8: No. 4, July 2011
Nicholas Freudenberg, DrPH; Kenneth Olden, PhD
Suggested citation for this article: Freudenberg N, Olden K. Getting
serious about the prevention of chronic diseases. Prev Chronic Dis 2011;8(4):A90.
http://www.cdc.gov/pcd/issues/2011/jul/10_0243.htm. Accessed [date].
Passage of the Patient Protection and Affordable Care Act of 2010 marks an
important step toward making health care available to all Americans. However, implementation of the legislation over the next
decade faces organizational, political, and economic challenges (1).
One of the surest ways to maximize the chances for health care reform to achieve
its aims is to reduce the burden of chronic disease on the nation’s health care
Chronic diseases such as heart disease, cancer, hypertension, stroke, and
diabetes now account for 80% of deaths in the United States and 75% of
health care costs. In 2005, 44% of all Americans had at least 1 chronic
condition and 13% had 3 or more. By 2020, an estimated 157 million US residents
will have 1 chronic condition or more (2). Although an aging population has
contributed to the increase in chronic conditions, children and young adults
face a growing prevalence of obesity, diabetes, and asthma. Between 1996 and 2005,
the number of people aged 25 to 44 years with more than 1 chronic disease doubled (2).
Health care reform legislation promises better access to screening and early
intervention for chronic conditions for vulnerable populations. Similarly,
advances in understanding the role of the human genome in the expression of
chronic conditions offers hope for new treatments (3). Unfortunately, evidence
suggests that innovations in genomic medicine are unlikely to reduce the
prevalence or costs of chronic conditions in the coming decade (4).
To lower the incidence of chronic diseases and thus the costs they impose on
our society and health care system will require addressing the deeper causes of
the increase in recent decades. Much evidence suggests concrete
action that could help to prevent further increases in chronic diseases. We
suggest 4 broad strategies.
First, the United States needs to bring its environmental and consumer
protection regulations into the 21st century. Air pollution, especially in urban
and low-income areas, contributes to illnesses and deaths from cancer and heart
and respiratory diseases. In 2002, at least 146 million people in the United
States lived in areas
that did not meet at least 1 US Environmental Protection Agency air pollution standard (5). Tobacco
and alcohol use and
consumption of foods high in fat, sugar, salt, and calories contribute to a substantial
of chronic disease deaths, yet most of the nation’s regulatory approaches to
these products were developed in the first half of the 20th century. New forms
of marketing, product design, and retail distribution make these old approaches
insufficient to protect the population against the aggressive promotion of these
unhealthful products. In the last 3 decades, the tobacco, alcohol, and food
industries have substantially increased their efforts to oppose public health
protection against these products and to persuade consumers to
use their products
(6). Developing stronger national, state, and local protections and finding new
ways to prevent these industries from externalizing their costs onto taxpayers
can contribute to reducing the behaviors that put people at risk for chronic
Second, the nation needs to maintain and strengthen federal, state, and local
public health infrastructure. In 2004, Frieden charged local public health
officials in the United States with being “asleep at the switch” in their response
to the growing threats from chronic disease (8). He urged stronger surveillance
programs, environmental interventions, new regulation, and more funding. In the
past 2 years, however, as a result of the economic crisis, many state and local
health departments have cut funding for services, including chronic disease
control (9). This action jeopardizes prevention of chronic diseases by increasing the
flow of people with chronic illnesses into the health care system, making it
more difficult for health reform to achieve its objectives.
Third, the country needs to offer new incentives to create a built
environment that promotes health. Increased physical activity protects against
several chronic conditions, yet urban, suburban, and rural environments often make
it difficult to walk, bicycle, or use other forms of active transport.
Government can help people make more healthful choices the default choice by
modifying zoning rules; developing transportation systems that encourage active
transport; and designing schools, workplaces, and communities that promote
physical activity and discourage being sedentary.
Finally, the nation’s health care system needs to modify its practices to
make prevention of chronic diseases a priority. This modification could be achieved by
extending the reach of evidence-based intervention programs; strengthening
community health centers; increasing reimbursement for services such as tobacco
use cessation, nutrition, and alcohol counseling; and providing health
professionals with additional prevention skills (10-12).
These 4 strategies offer several advantages. They rely on off-the-shelf
science, reducing the necessity of additional years of research before
implementation. Each contributes to improvements in various chronic conditions.
The proposed measures can contribute to reductions in cancer, diabetes,
hypertension, and heart disease (Table), each projected to increase in
prevalence by more than 40% in the next 2 decades (10). In addition, these
strategies reduce population incidence of chronic conditions and help shrink
disparities because the targeted conditions mostly affect low-income, black, and
Updating environmental and consumer protection,
strengthening the public health infrastructure, improving the built environment
that influences health, and making prevention a priority for our health care
system have the potential to win broad voter and policy maker support. Although
any policy reforms that threaten the status quo will be opposed by some special
interests, these recommendations will benefit most people in the United States, save taxpayer
dollars, and help the nation to achieve its health goals. Implementing the 4
simultaneously will help to achieve synergies that can accelerate and magnify
their effect. By providing the leadership needed to realize these changes,
health professionals can increase the likelihood that health care reform will
succeed and that the nation’s health will improve.
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No conflicts of interest are reported.
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Corresponding Author: Nicholas Freudenberg, DrPH, City University of New York
School of Public Health at Hunter College, Box 609, 425 E 25th
St, New York, NY 10010. Telephone: 212-481-4363. E-mail:
Author Affiliations: Kenneth Olden, City University of New York School of
Public Health at Hunter College, New York, New York.
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