Balancing the Scales on Overweight and Obesity

As I was trying to put together this session, I contacted several state people and particularly state nutrition directors. And I said, “You know, do you know anyone who could do a wonderful keynote presentation at this topic?” The same name kept coming up over and over and that’s Dr. Eduardo Sanchez, who is a Commissioner of Health for Texas. Interestingly enough, as life always has it, he had a conflict, and in talking to his assistant, you know, I said how much we wanted him to come. And he was trying to help me, and he said, “Well, tell me, you know, what you want him to talk and about maybe I can help you find someone else.” And when I finished telling him what I wanted him to talk about, he said, “Oh, you need Dr. Sanchez.” And I’m like, I know. So, thanks to Dr. Sanchez and his staff for really going to great efforts to rearrange his schedule so that he could be with us here today. Since November 5, 2001, Dr. Sanchez has served as the Texas Commissioner of Health. Prior to that time, from 1992 to 2001, he actively practiced as a board-certified family practice physician in Austin. He also served from 1994 to 1998 as a health authority and chief medical officer for the Austin Travis County Health and Human Services Department. Dr. Sanchez has a very impressive bio. He received his medical degree in 1988 from the Southwestern Medical School in Dallas and he holds a Master’s degree in Public Health from the University of Texas Health Science Center. He has a Bachelor’s degree in biomedical engineering and chemistry from Boston University, and he holds a Master’s degree in biomedical engineering from Duke University. As Commissioner and Chief Health Officer for the state of Texas, he oversees programs such as licensing and certification, disease prevention, and control bio-terrorism planning and environmental health. He is a member of the U.S.-Mexico Border of Health Commission, where he advises the federal government on border health issues. And in reading his bio, not only does Dr. Sanchez have a professional interest in promotion the health of the NCH population, but he has a personal interest. He is married and has four children. So please join me in welcoming Dr. Eduardo Sanchez.

Dr. Eduardo Sanchez: Good morning. Why don’t you all to stand for a minute. I know I felt better when I stood for a moment. Stretch your legs. Put your arms in the air, and just stretch your back. And I wish we could do this for about five more minutes, but let’s go ahead and sit. Thank you, Michelle. Thank you Cassie, Sally, Peter, for your comments. Thank you for what you do. I did have the opportunity a few weeks ago to meet the HRSA administrator, Dr. Duke, and we had a pleasant conversation, and she’s a great person to have as (inaudible) leader. I do want to recognize one fellow Texas Department of Health employee, and that would be Sam Cooper, our director of CSFCN. I’m going to get going and then it will be a little bit like a, like a revival in here. Once I get going about obesity, it’s just something I feel very, very passionate about. I’m very honored to have been invited. I’m very honored that people mention my name when thinking about who might be a good speaker about this topic. It’s just something I’m interested in and have been. Once clarification. Michelle said that I served as the health authority in Austin, and I made it very clear when I spoke in public that didn’t mean that I was the smartest person and that I knew everything. That’s the title for the Public Health Officer in Texas local health departments. This meeting is a great meeting about federal and state partnerships. And the notion from research to practice, I’m going to touch on that notion in the midst of my comments. I had a chance to look at the MCH Bureau webpage, but I’m not even going to cite from that because Peter spoke about the vision, the mission, and five strategies for the MCH Bureau that I think that very nicely with the comments that I want to make and actually fit very nicely with what we at the Texas Department of Health have recognized as priorities. Our mission at TDH is about partnerships. We’ve become perhaps painfully aware, as many of you have that state government and federal government is not the sole answer to many of our public health challenges, many of our health challenges. We must work in partnership with the non-profit sector with the private sector, and actually, we’ve all got to figure out, and we’re all working on this, not to say that we haven’t done it, but we’re all trying to figure out how to build non-traditional partnerships. Some of the partnerships make sense. But the business community, school boards, and depending on the area, those may be traditional, those may be non-traditional, but that’s part of our mission. And one of our priorities is to promote healthy eating physical activity to prevent and reduce obesity. And as it relates to the subtitle of this meeting, from research to practice, I do believe that public health needs a broader research agenda. In this country, we spend billions, not millions, but billions of dollars on medical research, on which statin works better, on which high blood pressure medication works better. And it’s not that that isn’t important, that’s vitally important, but we’re not spending that kind of money and applying that kind of rigor to looking at public health interventions. Interventions in our communities, in measuring what works and what doesn’t work. And what works in Alabama versus what works in Texas. And what works on the border with Mexico versus what works on the border with Canada. We need the evidence to do evidence-based interventions. So I’m very pleased to be here. I’m pleased to be invited to come here and talk about obesity and that this is the first topic. But I have a story. I am a dad. And our four-year-old, Isabella, is one who one might compare to she’s the female version of Dennis the Menace. And on one of the days when she was doing one of the menacing things that she does, my wife Catherine was chastising her and telling her what needed to be told to her, and says, “Isabella, that’s the bottom line.” And Isabella looked at her, not with a smile on her face, but certainly she didn’t, she didn’t have a distressed look on her face and said, “Mommy, what’s the top line?” So I’m going to try to talk about the top line and the bottom line. We’ve got to make sure that the federal-state relationship with regards to this issue stays in sync and I’m talking about obesity prevention and reduction. Everyone here knows that the essential development of lifelong habits of children occur in the first few critical months of pregnancy, the first few critical months of years and life. And the logic of an effective state-federal strategy on obesity is as evident as it is powerful. National recognition of the problem of obesity is obviously taking place. Some of you may remember a few weeks ago there was a front-page story in the New York Times about caskets. Oversized caskets. Who remembers that article? And that’s on the fringe of (inaudible) comparing and, I apologize, I don’t remember whether it was the New York Times or the Austin American Statesmen, not that they’re in any way similar, but I read them at the same time on Sunday mornings, but there was an article that compared four of the more popular diets today. The Sugar Busters diet, the South Beach diet, the Atkins diet, and a fourth one, which I really didn’t, I didn’t know a whole lot about, but it didn’t sound like one that I even want to, it’s a good thing I don’t remember because nothing about it sounded, it was a little more wacky than the other three. Every day across America, articles are written, news stories are heard. In fact this morning on one of the morning shows, was a story about resting metabolic rate, and big surprise, the bottom line is, we’ve got to be more physically active, try to build muscle tone, eat more healthy, and get plenty of rest. We need, do we need another best-seller to tell us that? So every day news stories are written and heard on NPR and on TV, and presentations and panels like this morning are dedicated to the issue of obesity. I had no hesitation in stating that in my opinion, the impact of obesity on the United States could be as dangerous, and perhaps more dangerous and damaging as smoking and tobacco ever were. We are reaching the point where obesity is, or will cause, more unnecessary deaths than the consumption of tobacco. And we’ve got to do something about it. Whereas 25% of adults in the United States are now smokers, 60% of adults are overweight or obese, 60%. And I don’t want to go into scientific definitions. I believe that one of the sessions is going to go into that, but roughly, overweight is 10 to 15 pounds over your ideal body weight, and obesity is 30-plus pounds over your ideal body weight. But one of the many articles that has appeared in the literature and even in the lay press recently, is that those folks who are morbidly, morbidly obese, 100 to 150 pounds over their ideal body weight, that group is actually growing faster than the less obese and the overweight population. That’s scary. But when we’re talking about MCH and we’re talking about the MCH population, I want to submit to you that there is a far greater crisis looming. And that’s obesity in our children. In Texas, 40% of fourth graders are overweight or obese, four zero percent. If you line up five kids, two of them are going to be overweight or obese. And some of you may be looking at me, some of you who know the literature and know the science, with children, we technically do not use the term “obese.” We use the terms “at-risk” and “overweight” and at-risk and overweight in children corresponds to overweight and obese in adults. I find that confusing myself. Think about when we’re trying to talk to folks who don’t understand the science and use that kind of language, so from this point forward, I will only be talking about overweight and obese, but when I’m talking about children, it corresponds to at-risk and overweight. Confused? I believe that we must implement strategies that concentrate on children. Because we can dampen the next wave of obesity before it gathers itself to threaten our future. As we heard, it is projected that one out of three children born in the year 2000 will develop diabetes. That is frightening. That is frightening. And if one out of three are going to develop diabetes, that means a larger fraction than that will be obese. Our discussion about obesity has to include pregnant women, however. For what is learned during and what happens during pregnancy, has an effect on a child’s weight. The state-federal relationship in regards to maternal and child health is especially important as we witness in all of the states the increase in childhood obesity and a demographic change that is very apparent in Texas, but is occurring nationwide. In Texas, 1000 children are born every day. We’re not number one, California has more births than that. But 1000 is an easier number to remember than any other number. 1000 births a day, 50% of those births, more than 50% of those births are to Hispanic women. And that demographic change is going to happen and is happening in your states. It may not be happening to the extent that it’s happening in Texas, but I was talking to some colleagues from Mississippi, and I know that every one of you has challenges in terms of Spanish language clientele and how you communicate and offer services. In Texas, we have the infrastructure, the people who are not just culturally sensitive and not just culturally competent, they’re the same people. We can offer services very effectively in most of our state. I won’t suggest that’s true everywhere. But let me as you a quiz question. Sam, you don’t get to answer this one. What’s the most popular boy’s name in the state of Texas? Who knows? Raise your hand. Come on, now. Somebody raise your hand and just offer a guess. Jose is the most popular boy’s name in the state of Texas. We use the same, we use the same system. Raise your hand. What’s the most popular girl’s name in the state of Texas. Someone raise their hand. Maria. Maria is an excellent guess, but the most popular girl’s name in the state of Texas is Emily. Go figure. Emily is probably the name of a Spanish language delanovella, as well as an English language soap opera and we know that we don’t name our children after presidents of famous people. We use names of characters and soap operas, so there you go. So demographically, more than 50% of the births in the state of Texas are to Hispanics. In our schools, in our public school system right now, 43% of students in the Texas public school system are Hispanic, 41% white, 14% African-American. Texas is going to look this way within the next 15 to 20 years. In Texas, you may be asking, “Well, what’s so important about that?” In Texas, we are seeing that the rate of obesity among Latino fourth-graders is higher than the state average. So whereas, 40% of fourth graders in Texas are overweight or obese, and some of our school districts that are predominantly Hispanic, that rate goes up to as high as 55%. So, so more than half of our children and fourth grade in some of our school districts are overweight or obese. This is a crisis. And again, one might say, “Well, this is a personal responsibility issue. People are just eating too much and they’re just not active enough.” And when it comes to adults, I’ll buy that. That’s fine. We’re grown-ups, we can make decisions. But when it comes to our children, it’s about what we, the collective we, I doubt that folks in this room would be supportive of the sorts of policies that have created the environment that has made this the reality in Texas, certainly, and I would argue in your states as well. If not now, it’s coming. I was at a American Heart Association health disparities conference a couple of weeks ago and someone, a speaker there, said the following, which I will attribute to him, but it’s a great line, and that is, that in the United States, super-sized hamburgers and super-sized sodas have become the weapons of mass destruction that we need to worry about. The implications are critical for Texas and critical for the United States as every state in the Union is experiencing increase in Hispanic population growth. Left unmet, obesity stemming from every population threatens to saddle our states and our federal government with huge medical and social costs because the growth of Hispanic population is accelerating, the impact of obesity could turn into an economic disaster, because all of this is occurring in the context of an aging population. Let me back up a minute. I’m a doctor, and let’s put this in a scientific context because obese children, fat kids, in and of itself may not be a bad thing. But the thing is, that obesity leads to a number of medical conditions that have dire, dire consequences. The number one cause of death in the United States and Texas is cardiovascular disease. Obesity contributes to that. Number two cause of death in the United States and Texas, cancer. Obesity contributes to some of that. In fact, a recent study in the New England Journal of Medicine (inaudible) 15 to 20% increase in mortality among those with obesity compared to those, those with cancer who are obese as compared to those with cancer who are not obese. Number three cause of death, stroke. Also obesity plays a role. Among Hispanic populations in some of our communities, the number four cause of death is diabetes, absolutely related to obesity. Then we talk about arthritis. Arthritis is made worse by obesity. Gall bladder disease, a definite relationship. And mental health issues, let’s not forget those. And so what we’re talking about and again, let’s talk about the science and the patho-physiology, is Type II diabetes. Type II diabetes developing in children. How many physicians, how many health professionals in here who have taken care of people with diabetes, please raise your hand. There’s, I would say, a fourth to a third. You may remember that there was a time when we talked about juvenile onset diabetes and adult onset diabetes. We don’t use that terminology any more. In Texas as young as nine and ten years old are being diagnosed with Type II diabetes. Pediatric endocrinologists, who used to have practices that were 99% Type I diabetes, juvenile onset diabetes, now have practices that are 50% Type I, 50% Type II. Type II diabetes in children only occurs in obese children. Only occurs in obese children. Those children with Type II diabetes in 20 years, are going to have the things that adults who develop diabetes and have it for twenty years develop. Kidney disease, blindness, cardiovascular disease, so practices are going to have 30- and 40-year-old folks coming to see them who have the things that we docs aren’t used to taking care of until people are in their 50s, 60s and 70s. This is all happening at the same time that our population is aging. So if you project forward 30 or 40 years, we’re talking about a time when the demand on the medical care delivery system is going to be about as intense as it’s ever been in the United States if you just think about the aging population. The baby boomers. I’m one of them. I’m on the late side, so I, everything may be taken by the time I get through the system. But when you consider the baby boomers by themselves are going to increase demand dramatically, and you super-impose on that, obesity in children, and the consequences, I’m trying to suggest, we’ve got, that spells a recipe for disaster. I believe the research agenda has to be expanded to devote some resources so that we can make sure that we apply scientific rigor to measure how community-based and school-based nutrition and physical activity-promoting intervention work so that we can make them part of a successful obesity-prevention reduction national strategy. Now I want to make clear, obesity is not an Hispanic problem. It’s an across-the-board phenomenon that is affecting every group at every age in this country. Again, to the degree that two out of three adults, almost two out of three adults in the United States is overweight or obese. I do, however, believe that we’ve got to zero in on African American and Hispanic children. Because although I didn’t mention it, African Americans also have an increased prevalence of obesity compared to whites. Health disparities persist now, and they will only get greater if we don’t do something about childhood obesity and realize that it affects our African American, Hispanic children in a disproportionate way. So again, obesity, there’s already the disparity. Cardiovascular disease, the disparity could grow. Cancer, stroke, diabetes, the disparities could grow if you do not pay attention. In addition to the disparities into the medical costs, I believe the cause of obesity will come in the forms of lost productivity, lost wages, lost hope in a population that is struggling to shake off the remnants of an uneven social and economic development. What am I saying there? I’m saying that Hispanics and African Americans have fought long and hard to achieve some level of equality, equity. But this obesity challenge threatens to undermine that because particularly, as we look at medical care, the ability to delivery the necessary medical care will be challenging. The Hispanic population of Texas right now is 34% of the population. It will be the largest population group in about 15 years. Yet, Hispanics are less likely to graduate from high school than whites. Hispanics are less likely to attend college or universities than whites. That means a less healthy Hispanic population, because, again, as we talk about maternal and child health issues as Sally was talking about, we can medicalize this thing, but if we think about root causes, poverty is one, and our ability as a nation to fix poverty, is probably best mediated by enhancing educational opportunity and educational attainment. But if we’re not graduating Hispanics and we’re not graduating African Americans into colleges and universities, not only will we have a less healthy Hispanic and African American population, but some of the goals that we would like to achieve in terms of a diverse work force that looks like the people we serve, is going to be also quite challenging. It has become more and more clear to me that cultural sensitivity is important, absolutely. You’ve got to know what’s coming through our doors, or who it is we’re trying to serve, and cultural competence is an important goal. But at the end of the day, cultural effectiveness is really what we’re trying to achieve. No matter how culturally competent we may think we are, if we don’t achieve the outcome that we were hoping to achieve by being cultural competent, then we’re not yet culturally effective, and we’ve ought to be measuring that as well. If we intervene today, we may be able to change the trajectory, the trajectory that we’re on. Reminds me. We sometimes talk about normal weight. What is a normal weight? And if we talk about adults in the United States, two-thirds are overweight or obese, normal is overweight or obese. So normal doesn’t fit any more. We need to talk about healthy weight. And some would say, programs, and I’m going to talk about this in a minute, but I’m going to jump the gun. Programs that try to focus on childhood obesity in schools, you’re just going to stigmatize the child. Stigmatize the child in some of our schools, 50% of the children are overweight or obese. How could you stigmatize them? It’s becoming the norm. And it’s not to suggest that I’m insensitive. It’s not that at all. It’s that we have got to do something. We have to measure our progress, however. We have to know that what we’re going makes a difference. We’ve got programs. Our states all have comprehensive school health education programs. In fact, in the state of Texas, one of the things that we have done on the positive side, not that we haven’t done a lot of positive things, don’t get me wrong, I didn’t mean to use that phraseology, but our state legislature put physical activity back in elementary schools. And I’ve actually say to me, well, you know, it wasn’t enough. Well, it was a first step, and in fact, that very same person, in a presentation, said that only 20 states in the United States right now have compulsory physical activity in elementary schools. We’re one of them. That’s a good thing. But more importantly, part of the legislation was that schools have to adopt comprehensive school health education programs. Programs that will teach children to eat healthier, be physically active, will hopefully take those lessons back to their parents. And there is a very promising program that I like to brag about because in Texas, we have taken it and run with it, and it’s a program that now we call CATCH: Coordinated Approach to Child Health. The Coordinated Approach to Child Health was based on an NIH-funded school-based community trial. And it showed much promise with the federal trials, and again, we’ve taken it and run with it. And what I want to say to you is that we have looked at it, and a researcher Coleman looked at a population of about 800 to 900 kids in El Paso, half of them exposed to CATCH, half of them not. Some other things about CATCH, it’s a third, fourth, fifth grade school-based curriculum, teaches kids, teaches teachers, teaches P. E. teachers, teaches cafeteria workers, changes the foods that are served in the cafeteria, and there is a parental education component. CATCH in El Paso. The kids who were exposed to CATCH showed a flat obesity prevalence among the kids from one year to the next over three years. The kids who were not exposed to CATCH, there was an increase in the prevalence of obesity from one year to the next. Is that enough, flat versus a slope? That’s a start. And again, if we could change the trajectory of what is being projected for the future, even a slight decrease could have astronomical economic positive consequences. We’ve got to evaluate state and federal programs that engage in maternal and child health and see how we can incorporate health-promoting and obesity preventing services in already existing clinical and family support settings. In my discussions with the practicing community, physicians, pediatricians and family physicians, family physicians more than pediatricians, it’s become clear that physicians do not feel that they’ve got the proper tools to screen, diagnose and counsel children or their parents about childhood obesity. We’ve got to do more of that. The American Academy of Pediatrics has adopted, has actually recommended that pediatricians begin to use body mass index as a vital sign, and I think you’ll hear about body mass index shortly. They have recommended that pediatricians begin to screen, diagnose, and counsel parents about their children’s obesity. But I’m here to tell you that the practicing docs don’t have all the tools they need to do that. So it’s a great recommendation, but the doc out there who’s in the community, in the office, in the clinic, does not have the tools available. Family physician, same thing. Bill Kaplan, at Kaiser Permanente, who heads up their chronic disease management component for Kaiser Permanente in California, is developing, they’ve been developing some materials and developing some techniques to teach physicians how to effectively counsel patients in one to three minutes. I think using some of the same techniques that were learned around tobacco cessation. The doc is not necessarily the one who has the time to spend the thirty minutes to sixty minutes that it may require on a regular basis, but the doc is in a position to motivate the patient or the parent to seek that additional counseling and to direct the patient to the right place. In the end, the campaign against obesity revolves around the decision-making of individuals, and so it should be clear to all of us that we have arrived at time when we have to be creative and open to new ideas by which we can succeed against obesity. We should walk away from this conference with a certain understanding, that those of us involved in public health, and those of us involved in, arguably, the most important aspect of health, that is the relationship of mother to child, have a specific challenge facing us. The challenge is how we move now to reconstruct our efforts and our systems so that we can build a new way to address what is an insidious enemy that threatens to wipe out whatever any of our programs accomplish for the young. We can say, wow, that sounds really cynical. But I ask you, what does it matter if we have the best maternal child programs, whose successes are then wiped out a few years later by an avalanche of diabetes, cardiovascular disease, cancer, and all of the other illnesses that I’ve talked about that obesity engenders. Are we ready for rationed medical care? And I ask you, and you may say, “What’s he talking about?” Again, remember, the aged, and the prematurely afflicted with chronic disease all seeking care at the same time. We’ve already got challenges. And are we ready to enter an age when public policy and public policy makers may feel that they have to limit personal freedoms because obesity is causing a financial and political crisis. The cost to all of us will be enormous if we do not answer in the only way that logic demands. If we do not find an answer, it will cause our children much pain and suffering. The take-home: Obesity is a public health epidemic. It may be in the moment, the greatest public health challenge facing us in this nation, and quite frankly, facing us in the world. I believe we have to first focus on children. And the Bureau of Maternal and Child Health as a role to play. Not only in how the programs are administered, but as one of the partners at the federal level that can help move the dialogue and move the discussion. Obesity will cost the United States more than the $123 billion annually that it is estimated to cost now. And it will cost us much of the progress that we have made. In Texas, the cost of obesity is estimated very conservatively to be $10 billion a year. That exceeds the entire HRSA annual budget. Think about it. The physical health of our children will determine the fiscal health of our nation. I thank you for listening. I thank you for your concern. And I hope that the next panel adds to your understanding of this epidemic that we are facing. Thank you.

Michelle Lawler: Thank you, Dr. Sanchez. I think that was an excellent beginning to this meeting, and one thing that I, as I sat and listened to you, that I thought of, again, going back to the block grant application and what states do in reporting, we had a revision this year that now has three years. A revision to the application process that all of the states submit to us on an annual basis. And when we were looking at revising it, lots of people came to us with ideas of different performance measures, or a different, or addition to our 18 national performance measures, and I will say that Michelle and her fellow nutritionists came to me and strongly encouraged us to include something on childhood overweight and obesity. And I appreciate the confusion that you stated in terms of how we even refer to that. And one thing that was the one piece that we did add because there are, there’s a lot of burden to the application when you look at the performance measures that we require states to report on, health system capacity indicators, and, but one thing that we didn’t know was that most states really don’t have the capacity to measure progress because they don’t really have a good system yet to even know what they’re talking about. And there was, in fact, great debate on how we would even refer to a performance measure, or a system capacity measure as it dealt with childhood overweight and obesity. So we may not have been politically correct in what we called it, but we did include as a new state system capacity measure, childhood overweight and obesity so states could at least start looking at how they can focus on this problem and start being able to gather data around it and report it because I think there is knowledge in the field that this is certainly a critical issue.

Eduardo Sanchez: It is welcome news, and I think that, as we have talked, one of the challenges is how we bridge our desire to have the medical solution to this, or the medical model solutions, the medical model systems, and then on the other side, the policy-making systems and ultimately, it’s going to be, it will have to be community-based systems that are neither overly medicalized, and not necessarily involved in the decision-making, but involved in the implementation of the decisions that are the solution and are the answer.

Michelle Lawler: Well, before we take a break, Dr. Sanchez unfortunately will not be able to be with us for the full meeting. We can entertain one or two questions of him, if we have a microphone in this aisle at least. If there are any questions before we take a break this morning. Yes.

Bill Hudson: Bill Hudson from Colorado Department of Health, and this, both a comment and a question. For starters, thank you very much for the way in which you brought this to the group. About a year and a half ago, I saw a presentation from a researcher at the University of Washington, Seattle, who had done an economic analysis of food types that was stunning and really spoke to how immensely difficult this problem was going to be. If you look at Big Mac versus fruits and vegetables, the cost ratio for a similar calorie load, on the Big Mac side being mostly fats, carbohydrates, roughly 18:30:1, so people who are impoverished, have a huge incentive to eat unhealthy foods. I think that, frankly, and in terms of ethnic disparities, also, is the ethnic disparities are probably largely a marker for poverty in this circumstance as well as others in public health, and my question is: How do we wrestle with that? That’s huge, and it absolutely beyond the medical model, it’s kind of in the policy realm, but I’m not sure any of us know where to go with that.

Eduardo Sanchez: We are at the beginning, I think, of trying to figure out obesity and what all the factors are that play into it. And I’m perhaps comforted, perhaps cynically comforted, but comforted, nevertheless, that I think it’s RJR, or is it Reynolds Tobacco, now has a web page where you can get information about how to go about tobacco cessation. Now I say that because I think that you’re correct. The economics to the household appear to be very black-white. But I think if we step back, we apply, again, an economic model that says, “What is the consequence of leaving the playing field, if you will, for food the way it is?” Is there, are there compelling reasons why we would want to make it easier for families to be able to purchase fruits and vegetables? Are there reasons why we would want to look at WIC programs, food stamp programs, and figure out, and again, not in an overly paternalistic way, but in an economically driven way, look at this issue. And I think that, perhaps, there are some policies that we can begin to look at. There was a pilot study done with USDA and school lunch programs, and school breakfast programs that showed that if you put the foods in front of the kids, they will acquire the taste to each fresh fruits and vegetables. It costs a little money, but again, if we stepped back and we looked at the entire budget that’s spent on health-related issues in this country, even just federal government, and could apply an economic model that said, “Why don’t we explore this and understand this better, and see if there aren’t some ways that we might re-think what were the traditional ways in which we encouraged certain kinds of production of foods, versus others.” Corn is an example. Abundantly inexpensive. But in the long run, if one were to step back and look at the cost, the contribution that low-cost corn has on obesity, one might reconsider that particular strategy, or a piece of that strategy. And I’m not saying that I have the answer. It’s very complicated, as you’re suggesting. But we’re beginning, I think, to understand, what the pieces are, and what role policy plays in terms of trying to achieve better outcomes. We still have to develop the informational foundation for our policymakers to make decisions, and I think that’s the place we’re at now. Is defining the problem, and making it clear that there’s an economic description, a biological description, and a medical description, and a social description of this problem. Put that altogether, and say, “Okay. Now, how do we make policy that takes all of this and make sense of it.” How about one more question.

Unidentified speaker: Thank you so much for your comments. You mentioned a school-based program, the CATCH program, that’s really looking at how you could make a difference. And many of us in this room, federal and state, are going to be part of an exciting initiative that’s looking at early childhood.

Eduardo Sanchez: Um-hmm.

Unidentified speaker: We’re looking at five critical areas, and one of which is early care and education. And we’re coming together with state counterparts across systems to look at how we can improve, protect, support the lives of children and their families, particularly this age group. With obesity at this age group, if it’s in early childhood, someone’s overweight or obesity, and looking at a child, a label, is another person’s healthy.

Eduardo Sanchez: Um-hmm.

Unidentified speaker: So the effort is a lot more difficult. I was wondering if you had any suggestions or advice to give us as we come together for the State Early Childhood System’s activity with state’s counterparts trying to develop a state plan. How we can get this issue more centrally on those tables that we talk about, making children healthy and ready to learn at school entry. So doing the work before school.

Eduardo Sanchez: Thank you for the question, and you’re absolutely right. As with so many things, by the time the child gets to school, there’s a lot that’s been missed. A lot of missed opportunities. Whether we’re talking about cognitive learning skills, whether we’re talking about diet and physical activity within the home, whether we’re talking about immunization rates, because we all know that when they’re in school, they have a hundred percent immunization rates, but when they’re two years old, we’re not doing so well. A couple of things, I think, and I suspect you’re already doing this. As maternal and child health programs come together that are looking at that stage of life and sort of the programming that is related to that, I believe it’s important to have the other partners that have significant activity for that population. WIC would be one. Medicaid and CHP would be another. Why Medicaid and CHP. Well, Medicaid and CHP, because the way Medicaid and CHP are set up with Texas, with EPSDT, we call it Texas Health Steps, we like to put word Texas on everything, but our EPSDT programs, the way they’re designed to work are supposed to bring Medicaid children and in our state, in the first year of life, that’s 50% of all children, supposed to bring them into the doctor’s office. And that’s the place so the doctor’s office through CHP and Medicaid, WIC offices, maternal and child health programs, are places where both at the prenatal opportunity, at the early infant and childhood opportunity, the messages and the shift in terms of what constitutes a healthy weight child can begin to be had. And again, with children, with infants, the interval, the confidence interval is far greater. It starts narrowing, I guess, as children get older. But you’re absolutely right. It’s a little bit difficult to do, but what we should be teaching, again, I think an important point that I would make is, we shouldn’t necessarily be trying to get families to focus on ideal weights. We should be asking families to focus on healthy behaviors. So eating the right kinds of foods in the right amounts and engaging in physical activity. Now you say in infants and toddlers. What kind of physical activity. With infants and toddlers, it’s about parents engaging in physical activity so that when those children become three- and four-year-olds, they start noticing, and probably start younger than that, that parents are involved in regular physical activity. It should be something that’s incorporated into the regular, into our family lives. Easier said than done. Believe me, I know. But it’s something we all should strive to do for the sake of our children. Does that help? I thank you so much. You can’t know, really, what a thrill and an honor it is for me to be here. You all do very, very important work in your states and you all will be at the tables as these discussions are had, and will be able to nudge, nudge policy, nudge behavior, nudge activities and communities in such a way that perhaps we can get a handle on this because we must get a handle on it.