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PREVENTIVE MEDICINE

EARLY INTERVENTION AND POTENTIAL PREVENTION MECHANISMS

MOHAMMED ASHRAF

ANALYTICS MEDICAL DIAGNOSTICS LIMITED

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Contents

Concepts of prevention of disease

Definition
Levels of prevention
Timelines of approaches to prevention

Types of health interventions
Beyond disease Prevention

Concept of health, wellness and wellbeing
Stages of wellness
Dimension of wellness

Life style modification in preventive care
Preventive self-care to stay healthy
Diagnostic screening for preventive care

Advantages of Preventive care

List of Screening tests
Final words

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CONCEPTS OF PREVENTION

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Disease prevention: Definition

Activities assigned to protect patients and other members of the public from actual and potential health threats and their harmful consequences.

Mosby’s Medical Dictionary, 8^th edition 2009

Disease prevention covers measures not only to prevent the occurrence of the disease, such as risk factor reduction, but also to arrest its progress and reduce its consequences once established

Reference: adapted from Glossary of Terms used in Health for All Series WHO, Geneva, 1984

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Successful prevention depends upon

Knowledge of causation
Dynamics of transmission
Identification of risk factors and risk groups
Availability of prophylactic or early detection and treatment measures
Facilities for these treatment procedures
Evaluation and development of these procedures

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Levels of prevention

The concepts of prevention can be best defined in the context of “levels of prevention”�

But…..

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Timeline

1953 – Leavell and Clark
1957 – Commission of chronic illness

1958 – Leavell and Clark

1965 – Leavell and Clark

1983 – Gordon

1985 – Tanahill

2001 – Froom and Benbassat

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1953 – Leavell and Clark

Book : Textbook of preventive medicine

5 levels of application

Health promotion
Specific promotion
Early recognition and prompt treatment
Disability limitation
Rehabilitation

Based on his paper on the disease syphilis

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1957 – Commission of chronic illness

Prevention of chronic illness – Volume 1
First use of the words primary and secondary prevention
Primary prevention : averting the occurrence of disease
Secondary prevention : halting the progression of disease from its early unrecognized stage to a more severe one and preventing complications.

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1958 – Leavell and Clark

Second edition : Preventive Medicine for the Doctor and the Community
Defined five levels into three categories

Primary prevention

Health promotion (serving to further general health and well-being)
Specific promotion (measures applicable to a particular disease or group of disease in order to intercept the causes before they involve man)

Secondary prevention

Early recognition and prompt treatment (preventing spread to others if the disease is communicable , complications or sequelae and prolonged disability )

Tertiary prevention

Disability limitation (prevention or delaying of the consequences of clinically advanced diseases)
Rehabilitation ( aiming at prevention of complete disability after anatomic and physiologic changes or stabilized)

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1965 – Leavell and Clark

Third edition : Preventive Medicine for the Doctor and the Community
Referred levels of prevention as “phases of prevention” and
Disability limitation was transferred to secondary phase of prevention

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1983 - Gordon

Public Health Reports
Limited the use of word prevention to persons who have not yet suffered any discomfort or disability due to the disease
Classification : Target population

Universal measures – for everyone
Selective measures – for above risk demographies
Indicated measures – for individuals at risk

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1985 - Tanahill

Reviewed the usage of primary, secondary and tertiary by different authors and proposed a new classification
Foci of prevention

Prevention of the first occurrence of the illness or unwanted phenomenon
Prevention of avoidable consequences of illness or other unwanted state through early detection when this favorably affects the outcome.
Prevention of avoidable complications of established disease or other unwanted state
Prevention of recurrence.

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2001 – Froom and Benbassat

Expanded the categories of prevention from three to seven

Level 1 : reducing exposure to an etiologic agent
Level 2 : increasing resistance to the disease
Level 3 : defining it as screening for risk factors for disease (in asymptomatic individuals ) in order to reduce them
Level 4 : prevention of recurrence (in asymptomatic individuals after a disease related event)
Level 5 : treatment aimed at prevention of complications (in asymptomatic individuals after a disease related event)
Level 6 : treatment of symptomatic patients for cure, palliation or reduction of mortality
Level 7 : rehabilitation for adjustment to irremediable conditions.

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2008 – 2009 : Hattis and Law

Classification according to stages of diseases

Stages of disease development		Corresponding stages of prevention
1	Exposure	Avoidance of exposure
2	Acquisition	Reduction of acquisition
3	Advancement / Progression	Interruption of progression (start with screening for early disease) Cure the disease Slow the progression Reverse the disease process Prevent transmission if infectious
4	Complications	Avoidance of complications Prevent initial complication Prevent recurrence of complication
5	Death or Disability	Delay of mortality Rehabilitation of disability Palliative care for inevitable death

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Stages of disease development		Disease 1 - Type 2 Diabetes	Disease 2 - HIV	Disease 3 – Breast Cancer
1	Avoidance of exposure	Healthy eating, limit simple carbohydrates, maintain health weight, exercise	Abstinence from sex(or screening and monogamy of seronegative partners), no injection drug use	Avoid known carcinogens (smoking, drinking ETOH), limit exogenous oestrogens, avoid obesity, regular exercise
2	Reduction of disease acquisition	Weight loss, consider metformin if insulin resistance/pre-diabetes	Condom promotion and programs to discourage drug abuse, needle sharing	Tamoxifen, raloxifine or mastectomy as prophylactic treatment if BRCA gene (genetic exposure)
3	Interruption or delay of disease progression	Anti-diabetic drugs, monitor HbA1c, FBS, Proteinuria, lipids, bariatric surgery if needed	Antibody screening, monitoring CD4, viral load, treatment with antiretroviral	Detection of cancer by examinations mammography, other imaging, biopsy, surgery, hormone antagonism if oestrogen receptor
4	Avoidance or delay of disease complications	ACE inhibitors/ARB to avoid renal sequelae, strict glucose control, lipid control, foot and eye care	Prophylactic treatment for opportunistic infections	Chemo/radiation therapy, mastectomy, follow-up biannual mammogram post surgery, PET scan
5	Delay of mortality from disease complication	Renal dialysis, coronary stent or bypass	Intensive treatment for opportunistic infections	Full body radiation, bone marrow transplant

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LEVELS OF PREVENTION

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Levels of prevention

The concept of prevention is best defined in terms of levels of prevention. Traditionally

Primordial prevention
Primary prevention
Secondary prevention
Tertiary prevention
Quaternary prevention

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Level of Prevention	Definition	Stage of the disease	Mode of Intervention	Target Population
Primordial Prevention	Prevention of emergence or development of risk factors	Underlying conditions leading to causation mainly associated to chronic diseases	Health education and promotion	Total Population, Selected group
Primary Prevention	Prevention of disease when a risk factor is present	Pre-pathogenesis stage of disease	Health education, Environmental modifications, Nutritional interventions, Lifestyle modification, Immunization	Total Population, Selected group, Healthy individuals
Secondary Prevention	Prevention of complication of disease from occurring	Early pathogenesis stage	Early diagnosis, Prompt, optimized and sustained care	Patients
Tertiary Prevention	Prevention of disability or death	Late pathogenesis stage	Rehabilitation, Disability prevention	Patients
Quaternary Prevention	Prevention of over diagnosis and treatment	Iatrogenesis	Rehabilitation, Disability prevention	Patients

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Example of levels of prevention in Cancer

Cancer Prevention	Aim	Target	Non-immunological examples	Immunological examples
Primary	Removal or avoidance of cancer risk factors	Healthy individuals	Healthy diet, Ban on carcinogenic in work places, quitting smoking, Prophylactic mastectomy in hereditary breast cancer	Anti-HBV & HPV vaccines
Secondary	Early diagnosis and therapy	Pre-symptomatic cancer bearers	Pap test, Mammography, Colonoscopy	Anti-Her2 and MUC1 vaccines against preneoplastic and early neoplastic lesions
Tertiary	Prevention of relapse and metastasis.	Survivors with occult neoplastic lesions	Prophylactic radiotherapy, Adjuvant chemotherapy	Adjuvant monoclonal antibodies, adjuvant therapeutic vaccines, Intravesical instillation of Basils

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Types of health interventions

Broadly classified into two categories

Preventive Care	Diagnostic or Therapeutic Care
Preventive care emphasizes evaluating your current health, concentrates on disease prevention. In other words, you get preventive care when you are symptom-free and have absolutely no reason to believe that you might be sick. E.g. – Cancer screening, Diabetes screening, STI screening, Mental health screening, etc.,	Diagnostic care involves treating or diagnosing a disease you are having by monitoring existing problems, checking new symptoms, and following up on test results that may not have been in the standard range. E.g. – Surgery or radiation, diagnostic tests like HbA1c, Troponin, Dimer, Viral loads, drugs for treatment etc.,

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Beyond disease prevention……..

Breslow proposed in 1999 moving beyond disease prevention and aiming for “ the energy and reserves of health that permit a buoyant life, full of zest, the eager ability to meet life’s challenges.”
Thus the supplementary paradigm consisting of four stages of “health promotion/wellness was developed”.

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Concept of health, wellness and wellbeing

WHAT IS HEALTH???

It is a state of body, mind and spirit that must be viewed within the context of community, society and environment
WHO defines health as “a state of complete physical, mental and social well being and not merely the absence of disease or infirmity”
It involves more than physical health.
Most people define health as

being free from symptoms of disease and pain as much as possible.
being able to be active and to do what they want to do or must do.
being in the good spirit most of the time.

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Concept of health, wellness and wellbeing cont.….

Wellness further describes the health status. It allows health to be placed on a continuum from ones optimal level (wellness) to maladaptive level (illness).
In 1961 Dunn defined high-level wellness as functioning to one’s maximum potential while remaining in balance with the environment.
Well-being is a subjective perception of vitality and feeling well …can be described objectively, experienced and measured….and can be plotted on a continuum. It is a component of health

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Stages of Wellness

Stage 1 : Exposure to positive health influences
Stage 2 : Adoption of positive health practices (such as health diet, ex0ercises, recreation, adequate sleep, etc.,)
Stage 3 : Increase in indicators of health and wellness due to the healthy practices (such as increased strength and flexibility, immunity, optimal BMI, etc.,)
Stage 4 : Achievement of specific defined health and wellness goals both

Subjective (e.g., sense of wellbeing and energy, fulfilling social relationships)
Objective measures ( e.g., high cognitive function, productivity, capacity for role fulfillment or achievement)

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Dimensions of wellness

The concept of “managing your health” or “staying healthy” can be best defined in the context of “4 important dimensions of wellness”

Physical Wellness - is caring about your body (Regular exercise, a healthy diet, staying away from harmful habits like excessive alcohol and smoking, getting regular medical checkups and caring for minor illnesses)
Social Wellness – means developing and maintaining healthy relationships (caring about other people and socially interacting with other individuals)
Spiritual Wellness - Spiritual wellness is establishing peace and harmony in our lives with or without organized religion (Have a set of guiding beliefs and principles that creates purpose, meaning and value to life)
Intellectual Wellness - The intellectual dimension focuses on the mind (encourages creative, stimulating mental activities)

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Lifestyle modification in preventive medicine

Lifestyle modification involves altering long-term habits, typically of eating or physical activity, and maintaining the new behaviour for months or years. Lifestyle modification can be used to treat a range of diseases.
Five key lifestyle factors

Nutrition
Exercise
Stress management
Sleep
Attitude

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Preventive self-care to stay healthy

All adults should visit their health care provider from time to time, even when they are healthy. The purpose of these visits is to:

Screen for diseases, such as high blood pressure and diabetes
Look for future disease risks, such as high cholesterol and obesity
Update vaccinations
Maintain a relationship with your health provider in case of illness
Discuss medicines or supplements that you are taking
Don't smoke or use tobacco.
Exercise at least 150 minutes a week (2 hours and 30 minutes).

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Preventive self-care to stay healthy cont.…

Eat healthy foods with plenty of fruits and vegetables, whole grains, lean proteins, and low-fat or nonfat dairy.
If you drink alcohol, do so in moderation (no more than 2 drinks a day for men and no more than 1 drink a day for women).
Maintain a healthy weight
Always use seatbelts, and use car seats if you have children.
Don't use illegal drugs.
Practice safer sex

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Screening for preventive care

Following 8 preventive care services are some of the most impactful and universal preventive care measures.

Blood pressure test
Diabetes screening
Cholesterol test
Routine Vaccination
Cancer screenings
STI screening
Child wellness check
Mental health screening

Another part of preventive health is learning to recognize changes in your body that may not be normal.

A lump anywhere on your body
Losing weight without trying
A lasting fever
A cough that does not go away
Body aches and pains that do not go away
Changes or blood in your stools
Skin changes or sores that do not go away or get worse
Other changes or symptoms that are new or do not go away

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Advantages of preventive care

Early diagnosis = early treatment
Avoid or reduce symptoms of illness
Many diseases, if caught early, can be eradicated
Enhances longevity
Improved quality of life
Productivity and efficiency at work can be maintained
Regular screenings can save you from crippling medical costs in the future

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List of screening test

Type	Topic Name	Age Group	Category
Screening	Syphilis Infection in Nonpregnant Adolescents and Adults: Screening	Adolescent, Adult, Senior	Infectious Diseases
Screening	Pre-diabetes and Type 2 Diabetes in Children and Adolescents: Screening	Adolescent, Paediatric	Metabolic, nutritional, and Endocrine Conditions
Screening	Impaired Visual Acuity in Older Adults: Screening	Adult, Senior	Vision and Hearing Disorders
Screening	Primary Open-Angle Glaucoma: Screening	Adult, Senior	Vision and Hearing Disorders
Screening	Chronic Obstructive Pulmonary Disease: Screening	Adult, Senior	Cardiovascular Disorders (Heart and Vascular Diseases)
Screening	Eating Disorders in Adolescents and Adults: Screening	Adolescent, Adult	Development and Behavior, Mental Health Conditions and Substance Abuse, Metabolic, nutritional, and Endocrine Conditions
Screening	Atrial Fibrillation: Screening	Adult, Senior	Cardiovascular Disorders (Heart and Vascular Diseases)
Counselling, Screening	Prevention of Dental Caries in Children Younger Than 5 Years: Screening and Interventions	Paediatric	Miscellaneous

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List of screening test cont.….

Type	Topic Name	Age Group	Category
Screening	Chlamydia and Gonorrhoea: Screening	Adolescent, Adult, Senior	Infectious Diseases
Screening	Pre-diabetes and Type 2 Diabetes: Screening	Adult, Senior	Metabolic, nutritional, and Endocrine Conditions
Screening	Gestational Diabetes: Screening	Adolescent, Adult	Obstetric and Gynaecologic Conditions
Screening	Colorectal Cancer: Screening	Adult, Senior	Cancer
Screening	Hypertension in Adults: Screening	Adult, Senior	Cardiovascular Disorders (Heart and Vascular Diseases)
Screening	Vitamin D Deficiency in Adults: Screening	Adult, Senior	Metabolic, nutritional, and Endocrine Conditions
Screening	Hearing Loss in Older Adults: Screening	Adult, Senior	Vision and Hearing Disorders
Screening	Lung Cancer: Screening	Adult, Senior	Cancer
Screening	Asymptomatic Carotid Artery Stenosis: Screening	Adult, Senior	Cardiovascular Disorders (Heart and Vascular Diseases)
Screening	Hepatitis B Virus Infection in Adolescents and Adults: Screening	Adolescent, Adult, Senior	Infectious Diseases

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Final words

The importance of focusing on preventive care right now is unbeatable.
Yearly comprehensive health check-ups for both males and females after an age of 40yrs is highly recommended to determine the pre-condition of severe diseases like diabetes, heart disease, cancers etc.
Early detection is the key word.
Preventive health check-up help the healthcare professions to detect the problems at the right time before it is too late.
The outcomes from such early actions help the individual lead a happy and healthy life.

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PREVENTION IS BETTER THAN CURE

THANK YOU