Creativity, Collaboration Needed to Reduce the Growing Burden of Chronic Disease
Symposium on Population Health — February 2017
Tex Med. 2018;114(2):22-27.
By John Hellerstedt, MD
John Hellerstedt, MD, is a board-certified pediatrician and commissioner of the Texas Department of State Health Services. His background includes office-based and hospital-based general pediatric practice, prior state service in Medicaid and the Children's Health Insurance Program, and experience as a physician executive with the Seton Family of Hospitals in Austin.
At the outset of the 20th century, the major health threats to individual and community health in the United States were infectious diseases, injuries due to unsafe workplaces, diseases due to poor nutrition, and poor maternal and infant health. Over the next 100-plus years, major advances in health were made, and as we entered the new millennium, the top 10 public health accomplishments of the past century in the United States were due to advances in:1
- Motor-vehicle safety,
- Safer workplaces,
- Control of infectious diseases,
- Decline in deaths from coronary heart disease and stroke,
- Safer and healthier foods,
- Healthier mothers and babies,
- Family planning,
- Fluoridation of drinking water, and
- Recognition of tobacco use as a health hazard.
This era witnessed tremendous advances in medical science and technology, vastly improving the clinician's ability to prevent, diagnose, treat, and cure disease. Many once-common, deadly diseases are now distant memories. While progress in medical science and technology has greatly reduced the impact of many of the most common causes of death and disease that prevailed over the past century, we have seen the pattern shift, and currently we are presented with a different set of diseases and medical conditions that, in turn, present a different set of challenges in our ongoing efforts to reduce human disease and suffering.
As the impact of certain historically significant diseases decreased, the pattern of public/population disease burden increasingly has been dominated by chronic diseases such as cardiovascular disease, diabetes, asthma, and cancer. As a consequence, the work of public health professionals is largely focused on identifying the risk factors for these chronic diseases via enhanced morbidity and mortality surveillance. Over time, a deep knowledge base has developed regarding the risk factors for many of these chronic diseases. In many instances, these chronic diseases are preventable, and despite our knowledge of how to prevent them, their significance persists and grows. Thus, we must turn our attention to identifying solutions to create awareness, educate, promote, and, ideally, eliminate preventable chronic disease. We must devise ways to turn knowledge into effective action.
Texas has the second largest population in the United States with approximately 29 million people in 2016. The population of Texas has been steadily increasing for the past 15 years. This trend is expected to continue, particularly in certain subpopulations, such as Hispanics and people 65 years and older. In 2015, the average life expectancy for Texans at birth was 78.3 years2 compared with 78.8 years for the United States.3 This is up from 1990, when the average life expectancy at birth was 75.1 years for Texas2 and 75.4 years for the United States.3 Disparities in life expectancy continue to exist with respect to gender and race/ethnicity (Figures 1 and 2).2 Overall, men have a lower life expectancy than women (75.8 years vs. 80.7 years). African-Americans on average have a lower life expectancy than Texans overall (74.8 years vs. 78.3 years).
Personal choices, lifestyle, and access to healthy alternatives affect the health of individuals and populations. Poor nutrition, physical inactivity, drug and alcohol abuse, and tobacco use are all known risk factors for many chronic diseases that increase the disease burden and health care costs in our state and that can lead to deaths that are often preventable. Other determinants of health ― such as where people live, economic security, education, and access to affordable and nutritious food ― also have a great impact on health. Strategies to improve health must include lifestyle and behavioral changes and improvements in these other determinants of health, and must foster concerted public health action.
Threats from acute infectious diseases such as Ebola (2014) and Zika (2016) make headlines. Clearly, the job of public health professionals includes preventing, detecting, and responding to such threats. However, if our goal is to measurably improve the overall well-being of our fellow Texans, we have to turn our attention in a much more significant way to a system-level approach to reducing the burden of chronic diseases among Texans.
In 2015, chronic diseases made up the top four causes of death in Texas and the United States. Cardiovascular disease continues to be the leading cause of death in Texas, followed by cancer, cerebrovascular disease, and chronic lower respiratory diseases.4 Figure 3 provides a more detailed perspective of the prevalence of these key chronic diseases and their contribution to mortality rates.4 These chronic conditions, in addition to being devastating for quality of life, are costly conditions to treat and manage, and are potentially preventable to a large degree.
A key point to note is that the greatest opportunity to improve upon these conditions and to potentially prevent deaths is by changing lifestyle and personal behaviors. Obesity and tobacco use are the two key risk factors (lifestyle and personal behaviors) contributing to many of these chronic conditions.
The United States and the state of Texas have both made great strides in reducing the rate of tobacco use in the past two decades. Tobacco use is the leading cause of preventable death in the nation.5 In 2015, the adult smoking rate in Texas was 15.2%, significantly lower than the state's 19.2% adult smoking rate in 2012 and lower than the 2015 national average of 17.5%.6 While tremendous progress in reducing tobacco use has been made, the 15% adult smoking rate means that a little more than 3 million adult Texans smoke. Furthermore, for some Texas counties, the smoking rate is much higher ― more than 20%.7
Disparities in smoking rates continue to persist. In Texas, smoking is more common among:
- People aged 18 to 44 years,
- People who live in rural areas,
- People with less than a high school education, and
- Lower income populations.6
In 2015, Texas households with the lowest annual income (less than $25,000) had the highest rate of smoking (23%).6
According to the 2016 Texas Youth Tobacco Survey, 25.4% of middle and high school students have used or tried electronic nicotine delivery systems, commonly referred to as e-cigarettes.8 The prevalence was highest among students in grade 12 (46.7%), followed those in grade 11 (41.4%) and middle school students (12.7%).8 Thus, we must remain vigilant in tobacco prevention and cessation efforts.
Tobacco use is the primary risk factor for chronic pulmonary disease and a risk factor for many other chronic diseases, including hypertension, heart disease, stroke, diabetes, asthma, and osteoporosis.9 More than 80% of deaths caused by lung cancer, the leading cause of cancer death, are directly attributable to smoking.9 Additionally, smoking and exposure to second-hand smoke during pregnancy are major risk factors for preterm births, low birth weight, and infant mortality.10 In 2015, 3.5% of all live births in Texas were to mothers who smoked cigarettes during pregnancy.11 The rate of maternal smoking was highest among non-Hispanic white mothers (7.6%), followed by non-Hispanic black mothers (3.6%), and Hispanic mothers (1.0%).11 Looking at this from a geographic perspective, in 2015, the highest percentage of live births to mothers who smoked during pregnancy was observed in East Texas (Figure 4).11
Two key strategies must continue to help lower the state's tobacco use rate: Prevent people from initiating tobacco use and help current smokers quit by providing evidence-based cessation interventions. Screening for tobacco use should be a part of every health care visit. A referral to the Texas Quitline12 or to a health plan's cessation services should be made if a person, or a household member in the case of a pregnant woman, is identified as a tobacco user.
The Texas Quitline, an evidence-based cessation service provided by the Texas Department of State Health Services, offers up to five free cessation telephone counseling sessions to all Texans and up to 10 sessions to pregnant women. In addition, the Texas Quitline offers qualifying individuals a free two-week Nicotine Replacement Therapy starter kit.
Obesity and tobacco use are similar, as they are both modifiable risk factors for other diseases. For both, socioeconomic disparities are well-established. Unlike tobacco, however, obesity is much more diffuse and complex. Obesity encompasses much broader facets of life and other determinants of health, such as diet and nutrition, physical activity, and lifestyle. While we have a choice to begin tobacco use, we do not with eating.
In 2014, a review of studies of the effectiveness of individual, community, and societal interventions in reducing socioeconomic inequalities in obesity among adults concluded: "Some individual and community-based interventions may be effective in reducing socio-economic inequalities in obesity among adults in the short term. Further research is required particularly of more complex, multi-faceted and societal-level interventions."13 The implication for population health is that longer-term effectiveness studies are needed to identify strong evidence-based interventions.
As a pediatrician, I am especially keen on promoting increased and sustained exclusive breastfeeding, which provides infants with ideal nutrition from the start and has proven potential for lasting health benefits. Among numerous positive health outcomes for infants and mothers, there is a reduction in adolescent and adult obesity rates if any breastfeeding occurred in infancy compared with no breastfeeding.14
Consequences of obesity on population health are numerous but potentially preventable. A number of chronic diseases such as diabetes, hypertension, cardiovascular disease, and some cancers are interrelated with obesity. Similar to the national data, the pattern of interrelatedness between diabetes and obesity is clearly observed in Texas as shown in Figure 5.15
As it did nationally, the prevalence of obesity in Texas steadily increased from 2000 to 2015, and so did the prevalence of diabetes in the state during the same period. Similar patterns are observed with cardiovascular disease and hypertension (data not shown).
According to the most current available data, the 2015 median obesity rates were 32.4% in Texas and 29.8% in the nation. In some areas of the state, the obesity rate is nearly 40%.7 Similar to tobacco use, disparities in the obesity rate exist nationally and in Texas. The obesity rate is highest among:
- People aged 45-64 years,
- People with less than a high school education,
- People living in rural areas,
- People in households with less than $25,000 annual income, and
- Non-Hispanic blacks.6
In 2015 in Texas, non-Hispanic blacks had the highest age-adjusted obesity rate (39.1%), followed by Hispanics (38.8%), non-Hispanic whites (28.7%), and Asians (9.7%).
Similar to tobacco use, obesity and interrelated chronic diseases (hypertension and diabetes) are major risk factors for maternal complications, such as preterm births, low birth weight, and infant mortality.10 In 2015, 25.2% of all live births in Texas were to mothers who were obese before pregnancy.11 The highest pre-pregnancy obesity rate was among non-Hispanic black mothers (31.0%), followed by Hispanic mothers (28.1%), non-Hispanic white mothers (21.9%), and all other mothers (11.8%).11
As with the obesity rate in Texas, the highest rate of maternal hypertension was among non-Hispanic black mothers (Figure 6).11 Mothers who identified as "Other" had the highest rate of maternal diabetes, followed by Hispanic mothers, non-Hispanic black mothers, and non-Hispanic whites (Figure 6).11 Even though the rate of maternal diabetes was highest among mothers who identify as "Other," this constitutes the smallest percentage of live births (7.0%) by race/ethnicity in Texas in 2015.11 In contrast, births to Hispanic mothers is nearly half of all births in Texas (47.4%).11
In 2015, non-Hispanic black mothers had the highest number of pre-term births (13.6%) as well as low birth weights (13.3%).11 In 2015, the infant mortality rate (deaths per 1,000 live births) was 2.2 times higher for non-Hispanic black babies versus non-Hispanic white babies in Texas (10.9 vs. 4.9).11 Overall, the highest infant mortality rate was seen in East Texas (Figure 7).11 DSHS, the Health and Human Services Commission, and UT Health Northeast are collaborating in a pilot study in East Texas to gain a deeper understanding of the causes of the high infant mortality in this region and to identify customized interventions to meet this population's needs.
As the prevalence of chronic diseases increases in women of childbearing age, improving health before and between pregnancies is of paramount importance to reduce maternal risk factors for better birth outcomes.10 Modifiable risk factors such as obesity must be addressed.
No single clinical intervention alone can reduce the obesity epidemic in our state. We need a multifaceted, system-wide approach that must include, in addition to clinical intervention, policies that help address the other determinants of health, such as economic security and affordable and nutritious food. In addition to health care professionals, policymakers, communities, schools, and businesses must work cohesively and collaboratively to help educate and promote healthy behaviors. A system-level change is needed in which all stakeholders have an equal role in tackling the obesity epidemic.
The 6|18 Initiative
The attention on population health at the national level also is focused on reducing the burden of chronic diseases. The Centers for Disease Control and Prevention (CDC) has recently launched the 6|18 Initiative.16 The "6" refers to the initial focus on six common, preventable health conditions, and "18" refers to evidence-based prevention and control interventions that can improve health and control costs. Four of the six conditions are chronic conditions: tobacco use, hypertension, asthma, and diabetes.
These conditions were selected because they affect large numbers of people, they are associated with high health care costs, there are evidence-based interventions known to prevent or control these conditions in a short time frame (less than 5 years), and the evidence-based interventions can be implemented within the current health care delivery system, that is, health care purchasers, payers, and providers.16 According to CDC, "Distinct characteristics of 6|18 are that it is specifically tailored for health care purchasers, payers, and providers, and it focuses on accelerating evidence into action."16
This is a key initiative of CDC's priority for public health. It is exploring more integrated, collaborative, and effective approaches among the public health sector and other stakeholders such as health care purchasers, payers, and providers.
Tremendous advances have been made in longevity and health status in the last 150 years. Public health owns a large part of this success. As we look at the next 10 years, a key area of focus must be in helping reduce the large and growing burden of chronic disease. In addition to health care providers and the health care sector, a cross-section of other stakeholders ― including businesses, communities, and social services ― must work collaboratively, creatively, and effectively to reduce the chronic disease burden.
As a state agency, DSHS has recently gone through transformation and is more highly focused on delivering core public health services and providing public health leadership to the benefit of all Texans. DSHS will continue to lead health-related efforts. In our 'convener' role, DSHS calls upon our public-health partners to continue the successes already achieved in the areas of immunization and HIV and to leverage the learnings from these efforts to help reduce the burden of chronic diseases. Let's continue to work together to build a healthier Texas, starting with our mothers and children.
- Centers for Disease Control and Prevention. Ten great public health achievements in the 20th century. www.cdc.gov/about/history/tengpha.htm. Accessed July 31, 2017.
- Texas Department of State Health Services. Texas 2015 Vital Statistics Annual Report. www.dshs.texas.gov/chs/vstat/annrpts.shtm. Accessed July 30, 2017.
- National Center for Health Statistics. Health, United States. 2016: With Chartbook on Long-Term Trends in Health. www.cdc.gov/nchs/data/hus/hus16.pdf#015. Accessed August 2, 2017.
- Centers for Disease Control and Prevention, National Center for Health Statistics. About Underlying Cause of Death, 1999–2015. CDC WONDER Online Database, released December 2016. Data are from the Multiple Cause of Death Files, 1999–2015. https://wonder.cdc.gov/ucd-icd10.html.
- Centers for Disease Control and Prevention. Tobacco-Related Mortality. www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/tobacco_related_mortality/index.htm. Accessed July 30, 2017.
- America's Health Rankings. 2016 Annual Texas Health Rankings Report. Trend: Smoking, Texas, United States. www.americashealthrankings.org/explore/2016-annual-report/measure/Smoking/state/TX.
- County Health Rankings. Texas health measures: adult smoking. www.countyhealthrankings.org/app/texas/2017/measure/factors/9/map. August 1, 2017.
- Texas Youth Tobacco Survey, 2016. College Station, Texas: Texas A&M University; 2016.
- US Department of Health and Human Services, Public Health Service, Office of the Surgeon General. The Health Consequences of Smoking — 50 Years of Progress. A Report of the Surgeon General. Rockville, MD: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health. Printed with corrections, January 2014. www.ncbi.nlm.nih.gov/books/NBK179276/pdf/Bookshelf_NBK179276.pdf.
- Shapiro-Mendoza CK, Barfield WD, Henderson Z, et al. CDC grand rounds: public health strategies to prevent preterm birth. MMWR Morb Mortal Wkly Rep. 2016;65(32):826–830. www.cdc.gov/mmwr/volumes/65/wr/mm6532a4.htm#B1_down.
- Texas Department of State Health Services. Center for Health Statistics, 2006–2015 birth files (unpublished raw data). Figures and graphs produced by Texas Department of State Health Services, Office of Program Decision Support, 2017.
- Texas Quitline. www.yesquit.org/about-the-program, or call 1-877-YES-QUIT (937-7848).
- Hiller-Brown FC, Bambra CL, Cairns JM, Kasim A, Moore HJ, Summerbell DS. A systematic review of the effectiveness of individual, community and societal-level interventions at reducing socio-economic inequalities in obesity among adults. Int J Obes. 2014;38:1483–1490.
- Breastfeeding and the use of human milk. Section on Breastfeeding. American Academy of Pediatrics Policy Statement. Pediatrics. 2012;129(3):e872–e841.
- Center for Health Statistics, Texas Department of State Health Services. Texas Behavioral Risk Factor Surveillance System survey data. www.healthdata.dshs.texas.gov/HealthRisks/BRFSS/. Accessed August 1, 12017.
- Centers for Disease Control and Prevention. The 6|18 Initiative: Accelerating Evidence into Action. www.cdc.gov/sixeighteen. Accessed July 31, 2017.
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