Focus

Now Is the Time for Prevention

"Prevention is the right cause, the right issue, the right time," says U.S. Department of Health and Human Services (HHS) Secretary Tommy G. Thompson in leading a new departmentwide effort, Steps to a HealthierUS.

Secretary Thompson has launched the Steps initiative in recognition of our Nation's current and ongoing healthcare crisis. His vision is to transform our disease care system into a true healthcare system. That opportunity and challenge are reflected in the calculation that approximately 95 percent of the $1.4 trillion we spend as a Nation on health goes to direct medical care services, while an estimated 5 percent is allocated to populationwide approaches to prevent disease and promote health.

As befitting its name, the new initiative takes the challenge in steps. The first step is reducing the burden of asthma, cancer, diabetes, heart disease and stroke, and obesity. The second step focuses on the relationship between health problems and lifestyle choices and how best to reduce risk-taking behaviors by youth.

With a strong emphasis on proven interventions and existing science, Steps to a HealthierUS will promote the following:

• Health promotion programs to motivate and support responsible health choices
• Community initiatives to promote and enable healthy choices
• Healthcare and insurance systems that put prevention first by reducing risk factors and complications of chronic disease
• State and Federal policies that invest in the promise of prevention for all Americans
• Cooperation among policymakers, local health agencies, and the public to invest in disease prevention instead of spending our resources to treat diseases after they occur

Steps Initiative Seeks To Reduce Burden of Disease

The Steps initiative is supported by the Healthy People framework and its overarching goals: to increase the quality and years of healthy life and to eliminate health disparities. For every chronic condition targeted in Steps—asthma, cancer, diabetes, heart disease and stroke, and obesity—Healthy People 2010 presents detailed information on death and illness, trends, disparities, and opportunities to improve health (www.healthypeople.gov/document).

Each Steps priority area represents an opportunity to increase public awareness and understanding of the benefits of prevention and to promote behavioral change. For example, many people are not applying what is already known about preventing the symptoms and consequences of asthma. Similarly, two out of three people with diabetes do not realize that cardiovascular disease is a serious threat to them.

Asthma. More than 27 million people in the United States have asthma, a serious and growing health problem. Every year, asthma is responsible for about 500,000 hospitalizations, 5,000 deaths, and 134 million days of restricted activity. Yet, most problems caused by asthma could be averted if people with asthma and their healthcare providers practiced secondary prevention by managing the disease according to established guidelines. Environmental health plays a key role in asthma prevention and represents a true opportunity for communities to take steps toward a healthier population.

Cancer. Cancer is the second leading cause of death in the United States, killing more than 1,500 people every day. More than 150,000 deaths each year are attributable to cigarette smoking. The financial costs of cancer are substantial, with annual costs estimated at more than $107 billion. Like the other priority areas, cancer data illuminate gender and racial/ethnic disparities, with African Americans experiencing the heaviest toll. The most significant number from the perspective of the Steps initiative is that as much as 50 percent or more of cancer cases can be prevented through smoking cessation and improved dietary habits. Physical activity and weight control also can help prevent cancer.

Diabetes. More than 200,000 diabetes-related deaths occur each year, making diabetes the fifth deadliest disease. Indirect and direct costs, including Medicare, total $132 billion. Risk factors for diabetes include overweight and obesity, age, race/ethnicity, and family history. Risks from having diabetes include loss of vision and blindness, foot ulcers, and lower extremity amputations, as well as pregnancy complications, birth defects, high blood pressure, nervous system damage, dental and gum disease, kidney disease, stroke, and flu and pneumonia-related deaths. Key steps in the prevention of such complications include glucose control, physical activity, and nutrition. Increased physical activity and modest weight loss are important in the primary prevention of diabetes, especially among the estimated 16 million people with prediabetes.

Heart Disease and Stroke. Heart disease is the leading cause of death for all people in the United States (267.8 deaths per 100,000 in 1999). Stroke is the third leading cause of death (about 158,000 deaths a year). Both heart disease and stroke continue to be major causes of disability and significant contributors to increased healthcare costs in our Nation, estimated at $351.8 billion in 2003. Heart disease and stroke share several risk factors, including high blood pressure, cigarette smoking, high blood cholesterol, and overweight. Primary prevention, specifically through lifestyle interventions such as tobacco cessation, physical activity, and proper nutrition, is a major strategy to reduce the burden of these health problems.

Obesity. As already mentioned, obesity is a major risk factor for diabetes. Overweight and obesity are known risk factors for heart disease, stroke, hypertension, gallbladder disease, osteoarthritis, sleep apnea and other breathing problems, and some forms of cancer, including uterine, breast, colorectal, kidney, and gallbladder cancers. The total direct and indirect costs attributed to overweight and obesity amounted to $117 billion in the year 2000. More than 64 percent of people in the United States are overweight or obese, and obesity is responsible for at least 300,000 deaths each year. "Move more, eat better" advises the Weight-control Information Network sponsored by the National Institute of Diabetes and Digestive and Kidney Diseases. Physical activity contributes to weight loss, especially when combined with calorie reduction. Regular physical activity helps in maintaining weight loss.

Steps Initiative Seeks To Improve Lifestyle Choices

As illustrated above for the Steps targeted conditions, poor nutrition, physical inactivity, and tobacco use are major risk factors for most of the leading causes of chronic disease deaths in this country. They also represent health risk behaviors that often are established in youth, making the earliest prevention the best prevention.

Nutrition. Increased consumption of fruits and vegetables helps reduce the risk for heart disease and certain cancers. Dietary factors are associated with 4 of the 10 leading causes of death and with the following priorities of the Steps initiative: heart disease and stroke, some types of cancer, and type 2 diabetes. These health conditions cost more than $200 billion each year in medical expenses and lost productivity.

Body Weight. On average, higher body weights are associated with higher death rates. As described above, overweight and obesity raise the risk of illness from numerous diseases. They also result in social stigmatization, discrimination, and lowered self-esteem.

Physical Activity. Regular physical activity helps control weight and reduces a person's risk for heart attack, colon cancer, diabetes, and high blood pressure. Other benefits of physical activity include enhanced psychological well-being and prevention of premature death. Physical activity is important at all ages-for example, to achieve and maintain peak bone mass as young adults and to improve and maintain strength and agility as older adults.

Tobacco Use. Tobacco use is the single most preventable cause of death and disease in the United States. Cigarette smoking is responsible for one in five deaths each year. The health benefits of quitting smoking are numerous, and many occur quickly. Just 1 year after quitting smoking, excess risk for heart disease is reduced by half; 15 years later, an ex-smoker's risk is about the same as that of a lifelong nonsmoker.

The Next Steps for the Steps Initiative

Under the Steps umbrella, many different activities are under way, including the dissemination of the Prevention Portfolio (see Resources: Steps to a HealthierUS in Print). Another is planning the 2004 Steps to a HealthierUS summit (see Save the Date). A third is the community grant program (see Spotlight) that targets diabetes, asthma, and obesity.

Communities selected for grant awards will use Federal resources to build partnerships between public and private organizations working in prevention, medical, social, educational, business, religious, and civic services. The three targets have been selected not only because of their debilitating effects and their rapidly increasing prevalence in the United States but also because of their responsiveness to prevention measures. The number of people with diabetes in the United States has nearly doubled in the past decade to 17 million. An estimated 10 million adults and 5 million children suffer from asthma, and the number of cases of obesity in the United States has increased more than 50 percent over the past two decades.

Under the Steps initiative, prevention is being put first, and the necessary information, tools, and funding are being put there too. The next step is promoting programs at the community level to encourage small behavior changes that can yield dramatic results and lead to a healthier Nation.

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Spotlight

Community Grant Awards Set

In September, only 4 months after he announced the availability of $15 million for Steps to a HealthierUS community grants, Secretary Thompson plans to make the awards to successful applicants. The 5-year cooperative agreements will enable selected State, local, and tribal health departments to create sustainable change in communities. Each awardee must focus on diabetes, obesity, and asthma and their related risk factors-physical activity, nutrition, tobacco use, and environmental exposures.

Interest in the community-based funding opportunity has been very high. Several hundred people tuned into
the pre-application workshop broadcast by satellite in May and later to the Webcast archives. CDC received more than 200 letters of intent in June and 145 applications by the July 15 deadline.

Award selection will be based on the applicant's ability to be "up and running within weeks." Within the first 8 months, grantees must finalize a 5-year community action plan that incorporates public-private partnerships and evidence-based public health strategies. All grantees are expected to begin implementing programs during the first year.

"To truly change our attitudes to focus on preventing chronic diseases rather than simply treating them, we need to reach Americans in their homes and neighborhoods with innovative programs that prevent diabetes and obesity and improve asthma management," Secretary Thompson said when he announced the RFA. "We've all got to think outside the box. The communities awarded the grants will help lead the country in changing our healthcare model from one that only treats the sick to one that successfully promotes better health."

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Resources

The main Federal site for the Steps to a HealthierUS initiative is www.healthierus.gov/. Information on the initiative also can be found at www.hhs.gov/news/newsletter/weekly/archive/23jun02.htm. For information on the President's HealthierUS initiative, visit www.whitehouse.gov/news/releases/2002/06/20020620-2.html. Federal Occupational Health assists Federal agencies in improving the health, safety, and productivity of the Federal workforce. Its Web site offers information on both initiatives as well as links to other resources (www.foh.dhhs.gov/Public/Productfocus/Oct2002/presidentschallenge.asp).

Other Sites

Many related sites offer information. Some examples are the U.S. Department of Agriculture (www.usda.gov/news/releases/2003/01/0009.htm), the National Governors Association (www.nga.org/center/frontAndCenter/1,1188,C_FRONT_CENTER%5ED_4863,00.html), the National Conference of State Legislators (www.ncsl.org/), and the Leadership for Active Living (www.leadershipforactiveliving.org/news2.htm). The latter group supports Government leaders as they create and promote policies, programs, and places to enable active living.

Many organizations, including national voluntary and professional organization as well as Federal agencies, are important resources for information related to the diseases and lifestyles targeted in Steps to a HealthierUS. For asthma: the American Lung Association (www.lungusa.org/), which serves older people as well as teens and healthcare providers, the Asthma and Allergy Foundation of America (www.aafa.org/), the National Institute of Environmental Health Sciences (www.niehs.nih.gov), and the National Heart, Lung, and Blood Institute (NHLBI) (www.nhlbi.nih.gov). For cancer: the American Cancer Society (www.cancer.org/docroot/home/index.asp) and the National Cancer Institute (www.nci.nih.gov/). For diabetes: the American Diabetes Association (www.diabetes.org) and the American Association of Diabetes Educators (www.aadenet.org/). For heart disease and stroke: the American Heart Association (www.americanheart.org), the National Stroke Association (www.stroke.org/), and NHLBI. For nutrition: the American Dietetic Association (www.eatright.org/). For physical activity: the Aquatic Exercise Association (www.aeawave.com/) and the President's Council on Physical Fitness and Sports (www.fitness.gov).

CDC (www.cdc.gov) has resources on all the Steps priorities, and its National Center for Health Statistics (www.cdc.gov/nchs/) hosts a substantial data warehouse.

National not-for-profit initiatives promote specific health-related topics. Two examples are the Campaign for Tobacco-Free Kids (http://tobaccofreekids.org/) and the Leadership to Keep Children Alcohol Free (www.alcoholfreechildren.org/). BAM! (Body and Mind) is an interactive new prevention site for kids, hosted by CDC (www.bam.gov/). The Office on Women's Health site focuses on many health topics, responds to adolescent girls' health concerns, and motivates girls to choose healthy behaviors (www.4girls.org/index2.htm).

For information on effective science-based strategies, see Guide to Clinical Preventive Services, Third Edition, 2000-2003, published by the U.S. Preventive Services Task Force (www.ahrq.gov/clinic/cps3dix.htm) and Guide to Community Preventive Services (www.thecommunityguide.org/).

Steps to a HealthierUS in Print

Three new Steps to a HealthierUS publications are available in print and on the Web (www.healthierus.gov). These documents present a strong rationale for prevention and many examples of how prevention works.

The Power of Prevention represents a powerful argument for prevention-the "why" underlying Secretary Thompson's rationale for launching the Steps initiative. He calls on public policymakers to share his conviction: "Preventing disease by promoting better health is the only smart policy choice for our future. We are in the midst of a chronic disease epidemic of unparalleled proportions. This epidemic is fueled both by the aging of the U.S. population and by the poor lifestyle choices that Americans continue to make."

The publication presents many hard facts supporting the statement about the epidemic: More than 1.7 million Americans die of a chronic disease each year, accounting for about 70 percent of all U.S. deaths. The hard data about deaths and illness are no less shocking than the economic numbers, such as the $132 billion estimated cost of diabetes in 2002.

Prevention Strategies That Work is a toolkit that includes how-to prevention guides for chronic conditions and provides information about risk factors, program examples, and technical resources.

Prevention Programs in Action showcases how prevention works by describing exemplary prevention programs across the United States. "Good work can be done," says Secretary Thompson in encouraging readers to follow others' good examples or to find their own steps to a healthier Nation. Examples of these prevention programs include an asthma-control program targeting nearly 3 million people in California, a State with an age-adjusted mortality rate for asthma (16.8 per million) above the national average (15.4 per million). In the Northeast, Vermont's Breast and Cervical Cancer Screening Program, known as Ladies First, has resulted in the detection of 70 cancers, most in the earliest, most treatable stage. The last example highlights a key aim of the Steps initiative: to reduce risk behavior among youth. Through a coordinated school health program in Wisconsin, more than 10,000 young people increased their physical activities in 2002.

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Activities

The Produce for Better Health Foundation has been on a mission for the last decade-to improve our Nation's health. The Foundation has educated Americans, promoted produce, and increased consumption levels of fruits and vegetables. The organization's Web site, www.5aday.com, offers many fun activities such as coloring pages and recipe tips to remind kids of the importance of fruits and vegetables in everyday diets.

World Asthma Day was May 6, 2003. The Environmental Protection Agency's World Asthma Day Event Planning Kit has everything you need to plan an asthma event for your community. The kit includes ideas for planning events in schools, hospitals, libraries, State capitol buildings, and other community settings, as well as a sample proclamation, a press release, local and regional contact lists, and a form for ordering free asthma materials for your event, such as videos, brochures, posters, coloring books, health curricula, and much more. Visit www.epa.gov/asthma01/wadevents.html for more information.

The net proceeds from each Breast Cancer Research 45-cent stamp goes to breast cancer research. People can help the cause in three ways: (1) Use the stamp, if not for every mailing, then at least for select mailings. (2) Tell coworkers by including an article about the stamp in company newsletters. Help get the word out to people who otherwise might not hear about it. (3) Show pictures of the stamp on brochures or other communications to hand out. Visit www.winabc.org/newweb/press-news/the-breast-cancer-research-stamp.htm for more information.

The American Heart Walk is a noncompetitive walking event geared to employees, family members, friends, and others. Participants raise money to fight heart disease and stroke, then walk in the event. Most walks are fewer than 5 miles. Join thousands from coast to coast who participate in the Nation's fastest growing walking events. Call (800) AHA-USA-1, or register at www.americanheart.com/presenter.jhtml?identifier=2281.

The Division of Nutrition and Physical Activity of the National Center for Chronic Disease Prevention and Health Promotion, CDC, provides science-based activities for children and adults that address the role of nutrition and physical activity in health promotion and the prevention and control of chronic diseases. Visit www.cdc.gov/nccdphp/dnpa to see some of the most popular activities.

Local public health agencies have provided the National Association of County and City Health Officials (NACCHO) with tobacco prevention and control program summaries and lessons learned. The Local Tobacco Prevention and Control Program Database is a compilation of this information. The database allows users to search programs by State or program component. It is organized to complement the comprehensive program framework guide called Program and Funding Guidelines for Comprehensive Local Tobacco Control Programs. Developed by local public health officials, the NACCHO tobacco control guidelines refine CDC's Best Practices for Comprehensive Tobacco Control Programs from a State level to community approach, thereby better addressing the specific needs and realities of tobacco control at the local level. The guidelines assist local public health agencies and their community partners in structuring tobacco control efforts around the seven components of a local, comprehensive tobacco control program recommended by NACCHO and CDC.

The National Association of Students Against Violence Everywhere and the Guidance Channel were founding partners of the National Youth Violence Prevention Campaign, a weeklong national education initiative held during the week of April 7-11, 2003. The goal of the campaign was to raise awareness and to educate students, teachers, school administrators, counselors, school resource officers, school staff, parents, and the public on effective ways to prevent or reduce youth violence. It involved activities that demonstrated the positive role young people can play in making their school and community safer. Visit www.nationalsave.org/main/YVPC.php for more information.

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In the Literature

Antiobesity Drugs: Current and Future Issues. M.A. Hatahet and N.V. Dhurandhar. Current Diabetes Report 2(October 2, 2002):409-415.
This article reviews commonly prescribed medications for obesity, their efficacy, and their side effects and also discusses some promising antiobesity pharmacologic agents.

Relations Among Asthma Knowledge, Treatment Adherence, and Outcome. J. Ho et al. Journal of Allergy and Clinical Immunology 111(March 2003): 498-502.
Findings from this study, in combination with previous studies of asthma knowledge questionnaires, suggest that the construction of a simple self-report asthma knowledge instrument for use as a primary outcome measure demonstrating mastery of asthma self-management skills may not be achievable.

Differences in Breast Cancer Stage, Treatment, and Survival by Race and Ethnicity. C.I. Li et al. Archives of Internal Medicine(January 13, 2003): 49-56.
Breast cancer survival may be improved by targeting socioeconomic factors that underlie racial and ethnic differences in breast cancer stage, treatment, and mortality rates.

Psychosocial and Educational Aspects in Prostate Cancer Patients. A. Visser and G. van Andel. Patient Education and Counseling 49(March 2003): 203-206.
This review of studies on the psychosocial and educational problems prostate cancer patients face presents conclusions regarding neglected research areas in psychosocial and educational aspects of living with prostate cancer.

Optimal Diets for Prevention of Coronary Heart Disease. F.B. Hu and W.C. Willett. Journal of the American Medical Association 288(November 27, 2002):2569-2578.
Together with regular physical activity, avoidance of smoking, and maintenance of a healthy body weight, substantial evidence indicates that diets consisting of nonhydrogenated unsaturated fats, whole grains, fruits, vegetables, and omega-3 fatty acids may prevent cardiovascular disease in Western populations.

African American Women and Smoking: Starting Later. J. Moon-Howard. American Journal of Public Health 93(March 2003):418-420.
Secondary analysis of data from the 2000 National Health Interview Survey showed that African American women initiate smoking later than white women at each age group, which indicates that prevention interventions need to continue beyond adolescence well into the adult years, especially for African American women.

Child and Adolescent Violence. D.M. Daane. Orthopaedic Nursing 22(January-February 2003):23-29.
A variety of factors affect the incidence of violent victimization against children as well as violent behavior by today's youth. Nurses who recognize dangerous or potentially dangerous behavior in children and adolescents are better able to provide violence prevention and intervention services and referrals to children at risk or in danger.

Predicting Long-Term Maintenance of Physical Activity in Older Adults. E. McAuley et al. American Journal of Preventive Medicine(August 2003):110-118
This prospective study provides support for the inclusion of social cognitive variables in models of exercise adherence and highlights the pivotal role of self-efficacy in the long-term exercise behavior of older adults.

Parenting Stress and Children with Heart Disease. K. Uzark and K. Jones. Journal of Pediatric Health Care(July-August 2003):163-168.
Parents of children older than 2 years with heart disease were found more likely than the normative population to report excessive parenting stress.

Help-Seeking and Risk-Taking Behavior Among Black Street Youth: Implications for HIV/AIDS Prevention and Social Policy. C.L. Snell. Journal of Health and Social Policy(2002):21-32. Major findings from this study of help-seeking and risk-taking behavior of black urban street youth in Washington, D.C., and Cape Town, South Africa, indicate that the youth did not translate their knowledge about HIV/AIDS into safer sexual practices, which has implications for health and social policy.

Effects of Anti-Smoking Advertising on Youth Smoking: A Review. M. Wakefield et al. Journal of Health Communication(2003):229-247. Overall, the findings of this review indicate that there is no single "recipe" for anti-smoking advertising that leads to reductions in youth smoking, although anti-smoking advertising appears to influence youth smoking.

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Meetings

Diabetes

American Association of Diabetes Educators' 30th Annual Meeting and Exhibition. Salt Lake City, UT. Visit www.aadenet.org/. August 6-9, 2003.

American Diabetes Association's 64th Annual Scientific Sessions. Orlando, FL. Visit www.diabetes.org/am04/. June 4-8, 2004.

Obesity

2003 North American Association for the Study of Obesity (NAASO) Annual Meeting. Fort Lauderdale, FL. Visit www.naaso.org/meetings. October 11-15, 2003.

Asthma

60th Annual American Academy of Allergy, Asthma, and Immunology Meeting. San Francisco, CA. Visit www.aaaai.org/members/annual_meeting/default.stm. March 19-23, 2004.

American College of Allergy, Asthma & Immunology (ACAAI) Annual Convention. Boston, MA. Visit www.acaai.org. November 11-17, 2004.

Nutrition and Physical Activity

American Dietetic Association Food and Nutrition Conference and Expo 2003. San Antonio, TX. Visit www.eatright.org/Public/96_13100.cfm. October 25-28, 2003.

American Public Health Association's 13th Annual Meeting and Exposition. San Francisco, CA. Visit www.apha.org/meetings/. November 15-19, 2003.

Tobacco Use

2003 National Conference on Tobacco or Health. Boston, MA. Visit www.tobaccocontrolconference.org/2003Conference. December 10-12, 2003.

Youth Risk Taking

National Organization on Adolescent Pregnancy, Parenting and Prevention's (NOAPPP) Annual Conference. Arlington, VA. Visit www.noappp.org/. November 10-13, 2003.

Heart Disease and Stroke

57th Annual Fall Conference and Scientific Sessions of the Council for High Blood Pressure Research in association with the Council on the Kidney in Cardiovascular Disease. Washington, DC. Visit www.americanheart.org/presenter.jhtml?identifier=3005606. September 23-26, 2003.

American Heart Association's Scientific Sessions 2003. Orlando, FL. Visit www.scientificsessions.org/portal/scientificsessions/ss/. November 9-12, 2003.

Cancer

Association of Community Cancer Centers' 20th National Oncology Economics Conference. San Diego, CA. Visit www.accc-cancer.org/meetings/. October 8-11, 2003.

American Association for Cancer Research's Advances in Breast Cancer Research: Genetics, Biology, and Clinical Implications. Huntington Beach, CA. Visit www.aacr.org/eServices/OnlineRegister/confDetails.asp?SCID=134. October 8-12, 2003.

14th Annual Cancer Patient Education Network Meeting: New Frontiers: Networking for Success. Toronto, Ontario, Canada. Visit http://cpen.nci.nih.gov/members/annual_meeting.htm. November 6-8, 2003.

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The mission of the Office of Disease Prevention and Health Promotion (ODPHP) is to provide leadership for disease prevention and health promotion among Americans by stimulating and coordinating prevention activities. Prevention Report is a service of ODPHP. This information is in the public domain. Duplication is encouraged.