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CE\TEP. FOR SCIENCE CSPI IN THE PUBLIC INTEP.EST Nutrition Action Healthletter Testimony Michael F. Jacobson, Ph.D. Executive Director, Center for Science in the Public Interest Washington, D.C. May 6, 1993 Senate Special Committee on Aging Hearing on Preventive Health ~/ 1875 Connectrcut Arenue. .1aC- Suite 300. WAshsn,qton. D.C ?0009-5?8 •1_'U?133Z 9110 • F.tt' I3U31 365--19>-1 . E.recutive Director: tlichael ku-obson. Ph.D.

Thank you very much for the opportunity to testify this morning on the important role prevention can play in health-care reform. In all the debate over reducing heatth-care costs, precious little attention has been paid to the savings that would result from preventing health problems or using inexpensive lifestyle changes to cure those problems. Heafth-care legislation without health promotion is like buying a Cadillac without brakes or headlights. A focus on prevention and lifestyle changes will be particularly important in the coming decades as the percentage of people over 60 soars from 11 percent now to 25 percent in 2030. I would like to discuss two vitally important opportunities to improve the public's health and balance the books on health care. One relates to nutrition, the other to alcohol. 1. Nutrition The typical American diet is high in fat, saturated fat, cholesterol, and sodium and low in dietary fiber. That kind of diet greatly increases the risk of numerous diseases, ranging from constipation and obesity to diabetes, hypertension, stroke, heart disease, and several cancers (colon, prostate, breast). All those health problems are especially common among the elderly. Poor nutrition contributes to over 300,000 premature deaths per year from heart disease, stroke, cancer, and diabetes - making diet the second leading contributor to premature death. Those are four of the top seven killers in the United States and account for two thirds of all deaths. Between medical costs and time lost from work, 1

those diseases cost America well over $200 billion annually, according to government and other studies. The Surgeon General, the National Academy of Sciences, and countess private organizations and physicians have concluded that Americans must change their diets, if we are to reduce rates of illness and premature death. If we r vent even a fraction of those illnesses, we could save billions of dollars and tens of thousands of lives. And, in fact, research has shown that the prevalence and severity of those illnesses could be reduced sharply through dietary changes. Prevention of Diseases Millions of Americans could lead richer lives, with far fewer trips to doctors and hospitals, if health agencies vigorously promoted a healthy diet. Unfortunately, local, state, and federal agencies have done precious little in this regard. In addition, current medical practices largely ignore preventive services. Of the $838 billion spent annually on health care, only 3 percent is spent on disease prevention or health promotion. Part of the problem is that most medical schools give short shrift to prevention in general and nutrition in particular. My own father was a victim of this indifference. He developed hypertension when he was about 70 years old. He went to three different doctors over several years. They all prescribed drugs, which ended up causing severe side effects. None of the doctors uttered a word about eating less salt and fat. ~ CD ~ 2 .A

Treatment of Diseases While government and health-care providers fail to promote healthy diets, opportunities and encouragement to eat fatty, salty diets abound. Just think of how many more commercials you see for pizza and bacon double cheeseburgers than for broccoli and whole-wheat bread. It is a lot easier to find a fast-food restaurant than a health-food restaurant. Fast-food outlets are very popular with older Americans, and all too many foods sold there are loaded with fat, cholesterol, and sodium. I have with me a tube with the amount of fat - 21 teaspoons! - that is in a double Whopper, medium order of fries, and milk shake at Burger King. That's more fat than a person should eat in an entire day. (This is for illustrative purposes; other chains offer equally shocking meals.) That imbalance in dietary influences and practices has resulted in epidemics of diet-related diseases that actually begin developing in childhood, but don't become apparent until adulthood or old age. To control the costs of treating chronic diseases, we must rely more on less expensive treatment methods. Research by Omish, Pritikin, and others has demonstrated that heart disease, diabetes, and hypertension can be tr t with diet instead of expensive surgery or drugs. This is particularly important for older Americans, who suffer the greatest rates of diet-related diseases, the most surgery, and the most adverse reactions to drugs. Good nutrition could greatly improve their quality of life. " 3 cA

My father, for instance, switched to a diet very low in salt and fat, threw away his medications, and his blood pressure returned to normal. I am submitting to the committee copies of letters that 22 distinguished medical researchers and ten health and nutrition organizations have sent to President Clinton, urging that nutritional services be included in the benefits package. Insurance Progr_ams Discourage Dietary Treatment Although switching to a healthy diet is cheap and can treat the underlying causes of certain diseases, diet counseling is often not covered by insurance. Lack of reimbursement presents a significant barrier for patients who are otherwise willing to change their lifestyle. Under the current system, consider the options open to someone with serious heart disease. The patient could opt for a program that teaches heart-healthy eating and exercise habits - but he or she would have to pay anywhere from several hundred dollars to a few thousand dollars out of Qocket. In contrast, that patient could have a $43,000 coronary-bypass operation that would be fully covered bv insurance. We spend over $22 illi n annually on bypass surgery and angioplasty alone. A regimen of fresh vegetables and lentil soup could save some of those costs and some of the lives lost on the operating table. Another example: The Massachusetts Dietetic Association describes a 56-year- old woman with diabetes who was taking expense medications. Then she paid $260 for six sessions with a dietitian and was able to discontinue all her drugs and prevent 4

future hospitalizations. That lifestyle change was estimated to save the health-care system an estimated $28,740 over her lifetime. In most cases, private insurance would have readily paid the $28,740, but would not have paid the $260 for nutrition counseling. That simply doesn't make sense. Thus, there is often a strong disincentive to choose the least expensive mode of treatment. The treatment that saves money for the individual patient often adds significant costs to the overall health-care system. Of all the changes being considered as agart of health-care reform oromoting a healthy diet is one that will actually lead to immediate cost savings Recommendations Health-care reform must emphasize Orevention. And by prevention, I mean not just screening and early detection, but measures that actually prevent disease from ever developing. Preventing disease through better nutrition, exercise, and less drinking and smoking makes not only for happier, more productive people, it also holds down costs and frees up resources that would permit universal coverage and generous benefits. Sensible health policies would also provide incentives for tr in illnesses with inexpensive diet-frfestyle approaches. We urge the federal government to: * indude nutrition services in the basic-benefit package of health-care legislation. Dietary approaches would save money in both the long-term (by preventing many cases of chronic disease) and the short-term (by providing ff iv treatment at a fraction of the cost of surgery and drugs); QO ~ ~ 5 ~ a ~

* include in heahh-care legislation a requirement for health-education campaigns in every community. Beyond health-care legislation, the federal govemment should: * provide the public - especially the elderly and low-income segments - with information about the life-saving benefits of diets very low in fat, saturated fat, and sodium. Food stamp recipients should be encouraged strongly to eat healthier diets - and even be given incentives to do so; * require all federal feeding programs - including Meals on Wheels, VA hospitals, civilian and military cafeterias, and school meals - to meet guidelines for fat, sodium, and fiber; * require nursing homes, hospitals, and other intitutions that receive Medicare reimbursement to serve meals that are low in fat and salt and high in dietary fiber; * publish an annual Surgeon General's Report on Diet and Health; and * conduct a review of dietary treatments of disease to compare their utility and costs to other approaches. AI h I The second issue I would like to discuss is alcohol. Unwise consumption of beer, wine, and liquor results in 100,000 deaths and at least $100 billion in economic costs annually. 6

According to the American Medical Association, 25 to 40 percent of all Americans in general hospital beds are there for treatment of complications of alcoholism. The costs incfude detoxification, psychotherapy, and treatment of diseases of almost every system of the body. Emergency room physicians also routinely report that at least 25 percent of their caseload is alcohol-related. That business comes in the form of drinking-driving crashes, alcohol poisonings, criminal violence, stabbings, gunshot wounds, falls, bums, drownings, child and spouse abuse, hypothermia, rapes, as well as alcohol/drug overdoses. Over in the intensive care units (ICU), over $6 billion is spent each year on alcohol-related health problems. There's something wrong when we spend about as much on alcohol-related ICU treatment as we spend on home health care. Although rates of alcohol problems are lower among the elderly than younger people, the director of the National Institute on Alcohol Abuse and Alcoholism told this committee a year ago that alcohol problems are often masked by other health problems and that NIAAA expected problems to increase in the coming years. Older people who drink heavily or unwisely are at an especially high risk of slips and falls, burns, and malnutrition. Alcohol also interferes with the action of numerous prescription drugs, rendering them ineffective or even dangerous. Alcohol-drug interactions pose a special problem for older Americans, because they (especially women) use more medications than anyone else. 7

Preventing alcohol problems - whether in teens or senior citizens - would save money or allow that money to pay for unavoidable medical costs and extend health coverage to the uninsured. Senators Glenn, Simon, Thurmond, and others are sponsoring legislation that would publicize the risks related to alcohol - including mixing of medications with drinking - by requiring health information in alcohol advertisements. Passage of that legislation would help take some of the glamour out of alcohol advertising. We need similar legislation to strengthen existing warnings on labels. Other means of preventing alcohol problems include such measures as lowering the level of alcohol permitted in blood in drunk-driving offenses; penalizing the sellers of alcoholic beverages to youth, as well as penalizing the buyers; cleaning up advertising by eliminating all references to sports, sex, and social success. Educational campaigns in schools and the media should make it as appealing to children to abstain from alcohol as beer ads make it appealing to drink. Raise Alcohol Taxes to Reduce Health Problems But the single most effective way to reduce alcohol problems is to raise prices through higher excise taxes. Surgeon General Koop's 1988 Workshop on Drunk Driving recommended that taxes be raised to correct for the inflation that has occurred since 1970. The workshop also recognized that beer and wine have long been taxed at much lower rates than hard liquor. It recommended equalizing the rates. Gb ~ ~ ~ C.1 8 O

Raising taxes along the lines suggested by Dr. Koop,s workshop would cut alcohol consumption by more than 10 percent, thereby reducing costs to our economy by about $10 billion. In addition, raising taxes would generate about $23 billion annually. Those funds could be used to help provide health care to the millions of people who lack health insurance or finance sophisticated alcohol education campaigns in schools and the media The National Alcohol Tax Coalition, whose members include such groups as the American Academy of Pediatrics, National PTA, American Association of Retired Persons, and the American Nurses Association, has urged Congress and the President to raise alcohol taxes by a dime a drink now - which would reduce alcohol problems by about 5 percent and raise $10 billion in new revenues per year. The excise tax rates should be increased further over the next several years. Recent polls show broad public support - between 75 and 87 percent - for higher alcohol taxes. In condusion, let me reiterate that health-care reform should include a strong dose of health promotion and nutrition. Doing so would lead to a healthier nation and would free up funds to cover the uninsured. Boosting alcohol taxes would simultaneously lower health costs and provide substantial new revenues. Thank you very much for this opportunity to testify. ~ ~ ~ ~ CD ~ 9 1+