Press Briefing Transcripts

CDC Weight of the Nation Press Briefing

July 27, 2009, 11:30 a.m. ET

• Audio recording (MPEG)

Von Roebuck: Welcome, everyone, we're from Washington, D.C. today.  I'm Von Roebuck with the CDC public affairs office and today we're with the Weight of the Nation.  This is CDC’s inaugural conference on obesity prevention and control.  With me today is Dr. Thomas Frieden, the director of CDC – the Centers for Disease Control and Prevention.  I also have Dr. Eric Finklestein who is a health economist at the Research Triangle Institute and also Dr. William Dietz who is the director of the Division of Nutrition, Physical Activity, and Obesity.  Today we'll have each speaker make a few brief comments and then we'll take a few questions from the reporters in the room and then the reporters that are joining us on the line.  Let's begin with comments from Dr. Thomas Frieden, director of CDC. 

Thomas Frieden: Good morning.  Obesity and with it diabetes are the only major health problems that are getting worse in this country and they're getting worse rapidly.  Although recent trends suggest there may be a leveling off in some populations, that the leveling off rate has doubled in three decades.  The average American is now 23 pounds overweight and collectively we are 4.6 billion pounds overweight.  Two recent scientific reports highlight important timely information.  First, on the enormous economic costs of obesity and second on the potential to reverse and prevent the epidemic.  In terms of the economic costs, we now know that the burden is about twice what it was the last time it was estimated.  Currently the burden is around $147 billion a year in direct medical costs.  People who are obese end up expending nearly $1500 more per person per year on health care.  That's about 40 percent more than an average-weight person. 

But beyond the economic costs are the disability, the suffering, and the early deaths caused by obesity.  And this is something that we as a society need to take more action to address.  The report that CDC released last week, Dr. Dietz will summarize briefly in a bit.  This highlights six strategies to reverse the obesity epidemic as well as a set of indicators which will help to monitor whether or not we're having success in doing so.  Reversing obesity is not going to be done successfully with individual effort.  It will be done successfully as a society only with societal effort.  We did not get to this situation over the past three decades because of any change in our genetics or any change in our food preferences. We got to this stage of the epidemic because of a change in our environment.  And only a change in our environment again will allow us to get back to a healthier place to a tipping point in the heavy scales that we now face in society.  We need effective sustained partnerships and we need action which is rigorously evaluated.  We have many promising strategies.  The challenge is to implement them, to evaluate them, and then scale up those that are most effective.  I'd now like to welcome Dr. Finklestein to make some remarks about his important work on the economic costs of obesity in this country. 

Eric Finklestein: Thank you very much.  And thanks for the opportunity to present.  What I’d like to do in the next couple minutes is talk about a paper that is actually coming out today on the health affairs website, healthaffairs.org, which talks about the annual medical expenditures attributable to obesity.  Perhaps I should add that former President Clinton broke the embargo on the estimates and stole some of my thunder, but with that said, let's go forward and talk about some of the estimates and what I think these estimates mean in terms of what we can expect to have in terms of health reform and health expenditures down the road.  First off I want to point out my colleagues at CDC and Agency for Health Care and Research and Quality at RTI who were co-authors on their study which was funded by the CDC Foundation.  Just by way of background, as I’m sure you all know, obesity is certainly bad for your health and raises the risk for many preventable health conditions.  And as a result, obesity increases annual medical expenditures because ultimately private or public payors are responsible for financing the cost of treatment for those conditions.  And, in fact, there was a study that we published several years back that showed that the cost of obesity alone, excluding overweight, was about $74 billion in 1998.  And so we wanted to update that study in light of the fact that between 1998 and 2006, the year that our new estimates are based on, obesity prevalence rates actually rose by 37 percent based on data from CDC's Behavioral Risk Factor Surveillance System.  So a 37 percent increase in obesity rates is likely to be accompanied by a significant increase in expenditures and we wanted to quantify the extent to which those expenditures have risen since that time. 

So we quantified those expenditure estimates in total as well as separately for the Medicare, Medicaid and private insurance and then separately by source of payment including inpatient, outpatient and prescription drug expenditures.  We used data that's released by the Agency for Health Care Research and Quality and we used regressive analysis, but the simplest way to think about it is we created essentially sets of individuals that differed in only by their BMI.  So the idea is that if people are similar in all other characteristics except for their weight, then any difference in expenditures must be caused by their weight.  So that's essentially the methodology that we used, and, therefore, we produced expenditure estimates that show the incremental costs for people who are obese compared to people who are in the normal or the healthy BMI range.  I do have a slide for those of you who are interested that talks about a BMI of 25 -- 18.5 to 25 is considered normal.  By way of example, I’m about 175 pounds, 5 foot 10. That puts me right around a BMI of 25, the high end of the normal range.  Working to get it down a little bit.  To have a BMI of about 30, that would essentially put you at about 210 pounds for somebody of my height.  So you can get a sense of 30 or 40 pounds would put you in the obese group if you're about my height.  So essentially we compare the differences in expenditures between these two groups, and what we found was that for a normal weight individual, their expenditures are about 41 percent less than expenditures for an obese individual if you look across all pairs, all types of individuals, whether on Medicare, Medicaid or private insurers. 

So to give you a little bit of an example, normally an individual would spend $3400 per year in medical expenditures and that number rises to about $4870 if that individual is obese.  And that's that 41 percent difference that I was talking about.  Now, if you're thinking with somebody on Medicare, for example, their average expenditures are about $4700 if they're normal weight.  And if they're obese, that number rises to about $6400.  And, in fact, for private insurers, if you go by percentage increase, obesity is responsible for a 48 percentage increase compared to expenditures for a normal weight individual.  Now, it turns out that if you want to look at the drivers behind those costs, prescription drug expenditures is actually a significant driver of those costs.  And, in fact, if you look at the normal weight population, prescription drug expenditures on average are about $700 per year and that figure increases to about almost $1300 or about an 80 percent increase for an obese individual.  And, in fact, for Medicare, as you know, obesity increases chronic diseases and those increases grow with age, so a lot of the Medicare population is going to essentially be financing the cost for obesity that occurs throughout adulthood and, in fact, for Medicare, the cost of obesity are about 72 percent greater just for prescription drugs.  And so a normal weight Medicare beneficiary will have about $1400 worth of prescription drug costs per year -- or I should say the increase associated with obesity is about $1400 per year and that that's added on to about $800 in costs for a normal weight Medicare beneficiary. 
So if you combine these estimates, the per capita estimates with the prevalence of obesity which I said increased by about 37 percent, what you find is that obesity now costs the health care system about $147 billion per year.  And roughly half of that is financed through Medicare and Medicaid.  And, in fact, the single largest contributor of those costs comes through prescription drugs.  And if you look by percentage, what we find is that 8.5 percent of Medicare expenditures, almost 12 percent of Medicaid expenditures and almost 13 percent of private payer expenditures are attributable to obesity.  And if you look across all payers combined, obesity is about 9.1 percent of annual medical expenditures, which is up from what we estimated to be 6.5 percent in 1998.  So, again, one of the drivers behind this rise in obesity rates is the fact that between 1998 and 2006, obesity prevalence increased by 37 percent, and, as you know, one in three adults now has a BMI greater than 30 and so is classified as obese.  In fact, one of the things we did in this study is we said suppose we were able to keep obesity prevalence rates at their 1998 levels, what would that do for annual health expenditures, and what we found was that, were we able to keep obesity prevalence steady at 1998 numbers, we could have reduced annual medical expenditures by $40 billion.  So I have some limitations in the slide.  You can certainly take a look at those.  In fact, I just want to conclude by saying clearly obesity is costly.  We've shown that to be the case.  And, in fact, I would argue that the only way to show real savings in health expenditures in the future is through efforts to reduce the prevalence of obesity and related health conditions, specifically improved diet and physical activity.  Thank you very much.
 
Thomas Frieden: Thank you.  And that's a segue into Dr. Dietz's remarks.  Dr. Dietz will provide details about CDC's newly released report on obesity strategies and community measures.  I would make the point that this is really the first time CDC has provided a comprehensive approach to addressing obesity on a community level through community prevention. 

William Dietz: Thanks, Tom.  It's a great pleasure to be here with you today.  Those of you who heard Tom's speech earlier heard him emphasize the need to act.  And as the IOM put it in their report several years ago, we can't wait for the best possible evidence.  We have to act on the best available evidence.  And President Clinton emphasized the how.  We know what to do.  The real challenge is how to do it.  And it was with that in mind that we came up with this report that was published in the MMWR late last week entitled "Recommended community strategies and measures to prevent obesity in the United States."  There are copies of this I believe in the back.  There is also a how-to guide that I think is also in the back for your reading pleasure.  Before I get into this, I should acknowledge the leadership of Laura Kettel Khan who led this project with able support from Katie Sovish and Amy Lowry.  And this project was also met a broadly shared need by a number of organizations active in this area, and particularly those interested in community-based interventions.  So this was not only supported by our division at CDC, but also by the Robert Wood Johnson Foundation, Kaiser Permanente, and the Kellogg Foundation with liaisons to NIH and USDA.  It was a very broad based initiative. 

Now, in this arena where there is limited guidance, we needed to decide on what issues that we needed to act on.  And so we composed an expert panel of experts in urban planning, built environment, obesity prevention, nutritional and physical activity to begin to build these strategies.  The criteria they used to select the strategies were the following:  that it has sufficient reach, meaning it was likely to affect a large percentage of the population.  That the strategy was in the control of communities.  That it could be implemented in a variety of communities that differed in size, resources and demographics.  That the magnitude of the health effect was meaningful.  And that the health effect of the strategy would endure over time.  These strategies fall into half a dozen areas such as promoting the availability of healthy foods and beverages, strategies to support choices of healthy foods and beverages, strategies to encourage breast feeding, strategies to encourage physical activity or to limit sedentary behavior , or strategies to create site communities that support physical activity.  Or strategies that encourage communities to organize for change.  Now, there are 24 of these strategies, and I don't want to review each one of them, so I’ll just give you a flavor of how those strategies -- what the strategies are that fall under each of those major headers.  So, for example, to promote food availability -- availability of healthy foods and beverages, one might promote those in public service venues controlled by communities like schools, recreation facilities, prisons.  That they be affordable in these public service venues, either through competitive pricing or subsidies.  That we increase the geographic availability of supermarkets, and you heard this morning that through the fresh food financing initiative in Pennsylvania, there are now something over 50 new supermarkets either in underserved areas or underdeveloped and underserved areas.
 
Strategies to support choices of healthy foods and beverages include restricting less healthful items in public venues such as those achieved by the Alliance for a Healthier Generation.  To offer smaller portion sizes in public venues or to limit ads like those in schools.  With respect to breastfeeding, it's critical to encourage increased support for breastfeeding.  And this just became a criteria for hospital approval in the last year.  That is efforts to improve exclusive breast feeding.  With respect to encouraging physical activity or limiting sedentary behavior, school P.E. is at the top of the list.  Not only to increase the offerings of school P.E., to increase the amount of physical activity in physical education programs.  Creating self-communities to support physical activity includes improving access to outdoor recreation facilities or enhancing infrastructure for bicycling or walking, improving access to public transportation or zoning for mixed use development, and, finally, encouraging communities to organize for change.  To participate in coalitions or partnerships to begin to build the necessary political will for change at the community level.  As Tom said, these are the first community-based recommendations around physical activity and nutrition to prevent obesity at the community level in the United States.  A significant challenge remains before us, that is, how intense do these need to be, how many of these need to be employed?  What does it really take to change the needle?  But it's quite clear that we're moving from the what and the why to the how.  And these recommendations I believe set the foundation for the community interventions necessary to reverse this problem in the United States. 

Von Roebuck: Thank you, Dr. Dietz.  Thank you, Dr. Finklestein and Dr. Frieden.  We're about ready to take questions, and I wish that when folks do indicate they have a question, if you'd identify yourself and which media you're from, it would be very helpful.  We'll take a couple questions from the floor here and then we'll also do a couple questions on the phone and rotate back and forth.  Operator, did you want to remind the folks on the line on how to get in the question queue.  Thank you very much.  We'll take a question from the floor here in the room.  Yes. 
[ inaudible question ]

Thomas Frieden: The question was about soda and caloric taxes.  I think soda and sugar-sweetened beverages play a particular role in the obesity epidemic.  The average American consumes roughly 250 calories more today than we did two or three decades ago, and of that, about 120 calories is in the form of soda and other sugar-sweetened beverages.  In addition, there is emerging evidence that we recognize the caloric intake from liquid calories less well than we do from solid calories.  The simple way to think of this is that if you have a candy bar before dinner, you're likely to spoil your appetite, but if you have a soda, you're not likely to spoil your appetite.  That said, I think anything that increases the availability and decreases the relative price of healthy foods and anything that decreases the availability and increases the price of unhealthy foods is likely to be effective.  The challenge, I think, is a political one of getting that approved as well as there are very important administrative and operational issues with implementation of such a tax.  One of them that we were just discussing before the session, the importance of doing it in the right way.  A tax that's done as an ad valorem tax, that is, a percentage tax, only pushes people to buy bigger, cheaper items.  A tax that's a specific tax, that is, a tax per ounce or per gram of sugar pushes people to consume less of that item.  I reiterate as I said in my remarks, this is not an administration position, but I’m giving the science behind as I did in an article in a medical journal a few months before. 

Von Roebuck: We’ll take another question from the floor.  And if we could use the mike.  Rachel, if you could give it to this lady here. 

Susan Landers: I’m Susan Landers with American Medical News.  And I wonder if you could address a little bit about what the primary care physician might be able to do to help in this problem.  It's not among the recommendations.  What are the roles that a primary care physician can assume here? 

William Dietz: The question was what can a primary care physician do.  I think there's been substantial progress on the pediatric side in terms of what primary care physicians can do beginning with the recommendations from an expert committee which was supported by us, by the AMA and by HRSA two years ago, which outlined in considerable detail the approaches to prevent and treat overweight within primary care settings.  One of the most innovative programs came out of the state of Maine where the American Academy of Pediatrics produced a program called Keep ME. Healthy, M.E. being a play on the abbreviation of the state of Maine, 5210, where five was five fruits and vegetables, two was two hours less of television, one was an hour of physical activity, and zero was no sugar-sweetened beverages.  That worked very well in primary care settings.  They don't yet have their outcome measures completely analyzed, but the algorithms that they developed for the assessment and treatment were good enough that the American Academy of Pediatrics picked those up and distributed them widely throughout the pediatric practices in the United States.  Frankly, I think there's been less progress on the adult side.  The irony is that on the adult side, there has been a lot of work on tertiary care for obesity and limited work on primary care.  The challenge in pediatrics is just the opposite.  There's been a lot of work on primary care, but very little on tertiary care.  So how to treat the severely obese in the pediatric population remains a challenge.  How to treat and prevent mild obesity in primary care settings on the adult side remains a challenge. 

Von Roebuck: That was Dr. William Dietz responding to that question that came up.  We'll now take a couple questions on the phone, please.  [ inaudible question ]

Thomas Frieden: It's very hard to hear you.  If you could just try to speak more directly into the phone.  We couldn't catch what you were saying. 

Brenda Wilson: Okay.  I've got an echo, but, anyway, you said there's a leveling off of obesity among certain groups.  And if you look at the charts, there's several groups where the problem is much more severe and continues to be descriptive across the country.  So which groups is it leveling off and is it getting worse?  Could you make some distinction? 

Thomas Frieden: What I said was that there may be evidence of a leveling off, but that doesn't indicate any less severe of a problem.  I think the analogy that one might use is if your town is 2/3 under water and the water level isn't rising as fast any more, you don't say the problem is solved, you say you still have a very serious problem that has to be addressed.  Information released last week showed that the rate of obesity among African Americans and among Hispanics is significantly higher than the rate among white Americans.  In addition, we know that there's a very tight correlation between obesity and poverty such that those who are living in poverty are much more likely to become obese.  Dr. Dietz, do you want to add to that? 

William Dietz:  Sure.  There was an article that was published in JAMA a year ago that looked at data from the National Health and Nutrition Examination Survey, which is a nationwide survey conducted by the CDC which includes about 4,000 children and adolescents in each two year interval.  In that study, there also appeared to be no significant change in the prevalence of obesity among 2- to 19-year-olds regardless of the ethnicity.  And the three major ethnic groups that were considered were Hispanic, African Americans and Caucasian.  Furthermore, there appeared to be no significant difference whether you looked at overweight, that is, children or adolescents with a BMI between 85 and 95th percentile.  Obesity meaning greater than the 95th percentile or severe obesity, greater than 97th percentile.  As Dr. Marks indicated in his presentation this morning, there are also data from the Pediatric Nutrition Surveillance System which we published last week showing a leveling of those data.  And there are data from several states which show the same thing, notably Texas and Arkansas.  So we think it's real, but it's no grounds for complacency given the fact that 16 percent of children and adolescents in the United States remain obese.
 
Von Roebuck: Thank you, Dr. Dietz.  We'll take our next question by phone, please.  [ inaudible ] Then we'll take our next question from the floor here.  Third row here. 

Reporter: There’s evidence in the scientific literature that being overweight has a protective health effect.  And so I was curious, this is for Dr. Finklestein, sorry, whether or not you looked at overweight and whether or not it was -- there was an increase in cost at overweight levels or if it was only seen at BMIs that are obese. 

Eric Finklestein: That's a great question.  In fact, you're absolutely right, there's mixed evidence concerning certainly the mortality effects of overweight, and, when we did the 1998 analysis, we found that the costs for overweight were not statistically different than the costs for a normal weight individual.  So given that result as well as the mortality estimates, in addition to self-reporting -- I should make this point, our data is based on self-reported BMI or self-reported height, and weight and overweight is where you tend to get the most -- essentially the least reliable estimates.  So for those three reasons, we thought it was more conservative to just focus on those with a BMI over 30.
 
Von Roebuck: Thank you, doctor.  Didn't catch your media. 

Reporter: I’m sorry. [ inaudible ]

Von Roebuck: Next question toward the back.  Betsy. 

Betsy McKay: Betsy McKay from the "Wall Street Journal."  One question about the medical costs.  I was wondering if you could walk us through which conditions were, you know -- if you have a ranking of which conditions were the most costly, one, two, three.  And I have a follow-up question for Dr. Frieden.  You talked about a tax on sugar-sweetened beverage.  I wonder if you see evidence for a tax on snack foods or other contributors to obesity or evidence for other forms of regulation. Thanks. 

Eric Finklestein: Let me respond first. In essence, because our approach allowed us to just compare expenditures between obese and normal weight individuals, we didn't actually go disease by disease, we just looked at aggregate annual expenditures separately for prescription drugs, inpatient and outpatient expenditures by pair.  So I don't have direct evidence for that question.  But certainly I can tell you that diabetes is a significant driver of those costs.  In fact, we cite a statistic in the paper about the annual costs for diabetes alone are about $180 billion.  In fact, the lion's share of diabetes in the U.S. is caused by excess weight.  So clearly much of that $180 billion is, as well.  So diabetes is certainly one of the largest drivers of those costs. 

Thomas Frieden: In terms of other junk food, snack food is harder to find and operationally harder to implement taxation compared to sugar-sweetened beverages just operationally.  And as I said earlier, it does appear that sugar-sweetened beverages provide the lion's share of the excess calories that we're consuming as well as the lion's share in the increase in calorie consumption.  But, again, anything that reduces the relative price of healthy foods and increases the relative price of unhealthy foods is likely to improve our situation with respect to obesity prevention and control. 

Von Roebuck: Thank you, Dr. Frieden.  Dr. Finklestein started that question.  We'll go back to the floor with another question.  Yes, sir.  Let's get the mike up to you, if we could. 

Reporter: During this period between the two time points you used the incidence of obesity increased 37 percent.  But the costs doubled.  Could you give us a better sense as to why that happened?  Was it inflation or are more people being treated, are the costs of interventions going up?  What explains this? 

Eric Finklestein: Sure.  In fact, if you look on your handouts, we actually have in one of the tables we show that the per capita cost increased about 41.5 percent in the 2006 data, so the average incremental cost for the obese individual was $1429, whereas in 1998, it was not statistically different, but smaller at $1145.  So even though those differences were statistically significant, it played into our aggregate calculations.  So if those numbers had stayed exactly the same, then the rise in prevalence would have been responsible for 100 percent of the increase.  And, in fact, I think we have the statistic in the paper.  What we say in the paper is that the rise in obesity prevalence was responsible for I think the number is 87 percent or 89 percent of the increase in obesity costs, where the remainder is this nonstatistically significant increase in the per capita costs.  So, again, it would have been 100 percent had this number remained identical up to the 1998 estimate. 

Von Roebuck: Thank you, Dr. Finklestein.  We'll take a couple more calls from the phone line if there are calls there. 

Operator: I show no questions at this time. 

Von Roebuck: Thank you.  We'll take another question from the floor.  Someone in the way.  Sorry, the light's there, but if we can get a mike to you. 

Emily Walker: I’m Emily Walker with Med Page Today.  I think somebody mentioned earlier the difficulty of the Congressional Budget Office not scoring some of the long term cost savers of these prevention efforts.  How big of a barrier is that?  It seems like a lot of members of Congress do support preventive efforts, but if no cost savings can actually be shown, how likely do you think it is some of these things will be included in health care reform legislation?  And maybe you could each say what you think is likely to be included prevention-wise in reform legislation. 

Von Roebuck: Go ahead. 

Thomas Frieden: All right, I’ll start.  I think the key is, first, to think of community prevention and clinical preventive services as different baskets, both of which are critically important.  In terms of community prevention efforts, anything that reduces the prevalence of obesity particularly among adults is going to have a substantial impact on costs.  One can debate the time frame for that impact, the quantity of that impact and whether that impact can be achieved.  All of those are valid questions, but there is really no legitimate doubt that if we're able to reduce the prevalence of obesity, we will drastically reduce costs in the middle and long term.  There's also no doubt that the only way on a societal basis to reduce the prevalence of obesity is through community action, not through individual clinical interventions.  At the same time, looking at individual clinical interventions, there is a need for some preventive interventions, there is evidence of cost effectiveness of some programs for certain groups at high risk of complications of diabetes and obesity, and looking at perhaps most importantly rigorously evaluating both community and clinical preventive services as something based into the health reform package and allows us to continuously evaluate and improve the effectiveness of those interventions is critically important not only to improving health, but also to reducing costs. 

William Dietz: I’d like to take a separate tack in response to that question.  I think there's a double standard between what's applied to clinical medicine and what's applied to public health.  One rarely asks whether surgical procedure or new instrument like a PET scan or MRI is cost savings, whereas public health is constantly held to that standard.  I think that's unfair.  Secondly -- and there are plenty of those procedures on the clinical side which are not cost savings and probably not even cost effective.  The other question which needs to be in front of us as we consider these community measures and other initiatives in terms of policy and environmental change is what creates the best value.  I'm not sure that more bariatric surgery is as valuable or carries as much value as community-based interventions that put supermarkets in underserved urban communities or that make recreation facilities available, that long term the net impact and the net value of those types of interventions probably ultimately is less costly than bariatric surgery and has considerably greater value. 

Eric Finklestein: I just want to follow-up with that, one other comment.  We did a lot of work on quantifying the cost of obesity from various perspectives and it certainly has a very difficult task in front of them trying to quantify what that true cost is going to be associated with particular interventions.  In fact, for a young individual who has a very high probability of being obese, the costs associated with that obesity are 10, 20, 30, 50 years down the road and there's lots of uncertainty associated with that.  So it's a very tricky business trying not only to forecast obesity prevalence down the road, changes in medical technology, so many differentials are involved, that the only thing that we do know is that in the absence of action it's unlikely that cost associated with obesity is going to decrease.  So the default is essentially inaction, and as President Clinton and others have said, clearly we know this alternative is very expensive.  How expensive it will be to deviate from that is hard to know and whether or not it will be cost saving or cost effective is certainly challenging, but we know the status quo is very costly.  Numbers we presented today give you some evidence around how costly. 

Von Roebuck: Thank you.  That was Dr. Finklestein following that up, Dr. Dietz, and Dr. Frieden was the first voice you heard.  We'll go back to the phone again and see if there is anybody else in the queue.  Doesn't sound like we do have anyone.  We have time for up a couple more questions.  We'll go to the floor here.  Let's go way in the back with the man holding up the white paper. 

Brian Moore: Thought that would get your attention.  Brian Moore from NBC news channel.  Can you talk a little more about the idea of taxing the sugar-sweetened sodas?  Would this be a national tax, would this be local communities?  And what would the benefit be of this?  Certainly there would be a backlash. 

Thomas Frieden: What I presented this morning and previously wrote up in the medical journal with a colleague from the center at Yale is simply the fact that if we look at our work on tobacco control and what's the most effective, price interventions have carried a significant portion of the decrease.  The rate of smoking among American males has fallen by 2/3 over the last several decades.  That is something which is a result of a series of comprehensive changes, but when we looked, for example, at our experience in New York City where we were able to reduce adult smoking by 25 percent and teen smoking by 50 percent in just six years, at least half or about half of that reduction was a result of taxation. Taxation follows a very clear rate of what is called price elasticity or elasticity of demand.  That elasticity in the case of smoking relates to both participation and prevalence or participation and consumption, so how much people smoke and how many people smoke. 

In the case of soda and other sugar-sweetened beverages, evidence from a couple of sources including industry sources suggests that the elasticity is quite high, meaning that higher prices will strongly discourage people from consuming soda and sugar-sweetened beverages.  Whether that gets done and whether it's done at a national, state or local level is a political question.  As the nation's prevention agency, what we can say is that obesity is an enormous problem.  Price interventions are likely to be effective and anything that is done needs to be rigorously evaluated.  There are important unknowns.  It's not known whether if people reduce their consumption of sugar-sweetened beverages they would offset that by consumption of other high caloric items.  But there is clear evidence that there is a strong price elasticity to soda and that increasing the tax would significantly reduce consumption as well as generate quite substantial revenues.  The estimates that we've seen suggest that a one penny per ounce tax nationally would raise something on the order of $100 billion to $200 billion over a ten year time frame.  As well as significantly reducing caloric intake at least from soda and sugar-sweetened beverages.

 
Von Roebuck: Thank you, Dr. Frieden.  We got a couple questions over here.  I know you've had your hand up for a while.  The lady in the blue. 

Reporter: I’m from thatwomanonthemountain.com.  Americans already spend billions of dollars on weight loss products and services.  So I’m wondering how you hope to bridge the gap between people who talk about obesity like yourselves and those people who talk about weight loss.  Because they're very different conversations.  And so moving forward knowing the cost of obesity, how are you going to bridge that gap between these two very different conversations.  Thank you. 

Thomas Frieden: It’s a very important question and I think, again, there's a parallel here in tobacco control.  Clinical cessation services for people who smoke are very important.  They can double the rate of success for people who want to quit smoking or even more.  And they're much more effective if they're done in a context where broader community intervention to reduce tobacco use are in place.  Taxation, counter-advertising, limitations on advertising, smoke replacers.  In the same way, trying to -- if you go with the flow in America today, you will end up overweight or obese.  That is not a reflection of individual personal failing.  It's a reflection of the structure of our society.  That does not absolve individuals from responsibility to try to get more exercise, to eat healthier.  There's a synergy between -- a potential synergy between policy intervention to encourage a healthier environment in terms of both our food environment and our physical activity environment and personal effort to lose weight.  And the popularity of weight loss programs is a reflection of the intense desire of both the intense desire of many people to lose weight as well as the great difficulty of doing so.  And another reason why it is so very important that we prevent the increase in obesity in the next generation of Americans. 

William Dietz: I would only add to that that people are losing weight all the time.  And the problem for the obese individual in our society has been defined as a problem of difficulty losing weight.  I think the more appropriate frame is the issue is not losing weight, but sustaining weight after it's lost.  And when one looks at the weight loss registries, particularly the one in Pittsburgh, people used a variety of strategies to lose weight, but the strategies they used to maintain weight were very common across people.  They ate breakfast, they restricted their fat intake, they were physically active, and they weighed themselves regularly.  And the kinds of environmental supports that we've been talking about in my view are going to help sustain weight loss for those people who are able to lose weight. 

Von Roebuck: Thank you, Dr. Dietz.  Dr. Frieden started that question.  I know someone back here kind of in the middle had also had their hand up quite a bit. Let's go to you next. 

Samantha Cassidy: I’m Samantha Cassidy from "Good Housekeeping."  I know we've talked a lot about putting grocery stores in low income areas and making healthy foods less expensive, but we haven't talked at all about fast foods and how inexpensive those options are for people and how they market to children.  Is there going to be anything on regulating fast foods? 

Thomas Frieden: There have been some jurisdictions that have looked at density of fast food outlets. There have been efforts with the fast food industry to try to increase the healthfulness of the options provided.  Some jurisdictions, including New York City, have required fast food chain restaurants to post calorie labels prominently on menus and menu boards.  That seems to be associated with two things.  One is an encouragement to the fast food industry to offer healthier options. In other words, changing the options, and second is to encourage consumers to select healthier food, that is, healthier choices.  In New York City, I can say that when this went into effect, there was widespread sticker shock about the number of calories in some common items.  Fast food is here.  It's here to stay.  It's convenient, it's affordable.  I think the challenge is to work with industry to the greatest extent possible to increase the extent to which it's healthy. 

Von Roebuck: Thank you, Dr. Frieden.  We'll take another question.  Let's see if anyone is in queue on the phone. 

Operator: There are no questions at this time. 

Von Roebuck: Thank you, operator.  We'll take one more question from the floor.  Let's do the lady in the green over here. 
Heidi: Hi, Heidi, Global Medical News.  For Dr. Frieden, a bit of a follow-up on the earlier question about getting physicians involved.  If as you were saying a lot of the success might come from community effort, what would be your message right now to physicians for how they can support efforts that are going on in the community so they won't have to deal with this as much in their office?  Thank you. 

Thomas Frieden: I think there is a responsibility to physicians, the medical profession generally, to be active in their communities, promoting prevention as a policy focus in many different areas of public health and prevention.  It is physicians who have been able to encourage concerted actions, physicians who can influence policymakers, physicians who often become policymakers.  This is one way that physicians can be active.  And, of course, there are important things that physicians can do in their own practices in terms of measuring BMI, counseling patients, and taking action to encourage weight loss and maintenance of weight loss.
 
Von Roebuck: Thank you, Dr. Frieden.  This kind of concludes our briefing today.  I want to thank Dr. Frieden, Dr. Finklestein, and Dr. Dietz.  The information that Dr. Dietz had mentioned is on CDC's website regarding community strategies.  It's available there.  Dr. Finklestein's study is available in health affairs' website.  I believe that's up later today.  Thank you all again for your continued interest in this important issue and have a great day.  Thank you.
 
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U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES