The Prevention Prescription, part 3

In my previous two posts I’ve written about different kinds of prevention (eg, primary, secondary, etc as well as vaccination which is a form of primary prevention). In this post I am going to talk about a couple of different things relating to prevention.

The first is that there are preventative measures which sometimes fall into more than one category. By this I mean that if we counsel someone to change their diet and exercise more because they’ve had a heart attack, give them aspirin, a statin, etc. that we’re engaging in tertiary prevention. However if they are on their way to becoming diabetic but because of the change in diet and increase the amount of exercise they do, and therefore lower their risk of Diabetes Mellitus, then one could argue that’s primary prevention (or secondary if they have metabolic syndrome…).

I’m a firm believer in using medication to lower cholesterol, blood pressure, etc when and if appropriate. However, I think we give short shrift to diet, exercise and sleeping enough as preventative measures to prevent or delay multiple medical problems.  Even if someone needs to be on medication, lifestyle changes are important to keep up. Exercise and diet do not become less important just because someone’s started medication. One recent study published in the New England Journal of Medicine comparing intensive lifestyle changes+usual care as compared to usual care did not reduce death. However there was evidence for a better quality of life and less need for medication, at least early on. There is a lot of evidence that enough exercise and good dietary practices can prevent and delay Diabetes. And for those that are cost conscious, a half an hour a day of walking is a lot cheaper than most medications!

There is a push by some physicians to actually prescribe exercise the same way we prescribe medications. Books have even been published on the matter!!

The Prevention Prescription, Part 2

In my last post I talked about vaccination, which is a form of primary prevention: it is the prevention of disease. There is also the concept of secondary prevention. In the case of secondary prevention, one has already has a disorder and doesn’t know it. Secondary prevention prevents the disease from getting to the point where it causes symptoms or complications (this is paraphrasing the definition on the CDC website). The example the CDC website uses is excising/taking a biopsy of a suspicious skin lesion before it becomes cancerous. Colonoscopy could also be put in the category of secondary prevention if pre cancerous polyps are found and removed before they become cancerous.

Sometimes it can be difficult to convince people to do some secondary prevention. Colonoscopy is one such item it is sometimes challenging to convince people to do. It is inconvenient as one needs to take a day off from work (if one is of working age and is working), has to have someone who’s willing to drive them home and requires taking things to clean their colon out so the colonoscopy can be done. When someone has a problem that can only be diagnosed by colonoscopy (eg: weight loss, fevers, and blood in the stool which could be a sign of inflammatory bowel disease, for example) people are worried enough about their health to get it.

Tertiary prevention is when one is trying to prevent complications or side effects of a disease which is already present. Examples of this are anticoagulation in people with atrial fibrillation, use of ACE inhibitors to prevent or slow kidney disease in diabetics.

In my next post I’ll take more about prevention and why it’s important.

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The Prevention Prescription, part 1

I suppose this is going to have some overlap with some of what I’ve already written. Even though I treat adults, I am routinely (every month or two)  giving people vaccines against various preventable diseases. Tetanus, diphtheria and pertussis being the most common vaccination I give, though I think perhaps only vaccination against influenza could be as or more as that in absolute numbers.  By the time most people get to me, they’ve had a majority of their vaccinations (except perhaps for those that didn’t exist when they were growing up or weren’t recommended outside of certain high risk groups).  Most people don’t seem to have a problem with getting a Tetanus/Diphtheria/Pertussis booster. Influenza vaccination seems harder to take for some people.

Other folks seem to take offense at getting any immunizations at all. Perhaps if we went back in time to an  era when people died of polio (1952 saw what is reported to be the worst epidemic in U.S. history: 57,628 cases,  3,145 died and 21,269 people were left with paralysis of some degree). People developed rubella while pregnant (between 1962 and 65 when there was a worldwide pandemic – an estimated 12.5 million rubella cases occurred in the United States.  There were a resulting  2,000 cases of encephalitis, 2,100 neonatal deaths, and 20,000 infants born with Congenital Rubella Syndrome).

I could go on about how vaccination has either eliminated disease (the last case of smallpox was in 1978) or vastly reduced the number of affected people. In some countries, vaccination has eliminated diseases (the U.S. has been polio free for the past 30 years) or vastly reduced the rate (only 223 reported cases worldwide in 2012 with only three countries being considered endemic for polio).

One might ask why an internist is writing about vaccinating against “childhood diseases”.  Viruses and bacteria do not know the ages of the people they infect. A lot of diseases are mild(er) in children but have higher complication rates in adults. Varicella (the chicken pox virus) can come back in adulthood and cause shingles as well as an encephalitis. Varicella is also a worse disease in adulthood and not everyone gets the disease in childhood. It’s now routinely recommended that if one is going to be around young children (I.E. infants) or in healthcare that people get vaccinated against Pertussis to prevent it spreading. People forget or don’t know how many lives have been spared because of vaccination and that a lot of diseases that caused death and disability are thankfully gone or almost gone. Part of my job is not just to treat illness but try and prevent it as well. With vaccinations it’s important not to forget them even in adults. It’s a matter of public health (preventing pertussis spreading to one of my patients’ children, grandchildren, nieces and nephews, etc): prevention of disease in my adult patients as well as those they come in contact with.  I also am trying to prevent disease on the individual patient level as well. If my patients aren’t getting the natural ‘booster shots’ of exposure to their (grand-)children while they’re infectious for varicella, there is the potential for waning immunity which puts them at risk for reactivation (I.E. Shingles in the case of varicella).

As time goes by, I think there is, and will be an appreciation that vaccination isn’t ‘The Answer” for everything. There is an appreciation that immunity wanes for some vaccinations, eg tetanus and diptheria, which is why it’s recommended to get boosters. It may be the case for the MMR vaccine as well. That immunization doesn’t always prevent a given disease is not  a reason to avoid vaccination. If we thought that way in other areas of our lives, we would not lock our car doors, the doors to our houses, look both ways before crossing the street because “doing these things don’t prevent cars being stolen, houses broken into or being run over by a car”.

Sometimes convincing people of the power of prevention is the hard part.