Steps for Better Practice

Educational Objectives

The goal of this program is to improve the practice of preventive medicine. After hearing and assimilating this program, the clinician will be better able to:

1.   Recommend nutritional supplementation clinically proven to benefit specific patient populations.

2.   Reduce a patient’s risk of complications related to overutilization of preventive screening practices.

3.   Offer appropriate interventions to patients who smoke or consume unhealthy amounts of alcohol.

4.   Recognize adult patients most likely to benefit from immunizations.

5.   Implement preventive screening practices clinically proven to reduce mortality or complications in specific patient populations.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of inter­est. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a pro­prietary business or commercial interest. For this program, the faculty and planning committee reported nothing to disclose.

Acknowledgments

Drs. Domino and Allen were recorded at American Academy of Family Physicians’ 2009 Scientific Assembly, held October 14-17, 2009, in Boston, MA, and sponsored by the American Academy of Family Physicians. The Audio-Digest Foundation thanks the speakers and the American Academy of Family Physicians for their cooperation in the production of this program.

Top Things I Learned This Past Year

Frank J. Domino, MD, Associate Professor, University of Massachusetts Medical School, Worcester

Nutritional supplementation: Mediterranean diet  —correlated with decreased cardiovascular risks (and possibly decreased cancer rates); contains high quantity of fruits, vegetables, olive oil, and nuts; antioxidants  —  primarily found in fruits and vegetables; theoretically capable of binding free radicals

Vitamins: factorial study  —  8000 women given either vitamin C plus vitamin E, vitamin C plus beta carotene, vita­min E plus beta carotene, or combinations of placebos; no reductions in cancer rates or improvements in overall mortality found after 8 yr; vitamins in prostate cancer study  —1400 men given vitamin C plus placebo, vitamin E plus placebo, or vitamin E plus vitamin C; no decreases in prostate cancer or total cancer found after 8 yr; selenium study  —  men given vitamin E plus selenium, vitamin E plus placebo, or selenium plus placebo; no significant de­crease in cancer rates after 5 yr; slight (nonsignificant) increase of prostate cancer rates in men receiving vitamin E; slight increase of type II diabetes rates in men receiving selenium plus vitamin E; Cochrane database  — systematically reviewed data from 68 studies of vitamin A, vitamin C, vitamin E, selenium, or beta carotene plus selenium; no significant reductions in overall mortality; restricting review to 47 highest quality studies showed sup­plementation associated with increased mortality risk; folic acid and cancer  —female health professionals with multiple cardiac risk factors or cardiac disease followed for 7 yr; no decrease in breast cancer rates or total cancer rates; multivitamin study  —  Women’s Health initiative; 161,000 women followed for 8 yr; no decreases seen in can­cer risks, cardiovascular disease (CVD), myocardial infarction (MI), stroke, deep venous thrombosis (DVT), or mortality; folic acid and homocysteine  —  patients with elevated homocysteine levels have higher risks for CVD; supplementing patients with folic acid and vitamins B6 and B12 reduces homocysteine levels; systematic review of folic acid and CVD  —  included 12 randomized controlled trials (RCTs) assessing folic acid vs placebo in patients with known cardiac disease; no decrease in CVD, coronary heart disease (CHD), stroke, or all-cause mortality; fo­lic acid associated with slight (nonsignificant) increase in CHD; gingko biloba  —  no reduction of progression to de­mentia in normal adults or patients with mild cognitive impairment

Vitamin D: deficiency increases risk for cardiac disease, death from CVD and MI, and first cardiac event; supplementation decreases risk for falls and nonvertebral fractures in seniors; hypertension  —  addressing vitamin D deficiency lowers blood pressure (particularly in black men); Epidemiologic Infectious Disease Journal study  —  2000 IU of vitamin D daily reduced upper respiratory infections (URIs), increased athletic performance, and decreased risks for breast and colon cancer; prenatal supplementation decreased rates of pediatric asthma; vitamin D deficiency in women  —  literature sug­gests addressing deficiency may slow progression to or prevent osteoarthritis; vitamin D deficiency and geography  —  in patients living in northern areas of United States and Europe, addressing deficiency may lower risk of developing multi­ple sclerosis; American Academy of Pediatrics and American Academy of Family Physicians joint guidelines  —  all breast­fed children should receive 400 IU of vitamin D starting at 2 mo of age; speaker recommends giving children 1000 IU daily and adults 2000 IU daily (in absence of liver or kidney disease)

Fish oil and CVD: meta-analysis of fish oil in patients with known heart disease  —  fish oil reduced cardiac death, but showed no effect on arrhythmia; no improvements in all-cause mortality

Gout and vitamin C: new-onset gout  —  surveyed vitamin C intake of 4700 men; over 20 yr, men with intakes of 500 to 1000 mg daily showed decreased rates of gout (intakes ³1500 mg daily cut risk in half)

Dementia screening: “test your memory” (TYM) screening  —not physician-dependent; in study of 540 healthy adults and 140 adults with dementia, sensitivity 93% (compared to 50% sensitivity shown with Mini-Mental State Examina­tion); early intervention in dementia improves quality of life (QOL) for patients and family members; in populations with dementia rates of 10% (eg, patients >80 yr of age), TYM showed positive predictive value of 99%

Aspirin: use not supported by data for patients >80 yr of age; not recommended for prevention of strokes in women <55 yr of age or prevention of MI in women <45 yr of age; meta-analysis of aspirin for primary prevention of cardiac disease  —  included >95,000 patients; vascular event rates reduced from 0.51% to 0.57% (number needed to treat, 1600); 3000 inci­dents of major gastrointestinal bleeding and 10,000 major hemorrhagic strokes reported; no reduction seen in vascular-re­lated deaths; speaker recommends using risk calculator for each patient before recommending aspirin or statins

Obesity: cost of treating obesity-related conditions in United States 10% of health care expenditures ($147 billion); water fountain study  —  elementary schools with water fountains showed obesity rates of 3.8% (compared to 6% for schools without fountains); fountains increased water consumption by »220 mL; speaker recommends writing pre­scriptions requiring overweight patients to keep water bottles constantly available; prescribed exercise study  —6300 sedentary patients with hypertension, diabetes, obesity, and musculoskeletal pain; specific scheduling and goals for exercise documented on prescription pad; significantly increased compliance with exercise (with recur­rent visits and reinforcement); successful weight loss   —  78% of patients successful at losing weight ate breakfast regularly; 75% measured weight weekly; 62% watched <10 hr of television per week; 90% exercised »1 hr daily; maintaining weight loss  —  associated factors include <2 fast food meals per week and consumption of ³5 servings of fruits and vegetables daily; eating practices  —  risk of becoming overweight doubled in men eating until “feeling full” and women eating rapidly (combining both practices tripled risks); phentermine plus fluoxetine  —  over 3 mo, 9% of patients receiving phentermine plus fluoxetine lost weight (compared to 12% receiving phentermine plus fenfluramine), but showed no lesions on heart valves (compared to 21% in phentermine plus fenfluramine group)

Ovarian cancer: retrospective analysis of screening  —  340 women, 179 of whom considered high-risk; measured sensi­tivity, specificity, and positive predictive value of transvaginal ultrasonography and cancer antigen-125 testing; only one incident of ovarian cancer detected; only 6.7% of women with abnormal screening results showed actual disease

Diabetes and heart disease: meta-analysis of CHD risks  —compared risk for CHD end points in patients with diabe­tes to risk in patients with history of MI; risk for cardiac events 43% lower in patients with diabetes and no history of MI (ie, diabetes not CHD equivalent); speaker recommends treating lifestyle issues aggressively in type 2 diabet­ics, but not managing markers aggressively (eg, low density lipoprotein [LDL] levels)

Heart disease: screening for silent ischemia in type 2 diabetes  —100 patients with type 2 diabetes and no cardiac symp­toms underwent myocardial imaging with radionuclide perfusion; 2% of patients in screened group died from cardiac disease or had nonfatal MI (compared to 3% of unscreened group; nonsignificant); screening had positive predictive value of only 12% in patients with moderate or large defects found on imaging; depression and heart disease  —  severity of depression correlated with heart failure, MI, stroke, and death; found that 10% of depressed patients had cardiac event in 5 yr; initial results found hazard ratio of 1.5 (indicating depression increases risk for heart disease by 50%); however, hazard ratio decreased to 1.3 after factoring in comorbidities and severity of heart disease, and decreased to 1 after factor­ing in behavioral differences (eg, physical inactivity)

Prescription medications: issues include diversion to nonpatients and addiction; addiction  —  occurs in »20% of inpatients and 50% of psychiatric patients; American Gastroenterological Association predicts that by 2020, nonalcoholic fatty liver disease will be most common cause of liver failure requiring transplantation; prescription narcotics  —  cause more overdose-related deaths than cocaine and heroin combined; drug poisoning currently second leading cause of overall injury and death in United States; speaker’s recommendations for preventing drug seeking in patients on long-term narcotics  —  establish con­tracts; conduct random drug testing; always practice cautiously

Prostate cancer: Cancer Journal for Clinicians editorial (2009)  —  results from prostate, lung, colorectal, and ovarian can­cer screening trial showed prostate cancer screening decreased longevity; authors of European randomized study of screen­ing for prostate cancer found 1400 men must undergo prostate screening and 48 men must undergo diagnosis and treatment to prevent one death from prostate cancer; 20% rate of overdiagnosis found after 17,000 biopsies; risk for radical prostatec­tomy increased 3-fold; risk of receiving radiation therapy increased 2-fold; patients undergoing screening 48 times more likely to experience negative effects after 9 yr (eg, impotence, incontinence, anguish, death); screening doubles diagnosis rate, but does not significantly decrease risk for death; editorial argued screening practiced on blind faith in early detection rather than evidence of decreased mortality; high profitability associated with early prostate cancer treatment; data supported recommendation against mass screening; editorial recommends sharing decision-making with patients

Diabetes control: 2 major clinical trials found no significant reduction in cardiovascular outcomes with intensive gly-cemic control (hemoglobin [Hb] A1C <6%); American Diabetes Association, American College of Cardiology Foundation, and American Heart Association joint position statement  —   intensive glycemic control shows no signifi­cant reduction in heart disease outcomes; statement recommends focusing on control of blood pressure, lowering of lipid levels, aspirin therapy, lifestyle modification, and maintaining HbA1c <7% (in patients with no history of hypoglycemia, with new onset of diabetes, with long life expectancy, and/or without heart disease); HbA1c >7% tolerable in patients with hypoglycemia, limited life expectancy, advanced micro- and macrovascular complications, extensive comorbidities, or long-standing diabetes; glycemic targets should be individualized

Top 10 Prevention Priorities for Saving Lives

Richard E. Allen, MD, Assistant Director, St. Mark’s Family Residency, Salt Lake City, UT

Heart disease and smoking: aspirin chemoprophylaxis  —multiple high-quality studies show cardiovascular benefits; ath­erosclerotic heart disease remains primary cause of death in United States; smoking intervention  —  involves questioning patients, providing counseling, and offering pharmacotherapies; tobacco cessation counseling  —  United States Preventive Services Task Force (USPTF) found good quality evidence for efficacy; sessions last 3 min (more frequent sessions showed superior results); “5 As” of tobacco screening  —  ask; advise to quit; assess (ie, ask about willingness); assist (eg, with medications and support); arrange follow-up

Colorectal cancer: screening in adults >50 yr of age  —reduces mortality from second highest cause of cancer-re­lated death; fecal occult blood testing (FOBT) costs »$3.50 (colonoscopy costs »$1000); however, FOBT and colo­noscopy comparable in calculations of cost per year of life saved; FOBT cards often show positive results and lead to colonoscopy; in areas lacking resources for colonoscopy, FOBT and flexible sigmoidoscopy sufficient for screening; FOBT testing with gloved finger during digital rectal examination not appropriate (patient should takes samples at home after adequate preparation); colonoscopy recommended every 10 yr (or flexible sigmoidoscopy every 5 yr); barium enema no longer recommended

Hypertension screening: low-cost; easily repeated; relatively low risk for false positives; Joint National Commission recommends repeating every 2 yr

Immunizations: annual flu shots  —  recommended for adults >50 yr of age; pneumococcal vaccines  —  recommended after re­tirement age; repeated for patients with asplenia or chronic renal failure (causes rapid loss of antibodies); Advisory Commit­tee on Immunization Practices includes smoking and asthma (at any age) as indications; influenza —vaccines more effective in younger patients; pneumonia  —  not prevented by pneumoccocal vaccine; pneumococcus causes one-third of all cases (with 5% mortality); air space disease (similar to abscess); invasive pneumococcal disease  —  vaccines prevent 70% of cases, eg, meningitis and bacteremia; 55,000 cases annually in United States; mortality 10-fold greater than that for pneumonia

Alcohol screening and counseling: factors associated with increased risk for alcoholism  —  frequent or large quantities of drinking; history of physical, psychologic, or social harm from drinking (eg, divorce, disability, unemployment, life dis­ruptions, health problems); “CAGE” assessment  —  short alcohol screening questionnaire recommended by speaker; screening  —  involves 15 min of counseling, feedback, advice, goal setting, and multiple interventions; follow-up may be overseen by nonphysicians; shown to decrease alcohol intake by 3 to 9 drinks per week

Vision screening: Snellen chart  —  recommended for patients >65 yr of age (5% blind and >50% show vision prob­lems); visual impairment increases risk for falls and motor vehicle accidents, and interferes with medication com­pliance and physical activity

Cervical cancer screening: cervical cytology recommended within 3 yr of start of sexual activity or at 21 yr of age; Papanicolaou test  —  effective due to high specificity (false positives rare); has decreased deaths from cervical can­cer 10-fold in developed countries

Cholesterol screening: best evidence for efficacy shown in men >34 yr of age and women >44 yr of age with inten­tion to treat for hyperlipidemia if found

Breast cancer and colon cancer: both double in incidence at 50 yr of age; breast cancer screening at 40 yr of age  —  guidelines now encourage informed decisions about screening made by patients (rather than absolute age recommenda­tions); some trials found no benefits associated with mammography for women 40 to 50 yr of age; Swedish mammography study  —showed 96% specificity; detection rates and false positive rates compound with repeated mammography (nearly 50% of women 40-50 yr of age show false positive results after 10 annual screenings, which often lead to unnecessary sur­gery and cancer treatment); recommendations  —  routine mammography for women ³50 yr of age (with or without clinical breast examination); discuss screening with women 40 to 50 yr of age

Suggested Reading

ADVANCE Collaborative Group et al: Intensive blood glucose control and vascular outcomes in patients with type 2 diabetes. N Engl J Med 358:2560, 2008; Andriole GL et al: Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 360:1310, 2009; Antithrombotic Trialists’ Collaboration et al: Aspirin in the primary and secondary prevention of vascular dis­ease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 373:1849, 2009; Bulugahapitiya U et al: Is diabetes a coronary risk equivalent? Systematic review and meta-analysis. Diabet Med 26:142, 2009; Choi HK et al: Vitamin C intake and the risk of gout in men: a prospective study. Arch Intern Med 169:502, 2009; DeKosky ST et al: Ginkgo biloba for preven­tion of dementia: a randomized controlled trial. JAMA 300:2253, 2008; Dobson R: Half of patients given exercise prescriptions are more active a year later. BMJ 337:a2084, 2008; Gaziano JM et al: Vitamins E and C in the prevention of prostate and total cancer in men. JAMA 301:52, 2009; Giovannucci E et al: 25-hydroxyvitamin D and risk of myocardial infarction in men. Arch Intern Med 168:1174, 2008; Leon H et al: Effect of fish oil on arrhythmias and mortality: systematic review. BMJ 337:a2931, 2008; Lin J et al: Vitamins C and E and beta carotene supplementation and cancer risk: a randomized controlled trial. J Natl Cancer Inst 101:14, 2009; Lippman SM et al: Effect of selenium and vitamin E on risk of prostate cancer and other cancers. JAMA 301:39, 2009; Muckel­bauer R et al: Promotion and provision of drinking water in schools for overweight prevention. Pediatrics 123:e661, 2009; Whigham LD et al: Comparison of combinations of drugs for treatment of obesity: body weight and echocardiographic status. Int J Obes (Lond) 31:850, 2007; Whooley MA et al: Depressive symptoms, health behaviors, and risk of cardiovascular events in patients with coronary heart disease. JAMA 300:2379, 2008; Zhang SM et al: Effect of combined folic acid, vitamin B6, and vitamin B12 on cancer risk in women: a randomized trial. JAMA 300:2012, 2008.