Testimony

July 15, 2004

Introduction

Mr. Chairman, Members of the Committee, thank you for the opportunity to participate in today's hearing and this important discussion on healthy lifestyles, health promotion, and disease prevention.

The United States faces a grave and significant health challenge. Seven of 10 deaths each year are caused by chronic diseases. The underlying causes of these diseases are often risk factors that can be successfully modified years before they ultimately contribute to illness and death. Three such factors-tobacco use, poor nutrition, and lack of physical activity-are major contributors to the nation's leading killers. America's poor eating habits and lack of physical activity are literally killing us. Even worse, America's children are more sedentary and overweight than ever before. The prevalence of overweight has more than doubled in children and tripled in adolescents, and there are indicators that suggest that diabetes rates among children are also increasing.

Chronic diseases account for more than 60% of medical care expenditures. The total cost of obesity is up to $117 billion per year. We estimate the number of Americans dying from obesity will surpass the number of deaths due to tobacco this year. Tobacco use causes 440,000 deaths annually and costs $75 billion just in direct medical costs. In 2002, the estimated cost of diabetes in the U.S. was $132 billion and the work disability rate is 26% for those with the disease and 8% for those without diabetes. That is a lot of bad news. The good news is that while the problem is vast, the solution is achievable, and I want to talk today about my vision for making that happen.

It is one of my primary goals as secretary to make certain that all Americans understand what they can do to protect their health. Prevention is the power to protect your health. I intend to continue to promote a national dialogue about the state of America's health - with prevention as the primary focus. We need to strike a better balance between preventive care and treatment. Our mission at the Department of Health and Human Services is to do just that. There is no better time to put the health of America front and center than now. We need to get off the couch, have fun and live healthy. By practicing even a little prevention, we will have a nation that is as strong in heart and body as it is in spirit.

Department of Health and Human Services Steps to a HealthierUS Initiative

The President recognizes that a healthy America is a strong America. In June 2002, President Bush launched the HealthierUS initiative designed to help Americans, especially children, live longer, better, and healthier lives. The President's HealthierUS initiative helps Americans take steps to improve personal health and fitness and encourages all Americans to: 1) be physically active every day; 2) eat a nutritious diet; 3) get preventive screenings; and 4) make healthy choices concerning alcohol, tobacco, drugs and safety.

Two years ago, I launched Steps to a Healthier US to help Americans lead healthier lifestyles. At the heart of this program lies both personal responsibility for the choices Americans make and social responsibility to ensure that policy makers support programs that foster healthy behaviors and prevent disease. The Steps initiative envisions a healthy, strong, U.S. population supported by a health care system in which diseases are prevented when possible, controlled when necessary, and treated when appropriate.

The central message of the Steps to a HealthierUS initiative is that small steps can make a big difference. We want people to understand that they do not need to make drastic changes to their lifestyles to be healthier. We are not asking every American to run a marathon, join a gym, or give up eating their favorite foods. Small steps, such as playing outside with your children, going for a walk, snacking on fruits and vegetables, or taking the stairs instead of the elevator, can make a big difference in our health.

The cornerstone of the Steps initiative is the community grant program. Last year, the first year of the grant program, 23 communities were funded. This year $44 million is set aside to help additional communities develop action plans to implement programs that promote disease prevention and health. The interest in this program has been overwhelming and we are receiving far more applications than we can fund each year. For next year, we have requested $125 million to support this grant program. These funds are used to help implement community action plans for activities ranging from establishing community walking programs to helping schools, worksites, shopping malls, senior centers and other community locations establish exercise, nutrition, and smoking cessation programs. We are targeting diabetes, asthma and obesity because of their rapidly increasing prevalence in the United States and the ability for individuals to control and even prevent these diseases through exercise, diet and other strategies that will be implemented with these grant funds.

In addition to the community grants, the Steps initiative has several other components. In December of 2003, HHS awarded eight Steps Innovation in Prevention Awards in seven categories to groups and organizations recognizing their accomplishments and highlighting the concrete health improvements that each has achieved. For the past two years in the spring, the Department has sponsored the Steps to a HealthierUS: Prevention Summit in Baltimore, Maryland. The summit brought together more than 1,000 providers and practitioners, educators, and policymakers, community and industry leaders to discuss promising approaches for tackling key challenges. Both of these components of the Steps initiative have fostered the exchange of information about what works to put prevention into practice.

Another aspect of the Steps initiative is the partnership program where other public and private sector organizations work with HHS to support and promote healthier living. These partnerships are designed to encourage other organizations to follow the lead of the Innovation Award recipients.

In the past year, I have met with many individuals and hosted a series of roundtable sessions with business leaders, researchers, providers, insurers, and other interested parties to discuss health promotion and disease prevention issues and strategies. I also convened several departmental workgroups on obesity, diabetes, tobacco use, health literacy and health messaging to review current programs and progress. In April of 2004, I released my "Blueprint for Action" which represents the product of these various efforts and outlines simple action steps to guide individuals in their quest for healthier lifestyles. It also encourages other interested parties and organizations, such as health care providers, employers, communities, insurers, media, schools, and government to collaborate and cooperate to overcome obstacles, to promote healthy lifestyles and reduce the burden of chronic diseases.

In addition, last fall I launched my "Secretary's Challenge-Steps to a HealthierHHS" for employees in the Hubert Humphrey Building. This work site health promotion program encouraged my employees to become more physically active by exercising at least 30 minutes a day, five days a week for six weeks. I plan to take this challenge to all HHS employees and other federal departments soon.

Advertising Campaign

We also are conducting a creative public education and advertising campaign. Our ads run on T.V., radio, and the Internet, in English and Spanish. They are humorous ads that show people finding body parts - love handles, double chins, and big bellies - that have been "lost" by people who are practicing healthier habits. They send the message that small steps can make a big difference in leading healthier lifestyles, and they do so without making people feel guilty or discouraged. This Healthy Lifestyles campaign includes a web site, www.smallstep.gov that offers consumers ongoing ideas, 100 small steps, and support to pave the road to a healthier lifestyle.

Our public service campaign will continue, and we are expanding it with the Ad Council. We will build upon the Small Steps campaign in the coming year, but we also will be adding a new advertising campaign targeting children. We want to educate children early about the importance of being active and eating healthy. We want to help reinforce the messages that parents teach their children: eat your vegetables; go outside and play; put down the video games and play a game of tag. Then later next year, we plan to freshen the adult campaign with new ads.

When you combine these two Ad Council campaigns with our VERB campaign demonstraton, which focused on increasing physical activity among 9 - 13 year olds, we are getting our targeted messages to much of our population. First year data from a VERB evaluation suggests that the campaign reached its target audience and contributed to improved levels of physical activity.

We are providing motivation for our children, their parents, and adults to take the right steps to lead a healthy life. We also can certainly use the media's continued help in getting out these important messages to adults, children, and entire families.

Medicare Modernization Act

If you talk to senior management of corporations in almost any industry about their biggest concerns, you hear over and over about rising health care costs. Much of these costs are linked to preventable chronic diseases. That is why employer spending on prevention is a wise investment. When I talk with employers or insurers or food producers, I tell them, if you have not made an effort to make your policies consistent with healthy habits, you are missing an opportunity to lower health care expenses and absenteeism, and increase productivity.

We at HHS are leading by example. Medicare is the Nation's largest provider of health insurance, affecting more than 40 million seniors and people with disabilities. With this past year's Medicare Modernization Act, I pushed to include more preventive benefits in Medicare. Now, starting in January 2005, seniors entering Medicare will be offered a complete, "Welcome to Medicare" physical. In addition, all people on Medicare will be covered for blood tests that can diagnose heart diseases. Additionally, those high at risk for diabetes will be covered for blood sugar screening tests.

It makes sense to spend money on preventive medicine. Preventive care enables doctors and patients to diagnose and treat health problems earlier, changing our health care system from a focus on treating disease to a focus on preventing disease. This shift in thinking will pay off not only in lower health care expenses, but also in a better quality of life for all Americans.

Overview of Obesity and Diabetes Epidemic in U.S.

Today we face an epidemic of obesity - a major risk factor for heart disease and stroke, diabetes, and certain forms of cancer. Right now, our country is just too fat, and we have a crisis on our hands. By way of comparison, obesity has roughly the same association with chronic health conditions as does 20 years of aging. Few of our citizens have healthy nutrition and physical activity levels. The impact of this physical inactivity on medical costs is substantial and is likely to grow unless trends in physical activity change among older adults.

In the United States, obesity has risen at an alarming rate during the past 20 years. In fact, two out of every three of Americans now are overweight or obese. Even worse, the prevalence of overweight children has risen drastically. More than half of children who are overweight have at least one additional cardiovascular disease risk factor, such as elevated cholesterol or high blood pressure.

In 2000, the cost of diseases associated with obesity was estimated to be $117 billion for direct and indirect costs. Of the approximately $1.6 trillion [$1.3 in 2000 but $1.6 in 2002 according to CMS] spent on health care each year, about 75 percent of these dollars are spent treating chronic diseases such as heart disease, cancer, and diabetes, and $75 billion of that treats obesity alone.

In fact, there is a corresponding overwhelming rise in diabetes that we cannot afford to ignore. Today, at least 18.2 million Americans have diabetes, of which 5.2 million have the disease but have not yet been diagnosed. At least 41 million more have the condition known as "pre-diabetes." These people have higher than normal blood glucose levels and are at increased risk of developing diabetes. These facts are too troubling to disregard and too grim to just accept. Type 2 Diabetes was once considered a disease of the middle-aged and elderly, but now we are seeing it in our children.

My Department and this Administration absolutely refuses to accept the increase in the prevalence of diabetes, currently the sixth leading cause of death in America. We must act against this long-term public health crisis of obesity. If we do not improve, the gains in life expectancy and quality of life resulting from modern medicine's advances on disease will erode, and more health-related costs will burden the nation. We must educate Americans about how to take responsibility for their own health and the health of their family members, how to build healthy nutrition and physical activity into their daily lives, and how to make wise choices.

Therefore, we are acting for change, acting boldly and with energy and focus. The agencies of my Department are performing leading-edge research, and looking for ways to use those research findings to lead us to action.

Although the increasing burden of diabetes and its complications is alarming, much of this burden could be prevented with early detection, improved delivery of care, and better education on diabetes self-management. A modest and attainable improvement in our level of activity and the food we eat will work wonders. It is scientifically proven that moderate physical activity can substantially reduce the risk of developing type 2 diabetes - not to mention heart disease, colon cancer, high blood pressure and obesity. We are doing everything we can to make diabetes a bad memory, and we will not accept such a thing as a "tolerable" incidence of diabetes, while we can still research more, educate more, and treat more Americans.

We are taking a number of other important steps to address obesity, diabetes and improve the overall wellness of Americans:

In November of 2003, HHS launched the Diabetes Detection Initiative: Finding the Undiagnosed. This community- based effort seeks to identify persons with undiagnosed type 2 diabetes and refer them to follow up blood testing and treatment if necessary.

We also are in the process of consulting with the public and relevant stakeholders on diabetes issues. As part of the process to create this action plan, three half-day town hall "listening sessions" are scheduled in different parts of the U.S., to highlight the important steps that individuals, health care practitioners and providers, businesses, and communities are taking to detect diabetes and educate patients, their families, and other Americans. The first town hall meeting focused on prevention of diabetes and was held in Cincinnati, Ohio on March 29, 2004 with over 350 attendees. The second town hall was held in Little Rock, Arkansas on June 18th and discussed diabetes detection and education. The third town hall meeting is scheduled for Seattle, Washington on July 26, and will focus on treatment of diabetes.

Other departmental activities include:

FDA

In August 2003, FDA established an Obesity Working Group (OWG) to advise the Agency on innovative ways to deal with the increase in obesity and to identify ways to help consumers lead healthier lives through better nutrition.

In March 2004, the FDA released its comprehensive report to combat obesity with a focus on the message, "Calories Count." The report focuses on providing consumers with better information to help them lead healthier lives through better nutrition.

The FDA is presently working to:

1. Improve Food Labels.
   Consumers need more information to make sound food choices in the areas of calories and serving sizes. FDA has received petitions from manufacturers to provide for nutrient content claims for the carbohydrate content of foods. FDA is in the process of evaluating the petitions and plans to define terms such as "net," "low," and "impact" so that consumers are armed with better and more accurate information when making food choices.

   FDA is also encouraging the use of comparative labeling statements to make it easier for consumers to compare different types of foods and make healthier substitutions. For example, "One medium apple (80 calories) contains 47% fewer calories than a one ounce serving of potato chips (150 calories)."

2. Restaurant Nutrition Information
   FDA is urging the restaurant industry to launch a nation-wide, voluntary, and point-of-sale nutrition information campaign for customers. FDA also encourages consumers routinely to request nutrition information when eating out. In addition, the final report calls for the development of options for providing voluntary, standardized, simple, and understandable nutrition information, including calorie information, at the point-of-sale in a restaurant setting.

3. Increased Enforcement Activity
   FDA plans various enforcement activities to ensure the accuracy of the information in the Nutritional Facts panel and to ensure that consumers can monitor their intake of calories and nutrients. This includes stricter enforcement activities against those manufacturers that declare inaccurate serving sizes.

This past year also witnessed a major change in the nutrition label on foods to include a separate listing of trans fatty acids. This was the first significant change on the Nutrition Facts panel since it was established in 1993.

The FDA has also undertaken a broad effort to crack down on misleading information and/or unsafe dietary supplements, and proposed new regulations to establish good manufacturing practice requirements for dietary supplements. The FDA took steps to remove dietary supplements containing ephedrine alkaloids from the market. These products were extensively promoted for aiding weight control and boosting sports performance and energy. One of the key messages of this effort is that there are no safe quick fixes when it comes to losing weight and improving athletic performance, and it is only through proper diet, nutrition and exercise that we can improve our physical performance and, more importantly, maintain and improve our health.

And, the FDA is partnering with other federal agencies to combat obesity among kids. The Power of Choice is an after-school program developed jointly by HHS's FDA and USDA's Food and Nutrition Service. The materials guide pre-teens toward a healthier lifestyle by motivating and empowering them to make smarter food and physical activity choices in real-life settings. A Leader's Guide, containing ten sequenced interactive sessions engage adolescents in fun activities that develop skills and encourage personal development related to choosing foods wisely, preparing foods safely, and reducing sedentary behaviors. Most activities require little or no pre-planning and are simple to do. The Leader's Guide also includes easy snack recipes, 170 Nutrition Facts cards, and posters on four key topics, and a computer disk provides supplemental activities to each of the 10 sessions, a self-training video for the leader, community support suggestions, and much more.

NIH

Through its research mission, the NIH is seeking to capitalize on recent scientific discoveries to further understand the forces contributing to obesity and develop strategies for prevention and treatment. NIH expects to spend roughly $400 million this year on obesity-related research, and the Administration has requested more than $440 million for FY 2005.

As the problems of overweight and obesity have grown, the need for new action and research has become more evident. In response, NIH assembled a Task Force to identify areas for new research across its many institutes. In March 2004, NIH released the draft of its Strategic Plan for NIH Obesity Research (www.obesityresearch.nih.gov). This report identifies key areas of research needed, priorities among those areas, a road map and strategies for advancing these research priorities, and the establishment of a committee for monitoring progress in addressing the issues and problems relating to overweight and obesity. The NIH expects to make the final, published Strategic Plan for NIH Obesity Research available shortly.

5 A Day for Better Health

One of the most recognizable efforts to promote good nutrition and healthy eating habits has been the National Cancer Institute's 5 A Day for Better Health Program. This national nutrition program seeks to increase to 5 or more the number of daily servings Americans eat of fruits and vegetables. In addition to its widely known slogan, the 5 A Day program reaches many individuals through health care provider networks, the internet, and print media to provide information about the health benefits of eating more fruits and vegetables, as well as easy steps for adding more of them into daily eating patterns.

CDC

The National Nutrition and Physical Activity Program to Prevent Obesity

With 2004 funding, the CDC will support obesity prevention programs in a total of 28 states. Of these, 23 states will be funded at the capacity-building level to hire staff with expertise in public health nutrition and physical activity, build broad based coalitions, develop state plans, identify community resources and gaps, implement small-scale interventions, and work to raise public health awareness of changes needed to help state residents achieve and maintain a healthy weight. The other five states are funded at the basic-implementation level to put their state plans into action, conduct and evaluate nutrition and physical activity interventions, train health care and public health professionals, provide grants to communities, make environmental changes, and strengthen obesity prevention programs in community settings.

In addition, CDC provides funding to 23 states for the implementation of school-based policies and programs to help young people avoid behaviors that increase their risk for obesity specifically unhealthy eating and inadequate physical activity.

Making it Happen - School Nutrition Success Stories (MIH)

This material features the stories of 32 schools and school districts that have implemented innovative strategies to improve the nutritional quality of foods and beverages offered and sold on school campuses. MIH is a joint project of the Food and Nutrition Service of USDA and the Division of Adolescent and School Health of CDC.

Other Key HHS Activities

Administration on Aging Action

The Administration on Aging's (AoA) National Policy and Resource Center on Nutrition, Physical Activity and Aging was created for the purpose of increasing and improving food and nutrition services to older Americans through their caregivers at home, with community-based service providers, and in long-term care systems. The Center focuses on linking proper nutrition and physical activity as key themes in the healthy aging process. One strategy for making this link has been the development and publication of a community guide entitled, "You Can! Steps to Healthier Aging", that details a 12-week program to help older Americans "eat better" and "move more." The Center is awarding 10 mini-grants to local communities to implement the You Can! Program in 2004.

AoA provides funding to states to implement health promotion and disease prevention activities. Educational information is disseminated through Senior Centers, congregate meal sites, and home-delivered meal programs. Health screening and risk assessment activities including hypertension, glaucoma, hearing, nutrition screening, cholesterol, vision, diabetes, bone density, and others are also provided. Physical activity and fitness programs are provided along with education about the prevention and reduction of alcohol, substance abuse, and smoking.

Conclusion

We must continue to work hard to spread the gospel of personal responsibility. Each of us has to take responsibility for making the right choices when it comes to diet and exercise. My Department has taken steps to promote this attitude - and most importantly, we are trying to do it in creative ways without inflicting the guilt that turns so many people off.

From the day I arrived at the Department, I made healthy living and disease prevention our cornerstone priority. I put our whole Department on a diet, and I lost fifteen pounds myself. I began handing out pedometers, to help people walk 10,000 steps a day. Now they are a fashion statement.

My challenge to Americans is to find a way, not just one way, but several ways to spread the message of healthy living. Through employers, neighbors, churches, community groups, and even your own family, there are countless opportunities for each of us to encourage disease prevention and healthy living in our own lives.

I thank you for your interest and the opportunity to share with you some of HHS's many activities related to promoting healthy lifestyles and reducing the burden of obesity and chronic diseases in America. Let's keep the dialogue going so this issue stays on our radar screen until it is not a problem anymore. We can work together to make this happen.

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