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Screening and Prevention of Disease: Introduction

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Screening and Prevention of Disease: Introduction

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  1. The leading global risks for mortality in the world are high blood pressure (responsible for 13% of deaths globally), tobacco use (9%), high blood glucose (6%), physical inactivity (6%), and overweight and obesity (5%). These risks are responsible for raising the risk of chronic diseases such as heart disease, diabetes and cancers.

  2. Screening and Prevention of Disease: Introduction A primary goal of health care is to prevent disease or detect it early enough that intervention will be more effective. Strategies for disease screening and prevention are driven by evidence that testing and intervention are practical and effective

  3. Basic Principles of Screening In general, screening is most effective when applied to relatively common disorders that carry a large disease burden . The five leading causes of mortality in the United States are heart diseases, malignantneoplasms, accidents, cerebrovascular diseases, and chronic obstructive pulmonary disease. many prevention strategies are targeted at these conditions. From a global health perspective, these conditions are priorities, but malaria, malnutrition, AIDS, tuberculosis, also carry a heavy disease burden

  4. A primary goal of screening is the early detection of a risk factor or disease at a stage at which it can be corrected or cured. For example, most cancers have a better prognosis when identified as premalignant lesions or when they are still resectable

  5. Similarly, early identification of hypertension or hyperlipidemia allows therapeutic interventions that reduce the long-term risk of cardiovascular or cerebrovascular events

  6. A routine health care examination should be performed every 1–3 years before age 50 and every year thereafter. History should include medication use ,allergies, dietary history, use of alcohol and tobacco, sexual practices, and a thorough family history, Routine measurements should include assessments of height, weight (body mass index), and blood pressure, in addition to the relevant physical examination

  7. Clinical Preventive Services for Normal-Risk Adults Recommended by the U.S. Preventive Services Task Force

  8. Cont,s

  9. Prostate-specific antigen (PSA) testing is capable of enhancing the detection of early-stage prostate cancer, but evidence is inconclusive that it improves health outcomes. PSA testing is recommended by several professional organizations and is widely used in clinical practice, but it is not currently recommended by the U.S. Preventive Services Task Force

  10. In controlled studies, the use of annual FOBT reduces colon cancer deaths by 15–30%. Flexible sigmoidoscopy reduces colon cancer deaths by –60%. Colonoscopy offers the same benefit as or greater benefit than flexible sigmoidoscopy, but its use incurs additional costs and risks.

  11. Age-Specific Causes of Mortality and Corresponding Preventive Options-cont,s

  12. The risk of certain cancers, such as cancer of the cervix, ultimately declines, and it is reasonable to cease Pap smears after about age 65 if recent Pap smears have been negative. For breast, colon, and prostate cancer, it is reasonable to reevaluate the need for screening after about age 75. For some older patients with advanced diseases such as severe chronic obstructive pulmonary disease and congestive heart failure and for those who are immobile, the benefit of some screening procedures is low, and other priorities emerge when life expectancy is <10 years. This shift in focus needs to be done tactfully and allows greater focus on the conditions likely to affect quality and length of life.

  13. Guideline cholestrol

  14. NCEP Major Risk Factors • Classification of an individual’s risk for cardiac events is based upon five risk factors: • smoking • hypertension • low HDL (<40) • family history- 1st degree relative with MI <55yo for male, <65 yo for female • age: male >45 yo, female >55 yo • **HDL > 60: reduction of 1 risk factor

  15. CVD Risk Assessment • Based upon the 10 year cardiovascular risk score. • >20% and/or coronary heart disease (CHD) equivalents: high risk • very high risk: CHD + other risk factors • 10-20% and 2+ risk factors: moderate high • <10% and 2+ risk factors: moderate risk • 0-1 risk factor: lower risk calculated using Framingham risk score

  16. CHD Equivalents • What are the recognized Coronary Heart Disease equivalents? • Diabetes Mellitus • Peripheral Arterial Disease • Symptomatic Carotid Artery Disease (TIA or stroke of carotid origin) • Abdominal Aortic Aneurysm • 10 yr risk for CHD >20% with 2+ risk factors

  17. ATP III Clinical Identification of the Metabolic Syndrome • Waist circumference: • Men>102 cm (>40 in) South Asians Male ≥ 90 cm Female ≥ 80 cm • Women>88 cm (>35 in) • Triglycerides >150 mg/dL • HDL cholesterol:  • Men<40 mg/dL • Women<50 mg/dL • Blood pressure 130/ 85 mm Hg • Fasting glucose >110 mg/dL* * New ADA guidelines suggest >100mg/dl increases risk for Metabolic Syndrome

  18. Necessary Criteria to Make Diagnosis: • IDF: • Require central obesity plus two of the other abnormalities • WHO: • Also requires microalbuminuria - Albumen/ creatinine ratio >30 mg/gm creatinine • ATP III: • Require three or more of the five criteria

  19. Clustering of Components: • Hypertension • Hypertriglyceridemia • Low HDL-cholesterol • Obesity (central) • Impaired Glucose Handling • Microalbuninuria (WHO)

  20. Linked Metabolic Abnormalities: • Impaired glucose handling/insulin resistance • Atherogenic dyslipidemia • Endothelial dysfunction • Prothrombotic state • Hemodynamic changes • Proinflammatory state • Excess ovarian testosterone production • Sleep-disordered breathing

  21. The Continuum of CV Risk in Type 2 Diabetes Adapted from American Diabetes Association. Diabetes Care. 2003;26:3160-3167. Tsao PS, et al. Arterioscler Thromb Vasc Biol. 1998;18:947-953. Hsueh WA, et al. Am J Med. 1998;105(1A):4S-14S. American Diabetes Association. Diabetes Care. 1998;21:310-314.

  22. Insulin Resistance: • Hyperinsulinemic individuals are at risk for developing diabetes, hyperlipidemia, HTN, & ultimately cardiovascular disease • Patients with Metabolic Syndrome are 3.5 times as likely to die from CVD as normal people

  23. Resulting Clinical Conditions: • Type 2 diabetes • Essential hypertension • Polycystic ovary syndrome (PCOS) • Nonalcoholic fatty liver disease • Sleep apnea • Cardiovascular Disease (MI, PVD, Stroke) • Cancer (Breast, Prostate, Colorectal, Liver)

  24. Diabetes Control - How Important? • For every 1% rise in Hgb A1c there is an 18% rise in risk of cardiovascular events & a 28% increase in peripheral arterial disease • Evidence is accumulating to show that tight blood sugar control in both Type 1 and Type 2 diabetes reduces risk of CVD • Goals: FSBS - premeal 90-130, postmeal<180. Hgb A1c <7%

  25. BP Control - How Important? • MRFIT and Framingham Heart Studies: • Conclusively proved the increased risk of CVD with long-term sustained hypertension • Demonstrated a 10 year risk of cardiovascular disease in treated patients vs non-treated patients to be 0.40. • 40% reduction in stroke with control of HTN • Precedes literature on Metabolic Syndrome • Goal: <130/80

  26. Lipid Control - How Important? • Multiple major studies show 24 - 37% reductions in cardiovascular disease risk with use of statins and fibrates in the control of hyperlipidemia. • Goals: LDL <70 mg% (<2.6 mmol/l) • Triglycerides <150 mg% (<1.7 mmol/l) • HDL >40 mg% (>1.1 mmol/l)

  27. Life-Style Modification: Is it Important? • Exercise • Improves CV fitness, weight control, sensitivity to insulin, reduces incidence of diabetes • Weight loss • Improves lipids, insulin sensitivity, BP levels, reduces incidence of diabetes • Goals: Brisk walking - 30 min./day • 10% reduction in body wt.

  28. Smoking Cessation/Avoidance: • A risk factor for development in children and adults • Both passive and active exposure harmful • A majorrisk factorfor: • insulin resistance and metabolic syndrome • macrovascular disease (PVD, MI, Stroke) • microvascular complications of diabetes • pulmonary disease, etc.

  29. Screening/Public Health Approach • Public Education • Screening for at risk individuals: • Blood Sugar/Hgb A1c • Lipids • Blood pressure • Tobacco use • Body habitus • Family history

  30. EBM Recommendations • Any person at high risk or moderately high risk who has lifestyle-related risk factors (e.g., obesity, physical inactivity, elevated triglyceride, low HDL-C, or metabolic syndrome) is a candidate for therapeutic lifestyle changes to modify these risk factors regardless of LDL-C level.

  31. EBM Recommendations (cont.) • There is some evidence that insulin sensitizing agents such as metformin are effective in treating features of metabolic syndrome.

  32. Current Treatments • Weight reduction • TLC: Diet and Exercise • Lower BP goals • Lower LDL goals • Statins • Metformin • Aspirin therapy

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