US Pharm. 2006;1:43-50.

Chronic diseases including cancer, diabetes, and cardiovascular disease are the leading causes of death and disability in the United States (Table 1). Each year, chronic diseases account for 70% of deaths and affect the quality of life of 90 million Americans.1 While chronic diseases are the most common causes of death in the U.S., many of them are preventable. Major risk factors include lack of physical activity, smoking, and being overweight.2 Healthy behaviors such as being physically active and avoiding tobacco use can reduce the risk of death from chronic disease and can prevent or control their devastating effects.1 Other major causes of morbidity and mortality in the U.S., such as unintentional injury and stroke, can also be reduced through patient education.3-5




Common Health Risks
Coronary artery disease (CAD): CAD is the most common type of heart disease and the leading cause of death in both men and women in the U.S., resulting in more than 500,000 deaths each year.6 The disease occurs when the coronary arteries become hardened and narrowed as a result of plaque buildup on artery walls. 6 Uncontrollable risk factors for CAD include age (e.g., risk increases after age 45 for men and after age 55 for women), family history of heart disease, having a father or brother diagnosed with the disease at age 55 or younger, and having a mother or sister diagnosed at age 65 or younger.6 Controllable risk factors include high blood cholesterol, high blood pressure (BP), smoking, diabetes, lack of physical activity, and being overweight. 6

It is recommended that patients who have had a myocardial infarction, unstable angina, ischemic stroke, or transient ischemic attacks use prophylactic aspirin therapy if not contraindicated.7 In patients at high risk for a future cardiac event, the benefits of aspirin therapy should be weighed against the risk for potential complications. In low-risk patients, possible hemorrhagic complications may outweigh the benefits; current data do not support the use of prophylactic aspirin therapy in this population.8

Cancer: Cancer is the second-leading cause of death in men and women, while lung cancer is the leading cause of cancer-related death in the U.S.9 Risk factors for cancer vary; cancers of the lung, mouth, larynx, bladder, kidney, cervix, esophagus, and pancreas are related to tobacco use, while skin cancer is related to unprotected exposure to strong sunlight.4

Risk factors for cancer include age and family history. Gender can also increase the risk of certain cancers (e.g., women are more likely than men to develop breast cancer), while the risk of some cancers (e.g., prostate cancer) increases with age.4   About 75% of all cancers in the U.S. are caused by environmental factors (e.g., tobacco use, poor diet, infectious disease, exposure to chemicals and radiation) and about one third of all cancer-related deaths result from dietary factors and lack of physical activity in adulthood.4

Unintentional injuries: Accidents are a leading cause of death for Americans of all ages, regardless of gender, race, or economic status.3 In 2003, more than 27 million people experienced a nonfatal unintentional injury that required a visit to an emergency department.3

In 2003, motor vehicle accidents (42,900), poisoning (14,500), and falls (14,200) were the leading causes of accident-related deaths in the U.S.10 To reduce injuries, the National Safety Council recommends learning first aid and cardiopulmonary resuscitation and encourages installing handrails, grab bars, and night-lights in homes to prevent falls, and storing all medications and cleaners in childproof cabinets to reduce poisonings.10

Stroke: Stroke, a disease that occurs when blood flow to the brain is interrupted, is the leading cause of serious long-term disability and the third-leading cause of death in the U.S.11 Every 45 seconds, an American has a stroke. 12 Treatable risk factors include high BP, smoking, heart disease, and a history of stroke and diabetes.13 Warning signs include sudden numbness or weakness of the face, arm, or leg (especially on one side of the body), confusion or trouble speaking or understanding, trouble seeing in one or both eyes, trouble walking, dizziness, loss of balance or coordination, and severe headache with no known cause.14

Chronic obstructive pulmonary disease (COPD): COPD, a group of chronic lung conditions that includes emphysema and chronic bronchitis, is the fourth-leading cause of death in the U.S. and is projected to be the third-leading cause of death by 2020.15 While about 24 million adults in the U.S. have impaired lung function, only 12.1 million adults over age 25 reported diagnosis of COPD in 2001, indicating that the disease is underdiagnosed.16

Smoking tobacco is the most common cause of COPD.15 Other risk factors include chronic exposure to air pollution, chemical fumes, and certain dusts.15 While most patients with lung cancer will develop COPD (since both diseases are caused primarily by smoking), only 1% to 2% of patients with COPD will develop lung cancer.17

Diabetes: Diabetes, a chronic metabolic disorder characterized by abnormalities in carbohydrate, fat, and protein metabolism, is a leading cause of blindness, kidney disease, neuropathy, amputation, skin disorders, gastroparesis, and depression.18 While about two out of three people with diabetes in the U.S. die from heart attack or stroke, the disease is underreported as a cause of death; studies have found that only 35% to 40% of patients with diabetes had the disease mentioned on their death certificate and the disease was listed as the underlying cause of death in only 10% to 15% of patients. 19,20

Risk of type 2 diabetes increases with age and degree of obesity and is more prevalent in Native American, Hispanic, and African American populations. Other risk factors include past gestational diabetes or giving birth to a baby 9 pounds or heavier, high BP, an abnormal serum lipid profile, a sedentary lifestyle (exercising fewer than three times per week), and having a parent or sibling with the disease.21

Influenza and pneumonia: Each year, influenza affects 5% to 20% of Americans and results in more than 200,000 hospitalizations and about 36,000 deaths.5 Symptoms of flu include fever, chills, fatigue, cough, headache, and muscle aches.22 Streptococcal pneumonia is the most common cause of community-acquired pneumonia, accounting for 25% to 35% of all cases and an estimated 40,000 deaths each year.23

Pneumonia, a general term for infection and inflammation of the lungs, is caused mainly by infections from viruses, bacteria, and mycoplasmas; other causes include fungal infections or inhalation of liquid, gases, or dust.23 Children, the elderly, and people with underlying health problems (e.g., COPD, diabetes) are at high risk for pneumonia. Pneumonia and influenza are preventable by vaccination.

Kidney disease: In 2002, kidney disease was the ninth-leading cause of death in the U.S., accounting for 40,974 deaths.24 Overuse of over-the-counter analgesics such as acetaminophen, aspirin, and NSAIDs and macrolide antibiotics can damage the kidneys; an estimated 3% to 5% of all new cases of chronic kidney failure may be caused by chronic overuse of these medications. 25

The Role of the Pharmacist
Screening and educating patients on reducing risk factors can help prevent or reduce their risk of developing chronic disease.26-28 Pharmacists should assess a patient's current health status and disease risk factors, including weight, BP, vaccination history, family history of chronic disease, and information regarding lifestyle (e.g., smoking, physical activity).29 Possible pharmacist activities are listed in Table 2.




Weight loss: Pharmacists should provide patients who are overweight with information on beginning a weight loss program and advise them to achieve a body weight as close to ideal for their height as possible. Identifying an individual who is overweight involves measuring body mass index (BMI), waist circumference, and risk factors for diseases and conditions associated with obesity. Waist circumference (measurement of the largest point of the abdomen) is associated with an increased risk of heart disease if greater than 40 inches in men
and 35 inches in women. BMI, a measure of body fat based on an individual's height and weight, can determine whether an individual is underweight (less than 18.5), normal weight (18.5 to 24.9), overweight (25 to 29.9), or obese (30 or greater). Losing 5% to 15% of body weight can significantly improve health (BMI Chart).30




Diet: Consuming nutrient-dense foods, limiting the intake of saturated and trans fats, cholesterol, sugar, salt, and alcohol, and meeting recommended calorie requirements can help reduce the risk of chronic disease (Table 3). A balanced eating plan such as the U.S. Department of Agriculture (USDA) Food Guide or the Dietary Approaches to Stop Hypertension (DASH) can help patients achieve their calorie requirements. A sample USDA Food Guide and DASH Eating Plan at the 2,000 calorie level can be found below.




Goals of any weight management plan should be safe and intended to improve the patient's health status and minimize future health-related problems.29 Regularly checking a patient's weight and waist measurements can help ensure compliance with the plan.29 Regular BP readings may also encourage compliance, since most people with elevated BP on the DASH diet experience a decrease in BP, sometimes in as little as two weeks.31




Exercise: Physical activity is crucial to good health and can have health benefits, including a decreased risk of coronary heart disease.2 To reduce the risk of chronic disease in adulthood, individuals should engage in 30 minutes of moderately intense physical activity most days of the week in addition to regular daily activities. To manage weight, 60 minutes of moderate to vigorous physical activity and not exceeding calorie requirements is recommended. Weight loss requires 60 to 90 minutes of moderately intense physical activity and not exceeding calorie requirements.32

A well-rounded exercise plan includes aerobic, muscle strengthening, and stretching activities. Patients should begin an exercise regimen slowly with small goals, such as walking 10 minutes a day three days per week. Patients are more likely to exercise if they like an activity and should be encouraged to select one they enjoy.33

Smoking cessation: Smoking cessation has major and immediate health benefits for men and women of all ages. People who quit smoking before age 50 have half the risk of dying in the next 15 years as compared with those who continue to smoke.27 Pharmacists can conduct screening programs and provide specialized services that focus on such areas as hypertension, diabetes, asthma, patient education, or general medication management.28 Pharmacists have proved to be effective smoking cessation counselors that can improve success rates.34 A smoking cessation program is available on the Washington State Pharmacy Association Web site at www.wsparx.org/sitemap.asp.

Vaccination: Pharmacists can help improve vaccination rates to reduce the risk of death from influenza and pneumococcal pneumonia.35 Influenza vaccination should be considered in children six to 23 months of age, people 65 years or older, residents of long-term care facilities, individuals six months to 18 years old on long-term aspirin therapy (due to the risk of Reye's syndrome), women who are pregnant during the flu season, people with nerve or muscle disorders (e.g., seizure disorders, cerebral palsy) and weakened immune systems, and anyone in close contact with these high-risk populations.

Conclusion
While lack of physical activity, smoking, and being overweight are major risk factors for the leading causes of morbidity and mortality in American adults, pharmacists are ideally trained and positioned to help reduce these risk factors. Patients should be given achievable, measurable goals and specific information regarding calorie intake, activity levels, vaccines, and use of smoking cessation products to maximize results. Pharmacists who choose to become involved in improving the health of patients can make a difference.

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