In all disease the goal is prevention. This is not to say that preventive activities are without side-effects. Classification: preventing a disease (eg by vaccination) is primary prevention. Controlling disease in an early form (eg carcinoma in situ) is secondary prevention. Preventing complications in those already symptomatic is tertiary prevention.
Prevention through the human life cycle
Pre-conception. Is she using folic acid supplements? Is she rubella immune? If not, vaccinateensure effective contraception for 1 month after vaccination. Is she diabetic? If so, optimize glycaemic control as early as possible.
The child
safety lessons; developmental tests.
Preventing myocardial infarction
See the UK National Service Framework for coronary heart disease. Smoking trebles the risk above the rate for men who have never smoked. A systolic BP >148mmHg (40% of men) doubles risk,1 and if serum cholesterol is in the top 20% of the observed range, the risk trebles. Help to stop smoking, and treating hypertension (OHCM p 142) and hyperlipidaemia (OHCM p 706) are the chief interventions. The UK government recommends reductions in total fat and saturated fat to 35% and 15%, respectively, of total energy. GPs and practice nurses have a central role in preventing cardiac deaths, eg by screening for hypertension, and encouraging less smokingand prescribing statins (not based on a particular cholesterol level, but according to overall risk of MI and stroke).
Preventing breast cancer deaths
Education and self-examination.[bomb] Well-woman clinics. Mammography (using negligible radiation)cancer pick-up rate: 5 per 1000 healthy women screened. Yearly 2-view mammograms in postmenopausal women might reduce mortality by 40%but the price is the serious but needless alarm caused: there are ~10 false +ve results for each true +ve result. The UK national health service offers 3-yearly single views to those between 55 and 64 years old (older women may be screened too).
Prevention in the reproductive years
Safe sex education starting in adolescence (teaching to use condoms need not increase rates of sexual activity); family planning, antenatal/prenatal care (eg folic acid), screening for cervical cancer , blood pressure, rubella serology.
Preventing oxidative damage by free radicals
Antioxidants, eg vitamin E, C, carotenoids, flavenoids, and selenium (OHCM) are found in diets rich in fruits, vegetables, grains, and nutsand are thought to protect from various diseases (free radical action on LDL is central to atherogenesis), diabetes mellitus, cancer, and Alzheimer's (see benefits of ginkgo biloba, extracted from the maidenhair tree).
Old age and prevention
Keep fit, pre-retirement lessons, bereavement counselling visits from the health visitor may help in preventing disease. But the main aim is to adopt the measures outlined above to ensure that there is an old age in which to prevent disease.
Side-effects
No intervention is without side-effects, and when carried out in large populations the problems may outweigh the benefits.
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