Yeager: Here to talk about the growing prevalence of chronic care are three guests. Bill Applegate, he's executive director of the Iowa Chronic Care Consortium. Kathy Leggett is director of the Center for Advocacy and Outreach at blank Children's Hospital in Des Moines. And Helen Eddy is assistant vice president of health and wellness for Hy-Vee, Inc. Thank you all for being here. Appreciate you having this discussion. Bill, I want to start with you. Will you give us a little bit of a - what we call a perspective of this problem? We talk about chronic conditions, is this something that's increased over the years?
Applegate: I think we've seen big increases in it, and it isn't just because we detect better. Since 1990, which isn't so long ago, we've had about 127-percent increase in obesity in this country and we have about - pretty close to 120-percent increase in diabetes. At the same time, we've had a reduction in what we would call infectious diseases of about 50 percent. So we're looking at health care now, and we're seeing a lot greater prevalence of chronic conditions that we are of what we call infectious diseases, which we've thought so much health care was about in the past.
Yeager: All right. Well, let's look -- that's on the -- more on the adult side. Let's now go out on the children's side. Is it the same statistics for children?
Leggett: Yeah, I don't know the statistics but it would be similar. We've just seen huge increases. I mean I think everybody has seen that in childhood obesity, a lot of attention paid to that in the last several years. And diabetes too, we're just seeing more and more children who are affected by that.
Yeager: From a consumer side when you're listening to this, does this mirror with what Hy-Vee has looked at, but does this -- also with consumer sectors and what you're seeing, is this kind of what you're seeing as well.
Eddy: Yes, I think we see that our consumers are very interested in how to improve their health. I think that they're confused, though, sometimes on how exactly do that. So we see a lot of interest out there in nutrition, in how do I lose weight, how do I help my children, how do I provide healthy snacks for my children, how do I really, really do this. We see the same challenges within our own employee population of growing obesity and really kind of the conditions that come right along with that.
Yeager: All right. You touched a little bit about children. But how do you assess anything that certainly children are at risk for any of these chronic conditions?
Leggett: How do you assess it?
Leggett: Well, certainly their physician plays a really important role in that, as children do have regular medical exams, you know, a shorter time frame when they're younger and then hopefully every year after that. So I would say that their physician really is the key person in that. But as far as what we've done, we've tried to take a little more of a preventive stance recently from our outreach program, not so much to -- or actually to really try and increase awareness about some of the risk factors that really do affect your overall health and certainly will affect you as you get older through a health risk assessment that we have implemented for children.
Yeager: More of an education type thing?
Leggett: Yes, awareness and education ideally. A lot of things -- I think there are a lot of things that we can do with it in the future but, of course, resources are always an issue. And really there are less resources a lot of times that are spent on prevention than treatment in many cases. So hopefully that will change, but our initial stance with this was, similar to what was mentioned in that second video, is how they want the children to realize that they have some responsibility in the care of their diabetes. We want children to realize that they have some responsibility in their health and really -- and also realize what are those things that actually affect it. There are multiple things that affect their health.
Yeager: And that's -- we were talking a little bit about type I diabetes in there, but there are also some type ii things. But, bill, I think I trumped what you were going to say. Sorry.
Applegate: Well, just the idea that probably what we need -- and this speaks to what Helen has said and Kathy -- and that is we really probably need a lot higher health literacy in this country. And the reason we do is because all of the things we're talking about in health care reform now, that is payment reform and everything, nothing has the impact that if we got everybody to reclaim responsibility for their own health. I mean everything else would be small potatoes compared to that. So using health risk assessments. The idea -- and Hy-Vee is doing a number of things in this area too -- is to identify people that are at risk for chronic conditions that haven't crashed and burned or have the diagnosis, because then it becomes more difficult to manage that. So the idea is to improve awareness, improve our knowledge of what our conditions and our risks are, and then aid people, as Helen talks about, in exercise things, in nutrition things, and in general changing health behaviors.
Yeager: So how do you identify or who is that group that identifies someone who might be at risk, if it is something that's hereditary or if it is I’ve got a family history, I should know these things or, you know what, I work in this environment, I might have a problem. Who does that?
Applegate: Quickly I’ll just say that a lot of people have been looking at chronic disease and they say that the environmental factors probably contribute maybe as much as 4 to 5 percent. Heredity contributes, say, 10 percent. The rest really turns on mostly behaviors. So it really has to do with things like smoking. It has to do with diet. We've had great increases in the number of calories in the last, say, three or four decades and a real reduction in the amount of exercise that we have.
Yeager: Well, you know, there's lots of people who know that sounds in paper. They read story after story, whether it's in North Carolina, where they want to have what they call a fat fee. The old saying goes, you can lead a horse to water, you can't make him drink. How do you make anything happen?
Eddy: Well, I think it starts with awareness. For us with our employees, it's starting down on a path of identifying their risk, putting them through a health risk appraisal and a series of biometric screenings that helps identify, much like bill said, those people that at risk, and then giving them really some education and options and some concrete things they can do. But I think sometimes when I look through the literature and things that are out there, it sometimes sounds harder than it is. Really, you can really address most of the obesity issues in this country if we reduce our caloric intake by a hundred calories a day. That's trading down from that 20 ounce regular soda to a diet soda. It's trading from whole milk to skim milk. So I like to say that it's really -- small changes can really bring about large health benefits.
Yeager: And you talked a little bit about, I think you said the word employer to start with. That's something Hy-Vee does with its employees. So would you envision that one of the best -- because if the company provides health insurance for their employees, they're going to want them to be as healthy as possible. So maybe employers need to pick up some slack and follow Hy-Vee’s lead?
Eddy: Well, they already are. We have lots of interest out there among other employer groups that are seeing what we're doing at Hy-Vee and seeing what's happening in other organizations. The wellness council of Iowa is a great resource here in this state that works with many, many employer groups. And I guess, I shouldn't say pick up the slack, but I think get on the bandwagon, and I think it's happening. And there are a lot of resources out there for those companies, really not always at a huge cost to them that can really help bring around some great savings to them and great health to their employees.
Yeager: So it's been some incentives or does -- do other companies need incentives, Bill?
Applegate: Well, I think incentives are good. The idea is if you're an employer, what you'd like to do is you'd like not to have 15 or 20 percent of your employees participate. You'd like to have 60 or 70 or 80 or 90 percent, and successful organizations are getting those high numbers. To do that, though, a lot of times there is -- there is -- how do I want to say it? It gets better. The percentage will get better when there are some incentives to do that. I think that right now in Iowa, we're getting more positive incentives than negative incentives. So we'd rather beat people with a carrot than use a stick, I think or something like that.
Yeager: Good choice of words with carrot. I like that, yes.
Applegate: But I think we're getting -- I think positive incentives really work most effective with employers in getting people to participate in the assessments and things like that. And Helen said something really great. That is if you reduce calories by a hundred a day and you walk two miles every other day, you'll just be amazing the kind of impact it will have on someone's health.
Yeager: Kathy, what about when it comes to children? Will they be the leaders in their home? I mean children have a big impact on their parents. Are they someone that can get to mom or dad and say, you know what, we're going to have water and milk tonight instead of pop for supper?
Leggett: I think it can happen. I think it absolutely can happen. But does it always? No, probably not. Because more than likely like my kids, they're, like, can we have pop. And I’m like, no, we don't have pop. They still want it. But I think that can happen. But I think you hit on a key thing as well. You know, while we're working with children, we have to engage their parents, their caregivers, and their families because, you know, at times they have a lot of control over what the situation is. So I think they're just a very important part. One thing I was mentioning -- or thinking when you were talking is talking about looking for those people at risk. And I think with children, we really want to focus on all of them, because we are looking for a preventive aspect versus, you know, wait until we see those symptoms. And that's why our catch problem is kind of doing -- we're doing that in mini after school programs. And the whole goal is to increase their activity and then talk a lot about nutrition. They have nutrition plans in eight times a year, the kids make a healthy snack, and that's what they eat after school. So it's just trying to integrate that more into their life.
Yeager: Have schools been -- we use the word incentives. Have they had any incentives to do any of these types of programs?
Leggett: Not that I’m aware of. I don't want to say. But I do know that there are schools that are working hard to look at those types of things. For instance, at one school I’m aware of just got accepted into the P.E. For Life program, which is really looking at keeping those things in the context of everything else that the kids have to do. So I do think there are schools that are working at that. As far as incentives, I’m not sure.
Yeager: Well, Bill, I need to keep putting on you here with provider incentives. Do we know of any or know what it's going to take for providers to lead the way on incentives or what incentives would help them?
Applegate: Well I think that there are some clues out there. We reimburse, by the way, physicians and other providers an awful lot on the treatment of sickness and illness as opposed to prevention. So one of the challenges we have now and why are we paying so much attention to chronic conditions. We're paying so much attention because we're spending so much money on them. And we need to help people self-manage chronic conditions. We need to do interventions that will reduce their hospitalizations. That's what really costs a lot of money. But for providers, it seems to me that we need to support things that build capacity for the medical home. That means that they'll -- that providers and physicians and doctors will take care of individuals on a preventative way prior to the time that they crash and burn. So there are some things and in health care reform, we're looking at the idea of paying for outcomes. So if you go to a physician and you have a chronic condition and you manage that chronic condition with the help of your physician, then the reimbursement would accrue to that physician based on your outcome, not just on the number of times that you visit the physician. So I think there are a number of things that have potential for providing some incentives, and certainly some incentives are needed.
Yeager: We're always in the middle, it seems, of writing policy. But is there anything more that needs to be done on a state or federal level to help what you're talking about?
Applegate: I think so. I think health care reform is -- we've heard a lot about health care reform, mostly talking about insurance reform. I think we're going to see in subsequent parts of health care reform kind of system reform, a focus on outcomes and a focus on prevention that we really haven't seen in the first part of the house bill.
Yeager: All right, Helen, you've got a program at Hy-Vee that helps a consumer when they go through, and it's kind of some of the labeling when it comes in. I think you call that NuVal?
Eddy: The NuVal system, yes.
Yeager: What has that been -- is that helping a consumer make a better choice when they're going shopping, and should others follow your lead?
Eddy: Well, we would hope that really all supermarkets and food providers would adopt the NuVal system. It is really an easy way to weed out kind of the noise that's out there in nutritional labeling. It's really a scientific -- it has not been funded by the manufacturers. It actually came out of a group of scientists and nutritionists led by Dr. David Katz from Yale University that have put together an algorithm that analyzes over 30 ingredients in foods and really ranks it on a score, a hundred being the best and one to zero being the worst. And it allows that consumer easily to identify within a section and looking at that label what might be a better food choice for me. So it makes that shopping experience easier, and we talk about it. It's not about eating all hundreds and avoiding only zeros. But it's about trading up, can I trade up. A great example of it -- I take my own kids into the aisles, talking about engaging children. It's easy. Kids can learn this system. Looking at the peanut butter section, you know, you'd read a label and think that low-fat peanut butter, that ought to be better for me than regular peanut butter. But it's not because when they take out the fat, they add in more sugar and they add in more salt. So that is actually a less healthy choice. So it really is an easy solution for consumers and families to be able to make those healthy choices that, really, they want to make. It's just hard to do so sometimes.
Applegate: Tell them where you find that in the aisles because that's important.
Eddy: It's on all of our tags and on that shelf label. Right next to the price is a little NuVal label, two little hexagons put together and the score is right on there.
Yeager: And have customers or consumers been actually paying attention to where they're buying more of a higher number and less of a lower number?
Eddy: Yes, especially in some of the first categories that we scored in some of the cereal sections. What we have seen is after the NuVal system was implemented, we've done some customer education and employee education on that. We do actually see that the shopping trends have changed. The consumers are moving towards the healthier items with the higher NuVal score.
Yeager: But it's not all food related. It's a big deal about it, Kathy, but there's other products, factors: sleep, stress. Talk about those too.
Leggett: Well, just -- you know, as it is like with many things, it's a comprehensive picture. And we can talk about just nutrition or exercise, but there are some studies linking some of the others, you know, sleep especially, to obesity and things like that. I think we don't know everything yet, and especially in regard to children. And one thing I do want to mention that I think is very exciting that people may be aware of is the national children's study that is started -- they started enrolling kids this spring. And Polk County will be actually be a site in a couple of years. And that's looking at kids from birth -- a hundred thousand children from birth to age 21 to really look at a lot of environmental and genetic factors in regard to health because a lot of times children are not the first to be researched, let's say. So I think we have a lot to learn. But sleep, as you mentioned, and I think, again, with just health in general and some of these other issues is a huge issue we have finding with children. It's one of the things on our health risk assessment that has come up as the highest risk for moderate and high risk is children not getting enough sleep. Along with just their health -- their nutrition, risk for obesity, but we also look at behavior issues, their ability to learn in school. All of those things are affected, and I think it's just an easy one that we as parents just kind of don't think about that much. But if you think about it for us, our days are harder and worse and things are more challenging when we're really tired and it is --
Applegate: Try to get more sleep.
Leggett: Exactly. And it is the same for our children. And I think, again, that's something that we can just raise awareness of, you know, start talking about more, putting on the priority list, and that would be something that we could change.
Yeager: Here's a question for you to chew on here in the final three minutes. What happens if we don't do anything?
Applegate: Well, one of the things that happens is that our population is growing older. What we have found -- and a lot of people have come to the conclusion that we -- if we don't change Medicare, for example, that will be our biggest Achilles heel as a nation, because of the growth and the increase in cost and that. So if we don't intervene some way to reduce the cost and kind of turn around some of this trend, it's going to be terribly devastating financially and, as well, hard on a lot of people, because there are lots of element to this. People's quality of life improves when they don't have chronic diseases as well as their costs being reduced.
Yeager: Maybe we need to get back into that fitness craze. Has that gone away?
Eddy: I think it's harder for people to do. I don't know, I’m a single mom with two kids, and it's hard to squeeze it in unless I really kind of pencil it in almost as an appointment on my calendar. And I don't think I’m unique in that. But again, I don't think that health and wellness has to be hard. It's extra steps: parking a little farther away from that front door; a little farther away from the front of your Hy-Vee store and walking in; whatever it takes to increase the activity. I think many of the programs that Kathy mentioned are great. P.E. For Life, we are a partner in that activity as well because we see that it's important to teach kids healthy habits early on. And it's keep moving and eat healthy.
Yeager: All right. You get one minute to answer the final question, Kathy. Will our children follow our example, or will they make their own new path and be much healthier? I'm speaking for myself, not for the rest of you.
Leggett: Yeah, if I had a crystal ball, I’d love to know the answer to that. But I’m always going to be on the hopeful side and hope that -- like, other generations have kind of made their own path, and I sure hope that our children will take this path of taking responsibility and just making health part of their lifestyle and learn from some of the things that we're experiencing now.Yeager: If not we're going to have to continue to have this program over and over again because we're going to have all sorts of problems to deal with. That is Kathy Leggett. She's with Blank Hospital. Also with us on this discussion today was Helen Eddy of Hy-Vee Incorporated. And Bill Applegate, he's with the Iowa Chronic Care Consortium. I appreciate you all for coming in to discuss this issue. It always continues.