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Stage 2: Lifestyle Factors and Chronic Disease

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As environmental supports for addressing infectious diseases were initiated (for example, potable water and vaccinations), deaths from infectious diseases were reduced. Compared with people who lived a century ago, most people in our nation and other developed nations are living longer and have a better quality of life—and better health. While new infectious diseases (e.g., HIV/AIDS, bird flu, MRSA, Ebola, COVID-19) have emerged since the end of the 20th century and continue to demand the attention of health workers, the emphasis of health promotion shifted in the last quarter of the 20th century to focus on the prevention and treatment of chronic diseases and injury, which are the leading causes of illness and death. This change was stimulated, in part, by the Lalonde report, which observed in 1974 that health was determined more by lifestyle than by human biology or genetics, environmental toxins, or access to appropriate healthcare. It was estimated that one’s lifestyle—specifically, those health risk behaviors practiced by individuals—could account for up to 50 percent of premature illness and death. Substituting healthy behaviors, such as avoiding tobacco use, choosing a diet that was not high in fat or calories, and engaging in regular physical activity, for high-risk behaviors (tobacco use, poor diet, and a sedentary lifestyle) could prevent the development of most chronic diseases, including heart disease, diabetes, and cancer (Breslow, 1999).

With recognition of the importance of one’s lifestyle in the ultimate manifestations of disease, a shift in the understanding of disease causation occurred, making health status the responsibility not only of the physician, who ensures health with curative treatments, but also of the individual, whose choice of lifestyle plays an important role in preventing disease.

The Lalonde report set the stage for the World Health Organization meeting in which the Ottawa Charter for Health Promotion (World Health Organization, 1986) was developed. This pivotal report was a milestone in international recognition of the value of health promotion. The report outlined five specific strategies (actions) for health promotion:

 Develop healthy public policy.

 Develop personal skills.

 Strengthen community action.

 Create supportive environments.

 Reorient health services.

In the United States, the Lalonde report formed the foundation for Healthy People: The Surgeon General’s Report on Health Promotion and Disease Prevention (U.S. Department of Health and Human Services, 1979), which sets national goals for reducing premature deaths (Healthy People is discussed in the next section). In the subsequent 50 years since the first Healthy People report, the focus on the root causes of premature illness and death now include an understanding of the social determinants of health. Choices individuals make about individual health behaviors are determined not only by personal choice but by opportunities or lack thereof in the places that they live, work, and play.

In 1997, the Jakarta Declaration on Leading Health Promotion into the 21st Century (World Health Organization, 1997) added to and refined the strategies of the Ottawa Charter by articulating the following priorities:

 Promote social responsibility for health.

 Increase investment for health developments in all sectors.

 Consolidate and expand partnerships for health.

 Increase community capacity and empower individuals.

 Secure an infrastructure for health promotion.

The Jakarta Declaration gave new prominence to the concept of the health setting as the place or social context in which people engage in daily activities in which environmental, organizational, and personal factors interact to affect health and well-being. No longer were health programs the sole province of the community or school. Various settings were to be used to promote health by reaching people who work in them, by allowing people to gain access to health services, and through the interaction of different settings. Most prominently, workplaces and healthcare organizations as well as schools and communities were now seen as sites for action in health promotion (World Health Organization, 1998).

Health Promotion Programs

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