Editorials

Preventive Health: Time for Change

Am Fam Physician. 2010 Sep 15;82(6):610-614.

It is time to make a decision. Which will be our health promotion strategy—primary prevention or secondary prevention?

Traditionally, the only one available to us was secondary prevention. Medicine consisted of a one-on-one physician-patient relationship, and taking care of patients meant minimizing the impact of any diseases the patient had. We did not have the time or tools to do anything else. More recently, we have been able to reduce a patient's mortality by 20 to 30 percent by treating heart disease with a statin or beta blocker. These two medications have had the most dramatic effects in secondary prevention.

But now, the way we practice medicine has changed. We have a real choice to make. According to recent literature, primary prevention appears to work better than any other strategy in medicine. So why do some physicians not implement primary prevention? Despite the literature, maybe physicians are not getting the news. We need to keep repeating the message to physicians and patients that primary prevention is simple and effective. Next, we need to take a look at our own behavior as physicians and determine if it makes sense in the context of primary prevention.

There are 10 major studies on the effects of primary prevention (Table 1).115 These studies demonstrate very large correlations between specific healthy lifestyle behaviors and decreases in major chronic diseases (e.g., diabetes mellitus, heart disease, stroke, cancer) and all-cause mortality.

Table 1.

Summary of Findings from Studies on the Effects of Primary Prevention

Study Type Number of participants Duration (years) Factors studied Major findings

NHS 20001

Prospective cohort study of women

84,129

14

Alcohol use, BMI, diet, exercise, smoking

83 percent reduction in CHD events in women with five healthy lifestyle behaviors compared with no behaviors

NHS 20012

Prospective cohort study of women

84,941

16

Alcohol use, BMI, diet, exercise, smoking

91 percent reduction in the risk of type 2 diabetes mellitus in women with five healthy lifestyle behaviors compared with no behaviors

NHS 20093

Prospective cohort study of women

83,882

14

Alcohol use, analgesic use, BMI, diet, exercise, folic acid use

78 percent reduction in the incidence of hypertension in women with six healthy lifestyle behaviors compared with no behaviors

Diabetes Prevention Program 20024

Randomized controlled trial

3,234

2.8

BMI, diet, exercise

58 percent reduction in the incidence of diabetes with lifestyle intervention, versus a 31 percent reduction with metformin (Glucophage)

HALE project 20045

Prospective cohort study

2,339

10

Alcohol use, diet, exercise, smoking

The presence of four healthy lifestyle behaviors reduced death from any cause by 65 percent, from CHD by 77 percent, from cardiovascular diseases by 67 percent, and from cancers by 68 percent

Adhering to none of the healthy behaviors was associated with a PAR of 60 percent of deaths from any cause, 64 percent from CHD, 61 percent from cardiovascular diseases, and 60 percent from cancers

INTERHEART study 20046

Case-control study

15,152 in case group, 14,820 in control group

No follow-up period

Alcohol use, diabetes, diet, exercise, hypertension, lipid levels, smoking, stress, waist:hip ratio

All unhealthy lifestyle factors were associated with a significantly increased risk of myocardial infarction

Smoking: OR = 2.87, PAR = 35.7 percent for current versus never smokers

Elevated lipids: OR = 3.25, PAR 49.2 percent

Hypertension: OR = 1.91, PAR 17.9 percent

Diabetes: OR = 2.37, PAR = 9.9 percent

Increased waist:hip ratio: OR = 1.12, PAR = 20.1 for highest versus lowest tertile

Stress: OR = 2.67, PAR = 32.5 percent

Lack of daily consumption of fruits and vegetables: OR = 0.70, PAR = 13.7 percent

Regular alcohol use: OR = 0.91, PAR 6.7 percent

Lack of regular physical activity: OR = 0.86; PAR 12.2 percent

These nine risk factors together accounted for 90 percent of the PAR in men and 94 percent in women

INTERHEART study 20047

Case-control study

11,119 in case group, 13,648 in control group

No follow-up period

Stress

Psychosocial stress was assessed by four simple questions about stress at work and at home, financial stress, and major life events in the previous year; persons with myocardial infarction reported higher prevalence of all four stress factors (P < .0001).

HPFS 20068

Prospective cohort study of men

42,847

16

Alcohol use, BMI, diet, exercise, smoking

A low-risk lifestyle reduced CHD by 87 percent, and may have prevented 62 percent of coronary events; among men taking medication for hypertension or hypercholesterolemia, a low-risk lifestyle may have prevented 57 percent of all coronary events

Men who adopted at least two additional healthy lifestyle factors during follow-up had a 27 percent lower risk of CHD compared with those who adopted no additional factors

HPFS/NHS 20089

Prospective cohort study

114,928

Variable

Alcohol use, BMI, diet, exercise, smoking

A healthy lifestyle reduced total strokes by 69 percent in men and by 79 percent in women

Women's Health Study 200610

Prospective cohort study of women

37,636

10

Alcohol use, BMI, diet, exercise, smoking

55 percent reduction in total stroke and 71 percent reduction in ischemic stroke in women with the healthiest lifestyle compared with women with the unhealthiest lifestyle; healthy lifestyle did not reduce hemorrhagic stroke

Atherosclerosis Risk in Communities survey 200711

Prospective cohort study

15,708

6

Alcohol use, BMI, diet, exercise, smoking

40 percent reduction in all-cause morality and 35 percent reduction in cardiovascular events after four years in persons among adults 45 to 64 years of age who had adopted a new healthy lifestyle compared with those who had not

EPIC-Norfolk study 200812

Prospective population study

20,244

11

Alcohol use, diet, exercise, smoking

Compared with persons with four healthy behaviors, the adjusted relative risks for all-cause mortality was 1.39 for three behaviors, 1.95 for two, 2.52 for one, and 4.04 for none

EPIC-Postdam study 200913

Prospective cohort study

23,153

7.8

BMI, diet, exercise, smoking

78 percent reduced risk of a chronic disease in persons with four healthy behaviors compared with no behaviors: 93 percent reduction in diabetes, 81 percent reduction in myocardial infarction, 50 percent reduction in stroke, 36 percent reduction in cancer

ACLS 200914

Prospective cohort study of men

23,657

14.7

Exercise, smoking, waist circumference

59 percent reduced risk of CHD events, 77 percent reduced risk of cardiovascular disease mortality, and 69 percent reduced risk of all-cause mortality in men with a normal waist circumference who were physically fit and did not smoke compared with men with no low-risk factors

Men with no low-risk factors had a shorter life expectancy (by 14.2 years) than men with three low-risk factors

Physicians' Health Study 200915

Prospective cohort study of men

20,900

22.4

Alcohol use, body weight, diet, exercise, smoking

50 percent reduction in the incidence of heart failure in men with at least four of six healthy lifestyle behaviors compared with no behaviors


ACLS = Aerobics Center Longitudinal Study; BMI = body mass index; CHD = coronary heart disease; EPIC = European Prospective Investigation into Cancer and nutrition; HALE = Healthy Ageing: a Longitudinal study in Europe; HPFS = Health Professionals Follow-up Study; NHS = Nurses Health Study OR = odds ratio; PAR = population attributable risk.

Information from references 1 through 15.

Table 1.   Summary of Findings from Studies on the Effects of Primary Prevention

View Table

Table 1.

Summary of Findings from Studies on the Effects of Primary Prevention

Study Type Number of participants Duration (years) Factors studied Major findings

NHS 20001

Prospective cohort study of women

84,129

14

Alcohol use, BMI, diet, exercise, smoking

83 percent reduction in CHD events in women with five healthy lifestyle behaviors compared with no behaviors

NHS 20012

Prospective cohort study of women

84,941

16

Alcohol use, BMI, diet, exercise, smoking

91 percent reduction in the risk of type 2 diabetes mellitus in women with five healthy lifestyle behaviors compared with no behaviors

NHS 20093

Prospective cohort study of women

83,882

14

Alcohol use, analgesic use, BMI, diet, exercise, folic acid use

78 percent reduction in the incidence of hypertension in women with six healthy lifestyle behaviors compared with no behaviors

Diabetes Prevention Program 20024

Randomized controlled trial

3,234

2.8

BMI, diet, exercise

58 percent reduction in the incidence of diabetes with lifestyle intervention, versus a 31 percent reduction with metformin (Glucophage)

HALE project 20045

Prospective cohort study

2,339

10

Alcohol use, diet, exercise, smoking

The presence of four healthy lifestyle behaviors reduced death from any cause by 65 percent, from CHD by 77 percent, from cardiovascular diseases by 67 percent, and from cancers by 68 percent

Adhering to none of the healthy behaviors was associated with a PAR of 60 percent of deaths from any cause, 64 percent from CHD, 61 percent from cardiovascular diseases, and 60 percent from cancers

INTERHEART study 20046

Case-control study

15,152 in case group, 14,820 in control group

No follow-up period

Alcohol use, diabetes, diet, exercise, hypertension, lipid levels, smoking, stress, waist:hip ratio

All unhealthy lifestyle factors were associated with a significantly increased risk of myocardial infarction

Smoking: OR = 2.87, PAR = 35.7 percent for current versus never smokers

Elevated lipids: OR = 3.25, PAR 49.2 percent

Hypertension: OR = 1.91, PAR 17.9 percent

Diabetes: OR = 2.37, PAR = 9.9 percent

Increased waist:hip ratio: OR = 1.12, PAR = 20.1 for highest versus lowest tertile

Stress: OR = 2.67, PAR = 32.5 percent

Lack of daily consumption of fruits and vegetables: OR = 0.70, PAR = 13.7 percent

Regular alcohol use: OR = 0.91, PAR 6.7 percent

Lack of regular physical activity: OR = 0.86; PAR 12.2 percent

These nine risk factors together accounted for 90 percent of the PAR in men and 94 percent in women

INTERHEART study 20047

Case-control study

11,119 in case group, 13,648 in control group

No follow-up period

Stress

Psychosocial stress was assessed by four simple questions about stress at work and at home, financial stress, and major life events in the previous year; persons with myocardial infarction reported higher prevalence of all four stress factors (P < .0001).

HPFS 20068

Prospective cohort study of men

42,847

16

Alcohol use, BMI, diet, exercise, smoking

A low-risk lifestyle reduced CHD by 87 percent, and may have prevented 62 percent of coronary events; among men taking medication for hypertension or hypercholesterolemia, a low-risk lifestyle may have prevented 57 percent of all coronary events

Men who adopted at least two additional healthy lifestyle factors during follow-up had a 27 percent lower risk of CHD compared with those who adopted no additional factors

HPFS/NHS 20089

Prospective cohort study

114,928

Variable

Alcohol use, BMI, diet, exercise, smoking

A healthy lifestyle reduced total strokes by 69 percent in men and by 79 percent in women

Women's Health Study 200610

Prospective cohort study of women

37,636

10

Alcohol use, BMI, diet, exercise, smoking

55 percent reduction in total stroke and 71 percent reduction in ischemic stroke in women with the healthiest lifestyle compared with women with the unhealthiest lifestyle; healthy lifestyle did not reduce hemorrhagic stroke

Atherosclerosis Risk in Communities survey 200711

Prospective cohort study

15,708

6

Alcohol use, BMI, diet, exercise, smoking

40 percent reduction in all-cause morality and 35 percent reduction in cardiovascular events after four years in persons among adults 45 to 64 years of age who had adopted a new healthy lifestyle compared with those who had not

EPIC-Norfolk study 200812

Prospective population study

20,244

11

Alcohol use, diet, exercise, smoking

Compared with persons with four healthy behaviors, the adjusted relative risks for all-cause mortality was 1.39 for three behaviors, 1.95 for two, 2.52 for one, and 4.04 for none

EPIC-Postdam study 200913

Prospective cohort study

23,153

7.8

BMI, diet, exercise, smoking

78 percent reduced risk of a chronic disease in persons with four healthy behaviors compared with no behaviors: 93 percent reduction in diabetes, 81 percent reduction in myocardial infarction, 50 percent reduction in stroke, 36 percent reduction in cancer

ACLS 200914

Prospective cohort study of men

23,657

14.7

Exercise, smoking, waist circumference

59 percent reduced risk of CHD events, 77 percent reduced risk of cardiovascular disease mortality, and 69 percent reduced risk of all-cause mortality in men with a normal waist circumference who were physically fit and did not smoke compared with men with no low-risk factors

Men with no low-risk factors had a shorter life expectancy (by 14.2 years) than men with three low-risk factors

Physicians' Health Study 200915

Prospective cohort study of men

20,900

22.4

Alcohol use, body weight, diet, exercise, smoking

50 percent reduction in the incidence of heart failure in men with at least four of six healthy lifestyle behaviors compared with no behaviors


ACLS = Aerobics Center Longitudinal Study; BMI = body mass index; CHD = coronary heart disease; EPIC = European Prospective Investigation into Cancer and nutrition; HALE = Healthy Ageing: a Longitudinal study in Europe; HPFS = Health Professionals Follow-up Study; NHS = Nurses Health Study OR = odds ratio; PAR = population attributable risk.

Information from references 1 through 15.

Although these studies offer a complex array of data to sift through, the elements of a healthy lifestyle are clear: not smoking, regular exercise, healthy diet, healthy body weight, and reduced stress.

Although exercise guidelines vary, I ascribe to the U.S. Department of Health and Human Services' Physical Activity Guidelines for Americans, which recommends at least 150 minutes of brisk walking or the equivalent per week.16 For the diet criterion, the Atherosclerosis Risk in Communities study illustrates that merely consuming five servings of fruits and vegetables per day is associated with the same benefits as consumption of a Mediterranean-style diet.11 A standard of five servings of fruits and vegetables is much easier to remember and adhere to.

There is strong support for at least one weight-related variable in a healthy lifestyle. This may include body weight, body mass index (BMI), waist circumference, or waist:hip ratio. The INTERHEART study showed waist:hip ratio to be the most predictive of cardiovascular disease.6 However, unlike BMI calculation, measurement of weight:hip ratio has not yet become standard in U.S. practices. I use BMI as the metric, and a value less than 30 kg per m2 as the cutoff between a healthy and unhealthy lifestyle. The goal is to move away from this outer limit toward a more ideal parameter, such as less than 25 kg per m2.

The final variable of a healthy lifestyle, which has strong support from the INTERHEART study, is stress reduction.7 The INTERHEART study offers useful suggestions for measuring stress—perception of severe stress at home or at work, financial stress, or major life events.7 The minimal lifestyle intervention that would be beneficial is not defined. However, 15 to 20 minutes of silence, relaxation, or meditation appears to be a common interval.17 To be more inclusive of patients, I set the criterion to an even less restrictive amount, about 10 minutes per day.17 This is enough time to produce a change in biorhythms and is achievable for most patients. Figure 1 presents a formula to make healthy lifestyle goals simple and accessible.

The Formula for Good Health

Figure 1.

Formula to help patients achieve healthy lifestyle goals.  Download in PDF format

View Large

The Formula for Good Health


Figure 1.

Formula to help patients achieve healthy lifestyle goals.  Download in PDF format

The Formula for Good Health


Figure 1.

Formula to help patients achieve healthy lifestyle goals.  Download in PDF format

Information alone does not lead to behavior change, however. Motivational interviewing or brief negotiation is a new framework that can close the gap between knowledge of available lifestyle interventions and changing behaviors. The framework has already been proven markedly effective for tobacco, drug, and alcohol addiction.18 Few physicians have received the training necessary to implement motivational interviewing or brief negotiation. Resources for learning about these skills include the Kaiser Permanente Medical Group Web site (http://www. kphealtheducation.org/bnroadmap/index.html) and the book Motivational Interviewing in Health Care: Helping Patients Change Behavior.18

In terms of health, we can have it all. We have the requisite tools to convert knowledge into healthy behaviors. This newfound power to reduce diabetes, heart disease, stroke, cancer, and all-cause mortality with primary prevention strategies should impel us to change how we counsel patients. Research is needed to explore why some physicians are not making this change.

Address correspondence to Colin Kopes-Kerr, MD, at cpkerr@nni.com. Reprints are not available from the author.

Author disclosure: Nothing to disclose.

REFERENCES

1. Stampfer MJ, Hu FB, Manson JE, et al. Primary prevention of coronary heart disease in women through diet and lifestyle. N Engl J Med. 2000;343(1):16–22.

2. Hu FB, Manson JE, Stampfer MJ, et al. Diet, lifestyle, and the risk of type 2 diabetes mellitus in women. N Engl J Med. 2001;345(11):790–797.

3. Forman JP, Stampfer MJ, Curhan GC. Diet and lifestyle risk factors associated with incident hypertension in women. JAMA. 2009;302(4):401–411.

4. Knowler WC, Barrett-Connor E, Fowler SE, et al.; Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2002;346(6):393–403.

5. Knoops KT, de Groot LC, Kromhout D, et al. Mediterranean diet, lifestyle factors, and 10-year mortality in elderly European men and women: the HALE project. JAMA. 2004;292(12):1433–1439.

6. Yusuf S, Hawken S, Ounpuu S, et al.; INTERHEART Study Investigators. Effect of potentially modifiable risk factors associated with myocardial infraction in 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):937–952.

7. Rosengren A, Hawken S, Ounpuu S, et al.; INTERHEART Investigators. Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study): case-control study. Lancet. 2004;364(9438):953–962.

8. Chiuve SE, McCullough ML, Sacks FM, et al. Healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. Circulation. 2006;114(2):160–167.

9. Chiuve SE, Rexrode KM, Spiegelman D, et al. Primary prevention of stroke by healthy lifestyle. Circulation. 2008;118(9):947–954.

10. Kurth T, Moore SC, Gaziano JM, et al. Healthy lifestyle and the risk of stroke in women. Arch Intern Med. 2006;166(13):1403–1409.

11. King DE, Mainous AG III, Geesey ME. Turning back the clock: adopting a healthy lifestyle in middle age. Am J Med. 2007;120(7):598–603.

12. Khaw KT, Wareham N, Bingham S, et al. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study [published correction appears in PLoS Med. 2008;5(3):e70]. PLoS Med. 2008;5(1):e12.

13. Ford ES, Bergmann MM, Kröger J, et al. Healthy living is the best revenge: findings from the European Prospective Investigation into Cancer and nutrition–Potsdam study. Arch Intern Med. 2009;169(15):1355–1362.

14. Lee CD, Sui X, Blair SN. Combined effects of cardiorespiratory fitness, not smoking, and normal waist girth on morbidity and mortality in men. Arch Intern Med. 2009;169(22):2096–2101.

15. Djoussé L, Driver JA, Gaziano JM. Relation between modifiable lifestyle factors and lifetime risk of heart failure. JAMA. 2009;302(4):394–400.

16. U.S. Department of Health and Human Services. 2008 physical activity guidelines for Americans. http://www.health.gov/paguidelines/guidelines/. Accessed March 17, 2010.

17. Dialogue Partner. http://www.zenmeditation.biz/. Accessed March 18, 2010.

18. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: Guilford Press; 2008.


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