. Page 1 . >> PENNY ROYAL Good morning. I hope all of you will come in and have a seat. We have a real treat for you this morning. I'm Penny Royal, acting executive director on the President's Council on Physical Fitness and Sports, and this morning we are bringing you, to help get you moving, someone who needs no introduction. She is the star of the number one fitness show on television. This show has been rated number 1 for the last 15 years. So she is no fly-by-night organization. She is a best selling author, and we are very proud that she is a member of the President's Council on Physical Fitness and Sports and is spreading the news that physical fitness means a better life. So I'd like to bring to you this morning Denise Austin. (Applause.) >>DENISE AUSTIN Welcome everybody! Thank you so much. I'm so excited to be here. Health is my business. I'm a big believer in exercise, making sure you do it on a regular basis to feel good and mainly to give yourself some energy and for better health. It's all about improving the quality of your life. You feel better when you exercise. I know it helps me, gives me tons of energy, I feel so much better after the workout. But today I'm . Page 2 . going to talk a bit about the President's Council and then stretch everybody out to begin and jump start our wonderful day. It's a beautiful day here in Baltimore, so I love it. The sun is shining and it's a way to start the day. First of all, I'm excited that President Bush appointed me on the President's Council on Physical Fitness and Sports because he is our best role model. He is so dedicated to fitness, he can run a mile in 6 and a half minutes. And that's an amazing mile. And our beautiful first lady, Mrs.Bush, is in fabulous shape. She works out. They are both dedicated to health and fitness and what a better role model that we could have, the President and Mrs.Bush. They are in fabulous shape and they are dedicated to work out. The President wakes up early. Gets his workout done and feels better for it. Less stress, too. So it's a wonderful role model to be out there in America to talk about the President's Council, because for the last 20 years I've been promoting health and fitness all over the country, motivating people to exercise, to feel better about themselves and give their bodies the better health their bodies need. God gave us one body. We have to take great care in that body; so exercise, as we know it's all about prevention. It's one of the best ways to prevent so many diseases, . Page 3 . and I know that for a fact. I feel good. And most importantly, you want to have the energy to do more things in life. I'm a mother of two daughters. They are both in grade school, 6th and 3rd grade, and it's great because on a family outing my husband and I take them on the weekend. Stay active with your family. We go for walks and bike rides. Anything to keep them active. Now, the President's challenge is a great award that all of you can take to your own work site. What you do is the President's challenge and the President's Council on Physical Fitness and Sports, this is their number one program that we are promoting all over the country. And it's for people of all ages. It doesn't matter if you're a school aged child all the way up into your 90s. And it doesn't matter how old you are, exercise can help improve your overall health and this challenge is all about activity. You get extra points by just walking to the -- to work, walking your kids to school. It's all about keeping your body active. We have over 600 muscles in the body. We need to keep them active, because sitting still is our worst enemy. Being sedentary is the worst thing. We have to move. What I do right there at my office, I pull in my tummy. Everybody right now, pull it in. You are your own architect by the way you sit and by the way you stand. . Page 4 . If you're slouched like this, your tummy has nowhere to go but up. But if you sit nice and tall, good posture is a key to that flat tummy and it keeps your back healthy. 80 percent of Americans who suffer from lower back pain have weak abdominals. That's why the news about the core muscles is important. It helps keep your ab strong and your back healthy. Your spine is your lifeline, so keep it healthy and strong. First of all, I want to start off by giving everybody an exercise break. Everybody stand up. Come on, we will do a little exercise and keep that energy flowing. It's very easy. Everyone can do it. Let's begin with music. Inhale. Take a nice deep breath and exhale. Good. Inhale up. Great. And exhale out. Beautiful. All the way up now. Stretch them up. Beautiful. Get that energy flowing. Circulation. What a way to start your day! Okay. Now, for the waistline, quick. Come on. Twist. Turn that back. You can do it. Just two more twists. Come on! Now knee bends to protect your back. Okay. Stretch your arms. Open up your chest. Okay. You can sit down. Give yourselves a big hand! You did great. Don't you feel better now? Don't you feel good? The oxygen is flowing. You'll think better and feel better for the whole day now. throughout the day, try to give yourselves some great . Page 5 . exercise breaks. Remember, exercise on a regular basis really helps with your overall good health. I wake up in the morning, 30 minutes and I get a workout in. That way I feel good all day. And I'm not worried how I'm going to squeeze it in in a busy day. Because every hour of the day, if you haven't exercised, chances are you won't. Especially as a mother, at dinner time, I have to cook the kids food and I don't want to have to worry about it. So I wake up in the morning, get it over with even before the children wake up in the morning. That way you feel energized for the day. And as you know, exercise and eating right, they go hand in hand. I'm a big believer in a well balanced meal. It's about eating well 80 percent of the time and once in a while having your treat. I'm a believer that moderation is the key and true balance and good food is so important for our body. So getting a good night's sleep and drinking lots of water. It's all about feeling good about yourself and really trying to add exercise into your day. Squeeze it in, any time. Right now. Come on. Squeeze your buttock muscles and you get a strong tushy. These are isometric exercises and they do work. This is the best way. So many of us, the number one excuse is "I don't have the time." Well, you can implement ten minutes here and there. Take an . Page 6 . exercise break around the lunchroom instead of a coffee break. So there are lots of ways that you can implement exercise into your daily life. Any time, anywhere. I even exercise my legs when I'm sitting down in a chair. Rotate your ankles. Flex and point your toes. Work on the thigh muscles right there at your office or at work. Even in the car, I do tummy tighteners. If you hold it and tighten up and really contract the muscles for five seconds, it's equivalent to the situps. So you can do them on the way to work and no one will know it. There's great ways to stay in shape. There's no excuses and that's why you can wear a suit and get in a bit of exercise. I appreciate all of you here this morning, and up next is the wonderful Dr. Carmona, the United States Surgeon General. He has done so many wonderful things for so many people. I appreciate everybody being here. And have a great session. Remember: Keep healthy. You can do it. And it's worth it. You are worth it. Thank you. (Applause.) >>RICHARD CARMONA Good morning, everybody. The first thing I need to say is the Surgeon General says she should not have caffeinated beverages. . Page 7 . (Laughter.) Wow, have you ever seen so much energy at 8 o'clock in the morning? Is that unbelievable? Okay. Good morning. Denise, thank you so much for setting things up for us and getting everything going. As you know, she is a member of the President's Council on physical fitness, headed by one of the commanders of the US public health service, commander Penny Royal. I want you to stand up. That's who is in charge. She has done an outstanding job with the President's Council on Physical Fitness. (Applause.) On behalf of Secretary Thompson and all of us at the Department of HHS, it's great to have you here to bring in Secretary Thompson's steps to a HealthierUS and the first prevention summit that has been sponsored by the Secretary. I also want to thank all the staff at HHS who organized this event. The summit has been so popular that we are at capacity. We are actually turning people away. Where is Elizabeth Majestic and her staff? All of you stand. This is why we are having the conference. They put in the work. (Applause). There you are, back there. I'm real fortunate to have such a team of talented people, like Elizabeth and . Page 8 . Penny Royals who make this happen and putting prevention on the forefront. And it's cool that prevention is such a hot ticket. That's the way it should be. The President, Secretary and I are committed to promoting a healthy lifestyle for every man and woman in America of every age and background. Personally, I work out every day. It gets tougher, especially in these jobs. I do my best to make healthy choices as well, because the President insisted that all of us in leadership positions lead by example. My boss, President Bush, probably the busiest guy in the world, works out just about every day, makes his healthy choices and leads by example. Secretary Thompson, my other boss, he put HHS on a diet and lost 15 pounds. You don't want to run into him in the hallway, because he is counting your steps all the time. I'm passionate about prevention and I've been since the old days. I'm a recovering surgeon that went into public health after having seen all of the trials and tribulations of an emergency room. And it drove me to go into prevention and public health. I work with a formidable team: President, Secretary Thompson -- and Secretary Thompson will go down in history as the guy who put prevention on the map. My first 8 months . Page 9 . as the Surgeon General, the Secretary had me out travelling to half the states in the United States, talking about health promotion and disease prevention. Last week, I kicked off 50 schools in 50 states initiative, right here in Baltimore at Patterson High School. The kids were terrific. Mayor O' Mally made me an honorary citizen. While I'm Surgeon General, I'm going to 50 schools in 50 states to talk to kids up personal. Healthy choices, risk avoidance and how making right choices can benefit them now and later. Kids ask good questions. I always get blindsided. a lot of times you feel comfortable in the environments. And you get the traditional questions, how do I get someone to stop smoking? But right out of the blue in the midst of a press conference one of the people said: What is this about SARS and what are you doing about it? You never get away from it. We have to teach our kids the benefits of eating right, making healthy choices and of being physically active. Not just in sports, but everyday things. Taking a walk. Walking up the stairs. Walking from the back of a parking lot. Playing with their friends. You're here because you're on the right track. I feel like I'm preaching to the choir. But all of us have to get out there and assemble these groups and fire them up. . Page 10 . You all embraced the prevention message as I have, as the President has, as the Secretary has. Like the President, Secretary Thompson and all of us who work for them, you know we must reverse the healthcare challenges we are facing as a nation. And it will take a multidisciplinary response to make that turn around a reality. We are at a crossroads in our nation. We are all standing at the corner of health and disease. Are we going to sentence ourselves to being a society defined by illness or choose to be a nation of health and well-being? Obviously we prefer the latter. Prevention touches every aspect of life. Look at national security. You think that our servicemen and service women could be executing their mission overseas without superior physical fitness? Obviously not. It's great that our men and women in uniform have a Commander in Chief who walks the talk. Whenever the President sees me, he asks me: Have you worked out today? My answer is yes. My fear is that he will have me running with him, and he will win every race. The Secretary -- well, I'm not that... you know... (Laughter). The Secretary has his entire staff wearing pedometers. He asks them how many steps they have taken. And now he has the whole staff wearing them up at HHS. . Page 11 . All of us can take a page from the President's book and Secretary's. They are leading the way. So many of you are in positions of great influence. This morning I met healthcare professionals, city planners, policymakers, business leaders and government officials. Many of you are parents, grandparents, people who care about kids and their health. You are in the trenches in the fight against disease. The summit will motivate you to try new prevention approaches and give you a chance to share your expertise. Over the next few days we will examine prevention from every angle. We will look at cost benefit analysis, real programs, and what I call best practices that are making a difference in the lives of Americans. Again, we must put prevention first in all we do. Thanks for being here. Let's get started with the first panel. I'd like to introduce my good friend, Rear Admiral Dr. James Marks, a friend, colleague, UCFF alumni and director of the National Center for Chronic Disease Prevention and Health Promotion. The science behind what we do. Thanks. (Applause.) >> JAMES MARKS Thank you. It's a pleasure for me to be here this . Page 12 . morning to set the stage for you. That is to outline what we see as some of the major issues in prevention, especially around the areas of chronic diseases, and to help lay out what are the things we are going to have to grapple with as a society. If I could have the next slide, please. There is the... this is the most important slide in the talk and the one that you really need to remember. I'll refer back to it at the end. In 1977, when Elvis died, there were an estimated 37 Elvis impersonators. By 1993, there were 48,000. A modelling that as a growth curve indicates that there will be 3 2.5 billion Elvis impersonators by 2010. The world's population is supposed to be 7.5 billion. So two people in the audience for every Elvis impersonator. It will be a heck of a cover charge to help support those Impersonators. If you didn't know, last year was the 25th anniversary of his death. And they did a poll in the US and asked the adults, how many of you have ever -- in front of your shower, in front of your mirror, impersonated Elvis? The answer was roughly 20 million in the U.S. so we are still on track. As I said, I'll refer back to this later in the talk. But please do remember this slide. . Page 13 . This is an update on a classic paper done about a decade ago by McGinnis and Fahey. Looking at the leading and actual causes of death. They took the way deaths are coded on the certificates as the leading causes, heart disease, cancer, stroke, chronic respiratory disease, principally emphysema and asthma, et cetera. And they said what caused these illnesses and how many of those deaths are due to these actual causes? And again, you can see the information there, tobacco being number one. Poor diet, lack of exercise being number 2, alcohol, et cetera. Because of time, I'm not going to be able to go through all of these and I'll concentrate on just a few. I'll concentrate mainly on heart disease, cancer and stroke and tobacco, poor diet, lack of exercise. I'll touch briefly on others. But there are a couple points to make here. If we are not working on heart disease, cancer and the chronic diseases, we are only working at the margins of the problems. 70 percent of all the deaths in this country are caused by chronic disease. And a similar proportion of total healthcare costs. We are only working at the margins. If you're not working on tobacco, poor diet and exercise, you are only working at the margins. It's critical that we make sure that we are working on the important issues of our time. Just to . Page 14 . make sure we pay attention to the issues of disability, especially with an aging population, you see here the leading causes of disability among persons aged 15 and older. Arthritis and rheumatism being number one. If you look further down, there are those people who don't know they have arthritis or they list stiffness or deformity of the limb as well. Back, heart trouble, lunk or respiratory trouble, deafness, et cetera. Again you can see what are the issues we need to be working on. If we are concerned about the issues of disparity in our population, this is the numbers of years difference in life expectancy between Blacks and whites by cause of death and sex. Number one. Heart disease, cancer, homicide, and then you see stroke. Again, the critical nature of the chronic illnesses in explaining much of the differential and that fundamental outcome of life expectancy. Again, because of time I'm not going to go through all of the racial and ethnic groups, but if you don't know, part of what this reflects is that these deaths occur at younger ages in our minority groups than they do in the white population. This is the rates for coronary heart disease. You can see the increase that occurred, increase actually extands back to roughly the -- to 1900. And . Page 15 . then the decline in age adjusted rate. this has been one of the real successes in health and public health. That is, that we have been able to reverse that epidemic and have it decline. Largely through, as you're all aware, both the treatment but also the prevention of coronary heart disease. This is age adjusted. When we look at it by total numbers of deaths. In fact, what we see is that we have been able to stop the increase. We haven't been able to reverse the number of deaths. So that when you look at the growth and the population and the aging of the population especially, all of our advances over the last three, four decades, have allowed us to arrest this epidemic but not turn it around and the burden to society or the number of cases, not the rates. This is still heart disease is still the leading cause of death in every state. Leading cause the death in men. It's the leading cause of death in women. It's the leading cause of death in every minority group. We have to be working on it. One of the things that is striking about heart disease or stroke or heart disease and stroke combined as shown here is that there is a substantial geographic difference. High states to low states, with the highest states having rates roughly twice that than the lower states. We did an analysis that said . Page 16 . what causes those differences? It turned out that about two-thirds of the difference in deaths under age 75 were due to modifiable risk factors. The proportion of the population that smoked, the portion that had high blood pressure, high cholesterol, diabetes, that didn't exercise, that was overweight, those things. So it's important that we have a good ambulance system and it's important that we have a really good surgeons and it's important that we have good coronary care units. But two-thirds of the difference is on modifiable risk factors. And we know that many people with these conditions have as their first symptom their death. So, in fact, the evidence is incredibly clear that if we are going to get ahead of this, the leading cause of death, it has got to be from prevention, because people don't know they have it until they die and the ways that we can prevent it. We have a lot of science that shows us that they can -- we can dramatically error rate. You should know the higher states have rates twice that of the lower states. Even the low states have a lot of improvement that they can make because they still have high rates of those preventible risk factors. Let's change subjects now to cancer. Cancer is probably the most feared of the chronic diseases. . Page 17 . Concern about pain, concern about wasting, concern about the dependence that can come with it. People don't realize that the rate of which the adult population will develop cancer. Here you see for men and women, about 35 to 40 percent will develop cancer in their lifetime, and enormously high rate. What are the leading cancers? This is for women, it's the number one is lung cancer. Number two, breast cancer. Number three Colo Rectal cancer. Those are about 60 percent of the deaths in women. If you do this for men, lung cancer number one as well. But it would be over twice as high. You replace breast with prostate, roughly the same level and colorectal cancer. A couple other points, the lung cancer rate in men is starting to decline. It's not in women. Women haven't had the same declines in tobacco use and they have come later than in men, so they are still seeing increases in lung cancer there. This has been one of the areas, and breast cancer, where we have seen real progress. And this is the percentage of women over 50 who had a mammogram in the last two years, has reported, self reported through the risk factor surveillance system, each state does this with CDC, and they indicate whether they had a mammogram. You can see the big shifts in the . Page 18 . proportion that had a mammogram. There are a couple points to make here, if you look at women who are poor, there have been large improvements there as well. It has also been one of the places when the steps to the HealthierUS initiative that you'll hear about, it's going to be encouraging community work. In fact, there is a report out of Wisconsin that said those communities that had coalitions had larger increases in mammography rates than those communities that did not. Just to remind you of lung cancer and the epidemic that it has become, lung cancer now, more common than breast cancer as a cause of death. Remember only 1 in 4 women roughly smoke. So if you're a woman who smokes, your chance of dying of lung cancer is 4 times greater than your chance of dying of breast cancer. We have been encouraging and seeing the states increasingly develop broad plans for cancer prevention and control. This is an example of some of the sections in New Mexico. But really now about 40 of the states have done these. A couple of important points here. It starts from prevention every cancer, reducing the Ricks, and through to the issues of quality of life for people affected by cancer. That's what we want. We want broad plans that mobilize their local resources. . Page 19 . We hope from CDC and other agencies to be able to increase support for those states. But what is exciting to see is the coming together of their communities in this area. And it's been very exciting to see it taken on by the national dialog on cancer, a group that is chaired by former President Bush and vice chaired by Senator Feinstein of the Senate, to take this on as one of the goals that they have over the next couple years to the dialog, to have every state have an up to date comprehensive cancer plan. You can't talk about cancer without talking about tobacco and this is a slide just to remind us about how important smoking in as a cause of death. If you're new in public health and say I want to work on an important issue, what should I work on, AIDS, alcohol, others, very important. But you look at this and you say we have to work on tobacco. You heard a lot about tobacco and how important it is. It's been in the news over the last several years but we have to remind ourselves of how critically important it is. 1 in 6 deaths in this country is from tobacco. 1 in 6. What happened in the '90s? We had an increase in tobacco use in children. This is the percentage of High School youth who are current cigarette smokers and then a decline in the late '90s. That increase is large enough that it represents an extra . Page 20 . million deaths from tobacco over their lifetime in that cohort of children. If they quit at the same rates that people have been quitting, we will end up with a million extra deaths from that, what looks like a gentle slope. Can we do something about it? California has had the best and longest experience. Beginning in 1989, when they passed an initiative to increase the tax on cigarettes and apply much of that tax to tobacco control efforts. They had adult prevalence decline, youth smoking was down 43 percent. 33,000 fewer deaths. 8 billion dollars saved and they are the only state to see lung cancer start to decline in women. It took 10 years to see that. That is a shorter time than people projected for the cancer turn down to start. We could show you data from a variety of other states, Oregon, Massachusetts, Mississippi, Arizona, this is from Florida, Where they early on invested in an aggressive media campaign named at youth. they had youth involved in crafting the messages and they quickly saw over a two-year period between a baseline and follow-up, cigarette uses in middle school decreased and in High School students decreased by 18 percent. There is strong evidence that aggressive sustained programs aimed at tobacco use, both initiation and cessation can make a substantial difference and in a . Page 21 . reasonable period of time. The obesity epidemic has been in front of the news. Most recently. I'll show you a bit about that. Again, reminding you that this is a survey done in the states where adults are asked their height and weight. And they give a weight. When they give a weight that puts them at roughle a BMI of greater than 30 or roughly 30 poupds overweight for a woman who is 54, a bit more the taller you are and if you are men. A couple points to make. People are asked how much they weigh, they usually say they weigh less than they do. They say they are taller than they actually are. So these are conservative estimates and we will walk you through it. You should see the scale on the bottom, the light blue, or -- less than 10 percent of the population gives a height and weight that indicates that they are obese. Darker blue, 10 to 15 percent. This is from 1990, '91. '92. '93. '94. '945. '96, '97. '98. '99. 2. 2001. We have never seen an epidemic like this come so quickly in the chronic disease area. And the numbers are conservative. A couple of quick points to make here. First of all, while the human genetic make up affects one's weight. This is not a change in the genome and all of the science that we have about the -- ( Laughter). . Page 22 . Genetic makeup and the human genome being mapped, this is all what is happening in our environment. It is about the systematic engineering out of our lives, physical activity and the systematic engineering into our lives many, many, many food choices, increasing portion, that the best value that one can get for 39 cents is about 7 or 800 calories of fat and sugar and supersizing, portion sizes changed. All of those things add up. And we can't go on like this. We are not going to solve this when there's that many millions and millions of people with drugs, and with what we do in clinical care. And while that was a 50 to 60 percent increase in that decade and the proportion that are obese in the US adults, what we have seen in children, this is from the Hanes series of surveys is in fact a much faster increase. You can see in the first two bars in each grouping, there was about no change from the '60s through early '70s. You see the epidemic starting, in the late '70s. Really taking off in the '80s, and continuing to accelerate in the late '90s. Tripling the personal of overweight in children and teens in the two decades since roughly the 1980. Tripling. Can't continue like this. I'm trained as a pediatrician. As a pediatrician, I saw children with diabetes. I never . Page 23 . saw Type II diabetes. They used to be called adult onset diabetes when I was training. Now it's about a third to half of all cases of diabetes in children are Type II diabetes. And like night follows day. Obesity and inactivity lead to diabetes. And this is the increase in the proportion of adults who say they have been diagnosed with diabetes, three points in this last decade. We have had to add categories to the scale in that decade. What can we do about it? This is a report in the USA Today that was of a randomized trial that took people at high risk of diabetes. They were showing difficulty in their glucose metabolism. Prediabetes. They randomized them to you are care, to a drug, to see if they could stop them from progressing to frank diabetes and to more intensive weight and exercise counselling than is usual. The drug reduced the progression of diabetes by 30 percent. 30 percent fewer people over the next five years ended up moving on to diabetes. The intensive exercise and weight counselling reduced it by 60 percent. They had to stop the trial early because that was so effective. It was the only thing that worked for people over 60. It was the only thing that had some people revert back to normal glucose metabolism. How extensive was the lifestyle change? They had to . Page 24 . walk 30 minutes. Five days a week. They had to lose 10 to 15 pounds. Not huge. Not huge. Well within what anybody could do. Make no mistake. Those of us with health insurance would have the drug paid for. None of us with health insurance would have that counselling paid for. The intervention that is twice as effective. It was considered the cadillac of interventions. Multiple visits, diet counselling, Internet access, telephone calls, et cetera. It was the same cost as the drug. Not everybody is going to get the message -- we have a long way to go. But at least people are are working hard to keep their pets healthy. (Laughter). I'm going to change topics again. You've probably seen headlines like this. This is from the Atlanta paper. Social Security and Medicare systems facing a possible crisis as baby boomers grow old. This is the baby boom generation, that change in slope is, and this is the proportion of the US population over age 65. You see the gentle slope and then the big up swing and that starts in 2011, when the first of the baby boomers starts to hit age 65. Total proportion over 65 will double over the next two decades. A couple points to make here. All of the struggle we . Page 25 . have had as a society on total healthcare costs and how do we keep those under control occurred at the flat part of that curve and we will double the size of the population that is going to be older. How much does it cost per person? This is the cost per person by age. 65 year old costs 4 times what a 45 year old done. The midpoint of the baby boom generation is in their late 40s. So we are going to double the proportion of the population that costs four times as much. and we are already having trouble with healthcare costs. We cannot sustain the healthcare system we have into the future. We have to have a much more preventive orientation. These are the projections from CMS, the national -- about national health expenditures. 2011, a couple points here. At the bottom you see 17 percent of the gross domestic product is projected by 2011 to be spent on healthcare costs, 9 thousand dollars a person, with nursing home costs going up to 240 billion dollars. 2011 is when the first of the baby boomers starts to hit 65. The first. That is when the costs will really start to escalate. What can we do about it? Well, this is a report that said what is the likelihood of developing coronary, stroke or diabetes by age 65 for a man? If you're not a . Page 26 . smoker, normal weight and active, 11 percent will have it by age 65. Smoker. Heavy, inactive, 58 percent. 550 percent difference. The numbers are similar for women. Shifted by five years or slightly lower relative risk ratio. If we had a drug that was this effective, we would put it in the water. Let's look at it another way. These are University of Pennsylvania alumni who graduated in 1939 and 40. They were all men. Pennsylvania only had men in its school then -- (Laughter) I had some Slides that were just women. They were followed until their late 70s. And they were asked, when will they start to have trouble with their activities of daily living? That is bathing themselves, dressing themselves, being ail to reach objects, things like that. Not that they needed a nursing home, but they were starting to have trouble. And they were also asked whether they smoked, they had maintained their weight, and whether they were active. You get a pattern there? You find that those who had high risk in those areas started to have trouble with the activities of daily living in their early to mid 60s. Those that were at low risk, nonsmokers, active, maintained their weight, didn't have trouble with their activities of daily living until their early . Page 27 . to mid 70s. 7 to 10 year difference from the three modifiable behaviors. We know that the federal government through Medicare pays for much of the medical costs for older population. But the states bear a large part of the costs for nursing homes. These are not people who needed to go into a nursing home, but were starting to have trouble and we know that as the population ages, there will be more and more people potentially needing nursing home or home healthcare to take care of themselves. And we have had as our policies how much can we squeeze what we pay a nursing home? Can we support people being in their home by getting enough home healthcare? But not so much that we take away the care that they get from their loved ones to keep them at home. We have not had as a policy leg to our stool, we have not had, can we prevent the need for such care through prevention? Back to the Elvis slide. This is from the Social Security trustees, the workers to retirees ratio. The number of people paying in compared to the number of retirees. When the program started, it was up around 9 or 10. You can see it dropping. By 2030, there will be two people paying for everyone on Social Security and Medicare. . Page 28 . Two people in the audience for every Elvis impersonator. We laughed at that. And in fact an enormous part of our social policy is based on numbers that we thought were silly earlier this this talk we will have to grapple with. And if we don't grapple with it soon it makes it harder and harder for us the longer we delay. What do the Americans think of healthcare problems? This is a survey done in November and December, after September 11th. And they said on the, your left, what are the most important health problems? They listed cancer, heart disease, HIV aids, diabetes, obesity, smoking. We said what are the most urgent ones? Bioterrorism, Anthrax, small pox, et cetera. I think the American people have it right. There is an urgency to terrorism, but when you look at what is going to kill us or at effect our society, we have to grapple with the chronic disease problems and we have to do it by prevention. These are the issues that public health programs need to address. I have arthritis here because of the cause of disability and we have to focus it on priority populations. Almost every physician takes a version of the hippocratic oath when they graduate. It's not part of it. It's another saying that we had. The function every . Page 29 . protecting and developing health must rank even above that and restoring it when it is impaired. Thank you very much. (Applause.) >> MALE SPEAKER Thank you, Jim. I really appreciate that. For those of us who work in the clinical world and programmatic world, it is the science, the evidence base that drives many of our programs. And there are many of our officers in the US public health service and at CDC and our civilian employees who work anonymously to bring that information to you that really drives the programmatic things that we move forward. And Jim has been a leader in that area. Jim, I'm sorry to say for over 30 years. So, it's wonderful. But I reflect back on my own life when I was a real doctor, taking care of patients at the bedside, and I think of, when I ran the EMS system and the emergency department and the trauma centero a given day, two or three out of every four patients that I would care for didn't have to be there. They were people that made bad decisions that day, and they came before me usually because of some injury or driving while intoxicated or shooting or stabbing or some violence. And then we had another . Page 30 . group of patients who came before us acutely because of a series of bad decisions throughout their life and that may have been a stroke, heart attack or so it's one of the things that drove me to public health and prevention years ago, because I saw how much of my time I was spending on caring for people that really didn't need to be there. And added disproportionately to the disease burden in our society and concomitantly to the cost burden. and as Jim said, we are on an unsustainable path. Unless we pay a lot of attention to this information that he provided to us, we will be setting ourselves up for a system that is going to fail in the future. The legacy we leave for our children and grandchildren will be one of unsustainability. They will be working their whole working year to pay for their healthcare, most of which the problems they have, if exemplified by the childhood obesity problem that Jim showed you, is preventible. It doesn't have to be there. So we must embrace prevention today for all of those reasons and many more. Let's move on with the program and I'd like to introduce Dr. Ron Goetzel. The first director for the Cornell instance stet of health and productivity studies. He leads research and consulting services. A . Page 31 . recognized expert in health management and applied research. I'm sure many of you know him and read his work. He will talk about cost issues and the burden of disease. Please help meal welcome Dr. Ron Goetzel. (Applause.) >>RON GOETZEL Thank you. I'm delighted and honored to be here this morning. You don't know this, Dr. Carmona, but we grew up together, 164th street and Washington Avenue. We probably ran across one another and played games today. I think the neighborhood inspired us to go out there and try to improve the health and well-being of Americans. So we are doing that together. I want to especially thank Nancy Stanasic and Matt Gidry for making it possible for me to be here and presenting some of the economic data that I've been involved with and worked with over the past 20 or so years. Much of my research has been in the private sector, in the corporate community. At a great small fraction of what the cost of what most research costs in the terms of the governmental sector and I'll be presenting some of those findings, and help you to make the business . Page 32 . case, the economic case for prevention and health promotion, which is a formidable task. It's a difficult task to do that. But there is enough new research coming out and I think for the first time we can begin to say that not only is health promotion and disease prevention a good investment in health, but also potentially a good investment from a business, financial perspective. As I go through my presentation, I'd like to -- oops. Whoa. Somehow I got pushed to the back of the presentation. Let me go all the way back. Okay. Here we are. As I go through the presentation, some issues and questions that I'd like you to ponder, and by the way I consider it as an opening exercise for everyone to grab their wallets and wave it over their hands and stretch that way. But I decided not to do that. The questions before us are as follows. Do health promotion and disease prevention programs work in real life, not just theoretically. Is there a business case to support increased investment in health promotion disease prevention? What is the evidence that it works? And is it strong enough? And finally, are there lessons that can be learned from the private sector that can be applied to public sector initiatives. . Page 33 . Here is the logical argument that we hope to follow. If an employer, health plan or government invests in the health and well-being of its population, then people will have lower healthcare problems and improve their quality of life. They will consume fewer healthcare resources. They will be absent from work less frequently. Be more productive and ultimately contribute more effectively to their employers and to society. When we go through this logical argument, though, there are some difficult issues that we have to grapple with. For example, what do we mean when we say investing in the health and well-being of the population? What is the difference between health promotion and disease prevention programs and to what extent -- sorry. To what extent -- what is the difference between primary, secondary and tertiary prevention programs, because those programs do get confused. Is health promotion the same as disease prevention? What can we distinguish between clinical preventive services, screening programs, early detection, lifestyle modification programs and finally, where does health promotion and disease prevention stand in terms of the priority of other national issues facing us today, such as increased healthcare cost inflation, patient safety, . Page 34 . quality of care, consumerism, prescription drug coverage, the uninsured, patient bills of rights and HIPPA. So there are many things that we are grappling with and how do we get these to be a front burner issue? Here is the sound bite. If you're stuck in an elevator and you are beinger viewed by a CNN reporter and you have 3 seconds. Healthy people consume fewer resources in the form of benefit payments for medical care, short and long-term competentization. They are absent from work less often. Their quality of life is improved. An employer or health plan or government that invests in the health and well-being of the population and the communities is socially responsible, which in turn in the long run will both benefit the employer, health plan or government and all -- in both monetary and nonmonetary ways. Now, here is the logic flow that follows. Essentially, I'll provide examples, case studies that support these various points of view. Now, Dr. Marks covered the first point well, which is the large proportion of diseases and disorders from which people suffer is preventible and modifiable health risk factors are precursors to many diseases and disorders and premature death. Many modifiable health risk factors can be helped . Page 35 . within a relatively short time window. Improvements in healthcare and the health profile of a population can also lead to reductions in healthcare costs and improvements in productivity. And finally, well designed and implemented programs can be cost beneficial. That is that they can save more money than they cost, thus producing something called a positive ROI, or positive return on investment. Again, what I'm going to do is walk through the evidence. The first bullet is supported by over 10,000 epidemiological studies conducted over many, many decades and all the medical journals are full of the evidence to support the relationship between disease and disorders and poor lifestyle habits and risk factors. I'll review with you some of the other points, that is that modifiable risk factors are associated with increased healthcare costs. They can be improved through and in the case of evidence that I'll show, through work side based programs, that these improvements can lead to reductions in cost and then finally, again from the corporate literature, enough evidence showing that there is a positive return on investment in the short-term as a result of these programs. In understanding the outcomes, you need to consider the sequence of events. Things that have to happen . Page 36 . sequentially in order to achieve this cost benefit positive ROI outcome. You have to make sure the population is aware of health issues. So there is an awareness campaign that has to happen. They have to participate in the programs. They need to change their behaviors and engage in programs that improve their health and well-being. This can be brought about through increased knowledge, improved attitudes, behavior change, risk reduction, reduced utilization of unnecessary healthcare services and then finally, reduced benefit costs and ultimately return on investment. Now, the first step in this process is documenting and highlighting that healthcare actually poor health actually costs quite a bit of money. And you can drill down and investigate this by looking at medical expenditures, absence and work loss related to poor health. Presenteeism, which is when you're at work, not being focused at work. So you're physically there, but not mentally there. Finally, risk factors that lead to more expensive care. We conducted a study a few years ago, pooling our corporate database of roughly 4 million lives, look at the top ten most costly health conditions affecting the employers. Coronary artery disease is number one on . Page 37 . the list. But as you move down the list, you see many other preventible health conditions. Taking it a step further, most recently, we added prescription drug data, absence and disability data, and then reran the analysis for a subset of -- subset of employers and looked at it, and as you can see, angina is one of the things most costly affecting employers. If you compin the three top cardiovascular on the list, there is a cost driver of roughly 500 dollars per employee per year. In terms of presenteeism. We are now beginning to look at people's on the job performance. Productivity while at work, again organized by disease categories and risk factors, heart disease is number one. Consuming half of your productive day when you suffer from heart disease and it's unmanaged. Looking at the relationship between modifiable health risk factors and increased healthcare costs. These are the results of what we call the health enhancement research organization, it was a compilation of data, across six employers in which we designed data across six years, looking at medical claims data. Eligibility data, and health risk assessment data, looking both at behavioral risk factors and biometric factor, a database of over 100,000 person years of experience, it turned out to be the largest database of its kind. And these were the . Page 38 . proportions of that employee database where people were at highest risk. A third of the population being sedentary. 31 percent former smokers, 20 percent being overweight, 20 percent having poor nutrition habits. 19 percent with high stress and so forth. Now, we looked at these risk factors independently and we controlled for over confounders, demographics and looked at a three year time window and discovered that the two psychosocial risk factors were the most predictive of increased healthcare costs in the short-term. Depression and stress. People who reported to you that they were depressed were 70 percent more expensive than those not depressed. People with high stress and were not able to manage that stress, 46 percent more expensive. People with high blood glucose 35 percent. Overweight, 21 percent and so on. We also looked at it from a population standpoint. 6 employers, all of the data in there. Roughly 80 million dollars spent on healthcare expendteres for the six employers. 25 percent fell into the 25 modifiable risk factors. And roughly 428 dollars per capita in 1996 dollars. So the question then becomes yes, we know that these modifiable health risk factors are expensive, they cost . Page 39 . us money and all else being held equal, if we have the risk profile in our population it will cost us more than if we don't. The question then becomes well, can you change the risk profile of the population? And the evidence is that yes, but it's not easy to do. It's not easy to change population health. However, there are good examples out there, again in the work site literature, that have demonstrated that if you construct, design and implement a multicomponent health promotion disease prevention program, that you can actually sustain health improvements over large populations over a long period of time. These were the results of a review of literature that we conducted that was funded by the centers for disease control and prevention, looking at studies spanning over a 20 year period, ended up with roughly 50 studies that came to the conclusion basically that health promotion programs, multicomponent programs, vary tremendously in terms of their comprehensiveness, intensity and duration, but well conducted studies suggest that providing opportunities for individualized risk reduction programming, within the context of a broader health promotion disease prevention program is the most important ingredient in terms of providing an effective program. . Page 40 . Now, there is a body of literature out there, this is an example of a study we did at Citibank that looked at time one, HRA administration, health risk administration, time 2, over a five-year period looking at changes in population health both of people who reduced their risks and people who may have moved into high risk categories, 8 out of the 11 factor, we found significant positive improvements in population health. But you can tell the improvements were not always very very large. But nonetheless, if you see changes in the population oftentimes you can then correlate financial impact as a result of those risk factor improvements. In this example, we found that people who showed a net improvement in three risk factors were able to save Citibank roughly 146 to 147 dollars per employee per month. And if you combine it altogether and look at the overall return on investment for this program, this was a study that we conducted for Citibank looking at its population. Consisting of close to 50,000 employees in the United States, 50 percent participation rate in the program, with a very modest incentive to participate in the program, just $10 rebate off their medical premium as an incentive for them to participate in the program. About 3,000 people were triaged in the high risk . Page 41 . intervention programs. The results are as follows. We looked at a 1 and a half year preperiod and 2 year post period after the program was initiated. Both participants and nonparticipants increased in terms of the overall healthcare costs. But if you look at the differences, there is roughly a 45 dollar difference between participants and nonparticipants. If you subtract the 10 dollars in the preperiod, you have 34 to 35 dollar cost savings of participants versus non, multiplied by the 11,219 participants over the roughly, 24 month period of intervention and you end up with a savings roughly 8.9 million dollars. And the question then is for Citibank, how much did they spend on the program and what was the ROI? They invested a little under 2 million dollars in the program, saved 8.9, so a net savings of 7 million dollars, which was a ROI in the program. We were involved in evaluations of wellness, health promotion and disease prevention programs at Johnson and Johnson. You may know they have been the leader in the health promotion and disease prevention programs, going back to the 1970s. In 1995 they decided to change and enhance the program and also offer a very significant incentive to participate in the . Page 42 . program. In fact, there was $500 reduction rebate in their medical premium for employees who participated. This garnered them a 90 percent participation rate in the program. And we looked at financial impact and health could you tell comes. This was the longest term one done, five years pre, four years post. On the medical side, we documented savings of roughly 2 25 dollars per employee per year. And what was remarkable is as we moved further along, from the point of when the program was changed in 1995, the savings actually increased over time. We also were able to track health improvements in the population and in 8 out of the 13 categories we saw significant positive improvements in the health risk profile of the population. Overall, Johnson and Johnson's health and wellness program resulted in annual savings of about 8.6 to 8.8 million dollars to the company. There were several systematic reviews of literature that looked at ROI for health disease management programs. This is one example of one that we conducted. If you are interested in any of these articles or literature, see me afterwards, give me your card and I'll be happy to e-mail it to you. We looked at health . Page 43 . management programs, and identified these 9 corporate initiatives that have been conducted over the past few years. You can see that the ranges in ROI were from a low of 1.4 to 1. 4.9 to 1. With a return on investment, 3 to 1. We conducted a study at Proctor & Gamble, polled the population, the employees in Cincinnati, 4,000 people in treatment and 4,000 in the control group. At the end of three years, there was a 29 percent difference in overalll healthcare expenditures. When we isolated lifestyle related categories, the difference was 36 percent difference. There was a more extensive review of literature on the financial impact of health promotion programs. He got 72 studies that met the criteria for inclusion in the review. And then assigned them various grades, depending on the level of rigor used in conducting the studies, from experimental design, down to e, expert opinion. The conclusions were that when you looked at health promotion program impact on healthcare costs, out of 32 studies evaluated, 28 had positive outcomes, 4 had no impact. But none of the four studies were the a category random mized trial disease. The average period was 3 and a quarter years, and ROI average 3 and a half to 1. When he looked at absenteeism studies, fewer numbers. 14 studies, but all . Page 44 . of them had positive outcomes, for those, where an ROI could be collated, it was higher, close to 6 to 1. Now, all of this work as I noted earlier has been done in the private sector with corporations. They have paid for this kind of research. The challenge is can we take some of this good work, not only the evaluation methodologies that have been tested in the corporate sector but also the intervention methodologies and try to implement and use them in the public sector? And Dr. Marks certainly highlighted the fact that our senior Medicare population is growing dramatically and the question then is whether some of these intervention programs and methods can then be applied, translated from private sector into public policy, and we are involved in one such initiative. It's one that is funded by the centers for Medicare and Medicaid services, Kathleen and Pauline are shepherding this program through. It's under the initiative for the senior risk program. The problem we are trying to solve is that of the 35 million seniors enrolled in Medicare, those who report poor health spend five times as much as those who report excellent health. Dr. Jim Freeze put forward a compression of morbidity theory. And Dr. Marks showed some of the data from the University of . Page 45 . Pennsylvania that supports some of the findings and some of the under pinning of Dr. Freeze. But the research suggests that people who adopt good health habits, even later in life, after age 65, can forestall disability, improve their health and use fewer healthcare resources. The Department of Health and human services has an interest in keeping beneficiaries as healthy as possible for as long as possible and the potential gains to seniors covered by Medicare and to society as a whole may be substantial. The purpose of this senior risk reduction program is to examine whether private health sector initiatives can work with Medicare beneficiaries and reduce avoidable healthcare expenditures. To identify best ways to reduce risk factorness a senior population. Identify and test effective tailored intervention programs. Facilitate evaluation of program impact. Test the program's ability to make referraling to community and volunteer programs. Determine whether program features are acceptable to beneficiaries, and then to test and develop a design that can test and examine the cost impact and eventually return on investment. Current status, we are involved now in designing the demonstration. This design is being coordinated with . Page 46 . other federal agencies. We hope to have the design completed. And presented to OMB later this year, in November. And once abproved, the demonstration, which is a randomized clinical trial study will be implemented and evaluated, which is over a 3 to 5 year time period. So to close, the vision that I have is that in the future health promotion disease prevention programs will become a critical factor that influences the health and productivity of Americans. Lessons learned from the private sector will be applied, where appropriate, in public sector initiatives. The value of health promotion and disease prevention will be supported by excellent research and demonstration projects. Increased investment in the health, promotion disease prevention will prove that it pays off again with large scale demonstration projects, through improvements in population health and efficient management of health and productivity costs. I thank you for the opportunity to present this morning. Thank you very much. (Applause.) >>RICHARD CARMONA Thanks Dr. Goetzel for that presentation. Both you and Dr. Marks made persuasive cases that prevention does pay. And now, it's my pleasure to introduce two . Page 47 . leaders who are putting prevention first. Last summer the President issued an executive order for 9 cabinet departments to work together to improve health for the American people. One outcome was the establishment of a memorandum of understanding to facilitate collaboration between the department's of education, agriculture and HHS. Together, we are encouraging youth to adopt healthy eating and physically active behaviors. We are cochairs on a committee that integrates efforts across the departments to improve the held and education of young people. This partnership is an example of how the federal government is coordinating efforts to create synergies in an environment where all Americans know how to make healthier choices and act on them. Let me start by introducing Secretary Paige, the Department of education, with the vast array of services is a partner in reaching the most valued treasure, our children. Current data shows that there is an obesity epidemic among our children as well as an increase in diabetes. Children are not as active as they once were and they are bombarded with advertisements for snacks, and that bigger is better. It is imperative that we proceed the prevention message to them but we must do more than express the . Page 48 . importance every making healthy choices, eating right, getting exercise, avoiding tobacco and drug use. We must also provide kids and teens the information and opportunities to engage in this healthy living. Physical activity, nutritious foods and safe environments. Our children need to learn the importance of healthy choices now, because these choices will be the basis for healthy lifestyle in adulthood. This is how we prevent future heart disease, cancer and diabetes. Communicating these messages and opportunities during the growing years and in their educational settings is imperative. And Secretary Paige is a dedicated partner to providing these opportunities. On january 20, 2001, the US Senate confirmed him as the US Secretary of education and the first African American to serve in this role. He has been a teacher, coach, a school Board member, dean of a College of education, and a superintendent of the nation's 7th largest school district in Houston. His vast experience as a practicioner from the blackboard to the Board room paid off during long hours of work to pass the no child left behind act of 2001. Now he leads the charge in partnership with the states to implement these historic reforms that give local districts the tools and resources to help every child learn, regardless of the color of the . Page 49 . skin or accent of the speech. I'm pleased and proud to present to you Secretary Paige. (Applause.) >>RODNEY PAIGE Good morning. Thank you so much for that warm introduction. I want to thank Secretary Thompson for this opportunity to come, and also for the compachl am that he is setting. I don't know if you noticed, but he lost a few pounds. He has been working on that, setting a great example. Secretary Veneman is here as well, and I'd like to say hello to her and thank her for her leadership. I'm having difficulties seeing this... I appreciate the opportunity to join you this morning. Because this gives me the opportunity to talk about something that is very dear on my heart and dear to the President's heart as well. And that is improving the quality of education in the United States of America. The no child left behind act of 2001 lays out the President's vision for America. And the President has tasked us with the responsibility of assisting with this vision. And he has put a goal before America and that bold goal is to create in the United States of America schools that are worthy of this great nation, schools that leave no child behind, that . Page 50 . set high expectations for all children. And expect high performance from all children. This is a bold goal. No society has ever attempted this and no society has ever accomplished this. But we believe it can be done because we are the United States of America. And every child has a right to a quality education. Education is a civil right; just like the right to vote or the right to be treated equally. No child can experience the other rights if they don't get a chance to get a proper education. I spent my entire life involved in education, either seeking an education for myself or in helping others gain an education. And in these years I've seen a lot of well meaning efforts to improve the quality of education in the United States of America. A lot of well funded efforts by good and caring people. But yet, even today, 20 years after a nation at risk alerted us that we had problems in our system, many of these problems still remain. But in all my years, I've never seen an opportunity better than the opportunity we have now in order to correct these problems. The no child left behind act provides the appropriate framework. This framework calls for accountability across all levels. It calls for flexibility and local control, concerting the United States Department of Education from an agency that primarily . Page 51 . monitors to an agency that works in partnership with the states in order to assist them in reaching the goals. Providing expanded options for parents so they can become a part of this activity and making sure that our pedagogy is based on science. Doing what works. I'm here today because our goal of making sure that every child has a quality education depends a lot on what happens here today and on what we do about children's health. A child that is not feeling well is not going to be a child who can learn well. So we begin to focus on the idea that our first responsibility is to make sure that a child is safe in school and that a child is well, so that they can function and concentrate on their lessons. When President Bush launched this initiative last June, better health is an individual responsibility was his comment. But it is of national interest. So we took that to heart in the U.S. Department of Education and we began to organize ourselves so that we can be a part of this great goal. And so that we can help accomplish it. We know the difficulties that health and obesity presents to children's learning. Researchers estimate that 1 in 7 children are severely overweight or obese. In an article published last June in the American Medical Association researchers explained what this means to a . Page 52 . child. And they indicated obese children rate their quality of life scores as low as those young cancer patients on chemotherapy. What kind of physical and emotional damage obesity does for children. Teasing in schools. Difficulty playing sports. Fatigue. Other obesity problems are all problems for children. They severely affect a child's ability to learn. So in the U.S. Department of Education, we are organizing ourselves so that we can point initiatives towards accomplishing the goal of providing better health for young children. I thank Secretary Thompson for this opportunity and we pledge the resources and efforts and the good will of all the men and women in the U.S. Department of Education to make sure that we do as much as we can to make sure each child comes to school, ready to learn, and that they are aware of the opportunities that health provides for them in order to accomplish the goal that the President set for all of us, to make sure that our schools are places of high learning, high expectations, and that we create in America school systems that are worthy of this great nation, schools that leave no child behind. Thank you so much for this opportunity. God bless you . Page 53 . and God bless America. (Applause.) >>RICHARD CARMONA Thank you Secretary Paige for your commitment, dedication and partnership in helping to teach our children to make dedicated choices, one they will continue as healthy adults. The 4 H clubs, the play hard initiative, wick program and the work with HHS on the development of the dietary guidelines for Americans, that is a small sampling of the Department of Agriculture's contributions to preventing disease and promoting healthy behaviors. This department with its exception sl leadership does so much in the area of prevention. HHS and the U.S. Department of Agriculture have a long history of collaboration, and we are grateful for the support, dedication and partnership with USDA in promoting the prevention message. Ann Veneman was sworn in as the 27th Secretary of the U.S. Department of Agriculture on January 20, 2001, from 91 to 93 she served as USDA's deputy Secretary, the department's second highest position. At various times, she served as deputy underSecretary of agriculture for international affairs and commodity programs as associate administrator for USDA's foreign agricultural service and Secretary of the . Page 54 . California Department of Food and agriculture. In this last position, she managed the agricultural programs and services for the nation's largest and most diverse agricultural producing state. The Secretary grew up on a farm and now is the nation's top spokesman on agriculture. Her lifelong commitment to food and with her bipartisan approach to solving problems and confronting new challenges make her a strong leader in prevention, especially in the area of nutrition. It's my honor and privilege to introduce Secretary Ann Veneman. (Applause.) >>ANN VENEMAN Good morning! Thank you very much for that kind introduction. It's a pleasure to be here this morning to share in this important conference with you. I want to thank both Secretary Thompson and Secretary Paige for being such wonderful partners in our mutual efforts to support the President's HealthierUS initiative. And it is great to be here today to talk about how we can advance this initiative. I think the title of the conference, steps to a HealthierUS, is appropriate. Every journey requires a first step and when it comes to something as vital as the health crisis facing Americans, we all must take that first step today, . Page 55 . even if it's just a baby step. The details of our health crisis are becoming more well-known. But they are no less shocking. Childhood obesity in the United States has tripled since 1980. 6 out of 10 adults are overweight or obese. And those numbers are increasing. The health related cost of obesity and other nutrition related diseases is a staggering $117 billion each year. That is more than the combined budgets of the states of California and Connecticut. The challenge is more than any one person or any entity can handle. And that is why President Bush called on all of us to participate when he announced the HealthierUS initiative last June. He knows and we must accept that all of us have a role to play when it comes to taking steps to a HealthierUS. The four pillars under the HealthierUS initiative show the importance of all of us working together to achieve our goals. First, preventive screenings. I understand firsthand the importance of that message. It was a routine screening last year that detected my breast cancer at a very early stage, which led to treatment. Routine screenings can tell you a lot about your current health status and provide the opportunity to make meaningful changes in your health and in your life. . Page 56 . Second, making healthy choices, such as avoiding tobacco and drugs and the abuse of alcohol. Third, being physically active every day. And fourth, eating a nutritious diet. USDA supports all four pillars. For instance, the US Forest service, which is part of the Department of Agriculture, has an initiative to promote recreational opportunities on our national Forests to enhance physical fitness. We are working in partnership with other public lands agencies such as the Department of The interior to enhance this part of the initiative. But my main focus today is nutrition education and healthy eating. The U.S. Department of Agriculture has been working closely with HHS and the Department of Education to implement the HealthierUS initiative through an action based memorandum of understanding which I signed with both Secretary Thompson and Secretary Paige. This broad memorandum of understanding forms the basis for many of our activities to support nutrition education and physical activities in our nation's schools. The agreement is helping to support USDA's team nutrition initiative, which has the goal of improving children's lifelong eating and physical activity habits. Teen nutrition provides training and technical assistance . Page 57 . to food preparers. It promotes nutrition curriculum and education in schools and it builds support through the the school and community for a healthy -- for healthy school environments. We have sent teen nutrition information to 104,000 schools. And thanks to that distribution, we have signed up hundreds of new teen nutrition schools. We are promoting the HealthierUS initiative nationwide at a conference for educators, business leaders, nutrition and public health professionals, school food professionals and parents and teachers. We are working with the CDC to develop materials that schools can use to improve their nutrition environment. We are working with both HHS and education to support action for healthy kids, a nationwide initiative dedicated to creating health promoting schools that support sound nutrition and physical activity. The collaboration among USDA, HHS, and education has also produced the healthy start, grow smart series. These booklets for parents are tailored for every month in the first year of a child's development. Another way the administration is implementing the HealthierUS initiative is through coordinated multidepartmental demonstration projects in schools that will be rigorously evaluated to help insure successful outcomes. . Page 58 . School districts will be asked to volunteer and participate in the demonstration projects and will be provided financial and other incentives to implement one or more of the four pillars of the HealthierUS. The administration's child nutrition reauthorization proposal includes the nutrition component for these HealthierUS demonstration projects. To earn these nutrition incentives, schools would serve meals that meet federal nutrition standards, offer healthful food options in vending machines, school stores and Ala Carte meals, promote the consumption of fruits and vegetables and deliver nutrition education. USDA is also improving the nutritional health of young people through the Pilot Project to provide fruit and vegetable snacks in schools in several areas of the country. We have heard countless stories about the popularity of these healthy choice alternatives in the schools, and we have included in our child nutrition reauthorization proposal the potential to continue and possibly expand these healthful pilot projects into the next year. Providing healthy school environments is a major goal for USDA in the reauthorization process, and the fruit and vegetable pilot is one innovative approach toward achieving that goal. Also under this reauthorization and . Page 59 . as part of the President's record budget requests for nutrition and food assistance programs, we have proposed $20 million for a breastfeeding peer counselling program under the women, infants and children program. This effort would target nutrition education and information aimed at encouraging women to begin breastfeeding and also increasing the length of time a woman breast feeds her baby. USDA also supports the eat smart, play hard campaign which focuses on the importance of breakfast, healthy snacks, physical activity, and achieving a healthy balance between what you eat and what you do. We recently launched a new website for the campaign at www.usda.gov that provides tools to reach children and their caregivers with these messages. USDA has also stepped up its efforts to support the five a day for better health program, which emphasizes the health benefits of five or more daily servings of fruits and vegetables. And we have the USDA national nutrient database is easier to use than ever. Now it can be downloaded to personal computers and laptops over the Internet. Last October we made a portable version available for PDAs. We all have a responsibility to promote healthy choices and nutrition. Parents can serve as examples of healthy eating and . Page 60 . physical activity. Family, communities and faith based institutions can make healthy eating and exercise shared activities. Teachers can find ways to build nutrition and physical education into their curricula and school administrators can work towards a healthy school environment. And the media can help by promoting nutrition and physical activity at times that reach children and their caregivers. I want to reiterate my thanks to Secretary Thompson and Secretary Paige for this enhanced commitment to the HealthierUS initiative. And I have mentioned today. USDA is committed to supporting the HealthierUS initiative and to helping Americans make better lifestyle choices. We are proud to be heading down this road with our partners, our colleagues, and all of you. The progress that we are able to make today will pay off many times over in a healthier society for tomorrow. Thank you very much. (Applause.) >>MALE SPEAKER Ladies and gentlemen. I'm delighted that we have a thousand plus people for this conference and I thank all of you from around the country for coming here. You're the messengers and -- . Page 61 . (Applause.) -- and I wanted to just close out this session by first thanking our wonderful Surgeon General. Richard Carmona, who travels all over the country, speaking about prevention and about how we can work together. So, I would love to have him get a big round of applause for the job that he does and I thank him so very much. (Applause.) And the two wonderful outstanding secretaries, the cabinet secretaries, who do such a tremendous job. Secretary Ann Veneman, who is the 27th Secretary of Agriculture is just doing a super job of getting out and talking to people about eating correctly. And we all know that's really the cornerstone of what we have to do. Plus she's recovering from her own bout with cancer and what a delightful, wonderful, vivacious person to work with and for America. It is my honor to just say Ann, you are outstanding, beautiful, dedicated, and talented. The great Ann Veneman. Thank you so very much. I really appreciate it. (Applause.) And then there is the shy guy, named Rodney Paige, that has taken on the country by storm, making sure that every child gets a chance for a good education and . Page 62 . has the audacity to stand up and say, you know, we should also speak about values in education. You know, something really radical. And I'll tell you, Rod, you just do a wonderful job and I'll tell you this much, ladies and gentlemen, what we have to do is we have to start convincing our education situation and systems all over America to start putting back physical education in our schools. And that's a promise -- and that's -- (Applause.) And that is the great Rod Paige just doing a wonderful job. I thank you, Rod for being my friend and doing the great job for children all over America. Keeping them well, and healthy and also intelligent. Thank you so very much. (Applause.) We also blessed today by having an outstanding Congressman from have area, the Congressman from Baltimore, Congressman Cardon who just does an excellent job. And he told me before I came out here that he wants to take our message that we are delivering here today to all of you and across America to the Congress, and that's what we have to get some dollars, get some prevention initiatives going, and I want to have Ben stand up and take a bow for the great job he does here and I thank him so very, very much. . Page 63 . (Applause.) And thank you again for coming. I'll be talking to you and with you at noon and we are going to have a wonderful couple days. And I just want to say once again, thank you for coming and being involved in prevention, because that's what's going to make a difference for America. Thank you very much. (Applause.) >> MALE SPEAKER Well, ladies and gentlemen, you can see why my job is made easier with this type of leadership. One of the things I've been fortunate with is having such a mode separated boss and Secretary Thompson who not only gives us leadership and direction but leads by example in everything that he does as does the President. And it's made the job of the Surgeon General much easier. At this point, we would like to take a break. 15 minutes, please, and if you're not back in time, I'll send Denise Austin after you. So 15 minutes, please. Thank you. . . .