Wednesday, March 21, 2007
Creating a "culture of prevention"
On CNN's American Morning today I talked about the latest news regarding heart disease. It's pretty sobering. Already heart disease is the biggest killer of men and women in most developed nations in the world. Unless we do more, the situation may become much, much worse.

A study published in one of the big medical journals is titled, "The International Pandemic of Chronic Cardiovascular Disease," and that really says it all. Researchers examined data of almost 70,000 people from 44 countries who had some confirmed evidence of heart disease or a combination of risk factors such as smoking, hypertension and excess weight. Most alarming was that one out of every seven had a catastrophic event within just one year. They either had a heart attack, a stroke or they died. (Full Story)

Certainly, we are better than ever at treating heart disease, but we are still not a society that practices a culture of prevention. We can unclog blood vessels with angioplasty, even bypass them with open-heart surgery. We can use medications to stop plaque from forming and sometimes reverse its growth. The problem is that too many people are waiting too long. Too many people never get a chance to prevent the diseases that eventually rob them of their lives and their well being.

One of my great passions is to try and create this "culture of prevention." It makes sense medically, morally and financially. People will live healthier and more functional lives without spending countless days in intensive care units and assisted-living facilities. Still, we are in constant firefighter mode, rushing to the scenes of disasters, instead of preventing the fires in the first place. I would love to hear your thoughts on how to work toward a culture of prevention.
A "culture" of prevention can be established if every concerned group is on the same page. These groups would inlude both political parties, Congress, all branches and levels of government, schools, professional groups, churches etc. Chronic diseases are devastating us as individuals and as a country. We need a call to arms and unprecedented financial and political committment toward the development of a "culture" of prevention rather than lip service!
In January 2007 I had a heart attack and triple bypass surgery. I still am not back to work due to still experiencing a lot of upper chest pain, possibly due to fluid build-up. Two weeks after the surgery I was hospitalized with pluerisy. Even with the pain involved, keeping to the diet is extremely difficult. Healthy eating in today's culture is not a pleasant task.
This post makes me so happy! My husband was recently diagnosed with heart disease, he is only 30 years old. He had no signs or symptoms. Two years ago his father had a heart attack and luckily survived. It was the persistence of my father-in-law's cardiologist that got my husband to the doctor for a stress test. I am so thankful that he did because he had 100% blockage in his LAD and had angioplasty last month. He is not overweight, eats really well and doesn't smoke. His LDL was under 100 before the surgery and now is below 70. I urge every one I know to go have a physical and become aware of your family medical history. We also need to find a way for hosptials and insurance companies to be interested in preventive care(and integrated medicine)and to find a way that is beneficial for them as well as the patient.
Interesting that cholesterol was not mentioned as a risk factor.
The Culture of prevention is something that has to be more on the top prioriity of medicine today. Osteopathic medical schools have always integrated this into their cirriculum and now some allopathic medical schools are also. Physicians and patients alike should be asking the right questions in routine visits to make sure that lifestyle choices and diet are in line for a reciepe that will act as a "vaccination" for the cardiovascular disease epidemic. Puttingf patients on costly statin drugs is not the answer. I believe that information is key and fine physicians like Dr. Gupta are getting that information across in this media driven age. I think that medical students should also pay as much attention in their nutrition classes as they do in their pathophysiology classes.
I think prevention is important. Although I have found that my doctor isn't very concerned about checking me out for heart problems. I am quite concerned about this.
Maggie's husband's case seems extreme and I would guess there are some genetic factors involved. We know that 80% of heart disease cases are preventable or postponable through healthy eating and exercise.

As a former resident of Korea and China, countries with traditionally low rates of heart disease, the root causes of our culture of cure versus culture of prevention are obvious. Asians eat dishes mostly prepared from whole foods and do more walking because they rely on public transport.

1) diet -

Help busy families eat better by providing public education programs. Hire chefs to prepare easy and delicious meals from whole foods (no name brand stuff in packaging) in the produce section of the supermarket on Saturdays.

Make healthy food accessible to the poor by encouraging supermarkets to open in low-income neighborhoods and revamping public assistance programs like food stamps and WIC to encourage healthy eating, rather than fobbing off low-quality surplus milk and cheese.

2) Support public facilities that help people be active, like parks and public transport. I live within the limits of a city of 25,000 and my neighborhood doesn't even have sidewalks! There is no safe place for me to take a walk in the evenings, and this is a real issue for many Americans.

As Richard Laeng noted, the development of a culture of prevention will take money and commitment. The current administration and Congress have moved away from public funding towards privatization, so I am pessimistic about our nation's ability to change our diets and our lifestyles in order to reduce preventable chronic diseases.

Asking readers for suggestions on how to create a culture of prevention, Dr. Gupta? Nice idea, but unless the medical community puts its power and money into helping Americans grow up healthy and stay healthy, the status quo will continue.
One problem is there is no way to know the actual percent blockage of coronary arteries without doing an invasive angiogram proedure. We need a reliable heart scan machine which will measure coronary artery blockage without doing invasive procedures. Most people don't have any symptoms until the disease is far advanced.
For a �Culture of Prevention�, information is key. The news media is very powerful because many people get their medical information solely from their television; medical news should be presented simply and as informatively as possible for that very reason.

Unfortunately in today�s society, there are massively conflicting sources of information. People have terrible diets, bad exercise habits, they smoke, sit, and pop vitamins and protein bars. Insisting they�re eating healthy, people will order a salad- topped with bacon bits, cheese, and a dressing loaded with fat!

To begin with, a simple change in exercise habits would be helpful. Many people don�t want to exercise, but it�s as simple as turning on the radio and dancing for half an hour. You don�t need to join a gym or work out till you drop to notice the benefit of a little cardio!

Second, a good diet. I could go on and on about diet (it�s my favorite subject), but I�ll attempt to sum it up. Vitamin supplements will not keep you healthy. You must have a healthy diet. A healthy diet consists of a variety of foods that supply you with the carbohydrates, fats, and protein that you need. Carb free diet? Terrible! You need carbohydrates for basic body processes! And completely fat free? You�d become deficient in Vitamins A, D, E, and K. If you�re eating the same food every day (for example, eggs three times a day and not much else), you�ll become ill because you�re nutrient deficient. And those portions at the fast food restaurants are three times the size they should be.

Third, quit smoking! That�s all I have to say about that.

Many Americans (or anyone, really) don�t have the slightest clue where to start with a healthy diet. If you say �Food Pyramid�, you�d probably get a blank stare. They�d rather go with the latest fad diet. If you�d like to evaluate your eating habits, and see how you measure up to how you SHOULD eat, I suggest the government�s website www.mypyramid.gov.
I agree that a culture of prevention is the best way to go. But like Richard said, we need both financial and political commitment to help. I like to drink OJ and eat my whole grain Cheerios everyday before class. But let's face it. $6.07 for a gallon of Orange juice and $4.99 for a small box of Cheerios is absolutely ridiculous. Whereas, if I were to go to the hospital if something happened, it would cost me less than the OJ and the cereal for a year. People need an incentive to be smart about their health. I think another thing that might help too, is if people could take "siestas" in the middle of their workday. I've snuck in a few naps before or just zoned out playing my gameboy and I feel much better for the rest of the day!
I ate a heart healthy diet and never had a cholesterol level above 120 and still had a heart attack at 45 years old. I have seven stents and take all kind of preventative medications and still have angina. My cholesterol is now below 70 and I go to the hospital daily for a treatment called ECCP. All I can say to healthy people heart disease is no fun and live a healthy life style. I think the biggest problem is restaurants put so much fat in stuff. When you go out to eat order all the sauces on the side and ask how something is cooked. Read labels and talk to you doctor about taking an 81 mg dose of aspirin every day. Pay attention to your blood pressure and if it is high get on medication immediately. If you have heart tests and the results turn out good and you still have chest pain see another doctor. In my case I had a stress echo and told the doctor I had serve chest pain and he said it was not a problem. Two day later I had a serious heart attack. Doctors make mistake and listen to your body.
Finally, a common sense appoach. Kudos to you. Make prevention as lucrative a business as treatment and you'll have yourself a winning outcome.
1.Insurance Companies need to start paying for procedures such as CT scans that can check your arteries beginning at age 35 and once every 5 years to see what is going on. You can't fix it if you don't know it is there.
2. Stop producing cigaretts, fast food items and start producing more healthy food items in all restaurants.
3. Education is the number 1 thing you need to do, especially in communities that do not speak English.
4. Physicians need to stop with the quick fix and educate themselves on proper diet (not just the quickie education you get in medical school-that is nowhere near enough.
5. More outreach to all communities-not just inner cities, but the suburbs too- using vans that can stop at senior centers and high schools with medical personnel that can teach people what to do.
6. There is a lot of talk by physicians but I see many of them eat the most unhealthy diets at the hospital. They need to lead by example.
I feel that health insurance companies are a great barrier to a "culture of prevention". They are the gate keepers to health in this country. Preventative medicine is so cost-effective it should be in the interest of insurance companies. However, convincing insurance companies to get on board is difficult because a person would have to be with the same insurance company for several years for that company to see a return on their investment. Fixing this problem, without going to nationalized health insurance, will be hard.
The first thing that has to change for the sake of our health as a country is the attitude of doctors towards women. I include women doctors in that statement.

For 3 or 4 yrs I told my family doctor and GYN that my heart wasn't beating correctly. They would smile and tell me it was hormones (I'm now 49). It got so bad I could hardly function and 3 times in two weeks I almost hit the floor, one of those times was at my GYNs office! They told me I needed to eat protein. I finally went to my family doctor and demanded, and I mean pound your fist on the counter temper tantrum type behavior to make my doctor check it out. After wearing a halter monitor for 24 hours they threw me into the hospital and did a heart cath, MRI, and other tests. The structure of my heart is fine. No blockage, no valve problems, but my heart rate was crazy. It took 3 regular EKGs for it to show up. The halter monitor showed the true picture. They couldn't believe I was still standing. I was diagnosed with Long QT Syndrome and now have a pacemaker/defibrillator which was implanted in Oct. 2006. If I had not thrown a fit and demanded another answer other than "hormones" I would be dead. It shouldn't be that way.
To Colleen - I know a NURSE who was treated that way by her doctors. Not for heart disease, but lyme disease. She had a long recovery process that could have been prevented had they listened to her in the first place (apparently they kept teling her it was "all in her head"). It really is a shame. Though I don't know if it's just women, or if some doctors just think evreybody who hasn't got an MD can't possibly know what's going on with their own bodies.

I think the biggest barriers to prevention and time, and habit. Humans are, on the whole, creatures of habit, and those become hard to break. We'll have to start with the young ones, I think. But then you have the problem of instilling that culture into their parents. As far as time goes, I will admit my eating habits could be better. It's hard to get healthy foods that don't feel like they take too much energy to cook after I've been at work all day (maybe that would be different if Ia ctually liked cooking, but I've never had a love of it). Fresh greens are great, and salads are wonderful, but two things are a block to this. One: I live alone, and it always seems like salad greens and similar fresh produce is sold in such bulk that somebody without a family can't eat all that before it goes bad. And I hate wasting food, so often simply won't buy it. Going back to time, I also have to juggle grocery trips with my other chores (I don't know how people with kids have time to get everything done!), and let's face it: it's much easier to buy something you can store for several weeks than to get something that will go bad soon, that you'll have to buy more of in a couple days. My eating habits were, ironically, better in college when I had a market within walking distance of my apartment. I don't have that anymore, so it's no longer as easy as "hey, I want broccoli today, I should go pick some up!" 10 minutes later I'd be back in my apartment happily snacking on my broccoli.

Where I live now, out in farm country, the nearest grocery store is at least a 20 minute drive away. But if I want GOOD produce I have to drive farther. The local places are somewhat lacking (and overpriced, considering they're chain stores like Kroger, and not local markets).
I believe that so many people are not taught to eat healthy foods as children. I know that their kids are surprised to see green vegetables & fruit on the dinner table at my home. It's easier and cheaper to go fast food until you figure days in cardiac rehab as the result. The kids in my neighborhood know that they have to try everything. It has not been a problem for my daughters or their friends. So the prevention practised in my house is 60+ minutes cardio daily & strength training 3x weekly. I've got to count calories and keep the junk food out. I've lost 70# in the last year doing that. My family DR is pleased.
Weight loss surgery is a procedure that effectively treats the medical disease of morbid obesity. The NIH agrees, as you mention in your article, that dieting is ineffective. Tufts has no magic formula that these patients have not tried before. They are delaying the surgery to avoid the expense. Who would want their medical decisions put in the hands of an insurance company. If we wouldn't tolerate that in our own lives, why should we condone it in the lives of those who need and want this surgery?
I haven't taken the time to read the other responses, so mine may possibly echo theirs.

I have been (for the past few months) enrolled in a Health Education Class through my Health Care Provider.

I truly believe that we eat waaay too much food, and seem to think that is a good thing because it is offered. We forget to look at portion sizes and understand that too much isn't always better, it is simply more.

And because we are eating more, we are moving even less.

We are eating the wrong foods. We are eating what we grew up to believe were health foods. Granted some are doing better, but according to all the statistics the media or studies provide, it doesn't look much better.

We need to re-educate ourselves, and understand that our plates should start showing more greens and beans as the main dish, and meats and greasy as side orders. We need to reverse what we have been doing for so many many years.

I know this all sounds foreign, but we have to not only change the foods we eat and the quantity, but our behaviors and attitudes must change as well or we will be in worse trouble.

I remember as a kid, every day playing hard on the playground, entereing middle school (or Junior High as we called it) and we would run the track every day. Some had difficulty, but they were still required to walk as long as there were no health problems present or a note wasn't sent from a Doctor for asthma. Upon entering High School, it was a requirement ot sign up for a class that required track, weight lifting, swimming or something that got us moving every day. That all stopped and was not longer a requirement. I think that was a huge detriment and sent a message that our health was no longer important.

So, we have now consumed more of the wrong foods, exercised less, and have not been educated on the dangers of the wrong foods. Look at us now is all I can say, and our children are headed for more serious health problems at a much younger age than their parents or grandparents ever encountered them. It would be safe to say I believe that according to their lifestyles, that they possibly have as much placque or clogging of the arteries now that we do when we enter middle age. It's just sad. We are teaching enough to promote good healty and prevent disease. And we aren't teaching that activity out is really a major factor in fighting disease as well.

Thanks for this blog.
I work in nuclear cardiology in Southern California and I have one comment whith regards to creating a culture of prevention. I read a study a while back (in a clinical cardiology bulletin) that yoga has a greater impact on cardiovascular disease than traditional medications (like Plavix) due to increased circulation, weight control, and stress reduction through breathing and movement. A cardiologist that I know in Burbank has started offering yoga to his patients on Saturdays as part of a cardiac maintenance/wellness exercise program. I think that's great. And numberous hospitals have started offering yoga in their preventive cardiology programs.

I have included some interesting web links for folks that would like to read more ...

The Benefits of Yoga for Stress Management.
http://stress.about.com/od/tensiontamers/p/profileyoga.htm

Cardiologist�s stress on yoga.
http://www.tribuneindia.com/2002/20020408/cth3.htm

Dr. Yoga: A Complete Guide to the Medical Benefits of Yoga.
http://www.alibris.com/search/search.cfm?qwork=8122553&wtopic=Medical%20Cardiology&matches=75&qsort=r&cm_re=works*listing*title

Also, in July of 2005 the first consensus paper published on the evidence and justification for integrating complimentary medicine (including mind-body therapies) into cardiology was published. This important paper has 16 expert authors and is FREE FULL TEXT on line in the Journal of the American College of Cardiology (see citation below in italics). This paper is the only thorough peer review (37 pages) of this subject and is necessary reading for anyone wishing to bring mind-body medicine into physician offices and/or acquire referrals from health care providers. The only shortcoming is the nearly complete absence of yoga-based therapies and some related mindful exercise disciplines. The nutrition and supplements and spirituality sections are outstanding and each section includes recommendations based on the strength of research evidence.

Integrating Complementary Medicine Into Cardiovascular Medicine
A Report of the American College of Cardiology Foundation Task Force on Clinical Expert Consensus Documents (Writing Committee to Develop an Expert Consensus Document on Complementary and Integrative Medicine) reference: Journal of The Am Coll Cardiol, 2005; 46:184-221

This paper includes sections on Nutrition and Supplements (very thorough), Mind Body Medicine, Acupuncture, Bioenergetics, Spirituality/Intentionality, etc. and many important references.
Sharla you need a snack:-(
Three years ago our 17 year old daughter collapsed while walking to school and died moments later. The coroner determined the cause of death was due to a Pulmonary Embolism (PE) triggered by blood clots that had formed in her pelvis. Erin was an active, health conscious girl. She didn�t smoke, drink, or use drugs. The only thing her death could be linked to was her use of the birth control pill that had been prescribed as a treatment for mild acne.

In researching my daughter�s death I have read a lot about the supposedly �rare� cases of blood clots that have been attributed to the use of the birth control pill or the birth control patch. I recently have learned that the most common genetic risk factor for forming these blood clots or Deep Vein Thrombosis (DVT) is a condition known as factor V Leiden. Present in about 5% of the white population, factor V Leiden predisposes affected individuals to thrombosis (blood clots). The link is this: healthy women taking oral contraceptives have a three to four time greater risk of developing DVT or PE than women not taking the pill. But women with factor V Leiden stand a 35-fold chance of developing a DVT or PE when taking oral contraceptives than women with factor V Leiden who are not taking the pill.

The risk is so great that some have called for all women to be screened before given a prescription of oral contraceptives. But the fear is that this policy could deny effective contraception to a larger number of women while preventing only a small number of deaths due to pulmonary emboli. I hear so much about protecting women�s right to choose, but my daughter was not given a choice � and my husband and I were not given a choice to have our daughter screened. Before Erin died I had never heard of a Pulmonary Embolism or Deep Vein Thrombosis. And until last week, I had never heard of factor V Leiden. To create a �culture of prevention� we must be given all the facts; be given all our options; be educated on all the risks associated with even the most common of medical procedures and medicines because �rare� isn�t so rare when it happens to your own.
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