MESSAGE FROM THE SECRETARY 

Over the past 100 years, our investment in research and technology has lead to 

unprecedented improvements in the lives of Americans. Life expectancy in the 

United States is at an all time high. Advances in medical treatment and care have 

dramatically reduced infant and childhood mortality and deaths from infectious 

diseases, trauma, and other acute medical emergencies. As a result of medical 

progress, individuals with chronic diseases are enjoying longer, more independent 

lives. Yet despite these achievements, complex chronic health problems persist in 

challenging us. 

For example, the percentage of Americans who are obese and overweight is at an 

all-time high. Obesity is a risk factor for other chronic conditions such as 

diabetes and some cancers, including cancers of the breast, colon, kidney, 

esophagus and endometrium. Along with the rise in obesity, we have seen a 

parallel increase in the incidence of type 2 diabetes. Yet, keeping to a healthy 

weight requires a healthy energy balance. While enhancing the health and wellbeing of Americans, technology has also had a major impact on our lifestyles. In 

general, labor-saving devices such as escalators, remote controls, self-propelled 

lawn mowers, electric garage openers, and moving walkways in airports have 

decreased the need for physical exertion for many Americans. At the same time, 

for most Americans, food is plentiful, with a wide variety of convenience foods at 

our fingertips, which may encourage overeating. In fact, Americans are 

consuming more calories than they did 30 years ago. Thus, maintaining a healthy 

weight becomes more difficult in the current environment where a few extra 

calories a day can add up to a significant weight gain over time. 

 

Chronic diseases and conditions account for at least 7 of every 10 deaths in the 

United States and for more than 60 percent of medical care expenditures. In 

2000, poor diet and physical inactivity, which contribute to obesity, cancer, 

cardiovascular disease and diabetes, accounted for 400,000 actual deaths in the 

U.S. Only tobacco use caused more preventable deaths (435,000). Moreover, 

many chronic diseases result in disability and decrease the quality of life for 

millions of Americans. 

Much of the chronic disease burden is preventable. Some chronic health 

problems are related to individual choices or behaviors: for example, tobacco use, 

which raises the risk of chronic obstructive lung disease, heart disease and stroke. 

People who avoid behaviors that increase their risk for chronic diseases and adopt 

healthy habits can expect to live healthier and longer lives. Often small changes--

such as physical activity for 30 minutes a day-- can result in large health benefits. 
In order for individuals to take action, they must have the right information to 

empower their lifestyle choices. A person’s health literacy is critical to acquiring 

the knowledge and understanding of health issues to make informed decisions 

regarding his/her health and well-being. Appropriate and timely health messaging 

can aid the individual in his/her quest for health information. 

I have made improving the health of Americans through physical activity and 

other prevention efforts a priority of the Department of Health and Human 

Services. Physical activity plays an essential role in promoting good health and 

preventing chronic diseases and is a leading component of President’s Bush’s 

HealthierUS initiative launched on June 20, 2002. To advance the President’s 

goal of helping American’s live longer, better, and healthier lives, I launched 

Steps to a HealthierUS initiative in 2003. At the heart of this program lies both 

personal responsibility for the choices Americans make and social responsibility 

to ensure that policy makers support programs that foster healthy behaviors and 

prevent disease. The Steps initiative envisions a healthy, strong, U.S. population 

supported by a health care system in which diseases are prevented when possible, 

controlled when necessary, and treated when appropriate. Realizing that small 

changes over time can yield dramatic results, the Steps initiative is committed to 

identifying and promoting programs that encourage small behavior changes. The 

Steps program has multiple components including grants to communities, the 

annual prevention summit, town hall meetings, the innovation in prevention 

awards program and the prevention partnership program. 

Motivated and guided by the goals of the Steps initiative, HHS agencies have 

“stepped-up” their efforts to promote healthy lifestyles and reduce the burden of 

chronic conditions. For example, the Food and Drug Administration (FDA) 

created an Obesity Working Group to develop an action plan to address critical 

dimensions of the overweight and obesity problem. The FDA’s report, “Calories 

Count”, which was released in March 2004, includes recommendations to 

strengthen food labeling, to educate consumers about maintaining a healthy diet 

and weight, to encourage restaurants to provide nutrition and calorie information, 

and to encourage the development of foods that are healthier and low in calories. 

In addition, the National Institutes of Health (NIH) established an Obesity 

Research Task Force to develop a strategic plan for obesity research. The strategic 

plan, to be released later this spring, is a cohesive, multidimensional research 

agenda that will intensify research to better understand, prevent, and treat obesity 

through: 

• behavioral and environmental approaches to modifying lifestyle; 

• pharmacologic, surgical, and other medical approaches; and 

• breaking the link between obesity and diseases such as type 2 diabetes, 

heart disease and some forms of cancer. 
However, to fully realize the benefit from technological advances, to achieve 

further gains in the health of Americans, and to reduce the burden of chronic 

disease, we must all work together to overcome obstacles and promote healthy 

habits. To this end, during my tenure, I have met with many individuals and 

hosted a series of roundtable sessions with business leaders, researchers, 

providers, insurers and other interested parties to discuss health promotion and 

disease prevention issues and strategies. I also convened several departmental 

workgroups on obesity, diabetes, tobacco use, health literacy and health 

messaging to review current programs and progress. This Blueprint for Action

represents the product of these various efforts and outlines simple action steps to 

guide individuals in their quest for healthier lifestyles. It also encourages other 

interested parties and organizations, such as providers, employers, communities, 

insurers, media, schools, and government to collaborate and cooperate to 

overcome obstacles, to promote healthy lifestyles and reduce the burden of 

chronic diseases. 

This Blueprint is just a beginning. By joining forces, resources and talents, we 

will be able to surmount this pressing public health challenge and enable all 

Americans to live longer healthier lives. I hope that this Blueprint for Action will 

inspire and encourage you to take the important steps to build a HealthierUS. 

 

 Tommy G. Thompson 
TABLE OF CONTENTS 

OVERVIEW ....................................................................................................................... 1 

SCOPE OF THE PROBLEM ............................................................................................. 4 

Overweight and Obesity ................................................................................................. 4 

Diabetes........................................................................................................................... 7 

Tobacco......................................................................................................................... 10 

Media and Messages..................................................................................................... 13 

Health Literacy.............................................................................................................. 14

OPPORTUNITIES FOR ACTION................................................................................... 18 

Action Steps for Individuals and Families.................................................................... 18 

Action Steps for Communities...................................................................................... 18 

Action Steps for Schools............................................................................................... 19 

Action Steps for Employers.......................................................................................... 20 

Action Steps for Health Insurers................................................................................... 21 

Action Steps for Health Care Providers and Professionals........................................... 21 

Action Steps for Researchers and Health Professions Educators ................................. 22 

Action Steps for Media ................................................................................................. 23 

Action Steps for State, Local, and Tribal Governments ............................................... 24 

Action Steps for HHS/Overweight and Obesity ........................................................... 24 

Action Steps for HHS/Diabetes .................................................................................... 26 

Action Steps for HHS/Tobacco .................................................................................... 27 

Action Steps for HHS/ Media and Messages................................................................ 28 

Action Steps for HHS/Health Literacy ......................................................................... 29 

ACRONYMS.................................................................................................................... 30 

RESOURCES ................................................................................................................... 31 

APPENDIX A - KEY HHS ACTIVITIES ....................................................................... 35 

APPENDIX B - STEPS COMMUNITY GRANTS ......................................................... 44 

APPENDIX C - STEPS INNOVATION AWARDS ....................................................... 45 

APPENDIX D--THE PRESIDENT’S CHALLENGE ..................................................... 47 

APPENDIX E—MEDICARE PREVENTIVE BENEFITS ............................................. 48 

APPENDIX F--INCENTIVES FOR HEALTHY BEHAVIOR....................................... 49 

REFERENCES ................................................................................................................. 52 
1

PREVENTION: A BLUEPRINT FOR ACTION OVERVIEW 

Prevention is an investment opportunity in our nation's future: for individuals, for 

community groups, for businesses, and for government. When we have this kind of 

opportunity to make a difference, it is incumbent upon us to embrace it 

wholeheartedly and take action. 

Tommy G. Thompson 

Secretary, HHS 

On June 20, 2002, President George W. Bush announced his HealthierUS Initiative, 

calling on government officials, business leaders, communities, health care providers, 

churches and civic organizations, to come together as partners in helping Americans live 

longer, better and healthier lives. HealthierUS identifies four key health-protection 

objectives for a healthier America: increased physical activity, responsible dietary habits, 

increased use of preventive health screenings, and healthy choices concerning alcohol, 

tobacco, drugs and safety. 

The U.S. Department of Health and Human Services (HHS) took up the President's 

challenge and Secretary Thompson launched Steps to a HealthierUS, a bold initiative that 

mobilizes the resources of HHS in collaboration with outside organizations to promote 

healthy habits and chronic disease prevention. Prevention: A Blueprint for Action, the 

latest activity in the HHS Steps Initiative, outlines simple steps that individuals and 

interested groups can take to promote healthy lifestyles and encourage healthy behavior. 

The Steps initiative is founded on a growing body of research showing that small, simple 

steps can often prevent or control chronic diseases. Its goal is to reverse the growth in the 

number of people suffering from diseases like asthma, diabetes, cancer, heart disease and 

stroke, as well as factors that contribute to them such as obesity and tobacco use. The 

intent of Steps to a HealthierUS is to reach the broadest number of Americans by using 

multiple approaches and involving groups and organizations to foster health, physical 

activity and good nutrition. To date, these approaches have focused on communities, 

businesses and organizations, and the actions that they can take to influence individuals’ 

choices and actions to improve health. The HHS prevention effort and Steps to a 

HealthierUS have many components: 

• Grants to Communities: As the cornerstone of the Steps initiative, HHS currently 

provides a total of $13.7 million for twelve cooperative agreements to establish 

community-wide partnerships to improve the health and well-being of individuals by 

encouraging people to maintain physically active lifestyles and make healthy lifestyle 

choices. 

• Roundtable Discussions: The Secretary hosted a series of Roundtable discussions, 

which brought together interested stakeholders including academia, insurers, business 

executives, health care providers, and researchers. The purpose of these roundtables 
2

was to highlight the importance of prevention and specifically discuss best 

approaches to stem the tide of chronic diseases and encourage healthy lifestyles - 

regular physical activity and balanced diets. The roundtables also identified 

obstacles to adopting healthy habits.

• Prevention Town hall: The Secretary hosted a Prevention Town hall in Austin, 

Texas in 2003. The goal of the town hall was to engage stakeholders in a discussion 

of the importance of health promotion and disease prevention. Featured experts 

identified successful approaches to foster healthy behaviors.

• Secretary’s Challenge--Steps to a HealthierHHS: This is a HHS worksite health 

promotion program encouraging department employees to become more physically 

active. This voluntary initiative promotes the benefits of a healthy lifestyle by 

challenging employees to be on the move -- at least 30 minutes a day, five days a 

week for six weeks. Nearly 800 employees participated and 25 percent completed the 

pilot program in the Washington, DC area. The Secretary plans to take this challenge 

to all HHS employees and other federal departments soon.

• Prevention Summit: Held on April 15-16, 2003 in Baltimore, Maryland, the Steps 

to a HealthierUS: Putting Prevention First Summit focused attention on the urgency 

of prevention and on promising approaches for tackling key challenges. At this 

inaugural conference, the Secretary laid out his priorities and programs for Steps to a 

HealthierUS. The second annual summit was held on April 29-30, 2004 in 

Baltimore, Maryland. 

• Awards for Innovation: Another component of the Steps initiative is the Steps 

Innovation in Prevention Awards Program. In December 2003, HHS awarded eight 

Steps Innovation Awards in seven categories, to groups and organizations 

recognizing their accomplishments and highlighting the concrete health 

improvements that each has achieved. 

• Partnerships: Another aspect of the Steps initiative is the Partnerships program 

where HHS seeks to work with other public and private sector organizations to 

support and promote healthier living. It is designed to encourage other organizations 

to follow the lead of the Innovation Award recipients. 

• Secretarial Workgroups and the Blueprint for Action: While recognizing the 

importance of many other diseases such as cancer, cardiovascular disease, and 

asthma, the Secretary established five senior staff workgroups on specific areas that 

were identified as presenting particular opportunities for cross-Departmental 

coordination and that are central to advancing health promotion and disease 

prevention: overweight and obesity, diabetes, tobacco, media and messages, and 

health literacy. This work provided the basis for the Blueprint for Action.

• Initial Preventive Physical Examination and Other New Medicare Benefits: The 

Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 
3

establishes coverage of a one-time “Welcome to Medicare Physical Examination” 

within 6 months of a beneficiary’s first coverage under Part B, with the goal of health 

promotion and disease detection. The benefit covers a physical exam (including 

measurement of height, weight and blood pressure, and an electrocardiogram) and 

includes education, counseling and referral with respect to screening and other 

preventive services. The effective date is January 1, 2005, for new beneficiaries 

whose coverage period under Medicare Part B begins on or after such date. The 

MMA also adds coverage for cardiovascular and diabetes screening for Medicare 

beneficiaries, which also begin on January 1, 2005. 

This report provides an overview of these efforts. First, it highlights the problems and 

challenges in these areas. Then, based on a series of roundtable discussions between the 

Secretary and various interested stakeholders, it delineates specific action steps that 

individuals, communities, insurers, employers, healthcare providers, and other public and 

private entities can take. Finally, it profiles HHS activities that address these challenges, 

reports on progress and accomplishments, and identifies opportunities for additional 

action. This Blueprint for Action will create a template for collaborative efforts to 

improve the health and well-being of all Americans. 
4

SCOPE OF THE PROBLEM 

As the latest element of the Steps initiative, the Secretary established five HHS 

workgroups on specific areas that are central to advancing health promotion and disease 

prevention: diabetes, overweight and obesity, smoking cessation, media and messages, 

and health literacy. Overweight and obesity, lack of physical activity, and smoking 

greatly increase the risk of developing serious diseases, such as diabetes, heart disease, 

stroke, and cancer, accounting for much of the morbidity and mortality in the U.S., and 

the enormous direct and indirect costs associated with them. In large part, these disorders 

stem from, and are exacerbated by, individual behaviors and, thus, are preventable. The 

Department’s efforts to promote health and prevent such disorders depend in part on 

developing effective messages that are appropriate for individuals and groups in ways 

that they can understand and act on. The goals of these workgroups were to evaluate 

current HHS programs and activities; recommend ways to better coordinate these efforts; 

and identify areas of opportunities for new initiatives.

Overweight and Obesity 

The nation is currently facing a major long-term public health crisis. In recent years, 

unprecedented numbers of Americans of all ages have become either overweight or obese 

(Figure 1). This trend toward overweight and obesity has accelerated during the past 

decade and is well documented by numerous scientific analyses (see Facts and Figures on 

Obesity). Unfortunately, this trend toward obesity shows no signs of abating. If it is not 

reversed, the gains in life expectancy and quality of life resulting from modern 

medicine’s advances on disease will erode, and more health-related costs will burden the 

nation. It is estimated that almost half of the annual costs of obesity reflects indirect

costs, such as loss of productivity caused by absenteeism, disability, and premature death 

[1]. Obesity and overweight are preventable conditions for most Americans. The 

increasing prevalence in obesity-related illnesses must be reversed. 

0

10

20

30

40

Percentage 

Obese 

20-39 40-59 60-74

Age Group

Prevalence of Obesity by Age, 

1999-2000

Men

Women

Source: NHANES Continuous, 1999-2000 (JAMA 2002; 288(14):1723-27) 
5

Health care providers can play a vital role in helping patients with obesity. The US 

Preventive Service Task Force (USPSTF) recently recommended that clinicians screen 

for obesity on all adult patients using the Body Mass Index (BMI), calculated as weight 

in kilograms divided by height in meters squared. People with a BMI between 25 and 

29.9 are considered overweight, and those with a BMI of more than 30 are considered 

obese. An online BMI calculator can be found at www.cdc.gov/nccdphp/dnpa/bmi/calcbmi.htm. The USPSTF also recommended that clinicians offer obese patients intensive 

counseling and behavioral interventions to promote sustained weight loss or refer them to 

other clinicians for these services. 

Poor diet and physical inactivity, resulting in an energy imbalance (an imbalance between 

the calories consumed and the calories expended), are two of the most important factors 

contributing to the increase in obesity. Other contributing factors include psychological 

considerations and motivations, education level, time constraints, and even cooking 

skills. 

Changes in food intake and energy expenditure. 

Substantial changes in food intake and physical activity have occurred over the last 20 

years in the U.S. Changes in food intake are better documented than changes in physical 

activity, since they have been easier to measure in research studies. Some examples of 

changes in food consumption and purchasing include: 

• Research has shown that when adolescents eat on their own and not with their 

families, they are less likely to eat healthy food, including fruits and vegetables [6]. 

Facts and Figures on Overweight and Obesity 

• In 1999-2000, 64 percent of U.S. adults were overweight, an increase from 56 percent when 

surveyed in 1988-1994; 30 percent of adults were obese, an increase from 23 percent in the earlier 

survey [2].

• Dramatic increases in the prevalence of overweight and obesity have occurred in children and 

adolescents of both sexes, with approximately 15.3 percent of children aged 6 to 11 years and 15.5 

percent of adolescents aged 12 to 19 years considered to be overweight [3].

• Overweight and obesity are associated with increased morbidity and mortality. An estimated 

300,000 deaths per year may be attributed to obesity, and overweight and obesity increase the risk 

for coronary heart disease, Type 2 diabetes, and certain cancers [4].

• The total economic cost of obesity in the U.S. is up to $117 billion per year, including more than 

$60 billion in avoidable medical costs, more than 5 percent of total annual health care expenditures 

[5].

• The prevalence of overweight and obesity varies by gender, age, socioeconomic status, and race 

and ethnicity. For example, although overweight has increased among all children, the prevalence 

of overweight and obesity is significantly higher among non-Hispanic black and MexicanAmerican adolescents than among non-Hispanic white teens (12-19 years old) [3]. A majority of 

non-Hispanic black women over 40 are overweight or obese [2].
6

• Soft drink consumption, which consists of both sodas and juice-based drinks, 

increased by over 60 percent between 1972 and 1992 [7], and accounts for over 10 

percent of the average adolescent’s daily caloric intake [8]. While such drinks can be 

enjoyed in moderation, for many they may substitute inappropriately for water, nonfat 

or low fat milk, and lower-calorie drinks. 

• An increased variety of products are available in supermarkets [9]. 

• People are eating outside the home more than ever [10]. The proportion of the food 

budget spent on food consumed outside the home has grown from approximately one 

third in the late 1970s to almost one half in the late 1990s, and over this same time 

period, portion sizes of foods consumed both outside and in the home have increased 

substantially [11, 12]. 

Although each of these shifts has been associated with an increase in food intake, none 

has clearly been linked to the onset of obesity. It is the imbalance between food intake 

and energy expended, however, that leads to weight gain. Calculations of the caloric 

content of fat suggest that an excess of 50 calories per day may produce as much as five 

pounds excess weight gain per year. (This is roughly the equivalent of one small cookie, 

per day.) Therefore, modest uncompensated changes in energy intake or expenditure 

over years may produce significant weight gains. 

Behavior and weight management. 

Many factors contribute to behaviors that lead to overeating, insufficient activity, and 

weight gain in contemporary American culture. There are intricate biological systems 

that regulate human hunger and satiety. It has been argued that humans are biologically 

programmed to prefer foods that are dense in fat, sugar and protein as a mechanism to 

assure adequate nutrition and healthy existence, particularly in times of scarce food. 

Additionally, human biology allows easy storage of nutrients in times of excess to 

provide a reserve for times of need. The biologic signals for satiety, or fullness, are often 

subtle, and are not perceived quickly or intensely. In ordinary circumstances, it is easy to 

eat more than is necessary to stop hunger anxiety signals. Eating food quickly furthers 

the likelihood of overshooting the satiety signal. The human predisposition toward 

conserving physical energy increases demand for inventions and technologies that help 

people increase productivity and reduce physical expenditure. For some individuals, 

exercising may run counter to the instinct to conserve physical energy. 

The American social environment greatly facilitates the biologic and psychological 

predispositions toward eating, often contributing to repeated overeating. Social 

interactions and connectivity are important factors in interpersonal success and mental 

well-being. Food is a central component of many social gatherings. For most of the 

population, an abundance of food is readily available. Grocery stores and other kinds of 

stores offer increasingly large varieties of food, including heavily marketed and already 

prepared items. Many grocery stores even offer convenient home deliveries. As 
7

consumers eat more of their meals outside the home, restaurants play a bigger role in 

shaping ideas on appropriate portion sizes and balance of nutrients. 

Diabetes 

An increasingly large proportion of people in the U.S. have diabetes (Figure 2). High 

health care costs are associated with this condition, and the consequences to individuals, 

families and society in terms of quality of life are even more staggering. Diabetes is a 

disease in which blood glucose (sugar) levels are elevated either because of the body’s 

failure to make adequate amounts of the hormone insulin and/or failure of cells to 

respond to insulin. There are several types of diabetes: 

• Type 1 diabetes, often called “insulin-dependent diabetes mellitus” or juvenile-onset 

diabetes, develops when the body’s immune system destroys pancreatic beta cells, the 

cells in the body that make the hormone insulin that regulates blood glucose. Thus, 

the pancreas can no longer produce insulin. This form of diabetes usually strikes 

children and young adults, but it may occur at any age, and requires individuals to 

take several insulin injections a day or use a pump to survive. Type 1 diabetes may 

account for 5 to 10 percent of all diagnosed cases of diabetes. [13, 14]. 

• Type 2 diabetes, formerly termed “adult-onset diabetes” is “non-insulin dependent 

diabetes mellitus,” even though some affected individuals require insulin for control 

of the disease. Type 2 diabetes usually begins as insulin resistance, a disorder in 

which cells do not use insulin properly. As it progresses, the pancreas gradually loses 

its ability to produce insulin. Type 2 diabetes often appears after age 40, although it 

is now being diagnosed increasingly in children and adolescents. This form of 

diabetes accounts for 90 to 95 percent of all diagnosed cases of diabetes. [13, 14]. 

• Gestational diabetes mellitus (GDM) is a form of diabetes that affects between 2.5 

percent and 4 percent of women in the U.S. during pregnancy. This type of diabetes 

results from the body's resistance to the action of insulin. The increased resistance 

during pregnancy is caused by hormones produced in the placenta. Gestational 

diabetes usually ends after the baby is born, but women with gestational diabetes have 

up to a 45 percent risk of recurrence with the next pregnancy and up to a 63 percent 

risk of developing type 2 diabetes later in life [15]. 

• Prediabetes is a condition that affects millions of people. It is defined as impaired 

fasting glucose or impaired glucose tolerance (IGT) or both. People with prediabetes 

are at high risk for developing full-blown diabetes and are also at risk of developing 

other serious health problems such as heart attack and stroke. Recently, the Expert 

Committee on the Diagnosis and Classification of Diabetes Mellitus of the American 

Diabetes Association lowered the blood glucose level threshold for diagnosis of 

impaired fasting glucose from 110mg/dl to 100mg/dl in order to provide a more 

reliable means of identifying persons at risk for developing diabetes [16]. This 

lowered threshold for impaired fasting glucose doubled the number persons identified 
8

as having prediabetes. As estimated in the CDC’s National Diabetes Fact Sheet, over 

40 million Americans aged 40-74 years have prediabetes.[13] 

Source: Centers for Disease Control and Prevention. Diabetes Surveillance System. Atlanta, GA, U.S. 

Department of Health and Human Services. Available at http://www.cdc.gov/diabetes/statistics/index.htm. 

Over the last half century there has been a 4- to 8-fold increase in the prevalence of 

diagnosed diabetes in the U.S. [17, 18]. Projections of diabetes into the 21st century are 

not comforting (Figure 3). A 165 percent increase in persons with diabetes in the U.S. is 

projected between 2000 and 2050, a rise from 11 to 29 million diagnosed persons of all 

ages [19]. Those aged over 75 years are expected to have the largest increases (271 

Source: Data for 1960-1998 from the National Health Interview Survey, NCHS, CDC 

Projected data for 2000-2050 from the Behavioral Risk Factor Surveillance System, Division of Diabetes 

Translation, CDC 
9

percent in women and 437 percent in men). Among racial and ethnic groups, African 

Americans are expected to have a larger increase (363 percent for males and 217 percent 

for females) than Caucasians (148 percent for males and 107 percent for females). 

Diabetes can have a major impact on both the quality and length of life. Acute 

complications, such as dangerously low blood glucose levels, called hypoglycemia, could 

be life-threatening. Chronic complications--such as eye disease leading to blindness, 

kidney disease leading to kidney failure, lower extremity nerve disease leading to 

amputations, and premature cardiovascular disease leading to heart disease and stroke-- 

are ultimately the main causes for reductions in the quality and also the length of life of 

persons with diabetes (Table 1). 

Table 1. Complications of Diabetes 

Condition Annual Number of Cases 

Associated with Diabetes 

Blindness 12,000 – 24,000 

Kidney failure 42,813 

Amputations 82,000 

Cardiovascular disease deaths 130,000 

Source: http://diabetes.niddk.nih.gov/dm/pubs/statistics

Facts and Figures on Diabetes 

• In 2002, an estimated 6.3 percent of the population, or some 18.2 million persons, had diabetes in the 

U.S.[13]. 

• About 70 percent are aware of their disease (13.0 million) compared to 30 percent (5.2 million) who 

are unaware [13]. 

• Diabetes affects various sociodemographic groups unequally. Persons aged 65 years and over make 

up almost 40 percent of all the persons with diagnosed diabetes, and this age group has a prevalence 

rate over 10 times that of persons under 45 years of age [17]. Minority populations also are 

disproportionately affected, with the prevalence of diabetes generally 1.5 to 4 times higher in those 

groups than in the majority population (Figure 2) [17, 18]. A higher prevalence in adults is 

associated with a lower educational level; adults with less than a high school education are more than 

twice as likely to have diabetes than college graduates [20]. 

• Rates of diabetes among adults also vary by geography; in 2001, prevalence ranged from 5.0 percent 

in Minnesota to 10.5 percent in Alabama [20]. The highest reported diabetes prevalence in the world 

(over 50 percent) is among the Pima Indians of the southwestern U.S. [21]. 

• Diabetes also imposes a tremendous economic burden, estimated at $132 billion in 2002 in the U.S. 

Most of this is spent on medical care for those affected ($92 billion) but a substantial proportion is 

also due to disability, work loss, and premature mortality ($40 billion) [13]. Unemployment and 

reduced productivity may also be manifestations of disability. The work disability rate is over three 

times as high for persons with diabetes as for those without the disease (26 percent versus 8 percent) 

[22]. Generally, diabetes results in the loss of about one third of a year’s earnings. 
10

Diabetes is the major cause of kidney failure, lower limb amputations and adult-onset 

blindness. Diabetes increases cardiovascular disease risk 2-4 fold. 

Among the elderly, diabetes-related cognitive impairment or dementia is also well 

recognized. Diabetes is the sixth leading cause of death and lowers average life 

expectancy by up to 15 years [23]. 

High quality of care for diabetes is based on ensuring that people with diabetes have 

needed tests that can help them and their providers manage their condition. All people 

with diabetes should obtain these services, which are relatively inexpensive to provide. 

However, only 20.7 percent of patients reported having received all five major tests for 

diabetes within the past 2 years. [24] 

Many factors have affected the upward trends in the prevalence of diabetes, including 

changes in diagnostic criteria, enhanced detection, decreasing general mortality, changes 

in population demographics (e.g., aging and growth in minority populations who 

experience higher prevalence rates), and increased incidence. Demographic changes in 

the population such as increases in minority populations at higher risk (37 percent), 

increasing prevalence rates (36 percent), and population growth (27 percent) have 

increased the diabetes burden. The concomitant rise in obesity and the elevated risk it 

presents for type 2 diabetes are also major contributors to these increases. The 

prevalence of overweight or obesity significantly increased from 1988-94 to 1999-2000 

(from 55.9 percent to 64.5 percent); and obesity also rose (from 22.9 percent to 30.5 

percent) [2]. The prevalence of overweight in children has doubled and in adolescents 

has tripled since 1970 (rising from 11 percent in 1988-94 to 15 percent in 1999-2000) [3]. 

While it is not yet possible to prevent type 1 diabetes, findings from major clinical trials 

have demonstrated that the onset of type 2 diabetes can be prevented or delayed in highrisk groups, including minority groups, who carry a disproportionately heavy burden of 

this disease. Clinical research has identified risk factors that place individuals at highrisk for this disease. Because over 5 million people are currently undiagnosed in the 

U.S., and because more intensive treatment of hypertension and hyperlipidemia is 

recommended for people with diabetes to reduce their increased risk of cardiovascular 

disease, the U.S. Preventive Services Task Force recommends that people with elevated 

levels of blood lipids (such as cholesterol and triglycerides) or high blood pressure be 

screened for type 2 diabetes [25]. 

Tobacco 

Every day in the U.S., 4,000 children and teenagers try their first cigarette and 2,000 

become regular smokers [26]. Tragically, more than 6.4 million young people alive 

today eventually could die from a decision they will make as adolescents – the decision 

to try cigarettes [27]. Among the 46.2 million U.S. adults who use tobacco, almost half 

will die prematurely from a tobacco-related disease [27]. 
11

The good news is that the nation is making steady progress to reduce smoking. Over the 

40 years since the release of the first Surgeon General’s report on smoking in 1964, this 

progress has been dramatic. Between 1965 and 2002, adult smoking rates have been cut 

nearly in half, from 42.4 percent to 22.8 percent, and per-capita annual consumption of 

tobacco products has fallen by more than half, from 4,345 cigarettes in 1963 to 1,979 

cigarettes in 2002 – the lowest level since before World War II [28, 29]. 

Perhaps the most impressive recent accomplishment has been the decline in smoking 

among adolescents after nearly a decade (during the 1990s) of rising smoking rates 

among youth (Figure 4). Although more than one in four U.S. high school students 

currently smokes cigarettes, smoking among this group has been falling since 1997. 

Facts and Figures on Tobacco [30] 

• An estimated 71.5 million Americans reported current use (past month use) of a tobacco product in 

2002, a prevalence rate of 30.4 percent for the population aged 12 or older. 

• Among that same population, 61.1 million (26.0 percent of the total population aged 12 or older) 

smoked cigarettes, 12.8 million (5.4 percent) smoked cigars, 7.8 million (3.3 percent) used 

smokeless tobacco, and 1.8 million (0.8 percent) smoked tobacco in pipes. 

• Young adults aged 18 to 25 continued to report the highest rate (45.3 percent) of use of tobacco 

products. Past month rates of use for this age group were 40.8 percent for cigarettes, 11.0 percent 

for cigars, 4.8 percent for smokeless tobacco, and 1.1 percent for pipes. 

• By age group, the prevalence of cigarette use was 13.0 percent among 12 to 17 year olds, 40.8 

percent among young adults aged 18 to 25 years, and 25.2 percent among adults aged 26 or older. 

• Higher proportion of males than females aged 12 or older smoked cigarettes in 2002 (28.7 vs. 23.4 

percent). However, among youths aged 12 to 17, girls were slightly more likely than boys to smoke 

(13.6 vs. 12.3 percent) 

• In 2002, 17.3 percent of pregnant women aged 15 to 44 smoked cigarettes in the past month 

compared with 31.1 percent of nonpregnant women of the same age group. 

• Current cigarette smoking rates among persons aged 12 or older were 37.1 percent among 

American Indians/Alaska Natives, 35.0 percent among persons reporting two or more races, 26.9 

percent among whites, 25.3 percent among blacks, 23.0 percent for Hispanics, and 17.7 percent for 

Asians. 

• The prevalence of cigarette smoking decreased with increasing levels of education. Among adults 

aged 18 or older in 2002, college graduates were the least likely to report smoking cigarettes (14.5 

percent) compared with 35.2 percent of adults who lacked a high school diploma. 

• The annual toll on the nation’s health and economy is staggering: 440,000 deaths, 8.6 million 

people suffering from at least one serious illness related to smoking, $75 billion in direct medical 

costs, $82 billion in lost productivity, and 5.6 million years of potential lives lost [31,32,33]. 
12

Tobacco use remains the leading preventable cause of death and disease in the U.S. and 

continues to pose a formidable challenge to the public health community. The downward 

trend in adult smoking is far too slow, particularly among people with lower education 

and income levels; declines in smoking among middle-school students appear to have 

stalled; and the long-term success rate for smokers who try to quit each year is still under 

5 percent [34]. 

Figure 4. Percentage of High School Students Who Reported Current Cigarette 

Smoking*—United States, 1991–2001 

*Smoked cigarettes on 1 or more of the 30 days preceding the survey. 

Source: CDC, Youth Risk Behavior Surveillance System (MMWR 2002;51(19):409–12).

Compounding these challenges is the current fiscal condition in several states that 

threatens successful statewide comprehensive tobacco control programs. The amount of 

money states are spending on tobacco prevention dropped by 28 percent over the past two 

years [35]. 

Over the past four decades, the scientific knowledge about the health consequences of 

tobacco use has expanded greatly. Much of this knowledge is the outgrowth of research 

that HHS has conducted or sponsored. It is now well documented that smoking cigarettes 

causes heart disease, lung cancer and many other cancers, chronic lung disease, and a 

wide range of other diseases and conditions affecting virtually every organ of the body. 

Cigar smoking and smokeless tobacco use have also been found to increase the risk of 

certain types of cancer and are not safe alternatives to smoking cigarettes. In addition to 

these conventional tobacco products, a new generation of nicotine products that purport 

to be less harmful has emerged, such as cigarettes that promise fewer carcinogens, and 

tobacco lozenges. However, establishing any claim of harm reduction requires extensive 

independent research on the products themselves and their impact on human health. 

The health hazards of tobacco use extend beyond the actual users. Exposure to 

secondhand smoke increases nonsmokers’ risk for cancer (particularly lung cancer), other 

respiratory diseases, and heart disease. Among children, secondhand smoke increases the 
13

risk of developing serious respiratory problems, including asthma, pneumonia, and 

bronchitis. Additionally, substantial evidence now links secondhand smoke with sudden 

infant death syndrome and low birth weight. 

The burden of tobacco use is not evenly distributed within the U.S. population. Specific 

population groups differ in the risk, incidence, morbidity, mortality, exposure, and burden 

of tobacco–related illness, as well as in their access to resources. For example, American 

Indians and Alaska Natives smoke at higher rates than any other ethnic/racial group. 

Media and Messages 

The dangers of risky behaviors – poor eating habits, lack of exercise, and smoking – and 

their potential effects on health are well known to many. We know many steps that can 

be taken to help reduce these behaviors and other risk factors, and to help promote 

healthy behaviors. The NICHD Back to Sleep campaign is an example of successfully 

conveying a health promotion message to the public. Research has shown that after this 

campaign was undertaken, the prevalence of infants placed in the prone sleep position 

declined by 66 percent between 1992 and 1996. Although causality cannot be proved, 

Sudden Infant Death Syndrome rates declined approximately 38 percent during this 

period [36]. Yet clinically based science is not always communicated in a meaningful 

way that engages individuals, communities, States and Federal agencies. 

Health communications and health messaging can contribute to taking what we know 

from science and clinical experience to support what is done at the personal, community, 

State, and National levels to prevent illness and disability. 

The challenge is to make health promotion and disease prevention messages as effective 

as possible. A variety of factors have been identified that may limit the effectiveness of 

messages: 

• Failure to deliver the right messages to the right segments of the audience at the right 

times. 

• Reluctance to combine service programs with public affairs/communications 

initiatives; neither alone may be sufficient to change behavior. 

• A “health problem at a time” approach creates multiple messages that can compete 

with each other for the same audiences and generate confusing “noise.” 

• Insufficient collaboration and coordination can limit the reach of prevention efforts. 

• The absence of a unified theme across prevention communication and programs that 

can create a strategic framework for partnerships. 

When it comes to communicating prevention messages or undertaking preventionoriented programs at the community level, there are several key guidelines: 
14

• Whether addressing diabetes or lung cancer, heart disease or drug addiction, the 

underlying message is about taking action to reduce the factors that might lead to 

long-term illnesses and to encourage the adoption of behaviors, attitudes and lifestyles 

that decrease the risks. 

• The readiness to receive and act on a prevention message varies. People have 

different levels of awareness and knowledge about their health, and these may vary 

with age, gender, geographic location, education, and race/ethnicity. Readiness, 

along with many other factors, must be assessed, target audience by target audience, 

so that messages will be appropriate for them. 

• Prevention messaging should not be an isolated incident or a one-time effort intended 

to reach all Americans. It is better to work with the intended audience segments to 

identify the most appropriate messages that will motivate action. 

• Over time, many prevention messages must change to reflect a changing society. 

When advertising has helped create a demand for a product, it shifts its orientation to 

selling that product. To keep the product fresh in the eyes of the consumer, the sales 

messages change over time – sometimes targeting different audiences, sometimes 

repositioning the product in the market. The same is true for prevention messaging. 

Static messages often become unheard messages over time; they must remain current 

as levels of awareness and readiness for behavior change increase. 

• It is more effective to communicate messages through multiple channels. No one 

channel works for every audience or all members of a particular audience. 

• Effective prevention messaging begins with assessments of the intended audiences for 

the prevention activity and ends with evaluation of successful efforts and activities. 

• Coordination and collaboration can help to reduce the “noise” of competing 

prevention messages and to leverage resources. Too much information, too many 

requests for behavior change in different arenas, absent an underlying theme, can lead 

to indecision about what to do in any one area or, worse, can result in a “turn off.” 

• Prevention messages should be integrated with prevention programs. 

• The effectiveness of messages promoting prevention needs to be evaluated to inform 

new directions. Is the message reaching the target audiences? Are they learning from 

and using the message? 

Health Literacy 

The innovations produced by the healthcare and public health systems often are poorly 

matched with the day-to-day information and services that the public needs to lead 

longer, healthier lives. This gap between what science has discovered and the public’s 
15

ability to put health information, messages and recommendations to appropriate use, may 

be explained in large part by limited understanding. Prevention often requires individuals 

to understand the effects of their behavior. Efforts to increase prevention often require 

significant resources. Realizing the benefits of investments in prevention requires that 

individuals have the capacity to take responsibility for making health-related choices and 

that policy makers and health professionals take responsibility for supporting and 

coordinating the information, resources and programs that foster healthy behaviors and 

prevent disease. 

 

It is critical that individuals have access to health information in a way they can 

understand to make appropriate health decisions. The corollary is that health 

professionals must provide useful information and be able to communicate clearly and 

effectively. The ability to access, understand and apply health information is known as 

“health literacy.” Information encompasses traditional print brochures, discussions 

between patients and healthcare providers, public health messages on the Internet, 

television and other mass media, instructions on food and medication labels, and forms to 

apply for insurance programs or provide informed consent. Efforts to promote health 

literacy continue to evolve. 

The basic definitions of literacy and health literacy are widely known and generally 

agreed upon. The National Literacy Act of 1991 defines functional literacy as 

The ability to read, write, speak, and compute and solve problems at levels 

of proficiency necessary to function on the job and in society, to achieve 

one’s goals, and develop one’s knowledge and potential. 

The following definition of health literacy was first used in a 1999 National Library of 

Medicine bibliography. It has since been widely adopted, and adapted. 

Health literacy is the degree to which individuals have the capacity to 

obtain, process and understand basic health information and services 

needed to make appropriate health decisions. 

Health literacy is not a set of skills specific to a health topic but basic communication 

capacities that consumers, patients, and providers bring to bear on many different types 

of health situations. The core of the health literacy concept is “understanding,” and the 

core of the health literacy problem is the mismatch between the public’s functional health 

literacy and the complexity of health terminology, recommendations, instructions, forms, 

healthcare systems and public health services. The mismatch is even more critical for 

individuals with limited literacy skills and multiple health conditions. Too often they 

have the greatest health burdens, limited access to relevant health information and limited 

abilities to understand the information. 

The concept of health literacy derives from the general idea of literacy as a set of 

functional skills that are applied in different situations or contexts. Thus, “health 

literacy” is typically described as literacy in health settings. There has not been sufficient 
16

research, however, to determine if health situations or contexts require skills in addition 

to or different from those described as basic literacy skills. Moreover, the research 

literature as well as HHS’s program operations and research projects indicate that “health 

literacy” refers not only to an individual’s or group’s capacities to understand information 

but also to their knowledge of a specific set of health-related facts, e.g., the acceptable 

range for blood pressure, the number and types of fruits and vegetables that a person 

should eat every day, or the frequency of a medication dose. The Agency for Healthcare 

Research and Quality (AHRQ) recently released a report on Literacy and Health 

Outcomes that provides new information on health literacy skills. 

Currently, national data on general literacy skills are used to assess health literacy. Data 

from the 1992 National Adult Literacy Survey (NALS) from the U.S. Department of 

Education indicate that approximately one-half of the adult English-speaking population 

has what researchers consider “limited literacy skills.” [37] HHS collaborated with the 

Department of Education to develop a module on health literacy for the 2003 National 

Assessment of Adult Literacy, that will provide the first-ever population-based 

assessment of health literacy. The data from this national population sample will be 

available in 2005. 

Consumers and patients increasingly manage their own health. Reading, writing, 

speaking, listening, and interpreting proficiencies are necessary to interact with the 

modern health care system. Moreover, health treatment and prevention services are more 

effective if they are geared toward different literacy levels and native languages, life 

stages, and nature and severity of illnesses. Health literacy is broader than general 

reading and writing skills, and includes abilities to: comprehend quickly “on your feet,” 

comprehend complex vocabulary and concepts relevant to health (e.g., medical terms or 

probability and risk), share personal information with providers about health history and 

symptoms, make decisions about basic healthy behaviors, such as healthy eating and 

exercise, and engage in self-care and chronic disease management. These health literacy 

skills enable consumers to identify and understand health risks, evaluate different health 

promotion, treatment, and intervention options, and follow specific health care 

recommendations. 

Health care providers and health information professionals need to communicate 

effectively with individuals with a variety of skills, from those with limited levels of 

understanding to those who have the skills to comprehend complex information and 

recommendations. Limitations and a mismatch of skills on both sides can hamper the 

effectiveness of prevention messages, health information, and health care. 

The nation's estimated 90 million adults with lower-than-average reading skills are less 

likely than other Americans to get potentially life-saving screening tests such as 

mammograms and Pap smears, to get flu and pneumonia vaccines, and to take their 

children for well child care visits, according to the recently released AHRQ literacy 

report. Research suggests that the consequences of low health literacy are poorer health 

because consumers, patients and their families are less likely to understand how to 

prevent disease and disability, and to benefit from health care advances. Research has 
17

linked limited health literacy with poorer self-management of chronic diseases [38-40]; 

less knowledge of healthy behaviors [41-44]; higher rates of hospitalizations [45, 46]; 

and overall poorer health [47, 48]. Low literacy also plays an important role in health 

disparities and may contribute to lower quality care and even medical errors. 
18

OPPORTUNITIES FOR ACTION 

During his tenure, Secretary Thompson has hosted many roundtable discussions and 

listening sessions with different stakeholders and interested parties. Drawing on these 

meetings, research and other information, this section suggests actions that specific 

stakeholders can take to promote health and prevent chronic disease in all Americans. 

These steps are not meant to be prescriptive but rather to identify starting points for 

individuals, families, communities and other interested constituencies as they begin to 

work for better health and wellness. 

Action Steps for Individuals and Families 

Individuals and families are the heart of healthy communities and provide the foundation 

for a strong and vibrant America. Individuals and families must adopt healthy habits and 

assume responsibility for living a healthy lifestyle. 

• Be physically active. Strive for at least 30 minutes of physical activity for adults and 

60 minutes for children each day. Play and be active as a family. Decrease time 

spent in sedentary activities such as watching television. 

• Eat a healthy diet. Consume 5 to 9 servings of fruits and vegetables each day. 

Consume fat and sugar in moderation. 

• Educate yourself about health and risk factors for disease and chronic conditions such 

as obesity. Become a student of healthy habits. Learn what constitutes a healthy diet 

and how to read and use food labels. 

• Set an example for your children by being physically active and eating a healthy diet. 

Instill healthy habits in children (e.g., play actively and eat healthy foods). Teach 

your children about the importance of exercise and a healthy diet. 

• Avoid risky behaviors. Limit alcohol intake. If you smoke, quit; if you do not 

smoke, don’t start. 

• Get recommended screenings (such as pap smears and mammograms) and 

immunizations (such as influenza vaccinations). 

Action Steps for Communities 

Communities are the cornerstones for promoting healthy behaviors of their residents. 

Partnerships within and among local private sector constituencies and stakeholders can 

promote and reinforce healthy habits and environments for individuals and families. 

• Engage individuals, families, policy makers, and community organizations in a 

process to enhance their understanding of the importance of healthy diets and regular 

physical activity. Raise consumer awareness about the adverse impact of inactivity 
19

and poor diets on overall health and well-being. Highlight community programs that 

support healthful food and physical activity. 

• Acting through community coalitions and partnerships, explore the creation of more 

community-based health promotion and disease prevention programs and initiatives 

for individuals and families. Empower individuals and families to manage weight 

and health through community programs that encourage skill-building, active 

parenting and behavioral management. 

• Consider providing for active lifestyles when planning and engineering community 

development and creating safe environments for physical activity, such as biking and 

walking trails, sidewalks, and playgrounds. 

Action Steps for Schools 

Schools are an especially critical site for encouraging healthy behaviors in youth. Most 

children spend a large portion of their time in school. In many cases, life-long habits and 

behaviors, good and bad, are formed during the elementary and middle school years. 

Schools, therefore, offer an opportunity to engage children in healthy eating and regular 

physical activity and to reinforce important health messages including those regarding 

avoidance of risky behaviors. Schools can also provide a bridge to eliciting parental 

involvement in shaping children’s habits and attitudes about healthy lifestyle choices. 

 

• Encourage cooperation among teachers, coaches, nurses, and food service staff to 

educate students about the importance of proper nutrition and regular physical 

activity to lifelong healthy weight maintenance. 

• Reinforce healthy habits by examples set by role models including teachers, coaches, 

and other school personnel. 

• Engage parents in a process to enhance their understanding of the importance of 

healthy diets and the benefits of exercise and engage them to reinforce this message 

in their homes. 

• Provide age-appropriate extracurricular physical activity and organized sports 

programs. 

• Provide elementary school students with daily recess periods for unstructured 

supervised play. 

• Encourage regular physical activity for all children (pre-school through 12th grade) in 

order to develop the knowledge, skills, attitudes, behaviors, and confidence to sustain 

life-long physically active lifestyles. 

• Explore the possibility of creating “before the bell” and after school physical fitness 

and nutrition programs for students. 
20

• Provide age-appropriate and culturally appropriate instruction in health education. 

• Provide healthy food and snack options in school cafeterias and vending machines. 

• Incorporate health-related tasks, materials and examples in regular everyday 

instruction for preschool to grade 12 education, including the topics of nutrition and 

the balance between calories consumed and calories expended in physical activity. 

Action Steps for Employers 

Working adults spend many of their waking hours at their worksite. Thus, the worksite 

is an important and convenient environment in which to foster healthier habits. 

Moreover, companies are beginning to recognize that the health of the individual 

employee is inseparable from the ‘health’ of the corporation. Employees with chronic 

diseases and/or conditions, which may be prevented or attenuated by diet and exercise, 

often have higher rates of absenteeism and health care usage than healthy employees 

without chronic ailments. Thus, worksite programs designed to promote health and 

prevent chronic disease are a wise investment for employers. 

• Design worksites and work schedules to provide opportunities for regular physical 

activity, including simple and readily available activities such as stair climbing. 

• Ensure that healthy food options are available for employees. 

• Consider creating exercise facilities at the worksite or providing incentives for 

employees to join local fitness centers. 

• Consider providing health promotion or wellness programs and disease management 

programs for employees as part of their health benefits. 

• Offer incentives to employees to adopt documentable healthy behaviors (e.g., miles 

walked or weight goals attained, obtaining recommended screenings, completion of a 

medically supervised smoking cessation treatment program). [See Appendix F.] 

• Engage employees in a process to enhance their understanding of the importance of a 

healthy lifestyle. 

• Actively partner with community and other local entities/stakeholders to develop and 

implement community health promotion and disease prevention initiatives. 

• Examine the cost and benefits of worksite health promotion and disease prevention 

efforts. 

• Request health insurers to develop appropriate information for employees to enhance 

health literacy. 
21

• Include health literacy measures in quality of care and outcomes assessments.

Action Steps for Health Insurers 

Health insurers can play a significant role in promoting health and preventing or 

lessening the consequences of chronic diseases and conditions for individuals. Insurers 

can design and offer innovative and comprehensive preventative services benefit 

packages based on scientific evidence. In addition, insurers can disseminate educational 

information about the importance of prevention to their customers/consumers. 

• Offer insurance products that include preventative services, disease management and 

wellness programs. 

• Engage consumers in a process to enhance their understanding of the importance of 

healthy habits and avoidance of risky behavior. 

• Encourage research evaluating the efficacy and cost/benefit of strategies to change 

behavior and translate research into clinical practice. Share this information with 

employers and other purchasers of health care. 

• Create incentives to encourage individuals to adopt healthy behaviors. [See 

Appendix F.] 

• Partner with communities and other entities to promote and encourage healthy 

lifestyles. 

• Include health literacy in quality of care and outcomes assessments. 

Action Steps for Health Care Providers and Professionals 

Health care providers/professionals are key for promoting healthy lifestyles and reducing 

the impact of chronic diseases and conditions. In any year, most Americans will interact 

with the health care system. Thus, health care providers are strategically poised to 

intervene and influence individuals to adopt healthy behaviors. Health care professionals 

can also provide critical leadership to communities, state and local governments, schools 

and other interested stakeholders to guide and catalyze health promotion and disease 

prevention efforts. 

• Lead by example; live a healthy lifestyle. 

• Accrue and maintain state-of-the-art knowledge about best practices and behavioral 

interventions to promote healthy habits and reduce risky behaviors. 

• Inform and educate individuals (patients, parents, students, community leaders, other 

health professionals, etc.) about the importance of healthy eating, regular physical 
22

activity, recommended disease screening, and avoidance of risky behaviors (such as 

tobacco use) to promote health and prevent chronic disease. 

• Implement effective weight reducing initiatives and smoking cessation programs. 

• Direct or participate in studies to explore the effectiveness of approaches to weight 

loss and healthy weight maintenance and smoking cessation. 

• Explore partnerships between health care providers/professionals and schools, 

communities, faith-based organizations, local and state governments, and other 

interested parties to develop and implement health promotion and disease prevention 

initiatives. 

• Seek out training in health literacy and effective provider-patient communication. 

• Practice evidence-based prevention—adhere to evidence-based recommendations of 

the US Preventive Services Task Force (USPSTF) on whether a clinical preventive 

service should be routinely delivered www.preventiveservices.ahrq.gov.

• Identify individuals who are ready to make important changes and take maximum 

advantage of the “teachable moment” that often occurs in clinical care (e.g., 

counseling individuals who have just had a heart attack or chest pain to quit 

smoking). 

• Harness the power of health information technology systems, including decision 

support systems, to remind clinicians and patients when preventive services are 

needed. HHS has supported much of the research that demonstrates the effectiveness 

of these systems to improve the use of clinical preventive services. 

Action Steps for Researchers and Health Professions Educators 

Progress in health promotion and disease prevention necessarily depends on continued 

research and knowledge generation and dissemination. Therefore, researchers and health 

professions educators are critical in furthering our understanding of the etiology of 

chronic conditions such as obesity and effective approaches for prevention and treatment 

of these conditions. In addition, successful health promotion and disease prevention 

requires translation and dissemination of scientific findings into effective clinical 

practices to reach all individuals. 

• Continue research into the pathogenesis, etiology, epidemiology, prevention and 

treatment of chronic diseases and conditions including obesity. Continue to explore 

optimal methods to translate research findings into clinical practice to change human 

behavior and foster healthy habits. 

• Develop outcome measures for health promotion and disease prevention activities, 

services, and practices. 
23

• Encourage and adopt an interdisciplinary approach to address chronic conditions such 

as obesity. 

• Develop and assess innovative methods to engage the public about the importance of 

health promotion and disease prevention and the link between the risk for chronic 

conditions and personal behaviors and choices such as physical activity and diet 

choices. Information, communication, and education should encompass the lifespan 

beginning in early childhood and continuing into older age. 

• Focus on identifying effective ways to improve the health literacy of all individuals to 

reinforce the importance of health promotion and disease prevention for all segments 

of the population. 

• Seek partnerships with community, public or private entities to promote research and 

educational initiatives regarding health promotion and disease prevention. Develop a 

multi-pronged community approach involving all stakeholders to reach all 

individuals. 

• Design curricula and testing for health professionals (undergraduate and graduate) 

that comprehensively cover the science of health promotion and disease prevention 

and that examine and teach effective approaches to change individual behaviors. 

Integrate health professional education and training across disciplines. 

Action Steps for Media 

The power of the media should be harnessed to educate the public by disseminating 

health information and to promote effective strategies to improve dietary and exercise 

habits. 

• Promote/conduct public awareness campaigns of the health benefits of energy balance 

through regular physical activity, and a healthy diet to maintain a healthy weight. 

• Partner with medical professionals, federal, state and local governments, and private 

sector and community entities to help the public understand the importance of 

preventive screenings. 

• Develop and disseminate appropriate messages that encourage healthy habits and 

avoidance of risky behaviors in youth. 

• Showcase successful initiatives and programs that promote health and prevent 

disease. 

• Conduct or participate in consumer research to study the appropriateness and 

effectiveness of media messages promoting healthy lifestyles and avoidance of risky 

behaviors. 
24

• Consider use of public access networks to broadcast local conferences or training 

videos on various health topics (e.g., exercise class for seniors). 

Action Steps for State, Local, and Tribal Governments 

State, local, and tribal governments can play a key role in coordinating an approach to 

encourage healthy habits and prevent chronic diseases. State, local and tribal 

governments can partner with, and provide guidance to, other organizations and entities 

to facilitate health promotion initiatives. They can also act as a bridge between Federal 

programs and community activities providing the necessary infrastructure and support 

needed to maximize and coordinate efforts among stakeholders. In addition, state, local, 

and tribal governments can create and implement policies that encourage healthy 

behaviors. 

• Review and design policies to ensure that health promotion and disease prevention 

are priorities. 

• Partner with communities and other entities to create environments and implement 

initiatives that encourage healthy lifestyles and habits. 

• Disseminate audience-appropriate information about the importance of healthy 

lifestyles and avoidance of risky behaviors. Foster a consistent age and culturally 

appropriate message to the public, especially high-risk groups, about the 

consequences of unhealthy lifestyles and practices. 

• Identify high-risk groups for targeting prevention initiatives and activities. 

• Provide guidance and support for research on the efficacy of different interventions to 

prevent and treat obesity, diabetes, and other chronic conditions and tobacco use. 

Action Steps for HHS/Overweight and Obesity 

HHS has a large number of current initiatives and programs underway to address obesity 

and overweight. They include programs in education, communication and outreach, 

intervention, diet and nutrition, physical activity and fitness, disease surveillance, 

research, clinical preventive services and therapeutics, and policy and web-based tools. 

The programs are targeted to a variety of populations including infants and breastfeeding 

mothers, children and adolescents, women, minorities, the elderly, the disabled, rural, and 

the general population. Additional areas to target initiatives may include: 

• Design and implement programs that work with children and parents to prevent and 

treat obesity, since the best opportunity to slow the U.S. obesity ‘epidemic’ may be in 

childhood. 
25

• Evaluate effectiveness of treatment and preventive programs to build a practical 

evidence base for new interventions. Relevant research questions may include: 

→ Do certain populations (e.g., gender or age-related, racial/ethnic populations) 

benefit more from certain therapies? 

→ What is the optimum amount of time to treat, and what is the optimum level of 

weight loss to target? 

→ What evidence exists to support long-term weight loss and weight-maintenance, 

e.g., over one year or five years? 

→ What is the safety and efficacy of certain therapies? 

→ What risks are associated with weight loss, especially for certain populations such 

as the elderly, for example, who generally are at high risk for osteoporosis? 

• Explore ways to increase awareness and knowledge, especially in certain populations, 

about obesity and interventions that may reduce obesity and promote healthy energy 

balance. 

• Develop interventions that address needs of special populations. 

• Focus further research on the psychological and motivational aspects of weight 

maintenance, and on identifying any demonstrable benefits for private or public 

health insurance programs. 

• Enhance food labels to display calorie count more prominently and to use meaningful 

serving sizes. 

• Evaluate and recommend the types of health communication activities that would 

most effectively support the "Calories Count" message. 

• Encourage restaurants to provide meaningful nutritional information to consumers. 

• Step up enforcement actions concerning accuracy of food labels. 

• Revise FDA guidance for developing drugs to treat obesity. 

• Work cooperatively with other government agencies, non-profit organizations, 

industry, and academia on obesity research. 

• Incorporate the findings from the recently released reports on health literacy from the 

Institute of Medicine and AHRQ into overweight and obesity information and 

communication activities. 
26

Action Steps for HHS/Diabetes 

HHS agencies are pursuing vigorous programs in prevention that include basic research, 

clinical trials, community health efforts, educational programs, translating research into 

practice, efforts in special populations, and providing a new Medicare benefit for diabetes 

testing. Through these comprehensive programs, HHS agencies are continuing to pursue 

prevention studies to optimize and identify additional intervention strategies. HHS also 

is improving methods to disseminate and implement effective strategies into diverse 

community settings. Particular opportunities for HHS action involve underserved or 

vulnerable populations and include: 

• To focus attention on the long-term implications of gestational diabetes mellitus 

(GDM), the National Diabetes Information Clearinghouse of the NIDDK/NIH will 

produce a new booklet entitled, “What I Need to Know about Gestational Diabetes,” 

which will incorporate messages based on diabetes prevention research. The National 

Diabetes Education Program’s Small Steps. Big Rewards. Prevent Type 2 Diabetes

campaign will also be expanded to include a specific focus on GDM. 

• To analyze the effects of treatment and ascertain the durability of these effects over 

time, a Diabetes Prevention Program follow-up study of women with a history of 

GDM is in progress. 

• Enhance the focus on women with GDM in community health centers and Indian 

Health Service programs, and through AHRQ’s Integrated Delivery System Research 

Network and Practice Based Research Networks.

• Since there is a disproportionate risk for the development of type 2 diabetes in 

persons with serious mental illness, in general, and treatment with antipsychotic 

medications predispose individuals to gain weight [49-54], examine and apply 

evidence-based lifestyle interventions in mental health settings that would reduce the 

rate of obesity and prevent the development of type 2 diabetes in Americans with 

serious mental illness. 

• Since American Indians and Alaska Natives have a higher incidence of diabetes, 

determine if diabetes prevention activities previously demonstrated to be efficacious 

under well-controlled conditions (such as the NIDDK-sponsored Diabetes Prevention 

Program study) can be implemented with fidelity in a variety of Indian health settings 

and through community-based human services providers.

• Evaluate whether a comprehensive health system intervention delivered through 

Indian health programs can reduce risk factors for cardiovascular disease in 

individuals with diabetes and/or the metabolic syndrome (characterized by insulin 

resistance and the presence of obesity, abdominal fat, high blood sugar and 

triglycerides, high blood cholesterol, and high blood pressure).
27

• Implement evidenced-based interventions to prevent diabetes as part of the Primary 

Prevention of Diabetes Initiative in 25-30 Health Service/Tribal/Urban (I/T/U) 

community sites of varying sizes and types. 

• Implement, as part of the Cardiovascular Disease Risk Reduction Initiative, a 

comprehensive health system intervention consisting of patient-, provider-, systemsand community-level components in 25-30 clinical sites that participate in the IHS 

Diabetes Care and Outcomes Audit. 

• Consider utilizing the community health center program Diabetes Prevention 

Collaborative and Health Disparity Collaborative strategy and models to translate 

and disseminate the results of Diabetes Prevention Program pilot into clinical 

practice. 

• Incorporate the findings from the recently released reports on health literacy from the 

Institute of Medicine and AHRQ into diabetes information and communication 

activities. 

• CMS should assess utilization of the new Medicare benefits (beginning in 2005) 

establishing coverage of an initial preventive physical exam, and diabetes and 

cardiovascular disease screening tests, to ensure beneficiaries are taking advantage of 

these services and getting the care they need to better manage their diabetes. 

Action Steps for HHS/Tobacco 

Prevention of the ill effects of tobacco is an essential part of the HHS mission, and HHS 

is committed to working in a coordinated, comprehensive, and effective manner to 

protect the public’s health from the harmful effects of tobacco use. In 2000, HHS 

launched a roadmap for improving the health of all people in the U.S. during the first 

decade of the 21st century, including objectives for reducing the death and disease caused 

by tobacco use. In addition, the Secretary’s Steps to a HealthierUS has as one of its 

major components avoiding risky behaviors, such as using tobacco products, to promote 

good health and save lives. There are many opportunities for strategic collaboration 

among agencies to further reduce the health and economic impact of tobacco-related 

diseases. 

• Consider opportunities for encouraging smoking cessation activities in a variety of 

programs and areas, such as: the Federal workplace; among hospitalized cardiac 

patients; among Americans who receive their health care through or with financing 

from the Federal Government (Veteran’s Administration, Medicaid, Medicare, Older 

Americans Act services provider network, Department of Defense, Indian Health 

Service); or in the HRSA prevention collaborative. 

• Examine ways to encourage use of the Web site, www.smokefree.gov, which offers 

science-driven tools, information, and other resources that have been found effective 

in helping smokers quit. 
28

• Consider opportunities for incorporating tobacco use prevention messages into 

community-based shelters for runaway and homeless youth and their families; and the 

National Youth Sports Program youth camps for middle-school-aged, low-income 

youth. 

• Examine opportunities for tobacco use prevention and smoking cessation among 

Head Start and Early Head Start staff and parents. 

• Examine opportunities to enhance the delivery of technical assistance on tobacco 

control through SAMHSA’s Center for Substance Abuse Prevention (CSAP) Center 

for the Application of Prevention Technologies. 

• Consider opportunities to deliver tobacco use and prevention messages to young 

people through sports and entertainment media campaigns. 

• Examine opportunities to enhance SAMHSA Best Practices via the National Registry 

of Effective Prevention Programs to include tobacco prevention programs. 

• Examine opportunities to expand the number of materials on tobacco prevention and 

control that are available through the National Clearinghouse for Alcohol and Drug 

Information. 

• Consider research that examines the toxicity of current and new tobacco products. 

• Incorporate the findings from the recently released reports on health literacy from the 

Institute of Medicine and AHRQ into tobacco information and communication 

activities. 

• Highlight community-based programs that provide rewards for young people who do 

not smoke. 

• Evaluate and disseminate the results of the Medicare Stop Smoking Program (a pilot 

currently underway in seven states). 

Action Steps for HHS/ Media and Messages 

HHS has a vast number of individual initiatives, products and messages designed to 

promote healthy behaviors and reduce illness and disability, such as the national nutrition 

program, 5 A Day for Better Health Program, the Small Steps program, and its 

accompanying advertising campaign (Healthy Lifestyles and Disease Prevention), which 

encourages American families to take small, manageable steps to ensure effective, longterm weight control. 

• Identify a standard for clear and effective communication for all information, forms, 

materials and communication from HHS with the public. 
29

• Update and change prevention messages to maintain ‘freshness’ and reflect the stateof-the-art practices and information. 

• Research the information and communication needs, characteristics, preferences, and 

environments to develop effective messages. 

• Coordinate prevention messages to reduce the ‘noise’ of competing messages and to 

leverage resources. 

• Integrate prevention messages with prevention programs. 

Action Steps for HHS/Health Literacy 

Health literacy and messaging are important aspects of HHS research and program 

activities focusing on prevention. The Department’s agencies are engaged in a variety of 

health literacy activities. HHS agencies are beginning to include health literacy as a 

consideration in their research, assessment, training, program operations, and 

communication with the public, but there are opportunities for improvement. 

• Continue research on multiple aspects of health literacy including: the impact of 

limited health literacy on health disparities; the nature and extent of limited health 

literacy in different populations and for different topics and contexts; the interaction 

of limited health literacy with other factors, such as age and disabilities; the most 

effective health literacy interventions for different segments of the population; and 

the impact of limited health literacy on the quality, access and outcomes of health 

care and public health services. 

• Develop health and program information in a variety of languages. 

• Emphasize the need to pre-test publications designed for wide-spread dissemination 

with the target audience prior to publication. 

• Support the development of an evidence-based approach to training a broad spectrum 

of healthcare and public health professionals to communicate effectively with 

different types of patients, including those with limited literacy. 

• Develop and validate measures of successful health literacy approaches. 

• Provide leadership to identify and build consensus for outcome measures needed to 

improve health literacy across the population, in particular for the most vulnerable 

groups. 

• Advise agencies to assess their information, communication, and programmatic 

activities with their intended audiences, particularly low literacy audiences. 
30

ACRONYMS 

AHRQ Agency for Healthcare Research and Quality 

AI/AN American Indians/Alaska Natives 

AoA Administration on Aging 

CDC Centers for Disease Control and Prevention 

CMS Centers for Medicare and Medicaid Services 

CSAP Center for Substance Abuse Prevention 

FDA Food and Drug Administration 

GDM Gestational Diabetes Mellitus 

HHS U.S. Department of Health and Human Services 

HRSA Health Resources and Services Administration 

IHS Indian Health Service 

I/T/U Indian Health Service/Tribal/Urban 

NCI National Cancer Institute 

NIA National Institute on Aging 

NICHD National Institute of Child Health and Human Development 

NIDA National Institute on Drug Abuse 

NIDDK National Institute of Diabetes and Digestive and Kidney Diseases 

NIH National Institutes of Health 

SAMHSA Substance Abuse and Mental Health Services Administration 

USPSTF US Preventive Service Task Force 
31

 RESOURCES 

Overweight and Obesity 

NIH Obesity Research 

http://www.obesityresearch.nih.gov/ 

 

NIDDK Weight Loss and Control 

http://www.niddk.nih.gov/health/nutrit/nutrit.htm 

 

NHLBI Aim for a Healthy Weight 

http://www.nhlbi.nih.gov/health/public/heart/obesity/lose_wt/index.htm 

 

NLM Medline Plus 

http://www.nlm.nih.gov/medlineplus/nutrition.html 

 

USDA Center for Nutrition Policy and Promotion 

http://www.usda.gov/cnpp/ 

 

CDC National Center for Chronic Disease Prevention and Health Promotion: Nutrition 

and Physical Activity 

http://www.cdc.gov/nccdphp/dnpa/obesity/resources.htm

 

Blueprint for Action on Breastfeeding 

HHS Office on Women's Health 

http://www.4woman.gov/Breastfeeding/index.htm

 

Bright Futures in Practice 

Bright Futures Project 

http://www.brightfutures.org 

 

Nutrition and Your Health: Dietary Guidelines for Americans 

http://www.health.gov/dietaryguidelines

 

Exercise: A Guide from the National Institute on Aging 

http://www.niapublications.org/exercisebook/index.asp

 

Exercise: A Video from the National Institute on Aging 

http://www.nia.nih.gov/exercisevideo/

 

5 A Day for Better Health 

National Cancer Institute 

http://dccps.nci.nih.gov/5aday/

 
32

Girls and Obesity Initiative 

HHS Office on Women's Health 

http://www.4woman.gov/owh/education.htm

 

FDA Guidance on How To Understand and Use the Nutrition Facts Panel on Food Labels 

http://www.cfsan.fda.gov/~dms/foodlab.html

 

Guide to Clinical Preventive Services, 2nd edition, 1996 

U.S. Preventive Services Task Force 

http://www.ahrq.gov/clinic/uspstfix.htm

 

Healthfinder® Gateway to Reliable Consumer Health Information on the Internet 

http://www.healthfinder.gov

Diabetes 

National Institute of Diabetes and Digestive and Kidney Diseases 

http://www.niddk.nih.gov

National Diabetes Education Program 

http://www.ndep.nih.gov/ 

National Diabetes Information Clearinghouse 

http://diabetes.niddk.nih.gov/ 

CDC Diabetes Public Health Resource 

http://www.cdc.gov/diabetes/ 

IHS National Diabetes Program 

http://www.ihs.gov/MedicalPrograms/diabetes/index.asp 

HRSA Health Disparities Collaborative 

http://bphc.hrsa.gov/programs/HDCProgramInfo.htm 

AHRQ Preventive Services Task Force 

http://www.preventiveservices.ahrq.gov/ 

Conquering Diabetes: A Strategic Plan for the 21st Century 

http://www.niddk.nih.gov/federal/dwg/fr.pdf 

Conquering Diabetes: Highlights of Program Efforts, Research Advances and 

Opportunities. A Scientific Progress Report on the Diabetes Research Working Group's 

Strategic Plan 

http://www.niddk.nih.gov/federal/dwg/2002/dwg02.htm 
33

Medicare Coverage of Diabetes Related Supplies and Services 

http://www.medicare.gov/Health/Diabetes.asp

Tobacco 

Centers for Disease Control and Prevention. Annual Smoking-Attributable Mortality, 

Years of Potential Life Lost, and Economic Costs --- United States, 1995--1999. MMWR 

2003; 52: 300-303. 

Centers for Disease Control and Prevention. Best Practices for Comprehensive Tobacco 

Control Programs. Atlanta: Centers for Disease Control and Prevention, National Center 

for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 

1999. 

Centers for Disease Control and Prevention. Cigarette smoking among adults—United 

States, 2001. Morbidity and Mortality Weekly Report 2003a;52(40):953–6. 

Centers for Disease Control and Prevention. Cigarette smoking-attributable morbidity—

United States, 2000. Morbidity and Mortality Weekly Report 2003b;52(35):842–4. 

Centers for Disease Control and Prevention. Early release of selected estimates from the 

National Health Interview Survey (NHIS). Available at 

http://www.cdc.gov/nchs/about/major/nhis/released200312.htm. 

Centers for Disease Control and Prevention. State-Specific Prevalence of Current 

Cigarette Smoking Among Adults- United States, 2002. MMWR 2004; 52: 1276-1280. 

Centers for Disease Control and Prevention. Tobacco Use Among Middle and High 

School Students-United States, 2002. MMWR 2003; 52: 1096-1098. 

Centers for Disease Control and Prevention. Trends in Cigarette Smoking Among High 

School Students — United States, 1991–2001. Morbidity and Mortality Weekly Report

2002;51(19) 409–12. 

National Cancer Institute, Centers for Disease Control and Prevention & American 

Cancer Society. You Can Quit Smoking Now!. http://www.smokefree.gov. 

Substance Abuse and Mental Health Services Administration, Center for Substance 

Abuse Prevention. State Synar Non-Compliance Rate Table, 

FFY 1997 - FFY 2003. http://prevention.samhsa.gov/tobacco/01synartable.asp

Substance Abuse and Mental Health Services Administration, U.S. Dept of Health and 

Human Services (HHS), “Overview of Findings from 2002 National Survey on Drug Use 

and Health (NSDUH),” 2002. Available at 

http://www.samhsa.gov/oas/nhsda/2k2nsduh/Overview/2k2Overview.htm#toc. 
34

U.S. Department of Health and Human Services. Reducing Tobacco Use: A Report of the 

Surgeon General. Atlanta, Georgia: U.S. Department of Health and Human Services, 

Centers for Disease Control and Prevention, National Center for Chronic Disease 

Prevention and Health Promotion, Office on Smoking and Health, 2000. 

U.S. Preventive Services Task Force. Counseling to Prevent Tobacco Use and TobaccoRelated Diseases: Recommendation Statement. November 2003. Agency for Healthcare 

Research and Quality, Rockville, MD. 

http://www.ahrq.gov/clinic/3rduspstf/tobacccoun/tobcounrs.htm.

Healthy Aging Initiative. Evidence Reports: Interventions to Promote Smoking Cessation 

in the Medicare Population

http://www.cms.hhs.gov/healthyaging/2b.asp

Health Literacy 

Dynamic search of the health literacy literature indexed in Medline. Available online at 

http://phpartners.org/hp/health_comm.html. Last viewed March 4, 2004. 

HRSA health literacy Web pages. Available online at 

http://www.hrsa.gov/quality/healthlit.htm. Last viewed March 4, 2004. 

NIDCD health literacy Web pages. Available online at 

http://www.nidcd.nih.gov/health/education/news/improving_health_literacy.asp. Last 

viewed March 4, 2004. 

U.S. Department of Health and Human Services. Health literacy action plan. In 

Communicating Health: Priorities and Strategies for Progress. Washington, D.C. July 

2003. Available online at http://odphp.osophs.dhhs.gov/projects/HealthComm/. Last 

viewed March 4, 2004. 

 

AHRQ report on Literacy and Health Outcomes. A summary is available online at 

www.ahrq.gov/clinic/epcsums/litsum.htm and the full report can be downloaded from 

www.ahrq.gov/clinic/evrptfiles.htm#literacy. 

National Library of Medicine. Understanding health literacy and its barriers. Bethesda, 

MD. Available May 2004 at 

http://www.nlm.nih.gov/pubs/cbm/healthliteracybarriers.html. 
35

APPENDIX A - KEY HHS ACTIVITIES 

Obesity Activities 

Cross-cutting focus at NIH and the Food and Drug Administration. 

As the problems of overweight and obesity have grown, the need for new action and 

research has become more evident. In response, NIH assembled a Task Force to identify 

areas for new research across its many institutes. In March 2004, NIH released the draft 

of its Strategic Plan for NIH Obesity Research (www.obesityresearch.nih.gov). This 

report identifies key areas of research need, priorities among those areas, a road map for 

advancing these research priorities, and the establishment of a committee for monitoring 

progress in addressing the issues and problems relating to overweight and obesity. 

Similarly, the Food and Drug Administration (FDA) established an Obesity Working 

Group to advise the agency on innovative ways to deal with the increase in obesity and to 

identify ways to help consumers lead healthier lives through better nutrition. In March 

2004, the working group released its report with a focus on the message, "calories count." 

The group’s long- and short-term proposals are based on the scientific fact that weight 

control is mainly a function of the balance between calories consumed and calories 

expended. That is, calories in must equal calories out. The report includes 

recommendations to strengthen food labeling, to educate consumers about maintaining a 

healthy diet and weight and to encourage restaurants to provide calorie and nutrition 

information. It also recommends increasing enforcement efforts to ensure food labels 

accurately portray serving size, revising and reissuing guidance on developing obesity 

drugs and strengthening coordinated scientific research to reduce obesity and to develop 

foods that are healthier and low in calories. 

Dietary guidelines. 

HHS is collaborating with the U.S. Department of Agriculture to review the Dietary 

Guidelines that were published in 2000 and to draft new 2005 Dietary Guidelines for 

Americans. In light of the growing number of overweight and obese Americans, a major 

focus of the new guidelines will be providing guidance to the public on maintaining a 

healthy weight, and creating lifestyles that balance the number of calories eaten with the 

number of calories expended. These guidelines must (1) contain nutritional and dietary 

information and guidelines for the general public, (2) be based in the preponderance of 

scientific and medical knowledge current at the time of publication, and (3) be promoted 

by each Federal agency in carrying out and Federal food, nutrition, or health program. 

5 a Day for Better Health. 

One of the most recognizable efforts to promote good nutrition and healthy eating habits 

has been the 5 A Day for Better Health Program. This national nutrition program seeks 

to increase to 5 or more the number of daily servings Americans eat of fruits and 

vegetables. In addition to its widely known slogan, the 5 A Day program reaches many 
36

individuals through health care provider networks, the internet, and print media to 

provide information about the health benefits of eating more fruits and vegetables, as well 

as easy steps for adding more of them into daily eating patterns. 

Administration on Aging action. 

The Administration on Aging’s (AoA) National Policy and Resource Center on Nutrition, 

Physical Activity and Aging was created for the purpose of increasing and improving 

food and nutrition services to older Americans through their caregivers at home, with 

community-based service providers, and in long-term care systems. The Center focuses 

on linking proper nutrition and physical activity as key themes in the healthy aging 

process. One strategy for making this link has been the development and publication of, 

You Can! Steps to Healthier Aging, a community guide detailing a 12-week program to 

help older Americans “eat better” and “move more.” The Center is awarding 10 minigrants to local communities to implement the You Can! Program in 2004. 

AoA provides funding to states to implement health promotion and disease prevention 

activities. Educational information is disseminated through Senior Centers, congregate 

meal sites and home-delivered meal programs. Health screening and risk assessment 

activities including hypertension, glaucoma, hearing, nutrition screening, cholesterol, 

vision, diabetes, bone density and others are also provided. Physical activity and fitness 

programs are provided along with education about the prevention and reduction of 

alcohol, substance abuse, and smoking. Further, the importance of appropriately 

managing medications is emphasized. 

VERB. It’s what you do.

Since the problem of overweight and obesity has also reached America’s young people, 

the youth media campaign, VERB. It’s what you do. was created. VERB’s goal is to 

promote social norms that support physical activity and portray fitness as fun and healthy. 

In order to reach tweens and motivate their participation, HHS/CDC has enlisted partner 

organizations in the campaign, such as 4-H, Boys and Girls Clubs and the National 

Hockey League (NHL), to brand the VERB message and make it appealing to its 

audience. VERB also reaches out to parents and other adults influential to young people, 

encouraging them to support and participate in physical activity with tweens. 

The President’s Council on Physical Fitness and Sports (PCPFS).

Although it is an independent agency, the PCPFS is headquartered at HHS. It promotes 

physical activity for all ages, backgrounds and abilities with information and publications 

(www.fitness.gov) and physical activity/fitness motivational awards programs 

(www.presidentschallenge.org). 
37

Diabetes Activities 

Diabetes Prevention Program. 

The Diabetes Prevention Program demonstrated that prevention of type 2 diabetes is 

possible in high-risk adults, including adults from minority populations who are at 

disproportionately increased risk [55]. 

The Diabetes Prevention Program clinical trial compared three approaches in overweight 

people with impaired glucose tolerance (IGT) to test whether type 2 diabetes could be 

delayed or prevented: 

• lifestyle modification [56] 

• treatment with the insulin-sensitizing drug metformin 

• standard medical advice 

The Diabetes Prevention Program demonstrated that diet and exercise that achieved a 5-

7 percent weight loss reduced diabetes incidence by 58 percent in participants 

randomized to the study's lifestyle intervention group. Participants in this group 

exercised at moderate intensity. The lifestyle intervention was effective in both men and 

women and in all of the racial/ethnic groups. Lifestyle intervention worked particularly 

well in people over age 60, reducing the development of diabetes by 71 percent in this 

group. Volunteers randomly assigned to treatment with metformin had a 31 percent 

lower incidence of type 2 diabetes over the 2.9 year average duration of participation in 

the trial. Metformin was most effective in younger and heavier study participants. 

About twice as many people in the lifestyle group compared to placebo regained normal 

glucose tolerance, showing that diet and exercise can reverse IGT. 

Following the dramatic and positive results of the Diabetes Prevention Program, in 2002 

the American Diabetes Association and the National Institute of Diabetes and Digestive 

and Kidney Diseases (NIDDK) published a position paper on “The Prevention or Delay 

of Type 2 Diabetes” [57]. In addition, a subsequent National Institutes of Health (NIH) 

and CDC co-sponsored study showed that the lifestyle and metformin interventions were 

cost-effective and could be implemented in routine clinical practice [58]. Ongoing 

follow-up studies of the Diabetes Prevention Program patient population are currently 

examining the durability of the interventions in preventing or delaying diabetes onset as 

well as their effects on cardiovascular disease and other diabetes complications. 

National Diabetes Education Program. 

The successful and well-recognized National Diabetes Education Program, a partnership 

of the NIDDK, the CDC, and more than 200 public and private organizations, was 

established to disseminate information about the importance of glucose control in those 

individuals with diabetes following a successful NIDDK-supported trial. Following 

announcement of the Diabetes Prevention Program results, this well-established program 

was expanded to launch the primary prevention campaign, Small Steps, Big 

Rewards, Prevent Type 2 Diabetes, in November 2002. The Small Steps educational 
38

material contains a “Game Plan” for health care providers and patients that gives 

information about implementing a program to prevent or delay disease onset. The Game 

Plan also includes a “fat and calorie counter” as well as a “food and activity tracker” so 

individuals can more easily monitor food intake and physical activity level. The Small 

Steps, Big Rewards, Prevent Type 2 Diabetes campaign has reached millions of people.

Diabetes Prevention Prototype Collaborative.

A pilot with five HRSA-funded health centers was initiated in November 2002 to 

translate the results of the Diabetes Prevention Program into practice, utilizing the 

Health Disparity Collaborative strategy and models. The Health Resources and Services 

Administration (HRSA), CDC, NIDDK/NIH, and the MedStar Research Institute support 

the Diabetes Prevention Prototype Collaborative. Health Disparity Collaboratives

represent a multi-pronged approach to improve quality that includes a care model, a 

system improvement model, and a model of learning and sharing that allows for 

systematic spread of quality improvements. Health Centers participate in year-long 

intense learning and quality improvement activities that involve attending learning 

sessions and a final meeting to disseminate outcomes. Health Centers report the results 

of nationally shared measures while disseminating successful changes throughout their 

system of care through uniform, nationally recognized process and outcome measures. 

As part of the Diabetes Prevention Collaborative pilot, teams have tested and 

implemented successful strategies to identify persons at-risk for diabetes, and screen 

them. As of November 2003, 3,167 high-risk persons have been identified; 903 (28.5 

percent) have been screened, resulting in 276 (30.6 percent) prediabetes patients in the 

registry and 155 (17.2 percent) newly diagnosed persons with diabetes. Thirty-four 

patients (16.6 percent) have met the goal of 7 percent or greater average weight loss. 

Efforts in American Indian Populations.

American Indians and Alaska Natives (AI/AN) have the highest prevalence rate of 

diabetes in the U.S. Diabetes mortality in AI/AN is increasing, as are the rates of 

diabetes in children and youth. In 1979, Congress established the Indian Health Service 

(IHS) National Diabetes Program to address the epidemic of diabetes in American 

Indians/Alaska Natives (AI/AN). The mission of the National Diabetes Program is to 

develop, document, and sustain a public health effort to prevent and control diabetes in 

AI/AN people. The agency promotes collaborative strategies for the prevention of 

diabetes and its complications in the 12 IHS Administrative Service Areas (regions) 

through coordination of a network of 19 Model Diabetes Programs and 12 Area Diabetes 

Consultants.

The Special Diabetes Program for Indians grant program, first established in1997 and 

now extended through 2008, distributes over 96 percent of its funds through grants 

awarded to 318 programs under 286 administrative organizations within the 12 IHS 

Areas in 35 states. Nationally, 67 percent of the new grant programs are focused on 

primary and secondary diabetes prevention. 
39

Medicare Disease Management Initiatives

Section 721 of the Medicare Prescription Drug, Improvement, and Modernization Act 

(MMA) of 2003 establishes the Chronic Care Improvement Program, a population-based 

approach to helping people with chronic diseases, such as diabetes, manage their illness. 

CMS also has several disease management demonstrations to help people with diabetes 

and other chronic conditions better manage their disease and prevent complications. A 

demonstration established by the Medicare, Medicaid, and SCHIP Benefits Improvement 

and Protection Act of 2000 provides disease management services and a comprehensive 

prescription drug benefit to 30,000 beneficiaries living in California, Arizona, and parts 

of Louisiana and Texas. The Coordinated Care Demonstration established by the 

Balanced Budget Act of 1997, currently operating in 15 sites, is testing whether case 

management and disease management approaches are clinically effective and costeffective. 

Tobacco Activities 

Tobacco use cessation. 

A recent accomplishment is the Public Health Service document, Treating Tobacco Use 

and Dependence: Clinical Practice Guideline, which identifies treatments with 

demonstrated effectiveness in helping smokers quit. This resource will be a tremendous 

aid to Americans trying to quit tobacco use. It is available online at: 

http://www.surgeongeneral.gov/tobacco. 

The FDA approves drugs intended for smoking cessation and has approved over-thecounter use for several of them. These steps have been instrumental in helping people 

quit smoking. Cessation materials across the Department also have been tailored to more 

effectively reach specific populations and decrease tobacco-related health disparities. 

Examples include the National Cancer Institute’s (NCI) La guía para dejar de fumar, a 

smoking cessation guide written in Spanish, and CDC’s Pathways to Freedom, a smoking 

cessation guide tailored to the African American community. This CDC guide provides 

education and guidance for individuals who smoke, helps friends and families be part of 

the solution, and provides strategies for community members who want to educate people 

about the dangers of tobacco. 

The Centers for Medicare and Medicaid Services’ (CMS) Medicare Stop Smoking 

Program is a demonstration project on the most effective and cost-effective ways to help 

Medicare beneficiaries quit smoking. Findings from this project may affect a substantial 

proportion of the country, and have implications for health plans and other populations. 

Programs from across the Department collectively create a comprehensive approach to 

promoting smoking cessation among women, particularly pregnant women. While 

women who smoke during pregnancy comprise a small percentage of the overall 

population, cessation efforts for these women are critical to protect the health and well 
40

being of future generations, including opportunities to continue smoking cessation 

following pregnancy and childbirth. Examples include the National Partnership to Help 

Pregnant Smokers Quit, a coalition of more than 50 federal, national, state, and local 

organizations that has developed guiding strategies around issues critical for pregnant 

women; several National Institute of Nursing Research-funded research projects; and 

CDC’s Dispelling the Myths About Tobacco: A Community Toolkit for Reducing Tobacco 

Use Among Women (www.cdc.gov/tobacco/sgr/sgr_forwomen/sgrtool.htm). These 

studies and programs seek to identify effective cessation and relapse prevention 

techniques, and to provide timely and relevant tools for community programs, including 

mass media and print materials. These efforts are critical to ensure that women who quit 

smoking during pregnancy continue to not smoke. 

Examples of successful collaboration among U.S. public health agencies and 

organizations include: the development of the National Blueprint for Disseminating and 

Implementing Evidence-based Clinical and Community Strategies to Promote Tobacco 

use Cessation, a practical guideline for implementation of cessation strategies with 

demonstrated effectiveness; and the National Blueprint for Action, developed by the 

Youth Tobacco Cessation Collaborative to guide future research on cessation strategies 

for youth. NCI has a toll-free “Smoking Quitline” that will connect individuals with 

information specialists to answer smoking-related questions in English or Spanish. 

The Synar program is one example of an effective collaboration between HHS and State 

governments to effectively prohibit the sale of tobacco products to minors. As a result, 

the rate at which retailers are willing to sell tobacco products to minors has decreased 

from a high of 41 percent in 1996 to approximately 14.5 percent in the most recent 

surveys in 2003. 

In February 2004, Secretary Thompson announced plans for a new toll-free telephone 

number that will serve as a single access point to the national network of “quitlines.” By 

providing one easy-to-remember number, smokers in every state will have access to the 

tools they need to quit smoking. The program has three main components: (1) States 

with existing “quitlines” will receive increased funding to enhance existing state 

“quitline” services. States could use these supplements to expand their hours of operation, 

hire bilingual counselors, build referral linkages with local health care systems, or 

promote “quitlines” to more individuals. (2) States that do not have “quitlines” will 

receive grants to establish them to provide their residents the tools that they need to quit 

smoking. (3) HHS' National Cancer Institute (NCI) Cancer Information Service 

telephone counselors will provide assistance to individuals in states without “quitlines.” 

HHS and its partner organizations also have helped state tobacco control programs 

through the creation of Smokefree.gov, the Web-based cessation tool provided by NCI 

with support from CDC and others, as well as by providing access to low-cost mass 

media materials and delivering relevant technical assistance and training through CDC’s 

Media Campaign Resource Center. 
41

Youth prevention. 

HHS has overseen the development of an array of programs to help youth through the 

media and in the home, classroom, and community. For example, the National Institute 

of Child Health and Human Development (NICHD) developed Smoke-Free Kids to lower 

children’s risk of future smoking by engaging their smoking parents in a home-based 

anti-smoking socialization program. In addition, comprehensive adolescent and school 

health programs, as recommended and supported by CDC, HRSA, and NCI, remain a 

critical link to improving the decision-making of our youth. HRSA’s Project Connect, 

for example, works to connect school-based efforts with community programs, thereby 

promoting consistent messages and reducing the likelihood of tobacco use among highrisk populations.

HHS agencies will continue monitoring youth tobacco-related behaviors through such 

programs as the following. The successful, ongoing surveillance of this ever-changing 

population through established tools, such as the National Institute on Drug Abuse 

(NIDA) Monitoring the Future Study, CDC’s Youth Risk Behavior Survey, and the 

Substance Abuse and Mental Health Services Administration’s (SAMHSA) National 

Survey on Drug Use and Health, has been vital to determine trends and focus efforts at 

the federal, state, and local levels. The Synar Regulation, which is implemented and 

monitored by SAMHSA's Center for Substance Abuse Prevention, and requires States, 

the District of Columbia and Territories to enact and enforce tobacco access laws that 

restrict the availability of tobacco products to youth under 18 years of age, has been 

demonstrated to be effective in reducing illegal sales to minors. 

Tobacco research. 

The simple facts about tobacco use – that it causes death and disease and results in a 

tremendous social and economic burden – are well documented. There is still a great 

deal to be known. NIH is conducting research aimed at better understanding the 

biological, genetic, and behavioral aspects of nicotine addiction, which will aid in the 

development of more effective pharmacological and behavioral treatments. 

As new tobacco products and cessation aids become available, many questions arise 

regarding their efficacy and health effects. 

Data collection on youth and adult knowledge, attitudes, and behaviors is conducted 

through a multi-factorial surveillance system for both adults and youth by CDC, NIH, 

and SAMHSA. This surveillance remains critical to understanding the impact of tobacco 

use over time, and to monitor trends in tobacco use among specific populations. 

The Department supports an extensive training network to provide technical assistance 

and expertise to State and local tobacco control program staff to implement the findings 

of Department-wide research. Examples include the National Conference on Tobacco or 

Health, CDC’s Annual Leadership Forum, Community Guide Workshops, and 

Disparities Pilot Training Programs. Through coordinated efforts across the agencies, 
42

communication campaigns disseminate key information to the public regarding effective 

cessation treatments, the hazards of exposure to secondhand smoke, and other prevention 

messages. 

Health Literacy Activities 

Research. 

HHS agencies conduct and sponsor research on the prevalence of low health literacy 

among specific populations and for specific topic areas; the barriers, skills and needs of 

low literacy audiences; different audiences’ health attitudes, knowledge, preferences, 

sources of information, and behaviors; and the health effects of low literacy and low 

health literacy. Most of this research is ongoing and part of broad programs in health 

communication research; specific topic areas, such as cancer, oral health, or dietary 

practices; or assessment of program operations, such as the National Medicare Education 

Program. Examples of health literacy research include: 

• First-ever national assessment of health literacy as part of the 2003 National 

Assessment of Adult Literacy (NAAL), in partnership with the U.S. Department of 

Education. Data will be available in 2005. 

• An evidence-based practice report on literacy and health outcomes was released in 

April 2004 by AHRQ. (A summary of Literacy and Health Outcomes is available 

online at www.ahrq.gov/clinic/epcsums/litsum.htm.) 

• The Institute of Medicine report, Health Literacy: A Prescription to End Confusion, 

sponsored in part by the National Cancer Institute, was released in April 2004. 

Guidelines and tools to improve communication with the public. 

HHS agencies have developed a large number of guidelines and tools to apply to HHS 

programs and communication. They address how to develop materials for print, video 

and Web sites to improve audiences’ understanding. Most of the agency-developed tools 

and guidelines are not specific to working with low literacy audiences. Some are based 

on plain language principles, and others promote well-recognized good health 

communication practices. Examples of guidelines and tools that can be used to improve 

public understanding include:

• Scientific and Technical Information: Simply Put – a guide to communicating in plain 

language from the CDC 

http://www.cdc.gov/communication/resources/resource_idea.htm

• HORIZONS Project – a communication toolkit that provides information on 

demographic research, tip sheets and sample prototype communication products for 

working with minority populations from CMS. 
43

• Research-based web design and usability guidelines from the NCI 

http://usability.gov/guidelines/

• Research-based web design and usability guidelines for older adults from the 

National Institute on Aging (NIA) http://nihseniorhealth.gov/about.html

Training and skill building. 

The Department supports training in clear and effective communication or plain language 

training for staff, grantees, and health professionals or intermediaries, such as lay 

community workers. CDC has a broad-based agency training program in health 

communication, health literacy, and effective Web-based communication. Other training 

activities in the department are individual efforts related to increasing health 

professionals’ knowledge of how to communicate about a specific health topic or with 

culturally diverse audiences, increasing translators’ and lay workers’ competence, or 

broad health communication and health literacy training. Examples of training and skill 

building include: 

• Agency and nationwide health communication, health literacy and risk 

communication training through the health communication certificate program and 

CDCynergy CDRom modules from CDC. 

• Training of healthcare providers in plain language, clear and effective 

communication, and health literacy through Area Health Education Centers, funded 

by HRSA. 

• NIH Plain Language Initiative and Award program – NIH requires the use of plain 

language in all new documents for the public, government entities and staff, and 

provides annual awards to staff for the effective use of plain language. 
44

APPENDIX B - STEPS COMMUNITY GRANTS 

In 2003, HHS awarded 12 communities with five-year grants to implement effective 

community-based chronic disease prevention and control programs. Twelve 

communities were selected for their innovative proposals to improve the health of their 

target populations. (For more information, visit: www.healthierus.gov/steps/grants.html.) 

The ultimate goal of these Steps Community grants is to improve the health of individuals 

in the communities. They do this by working to decrease risk factors for chronic 

diseases, to prevent the occurrence of these diseases, and to decrease their consequences 

in people’s lives. Each community focuses on three areas--asthma, diabetes and 

obesity—and, given the emphasis on prevention, each community also works to address 

the factors that put individuals at risk for these diseases, such as nutrition, physical 

activity, and preventive health screenings. 

 

Each grantee has assembled a community partnership that is charged with improving both 

the broader public’s health, as well as the health of specific target groups. These 

partnerships pursue interventions that address the community and the environment by: 

• Using media and information technology to educate and foster healthy behaviors; 

• Influencing the environment in ways that support and promote health and healthy 

lifestyles; 

• Fostering social support healthy behaviors and choices; and 

• Improving access to and quality of health care services. 

They also address the school environment by: 

• Establishing full-time health coordinators or councils; 

• Providing physical education for students; 

• Implementing staff wellness programs; 

• Ensuring the availability of healthy food choices in the schools; and 

• Establishing tobacco-free environments. 

Grantees 

Tribe

Intertribal Council of Michigan 

State-Coordinated Small Cities/Rural 

Communities

Washington 

New York 

Arizona 

Colorado 

Large Cities/Urban Communities

Seattle-King County, Wash. 

Salinas-Monterey County, Calif. 

Austin-Travis County, Texas 

New Orleans, La. 

Philadelphia, Pa. 

Boston, Mass. 

Pinellas County, Fla. 
45

APPENDIX C - STEPS INNOVATION AWARDS 

Innovation on the part of local groups and businesses is a central focus of the Steps 

Initiative. Secretary Thompson recently recognized eight organizations, in seven separate 

categories, for their creativity in helping Americans stay healthy in one or more of the 

following areas: asthma, cancer, diabetes, heart disease and stroke, obesity, physical 

activity, poor nutrition, and tobacco use. These eight Innovation Award recipients have 

modeled the Department’s ideals of partnership and individual action, and serve as 

examples for other groups and organizations: 

Faith Based Organization--The Church Health Center (Memphis, TN) was recognized 

for reaching more than 5,000 people each month, in its efforts to provide health care for 

the uninsured and prevention services to the community at large. 

Health Care Delivery System—The Southeast Kentucky Community Access Program

[SKYCAP] (Hazard, KY) was recognized for its innovative “patient navigators” 

program, which trains local residents to be advocates for the care and rehabilitation of 

individuals suffering from chronic diseases and other health conditions. 

Healthy Workplace/Small Employer---The Waco-McLennan County Public Health 

District Worksite Wellness Training Program (Waco, TX) was recognized for supporting 

and encouraging employees to set personal fitness goals and to establish flexible exercise 

routines. The program offers workers paid time to exercise and record their progress, 

which has resulted in greater physical activity, lower body weight and improved health 

statistics for participants. 

Healthy Workplace/Large Employer— The Johnson & Johnson (New Brunswick, NJ) 

was recognized for the success of its health and wellness program, which integrates 

disabilities management, employee assistance and occupational health into a 

comprehensive wellness approach that has reduced health risk among employees and 

saves approximately $9 million annually in medical expenses and administrative costs. 

Healthy Workplace/Large Employer—The Union Pacific Railroad (Omaha, NB) was 

recognized for its Health Index and Health Track programs. These comprehensive 

programs provide at-risk employees and work groups with opportunities to establish 

health goals and to monitor their progress toward improving their health. 

Schools (K-12)—The American Cancer Society’s Healthy Kids Network was recognized 

for its success in educating and mobilizing parents on how to promote healthier habits 

among children. Their efforts have brought about changes in school policies and 

educational materials, as well as improved the quality of school health programs in 19 

States. 

Public Sector—The Seattle-King County Healthy Homes Project (Seattle, WA) was 

recognized for its success in using community health workers to educate families on how 
46

to maintain “asthma-friendly” homes, as well as to educate public housing officials and 

builders on how to reduce “asthma triggers” in public housing and new construction. 

Non-Profit—The Campuses Organized & United for Good Health [COUGH], 

California Youth Advocacy Network [CYAN] (Sacramento, CA) was recognized for its 

success in fostering a campaign to establish healthy environments for students, ultimately 

making it possible for State Universities to create 20-foot no smoking zones around 

buildings and entrances. 

For more information: http://www.healthierus.gov/steps
47

APPENDIX D - THE PRESIDENT’S CHALLENGE 

The President’s Challenge is a physical activity and fitness awards program—a longstanding program of the President’s Council on Physical Fitness and Sports that is 

designed to motivate Americans of all ages, backgrounds and abilities to be physically 

active every day. To advance this goal, individuals are challenged to build a personal 

“Active Lifestyle Plan” that includes meeting an activity goal of exercising at least 5 days 

a week, for a total of 6 weeks, in order to Get Fit! Participants in the program are 

encouraged to track their activities and record their progress on paper or through an 

interactive website. The website, www.presidentschallenge.org, offers participants, as 

well as groups, the opportunity to collect useful health and fitness information, to tailor 

their Active Lifestyle Plans to their own personal characteristics, such as age, gender and 

current level of fitness, and to challenge and support others in achieving their fitness 

goals. Since its inception, the President’s Challenge has helped to motivate millions of 

people each year to be physically active. There are currently four President’s Challenge

programs: 1) Active Lifestyle Program—helping Americans ages 6 years and up become 

active, 2) Presidential Champions Program—encouraging already-active individuals to 

strive for even greater fitness improvements, 3) Physical Fitness Program—helping 

educators and community leaders plan events to assess the physical fitness of young 

people and recognize their achievements, and 4) Health Fitness Program—recognizing 

students who achieve a healthy level of fitness. This motivational, interactive tool has 

attracted corporations, community groups, schools, and state governors who are adopting 

the President’s Challenge to track physical activity within diverse venues. 

 
48

APPENDIX E - MEDICARE PREVENTIVE BENEFITS 

New Medicare Benefits in 2005 

• “Welcome to Medicare” visit (initial preventive exam)

• Diabetes screening

• Cardiovascular disease screening

Immunizations & Vaccinations

• Influenza 

• Pneumococcal 

• Hepatitis B 

Screening & Detection 

• Mammography 

• Pap test & pelvic exam 

• Colon cancer screening tests 

• PSA test & rectal exam 

• Bone density measurements 

• Glaucoma testing 

Chronic Disease Management

• Diabetes self-management 

• Medical nutrition therapy 
49

APPENDIX F - INCENTIVES FOR HEALTHY BEHAVIOR 

Employers and health plans may have questions about how the Health Insurance 

Portability and Accountability Act of 1996, and the Americans with Disabilities Act, 

apply to wellness programs and incentives for their employees or enrollees. In particular, 

they may want to know whether these laws prevent employers and health insurers from 

providing incentives for healthy behaviors or imposing penalties for unhealthy behavior. 

Health Insurance Portability and Accountability Act (HIPAA) 

Under HIPAA, group health insurance plans generally may not charge similarly situated 

individuals different premiums or contributions, based on a health factor.1

 For example, 

people whose body mass index is lower may not be charged a different premium or 

contribution from those having a higher body mass index, based on the body mass 

differential. However, group health insurance plans are not prohibited from establishing 

premium discounts or rebates, or modifying otherwise applicable copayments or 

deductibles in return for “adherence to programs of health promotion and disease 

prevention.”2 Such programs are often referred to as “bona fide wellness programs.”3 

A proposed regulation laying out the parameters for such “wellness” programs has been 

issued4; a final rule is expected to be published in 2005. Until then, the proposed rule 

indicated that group plans and issuers can currently rely on the proposed requirements in 

the proposed regulation in establishing bona fide wellness plans.5 The proposed rule 

stipulates that, if a program’s reward is contingent upon satisfying a standard related to a 

health factor: 

• The rewards that are offered to an individual must be limited. 

• The program must be reasonably designed to promote good health or prevent disease 

for the individuals in the program, and must give eligible individuals the opportunity 

to qualify for the reward at least once per year. 

• The reward must be available to all similarly situated individuals, and a reasonable 

alternative standard must be made available for any individual for whom, due to a 

health factor, it would be unreasonably difficult to meet the initial standard (or for 

whom it is medically inadvisable to attempt to satisfy that standard). 

• All plan materials that describe the terms of the wellness program must disclose the 

availability of a reasonable alternative standard.6

 

1 45 C.F.R. § 146.121(c); 42 U.S.C. 300gg-1(b)(1).

2

 42 U.S.C. 300-gg-1(b)(2)(B) 3 45 C.F.R. § 146.121(c)(3); 66 FR 1421, 1422.

4

 66 FR at 1421. 5

 66 FR at 1422. 6

 45 C.F.R. § 146.121(f), as proposed at 66 FR at 1434.
50

Finally, a wellness program that merely provides reimbursement for a health club 

membership or merely provides a health benefit, regardless of health status, does not 

have to satisfy the above requirements of a “bona fide wellness program,” because it does 

not require satisfaction of a standard related to a health factor and since it provides no 

rewards or penalties.7

The Americans with Disabilities Act (ADA): Nothing in the Americans with 

Disabilities Act (ADA) prohibits employers or health insurers from implementing 

wellness programs that are geared at promoting good health and disease prevention. The 

ADA prohibits covered entities from denying, on the basis of disability, qualified 

individuals with disabilities an equal opportunity to participate in, or receive benefits 

under, programs or activities conducted by those entities.8

Whether a wellness program that offers rewards or discounts to employees for weight 

loss or maintaining a certain body mass index violates the ADA will depend on how the 

program is designed and implemented. Under the proposed HIPAA nondiscrimination 

regulations, employers are permitted to offer discounts or rebates in return for 

employees’ adherence to programs of health promotion and disease prevention. The 

proposed HIPAA regulations for wellness programs describe a wide range of wellness 

programs that comply with the HIPAA nondiscrimination requirements without having to 

satisfy any additional standards.9

 In addition, employers would have flexibility to design 

wellness programs, other than those listed in the proposed regulations, that would also 

comply with HIPAA’s nondiscrimination requirements, if certain requirements are met. 

One of the proposed requirements is the reasonable alternative standard. The reasonable 

alternative standard would require employers to make an alternative standard available to 

individuals for whom it is unreasonably difficult to meet the initial standard (or for whom 

it is medically inadvisable to do so). 

Under the proposed HIPAA regulations for wellness programs, employers and health 

plans have considerable flexibility in designing wellness programs. That flexibility 

would also be useful to them in designing wellness programs that would be permissible 

under the ADA. However, employers and health plans should be aware that compliance 

with the proposed HIPAA wellness program requirements is not determinative of 

compliance with the ADA.10 Therefore, they should consider the applicability of the 

ADA to their wellness programs and may want to seek legal guidance in designing and 

implementing such programs to ensure that they comply with ADA nondiscrimination 

requirements. 

 

7

 66 FR 1421, 1422. 8

 42 U.S.C. § 12101. 9

 45 C.F.R. § 146.121(f)(1), as proposed at 66 FR at 1434. 10 45 C.F.R. § 146.121(b) and (h).
51

Conclusion 

While in general these laws do not prohibit wellness programs, their bearing on specific 

employer or health plan incentives for health and wellness is a matter of legal 

interpretation. Therefore, employers and health plans may want to seek legal guidance in 

designing and implementing wellness programs. 
52

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