Why healthy behaviors need to be the path of least resistance for people with chronic disease

Half of Americans have at least one chronic disease1 and 90% of the nation’s $3.5T in healthcare costs are for people with chronic disease2. These conditions are responsible for workplace absenteeism and presenteeism, disability and death. Despite increasing investments in solving this problem–including technology–the illnesses and costs are getting worse. Why is that?

Recently there has been quite a bit of attention paid to the determinants of health–and there are several. Social and environmental factors, comorbidities including mental health, and genes all play significant roles in determining the risk for developing conditions, the risk for complications from those conditions, cost and mortality. Racial and social inequities are major drivers of health disparity. There is no question we need to address these, and most stakeholders recognize this and are making changes to address them.

In nearly all cases, however, the proximal causes of chronic disease exacerbation are  behaviors. Behaviors drive far more of the risk from chronic conditions than genetics for the majority of chronic conditions. Take diabetes, for example–a study this year in Diabetologia3 found that genetics increased the risk for developing diabetes 2-fold. In comparison, obesity increased the risk 6-fold.


“Solving the crisis of chronic disease begins and ends with behavior change.”


Most people realize that physical inactivity, stress, challenges to medication adherence, smoking and alcohol use, and diet are major contributors to exacerbations of hypertension, coronary artery disease, diabetes, chronic pain and many other conditions. So while education can play an important role, this problem cannot be simply a matter of knowledge deficit.

Durably changing behaviors is extremely difficult. Even though it seems like they should, digital tools and connected devices alone have generally not worked to improve health4. So, the problem is not simply educational, and it’s not simply a matter of access to measuring capabilities–we shouldn’t expect these to work alone any more than we should expect diet books and scales alone to reduce America’s burgeoning obesity problem5.

Solving the crisis of chronic disease begins and ends with behavior change. It requires understanding the whole person, not just their diseases but their motivations and fears, and the use of digital tools enhanced with human connection. It demands answering one simple question with absolute precision for every individual: how to make the right thing to do the easiest thing to do. Only when we make healthy behaviors the path of least resistance will we durably change the trajectory of this immense issue.