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10 Top Chronic Disease Risk Factors

Jon-Michial Carter
Written by Jon-Michial Carter

One in four adults in the U.S. have multiple chronic conditions. And two-thirds of all deaths can be attributed to five chronic diseases—heart disease, cancer, stroke, chronic obstructive pulmonary disease (COPD), and diabetes.

These statistics emphasize the need to address health risk factors that make individuals more susceptible to chronic illnesses. Non-medical risk factors, or Social Determinants of Health (SDOH), include social and economic conditions that can hinder someone’s access to care, leading to poor health outcomes. Medical risk factors, like high blood pressure or obesity, also provoke the onset of chronic disease. 

Medical risk factors and SDOH are interconnected, mutually influencing each other to exacerbate chronic illnesses. For example, individuals facing socioeconomic disparities may encounter barriers to accessing healthy food options and opportunities for physical activity. These SDOHs can lead to obesity and hypertension, which may create further economic strain due to mounting healthcare expenses and diminished work productivity.

Unfortunately, the U.S. ranks poorly among developed nations in managing healthcare costs and outcomes due to a lack of effective chronic disease management. Providers must prioritize comprehensive care encompassing patients’ medical issues and their Social Determinants of Health to bridge this gap. 

The Centers for Medicare & Medicaid Services have created multiple programs to help providers and patients address chronic conditions, including Chronic Care Management

Through programs like these, we can effectively prevent and manage chronic diseases, ultimately reducing the trillions spent each year on treating chronically ill patients through improved CCM practices. In this article, we’ll examine the top risk factors contributing to chronic disease and share how you can assess and address the health risks of your patients with a CCM program. 

What is a health risk factor? 

A health risk factor includes any behavior, condition, or characteristic that increases the likelihood of developing a health problem. Some risk factors, like smoking, dietary choices, or excessive alcohol consumption, can be controlled and corrected. But others are related to genetic mutations, family history, or gender and cannot be improved with lifestyle changes. 

Health risk factors fall into one of five categories: 

Genetic risk factors

Genetic risk factors refer to inherited traits and genetic variations that can increase an individual’s susceptibility to specific diseases or health conditions. These factors are determined by a person’s genetic makeup and family history. They can include gene mutations or variations that make certain diseases more likely to occur, such as a family history of breast cancer or a genetic predisposition to high cholesterol levels.

Behavioral risk factors

Behavioral risk factors include lifestyle choices and actions that contribute to the development of chronic diseases. These factors are usually within an individual’s control and include behaviors like smoking, unhealthy diet, lack of physical activity, excessive alcohol consumption, and poor sleep habits. Engaging in these behaviors can significantly raise the risk of various health problems, including heart disease, cancer, and diabetes. Fortunately, adopting healthier habits can remedy behavioral risk factors. 

Environmental risk factors 

Environmental risk factors are external factors in an individual’s surroundings that can impact health. These factors include exposure to pollutants, toxins, and hazardous substances and the physical, social, and economic conditions of one’s environment. Environmental risk factors include air pollution, chemical exposures in the workplace, secondhand smoke, and the availability of healthcare resources in a community. 

Demographic risk factors 

Demographic risk factors are characteristics of an individual’s personal and social attributes that influence health outcomes. These factors include age, gender, race, ethnicity, socioeconomic status, education level, and marital status. Demographic risk factors may affect an individual’s access to healthcare, exposure to certain environmental conditions, and cultural factors that impact health behaviors and outcomes.

Physiological risk factors 

Physiological risk factors are aspects of an individual’s physical health and bodily functions that can contribute to the development of chronic diseases. These factors include high blood pressure, obesity, and chronic inflammation. Physiological risk factors directly affect the body’s functioning and can lead to a higher risk of conditions such as heart disease, diabetes, and stroke.

Awareness of a patient’s risk factors gives you a comprehensive view of their  health that enables you to forecast their risk for specific health conditions, tailor interventions and treatment plans to their unique needs, educate patients about their risk factors, and recommend screenings, providing more effective, personalized care.

Chronic disease risk factors 

The World Health Organization reports noncommunicable diseases (NCDs), or chronic illnesses, as a significant global health challenge resulting in premature death. 17.9 million people per year succumb to cardiovascular diseases, 9.3 million to various cancers, 4.1 million to chronic respiratory diseases, and 2 million to diabetes. 

Recognizing and addressing contributing risk factors is essential to manage and mitigate these conditions effectively. Here are ten of the most common risk factors associated with chronic diseases: 

1. Tobacco use

Tobacco use is a significant risk factor for several chronic diseases, including lung cancer, heart disease, and chronic obstructive pulmonary disease (COPD). The chemicals in tobacco smoke damage lung tissue, narrow blood vessels, and increase inflammation. Heavy smokers and those exposed to secondhand smoke are at risk for these chronic diseases. 

2. Physical inactivity

Physical inactivity is associated with a higher risk of developing obesity, type 2 diabetes, and cardiovascular diseases. Regular physical activity can help prevent these conditions by promoting weight management, improving blood sugar control, and enhancing cardiovascular health. 

People who lead sedentary lifestyles are at the highest risk for chronic diseases associated with physical inactivity. Social determinants such as access to safe recreational spaces, affordable fitness facilities, and community programs can significantly impact an individual’s ability to engage in regular physical activity. 

3. Excessive alcohol consumption

Excessive alcohol consumption increases the risk of liver disease, certain cancers, and heart problems. Individuals who consume alcohol excessively are most at risk for these alcohol-related chronic diseases. 

Social determinants influencing drinking patterns include prevailing cultural attitudes towards alcohol consumption, the ease of access to alcohol based on local availability and regulations, and economic factors like financial stability and employment circumstances, which can affect purchasing power and drinking behavior. Effective interventions should consider these cultural and economic influences and provide education and support for healthier alcohol use.

4. Unhealthy diet

An unhealthy diet, characterized by excessive consumption of processed foods, sugary drinks, and saturated fats, is a risk factor for obesity, type 2 diabetes, heart disease, and certain cancers. Individuals with poor dietary habits, often influenced by factors like food insecurity, lack of access to nutritious foods in their communities, and low income, are at higher risk for diet-related chronic diseases. Addressing these social determinants involves promoting food security, improving access to healthy foods, and nutrition education in underserved areas.

5. Air pollution 

Exposure to air pollution, especially fine particulate matter and toxic pollutants, can contribute to respiratory diseases such as asthma and COPD, heart diseases, and certain cancers. Populations living in areas with high levels of air pollution, influenced by urbanization and industrial activity, are most at risk for pollution-related chronic diseases. Related social determinants include housing location, economic disparities, and environmental policies. 

6. Inherited mutations

Inherited mutations can increase the risk of various genetic disorders and conditions. For example, mutations in the BRCA1 and BRCA2 genes can lead to a higher risk of breast and ovarian cancer, while mutations in the CFTR gene can cause cystic fibrosis. Genetic testing and early cancer screenings can help prevent the progression of these chronic diseases.

7. Family history 

Those with a family history of chronic diseases are at heightened risk, often due to shared genetic and environmental factors within families. Family history can contribute to an increased risk of conditions like heart disease, stroke, certain cancers (e.g., colon, lung, and breast cancer), and genetic disorders. Prevention strategies to mitigate these predispositions include regular medical check-ups, early screenings, and a healthy lifestyle. 

Social determinants such as access to healthcare and health education play a role in early detection and prevention. Healthcare practices should prioritize regular screenings and education for individuals with family histories of chronic disease.

8. Rural location 

Living in a rural area can be associated with limited access to healthcare facilities and resources, which can result in delayed diagnosis and treatment of chronic diseases. Preventive measures involve promoting telehealth services, improving access to healthcare through transportation services and Rural Health Clinics (RHCs), and raising awareness about risk factors in rural communities. 

9. Gender

Gender can play a role in chronic disease risk, as certain conditions may affect men and women differently. For example, men have a higher risk of heart disease, while women have unique risk factors for conditions like breast and ovarian cancer. Preventive measures involve understanding gender-specific risks and following recommended screenings and lifestyle modifications.

10. Low socioeconomic status

Low socioeconomic status is associated with limited access to healthcare, poor nutrition, and increased stress, contributing to chronic diseases such as diabetes, heart disease, and mental health disorders. Prevention strategies include improving access to healthcare services, social support, and initiatives to reduce economic disparities.

How do health risk factors lead to chronic disease? 

Health risk factors and chronic diseases share a reciprocal relationship, where each influences and exacerbates the other. On the one hand, health risk factors, such as smoking, sedentary lifestyles, unhealthy diets, and exposure to environmental pollutants increase an individual’s vulnerability to developing chronic diseases like heart disease, diabetes, and certain cancers. These risk factors often initiate or accelerate disease processes by contributing to physiological changes, inflammation, and tissue damage. 

Conversely, chronic diseases themselves can exacerbate risk factors. For example, individuals with chronic conditions may find it more challenging to engage in physical activity, maintain a healthy weight, or manage stress, further increasing their risk for additional health problems. This reciprocal influence underscores the importance of comprehensive healthcare approaches that address both risk factors and chronic diseases to effectively prevent, manage, and mitigate the impact of these conditions on individuals’ well-being.

How to identify health risks and take preventative measures in your practice

Identifying health risks and taking preventive measures in your medical practice allows for early detection of potential health issues and timely intervention, which can significantly improve patient outcomes. This proactive approach can prevent diseases from progressing to more severe stages and reduces the need for more extensive and costly treatments. 

Focusing on prevention rather than just treatment aligns with a holistic approach to healthcare that enhances the quality of life for patients and reduces the burden of chronic diseases and emergency interventions. 

Here are five strategies to integrate into your practice to effectively identify and address your patients’ risk factors:

1. Chronic Care Management program

Chronic Care Management (CCM) program can play a vital role in identifying risk factors by providing a structured and proactive approach to patient care. CCM involves ongoing monitoring of Medicare patients’ health through regular check-ins and periodic assessments. This continuous monitoring allows you to track changes in patient risk factors over time. For example, you can monitor critical risk indicators, like blood pressure trends, weight fluctuations, or medication adherence.

CCM programs include patient education to raise awareness of risk factors and provide guidance on healthier behaviors. Care coordinators can give patients  information on nutrition, physical activity, smoking cessation, and other lifestyle modifications tailored to their specific risk factors and based on their provider’s recommendations. CCM programs also help patients understand the importance of medication compliance and provide tools to support adherence, such as medication reconciliation and reminders.

CCM programs incorporate recommended screenings and preventive services into the care plan. For instance, patients may be scheduled for regular blood tests, cancer screenings, or vaccinations based on their risk factors and age. These screenings can detect early signs of diseases or further assess risks.

Not only do CCM programs encourage communication between patient and provider, but they also facilitate coordination among the various healthcare providers involved in a patient’s care, including primary care physicians, specialists, and allied health professionals. This collaborative approach ensures that all relevant risk factors are considered and preventive measures are implemented consistently.

2. Preventive screenings

Preventive screenings can identify health issues at an early and often more treatable stage. Detecting chronic diseases in their early phases allows for timely intervention, which can prevent the progression of the disease and reduce its impact on an individual’s health. For example, individuals at risk of heart disease may be advised to make dietary changes, exercise regularly, or take cholesterol-lowering medications to reduce their risk.

Preventive care screenings are often more cost-effective than treating advanced disease stages. Early detection and intervention can reduce the need for expensive and intensive treatments, hospitalizations, and long-term care, lowering healthcare costs for patients.

3. Annual Wellness Visits (AWVs) and Health Risk Assessments (HRAs)

The Annual Wellness Visit is the best time to identify and address a patient’s health risk factors through administering a Health Risk Assessment. The HRA gathers information about a patient’s family and medical history, lifestyle choices, mental health, and quality of life to highlight potential risk factors. 

During an AWV, you can use the HRA to schedule screenings and discuss lifestyle and dietary changes a patient can take to reduce behavioral risk factors. This proactive approach can lead to better management and prevention of chronic diseases.

4. Preventive care plans 

Based on the results of the HRA, you can offer personalized recommendations to patients and create preventive care plans. These plans may include recommendations for vaccinations, lifestyle modifications (e.g., diet and exercise), and screenings tailored to the patient’s age, gender, and medical history. 

Consider more frequent screenings, tests, or consultations for high-risk patients. You can collaborate with patients to customize these plans, emphasizing the importance of preventive measures in maintaining and improving health.

5. Patient education 

Educate patients about risk factors, healthy behaviors, how to manage their chronic conditions, and the importance of screenings and vaccinations. This education empowers them to make informed decisions about their health, adopt healthier lifestyles, and adhere to recommended preventive measures. Well-informed patients are more likely to actively participate in their care and take preventive actions to reduce their risk of chronic diseases. 

Identify health risks easily with ChartSpan

By integrating ChartSpan into the five strategies above, your practice can strengthen its effectiveness in Chronic Care Management and preventive care. Our comprehensive Chronic Care Management (CCM) program, advanced Annual Wellness Visit (AWV) software, and customizable Health Risk Assessments (HRAs) are designed to ease the workload of healthcare providers while enhancing preventive care.

ChartSpan’s Chronic Care Management Program

Our CCM program enhances patient care through proactive monitoring, consistent patient engagement, and collaborative care coordination. The program offers a structured approach to managing chronic conditions, providing regular monitoring and management to facilitate early identification and intervention for potential health complications. 

With ChartSpan, your patients gain increased access to care through consistent monthly touchpoints and a 24/7 nurse line, ensuring ongoing support and engagement. Our care team conducts SDOH, medication adherence, fall risk, and other types of assessments and reports the information to your practice. 

Consistent patient engagement through CCM is essential for educating patients about their health, fostering adherence to treatment plans, and detecting emerging health risks. 

Additionally, our CCM program promotes collaboration among healthcare providers, fostering comprehensive consideration of all patient health aspects for more effective and thorough preventive care.

ChartSpan’s Customizable Health Risk Assessments

ChartSpan’s customizable Health Risk Assessment software is vital in targeted risk identification, patient-specific interventions, and ongoing risk management. These HRAs collect extensive information on a patient’s medical history, lifestyle, and other vital factors influencing their health, pinpointing specific health risks needing attention. 

Our HRA software is specific to the Medicare Annual Wellness Visit, with customization options to suit your practice specialties and specific patient demographics. Whether your practice specializes in cardiology, urology, another specialty, or primary care, you can customize the HRA questions to address the most relevant health concerns and risks associated with your particular field for more targeted risk identification and management.

ChartSpan’s advanced Annual Wellness Visit Software

ChartSpan’s advanced AWV software, RapidAWV™, revolutionizes conducting wellness visits by offering efficient health assessments, personalized care planning, and data-driven decision-making. Our AWV software analyzes the results of HRAs and flags potential health risks, highlighting areas that may require immediate attention or further investigation.

RapidAWV™ identifies gaps in care, such as missed screenings or vaccinations, so that no critical aspect of a patient’s preventive care is overlooked during the visit. Additionally, the software recommends preventive measures based on an analysis of HRA results and the patient’s overall health profile. These recommendations are tailored to each patient’s specific needs.

Our AWV software automatically generates an editable patient care plan following the HRA. It offers a clear, structured outline of the required interventions and follow-up actions. The editable nature of the care plan allows for easy updates and modifications, ensuring that the plan remains relevant and responsive to the patient’s evolving health needs. 

ChartSpan’s integration of assessment, analysis, and action into your seamless workflow optimizes wellness visits’ efficiency and significantly enhances the quality and precision of patient care.

Choose ChartSpan for improved Chronic Care Management and patient health outcomes

By simplifying the complexities of Chronic Care Management and Annual Wellness Visits, ChartSpan allows your practice to focus on delivering quality care without being overwhelmed by the operational aspects of a CCM program. The result is a more efficient and patient-centric healthcare practice.

With ChartSpan, preventive care becomes manageable and sustainable, and your practice becomes more efficient in identifying and addressing health risks. Our comprehensive suite of tools and dedicated support is designed to elevate your practice’s capabilities in delivering exceptional care, enhancing patient outcomes, and maintaining a high standard of healthcare delivery. Choose ChartSpan to navigate the complexities of chronic care with ease. 

Contact us to learn more or schedule a consultation about our program. 

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