Remarks as prepared; not a transcript

Vice Admiral Richard H. Carmona, M.D., M.P.H, FACS
United States Surgeon General
U.S. Department of Health and Human Services

National Dialogue on Cancer
Kennebunkport, Maine

Monday, September 29, 2003

"Obesity and Cancer: The Scientific Links and the Future of Prevention"

Thank you, Andy. (Dr. Andy von Eschenbach, Director, National Cancer Institute)

It is a pleasure to be here with all of you today. Thank you for allowing me to join the team of the National Dialogue on Cancer.

President Bush, Secretary Thompson, and I are grateful to you for all you’re doing to improve health and health care, particularly in the area of cancer, for all Americans.

And in fact, both the current President, and the former President, whom we had the honor of seeing last night, deserve a great deal of the credit for bringing us further as a nation in the fight against cancer.

President George H.W. Bush has had a lifelong commitment to bettering the lives of cancer victims, and of finding ways to fight the disease.

And he has passed that passion on to his son, our current President, who is well on his way to keeping his commitment to double the budget of the National Institutes for Health in five years.

In fact, next year the National Cancer Institute alone will spend nearly $5 billion on cancer research, clinical trials, training and education.

Link Between Obesity and Cancer

Cancer is America’s second-leading killer. About 1 million new cases will be diagnosed this year alone, and half a million people will die of the disease. Certainly, there are no more frightening words you will hear from a doctor than "you have cancer."

A survey of men by Newsweek/Princeton Survey Research Associates conducted last spring found that a larger percentage of men feared prostate or other forms of cancer more than any other type of life-threatening emergency, including heart attacks, being killed or seriously injured in an accident, or stroke.

Similar poll data shows that a majority of American women are very concerned or somewhat concerned about contracting breast cancer at some point in their lives.

And part of that fear is that the survival period – while improving - is often shorter than it is for victims of other illnesses. Part of it, too, is that people generally think cancer is caused by genetic factors or by exposure to harmful environmental agents. They might never dream that cancer is related to a poor diet, or obesity.

We are here today because we need to understand the science that links diet, exercise, overweight and obesity to cancer, and what to do about it. New research shows that some cancers, like other life-threatening illnesses such as cardiovascular disease and diabetes, are more prevalent in those who are overweight and obese.

In fact research by the American Cancer Society as reported in the New England Journal of Medicine in April estimates that overweight and obesity could account for 14 percent of deaths from cancer in men, and 20 percent of cancer deaths in women.

The implications of this discovery are profound, and show yet another reason we must redouble our efforts nationally to prevent obesity.


The scope of our obesity epidemic is immense. Nearly 2 out of 3 of all Americans are overweight and obese; that’s a 50% increase from just a decade ago.

More than 300,000 Americans will die this year alone from heart disease, diabetes, and other illnesses related to overweight and obesity.

Obesity-related illness is the fastest-growing killer of Americans. In the year 2000, the total annual cost of obesity in the United States was $117 billion, not to mention the cost to individuals in terms of discomfort and suffering.

The good news is that obesity as we understand it today is completely preventable through healthy eating – nutritious food in appropriate amounts - and physical activity. The bad news is, Americans are not taking the steps they need to in order to prevent obesity and its co-morbidities.

The same is true for other diseases related to poor lifestyle choices, such as smoking and substance abuse.

Put simply, we need a paradigm shift in American health care.

There is no greater imperative in American health care than switching from a treatment-oriented society, to a prevention-oriented society. And from physicians providing treatment only, to physician and other health providers promoting health via prevention.

Right now we’ve got it backwards. We engage in unhealthy eating habits and lack of physical activity until people are symptomatic or diagnosed.

Then we spend billions of dollars on costly treatments, often when it is already too late to make meaningful improvements to their quality of life or lifespan.

An overweight or obese American spends an average of $700 more a year on medical bills than an American who is not overweight. That comes to a total of about $93 billion in extra medical expenses a year.

We simply must invest more in prevention, and the time to start is childhood – even before birth.

Fifteen percent of our children and teenagers are already overweight. Unless we do something now, they will grow up to be overweight adults.

While we need new knowledge from genetics, molecular biology and the behavioral and social sciences, the fundamentals seem clear. The reason Americans are overweight is very simple: We are eating too much and moving too little.

The average American child spends more than four hours every day watching television, playing video games, or surfing the web. They know more about the running style of ‘Sponge Bob Square Pants’ than Gail Devers or Maurice Green.

Instead of playing games on their computers, I want kids to play games on their playgrounds.

Play not only keeps the body healthy, but the mind as well.

Our commitment to disease prevention through healthy eating, physical activity, and avoiding risk – is one our entire society must be prepared to make in order for it to be effective.

President Bush is leading the way through the HealthierUS prevention initiative.

Healthier US says, "Let’s teach Americans the fundamentals of good health: exercise, healthy eating, getting check-ups, and avoiding risky behavior."

Secretary Thompson and the Department of Health and Human Services (HHS) are advancing the President’s prevention agenda through Steps to a HealthierUS, which emphasizes health promotion programs, community initiatives, and cooperation among policy makers, local health agencies, and the public to invest in disease prevention.

Steps also encourages Americans to make lifestyle choices that will prevent disease and promote good health from youth, such as avoiding tobacco use, which is still the leading preventable cause of death and disease in America, and avoiding alcohol, drug use and other behaviors that so often result in violence and unintentional injuries.

Congress has approved funds for Steps in FY 2004 for community initiatives to reduce diabetes, obesity, and asthma-related hospitalizations.

But, we cannot switch America’s paradigm from treatment to prevention through government action alone. This fight has to be fought by joining forces: public and private, community by community, one person at a time, a day at a time. Nowhere is this ‘battle’ motif more appropriate than in weight control.

Weight-loss is a multi-billion dollar industry. There are books, videos, pills, and self-help plans galore. But as a nation, we’re not losing the weight! Why? Indeed, seeking this answer must be part of our research agenda.

Personal responsibility plays a key role. But we must also look at cultural messages around food and nutrition, and the reasons why people eat what they eat, and in the amounts they do.

We know Americans lead stressful lifestyles, even here in the serenity of coastal Maine. And we often eat to calm down.

Now, experiments at the University of California, San Francisco suggest that extra fat – especially in the abdominal area – lowers production of cortisol and similar stress hormones. Our efforts to prevent obesity should take into account the reasons people overeat, or get too little physical activity.

And we must also remember, individual behavior change can occur only in a supportive environment.

What do we tell a young mother who feels it’s unsafe to let her children play outside?

What do we do in communities where fresh fruits and vegetables are in short supply at the grocery store? Or where there isn’t a grocery store, but instead just fast food restaurants?

We need to develop science-based strategies to ensure that affordable healthy food choices are available in our inner cities and that all Americans have the opportunity for regular physical activity.

Government needs help from all sectors: business, education, medicine, research and entertainment. All of us must work together, on many different levels, in this fight against obesity.

Earlier this month I joined former Surgeon General David Satcher and the National Football League in kicking off their partnership in promoting school-based solutions to the obesity epidemic.

Then I joined basketball star LeBron James to launch Nike’s PE2GO program, which provides equipment and expertise to schools so that they can offer fun physical activity.

School-based programs that focus on physical activity offer one of our best opportunities to improve children’s health — today and in the future. We welcome partnerships like these to improve the health of children from the earliest ages.

As I said, it will take all of us to switch from a treatment-oriented society to a prevention-oriented society, but the effort will be worth it, both to individuals and to the larger community.

Obesity and its comorbidities: diabetes, heart disease, and now as we are learning, many forms of cancer, can be prevented by Americans taking a few relatively simple steps, as I have described. But let’s be careful.

Our efforts to encourage Americans to adopt healthy behaviors are complicated by several factors, not the least of which is low health literacy.

Health Literacy and the Prevention Agenda

More than 90 million Americans cannot adequately understand basic health information. People of all ages, races, incomes, and education levels are challenged by low health literacy.

The problem has grown as patients have been asked to assume more responsibility for self-care in a complex health care system.

You only have to look at the past few decades to see the impact of low health literacy:

It took over 25 years with a major long-term initiative by NIH’s National Heart, Lung, and Blood Institute to get Americans to know their blood pressure level and seek appropriate treatment. Despite numerous efforts to eliminate smoking, more than 4,000 American children age 17 and younger will try their first cigarette today. Many Americans avoid getting appropriate medical check-ups for breast, colorectal, and cervical cancer even though these preventive screenings can help them live longer and healthier lives.

Consider this: A study of English-speaking patients in public hospitals revealed that one-third were unable to read basic health materials. 26% of the patients could not read their appointment slips, and 42% did not understand the labels on their prescription bottles.

The implications of low health literacy in our efforts to prevent obesity and disease are also serious. A health literate individual is more apt to know how to answer the question "How do I keep myself well?" While adopting behaviors to maintain a healthy weight might seem simple, I have found that many people really do not know what they need to know.

Experience with my own patients and students indicates that Americans do not understand the meaning of fat grams, or the impact of caloric intake versus expenditure.

Every morning people wake up and, while they’re sitting at the kitchen table, they read the newspaper and the cereal box.

Throughout the day they read the nutritional information on their meals and on their snacks.

But do they really understand the information they’re reading? The labels list grams of fat. But do people know how many grams of fat they should eat in a meal? Or in a day? Or how many is too many? Or how many is too few?

These are seemingly simple questions, but we’re not giving people simple answers.

Media coverage of the overweight and obesity epidemic has been fairly widespread. Americans know there is a problem. So they’re trying to figure out how much food they should eat. How much is too much? How much is too little? What constitutes a healthy diet?

They’re asking about calories, carbohydrates, vitamins, and fiber. They’re asking about salt, sugar, and portion sizes.

Health communication alone cannot change systemic problems related to health — such as poverty, environmental degradation, or lack of access to health care.

But comprehensive health programs must clearly communicate health information to populations across our diverse nation.

Many people, even educated Americans, don’t know what a calorie is, or how to burn it.

It’s our job to make that kind of health information meaningful, useful, and helpful. It’s time to start looking at a different way to provide nutritional information.

Maybe we need a point system like some weight- loss programs use. Maybe we need to help people understand food portions by describing portion sizes in terms of things people can already relate to.

Already HHS and the Department of Agriculture are redesigning the Food Guide Pyramid. It may end up as a food cube, or trapezoid, or a straight line. We don’t know yet.

For health literacy to improve, we need health professionals, policymakers, researchers, and the public to collaborate.

And our health care professionals must be trained in health literacy. As for what our future health professionals learn about nutrition, medical and nursing students learn more about the pathophysiology of disease than about answering these questions for their future patients.

As a medical student I spent thousands of hours learning about the origin and treatment of various diseases, and probably only ten minutes on nutrition.

The bottom line is, improved health literacy will translate into better prevention. Health literacy is the second step in prevention.

Once an individual recognizes the importance of good health, health providers must be able to provide her with the best possible information in a manner she can understand.

My mechanic doesn't expect me to know the intricacies of my car's transmission, and I don't expect my mechanic to know the intricacies of how the human body works.

So that's why doctors, nurses, and pharmacists need to provide the keys to good health in a manner that all Americans can understand. My goal in improving health literacy is to close the gap between what health care providers know and what patients understand.

Health literacy can save lives, save money, and improve the health and well-being of millions of Americans.


I have tried to relay the importance of this administration’s prevention agenda in fighting most of the diseases Americans are suffering and dying from today.

The National Dialogue on Cancer is doing very important work in preventing additional deaths from cancer. You are leading the knowledge and discovery; it will be my job to lead in communicating the science to the American people so that they will use it.

As your agenda in this overlap between obesity and cancer is clarified this afternoon, I welcome the opportunity to join you.

Thank you for bringing together my colleagues at HHS and key researchers and leaders in the private and non-profit sectors. It is only through new partnerships and collaborations like these that we will be able to make progress against obesity and cancer.

And continuing the fight is so important. All of us have lost someone close to us to this horrible disease.

In closing, I’d like to leave you with a thought from Tour de France winner and cancer survivor Lance Armstrong.

Armstrong was asked this question by Time magazine, "Why do you have to essentially stage a publicity stunt to get attention for a disease that will kill more than half a million people this year?"

Armstrong’s response, "The illness has gotten ‘old.’ My perception is that people have gotten used to the illness, of their grandfather dying of prostate cancer at 75, and saying ‘Boy, he had a great life’ – instead of saying Grandpa could have had another 20 good years."

Americans are far too tolerant of chronic disease. Let’s work harder on the prevention agenda and give them all a shot at another 20 good years.

Our goal should be to put ourselves out of business. Let’s work not to come back five years from now, ten years from now, and so on.

Let’s not lose any more sons and daughters to childhood cancers like leukemia; let’s not lose any more wives to breast cancer, or fathers to prostrate cancer.

Thank you.


Last revised: January 9, 2007