In the context of health care reform, too little attention has been given to efforts to promote healthier lifestyles to stem the rising costs of chronic care. Instead, it has been assumed that America will continue to be a nation of sick and unhealthy citizens who will increasingly be relying on pharmaceuticals and advances in medicine to prolong their lives. While this picture is a paradise for prescription drug makers and the private health care industry, as we have learned the percentage of GDP required to sustain our unhealthy lives is, well, unsustainable.
It’s time to take a stand against this idea that, when adjusted for population growth, demand for health care in the future will be greater than it is today. It’s time for people to take personal responsibility for their well being, it’s time for communities to invest in programs that promote healthy living, and it’s time for our government to set policies that create the conditions for wellness. The population-based intervention model is an excellent framework for designing health promotion strategies that intervene downstream (individual-level), midstream (population-level), and upstream (state and national policy level) (p.283). This model can also be effective for changing provider practices, so that hospitals and primary care practices who improve patient outcomes are rewarded by policies that encourage wellness.
With the CDC reporting that preventable chronic diseases contribute to 75% of health care spending, including almost a tenth of all health care spending on obesity-related diseases, the need for dietary changes on a mass scale (no pun intended) is in order. Unhealthy diets contribute to several of top ten leading causes of death, including coronary heart disease, Type 2 diabetes, stroke, and some cancers (p.273). Getting to healthy requires offsetting the energy balance equation by reducing calorie consumption and increasing physical activity. Here are several ideas for a healthier country:
Stop subsidizing corn. Corn subsidies between 1995 and 2006 amounted to $56 billion. Cutting the corn subsidies will buckle the knees of the fast food industry, as the majority of cows are fed nothing but corn-based diets. The result of these policies, as Michael Pollan writes, is that the government pays for the plentiful and cheap supply of high fructose corn syrup in your favorite soft drink, bread, ketchup, and jelly, and then must pay to treat your Type 2 diabetes.
While previously I may have advocated a soda tax to curb consumption of empty calories, simply eliminating this enormous subsidy (along with the armies of agricultural lobbyists) may suffice. This will raise the cost of fast food, soda, and other carb-intense items enough so that fruits and vegetables have a more level playing field. If anyone complains about the higher grocery bill, remember that Americans once spent nearly a quarter of their income on food, and now that figure is less than ten percent, which is less than comparable nations.
Complementing these dietary and agricultural reforms should be changes in urban landscapes: Make road more bicycle and pedestrian friendly. The Federal Highway Administration has a Bicycle & Pedestrian Program that invests in non-motorized transportation programs. Did you know that over $100 million federal dollars have been spent in North Carolina over the past ten years on pedestrian and bicycle facilities? Why don’t you bike to work? Urban planners should be engaged in the design of mixed use land areas, which can lower obesity rates by placing entertainment and shopping centers closer to housing developments. Bicycle sharing programs may be implemented to further popularize non-motorized transport.
Finally, health information technologies can be leveraged to enable individuals and communities to monitor progress towards healthy living. Private insurers are already attempting to reduce costs by investing in consumer health information technologies. Such programs may assist patients with the management of chronic diseases, facilitate doctor-patient communication, and reduce the overall costs associates with treating the disease. With these programs for healthy living in action, all citizens should be able to monitor their progress with inexpensive networked devices and share selected information with friends, family, and health providers. This data could even be aggregated anonymously to create a health surveillance network for cities. Are you ready to participate, and receive a discount on your insurance rate for doing so?
In summary, health care reform need not be focused on how to pay for chronic disease. Instead, efforts should be geared towards creating the societal conditions that encourage healthy lifestyles for everyone.
Heart disease is the #1 killer in the U.S. High cholesterol, high blood pressure, and obesity can be addressed by making healthier lifestyle choices. Altering the diet, exercising more, and managing stress can help ward off heart disease. The key is to create habits that can be used for a lifetime. Stanford University looked at a hundred thousand familes with heart disease and found that 8% had heart disease in the family primarily because of bad genes. 92% of the instances were because of lack of exercise and poor eating habits. Statistics show that 65% of American adults over 20 are overweight or obese, and 1 in 3 children and teens are overweight. The problem comes from larger portion sizes, more processed foods with fewer nutrients, and a more sedentary lifestyle. The obesity epidemic is clearly a growing problem for the health care industry.
I agree, the obesity rate is climbing and the one thing that can help this is prevention of others and trying to change habits. More healthy habits need to be advertised such as walking and a healthy diet. Walk from Obesity is one way they community of Greenville is reaching out and trying to put a stop to obesity, especially since we have the largest amount of fast food restaurants per capita. There should be more efforts on a national scale to fight obesity. Of course we see advertisements for gyms and new diets and see shows like the biggest loser. But what we really need are more programs like walk from obesity that are simple, cheap, and easliy accesible by all. I also agree that a tax on certain foods such as candy and soft drinks might help but then we also would have to lower the cost of healthier foods such as juice and organic vegetables.
Heather and Elizabeth,
Thank you for replying to my post and discussing how obesity and the health effects of being overweight and obese lead to chronic illness. I agree Elizabeth there should be greater local and national efforts to curb behaviors that lead to obesity, and I highlighted many of these ideas in my post. One question is, should individuals be penalized for engaging in poor dietary habits, or should the $92 billion spent on obesity-related illness in 2002 (p.274) be paid by everyone? If you think individuals should be penalized, should this be in the form of a tax at the time of consumption, or a higher premium on public and private insurance plans? Or, perhaps there is an even simpler solution to all of this: chew longer. See:
Obesity and the Fastness of Food
http://economix.blogs.nytimes.com/2009/05/05/obesity-and-the-fastness-of-food/
http://www.findingdulcinea.com/news/health/2009/august/Tackling-Fast-Food-Habits–With-a-Tax.html
I checked out your website and also found this one that had some good information. A proposal for tax of 1-3 cents per ounce would pump quite a bit of money to fund health care. The thought is if people can afford the sugary drinks after the tax is added, then they have the money to buy health insurance. 55% of polled people favor a tax on junk food, which would provide $500 billion in revenue over ten years. Critics say that a pound of broccoli costs more than anything on the menu at McDonald’s, but others say that the money spent on health care because of poor diets would be funded by the tax on fast food. People would be healthier and health insurance could be more affordable for everyone.
I had one quick thought regarding the corn subsidy. Why not get rid of it and subsidize healthy vegetables and fruits instead? This seems like an easy (although not politically easy) swap that would not cost the government any additional money and allowing a larger portion of the population to afford fresh produce and hopefully replace the higher calorie and fat processed foods containing corn syrup with healthy raw produce.
I find it very frustrating that a grilled chicken salad and water costs way more than a doulble cheeseberger, sm fry, large sweet tea, AND icecream cone. With a downward spiraling economy, many families are pressured to choose between eating healthy and stretching their paychecks. I look forward to the day that our society stands up to the fast food industry and the government and questions the logic in our system. I like your idea, Jonathan, regarding the soda tax. We currently tax tobacco and alcohol so why no tax processed, over- concentrated sugars? I also like your concept of rewarding those with healthy lifestyles as an incentive to maintain or improve positive healthy lifestyles.
To JL and All Fellow Bloggers,
I think all of you have offered some good ideas for specific issues, but I think you are missing some of the bigger picture. If you take away corn subsidies, you are not just penalizing those using high fructose corn syrup but also the farmers, the field hands, the distributors, the makers of ethanol, etc etc. In other words, if you bomb the source, you have unintended consequences sometimes called collateral damage.
In general, all the blogs touch upon incentives and disincentives. However, both can be a double-edged sword when applied. For instance, high taxes on fast foods and sodas affect the poorest segment of our population than most others. Higher taxes on cigarettes and liquor have not eliminated those unhealthy habits. However, they have redirected disposable income for those in the poverty level from buying less unhealthy food so that more money is available for alcohol and cigarettes. For a smoker or alcoholic, the decision to spend less on food in order to satisfy your cravings is not a difficult decision. In addition, we are NOT talking about giving up nutritional meals, but fast food and “mac and cheese” and canned spaghetti. These high carb foods are filling but cheap and easy to prepare. Education of those at the poverty level is absolutely useless–if you can’t afford healthy alternatives, then what difference does it make if you now know they exist?
I think incentives and disincentives, when logically and comprehensively applied can produce desired results. For instance, a type of disincentive already used by the Government is to ban certain food items or groups when purchased with Welafare or WIC funds. From an incentive perspecitve, weight loss or smoking cessation could be tied to decreased insurance costs or increased health insurance benefits. Most of all I believe education should start with the younger generation. Schools are the ideal environment to teach children about nutrition and other healthy lifestyle choices. However, schools must first take action to remove the unhealthy choices they now offer; soda dispensing machines, salted peanuts, and even high sugar content fruit juices in the cafeteria. If you study the decline in cigarette smoking in the U.S. you’ll find that it is not one major factor but a combination that has proved effective. Essentially, smoking is an expensive and troublesome experience rather than a leisurely break as it once was. Although the results are impressive, it is clear that a long run strategy is in place by banning tobacco ads near schools and other advertisements directed towards children.
There are no clear solutions; only logical choices.
Hi Ted,
Thank you for your comprehensive response. I understand that removing corn subsidies will have an effect across several industries that rely on the artificially low cost of corn and corn derivatives to profit. However, I believe that such action is essential to reduce overall health care costs associated with poor dietary habits.
I challenge your statement that higher cigarette and alcohol taxes causes people to buy “less unhealthy food so that more money is available for alcohol and cigarettes”. Can you provide evidence to this end, that higher taxes on unhealthy items do not affect their consumption, but simply diverts funds away from healthy choices?
I agree that education is essential, but it is also imperative to create the conditions that encourage healthy consumption. This may include subsidies for broccoli, oranges, and red peppers while taxing items heavy in corn syrup and ingredients that are known over time to be linked to chronic disease.
Is there something wrong with this picture for the health of our nation? List of agricultural subsidies in the US:
http://en.wikipedia.org/wiki/Agricultural_subsidy#United_States
I agree with JL that ‘efforts should be geared towards creating the societal conditions that encourage healthy lifestyles for everyone’. I believe that there can be no meaningful health care reform or decrease in health care costs unless there is some patient incentive for healthy behaviors. People have to wake up and take responsibility for their own health choices.
Tobacco abuse causes a myriad of health problems such as COPD, heart disease, peripheral vascular disease and cancers chiefly lung cancer. It accounts for annual health care costs of 75 billion $$. Smoking rates have dropped in the last 3 decades due to multiple upstream and mid stream interventions such as changes in laws (e.g. surgeon general’s warning, clean indoor air laws, recent FDA control over tobacco etc), economic disincentives (cigarette taxes) and mass communication.
At the downstream/ individual level, it was recently shown in a randomized trial that financial incentives for smoking cessation significantly increased the rates of smoking cessation (http://content.nejm.org/cgi/content/short/360/7/699). Thus it makes sense to have higher insurance premiums for smokers. Some companies offer an extra sum of money for quitters. Others invest in smoking cessation programs.
Similar studies have been conducted in the areas of weight loss and medication adherence. These studies highlight behavioral trends and help to frame incentives in the right manner. However it is not yet clear whether this sustains quitting over longer periods. What happens when the financial incentive is gone? http://knowledge.wharton.upenn.edu/article.cfm?articleid=2266
I also agree with Jonathan in that more changes should be made in our community. I think that make roads more bicycle and pedestrian friendly is a great idea. I also think that there should be more emphasis put on recreational sports and other forms of exercise.
As for taxation, I feel that taxes on sodas and junk foods should be implemented. Think about cigarettes. Back in the 1950s and 1960s, majority of people smoked. Now, our society is making it difficult to be a smoker. Most restaurants and public places have gone “tobacco free” and the taxes imposed on tobacco products has also slowed a lot of people down. I think that by putting “restrictions” or extra taxes on such products, people will hopefully think twice before purchasing.
Laughnan, I enjoyed reading your blog about “creating the conditions for wellness.” I agree that society needs to focus more on healthy living by taking proactive measures rather than reactive ones. Creating an environment that truly supports health is a long-term project that requires real dedication to wellness values and a lot of sustained hard work. Achieving better health requires action both by individuals and by society. If society supports and enables healthier choices—and individuals make them—we can achieve large improvements in our nation’s health. Too often, we focus on how medical care can make us healthier, but health care alone isn’t sufficient. We need to cultivate a national culture infused with health and wellness—among individuals and families and in communities, schools and workplaces. Just as America has “greened” in response to global warming, we can and must integrate healthier decisions in all we do. As you stated, more than 70 percent of health-care dollars are spent treating a handful of conditions: diabetes, heart disease, asthma and depression. But often people don’t get the evidence-based treatments that are proven to help manage these conditions. In addition, Nearly two-thirds of the U.S. population is considered overweight or obese, and an estimated quarter of Americans regularly use tobacco products. These modifiable lifestyle choices put the health of individuals and the economic health of the nation at serious risk. Communities should provide opportunities that promote wellness. Healthy communities can also foster and reinforce individual efforts to achieve and maintain health. The social and physical environment can reinforce social standards of a “culture of wellness.” Governors have a powerful platform for promoting healthier lifestyles and supporting community-based wellness efforts, using three basic strategies: 1) Use the office of the governor as a “bully” pulpit to promote healthy living. Governors can promote personal and civic responsibility for better health among millions of Americans by raising the public’s awareness of the benefits of healthy lifestyles. As visible role models, governors can set an example by drawing attention to their own pursuit of wellness. Governors can also encourage individuals to incorporate healthy choices into their daily routines by promoting the use of resources such as walking trails, recreational parks, and farmers’ markets (and the bicycle sharing program as you mentioned). 2) Educate state residents through community programs and messaging campaigns. As the state’s chief executive, governors have the opportunity to promote wellness education and to launch messaging campaigns to parents and children. Governors also can ensure that state agencies and programs provide consistent and practical information for healthy living. 3) Promote environments that support physical activity and healthy eating. Governors can create environments conducive to healthy lifestyles by providing access to safe local resources—such as parks and trails—and working with community organizations to help citizens lead healthier lives. Governors also have an opportunity to increase access to healthier foods through the development of supermarkets and other produce outlets. A number of governors have launched wellness campaigns and convened public and private sector leaders to raise awareness of healthier lifestyles. Wellness campaigns can significantly improve nutrition and increase physical activity among children, adults, and seniors. Governors can partner with the private sector or faith-based organizations, which can magnify a program’s impact by reaching a larger population in a sustained campaign. In 2005, California Governor Arnold Schwarzenegger partnered with the California Endowment—a foundation that seeks to increase healthy choices at the community level—to launch a wellness campaign called Get Healthy California: Governor’s Summit on Health, Nutrition and Obesity. The summit brought together parental advocacy groups and leaders in government, business, education, and medicine to explore potential partnerships between various sectors, and to garner commitments from partnering organizations for future efforts and programs. The Massachusetts Partnership for Healthy Weight focuses stakeholders on policy and systemic approaches to increasing healthy eating and physical activity. The partnership spurred efforts to provide healthier school lunches; to promote afterschool programs to combat obesity and physical inactivity; to incorporate nutrition and physical activities into programs for the elderly; and to increase awareness of the importance of physical activity and opportunities to be active. The partnership includes state departments of highways, parks, and education; health advocacy organizations such as the American Cancer Society and the American Heart Association; health insurers; health care providers; public and private universities; the YMCA Alliance; and activity advocacy organizations—the Massachusetts Bike Coalition and the Massachusetts Rails to Trails. As the key social and environmental setting for millions of Americans, communities are ideal venues for promoting and motivating people to make healthier lifestyle decisions. They provide vehicles for increasing awareness about the need for healthier lifestyles, carrying out policies conducive to better health, and linking residents to health-related programs, which governors can use to improve the health and wellness of their states.
Great post from the group on creating conditions for wellness. Again this is a complex issue that is multi-facted. Change that bring about policy changes will improve society health and in so doing over time will improve individual health. It will take time and a change in attitude about our indivdual health. Again, we as individuals must take personal responsibility for our health and be proactive regarding our lifestyle rather than reactive in our decisions regarding health.
Agricultural subsidies should definitely align with the environmental and health care agenda of the US government, the people’s representatives. It is counterproductive to taut the public take preventative measures in the lifestyle choices we make regarding health and fitness and then provide funding that increase unhealthy choices in the marketplace.
Jonathan, I really enjoyed reading your blog. I’m sure that many of the students from my program (Masters of Public Health Program) would support a lot of points and ideas! The reality is that we are not focusing on promoting health as much as we should. Instead, we are so quick to put people on medications (clinicians) or be put on medications ourselves (patients).
Each week, I visit outreach clinics to increase awareness about chronic kidney disease. Our study is funded by Kate B. Reynolds, and our original plan was to just focus on educating the primary care providers. As time went on, we decided that we would also provide kidney education to the patients. Just about every patient that speak with at the clinics have diabetes, hypertension, and/or obesity. As most of us know, these conditions are preventable (in most cases).
When I first started visiting the clinics, I was shocked to find out how many prescription drugs the patients were taking. With some patients, I can sense that they are content with taking so many medications. Others can’t afford to take the medications, and do not take the medications and continue living unhealthy lifestyles. I am certain that changes in lifestyle (i.e., physical and nutrition) would help many of the patients. Of course, there are certain barriers (i.e., low-income) that affect individuals. However, we must relay ways to overcome the barriers to these individuals. I feel that health has to be tackled at multiple levels: individual-, population-, and policy-levels. Many of your ideas are good starts.
Hi Jonathan,
Thanks for the insightful blog. I really liked the many points you made about the cost effectiveness of prevention as well as the many initiatives the government has implemented to promote wellness within the community. Not much funding is allocated to public services and preventative care, so we should definitely make use of the programs and services that are offered to us. Besides if we don’t value health promoting initiatives, why should they?
I also agree that most successful health promoting programs require not only individual change, however social and policy changes as well. One example is the implementation of tobacco prevention and cessation programs. At the government or “policy” level, policies are enforced to prevent the use of tobacco in public places to prevent exposure to secondhand smoke and make the use of tobacco difficult to encourage the user to quit. Socially, we change to social norm of using tobacco, especially among youth to something undesirable, and finally on the personal level, we provide education and skills to ensure they are able to remain or become tobacco free.
I think in the US it has become a norm to take everything the easy way; in order for our health to improve and to decrease the incidence of chronic disease, we must establish wellness and health as a social norm.
I enjoyed reading some of the conflicting ideas throughout this post. While I do agree that cutting corn subsidies would greatly effect many people, I think in the long run it will be better for everyone. I think to make the transition easier on everyone, it woul need to be announced ahead of time so workers are not blindsided. If we redirected the resources that are currently going to curn as someone mentioned, then that would allow for more jobs in that area.
In response to the bicycle program an the idea of biking to work, I think the biggest barrier at least for me is safety. Depite what the federal government has tried to implement with the share the road program, I still do not feel safe riding to work in traffic. I am a rider and I choose to do my rides early in the morning to avoid traffic. I just feel that all too often I am hearing on a cyclist hit and killed. So until people learn to drive better and pay attention, I think biking to work unless on a paved path seperate from the road is too dangerous.
Thank you everyone for your positive responses and ideas towards creating conditions for wellness. I agree Dana that unless roads are designed with bicycles in mind, then they are not a viable alternative to the automobile. Tilneil, you raise a good point regarding how social norms can create widespread changes in behavior. How do social norms become, well, the norm? I believe portable networked devices have the potential to distribute change in health behavior, by posting individual health data in social networking applications. Finally, Audrey thank you for sharing your clinic experience and the challenges involved for patients living with multiple chronic conditions. With so many medications for each patient to manage, this stresses the importance of a primary care physician or clinical care manager to coordinate treatment and path towards better health.