• 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.

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

Basic Principles of ScreeningIn 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

• 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

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

• 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

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

Force

Cont,s

• 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

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.

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

• 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.

Guideline cholestrol

NCEP Major Risk Factors

Classification of an individual’s risk for cardiac events is based upon five risk factors:

smokinghypertensionlow HDL (<40)family history- 1st degree relative with MI <55yo for male, <65 yo for femaleage: male >45 yo, female >55 yo

**HDL > 60: reduction of 1 risk factor

CVD Risk AssessmentBased 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 risk0-1 risk factor: lower riskcalculated using Framingham risk score

CHD Equivalents

What are the recognized Coronary Heart Disease equivalents?

Diabetes MellitusPeripheral Arterial DiseaseSymptomatic Carotid Artery Disease (TIA or stroke of carotid origin) Abdominal Aortic Aneurysm10 yr risk for CHD >20% with 2+ risk factors

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

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

Clustering of Components:

• Hypertension• Hypertriglyceridemia• Low HDL-cholesterol• Obesity (central)• Impaired Glucose Handling• Microalbuninuria (WHO)

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

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.

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

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)

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%

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

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)

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.

Smoking Cessation/Avoidance:

• A risk factor for development in children and adults

• Both passive and active exposure harmful

• A major risk factor for:– insulin resistance and metabolic syndrome– macrovascular disease (PVD, MI, Stroke)– microvascular complications of diabetes– pulmonary disease, etc.

Screening/Public Health Approach

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

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.

EBM Recommendations (cont.)

• There is some evidence that insulin sensitizing agents such as metformin are effective in treating features of metabolic syndrome.

Current Treatments

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

Medications:

• Hypertension:– ACE inhibitors, ARBs– Others - thiazides, calcium channel

blockers, beta blockers, alpha blockers

• Hyperlipidemia:– Statins, Fibrates, Niacin

• Platelet inhibitors:– ASA, clopidogrel

Summary of Care: ABC's for ProvidersA A1c Target

Aspirin Daily

B Blood Pressure Control

C Cholesterol ManagementCigarette Smoking Cessation

D Diabetes and Pre-Diabetes Management

E ExerciseF Food Choices

Principles Underlying the AACE/ACE Algorithm • Lifestyle (dietary and exercise) modifications are

essential for all patients with diabetes. Reduction of obesityor overweight and adjustment to an active lifestyle can

have major beneficial effects. In many cases, delaying

pharmacotherapy to allow for lifestyle modifications is inappropriate because these interventions are usually not adequate. Lifestyle modification together with specificdiabetes education, dietary consultation, and theintroduction of a program of self-monitoring of bloodglucose (SMBG) can be initiated concomitantly with medical therapy.

Achieving an A1C of 6.5% is

recommended as the primarygoal, but this goal must be customized for the individual patient, with consideration of numerous factors such as comorbid conditions, duration of diabetes,history of hypoglycemia, hypoglycemia unawareness,

patient education, motivation, adherence, age, limited

life expectancy, and use of other medications.

If a patient has failed to achieve the A1C goal, one cantitrate dosages of medications, change regimens (addor discontinue medications), or, under some

circumstances,reconsider and revise the goal.• When combination therapy is prescribed, it is

importantto use classes of medications that have complementarymechanisms of action.• Effectiveness of therapy must be evaluated

frequently—for example, every 2 to 3 months—with assessment ofA1C, logbook data for SMBG records, documented andsuspected hypoglycemia, and other potential adverseevents (weight gain, fluid retention, and hepatic, renal,or cardiac disease) as well as monitoring of

comorbidities,relevant laboratory data, concomitant drug administration,diabetes-related complications, and psychosocial factors affecting patient care.

2. minimizing risk and magnitude of weight gain3. inclusion of major classes of FDA-approved glycemicmedication, including incretin-based therapies andthiazolidinediones (TZDs)4. selection of therapy stratified by hemoglobin A1c(A1C) and based on documented A1C-loweringpotential5. consideration of both fasting and postprandial glucoselevels as end points6. consideration of total cost of therapy to the individualand society at large, including costs related to medications,glucose monitoring requirements, hypoglycemicevents, drug-related adverse events, and treatmentof diabetes-associated complications

• It covers prevention of Type 2 diabetes in the general population by reduction of obesity through promotion of healthy eating, maintaining a healthy weight and promotion of physical activity. Also by raising awareness of risk factors, so that individuals can take action to modify them

• The prevalence of Type 2 diabetes is rising rapidly - much of this rise can be attributed to the increase in obesity

The key to preventing Type 2 diabetes is to reduce the overall level of obesity in the population as a whole, in addition to raising awareness of, identifying and addressing, risk factors in individuals

UKPDS• Showed that glycemic control early

in diabetes has lasting benefit, including for CVD risk

• However, it was interpreted as implying that everyone should have an A1C <7%--and national guidelines followed suit–But UKPDS included only healthy,

newly-diagnosed patients <65 yrs old Lancet 1998;352:837-853

Remember when we thought that the same diabetes targets applied to everyone?

• A1C <7%• BP <130/80 mmHg• LDL <100

And the discussion has continued• Meta-analysis of 13 recent RCTs (>34,000 pts) that

evaluated intensive glucose lowering:– Limited benefits on all-cause and CV mortality– At best, modest benefits for microvascular disease

• ↓ albuminuria, a trend toward ↓retinopathy, but little else

– Severe hypoglycemic events doubled BMJ 2011;343:d4243 doi:10.1136/bmj.d4243

• Guidelines starting to reflect recent evidence, now Performance Measures will need to be re-thought– Much more benefit to ↓ patient’s A1C from 9% to 7.1%

than to ↓ it from 7.1% to 6.9%– Unknown effects of adding on multiple meds to achieve

target Diabetes Care 2011;34:1651-1659

ADA-EASD Position Statement: Management of Hyperglycemia in T2DM

3. ANTI-HYPERGLYCEMIC THERAPY

•Glycemic targets

- HbA1c < 7.0% (mean PG 150-160 mg/dl [8.3-8.9 mmol/l])

- Pre-prandial PG <130 mg/dl (7.2 mmol/l)

- Post-prandial PG <180 mg/dl (10.0 mmol/l)

- Individualization is key: Tighter targets (6.0 - 6.5%) - younger,

healthier Looser targets (7.5 - 8.0%+) - older,

comorbidities, hypoglycemia prone, etc.

- Avoidance of hypoglycemiaPG = plasma glucose

Diabetes Care, Diabetologia. 19 April 2012 [Epub ahead of print]

RISK FACTORS FORCHRONIC RESPIRATORYDISEASES

Ageing is a process associated with chronic and disablingdiseases . Chronic respiratory diseases are among the most

frequent and severe of all, also in the elderly.In low and middle income countries, those who spent a

large part of their lives in an urban setting tended to have unhealthier lifestyles and therefore a higherrisk of chronic diseases compared with their less urbanized counterparts. An exception to this rule may arise from exposure to indoor air pollution in rural areas where solid fuels are used for cooking and heating

Risk Factors for COPD

Lung growth and development GenderAge Respiratory infectionsSocioeconomic statusAsthma/Bronchial hyperreactivityChronic Bronchitis

GenesExposure to particles Tobacco smoke Occupational dusts,

organic and inorganic Indoor air pollution from

heating and cooking with biomass in poorly ventilated dwellings

Outdoor air pollution

Genes

Infections

Socio-economic

status

Aging Populations

Risk Factors for COPD

Diagnosis and Assessment: Key Points

A clinical diagnosis of COPD should be considered in any patient who has dyspnea, chronic cough or sputum production, and/or a history of exposure to risk factors for the disease.

Spirometry is required to make the diagnosis; the presence of a post-bronchodilator FEV1/FVC < 0.70 confirms the presence of persistent airflow limitation and thus of COPD.

Assess COPD Comorbidities

COPD patients are at increased risk for:

Cardiovascular diseasesOsteoporosisRespiratory infectionsAnxiety and DepressionDiabetesLung cancer

These comorbid conditions may influence mortality and hospitalizations and should be

looked for routinely, and treated appropriately.

Therapeutic Options: Key Points

Smoking cessation has the greatest capacity to influence the natural history of COPD. Health care providers should encourage all patients who smoke to quit.

Pharmacotherapy and nicotine replacement reliably increase long-term smoking abstinence rates.

All COPD patients benefit from regular physical activity and should repeatedly be encouraged to remain active.

Influenza vaccines can reduce serious illness. Pneumococcal polysaccharide vaccine is recommended for COPD patients 65 years and older and for COPD patients younger than age 65 with an FEV1 < 40% predicted.

The use of antibiotics, other than for treating infectious exacerbations of COPD and other bacterial infections, is currently not indicated.

Therapeutic Options: Other Pharmacologic Treatments

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! • Osteoporos is a disease of bones that leads

to an increased risk of fracture. In osteoporosis, the bone mineral density (BMD) is reduced, bone microarchitecture deteriorates, and the amount and variety of proteins in bone are altered. Osteoporosis is defined by the World Health Organization (WHO) as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass (average of young, healthy adults) as measured by dual-energy X-ray absorptiometry; the term "established osteoporosis" includes the presence of a fragility fracture.

• The disease may be classified as primary type 1, primary type 2, or secondary. The form of osteoporosis most common in women after menopause is referred to as primary type 1 or postmenopausal osteoporosis. Primary type 2 osteoporosis or senile osteoporosis occurs after age 75 and is seen in both females and males at a ratio of 2:1. Secondary osteoporosis may arise at any age and affect men and women equally. This form results from chronic predisposing medical problems or disease, or prolonged use of medications such as glucocorticoids, when the disease is called steroid- or glucocorticoid-induced osteoporosis.

treatment• Lifestyle change includes diet and

exercise, and preventing falls. Medication includes calcium, vitamin D, bisphosphonates and several others. Fall-prevention advice includes exercise to tone deambulatory muscles, proprioception-improvement exercises; equilibrium therapies may be included. Exercise with its anabolic effect, may at the same time stop or reverse osteoporosis

MedicationCertain medications have been associated with an increase in

osteoporosis risk; only steroids and anticonvulsants are classically associated, but evidence is emerging with regard to other drugs.

Steroid-induced osteoporosis (SIOP) arises due to use of glucocorticoids - analogous to Cushing's syndrome and involving mainly the axial skeleton. The synthetic glucocorticoid prescription drug prednisone is a main candidate after prolonged intake. Some professional guidelines recommend prophylaxis in patients who take the equivalent of more than 30 mg hydrocortisone (7.5 mg of prednisolone), especially when this is in excess of three months. Alternate day use may not prevent this complication.

Barbiturates, phenytoin and some other enzyme-inducing antiepileptics - these probably accelerate the metabolism of vitamin D.

L-Thyroxine over-replacement may contribute to osteoporosis, in a similar fashion as thyrotoxicosis does. This can be relevant in subclinical hypothyroidism.

Several drugs induce hypogonadism, for example aromatase inhibitors used in breast cancer, methotrexate and other antimetabolite drugs, depot progesterone and gonadotropin-releasing hormone agonists

• Anticoagulants - long-term use of heparin

is associated with a decrease in bone density, and warfarin (and related coumarins) have been linked with an increased risk in osteoporotic fracture in long-term use.

• Proton pump inhibitors - these drugs inhibit the production of stomach acid; this is thought to interfere with calcium absorption. Chronic phosphate binding may also occur with aluminium-containing antacids.

• Thiazolidinediones (used for diabetes) - rosiglitazone and possibly pioglitazone,

• Chronic lithium therapy has been associated with osteoporosis

• Screening• The

U.S. Preventive Services Task Force (USPSTF) recommended in 2011 that all women 65 years of age or older should be screened with bone densitometry. They recommend screening women of any age with increased risk factors that puts them at risk equivalent to a 65 year old without additional risk factors. The most significant risk factors is lower body weight (weight < 70 kg), with less evidence for history of smoking or family history.

• Medications• Most bisphosphonates are effective in

preventing fractures of the vertebrae, nonvertebral bones and hips. when taken for three to four years.Fracture risk reduction is between 25 and 70% depending on the bone involved.There are concerns of atypical femoral fractures and osteonecrosis of the jaw with long term use, but these risk are low.With evidence of little benefit when used for more than three to five years and in light of the potential adverse events, it may be appropriate to stop treatment after this time in some

• Other medicines prescribed for prevention of osteoporosis include raloxifene, a selective estrogen receptor modulator.

• Estrogen replacement therapy remains a good treatment for prevention of osteoporosis, but is not recommended yet unless other indications for its use are present, as well. There is uncertainty and controversy about whether estrogen should be recommended in women in the first decade after the menopause.

• In hypogonadal men, testosterone has been shown to give improvement in bone quantity and quality.

• Calcium and vitamin D decrease the risk of nonvertebral fractures in those with postmenopausal osteoporosis by about 18%. High intake of vitamin D reduces fractures in the elderly. (vitD100iu/day)

• Calcium1500mg/day or vit D amp 300,000 per month till 2time and then

q3month till long life. Vit Dpearl 50,000IUqweek till10week

then Q2week till life long. (vitD100iu/day)

• Hormone replacement therapy, while effective for osteoporosis, is only recommended in women who also have menopausal symptoms. Raloxifene, while effective in decreasing vertebral fractures, does not affect the risk of nonvertebral fracture.And while it reduces the risk of breast cancer, it increases the risk of blood clots and strokes

Blood Pressure TargetAs with glucose targets, UKPDS played a

major role in target selection for BP in international guidelines

For diastolic BP target, so did the randomized Hypertension Optimal Treatment (HOT) studyStudy paper noted ↓ CV risk in diabetic patients

with DBP <80 mm HgAccompanying editorial noted the slight ↑

mortality in intensively treated diabetic patients with ischemic heart disease so recommended caution in lowering BP to <140/85 in this group Lancet 1998;351:1755-62 and 1748-1749

Current BP Targets in Diabetes• ADA 2012:– “A goal SBP <130 mmHg is appropriate for most

patients with diabetes.” – “Based on patient characteristics and response to

therapy, higher or lower SBP targets may be appropriate.”

– “Patients with diabetes should be treated to a DBP <80 mm Hg.”

• Most benefit seen in reducing SBP to <140

– Target selection should be individualized: “first, do no harm”• Use caution in setting targets: older, comorbidities, longer

duration of DM, on lots of meds already, hypotensive symptoms, autonomic neuropathy

Hypertension or high blood pressure is a major risk factor for heart disease and stroke, costing the national almost $131 billion annually in direct medical expenses. In 2008 hypertension was reported as a primary or contributing cause of approximately 348,000 deaths in the U.S., which is nearly 1,000 deaths each day

Background• High Blood Pressure:

• Major risk factor for stroke, myocardial infarction, heart failure, chronic kidney disease, cognitive decline and premature death.• Untreated hypertension can cause

vascular and renal damage leading to a treatment-resistant state.• Each 2 mmHg rise in systolic blood

pressure associated with increased risk of mortality:– 7% from heart disease – 10% from stroke.

DefinitionsStage 1 hypertension: Clinic blood pressure (BP) is 140/90 mmHg or

higher and ABPM or HBPM average is 135/85 mmHg or

higher.

Stage 2 hypertension: Clinic BP 160/100 mmHg is or higher and ABPM or HBPM daytime average is 150/95 mmHg

or higher.

Severe hypertension: Clinic BP is 180 mmHg or higher or Clinic diastolic BP is 110 mmHg or higher.

Offer antihypertensive drug treatment to people:–who have stage 1 hypertension, are aged under 80 and meet identified criteria–who have stage 2 hypertension at any age.

If aged under 40 with stage 1 hypertension and without evidence of target organ damage, cardiovascular disease, renal disease or diabetes, consider:–specialist evaluation of secondary causes of hypertension–further assessment of potential target organ damage.

Initiating drug treatment

Use clinic blood pressure measurements to monitor response to treatment. Aim for target blood pressure below:

– 140/90 mmHg in people aged under 80– 150/90 mmHg in people aged 80 and over

Monitoring drug treatment (1)

Use a formal estimation of cardiovascular risk to discuss prognosis and healthcare options with people with hypertension.

For all people with hypertension offer to:

– test urine for presence of protein– take blood to measure glucose, electrolytes,

creatinine, estimated glomerular filtration rate and cholesterol

–examine fundi for hypertensive retinopathy–arrange a 12-lead ECG.

Assessing cardiovascular risk and target organ damage:

updated recommendations

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