Obesity: The Silent Environmental Epidemic

September 23, 2004
3:19 pm US Eastern Time

Background Information/Resources

Call Transcripts

1. Welcome: Call Moderator: Steve Heilig, M.P.H., Co-Director of CHE, Director of Public Health & Education, San Francisco Medical Society

Obesity, the topic of today’s call, is something that we’ve talked about doing for some time. This is a difficult topic. Many of the topics that we have covered to date have been multi-factorial. This one is even more so in terms of what is talked about and causality and what to do about it. It’s not a new issue, but it is something that in recent years has begun to be described as an epidemic. In the United States at least 1/3 of adults are obese and there’s been a 40% increase in the past 15 years in obesity in children, we obviously can call this an epidemic. The World Health Organization (WHO) has recognized it as well, as a pandemic. When you look at the official discussion so far within the Centers for Disease Control (CDC) and WHO, they focus most on the obvious factors: diet and exercise. We tried to put this call together to give a taste of why many people are starting to see this as an environmental health issue as well.

We will start with Dr. Ted Schettler who will frame the issue for us.

2. Featured Presentations

* First Speaker: Ted Schettler, MD, MPH, Science Director, Science and Environmental Health Network

In the final analysis, overweight or obesity results from a mismatch between caloric intake and energy expenditure. But that simple framing really obscures some important details, many of which will come out in today’s discussion. As Steve has mentioned, there’s really an epidemic of overweight and obesity in the United States, and the trend lines are clearly up, so that it’s happening across all age groups and it’s happening around the world.

Only about 1/3 of obesity begins in childhood, but obesity that begins in childhood tends to be more severe. Childhood obesity present in older children is likely to persist and increases the risk of stroke, hypertension, diabetes, and some forms of cancer and other chronic diseases. Childhood obesity increases the risk of type 2 diabetes at younger and younger ages, which is something that’s really troubling to the health care system right now and to the individuals involved. Girls are at a greater risk of obesity than boys.

African Americans and Hispanics are at greater risk than Whites. Years ago there was a direct relationship between socioeconomic status and obesity. The wealthier your parents were, the more likely you were to be overweight. But that’s changed; now it’s an inverse relationship, but only among Caucasians. The effect of socioeconomic status on obesity in African Americans and Hispanics is flat.

Obesity is an endpoint, which is probably a mixture of conditions with various causes and variable implications for disease risk. For example: general body fat and visceral fat, which is the fat around the organs and the abdominal cavity, do not correlate particularly well with each other. Among Caucasians, disease risk is associated with obesity that tends to correlate better with visceral fat than with general body fat. But this is less true for African Americans. So a simple measure of body mass index, for example, which is sort of a metric that combines both height and weight, is not necessarily a good predictor of disease risk in all populations.

Genetics has a modest influence on obesity, but by far the largest variance in body weight is due to environmental factors, which include: diet, physical, chemical, social, political, and economic environments. Diet can be thought of as total calories, distribution of calories among fats, carbohydrates and protein, and eating patterns. There have, for example, been marked patterns in eating habits in the United States over the past thirty years. There’s more microwaveable food. More people are making their own food decisions. There’s more fast food. Fast food now covers 30% of the average family food budget. High fructose corn syrup is added to a wide variety of foods and beverages. Some studies show an increased risk of obesity in people who regularly consume sweetened soft drinks, for example. But now we know, it’s not only the diet of the individual of interest, but also the maternal diet during pregnancy that influences eating patterns of offspring, and their tendency to obesity. Even in animal studies, maternal diet influences exercise behaviors in offspring. In humans, malnutrition with intrauterine growth restrictions and low birth weight, influences the risk of obesity and cardiovascular disease later in life. So the idea of prenatal origins of obesity and related health conditions is a topic of intense interest. The concerns go beyond simply maternal nutrition, but extend to chemical and environmental contaminants that may influence the development of physiological set points for appetite and weight. These may interfere with hormone levels, such as leptin and other signaling compounds that play an important role in the development of a particular phenotype later in childhood and adulthood.

On the expenditure side, regular exercise as a necessity or choice in daily life has generally decreased in large sections of the population. The reasons for this are multiple and varied, for example, television watching is related to obesity. This probably involves both inactivity and altered dietary patterns. The general built environment plays an important role. Physical education in schools is disappearing.

In summary, we can look at the problem of obesity through a variety of lenses, from the molecular and cellular, to sweeping public policies and cultural practices that are reflected in the body weight of individuals and populations. The food and other environmental influences that we ingest and the amount of activity that we engage in and the balance between the two are the result of our personal habits, our parent’s habits and experiences, agricultural and food policies, land use patterns, the price of gasoline, the availability of parking places, housing choices, community development, school curricula and many others. So, it seems to me that obesity and overweight are apical endpoints that undeniably result from a complex mixture of interacting factors. We like to try to tease them apart to determine the relative contribution of each, but at some point this becomes nearly impossible because of the limits of our ability to understand the complexities of systems with these multiple acting variables, and yet from a public health standpoint, we would really like to know how and where to intervene in the system to effect change.

I’ll just finish up with a quote from former Surgeon General, David Thatcher, who at a conference on childhood obesity said, “Where is community? The only way we are going to get a handle on childhood obesity is to answer that. We need to generate the kind of community that can allow and motivate physical activity, proper nutrition, and the general environment where people aspire to good health. Perhaps this implies that obesity is a manifestation of a larger set of issues that need to be addressed and when they are, obesity will decline along with many other problems that stress our limited public health resources.”

 * Second Speaker: Pete Myers, PhD, CEO, Environmental Health Sciences

I’ve posted some links to relevant resources on www.ourstolenfuture.org. If you go to that home page and look just below the masthead, where it says “Newest” you’ll see a new link called “Obesity Resources’. There are a series of links on that page, some of which I’ll be discussing right now.

Let me begin with the simple observation that we all know someone who’s tall and thin, and eats like a horse but can’t gain weight, or just the opposite. If you think about that, you realize that there’s a lot more going on in weight control than simply how much you eat, or how much you exercise. There are several vital biological processes involved. One of the most basic is the development of fat cells or adipocytes and the processes that determine how efficient adipocytes are at absorbing fat or lipids. It’s been known for a long time that the more adipocytes you have, the more at risk you are to obesity. There’s now a lot known about how certain genes turn on and off at specific times, causing stem cells to convert to fat cells, or adipocytes. That’s one of the basic processes, the determination of the number and the lipid efficacy of adipocytes.

A second category of process are several key hormonal feedback loops that are involved in control or weight homeostasis or weight regulation. One of the examples of these is one that Ted mentioned, leptin. Now leptin is produced by fat cells. The more fat cells that you have, and the fuller that they are of lipids, the more leptin that you produce. That leptin enters the blood stream, goes to control centers in the brain where it suppresses appetite and increases basal metabolic rate. When it works, it’s a perfect negative feedback loop. More fat means less appetite and more energy expenditure. When it doesn’t work, you have weight problems. Mice and people who aren’t sensitive to those leptin signals become obese. So that’s all background.

Over the last 20 years, scattered papers have appeared in the toxicological literature indicating that some exposures can cause obesity under certain circumstances. When you begin to explore that you begin to discover that there has been no systematic experimentation of this. For the most part, it’s because toxicologists have regarded weight gain as good and weight loss as bad. In 2002 a review by Bailey Hamilton was published, pulling together many of these scattered results and beginning to create a mosaic of results showing that contamination under some circumstances could contribute to obesity. In 2003 Jerry Heindel, a scientist at the National Institute of Health Sciences, wrote a commentary in the journal Toxicological Sciences, noting that there were some really intriguing results coming out of the study of endocrine disruption, showing that certain endocrine disruptors, specifically bisphenol A and nonylphenol were interfering with the expression of some of the key genes involved in the process of fat cell formation, in which it was discovered that those two endocrine disruptors can speed up the process of fat cell formation, lead to more fat cells and make them more efficient at absorbing lipids. Heindel went on this spring to organize a workshop at Duke specifically about this issue. You can find a webcast of most of the papers given at that workshop via the links at www.ourstolenfuture.org.

The most dramatic presented were from Dr. Retha Newbold, whose name some of you will recognize as a world expert on DES or diethylstilbestrol. Dr. Newbold had never asked this question of her experimental system before. She showed some new data where exposures to extremely low levels of DES in the womb showed grotesquely obese rats in adulthood. The exposures that she used were far beneath those used pharmacologically to treat people. In fact, as she increased the does, the effects disappeared. Some of you may have heard of the dose-response curve before, technically known as the nonmonotonic dose response curve, where low doses produce larger effects than high doses. A lot is now understood about why this happens, but it is a subject for another call. Another paper presented there was by Dr. Fred vom Saal, who now has a solid body of data looking at several different contaminants, including bisphenol A, and their ability to cause obesity in adulthood following in-utero exposure. Intriguingly, not all of these adult obesities are preceded by developmental or juvenile obesity; instead you have obesity setting in after puberty.

So, here’s where we are with this: first of all it’s clearly a hypothesis in development. We know that some contaminants change the behavior of genes that are crucial to weight regulation, in ways that would increase obesity risk. We know that some of the same contaminants cause obesity in adulthood following in-utero exposure in experimental animals. We know that some of the contaminants in those experimental animals are also interfering with adult weight regulation. But there’s no single experimental system in which this has all been put together from gene expression to adult obesity. It’s all coming from different directions, with different experimental systems asking, to some degree, quite uncoordinated questions. In response to that chaos, NIEHS is right now preparing a request for proposals to explore it further and I am sure we will be hearing a lot more about this in the future.

Steve Heilig: Thank you for this Pete. Our next speaker, Dr. Richard Jackson, has recently returned to California, basically as California’s number one doctor, after a long career at the CDC. He is co-author of a new book out titled Urban Sprawl and Public Health: Designing, Planning and Building for Healthy Communities. He spoke on this topic at our first National CHE Conference last fall here in San Francisco and we asked him to address this again today.

 * Third Speaker: Richard Jackson, MD, MPH, State Public Health Officer, California Department of Health Services

The severity of the obesity epidemic is staggering and stunning. I’ve had the opportunity to brief Governor Schwarzenegger on it and he is taking this very seriously.

We Americans have gained ten pounds in the last ten years. Therefore California has added 360 million pounds of adipocity, just in one decade. The average 11-year-old boy today, is 11 pounds heavier than he was in 1973. In 1973, when I was a young doctor, in the pediatric/diabetic clinic, we never saw a child with type 2 diabetes. Now it’s about a third of the pediatric/diabetic population. At the rate we are going a third of today’s babies will be diabetic by the time they are age 40, with an average reduction in life span of about 15 years, and average reduction in the quality of life of about 20 years. This is a hugely threatening and important epidemic that we are facing.

Howie Frumkin and others and I have had a strong interest in how the layout and design of our environments influence our well-being. This came out of my own interests in traditional environmental issues like air and water pollution and its effect on health. It didn’t take too long to realize that we’re never going to deal with air pollution unless we figure out how we build houses, homes, towns, cities and transport systems. We’re not going to deal with water pollution unless we can retain trees and infiltration of water and rain into the soils, as well as control at pollution sites. Over time, I’ve focused more and more on the design of the built environment and well-being.

In the beginning, when we were talking about this issue of sprawl and bad development influencing health, we were ridiculed, had our faces on the junk science website and all the rest along with a bunch of other folks I know. But I think the science is very much there at this point. When I was in Atlanta at the CDC, many of the hires we did were young folks that had worked on the Hill in Washington, DC. They would say to me, “You know, I moved to Atlanta and gained 15 pounds. When I was in Washington, DC, I walked all the time. Now that I’m in Atlanta, I almost never walk.” The incidental exercise that we have eliminated from our daily lives has had major implications, in terms of environmental pollution, in terms of mental health and socialization, but in particular in terms of our own strength, activity levels and obesity levels. While we focus on obesity, the activity level is of equal importance. The estimated difference between people living in sprawling areas versus non-sprawling areas, or more dense areas, is on average, about six to seven pounds. Which, compared to what we’ve gained, is probably half or a third, but it’s still a major contributor.

The Governor of California has and will be taking this seriously. He’s going to convene an invitational summit on obesity. He will be bringing in about 100 leaders of American society, particularly from California, to talk about how the state will take this on. This will take place in February. The Governor will be there both at the beginning and the end of the summit and will extract from insurance, restaurant, beverage, academic, entertainment and other industries what kind of commitments they would be willing to make in terms of turning around the obesity epidemic.

Steve Heilig: Thank you Dr. Jackson. The Trust for America’s Health has done some really innovative work in addressing public health issues under the leadership of Shelley Hearne, who is one of CHE’s founding Partners. We are pleased to have Patty Unruh here to tell us about a new report they have on this very topic.

* Fourth Speaker: Patty Unruh, Senior Policy and Communication Advocate, Trust for America's Health

Thank you for the opportunity to participate on this call. The speakers before me have given really interesting presentations on the causes, the factors and the science surrounding obesity. It is a huge problem.

We got started on our obesity work because our state community relations director had gone out to various faith-based partners of ours, including churches, and really polled them, asking for their number one health concerns. They responded quite strongly that their main concern was obesity. So that gave us the cue that, along with all the other signs out there, obesity is really an important issue and something that we should be taking a look at.

So our work is currently centering on a report that is due out next month. The goal of this report is to reframe the debate from largely advocating personal responsibility, we know this is true—it is what you put in to your body and how much you exercise, but it’s more than that: as Dr. Jackson was just talking about the built environment and Dr. Myers was talking about maternal diet influencing obesity. There are many other factors, other than your own personal behavior, and that’s what we’re trying to focus on here. So basically this report is going to look at the government efforts that are underway at the federal level (CDC, NIH, USDA) and also looking at the activities within each of the states. Through this report, we’re planning to set benchmarks so that we can help to evaluate and judge the effectiveness of the many different policies and strategies that are underway in all the states.

Basically the report is going to provide a state-by-state overview of their plans and policies on obesity as well as some state indicators, such as the ERFSS data on obesity rates, diabetes rates, hypertension rates, and how obesity is also related to many other diseases. We’re also going to examine the range of federal agencies and federal programs focusing on obesity. We plan to conclude with some policy recommendations that are being vetted right now internally. The whole hope and purpose is really to try to change the debate from just being that of personal responsibility and to look at the built environment. For example, what is going on in schools? In this report we have about four or five indicators that look at what schools have done in terms of physical education. While many of them are requiring physical education at some point in schools, there also are many exemptions and waivers that entire school districts or even individual students can be excused from physical education. Many of those are reasonable, but some are not. We’re also looking at the state level at health education. Are they teaching children to eat healthy and practice a physically active lifestyle? Of course another important issue is competitive foods. These schools are really cash-strapped. A lot of fund raising is done through the sale of competitive foods, candy bars, etc. We’re also going to look at what schools are doing to restrict competitive foods. Those are the foods that compete with the U.S. Department of Agriculture breakfast and lunch programs.

Those are the types of things that we’re looking at and we hope to try to answer some of the questions that have been raised from the public health system perspective. We need to know how and where to make a change. Hopefully this report will be a first step in answering some of those questions.

The report is now available on the Trust for America’s Health website.

3. Questions and Answer/Discussion

Anthony Robbins, MD, MPA, Professor of Public Health, Department of Family Medicine & Community Health, Tufts University School of Medicine and Chairperson, Board of Directors, Public Health Advocacy Institute: We have been working on legal approaches to the obesity epidemic for a while. We have just completed the Public Health Advocacy Institute's 2nd annual conference on Legal Approaches to the Obesity Epidemic. You can find the preprint of the special section of the Journal of Public Health Policy on the CHE website at http://www.healthandenvironment.org/articles/call_resources/122. We really got started much as Dr. Schettler and Dr. Jackson did, by seeing the public health consequences of this epidemic, and then looking for causes of it that could be changed. It’s very interesting that the notion of individual responsibility is waning to some extent. When we first described this as an epidemic that was environmentally caused, people said, “oh no, it’s just individual decisions about what to eat.” I think we’ve now come to an acceptance of the environmental notion and now it’s important to figure out what are the main contributors. The analogy between the marketing practices of the tobacco industry and that of the food industry has partly come because our group included some veterans of the tobacco wars, although they are quite different in their products and literally there’s no good use for tobacco and everyone needs food. But what we had seen was, with very inexpensive raw materials and produce, that most of the money to be made was in processing food in fancy and convenient packaging and making it more tasty, which is also usually sweeter, saltier and fattier. We have gotten into a situation where the food industry was dependent on selling the American public more food than it needed and the ultimate manifestation was exactly those ten pounds that Dr. Jackson has described. Then the question is are these marketing practices of the food industry the things that could be changed. Some of it the US Department of Agriculture is complicit about, and some of it could be dealt with, in part, by labeling and other approaches that are within the jurisdiction of the Food and Drug Administration. But in general, we don’t have in place a regulatory or legislative regime that is going to change how foods are marketed to the American public.

The most serious area is the kind of marketing to children and if the American public are very clear that children are not competent in the same was as adults, to make their own decisions and so efforts to develop regular use of a product and brand loyalty, early on through pouring rights in schools and other such activities has put the food industry in a position where they face some of the same legal problems that the tobacco industry did in terms of misleading and deceptive advertising.

Burton Danet, Ph.D., Founder, A Better Community For All (ABC4All): We have created a proposal to do a pilot study in the largest high school in San Diego County, California, which is going to present something, I believe, very consonant with what Dr. Jackson has envisioned with regard to community building. We’re going to bring in excellent nutrition. We have two fund-raisers, which are going to provide private sector funding for any school that goes into this particular kind of model for creating a community for a school district. Please visit http://abc4all.net/hfeeabc4all.htm for more details.       

Ngozi Oleru, Ph.D., Environmental Health Chief, Environmental Health Services Division, King County Dept of Public Health: We have, as a department, adopted land use planning and health as a strategic goal. I’m wondering what all is out there as examples that we could use, so we don’t reinvent the wheel? We’re working with our partner agencies at the county, regional and city level, to become involved in their processes as they do some long-range planning for community building and transportation.

Richard Jackson: First, I have been impressed that Richard Fenske’s study, looking at kids eating organic food versus nonorganic food and the differences in their body burdens of pesticides, has not gotten the public’s attention or imagination adequately. Second, California has put in place requirements for physical education in schools up to eighth grade and banning soft drinks in vending machines up to eighth grade. We failed in a bill to get it up to twelfth grade; in fact the bill was vetoed. There is a superintendent of education task force that is laying out a whole series of interventions, which will include provision of quality food in the schools all the way through, and a commitment to school gardens. First Lady Maria Shriver has asserted that every school ought to have a school garden so kids can learn where food comes from and get their hands in the soil, but also produce food for their own kitchens. Los Angeles school district has committed to rebuilding their schools and is very much on course to building both environmentally friendly and energy efficient schools, but also to building within the neighborhoods so kids aren’t being hauled long distances. They are also committed to bringing much more parental engagement. The critical issue is how to get the schools, the teachers, the PTAs and the principles to own this issue. When it comes from the outside it always is a foreign thing, but when it is seen as a way of benefiting attendance and employee and student satisfaction it really goes a long way.

Steve Heilig: In the San Francisco Unified School District we have done this in terms of eliminating some of the riskier foods for obesity and it’s been an interesting experiment, both politically and otherwise.

Sandra Miller Ross, PhD, Health and Habitat: I’m interested in the connection between allergies and obesity and there’s a new product out, titanium dioxide. It is a photo-catalyst, which reduces allergies and illnesses and it sanitizes and deodorizes by oxidizing and breaking down the pollutants. It makes a hydrophilic coat on the outsides and insides of buildings and they’re using it all over Japan and Taiwan. The company can be found at www.greentitan.com. I think this is something that we should consider putting on the school walls and public building walls that reduces the pollution that causes allergies and causes some people to feel like they have to go eat more.

Audrey R. McMahon, Research Committee, Learning Disabilities Association of America: Are endocrine disruptors and the environment, which causes hyperthyroid, etc., not to be considered as environmental issues in connection with obesity?

Pete Myers: To my knowledge, the people who are looking at the various effects on thyroid, from the perspective that you’ve been interested in Audrey, have not been following up on links to obesity.

Ana M. Soto, MD, Professor, Department of Anatomy and Cell Biology, Tufts University School of Medicine: I am the author of one of the studies that showed obesity after in-utero exposure to VPA. VPA also affects the thyroid gland.

Joel R. Seton, MES, Director, Health of People & the Environment (HOPE), Resource Renewal Institute (RRI): I am very heartened by the examples that I’ve been hearing of improvements in the schools and particularly in places like Los Angeles. I’m thinking that in California, the whole ongoing pattern of urban planning of building and development of schools is a very powerful real estate industry and I’m wondering what sort of vision you all have for how to summon the kind of political power necessary to change stated national policies?

Richard Jackson: There have been real incentives for the schools to move further and further out. One is that the land, on which the in-town school sits, has become more valuable. So the Superintendent of Education wants the funding from that land, so they hide under the rubric that they need 30 acres to have a school. Yet anyone that looks at size of school evidence finds that in smaller schools kids perform better, teachers are happier, the kids are happier. We’ve gone from fifty percent of our kids walking to school in about a generation and a half to about seven percent of our kids walking to school. So, I think the message that kids need to walk to school is critical.

We’ve seen, I think, in the last fifteen years, almost a tripling of the use of stimulants (Ritalin) in children. There are lots of reasons for this, and I don’t have the evidence, but this would be a wonderful research area. I have to think that kids having exercise engineered out of their lives may need chemical assistance to keep their activity under control, because we have not allowed the normal exercise ways of doing this. I think the message of exercise and socialization is a strong one. I think the dual use of schools is a strong one. I think the malicious incentives, where if fixing up an old school costs more than seventy percent of the cost of building a brand new one further outside of town, and they don’t calculate in the commuting costs. The rules right now are you go outside of town and build a new one. The leading causes of urban sprawl are new schools and a feeling of security and safety. So it’s very important that public safety officials become involved in this whole issue.

Also, there is folklore that both the blood pressure medications and the anti-depressants add pounds. When I’ve asked technical scientists about this they’ve said, “yes there is evidence that both the beta blockers and the SSRIs are related to increased weight gain.” Which is interesting to think about. These are two things that people need more of, as they exercise less and gain weight. Again we’re in a pernicious cycle rather than a positive one.

Pete Myers: That’s a good point. It’s an excellent example of Ted’s overview, in which he pointed out how many interacting factors are involved in generating this epidemic.

Nora Cody, Executive Director, DES Action U.S.A.: Following up in terms of schools. I have two children in Oakland public schools. As the rest of you know, physical education is minimal, especially for my daughter in elementary school. I’m wondering if you have any advice about how to approach this policy change? The pressure to get the time in to prepare for the standardized tests is so enormous, that to try to carve out more time for P.E. is really difficult.

Richard Jackson: I think in some ways this is another pernicious outcome of no child left behind, where everything is driven to some measured test and the whole contextual quality of the child’s learning experience and healthy body and healthy mind and the rest seems to be ignored as one pushes toward these measurements. Ideally, I think we need to get rid of this very narrow measurement of quality that we’ve put in place. There’s a wonderful group in Davis, the Prevention Institute. They have done the type two diabetes rates and the obesity rates by legislative district in California, both assembly and senate.

Lavinia Weissman, Founder, WorkEcology: I’m wondering if any of you know of research on the correlation of the way we work and the economic stress on the workweek in terms of how that relates to fitness, nutrition and obesity.

Richard Jackson: I’ve been really concerned about how housing policy dictates transportation policy. No one can really afford to live in Marin or Silicon Valley any more. People are commuting an hour and a half out from Modesto, etc. So we have the typical American working the longest hours of any developed country in the world and on top of that an hour and a half of commuting each way, dropping their kids off in the dark and picking them up in the dark. Someone who’s given a lot of thought to this is Kathleen Rest, who was the former deputy director of National Institute for Occupational Safety and Health (NIOSH), who’s now in Boston at the Union of Concerned Scientists. Kathy has given a number of very good talks on the new workplace risks. For a long time we focused on toxicologic and injury risks in the workplace, and of course they’re still important. But now overwork and underpay and overstress, combined with the long commute, is really a recipe for the deluge of antidepressants and other kinds of medications Americans are taking and these all lead to obesity.

Anthony Robbins: It also affects America’s eating patterns. Thirty percent of the meals are now being consumed outside of the home. Convenient processed foods are more common now and these foods are also terribly fattening. Both the busy work schedule and with both parents working, there’s more pressure to consume this kind of food. The other evidence that this is a problem is to look at the social class, the socioeconomic variables and obesity and it is the greatest problem among the poorest population.

Philip R. Lee, MD, Professor Emeritus of Social Medicine, UCSF and the Institute for Health Policy Studies, Stanford University, Program in Human Biology: I just want to go back to Ted’s initial comment about “Where is the Community.” I think we need to conceptualize the problem, rather than biomedically treat it with a pill. A friend of mine described the medical health care system as, “one ill, one pill and one bill.”

There’s an increasing tendency to look at the social determinants of health, then look at the pathways to changes physiologically or biochemically within us and this results in the wrong conceptualization of the problem. If we look at it as community and then look at the schools we will see that community is what will really deal with the problem. Looking at tobacco, when we got away from focusing on helping the individual smoker reduce their habit or not start, and instead started looking at the tobacco industry, we began to make progress.

Unless we look at this thing, and I think the Governor’s summit meeting will be a great opportunity to change the paradigm. We have moved into a consumption paradigm from a community paradigm. We have to make a very big conceptual shift and I think this is a very valuable discussion.

Steve Heilig: I am struck by how the tobacco analogy keeps coming up here. It was just a generation ago it was thought that we couldn’t do anything about it. The smoking rates have been halved in that generation. Obviously there’s still a lot more work to be done. With this kind of work being done, perhaps we can make some inroads. I would like to thank our speakers for joining us today and thank all for our participants for joining us as well.