Dr. William Dietz, Director, Sumner M. Redstone Center for Prevention and Wellness at GWU

Mark Masselli: This is Conversations on Healthcare, I'm Mark Masselli.

Margaret Flinter: And I'm Margaret Flinter.

Mark Masselli: Well, Margaret here we are again wondering what will become of the
th
Affordable Care Act based on another pending Supreme Court decision. June 16 is
the expected decision date for King v. Burwell a case that could have far reaching
implications on the fundamental foundation of the health law and its financing.

Margaret Flinter: And the case is challenging one of the econo mic foundations of the
healthcare law.

Mark Masselli: So here's what's at stack, the plaintiff argues that the law prohibits
residences states without state run health insurance market places from receiving
federal tax credits and cautionary reductions. If a high court decides in favor of the
plaintiffs millions of Americans will lose these vital tax subsidies that help fund their
health insurance.

Margaret Flinter: If the high court rules against this provision it will very far reaching
implications. A nd as you say Mark millions of newly insured Americans who rely heavily
on the ACAs tax subsidy provision could lose their benefit. And then the medical
industry would feel the brunt of it as well. It's estimated that physician practices,
hospitals, pres cription drug, other medical spending could see up to a 35% drop in
business if these millions of Americans lose coverage. And of course that's without
quantifying the price tag for what happens in the absence of prevention and effective
treatment.

Mark M asselli: We've said all along the healthcare law will continue to run the gauntlet
of challenges. But as providers we've seen the ACA having benefited so many
previously uninsured Americans who now have a affordable access to prevention and
good chronic disease management.

Margaret Flinter: Well insured or not America has another problem Mark, and that's
obesity. An estimated 1 in 3 Americans is obese or overweight and add significant cost
to the population's health. And our guest today is a world reno wned expert on the topic.

Mark Masselli: Dr. William Dietz is Director of the Sumner M. Redstone Global Center
for Prevention and Wellness at George Washington University. He'll talk about new
prevention initiatives to bring this weighty health crisis un der control.

Margaret Flinter: And Lori Robertson will be checking in, our managing editor of
FactCheck.org is always on the hunt for misstatement spoken about health and health
policy in the public domain.

Mark Masselli: But no matter what the topic you can hear all of our shows by going to
chcradio.com and as always if you have comments please email us at CHC Radio at
CHC1.com or find us on Facebook or Twitter we love hearing from you.

Margaret Flinter: And we'll get to our interview with Dr. William D ietz in just a moment.

Mark Masselli: But first here is our producer, Marianne O'Hare with this week's headline
news.

(Music)

Marianne O'Hare: I'm Marianne O'Hare with these Healthcare Headlines. The number
of uninsured Americans is at its lowest level in decades according to a recent analysis
done by the Centers for Disease Control. CDC survey the insurance landscape and
found that only 11.9% of respondents reported being uninsured for summer all of last
year. That number had been far higher since at least the mid 1990s anywhere from 18
to 22%. The National Health Institute survey report comes as a Supreme Court weighs
another decision on a fundamental aspect of the healthcare law. Whether the subsidies
received by some 13.4 million Americans purchas ing health insurance are actually legal
in a 37 states that didn’t set up their own exchanges that decision could lead to more
than 8 million Americans no longer being able to afford the cost of insurance.

And Medicaid expansion has only happened in about half of the states though the
number is growing, widening the eligibility for those living closer to the poverty line to
qualify for Medicaid coverage. The health laws expansion of Medicaid coverage to
adults with incomes over the poverty line was key to reducing the uninsured rate among
50 to 64 year olds from 12% to 8% in 2014 alone. The bipartisan policy center has
released a white paper on recommendations for incentivizing prevention in healthcare
setting, highlighting a new initiative from the center for Medicare and Medicaids
innovation program. They've launched a million hearts cardiovascular disease risk
reduction model which rewards physicians who significantly reduce the risk for stroke or
heart attack in patient panels. The program will marry financial incentives to improved
outcomes (inaudible 4:17 ) providers and patients will work to determine potential
cardiovascular risks device a preventive treatment plan and pay for positive outcomes
through Medicare.

And take two Shakespeare's and calmin g in the morning. Mount Sinai Medical School
in New York is loading its efforts to diversify its pool of medical students by plucking
students who didn’t go to traditional pre - med track of math and science but art and
humanities. Mount Sinai and a growin g number of institutions around the country are
expanding their admissions process to include more so called Humads [PH] humanities
majors seeking medical degrees. The dean of the program saying it's bringing in

diverse thinking approaches to the intercha nge among medical students and a creative
thought process as well. I'm Marianne O'Hare with these Healthcare Headlines.

(Music)

Mark Masselli: We're speaking today with Dr. William Dietz, Director of the Sumner M.
Redstone Global Center for Prevention an d Wellness at the Milken Institute School of
Public Health at George Washington University which is seeking solutions to the obesity
epidemic and the growing public health problems. Dr. Dietz is internationally
recognized expert on prevention obesity and nutrition, having serve for 15 years as the
director of the division of nutrition physical activity and obesity at the Centers for
Disease Control and Prevention. He's a member of the Institute of Medicine and is a
prolific author with over 200 peer revie wed articles and five books including the Clinical
Obesity in Adults and Children and nutrition. Dr. Dietz earned his B. A. at Wesleyan, his
M. D. at U Penn and his PhD in Nutritional Biochemistry from MIT. Bill welcome to
Conversations on Healthcare.

Dr . William Dietz: Thank you.

Mark Masselli: You've been long studying the links between nutrition physical exercise
and obesity its impact is well known now I think in the public's mind an estimated 1 in 3
people in the country. And certainly a problem a round the globe and a recent estimate
by the Brookings Institute projected obesity related medical cost little over a trillion
dollars. In the work that you've been doing, what's the most alarming to you in terms of
the pervasiveness of the obesity proble m?

Dr. William Dietz: Well obesity is as you point out is a pervasive problem. About 1 in 3
adults have obesity and about 17% of children and adolescence have obesity. And the
consequences of this overtime are substantial not only is it very expensive as you
pointed out with the recent Brookings study. But it also is associated with very
significant diseases it's an important cause of several different cancers about 20% of
cancers arise from obesity. It's a significant risk factor for cardiovascular d isease and
its strongest association is with type 2 diabetes.

What's encouraging about obesity is that the prevalence is now pretty flat in adults and
in adolescence, what's even more encouraging is that among 2 to 5 year old children
there are decreases i n the prevalence of childhood obesity which suggest that we're at
the corner and maybe slowly turning the corner on this epidemic. And what's
encouraging to me is that there is widespread awareness now of this epidemic. We've
been focused at -- at CDC an d now here at GW focused on policy and environmental
solutions to change the environments and which people live, work, play and pray.

Margaret Flinter: Well Dr. Dietz you recently participated in a panel discussion at the
Bipartisan Policy Center on this topic of chronic disease, obesity but also the need for
new comprehensive prevention strategies and we sort of sit here in 2015 of healthcare
transforming. They're still transitioning from a healthcare system that pays for sick care
versus a system that p ays for better outcomes and better health and what are your
thoughts on incentivizing the healthcare system to advocate for prevention?

Dr. William Dietz: There's a very important role that the healthcare system can play in
the treatment of severe obesity . What we've seen and what I think helps account for the
plateaus that we've seen I think those are consequence of increased awareness and
modest changes in practices. So we know that fast food consumption, soda
consumption and pizza consumption have all decreased recently. There's also been a
lot of interest and change in things like the school lunch, thanks to Michelle Obama and
the White House. But those environmental changes are -- I think very effective for
prevention but they're not going to help people who have significant obesity to begin
with. This is not a problem that's going to be exclusively solved through medical
interventions.

And one of the developments that we've talked about at Bipartisan Policy Center is the
need for integrating clini cal and community services. So that what's going on in the
community reinforces the kinds of changes that medical providers are trying to achieve
with their patients. So you can't very well consume a better diet if you don’t have
access to healthful food . And one of the key elements there is how does one
compensate either providers or invest in community systems in a way that saves
money, and how do we avoid the double pocket problem which is savings and on one
side are not realized by the groups that ar e achieving those savings.

Mark Masselli: You know, we have patients in front of us a 100 minutes out of their
526,000 minute a year life. And so the work that we need to do particularly on chronic
conditions really requires us to be engaged in the commu nity and to be thoughtful about
it. It is exciting you mention the First Lady certainly her Let's Move campaign. So we're
starting to see those types of programs take root, I'm wondering if you could talk about
programs that you're seeing that have meani ngful impact and how we might change the
behaviors of families. Even I'm wondering what you're seeing out there sort of on a
system side but also right down to the level of parents, what might be some
encouraging behavioral changes within families or comm unities that we might be
making?

Dr. William Dietz: Well one of the things that we know about obesity is that it spreads
along social networks, they're the Framingham Study there was a very nice study
showing that both obesity and tobacco uses spread alon g social networks. And there
are some recent very interesting work that is beginning to suggest that weight change,

weight decreases can occur along those same networks. In the case of children and
adolescence it's quite clear that family engagement is a crucial element that you can't
expect children and adolescence and a family to make changes that are helpful without
the kinds of reinforcement because parents are responsible for what comes into the
house. But parenting is also the toughest nut to crack although we have access to
parents in our pediatric practices. Engaging parents and change making it a meaningful
issue is often difficult for pediatricians. And when we talk about obesity, obesity is a
pejorative term, and work by the Robert Wood Johns on Foundation has shown that
talking about a healthy weight is more likely to engage parents. What we're seeing
though around the country is a very intense interest and changing the environments for
children. The work in schools, the Healthy, Hunger - Free Kids Act we're about to see
some guidelines for the child and adult care. Food programs which provide food early
care and education centers, those are all -- are environmental changes. And those are
likely to be significant because that's where children spend a lot of time. The question is
are the changes in early care and education and in schools enough so that they're not
counterbalanced by occurs outside early care and education and schools.

Margaret Flinter: Well, you know, Dr. Dietz so much of this is reminiscent of some of
the great public health social campaigns of recent decades certainly I think about the
use of seatbelts and how successful that has been. But you co - authored a article on
the journal pedi atrics talking about the link between one commonly consumed food item
and the growing growth of Americas children and I assume that, that was pizza maybe
you could tell us a little about the study and what it showed about the correlation
between some of Am ericas most popular food choices and the epidemic.

Dr. William Dietz: Right, well I'm not sure that, that article is the most popular article
that I've ever written or been part of. Because pizza is widely consumed, one of the
characteristics of fast foo d sodas and pizza is that when children and adolescence
consume those food they don’t compensate for the consumption of those foods by
reducing the intake of other foods. On any given day 1 in 5 children or teenagers in the
United States has pizza. On th ose days an adolescent consumes about 600 calories
worth of pizza. But in the adolescent they consume 250 extra calorie and we think
that's a significant contributor. And interestingly enough the healthiest pizza that kids
consume is the Pizza that they have at schools and that's a consequence I think of the
very nice work that the administration has done and setting standards for school meals.

Mark Masselli: We're speaking today with Dr. William Dietz, a Director of the Sumner
and Redstone Global Center for Prevention at George Washington University. So
during your time at CDC we're just start (inaudible 13:59 ) talk about prevention is
important directive for national health policy. I'm wondering what's your thought about
how this can be shaped I think Frieden and Bloomberg had a great run smoking where
they, you know, use New York City as the springboard. What do you see the role of an

elected official and any examples that you have of people who you're excited about the
work they're doing.

Dr. Willia m Dietz: Well six states and 16 municipalities have reported decreases in the
prevalence of childhood obesity. And although New York City has gotten the most
attention and certainly Mayor Bloomberg and Tom Frieden deserve credit. Even though
the limits on soda sized failed, if you look overtime the media's coverage of soda was
substantial and grew with time. And I think accounts in part for the declines in soda
consumption but not only in New York City but more nationally, New York was one of
those exam ples. But other examples that are being investigated include Anchorage,
Alaska and like New York City there was a champion and that champion was the
superintendent of schools. Philadelphia is another place which has reported declines
and Mayor Nutter was certainly a leader in this. What was interesting about
Philadelphia was that those decreases occurred in all ethnic groups. There have been
greater declines among the white population than among the African - American or
Hispanic population which means th at disparities in obesity become greater as a result
of those interventions.

Margaret Flinter: Well Dr. Dietz there is a merit of new technologies that make it easier
for folks to quantify their fitness behavior of maybe 50 million Americans that use some
kind of wearable of digital device. What role do you see for technology and health data
and these personal devices in the quest to improve health particularly from healthy
weight perspective?

Dr. William Dietz: My impression is that people who use those devices and wear them
are people who are already interested and concern and actively engaged in positive
health practices. The other challenge I think with the devices is who is using them are
we going to see another digital divide that is ethnic specifi c. But the other application
which I think there are some good studies on is the role of technology and internet
interventions related to obesity, there are clearly some success with the use of internet
reinforcement for weight loss practices that are not yet in wide use but are quiet
promising.

Mark Masselli: You know, Dr. Dietz another area where the population can be
motivated towards better fitness and nutrition and certainly in the work place. So this
area of corporations being engaged, can you share with our listener some success
stories where the business communities incentivize employees to take a more active
role in their health and well being?

Dr. William Dietz : The national business group on health has been actively engaged in
promoting wo rksite wellness among its members for at least a decades. But it's
important to remember that the national business group on health represents the

biggest companies in the country. And yet the biggest companies in the country employ
a minority of adults, but in those companies which have the capacity to build fitness
centers to have reinforcements for health risk assessments by lowering insurance rates
and so forth. And those companies have reported a good return on that investment.
But the bigger chall enge is about the medium and small worksites which are employee
the majority of American adults.

And in those companies I think the strategies are little more challenging, and I've always
felt that we're going to have a greater success in those companies i f we're able to link
those companies or get them to invest and support community based intervention that
would benefit not just the community but would benefit their employees. Worksites are
to adults what schools are to children very modest changes can m ake a big difference.

So for example we were talking earlier about the important role of elected officials
Mayor Menino when he was mayor in Boston eliminated sugar drinks and I can't
remember whether they eliminated vending machines or just mandated that vending
machines had to provide more helpful options. But in Boston setting policy for the
municipal agencies was a significant step forward. Another good example of how a
worksite can change the availability of less helpful products comes from the Bosto n
Hospital Commission which convinced the major teaching hospitals in Boston to change
the labels on sodas in their cafeterias and so they did a red light, yellow light, green light
type label for the less helpful to more helpful sodas.

And Mass General Ho spital not only did that but they also engaged choice architecture
by moving the sodas label right around the corner where they weren't the first thing that
people that use their cafeteria saw. And there's a consequence of that they saw a
decline in the c onsumption of the less helpful sodas and it increase in the consumption
of more helpful products including water and made a profit to boot. So structuring
worksite has been done quite successfully in Boston is a very easy way to make helpful
choices, easi er choices.

Margaret Flinter: We've been speaking today with Dr. William Dietz, Director of the
Sumner and Redstone Global Center for Prevention and Wellness at the Milken Institute
School of Public Health at George Washington University. You can learn m ore about
his work by going to GW Public Health. Dr. Dietz thank you so much for joining us on
Conversations on Healthcare today.

Dr. William Dietz: Well thank you so much.

(Music)

Mark Masselli: At Conversations on Healthcare we want our audience to be truly in the
know when it comes to the facts about healthcare reform and policy. Lori Robertson is

an award winning journalist and managing editor of FactCheck.org a nonpartisan, non -
profit consumer advocate for voters that aim to reduce the level of dece ption in US
politics. Lori what have you got for us this week?

Lori Robertson: Several law makers have made the claim that scientific study show a
20 week old fetus can feel pain. We looked into the research on this issue and it's a
complicated and cont roversial topic, but the ability to feel pain at that specific point in
gestation is unproven. The law maker's remarks were made during house debate on a
bill that would ban abortion beyond 20 weeks whit some exceptions for victims of rape
or incest or in case if the mother's life been endangered.

Research on this topic has focused on brain and nervous system development and
what scientist know about the process in pain. The issue is complicated primarily
because pain is a subjective experience and a fetus cannot indicate if something hurts.
Publish research generally supports pain been experienced later in gestation in 20
weeks. In 2005 a summary of the available evidence published in the journal of the
American Medical Association concluded that the lim ited evidence on the issue
indicated that the perception of pain is unlikely before the third trimester which begins at
27 to 28 weeks from conception.

One reason for that conclusion is that the connections between the thalamus and the
cortex have not yet formed, that happens between 23 and 30 weeks gestation and the
(inaudible 21:36 ) authors argue those connections are a precursor for the perception of
pain. Some expert say that pain in the fetus is not the same as it is in an adult but
scientific study h as not pinpointed a firm starting point for pain in a developing fetus.
One expert we interviewed had stress the need for more research on this complicated
issue. And that's my fact check for this week, I'm Lori Robertson, Managing Editor of
FactCheck.or g.

Margaret Flinter: FactCheck.org is committed to factual accuracy from the country's
major political players. And is a project of the Annenberg Public Policy Center at the
University of Pennsylvania. If you have a fact that you'd like checked email us at
chcradio.com we'll have FactCheck.org's Lori Robertson check it out for you here on
Conversations on Healthcare.

(Music)

Margaret Flinter: Each week Conversations highlight a bright idea about how to make
wellness a part of our communities and to ever yday lives. Healthcare providers are
forever on the lookout for that magical (inaudible 22:41 ) that can cure a host of chronic
ills in one step. And in the case of obesity, depression, anxiety and stress (inaudible
22:49 ) could be turns out a number of steps as in taking a hike.

A large study conducted by several institutions including the University of Michigan and
the Edge Hill University in the UK looked at the medicinal benefits derive from regular
group hikes conducted in nature.

Dr. Sarah Warber: We can see that these two different types of help for a mental well -
being they're operating independently, that means that if we go out in nature for a walk
we're getting an additional boost to manual our mental well - being.

Margaret Flinter: Researchers e valuated some 2000 participants in a program called
Walking for Health in England or sponsor some 3000 walks per week across the
country.

Dr. Sarah Warber: There was investment in these walking groups, in training leaders to
take people on walks, finding trails that were good for people to do even if they had
health problems.

Margaret Flinter: Dr. Sarah Warber Profe ssor of Family Medicine at the u niversity of
Michigan School of Medicine said the study showed a dramatic improvement in the
mental well - being of participants.

Dr. Sarah Warber: Depression was reduced, perceived stress was reduced and people
experienced more positive feelings or positive emotions.

Margaret Flinter: Dr. Warber says it seems to be the combination of breathing in fresh
air surro unded by nature during moderate exercise and a group dynamic adds a social
benefit. Other studies have shown a link between mood and exercise, but Dr. Warber
says this is the first study that reveled the added benefits of group hikes in nature and
signifi cant mitigation of depression.

Dr. Sarah Warber: Because we are really interested in whether issues are more
stressed, would you get some better benefits and in fact that did pan out.

Margaret Flinter: Walk for Health a simple guided group nature hike program which
incentivizes folks suffering from depression and anxiety to step into the fresh air with
others improving their mood, reducing their depression, now that's a bright idea.

(Music)

Margaret Flinter: This is Conversations on Healthcare, I'm Mar garet Flinter.

Mark Masselli: And I'm Mark Masselli, peace and health.

Female: Conversations on Healthcare broadcast from the campus of WESU at
Wesleyan University. Streaming live at WESUFM.org and brought to you by the
community health center.