All adults should be screened for alcohol misuse, and anyone engaged in hazardous or risky drinking be offered behavioral counseling interventions (grade B) [8]. It is estimated that 30 % of the US population is involved in alcohol misuse, resulting in more than 85,000 deaths per year [9]. Risky drinking is defined by consumption of more than four drinks on any day or more than 14 in a week. However, in men over 65 years of age, the acceptable amounts drop to three per day and seven per week [10]. The CAGE questionnaire remains a viable tool to use in the clinical setting in the assessment of alcohol use (Table 7.3) [11]. Each item is scored a 0 or a 1; a total score of 2 or higher is considered clinically significant [8].

Tobacco use continues to be a prevalent risk factor and remains the leading preventable cause of death in the USA [12]. Twenty-one percent of adult men are current smokers, while 55 % have never smoked. Social and ethnic differences apply as well. When considered by race without consideration of ethnicity, 10 % of Asian adults were active smokers, compared to 19 % of American Indian or Alaska Natives, 17 % of black adults, and 19 % of white adults; 17 % of Hispanic men were smokers, compared with 22 % each for non-Hispanic white men and non-Hispanic black men. Other factors that were associated with a higher rate of tobacco use were unemployed status, being in a poor family, and lack private insurance or Medicaid [13]. As such, all men should be screened for current or past tobacco use and clinicians should provide tobacco cessation interventions for those who use tobacco products (grade A). The “5-A” behavioral counseling framework is a useful tool for discussion of tobacco use with patients:

The American Academy of Family Physicians (AAFP) concurs with the USPSTF statements on alcohol and tobacco screening [14]. The American College of Preventive Medicine recommends the following:

The USPSTF has recommendation statements that apply for general counseling, as well as for screening for human immunodeficiency virus (HIV), hepatitis B and C, and syphilis.

Intensive behavioral counseling is recommended for all adults who are at increased risk for sexually transmitted infections (grade B). Risk groups that have been included in counseling studies include adults with current sexually transmitted infections (STIs) or other infections within the past year, adults who have multiple sexual partners, and men who do not consistently use condoms. Awareness of populations with increased risk of STIs should also help guide clinicians toward recommending counseling services. In particular, African Americans have the highest STI prevalence of any racial/ethnic group, and STI prevalence is higher in American Indians, Alaska Natives, and Latinos than in white persons.

Increased STI prevalence rates are also found in men who have sex with men (MSM), persons with low incomes living in urban settings, current or former inmates, military recruits, persons who exchange sex for money or drugs, persons with mental illness or a disability, current or former intravenous drug users, persons with a history of sexual abuse, and patients at public STI clinics. In general, the more time spent performing counseling, the better the evidence of benefit, with the best being intensive sessions lasting at least 2 h of contact time. Most successful approaches provided basic information about STIs and STI transmission, assessed the person’s risk for transmission, and provided training in pertinent skills, such as condom use, communication about safe sex, problem solving, and goal setting [16].

Screening for HIV is recommended for all adults up to 65 years of age and for older adults who are at increased risk (grade A) [17]. Overall, about 36 % of all adults aged 18 and over have ever been tested for HIV, with women more likely than men [13]. It is estimated that 20–25 % of individuals with HIV infection are unaware of their positive status, and there is clear benefit to early identification and treatment to markedly reduce the risk of progression to acquired immunodeficiency syndrome (AIDS), AIDS-related events, and death in individuals with immunologically advanced disease (defined as a CD4 count < 0.200 × 10⁹ cells/L) [17].

Men at high risk for infection with hepatitis B (HBV) should be screened (grade B). There are between 700,000 and 2.2 million people in the USA with chronic HBV. Persons considered at high risk for HBV infection include those from regions with a high prevalence of HBV infection (these include sub-Saharan Africa and Central and Southeast Asia), HIV-positive persons, intravenous drug users, household contacts of persons with HBV infection, and MSM. HBV infection carries the risk of long-term sequelae such as cirrhosis, hepatic decompensation, and hepatocellular carcinoma, thus testing and diagnosis are beneficial to determine candidacy for appropriate treatment and proper surveillance for other complicating conditions [18].

Screening for hepatitis C (HCV) is recommended for persons at high risk for infection, and one-time testing should be offered to any man born between 1945 and 1965 (grade B). HCV is the most common blood-borne pathogen in the USA and a leading cause of complications from chronic liver disease. It is estimated that 1.6 % of noninstitutionalized persons have the anti-HCV antibody. The most important risk factor for infection is past or present intravenous drug use, with a prevalence of 50 % or greater; others include sex with an injection drug user and having received a blood transfusion before 1992. Most patients with HCV were born between 1945 and 1965, hence the current recommendation for one-time testing in that defined group [19].

Screening for syphilis is recommended for all men at increased risk for infection (grade A), but the USPSTF recommends against routine screening on asymptomatic persons who are not at increased risk (grade D). At-risk populations include MSM and those who engage in high-risk sexual behavior, commercial sex workers, persons who exchange sex for drugs, and men in adult correctional facilities. There is no specific recommendation on frequency of testing in these groups. Of note, men diagnosed with other STIs may be more likely to engage in high-risk behaviors, placing them at greater risk for syphilis, but there is no evidence that supports routine screening of men with another diagnosed STI for syphilis [20].

As one of the leading causes of disability, depression affects individuals, families, businesses, and society [21]. It is estimated that 8 % of adult males have symptoms of depression, compared to 12 % of adult females [13]. All adults over the age of 18 should be screened for depression when support systems are in place to assure accurate diagnosis, effective treatment, and follow-up (grade B); when such supports are not in place, it is recommended that no such screening be performed (grade C) [21]. Other factors increase the likelihood of experiencing symptoms of depression including being unemployed, poverty, Medicaid status for those under age 65 years, and having both Medicare and Medicaid for those over 65 years of age [13]. A variety of screening tools exist that have been found to have good sensitivity, however, with only fair specificity. Such tools include the Zung Self-Rating Depression Scale, Beck Depression Inventory, General Health Questionnaire, Center for Epidemiologic Studies Depression Scale, SelfCARE (D), and the Geriatric Depression Scale [21]. All positive screening tests should lead to subsequent full diagnostic evaluation and assessment of severity.

All adults over 18 years of age should be screened for high blood pressure as a method of identifying adults at risk for cardiovascular disease (grade A). For this recommendation, hypertension was defined as a systolic blood pressure (SBP) of 140 mm Hg or higher, while the diastolic blood pressure (DBP) was 90 mm Hg or higher, and these measurements should be obtained on two occasions at least 1 week apart. There was no specific recommendation regarding frequency of measurements, due to lack of evidence. Rather than setting a cutoff point to implement treatment, clinicians are recommended to consider the man’s overall cardiovascular risk profile when making decisions [23].

The most recent report from the Eighth Joint National Committee (JNC 8) reinforced the definition of hypertension as noted above (systolic blood pressure of 140 mm Hg or greater and diastolic blood pressure of 90 mm Hg or greater). It stratified recommendations for adults based on age. For those 60 years or older, JNC 8 recommended initiating therapy for an SBP ≥ 150 mm Hg or DBP ≥ 90 mm Hg. For adults less than 60 years of age, the same DBP goal is recommended, but a more aggressive SBP goal of 140 mm Hg is advised [24].

The American Heart Association (AHA), in conjunction with the American Academy of Cardiology (ACC), released guidelines in 2013 recommending a comprehensive overall cardiovascular risk assessment starting at age 20 years [25].

Obesity rates in the USA are high, currently exceeding 30 % for all adults [26]. Data from the 2011–2012 National Health And Nutrition Examination Survey (NHANES) further show that 33.9 % of US adults 20 years of age and over are overweight, 35.1 % are obese, and 6.4 % are extremely obese [27]. These conditions are associated with other chronic health problems, such as coronary heart disease (CHD) and type 2 diabetes mellitus. Conversely, weight loss is associated with lower incidence of overall health problems and mortality. Therefore, all men should be screened for obesity, and those with a body mass index (BMI) of 30 kg/m² or higher should be offered referral to intensive, multicomponent behavioral interventions (grade B) [26] (Table 7.4). BMI is a calculation from measured height and weight, and therefore these should be obtained during the clinic visit. The USPSTF does not recommend a frequency of or interval between BMI measurements [26]. Abdominal waist circumference measurement should also be considered, as its relationship to outcomes in cardiometabolic syndrome has great significance.

Of note, Fryar and colleagues made this statement in regard to Asian adults: “The prevalence of obesity as measured by BMI among non-Hispanic Asian adults was much lower than that reported for non-Hispanic white, non-Hispanic black, and Hispanic adults. Although BMI is widely used as a measure of body fat, at a given BMI level body fat percentage and location may vary by gender, age, and race, and Hispanic origin. In particular, research suggests that Asian persons may have greater body fat percentages than white persons, especially at lower BMIs, and that significant health risks may begin at a lower BMI among Asian persons compared with others.” [27]

Abdominal aortic aneurysm (AAA) is estimated to occur between 3.9 % and 7.2 % of men over the age of 50 years. Risk factors include male gender, age greater than 60 years, cigarette smoking, hypertension, white or Native American ethnicity, obesity, family history of AAA, and underlying cardiovascular disease [28]. As such, the USPSTF recommends a one-time screening for AAA via ultrasonography for men ages 65–75 years who ever smoked (grade B) [29]. In a large trial with an AAA prevalence of 5 %, screening led to an absolute risk reduction in AAA death of 1.4 per 1000 men [30]. Offering screening to men who have never smoked is a grade C recommendation, based on other relevant risk factors [29].

Diabetes mellitus is estimated to be present in 13.2 % of the adult male population over the age of 20 years, and among those diagnosed by a physician with the condition, 26.2 % have a hemoglobin A1c greater than 9 %. Undiagnosed diabetics are thought to represent 4.2 % of all adult men [31]. The American Diabetes Association (ADA) notes that traditional diagnoses of type 2 diabetes (DM2) occurring only in adults and type 1 diabetes (DM1) only in children is no longer accurate, as both can be found in either group. It is possible for DM2 patients to present in diabetic ketoacidosis, so clinicians must be aware of this possibility. Diagnostic tests for diabetes mellitus include a hemoglobin A1c of 6.5 % or higher, a fasting plasma glucose of 126 mg/dL (7.0 mmol/L) or higher, a 2-hour postprandial glucose of 200 mg/dL (11.1 mmol/L) or higher following a 75 g glucose load, or a patient with classic symptoms of hyperglycemic crisis that has a random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher. Testing for DM2 in asymptomatic individuals should be considered in adults who qualify as overweight (BMI 25 kg/m² or higher or 23 kg/m² in Asian Americans) who have one or more risk factors for diabetes, starting at age 45 years and repeated every 3 years [32].

The USPSTF recommends screening for DM2 in asymptomatic individuals with a sustained blood pressure greater than 135/80 (grade B) and has insufficient evidence to make a recommendation in screening anyone with a blood pressure below that cutoff (grade I). The rationale for the USPSTF recommendation being different from the ADA was based on adequate evidence that lowering blood pressure in those with diabetes reduces the incidence of cardiovascular events and mortality [33].

Approximately 11 % of adults aged 18 and over have cardiovascular disease, which accounts for nearly half of all deaths in the USA [13, 34]. Nearly one-third of coronary heart disease (CHD) events are attributable to total cholesterol levels greater than 200 mg/dL. In addition, high low density lipoprotein cholesterol (LDL-C) and low high-density lipoprotein cholesterol (HDL-C) are risk factors for developing coronary artery disease (CAD), and the risk for coronary events and deaths increases with increasing levels of total cholesterol and LDL and declining levels of HDL. Other risk factors include diabetes mellitus, previous personal history of CHD or noncoronary atherosclerosis, family history of CVD before the age of 50 years in male relatives or 60 years in female relatives, tobacco use, hypertension, and obesity (BMI of 30 or higher). The USPSTF strongly recommends screening men aged 35 years and older for lipid disorders (grade A) and men aged 20–35 years if they are at increased risk for CHD (grade B). There is no recommendation for men aged 20–35 years who are not at increased risk for CHD (grade C) [34].

The ACC and AHA released guidelines in 2013 that make comprehensive recommendations on initiation of statin therapy across a spectrum of ages and lipid disorders, including other medical comorbidities [35].

The USPSTF recommends against screening with either resting or exercise electrocardiography (ECG) for the prediction of CAD in asymptomatic adults at low risk for CHD events (grade D). They concluded there was insufficient evidence to make a recommendation of ECG testing in asymptomatic adults at intermediate or high risk for CHD events (grade I) [36].

Approximately 1 in 5 men are at risk for an osteoporosis-related fracture during their lifetime; however, evidence is limited on the benefits of screening. The USPSTF found insufficient evidence to make a recommendation (grade I) but found that clinicians should consider the following factors when discussing the role of testing with patients: potential preventable burden due to fractures and fracture-related illnesses, potential harms, and costs [37].

Other groups make more specific recommendations in favor of testing. The Endocrine Society recommends testing men with risk factors (those age 70 or greater or those age 50–69 with any of the following: low body weight; prior fracture as an adult; smoking or alcohol abuse; conditions such as delayed puberty, hypogonadism, hyperparathyroidism, hyperthyroidism, or COPD; and chronic use of glucocorticoids or GnRH agonists) with dual-energy X-ray absorptiometry (DEXA) [38]. The American College of Physicians (ACP) recommends that clinicians periodically perform individualized assessment of risk factors for osteoporosis in older men and that clinicians obtain dual-energy X-ray absorptiometry (DEXA) for men who are at increased risk for osteoporosis and are candidates for drug therapy [39]. The National Osteoporosis Foundation recommends screening all men age 70 years and older, men aged 50–69 years with risk factors, all adults over age 50 years with a fracture, and adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids in a daily dose ≥5 mg prednisone or equivalent for ≥3 months) associated with low bone mass or bone loss [40].