Q: I’m Lynn Vaughn with the YMCA, and my question I guess to all of you, but Wayne I think you mentioned this too: When we begin to look at chronic disease in general the approach seems to be physical activity, healthy eating, good self management. There is a generic approach that is emerging that my question, that our question is, what is the evidence that we can begin to look at a generic approach and then the second part of it is what is the acceptance of both organizations and individuals to think about it in a generic way rather than disease specific?
Wayne Giles: I think there are a couple of things. I think we’ve got to realize that there’s a lot of combinability, and we talked about heart disease and arthritis, and diabetes and arthritis, and all of that very important work, and you’ve got to think about the risk factors that underlie that. Clearly nutrition, and physical activity, and all of that really underlie a lot of that work so thinking about policy work, there’s some really good work showing that increasing only moderate amounts of physical activity can have huge impacts in terms of disease management, both if you look at the specific disease outcome such as pain, for OA things like pain, quality of life, etc, but also if you look at things like blood pressure control, hemoglobin A1C for diabetes, etc, I think there’s good data there. So I think that’s how it cuts across. But I think what we really need is sort of a dual strategy because we do know that there are also some people who do resonate with some of the disease specific activity. So thinking about sort of how can you implement policies and put them in place around nutrition, physical activity, disease self management, some of which will be generic, but also some of which will need to be disease specific.
Ursula Bauer: And I just add that you know physical activity is the miracle drug, and increasing physical activity is a goal in and of itself. It improves sleep, it improves mental health, it improves, you know, the range of chronic diseases that we’re all worried about. I think that the problem is that our disease specific programs say that, “Oh, somebody’s taking care of physical activity” even though physical activity is important for diabetes prevention and control, hearth disease prevention and control, cancer prevention. We don’t, in those disease specific categories, really focus on physical activity. So we do have to take that step back and say, “We need to design the landscape and better promote physical activity” so that we’re addressing the range of diseases. But, physical activity needs to be a goal in and of itself.
Jack Klippel- This may sound entirely “unacademic” and I apologize for the comment, but I think far too often we focus on evidence based programs, where as I think the goal should be on physical activity. If we can get people more physically active, and Wayne commented on things that might involve policy changes to get people active. I think the other thing that we’ve come to realize is, like it or not, people turn to their healthcare provider for advice about their own healthcare. And I think making sure healthcare providers are very proactively pushing physical activity when they’re talking about disease management, and helping people understand how they can build that into their lives, and we have some members of those communities here, I think that would be an important step forward.
Q2: The injury prevention table would like to know, is there strong peer-reviewed evidence to support a direct link between obesity and osteoarthritis, and any one of you can answer that, or I suppose anyone in the audience who might have an answer as well.
Wayne Giles: So yeah, I mean there is strong evidence. I mean we do know if you look at the prevalence of OA among people who are obese, it’s about 30 percent. And if you look among people who are not obese, it’s about half of that. We also know that if folks lose weight, there can be reductions in pain. So, the evidence is pretty clear there in terms of the linkages.
Q3: How much of OA is a pain disease? And should pain really be the driver of discussions about OA, and the other part of that is, why is the system the way it is now? Why is it so difficult to reach these folks, why are they not getting the message, why are there challenges with access? So we want you to answer all of that, you know, and we’ve got more if you’d like.
Ursula Bauer: I’ll start with the second question which is why don’t people know, and we hear this a lot. People know smoking is bad for you, people know they should be more physically active, why don’t people just take responsibility and get out there and just do that they’re supposed to do. And my response is people know that physical activity is good for them in the same way that they know coke is the real thing. But we don’t have with physical activity, a three billion dollar a year campaign pushing that message that physical activity is the real thing. We don’t have physical activity within arms reach of every American the way we have a coke within arms reach of every American. So people “know” these things but even on the market side where we’re trying to earn a profit pushing behaviors, we have to continually push that with marketing dollars and with access to the behaviors that we want people to engage in. And we need to take that model and apply it to physical activity. Make sure that people are getting the message from their healthcare provider, from their community, from their workplace, from their schools, and making sure that physical activity is within arms reach of every American; safe, regular, physical activity.
Jack Klippel: So let me try the first question because it is all about pain. So if you poll the public, we actually have recent data from Harris Interactive in which if you ask people with arthritis what’s the single most important thing for them, it’s pain. And the second thing is, as a person who was trained as a rheumatologist, I wasn’t taught much about pain, how to manage it, other than occasionally there’s drugs that you can give. And I certainly wasn’t taught about the importance of physical activity as a way to improve pain. I think that if we get this right that it should resonate with the public. Even though it is difficult to push through pain, by doing physical activity what will happen over time is you will be in less pain. But it’s interesting that they actually resonate more to pain than loss of movement. However we get them to pay attention to us, and if it’s a pain message, let’s do a better job of focusing on that.
Q4: So one of the questions we had was what is the nutrition recommendation, specifically for osteoarthritis, and does that relate to the disease specifically, or weight management kind of indirectly?
Ursula Bauer: I think the nutrition recommendation for osteoarthritis and the range of chronic diseases is to follow the dietary guidelines for Americans. So it’s not a specific set of guidelines for osteoarthritis, but those are the guidelines to improve and maintain health and to improve and maintain your weight status.
Q5: Our table was very intrigued by the example that you provided, Dr. Giles about the new YMCA partnership with United Health around pre-diabetes as an evidence-based self management model that we should follow. So, we wanted to hear about other types of models that are, that we should know about.
Wayne Giles: So a couple of things that I would say to begin with. One is, and this is something that Jack mentioned earlier, getting healthcare providers engaged in this, and encouraging healthcare providers to make those very important referrals, I think that this is the very first, very important step. We do know that healthcare providers, providing information to patients, encouraging them do things, is a very important first step. So, that’s one thing I would say. We know that’s true in tobacco, we know that’s true in terms of dietary changes, getting healthcare providers to give that important advice is key to that. I think the other thing that is key for this, is if we’re going to do this, is having seamless ways that people can get referred. There are easy ways for healthcare providers to refer people to services within their community that is the other very important thing. We see that not just for self management, but there are also other opportunities. For example, physicians can find out if people smoke or not, and then quickly refer them to tobacco cessation programs in the community as well. And so that is also key.
Q6: When we’re asking, you know, other large employers, or folks looking at the workforce to take heed of this, are we doing that at CDC with regard to our own agency?
Ursula Bauer: Yeah, I think we are. Not just at CDC, across HHS, and actually with the prevention council created under the affordable care act. Looking at what we can do with policies that apply, excuse me, to our federal work force as well as those who are touched by the services that we provide to make sure that everything we are doing is improving health. So the prevention council has really taken this charge, and we’ll see over the coming years health questions being asked for the range of policies; the department of justice, the department of defense, the department of agriculture, department of health and human services, education, housing, and on and on, are routinely promulgating in the programs they are delivering. How can they be tweaked to improve health? And then, in terms of the workforce at CDC, we have major initiatives, both at CDC and at HHS, in terms of improving the nutrition quality of foods in our cafeterias, ensuring that our federal benefits cover treatment for tobacco use independence, and lots of creative ways to build physical activity into our lives in the work environment. So yes, we are practicing what we preach.
Q7: This question is from the physical activity table. We discussed for a while the use of the word disease, and how disease can have a connotation of something a doctor will take care of with a pill. And so we wanted to have all of your thoughts on the word ‘disease’ and whether patients might be more empowered if arthritis wasn’t labeled as a disease.
Jack Klippel: Well I mean a couple things. We actually try not to use the word ‘patients’. People with arthritis want to be referred to as ‘people with arthritis’ who’ve got a problem. I’m probably the wrong person to ask because I was trained as a physician to “address disease”. I actually think that the challenge we’ve got with osteoarthritis is that we’ve not been serious about talking about it as a disease. So I’d actually push this is the other direction, that I think it’d be positive to actually say this has nothing to do with aging, and there’s things that we can actually do to make it better. But it’s just very much a disease like diabetes is a disease, or any other disease that we as physicians were taught about. And I think we haven’t done a very good job about educating people about that.
Q8: Is there research, or in particular, more detailed evidence you can provide about what really motivates people to take action, particularly with physical action which we know everything thinks is good for them, but most people are either afraid to do or don’t like to do?
Ursula Bauer: Yeah, I think around physical activity and education, the evidence base is still evolving and emerging in terms of what works best. I’m not sure that our goal is to motivate people to undertake an exercise regimen, for example. The fact is, we have designed physical activity out of our lives. Whether is the garage door opener, or the rider lawn mower, I mean even the electric beater. You know, everything we do is a labor saving device. So we need to figure out as a society how do we re-engineer physical activity back into our lives. And we know there are lots of ways to make physical activity more accessible. Things like joint use agreements between public spaces, like schools and communities, so that those schools and the property are available after hours for people in the neighborhood to go and use to play on the play equipment, to walk on the school grounds. Things like complete street initiatives that ensure that when we’re building a roadway, when we’re renovating a roadway, we are making sure that the roadway is usable for all users, not just motorized users, so walkers, and bicyclists. As we’re designing our communities are we locating housing in proximity to shopping areas so that people can easily walk to their places of business, their places of work. Active transportation: if we had stronger public transportation systems across our country, people would use them to commute back and forth to work, to get them where they need to go. And when you use public transportation, you are being physically active because you are walking from stop A to stop B, and getting on and off that bus. So rather than focus on the physical activity regime that someone has to schedule into their day, we need to think about all those ways we can collect those minutes of activity over the course of the day. And then, for those of us with a chronic condition who want to better manage that condition, make sure that programs like the Y are offering to prevent or delay diabetes, or the self management activities that give people routine to go that extra step and better manage their pain, their heart disease, and so on. Making sure that that’s readily available to them in their communities would be a huge help.
Host: Thank you to our panelists. Thank you very much. Where going to wind this up.