Health promotion / disease prevention

This section is “categorized” under Clinical Medicine cf Primary Care – effectively it makes no difference the pages are still in the same place thanks to our close scrutiny of the RCGP syllabus and careful considerations of “best place to put everything”

There’s also of course a fair degree of overlap with other sections eg cervical screening — performing smears — colposcopy referrals go together in practice – so a degree of careful but not excessive cross referencing has been included to allow complete coverage of the syllabus whilst avoiding both repetition and too much jumping about

Full coverage but easy navigation is one of our main considerations – just look at the eBNF or Oxford handbooks on your ipad to see how hard that is to achieve in practice and how well or otherwise we might be doing


Health promotion

WHO Definition of Health 1948
a state of complete physical mental and social well being, not merely the abscence of disease and infirmity
Revised Definition of Health BMJ July 2011

Approaches to Health Promotion


Health determinants and risk factors

Fixed risk factors
Modifiable Risk Factors

Australian Institute of Health and Welfare AIHW


Public Health



Climate Change Population Growth War Famine and Boxing



Di Clemente and Prochaska cycle of change

NICE PH6 Behaviour change Oct 2007


Cycle of change di clemente
stage characteristics techniques
Pre-contemplation Not currently considering change:
“Ignorance is bliss”
Validate lack of readiness
Clarify: decision is theirs
Encourage self-exploration, not action
Explain and personalize the risk
Contemplation Ambivalent about change: “Sitting on the fence” Validate lack of readiness
Clarify: decision is theirs
Encourage evaluation of pros and cons of behavior change
Identify and promote new, positive outcome expectations
Preparation Some experience with change and are trying to change: “Testing the waters”
Planning to act within 1month
Identify and assist in problem solving re: obstacles
Help patient identify social support
Verify that patient has underlying skills for behavior change
Encourage small initial steps
Action Practicing new behavior
3-6 months
Focus on restructuring cues and social support
Bolster self-efficacy for dealing with obstacles
Combat feelings of loss and reiterate long-term benefits
Maintenance Continued commitment to sustaining new behavior Plan for follow-up support
Reinforce internal rewards
Discuss coping with relapse
Relapse Resumption of old behaviors: “Fall from grace Evaluate trigger for relapse
Reassess motivation and barriers
Plan stronger coping strategies


Ewles and Simnet Health Promotion Model

Ewles and Simnet Health Promotion Model

Ewles and Simnet @ Google Books


Motivational Interviewing



Primary Secondary Tertiary Prevention

Primary Secondary Tertiary Prevention
Primary Prevention intervention before disease develops – immunisation sanitation accident prevention healthy lifestyle advice often population based
Secondary Prevention preventing complications of disease by early recognition and effective management of established risk factors eg screening (would also include limiting spread of communicable diseases)
Tertiary Prevention limiting progression severity complications and disabilities in established disease eg monitoring therapeutic interventions rehabilitation


Vaccination and immunisation schedules

AGE Immunisation
2 months DTaP/IPV(polio)/Hib (diphtheria, tetanus, pertussis (whooping cough), polio, and Haemophilus influenzae type b) – all-in-one injection, plus:
PCV (pneumococcal conjugate vaccine) – in a separate injection.
3 months DTaP/IPV(polio)/Hib (2nd dose), plus:
MenC (Meningitis C) – in a separate injection.
4 months DTaP/IPV(polio)/Hib (3rd dose), plus:
MenC (2nd dose) – in a separate injection, plus:
PCV (2nd dose) – in a separate injection.
Between 12 and 13 months old Hib/MenC (combined as one injection – 4th dose of Hib and 3rd dose of MenC).MMR (measles, mumps and rubella – combined as one injection), plus:
PCV (3rd dose) – in a separate injection.
Around 3 years and 4 months Pre-school booster of:
DTaP/IPV(polio) (diphtheria, tetanus, pertussis (whooping cough) and polio), plus:
MMR (second dose) – in a separate injection.
Around 12-13 years (girls) HPV (human papillomavirus) – three injections. The second injection is given 1-2 months after the first one. The third is given about six months after the first one.
Around 13-18 years Td/IPV(polio) booster (combined injection of tetanus, low-dose diphtheria, and polio)


Childhood Vaccinations

eGuidelines Immunisation Schedules

Immunisation calendar pdf calpol.co.uk


Screening Wilson-Jungner criteria

Screening criteria GP training.net

Review of screening WHO

Wilsons Criteria Screening
1. The condition being screened for should be an important health problem
2. The natural history of the condition should be well understood
3. There should be a detectable early stage
4. Treatment at an early stage should be of more benefit than at a later stage
5. A suitable test should be devised for the early stage
6. The test should be acceptable
7. Intervals for repeating the test should be determined
8. Adequate health service provision should be made for the extra clinical workload resulting from screening
9. The risks, both physical and psychological, should be less than the benefits
10. The costs should be balanced against the benefits


UK Screening Programmes

NHS UK Screening Portal


Cancer screening

Cancer screening.nhs.uk

American Cancer Society guidelines for the early detection of cancer


Cervical screening


NHS Cervical Screening Programme

North West Cervical Screening Quality Assurance Reference Centre

Aims to reduce the number incidence of invasive cervical cancer and its mortality. Said to prevent around 5000 deaths per year in the UK.
It does this by regularly screening all women at risk so that conditions which might otherwise develop into invasive cancer can be identified and treated

Most cases of cervical cancer appear to be related to the human papillomavirus (HPV) virus. It is thought that a woman must have been infected with HPV for about 7 years before it causes an abnormal smear result and 15 years All women aged 25-49 should be screened every 3 years and women aged between 50 and 64 should be screened every 5 years.


Breast screening



Bowel cancer screening

NHS Bowel Cancer Screening Programme

About one in 20 people in the UK will develop bowel cancer during their lifetime. It is the third most common cancer in the UK, and the second leading cause of cancer deaths, with over 16,000 people dying from it each year.

The NHS Bowel Cancer Screening Programme offers screening every two years to all men and women aged 60 to 69. People over 70 can request a screening kit by calling a freephone helpline when the programme reaches their area. GPs are not directly involved in the delivery of the NHS Bowel Cancer Screening Programme but they will be notified when invitations for bowel cancer screening are being sent out in their area. They will also receive a copy of the results letters sent to their patients.

How will the screening process work?
Men and women eligible for screening will receive an invitation letter explaining the programme and an information leaflet entitled Bowel Cancer Screening The Facts. About a week later, an FOB test kit will be sent out along with step-by-step instructions for completing the test at home and sending the samples to the hub laboratory. The test will then be processed and the results sent within two weeks.

What happens next?
Around 98 in 100 people will receive a normal result and will be returned to routine screening. They will be invited for bowel cancer screening every two years if still within the eligible age range.
Around 2 in 100 people will receive an abnormal result. They will be referred for further investigation and usually offered a colonoscopy.
Around 4 in 100 people may initially receive an unclear result which means that there was a slight suggestion of blood in the test sample. This could be caused by conditions other than cancer such as haemorrhoids (piles). An unclear result does not mean that cancer is present, but that the FOB test will need to be repeated. Most people who repeat the test will then go on to receive a normal result.


AAA screening

NHS Abdominal Aortic Aneurysm screening

Between 5 and 10% of men over 65 years may have an asymptomatic aneurysm and 6000 men die each year from rupture (505) mortality
Ultrasound screening for aortic aneurysm has been shown to be of value in older men who are fit enough for surgery and who have an aneurysm of more than 5.5cm.


Prostate screening (screening)



NHS prostate screning

PSA factsheet cancer.gov


Vascular screening NHS Health Checks



Diabetes screening


Diabetes Screening PUK

Diabetes UK news support for hba1c testing for diabetes

Diabetes Risk Scoring


Well person health checks

New patient / well person health checks and MOTs gp-training.net


Child health surveillance



Screening in older people

Medscape Fact Sheet: Screening for Older Adults



The problem of tobacco smoking BMJ 2004

Smoking is the number-one preventable cause of ill health (120000 deaths/year).
One in four adults in the UK smokes (13 million in total in the UK).
The cost to the NHS is £1500 million/year.


Smoking cessation

Smoking Cessation Treatment Options MIMS online

NICE PH1 Smoking Cessation


Suicidal behavior and depression with smoking cessation treatments NELM Oct 2011

Tar wars over smoking cessation BMJ Aug 2011

Does stopping smoking within a few weeks of surgery increase postoperative complications?

Cigarette smoking cessation and total and cause-specific mortality: A 22-year follow-up study NeLM Nov 2011

plus Impact of smoking cessation advice on future smoking behaviour, morbidity, and mortality

ecigs NeLM Sep 2011


Lung age and pack years

Early-CDT Risk Calculator

Lung Age Calculator

Pack Years = Packs smoked per day x years as a smoker (1 pack = 20 cigarettes)
eg a patient who has smoked 15 cigarettes a day for 40 years has a (15×40) / 20 = 30 pack year smoking history.


Smoking – decline in lung function with age

Fletcher-Peto Curves



DOH Physical Activity Guidelines July 2011

NICE PH2 Four commonly used methods to increase physical activity Mar 2006

First Study to Quantify Benefits of Exercise on CHD Risk Heartwire Aug 2011

Around 90 minutes moderate exercise per week has significant health benefits NeLM/Lancet Aug 2011

iTunes U UCLA recreation 15 stretches

Evolutionary fitness / Paleo diet

RCGP journal Dec 2011 letter re beneficial effects of exercise


Exercise on prescription

Exercise prescription Medscape

Exercise on Prescription Birmingham City Council



Body Mass Index BMI Calculator BNF plus

NICE CG43 Obesity Dec 2006

SIGN qrg 115 Feb 10 Obesity

National obesity forum.org.uk

Commercial weight reduction service at least as good as standard primary care treatment NelM Sep 2011

QOF Obesity

Assessment of health risk based on BMI and waist circumference
Normal Men < 94cm
Women <80cm
no risk
Overweight Men 94- 102 cm
Women 80-88 cm
BMI >25kg/m2 low risk
Obese Grade 1 Men >102cm
Women >88cm
BMI >30kg/m2 increased
Obese Grade 2 BMI >35kg/m2 High risk
Obese Grade 3 BMI >40kg/m2 Very high


Health benefits of weight loss

Health benefits of weight loss Medscape


Realistic goals for weight and waist loss

weight loss resources.co.uk

Commercial vs GP weight loss programmes BMJ Nov 2011

Realistic goals for weight and waist loss
Short Term 1–4kg/month (2–8lb/month) 1–4cm/month (1–2 inches)
Medium term 10% of initial weight 12 weeks
Long term 10–20% of initial weight <88cm (35 inches) for women <102cm (40 inches) for men


Obesity drugs

Use in conjunction with lifestyle measures, set target 5% weight loss over 3 months.

NICE CG43 DEC 2006

Orlistat (Xenical)
better for those with high fat intake
ULowers fat absorption’:
TOS with or before meals.
NICE criteria: BMI >30 or >28 with co-morbidity (Type-2 OM, cholesterolaemia, hypertension) .
Continue>12 weeks only if 5% weight loss.
Can cause reduced absorption of fat-soluble vitamins (A, D, E, K) and reduced COCP efficacy.
CI: malabsorption, breastfeeding.
SEs: flatulence, diarrhoea.

Sibutramine (Reductil)
appetite Suppressant better for those who cannot control eating
Licensed for maximum of 1 year.
NICE criteria: BMI >30 or >27 with co-morbidity.
Monitor BP and pulse 2 weekly for first 3 months, then monthly.
Stop if BP >145/90 or >10 mmHg diastolic BP rise or 10 bpm pulse rise at two consecutive visits.
Continue >12 weeks only if 5% weight loss.
SEs: dry mouth, abdominal pain, hypertension.
Rimonobant (Acomplia)Appetite Suprressant
NICE criteria: BMI >30 or >27 with co-morbidity.
CI: psychiatric illness.
SEs: dry mouth, abdominal pain, depression, anxiety.


@@@ Metabolic syndrome

Metabolic Syndrome @ Southampton University

Central abdominal obesity plus two of the following :
Waist higher than 102 cm males 88 cm females (Caucasions)
Atherogenic Dislipidaemia
TG greater than 1.7mmmol/l
HDL lower than 0.9mmol/l in men  or 1.1mmol/l in women
FPG greater than 5.6mmol/l
Hypertension Systolic BP higher than 130 Diastolic BP higher than 85
Glucose intolerance/hyperinsulinaemia Fating glucose > 5.6 (6.1?)

check latest definition for these values

Metabolic Syndrome
Abdominal Obesity waist circ > 102 cm m > 88 cm f (Caucasions)
Hypertension BP> > 130/85 mmHg
Atherogenic Dislipidaemia TG>1.7 (1.69?) mmol HDL< 1.03 (1.04?) M or <1.29F
Glucose intolerance/hyperinsulinaemia


Bariatric surgery

NICE criteria for bariatric surgery
only if BMI >40 or >35 with co-morbidities and other measures conservative and medical measures have failed.
Patients must have exhausted all other nonsurgical measures >6m including intensive management in specialist clinic be fit for surgery including psychologically be seen in specialist clinic and committed to long term FU

BMI >35 kg/m2
BMI > 40 kg/m2
BMI > 50 kg/m2

More obesity surgery in England would save money BMJ Sep 2010


Childhood obesity

Obesity in Children PUK

Improving fitness and reducing obesity in preschool children BMJ Nov 2011

Consider drug treatment only after dietary, exercise and behavioural approaches have been started and evaluated.

Children under 12
drug treatment is not generally recommended
prescribe only in exceptional circumstances, if there are severe life threatening co morbidities (such as sleep apnoea or raised intracranial pressure)
prescribing should be started and monitored only in specialist paediatric settings.

Children 12 and older
drug treatment is recommended only if there are physical co morbidities (such as orthopaedic problems or sleep apnoea) or severe psychological co morbidities
prescribing should be started by a specialist multidisciplinary team with experience of prescribing for this age group.

Consider only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity


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