Diabetes alone accounted for $174 billion in health-care costs in the United States in 2007; diabetes incidence is expected to increase from 7 per 1,000 to 15 per 1,000 by 2050 and diabetes prevalence from 14% to 21% by 2050 and in some scenarios up to 33% (Boyle et al 2010). Thus, the consequences of not preventing chronic health conditions are large, not only in years of healthy life lost but in monetary costs.

There is growing recognition among scientists, communities, and policy-makers that health is affected by an array of factors that operate on multiple levels and throughout a person’s lifetime (Adler and Stewart 2010). Although the importance of access to and quality of health care is well recognized, prevention is key. Disease prevention and health promotion require addressing a much broader set of factors and policies that shape health-related behaviors in addition to trying to modify biologic processes specifically related to diseases. Efforts to improve early detection and treatment of diseases through improved access to high-quality medical care must be complemented by approaches that address the underlying or root causes of disease. The underlying causes include the factors that shape the conditions in which people are born, grow, live, work, and age, and the policies that affect them. Those factors and their implications for health have been highlighted in a number of recent reports (see, for example, WHO 2002; CSDH 2008; RWJF 2009).

The root causes that have been identified indicate that many policies or programs thought to be unrelated to health may have important health consequences. Indeed, it has been argued that major health problems, such as the obesity epidemic and its associated health and monetary costs, are essentially unintended consequences of various social and policy factors related, for example, to the mass production and distribution of energy-dense foods (Ledikwe et al. 2006; Mendoza et al. 2007; Wang et al. 2008) and the engineering of physical activity out of daily life through changes in how transportation is organized and how neighborhoods are designed and built (Gordon-Larsen et al. 2005; Li et al. 2008; Frank and Kavage 2009; Fitzhugh et al. 2010). Such policy and planning decisions have powerful implications for individual behaviors and public health. The prevention of today’s major health problems requires understanding and intervention to affect the root causes of ill health and the policies that shape and affect the root causes. To address them effectively, a better understanding of the possible health consequences of proposed policies and planning decisions as they are being developed is needed so that adverse health effects can be anticipated and minimized and health benefits maximized.

In summary, the health implications of decisions need to be considered explicitly not only to prevent harm but to promote health. Indeed, it can be argued that major improvements in the health of the U.S. public cannot be achieved without attention to the root causes of ill health and to the policies and programs that affect them. Furthermore, many root causes of ill health are common to the entire U.S. population, so interventions that address them can have broad-based impacts that benefit both high-risk groups and the general public.

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