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