|Assistant Secretary for Planning and Evaluation|
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.
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 . Obesity and overweight are preventable conditions for most Americans. The increasing prevalence in obesity-related illnesses must be reversed.
Figure 1. Prevalence of Obesity by Age, 1999
Source: NHANES Continuous, 1999-2000 (JAMA 2002; 288(14):1723-27)
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/calc-bmi.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:
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 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.
Facts and Figures on 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:
Figure 2. Prevalence of Diabetes:
Diagnosed and Undiagnosed
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  . Those aged over 75 years are expected to have the largest increases (271 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).
Figure 3. Prevalence of Diagnosed Diabetes in the United States
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
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).
Annual Number of Cases Associated with Diabetes
12,000 – 24,000
Cardiovascular disease deaths
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  .
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. 
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)  . 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) .
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 high-risk groups, including minority groups, who carry a disproportionately heavy burden of this disease. Clinical research has identified risk factors that place individuals at high-risk 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  .
Facts and Figures on Tobacco 
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.
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 .
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 .
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 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.
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 . 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:
When it comes to communicating prevention messages or undertaking prevention-oriented programs at the community level, there are several key guidelines:
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 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 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.”  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 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.
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