Four steps toward meeting the challenge of chronic disease

Despite spending $4.5 trillion dollars annually on healthcare — twice as much per capita as any other nation — the U.S. is suffering from lower life expectancy than comparable nations. This is in large part due to a crisis not getting the attention it demands: chronic disease.

Of the ten most common causes of death in the U.S., six are chronic conditions. In fact, two out of three American adults have two or more chronic conditions. This trend is on the rise, especially among racial and ethnic minorities and rural residents. Chronic disease has even been declared a threat to national security, with three out of five young people not well enough to serve in the military due to obesity and physical limitations. And as conditions like diabetes and obesity skyrocket and the population ages, the threat posed by chronic disease will only increase over time.

As cardiologists, we have spent our careers treating patients with chronic heart disease. By the time they come to the clinic or hospital, the underlying disease is well under way, so that efforts are focused on averting devastating complications rather than prevention. Heart disease is often one of many interconnected conditions our patients are struggling with in a fractured healthcare system, while living in environments that make living a healthy lifestyle impossible. Now as officials at the Food and Drug Administration, we simply cannot look away.

Overcoming this extensive and complex crisis requires a coalition across the medical field. There are solutions being driven by FDA and other actions that extend beyond the agency.

Poor nutrition is a major driver of heart disease, stroke, diabetes, obesity and certain cancers. Forty-two countries have lower rates of diet-related diseases than the U.S. with France, Spain and Japan leading the way. The average American diet has too much sodium (which causes high blood pressure), too much added sugar (which causes weight gain and diabetes), too much saturated fat (which causes heart disease and stroke), and too few whole grains, nuts, seeds, fruits and vegetables.

To reduce diet-related chronic diseases, the FDA has removed trans fats from food, included “added sugars” on the Nutrition Facts label, and issued industry guidance to reduce sodium voluntarily. The FDA is also redefining the “healthy” claim for food based on the latest nutritional science and dietary guidelines. The White House National Strategy on Hunger, Nutrition and Health outlined additional steps for the FDA and other agencies to make continuous progress in this regard. 

Smoking continues to kill half a million Americans every year. The proportion of people smoking menthol cigarettes has increased, especially amongst Black Americans, in part due to aggressive promotion of these products. Menthol cigarettes are also more likely to result in initiation among young people and are harder to quit. The FDA has proposed a rule that would prohibit menthol cigarettes and one that would prohibit flavored cigars, both of which would apply to companies that manufacture or sell cigarettes, not individuals. Further, we have announced plans for a proposed rule to reduce nicotine levels to make cigarettes less addictive.

With highly effective treatments for most chronic diseases available as low-cost generic medications, we will continue to work with partners in government and manufacturers to support a robust supply of safe, reliable drugs. Additionally, numerous medical products have recently gained FDA approval to treat such chronic conditions as obesity, heart failure and diabetes, amongst others. Yet the groups most likely to have a chronic disease are least likely to receive evidence-based therapies. Innovation thus has had the unintended consequence of widening the gap between the haves and the have nots.

Given the challenge posed by chronic disease, much more therefore needs to be done.

First, health systems, clinicians, professional societies and governmental agencies need to better support and advocate on behalf of patients with chronic conditions. Patient advocacy for those with common chronic conditions is not as robust as it ought to be. These conditions are often regarded as “background noise” rather than diseases, with a tendency to blame the individual rather than examining the broad factors that allow for chronic conditions to develop. 

Second, comprehensive approaches to chronic disease management need to be implemented. “Over-specialization” in American medicine has resulted in doctors too focused on individual aspects of health rather than the whole patient. This is worsening a critical shortage of primary care clinicians.

Revitalizing primary care will be the key. We must also develop models that bring specialists together, such as one recently presented by the American Heart Association, focusing on cardiovascular-kidney-metabolic health.  A program seeking to transform incentive structures for disease prevention by ARPA-H should also be tested and implemented. A similar cross-cutting approach for chronic conditions is needed in research, and technology development and evaluation as well.

Third, a better information ecosystem is needed to understand both the drivers of chronic disease and the tools to treat them. Nutrition, for example, is an important area where we need all involved entities, particularly the food industry, to contribute more data that can help us better understand the impact of different nutrients on health and ensure a safe food supply. The recent attention to ultra-processed food calls for more objective evidence to understand its relationship to obesity, diabetes and other chronic diseases.

Fourth, we must incentivize prevention of chronic disease. Our current system encourages highly technical and expensive treatment of individual components of chronic disease. For example, we have a system in which it is easier to get costly, often ineffective back surgeries but harder to get evidence-based behavioral therapies for chronic pain. These trends are enhanced by increasingly sophisticated financial systems designed to maximize profit rather than deliver what is best for the patient.

Lastly, for a crisis that cuts across all lines, we need a united bipartisan front to stem the onslaught of chronic disease. We are under no illusion about how difficult the task at hand will be, but the wellbeing of our nation depends upon reversing the rising tide of chronic disease.

Robert M. Califf, M.D. is the commissioner of Food and Drugs. Haider Warraich, M.D., is senior clinical advisor for chronic disease to the FDA commissioner.