© 1997 - 2004 lifelong health1 preventive health checks week 8 – eight weeks to wellness prepared...

© 1997 - 2004 LifeLong Health 1

Preventive Health Checks

Week 8 – Eight Weeks to WellnessPrepared by Don Hall, DrPH, CHES


• Sponsored by:

Lassen Foundation

2801 Williams Rd.

Butte Valley, CA 95965

• Your name, Health Educator


Strategy for Good Health

1. Live a healthy lifestyle (primary prevention)- eat well

- be physically active daily

- avoid substances or practices that harm health

2. Get regular health exams (secondary prevention)

- check regularly for any abnormalities

- early diagnosis and treatment for disease


Preventive ChecksThat Can Add Years to Your

Life


Blood Pressure CheckLess than 120/80 Normal (Healthy range)

120/80 -- 139/89 Pre-hypertension

140/90+ High blood pressure (high risk)

NIH, National High Blood Pressure Education Program, 2002


Blood Pressure and Cardiovascular Events

1.0 1.01.3

1.1

1.61.8

2.0

2.9

0.0

1.0

2.0

3.0

<120/80 120/80+ 130/85+ 140/90+

MenWomen

Rel

a ti v

e R

isk

Blood Pressure LevelsNew England Journal of Medicine, 345:1292-97, Nov. 1, 2001

n=6859


High Blood Pressure

• One out of every four adults has high blood pressure

• If you could lower the systolic BP by 5 points you would save:– 64,000 deaths from heart

disease– 23,000 fewer deaths from

stroke– 168,000 fewer deaths from

all causes each year

NHBPEP, JAMA Oct. 16, 2002


Lifestyle Modifications for Prevention of Hypertension

1. Achieve a healthy body weight (BMI <25)2. Reduce dietary sodium intake to <2400 mg/day

3. Engage in regular aerobic physical activity4. Limit alcohol consumption 5. Get adequate potassium, 3500 mg/day

6. Choose healthy meals (DASH Diet)– High in fruits and vegetables, 5-9 servings per day– Low fat dairy products, and reduced saturated fat

intakeNat. High BP Edu Program, JAMA 288:1882-88, Oct. 16, 2002


Cholesterol Check160 or less Optimum

Less than 200 Desirable

200-239 Elevated – increased risk

240+ High cholesterol – high risk NIH, National High Cholesterol Education Program, 2002


Cholesterol and Heart Health

0.0

10.0

20.0

30.0

40.0

160 180 200 240 300

Hea

rt D

isea

s e D

eat h

Rat

e

Serum Cholesterol (mg/dL)NCEP, MRFIT Study

n=361,662


Cholesterol and Mortality Rates

1.0

11.7

1.0

2.7

0

2

4

6

8

10

12

RelativeMortality

Rate

Heart Disease All Causes

LowestQuartile

HighestQuartile

NEJM, 1995, 332(22):1493

n = 101730 year study


Artery ModelCross section

An artery has three layers: the outside adventitia, muscle media, and the inner intima layer.

This artery model shows a buildup of cholesterol plaque in the lumen of the artery.

-- Adventitia

-- Media

-- Intima


There are usually no signs of disease until an artery is 90-95% plugged

Coronary arteryModerate atherosclerosis


ArterySevere Atherosclerosis

This artery is 99% plugged with buildup of cholesterol and plaque.


HDL Cholesterol

Goal: 45+ men, 55+ women

Factors that improve HDL– Aerobic exercise, 12-20

aerobic miles per week– Achieve/maintain ideal

body weight (lose 10 lbs)– Avoid smoking– Avoid trans fatty acids

Note: For every 1% you increase HDL levels, you decrease CHD risk by 2-3%

223

56

107

160

0

50

100

150

75+ 74-55 54-45 44-35 <35

HDL Levels mg/dL

CH

D m

ort

alit

y r

ate

, me

n

Framingham Heart Study


Therapeutic Lifestyle Change for a Healthy Cholesterol Level

• Achieve/maintain a healthy weight – BMI less than 25 - or lose 10-15+ excess lbs

• Limit animal/saturated/trans fats– Less than 7% of calories (less than 5% is ideal)– Avoid trans fats (partially hydrogenated vegetable oils)

• Limit dietary cholesterol– Less than 200 mg/day (0 intake is ideal)

• Choose healthy fats: unhydrogenated vegetable oils – Polyunsaturated fats, up to 10% calories– Monounsaturated fats, up to 20% of calories – Foods with healthy fats: avocado, olives, nuts, seeds


Therapeutic Lifestyle Change for a Healthy Cholesterol Level–2• Eat unrefined foods high in fiber

– Increase soluble fiber, 10-25 gm/day• Oats, oat bran, barley, pectin-rich fruit,

beans, psyllium

– Eat more fruits, vegetables, whole-grain breads and cereals

• Use margarines with plant stanols/sterols– 2-3 gm/day (e.g. Benecol, Take Control)

• Eat nuts, nut butters, or seeds daily• Get regular physical activity


Cholesterol Lowering DietsControl diet (Good diet)

Low saturated fat/cholesterol diet (STEP 2 diet plus whole grains to increase fiber), nonfat milk, nonfat cheese, egg replacer, vegetarian diet

Control diet + Lovastatin

“Best Diet”Low saturated fat/cholesterol diet (vegetarian), with soy milk, soy proteins, almonds, oat fiber cereal and bread, psyllium seed (high viscous fiber)

JAMA 290:502-10, July 23/30, 2003


Results of LDL Cholesterol Lowering Diet Versus Lovastatin

-8.0

-30.9-28.6

-35.00

-25.00

-15.00

-5.00

5.00

Control diet Lovastatin Best Diet

LD

L c

hole

ster

ol r

educ

tion

(%)

JAMA 290:502-10, July 23/30, 2003


Glucose CheckFasting blood test Non-fasting test

Normal 70-99 Diabetes 200+

Pre-diabetes 100-125

Diabetes 126+

American Diabetes Association, Diabetes Care, Nov. 2003


Diabetes – The Problem

• 17 million Americans have diabetes (8% of adults)– 6 million are unaware– 11 million are diagnosed and treated– Another 16 million people have prediabetes

• One million people will be diagnosed with diabetes this year (2,200 every day)

• Diabetes is the 6th leading cause of death• Diabetes increased by 33% this last decade

Diabetes Fact Sheet, ADA web site, 2002


ComplicationsDiabetes …• Is the leading cause of blindness in the U.S. • Is the leading cause of end stage kidney disease• Is responsible for 60% of nontraumatic leg amputations• Causes heart disease (diabetics leading cause of death)• Causes high blood pressure, 73% of adults with

diabetes have high blood pressure• Increases the risk for stroke by 2-4 times • Damages nerves in 60-70% of people with diabetes • Shortens life expectancy by 4-7 years

ADA, Fact Sheet 2003


Signs and Symptoms of Diabetes

• Unusual thirst and frequent urination

• Extreme hunger• Unusual weight loss• Fatigue, irritability• Frequent infections including

bladder infections• Blurred vision• Cuts/Bruises that are slow to heal• Tingling/Numbness in hands or feet

American Diabetes Association, 2003


Diabetes Can Be Prevented

The ADA recommends: – Walk briskly for 30-minutes daily – Maintain a healthy weight, or if overweight

lose even 10 pounds– They estimate that these two simple

changes could cut your risk of type 2 diabetes in half

– Making further changes in diet, stopping smoking, etc. can cut your risk even further

American Diabetes Association, 2003


Intervention Trial to Prevent Diabetes

• Researchers studied 3234 individuals at high risk for diabetes

• Participants were randomly assigned to one of three groups– Placebo– Medication

(metformin)– Lifestyle intervention

11.0

7.8

4.8

0

3

6

9

12

Placebo Medication Lifestyle

Inci

den

ce

Dia

be

tes

, ra

te/1

00 p

erso

n y

rs

NEJM 346:393-403, Feb. 7, 2002 Intervention Group



• Lifestyle intervention included:

– Weight loss, goal 7% of weight

– Exercise daily, goal 150 min/week

– Improve eating

• Higher fiber intake

• Lower saturated fat

• Lower glycemic load

11.0

7.8

4.8

0

3

6

9

12


Inci

den

ce

Dia

be

tes

, ra

te/1

00 p

erso

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rs

NEJM 346:393-403, Feb. 7, 2002

Intervention Group



ResultsAfter 3 years, the incidence of diabetes was 58% lower in the lifestyle intervention group, and 31% lower in the metformin group, compared to the placebo group

11.0

7.8

4.8

0

3

6

9

12


Inci

den

ce

Dia

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, ra

te/1

00 p

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rs

NEJM 346:393-403, Feb. 7, 2002

Intervention Group


Lifestyle and Risk of Diabetes

84,941 women, 16 year study

Studied 4 major risk factors: – Overweight– Sedentary lifestyle– Smoking– Poor diet

Women with none of these risks:– Cut their risk of diabetes by 88%

to 91% compared to all other women

– Risks were similar even if they had a family history of diabetes

NEJM 345:790-97, Sept. 13, 2001

11

100

0

20

40

60

80

100

Persons withno risks

All otherpersons

Re

lativ

e r

isk

of d

iabe

tes


Preventive Cancer Checks


Colorectal Cancer Check

• 130,000 cases per year

• 56,000 deaths

• American Cancer Society guidelines - at age 50+, get …

- Test for blood in stool yearly and a flexible sigmoidoscopy every 5 years, or

- double-contrast barium enema every 5 years, or

- colonoscopy every 10 years

• Do checks sooner or more often if you are high risk

People at High Risk1. Family history of hereditary

polyposis (numerous polyps in the colon).

2. Personal history of chronic inflammatory bowel disease.

3. History of colon cancer in a parent or sibling.

4. Personal history of large polyps or colon cancer.

5. Prior history of endometrial, ovarian, or breast cancer.

ACS Screening Guidelines, 2003


Colon Polyp

Colon cancer screening, using a colonoscopy, can find and remove polyps before they become cancerous.


Colon Polyps

Virtual Colonoscopy View

Optical Colonoscopy View

New Eng. J of Med, Dec 4, 2003


Pap Test for Women

• About 14,500 new cases and 4,800 deaths each year

• Screening guidelines

– An annual Pap test and pelvic exam for all women 3 years after becoming sexually active, or 21 years old

– Women 30+, after 3 normal consecutive tests, and if low risk, check every 2-3 years; clear with your doctor

– After 3 normal consecutive tests, women over 70 can stop taking the test

High Risk Women

1.Sexually active at early age

2.Multiple sex partners

3.Cigarette smoking

4.African-American women

CA: A Cancer Journal for Clinicians, Nov/Dec 2002


Mammogram for Women

• 212,600 breast cancer cases are expected this year and 40,200 deaths

• Recommendation NCI– Mammogram every 1-2

years after age 40– If high risk, ask doctor

when and how often to get a mammogram

Women at High Risk

1. Family history of breast cancer (mother, sister)

2. Over 30 and no births

3. Obesity

4. Personal history of ovarian or endometrial cancer

5. High alcohol intake

National Cancer institute (NCI)


Prostate Exam for Men

• 220,900 cases of prostate cancer are discovered each year, and 28,900 deaths.

• Offer screening beginning at age 50:– digital rectal exam annually– PSA test offered annually to

persons with a life expectancy of 10+ years

– Persons should be informed about benefits and limitations and then given a choice for the PSA test

Men at Higher Risk(start screening earlier, 45)

1. Family history of prostate cancer

2. African-American men3. Obesity4. PSA normal ranges may

vary with age and race. Values less than 2.5 are ideal. Ask your doctor for specific guidance.

Amer. Cancer Society Guidelines, 2003


Other Cancer Checks

• Depending upon the person’s age the doctor may also check for cancer of the:– Thyroid– Oral cavity– Skin– Lymph nodes– Testes and ovaries

• The exam should also include health counseling for:– Tobacco use– Sun exposure– Diet and nutrition– Risk factors– Sexual practices– Environmental

exposures


Other Checks


Immunizations

Adults should have:– tetanus shot every

10 years

– people 65+ need a pneumonia shot every 10 years

– annual flu shots are recommended for all over 65 (or for anyone who doesn’t want the flu)

Children’s Immunizations

• All children should be up-to-date on immunizations

Immunizations are one of the most effective ways of preventing

serious illness.


Influenza and Pneumonia Immunizations

In a study of 260,000 persons 65+, influenza and pneumonia vaccinations reduced: – Hospital admissions for

influenza by 46% and pneumonia by 29-52%

– Mortality from all causes by 57%

Lancet 2001; 357: 1008-11

15.1

34.7

0

5

10

15

20

25

30

35

Yes No

De

ath

s p

er 1

000

Vaccinated


Hearing and Vision Check

Hearing• The doctor should inquire

about hearing loss

• Hearing tests should be done

when appropriate

• If you have hearing loss, you

should be counseled on the

availability of treatment and

treatment options

• You should be referred for

treatment when appropriate

Vision• Periodic vision testing is

recommended, as needed,

especially past age 40 (more

often in elderly)

• Vision checks should include

screenings for

– glaucoma

– retinal problems (regularly

in diabetics)

– cataracts


Dental Exams

• Regular dental exams are an important part of maintaining health

• One purpose of dental exams is to preserve teeth and gums– Loss of teeth limits ability to chew

healthy food effectively – A tight gum around the base of a

tooth protects the root and tooth from decay

Sign in a Dentist Office

You don’t have to floss all your teeth, just the teeth you

want to keep.


The Tooth of History

• In the early 1600s in London, the 5th and 6th leading causes of death were listed as “teeth”.

J Hist Dent. 1999;47:11-3

• By the early 1700s, diet improved and dentition stayed intact longer, but cavities and gum disease became prevalent—and probably painful.

Br Dent J. 1998;184:397-9

• An ancient rule said that a slave who lost an eye while working must be freed.

• The same rule said that a slave could go free for the loss of one tooth.

Moses, Exodus 21:26, 27

• Eyes and teeth have had enormous personal value for a long time.


Tooth Decay

• Decay occurs at any age– Early fillings can fail in later years– Decay in later years occurs at base of gums

• Severe decay affects general health– Symptoms: pain, swelling, fever, fatigue– Prevention:

• Brushing and flossing• Good nutrition• Regular dental exams• Fluoride in water (or pills if not in water for children), and

tooth paste. Fluoride reduces decay by 40% or more


Nutrition and Tooth Decay

• Keep sugar intake low– 20-30 lb/person/year (140 lb/person/yr US)– Less than 10% calories

• Limit frequency of sweets/sugary foods– Candy, soft drinks, juices, desserts, pastry, cookies– Limit to no more than 4 times per day

• Promote adequate fluoride– Water (or pills for children)– Tooth paste

• Promote fruits, vegetables, whole grains, nuts, and foods that supply calcium

WHO, Diet, Nutrition, and Prevention, 2003


Periodontal Disease

• Bacteria cause gum disease when the immune system weakens or fails, especially in people with a genetic predisposition.

• To avoid gum disease:– Brush and floss regularly– Eat healthy foods– Don’t smoke (alcohol is also hard on gums)– Maintain overall health– Get regular dental checks and professional cleaning


In summary ...

• It’s important that you understand any health problem you have– ask for clarification if needed– ask for specific guidance, what you should do– ask for help in making lifestyle changes

• Work in partnership with your doctor or health provider — be a team player

• Take charge of your health and achieve your goal of health and wellness


Quiz1. An example of secondary prevention is ________.2. Normal or healthy blood pressure is ________.3. Name 4 lifestyle actions that can lower blood pressure.4. Cholesterol levels should be less than ________.5. The most important action to lower your cholesterol level is

______.6. What 4 lifestyle actions can you take to raise your HDL?7. What is a healthy fasting glucose level?8. What are 4 things a person can do to lower the risk of

diabetes?9. At what age should a person get a colon cancer screening

test?10. What immunizations are recommended for persons 65 and

older?


www.lifelonghealth.uswww.lifelonghealth.us


Dental Neglect is Expensive

• Preventive dentistry deters most complex and expensive dental problems

• The need for preventive maintenance increases with age

• Plan to visit your dentist at least every 6-12 months

• People with gum disease often need a 2-3 month interval between dental care


Dental Exams

• Visit a dental care provider on a regular basis (as recommended by your dentist)

• Good dental exams include counseling on– daily brushing using a fluoride

tooth paste– daily flossing– good nutrition

• avoid frequent snacking• get adequate calcium• eat lots of fruits & veggies

Sign in a Dentist Office

You don’t have to floss all your teeth, just the teeth you want to keep.


Triglycerides and Risk of Heart Attack

0

1

2

3

65 95 135 170 260

Relative Risk of a Heart Attack

Triglyceride Levels (Quintile medians)JAMA, Vol 276, No. 11

Physician’s HealthStudy n= 14, 916


Criteria for Metabolic Syndrome

Presence of any three indicators listed below:

1. Abdominal obesity, waist girth 35+ inches in women, 40+ inches in men (37-39 inches in genetically prone men)

2. High blood fats, triglycerides 150+ mg/dL

3. Low HDL cholesterol, men < 40, Women < 50

4. Elevated blood pressure, 130/85+

5. Elevated fasting blood sugar, 110-125 mg/dlNCEP, ATP 3 Report, and JAMA Jan. 16, 2002, 287:356-59


Prevention/Treatment Goals

To decrease insulin resistance by:• Losing excess weight, even 10-15 pounds

helps significantly• Increasing level of physical activity

– Goal of 30-45 minutes daily, 150+ min/week

• Decrease glycemic load of the diet– Low GI foods and high fiber diet

• Choose healthy fats– polyunsaturated fats decrease risk, sat. fats

increase risk


Glycated Hemoglobin and Coronary Heart Disease

1.00

2.74 2.77

5.20

0.0

1.0

2.0

3.0

4.0

5.0

<5% 5-5.4% 5.5-6.9% 7.0+%

Rel

a ti v

e ri s

k C

HD

Glycated Hemoglobin LevelsBritish Med. Jour., Jan. 6, 2001

n=4662


Glycated Hemoglobin and Mortality from All Causes

1.001.41

2.07

2.64

0.0

1.0

2.0

3.0

<5% 5-5.4% 5.5-6.9% 7.0+%

Rel

a ti v

e ri s

k o f

Dea

th

Glycated Hemoglobin LevelsBritish Med. Jour., Jan. 6, 2001

n=4662


Effect of a 1% Increase in Glycated Hemoglobin

• An increase of 1% in glycated hemoglobin is associated with roughly a …– 30% increase in mortality from all causes – 40% increase in mortality from coronary

heart disease

British Med. Jour., Jan. 6, 2001


Study Conclusions

• Only about 8% of the adult population (over 18) has diabetes

• But, about 70% of the non-diabetic population over 45 have a high hemoglobin A1c of 5% or higher

• Thus 80% of excess mortality due to high blood sugar is in those persons without diabetes

• That means most adults over 45 need to be taking steps to lower blood sugar levels

British Med. Jour., Jan. 6, 2001


Prevention Strategy

Reduce the average blood sugar level of the general population to achieve a glycated hemoglobin level less than 5.0% by:

1. Decreasing excess body fat

2. Increasing the level of physical activity

3. Improving eating habits

• Decrease the glycemic load in the diet

• Eat less refined carbohydrates and eat more foods high in dietary fiber


Risks and Benefits of HRT in Healthy Post Menopausal Women

1.29 1.26

0.63

0.83

0.66

1.41

0

0.5

1

1.5

CHD Breast CA ColorectalCA

EndometrrialCA

Hip fractures Stroke

HRTPlacebo

Women’s Health Initiative Study, JAMA 288:321-333, July 17, 2002

Rel

ativ

e R

isk

of H

RT

C

ompa

red

to P

lace

bo


Results of Cholesterol Lowering Diet on C-Reactive Protein

-10.0

-33.3

-28.2

-35.00

-25.00

-15.00

-5.00

5.00

Control diet Lovastatin Best Diet

C-R

eact

ive

Pro

tein

Red

uctio

n (%

)

JAMA 290:502-10, July 23/30, 2003

© 1997 - 2004 lifelong health1 preventive health checks week 8 – eight weeks to wellness prepared...

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