Chapter 2: Promoting Good Health

GOALS AND APPROACHES TO PREVENTION

Prevention of acute and chronic diseases before onset has long been a hallmark of excellent medical practice and is a metric for high-functioning health systems. The ultimate goal of preventive strategies is to avoid premature death. However, with increased longevity worldwide, emphasis has shifted to preserving quality of life and extending the health span, not just life span.

The concept of compression of morbidity aims to reduce disease burden and time spent ill before death. Figure 2-1 shows normative aging with gradual health decline, contrasting with an ideal “squared curve” representing greater longevity with less morbidity until shortly before death.

FIGURE 2-1

Loss of health with aging. The graph contrasts normative health decline with a squared curve showing greater longevity and less morbidity through prevention.

Prevention strategies:

Tertiary prevention: Rapid action to prevent imminent death during acute illness (e.g., PCI for STEMI).
Secondary prevention: Avoids recurrence/death in affected individuals (e.g., tamoxifen after breast cancer surgery).
Primary prevention: Reduces incident disease risk among at-risk individuals (e.g., treating hypertension before cardiovascular disease).
Primordial prevention: Prevents development of risk factors themselves by addressing upstream determinants (e.g., diet, physical activity, social determinants). It is the ultimate means to reduce chronic disease burden.

Primordial prevention emphasizes that once risk factors develop, restoring low risk is difficult due to irreversible damage accrued (e.g., treated hypertension patients still have increased cardiovascular risk compared to those never hypertensive).

Prevention should be distinguished from screening, which detects early disease stages to enable more effective treatment.

HEALTH PROMOTION

Medical practice increasingly focuses on health promotion, which encompasses more than disease prevention. Health is a continuum including biologic, physiologic, and psychological domains, and is somewhat subjective but can be assessed with objective criteria.

The American Heart Association (AHA) defined “cardiovascular health” by seven metrics:

Eating pattern
Physical activity
Smoking status
Body mass index (BMI)
Blood pressure
Blood cholesterol
Blood glucose

Optimal levels of all seven metrics correlate with greater longevity, lower chronic disease incidence, compression of morbidity, and lower healthcare costs.

Focusing on health promotion rather than only disease risk motivates better patient adherence. For example, emphasizing positive health goals over solely enumerating risks (e.g., smoking cessation) is more effective.

PRIORITIZING PREVENTION STRATEGIES

Secondary prevention: Patients with manifest disease require all evidence-based interventions (medications, lifestyle). Barriers like cost and health literacy must be addressed for adherence.
Only about 50% of patients take recommended secondary prevention meds (e.g., statins) one year post-MI.
Primary prevention: Discussions should cover absolute risk, patient understanding, readiness for change, and preferences.
Motivational interviewing and partnering with patients to prioritize achievable goals improve success.
Initial focus may be on risk factors with rapid impact (e.g., blood pressure control, smoking cessation).

PREVENTION AND HEALTH PROMOTION ACROSS THE LIFE COURSE

Periodic Health Evaluations

Routine annual physicals show mixed evidence for mortality benefit.
They improve diagnosis rates of conditions like hypertension and dyslipidemia.
Risks include overtesting and false positives.
Evidence-based components include age-appropriate screening, immunizations, chemoprevention, and counseling.
The U.S. Preventive Services Task Force provides evidence-based recommendations for preventive services.

Healthy Behaviors and Lifestyles

75% of premature deaths relate to adverse behaviors and lifestyles.
Less than 1% of Americans meet optimal heart-healthy eating patterns.
Assessing health behaviors during clinical encounters can itself improve behaviors.
Clinicians must be skilled in lifestyle assessment and counseling.

Healthy Eating Patterns

Consensus exists on healthy diets focusing on whole fruits and vegetables, whole grains, lean proteins, and healthy oils.
Limit foods high in refined sugars, saturated fats, and sodium.
Prefer cooking with whole foods and minimizing processed foods.
Sugar-sweetened beverages and unhealthy snacks should be minimized.
See Table 2-1 for Dietary Guidelines key recommendations.

Physical Activity

Any physical activity is better than none; increase gradually.
Adults: 150 min moderate-intensity or 75 min vigorous-intensity aerobic activity per week + muscle strengthening ≥2 days/week.
Sedentary time independently harms health; break up sitting with light activity.
Variety in aerobic activities prevents boredom and injury.
Sudden cardiac death risk during exercise is low and mitigated by training.
Extreme endurance activities require graded training due to higher musculoskeletal and cardiac risks.
See Table 2-2 for age-specific physical activity recommendations.

Sleep Hygiene

Optimal sleep for adults (≥18 years) is 7–9 hours/night.
<7 hours linked to obesity, diabetes, hypertension, cardiovascular disease, depression, impaired immunity, and cognitive dysfunction.
Over 9 hours may be normal for children or recovery.
Encourage regular sleep habits, activity, and avoid alcohol near bedtime.
Avoid sedatives due to dependence risk.

Weight Management

Obesity prevalence in the US is ~35%, overweight ~40%, disproportionately affecting minority and low socioeconomic groups.
Associated with diabetes, cancers, cardiovascular disease, joint disease.
Weight loss is challenging; early goal is weight stabilization.
Use food and activity logs, apps, and tailored approaches.
Weight loss requires negative calorie balance—reduce intake and/or increase activity.
Diet composition matters less than calorie reduction.
Maintenance requires ongoing activity.

Tobacco Cessation

Nicotine dependence is a major challenge.
Assess cessation history and readiness.
Use frequent follow-up, nicotine replacement, and medications.
Expect relapse; encourage persistence.
E-cigarettes may help adult cessation but pose risks for youth.
Vaping associated with pulmonary and cardiovascular harm.

VACCINATION

Vaccinations against infectious diseases have greatly improved health and longevity.
Counsel patients on age-appropriate vaccines.
Address vaccine hesitancy with clear communication about benefits and low risk.
Vaccines are safer than the diseases they prevent.

MENTAL HEALTH AND ADDICTION

Assess for depression and cognitive impairment when symptoms or concerns arise.
Screening tools are available (see Chap. 452).
Cognitive decline should be anticipated with aging and comorbidities.
Tools like the General Practitioner Assessment of Cognition and Mini-Cog™ aid rapid screening.

Alcohol and Opioids

Alcohol abuse is common but underdiagnosed.
The CAGE questionnaire is effective for screening.
The opioid epidemic presents substantial challenges.
Rapid screening tools assist opioid dependence detection.

ACCIDENTS AND SUICIDE

Regular assessment of patient safety includes questions about seat belt use, domestic violence, and gun safety.
Screening for suicidal ideation remains important in depression or prior attempts.

APPROACH TO THE PATIENT

History-taking remains vital in health promotion and prevention.
Engage patients using motivational interviewing and commitment elicitation.
New technologies (wearables, mobile health) expand tools but require further study.
Limited visit time requires prioritization of high-yield assessments and counseling.
Setting clear visit expectations and follow-up improves outcomes.