© 1997 - 2004 LifeLong Health 1
Preventive Health Checks
Week 8 – Eight Weeks to WellnessPrepared by Don Hall, DrPH, CHES
© 1997 - 2004 LifeLong Health 2
• Sponsored by:
Lassen Foundation
2801 Williams Rd.
Butte Valley, CA 95965
• Your name, Health Educator
© 1997 - 2004 LifeLong Health 3
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
© 1997 - 2004 LifeLong Health 4
Preventive ChecksThat Can Add Years to Your
Life
© 1997 - 2004 LifeLong Health 5
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
© 1997 - 2004 LifeLong Health 6
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
© 1997 - 2004 LifeLong Health 7
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
© 1997 - 2004 LifeLong Health 8
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
© 1997 - 2004 LifeLong Health 9
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
© 1997 - 2004 LifeLong Health 10
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
© 1997 - 2004 LifeLong Health 11
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
© 1997 - 2004 LifeLong Health 12
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
© 1997 - 2004 LifeLong Health 13
There are usually no signs of disease until an artery is 90-95% plugged
Coronary arteryModerate atherosclerosis
© 1997 - 2004 LifeLong Health 14
ArterySevere Atherosclerosis
This artery is 99% plugged with buildup of cholesterol and plaque.
© 1997 - 2004 LifeLong Health 15
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
© 1997 - 2004 LifeLong Health 16
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
© 1997 - 2004 LifeLong Health 17
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
© 1997 - 2004 LifeLong Health 18
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
© 1997 - 2004 LifeLong Health 19
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
© 1997 - 2004 LifeLong Health 20
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
© 1997 - 2004 LifeLong Health 21
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
© 1997 - 2004 LifeLong Health 22
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
© 1997 - 2004 LifeLong Health 23
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
© 1997 - 2004 LifeLong Health 24
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
© 1997 - 2004 LifeLong Health 25
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
© 1997 - 2004 LifeLong Health 26
Intervention Trial to Prevent Diabetes
• 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
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
© 1997 - 2004 LifeLong Health 27
Intervention Trial to Prevent Diabetes
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
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
© 1997 - 2004 LifeLong Health 28
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
© 1997 - 2004 LifeLong Health 29
Preventive Cancer Checks
© 1997 - 2004 LifeLong Health 30
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
© 1997 - 2004 LifeLong Health 31
Colon Polyp
Colon cancer screening, using a colonoscopy, can find and remove polyps before they become cancerous.
© 1997 - 2004 LifeLong Health 32
Colon Polyps
Virtual Colonoscopy View
Optical Colonoscopy View
New Eng. J of Med, Dec 4, 2003
© 1997 - 2004 LifeLong Health 33
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
© 1997 - 2004 LifeLong Health 34
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)
© 1997 - 2004 LifeLong Health 35
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
© 1997 - 2004 LifeLong Health 36
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
© 1997 - 2004 LifeLong Health 37
Other Checks
© 1997 - 2004 LifeLong Health 38
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.
© 1997 - 2004 LifeLong Health 39
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
© 1997 - 2004 LifeLong Health 40
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
© 1997 - 2004 LifeLong Health 41
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.
© 1997 - 2004 LifeLong Health 42
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.
© 1997 - 2004 LifeLong Health 43
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
© 1997 - 2004 LifeLong Health 44
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
© 1997 - 2004 LifeLong Health 45
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
© 1997 - 2004 LifeLong Health 46
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
© 1997 - 2004 LifeLong Health 47
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?
© 1997 - 2004 LifeLong Health 48
www.lifelonghealth.uswww.lifelonghealth.us
© 1997 - 2004 LifeLong Health 49
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
© 1997 - 2004 LifeLong Health 50
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.
© 1997 - 2004 LifeLong Health 51
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
© 1997 - 2004 LifeLong Health 52
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
© 1997 - 2004 LifeLong Health 53
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
© 1997 - 2004 LifeLong Health 54
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
© 1997 - 2004 LifeLong Health 55
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
© 1997 - 2004 LifeLong Health 56
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
© 1997 - 2004 LifeLong Health 57
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
© 1997 - 2004 LifeLong Health 58
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
© 1997 - 2004 LifeLong Health 59
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
© 1997 - 2004 LifeLong Health 60
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