The Surgeon General’s Vision 

for a Healthy and Fit Nation 

2010 

U.S. Department of Health and Human Services 
The Surgeon General’s Vision 

for a Healthy and Fit Nation 

2010 

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Office of the Surgeon General 

Rockville, MD 
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES 

Public Health Service 

Office of the Surgeon General 

This publication is available on the World Wide Web at 

http://www.surgeongeneral.gov 

Suggested Citation 

U.S. Department of Health and Human Services. The Surgeon General’s Vision for a Healthy and 

Fit Nation. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon 

General, January 2010. 
INTRODUCTION ◊ 1

MESSAGE FROM THE SURGEON 

GENERAL 

Our nation stands at a crossroads. Today’s 

epidemic of overweight and obesity threatens the 

historic progress we have made in increasing 

American’s quality and years of healthy life. 

Two-third of adults1

 and nearly one in three 

children are overweight or obese.2

 In addition, 

many racial and ethnic groups and geographic 

regions of the United States are 

disproportionately affected.3

 The sobering impact 

of these numbers is reflected in the nation’s 

concurrent epidemics of diabetes, heart disease, 

and other chronic diseases. If we do not reverse 

these trends, researchers warn that many of our 

children—our most precious resource—will be 

seriously afflicted in early adulthood with 

medical conditions such as diabetes and heart 

disease. This future is unacceptable. I ask you to 

join me in combating this crisis. 

Every one of us has an important role to play in 

the prevention and control of obesity. Mothers, 

fathers, teachers, business executives, child care 

professionals, clinicians, politicians, and 

government and community leaders—we must 

all commit to changes that promote the health 

and wellness of our families and communities. 

As a nation, we must create neighborhood 

communities that are focused on healthy nutrition 

and regular physical activity, where the healthiest 

choices are accessible for all citizens. Children 

should be having fun and playing in 

environments that provide parks, recreational 

facilities, community centers, and walking and 

bike paths. Healthy foods should be affordable 

and accessible. Increased consumer knowledge 

and awareness about healthy nutrition and 

physical activity will foster a growing demand 

for healthy food products and exercise options, 

dramatically influencing marketing trends. 

Hospitals, work sites, and communities should 

make it easy for mothers to initiate and sustain 

breastfeeding as this practice has been shown to 

prevent childhood obesity. Working together, we 

will create an environment that promotes and 

facilitates healthy choices for all Americans. And 

we will live longer and healthier lives. 

In the 2001 Surgeon General’s Call to Action to 

Prevent and Decrease Overweight and Obesity , 

former Surgeon General David Satcher, MD,

PhD, warned us of the negative effects of the 

increasing weight of our citizens and outlined a 

public health response to reverse the trend.4

 I 

plan to strengthen and expand this blueprint for 

action created by my predecessor. Although we 

have made some strides since 2001, the 

prevalence of obesity, obesity-related diseases, 

and premature death remains too high. 

I am calling on all Americans to join me in a 

national grassroots effort to reverse this trend. 

My plan includes showing people how to choose 

nutritious food, add more physical activity to 

their daily lives, and manage the stress that so 

often derails their best efforts at developing 

healthy habits. I envision men, women, and 

children who are mentally and physically fit to 

live their lives to the fullest. The real goal is not 

just a number on a scale, but optimal health for 

all Americans at every stage of life. To achieve 

this goal, we must all work together to share 

resources, educate our citizens, and partner with 

business and government leaders to find creative 

solutions in our neighborhoods, towns, and cities 

from coast to coast. Together, we can become a 

nation committed to become healthy and fit. 

Regina M. Benjamin, MD, MBA

VADM, USPHS

Surgeon General
2 ◊ BACKGROUND

Background on 

Obesity 

Obesity poses a major public health challenge. 

Each year, obesity contributes to an estimated 

112,000 preventable deaths.5

 Obese adults are at 

increased risk for many serious health conditions, 

including high blood pressure, high cholesterol, 

type 2 diabetes and its complications, coronary 

heart disease, stroke, gallbladder disease, 

osteoarthritis, sleep apnea, and respiratory 

problems, as well as endometrial, breast, 

prostate, and colon cancers.6

 Children with a high 

body mass index (BMI), an indicator of excess 

body weight, are more likely than those with a 

normal BMI to have insulin resistance7

 (which 

can lead to diabetes), high blood pressure, and 

unhealthy levels of fats and other lipids. 

Furthermore, obese children often become obese 

adults; some studies have found that even 2- to 5-

year-olds with a high BMI are likely to become 

obese adults.8

 Besides suffering from physical 

illnesses, obese adults and children also may 

experience social stigmatization and 

discrimination, as well as psychological 

problems. 

In recent decades, the prevalence of obesity has 

increased dramatically in the United States, 

tripling among children and doubling among 

adults.1-2,9-10 This epidemic increase is the result 

of specific changes in our environment and 

behaviors in susceptible people. High-calorie, 

good-tasting, and inexpensive foods have 

become widely available and are heavily 

advertised. Portion sizes have increased,11 and we 

are eating out more frequently.12 Our children 

drink more sugar-sweetened beverages than they 

did in the past, and they are drinking fewer 

beverages such as water or low or non- fat milk13

that are healthier for growing minds and bodies. 

However, dietary changes are not completely 

responsible for the epidemic. 

Widespread adoption of multiple technological 

innovations in the home, workplace, and schools 

has reduced our daily physical activity. Similarly, 

the car-dependent design of our communities has 

made it much harder for our children to walk to 

school—and much harder for us to shop and do 

other errands entirely on foot or by bicycle. On top 

of these changes, many of our nation’s schools 

have cut back or eliminated recess and physical 

education programs.14 

This document highlights the trends, health 

consequences, and causes related to the obesity 

epidemic. Given the multiple social changes behind 

the epidemic, this brief also proposes healthpromoting actions that can be taken by multiple 

sectors of society. 

Trends 

The prevalence of obesity changed relatively little 

during the 1960s and 1970s, but it increased 

sharply over the ensuing decades—from 13.4% in 

1980 to 34.3% in 2008 among adults and from 5% 

to 17% among children during the same period.1-2,9-

10 The prevalence of extreme obesity also increased 

during 1976–1980 and 2007–2008, and 

approximately 6% of U.S. adults now have a BMI 

of 40 kg/m2 or higher.15 

The United States is not alone in experiencing an 

obesity epidemic. Similar increases in the

prevalence of obesity have been reported in 

developed countries such as England and in 

countries where obesity was formerly rare.16-17 For 

example, the prevalence in China among 

preschool-aged children living in urban areas has 

increased eightfold—from 1.5% in 1989 to 12.6% 

in 1997.18

Disparities 

The burden of obesity is disproportionately borne 

by some racial and ethnic groups. For example, 

among 40- to 59-year-old women, about 52% of 

non-Hispanic blacks and 47% of Hispanics are 

obese; for non-Hispanic whites, the prevalence is 

36%.19 These differences also are seen among 

children and teenagers. For example, obesity is 
BACKGROUND ◊ 3

much more common among non-Hispanic black 

teenagers (29%) than among Hispanic teenagers 

(17.5%) or non-Hispanic white teenagers 

(14.5%).19 

The burden of obesity and the severity of related 

health conditions vary among different 

population groups. While obesity is a public 

health crisis within the general population, it is 

even more prevalent in persons with mental 

illness20-21 with some reports indicating 83% of 

people with serious mental illness being 

overweight or obese.22 This puts people with 

mental disorders in double jeopardy. Not only 

are they dealing with a mental disorder that often 

leads to social isolation, a sedentary lifestyle and 

physical inactivity – all risk factors for obesity - 

but they are also vulnerable to the chronic 

diseases associated with being overweight, mood 

instability and low self-esteem.23 People with 

serious mental illness have shortened life-spans, 

on average living only until 53 years of age.24

Their deaths are not brought on by their mental 

illness, but rather from other chronic health 

conditions, including obesity. Many people are 

not aware that rapid weight gain is one of the 

most common and alarming side effects of 

psychiatric medications for both children and 

adults.25 Youth aged 4 to 19 being treated with 

antipsychotic medications gained more than 7% 

of their total body weight in 12 weeks.26 Clearly 

persons with mental illness are a vulnerable 

population at high-risk for obesity and obesityrelated disorders. 

Measuring Overweight and Obesity 

Obesity is generally defined as excess body fat. 

However, since excess body fat is difficult to 

measure directly, obesity is often defined as 

excess body weight as measured by BMI. BMI, 

which is calculated as weight in kilograms 

divided by height in meters squared, is used to 

express weight adjusted for height. Although 

BMI has limitations as a measure,27 it has been a 

useful indicator of overweight and obesity. For 

example, several studies have found that adults 

with a high BMI are at increased risk for various 

diseases6

Figure 1. Adult BMI Classification 

Underweight ≤ 18.5 

Healthy Weight 18.5-24.9 

Overweight 25-29.9 

Obese ≥ 30 

Figure 2. Children BMI Classification 

Underweight ≤ 5th percentile 

Healthy Weight 5th to the 85th percentile 

Overweight 85th to the 95th percentile

Obese ≥95th percentile 

*BMI for Age Percentile [Age 2-19] 

and children who have a high BMI are likely to 

have relatively high levels of body fatness.28 Adults 

who have a BMI of 25.0 to 29.9 are considered to 

be overweight, those with a BMI ≥ 30 are 

considered obese, and those with a BMI ≥ 40 are 

considered extremely obese.6,29

In overweight and obese adults and children, other 

health risk factors (such as blood pressure, blood

sugar, and blood fats) should be assessed, as 

recommended by published guidelines. Because 

excess body fatness in the abdomen can be a 

marker for increased health risk even at a lower 

BMI, measurement of waist circumference is 

recommended in overweight and obese adults.30

BMI does not distinguish between lean tissue and 

body fat, and some growing children or athletic 

children and adults will have a BMI in the 

overweight or obese range without having an 

excess of body fat.31 However, most children and 

adults with a BMI in the range considered obese 

will also have excess body fat. 

Assessing if a child is at a healthy weight is 

complex. While BMI is often utilized, clinical

assessment and other markers should be considered 

when determining a child’s overall health and 

development. Among children, the marked BMI 

changes that occur with growth and development 

make it necessary to specify a high 
4 ◊ BACKGROUND

BMI relative to children of the same sex and age. 

The 2000 CDC growth charts are32 used for this 

purpose in the United States. Children and 

adolescents with a BMI at or above the sex-and 

age-specific 95th percentile of this reference 

population are often considered obese, and those 

with a BMI between the 85th and 94th 

percentiles are often considered overweight.33

Although these cut points are not diagnostic 

criteria, elevated BMI among children most often 

indicates increased risk for future adverse health 

outcomes and/or development of disease. 

Health Consequences 

Obesity in early life has been found to increase 

the risk for various diseases in adulthood, 

including diabetes and heart disease, in part 

because obese children are likely to become 

obese adults.34-35 Several studies also have found 

short-term effects of excess weight during 

childhood—for example, high BMI levels among 

children and teenagers are associated with 

childhood development of atherosclerosis.36-38

The growing U.S. obesity epidemic is reflected in 

the tripling, since 1980, of the number of 

Americans who have diabetes.39 Approximately 

8% of U.S. adults have type 2 diabetes,40 a 

disease that increases the risk for cardiovascular 

disease, stroke, kidney disease, blindness, lowerlimb amputation and other problems. Obesity is 

the most important risk factor for type 2 

diabetes.41 Although type 2 diabetes has 

traditionally been viewed as developing among 

middle-aged (or older) adults, type 2 diabetes is 

now occurring in early life.42 Although the rate of 

type 2 diabetes in children has increased, it is 

very low42 (one quarter of 1 percent), but more 

than 75% of children and adolescents with type 2 

diabetes are obese.43-44 The poor glycemic control 

of many adolescents with type 2 diabetes,45 along 

with the increased duration of diabetes diagnosed 

in early life, may increase the risk of subsequent 

complications. 

Causes of Obesity 

In addition to consuming too many calories and 

not getting enough physical activity, genes, 

metabolism, behavior, environment, and culture 

can also play a role in causing people to be 

overweight and obese. Identifying determinants 

of and supporting changes in behaviors and in the 

environment are likely to be the most effective 

actions to combat obesity. Key modifiable risk 

factors are physical activity, sedentary behavior 

and diet. Physical activity plays several important 

roles in the prevention and control of obesity, and 

it is essential for health at any weight. Increased 

physical activity and decreased sedentary 

behavior are associated with lower rates of 

obesity, and it reduces the risk for many of the 

diseases associated with obesity, such as diabetes 

and heart disease. 

A healthy diet is also important. Beginning early 

in life, breastfeeding is a relatively short-term 

intervention which has significant long-term 

potential for maintaining a lower BMI.46 At any 

stage of life, increased consumption of excess 

calories from fats and added sugars in foods that 

are energy dense, such as fast food, is associated 

with obesity. These foods are relatively higher in 

calories than nutrients that are needed for health. 

Sugar-sweetened beverages, such as soda, 

contribute to excess calorie intake from added 

sugars or displace more nutritious foods in the 

diet. Some evidence suggests that the body may 

not compensate for the calories consumed with 

these beverages.47 In contrast, consumption of 

fruits and vegetables in place of high calorie 

foods may reduce the risk for obesity and help 

sustain weight loss because the body’s sense of 

fullness at meals is partly regulated by volume. 

Fruits and vegetables contain few calories and 

are bulky foods, so they have a low caloric 

density and are more filling than fast foods. 

The amount of time spent watching television is 

another association with obesity in both children 

and adults. The association with obesity may be 

mediated in part by the effects of television time 

on food consumption. The more time children 

spend watching television, the more likely they 

are to eat while doing so and the more likely they 

are to eat the high-calorie foods that are heavily 

advertised on television.48 
PREVENTION ◊ 5

Stress is another contributing factor to 

overweight and obesity. Studies have shown 

chronic stress adversely affects blood pressure 

and cholesterol and may lead persons to increase 

their caloric intake.49 Furthermore stress may 

limit people’s motivation and ability to adopt 

positive weight-related behaviors.50

Opportunities for 

Prevention 

Interventions to prevent obesity should focus not 

only on personal behaviors and biological traits, 

but also on characteristics of the social and 

physical environments that offer or limit 

opportunities for positive health outcomes. 

Critical opportunities for interventions can occur 

in multiple settings: home, child care, school, 

work place, health care, and community. 

Individual Healthy Choices and Healthy 

Home Environments 

As a society, we have to begin to change our 

habits one healthy choice at a time. Change starts

with the individual choices we as Americans 

make each day for ourselves and those around us. 

Balancing good nutrition and physical activity 

while managing daily stressors is always a 

challenge, but one that can be achieved. Finding 

time to shop for and prepare healthy meals after 

work and between family activities requires 

planning. Stress and a lack of available healthy 

and affordable foods are some of the reasons why 

many people turn to fast food as a regular source 

for meals. Eating excess calories contributes to 

obesity, but so does watching too much 

television48 and sitting for hours in front of a 

computer. 

This fact is especially true for children and 

teenagers. Technological advancements have 

made our lives more convenient—but also more 

sedentary. Research shows that leading an 

inactive life not only increases the risk of 

becoming overweight or obese, but also 

contributes to an increased risk for disease and 

disability.51 

The good news is that we can overcome these 

challenges—and the reward is the creation of a 

healthy and fit nation. Healthy choices include:51-

53

• Reducing consumption of sodas and 

juices with added sugars. 

• Reducing consumption of energy dense 

foods that primarily contain added sugars 

or solid fats. 

• Eating more fruits, vegetables, whole 

grains, and lean proteins. 

• Controlling your portions. 

• Drinking more water. 

• Choosing low-fat or non-fat dairy 

products. 

• Limiting television viewing time and 

consider keeping televisions out of 

children’s rooms. 

• Becoming more physically active 

throughout the day. 

• Breastfeeding exclusively to 6 months. 

Creating a Healthy Home Environment 

As adults, we need to help our children get off to 

a good start. The earliest risks for childhood 

obesity begin during pregnancy. Excess weight 

gain, diabetes, and smoking during pregnancy are 

not just health risks for the mother—they also put 

children at risk for obesity early in life. Keeping 

pregnancy weight gain within recommended 

limits will help prevent diabetes in the mother. 

Stopping cigarette smoking and abstaining from 

alcohol and drug use will protect the health of the 

mother and the baby. 

The earliest decisions regarding food, activity, 

and television viewing occur in the home. 

Parents and other caregivers play a key role in 

making good choices for themselves and their 

loved one. Children and teenagers look to their 

mothers and fathers and other caregivers to 

model healthy lifestyle habits, and adults need to 

teach by example. In some households, several 

generations may live together or have 

responsibility for children at different times 
6 ◊ PREVENTION

during the day. This sharing of duties requires 

coordination and consistency in activities and 

habits related to food shopping and preparation, 

access to physical activity, and limits on 

television and computer use. 

Both young children and teenagers learn from the 

choices they see adults make. One way to help 

children learn is to involve all family members in 

family-based physical activities and in planning, 

shopping for, and preparing meals. These 

activities provide both an education in healthy 

nutrition and exercise, as well as a critical 

foundation for how to make healthy lifestyle 

choices. 

Healthy Food Choices 

The first decision that parents make about what 

to feed their child occurs during pregnancy. After 

the baby is born, mothers should breastfeed 

whenever possible because it provides the 

highest quality of nutrition and helps to prevent 

early childhood obesity.46 By age 2, children 

should be drinking low-fat or non-fat milk. As 

parents, we are in charge of the foods we provide 

to our children. Creativity with food preparation 

can often solve the problems presented by picky 

eaters. Adults also should offer children small 

portions and show them how to eat slowly and 

enjoy their meal. 

Healthy Teenagers 

The teenage years present unique challenges. 

Adolescence is a time of vulnerability to the 

development of psychiatric disorders, including 

eating disorders, depression, drug and alcohol 

abuse. Adolescent boys and girls are subjected to 

significant peer pressure related to eating and 

exercise, and most school systems provide 

limited opportunities for physical activity. 

Teenagers often drink more carbonated and 

caffeinated beverages and eat more fast foods. 

These multiple stresses and unhealthy habits 

make teenagers particularly vulnerable to 

becoming sedentary, overweight, and obese. An 

obese teenager has a greater than 70% risk of 

becoming an obese adult.34 Parents should guide 

their teenagers to become fit and healthy adults 

while being cautious not to trigger unhealthy 

eating behaviors or eating disorders. 

Physical Activity 

Scheduling time for the recommended levels of 

physical activity is essential to overall health. 

Physical activity can help control weight, reduce 

risk for many diseases (heart disease and some 

cancers), strengthen your bones and muscles, 

improve your mental health, and increase your 

chances of living longer.51 

Adults should do at least 150 minutes of 

moderate-intensity physical activity per week.51

Aerobic activity such as brisk walking or general 

gardening should be done in episodes of at least 

10 minutes and preferably should be spread 

throughout the week. For children and teenagers, 

the recommendation is for 1 hour of daily 

physical activity that includes vigorous activities 

and activities that strengthen their bones.51 

Making physical activities fun can affect how 

children and teenagers respond to changes in 

their routine. Programmed, repetitious exercise 

may work for adults, but it rarely works for 

children. Look for ways to add physical activity 

throughout the day. When possible, parents 

should walk with children to and from school, 

and children should have scheduled time to play. 

Because safety is a real concern in many 

neighborhoods, citizens should talk with their 

local elected officials and members of law 

enforcement to find ways to improve safety so 

everyone can walk or play outdoors. 

Television and Computer Use

In recent years, we have witnessed an explosion 

of technological advances in televisions, home 

entertainment centers, computers, and video 

game players. A new report released in 201054

found that nearly two-thirds of kids aged 8 - 18 

say the TV is usually on during meals and nearly 

half report the TV is left on “most of the time” in 

their home. Seven in ten young people have a 

TV in their bedroom and 50% also have a 
PREVENTION ◊ 7

console video game player in their room. 

 Overall, 8-18 year-olds spend over 7 hours per 

day using entertainment media (TV, video 

games, computers) amounting to more than 53 

hours a week. 

The hours that adults, teenagers, and children are 

spending in front of a television or computer 

screen contribute to their sedentary lifestyle and 

increase their risk for obesity. In particular, the 

more time children spend watching television, 

the more likely they are to eat while doing so and 

the more likely they are to eat the high-calorie 

food that are heavily advertised to both adults 

and children.55 

Most parents either do not set limitations on 

screen time or don’t enforce them. Studies have 

shown that when parents establish rules and 

implement them, screen time declines by 2 hours 

per day, leaving opportunities for more physical 

activity. Parents need to be role models by 

limiting their own television time and spending 

more time with their children. 

Creating Healthy Child Care Settings 

Early childhood settings, including child care and 

early childhood education programs, affect the

lives of millions of U.S. children. In 2005, 61% 

of children aged 0–6 years who were not yet in 

kindergarten (about 12 million children) received 

some form of child care on a regular basis from 

someone other than their parents.56 Child care 

programs should identify and implement 

approaches that reflect expert recommendations 

on physical activity, screen time limitations, 

good nutrition, and healthy sleep practices. Early 

childhood providers, like parents, should model 

healthy lifestyle behaviors and teach children 

how to make healthy choices. They also should 

reach out to parents to encourage them to 

practice and promote healthy habits at home. 

To choose a healthy child care environment, 

parents should: 

• Ask childcare providers about their 

approach to promoting healthy lifestyles 

for children. 

• Visit the setting to see how childcare 

providers model and teach physical 

activity, good nutrition, and healthy sleep 

practices. 

• Ask childcare providers how they keep 

parents informed about what they can do 

at home to support their child’s physical 

activity, good nutrition, and healthy sleep 

practices. 

• Ask childcare providers about their 

support of breastfeeding, breast milk 

storage and handling. 

Child care providers should: 

• Identify and use resources that 

recommend effective approaches to 

promoting physical activity, good 

nutrition, and healthy sleep in early 

childhood settings.

• Establish and post policies, procedures, 

and practices that support these 

approaches in ways that respect local 

communities and cultures. 

• Stay current in these approaches through 

required regular training. 

• Educate and involve parents in trainings 

and other activities. 

State regulations regarding physical activity, 

nutrition, and screen time vary greatly among 

child care settings by state and type (e.g., Head 

Start, center-based child care, family-based child 

care). Standardized national goals for early child 

care—especially ones related to healthy weight—

would improve the quality of early childhood 

settings and give childcare providers and parents 

a foundation to improve their knowledge and 

skills to support these goals. 

For example, recommended policies that can help 

child care programs support healthy weight for 

young children include the following: 

• Require 60 minutes of a mix of 

structured and unstructured daily 

physical activity. 

• Establish nutrition requirements in child 

care by using national recommendations 

such as the Dietary G uidelines for 

Americans.
8 ◊ PREVENTION

• Use a structured approach to training 

child care providers how to promote 

physical activity and good nutrition and 

how to educate and involve parents in 

these activities. 

• Give parents materials that reinforce the 

practices of child care settings that 

promote physical activity and good 

nutrition and limit screen time. 

Creating Healthy Schools 

Schools play a pivotal role in preventing obesity 

among children and teenagers. Each school day 

provides multiple opportunities for students to 

learn about health and practice healthy behaviors 

that affect weight, including physical activity and 

good nutrition. Well-designed school programs 

can promote physical activity and healthy eating, 

reduce the rate of overweight and obesity among 

children and teenagers, and improve academic 

achievement.57-64

To ensure that nutrition and physical activity 

programs are effective, school administrations 

need physical education specialists, health 

education specialists, and certified food service 

staff. Schools should encourage and reinforce 

healthy dietary behaviors by providing nutritious 

and appealing foods and beverages in all venues 

accessible to students, including the cafeteria, 

vending machines, school stores, and concession 

stands. A substantial percentage of students’ 

recommended physical activity can be provided 

through a comprehensive school-based physical 

activity program that includes high-quality 

physical education, recess and other physical 

activity breaks, intramurals and physical activity 

clubs, interscholastic sports, and walk- and biketo-school initiatives.65-66

High-quality physical education gives young 

people a chance to learn the skills needed to 

establish and maintain physically active lifestyles 

throughout their lives. States and local school 

districts set requirements for physical activity 

levels. 

In 2006, few schools provided daily physical 

education or its equivalent for the entire school 

year to all students.67 Nationwide, only 30% of 

high school students attended physical education 

classes 5 days in an average school week, 

compared with 42% in 1991.68 

To help students develop healthy habits, schools 

should have comprehensive wellness plans that 

include: 

• An active school health council to guide 

health-related policy decisions. 

• A planned and sequential health 

education curriculum for prekindergarten through grade 12. This 

curriculum should be based on national 

standards and address a clear set of 

behavioral outcomes that empower 

students to make healthy dietary choices 

and meet physical activity 

recommendations. 

• A school and school workplace wellness 

policy that includes teachers and other 

school employees to model healthy 

behaviors. 

• A comprehensive professional 

development and credentialing program 

for staff that addresses health education, 

physical education, food service, and 

health services. 

• Partnerships with parent-teacher 

organizations, families, and community

members to support healthy eating and 

physical activity policies and programs. 

To promote healthy nutrition, schools should: 

• Establish nutrition standards that 

promote healthy nutritious foods. 

• Ensure availability of appealing, healthy 

food options that that enable students to 

comply with recommendations in the 

U.S. Dietary Guidelines for Americans, 

including fresh fruits and vegetables, 

whole grains, and lean proteins. 

• Use presentation, marketing, and 

education techniques to encourage 
PREVENTION ◊ 9

students to eat more fruits and 

vegetables, whole grains, and lean 

proteins and to drink more water and 

low-fat or non-fat beverages. 

• Make sure water is available throughout 

the school setting. 

• Limit amounts of high calorie snack 

options, including beverages in vending 

machines. 

To promote physical activity, school systems 

should: 

• Require daily physical education for 

students in pre-kindergarten through 

grade 12, allowing 150 minutes per week 

for elementary schools and 225 minutes 

per week for secondary schools. 

• Require and implement a planned and 

sequential physical education curriculum 

for pre-kindergarten through grade 12 

that is based on national standards. 

• Require at least 20 minutes daily recess 

for all students in elementary schools. 

• Offer students opportunities to 

participate in intramural physical activity 

programs during after-school hours. 

• Implement and promote walk- and biketo-school programs. 

• Establish joint use agreements with local 

government agencies to allow use of 

school facilities for physical activity 

programs offered by the school or 

community-based organizations outside 

of school hours. 

Creating Healthy Work Sites 

The majority of the 140 million men and women 

who are employed in the United States spend a 

significant amount of time each week at their 

work site. Wellness programs in the workplace 

are an effective way to support people’s efforts to 

achieve and maintain a healthy weight.69 Because 

obesity reduces worker productivity70-71 and 

increases health care costs, employers are 

becoming more aware of the need to address risk 

factors for poor nutrition and physical inactivity 

through workplace initiatives.

Research has shown that health promotion 

programs in the workplace can be cost effective 

and well worth the ongoing costs of 

implementing these programs.72-75 Because the 

health and productivity of an employer’s 

workforce is affected by the vitality of the 

communities in which employees reside, 

businesses will benefit from being actively 

involved in health promotion efforts within their 

communities.76 

To create healthy work sites, employers can: 

• Establish and promote creative work site 

wellness programs, ask employees to be 

wellness champions, and set up ongoing 

employee challenges. 

• Support employees who want to 

breastfeed by providing written policies 

and designated private, clean spaces for 

breastfeeding or expressing milk. 

• Create a culture of wellness by 

integrating messages about the benefits 

of physical activity and healthy eating 

into the workplace. 

• Provide opportunities and incentives for 

physical activity through onsite facilities, 

group classes or personal training, 

outdoor exercise areas, walking paths, 

and stairwell programs. 

• Make healthy food and beverage 

available and affordable in the 

workplace. 

• Become active partners in the health 

promotion efforts of local community 

groups, such as community coalitions 

and task forces. 

• Sponsor community health events. 

• Help develop government policy and 

legislative initiatives that support 

employee wellness programs. 

• Provide health benefits that offer 

employees and their dependents 

coverage for obesity-related services and 

programs. 
10 ◊ PREVENTION

Mobilizing the Medical Community 

In 2002, Americans made an estimated 166 

million visits to medical offices.77 People access 

the health care system through multiple channels, 

and medical care settings are an important 

avenue for preventing and controlling overweight 

and obesity. Clinicians are often the most trusted 

source of health information and can be powerful 

role models for healthy lifestyle habits. 

Clinicians should make it a priority to teach their 

patients about the importance of achieving and 

maintaining a healthier body weight, becoming 

more physically active, selecting healthier food 

options and managing stress. They should 

provide comprehensive resources to help patients 

make healthy lifestyle choices. These resources 

should include in-office access or referrals to 

registered dietitians, health educators, counselors, 

psychologists, and fitness professionals, as well 

as to links to community resources.78 

To help their patients make healthy lifestyle 

choices, clinicians should: 

• Measure patients’ BMI and explain the 

connection between BMI and increased 

risk for disease and disability.

• Record patients’ physical activity levels 

and stress the importance of consistent 

exercise and daily physical activity.

• Assess and record information on 

patients’ dietary patterns. 

• Use terms that are appropriate for 

families and children to define healthy 

weight and BMI and explain how to 

achieve this goal. 

• Work as a team to provide a 

comprehensive assessment and learning 

experience for each patient. 

• Ensure that patients are referred to 

resources (both internal and external) 

that will help them meet their 

psychological, nutritional, and physical 

activity needs

• Promote awareness about the connection 

between mental and addiction disorders 

and obesity. 

• For treatment of people with severe 

mental illness who are at risk for 

overweight or obesity, consider 

medications that are more weight neutral. 

To support clinicians and their staff, the health 

care system should: 

• Encourage clinicians and their staff to 

practice healthy lifestyle behaviors and 

be role models for their patients.

• Use best practice guidelines to teach 

health professional students and 

clinicians how to counsel patients on 

effective ways to achieve and maintain 

healthy lifestyle habits. 

• Promote effective prenatal counseling 

about maternal weight gain, 

breastfeeding, the relationship between 

obesity and diabetes, and the need to 

avoid alcohol, tobacco, and drug use 

during pregnancy. 

• Help clinicians and their staff advocate 

for community strategies that improve 

nutrition and physical activity resources 

for their patients. 

• Promote innovative ways that clinicians 

and their staff can advocate for policy 

changes at local, state, and federal levels 

that will make it easier for their patients 

to adopt and sustain healthy habits. 

Improving Our Communities 

Americans need to live and work in 

environments that help them practice healthy 

behaviors. The social, cultural, physical, and 

economic foundations of a community are 

important factors in its ability to support a 

healthy lifestyle for its citizens. For example, 

government and private organizations should 

pool their resources to increase access to healthy 

foods—such as ensuring that all neighborhoods, 

especially in low-income areas, have full-service
PREVENTION ◊ 11

and safe options for physical activities, such as 

walking and bike paths, sidewalks, and parks. 

To reverse the obesity epidemic, every 

neighborhood and community should become 

actively involved in grassroots efforts to create 

healthier environments for all citizens, from 

infants to older adults. Individuals and groups of 

private citizens should work closely with 

community leaders to make the changes needed 

to support healthy lifestyles. 

To help lead our nation toward healthy eating 

and active living, The Centers for Disease 

Control and Prevention has recommended the 

following strategies:79 

• Increase availability of healthy,

affordable food and beverage choices in 

public service venues. 

• Improve geographic availability of 

supermarkets in underserved areas. 

• Improve access to fresh fruits and 

vegetables by providing incentives for 

the production, distribution, and 

procurement of foods from local farms. 

• Limit advertisements of less-healthy 

foods and beverages. 

• Increase support for breastfeeding. 

• Promote exclusive breastfeeding and 

worksite accommodations to express 

human milk. 

• Improve access to outdoor recreational 

facilities. 

• Build or enhance infrastructures to 

support more walking and bicycling. 

• Support locating schools within easy 

walking distance of residential areas. 

• Improve access to public transportation. 

• Support mixed-use development. 

• Enhance personal and traffic safety in 

areas where people are or could be 

physically active. 

• Participate in community coalitions or 

partnerships to address obesity. 

Community coalitions across the United States 

are working with their leaders, advocating for 

change, and seeing real results. All communities 

across the country should have community 

coalitions that focus on the health and wellness 

of their citizens. The most effective coalitions 

include representation from all sectors—

businesses, clinicians, schools, academia, 

government, and the faith community. These 

groups work together to assess the physical and 

social community, develop a plan when change is 

needed, and take action. History has shown that 

grassroots movements can make positive changes 

in their communities. 
12 ◊ CLOSING STATEMENT

Closing Statement and Charge from the 

Surgeon General 

To stop the obesity epidemic in this country, we 

must remember that Americans will be more 

likely to change their behavior if they have a 

meaningful reward—something more than just 

reaching a certain weight or BMI measurement. 

The real reward has to be something that people 

can feel and enjoy and celebrate. That reward is 

invigorating, energizing, joyous health. It is a 

level of health that allows people to embrace 

each day and live their lives to the fullest—

without disease, disability, or lost productivity. 

Good nutrition, regular physical activity, and 

stress management significantly contribute to 

achieving optimal health. By practicing these 

healthy lifestyle behaviors, excess weight is 

prevented, weight loss is sustained, and strength 

and endurance are achieved. This is the reward 

we need to communicate to the American public. 

We must help our communities make the 

important and life-saving connection between 

being healthy, fit and living well. 

We are indeed at a crossroads. The “old normal” 

was to stress the importance of attaining 

recommended numbers for weight and BMI. 

Although these numbers are important measures 

of disease and disability, the total picture is much 

bigger. It involves the creation of a “new 

normal”—an emphasis on achieving an optimal 

level of health and well-being. People want to 

live long and live well, and they are making their 

voices heard across this nation. Today’s obesity 

epidemic calls for committed, compassionate 

citizens to mobilize and demand the health and 

well-being they so richly deserve. I have heard 

this call to arms, and I am honored to do 

everything in my power to help Americans live 

long and live well. 
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Acknowledgements 

The Surgeon General’s Vision for a Healthy and Fit Nation was developed by the Office of the 

Surgeon General. Critical scientific oversight and writing support was provided by the Centers for 

Disease Control and Prevention (CDC) Division of Nutrition, Physical Activity, and Obesity. Data 

and analysis was provided by the (CDC) National Center for Health Statistics. Substantial 

scientific input was also provided by the National Institute of Diabetes and Digestive and Kidney 

Diseases. Technical and editorial support was also provided by numerous U.S. 

Department of Health and Human Services subject matter experts. 
U.S. Department of Health and Human Services