Research to Reduce Chronic Diseases and Health Disparities

Chronic Diseases and Health Disparities

Many of the most serious health problems affecting Floridians (and all Americans) are chronic diseases, such as heart disease, some cancers, and Type 2 diabetes. Chronic diseases are characterized by a long course of illness, rarely resolve themselves spontaneously, and generally are not cured by medication or prevented by vaccine. According to the Robert Woods Johnson Foundation, although the U.S. spends $2.2 trillion every year for health care - far more than any other nation - Americans are not as healthy as they could or should be. Besides human suffering and shortened life span, chronic disease is a major driver of health-care costs. Almost 75 cents of every dollar is spent treating chronic conditions, many of which, such as type 2 diabetes and heart disease, might have been prevented or delayed. (http://www.rwjf.org/pr/product.jsp?id=45408 ) As shown in the figure below, two-thirds of the increase in health care spending from 1989-2000 was attributable to the increase in chronic diseases.

Spending on Chronic Disease Treatment

Although chronic diseases are among the most common and costly health problems, they are also among the most preventable. Chronic diseases are caused, or are at least made worse, by personal choices individuals make about eating, smoking, and leisure activities. Therefore, one of the best ways to "cure" these widespread diseases is to improve health literacy and the choices people make that affect their health. The potential impact of changing poor health-related behaviors is huge. The U.S. Center for Disease Control (CDC) estimates that if tobacco use, poor diet and physical inactivity were eliminated in the U.S., it would prevent:

1. 80 percent of heart disease and stroke;
2. 80 percent of Type 2 diabetes; and
3. 40 percent of cancer

And, there are other health benefits as well, such as reductions in respiratory disease, some neurodegenerative diseases, joint problems, etc.

Health disparities, which are largely correlated with income levels and race, are a special area of concern for the state of Florida. Florida has the third and fourth largest Hispanic and African American populations, respectively, in the country. Within the state, 20% of residents are of Hispanic descent and 15% are African American. Certain diseases are more prevalent, more deadly, and in some cases, exclusive to certain populations. While 55% of premature deaths can be credited to social and behavioral determinants of health, 30% can be accounted for by genetics. Research to improve these disparities observed among gender, race, and socioeconomic levels is crucial in lowering healthcare costs and creating a better quality of life.

Smoking

Smoking-related diseases claim an estimated 430,700 American lives each year. Smoking costs the United States approximately $97.2 billion each year in health-care costs and lost productivity. It is estimated to be directly responsible for 87 percent of lung cancer cases and causes most cases of emphysema and chronic bronchitis.

The 2009 Legislature and the Governor took a major step to reduce tobacco use by passing a $1 per pack surcharge into law. The increased tax is expected to generate approximately $945 million in revenue for the state in the first year and much of that money is planned to be used to increase spending on smoking cessation programs and biomedical research, including the Jim and Esther King Biomedical Research Program focused on tobacco-related diseases. Florida's cigarette tax had been the 4th lowest in the nation, but now Florida's tobacco taxes rank 22nd. The FL CURED Advisory Council commends the Florida Legislature and Governor for taking this important, bold step to improve Floridians' health.

Poor Diet

Poor diets can mean a number of things; for example, for much of the world it means starvation and malnutrition. Although malnutrition is still an important problem in America, for this report the focus of poor diet is not the lack of food but rather too much food, especially fattening food- that is literally causing an epidemic of people who are overweight or obese. It is estimated that about 65% of Americans are overweight or obese. Obesity is known to contribute to a variety of diseases, including heart disease, diabetes and general poor health. For example, the incidence of Type 2 diabetes in the U.S. has risen in correlation with the increase in obesity. The American Diabetes Association estimates about 21 million people have diabetes, with another 54 million people diagnosed with pre-diabetes. Florida ranks 10th in the number of persons considered obese (a ranking of 1 is best), with approximately 24% of the population in that category. In 1990 13.6% of the population in Florida was obese. Thus, there has been more than 10% increase in the number of obese Floridians since 1990; yet, because the rest of the nation became even fatter over the past 18 years, Florida's ranking improved all the way from 43rd in 1990 to 10th today.

Physical Activity

Although it is common knowledge that exercise is healthful, according to the CDC, more than 60 percent of American adults are not regularly active, and 25 percent of the adult population are not active at all. In addition, although people often embark on vigorous exercise programs at one time or another, most do not sustain their participation. Clearly, the processes of developing and maintaining healthier habits are as important to study as the health effects of these habits. Of course, in addition to the obvious benefits of physical exercise, the associated risks must also be considered. The most common health problems are musculoskeletal injuries, which can occur with excessive amounts of activity or with suddenly beginning an activity for which the body is not conditioned. (http://www.cdc.gov/nccdphp/sgr/summ.htm)

Strategies to Reduce Chronic Diseases

Two strategies for helping prevent many chronic diseases from ever developing is to encourage and assist individuals in making healthier lifestyle choices by improving health literacy, and wellness.

For example, the Florida Department of Health is doing that through its Bureau of Chronic Disease Prevention and Health Promotion. At the national level, both the NIH and the CDC have programs (see, for example, http://www.cdc.gov/nccdphp/recovery/). In addition, many of the private, non-profit health-related organizations give attention to health literacy and wellness. As just two examples, the American Cancer Society has a number of cancer prevention and early detection programs, including those aimed at smoking cessation; and, the American Diabetes Association has several programs promoting improved nutrition and exercise to reduce the risks of developing Type 2 diabetes. Research has also shown that if you take action to manage your blood glucose when you have pre-diabetes, you can delay or prevent type 2 diabetes from ever developing.

Health Literacy

There are many definitions for health literacy. It is not simply the ability to read. Healthy People 2010, the CDC's roadmap for improving the nation's health, and the National Library of Medicine define health literacy as "the degree to which individuals have the capacity to obtain, process, and understand basic health information and services necessary to make appropriate health decisions." The American Medical Association defines it as "a constellation of skills, including the ability to perform basic reading and numerical tasks required to function in the health care environment." Examples of these skills would be the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, etc.

However, as stated above, health literacy is not simply the ability to read and understand what you are reading. Health literacy requires a complex group of reading, listening, analytical, and decision-making skills, as well as the ability to use technology, networks, engage health care professionals in dialogue, and navigate complex and daunting health care systems. Health literacy reflects an individual’s capacity to undertake activities related to their health care.

A study of health literacy among enrollees in a managed care organization published in the Journal of the American Medical Association (JAMA) found that 33.9% of English-speaking respondents had inadequate or marginal health literacy, 53.9% of Spanish-speaking respondents had low health literacy and, that health literacy declined dramatically with age. Another study published in JAMA, of patients at two public hospitals, found:

• 33% of patients at did not understand instructions for a common x-ray procedure written at the 4th grade level
• 24.3% to 58.2% of patients did not understand directions to take medication on an empty stomach,
• 20% of patients answered questions incorrectly regarding information on an appointment slip, and
• 40.7% to 74.5% of patients surveyed did not understand the standard informed consent document.

Wellness

Wellness is a concept that refers to physical, mental and social well-being and not merely the absence of disease or infirmity. It has been described as an interactive process of becoming aware of and practicing healthy choices to create a more successful and balanced lifestyle. The four key principles of wellness are:

1. Process Wellness is ongoing and individuals never reach a point where there is no further possibility of improving.
2. Awareness Individuals need to be knowledgeable about the state of their own well-being and are able to seek and obtain information about how they can improve their well-being.
3. Practicing Healthy Choices Individuals can engage in a variety of behaviors, each affecting their well-being, some positively, some negativity. This also requires access to the means of choosing health behaviors
4. Success and Balance Individuals subjectively experience wellness, and wellness is dependent upon factors unique to each individual

While wellness can be practiced on an individual basis, there is a growing recognition that organizations can help by providing wellness programs. These wellness activities are sets of organized activities and systematic interventions designed to provide health education, identify modifiable health risks, and influence health behavior changes. They are usually offered through corporations and worksites, managed care organizations, and governmental and community agencies.

Wellness can also be pursued through preventative medicine. Preventative medicine refers to medical interventions designed to prevent the onset or worsening of illness. Managed care organizations emphasize preventative medicine to keep their membership healthy and reduce the costs of medical treatment. In managed care settings, preventive care is practices through the primary care physician to maintain the health of patients at the highest possible level of wellness by providing systematic monitoring, detection, and correction of illnesses before they occur or before they develop into major health concerns.

Whether at the state level, or national level, it is not evident that the resources allocated for health literacy and wellness are commensurate with the magnitude of the economic and health problems caused by chronic diseases, especially when compared to the spending on research and treatment of these and other diseases. Perhaps there is an imbalance because there is little profit motive in health literacy and wellness.

And, while the NIH does address chronic disease prevention, much of this research is spread across its 27 institutes and centers. Obesity research at the NIH, for example, is coordinated by The NIH Obesity Research Task Force, but according to the NIH website, its latest Strategic Plan for NIH Obesity Research was done in 2004.