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The Wellness Guide to Preventive
Care
A recent government study showed that more than half
of all Americans do not receive many of the important preventive
services they need—that is, immunizations, screening tests
for early detection of disease, and education about healthy habits
and injury prevention. Why not?
• Many Americans—44
million—have no health insurance.
• Many people
do not get continuity of care. They may have to switch doctors
as they switch from one insurer to another, making it hard to
keep track of what services they've had.
• Patients
may not insist on getting preventive services. They may be confused
about which tests to ask for. They may not know that Medicare
(and some other insurance plans) covers some of the pricier items,
such as mammograms and colonoscopies, as well as the cheaper ones.
They may not know that prevention is usually the most economical
form of medicine—well worth budgeting for, even if insurance
doesn't cover it.
• With tests
for some cancers, there's the embarrassment factor. Some people
may dread being tested for colon, prostate, or breast cancer and
be relieved if the doctor fails to mention it. Some people would
rather not know.
• Both doctors
and patients may be confused by contradictory recommendations.
What should a medical checkup consist of? Does everybody need
an annual physical? Should all men get a PSA test? At what age
should a woman start having mammograms? (See
below for answers to such questions.)
• Doctors
may fail to ask patients about smoking and drinking, not to mention
exercise habits and diet. Some HMOs don't encourage their doctors
to counsel people. Some doctors think their job is to treat illness,
not prevent it.
• The watchword
among insurers now is cost containment. Yet medical technologies
and consumer demand for services are expanding daily. Thus, we
all have to make choices. Will patients in a big HMO get more
benefit from an additional MRI machine or from having their doctors
take time to counsel them about exercise and a heart-healthy diet?
The new MRI machine will be easier to justify, in terms of immediate,
measurable benefits.
How about that annual physical?
It used to seem simple: people were advised to undergo
a standardized annual or biannual "complete physical."
But in the 1980s, at the request of the government, an independent
committee of physicians known as the U.S. Preventive Services Task
Force reviewed all evidence and evaluated the benefits and drawbacks
of common screening tests and came up with recommendations. (A similar
group, the Canadian Task Force on Preventive Health Care, does the
same work in Canada.) That head-to-toe physical exam has now been
discarded for seemingly healthy people, since it yields too few
benefits for its cost. Over the long run, it doesn't pay off in
terms of better health and longer life.
Some tests that used to be routinely done, such as
chest X-rays, electrocardiograms (EKGs), urine tests, and complete
blood counts, are now reserved for people with symptoms or risk
factors. In other words, they are not general "screening"
tests and are not done routinely in everyone (and as such are not
covered in this article).
The U.S. and Canadian Task Forces continue to update
and re-evaluate their advice, reviewing thousands of studies every
year and consulting hundreds of scientific reviewers.
Health care: your role
You are responsible, in large part, for managing your
own preventive care. Your primary-care practitioner should be your
partner. If you need any of the tests listed on the chart, ask about
them. You should, if possible, have a copy of your test results
and records.
There are other important preventive measures not
listed on our chart—the kind of commonsense steps that could
save millions of medical dollars and prevent injury, illness, disability,
and premature death. Here's a checklist:
• Don't
smoke, and avoid secondhand smoke.
•
Maintain a healthy weight.
•
Get regular exercise. Brisk walking for just half an hour every
day can be a big factor in weight control and in staying healthy.
•
Choose a diet low in animal fat and sodium, and rich in fruits,
vegetables, whole grains, and low-fat or nonfat dairy products.
Eat at least two servings of fish a week.
•
Keep alcohol consumption moderate: no more than one drink daily
for a woman, two drinks for a man. If you are a heavy drinker,
seek counseling, and cut back or quit.
•
Do self-exams of your breasts or testes, as well as skin.
•
Fasten seat belts, see that kids ride in proper restraints, and
obey the law. Drive sober and defensively.
•
Brush and floss to prevent dental disease.
Medical experts may disagree about a lot of things,
but they all agree that good health depends on improved access to
and increased use of preventive services.
A test you don't need
Increasing numbers of readers ask
us for the lowdown on the so-called full-body CT scan—a flourishing
industry these days. It has even been featured on Oprah.
Symptomless people are signing up for these tests—not covered
by medical insurance—at a cost of about $1,000. For most people,
results are nil, unless you count a commodity called "peace
of mind." But peace of mind is really not something a full-body
scan can deliver. And if it could, how often would you have to get
one?
According to the American College
of Radiology, the full-body scan is not the right way to screen
for cancers of the breast, prostate, colon, or lung—at least
not without follow-up tests. It cannot spot high blood pressure
or diabetes. The American Cancer Society discourages it as a waste
of money, and a poor substitute for the tests listed below.
Furthermore, if the scan does find
anything suspicious, you may simply be subjected to more (sometimes
invasive) tests—and it may well turn out to be a false alarm.
Instead of peace of mind, you get anxiety.
Finally, the FDA worries about needless exposure to radiation from
a test that's unlikely to do you any good.
Someday there may be one magic
test that will accurately detect anything and everything. But the
full-body scan is definitely not it.
Preventive Services for
Healthy Adults
These are the major screening tests (that is, routine
tests for people without symptoms) and adult immunizations. Our
advice is based largely on the recommendations of the U.S. Preventive
Services Task Force. Most HMOs and Medicare cover these services;
fewer traditional insurers pay for them. Infants, children, and
pregnant women need other kinds of preventive care not described
here.
Blood pressure measurement (to
detect hypertension)
Who needs: All adults.
How often: Once every 2 years for
those with normal blood pressure.
Comments: More frequent monitoring
for those with readings of 130/85 or higher. See Wellness
Letter, May 1999.
Cholesterol measurement
Who needs: All adults.
How often: Once every 5 years. More
often if total or LDL ("bad") cholesterol is high, HDL
("good") is low, and/or you have risk factors.
Comments: Those at high risk for heart
disease need medical advice about life-style changes and possibly
drug therapy. See Wellness
Letter, August 2001.
Pap smear (for early detection
of cervical cancer)
Who needs: All women with a cervix,
starting at age 18, or earlier if sexually active.
How often: If 3 annual tests are normal,
then once every 3 years. More often if you smoke or have multiple
sex partners or other risk factors.
Comments: Some experts advise that
women who have never had an abnormal result can stop being screened
after age 65.
Breast cancer screening (mammography)
Who needs: All women 50 and over;
those 40-49 should discuss risk factors with a doctor. See Wellness
Letter, August 2000.
How often: Annually. Medicare reimburses
for it.
Comments: Clinical breast exams are
also important—consult your doctor.
Colorectal cancer screening (fecal occult
blood test, sigmoidoscopy, colonoscopy)
Who needs: Everyone 50 and over; earlier
for those at high risk.
How often: Occult
blood test annually; sigmoidoscopy every 5 years or colonoscopy
every 10 years.
Comments: Digital rectal exam and
X-ray with barium enema may also be done. Medicare now pays for
colonoscopy. See Wellness
Letter, December 2000.
Prostate cancer screening (prostate
specific antigen, or PSA, test; and digital rectal exam, or DRE)
Who needs: Blacks and men with family
history, DRE and PSA starting at age 40. For others, DRE, and possibly
PSA, starting at 50.
How often: DRE annually; PSA on professional
advice.
Comments: Usefulness of PSA screening
for all men remains controversial. See Wellness
Letter, November 2000.
Diabetes screening (fasting
blood glucose test)
Who needs: Everyone 45 and older;
earlier for those at high risk.
How often: Every 3 years.
Comments: Blacks, Hispanics, Asians,
Native Americans, obese people, and those with a strong family history
need more frequent screening, starting at age 30. See Wellness
Letter, October 1997.
Thyroid disease screening
Who needs: Women 50 and over; those
with high cholesterol or family history of thyroid disease.
How often: On professional advice.
Comments: Routine screening remains
controversial. Talk to your doctor about risk factors. See Wellness
Letter, June 2000.
Chlamydia screening
Who needs: Women 25 and younger, if
sexually active.
How often: Annually, or more often.
Comments: Men and women of any age
who are at risk for STDs (chlamydia, gonorrhea, syphilis, and HIV)
should be tested. See Wellness
Letter, October 1998.
Glaucoma screening
Who needs: People at high risk: those
over 65, very nearsighted, or diabetic; blacks over 40; those with
sleep apnea or family history of glaucoma.
How often: On professional advice
of eye specialist.
Comments: Many eye specialists advise
screening all adults every 3-5 years, starting at age 39. See Wellness
Letter, September 2000.
Dental checkup
Who needs: All adults.
How often: Every 6 months, or on professional
advice.
Comments: Should include cleaning
and exam for oral cancer.
Tetanus/diphtheria booster
Who needs: All adults.
How often: Every 10 years.
Comments: People over 50 are least
likely to be adequately immunized.
Influenza vaccine
Who needs: Everyone 50 and over, people
with lung or heart disease or cancer, and others at high risk.
How often: Annually, in autumn.
Comments: Even healthy younger adults
can benefit and should consider getting the shot.
Pneumococcal vaccine
Who needs: Everyone 65 and over, and
others at high risk for complications.
How often: At least once.
Comments: Effective against most strains
of pneumococcal pneumonia; lasts at least 5-10 years.
Rubella vaccine
Who needs: All women of childbearing
age.
How often: Once.
Comments: Avoid during pregnancy.
Hepatitis B vaccine
Who needs: All young adults, as well
as adults at high risk.
How often: On professional advice.
Comments: All newborns should be vaccinated.
Chickenpox vaccine
Who needs: Anyone who has never had
chickenpox.
How often: Once. But above age 13
it requires two shots.
Comments: Not recommended for pregnant
women or those with compromised immunity.
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