Prevention medicine is not just a blood test
A look at how we can focus on long term health based on two patient consultations in clinic this week
Zoe came in for a blood test, whereas John asked how we can prevent his future risk of illness.
Through discussing these consultations, we look at how you can make the most of your health consultations and work towards preventing the health conditions that really matter.
Zoe regards herself as healthy, goes on retreats to support her health, wellbeing and eats a range of food.
She avoids unhealthier sources of ultra-processed foods where possible, chooses to cook her own foods, rarely eats take outs and doesn’t drink any alcohol or smoke.
Zoe told me she’s predominantly plant-based, so she’s a bit worried about her nutrition intake of vitamins and that’s the main reason she’s come today. She doesn’t have any significant medical conditions or major medical history in the past.
Her agenda was to get her blood tests done, and find out what deficiencies she might have.
Previous tests have not found any deficiencies, and she has been doing this regularly over the past few years. She asked for magnesium as part of the tests; she’s clearly done some reading and aware of the potential impact of certain vitamins.
The impact on her long term health
There is always the possibility that she could have a deficiency, but with her lifestyle this is unlikely.
Zoe has decided to take control of her health. It may look like she is doing everything right, and that we can’t support her much more in her health prevention journey.
Yet, there are things we could do if we had more information and, if we could move away from the focus on blood tests.
Zoe isn’t wrong to ask for her blood tests
I requested more than vitamins, we considered the rest of her metabolic health profile including cholesterol.
We got Zoe’s blood tests back and they were all ‘normal’. Similar to the ones she had last year. This was Zoe’s health check from her perspective. It was what she needed, and she left a happy customer.
But there was a missed opportunity to really look at her overall health in the long-term.
Ultimately we want to protect the core drivers of poor ill health, illness and death:
Cardiovascular related illness - heart attacks and strokes
Metabolic - these are often the precursors to cardiovascular disease: diabetes, fatty liver disease, raised cholesterol and high blood pressure. These are also the main conditions that pre dispose to chronic kidney disease, neuropathy in the feet and contributing to eye disease and even dementia.
Musculoskeletal - osteoporosis, sarcopenia, fractures and pain
Memory - Preserving mental health, memory and preventing dementia
Malignancies - Preventing cancers.
We can instead target our conversations and consultations with patients to help make the healthiest choices that focus on preventing these illnesses, and creating a spectrum of resilience to move further away from illnesses.
John wanted to find out what he needed to do to protect his future health.
If there is anything more exciting than having the opportunity to have an open conversation with a patient about preventing future illness and focusing on their future self?
We went through his medical history, lifestyle and his family history.
We talked about his expectations for the future and what he was worried about.
We really did need to focus in on his heart health and disease prevention.
And when we focus on heart health. We also focus metabolic, musculoskeletal, memory and cancer prevention. They’re interlinked.
A more focused examination blood tests were arranged.
I listened to his heart to ensure there were no murmurs, checked his heart rate, took his blood pressure.
He had an ECG, and we arranged blood tests.
He had a fasting lipid profile, kidney, liver, blood counts checked. His standard profile included potassium, sodium, calcium and phosphate.
We didn’t focus on nutritional deficiencies but these are typically included.
He had a fasting cholesterol, also known as a lipid profile.
Because of his family history I recommended he should have an Lp(a) - a specific type of cholesterol particle that can significantly increase the risk of heart attacks for individuals, despite their healthy lifestyles.
It’s much more than just a standard cholesterol profile
It’s the discussion that you have with your health practitioner afterwards: How much do they really know about the cholesterol?
It’s in the detail: to understand and discuss his total cholesterol, HDL, LDL, non-HDL and fasting triglycerides, and understanding the ratios.
Then seeing how this impacts on long term risk, and how the actions John takes can help to change these numbers, and ultimately his risk of a heart attack.
John went for a CT Coronary Calcium Scan
Depending on your risk profile you might benefit from a CT coronary calcium scan. It comes with risks and benefits, including radiation exposure and is not 100% accurate, so a conversation is helpful with a practitioner.
John could have had a bone scan (DEXA) to check the strength of his bones, however based on his lifestyle this is unlikely to have been helpful.
He could have had a memory assessment but there was no suggestion that he had signs of dementia.
We could have arranged more nutrition analysis on his blood tests but this would unlikely have contribute to his future health protection.
John still does need to engage in his routine cancer screening as per the normal schedule. And of course if he develops symptoms they shouldn’t be ignored.
John had early signs of calcification.
Not a lot, but for someone in his early 50’s this was significant enough to consider a change in his medical management. His bad cholesterol (LDL and non-HDL) was raised despite his healthy lifestyle.
His Lp(a) however, was normal.
It could have been a different picture for John.
He may have had concerning changes, that would have led to a referral to the cardiologist to consider earlier intervention with possibly more intensive management of his cholesterol.
He didn’t have this which is reassuring. This, I think is worth knowing.
The impact for John
He knows that a statin is much more likely to be beneficial for him than previously expected. The earlier he takes it the more likely it would have an impact in the future.
He is aware that he has a higher risk than the average person; so he does need to continue his healthy lifestyle. This is significantly protective for him.
We have not just focused on medicines; we also had a discussion on vitamins and supplements.
John is going to take on a more intense lifestyle management of his cholesterol, combining dietary aspects of the ‘DASH diet’, ‘Mediterranean diet’ (pre-1960s Greek approach) and looking at the dietary eating patterns of the Blue Zones globally.
We know that a screen of a CT Coronary score in the future would likely be helpful for him to see if there is any progression.
He now has better control and information about his health. He can much better understand his heart risk.
Two contrasting consultations, both focused on health.
Both consultations were reasonable and met the patients’ immediate needs.
One consultation provided reassurance through normal results. The other identified future risk and led to decisions that may meaningfully reduce it.
Preventive care is most valuable when it moves beyond confirming normality and instead clarifies what is likely to cause harm in the future and how that risk can be modified.