Download Primary Prevention

Primary Prevention: Preventative Measures
Leading to Better Health Outcomes
(August 25th, 2006)
Impact of an Aging Society
In the early 20th century, only 3 million people (4%) in the
U.S. were over the age of 65.
Life expectancy has continued to increase. Today, more than
36 million Americans are over the age of 65. Over the next 25,
years, over 70 million Americans will be over 65. They will be
racially and ethnically diverse.
According to statistics, a child born in 2003 can expect to
live 77.6 years Can increase from 75.4 years in 1990.
The aging population is increasing the demand for health
care and social services.
Health status of the population
It appears that more older individuals are living
independently and enjoying it more than in the past.
Currently, about 80% of older adults have at least one
chronic condition, and 50% have at least two.
Chronic illnesses can cause many years of disability, pain,
and lost function. Three million older adults have trouble
performing basic activities of daily living such as bathing,
dressing, and eating.
Because the elderly population will be older and larger in the
coming years, overall U.S. health care costs are projected to
increase substantially by 2030.
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According to the latest reports from the National Center for
Health Statistics, half of all Americans aged 55 to 64 have high
blood pressure; 40 percent are obese.
Despite the benefits of regular activity, only 31% of adults in
the United States report engaging in recommended amounts of
physical activity (i.e., 30 minutes of moderate-intensity activity 5
or more days per week or 20 minutes of vigorous activity 3 or
more days per week), and 38% report no leisure-time regular
physical activity.
Causes of Death Among U.S. Adults Aged 65 or Older
In 2001, the leading causes of death among U.S. adults
aged 65 or older were:
 Heart Disease 33%
 Cancer 22%
 Stroke 8%
 Chronic Lower Respiratory Diseases 6%
 Influenza & Pneumonia 3%
 Diabetes 3%
 Alzheimer's Disease 3%
 All other causes 23%.
Opportunities To Improve Older Americans= Health and
Quality of Life
Deaths from heart disease, cancer and strokeCthe nation=s
three leading killersChave been dropping steadily.
Aging and Chronic Disease
Aging is a continuous process of change that begins at
conception. Everyone experiences physical changes as they age.
Eventually, he time comes when diseases associated with aging
begin to appear.
Among the most important changes accompanying aging is
the reduced reserve capacity of vital organs. This means that
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organs such as the heart, lungs, and kidneys that are affected by
age and disease may not be able to respond adequately to
additional illness or strain. Failure of organs may fail or may
initiate a Achain reaction@ or Adomino effect@ of failure in body
organ systems.
There is considerable growth in the field of anti-aging
medicine. However, at present, there are not any effective antiaging medicines.
Nevertheless, no one wants to become severely
incapacitated or dependent on others. It is possible to prevent or
slow the onset of certain diseases associated with aging or those
that cause serious illness and disability with age.
By definition, chronic diseases are incurable. But disease
does not have to lead to dysfunction and disability. Even after the
effects of aging and illness occur, it is still possible to try to
minimize complications and reduce risks.
A major goal of care for older adults is preventing, delaying
or successfully treating the diseases that shorten life and/or
impair its quality.
Prevention
Preventing health problems is one of the few known ways to
stem rising health care costs. By preventing disease and injury,
we also can help seniors remain independent for as long as
possible, which can improve their quality of life and delay the
need for costly long-term care.
Preventive Efforts
Prevention is generally classified as primary, secondary, and
tertiary
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Primary prevention refers to preventing a condition from
occurring; for example, preventing high blood pressure or
diabetes.
Secondary and tertiary prevention refer to preventing
complications or worsening of existing complications; for
example, preventing a stroke in someone with hypertension or
preventing falling with fracture in someone who has had a stroke.
Goals of Prevention
Primary prevention appears to be more effective when it is
started in youth and young adulthood.
Primary prevention is less effective when begun in old age.
There, the emphasis shifts to secondary and Bmost of allB tertiary
prevention.
Prevention in older individuals should focus not only on
reducing premature morbidity and mortality but also on
preserving function and quality of life, minimizing pain and
discomfort, enhancing autonomy, and minimizing subsequent
need for more costly and prolonged medical care.
Primary prevention
Poor health and loss of independence are not inevitable
consequences of aging. Certain strategies have proven effective
in improving the health of older adults, including:
- Early detection of diseases, including screening to detect
chronic diseases early in their course, when they are most
treatable.
- Healthy lifestyles, including diet, physical activity, and not
smoking. Habits acquired when younger, such as addiction to
tobacco, can increase the risk of chronic disease in later life.
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Maintaining a healthy lifestyle is challenging, and may have
less impact once chronic diseases have become established. But
continuing a healthy lifestyle throughout life can often prevent
more severe chronic conditions in those who have not yet
suffered from them.
- Preventing injury, including those due to falls.
- Immunizations. Over 35,000 people aged 65 or older die
each year of influenza and other forms of pneumonia.
Immunizations can reduce the risk of getting these infections or
may reduce the severity of infections that arise.
Smoking
Tobacco use is the leading preventable cause of illness and
death in the United States, increasing the odds of developing
many kinds of cancer and the risks of cardiovascular and
respiratory diseases. It results in approximately 440,000 deaths
each year.
According to the CDC, an estimated 44.5 million adults in
the United States smoke cigarettes even though smoking will
result in death or disability for half of all continuing smokers.
More than 8.6 million people in the United States have at least
one serious illness caused by smoking.
Smoking could cause an estimated 5 million people currently
younger than age 18 to die prematurely of a tobacco-related
disease. Directly or indirectly, tobacco use leads to more than
$75 billion per year in medical expenditures and another $92
billion per year in lost productivity.
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Physical Activity
Physical activity is an important determinant of body weight.
Physical activity influences physical fitness (which is related to
the ability to perform physical activity). Physical activity helps
prevent and can help reverse overweight and obesity. Activity
and fitness can help reduce mortality and morbidity related to
overweight and obesity and can reduce mortality in those with
diabetes.
According to one study, exercise counseling with a
prescription for walking at either a hard intensity or high
frequency produced significant long-term improvements in
cardiorespiratory fitness. More exercise or the combination of
hard intensity and high frequency exercise may provide additional
benefits, including larger fitness changes and improved lipid
profiles.
Avoiding a sedentary lifestyle during adulthood not only
prevents cardiovascular disease independently of other risk
factors but also substantially expands the total life expectancy
and the cardiovascular diseaseBfree life expectancy for men and
women. This effect is already seen at moderate levels of physical
activity, and the gains in cardiovascular diseaseBfree life
expectancy are twice as large at higher activity levels.
Vigorous walking has been shown to provide substantial
aerobic activity. Significant benefit from walking can be obtained
from approximate 45 minutes a day, an average of five days a
week.
Strength training is another important component of
physical activity. It helps to build and maintain bone and muscle
mass, which otherwise diminish with age.
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Flexibility and balance training can help reduce chronic
muscle tension and stiffness that cause pain and disability and
may increase fall risk with age.
Woman can reduce the risk of osteoporosis by consuming
calcium and exercising regularly when they are younger and
throughout their premenopausal years.
Stress reduction
Stress cannot be eliminated, but it is possible to reduce its
harmful effects on the body. Effective techniques can include
resolving personal and family issues, staying active, and using
relaxation techniques.
Diet and nutrition
The negative consequences of inactivity (an estimated 24
billion dollars) and obesity (an estimated 70 billion dollars)
contributed significantly to total health care costs in 1995.
Indirect costs include physician visits, disability, premature
mortality, and impaired quality of life. Increasing weight
increases the risks of diabetes, cardiovascular disease and
hypertension and their complications.
There are many ideas about the impact of diet and nutrition,
and many proposals for the right kind of nutrition. In general,
diet advice can be summarized as: eating a varied diet, with as
much fresh food as possible, including lots of fruits and
vegetables, and that includes carbohydrates, fat and protein in
every meal. Minimize consumption of processed and fast food.
Women and smaller, less active people should consume fewer
calories, while men and larger, more active people need more
calories. Calories should be derived approximately 40% to 50%
from carbohydrates, 30% from fat and 20% to 30% from protein.
It is apparently helpful to eat more whole grains (not
products made from whole-wheat flour), beans, winter squashes
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and sweet potatoes, and to minimize eating foods with wheat
flour and sugar, including bread and most packaged snack foods.
Fat should be in a ratio of 1:2:1 of saturated to
monounsaturated to polyunsaturated fat. Oils for cooking should
include extra-virgin olive oil, canola oil, or certain varieties of
sunflower and safflower oil. It is advisable to avoid margarine,
vegetable shortening and any products made with partially
hydrogenated oils. Saturated fat should be reduced by eating less
butter, cream, cheese and other full-fat dairy products, chicken
with skin intact, fatty meats and products made with coconut and
palm-kernel oils. Foods with omega-3 fatty acids are
recommended, including salmon, sardines, herring, and walnuts;
or alternatively a fish-oil supplement can be taken.
It is advised to eat more vegetable protein, especially from
beans. Consumption of animal protein is best limited to fish and
reduced-fat dairy products.
Fruits, vegetables and mushrooms are recommended,
including berries, tomatoes, orange and yellow fruits, and dark
leafy greens.
Other foods that appear to be beneficial include moderate
amounts of red wine and plain dark chocolate.
Although controversial, some recommend diet or
supplements that provide daily amounts of Vitamin C, vitamin E,
selenium, carotenoids, folic acid, calcium, vitamin D, and fish oil.
Oral and dental health
Oral health is critical for good nutrition and because gum
disease is an important cause and precursor of heart trouble and
possibly aspiration pneumonia.
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Screening and prevention
Emphasis should be on offering interventions that are
proven to be most effective to those who are at highest risk of
significant clinical problems in older individuals, such as
cardiovascular diseases, malignancies, thyroid disease, diabetes,
and certain infections.
When to screen
Different targets and frequencies for screening are
recommended for different age groups.
Age 85 is often suggested as a general cutoff range for
doing conventional screening tests.
But in healthier individuals above that age with a good
prognosis, it should be individualized.
Screening and prevention
Best proof is available for the following:
- Breast cancer screening
- Smoking cessation
- Hypertension treatment
- Vaccination for infectious diseases
Other measures likely to be beneficial include physical
exercise.
Alzheimer=s disease
Studies have identified genes that may be responsible for
being predisposed to Alzheimer=s.
Alzheimer=s is believed to be a disease where critical brain
cells are destroyed by deposition of a protein called amyloid. This
may be caused or associated with chronic inflammatory processes
in the body.
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Medications to date may improve symptoms of Alzheimer=s,
especially in its early stages, and may slow the progress of the
disease.
Anti-inflammatory agents, such as aspirin and the
nonsteroidal anti-inflammatory drugs; statin medications (used to
lower blood LDL and cholesterol); are often recommended.
Antibodies that clear the amyloid plaques in the brain,
thought to be responsible for Alzheimer=s, are being tested and
may soon be available.
Arthritis
Arthritis actually includes over 100 different diseases and
conditions, including osteoarthritis, gout, rheumatoid arthritis,
and fibromyalgia.
Nearly two-thirds of people with arthritis are younger than
65. Common symptoms include pain, aching, stiffness, and
swelling in or around the joints. Some forms of arthritis, such as
rheumatoid arthritis and lupus, can affect multiple organs and
cause widespread symptoms.
According to the CDC, arthritis is a major public health
problem, and the leading cause of disability, and has been
estimated to result in:
- 9,500 deaths
- 750,000 hospitalizations
- 16 million people with limitations
- 36 million ambulatory care visits
- 43 million people with self-reported, doctor-diagnosed
arthritis
- 51 billion in medical costs and $86 billion in total costs
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In 2002, 43 million American adults (about 1 in 5) reported
diagnosed arthritis. These numbers are expected to increase as
the population ages.
There are ways to prevent arthritis and to reduce the
symptoms, lessen the disability, and improve the quality of life
for people with arthritis.
Weight control and injury prevention measures can lower
the risk for getting osteoarthritis. Weight control and prudent
physical activity can reduce related pain and disability.
Some newer drugs can reduce the damage and control the
symptoms of rheumatoid arthritis, although these may also have
serious complications.
Exercise can reduce the disability of osteoarthritis, especially
of the knees, in people over 50.
Cancer
Cancer is another major cause of illness and death.
More malignancies can now be detected and successfully
treated than ever before.
Risk factors for various cancers are generally known, and
much is known about reducing cancer risk. Consumption of fruits
and vegetables, and physical activity (for breast cancer) are
protective. Tobacco use, overweight and obesity are important
avoidable causes of cancer.
Treatments for many cancers have improved.
Screening tests for breast, cervical, and colorectal cancers
reduce the number of related deaths by early detection.
Screening tests for cervical and colorectal cancers may help
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prevent some of these cancers from developing by detecting
treatable precancerous conditions.
Cancer risk can be reduced by a healthier lifestyleCfor
example, avoiding tobacco use, increasing physical activity,
achieving optimal weight, improving nutrition, and avoiding
excessive sun exposure.
Diabetes
According to the CDC, the number of people in the United
States with diagnosed diabetes has more than doubled, reaching
14.6 million in 2005. One in five adults over age 65 has diabetes.
Although more than 20.8 million Americans have diabetes, 6.2
million do not know they have the disease.
An estimated 41 million U.S. adults aged 40B74 years have
prediabetesCthat is, their blood sugar level is elevated but is not
high enough to be classified as diabetes. People with prediabetes
are at high risk for developing diabetes. Progression to full-blown
diabetes can be prevented by weight reduction, a low-fat diet,
moderate exercise and medications.
People with diabetes have a shortage of insulin or a
decreased ability to use insulin. Insulin is needed to allow sugar
to enter cells and be converted to energy. Uncontrolled diabetes
can damage vital organs, over time. Diabetes can cause heart
disease, stroke, blindness, kidney failure, and lower-extremity
amputations. Heart disease is the leading cause of diabetes
related deaths, and death rates are about 2B4 times higher for
adults with diabetes than for those without the disease.
Studies have found that better blood sugar control reduces
the risk for eye disease, kidney disease, and nerve disease by
40% in people with type 1 or type 2 diabetes. A healthy diet and
modest physical activity can reduce the risk for type 2 diabetes.
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Blood pressure control reduces the risk for heart, eye,
kidney, and nerve diseases and stroke among people with
diabetes. Improved blood cholesterol can reduce
cardiovascular complications. Detecting and treating diabetic
eye disease with laser therapy can reduce the risk for loss of
eyesight. Comprehensive foot care can reduce amputation
rates.
Heart disease
According to the CDC, heart disease and stroke are the
most common cardiovascular diseases. They are the first
and third leading causes of death for both men and women
in the United States, accounting for nearly 40% of all annual
deaths.
More than 910,000 Americans die of cardiovascular
diseases each year, which is 1 death every 35 seconds.
Although these conditions are more common among people
aged 65 or older, the number of sudden deaths from heart
disease among people aged 15B34 has increased.
More than 70 million Americans currently live with a
cardiovascular disease. Coronary heart disease is a leading
cause of premature, permanent disability in the U.S.
workforce.
Stroke causes disability among about 1 million
Americans. More than 6 million hospitalizations each year
are because of cardiovascular diseases.
During 1999B2002, nearly 29% of U.S. adults had high
blood pressure (hypertension); 45% were being treated with
medication, and only 29% had the condition under control.
For 2006, the estimated direct and indirect cost of high
blood pressure is $64 billion.
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The economic impact of heart disease and stroke in the
United States is projected to be $403 billion in 2006,
including health care expenditures and lost productivity from
death and disability.
The risk factors for having a heart attack (myocardial
infarction) are known, and can be controlled. Controlling risk
factors has helped to decrease deaths from heart disease.
Existing heart disease can be treated more effectively.
For example, blockages are removed by angioplasty or
bypass, medications can improve heart function, and
pacemakers have reduced the incidence of sudden death.
A 12- to 13-point reduction in blood pressure can
reduce heart attacks by 21%, strokes by 37%, and all
deaths from cardiovascular disease by 25%. A 10%
decrease in total blood cholesterol levels can reduce the
incidence of coronary heart disease by as much as 30%.
Current national guidelines recommend that all adults
have their blood pressure checked regularly and their blood
cholesterol levels checked every 5 years. Medications such
as beta-blockers and aspirin can help reduce the risk of
heart disease and stroke. Drugs such as statins can reduce
bad cholesterol and raise levels of good cholesterol. Other
risk factors for heart disease and strokeCsuch as diabetes,
tobacco use, physical inactivity, poor nutrition, and
overweight and obesityCcan be addressed through lifestyle
changes and appropriate use of medications.
There is controversy about the benefits of tight blood
pressure control in individuals over the age of 85.
Oral and dental disease
Mouth and throat diseases range from cavities to
cancer, and cause pain and disability for millions of
Americans. However, almost all oral diseases can be
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prevented.
According to the CDC, tooth decay affects more than
one-fourth of U.S. children aged 2B5, half of those aged
12B15, and many adults. Tooth loss remains a problem
among older adults. One fourth of adults over age 60 years
have lost all of their teeth, primarily because of tooth decay
and advanced gum disease, which affects 5%B15% of
adults. Tooth loss can cause nutritional problems and affect
self-esteem.
Oral cancers are identified in about 28,000 people each
year, and about 7,200 die of them.
Osteoporosis
Osteoporosis, which refers to thinning of bone to the
point that it is weakened and more easily fractured, is a
major cause of disability and death, especially in older
women. Osteoporosis accelerates in women after
menopause.
Among other things, weight-bearing exercise and
medications can prevent calcium loss, which thins the bones
and leads to fractures, especially after menopause.
Stroke
Hypertension is the leading cause of stroke.
Stroke prevention involves control of cardiovascular
risk factors including blood pressure and nonsurgical
techniques to remove or dissolve clots in the carotid arteries
in the neck.
Those who have had a stroke can benefit from approaches
that help to restore mobility and function to prevent the
complications of immobility and reduce the dependency
related to dysfunction.
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