PREVENTION OF CORONARY HEART-DISEASE

411

PREVENTION OF CORONARY HEART-DISEASE SIR,-We should like to reply to the many interesting comments on our paper (Nov. 17, p. 1137). First, screen-

ing. Obviously without screening we cannot discover those with hypertension and hyperlipidaemia, nor without inquiry can we identify the heavy smoker or the physically inert. Professor Morris (Dec. 22, p. 1435) agrees that high bloodpressure and high cholesterol are important risk factors, yet apparently believes that emphasis on screening is premature. Also he suggests that serum-cholesterol levels above 300 mg. per 100 ml. should be treated. However, since there is a near linear relationship between serumcholesterol and the incidence of coronary heart-disease, we consider that much lower levels should also be treated, particularly in those at high risk-that is to say, with other risk factors which are likely to be additive. He considers that exercise should be advocated primarily for its benefits on greater physical fitness and enjoyment. However, its benefit for the preservation of health is a powerful additional motive. He himself has shown that it is cardiopulmonary fitness which counts and this necessitates more vigorous exercise.1 We agree with Dr Thompson and his colleagues (Jan. 12, p. 63) and with Dr Lines (Jan. 5, p. 26) that screening is essential for the detection of those at high risk, since, if we cannot identify them, advice on preventive measures cannot be given. Part of the value of screening is the opportunity for advice to be given by a doctor on a multifactorial basis. We agree that the side-effects of screening and preventive advice need watching, especially as far as anxiety is concerned, but our experience, like that of others,2 is that confidence rather than anxiety is the usual result. In any case, by analogy it can be said that because a drug has side-effects it is not an indication to withhold it, but to observe its action. This is one of the reasons why we have advocated " feasibility trials in different general practices and health centres ", and we agree with Dr Mayou (Dec. 8, p. 1320) in demanding " larger scale and more comprehensive evaluation of primary prevention ". Greater disagreement concerns the evidence of the value of modifying risk factors, and here we take issue with Dr Mann (Jan. 12, p. 63) and with Dr Meade and his colleagues (Feb. 16, p. 269). Dr Mann believes that we have no proven methods for preventing coronary heartdisease, but his references are highly selective and much of the evidence to which we refer is ignored. The value of much of the advice we give as practising physicians regarding emotional stress, for example, is extremely difficult to prove, and, owing to the multifactorial nature of c.H.D., precise proof may never be possible. We agree that our attitude is based on our assessment of the evidence, which is clearly different from that of Dr Mann. Referring to the Leren, Dayton. and Miettinen studies, he states that " dietary treatment did not work ", attributing this view to Professor Cornfield, who in fact concluded his critique of the results of intervention, including dietary studies, by stating " there are good grounds for believing that certain potentially modifiable risk factors may have an important influence on the amount of coronary disease ". Our programme is based on advice to stop smoking, to change to a diet which has been found acceptable to most normal people, to increase physical activity, and to avoid excessive emotional stress. There are no side-effects from any of these measures properly applied, and apart from their action in the prevention of C.H.D. are in any case beneficial. Certainly people feel fitter. To believe that one day a single dominant factor will be discovered on which we can base the prevention of C. H. D. is in our opinion quite unrealistic. Despite Dr Mann’s doubt, it is our experience, like that

of Dr Leitner (Dec. 22, p. 1435), that nurses can and do help in screening, thus providing the evidence on which the doctor can give direct advice on health risks. Without the help of nurses, health visitors, and dietitians, an effective programme of prevention will never be possible, but we believe that the doctor has the main responsibility for assessing the risks and giving advice. Despite what Dr Meade and his colleagues state, we did not imply that further studies are unnecessary, but we agree with the need for more research into mechanisms which will identify those at high risk, and the sooner prediction is improved the better. They go on to doubt that advice on health measures will ever be acceptable. If we are not able to make them so, then, no matter how accurate our predictions, we must accept that c.H.D. will never be prevented by a change of behaviour. We agree that for some a revolution in life style may be needed, though perhaps a counter-revolution to the life-style of our forefathers would be a more accurate description. Our task is to see whether such changes are feasible. We do not accept their pessimistic predictions on smoking behaviour. The last report of the Royal College of Physicians, Smoking and Health Now, resulted in a 5% fall in cigarette consumption during the following year, temporarily countering the effect of over S50 million spent yearly on tobacco promotion. The tobacco companies clearly do believe that behaviour can be influenced, albeit in a different direction. We have found that the direct personal advice of the doctor on smoking is effective in the secondary prevention of C.H.D.3 Dr Meade and his colleagues state that " many of those who follow recommended preventive regimens will either none the less suffer clinical C.H.D., or will probably have never needed to modify their habits in the first place ". This is a viewpoint on preventive medicine which we fail A similar comment could be made with to understand. regard to seat-belts, yet their value in reducing death-rates has already been demonstrated. Many different ways are needed to attack the coronary epidemic which at present kills nearly one in three British males. Today much effort is being spent in trying to discover underlying mechanisms which may lead to better prediction and treatment, and it is sincerely to be hoped that they will be successful. Meanwhile, we intend to press for the application of what is known in the attempt to prevent some of the many deaths which, for the reasons we gave, are almost certainly

preventable. Central Middlesex Hospital, Park Royal, London NW10 7NS.

RICHARD TURNER KEITH BALL.

Morris, J. N., Chave, S. P. W., Adam, C., Sirey, C., Epstein, L., Sheehan, D. J. Lancet, 1972, i, 133. 2. Oliver, M. F. in Modern Trends in Cardiology (edited by A. Morgan Jones); p. 58. London, 1969. 3. Burt, A., Thorney, P., Illingworth, D., White, P., Shaw, T. R. D., Turner, R. Lancet, Feb. 23, 1974, p. 304. 1.

SIR,-Dr Turner and Dr Ball (Nov. 17, p. 1137) provide excellent summary of the " state of the art " of preventing coronary heart-disease (C.H.D.) and formulate a strong argument for vigorous efforts at primary prevention of C.H.D. Much of the subsequent correspondence printed in your columns, however, indicates widespread apathy, if not strong opposition, to the application of knowledge not an

yet totally proven. The problem lies neither with the art of medicine nor with its science but rather with its politics. In preventive medicine, it is axiomatic that primary prevention is more effective and less expensive than secondary or tertiary prevention in reducing morbidity and mortality. But secondary prevention has always been more attractive to

412 the student or practitioner because he can deal with a condition which does exist rather than try to prevent something which may never occur. Especially for chronic and

degenerative diseases-e.g., stroke secondary to hypertension, chronic obstructive pulmonary disease, or C.H.D.it is in most cases difficult to see the results of prevention in the individual patient. Successful prevention is rarely dramatic, may take years to be demonstrated, and may be a brief change in patient behaviour. Those who treat the individual rather than the community will derive little personal satisfaction from providing preventive care of C.H.D.; in the United States, private and Government insurance will pay thousands of dollars for intensive coronary care but little or nothing for the office visit when hypertension or hyperlipidaemia may be detected or treated. In short, the only way Governments, the profession, health authorities, and grant-giving bodies will be motivated to attack the problem of c.H.D. is through education, public relations, and political pressure. Those of us who believe that C.H.D. can be prevented must organise for these efforts, either within existing associations or as an independent body-e.g., an American Society for Preventive Cardiology. Membership in such an organisation would be open not only to physicians but also to health educators, nutritionists, and physical-education teachers, who are invaluable allies in the fight against c.H.D.

negated by

Department of Preventive Medicine and Community Health, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, U.S.A.

DANIEL

J. FINK.

European males.5 There is no available information on comparative levels of hormone production in African females, and whereas such differences might account for the high incidence of granulosa-cell tumours, it is difficult to explain the different incidences of other tumours. Pathology Department, General Hospital, Nottingham NG1 6HA.

P. D. JAMES.

James, P. D., Taylor, C. W., Templeton, A. C. in Recent Results in Cancer Research (edited by A. C. Templeton); vol. 41, p. 127. Berlin, 1973. 2. Grech, E. S., Lewis, M. G. E. Afr. med. J. 1967, 44, 489. 3. Berg, J. W., Baylor, S. M. Hum. Path. 1973, 4, 537. 4. Dodge, O. G., Owor, R., Templeton, A. C. in Recent Results in Cancer Research (edited by A. C. Templeton); vol. 41, p. 136. Berlin, 1973. 5. Wang, D. Y., Bulbrook, R. D., Clifford, P. Lancet, 1966, ii, 1342. 1.

BLOOD SUBSTITUTES p.

SIR,-I should like to comment on your editorial (Jan. 26, 126), since my colleagues and I have been working in

for a number of years. The perfluorodecalins1 are good oxygen solvents and, unlike other perfluorochemicals, they leave the body in a matter of days. The perfluorodecalins are obtained from England and are further purified here. Other perfluorochemicals, such as 3M Company’s FC47 and du Pont’s perfluoroethers, remain in the liver, largely in Kupffer cells and hepatocytes, for the rest of life. The liver becomes very heavy and discoloured.

this

area

Children’s Hospital Medical

Center, Cincinnati, Ohio 45229, U.S.A.

LELAND C.

CLARK, JR.

EPIDEMIOLOGY OF OVARIAN CANCER

SIR,-I read with interest your leading article (Jan. 26, p. 125), and I should like to draw your attention to a

1.

Clark, L. C., Jr., Becattini, F., Kaplan, S., Obrock, V., Cohen, D., Becker, C. Science, 1973, 181, 680.

recent survey in U ganda.1 This study showed that malignant ovarian neoplasms are at least as common there as in

other parts of the world. Burkitt’s lymphoma in females invariably affects the ovaries, although involvement is seldom exclusive. The most common primary malignant ovarian tumours seen in the five-year study period are shown in the table. During this time a total of 221 ovarian malignancies were reviewed. MALIGNANT OVARIAN TUMOURS IN UGANDA

Carcinomas

account

(1964-1968)

for two-thirds of ovarian malig-

nancies, although the relative proportion of mucinous Granulosa-cell tumours, cystadenocarcinomas is low. malignant teratomas, and dysgerminomas are relatively common. These findings agree with a previous study of ovarian tumours from Uganda,2 and the high incidence of is similar to findings in American malignant teratoma black populations.33 The incidence of ovarian tumours in females contrasts with the low incidence of testicular tumours in males,44 which is due largely to the infrequency of seminoma and teratoma in young men. The reason for this low incidence is unknown, but it is tempting to attribute it to the known differences in hormonal production between African and

SUBNORMALITY AT THE CROSSROADS

SIR,-I strongly support the recommendation in your editorial (Feb. 2, p. 156) that a number of academic units with a special interest in mental handicap should be set up. As you indicate, the subject remains neglected, despite its vast importance. A survey of the relative expenditures per head in this area indicates that it is still neglected, although there has been some improvement. Some academic support has been forthcoming, and the example of Penrose’s pioneering effort at University College should stimulate all of us. Some other schools have a formal teaching commitment to mental handicap, and others have relevant research interests. The quality of effort is good, but the quantitative deficiency still needs to be remedied by the energetic efforts of the Department of Health and Social Security and the Department of Education and Science, as well as by the universities and other interested bodies. Barnard1 lists 21 university centres in the United States with a special interest in mental retardation. About half of these are specifically related to mental retardation-e.g., the Eunice Kennedy Shriver Center for Mental Retardation, Inc., Walter E. Fernald State School, Waverley, Massachusetts. Others a more general approach-such as the John F. Kennedy Child Development Center, University of

have

Colorado. The Institute for Research into Mental and Multiple Handicap, set up in this country to encourage research, has already made a useful contribution; but much more needs to be done, and it is essential that the effort should be encouraged at a departmental level. The appointment of Professor Clarke to the chair of psychology at Hull and