CIBER Healthy Community Model

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CIBER Healthy Community Model

Executive Summary Part of a master strategy for creating jobs and improving Tennessee’s worst national rankings – in turn generate even more jobs – due to healthier citizens lower healthcare costs, lower taxes (govt productivity), and lower crime and fraud (leads to lower taxes and lower car insurance costs, lower drug abuse (health problem). Win Win Win for everyone – you need a strategy and well executed strategy – not government - outsourced Community Health Service – built in analytics (team with healthy Communities Institute in California). Use GIS and local phones to direct people to fruits and vegetables and encourage their lifestyles Every county in America now has an annual report card on the healthy of their county – America’s County Health Rankings Used by companies as tie breakers on where to locate business Tennessee vs North Carolina State ranking by America’s Health Rankings Modules for coordinated medical homes – primary care physicians Modules for preventative health Modules for senior health Modules for childrens health and WIC integration Outreach is Key (churches Janice Johnson) Education is key Screenings are key Health Risk Assessments are key Easier affordable access to healthy food is key (fruits and vegetables) Easy affordable access to exercise is key (treadmills free to those committed). Why getFit Tennessee is not enough to bring down Tennessee’s #2 ranking as the most obese state in America Focus on celebrities and token community “events” walk across Tennessee – great for publicity for Health Dept and Governor (like Green stuff) but does nothing to motivate individual that needs help – same with the Tenn Website health tracker – not for low income low educated which is where the most risk is NFIB should be included to help small biz with health issues Nashville Community Health Improvement Model R.Taylor 01-15-10

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Small businesses and unemployed or self employed are left out – no money for fancy health plans or gyms or expensive fruits and vegetables – we can make a difference here – most have TV’s and cell phones – broadband exercise classes on demand – watch TV and use treadmill Give coupons (travel for losing weight and keeping it off) = QTN travel cards $99 cards for vacation to show off the weight you lost or walk on tours where you could not do so before. In the 20th annual America’s Health Rankings study, Tennessee ranked 44th among states in overall health, up four spots from 2008. The report, by the United Health Foundation, the American Public Health Association and Partnership for Prevention, highlighted the need to change “unhealthy behaviors that contribute to preventable, chronic diseases as the key to improving the nation’s health.” Tennessee excelled in a number of areas reported. The prevalence of binge drinking in Tennessee is the third lowest in the nation at 9.8 percent. Tennessee is also the fourth highest state in immunization coverage with 83 percent of children ages 19 to 35 months receiving complete immunizations. Smoking and obesity are still challenges for the state, although Tennessee's rates are consistent with national numbers. The state's smoker rate is high, but is consistently decreasing. Since 1990, the prevalence of smoking decreased from 30.8 percent to 23.1 percent of the population, according to the report. The opposite has occurred with obesity. In the past ten years, the prevalence of obesity increased from 19.2 percent to 31.2 percent of Tennessee's population, according to the report. Nearly one third of the population of Tennessee is obese, earning the state the 47th rank in the country, the same ranking as 2008. However, with the help of programs such as Get Fit Tennessee, the prevalence of obesity is expected decrease in the years to come. Vermont was named the healthiest state, followed by Utah (2) and Massachusetts (3). Mississippi was named the least healthy state, with Oklahoma (49) and Louisiana (48) next in line. The annual America’s Health Rankings reports have tracked state-by-state statistics for 20 years. United Health Foundation was established by UnitedHealth Group (NYSE: UNH) in 1993 as a nonprofit private foundation. The American Public Health Association has been working to improve public health since 1872, focusing on community-based health promotion and disease prevention. The Partnership for Prevention is a membership group linking businesses, nonprofits and government agencies to prevent disease and improve Americans’ health. Get Fit Tennessee urges everyone in the state to utilize the free health and fitness tools available here on GetFitTN.com to benefit their health.

Great website to model – w.ediets.com The statistics paint a grim picture: Tennessee is 48th for children's overall health, has among the highest rates of infant mortality and is ranked in the top 10 for teen deaths. About 17 percent of the state's teens are obese, with many more at risk. 2/26/10

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Nashville Opportunity

Former Nashville CIO – Richard McKinley X is part of Microsoft Government Mary Miller Newton still at City 09-06-1009-06-10 Michael Galo Contact Info Update | Aug 27, 2010 Company Microsoft Corporation Job Title Technical Account Manager Work Address 2555 Meridian Blvd, Suite... Work Email [email protected]... Updated company Principal Consultant, The Consultant Workshop (20102010) Business leaders want to get things done. TCW uses smart planning, clear communications, and daily execution to get business IT projects ... more> done. New company Technical Account Manager

Partners Civic Health and CareScope Healthy Teacher Plumgood Founder in Nashville – now investor – distribution model to key delivery points Organic local farms and farmers markets – Amish model Myhealthmaster.com – Blender $200 healthy smoothies Green vegetables and fruits blended – disguise healthy food with tasty food – blend it together – lettuce, spinach, celery, strawberries, bananas, apples, blueberries, Edlets.com Learn more about meal delivery Healthy delicious meals delivered to your door Recommended for maximum weight-loss fast! Nashville Community Health Improvement Model R.Taylor 01-15-10

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No calorie counting, no cooking, no dishes Over 100 meals freshly prepared by our chefs Easy to follow, easy to stay disciplined See How Meal Delivery Works Buy up used treadmills (ebay and Craigs’s list) and loan them out – keep them as long as they are losing weight – high school students and unemployed repair and renovate the threadmills – lots of used parts in a school district inventory Build green houses with solar panels and back up stove with refuse and wood burning in really cold days – high school students build them and unemployed Online counselors and health coaches – unemployed

Mayor Dean has a vision of Nashville as a green city = and now as a blue city – to build an environment that promotes healthy well being. Well being defined as Gallup and Healthways Well Being Index Every county in America will get a health scorecard in February 2010 by CDC Green city = promotes sustainable use of natural resources around us. Key partners Eric Satz Plumgood Foods Founder JC Bowman and Angel Food Ministries Organic Farms in Nashville area CIBER = WIC and CDC connections – grant funding Mike Smerling and Jim Amos Jr. Tasti d Lite A Blue Ocean Strategy for Creating Blue Zones in America Venture Capital Proposal for Nashville Creating Jobs and Reducing Costs by Creating Healthier Citizens in Nashville

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Nutrition vs Exercise – impact analysis ESRI – mapping for food distribution and farmers market s see Research GIS file Data Futures Lunch Box

How it will work

Community Health Model for Nashville Draft RGT – 02-16-10

This document outlines a proposed strategy for reducing indigent care costs and improving the overall health of Nashville citizens that could serve as a national model. This strategy consists of four parts: 1. Reduce Nashville Indigent Care Costs One of Mayor Dean's top priorities for 2010 is to find a way to reduce indigent care costs which in 2008 cost the city approximately $66 million dollars. In 2009, the City hired John Snow Inc. to develop recommendations to reduce costs. CIBER and Data Futures presented the CareScope model to John Snow Inc. as part of this study. Based on the documented CareScope assisted savings in Minneapolis/St. Paul and Escambia County, we believe the use of the CareScope model could save Nashville up to $5 million a year in indigent care costs (after a $1.5 million investment (the net gain would be $3.5 million for Nashville). The non profit Bridges to Care and the Nashville Health Dept operate the CareScope system on an ongoing basis to generate annual savings of $ 5 million (which in turn could be used to fund the other 3 proposals below). 2. Improve Health Outcomes In Nashville At the Health and Well-Being: Keys to Transformation Conference in Nashville on November 2, Mayor Dean said he would like to see Nashville become a Blue Zone City (Healthy City). Newt Gingrich said his Center for Health Transformation is looking for a city that would be willing to become a national model city for improving community health. To accomplish this goal, CIBER has developed a high level plan based on successful models in other cities that could be implemented in Nashville. This plan calls for the State of Tennessee Health Planning, the Health Info Partnership of Tennessee, Vanderbilt University, Meharry Medical College, CIBER, Bridges to Care, Metro Nashville, the Nashville Area Chamber of Commerce, the Nashville Healthcare Council, and other key Nashville based private companies (Healthways and others) to develop and implement this proposed community health improvement system. This system would use the Gallup/Healthways Well Being Index and/or the upcoming CDC Nationwide County Health Rankings report (out in February 2010) as the benchmark to measure progress (the Center for Health Transformation) loves benchmarks and

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progress reports). We could then utilize an analytics solution (Microsoft and SAS based) to provide analytical reports). The Metropolitan Nashville Dept of Health and Healthways would assist in the analytical solution. This proposed solution could be paid for with grant funds from the CDC (part of their Healthy America 2020 program (CIBER has a close relationship with the CDC), cost savings from the Indigent Care Solution described above (take $1.5 million from the $3.5 million in savings), and/or money from Newt's Center for Health Transformation and possibly the State of Tennessee. In addition, the participating private companies could offer their services at cost or for free. 3. Implement a new health information exchange in Nashville that would capture the data needed for managing the health improvement program (item # 2 above) and to facilitate the sharing of medical data to improve the quality of healthcare and reduce costs. The Nashville based Middle Tennessee eHealth Connect RHIO has been created to implement a regional health information exchange network in the greater Nashville area. This HIE solution could be used to help coordinate the collection and analysis of data for community health. 4. Implement a community wellness outreach system and portal for information on health programs in the Nashville area. Reach out to increase Medicaid well child screenings and immunizations via a portal and 311/211 service (CareScope extension). This would include a portal for seniors and parents of K-12 children. Content could be provided by Nashville based Health Teacher. This could also include access to a personal health record for citizens that would be updated by the Nashville HIE. An analytics solution could also be included from Healthways, Meharry Medical College, and the Nashville Metro Health Department. How this Proposed Solution Will Generate new jobs for Nashville area companies. Implementing the four proposed solutions above using technology solutions from mostly Nashville based companies would help generate new high tech jobs for the Nashville area. It would also help attract new small businesses where their healthcare costs would be less than in other Southern cities. In addition, the exportation of the Nashville Community Health solution could generate additional jobs as the Nashville based companies the sell and implement their respective software/services to other communities in America and the world. The planned Nashville based HealthCare Trade Marts would be a great place to advertise Nashville’s Community Health Solution to the world. In summary, the proposed Nashville Community Health solution could: 1. Save the City of Nashville millions of dollars in reduced indigent care costs -freeing dollars that could be reinvested for improving the overall community health which will over time further reduce indigent care costs. 2. Significantly improve the health of Nashvillians - in turn reducing healthcare costs for area employers and making Nashville a more attractive city in which to base a business

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(e.g. to help counter the negative image of Tennessee's current health outcomes ranking of 45th in America). 3. Generate new healthcare IT jobs for Nashville based companies which in turn would increase tax revenue for the City of Nashville and help attract more healthcare companies to potentially locate in Nashville which in turn would help generate more health related conferences for the new Nashville Convention Center which would again generate more revenue for Nashville (visitor dollars). GetFit Tennessee Model

ww.getfittn.com/ GetFitTN is a statewide awareness program developed by Governor Phil Bredesen to address the rising epidemic of Type 2 diabetes and risk factors that lead to diabetes, like obesity. This initiative is aimed at educating both adults and children that Type 2 diabetes can be delayed or even prevented with modest lifestyle changes like increasing physical activity and a healthier diet.

How do I join Get Fit Tennessee?

This is your Get Fit Tennessee! Everyone can log onto our Web site and officially become a member of Team Tennessee by committing to make healthy food choices and exercise daily. We're here to encourage you to plan creative community events promoting health and fitness in your hometown, school, or organization and support your efforts. The Get Fit Tennessee Web site is your resource to help you with ideas, answer questions about nutrition and fitness, and to promote your events. We're here to rally Tennesseans to think about moving more and eating healthier. You can post your events on www.getfittn.com where it says submit your event. You can sign up to become a Team Tennessee member by clicking on submit your organization. And you can use the Get Fit Tennessee logo to create your own t-shirts, banners or promotional items for your events. Remember, this if your Get Fit Tennessee! We're excited to see what you can do with it!

Can Get Fit Tennessee come to my event? What will you do at the event?

The Get Fit Tennessee Team is based out of the Commissioner of Health's office in Nashville, with Team members spread out across the state in each Health Department. The Team makes several stops each month across the state to help promote events involving healthy living and spread the news about Get Fit Tennessee. You can see where we're headed next on the calendar page, where you see the Get Fit symbol. If we're available, we'll make every effort to attend events that involve health promotion. We tailor our plans for each stop based on the each event. We're happy to discuss options with you once a time and date of your event has been confirmed and we've agreed to attend. If you think Get Fit Tennessee would be a valuable addition to your event, please post your event on the calendar and send us an email.

Can Eddie George come to my event?

In our inaugural year, Eddie George was very instrumental in helping spread the word about Get Fit Tennessee. However, due to his busy schedule, Get Fit Tennessee is no longer booking events with Eddie George. He remains our number one supporter and a member of Team Tennessee!

Can a Get Fit representative speak at my event?

Please post your event on our Web site and send us an email with the details. Several members of the Get Fit Tennessee Team are available to speak at events involving health, nutrition or fitness.

How can I work for Get Fit Tennessee?

Get Fit Tennessee is Governor Bredesen's program, led by Commissioner of Health, Susan Cooper, M.S.N., R.N. Get Fit Tennessee is fully staffed and operated by the Department of Health, and is not currently hiring employees. Volunteer opportunities are available. If you are interested in volunteering at Get Fit events across the state, please send us an email with your resume, background, and availability. A brief screening process is required.

How do I apply to receive a grant from Get Fit Tennessee?

At this time, Get Fit Tennessee does not have funding to offer grant assistance. Please check the Department of Health's Web site, where you will find a link on the home page to any available funding opportunities, or click here: http://health.state.tn.us/vendors.htm.

How can I get in shape?

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This Web site is full of useful information to help you get started on your journey to better health. Our new, interactive Fitness Tracker allows you to develop health and fitness goals and track your progress. You can even start a competition and challenge your friends or co-workers to Get Fit! If you have a specific question about diet or exercise, please visit our "Ask an Expert" section, which will be reviewed and answered by a trained professional from the Get Fit Tennessee Team.

What is Team Tennessee?

Team Tennessee is a group of Tennesseans committed to living a healthy lifestyle through regular exercise, healthy eating, avoiding tobacco and risky alcohol use. By joining Team Tennessee, you are pledging to help yourself and your community Get Fit!

On the Fitness Tracker, I am trying to set up a personal fitness goal, but I don't see my fitness activity listed. What do I do? If you don't see your fitness activity listed, please choose any activity or other. If you choose any activity you will be given the option to measure times per week you perform that activity. If you choose other activity, you will be given the option to measure minutes per week you perform the activity.

I am having trouble getting in to the Fitness Tracker. I registered and received my confirmation link. I clicked on the link to activate my account, but it keeps telling me my account is not active and I need to re-click the activate my account link. I've done this already, several times, and I waited as long as it said. What do I do? If you continue receiving an error message or the Fitness Tracker site continues to ask you to activate your account or retry the link, please follow these steps: Go to tools (just below your internet browser) Go to internet options Click browsing history Click delete all Close the Web site and reopen. This should solve the problem.

The Department of Health urges Tennessee smokers to take part in this year’s Great American Smokeout on November 19, 2009. The goal of this annual health observance is to encourage smokers to quit for one day in the hope they may quit for good. In Tennessee, tobacco users can call the Tennessee Tobacco QuitLine free of charge at1-800-QUIT-NOW or 1-800-7848669 1-800-784-8669 to set a plan for how to quit. “Tennesseans who want to start the process of quitting smoking have a powerful tool available to help them in the QuitLine,” said Health Commissioner Susan R. Cooper, MSN, RN. “Research shows that smokers who have a cessation plan and a support system have a much better chance of success with their quit attempt.” The Tennessee Tobacco QuitLine offers personalized support for Tennessee residents who want to quit smoking by connecting them with trained coaches to guide them through the quitting process. Callers will receive ongoing professional coaching via individually scheduled calls with a quit coach personally assigned to them. This convenient and confidential service is free and available to Tennessee residents in both English and Spanish. The service is also available for the deaf and hard-of-hearing at TTY 1-877-559-3816 1-877-559-3816 . Since the launch of the Tennessee Tobacco QuitLine in August 2006, more than 33,000 Tennesseans have called the service. More than 10,800 callers completed the intake process and

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were assigned to a quit coach, and more than 7,450 people have enrolled in the "iCanQuit" tobacco cessation program. QuitLine callers have complimentary access to relapse prevention techniques, printed resource materials, information on nicotine replacement therapies and other services to aid in the quitting process. Smoking cessation services are also available at Tennessee’s county health department clinics. All patients are screened for tobacco use and asked if they are interested in quitting. Those who want to quit are evaluated by medical professionals to determine the best course of treatment to help them stop smoking. These services are offered on a sliding fee scale based on income. Smoking is responsible for almost one in five deaths in the United States, and according to the Centers for Disease Control and Prevention, smoking accounts for approximately 9,400 deaths in Tennessee every year, nearly half of which are due to lung cancer. Secondhand smoke is another serious problem in Tennessee. An estimated 1,730 Tennesseans die every year due to exposure to secondhand smoke. The healing process begins almost immediately after quitting smoking. Within 20 minutes of giving up tobacco, elevated heart rate and blood pressure decrease; in 12 hours, the carbon monoxide level in your blood drops to normal; within two weeks to three months, circulation improves and lung function increases; and in one year after quitting, the risk of coronary heart disease is cut in half. The Tennessee Tobacco QuitLine (1-800-QUIT-NOW 1-800-QUIT-NOW or 1-800-7848669 1-800-784-8669 ) is a statewide toll-free telephone tobacco cessation treatment program made possible through the Tennessee Department of Health. There is no charge to callers for services and callers have unlimited access to a quit coach through the QuitLine. Hours are Monday through Friday, 7 a.m. to 10 p.m., Saturday 9 a.m. to 6 p.m. and Sunday 10 a.m. to 4 p.m. Central time. Article provided by: www.clarksvilleonline.com

Team Tennessee enjoyed spending the day with the Mount Zion Baptist Church community for their first health and wellness day on Saturday, Sept. 26, at the Old Hickory Blvd. location. More than 300 members of the church congregation came out to participate in the fun-filled day with a focus on healthy living practices. Many families entered the fitness 5K, along with receiving free health and dental screenings on site. Local health vendors included Centennial Pediatrics, Matthew Walker Health Care Center, Meharry School of Dentistry and the Mount Zion Health and Wellness Ministry. Get Fit Tennessee hosted a booth at the event, providing educational material on healthy lifestyle choices and free pedometers to the participants. Each visitor to the Get Fit Tennessee booth was also given an introduction to the free tools and features available on GetFitTN.com and told how they could personally benefit from a free membership on the Health and Fitness Tracker. The Get Fit Tennessee team also played fitness games with the children and reminded them to get 60 minutes of physical activity each day.

NASHVILLE, Tenn. - Commissioner of Health Susan R. Cooper, MSN, RN, spent today at Camp Widjiwagan, a YMCA of Middle Tennessee day and overnight camp, where she spoke to more than 300 campers about the importance of making healthy choices and being active. Cooper and the Get Fit Tennessee team ate breakfast with the campers, discussed steps the children and their families can take to make Tennessee a healthier

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state, and led the campers in an obstacle course designed to showcase fun fitness activities.

"A recent study ranked Tennessee fifth in the nation for childhood obesity, and that is a number I am on a mission to change," said Cooper. "We need to teach our children at a young age that nutrition and exercise are important so they can grow up to be healthy adults living in a healthy Tennessee."

Get Fit Tennessee organized the event at Camp Widjiwagan to continue raising awareness about the importance of moving more and eating healthier in an effort to reduce health problems in Tennessee associated with obesity. Cooper was pleased with the activities and healthy food options offered at the YMCA camp.

"Camp Widjiwagan is a good example of adults understanding the health needs of children and putting them first," said Cooper. "They do a great job of offering healthy foods and plenty of physical activities for their campers."

“The YMCA of Middle Tennessee is committed to helping improve the overall health and wellness of Tennesseans, and we know teaching our children healthy habits is one of the best ways we can do that,” said YMCA Communications Director Jessica Fain. “We’re delighted to welcome Commissioner Cooper to this session of Camp Widjiwagan to join with us in helping kids have fun with fitness and develop good habits that will last a lifetime.”

Get Fit Tennessee is a statewide awareness program developed by Gov. Phil Bredesen to address the rising epidemic of Type 2 diabetes and risk factors that lead to diabetes, like obesity. This initiative is aimed at educating both adults and children that Type 2 diabetes can be delayed or even prevented with modest lifestyle changes like increasing physical activity and eating healthier.

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For more information on Get Fit Tennessee, including free fitness and nutrition tools, visit www.GetFitTN.com.

Hospitals across Tennessee are working to make the state a healthier place by banning tobacco use among employees. Chattanooga’s Memorial Hospital is leading the charge by announcing it will no longer hire anyone who uses tobacco products. Potential hires will be subject to a nicotine test in addition to required drug testing. Knoxville’s University of Tennessee Medical Center, Covenant Health, Mercy Health Partners, Blount Memorial Hospital and East Tennessee Children’s Hospital are expected to announce a similar ban on tobacco use soon. These hospitals are among a growing number of companies that will no longer hire tobacco users. The new regulations make this the perfect time to quit. Regardless of how long you have smoked or used tobacco, studies show quitting has immediate benefits. Within 20 minutes of giving up tobacco, elevated blood pressure and pulse decrease; in two days, nerve endings regenerate; in two weeks, circulation improves; in one to nine months fatigue and shortness of breath decrease; and in one year, the risk of a heart attack is cut in half. The Get Fit Tennessee web site offers several tools designed to motivate smokers to quit. The “Smoking Life Span Effect” calculator estimates how many years will be added to your life and the “Smoking Savings” calculator totals up the money you could save if you quit smoking today. There are also links and resources to help you on your journey to stop smoking including the Tennessee Tobacco QuitLine (1-800-784-8669 1-800-784-8669 ). Get Fit Tennessee was developed by Gov. Phil Bredesen to address the rising epidemic of Type 2 diabetes and risk factors that lead to diabetes, such as obesity. The initiative is aimed at educating both adults and children that Type 2 diabetes can be delayed or even prevented with modest lifestyle changes like increasing physical activity and eating healthier. For more information on Get Fit Tennessee, including free fitness and nutrition tools, visit www.GetFitTN. The sixth annual Walk Across Tennessee kicked off Saturday with a ceremonial lap around the Dyersburg Mall, a Zumba demonstration and free health screenings. Walk Across Tennessee officially begins Monday when teams of eight persons exercise to accrue enough mileage to take an imaginary walk across the state. Mileage is earned by walking, running, bicycling, lifting weights and other forms of exercise. The contest lasts for eight weeks. Actual mileage is used for walking and a conversion chart is used for other forms of exercise. For example, 14 minutes of weight lifting is equivalent to 1 mile. The top teams will be announced during an awards ceremony at 5:30 p.m. April 15, all in the mall's center court. Gold, silver and bronze medals are awarded to the teams with the most mileage. Each team also receives one gold medal that the team may award as it chooses. Every participant receives a certificate. A traveling trophy also is awarded to the top team. A new award this year will be given to the person who packs his or her fitness regimen with the biggest variety of activities. WAT Coordinator Beth Bell said she's looking for someone who pursues six or seven different kinds of fitness activities each week. Forty-eight teams had signed up by Saturday. Bell said she will continue accepting registration packets until Friday. She said the wintry weather had prevented some teams - particularly those based in schools - from registering yet. Registration packets for the sixth-annual Walk Across Tennessee are now available at the Dyer County Extension Office, the Dyersburg Mall customer service desk, the YMCA, Dyersburg Activity Center and First United Methodist Church. Forms may also be downloaded from the Walk Across Tennessee Web site: www.watdyer.org.

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During Saturday's kickoff, Bell told participants that more than 35 percent of the people who participate in WAT achieve one or more of their goals to lose weight, reduce stress, lower blood pressure levels and improve sleep. For those interested in weight loss, Bell said a realistic goal is to lose 1 to 2 pounds a week, or about 16 pounds during WAT. To help people envision a skinnier version of themselves, Sheila Jacobi, coordinator of the Delta regional health grant and employee of Le Bonheur Children's Medical Center, took photos of participants. The photos will be e-mailed to the participants. Then, they may use the digital photographs on the Weight Mirror Web site: weightmirror.com. The Web site allows users to see what they'd look like if they lost or gained weight. Participants may print the photos and use them for inspiration. WAT participants also received free screenings for blood pressure levels and body mass index. A number of organizations also set up educational booths during the kickoff. These included: * The McIver's Grant Public Library, which featured a number of books on exercise, sports, nutrition and weight-loss plans. * Dyersburg Parks and Recreation, which featured exercise and sports opportunities. * The Coordinated School Health Programs for city and county schools. * Tennessee Trails Association. * Curves. * Weight Watchers. Story and images from Dyersburg State Gazette: http://www.stategazette.com/story/1608993.html

My child doesn't get enough physical education or activity in school. Can you do anything about this problem? Tennessee schools are required to provide children with 90 minutes of physical activity each week, according to Chapter 1001 Public Acts, 2006 House Bill 3750. It is mandated that each local education agency will integrate a minimum of 90 minutes of physical activity per week into the instructional school day for elementary and secondary school students. Opportunities to engage in physical activity may include walking, jumping rope, playing volleyball, or other forms of physical activities that promote fitness and well-being. If you would like your child to have more physical activity in school, it is important to take the issue up with your Local Education Agency, School Board, Principal or other school and community leaders.

NASHVILLE, Tenn. - Commissioner of Health Susan R. Cooper, MSN, RN, announced today the addition of new sections for young people and their teachers on the Get Fit Tennessee website www.getfittn.com/kids to help the next generation of Tennesseans get fit. The new site presents fitness and nutrition information for middle school students with bold graphics and engaging activities. Interactive games and trivia encourage kids to learn more about nutrition, proper portion sizes and new ways to move more throughout the day.

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"Kids and teens are so technology-savvy, it was time we created a space for them to learn relevant health and fitness information through a medium they are already using," Cooper said. "As obesity rates among children are on the rise nationally, we want to provide a fun and interactive resource for them to learn how to make better food choices and how to get the recommended 60 minutes of movement a day.” The site also includes a section dedicated to teachers who want to incorporate fitness and nutrition information into the classroom. Sample lesson plans are provided, as well as online forums for teachers to discuss lessons, activities and initiatives that work to promote better health among students. Get Fit Tennessee is a statewide awareness program developed by Gov. Phil Bredesen to address the rising epidemic of Type 2 diabetes and risk factors that lead to diabetes, like obesity. This initiative is aimed at educating both adults and children that Type 2 diabetes can be delayed or even prevented with modest lifestyle changes like increasing physical activity and eating healthier. For more information on Get Fit Tennessee, including free fitness and nutrition tools, visit www.GetFitTN.com

Have you ever eaten a pluot? Would you be more likely to eat one if someone called it a "dinosaur egg?" Gov. Phil Bredesen and state Education Commissioner Timothy Webb on Thursday announced 121 elementary schools in Tennessee have been chosen to participate in the Fresh Fruit and Vegetable Program for the 2010-11 school year. The program allows students to newly experience fresh fruits and veggies in hopes their consumption will increase throughout their lives. These funds are provided to the state through the U.S. Department of Agriculture as part of the National School Lunch Program. Schools applied and were selected based on factors such as staff commitment, efficient use of resources and innovative promotional efforts. Schools with the greatest percentage of economically disadvantaged students were given the highest level of consideration. Janet Clarkson, child nutrition supervisor for Bedford County Schools, said she applies each year for all of the schools that meet the economic requirements in terms of percentage of students on free or reduced price lunches. This is the third year for the fresh fruit and vegetable program, she said, and Bedford County has had participating schools all three years. Clarkson said the fresh fruits and veggies are generally presented as snacks. Each school implements the program very differently. She had particular praise for

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Beverly Ward at East Side Elementary, who exposes children to unexpected items like dragonfruit. Ward says she offers the students two snacks a week plus monthly "taste testing" event at which they tray a small portion of some new kind of fruit. She's introduced the kids to mangoes, figs, dragonfruit, pomegranate, avocados, raspberries, fresh pineapples and coconut. When she introduced them to the pluot, a cross between a plum and an apricot, she sparked their interest by calling the fruit by its nickname, "dinosaur egg." "It was a huge hit," she said. "I've tasted fruit that I didn't think I would ever taste," said Ward. But the real pleasure is seeing the children introduced to new fruit and vegetable choices. "As much fresh fruit that they can eat," she said, "it's that much that they're not eating chips or anything else." Sometimes, she introduces an activity along with the fruit. For example, she researched avocados on the Internet and found the directions for starting an avocado tree from a pit. "We can't do enough to encourage healthy eating and living habits in our children," Bredesen said in a news release. "Programs like the School Nutrition Program are vital to the continued success of our students during the school day and throughout their lives. "I've very encouraged that we have a large number of schools participate in this grant process every year," Webb said in a news release. "Our teacher and administrators know the key to educational success is healthy students and healthy meal options." The program allows schools to provide approved fruits and vegetables at no charge to students during the school day. For examples, fruits and vegetables must be fresh, not canned, frozen, or vacuum packed. The program is effective from July 1 through June 30, 2011. Original story from Shelbyville Times-Gazette: http://www.t-g.com/story/1639412.html

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The Benwood Foundation will put nearly $100,000 into five Hamilton County elementary schools to help combat childhood obesity and expose more low-income students to fruits and vegetables. Brown Academy, Calvin Donaldson, Orchard Knob, Eastside, Hardy, Rivermont and Clifton Hills elementary schools are the first group to receive funding under Gaining Ground, Benwood's new initiative to promote local foods. "All of this is a win-win," said Russell Cliche, coordinator of school health for the Hamilton County Department of Education. "These students are from a lower socioeconomic background, and they aren't exposed to local growers. ... We need to increase consumption of fruits and vegetables. There is a very low percentage of our population living a healthy lifestyle." Issues of school nutrition and diet-related disease among students have taken front and center in recent months. The White House announced the Let's Move campaign in February to establish community support for addressing childhood obesity. Fifteen percent of elementary students in Hamilton County are classified as obese, school documents show. One in three children in the United States are either overweight or obese, according to figures from Benwood Foundation. "This is a great project because it touches the family and community in many different ways," said Jeff Pfitzer, program director for Gaining Ground. With the investment in school nutrition, Gaining Ground will provide one serving of fresh fruit and vegetables to students three or four days a week outside of the cafeteria. The produce will be used by teachers to educate students about healthy eating, said Mr. Cliche. The money also will help create training programs for cafeteria staff and parents to increase the number of fruits and vegetables in students' diets. The "Farm to School" program will increase cafeteria staff's knowledge of how to prepare and serve fresh fruits and vegetables, and "Healthy Home Kitchen" will provide cooking lessons from local chefs to parents in targeted schools. Local growers will be encouraged to come to schools and sell produce since many families don't have access to regional foods, officials said. "With this grant, we will be creating more opportunities for school leadership and staff, students, and families to understand, practice, and incorporate healthy eating habits," said Carolyn K. Childs, director of school nutrition in Hamilton County schools, in a statement. Story from Chattanooga Times Free Press http://www.timesfreepress.com/news/2010/apr/16/benwood-improves-student-access-to-produce/ Someone in the United States is diagnosed with diabetes every 20 seconds, according to the American Diabetes Association. Get Fit Tennessee is working to reduce the burden of diabetes in the state by urging all Tennesseans to know their risk factors for the disease as part of the observance of Diabetes Alert Day March 23. This annual health observance is dedicated to raising awareness of Type 2 diabetes and encouraging those who are at risk to take steps toward prevention.  “I encourage all Tennesseans to take this day to learn more about the risk factors for diabetes and make small changes to eat better and increase physical activity to help reduce those factors in their lives,” said Health Commissioner Susan R. Cooper, MSN, RN. “Contact your health care provider to talk about your personal risk factors and ways to lower your risk for diabetes.”

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 More than 10 percent of adult Tennesseans participating in the 2008 Behavioral Risk Factor Surveillance System responded they had been told by a health professional that they have diabetes. That ranks Tennessee 46th in the nation for diabetes incidence, with only four other states having a higher percentage of cases. The American Diabetes Association estimates 530,000 children and adults are living with diabetes in Tennessee, and an additional 50,000 people in the state are living with pre-diabetes. Nationwide, more than 20 million children and adults are living with diabetes, according to the ADA. Get Fit Tennessee has a number of resources available to help those managing diabetes or prediabetes. The free health and fitness tools found online at www.getfittn.com include a nutrition tracker based on the United States Department of Agriculture’s database of more than 7,500 food items. The nutrition tracker allows users to keep track of calories, fat grams and carbohydrates consumed each day in a virtual food journal. Users can also accumulate “fitness points” by logging physical activity in the fitness tracker, as well as set fitness and nutrition goals.  To learn more about diabetes and how to prevent it, visit www.getfittn.com or the American Diabetes Association Web site, www.diabetes.org. Visitors to the ADA Web site can also determine their risk for developing diabetes by taking the online Diabetes Risk Test.  Get Fit Tennessee is a statewide awareness program developed by Governor Phil to address the rising epidemic of Type 2 diabetes and risk factors that lead to diabetes, like obesity. This initiative is aimed at educating both adults and children that Type 2 diabetes can be delayed or even prevented with modest lifestyle changes like increasing physical activity and eating a healthier diet.

NASHVILLE, Tenn. — First Lady Andrea Conte and Health Commissioner Susan R. Cooper, MSN, RN, recognized state agencies and acknowledged National Public Health Week today during announcement of results of the March to the Moon fitness challenge for state employees. The top three placing state departments and agencies were honored with a presentation at Bicentennial Capitol Mall State Park. "This year’s results could not have come at a more appropriate time than during National Public Health Week," said First Lady Conte. "We hope this event will continue to inspire small actions in our state workers that can have big impacts toward making Tennessee a healthier state.” The March to the Moon fitness challenge was open to all state employees, and was designed as a fun way to help promote and improve health and fitness. Throughout the month of March, participants logged physical activity and earned fitness points using Get Fit Tennessee’s Fitness Tracker at www.getfittn.com, while competing as members of their department’s team. At the end of the month, departments were ranked by the

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average number of fitness points in hopes of claiming the Health Commissioner’s Challenge Trophy. The top five teams and their average fitness points are as follows:  Average

Department/Agency

Point

1. Tennessee Wildlife Resources Agency

4189.34

2. Bureau of TennCare

2735.30

3. Commission on Children and Youth

2706.80

4. Department of General Services

2422.44

5. Governor’s Office on Children’s Care Coordination

2401.18

There were 756 participants in this year’s March to the Moon Challenge. These state employees walked the equivalent of a total of 60,200.89 miles, took 120,401,777 steps and earned 1,204,017.77 fitness points toward the grand prize of better health. “We spend just as much time in our workplaces as at home, and health and safety of employees are a priority,” said Cooper. “Research shows more employers are offering programs to support a healthier lifestyle than ever before. A commitment to improving the health status of all employees promotes a comprehensive culture of well being as well as a more productive work environment.” Get Fit Tennessee offers free fitness and nutrition tools that individuals and employers can take advantage of online. Users can design their own fitness challenges for family, friends or coworkers, or simply track their own progress as they work to improve health and fitness. All Tennesseans are urged to visit the Get Fit Tennessee Web site to receive free daily tips via e-mail, and to access features including a food diary and a cookbook of simple, healthy and economical recipes. Get Fit Tennessee is a statewide awareness program developed by Governor Phil Bredesen with a focus on educating and empowering Tennesseans to move more and eat healthier to combat health risks facing the state, such as obesity, Type 2 diabetes, heart disease and stroke. Odds are slim that a Tennessee child will be in good health, advocates say.

 

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The statistics paint a grim picture: Tennessee is 48th for children's overall health, has among the highest rates of infant mortality and is ranked in the top 10 for teen deaths. About 17 percent of the state's teens are obese, with many more at risk.

  Behind the numbers are the real children like Faith Apperson, who struggles with being overweight; like Donovan Cotton, who was born prematurely at 23 weeks; and like April Alonzo, who at 16 suffers from bipolar disorder and has attempted suicide.

  Faith, Donovan and April and their families share their stories as faces behind Tennessee's health issues in a new seven-part series that will air over the next three years on Nashville Public Television.

  "I wanted to be a part of this to let other parents know they are not alone and there are resources for their children," said Tammy O'Rourke, who is Faith's mother. "I was lost too."

  The first episode of the documentary series, NPT Report: Children's Health Crisis, in February to start driving conversation and change in the community. The second episode is expected to run in June, with each new part airing every few months.

  Kimberly Williams-Paisley, an actress and mother of two, hosts the documentaries. The installments also feature experts who dissect the problems on film, including local and state health officials, doctors, professors, advocates and school officials.

  Faith and her mom were referred to Vanderbilt University Medical Center's Dayani Center, which focuses on health and wellness. They learned how to eat healthier meals.

 

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"We used to drink sweet tea and we found out how much sugar we were really using — one cup of sugar for every half-gallon of tea," said O'Rourke, of Brentwood. "It brought a lot of awareness about her diet and how we could make healthier choices."

  The family now drinks unsweetened tea with sugar substitute, among many other changes.

  The health series was a cooperative effort between Nashville Public Television, Monroe Carell Jr. Children's Hospital at Vanderbilt, the Vanderbilt University School of Medicine Department of Pediatrics, the Healthways Foundation and the Nashville Healthcare Council.

  "Nashville is the nation's health-care capital, yet that distinction stands in dark contrast to our city and state's poor health indicators," said Caroline Young, president of the HealthCare Council.

  Along with the seven episodes, there will be on-air panel discussions involving people in the community with reaction to the series and possible solutions beyond existing programs.

  Davidson County has an ongoing program called Alignment Nashville, launched in 2003, that brings together non-profits to work on improving the education and lives of the city's children. It also includes a health intiative to promote healthy births, ensure access to primary care, achieve mental and physical wellness and encourage sexual responsibility in teens.

  Mayor Karl Dean, who has worked on healthy eating and active living goals in Nashville, said it was sobering to see the whole picture of children's health in the city and the state.

  "It's not good," he said. "There is a real danger that our children's lifespan may be shorter than previous generations. Where we are on the list should not be the

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BOLIVAR, Tenn. — Carolyn Stewart looked over the contents of her grocery cart and let out a rueful chuckle at the inventory — three cases of Faygo soda, some gummy candy and a box of Froot Loops. It's an unhealthy shopping list for an unhealthy woman living in one of the unhealthiest places in Tennessee. "I'm diabetic and on a kidney machine," said Stewart, a Hardeman County native who is hoping for a kidney transplant, as soon as one of her daughters loses enough weight to qualify as a donor. In the meantime, she knows she needs to watch what she eats and drinks. "I try to eat right and everything." Stewart lives in the county with the highest obesity rate in Tennessee, but there's nothing in her community, or her grocery cart, that you won't also find everywhere else in the state. Tennessee consistently ranks as one of the most obese states in the nation, and weight-related health problems feed into sky-high rates of diabetes, cancer, hypertension and infant mortality. "Hardeman County does not look that much different from 20 or 30 other counties in this state … and no different than what you'd find in the rest of the nation," said Tennessee Department of Health Commissioner Susan Cooper. Hardeman, a county of rolling green hills, small farms and lovingly restored Civil War-era town squares, lies east of Memphis, north of the Mississippi line and at the rock bottom of the state health rankings. The county is working to improve public health, and finding out just how hard that can be. This is not a story about a county with a weight problem. This is a story about a county trying to get its people healthy again. Helping Hardeman County get fit won't be a simple matter of putting in a few salad bars or bike paths. The county has parks, ball fields, tennis courts, a golf course, a pool, two private gyms, a few walking paths and three grocery stores with decent produce sections. Three years ago, the county seat of Bolivar launched a farmers' market that brings heaps of farm-fresh produce downtown three times a week. Roadside stands groan under the weight of ripe watermelons, tomatoes and summer squash. The schools took out the vending machines, brought in salads and baked potato bars and stepped up nutrition counseling. Joe's Restaurant in Bolivar installed a salad bar to give customers an alternative to the six deep fryers bubbling in a row back in the kitchen.

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Fresh new sidewalks are all over downtown Bolivar, thanks to a redevelopment grant the city obtained a few years ago, and whimsical painted pianos lean on the street corners, beckoning people to come stroll the city square and listen to the live music performances every Friday. The facilities may not be as large or as nice as those in the metro areas, but there are options for people seeking a healthier lifestyle. But the healthy choice is not always the easy choice. "It's hard to get people to come," said Mary Heinzen, executive director of the Hardeman County Community Health Center, which has received multiple grants that allowed its staff to offer free nutrition counseling and exercise classes to low-income residents with weight problems. But few signed up. "Many of our clients feel very depressed and hopeless," Heinzen said. "When you're living what you feel is a hopeless life, it's hard to get people to come and listen to someone talk about what they should be doing with food choices." Hardeman is a rural, relatively poor county, where the median household income is $36,000, only 7 percent of the population has a college degree, the unemployment rate hovers around 13 percent, and those who work must often commute outside the county now that most of the factories here have shuttered their operations. "Our health-care costs are out the roof; we have unmotivated, depressed people; and I don't think the average person in the county recognizes that we have a problem with obesity," Heinzen said. When you're working long hours, or two jobs to make ends meet, finding the time or the energy to work in a brisk morning jog or to whip up a healthy dinner from scratch isn't high on your priority list. "I'm just trying to budget the best way I can," said Angela Lambert of Middleton, piling three frozen pizzas into her cart at Maxwell's Big Star, a locally owned grocery store in Bolivar that has survived the arrival of a Walmart grocery a few miles down the road. Lambert, who works at the county prison, gets paid twice a month and must stretch her $200-a-week food budget to make sure her three children — ages 2, 10 and 12 — have enough to eat as money gets tight and payday is still half a week away.

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Her children enjoy fruits and healthy foods, and she tries to walk two miles a day with a friend — or she did, before the temperatures outside started hitting the triple digits. The Robert Wood Johnson Foundation and the University of Wisconsin rank U.S. counties by health. When the latest survey came out in February, Hardeman County ranked worst in Tennessee — 95th out of 95 counties — for obesity. According to statistics gathered by the Centers for Disease Control and Prevention, an estimated 38 percent of Hardeman residents are obese, with body mass indexes of 30 or higher. Even for trained health workers, making healthy choices isn't always easy. The Curves gym shut down recently, leaving Carol Gill searching for a new workout routine. "I'm 59 years old, and I have battled with my weight all my life," said Gill, the new patient coordinator for the county health department. Over the years, she has tried everything from Weight Watchers to hypnotism to try to keep weight off her tiny 5foot frame. Like many of her neighbors, Gill is diabetic, which makes the battle with her weight all the more urgent. "Why we're so fat here, I don't know," she said with a smile. "It could be as simple as, if it's fried, we think it tastes good. The economy has a lot to do with it, too." Hardeman County has fallen on hard times in recent decades. Once, cotton was king. Then manufacturing moved in, bringing good jobs and good wages. Bill Strope followed one of those jobs south from Indiana to Bolivar 50 years ago and stayed, long after the auto parts plant where he worked pulled up stakes and moved out of state, along with most of the county's other manufacturing jobs. "They used to say this was a cotton town, but all the old farm people are dead and gone," said Strope, who survived a stroke and now devotes himself to regular exercise with a group of fellow die-hards at the Bolivar municipal gymnasium. "It keeps my sugar down," said Strope, who has been living with diabetes for 22 years. To stay fit, he plays golf and walks three or four times a week.

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Last week was the hottest of the year, 103 degrees outside with a heat index closer to 116 degrees. Hardeman County has no malls for walkers to stroll in airconditioned comfort, but there is the small municipal gym, where regulars circle the court, around and around, day after day, getting their miles in. It takes 14 laps of the gym to make a mile. Bolivar neighbors Jo Butler and Earline Cox wear pedometers and keep each other company as they make their circuit. Butler, who moved to Bolivar from Austin, Texas, two years ago, drives 70 miles west to Memphis to grocery shop at Whole Foods and pick up the vitamins and holistic supplements she credits for her continued good health at the age of 77. "It makes it hard," she said of healthy living in a small town. But her daily walks with a friend help. "I feel better when I do," said Cox, who was born and raised in Hardeman County, in a family where money was scarce but the food was always home-cooked, hearty and healthy. Danny Cheshier used to walk the mile from his home to his barbershop on Bolivar's square. The place looks a lot like it did when he opened for business in 1958 — the striped pole outside, the penny gumball machine inside and the sturdy antique chairs with their view onto the street outside. When a back injury made walking painful, Cheshier said he switched to riding his recumbent bike to stay fit. "I see a lot of obesity out there," said Cheshier, who runs the shop with his brother, Jerry. The daily exercised has helped him drop about 5 pounds off his already fit frame in recent months, but he knows a lot of his neighbors don't have the option of walking to work, or cycling to stay fit. "It's really sad. You have to understand, these people, they don't want to be like that. They just don't know what they need to do." Hardeman County Mayor Willie Spencer knows what people need to do. Getting them to do it is another matter. A physical education major in college, he eggs his staffers into taking the stairs to his third-floor office in the century-old courthouse and sometimes slips away to do pushups or jog in place in an empty meeting room. "We need to start strategizing," he said. "Poverty is our biggest issue. We do not have a lot of industry, we do not have a lot of good-paying jobs. … Education has to be the foundation." Down the street, Bolivar Mayor Barrett Stevens Sr. offers municipal employees 30 minutes a day to exercise, and the city offers quarterly competitions for workers who walk the farthest.

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The biggest changes are probably happening in the schools, which have been stripped of their vending machines and had their cafeterias greened with salads and baked potato bars. "When you work with younger kids, it makes the longest-term impact," said Dr. Karen Codjoe, a pediatrician who is seeing rising numbers of overweight and obese children, including many who have developed Type II diabetes. Last year, she said, the county schools hosted a fitness challenge for secondgraders, and "it took some of those kids 30 minutes to walk one mile." Alarmed, the county is organizing an obesity task force that hopes, among other things, to send adult mentors into the schools to encourage children to become more active and to make smarter meal choices. "The reality is, it's going to take a lot to make changes. … We're not going to see results for a number of years." Slow progress is not necessarily a bad thing. At the state health department, Cooper repeats the advice the state gives to people trying to lose weight and get fit: The way to go is with little changes, gradual changes, slow improvement. "Weight is the last thing people want to talk about. If you told me I had to lose 100 pounds, I wouldn't hear another word you said, because it would sound so unattainable," she said. But if you encourage people to be active for five minutes in the privacy of their home, or to bake the chicken for dinner instead of fry it, those small changes can add up, she said.

Original story from The Tennessean: http://www.tennessean.com/apps/pbcs.dll/article? AID=/201008080210/NEWS01/8080380 Bredesen Signs Executive Order Promoting Healthy Options for State Vending Machines 8/10/2010

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NASHVILLE – Governor Phil Bredesen signed Executive Order No. 69 promoting healthy options for food and beverages sold through vending facilities on properties within the executive branch of state government. The order directs that guidelines be developed establishing minimum nutritional standards and standards for labeling and placement of food and beverages along with pricing and other incentives to encourage the purchase of items that meet these nutritional standards. “Many of the health issues that face Tennesseans today are things that a prescription or a doctor’s appointment or health insurance can’t fix,” Bredesen said. “The state has spent the past several years investing in prevention strategies like GetFitTN to raise awareness and address behaviors that lead to chronic disease, including physical inactivity, nutrition and tobacco use. State employees deserve healthier food choices and ought to be the leaders in moving toward a healthier Tennessee." The executive order applies to all vending machines on public properties within the executive branch of state government that are serviced by licensed blind vendors, private third party vendors and private vending companies that operate on public properties under the authority of the Department of Human Services. The departments of Finance and Administration, Health and Human Services, as well as appropriate blind vendor representatives, will develop and publish the nutritional guidelines. The Department of Human Services will amend written agreements with property management officials and existing vendors to incorporate the new guidelines and standards by January 1, 2011. All permits issued after January 1, 2011 will include the guidelines and minimum standards. The Department of Health will also publish recommendations for nutritional food and beverages provided to state employees at breaks, meetings, conferences and other work-related events held on public property.

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Robert Wood Johnson Foundation w.countyhealthrankings.org/ The County Health Rankings The County Health Rankings are being developed by the University of Wisconsin Population Health Institute through a grant from the Robert Wood Johnson Foundation and will be released in February 2010. This Web site will serve as a focal point for information about the County Health Rankings, a project developed to:

• Increase awareness of the many factors—clinical care access and quality, health-

promoting behaviors, social and economic factors, and the physical environment—that contribute to the health of communities

• Foster engagement among public and private decision makers to improve community health and

• Develop incentives to encourage coordination across sectors for community health improvement.

The project builds on the University of Wisconsin Population Health Institute's experience in producing the Wisconsin County Health Rankings annually since 2003. The Robert Wood Johnson Foundation The Robert Wood Johnson Foundation focuses on the pressing health and health care issues facing our country. As the nation's largest philanthropy devoted exclusively to improving the health and health care of all Americans, we work with a diverse group of organizations and individuals to identify solutions and achieve comprehensive, meaningful and timely change. For more than 35 years we've brought experience, commitment and a rigorous, balanced approach to the problems that affect the health and health care of those we serve. When it comes to helping Americans lead healthier lives and get the care they need, we expect to make a difference in your lifetime. For more information visit RWJF.org.

The University of Wisconsin Population Health Institute The University of Wisconsin Population Health Institute is the focal point within the University of Wisconsin School of Medicine and Public Health for translating public health and health policy research into policy and practice. The Institute strives to:

• Address a broad range of real world problems of topical importance to government, business, providers, and the public;

• Promote partnerships of inquiry between researchers and users of research, breaking down barriers between the academic community and public and private sector policy makers;

• Advance the development of interdisciplinary research, along the spectrum from public health to health care;

• Provide continuing education for practitioners and opportunities for applied learning for graduate and medical students; and

• Make useful contributions to public health and health policy decisions that improve the health of the public.

1.

Why rank counties' health?

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To serve as a call to action for communities to

o

Understand the health problems in their community

o

Get more people involved in improving the health of communities

o

Recognize that factors outside medical care influence health

Ranking the health of counties using not only traditional health outcomes, but also the broad range of health determinants, can mobilize action, not only on the part of governmental public health, but also of the many other sectors that can influence and are affected by health. return to top

2.

Is there a model underlying the County Health Rankings?

The County Health Rankings are based upon the model of population health improvement in which health outcomes are the result of a set of health determinants (see diagram). These determining factors and their outcomes are also affected by policies or programs in the community. Once communities understand their current health (health outcomes) and the factors likely to impact their future health (health determinants), they can improve health by adopting effective programs and policies that address these key determining factors.

3.

How will you rank counties' health? We will rank counties' health on two sets of measures:

1.

Health outcomes (length and quality of life)

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2. Health determinants (health behaviors, access to and quality of clinical care, social and economic factors, and the physical environment).

More details are provided in the Ranking Methods section.

2.

Do some states already rank the health of their counties? Yes, building on the work of America's Health Rankings, the University of Wisconsin Population Health Institute has been ranking the health of Wisconsin counties for the past six years: o Wisconsin County Health Rankings Other states have developed their own rankings: o Tennessee* o Kansas* o Kentucky o New Mexico* *Based on the Wisconsin model.

4.

Our state already publishes county-level indicators –what is the value-added of the County Health Rankings? The County Health Rankings are designed as a call to action – the use of ranks can often serve as a more effective tool for drawing attention to community health issues than lengthy listings of indicators. We encourage any community that has not already done so to use the Rankings as a stimulus to engage community members in a more detailed community health assessment, using whatever additional data sources they have available.

1.

There is a major city in our state – will this city be included in the County Health Rankings? The County Health Rankings will be based on counties and county equivalents. Any entity that has its own Federal Information Processing Standard (FIPS) county code will be included in the Rankings. The FIPS county code is a five-digit code where the first 2 digits represent the state and the remaining 3 digits designate county or county equivalents. Certain major cities, such as the cities of Baltimore and St. Louis are considered county equivalents and have their own FIPS county code whereas other cities, such as the City of Milwaukee, do not.

2.

How do the County Health Rankings address the fact that the availability and quality of information for the various elements in the Rankings varies across states? The County Health Rankings will be presented by state with no comparisons across states.

3.

Our state department of health provides county-level data for many more indicators than are likely to be included in the County Health Rankings–why are composite scores and rankings helpful? The County Health Rankings use composite scores and rankings as a means to draw attention to the fact that health varies by place, that there are multiple factors that contribute to healthy communities, and that health is everybody's business (not just that of the state or local health department). Communities wishing to dig deeper and understand what can be done within their community should be encouraged to use additional more detailed data sources available within a state to conduct an indicatorspecific analysis. The Rankings can be used as a pointer to suggest areas where more in-depth analysis might be helpful.

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4.

How will the weights be assigned across and within the four health determinant categories in the County Health Rankings? For the past six years, the Wisconsin County Health Rankings have used a 40-10-40-10 weighting for the relative contribution of health behaviors, clinical care, social and economic factors, and the physical environment toward overall health. The exact weighting for the components of the forthcoming County Health Rankings has not yet been finalized. There is no "correct" weighting formula, but we are conducting additional literature reviews and having discussions with experts to determine an appropriate allocation of weights. Within each component, we will assign weights to constructs and individual indicators based on a combination of available information on the contribution of that construct and on the reliability of specific indicators.

5.

How should/can state departments of health respond when counties believe that the County Health Rankings may not accurately reflect their county and thus question their findings? We suggest that state departments use the release of the County Health Rankings as an opportunity to encourage communities to conduct more in-depth community health assessment using whatever additional more detailed county-level data are available within the state. If and when questions are raised by results in the County Health Rankings, the objective is to generate discussion about how healthy a county is and what can be done to improve its health, rather than focusing on whether or not its ranking is "correct."

Engaging

Partners

Healthy communities are good for everyone. Public health agencies alone can only make incremental improvements in health—to achieve major improvements in health requires involvement from everyone.

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IOM. The of the Public's Health in the 21st Century. Washington, DC: National Academies Press, 2002. The February 2010 release of the County Health Rankings in every state in the U.S. is an opportunity for each state to: • call attention to the need for health improvement and • get more people involved in improving the health of communities.

Finding Solutions What happens once the County Health Rankings are released? There are a number of steps that communities can take as a result of this "call to action" to improve health. This page highlights three steps communities can take and lists some resources to get you started. Step 1: Get people involved: see Engaging Partners Step 2: Use the County Health Rankings as a starting point for a more thorough community health assessment

• Mobilizing for Action through Planning and Partnerships (MAPP) • The Community Toolbox – Assessing Community Needs and Resources • PRECEDE/PROCEED • State tools: o Florida COMPASS (Comprehensive Assessment, Strategic Success) o Minnesota Community Health Assessment and Action Planning o North Carolina Community Assessment Guidebook o New York--10 Steps in Community Assessment Development Process o Washington State Assessment Initiative Web Site

Step 3: Identify and implement evidence-based policies and programs to improve health • Evidence databases o The Guide to Community Preventive Services o The Cochrane Library o Cochrane Reviews of Relevance to Health Promotion and Public Health o Health-Evidence.ca o The Campbell Collaboration Library of Systematic Reviews

• Action guides o Partnership for Prevention Community Health Promotion Handbook ww.thecommunityguide.org/index.html The Community Health Promotion Handbook Action Guides to Improve Community Health Partnership for Prevention and the Centers for Disease Control and Prevention have worked together to bridge the gap between research and practice by developing The Community Health Promotion Handbook: Action Guides to Improve Community Health. The Community Health Promotion Handbook is an evidence-based tool that consists of an Introduction and five Action Guides. Each Action Guides translates a specific recommendation from The Guide to Community Preventive Services (Community Guide) into “how to” guidance to help public health practitioners and others interested in promoting health implement effective

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community-level health promotion strategies. The five Action Guides address diabetes management, physical activity, and tobacco-use treatment. Order (Click here to order The Community Health Promotion Handbook in its entirety). To order or download an individual Action Guide, click on its title below. Diabetes Management Diabetes Self-Management Education: Establishing a Community-Based DSME Program for Adults with Type 2 Diabetes to Improve Glycemic Control—An Action Guide Physical Activity Places for Physical Activity: Facilitating Development of a Community Trail and Promoting Its Use to Increase Physical Activity Among Youth and Adults—An Action Guide School-Based Physical Education: Working with Schools to Increase Physical Activity Among Children and Adolescents in Physical Education Classes—An Action Guide Social Support for Physical Activity: Establishing a Community-Based Walking Group to Increase Physical Activity Among Youth and Adults—An Action Guide Tobacco-Use Treatment Healthcare Provider Reminder Systems, Provider Education, and Patient Education: Working with Healthcare Delivery Systems to Improve the Delivery of Tobacco-Use Treatment to Patients —An Action Guide Each Action Guide contains an overview of the recommendation and supporting evidence, links to tools and resources for planning and implementation, tips for implementation and overcoming potential obstacles, suggested resource needs, and questions and potential data sources for evaluation planning. In order to maximize the benefit of this "call to action," teams comprised of individuals from the public and private sectors will be forming in each state. These teams will serve as key project participants before, during, and after the release of the County Health Rankings. This page will serve as a source of information for people invited to join one of these teams as well as others who are interested in the communications and community engagement activities that will surround the upcoming release of the County Health Rankings.

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In order to maximize the benefit of this "call to action," teams comprised of individuals from the public and private sectors will be forming in each state. These teams will serve as key project participants before, during, and after the release of the County Health Rankings. This page will serve as a source of information for people invited to join one of these teams as well as others who are interested in the communications and community engagement activities that will surround the upcoming release of the County Health Rankings.

FOR MORE ABOUT JOINING YOUR STATE'S RANKINGS ROLLOUT TEAM, PLEASE CONTACT US.

The Model for Integrated Community Care Leading states = Vermont, North Carolina (Medicaid only), Colorado Aug 2009

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Health and Human Services Secretary Kathleen SebeliusWASHINGTON – Health and Human Services Secretary Kathleen Sebelius released a report Thursday on how information technology can improve healthcare for Americans living in rural communities. The report examines how the Columbia Basin Health Association in Othello, Wash., uses IT to improve healthcare quality and patient safety as well as promote care coordination and continuity. "The Columbia Basin Health Association is just one place in America where health information technology and electronic health records have helped ensure patients get better care," said Sebelius. "Health information technology can reduce paperwork, make care more efficient and let doctors spend more time practicing medicine and less time filling out forms." The CBHA provides 25,000 patients with access to a variety of medical, dental, prescription and other services at four sites and was one of the first health centers in the United States to fully transition from paper-based charts to an electronic health record system. In response to the growing prevalence of diabetes in rural communities, the CBHA used its EHR system to track 1,302 diabetic patients, monitoring whether they received recommended exams and providing feedback to healthcare providers on their performance. In January 2008, 31 percent of patients at the CBHA had received a foot exam and 37 percent had received an eye exam during the previous year. By June 2008, 86 percent of patients had received a foot exam and 63 percent had received an eye exam over the previous year. According to the report, since the CBHA's implementation of EHRs, the community health center has consistently ranked above the 95th percentile nationally in total medical and dental team productivity. Approximately 65 million Americans live in communities with shortages of primary care providers and nearly 50 million live in rural areas. Sebelius said health information technology, and specifically EHRs, can improve care for patients and assist in clinical decision-making and the use of evidence-based guidelines. EHRs can also decrease administrative hassle, increasing workplace satisfaction and productivity. The American Recovery and Reinvestment Act encourages greater use of health information technology through significant new investments, Sebelius said. Through incentive payments to providers and hospitals, she said, the ARRA will accelerate the adoption of health information technology and creation of an interoperable, nationwide network, and health insurance reform will build on this investment by simplifying and streamlining administrative procedures, investing in telehealth and improving the quality of healthcare

Secretary Siebelis

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Secretary's Corner Regional Framework: Introduction

It helps to have a “System” Recent evidence indicates that some Americans benefit from better care. Large health systems such as the Veteran’s Health Administration and Kaiser Permanente have significantly improved the quality of their care for their millions of patients (ref). How did they do it and, more importantly, is their experience relevant to the rest of American medical care? Studies of these high performing health systems tend to agree on the following predictors of success: •

Strong leadership committed to quality improvement;

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Shared vision among clinicians and “business” folks;

• • •

Routine measurement of the quality and costs of care;

Emphasis on primary care and its integration with specialty care;

Evidence-based guidelines integrated into performance measurement and clinical decision-making;

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•

Information technology that facilitates performance measurement, and provides decision support for clinical care; and •

Organized quality improvement activities.

Of course, this raises the question of what can be done for those people who are not part of a large, high performing system? A growing number of places in the United States, are exploring broad-based, geographically focused improvements to the community’s healthcare infrastructure. We have been examining the success stories among these coalitions, and seeing what common lessons can be drawn about how they are formed and the work they do. Detailed reports on what we have found to date can be read here, what follows is a brief and general overview of the constituent parts of successful healthcare coalitions.

The Framework for Creating a Regional Healthcare System The experience of community-based efforts to improve health and healthcare, complemented by that of successful large organizations, leads us to propose a framework for improving the quality and efficiency of healthcare for a geographically defined population. The proposed Framework and its specific components are not evidence-based, as rigorous research evaluating the impacts of regional initiatives and the proposed components on regional quality, health outcomes, and costs has been very limited. In fact, some of the elements mentioned in the Framework - such as public disclosure of performance data - remain controversial, at best. Therefore, the proposed Framework is descriptive and heuristic, a compendium of important local responses to the major problems and trends in current American healthcare The Framework might be best explained from the bottom up. The overall goals of the structure and activities described in the Framework are to: • •

improve the quality of care and outcomes across a population, especially for those with a chronic illness; and

reduce the costs of care for that population through waste reduction, outcome improvement, and greater administrative efficiency.

These ambitious goals will not be achieved without major redesign of our current care delivery systems, small and large. So, transformation or redesign of healthcare delivery in accord with the Quality Chasm aims is an essential intermediate outcome. Such broad scale delivery system changes are unlikely without direct support of practices and active programs of practice change, and changes to benefits and provider payment to make them more conducive to system change. It is also entirely possible that consumer encouragement of cost-effective care through advocacy and purchasing will accelerate change. All three strategies benefit from the pooling of clinical and cost data to support clinical care and for performance measurement. In most communities, data on

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clinical performance are mostly limited to what’s available in claims, and tightly held by each major provider organization, health plan or self-insured employer. Aggregate measures of quality or efficiency in the community, or by individual providers are generally missing, and clinical data on individual patients reside in disconnected provider record systems. The Framework reflects the fundamental role of pooled clinical data and performance measurement in creating a regional healthcare system with the capacity to improve. Providers would have feedback on their performance and the prospect of financial incentives, as well as improved access to and breadth of clinical data for patient care. Purchasers and insurers would have access to complete data on their network providers to guide payment and quality improvement activities. Consumers would have information on the performance of various community providers, and their full medical record could be available wherever they receive care. The Framework identifies three key sets of stakeholders in transforming care— consumers, providers, and purchasers/health insurers. The values and objectives of these three actors are not necessarily in alignment in typical American healthcare marketplaces without intervention. There needs to be an entity that convenes the three stakeholder groups, finds common ground, and provides leadership and direction. The literature on community health programming repeatedly gives emphasis to the importance of a shared vision and mission across the various stakeholder groups, and leadership that can make collaboration work. Providers must have the clinical data systems, quality improvement strategies, and infrastructure to motivate and support the redesign of their delivery systems. Practice information systems, at the very least, should furnish clinicians with: critical clinical information on key patient groups; reminders of needed services; and measures of quality and improvement (registry functions). Practice redesign is daunting, especially with proven models and quality improvement activities (e.g., collaboratives, practice coaches, problem-based learning). Consensus, evidence-based guidelines help focus measurement and quality improvement activities, and practices need access to care management and self-management support resources. Finally, the improvement experience of the Veteran’s Health Administration generated a model for spreading system change that emphasizes the importance of social networks in the process of diffusion. The growing isolation of small, primary care practices from traditional social and educational settings such as hospitals appears to be a barrier to the spread of system change, and the development of physician networks that provide programs and infrastructure locally may be a solution. While delivery system redesign is largely the work of motivated, prepared healthcare professionals, many believe that more informed and actively engaged consumers, through their purchasing and care decisions, can induce

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healthcare systems to improve and become more efficient. Public disclosure of performance data is widely recommended although there has been little if any demonstration of impact on consumer behavior. Purchasers are clearly shifting costs to consumers. While we lament the increased financial burden on consumers, cost-sharing strategies that increase consumer involvement in decisions about their care may encourage more cost-effective care and reduce unwarranted, supply-driven demand. Strategies to increase the use of effective generic drugs are a prime example. Removing some of the disincentives, redundancies and inefficiencies in current health insurance and payment should reduce costs as well as encourage a transformation of care, especially if accompanied by incentives for improvement. Financial incentives based on performance are viewed, along with information technology, as the saviors of American healthcare. As mentioned above, benefit designs that provide incentives to consumers and providers to deliver evidence-based services may contribute to higher quality. Standardization of processes for performance measurement and claims management could reduce administrative demands on practice settings and contribute to better data quality. Will the success of a regional improvement effort depend upon its implementation of all or most elements in the Framework, as has been the case with the Chronic Care Model? While the elements and strategies described in the Framework appear to be complementary, there is not sufficient evidence currently to even begin to answer this question.

Putting it all together The strategies described here are linked. A successful program in regional healthcare cannot exist in the absence of strong leadership and cooperation among those with the money and risk - those providing care and those receiving care. Performance measurement is essential for public disclosure and pay for performance, and a crucial tool for practice improvement. As a guide to regional healthcare improvement, we have tried to organize the strategies in this Framework. The goals are to improve the quality of care and reduce costs, which do not appear to be contradictory. The IOM makes clear that nothing short of major transformation of our current delivery systems will close the quality chasm, the gap between care as usual and best practice. There is insufficient evidence at present to delineate the essential features of an effective regional improvement program. Do you need activities in all areas or just a few? We believe that the four strategies—performance measurement, engaging consumers, supporting delivery system improvement, and aligning benefits and payment—are synergistic. If the IOM Quality Chasm report is correct, then effective regional programs would both change the financial and information technology environments to be more supportive of care Nashville Community Health Improvement Model R.Taylor 01-15-10

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improvement, and help providers redesign their care systems to better meet the needs of patients. •

Read "It Takes a Region: Creating a Framework to Improve Chronic Disease Care" •

Read the summary report

Ediets.com 09-06-10 Company Overview eDiets.com, Inc. (NASDAQ:DIET) is a leading provider of weight loss services, information and products based in Fort Lauderdale, Florida. Millions of people have visited the company's flagship website, www.ediets.com, which was a Forbes.com pick for "Best of the Web" in the diet and nutrition category. The company generates revenue in five ways: • We sell subscriptions to our online weight-loss program.

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We sell subscriptions to our home meal delivery weight loss program.

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We derive licensing revenues for the use of our intellectual property, and development/consulting revenues for the design and implementation of private-label nutrition websites.

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We sell advertising throughout our content assets, which are our diet, fitness and healthy lifestyle-oriented web sites.

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We sell diet, nutritional and fitness products through our online store.

We pioneered online dieting. We have been offering subscriptions to our online weight-loss program in the United States since 1998, when we launched our first diet plan. Our online programs are personalized according to an individual's weight goals, and food and cooking preferences. Members have access to shopping lists, recipes and weight management tools. eDiets offers approximately twenty different digital diet plans, some of which we have developed and some of which we have licensed from third parties. We have been offering our home meal delivery service in the United States since 2006. Our meal delivery service ships chill-fresh, nutritionally balanced meals, snacks and desserts directly to the doors of customers seeking a convenient way to eat well and lose weight. Customers can choose a 5-day or 7-day plan that includes breakfast, lunch, dinner and a snack. Our meals were named Epicurious.com's "Top Pick" among weight loss meal delivery services for Best Taste and Nutrition. Both our online and meal delivery subscribers have access to a wide array of support services, including access to registered dietitians, nutritionists, a fitness expert, interactive online information, online communities, articles, message boards and online meetings. In 2006, eDiets entered the corporate licensing business with the acquisition of Nutrio.com, now eDiets Corporate Services. eDiets Corporate Services builds and hosts customizable private label health and nutrition websites for which we receive development fees and licensing fees for the ongoing use of our intellectual property, which includes meal and fitness plans, logs, journals, tools, community and loyalty incentive programs. We provide these services primarily to the health insurance, pharmaceutical and food industries. Our advertising revenues are derived from our flagship website, www.ediets.com. The site includes free, regularly updated content developed primarily by our in-house editorial staff. Content is grouped into "channels" including Diet & Nutrition, Fitness, Mind & Body, Health, Food & Recipes and Success Stories. Additional advertising revenues are generated through placements in our free, opt-in email newsletters and through placements within the subscription sales process. In 2009, we re-established our online store where customers can purchase nutritional supplements and other diet related products such as fitness equipment and exercise videos.

Headquarters eDiets.com 1000 Corporate Drive

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Suite 600 Ft. Lauderdale, FL 33334 954-360-9022 The first things many women do when they want to lose weight is dramatically cut their calories and make a list of off-limit foods. Even with the best intentions, doing this is actually slowing down your metabolism and creating cravings. This results in more stored fat, and the eventual binge when cravings are finally too strong to ignore. Then there is the sense of failure and frustration due to feeling like you have fallen off the wagon. Determined to do better next time, the cycle begins all over again. Yo-yo dieting is a way of life for millions of Americans -- even though there is more than a 90-percent failure rate. Nutrition is the leading contributor to weight loss. It is imperative that you stay conscious of what goes into your body. The quality of food you eat is directly reflected in your body's appearance, as well as your overall health. No amount of exercise can counterbalance a poor diet. Here are some recommendations for lasting weight loss: 1. Do not drastically cut calories. They are your body's energy and necessary for it to function efficiently. What you can do is limit the empty calories. These come from foods with little or no nutrients. If some of the leading ingredients are flour, high fructose corn syrup, sugar or partially hydrogenated oils, you can bet the food does not support your health or weight loss. 2. Keep junk foods out of sight, and out of mind. When ice cream is in the freezer or potato chips are calling to you from the pantry, they are hard to ignore. Keep healthy snacks that satisfy your cravings close by. If you have a sweet tooth, strawberries should do the trick. If you crave crunchy or salty foods, keep carrots or a variety of nuts in stock. 3. Do not drink your calories. Soda, juice, coffee filled with creamer and alcohol can contain a ton of calories. By sticking to tea and water you can cut hundreds of calories each day. By simple cutting out a couple high-calorie beverages daily, you can lose several pounds. 4. Make fitness a priority. If exercise is something that's done only when you have the time, chances are that it will not happen very often. Make fitness a priority and schedule it on your calendar like you would a lunch date or a doctor's appointment. Find what works best for you and stick to it. The best time might be first thing in the morning before the kids wake up, or in the afternoon when they nap. You may find that exercising with your child works best. Whatever time of day or type of exercise you choose, it is important to be consistent. Make it a priority and a habit. 5. Every little bit counts. Getting in shape does not require a daily two-hour commitment at the gym. Something as simple as an afternoon walk around the neighborhood with the stroller, or squatting and lunging as you hold your baby can make a big difference. 6. Change your mindset. Developing a positive attitude towards weight loss and health is absolutely necessary if you want to be successful. It has been proven over and over again that the mind and body work closely together. When your mind is saying exercise is a miserable chore, that's most likely what it will feel like every time you do. When your thoughts dwell on the excess weight, your body is carrying with it a hopeless attitude that will undoubtedly make the pounds harder to lose. Many people find that positive affirmations help. When you exercise, tell yourself that you are becoming a thinner and healthier person. The more you do this and believe it, the more likely it is to actually be true. As you are eating your balanced diet of whole grains, fruits and vegetables, don't think about the junk food you are missing out on. Instead, think of how fit you are becoming by feeding your body what it needs to become its best. 7. Find inspiration that works for you. Some may want to lose the weight so they can fit into their prepregnancy clothes. Others may want to get healthy to reduce their risk of heart disease and diabetes so they have a better chance of being around longer for their children. Still others may need a role model or visual

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picture of someone they want to emulate. Motivations for getting in shape are unique. Figure yours out and use it to keep you going. 8. Get help. Fitness and nutrition can seem overwhelming at times. Using online resources and hiring a fitness coach can be very beneficial. Having a personal trainer who is knowledgeable about postpartum exercise will provide safe and effective workouts, as well as hold you accountable to regular exercise. It only takes minor lifestyle adjustments to have a noticeable impact on both your physique and your health. You can do things as simple as changing breakfast from white bread toast with margarine to whole grain toast with a thin spread of natural peanut butter. Adding as little as 5-10 minutes a day of physical activity to your daily routine can facilitate gains in weight loss and improve health. Most of our daily routine is simply habit. Creating new habits takes just a little bit of time, and can be completely life changing. Tatum Rebelle is the owner of Total Mommy Fitness and a certified personal trainer. She is certified in prenatal and postnatal fitness by the American Council on Exercise (ACE) as well as other health and wellness specialties. She's previously been a personal trainer at 24 Hour Fitness in Scottsdale, AZ and Dallas, TX and Fit for Life in Fort Worth

All diets work if they create a deficit in calories. But no diet works permanently -- unless you make permanent changes in what you eat. And if your weight-loss diet is boring, you may develop cravings and wind up eating everything in sight! Instead, make your meals interesting and fresh. 1. Variety is the spice of life, and it's good for you, too. Variety means good nutrition. Instead of the same old apple, orange and pear, try a mango, a kiwi fruit or a persimmon (fruits that are unfamiliar to your taste buds, but commonly found in grocery stores nationwide). Different foods contain different nutrition, so it's best to eat a variety. Looking to lose those love handles? Click here to start NOW! 2. Try a food that you've never tried before. If you see chicken on your meal plan, try Cornish hen instead. Instead of tuna fish, make a sandwich with canned salmon. Use low-fat mayonnaise or even nonfat yogurt instead of full-fat mayo. Try some mustard mixed with the mayo... it will make your "regular" sandwich more interesting. 3. Try a smoothie. A sweet smoothie is a great way to get a serving of fruit and nonfat dairy into your day -and it's delicious! Whip up a cup of nonfat milk and one-half cup of nonfat yogurt in a blender with some crushed ice and one-half banana, or a cup of berries. You can add a little sugar or honey (approximately 20 calories per teaspoon) if you choose. 4. Eat more often. If you're not succeeding on your weight-loss plan this week, try breaking your meals out into mini-meals, and eat every two to three hours to maintain your energy and to avoid hunger. 5. Eat breakfast. And lunch! And dinner! Skipping meals will backfire, and your metabolism will suffer for it. Your meals don't have to be large! A serving of high-fiber cereal and nonfat or low-fat milk and a piece of whole fruit will provide protein, carbohydrates and a little fat. This will give you energy to replenish your body from the previous night's "fast." 6. Are you bored with water? Try some brewed herbal teas, without caffeine, on ice. Keep a 20-ounce water bottle with you in your car, at your desk or in your shoulder bag. Sometimes you may think you're hungry, but you may actually be thirsty! Try drinking a cup of water, then re-evaluate! 7. Try soy. If you haven't tried tofu, you haven't tried one of the most nutritious and delicious foods around. Tofu is a versatile food that takes on the flavors you cook it with. Instead of chicken, try a stir-fry of extra firm tofu, garlic, sesame oil and vegetables. 8. If you're stuck on a weight-loss plateau, you need to make a change! Get off the plateau by increasing your aerobic exercise by 10 minutes every day. Instead of walking for 30 minutes, give it 10

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minutes more and make it a power walk! Increasing the intensity and the duration of your exercise will give you the push you need. 9. Eat breakfast for dinner and lunch for breakfast. If you're bored with your routine, challenge yourself to a new experience. There's no rule that you have to eat the same way every day. Have your breakfast meal in the evening, and enjoy your dinner meal at lunch. You won't be bored! Did You Know? An issue of the journal Stroke reports that fruits and vegetables protect against strokes in both men and women. A large study of 40,000 Japanese people confirmed that individuals who eat fruits and green-yellow vegetables "almost daily" are 20 to 40 percent less likely to suffer a fatal stroke of any kind than those eating these foods less than weekly. Now, take a look at your diet. Are you eating fresh fruit daily? What about vegetables? If your idea of a vegetable is ketchup, it's time to change. Try a smoothie... it's painless! There's no "magic" in weight loss. If it sounds too good to be true, it is. There is no potion, powder or pill that automatically helps you shed pounds. Weight loss is a numbers game, but there is a payoff if you follow my instructions. Make small changes, and you're going to see big results; small changes consistently pay off in pounds of weight lost. Notice that I didn't say, "Make small changes temporarily." Nope. You need to adopt these small changes as your own. Once you do that, you'll achieve permanent weight loss. Just a few key modifications to your usual diet and exercise habits are necessary. They're painless -- and they work. You have nothing to lose except excess weight! Tried every diet and can't lose that stubborn fat? eDiets can help! Our nutrition specialists are here to help you shape up for summer with a beach-ready body. Click here for a FREE diet profile! 1. Soda: If you usually drink regular soda, stop! Lose more than 2 pounds in a month without trying (if you drink about 10 cans per week). One 12-ounce can of soda has 150 to 170 calories and no nutrition. Have cold water or a can of diet soda if you like, but limit the diet stuff to one can per day. 2. Activity: Go for a 15-minute walk twice a day. It's not hard and it takes commitment, but in a month, there goes 1 pound! 3. Chips: Change the potato chips to pretzels. One serving of chips has 60 calories more than pretzels -and 10 times the fat grams. Just changing this snack will help you lose half a pound this month. Better yet, switch to baby carrots to lose an entire pound. 4. Fast Food: Order a Whopper Jr. instead of the regular one and sub those fries for a side salad. The smaller sandwich is plenty for most folks and is mighty satisfying on its own. The original with cheese has 770 calories, and the Whopper Jr. only has 420. Eliminate the mayonnaise and cheese for even more calorie savings. Assuming you eat out at least twice a week, you'll shed almost a pound a month just by switching from a large size to a smaller one. 5. Television: Instead of sitting for hours in front of the television, get on your exercise bike and pedal. Each time a commercial comes on, pedal! Burn about 200 calories when do it at least five evenings per week during your favorite program. 6. Breakfast: Lower sugar and fat effortlessly by switching from your usual Raisin Bran cereal to Bran Flakes and adding your own 2-tablespoon serving of raisins. This, plus switching from 2 percent to 1 percent milk, saves enough calories to lose another half a pound! 7. Fat: Do you add butter to your bread? Do you add mayo to your tuna? Do you drink full-fat milk? Eat fullfat ice cream? Just switch products to save fat and calories. Today's low-fat butters are great; you don't need to sacrifice the taste of butter, and you can avoid trans fats too. Buy a spread labeled "no trans fats" and save about 75 calories per tablespoon. Newly formulated low-fat mayonnaise is tasty, and you'll never

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miss the extra calories. Low-fat ice cream is superb, too. Just switch to lighter food choices and lose close to 2 pounds per month. 8. Lifestyle: Instead of paying someone else to wash your car this week, do it yourself. Spend an hour cleaning your car each week this month, save yourself some money and lose half a pound. Cut your housecleaner to once a month and take up the slack. Get up 30 minutes earlier in the morning Monday through Friday. Vacuum on one day, clean the floors the next, dust on the third, do the bathrooms on the fourth and clean the kitchen on the fifth. Put the savings toward a new bathing suit and lose another half a pound. 9. Omit the Fat: Avoid fried chicken. Eating either broiled, baked or grilled chicken, without skin, is the better choice and nets you delicious savings equal to about 200 calories. 10. Set Aside the Sugar: Your morning coffee can undo all the good efforts of the day before! A mocha latte with syrup and whipped cream has all the hallmarks of a decadent dessert and can add 420 calories -before you've eaten breakfast. Instead, have a cappuccino with nonfat milk and a sprinkle of cinnamon. You'll lose up to 3 pounds in a month and save a lot of money. It's the small stuff that adds up. I guarantee you'll never miss the calories by changing what you eat. By adding some simple activities, you can keep your body slim. I'm not saying never to indulge in an occasional dessert or a high-fat meal. Just remember that it's the day-to-day good eating that keeps you where you want to be. 7. Try soy. If you haven't tried tofu, you haven't tried one of the most nutritious and delicious foods around. Tofu is a versatile food that takes on the flavors you cook it with. Instead of chicken, try a stir-fry of extra firm tofu, garlic, sesame oil and vegetables. 8. If you're stuck on a weight-loss plateau, you need to make a change! Get off the plateau by increasing your aerobic exercise by 10 minutes every day. Instead of walking for 30 minutes, give it 10 minutes more and make it a power walk! Increasing the intensity and the duration of your exercise will give you the push you need. 9. Eat breakfast for dinner and lunch for breakfast. If you're bored with your routine, challenge yourself to a new experience. There's no rule that you have to eat the same way every day. Have your breakfast meal in the evening, and enjoy your dinner meal at lunch. You won't be bored! Did You Know? An issue of the journal Stroke reports that fruits and vegetables protect against strokes in both men and women. A large study of 40,000 Japanese people confirmed that individuals who eat fruits and green-yellow vegetables "almost daily" are 20 to 40 percent less likely to suffer a fatal stroke of any kind than those eating these foods less than weekly. Now, take a look at your diet. Are you eating fresh fruit daily? What about vegetables? If your idea of a vegetable is ketchup, it's time to change. Try a smoothie... it's painless! Here's a quick little recipe you can enjoy: For a really smooth smoothie, blend 1/2 cup plain, nonfat yogurt with 1 cup of strawberries, 1 cup of low fat milk, crushed ice and add sweetener to taste. A teaspoon of sugar has only 16 calories, or you can sweeten with a non-nutritive sweetener of your choice. Even though less sugary but sweet alternatives are best, there's no reason not to have a wee indulgence once in a while. Satisfy your sweet tooth with a bite-size piece of chocolate. And don't just inhale it! Keep it cold and let it sit in your mouth. That way, it will last much longer. Sugar-free powders and artificial sweeteners are a big help, too. Stir cheesecake mix or pudding mix into plain yogurt to make a delicious dessert. Fruity powders added to nonfat cream cheese can make a sweet but low-calorie spread.

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Find creative ways to satisfy your sweet tooth -- sprinkle candied ginger over mandarin oranges, put a dollop of low fat whipped cream on top of yogurt with strawberries. Even dunk a few strawberries into a little bit of chocolate. Include something sweet in most of your meals. Peanut butter on toast and fruit as a snack will reduce your cravings. If you have an unplanned slip -- and what slip IS planned anyway -- don't just shrug and say you'll get back on track tomorrow. There's no time like the present. Be proactive and positive at a time when you feel like a failure. Get right back on track, that very moment. Make your next meal or snack a positive one. The key? Always have healthy low-calorie sweets on hand, such as grapes, melon or frozen fruit bars. Consider this analogy... it's like having a fire extinguisher at your side, ready to extinguish those burning desires aching from your sweet tooth. It's become a national tradition: With the winter holidays comes an increase in weight. Although a variety of research has shown that most of us gain only a couple pounds each season, it starts to add up. Suppose you gain a pound a year for 10 years. Is that really an annual "gift" that you want to give yourself? Probably not. The solution: Learn about diet-friendly winter foods and beverages that can keep your tummy satisfied -- and your taste buds happy: Hot soup: Begin your lunch and dinner with a bowl of hot low-sodium, low-calorie soup, such as vegetable soup. You'll ward off the chill of winter and feel full on fewer calories. Just be sure to read the label before you buy: Some of those soups labeled "healthy" actually contain more sodium than the regular versions. Celebrities keep in tip-top shape with the help of personal chefs and nutritionists. You can have the same! With eDiets meal delivery, nutritionists plan your meals and gourmet chefs do the cooking. Then we deliver it to your door! Click here to learn more! Look for one that contains about 60 calories or fewer and 450 milligrams of sodium or fewer. Can't find one? Make your own by buying low-sodium chicken broth, chopping up fresh veggies such as broccoli, zucchini, celery and mushrooms, and heating until the vegetables are soft. Baked apples: Back away from that double-crusted apple pie for dessert and make your own healthy substitute! To make them, buy several large baking apples, such as Rome Beauty. Remove the core and set in a baking dish. Pour a small amount of sugar-free apple juice over them and sprinkle with cinnamon. Pierce with a fork, then bake at 375 degrees until soft. Fabulous served warm and topped with a spoonful of fat-free, sugar-free vanilla yogurt. Steamed vegetables topped with melted cheese: You're longing for an enormous stuffed baked potato, and we all know what it's stuffed with: butter, full-fat cheese and sour cream. The result: You're stuffed -and your waistline expands Try cutting up a generous assortment of veggies, including broccoli, mushrooms, zucchini, bok choy, Swiss chard and yellow squash. Steam until tender. Then, while they're still in the steamer, sprinkle with Italian herbs and garlic powder and place one slice of fat-free or low-fat cheese on top. Cover just until the cheese melts. Serve this delicious and filling treat, and you'll be amazed at how delicious such a low-calorie, highfiber dish can taste! Hot chocolate -- the low-cal way: Your BFF (Best Friend Forever) calls to invite you to a coffee house. She's longing for an extra-large hot chocolate with whipped cream. And she says that she wants to treat you. How can you refuse? You can -- by inviting her over to an even more exclusive place: your house! Save on the gas as well as car wear-and-tear and calories. Substitute sugar-free hot cocoa (most varieties contain from 25 calories to 50 calories) topped with a spoonful of fat-free whipped cream.

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Popcorn with butter:The weather outside is so frightful -- and popcorn topped with melted butter sounds so delightful. But those calories aren't so grand. Substitute air-popped popcorn topped with a sprinkle of butter salt. One cup of air-popped popcorn topped with butter salt has about 30 calories.

The Whole Story on Whole Foods By Elizabeth Yarnell eDiets Contributor Less than a century ago, our diet was made up entirely of whole foods. Nowadays, many people in our society wouldn't know how to prepare a whole food for eating if they were stuck on an episode of Survivor. Yet if you want to have a nutritionally sound diet, highly processed foods should make up fewer than 20 percent of our daily feed. But what exactly does the term "whole foods" mean, and why are they so important to a healthy body? Looking for expert help and personalized diets? Stop looking and take the FREE diet profile from eDiets. With more than 20 personalized plans, eDiets has the right one for you! The term "whole foods" has been thrown around so loosely that many people confuse it with "organic." Make no mistake: They do not mean the same thing. "Organic" refers to foods or ingredients grown without the use of artificial pesticides, fertilizers or hormones. "Whole food" is food that has only one ingredient: itself in its natural form. In other words, it's a food that hasn't been processed into another state. Organic foods can be processed and still be called organic if they are made with organic ingredients. For instance, you can have a package of organic cookies in which the cookies have been made with all organic ingredients, but this is still considered a processed food because the ingredients have been altered from their original state. The wheat has been ground, and the sugar has been extracted from the cane. While it is certainly an admirable goal to eat organic, we should strive to include whole foods in our daily diet as well. Why are whole foods so important? Our bodies -- our systems for digestion, absorption and metabolism -- evolved to use nutrients in the amounts and combinations provided by the food that grows naturally on this planet. Foods are made up of hundreds of different health-giving substances that work together for your well-being. The only way to take advantage of this packaging is by eating the whole food itself rather than a product that is a derivative of it. PAGEBREAK Many biochemical researchers, nutritionists and herbalists believe that the body will fail to achieve maximum nutrition and an ultimate healthy state without whole foods. Vitamin supplements do not replace the nutritional value of whole foods because vitamins only resemble selected parts of a food. They do not contain the complex, interwoven structure of nutrients and other substances found in one bite of whole food. Additionally, whole foods are alive with enzyme activity while isolated vitamins are not living substances. And even so-called "natural" vitamins are often more than 90 percent synthetic. Here's an example of the different effect of vitamins vs. whole foods: The medical community has long known that a diet full of plant-based foods that are rich in beta carotene can help protect against cancer. But a recent large-scale study that administered beta carotene supplements to lung cancer patients actually proved harmful. It

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seems that beta carotene is only one of the many substances contained in the whole foods that were providing the protection against cancer. The safest bet for getting the full benefit out of nutrients and other substances in plants is to consume them in their original packaging as designed by Mother Nature. The opposite of whole foods are processed foods. The more steps away from the original plant, the more processed the food is and the fewer nutrients remain. Processing increases our ability to store food for later use, allowing communities to live farther away from the source of the food. Let's look at the transformation of the whole food of a potato into a highly processed potato chip: First, the potato is peeled, losing fiber, iron and calcium along with the skin. Then it is washed, rinsing away carbohydrates, vitamin C and minerals. It's sliced, washed again and fried, removing water and destroying B vitamins while adding fat. Then it is salted, flavored with spices and given artificial colorings. Finally, it is preserved with chemical preservatives. The result of all this processing? Shelf life, crunch and convenience, along with 70 times the fat, 20 times the salt, 1/2 the carbohydrates, and less than 1/3 the fiber, iron, vitamin C and thiamin of a baked potato. And we haven't even begun to look at partitioning, which is when some part of the food is taken or separated from the rest, such as sugar from beets, oil from peanuts or refined flour from whole grains. Almost 70 percent of the U.S. food supply consists of partitioned foods that are almost completely devoid of fiber, vitamins and minerals. Adding whole foods to your diet enables you to enjoy all the nutrition offered by nature's bounty, leading to better health and better eating habits. Here is a recipe that uses only whole foods to make a flavorful, satisfying and nutritious meal. PAGEBREAK Cajun Fish (makes 2 servings) Ingredients 1 potato, russet or sweet or 1/2 of each 1/4 onion, peeled and sliced thinly 10-15 green or string beans, washed and trimmed 1/2-3/4 lb. white fish (e.g. catfish, sole, cod, halibut) Creole or Cajun seasoning 3-5 whole garlic cloves, peeled 4 small Roma tomatoes, washed and quartered Instructions Preheat oven to 450 degrees. Spray inside of a 2-quart cast-iron Dutch oven and lid with olive oil or canola oil spray. Scrub potato well and cut out any bad spots or eyes. Cube potato into 1-inch cubes. Halve beans or leave whole, as desired. Line base of pot with onions. Rinse fish and pat dry with paper towels. Lay the fish over the onions in the bottom of the pot. Sprinkle the top side liberally with Cajun seasoning mix according to taste, and then sprinkle with garlic. Make a layer of potatoes and then one of green beans, interspersing sprinkles of spices as desired. Tuck the tomatoes around the top. Cover and bake for about 40 minutes, or until fish flakes easily and potatoes are fork-tender. You should smell the aroma wafting from the oven that tells you everything is done. Tips We love Tony Chachere's Famous Creole Seasoning, but any Cajun or Creole seasoning mix from the grocery will do -- or mix together equal parts paprika, salt and a dash of cayenne to make your own. Careful with the cayenne as a little goes a long way and you may find that this unique cooking method intensifies spices.

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This cooking technique will accept any frozen elements without any change in cooking time or flavor. Feel free to substitute frozen green beans and frozen fish filets straight from the freezer. Don't feel like having fish? Just substitute the fish layer for chicken pieces, turkey tenderloin or pork tenderloin. "I BURN BOILED WATER." Does this sound like your cooking ability? Make healthy eating easy with eDiets Meal Delivery. All you need is a microwave and some silverware. Learn more! Elizabeth Yarnell is a certified nutritional consultant and the author of Glorious One-Pot Meals: A New Quick & Healthy Approach to Dutch Oven Cooking. couple of M&M's from the office candy bowl, a sample of cheese at the grocery store and a few bites of your kid's unfinished macaroni and cheese -- how many times have you grabbed a little here and there and not thought much about the impact on your weight? Most people consider these quick indulgences free calories, or they simply choose to forget they ate them. But the body remembers what the mind forgets! In fact, those forgotten calories add up to about 245 calories. That may sound insignificant but consider this: We are eating an average of 200 more calories per day than a decade ago, but the amount of time we exercise has remained the same. Without exercise, those extra 200 calories per day become 20 pounds in a year! When thought of in that light, the obesity crisis isn't such a mystery after all. Can't seem to win the fight against fat? eDiets has more than 20 personalized plans to help you beat the bulge. Take our FREE diet profile and get your plan! It's incredibly hard to stay conscious of your calorie intake without keeping track. How do your finances look when you don't pay attention or track your spending? The answer to that question is fairly clear -- and why would you expect anything different from your weight management? To stay in control of your weight, you need to write down the calories in everything you eat and drink. It sounds simple -- and it is -- but it takes discipline to make it happen on a daily basis. Researchers call this behavior self-monitoring. Call it what you'd like, but know that it is critical for successful weight management. In fact, self-monitoring is the cornerstone of any behavior-changing program regardless of what behavior you want to change. It brings awareness to current habits, and awareness is the key to doing things differently. Research proves that keeping a journal helps maintain weight loss. People resist this behavior change for a variety of reasons, such as "lack of time" or "too tedious." Some make a half-hearted attempt by "keeping track in my head." These excuses, or barriers to change as many behavioral counselors call them, become roadblocks to success. Writing it down certainly isn't rocket science, but those of you who have struggled to lose weight know that there is no magic solution. Writing down what you eat and tracking your calories is something you can start doing right now -- it doesn't cost you a dime and you'll take control of your weightloss efforts. To track accurately, you'll need to know the number of calories in the foods you're eating. You can find this information on food labels, company Web sites and at eDiets. Here are some tips for tracking calories accurately: • Write it after you bite it! You will forget.

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Be specific (e.g. 2 ounces of ham or a teaspoon of mayo).

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Take your journal with you.

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Subtotal after each meal or snack. This prevents the "I ate that much!" surprise at the end of

the day.

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Measure portions as accurately as possible.

Get dinner (and breakfast and lunch!) at your doorstep with an eDiets meal delivery plan. You pick the meals and we deliver them -- freshly prepared and nutritionist-approved! Lose 10 lbs. in 5 weeks!

Get the Most From the Treadmill By Lorra Garrick eDiets Contributor Do you hold onto the treadmill while walking? Here are the top excuses for doing that:

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"I'll fall off if I let go!" SLOW DOWN. "My trainer says it's OK." I once asked a trainer why he allowed his able-bodied client to hold on, despite three weeks of training. His response: "She's scared." Beware of trainers who fail to empower you. • "I'll lose my balance." Slow down and stop using your arms as anchors. Balancing is part of exercise. • "I've always done it this way." It's never too late to break a sabotaging habit. • "My doctor told me to do it." Shame on him or her for not telling you that holding on increases blood pressure and causes poor posture. • "The machine keeps telling me to hold on for heart rate." Select another program. Hold on for heart rate, but then let go after the number appears! • "But I'm sweating!" Many variables affect sweat: room ventilation, weight, body chemistry -- even mental state. • "I'm old!" If ever there were a reason NOT to hold on, this is it! "If the rails on the treadmill are positioned too low, holding on will encourage forward posture (especially for tall people), which exacerbates the slumping position most of us develop with aging," says Kelli Calabrese, exercise physiologist and certified personal trainer. "Grasping the rails does not promote natural walking biomechanics." This also applies to shorter people. Some people grip the front bar, yanking forward with each "step." Others grasp the side rails, shoulders bobbing up and down, body weight subtracted from the tread. And clinging on with one hand creates unequal stresses to the body. "Holding on and walking at top speeds is dangerous because of the ballistic hip rotation, overstriding and forward posture. It can lead to serious neck, back and knee injuries," says Calabrese. Standing straight while gripping won't correct the situation. Some people don leather gloves for increased gripping traction, and then proceed with their fake walking, legs wistfully moving through mere motions. But they're tricked into believing they're working hard because the settings are high: 4 mph, 12 percent incline! PAGEBREAK In the actual world, legs, knees, hips and back work in unison to support your full weight as you ambulate. Holding on, even lightly, takes valuable work away from your musculoskeletal and nervous systems. The calorie readout is triggered by the program setting, not the person on the machine! Walking hands-off burns about 20 percent more calories for the same length of time. "I've seen people increase the treadmill's elevation to augment the workload, then hold the handrails and lean back, defeating the entire purpose of the elevation," says Calabrese. The leaning back is at the same angle as the incline, literally canceling out its effect! Leaning forward won't correct this; you'd be pulling forward. People set the speed at an unrealistic pace for the elevation. Would you really walk 3.5 or 4 mph outdoors up a 15 percent hiking trail?

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Begin at a slower speed and let go. If you prefer a high incline, start slowly; this pace should be similar to an outdoor uphill-hiking pace. Any discomfort in your lower back means those muscles are working for the first time! Try this: Set the pace or incline at a challenging level, and walk hands off for only a few minutes. Then, slow down or lower the incline and continue hands off for a few minutes to catch your breath. Alternate between these more demanding intervals and easier "recovery" intervals. Regardless of your fitness level, weight or age, you must release your hands and walk the natural way. After all, haven't you been doing this since age 1? Psst... Want to know the easiest way to good nutrition and weight loss? Hint: It's delicious, you don't have to cook, count calories or do dishes -- and you get a FREE eDiets membership! Find out here. Lorra Kristene Garrick is a freelance writer and personal trainer.

Winterize Your Workout: Cool Ideas for Indoor Exercise By eDiets Staff Just because it's chilly out doesn't give you an excuse to hibernate. Instead of letting cold temperatures put your exercise routine on ice, bring your workout indoors. eDiets Chief Fitness Pro Raphael Calzadilla has some simple advice to help you maintain your fitness level this winter. After all, if your goal is to be fit for life, you can't afford to take a winter break. "If a person has been doing some exercises outside that they enjoy, the best thing to do in colder weather is to try to duplicate the same activity indoors," Raphael says. Too busy to cook? You can still lose weight! Let us do the cooking for you and deliver right to your front door! Sign up for eDiets meal delivery (rated #1 by epicurious.com!) and get a FREE GIFT! Click here for more info. For instance, if you like to walk or jog, Raphael recommends working with videos at home, such as the Leslie Sansone's Walk Away the Pounds series. Winter may also provide an ideal time to experiment with dance videos or mind-body tapes that teach yoga and Pilates. According to Raphael, it is important to make a realistic schedule for your indoor workouts. Many people find that the morning is the best time of the day to exercise. Whatever you do, try to vary your workouts in order to keep them fun. If you can afford it, Raphael also recommends investing in some home exercise equipment, such as dumbbells, a weight bench and a cardiovascular machine like a treadmill or an elliptical trainer. Even if you don't have much money to spend, Raphael says some useful pieces of equipment won't break the bank. In this category, he recommends a fitness ball, resistance bands, Aquabells (dumbbells that you can inflate with water) and a jump rope. When you are working out at home, it is also particularly important to get the proper support. Raphael suggests the fitness plans on eDiets, since they are available at all times. Using the animated exercises on the virtual trainer will help you learn the proper form for each of the movements. The many challenges on the eDiets support boards will also keep you accountable to a team. Raphael's Winter Workout To help you beat the winter blues, Raphael has designed a simple workout that you can do in the privacy of your own home. Performing these basic exercises two to four times per week will help you get in great shape in time for the holidays.

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Raphael recommends completing 12 to 15 repetitions of each exercise before moving on to the next one. If you are a beginner, your workout will consist of one set of each of these five exercises. Intermediate exercisers should perform two sets of each exercise, and advanced exercisers can perform as many as three sets in one workout session. PAGEBREAK Before you start the first exercise, Raphael recommends taking the time to warm yourself up. In fact, he suggests a completing minimum of 5-10 minutes of stretching before and after each workout. "Just like an automobile, you have to warm your body up," Raphael says. Lunge (with Household Cans) In case you don't have any dumbbells available, Raphael has designed an exercise you can perform while holding ordinary soup cans. Stand straight with your feet together. Hold a soup can in each hand with your arms down at your sides. Step forward with the right leg and lower the left leg until the knee almost touches the floor. Contracting the quadriceps muscles (at the front of the thigh), push off your right foot and slowly return to the starting position. Alternate the motion with the left leg to complete the set. Inhale while stepping forward and exhale while returning to the starting position. "If you have one leg that is more dominant than the other, start out with the less dominant leg first," Raphael says. "Make sure to keep your head up and your back straight. Your chest should be lifted, and your front leg should form a 90-degree angle at the bottom of the movement." Abdominal Bicycle Maneuver Lie on a mat with your lower back in a comfortable position. Put your hands on either side of your head by your ears. Bring your knees up to about a 45-degree angle. Slowly go through a bicycle pedaling motion -- alternating your left elbow to your right knee, then your right elbow to your left knee. Raphael cautions that you should not perform this activity if it puts strain on your lower back. "This is a more a more advanced exercise, so don't worry if you can't perform a lot of them," Raphael says. "Try not to pull on your head and neck during this exercise. The lower to the ground your legs bicycle, the harder your abs have to work." Bent Knee Push Ups Place a mat on the floor and get down on your hands and knees. Your hands should be shoulder-width apart, and your head, neck, hips and legs should form a straight line. Do not let your back arch and cave in. Maintain a slight bend in the elbows. Lower your upper body by bending your elbows outward, stopping before your chest touches the floor. Contracting the chest muscles, slowly return to the starting position. Inhale while lowering your body, and exhale while returning to the starting position. "After mastering this exercise, you may wish to try the full push up," Raphael says. PAGEBREAK Bench Dips Using two benches or chairs, sit on one. Place both palms on this bench, with your fingers wrapped around the edge. Now, put both feet up on the other bench or chair. Slide your upper body off the chair with your elbows nearly but not completely locked. Lower your upper body slowly toward the floor until your elbows are bent slightly more than 90 degrees. Contracting your triceps (at the back of the arm), extend your elbows and return to the starting position -stopping just short of your elbows fully extending. Inhale while lowering your body, and exhale while returning to the starting position. "Beginners should start with their feet on the floor and their knees at a 90-degree angle," Raphael says. "As you progress, move your feet out further until your legs are almost straight, keeping a slight bend in both knees."

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Abdominal Double Crunch Lie face up on the floor. Bend your knees until your legs are at a 45degree angle, keeping both feet on the floor. Your back should be comfortably relaxed on the floor. Place both hands crossed on your chest. Contracting your abdominals, raise your head and legs off the floor toward one another. Slowly return to the starting position, stopping just short of your shoulders and feet touching the floor. Exhale while rising up, and inhale while returning to the starting position. "Keep your eyes focused on the ceiling to avoid pulling with your neck," Raphael says. "Your hands should not be used to lift the head or assist in the movement." When it comes to losing weight, the more you know, the more you lose. eDiets has more than 20 personalized plans and a team of nutritionists and fitness professionals ready and eager to tackle your extra pounds. Click here for a FREE diet profile and see how to lose the most weight!

FAQs Diet Support How is the eDiets plan structured, and what are its nutritional standards? Our goal is to provide every member with the program that fits their individual needs. All eDiets members have the opportunity to consult with our credentialed nutritionists to find the program that's right for them. For example, if you're concerned about heart disease, you may want to follow our Heart Smart Plan which follows the recommendations of the American Heart Association. People with diabetes may prefer our Living with Diabetes Plan which meets the guidelines of the American Diabetes Association. Are the calories in my meal plan specific for me? Yes. Your meal plan is created just for you, based on the information in your personal profile. We use your Body Mass Index (BMI) to determine the healthy weight for your height. If you want to maintain your weight, your meal plan delivers balanced nutrition and the right amount of calories to keep your weight stable. If you need to lose weight, your daily calories will deliver balanced nutrition and help you to lose 1 to 2 pounds per week without compromising lean body mass or energy. Studies have shown that losing weight too quickly makes it difficult to keep off. The faster you lose it, the faster you will put it back on. But 1 to 2 pounds per week is perfect for optimal results. What is BMI? The federal government implemented the Body Mass Index as an accurate and convenient method of determining healthy weight and defining your health risks. BMI does not factor into body type or muscle mass. A "normal" BMI falls within the 18.5 to 24.9 range. How do I know this is an effective program? Our program is based on the same nutritional standards advocated by healthcare professionals, so they are designed to be safe. And since weight loss is more successful with support, companionship and guidance, we offer a comprehensive support network to help you make the most of your plan. But don't just take our Nashville Community Health Improvement Model R.Taylor 01-15-10

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word for it! Read some of our members' awesome Success Stories and judge for yourself. How hard is it to prepare the meals? eDiets offers a variety of diets and weekly meal plans personalized to fit your needs. Your profile helps us match you to your perfect diet and design the right meal plan for you. You can choose the Convenience Plan if you're always on the go; Recipe Plan if you love to cook; or a Combination Plan that includes both. If you need help with meal plan options, contact our credentialed nutritionists at [email protected]. You can check out our full meal plan offering on the View All Diet Plans page or click here. Can I have the meals from my online menu delivered to my home? You can have your meals delivered to you with eDiets Meal Delivery. Not all plans are featured on the meal delivery program, but there are still a variety of different cuisines, the ability to customize your menu and to choose the specific meals you prefer. What if I don't like to cook or don't have the time? If you want an even easier way to lose weight, then eDiets Meal Delivery may be the choice for you. There is no cooking or cleanup. The meals are shipped directly to your doorstep weekly. Simply refrigerate and heat them when you're ready to eat. It's that simple! Switching to Meal Delivery is easy and you can continue losing weight without missing a step. Can I change my meal plan at any time? Yes. To change your current meal plan, go to View/Edit Preferences and select the meal plan you desire from the drop down menu in the Switch My Diet Plan section at the bottom of the page. Remember, once you change your meal plan, your weekly menu will change to fit your new meal plan. If you have already completed your grocery shopping for the week, you may want to consider waiting until the next week to change your meal plan. Should I print out my program each week? Yes! It's great to have a printed copy of your meal plan that you can reference any time you need. You can even bring your meal plan along with your shopping list when you go to the grocery store. This will make it even easier to make substitutions. Where is my meal plan information displayed? You can access your meal plan directly from your member home page. In addition, your Diet section provides direct access to your meal plan and other tools that will help you on the way. How do I change my preferences? It's easy! To change your plan preferences, select the View/Edit Preferences option in the Diet section. Submit your changes and then, review your meals and print your shopping list. How do I get my weekly program? To view your new meal plan, you need to go through the weekly check-in process. The weekly check-in process will give you the option to enter your current weight and generate a new meal plan. To weigh-in, click on the Check-in

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link to process your weekly check-in. When you are due to complete your weekly check-in, a check-in link will appear in the Meal Plan section of your eDiets Member Home page or you can access the Check-in within the Diet section. How often do I weigh in? Can I do it every day? You must weigh in once a week. Weigh yourself on the same scale each week, at the same time of day, wearing a similar amount of clothing. Do not weigh yourself every day. Weighing yourself daily will not produce an accurate representation of your progress. How do I track my progress? With weekly check-ins, we make tracking your progress easy! Your weigh-in and measurement history are always just a few clicks away. To view your progress, simply log on to your Diet Progress and Fitness Progress pages. What happens when I reach my goal weight? When you reach your goal weight, we'll help you stay there with a maintenance plan designed just for you. The calorie level in your meal plan will help you control your weight, and our online support plan can help you stay focused. After achieving your personal goals you may be interested in becoming an eDiets Mentor or telling others about your success by becoming an eDiets Success Story. As a Mentor you will assist new members in becoming acclimated with the eDiets website and also provide support and encouragement. For more information on our Mentor Program please visit the Mentor Room Support Board in the Community section of our website. To share your story, please write to [email protected]. What is the nutritional breakdown of the meal plans? The nutritional breakdown can vary depending on the meal plan you choose. Our eDiets meal plans, apart from the Living with Diabetes Plan, contain about 50-60 percent carbohydrate calories, 20-25 percent calories from protein and the remaining calories from fat. We normally recommend complex carbohydrates ("whole" foods with fiber that have not been overly processed to lose their nutritional value), lean protein (lean meats, skinless poultry, fish and soy proteins) and unsaturated fats (like olive and canola oil). Our meals and recipes follow the recommendations of the American Heart Association, the American Dietetic Association and the American Diabetes Association. You can check out our full meal plan offering and information about each on the View All Diet Plans page or by clicking here. If you have any questions about a meal plan, please contact Nutrition Support at 1-800-265-6170 begin_of_the_skype_highlighting 1-800-265-6170 end_of_the_skype_highlighting. How can I get additional nutrition or meal plan questions answered? Please contact Nutrition Support toll free at 1-800-265-6170 begin_of_the_skype_highlighting 1-800-265-6170 end_of_the_skype_highlighting or email [email protected]. Our nutritionists are here daily to assist you with your meal plan and nutrition questions. They'll help you to select the best meal plan, make sure you're taking in the right amount of calories on the right track to achieving your weight-loss goals, so please contact them for consultation today. Also, you can visit any of the Meal Plan Specific Support Boards for assistance from Nutrition Support.

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-------------------------------------------------------------------------------Meals, Recipes & Shopping Lists How can I change my meal if I don't like it? Next to each meal, you'll find a Change Meal option. Clicking the Change Meal option will display a list of meals you can substitute for that meal. Once you've selected your substitute meal, make sure you update your plan. We suggest that you review your meals for the week and make substitutions before printing your meal plan and shopping list. How does the shopping list work? Your weekly shopping list contains all the items you need to have on hand for the week. Take a few minutes to review your meals for the week then make any substitutions to your meal plan. After that, print out your shopping list. For accuracy, always print the shopping list last. I don't like buying a lot of different foods each week. What can I do? When you review your meal plan at the beginning of the week, make some changes. Choose simple meals or repeat a few meals so you don't have to buy so many different food items. Use your Substitution List. If you want to have baked potatoes several times in a week, you can substitute potato for rice or pasta, or bread at any meal. How can I substitute items in my meal plan? Is there a Substitution List? Yes! You can find your Substitutions List on the Tools page in your Diet section. Learning how to substitute one item for another is the key to success. Suppose you want to choose a different serving of starch or bread. The Substitutions List gives you plenty of options in the appropriate portion size. Just pick the one that works for you. How do I know the "serving size" of a food? The Substitutions List shows the serving size for every food. Serving sizes vary. For example, a "serving" of fruit could be one medium-sized piece of fruit, 4 ounces of unsweetened fruit juice, or 2 tablespoons of raisins. A "serving" of bread is one (1-ounce) slice of bread, 1/2 cup of cooked cereal or 1/2 cup of cooked dried beans. For a more general illustration of serving sizes check out the Serving Size Guide on your Diet Tools page. My store doesn't carry the frozen entree on my menu. Can I pick a different one? Yes. The Substitutions List includes instructions about substituting one frozen entree for another while staying within your plan's nutritional guidelines. You can choose your favorite entree and, depending on the calories, you can choose items to complete your meal while staying within the guidelines of your plan. I'm unfamiliar with an item on the menu. Where can I get information? If you are unfamiliar with an item on your menu please contact Nutrition Support for help at [email protected] How can I get a vegetarian meal plan? Do you offer different vegetarian options?

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eDiets offers a Vegetarian Plan. If you are not already on this plan, you can switch to it on the View/Edit Preferences page of your Diet section. You have the ability to customize your menu through exclusion options. On your View/Edit Preferences page, exclude any foods you don't like to eat, like meat or dairy. Several of the other meal plans can also be customized this way to offer vegetarian options. At the beginning of each week, review your plan and change any meal you don't want using the Change Meal option. -------------------------------------------------------------------------------Special Rules for Special Days How can I stay on my meal plan during the holidays? Holiday eating can be difficult, so we'll help you to plan ahead. Join a Support Board to help you plan your holiday eating strategies. You can even get your own personal mentor to help you survive the holidays. How can I make healthy food choices at a restaurant? When you know how to make healthy choices, you can eat anywhere without sacrificing your eating plan. Check out our Dining Out Guide in the Tools page of your Diet section. The guide has information about how to stay on track while eating out. -------------------------------------------------------------------------------Special Dietary Needs What's the difference between "food allergy" and "food intolerance?" Both allergies and intolerances produce symptoms, but the symptoms are usually more severe with an allergy. An allergy usually produces immediate symptoms, and you can test for food allergies. I have food allergies. How can I change my plan to avoid those items? We can exclude certain foods like milk, red meat, fish and chicken from your plan. For specific food allergies, use the Substitutions List to choose different food items in the same category as the food you want to replace. If you're allergic to wheat, we offer a Wheat-Free plan and encourage you to use the Recipe Plan since wheat is a "hidden ingredient" in many packaged foods. Remember, for more help, you can always contact a nutrition professional at [email protected]. I don't like milk, but I do like other dairy products. What should I do? Dairy foods are a great source of calcium, Vitamin D and protein. The following dairy products are interchangeable, so you can always substitute one for the other. 8 oz. nonfat or 1% fat milk = 8 oz. low-fat milk substitute (low-fat soy milk or rice milk)8 oz. low-fat or 1% fat Lactaid milk6 oz. nonfat or 1% fat plain yogurt (sugar-free or artificially

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sweetened)4 oz. nonfat or 1% fat pudding8 oz. nonfat sugar-free pudding2 oz. nonfat or low-fat hard cheese½ cup nonfat or 1% fat cottage cheese½ cup nonfat or 1% fat ricotta cheese What if I'm sick and don't have much of an appetite? Just stick to simple foods. Low-fat foods are best tolerated and plain foods will be more easily digested than those with sauces and spices. Keep hydrated by drinking plenty of fluids such as water, herbal and decaffeinated teas and bouillon. When you recover, return to your meal plan. What if I need to exclude certain foods due to my culture or beliefs? No problem. Many of our members keep to their customs while using our healthy meal plans to successfully lose weight. Our plans are flexible, so you can easily change a meal. If you need to eliminate certain foods, you can exclude them on your View/Edit Preferences page. You can also take advantage of our Substitutions List. Here you will find healthy alternatives, in the right portions, to the foods you need to avoid. -------------------------------------------------------------------------------Meal Delivery What is eDiets Meal Delivery? eDiets Meal Delivery is a comprehensive weight-loss program that features premium quality, freshly prepared meals and snacks in calorie-smart portions. These nutritionally balanced meals are offered in conjunction with the Web's premier community for weight-loss support, expert advice and news to give you the support you need to succeed. Created by a team of dietitians and trained chefs, eDiets offers a delicious, convenient and effective way to lose weight. How does eDiets Meal Delivery work? Once you select the plan that best fits your needs, you're ready to begin customizing your menu. Choose from more than 100 great-tasting, freshly prepared, chef-created meals. You'll choose one breakfast, lunch, dinner and snack for each day, or you can order our Members' Favorites Package. If you choose not to customize your own menu, then we will send you our Members' Favorites Package. The meals you select are then made to order with only the highest-quality ingredients and NO ADDED PRESERVATIVES, packed in our advanced "chillfresh" packaging, and shipped directly to you. All you do when your chefprepared meals are delivered to your home is heat, eat and enjoy! It's that simple. How can the eDiets Meal Delivery program benefit my health? Weight loss is only one of many reasons to join eDiets Meal Delivery. There are numerous other benefits including better health, more energy and adopting healthy eating habits while enjoying great tasting meals. How can eDiets Meal Delivery benefit my lifestyle?

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eDiets Meal Delivery is healthy and convenient - it's like having your own personal chef and dietitian every day! Eat amazing gourmet food and lose weight. No shopping, no planning, no cooking, and no cleaning. Save time and money while looking and feeling your best. What programs does eDiets offer? eDiets offers several programs to help you reach your goals: eDiets Meal Delivery Plan What makes eDiets Meal Delivery better for me than other programs? eDiets Meal Delivery is an exceptional weight-loss experience because you do not have to eat dehydrated diet food to lose weight. eDiets offers freshly prepared foods, delivered chill-fresh each week, including the favorites YOU select from a wide variety of delicious entrees. Your meals are made-to-order in our USDA-inspected kitchen, securely packed using our advanced "chill-fresh" packaging and delivered fresh to your front door. Plus, while you are receiving your deliveries, you have full access to eDiets' award-winning online and phone support from registered dietitians and personal trainers. You can call, email or live chat with any question any day of the week. Whether you have questions on how best to build muscle or are looking to manage a particular aspect of your nutrition profile better, our team is here to help you make the most of your weight-loss experience. You also have 24/7 access to more than 80 member support boards that include age-specific forums, popular diet topics and motivational challenges. It all adds up to an unparalleled level of support. To what areas do you deliver? eDiets Meal Delivery is available throughout the continental United States! We ship all orders via FedEx? delivery to your home or office. Do I need to be home to receive the meals? No. The meals will be left for you in a sealed weatherproof cooler and will be safe and cool when you arrive home. Though a few hours on your front porch will not have an impact on the meals, we do recommend you choose a delivery day that will not result in an unattended delivery for an extended period of time. What if my cooler arrives and the gel-packs are melted? If your cooler arrives and the gel-packs are melted, do not be alarmed. As long as the meals are still refrigerator cold to the touch, your order can be placed in the fridge with no impact on the quality. If you are not sure, then call Customer Service at 1-877-968-7343 begin_of_the_skype_highlighting 1-877-9687343 end_of_the_skype_highlighting. What if I will be out of town during a scheduled meal delivery? Not a problem. If you know in advance that you will be out of town and unable to receive your weekly delivery, you can simply SKIP that week. To do so, go to your Meal Delivery Preferences page and select which week(s) you would like to skip or give our customer service team a call at 1-877-968-7343 begin_of_the_skype_highlighting 1-877-968-7343 end_of_the_skype_highlighting. Remember, you must make any changes to your delivery schedule prior to the Cutoff day and time for that shipment.

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I'm picky. How will eDiets Meal Delivery cater to my unique tastes and specific nutritional requirements? With eDiets, you always have the option to create your own menu from our wide selection of meals to ensure that you receive the best variety possible according to your needs and tastes. All meals and program menus are designed and approved by our staff of dietitians. What if I'm on medication? We suggest consulting your physician before you start this or any other nutrition program. Are any preservatives used in the meals? We do not add any artificial preservatives to our meals, and we continue to strive to eliminate all preservatives in our menu items. Some pre-packaged snacks, sauces or pre-prepared items (such as tortillas) may contain small amounts of preservatives. If you have any ingredient sensitivities, please be sure to review the ingredients list and nutritional breakdown found on the label of the package. For your added convenience, you may also preview this information online. Do eDiets foods have trans fats? No. All of the eDiets meals contain zero trans fats. How long will the meals keep in my refrigerator? eDiets meals will stay fresh in your refrigerator for up to 10 days from receipt of your cooler. You may freeze them for up to three months if you wish to keep them longer. How is the food heated? All eDiets meals come packed in microwave-safe containers and can be reheated in as little as 1 to 2 minutes. Detailed heating instructions are included with every meal. You can eat the meals directly from the container for easy cleanup. Or if you prefer, you can transfer the meals to a regular dish for a more traditional presentation. What if I go out to eat? We understand that sometimes situations arise when you may not require one of your eDiets meals. If you are eating out, you can save your eDiets meal to eat at the end of your cycle. Your meals will stay fresh for up to 10 days after delivery with refrigeration or you can store your meal in the freezer for up to three months to eat at a later date. Our five-day meal plan options offer the perfect balance of structure and flexibility for those who eat out frequently as part of their lifestyle. We recommend you use your eDiets meals as a guide to eating appropriate portion sizes while eating out. You may also want to consult your eDiets Dining Out Guide for some helpful suggestions. I like to eat out on the weekends. Will this program work for me? Of course! You may simply want to select the "weekends free" option. It's the same great food in a five-day plan. The five-day plan allows for more flexibility than the seven-day plan and you can easily switch from one plan to the other as your needs change. Can I drink alcohol?

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Your daily plan is specifically tailored to your nutritional requirements. If you choose to drink alcohol, limit intake to no more than two drinks a day for men and one a day for women. (One drink is 12 ounces of light beer, 5 ounces of wine, or 1.5 ounces of liquor.) Alcohol intake can increase your calorie intake and may inhibit or delay weight loss. How much weight loss can I expect? A safe and healthy weight loss is between 1-2 pounds per week. While our program has yielded excellent results, everyone is different, and individual results can vary, depending on many factors including age, activity level, amount of exercise, medical conditions and current weight. When I reach my weight goal, what happens? We suggest switching to one of our maintenance diets. You can still get your food delivered with our 5-Day Plan, or switch to online meal plans and prepare your meals yourself. You won't lose any history, and you can switch back to meal delivery whenever you wish. Do I eat my meal or snack even if I'm not hungry? We encourage eating all the meals listed on your meal plan. Your meal plan has been designed to provide you with essential nutrients necessary for optimal energy, nutrition and healthy weight loss. What if I am still hungry? In addition to eating your meals and snack, you should be adding in 2 servings of nonfat dairy and 3 servings of fruit daily. Please refer to your Shopping List for recommended portions. Whether you add these items to a meal or save them to eat as a snack in between your meals is up to you. Keep in mind, eating something every 2-3 hours will help to curb your hunger. If you need further assistance, don?t hesitate to contact Nutrition Support at 1-877-968-7343 begin_of_the_skype_highlighting 1-877-968-7343 end_of_the_skype_highlighting. I'm not overweight. Why would I want to follow eDiets Meal Delivery? Weight loss is only one of many reasons to sign up for eDiets Meal Delivery. There are a number of other benefits to our program, including better health and the simplicity and convenience of having freshly prepared gourmet meals delivered to your home! Do I have to order online? You can, or you may call 1-877-968-7343 begin_of_the_skype_highlighting 1-877-968-7343 end_of_the_skype_highlighting to reach an eDiets representative who will be happy to take your order over the phone and answer any questions you may have. What if I'd like to stop receiving deliveries? Do I have to cancel my account? No, you can simply switch to a digital plan to continue your weight loss without losing any of your history, support or member benefits. Switching back to Meal Delivery is easy whenever you are ready. Is there an additional fee for the fitness program and expert consultations? No. At eDiets, we believe that meals are only part of the weight-loss equation. Including a fitness program, following a meal plan, and receiving support from our experts and community will help you achieve your goals.

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All eDiets Meal Delivery memberships include FREE access to all the features and services eDiets offers, including: unlimited online and phone support, customized fitness plans, complete access to the community, eTools, newsletters, and so much more! What can I do with leftover packaging? We continually strive to provide the proper balance between minimizing packaging and providing a fresh, food-safe product. While improvements are an ongoing process, our current meal delivery packaging is highly recyclable as follows: Styrofoam Coolers Our Styrofoam coolers are expanded polystyrene, material #6 in the recycling system and contain no chlorofluorocarbons (CFCs). They are reusable and can maintain temperatures of perishable goods with a minimum amount of refrigeration for an extended period of time. If you choose not to keep and reuse your coolers, they can be donated to youth camps for outdoor activities, local food shelters or thrift stores. If you would like more information on polystyrene materials or local recycling drop-off locations, you can visit the Alliance of Foam Packaging Recyclers at http://epspackaging.org/info.html. Gel Packs To dispose of the gel packs, you may place them in the trash or reuse by placing them flat in a freezer for later use. The gel packs contain a USDA-approved, food-grade substance for safety reasons and are non-toxic. However, they should not be poured down a sink. Food Trays The plastic food trays can be recycled or reused to store food and non-food items, such as office, school or craft supplies. All other packaging materials contained in your Meal Delivery shipment can be deposited in your home recycling bin for regular pickup and sorting. Want a great way to recycle your gel packs and beautify your garden at the same time? Simply empty the liquid contents of each gel pack into your garden's soil or mulch and discard the outer bag in your recycling bin. The gel pack content will help your garden retain moisture and grow larger, healthier plants. Please be assured this food-grade liquid will not harm any plants, humans or animals that come in contact with the soil. -------------------------------------------------------------------------------eDiets.com Member Services Still have questions?

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Use the information below to contact us directly and we'll answer your question personally. Contact Us Feel free to contact us using any of the methods below: Customer Support: Toll-free: 1-800-265-6170 begin_of_the_skype_highlighting 1-800-2656170 end_of_the_skype_highlighting Meal Delivery Toll-free: 1-877-YOUR-DIET begin_of_the_skype_highlighting 1-877-YOUR-DIET end_of_the_skype_highlighting or 1-877-968-7343 begin_of_the_skype_highlighting 1-877-968-7343 end_of_the_skype_highlighting E-mail: [email protected] Nutrition Support: Toll-free: 1-800-265-6170 begin_of_the_skype_highlighting 6170 end_of_the_skype_highlighting E-mail: [email protected]

1-800-265-

Updates 12-11-09 Sent second time with attachment.) Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020

Announcement of the December 11, 2009 Meeting The Secretary's Advisory Committee on National Health Promotion and Disease Prevention Objectives for 2020 will hold a meeting on the Internet on December 11, 2009 from 1: 30 p.m. to 3: 30 p.m. Eastern Time. The meeting will be open to the public. The meeting agenda is attached. Members of the public are invited to listen to the online Committee meeting. To attend the online meeting, individuals must pre-register to attend at the Healthy People Web site at www.healthypeople.gov/hp2020/advisory/default.asp. There will be no opportunity for oral public comments during the meeting. Written comments are welcome throughout the development process of the national health promotion and disease prevention objectives for 2020. They can be submitted through the Healthy People Web site at: www.healthypeople.gov/hp2020/comments or they can be e-mailed to [email protected] . Please note that the public comment Web site will be updated throughout the Healthy People development process, so people should return to the site frequently to provide their input. Participation in the meeting is limited. Registrations will be accepted until maximum capacity is reached. Registration for the online meeting must be completed by 9:00 a.m. ET on December

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11, 2009. A waiting list will be maintained should registrations exceed meeting capacity. Individuals on the waiting list will be contacted as additional space for the meeting becomes available. For detailed instructions about how to make sure that your Windows-based computer and browser are set up for the online meeting using WebEx software, please visit the Healthy People Web site at www.healthypeople.gov/hp2020/advisory/default.asp. Registration questions may be directed to Hilary Scherer at [email protected] (e-mail), (301) 634-9374 (phone), or (301) 634-9301 (fax).

12-11-09

Email to Jeff

I will be meeting with Melissa at 10:30 am on Monday and would like to follow up that meeting with a meeting with you and Melissa right after the holidays.

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As I mentioned to you at our lunch meeting, I believe there is a unique window of opportunity to develop and implement a community health improvement solution in Nashville that could also serve as a national model for improving health value and health outcomes (which in turn would help support the stated mission of the Division of Health Planning to “ensure that relevant programs and services across state

government are coordinated and leveraged to optimize health outcomes and value for Tennesseans”. ). These ideas for an innovative community health improvement solution for Nashville are summarized below for your review and feedback (I would particularly like to have your feedback from a political perspective and how this might fit into your Tennessee Health Plan goals). 1. Reduce Nashville Indigent Care Costs One of Mayor Dean's top priorities for 2010 is to find a way to reduce indigent care costs which in 2008 cost the city about $66 million dollars. The City hired John Snow Inc. to develop recommendations to reduce costs. CIBER and Data Futures presented the CareScope model (that I sent to you) to John Snow a few weeks ago, and they loved the model. Based on the documented savings in Minneapolis/St. Paul and Escambia County, we believe the use of the CareScope model could save Nashville up to $5 million a year in indigent care costs (after a $1.5 million investment (the net gain would be $3.5 million for Nashville). We would propose that the non profit Bridges to Care and the Nashville Health Dept operate the CareScope model. 2. Improve Health Outcomes In Nashville At the Health and Well-Being: Keys to Transformation Conference in Nashville on November 2, Mayor Dean said he would like to see Nashville become America's 2nd Blue Zone City. Newt Gingrich said his Center for Health Transformation is looking for a city that would be willing to become a Blue Zone City. Governor Bredesen shared how he is a proponent for innovative health solutions (and had his picture taken shaking hands with Newt Gingrich). To accomplish this goal, I have developed a high level plan based on successful models in other cities that could be implemented in Nashville. This plan calls for the State of Tennessee Health Planning, Health INfo Partnership of Tennessee, Vanderbilt, Meharry College, CIBER, Bridges to Care, Metro Nashville, and key Nashville based private companies (Healthways and others) to develop and implement this proposed community health improvement system. This system would use the Gallup/Healthways Well Being Index and/or the upcoming CDC Nationwide County Health Rankings report (out in February) as the benchmark to measure progress (Newt loves benchmarks and progress reports). We could tap your new Health Plan data warehouse solution (Onpoint) to provide analytical reports). This proposed solution would be paid for with grant funds from the CDC (part of their Healthy America 2020 program (CIBER has a close relationship with the CDC), cost savings from the Indigent Care Solution described above (take $1.5 million from the $3.5 million in savings), and money from Newt's Center for Health Transformation and possibly the State. In addition, the participating private companies could offer their services at cost or for free. The code name I have given this system is "the Ultimate Community Health Improvement System" (I would like to share the details of this proposed system to you the next time we meet). Many of the technology components for this proposed system would come from Nashville based companies.

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3. Implement a new health information exchange in Nashville that would capture the data needed for managing the health improvement program (item # 2 above) and to facilitate the sharing of medical data to improve the quality of healthcare and reduce costs. The Nashville based Middle Tennessee eHealth group has already selected 3 finalists (one of which is Nashville based Informatics Corp of America (same system used for Memphis HIE) for the HIE software. They are just waiting on input from Melissa regarding stimulus money. This HIE solution could be used to help coordinate the collection and analysis of data for proposals 1 and 2 above. (I will be asking Melissa on Monday about the status of funding for the Nashville HIE) 4. Generate new jobs for Nashville area companies. Implementing proposals 1,2, and 3 above using technology solutions from mostly Nashville based companies would generate new high tech jobs for the Nashville area. In addition, these innovative "national model" solutions would generate additional jobs as the Nashville based companies sell and implement their respective Nashville solutions to other cities in the country. With the expectation that the recently announced Nashville based HealthCare Trade Mart will be built in the old Nashville Convention Center, we would have a great way to showcase and advertise these 3 Nashville Health Improvement Solutions to the world (in turn generating even more new jobs for the Nashville based companies that are providing the solutions described above (items 1,2, and 3). The bottomline is that the four proposals above could: 1. Save the City of Nashville millions of dollars in reduced indigent care costs -freeing dollars that could be reinvested in the proposed community health improvement solution. 2. Significantly improve the health of Nashvillians - in turn reducing healthcare costs for area employers and making Nashville a more attractive city in which to base a business (e.g. to help counter the negative image of Tennessee's health outcomes ranking of 47th in America). 3. Generate new healthcare IT jobs for Nashville based companies which in turn would increase tax revenue for the City of Nashville and help promote more healthcare companies to potentially locate in Nashville (and support the success of the new HealthCare Mart - which would help generate more health related conferences for the new Nashville Convention Center which would generate more revenue for Nashville (visitor dollars). P.S. 1. At the Well Being conference, Mayor Dean announced that he was planning a major community health summit in January (perhaps to announce or discuss the recommendations from the John Snow Nashville Indigent Care Report- do you know anything about this planned summit? P.S. 2 - My friend - Councilman Paul Burch - did meet with Mayor Dean on Wednesday and mentioned the CareScope model. Mayor Dean said he would like to hear more about this model. Consequently, I would like to pursue setting up a meeting with Mayor Dean in early January to discuss the CareScope model (and perhaps the other solutions above) in advance of his planned community health summit. As an experienced Councilman yourself, I would welcome your thoughts on scheduling this meeting with the Mayor and making a presentation (also - would you be interested in participating?). I would certainly like to say that you as the Director

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of Health Planning for the State of Tennessee - would support some of the proposed models for improving health outcomes and health value in Nashville). Your thoughts and suggestions regarding these ideas would be most welcomed. Thanks.

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Email from Jeff Ockermann

I enjoyed it, too! SHP is attached. Thanks for the CareScope solution description. Feel free to let Liesa know I'll contact her about the goals for the SHP. And thanks for letting me know about your setting up a meeting with Melissa. On the run! We'll get together again, soon. Thanks, Jeff >>> "Taylor, Richard" <[email protected]> 12/10/2009 9:58 AM >>> I certainly enjoyed our lunch meeting yesterday. It was so good to see you again. Glad to hear that you resolved your house matter, and am looking forward to our next meeting and seeing your pictures from Prague. Please find attached a description of the CareScope solution that we submitted to the city's consulting firm (John Snow Inc) to reference in their Indigent Care Study for the City of Nashville (as a possible model for reducing the city's indigent care costs ($66 million a year). As you will see in the attached report, the CareScope model was able to save the Minneapolis/St. Paul area about 50% in ER room costs over a one year time frame and generated similar savings for Escambia County in Florida. I am part of the CIBER team that is helping Data Futures implement the CareScope solution for Pinellas County Florida (Clearwater/St. Pete). Congratulations again on the state health plan and the all payor cost legislation. I would love to have a copy of the approved State Health Plan if you can send it. Also will let Liesa Jenkins (head of CareSpark) know that I mentioned her idea to you yesterday (should I also say that you are open to talking with her more about your plans for setting outcome goals for the state?). Melissa replied to my email yesterday that she would like to meet with me next week. I will let you know when we have a confirmed date and time.

Overview Common denominator = Improving Health Value and Health Outcomes Through Innovative Solutions for Improving Health Value and Health Outcomes It takes a village and a team and a plan to improve community health

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Better health = better students , better workers, and better quality of life and lower health care costs. Healthy Communities Institute

The Healthy Communities Institute developed the Healthy Communities Network (HCN) to provide an easy to understand dashboard view of the health and wellness of states, counties, and sub-county regions. For the Collaborative, HCN can provide a “living” report card on the heath and well-being of Colorado communities - enabling policymakers and stakeholders at state and local levels to evaluate progress on community health and wellness measures. One key aspect to the presentation of indicators in HCN is the ability to compare how Colorado and its communities are doing in relation to the distribution of U.S. states and counties as well as national public health standards such as the Center’s for Disease Controls Healthy People 2010 benchmarks. For the Collaborative, HCI would provide: • State-level HCN site for Colorado that provides a state-level of view of 100 core indicators and a pull-down navigation menu to view the same core indicators at a county level • Regional HCN sites for Colorado that provide county and regional views, including zipcode –level views of data when data is available, for 100 core indicators plus localization of each homepage to reflect the local community, stakeholders, and promote local health improvement initiatives. • State and regional systems include rich related content including over 1200 promising practices, heath and wellness news, and the tools to incorporate unlimited local reports, indicators, events, and local resource databases.

The Healthy Communities Network System Overview The Healthy Communities Institute has created a web-based information system for use by hospitals, counties and regions, which was designed based on research at the University of California at Berkeley. The system, called the Healthy Communities Network™ (HCN™), provides an easy to understand presentation layer of health, environmental and other quality of life indicators for stakeholders in communities (hospitals, Boards of Supervisors, Mayors, health departments, economic development, education centers, foundations, employers, etc). HCN™ can be thought of as a living Community Needs Assessment, and helps hospitals meet IRS 990 and California SB 697 requirements. It also links people in the community to promising practices and many other resources to help them move beyond a community report card to informed action. One local Health Director described this system as “providing a face to public health data and issues.”

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The primary problem the Healthy Communities Network™ was designed to solve is that health, environmental, economic and other departments collect a wide range of data, and yet it has remained a great challenge to help stakeholders in communities understand this data and be able to take concrete action to improve areas of target interest. The Healthy Communities Network™ tracks over 100 health and quality of life indicators for Counties, and contains over 1,000 community-level interventions and policy models. It offers many features to help users work with government and non-government groups to effect change, such as learning from the hundreds of successful community interventions around the country. In essence, the Healthy Communities Network™ allows communities to identify key areas requiring attention, and increases the efficiency of implementing tried and true programs to address target problems. About The Healthy Communities Institute Our mission is to help hospitals and counties improve the health and environmental sustainability of their communities. We believe you will find the HCN™ to be a great help to accomplish these goals. We are a team of scientists, researchers, technologists, community development experts and business people who are committed to providing the technology to support the community health development. Senior Management:  Deryk Van Brunt, DrPH, President Associate Professor, UC Berkeley; CEO, Chairman, eMedicine; COO HealthCentral; COO Windom Health  Marcos Athanasoulis, DrPH, CTO Director IT, Harvard Medical School; VP Product Development; Relay Health; CTO HealthCentral  Florence Reinisch, VP Research and Product MPH Epidemiology; 15 years Research Dir California Health Dept.,  Nick Beard, MD, MS, CMO, VP Marketing PricewaterhouseCoopers, IDX/GE; Professor, Oregon Health & Science University  Jan Barker, Business Development BOD Sleep Solutions; Investor/GM IPMC; Investor/Advisor PointShare; COO Alere Medical; Regional CEO MedPartners  Kathi de Fremery, MBA, Director of Finance Finance Director, Center for Volunteer & Non-profit Leadership Why Is Community Health Important? Over 50% of the determinants of health are related to people’s lifestyles and the environment (social and physical) in which we live. These factors contribute Nashville Community Health Improvement Model R.Taylor 01-15-10

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heavily to death rates, hospitalizations, productivity and happiness of people in communities. The HCN™ system supports a systematic method of identifying each community’s strengths and weaknesses, and enables the best practice sharing to address the high human and financial costs of poor health and poorly managed environments. What Do You Receive When You Obtain The HCN™ system? The HCN™ is a web-based information system that can be launched for any county or region in the United States. When the HCN™ is launched, it begins with a critical mass of content preloaded into the system; these features include:  Dashboard of Health and Quality of life Indicators (100+ per county)  Promising Practices (1,000+)  Local Resources (links to Network of Care and other resources)  Report Assistant (enables rapid development of reports and grant proposals focused on the community)  News, Newsletters, Featured Stories  Initiative Centers, Topic Centers  Event Calendar  Surveys  Search, Administrative Tools  Contextual links to county programs and services on all existing county websites  Priority pages to highlight community goals and progress towards those goals (coming Summer 2009) In addition, the HCN™ system enables communities to add content that is unique to them, such as local promising practices, new local indicators, etc. through an easy to use web interface. Why Use The System? What Are The Benefits? The benefits of using the HCN™ System are many. Hospitals, Boards of Supervisors, Mayors, Community Benefit Directors, government agencies, nonprofit organizations and civic minded members of the general public  all of these users have documented value and benefits from using HCN. Reported benefits of the HCN™ System include:  Provides a constantly updated Community Needs Assessment with reporting and tracking tools – a living community benefit.  Critically useful tool for community assessment reports and strategic planning

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 Increases capacity for local government and health directors to meet NACo and NACCHO Performance Standards (collect broad indicators, define priorities, apply new marketing methods to communicate, etc)  Strongly improves MAPP activities (systems approach, community partnerships, data requirements, engage community, etc.)  Brings stakeholders together, enabling traditional health care to partner with public health and the communities that the hospitals serve  Provides users with the convenience of having:  More than 100 indicators in one place, with context, constantly updated  Linked to 1,000+ Community Best Practices, Local Resources – to take action  Community Initiative Platform  The future of Public Health – transparency and best practice sharing  Provides links to vital health services as well as free and low-cost preventative programs and classes. How Do I Obtain The HCN System? The HCN™ System is available for any county or region in the United States, and takes roughly 3 to 4 months to launch. The team at HCI is ready to provide you and your colleagues with a demonstration of the HCN™ System and discuss the potential benefits for your community. Example Implementations San Francisco, CA: http://www.healthmattersinsf.org Marin County, CA: http://www.healthymarin.org Whatcom County, WA: http://www.whatcomcounts.org San Bernardino County, CA: http://www.healthysanbernardinocounty.org We are very excited to work closely with you to make the Healthy Communities Network™ a vibrant and valuable resource in your community, and throughout the United States. Deryk Van Brunt, DrPH Chairman, Healthy Communities Institute Clinical Professor, UC Berkeley Main Office Line: 866-499-6423 Direct Office 415-456-1842 [email protected]

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What We Really Do – and Don’t – Know About Health in This Nation

What do we know about the levels of population health and the state of medical care and the many other determinants of health across the United States? Despite years of data collection, it has been difficult to gain a comprehensive view of population health. As Atul Gawande wrote last year in the New Yorker, “The poverty of our health-care information is an embarrassment…The most recent data are at least three years old, if they exist at all, and aren’t broken down to a county level that communities can learn from. It’s like driving a car with a speedometer that tells you only how fast all cars were driving, on average, three years ago.” While Gawande was referring specifically to medical care, the same is true for all health outcomes and health determinants. Without this monitoring and measuring, it is impossible to know if we are making any headway, if we are investing our resources in the right places to improve health and reduce disparities, or if some areas are falling irrevocably behind. But new work is starting to lift this veil of ignorance. Here’s how. For the last six years the University of Wisconsin Population Health Institute has released rankings of the health of each county in Wisconsin. While calling attention to the counties with the highest and lowest health can be controversial, we have learned that the rankings often have raised awareness about the opportunities for action and improvement. But this year, with a grant from the Robert Wood Johnson Foundation, the Wisconsin model was used to rank the health of almost all 3,140 counties in all 50 states. Why would the Robert Wood Johnson Foundation invest significant resources to spread the Wisconsin model around the country? Isn’t being first or last pretty straightforward? Don’t we see rankings every week about how we compare to other states and nations on different measures, such as the environment or the economy? The answer is that the Wisconsin approach is far more thorough. It does not just label a county as high or low but assists in showing the path to improvement. Each county is not only ranked on its health outcomes – such as mortality and how many days we are unhealthy – but also on the factors that produce these outcomes. Importantly, these factors include medical care, as well as the other contributions from our health behaviors, like the physical environment and such social factors as income and education. Many people are not aware

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that nonmedical factors are as important as medical care in the health outcomes of individuals and communities. Also, counties vary in how well they are doing across these factors. In a particular county, lifestyle factors may be poor while health care access and quality rank high. The Wisconsin model of ranking allows counties to see where specific priorities for improvement exist. Over the past six years in Wisconsin, this ranking model has stimulated a much better understanding of the multiple factors producing health, as well as the recognition that many sectors have to be involved – not just doctors and hospitals, but also schools, businesses, state and local government, and community advocacy groups. We are hopeful that using this model around the country will create similar understanding and action nationwide. Since the February 17 release of information on every county in the nation, there have been more than 400,000 unique hits on the web site with the data, with most viewers viewing multiple pages. One government official from another state has already asked us, “Could we devise an incentive program for our counties that rewards them for advancement in their ranking scores or for advancement in particular indicators? I think we might be amazed at what we could stimulate in terms of action if we put a little structure around this and stimulated a competition among them.” That’s a good point. These rankings have enormous potential to mobilize community leaders to see what is making their residents sick or unhealthy and develop solutions that would give everyone healthier choices. Everyone in a community has a stake in this. We all need to work together to find solutions such as supporting early childhood education, making health care more affordable, providing more walking paths, promoting affordable access to healthier foods, or enacting smoke-free laws. We are pleased to have our Wisconsin rankings method recognized and adapted for all 50 states. Now that we can see how fast we are going, to use Gawande’s metaphor one more time, perhaps we can begin to engage in a new conversation about where we are headed, whether we really want to go there, and maybe even where else we might like to go instead. All postings to the Health Policy Forum (whether from employees or those outside the Institute) represent the views of the individual authors and/or organizations and do not necessarily represent the position, interests, strategy, or opinions of Altarum Institute. Read m

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Dept. of Medicine

TESTING, TESTING The health-care bill has no master plan for curbing costs. Is that a bad thing?

by Atul Gawande December 14, 2009 Text Size: Small Text Medium Text Large Text Print E-Mail Feeds In medicine, as in agriculture, efficiency cannot be achieved by fiat. Cost is the spectre haunting health reform. For many decades, the great flaw in the American health-care system was its unconscionable gaps in coverage. Those gaps have widened to become graves—resulting in an estimated forty-five thousand premature deaths each year—and have forced more than a million people into bankruptcy. The emerging health-reform package has a master plan for this problem. By establishing insurance exchanges, mandates, and tax credits, it would guarantee that at least ninetyfour per cent of Americans had decent medical coverage. This is historic, and it is necessary. But the legislation has no master plan for dealing with the problem of soaring medical costs. And this is a source of deep unease. Health-care costs are strangling our country. Medical care now absorbs eighteen per cent of every dollar we earn. Between 1999 and 2009, the average annual premium for employer-sponsored family insurance coverage rose from $5,800 to $13,400, and the average cost per Medicare beneficiary went from $5,500 to $11,900. The costs of our dysfunctional health-care system have already helped sink our auto industry, are draining state and federal coffers, and could ultimately imperil our ability to sustain universal coverage. What have we gained by paying more than twice as much for medical care as we did a decade ago? The health-care sector certainly employs more people and more machines than it did. But there have been no great strides in service. In Western Europe, most primary-care practices now use electronic health records and offer after-hours care; in the United States, most don’t. Improvement in demonstrated medical outcomes has been modest in most fields. The reason the system is a money drain is not that it’s so successful but that it’s fragmented, disorganized, and inconsistent; it’s neglectful of low-profit services like mentalhealth care, geriatrics, and primary care, and almost giddy in its overuse of highcost technologies such as radiology imaging, brand-name drugs, and many elective procedures. At the current rate of increase, the cost of family insurance will reach twentyseven thousand dollars or more in a decade, taking more than a fifth of every dollar that people earn. Businesses will see their health-coverage expenses rise from ten per cent of total labor costs to seventeen per cent. Health-care spending will essentially devour all our future wage increases and economic growth. State

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budget costs for health care will more than double, and Medicare will run out of money in just eight years. The cost problem, people have come to realize, threatens not just our prosperity but our solvency. So what does the reform package do about it? Turn to page 621 of the Senate version, the section entitled “Transforming the Health Care Delivery System,” and start reading. Does the bill end medicine’s destructive piecemeal payment system? Does it replace paying for quantity with paying for quality? Does it institute nationwide structural changes that curb costs and raise quality? It does not. Instead, what it offers is . . . pilot programs. This has provided a soft target for critics. “Two thousand seventy-four pages and trillions of dollars later,” Mitch McConnell, the Senate Minority Leader, said recently, “this bill doesn’t even meet the basic goal that the American people had in mind and what they thought this debate was all about: to lower costs.” According to the Congressional Budget Office, the bill makes no significant longterm cost reductions. Even Democrats have become nervous. For many, the hope of reform was to re-form the health-care system. If nothing is done, the United States is on track to spend an unimaginable ten trillion dollars more on health care in the next decade than it currently spends, hobbling government, growth, and employment. Where we crave sweeping transformation, however, all the current bill offers is those pilot programs, a battery of small-scale experiments. The strategy seems hopelessly inadequate to solve a problem of this magnitude. And yet—here’s the interesting thing—history suggests otherwise. At the start of the twentieth century, another indispensable but unmanageably costly sector was strangling the country: agriculture. In 1900, more than forty per cent of a family’s income went to paying for food. At the same time, farming was hugely laborintensive, tying up almost half the American workforce. We were, partly as a result, still a poor nation. Only by improving the productivity of farming could we raise our standard of living and emerge as an industrial power. We had to reduce food costs, so that families could spend money on other goods, and resources could flow to other economic sectors. And we had to make farming less labor-dependent, so that more of the population could enter non-farming occupations and support economic growth and development. America’s agricultural crisis gave rise to deep national frustration. The inefficiency of farms meant low crop yields, high prices, limited choice, and uneven quality. The agricultural system was fragmented and disorganized, and ignored evidence showing how things could be done better. Shallow plowing, no crop rotation, inadequate seedbeds, and other habits sustained by lore and tradition resulted in poor production and soil exhaustion. And lack of coördination led to local shortages of many crops and overproduction of others. You might think that the invisible hand of market competition would have solved these problems, that the prospect of higher income from improved practices would have encouraged change. But laissez-faire had not worked. Farmers relied so much on human muscle because it was cheap and didn’t require the long-term investment that animal power and machinery did. The fact that land, too, was cheap encouraged extensive, almost careless cultivation. When the soil became exhausted, farmers simply moved; most tracts of farmland

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were occupied for five years or less. Those who didn’t move tended to be tenant farmers, who paid rent to their landlords in either cash or crops, which also discouraged long-term investment. And there was a deep-seated fear of risk and the uncertainties of change; many farmers dismissed new ideas as “book farming.” Things were no better elsewhere in the world. For industrializing nations in the first half of the twentieth century, food was the fundamental problem. The desire for a once-and-for-all fix led Communist governments to take over and run vast “scientific” farms and collectives. We know what that led to: widespread famines and tens of millions of deaths. The United States did not seek a grand solution. Private farms remained, along with the considerable advantages of individual initiative. Still, government was enlisted to help millions of farmers change the way they worked. The approach succeeded almost shockingly well. The resulting abundance of goods in our grocery stores and the leaps in our standard of living became the greatest argument for America around the world. And, as the agricultural historian Roy V. Scott recounted, four decades ago, in his remarkable study “The Reluctant Farmer,” it all started with a pilot program. In February, 1903, Seaman Knapp arrived in the East Texas town of Terrell to talk to the local farmers. He was what we’d today deride as a government bureaucrat; he worked for the United States Department of Agriculture. Earlier in his life, he had been a farmer himself and a professor of agriculture at Iowa State College. He had also been a pastor, a bank president, and an entrepreneur, who once brought twenty-five thousand settlers to southwest Louisiana to farm for an English company that had bought a million and a half acres of land there. Then he got a position at the U.S.D.A. as an “agricultural explorer,” travelling across Asia and collecting seeds for everything from alfalfa to persimmons, not to mention a variety of rice that proved more productive than any that we’d had. The U.S.D.A. now wanted him to get farmers to farm differently. And he had an idea. Knapp knew that the local farmers were not going to trust some outsider who told them to adopt a “better” way of doing their jobs. So he asked Terrell’s leaders to find just one farmer who would be willing to try some “scientific” methods and see what happened. The group chose Walter C. Porter, and he volunteered seventy acres of land where he had grown only cotton or corn for twenty-eight years, applied no fertilizer, and almost completely depleted the humus layer. Knapp gave him a list of simple innovations to follow—things like deeper plowing and better soil preparation, the use of only the best seed, the liberal application of fertilizer, and more thorough cultivation to remove weeds and aerate the soil around the plants. The local leaders stopped by periodically to confirm that he was able to do what he had been asked to. The year 1903 proved to be the most disastrous for cotton in a quarter century, because of the spread of the boll weevil. Nonetheless, at the end of the season Porter reported a substantial increase in profit, clearing an extra seven hundred dollars. He announced that he would apply the lessons he had learned to his entire, eight-hundred-acre property, and many other farmers did the same. Knapp had discovered a simple but critical rule for gaining coöperation: “What a

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man hears he may doubt, what he sees he may possibly doubt, but what he does himself he cannot doubt.” The following year, the U.S.D.A. got funding to ramp up his activities. Knapp appointed thirty-three “extension agents” to set up similar demonstration farms across Texas and into Louisiana. The agents provided farmers with technical assistance and information, including comparative data on what they and others were achieving. As experience accrued, Knapp revised and refined his list of recommended practices for an expanding range of crops and livestock. The approach proved just as successful on a larger scale. The program had no shortage of critics. Southern Farm Magazine denounced it as government control of agriculture. But, in 1914, after two years of stiff opposition, Congress passed the Smith-Lever Act, establishing the U.S.D.A. Cooperative Extension Service. By 1920, there were seven thousand federal extension agents, working in almost every county in the nation, and by 1930 they had set up more than seven hundred and fifty thousand demonstration farms. As Daniel Carpenter, a professor of government at Harvard, points out, the demonstration-farm program was just one of a hodgepodge of successful U.S.D.A. initiatives that began as pilots. Another was devoted to comparativeeffectiveness research: experimental stations were established—eventually, in every state—that set about determining the most productive methods for growing plants and raising livestock. There was a pilot investigation program, which, among other things, traced a 1904 fruit-decay crisis in California to cuts in the fruit from stem clippers and the fingernails of handlers (and, along the way, introduced modern packing methods industry-wide). The U.S.D.A.’s scientific capabilities grew into the world’s greatest biological-discovery machine of the time. The department invested heavily in providing timely data to farmers, so that they could make more rational planting decisions. It ran the country’s weatherforecasting system. And its statistics service adopted crop-reporting systems from Europe that allowed it to provide independent crop forecasts—forecasts that, among other things, dramatically reduced speculation bubbles. (In 1927, Republicans, prompted by aggrieved New York speculators, managed to prohibit the U.S.D.A. from releasing the forecasts; the program was reinstituted three years later, following an outcry from farmers.) The department continuously updated its storehouse of technical assistance, so that when new technologies arrived—new hybrid varieties, new kinds of fertilizer, new forms of mechanization —farmers were able to make use of them more swiftly and effectively. The U.S.D.A. established an information-broadcasting service. A hundred and seventeen commercial and forty-six military radio stations carried crop reports; printed reports were distributed to fifteen million farmers a year. It also introduced a grading system for food—meat, eggs, dairy products, and fresh fruits and vegetables—to flag and discourage substandard quality. What seemed like a hodgepodge eventually cohered into a whole. The government never took over agriculture, but the government didn’t leave it alone, either. It shaped a feedback loop of experiment and learning and encouragement for farmers across the country. The results were beyond what anyone could have

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imagined. Productivity went way up, outpacing that of other Western countries. Prices fell by half. By 1930, food absorbed just twenty-four per cent of family spending and twenty per cent of the workforce. Today, food accounts for just eight per cent of household income and two per cent of the labor force. It is produced on no more land than was devoted to it a century ago, and with far greater variety and abundance than ever before in history. This transformation, though critical to America’s rise as a superpower, involved some painful dislocations: farms were consolidated; unproductive farmers were winnowed out. As the historian Sally Clarke, of the University of Texas at Austin, has pointed out, it’s astonishing that the revolution took place without vast numbers of farm foreclosures and social unrest. We cushioned the impact of the transformation—with, for instance, price supports that smoothed out the price decline and avoided wholesale bankruptcies. There were compromises and concessions and wrong turns. But the strategy worked, because United States agencies were allowed to proceed by trial and error, continually adjusting their policies over time in response not to ideology but to hard measurement of the results against societal goals. Could something like this happen with health care? There are, in human affairs, two kinds of problems: those which are amenable to a technical solution and those which are not. Universal health-care coverage belongs to the first category: you can pick one of several possible solutions, pass a bill, and (allowing for some tinkering around the edges) it will happen. Problems of the second kind, by contrast, are never solved, exactly; they are managed. Reforming the agricultural system so that it serves the country’s needs has been a process, involving millions of farmers pursuing their individual interests. This could not happen by fiat. There was no one-time fix. The same goes for reforming the health-care system so that it serves the country’s needs. No nation has escaped the cost problem: the expenditure curves have outpaced inflation around the world. Nobody has found a master switch that you can flip to make the problem go away. If we want to start solving it, we first need to recognize that there is no technical solution. Much like farming, medicine involves hundreds of thousands of local entities across the country—hospitals, clinics, pharmacies, home-health agencies, drug and device suppliers. They provide complex services for the thousands of diseases, conditions, and injuries that afflict us. They want to provide good care, but they also measure their success by the amount of revenue they take in, and, as each pursues its individual interests, the net result has been disastrous. Our fee-for-service system, doling out separate payments for everything and everyone involved in a patient’s care, has all the wrong incentives: it rewards doing more over doing right, it increases paperwork and the duplication of efforts, and it discourages clinicians from working together for the best possible results. Knowledge diffuses too slowly. Our information systems are primitive. The malpractice system is wasteful and counterproductive. And the best way to fix all this is—well, plenty of people have plenty of ideas. It’s just that nobody knows for sure. The history of American agriculture suggests that you can have transformation without a master plan, without knowing all the answers up front.

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Government has a crucial role to play here—not running the system but guiding it, by looking for the best strategies and practices and finding ways to get them adopted, county by county. Transforming health care everywhere starts with transforming it somewhere. But how? We have our models, to be sure. There are places like the Mayo Clinic, in Minnesota; Intermountain Healthcare, in Utah; the Kaiser Permanente healthcare system in California; and Scott & White Healthcare, in Texas, that reliably deliver higher quality for lower costs than elsewhere. Yet they have had years to develop their organizations and institutional cultures. We don’t yet know how to replicate what they do. Even they have difficulties. Kaiser Permanente has struggled to bring California-calibre results to North Carolina, for instance. Each area has its own history and traditions, its own gaps in infrastructure, and its own distinctive patient population. To figure out how to transform medical communities, with all their diversity and complexity, is going to involve trial and error. And this will require pilot programs—a lot of them. Pick up the Senate health-care bill—yes, all 2,074 pages—and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be. The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care. Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention—so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds. The bill has ideas for changes in other parts of the system, too. Some provisions attempt to improve efficiency through administrative reforms, by, for example, requiring insurance companies to create a single standardized form for insurance reimbursement, to alleviate the clerical burden on clinicians. There are tests of various kinds of community wellness programs. The legislation also continues a stimulus-package program that funds comparative-effectiveness research—testing existing treatments for a condition against one another— because fewer treatment failures should mean lower costs.

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There are hundreds of pages of these programs, almost all of which appear in the House bill as well. But the Senate reform package goes a few U.S.D.A.-like steps further. It creates a center to generate innovations in paying for and organizing care. It creates an independent Medicare advisory commission, which would sort through all the pilot results and make recommendations that would automatically take effect unless Congress blocks them. It also takes a decisive step in changing how insurance companies deal with the costs of health care. In the nineteen-eighties, H.M.O.s tried to control costs by directly overruling doctors’ recommendations (through requiring pre-authorization and denying payment); the backlash taught them that it was far easier to avoid sicker patients and pass along cost increases to employers. Both the House and the Senate bills prevent insurance companies from excluding patients. But the Senate plan also imposes an excise tax on the most expensive, “Cadillac” insurance plans. This pushes private insurers to make the same efforts that public insurers will make to test incentives and programs that encourage clinicians to keep costs down. Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan. That’s a crucial lesson of our agricultural experience. And there’s another: with problems that don’t have technical solutions, the struggle never ends. Recently, I spoke with the agricultural extension agent for my home town, Athens, Ohio. His name is Rory Lewandowski. He is fifty-one and has been the extension agent there for nine years. He grew up on a Minnesota dairy farm, and got a bachelor’s degree in animal science and agronomy from the University of Minnesota and a master’s degree in agronomy from the University of Wisconsin. He spent most of his career in farm education, including eight years in Bolivia, where, as a volunteer for the Mennonite Central Committee, he created demonstration farms in an area where the mining economy had collapsed. I had a vague childhood memory of the extension office, on West Union Street, near downtown Athens; kids in my school used to go to 4-H meetings there. But I had no idea what the agent really did. So I asked Lewandowski. “I just try to help make farming better in Athens County,” he said. Athens is a green, hilly county at the edge of the Appalachian Mountains, and the farms there are small—an average of a hundred and fifty acres, Lewandowski said. There are six hundred and sixty of them, with, he estimated, as many as a hundred kinds of produce and livestock. His primary task is to help farmers improve the productivity and quality of their farms and to reduce environmental harm. A hundred years after Seaman Knapp, the difficulties have changed but they haven’t gone away. I’d caught Lewandowski in his office on a Saturday. He routinely puts in sixtyfive to eighty hours a week at his job. He has a five-week small-ruminant course for sheep and goat producers; a ten-week master-gardener course; and a

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grazing school. His wife, Marcia, who has written two knitting books, handles registration at the door. He sends out a monthly newsletter. He speaks with about half the farmers in the county in the course of a year. Mostly, the farmers come to him—for guidance and troubleshooting. He told me about a desperate message that a farmer left him the other day. The man’s spinach plants had been afflicted with downy mildew and were collapsing. “He said he was going to lose his whole crop by the weekend and all the markets that he depended on,” Lewandowski said. He called the farmer back and explained that the disease gets started with cooler temperatures and high humidity. Had the farmer been using overhead watering? Yes, he said, but he had poked around the Internet and was thinking about switching to misting. Not a good idea. “That still leaves too much moisture on the leaf,” Lewandowski said. He recommended that the farmer switch to drip irrigation, and get some fans in his greenhouse, too. The farmer said that he’d thought about fans but worried that they would spread the spores around. They will, Lewandowski said. “But you need wetness on the leaves for four to six hours to get penetration through the leaf cuticle,” he explained. If the plants were dried out, it wouldn’t be a problem. “You’ve got to understand the biology of this,” he said to me. He doesn’t always understand the biology himself. He told me about a beef farmer who had been offered distiller’s grain from a microbrewery, and wanted to know whether he could feed it to his cows. Lewandowski had no idea, but he called the program’s beef extension expert and got the answer. (Yes, with some limits on how much he put in a ration.) A large organic farm called with questions about growing vegetables in high tunnels, a relatively new innovation that the farm had adopted to extend its growing season. Lewandowski had no experience with this, but an extension agent in Wooster, Ohio, was able to supply information on what had worked best elsewhere. “You have to be able to say, ‘I don’t know, but I can figure that out for you,’ ” Lewandowski said. If he could change one thing about farming in Athens, I asked, what would it be? “Grazing management,” he said. “Think about how the grass grows in your lawn. A grass plant needs at least a few days after a mowing to grow.” If you mowed your lawn every day, the grass would become thin and patchy. That’s what happens when farmers leave their animals out in one big pasture—which is what most small farmers do—or rotate them too slowly. In his grazing school and in demonstrations, he asks farmers to keep their animals in a given area for only a few days, then move them to a section where the grass is eight inches tall and has reached its highest nutrient value. This way, the pastures won’t erode, and the cattle will grow better, yielding higher-quality meat and more of it. The technique requires discipline, though, and extra work, and farmers have been slow to give it a try. I asked him if he has had any victories. All the time, he said. But he had no illusions: his job will never end.

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Cynicism about government can seem ingrained in the American character. It was, ironically, in a speech to the Future Farmers of America that President Ronald Reagan said, “The ten most dangerous words in the English language are ‘Hi, I’m from the government, and I’m here to help.’ ” Well, Lewandowski is from the government, and he’s here to help. And small farms in Athens County are surviving because of him. What he does involves continual improvisation and education; problems keep changing, and better methods of managing them keep emerging—as in medicine. In fact, when I spoke with Lewandowski about farming in Athens, I was struck by how much it’s like the health-care system there. Doctors typically work in small offices, with only a few colleagues, as in most of the country. The hospital in Athens has less than a tenth the number of beds that my hospital in Boston has. The county’s clinicians could do much more to control costs and improve quality of care, and they will have to. But it will be an ongoing struggle. My parents recently retired from medical practice in Athens. My mother was a pediatrician and my father was a urologist. I tried to imagine what it would be like for them if they were still practicing. They would be asked to switch from paper to electronic medical records, to organize with other doctors to reduce medical complications and unnecessary costs, to try to arrive at a package price for a child with asthma or a man with kidney stones. These are the kinds of changes that everyone in medicine has to start making. And I have no idea how my parents would do it. I work in an academic medical group in Boston with more than a thousand doctors and a vastly greater infrastructure of support, and we don’t know the answers to half these questions, either. Recently, I had a conversation with a few of my colleagues about whether we could accept a bundled payment for patients with thyroid cancer, one of the cancers I commonly treat in my practice as a surgeon. It seemed feasible until we started thinking about patients who wanted to get their imaging or radiation done elsewhere. There was also the matter of how we’d divide the money among the surgeons, endocrinologists, radiologists, and others involved. “Maybe we’d have to switch to salaries,” someone said. Things were getting thorny. Then I went off to do an operation in which we opened up about a thousand dollars’ worth of disposable materials that we never used. Surely we can solve such problems; the reform bill sets out to find ways that we can. And, in the next several years, as the knowledge accumulates, I suspect that we’ll need our own Seaman Knapps and Rory Lewandowskis to help spread these practices county by county. We’ll also need data, if we’re going to know what is succeeding. Among the most important, and least noticed, provisions in the reform legislation is one in the House bill to expand our ability to collect national health statistics. The poverty of our health-care information is an embarrassment. At the end of each month, we have county-by-county data on unemployment, and we have prompt and detailed data on the price of goods and commodities; we can use these indicators to guide our economic policies. But try to look up information on your community’s medical costs and utilization—or simply try to find out how many people died from heart attacks or pneumonia or surgical complications—and you

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will discover that the most recent data are at least three years old, if they exist at all, and aren’t broken down to a county level that communities can learn from. It’s like driving a car with a speedometer that tells you only how fast all cars were driving, on average, three years ago. We have better information about crops and cows than we do about patients. If health-care reform is to succeed, the final legislation must do something about this. Getting our medical communities, town by town, to improve care and control costs isn’t a task that we’ve asked government to take on before. But we have no choice. At this point, we can’t afford any illusions: the system won’t fix itself, and there’s no piece of legislation that will have all the answers, either. The task will require dedicated and talented people in government agencies and in communities who recognize that the country’s future depends on their sidestepping the ideological battles, encouraging local change, and following the results. But if we’re willing to accept an arduous, messy, and continuous process we can come to grips with a problem even of this immensity. We’ve done it before. ♦ Read more: http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande? printable=true#ixzz0mhJV1H8J

Notes on new Community Coordinated Care System 2010 Updated 09-06-10 Overview Offer a hosted community health management system that could be used to promote wellness, DM, medical homes, Coordinated Care Plans, etc for the entire community. Would include community nutrition management. Who would own and run this system? • • • •

Local health department? Local community health coalition? Local RHIO/HIE organization? Local hospital (if only game in town?)

CIBER Development team in Harrisburg

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CIBER DEVELOPS AIR POLLUTION DATA COLLECTION SYSTEM FOR CONNECTICUT DEPARTMENT OF ENVIRONMENTAL PROTECTION GREENWOOD VILLAGE, Colo. – March 4, 2010 – CIBER, Inc, (NYSE: CBR) and the Connecticut Department of Environmental Protection (DEP) have launched a new state-of-the-art, secure online system that begins a new era in air pollution emissions reporting, database management and pollution control planning. The new system will expand and improve emissions data collection and reporting in fulfillment of DEP’s obligations under the federal Clean Air Act, while also ensuring efficient access to that data for regulated entities and nonregulated businesses, agencies and members of the general public. The Emissions Inventory Tracking (EMIT) system will help Connecticut businesses and industries that face increasingly complex and demanding reporting requirements to comply with the federal Clean Air Act. Previously, DEP obtained point source emissions information through a paper-based annual emissions statement report that is submitted by the owner of a source of air pollution in the state. The submitted data has traditionally been quality assured and transferred to an electronic database. The EMIT system automates many of the manual, paper-based data collection processes, allowing the regulated community to streamline their emissions reporting. DEP Commissioner Amey Marrella said, “This new system puts the power of technology to work to improve government services and better serve the people of our state. By automating an antiquated, paper-based process for collecting information, we are enabling businesses and industries to streamline reporting that is required under the federal Clean Air Act. The system will also provide DEP staff with instant access to the information needed to ensure compliance with the requirements of emissions permits, which helps protect the quality of the air we breathe.” “CIBER and DEP are launching an innovative yet practical way of collecting and reporting data that not only complies with regulations but enhances the State’s ability to plan for and effectively institute pollution control

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measures. This was a very complex implementation, involving cleansing and conversion of historical data that could not have been successfully implemented without the strong working partnership that was formed between DEP and CIBER,” said Tom Saltzer, Vice President and Area Director of CIBER, and head of CIBER State and Local Government Development Center in Harrisburg, Penn. According to Saltzer, “The EMIT system’s architecture leverages all of the benefits of current web technologies, includes a greenhouse gas inventory and comprehensive reporting of industrial, area, and mobile emissions. EMIT will be the next generation of the Air Emissions Inventory System and will consist of a SQL Server database and user-friendly, browser-based applications developed with .NET technologies.” CIBER has more than 25 years experience working with state government clients to streamline operations, accurately meet reporting and other compliance requirements, and efficiently manage the basics of day-to-day operations. CIBER is also providing leadership on projects that address newer concerns such as Government Consolidation and Shared Services. About CIBER, Inc. CIBER, Inc. (NYSE: CBR) is a pure-play international IT outsourcing and software implementation and integration consultancy with superior valuepriced services and reliable delivery for both private and government sector clients. CIBER’s services are offered globally on a project- or strategic-staffing basis, in both custom and enterprise resource planning (ERP) package environments, and across all technology platforms, operating systems and infrastructures. Founded in 1974 and headquartered in Greenwood Village, Colo., CIBER now serves client businesses from over 40 U.S. offices, 25 European offices and seven offices in Asia/Pacific. Operating in 18 countries, with more than 8,000 employees and annual revenue in excess of $1 billion, CIBER and its IT specialists continuously build and upgrade clients’ systems to “competitive advantage status.” CIBER is included in the Russell 2000 Index and the S&P Small Cap 600 Index. CIBER, the Reliable Global IT Services Partner. www.ciber.com.

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How the Cloud Makes K-12 Wireless LAN Easier and More Affordable Date: September 1, 2009 at 12:00 PM PDT (3 PM EDT) Duration: One hour Sponsored by: Meraki More and more K-12 districts are deploying cloud-enabled applications, e.g., Google Apps, every day. Why? Simply put, cloud-based IT solutions have proven themselves easier to setup and maintain, and more affordable than traditional client server-based solutions. Join this free, one-hour session to hear how Meraki is revolutionizing networking with their cloud-based wireless solution that brings all the benefits of cloud computing to wireless networking. Get a first-hand look at Meraki in action at North Adams School District. See how they deployed Meraki wireless network across their campuses, and are thrilled with the results. Moderator

 Linda Briggs, contributing editor, T.H.E. Journal Magazine

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CIBER Healthy Community Model

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