Online health assessment - Bupa Phase 3 Site

Online health assessment

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DISCLAIMER: This report provides general information only and is not a substitute for professional medical attention. The Online Health Assessment and this report cannot diagnose any illness or medical condition. The report provides general information about what you can do to improve your health and wellbeing, based solely on the responses you have provided in the Online Health Assessment. Bupa Australia Pty Ltd (Bupa) and its related entities make no warranty, express or implied, as to the accuracy or suitability of the information contained in the report. Please note that outpatient medical consultations with GPs or specialists do not generally attract benefits under Bupa’s private health insurance products.

Medically Reviewed By: Expert-24 Medical Review Board on 30 April, 2011 | References

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The aim of the Expert Review Panel is to ensure that all Expert-24 clinical and epidemiological content is robust, independent and up to date.

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Reviewers are chosen for their expertise in fields such as medicine, public health, epidemiology and statistics.
All practicing doctors are members of the appropriate Royal College.
All practicing doctors participate in the appraisal process for their particular speciality, as applicable.

Medical Director and Editor

Dr. Katrina Herren

  • Year of graduation: - 1995
  • Qualifications: - BSc(Hons), PhD, MBBS
  • Current Post: - Clinical Chief Information Officer at Expert-24
  • Special Interests: - Health Information Technology, Medical Leadership and Management
  • License last verified: - June 2017

Chairman of the Expert Review Panel

Dr. Timothy Dudley

  • Year of qualification: - 1980
  • Qualifications: - B.S., M.D.
  • Current Post: - Family Physician, Denver, Colorado, USA
  • Special Interests: - Health Information Technology
  • License last verified: - June 2017

Current authors and reviewers for the Health Risk Assessment

Dr. Martin Dawes

  • Year of qualification: - 1978
  • Qualifications: - MB.BS DRCOG MRCGP MD
  • Current Post: - Royal Canadian Legion Professor and Head
    UBC Department of Family Practice
  • Special Interests: - Evidence Based Health Care, Ambulatory blood pressure monitoring, knowledge management.
  • GMC registration last verified: - June 2017

Dr. Jonathan Mant

  • Year of qualification: - 1985
  • Qualifications: - MA MSc MBBS MFPHM
  • Current Post: - Professor of Primary Care Research, University of Cambridge. Associate Director, Stroke Research Network.
  • Special Interests: - Stroke & cardiovascular disease
  • GMC registration last verified: - June 2017

Dr. Leila Kahwati

  • Year of qualification: - 1997
  • Qualifications: MD, MPH, FACPM (Fellow of the American College of Preventive Medicine)
  • Current Post: - Senior Research Scientist, RTI International, Attending Physician, Durham Veterans Affairs Medical Center Network.
  • Special Interests: - Clinical Preventive Services, Weight Management, Implementation Science
  • Medical license last verified: - June 2017

Emeritus authors and reviewers for the Health Risk Assessment


The following individuals were deeply involved in the creation of the health risk assessment at its inception, but are no longer active reviewers on the panel:

Dr. John Fletcher

  • Year of qualification: - 1985
  • Qualifications: - MA Cambridge, MPH Harvard, MB BChir Cambridge, MRCGP (Membership of the Royal College of General Practitioners), MFPHM (Membership of the Faculty of Public Health Medicine of the Royal College of Physicians).
  • Current Post: - Deputy Editor, Canadian Medical Association Journal, Company Director, Oxford Health Consulting.
  • Special Interests: - Applied Epidemiology, uResearch Methods
  • GMC registration last verified: - April 2011

Dr. Emma Boulton

  • Year of qualification: - 1989
  • Qualifications: - MB BS DRACOG MPH
  • Current Post: - Director, Oxford Health Consulting. Senior Lecturer, University of Sydney
  • Special Interests: - Public Health medicine in industry, the private sector and Government health sector. International Public Health. Primary Care Development.
  • GMC registration last verified: - April 2011. Australian HPRA last verified April 2011

Professor Larry Ramsay

  • Year of qualification: -1966
  • Qualifications: - MB,ChB [Glasgow, 1966], FRCP
  • Current Post: - Retired, (until recently Professor of Clinical Pharmacology & Therapeutics, University of Sheffield, and Consultant Physician, Royal Hallamshire Hospital, Sheffield.)
  • Special Interests: - General and cardiovascular medicine; treatment of hypertension and lipid disorders; cardiovascular risk estimation
  • Additional information: - Author of over 300 articles, chapters, etc on above topics; previously President of British Hypertension Society and Editor of British Journal of Clinical Pharmacology

Professor Klim McPherson

  • Year of qualification: -1966
  • Qualifications: - PhD FFPHM, FMedSci
  • Current Post: - Retired, (until recently Visiting Professor of Public Health Epidemiology Nuffield Dept of Obstetrics and Gynaecology, Churchill Hospital, Oxford)
  • Special Interests: - Medical statistics, particularly regarding coronary heart disease and cancer prevention and the health of women.

Patient-centred health risk using an Evidence Based Medicine approach

Who created it and how often is it reviewed and updated?

This health risk assessment is brought to you by Expert-24 Limited. Expert-24 Ltd has full editorial control over content and strives to ensure that the content is:

  • Robust - All information used is derived from reputable, referenced sources and subject to rigorous expert review. The content is written by the medical staff of Expert-24 and reviewed by an independent Expert Review Panel. All content is subject to regular review and updated to incorporate the latest evidence. Oxford Health Consulting was commissioned to conduct independent research to determine the model for disease and mortality-specific risks, the contents and its assumptions. The research and statistical modelling behind the risk assessment has been led by Dr. John Fletcher. Dr. Fletcher is deputy editor of the Canadian Medical Association Journal. He holds a Masters degree in Public Health Quantitative Methods and is a member of the Royal College of General Practitioners.
  • Independent - The content on the site is provided by Expert-24 Limited. Founded in 2001, Expert 24 has grown to be a world-leader in customised decision support applications, delivering the highest levels of clinical expertise across areas such as acute and primary care, integrated chronic care and population health management.
    The content on the site is provided by Expert 24. The robustness and quality of our content is supported by our independent Medical Review Panel, which comprises specialists and general practitioners with particular expertise in their fields.
  • Up to date - All clinical material is subject to review by Expert-24 and its Expert Review Panel at least annually.

Why is this health risk assessment different than others?

Most health risk assessments say if a person is at high, medium or low risk of either dying from or developing a given medical condition. Most also indicate what lifestyle factors contribute to this risk. What they do not say is the magnitude of each risk for an individual and how much that person’s risk will decrease if they change their lifestyle. For example, if one is at moderate risk of two diseases, say bowel cancer and heart disease, most people would be unaware that their risk of heart disease is still five times higher than their risk of bowel cancer.

To construct an electronic risk assessment tool for health and disease states, it is necessary to provide supporting research evidence and a method of encapsulating the best estimate of relative risk. For each medical condition, it is necessary to present credible estimates of risk, based on evidence from relevant, peer reviewed medical research. Important features of the risk assessment tool are:

  • The tool gives numerical estimates of risk, rather than an imprecise statement such as "increased risk" or "reduced risk".
  • The tool has the capability for interaction, allowing users to explore the impact on their personal risk of changing individual risk factors.
  • The tool utilises best available medical evidence.

The aim of this project is to provide healthy people with a quantitative assessment of their personal risk of developing some important diseases and some of the factors that influence their risk. This is an ambitious task and we would not claim to have produced the definitive approach. Although we believe this is the most informative collection of disease prediction equations available at the present time they do have limitations. The ones we are aware of are outlined below.

What exactly does a given percentage risk mean?

Someone looking at their risk of lung cancer until the age of 50 should read this model as saying, "Assuming survival to age 50 the chance of developing lung cancer during that time would be (some predicted value)". This approach has the appeal that changing risk factors will have the expected impact on cumulative risk and the mathematics remains transparent. We chose the risk of developing a certain condition rather than the risk of dying from it because for many people the fear of living and dealing with a disabling disease is as frightening as dying from it.

This is different than lifetime risk calculations, which generally calculate the risk of dying from a given condition. Lifetime risk must take account of the fact that we all die of something in the end and calculating the relative contribution of common competing causes of death at various ages is difficult. Not only that, but the interpretation by users is complex. For example, a user of an interactive model predicting lifetime risk of lung cancer would see their individual risk of lung cancer fall with increasing cigarette consumption, because they would be dying of heart disease and chronic lung disease before they could get lung cancer.

How accurate are these percentages?

These models are good for illustrating the change in risk due to the presence or absence of single risk factors for prediction times of up to 5 years. They are likely to be reasonably good for 15 or 20 years and for combinations of several risk factors. For longer prediction times and varying more than, say, four risk factors the results should be regarded as illustrative rather than precise. The absolute level of risk for an individual may also be wide of the mark because most of overall risk remains unexplained in most research studies. This explains why "confidence intervals" have not been included. That said these prediction equations do calculate the best estimate of risk that can be provided on the data given.

Is this useful in the end? We believe it is. We believe that putting some quantification on risk allows users to explore the possible impact on their health of altering what they do. We find this approach more informative than a bland statement of "high risk" that is often value laden or that a certain action will "cut down" a risk without any indication of by how much.

Is risk really reversible?

This is a difficult question to answer, but in many cases the answer seems to be, "yes". This is good news for people with high risks who are older. Intuition might tell you that you are constantly doing damage to your body that accumulates over time, and in many cases that may be true. An example of this is in skin cancer, where the earlier and more often you are badly burned in life, the higher your risk of skin cancer. Staying out of the sun when you are old cannot reverse this risk.

However, there is good evidence that for heart disease, for example, your risks can be significantly reduced no matter what your age. Cholesterol reduction by medications called "statins" reduces the risk of heart attack, angina or sudden death from heart problems by up to 30%, and this is entirely independent of age. Similarly, blood pressure reduction by drugs reduces the risk of stroke and heart disease by 25% - again entirely independent of age. Because in general it is older people who have the highest risks, they actually stand to benefit the most from treatment.

The risk for developing heart disease in tobacco users has been shown to decline to a level comparable with a person who has never smoked within 2-3 years of giving up. Furthermore, the risk of having a stroke is reversed after 5-10 years of stopping. Studies have also shown that life expectancy improves even in people who stop smoking later in life (i.e. at 65 years or older).

The reduction of risk that can be obtained from changing lifestyle habits such as diet, alcohol consumption and exercise is largely unknown. Therefore, the amount of risk reduction that can be expected from optimising these habits needs to be viewed with caution. Certainly they should not take the place of blood pressure control, cholesterol control, and smoking cessation as goals.

How good is the evidence?

Our aim in searching for evidence was to identify up to ten high quality, relevant research studies for each topic. We used Medline to search using free text, MeSH terms and thesaurus search terms specific to each medical condition. To narrow the documents we used filters using "risk" and study design type; cohorts, case control, longitudinal, follow up. Searches were limited to studies published in English language and human studies. Although a comprehensive systematic review of the literature on each disease was not possible due to the scope of this project, we feel that the evidence used represents a reasonable cross-section of high-quality literature on the subjects in question.

What we have done is to seek out plausible values of relative risk to use in the prediction equations. We have used an approach that searches for high quality research studies and have then applied our judgement tempered by Austin Bradford Hill's criteria for causation when selecting which risks to use. Hill's criteria are: strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experimental evidence and analogy.

If this sometimes appears somewhat subjective then that is because at times it is a matter of judgement. The judgements have seldom altered the relative risk by more than a small amount. For each risk factor we had to choose a value to use in the model and have been faced at times with a range from which to choose. While a meta-analysis may provide the best point estimate, one is not always available and would be spurious to conduct on the sample of studies we have used for each condition. Given the level of uncertainty surrounding an individual's absolute personal risk we are comfortable with a comparatively lesser degree of uncertainty regarding a risk factor's relative risk.

What is the mathematical model that is used?

The actual mathematical and statistical models and risk coefficients that are used to determine risk are proprietary at this time, but have been validated by the authors and reviewers to be appropriate for use in this setting.

References:

Cardiovascular Disease

New references:

  1. Cardiovascular disease: risk assessment and reduction, including lipid modification | Guidance and guidelines | NICE.
  2. Iribarren, C., Tekawa, I.S., Sidney, S., and Friedman, G.D. (1999). Effect of cigar smoking on the risk of cardiovascular disease, chronic obstructive pulmonary disease, and cancer in men. N. Engl. J. Med. 340, 1773–1780.
  3. Kivimäki, M., Nyberg, S.T., Fransson, E.I., Heikkilä, K., Alfredsson, L., Casini, A., Clays, E., De Bacquer, D., Dragano, N., Ferrie, J.E., et al. (2013). Associations of job strain and lifestyle risk factors with risk of coronary artery disease: a meta-analysis of individual participant data. CMAJ 185, 763–769.
  4. Peter WF Wilson, MD (2017). Overview of established risk factors for cardiovascular disease. UpToDate, Wolters Kluwer.
  5. Rozanski, A., Blumenthal, J.A., and Kaplan, J. (1999). Impact of psychological factors on the pathogenesis of cardiovascular disease and implications for therapy. Circulation 99, 2192–2217.

Previously used references:

  1. Abbasi, F., Brown, B.W., Lamendola, C., McLaughlin, T., and Reaven, G.M. (2002). Relationship between obesity, insulin resistance, and coronary heart disease risk. J. Am. Coll. Cardiol. 40, 937–943.
  2. Almgren, T., Persson, B., Wilhelmsen, L., Rosengren, A., and Andersson, O.K. (2005). Stroke and coronary heart disease in treated hypertension -- a prospective cohort study over three decades. J. Intern. Med. 257, 496–502.
  3. American Academy of Family Physicians (1996). Summary of recommendations for clinical preventive services (Medical Special Society).
  4. Antithrombotic Trialists’ (ATT) Collaboration (2009). Aspirin in the primary and secondary prevention of vascular disease: collaborative meta-analysis of individual participant data from randomised trials. Lancet 373, 1849–1860.
  5. Arnold, L.W., and Wang, Z. (2014). The HbA1c and all-cause mortality relationship in patients with type 2 diabetes is J-shaped: a meta-analysis of observational studies. Rev Diabet Stud 11, 138–152.
  6. Ashton, W.D., Nanchahal, K., and Wood, D.A. (2001). Body mass index and metabolic risk factors for coronary heart disease in women. Eur. Heart J. 22, 46–55.
  7. Becker, D.J., Gordon, R.Y., Halbert, S.C., French, B., Morris, P.B., and Rader, D.J. (2009). Red yeast rice for dyslipidemia in statin-intolerant patients: a randomized trial. Ann. Intern. Med. 150, 830–839, W147-149.
  8. Bobrie, G., Chatellier, G., Genes, N., Clerson, P., Vaur, L., Vaisse, B., Menard, J., and Mallion, J.-M. (2004). Cardiovascular prognosis of “masked hypertension” detected by blood pressure self-measurement in elderly treated hypertensive patients. JAMA 291, 1342–1349.
  9. British Cardiac Society, British Hypertension Society, Diabetes UK, HEART UK, Primary Care Cardiovascular Society, and Stroke Association (2005). JBS 2: Joint British Societies’ guidelines on prevention of cardiovascular disease in clinical practice. Heart 91 Suppl 5, v1-52.
  10. Britton, A., and Marmot, M. (2004). Different measures of alcohol consumption and risk of coronary heart disease and all-cause mortality: 11-year follow-up of the Whitehall II Cohort Study. Addiction 99, 109–116.
  11. Brugts, J.J., Yetgin, T., Hoeks, S.E., Gotto, A.M., Shepherd, J., Westendorp, R.G.J., de Craen, A.J.M., Knopp, R.H., Nakamura, H., Ridker, P., et al. (2009). The benefits of statins in people without established cardiovascular disease but with cardiovascular risk factors: meta-analysis of randomised controlled trials. BMJ 338, b2376.
  12. Ciardullo, A.V., Azzolini, L., Bevini, M., Cadioli, T., Malavasi, P., Morellini, A., Daghio, M.M., Guidetti, P., Lorenzetti, M., Carapezzi, C., et al. (2004). Non-HDL cholesterol predicts coronary heart disease in primary prevention: findings from an Italian 40-69 year-old cohort in general practice. Monaldi Arch Chest Dis 62, 69–72.
  13. Clarke, R., Lewington, S., Youngman, L., Sherliker, P., Peto, R., and Collins, R. (2002). Underestimation of the importance of blood pressure and cholesterol for coronary heart disease mortality in old age. Eur. Heart J. 23, 286–293.
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  15. Driver, J.A., Djoussé, L., Logroscino, G., Gaziano, J.M., and Kurth, T. (2008). Incidence of cardiovascular disease and cancer in advanced age: prospective cohort study. BMJ 337, a2467.
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Stroke

New references:

  1. Pandey, A., Salahuddin, U., Garg, S., Ayers, C., Kulinski, J., Anand, V., Mayo, H., Kumbhani, D.J., de Lemos, J., and Berry, J.D. (2016). Continuous Dose-Response Association Between Sedentary Time and Risk for Cardiovascular Disease: A Meta-analysis. JAMA Cardiol 1, 575–583.

Previously used references:

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Breast Cancer

New references

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Lung Cancer

New references:

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Prostate Cancer

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Bowel Cancer

New references:

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Diabetes

New references:

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All-Cause Mortality

New references:

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Physical Activity

New references:

  1. Biswas, A. et al. Sedentary time and its association with risk for disease incidence, mortality, and hospitalization in adults: a systematic review and meta-analysis. Ann. Intern. Med. 162, 123–132 (2015).
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Diet

New references:

  1. Cade, J. E., Warthon-Medina, M., Hooson, J. & Hancock, N. P63 Diet@net: development of the nutritools website for dietary assessment. J Epidemiol Community Health 71, A79–A79 (2017).
  2. Cleghorn, C. L. et al. Can a dietary quality score derived from a short-form FFQ assess dietary quality in UK adult population surveys? Public Health Nutr. 19, 2915–2923 (2016).
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  4. Micha, R. et al. Association Between Dietary Factors and Mortality From Heart Disease, Stroke, and Type 2 Diabetes in the United States. JAMA 317, 912–924 (2017).
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  6. Public Health England. National Diet and Nutrition Survey: results from Years 5 and 6 (combined). Available at: https://www.gov.uk/government/collections/national-diet-and-nutrition-survey. (Accessed: 10th January 2018)
  7. The Office of Disease Prevention and Health Promotion. Executive Summary - 2015-2020 Dietary Guidelines - health.gov. Available at: https://health.gov/dietaryguidelines/2015/guidelines/executive-summary/. (Accessed: 10th January 2018)

Previously used references:

  1. Schatzkin, A., Subar, A.F., Thompson, F.E., Harlan, L.C., Tangrea, J., Hollenbeck, A.R., Hurwitz, P.E., Coyle, L., Schussler, N., Michaud, D.S., et al. (2001). Design and serendipity in establishing a large cohort with wide dietary intake distributions : the National Institutes of Health-American Association of Retired Persons Diet and Health Study. Am. J. Epidemiol. 154, 1119–1125.
  2. The Women’s Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The women’s health initiative randomized controlled trial. JAMA 291, 1701–1712.

Stress

New references:

  1. Baxter, S., Goyder, L., Herrmann, K., Pickvance, S. & Chilcott, J. Mental well-being through productive and healthy working (Promoting well-being at work. (University of Sheffield, School of Health and Related Research (ScHARR), 2009).
  2. Mind, the mental health charity - help for mental health problems (2017). Causes of stress.
  3. Choices, N. H. S. Struggling with stress? - Stress, anxiety and depression - NHS Choices. (2017). Available at: https://www.nhs.uk/Conditions/stress-anxiety-depression/Pages/understanding-stress.aspx.
  4. The National Institute for Health and Care Excellence (NICE) (2009). Mental wellbeing at work, guidance and guidelines.
  5. The National Institute for Health and Care Excellence (NICE) (2008). Mental wellbeing in over 65s: occupational therapy and physical activity interventions, guidance and guidelines.
  6. MedlinePlus Medical Encyclopedia (2017). Stress and your health.

Prevention

Previously used references:

  1. Centres for Disease Control and Prevention (2015). Vaccine Information Statement, Tdap (Tetanus-Diphtheria-Pertussis) VIS.
  2. Hays, J., Hunt, J.R., Hubbell, F.A., Anderson, G.L., Limacher, M., Allen, C., and Rossouw, J.E. (2003). The Women’s Health Initiative recruitment methods and results. Ann Epidemiol 13, S18-77.
  3. Hill, A.B. (1965). The Environment and Disease: Association or Causation? Proc R Soc Med 58, 295–300.
  4. Patient.Info (2018). Immunisation Schedule (UK). Current Immunisation Schedule.