Practice Guidelines
ACS/ADA/AHA Issue Core Recommendations for Preventing Cancer, Cardiovascular Disease, and Diabetes
The American Cancer Society (ACS), the American Diabetes Association (ADA), and the American Heart Association (AHA) have issued a collaborative scientific statement announcing an initiative by these three organizations to create a national commitment to the prevention and early detection of cancer, cardiovascular disease, and diabetes. The goals of the recommendations are to stimulate improvements in prevention and early detection; to create greater public awareness about healthy lifestyles; to spur legislative action that will result in funding for and access to prevention programs; and to rethink the periodic checkup as a way to prevent, detect, and treat these three health problems. The full text of the recommendations was published in the June 29, 2004 issue of Circulation and is available online at http://circ.ahajournals.org/cgi/reprint/109/25/3244.
Although the age-standardized mortality rate from cancer and cardiovascular disease has decreased, the total number of people who die from these two diseases has increased because the population has increased and aged. The prevalence of diabetes increased dramatically-by 61 percent-from 1990 to 2001, primarily as a result of excess body weight. Troublingly, an epidemic of overweight and obese children means that the prevalence of diabetes will continue to increase.
Collectively, cancer, cardiovascular disease, and diabetes accounted for 65 percent of all deaths in the year 2000. The combined costs of these diseases comprise 32 percent of the $2,256.5 billion spent in the United States in total direct and indirect illness costs. The burden of these three diseases is expected to increase as a result of the aging of the population and an increasingly sedentary lifestyle that has resulted in an epidemic of obesity. Cancer, cardiovascular disease, and diabetes share common risk factors, so the recommended preventions also are shared. Primary prevention efforts need to focus on reducing tobacco use, reducing weight, improving nutrition, and increasing physical activity.
Reducing Tobacco Use
In the United States, tobacco use has been linked to approximately 30 percent of all deaths caused by cancer and 20 percent of all deaths caused by cardiovascular disease. In addition, smoking may be a risk factor for type 2 diabetes, with people who smoked two or more packs a day having a 45 percent (men) or 74 percent (women) higher incidence rate of diabetes. Reducing the initiation of tobacco use in children and young adults, and reducing smoking in adults will thus have a major impact on health.
Several strategies have been demonstrated to be successful in reducing tobacco use. States with strong tobacco-control laws have seen declines in smoking prevalence, cardiovascular mortality, and lung cancer incidence. Counseling by medical caregivers can profoundly increase smokers' motivation to stop smoking; such advice should be accompanied by informed guidance in the use of nicotine-replacement products and behavioral therapies-although counseling and pharmacologic interventions are underutilized. A good moment to counsel patients may occur when the patient is hospitalized for something perhaps related to smoking, such as ischemic heart disease.
Reducing Weight
Fourteen percent of all deaths that occurred in 1990 could be attributed to diet and physical activity. In 1999 to 2000, 64 percent of adults met the criteria for overweight (body mass index [BMI] of 25.0 to 29.9) or obese (BMI greater than 30). Since the late 1980s, children also have become heavier, and because overweight or obese children tend to grow into overweight or obese adults, interventions need to occur in this age group as well. Excess body weight is a risk factor for cardiovascular disease and diabetes, as well as stroke, hypertension, and dyslipidemia. Excess weight also has been linked to cancers at numerous sites, including breast, colon, endometrium, and esophagus. Furthermore, the heaviest men and women with cancer are much more likely to die of it.
Weight reduction should be encouraged in patients who are overweight or obese, regardless of the patient's age. Lifestyle modification, rather than pharmacologic intervention, should be suggested first: overweight patients must eat less and exercise more. Current studies suggest that even modest weight loss of just 5 to 10 percent can have a positive impact in diabetes risk and management. Patients need to be told directly that being overweight is hazardous to their health.
Improving Nutrition
Daily caloric intake in 2000 was about 300 calories greater than in 1985, with most of the excess calories coming from refined grains and foods high in added sugar. This caloric excess, combined with a lack of physical activity, has fueled the obesity epidemic. Diets that emphasize whole-grain foods, legumes, vegetables, and fruit, and that limit red meat, full-fat dairy products, and food and drink high in added sugars are associated with a decreased risk for a variety of chronic diseases.
Current recommendations are to eat a mostly plant-based diet with at least five servings of fruits and vegetables a day; to choose whole-grain carbohydrates over refined sources; and to limit intake of saturated fat and alcohol.
Increasing Physical Activity
In addition to the impact of physical activity on weight control, exercise also affects hormone levels and reduces circulating concentrations of insulin. People who are physically fit have a reduced incidence of coronary artery disease and stroke. The relationship between physical activity and cancer remains unknown, but moderate to vigorous activity has been shown to reduce the risk of breast and colon cancers.
Current recommendations suggest that people should engage in 30 minutes of physical activity a day, five days a week. This exercise need not occur all at once but can be broken up over the day. The beneficial effect of exercise is "dose related"-that is, the more vigorous the exercise and the longer its duration, the more benefits are seen. However, such exercise may be out of reach for many, so the current recommendations attempt to balance benefit and compliance. Seeking more exercise must become a habit.
Screening
Early detection of cancer, cardiovascular disease, and diabetes is crucial to successful treatment. However, because the need for an annual checkup has been challenged, it is now important to identify which age- and sex-appropriate screening tests need to be performed regularly.
Conclusion
This collaboration among the ACS, ADA, and AHA foregrounds the need for a clear, consistent message to be sent to patients: they must stop smoking, lose weight, exercise regularly, and eat better. These core messages must be sent consistently, not only by health care professionals, but by communities, insurers, and legislators. In addition, advocacy is required at local, state, and national levels.
Practice Guideline Briefs
Treatment of Postherpetic Neuralgia
The Quality Standards Subcommittee of the American Academy of Neurology has released a report on postherpetic neuralgia treatment. "Practice Parameter: Treatment of Postherpetic Neuralgia" appears in the September 2004 issue of Neurology and is available online at http://www.aan.com.
Acute herpetic neuralgia is characterized as burning, aching, electric-shock-like pain, or unbearable itching in association with the outbreak of a herpes zoster rash. The pain is associated with dysesthesias, paresthesias, hyperalgesia, hyperesthesia, and allodynia (production of pain by innocuous stimuli). The pain may precede the onset of the herpetic rash and, rarely, herpetic neuralgia can occur without the development of a rash.
Postherpetic neuralgia, persistence of the pain of herpes zoster more than three months after resolution of the rash, is relatively common, affecting 10 to 15 percent of those with herpes zoster. Zoster-associated pain is used to describe the continuum of pain from acute herpes zoster to the development of postherpetic neuralgia. The time interval used in the clinical case definition of postherpetic neuralgia varies in the literature from one to six months after resolution of the rash. The incidence of postherpetic neuralgia increases with age. The duration of postherpetic neuralgia is highly variable.
Administration of antiviral agents within 72 hours of the onset of herpes zoster can reduce the intensity and duration of acute illness, and can prevent postherpetic neuralgia, as may the use of amitriptyline. Efforts at prevention of herpes zoster and postherpetic neuralgia are important in that 40 to 50 percent of those with postherpetic neuralgia do not respond to any treatment. The practice parameter focused on which treatments provide benefit in terms of decreased pain and improved quality of life. Among the findings and key recommendations are the following:
- Tricyclic antidepressants (amitriptyline, nortriptyline, desipramine, and maprotiline), gabapentin, pregabalin, opioids, and topical lidocaine patches are effective and should be used in the treatment of postherpetic neuralgia. There is limited evidence to support the use of nortriptyline over amitriptyline and the data are insufficient to recommend one opioid over another. Amitriptyline has significant cardiac effects in elderly patients when compared with nortriptyline and desipramine.
- Aspirin in cream may be effective in the relief of pain in patients with postherpetic neuralgia but the magnitude of benefit is low, as with capsaicin.
- In countries where preservative-free intrathecal methylprednisolone is available, it may be considered in the treatment of postherpetic neuralgia.
- Acupuncture, benzydamine cream, dextromethorphan, indomethacin, epidural methylprednisolone, epidural morphine sulfate, iontophoresis of vincristine, lorazepam, vitamin E, and zimelidine are not of benefit.
- The efficacies of carbamazepine, nicardipine, biperiden, chlorprothixene, ketamine, He:Ne laser irradiation, intralesional triamcinolone, cryocautery, topical piroxicam, extract of Ganoderma lucidum, dorsal root entry zone lesions, and stellate ganglion block are unproven in the treatment of postherpetic neuralgia.
- There is insufficient evidence at this time to make any recommendations on the long-term effects of these treatments.
Pain and Anxiety Treatment in Children During Emergencies
The Committee on Pediatric Emergency Medicine and the Section on Anesthesiology and Pain Medicine of the American Academy of Pediatrics (AAP) has released a clinical report on emergency pain and anxiety treatment in children. "Relief of Pain and Anxiety in Pediatric Patients in Emergency Medical Systems" appears in the November 2004 issue of Pediatrics and is available online at http://www.aan.com.
Relief of pain and stress for children receiving emergency medical treatment is a vital, and readily available, component of care. Advances in the recognition and treatment of pain in children over the past 20 years have led to improved pain management for acutely ill and injured children. However, such care still lags behind adult pain management.
Severe pain and stress can have long-lasting implications for children. For example, a newborn infant who undergoes a procedure with inadequate pain relief may have permanent changes in his or her response to, and perceptions of, pain. Post-traumatic stress disorder also can occur after painful procedures and medical experiences. However, there is no evidence that pain management masks symptoms, clouds mental status, or in any way prevents physicians from making adequate assessments and diagnoses, according to the report.
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Immediate pain assessment for children, including newborns, should occur on emergency department (ED) admission, the report states, and every opportunity should be taken to use available methods of pain control during treatment, even for minor procedures. The recommendations in the report are summarized in the accompanying box.
More research and innovation on child pain and stress reduction techniques are needed, according to the report. As medications and technology evolve, EDs must continue to ensure that safe protocols and practices are in place for child pain management.
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Academy of Family Physicians. |
