> DEPARTMENT OF HEALTH AND HUMAN SERVICES
>
> SECRETARY\'S ROUNDTABLE ON
>
> OBESITY/NUTRITION
>
> Wednesday, July 30, 2003
>
> 10:00 a.m.
>
> Humphrey Building
>
> Secretary\'s Conference Room
>
> 200 Independence Avenue, S.W.
>
> Washington, D.C.
>
> PARTICIPANTS:
>
> SECRETARY TOMMY G. THOMPSON, DHHS
>
> DR. CAROLYN CLANCY, DHHS
>
> DR. CRISTINA BEATO, DHHS
>
> DR. JULIE GERBERDING, CDC
>
> DR. ELIAS ZERHOUNI, NIH
>
> DR. LES CRAWFORD, FDA
>
> DR. RICHARD CARMONA, FDA
>
> DR. MARK McCLELLAN, FDA
>
> DR. F. XAVIER PI-SUNYER, St. Luke\'s-Roosevelt
>
> Hospital and Columbia Hospital
>
> DR. CHARLES MUSCOPLAT, University of
>
> Minnesota
>
> DR. DONALD HENSRUD, Mayo Clinic
>
> DR. NANCY CHILDS, St. Joseph University
>
> DR. MICHAEL DOYLE, University of Georgia
>
> DR. MORGAN DOWNEY, American Obesity Association
>
> DR. LINDA MEYERS, Institute of Medicine
>
> DR. WALTER WILLETT, Harvard School of Public
>
> Health
>
> DR. MAUREEN STOREY, Virginia Tech
>
> DR. ALBERT STUNKARD, University of Pennsylvania
>
> DR. DENNIS SAVAIANO, Purdue University
>
> DR. JIM HILL, University of Colorado Health
>
> Sciences Center
>
> DR. SUE CUMMING, American Dietetic Association
>
> DR. GEORGE BLACKBURN, Harvard Medical School
>
> DR. GEORGE BOUCHARD, Pennington Biomedical
>
> Research Center
>
> DR. DAVID KATZ, Yale School of Medicine
>
> DR. SANDY SCHLICKER, American Society for
>
> Clinical Nutrition
>
> DR. BILL SOLOMON, Center for Medicare and
>
> Medicare Services
>
> C O N T E N T S
>
> [SPEAKERS:]{.underline} [PAGE]{.underline}
>
> Dr. Julie Gerberding 11
>
> Dr. Elias Zerhouni 14
>
> Dr. Les Crawford 17
>
> Dr. Richard Carmona 18
>
> Dr. Mark McClellan 19
>
> Dr. Carolyn Clancy 24
>
> Dr. Cristina Beato 25
>
> Dr. F. Xavier Pi-Sunyer 25
>
> Dr. Charles Muscoplat 30
>
> Dr. Donald Hensrud 35
>
> Dr. Nancy Childs 39
>
> Dr. Michael Doyle 43
>
> Dr. Morgan Downey 50
>
> Dr. Linda Meyers 61
>
> Dr. Walter Willett 63
>
> Dr. Maureen Storey 63
>
> Dr. Albert Stunkard 68
>
> Dr. Dennis Savaiano 70
>
> Dr. Jim Hill 73
>
> Dr. Sue Cumming 79
>
> Dr. George Blackburn 83
>
> Dr. George Bouchard 86
>
> Dr. David Katz 90
>
> Dr. Sandy Schlicker 98
>
> Dr. Bill Solomon 107
>
> P R O C E E D I N G S
>
> SECRETARY THOMPSON: I can\'t thank you enough for being here. I am
> just delighted that we are able to have so many distinguished
> researchers and scientists with us today. And to have the opportunity
> to discuss an issue that is plaguing America\--and for that matter the
> world.
>
> And when you look around and find out that, in America we have,
> according to CDC\--first, let me introduce Dr. Julie Gerberding from
> CDC and Dr. Elias Zerhouni from NIH and Les Crawford from FDA and
> Surgeon General, Dr. Richard Carmona and Dr. Mark McClellan from
> FDA\--all individuals that are as passionate as I am about this
> subject.
>
> But based upon the figures of CDC, 125 million Americans are suffering
> from one or more chronic illnesses. And then you look at the cost of
> those diseases affecting America and the health conditions of
> Americans, it\'s not very good. I mean, it\'s\--we\'re not a very
> healthy society. And \$155 billion a year goes into tobacco-related
> illnesses; easily preventable by stopping smoking. And 400,000
> Americans die each year; one out of five die from tobacco-related
> illnesses.
>
> And then \$132 billion a year spent on diabetes and 17 million
> Americans are diabetic; 16 million are prediabetic and 16 million of
> the 17 million have Type 2 diabetes. And NIH has just done an
> exhaustive study with 3,500 individuals and it was supposed to run
> five years and they terminated it after two and a half years because
> the evidence was so conclusive that if you walk 30 minutes a day and
> if you lose five to seven percent of your body weight, 10 to 15
> pounds, normally, for most of us\--anyway, me, I put myself in that
> category\--you\'re going to be able to reduce the incidence of
> diabetes by 60 percent. I mean, that\'s preventable and that\'s real
> money, considering the fact that 16 million more Americans are
> pre-diabetic and in the next five years, more than likely, will become
> diabetic and that will double the amount, from \$132- to \$264
> billion.
>
> And then the fastest growing one, of course, is obesity, the one
> we\'re going to talk about today. \$117 billion and 300,000 Americans
> die. And we have become a very fat society and it\'s time for all of
> us around this table to do something about it and that\'s why I\'m so
> pleased that all of you are here.
>
> And it wasn\'t that long ago that C. Everett Koop took on tobacco and
> made it a cause celebre across America. And we, as a society, you
> know, liked to look at his colorful uniforms and his statements, but
> he was able to ignite in America a desire to take a look at tobacco
> and tobacco-related illnesses. And now we fast-forward 20-some years
> later and we still have tobacco, diabetes, asthma and, more
> importantly, obesity.
>
> And I have, as secretary of this department, taken this on as a cause.
> I\'ve got to tell you that I couldn\'t do it without the tremendous
> support and the passion of the five doctors around this table that
> work for the Department of Health and Human Services. I can\'t tell
> you how appreciative I am of the jobs that all of these individuals
> are doing. I said this before, that I think the Department has the
> best employees in the federal government. And I think we have some of
> the best doctors, researchers, and scientists in the world working for
> this department. And I\'m blessed for that and I think America is. And
> they\'re as passionate as I am to try and something about prevention.
> And they have the scientific and the medical knowledge and background
> to do it. They are all out speaking across America about being able to
> accomplish something.
>
> We have been inviting different groups in and other groups have been
> asked\--are asking to come in. And I like that. A lot of corporations;
> first we met with the Restaurant Association and that was probably the
> poorest meeting that I\'ve had on the subject. They were not\--they
> were very defensive because it was right after McDonald\'s had gotten
> sued and they thought that I was going to beat them up and blame
> everything on them. And I wasn\'t, I was trying to elicit a response
> of partnership from them and they, at that meeting, were not going to
> hear any part of it. Subsequent to that time, they have changed and
> have been much more willing to do so.
>
> The fast food industries, on the other hand, have been quite
> supportive of trying to do something. And some of them are putting a
> lot of healthier items on their menus and we have to, I think, keep
> pushing them. McDonald\'s said they were going to stop using
> trans-fatty acids in the cooking of their French fries. They\'ve now
> backed off on that. And I did mention that in a speech to several
> thousand people in Chicago and McDonald\'s was not pleased that I
> mentioned the fact that they had backed off on that, but I don\'t
> care. I think they make a statement and I think that we should
> continue to push in that area.
>
> Coke-Cola came in because I was talking about how good Pepsi Cola was
> doing. And so,
>
> Coke-Cola came in and wanted to tell me that they were doing many good
> things and they\'re handing out the pedometers with McDonald\'s and so
> on and so forth. And everybody should\--I think, you know, everybody
> and I know, Jim, you\'ve got, you\'re using these a lot. I use it
> every day and I think we should get as many of these pedometers out
> and I think people should wear them and use them. I do. And I hand
> them out. I said, I\'ll give you one, but you\'ve got to promise me
> you\'ll use it. Some do, some don\'t. But I got a New York\--one of
> \"The New York Times,\" which, of course, has never written anything
> nice about me or a Republican, but he religiously has used his
> pedometer that I gave him and he let it be known that he\'s lost seven
> pounds. And so I think that\'s a positive thing even for \"The New
> York Times\" reporters, that we want everybody to be healthy, but we
> need to do more.
>
> Pepsi Cola was in yesterday and I was absolutely impressed by the fact
> that they have made a corporate goal that 50 percent of their foods
> and drinks are going to be healthy, that they\'re going to be selling;
> that that\'s their goal, 50 percent. And I said, well, what about 60
> percent? They said that\'s tomorrow. Right now they want to get to 50
> percent.
>
> And I\'m going to keep pushing, but why I bring up Pepsi and Coke and
> McDonald\'s and other fast food is because I think that there\'s a
> real opportunity, a real response out there waiting to happen if we
> really keep pushing this and making things happen.
>
> And that\'s why I\'m so pleased that all of you are here today because
> you are the experts. You have been in this field a lot longer than I
> have. You have much more knowledge and scientific basis for doing
> this. And what we need to do is, we need to join together and really
> develop a coalition and not let this fall through the gaps right now,
> but to really push this to the forefront, like Koop did with tobacco,
> only we\'re doing it with obesity and the whole gamut of prevention
> across the board. But really do something about obesity.
>
> I think America is ready for that. And when you look at the figures
> and see what\'s happening to our children and so on, it\'s amazing how
> much good we could accomplish if we really, really worked hard at it.
>
> So I just wanted to set the stage and thank you for being here and
> being involved and making things happen. And everyone of my division
> heads wants to make a short presentation about what they\'re doing and
> I really appreciate that and I will just go around and then we\'re
> going to open up and go right around the room and listen to your
> concerns.
>
> And I know I\'ve talked longer than I should have and I hope my
> administrators don\'t follow through and feel that they have to match
> me word-for-word. But I would like to have them each give a short
> presentation of what they\'re doing, because they\'re absolutely
> fantastic and are doing a tremendous job. Julie, we\'ll start with you
> and then go to Elias and then Les and then Dr. Carmona and end up with
> Dr. McClellan, as the clean-up batter, then we\'ll just go right down
> the table. Julie.
>
> DR. GERBERDING: Well, thank you. And I am certainly honored to be here
> around the table with this roundtable and to be able to contribute to
> what I think will be a next step in the long process of trying to
> really come to grips with obesity in this country.
>
> CDC has many, many roles in combatting obesity. One of the most
> important ones is the measurement of the problem in the first place.
> Most of the data that the Secretary has cited, of course, comes from
> various kinds of health surveys at CDC.
>
> But we are framing obesity as an epidemic. And I think if you looked
> at the trends of obesity across the United States over the last 15
> years and you watched states get more and more obese over time, it
> doesn\'t send you any other message than this is a powerful emerging
> health threat. The only difference between it and SARS or AIDS is that
> the time frame is slower. But, in fact, the impact on health is much
> larger. And so, we are shaping our strategies based on the framework
> of a major epidemic of a health problem in this country.
>
> We also have, in our chronic disease center, a large focus on
> nutrition and many studies related to understanding the relationship
> between nutrition and obesity and then the intervention programs that
> are really designed to help promote a healthier lifestyle and reduce
> individual weight.
>
> But we also have not just an individual focus. And I think that\'s
> very important to this kind of discussion that can really frame the
> whole issue as an environmental health issue. People are constantly
> exposed to on the one hand to environments that encourage them to eat
> more than they need to. And, on the other hand, environments that
> encourage them to reduce exercise and to have a much more sedentary
> lifestyle. And I think we are taking on the internal challenge at CDC
> to become the safest and healthiest workplace. And a major part of
> that is looking at ways to even, as employers, how can we promote
> better food choices and increased exercise in the context of our own
> buildings.
>
> If every employer in this country did that, we would be able to
> transform the health status because almost everybody whose affected by
> this epidemic works. And, likewise, if we had a similar approach in
> our schools, which we are doing now\--increasingly\--both looking at
> the environmental, as well as the food choice aspects of this. We can
> really make a difference.
>
> So our role is many-fold, primarily, measurement, intervention, and
> then assessment of the consequences of those changes over time. And I
> would add to that, of course, major health communications campaigns. I
> don\'t know how many of you have pre-teens, but if you happen to watch
> \"Nickelodeon\" or MTV, you will see a campaign called \"Verb,\" which
> is a campaign to motivate young pre-teens to get a verb, go where the
> action is, so to get up, get away from the TV and get out and do
> something interesting and exciting. So a variety of approaches, but I
> think that\'s what it\'s going to take to combat this problem.
>
> SECRETARY THOMPSON: Elias.
>
> DR. ZERHOUNI: Thank you, Mr. Secretary. I\'ll make my comments short.
> We had a large meeting of the senior staff of the Department in
> January. And from that meeting it was a priority that the Secretary
> asked all the agencies to work on and that was developing
> comprehensive and coordinated plans to address the issue of obesity.
> NIH put together an transNIH task force that was lead by Dr. Spiegel
> \[ph\] and Dr. L\'Enfant \[ph\] and almost every institute
> participated.
>
> So at this point, what NIH has focused on is to find ways of providing
> scientific evidence for intervention\--on-the-ground intervention
> approaches that could be of support to FDA and CDC and all the other
> agencies of HHS.
>
> However, our focus, also, is going to be on the molecular basis of the
> mechanisms of comorbidities that we are now seeing with obesity. This
> is, fundamentally, one of the implications of the obesity crisis. It
> is the mechanisms by which obesity, itself, is a driver of the
> comorbidities that we\'re seeing which are at risk of changing our
> public health picture over the next 20, 30 years. So that is one pole
> of prioritization.
>
> The second is going to be the understanding of gene environment
> interactions and understanding very, very carefully the relationship
> between neurobiological mechanisms of food intake, energy
> balance\--and we have developed a full matrix that actually has been
> presented to the Secretary that integrates with what Dr. McClellan and
> Dr. Gerberding want to do in terms of having a portfolio\--a transNIH
> portfolio that is comprehensive in its aspects which Dr. Spiegel and
> others\--some of my colleagues here\--can go into greater detail with
> you as needed.
>
> But the point is that we believe that, unless you have a multiprong,
> comprehensive strategy, you will not be able to make an impact because
> it is clear that obesity is not a monofactorial problem. And,
> therefore, it is important for NIH to step up to the plate and provide
> the funding and the ideas and the mechanisms to evaluate the evidence.
> In other words, have evidence-based approaches. Because one of the
> things that we\'re concerned about is that because it is an epidemic,
> because it is a major health problem, that it\'s coming at us at an
> incredible speed, that some of the actions we may take may not have
> the scientific basis that it needs to have. And I\'m really looking
> forward to hear what your advice would be.
>
> But, at the end of the day, we\'re currently trying to task a
> portfolio for about \$300 million of research that is obesity-driven
> and we\'ve committed to increase that according to this developmental
> matrix of the transNIH research program in obesity to a significant
> amount over the next two years.
>
> So that\'s where we are and we\'re looking forward, really, to
> coordinate our plans with those of the other agencies and try to make
> an impact on this issue.
>
> SECRETARY THOMPSON: Les.
>
> DR. CRAWFORD: My passion is for a clear, coherent, and effective
> message that will unify all of us in what we\'re trying to do in this
> initiative on obesity. And I hope this will be the beginning of the
> development of that.
>
> SECRETARY THOMPSON: Thank you, that was great. Thank you.
>
> \[Laughter.\]
>
> You got the gold medal this morning, Les. I\'ll tell you. Dr. Carmona,
> our great Surgeon General.
>
> DR. CARMONA: Thank you, sir. Picking up on what Les said, I always, of
> course, hate to follow my colleagues because there\'s not a lot left
> to say, once they\'ve preceded me. But one of the things that we\'ve
> noticed, and the Secretary has picked up and asked me and my
> colleagues to make sure is part of the equation in solving this
> problem that you\'ve heard is\--and you know\--is multifactorial, is
> the issue of health literacy.
>
> Because we have a wonderful amount of science that\'s emanating from
> all of my colleagues to address this issue. But the question is, is it
> falling on deaf ears. And, as you all are aware, the literature is
> pretty significant in the area to demonstrate that we have a very
> large population in the United States who are relatively health
> illiterate. Even educated people who have college degrees outside of
> science who can\'t read food labels, don\'t understand proteins,
> calories, exercise and the relationships between that.
>
> So, one of the other factors that we have to address is how do we take
> this wonderful science, put it in a culturally competent message to
> cause transformational behavior which will reduce morbidity,
> mortality, enhance wellness and so on. And so, that\'s another issue
> that we have to deal with as we move all of this great science out to
> the public and make the country a lot healthier.
>
> SECRETARY THOMPSON: Thank you, Elias. Mark McClellan.
>
> DR. McCLELLAN: Thank you. I, too, would like to thank all of you for
> coming. And I also want to thank the FDA staff, many of whom are here
> that helped you all get here. I know you had a lot of interactions
> with Pat Kuntze, in particular, Mary-Lacey Reuther and some of the
> rest of our staff.
>
> We really do mean to take your comments and suggestions seriously in
> this effort. We\'re opening a formal docket for comments. We\'re going
> to have a great chance for discussion today. But this is not going to
> be the end of the line. So if you\'ve got other suggestions you want
> to submit to us in writing that follow up on the discussion today;
> that we don\'t have time to get into today, we are going to take those
> and turn them into a report to the Secretary in a way of adding to
> this very extensive action plan that the Secretary has already
> implemented.
>
> You\'ve heard his passion on this issue that has spread out to all of
> us in the nation\'s public health agencies. You\'ve heard from Dr.
> Gerberding and Dr. Carmona, Surgeon General and FDA about what we\'re
> doing. I also want to thank Carolyn Clancy, the head of the agency for
> Health Care Research and Quality, who is working closely with us on
> helping make sure we can help consumers get accurate information about
> what science has to say about the steps they can take to improve their
> health.
>
> This is becoming a major focus at FDA. For all that we do to protect
> consumers from unsafe foods and other products; for all that we do to
> promote the availability of safe and effective medical treatments, it
> really is the decisions that people make themselves that have the
> potential for the greatest impact on the health of this nation.
>
> And that\'s why, in response to the Secretary\'s charge, we have
> implemented a major new program on improving nutrition and improving
> consumer information about nutrition in the United States. This
> includes giving consumers better information, right on the product
> labels. You all are probably familiar with the transfat announcement
> on labeling changes we made recently. That is already having an impact
> on the way that many companies are developing their products, ranging
> from Doritos to, you name it, in the way of snack foods to get those
> levels down.
>
> We are also taking steps to try to promote competition among food
> producers around good science-based evidence on how food choices can
> influence their diet. So, you\'re going to be seeing more
> advertisements soon, if you haven\'t already, about how eating lots of
> fresh fruits and vegetables, for example, can reduce the risk of some
> types of cancer and other chronic illnesses an effort we\'re
> undertaking with NCI. You\'ll see more about how substituting
> unsaturated fats for foods high in saturated and transfat in the diet
> can\--appears to be an important factor in reducing the risk of heart
> disease. You\'re going to see more competition about that.
>
> We are hoping that this will also translate into the development of
> better foods; healthier foods, like the PepsiCo announcement that the
> Secretary mentioned. And we want your suggestions on how we can best
> encourage that. I know many of you all are involved in those efforts
> in the nutraceuticals and the like.
>
> On the medical side, as well, we need to be doing more to translate
> good ideas and research into safe and effective treatments for
> patients. Today, too many people who are worried about losing weight,
> focus on dietary supplements that may help them lose weight but, also,
> appear to carry important risk of increased blood pressure and other
> serious adverse health events. And some people even turn to smoking to
> lose weight, which is definitely a net loser from a public health
> standpoint.
>
> So we need to do better on medical products and this is an area where
> we\'re in the process of developing guidance on product development
> with NIH\'s help and, hopefully, with some help from many of you.
>
> So in this whole area of informing consumers better, encouraging
> better and healthier foods and encouraging better and healthier
> medical products, we need some more applied guidance from you on how
> we can translate the best and latest research into steps that can
> really help consumers. And we thank you all, again, for coming today.
>
> SECRETARY THOMPSON: Thank you very much, Mark. I would like to\--I
> didn\'t realize that Carolyn Clancy and Dr. Beato are here. Carolyn
> runs our\--did you want to say something, Carolyn?
>
> MS. CLANCY: \[Off microphone.\] Sure, just to build on the prior
> comments, good morning. AHRC\'s focus is improving the quality and
> thinking of health care in this country. And if there\'s one area
> where I think all health care professionals recognize that they\'re
> failing\--and they feel very badly about it\--it\'s in dealing with
> obesity.
>
> So our focus, recently, has been, systematically reviewing and putting
> out
>
> evidence-based recommendations from the U.S. Preventive Services Task
> Force, about what can be done about screening and counseling for
> obesity. We\'re also working on some reviews for what is known and
> what\'s the best evidence available on the pharmacological management
> and are working closely with CMS because they, too, are under a great
> deal of pressure as this epidemic hits the Medicare population.
>
> If any of you are interested in reviewing any of these evidence
> reviews, please find me afterwards.
>
> SECRETARY THOMPSON: Thank you, Carolyn. Dr. Beato.
>
> DR. BEATO: Good morning, and thank you, again. As the Secretary
> clearly stated his vision and his passion, we have an incredible
> challenge and not just in terms of the medical information, in public
> health issues and translation. But how do we raise the awareness
> across the country that this is a problem that people need to be
> paying attention to. So we hope to be sort of coalescing all these
> great ideas. Thank you.
>
> SECRETARY THOMPSON: Thank you, Cristina. Now we\'re going to start out
> with, could you
>
> name\--put your name tags so I can see it, Dr.
>
> Pi-Sunyer, we\'re going to start out with you and I appreciate that
> very much. Thank you for coming, doctor.
>
> DR. PI-SUNYER: Thank you, my name is
>
> Pi-Sunyer and I\'m at St. Luke\'s-Roosevelt Hospital and Columbia
> University. I want to compliment you for having this meeting. We have
> one of the earliest NIH-supported obesity centers. So, we\'ve been
> supported and been trying to work in the area of obesity for many
> years.
>
> I think that I am in total agreement with what Dr. Zerhouni has
> mentioned about the need for really some basic research into the
> mechanism of risk that obesity brings.
>
> SECRETARY THOMPSON: This is because you got an NIH grant that
> you\'re\--
>
> \[Laughter.\]
>
> DR. PI-SUNYER: That\'s correct. That\'s correct. But I mean we need to
> know more about what we call the comorbid conditions and the
> relationships between fat, fat distribution, the biology of fat tissue
> and it\'s effect on the killers\--on high blood pressure, high blood
> lipids, high blood glucose, which is what leads to the killer diseases
> that are decimating our population. So, I\'m very much in favor of
> that.
>
> I think we also need more data on the genetic makeups and how
> different genes express different risk factors and the difference
> between people and I think we kind of focused on the biochemistry of
> genes. And I think we need to talk about the effect of genes on
> behavior. We know very little about the genetic make up of behavior.
> And yet, it\'s clear that different people behave differently in front
> of various stimulants, like different foods; different taste
> sensitivities; different smell sensitivities; different thresholds for
> feeling full or not feeling full. And all of these are really based,
> partly on environment, but, certainly, partly on genetics and we know
> very little about that.
>
> I think we need to do more translational kinds of research. I\'ve been
> a member of the Diabetes Prevention Program and the Look Ahead
> Program, both of which are efforts to translate some of the knowledge
> we know about behavior into a change in physical activity and dietary
> approaches and they\'ve been successful, but they\'re expensive
> studies. And now we need translation, how to make these less expensive
> and more practical in terms of the message for the population as a
> whole.
>
> I agree completely with Dr. Carmona that one of the biggest factors
> that we need to work on is education, health education of the public.
> I think, you know, the public certainly got the message\--or is
> getting the message\--about tobacco and they need to get a similar
> kind of message about being concerned.
>
> I think, in America today, you have to be a restrained eater, to
> maintain your weight and not gain weight. And anyone who is not a
> restrained eater is going to gain weight. And so we need to,
> essentially, create more restrained eaters. And to do that, they
> require\--
>
> SECRETARY THOMPSON: How would you get that message out, doctor?
>
> DR. PI-SUNYER: I think what Dr. Carmona was saying was correct about
> getting better, deeper knowledge about what a calory is\--
>
> SECRETARY THOMPSON: I like the phrase, restrained eaters.
>
> DR. PI-SUNYER: \--what a portion is. I think, also, the message can be
> given through the physicians. You know, we have a problem in America
> that physicians don\'t particularly want to treat obese patients;
> don\'t want to advise them; partly because they don\'t get reimbursed;
> partly because they don\'t have the education for it; they\'re not
> nutritionally well informed; they don\'t want to get into it with
> their patients. It takes a lot of time and so, we don\'t use them as
> instruments to influence the population and, yet, we know that doctors
> are one of the greatest influence for consumers that there are. So I
> think we need to do more in terms of\--in the field of education, in
> terms of physician understanding about obesity; what causes it; how
> they could prevent it and how they could try to treat it.
>
> I think the real message is prevention. It\'s so difficult to lose
> weight and keep it off. But the real message is prevention, keep
> people from gaining weight. And so you\'ve got to get the message out
> to people when they\'re 18 and 20 years old, we thought. Now you have
> to get the message when they\'re 5 or 6 years old. But, eventually,
> you know, what you what you want to do with an adult is make sure that
> they don\'t gain weight over time.
>
> SECRETARY THOMPSON: What is the number one thing\--best thing you\'re
> doing to get your message out and what your institution is doing?
>
> DR. PI-SUNYER: Well, you know, I work in a medical school and we have
> students and we have residents and we have attending physicians and I
> work with all three of those groups in our university and our
> hospitals. We also treat patients and try to have an impact in the
> clinics in our hospitals where people, the prevention message gets
> sent out.
>
> SECRETARY THOMPSON: You put out good dietary advisories to your
> students, to your faculty, your employees?
>
> DR. PI-SUNYER: Yes.
>
> SECRETARY THOMPSON: Good my friend. Dr. Charles Muscoplat.
>
> DR. MUSCOPLAT: Yes, thank you,
>
> from\--Charles Muscoplat, from the University of Minnesota, I\'m the
> dean of Agricultural, Food and Environmental Sciences.
>
> SECRETARY THOMPSON: Is Minnesota part of the country, yet?
>
> \[Laughter.\]
>
> DR. MUSCOPLAT: Particularly when it thaws out it is, otherwise it\'s
> kind of the frozen chosen, they say.
>
> But if I could maybe just pick up on your last question. One of the
> things we\'re speaking about at the University of Minnesota is,
> perhaps, making wellness the new land-grant mission of the century as
> agriculture and traditional land grant missions were of the last
> century. And our president is speaking about a new initiative that
> would focus on partnerships between the academy, government and
> commercial enterprises. That would be broad interdisciplinary efforts.
>
> One of the things that\'s unique about the University of Minnesota is
> that we are probably a one-of-a-kind university. In that we have the
> medical colleges, the agricultural colleges, and public health, all on
> a single campus, a single university. And that we have five of the ten
> largest food companies in the country within ten miles of our campus.
>
> So a physician are swell and we think that the key to our success will
> be bringing everyone together in a partnership and that would be from
> the basic agricultural sciences for increasing beta glucans in crops
> to lower cholesterol; increasing glucosinolates in vegetables; you
> know, between our horticultural sciences center, cancer center;
> everything will be a partnership. And we\'re going to try to take that
> from the core agricultural disciplines to food processing. We have one
> of the largest retail food industry economic centers. We\'re studying
> the business of food at the retail level. It\'s about 6 or 7 percent
> of U.S. economy.
>
> As the profits go in the food industry probably will go the outcome of
> the discussion we\'re having. We have the Retail Food Industry Center;
> we have a nutrition program, both in agricultural sciences and in
> public health; in genetics and genomics. But, also, trying to bring in
> cultural and behavioral issues. Many of these things are not simply
> based in the sciences but have long cultural issues. For example,
> we\'re working on programs with the Native Americans, looking at the
> value of traditional diets versus today\'s diets. The value of wild
> rice from the Native Americans and its effect on cholesterol or
> caloric consumption.
>
> Certainly, all of our medical sciences, we have the large medical
> complex. But I think we\'re also going to focus on partnership with
> industry, because I think, if this makes money, it will work.
>
> So our theme will be broad, interdisciplinary partnerships and to try
> to make this\--also the university has to take care of itself. We
> spoke at our recent executive committee if we can be a model for
> society and get our own health in order, lower our own health care
> costs\--
>
> SECRETARY THOMPSON: Absolutely.
>
> DR. PI-SUNYER: \--we spent \$300 million a year on health ins for the
> University of Minnesota, if we could drop it 10 or 20 percent, given
> the tight financial times, we could be a model for the state for our
> local industries and for our populations. So I think that will be the
> university\'s message.
>
> SECRETARY THOMPSON: That\'s wonderful. I meant that as a joke\--
> \[Laughter.\] I have the greatest admiration for the University of
> Minnesota and the State of Minnesota, except for the Vikings.
>
> DR. PI-SUNYER: I think we have reciprocity with the University of
> Wisconsin.
>
> SECRETARY THOMPSON: I expanded it when I was governor but really\--we
> put the whole Department of Health and Human Services on a diet and I
> like what you\'re doing with the University of Minnesota. If you could
> carry that through, and, as Julie said, if you can start making sure
> your employees are healthy and looking the part, we\'re much better
> off.
>
> I also noticed, yesterday, when I was talking to Pepsi Cola that they
> told me that their healthy foods was their biggest profit item, as
> their growing profits were in that area. And that is\--that is exactly
> the opposite of what McDonald\'s told me when I went out to see
> Hamburger University that people just didn\'t like healthy foods and
> their profit was in the other food.
>
> So, your job Charles, and all of yours, is to make sure that the food
> companies realize that they can make a profit, if they make their
> foods taste better and look better. And you\'ve
>
> got\--you\'re in a prime spot, with all the food companies around your
> university to be able to influence them in regards to that and I thank
> you very much for being here. Dr. Don. Dr. Hensrud?
>
> DR. HENSRUD: Yes, We\'re going to continue with the Minnesota
> connection here, we\'re from Rochester, Minnesota, Mayo Clinic.
>
> SECRETARY THOMPSON: Yes.
>
> DR. HENSRUD: At Mayo we\--our strength, obviously, is clinical
> medicine. And much as I\'d like to say we\'ve been successful in
> combatting this epidemic, everybody here knows that the treatment of
> obesity is not where we want it to be at this point. But we\'re going
> to continue on in our efforts in that area.
>
> The other strength of Mayo is our education. We try and put out
> education for the public. We sponsor the Surgeon General\'s comments,
> both printed material and on our Web site, we strongly believe in that
> in educating people.
>
> That isn\'t enough, however, if education was wholly enough, we would
> have made more headway than we have.
>
> I want to pick up on some of Dr. Gerberding\'s comments. Even though
> we\'re a clinical institution, I\'m in the division of preventative
> medicine, I wear a couple of hats there. I still see patients, half
> the time, both in a nutrition clinic for weight management and I
> direct our executive health program. We looked at our executive
> population, 85 percent of the executives who come through our program
> are overweight or obese. We\'re starting some clinical efforts in that
> realm.
>
> But we need to get the work site more involved. And I think that\'s an
> area, it\'s starting to hit the employers in the pocket and the more
> that we can convince them that eventually it\'ll save them money, I
> think the more we can do in that area.
>
> One of the executives I see runs
>
> medium-sized company, he\'s in pursuit of a wellness program and he\'s
> got data on cost effectiveness that has lowered his health care costs.
> So that\'s one area I think we need to concentrate on.
>
> The other is changing the environment, as you mentioned. There are
> powerful forces that have created this epidemic, over time, and I
> think many of the things that we\'re doing are chipping away, but,
> again, I think we need to take the choice away from people. One of the
> stark examples, in traveling here\--I don\'t know what we can do about
> that\--but the rolling walkways in airports. You\'ve got a population
> that\'s getting heavier, we\'re making it easier for people to get
> around. It\'s a simple example, but I think in society, we need to pay
> attention more to issues like that and painlessly make people move
> more.
>
> On the intake side of things, I think Barbara Rolls has done some very
> interesting work on energy density at Penn. Dr. Pi-Sunyer mentioned
> restrained eater. People to satiety and eating more low-energy-dense
> foods, I feel, is something that should be exploited more clinically,
> as well as healthwise, too\--eat more vegetables and fruits. We\'ve
> tried to get that message out for quite some time\--
>
> SECRETARY THOMPSON: How are you doing that?
>
> DR. HENSRUD: Again, starting out with education, I think the food
> industry needs to be more involved. Some of the\--this is looking at
> the big picture\--some of the commodities that are subsidized that I
> think are going in the wrong direction or have been in the wrong
> direction. I think to subsidize healthier foods, rather than
> commodities that have been subsidized.
>
> Again, we need to\--some other efforts with the food industry could be
> creating markets, getting them to\--there\'s some data from the
> University of Minnesota looked at pricing in vending machines that has
> a marked effect on the sales. So, multifactorial, difficult problem,
> but I think that there\'s areas that we can exploit in this.
>
> SECRETARY THOMPSON: But you have clinics in so many states, you could
> really be a driving force through your executive wellness program in
> getting executives to start taking care of themselves but also their
> employees.
>
> DR. HENSRUD: Absolutely.
>
> SECRETARY THOMPSON: So, I compliment you and wish you\'d do more and
> extort you to do more. Thank you very much for being here. Mayo is
> such a great clinic. Dr. Nancy Childs.
>
> DR. CHILDS: Hello, I\'m Nancy Childs and I\'m a professor of food and
> marketing in the Hobbs School of Business at St. Joseph\'s University
> in Philadelphia. And we have had a department of food and marketing
> focused on the business aspects of the industry for about 50 years
> now.
>
> We have a very popular undergraduate major and one of the largest on
> the campus, frankly, because their employment is so successful. And
> from that program over the decades, we now have a lot of industry
> executives from our program.
>
> Also, we have an M.S. executive program. So we are very actively
> educating an interfacing directly with people who are running and
> managing the food industry. And that includes the food retail
> industry.
>
> What I\'d like to do is make three brief comments. My own research
> area is specifically on the food label in the use of health claims and
> how they impact consumers, how they\--and types of business
> competition issues that they generate. So, I\'m very excited about the
> recent changes that are opening up information to consumers in a
> responsible way. I think that has a lot of potential. I think we need
> to look at the label more in terms of how it\'s perceived by the
> consumer. There\'s a lot we\'ve learned there but there\'s a lot we
> don\'t know.
>
> And, in particular, as we talk about physiological aspects being very
> individual in our research programs, how do we take mass messages,
> like a label represents and help a consumer utilize that for an
> individual health purpose. So we\'ve got some very interesting
> challenges in how we use the label and where we can go there. How it
> interfaces. How we target messages to different parts of the
> community. We\'re finding the obesity issue is universal on one level,
> but has different levels of impact within the various segments of our
> community. So targeted messages would have potential for impact,
> whether we\'re talking about minority groups; whether we\'re talking
> about children.
>
> Secondly, as a small point and going to Dr. Carmona\'s nutrition
> literacy. One of the issues about growing obesity is the fact that our
> metabolism decreases as we age. This is a very important finding that
> I don\'t think the American public understand yet. That if they do not
> change anything, they will gain weight. And I think that, itself, is
> one primary piece of information that we need to find a way of
> delivering. So that doing nothing means you\'ll grow.
>
> And my third point has to do with, really, the complexities of the
> business environment of marketing food, the grocery retail
> environment. And it\'s actually larger than grocery, because so many
> other channel are involved now. As we have seen our retail environment
> consolidate, it has dramatically impacted the opportunities that our
> food manufacturers have to put new products on shelves. And,
> particularly, healthy products run into more constraints than many of
> us realize in terms of getting shelf space and shelf sustainability so
> that consumers can retain choice.
>
> Through category management, these large retail groups constrain the
> number of brands and the number of facings on a shelf. And this, in
> turn, limits what your food manufacturers can do. So, though the
> industry, may have a lot of good intentions and be putting a lot of
> research effort there, there still is this filter they get through to
> put that final product on the shelf. And I just wanted to raise that
> as an issue that I don\'t think gets above the radar screen
> frequently. Thank you.
>
> SECRETARY THOMPSON: Thank you, Nancy. Dr. Doyle.
>
> DR. DOYLE: Good morning. Thank you, Mr. Secretary. I\'m Mike Doyle, I
> direct the Center for Food Safety at the University of Georgia. And I
> wear another hat and that is the chair of the Food Forum of the
> National Academy of Science and Institute of Medicine. And this food
> forum is comprised largely of corporate officers\--food industry
> corporate officers, as well as chief scientists of the leading food
> companies in the country; as well as several academics and many
> government leaders throughout the government.
>
> And the purpose of the forum is to bring government leaders and food
> industry leaders together to discuss issues of common interest which
> are largely focused on public health.
>
> And what I want to do is to share with you today some of the outcomes
> of yesterday\'s meeting. The Food Forum met yesterday. And the primary
> focus of our meeting was to address strategies to reduce obesity
> through the food industry. And because of National Academy policies, I
> cannot present these as recommendations from the Forum but, rather, my
> impressions or observations of the proceedings.
>
> And, to begin with, I want to share with you a qualifier. And that is
> this issue of obesity is a very complex issue and there\'s no silver
> bullet or one magic fix is going to eliminate the obesity issue. But
> there are from my perspective of the proceedings, opportunities that
> the industry can engage in that might effectively reduce obesity.
>
> And so, there\'s an overarching premise that was developed and that
> is: For consumers to accept foods that are reduced in calories and,
> also, for them\--for the consumer to increase exercise, which we
> believe is what it\'s going to take to reduce obesity, the consumer\'s
> going to have to accept this and want to do it.
>
> And what the industry has done in the past has been to eliminate
> calories or reduce calories of fatty foods to the point that the
> consumer doesn\'t accept it and, frankly, rejects low-calorie foods.
> So the goal, then, is to do this in a stepwise fashion. And that is
> to, in essence, provide more subtle changes that will result in
> satisfying portions with fewer calories.
>
> Now, there are three or four primary strategies that I perceived to
> come out of these proceedings. And one is that we should develop a
> mechanism for engaging the public, which, primarily, is the
> government, and private interaction to support a program which is
> called, \"America on the Move.\" And I think we\'re going to hear more
> about that from Jim Hill, who is largely responsible for developing
> this educational program.
>
> And it was thought that this program should be supported as a
> partnership between the government an the industry. And this would
> include not only verbal support, but also financial support from both
> sectors. And I\'m sure Jim will give you more details about this
> program as time permits.
>
> But, basically, it\'s a program that is simple and easy for consumers
> to adapt to. They\'re not saying eliminate thousands of calories from
> your diet and do an outrageous amount of exercise, but, rather, to
> increase your exercise by
>
> 200\--2,000 steps a day and reduce your intake by 100 calories a day
> and that will, or should have a significant impact.
>
> One other point to this is that more research needs to be done with
> this program and that we have to see how effective the program is in
> actually reducing weight. And so we want to get the government engaged
> in this to not only support the concept but also the research that
> needs to be a part or it.
>
> Secondly\--a second strategy that has been suggested is that we need
> to develop a government/industry partnership to conduct research on
> consumer issues. And the industry is a leader in marketing food
> messages. And if we\'re going to develop, I might say an anti-obesity
> message, you probably would find no other group more better equipped
> to develop that message than the food industry. And, also, no better
> equipped to effectively deliver that message than the food industry.
> At least that\'s what I hear from the food industry.
>
> They have a wealth of experience in marketing these messages and
> there\'s organizations like ITHIC \[ph\], which has been involved with
> the industry in developing effective public health messages and they
> are now showing an interest in developing antiobesity messages that
> consumers will embrace.
>
> And there were several major leaders in the food industry at the table
> who did indicate an interest in marketing good, effective, antiobesity
> messages, but what they need to know what the message should be before
> they can actually go about doing this. So that leads to Dr.
> Crawford\'s point is how do we develop that message?
>
> Another strategy suggested was the food industry must also conduct
> some research and this leads more to staying in business. They need to
> identify how the industry can not only reduce caloric intake, but also
> portion size, and still remain competitive and financially stable.
>
> There needs to be some degree of incentive that would enable them to
> reduce the food content or the calories and, yet, still make a profit.
> And it was suggested that, perhaps, the government can, in part,
> facilitate this through nutritional labeling claims and developing,
> perhaps, a consumer-friendly nutritional claim or message that could
> be put on a package when portion size and calorie levels are reduced.
>
> And then, finally, there was a suggestion that government leaders and
> leaders of the food industry, and this includes all parts of the food
> continuum, all the way from the producer to the processor to the
> retailer to the food service segment. They need to get together,
> perhaps, again and address strategies to reduce obesity. And it was
> suggested that this meeting should focus how the industry and the
> government can, together, partner to address the problem.
>
> And there\'s a program already in place called \"Fight Back,\" which
> was developed to address food safety. And that\'s an award-winning
> program that has shown great success and that is an industry partner
> program. And thought was that this could, perhaps, serve as a model
> from which the antiobesity campaign could evolve.
>
> My impression, Mr. Secretary, is that the food industry is very
> anxious and interested in addressing this problem. And is now
> committed to working with the government in moving this program along.
>
> SECRETARY THOMPSON: Michael, you\'re absolutely correct and thank you
> for your wonderful presentation. The question is\--for all of us\--is
> how do we coordinate\--how do we energize the food industry but then
> how do we coordinate the food industry with government and all of your
> institutes in order to get out a clear, concise, and consistent
> message for all the people dealing with intake and obesity?
>
> DR. DOYLE: Well, I think that
>
> meeting\--the next meeting with the food industry leaders\--might put
> you in that direction.
>
> SECRETARY THOMPSON: Fine, thank you. Mr. Morgan Downey?
>
> MR. DOWNEY: Thank you, sir. My name is Morgan Downey.
>
> SECRETARY THOMPSON: My apologies, I have to leave and Dr. McClellan is
> going to take over.
>
> MR. DOWNEY: Just before you do, I just wanted to say, I think, on
> behalf of all of us, no Administration or Secretary of Health and
> Human Services has done as much to raise the visibility and attention
> on obesity as you have and I think we all owe you a tremendous debt of
> gratitude for taking this leadership.
>
> SECRETARY THOMPSON: Thank you, very much.
>
> \[Applause.\]
>
> SECRETARY THOMPSON: I\'m very\--I came by this very naturally, because
> when I came in as governor of the State of Wisconsin, Wisconsin was
> the most obese state in the nation and I wanted to change that. And
> now we\'ve dropped down to 14th and it\'s not because we found a
> lower-caloried bratwurst, it\'s the fact that the rest of the country
> is growing faster. That\'s not a good sign. So, thank you very much.
> We\'ve got to do a lot more. Thank you.
>
> DR. McCLELLAN: Please go ahead.
>
> MR. DOWNEY: If I can continue the American Obesity Association is an
> education and advocacy group here in Washington. Our mission is,
> really, to reconceptualize thinking about obesity as a disease, should
> be regarded as we do other major disease of epidemic proportions. Our
> funding comes primarily from the pharmaceutical and the other elements
> of the weight-loss industry. We have about 15 companies, mainly
> pharmaceutical R&D, but also Weight Watchers, Slim-Fast, Jenny Craig,
> players in the industry. And as well as about 700 members both lay and
> professional. And several of our board members are actually around the
> table, so I\'m trying to be on good behavior.
>
> We are focused on about seven areas in obesity: they include research;
> treatment; prevention; education; consumer protection; and stigma. And
> I\'d like to just briefly touch on a couple of policy initiatives that
> we\'ve been working on. Three of them, really in conjunction with
> agencies represented here. We had an excellent meeting last December
> with Drs. Rooney and several of the institute directors at NIH about
> obesity research. Dr. Crawford addressed a meeting we had in April,
> with about 15 companies; following up on your initiatives for new
> guidances in diabetes and obesity. And when I talked to Dr. Crawford,
> we have another meeting coming up in October and maybe one later in
> the year that we certainly want to work with FDA on.
>
> The CDC, a while back, I think two years ago, asked the centers for
> Medicare and Medicaid services to review their policy coverage manual
> provisions that say obesity\'s not an illness, therefore, Medicare
> won\'t pay for any services. That has been kicked over to AHQR for a
> tech assessment, which we\'re hoping will come out before the end of
> the year. And so it\'s wonderful to see this kind of integration here.
>
> Let me touch on a couple of our big issues, which I think directly
> relate to the functions of the Department and our recommendations.
>
> As we talked with Dr. Rooney in December, we think there should be a
> national institute of obesity at NIH. The funding level for obesity
> research is just over \$300 million. And organizationally, the
> excellent people at NIH working on obesity are at a very, very low
> level organizationally. And we think if we\'re going to really attack
> this issue, like we do other epidemics, we have to both raise the
> visibility of obesity. We have to give it more money to cover
> everything from genetics to molecular to behavioral to neuroscience to
> clinical trials to health policy and economics to training and
> education. And it\'s going to take a huge investment.
>
> And also, we need at NIH, one of the most powerful places for an
> authoritative science voice about obesity amid all of the commercial
> noise and other information out there.
>
> And I just would pass down, this is a graph we did, Dr. Rooney
> complimented me on some of our other graphs, this is another one. But
> it just shows how disproportionate the funding is for obesity. The
> diseases caused by obesity, like Type 2 diabetes and heart disease\--
> not to mention cancers, stroke, and others\--they receive probably
> collectively 10 to 12 times the amount of funding that obesity itself
> receives. And so this needs to be corrected.
>
> Just another factoid on that: You know we have an aging institute
> works a lot with other institutes on Alzheimer\'s disease. There\'s
> 400 million people\--I mean 4 million Americans with Alzheimer\'s
> disease. There\'s 10 to 12 million with morbid obesity in this
> country. And Alzheimer\'s gets about \$600 million something in
> research and the total obesity budget, not even much for morbid
> obesity, is a third of that. So I think that\'s an area that needs a
> tremendous evaluation.
>
> We\'re very concerned about treatment. We think that oftentimes when
> we get talking about obesity, it\'s only about prevention, which is a
> very, very important and a key mission. But we can\'t hang our whole
> strategy on prevention when we don\'t know, really enough of what to
> do to prevent the condition.
>
> We\'ve very concerned about insurance coverage or the lack thereof
> that\'s available for persons with obesity. In this environment, just
> recently, there\'s been some state legislators who have wanted to put
> an authority to raise rates on a persons with obesity and have said
> lean people shouldn\'t be subsidizing them. As I told the reporters
> from Maryland when this came up, obese people now don\'t qualify for
> insurance, they\'re written out in most\--certainly in almost all
> individual plans. And inside the plans, obesity treatment isn\'t
> covered. There tends to be improving but limited coverage for obesity
> surgery; very, very little coverage for any obesity medications.
>
> And we think the Department, particularly through Medicare and
> Medicaid, Indian Health Service, can take a real lead in
> legitimatizing, basically, obesity treatment and getting focused on
> new and better treatments that we desperately need to develop out
> there.
>
> Right now, in Congress, with the Medicare drug legislation, obesity
> drugs are not covered, they would not be included in that legislation.
> Every other condition, basically, is, but obesity\'s excluded from the
> bills in conference.
>
> That may not be so important in terms of this generation of products,
> but we\'re looking downstream that the elderly obese population is the
> fastest growing segment of the obese population. And while researchers
> kind of have looked a lot at the diabetes and heart disease onset of
> the medical conditions, the implications for Medicare, in terms of
> hospitalizations, extended stays, institutionalization because of
> disability, are very serious. And that area, on a research basis, is
> almost totally untouched, it\'s just very little research at all going
> on about obesity in the elderly and what to do about it.
>
> As I mentioned, we\'re very interested and the industry\'s very
> interested in working with you at the FDA on modernizing the guidances
> for the treatment of obesity. I think the pharmaceutical industry
> feels that this is a time of very, very exciting opportunity
> scientifically and do have some problems with the FDA process and are
> looking forward to having a closer dialogue with you about resolving
> those and making sure we can get safe products and effective products
> and in the future out more quickly.
>
> We\'re very concerned about education. We\'re concerned about the
> dichotomy in the public\'s mind between what\'s a food\--a portion of
> a particular food. What the food pyramid uses as a portion and what is
> a portion on the food labels, which seem totally disconnected and
> we\'re unlikely to create a generation of restrained eaters when we
> don\'t even know what we\'re talking about consistently.
>
> But we have another problem, too, and that\'s in terms of people\'s
> perceptions of obesity. This isn\'t the HHS\'s doing, but with
> television, almost every time they report on obesity, which is almost
> every week now. The b-roll shows people who are morbidly obese. And
> people tend to think that to be obese, we\'re talking about
> individuals who are 300, 350 pounds or more. And this is not the case.
> And as we saw a couple of years ago with the NIH guidelines in terms
> of drawing new criteria for overweight and obesity, that\'s a
> tremendous confusion in people\'s minds, in doctors\' minds, in health
> professionals\' minds about when a person is obese.
>
> Parents have a very distorted view of their children\'s weight when
> we\'ve matched up surveying parents about their children\'s weights
> and what the CDC figures are. Parents in this country will tell you
> basically that 5 or 6 percent of children are obese, when we know
> according to the CDC standards that it\'s more like 13 or 14 percent.
> So we have some basic education to do there.
>
> And we also think that one important contribution that the Secretary
> can make at this time, is to look at establishing, inside the
> Secretary\'s office, a coordinating component to give place for
> individuals to come with ideas and suggestions that do involve various
> units of both within the Department and interdepartmentally. The
> Department of Defense, the VA, Social Security, FTC, Transportation
> and Agriculture, all need to be involved in this. And right now there
> is no center or no coordinating office that\'s really tasked with
> doing that. And that would be one of our recommendations, as well.
> Thank you.
>
> DR. McCLELLAN: Thank you, some very good comments on creating
> incentives for developing better treatments and education and a whole
> host of other issues.
>
> We\'ve got about 11 more people that we need to hear from and about 40
> minutes or so to do it. And we were hoping to have a little bit of
> time at the end for talking about next steps. That\'s why I want to
> emphasize all these are great comments and we also want written
> comments in more detail, we don\'t have time to go through now. We are
> going to follow up on all of these. As you heard from the Secretary,
> he means business on developing more effective obesity programs. But I
> do want to make sure we hear from everybody at the table today, so.
> All right, Dr. Meyers, go ahead, please.
>
> DR. MEYERS: I\'m Linda Meyers, I\'m the Director of the Food and
> Nutrition Board which is a unit of the Institute of Medicine, part of
> the National Academy. I\'d like to make four brief points.
>
> Number one, the Institute of Medicine is trying to contribute to your
> work in these efforts in a number of ways: Number one, we are, along
> with the Transportation Research Board, another unit in the National
> Academy\'s, working on a study of physical activity, land use, health,
> transportation, which is looking at trends in relationship to between
> physical activity and transportation and land use. And will develop a
> research agenda. This is supported by the Centers for Disease Control
> and the Robert Wood Johnson Foundation. So we hope this will be a
> contribution to your efforts.
>
> Secondly, with support from the various institutes of the National
> Institutes of Health, CDC, and the Robert Wood Johnson Foundation, we
> have convened a committee on prevention of childhood obesity, which
> has been tasked to develop recommendations and actionable
> interventions for prevention of childhood obesity. Both of these are
> to be completed next year, probably in the fall.
>
> Third point, this meeting has been very useful already in helping us
> think through the charge that we\'ve been given by OIM President
> Harvey Feinberg \[ph\], which is to develop a family of activities and
> think further about ways the Institute of Medicine can contribute to
> the prevention and treatment of obesity.
>
> Third, derivative of our experience in putting together both the
> committees on obesity but, also, one that we\'ve been hearing about
> working on related to nutrition labeling, two points: We would urge
> you to bring to the table beyond the health of players and look at
> transportation and agriculture, it\'s fantastic, the collaboration
> that we, from the outside are seeing among HHS agencies and would
> encourage you to take that even further; and, secondly, we\'ve heard a
> lot in our open meetings on nutrition labeling about the potential of
> the food label and the fact that the potential probably hasn\'t been
> realized, either in the way it could be implemented by other agencies
> within the Department and, also, because of the dearth of consumer
> understanding of the label. Thank you.
>
> DR. STOREY: I\'m Maureen Storey, I\'m the Director of the Center for
> Food and Nutrition Policy at Virginia Tech, which is the home of a
> rather robust looking turkey. I\'m also a recent graduate of the Les
> Crawford School of Communication of Brevity. So I will be brief.
>
> \[Laughter.\]
>
> I agree with what everybody else has said so far, and probably what
> everybody else will say after me. I do believe, as Dr. Crawford
> indicated, that we need a message that is very clear and consistent
> and I would also urge us to make sure that whatever that message is on
> nutrition that it also follows or is preceded by a message on physical
> activity because you cannot separate, in my opinion, those two
> elements. And I would also urge us to not only encourage food
> companies to provide the information that consumers need, but I would
> also encourage us to provide the education that consumers need in
> order to process that information properly.
>
> DR. WILLETT: Hi, I\'m Walter Willett and I chair the Department of
> Nutrition at Harvard School of Public Health. And I\'ve actually been
> thinking about this topic more than I might have otherwise because I
> had my arm twisted to head up a consortium to develop a strategic plan
> for control of overweight and obesity in the New England region. And
> I\'ve brought copies of the Executive Summary along and it will be on
> the Web by the end of the week. I should add this has been supported,
> in part, by HHS through Van Hubbard\'s group through CDC and through
> Region 1 of HHS and it\'s been very valuable to bring together all the
> state health departments, academics and representatives of various
> industries and employer groups in New England.
>
> And we\'ve really recognized that this is a multifaceted problem and
> that\'s why everything everybody has said is very valid. And there\'s
> no single solution, but almost everybody has a role to play in
> controlling this epidemic.
>
> So we\'ve broken it down by eight separate sections, including health
> care providers, which David Katz has headed up that section; and
> school services, media, physical environment, social environment, et
> cetera. So I\'d welcome anyone\'s comments when it goes up on the Web
> later.
>
> Part of this issue raised by Dr. Crawford came up here about a clear,
> succinct message and that actually got through the report and realized
> we, in the end, had not come up\--we had talked about healthy diet and
> physical activity, but never really said what it was. We said we
> really had to bit the bullet, so we had a separate workshop on that.
> And without going into\--it would be distracting and to be succinct I
> won\'t go into it. But it\'s in this little box in the Executive
> Summary, and I actually think it might be really useful to reconvene
> this group at some other point to see\--to really get a clear
> consensus on core set of messages and I suspect we have something
> close here that everybody could agree to, maybe with a little molding
> and refinement, but I do, very much agree that this is\--what we need
> to identify is the content and then it has to be developed into bumper
> stickers and messages and sound bytes and things like that by a media
> group and focus group tested and monitored all along in terms of
> implementation, like you would if you were really developing a major
> marketing campaign.
>
> And HHS could supply the resources to do that. ACS, American Heart
> Association and American Diabetes Association, I understand, are
> pooling some of their resources to do this, and it would really be
> good if that could be broadened to have a core set of messages that
> all these groups and the government conveys at the same time.
>
> One point that I did want to mention in our report that came up. And I
> know it\'s a bit of a sensitive area. And that\'s\--and I thin it\'s
> undeniable that children really do need protection from aggressive
> marketing. Marketing people have gotten so good and kids are still
> kids. And are much\--there\'s a huge imbalance. They won\'t read the
> label, don\'t understand heart disease 50 years down the road; it\'s
> not an agenda; and interestingly, the School of Public Health recently
> did a survey and there is strong general support in the population for
> constraint on advertising to children; not for adults but for kids. So
> that the large majority of the public does support that.
>
> And I would also think the industry would support this, too, because
> the problem now is an industry that wants to promote healthy products
> is going to be a that a disadvantage if you\'re competitor\'s out
> there marketing cheap junk. And so what we really need to do is raise
> the\--keep the playing field level, everybody compete, but have it be
> a high-level playing field that only
>
> nutritious\--that only healthy products be promoted to children. So I
> think that\'s something where HHS could play a very unique role
> bringing the parties together either as a very strong voluntary
> program or as a rule or regulation about what can be marketed to kids.
> But I can\'t see that we can actually settle this problem without
> having not be part of what we need to do.
>
> And coordinating government agencies is clearly critical to\--we were
> just stunned this past week when a committee in Congress killed the
> rails to trails program, which was the most important infrastructure
> program funded by the federal government. Somehow somebody\'s got to
> figure out and get to those people and indicate that this is really a
> key part of what we need to do to promote the physical activity
> component.
>
> And, finally, I just wanted to mention that when we talk about
> obesity, and that\'s what we see on the maps and that\'s the red flag,
> but to a large extent, some other people said that\'s loaded with a
> lot of stigma, it\'s always somebody else, that\'s not my problem and
> we really have to cast a lot of this in terms of weight control, which
> is something you talk to kids about, you can talk about, it\'s
> everybody\'s issue\--it\'s all of our issue and it\'s a lifetime skill
> that needs to be developed. So I think developing a language to that
> is the real focus.
>
> DR. McCLELLAN: Thank you. Dr. Stunkard.
>
> DR. STUNKARD: I\'m Dr. Albert Stunkard. I\'m a professor of psychiatry
> at the University of Pennsylvania. I\'ve been working on obesity for
> more than 50 years at a time when it was considered a minor cosmetic
> problem and people weren\'t sitting at high-level tables like this.
>
> I must say I agree with almost everything that\'s been said, I came
> down here very impressed with the possibility of working with industry
> and this has very much re-enforced me, particularly Jim Hill\'s notion
> of a government/industry interaction facilitated by scientists and by
> nonprofit organizations.
>
> One of the issues Mike Doyle points out is that the industry will not
> want to do anything if it causes them to lose money. And, yet, it\'s
> probable that they can move along without losing money and, perhaps,
> making more money. This can be helped by various studies. We have one
> small study that Gary Foster\'s doing at Penn that\'s quite, quite
> exciting along these lines. He\'s got soft drink manufacturers to put
> in no-cal beverages in five schools and leave five schools the way
> they were. And at the end of the study see if they lost money. Very
> cheap study to do and could be very persuasive, I think, if it comes
> out the way we hope.
>
> Finally, I\'d like to get a plug in for research. There\'s one thing
> here that says we can\'t talk about research and it has to do,
> particularly with Dr. Zerhouni\'s notion of gene bioenvironment
> interactions, which are going to be difficult to do, except in one
> way. And that is by longitudinal studies. And as of now, there are
> only\--in the country, only two longitudinal studies of the growth and
> development of obesity in children. One is a non-specific and ours is
> a high-risk study, which is really revealing fascinating things.
> Exactly how the obesity develops in the high-risk group, of which, at
> age 10, who we\'ve followed since birth. Half of them are now, frankly
> obese. And we can look back and look at all the metabolic and
> behavioral and all sorts issues like that, which are only in the
>
> high-risk group. Our low-risk group is totally, is so far
> invulnerable, probably they won\'t be when they grow up.
>
> But this kind of research, I think, could be very valuable. Thank you.
>
> DR. SAVAIANO: I\'m Dennis Savaiano, I\'m dean of Consumer and Family
> Sciences at Purdue and I have chaired the Food Nutrition Science
> Alliance for a number of years, which is a joint communications
> committee of IFTADA, ASNA and ASCN.
>
> I\'m going to try to become the second member of the Les Crawford
> Brevity Group. But I wanted to just reiterate a couple of points. Let
> me go to Dr. Willett\'s point about the message to children. I think
> that\'s extremely important, but let me take the other side of the
> issue and go back to the comments made by our CDC director about the
> Department of Education.
>
> The opportunity to conduct behavior research in the schools developing
> science-based curricula and health-based curricula that will provide
> the positive message and demonstrate reduced weight gain and obesity
> prevention, I think is substantial. I think the partnership with
> education has to be here. Our schools in this country have changed
> dramatically. And no one has talked about physical education in
> schools. And the loss of physical education programs in the schools
> over a number of decades, but that certainly has to be a component, as
> well.
>
> So I would urge for a very strong education partnership and a very
> positive approach to children in terms of the approach.
>
> Our school also has one of the largest and most respected restaurant
> management programs in the country and we see every day the National
> Restaurant Association and their incentives, their approach. Food is
> very inexpensive, as you all know, supersizing doesn\'t cost much and
> it\'s a great marketing tool. I guess what I\'m arguing is that the
> government incentives that have been in place in the last year picking
> up on where we put our price supports has, perhaps, been a factor that
> has exacerbated the available calories. Calories are inexpensive,
> extremely inexpensive and when you look at the at-risk low-income
> population that becomes an incredibly important issue. I wish I had an
> answer to that one, Walter, I don\'t.
>
> But I think I probably failed my test to be a member of the Les
> Crawford\-- \[Laughter.\]
>
> DR. McCLELLAN: Thank you, you did fine. Dr. Hill
>
> DR. HILL: Yeah, I\'m Jim Hill, I\'m Director for the Center of Human
> Nutrition at the University of Colorado Health Sciences Center. I\'d
> like to point out I\'m the sole representative of the country west of
> the Mississippi here. So a lot of weight here.
>
> I\'ve been funded by NIH for over 20 years. Dr. Zerhouni, I truly love
> NIH and the work they\'re doing. And most of time I\'ve spent trying
> to understand how ODC develops. In the last few years, I\'ve become
> committed to trying to do something, because I think we\'re at an
> incredible cross-roads right now, where we have to get\--we have to
> inspire Americans to take on this issue or we face the possibility
> that we simply lose and accept that obesity is our lot as a society.
>
> So I think the timing here is really, really quite critical. And as
> that, I helped found a program called America on the Move that you
> heard a little bit about before. The background for America on the
> Move is we were trying to figure out how we actually go out and help
> people get a handle on their weight.
>
> We looked at how we got here. We didn\'t wake up one morning and we
> all 65 percent overweight. What\'s happening is we\'ve been gaining
> weight slowly year by year by year. And the average American gains 1
> to 3 pounds a year. We looked at that from am energy balance point of
> view and that\'s less than 100 calories a day on average creating this
> small weight gain.
>
> So we said, well, it seems to us that the first strategy here is,
> let\'s stop the weight gain. That should be imminently doable. So
> wherever you are right now, you\'re underweight, you\'re normal
> weight, you\'re overweight, you\'re obese\--first thing we can do is
> no more weight gain and if we did that from a public health point of
> view it would be incredible.
>
> So America on the Move is fun and it\'s simple. It\'s small changes in
> energy balance to stop the weight gain. And what we advocate, as Mike
> said earlier, is we love the step counters and it\'s great to see the
> Secretary wearing them. It\'s easy, it provides feedback. It\'s a
> tool, it\'s not a program in and of itself it\'s a great tool. We ask
> people to do 2,000 calories more, it burns about 100 calories, it\'s
> walking a mile, it takes 15 minutes, everybody can do it. And on the
> food side, we say choose one behavior every day, make a substitute to
> get rid of 100 calories a non-calorie beverage substituted for a
> calorie beverage.
>
> This program is based on a pilot program in Colorado\--Colorado on the
> Move that\'s been going on for about two years. And we estimate that
> we have about 200,000 people participating in Colorado on the Move and
> Colorado\'s a pretty small state. So two weeks ago, we rolled out
> America on the Move nationally and the principle really is energy
> balance. And I think as we get back to education, it\'s not just
> teaching about nutrition, it\'s not just being physically active,
> it\'s teaching about energy balance.
>
> And back to a comment Dr. Pi-Sunyer made, he said people have to be
> restrained eaters to get by. I would couch that a little different. I
> think what\'s happening is, our environment encourages us to overeat
> and to be inactive. And, in a way, if you look at how strong that is,
> it\'s amazing anybody can fight back. And how do people fight back?
>
> Well, they\'re actually using their to fight back against the
> environment. And so what I think we have to teach people are the
> skills to manage their weight in this environment. And that\'s
> more\--eating is part of it. It\'s also physical activity. If you\'re
> not paying attention you\'re probably gaining weight. Paying attention
> means making the right nutrition choices, making the right physical
> activity choices but, also, understanding how the two relate together.
>
> So I think it would be great, Secretary Thompson mentioned
> McDonald\'s. I think it would be great if you walked in McDonald\'s
> and they asked you if you want to supersize those fries, and every kid
> in America knows that if I do that, that\'s an extra 4,000 steps. Now
> you may decide to do it or not to do it, but you\'ve got the skills to
> begin making those kinds of choices. Same thing on food label. We
> can\'t just do more on nutrition because you\'ve got to give people a
> context. What does it mean to make this choice?
>
> Same thing in restaurants. The Restaurant Association says, oh, we
> offer choice, it\'s not our problem. They offer choice but they don\'t
> give people the context to make the right choices. People don\'t know
> what those choices mean. So my dream is, we teach energy balance in
> schools. And Dr. Hubbard, through NIH, has sponsored the development
> of a really nifty curriculum for middle-school kids to teach them
> about energy balance.
>
> We teach them energy balance in the schools; that\'s re-enforced in
> the restaurants when you buy food, it\'s just like the way we teach
> kids about finances. They don\'t have a second-grade course in
> finances. You learn about what things cost, you learn about money, you
> go out in the real world, it\'s re-enforced in the sporting goods
> store and so forth. And I think we have to do that for energy balance.
> Start teaching them the skills in schools, but re-enforce that in the
> community.
>
> And in America on the Move, it\'s a public/private partnership and we
> don\'t think government can solve this problem alone, we don\'t think
> industry can solve it alone. We think everybody has to come together.
> Industry can play a big role in being the places where we teach about
> energy balance and so America on the Move welcomes industry to get
> involved, not just the food industry. We\'ve also got to engage the
> physical inactivity industry. You know Bill Gates has probably done as
> much to promote obesity as Ronald McDonald. We\'ve got to get these
> folks in the game, not to blame them for the problem but to help in
> terms of the solution.
>
> The way America on the Move is going to be rolled out briefly is
> we\'re going to have affiliates in probably every state within two
> years in every major city. We just rolled out two weeks ago and we
> already have about 25 states that have applied to be affiliates. We
> want to engage the public sector, we want to engage the private
> sector. We think this is a big deal, it can inspire Americans to begin
> to make small changes wherever you are right now. If you haven\'t been
> off the couch in 20 years, get up and walk around the kitchen. Start
> with small changes.
>
> And what we\'ve seen in Colorado is that when you start with these
> small changes, people make more and more small changes. Program like
> this needs to be science-based. We have to get our major universities
> involved. We have to get NIH, CDC funding to do the research. But I
> think we\'re ready for something big that we can all get behind and
> inspire Americans to start making small changes to be healthier.
>
> DR. GERBERDING: I\'d just like to add, if you follow the map of
> obesity in the United States, Colorado looks very good.
>
> MS. CUMMINGS: Hi, my name\'s Sue Cummings and I\'m representing the
> American Dietetic Association today. Would you share with us how many
> steps a day you take?
>
> DR. HILL: Eleven thousand.
>
> MS. CUMMINGS: I actually give step counters out to my population. I
> work at the Massachusetts General Hospital Weight Center. I\'ve been
> in the field of obesity, in the trenches for 20 years and I would say
> that the average patient that I work with does less than 1,500 or
> 1,000 steps a day. So, I mean, people do not move. And I, you know,
> compliment you on your efforts there. Also, I have to say that from
> the American Dietetic Association point of view, we have 70,000
> members, who are basically in the trenches working with individuals
> both in clinic settings, hospital settings, public health settings.
> And I think I can safely say that most of us spend a lot of our time
> trying to straighten out the information. You know, people come to us
> and they want to know should they be on Atkins or should they be on
>
> Slim-Fast, or what should they be doing or this is what they\'re doing
> or this is what\'s working for their friends.
>
> And, clearly, we do need a simple message about what is it that we\'re
> talking about when we say healthy eating. And what is it when they
> look at a label? When somebody looks at a label today, the portion
> sizes are sizes in 1970, you know, a cereal, a half a cup of cereal.
>
> People don\'t eat a half of cup of cereal, yet, a patient will look at
> it and say, calories, 80 calories. Well, great, I can eat this box.
> You know, we\'re supersizing. I went to the supermarket the other day
> an saw a can\--a bottle of Coke that we used to buy in the \'70s, it
> was eight ounces. I thought it was play, you know, food for kids. You
> know, my kid goes out and looks for Big Gulp. And so, certainly, we
> need to have a consistent message, the labeling needs to be clear, the
> emphasis needs to be on health education. When you talk about health
> literacy, I can tell you about a quarter of the patients I see come
> back. And the rest of them can\'t afford to come back. They\'re not
> reimbursed, nutrition services is very poorly reimbursed. Medicare
> reimburses for diabetes and renal only. Some of the private insurers
> will reimburse for a dietitian if they have a comorbidity, but it\'s
> six visits a year and I really don\'t think any of us can do much in
> six visits per year. So, clearly, we need to make access an issue.
>
> Then the whole issue of who responds to what. You know, there might be
> some people who do very well with Atkins. There might be some people
> who do very well on high protein, low carbohydrate and others who do
> much better on high carbohydrate, low protein. So some information on
> phenotyping.
>
> The Achilles\' heel in this field is maintenance. We can get people to
> lose weight. Lots of people lose weight. I don\'t think restraint is
> the issue with most of my patients who, average a BMI of 51. Restraint
> is easy
>
> for\--is something they\'ve been doing all their lives. It\'s keeping
> the lifestyle going; keeping the weight off is the Achilles\' heel.
> And that\'s where some of the research around phenotyping would be
> very valuable. I could go on and on. I get so excited, listening to
> each person talk, I wanted to have a comment as we go along with this.
>
> But I think, clearly, reimbursement, funding, a consortium of
> professionals from every field working together for a consistent
> messages. Some information about how people effectively make long-term
> behavior changes. All of these things are very important. And I\'ll
> just stop it there.
>
> DR. McCLELLAN: Thank you.
>
> DR. BLACKBURN: I\'m George Blackburn from the Harvard Medical School
> in Boston. I\'ve been asked by the North American Association for the
> Study of Obesity to include them in our remarks. The professional
> societies and I\'m sure we\'re going to be hearing about the American
> Society of Clinical Nutrition, soon, and it\'s mandate, which I\'ve
> also been involved with.
>
> But these professional societies are another venue besides our
> research venue besides our research facilities. We are blessed, in
> Boston, to have two new nutrition research centers and we\'ve been
> smart enough to put the whole town together. So we have the Boston
> Obesity Nutrition and Research Center.
>
> One of our focuses that excited me about your letter was talking about
> food. I\'m so envious of exercise that it\'s got its act together and
> everybody\'s on that. If we could get a matching message from FDA
> about food\--new food; current food; re-engineered food; food labels;
> food
>
> claims\--I think it would support the exercise effort quite a bit.
>
> Finally, I want to emphasize that Harvard Medical School is on the
> edge of one of the lower socioeconomic areas in Boston. I live in one
> of the nearby neighborhoods and our orientation has been toward the
> minorities. We need to get the language down. And I just want to
> compliment the Surgeon General for coming to Boston and he saw or high
> school students that we brought to the medical school. And he talked
> to them in a way that they\'re still talking about. You\'ve done more
> to recruit people to come into science when you come in and talk to
> that than all of our going our to the neighborhood.
>
> But we have a lot of neighborhood health clinics. We\'ve been actively
> involved in Black American Hispanic education in this area. So
> whatever the task for us\--and we really think this portion control is
> a message that we hope it would get involved. I would love to see the
> McClellan Healthy Food aisle in the grocery store.
>
> Really\--if you walk down this aisle, you know, and then get the
> Surgeon General aisle going, we\'ll have the proper food selections.
>
> DR. McCLELLAN: But CMS won\'t pay for it.
>
> \[Laughter.\]
>
> DR. BLACKBURN: Well, we can get to that in another time because,
> obviously, someone does have to pay for these messages. This
> supersizing is bringing us to our knees. We\'ve got to get the portion
> control going; the label; the Surgeon General taking it out\--we all
> want to help him.
>
> And I want to emphasize, professional societies. We\'ve been involved,
> Jim and I with CORE and SAVE and education the primary care physicians
> that want to do more and, obviously, we\'re going to hear more about
> preventive medicine soon.
>
> But I just wanted to say that, if we can make it work for, you know,
> the intercity and this group and in the schools, then I think it\'ll
> work for everybody.
>
> The final thing is this is such a deep penetrance that I think we can
> send the message to everybody. There\'s almost nobody who can\'t eat
> better portion-controlled healthy food. Thank you.
>
> DR. McCLELLAN: Thanks, George. Dr. Bouchard?
>
> DR. BOUCHARD: Thank you. I am the Executive Director of the Pennington
> Biomedical Research Center. The center is one of the ten campuses of
> the Louisiana State University System. Arguably, the Pennington Center
> is the largest obesity research center in the world, probably. And
> they\'re growing\--not in proportion to the epidemic, though.
>
> I am also the President of the International Association for the Study
> of Obesity. This Association groups 47 countries around the world and
> we monitor the epidemic around the world and devise and define
> programs to try to alleviate this.
>
> Obesity is the concern, not only in the developed countries but, also,
> in the developing world, particularly China and India. And once
> obesity reaches epidemic proportion in these countries, we are going
> to have a major crisis. Particularly in terms of diabetes,
> hypertension and heart disease.
>
> I was fortunate to co-chair the National Heart and Lung Blood
> Institute report on
>
> the\--symposium and report on the research priorities. And the
> transNIH committee has that report. And we certainly came to the
> conclusion that the problem is not only one of biology, it is also one
> of behavior, lifestyle, and environment.
>
> My own research is on genetics so I\'m very supportive of the notion
> of emphasizing basic research to understand why some people are more
> likely to become obese and, also, why some people are resistant to it.
> We might learn even more if we were able to understand why some
> individuals living in similar environments or in randomized or in the
> control trials when challenged by the same amount of calories, some
> become obese and others resist much better and can prevent the advent
> of obesity. So we need to identify these genes and understand their
> neurobiology.
>
> We also need to understand why some OBs become sick, become diabetics,
> have cancer and others do not. And some OBs go through life without
> being\--ever being affected. This is quite important. If we knew how
> to identify these people, we could define programs to prevent some of
> these diseases.
>
> But, in itself, this type of research will not solve the crisis. It
> will give us the tools to understand and to, perhaps, devise programs
> downstream, but it is not enough.
>
> The main central issue is that the human body\--the human organism has
> an extremely poor coupling between energy intake and energy
> expenditure; at low levels of energy expenditure. And since this is
> how we are living today, we expend very little energy for activity. At
> this level of expenditure, our regulatory system for appetite and
> satiety do not operate well in this kind of environment.
>
> So, since low energy expenditure is the norm and it\'s getting even
> more pronounced with the success in the labor-saving devices in our
> global work environment and even in our leisure time activity, I think
> that the problem is going to become more and more profound.
>
> And I subscribe to the theory that to be normal weight in our
> environment, most people have to be restrained eaters. Otherwise, they
> will gain. And how to cope with this? Well, obesity clinicians and
> scientists know how to induce weight loss. We all know how to do that;
> even profound weight loss. The challenge is that we cannot very
> successfully sustain this weight loss because the environment is so
> stacked against increased intake in the presence of low expenditure
> that most OBs, who have lost the weight, are losing the battle.
>
> So I, personally, have become somewhat pessimistic about our ability
> to deal with this epidemic. You know, there are about 1 billion people
> now on earth who are overweight or obese\--1 billion. And it is
> growing at an extraordinary rate. It\'s going to get much worse.
>
> Either we succeed in the kind of coalition that I have heard described
> today, in which all departments in the federal government, at the
> state level and local level, plus industry work together to change the
> environment over a period, maybe, of 20 years or we find a magic
> bullet. We find the right pill. Otherwise, I think we\'re doomed. We
> are going to be obese. Someone has predicted that by 2100, so about
> 100 years from now, 100 percent of the population would be overweight.
>
> DR. McCLELLAN: Thank you. Dr. Katz.
>
> DR. KATZ: David Katz, Yale School of Medicine, Yale School of Public
> Health and Director of Yale\'s Research Center. And among other
> things, my group is funded by the CDC to conduct a systematic review
> of population-relevant obesity prevention and control practices that
> will conclude in the fall and that will serve as the basis for a
> chapter in the guide to community preventive services. Dr. McClellan
> and other public health leaders, thank you for the honor and privilege
> of being here.
>
> I make my living as a researcher and so it\'s difficult not to concur
> with all the comments about the need for additional research. But I
> would argue that, fundamentally, the obesity epidemic is simple. And
> can derive insights for actions from some of the simplest and,
> perhaps, most legendary anecdotes of public health practice. One
> example being, John Snow\'s action in removing the handle from the
> Broad Street pump. He knew very little, nothing, in fact, about vibrio
> cholera, but saw the big picture and responded to it.
>
> I would argue that, if 100 years from now, everyone will be obese
> because we are less and less active and eating more and more, that the
> delineation of specifics genes underlying our susceptibility to
> obesity may be useful to a certain degree, but isn\'t really the
> essential matter. We are all vulnerable, it\'s just a matter the bell
> curve, some more so than others. So a population-level response based
> on what we already know makes sense.
>
> I would also agree with some of the comments regarding our capacity to
> out eat physical activity. I have great admiration for Dr. Hill\'s
> work and certainly support America on the Move, but it will be very
> easy to out eat 1,000 steps or 2,000 or even 4,000. So we need the
> dual messages of prudent diet and increased activity.
>
> And that\'s only been passing reference made to the public\'s
> preoccupation with fad diets. And, frankly, I think we need to address
> that directly. And the public can be inspired to step away from the,
> \"will-I-look-good-in-a-bathing-suit-six-weeks-from-now\" approach to
> weight control; if we tell them, with a unified voice that children
> today will suffer more long-term harm and premature death by virtue of
> the way they eat and their lack of activity than by exposure to
> alcohol, tobacco, and drugs combined.
>
> We can invoke parental responsibility if we tell them that 20 years
> ago we didn\'t have Type 2 diabetes in children that we now do and
> that the National Cholesterol Education Program tells us, that Type 2
> diabetes is heart disease and, therefore, the writing is on the wall.
> If current trends persist, heart disease will evolve into a pediatric
> scourge. We will see it in adolescence. Parents can be inspired to be
> responsible. We then have to give them the tools to utilize to respond
> to that sense of responsibility. And the tools we haven\'t conveyed
> involve skills and strategies, I think, for making healthful food
> choices.
>
> Let me make several very specific recommendations: One, safe
> nutritional environment on the go. I was in Chicago yesterday at an
> investigators\' meeting. This has been with me since I left home in
> Connecticut and goes with me everywhere. I don\'t trust the
> nutritional environment. I don\'t trust the guy who stocks the vending
> machine. And I don\'t think in the current obesigenic world we live
> in, none of us really can take charge.
>
> Let\'s tell people what to put in this and along with their pedometer
> clipped to their belt, let\'s see an insulated bag in the had that\'s
> not carrying the pocketbook or briefcase filled with nutritious,
> nutrient-dense, energy snacks that people can turn to when they get
> hungry so it\'s not a fast-food restaurant and it\'s not a vending
> machine.
>
> I think the Secretary\'s office can coordinate an effort to develop a
> national voice of reason, spokesperson, spokespeople, a campaign,
> because before we can rally people to the challenge of how, we have to
> make it clear to them that we really do know what. And I agree with
> Dr. Willett\'s remarks; we could rally around messages of reducing
> transfat, reducing saturated fat; increasing fruits and vegetables;
> increasing whole grain consumption; reducing refined starches;
> reducing simple sugars; where in that is the room for all of these
> competing fad diets?
>
> Are they dangerous? Yes. Frankly, cocaine can induce short-term weight
> loss, as well, who cares. But the issue is, as long as the public
> perceives the possibility of quick-fix and magic, they will not rally
> to the cause of long-term effective strategies.
>
> Specifically for FDA action, Dr. McClellan, I would suggest the
> following: In our look at the literature, something as simple as the
> traffic-light diet has consistently served to generate weightloss and
> appears to be reasonably sustainable. And this is a diet that relies
> on labeling foods: green\--eat with impunity;
>
> yellow\--pause and think about it; red\--these are not foods you have
> to avoid all together but the ratio of calories to nutrients is
> unfavorable.
>
> I think that a commission could be convened, or this could be embedded
> in the activities of the Dietary Guidelines Advisory Committee, to
> create a nutrition index that looks across the nutrients of foods;
> looks across issues of energy versus nutrient-density and we put a
> very simple label on everything out there, along the lines of green,
> yellow, and red.
>
> There would be no bad foods. But just as Weight Watchers uses a very
> simple point
>
> system\--effectively, I might add\--to steer people toward those foods
> that are highest in nutrients relevant to calories, I think we could
> do that with, essentially, the entire food supply.
>
> I have a number of other specific recommendations, I actually put them
> on a floppy disk\--
>
> DR. McCLELLAN: Which one is the green that you can eat with impunity?
>
> DR. KATZ: Fruits and vegetables, certainly. And that\--whole grains
> might also get a green label, but I don\'t think we should rush. We
> shouldn\'t get ahead of ourselves in the details. I think a very
> thoughtful group should look at the available evidence.
>
> But I have concerns of focusing guidance to the public on single
> nutrients. So, for example, if we remove transfat, one could envision
> a scenario where you have trans fat-free junk food that has big
> lettering on the package, free of transfat. Everybody remembers the
> opran \[ph\] craze of not all that long ago, and then it was, tropical
> oils, contains no tropical oil. One sees
>
> plant-based products that proudly boast, contains no cholesterol.
> Well, of course, it couldn\'t contain any cholesterol, it\'s an animal
> product. It\'s easy to mislead the public because the industry has
> been able to latch onto a single nutrient; some limited aspect of the
> overall nutritional character of the food. We could provide labeling
> that guides people with regard to nutritional character.
>
> The last comment I would make\--just recently I\'ve been involved in
> providing nutrition and cooking classes together with my wife to
> children 8 to 12 years old. We focused on practical skills, making
> them investigators so that they could find the partially hydrogenated
> oil on the food label. They knew that high fructose corn syrup was
> another long-winded name for sugar. They influenced over the span of
> these sessions, their entire family\'s shopping and eating patterns.
>
> I don\'t think we should underestimate the capacity of the public to
> react to what we have to teach if what we teach them is practical
> skills. And, regrettably, much of what they hear from us is
> hair-splitting about exactly what we do and don\'t know regarding
> nutrition. And in that regard, we risk letting perfect be the enemy of
> good. We know a lot. I think we could rally around simple messages;
> emphasize the practical; combine defense against a hostile nutritional
> environment what those steps each day and, although there is cause for
> greater concern, I\'m somewhat optimistic that there\'s great
> opportunity here. Thank you.
>
> DR. SCHLICKER: Hi, I\'m Sandy Schlicker, I\'m the Executive Officer of
> the American Society for Clinical Nutrition. And we represent the
> nutrition scientist who does the basic and clinical research with
> humans. And we publish a monthly journal \"The American Journal of
> Clinical Nutrition,\" which is the number one peer-reviewed journal in
> nutrition and dietetics. We have the number one impact factor and are
> the premiere journal.
>
> Many of the members sitting at this table are members of our Society,
> so I\'m delighted that you have so many of us here today. And we want
> to let you know, as a professional society, we are here to work with
> you how ever we can. One of our missions that Xav mentioned,
> interested more in physician education. One of our missions is to try
> to educate the physician more about nutrition. About half of our
> members are physicians, the other half are Ph.Ds. And I\'m sorry that
> Secretary Thompson had to leave because the President of our Society
> is at the University of Wisconsin as a nutrition scientist at the
> University of Wisconsin. But our Treasurer\'s from Texas, so\--
>
> \[Laughter.\]
>
> One of the things that we\'re very interested in is portion size. And
> we would like to see more information to the consumer about the
> portion size. And this was brought home to me yesterday when I was
> talking to one of our physician members who works in the obesity
> field.
>
> He said, you know, I started going to the gym and I was drinking this
> power drink after the gym and it said on the can it only had 120
> calories. And, boy, I felt really good and it was really great and I
> was very satisfied. And after a couple times going to the gym and
> drinking this power drink, I looked on the can and it said it was
> three servings.
>
> So it was 360 calories. But people don\'t look at the number of
> servings that are in a product. And maybe something that you would
> want to consider is putting it on food advertisements that, you know,
> a serving of this product is a half a cup, a cup, whatever and it
> contains so many calories. So people get the energy information
> there\--keep thinking of calories, even though people don\'t
> understand serving sizes, we need to do more educating. But at least
> we were putting on the advertisements and, in addition, putting it on
> all of our ads for food products that would encourage people to more
> physical activity and that arena. So I think we need more on portion
> size.
>
> The other think we would like to see is more funding for the for the
> NHANES, the National Nutrition Health And Examination Survey that CDC
> does. Right now it\'s just part of CDC\'s funding and we\'d like to
> really see a line item in the CDC budget for this survey. Because
> we\'re always wondering are we going to have the funding to do that?
>
> And this is where you\'re getting all the data that we\'re talking
> about today. We only survey 5,000 people a year in this survey. So we
> have very, very few people in many of the cells that we\'re doing. And
> we have an article, actually, I\'m going to leave this August issue of
> the AJCN for you. There\'s an editorial by Dr. Blackburn in the
> beginning talking about that when you do a Medline search, there are
> almost 8,000 hits for NHANES\--if you search for NHANES in Medline, if
> you just did a search for NHANES from 1997 to 1999, you get 165 pages
> of annotated bibliography, just for NHANES for two years.
>
> So it is something that is very, very important and it\'s something
> that we always worry about having enough funding to do and we\'re only
> doing 5,000 people.
>
> DR. GERBERDING: Let me just say that the Secretary understand the
> importance of NHANES and he has indicated that it\'s a priority.
>
> DR. SCHLICKER: Great. And we are working to get the nutrition
> monitoring legislation reauthorized, also, to help. We would like to
> see more community HANES, as you\'re doing these programs out in the
> community, what do we have to evaluate them? What can\'t\--and why
> can\'t we take what we\'re doing when we evaluate them before and
> evaluate them at the end of the education to see if this is really
> working, feed that into the NHANES databank. Use the same
> questionnaires we\'re using so you can get a more representative
> sample and feed it into the database. More longitudinal HANES to focus
> on our more vulnerable populations.
>
> Then the other thing that\'s been mentioned around the table is more
> communication between the government agencies and working more with
> the Department of Transportation, and working more with Education.
>
> And we\'re happy as the professional society representing the premier
> nutrition scientists to help you in any way that we can help
> facilitate this. So thank you for bringing us here.
>
> DR. McCLELLAN: Great, and thank you, very much, Dr. Schlicker. And
> thank all of\--I want to thank all of you again on behalf of the
> Secretary for coming. I guess no research meeting with leading
> researchers would be complete without recommendations for more and
> better research, I\'m pleased to see that many of you are already well
> supported by NIH and CDC. But there\'s some great suggestions here for
> how we can do a better job of understanding mechanisms of disease and
> a better job of understanding population impacts and how we can
> influence them.
>
> One of the things that I was surprised about and that is a clear
> action item for us from this is getting out an effective, simple,
> antiobesity mission message that transcends all of our public health
> agencies that includes both improvements on the food side, through
> restraint, through incremental steps and the like, through, as well as
> a clear message on the exercise side. And we know that we need to work
> with other agencies besides those represented here: Transportation;
> Education, the rest of government, as well. So we will definitely
> follow up with you on that.
>
> And there were specific messages or specific steps that all of our
> agencies can take. We talked about appropriate coverage based on
> science of effective treatments, including drugs, nutrition services
> and the like.
>
> We talked about steps that FDA can take in our work with industry,
> both to help better arm consumers so that they are\--they can do the
> job that we ask them to do in these overarching messages. And to
> promote more effective and nutritious foods out there.
>
> So there are a number of specific things in terms of messages,
> research, coverage, improved education and improved regulation that we
> will follow up with you on.
>
> We are out of time now. I would ask any of the other agency heads have
> any brief remarks they\'d like to make to close out.
>
> DR. ZERHOUNI: I have a question. It\'s interesting, as I was listening
> to all the conversations, that, except for a couple of comments, do we
> need to focus also on the fact that obesity is not affecting all of
> our population equally? There is a tremendous amount of diversity
> based on, you know, ethnic background or based on socioeconomic status
> and, you know, although a central message needs to be developed, it
> will need to be tailored.
>
> I\'d like to hear whether or not, it didn\'t seem to be an
> overwhelming message of adapt, adapt, adapt because the rate of
> obesity is different, when you look at the Hispanic Americans or you
> look at African Americans or American Indians. You really observe a
> very different pattern of evolution, as well, as a different
> correlation with comorbitidies. I\'m a little\--I\'m curious to hear
> what\'s\--
>
> DR. McCLELLAN: Just a couple of quick comments on that, Dr. Muscoplat?
>
> DR. MUSCOPLAT: I think that it\'s important to have a culturally
> relative message. As we are working in Minnesota with Native
> Americans, the message is very different than when we work with the
> FNET \[ph\] program in the inner cities. So I think it\'s important to
> have that message be clear and be culturally relevant.
>
> DR. McCLELLAN: Dr. Katz.
>
> DR. KATZ: I think the challenge goes beyond the message to the fact
> that the playing field of opportunity is not level. There are
> environmental barriers. You can convey a culturally relevant message
> about fruits and vegetables to people who can\'t find them anywhere.
> And so, the more disadvantaged the population, the greater the
> obesigenic aspects of the environment become an influence. And the
> more environmental the response needs to be.
>
> DR. ZERHOUNI: I was just saying this, I don\'t want to take your time,
> but I was just saying this. As far as the recommendations, I just
> would welcome more disparity tailored comments.
>
> DR. McCLELLAN: And we would appreciate follow up comments from you all
> on that. Anyone else for closing comments? Yeah, Bill.
>
> DR. SOLOMON: \[Off microphone.\] Bill Solomon \[ph\], Deputy Chief
> Medical Officer, Centers for Medicare and Medicaid Services which also
> gets disparaged\--needless to say, we don\'t do prevention, we don\'t
> do prescription drugs, I hope we\'re half right anyway and we\'re
> working toward being all right. The\--we do have a program, even
> though we don\'t pay for many preventive services, we\'re getting
> better at it. Senior risk-reduction program. It\'s a demonstration
> project and I had a wonderful session with the health economists who
> is associated with that, who shows me data from the banks and large
> 500\--Fortune 500 companies who have 11,000, 18,000 employees enrolled
> in their preventive programs, which include diabetes and obesity and
> smoking and inactivity and, frankly, lack of information. And they\'re
> finding somewhere around a \$4.70 return for every dollar spent on
> their program. So it saves money and there\'s\--I\'m not that liberty
> to say which of the large companies they re, but if you look at your
> credit card, there\'s a high likelihood about half you people here
> have a credit card from one of the banks whose employees went through
> this program and are saving almost \$5 for every dollar spent. So
> there\'s hope out there. I\'m a preventive medicine physician that\'s
> been trying for a quarter of a century to do preventive medicine. I
> would also say that all your ideas are terrific and I\'m enthused. But
> it would be helpful if we had one tangible thing that we could touch
> that when these ideas are abstracted and they\'re out in Waiverly
> \[ph\] and over here\--I\'m a concrete person, I want to touch it.
>
> We have 6,000 hospitals, we should have one \"healthspital.\" And we
> can afford that, maybe, I don\'t know. That\'s all I have.
>
> DR. McCLELLAN: Thank you.
>
> DR. GERBERDING: Yeah and just picking up on this prevention message, I
> think most of you know that all of us here have been very supportive
> of the President and Secretary Thompson\'s frame work for Medicare
> reform. And, you know, as the Director of CDC, the inclusion of
> preventive services in any kind reform bill that makes it through
> Congress is really an incredibly high priority. We really appreciate
> any thoughts or any support that you would have about the inclusion of
> prevention in this process because this is a very unique opportunity
> to get codified something that we\'ve had to really struggle with up
> until this point. So better benefits and better choices is really what
> we\'re asking for.
>
> DR. SOLOMON: I applaud that, CMS can only do what Congress legislates.
>
> DR. McCLELLAN: That\'s right. I want to thank you all, again, for
> coming. As I mentioned, we are going to follow up with you on this.
> And we\'d like to hear from you first, ideas that you want to further
> develop based on this discussion. Please send them in to us in
> writing. We do have that public docket open and you\'ve got a
> description of how to submit comments there. We were particularly
> interested in concrete steps relating to this overall message,
> including how we can tailor it effectively as necessary on education;
> on effective coverage, as in Medicare reform; on more effective
> regulation of nutrition labels and promotion of food products. And on
> better research, including translational research to make sure it has
> an impact quickly.
>
> I want to thank all of you again on behalf of the Secretary for
> coming. This will be an ongoing dialogue, not just with us, but with
> the staffs of our agency and increasingly people through the
> government who are hearing your message about how important it is to
> do a more effective job at addressing obesity. Thank you all, very
> much.
>
> \[Whereupon, at 12:10 p.m. the proceedings concluded.\]