>> From the Library of Congress in Washington, D.C.
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>> Good morning.  I'm Constance Carter, Head of the Science Reference Section of the Science Technology and Business Division and I'm delighted to welcome you to today's program on Weight Loss Through the Ages.  This event is one in a series of lectures in which we learn from scientists, researchers and practitioners about the various fields and --in science and business.  We are please to have such a distinguished panel of experts with us this morning to discuss dieting practices spanning a period of 150 years as we try to find lessons to address the obesity epidemic in the 21st century.  We're delighted to begin today's program with a charge from Representative Ron Kind from the Third District of the great state of Wisconsin.  With a Masters Degree from the London School of Economics and a seat on the Ways and Means Committee, Representative Kind certainly understands the high cost of obesity.  He also chairs the Congressional Fitness Caucus and the Congressional Task Force on Childhood Obesity.  Throughout his career in Congress, Representative Kind has worked to get the population healthy and moving and has received a number of awards for his efforts in--to end obesity.  Please join me in welcoming Representative Ron Kind.
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[ Applause ]
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>> Well thank you Connie.  Thank you for that very generous introduction.  Welcome everyone.  Happy New Year and welcome to the panel.  I wanna especially thank Connie for this vision of holding this forum especially this time of the year with all of us with our New Year's resolutions and the inspiration and the energy to move forward.  I couldn't think of a better time to assemble this group and this panel and have this conversation right now, and with the new session of Congress just getting up and going because Lord knows there's gonna be a role for all of us to play.  Now what I thought I'd do is just give a quick synopsis of kind of the public policy role when it comes to weight loss or healthier living in our country and in our society.  It's an issue that I care deeply about.  Obviously given my involvement in so many issues but I also wanna commend the panelists here who have devoted their intellectual energy and capital on this subject, David and Weight Watchers International and the work that they're doing at the Vanguard, at the forefront of helping people, to inspire people, to encourage them, to make sure that whatever they do is sustainable, not just at the beginning of the year but throughout the year and even beyond and I'm sure he's gonna make some points a little bit later on of the new program, and the new kind of point system that they're embarking upon, one that I'm encouraged because it doesn't exclude the use of chocolate chip cookies in our daily diet.  [Laughter]  So it gives me hope and inspiration that with Yin and Yang and balance with all things that we can find the sensible center with this but there are a few issues that are coming up in this session of Congress I think that's gonna be very pertinent to this conversation, not least of which.  And today we're gonna have a five-hour debate about repealing health care reform but let me talk about I think the important role that health care reform can play as far as helping to combat the obesity trends in our society and to help make the healthy choice, the easy choice in people's lives.  There was a lot included in the health care reform, upfront measures when it comes to prevention, when it comes to wellness programs and I think that's probably the best use of our limited dollars.  It would give us the best bang for the buck, that we can have early intervention, early identification and early incentives to encourage more people to get those up front test, to get into wellness programs, to take more affirmative action in their own lives and a lot of what you'll see as far as the implementation of health care reform moves us in this direction and there's still more work to be done 'cause let's face it, when you look at the rising cost in the health care system, the old 80/20 ratio where 80 percent of the expense is going to roughly 20 percent of the population, most of whom have chronic illnesses, most of which is obesity-related for us to get grips on the rising health care cost and the societal economic and budgetary impact that brings, it brings us back to this subject naturally.  So I'm hopeful that after we kinda let it out of our system over the next couple of years, the members of Congress and those in charge of implementing health care reform will settle down and make sure it's done the right way and not the wrong way because we've gotta do this right and you gotta wanna do it in order to do it well and there's a lot of work to be done.  But there are a couple of other measures too that I certainly will be pushing as I have in the past.  A legislation that I've authored in the past with Zack Wamp, a close friend of mine from Tennessee who unfortunately has left us, he ran for governor but I will find a new partner in order to push a bill called Fit Kids and it re-emphasizes the important role that Physical Education has in classroom curriculum, in our school system.  Unfortunately with high-stakes testing and the No Child Left Behind, many of the school districts with the budgetary squeeze have decided to start cutting a lot of the PE curriculum and that offering to the students which I think is very detrimental and very short-sided because we know through studies that it's hard to develop a healthy mind without a healthy body and the important role that PE can play in that to make sure that our children are getting off to the right start is an important component of their early childhood education.  And the incentives that we have in Fit Kids is to do just that because the Physical Education curriculum that exists today is probably not what we encountered as students growing up.  I mean it's much more integrated with classroom curriculum.  It doesn't matter now what the skill level of a child is, athletic or otherwise 'cause there's a role for every child to play in PE curriculum, making sure that training goes forward, making sure that grants are available for school districts to make sure that PE is a vital and important component of their curriculum is what Fit Kids is all about.  And with the help of Senator Harkin in the Senate, hopefully we're gonna be able to advance that measure and get it over to the White House where I know the President and the First Lady are personally vested with this issue.  Another bill that we will soon reintroduce is called the Healthy Choices Act and it's very--its goal is very simple.  It's to try to make the healthy choice, the easy choice in all of our lives, from adults to children, making sure that everyone has access to affordable and nutritious food no matter where they live, whether it's rural western Wisconsin where I reside from, intercity New York or any place throughout the country.  People need access to those healthy choices and nutrition as an important part of what this is all about and making sure that it's affordable and dealing with the food deserts that have existed for way too long.  And then also through community based programming and I think that's the only way you can do this from the ground up, making sure there's easier access to exercise opportunities in everyone's lives again.  But I also think that perhaps the best chance we have starting to bend these trend lines is with the youth of our country and that, I hope, is where a lot of the focus will be.  The early identification, the early intervention, making sure that our children are receiving positive reinforcement every time they turn around in whatever setting they are, whether it's in the home, in their neighborhood, in the school setting but also the important role, the essential, perhaps most crucial role that the home environment plays with our children and making sure that us parents of young children are proper role models in all this that we're doing appropriate things, eating well and exercising more.  But also the responsibility that we parents have with our children and that is unplugging them from time to time.  Given the power of technology today and how the kids have gravitated to it.  I swear my boys now, as another appendage of theirs, the internet and the iPods and the cell phones and it's just a way of life but it's important that we parents also unplug them and get away from the Xbox and the computers and all that technology and getting them up and moving again and exercising their creative imagination and making sure that that's a vital component of the home environment and then extending that into the community and in the classroom so that every time they turn around, they are getting that positive reinforcement.  Another important piece of legislation that I hope is taken up in the session of Congress is the reauthorization of the Farm Bill.  And I have led the charge in recent Farm Bills to try to make the Farm Bill the Healthy Food Bill of the 21st century and there are things that we can do in that regard starting with getting away from these senseless taxpayer subsidies going to large agribusinesses that are producing just a few commodity crops, much of which is used for high fructose, corn-based, processed foods which isn't conducive to fighting the obesity epidemic that we have in our country.  And there's a lot more that we can be doing in the Farm Bill through various policies and maybe someone on the panel can talk about this a little bit later, to make the next Farm Bill the Healthy Food Bill of the next century because this affects all of us at all levels.  Most businesses that I go into today, whether large or small, are either offering wellness programs to their employees or starting that process because they know the vital link of healthier workers within their setting, an increased worker productivity and reducing health care cost which is the bottom line for all of them.  But when you also are gonna hear this discussion about deficit reduction in Washington and there will be a lot of it I guarantee you over the next two years and beyond, you can't be serious about deficit reduction unless you're serious about reforming the health care system that we have today and arresting the rising cost within the health care system.
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>> It is the fastest and largest growing area of expense at the federal state and local level and for businesses and families alike.  So again, it gets me back to the health care reform and making sure it's done the right way and not the wrong way.  So it gives us an opportunity of enhancing quality care, an accessible and affordable care to all Americans but with a better bang for the buck, because studies show that we're spending close to one out of every three health care dollars on tests and procedures that don't work.  They don't improve patient care.  That's almost 800 billion dollars a year that we're not getting a good bang for the buck and a lot of this is within the chronic disease management field and health care reform is meant to get into that and address it.  But when you look at the exploding budget deficits we have, the trend lines especially in the area of health care spending, this topic, this issue I think is gonna be pushed to the forefront more and more and more.  So again, it gets me back to my original comment, complementing Connie, the Library of Congress, our panelist here today for kicking off this new year with such an overriding important issue and the role that all of us have to play in order to make sure that we're heading in the right direction.  Understanding there are structural difficulties, inspirational difficulties that we all have but the time for action is now and what I think, and my concluding comment, gives me the most hope and the most encouragement of what I see out there is this growing coalition of recognizing the issue that's in front of us and coming together to find some practical solutions on how best to do it.  If we can keep building on that moment, that's gonna make the public policy arena a lot easier to play and to get things done in in the coming years.  So thank you all for your attendance.  Again Connie, thank you for the invitation to help kick things off and thank you for the panelists for being here and offering your insight on this.  Thank you everyone.  Enjoy the day.
[ Applause ]
>> Thanks Dave.
>> Yup.
>> Good to see you again.
[ Inaudible Remarks ]
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>> Thank you for that charge.  Congressman Flemming is giving a speech on the floor but will join us sometime during the program and I will introduce him at that time and I'm delighted to see our own Dr. Charles [phonetic] in the audience.  She is the one that sponsors Weight Watchers at Work and for which we are grateful and for which we are now signing up.
[ Laughter ]
[ Applause ]
>> It's now my pleasure to introduce David Kirchhoff, President and CEO of Weight Watchers International who is co-sponsoring the program today.  Mr. Kirchoff will moderate the panel and will introduce our distinguished guests.  Thank you and please join me in welcoming David Kirchhoff to the Library of Congress.
>> Thank you.
[ Applause ]
>> Thanks for coming today.  Yeah it must be that time of year if you can get so many people to show up at obesity talk.  [Laughter]  You know, it's interesting for me.  I just--I had the opportunity to spend the last two days with an organization called the Healthcare Leadership Council which is a collection of healthcare CEOs from hospitals to insurance companies to medical device and pharmaceutical companies, et cetera, talking about this incredibly difficult issue of what to do with health reform in the long term.  I had an opportunity last week to be out at the conference in California which was a collection of 300 companies coming together to talk about their innovations in the world of healthcare for--it was at a J.P. Morgan.  And what was interesting for me about being at both sessions was that the topic of prevention was undeniable.  The need and recognition that prevention and wellness in dealing with are lifestyle as a nation is something we just cannot escape if we ever hope to have any expectation of reducing long term health care cost and improving quality of life in this country.  So there's never been a more important time to really discuss and get our arms around what to do about issues like obesity both for right now and also for the future but it is also pretty clear--and one of the decisions we made at Weight Watchers is we started coming down to D.C. much more frequently about 18 months ago.  You know, our normal MO is to kinda keep our heads down and our noses to the grindstone and do the things that we do in terms of just helping the people in our meetings and the people online deal with the process of adopting a healthier lifestyle but we started coming down to D.C. particularly once healthcare reform started heating up.  And really our only expectation coming down was we felt that we have a voice to share in terms of how to think about obesity and we chose to approach it as advocates for our members in terms of thinking about the things that would be helpful for them in their own process in ways the policy can be beneficial to that.  But I think the other thing we've made the decision to do when started coming to D.C. was simply come down armed with our insights and our research and bring that to bear and do what we could to be helpful.  And the reason I mentioned this is is that, you know, if you wanna have an impact on obesity, it's complicated.  It's a complicated topic.  Lifestyle change is a complicated topic and I think the better we're informed, the better we'd get the insights and sort of the nuances and develop kind of a natural intuition for what is a relatively recent phenomena, certainly from a policy point of view, you know, the better off we all are, so you know, knowledge is power.  And so, with that in mind we think that today's panel is ideally suited to help us get a better understanding and insight on topics ranging from interestingly enough the history of weight loss which is you're gonna hear as an old problem and a new problem all at the same time.  We're gonna talk about the difference between men and women when it comes to weight loss.  Weight loss and weight management and obesity is not a woman's issue, it's an everyone issue.  We're gonna spend some time talking about what is to me just a tragic trend which is the issue facing our country in terms of prevalence of diabetes and finally, we're gonna talk about the manner in which health insurance plays a critical role in terms of thinking through prevention strategies and weight management and obesity treatment.  So with that in mind, it is my very sincere pleasure to introduce Ellen Granberg.  Ellen is Associate Professor of Sociology at Clemson University where she specializes in the study of the mental and emotional consequences of obesity, dieting and weight loss.  Most recently, Dr. Granberg has published papers on social and emotional adjustments required to successfully sustain weight loss over time which is something we would all like to see more of.
[ Applause ]
>> Good morning!
>> Good morning!
>> As Dave said, I'm gonna set some of the context for this morning's panel by talking with you briefly about the history of dieting.  It's a long and fascinating topic and there isn't really time to do it justice.  So instead, what I wanna focus on today are two questions that I think are really relevant to what we're gathered here for and the first is, you know, when and why did America become a nation of dieters?  Now until I got interested in this area, I know I personally anyway assumed that Americans were relatively unconcerned about weight until the mid1960's when Twiggy and the miniskirt made their debut and changed everything.  But as I started to do more work in this area, what I've realized is that our national reaction to Twiggy and the course of diet history since then isn't something fundamentally new.  It's the latest chapter in a much longer story with roots going back at least to the dawn of the 20th century.  Now prior to that point in time, prior to about 1900, we weren't a country that glorified obesity but we did tend to equate extra weight with health and vitality.  We associated a little bit of girth with both our personal and our national prosperity.  But by 1900, this really began to change.  Obesity started to be seen as negative and poor diet started to become framed as a major culprit.  So to give you a little bit of a sense for this, I wanna share with you three quotes that I think do a good job of characterizing the way people started to talk about obesity and weight around 1900.  The first comes from a cookbook published around that time.  The author wrote that "An excess of flesh is to be looked upon as one of the most objectionable forms of disease."  A contributor to The Nation in 1914 asserted that "Any healthy, normal individual who is getting fat is unpatriotic."  This third quote is from a USDA nutrition researcher who was prominent around the same time and he emphasizes the importance of dieting to avoid unhealthy weight gain.  He wrote that "Unless care is exercised in selecting food, a diet may result which is one-sided or badly balanced, one in which protein, carbohydrate or fat is provided in excess.  The evils of overeating may not be felt at once but sooner or later they are sure to appear, perhaps in an excessive amount of fatty tissue, perhaps in general debility, perhaps in actual disease."
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>> And I think these quotes are helpful because they show us that the attitudes we think of as being so recent have roots that go back much further.  So this leads to what I think is a really interesting question, why this change at this particular point in time?  What was happening in the late 19th and early 20th centuries to bring about a change in attitudes for guarding body size norms?  Now there isn't time to talk about these causes in full but I do wanna briefly highlight three developments that I think are especially relevant to understanding the dieting landscape in which we're living today.  First, this was a period of change in the way we thought about health and disease.  Infectious diseases were becoming less of a threat which reduced the health benefits of carrying a little extra weight.  Attention to chronic illness was also increasing and this highlighted obesity's role in the risk for premature death.  So the meaning of obesity and its former association with vitality was breaking down because of advances in disease control in medical science.  Nutrition science was also really developing rapidly at this time and researchers had made some important breakthroughs in understanding the energy content of food and the physiology of food metabolism and this was important because it meant that for the first time we had access to dietary advice informed by scientific research.  Finally, this was the era in which labor-saving devices came into more common use.  The automobile, the trolley car, household labor-saving devices decreased the amount of energy required to conduct the regular activities of daily life.  As these demands lessened, individuals had to reduce their dietary intake in order to avoid gaining weight.  So when we consider the particular kinds of social change underway at the dawn of the 20th century it's perhaps less surprising that attitudes about obesity were evolving and interest in weight and diet was becoming more widespread.  Now as you might expect, this led to a surge in weight loss gimmicks and you probably saw this poster out front.  It's an example of a product advertised at the time, La Parle Obesity Soap which this ad asserts never fails to reduce flesh when directions are followed.  [Laughter]  And what I find actually particularly interesting about this is that in 1903 this soap caused a dollar a bar.  Now the rise in interest in dieting and the surge of weight loss products relates to the second question I wanted to talk about today which is when and how did the dieting infrastructure we live in today get started.  When did calorie counters, dietary guides, weight/height standards, diet plans and weight loss support groups really get started?  The first modern diet book, the Letter on Corpulence by William Banting appeared in London in 1863.  It was extremely popular.  It was published in America.  I actually saw out front starting in 1864 and it was, by the way, the original low carb food plan.  In 1894 the USDA published the first pamphlet describing the nutritional content of specific foods.  Statisticians used tables, used data from the insurance industry to create the first tables of average height and weight in 1908.  And in 1916 the USDA published its first dietary guide.  So by 1920, a real change in American culture was taking place.  People were becoming concerned about obesity as a health threat.  They were interested in diet and both commerce and medicine were developing resources to encourage dieting and weight management.  What had not yet developed though was this vast dieting infrastructure that surrounds us today.  Now following the Depression on World War II, there was another upsurge of interest in diet and in part this may have resulted from the publication of the first ideal height/weight recommendations in 1943.  But what was clear is that the commercial weight loss industry was growing rapidly by the early '50s.  Now an example of this is the liquid--an early liquid protein diet, Metrecal.  It entered the market in the 1950's.  It had sales of 40 million by 1960.  In the '50s it was also the time when it became popular to market foods on the basis of their low calorie content.  Between 1950 and 1955 sales of diet soft drinks increased nearly 3,000 fold and by 1961 it was estimated that 40 percent of all Americans were using some form of low calorie product and the miniskirt had not gotten here yet.  Now this was also the era of the diet book.  They became widely popular and by 1959 there were over 100 in print and the slide shows you a few of the more popular ones.  Now, finally this was also the period in which weight loss support groups became available.  One of the earliest, Taking Off Pounds Sensibly or TOPS formed in 1948, Overeaters Anonymous started in 1960 and Weight Watchers in 1964.  Now today groups like these, much like calorie guides, they're just a part of the background of everyday life and we don't really think about there having been a time when they didn't exist.  But several years ago, I did some field work interviewing women who had been very early members of Overeaters Anonymous and Weight Watchers and they recall that before the advent of weight loss support groups, the average person had very little access to diet help that they thought of as being both trustworthy and affordable.  So weight loss support groups, being inexpensive, were innovative for these women because they offer the opportunity to connect with and learn from other people who were trying to lose weight.  Now by 1970, the diet environment we have today was largely in place in its fundamentals.  Medicine and commerce were active in the dieting arena and large proportions of the American public were watching their weight.  So to close I just wanna offer two summary observations.  First I think it's worth noting that not only did interest in dieting and concern about weight develop earlier than we often think.  It also developed for many of the same reasons that we focus on as being unique about our time today, for example technology reducing energy requirements.  So we're actually living out a much longer story that might be--than might be immediately apparent to us today.  Second, when we look at today's dieting infrastructure, I think it can be easy to focus on what it doesn't do or the progress that we haven't yet made but if we consider the state of our scientific and cultural knowledge as it existed in 1890 then the ways in which we've made some important progress become more salient.  For me that's important because it suggests that we're not yet where we wanna be but we have made some measurable advances and we should continue to do so in the future.  So I very much appreciate the opportunity to be here today.  Thank you.
[ Applause ]
>> Thanks Ellen.  Our next speaker is going to be talking to us about something near and dear to my own personal heart which is women and men when it comes to weight loss.  I am a lifetime member of Weight Watchers, a fact that I'm very proud of.  I first went on the program about 10 years ago.  I became a lifetime member about two years ago.  I'm kind of a slow learner so it took me a little longer.  But, you know, I think what's interesting for me is the topic of men and weight loss is endlessly fascinating so much so that I spend an hour or two each weekend writing a post on my blog, Man Meets Scale, which as you can see I shamelessly promote, where I have the opportunity to navel-gaze and try to figure out why I do the things that I do and why I became the person I became and how I have weird food habits.  And, you know, I think that obesity is just such a common issue yet there are such significant differences and I think again the better we understand those differences the better we are in talking to people about how to address them.  But again, I'll just reemphasize the point that obesity is not--it's no longer a woman's issue.  I mean if you go back in the history of dieting, it really was.  It was sort of verboten for men to even talk at whisper level about the topic of weight.  I think that's starting to change and I think if it is starting to change it's a good thing.  Our next speaker who's gonna talk about that is Karen Miller-Kovach, Karen--my bio for Karen is, you know, a friend, co-worker and partner in crime for the past ten years but it seems that Karen actually has an official bio [laughter] which is Karen is Chief Scientific Officer of Weight Watchers International where she chairs our global R&D team and coordinates clinical research initiatives.  Before joining Weight Watchers, Karen was Director of Nutrition Services at the Cleveland Clinic Foundation.  She's been a Healthcare Administrator, nurse practitioner, clinical researcher and is the author of six books for numerous scientific papers.  Karen?
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[ Applause ]
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>> Thanks, Dave.  The topic is men, women and weight loss and I'll shamelessly promote my book [laughter].
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>> Where this book came from was that over the last 10, 15 years or so, Weight Watchers has done a fair amount of proprietary research not only on, you know, the physiological differences between men and women and weight loss but actually more importantly how people--the differences between the genders and how they think about weight, how they behave in terms of weight and the implications for that in relation to weight loss methods as we move forward in terms of this healthcare crisis that we are facing.  And I think that both Dave and Ellen made the point quite well in that when you look at the history of weight loss, it has been seen as a female issue.  So what that means is that all of us, you know, maybe unless you were on 1860, have grown up in a culture and in an environment where weight is a woman's issue.  That has an influence on our treatment methods.  All of the research that has been done in the area has had a bias and a grounding from a female point of view.  And when it comes to weight management the question is are men and women the same and our research would suggest no.  And so I'd like to take you through some of the differences between men and women and see if they sound right to you.  One of the things that frequently is though of or mentioned in terms of weight management is that women are emotional eaters and in fact our research would suggest that both men and women are equally emotional eaters.  Here's the difference.  Men eat when they're really happy, when they are in a joyful situation, when they are having a good time and emotion is running high in a positive way.  Women tend to be emotional eaters and equate that with sad emotions.  I'm angry, I'm depressed, I'm bored.  But I think it's important to keep in mind when we talk about emotional eating what emotion are we talking about because you just cannot make the assumption that emotional eating is cued with negative emotion, which is generally anything you read or whatever in the popular literature that's what you'll see.  Women have a high perceived knowledge of--in relation to weight management.  Men are less knowledgeable and I don't think I'd get into this but men don't like a lot of sources for their information.  They just want one source.  Who do they want their nutrition and weight management information from?  Their wife, much more important than anyone else.  [Laughter]  Men tend to have less experience.  We'll talk about that in terms of weight management, and they tend to prefer to make big changes.  "I'm cutting out the beer, no more burgers, no more fries," whereas women tend to make small changes.  "I'm gonna from regular mayo to light mayo."  [Laughter]  When it comes to approaching or thinking about weight loss, men and women also are often polar opposites of one another.  Women like lots of ideas.  Women can't get enough tips, suggestions, ideas of things to make, things to eat, things to try.  Men, strategic.  That's higher level.  I don't--you know, I just--I wanna know what to do, I wanna know where to go and I wanna get it done.  They like simple instructions.  Don't eat that.  [Laughter]  Women say, "Well I know I shouldn't eat that but maybe if I do this then," it's very, very different that way and the kind of information and the type coming out of that that men and women want is very different.  Exercise is yet another area where men and women are very different.  Women more and more are willing to work out but what we know is they don't do it 'cause they like it.  They do it to manage their weight.  "It's something I gotta do, generally, you know, if I wanna keep my weight in check, if I wanna be healthy, if I wanna look good, feel good, I have to exercise."  Men on the other hand tend to actually enjoy it.  They also are very different in that women like things kind of the opposite in terms of food than men and, you know, this is where we change roles, is women tend to like things simple.  "I wanna walk.  I wanna do something that I can do, enjoy, you know, that kind of thing."  You know, men really like those heart rate monitors, you know, high tech toys, the little gizmos, you know, very competitive in terms of, "I wanna track, I wanna be able to know what I'm doing and do better."  And [laughter] let's talk a minute about awareness, we have, and you know in terms as we've grown up have we not heard that there are many women out there that don't need to lose weight and feel they do?  The typical man doesn't feel like he needs to shed any weight until he is obese.  Another area of research that we found is what is the motivator?  What is the driver in terms of weight loss?  And one of the things that we see often in our research is that it's age-related and while we can't say for sure, it does appear that there is a definite difference between men and women.  What we cannot always tell is that men generally when it relates to weight have health as the motivator and what we don't know is that because they are now developing health issues and their doctor has that, you know, "Hey buddy, you're gonna have a heart attack if you don't shed that belly," or which is speaking to what Ellen was working at, in terms of where society was and where we're moving, men are much more becoming objectified as sexual beings based on their body.  And so the younger men now have a greater interest in it relating to appearance.  So putting this all together, what does that mean in terms of weight management approaches?  Simply, I always describe and many do, weight is a battle of the bulge.  The difference is that women approach it as the 100-year war.  They negotiate.  They have an offensive then they retreat then they negotiate, "Well, you know, I wanna lose 10 pounds but if I lose five I'll be okay, if I do this, that's okay," and then simply are unaware, unaware, unaware, find themselves obese in an area where they have a health crisis and they declare war.  It is the Invasion of Normandy.
[ Laughter ]
>> And this also then plays out and once that awareness or once that happens how is the best way to help the men and the women of the world to get rid of that excess weight.  Again, men are top-down thinkers.  Tell me what to do and I'm gonna do it and if it starts to work then I might start asking you some questions like, "Why am I doing this?  What does it do?"  Well, I mean understanding it.  But they don't care to know the details until they've started and they know it works.  Women won't start anything until they know every absolute little detail about it.  And so, in terms of as we approach weight loss, men and women are very, very different.  One of the key areas just like emotional eating where the genders are different but it's words as more than meaning is when it comes to support.  Women want lots and lots of verbal support.  They love unsolicited comments and feedback.  "You look great.  What are you doing?  Oh, I saw that you had that for lunch.  What's the thinking behind it?  You know, I tried this."  Guys, no, they want very practical support and only when they ask.  If I ask you a question, I appreciate the answer.  Don't volunteer.  Don't tell me I should have the salmon [inaudible] to eat unless I've said, "What should I eat?"  Then they want the advice.  But don't be thinking that men don't want support in terms of when they are losing weight.  They absolutely do, it's just a different kind of support than what women want.  What we know and several studies have shown is that because of those differences, when genders unite good things happen.  There was a study that was done in Australia.  Did you know that one of the most predictable times of weight gain for both men and women is the first year of marriage?  In fact, there was a CDC researcher that actually put in a paper that never went anywhere that he felt that the government should issue a warning [laughter], "Be careful, marriage is bad for your weight," but it didn't really go anywhere.  But there was a study in Australia where they took couples who were starting to live together and get married and as a couple worked in terms of weight management and they found that during that first year of marriage which is a very highly vulnerable weight gain period, they were able to prevent it and they were able to do that more successfully when working with the people as a couple than men and women differently and it makes sense.
^M00:40:05
>> Why would that--why would that make sense?  Because when men and women unite, they have a shared eating environment, they have shared activities and they have mutual support and because there are differences in terms of the approach, men and women have a lot to learn from each other and to be able to help each other in terms of weight management.  So in conclusion, what are the implications for this as we move from the past to the present that we're in now and going on to the future?  One is that men, you gotta wake up and look at the scale so that preventing weight gain prior to obesity, that there is an awareness and action is taken earlier.  And also continuing to have women understand when overweight and excess weight is a health issue and not encourage those that do not need to lose weight for health to try to do so.  I think a very key area of research for us and understanding is in the differences of gender and incorporating that into programs and services.  We've really developed skills in terms of adapting treatment interventions for ethnicity, for age, for all kinds of things but when it comes to weight, gender is so basic and it isn't something that we've looked at.  And lastly to leverage those differences so that as we work to improve the weight of our nation, we can maximize the good for both genders because as Dave said, obesity and weight management isn't a woman issue, it's an everybody issue and each gender brings a lot to the table in terms of helping us solve this problem.  So with that, thank you very much.
^M00:42:10
[ Applause ]
^M00:42:18
>> You know, you can't spend 11 years working for Weight Watchers and not get a little bit in touch with your feminine side [laughter] and I'm here to publicly announce that sometimes I eat when I'm sad.  [Laughter]  On to maybe a more heavy topic if you will--sorry, that was a bad pun.  You know, one of--I remember seeing a map of the U.S. that I saw referenced on a link on one of these Google News alerts that I get each day on obesity, but it is a map that anybody can see and Ann might actually be showing this but anybody can see on the CDC website which shows insidious levels of diabetes literally of the county by county level.  It is horrifying, period.  It is amazing that this condition has gotten as bad as it is and it's even that more frightening to think that this condition is likely to get as much worse as it's gonna potentially get.  It is the leading driver of healthcare cost associated with obesity, it is the leading driver of co-morbidities associated with obesity and it's truly becoming a national healthcare epidemic.  To talk about it, we have Dr. Ann Albright.  Dr. Albright is Director of Division Diabetes Translation at the Centers for Disease Control and Prevention in Atlanta.  She leads a team of more than 100 experts who work on diabetes prevention.  Among her work is the implementation of evidence-based diabetes care guidelines.  She has also developed models for care for community clinics and launched campaigns inquiries for your understanding of diabetes.  Dr. Albright has held key leadership roles with the American Diabetes Association, the American College of Sports Medicine, the American Association of Diabetes Educators and the American Dietetic Association.
[ Applause ]
>> I really wanna expression our appreciation at CDC for the invitation from the Library and from the sponsors of this meeting, really happy to be here with you today.  I'm gonna get a little group involvement here for a moment.  I'm gonna ask you a couple of questions and when you put your hand up, leave it up, okay?  How many of you in this room, if you're comfortable acknowledging this, how many of you in this room have diabetes?  How many of you in this room have a family member or close friend with diabetes?  How many of you know someone, co-worker, anyone in your life who has diabetes?  Okay, look around the room.  This tells you what the prevalence is like in this country.  If you don't know someone today or it's not impacting you personally today, it is highly likely that it will tomorrow.  So I hope that as you listen to this information and we talk about what we can do to stem the growing tide of diabetes that you do think about this not only from your personal walk in life and your profession walk that it really is impacting society as a whole.  It impacts us as individuals.  It impacts our loved ones and it is impacting us as a country.  So I would hope that you'll look at all of this information through all of those lenses.  So we are gonna talk about this.  It is an epidemic.  Sometimes people debate whether it's a growing epidemic.  Is it an epidemic yet?  Yes, it is an epidemic.  These are data for today and we actually are about to release new data very, very soon on what we refer to as the total number of people in the country.  We call that prevalence.  If 24 million have diabetes about a quarter of them do not know they have it.  So it still is a disease that people can walk around with and not know they have it although we've made progress.  This used to be about half of the country who had diabetes didn't know it and now we're done to about a quarter.  But look at what's below the surface.  Does this remind anybody of Titanic?  Look at what's below the water line.  It's people who we refer to as having pre-diabetes and I'll define these really briefly only 'cause I wanna make sure we're all on the same page.  So this gives you a sense of the magnitude of the problem and we'll give you a little more info about where we're headed.  I wanna just touch on this information 'cause there is a lot of confusion.  There is more than one form of diabetes and when we talk about diabetes we oftentimes don't distinguish and for those that have other forms of the disease in the most common form.  They actually get really quite frustrated because they can't prevent their form of diabetes and it was not a lifestyle issue that resulted in the development.  So Type I diabetes is usually diagnosed in children but can also happen for young adults but it can be diagnosed at any age.  It is due to an autoimmune and genetic and actually environmental component but the environment is not what we normally think of in the environment.  It is not about lifestyle.  It tends to be things more about exposure, things that have to do with your autoimmunity and your ability to fend off whether it's mumps, measles, Coxsackie B, protein in cow's milk, a number of initiators that cause Type I diabetes to develop.  It accounts for about five percent.  So those of us in the room who raised our hand that have diabetes and those of us that have Type I, we are the minority.  We have the--we are the smallest number that have this disease.  We have to be on insulin.  You cannot survive if you are not on insulin.  It's not a choice.  It is the medication that is life-saving and you must take insulin.  There is no yet known way to prevent Type I diabetes.  Now let's look at Type II.  This is the one that we much--hear much more about.  It is the public health problem in this country.  It does most often occur in older adults or in adults.  It often times is referred to as adult onset diabetes.  That's actually no longer true.  We are now seeing youth who are developing Type II diabetes and of course that is a concern for all of us.  However, the most common form of diabetes in youth is still Type I except for American Indian children and short on the heels of that, African-American and other high-risk ethnic minority populations.  We are now beginning to see many more children developing this but we have the only study of its kind at CDC.  We are monitoring diabetes in youth, all forms of diabetes and we're able to provide the only data really available for the monitoring of this condition.  This does result from a combination of resistance to insulin and insufficient insulin production and this form of the disease can be prevented or delayed and that's the good news part of the story that we'll share in just a minute.  And then it would be remiss if I didn't mention really the third form of diabetes.  Type I and II are the most common.  They are--they're responsible for the majority but there is just gestational diabetes and this happens when women are pregnant.  It's not as if you had Type I and you got pregnant and all of a sudden you magically have gestational diabetes.  This is the form that's first diagnosed during pregnancy.  The real deal with this one is that it is almost as if you got a preview.  If you have gestational diabetes you are at very high risk as you get older for developing Type II diabetes.  So it's a little preview.  So this is a population that really should be targeted for our intervention efforts because we've gotten a little window into the future for these women.  Pre-diabetes, this is a term that is actually a little controversial.  There are some people who don't like this term.  They don't--a pre--what's a pre something?  Is it a pre-hypertensive pre this--our colleagues in Europe really don't like this term but it is a term that has wrung with many Americans.  It is a blood glucose level that's higher than normal but not high enough yet to have diabetes.  So it's as if you're standing on the cliff.  You're at the edge.
^M00:50:08
>> This is giving again an indicator of being at very high risk.  Now not everybody with pre-diabetes will develop diabetes but this constitutes being at high risk.  We do have really strong evidence that tells us these are trials, randomized trials that have been done in the US, NIH-led trials and we have international trials that have shown us that we can indeed prevent or postpone Type II diabetes.  The later and longer you wait to get it, the less likely you are to suffer those complications.  What are the complications of diabetes?  Anybody know?
>> Heart disease.
>> Heart disease?  Big one.  I mean it's the number one killer in this country but heart disease and stroke are actually really significant.  And for women with diabetes it's even more of a risk for us.  Often times people will say, if you have diabetes it's as if you've already had a heart attack.  It gives you that sort of cardiovascular risk.  How about another one?
>> Neuropathy.
>> So neuropathy so it can affect your feet, your hands, your sexual function, your eating ability.  So you have both the autonomic and peripheral nerve problems as a result of diabetes can.  How about another one?
>> Blindness.
>> Blindness.  Number one cause of blindness in this country, anybody name another one?
>> Kidney failure.
>> Kidney failure, number one cause of kidney failure in this country.  It is the number one cause of lower limb amputation which is a combination of nerve problems and circulatory problems.  Again, the good news is these don't have to happen but in order for them not to happen, it means that people who do develop this disease have to have the ability to access good medical care, good self management training and good support because this is a 24/7 gig.  When you get diabetes, you don't get to sort of have it and decide you're gonna pay attention to it some days.  This is the real deal and you have to be able to pay attention to it and it does require support, medical management and strong self management training so you can learn how to live with it.  But let's turn our attention to what the data is telling us about the maps that we're referenced.  I'm gonna reference state maps, would you go to our website please?  You can look at county level data and I'm actually gonna put up data that looks at obesity and diabetes together.  If you don't look at anything else on the map, appreciate the colors.  The darker they get, the more--the greater the number of people who have these conditions whether it's obesity or diabetes and you can see what's been happening.  As our first speaker gave us the history of weight loss, here's a bit of the history of weight gain and diabetes in the country.  It is important to emphasize that this is what we call the prevalence, total number.  In an incurable disease like diabetes--and I'm happy to answer questions about whether or not you can cure any forms of diabetes or not yet, you can't give it back.  So prevalence goes up because people are living longer with the disease and because many more people are developing the disease.  So it's important to remember that as we're looking at this information.  Yes the numbers look darker and more frightening but it is a combination of people living longer and more healthfully with the disease as well as more people developing it.  That's what we wanna work on, is reducing the case--the number of people who develop the disease.  So here's a little bit more data for you and then I'll tell you finally about our National Diabetes Prevention Program.  One in three adults--this is our data from CDC--are projected to have diabetes in the year 2050.  Again as I've said it's for a variety of reasons, not all of which are bad but it really does tell us we've gotta focus on prevention.  If--it could be as low as one in five but again, these are if our trends continue or if we improve them to some degree but we will continue to see new cases.  If you want a point of reference to that, one in ten have diabetes right now.  So if you look around the room, count one, two, three, one, two, three, one, two, three, again if the hands go up, it'll be all of you in the room.  It is important when we're dealing with diabetes prevention and control to look at it from a multifactorial perspective and some of the previous speakers really touched on this.  It is important to consider the individual and what the individual needs to do for their own personal responsibility, if you will, for their own choices et cetera.  But people, as you look at the wording along the bottom, the health of the individual is inseparable from the health of communities.  People don't live in isolation.  So it matters what's going in the family, it matters what's going on in the environment around you, it matters what the policies are in this country that will help support people to make that healthy choice, the easier choice.  And it also matters that we work in childhood issues but you cannot forgo the issues in young adulthood and adulthood because we already have almost 60 million adults with pre-diabetes who are stepping off the cliff.  So we need to really work on preventing Type II diabetes and I wanna really close by sharing with you the National Diabetes Prevention Program that has been established.  It was authorized in the Affordable Care Act.  So CDC has been authorized to set up a National Diabetes Prevention Program.  We are taking the evidence that has been proven by well done scientific studies in the US and around the world where we know that by losing about five to seven percent of your body weight through healthy eating and physical activity of 150 minutes a week that you can prevent or postpone this disease.  It is delivered in a group program format.  It's 16 course sessions and then monthly meetings thereafter.  And what we're doing at CDC working with really critical partners including the YMCA of USA right now and UnitedHealth Group, they are critical partners for us because they're actually putting this program on the ground in your communities.  We're helping train the workforce.  It's great if we have these wonderful ideas to do things but if you don't have a trained workforce to deliver it and it can't just be healthcare professionals.  We've got to expand the workforce.  Establishing a recognition program so we can assure quality and fidelity so that really what we put on the ground makes a difference.  The fact that this is multifactorial and that it's gonna require work in different segments of the population, it's gonna require different interventions, we have to choose wisely.  So you can't just do any old thing that sounds good and looks nice.  It really has to be effective.  And right now the programs are in over 28 locations.  The handout that's in your bag also lets you know what's coming into the future.  So we're gonna hold out a lot of optimism for the direction that Congress is taking but the fact that this is a combined government, private sector, community organization intervention, we have a great opportunity to truly build a prevention system for this country.  Thanks.
[ Applause ]
>> So rounding out our list of speakers, we're now gonna hear about what does all this mean in terms of being on the ground and addressing weight management particularly as it relates to our current payer system.  And with that, I'm pleased to introduce Patrick O'Neil.  Pat is Professor at Psychiatry and Behavioral Sciences at the Medical University of South Carolina where he's also a Director of the Weight Management Center.  He's the author of more than 100 professional publications, chapters and presentations focused primarily on psychological, behavioral and clinical aspects of obesity and its management.  Dr. O'Neil is also the President Elect of the Obesity Society, the leading scientific society dedicated to the study of obesity.
^M00:57:43
[ Applause ]
^M00:57:51
>> Thank you very much.  Here we go.  I really appreciate the chance to talk to you.  You do not equally appreciate the chance to hear me when you're supposed to be starting lunch right now.  [Laughter]  I'll try to be mindful of the time.  When I first got this invitation I was thinking back to all the times I'd gotten thrown out of the library when I was growing up in Thibodaux, Louisiana and I though here I am not only being invited to the Library of Congress but they want me to talk when I get there.  [Laughter]  So there're several librarians from that day, good ladies who are now spinning in their graves.  Just in the interest of disclosure this is recent support sources that I've had.  We did wanna mention some numbers that came out just last week I believe in a report from the Society of Actuaries to really drive home the impact that the obesity epidemic is having on healthcare and healthcare cost in this country.  This was an estimate that the economic cost of obesity plus overweight are what you see here, 300 billion dollars annually in the US and Canada and 90 percent of that, about 270 billion is ours here in the US and this includes the cost of medical care not treating obesity but treating the excess amounts of these co-morbid health conditions that you've heard about as well as the productivity losses from excess mortality and excess disability associated with obesity.  So if we're thinking about healthcare costs, it's hard not to think about this.  I'm supposed to talk about what's going to happen in the future in terms of treatment and prevention of obesity and my crystal ball's basically been at the shop for some time.  So that won't take a long time but I wanted to focus on a couple of things that we should really be mindful of and think about when we're addressing this very, very important and pervasive and complicated problem.  First is that there are so many different influences on whether you're going to become obese or not.  There are contributors to the likelihood of becoming obese from the level of genes, cells, organ systems, other biological functions, psychological factors, behavioral factors be it dietary intake or exercise level, social factors, societal factors and environmental factors.
^M01:00:15
>> And I think it's really important to remember that all of these influences are operating on each and every person to different degrees.  We're learning more and more about contributors to obesity in some cases that we never would have thought about.  Dr. Nikhil Dhurandhar and Dick Atkinson have identified a virus which if you are exposed to this virus you are much more likely to be overweight or obese even though you might have a lower cholesterol level.  There's a recent paper a couple of years ago showing that people that had certain types of bacteria in their intestinal tract were less likely to be obese than if they did.  So I think as we learn more and more about the many pathways to obesity we should become much more conscious of the fact that just because somebody is obese it doesn't mean they got there the same way anybody else do.  As it turns out unfortunately out treatments really don't target the causes of obesity to any great extent.  So there's very little coordination between the contributors to obesity and the ways that we try to reduce obesity.  It's also important to remember that this is a chronic condition.  Again, as Dr. Albright said about diabetes you really have a hard time giving it back.  If you at 150 pounds and you gained to 200 pounds and then you lose back to 150 you don't have the same body you had initially.  Weight lose is often a temporary victory.  When you lose weight hunger hormones tend to increase satiety or fullness hormones tend to decrease, metabolic rate can drop and so there's this biological press to regain the fat that was lost.  I also think it's important to remember that this is not a sort of morally and socially neutral condition.  Obesity is spurned by many people.  Obese people are the victims of pervasive bias and prejudice directed at them because of their quite visible condition.  And there's quite a bit of moralism that's get thrown in to the mix off.  If you hear people say "Well, I don't know what the problem is.  They just need to push back from the table."  Well, if you've got certain physiological factors going on that make certain foods more rewarding to you, you may have genetic factors that actually make it less likely that you will benefit from cardiovascular training and that's been identified.  It's a lot harder for you to push back from the table or go out and start exercising than if that's not case.  There is certainly a role for personal responsibility but we've got to sort of be able to think about the part that the obese person can play in rectifying their situation while appreciating all of these other factors that are making it perhaps more difficult for many of them.  I'm gonna skip this and the next slide.  We all--we'll be talking about treatment and prevention.  And I'll assume you're aware of the differences there.  I do think it's important to recognize as we look ahead and we think about new approaches to treatment or prevention that we think about how we're going to assess them.  There's a lot more emphasis on evidence to support anything that's done clinically or on a public health basis these days.  And really treatments and prevention efforts should be judged somewhat differently.  When judging treatments I think it's really important that the risk benefit analysis include the cost of doing nothing, okay?  It's not if you take this medication or have this surgical procedure the risks are these, the benefits are these.  You need to realize what happens if you don't lose weight, if you don't receive those treatments.  I think it's important in evaluating treatments to remember that it's not necessary for everybody to get down below that magic BMI or 30 much less 25.  You've heard the losing 5 to 10 percent of your weight can make a huge difference in these comorbid health conditions that are so much of a cause of obese.  If we're gonna talk about treatment we need to remember that maintenance is a separate issue often if there's a treatment which is designed to be short term if it accomplishes its goals in the short term that does not mean that it's effective for long term maintenance but at the same time maybe it shouldn't be judged for that if that's not the original intent.  And maintenance efforts I think need to be judged according to--I'm sorry prevention efforts need to be judged according to what their mission is as well.  You shouldn't accept--expect a public health level intervention to really produce weight loss.  Let's look at what it's targeting, what specific behaviors it might be targeting and see if those are changing.  So what about the crystal ball?  What does it have to show us for the future?  Well, right now as you may be aware there are very limited choices available in terms of medications for weight loss.  Last year the FDA reviewed applications on 3 potential new weight lost applications.  They have not made a final decision on any of those 3 if one or more of those are approved I think we'll see the physicians will have at least 1 or 2 more options available to them than they do now.  Frankly, if one of these medications is approved for long term use that will double the number of medications that are approved for long term use in this country.  Regrettably, behind these 3 potential medications there's not much in the pipeline of other pharmaceutical approaches that's anywhere near approval at this point.  And the other thing that's unfortunate is that all three of these medications which are being considered now are all CNS drugs.  They all affect the brain to reduce appetite or feeling of fullness.  You're all aware of Bariatric surgery.  This will continue to be I think a very useful and important option for people whose obesity places them at more severe risk of medical problems and whose obesity is more intractable.  We're seeing this becoming much, much more mainstreamed over the last 10 or so years.  I think that will continue to be the case.  And I think we'll also see in the future that this will become some--obesity control, weight control will be something which is much more obvious and much more apparent in primary care settings of health care.  Particularly if we can equip physicians with some more tools to help their obese patients than they currently have.  And we can at least encourage physicians to try to look at--to track body mass index as a vital sign just as they track blood pressure now.  There are some new technologies that are on the horizon in addition to the growing number of smartphone apps and computer programs and online services to help you manage your weight.  If you look in today's USA Today right next to the piece on this meeting is an article about some new apps that help people monitor their health behaviors and health outcomes.  There are some other devices being made to help people monitor their behavior in addition to that.  Activity level monitoring is getting more sophisticated from the humble pedometer increasingly accelerometers which give you much more information are being used.  There are some devices that are being studied that I actually measure heat flux as an indication of on going energy expenditure not dependent on measuring actual motion.  And perhaps far in the future we may have some devices which actually have an interventional purpose to them.  This is data from a very, very preliminary study done by colleagues of mine at MUSC using transcranial direct current stimulation of--electrodes weren't placed on the brain directly as the conceptual drawing shows.  [Laughter]  They're placed on scalp of subjects and they were stimulated just for 20 minutes while they looked at pictures of foods that they craved and then they rated their levels of craving and you can see when people were being--receiving the actual stimulation their levels of craving dropped.  Certainly this is not ready for primetime but just as an idea of things that we might have in the future.  Two other things quickly before we leave treatment.  One is and I think this is very, very important if you think about all the different pathways to obesity and all the factors which can influence a given person's level of obesity and their resistance to weight loss I think it's gonna be increasingly important that we develop interventions that are tailored more to people so that we're not giving the same advice, we're not giving the same medications, we're not doing the same surgeries to everybody regardless of what their individual characteristics are.  And I think you'll see a growing emphasis on ways that we can help people maintain weight loss once they achieve it.  Prevention obviously is highly important in light of the waning minutes or seconds.  I won't go into this in great detail.  Representative Kind raised the very important issue which is the availability of healthy food choices and healthy beverage choices and if those are not available you're not likely to consume them.  And if it takes more effort or more money to get to them versus less healthy choices obviously you are less likely to consume them.  One of the other things that might be worth looking at in the future as we try to develop more effective prevention programs and this could be a very tricky issue but I think that we should take a look at whether it should be socially desirable to walk down the street with a 30-ounce Gulp cup of sugared beverage.
^M01:10:04
>> I think Starbucks is coming out with a 30-ounce coffee which is likely to contain a pound and a half of sugar by the time people get done dressing it up.  So I think we need to look at what we have as social norms about giant quantities of food for example but without demonizing, without stigmatizing obese people.  And that's why I say it's such a difficult and tricky issue.  And I think finally there are things that are being done now.  People are becoming more aware of the fact that the environment we live in contributes to this.  And that the built--the physical environment contributes to this.  We've built for 30 or 40 years subdivisions with no sidewalks and even if you had them there wasn't anywhere you wanted to walk to because it was nothing but single use residential for miles and miles.  People are realizing we need to have more walkable communities when we build streets they need to be with some people are calling complete streets so that there are sidewalks and bike pass so that people can avail themselves of these more active means of transportation or leisure time.  So the built environment can really make a difference and encourage us to [laughter] burn a few more calories and this is not what I had in mind.  By the way I thought--gee, I just have to wonder what that was.  I thought for years this thing was photoshopped.  It's an actual fitness center in San Diego I recently learned.  But here is one that really exists and really works.  This is--this pretty bridge is in my hometown of Charleston South Carolina and it spans the Cooper River in Charleston Harbor.  And after a lot of lobbying by a lot of people including Mayor Joe Riley of Charleston, a highway department decided to include a 12-foot wide lane for bikes and people, bikes and walkers and runners which you see in the bottom left photograph.  And I drive this bridge everyday and it has been amazing to see the level of use it's received, the fact that it's increased over the 5 years since the bridge opened.  And the fact that everybody in the area and a lot of visitors are using it.  It's not just the hard body bikers and marathon runners that are using it.  You can see an example of the diversity of users here with these photos taken on that pedestrian lane and it's really, really heart warming.  The lady in the top right with the walker, I watched her over a number of years and let me tell you she was hardly moving.  I mean she started and then she started going a little faster.  I'd see her in the morning, and the last time I saw her I think she would just have the walk around for exercise for the walker 'cause she wasn't [laughter] using it to any great extent.  So thank you.  I'm sorry to have gone over couple of minutes but thank you for your attention.
^M01:12:54
[ Applause ]
^M01:13:03
>> Thank Pat.  I'm pretty proud to work for an organization that's been at this for the better part half of a century.  It's kind of scary when I say it that way.  But, you know, even today Weight Watchers is running about 50,000 meetings each week, community meetings each week around the world.  We're seeing on average about--we've got about 1.4 million folks.  We've seen these community meetings.  We have another 1 million that we see as online subscribers.  We invest heavily in technology and consumer web-based applications iPhone, iPad, you name it we're spending on it.  And we believe fundamentally in the importance of education, behavior modification provided in a supportive environment.  That is the altar where we worship.  And for this--for as long as we've been doing this we can't stand still and I think none of us can because this is such a complicated issue.  It's one of the reasons why we made the difficult choice but the right choice to completely change out our program after thanksgiving.  If any of you were on it, the day before thanksgiving weekend you were doing 1 program the day after thanksgiving weekend you found yourself doing another program which I would sort of describe as going for an imperial to metric in a day.  But it was the right thing to do.  And I think that you know I think if we're gonna collectively have an impact on obesity we have to act boldly.  And we have to take demonstrable steps in lots of different ways.  I think Weight Watchers has a critical role to play.  We certainly can't do it by ourselves.  It's terrific to see other organizations and other initiatives like the Diabetes Prevention Program.  It's incredibly invaluable to see the sheer quantity of research that goes into obesity is absolutely critical.  One of the things that we who are in the obesity world need to continue doing is making sure that we're giving you all all the information and insights you need so that as you're reporting on this, as you're formulating policy, whatever the case might be that you're armed with the best insights possible for what it is as a health condition is still a relatively newer phenomena.  So with that I'd like to give you another crack at getting some of those insights by opening it up for any questions you might have for the panel.  Yes ma'am?
>> So the farm bill is coming and Mr. Kind referred to it.  What--what would be any of your recommendations about what we should be in the farm bill, the upcoming farm bill?
[ Laughter ]
>> I work for the president, so.
>> She wants to keep her job.
[ Laughter ]
[ Inaudible Remark ]
>> Do you want to take the question?
>> I think the issue of subsidizing high fructose corn syrup is one that bares examination without necessarily demonizing it excessively.  But I'm not quite sure why we are subsidizing a product which certainly contributes more to obesity than to nutrition.
>> Yes ma'am?
>> I really enjoyed your discussion from the entire panel.  Dr. O'Neil I was very glad you got into the built environment and the transportation system that we have deal with right now.  And I wonder if you have any ideas also along the lines of policy if there's any hope of having our federal budget designed with every agency doing a health impact assessment of what their--what their budget priorities are resulting in.  For example, most of our transportation budget goes towards supporting travel of people one at a time in their own car as opposed to complete streets.  And in that in fact is contributing to this enormous cost of obesity and the people that really don't want to voluntarily go to the gym to exercise but would walk to work or walk to the bus or walk to school if they had that nicer avenue how can we--how can we get to this point in this country?
>> I mean obviously in needs to be encouraged and supported.  I don't think anybody relishes the thought of more of mandates from the federal government and particularly if they're not funded.  I think you would find that would not be terribly politically popular right now.  But certainly there needs to be some strong encouragement that, you know, issues like sidewalks and walkability and bicycle lanes and such get addressed.  You know, I live in a place with lots of bridges and one of the things we know is it takes a long time to get a bridge built and it's a long time before they will build a new one after that.  And so if you don't fight hard to get these things included at least in those kinds of structures you may never see them.  So whether they should be required by the federal government I'll leave up to our legislators but that it may be the only way.
>> One thing I would add to that is I hope it gives you all some confidence in the fact that a number of us who do work for the federal government agencies like CDC are now working with Department of Education, Department of Transportation and others to really--we have a mantra at CDC and it is health in all policies.  So we really are--are seeking to be--avail ourselves as good partners and look at policy options that really marry well amongst the agencies within the federal government.
>> Yes?
^M01:18:35
[ Inaudible Remark ]
^M01:18:50
>> --the National Diabetes Prevention Program and what sorts of--how people would access that program and what sorts of numbers could be expected--numbers of people to develop diabetes could you prevent using this sort of program and sort of this--just more about sort of the scope of it and what's possible.
>> Sure.  Yeah let me try to do that a succinctly as possible.  You can't just flip a switch and a national program sort of sprouts up everywhere.  And so we're really been committed to working with partners, write up inaugural have been the Y and United Heath Group United is paying.  They are reimbursing for their beneficiaries who qualify.  This is really directed at those at high risk so those with pre-diabetes or who have other risk status.  Because the evidence is clear, not everybody is at the same risk for developing diabetes.  Not all overweight people will develop diabetes.  Right now we do have--in one year we have managed working with a government, private sector and nonprofit and American Diabetes has certainly been a participant as well.  We are in again over 28 locations there listed.  Our intent is certainly to continue that roll out into the coming years.
^M01:20:01
>> But we are getting other payers on board.  Those conversations are happening and other organizations are interested and also being knows that will offer the program.  But it does need to be done in a systematic organized way.  Otherwise you end up with a lot of nice, nice little programs sort of sprinkled around.  Our goal at CDC is by 2020 that we will have 15 million people exposed to this intervention.  They Y has done their calculations and in that time period they can--they believe that they can reach about 6 million of those people.  So we are very serious.  The risk for people developing diabetes as it stands now and some of you--1 in 3 seems to pop up a lot.  You heard earlier Congressman Kind say 1 in 3.  One in 3 that's the risk, people born in the year 2000 when you look at lifetime risk 1 in 3 are expected to develop diabetes over their lifetime so that's a 33 percent risk, it's about 1 percent per year.  So a structured program like this is critical but it must be complimented by environmental changes, by work in childhood obesity so that we have fewer people ever developing pre-diabetes.  All of these are required in order for us to really reach the goal we want which is fewer people developing type 2 and more healthy people who develop diabetes.
>> Just a comment on the person with the active environment raising it I was very pleased to see that.  The nation just had their first physical activity plan launched in May and that is all policy based and it's done on a sector basis so you've got education, transportation and act of living, parks, recreation, fitness and sports, health care, public health, media and we as National Coalition for Promoting Physical Activity are leading the implementation of that effort along with many of the nonprofits that specialize in health as well as some of the other areas.  And if you'd like to get involved with that please see me afterwards because it is all policy based and it was a cooperative effort with the CDC and academia as well.
>> Okay.  We can take one more question.  And I think I saw you first.
^M01:22:10
[ Pause ]
^M01:22:19
>> So for many companies in the United States for example like 7-Eleven or Starbucks where they have those big Gulps, and you know, the big sized drinks and the popcorn and chips in them, so many--many obese people, you know, shop there and there are adults--the adult sizes.  But I'm curious about the taxes and the tax price where the small drinks, maybe they would have a smaller tax on the drink and the larger maybe they could increase the tax to encourage people to think twice about buying the larger option of a drink or a size food.
>> Would any of our panelists like to gamely jump into the topic of soda tax?
[ Laughter ]
>> Do I look like your third real go-to guy?
[ Laughter ]
>> This has been suggested, using taxes has been suggested by a number of people as one potential public health approach to at least trying to prevent increases in the prevalence of obesity in a way of curbing consumption.  Some people have talked about per ounce tax on sugared beverages.  There actually were one or two pieces on this in the New England Journal of Medicine in the last 2 or 3 months I guess.  Suffice it to say that there are two elements to this debate.  One is the scientific debate about what the likely impact would be in reality in terms of consumption and weight but the consumption in particular, but of course the other side of this is the political one.  And that obviously is the part that would have to get resolved before anything on the scientific side could ever get implemented.  People often point to the data from tax rates on cigarettes and their impact on smoking rates as an example whether that would apply to this or not I don't know.
>> The one thing that maybe is also worth mentioning that has happened that I think we can all take some comfort in is that one of the provisions that did pass as part of the Affordable Care Act was a national standard on menu labeling in restaurant chains.  We at Weight Watchers have always been big supporters of that provision not because we think companies need to be taking the task but rather because we believe knowledge is power.  And that when people can actually see what they're getting access to it makes it easier for them to make a healthy choice since we thought that was a great provision.  It's going in as we speak and it's sort of fascinating for me living in New York or working in New York City I should say to where you have menu labeling already, you walk into a Starbucks and you literally still hear people committing 400-500 calories for that?  So it can help, so little--little bits here and there can ultimately add up to a big difference.  I'd like to extend my thanks first off to all of you for coming and certainly to the panelists particular Pat for taking all the really hard questions.  [Laughter]  And I'd like to just remind everybody that the Library of Congress has recorded the discussion and it will be posted on the Library's website within the next few weeks.  Thank you.
[ Applause ]
>> This has been a presentation of the Library of Congress.  Visit us at loc.gov.