The Journal for Nurse Practitioners
Volume 6, Issue 1 , Pages 16-24, January 2010

Chronic Disease Prevention Across the Lifespan

  • Jane Kapustin

      Affiliations

    • Jane Kapustin, PhD, CRNP, BC-ADM, FAANP, is associate professor and assistant dean of the master's program at the University of Maryland School of Nursing in Baltimore.

Article Outline

Abstract 

Over $2 trillion is spent annually in the United States on managing chronic disease, and 95% is for direct medical care. Because 40% of deaths are preventable, the result of unhealthy behavior patterns, more than 5% of the money should be directed to chronic disease prevention. This article focuses on the imbalance of health care resources and the economic issues associated with chronic disease prevention. Because the health of the nation is viewed in the past and present health of our children, a lifespan approach is applied. Population health determinants and policy implications of nonmedical influences of health promotion and disease prevention are explored. Specific nurse practitioner implications are highlighted and opportunities for health promotion are reviewed.

Keywords:  chronic disease prevention , economics , health determinants , health promotion

 

The imbalance of health care resources devoted to chronic disease management in the United States is staggering when compared to resources directed toward health promotion and chronic disease prevention. In fact, 95% of the $2 trillion spent annually on health care today is directed to medical care of chronic diseases and only 5% is left for prevention. Because over 40% of deaths in the United States are considered preventable due to unhealthy patterns of behavior such as smoking, overeating, or leading a sedentary lifestyle,1 would it be beneficial to direct a great proportion of funds to chronic disease prevention?

Although health promotion and chronic disease prevention success stories exist in the literature, they are not prominent when compared to other health care stories considered “newsworthy.” There remains a serious disconnect between chronic disease management funding and chronic disease prevention funding. One serious issue is that chronic disease prevention strategies do not typically “belong” to the clinical arena. Public health measures and community-based interventions are also required to make a significant impact in the prevention of chronic disease.2, 3 Chronic disease needs to be managed in an organized, coordinated fashion that focuses on: improving state and local policies; establishing primary, secondary, and tertiary prevention programs that improve quality of life; expanding access to care for disenfranchised persons who are vulnerable to chronic disease; and creating an infrastructure for preventing disease at the national, state, and local levels.2, 3, 4

Aspects of chronic disease prevention and health promotion are the focus of this exploration. Because the health of the nation is reflected in the past and present health of our children, the lifespan approach will be applied.5 Population health determinants such as genetic influences, social circumstances, environmental factors, behavior effects, and medical care will be included. Emphasis will be placed on the policy implications of nonmedical determinants that greatly influence health promotion and disease prevention. Specific nurse practitioner (NP) implications will be highlighted, and economic implications that consider cost-benefit analysis will be reviewed.

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The Scope of the Problem 

Over 90 million Americans live with chronic disease. Chronic diseases such as heart disease, diabetes, cancer, lung disease, and stroke cause approximately 70% (1.7 million) of all deaths each year in the United States, and many of these are preventable6 (Table 1).

Table 1. Common Causes of Death Across All Age Groups
Cause of DeathPercentage
Heart disease27.0
Cancer23.0
CVA6.0
Chronic lower respiratory disease5.0
Accidents4.5
Diabetes3.0
Alzheimer disease3.0
Influenza and pneumonia2.0
Kidney disease2.0
Septicemia1.0

Centers for Disease Control and Prevention, 2007. Available at: http://www.cdc.gov/nchs/FASTATS/lcod.htm.

At least half of all Americans suffer from at least one chronic disease, according to 2005 estimates, and the chronic disease burden will rise as age expectancies rise. The population over the age of 65 is expected to increase by 70% over the next 10 years, and many people in this age group have multiple chronic health problems. If current trends continue, our health care capacity could be depleted in the not too distant future.6

The costs associated with chronic disease management account for up to 75% of the nation's $2 trillion annual medical care costs. Consider the top 3 causes of death in the United States: in 2008, heart disease and stroke alone cost $448 billion, with cancer accounting for another $89 billion. These resources are directed at the most prevalent, costly, and preventable of our health problems6 (Table 2).

Table 2. Number of Deaths for Leading Causes of Death in U.S. in 2006 (Total 2,426,264)
Source: Centers for Disease Control and Prevention, May 2009. Available athttp://www.cdc.gov/nchs/FASTATS/deaths.htm
CauseNumber of Deaths
Heart disease631,636
Cancer559,888
Stroke (cerebrovascular diseases)137,119
Chronic lower respiratory diseases124,583
Accidents (unintentional injuries)121,599
Diabetes72,449
Alzheimer disease72,432
Influenza and pneumonia56,326
Nephritis, nephrotic syndrome, and nephrosis45,344
Septicemia34,234

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Health Promotion Opportunities 

Opportunities for health promotion are unlimited. The NP role was created over 40 years ago to help fill the primary care gap in rural areas, and health promotion and disease prevention were emphasized. Today's NP curriculum still reflects those same approaches. The American Academy of Nurse Practitioners states that NPs perform a variety of services, but they “focus on health promotion, disease prevention, health education, and counseling.”7 This role is also stressed by the American Colleges of Nurse Practitioners8 and “disease prevention” is specifically emphasized. So, are NPs really providing this valuable service?

The literature regarding NP outcomes is abundant, and overall, quite favorable. An early study conducted in 1974 found that patients fared similarly when care was provided by an NP as opposed to an MD.9 In a landmark 2000 study, Mary Mundinger and colleagues at Columbia University compared patient outcomes for primary care delivery by NPs versus physicians, and found them to be at least comparable.10 Since then, NP outcomes have gained more interest and research findings continue to demonstrate positive NP outcomes in chronic disease as well as acute care management.11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21 A 2005 Cochrane Review evaluated 16 studies of NP patient outcomes and concluded that NPs provided “as high quality care as primary care doctors and achieve as good health outcomes for patients.”19

Yet, a disconnect exists between health promotion and disease prevention interventions being conducted in practice by NPs and the documentation of such. Birkholz and Viens22 found, in a small pilot study, that NPs missed many opportunities for health promotion. In another small study, researchers estimated that less than 1% of observed NP-patient encounters involved health promotion activities.23

If NP education is purported as being strong in these areas, how do we account for the lack of evidence in research findings? One issue is that NPs think they provide more health promotion than is actually documented, yet NPs continue to express value for preventive services but are hindered by barriers.23, 24 Barriers that are identified by NPs and MDs as interfering with their preventive activities are similar: lack of knowledge of practice guidelines, provider forgetfulness, too focused on acute problem, lack of reimbursement, patient resistance, time constraints, and insufficient organization/agency support.24, 25 Thus, it is important for NPs to provide superb preventive services that are proclaimed as one strength of the profession as well a “value added” difference.

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Determinants of Health 

Before considering interventions to address disease prevention more effectively, consider the determinants of population health. Lifestyle choice plays a major role in chronic disease development, and its impact on population health is a major force to contend with.

The 5 domains of population health determinants include genetic inheritance, social circumstances, environmental influences, lifestyle choices, and medical care. Each plays an important role in influencing population health, and their interrelationships must be considered.1, 26 For example, genetic conditions are often underlying for some, yet they are not evident until social or environmental factors exert their influences. In the case of obesity, many people possess the genetic code that predisposes them to being overweight or obese, yet not all of them become overweight or obese. Social or environmental influences that favor obesity, such as learning unhealthy eating patterns or leading a sedentary lifestyle, are often the triggers that lead to weight gain.

Genetic influences are the blueprints for our lives. From the genetic code arises our variations in biological expression, and there are multiple sites in the genetic code where mutation can occur as a result of environmental exposure. Chronic diseases such as diabetes, heart disease, and cancer have genetic components that are often expressed later in life. These chronic disorders are multifactorial in nature such that numerous interactive genes are implicated for their expressions. In the case of obesity, up to two thirds of the risk may be genetic in nature, but controllable lifestyle factors signal the expression of obesity.27 Promising research in genomics will lead to better understanding of this powerful interaction so that specific interventions can be developed to alter an inevitable sequence of disease expression. The Institute of Medicine has proposed that genomics is one of the key areas for public health education,28 and the CDC Office of Genomics and Disease Prevention maintains that the integration of genetics and public health holds the future for managing population health.29, 30, 31

Health promotion activities that are vital in the arena of influencing genetics include conducting thorough family histories, screening for genetic disorders, and detecting genetic predispositions. Across the lifespan, NPs will take lead roles in screening for prenatal, infant, and childhood disorders; for adult disorders such as hemachromatosis or Factor Five Leiden; and for multifactorial conditions such as diabetes, hypertension, and depression. Patient services and counseling on dietary choices, exercise, weight management, vaccinations, and oral health are some of the numerous primary prevention services that could prevent the potential development of chronic diseases in those who are genetically susceptible.29, 30, 31

Social and economic determinants of health include circumstances into which we are born, such as family characteristics, social support, culture, income level, educational level, housing, community factors, crime levels, employment levels, and many others. The research base in this field has firmly established that certain social factors, such as income and educational level, are associated with poorer health. Disparities in income demonstrate higher risks of death in the lower income levels. Poorer individuals may lack preventive care, have poor nutrition, and may lack the means to manage chronic disease adequately.1, 26, 32 Additionally, poor health is associated with lower literacy levels.33 Limited educational opportunities make it difficult to break the cycle of social disadvantage, and providing educational opportunities creates an avenue for improvement.32, 33

NPs often take lead roles in the area of providing care for the underserved, where preventive services may be inadequate. In rural and remote areas, the NP may be the sole health care provider, and preventive services such as teaching dental hygiene, injury prevention, and domestic violence prevention need to be included in all encounters. Omitting interventions directed at the poor or disenfranchised will only widen the gap between the “haves and have nots” and further increase healthcare disparities.32, 33

Environmental factors are known triggers for disease expression. Examples include toxic agents, virulent bacteria and viruses, pollutants, contaminants, and commercial products. Elevated levels of these agents and substances are associated with disease burden and deaths. Well-publicized morbidity and mortality associated with infectious diseases such as HIV, hepatitis, Hantavirus, and seasonal and H1N1 influenza are together responsible for hundreds of thousands of deaths annually. Hazardous conditions in the environment claim thousands of lives each year. The intersection of environmental factors and other health determinants augment death and disability; examples include risky behaviors and exposure to sexually transmitted diseases, accidents related to substance abuse, and cancer related to tobacco use.1, 2, 26 To prevent this collision of environmental influences and disease development, NPs should be counseling patients about risky sexual practices, smoking cessation, and alcohol and substance abuse. In addition to promoting childhood vaccinations, adult vaccinations against tetanus-diphtheria, influenza, pneumonia, and hepatitis should be promoted as well. Accident prevention is a major focus for both adults and children; counseling about seatbelt and infant/child car seat safety, hands-free phones and not texting while driving, and motorcycle helmet safety are simple but effective measures.1, 2, 26

By far, the determinant that exerts the most powerful influence on health is lifestyle choice. Daily choices of food intake, exercise, sex, substance use, and maintenance of weight influence our development of chronic disease. The evidence base supports the association between being overweight/obese and leading a sedentary lifestyle with a higher risk of cancer, diabetes, heart disease, and arthritis. Tobacco use is still considered the leading single factor associated with death and disability. Taken all together, behavior choices account for close to 1 million deaths annually in the United States. These are all regarded as “early” deaths that are associated with significant disease burden. This health determinant is also the most controllable, responsible for the highest number of preventable diseases.1, 2 NPs should spend the greatest effort in this area to make a substantive difference in the rates of chronic disease prevalence. Secondary preventive services include blood pressure, cholesterol, mammography, alcohol, colorectal cancer, and obesity screening. Early intervention is key.1, 2

Lastly, medical care exerts influence on the health of populations. We spend over 15% of the gross national product to deliver medical care, and our increased life expectancies are in part attributable to our superb health care system.1 In spite of the accolades, there are deficiencies such as poor access to care, health care disparities related to ethnicity and income, and the plight of the uninsured. Another troubling factor is the high number of deaths associated with medical errors. Our system is flawed in several ways and it is estimated that medical care problems may contribute up to 10% of total mortality.34 Taking an active role in policy and legislative initiatives is paramount for NPs, and it is important to point out that many prevention initiatives are outside of the traditional health care field. Exerting legislative influence on imposing excise taxes on tobacco, zoning laws to discourage liquor establishments, or promoting use of community centers for exercise can be accomplished through forming coalitions with the public health sector and other interest groups.1, 2

It is important to remember that the 5 health determinants do not exist in isolation. In fact, they interconnect in numerous ways, thus further contributing to death and disability. Some of the determinants are nonmodifiable, such as genetic predisposition, but poor choices made for lifestyle and many adverse environmental and social circumstances are avoidable. Public health efforts to target these issues are inadequate, and policy initiatives need to be directed in this area.

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Barriers to Disease Prevention Interventions 

Our health care system is designed for disease management. Technology and other innovations are produced to support eradication of disease and there are few resources left over to support prevention programs. Adequate disease prevention systems would mandate major shifts in funding that support policies to promote health.1, 5

Because primary prevention targets children, emphasis needs to be placed on interventions that are not designed to be delivered in the typical examination room. The great majority of children will benefit from preventive efforts that focus on environmental forces, school interventions, and social policies that are designed to improve the health of children. These interventions are complex and have multifactorial root causes. This makes them difficult to deliver using one-dimensional modalities.5

Using childhood obesity as an example, policies that affect school meals and snacks, physical education programs, and health and nutrition courses to guide healthy choices require complex coordination of efforts. Because they are not intended to affect the health of a child in isolation, the necessary coordination of community and home interventions to provide safe places to play outdoors and to help limit the amount of television viewing and video games must also be orchestrated carefully. Supporting the family and providing social learning theory concepts of affecting the child's behavior by first influencing the parent's behavior need to be included. Multiple systems must be activated to ensure a thorough approach to the problem.5, 35

Another major barrier to providing adequate prevention programs involves lack of financial support. The traditional fee-for-service system of our health care infrastructure is not designed to support prevention or health promotion. Consider the above example: there are no billable procedures for school, home, or community interventions that address prevention of childhood obesity. And our current public health system is not adequate to absorb these initiatives without restructuring funding sources to support them.1, 35

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Is Prevention Cost Effective? 

Prevention is a complex issue and determining the economic soundness of preventive measures is equally complex. Determining the cost-effectiveness of a health care measure is not as straight-forward as it appears. Treatment interventions must be found safe and effective, something that can be concretely demonstrated, whereas preventive measures must demonstrate future savings in terms of health and social costs—projections that are difficult to ascertain and highly speculative. The disparate nature of these benchmarks creates an unequal footing that disadvantages prevention compared to medical care.1

It is perhaps better to expect that preventive services provide excellent value. Examples include vaccinations; aspirin to prevent heart disease; and screenings for colorectal cancer, cervical cancer, blood pressure, cholesterol, and blood glucose. Population level prevention measures can be equally effective and include policies and laws to discourage access to tobacco, to prevent pollution, and to reduce risky behavior.30, 36

Unfortunately, the success of preventive measures is determined in the short-run, not the long-run. So, unless it can achieve immediate cost savings, the measure is not regarded as being effective. In the example of tobacco cessation, evidence clearly links tobacco to cardiovascular disease and lung disorders. Yet, the short-term costs associated with smoking cessation are quite high, while the long-term avoidance of chronic disease later in life is hard to quantify monetarily. Does that mean that smoking cessation efforts should be abandoned? Of course not; yet, that is a difficult concept for policy makers, insurers, and lawmakers to endorse, especially when confronting the high up-front costs associated with cessation treatments.30, 32

Prevention is quite complex and mandates multiple upstream efforts to limit chronic disease. This is contrasted with medical treatments that often focus on single symptoms or presentations.1 In the case of type 2 diabetes, treatment is focused on managing blood sugar with multiple treatments; however, the prevention of diabetes involves multiple upstream efforts such as working with schools to promote healthy eating, physical activity, and limiting unhealthy snacks and sodas. Other diabetes prevention solutions require coordinated community efforts to ensure adequate outdoor space for exercise, funding of public service announcements, and diet and nutrition counseling. Naturally, these efforts require major and sometimes very different funding streams, so the costs associated with these interventions are hard to calculate and can be quite high.1, 36, 37

Prevention interventions often involve changes to behavior and value systems. From an economic perspective, improving health is not the sole goal of humans. Many other goals compete with maintaining health, such as the utility of consuming a particular product, or immediate pleasure gained from engaging in certain behaviors. The tricky aspect of prevention is creating opportunities to pursue health that outweigh the benefits derived from other pursuits. Moreover, imperfect market conditions prevent many consumers from making healthy choices because they lack the knowledge or resources to do so. In the case of children, they are not able to make decisions independently.30, 38

In terms of social preferences, medical care is highly desirable when it is acutely needed; yet, the public is reluctant to change behavior to reduce risk even when it is well established that certain behaviors increase risk.1 Take the example of overeating, being overweight or obese, and the strong association with developing diabetes and heart disease. In spite of that fact, millions are willing to continue to be overweight or obese. Of course, other factors, such as lack of knowledge of sound nutrition (knowledge asymmetry), lack of availability of nutritious foods, and lack of safe environments that are conducive to exercise may interfere with the ability to reduce that risk, but the majority choose to continue to engage in high-risk behaviors.1, 30, 38, 39

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Solutions and Policy Opportunities 

New technologies and innovative approaches to health care that are specifically designed for disease prevention will have a prominent role in our future health care system. Cancer vaccines that stimulate the immune system to target and eradicate cancer cells or telomerase inhibitors that prevent unchecked growth of cancer cells are examples of innovative approaches to disease prevention. The quest for new medications that treat diabetes more effectively or prevent the onset of type 1 diabetes continues, and major gains have been made.40 Obesity management technology should improve to offer more treatment options. The focus on obesity prevention needs to be augmented and directed to our children. It is far better to prevent obesity than to treat it and its associated complications such as diabetes, heart disease, arthritis, and cancer.41

There are a number of issues associated with chronic disease management that are examples of market failures, such as incomplete information, as well as information asymmetry. Others to consider include the influences of externalities on consumer behavior and consumer preferences. This boils down to immediate gratification on behalf of consumers as they receive disease management rather than preventive services that offer delayed benefits. When coupled with the government's favorable treatment of medical interventions, prevention and management of chronic disease is undermined.38

To address market failures and facilitate the process of preventive care, alternatives need to be explored and evaluated. One example is the case of chronic obesity. In addition to developing comprehensive public health strategies such as public service announcements, school policies, community policies, and health department interventions, employers must share a role in promoting healthy choices. Plus, the employer has an economic incentive to reduce the burden of obesity, because health care costs for obese individuals due to weight-related problems are significantly higher than for non-obese individuals.42 In one study, the authors found that obese female employees had health care costs of $2485 per year more than normal-weight females.43 Blue Cross Blue Shield of North Carolina reported that 55% of their 3 million members were either overweight or obese, and their claims were 18% to 32% higher than those of normal-weight members.42

There are numerous examples of employer interventions to reduce obesity among the workforce. Worksite wellness programs have been established to further motivate employees to lose weight, exercise, and choose healthier foods. The Mayo Clinic in Rochester, New York, offers a brown-bag health education series, walking areas, health newsletters, and other strategies to help their employees get and stay fit. They built a wellness center for employees that includes aerobic fitness, healthy nutrition, weight management, conditioning, and stress management. The monthly fee to belong is on a sliding scale, and if the employee uses the center at least 10 times per month for 3 months, the fee drops to $10 per month for at least 3 months. The center enjoys a robust membership and classes are at capacity for fitness and exercise.42

A Maine-based supermarket chain, Hannaford Brothers, offers a financial incentive for its employees to participate in a health risk assessment program that includes management of smoking cessation, stress, hyperglycemia, obesity, and depression. Hannaford regards the program as highly successful and estimates that it will reduce its health care spending by 25%.42

UnitedHealthcare began a multi-state policy to charge employees more for their health care in the form of higher deductibles. Employees can lower their deductibles by reaching targeted goals for blood pressure, cholesterol, height/weight ratios, and not smoking. For each goal reached, the deductible goes down $500, and an individual can reduce the $2500 deductible to as little as $500. This is an example of employers offering economic incentives for employees to lower health care risks, thereby bringing down costs.42

Many sense that we are entering an era in which more aggressive approaches will be taken to combat obesity. Financial incentives and disincentives through health insurance premiums, deductibles, bonus payments, and other benefits will center on intensive efforts to encourage healthy lifestyles, weight management, and exercise.38, 39

The fact is that maintaining a healthy lifestyle works to prevent disease. Consider the findings from the Diabetes Prevention Program Study,44 in which individuals with glucose intolerance were randomized to 3 groups. The study group received intensive lifestyle counseling, another group was given Metformin, and the control group received a placebo. The lifestyle modification group reduced their risk of developing type 2 diabetes mellitus by 58%, significantly more than the Metformin group (31% reduction). This trial demonstrated that lifestyle interventions alone will significantly reduce the risk of chronic disease development.44

The cost savings associated with this intervention cannot be understated. However, as the researchers pointed out, the costs associated with the rigorous intervention of dietitian visits, exercise coaches, exercise equipment, counseling sessions, and health club memberships made this somewhat impractical for general population use. Research for more practical ways to implement lifestyle modifications along with ensuring sustainability should be the next step.45

Another study,46 conducted in Germany, demonstrated that not smoking, maintaining normal weight, exercising, and adhering to a healthy diet reduces chronic disease development. The researchers followed 23,000 subjects to monitor their risks, and subjects who adhered to all 4 healthy habits had a 78% lower risk of developing a chronic disease.46

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Conclusions 

It is important that we strive to achieve parity for preventive measures and focus less on medical care as we continue to struggle to pay for high disease burden associated with chronic conditions. Funding for public health systems that have demonstrated high success rates with community-based preventive efforts needs to improve, but this goal remains elusive in a time of economic constraint and recession. A level playing field for evaluation of both medical care as well as prevention is needed.

The only way to achieve parity in funding and focus is through continued cost effectiveness investigations and translational research in the public health arena. After all, the ultimate goal is to ensure optimal health for all via long-lasting and low-cost strategies. It is imperative that we conduct studies that provide tangible demonstrations of the benefits of healthy lifestyles. Until health promotion and disease prevention are tied to reductions in medical expenses, they will be difficult to justify to as policy priorities.

We can approach this mission by supporting the Department of Health and Human Services' Healthy People 2020 health objectives.30 Medical care and treatment alone is inadequate: health outcomes can best be achieved by combining forces with preventive systems. Policies on education, community health, and other social determinants help shape the health of our nation, and cannot be underestimated.

There is no better time than now for NPs to get involved in local, state, and federal initiatives to fund prevention programs. With the focus on health care reform, legislators and policy makers are looking for solutions to our health care dilemmas. The role of the NP is a perfect fit because health promotion and disease prevention form the basic underpinning of our education.

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 This continuing education activity is designed to augment the knowledge, skills, and attitudes of nurses and nurse practitioners and thus increase the quality of their care.In compliance with national ethical guidelines, the author, reviewers, and editors report no relationships with business or industry that would pose a conflict of interest. The authors do not present any off-label or non-FDA-approved recommendations for treatment. There is no implied endorsement by NPA, MNA, or ANCC of any commercial products mentioned in the article.

PII: S1555-4155(09)00579-0

doi:10.1016/j.nurpra.2009.09.015

Refers to erratum:

  • Erratum

    The Journal for Nurse Practitioners March 2010 (Vol. 6, Issue 3, Page 168)

The Journal for Nurse Practitioners
Volume 6, Issue 1 , Pages 16-24, January 2010

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