Rethinking Prevention
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The document discusses prevention in public health and clinical contexts. It outlines the standard model of primary, secondary, and tertiary prevention. While clinical prevention focuses on high-risk individuals, public health prevention operates at the population level through policies. The document argues that the clinical model is unsustainable when applied to whole populations and that population-based strategies are needed to effectively address modern health challenges like obesity. Prevention requires considering individual and population factors as well as short and long-term impacts.
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Rethinking Prevention
- 1. (c) Jammi N Rao Prevention Time for a rethink Professor Jammi N Rao, FRCP FFPH
- 2. The clinical process • What is wrong with me? – diagnosis • What will happen to me? – prognosis • What can be done about it? – treatment • Why? • What should I have done or not done to prevent it?
- 3. Prevention is better than cure An ounce of prevention is worth a pound of cure A stitch in time saves nine Prevention is folklore It probably helped that ‘treatment’ was both unsafe and ineffective
- 4. The ‘standard model’ Primary Prevention Secondary Prevention Tertiary prevention
- 5. Standard model - examples Infectious disease Stroke I ry Avoid the infectious agent Low salt, exercise, diet II ry Immunise against the virus / bacterium Control cholesterol (Statins) Control blood pressure with drugs III ry Treat the infection to prevent disability or handicap Rehabilitation to restore function
- 6. Similar ideas prevail in industrial safety, e.g. nuclear plants Defence in depth: Engineering designed to stop critical systems from failing in the first place Catch and deal with systems failures before they cause harm Control the consequences of failure Deal with the emergencies that arise when the above fail
- 7. 0.0 2.0 4.0 6.0 8.0 10.0 12.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 160.0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total expenditure As % of GDP Expenditure on UK Health services – total ( £billions) and as proportion iof GDP (%) 1997 to 2010 Source: Office of National Statistics, 2012
- 8. Clinical v Public health model • Operates at level of individual. • Part of a clinical interaction between citizen and member of staff. • Examples: smoking cessation, statins, brief interventions for alcohol, clinical advice on diet and exercise • Operates at level of population. • Implemented as a public policy either by legislative, regulatory or fiscal measure • Examples: ban on smoking, food policy, tax on alcohol, investment in public transport
- 9. Rose’s Prevention paradox The Prevention paradox: an intervention that brings much benefit to the population offers little to each participating individual
- 10. High risk approach • Intervention seems appropriate to individual • High level of motivation for both patient and physisican • Targeted use of resources • Benefit:risk ratio favourable for the individual • Difficulties and costs of screening • Temporary solution not radical • Limited potential for individual and for population • Behaviourally inappropriate Key feature of high risk approach: based on individuals at ‘high risk’ taking certain actions. Pros Cons
- 11. Drawbacks of clinical model applied to whole population • People opt out • Opt outs higher in deprived groups • Unsutainable in the long run because we are for ever catching up • Activity has to be continually ratcheted up • If pharma product based then costs excalate as new products are intorduced.
- 12. Example 1. Diarrheal disease in poor countries • Diarrhoeal disease is the second leading cause of death in children under five years old. It is both preventable and treatable. • Diarrhoeal disease kills 1.5 million children every year. • Globally, there are about two billion cases of diarrhoeal disease every year. • Diarrhoeal disease mainly affects children under two years old. • Diarrhoea is a leading cause of malnutrition in children under five years old.
- 13. 13 / 25
- 16. ‘Shit happens. Like Bazalgette we need to deal with it.’ Mary E Black, Global health doctor, BMJ, 31 March 2012, p 51 If we in the rich world dont have to worry about diarrheal disease it’s because we have implemented a public health model of prevention
- 17. Obesity – an epidemic even on the web
- 18. The rising cost of obesity The rise in admissions with ‘obesity’ as a primary or contributory diagnosis, and the rising cost of drugs used to treat overweight Year from 1999 to 2009
- 20. Diabetes costs (£ billions) will cripple the NHS Type 1 Diabetes Type 2 Diabetes 1 0.9 1.8 2.4 0 1 2 3 4 Current spend 2035 8.8 13 15.1 20.5 0 5 10 15 20 25 30 35 40 Current spend 2035 Indirect costs Direct costs Source: Impact Diabetes Report 25 April 2012, York Health economics Consortium
- 21. screening: to identify people who are overweight/obese or at risk of obesity and assess readiness to change delivering a brief counselling intervention: providing information, increasing motivation to change, or teaching behavioural skills referring to brief intervention: for those at higher risk referral to more intensive treatment: for those at highest risk periodic follow-up: to help patients to track progress and ‘problem-solve’ about barriers which have arisen and how to overcome them. Proposed care pathway for weight management
- 22. London Marathon 1981 - 2003 0 5,000 10,000 15,000 20,000 25,000 30,000 35,000 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 RunnersFinishing 0 10 20 30 40 50 60 70 80 90 100 seeninhospital Seen in hospital, Right hand axis
- 23. Marathon Finishers USA 290000 300000 310000 320000 330000 340000 350000 360000 370000 380000 390000 400000 2000 2001 2002 2003 2004 2005 MarathonFinishersUSA 60 61.25 62.5 63.75 65 Malefinishers% %age Marathon finishers who are male, Rt hand axis
- 24. Private lesiure club membership 3.8 3.6 3.4 2.9 2.4 1.9 1.8 1.7 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 1998 1999 2000 2001 2002 2003 2004 2005 %ageofpopulation Figures are No. of people in millions
- 25. Fitness and Lesiure is a growth industry • Over 2 billion turnover in 2005 • 200,000 employees • Almost 12% of UK population (that’s 7 million people) are gym members • Ave duration of membership: 18 months • Source: FIA, 2005 0 100 200 300 400 500 600 700 2001 2002 2003 2004 UK Sales (£m) Source: ONS
- 26. • Popular interest in sport and fitness has never been higher • More people than ever before are taking part in high performance sporting activity regularly or fairly regularly • People are also spending their own money, buying sports gear or joining gyms • And yet..
- 27. 0 10 20 30 40 50 60 70 New Zealand United Kingdom Iceland Luxembourg ireland Finland Canada Slovak Republic Italy Netherlands Sweden Switzerland 2007 Estimates of Prevalence of Obesity + Overweight, selected OECD Countries
- 28. 36 47 28 36 0 5 10 15 20 25 30 35 40 45 50 2015 2025 Men Women Projected rise in Obesity (BMI > 30) prevalence in UK Source: Tackling Obesity: Future Choices 2nd Ed. , Foresight, Government Office For Science, 2007)
- 29. Obesity among older people Australian data • Older people (55 +) are caught up in obesity epidemic • 3 times as amany obese older people as 20 years ago • Older people now 6-7 Kg heavier than their counterparts 20 years ago • Even 50 and 60 yr olds continue to gain weight into mid-70s
- 30. Population naturally active and hard working Food supply adequate and well distributed No time for sport Population largely inactive, work not physically demanding Over-abundant supply of calorie dense food Relative disinterest in sport High levels of sports and leisure activity uptake Food supply adequate or abundant, but people eat sensibly ‘Fully engaged’ Asymmetric distribution of sport particpation and of physical activity/helath engagement Population segmented in two one in cell C; one in cell B Low Obesity Prevalence Low Sports uptake High Sports uptake High Obesity Prevalence A B C D Explaining the paradox
- 32. TB Mortality – the long view
- 33. There is always an easy solution – neat plausible and wrong H.L Mencken
- 34. Preventive strategies operate in many dimensions • Individual v. Population • Downstream v. Upstream • Immediate v. long term • Passive v. Active • Once only v. Repeated intrventions • Conscious decision v. default choice • Inertia v. self-perpetuating • Single objective v. Multi-Objective
- 35. Tactics without strategy is the noise before defeat
- 36. Thank you
Editor's Notes
- Expenditure on healthcare in the UK (in current prices) totalled £140.8 billion in 2010. This increased by 3.1 per cent, from £136.6 billion in 2009. This was considerably lower than the growth rate in 2009 of 8.8 per cent. These estimates are consistent with international definitions specified by the Organisation for Economic Co-operation and Development (OECD) in A System of Health Accounts (SHA). OECD (2000, 2011a). These data are provided to OECD annually for inclusion in OECD Health Data. This enables OECD to publish international comparisons on a consistent basis. These are total health care expenditure. In 2010 of the total 9.7% of GDP that was spent on healthcare (=140.8 billion), 1.6% was private health care and 8.0 was public i.e. largely NHS. Approximately 16.6 % of healthcare spend is private money. The rest is NHS.
- The figures come from a report of the York health Economics Consortium publioshed 25 April 2012. The press release (http://php.york.ac.uk/inst/yhec/web/news/impact_diabetes_press_release_25_04_12_final.pdf) said 25 April 2012, Guildford, UK – A new report published in the journal Diabetic Medicine has projected that the NHS’s annual spending on diabetes in the UK will increase from £9.8 billion to £16.9 billion over the next 25 years, a rise that means the NHS would be spending 17% of its entire budget on the condition. The Impact Diabetes report1 also suggests that the cost of treating diabetes complications (including kidney failure, nerve damage, stroke, blindness and amputation) is expected to almost double from the current total of £7.7 billion to £13.5 billion by 2035/6. Authored by the York Health Economic Consortium and developed in partnership between Diabetes UK, JDRF and Sanofi Diabetes, the report has highlighted the high percentage (79%) of NHS diabetes spending that goes on complications – many of which are preventable – and speculates that investing in the checks and services that help people manage the condition and therefore reduce risk of complications could actually be less expensive than the current approach. The report quantifies the current costs of direct patient care for diabetes (which includes treatment, intervention and complications) and indirect costs of diabetes, such as those related to increased death and illness, work loss and the need for informal care, and also predicts the UK’s future costs of diabetes. According to the report, the total cost associated with diabetes in the UK currently stands at £23.7 billion and is predicted to rise to £39.8 billion by 2035/6. Barbara Young, Chief Executive of Diabetes UK, said: “This report shows that without urgent action, the already huge sums of money being spent on treating diabetes will rise to unsustainable levels that threaten to bankrupt the NHS. But the most shocking part of this report is the finding that almost four fifths of NHS diabetes spending goes on treating complications that in many cases could have been prevented. The failure to do more to prevent these complications is both a tragedy for the people involved and a damning indictment of the failure to implement the clear and recommended solutions. Unless the Government and the NHS start to show real leadership on this issue, this unfolding public health disaster will only get worse.”
- Executive summary This briefing paper aims to provide a guide to current best available evidence around brief interventions for weight management with adults. ‘Brief interventions’ are interventions that are limited by time and focused on changing behaviour – often to a few minutes per session. The focus of this paper is on face-to-face consultations that are conducted in settings such as primary care. There is good evidence that brief interventions can lead to at least short-term changes in behaviour and body weight if they: • focus on both diet and physical activity • are delivered by practitioners trained in motivational interviewing • incorporate behavioural techniques, especially self-monitoring • are tailored to individual circumstances • encourage the individual or patient to seek support from other people More sustained changes in behaviour and body weight appear to require more intensive interventions conducted over an extended period. Motivational interviewing can be used as part of an initial consultation with a patient. This initial consultation should be used to assess a patient’s weight status and readiness to change behaviour. This, in turn, can help to inform the decision on whether to refer the patient to a more intensive intervention. Behavioural interventions can be undertaken with individuals or with groups and should include self-monitoring to enable patients to recognise progress towards a goal. These should be combined with other strategies such as: providing feedback on progress towards goals; providing regular and long-term follow-up; and improving selfefficacy. It is essential to evaluate the effectiveness of any intervention or service. The National Obesity Observatory’s Standard Evaluation Framework offers guidance on the evaluation of weight management interventions.1 Introduction