>>RICHARD CARMONA Can I have your attention, please? Thank you. You have to sit down and be quiet or Denise will come back and have more exercise for you. Thank you. Thank you so much for coming. We are thrilled to have this much participation and an overflow crowd on something that is very near and dear to our hearts: Prevention, and disease prevention and health promotion is where we think the majority of our resources should be in the future. But, we can't get there as much as we all are committed to and we have wonderful programs, we really can't get there unless we have good science, and that's the evidence base behind all of what we do. And again, there's another group of people that we often take for granted that toil anonymously that provide that good science for us. The National Institutes of Health is the preeminent research institution in the world. Yet, many of the programs that you all take to the communities, many of the other programs that are non-governmental organizations that are driven by good science come from these wonderful scientists who do the homework who let us know what the best practices are and to transform that into cultural competent messages through behavioral change in a community. They wouldn't be successful if they didn't have good leadership. One of my good friends, Dr. Zerhouni, the Director at NIH, leads that group, a humble man, one who doesn't look for any recognition for anything he does; just wants to get the job down. We had the fortune of being nominated on March 26 by President Bush and got to stand together with the President at that time and accept the awesome responsibilities that we both have been given. I've come to know him as a man of great integrity, of warmth, compassion and a great leader. And so we're fortunate to have him with us today to address some of these issues before us, but let's not forget that the programs that we have and anything that we do in the future will be driven by good science. And my good friend and colleague, Dr. Zerhouni, represents the leadership and good science in the United States and the world. (Applause) >>DR. ZERHOUNI It's a real pleasure to be with you at the podium again, and we share them from time to time, and I have to tell you the energy he brings to the message of prevention is refreshing. Now, as a director of the NIH, what I would like to do is talk about strategies for research and prevention and also give you the contacts, if I may, of where we see the future and why is it that in 2003, Secretary Thompson and all of his agency directors met on multiple occasions for the past two years, but in January we had a meeting and it was unanimous across the board from the most basic research endeavors of the NIH, through applied research to the most public health measures related areas of the department. We felt it was absolutely necessary to focus with laser lights on the issue of prevention, all the dimensions. Now, yesterday, something interesting happened in the world. At yesterday, the NIH released the complete sequence of the human genome, complete throughout the world (Applause). Thank you, all of it free to be accessed by anyone in the world. This is a great date. In fact, I would venture to say that for years to come, this date will be remembered, and immediately after that, as Secretary Thompson celebrated with us last night, he made a point that tomorrow, the most important meeting is going to happen here in Baltimore, and we want to make sure that the discoveries of the genomes are guided to understand the prevention disease better. For me, let me tell you, let me share with you a thought. This is day one of what I will call AG, a new era in medicine. It's After Genome. Yesterday was BG, before genome. For us, the challenge is how do we strategize research in the context of prevention? What I want to do is give you some thoughts in that regard and show you some examples. If you look at the impact of all the research and prevention measures and education on coronary heart disease, in the '70's, we as a nation decided not to invest in any of those steps that we took. Right now, you would be experiencing about over one million deaths from heart disease, but we expect about 60 percent less and we are saving about 815,000 people. When you see this decrease, you say, well, let's do an analysis of why it happened and you realize that in the context of decreasing the mortality for heart disease, many, many different aspects were important. One obviously was the -- Framingham study, which was science. One was public health measures, American Heart Association's effort in controlling high blood pressure, diet, and so on. What you realize is that success in the 21st Century is going to depend on an informed knowledge base that is multi-pronged in its approach to disease, and here is where I would like to leave you with a message that I think is key to me: There's always this concept out there that there's a magic cure for disease, that someday, somehow, we will come up with a drug that will do things. It's been hard to move the scientific opinion away from that, as we understand the complexity of biological systems, that no successful strategy can be unilateral but it has to be multi-pronged. That means, one, understanding the event that leads to the development for disease, and we can do this in the post-sequencing era where we understand the genomes. Second, delay the onset of disease by having, A, screening programs or, B, ability to modify the natural history of the disease. Delaying the onset of Alzheimer's will be a major public health success, and then reduce the burden. So as you can see, the paradigm of the 20th Century was curative disease. We waited for it to reach mass stages, where in the 21st Century, we intervene before the crash. So I'd like to basically go through some examples of how all of this works in real term contemporary disease states. Like if you take a look at AIDS and look at the U.S. incidence and mortality rates, in yellow, you see the incidents, they dropped drastically in 1993 because of preventive measures, because of behavioral prevention measures and transmission control. All of those measures were based on science at the level of virology. You can see we made a big impact on the incidence of disease. There's a flattening of the curve over the past three years and we need to work on it and the incidents of death, there's been a decrease because of drug therapy. So here is a principal of a strategy that you need to implement at all times, then the basic research that was made possible over the past five years, because of the increase in the NIH budget to let 80 new drugs in the pipeline for controlling this disease, but many, many side benefits to this research in other areas such as, for example, SARS where we've been able in a short time to mobilize resources that we put in AIDS and buy a defense to identify the virus quickly. But more importantly, we've been able to develop three times the number of vaccines in phase one trials because we believe that at the end of the day, this will be the solution. Well, let me just go on then to tell you about the new challenges that an agency like NIH and we, as a community of health care experts and involved constituents in better health have to deal with. New challenges are obviously related to a new threat of defenses. There are new health threats that are related to the globalization of the world. West Nile Virus is one, and when I made that slide, SARS had not been an emergency issue and so you're going to see SARS, many others. We need to be prepared for that. But then you look at emerging health issues and you see we are dealing with evolving landscape of challenges. I don't need to tell this audience about obesity and diabetes, but between 1970 and 2003, there were landscape changes in medicine. In the 1970's, the primary research was focused on disease states that were acute and lethal. So if you had coronary artery disease, your chances of survival were low. We have diseases that are chronic, low-term beast cancer success with interventions, but that means the landscape has been transformed from a more short-term acute type of disease to long-term and this needs to be taken into account in our strategies. And that is clearly related also to the ageing of the population. So when we look at this, and I don't have to tell you about the obesity trends, nor the worrisome trends in children, in children, and thousands of incidents of obesity, the problems of obesity, but let me just make a point here about the implications for our research strategies. If you look at the presence of diagnosed diabetes today, you'll find that, as you well know, about 11 to 12 million people have diabetes. Probably another five or six million have it but don't know it, but if you combine it in the modeling, the impacts of the obesity trends plus diabetes, you realize that we're going to see a huge acceleration in the rate of diabetes and when that happens, the consequences of diabetes and vision are going to lead to a change in the curves, health curves of the country if we don't tackle this issue. So we're very invested in prevention and investing the total scientific capital that we have in finding ways of preventing disease and as you know, prevention initiative certainly is one that plays a role in terms of making sure translation of best practices occurs and that in fact, when you really look at it from my standpoint, we have a systemic issue of putting prevention at the core of the system, rather than putting curative medicine at the core of the system. That is probably the issue that will define us. And that is way beyond what anyone of us can do. Because at the end of the day, if you do not put prevention as a component of appropriate health care strategies when a patient is not taking care of for years at a time because of the insurance system that we have or the health care system that is fragmented, you are dealing with systemic issues that need to be taken into account, so our struggle is going to be more, I mean obviously related to education, but also related to our understanding of the deeper relationships between systems organization and the goal of our preventative strategies. So, what do we need to do? There's no question that there's a need for new strategies. At NIH, we are blessed with a revolution in biomedical sciences. This is day one of a new era, and we need to take advantage of that, and I'll show you some examples of that. There's no question that the challenges we're facing are different than what we faced 30 years ago, but these challenges evolve. They don't change overnight. The opportunities are going to have to be taken care of by accelerating science discoveries and clear acceleration of discoveries which is possible today on a scale that is unprecedented and history will mean nothing if we are not able to translate that into real benefits. So there's a need for new approaches. And these new approaches have to be orders of magnitude that are more effective than current approaches, and as the director of the agency, I cannot imagine a way that would not involve, include, an order of magnitude increase in our prevention strategies. So we will have to invest in that area and find out where the best ways are of understanding our genes, environment, life-style, our relationships in the way that will allow us to intervene. Like I said before, the complete dysfunction of disease occurs. We know that based on the research we already have done, that disease states do not occur overnight because of a single cause, but they occur because of a cascade of molecular events. Cancer, there's at least five to seven different biological pathways that become dysfunctional before cancer occurs. We expect the same thing in diabetes. So if we can identify the five of seven pre-disease biological pathway disruptions, we could probably intervene, and this is the whole notion of molecular prevention, but we can not wait to have that, and change what I think is the real challenge for us and that is that our environment is changing at a speed which is absolutely unique in the history of humankind. I'm going to show you just one study that will demonstrate that. This is a study that was just published in Nature about two months ago. You may not have heard about this new technique called R & A (phonetic) interference. We didn't know about it four years ago. It was discovered about four years ago. What it is is a new mechanism that was discovered where small R & A (phonetic) molecules can repress or suppress the action of a particular gene. This is a discovery of great magnitude because for the first time, we have now a system where each gene in an organism can be stopped from functioning and then you can observe what the affect of that is. It's really functional genomics. Let me show you this relating to obesity. They took the 17,000 genes of a worm and suppressed each one, one by one, in a series of experiments that would have taken 30 years if we were using 1960's methods. It took them six months to test the system and another six months to identify the genes that relate to fat metabolism in the worm. They found that 305 genes in fact were promoting fat deposition and only 112 were preventing it. You may say how does this help us in understanding obesity? It tells you that three-quarters of our gene pool has been driven by evolution towards obesity. Because of starvation, because of low food supply, only a quarter of the genes have ever been designed by evolution to be controlling of weight. Now, is that important? It is very important because here in a simple organism, we're finding there are over 400 genes that control the homeostasis that drives obesity, and half were unknown to us, and you say how does that translate to human research? Half of the genes are exactly the same as what we have in our gene make-up. Doesn't mean each one of us is equal to worms but you can see that the research is going to be fantastically advanced and half of the genes that was discovered have nothing to do with direct metabolism of fat but neurobiological trial of feeding habits in an environment that changes food supply so when you change the environment of the worm, you can see different genes get turned on and off. Humankind is subjected to tremendous environmental stresses whether global, spread of diseases or a change in our food environment that occurs within 10, 20, 30 years. It's very difficult for a population to adapt to that because we need generations and generations naturally to do so. The strategies that we are talking about today -- hence, so prevention and health promotion is an integral part of NIH. When you look at the steps that we are taking, just about one-fourth of the overall budget is related to finding ways of doing what I just described. We do not consider prevention any one particular area of the activities that we have to have. We really thing it's continuing, a continuum that has to be interactive in education and training of multi-disciplinary teams of prevention scientists is going to be key to the process. At the end of the day, if we can't translate that to the public and health professionals, it won't work, so we see this as a complete process that goes from hypothetical development and controlling trials, population surveillance studies, and so on. But just to give you an example of where we are. In that kind of development, you'll know about the Framingham heart study, but we are looking now at the relationship environmental -- to the school in Southern California or the Women's Health Study which is really a fundamental, I think fundamental model to look at on how to survey populations or arthritis studies. I don't want to give you specific details or spend a lot of time, but each step of the continuum of prevention research, we have networks that are in place, the early detection in the worm to develop molecular markers of cancer. We can not do the research or intervention until we have validated markers to tell us whether or not we do have an effect on the population. So these measures are being developed. One trial that I know will be publicized soon is a prostate cancer prevention trial. This is an example of how serendipity works. It was found in Finland that the reason Vitamin E and selenium were tried is because there was a group being tested for lung disease and because of the good recording systems that they have in their health care system, it was found there was an effect on prostate cancer and prostate cancer incidence. So we need to have a system that catches the entirety of the health care continuum, the entirety of the disease burden and really, this is why you and this initiative is key to not to just say well, we know what we need to do, we need to do more exercise and that's important. We need to also find where the best messages, where the -- that will allow us to transmit messages and to do that in the most effective way. Key to this in our opinion is, as it is one priority that I have set for the agency as a road map towards faster translation of these discoveries is to re engineer our research enterprise whereby we will have a closer relationship between academic health centers, community physicians, communities of practitioners in prevention and patients. If we do not accomplish that, then I think the communication line is going to be so long and so broken up that I don't believe we will have an effective system in the 21st Century. The nation deserves it. And I'm committed to work with the NIH institutes in all of our communities to change the paradigm by which medical research, knowledge, is transferred into the public's benefit. So we're going to have a new infrastructure that will be -- for example, one of the ideas that we're working on is to develop a core of clinical research associates, physicians and health care professionals that would have credentials essentially to conduct,, clinical research appropriately, but also help in making sure that the translation of messages occurs in both directions so our goal is to create a more efficient national bench to bedside research system as part of the effort we are talking about today. So in summary, I wanted to give you a sense of where NIH was in terms of the healthy people, 2010 and this initiative. I'm pleased that the secretary has taken a leading role incoming, in becoming the secretary for prevention because from my standpoint as NIH director, from my standpoint as a previous academic health center official, there's no way we can overcome the challenges of the 21st Century in health without renewed focus and renewed energy in developing prevention strategies that work. So, on behalf of NIH, I thank you for your attention, and looking forward to your progress. Thank you very much (Applause) >>RICHARD CARMONA I remember back on March 26 when the President gave us this unbelievable opportunity that neither one of us expected, and Dr. Zerhouni and I have both a number of things in common: That neither one of us would have expected to ascend to this level of leadership in our government. He was a poor immigrant kid that came from northern Africa with not a lot of money and a lot of family and he moves to become a leader at John Hopkins, a well known researcher and director of the NIH, and myself, just being a high school dropout and street kid, we both meet on this podium a year ago and the President gives us this unbelievable opportunity and, you know, it really says a lot about our country and the diversity. And you know how somebody from our beginnings could be given this immense opportunity. A while ago, I was in Florida and I was, I did a presentation down there and on the way back up, I had to get back up to Washington quickly and I was fortunate to meet a military colleague of mine, General Tommy Franks, who is running the war, a humble man, nice man, and I just, I got to know him on the plane on the way up to the Pentagon. And I was so inspired by his very humble leadership and the things he was telling me, the humanitarian things, all the things he was concerned with in his position as a commanding general, and I got a different sense of him that when a couple of weeks later, I, it brought home to me what a wonderful country we have because I read an article in Time or Newsweek, one of those news magazines, and it talks about this guy as a wonderful leader, and went through about a page and it was this wonderful description of General Franks and then a counterpoint. It said we did some research in your background and we found that you really weren't such a good student and you had this problem and that problem, and you know, you didn't listen to your mother and on and on. And the reporter said to him, General Franks, what do you have to say about that? And he said, Ain't this a great country? (Applause) and I think that those remarks will stay with me forever because it underscores my feeling every day and the immense opportunity, privilege, responsibility of serving at this level; eight months later, never leaves me. I still pinch myself every morning. One of the duties I have in this job as U.S. Surgeon General is to work with the best leaders in health care -- both in our government, and in non-governmental organizations. And over the last few months, I've had a number of wonderful meetings at NIH, alluding to something that the doctor just said, where we spoke about how do we get this wonderful science and get it to the bedside? You know, before the announcement yesterday of the genome being done, Dr. Collins and I had had some meetings and we talked about how do we get this quickly? Let's not wait those two decades. Let's get the good science to the bedside and translate it into prevention. Dr. Lindbergh, an articulate man, was very, very enthusiastic about using all the present day methods of communication and his national library of medicine to get that word out that the President wants us to get out, that the Secretary wants us to get out, so it's incredible and I think the time is right, I think the country is ready for embrace prevention, but we all are just a few leaders that happen to be given opportunity as we pass through this part of life. It's really all of you and the President and Secretary, you always reinforce what we already know: That the strength of this wonderful country is in our communities. It's each and every one of you and the programs that you have and the dedication and commitment that you have to your citizens that are going to make the changes. So once again, I thank you for being here and making this commitment to lead this legacy of change because it's so important to the health, safety, welfare of our citizens. As you heard, steps to a -- in order to take steps to prevent diseases this initiative encourages changes in life-style that impact many of the major causes of death and morbidity. Some important points: Current health trends in ageing, baby boomers led to bigger cost, high prevalence of chronic disease. The unhealthy employed population costs businesses in many ways. Education interventions to prevent some of the leading causes of diseases and disability remain underutilized and yet can make the greatest difference. It's not just the education setting. Community partnerships between schools, departments of public health, businesses, civic organizations can teach and lead by example. A point that the President never fails to make when he speaks, that he does expect us to lead by example, that he does expect us not only to talk the talk but walk the walk. Public health is all about prevention. Health providers across the public health system have the capacity to contribute to dramatic reductions in health, economic, and social burdens of preventable disease. We are beginning to recognize a health system can health better than disease care. With those thoughts in mind, I would like to introduce experts from the areas of Business, Education, Public Health and Medicine, who will share their prevention messages. First, it's my privilege to introduce Dr. Joel Bender who is the Corporate Medical Director for General Motors Health Services. And Dr. Bender directs GM's global health services, acts as health care consultant and serves as a government liaison with health-related agencies. Dr. Bender? >>JOEL BENDER Thank you for your kind words. These opportunities are a joy for me to attend and oftentimes I'm asked to speak at, well, some town hall meetings. I gain more than I give in these settings, its professionalism, and I think the experiences that you have that you talk to me about really reward me. Secondly, it also provides me with some personal motivation. At the last town hall meeting when the Secretary was speaking, he challenged most of us to take a look at our weight, and I, too, took that challenge and over a period of about three month now, I've lost 15 pounds, but I must say -- (Applause) -- thank you. But in the spirit of what you hear oftentimes in corporate America, there are stretch goals, and so 20 was the stretch goal I had so I have five more to do. Let me talk to you this morning about a number of things that are probably important to GM and why would we be interested in preventative care. First of all, as you can see, GM is the largest non-government health care payer. We have over 1. 2 living coverages in the United States alone and we have a significant population of retirees. This mimics what is going on in the U.S. We are a large statistical sample of What's going on. Cash outflow for health care alone at General Motors is $4.5 billion a year and is going up about 9 percent each year, and with about $1.4 billion in drug costs for the corporation, and that's going up more than about 9 percent a year. So that's why GM has an interest in health care and particularly in prevention. I'm going to limit my talk today to three areas: Number one, I'll talk with you briefly about occupational health; secondly, about community initiatives, and then thirdly, about wellness and health promotion in a joint program with the united auto workers and GM called Life Steps. These programs are intertwined, they are related by a number of common threads in that they are multi-disciplinary, covering a large amount of individuals. To give you an example, I have 89 clinics in the United States, I have a staff of about 550 professionals that are greatly interested in prevention, and they make these programs work. Likewise, in community initiatives, we have a number of nurses that deal in the larger communities as well, providing these kinds of services to communities, to our retirees and employees. Let me talk about some of the things we see in terms of health risks in our population. If you look at this chart, I picked out a handful of risk factors that we see in our population at General Motors. And as you can see, we have some major issues with high blood pressure, cholesterol, but as well as we have another issue down there about second from the bottom dealing with obesity in that almost 40 percent of our population is overweight. When we look at what we're trying to do with our Life Steps program, we're seeing some positive trends. We're making some difference and we can measure those differences that take place. We have a long ways to go. If I look at this bottom of this rather busy chart, one of the ways we can measure our performance is by looking at the change in the risk factors in this population. The goal is to move people from high-risk to medium risk, and to low risks. So that's why you see that area growing under 0-2 risk. We want that area to grow because we want people to remove that risk from the high and the medium categories. That's a look at risks. What else is going on in this population? Well, you can see when we ask people what kind of diseases they may have, we have a rather small percentage though that are low risk that might have disease in the population. And it increases by age. As you start increasing risks, you see the percentage of individuals with disease that is acknowledged by them increases, increases to the point that when you have individuals at high-risk, you have almost 80 percent of the people of our population have some disease. Now, let's take and look at one small category of those diseases that people report. In here, if there's anything I can impress upon you on this chart, it's that the issue of weight control. Because as weight increases to a point where you are at least 30 pounds or 35 pounds overweight, and you have multiple risk factors, that is four or more risk factors, we can identify at least 16 percent of our work force that is a diabetic. 16 percent. It comes right back to controlling risks, controlling weight as well. These are very costly things for the corporation but more importantly, it's costly to those families and to those employees as well. That takes me to the reason that we set up. What we call a diabetes management work site pilot. One of the things that I noticed shortly after coming to General Motors was that when individuals would receive calls from the health care provider, they would get information from their primary care physician, get information from the health care plan, lot of it being different. People didn't like being contacted by multiple sources. So we decided to take the best of the best. And in three sites, we've set up a pilot program in which we made it free and confidential to every employee, we want to promote improved quality of patient care, we do implant screening for a variety of factors that are listed on the American Diabetes Association criteria, and most importantly, we do want to engage that primary care physician. We involve that physician because we feel that is the point at which people can have contact and we want to continue that momentum to identify and control those issues that involve the diabetic. Program may seem complicated but it starts with a plan employee, starts with a Life Steps program which is the health and wellness promotion program at General Motors and united auto workers, it deals with our own health care teams at each one of our plants and clinics, data is transmitted to the University of Michigan where it's held and analyzed and done confidentially and involves the primary care physician. Our goal was in one year to enroll at least 200 people in the four sites in this program. Already, we have enrolled 250 people after five months in the program. What do we see? We see about 50 percent who are in reasonably good control, the remaining 50 percent is in dismal control. Hemoglobin AIC and the other hemoglobins are not well controlled at all. We really need to work on these links. In a period of three months with a smaller segment of this population, those who have been actively involved in this pilot project, what we are seeing is reduced weight, control of the hemoglobin AIC and reduced cholesterol levels, so it's beginning to work, even with this modest level of individual involvement. Let me move on to one other aspect of our portfolio. That's called Community Initiatives. You heard the previous speaker speak about community, community involvement. It's obvious to me that as a corporate medical director. That I really can't do it all. That it takes involvement in the community. I personally believe strongly in a public health model and this is the beginnings of that model. What we've done here and the reason we've done this is because we are so spread all over the United States. However, we were able to identify in nine locations, nine communities, that account for 61 percent of that $4. 5 billion we couldn't control and couldn't really cooperate and involve 250,000 physicians, or 36,000 pharmacies so what we did was pick a smaller segment of the population where we would move in a collaborative fashion. The goal of our community effort is to improve quality of outcomes, increase collaboration and really drive towards best practices. Some examples that we're doing right now is just a get you fit campaign. We are in four communities with that project. We used some of CDC's surveillance to monitor our progress. Our ultimate goal in this particular program is to reduce sedentary life by at least 10 percent in the next three years. In Detroit, how appropriate, Motown in Motion. Similar type of concept involving the community, setting community goals. Lastly, and a major effort that we are working on is quality of care focus, and this is the Michigan Quality Improvement Consortium, here we're looking at evidence-based practices. Let me tell you how important patient safety is alone to General Motors. When we look at medical errors in the United States, and extrapolate that to General Motors where we have 1.2 million lives, the potential exists to safe practices reducing errors in medicine, is to prevent 1.3 deaths every day just in the General Motors population alone. Safety is very, very important. That's why we are driving towards best practices and are looking at those for heart disease, diabetes, and many other issues as well. And now let's talk about Life Steps, a General Motors program. Yes, you have to do more than think about fitness. Life Steps is truly one of the largest corporate wellness programs in the United States and we have the typical 1-800 phone numbers but personal trainers and I've got, I believe, about 55 fitness centers alone throughout our plants in the United States. And we track and measure progress in this population as well. Is it working? Well, we've conducted 850,000 health risks appraisals, and the goal is to move them to lower risk and over half have decreased at least 1 health risk factor, and when we look at the chart that is shown on this chart, on this slide alone, what we see is that those that have even three or more are making great improvement, we've had almost a 20 percent improvement in reducing risk factors in the population. When we look at what prevention eventually can do for us, we see that the percent of total costs attributable to such risks at General Motors is 20 percent. Low risk individuals cost a corporation less. How much is that? $450 million annually. That's direct cost only. That's not the cost of loss of productivity, absenteeism. That's the direct cost of hospital care, clinical care, pharmaceutical care for employees, and retirees. What have we learned? Well, certainly improving the health status of a community makes a big difference. We also know that improving the quality of care is imperative. We agree that there's a national epidemic of obesity. We know that excess risk factors increase the prevalence of diabetes, and we're working diligently to focus on diet and exercise and to make the workplace more friendly than it has been. But when we look at the total picture, we know that wellness and prevention improve the bottom line by helping our employees, helping their families and retirees because we know the cost of diabetes. The cost of missing that loved one, cost of morbidity associated with that disease and so other disease related to it. It's not just a dollar figure we are interested in but the bottom line for each and every employee that we serve. Thank you. (Applause) >>RICHARD CARMONA Thank you so much, Dr. Bender, for those remarks. It ties in with our own biases as far as achieving best practices, and we'll hear from Dr. Carolyn Clancy on some of those issues on reducing the variability and practice patterns and so on which we all need to step up to on medical side, but thanks for the GM approach. I'd like to now introduce to you Dr. Michael Ward, State Superintendent of Public Schools in North Carolina. Reelected in 2000, he is serving his second term in office. During his tenure the State's schools have earned a reputation as the nation's most rapidly improving system of education. Dr. Ward is an advocate of strong programs and consistent programs of healthful living and physical activity. Welcome Dr. Ward. (Applause) >>MICHAEL E. WARD Good morning. I'm grateful to have a chance to be part of this conversation. I've run into awfully friendly folks while I've been here. I had hoped that would be the case. In my role working with public schools, which puts me in a fairly conflict-rich environment, I sometimes run into folks who are less kindly disposed. We've been through some public hearings recently and they have been fairly contentious and folks have brought some concerns to the table and we have had our rounds. It got lively and I got gun shy going out in public. I recently concluded one of the sessions and was out on the street later in the day and a woman approached me, crossed her arms and said, You look just like Mike Ward, our state superintendent. I didn't know what she had in mind and I said, Yes, ma'am, I hear that a lot. She said, It makes you mad, doesn't it? That's not a true story, but most of the rest of what I share with you most of the rest I share will be. I really am honored to be part of this important conversation about the health and well-being of Americans and especially the health and well-being of children. I'm inspired by you and grateful that you make such issues a priority. I'm also grateful for the chance to learn from you. A couple of years back, I took on a personal challenge during Powerpoints. (inaudible) I decided in running a marathon race. They say that a marathon is two parts: The first two miles and final six. Most people don't ordinarily run in training for the entire marathon distance, theory being that you only have one or two optimal 26 mile runs during the space of months and you don't want to waste that in a training run. So I had never run prior to the marathon that full 26-mile distance. So I wasn't sure what the final miles would be like. I had heard that there are two phenomena late in the race: One is an experience called hitting the wall. Your legs turn to lead, breathing is labored, and it's hard to hold your arms up while running, and I was also told that there's the potential for another experience later in the marathon. That is a type of euphoria, almost a spiritual experience, a lightness sense that you can run forever, and sure enough, around mile 21, I felt a type of lightness of renewed strength, a sense that I could just keep running and not grow weary. Marathoner euphoria is real, so is the wall. It hit around mile 22. And from that point on, it felt like I was swinging blocks at the end of each leg. Weeks later I felt I could run and not grow weary. For folks like us, trying to advance the cause of healthy active Americans, it really is a marathon. It's not a sprint. There's an occasional euphoria but I suspect we agree we confront the wall more often. I want to share three observations. My wife is a United Methodist pastor, I think I'm a victim of like the preacher's wife. She has sermons in three points. I want to share three points. The advantage is if it's going badly, you have some sense of how much you have to endure. First point that I want to share with you is there's a real health crisis for kids out there. And there's some conflict in schools about the degree to be a part of the solution. I don't have to give you the statistics about the chronic problems; you've heard that already. As the CDC's own report points out, most Americans know the risk factors of serious chronic diseases, but most also have not changed their life-style sufficiently to reduce the risk of death or illness. Americans know what to do. We're just not doing it. Of course, it's not just adults. The increased rate of obesity, diabetes and other health problems among school-aged children is well documented. Public schools are sometimes guilty of failing to address the problem. Tough choices are confronting us in education. Educators are under tremendous pressure to be accountable, and that accountability is typically based on test scores, and with the enactment of No Child Left Behind, these pressures have increased leading some to wonder about the placement of health and physical education. You've heard about No Child Left Behind earlier from Secretary Paige and I want to share a few additional observations about this legislation. No Child Left Behind sets new standards for student achievement fore closing achievement gaps, for teacher and paraprofessional quality. I want to be clear as I begin, No Child Left Behind has the right goals, and I stand behind this legislation. You can not argue with goals which stress accelerating achievement of all children, and erases gaps in improvement and making sure kids have access to well qualified teachers and empowering parents whose children are trapped in school that chronically fail. The law identifies core subjects and specifically sets higher standards for teachers in these areas. Health and physical education is not identified in the legislation as a core content area. Pause for a minute and think about the pace at which reform has taken place in schools over the course of the past couple of hundred years. It's been about 150 years since the beginning of the common school movement. It took us 100 years to get serious about inclusion to assure that all youngsters had a plate at the table, and that just the advent was the Brown versus Topeka Board of Education decision, the desegregation case. Subsequent decades have affirmed rights of children with disabilities, students who are new English learners. It took us about 150 years to achieve the goal of universal access. No Child Left Behind accelerates now a new goal. We now have the challenge of moving to universal proficiency in the space of 12 years. 150 years to universal access, 12 years to universal proficiency, and I think that the contrast between the time frames creates an ununderstandable sense of urgency, a sense that there's perhaps not enough time for everything, and the fact that they are feeling this way makes us wonder if health and physical activity are going to decrease in importance at the very time the research says that we're facing a crisis. You and I know that the accountability movement in public education has not had as its goal as an explicit intent the need of the physical well-being of children but the unintended consequences that we need to be paying attention to. Consider some of the following illustrations of this point: In Connecticut and Virginia, there are discussions regarding cuts to health and physical education programs. It appears these programs are okay for now, but the discussion took place. In Minnesota, health and P.E. programs are scheduled to be cut and offered only as an elective. Rumors are building that other states may consider similar action. In addition, there's the concern about the message that is sent when we are not holding health and physical education teachers to the same standards for highly qualified teachers that other teachers are held to in the No Child Left Behind legislation. I want to stress, these are unintended consequences I believe. I'm confident that that's the case, especially at the national level because of other events that are occurring. For example, The National Summit On Action for Healthy Kids was recently held in Washington, DC. The surgeon general convened the meeting with the First Lady, Laura Bush, to signify the importance of this event. I doubt the First Lady's views varied significantly from the President who is known for his support of not only No Child Left Behind but for personal health and fitness. And this conference is another case in point that such outcomes run to the goals of health, such (inaudible) this crisis can't be denied and the competition among priorities in the mind of educators and health professionals is real. So point number one: There's a real health crisis for children and schools are conflicted about their role. Point number two: There's a compelling case for schools as problem solvers in the health crisis that's confronting our kids. As was noted previously, there are danger signs regarding the health and well-being of children, but with respect to issues of health and learning, there are some positive signs. There's research that points to the connectedness of health and physical education and academic well-being in schools and there are other positive signs shown to us by research. I want to give you a sample of some of this research. Health and physical activity are positively related to academic performance, and we'll just breeze through some of these reflections. This research I hope is not surprising but this is the core. There are other folks that don't get this connection very well and it's important that we get this research disseminated broadly. It's research from across significant time spans and it's research from across the country that supports the connectedness of physical activity and academic performance. There are strong correlations between physical activity and health education and youngsters and the sensibility of youngsters regarding their own health and wellness. There's also a relationship between students' participation in health education and decrease in their own risky behaviors. There's also a strong belief in the community that these contents are essential. 73 percent of adults from nationally represented samples felt that health education in school was definitely necessary, 82 percent of parents felt that health education is more or as important as other subjects. The community gets it. Health and physical education are as basic as it gets. The community when asked is with us. The test before us is to tabulate this support to assure concerted multi-agency and community policies and behavior in support of healthy, active children. Importance that parents and other adults place on helping our children create healthier life-styles makes it clear they expect schools to be important partners to assure better health with children. So point number two, for those keeping count, there's a compelling case for schools as problem solvers and there's steps we can take to address the crisis in spite of the challenges. I know there are things going on all over the country, but North Carolina's steps are those with which I'm most familiar. And so I want to share a few things we are doing in North Carolina. We've got a joint commitment between the Secretary of Health and Human Services, Carman Odem (sp) and by the Department to Improve Health and Academic Performance. -- we have also appointed healthy schools forums, meet with the legislature and support an adolescence health advocacy day. Our county directors, board of education, county health directors have created coalitions. We've developed a healthy active children policy which requires local advisory committees and adopts guidelines for the amount of physical activity that youngsters, in which they participate. Our Action for Healthy Kids Summit targets local boards of education members, their support and we model and profile best practices in districts with respect to this issue, but we've been the beneficiary of a CDC grant, but I want to point out we don't have to wait on grant money to advance causes like this, and there's things we can do now to help assure better emphasis on health and well-being among the children. First of all, we can strengthen agency partnerships with our counterparts and other agencies and develop common objectives. Our public schools in North Carolina -- think of our chances for advancing this cause, now that the North Carolina Public Health Director has the corresponding goal of eliminating health disparities among children. Shared objective like this advance our prospects for success, building goals around common objectives can help us move ahead even in times of tight resources. We can also work with and use our national organizations. CCSSO, my national organization, states school officers, is active, has been active in creating a task force on school health, safety and terrorism which is working to create, models of support, and your organizations are doing similar things. We can tap our organizations for assistance. We can also ask tough questions about the ways that we are using existing resources and in a time of tough choices, we can consolidate services, spend less time in another areas to funnel to another area, like the health and well-being of our children. And finally, we can advocate. We can be active in the process calling on policy makers to make sure that health and physical activity are being accounted for. We need to be personally engaged in the process of advocacy. I sometimes tell folks they ought to take a legislator to lunch, commissioner to coffee, member of Congress to an activity, and board members as well. We need to be advocating with the folks who are making policy for good policy that affects the well-being of our children. It matters that we do this. It matters that we attend to these issues. It matters to the economy, it matters to the community, it matters to moms and dads and most of all, it matters to children. One by one, for all that you will do and all this conference will do to advance these important causes, I say thank you. (Applause) >>RICHARD CARMONA Dr. Ward, I'd like to tell you, and I may be using your wife's, the minister's three-point rule. I appreciate your metaphor regarding the race for health being a marathon and not a sprint. Also, we will occasionally hit the wall in transitioning to prevention from a care -- but we persevere and experience the euphoria. And lastly, please tell your wife, the minister, she's trained you well and the sermon from this pulpit was well received. Next, it's a privilege to introduce David Hoffman, Director of the Bureau of Chronic Disease Services of the New York State Department of Health. This bureau contains programs including diabetes control and prevention, breast and cervical cancer screening, colorectal cancer screening, prostate and ovarian cancer education, cystic fibrosis assistance and Alzheimer's disease and other dementia services. He has a history of health public health service, having served as a program manager in child and adolescent health programs and chronic disease programs and most recently as Assistant Director of the Bureau of Chronic Disease Services. Please welcome Mr. Hoffman for me. Thank you. (Applause) >>DAVID HOFFMAN Thank you, Dr. Carmona. It's my pleasure to be here to share a few thoughts with you. By way of introduction, I would like to reference a question we heard earlier this morning regarding primary, secondary, and tertiary prevention and acknowledge that in state public health agencies and particularly their in-state chronic disease programs, we accepted the challenge as our responsibility to work with our communities in all three, and it worked. Let me share a few thoughts with you this morning about our diabetes prevention and control program. In the U.S. today, 17 million people have diabetes and about six million of them don't know it. There's an equal number of people with a new condition that we refer to as pre-diabetes which you're going to hear more about shortly. When we look at the risks for diabetes, non-Hispanics, and blacks are two times more likely to have diabetes, Latino Americans are 1.9 times more likely to have diabetes, American Indians and Alaskan natives 2.6 times more likely. The risk is also increased for Asian Americans, native Hawaiians, Pacific Islanders as well. When we look at mortality, the risk for death among people with diabetes is about twice that of people without diabetes, and diabetes is rated as the 6th leading cause of death although we know state by state that diabetes is under reported. Today, while we are here, 2,714 people will learn that they have diabetes. 105 people with diabetes will be diagnosed with blindness. 192 people with diabetes will have a lower extremity amputation to save their lives. When we look at complications, it's the things we heard about already this morning. Heart disease, stroke, high blood pressure, vision, kidney disease, etcetera. When we look at the economic impact of diabetes, the increasing costs parallel what we saw in the maps earlier in the morning from $98 billion in 1997 to $132 billion in 2002, with the difference in average costs of $13,000 spent on people with diabetes annually compared to $2500 for people who don't have diabetes. We know that preventing complications saves lives as well as dollars, but we know that it makes sense. For every 1 percent reduction in hemoglobin AIC which is a measure of blood glucose over time, the risk of developing microvascular complications, kidney and nerve complications is 40 percent. Keep that in mind. We'll come back to that. Blood pressure control can reduce cardiovascular disease by up to 50 percent, improve control of cholesterol and lipids, can reduce cardiovascular complications by 50 percent. Foot care programs can reduce amputation rates from 45 to 85 percent. Detection and early treatment of diabetes-related kidney disease can reduce the development of kidney failure up to 70 percent. We now know that to a great degree, diabetes is preventable. You're going to hear more about that as well, but the life-style interventions that we've heard so much about this morning and that we need to internalize and work on together are absolutely essential to what I'm about to tell you. In New York state, our diabetes prevention and control program has taken a global approach including a number of external partners. Our primary partner is the Centers for Disease Control and prevention where we receive our seed money. Without this money, our program in New York would not exist. We fund three diabetes centers of excellence, we fund 13 community coalitions for diabetes prevention, we have four governor's initiative projects for children with diabetes. I was pleased to hear so much about children, thank you. We also work with ten of the federally qualified health centers in New York as part of the diabetes collaborative and we have a special project with all of the health care plans in Westchester County, a highly populated area in New York. Internally, we work closely with the Office of Medicaid Management, with projects from drug utilization review, to chart review projects to try to improve the care that people in the Medicaid program receive as well as increasing the knowledge of Medicaid providers. We work closely with our Office of Managed Care for both the Medicaid Managed Care and commercial population and we showed good results which I'll show you soon. We have a protect with our AIDS Institute in New York called expanded syringe access, a demonstration project that is giving us access to a population that we typically don't work with in chronic disease. Our Centers of Excellence are university consortium-based projects that engage in diabetes related research, provider education, and state of the art care for people with diabetes. We charge them with improving access to special and at-risk population to comprehensive diabetes care, but more importantly, we charge them with developing tools, practical tools for working with people with diabetes or at great risk for diabetes. Our community coalitions are charged with addressing CDC national objectives for control, screening exams, annual flu vaccines, pneumococcal vaccines, smoking cessation, weight management, etcetera, and involve many community partners. The interventions that they gain include provider education, development of tool kits in their distribution, nutrition and physical activity programs and research projects with step counters, community education, educating the public. Teaching tool development, chart tool development, our supermarket project in many cities where people with diabetes and their families can go and have learning experiences, support groups and outreach to special populations. Our Governor's Initiative Project began a few years ago -- the opportunity where we found ADA, local diabetes center and the local school systems. These projects insure that children with diabetes are able to fully participate in all facets of their class, scholastic experience. Last year, we trained over 2500 school nurses as part of this project as well as other school-related persons which work hand in hand with nurses. It's an interagency project between the Bureau of Primary Health Care, AHERSA, CDC, our diabetes program and Institute for Health Care Improvement. They use proven, quality improvement and diabetes care practices to improve the health status of their patient population. Let's look at some numbers. Those numbers have reduced the average AIC value for their population of over 2000 patients by almost the full point in this two-year period. When we look at the progress towards national objectives, annual eye exams have increased, foot exams have increased, AIC numbers jumped from 97 to 24 percent -- to 68 percent of the population of New Yorkers with diabetes -- when we look at the managed care population in commercial managed care, we saw a 5 percent jump in the measurement of AIC. In the Medicaid Managed Care population, the increase was even more dramatic. You remember what I said earlier about improving H, excuse me, AIC having a positive benefit on all of those risk factors. Let's talk about the contributions of our primary, secondary and tertiary prevention efforts. We've seen a reduction in the incidence of end stage renal disease from 3.7 per thousand people with diabetes in 1993 to 3.2 thousand. That's a six year decline of 13.5 percent. When we look at the cost data nationally, $6.6 billion a year, and extrapolate the New York experience nationally, we could see that number reduced to $5.7 billion a year. When we look at hospitalization rates for people with diabetes, when we look at the national cost data at $4.6 billion a year, when we extrapolate the New York information, that's reduced to $3.3 billion. When we look at lower extremity amputations, we saw a six-year decline in New York of over 35 percent. That can be extrapolated nationally to a reduction in costs from $4.1 billion to $3.3 billion. Our flu immunization rates increased from 53.4 percent in 1993 to 59.8 percent in 1999. According to the CDC, flu and other infections caused an estimated 10,000 to 30,000 deaths to people with diabetes and most are preventable. So we're left with a number of challenges and also a number of opportunities. We have the twin epidemic of diabetes and obesity, but I'm pleased to say we have national attention and new resources to be brought to bear on these issues. We have a diverse and ageing population as we heard earlier this morning, and we have new culturally sensitive education materials and tools to use. We have categorically funded programs with similar goals and objectives that are collaborating more than ever before. We have our diabetes prevention findings which you'll hear about shortly and we'll be taking our next steps in the prevention of diabetes. We have all of these daunting statistics and the single largest prevention investment in history: Steps to a HealthierUs. Thank you. (Applause) >>RICHARD CARMONA Thank you for the New York perspective and comments about the values of partnerships and how effective they can be. I'd like to introduce our last speaker, and that is Francine Kaufman. Dr. Kaufman is currently President of the American Diabetes Association and Professor of Pediatrics at the Keck School of Medicine at USC. She is the Director of the Comprehensive Childhood Diabetes Center and Head of the Division of Endocrinology, Diabetes, and Metabolism at Children's Hospital in Los Angeles. She set up numerous support groups, family camps, retreats and patient and family seminars to aid those under her care. I wonder what she does in her free time, and please help me in welcoming Dr. Kaufman. (Applause) >>FRAN KAUFMAN I want to be sure I know how to work this first. It is such an honor to be here and particularly with our partners from the NIH, and Dr. Spiegel. And representing the American Diabetes Association, I was trying to count how many times the word "diabetes" has already been said this morning, but I ran out of patience at about 200. It's a real thrill to see diabetes as the prime initiative of this morning's conversations. Because of that, I think a lot of what I will say has been covered so I will just go quickly over most of these statistics and just stress that the complications of diabetes are devastating. Diabetes remains the leading cause of acquired blindness, kidney disease, and the need for amputation and most people with diabetes die of a cardiovascular event. And then, of course, the cost of diabetes last year exceeded the tremendous amount at $132 billion. Diabetes affects our Americans of minority ethnic groups, and you can see that there's an every increasing number from those who are Caucasian to Latinos to African Americans and native American. This is about the natural history of the development of type 2 diabetes. Right before I came, I diagnosed diabetes in a 9-year-old girl who weighed 120 pounds. She was profoundly ill when she presented at the hospital, and we had to do some, manipulations of her fluid, gave her medications to bring her back to a safe level. She had a 16-year-old sister who was hysterical and almost did not stop crying for the first 12 hours of that child's admission, so I went over and I said, she's going to be all right. Why are you so scared? And she said, I'm just so scared because the word "die" is in diabetes. So I think that as we see an ever increasing number of children affected by this devastating disease, which is sensitive to some of the concerns that they have as well, I think you can see from the scheme of it, the beginning of diabetes is really a genetic problem. Add the mix of environmental factors that lead to obesity and physical inactivity, and even if the beginning stage, before something is diagnosed due to an elevation of insulin, they already have a beginning of cardiovascular risk factors and probably beginning of cardiovascular disease. We go through this period in which we can diagnose pre-diabetes. It's referred to as IGT, or impaired glucose tolerance, and that is made by giving somebody a fasting blood glucose test and then followed by an oral glucose test and looking at the glucose to define the tolerance or pre-diabetes. We see the onset of clinical diabetes and I think what you heard today, we do not manage diabetes optimally. They experience -- high blood pressure and sugar lead to deadly complications, eventually to disability and death. We talk about usually about a 20 or so year time frame from the beginning of diabetes to the really onset of its devastating complications. For the 9-year-old child that I diagnosed yesterday, 20 years will make her still a very young adult, and I think as we see this increasing more and more in the pediatric population, we can be very concerned about the next generation of young Americans. What I want to really talk to you about is the diabetes prevention program that was a tremendous collaborative of a number of research centers across the country, tremendous number of research volunteers, who gave of their time, and of their years to be involved in such an important study, and it was funded by the National Institutes of Health, and also some partnership with the American Diabetes Association, and a number of other groups. Now, let me, you heard about it a little this morning. Let me give you more background as to what this study was about and what it showed. So what they had was, looked for adults with impaired glucose tolerance and had an oral glucose tolerance test at some point and those that met the criteria were randomized either into an intensive life-style, taking the drug metformin or into a placebo group, and at the bottom, you can see the study involved more than 3,000 participants, and these are the kind of data we saw and you can see that the curve for the life-style way succeeds what we saw with the medication. So the weight loss was the best with life-style and as a result of this weight loss, there was a significant decrease in progression to diabetes. And as you see, as that line goes up, that means more and more people have developed diabetes. We can compare it to the placebo group. There was some reduction with the drug, but then the most significant reduction was with life-style alone, and as a pediatric endocrinologist, when I think about this bullet that was talked about earlier by Dr. Zerhouni, some pill that could make everything well, it becomes unlikely that we will in the near future have any medication that will do what alteration of life-style has been able to do. Then we think about medication, are we going to start eight and nine year old children on these and have them on it for decades and decades? I think that would be a much poorer alternative than thinking of instilling a lifestyle (inaudible) on adults with impaired glucose tolerance or pre-diabetes, and they had diet and exercises, just routine care, and I think that you can see the intervention group compared to control group. At the end, reduction in diabetes was identical to that same with the prevention program of a 58 percent reduction and those with the life-style intervention compared to those with just routine lifestyle. Then there's a Chinese study and European study saying we can prevent it. None is as rich as what we see with life-style intervention. So, the big challenge, and I think the doctor mentioned this, is not how do we bring these results? How do we invigorate the American population, particularly those at risk to want to follow the life-style changes, protocols? First of all, I want to tell you that we are out there looking to find people at risk or who already have diabetes and don't know it, and the recommendations of the American Diabetes Association and the NIDDK are to do this in the context of a health care visit for adults, and to look at the risk groups of those greater than 45 years of age who have a BMI greater than 25, to be considered at risk and to be tested for diabetes in the context of their health care visit if they, if their health care provider feels that's indicated. For those less than 45, we add on other risk factors such as a positive family history, for women who have had gestational diabetes or a large baby in the past, or for people who have elevated cholesterol, hypertension, or are of an ethnic minority. They have a screen done in the context of their health care visit and if it's negative, it's repeated every three years. What exact tests need to be done? Fasting blood glucose, perhaps a two-hour glucose tolerance test if indicated and then what is the hope if somebody does have pre-diabetes that there will be a way to invigorate their life-style. Give therapy counseling about life changes and weight, to continue to monitor them for the development of diabetes or other cardiovascular risk factors, and at this point, to avoid drug therapy since there is none that is as impressive as life-style intervention. Similar recommendations for children. We now know that there's a tremendous cohort of at-risk children there and these children are for the most part over ten years of age, or in puberty because puberty is the time that we usually see type 2 diabetes develop due to insulin resistance. Puberty itself causes normal children to be resistant to insulin; it causes them to be resistant to about anything. Insulin happens to be something as well. And those that have a high BMI -- of the ethnic groups that are at risk, and then have other signs of insulin resistance. And again, it is advocated that the children be evaluated for this in the context of a health care visit with their health care provider, so that if they do have pre-diabetes or diabetes, there's good follow-up for them at that point in time. The real translation will have to be a tremendous partnership. Across the country, and I think some spearheaded by Secretary Thompson's small steps, big rewards, the NIH, National Diabetes Education Program are all involved as is the American Diabetes Association and a number of other agencies. But this is to really teach the primary care providers about the screening during the health care visit and the follow-up and counseling of those individuals who have pre-diabetes or diabetes to reduce their risk. I just want to tell you there's also studies being funded now by the NIH and NIDDK to look to similar kinds of events for children. And this is the study to treat or prevent pediatric type 2 diabetes and looking at one of the other ways to treat children with the type 2 diabetes, and I hope the superintendent realizes that the prevention efforts are school based, they are being done in North Carolina, California and Texas, and as they are going to design the trials, it will be really to invigorate physical activity in the school, health education, improve nutrition in the school, and, of course, some behavior change components for the children, the teacher and hopefully families as well. So just in conclusion, if we look at the overall cost of diabetes, they are immense. The direct cost is a significant proposition in the next health care expenditure and we need a modest weight loss, although I'm sitting here with a couple of marathoners, we are not asking people to become marathoners or being elite athletes or asking them for a modest weight loss that has a significant reduction in diabetes incidence and for those who do have diabetes already, a significant improvement in reduction of cost for diabetes treatment and an improvement in health outcome for those with diabetes. So I thank you very much for your attention, and I am so glad that diabetes has been the most common word said this morning. (Applause) >>RICHARD CARMONA Thank you for your remarks, and thank you for your leadership with the ADA. At this point, I think it would be extremely unhealthy of me to stand between you and your lunch. So I would like to direct you to -- as we leave, but first, would you please join me in thanking our wonderful speakers for the information they gave to us this morning? (Applause). Please be back at 1:30 to continue with our presentations. Thank you all so much.