Preventive Medicine
in Wales
Peter Elwood
Cochrane Institute
of Primary Care and Preventive Medicine
Cardiff University
Eyecare Conference
Optometry Wales: 19th September 2012
Eyecare in Wales
• My aims in this talk:
1. To encourage you in the life-changing and
life-enriching work you do
2. To challenge you to ‘up your game’ and to
‘widen your horizons’
Epidemiology
• There are three sources of evidence in medicine:
- clinical studies → effects of treatment; prognosis etc
- laboratory studies → mechanisms in disease
- epidemiology and Public Health - The Truth
Epidemiology
• There are three sources of evidence in medicine:
- clinical studies → effects of treatment; prognosis etc
- laboratory studies → mechanisms in disease
- epidemiology and Public Health
1. The prevalence and the importance of disease
to plan services more effectively and efficiently
to evaluate the importance of services more precisely
2. To identify factors predictive of disease
to obtain clues about possible preventive measures
Epidemiology
• There are three sources of evidence in medicine:
- clinical studies → effects of treatment; prognosis etc
- laboratory studies → mechanisms in disease
- epidemiology and Public Health
1. The prevalence and the importance of disease
to ‘Efficiency
plan servicesand
more
effectively and efficiently
effectiveness’
‘Evidence-based
practice’;
‘cost-effective
to evaluate
the importance
of servicespractice’
more precisely
2. To identify factors predictive of disease
to obtain clues about possible preventive measures
‘Prophylaxis, rather than ‘therapy’
Cochrane believed that epidemiology
can make important contributions to
every area of clinical practice
Archie Cochrane 1909-1988
The Ferndale Study of Eye Disease 1964
The Ferndale Glaucoma Survey 1964
The Ferndale Team
Tom Benjamin, Diana Seys Prosser, Archie Cochrane Hugh bates ? . ? , ?, Peter Graham ? Gwillam Jonathan, Irene Calford, Fred Moore, Glenys, ?.
The Ferndale Survey
4,246 people aged 40-75 were seen and examined
AIMS:
1. Determine the prevalence of eye diseases
2. Define the distribution of intraocular pressure
3. Determine the prevalence of glaucoma
4. Test a treatment of glaucoma in a randomised trial
5. Conduct long-term follow-up studies of the population
to study the development and the prognosis of various
eye-diseases
General examination:
- details questionnaire on health and social issues
- blood pressure measurement
Ophthalmic examination:
- general examination, with ophthalmoscopy
- field examination with the Friedman multiple pattern type machine
- instillation of fluorescine and local anaesthetic
- slit lamp examination
- applanation tonomotry
- Schiotz tonomotry
Output:
Hollows FC & Graham PA. Intraocular pressure, glaucoma and glaucoma
suspects in a defined population. Brit J Ophthal 1966;50:570-586
McGuinness R. Association of diabetes and cataract.
Graham PA Screening for chronic glaucoma.
BMJ 1967;i:416-7
Symposium on Presysymptomatic
Diagnosis
Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal
detection of registrable blindness. Brit J prev soc Med. 1968;22:238-41.
Output:
Hollows FC & Graham PA. Intraocular pressure, glaucoma and glaucoma
suspects in a defined population. Brit J Ophthal 1966;50:570-586
McGuinness R. Association of diabetes and cataract.
Graham PA Screening for chronic glaucoma.
BMJ 1967;i:416-7
Symposium on Presysymptomatic
Diagnosis
Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal
detection of registrable blindness. Brit J prev soc Med. 1968;22:238-41.
Output
Hollows FC & Graham PA.
Intraocular pressure, glaucoma and
suspects in a defined population. Brit J Ophthal 1966;50:570-586
McGuinness R. Association of diabetes and cataract.
Graham PA Screening for chronic glaucoma.
BMJ 1967;i:416-7
Symposium on Presysymptomatic
Diagnosis
Graham PA, Wallace J, Welsby E, Grace HJ. Evaluation of postal
detection of registrable blindness. Brit J prev soc Med. 1968;22:238-41.
Fred Holllows
(1929-1993)
Fred Hollows
Fred worked with Archie
Cochrane on the Ferndale
Eye Study in 1964.
He then left and
went to Australia.
Fred Hollows
‘Companion of the
Order of Australia’
Yet Fred was a Maverick and one
writer describes him as
“The wild boy of New Zealand’
Fred Hollows
‘Companion of the
Order of Australia’
Gabi Hollows Orthoptist
named as one of
Australia’s 100 Living Treasures
and given an
Advanced Australia Award
for community service
‘worked tirelessly with Fred until
his death. Together they set up
The Fred Hollows Foundation
to continue the work of eyecare
in Australia and overseas’
‘Hollows took up the cause
of the Aborigines. He set
up ‘The Aboriginal
Medical Service’ and ‘The
National Trachoma and
Eyehealth Programme’.
‘Over 100,000 Aborigines
were examined and tens of
thousands treated.’
‘Then, despite increasing
ill health, he expanded
his work to Eritrea, to
Nepal and to Vietnam.’
‘A Tireless Innovator, Healer & Campaigner’
‘A passionate ophthalmologist…’
‘He restored the eyesight of
countless thousands of
underprivileged people in
developing countries‘.
‘He had a passion to improve their
health in every way possible.’
‘It has been estimated
that through his work,
over one million people
had their sight restored
around the world.’
Fred Hollows (1929-1993)
Shortly before his
death,
Fred organised
the setting up of a
factory in Eritrea
to manufacture
inexpensive
intra-occular
lenses for use in
underprivileged
communities
A year before he died,
Fred and Gabi set up the
‘Fred Hollows
Foundation’
to continue the work he
had started amongst the
Aborigines and amongst
many other underprivileged communities
would continue.
The Fred Hollows Foundation
is is now a major international
charity
1981: Advance Australia Award for Aboriginal eye care.
1985: was a consultant to the World Health Organisation (WHO).
1985: offered appointment as an honorary Officer (AO) of the Order of Australia.
1990: received Human Rights Medal
1990: named Australian of the Year
1990: received a second Advance Australia Award, for Medicine and Overseas Aid
1991: named Humanist of the Year
1991: named a Paul Harris Fellow by Rotary International
1991: received Honorary Doctor of Medicine and Doctor of Science, University of New South Wales
1991: appointed Companion of the Order of Australia (AC)
1991: awarded Honorary Doctorate of Science, Macquarie University
1991: named the first honorary citizen of Eritrea
1992: received Honorary Doctorate, Queensland University of Technology
1993: received Albert Schweitzer Award of Distinction, Chapman University, USA
1993: received Rotary International's highest honour, the Rotary Award for World Understanding.
1993: received the Royal Australian College of Ophthalmologists Medal for his years of distinguished
meritorious and selfless service – presented to him the night before he died.
1993: posthumously named a Melvin Jones Fellow of Lions Clubs International.
1993: Fred Hollows Reserve in Hollow's hometown of Randwick, NSW Australia established
to preserve a natural rainforest gully and save it from future development.
2004: entered into the 'Hall of Fame' at the inaugural NSW Aboriginal Health Awards,
in recognition of his "outstanding contribution and achievement to Indigenous health in Australia".
2005: an operating theatre was named after him at Canberra Eye Hospital, ACT, Australia.
2005: named one of "New Zealand's Top 100 History Makers" by Prime Television New Zealand.
2006: named one of the "100 most influential Australians" by The Bulletin magazine.[15]
2010: featured on $1 Coin from the Royal Australian Mint as part of the Inspirational Australians Series
Hollows received twenty three
National and International awards
In 1993 Fred Hollows died, aged 63
He was given a state funeral.
Commerative stamps in Australia
Commerative stamps in Eritrea
Commerative coin in Australia
Fred Hollows worked in Wales!
In his autobiography, Hollows wrote:
“The most important influence on me in Wales was Archie
Cochrane… Archie and I co-operated in the Ferndale Study of
Eye Disease. Without that project in Wales, my later
work amongst the Aborigines and in other countries
would not have achieved what it did’.
(Quotation slightly adapted)
Yet, there is no record of Hollows in Wales
and only a very few remember him!
Sadly, and remarkably, there seems to be
no record of Hollows in Wales
and few seem to remember him
“Fred was a delightful man to work with. He had a lovely way
with subjects, especially if they were nervous…. Three years
after Ferndale I went to Australia and worked with Fred on
one of his mobile teams in the bush. It was hard work but
everyone enjoyed working with him. He was a truly dedicated
person and he himself worked very hard indeed.” Diana Pritchard
Diana Pritchard
(Seys Prosser)
Ralph Marshall
Fred Hollows worked in Wales!
I have therefore
proposed that a panel is
erected in the Cochrane
Building, with Fred’s
image, an account of
his work in Ferndale,
and details of his work
in Australia and in other
countries.
With postage stamps from
Australia and from Etreia
and two Australian coins
Fred Hollows
1929-1993
An inspiration to all of us
in healthcare
and especially to
you in Eyecare
in your
life-changing and
life-enriching
work in the
community
• My aims in this talk:
1. To encourage you in the life-changing
and life-enriching you do
2. To challenge you to ‘up your game’ and
to ‘widen your horizons’
Fred Hollows
1929-1993
An inspiration to all of us
in healthcare
A challenge to widen
your horizons!
Wales holds many records!
Smoking
Alcohol abuse
Obesity
Lack of exercise
Inappropriate diet
Health in Wales!
Cost of unhealthy behaviours to NHS Wales*
Smoking
£386 m
Obesity
£ 86 m
Lack of exercise
?
Inappropriate diet
?
Alcohol abuse £ 70 m
10% of total
NHS costs! *
* Making the economic case for prevention: a view from Wales.
Welsh Government Report: Hale, Phillips, Jewel 2012
And so, a number of our colleagues in Public
Health have launched….
Champions for Health
Stakeholder Briefing
A new campaign for a healthier Wales
A new campaign to encourage all NHS staff in
Wales to adopt a healthier lifestyle themselves
and become role-models and
encourage patients
and the public to do the same
A healthy lifestyle
its effectiveness and its up-take in Wales
The five
healthy behaviours
Non-smoking
‘Five a day’
BMI 18-25
½ hour exercise daily
Alcohol within
the guidelines
The Caerphilly Prospective Study
THE CAERPHILLY PROSPECTIVE STUDY 1980 -
2,500 men aged 45-59 yrs; First examined in 1980
re-questioned and re-examined every five years since then
The effectiveness of a healthy lifestyle
HEALTHY BEHAVIOURS at baseline in 1980
Non-smoking
Body weight
Diet
Exercise
Alcohol intake
Recorded for 2,500 men aged 45-59 yrs
OUTCOMES during the following 30 years
Diabetes, vascular disease, cancer, dementia and all-cause death
Output:
Around 400 reports published in medical journals
The effectiveness of a healthy lifestyle
Healthy
lifestyles
No healthy behaviour
REDUCTIONS (based on ORs) over the following 30 years
Diabetes
Ht. disease and
stroke
Dementia
All
deaths
1
1
1
1
Any two (813 men)
Any three (436)
Four/five (112)
Significance of trend
All relationships adjusted for age and social class
And dementia for baseline cognitive function
The effectiveness of a healthy lifestyle
Healthy
lifestyles
REDUCTIONS (based on ORs) over the following 30 years
Diabetes
Ht. disease and
stroke
Dementia
All
deaths
No healthy behaviour
1
1
1
1
Any two (813 men)
-35%
Any three (436)
-66%
Four/five (112)
-72%
Significance of trend
0.001
All relationships adjusted for age and social class
And dementia for baseline cognitive function
The effectiveness of a healthy lifestyle
Healthy
lifestyles
REDUCTIONS (based on ORs) over the following 30 years
Diabetes
Ht. disease and
stroke
Dementia
All
deaths
No healthy behaviour
1
1
1
1
Any two (813 men)
-35%
-17%
-44%
Any three (436)
-66%
-34%
-72%
-8%
-36%
Four/five (112)
-72%
-67%
-68%
-32%
Significance of trend
0.001
0.0005
0.002
0.002
All relationships adjusted for age and social class
And dementia for baseline cognitive function
The effectiveness of a healthy lifestyle
Healthy
lifestyles
REDUCTIONS (based on ORs) over the following 30 years
Diabetes
Ht. disease and
stroke
Dementia
All
deaths
No healthy behaviour
1
1
1
1
Any two (813 men)
-35%
-17%
-44%
Any three (436)
-66%
-34%
-72%
-8%
-36%
Four/five (112)
-72%
-67%
-68%
-32%
Significance of trend
0.001
0.0005
0.002
0.002
All relationships adjusted for age and social class
And dementia for baseline cognitive function
The effectiveness of a healthy lifestyle
Healthy
lifestyles
REDUCTIONS (based on ORs) over the following 30 years
Diabetes
Ht. disease and
stroke
Dementia
All
deaths
No healthy behaviour
1
1
1
1
Any two (813 men)
-35%
-17%
-44%
Any three (436)
-66%
-34%
-72%
-8%
-36%
-67%
-68%
-32%
0.0005
0.002
0.002
Four/five (112)
-72%
Another measure of benefit:
Significance of trend
0.001
The number of years before disease in subjects following a healthy
lifestyle will become the level in those who follow no healthy behaviour
All relationships adjusted for age and social class
And dementia for baseline cognitive function
For heart disease and stroke……..up to 13 years
For dementia
………up to 7 years
For death
……… up to 6 years
The effectiveness of a healthy lifestyle
Healthy
lifestyles
REDUCTIONS (based on ORs) over the following 30 years
Diabetes
Ht. disease and
stroke
Dementia
All
deaths
No healthy behaviour
1
1
1
1
Any two (813 men)
-35%
-17%
-44%
Any three (436)
-66%
-34%
-72%
-8%
-36%
-67%
-68%
-32%
Four/five
-72%
Yet
another (112)
measure of
benefit:
Significance
of trend in this0.001
0.002
0.002
Had
the subjects
30 year study0.0005
each been urged
at baseline
to
adopt one additional healthy behaviour, and if only half them had
relationships
adjusted for age and social class
complied, there wouldAllhave
been….
And dementia for baseline cognitive function
12% less diabetes;
6% less vascular disease
13% less dementia; 5% fewer deaths
Eye disease and Healthy Behaviours
?Eye disease
and a Healthy Lifestyle?
Eye disease and Healthy Behaviours
Two to three-fold increase in cataract in smokers, and
a two to three-fold increase in macular degeneration
American Council on Science and Health
Obesity increases risk of macular degeneration (Arch Ophthalmol. 2009)
?Increase cataract, glaucoma and diab. retinopathy Israli claim
Mediterranean diet (fish, nuts, and olive oil) beneficial Cheong; Tan
Sat. fats increase macular degeneration (Arch Ophthalmol. 2009)
Beneficial impact on ocular perfusion pressure and glaucoma,
macular degeneration 30% lower Brit J Ophthal.
Uncertainty about relationships with the eye
Wang S, Wang JJ, Wong TY.Surv Ophthalmol. 2008
Healthy Behaviours in Wales
Two to three-fold increase in cataract in smokers, and
a two to three-fold increase in macular degeneration
American Council on Science and Health
Possible increase in macular degeneration, cataract, glaucoma
and diabetic retinopathy Claim in a report from Israel
Obesity increases risk of macular degeneration
Mediterranean diet (fish, nuts, and olive oil) beneficial Cheong; Tan
Sat. fats increase macular degeneration (Arch Ophthalmol. 2009)
beneficial impact on ocular perfusion pressure and glaucoma,
macular degeneration 30% lower Brit J Ophthal.
Uncertainty about relationships with the eye
Wang S, Wang JJ, Wong TY.Surv Ophthalmol. 2008
The effectiveness of a healthy lifestyle
Overall summary……..
Following a healthy lifestyle
substantially reduces the risk of diabetes,
heart disease and death…..
and….. risk of certain eye diseases reduced
and….. during the extra years of life,
the risk of dementia is reduced
BUT, the bad news is…….
Unhealthy Behaviours in Wales
Target: non-smoking
25% of adults still smoke
28% of 15-year-old girls smoke
Target: BMI below 25
50% overweight or obese
Target: ‘5 a day’
66% fail to meet the target
Target: moderate exercise ½ hour x five/week
70% fail to reach the target
Target: drinking within guidelines
47% regularly exceed guidelines
28% admit to frequent ‘binge’ drinking
Healthy Behaviours in Wales
Target: non-smoking
25% of adults still smoke
28% of 15-year-old girls still smoke
50% overweight or obese
Target: ‘5 a day’
66% fail to meet the target
Target: moderate exercise ½ hour x five/week
70% fail to reach the target
Target: drinking within guidelines
47% regularly exceed guidelines
Champions for Health
Stakeholder Briefing
A project to encourage all healthcare
staff in Wales to become role models of
healthy living
and encouragers of patients and others
to follow a healthy lifestyle
The project is led by Directors of Public Health,
Champions for Health
Stakeholder Briefing
NHS Wales staff can register to take part in
Champions for Health, at:
www.championsforhealth.wales.nhs.uk
Closing date: Friday 28 September
AN ENCOURAGEMENT
…..up your game!
AN INSPIRATION
…Fred Hollows worked here!
A CHALLENGE
…..widen your horizons!
AN ENCOURAGEMENT
…..up your game!
Public health: gather evidence on cost-effectiveness
Epidemiology: seek evidence on possible preventive measures
AN INSPIRATION
…Fred Hollows worked here!
A CHALLENGE
…..widen your horizons!
www.championsforhealth.wales.nhs.uk
Closing date: Friday 28 September.