<DOC>
[108 Senate Hearings]
[From the U.S. Government Printing Office via GPO Access]
[DOCID: f:85831.wais]
S. Hrg. 108-234
IMPROVING NUTRITION AND HEALTH THROUGH LIFESTYLE MODIFICATIONS
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HEARING
before a
SUBCOMMITTEE OF THE
COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE
ONE HUNDRED EIGHTH CONGRESS
FIRST SESSION
__________
SPECIAL HEARING
FEBRUARY 17, 2003--SAN FRANCISCO, CA
__________
Printed for the use of the Committee on Appropriations
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COMMITTEE ON APPROPRIATIONS
TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri PATRICK J. LEAHY, Vermont
MITCH McCONNELL, Kentucky TOM HARKIN, Iowa
CONRAD BURNS, Montana BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama HARRY REID, Nevada
JUDD GREGG, New Hampshire HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas RICHARD J. DURBIN, Illinois
MIKE DeWINE, Ohio TIM JOHNSON, South Dakota
SAM BROWNBACK, Kansas MARY L. LANDRIEU, Louisiana
James W. Morhard, Staff Director
Lisa Sutherland, Deputy Staff Director
Terrence E. Sauvain, Minority Staff Director
------
Subcommittee on Departments of Labor, Health and Human Services, and
Education, and Related Agencies
ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi TOM HARKIN, Iowa
JUDD GREGG, New Hampshire ERNEST F. HOLLINGS, South Carolina
LARRY CRAIG, Idaho DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas HARRY REID, Nevada
TED STEVENS, Alaska HERB KOHL, Wisconsin
MIKE DeWINE, Ohio PATTY MURRAY, Washington
RICHARD C. SHELBY, Alabama MARY L. LANDRIEU, Louisiana
Professional Staff
Bettilou Taylor
Jim Sourwine
Mark Laisch
Sudip Shrikant Parikh
Candice Rogers
Ellen Murray (Minority)
Erik Fatemi (Minority)
Adrienne Hallett (Minority)
Administrative Support
Carole Geagley
C O N T E N T S
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Page
Opening statement of Senator Arlen Specter....................... 1
Statement of Dr. Julie L. Gerberding, Director, Centers for
Disease Control and Prevention, Department of Health and Human
Services, Atlanta, GA.......................................... 3
Prepared statement........................................... 4
Statement of Dr. Dean Ornish, president and director, Preventive
Medicine Research Institute, Sausalito, CA and professor of
medicine, University of California Medical School, San
Francisco, CA.................................................. 16
Prepared statement........................................... 18
Statement of Glenn Perelson, national marketing director,
Lifestyle Advantages........................................... 28
Summary statement of Mel Lefer................................... 30
Statement of Dr. Judith Stern, professor, Department of Nutrition
and Internal Medicine; director of the Food Intake Laboratory
Group, University of California, Davis......................... 31
Prepared statement........................................... 32
Statement of Dr. Naomi Neufeld, president, founder and medical
director of KidShape, Inc.; president of Neufeld Medical Group;
clinical professor of Pediatrics, UCLA School of Medicine...... 40
Prepared statement........................................... 41
Summary statement of Danielle Bailey............................. 43
Prepared statement of Lee Ida Boyd-Bailey........................ 44
Statement of Dr. Adam Drewnowski, director, Center for Public
Health Nutrition, University of Washington; member, Fred
Hutchinson Cancer Research Center, Seattle, WA................. 44
Prepared statement........................................... 46
Statement of Leslie Mikkelsen, managing director, Prevention
Institute...................................................... 48
Prepared statement........................................... 50
Prepared statement of Senator Barbara Boxer...................... 66
IMPROVING NUTRITION AND HEALTH THROUGH LIFESTYLE MODIFICATIONS
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MONDAY, FEBRUARY 17, 2003
U.S. Senate,
Subcommittee on Labor, Health and Human
Services, and Education, and Related Agencies,
Committee on Appropriations,
San Francisco, CA.
The subcommittee met at 10:30 a.m., in the University of
California at San Francisco Conference Room, 3333 California
Street, San Francisco, CA, Hon. Arlen Specter (chairman)
presiding.
Present: Senator Specter.
opening statement of senator arlen specter
Senator Specter. Good morning, ladies and gentlemen. The
Field Hearing of the Appropriations Subcommittee on Labor,
Health and Human Services, and Education will now begin. We
commence by expressing our thanks to the University of
California at San Francisco. We are very pleased to be here for
many reasons, among the foremost is that there are 2 feet of
snow in the East.
We are functioning here on a skeleton staff. Todd Averette
is my skeleton.
The staff is all in Washington, where airports are not open
and travel is impossible. Fortunately, Joan and I came out a
few days early, so we are able to be with you here today.
We have, I think, a very important hearing on improving
health through lifestyle modifications. The issue of
cardiovascular disease is one which our subcommittee has been
working on very intently for more than two decades, from my
personal experience in the U.S. Senate, and the statistics are
really overpowering. Cardiovascular disease afflicts 63 million
Americans, killing almost a million--960,000 each year. The
economic losses are more than any other disease, over $330
billion in medical expenses and lost productivity annually. The
cost of cancer, the dreaded disease, is about half that amount.
Cardiovascular disease kills almost as many Americans as
the next seven leading causes of death combined. It kills more
women than men. Six times as many women die from heart disease
as from breast cancer. The impact of obesity is tremendous, as
we will hear in some detail in today's hearing. In the past two
decades, obesity has increased by 100 percent among children
and adolescents. More than 16 percent of children are
overweight and, during the 1990s, the prevalence of diabetes
has increased by some 50 percent among adults.
On the issue of improving health through lifestyle
modifications, there have been very substantial increases in
funding. Senator Harkin and I have made an NIH funding the
principal, the number one priority for our subcommittee which
funds three departments--Health & Human Services is in
competition with Education, which is America's major capital
investment, and Worker Safety and Labor.
Since I became chairman of Appropriations in 1995, I have
been on the subcommittee--chairman of the Appropriations
Subcommittee on Health and Human Services. With Senator
Harkin's concurrence, we have increased the funding from $12
billion to $27 billion. Initially, we asked the Budget
Committee for $1 billion and we were turned down, so we took it
to the Floor for a fight, and we lost 63-37. But we got out our
sharp pencils and found other items to cut to make NIH a
priority. So having lost in our effort for $1 billion, the next
year we asked for $2 billion, which is the way of Washington.
And again, we lost--and this time 52-48. We went back to the
Budget and established the priority and put in the $2 billion.
Now it has become fashionable, at least up until last year,
when the administration asked for $3.4 billion and we added a
little to that to $3.7, so now we are at $27 billion. Next
year, the administration has asked for a very slight increase,
and that is a difficult matter with budget constraints, but
Senator Harkin and I, and the Subcommittee, and the full
committee, Senator Stevens being our full committee chairman,
are determined to review everything we can to increase the
funding for the National Institutes of Health. Now that
increase in funding has reflected itself with obesity research
funding moving from $128 million in 1998 to over $320 million
this year, and in nutrition research moving from under $500
million in 1998 to almost $1 billion this year, and CDC
Nutrition and Physical Activity funding moving from $11.5
million in the year 2000 to over $27 million now, and the
overall NIH Heart Disease Research funding moving from $75
million in 1999 to $1.9 billion this year. So you can see the
enormous increases.
We have some leading experts in the field today, and I will
particularize them in more detail as we move through the
hearing. We are delighted to have with us today as our lead
witness Dr. Julie Gerberding, who is the Director of the
Centers for Disease Control and Prevention, a very, very
important agency with so many jobs, Bioterrorism, I think,
being at the top of the list. The CDC in Atlanta is a premier
installation, and 3 years ago, I visited the CDC and was amazed
to see a leading scientist in the hallways, and very important
research substances in corridors in the closets. And I went
back to Washington and put up $170 million as emergency
funding. Two years ago, we increased that to $255 million. And
I think we are at about $250 million this year.
The reason I say ``I think'' is because we passed the bill
last Thursday night, and it is a thousand pages and I have not
read it all yet.
In fact, nobody has read it all. That is one of the
luxuries of a democracy.
STATEMENT OF DR. JULIE L. GERBERDING, DIRECTOR, CENTERS
FOR DISEASE CONTROL AND PREVENTION,
DEPARTMENT OF HEALTH AND HUMAN SERVICES,
ATLANTA, GA
Senator Specter. The CDC is really an enormously important
asset for America today. So thank you for joining us, Dr.
Gerberding, and thank you for bringing so much of your staff
with us. The traditional time is the 5-minute opening
statement, leaving more time for question and answer. I
recently attended the memorial service for Ambassador
Annenberg, and the time limit for speeches was set at 3
minutes, and former President Ford was limited to 3 minutes,
and Secretary of State Colin Powell was limited to 3 minutes,
and so was I and 14 other speakers, so I want you to know what
a generous time allocation 5 minutes is.
Dr. Gerberding, the floor is yours. And in the absence of
staff, Todd Averette has bought a kitchen timer. Why don't you
put it in front of Dr. Gerberding so that she can be harassed
by the timer?
Dr. Gerberding. Great. Thank you so much for inviting me
here to participate in this hearing. I think this is a
critically important topic, even in the time of Bioterrorism.
We have many important programs at CDC that we will highlight
in the few comments I am making, but I also really want to be
on the record as thanking you for the incredible support that
you and Senator Harkin have given CDC. The appropriation
includes $268 million for building some facilities and about
$400 million for activities at CDC promoting healthy
lifestyles, and you mentioned the importance of the NIH
research in all of this, but I think it is CDC that takes that
research and puts it to action in the trench, so that support
means everything. And thank you very much.
I am going to just touch on three issues, number (1) What
is the problem; and number (2) Why is it important; and number
(3) What are we doing about it now, and what should we be doing
about it? So if I could have just the first graphic here, I
wanted to emphasize a little bit of the comments that you were
making about the importance of chronic diseases overall. You
can see here in the United States the leading causes of death.
You mentioned heart disease and cancer and stroke as important
contributors to the cause of death, but if you look at the
bottom half of this chart, it shows what the actual causes of
death are. This is looking at the same data, but looking at
what is the underlying cause of these conditions. And the top
three here, tobacco, poor diet, and lack of exercise, are
really the things that we can do something about with the kinds
of lifestyle interventions that this hearing is focusing on.
I am going to be speaking particularly today about the poor
diet, lack of exercise, and its relationship to the epidemic of
obesity. On the next graphic, just in very simple picture
framework, shows how the epidemic of obesity is progressing
across the United States. Looking at this picture of the United
States in 1990, the number of States where the prevalence of
diabetes was evolving in 5 years, more States had a high
prevalence. By 2001, more than 30 States had a prevalence of
diabetes of approximately 1 in 12, or greater, so that this is
an epidemic that is astonishing. As you mentioned, the number
of individuals affected by this is extraordinary; but on the
right-hand side, you can see one of the impacts of this
epidemic of obesity, and that is the high prevalence of
diabetes. So here we see obesity, here we see diabetes, and
they are tracking right along together.
Particularly astonishing is the fact that now 15 percent of
kids between 6 and 19 years of age are overweight, and these
children are accounting for up to 50 percent of the new cases
of diabetes in many communities. So this is an astonishing and
sobering problem, and one that, from a CDC perspective, has got
to be the highest-priority domestic health issue that we are
facing today. This week in Science magazine, there is a whole
feature on the science of obesity, looking at it from a genetic
perspective, looking at it from an environmental perspective,
but I think we see it as a problem that gets boiled down to a
couple of real simple facts, and that is that we are taking in
more and more calories, and we are exercising less and less,
and utilizing fewer calories.
So the gap between what we are eating and what we are
expending is continuing to get larger and larger in our
society. And this has the consequences that you mentioned.
First of all, the chronic diseases of stroke, the cancers
including breast, endometrial and colon cancer are affected by
this high rate of obesity, and the diabetes that we have
already talked about. But the health expenses are enormous.
Some estimate that up to 8 percent of our healthcare expenses
would be eliminated if we could eliminate the obesity problem,
and that is just the direct expenses. If we take into
consideration all the indirect costs, including some 32 million
days of work lost each year from the complications of obesity,
it has a tremendous impact on our society, and we really do
need to do something about it.
So I would like to, on the next graphic, just talk a little
bit about some of the programs that are currently in place to
deal with this. We note just like we did with tobacco, that
starting with kids is important. So we have coordinated school
heath programs that are in many States, and on the next slide,
we have illustrated a youth media campaign that is going on in
several States.
prepared statement
Finally, just to mention that we are currently funding 12
States, including Pennsylvania, by the way, to implement
programs to address the problem of obesity at the community
level through community interventions and so forth. We hope in
the future to work with the program that President Bush
initiated, the HealthierUS Program. CDC has the lead for this
at HHS, but we are working with all of the Department to
implement new programs that help us take concrete steps in a
broader number of States across the country to really combat
obesity. And we look forward to getting those programs off the
ground. So with that, I will stop and take questions. Thank
you.
[The statement follows:]
Prepared Statement of Dr. Julie L. Gerberding
introduction
Good morning. I am Dr. Julie Gerberding, Director of the Centers
for Disease Control and Prevention. Thank you for inviting me here
today to participate in this important discussion of healthy lifestyles
and CDC's programs to support health promotion and disease prevention
programs in States and communities.
The United States faces an epidemic of unparalleled proportion, an
epidemic that is substantiated by the hard facts. Seven of 10 deaths,
or more than 1.7 million each year, are caused by chronic diseases.
Heart disease, cancer, stroke, chronic obstructive pulmonary disease
(such as asthma, bronchitis, emphysema) and diabetes cause more than
two-thirds of all deaths each year. Although 7 of every 10 deaths among
Americans are due to chronic diseases, the underlying causes of these
deaths are often risk factors that can be successfully modified years
before they ultimately contribute to illness and death. Three such
factors--tobacco use, poor nutrition, and lack of physical activity--
are major contributors to the nation's leading killers. Each year
430,000 deaths (about 20 percent of all deaths) are linked to tobacco
use, which causes not only lung cancer and emphysema but also one-fifth
of all cardiovascular disease deaths. Obesity is a major contributor to
heart disease, diabetes, arthritis, and some types of cancer. Recent
estimates suggest that obesity is associated with 300,000 deaths
annually, second only to tobacco related deaths.
burden of obesity
Today we face an epidemic of obesity--a major risk factor for heart
disease and diabetes. Few of our citizens have healthy nutrition and
physical activity levels. For example, only 28 percent of women and 20
percent of men eat at least five servings of fruits and vegetables per
day. More than 60 percent of adults do not engage in levels of physical
activity needed to provide health benefits. Large numbers of older
people are physically inactive, as many as 34 percent of adults aged
65-74 and 44 percent of adults aged 75+. This is of special concern
because the number of older Americans is expected to double from 35
million to 70 million by 2003. The impact of this physical inactivity
on medical costs is substantial and is likely to grow unless trends in
physical activity change among older adults. Currently one-third of
total US health care expenditures are for older adults.
In the past 15 years, the prevalence of obesity has increased by
over 30 percent among adults. In the past 20 years, prevalence in
children and adolescents has increased by 100 percent. More than 15
percent of children and adolescents are overweight, and more than half
of children who are overweight have at least one additional
cardiovascular disease risk factor, such as elevated cholesterol or
high blood pressure. Rates of overweight and obesity have increased in
older Americans by almost two-thirds since 1990. Almost 90 percent of
middle-aged Americans will develop high blood pressure in their
lifetime and nearly 70 percent of Americans with high blood pressure do
not have it under control. The cost of diseases associated with obesity
has been estimated to be $117 billion per year for direct and indirect
costs.
We have already begun to see the impact of the obesity epidemic on
other diseases. For example, type 2 diabetes, a major consequence of
obesity, has also reached epidemic proportions over the last 10 years.
During the 1990's, the prevalence of diabetes increased by 50 percent
in U.S. adults. This trend is expected to continue unless there is
substantial public health intervention. Although type 2 diabetes was
virtually unknown in children and adolescents 10 years ago, it now
accounts for almost 50 percent of new cases of diabetes in some
communities.
The combination of chronic disease death and disability accounts
for roughly 75 percent of the $1.3 trillion spent on health care each
year in the United States. Last year, the Surgeon General's Call to
Action on Obesity suggested that obesity and its complications were
already costing the nation $117 billion annually. By way of comparison,
obesity has roughly the same association with chronic health conditions
as does 20 years of aging.
The rapid increases in obesity across the population and the burden
of costly diseases that accompany obesity indicate that we can no
longer ignore it. The speed with which obesity has increased can be
explained by changes in society that have increased calorie intake and
reduced energy expenditure. Fast food consumption now accounts for over
40 percent of an average family's budget spent on food. Soft drink
consumption supplies the average teenager with over 10 percent of his
or her daily caloric intake. The variety of foods available has
multiplied, and portion size has increased dramatically. Fewer children
walk to school, and the lack of central shopping areas in our
communities means that we make fewer trips on foot than we did 20 years
ago. Hectic work and family schedules allow little time for physical
activity. Schools struggling to improve academic achievement are
dropping physical education and assigning more homework, which leaves
less time for sports and other physical activity. Television viewing
has increased. Many neighborhoods are unsafe for walking, and many
parks are unsafe for playing. Most office buildings have inaccessible
and uninviting stairwells that are seldom used. Many communities are
built without sidewalks or bike trails to support physical activity.
steps to a healthierUS
The President has announced the HealthierUS Initiative, which
focuses on nutrition, physical activity, health screening, and behavior
change. President Bush's HealthierUS Initiative is based on the premise
that increasing personal fitness and becoming healthier is critical to
achieving a better and longer life. The HealthierUS Initiative
encourages all Americans to be physically active every day, eat a
nutritious diet, get preventive screenings, and make healthy choices.
The President's fiscal year 2004 budget request includes an
increase of $100 million within CDC to pursue Steps to a HealthierUS.
The Steps Initiative advances President Bush's HealthierUS program by
focusing on obesity, diabetes, and asthma. Through Steps to a
HealthierUS, Secretary Thompson will lead the Department of Health and
Human Services (HHS) to reduce the burden of these conditions by
promoting healthy choices in nutrition, physical activity, and
preventive health care. HHS will provide national leadership for
states, communities, and schools. CDC will organize the HHS effort,
with full participation by sister agencies--the Health Resources
Services Administration, the Administration for Children and Families,
the Administration on Aging, and the Agency for Healthcare Research and
Quality.
The centerpiece of this initiative will be a single Steps to a
HealthierUS cooperative agreement program. This program will be
designed to stimulate and integrate public and private sector efforts
to improve health. The program will make substantial awards to states
and communities to implement effective public health strategies for
reducing the burden of diabetes, obesity, and asthma in their
populations. States, communities, and schools will also address related
risk factors, including a specific emphasis on promoting healthy
choices by youth and older Americans. The cooperative agreement program
will work in States, communities, and schools to:
--Prevent overweight and obesity
--Prevent development of diabetes in people with pre-diabetes
--Control the complications of diabetes for those with the disease
--Promote healthy youth
--Reduce the burden of asthma
As a part of Steps to a HealthierUS, HHS has undertaken a Healthy
Worksite Initiative within the Department's own agencies. Secretary
Thompson has asked CDC to lead this effort. CDC welcomes this
initiative because it provides the HHS workforce the opportunity to
become a model for strategies that can be applied elsewhere within the
federal government and by businesses across the United States. CDC is
working to provide attractive stairwells in buildings with a campaign
that promotes their use and healthier choices in vending machines and
cafeterias. We know from our experience that modest and inexpensive
changes, such as attractive stairwells with signs promoting their use,
can lead to increased physical activity in everyday life. We will soon
learn whether similar improvements in nutrition can be achieved by
changing and promoting the products sold in vending machines.
Widespread changes will not be achieved overnight. However, if we can
understand how to make changes in our own workplace that improve
nutrition and physical activity, we are much more likely to be
successful elsewhere. Given the size of the population that we are
trying to reach, both in our organization and in our nation, we cannot
rely solely upon interventions that target one person at a time.
Instead, the prevention of obesity and related conditions will require
coordinated policy and environmental changes that affect large numbers
of people simultaneously. CDC has developed effective prevention and
treatment strategies through our State obesity/physical activity/
nutrition programs, State coordinated school health programs, the youth
media campaign, partnerships with other organizations, and an applied
research agenda to develop and refine new approaches. Today I will
focus on CDC's current efforts that set the stage for achieving Steps
to a HealthierUS.
Preventing Overweight and Obesity.--Today we know that a few
changes can improve the health of a larger number of persons. These
include the development of sophisticated marketing messages designed to
increase health behaviors among youth; reduce television viewing in
children and adolescents; and increase physical activity for the
population. We now have evidence-based strategies for the promotion of
physical activity that include recommendations like physical education
programs in schools or access to and promotion of recreation
facilities. These approaches represent strategies that we are pursuing
today, while continuing the research necessary to identify additional
effective prevention approaches for States and communities. We will not
successfully reduce the burden of chronic diseases without an approach
that integrates nutrition and physical activity strategies across a
variety of settings and populations. For example, if physicians begin
counseling their patients to walk more, their patients will not be able
to do so unless their neighborhood has sidewalks or is a safe place to
walk. We also know that we must raise the awareness of people with risk
factors for Cardiovascular Disease like high cholesterol and blood
pressure and emphasize the link to prevention through physical activity
and good nutrition. As you may know, a study from Philadelphia has
shown that the areas with the highest death rates from nutrition
related diseases coincide with the areas of the city that lack
supermarkets. Inner city residents of Philadelphia will not be able to
increase their fruit and vegetable intake to prevent cancer and heart
disease without access to supermarkets.
Currently CDC funds 12 States, at a capacity-building level
(average award of $450,000) to prevent and reduce obesity and its
related chronic diseases. Our support permits States to develop and
test nutrition and physical activity interventions to prevent obesity
through strategies that focus on policy-level changes (e.g., the State
assesses and rates childcare centers for nutrition and active play) or
supportive environments (e.g., competitive pricing of fruits and
vegetables in school cafeterias). Examples of these approaches can be
illustrated by the experience in three States.
The Pennsylvania Department of Health received funding from CDC to
develop a State Nutrition and Physical Activity Program to Prevent
Obesity and Related Chronic Diseases in July 2001. The Department
convened stakeholders to develop a comprehensive and coordinated
nutrition and physical activity plan. The plan incorporates a broad
range of activities to promote nutrition and physical activity to
prevent obesity. An initial outcome of the planning process was the
creation of PANA (Pennsylvania Advocates for Nutrition and Activity), a
statewide coalition to coordinate the implementation and evaluation of
the state nutrition and physical activity plan. On February 11, PANA
released a community version of the plan at a meeting of
representatives from the six health regions across the state. Using the
plan as a guide, PANA will focus efforts around community environments,
youth and families, and healthcare practices. PANA will also coordinate
communication, information advocacy, and research and evaluation for
the priority areas.
The State of Rhode Island is using CDC's School Health Index as an
intervention tool to address policy and environmental change within
four high-risk elementary schools. Selected schools have at least a
greater than 30 percent Hispanic/Latino enrollment and 50 percent or
more of the student population is eligible for free or reduced lunch
programs. Based on the School Health Index model, four local school
advisory committees for each school will tailor school policy and
program intervention components to fit within their school structure
and population while maintaining a common purpose and shared activities
across schools. Program expectations include increased existence of
policy and environmental supports for nutrition and physical activity.
The North Carolina Healthy Weight Initiative has involved
communities and an energetic statewide task force comprised of
community leaders and health professionals. The group has developed a
curriculum known as ``Color Me Healthy'' for 4 and 5 year olds that
focuses on interactive learning opportunities to promote eating healthy
and being active. Through an innovative collaboration with the USDA,
``Color Me Healthy'' is being implemented in 71 counties through
cooperative extension and WIC, the Supplemental Food Program for Women,
Infants and Children.
CDC is also working with the U.S. Administration on Aging to
collaborate on 10 Aging State Projects to conduct health promotion
demonstration projects. CDC currently funds 29 states to prevent high
blood pressure and cholesterol. As an example, public health experts in
Virginia are working with the American Heart Association to raise
awareness among young African Americans of how high blood pressure
affects your health and of why it is important to control it.
These examples illustrate the importance of starting early to
impact health behaviors. In addition, improving physical activity and
nutrition prevents deadly chronic diseases and also helps control their
consequences in those who become ill. Nutrition and physical activity
are key to reducing harm caused by heart disease, stroke, and cancer,
as well as diabetes.
preventing the development of diabetes in those with pre-diabetes
Last year NIH's Diabetes Prevention Program demonstrated that diet,
exercise, and modest weight loss decreased the incidence of diabetes in
persons at very high risk for developing diabetes by almost 60 percent,
which was twice as effective as the pharmaceutical therapy in the
comparison group. These results emphasize the importance of lifestyle
modification in the treatment of obesity and prevention of diabetes.
Influencing lifestyle choices is particularly important for older
Americans because of the high prevalence of diabetes in this
population. In 1999, the prevalence of diagnosed diabetes among people
aged 65-74 was more than 13 times that of people less than 45 years of
age. We are currently working with health care organizations to begin
the process of translating these approaches into strategies that can be
used in primary care.
control the complications of diabetes for those with the disease
CDC provides leadership and funding to diabetes control programs
nationwide. We also work with many partners to provide data for sound
public health decisions, inform the public about diabetes, and ensure
good care and education for the American with diabetes. Many
complications from diabetes can be prevented, such as blindness, kidney
disease, amputations, and cardiovascular disease.
Timely data and public health research are essential to
understanding how diabetes affects different populations and improving
quality of care. CDC analyzes information from several national data
sources and works to translate scientific data into higher quality
care. As an example of how we work with partners in research, CDC has
teamed up with managed care organizations and community health centers
to assess how standards of care are applied in clinical care settings,
to explore variations in the quality of diabetes care, and to test
strategies to move existing care practices closer to optimal standards.
In fiscal year 2002, CDC provided $61.8 million in limited support
to 34 states, and 8 territories for Core Diabetes control. An
additional 16 states received support to implement Comprehensive
programs. For example, in California, the Diabetes Control Program
assessed the effects of case management on blood glucose levels among
Medicaid patients. Results revealed that improved nutrition education,
better glucose monitoring instruction, and improved instructions for
care reduced blood glucose levels which decreased the risk of
complications and reduced health care costs.
promoting healthy youth
Coordinated School Health Program
We like to think of ourselves as a youthful nation focused on
healthy lifestyles, but behind the exciting media images of robust
athletes and Olympic Dream Teams is a troubling reality--a generation
of young people that is in large measure inactive, unfit, eating
poorly, and at an alarming rate, becoming obese. CDC's Comprehensive
School Health Program focuses on improving health behaviors in youth.
Tobacco use remains the single leading preventable cause of death
in the United States, yet a large percentage of our young people
continue to smoke cigarettes. Each day, approximately 5,000 young
people try their first cigarette, and 3,000 become daily smokers. Rates
of smoking among high school students actually increased during much of
the 1990s. Although the rates have decreased over the past few years,
29 percent of U.S. high school students currently smoke cigarettes.
Among the sectors of society that can influence young people to
make sound health decisions, schools have a particularly important
role. Every school day, more than 53 million young people are in our
nation's 129,000 schools, which are an important source of health
education and provide many opportunities for young people to practice
healthy behaviors. Studies have documented that:
--School-based health promotion programs can effectively improve
physical activity and eating behaviors.
--Such programs can also reduce tobacco use among youth.
--Schools can improve the nutritional quality of foods offered to and
consumed by students as part of school meals.
--Schools can use creative marketing approaches to improve the
nutritional quality of foods that students buy outside of the
school meals program.
--Schools can increase the amount of time that students are active
during physical education.
Beyond the school grounds, schoolchildren face substantial
challenges to healthy living. School programs can support them in
making healthy choices. CDC emphasizes the importance of a multi-
component, coordinated school health approach that includes classroom
health education, high-quality physical education, regular
opportunities to participate in physical activity in addition to
physical education, nutritious and appealing school meals,
opportunities to make healthy eating choices through vending machines
and other settings outside of school meals, and strong policies
requiring and enforcing tobacco-free campuses. Furthermore, school-
based programs are more likely to have a substantial impact on youth
behaviors when they are part of a broader, comprehensive health
promotion approach that includes community-based activities.
CDC currently supports coordinated school health programs in 20
States that help ensure that students receive effective health
instruction in nutrition, physical activity, and tobacco use
prevention, integrated into a school health program that includes
health services, quality physical education, nutritious school meals,
and counseling and social services that remove barriers to students'
academic success. Through this program, State educational agencies work
with State health departments to:
--Plan, implement, and evaluate healthy lifestyle programs.
--Provide training to educators on how to promote healthy lifestyles.
--Monitor youth lifestyle behaviors and programs to influence them.
--Develop and implement policies to support effective implementation
of school health programs at the local level.
--Build effective partnerships with other government agencies and
non-governmental organizations.
I would like to describe some important activities supported by
CDC's comprehensive school health program.
--California has included health in new statewide standards for
teacher training, and has added physical fitness test results
to local school districts' accountability report cards.
--West Virginia has adopted some of the strongest standards in the
nation for the nutritional quality of foods and beverages
offered on school campuses, and it implements a week-long
nutrition symposium for food service and other school staff, to
help them implement the standards.
--The Rhode Island Department of Education has partnered with a
community-based agency to provide nutrition education services
and programs to more than 220 schools.
--The Wisconsin Department of Public Instruction has worked with the
University of Wisconsin to institute an annual Best Practices
in Physical Activity and Health Education Symposium that
showcases exemplary school health promotion programs.
Youth Media Campaign
Congress appropriated $193.4 million over the last two fiscal years
to develop and launch the CDC Youth Media Campaign using the same
strategies used by commercial marketers to reach our target audience of
9-13 year olds. The campaign, branded as ``VERB, It's what you do,''
uses the best principles of marketing and communications to deliver
messages to young people about the importance of building healthy
habits early in life with the full knowledge that today's youth are
very savvy about the messages they receive. This approach has proven
successful in preventing tobacco use in youth. The Youth Media Campaign
was launched in June of 2002 with the focus on getting kids excited
about increasing the amount of physical activity in their lives and
helping their parents to see the importance of physical activity to the
overall health of their kids. The early reports from the campaign's
evaluation show very exciting results with over 90 percent of the
target audience reporting they have seen the ads an average of almost
30 times. Most importantly, young people are not just seeing our ads
and messages, they are acting on them. Out of the possible universe of
22 million young people in this age group, almost 3 million of them
have already acted. They have gone to a VERB event, participated in a
contest or sweepstakes, or have logged on to our website.
The Verbnow.com website--in the first four weeks of being fully
live--got 1.1 million unique visitors who clicked down an average of
4.4 times. These young people report they understand the messages and
intent of the campaign, and they think the campaign is ``cool and
fun.'' In addition to advertising for young people and their parents,
the campaign uses events, website, viral and guerrilla marketing
(essential marketing concepts for young people), and partnerships with
community organizations to enhance the reach and effectiveness of these
important health messages.
A nine-city tour with the Nickelodeon Show began in October 2002
and concludes in April 2003. In addition, by April 2003 the campaign
will have taken part in more than 200 community and ethnic events
across the country. We will have the first evaluation results in fall
2003, allowing us to assess the impact of the campaign on youth
activity.
reducing the burden of asthma
Despite evidence that asthma death rates are leveling off and
asthma hospitalization rates are declining, asthma's impact on health,
quality of life, and the economy remain substantial. Rates of severe
asthma continue to disproportionately affect poor, minority, inner-city
populations. For example, African Americans visit emergency
departments, are hospitalized, and die due to asthma at rates three
times higher than rates for white Americans.
The initial onset of asthma cannot yet be prevented or cured.
However, asthma can be controlled, and people who have asthma still can
lead quality, productive lives. Asthma can be controlled by following a
medical management plan and by avoiding contact with environmental
``triggers'' such as cockroaches, dust mites, furry pets, mold, tobacco
smoke, and certain chemicals.
In 1999, CDC created the National Asthma Control Program. The goals
of the program are to reduce the number of deaths, hospitalizations,
emergency department visits, school or work days missed, and
limitations on activity due to asthma. CDC is working with over 90
partners (state health departments, school districts, and national
organizations) to collect and analyze data on an ongoing basis to
understand the ``who, what, and where'' of asthma, ensure that
scientific information is translated into public health practices and
programs to reduce the burden of asthma, and ensure that all
stakeholders have the opportunity to be involved in developing,
implementing, and evaluating local asthma control programs.
conclusion
Obesity, diabetes, asthma and other chronic diseases have increased
substantially over the past decade and take a heavy toll on the health
of the United States. CDC programs are addressing these problems, but
many are in the early stages of development. We are committed to
reducing the burden of these conditions by promoting healthy choices in
nutrition, physical activity, youth risk taking and preventive health
care. Through Steps to a HealthierUS, we look forward to working with
you to foster healthy behaviors and reduce illness and premature death.
Thank you for the opportunity to testify on this most important
topic. At this time I would be happy to answer any questions.
Senator Specter. Thank you very much, Dr. Gerberding. I
very much appreciate your service at the CDC, and the
outstanding record you bring to the position. I think it
important to note for the record that you are also Associate
Clinical Professor of Medicine at Emory, went to Case Western
for both your bachelor and MD, and were the chief medical
resident right here at University of California at San
Francisco, and had your masters of public health at the
University of California at Berkeley.
When you specify the final budget figure of $268 million,
the budget process is very complicated, so that I was unable to
give you a precise figure as in so many lines because I think
we started in excess of $270 million, and then there were
across-the-board cuts, and then there was reinstatement. And
then some items were exempted from the cuts, like veterans. We
completed the budget in 10 days. We did not fight on the budget
on anything but Defense last year on only two bills--the
Department of Defense and Military Construction.
I was recently in the Middle East and talked to the new
Finance Director of the Palestinian Authority where they have a
budget, but last year, the U.S. Senate did not have a budget--a
curious contrast--so that when we finally finished this bill
very late last Thursday evening, which enabled us to come out
here ahead of the snow, the 1,000 pages is sort of notorious
because it was reported all around, and nobody had read the
1,000 pages as the process was put together and staff--I have a
very extraordinary staff--Betty Lou Taylor is one of the most
knowledgeable--perhaps the most knowledgeable of all the
staffers on Capitol Hill, and our section was under a very
careful control, as was each of the others, but in terms of
somebody going through the 1,000 pages.
So I am pleased to find out what your budget is here at
$268 million on the construction alone, and I know how
important that is, so we are going to be providing in excess of
$1 billion. We have gotten three pretty good starts going up
another 3 years. I would like you to put the chart back up
which had all the factors of tobacco, diet, in descending
order, as to the causes of death. What progress do you think we
are making, Dr. Gerberding, on the tobacco issue, on reducing
the use of tobacco?
Dr. Gerberding. Well, we have mixed news. Over the decade
of the 1990s, youth tobacco use, which is one measure we track
through a survey that we do in all the States, actually
increased. But over the last couple of years now, we are
beginning to see some modest reductions in the proportion of
kids in high school who smoke. I think, overall, about a third
of kids have ever used tobacco at least once in their high
school, but the number who would be characterized as smoking
has gone down just a few percentage points.
We think this might be in part due to the school education
programs that have been implemented, and also to the fact that
the price of a pack of cigarettes has gone up substantially. We
know that is an important factor in influencing tobacco use
really in all ages, but particularly in kids who do not have
pocket change.
Senator Specter. Joan and I were in Palm Springs, and we
went into Rite Aid, and they had a sign up--you get carded for
buying cigarettes up to 40--and my wife was very offended she
was not carded.
I asked the clerk, ``How do you card up to 40?'' And the
answer was, ``Well, they do not want arguments.'' If you card
at 18, a lot of people argue with you, but if you card up to
40, nobody can argue with you. What more should we do?
We just had enormous settlements in litigation, lots of
money going to the States, more than $11 billion to
Pennsylvania. One of the concerns I have is that in some
States, the money is being used for other than health purposes,
some for highway construction, and I think that is a bad deal
if you produce all this money for tobacco settlements. But what
more can be done? What more should our subcommittee take the
lead on in trying to discourage the use of tobacco, especially
among young people?
Dr. Gerberding. Yes, this is a complex problem, and it
requires a lot of different solutions from a lot of different
directions. From a Federal perspective, I think enhancing the
educational and the school-based programs is a very, very
important component, and we can do more in that regard. We have
programs in all States, coordinated tobacco programs in all
States. But the penetration and the level of support in
individual jurisdictions is still variable. We know that the
younger you intervene and the more kids grow up with a culture
that does not support tobacco use, the more likely they are to
sustain abstinence from tobacco as they get into the teenage
years.
So I would say if there was one thing we could do, it would
be to focus on more school-based programs.
Senator Specter. And what is the right age to start?
Dr. Gerberding. I do not think there is an age that is too
young when it comes to tobacco. So as soon as kids are in
school, those messages about the health consequences----
Senator Specter. Should have the message start with
``Healthy Start?''
Dr. Gerberding. Yes.
Senator Specter. 3?
Dr. Gerberding. I think as soon as kids are old enough to
understand what tobacco is, they ought to know that it is bad.
Senator Specter. Earlier than 3?
Dr. Gerberding. Well, I do not think we have programs in
place to address that, but it would be at least worth asking
the question.
Senator Specter. If we do not have programs in place, that
is what we are here for.
Dr. Gerberding. Exactly, exactly.
Senator Specter. To put programs in place. Poor diet and
lack of exercise, that is number 2. What did you think of the
law suit as to McDonald's for making people fat?
Dr. Gerberding. The fast food industry----
Senator Specter. The case was dismissed, but it was brought
on the analogy of putting out a product for consumption with a
reckless disregard for the safety of the people who are going
to buy the product, which is the tobacco theory, even though
the warnings are on it. Do you think that was the right
decision, or should there be a public duty on restaurants like
fast food chains to take care not to feed unsuspecting people
food which is going to be injurious to their health?
Dr. Gerberding. We do not have scientific evidence that
links fast foods, per se, to obesity. So right now, the science
is not there to say that is an important component of the
problem.
Senator Specter. Need an extra appropriation?
Dr. Gerberding. We could discuss it.
Senator Specter. We have not had evidence yet to link Agent
Orange to many of the maladies that came out of the Vietnam
War.
Dr. Gerberding. Yes. And I think that we certainly support
that consumers need to understand what is in the food that they
are eating, including what is in the fast food. But what we are
doing with the fast food industry that I think is a very
proactive thing is to engage them in creating fast foods that
are healthier choices for people. Secretary Thompson had----
Senator Specter. What are you doing to engage them?
Dr. Gerberding. The first thing is to just sit down with
the leaders of those industries----
Senator Specter. Are you doing that?
Dr. Gerberding. Yes, we are doing that. The Secretary met
with them a few weeks ago in Washington, and we are looking at
ways that they can help us. For example, they know an awful lot
about why people make certain food choices, and if we had that
kind of information, it might help us get people to make
healthier food choices. So there is a lot of knowledge that
they have and can share with us, and so far, it looks very
optimistic that they would be willing to deal with this problem
in a constructive way, rather than through a punitive or a
regulatory manner. So that is the direction we are going right
now.
Senator Specter. So they--your point is, one of which is
pretty obvious, they do research to figure out how to attract
people to certain foods?
Dr. Gerberding. Exactly.
Senator Specter. Yes.
Dr. Gerberding. And if we knew--if we had that information,
or we were able to do that kind of public health research at
CDC, it would certainly help us understand what would make the
right foods more attractive, particularly for kids.
Senator Specter. Are they willing to share some of their
trade secrets?
Dr. Gerberding. Well, I do not know if we have gotten that
far in the negotiations, but I think it will have to come down
to the level where somebody has got to have that information
and we need it.
Senator Specter. That might be a good subject for a hearing
in Washington with the fast food people.
Dr. Gerberding. I agree.
Senator Specter. You might have to be the lead witness
again.
Dr. Gerberding. Well, I am getting some practice at it.
Senator Specter. Well, it would be interesting to be privy
to what they have found on what attracts people, and how you
attract people to other foods. That is something we are going
to be exploring later with Dr. Ornish in some greater detail,
but it would be interesting to bring them in.
That law suit against McDonald's drew a lot of ridicule and
was dismissed, but it is not too far-fetched, especially as
there is more information developing. And if their research
showed that there are ways to encourage people to eat other
kinds of food, and if they definitely want a way to make it
cheaper and more profitable without regard for health, that
could be a factor--like the Pinto case where they put the gas
tank in the back at a cost of $4, where to move it up front
would cost $8. That kind of engineering in food might be very
informative as well.
Without going into all of the details now, Dr. Gerberding,
our subcommittee would be interested in what your
recommendations would be on the entire list going down--
alcohol, firearms, motor vehicles, illicit drug use, et
cetera--as to what might be undertaken to change behavior on
those lines. Would you put up the other chart on Steps to
Better Health?
You have there ``Prevent the Development of Diabetes.'' How
do you do that?
Dr. Gerberding. Well, the first important component of that
is to prevent obesity because obesity is the number one risk
factor for at least adult onset diabetes, and now,
increasingly, for that kind of diabetes among children. So the
big ticket item here is to prevent obesity. But even if we have
an obese population, improving fitness will reduce the onset of
diabetes, and will reduce the complications of diabetes.
Senator Specter. Do you know the cause of diabetes?
Dr. Gerberding. Well, there are many causes. One important
etiology of the early onset diabetes is probably genetic and
immunologic. But in the older population, the theory is that
the cells become resistant to the effects of insulin, in part
because of the obesity and probably the changes that are
occurring at the receptors for the insulin hormone, so that
people with adult onset diabetes have insulin in their bodies,
but their cells do not react to it normally. So it takes more
insulin to control blood sugar than it really should. When you
lose weight then, in many people, you can restore that
sensitivity to the insulin, and so they do not have diabetes,
or they have fewer complications with controlling their blood
sugar.
Senator Specter. You had a line in your testimony about a
diet and its impact on colon cancer. Can you be specific as to
a cause of colon cancer related to diet?
Dr. Gerberding. Well, there are various ways in which diet
can affect colon cancer. We got clues to this in looking at
populations that seemed to be at higher risk for colon cancer,
like people in this country whose diet is very different from
people in, for example, some Asian countries that have a lower
risk. There are certain foods, you know, the cruciferous
vegetables like Brussels sprouts, cauliflower, and broccoli
that seem to be associated with a lower colon cancer risk.
Senator Specter. How do you quantify that statistically,
scientifically?
Dr. Gerberding. Well, that is part of the kind of public
health research we do at CDC where you can, for example, look
at people who have colon cancer, and compare them to similar
people who do not, and then compare their diets. And if you see
that, in the people with the cancer, there are fewer of these
good vegetables being taken in, that is a pretty strong hint
that the diet can be a factor. And by doing that kind of
research in larger populations, and repeating it in different
kinds of people, over time you develop a body of evidence that
is increasingly strong that diet really is an important risk
factor for colon cancer.
Senator Specter. So when you talk to people about their
diet and they tell you that they eat Brussels sprouts, are they
that specific, really? Cauliflower?
Dr. Gerberding. Well, there are tools. There are tools that
are developed to get very precise information about people's
dietary intake. Of course, we always remember what we have
eaten in the last 24 hours better than what we have eaten in
the last 3 days or 3 months. But there are valid scientific
methods for really getting a picture of people's diets, both
from the standpoint of kinds of foods, but also how foods are
prepared and what the caloric and fat and micronutrient
composition of those foods might be. And you can also do it in
a prospective sense by giving people a food diary and then
asking them to carefully record on a daily basis the kind of
food intake that they are having.
Senator Specter. How much of an educational effort is there
in this country generally on trying to influence people on
their diet on these issues?
Dr. Gerberding. You know, one of the ironies of this is
that at any given time, about half of the women in America are
trying to lose weight. And we have a large capacity to be
concerned about the cosmetic implications of how we look or
what we eat, but I do not think the emphasis has been on the
health aspects of our diet and our weight. I think we need to
do a lot more to educate people about the importance of
nutrition and the kinds of consequences that poor nutrition
really has. I mean, this obesity is malnutrition. It is just a
different kind of malnutrition in the developed world--and
people do not get it. They do not understand how critical this
is, not just to their appearance, but to the kinds of diseases
that we are talking about here.
Senator Specter. What role should the Federal Government
play in trying to promote that education?
Dr. Gerberding. I think we have a lot more that we can be
doing about getting the word out. There is a great need for
research, for public health research on what are the
determinants of people's food choices, what are the
determinants of their----
Senator Specter. Research on determinants for people's food
choices?
Dr. Gerberding. Their food choices, exactly.
Senator Specter. Well, what research have you undertaken so
far on that?
Dr. Gerberding. Well, part of this is just getting off the
ground. CDC does not have a large research enterprise in this
particular area, but we do collaborate with NIH.
Senator Specter. Why not?
Dr. Gerberding. Well, I think part of it is a budget issue.
As you----
Senator Specter. How much more money do you need?
Dr. Gerberding. I will have to get back to you for the
record on that because it is not something that I have really
had a costing-out----
Senator Specter. Will we have to give you an earmark?
Dr. Gerberding. I think we would like to be able to
describe for you the priorities of what needs to be done and
have a discussion about what it would take to do it----
Senator Specter. If we give you an earmark, then the
subcommittee will be criticized for politicizing scientific
choices.
Dr. Gerberding. We can get back to you with some ideas on
how to go forward on this.
Senator Specter. There is tremendous competition among all
the ailments--Alzheimer's, cancer, Parkinson's, and we stay
away from the effort to tell you anything----
Dr. Gerberding. I appreciate that----
Senator Specter [continuing]. Specifically about how you
divide up your budget, on the ground that we are not competent
to do that.
Dr. Gerberding. One of the ways that I think about this----
Senator Specter. Of course, we are competent to go to war,
but not to tell you, not to tell you how to allocate your
budget.
Dr. Gerberding. One of the ways that I would think about
this is not so much what do we need to do for diabetes or heart
disease, or any of these things, but the kind of public health
research that we need answers to are: ``What is the best way to
engage people in healthier decisions for a variety of these
issues? What are the best ways to communicate with kids?'' You
know, kind of the cross-cutting ways of deploying the health
information that our research at NIH gets out. How can we take
advantage of that and implement it? And that is kind of a
cross-cutting framework for this, that we are actually working
on how to get that across to----
Senator Specter. Do you have any clinical trials on these
issues?
Dr. Gerberding. We do not have any prospective clinical
trials. We have intervention projects. We are going into
communities and trying things that we think are going to work.
Senator Specter. What is an intervention project?
Dr. Gerberding. For example, if we go into a school and try
to work with the principal to change the vending machines and
change the menu in the school cafeteria, engage the PTA and the
parents' organizations in changing the culture of eating in
that school, that can lead to improvements in nutrition, and--
--
Senator Specter. How much of that do you do?
Dr. Gerberding. Well, we have programs like that right now
in 12 States where we are experimenting with different
strategies----
Senator Specter. Pennsylvania and Ohio, and what other 10
States?
Dr. Gerberding. Pennsylvania is one of the States,
California is one of the States, and I can tell you in a
second--the other States are Colorado, Connecticut, Florida,
Maine, Michigan, Montana, North Carolina, Rhode Island, Texas,
and Washington State.
Senator Specter. Does Senator Harkin know that Iowa is not
included?
Dr. Gerberding. I will make sure he does.
Senator Specter. No, you better make sure he does not.
Well, thank you very much, Dr. Gerberding. This is a much
more relaxed hearing than the subcommittee in Washington.
Dr. Gerberding. I agree.
Senator Specter. You have testified many times there, but
you have never testified this long, have you?
Dr. Gerberding. No, sir.
Senator Specter. Well, there was no ringing of the bell for
votes--one of the advantages of being in the field. Thank you
very much.
Dr. Gerberding. Thank you.
Senator Specter. I will call Panel 2, Dr. Dean Ornish, Mr.
Glenn Perelson, Mr. Mel Lefer, Dr. Judith Stern, Dr. Adam
Drewnowski, Dr. Naomi Neufeld, Ms. Danielle Bailey, Ms. Lee Ida
Boyd-Bailey, and Ms. Leslie Mikkelsen.
STATEMENT OF DR. DEAN ORNISH, PRESIDENT AND DIRECTOR,
PREVENTIVE MEDICINE RESEARCH INSTITUTE,
SAUSALITO, CA AND PROFESSOR OF MEDICINE,
UNIVERSITY OF CALIFORNIA MEDICAL SCHOOL,
SAN FRANCISCO, CA
ACCOMPANIED BY:
GLENN PERELSON, NATIONAL MARKETING DIRECTOR, LIFESTYLE
ADVANTAGE
MEL LEFER, PENNGROVE, CA
Senator Specter. Our lead witness is the world-renowned Dr.
Dean Ornish, founder, president and director of the Preventive
Medicine Research Institute in Sausalito, California, and
Clinical Professor of Medicine at the University of California
at San Francisco. He earned a bachelor's degree from the
University of Texas in Austin and received his medical training
at the Baylor College of Medicine, Harvard Medical School, and
Massachusetts General Hospital. We had a hearing at the
subcommittee last May on ``Reversing Heart Disease'' and the
impact of stress. Dr. Ornish is the author of many books, three
of which I have read, and has a program for reversing heart
disease, and has a branch of it called CADRe at Walter Reed
Hospital, which I personally participated in. Dr. Ornish, thank
you for joining us and the floor is yours.
Dr. Ornish. Well, thank you, Senator. It is a great
pleasure being here. I just want to begin by applauding you for
bringing so much awareness and attention to this area that I
think is so important for the health of our country, both
physically and metaphorically. As you know, for the last 25
years, I have directed a series of studies demonstrating first
that the progression of even severe heart disease often can
begin to reverse if people make much bigger changes in diet and
lifestyle that, until then, people had been recommending.
We have been able to show in a series of studies,
ironically using very expensive, high-tech, state-of-the-art
measures, how powerful these very simple and low-tech and low-
cost interventions can be, and how quickly they can occur, that
within weeks, people who are having severe chest pain or angina
become essentially pain-free. And Mel Lefer is one of the
people who went through one of our early studies who is here
today to put a more human face on that.
Part of what we have learned is what really works and what
does not work, as Dr. Gerberding was talking about in terms of
what really motivates people to make and maintain changes in
diet and lifestyle. And part of what we have learned does not
work is fear of dying because people just do not want to think
about it, it is too scary. Whereas fear of dying does not work
that well, joy of living does. And part of what we have learned
is that when people make changes in their diet and quit smoking
and exercise and manage stress better, they often feel so much
better so quickly that it re-frames the reason for making these
changes from prevention and risk factor reduction, which so
many people think are really boring, especially kids, to
feeling better.
Of course, there is no point in giving up something that
you like unless you get something back that is better, and
quickly.
So what we have been able to show is that heart disease is
reversible. Beginning in 1993, we began training hospitals
around the country through our non-profit institute. We have
trained about 30 so far, and we found that this was not only
medically effective, but also cost-effective, and that one of
the problems in going to insurance companies was that they were
saying: ``Well, we do not want to pay for diet and lifestyle
because that is prevention and we do not pay for prevention
because it takes too long to see the benefits. And 30 percent
of people change insurance companies every year, so why should
we spend our money today for some future benefit that someone
else is going to get?''
We re-framed that by saying that, for people who choose
this as a direct alternative to things like bypass surgery and
angioplasty, the cost savings occur dramatically and
immediately. The skepticism was, could people make these
changes? And we were able to show that almost 80 percent of the
people who were eligible for a bypass or angioplasty were able
to safely avoid it, and the insurance companies in this case,
Mutual of Omaha, saved almost $30,000 a patient.
Then, more recently, Highmark Blue Cross/Blue Shield in
your home State of Pennsylvania began not only covering the
program and reimbursing it, but also providing it. And they
found--and Glenn Perelson will talk more about this--that in
their first 350 people, 348 avoided surgery and they saved more
than $17,000 a patient. And as you know, and in part because of
your leadership, Medicare is now reimbursing 1,800 patients to
go through this program. And we are hoping that if Medicare
finds the same cost savings and medical outcomes that we have
already shown in two earlier demonstrations, that they will
make this a defined benefit, and then all Americans will have
access to it. And other insurance companies will follow their
lead.
I will be presenting at the American Neurological
Association's Annual Scientific Meeting in Chicago in April the
results of a study we have been doing the last several years to
see if early prostate cancer can be reversed through making
similar changes in diet and lifestyle, and our early data
indicate that it may.
Senator Specter. What was that that could be reversed?
Dr. Ornish. Prostate cancer. We found that--we took men
that had biopsy proven prostate cancer who had elected for
reasons unrelated to our study not to be treated. We randomly
divided them into two groups. Half of them went on our program
and half of them did not. And what we found was that PSA
levels, Prostate-Specific Antigen, a marker, as you know, for
prostate cancer, improved or went down in the group that made
these changes, and went up or got worse in the control group.
The differences between the groups were highly significant and
one of the interesting findings was, just as we found in the
cardiac studies where we found a dose response correlation
between adherence to the lifestyle program and changes in the
amount of blockages in their coronary arteries, we found a
direct correlation between adherence to the lifestyle program
and changes in their PSA.
We then added the serum of these patients to a standard
line of prostate tumor cells growing in tissue cultures around
the country called the LNCaP cell, and we found that the
patients who made lifestyle changes inhibited the growth of
prostate tumors much more than those who did not--also in
direct proportions of their adherence. And there was a 10-fold
difference between the two. And finally, I have been consulting
recently with McDonald's and with Pepsi to try to encourage
them to make healthier foods, and if you are interested, we can
talk more about the kind of receptivity that I am finding now
that did not exist even 1 or 2 years ago, in part because of
the fear of litigation that you talked about. That is my 5
minutes.
[The statement follows:]
Prepared Statement of Dr. Dean Ornish
introduction and background
Mr. Chairman, distinguished colleagues, thank you very much for the
privilege of being here today. My name is Dean Ornish, M.D., founder
and president of the non-profit Preventive Medicine Research Institute
and Clinical Professor of Medicine at the School of Medicine,
University of California, San Francisco (UCSF).
For the past 25 years, my colleagues and I at the Preventive
Medicine Research Institute have conducted a series of scientific
studies and randomized clinical trials demonstrating, for the first
time, that the progression of even severe coronary heart disease often
can be reversed by making comprehensive changes in diet and lifestyle,
without coronary bypass surgery, angioplasty, or a lifetime of
cholesterol-lowering drugs.
These lifestyle changes include stress management techniques (yoga-
based stretching exercises, breathing techniques, meditation, imagery,
and progressive relaxation); a very low-fat, plant-based, whole foods
diet; moderate exercise; smoking cessation; and psychosocial support
groups. When these lifestyle causes are addressed, then improvement in
coronary heart disease may begin to occur much more quickly than had
previously been documented.
We tend to think of advances in medicine as a new drug, a new
surgical technique, a laser, something high-tech and expensive. We
often have a hard time believing that the simple choices that we make
each day in our lives--what we eat, how we respond to stress, whether
or not we smoke, how much we exercise, and the quality of our social
relationships--can make such a powerful difference in our health and
well-being, even in our survival, but they often do.
When we treat these underlying lifestyle causes of heart disease,
we find that the body often has a remarkable capacity to begin healing
itself, and much more quickly than had once been thought possible. On
the other hand, if we just literally bypass the problem with surgery or
figuratively with drugs without also addressing these underlying
causes, then the same problem may recur, new problems may emerge, or we
may be faced with painful choices--like mopping up the floor around an
overflowing sink without also turning off the faucet.
For example, one-third to one-half of angioplastied arteries
restenose (clog up) again after only four to six months, and up to one-
half of bypass grafts reocclude within only a few years. When this
occurs, then coronary bypass surgery or coronary angioplasty is often
repeated, thereby incurring additional costs. Over $30 billion were
spent in the United States last year just on these two operations, many
of which could be avoided by making comprehensive changes in diet and
lifestyle, including stress management techniques.
In our research, we use the latest high-tech, expensive, state-of-
the-art medical technologies such as computer-analyzed quantitative
coronary arteriography and cardiac PET scans to prove the power of
ancient, low-tech, and inexpensive mind/body interventions. Below is a
summary of some of our scientific studies:
can lifestyle changes reverse heart disease?
We began conducting research in 1977 to determine if coronary heart
disease is reversible by making intensive changes in diet and
lifestyle. Within a few weeks after making comprehensive lifestyle
changes, the patients in our research reported a 91 percent average
reduction in the frequency of angina. Most of the patients became
essentially pain-free, including those who had been unable to work or
engage in daily activities due to severe chest pain. Within a month, we
measured increased blood flow to the heart and improvements in the
heart's ability to pump.\1\ \2\ And within a year, even severely
blocked coronary arteries began to improve in 82 percent of the
patients.\3\ The improvement in quality of life was dramatic for most
of these patients.
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\1\ Ornish DM, Scherwitz LW, Doody RS, et al. Effects of stress
management training and dietary changes in treating ischemic heart
disease. JAMA. 1983;249:54-59.
\2\ Ornish DM, Gotto AM, Miller RR, et al. Effects of a vegetarian
diet and selected yoga techniques in the treatment of coronary heart
disease. Clinical Research. 1979;27:720A.
\3\ Ornish DM, Brown SE, Scherwitz LW, et al. Can lifestyle changes
reverse coronary atherosclerosis? The Lifestyle Heart Trial. The
Lancet. 1990; 336:129-133.
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These research findings were published in the most well-respected
peer-reviewed medical journals, including the Journal of the American
Medical Association, The Lancet, Circulation, The New England Journal
of Medicine, The American Journal of Cardiology, and others. This
research was funded in part by the National Heart, Lung, and Blood
Institute of the National Institutes of Health.
In the Lifestyle Heart Trial, we found that most of the study
participants were able to maintain comprehensive lifestyle changes for
at least five years. On average, they demonstrated even more reversal
of heart disease after five years than after one year. In contrast, the
patients in the comparison group who made only the moderate lifestyle
changes recommended by many physicians and agencies (i.e., a 30 percent
fat diet) worsened after one year and their coronary arteries became
even more clogged after five years.\4\ \5\
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\4\ Ornish D, Scherwitz L, Billings J, et al. Can intensive
lifestyle changes reverse coronary heart disease? Five-year follow-up
of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.
\5\ Gould KL, Ornish D, Kirkeeide R, Brown S, et al. Improved
stenosis geometry by quantitative coronary arteriography after vigorous
risk factor modification. American Journal of Cardiology. 1992; 69:845-
853.
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Thus, instead of getting worse and worse, these patients who made
comprehensive lifestyle changes on average got better and better. Also,
we found that the incidence of cardiac events (e.g., heart attacks,
strokes, bypass surgery, and angioplasty) was 2.5 times lower in the
group that made comprehensive lifestyle changes after five years.
Cardiac PET scans revealed that 99 percent of these patients were able
to stop or reverse the progression of their coronary heart disease.\6\
A one-hour documentary of this work was broadcast on NOVA, the PBS
science series, and was featured on Bill Moyers' PBS series, Healing &
The Mind.
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\6\ Gould KL, Ornish D, Scherwitz L, Stuart Y, Buchi M, Billings J,
Armstrong W, Ports T, Scherwitz L. Changes in myocardial perfusion
abnormalities by positron emission tomography after long-term, intense
risk factor modification. JAMA. 1995;274:894-901.
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These research findings have particular significance for Americans
in the Medicare population. One of the most meaningful findings in our
research was that the older patients improved as much as the younger
ones. The primary determinant of change in their coronary artery
disease was neither age nor disease severity but adherence to the 5
recommended changes in diet and lifestyle. No matter how old they were,
on average, the more people changed their diet and lifestyle, the more
they improved. Indeed, the oldest patient in our study (now 86) showed
more reversal than anyone. This is a very hopeful message for Medicare
patients, since the risks of bypass surgery and angioplasty increase
with age, but the benefits of comprehensive lifestyle changes may occur
at any age.
These findings also have particular significance for women. Heart
disease is, by far, the leading cause of death in women in the Medicare
population. Women have less access to bypass surgery and angioplasty.
When women undergo these operations, they have higher morbidity and
mortality rates than men. However, women seem to be able to reverse
heart disease more easily than men when they make comprehensive
lifestyle changes.
multicenter lifestyle demonstration project
The next research question was: how practical and cost-effective is
this lifestyle program?
There is bipartisan interest in finding ways to control health care
costs without compromising the quality of care. Many people are
concerned that the managed care approaches of shortening hospital
stays, decreasing reimbursement, shifting from inpatient to outpatient
surgery, and forcing doctors to see more and more patients in less and
less time may compromise the quality of care because these approaches
do not address stress and other lifestyle factors that often lead to
illnesses like heart disease.
Almost ten years ago, my colleagues and I established the
Multicenter Lifestyle Demonstration Project. It was designed to
determine (a) if we could train other teams of health professionals in
diverse regions of the country to motivate their patients to follow
this lifestyle program; (b) if this program may be an equivalently safe
and effective alternative to bypass surgery and angioplasty in selected
patients with severe but stable coronary artery disease; and (c) the
resulting cost savings. In other words, can some patients avoid bypass
surgery and angioplasty by making comprehensive lifestyle changes at
lower cost without increasing cardiac morbidity and mortality?
In the past, lifestyle changes have been viewed only as prevention,
increasing costs in the short run for a possible savings years later.
Now, this program of stress management and other lifestyle changes is
offered as a scientifically-proven alternative treatment to many
patients who otherwise were eligible for coronary artery bypass surgery
or angioplasty, thereby resulting in an immediate and substantial cost
savings.
For every patient who chooses this lifestyle program rather than
undergoing bypass surgery or angioplasty, thousands of dollars are
immediately saved that otherwise would have been spent; much more when
complications occur. (Of course, this does not include sparing the
patient the trauma of undergoing cardiac surgery.) Also, providing
lifestyle changes as a direct alternative for patients who otherwise
would receive coronary bypass surgery or coronary angioplasty may
result in significant long-term cost savings.
Is it safe to offer intensive lifestyle changes as an alternative
to revascularization?
Bypass surgery is effective in reducing angina and improving
cardiac function. However, when compared with medical therapy and
followed for 16 years, bypass surgery improved survival only in a very
small subgroup of patients (about 2 percent of those undergoing bypass
surgery): those with reduced left ventricular function and lesions of
the left main coronary artery of at least 60 percent. Median survival
was not prolonged in patients with left main disease <60 percent and
normal LV function even if a significant right coronary artery stenosis
>70 percent was also present.\7\ \8\ \9\ \10\
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\7\ Alderman EL., Bourassa MG, Cohen LS, et al. Ten year follow up
of survival and myocardial infarction in the randomized Coronary Artery
Surgical Study. Circulation. 1990;82, 1629-1646.
\8\ Varnauskas, E., for the European Coronary Surgery Study Group.
Twelve-year followup of survival in the randomized European Coronary
Surgery Study. New England Journal of Medicine. 1998;319, 332-337.
\9\ Chaitman BR., Fisher LD, Bourassa MG, et al. Effect of coronary
bypass surgery on survival patterns in subsets of patients with left
main coronary artery disease. American Journal of Cardiology. 1981;48,
765-777.
\10\ Coronary Artery Bypass Surgery Cooperative Study Group.
Eleven-year survival in the Veterans Administration randomized trial of
coronary bypass surgery for stable angina. The New England Journal of
Medicine. 1984;311:1333-1339.
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Angioplasty was developed with the hope of providing a less
invasive, lower risk approach to the management of coronary artery
disease and its symptoms. Though widely utilized, there has never been
a randomized trial comparing angioplasty to medical therapy in stable
patients with coronary artery disease, therefore the mortality and
morbidity benefits of angioplasty are unknown. In low-risk patients
with stable coronary artery disease, aggressive lipid-lowering therapy
is at least as effective as angioplasty and usual care in reducing the
incidence of ischemic events.\11\
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\11\ Pitt B, Waters D, Brown WV, et al. Aggressive lipid-lowering
therapy compared with angioplasty in stable coronary artery disease.
Atorvastatin versus Revascularization Treatment Investigators. N Engl J
Med. 1999;341(2):70-6.
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The use of various types of stents during angioplasty may slow the
rate of restenosis, but there are no randomized controlled trial data
supporting the efficacy of these approaches. Compared to balloon
angioplasty patients, coronary stent patients have no statistically
significant differences in regard to additional percutaneous coronary
intervention or coronary artery bypass during a six-month follow-up
period, although they did have fewer heart attacks.\12\ The use of the
left internal mammary artery in bypass surgery may reduce reocclusion,
but vein grafts also must be used when patients have multivessel
disease. Thus, in addition to the costs of the original bypass or
angioplasty there are often costs of further procedures when restenosis
and reocclusion occur.
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\12\ Heuser R, Houser F, Culler S, et al. A Retrospective Study of
6,671 Patients Comparing Coronary Stenting and Balloon Angioplasty. J
Invas Cardiol. 2000;12(7):354-362.
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The majority of adverse events related to coronary artery disease,
MI, sudden death and unstable angina are due to the rupture of an
atherosclerotic plaque of less than 40-50 percent stenosis (blockage).
This often occurs in the setting of vessel spasm and results in
thrombosis and occlusion of the vessel.\13\ Bypass surgery and
angioplasty usually are not performed on lesions <50 percent stenosed
(blocked) and do not affect non-bypassed or non-dilated lesions,
whereas comprehensive lifestyle changes (or lipid-lowering drugs) may
help stabilize all lesions, including mild lesions (<50 percent
stenosis). Also, mild lesions that undergo catastrophic progression
usually have a less well-developed network of collateral circulation to
protect the myocardium than do more severe stenoses.
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\13\ Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis
of coronary artery disease and the acute coronary syndromes. New
England Journal of Medicine. 1992;326, 242-318.
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Bypass surgery and angioplasty have risks of morbidity and
mortality associated with them, whereas there are no significant risks
from eating a well-balanced low-fat, low-cholesterol diet, stopping
smoking, or engaging in moderate walking, stress management techniques,
and psychosocial support.
TABLE 2.--COMPARISON OF INTENSIVE LIFESTYLE CHANGES (ILC), ANGIOPLASTY (PTCA), AND BYPASS SURGERY (CABG)
----------------------------------------------------------------------------------------------------------------
ILC PTCA CABG
----------------------------------------------------------------------------------------------------------------
Rapid <d-arrow> angina............... X..................... X..................... X
Rapid <u-arrow> myocardial perfusion. X..................... X..................... X
<d-arrow> cardiac events............. X..................... ...................... X (subset)
Continued <d-arrow> in stenosis over X..................... ...................... .........................
time.
Continued <u-arrow> in perfusion over X..................... ...................... .........................
time.
Improvements in non-diluted lesions.. X..................... ...................... .........................
Improvements in non-bypassed lesions. X..................... ...................... .........................
Costs................................ +..................... +++................... +++++
----------------------------------------------------------------------------------------------------------------
Through our non-profit research institute (PMRI), we trained a
diverse selection of hospitals around the country. Also, Highmark Blue
Cross Blue Shield of Western Pennsylvania was the first insurer to both
cover and to provide this program to its members, now via Lifestyle
Advantage. Mutual of Omaha was the first insurance company to cover
this program in 1993. Over 40 other insurance companies are covering
this approach as a defined program either for all qualified members or
on a case by case basis at the sites we have trained.
A total of 333 patients completed the Multicenter Lifestyle
Demonstration Project (194 in the experimental group and 139 in the
control group). We found that almost 80 percent of experimental group
patients were able to safely avoid bypass surgery or angioplasty for at
least three years by making comprehensive lifestyle changes at
substantially lower cost without increasing cardiac morbidity and
mortality. These patients reported reductions in angina comparable to
what can be achieved with revascularization. Mutual of Omaha calculated
an immediate savings of almost $30,000 per patient. At Highmark Blue
Cross Blue Shield/Lifestyle Advantage, 348 of 350 patients were able to
safely avoid revascularization by making comprehensive lifestyle
changes. Patients reported reductions in angina comparable to what can
be achieved with bypass surgery or angioplasty without the costs or
risks of surgery.
Several patients with such severe heart disease that they were
waiting on the heart transplant list for a donor heart (due to ischemic
cardiomyopathies secondary to coronary heart disease) improved
sufficiently that they were able to get off the heart transplant list.
This improvement was not only clinically but also objectively verified
by cardiac PET scans and/or echocardiograms. Avoiding a heart
transplant saves more than $500,000 per patient as well as significant
physical and emotional trauma. Also, up to one-half of patients waiting
for a heart transplant die before a donor becomes available.
We are about to begin a randomized controlled trial to determine if
comprehensive lifestyle changes can prevent the need for a heart
transplant in these patients. This would be a way of demonstrating
quite convincingly how powerful changes in diet and lifestyle can be.
In summary, we found that we were able to train other health
professionals to motivate their patients to make and maintain
comprehensive lifestyle changes to a larger degree than have ever been
reported in a real-world environment. These lifestyle changes resulted
in cost savings that were immediate and dramatic in most of these
patients, even in those who were eligible for bypass surgery,
angioplasty, or a heart transplant and were able to safely avoid these
operations. These findings are giving many people new hope and new
choices.\14\
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\14\ Ornish D. Concise Review: Intensive lifestyle changes in the
management of coronary heart disease. In: Harrison's Principles of
Internal Medicine (online), edited by Eugene Braunwald et al., 1999.
Also to be published in hardcover in 2002.
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medicare
Good science is very important but not always sufficient to
motivate lasting changes in medical practice. When reimbursement
changes, then medical practice and medical education often follow.
Over 550,000 Americans die annually from coronary artery disease,
making it the leading cause of death in this country. Approximately
500,000 coronary artery bypass operations and approximately 700,000
coronary angioplasties were performed in the United States last year at
a combined cost of over $30 billion, more than for any other surgical
procedure. Much of this expense is paid for by Medicare. Not everyone
is interested in changing lifestyle, and some people with extremely
severe and unstable disease may benefit from surgery, but billions of
dollars per year could be saved immediately if only some of the people
who were eligible for bypass surgery or angioplasty were able to avoid
it by making comprehensive lifestyle changes instead.
Unfortunately, for many Americans on Medicare, the denial of
coverage is the denial of access. Because of the success of our
research and demonstration projects, we asked the Centers for Medicare
and Medicaid Services (CMS) to provide coverage for this program. We
believe that this can help provide a new model for lowering Medicare
costs without compromising the quality of care or access to care. In
short, a model that is caring and compassionate as well as cost-
effective and competent.
This approach empowers the individual, may immediately and
substantially reduce health care costs while improving the quality of
care, and offers the information and tools that allow individuals to be
responsible for their own health care choices and decisions. It
provides access to quality, compassionate, and affordable health care
to those who most need it.
Because of the success of our Multicenter Lifestyle Demonstration
Project, CMS conducted their own internal peer review of our program.
After seven years of discussions and review, CMS is now conducting a
demonstration project to determine the medical effectiveness of our
program in the Medicare population. If they validate the cost savings
that we have already shown in the Multicenter Lifestyle Demonstration
Project, then they may decide to cover this program as a defined
benefit for all Medicare beneficiaries. If this happens, then most
other insurance companies may do the same, thereby making the program
available to the people who most need it.
Medicare coverage also affects medical training and education. If
we demonstrate the cost-effectiveness of our program in the Medicare
population, we will provide a new model for lowering Medicare costs
without compromising the quality of care or access to care.
Also, Congress appropriated funds via the Department of Defense for
us to train the Walter Reed Army Medical Center in our program for
reversing heart disease. This program began four years ago.
can prostate cancer be slowed, stopped, or reversed by changing
lifestyle?
The significant benefits of stress management techniques and other
lifestyle changes extend beyond reversing and helping to prevent
coronary heart disease. Other illnesses that may benefit include
diabetes, hypertension, obesity, and cancers of the prostate, breast,
and colon.
Five years ago, we began conducting the first randomized controlled
trial to determine if prostate cancer may be affected by making
comprehensive changes in diet and lifestyle, without surgery,
radiation, or drug (hormonal) treatments. The scientific evidence from
animal studies, epidemiological studies, and anecdotal case reports in
humans is very similar to the way it was with respect to coronary heart
disease when my colleagues and I began conducting research in this area
over twenty-five years ago. For example, the incidence of clinically
significant prostate cancer (as well as heart disease, breast cancer,
and colon cancer) is much lower in parts of the world that eat a
predominantly low-fat, whole foods, plant-based diet. Subgroups of
people in the United States who eat this diet also have much lower
rates of prostate cancer and breast cancer than those eating a typical
American diet.
This study has been conducted in collaboration with Peter Carroll,
M.D. (Chairman, Department of Urology, UCSF School of Medicine) and the
late William Fair, M.D. (Professor and Chairman of Urology, Memorial
Sloan-Kettering Cancer Center in New York). Patients with biopsy-proven
prostate cancer who have elected to undergo ``watchful waiting'' (i.e.,
no treatment) are randomly assigned to an experimental group that is
asked to make comprehensive diet and lifestyle changes or to a control
group that is not. Both groups are studied and compared.
We enrolled 84 men with biopsy-proven prostate cancer who had
elected not to undergo conventional treatment for reasons unrelated to
the study. This unique design allowed us to have a non-intervention
control group to study the effects of diet and lifestyle alone on
cancer without confounding interventions such as chemotherapy,
radiation, and surgery.
These prostate cancer patients were randomly assigned into an
experimental group who were asked to make comprehensive lifestyle
changes or to a non-intervention control group. The comprehensive
lifestyle changes were very similar to the program that we documented
could reverse the progression of heart disease, including a very low-
fat plant-based diet (predominantly fruits, vegetables, whole grains,
beans, and soy products), moderate exercise, stress management
techniques (including yoga and meditation), and a weekly support group.
During the first year, none of the experimental group patients and
seven of the control group patients underwent conventional treatments
such as surgery or radiation.
After one year, PSA levels increased (worsened) in the control
group but decreased (improved) in the experimental group. These
differences were statistically significant after one year. This rise in
PSA in the control group would have been even greater if they had not
also made significant changes in diet and lifestyle. When we examined a
different control group of patients at the Walter Reed Army Medical
Center with similar disease severity who had not made such significant
changes in diet and lifestyle, we found their PSA rose substantially
more.
Of particular interest was the strong and statistically significant
correlation between adherence to the lifestyle program and changes in
PSA across both groups. This correlation between adherence to the
lifestyle program and changes in PSA was very similar to what we found
in our earlier studies when we found a strong correlation between
adherence to the lifestyle program and changes in coronary artery
disease.
We also measured the effects of this intervention on LNCaP cell
growth to evaluate a second level of evidence. LNCaP is a standard line
of prostate tumor cells growing in tissue culture in laboratories
around the world and is often used to evaluate new treatments,
including drug therapies. When we added blood serum of these patients
to these prostate cancer cells, we found that the experimental group
patients inhibited the growth six times more than the control group
patients. Also, we found a dose-response correlation between adherence
to the diet and lifestyle program and the degree of inhibition of the
LNCaP cells. The highest tertile of adherence inhibited the growth of
the prostate cancer cells ten times more than the lowest tertile of
adherence.
Thus, it appears that comprehensive lifestyle changes may stop or
even reverse the progression of both heart disease and prostate cancer.
However, adherence needed to be very high (>88 percent) in order to
stop the disease from progressing.
how does emotional stress affect the heart?
Emotional stress, in addition to diet and exercise, is one of the
underlying causes of coronary heart disease. During the past ten years,
increasing scientific evidence has provided a more complete
understanding of the mechanisms of coronary heart disease (CHD). This
understanding provides increasing justification for using intensive
lifestyle changes in managing CHD.
Coronary heart disease is a much more dynamic process than had once
been thought. While coronary atherosclerosis (arterial blockages)
contributes to myocardial ischemia (reduced blood flow to the heart),
so do other mechanisms that may change rapidly--for better and for
worse. These include variations in coronary artery vasomotor tone,
platelet viscosity, endothelial stability, inflammation, and collateral
circulation.
Each of these mechanisms may be directly influenced by lifestyle
factors, including cigarette smoking, diet, emotional stress,
depression, and exercise. These changes can occur--for better and for
worse--much more quickly than had once been believed.
The most common cause of myocardial infarction, sudden cardiac
death, or unstable angina is rupture of an atherosclerotic plaque,
often associated with localized coronary thrombosis and/or coronary
artery spasm.\15\ \16\ Research publications since 1990 have
consistently shown that intensive risk factor modification can reduce
cardiac events quite rapidly by stabilizing the endothelium within a
relatively short period of time, whether via comprehensive changes in
diet and lifestyle or with lipid-lowering drugs, or both, even before
there is time for meaningful regression in coronary
atherosclerosis.\17\
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\15\ Brown BG, Zhao XQ, Sacco DE, Albers JJ. Lipid lowering and
plaque regression: new insights into prevention of plaque disruption
and clinical events in coronary artery disease. Circulation.
1993;87:1781-1791.
\16\ van der Wal AC, Becker AE, van der Loos CM, Das PK. Site of
intimal rupture or erosion of thrombosed coronary atherosclerotic
plaques is characterized by an inflammatory process irrespective of the
dominant plaque morphology. Circulation. 1994;89:36-44.
\17\ Gould KL. Clinical Cardiology Frontiers: Reversal of Coronary
Atherosclerosis. Circulation. 1994;90(3):1558-1571.
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In addition to these mechanisms, emotional stress often motivates
people to overeat, drink too much alcohol, abuse drugs, work too hard,
and engage in other self-destructive behaviors. In addition, people who
are lonely, depressed, and isolated are many times more likely to get
sick and die prematurely than those who feel love, connection, and
community. The mechanisms for this understanding are not completely
understood: we know that it is true even though we do not always know
why it is true.
In this testimony, I will discuss some of these mechanisms,
describe the evidence from lifestyle intervention trials, and summarize
strategies that may be helpful in motivating patients to make and to
maintain beneficial changes in diet and lifestyle.\18\
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\18\ Ornish D. Dr. Dean Ornish's Program for Reversing Heart
Disease. New York: Random House, 1990; Ballantine Books, 1992.
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emotional stress and hostility
Emotional stress may lead to chest pain and heart attacks both via
coronary artery spasm and by increased platelet aggregation (blood
clots) within coronary arteries.\19\ Stress may lead to coronary spasm
(constriction of coronary arteries) mediated either by direct alpha-
adrenergic stimulation (i.e., direct connections between the brain and
the heart) or secondary to the release of hormones such as thromboxane
A2 from platelets, perhaps via increasing circulating stress hormones
or other mediators.\20\ Both thromboxane A2 and catecholamines (stress
hormones) are potent constrictors of arterial smooth muscle and
powerful endogenous stimulators of platelet aggregation.\21\
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\19\ Oliva, P. B. (1981). Pathophysiology of acute myocardial
infarction. Annals of Internal Medicine, 94, 236-250.
\20\ Schiffer, F., Hartley, L. H., Schulman, C. L., & Abelman, W.
H. (1980). Evidence for emotionally induced coronary arterial spasm in
patients with angina pectoris. British Heart Journal, 44, 62-66.
\21\ Moncada, S., & Vane, J. R. (1979). Arachidonic acid
metabolites and the interactions between platelets and blood vessel
walls. New England Journal of Medicine, 300, 1142-1147.
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Personally relevant mental stress may be an important precipitant
of reduced blood flow to the heart--often silent--in patients with
coronary artery disease.\22\ Acute mental stress may be a frequent
trigger of transient reductions in blood flow to the heart, heart
attacks and sudden cardiac death.\23\
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\22\ Rozanski A. Bairey CN. Krantz DS, et al. Mental stress and the
induction of silent myocardial ischemia in patients with coronary
artery disease. New England Journal of Medicine. 318(16):1005-12, 1988
Apr 21.
\23\ Bairey CN. Krantz DS. Rozanski A. Mental stress as an acute
trigger of ischemic left ventricular dysfunction and blood pressure
elevation in coronary artery disease. American Journal of Cardiology.
66(16):28G-31G, 1990 Nov 6.
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Women of postmenopausal age may have greater cardiovascular
responses to stress than men or premenopausal women.\24\
Atherosclerotic monkeys with chronic psychosocial disruption had
coronary artery constriction in response to acetylcholine, whereas
atherosclerotic monkeys living in a stable social setting had coronary
artery vasodilation in response to acetylcholine, even though both
groups of monkeys were consuming a cholesterol-lowering diet.\25\
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\24\ Bairey Merz CN. Kop W. Krantz DS, et al. Cardiovascular stress
response and coronary artery disease: evidence of an adverse
postmenopausal effect in women. American Heart Journal. 135(5 Pt
1):881-7, 1998 May.
\25\ Williams JK. Vita JA. Manuck SB. Selwyn AP. Kaplan JR.
Psychosocial factors impair vascular responses of coronary arteries.
Circulation. 1991;84(5):2201-2.
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In an analysis of over forty-five studies, hostility has emerged as
one of the most important personality variables in coronary heart
disease.\26\ The effects of hostility are equal to or greater in
magnitude to the traditional risk factors for heart disease.\27\
Hostility and cynicism appear to be the primary toxic components of the
Type A behavioral pattern. Other aspects of Type A behavior do not seem
to be harmful.
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\26\ Miller TQ, Smith TW, Turner CW, et al. A meta-analytic review
of research on hostility and physical health. Psychological Bulletin.
1996;119:322-348.
\27\ Review Panel on Coronary-Prone Behavior and Coronary Heart
Disease. Coronary-prone behavior and coronary heart disease: a critical
review. Circulation. 1978;65:1199-1215.
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depression
Several studies have shown that depression significantly increases
the risk of developing coronary heart disease. One study of 1,551
people in the Baltimore area who were free of heart disease in 1981
found that those who were depressed were more than four times as likely
to have a heart attack in the next 14 years. Depression increased risk
as much as did hypercholesterolemia.\28\
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\28\ Pratt LA, Ford DE, Crum RM, et al. Depression, psychotropic
medication, and risk of myocardial infarction. Circulation.
1996;94(12):3123-9.
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Depression also increases the risk of subsequent myocardial
infarction in patients with existing coronary heart disease.
Unfortunately, depression often goes untreated.
One study examined the survival of elderly men and women
hospitalized for an acute heart attack who had emotional support
compared with those patients who lacked such emotional support. More
than three times as many men and women died in the hospital who had no
source of emotional support compared with those with two or more
sources of support. Among those who survived and were discharged from
the hospital, after six months 53 percent of those with no source of
support had died compared with 36 percent of those with one source and
23 percent of those with two or more sources of support. These figures
did not change significantly after one year. When they looked at all
patients and controlled for other factors that might have influenced
survival (such as severity of the heart attack, age, gender, other
illnesses, depression), men and women who reported no emotional support
had almost three times the mortality risk compared with those who had
at least one source of support.\29\
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\29\ Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and
survival after myocardial infarction. A prospective, population-based
study of the elderly. Annals of Internal Medicine. 1992;117(12):1003-9.
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In another study, researchers followed 222 patients who had
suffered myocardial infarction and found that those who were depressed
were four times as likely to die in the next six months as those who
were not depressed.\30\
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\30\ Lesperance F, Frasure-Smith N, Talajic M. Major depression
before and after myocardial infarction: its nature and consequences.
Psychosomatic Medicine. 1996;58(2):99-110.
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Many depressed patients are, paradoxically, in a constant state of
hyperarousal, causing sustained hyperactivity of the two principal
effectors of the stress response, the corticotropin-releasing-hormone,
or CRH, system, and the locus ceruleus-norepinephrine, or LC-NE,
system. Norepinephrine may precipitate vasoconstriction, platelet
aggregation, and arrhythmias. Cortisol may accelerate
atherosclerosis.\31\ When patients are treated for depression, these
changes in CRH and LC-NE may return to normal. Beta-blockers help blunt
the hyperarousal state but may exacerbate depression, whereas
meditation may reduce hyper-reactivity without causing depression.
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\31\ Gold PW, Chrousos GP. The endocrinology of melancholic and
atypical depression. Proceedings of the Association of American
Physicians. 1999;111(1):22-34.
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Social factors, including social support, play an important role in
both adherence to comprehensive lifestyle changes and may have powerful
effects on morbidity and mortality independent of influences on known
risk factors. An increasing number of studies has shown that those who
feel socially isolated have three to five times the risk of premature
death not only from coronary heart disease but also from all causes
when compared to those who have a sense of connection and
community.\32\ \33\
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\32\ House JS, Landis KR, Umberson D. Social relationships and
health. Science. 1988; 241(4865):540-5.
\33\ Ornish D. Love & Survival: The Scientific Basis for the
Healing Power of Intimacy. New York: HarperCollins, 1998.
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For example, researchers at Duke studied almost 1,400 men and women
who underwent coronary angiography and were found to have had at least
one severe coronary artery stenosis. After five years, men and women
who were unmarried and who did not have a close confidante--someone to
talk with on a regular basis--were over three times as likely to have
died than those who were married, had a confidant, or both. These
differences were independent of any other known medical prognostic risk
factors.\34\
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\34\ Williams RB, Barefoot JC, Califf RM, et al. Prognostic
importance of social and economic resources among medically treated
patients with angiographically documented coronary artery disease.
Journal of the American Medical Association. 1992;267(4):520-524.
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exercise
One of the benefits of exercise is to help reduce stress and combat
depression. The role of exercise in the prevention and treatment of
coronary heart disease is well-known and is supported by several
reviews of the literature. Two meta-analyses indicate that the risk of
death was doubled in those who were physically inactive when compared
with more active individuals.\35\ \36\ Rehabilitation programs
incorporating exercise also show modest benefits of exercise in
preventing recurrent CHD events. None of 22 randomized trials in the
meta-analysis had the power to show a significant treatment effect, but
in a meta-analysis employing the intention-to-treat analysis, there was
a significant reduction of 25 percent in 1- to 3-year rates of CHD and
total mortality in the patients receiving cardiac rehabilitation when
compared with control patients.
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\35\ Berlin, J. A., & Colditz, G. A. A meta-analysis of physical
activity in the prevention of coronary heart disease. American Journal
of Epidemiology, 1990;132, 612-628.
\36\ Powell, K. E., Thompson, P. D., Caspersen, C. J., & Kendrick,
J. S. Physical activity and the incidence of coronary heart disease.
Annual Review of Public Health. 1987;8, 253-287.
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Moderate exercise provides most of the improvement in longevity as
more intensive exercise while minimizing the risks of exercising. In
one study, investigators performed treadmill testing on 10,224 men and
3,120 women who were apparently healthy. Based on their fitness level,
these participants were divided into five categories, ranging from
least fit (group 1) to most fit (group 5). The researchers followed
these people to determine how their level of physical fitness related
to their death rates. After eight years, the least fit (the sedentary
group 1) had a death rate more than three times greater than the most
fit (the very active group 5). More important, though, was the finding
that most of the benefits of physical fitness came between group 1 and
group 2, particularly in men.\37\
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\37\ Blair SN, Kohl HW, Paffenbarger RS, et al. ``Physical fitness
and all-cause mortality.'' JAMA. 1989;262:2395-2401.
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Even substantial decreases in cardiovascular fitness resulting from
decades of inactivity can be substantially reversed with modest
endurance training.
practical considerations
Lifestyle factors such as diet, smoking, and emotional stress often
interact. For example, people are often more likely to overeat, smoke,
work too hard, or abuse drugs and alcohol when they feel lonely,
depressed, or isolated. As one patient told me, ``I've got 20 friends
in this package of cigarettes and they're always there for me. Are you
going to take away my 20 friends? What are you going to give me
instead?''
Providing health information is important but not usually
sufficient to motivate lasting changes in behavior unless the
underlying psychosocial issues are also addressed. Thus, stress
management techniques and group support may address some of these
deeper concerns, thereby making it easier for patients to change diet
and quit smoking.\38\ \39\ Sometimes, patients also may benefit from
referral to a psychotherapist for treatment of depression with
counseling and/or antidepressants.
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\38\ Ornish D. Love & Survival: The Scientific Basis for the
Healing Power of Intimacy. New York: HarperCollins, 1998.
\39\ Ornish D, Hart J. Intensive Risk Factor Modification. In:
Hennekens C, Manson J, eds. Clinical Trials in Cardiovascular Disease.
Boston: W.B. Saunders, 1998.
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The conventional medical thinking is that taking a statin drug is
easy and most patients will comply, but making comprehensive lifestyle
changes is virtually impossible for almost everyone. In fact, less than
50 percent of patients who are prescribed statin drugs are taking them
as prescribed just one year later.\40\
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\40\ Rogers PG, Bullman WR. Prescription medication compliance: a
review of the baseline of knowledge. A report of the National Council
on Patient Information and Education. J Pharmacoepidemiology. 1995;2:3-
36.
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One might think that compliance to lipid-lowering drugs would
always be much higher than to comprehensive diet and lifestyle changes,
since taking pills is relatively easy and the side-effects are minimal
for most patients. However, cholesterol lowering drugs do not make most
patients feel better. They are taken today in hopes that there may be a
long-term benefit by reducing the risk of a myocardial infarction or
sudden cardiac death.
To many patients, concepts such as ``risk factor modification'' and
``prevention'' are considered boring and they do not initiate or
sustain the levels of motivation needed to make intensive lifestyle
changes. ``Am I going to live longer, or is it just going to seem
longer?''
Also, the prospect of a heart attack or death is so frightening for
many patients that their denial often keeps them from thinking about it
at all. Because of this, adherence becomes difficult for them to
maintain. (Patients often will adhere very well for a few weeks after a
heart attack until the denial returns.) Fear is a powerful motivator in
the short run but not in the long run, for when it's too scary to think
about something, many people simply don't.
While fear of dying may not be a sustainable motivator, joy of
living often is. In our experience, paradoxically, it may be easier for
some patients to make comprehensive changes all at once than to make
small, gradual changes or even to take a cholesterol-lowering drug.
For example, when patients follow a Step 2 diet, they often have a
sense of deprivation but not much apparent benefit. LDL-cholesterol is
reduced by an average of only 5 percent,\41\ frequency of angina does
not improve much, lost weight is usually regained, and coronary artery
lesions tend to progress. However, patients who make comprehensive
lifestyle changes often experience significant and sustained reductions
in frequency of angina, LDL-cholesterol, and weight; also, coronary
artery lesions tend to regress rather than progress.
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\41\ Hunninghake DB, Stein EA, Dujovne CA, et al. The efficacy of
intensive dietary therapy alone or combined with lovastatin in
outpatients with hypercholesterolemia. N Engl J Med. 1993;328(17):1213-
9.
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Patients usually report rapid decreases in angina and of ten
describe other improvements within weeks; these rapid improvements in
angina, well-being, and quality of life sustain motivation and help to
explain the high levels of adherence in these patients. Instead of
viewing lifestyle changes solely in terms of risk factor reduction in
hopes of future benefit, patients began to experience more immediate
benefits, thereby reframing the reason for making these changes in
behavior from fear of dying to joy of living.
This is a particularly rewarding and emotionally fulfilling way to
practice medicine, both for patients and the physicians and other
health professionals who work with them. Much more time is available to
spend with patients addressing the underlying lifestyle factors that
influence the progression of coronary artery disease, yet costs are
substantially lower.
As discussed earlier, the major reason that most stable patients
undergo bypass surgery or angioplasty is to reduce the frequency of
angina, and comparable results may be obtained by making comprehensive
lifestyle changes alone. Instead of pressuring physicians to see more
patients in less time, this is a different approach to reducing medical
costs that is caring and compassionate as well as cost-effective and
competent.
The physician, who is often pressed for time, need not provide all
of the training in changing diet and lifestyle. He or she can act as
the ``quarterback,'' providing direction and supervision. My colleagues
and I at the non-profit Preventive Medicine Research Institute and at
Lifestyle Advantage have trained teams of health professionals at
clinical sites around the country in this program of comprehensive
lifestyle changes. These include cardiologists, registered dietitians,
exercise physiologists, psychologists, chefs, stress management
specialists, registered nurses, and administrative support personnel.
These teams, in turn, work with their patients to motivate them to make
and maintain comprehensive lifestyle changes.
In practice, patients with coronary heart disease should be offered
a range of therapeutic options, including comprehensive lifestyle
changes, medications (including lipid-lowering drugs), angioplasty, and
bypass surgery. The physician should explain the relative risks,
benefits, costs, and side-effects of each approach and then support
whatever the patient decides. Whether or not a patient chooses to make
intensive lifestyle changes is a personal decision, but he or she
should have all the facts in order to make an informed choice.
Emotional stress affects the health and productivity of almost all
Americans. Therefore, I respectfully request the Committee on
Appropriations of the U.S. Senate to consider substantial increases in
funding for rigorous scientific research into the effects of emotional
stress on health and disease.
Those approaches that are found to be safe and effective should be
covered by Medicare and other third-party payers so that these methods
can be more widely available to other Americans who may benefit from
them regardless of socioeconomic and demographic background. Scientific
studies that find other approaches to be ineffective or unsafe will be
of great value in helping to protect the American people as well as
Medicare from fraud and abuse.
Thank you very much for the opportunity to share these thoughts
with you today.
Senator Specter. Thank you very much, Dr. Ornish. The
quality of your testimony exceeded your punctuality.
Dr. Ornish. Thank you.
Senator Specter. And there are quite a few questions. I
will be coming back to you.
Dr. Ornish. Thank you, sir.
STATEMENT OF GLENN PERELSON, NATIONAL MARKETING DIRECTOR,
LIFESTYLE ADVANTAGE
Senator Specter. Our second witness is Mr. Glenn Perelson,
National Marketing Director of Lifestyle Advantage, a joint
venture of Preventive Medicine Research Institute and Highmark
Blue Cross-Blue Shield. Mr. Perelson is a graduate of the
University of California. I participated just a week ago today
on the program at Allegheny General Hospital in Pittsburgh,
which marked the kick-off of Lifestyle with the test program
for Medicare, quite an achievement to get Medicare to spend any
money, directing people 65 and older who have arteriosclerosis,
heart disease, to have the program. They are very difficult to
deal with on many, many lines. But I think it was the prospect
of saving money which brought them in there because if they can
save money with their constraints, with the budget they have,
they will be able to spend it elsewhere. But that is a very
attractive program and I appreciate your work on it. I look
forward to your testimony.
Mr. Perelson. Thank you. And we very much appreciate your
support in terms of the roll-out of our program in
Pennsylvania. And just as a quick aside, in terms of the multi-
center research that Dr. Ornish and colleagues have done, a
full half of the people that went through that research were of
Medicare age, who did as well or better than people who were
not that age. And so we are looking forward to enrolling
Medicare-age participants in our 10 sites in West Virginia, our
nine new sites in Pennsylvania, Nebraska, and in Illinois.
Dr. Ornish asked me to speak briefly about the cost savings
associated with the Ornish program and we really have needed
partners in terms of looking at costs associated with the
Ornish program, and our two most significant partners have been
Mutual of Omaha very early in the process, and Highmark Blue
Cross Blue Shield, because you can make projections based on
risk factor changes, but it is much better to look at cost
savings when you have full control of all the costs associated
with the disease, and health plans do have that for their
members. And so what I would like to talk to you about today
are a number of studies that have been done by both Mutual of
Omaha and Highmark looking at cost savings associated with the
program.
When you look at heart disease and costs associated with
heart disease and the $330 billion a year associated with heart
disease and productivity costs, most of those costs are
associated with the procedures--about 80 to 85 percent of those
costs. And so the first study that I will note is that when we
were working with Mutual of Omaha in the multi-center trial, we
looked at the participants who went through the program who
were subject to invasive procedures and compared them to Mutual
of Omaha members who did not go through the program and went on
to have procedures. In that group, those Mutual of Omaha
members who had procedures experienced an additional 34
procedures, and the Ornish group who did not have the initial
procedure had 57 procedures.
The notes that I have provided for the testimony, if you do
the math associated with that, you end up with the $29,000
differential between the control group who did not have the
Ornish program and those folks who went through the Ornish
program. Again, the costs that were evaluated in terms of that
did not include additional items such as emergency room visits,
physician visits, or medications. It simply was a look at how
much cost was avoided by going through the Ornish program for
the procedures.
David Eddy, a noted health economist, also did a study in
the year of 2000 basically looking at all the literature
associated with our program and with lifestyle changes. And I
will quote. He concluded that: ``The program is at least cost-
neutral and is probably cost-saving, is robust under a wide
range of assumptions and sensitivity analyses. While it is
never possible to know the exact financial effects of a
treatment or its exact clinical effects for that matter, all
available evidence suggests the comprehensive lifestyle program
is highly likely to be cost-saving, and is extremely unlikely
to be cost-increasing.''
With our partnership in 1997 with Highmark Blue Cross Blue
Shield, who, as Dr. Ornish said, was the first insurance
company to both offer and pay for the program, the program has
been looked at from four different perspectives and each of
those perspectives has yielded significant cost savings
results. In fact, Dr. Fetterolf, who is a Senior Medical
Director at Highmark actually was skeptical about the program
when it was first brought on board, not from a clinical
perspective, but from a cost-savings perspective. And his staff
has showed in any way that you can look at the Ornish program
that there are significant cost savings--from an emergency and
admissions perspective, from an angina cessation perspective
using diagnostic software to project what costs should be in
the group; any way that the Info-matics program at Highmark has
looked at the Ornish program, it shows substantial savings. And
in 5 seconds will be the end of my time.
I wanted to beat you by 5.
Senator Specter. Well, the precedents that you establish on
timing are exemplary. The third witness today is in line with
the Dr. Ornish program, Mr. Mel Lefer from Penngrove,
California, a former San Francisco restaurant owner who brought
New York-style food to San Francisco.
Mr. Lefer. It is all true.
SUMMARY STATEMENT OF MEL LEFER
Senator Specter. That is quite an achievement. The
information provided to me, which I am sure Mr. Lefer has
approved my disclosing, is that he suffered a massive coronary
in 1985 and was advised that he had less than a year to live,
and he joined Dr. Ornish's Lifestyle Heart Trial in 1986 and is
here to tell the tale. Mr. Lefer?
Mr. Lefer. I will try to put a human face on it, Senator.
Well, my doctor called me and said this young doctor could help
me, and so he came over to my house and he told me that if I
ate good, exercised, I did yoga and I talked about my
feelings--I would get better. He figured he could help me. And
at the time, I did not know that I had only about a year to
live. And actually, Dean took everybody into the program, even
people worse off than I was. So at that time, I could only walk
a few steps and then I would have to stop, take some Nitrol. It
used to take me an hour, an hour-and-a-half to take a shower
because I would have to rest.
Immediately, within 1 week or 2, I started to feel better.
I started to walk more and eventually got up to 10 miles a day.
I started feeling happier. Up until my heart attack, I had some
terrible things happen in my life and my luck kind of went
south for a while, and I learned how to open up my heart, I
learned how to not let bad things--keep bad things out, put a
wall around my heart. I had the most difficulty doing the yoga
and so I became a yoga teacher.
My relationships with my wife and my kids improved and, I
would say, nowadays I am happier than I have ever been. And my
relationship with my family is closer and more loving than ever
before. About 2 years ago--my wife and I travel a lot--I was
hiking in the Alps at 10,000 feet. I went to the top of the
mountain in a snowstorm. That was one of the highlights of my
life, that I was able to do that. Nowadays, I never have to
take any angina pills, Nitrol, and I am just really happy.
I am still addicted to food. At that time, I used to travel
around the world, eating in all the great restaurants. I used
to smoke six to seven Cubans a day. I was a couch potato. Now I
usually hike every day for at least 3 miles. So I would say I
feel better now than I have ever felt before, and it is amazing
what a few vegetables can do.
I still have 2 minutes, but I am done.
Senator Specter. Well, that is very impressive, Mr. Lefer.
We will come back to you for some questions.
STATEMENT OF DR. JUDITH STERN, PROFESSOR, DEPARTMENT OF
NUTRITION AND INTERNAL MEDICINE; DIRECTOR
OF THE FOOD INTAKE LABORATORY GROUP,
UNIVERSITY OF CALIFORNIA, DAVIS
Senator Specter. Our next witness is Dr. Judith Stern,
professor in the Department of Nutrition and Internal Medicine
at the University of California, Davis, director of the Food
Intake Laboratory Group at UC Davis. She received her
bachelor's degree in food and nutrition from Cornell and her
doctor of science degree from Harvard University, and I have
been familiar with her professional work for more than a
decade. Among her many accomplishments is the education of my
Ph.D. son, Steven. Dr. Stern, thank you for joining us today.
We look forward to your testimony.
Dr. Stern. Mr. Chairman, thank you for the opportunity to
testify before you and also on behalf of the American Obesity
Association, which is a non-profit lay advocacy organization
that I helped to found.
In the last four decades of obesity research, progress has
been made on identifying causes and treatments, but despite
these research advances, children, adolescents, and adults
continue to become overweight and obese in record numbers--and
I gave you a few figures as a professor. Those are figures 1
through 3. But in 1999, your Senate Appropriations Committee
called on the Department of Health and Human Services to
develop a comprehensive research plan on obesity. This request
has not been implemented and it is needed even more today. So
in the absence of such research and such a research plan, there
has been an explosion of searches with simple global solutions
ranging from law suits against food companies to banning soft
drinks from schools.
I know you have heard this refrain before, but we are
simply not spending enough money on obesity research. I am
going to use NIH as an example. As Mr. Chairman knows, NIH has
provided a critical role in providing leadership and research
support needed for meeting medical modern health problems, both
great and small. And we have acknowledged that you and Senator
Harkin have provided a lot of the fuel for this research, so to
speak. So what I have done is I have used NIH's own criteria to
set research priorities, which include healthcare needs, the
number of people with disease, the number of deaths, degree of
disability, economic and social impacts, the need to control
the spread of the disease, and finally basic research which can
have a long-term impact on health. And given NIH's own
criteria, obesity should have a very high priority, but it does
not based on the level of obesity research funding and the
organizational level at NIH.
You can see in figure 4, NIH's obesity funding is far below
other diseases. And while obesity research investment at NIH
has more than doubled in the last 5 years from $128 million in
1998 to a projected greater than $300 million in 2003, it still
is a small percentage of NIH's budget, and if you look at
figure 6, the number of research grants are far below other
important areas of research. So the gravity and urgency of this
epidemic calls for obesity to be given a leading place in the
NIH organizational structure. And NIH's current obesity
research is really buried in organizations dedicated to other
diseases. There are 27 institutes, there are centers at NIH,
the lead institute for obesity research is NIDBK. NIDBK has six
divisions. In one of the divisions, it has three branches. In
one of the three branches, obesity has eating disorders.
So it really is on the lowest organizational rung. And I
think there are at least five negative effects of this low
position of obesity research in NIH. First of all, the budget
is far below what it should be. Second, there are insufficient
staff and time to integrate obesity questions and priorities
with NIH and their developing the Human Genome Project, and
also do research on stigma in healthcare, and so on. Three,
there is a vacuum of leadership. And four, we really need a
strong scientific leader to advise Congress and governments on
sound, workable solutions. Few other areas of healthcare
attract the enormous public and media attention of weight and
obesity, and also a lack of strong NIH voice. And fifth, the
resources at NIH need to be managed and anticipated. And we do
not do that. For example, to study food intake, we need doubly-
labeled water. There is a shortage of doubly-labeled water, and
we simply cannot get it.
Senator Specter. Government labeled----
Dr. Stern. Doubly-labeled water. It is an isotope to let us
do food intake research. We cannot get it and NIH did not
anticipate this.
So we are recommending that there be an Institute of
Obesity at NIH. This will improve the opportunities. We are
anticipating, certainly, a whole bunch of criticisms against
that. But my bottom line is that we really need a sense of
urgency in funding obesity research. If we do not immediately
adopt a proactive posture to develop these scientific
resources, public policy will continue to grope in the dark for
solutions to obesity and to the suffering due to obesity. The
healthcare system cannot respond to the millions of new,
younger cases of obesity and its associated diseases and, not
to be overdone by Dean, I thank you for the opportunity to
testify, and I am available to answer any questions at the end.
[The statement follows:]
Prepared Statement of Judith S. Stern
Mr. Chairman and members of the subcommittee:thank you for the
opportunity to testify before you on behalf of the American Obesity
Association (AOA), a non-profit corporation one of whose goals is to
expand research on Obesity. I am Judith S. Stern, Sc.D., Professor of
Nutrition and Internal Medicine at the University of California at
Davis and Vice President and co-founder of AOA. I want to express on
behalf of my colleagues our gratitude for the work of the Subcommittee
in providing appropriations for biomedical science and prevention
programs.
In the last four decades of obesity research, progress has been
made in identifying causes and treatments. Research has provided us
with a greater understanding of obesity as a chronic disease and the
complex role that genetic, metabolic, behavioral, psychological and
environmental factors play in the disease. Despite the advances in
research, however, children, adolescents and adults continue to become
overweight and obese in record numbers.\1\ Obesity is unique in that a
chronic disease is increasing at rates previously only seen with
infectious diseases (see Figures 1-3, data from the National Health and
Nutrition Examination Surveys, NHANES). For example, the prevalence of
obesity in women ages 20-29 years has more than doubled in the last 20
years (Figure 1). Over 60 percent of adult Americans are overweight or
clinically obese. Fourteen percent of American children and adolescents
are obese. More research is needed to understand and prevent this
complex epidemic disease.
Obesity is a leading cause of mortality, morbidity, disability,
discrimination in health care, education, and
employment.\2\<SUP>-</SUP>\11\ According to a recent RAND study, the
health consequences of obesity are as significant or greater than the
effects of smoking, alcohol overuse and poverty.\12\ The consequences
of obesity include various cancers, heart disease, stroke, type 2
diabetes, osteoarthritis, sleep apnea and problem pregnancies and
childbirth.\12\<SUP>-</SUP>\19\
Obesity is poorly treated by the medical community.\20\ Coverage
for effective treatments is modest to poor in both governmental and
non-governmental health insurance programs. As a result, patients are
denied access to effective treatments including surgery, FDA approved
medications, physician counseling, dietician services and behavioral
counseling. Inexplicably, the very insurance programs that do not
reimburse for weight maintenance do cover the costs of treating the
diseases caused by obesity.\21\ The desire for effective methods of
weight management can lead to adverse interventions including tobacco
smoking \22\ and the use of ineffective or harmful consumer
products.\23\
The rapid rise in obesity and its profound consequences for the
health of the population have resulted in a recent explosion of
searches for simple global solutions ranging from law suits against
food companies \24\ to banning soft drinks from schools.\25\
the role of nih in obesity research
The National Institutes of Health (NIH) has played a critical role
in providing the leadership and research support needed for meeting
modern health problems both great and small. The setting of research
priorities at NIH is a complicated process involving Congress, the
White House, various advocacy efforts and not least a scientific
judgment of the opportunities present in each field. NIH has documented
the process in its publication, Setting Research Priorities.\26\ The
process involves assessing health care needs, such as the number of
persons with a disease, the number of deaths, the degree of disability,
the degree to which a disease cuts shorts a normal, productive and
comfortable life, the economic and social impacts of a disease and the
need to act rapidly to control the spread of a disease. In addition,
the NIH places a high priority on funding basic research which can have
a long-term impact on health. The low priority given obesity can be
seen in the low level of obesity research funding and by the absence of
any NIH organization dedicated to obesity.
It would not be unreasonable, given NIH's own criteria, to expect
that obesity would be a very high priority. Unfortunately, that is not
the case. As illustrated in Figure 4, NIH obesity research funding is
far below other diseases, including conditions directly caused by
obesity such as cardiovascular disease and diabetes.
While the obesity research investment at NIH has nearly doubled in
the last five years, this increase has barely matched the overall
growth in NIH's budget (see Figure 5). While the obesity epidemic has
taken hold in America, NIH's obesity research funding share has
actually decreased. Accordingly, as indicated in Figure 6, research
grants in obesity are far below other important areas of research.
The gravity and urgency of the obesity epidemic call for obesity
research to be given a leading place in NIH's organizational structure.
This is emphatically not the case today. NIH's current obesity research
effort is buried in organizations dedicated to other diseases.\27\
There are five negative effects of this low position of obesity
research in NIH's organizational structure.
(1) The obesity research budget is far below what it should be
according to NIH's own criteria for research priorities and the obesity
research budget has not benefited from the recent rise in NIH funding.
(2) There is insufficient staff and time to fully integrate obesity
questions in the numerous research programs being developed by NIH such
as the next phase of the human genome project to the analysis of risk
data on hormone replacement therapy or research on the role of stigma
in health care.
(3) There is a vacuum of the high-ranking leadership on obesity
needed to develop collaborative approaches within the Department of
Health and Human Services (DHHS).\28\
(4) A strong scientific leader is needed to advise Congress and
guide the states and local governments on sound, workable solutions to
the obesity crisis. Few governmental officials can match the influence
and persuasive qualities of a Director of a NIH Institute. Obesity is
burdened with public misconceptions and confusion about causes, cures,
prevention and intervention strategies. Few other areas of health care
attract the enormous public and media attention of weight and obesity.
One only has to look as far as the invaluable role played by Dr.
Anthony S. Fauci, Director of the National Institute of Allergy and
Infectious Diseases on contentious debates about HIV/AIDS and
bioterrorism to appreciate the need for a credible scientific voice on
obesity.
(5) Research resources have to be anticipated and managed. Many
excellent research efforts in studying food intake and energy
expenditure, for example, have been delayed or halted by the shortage
of double-labeled water. Assuring that such research resources are met
is simply outside the capacity of the current structure.
We recommend that NIH, working in consultation with Congress, the
Administration and the obesity research community move quickly to
create and fund a National Institute on Obesity. Such an Institute
would provide a remedy to the weaknesses of the current structure. The
desire is not to just consolidate current obesity research in one
structure. The purpose is also to provide a platform for national and
international leadership and to bring new funding to meet the
significant challenges of the field. We propose at a new National
Institute on Obesity have seven components or divisions:
1. Basic Research on Adipose Tissue;
2. Epidemiology and Population Studies;
3. Genetics, Metabolism and Mechanisms of Disease Development;
4. Neuroscience and Behavioral Research;
5. Prevention, Therapeutic Development and Clinical Trials;
6. Economics and Health Policy; and
7. Training and Education.
These areas reflect both the needs and robustness of the obesity
research field. Critical work in all these areas is going on but vastly
more needs to be done. Above all, meaningful integration of the
specific research areas has not occurred. In 1999, the Senate
Appropriations Committee called on the Department of Health and Human
Services to develop a comprehensive research plan on obesity.\29\ This
request has not been implemented and is even more needed today. The
field of obesity research holds enormous scientific opportunities in
the near future including.
--Body fat is now known to be regulated by several hormones and
neuropeptides, including leptin and ghrelin.
--Food ingredients such as glucose, amino acids and fatty acids
affect the production of the hormones insulin, growth hormone,
insulin-like growth factor and leptin which act on specific
receptors in the hypothalamic circuits that regulate feeding
behavior.\30\
--The human genome program holds the promise to integrate such
molecular understanding of normal body weight regulation with
abnormal body weight regulation. Fresh insights on the
significant racial and ethnic disparities in obesity and its
comorbid conditions are foreseen.\31\
With such information, more precise and informed prevention
strategies, behavioral interventions, pharmacology, and surgical
interventions can be developed and tested. Such prevention and
treatment strategies will give rise to questions of economic efficiency
and legislative and regulatory approaches. The current lack of
attention in medical training and health professional disciplines on
obesity can be directly and immediately approached through programs to
develop obesity researchers and health education campaigns.
We anticipate objections to a proposal to create a new NIH
institute, to wit:
(1) NIH is already too big and complicated. Former directors of NIH
and some members of Congress have expressed this view. Currently, this
topic is under discussion by a committee of the Institute of Medicine.
This objection is a serious one which is of concern to the entire
research community. However, there is no reason why the concept and the
needs for a National Institute on Obesity cannot be part of this
debate. More importantly though, is the importance of not losing sight
of what is most critical--the administrative efficiency of NIH or the
public health problems caused by obesity. Experience shows that asking
other organizations with other primary responsibilities to share their
funding with a new area simply does not work.
(2) A new Institute is less desirable than getting all the existing
components of NIH to do more on obesity as it affects their particular
interest and to better coordinate research protocols and activities.
This too is an important argument. For this to occur, the current low
organizational level of obesity research must be changed. This approach
might go far to better integrate and enhance obesity research at NIH.
However, it is unlikely to provide the external leadership that an
Institute Director can bring to the raging debates about the causes and
cures of the obesity epidemic. In addition, this approach fails to
focus on adipose tissue, obesity and its prevention and treatments. It
runs the risk of the appearance of attention without actual
improvements.
(3) Do higher levels of funding precede evolution of a scientific
field or follow scientific insights? This `chicken or egg' debate has
been part of parcel of issues at NIH since the creation of the National
Cancer Institute. Since the tragedy of September 11, Congress has
decided that it would make a sudden and dramatic infusion of resources
into bioterrorism and anthrax (See Figure 4). At this point in time, it
appears that the research community is responding to this national
emergency by changing orientation if not careers into the field of
bioterrorism. It would have been inadequate if Congress and NIH had
merely told the research community that it was interested in receiving
more proposals without showing a commitment of funds adequate to elicit
the desired response by the scientific community.
Clearly, the interest of the current leadership at the DHHS and the
director of NIH and institute directors in obesity are sincere and
highly welcomed. We also welcome and need input from the Center for
Disease Control (CDC) and the U.S. Department of Agriculture. Our focus
on NIH is because this is the major source of funds for biomedical
research in the country.
What is needed is a sense of urgency. If we do not immediately
adopt a proactive posture to develop the scientific resources needed,
the public and policy makers will continue to grope in the darkness for
solutions to the tremendous human suffering caused by obesity. It is
doubtful that the health care system has the capacity to respond to
millions of new, younger cases of obesity and its co morbid conditions.
A National Institute on Obesity will, by itself, not prevent or cure
obesity. However, it is difficult to see scientifically valid
prevention strategies, more effective therapeutic approaches and better
understanding and education on obesity in the absence of such an
entity.
Mr. Chairman, thank you for this opportunity to testify and I am
available to answer any questions.
footnotes
\1\ World Health Report 2002, World Health Organization. [Internet]
Available at www.who.int/wh/en
\2\ Allison DB, Fontaine KR, Manson JE, Stevens J, VanItalie TB.
Annual deaths attributable to obesity in the United States JAMA 1999
Oct 27;282: 1530-8
\3\ Downey M, Obesity as a Disease Entity Am Heart J 2001;142:1091-
4
\4\ NCHS, CDC. Prevalence of overweight and obesity among adults:
United States, 1999 [internet] Hyattsville (MD): NCHS (cited 2001 Oct
31). Available from www.cdc.gov/nchs/products/pubs/hestats/obese/99.htm
\5\ NCHS, CDC Prevalence of overweight among children and
adolescents: United States, 1999 [Internet]. [Hyattsville (MD)):NCHS
(cited 2001 Oct 31] Available from: www. cdc.gov/nchs/products/pubd/
hestats/over99fig1.htm.
\6\ Koplan J, Fleming W, Current and Future Public Health
Challenges. JAMA Oct. 4 2002;284:1696.
\7\ Must A, Spadano J, Coakley EH et al. The disease burden
associated with overweight and obesity JAMA. 1999;282:1523-1529.
\8\ Weil, E, Wachterman M, McCarthy EP et al. Obesity among adults
with disabling conditions. JAMA 2002; 288:1265-1268
\9\ Puhl R, Brownell KD, Bias, discrimination, and obesity. Obesity
Res. 2001 Dec; 9: 788-805.
\10\ Crandall CD. Do heavy-weight students have more difficulty
paying for college? Pers Soc Psych Bull 1991;17:608-11.
\11\ Roehling M, Weight-based discrimination in employment:
psychological and legal aspects. Personnel Psych 1999; 52:969-1016.
\12\ Sturm R, Wells KB, Does obesity contribute as much to
morbidity as poverty or smoking? Public Health 2001 May;115:229-35
\13\ Bray GA.The underlying basis for obesity: relationship to
cancer. J Nutr.2002; 132:3415S-55S
\14\ Mann, JI Diet and risk of coronary heart disease and type 2
diabetes. Lancet 2002;360:783-9.
\15\ Kenchaiah S, Evans JC, Levy D et al. Obesity and the risk of
heart failure. N Engl J Med 2002 Aug1;347:305-13.
\16\ Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as
a risk factor for clinical diabetes mellius in women. Ann Intern Med.
1995;122:481-6.
\17\ Sowers M. Epidemiology of risk factors for osteoarthritis:
systemic factors. Curr Opin Rheumatol.2001 Sep; 13:447-51.
\18\ Young T, Peppard PE, Gotlieb DJ. Epidemiology of obstructive
sleep apnea: a population health perspective. Am J Respir Crit Care Med
2002 May 1;165(9):12-17-39.
\19\ Ramsay JE, Ferrell WR, Crawford L, et al., Maternal obesity is
associated with dysregulation of metabolic, vascular and inflammatory
pathways. J Clin Endocrinol Metab 2002 Sept.;87(9):4231-7
\20\ Kisteller JL, Hoerr RA, Physician attitudes toward managing
obesity: differences among six specialty groups. Prev Med 1997 Jul-Au;
26(4): 542-9.
\21\ Downey, M, Insurance coverage for obesity treatments. Chapter:
Evaluation and Management of Obesity, ed. Danieal H. Bessesen, 2002,
Hanley & Belfus, Inc. Philadephia, PA.
\22\ Strauss RS, Mir HM. Smoking and weight loss attempts in
overweight and normal-weight adolescents. Int J Obes Relat Metab Disord
2001 Sep;25(9): 1381-5
\23\ Cleland, RL, Gross WC, Moss,LD, et al. Weight-Loss
Advertising: An analysis of current trends, Federal Trade Commission
Staff Report, 2002
\24\ Santora, M. Teenagers' suit says McDonald's made them obese.
New York Times, Metropolitan Dessk, Nov. 21, 2002
\25\ Hayasaki,E. Schools to end soda sales. Los Angeles Times
Aug.28, 2002.
\26\ NIH, Setting Research Priorities. [Internet] Available at
http://public-council.nih.gov/SettingResearchPriorities.htm
\27\ Currently, several Institutes or Centers at NIH are involved
in obesity research. These include the National Cancer Institute, the
National Heart, Lung and Blood Institute, The National Institute on
Aging, the National Institute of Child Health and Human Development,
the National Institute of Mental Health, and the Office of Dietary
Supplements. The lead institute is the National Institute of Diabetes,
Digestive and Kidney Diseases (NIDDK). There are 27 Institutes or
Centers at NIH. Within NIDDK, there are six divisions. In one division,
one of its three branches houses the obesity program, together with
eating disorders. In a strongly hierarchical organization such as NIH,
obesity is on the lowest organizational rung.
\28\ Collaborative approaches are need in DHHS between the Centers
for Disease Control and Prevention, the Food and Drug Administration,
the Centers for Medicare and Medicaid Services, the Indian Health
Service and with other branches of the federal government such as the
Department of Agriculture, the Department of Education, the Department
of Defense and the Department of Veterans Affairs, all of which have
roles to play in the prevention and treatment of obesity.
\29\ Senate Appropriations Committee, Committee on Labor, Health
and Human Services and Education, 1999 Report 106-166;78.
\30\ Altman J, Weight in the Balance. Neuroendocrinology
2002;76:131-136.
\31\ Dubbert PM, Carithers T, Sumner AE, et al. Obesity, physical
inactivity, and risk for cardiovascular disease. Am J Med Sci 2002
Sep;324(3):116-26.
<GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT>
Senator Specter. Thank you very much, Dr. Stern. I have
quite a few questions. I will come back to you.
STATEMENT OF DR. NAOMI NEUFELD, PRESIDENT, FOUNDER AND
MEDICAL DIRECTOR OF KIDSHAPE, INC.;
PRESIDENT OF NEUFELD MEDICAL GROUP;
CLINICAL PROFESSOR OF PEDIATRICS, UCLA
SCHOOL OF MEDICINE
ACCOMPANIED BY:
MS. DANIELLE BAILEY, LOS ANGELES
MS. LEE IDA BOYD-BAILEY, LOS ANGELES
Senator Specter. Our next witness is Dr. Naomi Neufeld,
president, founder and medical director of KidShape, Inc.,
President of the Neufeld Medical Group, and a clinical
professor of Pediatrics at the UCLA School of Medicine. She
received her A.B. in biology and master's in medical science
from Brown University, and an M.D. from Tufts University. Dr.
Neufeld is accompanied by graduates of the KidShape program,
Ms. Danielle Bailey, who is 6 years old, and her mother, Ms.
Lee Ida Boyd-Bailey from Los Angeles. So welcome, Dr. Neufeld,
and we have an extra chair for Ms. Lee Ida Boyd-Bailey.
Dr. Neufeld. Good morning, Mr. Chairman. Thank you for the
opportunity to discuss lifestyle modification and weight
control for children and families. My name is Naomi Neufeld. I
am a pediatric endocrinologist in practice in Los Angeles, and
serve as the Medical Director of KidShape. I am here today with
Ms. Christiane Rivard, our Program Director, and the Bailey
family.
The present epidemic of childhood obesity is much more
serious than when I started KidShape in 1987 and it is
associated with serious diseases and disabilities previously
seen only in adults. This discussion is not just about obesity,
but the burden of those associated diseases. We have found that
the most effective way to deal with childhood obesity is a
program that capitalizes on the strength of the family.
KidShape is a family-based weight management program designed
for overweight children ages 6 to 14. Families enroll for 8
weekly 2-hour classes. A team of physicians, dieticians, and
other medical professionals wrote the KidShape workbooks, which
are published in English and Spanish.
Each KidShape class includes interactive nutrition lessons
designed for the entire family, discussion groups for parents
and for students which meet separately, and on-site physical
activity, where we teach families that physical activity can be
fun. Families work together as teams.
In 1997, the KidShape program was approved by Medi-Cal, our
local Medicaid, to treat eligible children. By obtaining third
party reimbursement, KidShape was able to expand and maintain
20 community-based sites in Los Angeles, Orange and Ventura
Counties. And last year we enrolled 1,285 families.
Additionally, several KidShape sites are operating in Western
Pennsylvania through Highmark Insurance, and Texas under
licensing agreements. And we have received hundreds of requests
to license our program throughout the country.
The cost of treating a family in the KidShape program is
$400 for the 8-week session. There are nearly 400,000 children
in Los Angeles and Orange Counties alone who would qualify for
KidShape. If we were to reach just 10 percent of these children
and their families, the cost would be $15 million, or less than
$1 per person.
Since Type 2 diabetes developing in a person before the age
of 20 costs an estimated $7.1 million in lifetime expenses, the
impact of such a program is considerable.
The KidShape program works. Eighty-seven percent of
children lose weight during the 8-week program, 87 percent of
children keep their weight off for 2\1/2\ years. We see changes
in diet, exercise, and personal habits which contribute to
weight loss.
However, this is not just about weight. Many children with
severe obesity already have evidence of coronary artery
disease, and some as young as 10 have already developed Type 2
diabetes. They show remarkable changes in blood pressure, blood
lipids and insulin sensitivity, which leads to a reduction in
diabetes in a period as short as 6 weeks.
This program not only improves lives, but also saves money.
Juan V. was a 7-year-old boy who weighed 179 pounds, suffered
from asthma and had hospital bills of $15,000 per year. He and
his family enrolled in KidShape and he lost nearly 40 pounds.
He no longer has recurrent asthma attacks, and his annual
medical bills are now less than $400.
There is even more to this story. Juan's mother, at age 38,
suffered from both diabetes and hypertension. She lost 25
pounds on the KidShape program. She no longer has high blood
pressure, and her doctor is taking her off diabetes medication.
prepared statement
Over 40 percent of parents of KidShape participants are
overweight themselves, and many suffer from diseases directly
related to obesity. Family-based weight management programs are
not only effective for the child, but may be even more
important as a means of reaching the hard-to-treat, resistant
adult population. I would like to turn this over to Danielle.
[The statement follows:]
Prepared Statement of Naomi D. Neufeld
introduction
Senator Specter, Members of the Committee and honored guests. Thank
you for the opportunity to discuss lifestyle modification and weight
control for children and families. My name is Naomi Neufeld. I am a
Pediatric Endocrinologist in practice in Los Angeles, and serve as the
medical director of KidShape. I am here today with Mrs. Christiane
Wert Rivard, KidShape Program Director and the Bailey Family, recent
KidShape graduates. The present epidemic of childhood obesity is much
more severe than when I started KidShape in 1987, and is associated
with serious diseases and disabilities, previously seen only in adults.
This discussion is not just about obesity, but about the burden of
associated diseases; it is not just about the burdens of disease on
patients and their families, but also the burden on a Medi-Caid system
which is stretched to capacity.
We have found that the most effective way to deal with obesity in
childhood is in a program that capitalizes on the strength of the
family unit.
description
KidShape is a family-based weight management program designed for
overweight children ages six to fourteen years old. Families enroll in
8 weekly two-hour classes. A team of physicians, dietitians, social
workers and psychologists wrote the KidShape workbooks, which are
published in English and Spanish.
Each KidShape class includes interactive nutrition lessons,
designed for the entire family, discussion groups for parents and for
students which meet separately, and on-site physical activity, where we
teach families that physical activity can be fun. Families work
together as teams.
availability
In 1997, the Kid Shape program was approved by Medi-CAL to treat
eligible children, and to bill in accordance with the EPSDT (Early and
Periodic Screening, Diagnostic and Treatment) Program. By obtaining
third party reimbursement, KidShape was able to expand and maintain 20
community-based sites in Los Angeles, Orange and Ventura counties. Last
year we enrolled 1285 children. Additionally, several KidShape sites
are operating in western Pennsylvania and Texas under licensing
agreements. We have received hundreds of requests from health care
providers, schools and health insurance companies to license our
program around the country.
To meet the demands of our clients, KidShape Foundation has
expanded its program activities to reach children of all ages.
costs
The cost of treating a family in the KidShape program is $400 for
the 8-week session. It is disheartening that despite the growing
epidemic of obesity, we received less than 20 percent of authorized
payments from Medi-CAL and other third-party payers last year; leaving
a significant shortfall to be covered by grants and private donations.
We have been successful in our goals and would like to extend the
services of the program, but the present method of financing is a
barrier.
outcomes
The KidShape program works! 87 percent of participants lose weight
within the 8-week program. 80 percent of children keep their weight off
up to 2\1/2\ years after the program. Additionally, we see changes in
diet, exercise and personal habits, which contribute to weight loss.
However, it is not just about weight. Many children with severe
obesity already demonstrate significant coronary artery disease, and
some as young as 10 have already developed type 2 diabetes. They show
remarkable changes in blood pressure, blood lipids and insulin
sensitivity-which leads to a reduction in the risk of diabetes, in a
period as short as 6 weeks.
Here is an example of how this program not only improves lives, but
also saves money. Juan V was a 7-year-old boy who weighed 179 lbs,
suffered from asthma and had hospital bills of $15,000/yr. He and his
family enrolled in KidShape, and he lost nearly 40 lb. He no longer has
recurrent asthma attacks, and his annual medical bills are now less
than $400.
But there is even more to this story. Juan's mother, at age 38
suffered from both diabetes and hypertension. She lost 25 lbs. during
the KidShape program. She no longer requires her blood pressure
medicine; and her doctor is considering taking her off diabetes
medication.
Over 40 percent of parents of KidShape participants are overweight
themselves, and many suffer from diseases directly related to obesity.
Family based weight management programs are not only effective for the
child, but may even be more important as a means for reaching the hard
to treat, resistant adult population
conclusion
I applaud your committee for addressing the most important public
health issue to face this generation. Lifestyle changes result in a
wise use of healthcare dollars for conditions that affect up to 40
percent of our children and nearly 70 percent of all adults; they
reduce the burden of disease and can be cost-effective. The cost of
such a program is relatively small compared to long-term direct and
indirect benefits-personal, medical and financial. Thank you.
KidShape Program Summary
KidShape is a non-profit community and family-based weight
management program, which offers two effective family-based pediatric
weight management programs throughout Southern California, including:
(1) KidShape, serving families with children ages six to fourteen; and
(2) KinderShape, serving families with children ages three to five.
Each program is taught by a team of health care professionals,
including: a registered dietitian, a mental health professional, a
physical activity instructor and a health educator. The goal of both
KidShape Foundation programs is to promote healthy lifestyles for
entire families with overweight children, focusing on healthy eating,
increased physical activity, and an appreciation for oneself regardless
of physical size.
Developed in 1987 by Naomi Neufeld, MD, pediatric endocrinologist,
KidShape (the first program developed by the KidShape Foundation)
originated out of a desperate need for effective prevention and
treatment of childhood obesity. KidShape empowers families to make
healthier lifestyle choices for their families and themselves. Since
its inception, KidShape has provided services to thousands of
families--demonstrating to each family the importance of healthy eating
and physically active lifestyles.
The KidShape program utilizes a curriculum based on structured
diet, exercise participation, parent support and behavior modification.
It was designed to respond to the needs of the multi-cultural community
in Southern California (CA), and has been available to low-income,
primarily minority families, many of whom are at risk for Type 2
Diabetes. The KidShape curriculum is divided into two 4-week modules;
each family attends a minimum of eight consecutive two-hour weekly
culturally relevant classes. Each KidShape class is divided into three
components, including: nutrition (where families participate in hands-
on nutrition activities designed to promote an understanding of healthy
eating), discussion groups (Parents and students meet separately;
parents discuss many topics including parenting skills; students
discuss body image and self-esteem; this component facilitates health
behavior changes, leading families to eating healthier and becoming
more physically active.), and on-site physical activity (kids are shown
that physical activity can be fun!; focuses on skill building and self-
efficacy and not on competitiveness). Parent participation is required
in the program. KidShape's most significant accomplishment is its
proven track record in helping children and their ENITRE families
improve lifestyle habits, which leads to weight loss and improved self-
esteem, as well as decreasing the risk factors associated with Type 2
diabetes and other debilitating diseases.
As reported in the Los Angeles Times in December 1997, KidShape is
the only program in Southern CA offering effective family-based weight
management services to all families regardless of their insurance
status or their ability to pay for the program. Until 1997, KidShape
had only one program site operating in Southern CA, located in West Los
Angeles, and enrolled families from over a 70-mile radius from that
site. Today KidShape operates 18 community-based sites throughout Los
Angeles, Orange and Ventura counties in Southern CA. In addition
several sites are operating in Western Pennsylvania and Texas under
licensing agreements with KidShape. KidShape Foundation is also
expanded its program activities. Currently the KinderShape program is
being implemented in Orange County, CA and will be expanding to
Northern California and throughout the County of Riverside, CA, through
additional licensure agreements. KidShape Foundation is currently
developing a program for overweight 13-18 year olds, TeenShape.
early and periodic screening, diagnosis, and treatment program (epsdt)
EPSDT is designed to improve primary health benefits for children
with emphasis on preventive care that has been a part of the federal
Medicaid program since its beginning in the late sixties. After a
Medicaid review in 1989, Congress moved to increase the services of
EPSDT through the Omnibus Budget Reconciliation Act. States must now
cover regular and periodic exams for all eligible children under the
age of 21. They must also provide any medically necessary services
prescribed by the exams, even those not covered in a state's Medicaid
plan. This includes many assistive devices and services for individuals
that are under 21 which have been excluded under the regular Medicaid
program in the past.
The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
service is Medicaid's comprehensive and preventive child health program
for individuals under the age of 21. EPSDT was defined by law as part
of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation
and includes periodic screening, vision, dental, and hearing services.
In addition, section 1905(r)(5) of the Social Security Act (the Act)
requires that any medically necessary health care service listed at
section 1905(a) of the Act be provided to an EPSDT recipient even if
the service is not available under the State's Medicaid plan to the
rest of the Medicaid population.
SUMMARY STATEMENT OF DANIELLE BAILEY
Ms. Bailey. My name is Danielle Bailey and I am 6 years
old. Before I went to KidShape, kids used to call me ``fat
girl.'' KidShape helped me change my eating habits, lose
weight, and not be a fat adult. I like going to KidShape and
learning about the food portion size, reading the labels,
talking to Dr. Beth, and making healthier food choices.
Senator Specter. Ms. Boyd-Bailey, would you care to add
something to this?
prepared statement
Ms. Boyd-Bailey. No. I just had a good time going to
KidShape. She encouraged me to go, ``Mom, I want to go, I want
to go,'' so we went. I lost weight, she lost weight, she has
kept me eating healthy. She keeps me--``Danielle, do you want
to go to McDonald's?'' ``Mom, that is not healthy.''
[The statement follows:]
Prepared Statement of Lee Ida Boyd-Bailey
My daughter and I were both ``overweight'' and I was not sure how
to teach a 6-year-old how to lose weight without using the word diet.
That's when we met Dr. Neufeld and found out about the Kidshape
program. I thought that the program would be ``over my daughters
head'', but we went anyway and she absorbed the information like a
sponge.
She enjoyed every aspect of the program: reading the nutrition
facts, the exercise program, talking with Dr. Beth, keeping a food
journal, learning to eat healthier meals and snacks and learning what a
real serving is.
Kishape has not only effected me and my family, but family members,
friends, even my co-workers. They have seen how easy it was for
Danielle and I to change our eating habits and they have integrated
some of the eating habit into there lives.
Danielle and I are much happier and slimmer since attending
Kidshape. She tells everyone she meet what a wonderful program it is
and that they should call Kidshape to help their child eat healthier,
lose weight and not be a big overweight adult who can't fit through a
door. (I don't have to say a word).
Senator Specter. So you are just a couple of kids from
KidShape. We will come back to you for some questions.
STATEMENT OF DR. ADAM DREWNOWSKI, DIRECTOR, CENTER FOR
PUBLIC HEALTH NUTRITION, UNIVERSITY OF
WASHINGTON; MEMBER, FRED HUTCHINSON CANCER
RESEARCH CENTER, SEATTLE, WA
Senator Specter. Our next witness is Dr. Adam Drewnowski,
director of the Center for Public Health Nutrition at the
University of Washington and a Member of the Fred Hutchinson
Cancer Research Center in Seattle. He has his master's degree
in biochemistry from Oxford University and a Ph.D. in
psychology from Rockefeller University. Thank you for joining
us, Dr. Drewnowski. The floor is yours.
Dr. Drewnowski. Thank you, Mr. Chairman. It is a privilege
to be here. Thank you for the opportunity to make these brief
remarks. I will limit myself to just three points. The first
one is this. It underscores what has been said here today, that
obesity represents a huge societal and public health problem.
It is a debilitating condition. It is linked to other chronic
diseases. It increases the cost of medical care and can damage
the quality of life beyond repair. We all know this. The
Centers for Disease Control has done an absolutely phenomenal
job in making sure the obesity epidemic is addressed at State,
local and community levels.
The word ``community'' brings me to my second point. It is
less appreciated that the obesity epidemic is really rooted in
the poorest neighborhoods. The highest rates of obesity and
diabetes are found among groups with the lowest education and
least income. The California Center for Public Health Advocacy
has analyzed data from the California Department of Education
Fitness grant and these are here. They make the point much more
eloquently than I could. They show that obesity rates in the
Bay Area are highest in Oakland, northern Palo Alto and that
among the districts with highest proportion of unfit and
overweight kids, ten of them are in Los Angeles County.
That underscores the point that obesity really is a major
issue for people with the least resources, least income, least
education. It really is a socioeconomic issue. And my
suggestion here is that the socioeconomic aspects of the
obesity epidemic deserve much more research attention.
Disadvantaged communities have much fewer options when it comes
to changing lifestyle, eating healthier diets, or exercising
more.
At this time, there are very limited data on how education
and incomes can affect diet quality and the economics of food
choice. We need more research to provide the research base for
fiscal and food policies, including food assistance programs.
Food assistance programs have recently been criticized in the
Washington Post for their alleged role in fattening the poor.
And I am sorry to say there is something to that because the
unfortunate fact is that healthier diets cost more. It is very
difficult to eat a healthy diet if you have fewer resources.
I just want to tell you that the price of added sugar and
added fat in our diet is extremely low. You can get 20,000
calories per dollar from sugar. Nutritionists equate 3,500
calories to a pound of body weight, so the cost of gaining
several pounds of body weight is under a dollar. And this is
why our diet is largely composed of added sugars and added
fats, not natural sugars in vegetables and fruit, but added
sugars; not natural fats in dairy products and meat, but added
fats. There is nothing cheaper.
It is very difficult to satisfy the economic constraints,
provide people with healthier diets, and address the obesity
epidemic. It really is a social issue. So we do have some data
on the determinants of food choice. We really ought to have
more.
Then, my final point is how the various efforts by the CDC
can be addressed at the local level. The CDC has immense
responsibilities and coordination at the local level is
critical. And here we have a number of centers that have been
springing up which specifically deal with the obesity epidemic
looking at policy, societal and community issues. We have a new
center at the University of Washington established with vitamin
antitrust settlement monies, secured for us by our Attorney
General, Christine Gregoire. There is a center at Berkeley
called the Center for Weight and Health that we propose to
partner with. The Berkeley Center organizes the California
Childhood Obesity Conference. There is a colleague of mine here
representing a center at Oakland. And these centers really
ought to be brought into the CDC structure.
So I propose expanding the PRC network that CDC already
has, 28 centers affiliated with schools of public health, to
include additional centers specifically addressing obesity. And
those would parallel NIH centers for obesity nutrition research
which deal with the metabolic, physiological and medical
aspects of obesity. We really need to address obesity from the
public health standpoint, and expanding the CDC centers would
be one way to do it.
prepared statement
As part of our Center, we have recently launched a small
grant campaign for healthy youth, and there was a huge
grassroots demand, which will remain unmet. We got 50 letters
of intent for projects totalling $1.5 million. We have $100,000
to give out. There was a huge, huge interest. And projects like
this really ought to be funded by the CDC, and we stand ready
to work with the CDC on this topic. Thank you.
[The statement follows:]
Prepared Statement of Dr. Adam Drewnowski
Mr. Chairman, it is a privilege to appear before the Subcommittee
and I thank you for giving me the opportunity to make these brief
remarks.
My name is Adam Drewnowski. I am Director of the new Center for
Public Health Nutrition at the University of Washington. I am Professor
of Epidemiology and Medicine and Director of the Nutritional Sciences
Program at the School of Public Health and Community Medicine in
Seattle, Washington.
My testimony concerns the national obesity epidemic--and the
strategies for improving nutrition and health at the neighborhood and
community level. National data indicate that two out of three U.S.
adults are overweight, and that almost one in three is obese. It is
shocking to note that 15 percent of American children and adolescents
(ages 6-19y) are overweight; this is three times the number we saw in
1980.
It is sometimes less appreciated that the obesity epidemic is
rooted in the poorest neighborhoods. The highest rates of obesity and
diabetes occur in groups with the highest poverty rates and the least
education. To understand the extent of the obesity epidemic among
California's children, the California Center for Public Health Advocacy
analyzed the percentage of children in each Assembly District who were
overweight or unfit. Data analyses were based on the California's
Department of Education 2001 FITNESSGRAM test. In 1995, California
mandated statewide physical performance testing for all fifth, seventh,
and ninth graders at least every two years.
Across all Districts statewide, not just 15 percent--but 34 percent
of Latino children were overweight and 45 percent were unfit. Twenty-
nine percent of African-American children were overweight and 46
percent were unfit. Of the 16 California Assembly Districts with the
highest proportion of overweight children, 10 were in Los Angeles
County. Clearly, obesity represents not only a medical issue but a huge
societal and public health problem--and one that is tied to economic
resources, education, and income.
The upper-income groups are by no means spared. Studies by Dr.
Roland Sturm, a prominent health economist at the RAND Corporation in
Santa Monica show that obesity rates are increasing evenly across the
board--across all education and income levels. There are suggestions
that education, rather than income, can offer some degree of
protection. This is an argument for supporting education in general and
nutrition education in particular as the key tools in our battle
against obesity.
Rates of extreme obesity among adults are exploding. Dr. Sturm
found that obesity rates--defined as weight in excess of 175 lb for a
woman 54" (body mass index = 30)--have doubled over the past two
decades. During that time, rates of massive obesity (>235 lb or BMI =
40) have quadrupled. We are not just becoming obese--we are becoming
gigantic. Massive obesity is linked to well-documented--and costly--
health problems.
poverty and obesity
Socioeconomic aspects of the obesity epidemic deserve more research
attention. As the CDC and other agencies develop prevention strategies,
we need to address problems faced by minorities and the poor.
Disadvantaged communities have more limited options when it comes to
better nutrition, fitness, and the adoption of healthier lifestyles.
There are limited data at this point on whether and how incomes,
education and ethnicity affect diets and fitness, to say nothing of the
issue of food pricing and the economics of food choice.
More research effort in this area is badly needed to provide
evidence base for fiscal and food policies, including food assistance
programs.
More research is needed on the economics of food choice, food
prices, and overall diet costs. Consumer decisions about what to eat,
where to eat, when to eat, and how much to eat are influenced by
economic resources and by the environment in which the choices are
made. People also make tradeoffs between immediate satisfaction and the
future promise of better health. We need to pay more attention to
societal influences on eating habits and their contribution to the
obesity epidemic. Some of the budget for primary prevention activities
at the CDC could be devoted to social disparities and their impact on
diet quality, nutritional status and body weight.
coordination at the local level
On behalf of the Public Health community, I want to say how much we
appreciate the very substantial efforts that the CDC has been making to
stem the obesity epidemic nationwide. We applaud the proposed increase
in funding for the Nutrition and Physical Activity initiative and for
other CDC-led prevention activities.
The CDC has immense responsibilities. It is now charged with
monitoring health and health behaviors at the national level,
coordinating national, state and school-based programs for health
promotion, developing evaluation, planning, and policy documents, media
campaigns and other initiatives and programs.
These tasks are critical to the nation's health. Please allow me to
suggest some ways in which CDC activities can be implemented at State
and local levels. The issue before us is finding the best ways in which
existing funds can be deployed to maximum effect. In the 2003 Senate
Bill, the Committee noted that coordination at the local level was
critical to ensure that CDC resources were used to their optimum
potential and to avoid duplication. The CDC was asked to urge its
grantees to establish state-level positions to oversee nutrition and
physical activity programs.
obesity prevention in washington state
I am pleased to say that, consistent with Congressional guidelines,
Washington State did establish a Physical Activity and Nutrition
Section within the State Department of Health. The PAN section was
charged with overseeing the CDC-funded plan for preventing obesity in
the State. In 2001, Washington State was one of 12 states to receive
CDC funding ($726,517) for state-based nutrition and physical activity
programs to prevent chronic diseases, including obesity. The State
convened a diverse group of individuals with expertise in education,
transportation, planning, nutrition, physical activity, agriculture,
parks and recreation, and health care to develop an action plan to: (1)
slow the increase in the proportion of adults who are obese; (2) reduce
rates of chronic diseases that are associated with obesity; and (3)
improve quality of life. The State Plan is being piloted in Moses Lake,
a small community in Eastern Washington. California was another state
that received CDC funding for such work.
I believe that state and local government agencies are most
effective when working together with academic institutions and
community groups. Our Center for Public Health Nutrition was created
last year by the University of Washington, thanks to a financial
settlement in a global vitamin price-fixing case. Our mission is to
advance and promote public health strategies to improve nutrition and
health of Washington State residents.
We believe that partnerships and alliances at the local level are
the key. To carry out our mission, we formed strong partnerships with
government agencies, including the State Health Department and the
local health authority, Public Health Seattle & King County. We will
support Washington State Department of Health in their application for
a CDC Comprehensive Grant for obesity prevention. We are also working
with Seattle Public Schools on environmental approaches to obesity
prevention in schools, a project funded by the National Institutes of
Health.
We have also reached out to the community. Using settlement funds,
we are able to sponsor a small program of grants for healthy youth,
destined for community based projects. The grassroots demand for such
programs is overwhelming--and unmet. We received 50 letters of intent
from school districts, community groups and other organizations for a
number of worthwhile projects--for a sum total of $1.5 million. Our
limited funds will allow us to meet one tenth of the demand. However,
any solution to the obesity epidemic needs to come from the community,
and we view such projects as a valuable contribution to capacity
building at State, local and community levels.
public-private alliances
We are encouraged by the fact that we are not alone. There are
other academic-based Centers on the West Coast that focus specifically
on obesity prevention through lifestyle modification and structural and
policy change. I want to mention specifically the Center for Weight and
Health affiliated with the University of California at Berkeley that
partners with California State agencies in running the biennial--and
hugely successful--Childhood Obesity Conference. The Berkeley Center is
the recipient of another NIH grant on schools nutrition and is engaged
in numerous community projects.
Our Center for Public Health Nutrition and the Center at Berkeley
share a number of common features. Both are University-affiliated and
both partner with State and local agencies. Both include a policy
component and community-based work. We are also reaching out to
foundations and private industry to support some of our efforts.
I want to make a case for engaging academic institutions,
particularly Schools of Public Health, in helping to coordinate CDC-led
obesity prevention efforts at the local level. Schools of Public Health
have expertise in the design and evaluation of health-related policies
and programs and can help build state capacity in this area. Schools of
Public Health train health professionals needed to address the obesity
issue. Schools of Public Health are also engaged in the local community
by taking the lead on many community based studies. Another way that
Schools of Public Health can help tackle the obesity problem is through
our HRSA-funded training centers for public health professionals that
allow us to reach out and work with local and state health departments.
Our School of Public Health serves the entire northwest region--the
states of Alaska, Washington, Wyoming, Montana and Idaho.
My suggestion is to build up the existing CDC-based infrastructure.
Both University of Washington and UC Berkeley host Health Promotion
Research Centers, 2 out of 28 academic research centers funded by the
CDC. Their mission is to improve health by conducting high-quality
prevention research that can be incorporated into community practice.
It would be my suggestion to expand the network of PRCs to include some
new Centers specifically devoted to obesity prevention.
The obesity epidemic cuts across disciplines and involves a
societal and policy component. The Center for Public Health Nutrition
and the Berkeley Center could be used as models for other Centers
throughout the US. Their mission and goal would be to address the
obesity epidemic from the public health and public policy perspective.
Such Centers would promote interactions between academia, local and
state government agencies, policy makers and local communities.
Providing support for such Centers would ensure that CDC funds are
optimally used at the local level.
To reiterate--the obesity epidemic is a huge public health problem
that needs to be addressed using public health approaches. We are
willing to work with the CDC to implement obesity prevention strategies
and programs at the local level.
Thank you for the opportunity to make these remarks.
I would be pleased to answer any questions that you may have.
Senator Specter. Thank you very much, Dr. Drewnowski. We
will come back for questioning in just a few minutes.
STATEMENT OF LESLIE MIKKELSEN, MANAGING DIRECTOR,
PREVENTION INSTITUTE
Senator Specter. Our final witness is Ms. Leslie Mikkelsen,
Managing Director of The Prevention Institute. She develops new
programs and strategies to place prevention in the center of
efforts to improve community health and well-being. She
received her Master of Public Health degree from the University
of California at Berkeley. Welcome, Ms. Mikkelsen. The floor is
yours.
Ms. Mikkelsen. Thank you, Chairman Specter. I really, too,
appreciate the opportunity to be here today. I was particularly
enthused to read your committee report that recommended not
only increased funding, but really focused on prevention. I
think it is critically important that we take a prevention
approach.
I am going to focus my remarks today on the need for
environmental and policy approaches to really support healthy
eating and activity at the community level. My own commitment
to this approach really comes from my experience being a
nutritionist. I worked for the New York City Food Bank, and
then here across the Bay in Alameda County. And I will never
forget a particular nutrition education class. It was very
successful. And then lunch came, and it was a Polish hot dog,
microwaved, potato chips, Hostess cupcakes, and Kool-Aid--
clearly, not the foods we were discussing as an ideal
nutritious meal. What might seem shocking, you know, is this
was a community agency and they had wanted a nutrition class.
Why did they serve this lunch?
Senator Specter. Where was this served?
Ms. Mikkelsen. This was actually in Oakland.
Senator Specter. Where?
Ms. Mikkelsen. In Oakland. I will not name the group, but
it was a small community organization that worked with women
that were recovering from substance abuse and who had young
children. My point with this is that that organization had
limited resources. They had no kitchen. They were dependent on
donations. And what I realized with that class was that the
women who I was working with, who were also very low income,
were going to face similar challenges when they went out into
their neighborhoods. What they were going to feed their family
was not only going to come from the information I had given
them, but it was going to come from what was affordable and
accessible and marketed to them.
But I would say that the issue of the environment is not
limited to people with low incomes. I think we all face
challenges in accessing healthy food and activity at certain
times, and that we are all influenced by the surrounding
environment, and that this issue applies to physical activity
as well as to nutrition. There are well-demonstrated links
between environmental factors and physical activity levels. For
example, people are far more likely to walk if they live in a
mixed-use neighborhood where there is both commercial and
residential close together. They are also more likely to be
active if there are more parks in their neighborhood. Concerns
about speeding cars and violence are keeping our seniors from
being out on the streets and getting their daily activity.
Likewise, parents are often afraid to let their children play
on the streets. These are serious neighborhood issues that keep
people from being active.
Our eating patterns are also influenced by the environment
around us. I find often in my trips from Oakland to Sacramento,
where I go a lot, that if I walk into a convenience store, it
is very hard to find a snack that is not high-fat or high-
sugar. My options are very limited. And I think we need to face
that, in our schools, and workplaces, and convenience stores,
high-fat and high-sugar foods are often the norm, and I think
that they have become the norm in part by the billions spent on
advertising. We mentioned earlier that these companies know a
lot about how to sell their products. Personally, as a
nutritionist, I find it very disturbing when I see an ad on TV
that is promoting a very high-sugar cereal, and it implies that
it is a good way to start the day. Many of these ads are
targeted specifically to children, and I think it sets up a
very difficult situation when a parent who is trying to do well
by their children goes to the supermarket, and these products
are at eye-level, they contain a toy, and their children are
demanding them.
I think that these are the kind of environmental issues we
need to start thinking about what we are going to do if we
really want to support a major change in the eating and
activity patterns in our country.
For these kinds of reasons, we have joined together in
California to create a new network called the Strategic
Alliance for Healthy Food and Activity Environments which is
really working to make sure that, along with good educational
programs, we have efforts to promote environmental change. And
I will just very briefly name a couple of things we have been
working on. One is we have been working across the State in
many school districts to look at the quality of the food and to
try to get out the soda and the high-fat snacks, and really
bring in healthy options. We have also been looking at this
issue of creating community environments that support physical
activity, and there are some really measured steps communities
can take, like design that encourages bicycling and walking.
And another area that I think is very important is that
government institutions have a great opportunity to be a model
for healthy practices. For example, you may have been in the
Health and Human Services Building in Rockville, Maryland, that
has a farm stand in the lobby. These are the kinds of things
that we can be doing and really change the environment so that
it is easy for people to make a healthy choice.
Senator Specter. What do they have in their lobby?
prepared statement
Ms. Mikkelsen. They have a farm stand, so that when you
walk in, there are fresh fruits and vegetables from their local
community. Thank you.
[The statement follows:]
Prepared Statement of Leslie Mikkelsen
My name is Leslie Mikkelsen. I am Managing Director of Prevention
Institute. I would like to thank you for the opportunity to be part of
this very important hearing to address a serious and growing health
problem in the United States.
I am very enthusiastic that The Committee on Appropriations has
recognized the gravity of this public health crisis and recommended
significant funding to increase physical activity, improve nutrition,
and reduce the prevalence of obesity and overweight.
I would like to share with you my perspective, gained through my
work as a nutritionist and public health practitioner, on effective
measures necessary to turn around the frightening statistics. There are
numerous factors which influence individual food and activity choices.
Changing the overall pattern of these choices requires a multi-faceted
approach that addresses not only individual knowledge, motivation, and
skills, but also ensures the surrounding environment supports healthy
behaviors.
This point was driven home for me in my work as the nutritionist
for the food banks of New York City and Alameda County. An important
lesson for me in this work occurred after I had led a particularly
successful nutrition education session with mothers of young children,
sponsored by a local community agency. The group was enthusiastic and
quite interested in practical guidance about how best to nourish their
children. Then lunch arrived. It consisted of a microwaved ``Polish''
hot dog, potato chips, cup cakes, and a fruit drink. At that moment, it
was clear to me why education was only one element of the strategy to
change the dietary habits of these families.
It might seem shocking that a community organization interested in
nutrition would serve this lunch, but they were a small organization,
without a kitchen and dependent on donations. The women who had
participated in this class were operating with the same limited
resources as this organization, and their ability to provide nutritious
foods to their family was limited by what was accessible and affordable
in their communities. This effect of the environment is not limited to
low-income families, as I will discuss later on.
This experience highlighted why environmental changes are an
important aspect of the strategies to achieve behavior change. It is
important to recognize that people are not making decisions about what
to eat and when to be active in a vacuum. Therefore it is important
that public policy and health promotion efforts support the creation of
an environment that makes healthy choices easy.
Turning around the obesity epidemic requires attention to this
community environment along with attention to individual behavior
change and provision of primary care. As noted in the Committee report,
a population-based primary prevention strategy needs to include policy
and environmental interventions.
A useful framework for visualizing this strategy is the Spectrum of
Prevention, a public health planning tool that identifies six levels of
action to achieve behavior change. This tool has been applied to major
health concerns ranging from tobacco control to traffic safety,
violence prevention, nutrition, and physical activity. It emphasizes
the importance of including systems changes along with individual
behavior change and community education.
--Influencing Policy Legislation.--Developing strategies to change
laws and policies
--Changing Organizational Practices.--Adopting regulations and
shaping norms
--Fostering Coalitions and Networks.--Convening groups and
individuals for greater impact
--Educating Providers.--Informing providers who influence others
--Promoting Community Education.--Reaching groups with information
and resources
--Strengthening Individual Knowledge and Skills.--Enhancing
individual capacity
It was the recognition of the need for environmental changes to go
hand-in-hand with individual behavior change efforts that led
Prevention Institute to join with other prominent public health
organizations to found the Strategic Alliance for Healthy Food and
Activity Environments. We also work in partnership with the National
Alliance for Nutrition and Activity.
Unfortunately, in many California communities, high-fat and high-
sugar foods and the marketing that promotes them have a prominent place
in our schools and neighborhoods, and are frequently the lowest-cost
options. Physical activity has been engineered out of our lives as
community design favors transportation by car over walking and biking,
and many parents are afraid to let their children play outside. While
meeting physical activity goals is frequently visualized as engaging in
scheduled exercise, it is frequently easier to increase activity by
incorporating it through one's daily life.
The limited availability of healthy options is even more pronounced
in low-income neighborhoods, where families must prioritize basic
needs. Unfortunately, healthy behaviors are often viewed as a luxury;
the survival mechanisms used to combat poor food access and unsafe
neighborhoods (i.e., consuming high-fat, fast foods, and staying
indoors rather than playing on the streets) establish patterns that put
children at risk for developing chronic disease.
The Alliance has identified five key sectors where we believe joint
action is needed to alter current eating and activity patterns and
shift the environment towards supporting healthy behaviors. These
include children's environments, government, industry practices, the
health care system, and the media. A complete description of this
approach is attached.
Today, I would like to highlight some of our areas of focus which
are being implemented in communities across the country. I urge you to
work to implement similar policies nationally. Some of the most
promising approaches include:
(1) Implementing Nutrition Standards for all Foods Sold in School, Pre-
school, and After School Programs
A key tenet of effective behavior change is to model and reinforce
healthy behaviors. Unfortunately, schools frequently provide easy
access to soft drinks, high fat snack foods, and dessert through
vending machines and a la carte lines. Brand name fast food is even
available in some high schools.
As public institutions dedicated to children's learning, schools
should serve as a model for healthy practices rather than a conduit for
unhealthy habits. These should apply to all institutions serving
children from pre-school, school, and after school programs.
The Alliance was involved in securing the passage of Senate Bill 19
which establishes nutritional standards for foods sold outside the
National School Breakfast and Lunch programs in elementary schools and
middle schools. We are currently helping to ensure adequate technical
assistance and evaluation of pilot projects taking place before the
bill takes effect. At the same time, members have been involved in the
passage of local school district measures to remove soda and in some
cases junk food from all schools. There is great interest in this
approach around the country, and we have heard from localities in
states as diverse as Alaska, Hawaii, New York, and Pennsylvania that
are moving towards similar restrictions. Where changes have been made,
preliminary results are positive, with sales of water, 100 percent
juice, and healthier snack choices yielding revenues equal or greater
than those previous.
(2) Cultivating Active Community Environments
There are well-demonstrated links between community design and
physical activity levels. Current land use trends have tended to
increase automobile dependency and make walking and biking less
practical, less convenient, less safe and less pleasant.\1\ From 1960-
1990, the percentage of workers with jobs outside their counties of
residence tripled.\2\ During the same period, vehicle miles traveled
rose dramatically while walking declined.\3\ Mixed land use increases
the number and percentage of walking and biking trips, generating up to
four times as many walk trips for trips less than one mile.\4\ Access
to neighborhood parks nearly doubled the likelihood that U.S. adults
were physically active compared to those without access to parks.
Concerns about neighborhood safety have been associated with lower
activity rates among older adults.\5\
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\1\ A Primer on Active Living by Design. Active Living By Design
Program. The Robert Wood Johnson Foundation.
www.activelivingbydesign.org
\2\ BTS Journey to Work trends, 2001; National Transportation
Statistics Report 1999.
\3\ BTS Journey to Work trends, 2001; National Transportation
Statistics Report 1999.
\4\ Holtzclaw J. (1994) Using Residential Patterns to Decrease Auto
Dependence and costs, Natural Resources Defense Council, San Francisco,
p. 16-23.
\5\ Centers for Disease Control and Prevention. Neighborhood safety
and the prevalence of physical inactivity-Selected states, 1996. MMWR.
1999; 48(7):143-6.
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Nationwide, only 31 percent of children who live within 1 mile of
school make the trip on foot; only 2 percent of school children who
live within 2 miles of school travel by bike.\6\ Parents are also
afraid to allow their children to play outside and turn to safe,
passive entertainment ranging from TV to home videos and computer games
to occupy their children's free time. Children in the United States
spend more hours watching television and videotapes and playing video
games than sleeping; these passive leisure time activities are linked
to increased risk for obesity.\7\
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\6\ Centers for Disease Control and Prevention. Calculations from
the 1995 Nationwide Personal Transportation Survey.
\7\ Robinson TN. ``Reducing Children's Television Viewing to
Prevent Obesity: A Randomized Controlled Trial.'' Journal of the
American Medical Association, Oct. 27, 1999, 282(16): 1561-1567.
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The Strategic Alliance is supporting a number of local and state
government policies that enhance active community environments, which
would benefit from support at the federal level. Measures being taken
by communities to alter environments to enhance physical activity
include traffic calming and routine accommodation of bicyclists and
pedestrians in all transportation projects. Opportunities exist to
reward local governments who promote infill development and more
walkable communities with transportation incentive grants. Funding of
the Safe Routes to School program has enhanced walking to school for
many children. Resources also need to be made available to support
maintenance and development of parks and areas for active recreation.
(3) Increasing Access to Nutritious Foods in all Neighborhoods
Anyone who has searched a convenience store for a healthy snack
knows that options can be limited. Restaurants can also be a
challenging place to find fruits and vegetables to contribute to 5 a
day. Access to nutritious foods is even more challenging in low-income
neighborhoods, where there are few supermarkets and small stores have
limited quantities of high-priced fresh items.
Supermarkets have become the primary source of fresh produce for
most grocery shoppers in the United States. Yet predominantly low-
income neighborhoods in both central cities and rural areas are less
likely to have supermarkets. A 1995 analysis of 21 major U.S.
metropolitan areas found there were 30 percent fewer supermarkets in
low-income areas than in higher-income areas; it also found low-income
consumers were less likely to possess automobiles, further limiting
their access to food choices.\8\ Studies have consistently shown that
prices at small grocery and convenience stores can exceed those at
chain supermarkets by as much as forty-eight percent and smaller stores
are also unlikely to offer the variety of products carried by most
major supermarkets.\9\ A recent University of North Carolina study has
demonstrated the link between supermarket access and healthy diets,
finding that residents in neighborhoods with higher concentration of
supermarkets ate higher amounts of fruits and vegetables.\10\
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\8\ Cotterill RW, Franklin AW. The Urban Grocery Store Gap. Food
Market Policy Center, University of Connecticut, Storrs, CT, April
1995.
\9\ Weinberg Z. No Place to Shop: Food Access Lacking in the Inner
City. Race, Poverty, and the Environment. Winter 2000.
\10\ Morland K, W. S., Diez Roux, A (2002). ``The Contextual Effect
of the Local Food Environment on Residents' Diets: The Atherosclerosis
Risk in Communities Study.'' American Journal of Public Health 92(11):
1761-1767.
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There are models around the country for innovative approaches to
increasing access to fresh produce, low-fat dairy and protein items.
These include joint community partnerships to site supermarkets in low-
income neighborhoods, establishment of farmers' markets, and training
and equipment provided to small retailers to successfully carry
produce. At the same, some community-based programs have sought to
improve transportation to bring consumers to existing stores by
coordinating transit services or providing van service or deliveries.
(4) Making Government and Health Care Workplaces Models for Supportive
Environments
Most adults spend a large portion of the day at work. The
organizational practices of their work place can make a difference in
their ability to achieve healthy behaviors. California adults reported
difficulty accessing fruits and vegetables at work as a key barrier to
increasing consumption.\11\
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11 Oppen M, et al. (1999). Fruit and Vegetable Consumption in
California Adults; Ten-Year Highlights from the California Dietary
Practices Survey 1989-1999, Public Health Institute, California
Department of Health Services.
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It is a concern when a local hospital served donuts as the only
breakfast food at a meeting on health disparities, or when fast food
outlets are located in the lobby. A far better example is set by the
Health and Human Services offices in Rockville, Maryland, where we were
pleased to discover a farmstand with an attractive array of local
fruits and vegetables set out for tasting.
Health care and government institutions have a special
responsibility to model wellness-encouraging organizational practices.
These offices can serve as a model ensuring availability of healthy and
appealing food options in cafeterias, vending machines and whenever
refreshments are served. Inspectors ensure the safety and accessibility
of elevators while failing to ensure safe, hospitable stairways, which
CDC has aptly described as ``expensive pieces of exercise equipment.''
Activity levels can be enhanced through support for well-lit and safe
stairwells, bike racks, lockers and showers, and incentives for walking
or biking to work.
Government and health care staff should serve as spokes people for
healthy food and activity practices at work and be able to proudly
describe how their own workplaces reflect such practices.
(5) Restricting Marketing to Children
Children in the United States are estimated to view as many as
40,000 commercial messages each year on television.\12\ More than 50
percent of these ads are estimated to be for food, predominantly
promoting soda, fast foods, high-sugar cereals and high-calorie snacks.
This advertising seeks to develop their brand loyalty to last a
lifetime and even utilizes children's entertainment characters to
promote food and beverage products. Even schools have become centers
for commercial messages as soft drink companies have targeted schools
for exclusive marketing contracts that prominently feature their
products and sometimes lead school administrators to promote sales in
order to increase revenue for the schools.\13\
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\12\ Strasburger VC. ``Children and TV advertising: nowhere to run,
nowhere to hide.'' Journal of Developmental and Behavioral Pediatrics.
Jun 2001;22(3):185-187.
\13\ Nestle, M. Soft Drink Pouring Rights. Public Health Reports.
July/August 2000, Vol. 115, 308-319.
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The serious health consequences that are resulting from over
consumption require that we look once again at the appropriateness of
marketing to children. Children below the age of eight are incapable of
even distinguishing commercial from non-commercial messages.\14\ At a
minimum, promotion of unhealthy food and beverages should be eliminated
from schools which are public institutions. Further, we need to
carefully consider the examples of other countries. Sweden and Norway
prohibit advertising targeted to children under 12 and Australia does
not allow ads during preschool programming.
---------------------------------------------------------------------------
\14\ ``Children, adolescents, and advertising. Committee on
Communications, American Academy of Pediatrics.'' Pediatrics. Feb
1995;95(2):295-297.
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In conclusion, I would like to say that it is very exciting to see
an increase in funding to CDC devoted to nutrition and physical
activity initiatives. Given the important contribution of environmental
and policy changes, I would strongly recommend that a high proportion
of these funds be devoted to nurturing the burgeoning movement for
these changes at the state, local and federal levels. Through the
synergy of individual-behavior change efforts and environmental
changes, we will be able to effectively shift community norms and
reduce the burden of preventable disease, disability, and premature
death.
Senator Specter. Thank you very much, Ms. Mikkelsen. So,
Danielle, who called you a fat girl?
Ms. Boyd-Bailey. She said she did not understand what you
said.
Senator Specter. How long ago did that happen?
Ms. Boyd-Bailey. He said, ``Who called you a fat girl.''
Dr. Neufeld. And how long ago.
Ms. Bailey. Legend.
Ms. Boyd-Bailey. Legend, a little boy at school. The kids
at school would tease her.
Dr. Neufeld. How long ago? When?
Senator Specter. How long ago? You look like a thin girl to
me. When did they call you ``fat girl''?
Dr. Neufeld. Before or after KidShape?
Ms. Bailey. Before.
Senator Specter. Danielle, at that rate, you are not going
to use up your 5 minutes. So, Danielle, did the incident where
they called you ``fat girl,'' did that make you want to change
your diet?
Ms. Bailey. Yes.
Senator Specter. And when somebody mentions McDonald's,
what do you say about going there?
Ms. Bailey. I say that is not healthy.
Senator Specter. It is not healthy, yes. And how did you
figure that out? What led you to decide that going to
McDonald's was not healthy?
Ms. Bailey. KidShape.
Senator Specter. Mr. Lefer, when you say you started
feeling better 1 or 2 weeks later, amplify that just a bit.
Mr. Lefer. Well, the angina started getting better. I could
walk farther. You feel it immediately.
Senator Specter. And what changes had you made in your diet
in that week or 2?
Mr. Lefer. Well, I became a vegetarian. I started doing the
yoga. We used to meet twice a week----
Senator Specter. Doing yoga can be fairly rigorous.
Mr. Lefer. Well, not the kind we do. We do a Hatha Yoga,
which is a gentle yoga. It is more for older people.
Senator Specter. Did you ask for Dr. Ornish to do what some
of the rest of us do, the less vigorous yoga?
Mr. Lefer. I did whatever he told me.
Senator Specter. And you say that opening your heart was a
key factor, letting bad things out. That may be too personal to
amplify, but if you care to comment further, we would be
interested to know.
Mr. Lefer. Yeah, well, we used to meet twice a week, and at
the end of the meeting--first we would exercise, then we would
eat, and then we would have group support. And we would sit
around in a circle. And people would talk about what was going
on in their lives and their feelings, and I just was the kind
of person that would just hope nobody would ask me anything,
and I was nervous that I would have to talk about what was
going on in my life, and I learned how to just express and have
empathy for other people's problems and, by doing that,
learning how to handle my own feelings.
Senator Specter. And you have had reversal of your heart
condition?
Mr. Lefer. Yeah. The program was for 1 year originally, but
then the government gave Dean some money and it was increased
to 4 years. And every year we would go down to Houston and have
a Pet Scan, and the first year I went down there--the Pet Scan
is the colors in the heart muscle are red and white when you
get good circulation, and the first year, mine was all dark and
green, and there was very little. And each year I went down
there, my heart started to come back. It started to rejuvenate
itself. I was not a candidate for bypass because I had so much
damage that there was nothing to bypass, really. So I had to
work with what I had left. And each year, the Pet Scan would
show more blood flow to the muscles.
Senator Specter. And these were your arteries would show--
--
Mr. Lefer. No, no, this is my heart muscle.
Dr. Drewnowski. But your arteries also show the reversal.
Mr. Lefer. Yeah, my arteries showed reversal also.
Senator Specter. Did you have significant weight loss?
Mr. Lefer. During the 4 years of the program, I lost about
25 pounds, yes. I am a pretty ferocious eater, though, even
today.
Senator Specter. Even with vegetables?
Mr. Lefer. Yeah.
Senator Specter. On a personal level, what vegetables
motivate you? I would like to find some.
Mr. Lefer. Well, I keep my weight up by eating
carbohydrates, mostly. I eat too much pasta. But I still eat
out quite a bit. I go to Chinese restaurants and I get steamed
vegetables with tofu, with soy sauce. What I do is I cultivate
places to make the food tasty. Luckily, I live in this area and
there are a lot of restaurants that have Dean Ornish- or Dr.
McDougall-type food on the menu. And it is pretty good.
Dr. Drewnowski. Tell them what you used to serve in your
restaurants.
Mr. Lefer. Oh, my restaurants--I killed thousands of
people.
Senator Specter. You have not changed your own restaurant
to incorporate all the valuable lessons you have learned----
Mr. Lefer. Oh, no, no, I sold my restaurants right after I
had my heart attack. I got out of the business. Actually, I
cannot stay away from it. Right now, I am working with a
company that develops products for the food industry, and I am
trying to develop a fat-free chocolate to cover different
products. And they think they are going to be able to do it.
Senator Specter. A fat-free chocolate?
Mr. Lefer. Yeah, that cover products.
Senator Specter. Which will not have all these adverse
health effects?
Mr. Lefer. Well, I am hoping to do that, yeah. And I am
hoping to use, instead of sugar, sugar substitutes.
Senator Specter. Well, you may be interested to know that
you can come to the Senate Dining Room because Dr. Ornish has
entries on the menu. He does not get credit for them because
that is the government way.
But we have taken some of his dishes and put them on the
Senate menu, so if you are in the neighborhood and can get by
the barricades, come on in.
Mr. Lefer. All right.
Senator Specter. Dr. Ornish, you mentioned prostate cancer
on a reversal. Could you amplify how that works?
Dr. Ornish. Sure. And I think, as you know, you can get a
lot of good done in the world if you do not care who gets the
credit. I think we are at a place with prostate, breast, and
colon cancer very much like we were 25 years ago with heart
disease. And that is, if you look at the animal data, the
epidemiological data from other countries, the anecdotal case
reports in humans, there is every reason to think that diet and
lifestyle might affect these diseases, but nobody had really
done a randomized trial until, beginning 5 years ago, in
collaboration with Dr. Peter Carroll here at UCSF, who is the
Chair of Urology, and the late Dr. William Fair, who at the
time was the Chair of Urology at Memorial Sloan-Kettering
Cancer Center in New York, we designed a study that took
advantage of the fact that a certain number of men who know
they have prostate cancer do not get treated for it for reasons
having to do with, if you are older, you are more likely to die
with prostate cancer, rather than from it. But we did not get
involved in those decisions.
But from a scientific standpoint on that, we could have a
group of men who all knew from biopsies that they had prostate
cancer, but none of them had been treated, so we then randomly
divided them into two groups, asked one to make big changes in
diet and lifestyle, and the other did not, and so we could have
a non-intervention control group which you could not do with
breast cancer, for example, because most women get treated
immediately.
Senator Specter. You could not do it with breast cancer.
Why?
Dr. Ornish. Because most women get treated. They get
chemotherapy or surgery or other things, and so then you would
not know whether the changes were due to the conventional
treatment, or whether they were due to diet and lifestyle
alone; whereas, in these men, none of them had conventional
treatment when they started. So, after 1 year, what we found is
that the control group--7 of those 84 men ultimately ended up
getting conventional treatment, surgery, radiation,
brachiotherapy, during the first year. But none of the people
in the lifestyle change group had conventional treatment. And
we found that the Prostate-Specific Antigen, or PSA, improved
or went down on average in the group that made these changes,
but went up in the group that did not, or they got worse.
We found a dose response correlation--the more people
change, the lower their PSA went, just like we found in a study
that Mel Lefer and others were in, that the more people change
their diet and lifestyle, the less clogged their arteries
became using quantitative arteriography.
But in order to get the patients to get better, as in both
studies, they had to make really big changes. The old saying
about an ounce of prevention and a pound of cure I think is
really true. To reverse disease, you have to make really big
changes. To prevent it, you do not have to be so strict. And if
you start at a young age, as you are doing, then you do not
have to make such big changes.
So I think our findings are really giving many people new
hope and new choices that they did not have before. And if it
is true for prostate cancer, it will almost certainly be true
for breast cancer as well, and likely colon cancer, and
diabetes, and hypertension, and obesity. And a wide range of
degenerative diseases are really directly linked to the diet
and lifestyle choices that we make every day--for better and
for worse.
Senator Specter. Has an effort been made to do for breast
cancer what you have done for prostate cancer?
Dr. Ornish. We would love to do a study on breast cancer as
our next study if funding were available. We would be thrilled
to do that. And I think one of the things that is kind of our
unique little niche is that we have really learned what
motivates people to make changes to this degree in the real
world, and it looks like it takes that degree of change in
order to show reversal.
Senator Specter. To the extent that you can comment, how
are your consultations with McDonald's going?
Dr. Ornish. Well, about 3 years ago, I was at a----
Senator Specter. Are they aware of Danielle's sentiments,
by the way?
Dr. Ornish. I think they will be soon. I will make them
aware of it. I remember about 3 years ago, I was at this
conference in Davos at the World Economic Forum, and I was at a
breakfast and I was seated next to a guy. And I said, ``Hi, I
am Dean Ornish.'' He said, ``I am Jack Greenberg.'' I said,
``What do you do?'' He said, ``I am the CEO of McDonald's
Worldwide.'' I said, ``Oh.''
I thought how interesting to be sitting next to the CEO of
McDonald's. So I began consulting with him and encouraging him
to make healthier foods. And it is interesting. There was kind
of a division in the company. The company started to not do so
well and there was the old guard that said: ``We ought to just
make cheaper burgers and that's it,'' and then the more
visionary people there who said: ``We really need to make
healthier food.'' And the old guard won temporarily. Their
stock went down by 50 percent. They have since replaced their
CEO, and now they are much more open.
Senator Specter. As soon as you started consulting with
him, he was replaced?
Dr. Ornish. See, that is why you have a control group in
science because association does not necessarily imply
causation. But I have also been consulting with PepsiCo in the
last year or so, and their CEO, Steve Reinemund, actually has
taken a very different approach. They have committed that half
of their new products in the coming year will be healthier
products. And I think they are doing it for two reasons----
Senator Specter. How can they do that?
Dr. Ornish. Well, that is the thing about these big
companies--if the CEO wants something to happen, they do it.
Senator Specter. But what do you do for the taste of Pepsi?
How do you make it different?
Dr. Ornish. Oh, well, Pepsi owns Tropicana, they own Quaker
Oats, they own Gatorade, they own other companies that, under
those umbrellas, they can make healthier foods. We have already
worked with McDonald's----
Senator Specter. Could they make Pepsi-Cola healthier?
Dr. Ornish. Well, not necessarily, but the idea is, first
of all, we have already gotten them to take their trans-fatty
acids out of the potato chips and things like that, so they can
make them healthier, if not healthy.
But the idea is that they realize two things--one is that
because of the threat of litigation you talked about, as well
as the fact that they see that as the baby boomers are getting
older, there is a real market for healthier foods, that they
cannot stop making the foods--the so-called ``junk foods''--
because that is a big part of their core business. But if they
also make a lot of healthy foods, then they can say, ``We are
making an entire spectrum of choices,'' and also educate people
how they can find their place on this spectrum because, you
know, for some people, if they have indulgent foods once in a
while it is not going to hurt them. For people who have heart
disease, they should probably never eat those foods.
So, by having the spectrum of choices, it both protects
them against litigation, as well as opening up new markets. And
one of the reasons I like working with them is, as you alluded
to, they know how to--I mean, in terms of behavioral
modification, they are the experts. You know, they know how to
influence people to eat certain ways. Unfortunately,
traditionally, it has been in ways that are not very good for
them. And if we can work with them to not only make healthy
foods, but to make them fun, and sexy, and hip, and
interesting, and all the kind of peer issues that particularly
affect younger kids in what they eat, then potentially, they
can find that they can make a good business out of it, as well
as making foods that are going to be healthier for Americans.
Senator Specter. You had an interesting dichotomy--fear of
dying, joy of living. How do you activate those feelings, not
too relevant perhaps to say which would be more significant or
more motivational, but how do you work on, say, the joy of
living as a motivating factor?
Dr. Ornish. Well, that is a very good question. I think Mel
Lefer is a perfect example. When he started our program, he
literally could not walk across the street without getting
severe chest pain. He could not take a shower, as he indicated.
He could not have sex without getting pain. And one of the
things I have learned is that when people make really big
changes in their diet and lifestyle, sometimes the reasons for
making these changes--because there is no point in giving up
something that you like unless you get something back that is
better--and not 30 years later for the heart attack that does
not come, but 1 week or 2, or 1 month later.
I think one of the most effective anti-smoking campaigns
here in California at the Department of Health Services was
not, ``Smoking causes emphysema, lung cancer, heart disease''
because people do not want to think about those things. They
are too terrified. But they had a picture of a guy, an actor
dressed like a Marlboro Man with a limp cigarette hanging out
of his mouth saying, ``Smoking causes impotence.'' And that got
people's attention because, again, when I----
Senator Specter. Smoking causes what?
Dr. Ornish. Impotence. Sexual dysfunction. And you know,
ironically, cigarettes are always marketed as being so sexy,
just like eating high-fat foods are, but it turns out that most
impotence--first of all, it is extremely common, which is why
Viagra is one of the best-selling drugs of all time. And it is
something that most guys do not talk about, except, I guess,
one of your former Senator colleagues does on some occasions--
and the point is----
Senator Specter. He talks about Pepsi more.
Dr. Ornish. And when I was in medical school, we were
taught that impotence was mostly in your head. We now know it
is mostly in your arteries. The same mechanisms that affect
blood flow to your heart also affect blood flow to sexual
organs. And so when people quit smoking, when they change their
diet, when they manage stress better, their blood flow to their
brain improves. They get more blood, they get more oxygen, they
think more clearly. Their heart disease improves. Their sexual
function improves. They do not have these aches and pains
oftentimes. And so those kind of immediate benefits, I find,
are much more motivating than simply talking about risk-factor
reduction because most people do not really think anything bad
is ever going to happen to them.
Senator Specter. Dr. Stern, the charts you have provided
are very impressive on how little attention is directed to
obesity. And it is only a comparative matter, but NIH obesity
has gone up from $127.6 million in 1998 to $324.3 million in
2003. Now, you are correct that, notwithstanding a very
substantial percentage increase, it is still relatively modest.
But how would you go about trying to persuade NIH to make an
institute? And where do you end up with all of the other
factors--an alcoholism institute, a tobacco institute? How do
we establish those priorities for NIH?
Dr. Stern. Well, my concern, Senator, is that we are in the
midst of this huge obesity epidemic. It is affecting children,
it is affecting adults. The healthcare costs are out of
control. And if you look at the number of people affected,
certainly with adults, it is over 60 percent of our population
is overweight or obese. And using NIH's criteria to establish
priorities, this would be a no-brainer. So the reason why we
are proposing an obesity institute is to try and increase the
visibility of obesity at NIH because it is not visible at all.
How would I go about it--if I were made king or queen for the
day? Or if it was the real world?
Senator Specter. How about chairman of the Appropriations
subcommittee?
Dr. Stern. Same thing.
Well, first of all, I want the Government, HHS, to come up
with a plan for how to deal with obesity in terms of research.
This is something you requested in 1999. And they have not done
that. So it is really hit or miss. And I would hold hearings in
this area to see why so little money has been--and so few
grants are being spent on obesity.
I will give you an example with CDC. CDC has done a
wonderful job with the amount of money that they have, but my
first three figures, looking at the incidence of obesity, that
comes from the National Health and Nutrition Examination Survey
that CDC manages. Just a few years ago, it was in danger of
really being de-emphasized because of lack of funds. And Sally
Squires' article in The Washington Post within a week resulted
in more money being appropriated for this.
So, first of all, we have to track what is happening to
this epidemic and that is critical with the CDC. But we also
have to do programs to see what works. And Dean, you are really
to be congratulated. You really have done research, you have
published your research, and that is really laudable. You have
not gotten a lot of money in terms of grants. If you take
Dean's counterpart, Dr. Atkins, there has been very little
research done in that area and we do not know--we know people
lose weight on it, we do not know about is it safe, does it
cause people to maybe increase heart attack risks? And does it
help people maintain weight? The research simply has not been
done. And I think it is going to have to be NIH, USDA, CDC that
actually does the research.
Then, finally, if you would ask me what prevents obesity,
what do we know from the research that is out there? I would
say we do not know because there has not been significant
research on prevention of obesity. We think the taking of
vending machines out might help, we think that de-emphasizing
portion size might help, but we simply do not know. We are
going ahead in the absence of research to make these changes,
and if they do not work, I think people are going to be very
angry.
Senator Specter. Dr. Stern, you have mentioned in your
testimony something about the isotopes. I did not quite follow
that. Could you amplify that?
Dr. Stern. Oh, sure. One of the ways you can find out what
people are eating--energy balance, what they need to keep them
going--is to give them a stable isotope, meaning it is not
radioactive, and it is called ``doubly-labeled water.''
Senator Specter. Doubly-labeled water?
Dr. Stern. Doubly-labeled water, right. The hydrogen and
the oxygen have different isotopes and it is not radioactive,
and you look at what happens--how you excrete it, how it is
utilized over 10 days. And it is a very valuable tool.
Well, literally, research in this area, if you do not
already have a lot of doubly-labeled water in your research
organization, you cannot do this research. You cannot do the
appropriate research if we are looking at food intake and
exercise because there is not enough doubly-labeled water.
There have been some steps taken that will increase the supply
of this in the next 2 or 3 years, but my comment here was, if
somebody were minding the shop and anticipated this, I do not
think we would be in this fix we are right now.
Senator Specter. Well, how do we get out of it?
Dr. Stern. Well, we need big columns to create the
isotopes. I mean, it is a technology problem. Right now, it is
a technology problem. We get some of our isotopes from Russia
because they still produce some things, but the supply is very
low.
Senator Specter. Well, I will pursue NIH on our
recommendation. Do you think the subcommittee ought to tell
them what to do, ought to mandate it?
Dr. Stern. Well, the problem, Senator, is----
Senator Specter. That is, the subcommittee recommend to the
full Congress that it be mandated.
Dr. Stern. The problem is that it has not been done and the
problem has gotten worse. You made suggestions in 1999. We are
now 4 years later and how many millions of people have gotten
Type 2 diabetes and gotten obese in that interim. I think that
this crisis really is severe enough that I would like to see it
mandated, but I am an activist and I would bow to whatever you
decide.
Senator Specter. Well, we approach it with recommendations
so that we do not give in to the politicization of having the
Congress make scientific judgments. We make political
judgments. But I am going to pursue that.
Dr. Stern. Well, let me just turn the question around
slightly. Let us say we had something like heart disease which
does kill a lot of us, or will kill a lot of us, and NIH was
not doing the appropriate research on heart disease because it
was not fashionable, because let us say people with heart
disease were viewed as less valuable or as weak-willed, would
your subcommittee at some point take action? And that is
rhetorical.
Senator Specter. Senator Stevens, as chairman of the full
committee some time ago, put in an extra $150 million for
prostate cancer when he had prostate cancer, but it got thrown
out.
Dr. Stern. But you asked for a billion at NIH? Or you were
looking at the increase in NIH budget and it got thrown out the
first year, the second year? So I----
Senator Specter. Well, it is true that if the chairman puts
a mark, then people are afraid to take it out, but that is to
NIH generally, without our telling NIH where to spend the
money. You might quarrel that it is a waste of money--or it is
not as high a priority item as more for the Department of
Defense. Somebody might argue that.
I am just kidding.
Dr. Neufeld, you had mentioned Medi-Cal and Medicaid on
your program for KidShape. Could you tell us a little more
about that?
Dr. Neufeld. Yes. In 1997, we went to meet with the Medi-
Cal Nutrition Subcommittee and they provide funding through a
program called EPSDT. It is the Early Periodic Screening
Diagnosis and Treatment Program. It comes from the Omnibus
Reconciliation Act of 1989, and it is for prevention of
disability. And as a result of that, it is limited to children
up to the age of 21, and it is to provide a variety of
programs----
Senator Specter. For people up to 21?
Dr. Neufeld. Up to 21.
Senator Specter. On disability?
Dr. Neufeld. No, no, it is for all children on Medicaid,
and it is money from the ORB, the 1989----
Senator Specter. And this was Medicaid, California? Did
that come out of Washington?
Dr. Neufeld. It came from Washington and I think each State
can make a decision as to how to use it. In California, they
have used it for nutrition services, as well, and essentially,
it is to identify disabilities which can be detected on a
physical examination.
Senator Specter. Does it require a disability finding?
Dr. Neufeld. No, no. It is to prevent disability. It is
EPSD----
Senator Specter. Prevent disability.
Dr. Neufeld. Right. Early Periodic Screening Diagnosis and
Treatment designed to improve primary health benefits for
children with an emphasis on preventive care.
Senator Specter. Dr. Stern, why would that not be
applicable to obesity?
Dr. Stern. Well, obviously you have used it in that area
and----
Dr. Neufeld. It is available--we were lucky.
Dr. Stern. Right. It is getting the priority highlighted.
Dr. Neufeld. So we were able to identify those funds--or
the State was able to identify them and provide them to us. Now
the problem is that this was done in 1997 and, from 1998 or so,
we were able to do our program, as I said, and develop up to 20
sites. But over the last year, because Medi-Cal in California
has taken a hit, we have been able to only obtain by
reimbursement 20 percent of the charges that we bill for. So,
in fact, we are Medi-Cal eligible, we can bill for our program,
and had we received all the funding that we legitimately bill
them for, we would be fine. But we in fact are living on
charity and private donation.
Senator Specter. And Dr. Neufeld, you are also working with
Highmark of Pennsylvania?
Dr. Neufeld. Yes, we are. And Christiane Rivard can explain
that, our program director.
Senator Specter. Sure. You are going to have to come
forward and identify yourself for the record, and get a chair.
Ms. Rivard. My name is Christiane Wert Rivard. I am the
program director for KidShape. And Highmark contacted us
because they were interested in--they were not interested in
re-creating the wheel, they wanted to bring a program that was
proven effective for their population. And what we developed
was a licensing program so that they could operate the program.
They pilot-tested it in both Erie and Pittsburgh, and Allegheny
General Hospital was one of their community partners, as well
as the public schools. With the two pilot programs, they were
very effective. And so, for the year 2003, now they are
licensing the program for ten sites throughout Western
Pennsylvania because it has gone over so well and it has been
so effective for the families that they served and that they
provided the program for.
Senator Specter. Well, we are glad to see you in
Pennsylvania. Thank you.
Dr. Drewnowski, you raised an interesting point, and Dr.
Gerberding, I would appreciate your comment on this, about
using the centers, as you articulate, to address the public
health standpoint, and to try to integrate those with CDC. How
would you suggest doing that?
Dr. Drewnowski. The CDC has a network of 28 prevention
research centers affiliated with major schools of public health
around the country. And some of those centers are devoted to
issues of physical activity, and others are interested in
issues of body weight. There are others, still, dealing with
other health prevention and other problems. My suggestion is,
we have new centers specifically devoted to obesity and
specifically devoted to policy, economic, and community aspects
of obesity that would not duplicate NIH work because the NIH
does the network of Obesity and Nutrition Research Centers, but
would add to the strategies and plans of the CDC and expand CDC
resources in this area, and policy focus would be very
important and also working with State and local government and
the communities.
Senator Specter. Dr. Gerberding, do you have the
flexibility to entertain such an idea?
Dr. Gerberding. We certainly do. I think this is a great
example of trying to bridge that gap between the basic science
and the community application, and the schools of public health
that house these centers are fine academic institutions. They
have creative investigators. We can either enhance or add this
activity to existing centers or create new centers with this
particular focus. So I think this is something that we need to
sit down and figure out how to make that happen.
Dr. Drewnowski. That would be great.
Senator Specter. Dr. Drewnowski, you raised a very
fundamental point about these foods appealing to people in the
lower economic groups and with the least resources and
education, as you say it. I am groping with a way to deal with
it. What do you do? If Dr. Ornish cannot persuade Pepsi-Cola,
what do you do?
Dr. Drewnowski. Well, the problem is that the determinants
of food choice--there are three of them--taste, cost,
convenience, and unfortunately to a lesser extent, health and
variety. So taste drives people toward sugar and fat and high,
energy-dense foods. Cost, the low cost of sugar and fat drives
them towards high-sugar, high-fat foods. And convenience, let
us face it, the packaged foods are convenient. They contain
fat, sugar and salt. So those three, like a triple-whammy--fat,
sugar and salt. But cost is very, very important and those
foods are low in cost.
So we need to know about the economic cost of various diets
and, at this point, we do not even have a national food price
database. There is not one that exists. So we have no idea what
people spend on food. There is some government databases that
tell us what people spend, but not what they eat, and other
databases that tell us what they eat, but not what they spend.
So you cannot really cross the two and price the quality of
diets. And I suspect the diets high in sugar and fat are
associated with obesity and, of course, diets high in
vegetables, fruit, and so on, are not, but those diets may be
more costly.
Dr. Ornish. Could I just add----
Senator Specter. Before you take it, Dr. Ornish, I would
like to follow up with Dr. Drewnowski. Are you suggesting that
there could be a specific research program which would answer
the issues you just raised?
Dr. Drewnowski. Absolutely. And CDC, as a matter of fact,
did have a September conference on the pricing of vegetables
and fruits, and they are really thinking about this, and there
are ways of addressing that. I would suggest a program of
research to begin with, and then establish a base for fiscal
food policies, and then start looking at food assistance
programs, subsidies for vegetables and fruit, farmers markets,
and other approaches at the community level. But the CDC did
have a price conference back in September.
Senator Specter. Well, Dr. Drewnowski, would you specify
those views in a letter to Dr. Gerberding and send me a copy?
Dr. Drewnowski. It would be a pleasure.
Senator Specter. Okay. Dr. Ornish, you had a comment?
Dr. Ornish. Yes, just two things. I agree with Dr.
Drewnowski that lower socioeconomic groups tend to eat foods
that are higher in fat, but I want to make two points, one is
that the kind of diet that we have been studying for 25 years
is essentially a Third World diet. It is not an inherently
expensive diet, it is the way that people eat who cannot afford
healthier food. But the system has become somewhat distorted in
this country, (a) because so many people in lower socioeconomic
groups get so much of their food from fast food places because
they do not have even access to local groceries and farmers
markets, and (b) because the governmental subsidies tend to
subsidize and make those high-fat foods and meats and dairy and
eggs less expensive than the fruits and vegetables that--in a
free market, actually you would find the opposite.
Senator Specter. Ms. Mikkelsen, you had commented about the
ads, ``Good way to start the morning.'' Do you think the
Federal Government ought to intervene on those ads?
Ms. Mikkelsen. Well, I think it would be something to think
about. I think the time has come--I know this was an issue that
was considered in the late 1970s about limiting advertising to
kids. In other countries--for example, Sweden and Norway, do
not allow television advertising directed to children under 12,
and I believe it is Australia that does not allow any kind of
ads during pre-school programming. I think we do have to think
about whether the seriousness of this health crisis requires--
as we did in taking tobacco ads off of TV, limiting ads that we
know are promoting unhealthy products.
Senator Specter. Do you think that is something the FDA
should get involved in?
Ms. Mikkelsen. I think it would be very great if it did. I
would love to see that happen. And I think there are many
people--I know that the California State Senate is looking at
holding a hearing on marketing to kids. I think there are a lot
of people around the country that are starting to question this
that have a real concern about the public health issue.
Senator Specter. One thing that you testified to somewhat
concerned me, about that Polish hot dog.
Ms. Mikkelsen. Yes. Right. It concerned me too.
Senator Specter. How did it taste?
Ms. Mikkelsen. I did not eat it.
Senator Specter. You did not eat it?
Ms. Mikkelsen. No. I did not do it, but I----
Senator Specter. They have a great event called Cannstatter
in Philadelphia once a year, the day after Labor Day. Dr.
Ornish will not like this, but I eat one of them once a year.
Dr. Ornish. Once a year is okay.
Ms. Mikkelsen. He said once in a while. And I do like
Polish hot dogs, but not in this context. I am sorry, but just
because I think this food access issue is so important and it
has been a very important part of my work--I think these models
of looking at opportunities to bring fresh food into
neighborhoods at a reasonable price are really important. And I
think it takes a dual approach. I think we need to look at
Federal policy in terms of agriculture and programs like the
Farmer's Market Nutrition Program that provide people with
resources to buy food.
But there are some really great things happening. For
example, in Oakland, there has been a pilot project that now
has been spread to three small stores that were essentially
convenience, liquor-type stores, where a person who was an
expert in produce-handling went in and helped these people get
some start-up funds to get the equipment they needed, and then
train them to buy produce. And they are now turning over $600 a
week of produce a week in low-income neighborhoods. I think
this is a model that can be replicated. I think we need to
think about can we do the same with small restaurants. You
know, there are a lot of mom-and-pop restaurants in these
neighborhoods. Can we help them become as appealing as the fast
food outlet? And it is supporting the local economy and
bringing in better products.
Senator Specter. Mr. Perelson, in your capacity as National
Marketing Director of Lifestyle Advantage, do you think this
hearing is going to help you a bit?
Mr. Perelson. I do indeed. We have had a very interesting
history, Dr. Ornish's research going back 20, 25 years. And
looking at the last 20, 25 years, and certainly over the course
of the last couple of years, the momentum certainly seems to be
moving in the direction of establishing support for people who
want to make healthier lifestyle changes. And I think hearings
such as this will enable us to move faster in that direction.
We have had a very unique opportunity over the course of the
last year. We have recently trained 10 hospitals in West
Virginia to deliver our program. And we are doing it in
partnership with Mountain State Blue Cross Blue Shield in West
Virginia and the Public Employees Insurance Agency in West
Virginia. And the opportunity is outstanding for us in the
sense that West Virginia is number one in the country in terms
of incidence of heart disease. And some things, you do not want
to be number one at, and heart disease certainly is that.
We sort of--listening to all these comments--the future for
us, as a Nation I think we spend so much time and attention on
the cost of the Nation in terms of the down side of these
diseases, that for us to focus on keeping people away from
these diseases, providing them with quality-of-life choices,
where even in neighborhoods and communities such as we are
hearing, to provide opportunities for people to make
appropriate choices.
What is a very important part of our program is that it
provides a supporting structure for people to make these
choices, that--for most of us, it is very difficult to make
changes. And we work with something called a ``Readiness for
Change'' model. In that model, about 5 percent of all of us can
make a choice today and change our lifestyle. They can buy Dr.
Ornish's book, or they can go on the Internet and make those
changes. There are about 5 percent of people who will never
ever, ever, ever make changes, and the rest of us are in two 40
percent groups--one heading towards change and one heading away
from change. Those people who are in the group moving away from
change, unless they hit some life event, a sibling comes down
with a disease, heart disease, or they test positive on the
stress test, may make the decision to move towards change. And
then there are the 40 percent who are moving towards change,
those people who have adopted an exercise program or a new diet
program and gone off of it. And what we know about that group
is that it is very difficult to make changes by yourself, and
so what we have provided in terms of Dr. Ornish's program, is a
very robust support system to help people do that.
I think that is what we are all talking about today, is
providing that support for people who want to make changes, in
our program--registered dieticians and exercise physiologists,
stress management instructors, psychologists, and a medical
director work to help people move through these lifestyle
changes.
Senator Specter. Well, thank you all very much. Let me
extend an invitation to you to let the subcommittee know if you
have more suggestions. We are very interested in your specific
suggestions that we can utilize in hearings or in our
legislation. We have bill language which is limited, but report
language is extensive, and I am going to pursue a number of
subjects, what Dr. Stern has commented about as to our 1999
recommendations. And I think we will schedule a hearing after a
little more thought on ways to motivate people to make diet
choices and to call in the experts--McDonald's, Pepsi, and the
other fast food chains, and find out what they have done, and
make an inquiry to the extent of trying to find out if they
make choices which are contrary to social policy--try to get
people to eat the wrong things, as Ms. Mikkelsen has said.
I have tried to observe the time limitation by holding this
hearing to two hours, and we are going to yield back about
three minutes on the two hours. And the final question which I
would like you all to submit in writing is, where should I go
to lunch today?
PREPARED STATEMENT
We have received the prepared statement of Senator Barbara
Boxer that will be made part of the record at this point.
[The statement follows:]
Prepared Statement of Senator Barbara Boxer
I want to welcome Senator Specter to California. Today, he will be
examining a serious health problem in our country--obesity.
Obesity is a complex chronic disease caused by many factors. It is
the second leading cause of preventable death in the United States.
Approximately 127 million adults in the United States are
overweight, 60 million obese, and 9 million severely obese. For
children, 30.3 percent are overweight and 15.5 percent are obese.
Alarmingly, these numbers are rapidly increasing every year.
I know that the results of this hearing will give all of us in
Congress important information as we work to improve the quality of
life for all Americans.
Again, I welcome Senator Specter to the great state of California
and thank him for taking time to examine this issue.
CONCLUSION OF HEARING
Senator Specter. Thank you all very much for being here.
That concludes our hearing.
[Whereupon, at 12:27 p.m., Monday, February 17, the hearing
was concluded, and the subcommittee was recessed, to reconvene
subject to the call of the Chair.]
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