Many of the 21st-century healthcare challenges will be directed toward management of chronic diseases. Congestive heart failure, asthma, and diabetes are examples of chronic diseases that command a tremendous amount of medical resources and provider time. The prevalence of these diseases in the American population is staggering. For instance, a person aged 40 or older has a 1 in 5 lifetime chance of developing congestive heart failure . An infant born in the year 2000, depending on ethnicity, has a1in3toa1in2 lifetime chance of developing diabetes . The National Health Interview Survey reported that for 2001 an estimated 31 million Americans would be diagnosed by a healthcare provider with asthma within their lifetime . These three chronic diseases impact the lives of millions of patients every day. Healthcare systems, procedures, and protocols are in place to assist the patient in living with the disease. However, the key factor in controlling any chronic disease is patient behavior.
How people live determines the impact of certain chronic diseases. The magnitude of this impact hinges on the patient's lifestyle and willingness to take charge of the disease . An unhealthy lifestyle can advance or enable the presence or consequences of a particular disease. In contrast, a healthy lifestyle can delay or eliminate the development of certain diseases.
Along with genetics, except for certain medical conditions, most patients' obesity is the result of an unhealthy lifestyle of overeating and lack of physical activity. Fortunately, improved medical management has lowered the prevalence of some cardiac risk factors, especially among obese patients. From 1962 to 2000, hypercholesterolemia was reduced among obese patients 21-percentage-points (39% vs 18%), and hypertension by an 18-percentage-point reduction (42% vs 24%) . Yet even with improved medical management of comorbidi-ties associated with obesity, the estimated number of excess deaths in 2000 associated with oesity was 111,909 .
A healthy lifestyle can help delay the onset or lessen the consequences of a chronic disease. A study by Mensink et al. showed a healthy lifestyle can improve glucose tolerance . The Diabetes Control and Complication Trial (DCCT) set the standard for demonstrating the powerful impact that a healthy lifestyle and active disease management can have on reducing the risk of potential complications from type 1 diabetes.
The DCCT was conducted over 10 years at multiple centers in America and Canada. Four times a day participants' blood glucose levels were checked and insulin was given. Participants followed a healthy diet and regular exercise and had monthly contact with the healthcare system. The results were remarkable. Compared to the standard of diabetic care at the time of this study, the intervention greatly reduced patients' relative risk of developing micro-vascular complications. Nephropathy was reduced by 50%, neuropathy by 60%, and retinopathy by 76% .
About the time of this study the phrase "controlled diabetic" entered the medical literature. Because of results like the DCCT, the medical community came to believe that if patients "controlled" their diabetes then they could lead a relatively healthy life. This was a tremendous advance from when diabetes was known as "sugar disease" prior to 1922. After Banting and Best's discovery of insulin, diabetes moved from a universally fatal disease of the young to a manageable disease with long-term complications. Now the focus has gone from management of the disease to control of the disease and avoidance of long-term complications.
Since the DCCT, the term "controlled diabetic" acknowledges the permanence of the disease but does not accept the inevitable consequences of having the disease. In this sense diabetes is the classic chronic disease model. Either the patient is a controlled diabetic or not a controlled diabetic. This simple but profound shift in thinking followed a logical pattern and greatly contributed to the medical community's understanding of chronic disease management. The logic for chronic disease management is based on the premise that certain diseases never go away. One might say, "Once a diabetic, always a diabetic."
The second premise, identified through studies like the DCCT, states that the presence of the disease does not mean the consequences of the disease are inevitable. For a patient who embraces a healthy lifestyle and optimally uses the medical tools available, the relative risk for certain comorbidities of the disease can be greatly reduced.
The conclusion that follows these two premises is that ultimately either the patient controls the chronic disease or the chronic disease controls the patient. Generally, patients who poorly control their diabetes are not lacking available medical care. Patients who deny having the disease, or refuse to eat properly, exercise, take medications, or regularly see their physician are making personal decisions. No matter how hard the medical community tries to help through newer medications, clinical protocols, or surgical interventions, the patient must ultimately be responsible for managing the disease.
Another landmark study that affirms the impact of a healthy lifestyle on a chronic disease is the Diabetes Prevention Program (DPP). This study demonstrated that patients with glucose intolerance could delay progression to diabetes through losing a reasonable amount of weight by eating properly and being physically active. The study's results were so impressive that the Health and Human Services Secretary, Tommy Thompson, halted the study a year early.
The DPP showed patients with glucose intolerance could reduce their risk of becoming diabetic by losing weight (7% the first year and keeping at least 5% off) and walking about 150 minutes per week. The results indicate that those with healthy lifestyle choices reduced their relative risk of becoming diabetic by 58% compared to a 31% reduction in those who only took medication but did not lose weight and exercise regularly .
The next logical step to see the impact of a healthy lifestyle and reasonable weight loss is to compare those at risk for a disease with those who have the disease. The Look AHEAD is an 11-year, multicenter study now under way. Applying the same DPP interventions to patients who have type 2 diabetes, two of the study's major endpoints are heart attacks and strokes .
Like diabetes, the goal for management of other chronic diseases is to control the disease to reduce or eliminate its long-term complications, not to cure the disease. The medical community provides patient education, medical equipment, and appropriate follow-up as a means to empower the patient to be in control. For instance, congestive heart failure patients frequently have home health nursing care and computer or telephone monitoring equipment that regularly connects the patient with the medical system. The goal is to identify early trends of deterioration so intervention can be made on an outpatient basis and not in the emergency room.
Asthma is a chronic disease whose prevalence is increasing; mortality from asthma more than doubled from 1979 to 1994 . Personal control of this disease involves many variables from not smoking, avoidance of triggers, and appropriate use of medications. A key intervention that provides this control is daily monitoring with peak flow meters (PFM), which provides feedback regarding the severity of bronchospasm. The patient has three PFM zones (green, yellow, red). If the PFM reading is in the green zone, then the patient is to take the medications and go about his or her daily routine. The green zone means the patient is in control of the asthma. If the reading falls into the yellow zone, then medication adjustment and contact with the physician's office is suggested. If the PFM enters the red zone, then the patient has additional instructions to follow and must make immediate contact with the physician or go to the emergency room. A reading in the red zone indicates a crisis where the disease is in control of the patient.
For most patients who have congestive heart failure, diabetes, or asthma, the disease is not likely to go away. Therefore, the management goal is to enable the patient to experience a normal life and to avoid a possible medical crisis through early interventions. Admission to the intensive care unit (ICU) for severe congestive heart failure, diabetic ketoacidosis, or status asthmaticus is the ultimate situation where the disease controls the patient.
The principles of chronic disease management are used in the real world. Consider the Air Force airman who develops either asthma or diabetes. After receiving a medical evaluation and certain deployment restrictions, in many instances the individual is returned to duty with the possibility of completing a 20-year military career. Just having the chronic disease is not an automatic reason for discharge. On the other hand, if the airman is in the emergency room every weekend with poorly controlled blood sugar or difficulty breathing, then the airman will be medically discharged. As a company that requires high health standards of its employees, the Air Force applies the fundamental principle for chronic disease management: if the airman controls the chronic disease, then a military career is possible; if the airman is controlled by the disease, then medical discharge is the only option. The implication of this approach is that the individual is the most important component of chronic disease management. Either the individual wants and achieves control or he does not. There is nothing the healthcare system can do to change this reality. Chronic disease management ultimately rests upon the diligence of the individual who has the disease.
Control of chronic diseases through empowerment is primarily accomplished through patient education. For instance, diabetic patients should know they do not have to lose their legs, eyes, or kidneys. They have a choice. Knowledge about both why and how they should frequently check blood glucose, why they should visit the doctor on a regular basis, have their feet examined, and so on is critical for controlling the disease. Without an effective patient education program, management of any chronic disease will be less than optimal.
Despite popular magazine and TV commercials that promise rapid, painless, weight loss, successful long-term management of obesity follows the principles for chronic disease management. However, before discussing how to manage or control obesity, let us first understand why obesity is a chronic disease.
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