A checklist to stay healthy at every age

University of Chicago Medical CenterMay 7 2010

Can a young doctor's advice to his mother save 100,000 lives a year?

Shantanu Nundy, MD, a second-year resident in internal medicine at the University of Chicago Medical Center may soon find out. Driven by his mother's health questions and the difficulty of providing simple, reliable answers, Nundy collected all of the "generally accepted truths" about preventing disease, organized them into checklists based on age, and persuaded the Johns Hopkins University Press to publish them as Stay Healthy at Every Age: What Your Doctor Wants you to Know.

"We all know it is far better to prevent an illness than to treat it," said Nundy, "yet because millions of Americans don't know these things, and doctors don't take the time to tell or remind them, thousands die each year from preventable disease."

Five well-established but little-used measures, he argues, could save 100,000 lives a year, things as simple as taking a daily aspirin or getting a flu shot. Yet, misled by a system designed to treat the sick rather than preserve health, fewer than half of those who could benefit know about and bother to take those simple steps. This guide gives readers the tools to understand and acquire the preventive services they need.

Checklists, the simpler the better, have recently gained status in the world of medicine. First employed in intensive care units, where complexity is vast, stakes are high and errors can be lethal, they have helped caregivers establish a higher standard of performance. Checklists serve to "make explicit the minimum, expected steps in complex processes," according to Atul Gawande, MD, a surgeon who has written a book about their value in medicine. They can lower infection rates, prevent complications and reduce time in the hospital.

Nundy has adopted the checklist approach but shifted it from the complex world of the ICU to primary care, and from the doctor to the patient.

The idea came from his mother. She struggles with type-2 diabetes. As a medical student, eager to help, he combed through his texts and patient encounters looking for ways to keep her healthy. He found quite a few-nothing new or surprising, but a long list of established, verified recommendations.

He was surprised to learn, however, that although his mother saw a physician regularly, much of the standard advice was new to her.

"She has a doctor," he said. "She has insurance. She has a college education and worked for the World Bank. But she didn't know a lot of the basic steps."

So he stepped in, with constant advice on medicines and tests, diet and exercise. Over time, thanks to his diligence, the suggestions piled up. They soon became overwhelming.

So Nundy began searching the medical literature for simple comprehensive lists of which steps to take, which tests to consider at each age and which ones to avoid. He found pieces of what his mother needed, but they were spread over many sources, primarily guidelines from the United States Preventive Services Task Force and the Centers for Disease Control and Prevention. He could not, however find all the preferred advice in one place, so he set out to compile it himself. That led to the book.

The core of the 366-page book is 18 pages of lists, the current state of the art of preventive health through each phase of life. There is a one-page checklist for early childhood and two pages for adolescents or those in their 20s. With age comes extra pages: three each for the 30s, 40s, 50 to 64, and 65 and over. Some advice is for everyone, some just for women or men, with additional measures for people at greater risk for specific ailments.

Early childhood is mostly about screening and vaccinations. Sexually transmitted disease become a prominent health issue during adolescence and never quite goes away. Diet and exercise, and alcohol and tobacco use, come to the fore in the 20s and 30s. Cardiovascular issues gain prominence in the 40s, especially for men, and breast cancer prevention and detection for women. Colon cancer screening tops the list for the 50s. After 65, vaccinations re-emerge as a crucial prevention tool. At age 80, those who started taking aspirin in their 40s or 50s can stop.

Many readers will be surprised by Nundy's emphasis on adult vaccines, a little-known but effective prevention tool. Vaccines "are not just for children anymore," he said, but because of lack of awareness, only one in three adults who should get a flu vaccine each year does so, one in four gets the pneumococcal vaccine to prevent pneumonia, and one in 50 gets the vaccine to prevent shingles. Instead, one in three Americans gets shingles.

Some widely promoted health measures, on the other hand, don't make the list. Despite nationwide campaigns for prostate cancer screening, the benefits remain uncertain, so no recommendation. Nor do vitamin supplements help those who eat a healthy diet. "They aren't cheap," Nundy said. "They aren't covered by insurance. It's just an extra pill."

What he does recommend is an annual visit to the doctor, ideally while healthy. Most people don't go to the doctor unless they're sick. They come when they feel lousy, he said, so diagnosis and treatment trump prevention. "If you come when you're well, for a prevention visit, there's a huge value that accumulates over time."

Although not in the book, he's now tackling the next issue: how can doctors persuade patients to heed their collected advice. Nundy and colleagues are testing a report-card system in patients at risk for cardiovascular problems. The report focuses on five key contributors to heart disease: blood pressure, cholesterol, smoking status, diabetes and weight.

"We give them a simple little table that lists where they are now, how they compare to others their age, where they need to go, and how we're going to get them there. They take this home and put it on the fridge. So the implications of what they are, or are not, doing cross their path at every meal. It seems to make an impact."

How does a medical resident, who works 80 hours a week and maintains a preventive health blog find time to produce a book? Nundy has a history of extracurricular productivity. As an undergraduate at MIT, he started a part-time clinic to provide free care for 2500 people in a small village outside of Kolkata, India. It's still in operation. The experience reinforced his decision to go into medicine, and gave him "a profound appreciation of what we all are capable of achieving."

The experience also drove home the benefits of low-tech medicine tied to simple but effective communication.

Every year, he said, billions of dollars goes into developing new drugs or new technology to treat advanced disease, much of which we could have prevented. "We need new and better drugs," he admitted, "but we also need new and better methods to transmit a few simple, basic messages to people in a way that they can understand and follow. That, and the notion that it could help people like my mom, helped me finish this project."