Health statistics often go unnoticed, especially when presented in bits and pieces. Viewed as a long-term trajectory spanning decades, however, deteriorating health in the United States is difficult to ignore. Chronic disease rates have steadily risen for the past 50 years.
In 2018, the Centers for Disease Control and Prevention reported that some 60 percent of the U.S. population had at least one chronic disease. Forty percent had two or more chronic diseases.1Boersma P, Black LI, Ward BW. Prevalence of multiple chronic conditions among US adults, 2018. Prev Chronic Dis. 2020;17:E106. https://doi.org/10.5888/pcd17.200130 In 2022, chronic conditions accounted for nearly 86 percent of all U.S. healthcare expenditures,2Holman HR. The relation of the chronic disease epidemic to the health care crisis. ACR Open Rheumatol. 2020;2(3):167-173. https://doi.org/10.1002/acr2.11114 totaling $4.5 trillion.3Trends in health care spending. American Medical Association. Updated April 25, 2024. Accessed May 20, 2024. https://www.ama-assn.org/about/research/trends-health-care-spending The health of our nation is clearly at risk.
Many factors have contributed to the upward trend in chronic disease, some more obvious than others. People are living longer, and older adults experience a higher prevalence of health issues. More time in front of a screen (and less time outside or exercising) affects kids and adults alike. Excess alcohol and tobacco use also contribute to disease propensity. What is mostly missing from the public health “playbook,” however, is the dwindling quality of diet and nutrition. Over the past five decades, the shift from homegrown produce to commercially produced food in North America has led to a notable decline in health. A large portion of the United States suffers from malnutrition.
Genetics and Disease Susceptibility
When babies, children, and pregnant and lactating women do not get proper nutrition, it alters how genes are expressed. This biological process is called epigenetics. Epigenetic changes in the womb can lead to variations in germ-line cells, eggs, and sperm passed from one generation to the next.
Professor David Barker, a renowned epidemiologist, first published the correlation between birth weight and chronic disease risk in 1990. Barker demonstrated that infants born with low birth weights (around five pounds) face a three to five times higher likelihood of heart disease–related mortality compared to those born at the higher end of the scale (nine pounds). Infants with higher birth weights have similar risks of diabetes, obesity, and heart disease as those in the lower weight range. These findings have been corroborated in five countries, including the United States.
Within the scientific community, there is widespread recognition of the connection between early-life stressors and subsequent risk of disease. Hundreds of studies have shown that maternal nutritional patterns before birth and during pregnancy and lactation not only affect birth weight but also influence the development of organs that could be susceptible to diseases throughout life. Nutrition and stress in childhood have a powerful effect on future disease risk.
The 100-Year Effect
The egg that forms a baby originates in its mother’s ovary when she is still a fetus. During fetal development, she is nourished by her mother’s diet and bodily nutrient reserves. If your grandmother ate poorly, it could influence your risk for chronic disease today. This enduring impact, known as the 100-year effect, illustrates how disease risk can be transmitted across generations.
Stress During Pregnancy
Malnutrition, partner abuse, exposure to toxic chemicals, and low oxygen levels during pregnancy are associated with increased risks of adult-onset diseases for the baby. Many mothers face multiple burdens—specifically poor nutrition and social stress—at the same time. Pregnant people who live in low-resource settings may encounter all of these stressors simultaneously. The cumulative impact of stress during pregnancy can disrupt hormonal balance and contribute to even greater risks of adverse epigenetic alterations in the womb, affecting lifelong susceptibility to diseases.
The Dutch Famine
Numerous studies have established a connection between stress during pregnancy and negative consequences for children. During the Hunger Winter of 1944, food blockades by the Nazis led to widespread malnutrition, with many pregnant women consuming 750 or fewer calories daily. Children of these pregnancies showed heightened rates of coronary heart disease, abnormal blood lipid profiles, obesity, and lung disease in subsequent studies.
Childhood Nutrition
Normal growth patterns among children typically begin accelerating at 7 or 8 years of age. However, children born at the low end of the birthweight scale who rapidly gain weight starting at age 4 or 5 are more susceptible to diabetes and heart disease. Adverse childhood experiences, including any kind of physical or emotional trauma, and poor nutrition further increase the risk. When young children regularly eat an excessive amount of simple carbohydrates, they may become prone to high-calorie malnutrition, also common among adults. These effects were documented in the Helsinki Birth Cohort.4Forsén T, Eriksson J, Tuomilehto J, Reunanen A, Osmond C, Barker D. The fetal and childhood growth of persons who develop type 2 diabetes. Ann Intern Med. 2000;133(3):176-182. https://doi.org/10.7326/0003-4819-133-3-200008010-00008
Obesity, Diabetes, and Heart Disease
While body mass index (BMI) may not accurately estimate fat mass in highly muscular individuals, it is a valuable tool for assessing fat levels and predicting disease outcomes. In the metric system, a BMI over 30 kilograms/meter2 indicates obesity. The risk of chronic disease increases with BMI, which have been rising since 1990, when no U.S. state had an obesity prevalence exceeding 15 percent of its population. By 2023, nearly 35 percent of adults in 22 states were grappling with obesity. Obesity rates in several states now exceed 40 percent.
In 2021, approximately 38.4 million Americans (11.6 percent of the population) were living with diabetes. Around 2 million had type 1 diabetes, and about 304,000 were under 18. Older adults (65 and up) made up almost a third of those affected, totaling 16.5 million. The disease poses one of the most formidable health challenges of the 21st century, with approximately 1 million new cases diagnosed each year and an additional 97 million people dealing with prediabetes.
Cardiovascular complications and diabetes are tightly linked, with around 68 percent of diabetes patients dying of heart disease.5Matheus AS, Tannus LR, Cobas RA, Palma CC, Negrato CA, Gomes MB. Impact of diabetes on cardiovascular disease: an update. Int J Hypertens. 2013;2013:653789. https://doi.org/10.1155/2013/653789 Rising rates of diabetes and obesity among young people serve as an early warning of serious health concerns, as the projected cost of managing heart disease is expected to exceed $1 trillion.6Gheorghe A, Griffiths U, Murphy A, Legido-Quigley H, Lamptey P, Perel P. The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review. BMC Public Health. 2018;18(1):975. Published 2018 Aug 6. https://doi.org/10.1186/s12889-018-5806-x
Reversing Epigenetic Changes
Although the genetic code is largely fixed, epigenetic changes are reversible. The key to this switch lies in dietary and lifestyle modifications. Eating nutritious foods that combat inflammation and reduce blood sugar, blood pressure, and cholesterol will improve overall health and potentially increase reproductive success for couples planning a family.
Health in the United States hinges on the collective well-being and disease status of the population. With optimal nutrition, minimal stress, and no exposure to harmful chemicals during pregnancy, the country’s disease patterns could drastically improve. As Professor Barker noted, healthier weights at birth and throughout early childhood could halve heart disease and diabetes rates in a single generation. The question remains: When will our society choose to end the upward trajectory of chronic disease? The time to act is now.
Footnotes
- 1Boersma P, Black LI, Ward BW. Prevalence of multiple chronic conditions among US adults, 2018. Prev Chronic Dis. 2020;17:E106. https://doi.org/10.5888/pcd17.200130
- 2Holman HR. The relation of the chronic disease epidemic to the health care crisis. ACR Open Rheumatol. 2020;2(3):167-173. https://doi.org/10.1002/acr2.11114
- 3Trends in health care spending. American Medical Association. Updated April 25, 2024. Accessed May 20, 2024. https://www.ama-assn.org/about/research/trends-health-care-spending
- 4Forsén T, Eriksson J, Tuomilehto J, Reunanen A, Osmond C, Barker D. The fetal and childhood growth of persons who develop type 2 diabetes. Ann Intern Med. 2000;133(3):176-182. https://doi.org/10.7326/0003-4819-133-3-200008010-00008
- 5Matheus AS, Tannus LR, Cobas RA, Palma CC, Negrato CA, Gomes MB. Impact of diabetes on cardiovascular disease: an update. Int J Hypertens. 2013;2013:653789. https://doi.org/10.1155/2013/653789
- 6Gheorghe A, Griffiths U, Murphy A, Legido-Quigley H, Lamptey P, Perel P. The economic burden of cardiovascular disease and hypertension in low- and middle-income countries: a systematic review. BMC Public Health. 2018;18(1):975. Published 2018 Aug 6. https://doi.org/10.1186/s12889-018-5806-x
