FIGURE 2-1 Loss of health with aging. Representation of normative aging with

loss of the full stock of health with which individuals are born (indicating gain of

morbidity), contrasted with a squared curve with greater longevity and fuller stock

of health (less morbidity) until shortly before death. The “squared curve” represents

the likely ideal situation for most patients.

worldwide over the last century (largely as a result of public health

practices), increasing emphasis is placed on prevention for the purpose

of preserving quality of life and extending the health span, not just the

life span. Given that all patients will eventually die, the goal of prevention ultimately becomes compression of morbidity toward the end of

the life span; that is, reduction of the amount of burden and time spent

with disease prior to dying. As shown in Fig. 2-1, normative aging

tends to involve a steady decline in the stock of health, with accelerating decline over time. Successful prevention offers the opportunity

both to extend life and to extend healthy life, thus “squaring the curve”

of health loss during aging.

Prevention strategies have been characterized as tertiary, secondary,

primary, and primordial. Tertiary prevention requires rapid action to

prevent imminent death in the setting of acute illness, such as through

percutaneous coronary intervention in the setting of ST-segment elevation myocardial infarction. Secondary prevention strategies focus on

avoiding the recurrence of disease and death in an individual who is

already affected. For example, tamoxifen is recommended for women

with surgically treated early-stage, estrogen receptor–positive breast

cancer, because it reduces the risk of recurrent breast cancer (including

in the contralateral breast) and death. Primary prevention attempts to

reduce the risk of incident disease among individuals with one or more

risk factors. Treatment of elevated blood pressure in individuals who

have not yet experienced cardiovascular disease represents one example of primary prevention that has proven effective in reducing the

incidence of stroke, heart failure, and coronary heart disease.

Primordial prevention is a more recent concept (first introduced in

1979) that focuses on prevention of the development of risk factors

for disease, not just prevention of disease. Primordial prevention

strategies emphasize upstream determinants of risk for chronic diseases, such as eating patterns, physical activity, and environmental

and social determinants of health. It therefore encompasses medical

treatment strategies for some individuals as well as a strong reliance on

public health and social policy. It is increasingly clear that primordial

prevention represents the ultimate means for reducing the burden

of chronic diseases of aging. Once risk factors develop, it is difficult

to restore risk to the low level of someone who never developed the

risk factor. The time spent with adverse levels of the risk factor often

causes irreversible damage that precludes complete restoration of low

risk. For example, individuals with hypertension who are treated back

to optimal levels (<120/<80 mmHg) do have a lower risk compared

with untreated patients with hypertension, but they still have twice the

risk of cardiovascular events as those who maintained optimal blood

pressure without medications. Patients with elevated blood pressure

that is subsequently treated have greater left ventricular mass index,

worse renal function, and more evidence of atherosclerosis and other

target organ damage as a result of the time spent with elevated blood

pressure; such damage cannot be fully reversed despite efficacious therapy with antihypertensive medications. Conversely, as described below

in greater detail, individuals who maintain optimal levels of all major

Promoting Good Health

9CHAPTER 2

may improve adherence; ignoring them will likely lead to therapeutic

failure. Numerous studies demonstrate that, even in high-functioning

health systems, only ~50% of patients are taking recommended,

evidence-based secondary prevention medications, such as statins, by

1 year after a myocardial infarction.

In patients who are eligible for primary prevention strategies, it is

important to frame the discussion around the overall evidence base

as well as an individual patient’s likelihood of benefit from a given

preventive intervention. A first step is to understand the patient’s

estimated absolute risk for disease in the foreseeable future or during

their remaining life span. However, absolute risk estimation and presentation of those risks are generally insufficient to motivate behavior

change. It is critical to assess the patient’s understanding and tolerance

of the risk, their readiness to implement lifestyle changes or adhere

to drug therapy, and their overall preferences regarding use of drug

therapy to prevent an event (e.g., cancer, myocardial infarction, stroke).

The clinician can help the patient by informing them of the risks for

disease and potential for absolute benefits (and harms) from the available evidence-based choices. This may take more than one conversation, but given that diseases, such as cancer and cardiovascular disease,

are the leading causes of premature death and disability, the time is well

spent.

Partnering with the patient through motivational interviewing

may assist in the process of selecting initial approaches to prevention.

Selecting an area that the patient feels they are ready to change can lead

to better adherence and greater achievement of success in the short and

longer term. If the patient is uncertain what course to choose, prudence

would dictate focusing on control of risk factors that may lead to the

most rapid reduction in risk for acute events. For example, blood pressure is both a chronic risk factor and an acute trigger for cardiovascular

events. Thus, if a patient has both significant elevations in blood pressure and dyslipidemia, it would be appropriate to focus initial efforts

on blood pressure control. Likewise, a focus on smoking cessation can

lead to more rapid reductions in risk for acute events than some other

lifestyle interventions.

■ PREVENTION AND HEALTH PROMOTION ACROSS

THE LIFE COURSE

Periodic Health Evaluations The “routine annual physical” has

in many ways become an expected part of the patient-physician relationship in primary care practice. However, evidence for the efficacy

of the periodic health evaluation in asymptomatic adults unselected

for risk factors or disease is mixed and depends on the outcome.

Systematic reviews and meta-analyses of published trials have consistently observed lack of benefit (and also lack of harm) in terms of

total mortality in association with periodic health evaluations. Data

are more heterogeneous but overall suggest no benefit for cancer- or

cardiovascular-specific mortality, with the potential for either benefit

or harm depending on number of evaluations and patient-level factors.

Well-designed studies on nonfatal clinical events and morbidity have

been sparsely reported, but there appear to be no large effects.

Periodic health evaluations do appear to lead to greater diagnosis of

certain conditions such as hypertension and dyslipidemia, as expected.

Likewise, periodic health examinations also improve the delivery of

recommended preventive services, such as gynecologic examinations

and Papanicolaou smears, fecal occult blood testing, and cholesterol

screening. The benefits and risks associated with screening tests are

discussed in detail in Chap. 6. Risks of routine evaluations include

inappropriate testing or overtesting or false-positive findings that

require follow-up and induce patients to worry. Periodic health examinations appear to be associated with less patient worry. On balance,

given the lack of convincing evidence of harm and the potential for

better delivery of appropriate screening, counseling, and preventive

services, periodic health evaluations appear reasonable for general

populations at average risk for chronic conditions.

It is important to note that routine annual comprehensive physical

examinations of asymptomatic adult patients have very low yield and

may take an inordinate amount of time in a wellness visit. Such time

cardiovascular risk factors into middle age through primordial prevention essentially abolish their lifetime risk of developing cardiovascular

disease while also living substantially longer and having a lower burden

and later onset of other comorbid illnesses (compression of morbidity).

Prevention strategies should be distinguished from disease screening strategies. Screening attempts to detect evidence of disease at its

earliest stages, when treatment is likely to be more efficacious than for

advanced disease (Chap. 6). Screening can be performed in service of

prevention, especially if it aids in identifying preclinical markers, such

as dyslipidemia or hyperglycemia, associated with elevated disease risk.

■ HEALTH PROMOTION

In recent decades, medical practice has increasingly focused on clinical

and public health approaches to promote health, and not just prevent

disease. Prevention of disease is a worthy individual and societal goal

in and of itself, but it does not necessarily guarantee health. Health is

a broader construct encompassing more than just absence of disease.

It includes biologic, physiologic, and psychological domains (among

others) in a continuum, rather than occurring as a dichotomous trait.

Health is therefore somewhat subjective, but attempts have been made

to use more objective criteria to define health in order to raise awareness, prevent disease, and promote healthy longevity.

For example, in 2010, the American Heart Association (AHA)

defined a new construct of “cardiovascular health” based on evidence

of associations with longevity, disease avoidance, healthy longevity, and

quality of life. The definition of cardiovascular health is based on seven

health behaviors and health factors (eating pattern, physical activity,

smoking status, body mass index [BMI], and levels of blood pressure,

blood cholesterol, and blood glucose) and includes a spectrum from

poor to ideal. Individuals with optimal levels of all seven metrics

simultaneously are considered to have ideal cardiovascular health. The

state of cardiovascular health for an individual or a population can be

assessed with simple scoring by counting the number of ideal metrics

(out of seven) or applying 0 points for each poor metric, 1 point for

each intermediate metric, and 2 points for each ideal metric, thus

creating a composite cardiovascular health score ranging from 0 to

14 points. Higher cardiovascular health scores in younger and middle

ages have been associated with greater longevity, lower incidence of

cardiovascular disease, lower incidence of other chronic diseases of

aging (including dementia, cancer, and more), compression of morbidity, greater quality of life, and lower health care costs, achieving both

individual and societal goals for healthy aging and further establishing

the critical importance of primordial prevention and cardiovascular

health promotion.

Focusing on health promotion, rather than just disease prevention,

may also provide greater motivation for patients to pursue lifestyle

changes or adhere to clinician recommendations. Extensive literature

suggests that providing patients solely with information regarding

disease risk, or risk reduction with treatment, is unlikely to motivate

desired behavior change. Empowering patients with strategies to

achieve positive health goals after discussing risks can provide more

effective adherence and better long-term outcomes. In the case of

smoking cessation, enumerating only the risks of smoking can lead

to patient inertia and therapeutic nihilism and has proven to be an

ineffective approach, whereas strategies that incorporate positive

health messaging, support, and feedback, with appropriate use of

evidence-based therapies, have proven far more effective.

■ PRIORITIZING PREVENTION STRATEGIES

In secondary prevention, the patient already has manifest clinical disease and is therefore at high risk for progression. The approach should

be to work with the patient to implement all evidence-based strategies

that will help to prevent recurrence or progression. This will typically

include drug therapy as well as therapeutic lifestyle changes to control

ongoing risk factors that may have caused disease in the first place.

Juggling priorities can be difficult, and barriers to implementation are

many, including costs, time, patient health literacy, and patient and

caregiver capacity to organize the regimen. Addressing these potential barriers with the patient can help to forge a therapeutic bond and