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CHAPTER7 Healthyliving
Prevention andscreening
In all disease, the goal is prevention.
Denitions
• Primary prevention Prevention of disease occurrence, e.g. childhood
vaccinations; prophylactic mastectomy for women with BRCA1/ 2 mutations
• Secondary prevention Controlling disease in early form, e.g. cervical
cancer and bowel cancer screening; AAA screening
• Tertiary prevention Prevention of complications once the disease is
present, e.g. screening for AF in order to anticoagulate
Barriers toprevention
• Patient Blinkering (‘It’ll never happen to me’); rebellion (‘I know it’s bad—
but it’s cool’); poor motivation (path of least resistance)
• Doctor Time; money— health promotion takes time and personnel;
motivation— health promotion is repetitive and boring
• Society Pressure from big business (e.g. cigarette advertising); other
priorities; ethics (e.g. public uproar at threats not to oer cardiac
surgery to smokers)
Screening The idea of screening is attractive— the ability to diagnose and
treat a potentially serious condition at an early stage when it is still treatable.
An ideal screening test must pick up all those who have the disease (have
high sensitivity) and must exclude those who do not (high specicity). It
must detect only those who have a disease (high positive predictive value)
and should exclude only those who do not have the disease (high negative
predictive value). See Table 7.1.
The Wilson– Jungner criteria All screening tests should meet the following
criteria before they are introduced to the target population:
• The condition being screened for is an important health problem
• Natural history of the condition is well understood
• There is a detectable early stage
• Treatment at early stage is of more benet than at late stage
• There is a suitable test to detect early- stage disease
• The test is acceptable to the target population
• Intervals for repeating the test have been determined
• Adequate health service provision has been made for the extra clinical
workload resulting from screening
• Risks, both physical and psychological, are < benets (Table 7.2)
• Costs are worthwhile in relation to benets gained
UK screeningprogrammes
• >40y health checks— E p. 214 • Antenatal— E p. 782
• Diabetic retinopathy— E p. 328 • Chlamydia— E p. 716
• Childhood— E p. 826 • Cervical cancer— E p. 704
• Neonatal bloodspot— E p. 830 • Breast cancer— E p. 670
• Neonatal hearing— E p. 836 • Colon cancer— E p. 368
• Screening for hip dysplasia— E p. 834 • Abdominal aortic
aneurysm— E p. 254
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PREVENTION ANDSCREENING
Table7.1 Screening test performance
Disease present Disease absent
Screening test positive a b
Screening test negative c d
• Sensitivity=a/ (a+c)
• Specicity=d/ (b+d)
• Positive predictive value=a/ (a+b)
• Negative predictive value=d/ (c+d)
Performance ofscreeningtests See Table 7.1. For a screening pro-
gramme to be eective and d morbidity and mortality there must be:
• Adequate participation of the target population
• Few false- negative or false- positive results
• Screening intervals shorter than the time taken for the disease to
develop to an untreatable stage
• Adequate follow- up of all abnormal results
• Eective treatment at the stage detected by screening
0 There is no ideal screening test. Always explain:
• Purpose of screening
• Likelihood of positive/ negative ndings and possibility of false- positive/
negative results
• Uncertainties and risks attached to the screening process
• Signicant medical, social, or nancial implications of screening for the
particular condition or predisposition
• Follow- up plans, including availability of counselling/ support services
Prevention ofcoronary heartdisease E p. 214
Table7.2 Benets and disadvantages ofscreening
Benets Disadvantages
• Improved prognosis for some
cases detected by screening
• Less radical treatment for some
early cases
• Reassurance for those with
negative test results
• Increased information on natural
history of disease and benets of
treatment at early stage
• Longer morbidity in cases where
prognosis is unaltered
• Overtreatment of questionable
abnormalities
• False reassurance for those with false-
negative results
• Anxiety and sometimes morbidity for
those with false- positive results
• Unnecessary intervention for those with
false- positive results
• Hazard of screening test
• Diversion of resources to the screening
programme
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Further information
Wilson JMG, Jungner G (1968) Principles and Practice of Screening for
Disease. Public Health Paper No. 34. Geneva:World Health Organization.
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CHAPTER7 Healthyliving
Prevention oftravel- relatedillness
UK residents going abroad The UK has reciprocal agreements
with some other countries for the provision of urgently needed medical
treatment at d cost or free of charge. Countries and the services available
are listed on the NHS website (M www.nhs.uk). Only urgently needed
treatment is provided on the same terms as for residents of that country.
Travellers should always ensure that they have adequate travel insurance
when going abroad.
Pre- travelassessment 8wk pre- departure where possible. Check:
• Age • Type of accommodation • General health
• Purpose of travel • Current vaccination status
• Where and when intending to travel (including areas within a country
and stopovers elsewhere)
• Previous experience of travel (including experience with antimalarials)
Health risks oftravel
• Environmental hazards (e.g. changes in altitude/ climate) Avoid rapid
changes of altitude— take time to readjust; avoid sunburn. Advise ♀
taking combined hormonal contraception and trekking to altitudes of
>4500m for >1wk to consider an alternative method of contraception
• Accidents Avoid potentially dangerous tasks under the inuence of
alcohol, e.g. swimming, driving. Avoid motorbikes— especially without
helmets and protective clothing
• Illness abroad MI causes 61% of deaths related to international
travel. Advise patients not to travel if unwell; to ensure adequate
insurance including repatriation costs; to take enough supplies of
regular medication when travelling to last the entire trip; and to take
preventative steps to avoid infection
• Transport- related problems:
• Fitness to y E p. 100
• Motion sickness— advise to take OTC medication if aicted
• DVT— on ights >3h:advise to drink plenty of water, avoid alcohol, regularly
get up and walk around, and consider prophylactic support stockings
• Psychological eects of travel
Vaccination 4% of deaths related to travel are due to infectious disease—
advise patients to ensure they are fully vaccinated for the areas they are intending
to visit. Information is available from Travax (M www.travax.nhs.uk)— registration
is needed.
Prevention of travellers’ diarrhoea 50% of travellers experience
some diarrhoea. Most cases last 4– 5d. 1– 2% last >1mo.
• Take care to eat and drink uncontaminated food and water
• Food should be freshly cooked and hot
• Avoid salads and cold meats/ sh
• Eat fruit that can be peeled
• Stick to drinks made with boiling water or bottled drinks and water with
an intact seal; avoid ice in drinks
• Use water purication tablets if necessary
• Jet lag
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PREVENTION OFTRAVEL-RELATEDILLNESS
Action If diarrhoea occurs when abroad, advise to use oral rehydration
uids (made up with fresh, boiled water), and only to take antidiarrhoeals if
impossible to get to a toilet. Seek medical advice if blood in stool, fever, or
not resolving in <72h (24h for the elderly or infants). • Warn not to use
antidiarrhoeals if blood in stool, fever, or child <10y.
Prevention ofmalaria
• Awareness of risk High- risk areas are Central and South America; South
East Asia; Pacic islands; sub- Saharan Africa— however brief the time
there. Pregnant and asplenic patients are at particular risk
• Reduce the risk of mosquito bites Mosquitoes bite at night:
• Accommodation— sleep in screened accommodation spraying screens with
insecticide each evening and use a pyrethroid vaporizer. If screens are not
available, use a permethrin- impregnated bed net (kits are available)
• Person— in the evenings wear long- sleeved shirts and trousers; protect
limbs with diethyltoluamide- containing repellent
• Chemoprophylaxis— Table 7.3. Regimens vary with location and time
of year. Information is available via Travax (M www.travax.nhs.uk—
registration needed)
• Awareness of residual risk Chemoprophylaxis is not 100% eective.
Advise to seek medical advice if unwell for 6mo after return. • Malaria
is a great mimic— have a high level of suspicion
Table7.3 Chemoprophylactic antimalarial drugs
Drug Dose Start Stop
Chloroquine 310mg/ wk 1wk before entering
Meoquine 250mg/ wk 2.5wk before entering
Proguanil 200mg/ d 1wk before entering
Proguanil +
atovaquone
Doxycycline 100mg/ d 1wk before entering
1 tablet/ d 1– 2d before entering
malaria area
malaria area
malaria area
malaria area
malaria area
4wk after leaving
malaria area
4wk after leaving
malaria area
4wk after leaving
malaria area
1wk after leaving
malaria area
4wk after leaving
malaria area
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Prevention ofHIV and hepatitis B andC Advise:
• Avoid casual sexual contacts. If these occur use barrier methods of
contraception (male and female condoms)
• Avoid shared needles (e.g. tattooing/ ear piercing/ drugs)
• Medical kits— if travelling to high- risk areas, take a clearly labelled
medical kit containing sutures, syringes, and needles for emergency use
• Avoid blood transfusion. Most blood donations in the developing world
are unscreened. Know your blood group. In an emergency, the Blood
Care Foundation can arrange screened blood to be provided anywhere
in the world (F 01403 262652; M www.bloodcare.org.uk)
• Vaccination for hepatitis B prior to travelling
Further information
Fit for Travel M www.tfortravel.nhs.uk
Travax M www.travax.nhs.uk— registration needed.
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CHAPTER7 Healthyliving
Diet
The role ofthe GP and primary careteam
• Screening Identication of obese patients and patients in need of dietary
advice for other reasons
• Assessment Current diet, motivation, and barriers to change
• Discussion and negotiation Exploration of knowledge about diet;
negotiation of goals
• Goal setting Provide information and 2– 3 food- specic goals on
each occasion— set a series of mini- targets that appear realistic and
achievable; tailor them to existing diet and usual schedule
• Monitoring progress
Barriers toa gooddiet
• Ignorance Posters in surgeries, leaets, screencasts on waiting room
screens, and/ or information on the practice website may help
• Cultural dierences Modify information to be relevant; provide
information in multiple languages as appropriate
• Enjoyment Perception of healthy diet as not enjoyable
• Poverty Fresh fruit/ vegetables and lean meat/ sh are expensive— some
elements are cheap, e.g. potatoes, pasta, rice
• Lifestyle Convenience foods contain a lot of salt, sugar, and fat
• Peer pressure Children are under pressure to eat sweets, crisps, etc.
• Habits of a lifetime We like the foods we have grown up with
• Confusion about what is good Packaging may be misleading, e.g.
breakfast cereals claiming health messages but containing high sugar
• Mixed messages One minute the press says something is good for you,
the next it causes some horrible disease and should be avoided
• Fatalism/ apathy
The idealdiet See Figure 7.1, E p. 150, Adjust composition/ portion
size of each meal to maintain a healthy weight. Include a variety of foods:
• Use starchy foods (e.g. bread, rice, pasta, potatoes) as the main energy source
• Eat plenty of fruit and vegetables (>5 portions of fruit/ vegetables daily);
do not overcook vegetables— steaming is preferable to boiling, and keep
delay between cutting and eating fruit/ vegetables to a minimum
• Eat plenty of bre— good sources are high- bre breakfast cereals,
beans, pulses, wholemeal bread, potatoes (with skins), pasta, rice, oats,
fruit/ vegetables
• Eat sh at least 2×/ wk including 1 portion (maximum 2 portions if
pregnant) of oily sh (e.g. mackerel, herring, pilchards, salmon)
• Cut back on cooked red or processed meat; consider substituting meat
with vegetable protein (e.g. pulses, soya)
• Choose lean meat— remove excess fat/ poultry skin and pour o fat
after cooking; avoid fatty meat products (e.g. sausages, salami, meat
pies); boil, steam, or bake foods in preference to frying; when cooking
with fat use unsaturated oil (e.g. olive, sunower oil) and use cornour
rather than butter and our to make sauces
• Use skimmed milk and low- f at yoghurts/ spreads/ cheese (e.g. Edam or
cottage cheese)
• Avoid adding salt to foods— aim for <6g of salt/ d. Avoid processed
foods, crisps, and salted nuts
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• Avoid adding sugar and cut down on sweets, biscuits, and desserts
• Drink at least 4– 6 pints (2– 3L) of uid daily— preferably not tea, coee,
or alcohol. Drinking a large glass of water with meals and instead of
snacks can reduce the urge to overeat
• Avoid excessive alcohol intake— <14U/ wk for ♂ and ♀— E p. 158
• Obesity E p. 152
Unintentional weightloss Non- specic symptom. Treat the cause.
Consider:
• GI causes— malabsorption, malnutrition, dieting
• Chronic disease— hyperthyroidism, DM, heart failure, renal disease,
severe COPD, degenerative neurological/ muscle disease, chronic
infection (e.g. TB, HIV) or infestation
• Malignancy
• Psychiatric causes— depression, anxiety, dementia, anorexia
Malnutrition 50% of ♀ and 25% of ♂ aged >85y are unable to cook a
meal alone. Malnutrition is common amongst the elderly.
Poor nutritional status Slows rate of wound healing, i risk of infection, d
muscle strength, is detrimental to mental well- being, and d the ability of
elderly people to remain independent.
Riskfactors
• Low income
• Living alone
• Dementia
• Recent bereavement
• Diculty eating and/ or swallowing, e.g. stroke, MND
• Presence of chronic disease, e.g. Crohn’s disease, UC, IBS, cancer,
COPD, CCF
Management
• General advice— encourage to eat more and i consumption of fruit
and vegetables; consider using nutritional supplements, e.g. vitamin D
supplements for the housebound and institutionalized
• Inability to prepare meals/ shop— consider referral to social services,
meals on wheels, community dietician; community day centre; local
voluntary support organization
• Diculty with utensils— aids or adapted equipment may help, e.g.
special cutlery, non- slip mats— consider OT referral
• Nausea— consider antiemetics
• Swallowing diculty— investigate the cause. If none is found or you are
unable to resolve the problem, consider pureed food and/ or thickened
uids— take dietician advice
• Mental health problems e.g. depression
• Gastric surgery
• Malabsorption
• i metabolism e.g. thyrotoxicosis
Further information
British Nutrition Foundation M www.nutrition.org.uk
Malnutrition Universal Screening Tool (MUST) www.bapen.org.uk/
screening- for- malnutrition/ must/ introducing- must
NICE (2006, updated 2017)Nutrition support for adults. M www.nice.
org.uk/ Guidance/ cg32
DIET
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Fruits and
vegetables
alternatives
Foods containing sugar
Bread, other cereals, and potatoes
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CHAPTER7 Healthyliving
Meat, sh, and
Figure7.1 The plate model. Developed to communicate current recommendations
for healthy eating. It shows rough proportions of the various food groups that should
make up each meal
Foods containing fat
What is a portion offruit or vegetables? 1 portion of fruit or
vegetables is roughly equivalent to:
• 1 normal portion (2 tablespoons) of any vegetable
• 1 dessert bowl of salad
• 1 large fruit, e.g. apple, banana, orange, pear, peach, large tomato, or a
large slice of pineapple or melon
• 2 smaller fruits, e.g. satsumas, plums, kiwi fruits, apricots
• 1 cup of small fruits, e.g. strawberries, raspberries, blackcurrants,
cherries, grapes
• 1 tablespoon of dried fruit
• 2 large tablespoons of fruit salad or stewed/ canned fruit in
natural juice
• 1 glass (150mL) of fresh fruit juice
Tips for avoiding snacking Discourage uncontrolled snacking of
junk food between meals. Suggest patients ask themselves the following
questions when they feel like eating between meals:
Am Ihungry? If unsure, wait 20min, and then ask the same question again.
When was thelast time Iate? If <3h ago, it may not be real hunger.
Could a small snack tide me overuntil the next meal? Have ready- to- eat
fruits or vegetables on hand for this.
Milk and dairy foods
Weight in kilogramsWeight in kilograms
Height in metresHeight in metres
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DIET
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1.481.48
1.441.44
1.401.40
1.361.36
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BMI 18.5–24.9—acceptable weightBMI 18.5–24.9—acceptable weight
BMI 25–29.9—overweightBMI 25–29.9—overweight
Figure7.2 Body mass index (BMI) ready reckoner for adults
Forchildren Body mass index child reference tables should
be used (available from M www.health forallchildren.co.uk).
Denitions:
• Overweight— weight ≥91st centile
• Obese— weight ≥98th centile
BMI 30–39.9—obeseBMI 30–39.9—obese
BMI ≥40—morbid obesityBMI ≥40—morbid obesity
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CHAPTER7 Healthyliving
Obesity
Obesity is one of the most important preventable diseases in the UK (see
Box 7.1). The best measure of obesity is body mass index (BMI).
Classication BMI (weight in kg ÷ (height in m)
• <18.5kg/ m2— underweight
• 18.5– 24.9kg/ m2— healthy weight
• 25– 29.9kg/ m2— overweight
• 30– 34.9kg/ m2— obesity I
• 35– 39.9kg/ m2— obesity II
• >40kg/ m2— obesity III or
‘morbid obesity’
Waist circumference See Table 7.4. Alternative measure of body
fat correlated with CVD risk, DM, hyperlipidaemia, and i BP. Measured
halfway between the superior iliac crest and the rib cage. Use in addition to
BMI to aid assessment of health risks.
Table7.4 Waist circumference withi risk (RR ≥3) ofCHD/ DM
Waist circumference White Caucasians Asians
Male ≥102cm (40inches) ≥90cm (36inches)
Female ≥88cm (35inches) ≥80cm (32inches)
0 For every 1cm i in waist circumference, the RR of a CVD event i by ~2%.
Causes ofobesity
• Socioeconomic factors • Physical inactivity
• Smoking cessation— mean weight i 3– 4kg
• Polygenic genetic predisposition (~1 in 3 obese people)— more prone
to obesity again after successful dieting
• Childbirth— especially if not breastfeeding
• Drugs— steroids, antipsychotics (e.g. olanzapine), contraceptives
(especially depo- injections), sulfonylureas, insulin
• Endocrine causes (rare) e.g. hypothyroidism, Cushing’s syndrome,
PCOS— only investigate if other symptoms/ signs of endocrine disease
• Ongoing binge eating disorder (E p. 992)
Prevention Begins in childhood with healthy patterns of exercise/ diet.
Management When the body’s intake > output over a period of time,
obesity results. Management aims to reverse this trend on a long- term basis
through healthy diet, adjustment of calorie intake, physical exercise, and
psychological support.
Initial assessment Assess willingness to change, eating behaviour and diet,
physical activity, psychological distress, and social and family factors affecting diet. Check a baseline BMI and waist circumference. Check BP, blood
glucose, and fasting lipid prole.
General advice Whether willing to change or not, provide advice on risks
of obesity, and benets of healthy eating (E p. 148) and physical exercise (Ep. 154). Tailor your advice to the individual. If unwilling to change,
reinforce this information at each subsequent encounter with the patient.
Diet Advise a weight loss diet for any patient who is overweight/ obese and
willing to change:
• Low- calorie diet— obese people do lose weight if they d their energy
intake. Aim for weight d of 1– 2lb (0.5– 1kg)/ wk using a d in calorie
2
) (Figure 7.2, E p. 151):
https://t.me/med1917
OBESITY
Box 7.1 Health risks ofobesity
Greatly increased risk (RR >3)
• Mortality (BMI >30kg/ m2)
• Type 2 DM (BMI of 35kg/ m2
confers a 92× i risk of DM)
• Gall bladder disease
• Dyslipidaemia
• Insulin resistance
• Breathlessness
• Sleep apnoea
Moderately increased risk (RR 2– 3)
• CHD (5– 6% of deaths are due
to obesity)
• i BP
• OA (knees)
• Hyperuricaemia/ gout
intake of ~600kcal/ d, and a target BMI of 25kg/ m2, in steps of 5– 10%
of original weight. There is no health benet of weight d below this. If
simple diet sheets are not eective, refer to a dietician
• Very low- calorie diets (<1000kcal/ d)— have only limited place in
management— use for a maximum of 12wk for obese patients when
weight loss has plateaued
Group and behavioural therapy Group activities, e.g. Weight Watchers,
have higher success rates in producing/ maintaining weight d. Behavioural
therapy together with low- calorie diets is also eective.
Drug therapy Orlistat (120mg tds with food) is the only drug licensed for
treatment of obesity in the UK. It acts by d fat absorption. Consider a 3mo
trial if supervised diet/ exercise has failed and
• BMI ≥30kg/ m2 or
• BMI ≥27kg/ m2 + co- morbidity (e.g. DM, i BP)
Continue treatment >3mo only if weight d is ≥5% of initial body weight.
Surgery Consider if BMI >40kg/ m2, or BMI 35– 39.9kg/ m2 and suering
from a condition that could be improved by weight loss, and non- surgical
measures have failed. Adjustable gastric banding is the most common procedure. Complications:band slippage/ damage; gastric erosion; pouch dilatation; infection; malabsorption.
Slightly increased risk (RR 1– 2)
• Cancer (breast in post- menopausal
women, endometrial, oesophageal,
colon)— 14– 20% of cancer deaths
are due to obesity
• Reproductive hormone
abnormalities
• PCOS
• Impaired fertility
• Low back pain
• Stress incontinence
• Anaesthetic and postoperative risk
• Fetal defects associated with
maternal obesity
• Suicide
• School/ workplace prejudice
Maintenance ofweightloss Once a patient has lost weight, continue
to monitor diet. Ongoing follow- up helps to sustain weight loss. Weight
uctuation (yo- yo dieting) may be harmful.
Further information
National Obesity Forum M www.nationalobesityforum.org.uk
SIGN (2010) Management of obesity. M www.sign.ac.uk/ sign- 115-
management- of- obesity.html
NICE (2014) Obesity:identication, assessment and management.
Mwww.nice.org.uk/ guidance/ cg189
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