adolescents and young adults. Bone mass peaks by age 30 and those who
make good choices about bone health have higher peak bone masses. It will
take longer to deplete a bone mass that is full, than it would to deplete a bone
mass that is only half full due to poor lifestyle choices in the younger years.
Table 6: Prevention of Osteoporosis

Eat a diet high in calcium and vitamin D (see table 7)

Perform regular weight bearing exercise

Perform regular weight training

Do not smoke

Do not use alcohol excessively

Screen appropriate patients
Table 7: Foods with calcium and Vitamin D
 Milk
 Milk (Vitamin D fortified)
 Ice Cream
 Liver
 Yogurt
 Egg Yolks
 Cheese
 Cereal (Vitamin D fortified)
 Salt water fish
Chronic back conditions
Back problems are a major cause of disability and reduced quality of life
among many Americans. Chronic back problems can be defined as pain that
lasts more than 7-12 weeks, pain that frequently reoccurs or pain that lasts
beyond the normal time expected16. Back or spine problems cause 13.5% of all
disability in the United States in those over the age of 154. It is the leading cause
of activity limitation in those under the age of 4516. Activity limited by chronic
back problems affects 28% of the population in 2007 with a goal of less than
25%4.
Certain groups of people are at greater risk for low back pain including those
who have jobs that entail heavy and/or forceful lifting and the use of whole body
vibration instruments such as jackhammers. Other risk factors include: obesity,
history of low back problems, lumbar inflexibility, low trunk muscle strength, and
hamstring stiffness16.
What can be done to limit low back pain and the impact it has? Since a
majority of these problems are work related, worksites and individual workers
need to take some responsibility in attempting to reduce the impact of conditions
that initiate or prolong back problems. Worksites can help reduce the physical
demands of work if possible. Developing programs to modify risk factors such as
poor endurance, poor strength, inflexibility and a reduction in body weight, can
help reduce the risk of back injury. Applying ergonomic approaches to work may
reduce the impact of back pain.
Cancer
Cancer – the second leading cause of death in the over 50 population affects many different body systems. In 2005, cancer caused 183.8 deaths for
every 100,000 people. HP2010 hopes to reduce this number by improved
screening, risk factor reduction, early detection and treatment to 158.6 people
per 100,000 in 20104.
Many strategies are available to help in the prevention of cancer. One of the
biggest is to not smoke or if a current smoker – stop smoking. Smoking is linking
to multiple cancers including: lung, oral, throat, pancreatic, stomach and
cervical17. Primary care providers do not do a great job in counseling patients
about smoking cessation. In 1988, 43% of family physicians and 50% of internal
medicine doctors counseled patients about smoking cessation. Dentists did
better than both groups of doctors with 59% of dentists counseling their patients
about smoking cessation in 19974.
Skin cancer risk can be reduced by decreasing exposure to ultraviolet light.
Avoiding the sun between 10 am and 4 pm and wearing clothing that protects the
majority of the body such as long pants, long sleeved shirts and a wide brimmed
hat can reduce exposure. Appling sunscreens on exposed skin will also reduce
risk.
HP2010 is shooting for 85% of people to use protective measures against the
sun. In 2000, 59% of people did and in 2005 the percentage increased to 71% 4.
In addition to smoking cessation, maintaining a healthy weight and exercise
lessens the risk of some types of cancer. Approximately 1/3 of the deaths from
cancer can be attributed to diet and activity choices18.
Exposure to asbestos, benzene and radiation – all occupational hazards –
increase the risk of cancer. Brain and bone cancer risk is elevated with those
exposed to ionizing radiation. Bladder cancer is more prevalent in those who
work in the rubber and dye industry. Asbestos increases the risk of laryngeal
and lung cancer. Ionizing radiation and benzene increase the risk of leukemia.
Lung cancer risk is increased with asbestos, aluminum production, arsenic,
beryllium, cadmium, chromium, ionizing radiation, iron and steel founding,
painters, radon, silica, and talc.
Early detection – through screening - of cancer lessens the risk of death from
certain cancers. Mammography with or without regular breast exam, every 1-2
years, for women after the age of 4019, is recommended for detecting breast
cancer. This research is most compelling for women between 50-69 years old.
The routine use of clinical breast exams alone is not recommended as a
screening tool for breast cancer. There is not enough data to recommend for or
against the use of breast self-exams in women19.
The United States Preventive Services Task Force20 (USPTF) has made
recommendations for chemoprophylaxis based on risk. Low or average risk
women should not take tamoxifen or raloxifene for primary prevention of breast
cancer because risks are greater than the benefit. Women at high risk for breast
cancer and low risk of adverse effects from the medications should consider the
use of tamoxifen or raloxifene. Research on tamoxifen is more robust than for
raloxifene. The main benefit noticed is the reduction of invasive estrogenreceptor positive breast cancer. Both medications increase the risk for stoke,
deep vein thrombosis and pulmonary embolism. Tamoxifen increases the risk of
endometrial cancer.
Sixty-seven percent of women over 40 have had a mammogram in the last
two years between the years of 1998 and 2005. This is just short of the goal of
70%4.
Cervical cancer is screened for by a Papanicolaou test. This test should
begin by age 21 or within 3 years of the first sexual encounter21. In 2005,
seventy-eight percent of adults had screenings in the last three, just short of the
90% goal4.
At the age of 50, colon cancer screening should begin, although some highrisk patients may begin earlier. Screening is done by annually checking the stool
for occult blood on three different samples, done at home. Sigmoidoscopy and
colonoscopy are recommended with the sigmoidoscopy to be done every 5 years
and the colonoscopy done every 10 years22.
HP2010 wants the rate of colorectal cancer deaths to be 13.7 per 100,000
people while the current rate was 17.5 in 20054.
Rates of screening are low; only 24 percent of those over 50 had screening
with a home test in 2000 and that number dropped to 17% in 2005. The goal set
by HP2010 is 33%4.
Screening for prostate cancer is controversial. When testing is done the use
of a digital rectal exam (DRE) and a blood test for prostate-specific antigen (PSA)
is typically utilized. The USPSTF23 recommends that there is not enough
evidence for or against regular prostate cancer screening with DRE or PSA.
Lung cancer screening is not recommended. Those individuals without
symptoms should not be screened by either spiral CT or chest x-ray for lung
cancer24.
Table 8: Cancer screening recommendations
Gender/Age
Men
19-39
40-49
50-59
Over 60
Fecal occult
Fecal occult
blood –
blood – annually
annually
Sigmoidoscopy/
Sigmoidoscopy/ Colonoscopy –
Colonoscopy –
every 5-10 years
every 5-10
years
PSA optional –
every year
PSA optional –
every year
Women
Pap smear
Pap Smear at Fecal occult
at least
least every
blood –
blood – annually
every three
three years
annually
Sigmoidoscopy/
Sigmoidoscopy/ Colonoscopy –
years
starting at
Mammogram
Colonoscopy –
age 21 or
every 1-2
every 5-10
at the onset years starting
of sexual
activity
Fecal occult
every 5-10 years
years
at age 40
Pap Smear at
Pap Smear at
least every three
least every
years (Before age
three years
65 and then there
are no strong
Mammogram
recommendations
every 1-2 years
Mammogram
every 1-2 years
Diet is correlated to cancer prevention. Eating a diet high if fruits and
vegetables reduces the risk of cancer. Vegetables such as lettuce, broccoli,
cabbage, garlic, onions and other leafy green vegetables likely reduce the
incidence of oral, esophagus, stomach and throat cancer25.
There is some
evidence that lycopenes reduce the chance of getting prostate cancer26.
Other dietary selections reduce the risk of cancer. A diet high in fiber
including whole grains, fruits, vegetables and beans may be helpful in the
reducing some forms of cancers. Diets high in fat may also increase the risk of
cancer.
Chronic Kidney Disease
Chronic kidney disease – which affects 20 million Americans - is a
progressive decline in kidney function that is typically not reversible. A
glomerular filtration rate (GFR) below 60 ml/minute per 1.73m2 consistently for
three months defines chronic kidney disease27. This approximates a serum
creatinine level of 1.5 mg/dl in men and 1.3 mg/dl in women.
The disease is seen more frequently today as the prevalence of CKD
increases with age and life expectancy is increasing. It is a costly disease. By
2010 it will cost 28 billion dollars annually to treat the disease. Complications
from the disease may cost 90 billion dollar27.
The disease often goes undetected, as symptoms do not present until the
disease is advanced - when the GFR is less than 15 ml/minute per 1.73m2. At
this point the patient may complain of fatigue, poor appetite, nausea, vomiting,
hiccups, irritability, insomnia, memory problems and pruritus. The physical exam
may reveal hypertension, yellowing of the skin, multiple bruises, and a chronically
ill appearance.
Diabetes is the leading cause of renal failure followed by hypertension.
Reduced kidney function and even kidney failure is a complication of longstanding diabetes or hypertension.
Other causes of chronic kidney disease include polycystic kidney disease,
autoimmune diseases, renal artery stenosis, renal veins thrombosis, thrombotic
thrombocytopenic purpura (TTP), hemolytic-uremic syndrome (HUS), HenochSchönlein purpura. Obstruction can also lead to CKD in conditions such as: an
enlarged prostate, tumors, urolithiasis, and neurogenic bladder.
The long-term use of certain medications is also possible causes of CKD.
Medications such as nonsteroidal anti-inflammatory drugs (ibuprofen and
celecoxib), acetaminophen, chemotherapeutic agents, allopurinol and some
antibiotics (sulfa medications, aminoglycosides, penicillin) may all cause CKD.
Increased blood urea nitrogen (BUN) and creatinine – persistently over three
months - are the two most common lab findings. Other findings may include
anemia, hyperkalemia, hypocalcemia, hyperphosphatemia and metabolic
acidosis. Echocardiograms are often done to evaluate the kidneys and may
reveal bilaterally small echogenic kidneys.
Fluid overload results when the disease progresses as the kidneys lose their
ability to regulate fluid balance.
Dialysis or kidney transplant is often needed in end stage renal disease
(ESRD). Dialysis should be started when the GFR is 10 ml/minute per 1.73m 2 or
serum creatinine is 8 mg/dl or more. The guidelines are a little bit stricter for
diabetics and dialysis should be started when the GFR is less than 15 ml/minute
per 1.73m2 or the creatinine is greater than 6 mg/dl27. Dialysis should also be
used for patients who have continued fluid overload even with diuretic use;
refractory hyperkalemia; pericarditis; encephalopathy; coagulopathy; metabolic
acidosis with a pH of less than 7.20; seizures; or neuropathy28.
Early detection of chronic kidney disease is critical because early intervention
has the potential to slow down kidney function decline. It also allows for
monitoring for complications and this is important because complications can
reduce quality of life or even be fatal. In addition, the only treatment for
advanced kidney failure is kidney transplant or dialysis, which significantly
impacts quality of life and costs the health care system a lot of resources.
Complications of renal failure need to be watched for. Hyperkalemia
becomes a significant problem when the GFR is less than 20 ml/minute per
1.73m2, but it can occur in those with higher GFR especially if other disease
states are present (type IV renal tubular acidosis). Certain medications,
especially angiotensin converting enzyme inhibitors (ACE-I), angiotensin receptor
blockers or potassium sparing diuretics can lead to hyperkalemia.
The failing kidney does not excrete salt and water as well. This increases the
risk of hypertension and congestive heart failure.
Anemia is common as the level of erythropoietin is reduced in renal failure.
Erythropoietin is a hormone excreted by the kidney that helps in the production of
red blood cells. Many patients are also afflicted with iron deficiency anemia.
With advancing CKD, mineral metabolism becomes abnormal. Calcium and
phosphorous are the two major minerals affected, which lead to renal
osteodystrophy. High phosphorus levels are accompanied by low levels of
calcium stimulating release of parathyroid hormone (PTH). The clinical
presentation of renal osteodystrophy may include bone pain, muscle weakness
and spontaneous bone fractures.
Prevention of chronic kidney disease starts with recognition. Teaching
patients about the treatment of chronic kidney disease improves care. The more
the patient knows, the better the chance that the patient will receive better care.
One of the goals of HP2010 is to reduce the incidence of ESRD. In 2005, there
were 347 new cases per million people per year. The goal for 2010 is 228 cases
per a one million population4.
Cardiovascular disease is a common complication in chronic kidney disease.
In 2005, 76.1 per 1000 people with CKD died from cardiovascular disease, which
is down from 93.8 per 1000 in 19974. Treating risk factors of cardiovascular
disease that are complications of CKD has the potential to reduce the impact of
cardiovascular disease.
Treating hypertension is a critical aspect in the prevention of chronic kidney
disease as well as cardiovascular disease. High blood pressure directly
damages the blood vessels in the nephron. Consequently filtration flow and
pressure is not able to be auto regulated by the glomerular apparatus. Overtime
this will result in kidney damage and proteinuria. It also activates the reninangiotensin-aldosterone system (RAAS), which further increases blood pressure
and fluid retention. Controlling blood pressure reduces the rate of kidney disease
progression. Blood pressure should be at highest 130/80 mmHg in those with
CKD.
Medications that regulate the RAAS are most effective at treating kidney
disease in patients with hypertension and kidney disease. Angiotensinconverting enzyme inhibitors (ACE-I) and angiotensin-II receptor blockers (ARB)
are the treatment of choice. Those on an ACE-I have a slower rate of GFR
decline than patients on placebo29.
The combination of ACE-I and ARB may reduce the progression to CKD in
high-risk patients. When both medications are used to treat hypertension, the
combination was more effective in reducing hypertension, microalbuminuria in
patients with high blood pressure, type 2 diabetes and microalbuminuria 30.
Even though these medications are effective in the treatment of CKD, they
need to be used with caution as they may lead to worsening renal failure and/or
hyperkalemia in some patients. Both kidney function and potassium levels need
to be monitored for those on these medications.
Those with diabetes need to have their disease closely watched to prevent
this disease from damaging the kidney. Controlling blood sugar and blood
pressure are critical aspects in diabetics in the prevention of renal dysfunction.
Diabetics should maintain a glycosylated hemoglobin below 7%, have blood
pressure controlled with an ACE-I or ARB and have their urine checked annually
for microalbumin.
Control of cholesterol is another factor that can help in the prevention of CKD.
The data for lipid control is not as robust in kidney disease as it is in other
conditions; there is some data that suggests that lipid reduction may help reduce
the progression of kidney disease. Those with CKD are most likely to have an
elevated triglyceride level as it is not cleared as well31.
Diabetes
Diabetes is the leading cause of kidney failure and of new blindness in adults.
It affects an estimated 20.8 million Americans32. Many diabetics are unaware of
their disease. Without awareness treatment cannot be implemented and
complications cannot be reduced.
In 2005, 1.5 million people over the age of 20 were diagnosed with diabetes.
It is the sixth leading cause of death, but it is probably underreported as a cause
of death. Those with diabetes have a risk of death, which is about 2 times
compared to healthy controls32.
The incidence of diabetes is increasing. Between the years of 1997 to 1999,
new cases of diabetes were at 5.5 per 1000 people in those aged 18 to 84. This
number increased to 7.6 per 1000 people in 2006, which is above of the goal of
3.8 per 1000 people4.
Similarly, the prevalence of diabetes has increased from 40 per 1000 people
to 57 per 1000 people from 1997 to 2006. The goal set by HP2010 is 25 per
1000 people4.
Diabetes is a disease associated with high blood sugar levels due to a
decreased amount of insulin or insulin resistance. Insulin, a hormone produced
by the pancreas, helps transport sugar into cells where it can be used for energy.
There are multiple factors that put one at risk for diabetes (Table 9). Diabetes is
an important disease to prevent because it increases the risk for heart disease,
stroke, heart failure, kidney failure and blindness. It also decreases quality of life
and shortens life span.
Types: Diabetes is classified as type 1, type II or gestational. Type I, is not
preventable with lifestyle choices, usually occurs in younger individuals and
accounts for about 10% of cases. It occurs after cells of the pancreas that
produce insulin are destroyed, rendering the body unable to produce insulin.
Pregnant women without diagnosed diabetes who have high blood sugar
during pregnancy have gestational diabetes. Gestational diabetes affects about
4% of all pregnant women and accounts for 135,000 cases of diabetes every
year in the United States33.
Type II diabetes occurs mostly in adults. The mechanism responsible for
diabetes is insulin resistance meaning that glucose is unable to get into the cells
and consequently the blood glucose increases. In response to the cells not
getting enough sugar, the body produces more insulin. Therefore, the individual
with diabetes type II has high levels of blood glucose and increased levels of
insulin (at least early in the disease). As the disease progresses the pancreas
loses its ability to produce insulin.
Pre-diabetes is a condition associated with elevated blood sugars but levels
are not high enough to be classified as diabetes. Pre-diabetes increases the risk
for developing diabetes. Those with pre-diabetes should focus on a healthy
lifestyle, including exercise, proper nutrition and weight control, to prevent
progression to diabetes.
Table 9: Risk Factors for Type II Diabetes Mellitus
1. Family history
2. Obesity, especially abdominal obesity
3. Physical inactivity
4. For females, having a baby that weighed more than nine pounds.
Complications
Diabetes is associated with many complications, which occur because of
increased insulin levels and increased blood sugars. Complications are
categorized as microvascular and macrovascular.
Macrovascular complications: Macrovascular complications include heart
disease, peripheral vascular disease and cerebral vascular disease. High levels
of sugar and resistance to insulin damage the blood vessels walls predisposing
one to disease.
Heart and vascular disease is very common in patients with diabetes and it
needs to be monitored for carefully. In addition to controlling blood sugar,
controlling blood pressure, lipid levels and blood clotting are keys to prevent
macrovascular complications.
Microvascular complications: Microvascular complications include
retinopathy, nephropathy and neuropathy. These are diseases of the small blood
vessels and associated with high sugar levels. The best way to decrease the risk
of these complications is to control blood glucose.
Retinopathy leads to blindness. Having annual eye exams and controlling
blood sugars reduce the risk of this disease. In 2003, 58% of diabetics over 18
had annual dilated eye exams regularly4.
Nephropathy, which affects 20-40% of diabetics, commonly advances to end
stage renal disease and dialysis4. Patients should be screened annually for
microalbuminuria, which is an early sign that diabetes is causing nephropathy.
Neuropathy results from high sugar levels that damages nerves causing
burning pain, decreased sensation and decreased function by areas innervated
by the nerves. This can present as chronic sensory or motor neuropathy or
autonomic neuropathy.
Other complications include: erectile dysfunction, non-healing wounds,
amputation, congestive heart failure and memory loss.
Amputation is often the end result from a number of complications including
peripheral vascular disease, poorly controlled blood sugar and neuropathy. The
number of lower extremity amputations over a three-year period is at 4.4 per
1000 diabetics in 2004. The goal is to lower that number to 2.9 per 1000
diabetics4.
Regular foot exams are one key measure to prevent amputation and other
problems in diabetic patients. In 2004, 67% of diabetics over the age of 18 had
an annual foot exam, which is short of the HP2010 goal of 91%4.
Signs and Symptoms:
Type II diabetes is typically present for years before it is diagnosed. The
diagnosis of diabetes is often found on routine blood work and not related to any
specific complaint. When symptoms are present they are usually related to the
increased amount of sugar in the body. The most common symptoms include:
polyuria, polydipsia and polyphagia (table 10).
Table 10: Signs and Symptoms of Type II Diabetes
1. Often none
2. Polyuria
3. Polyphagia
4. Polydipsia
5. Blurred vision
6. Fatigue
7. Sores that heal slowly
8. Frequent infections
Diagnosis:
Typically, by the time diabetes is diagnosed the disease has been present for
many years. This leaves a large window of time for complications of the disease
to damage the body. Simple screening tests are available to diagnosis diabetes,
which not only diagnosis the disease early but can reduce the number of
complications that diabetes imparts on the body.
Diagnosing diabetes is done by blood tests – ideally the fasting plasma
glucose. The three ways to diagnosis the disease include34 35:
1. Fasting blood sugar greater than 125 mg/dl.
2. Blood sugar greater than 200 mg/dl after eating 75 grams of glucose.
3. Signs and symptoms of diabetes with a random blood sugar over 200
mg/dl.
Pre-diabetes is diagnosed when:
1. Fasting blood sugar between 100-125 mg/dl or
2. Blood sugar readings between 140-200 mg/dl after eating 75 grams of
glucose.
It is important to have pre-diabetes diagnosed as it is a precursor to diabetes.
Screening: Screening is often carried out for diabetes II as routine blood work.
The USPSTF recommends screening all adults with blood pressures consistently
greater than 135/80 mm Hg36. Diabetes screens should also be carried out every
three years starting at the age of 4537. Those who are high-risk should be tested
earlier and more frequently34 36.
Prevention:
It is critical to control risk factors known to increase the risk of
diabetes. Many of those risk factors revolve around lifestyle changes.
Diet: Weight loss – even small amounts - is essential to controlling and
preventing diabetes. A diet with plenty of vegetables, fruits, whole grains, low-fat
dairy products and lean meats is important. Simple sugars such as juice, white
bread and candy can result in spikes of blood sugar and these foods should be
eaten in limited quantities if at all.
Exercise: Exercise aids in weight loss, which can help prevent diabetes. Aerobic
exercise - walking, biking and swimming - enhances insulin sensitivity, which
means that cells are utilizing insulin more effectively resulting in lower blood
sugar and lower insulin levels. Improved insulin sensitivity persists for
approximately 48 hours after an exercise session so exercise should be carried
out at least every other day. Exercise also improves lipid levels and blood
pressure, which are factors important to reduce complications of diabetes.
Prevention becomes even more important once diabetes sets in. Without
proper preventative health care diabetes can lead to many of the complications
listed above. Appointments with the health care provider should be set up every
3-6 months.
Blood sugar needs to be monitored for regularly. This includes testing for
long-term blood sugar control with a glycosylated hemoglobin (HbA1c) as well as
routine testing by patients at home. HP 2010 wants 61% of diabetics over the
age of 18 to check their blood sugar at least once a day. As of 2004, that goal
has been met4.
Glycemic control reduces many of the complications of diabetes. Depending
on how well diabetes is controlled the frequency of self-glucose monitoring may
vary. Someone with poor control may need to check blood sugars four times a
day, while someone with great control may need to only monitor levels a couple
times a week. If fasting levels are well controlled but long-term control is not
ideal – as evidence by an elevated glycosylated hemoglobin (HbA1c) – then
checking post-prandial blood sugar readings is appropriate, as elevated postprandial readings may be the cause of the poorly controlled diabetes.
Table 11: Goals for Blood Glucose Readings35
Fasting capillary plasma glucose between 90-130 mg/dl.
Capillary blood glucose 1-2 hours after meal of less than 180 mg/dl
HbA1c – Less than 7.0%
HbA1c, a key diagnostic tool in the management of diabetes, looks at how well
blood sugar has been controlled over the last 2-3 months. Levels should be less
than 7.0 %35. This correlates with an average blood sugar reading of less than
150 mg/dl. In people with diabetes only 65% have their HbA1c checked two times
per year4.
Medications: When lifestyle changes are unable to adequately manage blood
sugar, drug therapy is added. Multiple medications can be used to help in the
management of blood sugar. It goes beyond the scope of this article to detail the
different pharmacological agents.
Cholesterol should be checked in all diabetics. High cholesterol should also
be controlled to prevent many of the long-term complications of diabetes
including cardiovascular disease and death. The low-density lipoprotein (LDL) or
bad cholesterol is the most important number to manage. The main target is to
control the LDL cholesterol to less than 100 mg/dl with high-risk patients having
targets of less than 70 mg/dl35.
Diabetics are often afflicted with low high-density lipoproteins (HDL) or good
cholesterol and high triglycerides. Secondary goals in treating cholesterol in
diabetics include increasing the HDL cholesterol and reducing triglycerides.
A variety of methods are available to control cholesterol including lifestyle
changes and medications. Lifestyle changes that can be used to treat abnormal
cholesterol include exercise, weight loss and dietary changes. Dietary changes
that improve cholesterol include reducing saturated fats and increasing
monounsaturated fats in the diet.
Many medications are available to treat abnormal cholesterol. Diabetics may
benefit from the class of drugs called the statins, which include drugs such as
atorvastatin (Lipitor), simvastatin (Zocor) and fluvastatin (Lescol), to reduce the
risk of heart and vascular disease. The American Diabetes Association
recommends all diabetic patients over the age of 40 and those with overt
cardiovascular disease to be treated with statins to lower LDL to goal or if at goal,
by another 30-40%35. Niacin is another popular medicine used to treat abnormal
cholesterol but caution needs to be used in diabetics as this drug can increase
blood sugar.
Kidney protection reduces the risk of progression to kidney failure and
dialysis. The first step in treating kidney disease is recognizing that it is present.
This is accomplished by annual tests for microalbumin in the urine. Angiotensin
converting enzyme inhibitors (ACE-I) and angiotensin receptor blockers (ARB)
are two medicines that have been shown to protect the kidneys from
nephropathy. Again, controlling the blood sugar is essential in preventing this
complication.
Aspirin therapy reduces the risk heart disease. The American Diabetes
Association35 recommends the use of low dose aspirin in those who have any
type of heart disease or over the age of 40. It should be considered for those 3040 years old with risk factors for heart disease. Those with a bleeding disorders
including bleeding ulcers need to use aspirin with caution if at all.
HP 2010 has set a goal of 30% of patients with diabetes to take aspirin at
least 15 times a month. As of 1999- 2002 only 20% have meet this goal4.
Other keys to optimal management of diabetes include:
1. Proper treatment of diabetic eye disease reduces the risk of blindness by
50-60%35. Diabetics should have an annual dilated eye exam. Catching
eye problems early, when they are treatable, is paramount in preventing
blindness.
2. Proper foot care reduces the risk of amputation by 45-85%35. Feet should
be evaluated for wounds, nerve damage or peripheral vascular disease at
each visit. Annually, the feet should be evaluated by a foot doctor.
3. Diabetics are at increased risk for death and disability with flu or
pneumonia and should be vaccinated for flu and pneumonia.
4. The risk for periodontal disease is higher in diabetics and they should visit
the dentist 1-2 times a year
5. Diabetics are at an increased risk to develop a hip fracture. The
importance of a screening test for osteoporosis should also be discussed.
Diabetes is a widespread devastating disease. Treatment of the five major
areas – glycemic control, blood pressure control, lipid control, kidney protection
and platelet protection – is a key component to preventing complications and
improving quality and quantity of life
Diabetes is a very complex disease and requires a great deal of work by the
person afflicted with the disease. Educated patients are much more likely to have
better outcomes with the disease. HP2010 wants 60% of diabetics to have
diabetes education. In 1998 only 45% had education4.
Disability and Secondary Conditions
Patients with disability – either physical, emotional, or social - are at risk for
many problems. Watching out for these problems have the potential to reduce
death and disability among this group. Health care providers, particularly nurses,
should be key players in the prevention of disease, health promotion and
counseling in patients with disability.
The interaction between an individual’s health condition and the barriers in
their environment defines disability. This includes anyone with a limitation in
activity or is in need of assistance with an activity. The definition also includes
anyone who perceives themselves as having a disability38.
Common causes of disability are many of the diseases touched on in this
course. The most prevalent causes of disability include: arthritis and
rheumatism, back or spine problems and heart problems39.
Twenty percent of the population reports a disability38. Disability caused by
chronic conditions is most likely to affect American Indians and Alaskan natives.
It is least likely in Asian Americans. Females are more likely than males to have
disability and the prevalence of disability increases with age4.
Nurses need to understand the major causes of disability and which
interventions will help reduce the incidence of these disabilities. For those
afflicted with disability, nurses need to be involved with improving their quality of
life through prevention, rehabilitation and caring for these patients. Nurses need
to assist patients in accessing community services and attaining quality health
care. This will result in improvements to their quality of life.
Prevention of disabling conditions is a critical component to the nurse’s role.
This involves practicing good preventative health care among the healthy
population. Other sections of this course will address ways to prevent specific
disabling conditions. For example, the use of immunization, violence prevention,
motor vehicle safety, and maternal health services, all have the potential to
reduce disability.
Progress is being made in this objective by HP2010. Adults living with
disabilities in congregate care settings was reduced from over 93,000 to
approximately 65,000 from 1997 to 2003, which is still a little short of the goal of
46,681 set by HP20104.
The incidence of depression in disabled individuals is significantly higher than
the general population. Depression in disabled patients aged 4 to 17 years old
was 31% in 1997 and dropped to 25% in 2006. The goal of HP2010 is 17% 4.
Patients with disabilities need to be screened for depression regularly and
treated if appropriate. The use of medications or psychosocial therapy has the
potential to reduce depression and improve quality of life.
In addition, negative feelings, which affect quality of life, are a problem
tracked by HP2010. These feeling are linked to depression. The rate of negative
feelings among depressed people was 29% in 2006; well short of the goal of
7%4. One-way disability affects quality of life is it reduces the amount of social
interaction and lack of emotional support, which can lead to negative feelings.
Disabled patients are often not as involved in life as those without disabilities.
Including patients in regular education and helping them attain gainful
employment will help in the prevention of depression.
Access to resources is often limited in disabled patients, further impairing their
quality of life. Improving disabled individuals access to resources will aid in the
prevention of many health care problems. Consulting social workers who
specialize in the care of disabled patients will aid the nurse in getting resources
to help their patients.
Assistive devises or technology will help patients with disabilities function
effectively in society. Environmental barriers affect the ability of disabled
patients to participate in activities at home, work and school. Therapists may be
employed to help the patient attain devices to improve the quality of their life.
Nurses need to play key roles in the prevention of disability, identification of
patients with disabilities, identification of depression in those with disability and
helping the disabled patient adapt to their environment.
Education and Community-Based Programs
Each individual needs to take more responsibility for making education a
priority. If patients do not know what to do, they cannot do it. This is especially
true in regards to prevention, as many preventative health care activities are
highly dependent on individual health care consumers. Those who are educated
in health are more likely to live healthy lifestyles. Those who live healthy lifestyle
are more likely to be healthy.
Americans need to have not only formal education but also health education.
Education will assist people in understanding their bodies and health. Those
who are educated utilize the health care system more effectively. More effective
use of the health care system will result in improved health care and reduced
health care costs.
Education needs to be implemented in a variety of places. Formal education
in school is the first step. Education should include health education as well as
physical education. When patients are out of school, formal education typical
ceases. Education needs to be offered as there is typically much more learning
that needs to occur. Community programs and work site programs are two
venues which can improve health education.
In 1998, high school completion was 85% and 87% in 2003 and 2004. The
goal of HP 2010 is that 90% of people complete high school4.
While in school, health education is a critical part of improving health literacy.
In 1994, only 28% of people received comprehensive health education which is
well below the goal of 70% set by HP 2010. Specific areas of education tracked
by HP 2010 include: unintentional injury, violence, suicide, tobacco use,
alcohol/drug use, environmental health, physical activity, sexually transmitted
diseases and unintended pregnancy.
Education often becomes much more informal when patients are out of
school. Work-site educational programs are one way to get health information to
people. HP2010 has a goal that all companies with more than 50 employees will
have health promotion programs. In 1998-99, the number of companies that had
programs was variable depending on the size of the company. Of those
companies with 750 employees or more, 50 percent had programs; while those
with 250 to 749 employees, 38% had programs. Of those companies with fewer
than 250 employees, 33-34% had a program4.
Community health promotion programs are another way information is
transmitted to the community. The numbers of programs that are culturally
appropriate are low. Programs that are being tracked include: heart disease and
stroke, family planning, environmental health, immunization, maternal and infant
health, physical activity, oral health, nutrition programs, sexually transmitted
disease, and substance/alcohol/tobacco abuse programs.
What can health providers do to improve education and community-based
programs?
1. Encourage patients to compete high school.
2. Encourage the school to improve health education
3. Work with local health agencies to develop programs
for health promotion and disease prevention
4. Encourage workplaces to develop a work site health
promotion program.
Environmental Health
The environment is everything around us. Chemicals found in the
environment have the potential to lead to cancer, lung diseases such as asthma,
allergies and reproductive health problems. Environmental health is defined by
the World Health Organization as all aspects of human health that are
determined by chemical, physical, biological, social and psychosocial processes
in the environment40.
Air pollution is linked to harmful lung diseases such as asthma. The CDC is
working to determine the effect air pollution has on asthma41. Through multiple
public health agencies they are attempting to determine the severity of asthma in
a variety of locations and its impact on asthma.
With this data the CDC is attempting interventions to reduce air pollution and
its impact on asthma. The CDC is working with other groups to educate, train
and address respiratory health problems linked to air pollution.
Exposure to any harmful air pollutant is estimated to affect 137, 019 people in
2003. This number dropped to slightly more than 115,000 people in 2005. The
goal is no one is exposed to harmful air pollutants4.
Ozone is a gas that occurs in the sky and can be good or harmful to health.
The bad ozone is close to the ground and is a major part of urban smog.
Breathing this ozone can lead to health problem with symptoms such as
coughing, throat irritation, chest pain and congestion. It has the potential to
worsen many chronic lung diseases42.
Another layer of the ozone protects the earth and is about 6 miles from the
ground. Certain substances can destroy the ozone layer which results in an
increased amount of ultraviolet rays getting to the earth which increases the risk
of skin cancer, cataracts and a destruction of crops42.
The goal of HP2010 is that no people are exposed to ozone. In 1997, 43% of
people were exposed to ozone. The statistics have not shown much
improvement over the last few years. In 2004, 39% of people were exposed to
harmful ozone4.
Carbon monoxide (CO) is an odorless and colorless gas that is potentially
fatal. Symptoms of CO poisoning include: headache, nausea, confusion,
weakness, dizziness and fatigue. It can be found in fumes produced by trucks
and cars, stoves, lanterns, gas ranges and heating systems and from burning
wood and charcoal. These sources are most dangerous when people are
exposed to them in an enclosed area as it builds up43.
Twenty percent of persons were exposed to carbon monoxide in 1997. This
rate dropped significantly to 7% in 2004, but still short of the goal of zero percent
set by HP20104.
Lead has the potential to damage any organ in the body. It is especially
harmful to children as their brains and nervous systems are developing.
Lead poisoning is not as common as it once was. In the late 1970’s, lead
based paint stopped being manufactured. This led to a significant reduction in
lead poisoning because lead based paint was a major cause of lead poisoning.
Lead is also found in the air, dust, soil, water and food.
Less than one percent of all people are exposed to lead through the air. As
of 2004 that rate dropped to zero – which is currently at goal4.
Between 1991 and 1994, 4.4 percent of people had blood levels of lead above
10 ug/dl. The goal by 2010 is 0%4. The CDC is working to develop policies and
programs to reduce the risk of childhood lead poisoning. Providing education is
a critical part of the plan set up by the CDC. The government is looking to fund
health departments to screen for lead poisoning and adequately treat those who
are affected. Continued research will help ensure that lead poisoning is an issue
of the past44.
Water safety is another important part of environmental health. Amazingly,
one billion people over the globe do not have access to safe drinking water. The
United States has one of the best water systems in the world, but it is not perfect
as there is still risk for disease associated with the water or its shortage45.
Indoor allergens are another component to public health. Cockroach
allergens, dust mites, environmental tobacco smoke, animal dander, molds,
irritant fumes, chemicals and products from combustion devices are all allergens
that can lead to disease – especially asthma and allergies.
Mold is often seen after a natural disaster or any situation when there is an
excess of standing water. Those who are afflicted with allergies, asthma, other
lung conditions or are immunocompromised are at greatest risk from mold. Mold
may lead to irritated eyes, nasal congestion, irritated skin, wheezing or shortness
of breath.
Mold may be recognized by discolored ceilings or floors. The smell of the
mold is typically musty or earthy. When mold is recognized it should be cleaned
out. Some products may need to be removed from the home such as carpeting,
padding, drywall, insulation and wood. Wet items should be cleaned with
detergent and water to avoid mold growth. To prevent mold, the most important
step is to control moisture46.
Pesticides help control insects, animals, microorganisms and plants. There
are 600 approved pesticides in 20,000 different products. The United States
uses a large portion of the global pesticides. Humans are exposed through food,
gardening, lawn applications and through work. Pesticides are linked to many
health problems including: cancer, nerve damage and birth defects47.
What can people do to prevent health related complications from the
environment?

Avoid sun exposure during the hours of 10 AM to 4 PM and use a strong
sun screen on unprotected body parts when out in the sun.

Protect the face and head with a hat with a wide brim.

Wear sunglasses with UV protection

Use alternative methods for transportation – mass transit, biking, walking
or car pooling. This will help reduce the air pollution. In addition, if the
patient chooses to bike or walk there will be an improvement in health as
physical activity provides many health benefits.

When using pesticides at home make sure that patients read the container
and use as recommended.

When using pesticides mix them outside and use them in areas with good
air flow.

Store pesticides out of the reach of children

Open flues in the fireplace when in use

Have furnaces, gas appliances and chimneys tuned up

Use exhaust fans over gas stoves

Install CO detectors in the home

Do not keep the car on in a closed garage

Know if you have a home that may contain lead based paint (home build
before 1978)
Family Planning
Family planning is an important concept for Americans to understand.
Without adequate planning, patients are at increased risk for an unintended
pregnancy.
An unintended pregnancy is a mistimed or unwanted pregnancy. It is
important to prevent this as those with unintended pregnancies are at increased
risk for poor outcomes as health behaviors are more likely to not be optimal.
Those with an unintended pregnancy often delay prenatal care, suffer from poor
nutrition, use more toxic substances, have higher rates of smoking and ultimately
have poor fetal and maternal outcomes.
In females between 15-44 years old, the goal of HP2010 is a 70% intended
pregnancy rate. Another goal looked at is having children more than 2 years
apart. In 1995, 11% of children were born within 2 years of their sibling. The
goal is less than 6%4.
The use of contraception is another important measure looked at. Couples
who are not intending pregnancy should all use some form of birth control
method according to HP2010 goals. As of 1995, 93% of those who are at risk for
unintended pregnancy used birth control4.
Birth control failure can result from improper use. The goal of HP2010 is to
have a contraception failure rate over the period of one year at 8% for women
aged 15 to 444. Health care providers need to teach individuals about proper use
of birth control.
Adolescents are less prepared to raise children, both financially and
emotionally. HP2010 has goals to reduce the rates of teen pregnancy. The best
way to prevent pregnancy is to practice abstinence. In 1995, 81% of females
practiced abstinence before aged 15. Females between the ages of 15-17 have
an abstinence rate of 62% in 1995 with a goal of 75% in 20104.
The goal of pregnancy rates for 15-17 year-olds is 39 per 1000 people. In
1996, the pregnancy rate was 63 per a 1000 population. Race and ethnicity
strongly impacts the pregnancy rate. While the goals are the same despite race,
the pregnancy rates are significantly different, in regards to adolescent
pregnancy rates. Blacks or African Americans had a pregnancy rate of 126 per
1000 population, Hispanics or Latinos had a rate of 109 per 1000 and whites
have a rate of 40 per 1000 in 19964.
Condom use is not only effective at preventing pregnancy, but it can help
prevent sexually transmitted disease. HP2010 encourages the use of condoms.
Prevention of pregnancy and sexually transmitted diseases also includes
education. Important measures to teach patients, especially adolescents include:
1. Provide education either during office visits or through
referrals about pregnancy. Topics should include:
abstinence, birth control, STD prevention and HIV/AIDS
prevention.
2. Discuss contraception use with both male and female
patients
3. Develop a list of community resources for patients
regarding pregnancy and contraception
4. Discuss the benefits of abstinence with adolescent patients
5. Lobby for more health education in regard to sex and
sexual transmitted diseases in local schools
Food Safety
Consumption of contaminated food and/or water with bacteria, toxins, viruses,
parasites or chemical defines food poisoning. Food safety helps prevent a
variety of very common diseases that present with nausea, vomiting, diarrhea
and abdominal pain. A variety of factors including - toxins, microorganism and
chemical contaminants – can cause food poisoning. Many cases are never
reported to health care providers. Determining the exact cause of food related
illness can be difficult to track down and requires a good history and sometimes
laboratory testing.
The majority of the cases are mild and improve spontaneously, but some
cases can be severe requiring antibiotics and even hospitalization. An outbreak
is present when a similar illness affects at least two people and is there is
evidence that food is the source48.
Food poisoning affects approximately 76 million people in the United States
and causes as many as 5000 deaths48. Most cases of food poisoning do not
have the organism identified. Some organisms are much more deadly, with
Salmonella, Listeria, and Toxoplasma causing 1500 deaths annually; 3200
deaths are attributed to unidentified pathogens.
Almost all cases of food poisoning steam from improper food handling, with
79% of cases coming outside the home and 21% of cases in the home 48.
Food poisoning occurs from:

Leaving prepared food at temperatures that allow bacterial growth

Inadequate cooking or reheating

Cross-contamination

Infection in food handlers.
Specific factors that indicate potentially serious disease include: bloody
diarrhea, fever, prolonged diarrhea, severe abdominal pain, sudden onset of
symptoms, neurological symptoms, weakness, cranial nerve palsies,
paresthesia, dehydration and weight loss.
Diarrhea typically lasts only a few days but may last up to 14 days. In severe
disease the diarrhea may persist beyond two weeks. Blood or mucus in the stool
indicates involvement of the mucosa of the intestine or colon. Abdominal pain is
more common when inflammation is present. Fever is indicative of invasive
disease. Vomiting is present with some organisms such as Staphylococcus
aureus, Bacillus cereus, or Norovirus. Arthritis can occur after diarrhea caused by
Salmonella, Shigella, Campylobacter, and Yersinia. When there is a report of
abdominal distention the infecting organism may be giardiasis. Shigellosis is
associated with rectal discomfort and painful bowel movements with blood or
mucus.
Certain foods are linked to different infecting organisms. Salmonella can
occur with raw eggs or unpasteurized milk or cheese. Unpasteurized milk, juice
or cheese can also cause E. coli, Yersinia and Campylobacter. Meat is also
linked to many cases of food poisoning. Poultry that is not properly prepared
may pass on Salmonella, Campylobacter, Shiga toxin, E coli, and Clostridium
perfringens. Improperly prepared or raw seafood may cause a Norwalk-like virus,
Vibrio organism, or hepatitis A. Deli meats can pass on listeriosis. Canned foods
have the potential to pass on Clostridium botulinum.
Incubation period can give an idea about the potential causative organism.
Staphylococcus aureus and Bacillus cereus have an incubation period of one to
six hours and is associated with vomiting; the patient is typically afebrile.
Staphylococcus is associated with vomiting and sometimes watery diarrhea that
can last up to 48 hours. Bacillus cereus has vomiting that lasts about 9 hours
and diarrhea that starts about 8-16 hours after ingestion that persists about one
day48.
When the incubation period is between 8-16 hours vomiting is less common
and abdominal cramping is often seen. Diarrhea may occur. Clostridium
perfringens - one example of this – is associated with diarrhea that starts 8-24
hours after ingestion which lasts about one day48.
Incubations that are between 12-72 hours are usually associated with
diarrhea (inflammatory and non-inflammatory).
Common bacteria that can lead to infection include: Campylobacter species,
Escherichia coli 0157:H7, Listeria species and Salmonella species.
Enterotoxigenic E. coli (traveler’s diarrhea) has an onset of diarrhea about 1-2
days after ingestion and is often associated with vomiting that last for 1-2 days.
Enterohemorrhagic E. coli has diarrhea that starts about 3 to 4 days after
ingestion with diarrhea – that is often bloody – lasting 3-8 days48.
Proper food preparation is an important step in preventing food bourn illness.
Consumer food safety practices were 73% in 1998 with a goal of 79% by 2010.
Retail food preparation is another measure looked at. In a full-service restaurant
HP2010 has a goal of 70% safe food preparation. In 1998, only 60% was
considered safe food preparation in a full service restaurant. Fast food
restaurants had a 74% safe food preparation, while the goal is 81% by 2010 4.
Techniques to prevent food related illnesses are varied depending on which
illness one is trying to prevent. Some general principles apply. Below are some
strategies that should be taught to all patients about food safety, which should
reduce the incidence of passing on food borne illness:

Do not eat raw or undercooked meat and poultry.

Toxoplasmosis – commonly passed on by eating raw meat – can also be
caught by contact with cat litter, soil, water, and vegetables contaminated
with cat feces

Obtain vaccinations including vaccination against hepatitis A – especially if
at risk for hepatitis A such as someone traveling to endemic regions. The
vaccine should be given as a series of two, 6 months apart.

If traveling to the region within 30 days, immune globulin may help prevent
hepatitis A in patients over the age of 2

Anyone in the food business with diarrhea should not come to work for 2448 hours after diarrhea stops

Fully cook meat and eggs to prevent Salmonella

Refrigerate leftovers promptly

Wash hands after contact with raw meat

Wash utensils after contact with raw meat

Wash hand after using the bathroom with soap and running warm water
Health Communication
Health communication is a complex, broad topic that entails developing a
message and strategy to improve the health of communities and individual
patients. Because health information is confusing, clear health communication is
critical in order for patients to understand and utilize it.
Access to health information is one aspect of health communication. Many
people get health information from the internet. One measure that HP 2010 is
looking at is the percentage of people with internet access. In those over the age
of 18, the goal is that at least 80% of people have access to the internet in the
home. As of 2003, only 64% of people had internet access at home4.
Forty million Americans are functionally illiterate. These individuals are at a
distinct disadvantage at getting information from the health care system as many
instructions are written. Today’s health care system is based mainly in outpatient
care and many health care visits are very short. This gives limited time to
provide teaching to patients. This is especially dangerous in complex diseases
like diabetes.
The American Medical Association reports that 90 million Americans have
problems acting on health information. In order to improve the health of
Americans, we need to improve health literacy.
Proficient health literacy assures that patients have the skills to locate and
understand health related information. There are varying degrees of health
literacy from proficient to basic. Proficient explains the patient who is able to
perform complex tasks and basic literacy is those who can handle only mundane
tasks. Health literacy is important because health care is a complex venture that
requires the participation of patients. Patients need to be able to fill out forms,
follow guidelines and navigate the health care system. There is a strong
connection between health literacy and health outcomes.
Many patients do not understand common terms that are used by health care
providers. Many do not ask questions for fear of looking unintelligent.
When patients understand what needs to be done, they are more likely to do
it. Preventative health care is highly dependent on patient participation. If
patients are unaware of what needs to be done, they will be unlikely to do it.
Health care providers need to keep many factors in mind when
communicating with patients. They should limit information given to patients to 3
to 5 points, use simple language, utilize models and pictures to illustrate points
and make sure patients repeat information back.
Many cases of non-compliance are just because patients do not understand
health care instruction. Health care providers need to provide simple, easy to
follow instructions. As of 2003, only 12% of people had proficient health literacy.
The goal by 2010 is 13%4.
Interaction between doctor and patient is a key component to quality health
care. Patients that report health care providers always listen carefully to them
was 57% in 2003 and the goal is to have at least 65% by 2010. Doctors who
explain things so their patients can understand them was 59% in 2000 with a
goal of 66% by 20104.
Respect is taking another’s feelings, ideas, thoughts, needs, wishes and
preferences into consideration. Quality health care involves patients that respect
their health care provider and health care providers that respect their patients.
Fifty-nine percent of patients report that doctors showed respect for them in
2000. But, only 46% of patients report that doctors spend enough time with their
patients.
Tips for improving health communication
1. Develop a list of reputable websites for patients to visit
2. Listen carefully to each patient
3. Explain instructions and other health information to patients
carefully
4. Respect patients and families
5. Do not rush through health care encounters
Heart Disease and Stroke
Heart disease is the number one killer of Americans – affecting about 15
million Americans49. Coronary artery disease (CAD) is the result of plaque build
up on the arterial walls of the coronary arteries. CAD causes the coronary
arteries to narrow, reducing blood flow to the heart tissue with the end result
being angina, shortness of breath or even myocardial infarction.
Plaque usually does not develop in isolation around the heart. If one is
unfortunate enough to have plaque around the heart it is likely that plaque has
developed in other areas of the body. Some other common areas of plaque
development include the carotid arteries, which can lead to stroke; and vessels of
the legs, which can lead to peripheral vascular disease. Stroke affects
approximately 700,000 Americans each year50. Peripheral artery disease affects
8-12 million people.
The goal of HP2010 is to attain a death rate from coronary heart disease of
162 people per a 100,000 population. In 1999, the rate was 203 per 100,000
people; as of 2005 the rate was at target at 154 per 100,000 people 4.
Many factors go into the reduction of death rates. Educating the population
about the signs and symptoms of a heart attack is important. If patients are
aware and obtain medical treatment early, outcomes, including reduced death
rates, will improve. Early medical intervention is a key factor in the treatment of
heart disease. Artery opening therapy within an hour of symptom onset during a
myocardial infarction is a goal of HP2010. Early intervention improves survival
and outcome and is dependent on early recognition by the patient and early
intervention by health care providers.
Risk Factors
Controlling risk factors is the main weapon in preventing heart disease. Some
risk factors are modifiable (Table 9) and others are not (Table 8).
Table 12: Non-modifiable Cardiac Risk Factors

Family history of heart disease

Male gender

Increased age
Table 13: Modifiable Cardiac Risk Factors

Tobacco use - especially cigarettes

Obesity

Dyslipidemia

Diabetes

Hypertension

Physical inactivity

High levels of blood homocysteine

Inflammation

Stress

Diet low in fruit and vegetables
Non-modifiable risk factors
When a first-degree relative – parent, sibling or child – has a history of heart
disease it increases the risk of heart disease. This risk factor is most relevant for
those individuals who have a family history of heart disease detected at an early
age – before 55 in males and before 65 in females.
Males are at increased risk for heart disease especially before menopause
when female rates of heart disease approach men’s. Also, the older age
increases the risk of heart disease49
Modifiable risk factors
Cholesterol: Cholesterol is essential to many body functions as it helps build
steroid hormones, bile acids and vitamin D, but too much bad cholesterol
increases the risk of cardiovascular disease. Optimal lipid levels reduce
morbidity and mortality especially in regards to cardiovascular disease.
The low-density lipoprotein (LDL) cholesterol – the primary target in improving
lipids - is responsible for carrying cholesterol to tissues. It builds up in the blood
vessel and adheres to the blood vessel wall when there is an excess.
Values
should be less than 160 mg/dl for the low-risk patient; below 130 mg/dl if the
patient is at moderate or moderately high-risk; and if the patient is high-risk with a
diagnosis of heart disease and/or diabetes, below 100 mg/dl and some high-risk
patients warrant values less than 70 mg/dl51.
High levels of high-density lipoprotein (HDL) improves cardiovascular health.
The HDL cholesterol removes the LDL cholesterol from the vessel. The minimum
number that should be attained is greater than 40-50 mg/dl in men and greater
than 50-60 mg/dl in women – the higher the better.
The role of triglycerides – another fat in the blood - is not as strongly linked to
heart disease. The body converts extra calories to triglycerides, which are stored
in the fat cell. They are later released for energy between meals. High levels
possible increase the risk of stroke and heart disease. Elevated levels are often
seen in those with poorly controlled sugar, abdominal obesity, hypothyroidism,
liver or kidney disease. Certain medications have the potential to increase
triglyceride levels including: some birth control pills, tamoxifen, beta blockers,
diuretics or steroids. Levels should be less than 150 mg/dl51.
Men over age 35 should have a their cholesterol level screened and men
between the age of 20 and 35 should be screened if at increased risk for heart
disease52. Women over 45 have should have their lipids evaluated; and women
between the ages of 20 to 45 should have their lipid levels evaluated if they are
high risk.
Improving the lipid panel, especially lowering the LDL cholesterol, reduces the
risk of cardiovascular disease and is accomplished through lifestyle changes and
often times with medications. First line medications recommended for the
treatment of heart disease are the statins (atorvastatin, simvastatin and
pravastatin).
Diabetes: Diabetes is a major risk factor for heart disease as high levels of
insulin and glucose in the blood can damage the vessels. Anyone with
diagnosed diabetes or prediabetes should make every effort to control blood
sugar, blood pressure and cholesterol to reduce the impact of cardiovascular
disease.
Patients with established heart disease or risks for heart disease should be
evaluated for diabetes.
Hypertension: High blood pressure increases the risk for heart disease.
Ideally, blood pressure should be less than 120/80 mmHg. All people over the
age of 18 should be screened for hypertension as prompt recognition of elevated
blood pressure will reduce the incidence of cardiovascular events53.
Physical inactivity: Physical inactivity is an independent risk factor for
cardiovascular disease, and it contributes to many other risk factors. Those who
are not physically active have a greater risk of elevated blood pressure, low HDL
cholesterol and obesity49.
Smoking: Cigarette smoking increases the risk of developing heart disease.
Smoker’s risk is 2-4 times more than non-smokers49. Toxins in cigarette smoke
damages the vascular wall and may precipitate plaque formation.
Stress: Chronic daily stress boosts the risk for heart disease49. It is unclear if
there is a direct link of the stress damaging the cardiovascular system or if the
stress manipulates lifestyle choices (such as overeating) that damage the
cardiovascular system49.
Obesity: Being overweight increases the risk of heart disease. The way in
which the weight is carried also affects risk. Those who have a large waist
circumference are at greater risk than those who carry their weight in their hips
and gluteal area. Men with a waist circumference greater than 37 inches and
females with a waist circumference greater than 32 inches are at increased risk
for heart disease54. In addition, obesity, negatively affects other risk factors such
as cholesterol levels, diabetes risk and hypertension risk.
Eating few fruits, vegetables and fish: Fruits and vegetables contain
antioxidants and fiber, which reduce the risk of heart disease55. Unfortunately,
taking antioxidant supplementation does not treat or prevent CAD56.
Fatty fish - salmon, lake trout, herring, mackerel, sardines and albacore tuna lowers the risk for heart disease. The American Heart Association recommends
eating fish at least two times a week. They recommend fish that are high in
omega 3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA)49.
Excessive alcohol use: One drink a day for females and 1 to 2 per day for
males reduces the risk of heart disease. Excessive drinking increases the risk of
heart disease as well as stroke, liver problems, gastrointestinal problems, erectile
dysfunction and cancer49.
High level of blood homocysteine: Increased levels of this chemical may
increase the risk of vascular events. Homocysteine levels may be reduced with
folic acid, vitamins B6 and B12. This should be attained through the diet if
possible but supplements can be used if the diet is inadequate 49.
Inflammation: High levels of inflammation in the body boost the risk for heart
disease. A blood test – the high sensitivity C-reactive protein (hs-CRP) may help
determine risk for heart disease. Studies have showed that high levels of hsCRP foretell recurrent coronary events in patients with a history of unstable
angina and acute myocardial infarction57. Higher hs-CRP levels also are
associated with lower survival rates in these patients. After adjusting for other
factors, hs-CRP is helpful as a predictor of cardiovascular events57.
Risk Reduction
Patients should be encouraged to reduced risk factors for heart disease, but it
is unclear if the damage of years of exposure to risk factors can be reversed.
Lifestyle modifications – increasing physical activity, weight loss, improved eating
habits, smoking cessation – are recommended.
Treatment
When heart disease has been diagnosed, prevention methods are classified
as tertiary prevention. The goal is to stop progression of the disease and
possibly reserve the disease process.
Lifestyle modification techniques shown to treat and prevent heart disease are
weight loss, reducing saturated fat in the diet, stopping smoking and increasing
physical activity. Most people know that they need to involve themselves in
lifestyle modifications but few do a good job at following this recommendation. A
lifetime of habits is difficult to break even when diagnosed with a serious disease.
Lifestyle modification involving starting an exercise program and changing eating
habits and can be very difficult to maintain over the long haul.
Heart Failure
Heart failure is another form of heart disease that is targeted by HP2010. In
2005, there were 11.1 heart failure hospitalization for each 1000 patients
between the ages of 65-71 and 23.7 per 1000 in those 75-84 years old. The goal
is to reduce this number to 6.5 per 1000 people between the ages of 65 and 74
and 13.5 per 1000 in those 75 to 84 years old4.
Heart failure is the inability of heart to pump adequate blood throughout the
body. Fluid and blood, consequently, back up into the lungs, venous system,
abdomen and legs contributing to the signs and symptoms of heart failure.
Heart failure – which affects 5 million people and costs the United States’
health care system 29.6 billion dollars annually - causes more than 287,000
deaths annually and is the most common reason for hospitalization in those over
the age of 65 58.
Heart failure is more common in African Americans, Hispanics and Native
Americans than in white Americans, which may be because hypertension and
diabetes is more common in this population59. Heart failure is equally prevalent
in men and women.
Signs and symptoms
Heart failure is characterized by: shortness of breath, wheezing, chest pain,
cough, heart palpitation, edema, weight gain, orthopnea, fatigue and sometimes
cardiac arrest.
Risk Factors
Heart failure is more common in those with risk factors. Heart failure may be
present with one or two risk factors, but when more than one are present the risk
increases. Hypertension is the most prevalent risk factor in those with heart
failure, seventy percent of those with heart failure have hypertension58 59.
In addition to hypertension, previous myocardial infarction, diabetes, coronary
heart disease, cardiac arrhythmias, kidney disease, alcohol use, certain viruses,
sleep apnea, certain medications (doxorubicin, cocaine, rosiglitazone (Avandia)
and pioglitazone (Actos)), and congenital heart defects can all increase the risk
of heart failure58 59.
Treatment and Prevention of Progression Heart Failure
Identifying patients early in the course of their disease has the potential to
slow down the progression of heart failure. In some cases proper treatment can
improve heart function.
Heart failure is treated with lifestyle interventions, medications, devices, and
surgical options. Risk factors should be treated aggressively.
In all stages of heart failure non-pharmacological interventions are helpful in
the treatment and the prevention of progression. Exercise should be supported
unless there is a contraindication. Exercise can enhance overall function in heart
failure as well as help manage the risk factors. Exercise improves weight,
controls hypertension, dyslipidemia, improves glucose metabolism and reduces
cardiovascular risk.
Toxic habits must be hastened. Alcohol consumption should be minimized
(equal to or less than one drink per day in women and two drinks in men) or
stopped in those with heart failure. Smoking cessation should be encouraged.
Changing the diet helps in the management of heart failure. Sodium intake
should be decreased to 2-3 grams per day and those with advanced heart failure
should consume less than 2 grams of sodium per day60. Overweight or obese
patients should be encouraged to lose weight.
It is beyond the scope of this article to discuss the medications used to treat
heart failure. A few comments about medications and heart failure will help the
reader understand the importance of treatment in early disease to prevent
progression to advanced disease.
Angiotensin-converting enzyme inhibitors (ACE-I) reduce the level of
angiotensin II, which is a hormone that is elevated in the heart failure patient as a
compensatory mechanism. Angiotensin II leads to vasoconstriction and retention
of water and salt. While this is helpful for the short-term to help the body
compensate; overtime it will stress the heart and lead to progressive heart failure.
ACE-I should be taken by all patients with systolic HF (and many with diastolic
dysfunction) unless there is a contraindication61. ACE-I include: enalapril
(Vasotec), lisinopril (Prinivil, Zestril) and captopril (Capoten).
Some are bothered by a cough from the ACE-I. In this case it may be
switched to an angiotensin II receptor blocker (ARB). Individuals who develop
worsening renal failure or hyperkalemia while on ACE-Is should be switched to
the combination of an oral nitrate and hydralazine. Those who are get
angioedema while on ACE-I may be tried on a hydralazine/nitrate combination or
possibly an ARB.
Angiotensin II receptor blockers ARBs, while not as well studied in heart
failure have many of the beneficial effects of ACE inhibitors, but they do not
cause a persistent cough. ARBs include losartan (Cozaar) and valsartan
(Diovan). ACE-I are first line agents and if they are not tolerated, an ARB is
substituted.
Beta-blockers (BB) are used in patients with systolic HF. The combination of
beta-blockers (BB) with an ACE-I should be routine therapy for all patients with a
left ventricular ejection fraction of less than 40%61.
Aldosterone antagonists (AA) are potassium sparing diuretics that help the
heart function better and include the drugs spironolactone (Aldactone) and
eplerenone (Inspra). They are used for those with more advanced heart failure.
Diuretics are helpful in the patient with fluid overload and have limited role in
prevention of heart failure.
Nitrates and Hydralazine can be used in a combination medication called
BiDil. BiDil combines hydralazine and isosorbide dinitrate — both of which dilate
and relax the blood vessels. This combination increases survival when added to
standard therapy in black people with advanced heart failure62.
Digoxin increases the strength of heart muscle contractions but its use is less
frequent today than it was years ago. It has no role in prevention.
Prevention
The nurse’s role in the prevention of heart failure is to help identify cases of
heart failure so they can be managed properly, identify exacerbations, educate
patients and monitor treatments. Patients with heart failure need to be identified
so treatment can reduce the incidence of exacerbation.
Patients with heart failure need to properly utilize preventative services.
Annual influenza vaccinations and staying up to date on the pneumonia
vaccination are critical to prevent these two diseases that can lead to a severe
exacerbation of heart failure. Patients should avoid nonsteroidal antiinflammatory medications such as ibuprofen or naproxen as these medications
raise the risk of an exacerbation
Stroke
Stroke death rates are below the goal of 50 deaths per 100,000 people. In
2005, only 47 per 100,000 people died from stroke. Part of the reason that death
rates are improved is because of early treatment as patients are able to
recognize warning signs earlier.
Can screening for carotid artery disease reduce the impact of disease? It is
not recommend to screen patients without symptoms. While screening has the
potential to pick up blockages in the carotid arteries and possibly prevent a
stroke, the test comes along with a risk of a false positive test. This will lead to
further invasive testing such as angiography, which has the possibility to cause
harm. Magnetic resonance angiography may also be used as a confirmatory
test, but it also has a high false positive rate. Therefore, screening with duplex
ultrasonography in asymptotic patients is not recommended63.
Peripheral Vascular Disease
Peripheral vascular disease (PVD) affects between 8-12 million people in the
United States64 and has the potential to cause amputation of limb, disabling leg
pain or even death.
PVD results from an interruption of the arterial blood flow distal to the aortic
arch, most commonly symptoms manifest in the legs. It is typically related to
atherosclerosis. Atherosclerosis is a systemic disease and if patients have
disease related to atherosclerosis in the legs it is likely that they also have
atherosclerosis in other areas of the body such as the coronary vasculature or
the carotid arteries.
PVD results in lack of blood flow to points distal to the area of blockage. The
condition may be made worse or critical when a blood clot – emboli or thrombi –
block off the narrowed area. The blood clot may lead to critical limb ischemia
and without intervention, loss of leg may ensue. In addition, acute trauma may
precipitate acute occlusion.
Three types of PVD exist65. In type 1, the disease is localized to the aorta and
common iliac arteries and is found in those between the ages of 40 and 55.
These patients typically have high cholesterol and are smokers. Type 2 involves
the aorta, common iliac artery and the external iliac artery. Type 3 affects 60-70
percent of patients with PVD and can be found in many different arteries. Those
with PVD very typically have cardiac risk factors.
Risk Factors
Risk factors for PVD are similar to risk factors for CAD. Smoking is the
greatest risk factor. In addition, diabetes, high blood pressure, abnormal
cholesterol, chronic renal insufficiency, high levels of homocysteine in the blood,
and elevated C-reactive protein are all associated with PVD66.
Signs and Symptoms
Those with PVD will likely have a medical history that is positive for coronary
artery disease or have risk factors for coronary artery disease such as smoking,
high cholesterol, hypertension and diabetes. In addition other conditions that
may be noted include: atrial fibrillation, stroke and renal disease.
The most common finding in the PVD patient is discomfort upon ambulation.
The presentation is insidious. The patient describes cramping, weakness, aching
that is made worse by ambulation and improved with rest. Discomfort is felt
below the area of blockage. Depending on the site of the obstruction, the
presenting area of pain will be variable. When disease is in the femoral-popliteal
area the pain is typically in the calf. When the distal aorta is affected it may lead
to not only claudication, but impotence as well.
With severe disease – rest pain is present. Pain is so severe that it may wake
the person at night. Pain is felt in the lower leg and is improved by putting the
foot in the dependent position. Coolness or numbness may be reported.
When a history of rest pain is given, it is more concerning. This is typically
due to severe PVD and poor cardiac output.
Upon evaluation the extremity may be pale, cool and cyanotic. The pulses
distal to the blockages are diminished or absent. A femoral artery bruit may be
present. The nails may be thick and opaque. Hair growth may be minimal or
absent on the extremity affected by PVD.
Ulcers on the legs are a common complication for those with PVD. Ulcers on
the legs of patients with PVD present with well-demarcated edges, are painful
and have a deep base. Prevention or early detection of ulcers is important for
those with PVD or at risk of PVD.
Severe presentation of peripheral occlusive disease may lead to limb loss.
When there is paralysis or paresthesia of the limb it indicates more severe
disease. Worrisome signs and symptoms include: rest pain, gangrene and
ischemic ulceration65.
Diagnosis
Other conditions mimic PVD and should be considered when the patient
presents with symptoms suggestive of PVD. Deep vein thrombosis, back or
other muscle/tendon strain or lumbar disc pathology, arthritis, lower leg injury,
abdominal aneurysm, restless leg syndrome, nocturnal leg cramps or superficial
thrombophlebitis may all present with similar symptoms.
Spinal stenosis presents very similarly to PVD. Spinal stenosis causes pain in
both legs that increases in walking. In spinal stenosis the pain does not go away
quickly with rest and pain may also be present with prolonged standing.
Hip arthritis can cause pain in the leg, hip or gluteal region, which increases
with walking.
Screening
Screening for PVD is executed by performing an ankle to brachial index (ABI),
which is the ratio of systolic blood pressure in the lower extremity divided by the
systolic pressure in the brachial artery. A number above 0.9 is a normal reading.
Screening is not recommended in asymptomatic patients as the harms are larger
than the possible benefits67. Those who are smokers and have symptoms
indicative of this disease (such as intermittent claudication) should discuss this
test with their physician.
Management
Lifestyle modifications are key in the treatment and prevention of PVD. The
most important intervention is stopping smoking as it causes coagulation of the
blood and vasoconstriction. Smoking cigarettes increases the odds of PVD by
1.4 for each 10 cigarettes smoked per day68.
Dietary changes to reduce cholesterol levels and improve blood pressure
should be included as part of the treatment/prevention plan.
Exercise, while providing many health benefits, will increase pain-free walking
distance by up to 150 percent69. Exercise should incorporate walking up to a
point of discomfort, resting until pain subsides, and then continuing the walk.
Those with PVD need to be taught techniques to prevent complications of
PVD. Relaxation techniques may be helpful in reducing the vasoconstriction
associated with PVD. Teach patients to maintain feet warm and in a dependent
position to maximize pain relief.
Patients with diagnosed disease should look at the feet everyday as they are
at risk for skin breakdown. Any area of skin breakdown should be reported to the
health care provider immediately. When walking around the house encourage
the patient to wear shoes or slippers. Avoid contact with hot water – always
check the bath water before entering. Toenails should be clipped by a
professional.
After lifestyle interventions, treatment can be medical or surgical. Surgery is
associated with risks, but is often much more effective in symptoms relief than
medical treatment.
Antiplatelet70 medication has the potential to reduce the incidence of
cardiovascular disease. Other medications may help treat the symptoms of PVD.
Cilostazol (Pletal) – which has vasodilator properties in addition to antiplatelet
action - improves the exercise time and quality of life. Pentoxifylline (Trental)
was no better than placebo, and is not effective in the treatment of PVD 66.
Reduction in cholesterol is an important step in the management of occlusive
disease. Dietary intervention alone are often insufficient to reduce levels enough
to cause any clinically significant improvement in disease. The addition of
pharmacological agents are often necessary to manage dyslipidemia.
Controlling blood pressure is a critical factor in preventing atherosclerosis,
which is a key factor in PVD. In 2003, 31% of people over the age of 20 had
high blood pressure, the goal is to reduce this number to 14% by 2010. For
those with high blood pressure only 36% of patients had it controlled in 2003,
while the goal is to improve control rates to 68%4.
Cholesterol is another factor that will reduce disability from cardiovascular
disease. Mean cholesterol levels were 203 in 2003; with a goal of having a mean
cholesterol level of 199 by 20104.
In order to identify people with high blood pressure and high cholesterol they
must be screened. The public is fairly well informed about the importance of
screening and many have obtained screenings. In 1998, 73% of adults have had
cholesterol screenings, which is just a little short of the 80% goal set by HP 2010.
In 2003, 90% of people knew if their blood pressure was high or low which is a
little below the goal of 95% set by HP20104.
A last topic on cardiovascular disease is abdominal aortic aneurysm. This is a
weakening of the aorta, which is at risk to burst. Rupture of this vessel is
associated with a high mortality rate.
Abdominal aortic aneurysm screening by ultrasound should occur in men
between the ages of 65-75 who are current smokers or ever smoked71 as
smokers are at increased risk for rupture. No recommendation has been
formulated for those in this age group who have never smoked. Women should
not be screened as there is more potential harm for screening than benefit.
HIV
Human immunodeficiency virus (HIV), which once was incurable, is now a
manageable chronic disease. HIV is the virus that causes acquired
immunodeficiency syndrome (AIDS). AIDS is late-stage HIV. Years pass until
HIV transforms into AIDS. It destroys the immune system rendering it unable to
fight infections. Advanced HIV is characterized by low T cells or CD4 cells,
which are major players in the fight against infection. This renders the body
susceptible to infections that someone with an intact immune system could fight.
The incidence of HIV and AIDS is much lower now than it was in the early
1990’s. In 1998, new cases of AIDS were 17.9 per 100,000 people. Rates have
remained stable at 16.6 per 100,000 people in 2005. The goal targeted by
HP2010 is to lower this incidence to 1.0 per 100,000 people.
Certain ethnic groups are much more prone to the disease. Therefore, they
should be targeted for prevention education. The Black or African American
population is affected at a rate of 68.7 per 100,000 people when compared to 6.9
per 100,000 people for the white population. Forty-nine percent of the people
with HIV/AIDS are African Americans, although African Americans only make up
13 percent of the population72.
HIV is a very preventable disease as it is transmitted by sex, IV drug use and
exposure of infected material to mucous membranes. It can also be transmitted
from mother to infant in the birthing process. This is much more common in subSaharan Africa where 630,000 children are born HIV positive every year 73, when
compared to the United States where about 70-246 cases are reported each
year74. The use of condoms can reduce the risk of HIV transmission.
Education is important in the prevention of HIV. Those in high-risk groups
should be targeted for education. This includes men who have sex with men,
substance abusers and tuberculosis patients. Pharmacotherapy is available to
reduce mother to infant transmission, but HIV status has to known and the drugs
have to be available.
In the United States, approximately 40,000 people each year are infected with
HIV. Currently, approximately one million people in the United States are living
with HIV or AIDS74. Most cases are found in the developing world. Sub-Saharan
Africa has approximately 40 million people affected74.
Health care workers are at risk for HIV as they can be exposed through
needle injury, mucous membrane, skin or blood exposure. As of 2003, in the
United States, 57 health care workers have seroconverted to HIV following
occupational exposures. Also, 139 health care workers have HIV or AIDS and
deny any other risk factors75.
Transmission
In order to understand prevention it is important to understand transmission.
HIV is found in body fluid including blood, semen and vaginal fluid. It is easier to
transmit the virus when there are higher levels of virus in the body.
It is transmitted when infected fluid from one person is received by another.
The most common ways it is transmitted are:

Sex – vaginal, oral, anal

Sharing needles/syringes

The birthing process – an infected mother to her child

Breastfeeding

Contact with infected fluid from another person on the mucous
membranes or an open wounds
High-risk individuals include those: involved in the sex industry, drug abusers,
men who have sex with men, those who have unprotected sex and multiple
sexual partners. Other risk factors are those with hepatitis, tuberculosis or other
sexual transmitted diseases73 76.
Many people have misperception about transmission rates. Statistics listed
below give some information about the risk with certain activities, but many
factors can affect transmission rates, such as someone with a high viral load is
more likely to transmit. Sex during the menstrual period increases the risk or any
ulcerative lesions in the genital area during sexual contact increase the
transmission rates76.

Receptive anal intercourse is between 1:30 to 1:100

Sharing needles during illicit drug use is approximately 1:150

Needle stick with infected blood 1:300

Receptive vaginal intercourse 1:1000

Receptive fellatio with ejaculation 1:1000

Insertive anal intercourse 1:1000

Insertive vaginal intercourse 1:10,000
As of 1985, all blood is screened for HIV and the current risk for acquiring HIV
from a blood transfusion is about 1 in a 1,000,00076.
Prevention
To prevent HIV, avoid any activity that may transmit the disease. This is not
always realistic so there are strategies to reduce risk.
Abstinence is the most effective way to avoid HIV from sexual contact. The
next safest strategy is to only have sex with one person who is known to be HIV
negative (or any other STD). Condom use is recommended if having sex with
someone with an unknown HIV status or if the HIV status is unknown. Latex
condoms that are used correctly every time should prevent the transmission of
HIV and most other STDs. If both partners are HIV positive a condom is
encouraged to stop transmission of a different strain of HIV.
Keeping an open communication line between partners is critical. Previous
sexual partners, any drug use, HIV status and any other STDs should be
discussed. Those who have not been tested should be tested before starting a
new sexual encounter.
Transmission through intravenous drug use can also occur. It is best not to
use illegal intravenous drugs, but for those who do should use precautions: do
not share needles and only use only clean needles – one time use for all
syringes.
Circumcision affects HIV transmission rates. Those who are circumcised
have a smaller risk of getting HIV than those who are uncircumcised77.
To prevent mother to infant transmission multiple steps need to occur. The
mother needs to know her HIV status, by testing. Any mother who is positive,
should be treated during her pregnancy by an experienced clinician. This will
reduce the chance of transmission to the baby.
Screening
Patients who are at high risk for HIV – sex industry workers, IV drug users
and non-monogamous men who have sex with men - should be tested every
year. Those who are in a high-risk group for HIV transmission should have an
HIV test every year. Women who are considering pregnancy or are pregnant
should also be screened for HIV.
The blood is checked for antibodies to HIV and can be done at a doctor’s
office, independent labs, at some free health clinics and at home with home
testing kits.
The HIV enzyme-linked immunoassay (ELISA) is a popular test to screen for
HIV and is very effective at ruling out HIV, except for those in the window period.
Ninety-five percent of patients with HIV are positive on blood test within 6 weeks
of being infected76. A positive test does not definitely diagnosis HIV, as there is a
small number or false positive tests. Therefore another test – the Western blot –
is needed to verify that HIV is present.
Symptoms
Most cases of HIV are detected by testing. While many patients go through a
short period of symptoms (which resembles influenza) when the disease is first
contracted (acute seroconversion), symptoms are typically not present until late
in the disease. It is estimated that twenty-five percent of patients with HIV do not
know they are infected74. The mean time from contracting the virus to the
development of AIDS (without treatment) is 10 years73 76.
Management
Management of HIV is a complex and involves monitoring the disease,
providing antiretroviral therapy, treating and preventing opportunistic infections
and cancers, and treating abnormal blood values. Management of the disease
will not be discussed
Heath care exposure
The risk of contracting the disease is low among health care workers. The
most common way of getting the disease is from a needle stick – where the risk
is 1:250 to 1:300 when receiving a needle stick from a needle from an HIV
positive person76 78 79. Proper management with antivirals will reduce this risk to
almost zero76.
Death
Medial science has tremendously improved treatment options for HIV/AIDS.
The developed world has a very low death rate from the disease, but in the
undeveloped world, access to treatment is not available, and death rates remain
high.
Nurses have key roles in the prevention, detection and treatment of HIV and
AIDS. Nurses need to recognize high-risk patients and promote screening. This
will help raise awareness and hopefully reduce transmission. Nurses should
encourage women who are pregnant or are thinking about becoming pregnant to
be screened for HIV.
Immunization and Infectious Diseases
Immunizations – along with clean water - are important success of American
public health in the 20th century80. Immunizations have almost eliminated many
diseases and have significantly reduced others. There remains much room for
improvement as some disease states have not had ideal rates of vaccinations for
multiple reasons. Reasons that rates are less than idea include: vaccine failure,
patient non-compliance, missed opportunities to immunize and patients and
providers being unsure of the recommendations.
The next section will look at some common disease that are controlled with
vaccinations.
Diphtheria – which is rare in the United States with only 5 cases being
reported between 2000-200481 - is an acute infection, caused by
Corynebacterium diphtheriae. It is spread primarily by respiratory secretions and
typically infects the respiratory tract but may infect other mucous membranes or
skin wounds. Sometimes the infection can become systemic. Exotoxin created
by the organism may cause myocarditis and neuropathy82. Myocarditis may lead
to cardiac arrhythmias, heart block, and heart failure; whereas neuropathy
usually involves the cranial nerves first, producing diplopia, slurred speech, and
difficulty in swallowing82.
Pertussis infects the respiratory tract and is transmitted by respiratory
droplets. About half of the cases occur in those before age 2, but it may occur in
adulthood82. Therefore, adults should be immunized against the disease. A
single dose of the pertussis vaccination is recommended in the form of Tdap for
children 11 or 12 years of age, or in place of one Td booster in older adolescents
and adults age 19 through 6483.
Poliomyelitis virus, an enterovirus, is present in the throat and stools.
Infection is most commonly acquired by the fecal-oral route and can be present
in the stools for several weeks. Wild-type poliovirus infection has not been
reported in the United States since 1979. A few cases of vaccine stimulated polio
were reported with the oral vaccination which was changed in 199884. The oral
form of the vaccine is not available in the United States but can be used in other
parts of the world. Global incidence has decreased in the last 20 years. In 2004,
6 countries - India, Egypt, Nigeria, Niger, Pakistan, and Afghanistan - had wild
poliovirus transmission84.
Most cases of polio – about 95% - have asymptomatic courses, and those
who do have symptoms present in one of three ways82. The first is a mild viral
like illness with: fever, headache, vomiting, diarrhea, constipation, and sore
throat. Non-paralytic poliomyelitis - in addition to fever, headache, vomiting,
diarrhea, constipation, and sore throat – presents with signs of meningeal
irritation and muscle spasms. Lastly, the most dangerous, but most rare, is
paralytic poliomyelitis which represents 0.1% of all poliomyelitis cases82. The
paralysis – which may present with muscle weakness, tremor, constipation and
ileus - may occur anytime the patient is febrile.
Measles, Mumps, and Rubella (MMR)
Measles – a major cause of worldwide pediatric morbidity and mortality - is an
acute systemic viral (paramyxovirus) infection transmitted by inhalation of
infective droplets. There are periodic outbreaks in the United States, but its
prevalence is not high due to effective vaccination programs. In 2006,
unvaccinated patients accounted for 49 cases in the United States85.
Measles is characterized by a fever – often up to 40 degrees Celsius which
persists 5 to 7 days during the prodromal stage - and an early rash. Patients feel
wiped out and have nasal congestion, sore throat, sneezing, conjunctivitis and
sometimes photophobia. Koplik’s spots may show up 48 hours before the rash
and persist for 1 to 4 days on the oral mucous membranes and often on the inner
conjuctival folds. The rash starts on the face and behind the ears approximately
4 days following the onset of symptoms82.
Complications of measles include: ear infections, bronchopneumonia,
encephalitis, sub acute sclerosing panencephalitis, premature labor,
spontaneous abortion, and delivery of low birth weight infants 82 85. Therefore
vaccination is critically important and all children should be given their first
vaccine dose between 12 to 15 months of age and again at age 4 to 682.
Mumps - a viral (paramyxovirus) disease, which is passed from patients by
respiratory droplets - is characterized by inflammation of the salivary glands and
less commonly, orchitis, aseptic meningitis, pancreatitis and oophoritis. Fever
and malaise is present in some patients. On average, the incubation period is 14
to 21 days and the patient can transmit the infection in the saliva or urine about
1-3 days before the onset of symptoms82.
The vaccine for mumps is a live virus vaccine and should not be given to
women who are pregnant or plan to become pregnant or immunocompromised
patients82.
Rubella - a virus transmitted by breathing in infected droplets – has an
incubation period of 14 to 21 days and is able to be transmitted 7 days before
and 15 days after the appearance of the rash82.
It is characterized by malaise,
fever, rash, lymphadenopathy and coryza.
One of the biggest risks with rubella is the congenital rubella syndrome. It is
rare today with seven to 23 cases of rubella and 0-3 cases of the congenital
rubella syndrome annually present since 200186. Congenital rubella can lead to
birth defects including hearing loss. It is a much bigger problem in the
developing world with more than 100,000 cases annually in the developing
world86.
This vaccine is given with the mumps and measles vaccine.
Mainly,
because of the congenital rubella syndrome, women should not be pregnant
when they receive the immunization and be immunized before becoming
pregnant. They should not become pregnant until antibodies are present and
should be placed on birth control pills for at least 3 months after inoculation 82 86.
Haemophilus influenzae are small, gram-negative bacteria that are native to
humans and do not have any other natural hosts. It often colonizes the
nasopharynx and upper respiratory tract and typically is transmitted by direct
contact or inhalation of airborne droplets87.
The clinical manifestations of Haemophilus influenzae are variable depending
on the site of infection. Meningitis is the most serious and acute manifestation of
infection and accounts for the greatest morbidity and mortality. Other
manifestations of infection include: bacteremia without an identifiable source,
cellulites, epiglottitis, pneumonia with and without empyema, and septic arthritis.
Regular immunizations have significantly reduced the incidence of
Haemophilus influenzae with young children and infants having less than 1 case
per 100,000 people88.
Rotavirus vaccine – which can prevent a common gastrointestinal infection is administered as a sequence of three vaccinations at 2, 4 and 6 months. It
should not be given after 32 weeks.
Before the age of 2, the pneumococcal vaccine is given as a sequence of
three shots. After the age of 2 years a dose of the pneumococcal polysaccharide
vaccine should be given once.
The varicella vaccine – a live vaccine to prevent chickenpox - should be
administered between 12-15 months and then a second dose given between the
ages of 4 and 6.
Hepatitis A - which can cause severe liver disease - can be prevented by
sanitation as well as immunizations. Vaccines are given as a 2 dose series – six
months apart - starting at the age of 12 months and older.
Hepatitis B should be given to all newborns before to discharge from the
hospital. A second dose is administered at age 1-2 months and the third dose is
given after 24 weeks of age.
Hepatitis B virus is transmitted via sexual contact or through blood. Onset of
acute illness is 6 weeks to 6 months after infection with an average incubation
period of 12-14 weeks89. Of those affected with acute hepatitis B, 1-2% of adults
with intact immune systems go on to develop chronic disease, but this
percentage is higher in those adults who are immunocompromised or in
children89. Those with chronic infection have no symptoms but are at increased
risk for cirrhosis and hepatocellular carcinoma.
The disease typically presents insidiously with malaise, fatigue, myalgias,
arthralgias and anorexia. Abdominal pain is typically mild and present in the
upper right quadrant of the abdomen. Jaundice, hepatomegaly, splenomegaly,
lymphadenopathy and liver tenderness occurs in some patients. The patient will
typically recover in 2-3 weeks, but some have a protracted recovery.
Immunization programs are the most important intervention in prevention of
hepatitis B. Other interventions to reduce transmission rates includes: practicing
safe sex and for health care workers the utilization of universal precautions.
Pneumonia and influenza are two deadly, yet somewhat preventable
diseases. It is estimated that 36,000 deaths and 200,000 hospitalizations occur
each year due to influenza4. Only 42.2 percent of adults age 50-64 and 68.8
percent of adults over age 65 get the influenza immunization90. HP 2010 has set
a goal that 90% of high-risk adults over the age of 65 receive vaccination with the
pneumococcal and influenza vaccine. In 2006, only 64% received vaccination
with the influenza vaccine with in the last year and 57% ever received
vaccination by the pneumococcal vaccine4.
The rates of vaccination are much lower in high risk patients below the age of
65. For those between the age of 18 and 64 who are deemed high risk only 28%
received the influenza vaccine in the last year and 18% every received the
pneumococcal vaccine4.
Reducing the rates of pneumococcus – particularly invasive pneumococcal
infection – is another goal of HP 2010. Penicillin resistant pneumococcal disease
is another problem that hopes to be reduced by 2010.
Many of the goals set by HP2010 look at vaccination rates. The goal of HP
2010 includes the use of standard vaccination on most children. Vaccinations
specifically looked at include: diphtheria-tetanus-acellular pertussis, Haemophilus
influenza type b (Hib), hepatitis B, MMR, polio, varicella and pneumococcal.
The current immunization schedule for 2008 is updated on-line at:
http://www.cdc.gov/vaccines/recs/schedules/child-schedule.htm#printable.
Please review the following links to the CDC website for a complete listing of
vaccine schedule:

Children 0-6:
http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2008/08_06yrs_schedule_pr.pdf

Children 7-18:
http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2008/08_718yrs_schedule_pr.pdf

Catch up schedule:
http://www.cdc.gov/vaccines/recs/schedules/downloads/child/2008/08_cat
ch-up_schedule_pr.pdf

Adult vaccination schedule:
http://www.cdc.gov/vaccines/recs/schedules/downloads/adult/07-08/adultschedule-11x17.pdf
For children in day care settings the goal for vaccination rates is a little higher
than the general population. The goal set by HP 2010 is 95% for children in
daycare4.
Complete eradication is the goal with many diseases. Congenital rubella,
diphtheria, Haemophilus influenza type b, measles, mumps, polio, rubella,
tetanus are all disease that HP2010 has set a goal of affecting 0 patients. With
many other diseases the goal is not for complete elimination but a significant
reduction in the number of cases. Hepatitis B, pertussis, varicella are all
conditions that should be reduced by 2010.
Lyme Disease
Lyme disease– caused by Borrelia burgdorferi - is an infectious disease that
results in systemic illness. It is a bacterium that is transmitted to humans and
animals by the bite of an infected tick. It is the number one insect-borne infection
in the United States.
Lyme disease prevalence is highly concentrated in the Northeastern regions
of the United States – between 2003 and 2005 there were 64,382 cases of Lyme
disease91. The ten most affected states – Connecticut, Delaware, Maryland,
Massachusetts, Minnesota, New Jersey, New York, Pennsylvania, Rhode Island,
and Wisconsin – are responsible for 93% of cases91. Lyme disease continues to
affect 31.6 people per 100,000. HP2010 has a lofty goal of reducing this number
to 9.7 per 100,000 people4.
Lyme disease has been transmitted throughout the country as animals that
migrate harbor some ticks. The most common animals that harbor these ticks
are mice and deer, but other animals can harbor infected ticks including birds,
rodents, dogs, horses and cattle92.
Lyme disease prevalence hits its peak in the summer and late spring. Lyme
disease is transmitted during the tick’s nymphal stage which usually occurs in
late May – this explains why most cases are diagnosed in June and July as the
incubation ranges from 3 to 30 days92.
Initial signs and symptoms are a bull’s eye rash called erythema migrans.
There may be single or multiple lesions and they often occur in the groin, axillae
or thigh. This is accompanied by influenza like symptoms with malaise, myalgia,
headache, chills and sore throat.
Later symptoms include arthritis, neurological problems and cardiovascular
dysfunction. Swollen, painful, hot joins with asymmetric involvement may occur.
Large joints – especially the knee – are often involved. Depression and
dementia have been reported with Lyme disease.
Late stage Lyme disease may occur months or even years after the initial
neurological or musculoskeletal problems. Late stage problems may be chronic
and include arthritis, dementia, radicular pain, spastic paraparesis, bladder
dysfunction or ataxia92.
Serological tests are not sensitive to pick up the disease early in the course of
the disease. Testing can be helpful later in the course of the disease. A positive
enzyme-linked immunosorbent assay (ELISA) is followed by the Western
immunoblot (WB) test, which shores up the diagnosis92.
Treatment
Individuals affected with localized or early disseminated Lyme disease are
treated with doxycycline (100 mg twice per day), amoxicillin (500 mg 3 times per
day), or cefuroxime axetil (500 mg twice per day) for 14 days93. More aggressive
treatment is warranted if complications have arisen.
Symptoms typically resolve in 4 weeks in patients who are treated. Very few
patients have treatment failure or have relapses
Early Intervention after a tick bite
Early removal of the tick significantly reduces the risk of disease as about
96% of individuals who remove the tick early do not develop Lyme disease94.
While many preventative steps can be taken to prevent tick bites (see below).
The use of doxycycline 200 mg orally times one –in those over 8 years old – can
be given if the attached tick is identified as an adult or nymphal I. scapularis tick
and it has been attached for greater than 36 hours. The antibiotic must be
started within 72 hours of the tick removal and the local rates of infection with B.
burgdorferi must be equal to or greater than 20%93 for treatment to be indicated.
Prevention of tick bites
The most reliable method to avoid Lyme disease is avoiding outdoor activities.
This is not a practical suggestion, but caution must be exercised – especially in
endemic areas. When outside:

Wear clothes that cover the extremities, including long sleeves and long
pants that tuck into the socks or shoes.

Avoid areas that are not cleared of long grass. Try to walk on paved
areas.

Use insect repellent with DEET when out in areas with ticks.

After being outside shower immediately as it may take a few hours for the
tick to attach to the skin and then look at skin and clothes for ticks and
remove if found using tweezers.

If a tick cannot be removed see a health care provide

Protect pets with tick and flea collars, avoid taking them in grassy areas
and brush them after then return from outside.

In 2002, a vaccine that was helpful in fighting Lyme disease was
withdrawn from the market.
Miscellaneous Problems in Infectious Disease
The overuse of antibiotics is a dilemma that will lead to problems including:
antibiotic resistance and adverse events from antibiotic use. The use of
antibiotics for the common cold is often done but should not be. Strides have
been made over the past few years with antibiotic prescription for the common
cold being reduced from 2535 antibiotic prescriptions per 100,000 people down
to 1376 in 2005 per 100,0004.
Antibiotic resistance needs to be prevented with good medical care. Do not
take an antibiotic for a virus - only for bacterial infections. The antibiotic should
be taken as prescribed without skipping does. Do not take someone else
antibiotics and do not save them for future use. Patients should not demand
antibiotics and patients should be encouraged to talk to the health care provider
about antibiotic resistance.
Hospital acquired infections can occur for many reasons, but certain
preventative measures can reduce the incidence of these infections. Prevention
of hospitalized acquired infections revolves around good health care practices.
Infection related to central lines, urinary catheters, ventilators can all be reduced
with good health care practices.
Injury and Violence Prevention
Injury is a common cause of death and disability in those younger than 65
years old. Common injuries include: motor vehicle accidents, falls, violence and
self-inflicted injuries.
Traumatic brain injury (TBI) is caused by a hit or jolt to the head or a
penetrating injury. Approximately 1.4 million people have a TBI every year;
50,000 die and 235,000 are put in the hospital95. Brain injury can lead to lifelong
disability – the CDC estimates that approximately 5.3 million Americans have
disability secondary to TBI95. Disability can come in many forms including
problems with speech, emotions, thinking or sensation. Brain injury increases
the risk of certain diseases such as epilepsy, dementia and Parkinson’s disease.
TBI can result from a variety of causes including falls, motor vehicle accidents
(MVA) or assaults. Motor vehicle accidents – a common cause of death - is the
leading cause of TBI related hospitalization95. Seatbelt use is the most important
preventative strategy in preventing mortality from MVA. Other strategies useful in
preventing accidents include: not using cell phones when driving and no drinking
and driving.
Spinal cord injury (SCI) is another major cause of disability in the United
States with about 200,000 people with a disability secondary to SCI. The
condition also kills about 11,000 Americans every year96. The causes of SCI are
variable but common causes include falls, motor vehicle accidents and sports
and recreation activities. This condition costs the United States 9.7 billion dollars
annually and complications are common. The most common risk factors for SCI
are being male, African American and between the age of 15-2996.
Bicycle injury is another common cause of injury. It can lead to both TBI and
SCI. The use of a helmet reduces the risk of injury on a bicycle.
Falls are a very common cause of mortality and morbidity among older adults.
Multiple strategies can help reduce the risk of falls in older adults. Adults who
are physically active have more muscle tone and balance and are less likely to
fall. Yet, another good reason to encourage exercise.
Making sure that medical conditions are properly managed can help reduce
falls. Falls often occur secondary to low blood pressure, which may be due to
overmedication. Older adults may have urinary urgency and in a rush to get to
the bathroom they may fall. Properly managing all conditions common to older
adults is key. This is often best handled by an experienced health care provider
who regularly cares for older adults such as a geriatric nurse practitioner or a
geriatrician. Home safety is another factor that must be taken into account. An
evaluation by an occupational therapist can help assure that the home is set up
in a safe and effective way. Some tips for home safety include:

The avoidance of throw rugs

Reduction of clutter

Raised toilet seats

Grab bars next to the toilet and in the shower.

Assure proper lighting
Violence prevention has the potential to reduce the incidence of morbidity
and mortality. Assault with a firearm is the leading cause of death due to TBI 95.
Many injuries and deaths related to firearms are suicidal in nature.
What can be done to reduce the risk of injury and violence. Seatbelt use is
one of the most important interventions to reduce the risk of injury when in the
car. Utilizing a seat belt and booster seat on children is critical. Children should
use a booster seat when they outgrow the child safety seat. This typically occurs
when the child reaches about 40 pounds. When the lap/shoulder belt fits
properly they can stop using a booster seat. This typically occurs when the child
is over 57 inches95.
Wearing a helmet can help reduce the risk of brain injury. When on a bike,
motorcycle, scooter, skis, snowboard, horse, snowmobile or playing a contact
sport or baseball the use of a helmet can be lifesaving.
Education should be provided about child abuse. The abuser is typically
known to the abused person such as a parent, caregiver or teacher. Those who
have been abused need to be monitored closely as they are at increased risk of
alcoholism, drug abuse, depression, smoking, and suicide97
Encourage the use of fire detectors in the home. Fire detectors should be
checked every six months to assure that they are working. Providing education
to children and parents about fire safety is important.
Violence in the schools has been a major problem with some very tragic
events. Preventing violence in school is a joint effort between the student,
educators, parents and health care provider. The health care provider’s role is to
serve as educator and help teach students and parents techniques to reduce
violence. Parents should be encouraged to talk to their children about violence
and help their children develop strategies to help them cope.
Parents who are actively involved with their children will reduce the risk of
violence. Community events that revolve around violence or violent movies that
children may be watching should be monitored and limited. Encourage open and
continued discussion about violence as well as other healthy behaviors between
parent, health care provider and child.
Children should know they have someone to turn to if they become upset or
overwhelmed. These feelings are often predecessors to violence. They can be
encouraged to turn to a parent, teacher or guidance counselor.
Maternal, Infant, and Child Health
Mothers, infants and children represent a very large segment of the
population. Maintaining health in this population is important because it will help
shape the health of future generations.
Complications or maternal illness during labor and delivery resulting in
hospitalization have remained stable over the last 6 years. In 2005, 32.7 mothers
per 100 deliveries were hospitalized4. Complications during pregnancy include:
obstetric trauma, infection, preeclampsia, eclampsia and hemorrhage.
Death rates from child birth have decreased since the 1950 when there was a
rate of 83.3 deaths per 100,000 live births among mothers4. In 2005 the rate was
15.1 people per 100,000. Black women have the highest rates of maternal
death, with 36.5 mothers dying during childbirth for each 100,000 live births in
20054.
Neonatal death rates were 4.8 per 1000 live births in 1998 and remained fairly
stable with a rate of 4.5 per 1000 in 2004. The goal of HP2010 is 2.9 per 1000
live births4. In addition to improved neonatal death rates, improved maternal
and infant health care will reduce the rates of sudden infant death syndrome,
infant deaths from congenital disorders and child/adolescent death.
Prenatal care is an important marker of good maternal and infant outcomes.
The number of pregnant women who receive care remains relatively stable. In
2001, 83 % of pregnant women received prenatal care with the lowest portion
noted in the American Indian and the Alaskan Native population.
Abstaining from alcohol and cigarette smoking is important in good pregnancy
outcomes and most women do abstain with 88% of women abstaining from
alcohol and 89% of women abstaining from cigarettes in 20054.
Breastfeeding has multiple benefits for mother and infant. Breastfeeding is an
ideal way to deliver food to children. Breast feed children have higher scores on
cognitive and IQ tests, reduced risk of sudden infant death syndrome (SIDS),
lower risk of Hodgkin’s disease and childhood leukemia, lower risk of type I
diabetes, reduced risk of cavities, reduced rates of childhood and adolescent
obesity, reduced risk of asthma, eczema and allergic disorders and reduced risk
of many infectious diseases such as ear infections, meningitis, diarrhea and
respiratory tract infections98.
Mothers also derive benefits from breast feeding. Breastfeeding reduces the
risk of ovarian and premenopausal breast cancers, reduces the risk of
osteoporosis, reduces the risk of postpartum bleeding, increases bonding with
the infant, helps induce weight loss and may act as a birth control method
(though not 100% effective).
The USPSTF recommends the use of structured education and counseling to
promote breastfeeding. Sessions should be at last one extended session that
includes teaching behavioral skills and problem solving related to breastfeeding.
The USPSTF does not make a recommendation for or against peer counseling,
brief educational counseling by the PCP or the use of written materials 99.
Birth defects – particularly spinal bifida – are decreasing. This is mainly due
to the fortification of folic acid in foods or the use of dietary supplements.
Prevention strategies to improve maternal outcomes include:

Educating mothers about the importance of prenatal care, abstinence from
cigarettes, tobacco use and alcohol use.

Encourage prenatal care so problems can be found early and
complications averted.

Use of folic acid supplementation has reduced the rates of spina bifida

Encourage breast feeding
Improved death rates for infant and children depend on many factors. While
improvement in treatment of disease is one factor that will reduce death and
disability, prevention of disease is another key factor. Here are a list of health
promotion activities that can help reduce death and disability in infants, children
and adolescents.

Place infants to sleep on their back

Utilization of proper car seats/booster seats and seat belts in children

Reduce exposure to second hand smoke

Talk to children about the dangers of alcohol/tobacco and drugs.

Encourage physical activity

Promote good nutrition

Encourage the use of fire detectors in the house

Encourage the use of helmets with bike riding

If guns are in the home – practice home gun safety
Medical Device Safety
Monitoring medical product associated adverse events is one of the key
indicators measured in HP2010100. This focus area looks at adverse events due
to the medical management of the disease and not the disease itself. Adverse
events can be from medications, medical devices or diagnostic or procedural
errors. In the over 65 year old population, emergency department visits for
adverse events are increasing with emergency room visits for adverse medical
events occurring in 14 per 1,000 poeple100. Adverse medical events account for
10.9 million outpatient health care appointments and 1.8 million emergency room
visits100.
Health care organizations should be monitoring their adverse events. In
2003, 84 percent of organizations were; HP2010 goal is 90%.
The use of electronic medical records and a computerized physician order
system has been implemented in many health care systems with the hope of
improving medical care and reducing medical errors. The use of computerized
prescriber order entry forms in general and children hospitals was 4% in 2001,
increasing to 9% in 2006, which is above the goal set by HP2010 of 6% by 2010.
Counseling about the use of medications should occur from both prescriber
and pharmacist. In 2004, only 6% of pharmacists counseled patients; well short
of the goal of 95% set by HP20104.
Increasing the blood supply is another factor looked at by HP2010. Supplies
of blood are critical to good medical care. Many organizations – such as the
American Red Cross – continually work to improve the supply of blood. Currently
demand is approaching supply.
The U.S. Department of Health100 has made suggestions to improve
outcomes in this section of HP 2010. Providing financial incentives to counsel
patients may help improve rates of medication counseling. More written
information – including information for non- English speaking patients - about
medications have the potential to reduce mediation errors and improve
compliance. Implementing a global system to report blood supplies will help
assure supply keeps up with demand. The health care system needs to
encourage the donation of blood and improve the storage ability of blood. There
needs to be improvement in the communication of information by encouraging
collaboration between the Food and Drug Administration, Center of Medicare
Services, the Indian Health Services and the Agency of Healthcare Research
and Quality.
Mental Health and Mental Disorders
Mental health can have a profound effect on the health of Americans. Most
mental health problems increase the risk of poor quality of life and some mental
diseases even increase death rates. This section will look at some common
mental health problems. Understanding mental disease is a critical factor in
preventing them or catching them early and thereby reducing the negative impact
they have on the over all health care system as well as the health of individuals
affected by mental disease.
One measure of function in mental illness is employment. In 2002, those who
had severe mental illness had an employment rate of 52%, only 2% short of the
2010 goal of 54%4.
Depression globally impacts 121 million people and causes work, home life
and relationships to suffer101. Depression, which affects 10-20% of people
throughout life, increases health care costs by increasing the severity of many
diseases. Depression often occurs in combination with other mental illnesses,
such as anxiety disorders; other symptoms, such as pain; and chronic medical
illnesses, such as heart disease and chronic lung disease. Depression impairs
quality of life, physical and mental functioning and increases disability rates.
Depression is undiagnosed in many patients and some cases may result in
suicide. More commonly, untreated depression leads to poor quality of life.
Depression also increases the risk of death in many other diseases. Depressed
patients are less able to care for themselves and consequently do not manage
chronic disease as well as their non-depressed counterpart.
Even when diagnosed, not all patients with depression receive treatment. Of
adults with serious mental illness only 62% receive treatment. Only 58% of
adults with depression receive treatment which is just short of the HP2010 goal
of 64%4.
Not only does depression decrease quality of life, but it can also be deadly.
Those with depression are at increased risk for suicide. Suicide is a deadly
consequence of many different mental illnesses. In 2005, 10.9 per 100,000
people committed suicide. The goal for 2010 is 4.8 per 100,000 4.
Screening helps identify depressed patients in primary care settings and the
subsequent treatment of depression in adults most likely reduces morbidity and
suicide rates. It is important to provide follow up on depressed patients or the
benefits of screening are not recognized. There is no recommendation for or
against routine screening for children and adolescents for depression 102.
Multiple techniques are available to screen for depression including: the Zung
Self-Assessment Depression scale and the Beck Depression Inventory. The two
most important questions to ask include:
1. Have you felt depressed, hopeless, down or blue within the
past 2 weeks?
2. Have you had little interest or enjoyment in doing things in
the last 2 weeks103?
Those with a positive screen should have a full evaluation for depression so
diagnosis and treatment may ensue.
Causes
Although the exact cause of depression is not known, scientists believe that
there is an imbalance in the neurotransmitters in the brain. This hypothesis has
led to the development of many medications used to adjust the neurotransmitters
in the brain. Some believe a chemical imbalance leads to depression while
others argue it is a pattern of thinking.
Depression is often precipitated by a stressful life event, such as a death of a
loved one or placement in a nursing home. It is normal to have a grief reaction
after a stressful life event but prolonged depression is not normal. Other risk
factors for depression are listed in table 14.
Table 14: Risk Factors for Depression

Nursing home resident

Multiple medical co-morbidities

History of depression

Family history of depression

Age greater than 65

Alcohol or drug use

Lack of social support

Having a family history of depression

Going through a stressful life situation such as a death of a loved
one

Being female

Chronic pain

Disability

Having traumatic experience in childhood such as growing up in a
house with conflicts including abuse, family violence or abuse or
growing up in an alcoholic environment

Certain medications including steroids, theophylline, sleeping pills,
and beta -blockers

Any disease states can be compounded by depression especially
hypothyroidism, heart disease, after a heart attack, after a stroke,
Parkinson’s disease, Alzheimer’s disease and anemia
Presentation
Inability to function due to profound sadness is a common malady among
depressed patients. It is normal to feel sad from time to time, but one should not
be so sad that it interferes with daily functioning. Patients with depression
usually feel worse in the morning. Symptoms of depression have to be present
for at least two weeks and cause disability or dysfunction and not be related to
another medical disease. Many individuals suffer from a less severe form of
depression called dysthymic disorder, where a less severe sad mood persists for
at least two years.
The classical diagnosis of depression includes presenting with five or more of
the nine common symptoms on most days over the past two weeks104 (one
symptom being depressed mood or decreased interest).

Depressed mood most of the day, nearly every day, either self-reported or
as an observation made by others (e.g., crying).

Markedly diminished interest or pleasure in all, or almost all, activities
most of the day, nearly every day.

Appetite change as evidence by significant weight loss when not dieting,
weight gain, decrease or increase in appetite.

Insomnia or hypersomnia.

Psychomotor agitation or retardation.

Fatigue or loss of energy.

Feelings of worthlessness or guilty.

Diminished ability to think or concentrate or indecisiveness.

Recurrent thoughts of death (not just fear of dying), recurrent suicidal
ideation without a specific plan, or a suicide attempt or a specific plan for
committing suicide
Despite the fact that depression is an extremely severe disease, it often goes
untreated. This is unfortunate because many effective treatments are available.
There are major barriers to the treatment of depression. A patient not reporting
it to his or her doctor or the doctor not asking about it is one common barrier.
Another barrier is embarrassment on the part of the patient or health care
provider to discuss it. It can be a time consuming diagnosis to deal with in the
office so doctors are sometime reluctant to bring it up.
Depression is a difficult diagnosis to make. No characteristic exam finding,
specific blood marker or diagnostic test definitively diagnoses depression. It is a
diagnosis based primarily on the history. If depression is not discussed, it cannot
be diagnosed.
Treatment
Treatments for depression can be broken down into drug and non-drug
treatment. Without treatment most patients decline both mentally and physically.
Treatments include lifestyle changes, counseling, medicines, photo therapy, and
electro convulsive therapy.
Nurse need to be at the forefront of identifying and monitoring depression to
prevent the many problems that accompany this disabling disease.
Nurse’s role
Preventing severe depression and treating depression is a key to preventing
significant disability. Making sure all patients are properly screened for
depression is a primary goal of nurses.
Nurses need to recognize symptoms of a depressed mood such as withdrawn
behavior and lack of social interaction. This behavior needs to be documented,
formal screening tests needs to be done and reported to the primary care
provider for evaluation and consideration for a psychiatric referral.
Depression is very common and it is frequently under recognized and under
treated. Nurses can ask two simple questions to effectively screen patients (see
above). There are many safe and effective therapies and they should be used to
improve quality and quantity of life.
It important to evaluate for suicide in all depressed patients. But routine
screening for suicide is probably not necessary in patients who do not suffer from
depression or another mental illness. The USPSTF states that there is not
enough evidence to recommend for or against routine screening by the PCP to
determine suicide risk105.
Eating Disorders
Anorexia nervosa (AN) and bulimia nervosa (BN) are the two most common
eating disorders. They are under diagnosed and often overlooked or hidden by
the patient. Preventing complications involves early preventative education of
adolescents, screening and early intervention.
Anorexia usually affects women between the ages of 14 and 40, but can be
present at a younger or later age. While it is most commonly reported in white
middle to upper class American women, it also can affect men and those in other
social classes, racial groups or of other ethnic backgrounds106.
AN is associated with weight loss, extreme fear of weight gain and body
image disturbance106 and may lead to malnutrition and semi-starvation. BN is
characterized by binge eating with compensatory purging107. Purging can also be
seen in AN.
BN has an onset around the age of 18107 108 and is usually associated with
other psychiatric problems such as depression, anxiety, substance abuse
disorders and personality disorders. Research suggests that those with cluster B
personality disorders and impulsivity have the worst outcome107.
Males who are bulimic have a higher prevalence of homosexuality,
bisexuality, psychiatric co-morbidity, and/or substance abuse108.
Those with eating disorders are preoccupied with body weight, food, and a
sense of control. Many patients suffer from feeling that their life is out of control
and controlling their eating habits will help them maintain a sense of control.
The etiology of AN and BN is not well understood, but the cause is likely
multifactorial.
Among the many contributing factors include: family, peer and
societal pressures; childhood teasing; media, including internet; involvement in
certain sports and careers; genetics; type I diabetes; hormone and
neurotransmitter imbalance; puberty; psychiatric co-morbidity; altered self-image;
powerlessness; perfectionism; environmental stressors and sexual or physical
abuse109 110.
Factors associated with eating disorders include
107 108 109:
childhood sexual
or physical abuse, early onset of menses, psychiatric co-morbidity (depression,
obsessive –compulsive), binge drinking, low self-esteem, preoccupation with
weight, dissatisfaction with body image, helplessness, history of self-harm,
substance abuse, decreased sex drive, interpersonal conflict, homosexuality,
participation in a sport or occupation that values thinness.
Treatment of eating disorders includes psychotherapeutic and
psychopharmacologic interventions. Therapy should look at the underlying
causes of the disorder including: hunger, chaotic eating, inadequate caloric
intake, conditioned response, and profound fear of expressing impulses and
feelings, particularly feelings of anger and sadness.
Purging behaviors need to be addressed because they lead to many
complications of eating disorders107. Purging behaviors include vomiting,
excessive exercise, or the use of laxatives or diuretics.
Treatment is usually in an outpatient setting but if the disease is advanced,
there is suicidal ideation, treatment is refractory or there is a medical
complication, an inpatient stay may be warranted107 108 111. Timely intervention is
critical; health care professionals need to be mindful of the warning signs and to
evaluate their own beliefs and attitudes about body weight.
Diagnosis
Anyone with risk factors for eating disorders should be screening. The DSMIV defines AN as a refusal to maintain a body weight at or above 85% of ideal
body weight104. In addition, anorexics usually have an intense fear of gaining
weight or becoming fat and a distorted body image. The absence of menses for
at least 3 menstrual cycles is necessary for the diagnosis of AN.
Early detection and intervention is critical as these behaviors may lead to a
decline in overall health and may threaten reproductive health.
Three
screening questions may be used for anorexia109:

How much would you like to weigh?

How do you feel about your present weight?

Are you concerned, or is anyone else concerned, about your eating or
exercise habits?
The DSM-IV104 defines bulimia nervosa as uncontrollable, repeated bingeeating; recurrent inappropriate compensatory behaviors to control weight,
including: self-induced vomiting; laxative, diuretic and enema misuse; fasting;
compulsive exercise; and abuse of diet pills. These behaviors have to be
continued for at least three months at least twice a week.
Most people with BN are of typical weight; some even have a history of
obesity. BN patients have a fear of weight gain, a history of purging by selfinduced vomiting, excessive exercise, strict fasting, or the abuse of laxatives, diet
pills, enemas or diuretics.
Anorexia nervosa may be associated with changes in multiple body systems
including110: fatigue, hypothermia, cold extremities, acrocyanosis, dizziness,
abdominal pain, bradycardia, hypotension, heart murmur, orthostatic vital sign
changes, thin hair, brittle nails, sunken checks, lanugo, atrophic vaginitis,
atrophic breasts, flat affect and pitting edema.
Bulimics may have no symptoms or may have many. Some are related to
the compensatory techniques such as diuretic or laxative abuse. The bulimic
may be afflicted with: fatigue, insomnia, constipation, edema, weight fluctuation,
weakness, abnormal menses, insomnia, heartburn, bloating, swollen cheeks and
dental problems107 108.
When eating disorders are uncovered it is essential that the patient is
referred to an expert for comprehensive evaluation and treatment. Experts have
access to resources and a team of members who are skilled in dealing with
patients with eating disorders.
It is difficult for health care providers to diagnose eating disorders because
abnormal behaviors are often done in secret. Patients do not appear ill and their
weight may be normal (in BN) or low weight may be hidden by baggy clothes 108.
Recognition of characteristic signs and symptoms is essential as timely
evaluation and interventions improve outcomes.
Patients with eating disorders may be depressed, ashamed, isolated, and out
of control. They may be preoccupied with food and weight and be unable to
carry out any other activity.
Prevention of eating disorders
The more health care providers are aware of eating disorders, the more that
can be done to prevent them or catch them early. Early intervention improves
prognosis. Ideally prevention is the best strategy; but, little is known about
techniques to prevent eating disorders.
Nurses have key roles in the prevention, early identification and treatment of
eating disorders.
Below are multiple interventions to reduce the incidence and
improve the treatment of eating disorders.

Evaluate patients for eating disorders and refer high risk patients.

Foster therapeutic relationship with those at high risk - girls and teens.

Evaluate teens and girls about how they are handling the changing body
image that comes with the adolescent years. Evaluate diet habits, risk for
dieting, and body image disturbance.

Encourage parents to discuss body images in the media with their children
and help them comprehend that there are an array of body proportions
and the slender body shape is not necessarily the most idyllic body type.

Teach parents to not accentuate thinness, body shape and beauty in the
home.

Speak out against society’s enthrallment with thin models

Educate parents about the relationship between parents’ dieting behaviors
and children’s attitudes about weight loss.

Assist patients in evaluating medical information especially information on
the world wide web as there are many “pro-eating disorder” websites.

Teach adolescent females about their vulnerability to media images.

Teach males how to be more robust to negative comments about weight.

Teach fathers that children are inclined to eating disorders based on
negative statements about weight by the father.
Schizophrenia
Schizophrenia – another disease looked at by HP2010 - is a severe
psychiatric disease that reduces quality of life of the patient as well as the
patient’s loved ones. Like many other psychiatric illnesses, early identification is
critical as delay in diagnosis and treatment reduces the effectiveness of
treatment.
Schizophrenia it not an extremely prevalent disease as only one percent of
the population is affected. Men are afflicted with disease earlier (later teen years
or early 20’s) and more severely than women111. Women present about 10 years
later, typically with less severe disease. This may be because of the effect
estrogen has on dopamine (which is a key chemical in the pathophysiology of the
disease).
Schizophrenics marry less frequently, get divorced more, have higher rates of
incarceration and more likely to live in poverty or be homeless112.
Prevention of schizophrenia is challenging, but recognition of those at risk and
early identification of the disease has the potential to reduce morbidity and
mortality as well as reduce health care costs. There is currently no cure for the
disease, so once it is present, treatment is meant to manage the symptoms. It is
a chronic disease that most individuals never fully recover.
Risk Factors
Identifying those at risk involves identifying those with multiple risk factors for
the disease. The greatest risk factor is a family history of schizophrenia. Nine
genetic markers are known to increase a person's risk for schizophrenia
113.
If a
first degree relative has schizophrenia then the life-time risk is about 10 percent;
if both parents are affected than the life-time risk is 40%114.
Other risk factors include112 113 114 116:

African American

Living in a poorer residential area

Years of education for the mother and father

Lower occupational status of the father

Complications during birth and pregnancy

Poor nutritional status of the mother

Certain viral illness contracted by the mother during pregnancy

Being born in an urban center

Being born in February or March (lowest risk found in those born in August
or September

Having parents that do not communicate well and criticize frequently
Signs and Symptoms
Items that suggest schizophrenia are as follows:

Risk factors as noted above

Problems during the teenager years – socially or academically

Positive symptoms include: hallucinations and delusions

Negative symptoms include: flat affect, social withdrawal, loss of pleasure,
poor grooming, poor social skills, catatonia, poverty of speech and lack of
motivation or energy. These symptoms often present before positive
symptoms.

Inability to think clearly

Disorganized speech

Forgetfulness

Frequently losing items

Repetitive speech

Repetitive movements or gestures: pacing, odd facial expression or
unusual hand movements

Poor insight

Poor personal hygiene

Odd believes

Socially withdrawal

Agitation
Symptoms must be present for a significant portion of one month to make
the diagnosis with some symptoms being present for at least six months115.
Typically the symptoms come on gradually and are difficult to pick up.
Prevention of schizophrenia involves management of risk factors and closely
monitoring those at high risk.
Recommended prevention strategies include

Do not use illegal drugs
111 113 114 116:

Drink alcohol in moderation if at all

Develop and maintain lasting relationships

Avoid social isolation

Learn how to deal with stress

Develop a positive attitude

Marry and work on maintaining a loving relationship

Plan a healthy pregnancy, eat healthy during pregnancy, maintain a
healthy weight and avoid illness during pregnancy

Do not smoke or use alcohol during pregnancy

Learn to resolve differences

Raise children in a loving nurturing manner

Maintain good nutrition in early childhood

Teach children to mange stress

Encourage social skills for children and foster relationships
Anxiety
It is hard to get a firm grasp on the incidence and prevalence of anxiety,
because it is an under reported disease. It is a common condition with some
estimating that generalized anxiety has a lifetime prevalence between 4 and 6
percent117. Anxiety not only includes general nervousness but phobias,
obsessive-compulsive disorder and panic disorders. More recent estimates
suggest that eighteen percent of primary care patients have some form of anxiety
disorder while about 7% are generalized118. GAD is undertreated; it is treated in
only 60% of those afflicted in 20024.
The diagnosis of GAD involves identifying the defining characteristics. The
main criterion is excessive worry more than half of the days over a 6 month
period. Other criteria need to present such as muscle tension, irritability,
sleeping difficulty, difficulty concentrating, fatigue and restlessness104.
Those with anxiety utilize the health care system more often and place a
burden on health care. Generalized anxiety disorder is associated with an
increased incidence in cardiovascular disease and suicide. Early recognition of
this disorder has the potential to improve the health of these patients.
A mnemonic described by Seitz118 can be used to help determine if someone
is afflicted with GAD. The mnemonic is AND I C REST.
Anxious – Do you feel anxious worried or nervous most of the time?
No control - Do you have a hard time controlling the worry?
Duration – How long have you worried? (must be more than 6 months)
Irritable – Do you find yourself more irritable than usual?
Concentration impairment – Do you have a hard time concentrating?
Restless – Are you restless or fidgety?
Energy decrease – Do you have a decrease in energy?
Sleep impairment – Do you have problem falling/staying asleep?
Tension – Do you have a lot of muscle tension?
Utilizing the first three questions is a good screening test. The first three
needs to be present for GAD and then the remainder of the questions can help
delineate the severity of the disease.
Failure to answer positively to all the first
three questions makes the diagnosis of GAD unlikely, and proceeding with the
remainder of the mnemonic is unnecessary118.
Table 15: Criteria for GAD

Excessive anxiety and worry for greater than 6 months

Difficulty controlling worry

Worry that impairs social or work functioning

Anxiety that focuses on everyday events

Focus of worry not related to other disease states
Nutrition and Overweight
Obesity rates increased from 15.0% in the late 1970’s to about 34% of
Americans - including 33.3 percent of men and 35.3 percent of women119 – in
the mid-2000’s. In 1991 only 4 states had obesity rates greater than 15%; fifteen
years later no state had a rate of obesity below 15%120.
Obesity is one of the biggest risk factors for many diseases including
cardiovascular disease, diabetes, hypertension and multiple types of cancer. In
addition it is a costly; it costs America society about 100 billion dollars
annually121.
Classifying weight is a typically done by determining the body mass index
(BMI), but other methods do exist such as determining percentage of body fat.
Determining body fat is more technically challenging as many methods for this
determination take more training than measuring a height and a weight.
Bioelectrical impedance is one method that is sometimes used and it is easy to
perform. Unfortunately its accuracy has been questioned and machines needed
to test are expensive.
Generally, for adults, the BMI is closely related to the amount of body fat. It
will overestimate the amount of fat for an individual with a lot of muscle mass and
underestimate the degree of fat in someone with substantial muscle wasting.
Mathematical formulas, charts and websites are available to help clinicians
determine BMI. The formula requires that the clinician knows the patients height
and weight. Depending on the number assigned to the given height and weight
the patient will be placed in a classification of underweight, normal, overweight or
obese. Underweight is a BMI less than 18.6; normal weight is a BMI between
18.6 and 24.9; overweight is a BMI between 25-29.9 and anything over 30 is
considered obese. Online tools are available. An on-line calculator
(http://www.nhlbisupport.com/bmi/bmicalc.htm ) and an on-line chart
(http://www.nhlbi.nih.gov/guidelines/obesity/bmi_tbl.htm ) is available.
Another way to determine risk from body fat is to determine where the
patient holds most of his/her fat. Obesity that is localized to the abdomen is
much more dangerous than fat on the legs, arms or hips.
Abdominal obesity can be measured by diagnostic scans, but this is an
expensive way to determine how much fat is in the abdomen. Measuring waist
circumference is the most common method to determine abdominal fat. Men
with a waist circumference greater than 37 inches and females with a waist
circumference greater than 32 inches are at increased risk for heart disease122.
To determine the waist-to-hip ratio, the waist circumference is divided by the hip
circumference. If the waist-to-hip ratio is greater than 0.9 in men or 0.8 in women,
than the patient is at risk for complications related to obesity.
Causes of Obesity
When the amount of energy consumed by someone is greater than the
energy expended the excess energy will be stored as fat. The opposite is true;
and is the main principal in weight loss. In order to lose weight one must burn
more energy than one consumes.
Food and drink are the two main determinates of energy in, but energy out is
affected by many other factors. These factors include: age, sex, amount of
muscle mass, activity level, genetics, temperature and current disease states.
One pound of energy is equivalent to 3500 calories, therefore, to lose one
pound one must create an energy deficit of 3500 calories. Likewise, in order to
gain one pound of weight one must have a net gain in energy expenditure of
3500 calories. The individual who eats the same thing every day and goes on a
one mile walk after dinner, every day, will lose approximately 1 pound in 35 days.
This may not sound like a lot but it does equate to almost 11 pounds a year.
It may even be more than that. When someone exercises they tend to put on
muscle mass. Muscle mass is more metabolically active, so if someone gains 5
pounds of muscle mass they may increase there daily energy expenditure by 50
calories a day. This means that this individual is burning more calories with
every activity that they do. Fifty extra calories per day will add up to about 6
pounds of fat burning per year.
You may be thinking that will only be a one pound weight loss over one year.
While that is technically true – you have lost 6 pounds of fat, while putting on 5
pounds of muscle. This will result in clothes fitting better, feeling better, looking
better and possibly an improvement in blood pressure, blood glucose and
cholesterol levels.
Long-work schedules, inactive lifestyles, large portion sizes available at
restaurants, being involved in more spectator sports than participating in them,
availability of high calorie snack food and the abundance of fast food restaurants
are a few factors that contribute to the increasing prevalence of obesity in
American society.
There is a complex interaction between genetics and learned lifestyle choices
that contributes to obesity rates. Dopamine in the brain – which regulates eating
habits – is genetically variable123. Genetics may also determine if fat is stored in
the abdomen, legs or gluteal region. Families also have shared lifestyles.
Parents who eat well and exercise regularly typically have children who share
similar habits.
Sleep deprivation, depression, hypothyroidism, Cushing’s disease and
polycystic ovarian disease may all increase the risk of obesity. Medications
responsible for weight gain include: antidepressants, antipsychotics, lithium,
insulin, sulfonylureas and corticosteroids.
Why is obesity bad? Obesity increases the risk of many disease such as
heart disease, stroke, high blood pressure, dyslipidemia, stroke, diabetes,
osteoarthritis, gout, gallbladder disease, gastroesophageal reflux, erosive
esophagitis, non-alcoholic fatty liver disease, sleep apnea, stress incontinence,
depression and multiple cancers including; endometrial, breast, colon, rectal,
pancreatic, kidney, esophageal124 125 126.
Treatment
Individuals with a BMI above 25 with greater than or equal to two obesity
related risk factors (hypertension, abdominal obesity, family history or heart
disease or diabetes or dyslipidemia) should be treated. Anyone with a BMI
greater than 30 should be treated regardless of risk factors.
Rapid weight loss is often more satisfying to the patient, but long-term
success with rapid weight loss is not good. In addition, rapid weight loss can be
dangerous. Therefore weight loss should be slow – at a rate of about one to two
pounds a week.
A weight loss plan needs to be individualized and treatment is variable.
Lifestyle changes – dietary and physical activity – should be recommended for
all.
The Dietary Guidelines for Americans127 recommended consuming a variety
of fresh fruits and vegetables, whole grains, low-fat proteins and healthy fats.
Weight loss should not include drastic measures but include a reduction in total
energy intake while sustaining nutrient intake and increasing physical activity.
Very-low calorie diets are often used to treat obese patients. They typically
are composed of 400-800 calories per day and result in rapid weight loss (often
1.5 to 2.5 kg/week)121. They are not without risk though. Muscle wasting and a
decrease in lean mass can happen. A resistance-training program is
recommended to go along with this type of diet as it may help preserve lean
mass. Physicians are typically involved in the care of these patients as there is
risk of dehydration, gallstone formation and electrolyte imbalance.
Physical activity is critical in anyone who participates in a weight loss
program. A minimum of 150 minutes of aerobic exercise per week of moderately
intense exercise should be incorporated into each weight loss plan128. In
addition, increasing leisure time activity will aid in weight loss. Exercising and
burning calories offers benefits above weight loss. Overweight, fit people
statistically outlive leaner people who are out of shape129.
Another tip that can be used for weight loss includes the use of a pedometer.
Pedometers measure the number of steps taken each day. They serve as
motivating factors and often get people to be more active130.
Medication for weight loss can increase energy expenditure or impair energy
intake or absorption. When lifestyle intervention is not successful, medications
are often implemented to aid in weight loss. They are indicated with the BMI
above 30 or above 27 with obesity-related conditions, such dyslipidemia,
hypertension or type II diabetes121 131.
When the BMI is greater than 40 than surgery is considered after non-surgical
interventions have failed. It is also indicated if the BMI is 35 or above and the
patient is plagued with an at risk condition such as heart disease, sleep apnea or
diabetes131 132. Surgery should be carefully considered as there are risks and the
patient should be willing to commit to lifestyle changes after surgery.
What ever method is used to provide weight loss, multiple benefits will be
seen. Hopefully, in the process of weight loss the patient will have developed an
improvement in eating habits such as an increased intake of fruits and vegetable,
fibers, lean meats. These changes, independent of weight loss, should improve
health and quality of life.
Weight loss also has the potential to improve many disease states including:
arthritis, gastroesophageal reflux disease, hypertension, diabetes, dyslipidemia,
and depression. At the same time it reduces the risk of future diseases such as:
atherosclerosis, diabetes and some types of cancer.
Occupational Safety and Health
Occupational safety and health is an important part of preventative health
care. Every day approximately 9,000 workers in America sustain an injury that
leads to disability on the job133. Sometimes, injuries are responsible for death 137 workers die from work related disease each day133.
More and more health care workers are becoming trained in health care
issues related to occupational safety. The National Institute for Occupational
Safety and Health (NOISH) are responsible for training 700 workers with
backgrounds in medicine, nursing, safety engineering and industrial hygiene. In
addition there are many continuing education courses offered in occupational
safety funded by NIOSH. Other training courses that NOISH offers include: fire
fighter training and occupational health psychology.
Properly trained health care workers need be in place in industrial sites to
help improve work conditions. Worksites need to assure that these health care
workers have training in occupational health to minimize the risk of injury and to
receive proper treatment when injuries do occur.
While the majority of health care workers will have limited impact on
occupation safety and health, preventative measures in the workplace should be
encouraged by occupational health and safety practitioners.
Main goals in this section of healthy people 2010 include: reducing the
number of work related deaths and injuries
Back pain a common problem that is seen in workers. Control of worksite
conditions is out of the hands of most community health care providers, but
certain interventions can be implemented by community health care providers to
reduce the incidence of back pain.
Encouraging a healthy lifestyle can reduce the risk of back injury. Those who
are overweight are at increased risk of back strain. In addition, poor physical
conditioning increases the risk of back strain. Regular exercises for the back
done a few times a week can strengthen muscles and help maintain flexibility to
reduce the risk of back injury. Exercises that focus on strengthening the stomach
– such as a partial sit-up – are recommended. Stretching the hamstrings and low
back helps maintain flexibility and reduces the incidence of back injury.
Maintaining a good posture when sitting and standing will help reduce the risk
of back strain. When standing, the ears, shoulders, hips and knees should all be
in line. When lifting, do not bend the back, instead lift with the leg by bending at
the hips and/or knees. Types of shoes are an important consideration to reduce
strain on the low back. One of the most important considerations is to not wear
high-heeled shoes.
Oral Health
Oral health care has significantly improved the health of Americans. It is an
expensive service with an estimated $70.1 billion dollars going to dental health
care134. Many oral conditions are preventable and good health care has the
potential to either prevent or pick up many conditions early before they lead to
significant morbidity or mortality.
Fluoride is the most cost effective method to prevent tooth decay. Fluoride
can be ingested in multiple ways. Most communities have water fluoridation, but
consideration to supplementation should be given to those individuals who do not
have fluoride in the water. Most toothpastes have fluoride as well.
Dental cavities are decay of the tooth and are a preventable disease. Dental
cavities typically occur on teeth with pits and fissures, especially on chewing
surfaces135. Tooth decay is the most prevalent chronic disease of childhood 134.
Prevention of dental caries and gingivitis is accomplished though regular oral
care, water fluoridation and regular dental visits. In 2004, 45% of those two
years old and over had dental visits. Water fluoridation is present in 69% of
communities in 20064.
Oral health education should be done by health care providers, school
educators and parents. Teaching needs to be started early and frequently
reinforced. Good role models are also important, so teaching parents to model
for their children is a great way to instill lifelong habits. Not giving the bottle to
the infant/toddler in the bed is an important technique to prevent dental caries.
Tooth loss is the loss natural permanent teeth. It leads to a reduction in the
quality of life, self-image and ability to function. It often results from dental decay
and is affected greatly by previous dental care.
Gingivitis affects 22% of people. The best way to prevent gingivitis is good
oral hygiene with flossing and brushing. In the years 1988 to 1994, 48% of the of
adults aged 35-44 had gingivitis, which is short of he HP2010 goal of 41%4.
Patients should visit a dental professional at least every year. The purpose
of this visit is to monitor oral health, provide teaching, catching disease early and
screening for oral cancers.
Oral and pharyngeal cancer is primarily diagnosed in the elderly. They are
diagnosed in about 30,000 Americans annually and 8,000 die from this disease
each year136. Cancer in the throat and mouth is typically squamous cell
carcinoma. Early detection is critical as treatment early is effective, but if caught
late the prognosis is poor. Between the years 1990 to 1995, 36% of cases were
detected early4. Tobacco products are strongly linked to oral and pharyngeal
cancers.
Unfortunately, not all organizations see the value in screening for oral cancer.
The USPSTF reports that evidence is not sufficient to recommend for or against
routine screening for oral cancer137.
HP2010 has a goal that 51% of people are
screened by 2010. In 1998, only 13% of patients had this annual evaluation 4.
Dental sealants are recommended for the biting surfaces in 6-8 year-olds that
are at risk for tooth decay on molars which start to develop between the ages of
6-8. The goal is to have 50% of adolescents to have dental sealants4.
Multiple recommendations for improving the oral health for America have
been suggested134 135
1. Community water fluoridation
2. For those communities that do not have fluoridation, consideration should
be given to supplements for fluoride
3. Consider dental sealants in those who are at high risk
4. Brush at least twice a day. Brushing should occur, at minimum, after
breakfast and before bed.
5. Restrict sweets – especially sticky sweets
6. School based or school linked pit and fissure sealant programs
7. Community based screening for early detection of oral and pharyngeal
cancer
8. Encourage the use of helmets, mouth guards and facemasks in contact
sports
9. Reduce the use of tobacco products
10. Encourage regular dental appointment
Physical Activity and Fitness
Physical inactivity leads to many preventable deaths. Regular physical
activity reduces their risk for heart attack, stroke, diabetes type 2, dyslipidemia,
hypertension, certain cancers and osteoporosis138 139 140 141. In addition to its
effect on chronic disease and death rates, exercise improves quality of life138 141.
Exercise can be classified as aerobic exercise, strength and flexibility training.
A well balanced exercise program incorporates all three. Aerobic exercise
provides benefits to the cardiovascular system as well as many other systems.
These benefits translate into prevention and sometimes treatment of many
disease states. Bone and muscle strength is improved with strength training.
Stretching allows the muscles to stay loose, provides a sense of well-being and
prevents injury.
Aerobic exercise lowers blood pressure, improves cholesterol and improves
blood clotting parameters138 140. Exercise lowers risk for cardiovascular disease;
specifically, it reduces the risk of heart attack, stroke and peripheral vascular
disease138 139.
Exercise improves mood; it may help prevent and even treat anxiety and
depression as well as improve sleep138 139.
Aerobic exercise - walking, biking, jogging, swimming and aerobic exercise
classes - utilizes large muscle groups to increase heart and respiratory rate and
results in increased endurance.
Strength training - which can be accomplished with free weights, machine
weights or the body weight - offers different benefits than aerobic training. It
increases muscle mass, enhances functional capacity, burns fat and strengthens
bones.
Flexibility training improves the ability to move the limbs through a complete
range of motion and provides a feeling of relaxation and well being. Poor
flexibility increases the risk of injury, especially low back injuries.
Many people do not exercise. In 2006, 39% of those over the age of 18 did not
engage in physical activity. The goal for HP2010 is to reduce this percentage to
20%. In 2006, 31% of people engaged in regular physical activity either of
moderate or vigorous intensity. The goal of HP2010 is that 50% of people
engage in regular physical activity4.
With the increasing prevalence of home video game systems, fewer children
are regularly active. It is important to encourage children to live active lifestyles
so these habits are engrained in the future. In 2004, 27% of high school students
engaged in moderate physical activity and 64% engaged in vigorous physical
activity4 – mostly through organized sporting activities.
Physical education classes encourage physical activity and helps set a
pattern of lifelong habits. Not all schools require physical education. In 2006,
7.9% of middle schools and 2.1% of high schools mandated physical education 4.
Thirty-three percent of high school students partake in daily physical education 4.
The numbers are even worse for resistance training. In 2006, only 19% of
adults routinely participated in resistance training falling well short of the HP 2010
goal of 30%4. Thirty percent of adults participated in flexibility training which is
short of the HP2010 goal of 43%4.
Risk of Exercise
While exercise is highly recommended, there is risk. High risk individuals
should discuss an exercise program with their health care provider. Most
individuals who participate in moderate activity will be encouraged to exercise
without limitations. Some higher risk patients who want to engage in vigorous
exercise will require a complete medical evaluation including an exercise stress
test.
Certain conditions require exercise to be held. Uncontrolled chronic disease
or a new onset of an acute illness warrants exercise to be put on hold. Some
conditions that necessitate exercise precautions include: new onset of chest
pain; severe shortness of breath, irregular or fast heart beat; fever; significant,
ongoing weight loss; blood clot; infection; hernia; dehydration; new joint swelling
or pain; cardiac valve pathology; and abdominal aortic aneurysm139.
Exercise Prescription
Exercise prescription describes how one should exercise. Each mode of
exercise - aerobic exercise, strength training and stretching - has a specific
exercise prescription.
Aerobic Exercise
Aerobic exercise prescription is broken down into frequency, intensity,
duration and type.
Frequency: Aerobic exercise should be done three to seven times a week.
When starting out, especially for the novice exerciser, it is a good idea to
exercise three times a week with one day rest between exercise sessions.
Increasing the frequency to 4 days a week is sensible in the beginning. Adding
one day a week every few weeks assures the body adapts to exercise thereby
minimizing soreness, injury risk or psychological burnout142. Working up to some
form of aerobic exercise or physical activity everyday is a good goal for all to
have.
Intensity: Risks are minimized and benefits are maximized with moderate
exercise. Vigorous exercise increases the risk of burn out, injury and non-
compliance.
A simple method to gauge intensity is to use the talk test. Exercise hard
enough to increase breathing rate, but, not working so hard that a conversation
cannot be maintained without gasping for air.
The heart rate can be used to measure intensity, but this is a little more
challenging for most patients. Typically the maximal heart rate is determined and
then the individual exercises at a percentage of the maximal heart rate.
The predicted maximal heart rate is calculated by subtracting the patient’s
age from 220. For example, a 30 year-old would have a (theoretical) maximal
heart rate of 220-30 or 190 beats a minutes.
There can be individual variation using this method – not every 30 year old has
a maximal heart rate of 190. Some exercise professionals use a maximal stress
test to determine the true maximal heart rate. The exercise professional can use
a variety of formulas to determine the optimal heart rate training zone based on
the results of a maximal stress test. Unfortunately, not all exercisers have a
maximal stress test prior to exercise so this is not practical for everyone.
Individuals who want to utilize the heart rate method to determine exercise
intensity should use a heart rate monitor strap or use the services of trained
exercise professionals.
Duration: When starting an exercise program, the novice exerciser, should
keep the duration minimal. The exerciser should gradually increase the duration
of exercise. Patients may start out 10-20 minutes a day and add 1-3 minutes per
exercise session until they are exercising for a minimum of 30 minutes per
session. Aerobic exercise should be carried out for a maximum of 60 minutes
per day.
Type: Exercise should involve the large muscle groups such as the legs,
performing exercises like walking, biking, exercise classes and swimming.
Exercises that are enjoyed are complied with better, therefore, it is important to
consider personal preference when selecting an exercise.
Exercisers can employ cross training which reduces boredom and may
reduce injury risk. Cross training involves either performing a different mode of
exercise during each exercise session or doing different modes of exercises
within one training session. Cross training could include:

Monday: walk on the treadmill for 20 minutes, Wednesday: a water
aerobic class, and Friday: riding the stationary bike for 30 minutes.
or

Ten minutes on the stationary bike, ten minutes on the elliptical trainer
and 15 minutes walking on the track during one session.
Strength Training
Strength training increases muscle strength and mass. It also enhances the
ability to function in day-to-day life and reduces the risk of certain diseases.
Safety is an important part of strength training. Picking conservative weights
during the initiation of an exercise program is critical. Proper breathing- most
importantly not holding the breath - reduces extreme elevations in blood
pressure. Patients should be taught to breath out with each exertion and breath
in with the easier part of the lift. Warming up before and cooling down after
exercise should also be encouraged
While many body builders lift weights every day of the week, for health
benefits strength training should be done 2-3 times a week with at least 48 hours
rest between sessions. Muscles need time to recover after a weight training
session. When the same muscle group is stressed within 48 hours of the
previous session the muscles will not adapt ideally and may be overworked.
Each weight training session typically takes between 15-45 minutes and includes
at least one exercise for each major muscle group of the body (table 17).
Intensity is difficult to conceptualize in regard to weight training. There is no
specific formula or weight to tell a person what to lift – it often requires a lot of
trial and error. Each muscle group and each exercise will require a different
weight and a general rule should include picking a conservative weight. The
eventual goal is to select a weight that offers enough resistance so the last
repetition in a set is the last repetition that can be done without compromising
form.
Progressive overload should be incorporated into an exercise training
session. Progressive overload involves increasing the amount of work – either
with weight, repetitions or sets – on subsequent exercise sessions. Progressive
overload obliges the muscle to gain strength. Remember, safety first, never
compromise form to overload, if the body cannot do more work – do not force it.
For health benefits it is best to choose a weight that allows 8-15 repetitions to
be performed. This is the correct range for improving strength and endurance.
Power athletes will select higher weights and do fewer repetitions. This will
improve strength, but it does increase the risk of injury.
One to two exercises for every major muscle group is recommended. Select
an exercise for each muscle group using table 17. Bigger muscle groups may
have 2 different exercises.
As strength and endurance improves, the patients
can be permitted to increase the number of sets to 3 for each muscle group.
This will result in more benefit in relation to strength and endurance, but will add
more time to the routine and increase the risk of psychological burn out or injury.
Start off being conservative with weights, sets and repetitions and gradually
increase.
Key points to strength training142

Warm up before and cool down after each weight training session

Perform movements slow and under control

Use proper breathing with exercise

Progress gradually

Exercise 2-3 times a week

Exercise every major muscle group

Start with one set per exercise - work up to two to three sets per exercise

Take at least 48 hours rest between weight lifting sessions

Choose a weight that can be done 8-15 times

Incorporate progressive overload
Table 16: Example of Progressive overload (used with permission from142)
Monday
Thursday
Monday
Thursday
Monday
(3/6)
(3/9)
(3/13)
(3/16)
(3/20)
Chest
50 lbs./10
50 lbs./11
50 lbs./11
50 lbs./11
50 lbs./12
press
times – one
times – one
times – two
times – two
times – two
set
set
sets
sets
sets
Leg
90 lbs/12
90 lbs/13
90 lbs/14
90 lbs/15
100 lbs/12
press
times – one
times – one
times – one
times- one
times – one
set
set
set
set
set
Arm
20 lbs/15
20 lbs/ 15
25
25
25
Curl
times – one
times – two
pounds/10
pounds/11
pounds/11
set
sets
times – two
times/ two
times for
sets
sets
two sets
and 10
times for
one set
Stretching
Major muscles of the body should be stretched. Stretching should not be
vigorous; stretch each muscle to a point of minimal discomfort and hold. Each
stretch should be held for 10-30 seconds. Improving flexibility is more a product
of the duration of the stretch and not the intensity of the stretch142.
In order to minimize injury, it is best to stretch a warm muscle. Warm the
muscles by doing ten minutes of aerobic exercise (e.g. walking) prior to
stretching. Think of the muscles as a piece of gum. Imagine a cold piece of
gum, if you try to bend it, it will snap. On the other hand if you take a warm piece
of gum and bend it, it will bend nicely. Think of your muscles as that piece of
gum and warm them up prior to stretching them142.
Table 17: Major Muscle Groups

Chest

Back

Quadriceps

Abdominal

Lower Back

Shoulders

Hamstring

Bicep

Triceps

Calves
Public Health Infrastructures
To assure that public health remains strong it is essential that the public
health infrastructure is strong. In order to strengthen public health, three core
areas need to be addressed. They include: the public health workforce;
organizational and systems capacity; and the information, data and
communication system143.
Public health workers need to assure that they are able to meet the demands
of public health. There has to be training and education to prepare the worker for
the demands of public health service.
The public health system needs to have
the tools, resources, workforce and ability to impact the health of the nation.
Information, data, and communication systems are essential to help workers
identify the health of the population as a whole, allocate resources, and educate
the public about important health issues143.
Healthy People 2010 is a major public health endeavor. One of the goals
under the public health infrastructure section is that objectives are tracked every
three years. As of 2004, this goal is only being met 44% of the time4.
Improvement of the public health infrastructure is to be accomplished through
multiple measures. Providing continuing education for public health employees
will improve the system. Another strategy involves developing pubic health
improvement plans and improving the public health laboratory services.
Employing adequate staff will improve the public health system. Hiring state
epidemiologists with formal training will help assure proper policies are followed.
Public health laboratories are an important part of the public health. Before
1999 this system was declining. After 1999, funding had improved and public
health laboratories got their labs up to standards and updated their equipment.
Public health laboratories are now able to perform tests for biological agents
rapidly.
Respiratory Diseases
Respiratory diseases comprise a variety of illness. Chronic respiratory
disease is a major factor that leads to much death and disability. This section will
look at the two most prevalent chronic lung diseases: asthma and chronic
obstructive pulmonary disease (COPD).
Asthma - a chronic disease that affects the airways – is characterized by
bronchial constriction and excessive mucus production that occludes the airways
leading to less air getting to the alveoli. The asthmatic lung reacts to a variety of
substances which need to be preventing to avoid worsening or exacerbation of
asthma. Patients with asthma have a variety of symptoms including: wheeze,
cough, shortness or breath and chest tightness.
Managing symptoms of asthma is the hallmark of treatment as there is
currently no cure. Treatment involves controlling triggers, tracking symptoms
and taking medications to control symptoms.
Prevention of asthma involves not only preventing it from occurring, but
preventing worsening of the disease or complications once it is present. A
primary goal is to have a plan for managing the disease. A written plan –
detailing the maintenance medications as well as what to do in an acute attack –
is the first step.
Teaching patients to monitor their breathing will help them identify an early
asthma attack. Symptoms to monitor for include: increased wheezing, shortness
of breath or new coughing. In addition, monitoring peak flow levels regularly may
help pick up an impending asthma attack before symptoms are manifested.
Early treatment of attacks will reduce the risk the patient has a severe attack.
When an early attack is identified it is important to stop any factor that may be
causing the attack and take medications as described by the asthma plan.
Symptoms that do not improve, should be followed up on by a health care
provider.
To prevent complications it is important to determine what triggers asthma
attacks in the patient and help them develop strategies to avoid these triggers.
Common triggers include: pollen, cold air, mold and animal dander. Some
patients benefit from allergy skin testing or RAST testing to determine what
exactly triggers their asthma. Some patients may be candidates for
immunotherapy.
The use of the air conditioner may reduce attacks. This will allow patients to
keep the windows closed while remaining cool. Keeping the windows closed
reduces the chance outdoor allergens will affect the patient whose asthma is
triggered by outdoor allergens. Air conditioners also decrease humidity which
can trigger an asthma attack. If humidity is high in the home, the use of a
dehumidifier can help. The water in the humidifier should be changed daily.
Cleanliness of the inside of the home may also reduce the incidence of
asthma attacks. The home should be regularly cleaned. The utility company can
check the air conditioner and furnace to assure they are working properly.
Regularly replacing filters in the furnaces will reduce the amount of dust. The
use of a small-particle filter within the ventilation system can help.
The bedroom should be modified to reduce allergens that increase the
incidence of nighttime symptoms. Pillows, mattresses and box springs should be
encased in dust proof covers. If possible having a hardwood or linoleum floor
can reduce dust. Do not let animals in the bedroom.
Animal dander is an allergen to many patients. This is a problem in pets with
fur or feathers. If these animals are kept in the home they should be bathed
regularly and kept out of the bedroom.
When going outside in cold weather it is critical to cover up the mouth and
nose, as cold air can lead to significant bronchoconstriction.
A healthy lifestyle can help in the management of asthma. Asthmatics should
be encouraged to exercise. Unfortunately, many individuals with asthma limit
their exercise as they fear asthma will interfere with it. Being overweight can
worsen asthma. Strongly discourage smoking, as smoking can exacerbate
asthma. This includes second hand smoke as well as smoke from fires.
Gastroesophageal reflux disease can worsen asthma. If it is present,
treatment is necessary or it may worsen asthma symptoms.
Patients with asthma should get the influenza vaccine every year and most
should be immunized against pneumonia.
Chronic obstructive pulmonary disease
Chronic obstructive pulmonary disease (COPD) - a wide-ranging term
describing diseases of the lungs with limited airflow - is the fourth leading cause
of death, and over the next 10-15 years may become the third leading cause of
death. Chronic bronchitis impacts 8.9 million individuals who reside in the
community and 3.8 million are affected by emphysema144. COPD is an
expensive disease costing the United States 18 billion dollars directly and 14.1
billion dollars indirectly.
COPD is caused by environmental exposure (smoking), genetics and
advancing age. Smoking – the greatest risk factor – leads to greater than 75-
90% of the cases of COPD145. Not every body who smokes gets COPD; only
15% of smokers develop COPD146. It is currently unknown why some smokers
get COPD and others do not, but it probably has something to do with genetics.
Years of exposure are typically required before COPD develops – typically 20-30
years.
Pollution and occupational exposures to dust and other chemical are also
associated with COPD. Other risk factors for COPD include: older age, male
gender, respiratory problems, as a child and low socioeconomic status146.
Alpha-1-antitrypsin deficiency - a genetic defect – is associated with a reduction
in the enzyme elastin. It is a critical enzyme that stops the body from destroying
healthy lung tissue. When this deficiency is present, lung function declines faster
and emphysema starts at an early age. On average, emphysema is diagnosed
around age 53 for non-smokers with alpha-1-antitrypsin deficiency and age 40 for
smokers146.
Prevention of lung disease helps in reducing the impact respiratory illness has
on the health of the nation. A few steps that can reduce the impact of lung
disease will be discussed below.
The most important step is to cease use of all inhaled tobacco products, which
will be discussed further below in the section on smoking cessation.
Testing the home for radon and performing interventions to reduce any radon
found will reduce the incidence of lung disease. In addition to COPD, radon is a
leading cause of lung cancer. It cannot be detected by the homeowner as it is an
invisible, tasteless and odorless gas. It can be tested for by do-it yourself kits or
hiring a company to do the test.
Avoid exposure to asbestos will also reduce the incidence of lung disease.
Asbestos is linked to respiratory infections, mesothelioma, lung cancer and
asbestosis. Due to removal of asbestos from many public buildings it is less of a
problem today, but certain groups are at high risk. Dangerous exposure most
commonly affects those who work in the asbestos industry, construction workers,
shipbuilders, demolition workers, drywall workers and firefighters.
The avoidance of air pollution is important to reduce the risk of lung disease.
Those who live in large cities or an area where there are many industries
expelling pollution are at highest risk of lung disease.
Reducing pollution in the home is another step that can help reduce the
incidence of lung disease. Certain pollutants – animal dust, smoking, mold, dust
mites, radon, asbestos, and chemicals – are able to be controlled by individuals.
Sexually Transmitted Diseases
Sexually transmitted diseases (STDs) – which are very preventable - are
infections that are usually spread by sexual contact. STDs can also be passed
from mother to baby during delivery. Common STDs include: Condyloma
acuminatum, human immunodeficiency virus, Chlamydia, herpesvirus,
gonorrhea, syphilis, trichomonas vaginitis, chancroid, granuloma inguinale,
scabies, louse infestation and bacterial vaginosis. The organisms that leads to
STDs do not live outside the body well and flourish by contact with mucous
membranes and warm moist areas.
In females between the ages of 15-24, 6.9-15.3% had Chlamydia in 2004.
This makes it the most common bacterial STD. The target goal is to reduce this
number to 3 percent by 2010. In STD clinics (which have rates higher than the
general population), the rate of Chlamydia in males aged 15-24 is 20.2%4.
Most of the time, when affected with Chlamydia, the patient will be
asymptomatic. If symptoms are present, they occur 1 to 3 weeks after exposure
and may include: dysuria, vaginal or urethral discharge and genital itching.
Gonorrhea - caused by Neisseria gonorrhoeae – grows best in warm, moist
regions of the female reproductive tract. This bacterium can also grow in the
urethra in men and women as well as the mouth, eyes, throat, joints and anus147.
Gonorrhea affects 267 females aged 15-44 per 100,000 people. African
American females in this age category are affected at a much higher rate with
1261 per 100,000 people being affected4.
Many people with gonorrhea are asymptomatic, but may present with dysuria,
urethral discharge, vaginal discharge or vaginal bleeding. It may affect the
male’s testicles and lead to epididymitis. Both Chlamydia and gonorrhea can
lead to infertility.
The infection may also settle in the rectum and present with symptoms such
as soreness, bleeding, pain with bowel movements, rectal discharge or anal
itching.
Syphilis - caused by the bacterium Treponema palladium – has rates that are
lower than other STDs. In 2004, 2.7 per 100,000 people have primary or
secondary syphilis4.
Like other STDs it most commonly presents without symptoms. Symptoms
are vague and are often attributed to other disease processes. The disease is
grouped into three stages: primary, secondary and latent. The primary stage is
characterized by a lesion or multiple lesions which manifest about three weeks
after infection but the primary stage may start anytime between 10 and 90 days.
The lesion – which typically lasts about 3-6 weeks - is firm, round, and
painless148.
The secondary stage is associated with a non-pruritic rash and mucous
membrane lesions. Typically the rash – which is often noted on the hands and
feet - begins as the primary lesion heals. The secondary stage may also be
associated with pharyngitis, fever, hair loss, headache, myalgia, fatigue and
weight loss148.
The latent stage occurs in 10 percent of those with untreated disease. The
symptoms may not occur for 10-20 years and may lead to dementia, blindness,
neurological dysfunction and even death.
Genital herpes is caused by the herpes simplex virus type 1 (HSV-1), or, more
typically, type 2 (HSV-2). The disease affects about 17% of women between 2029 years old4. While the disease can be disabling, it is most often mild. Blisters
(that ulcerate after they open) may take up to 2-4 weeks to heal. They occur on
or around the genitals or rectum and are the most typical symptoms. It is a
reoccurring disease, but the severity usually lessens overtime149.
The disease is more prevalent in women as male-to-female transmission is
more frequent than female-to-male transmissin149. The virus is released from
infected sores but infection can be transmitted between outbreaks, so prevention
must always be kept in mind for individuals afflicted with genital herpes.
Condoms may not guard against transmission, when the disease is passed from
a lesion not covered up by the condom – such as in the pubic area, but not on
the penis.
Within 2 weeks of infection, the first outbreak occurs. The sores may be
accompanied by lymphadenopathy and fever. Many people are affected by the
disease and are unaware.
Prevention of STDs
STDs are prevented by avoiding risky situations where they may be passed
from one person to another. Participating in abstinence or engaging in sexual
relations with one partner who is free of STDs is one method of prevention.
Condom use is critical, but not completely effective. A latex condom with a
lubricant is recommended – for STD prevention - whenever having sexual
relations with someone of an unknown STD status or with a known STD. Its use
does not guarantee prevention of the disease, but it does reduce risk. If both
partners are afflicted with an STD a latex condom with lubricant should be used
to prevent transmission of a different infection or a different strain of infection.
Sexual partners should discuss personal history of drug use, HIV status and
all other sexually transmitted diseases with each other. Testing should be done
before a sexual relationship is commenced.
HIV and hepatitis can be spread by injection drugs in addition to sexual
contact. For those individuals who inject drugs should be encouraged to stop,
but must also be taught about not sharing needles, using only clean needles and
using disposable needles only once.
Prevention of STDs is the best strategy to reduce the impact they have on the
country. Testing for disease is critical as many STDs are asymptomatic. These
patients have the potential to pass on disease. In addition, early detection of
signs and symptoms should prompt treatment to prevent transmission.
Patients with a diagnosed STD should make all previous sexual partners aware
so they can have properly testing.
Prevention and treatment of STDs, particularly gonorrhea and Chlamydia, is
critical so the incidence of pelvic inflammatory disease (PID) will be decreased.
PID – which affects 8% of females between the ages of 15-44 - is an infection of
the uterus, ovaries and fallopian tubes4. Chlamydia and gonorrhea are the two
most common diseases that are responsible for PID.
PID risk is increased in sexually active women, those with multiple sex
partners, women who douche after sex and those under 25.
Symptoms of PID can range from asymptomatic to severe. Symptoms
include: fever, vaginal discharge, lower abdominal pain, vaginal bleeding and
dyspareunia.
The prevention of PID involves preventing STDs or adequately treating STDs.
Untreated PID is associated with an increased risk recurrent PID, scaring of the
reproductive tract which increases the risk of ectopic pregnancy and infertility.
Ectopic pregnancy can be fatal.
Substance Abuse
Substance abuse is a major problem and is linked to many negative health
effects. Substance abuse takes many forms including the abuse of alcohol, illegal
drugs and tobacco. It is responsible for many preventable health problems
including diseases such as cirrhosis, heart disease and multiple cancers as well
as accidents such as motor vehicle accidents.
Alcoholism is one of the most prevalent modes of substance abuse as there is
a lifetime prevalence of 12-16 percent150. Small amounts of alcohol have been
shown to be potentially beneficial in cholesterol readings49, but excessive use of
alcohol can lead to liver damage, hypertension, gastrointestinal problems, mood
disturbances, erectile dysfunction and problems with balance which leads to falls
and fractures. Deaths related to cirrhosis are 9.6 per 100,000 people4.
Excessive use of alcohol also leads to accidents often times due to poor
decision making or impaired coordination. In 1998, 5.3 deaths per a 100,000
population were an alcohol-related motor vehicle accident.
This rate of alcoholism is higher among certain ethnic groups. American
Indians and Alaskan Natives had rates of alcoholism in 1999 of 24.8 per 100,000
people. This rate remained stable through out the early 2000’s. In 2005, nine
out of 100,000 people in the general population while 22.6 per 100,000 American
Indians/Alaskan Natives were afflicted with alcoholism4.
Alcohol and drug use is becoming a bigger problem among the youth. Eightyone percent of high school seniors have consumed alcohol at some point. The
average amount of alcohol consumption for people over the age of 14 has
increased from 1997 to 20054. Reducing the amount of alcohol and drugs used
by those before the age of 20, would significantly reduce the amount of alcohol
and drug abuse in society.
Being aware of high-risk times has the potential to significantly reduce the
impact of alcohol use among adolescents. Boredom is a prime impetus for
alcohol or drug use. Encouraging kids to remain active with multiple activities
has the potential to reduce the amount of drugs and alcohol used. Another time
that is deemed high risk is when a family moves. Moving to a new community
typically brings new friends. Parents should be encouraged to closely monitor
their children’s new friends. Talking to them about the drugs and alcohol during
these high-risk time is critical.
“Just say no”, was Nancy Regan’s hallmark slogan. This applies to kids and
parents. Parents need to talk to their children and act as role models. Teaching
children strategies for avoiding situations where alcohol and drug use is
prevalent and providing them with strategies to implement when they are faced
with tough choices is critical for all parents.
Binge-drinking – heavy consumption of alcohol over a short period of time - is
a major cause of morbidity and mortality. In 2006, 25% of high school seniors
binge drank in the past two weeks while in that same period of time 40% of
college students binge drank4.
In the primary care setting all patients should be screened and offered
behavioral counseling. Even in those patients who are not dependent on alcohol,
the primary care setting is the ideal place to screen patients, provide counseling
and follow up to reduce the amount of alcohol consumption151.
Illegal drugs remain a common problem. Drug-induced deaths were higher in
2005 than in 1999. In 2005, 11.3 per 100,000 deaths were related to drugs. The
goal is to reduce this number to 1.2 per 100,000 people4. In addition to death,
drugs cause a lot of other problems. In 1998, about 542,000 people visited
hospital emergency rooms secondary to the use of illegal drugs. In 1998, 360
dollars per person are lost in productivity due to drugs and 468 dollars for
alcohol4.
Steroids are used among adolescents and young adults to improve strength,
muscle mass, athletic performance and physique. Among high school seniors,
1.5-2.5 percent of them use steroids4. It is not a problem of just boys. Girls also
use steroids, mainly for body sculpting purposes.
What can health care providers do to reduce the incidence of substance abuse:

Teach parents to be good role models

Teach parents to be engaged with their kids

Teach parents to watch their kids closely

Work with the media to increase the prevalence of mass media prevention
messages

Work with community groups (youth groups, schools) to increase
community education

Lobby for more education in the schools
Tobacco Use
Cigarette smoking is the most common form of tobacco use with 21% of those
over 18 currently smoking4. Twenty-eight percent of high school students used
tobacco in the last year4. Tobacco use is a major cause of morbidity and
mortality as it leads to problems and diseases with many different body systems.
It is linked to multiple lung diseases (COPD, asthma and lung cancer),
cardiovascular disease, certain cancers (lung, oral, esophagus, larynx, throat,
bladder, pancreas, kidney, cervix and stomach) and many infectious diseases
(respiratory infections and middle ear infections).
If no one smoked, there would be improved health, more health care dollars
and more money in the pocket of those who currently smoke. America has to do
a better job at reducing the number of smokers, by reducing the number of
current smokers, as well as stopping people from starting smoking.
Between 1998 and 2006, 41-43% of smokers over the age of 18 attempted to
cease smoking. This is short of the HP2010 goal of 75 percent of smokers
making an attempt to quit4.
Second-hand smoke is another factor that affects the health of those afflicted.
About 20% of individuals under 6 years old were exposed to second-hand smoke
in the late 1990’s but with improved awareness and improved public smoking
laws this number was reduced to 8% in 20044.
In 1998, 24% of those over age 18 smoked. In 2006, the number dropped to
21%, well short of the 12% target desired by HP20104. In 1998, forty percent of
high-school students used tobacco – with cigarettes being the most commonly
used form of tobacco - in the last year; but this number decreased to 28% in
20054.
Smokeless tobacco – only used by 2.5% of adults in 1998 – is associated with
multiple negative side effects such as oral cancer, pancreatic cancer,
leukoplakia, bad breath, dental erosion, tooth discoloration and bone loss around
the roots of the teeth152.
Vision and Hearing
Screening for eye and ear disease is a large part of catching disease early,
implementing treatment and in some cases preventing vision and hearing
problems. In 2002, 36% of those 5 years old and younger had their vision
screened. This number needs to be increased to 52% by 2010 to reach goal 4.
Corrected vision is important to assure that individuals can see optimally.
Optimal vision is important because poor vision leads to many problems
including: reduced work effectiveness, reduced driving efficiency, reduced quality
of life and increased risk of falls. In 1999-2000, 110.7 people per 1000 had
uncorrected vision in those 12 and older4.
Diabetes is a major cause of blindness and visual impairment. While
screening for vision problems is important across all populations, it may be more
important in the diabetic. Of those with diabetes 45.8 for each 1000 people have
visual impairment due to diabetes. Diabetic patients should have annual dilated
eye exams to monitor for multiple eye diseases including diabetic retinopathy.
Other causes of visual impairment include: glaucoma, cataracts and macular
degeneration. These conditions can be detected and visual impairment can be
mitigated with early intervention. It is important to encourage regular eye care
especially in high-risk groups such as diabetics and the older population.
Eye injuries are a major problem in the work place. They can lead to lost
workdays, reduced work efficacy, vision impairment and reduced quality of life.
The use of protective eye ware can reduce the incidence of eye injury.
Certain workplaces require the use of protective eye ware. Eye ware should be
used in the home, on the workbench, in the garden, some workplaces and when
working on the car. Many household chemicals have the potential to damage the
eyes. In addition to wearing eye wear when working with household chemicals it
is important to read instructions carefully and do work in a well ventilated area.
The workbench may involve activities that result in fragments, fumes, sparks,
particles, radiation, chemicals and dust which all may injure the eye. When
cutting the grass or trimming/edging using eye ware will reduce the risk of injury
from flying particles or rocks. When working on the car certain factors – sparks,
debris or battery acid - can damage the eye.
Hearing screening will help detect problems and improve quality of life.
Newborn screening should occur within the first month of life. In 2001, only 66%
of newborns where screened. The goal of HP2010 is 90%4. When hearing
problems have been detected it is important that interventions are implemented.
Adults need to be screened for hearing loss as well. Hearing screening in the
last five years occurred in 29% of adults aged 20-69 in 1999-2000. In adults over
70, 37% were screened4.
Hearing loss can be secondary to loud noise. The use of ear protection when
exposed to loud noises should reduce the incidence of hearing loss. In 1999-
2000, 457 of 1000 people who are exposed to loud noises used protective
measures4.
Many adults with hearing aids do not use their aids. Teaching patients about
the use of hearing aids and cochlear implants are appropriate interventions.
What can the health care provider do?
1. Encourage regular eye evaluation by an ophthalmologist/optometrist
2. Encourage regular hearing screening for those at risk for hearing loss
including the over 65 year-old population
3. Teach about the use of wearing protective eye ware
4. Encourage the use the ear protection by those who are exposed to loud
noises
5. Referral of older adults with hearing impairment for screening and hearing
aids
Conclusion
Preventative health care has the potential to reduce morbidity and mortality. It
entails a wide range of activities that are currently under utilized, but have the
potential to significantly improve the quality of life.
As seen above, many of the goals of HP2010 are probably not going to be
met. The goals that are set by HP2010 will help improve the health of the
American population.
Some of the goals and target areas are things that can be improved by
individual health care providers. Others goals are more difficult for the individual
health care provider to change and may require changes in the health care
structure.
What can the average health care provider do to help reach the goals of
HP2010? While one health care provider’s efforts will not assure that HP2010
goals are meet, if all health care providers take responsibility for teaching,
intervening and implementing – health care will improve.
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