Testimony

Statement by
Julie L. Gerberding, M.D., M.P.H.
Director, Centers for Disease Control and Prevention, Department of Health and Human Services
on
CDC's Role in Promoting Healthy Lifestyles
before the
Senate Committee on Appropriations, Subcommittee on Labor, HHS, Education and Related Agencies

Monday, January 17, 2003

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% of middle-aged Americans will develop high blood pressure in their lifetime and nearly 70% 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 Healthier US

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 FY 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 US 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 FY02, 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.

Last Revised: January 29, 2003