In early 2004, the U.S. Centers for Disease Control and Prevention reported on the most common actual causes of death for the year 2000 in the United States (1). The report served as an update to a similar analysis for the year 1990 and indicates that the leading actual causes of death for 2000 are tobacco, poor diet and physical inactivity, alcohol consumption, microbial agents (e.g., influenza, pneumonia), toxic agents (e.g., asbestos, pollutants), motor vehicles, firearms, sexual behavior, and illicit use of drugs (see Figure). These actual causes of death are defined as lifestyle and behavioral factors such as smoking and physical inactivity that contribute to the nation's leading causes of death such as heart disease, cancer, respiratory diseases, and diabetes. The result of the updated list indicates that physical inactivity and poor diet are catching up fast with tobacco; these top two actual causes of death combine to account for approximately one third of all deaths in the United States.
The list of actual causes of death may inform us upon which health risks to focus our preventive efforts. What it doesn't tell us, however, is how these behavioral factors cluster within individuals. Does a smoker have a greater likelihood to also be a risky drinker? Do physical inactivity and poor diet combine readily and thereby at least partially explain the increase in the number of people who are overweight and obese? Do clusters of behavioral risk factors relate to specific chronic diseases? These questions and others make us consider the opportunities and challenges in addressing multiple risk factors among large groups of people. For example, which combinations of behavioral risks occur most often at the worksite? Studies indicate that risk factors do not cluster at random but often occur in specific combinations (2, 3). Further, this research points out that highly educated individuals, older people, and women tend to have a lower prevalence of behavioral risk factors. What does that mean for your worksite health promotion program? How does this affect your planning and ability to support other company-wide objectives related to health and well-being, but also productivity?
Based upon an analysis conducted on the 2001 National Health Interview Survey (NHIS), L. J. Fine, Ph.D., and colleagues recently presented an overview of the prevalence of various multiple risk factor clusters among adults in the United States (4). The clusters considered the top four factors related to actual causes of death but used body mass index instead of poor diet. Hence, the various clusters included smoking, physical inactivity, risky alcohol consumption, and being overweight. Tables 1 and 2 describe some of their findings.
Prevalence of Multiple Risk Factors
We already know that each of the risk factors occur relatively often among adults in the United States. Prevalence of smoking is approximately 23%, physical inactivity is approximately 65%, risky drinking is approximately 21%, and being overweight is approximately 58%, based upon self-reported data. When the multiple combinations are considered, the estimated number of people in each of the clusters varies and is outlined in Table 1 (4).
Hence, less than 10% of the U.S. population has none of these four risk factors. Further, the majority of adult Americans have two or more risk factors at the same time (57.7%). As noted in Table 2, the most common cluster of risk factors involves both physical inactivity and being overweight. These two risk factors co-occur in approximately 39% of the population. Another interesting finding includes the fact that only 1.8% of the population smokes without having any of the other three risk factors.
Multiple Risk Factors and the Worksite
To take action on this knowledge in the context of worksite health promotion programming, the following are some issues to consider:
- Which risk factors occur among employees?
- How do they cluster?
- How ready are employees to take action on them?
- What programs are available for employees?
- How do they access those programs?
- How can employees prioritize taking action on more than a single risk factor?
- How do we provide a supportive environment for such efforts to be successful?
"5 As" at the Worksite
One approach may be to use the "5 As" that have been successfully applied to tobacco cessation programs, but apply this to address multiple risk factors at the worksite. The "5 As" approach refers to the steps shown in Table 3 and may be adapted to the worksite setting using the tools and methods also shown.
The multiple risk factor approach also allows another important concept to emerge, namely the notion of "employee centeredness." Assessing all risk factors and supporting follow-up action on them, singly or in combination, supports the individual employee regardless of the risk factors present. In this way, employees are encouraged to take action on the risks they would like to address, when they are ready, at a time of their own choosing. This is a different approach than providing a single risk factor focused program according to a pre-set program implementation plan that provides access to only a few programs at pre-specified times of the year. Using the multiple risk factor approach, the worksite health promotion staff does not lose its ability to prioritize specific areas of focus, such as smoking or physical activity. However, any employee can decide to take action regardless of what the topic of the month may be.
Given that most people have at least two out of four behavioral risk factors and that this is especially true for the working population, multiple risk factor approaches to worksite health promotion programming may be an idea whose time has come.
1. Mokdad, A.H., J.S. Marks, D.F. Stroup, et al. Actual causes of death in the United States, 2000. JAMA
2. Berrigan, D., K. Dodd, R.P. Troiano, et al.Patterns of health behavior in U.S. adults. Preventive Medicine
3. Ford, E.S., M.A. Ford, J.C. Will, et al.Achieving a healthy lifestyle among United States adults: a long way to go. Ethnicity and Disease
4. Fine, L.J., G.S. Philogene, R. Gramling, et al. Prevalence of multiple behavioral chronic disease risk factors in the United States: results from the 2001 National Health Interview Survey. American Journal of Preventive Medicine
27(2 Suppl):18-24, 2004.
© 2004 American College of Sports Medicine
5. Dawson, D.A. U.S. low risk drinking guidelines: an examination of four alternatives. Alcoholism, Clinical And Experimental Research