16
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
http://www.whatispublichealth.org
Climate Change Population Growth War Famine and Boxing
http://blog.hacking-medschool.com/war-famine-and-boxing
Di Clemente and Prochaska cycle of change
NICE PH6 Behaviour change Oct 2007
http://www.studentnurse.org.uk/midwifery%20HP.htm
| 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
EACH.com.au
Ewles and Simnet @ Google Books
Motivational Interviewing
http://www.motivationalinterview.org/
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) |
hacking-medschool/immunisation-vaccination
eGuidelines Immunisation Schedules
Immunisation calendar pdf calpol.co.uk
Screening Wilson-Jungner criteria
Screening criteria GP training.net
| 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
Cancer screening
American Cancer Society guidelines for the early detection of cancer
Cervical screening
hacking-medschool/cervical-screening-2
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
hacking-medschool/breast-cancer-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)
hacking-medschool/prostate-screening-2
Vascular screening NHS Health Checks
hacking-medschool/vascular-screening-2
Diabetes screening
hacking-medschool/diabetes-screening-2
Diabetes UK news support for hba1c testing for diabetes
Diabetes Risk Scoring
qdscore.org
Well person health checks
New patient / well person health checks and MOTs gp-training.net
Child health surveillance
hacking-medschool/child-health-surveillance
Screening in older people
Medscape Fact Sheet: Screening for Older Adults
Smoking
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
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
Lung age and pack years
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
Exercise
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
Obesity
Body Mass Index BMI Calculator BNF plus
| 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
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.
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
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.
Surgery
Consider only in exceptional circumstances, and if they have achieved or nearly achieved physiological maturity