REVIEW

The Burden of Chronic Disease

Karen Hacker, MD, MPH

Abstract

Chronic diseases like diabetes, heart disease, stroke, and cancer have been and continue to be some of the
major causes of worldwide morbidity and mortality. A transition between infectious and non-
communicable diseases occurred in the early 1900s as a result of improved public health and has persisted
ever since. Now, as individuals live longer, the prevalence and cost of chronic disease continue to grow.
The estimated cost of chronic disease is expected to reach $47 trillion worldwide by 2030. Individual
lifestyle and behaviors and community factors play important roles in the development and management
of chronic diseases. Many of these conditions (diabetes, heart disease, and respiratory diseases) are pre-
ventable, and their leading risk factors are physical inactivity, poor nutrition, tobacco use, and excessive
alcohol. Unfortunately, the investment in prevention remains small compared with treatment, both from a
lifestyle perspective and a social determinants of health perspective. Given the future trajectory of chronic
disease, innovation in technology and pharmaceuticals with a concomitant investment in prevention will
be required. Our future depends on it.
Published by Elsevier Inc on behalf of Mayo Foundation for Medical Education and Research. This is an open access article under the CC BY-NC-
ND license ([Link] n Mayo Clin Proc Inn Qual Out 2024;8(1):112-119

From the National Center for

C
hronic diseases like diabetes, heart were identified as major risk factors for severe
Chronic Disease Prevention
and Health Promotion, Cen- disease, stroke, and cancer are some morbidity and mortality from COVID-19.8
ters for Disease Control and of the major causes of morbidity Part of the challenge moving forward is the
Prevention, Atlanta, GA and mortality in the United States.1 This has demographic characteristic shift occurring in
(K.M.).
been true since the early 1900s when there the United States and around the world.
was an epidemiologic transition from infec- Longer lives and lower birth rates have trans-
tious disease to noncommunicable diseases.2 lated to an increase in the average population
This transition was partly due to improved age.9 For example, the average age in the
nutrition, sanitation, and other public health United States was 29.5 in 1960 and in 2021
successes and medical technology and innova- it was 38.6.10 As the population ages, so does
tion. Since 1950, heart disease has been the the prevalence of chronic disease. In addition,
leading cause of death in the United States.3 many individuals have multiple chronic condi-
Worldwide, this transition has also taken tions. In 2018, it was estimated that 27% of
place, although often at a different pace adults in the United States had multiple
depending on the individual country. Today, chronic conditions.11 The cost of chronic dis-
chronic noncommunicable disease is the lead- ease to the American medical system is enor-
ing cause of death worldwide.4 mous, accounting for more than $1 trillion
In the past several years, COVID-19 and every year.12 Chronic disease accounts for the
the diseases of despair, such as overdose, sui- overwhelming percentage of preventable deaths
cide, and excessive alcohol use,5,6 have and disabilities in the United States and around
contributed to a decline in the American life- the world. According to the World Health
span. However, chronic diseases remain 8 of Organization, 63% of worldwide deaths in
the 10 leading causes of death in the United 2008 were caused by major preventable dis-
States.6,7 Even in the context of COVID-19, eases (cardiovascular disease, cancer, chronic
heart disease and cancer accounted for nearly respiratory diseases, and diabetes).13 In 2011,
40% of all US deaths in 2022.6 It is also the cost of chronic disease worldwide was esti-
important to remember that COVID-19 inter- mated to reach $47 trillion by 2030.14
acted extensively with chronic diseases. These In addition to an older population, there
diseases, such as diabetes and heart disease, are numerous risk factors that involve

112 Mayo Clin Proc Inn Qual Out n February 2024;8(1):112-119 n [Link]
[Link] n Published by Elsevier Inc on behalf of Mayo Foundation for Medical Education and Research. This is an open access article
under the CC BY-NC-ND license ([Link]
THE BURDEN OF CHRONIC DISEASE

individual behavior and lifestyle and commu-

nity factors that affect the prevention and ARTICLE HIGHLIGHTS
management of chronic disease. The leading
d Chronic diseases are among the leading causes of chronic dis-
risk factors for preventable chronic disease
are physical inactivity, poor nutrition, tobacco ease worldwide.
use, and excessive alcohol use.15 These ac- d Chronic diseases such as heart disease, diabetes, cancer, and
count for more than 50% of preventable dis- associated risk factors such as smoking and physical inactivity,
ease deaths in the United States, including increased the risk of severe COVID-19 morbidity and mortality.
those caused by cancer, chronic respiratory
d The cost of chronic disease worldwide is estimated to reach
diseases, type 2 diabetes, and cardiovascular
disease (CVD).15 However, the worldwide $47 trillion by 2030.
financial contribution to ameliorating these d Many preventable chronic diseases can be modified by
risk factors, ranging from access to healthy addressing 4 major risk factors: physical inactivity, poor nutri-
food and places to exercise to smoking cessa- tion, tobacco use, and excessive alcohol.
tion and cancer screening, is minimal. The
d Lifestyle behavior change and nonmedical factors that influence
percentage of total national health care
spending on public health initiatives in the health (social determinants of health) are critical to addressing
United States and comparable countries rising rates of chronic disease.
ranged from 1.1% to 5.9% in 2018. In the
United States, it was 2.9%.16
death both in the United States and world-
wide. In the United States, cancer is the num-
ber 2 cause of death and is responsible for 1 in
Heart Disease and Stroke every 5 reported deaths, or about 600,000
In 2020, worldwide, an estimated 523 million deaths a year.6 Of the leading cancers, the
people reported some form of CVD, and approx- number 1 cause of cancer deaths remains
imately 19 million deaths were attributable to lung cancer, followed by female breast cancer
CVD. This represents w32% of all global deaths (Figure 3). Rates vary by race and ethnicity.22
and is an absolute increase of 18.7% from The cost of cancer in the United States was
2010.17,18 In the United States in 2021, estimated at more than $180 billion in 2015,
934,509 people died of CVD (including heart with a projected increase to $246 billion by
disease and stroke, the first and fifth leading 2030.23 Worldwide, cancer is the second lead-
causes of death, respectively), a 0.6% increase ing cause of death. In 2020, almost 10 million
when compared with 2020. Figure 1 provides deaths were because of cancer.24 The leading
information on the rates of heart disease deaths cause of cancer deaths worldwide was lung
from 2010-2020 by race and ethnicity and dem- cancer, followed by colorectal cancer.25 It is
onstrates large disparities.19 Stroke was also one estimated that cancer incidence will rise by
of the leading causes of death in the United States over 40% by 2040.25The total cost of global
and 162,890 people died of stroke in 2021. cancer is estimated to reach over $25 trillion
Black adults are twice as likely to die of stroke between 2020 and 2050. In particular, 5 can-
as White adults.19 cers: tracheal, bronchial, and lung; colon and
Annual CVD costs to the nation averaged rectal; breast; liver; and leukemia, represent
$407.3 billion in 2018-2019, up from $378.0 almost half of the global cost.26
billion in 2017-2018.18 Over time, cardiovascu-
lar health has improved, but during the Diabetes
pandemic, there were slight increases in mortal- Diabetes was responsible for over 103,000
ity related to heart disease. It is hard to determine deaths in the United States in 2021. It is the
if this was due to shifts in health care access, eighth leading cause of death.27 In 2019,
medication management, or other factors.20 over 37 million people in the United States
had diabetes. Some 8.5 million adults aged
Cancer 18 years or older met laboratory criteria for
Despite downward trends in rates (Figure 2), diabetes but were undiagnosed, and an esti-
cancer remains one of the leading causes of mated 96 million adults aged 18 years or older
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 MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES

1900

1800
Death rate (per 100,000)
75+
1700

Black
Male
400

White
Overall
300 55-74
AI/AN
Female
Hispanic or latino
200
AAPI

100
35-54

2010 2015 2019 2020

Year

FIGURE 1. Heart disease death rates among adults aged
35 years of age, sex, and race and Hispanic
ethnicity groupdUnited States, 2010-2020.20

had prediabetes.27 Diabetes is growing in (Figure 5). Recent data suggest that 1 in 10 peo-
prevalence in the United States with rates ple over 45 years of age report subjective cogni-
increasing among adults from 10.3% in tive decline.35 It is estimated that 6.7 million
2001-2004 to 13.2% in 2017-2020 (Figure Americans aged 65 years and older are living
4).28 Worldwide, about 422 million people with Alzheimer disease.35 In 2022, Alzheimer
have diabetes and the prevalence has been disease was the 7th leading causes of death.6
increasing steadily.29 A total of 1.5 million In 2023, it is estimated that Alzheimer disease
deaths worldwide are directly attributed to and other dementias will cost the nation over
diabetes annually, as reported in 2019.30 Esti- $345 billion, and by 2050, cost could rise to
mates in 2016 suggested that if the trends nearly a trillion dollars.36 According to the
continue, more than 700 million adults world- World Health Organization, there are currently
wide could have diabetes by 2025.31 Cost es- more than 55 million people worldwide with
timates for the US health care system, last dementia, and every year there are almost 10
assessed in 2017, estimate a cost of $237 million new cases.34 In 2019, it was estimated
billion.32 The global health expenditure on that the burden of dementia was costing global
diabetes was estimated at $966 billion in economy $1.3 trillion.34
2021 for adults aged 20 to 79 years.33

Alzheimer Disease and Other Dementias Effect of COVID-19 Pandemic on the Burden
Alzheimer disease (which accounts for 60%- of Chronic Disease in the United States
70% of dementias)34 and other dementias The COVID-19 pandemic represented a
represent a growing issue in chronic disease major disruption to health care and
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THE BURDEN OF CHRONIC DISEASE

250.0

200.0
Rate per 100,000 people

150.0

100.0

50.0

0.0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
Year

FIGURE 2. Annual rates of cancer deaths, 1999-2019. All types of cancer, United States.21

disproportionately affected people with the pandemic, people stopped or delayed

chronic diseases. Older age, having a chronic health care.37 Partly, this was because of fear
disease (ie, diabetes, heart disease, cancer, of contracting COVID-19, but it was also
and obesity), or having some of the risk factors because of delays and changes in access.
for chronic disease (smoking and inactivity) Clinics closed, protocols changed, and indi-
put people at elevated risk for severe viduals lost insurance when businesses closed.
morbidity and mortality.8 In addition, during COVID-19 worsened chronic diseases by

Lung and bronchus 31.8

Female breast 19.1

Prostate 18.5

Colon and rectum 12.6

Pancreas 11.0

Liver and intrahepatic bile duct 6.5

Ovary 5.9

Leukemias 5.8

Corpus and uterus, NOS 5.1

Non-hodgkin lymphoma 4.9

FIGURE 3. Top 10 cancers by rates of cancer deaths United States 2019, all races and ethnicities, man and
woman.21

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Mayo Clin Proc Inn Qual Out February 2024;8(1):112-119 [Link] 115
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 MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES

14

12 Total diabetes

Age-adjusted percentage
10
Diagnosed diabetes
8

4 Undiagnosed diabetes

0
2001–2004 2005–2008 2009–2012 2013–2016 2017–2020
Time period

FIGURE 4. Trends in age-adjusted prevalence of diagnosed diabetes, undiagnosed diabetes, and total
diabetes among adults aged 18 years or older, United States, 2001-2020.28

creating what has been called a health debt.38 consumption, and physical activity. Physical
This resulted in a substantial decrease in pre- inactivity increased (at least for some of the
ventive care, such as screening for breast and population), as did alcohol consumption.41
cervical cancer.39 Long-standing health dispar- Studies suggest that childhood obesity
ities were also exacerbated during the increased during the pandemic.42 Although
pandemic. African Americans, Hispanic or the full effect of COVID-19 on individuals
Latino, Native Americans, and people experi- with existing chronic diseases is as yet un-
encing poverty bore a disproportionate known, early evidence suggests that both dia-
burden of COVID-19 morbidity and betes and heart disease increased during the
mortality.40 pandemic.41 There is even some suggestion
To add to this, COVID-19 affected lifestyle that individuals with existing chronic diseases
behaviors including nutrition, alcohol may have been more likely to get long-COVID

13.8
14
12.7
12 11.2

10
8.5
8
6.1
6

0
Millions of people Ages 65–74 Ages 75–84 Ages 85+

FIGURE 5. Projected number of people age 65 years and older (total and by age) in the US population
with Alzheimer dementia, 2020-2060.35

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THE BURDEN OF CHRONIC DISEASE

after a COVID-19 infection.43 It is also screening for social needs and developing
possible that stress and anxiety associated referral strategies with community partners.
with the pandemic played a role in lifestyle Simultaneously, community coalitions and
choices, but early data is not clear.44-47 As public health and representatives from multi-
we look to the future, it will be important to ple sectors (ie, transportation, housing, and
regain our losses and enhance prevention economic development), are aligning to
efforts. address population-based SDOH.

Supporting Lifestyle Changes and Address- The Future and Innovation

ing Social Determinants of Health The epidemiology of preventable chronic dis-
The major risk factors for all of the aforemen- eases such as cancer, respiratory conditions,
tioned chronic diseases are intimately con- type 2 diabetes, heart disease, and stroke is
nected to lifestyle changes. Healthy eating, deeply affected by shifts and changes in life-
physical activity, smoking cessation, and style related to diet, smoking, physical activity,
alcohol reduction require individual action and alcohol use. It is evident that these behav-
and lifestyle changes. The role of medical pro- iors also effect the development of Alzheimer
fessionals in supporting these lifestyle disease and other dementias.51 In addition,
behavior changes cannot be underestimated large percentages of individuals are burdened
and is an important adjunct to treatment.48 with multiple chronic conditions, further
In addition, ensuring an equitable and respect- complicating health care and health outcomes.
ful approach to care will help mitigate known As we look to the future to reduce the burden
health disparities and establish trust.49 How- of chronic disease, we anticipate continued
ever, lifestyle changes also require opportu- innovation. For example, there is an increasing
nity. In jurisdictions without opportunity, focus on the self-monitoring of biometrics
behavioral change is difficult. For example, related to physical activity, diet, and blood
when you live in a food desert, it is difficult pressure. As consumers take their health met-
to engage in healthy eating behaviors, and rics into their own hands through wearable
when there are no safe and easily accessible devices, technology applications, and auto-
places to exercise, it is difficult to enhance mated messaging, we expect to see shifts in
your physical activity. And, when your eco- the use of health care, interoperability, and
nomic circumstances, your distance to health hopefully encouraging news in behavior
care, or your access to transportation get in change and chronic disease self-management.
the way of lifestyle changes, your road to However, technology is costly, requires acces-
health is uphill. Thus, if we do not address sibility, and must be culturally competent. To
these factors, often called social determinants date, disparities exist, such as internet access,
of health (SDOH) or nonmedical factors that insurance coverage, educational awareness,
influence health, individual and population- and other contributors. These disparities
based behavioral change is elusive. The were amplified during the pandemic as spe-
SDOH as defined by the Centers for Disease cific populations, such as racial and ethnic
Control and Prevention are “the nonmedical groups, those living in low socioeconomic
factors that influence health outcomes. They conditions, and specific geographic regions,
are the conditions in which people are born, were at higher risk for severe COVID-19 out-
grow, work, live and age, and the wider set comes. To achieve health equity, these innova-
of forces and systems shaping the conditions tions must adopt nuanced strategies with
of daily life. These forces and systems include health equity in mind.
economic policies and systems, development As we look to the future regarding lifestyle
agendas, social norms, social policies, racism, changes, we will be contending with both the
climate change, and political systems.”50 challenges to prevention and the opportunities
Today, there is a movement to address both that technological innovation brings. Simulta-
the SDOH and individual health-related neously, the burgeoning pharmaceutical op-
needs. With the recognition that one’s social tions for the treatment of diabetes and
needs have a direct effect on health outcomes, obesity, for example, may make prevention
the health care system is moving toward less urgent. After all, why focus on
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Mayo Clin Proc Inn Qual Out February 2024;8(1):112-119 [Link] 117
[Link]
 MAYO CLINIC PROCEEDINGS: INNOVATIONS, QUALITY & OUTCOMES

environmental changes if treatment is avail- statistics/241494/median-age-of-the-us-population/. Accessed

April 17, 2023.
able? Without prevention, across the world, 11. Boersma P, Black LI, Ward BW. Prevalence of multiple chronic
we will likely continue to see increases in conditions among US adults, 2018. Prev Chronic Dis. 2020;17:
chronic diseases at younger ages and all the E106.
12. Waters H, Graf M, eds. The costs of chronic disease in the U.S. 1st ed.
consequent results of growing morbidity and Milken Institute; 2018. [Link]
economic consequences. This will also be a files/reports-pdf/ChronicDiseases-HighRes-FINAL_2.pdf.
challenge to lifestyle medicine given the pub- 13. World Health Organization. Global Action Plan For The Preven-
lic’s appetite for easy fixes. But, as providers tion and Control of Noncommunicable Diseases 2013-2020. 1st
ed. World Health Organization; 2013. [Link]
and public health professionals, our efforts bitstream/handle/10665/94384/?sequence¼1.
are sorely needed now more than ever. Our 14. World Economic Forum and The Harvard School of Public
Health. Methodological Appendix: The Global Economic Burden
future depends on it. of Non-Communicable Diseases. 1st ed. World Economic
Forum; 2011. [Link]
HE_GlobalEconomicBurdenNonCommunicableDiseases_
POTENTIAL COMPETING INTERESTS MethodologicalAppendix_2011.pdf.
15. Chronic disease fact sheets. Centers for Disease Control and
The author reports no conflict of interest. The Prevention. [Link]
findings and conclusions in this report are publications/[Link]. Accessed April 17, 2023.
those of the author and do not necessarily 16. Kamal R, Hudman J. What do we know about spending related
to public health in the U.S. and comparable countries. Health
represent the views of [the Centers for Disease System Tracker. [Link]
Control and Prevention. collection/what-do-we-know-about-spending-related-to-public-
health-in-the-u-s-and-comparable-countries/#Preventive%20care
%20spending%20by%20government/compulsory%20schemes
Abbreviations and Acronyms: CVD, cardiovascular dis- %20as%20a%20share%20of%20total%20national%20health%20
ease; SDOH, social determinants of health expenditures,%202018. Accessed September 14, 2023.
17. Roth GA, Mensah GA, Johnson CO, et al. Global burden of
Correspondence: Address to Karen Hacker, MD, MPH, cardiovascular diseases and risk factors, 1990-2019: update
National Center for Chronic Disease Prevention and Health from the GBD 2019 study. J Am Coll Cardiol. 2021;76(25):
Promotion, Centers for Disease Control and Prevention, 2982-3021.
4770 Buford Highway, NE Atlanta, GA 30341 (Pju3@cdc. 18. Tsao CW, Aday AW, Almarzooq ZI, et al. Heart disease and
gov). stroke statistics-2022 update: a report from the American
Heart Association. Circulation. 2022;145(8):e153-e639.
19. Multiple cause of death 2018-2021. National Center for Health
Statistics. [Link] Accessed April 18,
REFERENCES 2023.
1. Murphy Sl, Kochanek KD, Xu J, Arias E. Mortality in the United 20. Woodruff RC, Tong X, Jackson SL, Loustalot FV, Vaughan AS.
States, 2020. NCHS Data Brief. 2021;(427):1-8. Abstract 9853: Trends in national death rates from heart dis-
2. Adogu POU, Ubajaka CFE, O.F. Alutu, C.O.C. Epidemiologic ease in the United States, 2010-2020. Circulation. 2022;
transition of diseases and health-related events in developing 146(Suppl 1):A9853.
countries: a review. Am J Med Med Sci. 2015;5(4):150-157. 21. United States Cancer. Statistics Data Visualization. Centers for
3. Heart disease deaths. National Center for Health Statistics. Disease Control and Prevention. 2023: [Link]
[Link] Cancer/USCS/#/Trends/. Accessed May 10, 2023.
Accessed April 12, 2023. 22. U.S. cancer statistics data visualizations tool. Centers for Dis-
4. The top 10 causes of death. World Health Organization. ease Control and Prevention. [Link]
[Link] uscs/dataviz/[Link]#Suggested%20Citation. Accessed May
causes-of-death. Accessed April 12, 2023. 22, 2023.
5. Cohen J. Diseases of despair contribute to declining U.S. life ex- 23. Health and economic costs of chronic disease. Centers for Disease
pectancy. Forbes Healthcare. [Link] Control and Prevention. [Link]
joshuacohen/2018/07/19/diseases-of-despair-contribute-to- about/costs/[Link]#ref4. Accessed May 10, 2023.
declining-u-s-life-expectancy/?sh¼58fef150656b. Accessed 24. Sung H, Ferlay J, Siegel RL, et al. Global Cancer Statistics 2020: GLO-
September 14, 2023. BOCAN estimates of incidence and mortality worldwide for 36
6. Ahmad FB, Cisewski JA, Xu J, Anderson RN. Provisional mor- cancers in 185 countries. CA Cancer J Clin. 2021;71(3):209-249.
tality datadUnited States, 2022. MMWR Morb Mortal Wkly 25. Cancer. World Health Organization. [Link]
Rep. 2023;72(18):488-492. news-room/fact-sheets/detail/cancer. Accessed May 1, 2023.
7. Leading causes of death. National Center for Health Statistics. 26. Chen S, Zhong C, Prettner K, et al. Estimates and projections of
[Link] the global economic cost of 29 cancers in 204 countries and
Accessed April 12, 2023. territories from 2020 to 2050. JAMA Oncol. 2023;9(4):465-472.
8. People with certain medical conditions. Centers for Disease 27. National Center for Health Statistics. Diabetes. Centers for Dis-
Control and Prevention. [Link] ease Control and Prevention. 2023. [Link]
2019-ncov/need-extra-precautions/people-with-medical-con- fastats/[Link]. Accessed April 18, 2023.
[Link]. Accessed April 12, 2023. 28. National Diabetes Statistics Report 2020. Centers for Disease Control
9. Ritchie H, Roser M. Age structure. [Link]. https:// and Prevention. [Link]
[Link]/age-structure#the-global-population-pyra [Link]. Accessed September 14,
mid. Accessed April 17, 2023. 2023.
10. Median age of the resident population of the United States 29. Diabetes. World Health Organization. [Link]
from 1960 to 2021. Statista. [Link] health-topics/diabetes#tab¼tab_1. Accessed April 18, 2023.

n n
118 Mayo Clin Proc Inn Qual Out February 2024;8(1):112-119 [Link]
[Link]
THE BURDEN OF CHRONIC DISEASE

30. Diabetes Key Facts. World Health Organization. [Link] data/investigations-discovery/hospitalization-death-by-race-

[Link]/news-room/fact-sheets/detail/diabetes. Accessed April [Link]. Accessed April 20, 2023.
18, 2023. 41. Balasuriya L, Briss PA, Twentyman E, et al. Impacts of the
31. Collaboration NCDRF. Worldwide trends in diabetes since COVID-19 pandemic on nationwide chronic disease preven-
1980: a pooled analysis of 751 population-based studies tion and health promotion activities. Am J Prev Med. 2023;
with 4.4 million participants. Lancet. 2016;387(10027): 64(3):452-458.
1513-1530. 42. Jenssen BP, Kelly MK, Powell M, Bouchelle Z, Mayne SL,
32. American Diabetes Association. Economic costs of dia- Fiks AG. COVID-19 and changes in child obesity. Pediatrics.
betes in the U.S. in 2017. Diabetes Care. May 2018; 2021;147(5). [Link]
41(5):917-928. 43. Song Z, Giuriato M. Demographic and Clinical Factors Associ-
33. IDF diabetes Atlas 2022 Reports. International Diabetes Foun- ated with Long COVID. Health Aff (Millwood). 2023;42(3):433-
dation. [Link] Accessed May 442.
22, 2023. 44. Crost AD, Ceccato I, Marchetti D, et al. Psychological factors
34. Dementia. World Health Organization. [Link] and consumer behavior during the COVID-19 pandemic.
room/fact-sheets/detail/dementia#:w:text¼Currently%20more% PLoS ONE. 2021;16(8):e0256095.
20than%2055%20million%20people%20have%20dementia, 45. Cummings JR, Ackerman JM, Wolfson JA, Gearhardt AN.
dementia%20and%20may%20contribute%20to%2060%E2%80% COVID-19 stress and eating and drinking behaviors in the
9370%25%20of%20cases. Accessed April 27, 2023. United States during the early stages of the pandemic. Appetite.
35. Alzheimer’s Association. Alzheimer’s Disease Facts and Figures. 2021;162:105163.
Alzheimers Dement. 2023;19(4):1598-1695. 46. Cummings JR, Wolfson JA, Gearhardt AN. Health-promoting
36. Facts and Figures. Alzheimer’s Association. [Link] behaviors in the United States during the early stages of the
alzheimers-dementia/facts-figures#:w:text¼More%20than%206 COVID-19 pandemic. Appetite. 2022;168:105659.
%20million%20Americans%20are%20living%20with,other%20 47. Hu Z, Lin X, Kaminga AC, Xu H. Impact of the COVID-19
dementias%20will%20cost%20the%20nation%20%24345%20 epidemic on lifestyle behaviors and their association with sub-
billion. Accessed May 22, 2023. jective well-being among the general population in mainland
37. Czeisler MÉ, Kennedy JL, Wiley JF, et al. Delay or avoidance of china: cross-sectional study. J Med Internet Res. 2020;22(8):
routine, urgent and emergency medical care due to concerns e21176.
about COVID-19 in a region with low COVID-19 prevalence: 48. Jepson RG, Harris FM, Platt S, Tannahill C. The effectiveness of
Victoria, Australia. Respirology. 2021;26(7):707-712. interventions to change six health behaviors: a review of re-
38. Ruth L, Alongi J, Robitscher J. Confronting the health debt: the views. BMC Public Health. 2010;10:538.
impact of COVID-19 on chronic disease prevention and man- 49. Jack L. Advancing health equity, eliminating health disparities,
agement. Health Affairs Forefront. [Link] and improving population health. Prev ChronicDis. 2021;18:
do/10.1377/hblog20210914.220940/full/. Accessed September E79.
17, 2021. 50. Social Determinants of Health at CDC. Centers for Disease
39. Patt D, Gordan L, Diaz M, et al. Impact of COVID-19 on cancer Control and Prevention. [Link]
care: how the pandemic is delaying cancer diagnosis and treatment [Link]. Accessed May 1, 2023.
for American seniors. JCO Clin Cancer Inform. 2020;4:1059-1071. 51. Reducing Risk of Alzheimer’s Disease. Centers for Disease Con-
40. Risk for COVID-19 infection, hospitalization, and death by trol and Prevention. [Link]
race/ethnicity. Centers for Disease Control and Preven- features/reducing-risk-of-alzheimers-disease/[Link]. Accessed
tion. [Link] August 20, 2023.

n n
Mayo Clin Proc Inn Qual Out February 2024;8(1):112-119 [Link] 119
[Link]