preventive medicine in wales

Preventive Medicine

in Wales

Eyecare ConferenceOptometry Wales: 19th September 2012

Peter ElwoodCochrane Institute

of Primary Care and Preventive Medicine

Cardiff University

• My aims in this talk:

1. To encourage you in the life-changing and

life-enriching work you do

2. To challenge you to ‘up your game’ and to

‘widen your horizons’

Eyecare in Wales

• There are three sources of evidence in medicine:

- epidemiology and Public Health

- laboratory studies

- clinical studies → effects of treatment; prognosis etc

→ mechanisms in disease

Epidemiology

- The Truth

• There are three sources of evidence in medicine:

- epidemiology and Public Health

- laboratory studies

- clinical studies → effects of treatment; prognosis etc

→ mechanisms in disease

1. The prevalence and the importance of disease

to plan services more effectively and efficiently

to evaluate the importance of services more precisely

Epidemiology

2. To identify factors predictive of disease

to obtain clues about possible preventive measures

• There are three sources of evidence in medicine:

- epidemiology and Public Health

- laboratory studies

- clinical studies → effects of treatment; prognosis etc

→ mechanisms in disease

1. The prevalence and the importance of disease

to plan services more effectively and efficiently

to evaluate the importance of services more precisely

Epidemiology

2. To identify factors predictive of disease

to obtain clues about possible preventive measures

‘Efficiency and effectiveness’‘Evidence-based practice’; ‘cost-effective practice’

‘Prophylaxis, rather than ‘therapy’

Cochrane believed that epidemiology

can make important contributions to

every area of clinical practiceArchie Cochrane 1909-1988

The Ferndale Study of Eye Disease 1964

The Ferndale Glaucoma Survey 1964

The Ferndale TeamTom Benjamin, Diana Seys Prosser, Archie Cochrane Hugh bates ? . ? , ?, Peter Graham ? Gwillam Jonathan, Irene Calford, Fred Moore, Glenys, ?.

The Ferndale Survey

4,246 people aged 40-75 were seen and examined

AIMS: 1. Determine the prevalence of eye diseases 2. Define the distribution of intraocular pressure 3. Determine the prevalence of glaucoma 4. Test a treatment of glaucoma in a randomised trial

5. Conduct long-term follow-up studies of the population to study the development and the prognosis of various eye-diseases

General examination: - details questionnaire on health and social issues

- blood pressure measurement

Ophthalmic examination: - general examination, with ophthalmoscopy

- field examination with the Friedman multiple pattern type machine

- instillation of fluorescine and local anaesthetic

- slit lamp examination

- applanation tonomotry

- Schiotz tonomotry

Output:

Hollows FC & Graham PA. Intraocular pressure, glaucoma and glaucoma suspects in a defined population. Brit J Ophthal 1966;50:570-586

McGuinness R. Association of diabetes and cataract. BMJ 1967;i:416-7

Graham PA Screening for chronic glaucoma. Symposium on Presysymptomatic Diagnosis

Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal detection of registrable blindness. Brit J prev soc Med. 1968;22:238-41.

Output:

Hollows FC & Graham PA. Intraocular pressure, glaucoma and glaucoma suspects in a defined population. Brit J Ophthal 1966;50:570-586

McGuinness R. Association of diabetes and cataract. BMJ 1967;i:416-7

Graham PA Screening for chronic glaucoma. Symposium on Presysymptomatic Diagnosis

Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal detection of registrable blindness. Brit J prev soc Med. 1968;22:238-41.

“Unless a follow-up is successfully concluded the value of

eye screening tests in preventive ophthalmology would

seem to be doubtful.”

ophthalmologist

Output

Hollows FC & Graham PA. Intraocular pressure, glaucoma and

suspects in a defined population. Brit J Ophthal 1966;50:570-586

McGuinness R. Association of diabetes and cataract. BMJ 1967;i:416-7

Graham PA Screening for chronic glaucoma. Symposium on Presysymptomatic Diagnosis

Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal detection of registrable blindness. Brit J prev soc Med. 1968;22:238-41.

Fred Holllows (1929-1993)

Fred worked with Archie Cochrane on the Ferndale

Eye Study in 1964.

He then left and went to Australia.

Fred Hollows

‘Companion of the Order of Australia’

Fred Hollows

Yet Fred was a Maverick and one writer describes him as

“The wild boy of New Zealand’

Fred Hollows

named as one of

Australia’s 100 Living Treasures and given an

Advanced Australia Award for community service

‘worked tirelessly with Fred until his death. Together they set up

The Fred Hollows Foundation

to continue the work of eyecare

in Australia and overseas’

Gabi Hollows Orthoptist

‘Companion of the Order of Australia’

‘Hollows took up the cause of the Aborigines. He set

up ‘The Aboriginal Medical Service’ and ‘The National Trachoma and

Eyehealth Programme’.

‘Over 100,000 Aborigines were examined and tens of

thousands treated.’

‘Then, despite increasing ill health, he expanded his work to Eritrea, to

Nepal and to Vietnam.’

‘A passionate ophthalmologist…’

‘He restored the eyesight of countless thousands of

underprivileged people in developing countries‘.

‘He had a passion to improve their health in every way possible.’

‘A Tireless Innovator, Healer & Campaigner’

Fred Hollows (1929-1993)

‘It has been estimated that through his work,

over one million people had their sight restored

around the world.’

Shortly before his death,

Fred organised the setting up of a factory in Eritrea to manufacture

inexpensive intra-occular

lenses for use in underprivileged

communities

A year before he died, Fred and Gabi set up the

‘Fred Hollows Foundation’

to continue the work he had started amongst the Aborigines and amongst

many other under-privileged communities

would continue.

The Fred Hollows Foundation is is now a major international

charity

1981: Advance Australia Award for Aboriginal eye care.1985: was a consultant to the World Health Organisation (WHO).1985: offered appointment as an honorary Officer (AO) of the Order of Australia.1990: received Human Rights Medal1990: named Australian of the Year1990: received a second Advance Australia Award, for Medicine and Overseas Aid1991: named Humanist of the Year1991: named a Paul Harris Fellow by Rotary International1991: received Honorary Doctor of Medicine and Doctor of Science, University of New South Wales1991: appointed Companion of the Order of Australia (AC)1991: awarded Honorary Doctorate of Science, Macquarie University1991: named the first honorary citizen of Eritrea1992: received Honorary Doctorate, Queensland University of Technology1993: received Albert Schweitzer Award of Distinction, Chapman University, USA1993: received Rotary International's highest honour, the Rotary Award for World Understanding.1993: received the Royal Australian College of Ophthalmologists Medal for his years of distinguished

meritorious and selfless service – presented to him the night before he died.1993: posthumously named a Melvin Jones Fellow of Lions Clubs International.1993: Fred Hollows Reserve in Hollow's hometown of Randwick, NSW Australia established

to preserve a natural rainforest gully and save it from future development.2004: entered into the 'Hall of Fame' at the inaugural NSW Aboriginal Health Awards,

in recognition of his "outstanding contribution and achievement to Indigenous health in Australia".2005: an operating theatre was named after him at Canberra Eye Hospital, ACT, Australia.2005: named one of "New Zealand's Top 100 History Makers" by Prime Television New Zealand.2006: named one of the "100 most influential Australians" by The Bulletin magazine.[15]2010: featured on $1 Coin from the Royal Australian Mint as part of the Inspirational Australians Series

Hollows received twenty three National and International awards

In 1993 Fred Hollows died, aged 63

He was given a state funeral.

Commerative stamps in Australia

Commerative stamps in Eritrea

Commerative coin in Australia

Fred Hollows worked in Wales!

In his autobiography, Hollows wrote:

“The most important influence on me in Wales was Archie Cochrane… Archie and I co-operated in the Ferndale Study of Eye Disease. Without that project in Wales, my later work amongst the Aborigines and in other countries would not have achieved what it did’.

(Quotation slightly adapted)

Yet, there is no record of Hollows in Wales

and only a very few remember him!

Diana Pritchard Ralph Marshall (Seys Prosser)

Sadly, and remarkably, there seems to be no record of Hollows in Wales

and few seem to remember him

“Fred was a delightful man to work with. He had a lovely way with subjects, especially if they were nervous….

Three years after Ferndale I went to Australia and worked with Fred on one of his mobile teams in the

bush. It was hard work but everyone enjoyed working with him. He was a truly dedicated person and he

himself worked very hard indeed.” Diana Pritchard

I have therefore proposed that a panel is erected in the Cochrane

Building, with Fred’s image, an account of his work in Ferndale, and details of his work

in Australia and in other countries.

With postage stamps from Australia and from Etreiaand two Australian coins

Fred Hollows worked in Wales!

Fred Hollows 1929-1993

An inspiration to all of us in healthcare

and especially to you in Eyecare

in your life-changing and

life-enriching work in the community

• My aims in this talk:

1. To encourage you in the life-changing

and life-enriching you do

2. To challenge you to ‘up your game’ and

to ‘widen your horizons’

A challenge to widen your horizons!

Fred Hollows 1929-1993

An inspiration to all of us in healthcare

Wales holds many records!

Smoking Smoking

Alcohol abuseAlcohol abuse

ObesityObesity

Lack of exercise Lack of exercise

Inappropriate diet Inappropriate diet

Health in Wales!

Cost of unhealthy behaviours to NHS Wales*Cost of unhealthy behaviours to NHS Wales*

Smoking Smoking £386 m£386 mObesityObesity £ 86 m£ 86 mLack of exercise ?Lack of exercise ?Inappropriate diet ?Inappropriate diet ?Alcohol abuseAlcohol abuse £ 70 m£ 70 m

* * Making the economic case for prevention:Making the economic case for prevention: a view from Wales. a view from Wales.

Welsh Government Report: Hale, Phillips, Jewel 2012Welsh Government Report: Hale, Phillips, Jewel 2012

10% of total10% of total

NHS costs! *NHS costs! *

A new campaign for a healthier Wales

A new campaign to encourage all NHS staff in Wales to adopt a healthier lifestyle

themselves

and become role-models and encourage patients

and the public to do the same

Champions for HealthStakeholder Briefing

And so, a number of our colleagues in Public Health have launched….

The five healthy behaviours

A healthy lifestyleits effectiveness and its up-take in Wales

Non-smoking BMI 18-25 ½ hour exercise daily

‘Five a day’ Alcohol within the guidelines

The Caerphilly Prospective Study

THE CAERPHILLY PROSPECTIVE STUDY 1980 -

2,500 men aged 45-59 yrs; First examined in 1980 re-questioned and re-examined every five years since then

The effectiveness of a healthy lifestyle

HEALTHY BEHAVIOURS at baseline in 1980

Non-smoking Body weight Diet Exercise Alcohol intake

Recorded for 2,500 men aged 45-59 yrs

OUTCOMES during the following 30 years

Diabetes, vascular disease, cancer, dementia and all-cause death

Output:Around 400 reports published in medical journals

Healthylifestyles Diabetes Ht. disease and

strokeDementia All

deaths

No healthy behaviour

Any two (813 men)

Any three (436)

Four/five (112)

1 1 1 1

Significance of trend

The effectiveness of a healthy lifestyle

All relationships adjusted for age and social classAnd dementia for baseline cognitive function

REDUCTIONS (based on ORs) over the following 30 years

Healthylifestyles Diabetes Ht. disease and

strokeDementia All

deaths

No healthy behaviour

Any two (813 men)

Any three (436)

Four/five (112)

1

-35%

-66%

-72%

1 1 1

Significance of trend 0.001

The effectiveness of a healthy lifestyle

All relationships adjusted for age and social classAnd dementia for baseline cognitive function

REDUCTIONS (based on ORs) over the following 30 years

Healthylifestyles Diabetes Ht. disease and

strokeDementia All

deaths

No healthy behaviour

Any two (813 men)

Any three (436)

Four/five (112)

1

-35%

-66%

-72%

1

-17%

-34%

-67%

1

-44%

-72%

-68%

1

-8%-36%

-32%Significance of trend 0.001 0.0005 0.002 0.002

The effectiveness of a healthy lifestyle

All relationships adjusted for age and social classAnd dementia for baseline cognitive function

REDUCTIONS (based on ORs) over the following 30 years

Healthylifestyles Diabetes Ht. disease and

strokeDementia All

deaths

No healthy behaviour

Any two (813 men)

Any three (436)

Four/five (112)

1

-35%

-66%

-72%

1

-17%

-34%

-67%

1

-44%

-72%

-68%

1

-8%-36%

-32%Significance of trend 0.001 0.0005 0.002 0.002

The effectiveness of a healthy lifestyle

All relationships adjusted for age and social classAnd dementia for baseline cognitive function

REDUCTIONS (based on ORs) over the following 30 years

Healthylifestyles Diabetes Ht. disease and

strokeDementia All

deaths

No healthy behaviour

Any two (813 men)

Any three (436)

Four/five (112)

1

-35%

-66%

-72%

1

-17%

-34%

-67%

1

-44%

-72%

-68%

1

-8%-36%

-32%Significance of trend 0.001 0.0005 0.002 0.002

The effectiveness of a healthy lifestyle

All relationships adjusted for age and social classAnd dementia for baseline cognitive function

REDUCTIONS (based on ORs) over the following 30 years

Another measure of benefit:

The number of years before disease in subjects following a healthy lifestyle will become the level in those who follow no healthy behaviour

For heart disease and stroke……..up to 13 years

For dementia ………up to 7 years

For death ……… up to 6 years

Healthylifestyles Diabetes Ht. disease and

strokeDementia All

deaths

No healthy behaviour

Any two (813 men)

Any three (436)

Four/five (112)

1

-35%

-66%

-72%

1

-17%

-34%

-67%

1

-44%

-72%

-68%

1

-8%-36%

-32%Significance of trend 0.001 0.0005 0.002 0.002

The effectiveness of a healthy lifestyle

All relationships adjusted for age and social classAnd dementia for baseline cognitive function

REDUCTIONS (based on ORs) over the following 30 years

Yet another measure of benefit:

Had the subjects in this 30 year study each been urged at baseline to adopt one additional healthy behaviour, and if only half them had complied, there would have been….

12% less diabetes; 6% less vascular disease

13% less dementia; 5% fewer deaths

Eye disease and Healthy Behaviours

?Eye disease

and a Healthy Lifestyle?

Eye disease and Healthy Behaviours

Two to three-fold increase in Two to three-fold increase in cataractcataract in smokers, and in smokers, anda two to three-fold increase in a two to three-fold increase in macular degenerationmacular degeneration

American Council on Science and HealthAmerican Council on Science and Health

Obesity increases risk of macular degeneration (Arch Ophthalmol. 2009)

?Increase ?Increase cataract, glaucoma and diab. retinopathycataract, glaucoma and diab. retinopathy Israli claimIsrali claim

Mediterranean diet (fish, nuts, and olive oil) beneficial Cheong; Tan

Sat. fats increase macular degeneration (Arch Ophthalmol. 2009)

Beneficial impact on ocular perfusion pressure and glaucoma, macular degeneration 30% lower Brit J Ophthal.

Uncertainty about relationships with the eyeWang S, Wang JJ, Wong TY.Surv Ophthalmol. 2008

Healthy Behaviours in Wales

Two to three-fold increase in Two to three-fold increase in cataractcataract in smokers, and in smokers, anda two to three-fold increase in a two to three-fold increase in macular degenerationmacular degeneration

American Council on Science and HealthAmerican Council on Science and Health

Possible increase in Possible increase in macular degeneration, cataract, glaucoma macular degeneration, cataract, glaucoma and diabetic retinopathyand diabetic retinopathy Claim in a report from IsraelClaim in a report from Israel

Obesity increases risk of macular degeneration Mediterranean diet (fish, nuts, and olive oil) beneficial Cheong; Tan

Sat. fats increase macular degeneration (Arch Ophthalmol. 2009)

beneficial impact on ocular perfusion pressure and glaucoma, macular degeneration 30% lower Brit J Ophthal.

Uncertainty about relationships with the eyeWang S, Wang JJ, Wong TY.Surv Ophthalmol. 2008

Prospective epidemiological studies are invaluable!

Some records of the Ferndale study are still

available

The Speedwell Prospective Study in Bristol, set up in 1979,

has data on healthy behaviours and on macular degeneration

Following a healthy lifestyle

substantially reduces the risk of diabetes,heart disease and death…..

and….. risk of certain eye diseases reduced

and….. during the extra years of life, the risk of dementia is reduced

The effectiveness of a healthy lifestyle

Overall summary……..

BUT, the bad news is…….

Unhealthy Behaviours in Wales

Target: Target: non-smokingnon-smoking25%25% of adults still smoke of adults still smoke28% 28% of 15-year-old girls smokeof 15-year-old girls smoke

Target: Target: BMI below 25BMI below 25

50% 50% overweightoverweight or obese or obese

Target: ‘5 a day’

66% fail to meet the target

Target: moderate exercise ½ hour x five/week 70% fail to reach the target

Target: drinking within guidelines47% regularly exceed guidelines 28% admit to frequent ‘binge’ drinking

Healthy Behaviours in Wales

Target: Target: non-smokingnon-smoking25%25% of adults still smoke of adults still smoke28% 28% of 15-year-old girls still smokeof 15-year-old girls still smoke

50% 50% overweightoverweight or obese or obese

Target: ‘5 a day’

66% fail to meet the target

Target: moderate exercise ½ hour x five/week 70% fail to reach the target

Target: drinking within guidelines

47% regularly exceed guidelines

Of the adult population in Wales:

Only 1% meet the targets for all five

healthy

behaviours

Only 7% meet four of the targets

Champions for HealthStakeholder Briefing

A project to encourage all healthcare staff in Wales to become

role models of healthy living

and encouragers of patients and others to follow a healthy lifestyle

The project is led by Directors of Public Health,

Champions for HealthStakeholder Briefing

NHS Wales staff can register to take part in Champions for Health, at:

www.championsforhealth.wales.nhs.uk

Closing date: Friday 28 September

AN INSPIRATION A CHALLENGE

AN ENCOURAGEMENT

…..widen your horizons!…Fred Hollows worked here!

…..up your game!

AN INSPIRATION A CHALLENGE

AN ENCOURAGEMENT

Public health: gather evidence on cost-effectiveness

Epidemiology: seek evidence on possible preventive measures

…..widen your horizons!…Fred Hollows worked here!

…..up your game!

www.championsforhealth.wales.nhs.uk Closing date: Friday 28 September.