Reckless commendably suggests that the current model for primary
prevention of cardiovascular disease in the UK is not necessarily the
right one or the only one. [1] However he then writes a thoughtful
editorial predominantly about secondary prevention and treatment.
In pathological and public health terms it is not correct to label
'diseases' such as hypertension, hypercholesterolaemia, obesity and Type 2
diabetes as the true primary causes of cardiovascular disease. Physical
inactivity, smoking and diet are the key modifiable 'vital signs' of most
modern non-communicable diseases and are responsible for the vast majority
of the aforementioned diseases over time. [2,3]
Headlines for primary prevention must focus on changing these primary
modifiable 'vital signs', for it is these that will always reap the
greatest health and financial rewards. [4] Medical education and research
principally focuses on 'treating' disease, rather than promoting health.
Consequently, too many doctors fail to understand the basis and potential
benefits of preventive medicine in its true wisdom. Improved education,
awareness and the application of evidence based behaviour change
techniques can achieve similar concordance and better morbidity and
mortality outcomes, than the consumption of prescribed medications, and
have numerous positive outcomes for patient and society, with hardly any
risks. [5] It is important to note that in the Diabetes Prevention
Program, lifestyle intervention was about twice as effective as a drug in
preventing diabetes in a high risk population. [6] It also is possible to
deliver highly effective behavioural lifestyle interventions through
clinical practice, and at a much lower cost per quality adjusted life
years, than can be achieved by prescribing drugs. [7] As Aristotle wrote
'if you would understand anything, observe its beginning and its
development.'
1. Reckless J. Primary prevention of cardiovascular disease. BMJ
2011; 2011; 342:d201
2. Blair SN. Physical inactivity: the biggest public health problem
of the 21st century. Br J Sports Med. 2009 Jan;43(1):1-2
3. Powell KE, Blair SN. The public health burden of sedentary living
habits: theoretical but realistic estimates. Med Sci Sports Exerc
1994;26:851-6
5. Stamatakis E, Weiler R. Prevention of cardiovascular disease: why
do we neglect the most potent intervention? Heart. 2010 Feb;96(4):261-2
6. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM,
Walker EA, Nathan DM; Diabetes Prevention Program Research Group.
Reduction in the incidence of type 2 diabetes with lifestyle intervention
or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403
7. Herman WH, Hoerger TJ, Brandle M, Hicks K, Sorensen S, Zhang P,
Hamman RF, Ackermann RT, Engelgau MM, Ratner RE; Diabetes Prevention
Program Research Group. The cost-effectiveness of lifestyle modification
or metformin in preventing type 2 diabetes in adults with impaired glucose
tolerance. Ann Intern Med. 2005 Mar 1;142(5):323-32
Competing interests:
SB serves on the scientific or medical advisory boards of Alere, Jenny Craig, and Technogym and has received consultation fees for these services. He also has received research funding from the US National Institutes of Health, Body Media, Coca Cola, and the US Department of Defense.
26 January 2011
Richard Weiler
Specialist Registrar in Sport and Exercise Medicine and General Practitioner
Rapid Response:
What is primary prevention?
Reckless commendably suggests that the current model for primary
prevention of cardiovascular disease in the UK is not necessarily the
right one or the only one. [1] However he then writes a thoughtful
editorial predominantly about secondary prevention and treatment.
In pathological and public health terms it is not correct to label
'diseases' such as hypertension, hypercholesterolaemia, obesity and Type 2
diabetes as the true primary causes of cardiovascular disease. Physical
inactivity, smoking and diet are the key modifiable 'vital signs' of most
modern non-communicable diseases and are responsible for the vast majority
of the aforementioned diseases over time. [2,3]
Headlines for primary prevention must focus on changing these primary
modifiable 'vital signs', for it is these that will always reap the
greatest health and financial rewards. [4] Medical education and research
principally focuses on 'treating' disease, rather than promoting health.
Consequently, too many doctors fail to understand the basis and potential
benefits of preventive medicine in its true wisdom. Improved education,
awareness and the application of evidence based behaviour change
techniques can achieve similar concordance and better morbidity and
mortality outcomes, than the consumption of prescribed medications, and
have numerous positive outcomes for patient and society, with hardly any
risks. [5] It is important to note that in the Diabetes Prevention
Program, lifestyle intervention was about twice as effective as a drug in
preventing diabetes in a high risk population. [6] It also is possible to
deliver highly effective behavioural lifestyle interventions through
clinical practice, and at a much lower cost per quality adjusted life
years, than can be achieved by prescribing drugs. [7] As Aristotle wrote
'if you would understand anything, observe its beginning and its
development.'
1. Reckless J. Primary prevention of cardiovascular disease. BMJ
2011; 2011; 342:d201
2. Blair SN. Physical inactivity: the biggest public health problem
of the 21st century. Br J Sports Med. 2009 Jan;43(1):1-2
3. Powell KE, Blair SN. The public health burden of sedentary living
habits: theoretical but realistic estimates. Med Sci Sports Exerc
1994;26:851-6
4. Chief Medical Officer. On the state of the public health. Annual
report of the chief medical officer 2009.
www.dh.gov.uk/en/Publicationsandstatistics/Publications/AnnualReports/DH...
5. Stamatakis E, Weiler R. Prevention of cardiovascular disease: why
do we neglect the most potent intervention? Heart. 2010 Feb;96(4):261-2
6. Knowler WC, Barrett-Connor E, Fowler SE, Hamman RF, Lachin JM,
Walker EA, Nathan DM; Diabetes Prevention Program Research Group.
Reduction in the incidence of type 2 diabetes with lifestyle intervention
or metformin. N Engl J Med. 2002 Feb 7;346(6):393-403
7. Herman WH, Hoerger TJ, Brandle M, Hicks K, Sorensen S, Zhang P,
Hamman RF, Ackermann RT, Engelgau MM, Ratner RE; Diabetes Prevention
Program Research Group. The cost-effectiveness of lifestyle modification
or metformin in preventing type 2 diabetes in adults with impaired glucose
tolerance. Ann Intern Med. 2005 Mar 1;142(5):323-32
Competing interests: SB serves on the scientific or medical advisory boards of Alere, Jenny Craig, and Technogym and has received consultation fees for these services. He also has received research funding from the US National Institutes of Health, Body Media, Coca Cola, and the US Department of Defense.