Structural Interventions for Addressing
Chronic Health Problems
Mitchell H. Katz, MD
HE CHRONIC HEALTH PROBLEMS OF OBESITY, DIABE-
tes, heart disease, and cancer commonly affect
adults living in developed countries and are both
difficult to treat and costly, leading experts to
stress the importance of prevention.
Elimination of the 3
behavioral risk factors of sedentary lifestyle, poor diet,
and smoking would decrease mortality by 35%.
do we get individuals to exercise more, eat better, and
Health education has been effective in diminishing these
risk factors, especially smoking, but education alone is un-
likely to bring further progress. In fact, it would be diffi-
cult to find a sedentary obese smoker who did not know
that he should exercise more, eat less, and stop smoking.
Intensive one-to-one and group behavioral interven-
tions have been demonstrated to increase activity,
and promote smoking cessation,
but effects have
been modest and difficult to maintain. Moreover, translat-
ing these findings into practice has been hampered by in-
sufficient funding and difficulty reaching those persons in
Structural interventions offer a complementary ap-
proach to improving health by focusing on changing the
physical, social, and economic environment.
tions are structural in that, unlike individualized interven-
tions, persons do not enroll or even know that they are par-
Structural interventions are not a new idea. The increase
in longevity that occurred in the early 20th century was
largely due to physical improvements in the environment
(eg, sewage treatment) and at work sites (eg, safer equip-
ment). Other successful structural interventions include seat
belts in cars, road safety standards, elimination of toxins such
as lead in paint and gasoline, and water fluoridation. What
is new, and potentially more challenging, is the use of struc-
tural interventions for chronic diseases.
Structural Interventions to Increase Physical