2006 November 13 • Avoid over exposure to the sun

N-107 | HEALTH PROMOTION AND DISEASE PREVENTION • Support antipollution legislation

Prof. Queenie R. Ridulme • Practice safe sex, monogamy, or abstinence
Health Promotion and Disease Prevention • Obtain genetic counseling for family-linked disorders
Goals • Design and follow a regular exercise plan
• Assess protective and predictive factors that influence health. • Maintain ideal body weight
• Assess genetic factors and risks that influence health. • Maintain a low-cholesterol, low-fat, high-fiber nutritious diet
• Foster strategies for health promotion, risk reduction, and • Wear a seat belt and helmet
disease prevention across the life span. • Identify and eliminate stressors
• Recognize the need for and implement risk reduction strategies • Limit alcohol intake, and never drink and drive
to address social and public health issues, including societal • Have regular dental care
and domestic violence, family abuse, sexual abuse, and
substance abuse. Behaviors Associated with Each level of Prevention
• Use information technologies to communicate health promotion SECONDARY
and disease prevention. • Obtain genetic counseling for family-linked disorders
• Develop and awareness of complementary modalities and their • Undergo screening for tuberculosis
usefulness in promoting health (e.g., relaxation techniques, • Obtain tonometry yearly after age 40 for glaucoma screening
stress management). • Have yearly Pap smears and mammograms per recommended
• Assist patient to access and interpret health information to guidelines
identify healthy lifestyle behaviors. • Have eye exams every 2 years
• Evaluate the efficacy of health promotion and education • Practice monthly self-breast, self-testicular, self-skin, and self-
methods to use in a variety of settings, with diverse oral examinations
populations. • Undergo a physical exam yearly after age 40
• Demonstrate sensitivity to personal and cultural definitions of • Self-monitor BP for hypertension
health.
Behaviors Associated with Each level of Prevention
Health Promotion and Disease Prevention in Primary Care TERTIARY
Primary care is a form of care delivery that has the following • Have a complete blood count before chemotherapy
components • Have speech therapy after a stroke
• It is personalized care. • Participate in cardiac rehabilitation
• It is care that is provided to patients who are entering the • Have breast reconstruction
health care system for the first time. • Participate in stroke or coma rehabilitation
• It is comprehensive care, based on knowledge from related
disciplines. Recommendations for Preventive Care for Asymptomatic,
• It provides continuity of care, in that patients are cared for over Low-Risk Adults
long periods, whether sick or healthy (i.e., chronic and episodic • Physical Examination
illnesses). - Blood Pressure
• It is coordinated care, with referrals made to other health care - Clinical Breast Examination
professionals. • Laboratory Test
• The primary goal in care coordination is to see that the patient - Papanicolaou test
receives the right care at the right time, for the least cost in - Stool: occult blood
terms of money, time and effort. - Sigmoidoscopy
• It is care that incorporates the patient, the family, and the - Mammography
community in terms of water supply, housing, safety, - Cholesterol
environmental hazards, traffic hazards, and communication. • Immunizations
- Tetanus-Diphtheria
Health Promotion - Influenza vaccine
• It incorporates the following: - Pneumococcal vaccine
- Identification of health risks • Counseling
- Reduction of health risks Risk Factors
- Preventive measures • Age
- Screening tests • Gender
- Human development across the life span • Genetic makeup
- Methods to prevent disease: immunization, screening when risk • Family History
factors are present • Race
- Early diagnosis and treatment • Substance use: tobacco, alcohol, street drugs
• Health promotion applies to all members of a family, with • Obesity
regard to the following: • Others
- Lifestyle behaviors
- Diet and exercise Health Risk Appraisal
- Sleep Factors that affect potential for developing a particular health
- Weight problem
• Genetic or biologic (race, family history, personal history)
Types of Prevention • Behavioral (health habits such as smoking)
• Primary: No symptom or disease is evident, but risk factors are • Environmental (living in a locale with smog
present. • Lifestyle
• Secondary: Disease is present and can be diagnosed, but no • Occupational Socioeconomic
symptoms are present (early disease).
• Tertiary: Disease is diagnosed, and symptoms are present. Obstacles to Providing Comprehensive Preventive Health
Treatment is aimed at preventing advance of the disease and Care
avoiding disability resulting from effects of the disease (e.g., • Lack of family and community resources
RA, TB, DM, COPD). • Patients who do not know about the benefits of preventive
health care.
Behaviors Associated with Each level of Prevention • Time limits (e.g., work schedules of both provider and patient)
PRIMARY • Lack of transportation
• Stop smoking, or do not start smoking • Under managed care, the health care system administrators
now recognize that prevention and treatment of disease at
 early stages are much less costly than treating advanced • Cholesterol-lowering drugs have proven efficacy in reducing the
disease. incidence and mortality of MI in both symptomatic and
nonsymptomatic patients.
Decision About Screening
• Benefits of screening for particular diseases in terms of impact RISK FACTORS (CHD)
on patient, family, and community Positive
• Identification of those individuals or groups most likely to • Age
develop the disease, based on risk factors and screening tests. - Men: over 45
• Available screening tests that are accurate, have no adverse - Women: over 55 or in early menopause without hormone
effects, and are acceptable to patients replacement therapy (HRT)
• Availability of treatment modalities that will significantly alter • Family history of CHD (men <55; women <65)
the course of the disease and improve patients’ quality of life. • Cigarette smoking (active and passive)
• Treatments that have proven effectiveness, low risk, few side • Hypertension
effects, low costs, and patient acceptance • Low high-density lipoprotein (HDL) cholesterol; (<35 mg/dl)
• Diabetes Mellitus
Principles of Prevention Use in Specific Diseases • Lack of information about early symptoms (e.g. chest pain,
• Assess the impact and degree of support and participation by fatigue)
family members.
• Involve at least one family member (e.g., spouse) in all Negative
preventive strategies. • High HDL cholesterol (60 mg/dl or higher)
• Be flexible in all aspects of prevention.
Other
Coronary Heart Disease (CHD) • Elevated triglyceride levels
Incidence • High stress personality profile
- Annual Incidence: estimated 1.5 million persons • Inactive lifestyle
- Rate: 67% men; 43% women • Oral contraceptive use, especially smokers age 35 and older
Presenting Event • Severe obesity (>30% over ideal weight)
- MI • History of any occlusive vascular disease, peripheral or
- Sudden death cerebrovascular
Morbidity and Mortality
• One in every 4.6 deaths in the US is caused by CHD, accounting GOALS OF TREATMENT (CHD)
for 489, 970 deaths each year (30% of all patients with MI) • Control cholesterol – dietary changes
• Among survivors, 65% do not recover fully. • Control hypertension
• About 88% of persons under age 65 are able to return to work. • Cease smoking
• Six-year follow-up shows the ff: • Improve lifestyle behaviors
- 13% of men and 6% of women who have had MI die suddenly
- 23% of men and 31% of women have a second MI. Cerebrovascular Disease (CVA)
MORBIDITY AND MORTALITY
Screening and Monitoring (CHD) • One in 15 deaths is caused by stroke.
• Assess total cholesterol and high-density lipoprotein (HDL) • About 31% of stroke victims die within 1 year of the CVA
cholesterol between ages 20-30, then every 5 years. • Stroke is the leading cause of long-term disability.
• Those at high risk, based on screening values, should have a - About 40% of stroke survivors require special services (e.g.,
complete fasting lipid panel to determine risk status. rehabilitation)
• Record BP at each check-up visit in both arms, with patient - About 10% require total care
sitting and lying.
• Monitor weight for obesity (>20% to 30% above ideal weight. FACTORS RELEVANT TO PREVENTION (CVA)
• Provide written low-fat, low-calorie diet for steady weight loss. • The major risk factor for stroke is hypertension.
• Recommend 30-40 minutes of aerobic exercises 3 to 4 times • CHD or atrial fibrillation indicates a high risk for emboli to the
per week. brain.
• Assess stress levels every 6 months • Diabetes mellitus significantly increases the risk for stroke.
• Determine fasting blood glucose annually to detect DM. • Transient ischemic attacks (TIAs) are a major risk factor for
• Echocardiography stroke
• Cardiac Perfusion Studies • One in five stroke victims had at least 1 out of the following 4
• ECG symptoms of TIA within the previous year:
- Temporary loss of vision (one eye only)
Preventive Strategies (CHD) - Unilateral numbness, tingling
• It is care that incorporates the patient, the family, and the - Aphasia
community in terms of water supply, housing, safety, - Focal weakness
environmental hazards, traffic hazards, and communication. • Patients who have carotid artery bruit have a 1% to 3%
• Encourage healthy lifestyles for all patients of all ages incidence of stroke each year.
• Identify and reduce risk factors to decrease the incidence of • Aspirin, anticoagulants, and surgery are used to treat carotid
CHD bruits, but data are not sufficient to show that these treatments
- Serum cholesterol are effective in preventing stroke.
• Inactive lifestyle • Additional risk factors include family history, cigarette smoking,
- Hypertension oral contraceptive use, hyperlipidemia, and elevated
- Cigarette smoking hematocrit.
- Sedentary lifestyle
• Consider dietary changes SCREENING RECOMMENDATIONS (CVA)
- Low fat • Elevated BP (systolic and diastolic) is the most significant risk
- Low cholesterol factor for stroke.
• High serum cholesterol is strongly correlated with CHD • Cigarette smoking is the second most significant risk factor for
• Nonpharmaceutical treatment can result in regression of stroke.
coronary artery lesions and thus the risk of MI. • For carotid bruit, those over age 40 should be assessed
- Very low fat diet annually.
- Exercise program
- Meditation PREVENTIVE STRATEGIES (CVA)
- Relaxation • Provide treatment for mild but sustained hypertension
• Tell those who smoke to stop; provide programs and
suggestions for cessation
• Prescribe aspirin prophylaxis for those who have had symptoms
of TIA
• Assess impact of stroke on families.
- Disability may be both physical and cognitive
- Family members may become caregivers
- Rehabilitation and care of stroke victims can be costly
- Patient’s condition may require decision regarding placement in
nursing home.
Cancer (CA)
MORBIDITY AND MORTALITY
• Leading causes of deaths from cancer involve the lungs, colon
or rectum, breasts, prostate, pancreas, urinary system,
lymphoma, and leukemia.
• Cancer is the second leading cause of death after
cardiovascular disease.
FACTORS RELEVANT TO PREVENTION (CA)
• About 35% of all cancer deaths are likely related to diet
(includes obesity)
• Obese patients have increased risk of colorectal, breast,
prostate, gallbladder, ovarian, and uterine cancers.
• Foods considered to have protective properties against cancers
include the following:
- Those rich in Vit. A, including dark green and deep yellow
vegetables and fruits
- Those rich in Vit. C, including citrus fruits, strawberries, and
sweet peppers
- Cruciferous vegetables, including cabbage, broccoli, Brussel’s
sprouts, and cauliflower
• Smoking accounts for 30% of cancer deaths (lung, bladder,
mouth, throat, larynx).
• Alcohol is responsible for about 3% of cancer deaths
• Diet, smoking, alcohol, and occupational exposure account for
more than 73% of all cancer deaths
Colorectal Cancer
INCIDENCE
- Incidence begins to increase after age 40, about doubling every • Mammogram
7 years after age 50.
- Incidence increases in patients with a family history of colorectal
cancer
- Incidence is decreased among patients who regularly use aspirin
and other nonsteroidal antiinflammatory drugs among women
who use postmenopausal HRT
FACTORS RELEVANT TO PREVENTION (Colorectal CA)
• Colorectal cancers develop over 5 to 10 years from benign
adenomatous colon polyps
- From 20% to 30% of polyps are adenomas.
- Only 5% to 10% of adenomatous polyps becxome malignant.
- Appearance of adenomas begins after age 40 and increases
significantly between ages 45-50.
• Compared with pathologic findings on colonoscopy, stool guaic FACTORS RELEVANT TO PREVENTION (Lung CA)
tests for occult blood, taken 3 days in succession, are 52%
sensitive for carcinoma, 23% sensitive for polyps greater than 1
cm, and 4.4% sensitive for polyps less than 1 cm.
• Early detection and treatment result in much higher survival
rates.
- Current survival rate is 61%
- Survival rates of 80% to 90% are possible with screening for
occult blood, sigmoidoscopy, and removal of adenomatous
polyps.
• About 20% of colorectal cancers are attributed to a low-fiber
diet.
• High-fat diets are also implicated.
SCREENING RECOMMENDATIONS (Colorectal CA)
• Rectal examinations and six-slide fecal occult blood tests
annually after age 40.
• Sigmoidoscopy every 3-5 years beginning at age 50.
PREVENTIVE STRATEGIES (Colorectal CA)
• Risk factor analysis includes the following:
- Age over 50
- History of adenomas
- Personal or family history of colorectal cancer or polyps
- Ulcerative colitis
- Crohn’s disease
- Personal or family history of genital or breast cancer in women
- Physical inactivity
- All patients should eat a high-fiber, low-fat diet
Breast Cancer
INCIDENCE
- Lifetime incidence of breast cancer in women is 1:9
- Of all new cancers in women, 31% are breast cancer (13% are
lung cancer, the second most common cancer in women)
- Incidence increases with age
MORBIDITY AND MORTALITY
• Breast cancer accounts for 17% of all cancer deaths.
• In situ breast cancer has a cure rate of almost 100%
• Five-year survival rate for localized breast cancer is 96%.
FACTORS RELEVENT TO PREVENTION (Breast CA)
RISK FACTORS
- Family history in first degree relatives
- Nulliparity
- First child born after age 30
- First menstrual period before age 12
- Last menstrual period after age 55
- Atypical hyperplasia on previous biopsy
- Obesity
- Current oral contraceptive use
- Past oral contraceptive use
- Post menopausal HRT
- Alcohol use
SCREENING RECOMMENDATIONS (Breast CA)
• Breast Self-Examination (BSE) has an average sensitivity of
26%
• Regular screening mammography results in a 20% tp 35%
decrease in mortality among women age 50 to 69.
• A 1995 meta-analysis showed a statistically significant
reduction (24%) in mortality among women age 40 to 50 who
were screened by mammography.
• Biennial mammography plus annual clinical breast examination
is as effective as both done annually
• Up to date research on the effectiveness of screening methods
and scheduling is important
Lung Cancer
INCIDENCE
- Second highest incidence of all cancers for both men and
women in the US
- Most preventable of all cancers
MORBIDITY AND MORTALITY
• Leading cause of cancer mortality for both men and women
• Five-year survival rate only 13%
• Small number of cases result from exposure to industrial
pollutants
• About 87% of all lung cancers are attributable to smoking
• A major public health goal is to reduce environmental tobacco
smoke (ETS)
• About 3000 lung cancer deaths annually in nonsmoking adults
are attributable to ETS.
SCREENING RECOMMENDATIONS (Lung CA)
• Although a Chest X-Ray film and sputum cytologic examination
detect lung cancer at a pre-symptomatic stage, no definitive
data indicate that early detection results in improved
prognosis.
PREVENTIVE STRATEGIES (Lung CA)
• People of all ages should be educated about cigarette smoking
as the cause of lung cancer with the message:
“It’s addictive. Don’t start. If you have started, stop…!”
Cervical Cancer
INCIDENCE
- Incidence of invasive cervical cancer is decreasing
- Incidence increases steadily through age 50, then remain stable
- Worldwide, cervical cancer is the most common malignancy in
women
- In the US, cervical cancer ranks 8th among cancers in women.
MORBIDITY AND MORTALITY
• Patients with a preinvasive lesion of cervical intraepithelial
neoplasia (CIN II, or carcinoma in situ) have a 100% cure rate
with appropriate treatment
• Women with localized cancer have a five-year survival rate of
91%
• Patients with distant spread have a 4-year survival rate of 30%
• The mortality rate has declined by 70% in the last 40 years
because of early detection with Pap testing
FACTORS RELEVANT TO PREVENTION (Cervical CA)
• Squamous cell carcinoma of the cervix occurs almost
exclusively in women who have had coitus
• Average time for progression to invasive carcinoma is an
additional 10 years
• CIN may regress spontaneously in 30% to 50% of cases
• At least 30% of patients with CIN III progress to invasive
carcinoma.
RISK FACTORS (Cervical CA)
• Early age for first intercourse
• Women who have coitus less than 1 year after menarche are
26 times more likely to develop cervical carcinoma than the
general population
• Multiple sexual partners
• HIV infection
• Herpes simplex virus infection
• History of condylomas (HPV infection)
• Smoking
• Low socioeconomic status
• No Pap testing
- One Pap test is 55% to 80% sensitive
- Specificity in Pap results and effectiveness depend on proper
sampling, proper specimen handling, and quality of the
laboratory.
SCREENING RECOMMENDATIONS (Cervical CA)
• All women should begin having Pap tests when they become
sexually active
• After at least 3 negative annual Pap tests, the frequency can be • High-risk women should be screened for gonorrhea during
reduced to every 3 years among low-risk populations
• Pap tests can be discontinued in women over age 65 who have
had consistently normal examinations
PREVENTIVE STRATEGIES (Cervical CA)
• Review risk status at each visit, particularly, in pts with multiple • Clinicians should maintain a high index of suspicion for all STDs
sexual partners, HPV infection, or other risk factors
• Advise pts that barrier contraceptives, such as condom, do not
necessarily prevent cancer of the cervix, but they do prevent
transmission of STDs.
Prostate Cancer
INCIDENCE
- It is the most common cancer in men
- Risk increases with age, beginning at age 50.
- Black men have the highest incidence of prostate cancer in the
world, 37% higher than white men.
- Population studies indicate that the consumption of high levels
of dietary fat may be implicated in an increased incidence of
prostate cancer
PREVALENCE
- Prevalence increases with age
- Studies have shown microscopic evidence of prostate cancer in
30% of autopsies of men age 30 to 49
- Estimated prevalence among men over age 80 ranges up to
100%
MORBIDITY AND MORTALITY
- Morbidity is associated with metastases that result in bone pain
and urinary tract obstruction
FACTORS RELEVANT TO PREVENTION (Prostate CA)
• Only a small number of men with microscopic evidence of
prostate cancer have clinical evidence of disease
• According to many specialists, if all men lived to old-old age,
100% would develop prostate cancer
SCREENING RECOMMENDATIONS (Prostate CA)
• Principal screening tests are digital rectal examination (DRE);
serum tumor markers such as the prostate-specific antigen
(PSA); transrectal ultrasound
• None of these tests prolongs life, and the sensitivity and
specificity are difficult to calculate
• Clinicians should counsel all men over 50 about the availability,
risks, and benefits of PSA testing
Sexually Transmitted Diseases (STD)
INCIDENCE
- Peak incidence of STDs occurs in teenagers and young adults
- Actual incidence of STDs may be twice the reported figures
- About 120,000 infants every year are infected with chlamydia at
birth
PREVALENCE
- Because of the prolonged length of infection, the two most
prevalent STDs are herpes simplex virus (HSV) and human
pappillomavirus (HPV).
- Most cases of chlamydial infection are asymptomatic, but an
estimated 5% of the population is affected.
FACTORS RELEVANT TO PREVENTION (STD)
• All STDs have a high asymptomatic carrier rate, making
prevention of transmission difficult.
• Most significant risk factor is multiple sexual partners
• Only abstinence, monogamy, or condom use dramatically
affects the risk
SCREENING RECOMMENDATIONS (STD)
• Routine serologic tests for syphilis should be done on all
pregnant women and persons at high risk for infection
• High-risk groups should also have a screening gonorrhea
culture and direct flourescent antibody test or enzyme-linked
immunosorbent assay (ELISA) for chlamydia at routine pelvic
examinations
• Persons with multiple sexual partners should be examined
every year
• All sexually active adolescent women should be screened for
chlamydia infection
pregnancy.
PREVENTIVE STRATEGIES (STD)
• Education about STDs should begin before the start of sexual
activity.
because of the extremely high rates of asymptomatic and
minimally symptomatic patients
• In high-risk populations, even with few or no symptoms, most
experts recommend presumptive treatment of chlamydia
Health Promotion in Older Adults
PHYSIOLOGIC FACTORS THAT INFLUENCE FUNCTIONAL STATUS
Sleep
Sensory impairments
Mobility and balance
PSYCHOSOCIAL FACTORS THAT INFLUENCE FUNCTIONAL STATUS
Ageism
- The prejudices and stereotypes applied to older people purely
because of their age.
Multiple losses
Neglect and abuse
MENTAL HEALTH DISORDERS IN OLDER ADULTS
Dementia
- Severe intellectual deterioration that interferes with one’s ability
to cope with daily life
Delirium
- Acute confusion, reversible dementia, clouded mental state
Depression
- Insomnia, fatigue, wt loss
- Can also lead to cognitive impairment
Elderly suicide

4 Treatment strategies
- Reality orientation
- Validation therapy
- Remotivation therapy
- Reminiscence therapy