(252) Monica project has found little correlation between coronary heart disease mortality and mean level of cholesterol, systolic blood pressure and proportion of smokers. Great difference in coronary heart disease mortality in the French and the British. ?Due to protection of higher wine consumption? Is the French paradox real? (472)
(253) "The fall in smoking prevalence in this country owes more to people giving up the habit than fewer people taking it up." 1 in 4 15 year olds already regular smokers. 450 children start smoking every day. Tobacco industry spends £72 million on advertising in Britain each year. Cigarette smoking makes subarachnoid haemorrhage six times more likely in young smokers and doubles or trebles the chance of female infertility. Parental smoking and asthma and middle ear effusion; allergic diseases during infancy. More girls than boys now smoke, and the prevalence of maternal smoking in pregnancy is high. This results in more miscarriages and cases of premature labour and higher perinatal mortality and has effects extending beyond infancy, with a reduction in growth and educational achievement.
(255) "The SF-36 is a promising new instrument for measuring health perception in a general population. It is easy to use, acceptable to patients, and fulfils stringent criteria of reliability and validity."
(256) "A survey was carried out among 281 men & women aged between 30/64 randomly selected from 5 general practices in Tower Hamlets to determine prevalence of risk factors for coronary heart disease. Smoking & obesity were both more pronounced than in comparable national studies. 51% men, 44% women smokers (57% > 20/day). Body mass index 30 or more in 18% men 10% women, 25 or more 71% men 49% women. 2 or more risk factors for coronary heart disease (smoking, blood pressure, cholesterol) in 25% men 22% women. For every person known by their general practitioner to have established coronary heart disease, there were an additional 2 people at risk on the basis of multiple risk factors."
(257) Costings of running a diabetic clinic (day). Work out at £54.02 per attendance.
(258) "Tamoxifen significantly reduces the serum cholesterol concentration in post menopausal women with breast cancer."
(261) Stopping smoking :- advice only from general practitioner 6% success after 1 year: combined with other components up to 23%.
(262) 10 to 15 mins of general practitioner advice cuts heavy drinkers alcohol consumption by 15% and the proportion of heavy drinkers by 20%. Alcohol is estimated to cause 6% of all deaths in people aged 15-74. Up to one fifth of admissions of men to hospital are alcohol related.
Often patients seek help only when they experience the negative consequences of excessive alcohol use.
(263) Meta-analysis 20 trials. 3grams plus per day of oat soluble fibre can lower cholesterol levels by 0.13-0.16. "The important finding is that soluble fibre has a small but significant cholesterol lowering effect, independent of the effect of a low fat diet." There is no definite amount but regularity is important.
(264) Short account of Sir Richard Doll's life & work. Survey of smoking habits of 34,000 general practitioners over 40 years. Death rate after 20 yrs was 2:1 "I have no doubt that lowering low density lipoprotein is enormously beneficial; everyone ought to do it. I think this is the most important public health issue, one people should be taking very seriously.
"But they are getting confusing messages. A number of people in Britain misunderstand the statistics and the waters have been muddied by a number of incompetent reports. The only way we can get it quite straight is by a large study over a long period. But the only way you can prove that lowering cholesterol reduces heart disease is by means of drugs. It is possible to lower cholesterol by 30% quite easily but it is very expensive and I think the health department is frightened. If you show it is beneficial, everybody will want to have drugs. But there is no other way of getting a clear answer and it is so important to get it clear. You have got to have really large studies to show moderate benefit. Moderate benefit for a common disease is much more important than 100% benefit for something that only affects one person in 10,000."
(265) David Bullock on quality assurance for near patient testing. Discusses importance of Internal Quality Control and External Quality Assessment.
(266) "In the light of the above criticisms, it seems clear that the present wave of idealistic health promotion, both in primary care and through community oriented programmes, must be exposed to thorough scientific, moral and philosophical scepticism. While acknowledging that the traditional view of medicine is both naive and incomplete in itself, and that much of accepted clinical practice has little scientific basis; to embrace the current philosophy of health promotion without serious critical appraisal would be an expensive recipe for disillusion and disaster in the long term."
(267) Negative health - the absence of disease - old fashioned "(a long life expectancy, a low rate of serious disease, a good health service for all the population etc.)"
Positive health - A commodity "fitness" that can be bought and is subject to fashion.
Health promotion perhaps should think about negative health.
"The government, doctors, scientists, health promotion specialists and other such dull professional folk have a duty to promote old fashioned negative health: but they should not make attempts to mount the positive health bandwagon".
(269) "If greater cultural sensitivity could be achieved in health promotion practice, some important areas of conflict could be eased."
"1) The content of health promotion messages could be re-assessed.
2) An easing of the stark official division between spheres open or closed to human control and a greater institutional interest in collective as well as individual action could be productive."
(270) Distinction between Health Promotion and the Management of illness and disease. "The major duty of a general practitioner is to react appropriately to a patient's actual problems. Proactive interventions such as health checks, screening for early disease and unsolicited advice ought to take second place, and only then if underpinned by proper sociological and psychological techniques.".
(271) "The importance of the data presented is to emphasise that the real work in cardiovascular disease prevention is not in screening but in providing and sustaining follow up. The major failing of health checks has been to confuse the process of screening with that of intervention and follow up. It is time that these two processes were separately identified so that it becomes clear to all concerned that identifying risk does not necessarily reduce it."
(272) Analysis of 5 major intervention trials involving dietary advice given to individual subjects and involving a step one diet showed a serum cholesterol reduction of only 2%. Difference in response between men and women to intervention. Women cholesterol dropped by 0.5%, men by 3%.
(273) Families given dietary advice. Women cholesterol rose by 1% and men dropped by 5.5%.
(274) Positive correlation between dietary intake of saturated fatty acids and total cholesterol in men, but not in women.
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(275) National Heart Blood and Lung Institute of USA. Cardiovascular risk and indeed overall mortality risk in women is not associated with high cholesterol levels..
(276) Guidelines for cholesterol testing in community pharmacies.
(277) Multiple Risk Factor Intervention Trial low risk group with no coronary heart disease risk factors who had 19% lower risk of developing coronary heart disease, 30% lower risk of cancer and 54% reduced overall mortality.
Coronary heart disease risk reduced by 20-30% with 10% reduction in serum cholesterol, by 10-15% with a 5-6 mm reduction in diastolic blood pressureBP and by 50-70% with smoking cessation.
Patients who have had a myocardial infarct will benefit most from a reduction in coronary heart disease risk factors.
Many lipid specialists express frustration at the slow uptake of cholesterol testing in the United Kingdom.
(278) News item in British Medical Journal. Richard Doll quoted
Numbers of people out of 200 living to be 90
|Heavy 35 year smokers||3|
--- Pantox Labs (United States) offers serum testing facility that can diagnose patients at high risk of coronary heart disease. Samples sent to San Diego and analysed for lipid soluble anti-oxidants, water soluble anti-oxidants, iron status, lipid status, albumin, glucose and gamma-glutamyl-transpeptidase. Joel Huizenga.
(279) Cholesterol screening in young adults should be limited to those with coronary heart disease or other unusual factors which place them at high short term risk of death from coronary heart disease. Middle aged men involved in primary prevention trials of cholesterol interventions have an increased risk of non coronary heart disease death.
(284) Near patient testing in general practice is not as cost effective as it should be.
(285) In general practice cholesterol testing shows a bias of +8% and an imprecision of 7%.
(288) 25,000 men and 25,000 women followed over 15 years. The role of triglycerides in predicting coronary heart disease not yet established. Raised triglycerides came out as an independent risk factor in women but not in men. Other risk factors (total cholesterol, systolic blood pressure, smoking, age) equal relative strength between men and women. Total mortality in women also related to raised triglycerides.
*** Drugs which induce liver enzymes and may therefore affect gamma-glutamyl-transpeptidase
(290) "If doctors say something about cessation, however brief, to their smoking patients a small, but often significant, number of these will go on to quit compared with those with whom the subject has been avoided."
"More needs to be done to show doctors that, although their success rate with individual patients may be small, it is important in public health terms."
(291) The gamma-glutamyl-transpeptidase level is raised in 80% of problem drinkers. The heavier the drinking the higher the level.
(292) Early detection and counselling of hazardous drinkers works. Consumption reduced one year later.
(293) A third of drivers arrested for driving under the influence have a raised gamma-glutamyl-transpeptidase.
(294) Safe levels of 21/14 units per week. Hazardous 21-49/14-35
Dangerous above this.
Average consumption per adult over 15 in Great Britain in 1983 equivalent to 9 litres of absolute alcohol. 1860-1890 it was 10 litres. Declined to early thirties at 4 litres. Slow increase to fifties and now a more rapid increase. (France was 22 litres in 1950).
**** Jellinek's Formula R(PD)/K D = Number of deaths from cirrhosis of the liver P = % of such deaths due to alcohol K = % of all alcoholics with complications who die with cirrhosis R is the ratio of all alcoholics to alcoholics with complications Based on this formula in 1951 World Health Organisation calculated there to be 350,000 alcoholics in England and Wales. The formula is no longer used.
(295) Risk factors not a useful screening test - too many false positives and negatives. If measures to be taken by positives would benefit everybody why bother to discriminate? Policy should be to lower the risk factors in the population.
(296) A meta analysis of the NHLBI, CLAS, POSCH, FATS, UCSF and STARS controlled trials. "Lipid-lowering therapy has consistently produced an angiographic improvement in coronary artery disease, but it is impossible to be certain that this was true shrinkage of plaque, or that the results were not biased by the variability of the technique." "Treatment of asymptomatic patients with elevated cholesterol levels in GP may not produce any substantial regression of atheroma, although the rate of atheroma formation should decline."
(297) Ref Cholestech (C)
"In the United States Cholestech is focusing on the corporate wellness market, since there is a growing number of companies, adding on-site fitness centres and offering health promotion activities, such as cholesterol and glucose screening in an attempt to lower medical costs and have a healthier and more efficient work-force."
"Heart disease is the number one killer of American adults, with more than 1.25 million suffering heart attacks at a cost of $50bn. a year. Over half the adult population has a high or borderline cholesterol. Many others are at risk due to low levels of high density lipids."
"Cholestech have recognised the aggressive action many companies have taken to improve the health of their employees. Driven by the desire for a fitter and therefore more efficient work force and the need to lower medical costs, work site health promotion and disease prevention have grown rapidly over the past decade."
"Preventative medicine, specifically screening tests and changes in lifestyle could reduce the risk of premature death while greatly improving the quality of life. Corporations realised that healthcare costs would go down as a consequence of they helping their employees to live healthy lives. Results would also include a more vibrant work force with less absenteeism, improved morale and heightened productivity."
"It is known that screening tests on healthy young people can predict whether they are at risk of developing disease in their middle years. One such study showed that in healthy young men (mean age 22 years) the level of total cholesterol was a strong predictor of cardiovascular disease in mid-life."
(298) Prospective BUPA study. The association between serum cholesterol and ischaemic heart disease is 50% greater than has been directly observed.
(299) Corrects the 10 largest cohort studies and shows that cholesterol reduction of 0.6mmol/l (about 10%) will reduce long term mortality from ischaemic heart disease by about:-
|50%||at age 40|
|40%||at age 50|
|30%||at age 60|
|20%||at age 70|
(300) No evidence that cholesterol reduction is harmful to health. The evidence for the efficacy and safety of lowering cholesterol in Western populations is substantial.
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