[Senate Hearing 108-234]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-234
 
     IMPROVING NUTRITION AND HEALTH THROUGH LIFESTYLE MODIFICATIONS
=======================================================================

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             FIRST SESSION

                               __________

                            SPECIAL HEARING

                  FEBRUARY 17, 2003--SAN FRANCISCO, CA

                               __________

         Printed for the use of the Committee on Appropriations


 Available via the World Wide Web: http://www.access.gpo.gov/congress/
                                 senate

                               __________



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                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
MITCH McCONNELL, Kentucky            TOM HARKIN, Iowa
CONRAD BURNS, Montana                BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama           HARRY REID, Nevada
JUDD GREGG, New Hampshire            HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah              PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado    BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho                   DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas          RICHARD J. DURBIN, Illinois
MIKE DeWINE, Ohio                    TIM JOHNSON, South Dakota
SAM BROWNBACK, Kansas                MARY L. LANDRIEU, Louisiana
                    James W. Morhard, Staff Director
                 Lisa Sutherland, Deputy Staff Director
              Terrence E. Sauvain, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
JUDD GREGG, New Hampshire            ERNEST F. HOLLINGS, South Carolina
LARRY CRAIG, Idaho                   DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas          HARRY REID, Nevada
TED STEVENS, Alaska                  HERB KOHL, Wisconsin
MIKE DeWINE, Ohio                    PATTY MURRAY, Washington
RICHARD C. SHELBY, Alabama           MARY L. LANDRIEU, Louisiana
                           Professional Staff
                            Bettilou Taylor
                              Jim Sourwine
                              Mark Laisch
                         Sudip Shrikant Parikh
                             Candice Rogers
                        Ellen Murray (Minority)
                         Erik Fatemi (Minority)
                      Adrienne Hallett (Minority)

                         Administrative Support
                             Carole Geagley


















                            C O N T E N T S

                              ----------                              
                                                                   Page

Opening statement of Senator Arlen Specter.......................     1
Statement of Dr. Julie L. Gerberding, Director, Centers for 
  Disease Control and Prevention, Department of Health and Human 
  Services, Atlanta, GA..........................................     3
    Prepared statement...........................................     4
Statement of Dr. Dean Ornish, president and director, Preventive 
  Medicine Research Institute, Sausalito, CA and professor of 
  medicine, University of California Medical School, San 
  Francisco, CA..................................................    16
    Prepared statement...........................................    18
Statement of Glenn Perelson, national marketing director, 
  Lifestyle Advantages...........................................    28
Summary statement of Mel Lefer...................................    30
Statement of Dr. Judith Stern, professor, Department of Nutrition 
  and Internal Medicine; director of the Food Intake Laboratory 
  Group, University of California, Davis.........................    31
    Prepared statement...........................................    32
Statement of Dr. Naomi Neufeld, president, founder and medical 
  director of KidShape, Inc.; president of Neufeld Medical Group; 
  clinical professor of Pediatrics, UCLA School of Medicine......    40
    Prepared statement...........................................    41
Summary statement of Danielle Bailey.............................    43
Prepared statement of Lee Ida Boyd-Bailey........................    44
Statement of Dr. Adam Drewnowski, director, Center for Public 
  Health Nutrition, University of Washington; member, Fred 
  Hutchinson Cancer Research Center, Seattle, WA.................    44
    Prepared statement...........................................    46
Statement of Leslie Mikkelsen, managing director, Prevention 
  Institute......................................................    48
    Prepared statement...........................................    50
Prepared statement of Senator Barbara Boxer......................    66



















     IMPROVING NUTRITION AND HEALTH THROUGH LIFESTYLE MODIFICATIONS

                              ----------                              


                       MONDAY, FEBRUARY 17, 2003

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                 San Francisco, CA.
    The subcommittee met at 10:30 a.m., in the University of 
California at San Francisco Conference Room, 3333 California 
Street, San Francisco, CA, Hon. Arlen Specter (chairman) 
presiding.
    Present: Senator Specter.


               opening statement of senator arlen specter


    Senator Specter. Good morning, ladies and gentlemen. The 
Field Hearing of the Appropriations Subcommittee on Labor, 
Health and Human Services, and Education will now begin. We 
commence by expressing our thanks to the University of 
California at San Francisco. We are very pleased to be here for 
many reasons, among the foremost is that there are 2 feet of 
snow in the East.
    We are functioning here on a skeleton staff. Todd Averette 
is my skeleton.
    The staff is all in Washington, where airports are not open 
and travel is impossible. Fortunately, Joan and I came out a 
few days early, so we are able to be with you here today.
    We have, I think, a very important hearing on improving 
health through lifestyle modifications. The issue of 
cardiovascular disease is one which our subcommittee has been 
working on very intently for more than two decades, from my 
personal experience in the U.S. Senate, and the statistics are 
really overpowering. Cardiovascular disease afflicts 63 million 
Americans, killing almost a million--960,000 each year. The 
economic losses are more than any other disease, over $330 
billion in medical expenses and lost productivity annually. The 
cost of cancer, the dreaded disease, is about half that amount.
    Cardiovascular disease kills almost as many Americans as 
the next seven leading causes of death combined. It kills more 
women than men. Six times as many women die from heart disease 
as from breast cancer. The impact of obesity is tremendous, as 
we will hear in some detail in today's hearing. In the past two 
decades, obesity has increased by 100 percent among children 
and adolescents. More than 16 percent of children are 
overweight and, during the 1990s, the prevalence of diabetes 
has increased by some 50 percent among adults.
    On the issue of improving health through lifestyle 
modifications, there have been very substantial increases in 
funding. Senator Harkin and I have made an NIH funding the 
principal, the number one priority for our subcommittee which 
funds three departments--Health & Human Services is in 
competition with Education, which is America's major capital 
investment, and Worker Safety and Labor.
    Since I became chairman of Appropriations in 1995, I have 
been on the subcommittee--chairman of the Appropriations 
Subcommittee on Health and Human Services. With Senator 
Harkin's concurrence, we have increased the funding from $12 
billion to $27 billion. Initially, we asked the Budget 
Committee for $1 billion and we were turned down, so we took it 
to the Floor for a fight, and we lost 63-37. But we got out our 
sharp pencils and found other items to cut to make NIH a 
priority. So having lost in our effort for $1 billion, the next 
year we asked for $2 billion, which is the way of Washington. 
And again, we lost--and this time 52-48. We went back to the 
Budget and established the priority and put in the $2 billion.
    Now it has become fashionable, at least up until last year, 
when the administration asked for $3.4 billion and we added a 
little to that to $3.7, so now we are at $27 billion. Next 
year, the administration has asked for a very slight increase, 
and that is a difficult matter with budget constraints, but 
Senator Harkin and I, and the Subcommittee, and the full 
committee, Senator Stevens being our full committee chairman, 
are determined to review everything we can to increase the 
funding for the National Institutes of Health. Now that 
increase in funding has reflected itself with obesity research 
funding moving from $128 million in 1998 to over $320 million 
this year, and in nutrition research moving from under $500 
million in 1998 to almost $1 billion this year, and CDC 
Nutrition and Physical Activity funding moving from $11.5 
million in the year 2000 to over $27 million now, and the 
overall NIH Heart Disease Research funding moving from $75 
million in 1999 to $1.9 billion this year. So you can see the 
enormous increases.
    We have some leading experts in the field today, and I will 
particularize them in more detail as we move through the 
hearing. We are delighted to have with us today as our lead 
witness Dr. Julie Gerberding, who is the Director of the 
Centers for Disease Control and Prevention, a very, very 
important agency with so many jobs, Bioterrorism, I think, 
being at the top of the list. The CDC in Atlanta is a premier 
installation, and 3 years ago, I visited the CDC and was amazed 
to see a leading scientist in the hallways, and very important 
research substances in corridors in the closets. And I went 
back to Washington and put up $170 million as emergency 
funding. Two years ago, we increased that to $255 million. And 
I think we are at about $250 million this year.
    The reason I say ``I think'' is because we passed the bill 
last Thursday night, and it is a thousand pages and I have not 
read it all yet.
    In fact, nobody has read it all. That is one of the 
luxuries of a democracy.
STATEMENT OF DR. JULIE L. GERBERDING, DIRECTOR, CENTERS 
            FOR DISEASE CONTROL AND PREVENTION, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES, 
            ATLANTA, GA
    Senator Specter. The CDC is really an enormously important 
asset for America today. So thank you for joining us, Dr. 
Gerberding, and thank you for bringing so much of your staff 
with us. The traditional time is the 5-minute opening 
statement, leaving more time for question and answer. I 
recently attended the memorial service for Ambassador 
Annenberg, and the time limit for speeches was set at 3 
minutes, and former President Ford was limited to 3 minutes, 
and Secretary of State Colin Powell was limited to 3 minutes, 
and so was I and 14 other speakers, so I want you to know what 
a generous time allocation 5 minutes is.
    Dr. Gerberding, the floor is yours. And in the absence of 
staff, Todd Averette has bought a kitchen timer. Why don't you 
put it in front of Dr. Gerberding so that she can be harassed 
by the timer?
    Dr. Gerberding. Great. Thank you so much for inviting me 
here to participate in this hearing. I think this is a 
critically important topic, even in the time of Bioterrorism. 
We have many important programs at CDC that we will highlight 
in the few comments I am making, but I also really want to be 
on the record as thanking you for the incredible support that 
you and Senator Harkin have given CDC. The appropriation 
includes $268 million for building some facilities and about 
$400 million for activities at CDC promoting healthy 
lifestyles, and you mentioned the importance of the NIH 
research in all of this, but I think it is CDC that takes that 
research and puts it to action in the trench, so that support 
means everything. And thank you very much.
    I am going to just touch on three issues, number (1) What 
is the problem; and number (2) Why is it important; and number 
(3) What are we doing about it now, and what should we be doing 
about it? So if I could have just the first graphic here, I 
wanted to emphasize a little bit of the comments that you were 
making about the importance of chronic diseases overall. You 
can see here in the United States the leading causes of death. 
You mentioned heart disease and cancer and stroke as important 
contributors to the cause of death, but if you look at the 
bottom half of this chart, it shows what the actual causes of 
death are. This is looking at the same data, but looking at 
what is the underlying cause of these conditions. And the top 
three here, tobacco, poor diet, and lack of exercise, are 
really the things that we can do something about with the kinds 
of lifestyle interventions that this hearing is focusing on.
    I am going to be speaking particularly today about the poor 
diet, lack of exercise, and its relationship to the epidemic of 
obesity. On the next graphic, just in very simple picture 
framework, shows how the epidemic of obesity is progressing 
across the United States. Looking at this picture of the United 
States in 1990, the number of States where the prevalence of 
diabetes was evolving in 5 years, more States had a high 
prevalence. By 2001, more than 30 States had a prevalence of 
diabetes of approximately 1 in 12, or greater, so that this is 
an epidemic that is astonishing. As you mentioned, the number 
of individuals affected by this is extraordinary; but on the 
right-hand side, you can see one of the impacts of this 
epidemic of obesity, and that is the high prevalence of 
diabetes. So here we see obesity, here we see diabetes, and 
they are tracking right along together.
    Particularly astonishing is the fact that now 15 percent of 
kids between 6 and 19 years of age are overweight, and these 
children are accounting for up to 50 percent of the new cases 
of diabetes in many communities. So this is an astonishing and 
sobering problem, and one that, from a CDC perspective, has got 
to be the highest-priority domestic health issue that we are 
facing today. This week in Science magazine, there is a whole 
feature on the science of obesity, looking at it from a genetic 
perspective, looking at it from an environmental perspective, 
but I think we see it as a problem that gets boiled down to a 
couple of real simple facts, and that is that we are taking in 
more and more calories, and we are exercising less and less, 
and utilizing fewer calories.
    So the gap between what we are eating and what we are 
expending is continuing to get larger and larger in our 
society. And this has the consequences that you mentioned. 
First of all, the chronic diseases of stroke, the cancers 
including breast, endometrial and colon cancer are affected by 
this high rate of obesity, and the diabetes that we have 
already talked about. But the health expenses are enormous. 
Some estimate that up to 8 percent of our healthcare expenses 
would be eliminated if we could eliminate the obesity problem, 
and that is just the direct expenses. If we take into 
consideration all the indirect costs, including some 32 million 
days of work lost each year from the complications of obesity, 
it has a tremendous impact on our society, and we really do 
need to do something about it.
    So I would like to, on the next graphic, just talk a little 
bit about some of the programs that are currently in place to 
deal with this. We note just like we did with tobacco, that 
starting with kids is important. So we have coordinated school 
heath programs that are in many States, and on the next slide, 
we have illustrated a youth media campaign that is going on in 
several States.

                           prepared statement

    Finally, just to mention that we are currently funding 12 
States, including Pennsylvania, by the way, to implement 
programs to address the problem of obesity at the community 
level through community interventions and so forth. We hope in 
the future to work with the program that President Bush 
initiated, the HealthierUS Program. CDC has the lead for this 
at HHS, but we are working with all of the Department to 
implement new programs that help us take concrete steps in a 
broader number of States across the country to really combat 
obesity. And we look forward to getting those programs off the 
ground. So with that, I will stop and take questions. Thank 
you.
    [The statement follows:]
             Prepared Statement of Dr. Julie L. Gerberding
                              introduction
    Good morning. I am Dr. Julie Gerberding, Director of the Centers 
for Disease Control and Prevention. Thank you for inviting me here 
today to participate in this important discussion of healthy lifestyles 
and CDC's programs to support health promotion and disease prevention 
programs in States and communities.
    The United States faces an epidemic of unparalleled proportion, an 
epidemic that is substantiated by the hard facts. Seven of 10 deaths, 
or more than 1.7 million each year, are caused by chronic diseases. 
Heart disease, cancer, stroke, chronic obstructive pulmonary disease 
(such as asthma, bronchitis, emphysema) and diabetes cause more than 
two-thirds of all deaths each year. Although 7 of every 10 deaths among 
Americans are due to chronic diseases, the underlying causes of these 
deaths are often risk factors that can be successfully modified years 
before they ultimately contribute to illness and death. Three such 
factors--tobacco use, poor nutrition, and lack of physical activity--
are major contributors to the nation's leading killers. Each year 
430,000 deaths (about 20 percent of all deaths) are linked to tobacco 
use, which causes not only lung cancer and emphysema but also one-fifth 
of all cardiovascular disease deaths. Obesity is a major contributor to 
heart disease, diabetes, arthritis, and some types of cancer. Recent 
estimates suggest that obesity is associated with 300,000 deaths 
annually, second only to tobacco related deaths.
                           burden of obesity
    Today we face an epidemic of obesity--a major risk factor for heart 
disease and diabetes. Few of our citizens have healthy nutrition and 
physical activity levels. For example, only 28 percent of women and 20 
percent of men eat at least five servings of fruits and vegetables per 
day. More than 60 percent of adults do not engage in levels of physical 
activity needed to provide health benefits. Large numbers of older 
people are physically inactive, as many as 34 percent of adults aged 
65-74 and 44 percent of adults aged 75+. This is of special concern 
because the number of older Americans is expected to double from 35 
million to 70 million by 2003. The impact of this physical inactivity 
on medical costs is substantial and is likely to grow unless trends in 
physical activity change among older adults. Currently one-third of 
total US health care expenditures are for older adults.
    In the past 15 years, the prevalence of obesity has increased by 
over 30 percent among adults. In the past 20 years, prevalence in 
children and adolescents has increased by 100 percent. More than 15 
percent of children and adolescents are overweight, and more than half 
of children who are overweight have at least one additional 
cardiovascular disease risk factor, such as elevated cholesterol or 
high blood pressure. Rates of overweight and obesity have increased in 
older Americans by almost two-thirds since 1990. Almost 90 percent of 
middle-aged Americans will develop high blood pressure in their 
lifetime and nearly 70 percent of Americans with high blood pressure do 
not have it under control. The cost of diseases associated with obesity 
has been estimated to be $117 billion per year for direct and indirect 
costs.
    We have already begun to see the impact of the obesity epidemic on 
other diseases. For example, type 2 diabetes, a major consequence of 
obesity, has also reached epidemic proportions over the last 10 years. 
During the 1990's, the prevalence of diabetes increased by 50 percent 
in U.S. adults. This trend is expected to continue unless there is 
substantial public health intervention. Although type 2 diabetes was 
virtually unknown in children and adolescents 10 years ago, it now 
accounts for almost 50 percent of new cases of diabetes in some 
communities.
    The combination of chronic disease death and disability accounts 
for roughly 75 percent of the $1.3 trillion spent on health care each 
year in the United States. Last year, the Surgeon General's Call to 
Action on Obesity suggested that obesity and its complications were 
already costing the nation $117 billion annually. By way of comparison, 
obesity has roughly the same association with chronic health conditions 
as does 20 years of aging.
    The rapid increases in obesity across the population and the burden 
of costly diseases that accompany obesity indicate that we can no 
longer ignore it. The speed with which obesity has increased can be 
explained by changes in society that have increased calorie intake and 
reduced energy expenditure. Fast food consumption now accounts for over 
40 percent of an average family's budget spent on food. Soft drink 
consumption supplies the average teenager with over 10 percent of his 
or her daily caloric intake. The variety of foods available has 
multiplied, and portion size has increased dramatically. Fewer children 
walk to school, and the lack of central shopping areas in our 
communities means that we make fewer trips on foot than we did 20 years 
ago. Hectic work and family schedules allow little time for physical 
activity. Schools struggling to improve academic achievement are 
dropping physical education and assigning more homework, which leaves 
less time for sports and other physical activity. Television viewing 
has increased. Many neighborhoods are unsafe for walking, and many 
parks are unsafe for playing. Most office buildings have inaccessible 
and uninviting stairwells that are seldom used. Many communities are 
built without sidewalks or bike trails to support physical activity.

                         steps to a healthierUS

    The President has announced the HealthierUS Initiative, which 
focuses on nutrition, physical activity, health screening, and behavior 
change. President Bush's HealthierUS Initiative is based on the premise 
that increasing personal fitness and becoming healthier is critical to 
achieving a better and longer life. The HealthierUS Initiative 
encourages all Americans to be physically active every day, eat a 
nutritious diet, get preventive screenings, and make healthy choices.
    The President's fiscal year 2004 budget request includes an 
increase of $100 million within CDC to pursue Steps to a HealthierUS. 
The Steps Initiative advances President Bush's HealthierUS program by 
focusing on obesity, diabetes, and asthma. Through Steps to a 
HealthierUS, Secretary Thompson will lead the Department of Health and 
Human Services (HHS) to reduce the burden of these conditions by 
promoting healthy choices in nutrition, physical activity, and 
preventive health care. HHS will provide national leadership for 
states, communities, and schools. CDC will organize the HHS effort, 
with full participation by sister agencies--the Health Resources 
Services Administration, the Administration for Children and Families, 
the Administration on Aging, and the Agency for Healthcare Research and 
Quality.
    The centerpiece of this initiative will be a single Steps to a 
HealthierUS cooperative agreement program. This program will be 
designed to stimulate and integrate public and private sector efforts 
to improve health. The program will make substantial awards to states 
and communities to implement effective public health strategies for 
reducing the burden of diabetes, obesity, and asthma in their 
populations. States, communities, and schools will also address related 
risk factors, including a specific emphasis on promoting healthy 
choices by youth and older Americans. The cooperative agreement program 
will work in States, communities, and schools to:
  --Prevent overweight and obesity
  --Prevent development of diabetes in people with pre-diabetes
  --Control the complications of diabetes for those with the disease
  --Promote healthy youth
  --Reduce the burden of asthma
    As a part of Steps to a HealthierUS, HHS has undertaken a Healthy 
Worksite Initiative within the Department's own agencies. Secretary 
Thompson has asked CDC to lead this effort. CDC welcomes this 
initiative because it provides the HHS workforce the opportunity to 
become a model for strategies that can be applied elsewhere within the 
federal government and by businesses across the United States. CDC is 
working to provide attractive stairwells in buildings with a campaign 
that promotes their use and healthier choices in vending machines and 
cafeterias. We know from our experience that modest and inexpensive 
changes, such as attractive stairwells with signs promoting their use, 
can lead to increased physical activity in everyday life. We will soon 
learn whether similar improvements in nutrition can be achieved by 
changing and promoting the products sold in vending machines. 
Widespread changes will not be achieved overnight. However, if we can 
understand how to make changes in our own workplace that improve 
nutrition and physical activity, we are much more likely to be 
successful elsewhere. Given the size of the population that we are 
trying to reach, both in our organization and in our nation, we cannot 
rely solely upon interventions that target one person at a time. 
Instead, the prevention of obesity and related conditions will require 
coordinated policy and environmental changes that affect large numbers 
of people simultaneously. CDC has developed effective prevention and 
treatment strategies through our State obesity/physical activity/
nutrition programs, State coordinated school health programs, the youth 
media campaign, partnerships with other organizations, and an applied 
research agenda to develop and refine new approaches. Today I will 
focus on CDC's current efforts that set the stage for achieving Steps 
to a HealthierUS.
    Preventing Overweight and Obesity.--Today we know that a few 
changes can improve the health of a larger number of persons. These 
include the development of sophisticated marketing messages designed to 
increase health behaviors among youth; reduce television viewing in 
children and adolescents; and increase physical activity for the 
population. We now have evidence-based strategies for the promotion of 
physical activity that include recommendations like physical education 
programs in schools or access to and promotion of recreation 
facilities. These approaches represent strategies that we are pursuing 
today, while continuing the research necessary to identify additional 
effective prevention approaches for States and communities. We will not 
successfully reduce the burden of chronic diseases without an approach 
that integrates nutrition and physical activity strategies across a 
variety of settings and populations. For example, if physicians begin 
counseling their patients to walk more, their patients will not be able 
to do so unless their neighborhood has sidewalks or is a safe place to 
walk. We also know that we must raise the awareness of people with risk 
factors for Cardiovascular Disease like high cholesterol and blood 
pressure and emphasize the link to prevention through physical activity 
and good nutrition. As you may know, a study from Philadelphia has 
shown that the areas with the highest death rates from nutrition 
related diseases coincide with the areas of the city that lack 
supermarkets. Inner city residents of Philadelphia will not be able to 
increase their fruit and vegetable intake to prevent cancer and heart 
disease without access to supermarkets.
    Currently CDC funds 12 States, at a capacity-building level 
(average award of $450,000) to prevent and reduce obesity and its 
related chronic diseases. Our support permits States to develop and 
test nutrition and physical activity interventions to prevent obesity 
through strategies that focus on policy-level changes (e.g., the State 
assesses and rates childcare centers for nutrition and active play) or 
supportive environments (e.g., competitive pricing of fruits and 
vegetables in school cafeterias). Examples of these approaches can be 
illustrated by the experience in three States.
    The Pennsylvania Department of Health received funding from CDC to 
develop a State Nutrition and Physical Activity Program to Prevent 
Obesity and Related Chronic Diseases in July 2001. The Department 
convened stakeholders to develop a comprehensive and coordinated 
nutrition and physical activity plan. The plan incorporates a broad 
range of activities to promote nutrition and physical activity to 
prevent obesity. An initial outcome of the planning process was the 
creation of PANA (Pennsylvania Advocates for Nutrition and Activity), a 
statewide coalition to coordinate the implementation and evaluation of 
the state nutrition and physical activity plan. On February 11, PANA 
released a community version of the plan at a meeting of 
representatives from the six health regions across the state. Using the 
plan as a guide, PANA will focus efforts around community environments, 
youth and families, and healthcare practices. PANA will also coordinate 
communication, information advocacy, and research and evaluation for 
the priority areas.
    The State of Rhode Island is using CDC's School Health Index as an 
intervention tool to address policy and environmental change within 
four high-risk elementary schools. Selected schools have at least a 
greater than 30 percent Hispanic/Latino enrollment and 50 percent or 
more of the student population is eligible for free or reduced lunch 
programs. Based on the School Health Index model, four local school 
advisory committees for each school will tailor school policy and 
program intervention components to fit within their school structure 
and population while maintaining a common purpose and shared activities 
across schools. Program expectations include increased existence of 
policy and environmental supports for nutrition and physical activity.
    The North Carolina Healthy Weight Initiative has involved 
communities and an energetic statewide task force comprised of 
community leaders and health professionals. The group has developed a 
curriculum known as ``Color Me Healthy'' for 4 and 5 year olds that 
focuses on interactive learning opportunities to promote eating healthy 
and being active. Through an innovative collaboration with the USDA, 
``Color Me Healthy'' is being implemented in 71 counties through 
cooperative extension and WIC, the Supplemental Food Program for Women, 
Infants and Children.
    CDC is also working with the U.S. Administration on Aging to 
collaborate on 10 Aging State Projects to conduct health promotion 
demonstration projects. CDC currently funds 29 states to prevent high 
blood pressure and cholesterol. As an example, public health experts in 
Virginia are working with the American Heart Association to raise 
awareness among young African Americans of how high blood pressure 
affects your health and of why it is important to control it.
    These examples illustrate the importance of starting early to 
impact health behaviors. In addition, improving physical activity and 
nutrition prevents deadly chronic diseases and also helps control their 
consequences in those who become ill. Nutrition and physical activity 
are key to reducing harm caused by heart disease, stroke, and cancer, 
as well as diabetes.
   preventing the development of diabetes in those with pre-diabetes
    Last year NIH's Diabetes Prevention Program demonstrated that diet, 
exercise, and modest weight loss decreased the incidence of diabetes in 
persons at very high risk for developing diabetes by almost 60 percent, 
which was twice as effective as the pharmaceutical therapy in the 
comparison group. These results emphasize the importance of lifestyle 
modification in the treatment of obesity and prevention of diabetes. 
Influencing lifestyle choices is particularly important for older 
Americans because of the high prevalence of diabetes in this 
population. In 1999, the prevalence of diagnosed diabetes among people 
aged 65-74 was more than 13 times that of people less than 45 years of 
age. We are currently working with health care organizations to begin 
the process of translating these approaches into strategies that can be 
used in primary care.
    control the complications of diabetes for those with the disease
    CDC provides leadership and funding to diabetes control programs 
nationwide. We also work with many partners to provide data for sound 
public health decisions, inform the public about diabetes, and ensure 
good care and education for the American with diabetes. Many 
complications from diabetes can be prevented, such as blindness, kidney 
disease, amputations, and cardiovascular disease.
    Timely data and public health research are essential to 
understanding how diabetes affects different populations and improving 
quality of care. CDC analyzes information from several national data 
sources and works to translate scientific data into higher quality 
care. As an example of how we work with partners in research, CDC has 
teamed up with managed care organizations and community health centers 
to assess how standards of care are applied in clinical care settings, 
to explore variations in the quality of diabetes care, and to test 
strategies to move existing care practices closer to optimal standards.
    In fiscal year 2002, CDC provided $61.8 million in limited support 
to 34 states, and 8 territories for Core Diabetes control. An 
additional 16 states received support to implement Comprehensive 
programs. For example, in California, the Diabetes Control Program 
assessed the effects of case management on blood glucose levels among 
Medicaid patients. Results revealed that improved nutrition education, 
better glucose monitoring instruction, and improved instructions for 
care reduced blood glucose levels which decreased the risk of 
complications and reduced health care costs.
                        promoting healthy youth
Coordinated School Health Program
    We like to think of ourselves as a youthful nation focused on 
healthy lifestyles, but behind the exciting media images of robust 
athletes and Olympic Dream Teams is a troubling reality--a generation 
of young people that is in large measure inactive, unfit, eating 
poorly, and at an alarming rate, becoming obese. CDC's Comprehensive 
School Health Program focuses on improving health behaviors in youth.
    Tobacco use remains the single leading preventable cause of death 
in the United States, yet a large percentage of our young people 
continue to smoke cigarettes. Each day, approximately 5,000 young 
people try their first cigarette, and 3,000 become daily smokers. Rates 
of smoking among high school students actually increased during much of 
the 1990s. Although the rates have decreased over the past few years, 
29 percent of U.S. high school students currently smoke cigarettes.
    Among the sectors of society that can influence young people to 
make sound health decisions, schools have a particularly important 
role. Every school day, more than 53 million young people are in our 
nation's 129,000 schools, which are an important source of health 
education and provide many opportunities for young people to practice 
healthy behaviors. Studies have documented that:
  --School-based health promotion programs can effectively improve 
        physical activity and eating behaviors.
  --Such programs can also reduce tobacco use among youth.
  --Schools can improve the nutritional quality of foods offered to and 
        consumed by students as part of school meals.
  --Schools can use creative marketing approaches to improve the 
        nutritional quality of foods that students buy outside of the 
        school meals program.
  --Schools can increase the amount of time that students are active 
        during physical education.
    Beyond the school grounds, schoolchildren face substantial 
challenges to healthy living. School programs can support them in 
making healthy choices. CDC emphasizes the importance of a multi-
component, coordinated school health approach that includes classroom 
health education, high-quality physical education, regular 
opportunities to participate in physical activity in addition to 
physical education, nutritious and appealing school meals, 
opportunities to make healthy eating choices through vending machines 
and other settings outside of school meals, and strong policies 
requiring and enforcing tobacco-free campuses. Furthermore, school-
based programs are more likely to have a substantial impact on youth 
behaviors when they are part of a broader, comprehensive health 
promotion approach that includes community-based activities.
    CDC currently supports coordinated school health programs in 20 
States that help ensure that students receive effective health 
instruction in nutrition, physical activity, and tobacco use 
prevention, integrated into a school health program that includes 
health services, quality physical education, nutritious school meals, 
and counseling and social services that remove barriers to students' 
academic success. Through this program, State educational agencies work 
with State health departments to:
  --Plan, implement, and evaluate healthy lifestyle programs.
  --Provide training to educators on how to promote healthy lifestyles.
  --Monitor youth lifestyle behaviors and programs to influence them.
  --Develop and implement policies to support effective implementation 
        of school health programs at the local level.
  --Build effective partnerships with other government agencies and 
        non-governmental organizations.
    I would like to describe some important activities supported by 
CDC's comprehensive school health program.
  --California has included health in new statewide standards for 
        teacher training, and has added physical fitness test results 
        to local school districts' accountability report cards.
  --West Virginia has adopted some of the strongest standards in the 
        nation for the nutritional quality of foods and beverages 
        offered on school campuses, and it implements a week-long 
        nutrition symposium for food service and other school staff, to 
        help them implement the standards.
  --The Rhode Island Department of Education has partnered with a 
        community-based agency to provide nutrition education services 
        and programs to more than 220 schools.
  --The Wisconsin Department of Public Instruction has worked with the 
        University of Wisconsin to institute an annual Best Practices 
        in Physical Activity and Health Education Symposium that 
        showcases exemplary school health promotion programs.
Youth Media Campaign
    Congress appropriated $193.4 million over the last two fiscal years 
to develop and launch the CDC Youth Media Campaign using the same 
strategies used by commercial marketers to reach our target audience of 
9-13 year olds. The campaign, branded as ``VERB, It's what you do,'' 
uses the best principles of marketing and communications to deliver 
messages to young people about the importance of building healthy 
habits early in life with the full knowledge that today's youth are 
very savvy about the messages they receive. This approach has proven 
successful in preventing tobacco use in youth. The Youth Media Campaign 
was launched in June of 2002 with the focus on getting kids excited 
about increasing the amount of physical activity in their lives and 
helping their parents to see the importance of physical activity to the 
overall health of their kids. The early reports from the campaign's 
evaluation show very exciting results with over 90 percent of the 
target audience reporting they have seen the ads an average of almost 
30 times. Most importantly, young people are not just seeing our ads 
and messages, they are acting on them. Out of the possible universe of 
22 million young people in this age group, almost 3 million of them 
have already acted. They have gone to a VERB event, participated in a 
contest or sweepstakes, or have logged on to our website.
    The Verbnow.com website--in the first four weeks of being fully 
live--got 1.1 million unique visitors who clicked down an average of 
4.4 times. These young people report they understand the messages and 
intent of the campaign, and they think the campaign is ``cool and 
fun.'' In addition to advertising for young people and their parents, 
the campaign uses events, website, viral and guerrilla marketing 
(essential marketing concepts for young people), and partnerships with 
community organizations to enhance the reach and effectiveness of these 
important health messages.
    A nine-city tour with the Nickelodeon Show began in October 2002 
and concludes in April 2003. In addition, by April 2003 the campaign 
will have taken part in more than 200 community and ethnic events 
across the country. We will have the first evaluation results in fall 
2003, allowing us to assess the impact of the campaign on youth 
activity.
                     reducing the burden of asthma
    Despite evidence that asthma death rates are leveling off and 
asthma hospitalization rates are declining, asthma's impact on health, 
quality of life, and the economy remain substantial. Rates of severe 
asthma continue to disproportionately affect poor, minority, inner-city 
populations. For example, African Americans visit emergency 
departments, are hospitalized, and die due to asthma at rates three 
times higher than rates for white Americans.
    The initial onset of asthma cannot yet be prevented or cured. 
However, asthma can be controlled, and people who have asthma still can 
lead quality, productive lives. Asthma can be controlled by following a 
medical management plan and by avoiding contact with environmental 
``triggers'' such as cockroaches, dust mites, furry pets, mold, tobacco 
smoke, and certain chemicals.
    In 1999, CDC created the National Asthma Control Program. The goals 
of the program are to reduce the number of deaths, hospitalizations, 
emergency department visits, school or work days missed, and 
limitations on activity due to asthma. CDC is working with over 90 
partners (state health departments, school districts, and national 
organizations) to collect and analyze data on an ongoing basis to 
understand the ``who, what, and where'' of asthma, ensure that 
scientific information is translated into public health practices and 
programs to reduce the burden of asthma, and ensure that all 
stakeholders have the opportunity to be involved in developing, 
implementing, and evaluating local asthma control programs.
                               conclusion
    Obesity, diabetes, asthma and other chronic diseases have increased 
substantially over the past decade and take a heavy toll on the health 
of the United States. CDC programs are addressing these problems, but 
many are in the early stages of development. We are committed to 
reducing the burden of these conditions by promoting healthy choices in 
nutrition, physical activity, youth risk taking and preventive health 
care. Through Steps to a HealthierUS, we look forward to working with 
you to foster healthy behaviors and reduce illness and premature death.
    Thank you for the opportunity to testify on this most important 
topic. At this time I would be happy to answer any questions.

    Senator Specter. Thank you very much, Dr. Gerberding. I 
very much appreciate your service at the CDC, and the 
outstanding record you bring to the position. I think it 
important to note for the record that you are also Associate 
Clinical Professor of Medicine at Emory, went to Case Western 
for both your bachelor and MD, and were the chief medical 
resident right here at University of California at San 
Francisco, and had your masters of public health at the 
University of California at Berkeley.
    When you specify the final budget figure of $268 million, 
the budget process is very complicated, so that I was unable to 
give you a precise figure as in so many lines because I think 
we started in excess of $270 million, and then there were 
across-the-board cuts, and then there was reinstatement. And 
then some items were exempted from the cuts, like veterans. We 
completed the budget in 10 days. We did not fight on the budget 
on anything but Defense last year on only two bills--the 
Department of Defense and Military Construction.
    I was recently in the Middle East and talked to the new 
Finance Director of the Palestinian Authority where they have a 
budget, but last year, the U.S. Senate did not have a budget--a 
curious contrast--so that when we finally finished this bill 
very late last Thursday evening, which enabled us to come out 
here ahead of the snow, the 1,000 pages is sort of notorious 
because it was reported all around, and nobody had read the 
1,000 pages as the process was put together and staff--I have a 
very extraordinary staff--Betty Lou Taylor is one of the most 
knowledgeable--perhaps the most knowledgeable of all the 
staffers on Capitol Hill, and our section was under a very 
careful control, as was each of the others, but in terms of 
somebody going through the 1,000 pages.
    So I am pleased to find out what your budget is here at 
$268 million on the construction alone, and I know how 
important that is, so we are going to be providing in excess of 
$1 billion. We have gotten three pretty good starts going up 
another 3 years. I would like you to put the chart back up 
which had all the factors of tobacco, diet, in descending 
order, as to the causes of death. What progress do you think we 
are making, Dr. Gerberding, on the tobacco issue, on reducing 
the use of tobacco?
    Dr. Gerberding. Well, we have mixed news. Over the decade 
of the 1990s, youth tobacco use, which is one measure we track 
through a survey that we do in all the States, actually 
increased. But over the last couple of years now, we are 
beginning to see some modest reductions in the proportion of 
kids in high school who smoke. I think, overall, about a third 
of kids have ever used tobacco at least once in their high 
school, but the number who would be characterized as smoking 
has gone down just a few percentage points.
    We think this might be in part due to the school education 
programs that have been implemented, and also to the fact that 
the price of a pack of cigarettes has gone up substantially. We 
know that is an important factor in influencing tobacco use 
really in all ages, but particularly in kids who do not have 
pocket change.
    Senator Specter. Joan and I were in Palm Springs, and we 
went into Rite Aid, and they had a sign up--you get carded for 
buying cigarettes up to 40--and my wife was very offended she 
was not carded.
    I asked the clerk, ``How do you card up to 40?'' And the 
answer was, ``Well, they do not want arguments.'' If you card 
at 18, a lot of people argue with you, but if you card up to 
40, nobody can argue with you. What more should we do?
    We just had enormous settlements in litigation, lots of 
money going to the States, more than $11 billion to 
Pennsylvania. One of the concerns I have is that in some 
States, the money is being used for other than health purposes, 
some for highway construction, and I think that is a bad deal 
if you produce all this money for tobacco settlements. But what 
more can be done? What more should our subcommittee take the 
lead on in trying to discourage the use of tobacco, especially 
among young people?
    Dr. Gerberding. Yes, this is a complex problem, and it 
requires a lot of different solutions from a lot of different 
directions. From a Federal perspective, I think enhancing the 
educational and the school-based programs is a very, very 
important component, and we can do more in that regard. We have 
programs in all States, coordinated tobacco programs in all 
States. But the penetration and the level of support in 
individual jurisdictions is still variable. We know that the 
younger you intervene and the more kids grow up with a culture 
that does not support tobacco use, the more likely they are to 
sustain abstinence from tobacco as they get into the teenage 
years.
    So I would say if there was one thing we could do, it would 
be to focus on more school-based programs.
    Senator Specter. And what is the right age to start?
    Dr. Gerberding. I do not think there is an age that is too 
young when it comes to tobacco. So as soon as kids are in 
school, those messages about the health consequences----
    Senator Specter. Should have the message start with 
``Healthy Start?''
    Dr. Gerberding. Yes.
    Senator Specter. 3?
    Dr. Gerberding. I think as soon as kids are old enough to 
understand what tobacco is, they ought to know that it is bad.
    Senator Specter. Earlier than 3?
    Dr. Gerberding. Well, I do not think we have programs in 
place to address that, but it would be at least worth asking 
the question.
    Senator Specter. If we do not have programs in place, that 
is what we are here for.
    Dr. Gerberding. Exactly, exactly.
    Senator Specter. To put programs in place. Poor diet and 
lack of exercise, that is number 2. What did you think of the 
law suit as to McDonald's for making people fat?
    Dr. Gerberding. The fast food industry----
    Senator Specter. The case was dismissed, but it was brought 
on the analogy of putting out a product for consumption with a 
reckless disregard for the safety of the people who are going 
to buy the product, which is the tobacco theory, even though 
the warnings are on it. Do you think that was the right 
decision, or should there be a public duty on restaurants like 
fast food chains to take care not to feed unsuspecting people 
food which is going to be injurious to their health?
    Dr. Gerberding. We do not have scientific evidence that 
links fast foods, per se, to obesity. So right now, the science 
is not there to say that is an important component of the 
problem.
    Senator Specter. Need an extra appropriation?
    Dr. Gerberding. We could discuss it.
    Senator Specter. We have not had evidence yet to link Agent 
Orange to many of the maladies that came out of the Vietnam 
War.
    Dr. Gerberding. Yes. And I think that we certainly support 
that consumers need to understand what is in the food that they 
are eating, including what is in the fast food. But what we are 
doing with the fast food industry that I think is a very 
proactive thing is to engage them in creating fast foods that 
are healthier choices for people. Secretary Thompson had----
    Senator Specter. What are you doing to engage them?
    Dr. Gerberding. The first thing is to just sit down with 
the leaders of those industries----
    Senator Specter. Are you doing that?
    Dr. Gerberding. Yes, we are doing that. The Secretary met 
with them a few weeks ago in Washington, and we are looking at 
ways that they can help us. For example, they know an awful lot 
about why people make certain food choices, and if we had that 
kind of information, it might help us get people to make 
healthier food choices. So there is a lot of knowledge that 
they have and can share with us, and so far, it looks very 
optimistic that they would be willing to deal with this problem 
in a constructive way, rather than through a punitive or a 
regulatory manner. So that is the direction we are going right 
now.
    Senator Specter. So they--your point is, one of which is 
pretty obvious, they do research to figure out how to attract 
people to certain foods?
    Dr. Gerberding. Exactly.
    Senator Specter. Yes.
    Dr. Gerberding. And if we knew--if we had that information, 
or we were able to do that kind of public health research at 
CDC, it would certainly help us understand what would make the 
right foods more attractive, particularly for kids.
    Senator Specter. Are they willing to share some of their 
trade secrets?
    Dr. Gerberding. Well, I do not know if we have gotten that 
far in the negotiations, but I think it will have to come down 
to the level where somebody has got to have that information 
and we need it.
    Senator Specter. That might be a good subject for a hearing 
in Washington with the fast food people.
    Dr. Gerberding. I agree.
    Senator Specter. You might have to be the lead witness 
again.
    Dr. Gerberding. Well, I am getting some practice at it.
    Senator Specter. Well, it would be interesting to be privy 
to what they have found on what attracts people, and how you 
attract people to other foods. That is something we are going 
to be exploring later with Dr. Ornish in some greater detail, 
but it would be interesting to bring them in.
    That law suit against McDonald's drew a lot of ridicule and 
was dismissed, but it is not too far-fetched, especially as 
there is more information developing. And if their research 
showed that there are ways to encourage people to eat other 
kinds of food, and if they definitely want a way to make it 
cheaper and more profitable without regard for health, that 
could be a factor--like the Pinto case where they put the gas 
tank in the back at a cost of $4, where to move it up front 
would cost $8. That kind of engineering in food might be very 
informative as well.
    Without going into all of the details now, Dr. Gerberding, 
our subcommittee would be interested in what your 
recommendations would be on the entire list going down--
alcohol, firearms, motor vehicles, illicit drug use, et 
cetera--as to what might be undertaken to change behavior on 
those lines. Would you put up the other chart on Steps to 
Better Health?
    You have there ``Prevent the Development of Diabetes.'' How 
do you do that?
    Dr. Gerberding. Well, the first important component of that 
is to prevent obesity because obesity is the number one risk 
factor for at least adult onset diabetes, and now, 
increasingly, for that kind of diabetes among children. So the 
big ticket item here is to prevent obesity. But even if we have 
an obese population, improving fitness will reduce the onset of 
diabetes, and will reduce the complications of diabetes.
    Senator Specter. Do you know the cause of diabetes?
    Dr. Gerberding. Well, there are many causes. One important 
etiology of the early onset diabetes is probably genetic and 
immunologic. But in the older population, the theory is that 
the cells become resistant to the effects of insulin, in part 
because of the obesity and probably the changes that are 
occurring at the receptors for the insulin hormone, so that 
people with adult onset diabetes have insulin in their bodies, 
but their cells do not react to it normally. So it takes more 
insulin to control blood sugar than it really should. When you 
lose weight then, in many people, you can restore that 
sensitivity to the insulin, and so they do not have diabetes, 
or they have fewer complications with controlling their blood 
sugar.
    Senator Specter. You had a line in your testimony about a 
diet and its impact on colon cancer. Can you be specific as to 
a cause of colon cancer related to diet?
    Dr. Gerberding. Well, there are various ways in which diet 
can affect colon cancer. We got clues to this in looking at 
populations that seemed to be at higher risk for colon cancer, 
like people in this country whose diet is very different from 
people in, for example, some Asian countries that have a lower 
risk. There are certain foods, you know, the cruciferous 
vegetables like Brussels sprouts, cauliflower, and broccoli 
that seem to be associated with a lower colon cancer risk.
    Senator Specter. How do you quantify that statistically, 
scientifically?
    Dr. Gerberding. Well, that is part of the kind of public 
health research we do at CDC where you can, for example, look 
at people who have colon cancer, and compare them to similar 
people who do not, and then compare their diets. And if you see 
that, in the people with the cancer, there are fewer of these 
good vegetables being taken in, that is a pretty strong hint 
that the diet can be a factor. And by doing that kind of 
research in larger populations, and repeating it in different 
kinds of people, over time you develop a body of evidence that 
is increasingly strong that diet really is an important risk 
factor for colon cancer.
    Senator Specter. So when you talk to people about their 
diet and they tell you that they eat Brussels sprouts, are they 
that specific, really? Cauliflower?
    Dr. Gerberding. Well, there are tools. There are tools that 
are developed to get very precise information about people's 
dietary intake. Of course, we always remember what we have 
eaten in the last 24 hours better than what we have eaten in 
the last 3 days or 3 months. But there are valid scientific 
methods for really getting a picture of people's diets, both 
from the standpoint of kinds of foods, but also how foods are 
prepared and what the caloric and fat and micronutrient 
composition of those foods might be. And you can also do it in 
a prospective sense by giving people a food diary and then 
asking them to carefully record on a daily basis the kind of 
food intake that they are having.
    Senator Specter. How much of an educational effort is there 
in this country generally on trying to influence people on 
their diet on these issues?
    Dr. Gerberding. You know, one of the ironies of this is 
that at any given time, about half of the women in America are 
trying to lose weight. And we have a large capacity to be 
concerned about the cosmetic implications of how we look or 
what we eat, but I do not think the emphasis has been on the 
health aspects of our diet and our weight. I think we need to 
do a lot more to educate people about the importance of 
nutrition and the kinds of consequences that poor nutrition 
really has. I mean, this obesity is malnutrition. It is just a 
different kind of malnutrition in the developed world--and 
people do not get it. They do not understand how critical this 
is, not just to their appearance, but to the kinds of diseases 
that we are talking about here.
    Senator Specter. What role should the Federal Government 
play in trying to promote that education?
    Dr. Gerberding. I think we have a lot more that we can be 
doing about getting the word out. There is a great need for 
research, for public health research on what are the 
determinants of people's food choices, what are the 
determinants of their----
    Senator Specter. Research on determinants for people's food 
choices?
    Dr. Gerberding. Their food choices, exactly.
    Senator Specter. Well, what research have you undertaken so 
far on that?
    Dr. Gerberding. Well, part of this is just getting off the 
ground. CDC does not have a large research enterprise in this 
particular area, but we do collaborate with NIH.
    Senator Specter. Why not?
    Dr. Gerberding. Well, I think part of it is a budget issue. 
As you----
    Senator Specter. How much more money do you need?
    Dr. Gerberding. I will have to get back to you for the 
record on that because it is not something that I have really 
had a costing-out----
    Senator Specter. Will we have to give you an earmark?
    Dr. Gerberding. I think we would like to be able to 
describe for you the priorities of what needs to be done and 
have a discussion about what it would take to do it----
    Senator Specter. If we give you an earmark, then the 
subcommittee will be criticized for politicizing scientific 
choices.
    Dr. Gerberding. We can get back to you with some ideas on 
how to go forward on this.
    Senator Specter. There is tremendous competition among all 
the ailments--Alzheimer's, cancer, Parkinson's, and we stay 
away from the effort to tell you anything----
    Dr. Gerberding. I appreciate that----
    Senator Specter [continuing]. Specifically about how you 
divide up your budget, on the ground that we are not competent 
to do that.
    Dr. Gerberding. One of the ways that I think about this----
    Senator Specter. Of course, we are competent to go to war, 
but not to tell you, not to tell you how to allocate your 
budget.
    Dr. Gerberding. One of the ways that I would think about 
this is not so much what do we need to do for diabetes or heart 
disease, or any of these things, but the kind of public health 
research that we need answers to are: ``What is the best way to 
engage people in healthier decisions for a variety of these 
issues? What are the best ways to communicate with kids?'' You 
know, kind of the cross-cutting ways of deploying the health 
information that our research at NIH gets out. How can we take 
advantage of that and implement it? And that is kind of a 
cross-cutting framework for this, that we are actually working 
on how to get that across to----
    Senator Specter. Do you have any clinical trials on these 
issues?
    Dr. Gerberding. We do not have any prospective clinical 
trials. We have intervention projects. We are going into 
communities and trying things that we think are going to work.
    Senator Specter. What is an intervention project?
    Dr. Gerberding. For example, if we go into a school and try 
to work with the principal to change the vending machines and 
change the menu in the school cafeteria, engage the PTA and the 
parents' organizations in changing the culture of eating in 
that school, that can lead to improvements in nutrition, and--
--
    Senator Specter. How much of that do you do?
    Dr. Gerberding. Well, we have programs like that right now 
in 12 States where we are experimenting with different 
strategies----
    Senator Specter. Pennsylvania and Ohio, and what other 10 
States?
    Dr. Gerberding. Pennsylvania is one of the States, 
California is one of the States, and I can tell you in a 
second--the other States are Colorado, Connecticut, Florida, 
Maine, Michigan, Montana, North Carolina, Rhode Island, Texas, 
and Washington State.
    Senator Specter. Does Senator Harkin know that Iowa is not 
included?
    Dr. Gerberding. I will make sure he does.
    Senator Specter. No, you better make sure he does not.
    Well, thank you very much, Dr. Gerberding. This is a much 
more relaxed hearing than the subcommittee in Washington.
    Dr. Gerberding. I agree.
    Senator Specter. You have testified many times there, but 
you have never testified this long, have you?
    Dr. Gerberding. No, sir.
    Senator Specter. Well, there was no ringing of the bell for 
votes--one of the advantages of being in the field. Thank you 
very much.
    Dr. Gerberding. Thank you.
    Senator Specter. I will call Panel 2, Dr. Dean Ornish, Mr. 
Glenn Perelson, Mr. Mel Lefer, Dr. Judith Stern, Dr. Adam 
Drewnowski, Dr. Naomi Neufeld, Ms. Danielle Bailey, Ms. Lee Ida 
Boyd-Bailey, and Ms. Leslie Mikkelsen.
STATEMENT OF DR. DEAN ORNISH, PRESIDENT AND DIRECTOR, 
            PREVENTIVE MEDICINE RESEARCH INSTITUTE, 
            SAUSALITO, CA AND PROFESSOR OF MEDICINE, 
            UNIVERSITY OF CALIFORNIA MEDICAL SCHOOL, 
            SAN FRANCISCO, CA
ACCOMPANIED BY:
        GLENN PERELSON, NATIONAL MARKETING DIRECTOR, LIFESTYLE 
            ADVANTAGE
        MEL LEFER, PENNGROVE, CA
    Senator Specter. Our lead witness is the world-renowned Dr. 
Dean Ornish, founder, president and director of the Preventive 
Medicine Research Institute in Sausalito, California, and 
Clinical Professor of Medicine at the University of California 
at San Francisco. He earned a bachelor's degree from the 
University of Texas in Austin and received his medical training 
at the Baylor College of Medicine, Harvard Medical School, and 
Massachusetts General Hospital. We had a hearing at the 
subcommittee last May on ``Reversing Heart Disease'' and the 
impact of stress. Dr. Ornish is the author of many books, three 
of which I have read, and has a program for reversing heart 
disease, and has a branch of it called CADRe at Walter Reed 
Hospital, which I personally participated in. Dr. Ornish, thank 
you for joining us and the floor is yours.
    Dr. Ornish. Well, thank you, Senator. It is a great 
pleasure being here. I just want to begin by applauding you for 
bringing so much awareness and attention to this area that I 
think is so important for the health of our country, both 
physically and metaphorically. As you know, for the last 25 
years, I have directed a series of studies demonstrating first 
that the progression of even severe heart disease often can 
begin to reverse if people make much bigger changes in diet and 
lifestyle that, until then, people had been recommending.
    We have been able to show in a series of studies, 
ironically using very expensive, high-tech, state-of-the-art 
measures, how powerful these very simple and low-tech and low-
cost interventions can be, and how quickly they can occur, that 
within weeks, people who are having severe chest pain or angina 
become essentially pain-free. And Mel Lefer is one of the 
people who went through one of our early studies who is here 
today to put a more human face on that.
    Part of what we have learned is what really works and what 
does not work, as Dr. Gerberding was talking about in terms of 
what really motivates people to make and maintain changes in 
diet and lifestyle. And part of what we have learned does not 
work is fear of dying because people just do not want to think 
about it, it is too scary. Whereas fear of dying does not work 
that well, joy of living does. And part of what we have learned 
is that when people make changes in their diet and quit smoking 
and exercise and manage stress better, they often feel so much 
better so quickly that it re-frames the reason for making these 
changes from prevention and risk factor reduction, which so 
many people think are really boring, especially kids, to 
feeling better.
    Of course, there is no point in giving up something that 
you like unless you get something back that is better, and 
quickly.
    So what we have been able to show is that heart disease is 
reversible. Beginning in 1993, we began training hospitals 
around the country through our non-profit institute. We have 
trained about 30 so far, and we found that this was not only 
medically effective, but also cost-effective, and that one of 
the problems in going to insurance companies was that they were 
saying: ``Well, we do not want to pay for diet and lifestyle 
because that is prevention and we do not pay for prevention 
because it takes too long to see the benefits. And 30 percent 
of people change insurance companies every year, so why should 
we spend our money today for some future benefit that someone 
else is going to get?''
    We re-framed that by saying that, for people who choose 
this as a direct alternative to things like bypass surgery and 
angioplasty, the cost savings occur dramatically and 
immediately. The skepticism was, could people make these 
changes? And we were able to show that almost 80 percent of the 
people who were eligible for a bypass or angioplasty were able 
to safely avoid it, and the insurance companies in this case, 
Mutual of Omaha, saved almost $30,000 a patient.
    Then, more recently, Highmark Blue Cross/Blue Shield in 
your home State of Pennsylvania began not only covering the 
program and reimbursing it, but also providing it. And they 
found--and Glenn Perelson will talk more about this--that in 
their first 350 people, 348 avoided surgery and they saved more 
than $17,000 a patient. And as you know, and in part because of 
your leadership, Medicare is now reimbursing 1,800 patients to 
go through this program. And we are hoping that if Medicare 
finds the same cost savings and medical outcomes that we have 
already shown in two earlier demonstrations, that they will 
make this a defined benefit, and then all Americans will have 
access to it. And other insurance companies will follow their 
lead.
    I will be presenting at the American Neurological 
Association's Annual Scientific Meeting in Chicago in April the 
results of a study we have been doing the last several years to 
see if early prostate cancer can be reversed through making 
similar changes in diet and lifestyle, and our early data 
indicate that it may.
    Senator Specter. What was that that could be reversed?
    Dr. Ornish. Prostate cancer. We found that--we took men 
that had biopsy proven prostate cancer who had elected for 
reasons unrelated to our study not to be treated. We randomly 
divided them into two groups. Half of them went on our program 
and half of them did not. And what we found was that PSA 
levels, Prostate-Specific Antigen, a marker, as you know, for 
prostate cancer, improved or went down in the group that made 
these changes, and went up or got worse in the control group. 
The differences between the groups were highly significant and 
one of the interesting findings was, just as we found in the 
cardiac studies where we found a dose response correlation 
between adherence to the lifestyle program and changes in the 
amount of blockages in their coronary arteries, we found a 
direct correlation between adherence to the lifestyle program 
and changes in their PSA.
    We then added the serum of these patients to a standard 
line of prostate tumor cells growing in tissue cultures around 
the country called the LNCaP cell, and we found that the 
patients who made lifestyle changes inhibited the growth of 
prostate tumors much more than those who did not--also in 
direct proportions of their adherence. And there was a 10-fold 
difference between the two. And finally, I have been consulting 
recently with McDonald's and with Pepsi to try to encourage 
them to make healthier foods, and if you are interested, we can 
talk more about the kind of receptivity that I am finding now 
that did not exist even 1 or 2 years ago, in part because of 
the fear of litigation that you talked about. That is my 5 
minutes.
    [The statement follows:]
                 Prepared Statement of Dr. Dean Ornish
                      introduction and background
    Mr. Chairman, distinguished colleagues, thank you very much for the 
privilege of being here today. My name is Dean Ornish, M.D., founder 
and president of the non-profit Preventive Medicine Research Institute 
and Clinical Professor of Medicine at the School of Medicine, 
University of California, San Francisco (UCSF).
    For the past 25 years, my colleagues and I at the Preventive 
Medicine Research Institute have conducted a series of scientific 
studies and randomized clinical trials demonstrating, for the first 
time, that the progression of even severe coronary heart disease often 
can be reversed by making comprehensive changes in diet and lifestyle, 
without coronary bypass surgery, angioplasty, or a lifetime of 
cholesterol-lowering drugs.
    These lifestyle changes include stress management techniques (yoga-
based stretching exercises, breathing techniques, meditation, imagery, 
and progressive relaxation); a very low-fat, plant-based, whole foods 
diet; moderate exercise; smoking cessation; and psychosocial support 
groups. When these lifestyle causes are addressed, then improvement in 
coronary heart disease may begin to occur much more quickly than had 
previously been documented.
    We tend to think of advances in medicine as a new drug, a new 
surgical technique, a laser, something high-tech and expensive. We 
often have a hard time believing that the simple choices that we make 
each day in our lives--what we eat, how we respond to stress, whether 
or not we smoke, how much we exercise, and the quality of our social 
relationships--can make such a powerful difference in our health and 
well-being, even in our survival, but they often do.
    When we treat these underlying lifestyle causes of heart disease, 
we find that the body often has a remarkable capacity to begin healing 
itself, and much more quickly than had once been thought possible. On 
the other hand, if we just literally bypass the problem with surgery or 
figuratively with drugs without also addressing these underlying 
causes, then the same problem may recur, new problems may emerge, or we 
may be faced with painful choices--like mopping up the floor around an 
overflowing sink without also turning off the faucet.
    For example, one-third to one-half of angioplastied arteries 
restenose (clog up) again after only four to six months, and up to one-
half of bypass grafts reocclude within only a few years. When this 
occurs, then coronary bypass surgery or coronary angioplasty is often 
repeated, thereby incurring additional costs. Over $30 billion were 
spent in the United States last year just on these two operations, many 
of which could be avoided by making comprehensive changes in diet and 
lifestyle, including stress management techniques.
    In our research, we use the latest high-tech, expensive, state-of-
the-art medical technologies such as computer-analyzed quantitative 
coronary arteriography and cardiac PET scans to prove the power of 
ancient, low-tech, and inexpensive mind/body interventions. Below is a 
summary of some of our scientific studies:
              can lifestyle changes reverse heart disease?
    We began conducting research in 1977 to determine if coronary heart 
disease is reversible by making intensive changes in diet and 
lifestyle. Within a few weeks after making comprehensive lifestyle 
changes, the patients in our research reported a 91 percent average 
reduction in the frequency of angina. Most of the patients became 
essentially pain-free, including those who had been unable to work or 
engage in daily activities due to severe chest pain. Within a month, we 
measured increased blood flow to the heart and improvements in the 
heart's ability to pump.\1\ \2\ And within a year, even severely 
blocked coronary arteries began to improve in 82 percent of the 
patients.\3\ The improvement in quality of life was dramatic for most 
of these patients.
---------------------------------------------------------------------------
    \1\ Ornish DM, Scherwitz LW, Doody RS, et al. Effects of stress 
management training and dietary changes in treating ischemic heart 
disease. JAMA. 1983;249:54-59.
    \2\ Ornish DM, Gotto AM, Miller RR, et al. Effects of a vegetarian 
diet and selected yoga techniques in the treatment of coronary heart 
disease. Clinical Research. 1979;27:720A.
    \3\ Ornish DM, Brown SE, Scherwitz LW, et al. Can lifestyle changes 
reverse coronary atherosclerosis? The Lifestyle Heart Trial. The 
Lancet. 1990; 336:129-133.
---------------------------------------------------------------------------
    These research findings were published in the most well-respected 
peer-reviewed medical journals, including the Journal of the American 
Medical Association, The Lancet, Circulation, The New England Journal 
of Medicine, The American Journal of Cardiology, and others. This 
research was funded in part by the National Heart, Lung, and Blood 
Institute of the National Institutes of Health.
    In the Lifestyle Heart Trial, we found that most of the study 
participants were able to maintain comprehensive lifestyle changes for 
at least five years. On average, they demonstrated even more reversal 
of heart disease after five years than after one year. In contrast, the 
patients in the comparison group who made only the moderate lifestyle 
changes recommended by many physicians and agencies (i.e., a 30 percent 
fat diet) worsened after one year and their coronary arteries became 
even more clogged after five years.\4\ \5\
---------------------------------------------------------------------------
    \4\ Ornish D, Scherwitz L, Billings J, et al. Can intensive 
lifestyle changes reverse coronary heart disease? Five-year follow-up 
of the Lifestyle Heart Trial. JAMA. 1998;280:2001-2007.
    \5\ Gould KL, Ornish D, Kirkeeide R, Brown S, et al. Improved 
stenosis geometry by quantitative coronary arteriography after vigorous 
risk factor modification. American Journal of Cardiology. 1992; 69:845-
853.
---------------------------------------------------------------------------
    Thus, instead of getting worse and worse, these patients who made 
comprehensive lifestyle changes on average got better and better. Also, 
we found that the incidence of cardiac events (e.g., heart attacks, 
strokes, bypass surgery, and angioplasty) was 2.5 times lower in the 
group that made comprehensive lifestyle changes after five years. 
Cardiac PET scans revealed that 99 percent of these patients were able 
to stop or reverse the progression of their coronary heart disease.\6\ 
A one-hour documentary of this work was broadcast on NOVA, the PBS 
science series, and was featured on Bill Moyers' PBS series, Healing & 
The Mind.
---------------------------------------------------------------------------
    \6\ Gould KL, Ornish D, Scherwitz L, Stuart Y, Buchi M, Billings J, 
Armstrong W, Ports T, Scherwitz L. Changes in myocardial perfusion 
abnormalities by positron emission tomography after long-term, intense 
risk factor modification. JAMA. 1995;274:894-901.
---------------------------------------------------------------------------
    These research findings have particular significance for Americans 
in the Medicare population. One of the most meaningful findings in our 
research was that the older patients improved as much as the younger 
ones. The primary determinant of change in their coronary artery 
disease was neither age nor disease severity but adherence to the 5 
recommended changes in diet and lifestyle. No matter how old they were, 
on average, the more people changed their diet and lifestyle, the more 
they improved. Indeed, the oldest patient in our study (now 86) showed 
more reversal than anyone. This is a very hopeful message for Medicare 
patients, since the risks of bypass surgery and angioplasty increase 
with age, but the benefits of comprehensive lifestyle changes may occur 
at any age.
    These findings also have particular significance for women. Heart 
disease is, by far, the leading cause of death in women in the Medicare 
population. Women have less access to bypass surgery and angioplasty. 
When women undergo these operations, they have higher morbidity and 
mortality rates than men. However, women seem to be able to reverse 
heart disease more easily than men when they make comprehensive 
lifestyle changes.
              multicenter lifestyle demonstration project
    The next research question was: how practical and cost-effective is 
this lifestyle program?
    There is bipartisan interest in finding ways to control health care 
costs without compromising the quality of care. Many people are 
concerned that the managed care approaches of shortening hospital 
stays, decreasing reimbursement, shifting from inpatient to outpatient 
surgery, and forcing doctors to see more and more patients in less and 
less time may compromise the quality of care because these approaches 
do not address stress and other lifestyle factors that often lead to 
illnesses like heart disease.
    Almost ten years ago, my colleagues and I established the 
Multicenter Lifestyle Demonstration Project. It was designed to 
determine (a) if we could train other teams of health professionals in 
diverse regions of the country to motivate their patients to follow 
this lifestyle program; (b) if this program may be an equivalently safe 
and effective alternative to bypass surgery and angioplasty in selected 
patients with severe but stable coronary artery disease; and (c) the 
resulting cost savings. In other words, can some patients avoid bypass 
surgery and angioplasty by making comprehensive lifestyle changes at 
lower cost without increasing cardiac morbidity and mortality?
    In the past, lifestyle changes have been viewed only as prevention, 
increasing costs in the short run for a possible savings years later. 
Now, this program of stress management and other lifestyle changes is 
offered as a scientifically-proven alternative treatment to many 
patients who otherwise were eligible for coronary artery bypass surgery 
or angioplasty, thereby resulting in an immediate and substantial cost 
savings.
    For every patient who chooses this lifestyle program rather than 
undergoing bypass surgery or angioplasty, thousands of dollars are 
immediately saved that otherwise would have been spent; much more when 
complications occur. (Of course, this does not include sparing the 
patient the trauma of undergoing cardiac surgery.) Also, providing 
lifestyle changes as a direct alternative for patients who otherwise 
would receive coronary bypass surgery or coronary angioplasty may 
result in significant long-term cost savings.
    Is it safe to offer intensive lifestyle changes as an alternative 
to revascularization?
    Bypass surgery is effective in reducing angina and improving 
cardiac function. However, when compared with medical therapy and 
followed for 16 years, bypass surgery improved survival only in a very 
small subgroup of patients (about 2 percent of those undergoing bypass 
surgery): those with reduced left ventricular function and lesions of 
the left main coronary artery of at least 60 percent. Median survival 
was not prolonged in patients with left main disease <60 percent and 
normal LV function even if a significant right coronary artery stenosis 
>70 percent was also present.\7\ \8\ \9\ \10\
---------------------------------------------------------------------------
    \7\ Alderman EL., Bourassa MG, Cohen LS, et al. Ten year follow up 
of survival and myocardial infarction in the randomized Coronary Artery 
Surgical Study. Circulation. 1990;82, 1629-1646.
    \8\ Varnauskas, E., for the European Coronary Surgery Study Group. 
Twelve-year followup of survival in the randomized European Coronary 
Surgery Study. New England Journal of Medicine. 1998;319, 332-337.
    \9\ Chaitman BR., Fisher LD, Bourassa MG, et al. Effect of coronary 
bypass surgery on survival patterns in subsets of patients with left 
main coronary artery disease. American Journal of Cardiology. 1981;48, 
765-777.
    \10\ Coronary Artery Bypass Surgery Cooperative Study Group. 
Eleven-year survival in the Veterans Administration randomized trial of 
coronary bypass surgery for stable angina. The New England Journal of 
Medicine. 1984;311:1333-1339.
---------------------------------------------------------------------------
    Angioplasty was developed with the hope of providing a less 
invasive, lower risk approach to the management of coronary artery 
disease and its symptoms. Though widely utilized, there has never been 
a randomized trial comparing angioplasty to medical therapy in stable 
patients with coronary artery disease, therefore the mortality and 
morbidity benefits of angioplasty are unknown. In low-risk patients 
with stable coronary artery disease, aggressive lipid-lowering therapy 
is at least as effective as angioplasty and usual care in reducing the 
incidence of ischemic events.\11\
---------------------------------------------------------------------------
    \11\ Pitt B, Waters D, Brown WV, et al. Aggressive lipid-lowering 
therapy compared with angioplasty in stable coronary artery disease. 
Atorvastatin versus Revascularization Treatment Investigators. N Engl J 
Med. 1999;341(2):70-6.
---------------------------------------------------------------------------
    The use of various types of stents during angioplasty may slow the 
rate of restenosis, but there are no randomized controlled trial data 
supporting the efficacy of these approaches. Compared to balloon 
angioplasty patients, coronary stent patients have no statistically 
significant differences in regard to additional percutaneous coronary 
intervention or coronary artery bypass during a six-month follow-up 
period, although they did have fewer heart attacks.\12\ The use of the 
left internal mammary artery in bypass surgery may reduce reocclusion, 
but vein grafts also must be used when patients have multivessel 
disease. Thus, in addition to the costs of the original bypass or 
angioplasty there are often costs of further procedures when restenosis 
and reocclusion occur.
---------------------------------------------------------------------------
    \12\ Heuser R, Houser F, Culler S, et al. A Retrospective Study of 
6,671 Patients Comparing Coronary Stenting and Balloon Angioplasty. J 
Invas Cardiol. 2000;12(7):354-362.
---------------------------------------------------------------------------
    The majority of adverse events related to coronary artery disease, 
MI, sudden death and unstable angina are due to the rupture of an 
atherosclerotic plaque of less than 40-50 percent stenosis (blockage). 
This often occurs in the setting of vessel spasm and results in 
thrombosis and occlusion of the vessel.\13\ Bypass surgery and 
angioplasty usually are not performed on lesions <50 percent stenosed 
(blocked) and do not affect non-bypassed or non-dilated lesions, 
whereas comprehensive lifestyle changes (or lipid-lowering drugs) may 
help stabilize all lesions, including mild lesions (<50 percent 
stenosis). Also, mild lesions that undergo catastrophic progression 
usually have a less well-developed network of collateral circulation to 
protect the myocardium than do more severe stenoses.
---------------------------------------------------------------------------
    \13\ Fuster V, Badimon L, Badimon JJ, Chesebro JH. The pathogenesis 
of coronary artery disease and the acute coronary syndromes. New 
England Journal of Medicine. 1992;326, 242-318.
---------------------------------------------------------------------------
    Bypass surgery and angioplasty have risks of morbidity and 
mortality associated with them, whereas there are no significant risks 
from eating a well-balanced low-fat, low-cholesterol diet, stopping 
smoking, or engaging in moderate walking, stress management techniques, 
and psychosocial support.

    TABLE 2.--COMPARISON OF INTENSIVE LIFESTYLE CHANGES (ILC), ANGIOPLASTY (PTCA), AND BYPASS SURGERY (CABG)
----------------------------------------------------------------------------------------------------------------
                                                 ILC                    PTCA                      CABG
----------------------------------------------------------------------------------------------------------------
Rapid  angina...............  X.....................  X.....................  X
Rapid  myocardial perfusion.  X.....................  X.....................  X
 cardiac events.............  X.....................  ......................  X (subset)
Continued  in stenosis over   X.....................  ......................  .........................
 time.
Continued  in perfusion over  X.....................  ......................  .........................
 time.
Improvements in non-diluted lesions..  X.....................  ......................  .........................
Improvements in non-bypassed lesions.  X.....................  ......................  .........................
Costs................................  +.....................  +++...................  +++++
----------------------------------------------------------------------------------------------------------------

    Through our non-profit research institute (PMRI), we trained a 
diverse selection of hospitals around the country. Also, Highmark Blue 
Cross Blue Shield of Western Pennsylvania was the first insurer to both 
cover and to provide this program to its members, now via Lifestyle 
Advantage. Mutual of Omaha was the first insurance company to cover 
this program in 1993. Over 40 other insurance companies are covering 
this approach as a defined program either for all qualified members or 
on a case by case basis at the sites we have trained.
    A total of 333 patients completed the Multicenter Lifestyle 
Demonstration Project (194 in the experimental group and 139 in the 
control group). We found that almost 80 percent of experimental group 
patients were able to safely avoid bypass surgery or angioplasty for at 
least three years by making comprehensive lifestyle changes at 
substantially lower cost without increasing cardiac morbidity and 
mortality. These patients reported reductions in angina comparable to 
what can be achieved with revascularization. Mutual of Omaha calculated 
an immediate savings of almost $30,000 per patient. At Highmark Blue 
Cross Blue Shield/Lifestyle Advantage, 348 of 350 patients were able to 
safely avoid revascularization by making comprehensive lifestyle 
changes. Patients reported reductions in angina comparable to what can 
be achieved with bypass surgery or angioplasty without the costs or 
risks of surgery.
    Several patients with such severe heart disease that they were 
waiting on the heart transplant list for a donor heart (due to ischemic 
cardiomyopathies secondary to coronary heart disease) improved 
sufficiently that they were able to get off the heart transplant list. 
This improvement was not only clinically but also objectively verified 
by cardiac PET scans and/or echocardiograms. Avoiding a heart 
transplant saves more than $500,000 per patient as well as significant 
physical and emotional trauma. Also, up to one-half of patients waiting 
for a heart transplant die before a donor becomes available.
    We are about to begin a randomized controlled trial to determine if 
comprehensive lifestyle changes can prevent the need for a heart 
transplant in these patients. This would be a way of demonstrating 
quite convincingly how powerful changes in diet and lifestyle can be.
    In summary, we found that we were able to train other health 
professionals to motivate their patients to make and maintain 
comprehensive lifestyle changes to a larger degree than have ever been 
reported in a real-world environment. These lifestyle changes resulted 
in cost savings that were immediate and dramatic in most of these 
patients, even in those who were eligible for bypass surgery, 
angioplasty, or a heart transplant and were able to safely avoid these 
operations. These findings are giving many people new hope and new 
choices.\14\
---------------------------------------------------------------------------
    \14\ Ornish D. Concise Review: Intensive lifestyle changes in the 
management of coronary heart disease. In: Harrison's Principles of 
Internal Medicine (online), edited by Eugene Braunwald et al., 1999. 
Also to be published in hardcover in 2002.
---------------------------------------------------------------------------
                                medicare
    Good science is very important but not always sufficient to 
motivate lasting changes in medical practice. When reimbursement 
changes, then medical practice and medical education often follow.
    Over 550,000 Americans die annually from coronary artery disease, 
making it the leading cause of death in this country. Approximately 
500,000 coronary artery bypass operations and approximately 700,000 
coronary angioplasties were performed in the United States last year at 
a combined cost of over $30 billion, more than for any other surgical 
procedure. Much of this expense is paid for by Medicare. Not everyone 
is interested in changing lifestyle, and some people with extremely 
severe and unstable disease may benefit from surgery, but billions of 
dollars per year could be saved immediately if only some of the people 
who were eligible for bypass surgery or angioplasty were able to avoid 
it by making comprehensive lifestyle changes instead.
    Unfortunately, for many Americans on Medicare, the denial of 
coverage is the denial of access. Because of the success of our 
research and demonstration projects, we asked the Centers for Medicare 
and Medicaid Services (CMS) to provide coverage for this program. We 
believe that this can help provide a new model for lowering Medicare 
costs without compromising the quality of care or access to care. In 
short, a model that is caring and compassionate as well as cost-
effective and competent.
    This approach empowers the individual, may immediately and 
substantially reduce health care costs while improving the quality of 
care, and offers the information and tools that allow individuals to be 
responsible for their own health care choices and decisions. It 
provides access to quality, compassionate, and affordable health care 
to those who most need it.
    Because of the success of our Multicenter Lifestyle Demonstration 
Project, CMS conducted their own internal peer review of our program. 
After seven years of discussions and review, CMS is now conducting a 
demonstration project to determine the medical effectiveness of our 
program in the Medicare population. If they validate the cost savings 
that we have already shown in the Multicenter Lifestyle Demonstration 
Project, then they may decide to cover this program as a defined 
benefit for all Medicare beneficiaries. If this happens, then most 
other insurance companies may do the same, thereby making the program 
available to the people who most need it.
    Medicare coverage also affects medical training and education. If 
we demonstrate the cost-effectiveness of our program in the Medicare 
population, we will provide a new model for lowering Medicare costs 
without compromising the quality of care or access to care.
    Also, Congress appropriated funds via the Department of Defense for 
us to train the Walter Reed Army Medical Center in our program for 
reversing heart disease. This program began four years ago.
    can prostate cancer be slowed, stopped, or reversed by changing 
                               lifestyle?
    The significant benefits of stress management techniques and other 
lifestyle changes extend beyond reversing and helping to prevent 
coronary heart disease. Other illnesses that may benefit include 
diabetes, hypertension, obesity, and cancers of the prostate, breast, 
and colon.
    Five years ago, we began conducting the first randomized controlled 
trial to determine if prostate cancer may be affected by making 
comprehensive changes in diet and lifestyle, without surgery, 
radiation, or drug (hormonal) treatments. The scientific evidence from 
animal studies, epidemiological studies, and anecdotal case reports in 
humans is very similar to the way it was with respect to coronary heart 
disease when my colleagues and I began conducting research in this area 
over twenty-five years ago. For example, the incidence of clinically 
significant prostate cancer (as well as heart disease, breast cancer, 
and colon cancer) is much lower in parts of the world that eat a 
predominantly low-fat, whole foods, plant-based diet. Subgroups of 
people in the United States who eat this diet also have much lower 
rates of prostate cancer and breast cancer than those eating a typical 
American diet.
    This study has been conducted in collaboration with Peter Carroll, 
M.D. (Chairman, Department of Urology, UCSF School of Medicine) and the 
late William Fair, M.D. (Professor and Chairman of Urology, Memorial 
Sloan-Kettering Cancer Center in New York). Patients with biopsy-proven 
prostate cancer who have elected to undergo ``watchful waiting'' (i.e., 
no treatment) are randomly assigned to an experimental group that is 
asked to make comprehensive diet and lifestyle changes or to a control 
group that is not. Both groups are studied and compared.
    We enrolled 84 men with biopsy-proven prostate cancer who had 
elected not to undergo conventional treatment for reasons unrelated to 
the study. This unique design allowed us to have a non-intervention 
control group to study the effects of diet and lifestyle alone on 
cancer without confounding interventions such as chemotherapy, 
radiation, and surgery.
    These prostate cancer patients were randomly assigned into an 
experimental group who were asked to make comprehensive lifestyle 
changes or to a non-intervention control group. The comprehensive 
lifestyle changes were very similar to the program that we documented 
could reverse the progression of heart disease, including a very low-
fat plant-based diet (predominantly fruits, vegetables, whole grains, 
beans, and soy products), moderate exercise, stress management 
techniques (including yoga and meditation), and a weekly support group.
    During the first year, none of the experimental group patients and 
seven of the control group patients underwent conventional treatments 
such as surgery or radiation.
    After one year, PSA levels increased (worsened) in the control 
group but decreased (improved) in the experimental group. These 
differences were statistically significant after one year. This rise in 
PSA in the control group would have been even greater if they had not 
also made significant changes in diet and lifestyle. When we examined a 
different control group of patients at the Walter Reed Army Medical 
Center with similar disease severity who had not made such significant 
changes in diet and lifestyle, we found their PSA rose substantially 
more.
    Of particular interest was the strong and statistically significant 
correlation between adherence to the lifestyle program and changes in 
PSA across both groups. This correlation between adherence to the 
lifestyle program and changes in PSA was very similar to what we found 
in our earlier studies when we found a strong correlation between 
adherence to the lifestyle program and changes in coronary artery 
disease.
    We also measured the effects of this intervention on LNCaP cell 
growth to evaluate a second level of evidence. LNCaP is a standard line 
of prostate tumor cells growing in tissue culture in laboratories 
around the world and is often used to evaluate new treatments, 
including drug therapies. When we added blood serum of these patients 
to these prostate cancer cells, we found that the experimental group 
patients inhibited the growth six times more than the control group 
patients. Also, we found a dose-response correlation between adherence 
to the diet and lifestyle program and the degree of inhibition of the 
LNCaP cells. The highest tertile of adherence inhibited the growth of 
the prostate cancer cells ten times more than the lowest tertile of 
adherence.
    Thus, it appears that comprehensive lifestyle changes may stop or 
even reverse the progression of both heart disease and prostate cancer. 
However, adherence needed to be very high (>88 percent) in order to 
stop the disease from progressing.
              how does emotional stress affect the heart?
    Emotional stress, in addition to diet and exercise, is one of the 
underlying causes of coronary heart disease. During the past ten years, 
increasing scientific evidence has provided a more complete 
understanding of the mechanisms of coronary heart disease (CHD). This 
understanding provides increasing justification for using intensive 
lifestyle changes in managing CHD.
    Coronary heart disease is a much more dynamic process than had once 
been thought. While coronary atherosclerosis (arterial blockages) 
contributes to myocardial ischemia (reduced blood flow to the heart), 
so do other mechanisms that may change rapidly--for better and for 
worse. These include variations in coronary artery vasomotor tone, 
platelet viscosity, endothelial stability, inflammation, and collateral 
circulation.
    Each of these mechanisms may be directly influenced by lifestyle 
factors, including cigarette smoking, diet, emotional stress, 
depression, and exercise. These changes can occur--for better and for 
worse--much more quickly than had once been believed.
    The most common cause of myocardial infarction, sudden cardiac 
death, or unstable angina is rupture of an atherosclerotic plaque, 
often associated with localized coronary thrombosis and/or coronary 
artery spasm.\15\ \16\ Research publications since 1990 have 
consistently shown that intensive risk factor modification can reduce 
cardiac events quite rapidly by stabilizing the endothelium within a 
relatively short period of time, whether via comprehensive changes in 
diet and lifestyle or with lipid-lowering drugs, or both, even before 
there is time for meaningful regression in coronary 
atherosclerosis.\17\
---------------------------------------------------------------------------
    \15\ Brown BG, Zhao XQ, Sacco DE, Albers JJ. Lipid lowering and 
plaque regression: new insights into prevention of plaque disruption 
and clinical events in coronary artery disease. Circulation. 
1993;87:1781-1791.
    \16\ van der Wal AC, Becker AE, van der Loos CM, Das PK. Site of 
intimal rupture or erosion of thrombosed coronary atherosclerotic 
plaques is characterized by an inflammatory process irrespective of the 
dominant plaque morphology. Circulation. 1994;89:36-44.
    \17\ Gould KL. Clinical Cardiology Frontiers: Reversal of Coronary 
Atherosclerosis. Circulation. 1994;90(3):1558-1571.
---------------------------------------------------------------------------
    In addition to these mechanisms, emotional stress often motivates 
people to overeat, drink too much alcohol, abuse drugs, work too hard, 
and engage in other self-destructive behaviors. In addition, people who 
are lonely, depressed, and isolated are many times more likely to get 
sick and die prematurely than those who feel love, connection, and 
community. The mechanisms for this understanding are not completely 
understood: we know that it is true even though we do not always know 
why it is true.
    In this testimony, I will discuss some of these mechanisms, 
describe the evidence from lifestyle intervention trials, and summarize 
strategies that may be helpful in motivating patients to make and to 
maintain beneficial changes in diet and lifestyle.\18\
---------------------------------------------------------------------------
    \18\ Ornish D. Dr. Dean Ornish's Program for Reversing Heart 
Disease. New York: Random House, 1990; Ballantine Books, 1992.
---------------------------------------------------------------------------
                     emotional stress and hostility
    Emotional stress may lead to chest pain and heart attacks both via 
coronary artery spasm and by increased platelet aggregation (blood 
clots) within coronary arteries.\19\ Stress may lead to coronary spasm 
(constriction of coronary arteries) mediated either by direct alpha-
adrenergic stimulation (i.e., direct connections between the brain and 
the heart) or secondary to the release of hormones such as thromboxane 
A2 from platelets, perhaps via increasing circulating stress hormones 
or other mediators.\20\ Both thromboxane A2 and catecholamines (stress 
hormones) are potent constrictors of arterial smooth muscle and 
powerful endogenous stimulators of platelet aggregation.\21\
---------------------------------------------------------------------------
    \19\ Oliva, P. B. (1981). Pathophysiology of acute myocardial 
infarction. Annals of Internal Medicine, 94, 236-250.
    \20\ Schiffer, F., Hartley, L. H., Schulman, C. L., & Abelman, W. 
H. (1980). Evidence for emotionally induced coronary arterial spasm in 
patients with angina pectoris. British Heart Journal, 44, 62-66.
    \21\ Moncada, S., & Vane, J. R. (1979). Arachidonic acid 
metabolites and the interactions between platelets and blood vessel 
walls. New England Journal of Medicine, 300, 1142-1147.
---------------------------------------------------------------------------
    Personally relevant mental stress may be an important precipitant 
of reduced blood flow to the heart--often silent--in patients with 
coronary artery disease.\22\ Acute mental stress may be a frequent 
trigger of transient reductions in blood flow to the heart, heart 
attacks and sudden cardiac death.\23\
---------------------------------------------------------------------------
    \22\ Rozanski A. Bairey CN. Krantz DS, et al. Mental stress and the 
induction of silent myocardial ischemia in patients with coronary 
artery disease. New England Journal of Medicine. 318(16):1005-12, 1988 
Apr 21.
    \23\ Bairey CN. Krantz DS. Rozanski A. Mental stress as an acute 
trigger of ischemic left ventricular dysfunction and blood pressure 
elevation in coronary artery disease. American Journal of Cardiology. 
66(16):28G-31G, 1990 Nov 6.
---------------------------------------------------------------------------
    Women of postmenopausal age may have greater cardiovascular 
responses to stress than men or premenopausal women.\24\ 
Atherosclerotic monkeys with chronic psychosocial disruption had 
coronary artery constriction in response to acetylcholine, whereas 
atherosclerotic monkeys living in a stable social setting had coronary 
artery vasodilation in response to acetylcholine, even though both 
groups of monkeys were consuming a cholesterol-lowering diet.\25\
---------------------------------------------------------------------------
    \24\ Bairey Merz CN. Kop W. Krantz DS, et al. Cardiovascular stress 
response and coronary artery disease: evidence of an adverse 
postmenopausal effect in women. American Heart Journal. 135(5 Pt 
1):881-7, 1998 May.
    \25\ Williams JK. Vita JA. Manuck SB. Selwyn AP. Kaplan JR. 
Psychosocial factors impair vascular responses of coronary arteries. 
Circulation. 1991;84(5):2201-2.
---------------------------------------------------------------------------
    In an analysis of over forty-five studies, hostility has emerged as 
one of the most important personality variables in coronary heart 
disease.\26\ The effects of hostility are equal to or greater in 
magnitude to the traditional risk factors for heart disease.\27\ 
Hostility and cynicism appear to be the primary toxic components of the 
Type A behavioral pattern. Other aspects of Type A behavior do not seem 
to be harmful.
---------------------------------------------------------------------------
    \26\ Miller TQ, Smith TW, Turner CW, et al. A meta-analytic review 
of research on hostility and physical health. Psychological Bulletin. 
1996;119:322-348.
    \27\ Review Panel on Coronary-Prone Behavior and Coronary Heart 
Disease. Coronary-prone behavior and coronary heart disease: a critical 
review. Circulation. 1978;65:1199-1215.
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                               depression
    Several studies have shown that depression significantly increases 
the risk of developing coronary heart disease. One study of 1,551 
people in the Baltimore area who were free of heart disease in 1981 
found that those who were depressed were more than four times as likely 
to have a heart attack in the next 14 years. Depression increased risk 
as much as did hypercholesterolemia.\28\
---------------------------------------------------------------------------
    \28\ Pratt LA, Ford DE, Crum RM, et al. Depression, psychotropic 
medication, and risk of myocardial infarction. Circulation. 
1996;94(12):3123-9.
---------------------------------------------------------------------------
    Depression also increases the risk of subsequent myocardial 
infarction in patients with existing coronary heart disease. 
Unfortunately, depression often goes untreated.
    One study examined the survival of elderly men and women 
hospitalized for an acute heart attack who had emotional support 
compared with those patients who lacked such emotional support. More 
than three times as many men and women died in the hospital who had no 
source of emotional support compared with those with two or more 
sources of support. Among those who survived and were discharged from 
the hospital, after six months 53 percent of those with no source of 
support had died compared with 36 percent of those with one source and 
23 percent of those with two or more sources of support. These figures 
did not change significantly after one year. When they looked at all 
patients and controlled for other factors that might have influenced 
survival (such as severity of the heart attack, age, gender, other 
illnesses, depression), men and women who reported no emotional support 
had almost three times the mortality risk compared with those who had 
at least one source of support.\29\
---------------------------------------------------------------------------
    \29\ Berkman LF, Leo-Summers L, Horwitz RI. Emotional support and 
survival after myocardial infarction. A prospective, population-based 
study of the elderly. Annals of Internal Medicine. 1992;117(12):1003-9.
---------------------------------------------------------------------------
    In another study, researchers followed 222 patients who had 
suffered myocardial infarction and found that those who were depressed 
were four times as likely to die in the next six months as those who 
were not depressed.\30\
---------------------------------------------------------------------------
    \30\ Lesperance F, Frasure-Smith N, Talajic M. Major depression 
before and after myocardial infarction: its nature and consequences. 
Psychosomatic Medicine. 1996;58(2):99-110.
---------------------------------------------------------------------------
    Many depressed patients are, paradoxically, in a constant state of 
hyperarousal, causing sustained hyperactivity of the two principal 
effectors of the stress response, the corticotropin-releasing-hormone, 
or CRH, system, and the locus ceruleus-norepinephrine, or LC-NE, 
system. Norepinephrine may precipitate vasoconstriction, platelet 
aggregation, and arrhythmias. Cortisol may accelerate 
atherosclerosis.\31\ When patients are treated for depression, these 
changes in CRH and LC-NE may return to normal. Beta-blockers help blunt 
the hyperarousal state but may exacerbate depression, whereas 
meditation may reduce hyper-reactivity without causing depression.
---------------------------------------------------------------------------
    \31\ Gold PW, Chrousos GP. The endocrinology of melancholic and 
atypical depression. Proceedings of the Association of American 
Physicians. 1999;111(1):22-34.
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    Social factors, including social support, play an important role in 
both adherence to comprehensive lifestyle changes and may have powerful 
effects on morbidity and mortality independent of influences on known 
risk factors. An increasing number of studies has shown that those who 
feel socially isolated have three to five times the risk of premature 
death not only from coronary heart disease but also from all causes 
when compared to those who have a sense of connection and 
community.\32\ \33\
---------------------------------------------------------------------------
    \32\ House JS, Landis KR, Umberson D. Social relationships and 
health. Science. 1988; 241(4865):540-5.
    \33\ Ornish D. Love & Survival: The Scientific Basis for the 
Healing Power of Intimacy. New York: HarperCollins, 1998.
---------------------------------------------------------------------------
    For example, researchers at Duke studied almost 1,400 men and women 
who underwent coronary angiography and were found to have had at least 
one severe coronary artery stenosis. After five years, men and women 
who were unmarried and who did not have a close confidante--someone to 
talk with on a regular basis--were over three times as likely to have 
died than those who were married, had a confidant, or both. These 
differences were independent of any other known medical prognostic risk 
factors.\34\
---------------------------------------------------------------------------
    \34\ Williams RB, Barefoot JC, Califf RM, et al. Prognostic 
importance of social and economic resources among medically treated 
patients with angiographically documented coronary artery disease. 
Journal of the American Medical Association. 1992;267(4):520-524.
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                                exercise
    One of the benefits of exercise is to help reduce stress and combat 
depression. The role of exercise in the prevention and treatment of 
coronary heart disease is well-known and is supported by several 
reviews of the literature. Two meta-analyses indicate that the risk of 
death was doubled in those who were physically inactive when compared 
with more active individuals.\35\ \36\ Rehabilitation programs 
incorporating exercise also show modest benefits of exercise in 
preventing recurrent CHD events. None of 22 randomized trials in the 
meta-analysis had the power to show a significant treatment effect, but 
in a meta-analysis employing the intention-to-treat analysis, there was 
a significant reduction of 25 percent in 1- to 3-year rates of CHD and 
total mortality in the patients receiving cardiac rehabilitation when 
compared with control patients.
---------------------------------------------------------------------------
    \35\ Berlin, J. A., & Colditz, G. A. A meta-analysis of physical 
activity in the prevention of coronary heart disease. American Journal 
of Epidemiology, 1990;132, 612-628.
    \36\ Powell, K. E., Thompson, P. D., Caspersen, C. J., & Kendrick, 
J. S. Physical activity and the incidence of coronary heart disease. 
Annual Review of Public Health. 1987;8, 253-287.
---------------------------------------------------------------------------
    Moderate exercise provides most of the improvement in longevity as 
more intensive exercise while minimizing the risks of exercising. In 
one study, investigators performed treadmill testing on 10,224 men and 
3,120 women who were apparently healthy. Based on their fitness level, 
these participants were divided into five categories, ranging from 
least fit (group 1) to most fit (group 5). The researchers followed 
these people to determine how their level of physical fitness related 
to their death rates. After eight years, the least fit (the sedentary 
group 1) had a death rate more than three times greater than the most 
fit (the very active group 5). More important, though, was the finding 
that most of the benefits of physical fitness came between group 1 and 
group 2, particularly in men.\37\
---------------------------------------------------------------------------
    \37\ Blair SN, Kohl HW, Paffenbarger RS, et al. ``Physical fitness 
and all-cause mortality.'' JAMA. 1989;262:2395-2401.
---------------------------------------------------------------------------
    Even substantial decreases in cardiovascular fitness resulting from 
decades of inactivity can be substantially reversed with modest 
endurance training.
                        practical considerations
    Lifestyle factors such as diet, smoking, and emotional stress often 
interact. For example, people are often more likely to overeat, smoke, 
work too hard, or abuse drugs and alcohol when they feel lonely, 
depressed, or isolated. As one patient told me, ``I've got 20 friends 
in this package of cigarettes and they're always there for me. Are you 
going to take away my 20 friends? What are you going to give me 
instead?''
    Providing health information is important but not usually 
sufficient to motivate lasting changes in behavior unless the 
underlying psychosocial issues are also addressed. Thus, stress 
management techniques and group support may address some of these 
deeper concerns, thereby making it easier for patients to change diet 
and quit smoking.\38\ \39\ Sometimes, patients also may benefit from 
referral to a psychotherapist for treatment of depression with 
counseling and/or antidepressants.
---------------------------------------------------------------------------
    \38\ Ornish D. Love & Survival: The Scientific Basis for the 
Healing Power of Intimacy. New York: HarperCollins, 1998.
    \39\ Ornish D, Hart J. Intensive Risk Factor Modification. In: 
Hennekens C, Manson J, eds. Clinical Trials in Cardiovascular Disease. 
Boston: W.B. Saunders, 1998.
---------------------------------------------------------------------------
    The conventional medical thinking is that taking a statin drug is 
easy and most patients will comply, but making comprehensive lifestyle 
changes is virtually impossible for almost everyone. In fact, less than 
50 percent of patients who are prescribed statin drugs are taking them 
as prescribed just one year later.\40\
---------------------------------------------------------------------------
    \40\ Rogers PG, Bullman WR. Prescription medication compliance: a 
review of the baseline of knowledge. A report of the National Council 
on Patient Information and Education. J Pharmacoepidemiology. 1995;2:3-
36.
---------------------------------------------------------------------------
    One might think that compliance to lipid-lowering drugs would 
always be much higher than to comprehensive diet and lifestyle changes, 
since taking pills is relatively easy and the side-effects are minimal 
for most patients. However, cholesterol lowering drugs do not make most 
patients feel better. They are taken today in hopes that there may be a 
long-term benefit by reducing the risk of a myocardial infarction or 
sudden cardiac death.
    To many patients, concepts such as ``risk factor modification'' and 
``prevention'' are considered boring and they do not initiate or 
sustain the levels of motivation needed to make intensive lifestyle 
changes. ``Am I going to live longer, or is it just going to seem 
longer?''
    Also, the prospect of a heart attack or death is so frightening for 
many patients that their denial often keeps them from thinking about it 
at all. Because of this, adherence becomes difficult for them to 
maintain. (Patients often will adhere very well for a few weeks after a 
heart attack until the denial returns.) Fear is a powerful motivator in 
the short run but not in the long run, for when it's too scary to think 
about something, many people simply don't.
    While fear of dying may not be a sustainable motivator, joy of 
living often is. In our experience, paradoxically, it may be easier for 
some patients to make comprehensive changes all at once than to make 
small, gradual changes or even to take a cholesterol-lowering drug.
    For example, when patients follow a Step 2 diet, they often have a 
sense of deprivation but not much apparent benefit. LDL-cholesterol is 
reduced by an average of only 5 percent,\41\ frequency of angina does 
not improve much, lost weight is usually regained, and coronary artery 
lesions tend to progress. However, patients who make comprehensive 
lifestyle changes often experience significant and sustained reductions 
in frequency of angina, LDL-cholesterol, and weight; also, coronary 
artery lesions tend to regress rather than progress.
---------------------------------------------------------------------------
    \41\ Hunninghake DB, Stein EA, Dujovne CA, et al. The efficacy of 
intensive dietary therapy alone or combined with lovastatin in 
outpatients with hypercholesterolemia. N Engl J Med. 1993;328(17):1213-
9.
---------------------------------------------------------------------------
    Patients usually report rapid decreases in angina and of ten 
describe other improvements within weeks; these rapid improvements in 
angina, well-being, and quality of life sustain motivation and help to 
explain the high levels of adherence in these patients. Instead of 
viewing lifestyle changes solely in terms of risk factor reduction in 
hopes of future benefit, patients began to experience more immediate 
benefits, thereby reframing the reason for making these changes in 
behavior from fear of dying to joy of living.
    This is a particularly rewarding and emotionally fulfilling way to 
practice medicine, both for patients and the physicians and other 
health professionals who work with them. Much more time is available to 
spend with patients addressing the underlying lifestyle factors that 
influence the progression of coronary artery disease, yet costs are 
substantially lower.
    As discussed earlier, the major reason that most stable patients 
undergo bypass surgery or angioplasty is to reduce the frequency of 
angina, and comparable results may be obtained by making comprehensive 
lifestyle changes alone. Instead of pressuring physicians to see more 
patients in less time, this is a different approach to reducing medical 
costs that is caring and compassionate as well as cost-effective and 
competent.
    The physician, who is often pressed for time, need not provide all 
of the training in changing diet and lifestyle. He or she can act as 
the ``quarterback,'' providing direction and supervision. My colleagues 
and I at the non-profit Preventive Medicine Research Institute and at 
Lifestyle Advantage have trained teams of health professionals at 
clinical sites around the country in this program of comprehensive 
lifestyle changes. These include cardiologists, registered dietitians, 
exercise physiologists, psychologists, chefs, stress management 
specialists, registered nurses, and administrative support personnel. 
These teams, in turn, work with their patients to motivate them to make 
and maintain comprehensive lifestyle changes.
    In practice, patients with coronary heart disease should be offered 
a range of therapeutic options, including comprehensive lifestyle 
changes, medications (including lipid-lowering drugs), angioplasty, and 
bypass surgery. The physician should explain the relative risks, 
benefits, costs, and side-effects of each approach and then support 
whatever the patient decides. Whether or not a patient chooses to make 
intensive lifestyle changes is a personal decision, but he or she 
should have all the facts in order to make an informed choice.
    Emotional stress affects the health and productivity of almost all 
Americans. Therefore, I respectfully request the Committee on 
Appropriations of the U.S. Senate to consider substantial increases in 
funding for rigorous scientific research into the effects of emotional 
stress on health and disease.
    Those approaches that are found to be safe and effective should be 
covered by Medicare and other third-party payers so that these methods 
can be more widely available to other Americans who may benefit from 
them regardless of socioeconomic and demographic background. Scientific 
studies that find other approaches to be ineffective or unsafe will be 
of great value in helping to protect the American people as well as 
Medicare from fraud and abuse.
    Thank you very much for the opportunity to share these thoughts 
with you today.

    Senator Specter. Thank you very much, Dr. Ornish. The 
quality of your testimony exceeded your punctuality.
    Dr. Ornish. Thank you.
    Senator Specter. And there are quite a few questions. I 
will be coming back to you.
    Dr. Ornish. Thank you, sir.
        STATEMENT OF GLENN PERELSON, NATIONAL MARKETING DIRECTOR, 
            LIFESTYLE ADVANTAGE
    Senator Specter. Our second witness is Mr. Glenn Perelson, 
National Marketing Director of Lifestyle Advantage, a joint 
venture of Preventive Medicine Research Institute and Highmark 
Blue Cross-Blue Shield. Mr. Perelson is a graduate of the 
University of California. I participated just a week ago today 
on the program at Allegheny General Hospital in Pittsburgh, 
which marked the kick-off of Lifestyle with the test program 
for Medicare, quite an achievement to get Medicare to spend any 
money, directing people 65 and older who have arteriosclerosis, 
heart disease, to have the program. They are very difficult to 
deal with on many, many lines. But I think it was the prospect 
of saving money which brought them in there because if they can 
save money with their constraints, with the budget they have, 
they will be able to spend it elsewhere. But that is a very 
attractive program and I appreciate your work on it. I look 
forward to your testimony.
    Mr. Perelson. Thank you. And we very much appreciate your 
support in terms of the roll-out of our program in 
Pennsylvania. And just as a quick aside, in terms of the multi-
center research that Dr. Ornish and colleagues have done, a 
full half of the people that went through that research were of 
Medicare age, who did as well or better than people who were 
not that age. And so we are looking forward to enrolling 
Medicare-age participants in our 10 sites in West Virginia, our 
nine new sites in Pennsylvania, Nebraska, and in Illinois.
    Dr. Ornish asked me to speak briefly about the cost savings 
associated with the Ornish program and we really have needed 
partners in terms of looking at costs associated with the 
Ornish program, and our two most significant partners have been 
Mutual of Omaha very early in the process, and Highmark Blue 
Cross Blue Shield, because you can make projections based on 
risk factor changes, but it is much better to look at cost 
savings when you have full control of all the costs associated 
with the disease, and health plans do have that for their 
members. And so what I would like to talk to you about today 
are a number of studies that have been done by both Mutual of 
Omaha and Highmark looking at cost savings associated with the 
program.
    When you look at heart disease and costs associated with 
heart disease and the $330 billion a year associated with heart 
disease and productivity costs, most of those costs are 
associated with the procedures--about 80 to 85 percent of those 
costs. And so the first study that I will note is that when we 
were working with Mutual of Omaha in the multi-center trial, we 
looked at the participants who went through the program who 
were subject to invasive procedures and compared them to Mutual 
of Omaha members who did not go through the program and went on 
to have procedures. In that group, those Mutual of Omaha 
members who had procedures experienced an additional 34 
procedures, and the Ornish group who did not have the initial 
procedure had 57 procedures.
    The notes that I have provided for the testimony, if you do 
the math associated with that, you end up with the $29,000 
differential between the control group who did not have the 
Ornish program and those folks who went through the Ornish 
program. Again, the costs that were evaluated in terms of that 
did not include additional items such as emergency room visits, 
physician visits, or medications. It simply was a look at how 
much cost was avoided by going through the Ornish program for 
the procedures.
    David Eddy, a noted health economist, also did a study in 
the year of 2000 basically looking at all the literature 
associated with our program and with lifestyle changes. And I 
will quote. He concluded that: ``The program is at least cost-
neutral and is probably cost-saving, is robust under a wide 
range of assumptions and sensitivity analyses. While it is 
never possible to know the exact financial effects of a 
treatment or its exact clinical effects for that matter, all 
available evidence suggests the comprehensive lifestyle program 
is highly likely to be cost-saving, and is extremely unlikely 
to be cost-increasing.''
    With our partnership in 1997 with Highmark Blue Cross Blue 
Shield, who, as Dr. Ornish said, was the first insurance 
company to both offer and pay for the program, the program has 
been looked at from four different perspectives and each of 
those perspectives has yielded significant cost savings 
results. In fact, Dr. Fetterolf, who is a Senior Medical 
Director at Highmark actually was skeptical about the program 
when it was first brought on board, not from a clinical 
perspective, but from a cost-savings perspective. And his staff 
has showed in any way that you can look at the Ornish program 
that there are significant cost savings--from an emergency and 
admissions perspective, from an angina cessation perspective 
using diagnostic software to project what costs should be in 
the group; any way that the Info-matics program at Highmark has 
looked at the Ornish program, it shows substantial savings. And 
in 5 seconds will be the end of my time.
    I wanted to beat you by 5.
    Senator Specter. Well, the precedents that you establish on 
timing are exemplary. The third witness today is in line with 
the Dr. Ornish program, Mr. Mel Lefer from Penngrove, 
California, a former San Francisco restaurant owner who brought 
New York-style food to San Francisco.
    Mr. Lefer. It is all true.

                     SUMMARY STATEMENT OF MEL LEFER

    Senator Specter. That is quite an achievement. The 
information provided to me, which I am sure Mr. Lefer has 
approved my disclosing, is that he suffered a massive coronary 
in 1985 and was advised that he had less than a year to live, 
and he joined Dr. Ornish's Lifestyle Heart Trial in 1986 and is 
here to tell the tale. Mr. Lefer?
    Mr. Lefer. I will try to put a human face on it, Senator. 
Well, my doctor called me and said this young doctor could help 
me, and so he came over to my house and he told me that if I 
ate good, exercised, I did yoga and I talked about my 
feelings--I would get better. He figured he could help me. And 
at the time, I did not know that I had only about a year to 
live. And actually, Dean took everybody into the program, even 
people worse off than I was. So at that time, I could only walk 
a few steps and then I would have to stop, take some Nitrol. It 
used to take me an hour, an hour-and-a-half to take a shower 
because I would have to rest.
    Immediately, within 1 week or 2, I started to feel better. 
I started to walk more and eventually got up to 10 miles a day. 
I started feeling happier. Up until my heart attack, I had some 
terrible things happen in my life and my luck kind of went 
south for a while, and I learned how to open up my heart, I 
learned how to not let bad things--keep bad things out, put a 
wall around my heart. I had the most difficulty doing the yoga 
and so I became a yoga teacher.
    My relationships with my wife and my kids improved and, I 
would say, nowadays I am happier than I have ever been. And my 
relationship with my family is closer and more loving than ever 
before. About 2 years ago--my wife and I travel a lot--I was 
hiking in the Alps at 10,000 feet. I went to the top of the 
mountain in a snowstorm. That was one of the highlights of my 
life, that I was able to do that. Nowadays, I never have to 
take any angina pills, Nitrol, and I am just really happy.
    I am still addicted to food. At that time, I used to travel 
around the world, eating in all the great restaurants. I used 
to smoke six to seven Cubans a day. I was a couch potato. Now I 
usually hike every day for at least 3 miles. So I would say I 
feel better now than I have ever felt before, and it is amazing 
what a few vegetables can do.
    I still have 2 minutes, but I am done.
    Senator Specter. Well, that is very impressive, Mr. Lefer. 
We will come back to you for some questions.
STATEMENT OF DR. JUDITH STERN, PROFESSOR, DEPARTMENT OF 
            NUTRITION AND INTERNAL MEDICINE; DIRECTOR 
            OF THE FOOD INTAKE LABORATORY GROUP, 
            UNIVERSITY OF CALIFORNIA, DAVIS
    Senator Specter. Our next witness is Dr. Judith Stern, 
professor in the Department of Nutrition and Internal Medicine 
at the University of California, Davis, director of the Food 
Intake Laboratory Group at UC Davis. She received her 
bachelor's degree in food and nutrition from Cornell and her 
doctor of science degree from Harvard University, and I have 
been familiar with her professional work for more than a 
decade. Among her many accomplishments is the education of my 
Ph.D. son, Steven. Dr. Stern, thank you for joining us today. 
We look forward to your testimony.
    Dr. Stern. Mr. Chairman, thank you for the opportunity to 
testify before you and also on behalf of the American Obesity 
Association, which is a non-profit lay advocacy organization 
that I helped to found.
    In the last four decades of obesity research, progress has 
been made on identifying causes and treatments, but despite 
these research advances, children, adolescents, and adults 
continue to become overweight and obese in record numbers--and 
I gave you a few figures as a professor. Those are figures 1 
through 3. But in 1999, your Senate Appropriations Committee 
called on the Department of Health and Human Services to 
develop a comprehensive research plan on obesity. This request 
has not been implemented and it is needed even more today. So 
in the absence of such research and such a research plan, there 
has been an explosion of searches with simple global solutions 
ranging from law suits against food companies to banning soft 
drinks from schools.
    I know you have heard this refrain before, but we are 
simply not spending enough money on obesity research. I am 
going to use NIH as an example. As Mr. Chairman knows, NIH has 
provided a critical role in providing leadership and research 
support needed for meeting medical modern health problems, both 
great and small. And we have acknowledged that you and Senator 
Harkin have provided a lot of the fuel for this research, so to 
speak. So what I have done is I have used NIH's own criteria to 
set research priorities, which include healthcare needs, the 
number of people with disease, the number of deaths, degree of 
disability, economic and social impacts, the need to control 
the spread of the disease, and finally basic research which can 
have a long-term impact on health. And given NIH's own 
criteria, obesity should have a very high priority, but it does 
not based on the level of obesity research funding and the 
organizational level at NIH.
    You can see in figure 4, NIH's obesity funding is far below 
other diseases. And while obesity research investment at NIH 
has more than doubled in the last 5 years from $128 million in 
1998 to a projected greater than $300 million in 2003, it still 
is a small percentage of NIH's budget, and if you look at 
figure 6, the number of research grants are far below other 
important areas of research. So the gravity and urgency of this 
epidemic calls for obesity to be given a leading place in the 
NIH organizational structure. And NIH's current obesity 
research is really buried in organizations dedicated to other 
diseases. There are 27 institutes, there are centers at NIH, 
the lead institute for obesity research is NIDBK. NIDBK has six 
divisions. In one of the divisions, it has three branches. In 
one of the three branches, obesity has eating disorders.
    So it really is on the lowest organizational rung. And I 
think there are at least five negative effects of this low 
position of obesity research in NIH. First of all, the budget 
is far below what it should be. Second, there are insufficient 
staff and time to integrate obesity questions and priorities 
with NIH and their developing the Human Genome Project, and 
also do research on stigma in healthcare, and so on. Three, 
there is a vacuum of leadership. And four, we really need a 
strong scientific leader to advise Congress and governments on 
sound, workable solutions. Few other areas of healthcare 
attract the enormous public and media attention of weight and 
obesity, and also a lack of strong NIH voice. And fifth, the 
resources at NIH need to be managed and anticipated. And we do 
not do that. For example, to study food intake, we need doubly-
labeled water. There is a shortage of doubly-labeled water, and 
we simply cannot get it.
    Senator Specter. Government labeled----
    Dr. Stern. Doubly-labeled water. It is an isotope to let us 
do food intake research. We cannot get it and NIH did not 
anticipate this.
    So we are recommending that there be an Institute of 
Obesity at NIH. This will improve the opportunities. We are 
anticipating, certainly, a whole bunch of criticisms against 
that. But my bottom line is that we really need a sense of 
urgency in funding obesity research. If we do not immediately 
adopt a proactive posture to develop these scientific 
resources, public policy will continue to grope in the dark for 
solutions to obesity and to the suffering due to obesity. The 
healthcare system cannot respond to the millions of new, 
younger cases of obesity and its associated diseases and, not 
to be overdone by Dean, I thank you for the opportunity to 
testify, and I am available to answer any questions at the end.
    [The statement follows:]
                 Prepared Statement of Judith S. Stern
    Mr. Chairman and members of the subcommittee:thank you for the 
opportunity to testify before you on behalf of the American Obesity 
Association (AOA), a non-profit corporation one of whose goals is to 
expand research on Obesity. I am Judith S. Stern, Sc.D., Professor of 
Nutrition and Internal Medicine at the University of California at 
Davis and Vice President and co-founder of AOA. I want to express on 
behalf of my colleagues our gratitude for the work of the Subcommittee 
in providing appropriations for biomedical science and prevention 
programs.
    In the last four decades of obesity research, progress has been 
made in identifying causes and treatments. Research has provided us 
with a greater understanding of obesity as a chronic disease and the 
complex role that genetic, metabolic, behavioral, psychological and 
environmental factors play in the disease. Despite the advances in 
research, however, children, adolescents and adults continue to become 
overweight and obese in record numbers.\1\ Obesity is unique in that a 
chronic disease is increasing at rates previously only seen with 
infectious diseases (see Figures 1-3, data from the National Health and 
Nutrition Examination Surveys, NHANES). For example, the prevalence of 
obesity in women ages 20-29 years has more than doubled in the last 20 
years (Figure 1). Over 60 percent of adult Americans are overweight or 
clinically obese. Fourteen percent of American children and adolescents 
are obese. More research is needed to understand and prevent this 
complex epidemic disease.
    Obesity is a leading cause of mortality, morbidity, disability, 
discrimination in health care, education, and 
employment.\2\-\11\ According to a recent RAND study, the 
health consequences of obesity are as significant or greater than the 
effects of smoking, alcohol overuse and poverty.\12\ The consequences 
of obesity include various cancers, heart disease, stroke, type 2 
diabetes, osteoarthritis, sleep apnea and problem pregnancies and 
childbirth.\12\-\19\
    Obesity is poorly treated by the medical community.\20\ Coverage 
for effective treatments is modest to poor in both governmental and 
non-governmental health insurance programs. As a result, patients are 
denied access to effective treatments including surgery, FDA approved 
medications, physician counseling, dietician services and behavioral 
counseling. Inexplicably, the very insurance programs that do not 
reimburse for weight maintenance do cover the costs of treating the 
diseases caused by obesity.\21\ The desire for effective methods of 
weight management can lead to adverse interventions including tobacco 
smoking \22\ and the use of ineffective or harmful consumer 
products.\23\
    The rapid rise in obesity and its profound consequences for the 
health of the population have resulted in a recent explosion of 
searches for simple global solutions ranging from law suits against 
food companies \24\ to banning soft drinks from schools.\25\
                  the role of nih in obesity research
    The National Institutes of Health (NIH) has played a critical role 
in providing the leadership and research support needed for meeting 
modern health problems both great and small. The setting of research 
priorities at NIH is a complicated process involving Congress, the 
White House, various advocacy efforts and not least a scientific 
judgment of the opportunities present in each field. NIH has documented 
the process in its publication, Setting Research Priorities.\26\ The 
process involves assessing health care needs, such as the number of 
persons with a disease, the number of deaths, the degree of disability, 
the degree to which a disease cuts shorts a normal, productive and 
comfortable life, the economic and social impacts of a disease and the 
need to act rapidly to control the spread of a disease. In addition, 
the NIH places a high priority on funding basic research which can have 
a long-term impact on health. The low priority given obesity can be 
seen in the low level of obesity research funding and by the absence of 
any NIH organization dedicated to obesity.
    It would not be unreasonable, given NIH's own criteria, to expect 
that obesity would be a very high priority. Unfortunately, that is not 
the case. As illustrated in Figure 4, NIH obesity research funding is 
far below other diseases, including conditions directly caused by 
obesity such as cardiovascular disease and diabetes.
    While the obesity research investment at NIH has nearly doubled in 
the last five years, this increase has barely matched the overall 
growth in NIH's budget (see Figure 5). While the obesity epidemic has 
taken hold in America, NIH's obesity research funding share has 
actually decreased. Accordingly, as indicated in Figure 6, research 
grants in obesity are far below other important areas of research.
    The gravity and urgency of the obesity epidemic call for obesity 
research to be given a leading place in NIH's organizational structure. 
This is emphatically not the case today. NIH's current obesity research 
effort is buried in organizations dedicated to other diseases.\27\
    There are five negative effects of this low position of obesity 
research in NIH's organizational structure.
    (1) The obesity research budget is far below what it should be 
according to NIH's own criteria for research priorities and the obesity 
research budget has not benefited from the recent rise in NIH funding.
    (2) There is insufficient staff and time to fully integrate obesity 
questions in the numerous research programs being developed by NIH such 
as the next phase of the human genome project to the analysis of risk 
data on hormone replacement therapy or research on the role of stigma 
in health care.
    (3) There is a vacuum of the high-ranking leadership on obesity 
needed to develop collaborative approaches within the Department of 
Health and Human Services (DHHS).\28\
    (4) A strong scientific leader is needed to advise Congress and 
guide the states and local governments on sound, workable solutions to 
the obesity crisis. Few governmental officials can match the influence 
and persuasive qualities of a Director of a NIH Institute. Obesity is 
burdened with public misconceptions and confusion about causes, cures, 
prevention and intervention strategies. Few other areas of health care 
attract the enormous public and media attention of weight and obesity. 
One only has to look as far as the invaluable role played by Dr. 
Anthony S. Fauci, Director of the National Institute of Allergy and 
Infectious Diseases on contentious debates about HIV/AIDS and 
bioterrorism to appreciate the need for a credible scientific voice on 
obesity.
    (5) Research resources have to be anticipated and managed. Many 
excellent research efforts in studying food intake and energy 
expenditure, for example, have been delayed or halted by the shortage 
of double-labeled water. Assuring that such research resources are met 
is simply outside the capacity of the current structure.
    We recommend that NIH, working in consultation with Congress, the 
Administration and the obesity research community move quickly to 
create and fund a National Institute on Obesity. Such an Institute 
would provide a remedy to the weaknesses of the current structure. The 
desire is not to just consolidate current obesity research in one 
structure. The purpose is also to provide a platform for national and 
international leadership and to bring new funding to meet the 
significant challenges of the field. We propose at a new National 
Institute on Obesity have seven components or divisions:
    1. Basic Research on Adipose Tissue;
    2. Epidemiology and Population Studies;
    3. Genetics, Metabolism and Mechanisms of Disease Development;
    4. Neuroscience and Behavioral Research;
    5. Prevention, Therapeutic Development and Clinical Trials;
    6. Economics and Health Policy; and
    7. Training and Education.
    These areas reflect both the needs and robustness of the obesity 
research field. Critical work in all these areas is going on but vastly 
more needs to be done. Above all, meaningful integration of the 
specific research areas has not occurred. In 1999, the Senate 
Appropriations Committee called on the Department of Health and Human 
Services to develop a comprehensive research plan on obesity.\29\ This 
request has not been implemented and is even more needed today. The 
field of obesity research holds enormous scientific opportunities in 
the near future including.
  --Body fat is now known to be regulated by several hormones and 
        neuropeptides, including leptin and ghrelin.
  --Food ingredients such as glucose, amino acids and fatty acids 
        affect the production of the hormones insulin, growth hormone, 
        insulin-like growth factor and leptin which act on specific 
        receptors in the hypothalamic circuits that regulate feeding 
        behavior.\30\
  --The human genome program holds the promise to integrate such 
        molecular understanding of normal body weight regulation with 
        abnormal body weight regulation. Fresh insights on the 
        significant racial and ethnic disparities in obesity and its 
        comorbid conditions are foreseen.\31\
    With such information, more precise and informed prevention 
strategies, behavioral interventions, pharmacology, and surgical 
interventions can be developed and tested. Such prevention and 
treatment strategies will give rise to questions of economic efficiency 
and legislative and regulatory approaches. The current lack of 
attention in medical training and health professional disciplines on 
obesity can be directly and immediately approached through programs to 
develop obesity researchers and health education campaigns.
    We anticipate objections to a proposal to create a new NIH 
institute, to wit:
    (1) NIH is already too big and complicated. Former directors of NIH 
and some members of Congress have expressed this view. Currently, this 
topic is under discussion by a committee of the Institute of Medicine. 
This objection is a serious one which is of concern to the entire 
research community. However, there is no reason why the concept and the 
needs for a National Institute on Obesity cannot be part of this 
debate. More importantly though, is the importance of not losing sight 
of what is most critical--the administrative efficiency of NIH or the 
public health problems caused by obesity. Experience shows that asking 
other organizations with other primary responsibilities to share their 
funding with a new area simply does not work.
    (2) A new Institute is less desirable than getting all the existing 
components of NIH to do more on obesity as it affects their particular 
interest and to better coordinate research protocols and activities. 
This too is an important argument. For this to occur, the current low 
organizational level of obesity research must be changed. This approach 
might go far to better integrate and enhance obesity research at NIH. 
However, it is unlikely to provide the external leadership that an 
Institute Director can bring to the raging debates about the causes and 
cures of the obesity epidemic. In addition, this approach fails to 
focus on adipose tissue, obesity and its prevention and treatments. It 
runs the risk of the appearance of attention without actual 
improvements.
    (3) Do higher levels of funding precede evolution of a scientific 
field or follow scientific insights? This `chicken or egg' debate has 
been part of parcel of issues at NIH since the creation of the National 
Cancer Institute. Since the tragedy of September 11, Congress has 
decided that it would make a sudden and dramatic infusion of resources 
into bioterrorism and anthrax (See Figure 4). At this point in time, it 
appears that the research community is responding to this national 
emergency by changing orientation if not careers into the field of 
bioterrorism. It would have been inadequate if Congress and NIH had 
merely told the research community that it was interested in receiving 
more proposals without showing a commitment of funds adequate to elicit 
the desired response by the scientific community.
    Clearly, the interest of the current leadership at the DHHS and the 
director of NIH and institute directors in obesity are sincere and 
highly welcomed. We also welcome and need input from the Center for 
Disease Control (CDC) and the U.S. Department of Agriculture. Our focus 
on NIH is because this is the major source of funds for biomedical 
research in the country.
    What is needed is a sense of urgency. If we do not immediately 
adopt a proactive posture to develop the scientific resources needed, 
the public and policy makers will continue to grope in the darkness for 
solutions to the tremendous human suffering caused by obesity. It is 
doubtful that the health care system has the capacity to respond to 
millions of new, younger cases of obesity and its co morbid conditions. 
A National Institute on Obesity will, by itself, not prevent or cure 
obesity. However, it is difficult to see scientifically valid 
prevention strategies, more effective therapeutic approaches and better 
understanding and education on obesity in the absence of such an 
entity.
    Mr. Chairman, thank you for this opportunity to testify and I am 
available to answer any questions.
                               footnotes
    \1\ World Health Report 2002, World Health Organization. [Internet] 
Available at www.who.int/wh/en
    \2\ Allison DB, Fontaine KR, Manson JE, Stevens J, VanItalie TB. 
Annual deaths attributable to obesity in the United States JAMA 1999 
Oct 27;282: 1530-8
    \3\ Downey M, Obesity as a Disease Entity Am Heart J 2001;142:1091-
4
    \4\ NCHS, CDC. Prevalence of overweight and obesity among adults: 
United States, 1999 [internet] Hyattsville (MD): NCHS (cited 2001 Oct 
31). Available from www.cdc.gov/nchs/products/pubs/hestats/obese/99.htm
    \5\ NCHS, CDC Prevalence of overweight among children and 
adolescents: United States, 1999 [Internet]. [Hyattsville (MD)):NCHS 
(cited 2001 Oct 31] Available from: www. cdc.gov/nchs/products/pubd/
hestats/over99fig1.htm.
    \6\ Koplan J, Fleming W, Current and Future Public Health 
Challenges. JAMA Oct. 4 2002;284:1696.
    \7\ Must A, Spadano J, Coakley EH et al. The disease burden 
associated with overweight and obesity JAMA. 1999;282:1523-1529.
    \8\ Weil, E, Wachterman M, McCarthy EP et al. Obesity among adults 
with disabling conditions. JAMA 2002; 288:1265-1268
    \9\ Puhl R, Brownell KD, Bias, discrimination, and obesity. Obesity 
Res. 2001 Dec; 9: 788-805.
    \10\ Crandall CD. Do heavy-weight students have more difficulty 
paying for college? Pers Soc Psych Bull 1991;17:608-11.
    \11\ Roehling M, Weight-based discrimination in employment: 
psychological and legal aspects. Personnel Psych 1999; 52:969-1016.
    \12\ Sturm R, Wells KB, Does obesity contribute as much to 
morbidity as poverty or smoking? Public Health 2001 May;115:229-35
    \13\ Bray GA.The underlying basis for obesity: relationship to 
cancer. J Nutr.2002; 132:3415S-55S
    \14\ Mann, JI Diet and risk of coronary heart disease and type 2 
diabetes. Lancet 2002;360:783-9.
    \15\ Kenchaiah S, Evans JC, Levy D et al. Obesity and the risk of 
heart failure. N Engl J Med 2002 Aug1;347:305-13.
    \16\ Colditz GA, Willett WC, Rotnitzky A, Manson JE. Weight gain as 
a risk factor for clinical diabetes mellius in women. Ann Intern Med. 
1995;122:481-6.
    \17\ Sowers M. Epidemiology of risk factors for osteoarthritis: 
systemic factors. Curr Opin Rheumatol.2001 Sep; 13:447-51.
    \18\ Young T, Peppard PE, Gotlieb DJ. Epidemiology of obstructive 
sleep apnea: a population health perspective. Am J Respir Crit Care Med 
2002 May 1;165(9):12-17-39.
    \19\ Ramsay JE, Ferrell WR, Crawford L, et al., Maternal obesity is 
associated with dysregulation of metabolic, vascular and inflammatory 
pathways. J Clin Endocrinol Metab 2002 Sept.;87(9):4231-7
    \20\ Kisteller JL, Hoerr RA, Physician attitudes toward managing 
obesity: differences among six specialty groups. Prev Med 1997 Jul-Au; 
26(4): 542-9.
    \21\ Downey, M, Insurance coverage for obesity treatments. Chapter: 
Evaluation and Management of Obesity, ed. Danieal H. Bessesen, 2002, 
Hanley & Belfus, Inc. Philadephia, PA.
    \22\ Strauss RS, Mir HM. Smoking and weight loss attempts in 
overweight and normal-weight adolescents. Int J Obes Relat Metab Disord 
2001 Sep;25(9): 1381-5
    \23\ Cleland, RL, Gross WC, Moss,LD, et al. Weight-Loss 
Advertising: An analysis of current trends, Federal Trade Commission 
Staff Report, 2002
    \24\ Santora, M. Teenagers' suit says McDonald's made them obese. 
New York Times, Metropolitan Dessk, Nov. 21, 2002
    \25\ Hayasaki,E. Schools to end soda sales. Los Angeles Times 
Aug.28, 2002.
    \26\ NIH, Setting Research Priorities. [Internet] Available at 
http://public-council.nih.gov/SettingResearchPriorities.htm
    \27\ Currently, several Institutes or Centers at NIH are involved 
in obesity research. These include the National Cancer Institute, the 
National Heart, Lung and Blood Institute, The National Institute on 
Aging, the National Institute of Child Health and Human Development, 
the National Institute of Mental Health, and the Office of Dietary 
Supplements. The lead institute is the National Institute of Diabetes, 
Digestive and Kidney Diseases (NIDDK). There are 27 Institutes or 
Centers at NIH. Within NIDDK, there are six divisions. In one division, 
one of its three branches houses the obesity program, together with 
eating disorders. In a strongly hierarchical organization such as NIH, 
obesity is on the lowest organizational rung.
    \28\ Collaborative approaches are need in DHHS between the Centers 
for Disease Control and Prevention, the Food and Drug Administration, 
the Centers for Medicare and Medicaid Services, the Indian Health 
Service and with other branches of the federal government such as the 
Department of Agriculture, the Department of Education, the Department 
of Defense and the Department of Veterans Affairs, all of which have 
roles to play in the prevention and treatment of obesity.
    \29\ Senate Appropriations Committee, Committee on Labor, Health 
and Human Services and Education, 1999 Report 106-166;78.
    \30\ Altman J, Weight in the Balance. Neuroendocrinology 
2002;76:131-136.
    \31\ Dubbert PM, Carithers T, Sumner AE, et al. Obesity, physical 
inactivity, and risk for cardiovascular disease. Am J Med Sci 2002 
Sep;324(3):116-26.



    Senator Specter. Thank you very much, Dr. Stern. I have 
quite a few questions. I will come back to you.
STATEMENT OF DR. NAOMI NEUFELD, PRESIDENT, FOUNDER AND 
            MEDICAL DIRECTOR OF KIDSHAPE, INC.; 
            PRESIDENT OF NEUFELD MEDICAL GROUP; 
            CLINICAL PROFESSOR OF PEDIATRICS, UCLA 
            SCHOOL OF MEDICINE
ACCOMPANIED BY:
        MS. DANIELLE BAILEY, LOS ANGELES
        MS. LEE IDA BOYD-BAILEY, LOS ANGELES
    Senator Specter. Our next witness is Dr. Naomi Neufeld, 
president, founder and medical director of KidShape, Inc., 
President of the Neufeld Medical Group, and a clinical 
professor of Pediatrics at the UCLA School of Medicine. She 
received her A.B. in biology and master's in medical science 
from Brown University, and an M.D. from Tufts University. Dr. 
Neufeld is accompanied by graduates of the KidShape program, 
Ms. Danielle Bailey, who is 6 years old, and her mother, Ms. 
Lee Ida Boyd-Bailey from Los Angeles. So welcome, Dr. Neufeld, 
and we have an extra chair for Ms. Lee Ida Boyd-Bailey.
    Dr. Neufeld. Good morning, Mr. Chairman. Thank you for the 
opportunity to discuss lifestyle modification and weight 
control for children and families. My name is Naomi Neufeld. I 
am a pediatric endocrinologist in practice in Los Angeles, and 
serve as the Medical Director of KidShape. I am here today with 
Ms. Christiane Rivard, our Program Director, and the Bailey 
family.
    The present epidemic of childhood obesity is much more 
serious than when I started KidShape in 1987 and it is 
associated with serious diseases and disabilities previously 
seen only in adults. This discussion is not just about obesity, 
but the burden of those associated diseases. We have found that 
the most effective way to deal with childhood obesity is a 
program that capitalizes on the strength of the family. 
KidShape is a family-based weight management program designed 
for overweight children ages 6 to 14. Families enroll for 8 
weekly 2-hour classes. A team of physicians, dieticians, and 
other medical professionals wrote the KidShape workbooks, which 
are published in English and Spanish.
    Each KidShape class includes interactive nutrition lessons 
designed for the entire family, discussion groups for parents 
and for students which meet separately, and on-site physical 
activity, where we teach families that physical activity can be 
fun. Families work together as teams.
    In 1997, the KidShape program was approved by Medi-Cal, our 
local Medicaid, to treat eligible children. By obtaining third 
party reimbursement, KidShape was able to expand and maintain 
20 community-based sites in Los Angeles, Orange and Ventura 
Counties. And last year we enrolled 1,285 families. 
Additionally, several KidShape sites are operating in Western 
Pennsylvania through Highmark Insurance, and Texas under 
licensing agreements. And we have received hundreds of requests 
to license our program throughout the country.
    The cost of treating a family in the KidShape program is 
$400 for the 8-week session. There are nearly 400,000 children 
in Los Angeles and Orange Counties alone who would qualify for 
KidShape. If we were to reach just 10 percent of these children 
and their families, the cost would be $15 million, or less than 
$1 per person.
    Since Type 2 diabetes developing in a person before the age 
of 20 costs an estimated $7.1 million in lifetime expenses, the 
impact of such a program is considerable.
    The KidShape program works. Eighty-seven percent of 
children lose weight during the 8-week program, 87 percent of 
children keep their weight off for 2\1/2\ years. We see changes 
in diet, exercise, and personal habits which contribute to 
weight loss.
    However, this is not just about weight. Many children with 
severe obesity already have evidence of coronary artery 
disease, and some as young as 10 have already developed Type 2 
diabetes. They show remarkable changes in blood pressure, blood 
lipids and insulin sensitivity, which leads to a reduction in 
diabetes in a period as short as 6 weeks.
    This program not only improves lives, but also saves money. 
Juan V. was a 7-year-old boy who weighed 179 pounds, suffered 
from asthma and had hospital bills of $15,000 per year. He and 
his family enrolled in KidShape and he lost nearly 40 pounds. 
He no longer has recurrent asthma attacks, and his annual 
medical bills are now less than $400.
    There is even more to this story. Juan's mother, at age 38, 
suffered from both diabetes and hypertension. She lost 25 
pounds on the KidShape program. She no longer has high blood 
pressure, and her doctor is taking her off diabetes medication.

                           prepared statement

    Over 40 percent of parents of KidShape participants are 
overweight themselves, and many suffer from diseases directly 
related to obesity. Family-based weight management programs are 
not only effective for the child, but may be even more 
important as a means of reaching the hard-to-treat, resistant 
adult population. I would like to turn this over to Danielle.
    [The statement follows:]
                 Prepared Statement of Naomi D. Neufeld
                              introduction
    Senator Specter, Members of the Committee and honored guests. Thank 
you for the opportunity to discuss lifestyle modification and weight 
control for children and families. My name is Naomi Neufeld. I am a 
Pediatric Endocrinologist in practice in Los Angeles, and serve as the 
medical director of KidShape. I am here today with Mrs. Christiane 
Wert Rivard, KidShape Program Director and the Bailey Family, recent 
KidShape graduates. The present epidemic of childhood obesity is much 
more severe than when I started KidShape in 1987, and is associated 
with serious diseases and disabilities, previously seen only in adults. 
This discussion is not just about obesity, but about the burden of 
associated diseases; it is not just about the burdens of disease on 
patients and their families, but also the burden on a Medi-Caid system 
which is stretched to capacity.
    We have found that the most effective way to deal with obesity in 
childhood is in a program that capitalizes on the strength of the 
family unit.
                              description
    KidShape is a family-based weight management program designed for 
overweight children ages six to fourteen years old. Families enroll in 
8 weekly two-hour classes. A team of physicians, dietitians, social 
workers and psychologists wrote the KidShape workbooks, which are 
published in English and Spanish.
    Each KidShape class includes interactive nutrition lessons, 
designed for the entire family, discussion groups for parents and for 
students which meet separately, and on-site physical activity, where we 
teach families that physical activity can be fun. Families work 
together as teams.
                              availability
    In 1997, the Kid Shape program was approved by Medi-CAL to treat 
eligible children, and to bill in accordance with the EPSDT (Early and 
Periodic Screening, Diagnostic and Treatment) Program. By obtaining 
third party reimbursement, KidShape was able to expand and maintain 20 
community-based sites in Los Angeles, Orange and Ventura counties. Last 
year we enrolled 1285 children. Additionally, several KidShape sites 
are operating in western Pennsylvania and Texas under licensing 
agreements. We have received hundreds of requests from health care 
providers, schools and health insurance companies to license our 
program around the country.
    To meet the demands of our clients, KidShape Foundation has 
expanded its program activities to reach children of all ages.
                                 costs
    The cost of treating a family in the KidShape program is $400 for 
the 8-week session. It is disheartening that despite the growing 
epidemic of obesity, we received less than 20 percent of authorized 
payments from Medi-CAL and other third-party payers last year; leaving 
a significant shortfall to be covered by grants and private donations. 
We have been successful in our goals and would like to extend the 
services of the program, but the present method of financing is a 
barrier.
                                outcomes
    The KidShape program works! 87 percent of participants lose weight 
within the 8-week program. 80 percent of children keep their weight off 
up to 2\1/2\ years after the program. Additionally, we see changes in 
diet, exercise and personal habits, which contribute to weight loss.
    However, it is not just about weight. Many children with severe 
obesity already demonstrate significant coronary artery disease, and 
some as young as 10 have already developed type 2 diabetes. They show 
remarkable changes in blood pressure, blood lipids and insulin 
sensitivity-which leads to a reduction in the risk of diabetes, in a 
period as short as 6 weeks.
    Here is an example of how this program not only improves lives, but 
also saves money. Juan V was a 7-year-old boy who weighed 179 lbs, 
suffered from asthma and had hospital bills of $15,000/yr. He and his 
family enrolled in KidShape, and he lost nearly 40 lb. He no longer has 
recurrent asthma attacks, and his annual medical bills are now less 
than $400.
    But there is even more to this story. Juan's mother, at age 38 
suffered from both diabetes and hypertension. She lost 25 lbs. during 
the KidShape program. She no longer requires her blood pressure 
medicine; and her doctor is considering taking her off diabetes 
medication.
    Over 40 percent of parents of KidShape participants are overweight 
themselves, and many suffer from diseases directly related to obesity. 
Family based weight management programs are not only effective for the 
child, but may even be more important as a means for reaching the hard 
to treat, resistant adult population
                               conclusion
    I applaud your committee for addressing the most important public 
health issue to face this generation. Lifestyle changes result in a 
wise use of healthcare dollars for conditions that affect up to 40 
percent of our children and nearly 70 percent of all adults; they 
reduce the burden of disease and can be cost-effective. The cost of 
such a program is relatively small compared to long-term direct and 
indirect benefits-personal, medical and financial. Thank you.
                        KidShape Program Summary
    KidShape is a non-profit community and family-based weight 
management program, which offers two effective family-based pediatric 
weight management programs throughout Southern California, including: 
(1) KidShape, serving families with children ages six to fourteen; and 
(2) KinderShape, serving families with children ages three to five. 
Each program is taught by a team of health care professionals, 
including: a registered dietitian, a mental health professional, a 
physical activity instructor and a health educator. The goal of both 
KidShape Foundation programs is to promote healthy lifestyles for 
entire families with overweight children, focusing on healthy eating, 
increased physical activity, and an appreciation for oneself regardless 
of physical size.
    Developed in 1987 by Naomi Neufeld, MD, pediatric endocrinologist, 
KidShape (the first program developed by the KidShape Foundation) 
originated out of a desperate need for effective prevention and 
treatment of childhood obesity. KidShape empowers families to make 
healthier lifestyle choices for their families and themselves. Since 
its inception, KidShape has provided services to thousands of 
families--demonstrating to each family the importance of healthy eating 
and physically active lifestyles.
    The KidShape program utilizes a curriculum based on structured 
diet, exercise participation, parent support and behavior modification. 
It was designed to respond to the needs of the multi-cultural community 
in Southern California (CA), and has been available to low-income, 
primarily minority families, many of whom are at risk for Type 2 
Diabetes. The KidShape curriculum is divided into two 4-week modules; 
each family attends a minimum of eight consecutive two-hour weekly 
culturally relevant classes. Each KidShape class is divided into three 
components, including: nutrition (where families participate in hands-
on nutrition activities designed to promote an understanding of healthy 
eating), discussion groups (Parents and students meet separately; 
parents discuss many topics including parenting skills; students 
discuss body image and self-esteem; this component facilitates health 
behavior changes, leading families to eating healthier and becoming 
more physically active.), and on-site physical activity (kids are shown 
that physical activity can be fun!; focuses on skill building and self-
efficacy and not on competitiveness). Parent participation is required 
in the program. KidShape's most significant accomplishment is its 
proven track record in helping children and their ENITRE families 
improve lifestyle habits, which leads to weight loss and improved self-
esteem, as well as decreasing the risk factors associated with Type 2 
diabetes and other debilitating diseases.
    As reported in the Los Angeles Times in December 1997, KidShape is 
the only program in Southern CA offering effective family-based weight 
management services to all families regardless of their insurance 
status or their ability to pay for the program. Until 1997, KidShape 
had only one program site operating in Southern CA, located in West Los 
Angeles, and enrolled families from over a 70-mile radius from that 
site. Today KidShape operates 18 community-based sites throughout Los 
Angeles, Orange and Ventura counties in Southern CA. In addition 
several sites are operating in Western Pennsylvania and Texas under 
licensing agreements with KidShape. KidShape Foundation is also 
expanded its program activities. Currently the KinderShape program is 
being implemented in Orange County, CA and will be expanding to 
Northern California and throughout the County of Riverside, CA, through 
additional licensure agreements. KidShape Foundation is currently 
developing a program for overweight 13-18 year olds, TeenShape.
 early and periodic screening, diagnosis, and treatment program (epsdt)
    EPSDT is designed to improve primary health benefits for children 
with emphasis on preventive care that has been a part of the federal 
Medicaid program since its beginning in the late sixties. After a 
Medicaid review in 1989, Congress moved to increase the services of 
EPSDT through the Omnibus Budget Reconciliation Act. States must now 
cover regular and periodic exams for all eligible children under the 
age of 21. They must also provide any medically necessary services 
prescribed by the exams, even those not covered in a state's Medicaid 
plan. This includes many assistive devices and services for individuals 
that are under 21 which have been excluded under the regular Medicaid 
program in the past.
    The Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) 
service is Medicaid's comprehensive and preventive child health program 
for individuals under the age of 21. EPSDT was defined by law as part 
of the Omnibus Budget Reconciliation Act of 1989 (OBRA 89) legislation 
and includes periodic screening, vision, dental, and hearing services. 
In addition, section 1905(r)(5) of the Social Security Act (the Act) 
requires that any medically necessary health care service listed at 
section 1905(a) of the Act be provided to an EPSDT recipient even if 
the service is not available under the State's Medicaid plan to the 
rest of the Medicaid population.

                  SUMMARY STATEMENT OF DANIELLE BAILEY

    Ms. Bailey. My name is Danielle Bailey and I am 6 years 
old. Before I went to KidShape, kids used to call me ``fat 
girl.'' KidShape helped me change my eating habits, lose 
weight, and not be a fat adult. I like going to KidShape and 
learning about the food portion size, reading the labels, 
talking to Dr. Beth, and making healthier food choices.
    Senator Specter. Ms. Boyd-Bailey, would you care to add 
something to this?

                           prepared statement

    Ms. Boyd-Bailey. No. I just had a good time going to 
KidShape. She encouraged me to go, ``Mom, I want to go, I want 
to go,'' so we went. I lost weight, she lost weight, she has 
kept me eating healthy. She keeps me--``Danielle, do you want 
to go to McDonald's?'' ``Mom, that is not healthy.''
    [The statement follows:]
               Prepared Statement of Lee Ida Boyd-Bailey
    My daughter and I were both ``overweight'' and I was not sure how 
to teach a 6-year-old how to lose weight without using the word diet. 
That's when we met Dr. Neufeld and found out about the Kidshape 
program. I thought that the program would be ``over my daughters 
head'', but we went anyway and she absorbed the information like a 
sponge.
    She enjoyed every aspect of the program: reading the nutrition 
facts, the exercise program, talking with Dr. Beth, keeping a food 
journal, learning to eat healthier meals and snacks and learning what a 
real serving is.
    Kishape has not only effected me and my family, but family members, 
friends, even my co-workers. They have seen how easy it was for 
Danielle and I to change our eating habits and they have integrated 
some of the eating habit into there lives.
    Danielle and I are much happier and slimmer since attending 
Kidshape. She tells everyone she meet what a wonderful program it is 
and that they should call Kidshape to help their child eat healthier, 
lose weight and not be a big overweight adult who can't fit through a 
door. (I don't have to say a word).

    Senator Specter. So you are just a couple of kids from 
KidShape. We will come back to you for some questions.
STATEMENT OF DR. ADAM DREWNOWSKI, DIRECTOR, CENTER FOR 
            PUBLIC HEALTH NUTRITION, UNIVERSITY OF 
            WASHINGTON; MEMBER, FRED HUTCHINSON CANCER 
            RESEARCH CENTER, SEATTLE, WA
    Senator Specter. Our next witness is Dr. Adam Drewnowski, 
director of the Center for Public Health Nutrition at the 
University of Washington and a Member of the Fred Hutchinson 
Cancer Research Center in Seattle. He has his master's degree 
in biochemistry from Oxford University and a Ph.D. in 
psychology from Rockefeller University. Thank you for joining 
us, Dr. Drewnowski. The floor is yours.
    Dr. Drewnowski. Thank you, Mr. Chairman. It is a privilege 
to be here. Thank you for the opportunity to make these brief 
remarks. I will limit myself to just three points. The first 
one is this. It underscores what has been said here today, that 
obesity represents a huge societal and public health problem. 
It is a debilitating condition. It is linked to other chronic 
diseases. It increases the cost of medical care and can damage 
the quality of life beyond repair. We all know this. The 
Centers for Disease Control has done an absolutely phenomenal 
job in making sure the obesity epidemic is addressed at State, 
local and community levels.
    The word ``community'' brings me to my second point. It is 
less appreciated that the obesity epidemic is really rooted in 
the poorest neighborhoods. The highest rates of obesity and 
diabetes are found among groups with the lowest education and 
least income. The California Center for Public Health Advocacy 
has analyzed data from the California Department of Education 
Fitness grant and these are here. They make the point much more 
eloquently than I could. They show that obesity rates in the 
Bay Area are highest in Oakland, northern Palo Alto and that 
among the districts with highest proportion of unfit and 
overweight kids, ten of them are in Los Angeles County.
    That underscores the point that obesity really is a major 
issue for people with the least resources, least income, least 
education. It really is a socioeconomic issue. And my 
suggestion here is that the socioeconomic aspects of the 
obesity epidemic deserve much more research attention. 
Disadvantaged communities have much fewer options when it comes 
to changing lifestyle, eating healthier diets, or exercising 
more.
    At this time, there are very limited data on how education 
and incomes can affect diet quality and the economics of food 
choice. We need more research to provide the research base for 
fiscal and food policies, including food assistance programs. 
Food assistance programs have recently been criticized in the 
Washington Post for their alleged role in fattening the poor. 
And I am sorry to say there is something to that because the 
unfortunate fact is that healthier diets cost more. It is very 
difficult to eat a healthy diet if you have fewer resources.
    I just want to tell you that the price of added sugar and 
added fat in our diet is extremely low. You can get 20,000 
calories per dollar from sugar. Nutritionists equate 3,500 
calories to a pound of body weight, so the cost of gaining 
several pounds of body weight is under a dollar. And this is 
why our diet is largely composed of added sugars and added 
fats, not natural sugars in vegetables and fruit, but added 
sugars; not natural fats in dairy products and meat, but added 
fats. There is nothing cheaper.
    It is very difficult to satisfy the economic constraints, 
provide people with healthier diets, and address the obesity 
epidemic. It really is a social issue. So we do have some data 
on the determinants of food choice. We really ought to have 
more.
    Then, my final point is how the various efforts by the CDC 
can be addressed at the local level. The CDC has immense 
responsibilities and coordination at the local level is 
critical. And here we have a number of centers that have been 
springing up which specifically deal with the obesity epidemic 
looking at policy, societal and community issues. We have a new 
center at the University of Washington established with vitamin 
antitrust settlement monies, secured for us by our Attorney 
General, Christine Gregoire. There is a center at Berkeley 
called the Center for Weight and Health that we propose to 
partner with. The Berkeley Center organizes the California 
Childhood Obesity Conference. There is a colleague of mine here 
representing a center at Oakland. And these centers really 
ought to be brought into the CDC structure.
    So I propose expanding the PRC network that CDC already 
has, 28 centers affiliated with schools of public health, to 
include additional centers specifically addressing obesity. And 
those would parallel NIH centers for obesity nutrition research 
which deal with the metabolic, physiological and medical 
aspects of obesity. We really need to address obesity from the 
public health standpoint, and expanding the CDC centers would 
be one way to do it.

                           prepared statement

    As part of our Center, we have recently launched a small 
grant campaign for healthy youth, and there was a huge 
grassroots demand, which will remain unmet. We got 50 letters 
of intent for projects totalling $1.5 million. We have $100,000 
to give out. There was a huge, huge interest. And projects like 
this really ought to be funded by the CDC, and we stand ready 
to work with the CDC on this topic. Thank you.
    [The statement follows:]
               Prepared Statement of Dr. Adam Drewnowski
    Mr. Chairman, it is a privilege to appear before the Subcommittee 
and I thank you for giving me the opportunity to make these brief 
remarks.
    My name is Adam Drewnowski. I am Director of the new Center for 
Public Health Nutrition at the University of Washington. I am Professor 
of Epidemiology and Medicine and Director of the Nutritional Sciences 
Program at the School of Public Health and Community Medicine in 
Seattle, Washington.
    My testimony concerns the national obesity epidemic--and the 
strategies for improving nutrition and health at the neighborhood and 
community level. National data indicate that two out of three U.S. 
adults are overweight, and that almost one in three is obese. It is 
shocking to note that 15 percent of American children and adolescents 
(ages 6-19y) are overweight; this is three times the number we saw in 
1980.
    It is sometimes less appreciated that the obesity epidemic is 
rooted in the poorest neighborhoods. The highest rates of obesity and 
diabetes occur in groups with the highest poverty rates and the least 
education. To understand the extent of the obesity epidemic among 
California's children, the California Center for Public Health Advocacy 
analyzed the percentage of children in each Assembly District who were 
overweight or unfit. Data analyses were based on the California's 
Department of Education 2001 FITNESSGRAM test. In 1995, California 
mandated statewide physical performance testing for all fifth, seventh, 
and ninth graders at least every two years.
    Across all Districts statewide, not just 15 percent--but 34 percent 
of Latino children were overweight and 45 percent were unfit. Twenty-
nine percent of African-American children were overweight and 46 
percent were unfit. Of the 16 California Assembly Districts with the 
highest proportion of overweight children, 10 were in Los Angeles 
County. Clearly, obesity represents not only a medical issue but a huge 
societal and public health problem--and one that is tied to economic 
resources, education, and income.
    The upper-income groups are by no means spared. Studies by Dr. 
Roland Sturm, a prominent health economist at the RAND Corporation in 
Santa Monica show that obesity rates are increasing evenly across the 
board--across all education and income levels. There are suggestions 
that education, rather than income, can offer some degree of 
protection. This is an argument for supporting education in general and 
nutrition education in particular as the key tools in our battle 
against obesity.
    Rates of extreme obesity among adults are exploding. Dr. Sturm 
found that obesity rates--defined as weight in excess of 175 lb for a 
woman 54" (body mass index = 30)--have doubled over the past two 
decades. During that time, rates of massive obesity (>235 lb or BMI = 
40) have quadrupled. We are not just becoming obese--we are becoming 
gigantic. Massive obesity is linked to well-documented--and costly--
health problems.
                          poverty and obesity
    Socioeconomic aspects of the obesity epidemic deserve more research 
attention. As the CDC and other agencies develop prevention strategies, 
we need to address problems faced by minorities and the poor. 
Disadvantaged communities have more limited options when it comes to 
better nutrition, fitness, and the adoption of healthier lifestyles. 
There are limited data at this point on whether and how incomes, 
education and ethnicity affect diets and fitness, to say nothing of the 
issue of food pricing and the economics of food choice.
    More research effort in this area is badly needed to provide 
evidence base for fiscal and food policies, including food assistance 
programs.
    More research is needed on the economics of food choice, food 
prices, and overall diet costs. Consumer decisions about what to eat, 
where to eat, when to eat, and how much to eat are influenced by 
economic resources and by the environment in which the choices are 
made. People also make tradeoffs between immediate satisfaction and the 
future promise of better health. We need to pay more attention to 
societal influences on eating habits and their contribution to the 
obesity epidemic. Some of the budget for primary prevention activities 
at the CDC could be devoted to social disparities and their impact on 
diet quality, nutritional status and body weight.
                    coordination at the local level
    On behalf of the Public Health community, I want to say how much we 
appreciate the very substantial efforts that the CDC has been making to 
stem the obesity epidemic nationwide. We applaud the proposed increase 
in funding for the Nutrition and Physical Activity initiative and for 
other CDC-led prevention activities.
    The CDC has immense responsibilities. It is now charged with 
monitoring health and health behaviors at the national level, 
coordinating national, state and school-based programs for health 
promotion, developing evaluation, planning, and policy documents, media 
campaigns and other initiatives and programs.
    These tasks are critical to the nation's health. Please allow me to 
suggest some ways in which CDC activities can be implemented at State 
and local levels. The issue before us is finding the best ways in which 
existing funds can be deployed to maximum effect. In the 2003 Senate 
Bill, the Committee noted that coordination at the local level was 
critical to ensure that CDC resources were used to their optimum 
potential and to avoid duplication. The CDC was asked to urge its 
grantees to establish state-level positions to oversee nutrition and 
physical activity programs.
                 obesity prevention in washington state
    I am pleased to say that, consistent with Congressional guidelines, 
Washington State did establish a Physical Activity and Nutrition 
Section within the State Department of Health. The PAN section was 
charged with overseeing the CDC-funded plan for preventing obesity in 
the State. In 2001, Washington State was one of 12 states to receive 
CDC funding ($726,517) for state-based nutrition and physical activity 
programs to prevent chronic diseases, including obesity. The State 
convened a diverse group of individuals with expertise in education, 
transportation, planning, nutrition, physical activity, agriculture, 
parks and recreation, and health care to develop an action plan to: (1) 
slow the increase in the proportion of adults who are obese; (2) reduce 
rates of chronic diseases that are associated with obesity; and (3) 
improve quality of life. The State Plan is being piloted in Moses Lake, 
a small community in Eastern Washington. California was another state 
that received CDC funding for such work.
    I believe that state and local government agencies are most 
effective when working together with academic institutions and 
community groups. Our Center for Public Health Nutrition was created 
last year by the University of Washington, thanks to a financial 
settlement in a global vitamin price-fixing case. Our mission is to 
advance and promote public health strategies to improve nutrition and 
health of Washington State residents.
    We believe that partnerships and alliances at the local level are 
the key. To carry out our mission, we formed strong partnerships with 
government agencies, including the State Health Department and the 
local health authority, Public Health Seattle & King County. We will 
support Washington State Department of Health in their application for 
a CDC Comprehensive Grant for obesity prevention. We are also working 
with Seattle Public Schools on environmental approaches to obesity 
prevention in schools, a project funded by the National Institutes of 
Health.
    We have also reached out to the community. Using settlement funds, 
we are able to sponsor a small program of grants for healthy youth, 
destined for community based projects. The grassroots demand for such 
programs is overwhelming--and unmet. We received 50 letters of intent 
from school districts, community groups and other organizations for a 
number of worthwhile projects--for a sum total of $1.5 million. Our 
limited funds will allow us to meet one tenth of the demand. However, 
any solution to the obesity epidemic needs to come from the community, 
and we view such projects as a valuable contribution to capacity 
building at State, local and community levels.
                        public-private alliances
    We are encouraged by the fact that we are not alone. There are 
other academic-based Centers on the West Coast that focus specifically 
on obesity prevention through lifestyle modification and structural and 
policy change. I want to mention specifically the Center for Weight and 
Health affiliated with the University of California at Berkeley that 
partners with California State agencies in running the biennial--and 
hugely successful--Childhood Obesity Conference. The Berkeley Center is 
the recipient of another NIH grant on schools nutrition and is engaged 
in numerous community projects.
    Our Center for Public Health Nutrition and the Center at Berkeley 
share a number of common features. Both are University-affiliated and 
both partner with State and local agencies. Both include a policy 
component and community-based work. We are also reaching out to 
foundations and private industry to support some of our efforts.
    I want to make a case for engaging academic institutions, 
particularly Schools of Public Health, in helping to coordinate CDC-led 
obesity prevention efforts at the local level. Schools of Public Health 
have expertise in the design and evaluation of health-related policies 
and programs and can help build state capacity in this area. Schools of 
Public Health train health professionals needed to address the obesity 
issue. Schools of Public Health are also engaged in the local community 
by taking the lead on many community based studies. Another way that 
Schools of Public Health can help tackle the obesity problem is through 
our HRSA-funded training centers for public health professionals that 
allow us to reach out and work with local and state health departments. 
Our School of Public Health serves the entire northwest region--the 
states of Alaska, Washington, Wyoming, Montana and Idaho.
    My suggestion is to build up the existing CDC-based infrastructure. 
Both University of Washington and UC Berkeley host Health Promotion 
Research Centers, 2 out of 28 academic research centers funded by the 
CDC. Their mission is to improve health by conducting high-quality 
prevention research that can be incorporated into community practice. 
It would be my suggestion to expand the network of PRCs to include some 
new Centers specifically devoted to obesity prevention.
    The obesity epidemic cuts across disciplines and involves a 
societal and policy component. The Center for Public Health Nutrition 
and the Berkeley Center could be used as models for other Centers 
throughout the US. Their mission and goal would be to address the 
obesity epidemic from the public health and public policy perspective. 
Such Centers would promote interactions between academia, local and 
state government agencies, policy makers and local communities. 
Providing support for such Centers would ensure that CDC funds are 
optimally used at the local level.
    To reiterate--the obesity epidemic is a huge public health problem 
that needs to be addressed using public health approaches. We are 
willing to work with the CDC to implement obesity prevention strategies 
and programs at the local level.
    Thank you for the opportunity to make these remarks.
    I would be pleased to answer any questions that you may have.

    Senator Specter. Thank you very much, Dr. Drewnowski. We 
will come back for questioning in just a few minutes.
STATEMENT OF LESLIE MIKKELSEN, MANAGING DIRECTOR, 
            PREVENTION INSTITUTE
    Senator Specter. Our final witness is Ms. Leslie Mikkelsen, 
Managing Director of The Prevention Institute. She develops new 
programs and strategies to place prevention in the center of 
efforts to improve community health and well-being. She 
received her Master of Public Health degree from the University 
of California at Berkeley. Welcome, Ms. Mikkelsen. The floor is 
yours.
    Ms. Mikkelsen. Thank you, Chairman Specter. I really, too, 
appreciate the opportunity to be here today. I was particularly 
enthused to read your committee report that recommended not 
only increased funding, but really focused on prevention. I 
think it is critically important that we take a prevention 
approach.
    I am going to focus my remarks today on the need for 
environmental and policy approaches to really support healthy 
eating and activity at the community level. My own commitment 
to this approach really comes from my experience being a 
nutritionist. I worked for the New York City Food Bank, and 
then here across the Bay in Alameda County. And I will never 
forget a particular nutrition education class. It was very 
successful. And then lunch came, and it was a Polish hot dog, 
microwaved, potato chips, Hostess cupcakes, and Kool-Aid--
clearly, not the foods we were discussing as an ideal 
nutritious meal. What might seem shocking, you know, is this 
was a community agency and they had wanted a nutrition class. 
Why did they serve this lunch?
    Senator Specter. Where was this served?
    Ms. Mikkelsen. This was actually in Oakland.
    Senator Specter. Where?
    Ms. Mikkelsen. In Oakland. I will not name the group, but 
it was a small community organization that worked with women 
that were recovering from substance abuse and who had young 
children. My point with this is that that organization had 
limited resources. They had no kitchen. They were dependent on 
donations. And what I realized with that class was that the 
women who I was working with, who were also very low income, 
were going to face similar challenges when they went out into 
their neighborhoods. What they were going to feed their family 
was not only going to come from the information I had given 
them, but it was going to come from what was affordable and 
accessible and marketed to them.
    But I would say that the issue of the environment is not 
limited to people with low incomes. I think we all face 
challenges in accessing healthy food and activity at certain 
times, and that we are all influenced by the surrounding 
environment, and that this issue applies to physical activity 
as well as to nutrition. There are well-demonstrated links 
between environmental factors and physical activity levels. For 
example, people are far more likely to walk if they live in a 
mixed-use neighborhood where there is both commercial and 
residential close together. They are also more likely to be 
active if there are more parks in their neighborhood. Concerns 
about speeding cars and violence are keeping our seniors from 
being out on the streets and getting their daily activity. 
Likewise, parents are often afraid to let their children play 
on the streets. These are serious neighborhood issues that keep 
people from being active.
    Our eating patterns are also influenced by the environment 
around us. I find often in my trips from Oakland to Sacramento, 
where I go a lot, that if I walk into a convenience store, it 
is very hard to find a snack that is not high-fat or high-
sugar. My options are very limited. And I think we need to face 
that, in our schools, and workplaces, and convenience stores, 
high-fat and high-sugar foods are often the norm, and I think 
that they have become the norm in part by the billions spent on 
advertising. We mentioned earlier that these companies know a 
lot about how to sell their products. Personally, as a 
nutritionist, I find it very disturbing when I see an ad on TV 
that is promoting a very high-sugar cereal, and it implies that 
it is a good way to start the day. Many of these ads are 
targeted specifically to children, and I think it sets up a 
very difficult situation when a parent who is trying to do well 
by their children goes to the supermarket, and these products 
are at eye-level, they contain a toy, and their children are 
demanding them.
    I think that these are the kind of environmental issues we 
need to start thinking about what we are going to do if we 
really want to support a major change in the eating and 
activity patterns in our country.
    For these kinds of reasons, we have joined together in 
California to create a new network called the Strategic 
Alliance for Healthy Food and Activity Environments which is 
really working to make sure that, along with good educational 
programs, we have efforts to promote environmental change. And 
I will just very briefly name a couple of things we have been 
working on. One is we have been working across the State in 
many school districts to look at the quality of the food and to 
try to get out the soda and the high-fat snacks, and really 
bring in healthy options. We have also been looking at this 
issue of creating community environments that support physical 
activity, and there are some really measured steps communities 
can take, like design that encourages bicycling and walking. 
And another area that I think is very important is that 
government institutions have a great opportunity to be a model 
for healthy practices. For example, you may have been in the 
Health and Human Services Building in Rockville, Maryland, that 
has a farm stand in the lobby. These are the kinds of things 
that we can be doing and really change the environment so that 
it is easy for people to make a healthy choice.
    Senator Specter. What do they have in their lobby?

                           prepared statement

    Ms. Mikkelsen. They have a farm stand, so that when you 
walk in, there are fresh fruits and vegetables from their local 
community. Thank you.
    [The statement follows:]
                 Prepared Statement of Leslie Mikkelsen
    My name is Leslie Mikkelsen. I am Managing Director of Prevention 
Institute. I would like to thank you for the opportunity to be part of 
this very important hearing to address a serious and growing health 
problem in the United States.
    I am very enthusiastic that The Committee on Appropriations has 
recognized the gravity of this public health crisis and recommended 
significant funding to increase physical activity, improve nutrition, 
and reduce the prevalence of obesity and overweight.
    I would like to share with you my perspective, gained through my 
work as a nutritionist and public health practitioner, on effective 
measures necessary to turn around the frightening statistics. There are 
numerous factors which influence individual food and activity choices. 
Changing the overall pattern of these choices requires a multi-faceted 
approach that addresses not only individual knowledge, motivation, and 
skills, but also ensures the surrounding environment supports healthy 
behaviors.
    This point was driven home for me in my work as the nutritionist 
for the food banks of New York City and Alameda County. An important 
lesson for me in this work occurred after I had led a particularly 
successful nutrition education session with mothers of young children, 
sponsored by a local community agency. The group was enthusiastic and 
quite interested in practical guidance about how best to nourish their 
children. Then lunch arrived. It consisted of a microwaved ``Polish'' 
hot dog, potato chips, cup cakes, and a fruit drink. At that moment, it 
was clear to me why education was only one element of the strategy to 
change the dietary habits of these families.
    It might seem shocking that a community organization interested in 
nutrition would serve this lunch, but they were a small organization, 
without a kitchen and dependent on donations. The women who had 
participated in this class were operating with the same limited 
resources as this organization, and their ability to provide nutritious 
foods to their family was limited by what was accessible and affordable 
in their communities. This effect of the environment is not limited to 
low-income families, as I will discuss later on.
    This experience highlighted why environmental changes are an 
important aspect of the strategies to achieve behavior change. It is 
important to recognize that people are not making decisions about what 
to eat and when to be active in a vacuum. Therefore it is important 
that public policy and health promotion efforts support the creation of 
an environment that makes healthy choices easy.
    Turning around the obesity epidemic requires attention to this 
community environment along with attention to individual behavior 
change and provision of primary care. As noted in the Committee report, 
a population-based primary prevention strategy needs to include policy 
and environmental interventions.
    A useful framework for visualizing this strategy is the Spectrum of 
Prevention, a public health planning tool that identifies six levels of 
action to achieve behavior change. This tool has been applied to major 
health concerns ranging from tobacco control to traffic safety, 
violence prevention, nutrition, and physical activity. It emphasizes 
the importance of including systems changes along with individual 
behavior change and community education.
  --Influencing Policy Legislation.--Developing strategies to change 
        laws and policies
  --Changing Organizational Practices.--Adopting regulations and 
        shaping norms
  --Fostering Coalitions and Networks.--Convening groups and 
        individuals for greater impact
  --Educating Providers.--Informing providers who influence others
  --Promoting Community Education.--Reaching groups with information 
        and resources
  --Strengthening Individual Knowledge and Skills.--Enhancing 
        individual capacity
    It was the recognition of the need for environmental changes to go 
hand-in-hand with individual behavior change efforts that led 
Prevention Institute to join with other prominent public health 
organizations to found the Strategic Alliance for Healthy Food and 
Activity Environments. We also work in partnership with the National 
Alliance for Nutrition and Activity.
    Unfortunately, in many California communities, high-fat and high-
sugar foods and the marketing that promotes them have a prominent place 
in our schools and neighborhoods, and are frequently the lowest-cost 
options. Physical activity has been engineered out of our lives as 
community design favors transportation by car over walking and biking, 
and many parents are afraid to let their children play outside. While 
meeting physical activity goals is frequently visualized as engaging in 
scheduled exercise, it is frequently easier to increase activity by 
incorporating it through one's daily life.
    The limited availability of healthy options is even more pronounced 
in low-income neighborhoods, where families must prioritize basic 
needs. Unfortunately, healthy behaviors are often viewed as a luxury; 
the survival mechanisms used to combat poor food access and unsafe 
neighborhoods (i.e., consuming high-fat, fast foods, and staying 
indoors rather than playing on the streets) establish patterns that put 
children at risk for developing chronic disease.
    The Alliance has identified five key sectors where we believe joint 
action is needed to alter current eating and activity patterns and 
shift the environment towards supporting healthy behaviors. These 
include children's environments, government, industry practices, the 
health care system, and the media. A complete description of this 
approach is attached.
    Today, I would like to highlight some of our areas of focus which 
are being implemented in communities across the country. I urge you to 
work to implement similar policies nationally. Some of the most 
promising approaches include:
(1) Implementing Nutrition Standards for all Foods Sold in School, Pre-
        school, and After School Programs
    A key tenet of effective behavior change is to model and reinforce 
healthy behaviors. Unfortunately, schools frequently provide easy 
access to soft drinks, high fat snack foods, and dessert through 
vending machines and a la carte lines. Brand name fast food is even 
available in some high schools.
    As public institutions dedicated to children's learning, schools 
should serve as a model for healthy practices rather than a conduit for 
unhealthy habits. These should apply to all institutions serving 
children from pre-school, school, and after school programs.
    The Alliance was involved in securing the passage of Senate Bill 19 
which establishes nutritional standards for foods sold outside the 
National School Breakfast and Lunch programs in elementary schools and 
middle schools. We are currently helping to ensure adequate technical 
assistance and evaluation of pilot projects taking place before the 
bill takes effect. At the same time, members have been involved in the 
passage of local school district measures to remove soda and in some 
cases junk food from all schools. There is great interest in this 
approach around the country, and we have heard from localities in 
states as diverse as Alaska, Hawaii, New York, and Pennsylvania that 
are moving towards similar restrictions. Where changes have been made, 
preliminary results are positive, with sales of water, 100 percent 
juice, and healthier snack choices yielding revenues equal or greater 
than those previous.
(2) Cultivating Active Community Environments
    There are well-demonstrated links between community design and 
physical activity levels. Current land use trends have tended to 
increase automobile dependency and make walking and biking less 
practical, less convenient, less safe and less pleasant.\1\ From 1960-
1990, the percentage of workers with jobs outside their counties of 
residence tripled.\2\ During the same period, vehicle miles traveled 
rose dramatically while walking declined.\3\ Mixed land use increases 
the number and percentage of walking and biking trips, generating up to 
four times as many walk trips for trips less than one mile.\4\ Access 
to neighborhood parks nearly doubled the likelihood that U.S. adults 
were physically active compared to those without access to parks. 
Concerns about neighborhood safety have been associated with lower 
activity rates among older adults.\5\
---------------------------------------------------------------------------
    \1\ A Primer on Active Living by Design. Active Living By Design 
Program. The Robert Wood Johnson Foundation. 
www.activelivingbydesign.org
    \2\ BTS Journey to Work trends, 2001; National Transportation 
Statistics Report 1999.
    \3\ BTS Journey to Work trends, 2001; National Transportation 
Statistics Report 1999.
    \4\ Holtzclaw J. (1994) Using Residential Patterns to Decrease Auto 
Dependence and costs, Natural Resources Defense Council, San Francisco, 
p. 16-23.
    \5\ Centers for Disease Control and Prevention. Neighborhood safety 
and the prevalence of physical inactivity-Selected states, 1996. MMWR. 
1999; 48(7):143-6.
---------------------------------------------------------------------------
    Nationwide, only 31 percent of children who live within 1 mile of 
school make the trip on foot; only 2 percent of school children who 
live within 2 miles of school travel by bike.\6\ Parents are also 
afraid to allow their children to play outside and turn to safe, 
passive entertainment ranging from TV to home videos and computer games 
to occupy their children's free time. Children in the United States 
spend more hours watching television and videotapes and playing video 
games than sleeping; these passive leisure time activities are linked 
to increased risk for obesity.\7\
---------------------------------------------------------------------------
    \6\ Centers for Disease Control and Prevention. Calculations from 
the 1995 Nationwide Personal Transportation Survey.
    \7\ Robinson TN. ``Reducing Children's Television Viewing to 
Prevent Obesity: A Randomized Controlled Trial.'' Journal of the 
American Medical Association, Oct. 27, 1999, 282(16): 1561-1567.
---------------------------------------------------------------------------
    The Strategic Alliance is supporting a number of local and state 
government policies that enhance active community environments, which 
would benefit from support at the federal level. Measures being taken 
by communities to alter environments to enhance physical activity 
include traffic calming and routine accommodation of bicyclists and 
pedestrians in all transportation projects. Opportunities exist to 
reward local governments who promote infill development and more 
walkable communities with transportation incentive grants. Funding of 
the Safe Routes to School program has enhanced walking to school for 
many children. Resources also need to be made available to support 
maintenance and development of parks and areas for active recreation.
(3) Increasing Access to Nutritious Foods in all Neighborhoods
    Anyone who has searched a convenience store for a healthy snack 
knows that options can be limited. Restaurants can also be a 
challenging place to find fruits and vegetables to contribute to 5 a 
day. Access to nutritious foods is even more challenging in low-income 
neighborhoods, where there are few supermarkets and small stores have 
limited quantities of high-priced fresh items.
    Supermarkets have become the primary source of fresh produce for 
most grocery shoppers in the United States. Yet predominantly low-
income neighborhoods in both central cities and rural areas are less 
likely to have supermarkets. A 1995 analysis of 21 major U.S. 
metropolitan areas found there were 30 percent fewer supermarkets in 
low-income areas than in higher-income areas; it also found low-income 
consumers were less likely to possess automobiles, further limiting 
their access to food choices.\8\ Studies have consistently shown that 
prices at small grocery and convenience stores can exceed those at 
chain supermarkets by as much as forty-eight percent and smaller stores 
are also unlikely to offer the variety of products carried by most 
major supermarkets.\9\ A recent University of North Carolina study has 
demonstrated the link between supermarket access and healthy diets, 
finding that residents in neighborhoods with higher concentration of 
supermarkets ate higher amounts of fruits and vegetables.\10\
---------------------------------------------------------------------------
    \8\ Cotterill RW, Franklin AW. The Urban Grocery Store Gap. Food 
Market Policy Center, University of Connecticut, Storrs, CT, April 
1995.
    \9\ Weinberg Z. No Place to Shop: Food Access Lacking in the Inner 
City. Race, Poverty, and the Environment. Winter 2000.
    \10\ Morland K, W. S., Diez Roux, A (2002). ``The Contextual Effect 
of the Local Food Environment on Residents' Diets: The Atherosclerosis 
Risk in Communities Study.'' American Journal of Public Health 92(11): 
1761-1767.
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    There are models around the country for innovative approaches to 
increasing access to fresh produce, low-fat dairy and protein items. 
These include joint community partnerships to site supermarkets in low-
income neighborhoods, establishment of farmers' markets, and training 
and equipment provided to small retailers to successfully carry 
produce. At the same, some community-based programs have sought to 
improve transportation to bring consumers to existing stores by 
coordinating transit services or providing van service or deliveries.
(4) Making Government and Health Care Workplaces Models for Supportive 
        Environments
    Most adults spend a large portion of the day at work. The 
organizational practices of their work place can make a difference in 
their ability to achieve healthy behaviors. California adults reported 
difficulty accessing fruits and vegetables at work as a key barrier to 
increasing consumption.\11\
---------------------------------------------------------------------------
    11 Oppen M, et al. (1999). Fruit and Vegetable Consumption in 
California Adults; Ten-Year Highlights from the California Dietary 
Practices Survey 1989-1999, Public Health Institute, California 
Department of Health Services.
---------------------------------------------------------------------------
    It is a concern when a local hospital served donuts as the only 
breakfast food at a meeting on health disparities, or when fast food 
outlets are located in the lobby. A far better example is set by the 
Health and Human Services offices in Rockville, Maryland, where we were 
pleased to discover a farmstand with an attractive array of local 
fruits and vegetables set out for tasting.
    Health care and government institutions have a special 
responsibility to model wellness-encouraging organizational practices. 
These offices can serve as a model ensuring availability of healthy and 
appealing food options in cafeterias, vending machines and whenever 
refreshments are served. Inspectors ensure the safety and accessibility 
of elevators while failing to ensure safe, hospitable stairways, which 
CDC has aptly described as ``expensive pieces of exercise equipment.'' 
Activity levels can be enhanced through support for well-lit and safe 
stairwells, bike racks, lockers and showers, and incentives for walking 
or biking to work.
    Government and health care staff should serve as spokes people for 
healthy food and activity practices at work and be able to proudly 
describe how their own workplaces reflect such practices.
(5) Restricting Marketing to Children
    Children in the United States are estimated to view as many as 
40,000 commercial messages each year on television.\12\ More than 50 
percent of these ads are estimated to be for food, predominantly 
promoting soda, fast foods, high-sugar cereals and high-calorie snacks. 
This advertising seeks to develop their brand loyalty to last a 
lifetime and even utilizes children's entertainment characters to 
promote food and beverage products. Even schools have become centers 
for commercial messages as soft drink companies have targeted schools 
for exclusive marketing contracts that prominently feature their 
products and sometimes lead school administrators to promote sales in 
order to increase revenue for the schools.\13\
---------------------------------------------------------------------------
    \12\ Strasburger VC. ``Children and TV advertising: nowhere to run, 
nowhere to hide.'' Journal of Developmental and Behavioral Pediatrics. 
Jun 2001;22(3):185-187.
    \13\ Nestle, M. Soft Drink Pouring Rights. Public Health Reports. 
July/August 2000, Vol. 115, 308-319.
---------------------------------------------------------------------------
    The serious health consequences that are resulting from over 
consumption require that we look once again at the appropriateness of 
marketing to children. Children below the age of eight are incapable of 
even distinguishing commercial from non-commercial messages.\14\ At a 
minimum, promotion of unhealthy food and beverages should be eliminated 
from schools which are public institutions. Further, we need to 
carefully consider the examples of other countries. Sweden and Norway 
prohibit advertising targeted to children under 12 and Australia does 
not allow ads during preschool programming.
---------------------------------------------------------------------------
    \14\ ``Children, adolescents, and advertising. Committee on 
Communications, American Academy of Pediatrics.'' Pediatrics. Feb 
1995;95(2):295-297.
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    In conclusion, I would like to say that it is very exciting to see 
an increase in funding to CDC devoted to nutrition and physical 
activity initiatives. Given the important contribution of environmental 
and policy changes, I would strongly recommend that a high proportion 
of these funds be devoted to nurturing the burgeoning movement for 
these changes at the state, local and federal levels. Through the 
synergy of individual-behavior change efforts and environmental 
changes, we will be able to effectively shift community norms and 
reduce the burden of preventable disease, disability, and premature 
death.

    Senator Specter. Thank you very much, Ms. Mikkelsen. So, 
Danielle, who called you a fat girl?
    Ms. Boyd-Bailey. She said she did not understand what you 
said.
    Senator Specter. How long ago did that happen?
    Ms. Boyd-Bailey. He said, ``Who called you a fat girl.''
    Dr. Neufeld. And how long ago.
    Ms. Bailey. Legend.
    Ms. Boyd-Bailey. Legend, a little boy at school. The kids 
at school would tease her.
    Dr. Neufeld. How long ago? When?
    Senator Specter. How long ago? You look like a thin girl to 
me. When did they call you ``fat girl''?
    Dr. Neufeld. Before or after KidShape?
    Ms. Bailey. Before.
    Senator Specter. Danielle, at that rate, you are not going 
to use up your 5 minutes. So, Danielle, did the incident where 
they called you ``fat girl,'' did that make you want to change 
your diet?
    Ms. Bailey. Yes.
    Senator Specter. And when somebody mentions McDonald's, 
what do you say about going there?
    Ms. Bailey. I say that is not healthy.
    Senator Specter. It is not healthy, yes. And how did you 
figure that out? What led you to decide that going to 
McDonald's was not healthy?
    Ms. Bailey. KidShape.
    Senator Specter. Mr. Lefer, when you say you started 
feeling better 1 or 2 weeks later, amplify that just a bit.
    Mr. Lefer. Well, the angina started getting better. I could 
walk farther. You feel it immediately.
    Senator Specter. And what changes had you made in your diet 
in that week or 2?
    Mr. Lefer. Well, I became a vegetarian. I started doing the 
yoga. We used to meet twice a week----
    Senator Specter. Doing yoga can be fairly rigorous.
    Mr. Lefer. Well, not the kind we do. We do a Hatha Yoga, 
which is a gentle yoga. It is more for older people.
    Senator Specter. Did you ask for Dr. Ornish to do what some 
of the rest of us do, the less vigorous yoga?
    Mr. Lefer. I did whatever he told me.
    Senator Specter. And you say that opening your heart was a 
key factor, letting bad things out. That may be too personal to 
amplify, but if you care to comment further, we would be 
interested to know.
    Mr. Lefer. Yeah, well, we used to meet twice a week, and at 
the end of the meeting--first we would exercise, then we would 
eat, and then we would have group support. And we would sit 
around in a circle. And people would talk about what was going 
on in their lives and their feelings, and I just was the kind 
of person that would just hope nobody would ask me anything, 
and I was nervous that I would have to talk about what was 
going on in my life, and I learned how to just express and have 
empathy for other people's problems and, by doing that, 
learning how to handle my own feelings.
    Senator Specter. And you have had reversal of your heart 
condition?
    Mr. Lefer. Yeah. The program was for 1 year originally, but 
then the government gave Dean some money and it was increased 
to 4 years. And every year we would go down to Houston and have 
a Pet Scan, and the first year I went down there--the Pet Scan 
is the colors in the heart muscle are red and white when you 
get good circulation, and the first year, mine was all dark and 
green, and there was very little. And each year I went down 
there, my heart started to come back. It started to rejuvenate 
itself. I was not a candidate for bypass because I had so much 
damage that there was nothing to bypass, really. So I had to 
work with what I had left. And each year, the Pet Scan would 
show more blood flow to the muscles.
    Senator Specter. And these were your arteries would show--
--
    Mr. Lefer. No, no, this is my heart muscle.
    Dr. Drewnowski. But your arteries also show the reversal.
    Mr. Lefer. Yeah, my arteries showed reversal also.
    Senator Specter. Did you have significant weight loss?
    Mr. Lefer. During the 4 years of the program, I lost about 
25 pounds, yes. I am a pretty ferocious eater, though, even 
today.
    Senator Specter. Even with vegetables?
    Mr. Lefer. Yeah.
    Senator Specter. On a personal level, what vegetables 
motivate you? I would like to find some.
    Mr. Lefer. Well, I keep my weight up by eating 
carbohydrates, mostly. I eat too much pasta. But I still eat 
out quite a bit. I go to Chinese restaurants and I get steamed 
vegetables with tofu, with soy sauce. What I do is I cultivate 
places to make the food tasty. Luckily, I live in this area and 
there are a lot of restaurants that have Dean Ornish- or Dr. 
McDougall-type food on the menu. And it is pretty good.
    Dr. Drewnowski. Tell them what you used to serve in your 
restaurants.
    Mr. Lefer. Oh, my restaurants--I killed thousands of 
people.
    Senator Specter. You have not changed your own restaurant 
to incorporate all the valuable lessons you have learned----
    Mr. Lefer. Oh, no, no, I sold my restaurants right after I 
had my heart attack. I got out of the business. Actually, I 
cannot stay away from it. Right now, I am working with a 
company that develops products for the food industry, and I am 
trying to develop a fat-free chocolate to cover different 
products. And they think they are going to be able to do it.
    Senator Specter. A fat-free chocolate?
    Mr. Lefer. Yeah, that cover products.
    Senator Specter. Which will not have all these adverse 
health effects?
    Mr. Lefer. Well, I am hoping to do that, yeah. And I am 
hoping to use, instead of sugar, sugar substitutes.
    Senator Specter. Well, you may be interested to know that 
you can come to the Senate Dining Room because Dr. Ornish has 
entries on the menu. He does not get credit for them because 
that is the government way.
    But we have taken some of his dishes and put them on the 
Senate menu, so if you are in the neighborhood and can get by 
the barricades, come on in.
    Mr. Lefer. All right.
    Senator Specter. Dr. Ornish, you mentioned prostate cancer 
on a reversal. Could you amplify how that works?
    Dr. Ornish. Sure. And I think, as you know, you can get a 
lot of good done in the world if you do not care who gets the 
credit. I think we are at a place with prostate, breast, and 
colon cancer very much like we were 25 years ago with heart 
disease. And that is, if you look at the animal data, the 
epidemiological data from other countries, the anecdotal case 
reports in humans, there is every reason to think that diet and 
lifestyle might affect these diseases, but nobody had really 
done a randomized trial until, beginning 5 years ago, in 
collaboration with Dr. Peter Carroll here at UCSF, who is the 
Chair of Urology, and the late Dr. William Fair, who at the 
time was the Chair of Urology at Memorial Sloan-Kettering 
Cancer Center in New York, we designed a study that took 
advantage of the fact that a certain number of men who know 
they have prostate cancer do not get treated for it for reasons 
having to do with, if you are older, you are more likely to die 
with prostate cancer, rather than from it. But we did not get 
involved in those decisions.
    But from a scientific standpoint on that, we could have a 
group of men who all knew from biopsies that they had prostate 
cancer, but none of them had been treated, so we then randomly 
divided them into two groups, asked one to make big changes in 
diet and lifestyle, and the other did not, and so we could have 
a non-intervention control group which you could not do with 
breast cancer, for example, because most women get treated 
immediately.
    Senator Specter. You could not do it with breast cancer. 
Why?
    Dr. Ornish. Because most women get treated. They get 
chemotherapy or surgery or other things, and so then you would 
not know whether the changes were due to the conventional 
treatment, or whether they were due to diet and lifestyle 
alone; whereas, in these men, none of them had conventional 
treatment when they started. So, after 1 year, what we found is 
that the control group--7 of those 84 men ultimately ended up 
getting conventional treatment, surgery, radiation, 
brachiotherapy, during the first year. But none of the people 
in the lifestyle change group had conventional treatment. And 
we found that the Prostate-Specific Antigen, or PSA, improved 
or went down on average in the group that made these changes, 
but went up in the group that did not, or they got worse.
    We found a dose response correlation--the more people 
change, the lower their PSA went, just like we found in a study 
that Mel Lefer and others were in, that the more people change 
their diet and lifestyle, the less clogged their arteries 
became using quantitative arteriography.
    But in order to get the patients to get better, as in both 
studies, they had to make really big changes. The old saying 
about an ounce of prevention and a pound of cure I think is 
really true. To reverse disease, you have to make really big 
changes. To prevent it, you do not have to be so strict. And if 
you start at a young age, as you are doing, then you do not 
have to make such big changes.
    So I think our findings are really giving many people new 
hope and new choices that they did not have before. And if it 
is true for prostate cancer, it will almost certainly be true 
for breast cancer as well, and likely colon cancer, and 
diabetes, and hypertension, and obesity. And a wide range of 
degenerative diseases are really directly linked to the diet 
and lifestyle choices that we make every day--for better and 
for worse.
    Senator Specter. Has an effort been made to do for breast 
cancer what you have done for prostate cancer?
    Dr. Ornish. We would love to do a study on breast cancer as 
our next study if funding were available. We would be thrilled 
to do that. And I think one of the things that is kind of our 
unique little niche is that we have really learned what 
motivates people to make changes to this degree in the real 
world, and it looks like it takes that degree of change in 
order to show reversal.
    Senator Specter. To the extent that you can comment, how 
are your consultations with McDonald's going?
    Dr. Ornish. Well, about 3 years ago, I was at a----
    Senator Specter. Are they aware of Danielle's sentiments, 
by the way?
    Dr. Ornish. I think they will be soon. I will make them 
aware of it. I remember about 3 years ago, I was at this 
conference in Davos at the World Economic Forum, and I was at a 
breakfast and I was seated next to a guy. And I said, ``Hi, I 
am Dean Ornish.'' He said, ``I am Jack Greenberg.'' I said, 
``What do you do?'' He said, ``I am the CEO of McDonald's 
Worldwide.'' I said, ``Oh.''
    I thought how interesting to be sitting next to the CEO of 
McDonald's. So I began consulting with him and encouraging him 
to make healthier foods. And it is interesting. There was kind 
of a division in the company. The company started to not do so 
well and there was the old guard that said: ``We ought to just 
make cheaper burgers and that's it,'' and then the more 
visionary people there who said: ``We really need to make 
healthier food.'' And the old guard won temporarily. Their 
stock went down by 50 percent. They have since replaced their 
CEO, and now they are much more open.
    Senator Specter. As soon as you started consulting with 
him, he was replaced?
    Dr. Ornish. See, that is why you have a control group in 
science because association does not necessarily imply 
causation. But I have also been consulting with PepsiCo in the 
last year or so, and their CEO, Steve Reinemund, actually has 
taken a very different approach. They have committed that half 
of their new products in the coming year will be healthier 
products. And I think they are doing it for two reasons----
    Senator Specter. How can they do that?
    Dr. Ornish. Well, that is the thing about these big 
companies--if the CEO wants something to happen, they do it.
    Senator Specter. But what do you do for the taste of Pepsi? 
How do you make it different?
    Dr. Ornish. Oh, well, Pepsi owns Tropicana, they own Quaker 
Oats, they own Gatorade, they own other companies that, under 
those umbrellas, they can make healthier foods. We have already 
worked with McDonald's----
    Senator Specter. Could they make Pepsi-Cola healthier?
    Dr. Ornish. Well, not necessarily, but the idea is, first 
of all, we have already gotten them to take their trans-fatty 
acids out of the potato chips and things like that, so they can 
make them healthier, if not healthy.
    But the idea is that they realize two things--one is that 
because of the threat of litigation you talked about, as well 
as the fact that they see that as the baby boomers are getting 
older, there is a real market for healthier foods, that they 
cannot stop making the foods--the so-called ``junk foods''--
because that is a big part of their core business. But if they 
also make a lot of healthy foods, then they can say, ``We are 
making an entire spectrum of choices,'' and also educate people 
how they can find their place on this spectrum because, you 
know, for some people, if they have indulgent foods once in a 
while it is not going to hurt them. For people who have heart 
disease, they should probably never eat those foods.
    So, by having the spectrum of choices, it both protects 
them against litigation, as well as opening up new markets. And 
one of the reasons I like working with them is, as you alluded 
to, they know how to--I mean, in terms of behavioral 
modification, they are the experts. You know, they know how to 
influence people to eat certain ways. Unfortunately, 
traditionally, it has been in ways that are not very good for 
them. And if we can work with them to not only make healthy 
foods, but to make them fun, and sexy, and hip, and 
interesting, and all the kind of peer issues that particularly 
affect younger kids in what they eat, then potentially, they 
can find that they can make a good business out of it, as well 
as making foods that are going to be healthier for Americans.
    Senator Specter. You had an interesting dichotomy--fear of 
dying, joy of living. How do you activate those feelings, not 
too relevant perhaps to say which would be more significant or 
more motivational, but how do you work on, say, the joy of 
living as a motivating factor?
    Dr. Ornish. Well, that is a very good question. I think Mel 
Lefer is a perfect example. When he started our program, he 
literally could not walk across the street without getting 
severe chest pain. He could not take a shower, as he indicated. 
He could not have sex without getting pain. And one of the 
things I have learned is that when people make really big 
changes in their diet and lifestyle, sometimes the reasons for 
making these changes--because there is no point in giving up 
something that you like unless you get something back that is 
better--and not 30 years later for the heart attack that does 
not come, but 1 week or 2, or 1 month later.
    I think one of the most effective anti-smoking campaigns 
here in California at the Department of Health Services was 
not, ``Smoking causes emphysema, lung cancer, heart disease'' 
because people do not want to think about those things. They 
are too terrified. But they had a picture of a guy, an actor 
dressed like a Marlboro Man with a limp cigarette hanging out 
of his mouth saying, ``Smoking causes impotence.'' And that got 
people's attention because, again, when I----
    Senator Specter. Smoking causes what?
    Dr. Ornish. Impotence. Sexual dysfunction. And you know, 
ironically, cigarettes are always marketed as being so sexy, 
just like eating high-fat foods are, but it turns out that most 
impotence--first of all, it is extremely common, which is why 
Viagra is one of the best-selling drugs of all time. And it is 
something that most guys do not talk about, except, I guess, 
one of your former Senator colleagues does on some occasions--
and the point is----
    Senator Specter. He talks about Pepsi more.
    Dr. Ornish. And when I was in medical school, we were 
taught that impotence was mostly in your head. We now know it 
is mostly in your arteries. The same mechanisms that affect 
blood flow to your heart also affect blood flow to sexual 
organs. And so when people quit smoking, when they change their 
diet, when they manage stress better, their blood flow to their 
brain improves. They get more blood, they get more oxygen, they 
think more clearly. Their heart disease improves. Their sexual 
function improves. They do not have these aches and pains 
oftentimes. And so those kind of immediate benefits, I find, 
are much more motivating than simply talking about risk-factor 
reduction because most people do not really think anything bad 
is ever going to happen to them.
    Senator Specter. Dr. Stern, the charts you have provided 
are very impressive on how little attention is directed to 
obesity. And it is only a comparative matter, but NIH obesity 
has gone up from $127.6 million in 1998 to $324.3 million in 
2003. Now, you are correct that, notwithstanding a very 
substantial percentage increase, it is still relatively modest. 
But how would you go about trying to persuade NIH to make an 
institute? And where do you end up with all of the other 
factors--an alcoholism institute, a tobacco institute? How do 
we establish those priorities for NIH?
    Dr. Stern. Well, my concern, Senator, is that we are in the 
midst of this huge obesity epidemic. It is affecting children, 
it is affecting adults. The healthcare costs are out of 
control. And if you look at the number of people affected, 
certainly with adults, it is over 60 percent of our population 
is overweight or obese. And using NIH's criteria to establish 
priorities, this would be a no-brainer. So the reason why we 
are proposing an obesity institute is to try and increase the 
visibility of obesity at NIH because it is not visible at all. 
How would I go about it--if I were made king or queen for the 
day? Or if it was the real world?
    Senator Specter. How about chairman of the Appropriations 
subcommittee?
    Dr. Stern. Same thing.
    Well, first of all, I want the Government, HHS, to come up 
with a plan for how to deal with obesity in terms of research. 
This is something you requested in 1999. And they have not done 
that. So it is really hit or miss. And I would hold hearings in 
this area to see why so little money has been--and so few 
grants are being spent on obesity.
    I will give you an example with CDC. CDC has done a 
wonderful job with the amount of money that they have, but my 
first three figures, looking at the incidence of obesity, that 
comes from the National Health and Nutrition Examination Survey 
that CDC manages. Just a few years ago, it was in danger of 
really being de-emphasized because of lack of funds. And Sally 
Squires' article in The Washington Post within a week resulted 
in more money being appropriated for this.
    So, first of all, we have to track what is happening to 
this epidemic and that is critical with the CDC. But we also 
have to do programs to see what works. And Dean, you are really 
to be congratulated. You really have done research, you have 
published your research, and that is really laudable. You have 
not gotten a lot of money in terms of grants. If you take 
Dean's counterpart, Dr. Atkins, there has been very little 
research done in that area and we do not know--we know people 
lose weight on it, we do not know about is it safe, does it 
cause people to maybe increase heart attack risks? And does it 
help people maintain weight? The research simply has not been 
done. And I think it is going to have to be NIH, USDA, CDC that 
actually does the research.
    Then, finally, if you would ask me what prevents obesity, 
what do we know from the research that is out there? I would 
say we do not know because there has not been significant 
research on prevention of obesity. We think the taking of 
vending machines out might help, we think that de-emphasizing 
portion size might help, but we simply do not know. We are 
going ahead in the absence of research to make these changes, 
and if they do not work, I think people are going to be very 
angry.
    Senator Specter. Dr. Stern, you have mentioned in your 
testimony something about the isotopes. I did not quite follow 
that. Could you amplify that?
    Dr. Stern. Oh, sure. One of the ways you can find out what 
people are eating--energy balance, what they need to keep them 
going--is to give them a stable isotope, meaning it is not 
radioactive, and it is called ``doubly-labeled water.''
    Senator Specter. Doubly-labeled water?
    Dr. Stern. Doubly-labeled water, right. The hydrogen and 
the oxygen have different isotopes and it is not radioactive, 
and you look at what happens--how you excrete it, how it is 
utilized over 10 days. And it is a very valuable tool.
    Well, literally, research in this area, if you do not 
already have a lot of doubly-labeled water in your research 
organization, you cannot do this research. You cannot do the 
appropriate research if we are looking at food intake and 
exercise because there is not enough doubly-labeled water. 
There have been some steps taken that will increase the supply 
of this in the next 2 or 3 years, but my comment here was, if 
somebody were minding the shop and anticipated this, I do not 
think we would be in this fix we are right now.
    Senator Specter. Well, how do we get out of it?
    Dr. Stern. Well, we need big columns to create the 
isotopes. I mean, it is a technology problem. Right now, it is 
a technology problem. We get some of our isotopes from Russia 
because they still produce some things, but the supply is very 
low.
    Senator Specter. Well, I will pursue NIH on our 
recommendation. Do you think the subcommittee ought to tell 
them what to do, ought to mandate it?
    Dr. Stern. Well, the problem, Senator, is----
    Senator Specter. That is, the subcommittee recommend to the 
full Congress that it be mandated.
    Dr. Stern. The problem is that it has not been done and the 
problem has gotten worse. You made suggestions in 1999. We are 
now 4 years later and how many millions of people have gotten 
Type 2 diabetes and gotten obese in that interim. I think that 
this crisis really is severe enough that I would like to see it 
mandated, but I am an activist and I would bow to whatever you 
decide.
    Senator Specter. Well, we approach it with recommendations 
so that we do not give in to the politicization of having the 
Congress make scientific judgments. We make political 
judgments. But I am going to pursue that.
    Dr. Stern. Well, let me just turn the question around 
slightly. Let us say we had something like heart disease which 
does kill a lot of us, or will kill a lot of us, and NIH was 
not doing the appropriate research on heart disease because it 
was not fashionable, because let us say people with heart 
disease were viewed as less valuable or as weak-willed, would 
your subcommittee at some point take action? And that is 
rhetorical.
    Senator Specter. Senator Stevens, as chairman of the full 
committee some time ago, put in an extra $150 million for 
prostate cancer when he had prostate cancer, but it got thrown 
out.
    Dr. Stern. But you asked for a billion at NIH? Or you were 
looking at the increase in NIH budget and it got thrown out the 
first year, the second year? So I----
    Senator Specter. Well, it is true that if the chairman puts 
a mark, then people are afraid to take it out, but that is to 
NIH generally, without our telling NIH where to spend the 
money. You might quarrel that it is a waste of money--or it is 
not as high a priority item as more for the Department of 
Defense. Somebody might argue that.
    I am just kidding.
    Dr. Neufeld, you had mentioned Medi-Cal and Medicaid on 
your program for KidShape. Could you tell us a little more 
about that?
    Dr. Neufeld. Yes. In 1997, we went to meet with the Medi-
Cal Nutrition Subcommittee and they provide funding through a 
program called EPSDT. It is the Early Periodic Screening 
Diagnosis and Treatment Program. It comes from the Omnibus 
Reconciliation Act of 1989, and it is for prevention of 
disability. And as a result of that, it is limited to children 
up to the age of 21, and it is to provide a variety of 
programs----
    Senator Specter. For people up to 21?
    Dr. Neufeld. Up to 21.
    Senator Specter. On disability?
    Dr. Neufeld. No, no, it is for all children on Medicaid, 
and it is money from the ORB, the 1989----
    Senator Specter. And this was Medicaid, California? Did 
that come out of Washington?
    Dr. Neufeld. It came from Washington and I think each State 
can make a decision as to how to use it. In California, they 
have used it for nutrition services, as well, and essentially, 
it is to identify disabilities which can be detected on a 
physical examination.
    Senator Specter. Does it require a disability finding?
    Dr. Neufeld. No, no. It is to prevent disability. It is 
EPSD----
    Senator Specter. Prevent disability.
    Dr. Neufeld. Right. Early Periodic Screening Diagnosis and 
Treatment designed to improve primary health benefits for 
children with an emphasis on preventive care.
    Senator Specter. Dr. Stern, why would that not be 
applicable to obesity?
    Dr. Stern. Well, obviously you have used it in that area 
and----
    Dr. Neufeld. It is available--we were lucky.
    Dr. Stern. Right. It is getting the priority highlighted.
    Dr. Neufeld. So we were able to identify those funds--or 
the State was able to identify them and provide them to us. Now 
the problem is that this was done in 1997 and, from 1998 or so, 
we were able to do our program, as I said, and develop up to 20 
sites. But over the last year, because Medi-Cal in California 
has taken a hit, we have been able to only obtain by 
reimbursement 20 percent of the charges that we bill for. So, 
in fact, we are Medi-Cal eligible, we can bill for our program, 
and had we received all the funding that we legitimately bill 
them for, we would be fine. But we in fact are living on 
charity and private donation.
    Senator Specter. And Dr. Neufeld, you are also working with 
Highmark of Pennsylvania?
    Dr. Neufeld. Yes, we are. And Christiane Rivard can explain 
that, our program director.
    Senator Specter. Sure. You are going to have to come 
forward and identify yourself for the record, and get a chair.
    Ms. Rivard. My name is Christiane Wert Rivard. I am the 
program director for KidShape. And Highmark contacted us 
because they were interested in--they were not interested in 
re-creating the wheel, they wanted to bring a program that was 
proven effective for their population. And what we developed 
was a licensing program so that they could operate the program. 
They pilot-tested it in both Erie and Pittsburgh, and Allegheny 
General Hospital was one of their community partners, as well 
as the public schools. With the two pilot programs, they were 
very effective. And so, for the year 2003, now they are 
licensing the program for ten sites throughout Western 
Pennsylvania because it has gone over so well and it has been 
so effective for the families that they served and that they 
provided the program for.
    Senator Specter. Well, we are glad to see you in 
Pennsylvania. Thank you.
    Dr. Drewnowski, you raised an interesting point, and Dr. 
Gerberding, I would appreciate your comment on this, about 
using the centers, as you articulate, to address the public 
health standpoint, and to try to integrate those with CDC. How 
would you suggest doing that?
    Dr. Drewnowski. The CDC has a network of 28 prevention 
research centers affiliated with major schools of public health 
around the country. And some of those centers are devoted to 
issues of physical activity, and others are interested in 
issues of body weight. There are others, still, dealing with 
other health prevention and other problems. My suggestion is, 
we have new centers specifically devoted to obesity and 
specifically devoted to policy, economic, and community aspects 
of obesity that would not duplicate NIH work because the NIH 
does the network of Obesity and Nutrition Research Centers, but 
would add to the strategies and plans of the CDC and expand CDC 
resources in this area, and policy focus would be very 
important and also working with State and local government and 
the communities.
    Senator Specter. Dr. Gerberding, do you have the 
flexibility to entertain such an idea?
    Dr. Gerberding. We certainly do. I think this is a great 
example of trying to bridge that gap between the basic science 
and the community application, and the schools of public health 
that house these centers are fine academic institutions. They 
have creative investigators. We can either enhance or add this 
activity to existing centers or create new centers with this 
particular focus. So I think this is something that we need to 
sit down and figure out how to make that happen.
    Dr. Drewnowski. That would be great.
    Senator Specter. Dr. Drewnowski, you raised a very 
fundamental point about these foods appealing to people in the 
lower economic groups and with the least resources and 
education, as you say it. I am groping with a way to deal with 
it. What do you do? If Dr. Ornish cannot persuade Pepsi-Cola, 
what do you do?
    Dr. Drewnowski. Well, the problem is that the determinants 
of food choice--there are three of them--taste, cost, 
convenience, and unfortunately to a lesser extent, health and 
variety. So taste drives people toward sugar and fat and high, 
energy-dense foods. Cost, the low cost of sugar and fat drives 
them towards high-sugar, high-fat foods. And convenience, let 
us face it, the packaged foods are convenient. They contain 
fat, sugar and salt. So those three, like a triple-whammy--fat, 
sugar and salt. But cost is very, very important and those 
foods are low in cost.
    So we need to know about the economic cost of various diets 
and, at this point, we do not even have a national food price 
database. There is not one that exists. So we have no idea what 
people spend on food. There is some government databases that 
tell us what people spend, but not what they eat, and other 
databases that tell us what they eat, but not what they spend. 
So you cannot really cross the two and price the quality of 
diets. And I suspect the diets high in sugar and fat are 
associated with obesity and, of course, diets high in 
vegetables, fruit, and so on, are not, but those diets may be 
more costly.
    Dr. Ornish. Could I just add----
    Senator Specter. Before you take it, Dr. Ornish, I would 
like to follow up with Dr. Drewnowski. Are you suggesting that 
there could be a specific research program which would answer 
the issues you just raised?
    Dr. Drewnowski. Absolutely. And CDC, as a matter of fact, 
did have a September conference on the pricing of vegetables 
and fruits, and they are really thinking about this, and there 
are ways of addressing that. I would suggest a program of 
research to begin with, and then establish a base for fiscal 
food policies, and then start looking at food assistance 
programs, subsidies for vegetables and fruit, farmers markets, 
and other approaches at the community level. But the CDC did 
have a price conference back in September.
    Senator Specter. Well, Dr. Drewnowski, would you specify 
those views in a letter to Dr. Gerberding and send me a copy?
    Dr. Drewnowski. It would be a pleasure.
    Senator Specter. Okay. Dr. Ornish, you had a comment?
    Dr. Ornish. Yes, just two things. I agree with Dr. 
Drewnowski that lower socioeconomic groups tend to eat foods 
that are higher in fat, but I want to make two points, one is 
that the kind of diet that we have been studying for 25 years 
is essentially a Third World diet. It is not an inherently 
expensive diet, it is the way that people eat who cannot afford 
healthier food. But the system has become somewhat distorted in 
this country, (a) because so many people in lower socioeconomic 
groups get so much of their food from fast food places because 
they do not have even access to local groceries and farmers 
markets, and (b) because the governmental subsidies tend to 
subsidize and make those high-fat foods and meats and dairy and 
eggs less expensive than the fruits and vegetables that--in a 
free market, actually you would find the opposite.
    Senator Specter. Ms. Mikkelsen, you had commented about the 
ads, ``Good way to start the morning.'' Do you think the 
Federal Government ought to intervene on those ads?
    Ms. Mikkelsen. Well, I think it would be something to think 
about. I think the time has come--I know this was an issue that 
was considered in the late 1970s about limiting advertising to 
kids. In other countries--for example, Sweden and Norway, do 
not allow television advertising directed to children under 12, 
and I believe it is Australia that does not allow any kind of 
ads during pre-school programming. I think we do have to think 
about whether the seriousness of this health crisis requires--
as we did in taking tobacco ads off of TV, limiting ads that we 
know are promoting unhealthy products.
    Senator Specter. Do you think that is something the FDA 
should get involved in?
    Ms. Mikkelsen. I think it would be very great if it did. I 
would love to see that happen. And I think there are many 
people--I know that the California State Senate is looking at 
holding a hearing on marketing to kids. I think there are a lot 
of people around the country that are starting to question this 
that have a real concern about the public health issue.
    Senator Specter. One thing that you testified to somewhat 
concerned me, about that Polish hot dog.
    Ms. Mikkelsen. Yes. Right. It concerned me too.
    Senator Specter. How did it taste?
    Ms. Mikkelsen. I did not eat it.
    Senator Specter. You did not eat it?
    Ms. Mikkelsen. No. I did not do it, but I----
    Senator Specter. They have a great event called Cannstatter 
in Philadelphia once a year, the day after Labor Day. Dr. 
Ornish will not like this, but I eat one of them once a year.
    Dr. Ornish. Once a year is okay.
    Ms. Mikkelsen. He said once in a while. And I do like 
Polish hot dogs, but not in this context. I am sorry, but just 
because I think this food access issue is so important and it 
has been a very important part of my work--I think these models 
of looking at opportunities to bring fresh food into 
neighborhoods at a reasonable price are really important. And I 
think it takes a dual approach. I think we need to look at 
Federal policy in terms of agriculture and programs like the 
Farmer's Market Nutrition Program that provide people with 
resources to buy food.
    But there are some really great things happening. For 
example, in Oakland, there has been a pilot project that now 
has been spread to three small stores that were essentially 
convenience, liquor-type stores, where a person who was an 
expert in produce-handling went in and helped these people get 
some start-up funds to get the equipment they needed, and then 
train them to buy produce. And they are now turning over $600 a 
week of produce a week in low-income neighborhoods. I think 
this is a model that can be replicated. I think we need to 
think about can we do the same with small restaurants. You 
know, there are a lot of mom-and-pop restaurants in these 
neighborhoods. Can we help them become as appealing as the fast 
food outlet? And it is supporting the local economy and 
bringing in better products.
    Senator Specter. Mr. Perelson, in your capacity as National 
Marketing Director of Lifestyle Advantage, do you think this 
hearing is going to help you a bit?
    Mr. Perelson. I do indeed. We have had a very interesting 
history, Dr. Ornish's research going back 20, 25 years. And 
looking at the last 20, 25 years, and certainly over the course 
of the last couple of years, the momentum certainly seems to be 
moving in the direction of establishing support for people who 
want to make healthier lifestyle changes. And I think hearings 
such as this will enable us to move faster in that direction. 
We have had a very unique opportunity over the course of the 
last year. We have recently trained 10 hospitals in West 
Virginia to deliver our program. And we are doing it in 
partnership with Mountain State Blue Cross Blue Shield in West 
Virginia and the Public Employees Insurance Agency in West 
Virginia. And the opportunity is outstanding for us in the 
sense that West Virginia is number one in the country in terms 
of incidence of heart disease. And some things, you do not want 
to be number one at, and heart disease certainly is that.
    We sort of--listening to all these comments--the future for 
us, as a Nation I think we spend so much time and attention on 
the cost of the Nation in terms of the down side of these 
diseases, that for us to focus on keeping people away from 
these diseases, providing them with quality-of-life choices, 
where even in neighborhoods and communities such as we are 
hearing, to provide opportunities for people to make 
appropriate choices.
    What is a very important part of our program is that it 
provides a supporting structure for people to make these 
choices, that--for most of us, it is very difficult to make 
changes. And we work with something called a ``Readiness for 
Change'' model. In that model, about 5 percent of all of us can 
make a choice today and change our lifestyle. They can buy Dr. 
Ornish's book, or they can go on the Internet and make those 
changes. There are about 5 percent of people who will never 
ever, ever, ever make changes, and the rest of us are in two 40 
percent groups--one heading towards change and one heading away 
from change. Those people who are in the group moving away from 
change, unless they hit some life event, a sibling comes down 
with a disease, heart disease, or they test positive on the 
stress test, may make the decision to move towards change. And 
then there are the 40 percent who are moving towards change, 
those people who have adopted an exercise program or a new diet 
program and gone off of it. And what we know about that group 
is that it is very difficult to make changes by yourself, and 
so what we have provided in terms of Dr. Ornish's program, is a 
very robust support system to help people do that.
    I think that is what we are all talking about today, is 
providing that support for people who want to make changes, in 
our program--registered dieticians and exercise physiologists, 
stress management instructors, psychologists, and a medical 
director work to help people move through these lifestyle 
changes.
    Senator Specter. Well, thank you all very much. Let me 
extend an invitation to you to let the subcommittee know if you 
have more suggestions. We are very interested in your specific 
suggestions that we can utilize in hearings or in our 
legislation. We have bill language which is limited, but report 
language is extensive, and I am going to pursue a number of 
subjects, what Dr. Stern has commented about as to our 1999 
recommendations. And I think we will schedule a hearing after a 
little more thought on ways to motivate people to make diet 
choices and to call in the experts--McDonald's, Pepsi, and the 
other fast food chains, and find out what they have done, and 
make an inquiry to the extent of trying to find out if they 
make choices which are contrary to social policy--try to get 
people to eat the wrong things, as Ms. Mikkelsen has said.
    I have tried to observe the time limitation by holding this 
hearing to two hours, and we are going to yield back about 
three minutes on the two hours. And the final question which I 
would like you all to submit in writing is, where should I go 
to lunch today?

                           PREPARED STATEMENT

    We have received the prepared statement of Senator Barbara 
Boxer that will be made part of the record at this point.
    [The statement follows:]
              Prepared Statement of Senator Barbara Boxer
    I want to welcome Senator Specter to California. Today, he will be 
examining a serious health problem in our country--obesity.
    Obesity is a complex chronic disease caused by many factors. It is 
the second leading cause of preventable death in the United States.
    Approximately 127 million adults in the United States are 
overweight, 60 million obese, and 9 million severely obese. For 
children, 30.3 percent are overweight and 15.5 percent are obese. 
Alarmingly, these numbers are rapidly increasing every year.
    I know that the results of this hearing will give all of us in 
Congress important information as we work to improve the quality of 
life for all Americans.
    Again, I welcome Senator Specter to the great state of California 
and thank him for taking time to examine this issue.

                         CONCLUSION OF HEARING

    Senator Specter. Thank you all very much for being here. 
That concludes our hearing.
    [Whereupon, at 12:27 p.m., Monday, February 17, the hearing 
was concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

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