Promoting Good Health¶

Chapter 2 | Part 1: The Profession of Medicine

KEY CLINICAL POINTS¶

Prevention strategies range from primordial (preventing risk factor development) to tertiary (preventing death in acute illness), with primordial prevention offering the greatest long-term health benefits
Life's Essential 8 metrics (diet, physical activity, sleep, nicotine exposure, BMI, blood lipids, glycemia, blood pressure) scored 0-100 predict longevity, disease avoidance, and quality of life
Adults should achieve ≥ 150 min/week moderate-intensity or ≥ 75 min/week vigorous-intensity aerobic activity plus muscle-strengthening activities ≥ 2 days/week
Optimal sleep duration is 7-9 hours per night for adults; both short and excessive sleep are associated with adverse health outcomes
Weight stabilization is an appropriate initial goal before weight loss; negative calorie balance through reduced intake and increased activity is key to weight management

1. DEFINITION & OVERVIEW¶

Prevention of acute and chronic diseases before their onset is a hallmark of excellent medical practice and a metric for highly functioning health care systems. The ultimate goal of preventive strategies is to avoid premature death while preserving quality of life and extending health span, not just 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—reducing the burden and time spent with disease prior to dying.

1.1 Compression of Morbidity Concept¶

Normative aging involves 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. The squared curve represents the ideal situation for most patients—greater longevity with a fuller stock of health until shortly before death.

1.2 Health vs. Disease Prevention¶

Health promotion focuses on clinical and public health approaches to promote health, not just prevent disease. Health is a broader construct encompassing biologic, physiologic, and psychological domains in a continuum rather than a dichotomous trait. Prevention of disease does not necessarily guarantee health. Empowering patients with strategies to achieve positive health goals after discussing risks can provide more effective adherence and better long-term outcomes.

2. PREVENTION STRATEGIES: CLASSIFICATION¶

Prevention strategies are characterized into four levels based on the stage of disease development and the target population.

2.1 Tertiary Prevention¶

Requires rapid action to prevent imminent death and preserve organ function in the setting of acute illness. Example: Thrombolysis or thrombectomy in acute ischemic stroke.

2.2 Secondary Prevention¶

Focuses on avoiding recurrence of disease and death in an individual who is already affected. Example: Tamoxifen for women with surgically treated early-stage, estrogen receptor-positive breast cancer reduces the risk of recurrent breast cancer (including contralateral breast) and death.

2.3 Primary Prevention¶

Attempts to reduce the risk of incident disease among individuals with one or more risk factors. Example: Treatment of elevated blood pressure in individuals who have not yet experienced cardiovascular disease reduces incidence of stroke, heart failure, and coronary heart disease.

2.4 Primordial Prevention¶

First introduced in 1979, focuses on prevention of the development of risk factors for disease, not just prevention of disease. Emphasizes upstream determinants of risk for chronic diseases: eating patterns, physical activity, and environmental/social determinants of health. Encompasses medical treatment strategies as well as public health and social policy. Represents the ultimate means for reducing the burden of chronic diseases of aging.

2.5 Evidence for Primordial Prevention¶

Once risk factors develop, it is difficult to restore risk to the low level of someone who never developed the risk factor. Time spent with adverse levels of risk factors causes irreversible damage. Example: Individuals with hypertension treated back to optimal levels (<120/<80 mmHg) have lower risk than untreated hypertensives but still have TWICE the risk of cardiovascular events as those who maintained optimal blood pressure without medications. These treated patients have greater left ventricular mass index, worse renal function, and more atherosclerosis/target organ damage that cannot be fully reversed despite efficacious therapy.

2.6 Prevention vs. Screening¶

Prevention strategies should be distinguished from disease-screening strategies. Screening attempts to detect evidence of disease at its earliest stages when treatment is likely more efficacious. Screening can serve prevention by identifying preclinical markers (dyslipidemia, hyperglycemia) associated with elevated disease risk.

3. CARDIOVASCULAR HEALTH METRICS¶

The American Heart Association formally defined 'cardiovascular health' in 2010, updated and expanded in 2022 to Life's Essential 8™. This construct is based on evidence of associations with longevity, disease avoidance, healthy longevity, and quality of life.

3.1 Life's Essential 8 Components¶

Eight metrics define individual or population health status: 1. Diet 2. Physical activity 3. Sleep 4. Nicotine exposure 5. Body mass index 6. Blood lipids 7. Glycemia 8. Blood pressure Each metric is scored on a scale of 0-100 points (higher is better). Overall health is measured as the average of the scores (also 0-100).

3.2 Health Benefits of Higher Scores¶

Higher cardiovascular health scores at ALL ages have been associated with: - Greater longevity - Lower incidence of cardiovascular disease - Lower incidence of other chronic diseases of aging (dementia, cancer, diabetes) - Compression of morbidity - Greater quality of life - Lower health care costs This establishes the critical importance of primordial prevention and health promotion.

4. PRIORITIZING PREVENTION STRATEGIES¶

Different approaches are required for secondary versus primary prevention settings, with attention to patient-specific factors and barriers to implementation.

4.1 Secondary Prevention Approach¶

Patient already has manifest clinical disease and is at high risk for progression. Work with patient to implement ALL evidence-based strategies to prevent recurrence/progression. Typically includes drug therapy AND therapeutic lifestyle changes to control ongoing risk factors. Address potential barriers: costs, time, patient health literacy, patient/caregiver capacity to organize regimen. Only ~50% of patients take recommended secondary prevention medications (e.g., statins) by 1 year after myocardial infarction, even in high-functioning health systems.

4.2 Primary Prevention Approach¶

Frame discussion around overall evidence base AND individual patient's likelihood of benefit. First step: Understand patient's estimated absolute risk for disease in foreseeable future or remaining life span. Absolute risk estimation alone is generally insufficient to motivate behavior change. Assess: Patient's understanding and tolerance of risk, readiness to implement lifestyle changes or adhere to drug therapy, overall preferences regarding drug therapy use.

4.3 Motivational Interviewing and Prioritization¶

Partner with patient through motivational interviewing to select initial approaches. Select an area the patient feels ready to change for better adherence and success. If patient is uncertain, focus on control of risk factors that may lead to most rapid reduction in risk for acute events. Example: Blood pressure is both a chronic risk factor AND an acute trigger for cardiovascular events. If patient has both elevated blood pressure and dyslipidemia, focus initial efforts on blood pressure control. Smoking cessation leads to more rapid reductions in acute event risk than some other lifestyle interventions.

5. PERIODIC HEALTH EVALUATIONS¶

The 'routine annual physical' has become an expected part of primary care practice, but evidence for efficacy in asymptomatic adults unselected for risk factors is mixed.

5.1 Evidence Summary¶

Systematic reviews and meta-analyses consistently show: - NO benefit (and no harm) for total mortality - Heterogeneous data suggesting no benefit for cancer- or cardiovascular-specific mortality - Potential for either benefit or harm depending on number of evaluations and patient-level factors - Sparse data on nonfatal clinical events and morbidity with no large effects apparent

5.2 Benefits of Periodic Evaluations¶

Greater diagnosis of certain conditions (hypertension, dyslipidemia)
Improved delivery of recommended preventive services: - Gynecologic examinations and Papanicolaou smears - Fecal occult blood testing - Cholesterol screening
Associated with less patient worry

5.3 Risks of Periodic Evaluations¶

Inappropriate testing or overtesting
False-positive findings requiring follow-up
Patient worry from false-positive findings

5.4 Recommendations¶

On balance, periodic health evaluations appear reasonable for general populations at average risk for chronic conditions. Routine annual comprehensive physical examinations of asymptomatic adults have very low yield and may take inordinate time. Time may be better spent assessing and counseling on other aspects of health. Evidence-based components should include: - Age-appropriate screening tests for chronic disease and risk factors - Preventive interventions including immunizations and chemoprevention - Preventive counseling The U.S. Preventive Services Task Force publishes the Guide to Clinical Preventive Services with evidence-based recommendations.

6. HEALTHY EATING PATTERNS¶

Adverse behaviors and lifestyles contribute to >75% of premature, preventable deaths and disability. Fewer than 1% of Americans achieve an optimal heart-healthy eating pattern. Despite numerous 'fad' diets, there is remarkable agreement about what constitutes a healthy eating pattern.

Dietary Guidelines for Americans 2020-2025: Guidelines and Key Recommendations¶

Guideline	Key Recommendations
1. Follow a healthy dietary pattern at every life stage	Infants 0-6 months: exclusive human milk or iron-fortified formula; 6-12 months: introduce complementary nutrient-dense foods; ‡12 months: meet nutrient needs, achieve healthy weight, reduce chronic disease risk

Guideline	Key Recommendations
2. Customize food/beverage choices	Reflect personal preferences, cultural traditions, budgetary considerations; framework intended to be customized to individual needs
3. Focus on nutrient-dense foods within calorie limits	Nutrient-dense foods provide vitamins, minerals, health-promoting components with no/little added sugars, saturated fat, sodium
4. Limit added sugars, saturated fat, sodium, alcohol	Meeting food group recommendations fulfills most daily calorie needs and sodium limits with little room for extras

6.1 Core Elements of Healthy Eating¶

Optimal eating patterns consist of: - Whole fruits and vegetables - Whole grains - Lean proteins - Healthy oils - Nonfat or low-fat dairy (allowed) Should exclude frequent ingestion of: - Foods high in refined sugars and starches - Saturated fat - Sodium Simple rule: Provide or cook the majority of meals starting from whole foods, emphasizing fruits and vegetables. Foods prepared outside the home tend to have higher fat and sodium content.

6.2 Key Recommendations from Dietary Guidelines 2020-2025¶

Core dietary elements: - Vegetables of all types (dark green; red and orange; beans, peas, lentils; starchy; others) - Fruits, especially whole fruit - Grains, at least half whole grain - Dairy (fat-free or low-fat milk, yogurt, cheese; lactose-free versions; fortified soy alternatives) - Protein foods (lean meats, poultry, eggs; seafood; beans, peas, lentils; nuts, seeds, soy products) - Oils (vegetable oils and oils in food such as seafood and nuts) Healthy eating pattern limits: - Added sugars: <10% of calories/day starting at age 2; avoid in those <2 years - Saturated fat: <10% of calories/day starting at age 2 - Sodium: <2300 mg/day; even less for children <14 years - Alcohol: ≤ 2 drinks/day for men, ≤ 1 drink/day for women if consumed

6.3 USDA Dietary Patterns¶

USDA guidelines focus on a healthy plate concept (rather than prior food pyramid): - 50% vegetables and whole fruits - Remaining portions for whole grains and lean protein foods - Cook with healthier oils (e.g., canola oil) by sautéing - Add judicious amounts of healthy raw oils (e.g., olive oil, nuts) Three identified patterns: 1. Healthy U.S.-Style Dietary Pattern (closely adheres to DASH) 2. Healthy Mediterranean-Style Dietary Pattern 3. Healthy Vegetarian Dietary Pattern These vary more in emphasis than content and are customizable for cultural/personal preferences.

6.4 Age- and Sex-Specific Recommendations¶

Recommendations are generally similar for all life stages from ≥ 12 months, but caloric intake differs by age, sex, and activity level. - Range: 1000 calories/day (sedentary 2-year-old) to 3200 calories/day (active 16-18-year-old males) - Caloric needs peak in late adolescence/early adulthood - Gradually decrease over ensuing decades

6.5 Counseling Approach¶

Focus on whole foods, eating patterns, and appropriate calorie balance rather than specific micronutrients. Most patients have difficulty understanding nutritional labels (numeracy and health literacy challenges). Use motivational interviewing strategies with shared goals and commitments. Specific conditions (diabetes, hypertension, metabolic disorders, allergies, GI disorders) may require tailored approaches.

7. PHYSICAL ACTIVITY¶

A simple rule for patients: 'If you are doing nothing, do something; and if you are doing something, do more, every day.' The marginal benefits from physical activity are greatest in advancing from no activity to low levels of moderate activity.

Physical Activity Guidelines for Americans (2018) - Summary by Age Group¶

Age Group	Aerobic Activity	Strength/Other Activities
3-5 years	Active throughout the day; variety of activity types	Active play encouraged by caregivers
6-17 years	‡60 min/day moderate-to-vigorous; vigorous ‡3 days/week	Muscle-strengthening ‡3 days/week; Bone-strengthening ‡3 days/week
18-64 years	150-300 min/week moderate OR 75-150 min/week vigorous (or equivalent combination)	Muscle-strengthening ‡2 days/week involving all major muscle groups
‡65 years	Follow adult guidelines or as abilities allow	Multicomponent including balance training, aerobic, muscle-strengthening

Physical Activity Intensity Definitions¶

Intensity Level	Description	Examples
Moderate-intensity	Increases heart rate and breathing to some extent; 5-6 on 0-10 scale relative to capacity	Brisk walking, dancing, swimming, bicycling on level terrain
Vigorous-intensity	Greatly increases heart rate and breathing; 7-8 on 0-10 scale relative to capacity	Jogging, singles tennis, swimming continuous laps, bicycling uphill
Muscle-strengthening	Increases skeletal muscle strength, power, endurance, mass	Strength training, resistance training, muscular endurance exercises
Bone-strengthening	Produces impact or tension force on bones promoting bone growth and strength	Running, jumping rope, lifting weights

7.1 Adult Recommendations (18-64 years)¶

≥ 150 minutes moderate-intensity OR ≥ 75 minutes vigorous-intensity aerobic activity per week - Performed in episodes of at least 5 minutes - Preferably spread throughout the week - Muscle-strengthening activity at least 2 days per week - Additional health benefits with activity beyond these amounts - Move more and sit less throughout the day—some activity is better than none

7.2 Children and Adolescents (6-17 years)¶

≥ 60 minutes of physical activity daily - Most should be moderate- or vigorous-intensity aerobic activity - Include vigorous-intensity physical activity at least 3 days/week - Include muscle-strengthening activity at least 3 days/week - Include bone-strengthening activity at least 3 days/week

7.3 Preschool-Aged Children (3-5 years)¶

Should be physically active throughout the day
Active play with variety of activity types
Enhances growth and development

7.4 Older Adults ( ≥ 65 years)¶

Follow adult guidelines OR be as active as abilities and conditions allow
Multicomponent physical activity including balance training as well as aerobic and muscle-strengthening activities
Determine level of effort relative to level of fitness
Understand how chronic conditions affect ability to exercise safely

7.5 Sedentary Time and Practical Considerations¶

Sedentary time has adverse health consequences independent of lack of physical activity. Modest efforts like standing at desk and gentle stretching during day may be beneficial. Encourage variety of aerobic activities (biking, swimming, walking, jogging, rowing, elliptical, stair-climbing) to avoid overuse injuries and boredom. For resistance training: emphasize body-weight resistance or weights allowing more repetitions (3 sets of 15-20 repetitions with rest periods), avoiding breath-holding and straining against closed glottis.

7.6 Sudden Cardiac Death Risk¶

Risk of sudden death during exercise increases directly with time spent exercising, BUT this association is substantially mitigated by training effects. Patients should increase duration of aerobic exercise gradually as tolerated, aiming for episodes of at least 30 minutes, 5 times per week as ideal. Once comfortable duration is reached, incorporate interval training periods of more intensive activity for greater fitness gains.

7.7 Extreme Endurance Activities¶

Triathlons and marathons should be undertaken only with appropriate graded training. Greater toll on musculoskeletal system over time. Associated with measurable myocardial damage and greater risks for other organ damage. Athletes routinely have elevated cardiac troponin at race end (lower in well-trained). Consider overall health, specific limitations, potential for injury, and ability to train when deciding on participation.

8. SLEEP HYGIENE¶

Sleeping between 7-9 hours per night appears optimal for health in adults ≥ 18 years.

8.1 Consequences of Inadequate Sleep (<7 hours)¶

Adverse outcomes include: - Obesity - Diabetes - Elevated blood pressure - Cardiovascular disease - Depression - All-cause mortality Physiologic disturbances: - Impaired immune function - Increased pain sensitivity - Impaired cognitive performance

8.2 Benefits of Appropriate Sleep¶

More success in weight loss
Better blood pressure control in hypertensive patients
Improved mental health and performance

8.3 Excessive Sleep (>9 hours)¶

Regular sleep >9 hours/night is appropriate for: - Children and adolescents - Individuals recovering from sleep deprivation or illness For most adults, health effects of regular excessive sleep are uncertain.

8.4 Sleep Counseling Strategies¶

With aging, both quantity and quality of sleep tend to decline even without overt sleep disorders. Documentation using a sleep log may help understand different types of insomnia and sleep disorders. Encourage: - Daily activity to promote fatigue - Avoidance of eating and drinking alcohol too close to bedtime - Regular daily sleep habits Discourage regular use of sedative medications due to high potential for dependence, addiction, and altered sleep quality.

8.5 Obstructive Sleep Apnea Screening¶

Prevalence of OSA in general adult population: 9-38%, with higher rates in: - Men vs. women - Older vs. younger adults - Higher vs. lower BMI Worldwide: ~40 million U.S. adults, nearly 1 billion adults globally affected. Screening tools: - Epworth Sleepiness Scale - STOP Questionnaire (Snoring, Tiredness, Observed apnea, high blood Pressure) - STOP-Bang Questionnaire (STOP + BMI, Age, Neck circumference, Gender) USPSTF found insufficient evidence to assess balance of benefits/harms of OSA screening in asymptomatic adults. However, clinicians should be alert for potential OSA, particularly in obese patients with excessive daytime somnolence or witnessed apnea.

9. WEIGHT MANAGEMENT¶

Overweight and obesity are prevalent in epidemic proportions. Since 1985, U.S. obesity prevalence increased from ~10% to ~35%; overweight prevalence is now ~40%.

9.1 Epidemiology and Health Consequences¶

Overweight and obesity disproportionately affect: - Individuals in lower socioeconomic strata - Many underrepresented populations (Black, Latino, American Indian) Associated adverse health consequences: - Diabetes - Certain cancers - Cardiovascular diseases - Degenerative joint disease

9.2 Eating Disorders¶

Anorexia and bulimia are much less common but pose major health consequences. Should be suspected particularly in younger women with: - History of rapid weight shifts - Electrolyte disturbances - Underweight status

9.3 Weight Loss Approach¶

Weight loss is one of the most difficult preventive interventions to achieve and sustain. Key factors: 1. Initial goal: Weight stabilization - Risks of overweight/obesity are driven more strongly by continued weight gain than current status per se - Weight maintenance can be a successful initial step 2. Tools for patients: - Food and weight logs - Activity logs - Smartphone apps 3. Structured approaches (may help some patients): - Intermittent fasting regimens - Commercial dietary programs with provided meals - With or without social group supports

9.4 Key Constructs for Weight Loss¶

Negative calorie balance through: - Reduced caloric intake - Increased physical activity Well-done feeding studies indicate weight loss depends FAR MORE on reduction of caloric intake than on relative composition of fat, protein, and carbohydrate. Encourage patients to find what works for them and document results. Once weight loss is achieved, increased activity is often required for successful maintenance.

9.5 Pharmacologic Options¶

Newer agents (e.g., GLP-1 receptor agonists) appear remarkably successful: - Up to 20% loss of baseline body weight - Proven short-term benefits in cardiovascular risk reduction Remaining issues: - Access - Cost - Long-term safety

10. TOBACCO CESSATION¶

Escaping nicotine dependence is a major but critical challenge. Addictive effects of nicotine can last for years after successful cessation.

10.1 Assessment and Approach¶

Key first steps: - Assess patient's past history of cessation attempts - Assess current readiness for change Critical elements: - Frequent follow-up and reinforcement - Nicotine replacement therapy - Other cessation-promoting medications Recidivism is the rule—patients should expect to resume smoking and attempt again on the journey to cessation.

10.2 Counseling Strategies¶

Enumerating only risks of smoking leads to patient inertia and therapeutic nihilism—this is an ineffective approach. Strategies incorporating positive health messaging, support, feedback, with appropriate use of evidence-based therapies have proven far more effective.

10.3 Electronic Cigarettes and Vaping¶

E-cigarettes have some evidence for benefit in adult cessation of combustible tobacco. Concerns: - May transfer and worsen nicotine addiction - Major public health threat from use by adolescents and young adults who are not smokers - Unknown health consequences from high doses of nicotine to developing organs including brain Vaping of other substances with flavoring compounds has been associated with pulmonary and cardiovascular damage—should be actively discouraged.

11. VACCINATION¶

One of the major advances in public health contributing to increases in health and longevity worldwide. Patients should be counseled regarding age-appropriate vaccinations for children and themselves.

11.1 Addressing Vaccine Hesitancy¶

For reluctant patients: 1. Listen to patient's concerns 2. Explain benefits to individual, family, and community 3. Review low risk for potential harms Key point: No current vaccines are ever worse than the disease they prevent, although side effects may occur rarely. Thorough knowledge of side effect rates and efficacy aids in helping patients make fully informed decisions.

12. MENTAL HEALTH AND ADDICTION SCREENING¶

Assessment for depression, cognitive impairment, and substance use disorders is important when symptoms are present or concerns are expressed.

12.1 Depression and Cognitive Function¶

Both conditions play major roles in reducing quality of life and are high on patients' lists of concerns. Cognitive function decline occurs with aging or comorbid illness including depression. Assessment tools: - General Practitioner Assessment of Cognition - Mini-Cog test (Both are effective rapid assessment tools)

12.2 Alcohol Screening¶

Alcohol dependence and abuse are common and underdiagnosed. CAGE Questionnaire most effective at identifying alcohol abuse and dependence: - Cut down - Annoyed - Guilty - Eye opener Has reasonable sensitivity and high specificity.

12.3 Opioid Screening¶

The current opioid epidemic presents a substantial public health challenge due to high potential for dependency and abuse. Rapid screening tools are available to assist clinicians in screening for opioid dependence.

13. ACCIDENTS AND SUICIDE¶

Regular assessment of patient safety through simple questions remains important for health promotion and wellness.

13.1 Safety Assessment Components¶

Seat belt use
Domestic violence
Gun safety in the home
Suicidal ideation assessment (in patients with depression or history of suicide attempts)

14. APPROACH TO THE PATIENT¶

In clinical visits focused on health assessment, promotion, and prevention, basic skills of history-taking are paramount. Engagement and buy-in from the patient are required for behavior recognition and adherence to therapeutic plans.

14.1 Essential Skills¶

Beyond standard history-taking: - Motivational interviewing - Eliciting patient commitments and contracting New tools (with uncertain implications for future): - Online screening, monitoring, and chronic management tools - Wearable devices - Mobile health technologies Behavioral economics concepts are being explored to better understand psychology of decision-making and incentives for improving lifestyle choices and treatment adherence.

14.2 Prioritization in Wellness Visits¶

Limited time makes prioritization important. Prioritize assessment and counseling for factors affecting: - Longevity - Health span - Quality of life Over low-yield approaches such as annual comprehensive physical examination in asymptomatic patients. Key steps: - Set clear expectations for wellness visit content - Schedule follow-up visits for findings or to continue indicated counseling

15. KEY POINTS & CLINICAL PEARLS¶

Summary of essential clinical concepts for health promotion and prevention.

Clinical Pearls for Health Promotion and Prevention¶

Topic	Key Pearl
Primordial Prevention	Maintaining optimal risk factor levels into middle age essentially abolishes lifetime risk of CVD while extending longevity and compressing morbidity
Treated Hypertension	Patients treated to optimal BP still have 2x CV risk of those who never developed hypertension—emphasizes primordial prevention value
Dietary Counseling	Focus on whole foods, eating patterns, and calorie balance—not specific micronutrients; <1% of Americans achieve optimal heart-healthy eating
Physical Activity	Greatest marginal benefits occur moving from no activity to low levels; 'do something' is the first goal

Topic	Key Pearl
Weight Management	First goal is weight stabilization; caloric reduction more important than macronutrient composition for weight loss
Sleep	Both short (<7 hours) and long (>9 hours) sleep associated with adverse outcomes; 7-9 hours optimal for adults
Smoking Cessation	Positive health messaging more effective than risk enumeration; recidivism is expected—encourage repeated attempts
Secondary Prevention Adherence	Only ~50% of patients take recommended secondary prevention medications 1 year post-MI
Annual Physical	Comprehensive annual physical exam has low yield in asymptomatic adults; time better spent on counseling
Vaccine Counseling	No current vaccine is worse than the disease it prevents; address concerns with data on efficacy and side effect rates