The July 5th edition of The Lancet contained an interesting article, the first in their “Health of Americans” series, entitled “Prevention of chronic disease in the 21st century: elimination of the leading preventable causes of premature death and disability in the USA.” The article made a clear point of stating that chronic disease has overtaken communicable disease as the leading cause of death, not just in the US but also worldwide. In fact, it stated: “the WHO noted that non-communicable conditions – including cardiovascular diseases, diabetes, cancers and chronic respiratory diseases – accounted for nearly two-thirds of deaths worldwide.”
"10 of the 15 leading causes of death in the USA were chronic conditions"
Specifically, the article stated: “in the USA, chronic diseases are the main cause of poor health, disability and death, and account for most health-care expenditures,” something that anyone remotely connected to the medical industry recognizes immediately as not only a correct statement, but the direct cause of an enormous amount of restructuring of our healthcare delivery system.
It went on to clarify that “10 of the 15 leading causes of death in the USA were chronic conditions” and that “the USA is less healthy in key areas – including obesity, diabetes, heart disease, chronic lung disease and disability, compared with 16 high-income or peer countries.” The report was clear in its message: “Much of the chronic disease burden results from a small number of key risk factors that include high blood pressure, tobacco smoking and second hand smoke exposure, high BMI, physical inactivity, alcohol use and diets low in fruits and vegetables and high in sodium and saturated fats.”
Further facts demonstrated that “the burden of chronic disease is not distributed equitably. People with lower educations or incomes, of specific races or ethnic backgrounds and in specific geographical locations… are disproportionately affected by chronic diseases.” The article highlighted some successes, such as the reduction of self-reported cigarette smoking from a high of 42% of adults in 1965 to 18% in 2011 as well as a sharp reduction in hypertension in adults aged 20 or older between 1988 and 2010, during which it fell from 77% to 56%, accompanied by a dramatic drop in coronary heart-disease death rates from nearly 500 to just over 100 deaths per 100,000 population.
But the battle is not done. The article suggested a four-pronged approach to improving overall healthcare in the U.S.:
- Epidemiology and surveillance to monitor trends and track progress
- Environmental approaches that promote health and support and reinforce healthy behaviors
- Health-system interventions to improve the effective delivery and use of clinical and other preventive services
- Community programs linked to clinical services to improve and sustain management of chronic conditions
But will this plan work?
The authors recommend an approach that includes policy changes, and they point to community programs, such as the Chronic Disease Self-Management Program and the National Diabetes Prevention Program, as models of success.
One item the report offered scant advice on, though, was the issue of how we, as a nation, can actually change the behavior of virtually everyone in the U.S. on a one-by-one basis.
That is the question. We know from thousands of publications that a behavioral health approach to improving outcomes through patient/clinician intervention works in multiple settings to improve long-term behavior, which is the major contributing factor to our national “bad health.” But these programs have almost never been applied to larger populations, and they’re nearly impossible to scale to the current need to change the behavior of hundreds of millions of people.
Why is this so hard? Modern advertising and marketing programs have been very successful at training us to pick and choose what advertisers have paid for. Examples include wildly successful campaigns like “I’d like to buy the world a Coke,” “Pizza, Pizza,” “Finger-Lickin’ Good,” Have it Your Way,” or the more recent Doritos “Cowboy Kid” commercial during the 2014 Super Bowl.
“Advertising has changed how we eat, drink, smoke, exercise, spend our leisure time, and do nearly everything else.”
And remember that advertising is almost impossible to avoid. Estimates of the number of ads we see per day are as high as 4000. Fast food companies spend over $4 billion each year on advertising, and we’re smothered by ads for other unhealthy choices including sedentary lifestyle, excessive alcohol consumption, tobacco use… the list goes on and on.
Advertising has changed how we eat, drink, smoke, exercise, spend our leisure time, and do nearly everything else. And, even more importantly, it affects the choices our children make. For anyone who disagrees, I challenge them to quietly spend an hour at any large-chain grocery store and watch what cereals kids gravitate toward. Parents invariably cave to what advertisers have chosen for their children. And remember, once a bad habit is established, it is very difficult to unseat it. Anyone who has attempted to teach himself how to play golf knows how difficult it is to then correct a bad swing.
Influencing change on a national level
So, how does the healthcare system go about changing the behavior of our population? One example of success is the coaching model. Think of the personalized and intense coaching a world-class athlete receives and how it allows them to reach the peak of their athletic ability. We know this model works with scientists, athletes, pilots, musicians, singers or virtually any profession. One-on-one training that’s available around the clock can improve the outcome of each discipline it is associated with. But it’s very expensive, and it’s very hard to find.
How can we provide constant positive reinforcement of healthy behaviors and constant correction of less desirable behaviors to a population? There is no way it can be done using human coaches alone. The coaching that most people need is in short supply, and it’s much too expensive for a healthcare system that’s already the most expensive in the world on a per-capita basis.
Technology holds the key. But with all the focus on apps and wearables, the population has not really changed much at all. We need to look for another solution involving a personal health coach, but in a virtual format. I call this the virtual health assistant, or VHA.
With its foundation firmly planted in science and the best medical evidence, activated by over 50 years of artificial intelligence and made possible by natural language processing, we can now put a highly personalized counselor in the hands of virtually everyone in the U.S. via their smartphones and tablets. VHAs can fulfill the needed educational gap, influence behavior by encouraging positive choices and assist in self-motivation, which is the key to behavioral change.
To use food as an example of the nearly limitless lifestyle and medical adherence goals that can be targeted, a VHA can inform somebody that he is about to eat a 1020-calorie Burger King Triple Whopper, a seemingly healthy 1060-calorie Veggie Deluxe sandwich at Quizno’s, a 1160-calorie foot-long Subway Chicken, Bacon and Ranch sandwich, a 1460-calorie Smoothie King Peanut Power plus Grape Smoothie, IHOP’s 1760-calorie Country Fried Steak and Eggs, a 1820-calorie Maggiano’s Little Italy Chocolate Zuccotto Cake or the 3120-calorie Bistro Shrimp Pasta at The Cheesecake Factory.
I doubt whether many of the readers would be able to guess the calorie count of these foods, but a VHA can tell them the calories each has, suggest an alternative food and, by using the GPS function of a smart phone, give directions to a close-by restaurant that offers a healthier selection!
“VHAs can fulfill the needed educational gap, influence behavior by encouraging positive choices and assist in self-motivation, which is the key to behavioral change.”
Americans love to eat and, of course, food is necessary for life, but we simply do not know how to eat anymore. We accept unhealthy behavior as the norm. The training our parents and their parents gave us has been washed away by the hundreds of billions of dollars’ worth of advertising that we’ve seen over our lifetimes. And remember that most of these influences are subconscious. These messages are so ubiquitous that they have become part of our collective DNA, so to speak.
Only by constantly challenging these subtleties with a virtual health assistant can we hope to overcome their influence… and that challenge cannot happen once every three months at the next medical visit. Help rising above these challenges must be there daily, multiple times per day perhaps.
The time is ripe, the technology is highly developed and the smartphone is in virtually every pocket, so what is keeping our nation from acting on its greatest healthcare need: lifestyle change?