A culture of alcohol, blue cheese and wings, cigarettes, and destructive diet

Western New York is notorious for poor healthcare statistics which include an incidence of stroke 25% higher than the national rate and 33% more heart disease death than the US average.

As a practicing internist in Western New York, I attribute this to the “ABCDs”—alcohol, blue cheese and Buffalo wings, cigarettes, and destructive dietary habits—coupled with environmental and socio-economic factors.

Western New York residents must take measures to ensure they preserve the integrity of their overall health. There are positive “ABCDs” that can help people achieve healthier lifestyles. These include activity, blood pressure monitoring, cholesterol and cancer screening, and dietary improvements.

There continues to be controversy pertaining to how often a patient should visit their primary care physician and have preventive screening tests. Only 58 percent of Western New York residents (compared to 75 percent nationally) report visiting their doctors routinely to have their blood pressure and cholesterol checked.

Quality healthcare involves two key components: appropriate preventive screening to avoid future health problems and treatment for current medical illnesses. The dilemma for physicians is to help their patients prioritize and obtain the many preventive tests and services that are currently available. This can be done during the patient’s annual physical exam or during a routine “check up” visit. Prevention should be the focus at nearly every visit, so that the patient is always receiving a continuous health maintenance evaluation.

Unfortunately choosing the right preventive screening test is complicated by the discordance and lack of agreement between different health organizations, i.e., the American Cancer Society (ACS) and the United States Preventive Services Task Force (USPSTF). The other controversy is whether the benefits of screening outweigh the risks of the test. This is where the primary care doctor plays a pivotal role, providing an unbiased opinion and helping to meet the specific needs of the patient.

Cancer screening

The WHO (World Health Organization) has stated that more than 30 percent of cancer deaths are preventable. Considering that cancer is about to replace heart disease as the leading cause of death worldwide, the importance of appropriate cancer screening cannot be overstated. However, not all cancers have been shown to benefit from early screening. For example, lung cancer is the most common cause of cancer-related death in men and women. However, evidence is lacking regarding the benefit of screening for lung cancer (i.e., with a CXR) and definitive screening guidelines have not been established.

Screening has definitely been shown to be beneficial in the detection of three cancers—breast, cervix, and colon cancer.

As per the updated guidelines from USPSTF, all women should have mammograms starting at age 50, with a repeat study every two years. The ACS recommends screening every year starting at 40. A decision to start screening at an earlier age should be individualized based on specific risk factors and the use of other modalities (i.e., MRI and/or genetic testing) may be warranted.

For cervical cancer screening, PAP smears starting at age 21 or within three years of sexual activity with repeat every three years is recommended. Screening may be discontinued at 65 provided adequate screening was performed and the patient is not at high risk for cervical cancer. Incidentally, PAP smear screening has been shown to provide the most cost benefit of all forms of cancer screening.

Screening for colorectal cancer should be initiated at age 50 and earlier for those with increased risk. It should be repeated every 10 years provided there are no additional risk factors and the procedure does not reveal precancerous polyps.

Screening for prostate cancer (the second leading cause of death in men) has also been debated. While the ACS and AUA (American Urological Association) recommends screening for prostate cancer, the USPSTF does not recommend routinely screening all men. Annual prostate exams with testing for PSA (Prostatic Specific Antigen) should be performed starting at age 50. For high risk patients (African American and those with a strong family history) screening should be performed earlier. However, there is no definitive evidence to decide if the potential benefits of screening outweigh the potential risks. The decision should be individualized based on risk factors and patient preferences.

Primary prevention

Apart from cancer screening, additional preventive measures include screening for hypertension, high cholesterol, diabetes, depression, osteoporosis, and vitamin D deficiency.

Screening for hypertension (HTN) should be performed for adults 18 and older annually. Screening for cholesterol should be performed starting at age 35 in men and age 45 in women, provided that there are no additional risk factors for coronary heart disease (CHD) i.e., smoking, obesity, HTN, or diabetes. For males and females with high risk of CHD, screening for cholesterol should begin at 20.

The ADA (American Diabetes Association) recommends screening for diabetes at three-year intervals beginning at age 45. However, testing should be considered at an earlier age or be carried out more frequently in those patients who are overweight and have other risk factors for diabetes, i.e., HTN, family history, and elevated triglycerides. Hemoglobin A1C can now be used for diabetic screening instead of a fasting blood sugar.

Screening for depression should be performed in adults 18 and over, particularly in those patients with psychiatric disorders, chronic medical illnesses and family history of depression. Considering the high prevalence of vitamin D deficiency due to a lack of adequate sunlight exposure, screening for vitamin D deficiency should be an integral part of primary prevention in Western New York as most patients end up needing supplementation.

Women and men aged 65 and older should be routinely screened for low bone mineral density using a DEXA scan. However, screening should be started at age 60 or earlier if the patient is considered at increased risk for fractures. Body weight of less than 154 pounds is considered the most powerful predictor for osteoporosis.

Behavior and lifestyle modification

Screening for obesity, counseling about physical activity and lifestyle modifications (i.e., smoking cessation and moderate alcohol intake) are equally important in the primary care setting. These changes complement pharmacological interventions by the physician for diseases such as HTN, elevated cholesterol, and diabetes.

To easily understand the core measures involved in preventive screening, please cut out the list below and discuss it with your doctor at your next visit.