Does the United States need a change in health care strategy?

How health behaviors lower life expectancy and increase costs
November 1, 2016

Despite the fact that the United States spends more than most other developed countries on health care, we’re still lagging behind in terms of life expectancy. We have a relatively high infant mortality rate, and Americans age 50–74 have a higher prevalence of chronic disease and disability compared to their peers in England or mainland Europe, according to the World Health Organization.

But why is this the case? To a large extent, these differences can be attributed to health behaviors that prevent death or disability later. For the most part, the American health care system focuses on treating problems, rather than preventing them. Although it is the flashy new treatments that get the headlines, experts say that we might be better off if we devoted greater resources to encouraging basic health behaviors.

“Everyone wants the best care, which is perfectly understandable, but, unfortunately, we don’t spend enough time or money on preventing disease in the first place,” said Jay Maddock, PhD, dean of the Texas A&M School of Public Health. “We only spend about 5 percent of our health care budget on prevention.”

Prevention can be things that occur within the medical arena—like vaccinations or screenings—and getting a flu shot can certainly save lives. However, prevention also encompasses people’s day-to-day behavior.

Behaviors that lower life expectancy

“Two-thirds of premature deaths can be attributed to three things: tobacco use, poor nutrition and physical inactivity,” Maddock said. Although the United States has done well cutting tobacco use, many Americans still struggle with poor eating habits and lack of physical activity, which are, of course, the two big contributors to obesity, which is related to heart disease, stroke, diabetes and even cancer.

“We tend to think of these things as personal behaviors, and what we forget is how much the society drives this,” Maddock said. “If you look at obesity rates by state, you’ll see huge differences. Why should people be leaner in Colorado than in Texas, for example?” Part of these differences, then, are likely related to the infrastructure of a town or city, especially how it is zoned.

“When you put residential and retail together, people tend to walk more, just to run their daily errands, and they like doing it,” Maddock said. “On the other hand, in much of Texas, there’s plenty of land, so we tend to sprawl. The city gets bigger, and there’s no density.” That’s why the School of Public Health has a $2.7 million National Institutes of Health grant to study so-called mixed-use communities that include retail, housing and community spaces like parks, all within easy walking or biking distance. Using these kinds of transportation methods instead of automobiles help people get the recommended 150 minutes of weekly activity.

Still, even for people who are getting that much physical activity, there are still the other 9,930 minutes in a week to consider. “If your environment is such that you’re sedentary most of the day, it’s going to be hard to be as healthy as you can, even if you’re getting the recommended amount of exercise,” Maddock said. “There are a lot more sedentary jobs than there used to be, and as a result, people tend to be sitting for eight or more hours per day.” He and other public health professionals have turned to standing desks as the solution.

“We first thought of exercise as vigorous activity,” Maddock said. “Then the research progressed and about 20 years ago, moderate activity, like walking, started being considered ‘exercise.’ Now people are interested in light physical activity, like standing, and that’s the piece that’s going to take up the biggest part of your day. The more that we can shift from sedentary activity to light activity, through making the design conducive to movement, the better.”

Still, even a great exercise regimen isn’t going to make much of a difference if someone’s diet is poor. Although this is another area that people commonly think of as a personal choice, the person’s environment plays a major role. People who live in food deserts, which are areas without access to affordable healthy foods like fresh fruits and vegetables, tend to have poorer diets. “We need to do a better job at getting fresh food from the farmers to the population, Maddock said. “You’re seeing more of a recognition that this is important, and there are slow changes, but it’s a big uphill battle.”

Portion sizes are also an issue. “When people are served larger portions, they tend to eat more, Maddock said. “People are eating more outside the home than they used to, and restaurant meals tend to have more calories than we would recommend one person eat at once.” It’s not just food, though: The calories people drink can be even more insidious. “People don’t think of a soda as being something really bad for their health,” Maddock said, “but it is a lot of calories, and liquid calories don’t fill you up as much as eating a dessert would.” Beyond soda consumption—which by some measures may be declining—coffee and energy drinks with a good deal of added sugar are also contributing to unhealthy diets.

A change in the system

“Europe has been progressive with lots of their policies,” Maddock said. “A health care system is truly a system, and therefore there are greater incentives to reduce the total cost of care by focusing more on prevention.” Although he’s not advocating for the same sort of single-payer system seen in many European countries, Maddock does think there are ways the American health care system could make changes that would improve overall health.

Health care providers have the anti-smoking message down,” Maddock said, “but many find it more difficult to give advice about exercise and nutrition, especially if they don’t have the background.”

Having the physicians, who tend to already be overworked, provide nutrition guidance might not be the most efficient approach. Instead, having a nutritionist and a behavioral specialist on the team in the primary care practice could be a much more affordable way to help patients modify their behavior. “It’s a much better use of our resources to have people trained in behavior change giving this advice, which can result in health care savings, along with cost savings associated with keeping people in the workforce.”

The School of Public Health offers degrees in health promotion, and students learn theories of how people change their behaviors. “We know that if people are moved from not thinking about a health behavior to thinking about it, they’re much more likely to actually make the change,” Maddock said. Other strategies include having people think about the good things that would happen if they made the behavioral change and working with people to think through the obstacles that might be stopping them from engaging in the behavior.

“I believe these relatively simple interventions can impact the health of Americans in a very positive way,” Maddock said. “It’s simply a matter of choosing to make them important.”

— Christina Sumners

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