THE GREAT KILLERS OF HUMANITY for most of our history have been infectious diseases. Now most premature deaths and illnesses are the result of poor lifestyle choices. It is estimated that people’s lifestyles account for 70 percent of hospitalizations and 80 percent of health care-related expenses.1-5 The four main lifestyle issues related to poor health are: 1) lack of exercise, 2) smoking, 3) poor diet choices and 4) stress. Numerous researchers have found that lifestyle behaviors are the root cause of many chronic diseases.6-10 Smoking, unhealthy diets and sedentary behavior make people vulnerable to diseases that rank among the leading causes of death, such as heart disease, cancer, stroke and diabetes. Fortunately, there is a dose-response association between the number of healthy lifestyle indicators and a lower risk of heart disease.11-12
In a large prospective population study, Khaw et al. examined the combined impact on mortality of not smoking, being physically active, having a moderate alcohol intake and having a high fruit and vegetable intake among men and women 45 to 79 years of age.13 The study concluded that the difference between the highest and lowest health behavior score was equivalent to approximately 14 years in chronological age. Another research team found that those with four poor health behaviors compared with those with no poor health behaviors had an all-cause mortality risk equivalent to being 12 years older.14 Ford et al. found that Americans who had a healthy lifestyle lived 11 years longer than those who did not.11 Moreover, increasing healthy lifestyle behaviors improves the length and also the quality of life.15-17 Research suggests that if you want to add 11 to 14 quality years to your life, simply select and apply these healthy behaviors.
According to several research teams, an underutilization of effective prevention strategies contributes appreciably to excess morbidity and mortality, as well as to higher healthcare costs.18,19 Although chiropractic has its roots in preventive strategies, as a profession, we are not doing a good job of promoting prevention. A National Health Interview Survey found doctors of chiropractic (DCs) gave health promotion recommendations to only 21 percent of their patients.20 Obviously, that is unacceptable. DCs need to rededicate themselves to the prevention paradigm.
A core component supporting this paradigm is using the right preventive screenings at the right time based on each patient’s health-risk profile. It is not only which screenings are appropriate but which are appropriate to exclude. The bottom line is that these screenings should provide a net health benefit to the patient (i.e., the potential benefit needs to be greater than the potential harm). A preventive screening test should meet four criteria before it is included in a prevention program:21
1. The disease should be an important health problem that imposes a notable burden on the affected population;
2. The natural history of the disease should be understood and measurable for monitoring;
3. There should be a safe, cost-effective, acceptable and predictive test to detect the pre-disease state; and
4. There should be safe, effective and costeffective ways to prevent or at least delay the disease from occurring.
If chiropractic physicians want to be holistic in our approach, we need to be well-versed in a variety of preventive screening tests, not focused only on neuromusculoskeletal issues. An understanding of the appropriate and inappropriate tests will help us provide guidance to our patients on key health issues. By way of example, we should understand the benefits and risks associated with prostatespecific antigen (PSA) testing. Does this popular screening test meet the outlined criteria?
Prostate cancer does impose significant suffering, but PSA testing fails to provide reasonable predictive accuracy for diagnosis or monitoring. When PSA testing was introduced, prostate cancer incidence increased dramatically in the Western world.22 But PSA screening is unable to distinguish indolent from aggressive cancers, which leads to overdiagnosis, more biopsies and an increased risk of overtreatment of clinically irrelevant tumors.23,24
Multiple research teams have found that PSA testing is not beneficial on the most important metric: What is its ability to reduce mortality? In a large North American study, Andriole et al. found that PSA screening had no effect on prostate cancer mortality.25 A metaanalysis of two RCTs of populationbased screening for prostate cancer using PSA and digital rectal examination found no reduction in prostate cancer mortality in men invited versus men not invited for screening.26 In a systematic review, early detection has not been shown to have an impact on mortality, and it comes at the price of additional testing, the risk of overtreatment and downstream adverse effects and impaired quality of life.27 After 20 years of follow-up, the rate of death from prostate cancer did not differ significantly between men in the screening group and those in the control group.28
The U.S. Preventive Services Task Force concludes that for asymptomatic men younger than 75 years, the benefits of routine screening for prostate cancer are uncertain, and the balance of benefits and harms cannot be determined.29 For men 75 years or older, there is moderate certainty that the harms of routine screening for prostate cancer outweigh the benefits.29
At the individual level, it is conceivable that some patients would value early detection, while others might want to avoid the risk of overdiagnosis and the cascade of unnecessary interventions. Moreover, a diagnosis of prostate cancer may increase the immediate risks of suicide and cardiovascular death.30,31 So it is important to counsel patients in a balanced manner by providing the best information to reach a shared decision.
It is fundamental to carefully and systematically determine which tests should be included and which tests should be avoided, because the health of your patients hangs in the balance. Providing the right kinds of preventive screenings, counseling and preventive therapies at the right times is vital to the health of your patients. Indiscriminately selecting tests is highly likely to cause patient harm.
1. deVol R. & Bedrosian A. An unhealthy America: The economic burden of chronic disease—charting a new course to save lives and increase productivity and economic growth. Los Angeles, CA: The Milken Institute, 2007.
2. U.S. Department of Health and Human Services. HHS announces the nation’s new health promotion and disease prevention agenda. 2010. Retrieved from www.hhs.gov/news/press/2010pres/12/20101202a.html.
3. Centers for Disease Control and Prevention. Smoking and tobacco use [fact sheet]. Available at www.cdc.gov/tobacco/data_statistics/fact_sheets/index.htm. Accessed August 20, 2010.
4. Colditz GA. Economic costs of obesity and inactivity. Med Sci Sports Exerc 1999;31:S663-S667.
5. Dall TM, Fulgoni VL 3rd, Zhang Y, Reimers KJ, Packard PT, Astwood JD. Potential health benefits and medical cost savings from calorie, sodium, and saturated fat reductions in the American diet. Am J Health Promot 2009;23:412-22.
6. Andersen LB, Schnohr P, Schroll M, Hein HO. Allcause mortality associated with physical activity during leisure time, work, sports, and cycling to work. Arch Intern Med 2000;160:1621-1628.
7. McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA 1993;270:2207-2212.
8. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA 2004;291:1238-1245.
9. Batty GD, Kivimaki M, Gray L, Smith GD, Marmot MG, Shipley MJ. Cigarette smoking and sitespecific cancer mortality: testing uncertain associations using extended follow-up of the original Whitehall study. Ann Oncol 2008;19:996-1002.
10. Danaei G, Ding EL, Mozaffarian D, Taylor B, Rehm J, Murray CJ, Ezzati M. The preventable causes of death in the United States: comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 2009;6:e1000058.
11. Ford ES, Zhao G, Tsai J, Li C. Low-risk lifestyle behaviors and all-cause mortality: findings from the National Health and Nutrition Examination Survey III Mortality Study. Am J Public Health 2011;101:1922-9.
12. Zhang Y, Tuomilehto J, Jousilahti P, Wang Y, Antikainen R, Hu G. Lifestyle factors on the risks of ischemic and hemorrhagic stroke. Arch Intern Med 2011;171:1811-8.
13. Khaw KT, Wareham N, Bingham S, Welch A, Luben R, Day N. Combined impact of health behaviours and mortality in men and women: the EPIC-Norfolk prospective population study. PLoS Med 2008;5:e12.
14. Kvaavik E, Batty GD, Ursin G, Huxley R, Gale CR. Influence of individual and combined health behaviors on total and cause-specific mortality in men and women: the United Kingdom health and lifestyle survey. Arch Intern Med 2010;170:711-8.
15. Ford ES, Bergmann MM, Kröger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med 2009;169:1355-62.
16. Fries JF, Koop CE, Sokolov J, Beadle CE, Wright D. Beyond heath promotion: reducing need and demand for medical care. Health Aff(Millwood) 1998;17:70-84.
17. Chakravarty EF, Hubert HB, Lingala VB, Fries JF. Reduced disability and mortality among aging runners: a 21-year longitudinal study. Arch Intern Med 2008;168:1638-46.
18. Strong K, Mathers C, Leeder S, Beaglehole R. Preventing chronic diseases: How many lives can we save? Lancet 2005;366:1578-1582.
19. DiMatteo, MR. Variations in patients’ adherence to medical recommendations: A quantitative review of 50 years of research. Medical Care 2004; 42:200-209.
20. Ndetan H, Evans MW Jr, Bae S, Felini M, Rupert R, Singh KP. The health care provider’s role and patient compliance to health promotion advice from the user’s perspective: analysis of the 2006 National Health Interview Survey data. J Manip Physiol Ther 2010;33:413-8.
21. Sherwin RS, Anderson RM, Buse JB, Chin MH, Eddy D, Fradkin J, Ganiats TG, Ginsberg HN, Kahn R, Nwankwo R, Rewers M, Schlessinger L, Stern M, Vinicor F, Zinman B; American Diabetes Association; National Institute of Diabetes and Digestive and Kidney Diseases. Prevention or delay of type 2 diabetes. Diabetes Care 2004;27 Suppl 1:S47-54.
22. Kvåle R, Auvinen A, Adami HO, et al. Interpreting trends in prostate cancer incidence and mortality in the five Nordic countries. J Natl Cancer Inst 2007;99:1881–1887.
23. Shao YH, Albertsen PC, Roberts CB, Lin Y, Mehta AR, Stein MN, DiPaola RS, Lu-Yao GL. Risk profiles and treatment patterns among men diagnosed as having prostate cancer and a prostate-specific antigen level below 4.0 ng/ml. Arch Intern Med 2010;170:1256-61.
24. van Leeuwen PJ, Connolly D, Tammela TL, Auvinen A, Kranse R, Roobol MJ, Schroder FH, Gavin A. Balancing the harms and benefits of early detection of prostate cancer. Cancer 2010;116:4857-65.
25. Andriole GL, Crawford ED, Grubb RL III, et al; PLCO Project Team. Mortality results from a randomized prostate-cancer screening trial. N Engl J Med 2009;360:1310-1319.
26. Ilic D, O’Connor D, Green S, Wilt T. Screening for prostate cancer. Cochrane Database Syst Rev 2006;3:CD004720.
27. Djulbegovic M, Beyth RJ, Neuberger MM, Stoffs TL, Vieweg J, Djulbegovic B, Dahm P. Screening for prostate cancer: systematic review and meta-analysis of randomised controlled trials. BMJ 2010;341:c4543.
28. Sandblom G, Varenhorst E, Rosell J, Löfman O, Carlsson P. Randomised prostate cancer screening trial: 20-year follow-up. BMJ 2011;342:d1539.
29. US Preventive Services Task Force. Screening for prostate cancer. www.ahrq.gov/clinic/uspstf/uspsprca.htm. Accessed May 27, 2008.
30. Fall K, Fang F, Mucci LA, Ye W, Andrén O, Johansson JE, Andersson SO, Sparén P, Klein G, Stampfer M, Adami HO, Valdimarsdóttir U. Immediate risk for cardiovascular events and suicide following a prostate cancer diagnosis: prospective cohort study. PLoS Med 2009;6:e1000197.
31. Fang F, Keating NL, Mucci LA, Adami HO, Stampfer MJ, Valdimarsdóttir U, Fall K. Immediate risk of suicide and cardiovascular death after a prostate cancer diagnosis cohort study in the United States. J Natl Cancer Inst 2010;102:307-14.