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Advisory Group on Prevention, Health Promotion, and Integrative and Public Health Meeting Summary

June 11, 2015

Attendees

Advisory Group Members: Jeff Levi (Chair), JudyAnn Bigby, Richard Binder, Valerie Brown, Ned Helms, Janet Kahn, Charlotte Kerr, Jacob Lozada, Elizabeth Mayer-Davis, Dean Ornish, Linda Rosenstock, John Seffrin, Susan Swider, and Kimberlydawn Wisdom

Regrets: Johnathan Fielding, Patrik Johannson, Jerry Johnson, Barbara Otto, Herminia Palacio, Ellen Semonoff, and Sharon Van Horn

HHS: Lt. Laura Annetta, Corinne Graffunder (DFO), Ayanna Johnson, Sudeshna Mukherjee, VAMD Surgeon General Vivek Murthy, Brigette Ulin, and Elizabeth Walker

11:30 a.m. - Roll Call and Introductions

Dr. Corinne Graffunder called the roll and confirmed a quorum was present. She thanked the public for attending and noted that no one from the public registered to provide a comment.

11:40 a.m. – Review of Meeting Purpose

Dr. Jeff Levi reviewed the purpose of the meeting. The Advisory Group will discuss and vote on the fourth draft recommendation. The other three recommendations have been previously approved by the Advisory Group and submitted to the Surgeon General. The Surgeon General will join the call to give his feedback on these recommendations.  The Advisory Group will also plan for the meeting on August 31 – September 1, 2015. Advisory Group members will have an opportunity to provide updates on their related professional efforts throughout the call.

11:45 a.m. – Discussion of Draft Recommendation #4

The focus for a 4th recommendation was initially proposed by Dr. Dean Ornish, during the full Advisory Group meeting on April 20, 2015. At that time, the Advisory Group decided to develop a small drafting committee to further develop this recommendation. Participants on the drafting committee included Dr. Levi, Dr. Ornish, Dr. JudyAnn Bigby, Dr. Elizabeth Mayer-Davis, Dr. Kimberlydawn Wisdom, Mr. Ned Helms, and Dr. Johnathan Fielding.

Dr. Ornish explained that Lifestyle Medicine views lifestyle as a form of treatment, not just a way to prevent disease. Recent shifts in the medical field support the adoption of Lifestyle Medicine. For example, the Affordable Care Act, to align with the Triple Aim, changed payment structures from focusing on value (e.g., number of hospitalizations, prescriptions) to value of health outcomes. The Affordable Care Act incentivizes accountable care organizations, centralized delivery care networks, and bundled payments. Research evidence is also growing in support of Lifestyle Medicine. Randomized controlled trials have shown that, for stable individuals with certain medical conditions, medications and surgical procedures are not as effective in prolonging life or preventing future medical events as lifestyle changes. Medications and surgical procedures work best for people that are in immediate need.

The draft recommendation reads: “The Advisory Group encourages the Surgeon General, the National Prevention Council, and the Center for Medicare and Medicaid Innovation to identify and promote best practices and supportive policies to advance the use of lifestyle interventions, including optimal nutrition, exercise, stress management, smoking cessation, and social support, in the treatment and management of chronic diseases. Beneficial lifestyle interventions can complement or provide an alternative to medications or surgical approaches for optimal health, including preventing and treatment chronic diseases and preventing people living with chronic diseases from developing complications. Identifying effective strategies to promote beneficial lifestyle interventions is particularly important among populations with the greatest burden of diseases.”

Dr. Mayer-Davis indicated that she hopes that this recommendation will have a positive impact and noted that the drafting committee framed this recommendation so that it can be applied to all populations, including underserved individuals or communities. Dr. Richard Binder thought the recommendation was well-crafted.

Dr. Linda Rosenstock asked if the Advisory Group normally solicits guidance from groups such as the U.S. Preventive Services Task Force or the Community Preventive Services Task Force before issuing recommendations. She feels that the recommendation could include references to reports and evidence developed by independent bodies that could show their support for this recommendation. Dr. Ornish pointed out that the recommendation language is not stating the Surgeon General, National Prevention Council, and the Centers for Medicare and Medicaid Innovation immediately adopt and support lifestyle interventions; the recommendation encourages these groups to research and promote best practices, which could include these task forces. Dr. Levi said that the U.S. Preventive Services Task Force or the Community Preventive Services Task Force could certainly review the evidence, but these task forces have are limited in the number of reviews they are able to complete. The Surgeon General, the National Prevention Council, and the Centers for Medicare and Medicaid Services should not be limited in what they can do pending a review of the evidence by one of these task forces. He also noted that this topic might be outside the scope of the task forces’ purview. Dr. Mayer-Davis disagreed with having the recommendation reviewed by one of the task forces. Dr. Rosenstock clarified that she was not suggesting that the Advisory Group send their recommendation for external review, but was asking if the Advisory Group had support for this recommendation from one of these bodies as the literature on this topic is evolving.

Dr. Rosenstock further asked why lifestyle interventions were chosen over other prevention issues. Dr. Ornish stated that the Advisory Group is not able to make recommendations for every prevention issue, but can only focus on a few issues. He elaborated on his rationale for proposing this recommendation by referencing the randomized controlled trials and other evidence that supports lifestyle interventions. He also noted that lifestyle interventions are becoming mainstream as Medicare is now covering lifestyle interventions and Million Hearts™ is soliciting requests for proposals on lifestyle interventions. He stated that the Surgeon General directly expressed interest in this topic so including this recommendation will encourage him to move forward with exploring lifestyle medicine. Finally, Dr. Ornish stated that lifestyle interventions also fit well into the Affordable Care Act’s payment incentive model. Dr. Levi supported Dr. Ornish’s statements noting  that the Advisory Group explores issues as they are brought to them from the Surgeon General, Advisory Group members, National Prevention Council members, or a third party. The issues that are most relevant to the group’s interests and expertise are then explored. With this recommendation, the Advisory Group is not suggesting a particular view point on lifestyle interventions or which policies and evidence to explore. To support the point about lifestyle interventions becoming mainstream, Dr. Mayer-Davis stated that the American Heart Association and the American Diabetes Association have integrated guidance on physical activity, stress management, nutrition, smoking cessation, and social support into their treatment guidelines.

Dr. Levi call for a vote. Advisory Group members unanimously voted to approve the recommendation.

12:15 p.m. - Planning for Next Full Advisory Group Meeting (August 31 – September 1, 2015)

Dr. Levi proposed three areas for the Advisory Group to explore at their meeting on August 31 – September 1, 2015. The discussion of these proposed focus areas is described below.

Surgeon General’s Priorities

The Advisory Group could do a more thorough examination of one of the Surgeon General’s four priorities: tobacco-free living, healthy eating, healthy living, and mental and emotional wellbeing. The Advisory Group could develop a strategy to advise specific National Prevention Council Departments on their ongoing efforts on the priorities. Additional expertise might need to be identified.

Dr. Mayer-Davis voiced that the Advisory Group’s discussions should first reflect the Surgeon General’s priorities before other topics of interest. Dr. Bigby noted that the first recommendation encourages the Surgeon General to approach his priorities by keeping the National Prevention Strategy’s overarching themes in mind. She stated that the Advisory Group should have a discussion on how this recommendation is operationalized. Dr. Levi agreed with Dr. Bigby.

Environmental and Climate Change Issues

Sister Charlotte Kerr stated that nutrition, exercise, stress management, and social support are all important for addressing obesity and other health issues. She proposed that the Advisory Group spend time discussing how environmental toxins impacts individual’s health and lifestyle changes. She suggested that experts from the U.S. Department of Agriculture and the Environmental Protection Agency, both National Prevention Council members, should speak on these issues. She also suggested that other organizations, like the Department of Justice, should be involved to discuss the manufacturing, commercial business, occupational, and social justice issues related to this topic. Dr. Janet Kahn supports the Advisory Group discussing the connection between environmental factors and health. She stated that there are systemic issues that prevent or counteract healthy lifestyle choices made by individuals. Ms. Valerie Brown, along with Dr. Kahn, agreed with Sister Kerr that experts should be brought in to discuss current efforts and evidence.

Dr. Ornish offered to do a presentation on how lifestyle interventions and the environment are connected.

Dr. Rosenstock liked this presentation idea, but does not feel a broad review of the evidence is necessary and would prefer discussing specific topics. She noted that this topic relates to the President’s work on climate change. The Advisory Group could use this discussion as an opportunity to provide background on this topic for the Surgeon General. Dr. Levi noted that the Surgeon General is working on climate change. The Advisory Group could discuss how this topic relates to the National Prevention Strategy and how to advance the Surgeon General’s efforts in this area, including hearing from experts in the field.

Dr. Bigby noted that environmental toxins and climate change, when discussed together, become quite burdensome to understand and address. The Advisory Group established a workgroup to help narrow the focus of this discussion due to the limited time and capacity. Dr. Levi suggested that the Advisory Group focus on particular topics and identify what experts and materials are needed for a productive conversation. The workgroup will need to consider the varying levels of agreement and concern on this topic. Some issues are gaining more traction than other issues, such as the recently released Presidential Memorandum charging GSA to work with USDA and HHS on developing an action plan to include antibiotic free meat as an option in all federal dining facilities.

Sister Kerr suggested that the Advisory Group learn more about the Surgeon General’s thoughts and interest in climate change. She also noted that Pope Francis is releasing a white paper on a global initiative on climate change and ecology in June.

Commission to Eliminate Child Abuse and Neglect Fatalities

The Advisory Group has been approached by the Commission to Eliminate Child Abuse and Neglect Fatalities, a Congressionally-chartered time-limited commission that includes Presidential and Congressional appointees. The commission will release a report in March 2016. The commission would like to discuss how to adopt a prevention framework like the National Prevention Strategy. This collaboration is aligned with the Surgeon General’s priority of mental and emotional wellbeing.

Establishment of Workgroups and Planning Process

Dr. Kahn suggested that the Advisory Group might need to meet for longer than a day and a half or make sure that the working groups develop focused agendas. She also voiced that the Advisory Group should frame conversations around concrete deliverables and actions.

Dr. Levi called for the development of two workgroups.

Planning Workgroup

This workgroup will plan agendas for upcoming meetings, including the August 31 – September meeting. Dr. Levi explained that the Advisory Group is a Presidentially-appointed group that serves at the pleasure of the President. He stated that the Advisory Group will meet three more times in-person during this Administration and has more opportunities for conference calls. Dr. Mayer-Davis reiterated that the agenda should be framed around the Surgeon General’s priorities. Mr. Helms agreed with Dr. Mayer-Davis and said that the Advisory Group should strategize with the Office of the Surgeon General on how to advance and support his priorities; he proposed that the Advisory Group could produce a report on these deliberations. Mr. Helms, Dr. Susan Swider, Dr. Binder, Dr. Mayer-Davis, Ms. Barbara Otto, and Dr. Wisdom will participate on this workgroup. Dr. Levi also suggested that this workgroup also focus on the Advisory Group’s legacy. Dr. Kahn pointed out that new Advisory Group members should not be afraid to take risks and not become frustrated with incremental changes to large problems or issues.

Environment and Health

The second workgroup will explore the connection between environment and health, focusing on environmental toxins and climate change. Dr. Levi charged this workgroup with preparing background information and coordinating experts for the August 31 – September 1 meeting. This workgroup will consist of Ms. Brown, Dr. Kahn, Sister Kerr, and Dr. Swider.

12:45 p.m. – Updates from Advisory Group Members

Dr. Wisdom mentioned that a white paper and concept paper on efforts of the State Surgeons General and the U.S. Surgeon General to advance health care reform has been developed. They are organizing stakeholders to develop a pilot project that will be evaluated and replicated. She would like to present this plan to the Advisory Group at a future meeting to obtain their feedback.

The Center for Medicare and Medicaid Innovation will release the funding announcement for the accountable health communities project soon. Dr. Levi is not sure what level of engagement the Advisory Group will be requested to provide. Dr. Levi or Dr. Graffunder will let the Advisory Group know when the announcement is released.

The Department of Education will soon announce an initiative around chronic absenteeism in the context of My Brother’s Keeper.

Dr. Wisdom participated in a statewide meeting led by the Michigan Community Health Worker Alliance (www.michwa.orgSite exit disclaimer) on the restructuring of payment systems to allow reimbursement for advocates and other community health workers. Many health plans and providers attended the event.  Dr. Swider stated that the Governor of Illinois has a taskforce on this issue.  

1:00 p.m. - Presentation from the Surgeon General

The Surgeon General thanked the Advisory Group for their recommendations. After the March 2015 Advisory Group meeting the Surgeon General met with the National Prevention Council and discussed two priorities areas: healthy eating and tobacco-free living. He noted that some federal departments have made successful strides in these areas and the National Prevention Council is enthusiastic about advancing these priorities.

During the Surgeon General’s swearing-in ceremony in April 2015, he presented his five priority areas of focus: mental health, violence, nutrition, activity, and tobacco and substance use. The Office of the Surgeon General is currently developing focused campaigns and engaging leadership on these issues. These campaigns will have a community-driven component. The Surgeon General would like the Advisory Group to aid in the development of these campaigns. Dr. Levi said that the Advisory Group will devote a significant portion of their August 31 – September 1 meeting on improving and promoting his efforts. The Surgeon General stated that he would like the Advisory Group’s input before the August 31 – September 1 meeting as the campaigns will be further developed over the next few weeks. Dr. Levi and Dr. Graffunder agreed that workgroups could be established to provide input on the campaigns.

Ms. Brown expressed enthusiasm for these priorities, but sought clarification on the Surgeon General’s process for approaching these campaigns as the topics are broad. She also expressed concern that the Advisory Group might not have all the expertise needed to provide appropriate input to all these priorities. The Surgeon General stated that the initiatives will be released at different times and will have specific foci. For example, the mental health campaign will work to address stigma by engaging community leaders. The campaigns will also be targeted to specifics geographical areas. He noted that the Advisory Group would only be asked to provide input for campaigns that relate to their areas of expertise.

Dr. Wisdom asked how the Office of the Surgeon General is leveraging existing mechanisms and efforts. The Surgeon General stated that his staff is currently identifying potential partnerships, but he would like the Advisory Group’s assistance in identifying additional partnerships.

Dr. Wisdom also asked how the National Prevention Strategy’s strategic direction of elimination of health disparities is being incorporated into their campaigns. The Surgeon General stated that prevention and health equity will be the bedrock for all of his initiatives. His office has been building relationships with organizations that are addressing health disparities in their communities.

Sister Kerr mentioned the Advisory Group’s discussion on ecological toxicity and related it to the Surgeon General’s priorities. She noted the environmental and social factors that affect mental and physical health, referencing the Blue Zone concept. She hopes that the Advisory Group and the Surgeon General will highlight the interconnectedness of these public health issues and incorporate social epidemiology into their initiatives. The Surgeon General agreed with Sister Kerr and noted that emotion wellbeing is a component of his mental health priority. Dr. Wisdom noted that initiatives should also focus on the underlying factors of these public health issues to ensure that systems and policies allow for positive change. The Surgeon General agreed with Dr. Wisdom, elaborating that comprehensive engagement from all demographic and interests groups are needed for change.

1:25 p.m. – Next Steps

The Advisory Group will devote a substantial portion of the meeting to discuss the Surgeon General’s priorities. Workgroup will be convene to discuss the Surgeon General’s priorities, ecological toxicity, future meetings, and the Advisory Group’s legacy.

1:30 p.m. - Adjourn