for people with insulin-dependent diabetes, multilevel programs aimed at the simultaneous problems of weight control, glucose management, diet control, exercise, and stress management have the strongest impact on disease course when they are put together in a package and the elements of each segment are linked to each other (Wing et al., 1986). Such findings have implications for understanding predisease pathways through the alteration of multiple health habits as well.

Even when effective intervention packages have been created in research settings, there may be a gap between scientific knowledge and clinical practice. Despite demonstrated efficacy of research therapies in treating a broad array of disorders in children, adolescents, and adults (e.g., depression, phobia, other anxiety disorders), factors demonstrated to be effective in research are often not incorporated into clinical practice, consequently producing far poorer outcomes (Weisz et al., 1995). What is needed is careful attention to the design and implementation of effective intervention packages, so that they can become the standard of care administered by primary care practitioners.

Environmental Stressors

The social environment is critically important in influencing when disease processes will be initiated and what their course will be across the life span. Over 100 investigations of social ties and social support are testimony to the vital role these processes play in predisease pathways, as well as for disease course and recovery processes (Seeman, 1996).

The positive effects of the social environment on predisease processes begins very early. For example, in a review of more than 200 investigations of the determinants of adverse birth outcomes, social support from the baby's father or, in the case of unmarried girls, from their family members predicted beneficial birth outcomes, especially higher birth weight. These direct effects were indirectly mediated by less use of health-compromising substances such as cigarettes, alcohol, and drugs; better prenatal care; and lower stress (Dunkel-Schetter et al., in press). These health behaviors are inversely linked to risk of spontaneous abortion, fetal growth restriction, preterm delivery, and cognitive and motor deficits in offspring (Ness et al., 1999; Abrams, 1994).

The beneficial effects of social ties in adolescence and adulthood also are manifold. For example, individuals with higher levels of social ties were better able to avoid illness in response to experimentally induced exposure to a virus (Cohen et al., 1997). Such investigations suggest a significant role for social ties in predisease processes, specifically by reducing initial vulnerability, although the exact physiological and immunological mechanisms remain to be demonstrated. Nonetheless, there is substantial potential for



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