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A strategic framework for health improvement in San Diego County

The 3-4-50 imperative

Lately, there has been much talk and action in Washington, D.C., regarding health care reform, and some of the reform talk has focused on prevention and proactive intervention. While we care about health care coverage, which is the main thrust of the federal debate, prevention can be the key to reforming the health of the San Diego community. To see the possibilities for transforming the health of all San Diegans, one need only examine these three numbers: 3, 4 and 50.

Worldwide, three risk factors (tobacco use, poor diet and physical inactivity) contribute to four of the most prevalent chronic diseases (cancer, cardiovascular disease, type 2 diabetes and respiratory disease) that are responsible for more than 50 percent of all deaths. Also, co-morbidity of these prevalent physical diseases with common mental health disorders is found across the lifespan and linked to many chronic complications.

Local San Diego health statistics indicate 57 percent of all deaths are attributed to these four chronic diseases, which are highly associated with the three behavioral risk factors. The potential impact of reducing mortality by addressing these three risk factors represents a significant opportunity to reduce the burden of disease in San Diego County and improve the health and well-being of all the members of our community.

Chronic diseases are common and preventable. They are also costly. Most importantly, these medical conditions extend pain and suffering, and decrease quality of life for tens of thousands of San Diegans each year. In San Diego County alone, a total of more than $4 billion is spent annually on health care costs for these four chronic diseases -- excluding the treatment of lung cancer.

Physicians make health recommendations to patients that emphasize the importance of good nutrition, increased physical activity and being smoke-free. But when patients leave the office, does the environment support these healthy choices? Are they living in "healthy environments" that include access to fresh and healthful produce, walkable and safe neighborhoods, opportunities for recreation and social connections, and decreased exposure to tobacco products?

Unfortunately for the majority of low-income patients and their families, the answer is probably "no." Patients often face obstacles in the community to implementing the healthy choices recommended. In order to facilitate patients making healthy decisions and reducing chronic conditions, an "Ecological Model" of health promotion is needed to improve outcomes. This model encompasses a range of environmental approaches and policies at various levels, including individuals, families, neighborhoods, schools, businesses, faith-based institutions and government. The approaches and policies impact multiple environments and their relationship to people at the individual, interpersonal, organizational and community levels.

In addition to focusing on environments that support healthy choices, there must also be a focus on the impact of mental illness on physical health. Research shows that people with serious mental illnesses served by the public mental health system die on average 25 years earlier than the general population -- a tremendous health disparity that should be unacceptable to all of us.

The links between mental health and general health are significant. For example, research shows that increased physical activity can reduce depression. Risk factors for poor mental health include isolation, low self-esteem, social discrimination and school failure.

Protective factors to address these risks include a sense of belonging, attachment to social networks, social skills and participation in school and community groups. A practical example of a strategy that focuses on the link between physical and mental wellbeing is increasing the number of children who walk to school -- increasing physical activity can enhance children's self-esteem, broaden social networks and decrease depression and isolation, as well as promote physical health and fitness.

How can physicians and the County of San Diego Health and Human Services Agency (HHSA) partner to reduce the three behaviors and four diseases leading to more than 50 percent of the mortality in our community? Environmental strategies must be employed.

HHSA and its many community partners, including the San Diego County Medical Society, are actively pursuing evidence-based strategies for making changes to the physical, economic, social and service environments.

Why? We must encourage and support healthy behaviors that then contribute to healthier outcomes for everyone and a reduction in chronic diseases. However, we cannot do this alone, and need to enlist the help from our entire allied health professional community, starting with physicians.

The framework that can be used to carry out these changes in the San Diego community is laid out in the "Action Strategies Toolkit" from the Leadership for Healthy Communities, a national program of the Robert Wood Johnson Foundation. The toolkit contains best and promising practices that include evidence-based research supporting:

• Transportation, planning and community design to increase physical activity.

• Increasing availability of healthy foods in stores, and supporting local agriculture.

• Increased opportunities to walk or ride a bike from home to schools, parks and businesses.

• Access to safe places to recreate, and increasing physical activity in underserved communities.

HHSA has integrated these concepts into its newly developed Health Strategy Agenda, which is an integral part of a larger effort to transform HHSA's approach to addressing the total health of county residents. HHSA's Health Strategy Goal is that by 2020, the people and communities that HHSA serves will receive cost-efficient, integrated services that improve health (defined as physical, mental, social and spiritual wellbeing). Prevention efforts will reflect systems change, strategies that address the social determinants of health and policies and practices that advance changes to the built environment.

These activities will collectively create healthy environments for communities throughout San Diego County to meaningfully improve the health of our community.


Macchione is the director of the Health and Human Services Agency of the County of San Diego. Dr. Wooten, a SDCMS and CMA member since 2006, is its public health officer. The preceding article was originally published in the January edition of San Diego Physician.

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