I know someone, Jane, who goes to the doctor all the time. She has every ache, bump, rash or other symptom seen by a physician, usually a specialist. Jane often starts a statement with “my (insert a specialist type like orthopedic surgeon) says….” She is vigilant about regular check-ups and timely screening tests, which in her mind means she is practicing prudent prevention.
The media (and discussions of healthcare reform), often limit their discussions of prevention to activities like check-ups and screening tests. A recent White House stakeholder’s meeting included suggestions from physicians such as: “the best prevention is providing people with health insurance,” and that “employers allot a certain number of hours for regular preventative check-ups” (1). So, it’s no surprise that Jane feels this way. She checks and monitors everything (a lot), so that means she is health-conscious.
But, there is more to the story. Jane eats a high-fat, high-sugar diet, does not exercise regularly, she is quite overweight, and takes several medications to manage several chronic issues.
Which set of behaviors will protect her most: her medical care-seeking behaviors, or her own lifestyle? It’s not an either-or proposition. What shape you are in when you arrive at the doctor’s office helps determine how helpful the medical system will be.
Let’s also make a distinction: finding a disease is different than avoiding it. Screening tests—mammograms, blood glucose and cholesterol tests, colonoscopies, etc.,—are methods of early detection. They find problems that already exist sooner. They don’t PREVENT that problem from happening; finding out only prevents a WORSE problem IF you do something with the results. What is important to realize is that there is a lot you can do besides get more medicine.
In the case of high blood pressure or high cholesterol, tests that FIND the problem are not preventive; it means the problem is already there. Then, some sort of action is required to deal with the problem, usually medicines or procedures. Some insurance rules designate medications that TREAT these issues as “preventive,” because they are meant to prevent a future heart attack or stroke (referred to as “secondary prevention”). But, in reality, the problem has already begun.
It is also important to remember that the primary value of early detection is increased survival, not cost reduction. If we catch cancer before it spreads, the person with cancer survives longer on average. If it is found early enough, MAYBE it saves money; but often early stage cancers must be treated aggressively (expensively) to have the best chance of cure. For this reason, early detection should not be considered a pathway to significant cost savings.
But comprehensive reviews of prevention and early detection show that lifestyle, specifically body weight and smoking, far outweighs (pun intended) screening in the avoidance of both costs and premature death (2).
So where does prevention really start?
To me, the first and best steps of prevention are those that prevent the very first problem in a chain of events. These consist of measures that avoid a disease all together.
In public health, this comes in the form of water treatment and sanitation, fluoridation of water, food safety rules, iodine in salt, and vitamin D in milk. In the medical arena, these measures include immunizations, hand-washing, sterilization of equipment, and vitamins during pregnancy.
When you think about it, avoiding unnecessary contact with the medical system, where one experiences some inherent risk, can also be preventive. For example, x-rays and CT scans expose us to radiation that carries a small risk for cancer, and almost all medications carry risk of creating other problems; just listen to lists of possible side-effects given on television advertisements!
Like it or not, we individually have the greatest power in prevention. How we live our lives can prevent more diseases or injuries than any after-the-fact treatment. We all know the way to actually prevent most instances of high blood pressure, diabetes, and high cholesterol is to eat right, don’t use tobacco, exercise, maintain a healthy weight, and manage stress.
One statistic we don’t hear frequently enough is that NO heart attack has ever been documented in a person with who has a total cholesterol reading under 150 (3). Although cholesterol is partly determined by genetics, a great deal is determined by lifestyle. A high-vegetable, low-animal-fat diet, combined with regular exercise and weight maintenance will help most of us, if we are willing to make the effort.
It is also true that people who have pre-diabetes (elevated blood glucose, which can be found in blood screening tests) will reduce their likelihood of getting diabetes by about 60% if they exercise and lose a little bit of weight. If they take a common medication instead, they will only decrease their risk of diabetes half as much (4). It’s just another example of what we can do for ourselves.
What are the first steps in prevention?
Things we can do ourselves, like not taking excess risks, not drinking and driving, wearing helmets when bike riding.
To be clear, early detection can be life-saving. Many screening tests are strongly recommended (5) and useful in improving our survival. Awareness can encourage us to take healthier actions. Finding pre-cancerous skin spots, for example, can prevent progression to more serious disease.
So yes, early detection has its rightful place in high-quality care.
But we mustn’t fool ourselves into thinking these tests can in some way be substituted for everyday behaviors that help us protect ourselves. The goal is to avoid the FIRST issue so we don’t have to prevent the subsequent chain of potential consequences. Getting regular screenings to find problems sooner, but NOT taking control of our own habits, can only get us so far. The medical system may be full of great tools, but we want to avoid needing them for as long as possible.
Why this matters: In many instances early detection has great value, but it isn’t a guaranteed pathway to cost reduction. Early detection finds the first problem, after which we must take action to prevent the next one. Too often we perpetuate the idea that medical treatment is a primary pathway to better health, when we would be better served by emphasizing the opposite. Medical treatment is what we get AFTER a problem develops; NOT needing medical care is what we should strive for. What we do every day—eating, sleeping, living actively—gives us the best chance of delaying the need for medicine for as long as possible.
1. Lee J. Streamed and Interactive at 2:30: Health Reform Stakeholder Meeting with Physicians. The White House Briefing Room Blog; June 18, 2009: Accessed July 30, 2009
2. DeVol R, Bedroussian A, et al. An Unhealthy America: The Economic Burden of Chronic Disease. Milken Institute; July 2007. Accessed July 30, 2009.
3. Springer I. Dr. William Castelli: A Pioneer Speaks Out! Coronary Health Improvement Project. Accessed July 30, 2009.
4. Knowler WC, Barrett-Connor E, Fowler SE, et al. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N England J Med. 2002;346:393-403: Accessed July 30, 2009.
5. U.S. Department of Health & Human Services Agency for Healthcare Research & Quality. Preventive Services Recommendations. Accessed July 30, 2009.