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“If it were not for the Steps Program in Broome County, I might not be alive today. I am free of blood pressure medication, I have lost weight, and I have more energy because I live in a place that supports my healthy lifestyle.”

Alan Wilmarth
Beneficiary of the Steps to a HealthierNY-Broome County Program

Chronic Diseases: A National Crisis

Today, chronic diseases account for 7 in 10 deaths and affect the quality of life of 90 million Americans. Diseases such as obesity, diabetes, and asthma are some of the leading causes of death, disability, and rising health care costs in the United States. The significant rise in chronic disease rates among adults and young people is a concern across the country, including in communities, schools, and work sites and
among families, health care providers, and policy makers. The following data indicate the extent of this burden:

• Obesity. In the past 30 years, the prevalence of overweight and obesity has increased sharply for both U.S. adults and children. During 2005–2006, 34% of adults aged 20 or older were obese, and 17.4% of young people aged 12–19 years were overweight. In 2000, the estimated annual cost of obesity in the United States was $117 billion.
   
• Diabetes. In the past 15 years, the number of Americans with diagnosed diabetes has more than doubled, reaching 14.6 million in 2005. One of every 3 children born in 2000 is expected to develop diabetes during his or her lifetime. The annual cost of diabetes in 2002 was $132 billion.
   
• Asthma. In 2005, asthma was diagnosed in 33 million people. In 2004, the disease accounted for more than 13 million doctor visits and nearly 2 million emergency department visits. Unhealthy behaviors continue to increase in the United States, putting people more at risk for chronic illnesses.

For example:

• Physical Inactivity. More than 50% of U.S. adults do not get enough exercise to benefit their health, and 25% are not active at all in their leisure time.
   
• Poor Nutrition. In 2005, only 23% of U.S. adults and 20% of young people ate five or more fruits and vegetables each day.
   
• Tobacco Use. Cigarette smoking is responsible for about 440,000 deaths in the United States each year. More deaths are caused each year by tobacco use than by HIV/AIDS, alcohol use, motor vehicle injuries, suicide, and murder combined.

Exercising regularly, eating a healthy diet, and avoiding tobacco use and exposure can help people prevent and manage chronic diseases. However, many people in the United States do not have easy access to healthy foods and safe, convenient places to exercise. These barriers have led to increasingly unhealthy and sedentary lifestyles for the majority of Americans. Concentrated efforts are needed in local communities across the country to confront the national epidemic of chronic diseases.

CDC’s National Leadership

CDC is committed to ensuring that all people, especially those at greater risk for health disparities, achieve their optimal lifespan with the best possible quality of health in every stage of life. With agency-wide health protection goals that support healthy people in healthy places across all life stages, CDC is setting the agenda to enable people to enjoy a healthy life by delaying death and the onset of illness and disability by accelerating improvements in public health.

One important way that CDC is responding to the country’s rising chronic disease burden is by accelerating change at the local level. To support this goal, the Steps Program funds communities across the country to show how local initiatives can reduce the burden of obesity and other chronic diseases and to encourage people to be more physically active, eat a healthy diet, and not use tobacco. The Steps Program is accelerating change at the local level by

• Creating a groundswell of activity in local communities to support healthier lifestyles and prevent chronic diseases.
   
• Reaching beyond the public health sector and bringing together a range of disciplines (e.g., business, transportation, and city planning) to improve the health of communities.

• Funding rural counties (through state health departments), urban areas, and tribal groups in areas where the chronic disease burden is especially high and people are most in need of prevention programs.
   
• Implementing public health interventions that are evidence-based and have been successful in changing people’s behaviors.
   
• Convening and training teams of community leaders who make long-lasting local change.

National Impact of Steps

Steps communities document progress toward key health outcomes by participating in the Behavioral Risk Factor Surveillance System (BRFSS) and the Youth Risk Behavior Surveillance System. Data from selected communities funded in 2003 indicate that

• In 2004, the percentage of adults living in Steps communities who have diabetes and who reported having a foot exam in the past year was 71.1%, compared with the national average of 70.8%. In 2006, this increased to 77.2%, surpassing the national average of 71.7% (see Figure).
   
• The proportion of adults living in Steps communities who have asthma and who reported days on which they experienced no asthma-related symptoms increased from 23.9% in 2004 to 28.6% in 2006, surpassing the national average of 26.2%.
   
• In 2004, the percentage of adult smokers living in Steps communities who reported trying to quit smoking during the past 12 months was 53.4%, compared with the national average of 54.8%. In 2006, this increased to 58.4%, surpassing the national average of 57.5%.

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Keys to Local Success

The Steps Program is using the following key principles and strategies to create and sustain change at local levels across the country.

Responding to Community Needs

Real community involvement is needed to successfully change policies and environments and prevent chronic diseases at the local level. In each community, the Steps Program brings together a diverse group of leaders from the public sector, nonprofit organizations, and private entities to design unique disease prevention and health promotion strategies that respond to local needs and take advantage of local assets.

Reaching Diverse Population Groups

Steps communities partner with members of groups that are most at risk for chronic diseases, including rural residents, racial and ethnic minority groups, and poor and underserved populations. Creating Nontraditional Partnerships Steps communities are reaching out to people in nonhealth sectors—such as transportation, chambers of commerce, the media, and cooperative extension services—to increase their participation in local chronic disease prevention programs. These partnerships help pool resources to more effectively confront the burden of chronic disease in local communities.

Working in a Wide Range of Settings

The Steps Program collaborates with partners in many different areas where actions are needed to promote health. Examples include schools, work sites, health care settings, and faith-based settings. These partnerships are helping institutions make the kinds of decisions that will be required at the local level to prevent the rising rates of chronic disease.

Implementing Large-Scale Interventions

Steps communities are charged not only with addressing a wide range of health challenges, but also with doing so across the entire life span. This multigenerational approach is providing millions of people with integrated and urgently needed activities and programs designed to prevent chronic diseases.

Making Programs Sustainable

Steps communities collaborate with local, regional, and national groups to ensure that their programs are sustainable. Partners are often encouraged to take ownership of projects within local Steps programs and to integrate those activities into existing operations. Partnerships with organizations such as the YMCA of the USA and state health departments are expanding the impact of the Steps Program.

The Steps Program in Action

Community-Based Diabetes Management Reduces Emergency Room Visits

The Steps Program in the River Region of Alabama trained diabetes wellness advocates to help people with diabetes set health and wellness goals and manage their condition. As a result of this program, emergency room visits among participants decreased more than 50% during 2004–2007.

Work Sites Make Important Changes

The Steps Program in Austin, Texas, established a work-site wellness program with Capital Metro, the Austin transit authority. Employees received customized health assessments and action plans for creating healthier lifestyles. As a result of this program, employee absences dropped more than 44% during 2004–2006. Annual health care costs increased by only 9% during 2004–2005, compared with 27% during 2003–2004. The use of “healthy choice” options in the employee cafeteria increased 172%.

Addressing Obesity Among Young People and Adults

In Broome County, New York, the Steps Program has reached families in rural areas by implementing an innovative walking program that has enrolled more than 50,000 people in 4 years. The proportion of adults who walk for more than 30 minutes on 5 or more days each week increased from 47% to nearly 54% in 1 year. Broome County’s Steps Program also has improved the food offered in local schools. Fifteen school districts worked together to buy healthy foods at lower cost so schools could afford them. As a result, fresh fruits and vegetable consumption has increased 14% in participating schools. The Steps Program also expanded the county’s nationally recognized Mission Meltaway program to reach more than 2,500 people; more than half of the participants in this program lost weight.

Promoting Fruit and Vegetable Consumption in Schools

The Steps Program in Pinellas County, Florida, implemented a program in K–12 schools to increase fruit and vegetable consumption among students and staff members. Lunch lines were revamped to display prepackaged salads that are easy for children to open and eat; school administrators, cafeteria managers, and food service employees received training in the importance of healthy eating and proper food preparation; and a local vegetable distributor set up farmers’ markets on school grounds.

As a result, more than 3,700 students and staff members increased their fruit and vegetable intake, and 84% of schools and 90% of their students and staff are participating in the farmers’ markets. In August 2007, the Pinellas County School District was rated first in the nation among large school districts on the Physicians Committee for Responsible Medicine’s School Lunch Report Card.

Native American Nations Take Action

The Steps Program of the Cherokee Nation in Oklahoma made important changes to the school environment in all 19 schools with predominantly American Indian students. These changes include developing wellness policies, offering healthier choices in vending machines and cafeterias, and providing access to exercise facilities after school. Nine schools developed and implemented 24/7 tobacco-free school policies. In Michigan, the Anishinaabe Steps Program and the Inter-Tribal Council of Michigan have undertaken groundbreaking work to collect data in American Indian communities. They used BRFSS surveys to provide baseline data on how much residents know about disease prevention. The data will be used to design and deliver more effective programs to promote
health and prevent disease in American Indian communities.

Increasing Tobacco Cessation Rates Through Health Systems Change

In collaboration with the Steps Program in Chautauqua County, New York, a local hospital changed its policy on asking patients about tobacco use and implemented a 2-minute tobacco cessation intervention that has been shown to be effective in helping smokers quit. More than 547 health care providers were trained on the intervention, and the hospital changed its patient intake and education forms to reflect the new process. As a result of the new policy, total calls to the New York State Smokers’ Quitline from health care provider referrals increased four-fold during 2005–2006. In addition, county data show a decrease in smoking rates in Chautauqua County, from nearly 29% in 2004 to less than 24% in 2006.