Prevention of disease and injury is a major part of routine health care. It is important to identify risk factors that predispose patients to a myriad of different illnesses. By identifying risky behaviors or abnormalities, such as high blood pressure, these problems can be modified or eliminated entirely, thus reducing the woman’s risk of future illnesses. In order for a population to be screened or counseled for any given illness, it must be a common illness that causes a significant burden of suffering in people. It must be proven that the early detection of these problems in persons before they develop symptoms actually helps them to live better and longer. Screening for cancers is a major part of preventive care and these are addressed in other sections. Screening for high blood pressure, a key component of preventive care, is covered in the entry Hypertension.
EVALUATION OF CHOLESTEROL
There is clear evidence that high cholesterol is a cause of coronary artery disease (heart disease) and that lowering the level of cholesterol can reduce the risk of heart disease. The American College of Physicians and the U.S. Preventive Services Task Force recommend that screening for high cholesterol begin at the age of 45 for women. Screening women younger than 45 years of age is not recommended by these two groups unless the patient has known heart disease, a family history of heart disease, or unless she has multiple other risk factors for coronary artery disease. The National Cholesterol Education Program (NCEP) suggests that screening begin at the age of 20 and that blood tests be checked every 5 years. The NCEP delineates between high-risk and low-risk persons. The NCEP defines risk factors for coronary artery disease as age, family history of early coronary artery disease, current smoker, hypertension, diabetes, and a low level of high-density lipoprotein (HDL), the protective form of cholesterol. Screening is usually done with a serum total cholesterol. High is considered over 200 mg/dl. If there are two of the above risk factors, it is appropriate to measure a fasting lipid panel to determine the levels of low-density lipoprotein (LDL), triglycerides (TGs), and HDL. Unless the LDL level is very high, coupled with multiple risk factors for heart disease, treatment usually begins with dietary restriction of fat. However, based on the NCEP guidelines, immediate initiation of drug therapy may also be indicated based on risk factors, along with the absolute level of cholesterol, specifically the LDL.
At the age of 50 years, vaccination status should be reviewed for all patients. The tetanus-diphtheria boosters should be given every 10 years throughout a person’s life. Unfortunately, compliance with this regimen has been poor. Therefore, tetanus cases continue to occur.
Immunizations for influenza are recommended for normal-risk adults between the ages of 65 and 75 years. Younger persons who qualify for an influenza vaccination include those with chronic diseases of the heart, lungs, and kidneys or other diseases causing immunosuppression (decrease ability to fight infection). Diabetics and persons who live with diabetics are also high-priority patients for this vaccination. Public health authorities are increasingly recommending offering influenza vaccination to all healthy adults.
The pneumonia vaccine should be given once between the ages of 65 and 75 years in normal-risk adults. If a patient received the pneumococcal vaccine before the age of 65, she should receive a second dose 5 years after that vaccination was given. Patients younger than 65 who are at high risk for pneumococcal disease include the following: Those with chronic diseases of the heart, lungs, and kidneys, diabetics, alcoholics, persons with serious liver disease, patients with immunosuppression, patients with no spleen (either through illness, surgery, or a nonfunctioning spleen), and patients with lymphoma or a history of multiple myeloma would qualify at a younger age. The pneumococcal vaccination is a 23-valent vaccine and it contains capsular materials from 88% of the strains responsible for serious illness from pneumonia in the United States. It does decrease the rate of pneumonia.
Hepatitis A Vaccine
Hepatitis A vaccine is a vaccine prepared from virus and is very effective in the populations of healthy volunteers in whom it has been studied. Hepatitis is a viral infection of the liver that is usually self-limited but causes a great deal of suffering for the patient. Hepatitis A vaccine should be considered for international travelers going to developing countries, persons relocating to areas of poor sanitation, military personnel, intravenous (IV) drug users, and persons with occupational risks (such as sanitation workers).
Hepatitis B Vaccine
Hepatitis B vaccine is now routinely given to children and adolescents not previously vaccinated, and should be considered in persons at increased risk including women with multiple sexual partners, injection drug users, and health care workers. The effect lasts at least 7 years and does decline over time.
The varicella vaccine should be considered for women without a history of chicken pox or antibodies to the varicella-zoster virus who work in high-risk environments, including day-care centers or health care settings. It is important that women of childbearing age not become pregnant for 3 months after having received this vaccine. (Pregnant women in the third trimester who do not have history of chicken pox or antibody evidence of previous infection should be considered for varicella immunoglobulin if they are exposed to an individual with chicken pox.)
The use of alcohol causes many serious health problems in adults. Women are affected to a greater extent because it takes less alcohol in women to cause the adverse effects than in men. It is felt that they have a decreased level of a liver enzyme that detoxifies alcohol, and being smaller, they have a lower volume of distribution of the alcohol. Seventeen to nineteen percent of persons, men and women, in the primary care setting have evidence of risky drinking behaviors. Thirteen to thirty-five percent of persons, at some point in their lifetime, will have some problem with alcohol abuse and dependence. As this is such a common disorder, it is important that patients share honestly with regard to the amount and the frequency that they use alcohol. Lack of being forthcoming with this information leads to underrecognition of alcohol use, and misses an important opportunity to get help for the drinking problem. For patients who are dependent on alcohol, their physician can refer them to the appropriate groups or specialist to help them. Alcohol treatment programs are also available and can improve abstinence from alcohol and increase the intervals between relapse.
Part of preventive care is to assess a person’s use of illicit drugs. For many reasons, especially out of concern for legal and social implications, many patients will understate the use of illicit drugs. Marijuana is the most commonly used drug, followed by cocaine. Women over the age of 18 are half as likely to use illicit drugs, as are men. Drug use carries serious risks including the risk of HIV infection due to injection drug use and the fact that drug use is commonly involved in motor vehicle injuries. While the U.S. Preventive Services Task Force does not recommend routine screening for drug abuse with either questionnaires or serum or urine testing, the task force does acknowledge that a careful drug history is important on other grounds. It is very important for your future to share this information openly with your physician.
Tobacco smoke causes much disease and a great deal of suffering in men and women. It is definitely a positive factor in many cancers, as well as in heart disease and emphysema. It is the most preventable cause of premature death. In 1994, nearly one fourth of women smoked. Lung cancer is now more common in women than breast cancer.
One year after stopping smoking, there is a 50% reduction in the risk of heart disease death or heart attack. The stroke risk reduces 2 years after, and after 10-15 years, approaches that of a nonsmoker. The cancer risk drops more slowly with lung cancer being 50% at 10 years, and esophagus and oral cavity cancers are reduced by 50% at 5 years.
It is important for the smoker to involve her physician in her smoking cessation plan. Advice from the physician can help to motivate the patient and provide information that may help when there is a temptation to smoke. There are methods to stop smoking, including working with the physician to set a quit date, identification of barriers to stopping smoking, and dealing with the temptation that might lead one back to smoking. Drug therapy is available to help a person wean from the effects of nicotine. The withdrawal symptoms can begin 24 hr after the last cigarette and last for several weeks. These symptoms can be extremely bothersome and often intolerable. Most smokers gain approximately 10 lb after they stop smoking. The Agency for Healthcare Research and Quality (AHRQ) recommends a nicotine patch initially. Another drug used for treatment of nicotine dependence is bupropion, which is an antidepressant. It has shown good success in increasing the number of persons who quit smoking. It does carry some adverse effects and the physician and patient must weigh these.
It is extremely important that physical activity be a part of one’s life. Hypertension, diabetes, obesity, osteoporosis, anxiety, and depression are all less common in those who participate in regular exercise. The majority of Americans tend to lead a very sedentary lifestyle. It is not necessary to be involved in an organized exercise program, although it is desirable. However, many patients do not have the time or the access to the facilities to get into a regular program. What is important in an exercise program is to make it easily achievable and easily adopted into the person’s life. The goal is that adults do a total of 30 min or more of continuous or intermittent moderate to intense physical activity on most days of the week. Walking, hiking, stair climbing, aerobics, rowing, swimming, and other sports such as tennis and racquetball are excellent ways to achieve this 30 min of exercise. Gardening, housework, and other active tasks apply to the 30 min recommended physical activity per day. It need not be an organized activity on a court or in a gym! For those who are accustomed to an inactive lifestyle, starting a walking program is an excellent way to achieve success in the area of exercise. It is important to understand that there will be muscle aches at the beginning of any program and to not be discouraged when this occurs.
Injuries are the fifth leading cause of death overall and the most common cause of death in persons under the age of 40. Smoke detectors, air bags, and seat belt use are paramount in injury prevention. It is important that firearms in the home are in a secure and safe place at all times. It is important to keep the water temperature at a safe level to avoid burns and secure all rugs to avoid falls in the home.
NUTRITION IN THE PRIMARY CARE SETTING
A healthy diet is paramount to reducing one’s risk for chronic diseases. Four of the ten causes of death, heart disease, cancer, stroke, and diabetes, are all associated with unhealthy diets. An optimal diet is low in fat, especially saturated fat, trans-fats, and cholesterol. The other characteristics of a good diet include one that is high in fruits, vegetables, and whole-grain products containing fiber. The Dietary Guidelines for Americans recommend 3-5 daily servings of vegetables and vegetable juices, 2-4 daily servings of fruits and fruit juices, and 6-11 daily servings of grain products. Saturated fat should make up less than 10% of the calories and no more than 30% of calories should come from fat.
Healthy women should ingest between 1,000 and 1,500 mg of elemental calcium per day, either through diet or oral supplements. Vitamin D deficiency, which can reduce the absorption of calcium through the intestines, is common, thus a supplement of 400-800 IUs per day is recommended. It is important that one engage in daily physical activity, especially weight-bearing exercise, including walking, jogging, and climbing stairs.
There is evidence that folic acid is instrumental in the prevention of neural tube defects in babies (spina bifida) and is recommended for women considering pregnancy and definitely during pregnancy.