Avalanches seem to happen randomly, out of the blue. But to experienced skiers and climbers, the warning signs are obvious. Similarly, people with asymptomatic preconditions can appear healthy, but the warning signs of impending chronic conditions are there if you know what to look for.

Most chronic conditions that are prevalent today start out as preconditions, such as prediabetes, prehypertension, overweight, subclinical depression, and borderline high cholesterol. But people with preconditions may not feel ill and may not see a doctor. So their preconditions commonly get overlooked until they turn into chronic, irreversible conditions like diabetes. Preconditions can be managed and often reversed, but to do so requires a shift in perspective, illustrated here using the analogy of an avalanche.

An avalanche starts with snow falling on a mountain top, gradually building up until a gravitational force causes a slab of snow to start moving down the mountain. This slab gains mass and momentum until it reaches the run-out zone where it comes to rest. The avalanche scenario bears a striking resemblance to the progression of chronic diseases in individuals, albeit with a much different time frame.

 

The avalanche model

Avalanches have their own anatomy, with three main parts: starting zone, avalanche track and run-out zone. The starting zone generally looks innocuous, but is the most unstable part. This part is comparable to acquiring risk factors for chronic diseases, such as age, sedentary lifestyle and poor diet. In this phase, an individual's health appears good, but a lot of changes are happening beneath the surface.

The avalanche track is the path that the avalanche takes down the mountain slope. This path is influenced by certain physical forces such as critical mass, velocity, mean slope and frictional forces. Similarly, each person's health trajectory is influenced by factors such as the number of preconditions, severity of chronic conditions and genetic endowment. The greater the burden from these factors, the faster an individual's health will deteriorate.

Finally, the run-out zone is the area at the bottom where the avalanche stops. In this model, it corresponds to end-stage disease, the phase of irreversible decline that leads to death. Since this phase is inevitable, our focus is on compressing the period of disability as much as possible toward the end of life.

James Fries, M.D., introduced the concept of the compression of morbidity in 1980. He explained that with the human lifespan approaching its maximum, practicing a healthier lifestyle should result in a shorter period of disability because chronic illness will occur later in life - in "the shorter span between the increasing age at onset of disability and the fixed occurrence of death. The end of the period of adult vigor will come later than it used to." Not only does this approach potentially reduce overall lifetime disability, but it would also lead to decreased health care costs.

 

Preventing an avalanche

A quick look at the statistics shows that preconditions affect a very large number of American adults: More than one third have prehypertension, almost 60 million have prediabetes, and about one third are overweight. Once an avalanche starts, it cannot be stopped. Likewise, once a chronic disease is diagnosed, it's not usually reversible.

On the other hand, preconditions are generally easier to manage and have the potential to be reversed. Research has shown that it is possible to delay or avoid diabetes in people with prediabetes who are treated with intensive lifestyle interventions. In fact, the Diabetes Prevention Program, a three-year research study, showed that lifestyle intervention worked better than medication at preventing the progression to diabetes among 3,200 nondiabetic people with elevated blood sugar. The lifestyle intervention was estimated to be more cost-effective than taking the medication.

Reversing one person's prehypertension or prediabetes will have a very small effect on health care costs. But when the savings are multiplied by the large number of people with these preconditions, the amount of money saved can be significant. This becomes especially apparent when compared to the energy and resources needed to treat most chronic diseases. But who will take on the task of helping people avoid or reverse these common preconditions?

 

Employers' role in disease prevention

It would be ideal if primary care physicians were able to teach their patients about avoiding and managing preconditions. But the reality is many people with preconditions don't even make it to the doctor's office and are never identified as being at risk.

The Institute of Medicine believes that the workplace holds great potential to help minimize health care costs and to promote health and well-being. The IOM's 2001 report, Health and Behavior: The Interplay of Biological, Behavioral and Societal Influences, concludes, "[Organizations] exert considerable influence over the choices people make, the resources they have to aid them in those choices and the factors in the workplace that could influence healthy lifestyles."

Workplace wellness programs, when used by a significant proportion of the at-risk population, are potentially some of the best interventions for preventing and reversing preconditions. Effective interventions often include:

* Conducting health risk appraisals with biometric measurements to identify people who are at risk.

* Educating employees about the importance of addressing preconditions before they develop into chronic diseases.

* Offering employees with preconditions the opportunity to participate in behavior change programs that are specific to their needs.

* Offering effective programs to all employees at risk.

* Incentivizing participation or rewarding accomplishments, where appropriate.

* Providing a variety of programs that are available at convenient times.

* Enlisting the support and active participation of upper management.

* Creating a workplace environment that supports employee efforts to live a healthier lifestyle.

Employers traditionally have focused on helping improve disease management for employees with serious chronic diseases like asthma, diabetes and depression, using face-to-face and telephonic counseling. This makes sense when the cost of treating a condition is high and the number of employees with the condition is small. But for asymptomatic preconditions that are highly prevalent in the population, this approach is too expensive.

On the other hand, effective, scalable and cost-effective workplace health promotion programs directed at employees with preconditions can help prevent the progression to chronic conditions at a reasonable cost to the employer. One solution is digital health coaching, which describes technology-based, automated, personalized interventions that differ from multimedia psycho-educational programs and generic health information delivered on the Web. Digital health coaching is attractive because it can be disseminated to an unlimited number of users at low cost, it's private, and yet each individual gets a plan tailored to his or her unique needs and preferences.

Just as it is wiser to avoid an avalanche rather than try to cope with its effects after it has occurred, it makes sense to prevent or delay the onset of chronic conditions by dealing with the preconditions that precede them. The best avalanche is the one that doesn't happen.

Janet Greenhut, M.D., MPH, is senior medical consultant at Wellness & Prevention Inc, a Johnson & Johnson company, in the behavior science and data analytics group. She has been in practice since 1980 and has been with Wellness & Prevention since 1999.

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