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6 Controllable Risk Factors for Chronic Illness

Genetics are not fate, and that’s good news for providers and patients alike. While family health history does play a role in developing a chronic illness, many risk factors are controllable. People with a higher predisposition for conditions such as heart disease, obesity, or osteoporosis, for example, can take steps to manage or prevent chronic illness.

Healthcare providers have an important function in educating and equipping patients to reduce their disease risk. Early interventions and self-management tools help put patients on the path toward better lifelong health. Likewise, preventative care programs, like Chronic Care Management (CCM), provide the framework to help patients and providers better manage chronic disease risk. 

In this article, we will identify six controllable risk factors for chronic disease and provide suggestions for managing each. We will also examine the critical ways you can support risk factor management in your practice, including through programs like CCM. 

What are controllable risk factors?

Controllable risk factors are modifiable behaviors and lifestyle choices that significantly influence a person's risk of developing chronic diseases. Unlike fixed factors such as age, sex, or genetics, these risks can be reduced through targeted interventions and sustained behavior change. Common controllable risk factors include poor nutrition, physical inactivity, tobacco use, excessive alcohol consumption, inadequate sleep, and chronic stress.

Addressing these risk factors early can slow disease progression, improve treatment outcomes, and in some cases, prevent the onset of chronic conditions altogether. For healthcare providers, identifying and managing these risks is a key component of preventive care.

6 controllable risk factors of chronic illness 

The presence of the following factors puts patients at increased risk of developing a chronic disease like hypertension, chronic depression, or diabetes. Addressing these factors through lifestyle adjustments improves patients’ health outlook and reduces their risk of developing a serious condition.

1. Poor nutrition 

Diets high in saturated fats, red meat, and highly processed foods all put patients at an increased risk of chronic diseases, including heart disease, hypertension, and obesity. Many people can benefit from a low-fat, vegetable-rich diet balanced with lean proteins and whole fruits and grains. Patients can also better their health by following individualized diets recommended by their provider for their specific health needs.

2. Lack of exercise

Too little physical activity is a top risk factor for many chronic diseases. Regular exercise keeps the heart and lungs functioning correctly, maintains a healthy weight, and improves mood and mobility. Incorporating regular age- and ability-appropriate activity can help stave off the risk of developing a chronic disease. 

3. Excessive alcohol use

Consuming too much alcohol can contribute to high blood pressure, organ inflammation, and reduced immune function. Patients who struggle with excessive alcohol use are also at heightened risk of developing certain cancers. Reducing alcohol consumption is an important step in risk management. 

4. Smoking and tobacco use 

Just like alcohol, smoking and tobacco use also damage organs, including the heart, lungs, and blood vessels. The risk of developing chronic diseases like lung cancer, stroke, type 2 diabetes, and heart disease is heightened for people who smoke. For these patients, reducing exposure to secondhand smoke or engaging in a smoking cessation program can help curb risk. 

5. Poor sleep hygiene

Sleep plays a critical role in mind and body recovery, immune system function, hormone regulation, mood management, and cognitive function. Patients who experience consistent sleep deprivation face a higher risk of developing serious chronic conditions, like cardiovascular disease, chronic anxiety and depression, and inflammatory diseases, among others. Sleep hygiene can be improved through behavior changes, like limiting screen time before bed, establishing a consistent sleep schedule, managing stress, incorporating consistent exercise, and reducing alcohol and caffeine consumption. 

6. Unmanaged stress 

Stress is a normal part of life, but unmanaged stress can lead to many health issues. Having a heightened level of cortisol in the body takes a toll on digestion, mental health, hormone regulation, and other essential functions. To prevent stress-related chronic diseases, such as gastrointestinal disorders and inflammatory conditions, patients can nourish healthy relationships, practice mindfulness, exercise, and seek mental health support—all of which improve chronic disease outlook. 

The role of controllable risk factors in disease prevention

Unhealthy vital signs such as high blood pressure, unhealthy weight, and high cholesterol drive chronic illness progression. Managing lifestyle factors, like alcohol or tobacco use, that spike these key metrics, is one of the best ways to prevent disease. With just a few behavior changes, patients can dramatically improve their long-term risk profiles.

For example, in a study of the link between physical activity and cardiovascular risk, researchers found that for every 1 metabolic equivalent (MET) increase in exercise capacity, patients can reduce their mortality risk by 10 to 20 percent.

Likewise, establishing a healthy diet can improve sleep and help patients maintain a healthy weight, both of which reduce the underlying drivers of chronic disease. In a study at the University of Michigan, researchers discovered that participants who increased their intake of fruits and vegetables reported better sleep quality and improvements in insomnia.

By addressing controllable risk factors early, you and your patients can work together to prevent the onset of chronic disease. 

Why healthcare providers should focus on risk factor management

There are many reasons to prioritize risk factor management. Better health offers compelling advantages, both for patients and for your practice. 

For patients, a reduced risk of chronic disease may mean: 

• Fewer hospital visits 
• More time with loved ones
• Greater mobility and independence 
• Less pain and discomfort 
• Ability to participate in activities that bring joy 
• Improved mood and mental health

By supporting risk management, you can improve health outcomes and quality of life for your patients. At the same time, reducing patients’ chronic illness risk offers advantages for providers too, including: 

• Lower healthcare costs 
• Better patient satisfaction 
• Improved resource and workforce efficiency 
• Better population health for the communities you treat 
• Strong reputation for quality preventive care 
• Improved quality scores for ACOs or shared savings programs

From both a provider and patient perspective, focusing on risk factor management is a common-sense choice that offers tremendous benefits. 

The role of CCM in risk factor management

Chronic Care Management is a Medicare program designed to support better health outcomes for patients with multiple chronic conditions. This comprehensive, preventative care framework provides essential tools to help patients and providers manage disease risks and prevent additional chronic conditions. 

Here’s a closer look at the ways CCM supports risk factor management. 

1. Self-management support

CCM is designed to put patients in the driver’s seat of their health journey. Patient education via email, mail or text and monthly outreaches via phone build understanding while also offering patients a platform to voice questions and concerns. The Centers for Medicare & Medicaid Services (CMS) also require the use of an Electronic Health Record (EHR), which offers the transparency and data access patients need to address controllable risk factors. Care managers will share patients’ care plans and care goals with them, as well as inform patients’ providers when the EHR needs to be updated. 

2. Personalized care plans 

As part of CCM, patients receive individualized care plans with unique goals and recommendations. Since these care plans are tailored to patients’ conditions, lifestyles and risk factors, they improve the chances of patient compliance. Reasonable goals and benchmarks encourage patients to adopt healthy habits that reduce their risks of chronic disease. 

3. 24/7 access to care 

The traditional model of healthcare reacts to, rather than prevents, acute incidents. CCM improves on that status quo by supporting a proactive, preventive care approach. 24/7 access  to care, even on nights and weekends, is a Chronic Care Management requirement. Patients can call with care concerns, and care managers can help them find transportation services, food pantries, exercise classes, or other resources they may need. They can also assist with refilling medications, scheduling appointments, and addressing symptoms patients are concerned about before they escalate.  

4. Medication management 

Some chronic conditions, such as diabetes, asthma, and depression, require precise medication alignment. CCM includes ongoing follow-ups with patients on their medications. Care coordinators can report to providers when medications have changed so providers can evaluate how they interact and their efficacy in managing risk factors. In this way, Chronic Care Management helps providers keep a close watch on patient symptoms and adjust medications before health issues contribute to additional chronic conditions. 

5. Care coordination

At the heart of Chronic Care Management is an effort to ensure patients receive seamless, well-coordinated care across providers. CCM programs support proactive communication between care teams and a unified plan of action. For example, a care coordinator can check in on whether a patient has visited a specialist or an urgent care and report that visit to the CCM provider. For the patient, care coordination means fewer gaps in care, a better experience, and a decrease in redundant tests and appointments. 

How ChartSpan can support your practice with CCM

Each element of ChartSpan’s CCM program plays a role in supporting lifestyle and behavioral changes, helping patients reduce their risk of chronic illness through sustained support and timely interventions.

However, implementing a CCM program—and managing it well—can be a massive undertaking. Partnering with a CCM provider brings the benefits of care management within reach. As a fully managed CCM provider, we offer the technology, staff, and Medicare-compliant processes to support your practice. Here’s how we help providers like you prioritize risk factor management. 

• Dedicated care manager: ChartSpan assigns a dedicated care manager to each patient enrolled in our program. This critical role helps patients seamlessly navigate care, make sense of diagnoses, and escalate concerns or changes to providers. They also proactively engage the patient to improve adherence to care plans and medications. 
• 24/7/365 care line: Day or night, your patients can access our phone line, staffed by an expert care team. This convenient channel allows patients to report health concerns or ask questions. The care team can escalate concerns to providers as needed. By improving provider-patient communication, ChartSpan helps you better manage acute incidents and empower patient self-management of risks. 
• Patient education support: We supplement provider visits with patient education on diagnoses and treatments. Armed with a clear understanding of their conditions and risks, patients become better equipped to follow recommendations and seek help when needed. 
• Care plan access: ChartSpan ensures personalized care plans are always accessible to the patient. Instead of trying to recall what a provider shared in an appointment, patients can return to the care plan when needed. We also monitor care plans, identify areas where adjustments may be needed, and loop in providers to oversee changes. 
• Patient communication and follow-ups: From appointment and medication refill reminders during monthly touchpoints to digital outreaches, we facilitate consistent communication with patients. Timely notifications help patients stay on top of their health goals. If additional assistance is needed, ChartSpan can help patients schedule visits, submit medication requests, find Social Determinant of Health resources, and set new care goals.

Managing controllable risk factors for chronic disease can mean improved quality of life and better outcomes for patients and lower costs and higher quality scores for providers. A preventive approach, aided by a Chronic Care Management program and a full-service partner like ChartSpan, can help you realize these benefits and improve the care your practice delivers.

Interested in exploring our CCM services? Learn more about the way we support providers and patients. 

You may also like: 

• 10 Top Chronic Disease Risk Factors
• Managing Multiple Chronic Conditions: A Guide to Patient Care
• 7 Challenges in Delivering High-Quality Care to Patients with Chronic Conditions