ISSUE BRIEF Healthier Americans for a Healthier Economy INTRODUCTION P reventing disease is one of the most common sense ways to improve health in America. But it is also a major factor for improving the economy. More than half of all Americans currently win-win way to make a real difference. They live with one or more chronic illness, includ- can make sense for the health of employees ing heart disease, stroke, diabetes and can- and their families and for the employer’s cer.1 High rates of these diseases, which in bottom line. many cases are preventable, are among the This report features six examples of places biggest drivers of U.S. health care costs and around the country where employers are they are harming worker productivity. working with communities to provide com- Employers around the country are searching mon sense ways to make healthier choices for ways to support the health and wellness of easier for employees and their families. their employees and their families while also These stories examine how different states, struggling with high costs of benefits. For ex- cities and towns have recognized that a com- ample, as Tom Mason, president of the Al- munity’s health affects its ability to attract liance for a Healthier Minnesota has said, and retain employers, and how many busi- “we’ve heard from employers around the state nesses and organizations understand the that their health care costs are unsustainable value of workplace and community wellness and they want to do something about it.” programs for improving productivity and re- Many employers are finding that workplace ducing health spending. and community wellness programs offer a HEALTH AND ECONOMY CASE STUDIES 1. In Minnesota, SHIP Comes In, Saving Lives — and Money 2. Texas Recognizes the Costs of Excess Weight, and Tries to Do Something about It 3. Nashville’s New Tune: Investing In Health 4. Taking Steps to Tackle Obesity and Smoking in Indiana 5. San Diego: Building an Environment that Encourages Health 6. Hernando, Mississippi, Bucks a Statewide Trend OCTOBER 2011 PREVENTING EPIDEMICS. PROTECTING PEOPLE. 1. IN MINNESOTA, SHIP COMES IN, SAVING LIVES — AND MONEY For years, Minnesota has been among the health- health from the United Health Foundation and iest states in the country.2 It has low rates of to- the American Public Health Association, Min- bacco use, obesity and chronic disease, and high nesota dropped from first in 2006 to sixth in 2010.3 rates of physical activity. But in recent years, Min- And even though it remained near the top, the nesota has slipped. In annual rankings of state state still has millions of citizens with preventa- ble diseases. More than 60 percent of Minnesota residents are either obese or overweight; 17 per- cent — almost a million people — use tobacco products.4 Obesity and tobacco use significantly increase the risk of chronic ailments such as heart disease, diabetes, cancer and asthma. These conditions not only cause suffering; they are also expensive. Studies have shown that three-quarters of the money Americans spend on health care is devoted to dealing with largely pre- ventable chronic diseases.5 In Minnesota alone, smoking kills more than 5,000 people a year, and leads to almost $3 billion in excess medical costs annually. According to a study published this year, obesity costs the state $2.8 billion a year;6 of that, $515 million came from Medicare, while $468 million came from Medicaid.7 In addition, experts say, high rates of preventa- ble chronic disease can also harm the bottom line, increasing health care costs for businesses, and decreasing the possibility that new busi- nesses will expand or relocate to a given area. “Companies in Minnesota are now really thinking about how they can lower their health care costs,” said Sanne Magnan, MD, PhD, who from 2007 to 2010 was Minnesota’s health commissioner. “They are very interested in how to do that efficiently.” The Goal: Improving Health on a Wide Scale Four years ago, Minnesota started an ambitious SHIP was passed with the backing of then-gover- attempt to reduce its burden of chronic disease nor Tim Pawlenty, and got bipartisan support in by helping millions of residents lead healthier the legislature. “Everyone recognized that you lives.8 Officials say the program, the Statewide had to invest in helping the population get Health Improvement Program, or SHIP, could healthier,” said Magnan. “That had wide appeal.” save the state billions of dollars in healthcare The idea behind SHIP is simple. In recent years, expenses, and could help private business cut public health researchers have found that peo- costs too.9 ple are more likely to change unhealthy behav- “This is aimed at keeping people from getting ior — give up smoking, increase physical activity, these chronic diseases,” said Minnesota state or eat more healthily — when such choices are representative Thomas Huntley, who was one of easy. But right now, most Minnesotans, and the law’s architects. “If they don’t smoke, and most Americans, live in an environment domi- they watch what they eat and stay active, people nated by fast food restaurants, high-calorie, low- are less likely to get heart disease or diabetes in nutrition snack food, television and the the first place.” automobile, an environment that strongly en- courages obesity and its attendant ailments.10 2 Aiming for Long-Term Change SHIP aims to turn this equation on its head. portant to stop the rise of preventable chronic dis- Through a variety of methods, the program is ease. The idea is to generate savings by reducing trying to modify the environment in which Min- the number of people who have these conditions.” nesota residents live, so that it becomes much In addition, SHIP is helping small businesses simpler to live in a healthy way. For instance, in- across the state set up wellness programs, which stead of funding a short-term program focused can also save money. Studies suggest that for on weight loss, SHIP will help communities every dollar a company spends on these pro- build new sidewalks and bike lanes, which will grams, it can save between three and six dollars permanently increase the likelihood that all res- in health care costs.11 Researchers have also idents will walk and ride bicycles. found that employer wellness programs can cut “We’re giving people more healthy food choices, costs related to sick leave, workers’ compensa- more opportunities for physical activity, more tion and disability compensation by as much as opportunities to live in a smoke-free environ- 25 percent.12 ment,” said epidemiologist Rachel Cohen, who Beyond SHIP, the state’s private sector is in- is overseeing SHIP for the Minnesota Depart- creasingly aware that improving employee ment of Health. health can be a good investment. Last year, the State officials say that over time, SHIP will save the non-profit group Alliance for a Healthier Min- state money. Julie Sonier, who until last year was nesota polled 400 Minnesota manufacturers. Minnesota’s state health economist, estimated “Health care costs were the top concern,” said that if it receives funding through 2015, SHIP will Tom Mason, the group’s president. “It wasn’t help more than a quarter million Minnesotans even close. Even in the midst of the recession, stop smoking, and more than 460,000 residents health care was seen as the top issue.”13 lose enough weight to no longer be classified as He said that for the first time, many of the com- obese or overweight. According to the estimates, panies are considering wellness programs as a way these reductions will allow Minnesota to save al- to lower costs. “This is a big trend,” said Mason. most $2 billion in health care costs annually. “My sense is that businesses are now really looking “There is a lot of potential with this,” said Sonier. for ways to address spiraling health care costs.” “If you’re going to contain health care costs, it’s im- State Funding, Local Autonomy But SHIP is much more comprehensive. The “The idea is that individual counties and com- legislature provided the program with $47 mil- munities can do their own thing, with oversight lion over two years, through 2011. Per capita, the from the state,” said Huntley. cost ends up being $3.89 per person. “A Happy The options include Complete Streets initiatives Meal costs more than that,” said Cara McNulty, a to build more sidewalks and bike lanes; efforts to health policy expert who until earlier this year improve the nutrition of school meals; “Walking oversaw SHIP for the state health department. School Bus” programs that encourage kids to walk The money is divided between 87 counties and to school; farm-to-school initiatives that supply nine tribal governments, with each region get- local food to students; and cessation programs ting a base amount, as well as additional fund- that make it easy for citizens to stop using tobacco. ing based on population.14 SHIP gives each Each county or region must choose at least one region leeway to choose measures that will help tobacco program and one obesity program. local residents. Counties and tribal areas pick Each of the 98 zones has created a health council from a menu of 33 programs created by the state made up of local health, school and government department of health, with input from the U.S. officials, as well as business leaders. With help Centers for Disease Control and Prevention from experts at the state department of health, (CDC) and other experts. the councils set up and manage local SHIP efforts. 3 Corner Stores and Complete Streets Some communities have focused on policy hood and adolescence are crucial windows for change. In Minneapolis, SHIP staff helped im- introducing healthy behavior: it is much easier plement a law requiring convenience stores to to prevent obesity than it is to help those who carry a minimum quantity of healthy foods, in- are already obese lose weight. Similarly, it is eas- cluding at least five varieties of fresh fruit or veg- ier to prevent tobacco addiction than it is to per- etables. The goal: to increase the availability of suade smokers to quit. nutritious food in areas that lack full-service gro- St. Paul passed a law prohibiting candy cigarettes cery stores. In these neighborhoods, which are and lighters that look like toys. Dakota County, known as “food deserts,” residents often end up a rural area south of Minneapolis, used SHIP doing much of their food shopping at corner funding to set up a “Safe Routes to School” pro- stores. Also with the help of SHIP staff, the town gram: all of Dakota County’s 10 schools have de- of Eyota passed a Complete Streets law.15, 16 veloped routes that will allow more students to Other regions have emphasized increasing con- safely walk or bike to school. One school has its sumption of healthy food. In the northeast part buses drop kids a half-mile from the campus, of the state, a group of Ojibwe Native American and students walk the rest of the way.19 communities created or expanded 13 commu- In its first year, SHIP helped nearly 350 Min- nity gardens and started 482 backyard gardens. nesota child care centers improve nutritional Using vegetables they’ve grown in the gardens, value of the food they offer, and teach children several of these communities created farm-to- about what to eat, and what to avoid. These cen- school programs. In addition, the group has ters take care of almost 8,000 young children. started four new farmers’ markets.17 With help from SHIP, more than 300 child care Many counties and tribal areas have targeted centers set up exercise programs for their kids.20 childhood obesity and teen and young adult In addition, SHIP has helped many schools set up smoking. Last year, a survey of Minnesota stu- farm-to-school programs. More than 130 Min- dents found that just one in five sixth-graders ate nesota schools now have such efforts, enabling the recommended five daily servings of fruits nearly 70,000 students to eat healthier food.21 and vegetables.18 Studies have shown that child- Helping Business Help Employees SHIP also works with local businesses to develop SHIP funds to help pay for a dietician to help worker wellness programs. It offers advice, and employees eat healthier. SHIP helped Eastwood sometimes gives grants to employers who want Bank, a locally-owned institution just down the to start a program. Across the state, businesses street, set up an employee fitness program. Hy- have taken a range of steps. Some have reduced Vee, a regional grocery chain, used a SHIP grant the amount of junk food in vending machines to start smoking cessation classes at its Olmsted or improved the nutritional value of cafeteria County store. So far, six workers have quit smok- food; others have built onsite gyms, paid for gym ing. With help from state health department memberships, or otherwise encouraged workers workers, the store set a no-smoking policy that to get more exercise. Some companies have of- got rid of almost all smoking during work fered incentives to employees who take smoking hours.23 cessation classes, or who quit smoking, while This summer, the state legislature voted to ex- others have prohibited smoking on company tend SHIP through 2013. But it provided less property.22 money — $15 million — than it did for the first Huntley said that many counties have focused two years.24, 25 Magnan and others argue that on helping small businesses set up employee SHIP needs continued support; they say that programs. “Nationally, big companies are al- while it is already showing results, real changes ready into wellness programs, because they see will only show up after five or even 10 years. And that it saves them money,” said Huntley, the state they argue that because the program focuses on representative. “But most small businesses don’t systemic change rather than quick results, the have the infrastructure to set up those kinds of eventual improvements will be sustainable. programs. They need help.” “With a problem as big as this,” Magnan said, In Olmsted County, in the southern part of the “we need to have patience. We’ll see health im- state, Mark!t, a small marketing company, used provements, and savings, but it will take time.” 4 TARGET: AIMING HIGH TO IMPROVE EMPLOYEE HEALTH — AND CUT HEALTH CARE COSTS With 355,000 employees, Target, which operates 1,755 stores in 49 states, has the population of a large city.26 The company provides health insurance to nearly a quarter of a million people.27 This cost is rising rapidly, as it is throughout the private sector.28 In an attempt to control that expense — and to help its employees and their families improve their health — the Minneapolis-based company is rolling out an ambitious wellness program.29 The effort is modeled in part on SHIP Minnesota’s statewide prevention program.30 , The company hired one of the architects of SHIP Cara McNulty, to develop and oversee its initiative. , Both programs share the same basic goals: increasing physical activity, improving eating habits and reducing tobacco use. In a bid to change its culture, Target has designated 2,000 workers across the country as “Wellness Champions,” who encourage colleagues to get more exercise and eat right.31 The company gives information on healthy living to the Champions, who share it with other workers and encourage them to change their behavior. And the company has increased the number of healthy foods available in store vending machines. Target is considering a range of other steps. Among them: n Subsidizing healthy food in company cafeterias and encouraging workers to offer healthier snacks and drinks during meetings. n Giving employees free or subsidized access to gyms, either on site or nearby. n Providing individualized cessation programs to help some of the 35,000 or so Target workers who smoke. n Offering discounts on insurance to employees and family members who take steps to improve their health. n Sending sick workers for treatment in regions of the country that have a particular expertise in a given illness. The goal: to improve quality of care and reduce unnecessary treatment. The company is also discussing ways to attack childhood obesity among workers’ children, as well as in the communities where it operates. McNulty said that the program could yield multiple benefits: not only lowering health care costs and improving health, but also improving employee productivity. 5 2. TEXAS RECOGNIZES THE COSTS OF EXCESS WEIGHT, AND TRIES TO DO SOMETHING ABOUT IT Texas has a reputation as a pro-business state. It “Those are shocking numbers,” said Susan has a long history of embracing and encourag- Combs, the state comptroller. ing entrepreneurs, from wildcat oil prospectors Obesity is a serious problem for Texas. Nearly 30 to cutting-edge energy companies, and it regu- percent of the state’s residents — more than eight larly tops state rankings for its educated work- million people — are obese, while another 37 per- force, low taxes and relative lack of regulation. cent are overweight.35 Over the past 20 years, But in one key way, businesses in Texas are at a these rates have increased dramatically; in 1990, disadvantage. A report published earlier this just over 12 percent of residents were obese.36 year by the state comptroller found that obesity Overall, Texas is the 12th most obese state in the cost Texas businesses an extra $9.5 billion in country, according to a report released earlier this 2009: more than $4 billion for health care, $5 year by the Trust for America’s Health.37 billion for lost productivity and absenteeism and Of course, Texas is not the only state where obe- $321 million for disability.32, 33 The analysis esti- sity hinders economic development. But for al- mated that if current trends continue, the cost most a decade, Combs has focused on the could more than triple by 2030.34 economic costs of the obesity crisis. As a result, more information exists about Texas’ situation than for most states. First as agriculture com- missioner and then as comptroller, she has worked to alert Texans to the health and eco- nomic risks of obesity. In addition, Combs has focused on raising awareness in the private sector. “This is a huge issue for the financial security of our state,” she said. “We know we have to get business involved. I don’t know any other way to do it.” Combs is not the only one worried about obe- sity’s effect on the state’s economy. “If obesity continues to rise, we will have a workforce that will not be as attractive as it could be to compa- nies thinking of expanding or moving to Texas,” said Eduardo Sanchez, a former state health commissioner who is now the Chief Medical Of- ficer for Blue Cross Blue Shield of Texas, as well as a member of the TFAH board of directors. “Obese workers tend to have lower productivity because they have chronic disease, and they tend to lose time to disability. These are things that companies think about.” The situation could get much worse. A 2009 re- port by the state demographer estimated that if current trends continue, 15 million Texas adults will be obese by 2040 — three times as many as now.38 “Future levels of obesity will be intolerable un- less we make some changes,” said demographer Karl Eschbach, who wrote the report. “If you look at this from a financial point of view, it’s scary.” Eschbach, who is now a professor at the University of Texas at Galveston, pointed espe- cially to the growing cost of type 2 diabetes, a dis- ease closely linked to obesity. 6 Based on the possible projections, “you’re look- some cities, counties and businesses, has taken ing at the state of Texas going from 10 percent of steps to help residents, students and workers in- adults with diabetes to 25 percent with diabetes,” crease their physical activity and eat more wisely. he said. “Diabetes is a very expensive disease.” “Texas has been on the cutting edge in fighting As more in both the public and private sector have obesity,” said Carrie Kroll, chairwoman of the recognized the financial and medical costs of obe- Partnership for a Healthy Texas, a coalition of sity, the state has become a leader in the fight to more than 20 health and medical organizations improve health. The state government, as well as trying to reduce the state’s obesity rates. Toward Healthier Communities: San Antonio Many Texas cities and towns are working to help A national study published last year found that residents improve nutrition and increase activ- for one large corporation, average health insur- ity. Last year, San Antonio embarked on an am- ance costs for an obese child were more than bitious anti-obesity program, paid for by a $15.6 $1,200 higher than for a healthy-weight child. million federal grant.39 For a child with type 2 diabetes, costs were more than $9,000 higher annually.44 And of course, The program is funding the creation of three obese children are more likely to become obese new farmers’ markets around the city, and has adults, who spend an average of more than started an effort to encourage people to choose $1,400 extra on health care annually compared healthy food when eating out. Health depart- to healthy-weight adults.45 ment dieticians have analyzed the menus of more than 100 local restaurants and identified To help its children lose weight and stay healthy, the healthiest items, which receive stickers that San Antonio is installing salad bars in 100 say “¡Por Vida!” Some local fast food restaurants schools, and it has bought exercise equipment have even joined the program: for instance, at for 365 schools, which together serve 275,000 McDonalds, oatmeal and yogurt received the students. The material includes hundreds of health department’s approval.40 balance balls, hula hoops and jump ropes, as well as thousands of orange plastic cones for In addition, San Antonio has bought 150 bikes, relay races and obstacle courses.46 which can be used for a few hours at a time by any city resident who registers online and pays a $10 Some evidence indicates that in San Antonio (as yearly fee. So far, the bikes, which are stored at 14 in most places), those with lower incomes tend to kiosks around the city, are averaging 100 checkouts have higher obesity rates.47 To help deal with a day. And the city is crafting Complete Streets reg- this, the health department will give away 1,000 ulations, which would require any new projects to bikes to lower-income residents. The bikes are include consideration of walkers and bicyclists.41 free, but recipients must first show their com- mitment by taking classes on bike safety and bike The program has installed playgrounds and ex- maintenance. The city has also built five walking ercise equipment in 26 parks around the city, as trails in public housing projects around the city.48 well as outside several city libraries. To encour- age activity, the parks department is offering To publicize all of this work, San Antonio will free exercise classes in various parks: yoga, tai soon roll out an integrated media campaign, chi, as well as more intensive “boot camp” ses- whose slogan is “Find Your Balance.” It will sions. Since last year, more than 4,000 people include TV, radio and print ads, a website and have taken the classes.42 social media.49 The initiative has also focused on childhood San Antonio is not the only place in the state try- obesity, which is a major problem for San Anto- ing to lose weight. Over the past decade, El Paso nio: nearly one in three of the city’s public has undertaken several anti-obesity efforts, much school students have an unhealthy weight.43 of it funded by the Paso Del Norte Foundation, a local non-profit group.50, 51 The group is fund- Combs and others emphasize that childhood ing a community walking program, cooking obesity is also an economic problem. “The cost classes and food labeling in supermarkets and of childhood obesity is not as well appreciated restaurants, so shoppers and diners can more by policymakers, and by the private sector, as it easily identify healthy and unhealthy foods. ought to be,” said Sanchez. 7 Employers: Helping Workers Get Healthy, Lowering Insurance Costs Across the state, businesses are also realizing how addition, each of the 15 regions sponsors at least obesity can significantly increase health care costs one 5k community race.55 and reduce productivity. Some are attacking the HEB is also encouraging kids to be more active. problem by setting up wellness programs that It will award 12 schools $15,000 each to improve help workers better control their weight. “Cor- their health and nutrition education programs. porations are starting to realize that this is cost- The contest is open to any school in Texas ing them a lot of money,” said University of Texas within 60 miles of an HEB store.56, 57 epidemiologist Steve Kelder, who has studied the state’s obesity problem for more than a decade. Some towns and cities in the state are also trying to cut costs through wellness programs. Hurst, a For instance, the regional supermarket chain HEB, suburb of Fort Worth, developed a comprehen- which is based in San Antonio, has also developed sive wellness program for employees, retirees and a successful wellness program.52 “We wanted to re- their families.58 Started six years ago, it encour- duce health care costs and get people to take more ages participation with bonuses, gifts and extra va- responsibility for their health,” said Kate Rogers, cation time. For the last two years, the program who oversees the company’s program. More than has had a weight loss contest, and more than a 700 workers serve as “wellness champions,” en- third of all city workers have taken part. Due couraging colleagues to join and answering their largely to the wellness program, the city’s health questions. Over the past eight years, the program insurance premiums have risen little over the past has helped HEB keep health care cost increases at five years, much less than would be expected. less than half of the national average.53, 54 And between 2007 and 2009, absenteeism among Last year, the company inaugurated its “Slim- Hurst workers fell by nearly 40 percent.59 down Showdown”: 15 employees, one from The city also offers a less extensive web-based each region, competed to see who could lose the wellness program to all of its 36,000 residents. most weight. The winner received $10,000. That program, Healthy Hurst, helps participants Rogers said the contest helped energize other with exercise plans, nutrition information, food employees who want to improve their health. In logs and a program to track progress.60 Health in Schools: Investing in the State’s Future Across the state, childhood obesity is a major cal activity, training for teachers and expert ad- problem: one in five Texas children is obese, vice for cafeteria workers on how to make school higher than the national average.61 food healthier. The program was developed two decades ago by researchers at four universities, Over the past decade, the state government has including the University of Texas Health Science made several moves to reduce the problem. In Center at Houston. Studies have shown that 2001, it required all elementary schools to provide CATCH can reduce the fat content of school 135 minutes of physical education per week.62 A lunches, increase physical activity during PE large percentage of schools, especially elementary classes and improve students’ eating and exer- schools, have adopted these guidelines.63 cise habits.68 Two years ago, the legislature passed regulations An independent study of CATCH in the El Paso requiring schools to devote at least half of every PE school district found a seven percent decrease class to physical activity.64 Previously many schools in obesity rates among fourth graders.69 “There used PE as study hall or supervised free time. were dramatic reductions in rates of obesity and In 2003, the state department of agriculture lim- overweight,” said Kelder, one of the study’s au- ited access to unhealthy competitive foods — thors. “This is a good example of what a com- products sold at on campus that are not part of munity can do.” the school meal program.65 Texas was one of the CATCH has been implemented in schools first states to regulate competitive foods.66 across the country, but it has been used most Many state elementary and middle schools have widely in Texas.70 Kelder, who is one of the pro- also adopted the Coordinated Approach To gram’s original developers, estimates that half Child Health (CATCH), a program to help stu- of the state’s elementary schools have received dents control weight and improve health.67 CATCH training, as have 30 to 40 percent of CATCH includes a range of features, such as middle schools.71 classroom education about nutrition and physi- 8 Research suggests that CATCH is a good invest- Most schools have used the grants to train teachers ment. A 2007 study found that the program was and buy physical education equipment. An evalu- the most cost-effective way to prevent obesity ation of the program found that participating among youth. According to the study, the pro- schools significantly improved the percentage of gram costs $900 for every healthy year it adds to students who passed their Fitnessgram tests. an obese child’s life. This is far below the cut-off Researchers have correlated the Fitnessgram re- point of $30,000 a year that the study used to de- sults with other data from school districts, and termine cost-effectiveness.72 found links between physical fitness and im- In 2007, Texas instituted a comprehensive evalu- proved academic performance, school atten- ation of students’ physical fitness levels. Known dance and good behavior.75, 76 as the Fitnessgram, the analysis consists of six Combs has more plans for the Fitnessgram data. tests, which measure body composition, aerobic Her office is now integrating the results with in- capacity, strength, endurance and flexibility.73 formation about communities’ obesity rates During the 2009-2010 school year, the state tested along with the number of parks and grocery nearly three million students. Only 31 percent of stores. She plans to share the results with com- third-grade boys and 37 percent of third-grade munities so that officials, parents and others will girls could pass all of the tests. For older students, have a better sense of how these environmental the results got progressively worse. For seventh- factors may affect health and weight. graders, 28 percent of girls and 21 percent of boys passed every test. Less than ten percent of high Combs and other experts realize that Texas faces school seniors of either gender passed. years of hard work. The obesity crisis has many causes, and reversing it will not be easy. The state But the situation may be improving. In 2007, at faces significant obstacles, including potential state Combs’ urging, the legislature created Texas Fit- and local budget cuts. ness Now, which provides state middle schools with grants to improve physical and nutrition education “This is a 20- to 30-year process,” said Kelder, the programs.74 So far the state education agency has University of Texas epidemiologist. “We can’t given $27 million to more than 2,100 schools. expect dramatic results quickly.” USAA TAKES WELLNESS TO THE NEXT LEVEL Peter Wald is willing to try almost anything to help his com- you is lower down — the opposite approach taken by many pany’s workers get healthy. As the director of USAA’s well- supermarkets. Healthy items have a prominent green tag. ness program, he has instituted discounted salads, bonuses for n In 2008, the program added weight loss and other health in- going to the gym, even mileage signs in long hallways.77 centives; employees who meet requirements can earn up to His work seems to be paying off. Since starting the program $550 a year. USAA also offers lower health insurance premi- in 2002, the San Antonio-based financial services company has ums for improving health; single workers can save up to $300, reined in health costs.78 And 85 percent of the company’s while those with dependents can save as much as $950. 22,000 workers have joined.79 n In company cafeterias, pricing encourages workers to buy healthy food, water costs $1.25, while soda is $1.50; a The company’s program has three goals: to improve health, turkey burger costs slightly less than a beef burger; and a lower company health costs and improve productivity. Reduc- veggie burger costs less than a turkey burger. “We keep ing and controlling obesity is a key focus. USAA researchers track of consumption,” Wald said. “It works.” found that obesity is behind a significant amount of the com- pany’s health care spending. “Health care is always a big The incentives have contributed to increased weight loss, im- chunk of your labor costs,” Wald said. “With obesity, health proved health measurements and decreased costs. In 2009, care costs have the potential to really go up.” the company’s average employee BMI fell for the first time in five years. Over the past five years, its health insurance costs USAA offers employees a variety of inducements to get healthy: rose just two percent a year, far below the national average.80 n Employees pay $300 a year to use company fitness centers, which are in almost every company building. But workers In recent years, USAA’s annual health care costs have in- who go once a week for a year get 25 percent off; those creased by just two percent a year, a quarter of the national av- who go twice a week get half off; those who go three or erage. On top of that, the average employee BMI has gone more times a week get 75 percent off. down slightly for two years in a row.81, 82, 83 n USAA has built running and walking trails and paths at many “It’s much cheaper to keep people healthy than it is to take of its campuses, and painted mileage markers in company care of them when they’re sick,” said Wald. “The way for us hallways to encourage indoor walking. In company cafete- to control costs is to keep people healthy. We’re doing a full rias, healthy food is at eye level, while food that’s bad for court press.” 9 3. NASHVILLE’S NEW TUNE: INVESTING IN HEALTH Nashville is known as the home of country music. At the same time, he said, a healthy population But these days, the industry that really makes the can be a major draw for companies looking to city move is health care. More than 20 large relocate or expand. “Nashville wants to attract health care companies are based there, includ- new business,” said Paul. “If we’re known as a ing the Hospital Corporation of America (HCA), healthy city, that becomes a positive thing for one of the country’s largest hospital chains. economic development. If we’re known as a city Health care revenues account for more than $29 that thinks about the health of our workforce, billion a year, a fifth of the city’s total economy.84 that will be a big plus for companies.” But when it comes to its own health, Nashville is To improve Nashville’s long-term prognosis, the a beat behind. Nearly 28 percent of its adults are city government, along with businesses and non- obese, and another 36 percent are overweight.85 profit groups, have undertaken an ambitious ef- fort to increase residents’ physical activity and This disconnect has alarmed city officials, health improve their eating habits. Combining money advocates and business leaders — not only be- from the city budget with more than $7 million in cause obesity and its related ills are consigning federal funds, Nashville is adding sidewalks and tens of thousands of the city’s citizens to unnec- bike lanes, making healthy food more widely avail- essary illness or disability. They also realize that able and encouraging citizens to get more active. poor health is expensive, and can harm economic development, both in the short and long term. While the central goal is improving Nashville’s health, saving money is also crucial, said Alisa “If your company has a lot of people with chronic Haushalter, a nurse with the health department disease, you’re spending a lot of money,” said who is project director for the program. “Every- William Paul, the city’s health commissioner. “If thing we do takes economic impact into ac- you can prevent those diseases from happening, count,” she said. “It’s the old adage, an ounce of you can save a significant amount.” prevention is worth a pound of cure.” Encouraging Exercise and Better Nutrition City officials are focusing on changing systemic cost. To ensure that the bikes are not stolen, those policies rather than just introducing specific, time- who want to use them must first register online. In limited programs. For instance, instead of starting addition, the parks department is improving signs an exercise program that will end when funding and markings along many city trails and bike paths. runs out, the city passed a Complete Streets law, This summer, to make sure that residents know which encourages street improvement projects to about this work, and to encourage them to include sidewalks and bike lanes.86 The goal is to change how they live, the city rolled out “Nashvi- change the overall environment in which people tality,” a media campaign with radio and TV ads, live, work and play, making it easier to exercise as well as a web site. and eat healthy foods.87 In addition, the health department is working This year, Nashville also allocated $30 million for to improve food in neighborhoods that have lit- parks and greenways, a 30 percent increase from tle access to healthy food. In these areas, many the year before. Nashville is planning to build 25 residents end up shopping at convenience miles of new walking trails, and has allotted $3 mil- stores, which typically sell few nutritious prod- lion for 19 miles of new bike paths and $12.5 mil- ucts. In partnership with Community Food Ad- lion to build or improve 19 miles of sidewalks.88 vocates, another local non-profit, Nashville is In addition, the city helped set up 80 urban veg- helping 29 of these stores improve what they etable gardens around the city, to encourage offer. The city provides coolers to each store both exercise — gardening burns calories — and offers advice on how to choose, stock and and healthy eating. Many of the gardens pair market fresh fruits and vegetables, as well as teens with senior citizens as a way to create so- other items such as whole wheat bread.90 cial bonds that might not occur otherwise.89 “Before, all you could buy in these stores was The health department also bought 126 bikes, chips, candy and beer,” said David Campbell, which will be stored around the city on racks near one of the project’s coordinators at the city bike paths and greenways. The bikes can be used health department. “There was hardly any fresh by any city resident for a few hours at a time, at no fruit or vegetables.” 10 Nashville’s mayor, Karl Dean, has taken a lead- dents have signed up; together, they have walked ing role in improving the city’s health. Earlier more than 100,000 miles.92 this year, he started “Walk 100 Miles with the “This is a difficult problem, but obesity comes Mayor,” a program that challenged residents to down to issues we can control — what we eat walk that distance over the course of several and how much we exercise,” Dean said. He months.91 This spring and summer, he took part takes the message personally: he lifts weights al- in 28 public walks around the city, all between most every other day, and does cardiovascular two and 10 miles. So far, more than 4,000 resi- exercise several times a week. Businesses on Board Nashville is also focusing on the workplace. MD, who helps direct Vanderbilt’s wellness pro- Health department officials, along with the Cham- gram. “We’re pretty excited about this.”97 ber of Commerce, are talking to 10 of the city’s He is now working to expand the program. largest companies and institutions, including Van- “The question,” he said, “is how to scale this up derbilt University and HCA, which together em- for 43,000 people. But if we can get more of our ploy tens of thousands of residents, about how to population to do these intensive lifestyle pro- encourage physical activity and smarter eating.93 grams, we can see substantial savings.” Among the options being discussed: increasing HCA is also trying to cut costs by improving nutritious options in vending machines; requir- workers’ health. This year, the company, which ing water and healthy food at meetings; subsidiz- insures 148,000 employees and 72,000 depend- ing gym memberships and mass transit passes; ents around the country, began offering a $250 allowing employees to exercise during work time; health care spending credit to those who com- and installing bike racks on company grounds. plete an online health survey and assessment. Vanderbilt has already developed an extensive So far 65 percent of workers have taken part. wellness program for the 43,000 participants in About 15,000 were found to have increased risk its health plan (25,000 employees and 18,000 of a chronic disease; they were advised to see a family members). Seven years ago, the institu- doctor and to visit a company website with dis- tion created “Go For The Gold,” a program that ease information.98 pays people up to $360 a year if they provide in- The company is also testing a pilot program for- formation about their health and lifestyle and re- people with pre-diabetes or diabetes. Once a ceive instruction in how to get healthier. Almost month, about 350 workers receive individual 90 percent of those in the school’s health plan coaching from a certified diabetes educator on participated in at least part of the program.94 In how to reduce risks through exercise, healthy eat- 2008, the program received the prestigious C. ing and medication. HCA researchers found that Everett Koop National Health Award.95 compared to a control group, those who were The university is also revamping its cafeterias, sub- coached had a nearly 50 percent drop in emer- sidizing some nutritious foods and prominently gency room visits, and a five percent drop in over- displaying healthier choices. In one building, all health care costs. None of the pre-diabetics they replaced a McDonalds with an Au Bon Pain.96 who were coached became fully diabetic, and 57 percent stopped being pre-diabetic altogether.99 Vanderbilt has also developed a pilot program de- signed to help those most at risk. It started 30 em- Yonnie Chesley, who is in charge of HCA’s well- ployees, all recently diagnosed with diabetes, on ness efforts, said the pilot program will soon ex- an intensive exercise and nutrition program. All pand to 1,000 people. If that proves successful, participants improved their cholesterol and blood the initiative will go company-wide next year; sugar measurements, and nearly a quarter were overall, the company has about 17,000 pre-dia- able to stop taking all their medications. “We’ve betic or diabetic employees. seen dramatic changes,” said Dexter Shurney, 11 Improving Children’s Lives — and Saving Money The city is also investing in ways to improve the This summer, 20 of the district’s cafeteria man- health of the city’s future workforce, with efforts agers, who together are responsible for food at aimed at children and schools. more than 140 schools, received training on im- proving nutrition. Many of these schools are Improving the health of Nashville’s children will do adding salad bars, and most are increasing the more than reduce costs in decades to come; it will number of dishes that are prepared from also help cut current costs. Childhood obesity is ex- scratch or with fresh fruits and vegetables.103 pensive: a recent study calculated that in the United States, each obese child costs the health care system Other changes are on the way too. “Nashville is nearly $300 a year more than a healthy weight like most places,” said Campbell. “The food you child.100 The researchers calculated that reducing eat in a school is generally not very healthy — the rate of childhood obesity by just one percent- tater tots, hot dogs, french fries. We want to age point would save at least $1.4 billion annually.101 move to salads, fresh fruit and vegetables.” And because obese adults tend to use even more In addition, the city is targeting children who health care resources, helping obese children aren’t yet old enough for school. The health de- lose weight before they grow up will eventually partment is working with eight Head Start pro- save even more money. “Helping them learn grams, which together have nearly 2,000 students, healthy habits will really help down the road,” to incorporate physical activity into learning and said Haushalter, the city’s obesity program di- teach children about good nutrition.104 rector. “It’s a long-term economic solution.” Paul, the health commissioner, is confident Last year, the Nashville school district lowered that the combination of Nashvitality and pri- sugar levels in flavored milk, a reduction of 22 vate sector efforts will yield results. “If we can calories per carton. Because of the change, have even a small effect on health care costs,” Nashville’s 77,000 public school students will in- he said, “it’s going to be a big payoff, for a rel- gest 50,000 fewer pounds of sugar a year. In con- atively small investment.” junction with a local non-profit, the district is Haushalter agrees, but preaches patience. “We also working to improve the nutrition of prod- are in an epidemic that has occurred over sev- ucts sold in school vending machines.102 eral decades,” she said. “We have to be very dili- More than 40 schools have set up vegetable gar- gent. This will take many years to change.” dens, which are tended primarily by students. 12 4. TAKING STEPS TO TACKLE OBESITY AND SMOKING IN INDIANA Indiana faces serious health challenges. Almost of the Wellness Council of Indiana, a private group two-thirds of the state’s population is either affiliated with the state chamber of commerce, overweight or obese.105 Nearly 10 percent of the which helps companies set up or improve wellness state’s 6.4 million people have diabetes, double programs. “I’m concerned that companies may the rate 20 years ago.106 More than a quarter get think twice about relocating here.” little or no exercise and just one in five eats Over the past six years, the state’s public and private enough fruits and vegetables.107 And, more than sectors, led by Governor Mitch Daniels, have a quarter of the state’s adults smoke, the second- worked hard to increase physical activity, improve highest rate in the country.108 smoking cessation and decrease tobacco use. In Obesity, tobacco, and unhealthy lifestyle choices 2005, the state rolled out INShape Indiana, an effort all contribute to higher rates of chronic illness, to help residents get healthier; in 2007, with the gov- including heart disease, hypertension, diabetes ernor’s support, the state legislature passed a sig- and cancer.109 The result: hundreds of thou- nificant tax on cigarettes; and earlier this year, the sands of Hoosiers don’t live as long as they state released an ambitious ten-year plan to reduce should, experience a lower quality of life, and obesity and boost residents’ overall health.111, 112, 113 spend billions extra on health care. “Adopting a healthy lifestyle is good for you and According to a study published earlier this year, good for Indiana,” the governor has said. “Too obesity alone costs the state more than $3.5 bil- many Hoosiers are losing years because they do not lion a year in health care and lost productivity.110 embrace healthy habits. And, health care costs in “We are spending an enormous amount on obe- Indiana are among the highest in the country. Our sity-related disease,” said Marcie Memmer, direc- rising cost of health insurance coverage, combined tor of the Indiana State Department of Health’s with lost productivity due to illness, has made Indi- Division of Nutrition and Physical Activity. ana a less desirable place to do business.”114 The private sector also recognizes that the state’s Daniels himself is a fitness buff: almost every health holds back economic development. “When day, he runs, swims, works out in the gym, or you look at the drawbacks to Indiana, health is at golfs (he usually walks all 18 holes).115 His wife the top of the list,” said Chuck Gillespie, director Cheri walks 10 miles nearly every day.116 Information to Help Hoosiers Help Themselves The core of INShape Indiana is a website, which kets tend to have more processed foods, such as serves as a clearinghouse of information for potato chips, cookies and sodas.) The section Hoosiers who want to lose weight, quit smoking also has a list of more than 100 healthy recipes, or otherwise improve their health. including vegetable pasta with tomatoes and green beans with roasted red peppers. The site includes advice and recommendations on a range of health-related topics. It features In addition, the site has a link to a list of every farm- information on how to incorporate walking into ers’ market in the state, and a downloadable nutri- daily life (walk at work, use a pedometer, wear tion log to help users keep track of what they eat. shoes with proper support), as well as maps of In the tobacco section, residents can find out how appealing walks all over the state. It also gives to join a cessation program, and how, if they still advice on how to reach CDC’s recommended smoke, to minimize exposure of family and friends 150 minutes of exercise per week (do small to second-hand smoke. In the Community Corner amounts of exercise several times a day). section, the site lists health-related resources — The site is divided into three sections: “Eat Bet- trails, gardens, nutrition education centers, YMCAs, ter,” “Move More” and “Avoid Tobacco.” Each and so on — in each of the state’s 92 counties. section offers information on how to be health- For inspiration and guidance, the site also offers ier, as well as practical hints about how to reach stories from people who have improved their your specific goals. For example, the section on health in one way or another. Among those fea- diet counsels residents to do most of their shop- tured is Allison Fore, of Indianapolis, Indiana. In ping in the perimeters of the grocery store, 2009, after hearing the governor’s wife speak about which generally includes fresh and frozen fruits INShape Indiana at the state fair, Fore, who is 49, and vegetables, dairy, eggs, meat, chicken and began visiting the site regularly and going on some seafood. (The central aisles of most supermar- 13 of the walks listed there. Over the past two years, INShape Indiana also works in the non-virtual she has lost more than 40 pounds. This spring, she world. It helps the Indiana Department of Nat- completed a 13-mile race, her longest so far. She ural Resources promote its improved network of visits the site about twice a week for events and tips. trails. Along with the state Chamber of Com- “I like reading the stories about other people,” she merce and the Wellness Council of Indiana, IN- said. “So many of us share the same problems. It Shape Indiana puts on an annual conference on gives you a sense of community.”117 private sector wellness programs.120 Businesses and community groups around the Gillespie, director of the Wellness Council of In- state have also leaned on INShape Indiana for diana, said the state’s program encourages busi- weight loss guidance. The Northwest Indiana nesses to do more for workers’ health. “When Community Action Corporation adapted IN- the governor lives it, breathes it and supports it,” Shape’s “10 in 10 Challenge” — an approach he said, “it makes it very hard for corporate lead- that encourages people to lose 10 pounds over ers to ignore it.” 10 weeks — for use with senior citizens. Partic- He said Indiana businesses are starting to under- ipants learned how to exercise at home and eat stand the importance of encouraging employees smaller portions; some lowered their cholesterol to be healthy. His group has 70 members; he ex- and reduced their consumption of sugar.118 pects that to double or triple over the next two Earlier this year, the site went through an ex- years. “CEOs are saying ‘What can we do to lower tensive redesign to make it easier to use. In ad- health care costs?’” Gillespie said. “The conver- dition, INShape Indiana has increased its use of sation is starting to move toward prevention.” social media, and now regularly posts health in- The state has also focused on reducing tobacco formation to Twitter and Facebook. use. In 2006, Daniels eliminated smoking at the Over the past six years, INShape Indiana has state government complex.121 In 2007, the state also rolled out several marketing campaigns to raised the tax on a pack of cigarettes by 44.5 spread the word about its web site and the im- cents — a move supported by Daniels. “The portance of being healthy. A survey last year biggest impact of a higher price is on dissuading found that almost 60 percent of state residents young people or nonsmokers from taking it up were aware of the program. Since 2005, 86,000 in the first place,” the governor has said.122 state residents have asked to receive INShape In- According to the state health department, in the diana’s regular emails. More than 50,000 are year after the increase went into effect, con- currently signed up. sumption of tobacco products dropped by almost In 2007, INShape Indiana started the “10 in 10 20 percent, a decrease of 81 million packs.123 Challenge,” encouraging people to lose 10 pounds Earlier this year, a bill to ban workplace smoking was in 10 weeks. The campaign included an extensive defeated in the state senate. A study by the Ameri- media campaign, and more than 40,000 people can Cancer Society found that the ban would have signed up. That same year, INShape Indiana won saved the state $84 million in health care costs.124 an “Innovation in Prevention” award from the U.S. Department of Health and Human Services.119 An Ambitious Plan to Improve Health Following up on the progress of the INShape n Reduce the state’s obesity rate from 30 per- Indiana efforts, in January 2011, the state health cent to 25 percent by 2020; department announced a comprehensive 10-year n Create a system to measure students’ body plan to reduce obesity, as well as increase physical mass index in at least three different grades activity and access to healthy food. “We’ve been by 2013; encouraging Hoosiers to eat better and move more since launching INShape Indiana nearly six n By 2020, increase the state’s trail mileage by years ago,” Gov. Daniels has said.125 “Since then, one-fifth; and I’ve heard many individual success stories, but we n By 2020, decrease the number of adults who can’t truly solve this issue without affecting drink one or more cans of sugar-sweetened change on a much broader scale. We’re taking beverage a day, from 69 percent to 59 percent. the next step with this plan.” The state has already started several obesity-related The plan calls for systemic changes at both the projects. The health department is training pub- state and local level, and offers a list of goals, lic health workers from around the state to better including:126 14 advocate for policies that can reduce obesity — for The department is now developing a free online example, laws that require new road construction toolkit so that other Indiana businesses can to include sidewalks, trails and bike lanes. The de- make the same changes. partment has started a pilot program, working And, to improve the health of Indiana students, with more than 30 small businesses to create work the department is undertaking a similar project environments that encourage healthy eating and with 25 state school districts.128 Memmer said physical activity. State health workers evaluate the the department will eventually create another companies and offer ideas: adding a refrigerator online toolkit aimed at schools. in the break room so employees can bring lunch, adding healthy snacks and water to vending ma- “I feel optimistic,” said Memmer. “This plan chines or installing bike racks and showers to make provides a roadmap for what we need to do. We it easier for employees to bike to work.127 now have a very aggressive population-based public health approach to obesity.” 5. SAN DIEGO: BUILDING AN ENVIRONMENT THAT ENCOURAGES HEALTH San Diego County has a reputation as a sand- and-sun sort of place, peopled by slim surfers catching waves and trim Navy sailors walking the beach. But the county is much more diverse than that. It encompasses more than 4,000 square miles, stretching from the Pacific to the fertile avocado and strawberry farms further in- land. It has a population of more than three million, spread over 18 cities, suburbs and un- incorporated rural areas.129, 130 And, like the rest of the country, San Diego County has its share of fast food restaurants, televisions, Xboxes and cars — and its share of excess weight. More than 21 percent of the area’s population is obese and another 37 percent are overweight.131 Increasingly, public officials in the county, as well as business leaders, are realizing that this problem is more than a health issue. County su- pervisor Ron Roberts has been concerned about the issue for a decade. He worries that chronic illnesses such as diabetes will slow economic de- velopment. “Looking ahead to our future work- force, these people’s performance will be severely hampered,” he said. “You end up pay- ing for that. It is almost like a monster movie. There’s something lurking out there.” Research backs up Roberts’ concern. A study re- leased two years ago by the California Center for Public Health Advocacy calculated that obesity California state officials have also recognized the and physical inactivity cost San Diego County issue. “The economic cost to California of adults more than $3 billion a year in health care ex- who are obese, overweight and physically inactive penses and lost productivity.132 is equivalent to more than a third of the state’s “Obesity is a massive drain on our country’s eco- total budget,” California State Controller John nomic productivity,” said Dr. Harold Goldstein, Chiang has said. “Think of the programs we executive director of the group. “We need to could protect, the children we could educate and recognize that it is not only a huge health risk, the families we could help if we could recapture but a huge fiscal risk too.”133 those dollars by investing in prevention.”134 15 An Ambitious Effort to Make Healthy Living Easier As part of the initiative, the health department has focused on increasing the number of com- munity produce gardens. These gardens in- crease fruit and vegetable consumption, and also help the gardeners burn calories. The depart- ment has also created five regional garden train- ing centers to teach garden managers, school staff and volunteers about the best ways to set up a garden and grow produce. In addition, the de- partment is working with the county government to remove barriers that have blocked people from starting gardens. For example, until re- cently, groups that wanted to start a garden were required to pay a $40,000 startup fee.138, 139 In addition, Healthy Works is trying to make local fruits and vegetables more accessible to members of the community. San Diego has more than 6,000 farms, more than any other county in the country. They grow a variety of fruits and vegeta- bles, including broccoli, avocados, strawberries and oranges. But very little of this produce goes directly to San Diego stores or tables. Instead, it is trucked to processing centers 120 miles north in Los Angeles. (Some then travels south again, and ends up in San Diego stores – but it is more ex- pensive and not as fresh.)140, 141 To increase the local availability of this produce, Healthy Works is examining several alternatives: creating a processing center in the county; start- ing farmers’ markets to sell produce bought di- rectly from county farmers; and linking county farmers to schools and other institutions that want fresh, lower-cost produce.142, 143 Over the past five years, San Diego County has Healthy Works is also setting up a system that al- begun a major effort to reduce and prevent obe- lows residents who receive food stamps to redeem sity. Last year, the county began a $16 million them at some of the county’s 50 farmers’ markets. project to develop policies that encourage exer- Those who enroll receive $20 in matching funds, cise and better eating. The project, known as allowing them to buy more fresh produce.144, 145 “Healthy Works,” is part of the county’s 10-year strategic plan for improving residents overall And, to counteract the effects of billion-dollar health and reducing rates of chronic disease. 135 marketing campaigns for unhealthy foods and The plan lays out a broad strategy to reduce car- sedentary activities such as video games, the diovascular disease, cancer, type 2 diabetes and county is rolling out its own TV, radio and web respiratory conditions. Because excess weight campaign, encouraging residents to be more ac- contributes to many of these problems, the plan tive and to eat more fresh local produce.146, 147 emphasizes the need to reduce obesity. Other groups are joining in too. The San Diego Healthy Works, which is overseen by the county Childhood Obesity Initiative, a non-profit col- health department, focuses on making long- laboration of several local organizations, is re- term environmental and policy changes to en- vamping four corner stores by providing them courage physical activity and healthy eating.136 with coolers and refrigeration units so they can For example, county health officials are working store and sell fresh fruits and vegetables. In ex- with the regional planning agency on its 40-year change, the stores, which are in neighborhoods transportation plan to ensure that the plan in- that have little access to fresh fruit and vegeta- cludes bike trails, walking paths and other bles, must promise to continue selling produce means that promote physical activity.137 after they receive the equipment.148 16 The Private Sector Responds Area companies are also realizing that improv- proaches to encourage healthy living. The com- ing workers’ health can reduce costs. pany offers a free screening program that checks cholesterol levels, blood pressure, triglyc- In 2003, the San Diego County Regional Airport erides and blood sugar. Employees who take Authority, which oversees the San Diego Inter- part receive a $650 reduction in their health in- national airport, launched a wellness program surance premiums; 93 percent of all Intuit work- for its 360 employees. The Authority built an ers take part. The screening is also open to onsite 24-hour gym (airport employees work spouses and domestic partners.152 three shifts), and added incentives, such as gift certificates and extra days off, for workers who Lecuna sees this group as a crucial part of the exercise. “People say it’s changed their lives,” wellness program. “If you don’t have a support said Marci Fredericksen, who directs the Au- system at home, this doesn’t go very far,” she thority’s wellness program. “You can see people said. “It’s got to be a lifestyle change.” shedding pounds.”149 In addition, workers who pledge to stay tobacco- From 2008 to 2009, the percentage of employ- free for the year receive another $650 discount ees with a normal BMI increased by five percent. on premiums. In addition, Intuit provides em- By 2010, 10 percent of workers had reduced ployees with free pedometers. Depending on their BMI. The Authority calculates that the the number of steps they take, participants are program likely saved $1 million in health insur- eligible for up to $300 in cash and prizes. Intuit ance costs between 2009 and this year.150 cafeterias offer a range of healthy choices at sig- nificant discounts, and the company also offers Software maker Intuit has also developed a vig- free exercise classes, in San Diego and at several orous wellness program. The company has other locations.153 about 1,400 employees in the San Diego area (its headquarters are in Mountain View, California, Lecuna said that because the screening program near San Jose).151 has been so successful, Intuit’s health insurance costs have gone up slightly, because so many Part of the motivation is economic, says Intuit’s people see doctors after getting screened. How- Sarah Lecuna, who helps run the program. ever, she expects that over the long term, the “We’re looking to lower health care costs,” she program will lower health costs.154 said. “If we take preventive measures up front, we hope to see cost reductions in the future.” “Down the road,” she said, “we expect we won’t be paying as many huge claims, because people The program, which is available to all of Intuit’s are taking better care of themselves.” 7,200 American workers, offers a range of ap- Targeting Childhood Obesity The county is also focusing on childhood obe- school; by comparison, in 1969, the rate was four sity, which is a costly problem. According to re- times higher.158 The county is also giving out sev- search published this year in Academic eral smaller grants to educate parents, students Pediatrics, the average obese child costs the and teachers on walking and bicycle safety.159, 160 health care system nearly $300 a year more than The school district is also changing its approach a healthy-weight child.155 Reducing the child- to food. It published new guidelines that en- hood obesity rate by just a single percentage courage administrators, teachers and parents to point would save at least $1.4 billion a year.156 In have healthy food at school events and meet- addition, obese children have a significantly ings. And it is expanding its breakfast program, higher risk of growing up to be obese, and obese offering it to more students and making the adults spend, on average, $1,400 more per year food healthier. Previously, only 25 to 30 percent on health care than healthy-weight adults.157 of eligible students ate breakfast at school and As part of Healthy Works, the county is award- only three percent of eligible students partici- ing $50,000 grants to five county schools to de- pated in the summer breakfast program.161, 162 velop Safe Routes to School programs, which Roberts, the county supervisor, is optimistic about encourage children to walk or bike to school. his community’s prospects. “We’re moving in an Research shows that few contemporary students aggressive way,” he said. “I think it’s going to expend calories getting to and from school. In bring positive results. We still have a long way to 2001, one in ten students walked or biked to go. But we’re going in the right direction.” 17 6. HERNANDO: A SMALL MISSISSIPPI TOWN BUCKS A STATEWIDE TREND Between 2000 and 2010, average health insur- for hypertension, diabetes, and other chronic ance premiums for the private sector more than ailments. They can get free help to quit using doubled.163 Across the country, thousands of tobacco. They are encouraged to exercise reg- companies, and tens of millions of employees, ularly. Johnson thinks the wellness program face higher health costs every year. likely played a large role in the rate reduction. Hernando, Mississippi, is an exception. This That’s not all. Hernando employees signed a year, the town of 14,000 has lowered its health pledge agreeing not to smoke at all during work insurance costs by 15 percent — without reduc- hours, even on breaks. In exchange, the city’s in- ing benefits. The savings come to $130,000. surance company lowered rates by another $21,000. Johnson said the pledge is simply good “For us, that’s a lot of money,” said Hernando business. “I saved our taxpayers $21,000,” he said. Mayor Chip Johnson. “I can’t picture taxpayers wanting to pay that kind Over the past five years, Hernando has devel- of money so our employees can smoke at work.” oped a comprehensive wellness program for its Johnson said that so far, three employees have 115 workers. Employees receive free screenings stopped using tobacco as a result of the policy.164 A Model For Active Living The city is doing more than lowering its premiums. In 2008, the state spent more than a billion dol- Over the past five years, Hernando has become a lars on obesity-related health care. By 2018, model for how a city can encourage residents and those costs could quadruple, according to a re- workers to improve their health — and improve cent report.166 “That would bankrupt the state. economic prospects at the same time. We need to deal with this. It’s a dollars and cents issue,” Johnson said. “Our state’s health is Leading this effort has been Mayor Johnson, an holding us back economically.” energetic Republican who owns a carpet cleaning business. Before becoming mayor, he wasn’t par- “People don’t think of the economic impact of ticularly interested in prevention or public health. obesity and other chronic diseases,” said Mis- But six years ago, just after being elected for the sissippi State University researcher Judith first time, he was asked to serve on a regional Phillips, who has examined the economic and health group trying to reduce obesity. Soon after, medical costs of obesity in the state. “But it’s a he attended a conference on obesity in the South. serious issue.”167 As he listened to speaker after speaker describe In some ways, Hernando is not a typical Missis- the medical, social and economic damage sippi town. Over the past 20 years, it has in- wrought by the region’s weight problem, John- creasingly become a bedroom community of son realized that obesity, and the chronic dis- Memphis, 20 miles to the north. As a result, eases linked to it, were major obstacles to the Hernando has a relatively affluent, professional state’s health and prosperity. “That’s where I population, and, as a result, has more social and had my ‘aha’ moment,” he said. economic resources to support the creation of bike paths and playgrounds. Mississippi is among the least healthy states in the country. It has the highest obesity rate in Even so, Hernando remains a thoroughly South- the country; more than a third of its adults are ern place, and even if its obesity rates aren’t as obese, as are more than 20 percent of its chil- high as some other Mississippi communities, it dren. It has the highest rates of hypertension, still has its fair share of fast food, Southern cook- and of physical inactivity among adults. Almost ing, and sedentary living. The town doesn’t keep 12 percent of the state’s adults have diabetes, its own statistics on obesity, but it is part of Des- the third highest rate in the country.165 oto County, where a third of adults are obese. 18 Exercise Without Planning Johnson and other city officials have focused said Bo McAnich, a Hernando resident and bi- much of their work on making it easier for resi- cyclist who helps manage the city’s bicycle club. dents to be active within the context of everyday “Anything to do with bicycling, they highly en- routines. Although the mayor himself often gets courage. There’s been a big improvement since up at 4 a.m. to exercise, he realizes that this ap- Chip has been mayor.” The mayor himself takes proach doesn’t work for everyone. Many experts advantage of the new sidewalks and bike lanes: argue that if people are to burn adequate calo- he often walks to work from his downtown ries, they must get activity by walking or biking to home, and bikes around town. and from work, or around their neighborhoods. In 2006, Johnson convinced city officials to cre- Hernando began by introducing a design stan- ate a parks department — Hernando didn’t dard requiring sidewalks for all new, and some ex- have one. The new agency has revamped all isting, commercial and residential developments. seven of the town’s parks, adding modern play- Research has shown that sidewalks can increase grounds to several. KaBoom, a national non- walking by giving pedestrians safe, clearly-marked profit group that works to increase children’s space to stroll.168 The city repaired crumbling playtime, has recognized Hernando as a one of downtown sidewalks, and the design standard re- the country’s most “Playful” cities, for improv- sulted in miles of new sidewalks in suburban de- ing its parks and playgrounds. velopments that previously had none. Three years ago, the city started a weekly farmers’ With encouragement from Johnson, the city also market, which offers fresh fruits, vegetables, and passed a Complete Streets law, which requires meats raised by approximately 65 farmers and ven- new road construction to include consideration dors from North Mississippi. From March to No- of pedestrians and bicyclists. And the city is vember, about 400 people visit the market every building almost a mile of sidewalks connecting a weekend. This spring, to encourage lower-income lower-income neighborhood to a nearby ele- families to participate, the market began accept- mentary school, so students can walk to the ing food stamps. The city started a community gar- school more easily. den, which is cultivated by a range of community organizations, including churches and youth Since 2008, Hernando has striped bike lanes on groups. Much of this produce ends up in the several main streets and added new walking kitchens of Hernando’s lower-income residents. trails in existing parks. “The city has done a lot,” 19 Health — An Unrecognized Engine of Growth Johnson sees healthy living as a mechanism to in- Some local companies have also joined in. crease private investment. The city is now mar- Williams, Pitts & Beard, a local accounting firm keting itself as a site for corporate headquarters. with 18 employees, has held two weight-loss con- The city’s efforts to improve health play a key role tests for employees over the past three years. in that campaign, Johnson said. This year, one employee lost 25 pounds.170 “We want to recruit corporations to Hernando,” Johnson realizes that his policies and programs he said. “They’re not stupid. When they make won’t reach everyone. “Your personal health is their decisions, they look at health care costs.” In a personal choice,” he said. “My job is to create addition, he notes that in addition to helping peo- an atmosphere and an opportunity for good ple burn calories, new sidewalks and greenways health. If you want to take advantage of it, that’s also raise property values. great. If you want to stay home on your couch, go ahead.” Over the past six years, Johnson himself has be- come a poster boy for active living. He regularly But many residents have bought in. At Oak Hill talks to public officials around the state and the Baptist Church in Hernando, Rev. Michael country about Hernando’s efforts. His message Minor persuaded his flock to start a walking is simple: Get started now, with the resources club, and to measure a walking track in the you have. church parking lot.171 “We are doing the best we can without a lot of With support from groups including the Robert money,” he said. “I tell people to go out and do Wood Johnson Foundation’s faith initiative, Rev. something, and do it now.” And he points out Minor started Healthy Congregations, which that for enterprising towns and counties, help is helps local churches set up programs to help available: Hernando has worked with and re- members lose weight and improve their health. ceived funding from a range of private groups, So far, more than 60 churches in North Mississippi as well as state and federal agencies. Shelly have joined. He is also working with the National Johnstone, Hernando’s director of community Baptist Convention to install “health ambassa- development, said that over the past six years, dors” in the group’s nearly 10,000 churches the city has received more than $800,000 from around the nation by September 2012.172 various sources for programs that encourage ac- “If we can do this in Mississippi,” said Minor, tivity and healthy eating.169 “then we can do it anywhere.” 20 24 Cohen R, personal communication, August 2011. Endnotes 25 Legislative Update. Minnesota Academy of Family Physicians website, http://www.mafp.org/legup- 1 DeVol R and Bedroussian A, et al. An Unhealthy Amer- ica: The Economic Burden of Chronic Disease. Santa date07252011.asp (accessed August 2011). Monica, CA: Milken Institute, October 2007. 26 Target Corporation Medical Affairs Department, http://www.milkeninstitute.org/publications/publi- “Target Fact Sheet,” 2011 cations.taf?function=detail&ID=38801020&cat=ResRe 27 McNulty C, Target, personal communication, July 2011. p. (accessed October 10, 2007). 28 Kaiser Health Foundation. “Annual Employer Health 2 The American Public Health Association, Partnership Benefits Survey.” 2010. http://ehbs.kff.org/pdf/2010/ for Prevention, and United Health Foundation. 8086.pdf (accessed July 2011) “America’s Health Rankings.” 2010. 29 McNulty C, personal communication, July 2011. http://www.americashealthrankings.org/yearcom- pare/2009/2010/MN.aspx (accessed July 2011) 30 Minnesota Department of Health. “Statewide Health Improvement Program Progress Brief” 3 Ibid. 31 McNulty C, personal communication, July 2011. 4 U.S. Centers for Disease Control and Prevention. Be- havioral Risk Factor Surveillance System Prevalence and 32 Gaining Costs, Losing Time: The Obesity Crisis in Texas. Trends Data. http://apps.nccd.cdc.gov/brfss/ (ac- Austin, Texas: Texas Comptroller’s Office, 2011. cessed July 2011). http://www.window.state.tx.us/specialrpt/obesity- cost/index.php (accessed July 2011) 5 U.S. Centers for Disease Control and Prevention. Chronic Diseases: The Power to Prevent, the Call to Control, 33 Ibid. 2009. http://www.cdc.gov/chronicdisease/resources/ 34 Ibid. publications/AAG/chronic.htm (accessed July 2011). 35 F as in Fat: How Obesity Threatens America’s Future 2011. 6 Trogdon JG, Finkelstein EA, Feagan CW, et al. State- 36 Ibid. and Payer-Specific Estimates of Annual Medical Ex- penditures Attributable to Obesity. Obesity, 16. doi: 37 Ibid. 10.1038/oby.2011.169, 2011. (published online 38 Findings about the Obesity Epidemic in Texas. Austin, ahead of print) Texas: Health Institute and Methodist Healthcare Min- 7 Ibid. istries, 2009. http://www.healthpolicyinstitute.org/ files/Key_findings_obesity_Eschbach.pdf (accessed 8 Minnesota Department of Health. “Statewide Health July 2011). Improvement Program Progress Brief: Results from the First Year.” 2011. http://www.health.state.mn.us/ 39 City of San Antonio, Press Release. “City of San Anto- healthreform/ship/about/shipbriefmarch2011.pdf nio’s Metro Health Department awarded $15.6 million (accessed July 2011) as Part of Recovery Act Prevention and Wellness Initia- tive.” http://www.sanantonio.gov/news/NewsReleases/ 9 Ibid. nr2010metrohealthgrant.asp (accessed July 2011). 10 F as in Fat: How Obesity Threatens America’s Future 2011. 40 Thompson M, San Antonio CPPW program manager, Washington, D.C.: Trust for America’s Health, 2011. personal communication, July 2011. 11 Goetzel RZ, Juday TR, Ozminkowski RJ. What’s the 41 Ibid. ROI? A Systematic Review of Return on Investment Stud- ies of Corporate Health and Productivity Management Ini- 42 Ibid. tiatives. Association for Worksite Health Promotion’s 43 Ibid. Worksite Health, 6: 12-21, 1999. 44 Sepulveda M, Tait F, Zimmerman E, et al. Impact of 12 Chapman LS. Meta-Evaluation of Worksite Health Childhood Obesity on Employers. Health Affairs, Promotion Economic Return Studies: 2005 Update. 29(3): 513-521, 2010. American Journal of Health Promotion, 19(6): 1-11, 2005. 45 Finkelstein EA, Trogdon JG, Cohen JW, et al. Annual 13 Mason T, Alliance for a Healthier Minnesota, per- medical spending attributable to obesity: payer- and sonal communication, September 2011. service-specific estimates. Health Affairs, 28(5): w822- 14 Minnesota Department of Health. “Minnesota De- 831, 2009. partment of Health awards $47 million in state 46 Thompson M, personal communication, July 2011. grants to fight chronic disease.” August 26, 2009. 47 Berlanga J. The Prevalence Of Obesity In Children by http://www.health.state.mn.us/healthreform/ship/ Campus. Analysis based on data from Fitnessgram, SHIPLaunch_Aug2009.pdf (accessed July 2011) Texas Health Agency. San Antonio Metro Depart- 15 Minnesota Department of Health. “Statewide ment of Health and Texas Education Agency, 2010. Health Improvement Program Progress Brief: Re- 48 Thompson M, personal communication, July 2011. sults from the First Year, Grantee Fact Sheets.” 2011. http://www.health.state.mn.us/healthreform/ship/ 49 Ibid. about/legislativereport.html (accessed July 2011) 50 Gaining Costs, Losing Time: The Obesity Crisis in Texas. 16 Cohen R, Minnesota Department of Health, per- 51 Kelly M, Paso Del Norte Foundation, personal com- sonal communication, August 2011. munication, July 2011. 17 Minnesota Department of Health. “Statewide 52 Gaining Costs, Losing Time: The Obesity Crisis in Texas. Health Improvement Program Progress Brief” 53 Ibid. 18 Ibid. 54 Rogers K, HEB, personal communication, July 2011. 19 Ibid. 55 Ibid. 20 Ibid. 56 Excellence in Education Awards. HEB website, 21 Ibid. http://www.heb.com/sectionpage/about-us/com- 22 Ibid. munity/excellence-in-education/26501118 (ac- cessed July 2011). 23 Ibid. 57 Rogers K, personal communication, July 2011. 21 58 Gaining Costs, Losing Time: The Obesity Crisis in Texas. 89 Campbell D, Nashville Metro Public Health Depart- 59 Ibid. ment, personal communication, July 2011. 60 Healthy Hurst: A Community-wide Wellness Program. Hurst 90 Ibid. website, http://www.ci.hurst.tx.us/Departments/ 91 DeVille N. “Mayor’s walks inspire many.” The Ten- Recreation/HealthyHurst.htm (accessed July 2011). nessean May 25, 2011. 61 Gaining Costs, Losing Time: The Obesity Crisis in Texas. 92 Metropolitan Government of Nashville and David- 62 Legislative Updates — School Health. Austin, Texas: son County. “Mayor Announces New Healthy Living Texas Education Agency. http://www.dshs.state.tx.us/ Initiative.” Press Release, July 9, 2011. https://se- schoolhealth/legisup.shtm (accessed July 2011) cure.nashville.gov/mayor/news/2011/0709.asp (ac- cessed July 2011) 63 Combs S, Texas State Comptroller, personal commu- nication, July 2011. 93 Campbell D, personal communication, July 2011. 64 F as in Fat: How Obesity Threatens America’s Future 2011. 94 Shurney D, Vanderbilt University, personal commu- nication, July 2011. 65 Beyer V, Texas Department of Agriculture, personal communication, August 2011. 95 C. Everett Koop National Health Awards. Website, http://www.sph.emory.edu/healthproject/past_win- 66 F as in Fat: How Obesity Threatens America’s Future 2011. ners/year/2008/vanderbilt/index.html (accessed 67 Catch Texas. Website, http://www.sph.uth.tmc.edu/ July 2011). catch/ (accessed July 2011). 96 Shurney D, personal communication, July 2011. 68 Ibid. 97 Ibid. 69 Hoelscher DM, Springer AE, Ranjit N, et al. Reduc- 98 Chesley Y, HCA, personal communication, July 2011. tions in child obesity among disadvantaged school chil- dren with community involvement: the Travis County 99 Ibid. CATCH Trial. Obesity, 18(Suppl 1): S36-44, 2010. 100 Ma S, Frick KD. A simulation of affordability and 70 Kelder S, University of Texas Houston Health Sci- effectiveness of childhood obesity interventions. ence Center, personal communication, July 2011. Academic Pediatrics, 11(4): 342-350, 2011. 71 Ibid. 101 Ibid. 72 Brown HS, Pérez A, Li YP, et al. The cost-effectiveness of 102 Carr F, Nashville Metro Public Schools, Chief Oper- a school-based overweight program. International Journal ating Officer, personal communication, July 2011. of Behavior, Nutrition and Physical Activity, 4-47, 2007. 103 Ibid. 73 Marchman S, Texas Education Agency communica- 104 Campbell D, personal communication, July 2011. tions office, personal communication, July 2011 105 Behavioral Risk Factor Surveillance System (BRFSS), 74 Evaluation of the Texas Fitness Now Grant Program. CDC, 2011. Austin, Texas: Texas Education Agency, 2011. 106 Ibid. http://www.tea.state.tx.us/TFN_Comp_Rpt.pdf (ac- cessed July 2011) 107 Ibid. 75 Welk GJ, Jackson AW, Morrow JR, et al. The association 108 U.S. Centers for Disease Control and Prevention. of health-related fitness with indicators of academic Smoking and Tobacco Use, State Highlights. 2010. performance in Texas schools. Research Quarterly for Ex- http://www.cdc.gov/tobacco/data_statistics/state_ ercise and Sport, 81(3 Suppl): S16-23, 2010. data/state_highlights/2010/states/indiana/index. htm (accessed July 2011). 76 Greenleaf CA, Petrie TA, Martin SB. Psychosocial variables associated with body composition and car- 109 Diabetes in Indiana: A Report on Diabetes Morbidity and diorespiratory fitness in middle school students. Re- Mortality. 2010. Indianapolis, Indiana: Indiana State search Quarterly for Exercise and Sport, 81(3 Suppl): Department of Health. http://www.in.gov/isdh/ S65-74, 2010. files/IndianaDiabetesBurdenReport2010.pdf (ac- cessed July 2011) 77 Wald P, USAA, personal communication, July 2011. 110 Trogdon et al, 1-7. 78 Ibid. 111 Berggoetz B. “Out of shape.” The Indianapolis Star 79 Ibid. May 1, 2011 80 Gaining Costs, Losing Time: The Obesity Crisis in Texas. 112 2007 Annual Report. 2007. Indianapolis, Indiana: 81 Ibid. Indiana Tobacco Prevention and Cessation. 82 Wald P, personal communication, August 2011. http://www.in.gov/legislative/igareports/agency/r eports/TPREV03.pdf (accessed August 2011) 83 Ibid. 113 Indiana State Health Department, Press Release. 84 Britt R. “Southern-fried health care.” MarketWatch “Indiana Takes Next Step In Tackling Obesity.” July 27, 2010. http://www.in.gov/icw/files/PR_1.28.11.pdf (ac- 85 Centers for Disease Control and Prevention. Behav- cessed August 2011). ioral Risk Factor Surveillance System (BRFSS), Selected 114 “Gov. Daniels Asks Hoosiers To Get ‘Inshape Indi- Metropolitan/Micropolitan Area Risk Trends, ana’.” US Fed News July 13, 2005. http://apps.nccd.cdc.gov/BRFSS-SMART/MMSAC- tyRiskChart.asp?MMSA=57&yr2=2009&qkey=4409& 115 INShape Indiana. Website, http://www.inshapein- CtyCode=132&cat=OB#OB (accessed August 2011). diana.org/276.htm (accessed July 2011). 86 Nashvitality. Website, http://www.nashvitality.org/ 116 McLain N. “Getting Stonegate students INShape.” active/building-active-places/complete-streets.aspx Zionsville Times Sentinel March 31, 2010, http://times (accessed July 2011). sentinel.com/local/x1687694952/Getting-Stonegate- students-INShape (accessed July 2011). 87 Nashvitality. Website, http://www.nashvitality.org/ about/about-nashvitality.aspx (accessed July 2011). 117 Fore A, personal communication, August 2011. 88 Johnson BD, Office of Mayor Dean, Press Secretary, 118 INShape Indiana. Website, http://www.inshapein- personal communication, July 2011. diana.org/284.htm (accessed August 2011). 22 119 U.S. Department of Health & Human Services, 139 Yancey A, personal communication, July 2011. Press Release. “HHS Launches Childhood Over- 140 County of San Diego, Healthy Works. Website. weight and Obesity Prevention Initiative.” http://www.hhs.gov/news/press/2007pres/11/pr2 141 Yancey A, personal communication, July 2011. 0071127a.html (accessed July 2011). 142 County of San Diego, Healthy Works. Website. 120 Whitt E, INShape Indiana, personal communication, 143 Yancey A, personal communication, July 2011. August 2011. 144 County of San Diego, Healthy Works. Website. 121 Smith M. “State smoke-free movement has a 145 Yancey A, personal communication, July 2011. foothold.” The Associated Press July 9, 2007 146 County of San Diego, Healthy Works. Website. 122 Malik M. “Tax hike could be habit-breaking; Officials expect 23,000 Hoosiers to quit smoking, almost 40,000 147 Yancey A, personal communication, July 2011. youths not to start.” The Indianapolis Star July 1, 2007 148 Moder C, San Diego County Childhood Obesity 123 Rudavsky S. “Cigarette sales dive 17.8% after tax Initiative, personal communication, July 2011 hike; Smokers paying 44 cents more per pack; ces- 149 Fredericksen M, San Diego County Regional Airport sation programs report booking up quickly.” The Authority, personal communication, August 2011 Indianapolis Star June 3, 2008 150 Ibid. 124 Saving Lives, Saving Money: A state-by-state report on 151 Lecuna S, Intuit, personal communication, Sep- the health and economic impact of comprehensive smoke- tember 2011. free laws. Washington, D.C.: American Cancer Soci- 152 Ibid. ety, 2011. http://www.acscan.org/pdf/tobacco/ reports/acscan-smoke-free-laws-report.pdf (ac- 153 Ibid. cessed August 2011) 154 Ibid. 125 Indiana State Health Department, Press Release. 155 Ma et al, 342-350. “Indiana Takes Next Step In Tackling Obesity.” 156 Ibid. 126 Indiana’s Comprehensive Nutrition and Physical Activity 157 Finkelstein et al, 822-831. Plan, 2010-2020. Indianapolis, Indiana: Indiana State Department of Health and the Indiana 158 National Center for Safe Routes to School and Safe Healthy Weight Initiative Task Force, 2010. Routes to School National Partnership. “U.S. Travel http://www.in.gov/icw/files/IN_State_Obesity_Pla Data Show Decline In Walking And Bicycling To n_2010-2020.pdf (accessed August 2011) School Has Stabilized.” Press Release, April 8, 2010. http://www.saferoutespartnership.org/media/file/ 127 Memmer M, Indiana State Department of Health, NHTS-SRTS-Press-Release-04082010.pdf (accessed personal communication, August 2011. August 2011). 128 Ibid. 159 County of San Diego, Healthy Works. Website. 129 U.S. Census Bureau, 2010. State and County Quick- 160 Yancey A, personal communication, July 2011. Facts. http://quickfacts.census.gov/qfd/states/ 06/06073.html (accessed August 2011) 161 County of San Diego, Healthy Works. Website. 130 Ibid. 162 Yancey A, personal communication, July 2011. 131 Centers for Disease Control and Prevention. Behav- 163 Kaiser Family Foundation and Health Research ioral Risk Factor Surveillance System (BRFSS), Selected and Educational Trust. 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National and State Estimates of the Impact of fobesity.html (accessed August 2011) Obesity on Direct Health Care Expenses. 133 Goldstein H, California Center for Public Health http://www.nccor.org/downloads/CostofObesi- Advocacy, personal communication, August 2011. tyReport-FINAL.pdf (accessed September 2011). 134 California Center for Public Health Advocacy, 167 Phillips J, Stennis Institute, Mississippi State Uni- Press Release, July 9, 2009. “California’s Cost of versity, personal communication, September 2011. Obesity Climbs to $41 Billion.” http://www.pub- 168 Smith KR, Brown BB, Yamada I, et al. Walkability and lichealthadvocacy.org/_PDFs/Costofobesity_Press- body mass index density, design, and new diversity Release_070909.pdf (accessed August 2011). measures. American Journal of Preventive Medicine, 135 County of San Diego, Live Well, San Diego. Web- 35(3): 237-44, 2008. site, http://www.sdcounty.ca.gov/hhsa/pro- 169 Johnstone S, Hernando City Government, personal grams/sd/health_strategy_agenda/index.html communication, June 2011. (accessed August 2011). 170 Beard B, Williams, Pitts & Beard, personal commu- 136 County of San Diego, Healthy Works. Website, nication, September 2011. http://www.sdcounty.ca.gov/hhsa/programs/phs/ chronic_disease_health_disparities/CPPW.html 171 Minor M, Oak Hill Baptist Church, personal com- (accessed August 2011) munication, May 2011. 137 Yancey A, San Diego County Health and Human 172 Robertson C. “Preaching a Healthy Diet in the Deep- Services Agency, personal communication, July 2011. Fried Delta.” The New York Times August 21, 2011 138 County of San Diego, Healthy Works. Website. 23 ACKNOWLEDGEMENTS TRUST FOR AMERICA’S HEALTH (TFAH) is a non-profit, non-partisan organization dedicated to saving lives and making disease prevention a national priority. For more information, visit www.healthyamericans.org The Robert Wood Johnson Foundation (RWJF) focuses on the pressing health and health care issues facing our country. As the nation’s largest philanthropy devoted exclusively to improving the health and health care of all Americans, the Foundation works with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years the Foundation has brought experience, commitment, and a rigorous, balanced approach to the problems that affect the health and health care of those it serves. Helping Americans lead healthier lives and get the care they need — the Foundation expects to make a difference in our lifetime. For more information, visit www.rwjf.org. About The California Endowment The California Endowment, a private, statewide health foundation, was established in 1996 to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental improvements in the health status of all Californians. The En- dowment challenges the conventional wisdom that medical settings and individual choices are solely re- sponsible for people’s health. The Endowment believes that health happens in neighborhoods, schools, and with prevention. For more information, visit The Endowment’s Web site at www.calendow.org. Established in 1930, the W.K. Kellogg Foundation (www.wkkf.org) supports children, families and com- munities as they strengthen and create conditions that propel vulnerable children to achieve success as in- dividuals and as contributors to the larger community and society. This report was supported by the Robert Wood Johnson Foundation, The California Endowment and the W.K. Kellogg Foundation. TFAH BOARD OF DIRECTORS David Fleming, MD Director of Public Health Lowell Weicker, Jr. Seattle King County, Washington President Former three-term U.S. Senator and Governor of Connecticut Arthur Garson, Jr., MD, MPH Director, Center for Health Policy, University Professor, and Cynthia M. Harris, PhD, DABT Professor of Public Health Sciences Vice President University of Virginia Director and Professor Institute of Public Health, Florida A & M University Alonzo Plough, MA, MPH, PhD Director, Emergency Preparedness and Response Program Robert T. Harris, MD Los Angeles County Department of Public Health Secretary Former Chief Medical Officer and Senior Vice President for Eduardo Sanchez, MD, MPH Healthcare Chief Medical Officer BlueCross BlueShield of North Carolina Blue Cross Blue Shield of Texas John W. Everets Jane Silver, MPH Treasurer President Irene Diamond Fund Gail Christopher, DN Vice President for Health Theodore Spencer WK Kellogg Foundation Senior Advocate, Climate Center Natural Resources Defense Council REPORT AUTHORS Laura M. Segal, MA Director of Public Affairs Jeffrey Levi, PhD. Trust for America’s Health Executive Director Trust for America’s Health David Kohn, MA and Professor of Health Policy Senior Communications Manager The George Washington University School of Public Trust for America’s Health Health and Health Services 1730 M Street, NW, Suite 900 • Washington, DC 20036 • (t) 202-223-9870 • (f) 202-223-9871 24