more effectively and more quickly than the federal government and we in washington need to be on guard for federal initiatives that preempt or place obstacles in the path of state and local government from acting.

>> unfortunately we have lost our signal from our live event today and we are working to correct that problem and we plan to rejoin momentarily. this is c-span 2.

>> unfortunately and again we are having technical issues with our daylong coverage of a supposed him on food posted by georgetown university law center we are working quickly to return to that effect. in the meantime, we will show you comments and remarks from earlier today from the same event. [inaudible conversations] [inaudible conversations] [inaudible conversations]

[inaudible conversations] [inaudible conversations] >> good morning. my name is tim westmoreland and i'm a professor here at georgetown law and more important for today's purposes i'm a senior scholar at the o'neill institute on health. i am sorry to say that dena trainor has just the story then called away for a family issue and so i'm happy to say that probably makes me dean for the day. but, i'm welcoming you here today for the o'neill institute, which was founded about 10 years ago because law is and will be a tool to solve health problems, locally, nationally and globally. for almost a decade o'neill has worked with all parties, governments, policymakers, ngos

and the private sector to develop law as a means to arrive to innovative answers to domestic and international concerns. o'neill is hosting this conference on food to help understand the many ways the public health can be improved by addressing how americans produce and eat food. it is obviously when the most basic part of our lives. food is one of our business-- personal expenditures and one of the biggest sources of jobs in america. increasingly, it is recognized as one of the biggest components of our public and personal health. many americans have some food insecurity three-year. the use of antibiotics and livestock contribute to the development of antibiotic resistance and of course obesity is one of the most pressing health concerns for individuals in the nation. we hope that today's meeting will further development of

renewed attention to food policy and to the creation of bipartisan and nonpartisan attention to these and other problems. as a new president and a new congress come to power, it is important to ensure that food problems on the table. it's important that we present not only the problems, but also the legal and policy solutions to be considered. fortunately, we have a who's who -- who up policy experts to discuss these policies and solutions today. the o'neill institute will synthesize the problem and potential solutions discussed into a white paper to be used by policy makers, advocates and consumers as part of the 2017 political agenda. today's event is open to the press and is being live streamed and televised your queen bite our audience here and online to ask questions throughout the day for those of you who are not

physically present, i am told you can join in on twitter using the #boat food 2016. there are also twitter handles available for the speakers on the bio pages in the conference materials. >> we will leave these remarks from earlier today to return to live coverage of the symposium on food lot of food policy. we joined it in progress-- progress with the keynote address. >> impactful, sustainable and create changes in behavior that will result in health when it comes to food or kai will provide examples of the new york city context and approaching food policy with health equity lens, but i think it is something we need to have central in the way we think about food and its meaning to help and advancement of our society at large. i'm going to talk a little bit about the value of state local innovation. i think in the introduction

there was in-- examples that i feel the contributions that state local government make to government policy is sharing and testing different mechanisms that may or sometimes may not be best. evaluation component is important and i will talk about examples of innovation in new york city and then i will talk a little bit about the power of integration because i think we often talk about food food policy as if it's just about food, but opportunities to change the food of arm in our massive and are broader than what we would just perhaps consider to be specifically food. going to talk about opportunities to leverage large movements currently underway. so first of all of me talk about health and of this. why we care about food is because it's so important to health and that we all know. heart disease is the leading cause of death in the united states. i put it this light of heart disease, stroke and cancer illustrating that they are responsible for about 50% of all premature deaths. i talk about premature death

because no one should die from these diseases which are largely preventable before age 65 when we have high rates of preventable death we also reflect a society inequity for structural things preventing people from actually being able to live as long as we all should. not only is dying that leading cause of death and also the leading cause of premature death. there are things that should give us pause and that food kicks into this because when it comes to prevention and prevention of chronic diseases in particular, food is a central part. it's one of the leading can contributes to health and one of the leading contributors to illness as well, so this slide shows sort of a comparison of deaths attributed to individual risks in the thousands in both sectors combined. smoking is at the top and there are many iterations of this

analysis. smoking comes out ahead of times and sometimes high blood pressure, but in the end what you will see here he is of all of the major contributors to death, the vast majority, the vast majority are related to food, which means this if we really really care about health we have to care about food. so, this is a slide that i think simplifies this idea of how we address chronic diseases. what i call the making and breaking of chronic disease. on the right-hand side you will see the major causes of death, cardiovascular disease and cancer as we just mentioned and diabetes, which is a top leading cause. it's a contributor to cardiovascular disease as well as death itself also has a special color. there are different pathways you can get to those diseases, but the metabolic risk factor, which are product and result of the common risk factors including tobacco, poor diet, harmful use of alcohol and physical inactivity is one of the sort of pathways to which we also must consider the impacts we can

have. sort of two different ways we can think about where to intervene. we can think about these sort of two arrows here where i think most of us and it's not entirely, but most of us consider those places where our clinical environment is one of those important places to intervene and to save lives and i think that is true and that's where clinical intervention can make a huge difference. but, it is this pipeline oversteer that is of greatest concern in this is where we really start to talk about health policy and legal and regulatory framework that could actually stem the tide into this process. i want to go back to sort of the theme of health inequities and disparities because i don't think they can be ignored when we think about food and the distribution of food. this slide shows in new york city, the concentration of race by neighborhood of poverty by neighborhood and premature

mortality by neighborhood. so come i don't know how many of you are familiar with new york city, but this represents our boroughs. two things going here. so, you will see here these two concentrated areas here throughout the city. they just sort of track. that doesn't mean everywhere else is healthy. that's not what i meant flying and it doesn't mean we should just target these areas, but we do need to be sensitive and aware that there are areas experiencing unacceptable higher levels of disease and those are clearly marked by higher rates of poverty and higher concentration of minority populations. in new york city they are so-called minority, but they are actually the majority of the population. so, how do we intervene? i like this slide because this is doctor thomas friedman who is the former commissioner of health that heads up the cdc now

, that sort of speaks to the different places in which we can make an where the greatest impact would be. at the very top would be counseling people about eating healthy and talking to them one-on-one. as you can see can make a difference, but it's labor-intensive and the impact to have because of research is so intense it would be minimal-- you work your way down you go through clinical intervention. you can-- the next long acting includes things like facts can eight-- vaccination, colonoscopy and then we spent time in the food conversation about change in the context and that means creating an environment where the healthy choice is the easy choice individuals. that's where we spend most of our time in new york city and that's the policies i will talk to you about. i used it to slow-- zero this letter would get uncomfortable and acknowledge that uncomfortable got to socioeconomic factors because we are acknowledging that it is the leading cause and it would have the greatest impact if we would address them, but we spend little time no space and public

health. it's an area perhaps we did not feel like we necessarily had authority over or the means to actually make a difference. so we spent time in the disk area changing the context where it was safe and we could be very effective and i say finding more -- it was an area where we had authority and we also have the tools in the history of the track record and a sort of a comfort level of working in. now i'm proud to say that we are much more aggressive in thinking about changing socioeconomic factors into that and i will speak more about some of the opportunities when we think about food policy both regulatory-- [inaudible] clec things we can do, i love this slide. this was shared with me from a colleague when i was at the cdc and i think it helps to illustrate the two sort of edges in where we work so we can talk about individual assets. an individual can be empowered to make healthy decisions. they could have resources to purchase food that is good for them.

they might know what they need. they might have time and be able to afford it, but if the environment around them does not allow them to do that and healthy foods are nestled in the neighborhood, so they don't have access or perhaps they don't have the resources because they are too expensive, if they are being bombarded by media telling them fast food is not necessarily the food they should desire, at the point of decision they don't know the information they need, for example there is a cowardly labeling available, so they don't know one product or another product would be better. or they don't have the education or the environment around them does not promote or educate then that really is the disadvantage and no matter how many assets you build into the individual they will not be able to be healthy unless you think about the community environmental system and adjust them so they can roll that ball up with these that's where we are working. lets me talk a little bit about the value of state local intervention. i will give you examples of new york city and talk about how as mentioned earlier they became

relevant in the national landscape quite quickly. it took testing them at the local level to make that difference. or to contribute to making that difference let me say because there are many people working in different environments around these areas. these just happened to be areas with examples at this moment. so, the food environment in new york city specifically as we thought about what we could do this lays out nicely the different sort of actors or domains in which we really could think about whether or not we have authority and if we had authority would we want to exercise that through encouraging voluntary change, providing guidance, providing education information or looking for either legal or regulatory options. we could think about the

distributors and try to think about how foods or which foods are being distributed in what way and there are city agencies over which have authority, hospitals, restaurants become a very important domain in which about one third of calories come from restaurants. so, there is space where perhaps historically we have not spent as much time, but i think in recent years everyone is realizing how important it is to work with restaurants to ensure this move they make is healthy. grocery stores and what we call bodegas and for those of you who are not in new york city it's a very caring name for our neighborhood shops. of course, the consumer in the way in which we can influence or have responsibility over consumers in new york city. the spectrum of opportunities for policy information around the food environment within include thinking about industry reformulation, talking about procurement like the responsibility of government to purchase anyway that provides healthy food to those serving.

the private sector has huge peak kermit power. being programs, labeling, pricing, media awareness campaign and when you get to the body of-- bottom it's a systematic way to include changing influences in home and changing the habits of home prepared food. we work and everyone of those areas and for the purposes of time i will speak about a couple of them. so salt, sodium is a major risk factor that raises the blood fetish-- pressure and increases your risk for heart attack and stroke. adults in the united states consumes 50% more sodium than is recommended. the problem is the majority of it is already in the food when purchased, so people really don't have an option. excuse me. people really do have an option about what is in their food was the purchaser. about 77% of sodium is then

processed and restaurant food, so while you are eating and what you are adding at the table that saltshaker, it isn't necessarily the culprit in and of itself. what could we do if we really wanted to change what was happening in processed food? we have two targets or areas we could focus on and one is packaged retail food and the others restaurant environment. ultimately, what you want to do is reduce the sodium in the food gradually over time and ship that curve. so, ultimately that sodium of any food category would be reduced and this is also what was recently announced with the fda, so as we looked at trying to think about how to do this, there is an interesting model in the uk that showed success and we learned from them. we adapted it to think about the us context which included in our mind expanding it also to restaurant food. they were focused at that time only on package food and we learn from them. this global environment that exists.

it was one we drawn to think about what a model might be. we also realized that the manufacturers of food don't produce for new york city. they produce for the nation out large. prior to the administration, not this administration and so one might argue the manufacturer certainly shared with us there should thought that they should be federal action not local action. we realized quickly that it's true. we did not have much control over this at the local level, but at the federal level they could take action. we reached out to colleagues across the united states and other local and state health departments so this is a nice example of local and state health department saying this is an issue and let's work on it together. we crated something called the national site reduction and convened a partnership of over 100 state health departments in march help organizations to demonstrate national support share best practices and to move forward in this model i just

described and we created food databases. we created one to us understand the food environment of packaged food and also when it helps us understand the restaurant food environment. we focused on chain restaurants because they are standardized and created targets and set targets for food categories for 2012 and 2014. we created 62 packaged food targets and .5 restaurant food targets and invited industry to the table when the targets were discussed. they were part of the process and setting targets in nearly 30 food companies committed. plan was to analyze changes in sodium food over time, so we have updated these databases. it was launched in 2009, and here are examples of individual products. just to illustrate some of the big changes that were made over time. really demonstrated to us that this is a feasible way to engage with industry to have the conversation and to monitor and understand the impact. that said, we still have strongly encourage the federal government to be engaged in this

and so we were absolutely thrilled on june 1, the fda announced voluntary guidance for, and included a model very much like ours and major cities throughout the united states have engaged in this process did issue a statement really congratulating the fda encouraging them insane this is the right thing to do. we are very, very, very supportive of that and we like to think that the energy that was already created across united states and city governments engaged in thinking about this and encouraging this was something out support the the fda move forward with this process. chain restaurants, so chain restaurants were part of the national site reduction initiative. they were not as fully engaged as packaged food restaurants were and we were concerned there was still high levels of sodium and in chain restaurants or restaurants in general there is no nutrition panel to help guide you in making a decision. your pre-much on your own or you

need to check a website or ask for special information, but there is no information at the moment. so, we ran the data on sunday called menu stat, which is a database we created and put online for use for free it has nutrient content of all products in about 150 change that includes 150,000 items. we search to see those once in new york city, what was the sodium content of the item and this is the distribution we found. we found that about 10% of all items in chain restaurants had greater than 2300 milligrams of sodium. has more than you should have in an entire day and anything above 2300 west 3200 milligrams of sodium. that's a lot of sodium. that's a lot of risk for high blood pressure, heart attack and stroke. that made us think that maybe this is a space where we really should be sharing with consumers what's going on because what you will also see illustrated here is that it's not just in one type of food items. is food items across a spectrum,

which it makes it hard for consumers to understand where the sodium is in their products and studies have bore that out that people underestimate that a lot of sodium. we propose went to the board of health a requirement that they-- and amendment to the health code that would require chain store it high sodium items in this is the label that we seen earlier, the saltshaker and tribal icons that will go next to menu items that had greater than 2200 milligrams and include a warning statement at the point of purchase. it tells people it has sodium, more than the recommended amount and it increases your risk for raise blood pressure, heart attack and heart disease and stroke. it was upheld-- it was challenged, upheld by a lower court and we just found out the preliminary injection was denied by the appellate division and so it goes into enforcement on june 6, and we are excited for new york city. [applause]. >> that transparency of information is so important.

we also think this might encourage restaurants to think about perhaps reformulating if they don't want icon next to it which would be a benefit to consumers. transpac restaurants. new york city became extremely concerned about transpac in restaurants and some important reports over time with a lot of science around it, but not a lot of action, so we moved again using our authority through the board of health. we introduced a minute to the health code that would restrict the use of trans fat in restaurants. that happened in 2006 and very quickly it spread across united states, so you see the number of millions of people that were covered by this, but still there was only 18% of the population. i think this illustrates where local action is so important in raising an issue and demonstrating changes actually feasible in the industry can reformulate. it really needs federal action to protect all americans. again, in june 2015, the fda

announced trance fast-- trans fat-- [inaudible] >> a benefit for the country at large and really a product with many cities and states becoming engaged and willing to step out and pass regulation. food's standards, another example of trying to think about where our authority lies in new york city and how we can really help to use the resources that we have to change purchasing patterns. also, change the food served to new york city residents and consumers, so we pass these new york city standards that applies to all new york city agencies. it was done by executive order. it covers all meals served by the city and also covers vending machines and affects over 260 million meals and snacks each year, which is a lot of food.

we were pleased with the downstream effects once a company reformulate its food in order to bid on new york city contracts. there may not be a reason for them to make them less healthy for other bidders, so it may have a downstream benefit to people who contract with the same companies. another example, new york city calorie labeling regulation, which as you know was adopted into the aca. we initiated in 2000 and amendment to the new york city of health code, so years before also and it requires certain food service establishments, these are chain restaurants to post calorie content information. it covers-- we have about 3000 restaurants in new york city that are chain restaurants. again, another really important opportunity for consumers to have transcript-- transparency at the point of purchase. that is the time to get the information. i want to acknowledge as i move out of this space, the value of

giving examples of what local and state can do that there is this tension of preemption. so, while-- when something goes from local to national it presents an amazing opportunity to protect all americans. at the same time, there is the preemption that can occur when other policies that are related are printed by this. so, i also want to acknowledge for example how important it was for warnings and as to be a vote to have for sodium. ..

a and providing resources and support for that because if we want to great good national policies with a very good evaluation of local policies, understand that they truly were. it's like if they don't work but you don't want to elevate to the national level something that doesn't work and should be abandoned at the local level anyway. so evaluation. we will move on now to talk about integration, but with a clinical, many ways which you can integrate food policy might want to talk about clinical needs community. we been talking about, i want to acknowledge begin the role of clinical private template and preventing diseases, these hard outcomes. this is a nice study that looks, using cardiovascular disease model tested all these different interventions to compare them to

do the impact would be. i'm just comparing the salt reduction intervention of the pharmacologic treatment of all people with hypertension. i point this out because they ever different, reach different populations but they can have relatively equal impact. the point is to say one should pick one over the other one over the other tickets to acknowledge both environments are very important and we should figure out how to connect and relate. the resources really write out in a clinical environment. the prevention and resources that go, are miniscule compared to that of resources when testing. in a clinical environment and we could save a lot if we prevented many people from getting into that cascade. many people from getting high blood pressure or having heart disease to begin with. how do we marry the two? we operate separately but where are the opportunities for intervention and why would want to integrate the two anyway? i'm going to talk with the example of diabetes.

one of the reasons i have this slide is because of the thai people get into the clinic and being treated there in a small sliver, only 13%. they are are all of these people with prediabetes that we don't have good interventions for right now. there's a number of typos tested models that we move people into like the diabetes prevention program budget is limited number of people that can participate. even if better if so never got it prediabetic area. let's look again at what the problem of diabetes in new york city. is lower than the national level, a little over 10% over all. as you will recall, we had these areas where the rates are extremely high. diabetes, the leading cause, most common form is type ii diabetes and the leading causes of overweight and obesity. this is related to the food

environment in which people are consuming food, the patterns, habits would have available and access to. in the statement we have high rates compared to other areas. which really makes diabetes at issue of health we again or a model or a spectrum to one which can consider health equity at large. here we have premature deaths in the same neighborhoods lining up once again. these are related to one another. diabetes prevention and control as we think of them as social determined that lens, the key things about diabetes prevention and control is active to good health care once you have diabetes. also access to health promoting food department. furthermore, access to your basic needs like housing to education and implement. the literature is a little more limited but it lights up and it's very clear when you look at the data i just showed you in terms of where the distribution is, is something going on that's very different.

in new york city in 2006, there had been a decade pursued that from 1994-2004 where the rates of diabetes in our community health survey doubled. new york city took the bold move of making hemoglobin a1c, the marker of diabetes, understand or the condition for the level of the control condition making that laboratory mandatory, mandatorily reported. this is very much using the same approach we use in infectious disease but recognize in infectious disease but recognizable was killing people is not infectious disease, it's chronic disease. how can we use the same tools for infectious disease and chronic disease? since 2006 all able to laboratory tests that are drunk on new york city residents are recordable to the department of health. we did an analysis that showed the majority of people are not well controlled in new york

city. we look at 132000 individuals that have had their a1c chart consecutively for number of years between 2006-2012. nearly two-thirds did not consistently maintain a a1c below eight which would be considered controlled. we understood there was a problem. the we conducted an analysis to understand where the concentration and density of these people were, what was happening within? what you see on the left hand side is a larger city hotspots. the right inside, i'm just going to show you, this right here is a zoom in this area right here that we look more closely at. what w we thought is we know people are not well controlled and we know where they're living. we know this concentration. what can we do? how can we create change? what was happening in those neighborhoods? this happens to be a number of five nights of houses, new york

city housing authority public housing. this concentrated area here. in response to that, we started thinking about what was happening related to food for these purposes but also much more broadly as well. what was happening to these communities. is was a study i did want to share with you done in boston looking at a cohort of people with diabetes and asking them about what their material needs and security. what i want to show you this across the bottom of the different types of material need integrated was reported by these people with diabetes. if your food insecurity, 20% of those people with diabetes reported that they had food insecurity. there's a signal that something is going on relating to food. for people with diabetes. the other signal a want to talk about is this article was

published that reported out on the move to opportunities with socialist government that was introduced by hud recruiting 4500 individuals giving them vouchers to move from a high poverty area, some two or lower poverty area, some to a place higher low as they wish and a control group without receiving vouchers. what they found is those who move from low to high poverty areas had lower rates, sorry, those who move from high poverty to low poverty areas had lower rates of diabetes. their rates were about double the rates. that gives us a sense also just been physically and, therefore, does not poverty can actually change your projector with respect to diabetes. it may be direct right to housing these were housing vouchers but it could be mediated by food insecurity in that environment in an area that is more impoverished.

i look at which food is cheaper because by money is very small. after getting rid i does have a little bit of money. these are things that are in place the way people are making decisions and those decisions have impact on their health. so what we did in new york city end is near the city housing authority area, which is high poverty area, look income area, we created something called for harlem hellfighters the partners. and they basically committee held, go into the community and focus on these five buildings that we know that these very high rates of diabetes. and work with them individually around not only helping to make that appointment with a physician but also helping them navigate the space around them in their community to make healthier choices. they connected them with many programs would also have in the neighborhood like health box which are 2-dollar coupons redeemable to buy fresh fruits and vegetables at new york city

markets, farmers markets for every five hours you spend you can get an additional $2. we do this throughout the city but particularly we focus on very high poverty areas. again linking what started as a clinical issue related to the kennedy through community health workers to the '70s in private that can affect the way an individual feeds. we also in the neighbors and the other neighborhoods created a program called shop healthy that works with the cornerstones i described to you to help those doors improve the types of food available to people and to help them stock healthier foods and deal talking to that, the workers, public health workers, they help, cushioned the stock healthier cancers can healthier snacks display we display water and other low-calorie calories makes a difference about how often you purchase the. basic grading a healthier food in private about these neighborhoods or these housing

areas that i described before where we have high rates of diabetes. changing the food environment influencing the social determinants come acknowledging the social determinants and really look at what we can do to change that and to mitigate the impact that would have. i want to conclude here because the very last example, i think there's a couple other areas to think specifically about but the most important sort of message that i want to convey is that food policy is about so much more than food. we really need to aim for policy changes the context of the community. change the context of the food environment itself, making the healthier choices, the easier choices but all we really think about a state of the social determinants, thinking that we target specific areas because they are high poverty, recognizing it took a great healthier environments we can also help you physically up the environment, help support

economically more prosperous environment. again emphasize importance of local and states as laboratories and that we really need to the board solid evaluation for the. we really should protect and honor and be very proud of the the changes that happe happenede local level and the impact that can have, helping us make really thoughtful and feasible and reasonable decisions at the national level. and then finally the last message by the power of integration, thinking that opportunity to leverage. the affordable care act include in it, relabeling that is so much more than that. when we are talking about value based here in the way in which providers will be paid, it's on the outcome and we know the outcome depends on what's happening in the community. that's an important opportunity to have conversations about food, and availability of food, the health of the food environment to the health of individuals and have those conversations with a clinical environment and the people that

are making decisions in a clinical invited because there are resources and ways we can work together. another area think is exciting and think a lot about that i am example o of his of his idea of precision medicine. huge investment, $215 million was announced by obama in january come investing a huge amount in creating data that helps us understand individual. why talk about the kremlin laboratory, that the data being collected in a clinical environment. how can we be thinking about using data being collected and a clinical invited to influence and help us understand the and private outside the clinics to really help inform the types of programming that we designed the precision medicine is an important beginning list of that conversation. so given how do we move data? i hope i challenge you to think and giveaways about the food in five and policies, and i really appreciate this opportunity. [applause]

[inaudible] >> thank you for that. one of the things that came up during the fountain drink episode in new york city was this idea of cities and governments telling people what to eat and his nanny state perspective. what kinds of efforts have you found worked well in communicating with the citizens about how this really is in your best interest? this really is something that will help you, rather than us telling you what to do? >> i think this conversation about the nanny state is, it should be expected in any environment. in some ways part of the

response to it is to accept it and to recognize the pain is there and that everybody -- it's okay for people of different views about what should be done. [inaudible] i'm not sure that the goal is ultimately to convince people philosophically that they should feel differently. i think what happens what we do see is that we need policies to go through, people forget very quickly those discussions. i think another example of that that's so important to public health is in the conversation around tobacco and where people can smoke. those same conversations came up and get the healthy needs of the population and the majority won that debate and ultimately the rest of everybody else figured out how to sort of look in those kinds of pentagon finds. the other thing is that a minority voice sometimes that

can become confusing to others. many people don't necessarily share that opinion. in those cases it takes really going back to the community have the conversation ended with you can't explain fully. the sodium labeling, their survey was raised in the media some concerns that we were telling people what to do. i think in the end people felt like it was really great to get information. information let's you make the choice and be empowered. i think people want to be empowered. >> i'm just wondering, it feels like there's a lot of consensus what you eat is very important for your health but also a to be difficult to pin point exactly the effect of one element of a tight on one's overall health. scientific consensus sort of shifts over time on some of these topics, people raise questions, a lot of questions

get raised about fat, saturated fat, are the actually bad and also about what the sort of good, the popular come a good integrated of the day always just. i'm wondering how you grapple with that? >> we spent a lot of time looking at evidence and with the burden of disease is and where it was talking about. salt is a perfect ingredient of that. it can make such a difference to individual. there's very interesting studies with dash dietary approaches to stop hypertension with a should impact of changing your diet we can leave a guy at the same edges to change the sodium. basically you get the same reduction. it's pretty remarkable. you get better reduction by changing you their diet and redg sodium but it's remarkable what this one ingredient into to some with blood pressure. heart disease is the leading cause of death.

ingredients, taking trans fat, that's something that should be a discussion with manufacturers on how the ingredients are changed, with consumers, the big message is that patterns. whole foods, more fresh fruits and vegetables. the challenge is you can have that conversation and they don't make immediately easy then it will not happen. that's what we get into the conversation about food deserts or you can tell people to eat fruits and vegetables and measure outside that of store carries fruits of that some of them in your potatoes and yams. i like those items don't get me wrong but they are not the fruits and vegetables we want people to be involved if they're going to maintain a healthy diet. it's about changing the vibe around them to make it more accessible. >> thank you so much for the presentation and for the leadership of mucus city health department. i'm with change labs solution ever wanted to ask you about the example you gave from harlem. how do you scale up something

like that quick someone if your having conversations with the state medicaid programs to see if there are any opportunities to scale through medicaid? >> i think this is a perfect example of integration when you find a mechanism like that that can make a difference. the question for sustainability is reimbursement and how that can or should be set up. value-based payments to provide organizations and systems. that is i this is something that improves health, then it's worth the medical community investing in and investing in long-term and that allows for the scale up. ultimately, that's going to improve the outcome which makes their value-based payments possible, and sort of helps move the whole system. but that's why think we really get this really sweet spot of integrating population health and clinical care. you exactly spot on.

>> i wan want to echo the thickt to echo the thick of it, ensuring to work with us today. i have been hearing about the initiatives and success and innovation is really exciting and inspiring, especially to new entered just finished my first year as a 34 year because the interest in food and health equity. i appreciate the lens that you brought to this day. and with that my question is, what areas do you see lawyers helping in this advocacy, and the work you are doing? exploring many different things i want to know where you see the greatest need for legal recour recourse. >> i would say in general at the health department we have an amazing legal department led by an incredible general counsel. we meet not infrequently. we have lots and lots and lots of conversations with our legal department. and so i think it might be less about me saying specifically where we need legal help and more about encouraging legal

engagement, fold in the team. -- fully in the team. a lot of the work is done with our cardiovascular disease team, i'm a physician, an epidemiologist. i have an mba, i needed to understand the food industry. i don't speak that language. that's the other thing to do. likewise, having legal counsel, legal engagement on the team thinking with you about what the opportunities are. is a really, really valuable addition to this multidisciplinary team. that every solution is legal but some can be and in some cases it makes sense. it's more effective if that's the means that issues. it's great when everyone is bringing their different perspective. >> i'm executive director for treachery and you basically just spoke about the underpinning of one talk about and that is basically can they keep propping up this office complex problems.

i salute you. if you stick around -- >> i will, i will. >> i want to get at the same conclusion at a higher level in terms of connecting these people together, these disciplines and creating the condition wher we d do the work. my question is, are you at all advocating at the congressional level? did you include the congressional level bipartisan individuals on your great state to articulate how this can laughter up to washington? >> we have a d.c. presents and so when it's appropriate we have those conversations but if you're speaking this about medicaid, these are conversations would have at the state level and i get to the exact status but they are ongoing. we are constantly bringing up and exploring ways. [inaudible] >> absolutely. all of these have connections. we are always looking for opportunities for collaboration,

and i think we have been very fortunate and it really good relationship at the federal level about a lot of these things that i think there's been a lot of mutual learning and opportunities are there. okay, thank you, everyone. appreciate it. [applause] >> we will reconvene at approximately 1:45. [inaudible conversations]

[inaudible conversations] spin we are in a lunch break out for this daylong forum on food policy and public health posted by georgetown university law center. the nextel gets underway at around 2 p.m. eastern and we will bring you that live in it is entire congress, sugar and where to begin. until then, now discussion from earlier in the day with former fda commissioner margaret hamburg and former health and human secretary donna shalala. [inaudible conversations]

>> good morning. my name is kim westmoreland. i'm a professor here at georgetown law and more important for today's purpose i'm a senior scholar at the ona institute. i am sorry to say that dean china has just this morning been called away for a family issue, and so i'm happy to say the public makes me being for the day, if there's anything people want from the law school. i'm welcoming you here today for the o'neill institute which was founded about 10 years ago because law is and will be a tool to solve health problems locally, nationally and globally. for almost a decade, o neill has worked with all parties, governments, policymakers and

ngos and the private sector to develop law as a means to arrive in innovative answers to domestic and international concerns. own u.s. hosting this conference on food to understand the many ways the public health can be improved by addressing of americans produce in the food. it is obvious what of the most basic part of our lives are put is one of our biggest personal expenditures, one of the biggest part of our economy and one of the biggest sources of jobs in america. and increasingly it is recognized as one of the biggest components of our public and personal health. many americans have some food insecurity during the year. the use of antibiotics in livestock continues to development of antibiotic resistance and, of course, the b.c. is one of the most pressing health concerns for individuals and of the nation. we hope today's meeting will further develop with a renewed attention to food policy and to

the creation of bipartisan, indeed nonpartisan attention to these and other problems. as a new president at a new congress come to power, it's important to ensure that food problems are on the table. it's important we present not only the problems but also the legal and the policy solutions to be considered. fortunately, we have a who's who of food policy expert to discuss these problems and solutions today. the proceedings from today are to be published. over the o'neill institute to synthesize the problems and potential solutions discussed into a white paper to be used by policymakers at come advocate consume as part of a 2017 political agenda. today's event is open to the press that is being live stream and televised. we invite our audience here and online to ask questions throughout the day. for those of you who are not physically present i am told you can join in on twitter also

using the hashtag vote through 2016. the are also twitter handles available for the speakers on the final pages in the conference but feels. please help us keep the conversation going on social media and don't forget to add hashtag vote food 2016 to your tweet. finally, this would not be a complete introduction and welcome if i did that if i did that i don't think the people from the o'neill institute who put this together and made it possible. oscar, the executive director, susan, deputy director, sarah roche, the ona associate and give initiative team, and the one those personally responsible for this meeting, lisa, food of law extraordinary who has made this can who is overseeing this conference from beginning and made it actually happen. thank you to them. and welcome to georgetown from the o'neill institute, and it is my great pleasure to introduce

to you as the next speaker, 9/11, professor at georgetown but it's also been associated with the o'neill institute founding. david? [applause] >> good morning, everybody. we have a busy day ahead of us, and wonderful panelists. before we get sort of want to point out that i've been slighted or anyone else is the honorable, and i'm not. i wonder what that says rex so today we have sort of the all-stars of the all-stars in terms of public health and food safety. they need no introduction. instead of residing at the biographies which are in your handouts, let me just sort of point out one or two of the key successes each of them had during their tenure and these are secretaries, department of agriculture, hhs or as commissioner of the food and

drug administration. the honorable donna shalala, she oversaw the department during one of the most important periods in terms of food and health. this was a time when our nutritional labeling information package was being designed, and the theme of her administration was making sure consumers are betting informed about the quality and ingredients of the food that they were eating, enormously important time. >> we are leaving this now for a brief pro forma session in the city. they have been out this week for the memorial day recess, returning for business on monday.