Prevention in family

medicine

Grzegorz Margas

The scope for prevention



Socio-economic improvements



Modification of personal habits



Protection against trauma



Control of infection



Control of pollution



Screening



Prophylactic medication

Prevention

Primary

prevention

Secondary

prevention

Disease

onset

Tertiary

prevention

Complications

Symptoms

Prevention in family

medicine



Life style advises



Screening for common diseases



Early detection of cancer



Vaccination

Main causes of death in developed

countries

48

19

7,5

7

18,5

Cardiovascular

diseases
Cancer

Respiratory diseases

Accidents

Other

Main causes of death in developing

countries

21

18

16

7

6

5

27

Respiratory diseases

Infective and parasitic

diseases
ardiovascular diseases

Perinatal diseases

Cancer

Accidents

All other diseases

ISCHAEMIC HEART

DISEASE



The single most important killer in

developed countries



Cause of almost half of all deaths
in middle-aged men

Risk factors of IHD

Modifiable by life style:



Diet (cholesterol, saturated fat

and calories)



Smoking



Obesity



Sedentary life-style

Risk factors of IHD

Modifiable by pharmacology and/or life-

style

• High blood pressure
• Raised LDL cholesterol
• Low HDL cholesterol
• Raised triglycerides
• Thrombogenic factors
• Diabetes / Insulin resistance

Risk factors of IHD

Non-modifiable
• Age (45 years male, 55 years

female)
• Male sex
• Family history of CHD
• Personal history of CHD
• Low birth weight

Risk factors of IHD

Recently identified
• Raised high-sensitivity C-reactive
protein

(hs-CRP)

• Increased homocysteine levels
• Low serum folate

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Assessment

●

Risk factor assessment in adults should begin at age 20 y.

●

Family history of CHD should be regularly updated.

●

Smoking status, diet, alcohol intake, and physical activity
should be assessed at every routine evaluation.

●

Blood pressure, body mass index, waist circumference,
and pulse (to screen for atrial fibrillation) should be
recorded at each visit (at least every 2 y).

●

Fasting serum lipoprotein profile (or total and HDL
cholesterol if fasting is unavailable) and fasting blood
glucose should be measured according to patient’s risk for
hyperlipidemia and diabetes, respectively (at least every
5y; if risk factors are present, every 2 y).

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Assessment

●

Global risk estimation

●

Every 5 y (or more frequently if risk factors change),

adults, especially those 40 y of age or those with 2 risk
factors, should have their 10-y risk of CHD assessed.

●

Risk factors used in global risk assessment include age,

sex, smoking status, systolic and diastolic blood
pressure, total (and sometimes LDL) cholesterol, HDL
cholesterol, and diabetes.

●

Persons with diabetes or 10-y risk >20% can be

considered at a level of risk similar to a patient with
established cardiovascular disease (CHD risk equivalent).

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

Smoking



Goal: Complete cessation. No exposure to
environmental tobacco smoke.



Ask about tobacco use status at every visit. In a
clear, strong, and personalized manner, advise
every tobacco user to quit. Assess the tobacco
user’s willingness to quit. Assist by counseling
and developing a plan for quitting. Arrange
follow-up, referral to special programs, or
pharmacotherapy. Urge avoidance of exposure
to secondhand smoke at work or home.

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

BP control



Goal: <140/90 mm Hg; <130/85 mm Hg if renal

insufficiency or heart failure is present; or <130/80 mm

Hg if diabetes is present.



Promote healthy lifestyle modification.



weight reduction;



reduction of sodium intake;



consumption of fruits, vegetables, and low-fat dairy

products;



moderation of alcohol intake;



physical activity



Add medication with BP 140/90 mm Hg if 6 to 12 months

of lifestyle modification is not effective,

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

Diet



Advocate consumption of a variety of fruits,
vegetables, grains, low-fat or nonfat dairy products,
fish, legumes, poultry, and lean meats.



Match energy intake with energy needs and make
appropriate changes to achieve weight loss when
indicated.



Modify food choices to reduce saturated fats (<10% of
calories), cholesterol (<300 mg/d), and trans-fatty
acids by substituting grains and unsaturated fatty
acids from fish, vegetables, legumes, and nuts.



Limit salt intake to <6 g/d.



Limit alcohol intake (2 drinks/d in men, 1 drink/d in
women) among those who drink.

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

Aspirin



Goal: Low-dose aspirin in persons at higher CHD risk

(especially those with 10-y risk of CHD = 10%).



Do not recommend for patients with aspirin intolerance.



Low-dose aspirin increases risk for gastrointestinal

bleeding and hemorrhagic stroke.



Do not use in persons at increased risk for these diseases.

Benefits of cardiovascular risk reduction outweigh these

risks in most patients at higher coronary risk.



Doses of 75–160 mg/d are as effective as higher doses.

Therefore, consider 75–160 mg aspirin per day for

persons at higher risk (especially those with 10-y risk of

CHD of 10%).

European guidelines

Primary prevention guide to lipid management

Estimate absolute CHD risk* using the Coronary Risk

Chart

Use initial total cholesterol to estimate coronary risk

Absolute coronary risk <20%

TC > 5.0mmol/L (190mg/dL)

Lifestyle advice with the goal of

reducing

TC<5.0mmol/L (190mg/dL) and

LDL-C <3.0mmol/L (115mg/dL)

Follow-up at a minimum of 5-

year intervals

Absolute risk > 20%

Measure fasting lipids:

TC, HDL-C, triglycerides and calculate

LDL-C cholesterol

Lifestyle advice for at least 3 months

with repeat lipid measurements

TC <5.0mmol/L (190mg/dL)

and LDL-C <3.0mmol/L

(115mg/dL)

Maintain lifestyle advice

with annual follow-up

TC >5.0mmol/L

(190mg/dL) and LDL-C

>3.0mmol/L (115mg/dL)

Maintain dietary advice

with drug therapy

* High CHD risk >20% over 10 years or
will exceed 20% if projected age 60 years

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention



Physical activity



Minimal goal: 30-60 min, 3-4 times
a week

Obesity



Adult acceptable weight: BMI of 20-25.



Overweight : BMI of 25-30



Obesity: BMI of 30 or more.



Almost 10 per cent of the adult
population is obese by this definition
and about one-third is overweight

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

Weight management



Initiate weight-management program

through caloric restriction and increased

caloric expenditure as appropriate.



For overweight/obese persons, reduce

body weight by 10% in first year of

therapy.



Goal: Achieve and maintain desirable

weight (body mass index 18.5–24.9

kg/m

2

).

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

Diabetes



Goals: Normal fasting plasma glucose (<110

mg/dL) and near normal HbA1c (<7%).



Initiate appropriate hypoglycemic therapy

to achieve near-normal fasting plasma

glucose or as indicated by near-normal

HbA1c.



Treat other risk factors more aggressively

(eg, change BP goal to <130/80 mm Hg and

LDL-C goal to <100 mg/dL).

Primary Prevention of

Cardiovascular Disease and

Stroke: Risk Intervention

Chronic atrial fibrillation



Irregular pulse should be verified by an

electrocardiogram. Conversion of appropriate

individuals to normal sinus rhythm.



For patients in chronic or intermittent atrial

fibrillation, use warfarin anticoagulants to INR

2.0–3.0 (target 2.5).

1409053
0

140/90

healthy people tend to have

blood pressure below this

level

5

a cholesterol level below 5 is

good

3

walk 3 km a day if You can, or
exercise for 30 minutes

0

tobacco kills! Zero!

“14090530”

The European telephone
number for health

Western diet

A Western diet is characterized by:

•

a high content of fat (especially saturated fat)

•

a high content of sugar

•

a low content of fibre

•

increased salt intake

•

increased alcohol consumption

The following questions can

act as a stimulus for

discussion about diet:

1. What sort of milk do you usually have?

2. What sort of bread do you usually eat?

3. What sort of fat or oil do you use for

cooking?

4. Do you put butter or margarine on

bread?

5. How often do you eat fresh fruit?

6. How often do you eat fresh green

vegetables?

7. How often do you eat fresh fish?

8. Do you have sugar in tea/coffe?

9. How often do you eat

sweets/chocolate?

10. Do you usually read food labels?

Alcohol's effects on the public

health:

each year excessive drinking plays a part in:



thousens of deaths on the road



one in four emergency hospital admissions



nearly 70 per cent of suicides



one in three accidents in the home



60 per cent of serious head injuries

Patients who may be at risk from

alcohol abuse



Select patients with any of the following

characteristics:



raised blood pressure



recurrent injuries or accidents



non-specific gastrointestinal complaints



marital or family problems



record of absenteeism



history of anxiety/depression



high risk occupatios (publicans, seamen,

journalists)

Cancer deaths: men

33%

10%

7%

7%

4%

4%

4%

4%

27%

Lung
Prostate
Stomach
Colon
Bladder
Rectum
Oesophagus
Pancreas
Others

Cancer deaths: women

20%

16%

9%

6%

5%

5%

4%

3%

32%

Breast
Lung
Colon
Stomach
Ovary
Pancreas
Rectum
Oesophagus
Others

Estimated percentage of cancer

deaths attributed to various

factors

30%

35%

10%

7%

4%

3%

3%

2% 6%

Tobacco

Diet

Infection

Reproductive and sexual behaviour

Occupation

Alcohol

Geophysical factors

Pollution

Others



Coverage - primary care provides

access to almost entire population



Health promotion and screening



Practice registers - ideal basis for
the provision of cancer screening

Cancer prevention and early

diagnosis in general parctice:

Cancer prevention and early

diagnosis in general parctice:



Advice - lifestyle advice given in general practice

can be effective (e.g. advice to stop smoking)



Motivation - primary care can provide a source
of encouragement for the less motivated and
those who do not attend for screening



Continuum of care - preventive intervention
should be followed through on a long-term basis.

Breast cancer screening

Breast cancer screening is designed to detect

invasive breast cancer at a very early stage, or

to detect ductal carcinoma in situ.

Efficacy of screening in reducing mortality from

breast cancer in woman aged 40 years and over

has been demonstrated in randomized

controlled studies.

The screening procedure can be divided into

three stages:

1.

Identification and invitation

2.

Mammography

3.

Further investigation, followed by

treatment

Numbers of women at each

stage of breast cancer

screening:

2000 patients listed

150 women eligible for screening

7-10 may require further investigation

2-3 may require a biopsy

1 may have cancer

Screening for other

cancers



Cervical screening



Pap smears



Colorectal cancer



test for faecal occult blood



Ovarian cancer



ultrasound, CA 125 antigen



Prostate cancer



PSA

Communicable disease

control - vaccination



Vaccination is an effective means of controlling infections



To be successful, a high uptake of vaccination is essential.



There will always be a few individuals who cannot be

vaccinated because of hypersensitivity, immunodeficiency,

or religious convictions. Their protection depends on

reaching the other 99 per cent of the population.



The main obstacle to high immunization rates is poor

administration, not parental resistance.

Children

BCG vaccine (against tuberculosis)

Viral hepatitis type B

Diphteria

Tetanus

Pertussis

Poliomyelitis (IPV)

Measles

Mumps

Rubella

Haemophilus influezae vaccine (Hib)

Viral hepatitis type A

Varicella

Young adults

Vaccination after childhood is

selective, for occupational, travel or

other risks.

To the individual, the complications

and costs of vaccination are small

compared with a disease like

hepatitis, meningococcal meningitis

or rabies.

Exposed to risk of infection:

BCG vaccine (against tuberculosis)

medical staff

Hepatitis B

Health service staff in clinical practice

People whose sexual partners are infected

Rubella

Tetanus

Diphtheria

Rabies

Salmonella typhi

Hepatitis A

tick-borne encephalitis

Hemophilus influenzae (meningitis)

Yellow fever

Varicella

Influenza vaccination



The morbidity in the general population

as a result of an influenza epidemic

ranges from 50 to 200 per 1000 people.



The morbidity, mortality, long
convalescence and complications
associated with influenza are all
reasons for vaccination.



The influenza vaccination reduces both the

morbidity and mortality.



The efficacy of the vaccination depends on the

virus group in circulation, but is independent

of the preparation of the vaccine.



The reduction in morbidity is estimated at 70

to 80%.



Sufficient titre increase occurs ten days after

vaccination.

Influenza vaccination

Indication:

Patients at high risk of

complications



all people of age > 50 years



domiciled in residential or nursing homes



deviations and disturbances of function of

respiratory tracts and lungs (bronchial asthma,

chronic bronchitis, emphysema, lung carcinoma

etc.)



disorders which can lead to cardiac failure

(myocardial infarction, angina pectoris, rhythm

disturbance, valve faults)

Indication:

Patients at high risk of

complications



children and adults, who during last

year were frequently hospitalized



children and young adults (6 months -
18 years) at chronic aspirin therapy
(risk of Rey's syndrome during
influenza)



women who will be pregnant (II or III
trimester) during next influenza
epidemic

Indications for influenza

vaccination:

People being source of infection

for people with high risk of

complications

doctors, nurses and other staff of

hospitals, outpatient clinics

staff members of homes for elderly

people

people giving home care to patients with

high risk

people living together with persons with

high risk

Term of vaccination

optimal: from beginning of October to

half of November

acceptable: all patients with high risk

during epidemic season

Dose:

two doses in children of age 6 mths -

9 years during one month

single dose in adults

Contraindications:

• acute illness

• convalescence

• allergy to chicken protein