>>RICHARD CARMONA
Can I have your attention, please?  Thank you.  You
have to sit down and be quiet or Denise will come back
and have more exercise for you.  Thank you.  Thank you
so much for coming.  We are thrilled to have this much
participation and an overflow crowd on something that is
very near and dear to our hearts:  Prevention, and disease
prevention and health promotion is where we think the
majority of our resources should be in the future.  But, we
can't get there as much as we all are committed to and
we have wonderful programs, we really can't get there
unless we have good science, and that's the evidence
base behind all of what we do.  And again, there's
another group of people that we often take for granted
that toil anonymously that provide that good science for
us.  The National Institutes of Health is the preeminent
research institution in the world.  Yet, many of the
programs that you all take to the communities, many of
the other programs that are non-governmental
organizations that are driven by good science come from
these wonderful scientists who do the homework who let
us know what the best practices are and to transform that
into cultural competent messages through behavioral
change in a community.  They wouldn't be successful if
they didn't have good leadership.  One of my good
friends, Dr. Zerhouni, the Director at NIH, leads that
group, a humble man, one who doesn't look for any
recognition for anything he does; just wants to get the job
down.  We had the fortune of being nominated on March
26 by President Bush and got to stand together with the
President at that time and accept the awesome
responsibilities that we both have been given.  I've come
to know him as a man of great integrity, of warmth,
compassion and a great leader.  And so we're fortunate
to have him with us today to address some of these issues
before us, but let's not forget that the programs that we
have and anything that we do in the future will be driven
by good science.  And my good friend and colleague, Dr.
Zerhouni, represents the leadership and good science in
the United States and the world.  (Applause)
>>DR. ZERHOUNI
It's a real pleasure to be with you at the podium again,
and we share them from time to time, and I have to tell
you the energy he brings to the message of prevention is
refreshing.  Now, as a director of the NIH, what I would
like to do is talk about strategies for research and
prevention and also give you the contacts, if I may, of
where we see the future and why is it that in 2003,
Secretary Thompson and all of his agency directors met
on multiple occasions for the past two years, but in
January we had a meeting and it was unanimous across
the board from the most basic research endeavors of the
NIH, through applied research to the most public health
measures related areas of the department.  We felt it was
absolutely necessary to focus with laser lights on the issue
of prevention, all the dimensions.  Now, yesterday,
something interesting happened in the world.  At
yesterday, the NIH released the complete sequence of
the human genome, complete throughout the world
(Applause).  Thank you, all of it free to be accessed by
anyone in the world. This is a great date.  In fact, I would
venture to say that for years to come, this date will be
remembered, and immediately after that, as Secretary
Thompson celebrated with us last night, he made a point
that tomorrow, the most important meeting is going to
happen here in Baltimore, and we want to make sure that
the discoveries of the genomes are guided to understand
the prevention disease better.  For me, let me tell you, let
me share with you a thought.  This is day one of what I
will call AG, a new era in medicine.  It's After Genome.
Yesterday was BG,  before genome.  For us, the
challenge is how do we strategize research in the context
of prevention?  What I want to do is give you some
thoughts in that regard and show you some examples.  If
you look at the impact of all the research and prevention
measures and education  on coronary heart disease, in
the '70's, we as a nation decided not to invest in any of
those steps that we took.  Right now, you would be
experiencing about over one million deaths from heart
disease, but we expect about 60 percent less and we are
saving about 815,000 people.  When you see this
decrease, you say, well, let's do an analysis of why it
happened and you realize that in the context of
decreasing the mortality for heart disease, many, many
different aspects were important.  One obviously was the
-- Framingham study, which was science.  One was
public health measures, American Heart Association's
effort in controlling high blood pressure, diet, and so on.
What you realize is that success in the 21st Century is
going to depend on an informed knowledge base that is
multi-pronged in its approach to disease, and here is
where I would like to leave you with a message that I
think is key to me:  There's always this concept out there
that there's a magic cure for disease, that someday,
somehow, we will come up with a drug that will do
things.  It's been hard to move the scientific opinion away
from that, as we understand the complexity of biological
systems, that no successful strategy can be unilateral but it
has to be multi-pronged.  That means, one, understanding
the event that leads to the development for disease, and
we can do this in the post-sequencing era where we
understand the genomes.  Second, delay the onset of
disease by having, A, screening programs or, B, ability to
modify the natural history of the disease.  Delaying the
onset of Alzheimer's will be a major public health
success, and then reduce the burden.  So as you can see,
the paradigm of the 20th Century was curative disease.
We waited for it to reach mass stages, where in the 21st
Century, we  intervene before the crash.  So I'd like to
basically go through some examples of how all of this
works in real term contemporary disease states.  Like if
you take a look at AIDS and look at the U.S. incidence
and mortality rates, in yellow, you see the incidents, they
dropped drastically in 1993 because of preventive
measures, because of behavioral prevention measures
and transmission control.  All of those measures were
based on science at the level of virology.  You can see
we made a big impact on the incidence of disease.
There's a flattening of the curve over the past three years
and we need to work on it and the incidents of death,
there's been a decrease because of drug therapy.  So
here is a principal of a strategy that you need to
implement at all times, then the basic research that was
made possible over the past five years, because of the
increase in the NIH budget to let  80 new drugs in the
pipeline for controlling this disease, but many, many side
benefits to this research in other areas such as, for
example, SARS where we've been able in a short time to
mobilize resources that we put in AIDS and buy a
defense to identify the virus quickly.  But more
importantly, we've been able to develop three times the
number of vaccines in phase one trials because we
believe that at the end of the day, this will be the solution.
Well, let me just go on then to tell you about the new
challenges that an agency like NIH and we, as a
community of health care experts and involved
constituents in better health have to deal with.   New
challenges are obviously related to a new threat of
defenses.  There are new health threats that are related to
the globalization of the world.  West Nile Virus is one,
and when I made that slide, SARS had not been an
emergency issue and so you're going to see SARS, many
others.  We need to be prepared for that.  But then you
look at emerging health issues and you see we are dealing
with evolving landscape of challenges.  I don't need to tell
this audience about obesity and diabetes, but between
1970 and 2003, there were landscape changes in
medicine.  In the 1970's, the primary research was
focused on disease states that were acute and lethal.  So
if you had coronary artery disease, your chances of
survival were low.  We have diseases that are chronic,
low-term beast cancer success with interventions, but that
means the landscape has been transformed from a more
short-term acute type of disease to long-term and this
needs to be taken into account in our strategies.  And that
is clearly related also to the ageing of the population.  So
when we look at this, and I don't have to tell you about
the obesity trends, nor the worrisome trends in children,
in children, and thousands of incidents of obesity, the
problems of obesity, but let me just make a point here
about the implications for our research strategies.  If you
look at the presence of diagnosed diabetes today, you'll
find that, as you well know, about 11 to 12 million people
have diabetes.  Probably another five or six million have it
but don't know it, but if you combine it in the modeling,
the impacts of the obesity trends plus diabetes, you
realize that we're going to see a huge acceleration in the
rate of diabetes and when that happens, the
consequences of diabetes and vision are going to lead to
a change in the curves, health curves of the country if we
don't tackle this issue.  So we're very invested in
prevention and investing the total scientific capital that we
have in finding ways of preventing disease and as you
know, prevention initiative certainly is one that plays a
role in terms of making sure translation of best practices
occurs and that in fact, when you really look at it from my
standpoint, we have a systemic issue of putting prevention
at the core of the system, rather than putting curative
medicine at the core of the system.  That is probably the
issue that will define us.  And that is way beyond what
anyone of us can do.  Because at the end of the day, if
you do not put prevention as a component of appropriate
health care strategies when a patient is not taking care of
for years at a time because of the insurance system that
we have or the health care system that is fragmented, you
are dealing with systemic issues that need to be taken into
account, so our struggle is going to be more, I mean
obviously related to education, but also related to our
understanding of the deeper relationships between
systems organization and the goal of our preventative
strategies.  So, what do we need to do?  There's no
question that there's a need for new strategies.  At NIH,
we are blessed with a revolution in biomedical sciences.
This is day one of a new era, and we need to take
advantage of that, and I'll show you some examples of
that.  There's no question that the challenges we're facing
are different than what we faced 30 years ago, but these
challenges evolve.  They don't change overnight.  The
opportunities are going to have to be taken care of by
accelerating science discoveries and clear acceleration of
discoveries which is possible today on a scale that is
unprecedented and history will mean nothing if we are not
able to translate that into real benefits.  So there's a need
for new approaches.  And these new approaches have to
be orders of magnitude that are more effective than
current approaches, and as the director of the agency, I
cannot imagine a way that would not involve, include, an
order of magnitude increase in our prevention strategies.
So we will have to invest in that area and find out where
the best ways are of understanding our genes,
environment, life-style, our relationships in the way that
will allow us to intervene.  Like I said before, the
complete dysfunction of disease occurs.  We know that
based on the research we already have done, that disease
states do not occur overnight because of a single cause,
but they occur because of a cascade of molecular events.
Cancer, there's at least five to seven different biological
pathways that become dysfunctional before cancer
occurs.  We expect the same thing in diabetes.  So if we
can identify the five of seven pre-disease biological
pathway disruptions, we could probably intervene, and
this is the whole notion of molecular prevention, but we
can not wait to have that, and change what I think is the
real challenge for us and that is that our environment is
changing at a speed which is absolutely unique in the
history of humankind.  I'm going to show you just one
study that will demonstrate that.  This is a study that was
just published in Nature about two months ago.  You may
not have heard about this new technique called R & A
(phonetic) interference.  We didn't know about it four
years ago.  It was discovered about four years ago.
What it is is a new mechanism that was discovered where
small R & A (phonetic) molecules can repress or
suppress the action of a particular gene.  This is a
discovery of great magnitude because for the first time,
we have now a system where each gene in an organism
can be stopped from functioning and then you can
observe what the affect of that is.  It's really functional
genomics.  Let me show you this relating to obesity.
They took the 17,000 genes of a worm and suppressed
each one, one by one, in a series of experiments that
would have taken 30 years if we were using 1960's
methods.  It took them six months to test the system and
another six months to identify the genes that relate to fat
metabolism in the worm.  They found that 305 genes in
fact were promoting fat deposition and only 112 were
preventing it.  You may say how does this help us in
understanding obesity?  It tells you that three-quarters of
our gene pool has been driven by evolution towards
obesity.  Because of starvation, because of low food
supply, only a quarter of the genes have ever been
designed by evolution to be controlling of weight.  Now,
is that important?  It is very important because here in a
simple organism, we're finding there are over 400 genes
that control the homeostasis that drives obesity, and half
were unknown to us, and you say how does that translate
to human research?  Half of the genes are exactly the
same as what we have in our gene make-up.  Doesn't
mean each one of us is equal to worms but you can see
that the research is going to be fantastically advanced and
half of the genes that was discovered have nothing to do
with direct metabolism of fat but neurobiological trial of
feeding habits in an environment that changes food supply
so when you change the environment of the worm, you
can see different genes get turned on and off.  Humankind
is subjected to tremendous environmental stresses
whether global, spread of diseases or a change in our
food environment that occurs within 10, 20, 30 years.
It's very difficult for a population to adapt to that because
we need generations and generations naturally to do so.
The strategies that we are talking about today -- hence,
so prevention and health promotion is an integral part of
NIH.  When you look at the steps that we are taking, just
about one-fourth of the overall budget is related to finding
ways of doing what I just described.  We do not consider
prevention any one particular area of the activities that we
have to have.  We really thing it's continuing,  a continuum
that has to be interactive in education and training of
multi-disciplinary teams of prevention scientists is going to
be key to the process.  At the end of the day, if we can't
translate that to the public and health professionals, it
won't work, so we see this as a complete process that
goes from hypothetical development and controlling trials,
population surveillance studies, and so on.  But just to
give you an example of where we are.  In that kind of
development, you'll know about the Framingham heart
study, but we are looking now at the relationship
environmental -- to the school in Southern California or
the Women's Health Study which is really a fundamental,
I think fundamental model to look at on how to survey
populations or arthritis studies.  I don't want to give you
specific details or spend a lot of time, but each step of the
continuum of prevention research, we have networks that
are in place, the early detection in the worm to develop
molecular markers of cancer.  We can not do the
research or intervention until we have validated markers
to tell us whether or not we do have an effect on the
population.  So these measures are being developed.
One trial that I know will be publicized soon is a prostate
cancer prevention trial.  This is an example of how
serendipity works.  It was found in Finland that the
reason Vitamin E and selenium were tried is because
there was a group being tested for lung disease and
because of the good recording systems that they have in
their health care system, it was found there was an effect
on prostate cancer and prostate cancer incidence.  So we
need to have a system that catches the entirety of the
health care continuum, the entirety of the disease burden
and really, this is why you and this initiative is key to not
to just say well, we know what we need to do, we need
to do more exercise and that's important.  We need to
also find where the best messages, where the -- that will
allow us to transmit messages and to do that in the most
effective way.  Key to this in our opinion is, as it is one
priority that I have set for the agency as a road map
towards faster translation of these discoveries is to re
engineer our research enterprise whereby we will have a
closer relationship between academic health centers,
community physicians, communities of practitioners in
prevention and patients.  If we do not accomplish that,
then I think the communication line is going to be so long
and so broken up that I don't believe we will have an
effective system in the 21st Century.  The nation deserves
it.  And I'm committed to work with the NIH institutes in
all of our communities to change the paradigm by which
medical research, knowledge, is transferred into the
public's benefit.  So we're going to have a new
infrastructure that will be -- for example, one of the ideas
that we're working on is to develop a core of clinical
research associates, physicians and health care
professionals that would have credentials essentially to
conduct,, clinical research appropriately, but also help in
making sure that the translation of messages occurs in
both directions so our goal is to create a more efficient
national bench to bedside research system as part of the
effort we are talking about today.  So in summary, I
wanted to give you a sense of where NIH was in terms of
the healthy people, 2010 and this initiative.  I'm pleased
that the secretary has taken a leading role incoming, in
becoming the secretary for prevention because from my
standpoint as NIH director, from my standpoint as a
previous academic health center official, there's no way
we can overcome the challenges of the 21st Century in
health without renewed focus and renewed energy in
developing prevention strategies that work.  So, on behalf
of NIH, I thank you for your attention, and looking
forward to your progress.  Thank you very much
(Applause)
>>RICHARD CARMONA
I remember back on March 26 when the President gave
us this unbelievable opportunity that neither one of us
expected, and Dr. Zerhouni and I have both a number of
things in common:  That neither one of us would have
expected to ascend to this level of leadership in our
government.  He was a poor immigrant kid that came
from northern Africa with not a lot of money and a lot of
family and he moves to become a leader at John
Hopkins, a well known researcher and director of the
NIH, and myself, just being a high school dropout and
street kid, we both meet on this podium a year ago and
the President gives us this unbelievable opportunity and,
you know, it really says a lot about our country and the
diversity.  And you know how somebody from our
beginnings could be given this immense opportunity.  A
while ago, I was in Florida and I was, I did a presentation
down there and on the way back up, I had to get back up
to Washington quickly and I was fortunate to meet a
military colleague of mine, General Tommy Franks, who
is running the war, a humble man, nice man, and I just, I
got to know him on the plane on the way up to the
Pentagon.  And I was so inspired by his very humble
leadership and the things he was telling me, the
humanitarian things, all the things he was concerned with
in his position as a commanding general, and I got a
different sense of him that when a couple of weeks later,
I, it brought home to me what a wonderful country we
have because I read an article in Time or Newsweek,
one of those news magazines, and it talks about this guy
as a wonderful leader, and went through about a page
and it was this wonderful description of General Franks
and then a counterpoint.  It said we did some research in
your background and we found that you really weren't
such a good student and you had this problem and that
problem, and you know, you didn't listen to your mother
and on and on.  And the reporter said to him, General
Franks, what do you have to say about that?  And he
said, Ain't this a great country?  (Applause) and I think
that those remarks will stay with me forever because it
underscores my feeling every day and the immense
opportunity, privilege, responsibility of serving at this
level; eight months later, never leaves me.  I still pinch
myself every morning.  One of the duties I have in this job
as U.S. Surgeon General is to work with the best leaders
in health care -- both in our government, and in
non-governmental organizations.  And over the last few
months, I've had a number of wonderful meetings at NIH,
alluding to something that the doctor just said, where we
spoke about how do we get this wonderful science and
get it to the bedside?  You know, before the
announcement yesterday of the genome being done, Dr.
Collins and I had had some meetings and we talked
about how do we get this quickly?  Let's not wait those
two decades.  Let's get the good science to the bedside
and translate it into prevention.  Dr. Lindbergh, an
articulate man, was very, very enthusiastic about using all
the present day methods of communication and his
national library of medicine to get that word out that the
President wants us to get out, that the Secretary wants us
to get out, so it's incredible and I think the time is right, I
think the country is ready for embrace prevention, but we
all are just a few leaders that happen to be given
opportunity as we pass through this part of life.  It's really
all of you and the President and Secretary, you always
reinforce what we already know:  That the strength of this
wonderful country is in our communities.  It's each and
every one of you and the programs that you have and the
dedication and commitment that you have to your citizens
that are going to make the changes.  So once again, I
thank you for being here and making this commitment to
lead this legacy of change because it's so important to the
health, safety, welfare of our citizens.  As you heard,
steps to a -- in order to take steps to prevent diseases
this initiative encourages changes in life-style that impact
many of the major causes of death and morbidity.  Some
important points:  Current health trends in ageing, baby
boomers led to bigger cost, high prevalence of chronic
disease.  The unhealthy employed population costs
businesses in many ways.  Education interventions to
prevent some of the leading causes of diseases and
disability remain underutilized and yet can make the
greatest difference.  It's not just the education setting.
Community partnerships between schools, departments
of public health, businesses, civic organizations can teach
and lead by example.  A point that the President never
fails to make when he speaks, that he does expect us to
lead by example, that he does expect us not only to talk
the talk but walk the walk.  Public health is all about
prevention.  Health providers across the public health
system have the capacity to contribute to dramatic
reductions in health, economic, and social burdens of
preventable disease.  We are beginning to recognize a
health system can health better than disease care.  With
those thoughts in mind, I would like to introduce experts
from the areas of Business, Education, Public Health and
Medicine, who will share their prevention messages.
First, it's my privilege to introduce Dr. Joel Bender who is
the Corporate Medical Director for General Motors
Health Services.  And Dr. Bender directs GM's global
health services, acts as health care consultant and serves
as a government liaison with health-related agencies.   Dr.
Bender?
>>JOEL BENDER
Thank you for your kind words.  These opportunities are
a joy for me to attend and oftentimes I'm asked to speak
at, well, some town hall meetings.   I gain more than I
give in these settings, its professionalism, and I think the
experiences that you have that you talk to me about really
reward me.  Secondly, it also provides me with some
personal motivation.  At the last town hall meeting when
the Secretary was speaking, he challenged most of us to
take a look at our weight, and I, too, took that challenge
and over a period of about three month now, I've lost 15
pounds, but I must say -- (Applause) -- thank you.  But
in the spirit of what you hear oftentimes in corporate
America, there are stretch goals, and so 20 was the
stretch goal I had so I have five more to do.  Let me talk
to you this morning about a number of things that are
probably important to GM and why would we be
interested in preventative care.  First of all, as you can
see, GM is the largest non-government health care payer.
We have over 1. 2 living coverages in the United States
alone and we have a significant population of retirees.
This mimics what is going on in the U.S.  We are a large
statistical sample of What's going on.  Cash outflow for
health care alone at General Motors is $4.5 billion a year
and is going up about 9 percent each year, and with
about $1.4 billion in drug costs for the corporation, and
that's going up more than about 9 percent a year.  So
that's why GM has an interest in health care and
particularly in prevention.  I'm going to limit my talk today
to three areas:  Number one, I'll talk with you briefly
about occupational health; secondly, about community
initiatives, and then thirdly, about wellness and health
promotion in a joint program with the united auto
workers and GM called Life Steps.  These programs are
intertwined, they are related by a number of common
threads in that they are multi-disciplinary, covering a large
amount of individuals.  To give you an example, I have 89
clinics in the United States, I have a staff of about 550
professionals that are greatly interested in prevention, and
they make these programs work.  Likewise, in
community initiatives, we have a number of nurses that
deal in the larger communities as well, providing these
kinds of services to communities, to our retirees and
employees.  Let me talk about some of the things we see
in terms of health risks in our population.  If you look at
this chart, I picked out a handful of risk factors that we
see in our population at General Motors.  And as you can
see, we have some major issues with high blood
pressure, cholesterol, but as well as we have another
issue down there about second from the bottom dealing
with obesity in that almost 40 percent of our population is
overweight.  When we look at what we're trying to do
with our Life Steps program, we're seeing some positive
trends.  We're making some difference and we can
measure those differences that take place.  We have a
long ways to go.  If I look at this bottom of this rather
busy chart, one of the ways we can measure our
performance is by looking at the change in the risk factors
in this population.  The goal is to move people from
high-risk to medium risk, and to low risks.  So that's why
you see that area growing under 0-2 risk.  We want that
area to grow because we want people to remove that
risk from the high and the medium categories.  That's a
look at risks.  What else is going on in this population?
Well, you can see when we ask people what kind of
diseases they may have, we have a rather small
percentage though that are low risk that might have
disease in the population.  And it increases by age.  As
you start increasing risks, you see the percentage of
individuals with disease that is acknowledged by them
increases, increases to the point that when you have
individuals at high-risk, you have almost 80 percent of the
people of our population have some disease.  Now, let's
take and look at one small category of those diseases that
people report.  In here, if there's anything I can impress
upon you on this chart, it's that the issue of weight
control.  Because as weight increases to a point where
you are at least 30 pounds or 35 pounds overweight, and
you have multiple risk factors, that is four or more risk
factors, we can identify at least 16 percent of our work
force that is a diabetic.  16 percent.  It comes right back
to controlling risks, controlling weight as well.  These are
very costly things for the corporation but more
importantly, it's costly to those families and to those
employees as well.  That takes me to the reason that we
set up.  What we call a diabetes management work site
pilot.  One of the things that I noticed shortly after coming
to General Motors was that when individuals would
receive calls from the health care provider, they would
get information from their primary care physician, get
information from the health care plan, lot of it being
different.  People didn't like being contacted by multiple
sources.  So we decided to take the best of the best.
And in three sites, we've set up a pilot program in which
we made it free and confidential to every employee, we
want to promote improved quality of patient care, we do
implant screening for a variety of factors that are listed on
the American Diabetes Association criteria, and most
importantly, we do want to engage that primary care
physician.  We involve that physician because we feel that
is the point at which people can have contact and we
want to continue that momentum to identify and control
those issues that involve the diabetic.  Program may seem
complicated but it starts with a plan employee, starts with
a Life Steps program which is the health and wellness
promotion program at General Motors and united auto
workers, it deals with our own health care teams at each
one of our plants and clinics, data is transmitted to the
University of Michigan where it's held and analyzed and
done confidentially and involves the primary care
physician.  Our goal was in one year to enroll at least 200
people in the four sites in this program.  Already, we have
enrolled 250 people after five months in the program.
What do we see?  We see about 50 percent who are in
reasonably good control, the remaining 50 percent is in
dismal control.  Hemoglobin AIC and the other
hemoglobins are not well controlled at all.  We really
need to work on these links.  In a period of three months
with a smaller segment of this population, those who have
been actively involved in this pilot project, what we are
seeing is reduced weight, control of the hemoglobin AIC
and reduced cholesterol levels, so it's beginning to work,
even with this modest level of individual involvement.  Let
me move on to one other aspect of our portfolio.  That's
called Community Initiatives.  You heard the previous
speaker speak about community, community
involvement.  It's obvious to me that as a corporate
medical director.  That I really can't do it all.  That it
takes involvement in the community.  I personally believe
strongly in a public health model and this is the beginnings
of that model.  What we've done here and the reason
we've done this is because we are so spread all over the
United States.  However, we were able to identify in nine
locations, nine communities, that account for 61 percent
of that $4. 5 billion we couldn't control and couldn't really
cooperate and involve 250,000 physicians, or 36,000
pharmacies so what we did was pick a smaller segment
of the population where we would move in a
collaborative fashion.  The goal of our community effort is
to improve quality of outcomes, increase collaboration
and really drive towards best practices.  Some examples
that we're doing right now is just a get you fit campaign.
We are in four communities with that project.  We used
some of CDC's surveillance to monitor our progress.
Our ultimate goal in this particular program is to reduce
sedentary life by at least 10 percent in the next three
years.  In Detroit, how appropriate, Motown in Motion.
Similar type of concept involving the community, setting
community goals.  Lastly, and a major effort that we are
working on is quality of care focus, and this is the
Michigan Quality Improvement Consortium, here we're
looking at evidence-based practices.  Let me tell you
how important patient safety is alone to General Motors.
When we look at medical errors in the United States, and
extrapolate that to General Motors where we have 1.2
million lives, the potential exists to safe practices reducing
errors in medicine, is to prevent 1.3 deaths every day just
in the General Motors population alone.  Safety is very,
very important.  That's why we are driving towards best
practices and are looking at those for heart disease,
diabetes, and many other issues as well.  And now let's
talk about Life Steps, a General Motors program.  Yes,
you have to do more than think about fitness.  Life Steps
is truly one of the largest corporate wellness programs in
the United States and we have the typical 1-800 phone
numbers but personal trainers and I've got, I believe,
about 55 fitness centers alone throughout our plants in the
United States.  And we track and measure progress in
this population as well.  Is it working?  Well, we've
conducted 850,000 health risks appraisals, and the goal
is to move them to lower risk and over half have
decreased at least 1 health risk factor, and when we look
at the chart that is shown on this chart, on this slide alone,
what we see is that those that have even three or more
are making great improvement, we've had almost a 20
percent improvement in reducing risk factors in the
population.  When we look at what prevention eventually
can do for us, we see that the percent of total costs
attributable to such risks at General Motors is 20
percent.  Low risk individuals cost a corporation less.
How much is that?  $450 million annually.  That's direct
cost only.  That's not the cost of loss of productivity,
absenteeism.  That's the direct cost of hospital care,
clinical care, pharmaceutical care for employees, and
retirees.  What have we learned?  Well, certainly
improving the health status of a community makes a big
difference.  We also know that improving the quality of
care is imperative.  We agree that there's a national
epidemic of obesity.  We know that excess risk factors
increase the prevalence of diabetes, and we're working
diligently to focus on diet and exercise and to make the
workplace more friendly than it has been.  But when we
look at the total picture, we know that wellness and
prevention improve the bottom line by helping our
employees, helping their families and retirees because we
know the cost of diabetes.  The cost of missing that loved
one, cost of morbidity associated with that disease and so
other disease related to it.  It's not just a dollar figure we
are interested in but the bottom line for each and every
employee that we serve.  Thank you.  (Applause)
>>RICHARD CARMONA
Thank you so much, Dr. Bender, for those remarks.  It
ties in with our own biases as far as achieving best
practices, and we'll hear from Dr. Carolyn Clancy on
some of those issues on reducing the variability and
practice patterns and so on which we all need to step up
to on medical side, but thanks for the GM approach.  I'd
like to now introduce to you Dr. Michael Ward, State
Superintendent of Public Schools in North Carolina.
Reelected in 2000, he is serving his second term in office.
During his tenure the State's schools have earned a
reputation as the nation's most rapidly improving system
of education.  Dr. Ward is an advocate of strong
programs and consistent programs of healthful living and
physical activity.  Welcome Dr. Ward.  (Applause)
>>MICHAEL E. WARD
Good morning.  I'm grateful to have a chance to be part
of this conversation.  I've run into awfully friendly folks
while I've been here.  I had hoped that would be the
case.  In my role working with public schools, which puts
me in a fairly conflict-rich environment, I sometimes run
into folks who are less kindly disposed.  We've been
through some public hearings recently and they have been
fairly contentious and folks have brought some concerns
to the table and we have had our rounds.  It got lively and
I got gun shy going out in public.  I recently concluded
one of the sessions and was out on the street later in the
day and a woman approached me, crossed her arms and
said, You look just like Mike Ward, our state
superintendent.  I didn't know what she had in mind and I
said, Yes, ma'am, I hear that a lot.  She said, It makes
you mad, doesn't it?  That's not a true story, but most of
the rest of what I share with you most of the rest I share
will be.  I really am honored to be part of this important
conversation about the health and well-being of
Americans and especially the health and well-being of
children.  I'm inspired by you and grateful that you make
such issues a priority.  I'm also grateful for the chance to
learn from you.  A couple of years back, I took on a
personal challenge during Powerpoints.  (inaudible) I
decided in running a marathon race.   They say that a
marathon is two parts:  The first two miles and final six.
Most people don't ordinarily run in training for the entire
marathon distance, theory being that you only have one
or two optimal 26 mile runs during the space of months
and you don't want to waste that in a training run.  So I
had never run prior to the marathon that full 26-mile
distance.  So I wasn't sure what the final miles would be
like.  I had heard that there are two phenomena late in the
race:  One is an experience called hitting the wall.  Your
legs turn to lead, breathing is labored, and it's hard to
hold your arms up while running, and I was also told that
there's the potential for another experience later in the
marathon.  That is a type of euphoria, almost a spiritual
experience, a lightness sense that you can run forever,
and sure enough, around mile 21, I felt a type of lightness
of renewed strength, a sense that I could just keep
running and not grow weary.  Marathoner euphoria is
real, so is the wall.  It hit around mile 22.  And from that
point on, it felt like I was swinging blocks at the end of
each leg.  Weeks later I felt I could run and not grow
weary.  For folks like us, trying to advance the cause of
healthy active Americans, it really is a marathon.  It's not
a sprint.  There's an occasional euphoria but I suspect we
agree we confront the wall more often.  I want to share
three observations.  My wife is a United Methodist
pastor, I think I'm a victim of like the preacher's wife.
She has sermons in three points.  I want to share three
points.  The advantage is if it's going badly, you have
some sense of how much you have to endure.  First point
that I want to share with you is there's a real health crisis
for kids out there.  And there's some conflict in schools
about the degree to be a part of the solution.  I don't have
to give you the statistics about the chronic problems;
you've heard that already.  As the CDC's own report
points out, most Americans know the risk factors of
serious chronic diseases, but most also have not changed
their life-style sufficiently to reduce the risk of death or
illness.  Americans know what to do.  We're just not
doing it.  Of course, it's not just adults.  The increased
rate of obesity, diabetes and other health problems
among school-aged children is well documented.  Public
schools are sometimes guilty of failing to address the
problem.  Tough choices are confronting us in education.
Educators are under tremendous pressure to be
accountable, and that accountability is typically based on
test scores, and with the enactment of No Child Left
Behind, these pressures have increased leading some to
wonder about the placement of health and physical
education.  You've heard about No Child Left Behind
earlier from Secretary Paige and I want to share a few
additional observations about this legislation.  No Child
Left Behind sets new standards for student achievement
fore closing achievement gaps, for teacher and
paraprofessional quality.  I want to be clear as I begin,
No Child Left Behind has the right goals, and I stand
behind this legislation.  You can not argue with goals
which stress accelerating achievement of all children, and
erases gaps in improvement and making sure kids have
access to well qualified teachers and empowering parents
whose children are trapped in school that chronically fail.
The law identifies core subjects and specifically sets
higher standards for teachers in these areas.  Health and
physical education is not identified in the legislation as a
core content area.  Pause for a minute and think about
the pace at which reform has taken place in schools over
the course of the past couple of hundred years.  It's been
about 150 years since the beginning of the common
school movement.  It took us 100 years to get serious
about inclusion to assure that all youngsters had a plate at
the table, and that just the advent was the Brown versus
Topeka Board of Education decision, the desegregation
case.  Subsequent decades have affirmed rights of
children with disabilities, students who are new English
learners.  It took us about 150 years to achieve the goal
of universal access.  No Child Left Behind accelerates
now a new goal.  We now have the challenge of moving
to universal proficiency in the space of 12 years.  150
years to universal access, 12 years to universal
proficiency, and I think that the contrast between the time
frames  creates an ununderstandable sense of urgency, a
sense that there's perhaps not enough time for everything,
and the fact that they are feeling this way makes us
wonder if health and physical activity are going to
decrease in importance at the very time the research says
that we're facing a crisis.  You and I know that the
accountability movement in public education has not had
as its goal as an explicit intent the need of the physical
well-being of children but the unintended consequences
that we need to be paying attention to.  Consider some of
the following illustrations of this point:  In Connecticut and
Virginia, there are discussions regarding cuts to health
and physical education programs.  It appears these
programs are okay for now, but the discussion took
place.  In Minnesota, health and P.E. programs are
scheduled to be cut and offered only as an elective.
Rumors are building that other states may consider similar
action.  In addition, there's the concern about the
message that is sent when we are not holding health and
physical education teachers to the same standards for
highly qualified teachers that other teachers are held to in
the No Child Left Behind legislation.  I want to stress,
these are unintended consequences I believe.  I'm
confident that that's the case, especially at the national
level because of other events that are occurring.  For
example, The National Summit On Action for Healthy
Kids was recently held in Washington, DC.  The surgeon
general convened the meeting with the First Lady,  Laura
Bush, to signify the importance of this event.  I doubt the
First Lady's views varied significantly from the President
who is known for his support of not only No Child Left
Behind but for personal health and fitness.  And this
conference is another case in point that such outcomes
run to the goals of health, such (inaudible) this crisis can't
be denied and the competition among priorities in the
mind of educators and health professionals is real.  So
point number one:  There's a real health crisis for children
and schools are conflicted about their role.  Point number
two:  There's a compelling case for schools as problem
solvers in the health crisis that's confronting our kids.  As
was noted previously, there are danger signs regarding
the health and well-being of children, but with respect to
issues of health and learning, there are some positive
signs.  There's research that points to the connectedness
of health and physical education and academic well-being
in schools and there are other positive signs shown to us
by research.  I want to give you a sample of some of this
research.  Health and physical activity are positively
related to academic performance, and we'll just breeze
through some of these reflections.  This research I hope is
not surprising but this is the core.  There are other folks
that don't get this connection very well and it's important
that we get this research disseminated broadly.  It's
research from across significant time spans and it's
research from across the country that supports the
connectedness of physical activity and academic
performance.  There are strong correlations between
physical activity and health education and youngsters and
the sensibility of youngsters regarding their own health
and wellness.  There's also a relationship between
students' participation in health education and decrease in
their own risky behaviors.  There's also a strong belief in
the community that these contents are essential.  73
percent of adults from nationally represented samples felt
that health education in school was definitely necessary,
82 percent of parents felt that health education is more or
as important as other subjects.  The community gets it.
Health and physical education are as basic as it gets.  The
community when asked is with us.  The test before us is
to tabulate this support to assure concerted multi-agency
and community policies and behavior in support of
healthy, active children.  Importance that parents and
other adults place on helping our children create healthier
life-styles makes it clear they expect schools to be
important partners to assure better health with children.
So point number two, for those keeping count, there's a
compelling case for schools as problem solvers and
there's steps we can take to address the crisis in spite of
the challenges.  I know there are things going on all over
the country, but North Carolina's steps are those with
which I'm most familiar.  And so I want to share a few
things we are doing in North Carolina.  We've got a joint
commitment between the Secretary of Health and Human
Services, Carman Odem (sp) and by the Department to
Improve Health and Academic Performance.  -- we have
also appointed healthy schools forums, meet with the
legislature and support an adolescence health advocacy
day.  Our county directors, board of education, county
health directors have created coalitions.  We've
developed a healthy active children policy which requires
local advisory committees and adopts guidelines for the
amount of physical activity that youngsters, in which they
participate.  Our Action for Healthy Kids Summit targets
local boards of education members, their support and we
model and profile best practices in districts with respect
to this issue, but we've been the beneficiary of a CDC
grant, but I want to point out we don't have to wait on
grant money to advance causes like this, and there's
things we can do now to help assure better emphasis on
health and well-being among the children.  First of all, we
can strengthen agency partnerships with our counterparts
and other agencies and develop common objectives.
Our public schools in North Carolina -- think of our
chances for advancing this cause, now that the North
Carolina Public Health Director has the corresponding
goal of eliminating health disparities among children.
Shared objective like this advance our prospects for
success, building goals around common objectives can
help us move ahead even in times of tight resources.  We
can also work with and use our national organizations.
CCSSO, my national organization, states school officers,
is active, has been active in creating a task force on
school health, safety and terrorism which is working to
create, models of support, and your organizations are
doing similar things.  We can tap our organizations for
assistance.  We can also ask tough questions about the
ways that we are using existing resources and in a time of
tough choices, we can consolidate services, spend less
time in another areas to funnel to another area, like the
health and well-being of our children.  And finally, we can
advocate.  We can be active in the process calling on
policy makers to make sure that health and physical
activity are being accounted for.  We need to be
personally engaged in the process of advocacy.  I
sometimes tell folks they ought to take a legislator to
lunch, commissioner to coffee, member of Congress to an
activity, and board members as well.  We need to be
advocating with the folks who are making policy for good
policy that affects the well-being of our children.  It
matters that we do this.  It matters that we attend to these
issues.  It matters to the economy, it matters to the
community, it matters to moms and dads and most of all,
it matters to children.  One by one, for all that you will do
and all this conference will do to advance these important
causes, I say thank you.  (Applause)
>>RICHARD CARMONA
Dr. Ward, I'd like to tell you, and I may be using your
wife's, the minister's three-point rule.  I appreciate your
metaphor regarding the race for health being a marathon
and not a sprint.  Also, we will occasionally hit the wall in
transitioning to prevention from a care -- but we
persevere and experience the euphoria.  And lastly,
please tell your wife, the minister, she's trained you well
and the sermon from this pulpit was well received.  Next,
it's a privilege to introduce David Hoffman, Director of
the Bureau of Chronic Disease Services of the New
York State Department of Health.  This bureau contains
programs including diabetes control and prevention,
breast and cervical cancer screening, colorectal cancer
screening, prostate and ovarian cancer education, cystic
fibrosis assistance and Alzheimer's disease and other
dementia services.  He has a history of health public
health service, having served as a program manager in
child and adolescent health programs and chronic disease
programs and most recently as Assistant Director of the
Bureau of Chronic Disease Services.  Please welcome
Mr. Hoffman for me.  Thank you.  (Applause)
>>DAVID HOFFMAN
Thank you, Dr. Carmona.  It's my pleasure to be here to
share a few thoughts with you.   By way of introduction, I
would like to reference a question we heard earlier this
morning regarding primary, secondary, and tertiary
prevention and acknowledge that in state public health
agencies and particularly their in-state chronic disease
programs, we accepted the challenge as our responsibility
to work with our communities in all three, and it worked.
Let me share a few thoughts with you this morning about
our diabetes prevention and control program.  In the U.S.
today, 17 million people have diabetes and about six
million of them don't know it.  There's an equal number of
people with a new condition that we refer to as
pre-diabetes which you're going to hear more about
shortly.  When we look at the risks for diabetes,
non-Hispanics, and blacks are two times more likely to
have diabetes, Latino Americans are 1.9 times more
likely to have diabetes, American Indians and Alaskan
natives 2.6 times more likely.  The risk is also increased
for Asian Americans, native Hawaiians, Pacific Islanders
as well.  When we look at mortality, the risk for death
among people with diabetes is about twice that of people
without diabetes, and diabetes is rated as the 6th leading
cause of death although we know state by state that
diabetes is under reported.  Today, while we are here,
2,714 people will learn that they have diabetes.  105
people with diabetes will be diagnosed with blindness.
192 people with diabetes will have a lower extremity
amputation to save their lives.  When we look at
complications, it's the things we heard about already this
morning.  Heart disease, stroke, high blood pressure,
vision, kidney disease, etcetera.  When we look at the
economic impact of diabetes, the increasing costs parallel
what we saw in the maps earlier in the morning from $98
billion in 1997 to $132 billion in 2002, with the difference
in average costs of $13,000 spent on people with
diabetes annually compared to $2500 for people who
don't have diabetes.  We know that preventing
complications saves lives as well as dollars, but we know
that it makes sense.  For every 1 percent reduction in
hemoglobin AIC which is a measure of blood glucose
over time, the risk of developing microvascular
complications, kidney and nerve complications is 40
percent.  Keep that in mind.  We'll come back to that.
Blood pressure control can reduce cardiovascular
disease by up to 50 percent, improve control of
cholesterol and lipids, can reduce cardiovascular
complications by 50 percent.  Foot care programs can
reduce amputation rates from 45 to 85 percent.
Detection and early treatment of diabetes-related kidney
disease can reduce the development of kidney failure up
to 70 percent.  We now know that to a great degree,
diabetes is preventable.  You're going to hear more about
that as well, but the life-style interventions that we've
heard so much about this morning and that we need to
internalize and work on together are absolutely essential
to what I'm about to tell you.  In New York state, our
diabetes prevention and control program has taken a
global approach including a number of external partners.
Our primary partner is the Centers for Disease Control
and prevention where we receive our seed money.
Without this money, our program in New York would
not exist.  We fund three diabetes centers of excellence,
we fund 13 community coalitions for diabetes prevention,
we have four governor's initiative projects for children
with diabetes.  I was pleased to hear so much about
children, thank you.  We also work with ten of the
federally qualified health centers in New York as part of
the diabetes collaborative and we have a special project
with all of the health care plans in Westchester County, a
highly populated area in New York.  Internally, we work
closely with the Office of Medicaid Management, with
projects from drug utilization review, to chart review
projects to try to improve the care that people in the
Medicaid program receive as well as increasing the
knowledge of Medicaid providers.  We work closely
with our Office of Managed Care for both the Medicaid
Managed Care and commercial population and we
showed good results which I'll show you soon.  We have
a protect with our AIDS Institute in New York  called
expanded syringe access, a demonstration project that is
giving us access to a population that we typically don't
work with in chronic disease.  Our Centers of Excellence
are university consortium-based projects that engage in
diabetes related research, provider education, and state
of the art care for people with diabetes.  We charge them
with improving access to special and at-risk population to
comprehensive diabetes care, but more importantly, we
charge them with developing tools, practical tools for
working with people with diabetes or at great risk for
diabetes.  Our community coalitions are charged with
addressing CDC national objectives for control,
screening exams, annual flu vaccines, pneumococcal
vaccines, smoking cessation, weight management,
etcetera, and involve many community partners.  The
interventions that they gain include provider education,
development of tool kits in their distribution, nutrition and
physical activity programs and research projects with
step counters, community education, educating the public.
Teaching tool development, chart tool development, our
supermarket project in many cities where people with
diabetes and their families can go and have learning
experiences, support groups and outreach to special
populations.  Our Governor's Initiative Project began a
few years ago -- the opportunity where we found ADA,
local diabetes center and the local school systems.  These
projects insure that children with diabetes are able to fully
participate in all facets of their class, scholastic
experience.  Last year, we trained over 2500 school
nurses as part of this project as well as other
school-related persons which work hand in hand with
nurses.  It's an interagency project between the Bureau of
Primary Health Care, AHERSA, CDC, our diabetes
program and Institute for Health Care Improvement.
They use proven, quality improvement and diabetes care
practices to improve the health status of their patient
population.  Let's look at some numbers.  Those numbers
have reduced the average AIC value for their population
of over 2000 patients by almost the full point in this
two-year period.   When we look at the progress
towards national objectives, annual eye exams have
increased, foot exams have increased, AIC numbers
jumped from 97 to 24 percent -- to 68 percent of the
population of New Yorkers with diabetes -- when we
look at the managed care population in commercial
managed care, we saw a 5 percent jump in the
measurement of AIC.  In the Medicaid Managed Care
population, the increase was even more dramatic.  You
remember what I said earlier about improving H, excuse
me, AIC having a positive benefit on all of those risk
factors.  Let's talk about the contributions of our primary,
secondary and tertiary prevention efforts.  We've seen a
reduction in the incidence of end stage renal disease from
3.7 per thousand people with diabetes in 1993 to 3.2
thousand.  That's a six year decline of 13.5 percent.
When we look at the cost data nationally, $6.6 billion a
year, and extrapolate the New York experience
nationally, we could see that number reduced to $5.7
billion a year.  When we look at hospitalization rates for
people with diabetes, when we look at the national cost
data at $4.6 billion a year, when we extrapolate the New
York information, that's reduced to $3.3 billion.  When
we look at lower extremity amputations, we saw a
six-year decline in New York of over 35 percent.  That
can be extrapolated nationally to a reduction in costs
from $4.1 billion to $3.3 billion.  Our flu immunization
rates increased from 53.4 percent in 1993 to 59.8
percent in 1999.  According to the CDC, flu and other
infections caused an estimated 10,000 to 30,000 deaths
to people with diabetes and most are preventable.  So
we're left with a number of challenges and also a number
of opportunities.  We have the twin epidemic of diabetes
and obesity, but I'm pleased to say we have national
attention and new resources to be brought to bear on
these issues.  We have a diverse and ageing population as
we heard earlier this morning, and we have new culturally
sensitive education materials and tools to use.  We have
categorically funded programs with similar goals and
objectives that are collaborating more than ever before.
We have our diabetes prevention findings which you'll
hear about shortly and we'll be taking our next steps in
the prevention of diabetes.  We have all of these daunting
statistics and the single largest prevention investment in
history:  Steps to a HealthierUs.  Thank you.  (Applause)
>>RICHARD CARMONA
Thank you for the New York perspective and comments
about the values of partnerships and how effective they
can be.  I'd like to introduce our last speaker, and that is
Francine Kaufman.  Dr. Kaufman is currently President
of the American Diabetes Association and Professor of
Pediatrics at the Keck School of Medicine at USC.  She
is the Director of the Comprehensive Childhood Diabetes
Center and Head of the Division of Endocrinology,
Diabetes, and Metabolism at Children's Hospital in Los
Angeles.  She set up numerous support groups, family
camps, retreats and patient and family seminars to aid
those under her care.  I wonder what she does in her free
time, and please help me in welcoming Dr. Kaufman.
(Applause)
>>FRAN KAUFMAN
I want to be sure I know how to work this first.  It is such
an honor to be here and particularly with our partners
from the NIH, and Dr. Spiegel.  And representing the
American Diabetes Association, I was trying to count
how many times the word "diabetes" has already been
said this morning, but I ran out of patience at about 200.
It's a real thrill to see diabetes as the prime initiative of
this morning's conversations.  Because of that, I think a
lot of what I will say has been covered so I will just go
quickly over most of these statistics and just stress that
the complications of diabetes are devastating.  Diabetes
remains the leading cause of acquired blindness, kidney
disease, and the need for amputation and most people
with diabetes die of a cardiovascular event.  And then, of
course, the cost of diabetes last year exceeded the
tremendous amount at $132 billion.   Diabetes affects our
Americans of minority ethnic groups, and you can see
that there's an every increasing number from those who
are Caucasian to Latinos to African Americans and native
American.  This is about the natural history of the
development of type 2 diabetes.  Right before I came, I
diagnosed diabetes in a 9-year-old girl who weighed 120
pounds.  She was profoundly ill when she presented at
the hospital, and we had to do some, manipulations of her
fluid, gave her medications to bring her back to a safe
level.  She had a 16-year-old sister who was hysterical
and almost did not stop crying for the first 12 hours of
that child's admission, so I went over and I said, she's
going to be all right.  Why are you so scared?  And she
said, I'm just so scared because the word "die" is in
diabetes.  So I think that  as we see an ever increasing
number of children affected by this devastating disease,
which is sensitive to some of the concerns that they have
as well, I think you can see from the scheme of it, the
beginning of diabetes is really a genetic problem.  Add
the mix of environmental factors that lead to obesity and
physical inactivity, and even if the beginning stage, before
something is diagnosed due to an elevation of insulin, they
already have a beginning of cardiovascular risk factors
and probably beginning of cardiovascular disease.  We
go through this period in which we can diagnose
pre-diabetes.  It's referred to as IGT, or impaired glucose
tolerance, and that is made by giving somebody a fasting
blood glucose test and then followed by an oral glucose
test and looking at the glucose to define the tolerance or
pre-diabetes.  We see the onset of clinical diabetes and I
think what you heard today, we do not manage diabetes
optimally.  They experience -- high blood pressure and
sugar lead to deadly complications, eventually to disability
and death.  We talk about usually about a 20 or so year
time frame from the beginning of diabetes to the really
onset of its devastating complications.  For the
9-year-old child that I diagnosed yesterday, 20 years will
make her still a very young adult, and I think as we see
this increasing more and more in the pediatric population,
we can be very concerned about the next generation of
young Americans.  What I want to really talk to you
about is the diabetes prevention program that was a
tremendous collaborative of a number of research centers
across the country, tremendous number of research
volunteers, who gave of their time, and of their years to
be involved in such an important study, and it was funded
by the National Institutes of Health, and also some
partnership with the American Diabetes Association, and
a number of other groups.  Now, let me, you heard about
it a little this morning.  Let me give you more background
as to what this study was about and what it showed.  So
what they had was, looked for adults with impaired
glucose tolerance and had an oral glucose tolerance test
at some point and those that met the criteria were
randomized either into an intensive life-style, taking the
drug metformin or into a placebo group, and at the
bottom, you can see the study involved more than 3,000
participants, and these are the kind of data we saw and
you can see that the curve for the life-style way succeeds
what we saw with the medication.  So the weight loss
was the best with life-style and as a result of this weight
loss, there was a significant decrease in progression to
diabetes.  And as you see, as that line goes up, that
means more and more people have developed diabetes.
We can compare it to the placebo group. There was
some reduction with the drug, but then the most
significant reduction was with life-style alone, and as a
pediatric endocrinologist, when I think about this bullet
that was talked about earlier by Dr. Zerhouni, some pill
that could make everything well, it becomes unlikely that
we will in the near future have any medication that will do
what alteration of life-style has been able to do.  Then we
think about medication, are we going to start eight and
nine year old children on these and have them on it for
decades and decades?  I think that would be a much
poorer alternative than thinking of instilling a lifestyle
(inaudible) on adults with impaired glucose tolerance or
pre-diabetes, and they had diet and exercises, just routine
care, and I think that you can see the intervention group
compared to control group.  At the end, reduction in
diabetes was identical to that same with the prevention
program of a 58 percent reduction and those with the
life-style intervention compared to those with just routine
lifestyle.  Then there's a Chinese study and European
study saying we can prevent it.  None is as rich as what
we see with life-style intervention.  So, the big challenge,
and I think the doctor mentioned this, is not how do we
bring these results?  How do we invigorate the American
population, particularly those at risk to want to follow the
life-style changes, protocols?  First of all, I want to tell
you that we are out there looking to find people at risk or
who already have diabetes and don't know it, and the
recommendations of the American Diabetes Association
and the NIDDK are to do this in the context of a health
care visit for adults, and to look at the risk groups of
those greater than 45 years of age who have a BMI
greater than 25, to be considered at risk and to be tested
for diabetes in the context of their health care visit if they,
if their health care provider feels that's indicated.  For
those less than 45, we add on other risk factors such as a
positive family history, for women who have had
gestational diabetes or a large baby in the past, or for
people who have elevated cholesterol, hypertension, or
are of an ethnic minority.  They have a screen done in the
context of their health care visit and if it's negative, it's
repeated every three years.  What exact tests need to be
done?  Fasting blood glucose, perhaps a two-hour
glucose tolerance test if indicated and then what is the
hope if somebody does have pre-diabetes that there will
be a way to invigorate their life-style.  Give therapy
counseling about life changes and weight, to continue to
monitor them for the development of diabetes or other
cardiovascular risk factors, and at this point, to avoid
drug therapy since there is none that is as impressive as
life-style intervention.  Similar recommendations for
children.  We now know that there's a tremendous cohort
of at-risk children there and these children are for the
most part over ten years of age, or in puberty because
puberty is the time that we usually see type 2 diabetes
develop due to insulin resistance.  Puberty itself causes
normal children to be resistant to insulin; it causes them to
be resistant to about anything.  Insulin happens to be
something as well.  And those that have a high BMI -- of
the ethnic groups that are at risk, and then have other
signs of insulin resistance.  And again, it is advocated that
the children be evaluated for this in the context of a health
care visit with their health care provider, so that if they do
have pre-diabetes or diabetes, there's good follow-up for
them at that point in time.  The real translation will have to
be a tremendous partnership.  Across the country, and I
think some spearheaded by Secretary Thompson's small
steps, big rewards, the NIH, National Diabetes
Education Program are all involved as is the American
Diabetes Association and a number of other agencies.
But this is to really teach the primary care providers
about the screening during the health care visit and the
follow-up and counseling of those individuals who have
pre-diabetes or diabetes to reduce their risk.  I just want
to tell you there's also studies being funded now by the
NIH and NIDDK to look to similar kinds of events for
children.  And this is the study to treat or prevent
pediatric type 2 diabetes and looking at one of the other
ways to treat children with the type 2 diabetes, and I
hope the superintendent realizes that the prevention
efforts are school based, they are being done in North
Carolina, California and Texas, and as they are going to
design the trials, it will be really to invigorate physical
activity in the school, health education, improve nutrition
in the school, and, of course, some behavior change
components for the children, the teacher and hopefully
families as well.  So just in conclusion, if we look at the
overall cost of diabetes, they are immense.  The direct
cost is a significant proposition in the next health care
expenditure and we need a modest weight loss, although
I'm sitting here with a couple of marathoners, we are not
asking people to become marathoners or being elite
athletes or asking them for a modest weight loss that has
a significant reduction in diabetes incidence and for those
who do have diabetes already, a significant improvement
in reduction of cost for diabetes treatment and an
improvement in health outcome for those with diabetes.
So I thank you very much for your attention, and I am so
glad that diabetes has been the most common word said
this morning.  (Applause)
>>RICHARD CARMONA
Thank you for your remarks, and thank you for your
leadership with the ADA.  At this point, I think it would
be extremely unhealthy of me to stand between you and
your lunch.  So I would like to direct you to -- as we
leave, but first, would you please join me in thanking our
wonderful speakers for the information they gave to us
this morning?  (Applause).  Please be back at 1:30 to
continue with our presentations.  Thank you all so much.