Preventive Health Care

• To learn the basic concepts of preventive health care
• To understand the importance of evidence based medicine in preventive health care
• To be able to formulate a preventive health care plan for a patient based on the patient's age and risk factors

Primary prevention: Prevent the development of the disease

Immunizations

Lifestyle changes (i.e. losing weight, exercise, modifying high risk sexual behavior)

 Pap smears

 Blood pressure screening

 Insulin therapy in diabetes

 Cholesterol management in coronary artery disease

The value of preventive medicine becomes obvious when historical disease numbers in the U.S. are examined.
 

• Poliomyelitis, for example, which affected 18,300 people in 1954, has become virtually eliminated in our country secondary to universal immunization. The last reported case of indigenously acquired, wild strain poliomyelitis was in 1979.
• Rubella epidemics were common in the United States prior to the introduction of the vaccine, and in 1964 a pandemic resulted in 12,000,000 infections, 11,000 fetal losses, and approximately 20,000 infants born with congenital rubella syndrome. The incidence of rubella has decreased 99% since the vaccine became available in 1969.
• The incidence of invasive cervical cancer has decreased dramatically since the introduction of Pap smear screening.
• The age adjusted mortality from strokes has decreased >50% since 1972, in part related to earlier detection and treatment of hypertension. ¹

Below are listed the fifteen leading causes of death in the United States in 2002 (total number of deaths 2,447,862) ²

1. Diseases of the heart:  695,794
2. Malignant neoplasms: 558,847
3. Cerebrovascular diseases: 163,010
4. Chronic lower respiratory diseases: 125,500
5. Accidents: 102,303
6. Diabetes: 73,119
7. Influenza and pneumonia: 65,984
8. Alzheimer's disease:  58,785
9. Nephritis, nephrotic syndrome, and nephrosis: 41,018
10. Septicemia: 33,881
11. Suicide: 30,646
12. Chronic liver disease and cirrhosis:  27,045
13. Essential (primary) hypertension and hypertensive renal disease:  20,241
14. Pneumonitis due to solids and liquids: 17,693
15. Homicide:  17,045
    

• Smoking contributes to one out of five deaths annually in the United States. ¹
• Driving under the influence of alcohol contributes to a major portion of motor vehicle accidents, injuries, and fatalities each year (37,795 auto related fatalities in 2001, 41% alcohol-related). ³
• The use of seat belts greatly reduces the risk of fatal injury in automobile accidents. ⁴
• Alcohol abuse is a major cause of chronic liver disease and cirrhosis.
• Physical inactivity and dietary factors contribute to a host of health problems such as obesity, coronary artery disease, diabetes, cancer, osteoporosis, degenerative joint disease, and hypertension.

Diet:

Studies have shown that a diet high in fruits and vegetables can reduce the incidence of heart disease and cancer. ⁵ The mediterranean diet in particular has been shown to reduce the risk of repeat coronary events by as much as 70% as compared to a standard American diet.⁶ Some experts are now recommending  the Mediterranean diet instead of the standard American Heart Association Step I diet to reduce the risk of coronary events. ⁷ The mediterranean diet is low in saturated fats and trans-fatty acids and contains very little red meat. This diet contains mostly mono-unsaturated oils, like olive oil, and includes a high intake of whole grains, fresh fruits and vegetables, legumes, and fish rich in omega-3 fatty acids. ^8,9  Most dietary experts recommend counseling adults and children over age 2 to limit dietary intake of fat (especially saturated fat) and cholesterol, maintain caloric balance in their diet, and emphasize foods containing fiber (i.e., fruits, vegetables, grain products).  The USPSTF concluded that the evidence is insufficient to recommend for or against routine behavioral counseling to promote a healthy diet in unselected patients in primary care settings. However, intensive behavioral dietary counseling is recommended for adult patients with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. 

 

Dental Care

Patients should be counseled to visit a dental care provider on a regular basis, brush and floss daily, use a fluoride-containing toothpaste, and appropriately use fluoride for caries prevention and chemotherapeutic mouth rinses for plaque prevention. These recommendations are based on evidence for risk reduction from these interventions. Educating parents to curb the practice of putting infants and children to bed with a bottle is also recommended based on limited evidence of risk reduction. The effectiveness of clinician counseling to change any of these behaviors has not been adequately evaluated.

Household Injuries

The parents of small children should be counseled on measures to reduce the risk of unintentional household and recreational injuries. Counseling to prevent household and recreational injuries is also recommended for adolescents and adults based on the proven efficacy of risk reduction, although the effectiveness of counseling these patients to prevent injuries has not been adequately evaluated. Patients who use alcohol or illicit drugs should be warned against engaging in potentially dangerous activities while intoxicated. Counseling elderly patients on fall prevention methods is recommended based on fair evidence that these measures reduce the risk of falls, although the effectiveness of counseling elders to prevent falls has not been adequately evaluated. 

Sexually Transmitted Diseases

All adolescent and adult patients should be advised about risk factors for human immunodeficiency virus (HIV) infection and other sexually transmitted diseases (STDs), and counseled appropriately about effective measures to reduce the risk of infection. This recommendation is based on the proven efficacy of risk reduction, although the effectiveness of clinician counseling in the primary care setting is uncertain. 

Tobacco

Tobacco cessation counseling on a regular basis is recommended for all persons who use tobacco products.  Prescription smoking cessation aids should be offered for select patients.

Unintended Pregnancy

Counseling about effective contraceptive methods is recommended for all women and men at risk for unintended pregnancy. Sexually active patients should also receive information about prevention of sexually transmitted diseases 

Vitamin Supplementation to Prevent Cancer and Cardiovascular Disease

There is insufficient evidence to recommend for or against the use of supplements of vitamins A, C, or E; multivitamins with folic acid; or antioxidant combinations for the prevention of cancer or cardiovascular disease.
The USPSTF recommends against the use of beta-carotene supplements, either alone or in combination, for the prevention of cancer or cardiovascular disease.

Exercise

Although a multitude of studies show that physical activity prevents heart disease, diabetes, obesity, and osteoporosis, and promotes a general sense of well being, ¹⁰   evidence that physician counseling affects patient behavior is lacking. There is insufficient evidence to recommend for or against behavioral counseling in primary care settings to promote physical activity.

Many screening tests are available to detect various disease states. Before a screening test is considered an effective preventive intervention, however, a number of criteria must be met. ^11,12,13,14

• The disease must have a significant effect on the quality of life.
• Acceptable methods of treatment must be available.
• There must be an asymptomatic period during which detection and treatment reduces morbidity and mortality.
• Treatment in the asymptomatic phase must yield a therapeutic result.
• Tests must be available at a reasonable cost and must be acceptable to the patient.
• The incidence of the condition must be sufficient to justify the cost of screening.

Breast Cancer

Women aged 40 and older should undergo screening mammography, with or without clinical breast exam, every 1-2 years. 

There is insufficient evidence to recommend for or against routine CBE alone to screen for breast cancer. 

There is insufficient evidence to recommend for or against teaching or performing routine breast self-examination.

Colorectal Cancer

Screening for colorectal cancer is recommended for all persons aged 50 and older. Screening may be performed with home fecal occult blood testing (FOBT), flexible sigmoidoscopy, a combination of home FOTB and flexible sigmoidoscopy, double contrast barium enema, or colonoscopy. 

The frequency of screening varies with the test chosen. FOBT should be done annually, flexible sigmoidoscopy or double-contrast barium enema every 3- 5 years, and colonoscopy every 10 years.  

High risk patients (i.e., familial polyposis, HNPCC, ulcerative colitis, adenomatous polyps, or colon cancer) should have earlier and more frequent screening. 

Digital rectal examination (DRE) and/or FOBT at the time of DRE are not recommended as screening tests for colon cancer.

Cervical Cancer

Regular Pap smear screening is recommended every one to three years in all women with a cervix who are or have been sexually active or who are 21 years of age or older.

There is no evidence that screening annually leads to a better outcome than screening every three years, but screening schedules for individual patients should be determined with consideration of that patient's risk factors for cervical cancer.

Pap smears should be discontinued after age 65 if the patient has received regular screening prior to that time and if all of the patient's smears have been normal and they are otherwise not at high risk for cervical cancer. Screening after hysterectomy is not recommended unless cancer was the reason for the surgery.

Lung Cancer

There is insufficient evidence to recommend for or against screening asymptomatic persons for lung cancer with either low dose computerized tomography (LDCT), chest x-ray (CXR), sputum cytology, or a combination of these tests.

Ovarian Cancer

Prostate Cancer

There is insufficient evidence to recommend for or against routine screening for prostate cancer using prostate specific antigen (PSA) testing or digital rectal examination (DRE).

There is good evidence that PSA screening can detect early-stage prostate cancer but mixed and inconclusive evidence that early detection improves health outcomes. Screening is associated with important harms, including frequent false-positive results and unnecessary anxiety, biopsies, and potential complications of treatment of some cancers that may never have affected a patient’s health. The USPSTF concludes that evidence is insufficient to determine whether the benefits outweigh the harms for a screened population.

The ACS and the American Urological Association recommend annual DRE beginning at age 40, and PSA measurement beginning at age 50 (age 40 for African American men).

If screening is to be performed, the patient should be informed of the potential benefits and risks of screening.

If screening is performed, the best approach is DRE and PSA in men with a life expectancy of >ten years.

Please see the CDC's   Prostate Cancer Screening Decision Guide for more information.

Cholesterol

All men aged 35 and older and all women aged 45 and older should be screened routinely for lipid disorders. Individuals with increased risk for heart disease should be treated.

Younger adults—men aged 20-35 and women aged 20-45—should be screened if they have other risk factors for heart disease. These risk factors include:

• Diabetes
• A family history of cardiovascular disease before age 50 years in male relatives or age 60 years in female relatives
• A family history suggestive of familial hyperlipidemia
• Multiple coronary heart disease risk factors (e.g., tobacco use, hypertension)

Screening for lipid disorders should include measurement of total cholesterol (TC) and high-density lipoprotein cholesterol (HDLC).

There is insufficient evidence to recommend for or against measuring triglycerides. 

The optimal frequency of screening has not yet been determined, but every five years seems reasonable. Longer intervals may be appropriate in people with normal cholesterol and no risk factors for CAD, and shorter intervals may be appropriate for people whose cholesterol levels are near treatment levels.

Depression

Screening adults for depression is recommended in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and follow-up

Diabetes

Hearing Impairment

Screening older adults for hearing impairment by periodically questioning them about their hearing, counseling them about the availability of hearing aid devices, and making referrals for abnormalities when appropriate, is recommended.

Hepatitis B

Screening with hepatitis B surface antigen (HBsAg)  is recommended for all pregnant women at their first prenatal visit. Routine screening for HBV infection in the general population is not recommended, but certain persons at high risk may be screened to assess eligibility for vaccination

Human Immunodeficiency Virus

All patients should be asked about injection drug use and their sexual history. Those persons at risk for HIV infection should be periodically screened.

Hypertension

Screening of all adults age 18 and older is recommended at least every two years. Hypertension currently is defined as blood pressure >140/90, though this is more an arbitrary cutoff level than a biological one. In fact, cardiovascular mortality begins to increase at systolic pressures >110 mm Hg, and diastolic pressures > 70 mm Hg.

Hypertension should be diagnosed using an average of more than one reading taken at each of three separate visits. Once confirmed:

Patients should be counseled concerning physical activity, dietary sodium intake, weight loss, and  alcohol intake.

Risk factors for CAD such as elevated cholesterol and smoking should be assessed.

Decisions on beginning drug therapy should be based on the level of blood pressure elevation, patient's age, concomitant disease, risk factors, and evidence of target-organ damage.

All patients should be counseled concerning physical activity and weight control as primary prevention of hypertension.

Rubella

Adult

Hepatitis A Vaccine

Recommended for all high risk adults (persons living in and traveling to endemic areas, homosexual men, IV drug users, military personnel, and certain hospital and laboratory workers).

Hepatitis B Vaccination

Recommended for all young adults not previously immunized, as well as for those at high risk for acquiring the disease, such as homosexual men, injection drug users and their sexual partners, persons with multiple sexual partners or those who have recently acquired another sexually transmitted disease, patients who receive blood products, and health care workers who are
frequently exposed to blood or blood products.

Influenza Vaccination

Recommended for all persons 50 years of age and older. Also recommended for patients considered to be at high risk for the complications of influenza, including residents in chronic care facilities, and patients with chronic cardiopulmonary disorders, metabolic diseases (including diabetes mellitus), hemoglobinopathies, immunosuppression, or renal dysfunction. The vaccine also is recommended for health care workers who care for high risk patients.

Amantadine or rimantadine prophylaxis is recommended for high risk persons after exposure or during an epidemic. Medication may be started at the time of immunization and continued for two weeks. If the vaccine is contraindicated, amantadine or rimantadine should be continued daily for the entire season of influenza activity in the community.

Pneumococcal Vaccination

Recommended for all immunocompetent persons 65 years of age and older and those at increased risk for pneumococcal disease. High risk groups include institutionalized persons >50 years of age, and persons two years of age or older with chronic cardiac or pulmonary disease, diabetes mellitus, or anatomic asplenia.

Though routine revaccination is not recommended at the present time, it should be considered in individuals at highest risk for pneumococcal disease who were vaccinated more than five years previously.

There is not enough evidence to recommend for or against routine vaccination for immunocompromised patients, but many authorities cite a high incidence of pneumococcal disease in this population and a low incidence of severe side effects from the vaccine as reasons to give it. (Immunocompromised conditions associated with a high incidence of pneumococcal disease include alcoholism, cirrhosis, chronic renal failure, nephrotic syndrome, sickle cell disease, multiple myeloma, metastatic or hematological malignancy, acquired or congenital immunodeficiency, and organ transplant.)

Td Vaccine Series

Should be completed for all patients who did not receive the primary series. The optimal frequency of booster doses has not been established. Current practice is to give Td boosters every ten years, but giving them every 15 to 30 years is probably adequate in a person who completed a primary series in childhood. The ten year interval is recommended for international travelers.

Varicella Vaccine

Recommended for healthy adults with no history of previous infection with varicella or previous vaccination. The vaccine is to be given in two doses, four to eight weeks apart. Serologic testing may be offered to patients with no history of infection.

 
Children

Recommended Childhood Immunization Schedule

 

This schedule indicates the recommended ages for routine administration of currently licensed childhood vaccines, as of April, 2004, for children through age 18 years. Any dose not given at the recommended age should be given at any subsequent visit when indicated and feasible. Indicates age groups that warrant special effort to administer those vaccines not previously given. Additional vaccines may be licensed and recommended during the year. Licensed combination vaccines may be used whenever any components of the combination are indicated and the vaccine’s other components are not contraindicated. Providers should consult the manufacturers' package inserts for detailed recommendations. Clinically significant adverse events that follow immunization should be reported to the Vaccine Adverse Event Reporting System (VAERS).  Guidance about how to obtain and complete a VAERS form can be found on the Internet: http://www.vaers.org/ or by calling 1-800-822-7967.

1. Hepatitis B (HepB) vaccine. All infants should receive the first dose of hepatitis B vaccine soon after birth and before hospital discharge; the first dose may also be given by age 2 months if the infant’s mother is hepatitis B surface antigen (HBsAg) negative. Only monovalent HepB can be used for the birth dose. Monovalent or combination vaccine containing HepB may be used to complete the series. Four doses of vaccine may be administered when a birth dose is given. The second dose should be given at least 4 weeks after the first dose, except for combination vaccines which cannot be administered before age 6 weeks. The third dose should be given at least 16 weeks after the first dose and at least 8 weeks after the second dose. The last dose in the vaccination series (third or fourth dose) should not be administered before age 24 weeks.                     Infants born to HBsAg-positive mothers should receive HepB and 0.5 mL of Hepatitis B Immune Globulin (HBIG) within 12 hours of birth at separate sites. The second dose is recommended at age 1 to 2 months. The last dose in the immunization series should not be administered before age 24 weeks. These infants should be tested for HBsAg and antibody to HBsAg (anti-HBs) at age 9 to 15 months.                                                           Infants born to mothers whose HBsAg status is unknown should receive the first dose of the HepB series within 12 hours of birth. Maternal blood should be drawn as soon as possible to determine the mother's HBsAg status; if the HBsAg test is positive, the infant should receive HBIG as soon as possible (no later than age 1 week). The second dose is recommended at age 1 to 2 months. The last dose in the immunization series should not be administered before age 24 weeks. 2. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. The fourth dose of DTaP may be administered as early as age 12 months, provided 6 months have elapsed since the third dose and the child is unlikely to return at age 15 to 18 months. The final dose in the series should be given at age >4 years. Tetanus and diphtheria toxoids (Td) is recommended at age 11 to 12 years if at least 5 years have elapsed since the last dose of tetanus and diphtheria toxoid-containing vaccine. Subsequent routine Td boosters are recommended every 10 years. 3. Haemophilus influenzae type b (Hib) conjugate vaccine. Three Hib conjugate vaccines are licensed for infant use. If PRP-OMP (PedvaxHIB or ComVax [Merck]) is administered at ages 2 and 4 months, a dose at age 6 months is not required. DTaP/Hib combination products should not be used for primary immunization in infants at ages 2, 4 or 6 months but can be used as boosters following any Hib vaccine. The final dose in the series should be given at age >12 months.

4. Measles, mumps, and rubella vaccine (MMR). The second dose of MMR is recommended routinely at age 4 to 6 years but may be administered during any visit, provided at least 4 weeks have elapsed since the first dose and both doses are administered beginning at or after age 12 months. Those who have not previously received the second dose should complete the schedule by the 11- to 12-year-old visit. 5. Varicella vaccine. Varicella vaccine is recommended at any visit at or after age 12 months for susceptible children (i.e., those who lack a reliable history of chickenpox). Susceptible persons age >13 years should receive 2 doses, given at least 4 weeks apart. 6. Pneumococcal vaccine. The heptavalent pneumococcal conjugate vaccine (PCV) is recommended for all children age 2 to 23 months. It is also recommended for certain children age 24 to 59 months. The final dose in the series should be given at age >12 months. Pneumococcal polysaccharide vaccine (PPV) is recommended in addition to PCV for certain high-risk groups. See MMWR 2000;49(RR-9):1-38. 7. Hepatitis A vaccine. Hepatitis A vaccine is recommended for children and adolescents in selected states and regions and for certain high-risk groups; consult your local public health authority. Children and adolescents in these states, regions, and high-risk groups who have not been immunized against hepatitis A can begin the hepatitis A immunization series during any visit. The 2 doses in the series should be administered at least 6 months apart. See MMWR 1999;48(RR-12):1-37. 8. Influenza vaccine. Influenza vaccine is recommended annually for children age >6 months with certain risk factors (including but not limited to children with asthma, cardiac disease, sickle cell disease, human immunodeficiency virus infection, and diabetes; and household members of persons in high-risk groups [see MMWR 2003;52(RR-8):1-36]) and can be administered to all others wishing to obtain immunity. In addition, healthy children age 6 to 23 months are encouraged to receive influenza vaccine if feasible, because children in this age group are at substantially increased risk of influenza-related hospitalizations. For healthy persons age 5 to 49 years, the intranasally administered live-attenuated influenza vaccine (LAIV) is an acceptable alternative to the intramuscular trivalent inactivated influenza vaccine (TIV). See MMWR 2003;52(RR-13):1-8. Children receiving TIV should be administered a dosage appropriate for their age (0.25 mL if age 6 to 35 months or 0.5 mL if age >3 years). Children age <8 years who are receiving influenza vaccine for the first time should receive 2 doses (separated by at least 4 weeks for TIV and at least 6 weeks for LAIV)15

  Chemoprophylaxis

Aspirin for the prevention of cardiovascular events:

The United States Preventive Services Task Force (USPSTF) recommends that physicians discuss aspirin chemoprophylaxis with patients at increased risk for coronary heart disease. ¹⁶ This discussion should include both the risks and benefits of aspirin chemoprophylaxis. The decision to initiate aspirin therapy should be guided by the patient's overall risk for coronary heart disease ¹⁷ as well as patient preferences. Coronary heart disease risk calculators can be found at http://hin.nhlbi.nih.gov/atpiii/calculator.asp?usertype=prof and http://www.intmed.mcw.edu/clincalc/heartrisk.html .   

Tamoxifen or raloxifene for prevention of breast cancer

The USPSTF recommends against the routine use of tamoxifen or raloxifene for the primary prevention of breast cancer in women at low or average risk for breast cancer. Clinicians should discuss chemoprevention with women at high risk for breast cancer.

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There are a number of ways to improve patient education and counseling:

Develop a system that works for you.

Make prevention a part of every visit.

Try to frame the teaching to match the patient's culture and belief systems. Ask questions like "What do you think of when you hear someone talk about heart disease?" or "Why do you think it's hard for you to stop smoking?" to elicit the patient's beliefs about certain health issues.

Give the patient complete information concerning the purpose and expected effects of your interventions and when to expect these effects.

Suggest small changes at a time. Ask patients to do slightly more than they already are doing.

Be specific. Written information is best. Be sure to make the written material at an appropriate educational level for your patient population. (national average reading level 8th grade, LSUSHC average reading level 5th grade)

Adding new behaviors is sometimes easier than trying to change old ones. For example, suggesting an exercise program for weight loss may be more effective than trying to change existing dietary patterns.

Link new behaviors with old ones, like taking medicines when brushing teeth.

Use the power of the profession. Don't be afraid to say, "I want you to stop smoking."

Obtain specific commitments from patients. For example, ask patients who say they are going to increase their exercise exactly what they intend to do and how often.

Use a combination of methods. Group classes, audiovisual aids, written materials, and community resources combined have a greater impact than any one method alone.

Involve other health professionals such as dietitians, patient educators, and nurses in the education process.

Refer.

Provide close follow-up.

1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services
2. National Vital Statistics Report, Vol. 52, No 13
3.   National Highway Safety Administration: Traffic Safety Facts 2001
4.   National Highway Safety Administration: Traffic Safety Facts- Restraints
5. Joshipura KJ, Hu FB, Manson JE, et al. The effect of fruit and vegetable intake for coronary heart disease. Ann Intern Med 2001; 134(12): 1106-14
6. de Lorgeril M, Salen P, Martin JL, et al. Medterranean diet, traditional risk factiors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation 1999;99(6):779-85
7. Curtis BM, O'Keefe JH. Understanding the Mediterranean diet. Postgrad Med 2002;112(2):35-44
   
8. Renaud S, de Lorgeril M, Delaye J, Guidollet J, Jacquard F, Mamelle N, et al. Cretan Mediterranean diet for prevention of coronary heart disease. Am J Clin Nutr 1995;61 (Suppl 6):1360-7.
9. de Lorgeril M, Renaud S, Mamelle N, Salen P, Martin JL, Monjaud I, et al. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lance t 1994;343:1454-9 [Published erratum appears in Lancet 1995;345:738].
10. The President's Council on Physical Activity and Sports
    
11. Frame and Carlson, J Fam Pract 1975;2:29-36
12. Frame and Carlson, J Fam Pract 1975;2:123- 129
13. Frame and Carlson, J Fam Pract 1975;2:189-194
14. Frame and Carlson, J Fam Pract 1975;2:283-289
15. Recommended Childhood Immunization Schedule 2004
16. U.S. Preventive Services Task Force: Aspirin
17. Wilson, PW, et. al. Prediction of Coronary Heart Disease Using Risk Factor Categories. Circulation 1998 97 (18): 1837-1847

Suggested Reading

The Prostate Specific Antigen Era in the United States is over for Prostate Cancer: What Happened in the Last 20 Years?  The Journal of Urology, October 2004
Mediterranean Diet, Lifestyle Factors, and 10-Year Mortality in Elderly European Men and Women  JAMA Vol. 292 No. 12, September 22/29, 2004
Prostate Cancer Screening: More Harm Than Good?   American Family Physician. August 1998. 
Colorectal Cancer: Risk Factors and Recommendations for Early Detection . American Family Physician. June 1999.
Screening for Genetic Risk of Breast Cancer. American Family Physician. January 1999.
Breast Cancer in Older Women American Family Physician. October 1998.
Dietary Therapy for Preventing and Treating Coronary Artery Disease American Family Physician. March 1998.
Bright Futures-Developmentally Appropriate Physical Activity: A Guide for Health Professionals
Recommended Childhood Immunization Schedule, January-December 2004
Cancer Screening Guidelines American Family Physician. March 2001
AAFP Summary of Policy Recommendations for Periodic Health Examiniation
A Third Report of the Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults