Preventive Medicine in Wales

1
Preventive Medicine in Wales
Peter Elwood Cochrane Institute of Primary Care
and Preventive Medicine Cardiff University

• Eyecare Conference
• Optometry Wales 19th September 2012

2
Eyecare in Wales

• My aims in this talk

• 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

3
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
4
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 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
5
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 prevalence and the importance of disease
• to plan services more effectively and
  efficiently
• to evaluate the importance of services more
  precisely

Efficiency and effectiveness Evidence-based
practice cost-effective practice
2. To identify factors predictive of disease
to obtain clues about possible preventive
measures
Prophylaxis, rather than therapy
6
Cochrane believed that epidemiology can make
important contributions to every area of clinical
practice
Archie Cochrane 1909-1988
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The Ferndale Study of Eye Disease 1964
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The Ferndale Glaucoma Survey 1964
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The Ferndale Team Tom Benjamin, Diana Seys
Prosser, Archie Cochrane Hugh bates ? . ? , ?,
Peter Graham ? Gwillam Jonathan, Irene Calford,
Fred Moore, Glenys, ?.
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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
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General examination
- details questionnaire on health and social
issues - blood pressure measurement
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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
13
Output
Hollows FC Graham PA. Intraocular pressure,
glaucoma and glaucoma suspects in a defined
population. Brit J Ophthal 196650570-586
McGuinness R. Association of diabetes and
cataract. BMJ 1967i416-7 Graham PA
Screening for chronic glaucoma. Symposium on
Presysymptomatic Diagnosis Graham PA,
Wallace J, Welsby E, Grace HJ. Evaluation of
postal detection of registrable blindness. Brit
J prev soc Med. 196822238-41.
14
Output
Hollows FC Graham PA. Intraocular pressure,
glaucoma and glaucoma suspects in a defined
population. Brit J Ophthal 196650570-586
McGuinness R. Association of diabetes and
cataract. BMJ 1967i416-7 Graham PA
Screening for chronic glaucoma. Symposium on
Presysymptomatic Diagnosis Graham PA,
Wallace J, Welsby E, Grace HJ. Evaluation of
postal detection of registrable blindness. Brit
J prev soc Med. 196822238-41.
Unless a follow-up is successfully concluded
the value of eye screening tests in preventive
ophthalmology would seem to be doubtful. ophthalm
ologist
15
Output
Hollows FC Graham PA. Intraocular pressure,
glaucoma and suspects in a defined population.
Brit J Ophthal 196650570-586 McGuinness R.
Association of diabetes and cataract. BMJ
1967i416-7 Graham PA Screening for chronic
glaucoma. Symposium on Presysymptomatic
Diagnosis Graham PA, Wallace J, Welsby E,
Grace HJ. Evaluation of postal detection of
registrable blindness. Brit J prev soc Med.
196822238-41.
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Fred Holllows (1929-1993)
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Fred Hollows
Fred worked with Archie Cochrane on the Ferndale
Eye Study in 1964. He then left and went to
Australia.
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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
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Fred Hollows
Companion of the Order of Australia
Gabi Hollows Orthoptist
named as one of Australias 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
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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.
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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)
22
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
23
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 under-privileged communities would
continue. The Fred Hollows Foundation is is now
a major international charity
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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
25
In 1993 Fred Hollows died, aged 63 He was given
a state funeral.
26
Commerative stamps in Australia
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Commerative stamps in Eritrea
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Commerative coin in Australia
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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!
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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
Ralph Marshall (Seys Prosser)
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Fred Hollows worked in Wales!
I have therefore proposed that a panel is
erected in the Cochrane Building, with Freds
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
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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
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• My aims in this talk

• 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

34
Fred Hollows 1929-1993 An inspiration to all of
us in healthcare
A challenge to widen your horizons!
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Wales holds many records!
Smoking Alcohol abuse Obesity Lack of
exercise Inappropriate diet
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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
37
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
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A healthy lifestyle its effectiveness and its
up-take in Wales
The five healthy behaviours
Non-smoking BMI 18-25
½ hour exercise daily Five a day
Alcohol within
the guidelines
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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
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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
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The effectiveness of a healthy lifestyle
Healthy lifestyles
Healthy lifestyles Diabetes Ht. disease and stroke Dementia All deaths
No healthy behaviour Any two (813 men) Any three (436) Four/five (112) 1 1 1 1
Significance of trend
REDUCTIONS (based on ORs) over the following 30
years
All relationships adjusted for age and social
class And dementia for baseline cognitive function

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The effectiveness of a healthy lifestyle
Healthy lifestyles
Healthy lifestyles Diabetes Ht. disease and stroke Dementia All deaths
No healthy behaviour Any two (813 men) Any three (436) Four/five (112) 1 -35 -66 -72 1 1 1
Significance of trend 0.001
REDUCTIONS (based on ORs) over the following 30
years
All relationships adjusted for age and social
class And dementia for baseline cognitive function

43
The effectiveness of a healthy lifestyle
Healthy lifestyles
Healthy lifestyles Diabetes Ht. disease and stroke Dementia All deaths
No healthy behaviour Any two (813 men) Any three (436) Four/five (112) 1 -35 -66 -72 1 -17 -34 -67 1 -44 -72 -68 1 -8 -36 -32
Significance of trend 0.001 0.0005 0.002 0.002
REDUCTIONS (based on ORs) over the following 30
years
All relationships adjusted for age and social
class And dementia for baseline cognitive function

44
The effectiveness of a healthy lifestyle
Healthy lifestyles
Healthy lifestyles Diabetes Ht. disease and stroke Dementia All deaths
No healthy behaviour Any two (813 men) Any three (436) Four/five (112) 1 -35 -66 -72 1 -17 -34 -67 1 -44 -72 -68 1 -8 -36 -32
Significance of trend 0.001 0.0005 0.002 0.002
REDUCTIONS (based on ORs) over the following 30
years
All relationships adjusted for age and social
class And dementia for baseline cognitive function

45
The effectiveness of a healthy lifestyle
Healthy lifestyles
Healthy lifestyles Diabetes Ht. disease and stroke Dementia All deaths
No healthy behaviour Any two (813 men) Any three (436) Four/five (112) 1 -35 -66 -72 1 -17 -34 -67 1 -44 -72 -68 1 -8 -36 -32
Significance of trend 0.001 0.0005 0.002 0.002
REDUCTIONS (based on ORs) over the following 30
years
Another measure of benefit 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
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The effectiveness of a healthy lifestyle
Healthy lifestyles
Healthy lifestyles Diabetes Ht. disease and stroke Dementia All deaths
No healthy behaviour Any two (813 men) Any three (436) Four/five (112) 1 -35 -66 -72 1 -17 -34 -67 1 -44 -72 -68 1 -8 -36 -32
Significance of trend 0.001 0.0005 0.002 0.002
REDUCTIONS (based on ORs) over the following 30
years
Yet another measure of benefit Had the subjects
in this 30 year study each been urged at baseline
to adopt one additional healthy behaviour, and if
only half them had complied, there would have
been.
All relationships adjusted for age and social
class And dementia for baseline cognitive function

12 less diabetes 6 less vascular
disease 13 less dementia 5 fewer deaths
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Eye disease and Healthy Behaviours
?Eye disease and a Healthy Lifestyle?
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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
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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
Prospective epidemiological studies are
invaluable! Some records of the Ferndale study
are still available The Speedwell Prospective
Study in Bristol, set up in 1979, has data on
healthy behaviours and on macular degeneration
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
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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.
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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
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Healthy Behaviours in Wales
Target non-smoking 25 of adults still
smoke 28 of 15-year-old girls still smoke
50 overweight or obese
Of the adult population in Wales Only 1
meet the targets for all five healthy
behaviours Only 7 meet four of the
targets
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
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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,
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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
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AN ENCOURAGEMENT
..up your game!
A CHALLENGE
AN INSPIRATION
..widen your horizons!
Fred Hollows worked here!
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AN ENCOURAGEMENT
..up your game!
Public health gather evidence on
cost-effectiveness Epidemiology seek evidence
on possible preventive measures
A CHALLENGE
AN INSPIRATION
..widen your horizons!
Fred Hollows worked here!
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www.championsforhealth.wales.nhs.uk  Closing
date Friday 28 September.