The most fundamental sources of health are food, the environment, and behavior. Whereas public health managers are concerned with the availability of healthy food and the safety of the environment for the population (see Section 4), this chapter and Chapter 16 explore how preventive medicine clinicians can intervene with individual patients for better health. Here we discuss primary prevention of disease through general health promotion and specific protection. General health promotion by preventive medicine practitioners requires effective counseling driven by theories of behavior change. Chapters 16 and 17 discuss secondary and tertiary prevention for the general population. Chapters 18 to 23 discuss clinical prevention specific diseases for particular populations.

I Society’s Contribution to Health

In addition to the sometimes profound effects of genetics, the most fundamental sources of health do not come from access to the health care system, but rather from the following ^1,²:

1. Adequate healthy food

2. A clean and safe environment

3. Prudent behavior

The health care system is of vital importance when it comes to treating disease (and injury), but all of society, and personal actions, provide the basic structure for these three sources of health. Examples for societal sources of health include socioeconomic conditions, opportunities for safe employment, environmental systems (e.g., water supply, sewage disposal), and the regulation of the environment, commerce, and public safety. Society also helps to sustain social support systems (e.g., families, neighborhoods) that are fundamental to health and facilitate healthful behaviors.³

Because socioeconomic and other conditions vary greatly from country to country and over time, health problems and the success of health promotion efforts also vary. For example, wartime conditions in Sudan (1998) precluded adequate nutrition and medical assistance, and even international relief efforts were hindered. Immediately after the chemical disaster in Bhopal, India (1984), or the radiation disaster in Chernobyl, Ukraine (1986), it was impossible for people in the immediate area to find an environment safe from these toxic exposures. In both cases the toxic effects were spread rapidly by wind, and there were no effective evacuation plans. Natural disasters, such as tsunamis (Indian Ocean, 2004), earthquakes (Haiti, 2010), or both (Japan, 2011), may create conditions such as damaged roads and transportation systems that hinder quick and effective responses.

Even in reasonably ordered societies, income must be sufficient to allow for adequate nutrition and a safe environment for individuals and families. Education enhances employment opportunities and helps people understand the forces that promote good health. Coordinated systems of resource distribution are needed to avoid disparities and deprivation that compromise health. A landmark study among British civil servants showed that lower socioeconomic status correlates with poorer health, regardless of the country studied.⁴ This trend applies not only to direct measures of health or lack of health (e.g., death rates), but also to nutrition, health behaviors, fertility, and mental health.⁵ Debate continues about what factors to consider in defining socioeconomic groups. In the 1990s, using educational background as a measure of socioeconomic status, investigators showed that disparities between socioeconomic groups in the United States persisted.⁶ Currently, U.S. statistics are stratified by educational attainment and sometimes by income level or poverty status, but not by a comprehensive measure of socioeconomic status. It is becoming increasingly clear that unhealthy lifestyles and access to medical care explain only some of the socioeconomic differences observed in the United Kingdom and the United States.⁷

Once people have access to adequate nutrition, clean water, and a safe environment, behavior becomes the major determining factor for health (see Chapters 20 and 21). Genetic makeup and behavior also interact; people’s genes may increase their risk of developing certain diseases. However, it is their behavior that can hasten, prevent, or delay the onset of such diseases.

II General Health Promotion

The World Health Organization (WHO) defines health promotion as “the process of enabling people to increase control over their health and its determinants, and thereby improve their health.”⁸ It is customary to distinguish general health promotion from specific health protection. General health promotion addresses the underpinnings of general health, especially the following six suggested health behaviors⁹:

Specific health protection activities such as vaccines, antimicrobial drugs, and nutritional interventions are aimed at preventing specific diseases.

III Behavioral Factors in Health Promotion

Human behavior is fundamental to health. The actual, primary causes of death in the United States and most other countries involve modifiable lifestyle behaviors: cigarette smoking, poor diet, and lack of exercise.² Therefore, efforts to change patients’ behavior can have a powerful impact on their short-term and long-term health. Clinicians may not be aware of individual behavioral choices made by their patients, and if they are aware, they may not feel comfortable in trying to influence patient choices. Clinicians may also be more likely to counsel patients regarding topics with clear scientific support, such as nutrition and exercise, or that require medical techniques, such as screening or family planning. They are more likely to counsel patients when they discover definite risk factors for disease, such as obesity, hypertension, elevated cholesterol levels, or unprotected sexual activity.

An important window of opportunity for counseling occurs after the development of symptomatic disease, such as an acute myocardial infarction, when a patient’s motivation to modify diet, begin exercising regularly, and quit smoking may be at its peak (“teachable moment”). Another situation in which many patients are open to behavior change is pregnancy.

Boxes 15-1 and 15-2 provide specific recommendations for promoting a healthy diet and for smoking cessation. The most recent U.S. Preventive Services Task Force report offers recommendations for clinician counseling on a variety of additional topics, including motor vehicle, household, and recreational injury prevention; youth violence; sexually transmitted diseases; unintended pregnancy; gynecologic cancer; low back pain; and dental/periodontal disease.¹⁰

Box 15-1 Health-Promoting Dietary Guidelines

In the past, various expert panels and organizations have recommended different types of diets for the prevention of particular diseases. These individual disease-preventing diets have largely been supplanted by one health-promoting diet designed to prevent multiple diseases by enhancing health. Dietary guidelines generated by the U.S. Department of Agriculture, American Heart Association, American Cancer Society, National Cancer Institute, and Institute of Medicine differ only in minor points, whereas all support the goal of maintaining and promoting health by engaging in regular physical activity; eating appropriately sized portions of food; limiting the intake of saturated and trans fats; and eating relatively generous amounts of whole grains, vegetables, and fruits. Also encouraged is the inclusion of healthful polyunsaturated and monounsaturated fats from such sources as nuts, seeds, olives, avocado, and olive and canola oils. Recommended intake ranges for the major nutrient classes—carbohydrate, fat, and protein—are provided by the Food and Nutrition Board of the Institute of Medicine at the National Academy of Sciences.

With regard to macronutrient distribution, the Institute of Medicine guidelines call for 20% to 35% of total calories from total fat, 45% to 65% from carbohydrates, and 10% to 35% from proteins. The guidelines further emphasize the restriction of saturated and trans fat and their replacement with monounsaturated and polyunsaturated fat. Processed foods should be eaten sparingly. Alcohol consumption should be modest, with ethanol levels not exceeding 15 g/day for women or 30 g/day for men (one drink for women or two drinks for men).*

See these websites:

http://www.iom.edu/About-IOM/Leadership-Staff/Boards/Food-and-Nutrition-Board.aspx

http://www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/ExecSumm.pdf

http://www.choosemyplate.gov/

http://fnic.nal.usda.gov/nal_display/index.php?info_center=4&tax_level=3&tax_subject=256&topic_id=1342&level3_id=5140

From Otten JJ, Hellwig JP, Meyers LD, editors: Dietary reference intakes: the essential guide to nutrient requirements, Institute of Medicine of the National Academies, Washington, DC, 2006, National Academies Press.

^*Katz DL: Nutrition in clinical practice, Philadelphia, 2008, Lippincott, Williams & Wilkins.

Box 15-2 The Five “A”s Model for Facilitating Smoking Cessation, with Implementation Suggestions *

1. Ask about tobacco use during every office visit.

Include questions about tobacco use when assessing the patient’s vital signs. Placing tobacco-use status stickers on patient charts, noting tobacco use in electronic medical records, or using computer reminder systems also may be helpful.

2. Advise all smokers to quit.

Advice should be:

Clear: “I think it is important for you to quit smoking now. Cutting down or changing to light cigarettes is not enough.”

Strong: “As your physician, I need to tell you that smoking cessation is one of the most important decisions you can make for your health.”

Personalized: Physicians should talk with patients about how smoking has affected their health, children, or other family members; the social and economic costs of smoking; and the patient’s readiness to quit.

3. Assess the patient’s willingness to quit.

Assess the patient’s willingness to quit by asking, “On a scale from 0 to 10, with 0 being ‘not at all motivated’ and 10 being ‘extremely motivated,’ how motivated are you to quit smoking?” Use the patient’s level of motivation to determine the next step:

If the patient is willing to make a quit attempt, offer medication, brief counseling, and self-help resources and schedule a follow-up visit.

If the patient is unwilling to quit, identify why the patient is not motivated. Explore what he or she likes and does not like about smoking and the potential advantages and disadvantages of quitting. Identify the patient’s core values (e.g., health, being a role model for children) and how smoking affects these values.

4. Assist the patient in his or her attempt to quit.

Help the patient make a quit plan:

Set a quit date, ideally within 2 weeks of the office visit.

Request encouragement and support from family and friends.

Anticipate triggers and cues to smoking, and identify alternative coping strategies.

Help the patient change his or her environment:

Throw away cigarettes, matches, lighters, and ashtrays; launder clothing; and vacuum home and car.

Avoid smoking in places where the patient spends a lot of time (e.g., home, work, car).

Avoid other smokers and drinking alcohol.

Provide basic information about smoking and cessation (e.g., addictive nature of smoking, importance of complete abstinence, possible withdrawal symptoms).

Recommend pharmacotherapy, unless contraindications exist, and behavior therapy for smoking cessation.

Provide supplementary self-help materials.

5. Arrange follow-up contact.

Follow-up should occur within the first week after the quit date. A second follow-up contact is recommended within the first month. Further follow-up visits should be scheduled as needed.

During a follow-up visit, success should be congratulated. If the patient has relapsed, review the circumstances and elicit a new commitment to quit. Consider referral for more intensive treatment.

Follow-up contact can be by telephone, e-mail, or in person.

http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat2.section.7741, cited from http://www.aafp.org/afp/2006/0715/p262.html#afp20060715p262-b2.

Modified from National Heart, Lung, and Blood Institute and American Lung Association recommendations.

^*The five “A”s from Fiore MC: Treating tobacco use and dependence, Rockville, Md, 2000, US Department of Health and Human Services, Public Health Service.

A Theories of Behavior Change

In order to impact behavior, it is helpful to understand how health behavior is shaped and how people change. Behavior change is always difficult. The advantage of intervening in accordance with a valid theory of behavior change is that the intervention has a higher chance of success. Most health behavior models have been adapted from the social and behavioral sciences. Theories also help in targeting interventions, choosing appropriate techniques, and selecting appropriate outcomes to measure.¹¹ We can only sketch out the basics of the most common health theories here. For further details, readers should consult monographs on the topic.¹¹ Other theories support the approach to changing group norms and helping communities identify and address health problems (see Chapter 25).

Most health behavior theories have been adapted from the social and behavioral sciences. Therefore, they share common assumptions, as follows:

Knowledge is necessary, but not sufficient, for behavior change.

Behavior is affected by what people know and how they think.

Behavior is influenced by people’s perception of a behavior and its risks, their own motivation and skills, and the social environment.

An important part of motivation is also their self-perceived ability to influence their life. The degree to which people believe this is most often called self-efficacy.

The most common theories for health behavior counseling are the health belief model, transtheoretical model (stages of change), theory of planned behavior, and precaution adoption process model (Table 15-1).

Table 15-1 Overview of Common Theories of Behavior Change

B Behavioral Counseling

Patients often want and need counseling, particularly those with risk factors for significant diseases. If medications can be prescribed, it is tempting for the physician to provide these as the first line of treatment for obesity, smoking, hypertension, and elevated cholesterol levels. Nevertheless, unless the problem is severe when the patient is first seen, generally the best approach is to try first to modify diet, exercise, or other aspects of lifestyle. If these approaches to reducing risk factors are refused or are unsuccessful within a reasonable time, or if the risk to the patient is high, medications can be considered. However, medications should not replace counseling, only supplement it.

Many clinicians are uncomfortable with risk factor counseling, thinking they lack counseling skills or time. However, good data show that even brief interventions can have a profound impact on patients. Each year, millions of smokers quit smoking because they want to, because they are concerned about their health, and because their providers tell them to quit. At the same time, even more individuals begin smoking worldwide. Box 15-2 summarizes the approach that the National Heart, Lung, and Blood Institute and the American Lung Association recommend for use by clinicians in counseling their patients. Many online training programs are available to assist clinicians in counseling.¹⁴

Across a broad area of behavior, patient adherence is based on a functioning physician-patient relationship and skilled physician communication.¹⁵ Beyond a good relationship, it matters how clinicians counsel. Despite its venerable tradition, simply giving advice is rarely effective.¹⁶ Given the importance of social determinants of health, physician counseling is only one, often minor influence. Even though insufficient to cause change, however, counseling can provide motivation and support behavior change.