Leading Lifestyle-Related Chronic Conditions Among Adults
Leading Lifestyle-Related Chronic Conditions Among Adults
Unhealthy lifestyle behaviors are responsible for much of the disease and death from the leading chronic diseases. Our analysis of recent national data, which shows that about 1 in 7 adults had at least 2 of 5 chronic conditions associated with disease and death, helps to address a gap in the existing knowledge base. On the basis of our analysis, an estimated 30.9 million adults had 2 or more major lifestyle behavior-related chronic conditions in 2009. Furthermore, the prevalence of having at least 2 such chronic conditions increased by an average 0.26% per year from 2002 to 2009 (P = .011), with significant increases in cancer (P < .001), diabetes (P < .001), and arthritis (P = .021) likely contributing to the increase.
Because certain lifestyle behaviors are risk factors for many chronic conditions, including the 5 leading chronic diseases included in this study, improving the behavioral risk factor profile of the population could lower the prevalence of these conditions and decrease their co-occurrence. For example, enormous progress has been made in reducing the prevalence of smoking in the United States, and the stable prevalence estimates for chronic obstructive pulmonary disease are likely a reflection of this. However, chronic obstructive pulmonary disease remains the only major chronic disease that has not experienced a large decline in mortality since 1999.
The heavy toll exacted by the co-occurrence of multiple chronic conditions is demonstrated by its effect on death, quality of life, hospitalizations, outpatient visits, health care costs, and other health care metrics. We found that the largest relative increase in the percentage of adults with 2 or more chronic conditions occurred in the youngest group, albeit over a small baseline. If sustained, this increase would have implications for the health of the nation in future decades.
Not only does the number of chronic conditions have serious implications for disease, death, and health care costs, but specific combinations of chronic conditions may also negatively or positively influence health and economic outcomes. Specific combinations of chronic conditions may affect quality of life, functional recovery, disability, health care use, health care costs, and polypharmacy (the use of multiple medications by a patient). Furthermore, combinations of comorbidity may also affect survival after serious conditions such as heart failure. For example, the combination of chronic kidney disease and dementia was associated with greatly reduced survival among hospitalized patients with heart failure. A previous analysis of NHIS data that included 9 chronic conditions found that the combinations of hypertension and diabetes, hypertension and heart disease, and hypertension and cancer were the most common 2-condition combinations. An analysis of German insurance claims data showed that the most common combination of 3 conditions among 46 chronic conditions included in the study was hypertension, lipid disorder, and chronic low back pain. In comparison, we found that the combination of cardiovascular disease and arthritis was the most common 2-condition combination, and the combination of cardiovascular disease, diabetes, and arthritis was the most common 3-condition combination.
Our study has limitations. First, the self-reported nature of the data likely led to an underestimate of the true prevalence of the chronic conditions. For example, the prevalence of self-reported diabetes underestimates the gold standard prevalence estimated from self-reported data and blood measurements of glucose by about a third to a half. Recent national data about the trends of cardiovascular disease, cancer, chronic obstructive pulmonary disease, and arthritis based on information other than self-report are not available. Therefore, our results require confirmation with other data based on more rigorous assessments of chronic conditions. Second, we were not able to measure undiagnosed disease; therefore, an alternative explanation of the increase in the percentage of adults having 1 or more chronic conditions is that awareness of these conditions may have improved in the face of a stable prevalence of conditions, thus contributing to the apparent trend. However, the increase in the prevalence of diabetes noted in our study is consistent with data from the National Health and Nutrition Examination Survey in which questionnaires were complemented with measurements of plasma glucose.
Another possible limitation is that the decrease in response rates during the study period raises the possibility that the results may have been subject to a bias. If participants who increasingly refused to participate were healthier than participants who opted to participate, a trend showing an increase in multiple chronic conditions may have represented an artifact. However, the lack of information about the health of adults who refused to participate precludes a thorough exploration of this possibility.
The reports of other investigators continue to shape and strengthen our knowledge base characterizing the prevalence and heterogeneity of multiple chronic conditions. Various studies provide estimates of the prevalence of multiple chronic conditions (Table 4). A recent NHIS analysis of data on 9 chronic conditions showed that 21.0% of adults aged 45 to 64 years and 45.3% of adults aged 65 years or older had 2 or more chronic conditions. That study examined only adults aged 45 or older. In comparison, we found that 14.7% of adults had 2 or more lifestyle-related chronic conditions in 2009, and 4.5% had 3 or more. Many of these analyses used different sets of chronic conditions in establishing their indices. Prevalence estimates of multiple chronic conditions are clearly influenced by the number of conditions that are considered: the more conditions that are included in a study, the higher the estimates will be. Thus, because we restricted our analyses to 5 chronic conditions that are leading sources of disease and death and that are strongly related to lifestyle factors, the estimates of the noninstitutionalized US population generated in our study are lower than those found elsewhere. Consequently, our analyses yield a complementary perspective on a subset of multiple chronic conditions that had not been previously considered.
Our results provide a new dimension in understanding the increasing burden of chronic diseases in the United States. An increasing percentage of adults are living with 2 or more chronic conditions, and more young people are reporting multiple chronic conditions. These trends, if unabated, could increase the nation's future health care costs and required health care resources. In particular, several researchers report that increases in the rate of hospitalizations and medical expenditures are related to increases in the number of co-occurring chronic conditions.
The high, increasing prevalence of lifestyle-related multiple chronic conditions provides yet another reason to aggressively promote population-based actions to improve lifestyle behaviors. In many parts of the country, efforts are under way to implement systems and environmental change in schools, communities, and workplaces. A prominent example of such efforts is the Community Transformation Grants program that seeks to build healthier communities and lifestyles through evidence-based approaches to reduce chronic diseases.
Although clinicians routinely manage patients who have more than 1 chronic condition, the growing prevalence of patients with multiple chronic conditions may pose additional challenges. First, the large numbers of prescriptions that may be required by such patients may affect a patient's adherence to taking medications. Second, the risk for adverse reactions from possible interactions among medications increases as the numbers of medications that patients are required to take increases. Finally, the presence of comorbidities may limit the clinician's therapeutic options. Thus, the coordination of care in such patients poses a serious clinical challenge.
Additional multifaceted research concerning the epidemiology of lifestyle-related multiple chronic conditions is needed to build a more complete understanding of this area. First, studies using large administrative databases would allow a fuller accounting of lifestyle-related conditions and provide sufficient power to characterize the prevalence of unique combinations of conditions. Second, determinants of lifestyle-related chronic diseases require further study. Third, characterizing potential health disparities is essential to designing and directing relevant interventions. Fourth, studies describing the effect of multiple chronic conditions on health-related quality of life and economic studies concerning the direct and indirect costs exacted on the economy by people with multiple chronic conditions are also useful in gauging the clinical and public health burden of these conditions. Fifth, research is needed to characterize the proportions of patients with multiple chronic conditions who are candidates for nonpharmacological treatments and to define possible contraindications or special considerations for subsets of patients. Clinical research examining optimal therapeutic lifestyle treatment models, including optimal composition of therapeutic lifestyle modification and delivery mode, for patients with different combinations of multiple chronic conditions can provide clinicians with evidence-based approaches to managing such patients. Finally, past studies of people with a predominant condition can be useful to inform the development of a generation of studies focused on people with multiple chronic conditions.
The results of our study suggest that the burden of selected major lifestyle-related chronic conditions is increasing slowly but steadily in the United States, a trend that has serious implications for health care costs and the future delivery of health care in the United States. The recently developed HHS strategic framework with national-level strategies for managing patients with multiple chronic conditions is a timely and prudent coordinated response to an evolving public health challenge. Continued surveillance of the trend in lifestyle-related chronic conditions with data from the NHIS and other data systems can provide critical feedback to track the evolution of the temporal, spatial, and sociodemographic dimensions of multiple lifestyle-related chronic conditions that will allow timely adjustments to the nation's health care system to mitigate the effect of this mounting public health concern.
Discussion
Unhealthy lifestyle behaviors are responsible for much of the disease and death from the leading chronic diseases. Our analysis of recent national data, which shows that about 1 in 7 adults had at least 2 of 5 chronic conditions associated with disease and death, helps to address a gap in the existing knowledge base. On the basis of our analysis, an estimated 30.9 million adults had 2 or more major lifestyle behavior-related chronic conditions in 2009. Furthermore, the prevalence of having at least 2 such chronic conditions increased by an average 0.26% per year from 2002 to 2009 (P = .011), with significant increases in cancer (P < .001), diabetes (P < .001), and arthritis (P = .021) likely contributing to the increase.
Because certain lifestyle behaviors are risk factors for many chronic conditions, including the 5 leading chronic diseases included in this study, improving the behavioral risk factor profile of the population could lower the prevalence of these conditions and decrease their co-occurrence. For example, enormous progress has been made in reducing the prevalence of smoking in the United States, and the stable prevalence estimates for chronic obstructive pulmonary disease are likely a reflection of this. However, chronic obstructive pulmonary disease remains the only major chronic disease that has not experienced a large decline in mortality since 1999.
The heavy toll exacted by the co-occurrence of multiple chronic conditions is demonstrated by its effect on death, quality of life, hospitalizations, outpatient visits, health care costs, and other health care metrics. We found that the largest relative increase in the percentage of adults with 2 or more chronic conditions occurred in the youngest group, albeit over a small baseline. If sustained, this increase would have implications for the health of the nation in future decades.
Not only does the number of chronic conditions have serious implications for disease, death, and health care costs, but specific combinations of chronic conditions may also negatively or positively influence health and economic outcomes. Specific combinations of chronic conditions may affect quality of life, functional recovery, disability, health care use, health care costs, and polypharmacy (the use of multiple medications by a patient). Furthermore, combinations of comorbidity may also affect survival after serious conditions such as heart failure. For example, the combination of chronic kidney disease and dementia was associated with greatly reduced survival among hospitalized patients with heart failure. A previous analysis of NHIS data that included 9 chronic conditions found that the combinations of hypertension and diabetes, hypertension and heart disease, and hypertension and cancer were the most common 2-condition combinations. An analysis of German insurance claims data showed that the most common combination of 3 conditions among 46 chronic conditions included in the study was hypertension, lipid disorder, and chronic low back pain. In comparison, we found that the combination of cardiovascular disease and arthritis was the most common 2-condition combination, and the combination of cardiovascular disease, diabetes, and arthritis was the most common 3-condition combination.
Our study has limitations. First, the self-reported nature of the data likely led to an underestimate of the true prevalence of the chronic conditions. For example, the prevalence of self-reported diabetes underestimates the gold standard prevalence estimated from self-reported data and blood measurements of glucose by about a third to a half. Recent national data about the trends of cardiovascular disease, cancer, chronic obstructive pulmonary disease, and arthritis based on information other than self-report are not available. Therefore, our results require confirmation with other data based on more rigorous assessments of chronic conditions. Second, we were not able to measure undiagnosed disease; therefore, an alternative explanation of the increase in the percentage of adults having 1 or more chronic conditions is that awareness of these conditions may have improved in the face of a stable prevalence of conditions, thus contributing to the apparent trend. However, the increase in the prevalence of diabetes noted in our study is consistent with data from the National Health and Nutrition Examination Survey in which questionnaires were complemented with measurements of plasma glucose.
Another possible limitation is that the decrease in response rates during the study period raises the possibility that the results may have been subject to a bias. If participants who increasingly refused to participate were healthier than participants who opted to participate, a trend showing an increase in multiple chronic conditions may have represented an artifact. However, the lack of information about the health of adults who refused to participate precludes a thorough exploration of this possibility.
The reports of other investigators continue to shape and strengthen our knowledge base characterizing the prevalence and heterogeneity of multiple chronic conditions. Various studies provide estimates of the prevalence of multiple chronic conditions (Table 4). A recent NHIS analysis of data on 9 chronic conditions showed that 21.0% of adults aged 45 to 64 years and 45.3% of adults aged 65 years or older had 2 or more chronic conditions. That study examined only adults aged 45 or older. In comparison, we found that 14.7% of adults had 2 or more lifestyle-related chronic conditions in 2009, and 4.5% had 3 or more. Many of these analyses used different sets of chronic conditions in establishing their indices. Prevalence estimates of multiple chronic conditions are clearly influenced by the number of conditions that are considered: the more conditions that are included in a study, the higher the estimates will be. Thus, because we restricted our analyses to 5 chronic conditions that are leading sources of disease and death and that are strongly related to lifestyle factors, the estimates of the noninstitutionalized US population generated in our study are lower than those found elsewhere. Consequently, our analyses yield a complementary perspective on a subset of multiple chronic conditions that had not been previously considered.
Our results provide a new dimension in understanding the increasing burden of chronic diseases in the United States. An increasing percentage of adults are living with 2 or more chronic conditions, and more young people are reporting multiple chronic conditions. These trends, if unabated, could increase the nation's future health care costs and required health care resources. In particular, several researchers report that increases in the rate of hospitalizations and medical expenditures are related to increases in the number of co-occurring chronic conditions.
The high, increasing prevalence of lifestyle-related multiple chronic conditions provides yet another reason to aggressively promote population-based actions to improve lifestyle behaviors. In many parts of the country, efforts are under way to implement systems and environmental change in schools, communities, and workplaces. A prominent example of such efforts is the Community Transformation Grants program that seeks to build healthier communities and lifestyles through evidence-based approaches to reduce chronic diseases.
Although clinicians routinely manage patients who have more than 1 chronic condition, the growing prevalence of patients with multiple chronic conditions may pose additional challenges. First, the large numbers of prescriptions that may be required by such patients may affect a patient's adherence to taking medications. Second, the risk for adverse reactions from possible interactions among medications increases as the numbers of medications that patients are required to take increases. Finally, the presence of comorbidities may limit the clinician's therapeutic options. Thus, the coordination of care in such patients poses a serious clinical challenge.
Additional multifaceted research concerning the epidemiology of lifestyle-related multiple chronic conditions is needed to build a more complete understanding of this area. First, studies using large administrative databases would allow a fuller accounting of lifestyle-related conditions and provide sufficient power to characterize the prevalence of unique combinations of conditions. Second, determinants of lifestyle-related chronic diseases require further study. Third, characterizing potential health disparities is essential to designing and directing relevant interventions. Fourth, studies describing the effect of multiple chronic conditions on health-related quality of life and economic studies concerning the direct and indirect costs exacted on the economy by people with multiple chronic conditions are also useful in gauging the clinical and public health burden of these conditions. Fifth, research is needed to characterize the proportions of patients with multiple chronic conditions who are candidates for nonpharmacological treatments and to define possible contraindications or special considerations for subsets of patients. Clinical research examining optimal therapeutic lifestyle treatment models, including optimal composition of therapeutic lifestyle modification and delivery mode, for patients with different combinations of multiple chronic conditions can provide clinicians with evidence-based approaches to managing such patients. Finally, past studies of people with a predominant condition can be useful to inform the development of a generation of studies focused on people with multiple chronic conditions.
The results of our study suggest that the burden of selected major lifestyle-related chronic conditions is increasing slowly but steadily in the United States, a trend that has serious implications for health care costs and the future delivery of health care in the United States. The recently developed HHS strategic framework with national-level strategies for managing patients with multiple chronic conditions is a timely and prudent coordinated response to an evolving public health challenge. Continued surveillance of the trend in lifestyle-related chronic conditions with data from the NHIS and other data systems can provide critical feedback to track the evolution of the temporal, spatial, and sociodemographic dimensions of multiple lifestyle-related chronic conditions that will allow timely adjustments to the nation's health care system to mitigate the effect of this mounting public health concern.
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