Elsevier

The Lancet

Volume 384, Issue 9937, 5–11 July 2014, Pages 45-52
The Lancet

Series
Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA

https://doi.org/10.1016/S0140-6736(14)60648-6Get rights and content

Summary

With non-communicable conditions accounting for nearly two-thirds of deaths worldwide, the emergence of chronic diseases as the predominant challenge to global health is undisputed. In the USA, chronic diseases are the main causes of poor health, disability, and death, and account for most of health-care expenditures. The chronic disease burden in the USA largely results from a short list of risk factors—including tobacco use, poor diet and physical inactivity (both strongly associated with obesity), excessive alcohol consumption, uncontrolled high blood pressure, and hyperlipidaemia—that can be effectively addressed for individuals and populations. Increases in the burden of chronic diseases are attributable to incidence and prevalence of leading chronic conditions and risk factors (which occur individually and in combination), and population demographics, including ageing and health disparities. To effectively and equitably address the chronic disease burden, public health and health-care systems need to deploy integrated approaches that bundle strategies and interventions, address many risk factors and conditions simultaneously, create population-wide changes, help the population subgroups most affected, and rely on implementation by many sectors, including public–private partnerships and involvement from all stakeholders. To help to meet the chronic disease burden, the US Centers for Disease Control and Prevention (CDC) uses four cross-cutting strategies: (1) epidemiology and surveillance to monitor trends and inform programmes; (2) environmental approaches that promote health and support healthy behaviours; (3) health system interventions to improve the effective use of clinical and other preventive services; and (4) community resources linked to clinical services that sustain improved management of chronic conditions. Establishment of community conditions to support healthy behaviours and promote effective management of chronic conditions will deliver healthier students to schools, healthier workers to employers and businesses, and a healthier population to the health-care system. Collectively, these four strategies will prevent the occurrence of chronic diseases, foster early detection and slow disease progression in people with chronic conditions, reduce complications, support an improved quality of life, and reduce demand on the health-care system. Of crucial importance, with strengthened collaboration between the public health and health-care sectors, the health-care system better uses prevention and early detection services, and population health is improved and sustained by solidifying collaborations between communities and health-care providers. This collaborative approach will improve health equity by building communities that promote health rather than disease, have more accessible and direct care, and focus the health-care system on improving population health.

Introduction

The emergence of chronic diseases as the predominant challenge to global health is undisputed.1, 2, 3, 4 In its 2010 report on the global status of the challenges presented by chronic diseases, WHO noted that non-communicable conditions—including cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases—accounted for nearly two-thirds of deaths worldwide.5

The updated Global Burden of Disease Study, 2010 provides further documentation of the continued shift from communicable to non-communicable diseases, and from premature death to years lived with disability.4 Related research indicates the scope of the problem and key risk factors that cause the global trends, including high blood pressure, tobacco smoking and second-hand smoke exposure, high body-mass index (BMI), physical inactivity, alcohol use, and diets low in fruits and vegetables and high in sodium and saturated fats (eg, artificial trans fats).4, 6, 7

In the USA, chronic diseases are the main cause of poor health, disability, and death, and account for most of health-care expenditures.8, 9, 10, 11 Around half (50·9%) of adults in the USA have at least one chronic condition and 26% have two or more conditions.12 In 2011, 13·1% of the population had a disability, including 46·3% of those in people aged 75 years and older.13 In 2011, ten of the 15 leading causes of death in the USA were chronic conditions, including seven in the top ten (diseases of the heart, malignant neoplasms, chronic lower respiratory diseases, cerebrovascular diseases, Alzheimer's disease, diabetes, and the combination of nephritis, nephrotic syndrome, and nephrosis).8

The Institute of Medicine reported that the USA is less healthy in key areas—including obesity, diabetes, heart disease, chronic lung disease, and disability—compared with 16 high-income or peer countries.14, 15, 16 The provision of care for people with chronic illnesses is very costly; in 2010, total spending for the Medicare population (largely people ≥65 years) was more than US$300 billion, with almost all (93%) spending in support of people with two or more chronic conditions.11 Similarly, lost productivity from chronic diseases, other chronic conditions, and risk factors is associated with enormous costs both for those remaining in the workforce and for those who prematurely leave because of a disability.17

Key messages

  • Non-communicable diseases (eg, cardiovascular diseases, diabetes, cancers, and chronic respiratory diseases) account for most deaths globally, and are the main drivers of morbidity, disability, and health-care costs in the USA.

  • Much of the chronic disease burden results from a small number of key risk factors that include high blood pressure, tobacco smoking and second-hand smoke exposure, high BMI, physical inactivity, alcohol use, and diets low in fruits and vegetables and high in sodium and saturated fats. Most adults in the USA have more than one risk factor.

  • All of these risk factors can be effectively addressed at both the individual and population levels; work at both levels is essential. To address the challenge of chronic diseases needs a sustained cross-sectoral policy and programme focus on high-value prevention targets at the individual (clinical) and population levels.

  • Reduction to the chronic disease burden needs coordinated and mutually-reinforcing actions: epidemiology and surveillance to monitor trends and track progress, policy and environmental approaches to promote health and support healthy behaviours, health-care interventions to improve the effective delivery and use of preventive and other high-value clinical services, and links between community programmes and clinical services to improve and sustain the management of chronic conditions.

  • Establishment of community conditions to support behaviours that lead to a healthy life and promote effective management of chronic conditions will deliver healthier students to schools, healthier workers to employers and businesses, and a healthier population to the health-care system.

US national health priorities include prevention of the development and early detection of chronic diseases, slowing disease progression, mitigating complications to optimise quality of life, and a decrease in the demand on the health-care system.18, 19, 20 In this review, we assess the burden of chronic diseases in the USA, and describe the USA's public health practice-focused approach that is used by CDC's National Center for Chronic Disease Prevention and Health Promotion to reduce the preventable burden of chronic diseases.

Section snippets

The chronic disease burden in the USA

In the USA, the burden of chronic disease is not distributed equitably. People with lower educations or incomes, of specific races or ethnic backgrounds, and in specific geographical locations, among other factors, are disproportionately affected by chronic diseases, often as a result of social disadvantages and vulnerability.21 For example, stroke death rates are highest in the southeastern states; smoking prevalence is highest in some American Indian tribes, particularly in the northern

Addressing the chronic disease burden

To effectively and equitably address the chronic disease burden, collaborations between health-care systems and public health are needed to bundle strategies and interventions, address combinations of risk factors and conditions, create population-wide changes, help the most affected population subgroups, and to ensure implementation of measures by many sectors, including public–private partnerships with involvement from all stakeholders. The magnitude of the chronic disease challenge in the

Conclusions and future directions

Chronic diseases and non-communicable conditions are common, costly, and debilitating. With effective community and clinical strategies, they can often be prevented, or their onset delayed and duration shortened substantially. As the US population continues to age and many low-income and middle-income countries undergo similar demographic transitions, the adverse effects of chronic diseases on population health, economic growth and development, and the world's workforce will continue to grow.

References (74)

  • America's Health Rankings. A call to action for individuals and their communities. 2012 edition

  • P Rudegeair

    Americans living longer, with unhealthy lifestyles: report. Reuters

  • Chronic conditions among Medicare beneficiaries, chartbook, 2012 edition. Baltimore

  • BW Ward et al.

    Prevalence of multiple chronic conditions among US adults: estimates from the National Health Interview Survey, 2010

    Prev Chronic Dis

    (2013)
  • PF Adams et al.

    Summary health statistics for the U.S. population: national health interview survey, 2011

    Vital Health Stat

    (2012)
  • U.S. Health in International Perspective: Shorter lives, poorer health. Panel on understanding cross-national health differences among high-income countries

  • U.S. health in international perspective: shorter lives, poorer health. Report brief

    (January, 2013)
  • SH Woolf et al.

    The US health disadvantage relative to other high-income countries: findings from a National Research Council/Institute of Medicine report

    JAMA

    (2013)
  • R DeVol et al.

    An unhealthy America: the economic burden of chronic disease charting a new course to save lives and increase productivity and economic growth. Milken Institute

  • Healthy People.gov. 2020 topics and objectives. Dec 2, 2010. http://www.healthypeople.gov/2020/default.aspx (accessed...
  • National Prevention Council Action plan: implementing the national prevention strategy

  • Multiple chronic conditions—a strategic framework: optimum health and quality of life for individuals with multiple chronic conditions. Washington, DC. December, 2010

  • PA Braveman et al.

    Health disparities and health equity: the issue is justice

    Am J Public Health

    (2011)
  • TR Frieden

    CDC health disparities and inequalities report–United States, 2013. Foreword

    MMWR Surveill Summ

    (2013)
  • TR Frieden

    A framework for public health action: the health impact pyramid

    Am J Public Health

    (2010)
  • AH Mokdad et al.

    Actual causes of death in the United States, 2000

    JAMA

    (2004)
  • KR Lorig et al.

    Effect of a self-management program on patients with chronic disease

    Eff Clin Pract

    (2001)
  • American recovery and reinvestment act communities putting prevention to work: chronic disease self-management program

  • Grants.gov. CDC-RFA-DP13-1305: State public health actions to prevent and control diabetes, heart disease, obesity and...
  • C1 Li et al.

    Surveillance of certain health behaviors and conditions among states and selected local areas—behavioral risk factor surveillance system, United States, 2009

    MMWR CDC Surveill Summ.

    (2011)
  • Health, United States, 2012: With special feature on emergency care. Hyattsville, MD

  • TA Pearson et al.

    American Heart Association guide for improving cardiovascular health at the community level, 2013 update: scientific statement for public health practitioners, healthcare providers, and health policy makers

    Circulation

    (2013)
  • RC Brownson et al.

    Chronic disease control in public health practice: looking back and moving forward

    Public Health Rep

    (2004)
  • MV Wegner et al.

    Chronic disease surveillance

  • National health and nutrition examination survey, 2013–2014: overview

  • G Anderson

    Chronic care: making the case for ongoing care. Princeton: Robert Woods Johnson Foundation, 2010

  • SR Machlin et al.

    Health care expenditures for adults with multiple treated chronic conditions: estimates from the Medical Expenditure Panel Survey, 2009

    Prev Chronic Dis

    (2013)
  • Cited by (934)

    View all citing articles on Scopus
    View full text