ChroniC disease . . . the publiC health Challenge of the 21st Century
The United States spends significantly more on health care than any other nation. In 2006, our health care expenditure was over $7,000 per person, more than twice the average of 29 other developed countries.2 We also have one of the fastest growth rates in health spending, tripling our expenditures since 1990. Yet the average life expectancy in the United States is far below many other nations that spend less on health care each year.
As a nation, more than 75% of our health care spending is on people with chronic conditions.3 These persistent conditions _ the nation's leading causes of death and disability _ leave in their wake deaths that could have been prevented, lifelong disability, compromised quality of life, and burgeoning health care costs. The facts are arresting:
The scope and severity of the chronic disease problem has not escaped the public's attention. More than two-thirds of all adults believe that the U.S. health care system should place more emphasis on chronic disease preventive care, and more than 4 in 5 Americans (84%) favor public funding for such prevention programs.8
ChroniC disease . . . the publiC health Challenge of the 21st Century
Tackling chronic disease requires a closer look at the major conditions that affect our nation _ namely, heart disease and stroke, cancer, diabetes, arthritis, obesity, respiratory diseases, and oral conditions.
Heart disease and stroke
The good news is that since 1999, death rates for coronary heart disease and stroke have declined 20.8% and 24.4%, respectively.4 In addition, the percentage of adults with high cholesterol, a major risk factor for heart disease, has been cut by almost half since the early 1960s.6
During the past two decades, tremendous progress has been made in developing and using effective cancer prevention strategies, early detection interventions, and cancer treatments. Largely through public health efforts targeting screening, breast cancer deaths among women decreased by 2% per year from 1998 to 2005, and deaths from colorectal cancer decreased among both men and women by 4% per year from 1995 to 2005.
Tremendous progress has been made in managing diabetes and its complications. Because of public health efforts, higher percentages of people with diabetes are monitoring their blood sugar daily and receiving, through health professionals, annual foot exams, eye exams, and influenza and pneumococcal vaccinations. The incidence of treatment for diabetes-related end-stage renal disease declined 21% from 1997 to 2002, and the prevalence of visual impairment among people with diabetes decreased as well, from 24% in 1997 to 18% in 2005.*
Arthritis is the nation's most common cause of disability, affecting 1 of every 5 adults.16 As the U.S. population ages, the number of adults with doctor-diagnosed arthritis is projected to increase from 46 million to 67 million by 2030, and 25 million of these individuals will have limited activity as a result.17 Considerable progress has been made in raising awareness and understanding of effective, evidence-based messages and interventions (such as physical activity) to decrease disability and increase quality of life among those with arthritis.
Obesity has emerged as a priority in chronic disease prevention and has been linked to increased risk for heart disease, high blood pressure, type 2 diabetes, arthritis-related disability, and some cancers. After a quarter-century of increasing rates, obesity prevalence among children and adults appears to be leveling.19, 20
Smoking is the primary risk factor for chronic respiratory diseases, such as emphysema and chronic bronchitis, both of which are major conditions of chronic obstructive pulmonary disease (COPD). 3 COPD, as well as lung cancer, could become relatively uncommon in future generations if smoking rates were substantially reduced.13,22
Mouth and throat diseases _ such as tooth decay, periodontal (gum) disease, and oral cancers _ cause pain and disability for millions of Americans each year. The good news is that remarkable progress has been made in oral health over the past few decades. The baby boomer generation will be the first in which the majority will maintain their natural teeth over their entire lifetime, having benefited from water fluoridation and fluoride toothpastes.26 In addition, the use of dental sealants over the past several decades has significantly improved the oral health of children.
whaT are The causes?
Four modifiable health risk behaviors _ lack of physical activity, poor nutrition, tobacco use, and excessive alcohol consumption _ are responsible for much of the illness, suffering, and early death related to chronic diseases.
Lack of physical activity
Regular physical activity is one of the most important things a person can do to stay healthy. Not only will physical activity increase one's chances of living longer _ it can also help control weight; reduce risks for cardiovascular disease, type 2 diabetes, metabolic syndrome, and some cancers; strengthen bones and muscles; improve mental health and mood; and improve ability to do daily activities and prevent falls among older adults.28
The World Health Organization has estimated that if the major risk factors for chronic disease were eliminated, at least 80% of all heart disease, stroke, and type 2 diabetes would be prevented, and more than 40% of cancer cases would be prevented.31
Good nutrition can help lower risk for many chronic diseases, including heart disease, stroke, some cancers, diabetes, and osteoporosis. Increased consumption of fruits and vegetables helps reduce the risk for heart disease and certain cancers as well. Managing weight is all about balance _ balancing the number of calories consumed with the number of calories the body uses or “burns off.“
Since 1964, an ongoing series of Surgeon General's reports on smoking and health has concluded that tobacco use is the single most avoidable cause of disease, disability, and death in the United States. The tobacco use epidemic can be stopped. Evidence-based, statewide tobacco control programs that are comprehensive, sustained, and accountable have been shown to reduce smoking rates, tobacco-related deaths, and disease caused by smoking.34
Excessive alcohol consumption
Excessive alcohol use is the nation's third leading lifestyle-related cause of death, and is associated with a wide range of health and social problems, including acute myocardial infarction, unintended pregnancy, and interpersonal violence.37 The current Dietary Guidelines for Americans recommends that people who choose to drink alcoholic beverages do so sensibly and in moderation, defined as up to 1 drink per day for women and up to 2 drinks per day for men.38 These guidelines also specify that some people should not drink alcoholic beverages at all, including underage youth.
aT whaT cosT?
Chronic diseases and their major risk factors place huge economic demands on our nation. For example, from 1987 through 2001, increases in obesity prevalence alone accounted for 12% of the growth in health spending.43 Without concerted interventions, these and other costs can be expected to increase in the years ahead.
Americans are living longer than ever before. In 30 years, the number of Ameri_cans aged 65 years or older is expected to double,44 generating a 25% increase in health care spending before taking infla- tion or new technologies into account.45
Complementing this trend is the expected growth in demand for family and profes-sional caregivers, now present in 1 of every 5 households.46 The toll on caregivers' health and well-being is tremendous, and it accounts for significant costs to families, employers, and communities.
The Chronic Disease Price Tag _ Estimated Annual Direct Medical Expenditures*
* Different methodologies were used in calculating costs.
** Includes heart diseases, coronary heart disease, stroke,hypertensive disease, and heart failure combined.
*** Average annual expenditure, 2001 _ 2004.
Without concerted strategic intervention, chronic diseases and their risk factors can be expected to cause more harm_ and be more costly to society. We cannot effectively address escalating health care costs without addressing the problem of chronic diseases.
The Power of PrevenTion
Although chronic diseases are among the most common and costly of all health problems, they are also among the most preventable. Chronic disease prevention, to be most effective, must occur in multiple sectors and across individuals' entire life spans. Prevention encompasses health promotion activities that encourage healthy living and limit the initial onset of chronic diseases. Prevention also embraces early detection efforts, such as screening at-risk populations, as well as strategies for appropriate management of existing diseases and related complications. The following examples show what targeted investments in prevention can achieve.
The health benefits of quitting smoking are numerous, and many are experienced rapidly. Within 2 weeks to 3 months after quitting, heart attack risk begins to drop and lung function begins to improve.52 One year after quitting, excess risk for heart disease is reduced by half, and 10 years after quitting, the lung cancer death rate is about half that of a current smoker. Fifteen years after quitting, an ex-smoker's risk for heart disease is about the same as that of a lifelong nonsmoker.
Lifestyle changes in diet and exercise, including a 5%_7% maintained weight loss and at least 150 minutes per week in physical activity, can prevent or delay the onset of type 2 diabetes for Americans at high risk for the disease.53 Participants in a major clinical trial group exercised at moderate intensity, usually by walking an average of 30 minutes a day, 5 days a week, and lowered their intake of fat and calories. Their efforts resulted in a sustained weight loss of about 10 to 15 pounds, reducing their risk of getting diabetes by 58%.
An adult with healthy blood pressure and healthy blood cholesterol levels has a greatly reduced risk for cardiovascular disease. A 12- to 13-point reduction in systolic blood pressure can reduce cardiovascular disease deaths by 25%,54 and a 10% decrease in total cholesterol levels reduces the risk for coronary heart disease by 30%.55
Instilling healthy behaviors and practices during youth, particularly in school settings, is far more cost-effective than waiting until unhealthy behaviors are entrenched. A study of the Toward No Tobacco program, which was designed to prevent cigarette use among middle and high school students, found that for every dollar invested in school tobacco prevention programs, almost $20 in future medical care costs would be saved.56
Community water fluoridation results in fewer cavities among community members. In one study of communities with at least 20,000 residents, every $1 invested in community water fluoridation yielded about $38 in savings from fewer cavities treated.57
Regular screening for colorectal cancer can reduce the number of people who die from this disease.58 When colorectal cancer is found early and treated, the 5-year relative survival rate is 90%.11
For women aged 40 years or older, mammograms every 12_33 months significantly reduce mortality from breast cancer.58 For women who have been sexually active and have a cervix, screening with a Pap test reduces incidence of, and mortality from, cervical cancer. Females aged 11_26 years can help prevent cervical, vaginal, and vulvar cancers by getting the HPV vaccine.
Improved glycemic control benefits people with either type 1 or type 2 diabetes. In general, every percentage point drop in A1c blood test results (e.g., from 8.0% to 7.0%) can reduce the risk of microvascular complications (eye, kidney, and nerve diseases) by 40%.59,60 Among people with diabetes, annual eye and foot exams can reduce vision loss and lower-extremity amputations. Detecting and treating diabetic eye disease with laser therapy can reduce the development of severe vision loss by an estimated 50% to 60%. 4 Comprehensive foot care programs can reduce amputation rates by 45% to 85%.61,62
Early diagnosis and appropriate management of arthritis, including self-management activities, can help people with arthritis decrease pain, improve function, and stay productive.63
a vision for PrevenTion
We have indisputable evidence of the power of prevention. Researchers and practitioners at national, state, and local levels have designed, tested, and implemented effective programs and policies for chronic disease prevention and control, many at very little cost.
For example, Trust for America's Health estimates that an investment of $10 per person per year in community-based programs tackling physical inactivity, poor nutrition, and smoking could yield more than $16 billion in medical cost savings annually within 5 years.64 This savings represents a remarkable return of $5.60 for every dollar spent, without considering the additional gains in worker productivity, reduced absenteeism at work and school, and enhanced quality of life.64
Despite this evidence, our health care system has primarily focused on discovering treatments and cures for disease _ not on preventing disease. In short, our health care system is not designed to prevent chronic illnesses. At the heart of our system is the traditional physician-patient interaction. As effective as these interactions are, they are generally infrequent and brief. Whether healthy or ill, a person spends far more time outside the physician's office than inside it. Of special concern are the 46 million uninsured Americans under the age of 65 who have limited coverage for health care services.65
To reduce chronic disease across the nation, we must rethink our health care system. It is essential to have a coordinated, strategic prevention approach that promotes healthy behaviors, expands early detection and diagnosis of disease, supports people of every age, and eliminates health disparities. With community-based public health efforts that embrace prevention as a priority, we can become a healthier nation.
The function of protecting and developing health must rank even above that of restoring it when it is impaired. _ Hippocrates
The call To acTion
Just a few years into the 21st century, America is at a critical crossroads in the fight against chronic disease. Significant progress has been made, but much hard work remains. As the nation's premier public health agency, CDC is at the forefront of efforts to prevent and control chronic disease. CDC's National Center for Chronic Disease Prevention and Health Promotion envisions a nation in which all people live healthy lives free from the devastation of chronic diseases. To realize this vision, the nation must harness the collective capacity and energy of communities, health care professionals, voluntary and professional organizations, the private sector, governmental agencies, and academic institutions to take tangible action in the following key areas: well _ being, policy promotion, health equity, research translation, and workforce development.
Evidence indicates that with education, social support, and healthy policies and environments, people can and will take charge of their health. Strategies are needed to facilitate and support individual responsibility and behavior change at schools and workplaces and in faith, community, and medical-based settings, such as:
Policy and environmental changes can affect large segments of the population simultaneously. Adopting healthy behaviors is much easier if we establish supportive community norms and adopt a philosophy that embraces health in all policies and settings. We must promote proven social, environmental, policy, and systems approaches that support healthy living for individuals, families, and communities, such as:
Health equity is achieved when every person has the opportunity to “ attain his or her full health potential “ and no one is “ disadvantaged from achieving this potential because of social position or other socially determined circumstances.“ 66 Health inequities are reflected in differences in length of life; quality of life; rates of disease, disability, and death; severity of disease; and access to treatment. To ensure health equity, we must:
Promising research findings are relevant only when they reach the people they are designed to serve. Key scientific advances must be applied and evaluated, reflected in state and local health policies, and widely adopted as community practices across the country. We must:
A skilled, diverse, and dynamic public health workforce and network of partners is crucial to promote health and prevent chronic disease at the national, state, and local levels. We must work toward the day when:
CDC can help lead the nation to a day when chronic disease prevention is another success story in public health history.