During his tenure, Secretary Thompson has hosted many roundtable discussions and listening sessions with different stakeholders and interested parties. Drawing on these meetings, research and other information, this section suggests actions that specific stakeholders can take to promote health and prevent chronic disease in all Americans. These steps are not meant to be prescriptive but rather to identify starting points for individuals, families, communities and other interested constituencies as they begin to work for better health and wellness.
Action Steps for Schools
Schools are an especially critical site for encouraging healthy behaviors in youth. Most children spend a large portion of their time in school. In many cases, life-long habits and behaviors, good and bad, are formed during the elementary and middle school years. Schools, therefore, offer an opportunity to engage children in healthy eating and regular physical activity and to reinforce important health messages including those regarding avoidance of risky behaviors. Schools can also provide a bridge to eliciting parental involvement in shaping children’s habits and attitudes about healthy lifestyle choices.
- Encourage cooperation among teachers, coaches, nurses, and food service staff to educate students about the importance of proper nutrition and regular physical activity to lifelong healthy weight maintenance.
- Reinforce healthy habits by examples set by role models including teachers, coaches, and other school personnel.
- Engage parents in a process to enhance their understanding of the importance of healthy diets and the benefits of exercise and engage them to reinforce this message in their homes.
- Provide age-appropriate extracurricular physical activity and organized sports programs.
- Provide elementary school students with daily recess periods for unstructured supervised play.
- Encourage regular physical activity for all children (pre-school through 12th grade) in order to develop the knowledge, skills, attitudes, behaviors, and confidence to sustain life-long physically active lifestyles.
- Explore the possibility of creating “before the bell” and after school physical fitness and nutrition programs for students.
- Provide age-appropriate and culturally appropriate instruction in health education.
- Provide healthy food and snack options in school cafeterias and vending machines.
- Incorporate health-related tasks, materials and examples in regular everyday instruction for preschool to grade 12 education, including the topics of nutrition and the balance between calories consumed and calories expended in physical activity.
Action Steps for Employers
Working adults spend many of their waking hours at their worksite. Thus, the worksite is an important and convenient environment in which to foster healthier habits. Moreover, companies are beginning to recognize that the health of the individual employee is inseparable from the ‘health’ of the corporation. Employees with chronic diseases and/or conditions, which may be prevented or attenuated by diet and exercise, often have higher rates of absenteeism and health care usage than healthy employees without chronic ailments. Thus, worksite programs designed to promote health and prevent chronic disease are a wise investment for employers.
- Design worksites and work schedules to provide opportunities for regular physical activity, including simple and readily available activities such as stair climbing.
- Ensure that healthy food options are available for employees.
- Consider creating exercise facilities at the worksite or providing incentives for employees to join local fitness centers.
- Consider providing health promotion or wellness programs and disease management programs for employees as part of their health benefits.
- Offer incentives to employees to adopt documentable healthy behaviors (e.g., miles walked or weight goals attained, obtaining recommended screenings, completion of a medically supervised smoking cessation treatment program). [See Appendix F.]
- Engage employees in a process to enhance their understanding of the importance of a healthy lifestyle.
- Actively partner with community and other local entities/stakeholders to develop and implement community health promotion and disease prevention initiatives.
- Examine the cost and benefits of worksite health promotion and disease prevention efforts.
- Request health insurers to develop appropriate information for employees to enhance health literacy.
- Include health literacy measures in quality of care and outcomes assessments.
Action Steps for Health Insurers
Health insurers can play a significant role in promoting health and preventing or lessening the consequences of chronic diseases and conditions for individuals. Insurers can design and offer innovative and comprehensive preventative services benefit packages based on scientific evidence. In addition, insurers can disseminate educational information about the importance of prevention to their customers/consumers.
- Offer insurance products that include preventative services, disease management and wellness programs.
- Engage consumers in a process to enhance their understanding of the importance of healthy habits and avoidance of risky behavior.
- Encourage research evaluating the efficacy and cost/benefit of strategies to change behavior and translate research into clinical practice. Share this information with employers and other purchasers of health care.
- Create incentives to encourage individuals to adopt healthy behaviors. [See Appendix F.]
- Partner with communities and other entities to promote and encourage healthy lifestyles.
- Include health literacy in quality of care and outcomes assessments.
Action Steps for Health Care Providers and Professionals
Health care providers/professionals are key for promoting healthy lifestyles and reducing the impact of chronic diseases and conditions. In any year, most Americans will interact with the health care system. Thus, health care providers are strategically poised to intervene and influence individuals to adopt healthy behaviors. Health care professionals can also provide critical leadership to communities, state and local governments, schools and other interested stakeholders to guide and catalyze health promotion and disease prevention efforts.
- Lead by example; live a healthy lifestyle.
- Accrue and maintain state-of-the-art knowledge about best practices and behavioral interventions to promote healthy habits and reduce risky behaviors.
- Inform and educate individuals (patients, parents, students, community leaders, other health professionals, etc.) about the importance of healthy eating, regular physical activity, recommended disease screening, and avoidance of risky behaviors (such as tobacco use) to promote health and prevent chronic disease.
- Implement effective weight reducing initiatives and smoking cessation programs.
- Direct or participate in studies to explore the effectiveness of approaches to weight loss and healthy weight maintenance and smoking cessation.
- Explore partnerships between health care providers/professionals and schools, communities, faith-based organizations, local and state governments, and other interested parties to develop and implement health promotion and disease prevention initiatives.
- Seek out training in health literacy and effective provider-patient communication.
- Practice evidence-based prevention—adhere to evidence-based recommendations of the US Preventive Services Task Force (USPSTF) on whether a clinical preventive service should be routinely delivered www.preventiveservices.ahrq.gov.
- Identify individuals who are ready to make important changes and take maximum advantage of the “teachable moment” that often occurs in clinical care (e.g., counseling individuals who have just had a heart attack or chest pain to quit smoking).
- Harness the power of health information technology systems, including decision support systems, to remind clinicians and patients when preventive services are needed. HHS has supported much of the research that demonstrates the effectiveness of these systems to improve the use of clinical preventive services.
Action Steps for Researchers and Health Professions Educators
Progress in health promotion and disease prevention necessarily depends on continued research and knowledge generation and dissemination. Therefore, researchers and health professions educators are critical in furthering our understanding of the etiology of chronic conditions such as obesity and effective approaches for prevention and treatment of these conditions. In addition, successful health promotion and disease prevention requires translation and dissemination of scientific findings into effective clinical practices to reach all individuals.
- Continue research into the pathogenesis, etiology, epidemiology, prevention and treatment of chronic diseases and conditions including obesity. Continue to explore optimal methods to translate research findings into clinical practice to change human behavior and foster healthy habits.
- Develop outcome measures for health promotion and disease prevention activities, services, and practices.
- Encourage and adopt an interdisciplinary approach to address chronic conditions such as obesity.
- Develop and assess innovative methods to engage the public about the importance of health promotion and disease prevention and the link between the risk for chronic conditions and personal behaviors and choices such as physical activity and diet choices. Information, communication, and education should encompass the lifespan beginning in early childhood and continuing into older age.
- Focus on identifying effective ways to improve the health literacy of all individuals to reinforce the importance of health promotion and disease prevention for all segments of the population.
- Seek partnerships with community, public or private entities to promote research and educational initiatives regarding health promotion and disease prevention. Develop a multi-pronged community approach involving all stakeholders to reach all individuals.
- Design curricula and testing for health professionals (undergraduate and graduate) that comprehensively cover the science of health promotion and disease prevention and that examine and teach effective approaches to change individual behaviors. Integrate health professional education and training across disciplines.
Action Steps for State, Local, and Tribal Governments
State, local, and tribal governments can play a key role in coordinating an approach to encourage healthy habits and prevent chronic diseases. State, local and tribal governments can partner with, and provide guidance to, other organizations and entities to facilitate health promotion initiatives. They can also act as a bridge between Federal programs and community activities providing the necessary infrastructure and support needed to maximize and coordinate efforts among stakeholders. In addition, state, local, and tribal governments can create and implement policies that encourage healthy behaviors.
- Review and design policies to ensure that health promotion and disease prevention are priorities.
- Partner with communities and other entities to create environments and implement initiatives that encourage healthy lifestyles and habits.
- Disseminate audience-appropriate information about the importance of healthy lifestyles and avoidance of risky behaviors. Foster a consistent age and culturally appropriate message to the public, especially high-risk groups, about the consequences of unhealthy lifestyles and practices.
- Identify high-risk groups for targeting prevention initiatives and activities.
- Provide guidance and support for research on the efficacy of different interventions to prevent and treat obesity, diabetes, and other chronic conditions and tobacco use.
Action Steps for HHS/Overweight and Obesity
HHS has a large number of current initiatives and programs underway to address obesity and overweight. They include programs in education, communication and outreach, intervention, diet and nutrition, physical activity and fitness, disease surveillance, research, clinical preventive services and therapeutics, and policy and web-based tools. The programs are targeted to a variety of populations including infants and breastfeeding mothers, children and adolescents, women, minorities, the elderly, the disabled, rural, and the general population. Additional areas to target initiatives may include:
- Design and implement programs that work with children and parents to prevent and treat obesity, since the best opportunity to slow the U.S. obesity ‘epidemic’ may be in childhood.
- Evaluate effectiveness of treatment and preventive programs to build a practical evidence base for new interventions. Relevant research questions may include:
- Do certain populations (e.g., gender or age-related, racial/ethnic populations) benefit more from certain therapies?
- What is the optimum amount of time to treat, and what is the optimum level of weight loss to target?
- What evidence exists to support long-term weight loss and weight-maintenance, e.g., over one year or five years?
- What is the safety and efficacy of certain therapies?
- What risks are associated with weight loss, especially for certain populations such as the elderly, for example, who generally are at high risk for osteoporosis?
- Explore ways to increase awareness and knowledge, especially in certain populations, about obesity and interventions that may reduce obesity and promote healthy energy balance.
- Develop interventions that address needs of special populations.
- Focus further research on the psychological and motivational aspects of weight maintenance, and on identifying any demonstrable benefits for private or public health insurance programs.
- Enhance food labels to display calorie count more prominently and to use meaningful serving sizes.
- Evaluate and recommend the types of health communication activities that would most effectively support the "Calories Count" message.
- Encourage restaurants to provide meaningful nutritional information to consumers.
- Step up enforcement actions concerning accuracy of food labels.
- Revise FDA guidance for developing drugs to treat obesity.
- Work cooperatively with other government agencies, non-profit organizations, industry, and academia on obesity research.
- Incorporate the findings from the recently released reports on health literacy from the Institute of Medicine and AHRQ into overweight and obesity information and communication activities.
Action Steps for HHS/Diabetes
HHS agencies are pursuing vigorous programs in prevention that include basic research, clinical trials, community health efforts, educational programs, translating research into practice, efforts in special populations, and providing a new Medicare benefit for diabetes testing. Through these comprehensive programs, HHS agencies are continuing to pursue prevention studies to optimize and identify additional intervention strategies. HHS also is improving methods to disseminate and implement effective strategies into diverse community settings. Particular opportunities for HHS action involve underserved or vulnerable populations and include:
- To focus attention on the long-term implications of gestational diabetes mellitus (GDM), the National Diabetes Information Clearinghouse of the NIDDK/NIH will produce a new booklet entitled, “What I Need to Know about Gestational Diabetes,” which will incorporate messages based on diabetes prevention research. The National Diabetes Education Program’s Small Steps. Big Rewards. Prevent Type 2 Diabetes campaign will also be expanded to include a specific focus on GDM.
- · To analyze the effects of treatment and ascertain the durability of these effects over time, a Diabetes Prevention Program follow-up study of women with a history of GDM is in progress.
- Enhance the focus on women with GDM in community health centers and Indian Health Service programs, and through AHRQ’s Integrated Delivery System Research Network and Practice Based Research Networks.
- Since there is a disproportionate risk for the development of type 2 diabetes in persons with serious mental illness, in general, and treatment with antipsychotic medications predispose individuals to gain weight [49-54] , examine and apply evidence-based lifestyle interventions in mental health settings that would reduce the rate of obesity and prevent the development of type 2 diabetes in Americans with serious mental illness.
- Since American Indians and Alaska Natives have a higher incidence of diabetes, determine if diabetes prevention activities previously demonstrated to be efficacious under well-controlled conditions (such as the NIDDK-sponsored Diabetes Prevention Program study) can be implemented with fidelity in a variety of Indian health settings and through community-based human services providers.
- Evaluate whether a comprehensive health system intervention delivered through Indian health programs can reduce risk factors for cardiovascular disease in individuals with diabetes and/or the metabolic syndrome ( characterized by insulin resistance and the presence of obesity, abdominal fat, high blood sugar and triglycerides, high blood cholesterol, and high blood pressure).
- Implement evidenced-based interventions to prevent diabetes as part of the Primary Prevention of Diabetes Initiative in 25-30 Health Service/Tribal/Urban (I/T/U) community sites of varying sizes and types.
- Implement, as part of the Cardiovascular Disease Risk Reduction Initiative, a comprehensive health system intervention consisting of patient-, provider-, systems- and community-level components in 25-30 clinical sites that participate in the IHS Diabetes Care and Outcomes Audit.
- Consider utilizing the community health center program Diabetes Prevention Collaborative and Health Disparity Collaborative strategy and models to translate and disseminate the results of Diabetes Prevention Program pilot into clinical practice.
- Incorporate the findings from the recently released reports on health literacy from the Institute of Medicine and AHRQ into diabetes information and communication activities.
- CMS should assess utilization of the new Medicare benefits (beginning in 2005) establishing coverage of an initial preventive physical exam, and diabetes and cardiovascular disease screening tests, to ensure beneficiaries are taking advantage of these services and getting the care they need to better manage their diabetes.
Action Steps for HHS/Tobacco
Prevention of the ill effects of tobacco is an essential part of the HHS mission, and HHS is committed to working in a coordinated, comprehensive, and effective manner to protect the public’s health from the harmful effects of tobacco use. In 2000, HHS launched a roadmap for improving the health of all people in the U.S. during the first decade of the 21st century, including objectives for reducing the death and disease caused by tobacco use. In addition, the Secretary’s Steps to a HealthierUS has as one of its major components avoiding risky behaviors, such as using tobacco products, to promote good health and save lives. There are many opportunities for strategic collaboration among agencies to further reduce the health and economic impact of tobacco-related diseases.
- Consider opportunities for encouraging smoking cessation activities in a variety of programs and areas, such as: the Federal workplace; among hospitalized cardiac patients; among Americans who receive their health care through or with financing from the Federal Government (Veteran’s Administration, Medicaid, Medicare, Older Americans Act services provider network, Department of Defense, Indian Health Service); or in the HRSA prevention collaborative.
- Examine ways to encourage use of the Web site, www.smokefree.gov, which offers science-driven tools, information, and other resources that have been found effective in helping smokers quit.
- Consider opportunities for incorporating tobacco use prevention messages into community-based shelters for runaway and homeless youth and their families; and the National Youth Sports Program youth camps for middle-school-aged, low-income youth.
- Examine opportunities for tobacco use prevention and smoking cessation among Head Start and Early Head Start staff and parents.
- Examine opportunities to enhance the delivery of technical assistance on tobacco control through SAMHSA’s Center for Substance Abuse Prevention (CSAP) Center for the Application of Prevention Technologies.
- Consider opportunities to deliver tobacco use and prevention messages to young people through sports and entertainment media campaigns.
- Examine opportunities to enhance SAMHSA Best Practices via the National Registry of Effective Prevention Programs to include tobacco prevention programs.
- Examine opportunities to expand the number of materials on tobacco prevention and control that are available through the National Clearinghouse for Alcohol and Drug Information.
- Consider research that examines the toxicity of current and new tobacco products.
- Incorporate the findings from the recently released reports on health literacy from the Institute of Medicine and AHRQ into tobacco information and communication activities.
- Highlight community-based programs that provide rewards for young people who do not smoke.
- Evaluate and disseminate the results of the Medicare Stop Smoking Program (a pilot currently underway in seven states).
Action Steps for HHS/ Media and Messages
HHS has a vast number of individual initiatives, products and messages designed to promote healthy behaviors and reduce illness and disability, such as the national nutrition program, 5 A Day for Better Health Program, the Small Steps program, and its accompanying advertising campaign (Healthy Lifestyles and Disease Prevention), which encourages American families to take small, manageable steps to ensure effective, long-term weight control.
- Identify a standard for clear and effective communication for all information, forms, materials and communication from HHS with the public.
- Update and change prevention messages to maintain ‘freshness’ and reflect the state-of-the-art practices and information.
- Research the information and communication needs, characteristics, preferences, and environments to develop effective messages.
- Coordinate prevention messages to reduce the ‘noise’ of competing messages and to leverage resources.
- Integrate prevention messages with prevention programs.
Action Steps for HHS/Health Literacy
Health literacy and messaging are important aspects of HHS research and program activities focusing on prevention. The Department’s agencies are engaged in a variety of health literacy activities. HHS agencies are beginning to include health literacy as a consideration in their research, assessment, training, program operations, and communication with the public, but there are opportunities for improvement.
- Continue research on multiple aspects of health literacy including: the impact of limited health literacy on health disparities; the nature and extent of limited health literacy in different populations and for different topics and contexts; the interaction of limited health literacy with other factors, such as age and disabilities; the most effective health literacy interventions for different segments of the population; and the impact of limited health literacy on the quality, access and outcomes of health care and public health services.
- Develop health and program information in a variety of languages.
- Emphasize the need to pre-test publications designed for wide-spread dissemination with the target audience prior to publication.
- Support the development of an evidence-based approach to training a broad spectrum of healthcare and public health professionals to communicate effectively with different types of patients, including those with limited literacy.
- Develop and validate measures of successful health literacy approaches.
- Provide leadership to identify and build consensus for outcome measures needed to improve health literacy across the population, in particular for the most vulnerable groups.
- Advise agencies to assess their information, communication, and programmatic activities with their intended audiences, particularly low literacy audiences.