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With an aging American population, a significant amount of research has focused on people with one or more chronic medical conditions and the individual unhealthy behaviors, such as physical inactivity or smoking, that lead to chronic conditions. Unhealthy behaviors and related chronic diseases are among the costliest health conditions in the United States. Approximately 71% of total health care spending is associated with care for Americans with multiple chronic medical conditions. [i] Among Medicare fee-for-service beneficiaries, people with multiple chronic conditions account for 93% of total Medicare spending. [ii] Unhealthy behaviors associated with chronic diseases also cost the United States billions of dollars in medical expenses and lost productivity. [iii], [iv], [v] For example, nearly $170 billion in direct medical expenses and $156 billion in lost productivity are attributed to smoking annually in the United States.[vi], [vii]
Less research has focused on the impact of multiple unhealthy behaviors on a person’s health status. Traditionally, population risk behaviors are reported at the individual level. However, just like diseases, the combination of multiple unhealthy behaviors, even though they are often highly correlated, presents a different challenge for improving public health compared with examining the same behaviors in isolation. Understanding the distribution of multiple unhealthy behaviors within a population and risks to health status from these behaviors can help focus efforts of public health officials, policy makers, clinicians, and communities on the most affected populations.


This Spotlight: Impact of Unhealthy Behaviors examines the prevalence of unhealthy behaviors among noninstitutionalized adults in the United States, and the association of these risk factors with self-reported health status [1], a validated health status measure in general and disabled populations. [viii] The following five unhealthy behaviors from the 2011 to 2014 Behavioral Risk Factor Surveillance System were selected for analysis because of their strong association with heart and other chronic diseases:[ix] smoking [2], physical inactivity [3], excessive drinking [4], obesity [5], and insufficient sleep. [6] Smoking cigarettes, being physically inactive, excessive drinking, and being overweight or obese, have all been individually linked to premature morbidity and mortality. [x] For the full methodology, see Appendix 1.


i Gerteis J, Izrael D, Deitz D, LeRoy L, Ricciardi R, Miller T, et al. Multiple Chronic Conditions Chartbook. AHRQ Publications No, Q14-0038.Rockville, MD: Agency for Healthcare Research and Quality. April 2014. Accessed March 7, 2016.
ii Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf. Accessed March 7, 2016.
iii Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE,Brewer RD. 2010 National and State Costs of Excessive Alcohol Consumption. Am J Prev Med. 2015;49(5):e73-79.
iv Cawley J, Meyerhoefer C. The medical care cost of obesity: An instrumental variables approach. J Health Econ. 2012;31(1):219-230.
v Carlson SA, Fulton JE, Pratt M, Yang Z, Adams EK. Inadequate physical activity and health care expenditures in the United States. Prog Cardiovasc Dis. 2015;57(4):315-323.
vi Xu X, Bishop EE, Kennedy SM, Simpson SA, Pechacek TF. Annual healthcare spending attributable to cigarette smoking: an update. Am J Prev Med. 2015;48(3):326-333.
vii US Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
viii Li C, Ford ES, Mokdad AH, Balluz LS, Brown DW, Giles WH. Clustering of Cardiovascular Disease Risk Factors and Health-Related Quality of Life among US Adults. Value Health. 2008;11(4):689-699.
ix Liu Y, Croft JB, Wheaton AG, Perry GS, Chapman DP, Strine TW et al. Association between perceived insufficient sleep, frequent mental distress, obesity and chronic diseases among US adults, 2009 behavioral risk factor surveillance system. BMC Public Health. 2013,13:84. Accessed February 17, 2016.
x Lantz PM, House JS, Lepkowski JM, Williams DR, Mero RP, Chen J. Socioeconomic factors, health behaviors, and mortality: Results from a nationally representative prospective study of US adults. JAMA. 1998;279(21):1703-1708.
1. Five levels: excellent, very good, good, fair, or poor. 2. Currently a smoker. 3. No physical activity outside of work. 4. For women, four or more alcoholic drinks in one sitting or an average of greater than one drink per day; for men, five or more alcoholic drinks in one sitting or an average of greater than two drinks per day. 5. Body mass index ≥30. 6. Less than seven hours of sleep per night.

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