STEPS TO A HEALTHIER U S :

The Power of Prevention

A PROGRAM AND POLICY PERSPECTIVE

2003

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

FOREWORD

As public policy makers, we seek compelling arguments to drive our decisions—

arguments that show our actions will have short- and long-term benefits. I am

convinced that preventing disease by promoting better health is the only smart

policy choice for our future.

President Bush is convinced, too. He created HealthierUS, an initiative to

improve the health of all Americans by providing credible, accurate information

to help us live healthier lives.

In support of the President’s initiative, I am leading a new department-wide

effort—Steps to a HealthierUS. The heart of this program is personal

responsibility for the choices Americans make and social responsibility to ensure

that policy makers support prevention programs that foster healthy behaviors.

Steps envisions a healthy, strong United States—where diseases are prevented

when possible, controlled when necessary, and treated when appropriate. Steps is

a bold shift in our approach to the health of our citizens, moving us from a

disease care system to a health care system. As this document demonstrates, we

can no longer sustain the skyrocketing health care costs that over-reliance on

treatment has created, nor can Americans sustain the suffering that preventable

diseases cause.

Please take a few minutes to read this volume and consider our case for

strengthening the emphasis on prevention in America. If you have seen the light

of prevention, please use this document as a tool to bring other leaders in your

community along as we take steps to a healthier US.

Tommy G. Thompson

Secretary of Health and Human Services

U.S. Department of Health and Human Services

The Power

of Prevention

WE FACE AN EPIDEMIC OF UNPARALLELED PROPORTIONS . . .

More than ever, it is critical that we, as a nation, step up prevention efforts to fight chronic disease.

In recent years, we have become increasingly aware of the burden of illness and death caused by

chronic diseases such as cancer, diabetes, heart disease, stroke, and obesity, and of the connection

between these chronic diseases and lifestyle choices such as tobacco use, poor diet, and lack of

exercise. Despite this awareness, however, we are in the midst of a chronic disease epidemic of

unparalleled proportions. This epidemic is fueled both by the aging of the U.S. population and by

the poor lifestyle choices that Americans continue to make.

These hard facts substantiate the health crisis that chronic diseases have created in the United

States:

• More than 1.7 million Americans die of a chronic disease each year, accounting for about 70%

of all U.S. deaths.

• Five chronic diseases—heart disease, cancer, stroke, chronic obstructive pulmonary disease (e.g.,

asthma, bronchitis, emphysema), and diabetes—cause more than two-thirds of all deaths each

year.

• Chronic disease is not just an issue among older adults. One-third of the years of potential life

lost before age 65 is due to chronic disease.

1

U.S. DEPARTMENT OF HEALTH AND

HUMAN SERVICES

Source: McGinnis JM, Foege WH. Actual causes of death in the

United States. JAMA 1993; 270:2207–12

0 5 10 15 20

Illicit drug use

Motor vehicles

Sexual behavior

Firearms

Pollutants/toxics

Infectious agents

Alcohol

lack of excercise Poor diet/

Tobacco

Percentage (of all deaths)

19

14

5

4

3

1

1

1

2

Figure 2. Actual Causes of Death,

United States, 1990

Boldface type indicates chronic disease or condition.

Source: National Center for Health Statistics. Mortality Report.

Hyattsville, MD: U.S. Department of Health and Human Services,

2002.

Figure 1. Most Common Causes of

Death, United States, 2000

0 5 10 15 20 25 30

Nephritis and nephrosis

Alzheimer's disease

Influenza and pneumonia

Diabetes mellitus

Unintentional injuries

pulmonary diseases

Chronic obstructive

Stroke

All cancers

Diseases of the heart

Percentage (of all deaths)

29.5

22.9

6.9

5.1

3.8

2.7

2

1.5

2.8
The number of deaths alone, however, fails to convey the full picture of the toll of chronic disease.

More than 125 million Americans live with chronic conditions, and millions of new cases are

diagnosed each year. These serious diseases are often treatable but not always curable. Thus, an

even greater burden befalls Americans from the disability and diminished quality of life resulting

from chronic disease.

Chronic, disabling conditions cause major limitations in activity for 1 of every 10 Americans, or 30

million people.

• Arthritis or chronic joint symptoms is the number one cause of disability, affecting nearly 1 of

every 3 adults in the United States.

• Stroke has left 1 million Americans with disabilities; many can no longer perform daily tasks,

such as walking or bathing, without help.

• Diabetes is the leading cause of kidney failure and of new blindness in adults. More than 60%

of leg and foot amputations unrelated to injury are among people with diabetes.

• Asthma causes 400,000–500,000 hospitalizations, 14 million missed school days, and 100

million days of restricted activity each year.

Almost every American is adversely affected by chronic disease in one way or another—through the

death of a loved one; a family member's struggle with lifelong illness, disability, or compromised

quality of life; or the huge personal and societal financial burden wrought by chronic disease.

When we measure our nation’s health, by the length of life

or by the quality of that life . . .

. . . we cannot afford to ignore the urgency of chronic disease.

HEALTH CARE SPENDING IS ON THE RISE . . .

Our nation spends more on health care than any other country in the world. In 1980, the nation's

health care costs totaled $245 billion—an average of $1,066 for each American. In 2001, the total

health care cost was an astounding $1.4 trillion. This is an average of $5,035 for each American.

Chronic disease accounts for roughly 75% of health care costs each year. According to the latest

available figures,

• The estimated cost of cardiovascular disease and stroke in 2003 is $351.8 billion. Of this

amount, $209.3 billion is due to direct medical costs and $142.5 billion to lost productivity.

• In 2000, the total cost of obesity was estimated to be $117 billion. Of this amount, $61 billion

was due to direct medical costs and $56 billion to lost productivity.

• The estimated cost of cancer in 2002 was $171.6 billion. Of this amount, $60.9 billion was due

to direct medical costs and $110.7 billion to lost productivity.

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• The estimated cost of

diabetes in 2002 was

$132 billion. Of this

amount, $91.8 billion

was due to direct

medical costs and $39.8

billion to lost

productivity.

• The estimated cost of

arthritis in 1995 was

$82 billion. Of this

amount, more than $22

billion was for direct

medical care and $60

billion for lost

productivity.

• The cost of asthma to

the U.S. economy in

1998 was estimated to

be $12.7 billion.

Chronic disease risk factors also place huge economic demands on our nation.

• Direct medical expenditures attributed to smoking total more than $75 billion per year. In

addition, smoking costs an estimated $80 billion per year in lost productivity.

• In 2000, health care costs associated with physical inactivity were more than $76 billion.

• Each year, over $33 billion in medical costs and $9 billion in lost productivity due to heart

disease, cancer, stroke, and diabetes are attributed to poor nutrition.

Why is health care for chronic

disease so costly?

Because of breakthroughs in science and

technology and improvements in

environmental and social conditions,

Americans are living longer than ever

before. In 1950, the average life

expectancy was 59 years; today it is

nearly 77 years.

The percentage of the population over

age 65 has grown dramatically and will

continue to do so. Since 1900, the

number of people in America aged 65

years or older has increased 11-fold,

from more than 3 million to nearly 35

million. The number of Americans aged

3

Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population.

Washington, DC: Watson Wyatt Worldwide, 1996.

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

>80

10-14 

15-19 

20-24 

25-29 

30-34 

35-39 

40-44 

45-49 

50-54 

55-59 

60-64

70-74 

75-79 

5-9 

65-69

Women

Men

Dollars

Age in Years

0-4 

Figure 3. Estimated Per Capita Health

Expenditures, by Age and Sex, 1995

Figure 4. Percentage of U.S. Population

Over 65 Years of Age

Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging

Population. Washington, DC: Watson Wyatt Worldwide, 1996.

1930 1950 1970 1990

Year

2010 2030 2050

0

5

10

15

Percent

20

25

Projected
65 years or older is expected to double to 70 million people over the next 30 years. Because older

adults typically require more health care than their younger counterparts, medical costs will increase

as the population ages. Health care expenditures for a 65-year-old are now 4 times those of a 40-

year-old. By 2030, health care spending will rise by 25%, before taking inflation or new

technologies into account, simply because more Americans will be older.

We have also experienced a recent explosion in health care technology. We point proudly to the

past century's advancements in medical technology, many of which have enabled better diagnosis

and treatment. However, these advances do not come cheaply; in fact, they account for about 60%

of the increased cost of health care.

Inflation has also taken its toll on rising health care costs, adding another 20% to the total bill.

If current policies and conditions hold true, by the year 2011, our nation

will be spending over $2.8 trillion on health care . . .

. . . we cannot afford this escalating cost.

THE POWER OF PREVENTION . . .

Although chronic diseases are among the most common and costly of all health problems, they are

also among the most preventable. The following examples show what targeted investments in

prevention can achieve:

• About 90% of middle-aged

Americans will develop high

blood pressure in their lifetime,

and nearly 70% of those who

have it now do not have it under

control. Lowering blood pressure

levels reduces risk of death from

coronary heart disease, stroke,

and total cardiovascular disease.

• Regular screening for colorectal cancer can reduce the number of people who die of this disease

by at least 30%. Regular mammograms can dramatically reduce a woman's risk of dying of

breast cancer. A mammogram every 1–2 years can reduce this risk by about 16% for women

aged 40 years or older.

• Preventive efforts can benefit the 17 million Americans with type 1 or type 2 diabetes. Research

has shown that improved glycemic control leading to a 1% reduction in results of A1C blood

tests reduces the risk of developing microvascular diabetic complications (eye, kidney, and nerve

disease) by 40%. Regular eye exams and timely treatment could prevent up to 90% of diabetesrelated blindness. Health care services that include regular foot examinations and patient

education could prevent up to 85% of diabetes-related amputations.

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Access to high-quality and affordable

prevention measures (including

screening and appropriate follow-up)

is essential if we are to save lives and

reduce medical care costs.
• People who are obese (body mass index ≥ 30) have

a 50% to 100% greater risk of premature death

from all causes than do people at a healthy weight.

Three modifiable health-damaging behaviors—

tobacco use, lack of physical activity, and poor eating

habits—are responsible for much of the inordinate

suffering and early death of millions of Americans. In

fact, approximately 33% of all U.S. deaths (about

800,000 deaths each year) can be attributed to these

behaviors. Additionally, alcohol consumption, mainly

heavy drinking, is associated with 5% of these deaths.

Tremendous achievements in health are possible if we

focus on the risk factors that underlie chronic disease.

• The health benefits of quitting smoking are

numerous, and many are experienced quickly.

Within several months, coughing and other

respiratory symptoms decrease and lung function

increases. One year after quitting, excess risk for

heart disease is reduced by half; risk for stroke is

reduced after 5 years of not smoking. Ten years

after quitting, the lung cancer death rate is about

half that of a current smoker; 15 years after

quitting, an ex-smoker's risk for heart disease is about the same as that of a lifelong nonsmoker.

• Lifestyle changes in diet and exercise to promote losses of 5% to 7% in body weight can prevent

or delay the onset of type 2 diabetes for Americans at high risk for the disease—those defined

as prediabetic. Participants in a major clinical trial group exercised at moderate intensity, usually

by walking an average of 30 minutes a day, 5 days a week, and lowered their intake of fat and

calories. Their efforts resulted in an average weight loss of 10–15 pounds, reducing their risk for

diabetes by 58%.

• Regular physical activity helps control weight and reduces a person’s risk for heart attack, colon

cancer, diabetes, and high blood pressure. Physical inactivity is a leading contributor to disease

and disability, accounting for 22% of colon cancer, 18% of osteoporotic fractures, and 12% of

diabetes and hypertension.

• Increased consumption of fruits and vegetables helps reduce the risk for heart disease and

certain cancers.

If we are serious about improving the health and quality of life of

Americans AND keeping our health care

budget under control . . .

. . . we cannot afford to ignore the power of prevention.

5

1991

MA

NJ

RI

CT

DE

MD

NH

VT

2000

CT

DE

MA

MD

NH

NJ

RI

VT

No data

available

<10% 10%–14.9% 15%–19.9% ≥20%

*Body mass index ≥ 30, or ~ 30 pounds overweight for a 5’ 4”

person.

Source: CDC, Behavioral Risk Factor Surveillance System.

Figure 5. Percentage of Adults

Who Are Obese,* by State
A VISION FOR PREVENTION

Despite the evidence that prevention works,

the focus in our health care system over the

past century has not been on prevention of

chronic disease, but on treatment of shortterm, acute health problems. As a nation,

we have emphasized expensive cures for

disease rather than cost-effective

prevention. In addition, our health care

system is not designed to meet the needs of people with chronic illnesses.

At the heart of our system is the traditional physician-patient interaction. While effective, these

interactions occur infrequently at best and typically last no longer than 30 minutes every several

months. Whether sick or well, a person spends far more time making independent decisions—

outside of the physician's office—that affect his or her health and does so with minimal training or

information. This is particularly true for the 40.5 million uninsured Americans under the age of 65,

who have very limited access to health care

services.

With a community-based public health

infrastructure that embraces prevention as a

priority, we can become a healthier nation.

Many Americans could enjoy 5–7

additional years of healthy life and avoid

the costs associated with chronic disease if

we improve access to quality health care

services, emphasize healthy behavior, and

focus on broad policies and strategies that

offer the greatest good for the greatest number of people at the lowest cost.

The U.S. Department of Health and Human Services (HHS), through its many agencies, has a

vision of a nation in which all people lead long, healthy, satisfying lives in an increasingly diverse

society. To realize this

vision, we must harness

the collective capacity

and energy of families,

communities, health care

professionals, voluntary

and professional

organizations, the

private sector, other

governmental agencies,

and academic institutions. HHS is leading

the nation to a healthier

future through its new

initiative, Steps to a

HealthierUS.

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The function of protecting and

developing health must rank even

above that of restoring it when it is

impaired.

—Hippocrates

Prevention is the right cause, the

right issue, the right time.

— Tommy G. Thompson

Secretary, U.S. Department of Health and Human Services

U.S. Department of Health and Human Services Agencies

• Administration for Children and Families (ACF)

• Administration on Aging (AoA)

• Agency for Healthcare Research and Quality (AHRQ)

• Centers for Disease Control and Prevention (CDC)

• Centers for Medicare & Medicaid Services (CMS)

• Food and Drug Administration (FDA)

• Health Resources and Services Administration (HRSA)

• Indian Health Service (IHS)

• National Institutes of Health (NIH)

• Substance Abuse and Mental Health Services Administration

(SAMHSA)
STEPS TO A HEALTHIERUS

At the heart of the Steps to a HealthierUS initiative lie both personal responsibility for the choices

Americans make and social responsibility to ensure that policy makers support programs that foster

healthy behaviors and prevention. These steps include

Promote health and wellness programs at schools and work sites and in faith- and

community-based settings.

Developing chronic diseases is not an inevitable consequence of aging; in many cases, their origins

are grounded in health-damaging behaviors practiced by people every day for much of their lives.

Evidence indicates that with education and social support, people can and will take charge of their

health. The national agenda must call for programs that focus on individual responsibility and

behavior change, such as the following:

• School health programs that provide environments and instruction that promote healthy eating,

daily physical activity, and the avoidance of tobacco, alcohol, and illicit drugs.

• Smoking cessation strategies, such as improved access to quit lines, improved insurance

coverage of smoking cessation services, and greater involvement of health providers and health

care systems in the routine delivery of cessation advice and services to patients who want to quit

smoking.

• Physical activity strategies such as motivational signs and reminders placed near elevators and

escalators encouraging the use of stairs for health benefits or weight loss.

• Faith- and community-based programs that bring together community health advisors, nurses,

and church representatives to support, encourage, and help people to obtain cancer-screening

services and to navigate the health care system.

Enact policies that promote healthy environments.

Policy and environmental changes can affect large segments of the population simultaneously.

Adopting healthy behaviors is much easier if we establish supportive community norms and health

policies. The national agenda must call for proven health promotion measures such as

• Safe walking and cycling trails.

• Low-fat/high-fruit-and-vegetable menu selections in restaurants, schools, and employee

cafeterias.

• Incentives to schools for physical education.

• Smoke-free policies in workplaces and public areas.

• Universal availability of 911 emergency services for stroke and heart attack care.

Ensure access to a full range of quality health services.

Physicians and other health care practitioners play a critical role in providing chronic disease

screening and early detection services. They are also uniquely positioned to influence patients to

adopt healthy behaviors that help prevent chronic disease. The national agenda must call for

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• Improved access to effective screening and

diagnostic tools for breast, cervical, and

colorectal cancers; diabetes; high blood

pressure; and high cholesterol.

• Better training and education of health care

professionals to close the gap in time between

discovering effective prevention tools and

strategies and applying these tools in medical

practice.

• Public and private health insurance programs

that provide appropriate chronic disease

prevention, screening, and treatment services.

• Training to empower patients to manage

their chronic conditions effectively.

Implement programs that focus on

eliminating racial, ethnic, and

socioeconomic-based health disparities.

Of utmost importance is a constant vigilance to

reduce health disparities among racial and ethnic

groups. These disparities are reflected in

differences in length of life; rates of disease, disability, and death; severity of disease; and access

to treatment.

• In 1999, death rates from heart disease were 29% higher and death rates from stroke were

40% higher among African American adults than among white adults.

• American Indians and Alaska Natives are 2.6 times more likely, African Americans are 2

times more likely, and Hispanics are 1.9 times more likely to have diagnosed diabetes than

whites.

• African American women are more likely to die of breast cancer than are women of any

other racial or ethnic group.

• Nearly half of African American women are classified as obese.

Prevention research is needed to identify the causes of health disparities and the best ways to

provide access to high-quality preventive care and clinical services. Effective programs will

require new and innovative partnerships among federal, state, local, and tribal governments and

communities.

Educate the public effectively about their health.

Scientific evidence indicates the public listens to and acts on clear, compelling health information.

We must use communication strategies to inform and influence individual and community

decisions on health. Scientific approaches to social marketing, health education, and consumer

research must be applied to public health initiatives—everything from simple brochures to public

service announcements to comprehensive media campaigns. We must market health effectively,

just as corporations market their products and images.

8

*Percentage of women 50 or older who reported they had a

mammogram within the previous 2 years.

Source: CDC, Behavioral Risk Factor Surveillance System.

Figure 6. More Women at Risk Are

Having Mammograms*

No data <60% 60% – 69.9% 70% – 79.9%

available

≥ 80%

2000

CT

DC

DE

MA

MD

NH

RI

VT

NJ

1991

CT

DE

NH

RI

VT

MA

MD

DC

NJ
MEETING THE CHALLENGE

At the turn of the 20th century, the major causes of illness and death were infectious diseases such

as pneumonia, influenza, and tuberculosis. Thanks to vaccines, environmental and social

improvements, and technological developments, these diseases pose a much smaller threat to the

health of our nation.

This same accomplishment is possible for chronic disease. As a nation, we have the capability and

the expertise to meet the unique challenges of the leading causes of death, disease, and disability.

Now we need a concerted, focused effort to apply what we know about prevention and treatment.

The national prevention agenda is clear. With the collective will for its implementation, HHS and

a host of public and private organizations joined in spirit and vision can lead the nation to a day

when preventable disease is yet another chapter in public health history that is successfully closed.

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