Do Healthy Behaviors and Risk Factor Reductions Really Help?
A Local Example
We hear constant claims that various behaviors and treatments can prevent disease, on TV, in the newspapers, from neighbors and friends, as well as from doctors and other clinicians. The scientific proof of these claims can come only from large, population-based, long-term studies. Not many such studies have found significant (odds of helping better than just chance) benefits for most proposed interventions, but some have. The National Institutes of Health began funding such population studies in Framingham, Massachusetts, in the early 1960s. They found and continue to find poorer health outcomes in people who smoke, have uncontrolled high blood pressure, high cholesterol, and are obese. By the early 1970s, related studies were clearly showing that high blood pressure control and smoking cessation reduced the incidence of heart attacks and strokes. And by the early 1980s, other studies clearly demonstrated further reductions in heart disease and stroke with cholesterol and obesity reductions. They show gradual but persistent improvements in cardiovascular mortality rates from nearly 400 deaths per 100 000 people annually down to now less than 150/100 000 nationally, in Maine overall and in most Maine counties.
I practiced, supported, and saw the benefits to my patients of several such risk reduction programs in Farmington in the 1970s and 80s, and am now a member of a group there, that includes Dr. Jay Naliboff from Vienna, to analyze Franklin County against national and Maine averages since 1970. We are finding that Franklin, led by Dr. Burgess Record, was ahead of the curve in improving the detection, treatment and control of high blood pressure and later of high cholesterol. Some of those programs were implemented through doctors’ offices, but most took place in the communities and workplaces. By the late 1970s, Franklin County went from only 1/3 of people with hypertension detected and only 1/3 of those controlled on medicines, to the inverse of that with 2/3 detected and controlled. Within less than 5 years, Franklin County heart attack rates and mortality dropped from well above, to 15% below, Maine averages, and even more dramatically below adjacent Somerset and Oxford counties, which have similar socio-economic profiles. Gradually the rest of Maine caught up to Franklin County. Then, when public screening and more aggressive cholesterol treatments were shown to clearly help and were implemented in Franklin, another improvement in Franklin rates occurred decades before other adjacent counties gradually caught up. Other Franklin public programs to promote exercise, reduce obesity, eat more healthily also likely contributed. Early improvements in the medical treatment of heart disease, like the use of aspirin and balloon opening of heart arteries, contributed to the improved survival too, though to a much lesser extent.
Another major contributor to these cardiovascular mortality results was the dramatic drop in Franklin County smoking rates from area-wide intensive efforts to curb them. Predictably, other smoking-related mortalities, from lung and head and neck cancers, asthma, and chronic lung disease dropped below state and adjacent county rates as well. Again, rates in Maine and nationally, have been dropping for decades, but Franklin led the way in restricting smoking in public places, starting with the hospital. And it now has the lowest rate of teen smoking in the state. Public/community expectations have shifted and support such changes in behaviors. Most of this change has been effected by public education.
So the lessons of this experience are that we should focus our limited energies and resources on decreasing the prevalence of those risk factors scientifically known to be susceptible to proven community-wide interventions. When we do, we can expect to be able to see within a few years. Continued measurement of outcomes, especially mortality, strengthens the case for continuing; people can, in fact live longer, more productive lives if we set up and support community-wide adoptions of healthy behaviors and reductions of significant risk factors.
Daniel K. Onion, MD, MPH
Vienna Health Officer