Dick Merritt
Group Director,
Forum for State Health Policy Leadership
National Conference of State Legislatures
Jim Marks, MD
Assistant Surgeon General
Director,
National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention
Ladies and gentlemen, welcome. I'm on the staff of NCSL and I really want to welcome you to this 5th Spring Meeting of the Health Chairs Project. It's terrific to see some familiar faces and a few unfamiliar faces this time. I know several of your colleagues are still on their way. I had 2 or 3 calls this morning saying that some flights had been cancelled and they're making other arrangements and so you'll be joined by several others as the day progresses and of course at noon time we'll also be joined by the Assembly on Federal Issues Health Committee, which some of you are members of both. So there's a fair amount of crossover here.
We certainly recognize that each of you had at least half a dozen other options for how to spend your time over the next 2 or 3 days and we are very happy that you chose to be with us, so we certainly hope to make that decision a good one and make your time well worth the while being here. As I said, several others are still floating in.
We have really three key objectives for this meeting. The first objective really is to introduce you to some of the most senior health officials in Washington who administer federal agencies with responsibilities for regulating, administering financing or conducting research on a myriad of health care programs that are operating in your states.
The second objective is really the traditional one, which is to allow opportunities for networking to enable you to really develop or improve on the relationships and friendships that you develop through past meetings with your counterparts in other states.
The third objective is really to get you more familiar with some of the really wonderful staff resources that exist at NCSL, not just solely with the Health Chairs Project but with NCSL in general. In order to do that we're going to be introducing you through the course of the next 48 hours to some of the senior staff and getting you more familiar with some of the expertise that they have available at your beckon call.
I was going to introduce some of my colleagues but I think I'm going to wait until this evening. We're going to also postpone the traditional kind of around the table introductions until this evening because I know that there will be several more members joining us this afternoon.
I want to acknowledge of course the fine contribution of the Henry J. Kaiser Family Foundation. It is the original sponsor of the Health Chairs Project and the continued sponsor for this project. They've been with us for 5 years. We very much appreciate their support. Julie Hudman who is our project officer will be joining us tomorrow.
I'm also pleased to announce the contributions of three new organizations to the Health Chairs Project and we're joined by several individuals. We have the American Association of Retired Persons; the American Company and also the National Pharmaceutical Council and I want to recognize the individuals who are with us over the next couple of days, Eileen Henshaw and Kathy McDougal with AARP; Chuck Greslack and Terry Lee with Merck and Patricia Adams, Jean Polichek and Mary Kay Owens with the National Pharmaceutical Council. We appreciate your being here.
I also want to acknowledge the great work that Natalie Fawcett on my staff has done in getting this whole meeting together. She's really been the workhorse behind this. Natalie is outside and I hope you'll introduce yourself to her. Greg Martin on our staff also has been a major contributor.
I also want to acknowledge our partnership with Brandeis University. Most of you know John McDonnough, who is sitting over here. The Health Chairs Project is a partnership with the Schneider Institute of Health Policy at Brandeis University. John is the co-project director of the Health Chairs Project and most of you know, but those of you who don't, John is a former member of the Massachusetts House of Representatives and a former Health Chair himself and now a well-reviewed author. He's written a book about his political experience, which I'm sure he'll be happy to tell you how to order the book.
During the course of the next couple of days we're going to be asking for your help on a number of things. The next Chairs meeting will be in conjunction with the NCSL Annual Meeting which is in Denver, Colorado and we already have a date for that Chairs Meeting which will be Tuesday, July 23rd, so I hope you'll write that down, put it on your calendar, and towards the end of this meeting, day after tomorrow, we're going to be asking for your ideas about what sort of agenda items you'd like to see at that meeting.
Later this year we will have the 6th Annual NCSL Health Care Conference and we'll also be having a day of meetings with the Health Chairs at that meeting as well. That will be in New Orleans in November. The dates were just set yesterday, November 17 - 19. That's the week before Thanksgiving so please put those dates on your calendar as well. We're going to be asking for your input for agenda items as well. We'll be looking to get some feedback from you day after tomorrow in our closing session about some of the products and services we've been providing through the Chairs Project. We're going to ask you to help us update our mailing list too. I hope all of you have gotten the Health Chairs Directory. If you don't have this let me know and it's already of course out of date. I'm going to pass this around and ask you to take a look at your profiles and make sure we have the correct address, e-mail, phone numbers, etc.
Finally of course we're going to be asking you to evaluate this program. I'm going to be passing out evaluation forms tomorrow and harassing you to no end to make sure you get those evaluations in.
We have a very full agenda, today and tomorrow and Friday morning. We're going to be parading a lot of intelligent, high-powered, very experienced health officials in front of you over the next couple of days. However, we have built in to the program three generally unstructured chairs round table discussions, which we will allow you to talk about whatever is really on your mind.
So we begin our program really today with a presentation from Dr. Jim Marks from the Centers for Disease Control and Prevention. I think this is really appropriate because the CDC is really no stranger to the Health Chairs project. It was actually three years ago this Spring, that we took the Health Chairs to Atlanta and visited the CDC. How many in the room were at that meeting? At least 4 or 5 of you, good. We may want to consider, I don't know for next year or the year after, maybe revisiting CDC. Of course last November at our Annual Conference in Seattle we heard from the then director, Jeff Copeland, of CDC. He was one of our keynote speakers. So we have a pretty good relationship; we want to continue that relationship which is why we invited Dr. Marks to be with us and to really kick this off.
Dr. Jim Marks serves as an Assistant Surgeon General and is the Director of the National Center for Chronic Disease Prevention and Health Promotion at the Centers for Disease Control and Prevention. I think for purposes of our meeting it is important to know that he's held numerous positions as CDC but he's also served within two separate state health departments; I believe in Connecticut and Ohio. Jim; thanks for being with us.
I'm really pleased to be here. It is a great opportunity for us at CDC to address a group such as your self. I was not there three years ago to address you but I'm looking forward to the time today. As you heard, I'm Director of the National Center for Chronic Disease Prevention and Health Promotion and that's probably among the lesser-known parts of CDC. CDC is most known for its work in infectious disease and most recently in the area of bio-terrorism and most of the public recognizes the work we do in investigation of epidemics and concerns about that. We work very closely with the state health agencies in that area, but as you'll hear also, in the area of chronic disease prevention and health promotion and that's really what I'm going to talk about and try to paint the picture for you about those diseases and the implications that they have for the future of our country, our health care system, but society as a whole as well.
So my job is to tell you about them and to run you through those fairly quickly; the leading chronic diseases, their principal risk factors, what can be done and what we need to do as a society and then the implications of those diseases for cost in the future, current in the future and the additional impact that an aging population will have.
This is the slide that you need to remember. I'll quiz you on it at the end when we come back to it. In the mid 1990's, there was a report in the San Francisco paper that said when Elvis died there were 37 Elvis impersonators at that time. By 1993 there were 48, 000; this is not a statistic that we keep close track of so I don't have a more up to date number, but there was an expediential growth that projected by 2010 there would be 2.5 billion Elvis impersonators in the world. Now my wife is a guidance counselor and helps people decide about career paths and things like that but she doesn't recommend this even though it looks like there's a real growth phase going on.
For those of you who don't know, by 2010, the world population is expected to be about 7.5 billion; so about two people in the audience for every Elvis impersonator. Pretty big cover charge would be necessary for that. I want to come back to this; it was for me a humorous thing to see in the paper but I will come back to it and say how our current social policies in fact look disturbingly similar.
Now I'm going to treat you like a public health professionals group and I'm going to give you a lot of data but I'm going to try to tell you a story with that data. First of all on the left are the most common causes of death as well understood. The top one is cardiovascular disease, which breaks out largely into heart disease and stroke. If you separate them out as heart disease and stroke, heart disease is No 1; stroke, No. 3. The second leading cause is cancer, followed by chronic pulmonary disease, injuries, pneumonia, diabetes, further down, etc. The reason that I wanted to point these out to you and have this slide is that those two conditions right there are 2/3 of all the deaths in this country. So if we're not working on those conditions, we're only working on the margins of the health problems we have as a society.
In the analysis that this was drawn from, the authors, said what are the causes of those diseases, or the preventable causes and they went through these risk factors. Tobacco turned out to be No. 1; poor diet, lack of exercise, No. 2. So that tobacco causes heart disease in many people; it causes cancer in many people; it causes chronic lung disease. So if you say what can we modify, how can we prevent the onset of these diseases. Again, if you're not focusing on tobacco, poor diet and lack of exercise, we're only working at the margins. We have to work on those. As you started to hear, there's a lot of concern about the issues of obesity among youth and adults and there's been a lot of concern in the past few years about tobacco and I'll address those a little bit more.
I will talk about heart disease and stroke, cancer, a little bit about diabetes and then tobacco, poor diet and lack of exercise. So I'm going to concentrate my remarks in those areas. Again, exercise if you don't know, has been associated, increased exercise with reductions in certain types of cancers, as well as heart disease and diabetes and we'll talk about those. It is going to be a little quick but I think you'll find it informative.
Another hot area for health in the past few years has been that of disparities. Where is the source of disparity, principally formed as minority v majority populations but the same with rich v poor. This is the number of years difference in life expectancy between Blacks and Whites by cause of death in the United States. No. 1, source of disparity is heart disease, excess risk of heart disease among African Americans v White. No. 2, cancer; No. 3, homicide, especially among men, the orange bar; and No. 4, stroke. Again if you're concerned about the issue of disparity, disparities in Blacks v Whites, disparities of rich v poor, we have to be working on the areas of cardiovascular disease and cancer very, very heavily.
I want to concentrate now on heart disease quite specifically. What we have here is a graph that takes the increase, this is coronary heart disease in the 1940's and '50's, projects it forward with the top dotted line being what would have happened had there been no change. And we see a rate there that when age adjusted it was about 300 per 100,000 people. The peak was about 225 and where we actually are in the 1990's and I'll get some slides that are a little bit further out from that is a rate of about 100. We're at a rate that's about 1/3 of where we would have been had things not improved. We'll talk about a little bit of the sources of that improvement.
This is one of the public health's successes of the last half of the last century. But make no mistake, with an aging population the number of deaths from coronary heart disease is about the same as it was in the 1960's at the time of the peak. We have just barely kept up with all of the advances. We've not materially lowered the total number of deaths.
If you don't know, heart disease is the leading cause of death for men and for women; many women think it's breast cancer. It is the leading cause of death in every state. It is the leading cause of death in every racial and ethnic minority group in the country. So it is so overwhelmingly No. 1 that there's just no group for whom it's not No. 1, despite that rate decline.
When you look at it by Black v White we see that in fact the disparity has come fairly recently. It didn't exist to the extent that we see it now. Probably reflecting the advances we've had in prevention and treatment that have gotten preferentially more quickly and more effectively to White's than African Americans. This is men; same graph would hold for women, same graph would hold for Hispanics. There were not nearly as good data on Hispanic populations in the early part of these years. So that what we've seen is that while both groups have improved, the rate of improvement has been faster among Whites than Blacks and that means that the relative disparity has grown.
When you look at it by age, this is stroke, by racial and ethnic minority groups and by age, with the orange column being 35 to 44 years, the blue column being 45 to 54, we see that most of the disparity is shifted towards the younger ages. So it's not just that there is a disparity among minority populations and African American populations and American Indians, Hispanics, etc., but it has shifted toward the younger years so that the excess is occurring among people who have young children, or working, or just trying to prepare their families for retirement. The disparity is not at the oldest ages.
If you look at it geographically we see that, this is total cardiovascular, so heart disease and stroke, it's concentrated heavily in the Southeast; that's where the rates are the highest. They've been the highest there for a long time, probably reflecting some things like elevated rates of high blood pressure, high cholesterol and higher rates of tobacco use. Again, even those for whom the rates are the lowest it's still the No. 1 cause of death in those states. So if you're from Utah or Idaho or Colorado, it's still No. 1 in your state.
One of the things we did was we said how much of a difference between the states is due to the factors that can be modified. So we took here, for men and for women, each dot represents a state, and we took their coronary heart disease mortality, under age 75, so premature mortality, and said how much of this could be explained by the proportion of the population that smoke, that have high blood pressure that's uncontrolled, that have high cholesterol, that don't exercise and are overweight, things like that. When you take and you put all of that together about 2/3 of the difference between the states, and the highest states have rates of about twice as high as the low states, about 2/3 of the difference are due to these modifiable risk factors. What does that mean? It means it's not how fast our ambulances are. For many people the first symptom they have of heart disease is when they keel over and die. It's not how good our coronary care units are. It's not how skilled our surgeons are. 2/3 of the difference are due to the risk factors that we have as a population and how we can lower those rates for premature is by changing our prevalence of those risk factors.
I'm going to move on to cancer. Cancer is probably the most feared of the chronic diseases. Here you see the lifetime risk of being diagnosed with cancer; 35% - 40% all sites; women in yellow, men in orange and you see here the leading cause is prostate for men, breast and lung and we'll talk about some others. When you look at what's happened with cancer, this is in men; three cancers, just three cancers are about 60% of all the cancer deaths. Lung cancer, we've seen some declines in lung cancer, an average decline of about 2% per year in mortality. That's actually largely due to declines in the numbers of cases of lung cancer, due to the declines and tobacco use that occurred in the '60's and early '70's. Prostate cancer; dropping even more quickly in the '90's and colorectal cancer, also around 2%. Those are the top three cancers in men.
In women, top three cancers are lung again, breast and colorectal and here the striking difference is we've seen a decline in mortality in breast cancer, probably reflecting both the increases in mammography use and then having effective treatment once a cancer is detected early. Colorectal for both, there are issues of improved cancer therapy but also some modest increases in screening and we'll get back to that. Lung cancer in women continues to increase and I'll show you a little bit more about that. Women did not have the same decline in smoking rates. Their rate of overall tobacco use was not as high as men in the 1960's but they also did not decline and so now the rates are almost the same in men and women. Men came down quickly and then they gradually came down a little bit but that's leveled off, as we'll describe.
Here's how it looks graphically for women. Breast cancer has been a fairly level age adjusted death rates. Lung cancer: nothing short of an epidemic. You find the same curve in men actually higher for lung cancer but theirs has started to turn down. We don't see that yet in women. Most women don't realize that there are more deaths from lung cancer than breast cancer. Most in the public don't realize that. Because only about 1 in 4 women smoke, the public doesn't realize that "if" a woman smokes, her chance of dying of lung cancer is 4 times that than her risk of dying of breast cancer, because all of the female population is at risk of breast cancer. Only those who smoke are really at risk of lung cancer. There was a Surgeon General's report on tobacco use in women that came out about a year ago that emphasized this point.
Mammography use, I commented on that. One of the things that CDC supports in your states is a program to pay for breast cancer and cervical cancer screening for women who have no form of health insurance; that is they're not on Medicaid, they not on Medicare, they don't have private health insurance. One of the things that we've been very pleased to see is the increase in mammography use. Here, light yellow, is under 60%, the dark blue is over 80%. You can see over the decade we've shifted from many, most states probably in the light yellow to none in light yellow by the end of the 1990's. There's been a huge shift in the rate of mammography. This is for women 50 and older because that was where the recommendations were consistent for that whole decade and asking if it was the past two years because as many of you recall Medicare only paid for screening for the two years and so we could ask the same question for all women.
We have maps like this that are for women of low income and you also see big changes in the prevalence of screening for women. That's one of the things your state health department's do is that they administer that program and see that women get screened. It has been really one of the successes of the last decade and as I showed you earlier, we've seen the declines in breast cancer mortality.
This is Michigan. One of the other things we support in all the states that don't have a registry supported by NIH; so that's 45 states, is a statewide cancer registry. This is for Michigan where they looked at the stage that breast cancer was diagnosed. You can't get that from death certificates alone. You only get it from a registry. And before we see a decline in mortality we ought to see that more cancer is diagnosed early. So that's one of the things they looked at. This is breast cancer, 1985 - 1987, the stage diagnosed, dark red is 56% and over and this is by the mid to late 1990's. A huge shift from very few in the dark red where 56% of the cases were diagnosed early to almost every place where we've seen that shift. So again evidence that our public health programs of supporting, educating the public, educating the providers and supporting the screening has led to a major shift. That suggests to me that we will see even greater declines in mortality in the future years because before we see the decline in mortality, we've got to see the cancers diagnosed at a stage when they are able to be cured.
They also looked at another cancer. Colorectal cancer is the No. 2 cancer in the nation; No. 3 for men, No. 3 for women, but when combined No. 2 in the nation. The science on colorectal cancer screening was pretty good by the mid 1980's. It really came out for mammography in the late 1970's but it was in the early to mid '80's that it came out in colorectal cancer. Here we see 1985 - 1987, again just a few counties that have 56% and over of the percentage of cases being diagnosed early.
By the mid 1990's, almost no change. What does that tell you? Certainly there might be a little squeamishness about discussing colorectal cancer screening but there's been no systematic effort to educate the public, to educate providers on how important this is to make sure that they know people need to be screened and we see that without that it comes very, very gradually. One of the things we have to recognize as a society is that if we do the science but we don't get it out, we may as well not have done it. The advantage of the science is when it's applied. We in public health have to have a science behind what we recommend or we're wasting our time. If science progresses, but it doesn't get out, they're wasting their time; we're joined at the hip. One of the things, we in public health and you in the states have as your role, is helping to get that out and getting it applied. This is one of the best examples. We know in mammography, as I said the recommendations came out in the late 1970's, we're now approaching roughly overall nationwide 70% of women getting screened with some regularity. That means many, many thousands of women died of breast cancer after the science was done and it's happening right now in colorectal cancer.
Colorectal cancer screening is actually more effective in preventing the death than mammography. Mammography can prevent about 1/3 of the deaths when the cancer is found early. Colorectal cancer, the estimates are 50% of the deaths can be prevented if people are screened. That's not happening in this country. Michigan is not a-typical. This is actually fairly typical.
I'm going to talk a little bit about tobacco. If you've been in your health committees for a while you've heard a lot about tobacco. I'm not going to spend a lot of time on it but I just want to remind you why we spend so much time in public health about it. These are deaths from smoking, deaths from suicide, illicit drugs, homicide, fires, motor vehicles, alcohol, AIDS. If you were to look at these statistics and say where can we have the most bang for the buck, you'd have to say we have to deal with tobacco and that's why we in public health see that as so critically important.
What's happened with tobacco? I'm not going to talk about how you use your money but I could if you like. In the 1990's when all of the concerns grew we saw in youth and most people who start smoking start smoking by age 18 or earlier; an increase from 27% among high school students to 36% smoking. That 1/3 increase translates if they quit at the same rate that people before have quit that about a million more deaths than would have been the case before. About 1/3 of people who start smoking regularly, die from tobacco related illness. That takes into account the fact that many people quit before they're ill. If they don't quit before they're ill, about half the people who stay smokers, will die from tobacco; a huge number. It's about 15% of all the deaths in this country and we were seeing an epidemic in use among kids. That's what led to the furor. We had seen a decline in kids through the early '80's, a leveling off and then this increase in the 1990's.
A lot of concern about Joe Camel, cartoon character being used to advertise cigarettes; Camel cigarettes, that started in the late 1980's, '87, '88. Camel cigarettes were not in the top 10 brands that kids used. It was No. 1 with a bullet by 1993 actually. It was far and away several times the second brand.
You could see there by the way that we're starting to see a decline from the state tobacco control programs, the ads, the efforts in schools. This is a study from Oregon. CDC had put out guidelines on how schools should approach tobacco education. There are a number of studies saying that if you do good, school health education, you can lower the rate of use, the rate of initiation especially in middle schools. They found that the schools that were most faithful to the approach that was recommended in using the type of curricula that had the best science had the biggest declines; those that did it less so, had lower; those that did it least had very little decline from their non-funded schools. Schools had to apply to get state funds in Oregon to do this.
How effective are the public health programs. The Institute of Medicine did a review and said that they clearly are effective. California was the first state to devote a lot of money to tobacco control. They found that their adult use rate declined at twice the U.S. rate and youth smoking was down 43% from 1995 and that's when their program had already been in existence for a while. California is the only state to see a decline in lung cancer deaths among women. We actually did not think we'd see it as quickly as we did. They had seen it after about 10 years of their programs. They think they've had 30,000 fewer deaths from heart disease. They think they've saved $8 billion in health care costs over the life of this program. Huge.
Arizona, one of the states to begin to do it. Adult smoking declined 21% across the board; men, women, young adults, Hispanic population, one that they are very concerned about.
This is from Florida. Florida had a very aggressive media campaign aimed at youth. They had kids involved in helping to frame the ad spots. They're reacting to the ones that were put together saying the ones that they liked the best. They had a 40% decline in initiation of cigarette use by their middle school age kids and an 18% decline among high school age kids.
Nearly every state that devoted substantial resources to tobacco for a sustained period of time had large declines in tobacco use among their youth. If they targeted their campaigns to include cessation by adults they solved that as well. Only a few have had programs long enough to be able to replicate what California has seen in the declines in mortality from cancer and heart disease. But make no mistake; we have a long way to go in that area. Make also no mistake; one of the most effective ways is price. No question that among the poor and among youth they are the most price sensitive. So when price goes up their use drops.
This is from Newsweek, "Fat for Life". It's about the issue of obesity in this country and I'm going to talk about that as a key risk factor because it's one where most state health departments are very, very weak. Most of the work that they do in nutrition is related to WIC, a nutrition supplementation for pregnant women and young infants. Most states do not have any program aimed at nutrition among adolescents or among adults.
I'm going to take you through this quickly. Every state now, in 1985 it wasn't every state, has a telephone survey that we support at CDC called the Behavioral Risk Factor Surveillance System, BRFSS there. People are asked how much do they weigh and how tall are they. Taking that bit of information we calculate whether they are overweight; in this instance we're saying whether they have a BMI greater than 30; body mass index. Roughly for an average height person that means being overweight by 30 pounds or more.
At the bottom we've got light blue, is 10%. Less than 10% of the adult population; darker blue, 10% - 14%; you'll see some real dark blue, 15% - 19%; you'll see some states that are red, meaning greater than 20% of the adult population that says that they are more than 30 pounds overweight. A couple of things to remind you of. Most people when they're asked how tall they are say they're a little bit taller than they really are. Most people when asked how much they weigh, they say they weigh a little less than they really do. So these are conservative estimates but you'll see the change.
That's 1985, '86, '87, '88, '89, '90, '91, '92, '93, '94, '95, '96, '97, '98, '99, 2000; a couple of things to comment about that. Other than lung cancer this is probably the most striking epidemic we've seen in the chronic disease area. It is not due to genetics. The human genome did not change in the last 20 years. It is all due to things in our environment. It's not due to the fact that 20 years ago the pharmaceutical companies took all of the drugs off the market to help people lose weight. In fact, the first effective drugs have come on the market since this. It's not due to the fact that everybody said I think I'm going to have seconds on dessert. In fact when you look at purchasing trends, the fastest growing rate of purchasing from super markets is the Lean Cuisine, Healthy Choice, the low fat, low calorie foods. People are trying. We actually do see that they're having an impact because their average cholesterol has declined, but they haven't been able to keep up.
What are the kinds of things that have caused this? We know that rats, fed their regular food as much as they want, don't gain weight. Rats, fed from a buffet as much as they want, all gain weight. We have 12,000 new food products a year introduced in this country. We've systematically engineered activity out of our lives, even sort of routine light activity. I don't know about you; I e-mail people in the office next door to me. I used to walk over and talk to them. Little things add up and it isn't a lot. This is not a lot of extra calories a day, but it is extra calories over what we use gradually accumulating.
This is a 50% increase in the rates of obesity in the country since 1985 and it is due to things in our society that have brought about an imbalance between what we eat and how active we are.
This is in children. We don't have state-specific data in children. We have no data systems that track this. We have here in the blue column, the first survey, nationwide, done in the 1960's. The next one, the green column is the early 1970's; the orange column in the late 1970's; the yellow column in the 1980's and early '90's. This is a faster increase in obesity than we saw in the adults. This is a doubling in kids. Boys and girls, young and in teens and it has occurred largely since the middle 1980's; fairly stable through the '60's and '70's and then since then increasing. It is now faster as I said than in adults. If you don't know, the military has changed its weight standards for admitting people into basic training and their weight and fitness standards for letting people graduate to stay in the military in order that they can get enough people.
What are some of the things that contribute there? Same things: relative inactivity and relative eating. This is how it relates to hours of TV per day, the last survey, 1990. The more hours you watch the greater the likelihood that you are as a youth, obese.
A couple of things to point out here. These are number of hours, as you go across the graph, so that the more hours the more likely to be obese. The white v maroon is over time. So that people with the same number of hours more recently are more obese than people with that number of hours before. So as a society we're more overweight than we were, our youth are and TV watching contributes some of that excess or is related to some of that excess. Make no mistake, this does not count video games; it does not count computers or any Internet.
I trained as a pediatrician in the 1970's. I never saw a case of adult type diabetes in a child. The first reported case was 1979. Now about 1/3 of the cases of diabetes in children are what used to be called adult type. I was out in the San Francisco area; the Oakland Children's Hospital saw its first case in 1989. They get 2 to 5 cases of adult type diabetes in a week now in children.
Same things; if you're an adult over 40, overweight or under active with the risk factors. In kids it's the same thing for adult type diabetes, under active and overweight. Far fewer kids where sports teams are better but fewer kids are active.
We now estimate, this is a study done, it was published, there have been two different studies; about $100 billion of health care costs and lost productivity are due to obesity in our society. This is based on data from the middle 1990's; it's undoubtedly higher. We just published a paper showing that there are increasing costs in children from obesity.
Like night follows day, diabetes follow obesity, and in the 1990's we saw a 50% increase in the rate of diabetes in adults; the second epidemic but related to the first. It went up faster among people in their 30's. It used to be uncommon in people in their 30's. It went up 70% in people in their 30's. 20% of people over 65 have diabetes now. If you went to the maps, you would see the same kind of shifting to red for diabetes in the population as a whole. Can you do things about it? I'll talk a little bit about that. But make no mistake, what does diabetes do? Because of the on the circulation, it leads to blindness. It's the leading cause of blindness among adults. It is the leading cause of kidney failure and everybody that gets kidney failure has to go on social security and Medicaid to pay for those costs of dialysis and transplants.
It's the leading cause of amputations because of the loss of circulation in the feet. Can you do something about that? The science is very, very good. If you can maintain good glucose control as a person with diabetes you can delay those complications and lower the rates by about 1/3. Can public health contribute to that? In fact we've got very, very good data on that. In Michigan, in New York, they set up networks to remind people with diabetes and their primary care providers to check the feet to make sure that they come in with some regularity and check their blood sugar, get their screenings. In New York, it took only 2 years; they found a 25% reduction in amputations and a similar reduction in hospitalizations. Michigan first did it in the Upper Peninsula, the most rural area where they thought there were real problems with access to care. They found similar reductions. It took a little longer to organize there. Their state legislature was so impressed, that was CDC grant funds, they provided money so that the state could set up networks around the state to do that kind of organization. I saw them and heard some of the data from the Southern Michigan group where they found very large increases. They haven't' yet seen the decreases in amputations and hospitalizations; it's too early. But they've seen big declines in the levels of blood sugar and big increases in the numbers of people getting their eyes checked and their feet check and things like that. We're seeing that elsewhere.
Minnesota, we funded four states with a larger grant, meaning about $800,000. Minnesota chose to work with their largest managed care organization to look at quality of care. These are people who all had the same access to care. Again, big shifts in the preventive services there. They were so impressed that that managed care organization has moved it to all of the clinics, not just the study clinics, and they're seeing declines. Declines in blood sugar that are as good as the randomized trials that proved you could lower the complication rates but those trials were conducted in the best universities. Could you do it in the public at large is a question we're always asked when there's good research and in fact they've done it there. I've seen the same thing in North Carolina, in the Raleigh/Durham area. There are more and more sites. Utah has had some good findings as well.
Providing the glue to the system. The reminders to the patients; the reminders to the physicians; the tracking; the making sure that axis points are there because most of the physicians can't do that kind of eye screening that they know where to send people. You can in fact dramatically lower the complication rates and the costs of those complications.
Last summer an important study was released. This was a study of could you prevent the onset of diabetes. There are about 16 million - 17 million people with diabetes in this country and there are another 16 million - 17 million people who have elevated blood sugar but not yet high enough to be called diabetes. They're at great risk of moving onto diabetes. Compare glucose tolerance for pre-diabetes. In this study, people were given a medication to see if they could prevent that onset and some were given intensive counseling about their diet and to help them lose weight and to exercise. They had to stop the study early. The diet and physical activity where they got counseling and they got reminders and they could call into a nurse, kept 60% of people from moving on to diabetes. It was twice as effective as the drug.
The drug kept 30% of people from going on. The diet and exercise was the only thing that worked for people over 60. The diet and exercise was the only thing that had some people convert back to normal. In our health care system currently, if you have health insurance, almost all of you would have that drug paid for. If you have health insurance, no matter how good it is none of you would have the counseling on diet and exercise.
How drastic were the lifestyle changes? People who had that 60% reduction lost 10 to 15 lbs. They walked 30 minutes a day, 5 or more days a week; moderate lifestyle changes. This is the first study in the U.S. but it's the third in the world. There's one been done in China; one been done in Finland and had roughly the same results.
We have a tremendous amount we can do to prevent the onset and the costs and the suffering from these illnesses but we're not there yet as a society in this health system we currently support. We think of our support as needing to be a medical care, illness care system, and not the prevention of disease.
We started to support some other programs for youth. This is called Kids Walk to School. It's on our website; we've materials on it. It grows out of an example that was started in Europe called the Walking School Bus. A parent in the neighborhood, two parents usually, one in front and one in back, go along the neighborhood and pick up the kids that need to go on to the elementary school and they all walk together and the parents rotate who does it, whether it's a week at a time or things like that. So, there's a walk to school. Right now about 2/3 of kids in elementary school who live within a mile of their school are driven.
Walking trails. We know that people who exercise do better health wise. One of the things that they often talk about is where could I do it. Is it easy to do? How difficult is it? In this study that we supported in Missouri, rural Missouri, we supported community coalitions who took on the issue of getting more walking trails in their community. We supported surveys of the people in the community and counters to see how many people use the trails. What we found was that people who were already exercising, did it more, use the trails; people that weren't started to do it, especially women and poor minority women. The increases were highest among them. This is in the poorest area of the state, poorest rural area of the state, and they were able to do this. It's something that may not be under your jurisdiction in health, but make no mistake, these kinds of things are important to health.
Building design. This is the stairwell in one of our buildings that we rent in Atlanta. It was sort of dark and fairly stark. We gradually added at each step a little bit more plush colorful carpeting, painted the walls, added photos at each landing; at the top landing we actually had drawings from the children of the people who work there and most recently they've added music to the stairwell. We put counters on the doors, put little signs near the elevators "no waiting, one door over", that sort of thing. Every thing we did, each thing, added a little bit to the number of trips, now I can't say that they go from the first floor to the fifth floor, only that the number of trips went up. Music being the last we added was also the most effective.
The office complex that CDC rents from, the original, the oldest building in there, built in the early 1960's, have wide stairwells that open into the lobby and you have to go around the corner to find the elevator that is there for people who are troubled with the stairs. More recent buildings have wide stairwells off to the side with a fire door, but they're there, they're visible from the elevator. The newest building we're in, you cannot see the stairwell when you come in the main entrance. You have to squeeze by the guard stand and it's in the back and it's even narrower and darker than the one that I just showed you. I think that we're evolving to a rope ladder as our next version of the stairwell in building design.
We know if you go to Las Vegas, you know, that they know how they design their buildings affects human behavior. They know if you go there for a meeting, you have to walk by the gaming area to get to the conference rooms. If you're in the conference room you can't see outside so you don't know night from day. Every time anybody wins the bells and whistles go off and it's a big to do. They give you alcohol for free so that you'll gamble more. The slot machines near the aisles pay off more, on and on. The one that I was in most recently, they also had a thing where you could use your credit card and get casino cash, things that weren't really money. So they separate you from your money before they separate you from your money. They know that how they design the atmosphere, the buildings, affects human behavior. Same thing for being active or inactive: same thing for communities. Are there sidewalks, can you walk and get to somewhere. We have a lot more cul-de-sac type communities that are nice in some ways but a person going out to go to a store can't get there; they have to go very far. We've centralized our stores a much greater distance from our neighborhoods than we used to than the neighborhoods that have the crisscross streets where you could in fact get to the stores. How we do that; we have to work with the smart growth groups. But make no mistake; those things affect our health. Their changes were not there to help us get fat or inactive, but they have that impact and we have to recognize that and work with them so that they can recognize that there are things that they can do that can help us be active again.
In the Atlanta area, the newer subdivisions are in fact putting in walking trails and things like that that are selling points to make them seem more attractive and I think there's a lot that can be done in that regard.
So we talk about from the community based approaches the public education around it, actual programs some churches are setting up walking groups, there's the issues of transport policy, as well as the environmental changes like trails, recreational facilities, neighborhood safety, that sometimes is a problem for communities, etc.
Let's talk now about the issue of an aging population. You've all probably seen headlines like this in your papers or in the national papers "Social Security, Medicare System Facing Crisis as Baby Boomers Grow Old". Baby boomers were born in 1946 to 1964, after WWII. About twice as many per year as had been the births before that time period. This is the proportion of the population over age 65. Baby boomers in 2011 start to turn 65 and this is what happens to the proportion of the population. It is essence doubles. All of the debate all of the struggle that we've had as a society on health care costs have occurred in the relative flat part of that curve. Think what it's going to be like a decade from now.
This is the cost per capita by age. The average baby boomer born in 1955 is in this area, here's 65; a person at that age, a 65 year old costs about four times what a 40 year old does in health care costs. The proportion of the people that are that age and that costly are going to double.
How important is this? This is a complex slide of men, age 50. What's the likelihood that they'll make it to 65 free of heart disease or stroke or diabetes; whether they smoked; whether they maintain their weight and whether they were active; three things that we've had as the whole basis for this discussion as far as risk. If you were never a smoker and you're active and you've maintained your weight, you have an 89% chance of making it to 65 without one of those conditions.
If you're a current smoker, inactive and overweight, 30 or more lbs roughly, you've got a 42% chance of making it to 65 without those conditions. Ratios are roughly the same for women; a little lower overall because they tend to be a little bit healthier early on and then catch up as they get a little bit older. Another way of looking at this; what's the likelihood that you'll have one of those conditions; a non-smoker, normal weight, active, 11%; smoker, heavy, inactive, 58% that you'll have one of those conditions by age 65; a 5.5 fold difference, 500% difference. It's not whether you took a specific drug or not; it is those behaviors and whether we're able to sustain them over time.
If it were a drug that had a 500% reduction in disease rates, everybody would want them. We have those. I want to make sure that you're aware of this. It's not just every person for themselves, that it's pure personal responsibility. There is a personal aspect to it but how we frame our buildings, our society, our structures, our policies, influence the likelihood of success for individuals who are trying to do the right thing.
This is a study from the University of Pennsylvania graduates. They graduated in 1939 and 1940. It followed them to age 75. Did they smoke? Were they inactive? Did they maintain their weight? They structured it by whether they were at low risk, meaning they did well in those areas and by whether they were at high risk in those areas, the amount they smoked, how active they were, etc. And they said to them, at what age did you first start to have trouble with your activities of daily living; bathing one's self, doing errands, dressing one's self, things like that. For those who were at low risk, that is in good health habits, occurred in their mid 70's. For those at high risk where their health habits were not as good, it occurred in their mid 60's, a 7 - 10 year difference. It's not that they needed a nursing home; it was just that they were starting to have trouble on average. A 7 - 10 year delay on those habits alone.
This is nursing home cost; a big expense in every state budget; nursing home $100 billion a year. Medicaid, is that orange, the start part. This is nursing home plus assisted home care on the side closest to me, $150 billion. It's among the fastest growing parts of state budgets. As you all know, people have to spend down and then they have to go on Medicaid for nursing home care. If that University of Pennsylvania study projects out for need for assisted care at home, or nursing home care, and you could delay that need by 7 - 10 years, huge, huge value for state budgets. We've often thought of the costs of health care in aging as being largely a federal response because of Medicare, and it is, but you all are having to grapple with the cost of long term care.
Remember the Elvis slide. There were two people in the audience for every Elvis impersonator. This is the projection from the Social Security's Trustee report on the number of workers who are helping to support people on Social Security and Medicare. By 2030 when the last of the baby boomers hits 65, they'll be two workers paying for those Medicare and Social Security costs. That's going to be a heck of a cover charge. That's why you need to remember that Elvis slide.
We have a social policy that is predicated on this and it's predicated that people will be able to retire. We're going to have to have major changes in our social institutions unless we can find a way to handle the health care costs and what I'm submitting to you in this is that there is tremendous, unmet potential in our ability to delay these health care costs substantially. People will get old at the same rate but they don't have to get ill at the same rate and we have not had that. We've had as our policy arms how much we pay for long term care; how much we support having people stay at home; but we've had very little effort on whether we can delay substantially the need for those sorts of care.
One of the things in CDC, the center that I head, is a fairly new center. Most public health departments did not have a tobacco control program in 1990. Most did not have a cancer control program in 1990. Most did not have a cardiovascular disease program. Most still do not have a program aimed at prevention of obesity and encouragement of physical activity among adults and youth. We have to increase that level of effort as a society.
This is a survey done in November, December of 2001, after September 11th. It said Americans views are the most important health problems. No. 1, cancer; No. 2, heart disease, HIV, diabetes, obesity, smoking. Health problems from terrorist attacks are at the bottom for the most important. Most urgent, it flips around and I think that they have it quite right on this, that there is a real urgency around bio-terrorism but then health care costs, cancer, heart disease, smoking, they have as we would expect a pretty good handle on what are the issues. But we can't just deal with what's the most urgent; we have to deal also with the very, very unimportant. And remember, this was just in November.
What do we think state public health programs need? They need to address the leading causes of death and disability. I've talked very little about arthritis but arthritis is the leading cause of disability among adults, principally arthritis of the knee and the hip but sometimes of the hands as well.
The principal risk factors, we've talked about those and we have to target priority populations. I've only talked a little bit about the youth but certainly the aging and in the settings if we can reach them in communities, schools, worksites, and in health care settings. Make no mistake, there's a lot more that can be done in health care settings and one of the things we need to make sure is that the quality of care that we provide is good.
Many of you may be aware that there is an interest among the governors to start to do comprehensive cancer plans. Several governors that I'm aware of are looking at that or updating cancer plans that they have. I think this is starting to catch on in the states, these issues.
I'm happy to take questions. We won't always get everybody convinced. This is a photo of a person taking his dog for a walk, a canine constitutional. The right idea for the dog and maybe could convert it for themselves. Thank you very much.
QUESTION: One of the things that really has disturbed me lately in this whole issue is more and more we're seeing movies both on TV and in theatres where they are constantly smoking cigarettes, one after another. This seems to be an increasing trend and what are we going to do about it because I think that's another example of getting kids as well as adults to get them smoking.
There was clearly an effort to pay for the use of cigarette ads in the movies in the '80's and early '90's. That supposedly has stopped but it is still widely used among the characters and when you look at, and there have been some studies of this, characters, the prominent characters are more likely to smoke than the population is at large. There's been a recent study that we're starting to see it more among television characters than we used to as well, not just in the movies. So you're absolutely right. As you would expect any discussions with the industry and we've had some discussions as have other groups like the Cancer Society and others, they see it as both artistic freedom but also freedom of speech issues and they see it as issues of; you know it's a prop for certain types of contemplation or discussions. But you're absolutely right that it's more prominent than we would expect.
QUESTION: We meet every other year and we use 10% of our tobacco money for tobacco. That's not a lot but that we have 10%. As a supporter of public health we've put all of that money out to the public health units if they've partnered with the school systems or with the communities to do a community based program. Now with the new dollar for dollar hard match that the CDC is requiring you're causing us some real problems, because we thought we could keep the CDC dollars that we get for tobacco and use it the way we always did and the tobacco settlement would just go out to the public. Is there going to be any changes on that? We're going to have to redo our whole tobacco organization if that doesn't change.
I don't know the specifics of your state but let me comment on that. There age a couple of things. First of all, your comment about the proportion of your tobacco settlement dollars, CDC had taken the data from California, Massachusetts and smaller studies and said what are the elements and how much will they need to cost for an average state to have a tobacco control program of that level of effectiveness. We then made estimates for each of the states as to what that would be. That generally turns out to be about 10% - 20% of the total tobacco settlement dollars, so that people have that as a context. The question of we, at CDC, also has direct grants to states that are to support tobacco control efforts. Those grants average about $1,000,000 a year. We are regularly asked by Congress, if this is so important are the states putting in their own money and if they see it as important or is it just a federal initiative and so we are asked in many of our programs that we ask the states to match. In fact for us they say why do we even need the federal dollars because the states have all of this money now and as you know, there are many other uses for that and those dollars are not necessarily targeted for tobacco unless you and the legislature decide or the governor decides that they are such. So it was in that context that we were urged to have a match. Now your description as I heard it and it sounds like you're using a lot of that money to give out directly to locals for tobacco work [all of it] as opposed to what's at the state health department level who might then themselves give it out to locals, whereas we would readily, except that monies that went to the state health department who then granted to the locals money for tobacco, that's considered I'm pretty sure matching monies. I don't know if I'm getting your context right if money is directly appropriated to the locals for tobacco work that never passed through the health department would count and I guess that that's really sort of the crux of your question.
QUESTION: As long as it's going for that, does it have to go through the state health department? That's a real strong issue in our state.
I'll have to check on whether we have flexibility in that, but I appreciate that question because it's not a specific example that I had thought of.
QUESTION: From the statistics that you had regarding coronary heart disease and then you related it to as sort of the last slide talked about exercise and diet. On the other hand it seems like there is a counter movement, which says gee, an easier way is to pop a pill. I mean does that play at all in this. I mean obviously it's pretty popular and it's a large expenditure as the public seems to be, on my question about the expenditure, but how about the effectiveness? What about the other side of this, popping pills?
There's no pill that does the same thing as exercise or maintaining one's weight. There are pills that can lower blood pressure if it's high; can lower cholesterol if it's high; aspirin can be used to prevent clotting off of the arteries and so those pills do lower risk for those that are at high risk. The issues of are they as effective; they're costly and they're not as we believe as effective long run. Nobody has those kinds of long term data. And they do have side effects; many of them have side effects. There are some side effects with exercising, usually it's changing clothes size and sometimes injuries of course. But there's no evidence that the pills duplicate that and there are many people who exercise well and maintain their diet but still also develop high blood pressure or high cholesterol and need to take those. The data is very, very clear on exercise though for a whole array of conditions. There is no pill that prevents cancer like exercise and good diet. The estimates are that about 1/3 of cancer is caused by tobacco; about 1/4 to a 1/3 caused by dietary factors and physical activity is probably part of that. So maintaining weight and so there's nothing like those. Those are additive or helpful as you get older, sorry.
QUESTION: One of the questions I have particularly for the states because we're all, at least most of us, are in budget shortfalls. None of the statistics that were up there were based on where that population was economically, particularly as you start getting into the older populations, you see a lot of older people of moderate incomes that are exercising, that are moving to places where there is more activity. It seems to me if it were more targeted to economic status and rate of disease that we'd be able to target our funds better on the prevention side.
That's a very good question. I didn't show much that was related to socio-economic status or surrogate measure of education. But for almost all of these conditions, hose that are poorly educated or lower socioeconomic status have higher rates of these diseases. They have it in cancer overall, or if they don't have higher rates of cancer, they have poor survival when they get it and so again, prevention is important. The issue of then targeting, can you target the prevention programs to those groups, is also an important one and they're sort of two schools of thought to that. It is harder for them because they're often to make the lifestyle changes. We talked about good places to exercise. I was in Inner City Detroit and there are not many places that I would like to take a nice long walk in Inner City Detroit. So it's harder for us to encourage a person to say well, after work, especially if it's a little dark out, that you should take a walk in those areas; much hard to do. Issues of safety and of attractiveness frankly are there. So the issues of where do you get your biggest bang for the buck I think are a little uncertain, but you're absolutely right that the rates are higher among the poor, lower socioeconomic status.
QUESTION: Rep. Dennis Arakaki, Hawaii. One of the challenges we have in our state is trying to work with our Department of Education and a lot of time they seem to run contrary; although there's a lot of opportunity I think to promote good health and healthy lifestyles. I'll give you a couple of examples in terms of physical education because we're on developing standards for education. PE is really low on the priority, especially at the elementary age level. That's one problem and in terms of nutrition, we've seen a proliferation of vending machines, soda machines on campus because they provide a great deal of profit to the schools. I've also heard that the school menus are determined to a great extent by what I think the Department of Agriculture provides in terms of surplus and a lot of those are really fatty foods. Maybe one of the things that the Health Chairs Project could do is get us together with the Education Chairs and see how we can work together to develop good policy at the school level.
That's a good comment; I'll comment briefly on it. First of all, you're absolutely right. The schools are being pressured more and more to say they've got to deliver on test scores and those tests don't include strength or agility or endurance. They're reading, writing and arithmetic and so they've got to find the time, when they need more time to do that and that is a problem and we've seen physical education drop nationwide. At the same time that this has been going on, the proportion of kids getting daily physical education has dropped substantially in this country.
We have been supporting Departments of Education around HIV and a limited number of departments around broader issues of health, where they'll be a person in the health department and a person in the education department whose job is to work together to improve the policies overall and not just PE but health education, policies about whether there's any tobacco use permitted on the school grounds and things like that. So I think that while it is hard for a head of an education agency to say this is their No. 1, I think they're more willing to consider it but we do have to recognize that their pressures are all on test scores.
Your issue about food and vending machines; there's no question that that's raising a lot of concern now. Soda pop and sugared drinks are about 10% of the calories that kids consume. The contracts on pouring rights are very, very lucrative for the companies and the schools need the resources. Some places are saying that they'll only permit water; the elementary school in our neighborhood, the only vending machine that I've seen has only bottled water available and so there are places that are looking at are there standards that can be enforced. Some legislative, some states have started to move in that direction. Some of the companies are concerned that they're going to be viewed as the bad guys, like Coca-Cola has started to back away from exclusive contracting. The issue of USDA, in fact USDA is working to change the standards for the foods that they can subsidize and what they say is a good school lunch but there's a long way to go.
QUESTION: One of the issues that I'm quite concerned with is of course the increase or skyrocketing cost of the medical care, and the decrease that we've had in revenues in the states since 9/11 have been rather drastic and dramatic and a lot of the states I'm sure there's been a raid on the tobacco settlement funds to use those to a greater extent to offset some of the costs of medical care and so the amount of money that's left for tobacco prevention has decreased in many instances. We went to an increase in our taxes, cigarette taxes, in our state this last year. We were able to get, after a tough fight, we got an $.18 increase in the tax on cigarettes. However, it's caused a much greater disparity with some of our neighbors in the amount of tax they charge on the tobacco products and of course has increased the number of people that go over the state lines to purchase tobacco products. I'm just wondering from the federal standpoint if there can't be some regulation in the amount of federal money available as compared with the amount of tax that some of the states charge on their tobacco products. Has there been any study of that or any encouragement from the federal level for states to increase those taxes? I know it certainly has an effect on the number of people that smoke. There's a direct correlation between the decrease of tobacco use and the increase in the taxes. Maybe you can comment on that some. Then I also have a question regarding the obesity issue that I'd like to ask afterwards.
Regarding tobacco taxes, I don't know of any discussion about tying federal dollar support to a state for anti-tobacco programs based on their level of taxation. You're absolutely right. There are large disparities in the taxation or the cost of cigarettes, there is often a shift of people, along the border to neighboring states. That occurs in states that have tribes or reservations where there often can be cheap cigarettes as well. But I know many states now are considering whether they're going to raise further their tobacco tax and even some cities, New York City, is considering it for example among others. But no discussion about sort of saying if we raise our tax a lot can we get a larger share of the federal dollars for anti-tobacco work. I don't know that at all. Of course, people would resist it. They'd say the places that are raising their taxes are going to already have a big decrease in tobacco use so they need the program less. But as you're saying those are the states that have taken on the difficult political fight to raise tobacco taxes that might be more effective.
QUESTION: There's also a problem with people going to military installations to purchase those products.
There has been some discussion about whether the military installations would, I don't know whether they would charge taxes and then remit them or whether they would just raise the price to the average price but there's been some discussion about that because the military has realized increasingly the cost that tobacco means for them in their health care costs. I met with one of the Surgeon Generals of the Air Force and they estimate about 20% of their health care costs are related to tobacco. So they're recognizing that they've got to turn that around. They had gone to no tobacco use during basic training but found that for a lot of reasons after basic, people went back to smoking.
QUESTION: This pertains to the obesity issue. We've searched and searched for ways to try to legislate some things that would reduce the amount of fatty products in the vending machines, etc., but seems to me that still about 90% of the issue has got to be education and to change our style of living and get away from the television and get more exercise. If there are any good pieces of legislation out there regarding vending machines we'd certainly like to get some models that we can maybe put into use.
There are states that have taxes on soda, usually related to the issue of recycling. There are studies that say that soda or probably any snack food, as prices go up, consumption goes down and there have been places where they have subsidized the healthier snacks as they've raised the price of the less healthy snacks and seen a shift toward the healthier snack option, whether it's fruit or water or juice. So there's been some of that. There have also been several very good studies of education programs in the elementary schools that can get kids more active, especially those who are not really athletic, more active, eating better. One of the best of them was called the Catch Program, cardiovascular oriented program. Texas legislature has supported, the University of Texas was one of the study sites to get that to schools in that state and they are now in over 800 schools statewide, that education program. So there are some things like that that can be done but we're at a much earlier stage in this than we are for example in some of the other areas.
QUESTION: Sen. Maggie Tinsman, Iowa. I'd like to talk a little bit more about obesity. I don't think it's just legislatively that we need to do things. I wonder if there's a way that you can help us through our health departments I believe is probably the way to go but we have a couple of things that are working against change of behavior. One is government dictation of either what I eat or what I do with my free time with activity. In Iowa that is just absolutely forbidden that we get into directing that. But besides that, we're, as you know, a major agricultural state and there is a fear by some that the pork and beef industry which are major industries in Iowa will be affected negatively with lawsuits against them because of the obesity thing and if you affect the economy of Iowa, you have no chance of talking about obesity. So I need some help.
I actually very much appreciate your raising that because that's an important area and an important comment in a couple of ways. First of all I don't think federal government, state government or any government is going to dictate how people use their time, but we have to recognize that there are policies or things that we do as a society to make it easier or harder for people; make certain choices more popular, less popular. If we think we're going to get most of the people to do what they don't want, to deprive themselves of what they like and to make it work and hard for them to do, the things that we're recommending for them, we're not going to get there. We have to make them realize that these are things that are more fun; they'll enjoy it; they'll get to know their neighbors more, things like that so that they choose to do it and that they can see some of that. So you're absolutely right.
Regarding the issue of individual industries; I know there are people who talk about, you know, should we make the food; is the food industry as bad as the tobacco industry; let's put it out the way I hear it and I don't think any of us feel that way. In fact, we feel very, very differently about that. There's no question that there are some cuts of meat that are lower fat than others and there's also no question that realistically there is no such thing as a bad food. It's how much you eat and how much you eat in balance to other things. And there are some people who are very, very prone to elevate their cholesterol if they've got a diet that has a lot of saturated or trans-saturated fats in it and other people who have little impact on it. And those are all things that have to be taken into consideration. But you're absolutely right, that those sorts of stories or directions strike a lot of fear into people about what government is going to do to them and I don't think that government will ever get that way but I am worried as you may be also implying that our ability to help people protect their health will be constrained by some people feeling that that's in fact what government is trying to do, but I don't think that that is what government is trying to do.
Question: [Sen. Tinsman] No, I agree with you. I think it's exactly because the tobacco industries were totally sued by everybody as well as they should have been, the feeling is well what's next? Are we next then? The food industry and particularly I guess well since we raise mainly corn and soybeans and we feed them to animals for beef and pork, so it gets all wrapped up into our whole economy and we do have an obesity problem in Iowa, terrible. So I'm almost thinking is there some pilot projects we can do with you that you can figure out some kind of unique way to talk about this and how we eat, etc.
There have been some small projects and like sort of where you're going in this, I believe we have to find a way to enlist industry to recognize that it's in their best interest too. I'll tell you some of the small projects. They're not large and there may be others that I'm unaware of. In several places they have worked with the Dairy Council to say shift to lower fat milk and in one area they saw big shifts; you said an easy exercise that can lower your cholesterol, it's moved from here full-fat milk to here the 1% and skim milk, big shifts in what was consumed; smaller shifts in meaning increases in dairy product consumption overall. But the Dairy Council was part of that; wanted to be part of that in the place that they'd have done that as an example.
QUESTION: Sen. Pat Thibaudeau, Washington State. Our citizens insisted that we raise taxes on cigarettes. I need to say that; I'm boasting. One question I have about tobacco; do the citizens really care if we really raise taxes on tobacco and it's kind of interesting in terms of tobacco. Terrible racial disparities that our state board of health has identified were the Native American Indians and the irony is they are selling cigarettes on the reservation and we're not collecting taxes which is a constant bone of contention but at any rate, as far as obesity is concerned, does the insurance industry do anything about better diets, better exercise for health insurance?
Generally the insurance industry does very little. If it is prescribed they will pay for surgery for people that are very obese and have been unable to lose weight and are starting to have the health effects of that obesity. Medicare for example can pay for it but they don't pay for the kinds of extensive counseling that is often needed to help people start to make effective steps in changing diet and being more active. That's generally not covered.
Relative to tobacco I know one of the things you all have to be wondering about is if we're real successful in reducing the rate of tobacco use will we run out of money then for these programs and probably so. On the other hand think what it will be if you're not very successful and the money is spent on the diseases, the lung cancer, the heart disease. At the end of it you may not have the money but you'll still have all the disease that you'll have to pay for too or you get more modest reductions.
QUESTION: You talked quite a bit about health risks related to behavior. I'm interested in some of the other chronic diseases like asthma, some of which don't have much to do with aging but which we're seeing, not necessarily surprising, but some significant increases in and what issues you see in terms of those sorts of disease that may not have so much to do with what happens to us when we're 50 and we've been living for 40 years in a way we shouldn't.
Couple of things; first of all there actually are increases in asthma in adults too, but the largest increases and the most disturbing are in children. It's clear that we have better medications than we used to and that asthma as with other chronic diseases very good concentrated patient education or family education for asthma, can dramatically lower the need for hospitalizations and the level of difficulty that a patient has. We've known that in diabetes; we know that in arthritis; we know that in asthma, with very good randomized trials, the kind of trials that are used for medications but they're very, very rarely applied.
The other issue is what's causing it and can we get ahead of that cause and I'm not sure we know some of the causes, but for me the most important part of that is do we know the causes of the increase because that's the ones that we then know are absolutely modifiable and we ought to be able to change. There's increasing concern about issues of certain types of pollutants in the urban areas but there's also concerns about molds, cockroach and other kinds of exposures in houses, especially older houses for people. Those are the two areas that I have heard the most about as suggested causes for increases in asthma because they believe that both of those are starting to get worse. But we don't have that kind of trend data to know that for sure. It is an area though that we could do a far better job in the quality of care and the education that we give families and we just don't do that very well. We don't do that in any of the chronic disease areas.
Arthritis, we know of arthritis self-help course randomized trial reduces pain, need for physician visits by about 40%. 1% of people with arthritis get it.
QUESTION: I just wondered if you have any information about the connection between obesity and tobacco because I have a totally undocumented opinion that young ladies are smoking, girls are smoking in order to accomplish weight control and it's a personal responsibility issue but still a challenge to tell somebody who at that age thinks their immortal, invincible and bullet proof, that this is something that they need to think about.
There's been a lot of "look" at that. First of all people who smoke, often it contributes to suppression of appetite. People who quit we know that many gain some weight. They gain usually in the neighborhood of 3 to 5 or 6 pounds, but some gain more. But it's been clear that the imagery, some of the thinnest women in advertising are the women in cigarette ads and there have been some studies of that beginning back in the 1970's when it was the Virginia Slims and all of that of tying the image of thinness to tobacco use. Even before that there were ads that said reach for a cigarette instead of a sweet. That was in the 1930's and 40's for women. So there's been a conscious effort on the part of the industry to tie those together and there's no question that there are many women who think about that as a reason to smoke when they're trying to maintain weight like the high-fashion models. So there's been a great concern towards many women who are active researchers in the field and to see how that's been positioned with the issues of women having a more equal place in society than they used to.
Thank you very much for your attention.
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