Primordial Prevention: The First Should Be Last
Primordial Prevention: The First Should Be Last
Henry R. Black, MD: Hi. I'm Dr. Henry Black. I'm Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at that institution, and former President of the American Society of Hypertension.
I'm here with my colleague, Dr. Howard Weintraub, and today we want to talk about the approach to prevention. First, let's review some definitions.
Secondary prevention tends to be what we talk about for people who have already had an event. Primary prevention is for people who haven't had that event, regardless of whether they have evidence of a tendency to have that event, such as plaque in the carotid arteries. Primordial prevention is for people who haven't had anything.
It seems to me that primordial prevention is something that ought to be the focus of pediatricians and internists; secondary prevention should be the focus of specialists, be they cardiologists or surgeons; and primary prevention should be the focus of almost everybody. How do you feel about that?
Howard S. Weintraub, MD: I agree, Henry. I think you hit this right on the head. There was an excellent article in Circulation earlier this year that highlighted the idea that it is not what a lot of physicians feel, which is that as long as the blood pressure is lowered and the lipids are lowered, everything is hunky dory.
Dr. Black: Everybody would rather not have the event than treat it after they do.
Dr. Weintraub: Absolutely correct. What the authors in Circulation showed is that it is not a matter of lowering the LDL cholesterol level; it is to never get an elevated LDL and to never get hypertensive. I think this is very important, because there are about 23 million kids under the age of 19 years who are obese or overweight.
Dr. Black: How do you do something about it when they are adolescents, and they drink sugared beverages and eat the wrong things? How do you get them to change?
Dr. Weintraub: It needs to be a multipronged effort. Parents are worried about the things that would get their kids immediately ill, such as vaccines. I think it needs to be something that is promoted in advertising and in schools.
Dr. Black: The effort to promote smoking cessation showed us that we have to be patient. It took 25 years from the time that the Surgeon General said that smoking is bad for you. We had lots of evidence that it was, but they finally came out and said so. It wasn't until about 25 years later, though, that we actually saw the rates going down, so we can't expect an overnight change.
One thing that really helped with smoking cessation was to teach kids in elementary school to come back and tell their parents to stop smoking. We probably ought to take the same approach with this. Teach children to ask, "Why are you feeding me this? Why did you send me to McDonald's or Burger King?" Some of those companies have been very good about this by making the portion sizes smaller and providing alternatives. That is the behavioral thing we need to do, and I am not sure we are doing it adequately enough.
Dr. Weintraub: I agree. One thing that has changed in the last half-century is the amount of physical exercise that kids are getting. The place of leisure activity went from the schoolyard to the computer laboratory. When I was growing up, we would come home from school, and there would either be a punch-ball game or a touch football game, but that is not what goes on anymore. I think that physical exercise, along with better nutritional choices, would make a huge difference. I agree wholeheartedly.
Dr. Black: Should we tax sugared beverages?
Dr. Weintraub: I don't know that taxing larger volumes of sugared beverages is right, but I think there should be a tariff to drinking them, however you put it. Let it be more expensive than the diet beverage. Maybe we should give people a chance to do it on their own, and when they don't, we can help them do it. Are we going to get people to drink unsweetened fruit juices? Are we going to get people to drink the best thing for them, which is water or iced teas? I would like to think so.
I know that in our house, it has changed dramatically. My daughters, who are now 22, were never raised with sweetened drinks, and they don't even know what whole milk is because they have been drinking skim milk all the time. I think this reflects an attitude in our community and also in our household. This needs to be carried through nationally.
Dr. Black: I agree. Thank you very much, Howard.
Henry R. Black, MD: Hi. I'm Dr. Henry Black. I'm Clinical Professor of Internal Medicine at the New York University School of Medicine, a member of the Center for the Prevention of Cardiovascular Disease at that institution, and former President of the American Society of Hypertension.
I'm here with my colleague, Dr. Howard Weintraub, and today we want to talk about the approach to prevention. First, let's review some definitions.
Secondary prevention tends to be what we talk about for people who have already had an event. Primary prevention is for people who haven't had that event, regardless of whether they have evidence of a tendency to have that event, such as plaque in the carotid arteries. Primordial prevention is for people who haven't had anything.
It seems to me that primordial prevention is something that ought to be the focus of pediatricians and internists; secondary prevention should be the focus of specialists, be they cardiologists or surgeons; and primary prevention should be the focus of almost everybody. How do you feel about that?
Howard S. Weintraub, MD: I agree, Henry. I think you hit this right on the head. There was an excellent article in Circulation earlier this year that highlighted the idea that it is not what a lot of physicians feel, which is that as long as the blood pressure is lowered and the lipids are lowered, everything is hunky dory.
Dr. Black: Everybody would rather not have the event than treat it after they do.
Dr. Weintraub: Absolutely correct. What the authors in Circulation showed is that it is not a matter of lowering the LDL cholesterol level; it is to never get an elevated LDL and to never get hypertensive. I think this is very important, because there are about 23 million kids under the age of 19 years who are obese or overweight.
Dr. Black: How do you do something about it when they are adolescents, and they drink sugared beverages and eat the wrong things? How do you get them to change?
Dr. Weintraub: It needs to be a multipronged effort. Parents are worried about the things that would get their kids immediately ill, such as vaccines. I think it needs to be something that is promoted in advertising and in schools.
Dr. Black: The effort to promote smoking cessation showed us that we have to be patient. It took 25 years from the time that the Surgeon General said that smoking is bad for you. We had lots of evidence that it was, but they finally came out and said so. It wasn't until about 25 years later, though, that we actually saw the rates going down, so we can't expect an overnight change.
One thing that really helped with smoking cessation was to teach kids in elementary school to come back and tell their parents to stop smoking. We probably ought to take the same approach with this. Teach children to ask, "Why are you feeding me this? Why did you send me to McDonald's or Burger King?" Some of those companies have been very good about this by making the portion sizes smaller and providing alternatives. That is the behavioral thing we need to do, and I am not sure we are doing it adequately enough.
Dr. Weintraub: I agree. One thing that has changed in the last half-century is the amount of physical exercise that kids are getting. The place of leisure activity went from the schoolyard to the computer laboratory. When I was growing up, we would come home from school, and there would either be a punch-ball game or a touch football game, but that is not what goes on anymore. I think that physical exercise, along with better nutritional choices, would make a huge difference. I agree wholeheartedly.
Dr. Black: Should we tax sugared beverages?
Dr. Weintraub: I don't know that taxing larger volumes of sugared beverages is right, but I think there should be a tariff to drinking them, however you put it. Let it be more expensive than the diet beverage. Maybe we should give people a chance to do it on their own, and when they don't, we can help them do it. Are we going to get people to drink unsweetened fruit juices? Are we going to get people to drink the best thing for them, which is water or iced teas? I would like to think so.
I know that in our house, it has changed dramatically. My daughters, who are now 22, were never raised with sweetened drinks, and they don't even know what whole milk is because they have been drinking skim milk all the time. I think this reflects an attitude in our community and also in our household. This needs to be carried through nationally.
Dr. Black: I agree. Thank you very much, Howard.
