Nashville is known as the home of country music. But these days, the industry that really makes the city move is health care. More than 20 large health care companies are based there, including the Hospital Corporation of America (HCA), one of the country’s largest hospital chains.
Health care revenues account for more than $29 billion a year, a fifth of the city’s total economy. But when it comes to its own health, Nashville is a beat behind. Nearly 28 percent of its adults are obese, and another 36 percent are overweight.
This disconnect has alarmed city officials, health advocates and business leaders — not only because obesity and its related ills are consigning tens of thousands of the city’s citizens to unnecessary illness or disability. They also realize that poor health is expensive, and can harm economic development, both in the short and long term.
“If your company has a lot of people with chronic disease, you’re spending a lot of money,” said William Paul, the city’s health commissioner. “If you can prevent those diseases from happening, you can save a significant amount.”
At the same time, he said, a healthy population can be a major draw for companies looking to relocate or expand.
“Nashville wants to attract new business,” said Paul. “If we’re known as a healthy city, that becomes a positive thing for economic development. If we’re known as a city that thinks about the health of our workforce, that will be a big plus for companies.”
To improve Nashville’s long-term prognosis, the city government, along with businesses and nonprofit groups, have undertaken an ambitious effort to increase residents’ physical activity and improve their eating habits. Combining money from the city budget with more than $7 million in federal funds, Nashville is adding sidewalks and bike lanes, making healthy food more widely available and encouraging citizens to get more active.
While the central goal is improving Nashville’s health, saving money is also crucial, said Alisa Haushalter, a nurse with the health department who is project director for the program. “Everything we do takes economic impact into account,” she said. “It’s the old adage, an ounce of prevention is worth a pound of cure.”
Encouraging Exercise and Better Nutrition
City officials are focusing on changing systemic policies rather than just introducing specific, time-limited programs. For instance, instead of starting an exercise program that will end when funding runs out, the city passed a Complete Streets law, which encourages street improvement projects to include sidewalks and bike lanes.86 The goal is to change the overall environment in which people live, work and play, making it easier to exercise and eat healthy foods.
This year, Nashville also allocated $30 million for parks and greenways, a 30 percent increase from the year before. Nashville is planning to build 25 miles of new walking trails, and has allotted $3 million for 19 miles of new bike paths and $12.5 million to build or improve 19 miles of sidewalks.
In addition, the city helped set up 80 urban vegetable gardens around the city, to encourage both exercise — gardening burns calories —and healthy eating. Many of the gardens pair teens with senior citizens as a way to create social bonds that might not occur otherwise.
The health department also bought 126 bikes, which will be stored around the city on racks near bike paths and greenways. The bikes can be used by any city resident for a few hours at a time, at no cost. To ensure that the bikes are not stolen, those who want to use them must first register online. In addition, the parks department is improving signs and markings along many city trails and bike paths.
This summer, to make sure that residents know about this work, and to encourage them to change how they live, the city rolled out “Nashvitality,” a media campaign with radio and TV ads, as well as a web site.
In addition, the health department is working to improve food in neighborhoods that have little access to healthy food. In these areas, many residents end up shopping at convenience stores, which typically sell few nutritious products.
In partnership with Community Food Advocates, another local non-profit, Nashville is helping 29 of these stores improve what they offer. The city provides coolers to each store and offers advice on how to choose, stock and market fresh fruits and vegetables, as well as other items such as whole wheat bread.90 “Before, all you could buy in these stores was chips, candy and beer,” said David Campbell, one of the project’s coordinators at the city health department. “There was hardly any fresh fruit or vegetables.”
Nashville’s mayor, Karl Dean, has taken a leading role in improving the city’s health. Earlier this year, he started “Walk 100 Miles with the Mayor,” a program that challenged residents to walk that distance over the course of several months. This spring and summer, he took part in 28 public walks around the city, all betweentwo and 10 miles. So far, more than 4,000 residents have signed up; together, they have walked more than 100,000 miles.
“This is a difficult problem, but obesity comes down to issues we can control — what we eat and how much we exercise,” Dean said. He takes the message personally: he lifts weights almost every other day, and does cardiovascular exercise several times a week.
Businesses on Board
Nashville is also focusing on the workplace. Health department officials, along with the Chamber of Commerce, are talking to 10 of the city’s largest companies and institutions, including Vanderbilt University and HCA, which together employ tens of thousands of residents, about how to encourage physical activity and smarter eating.
Among the options being discussed: increasing nutritious options in vending machines; requiring water and healthy food at meetings; subsidizing gym memberships and mass transit passes; allowing employees to exercise during work time; and installing bike racks on company grounds.
Vanderbilt has already developed an extensive wellness program for the 43,000 participants in its health plan (25,000 employees and 18,000 family members). Seven years ago, the institution created “Go For The Gold,” a program that pays people up to $360 a year if they provide information about their health and lifestyle and receive instruction in how to get healthier. Almost 90 percent of those in the school’s health plan participated in at least part of the program.
In 2008, the program received the prestigious C. Everett Koop National Health Award.95 The university is also revamping its cafeterias, subsidizing some nutritious foods and prominently displaying healthier choices. In one building, they replaced a McDonalds with an Au Bon Pain.96 Vanderbilt has also developed a pilot program designed to help those most at risk. It started 30 employees, all recently diagnosed with diabetes, on an intensive exercise and nutrition program. All participants improved their cholesterol and blood sugar measurements, and nearly a quarter were able to stop taking all their medications. “We’ve seen dramatic changes,” said Dexter Shurney, MD, who helps direct Vanderbilt’s wellness program. “We’re pretty excited about this.”97 He is now working to expand the program.
“The question,” he said, “is how to scale this up for 43,000 people. But if we can get more of our population to do these intensive lifestyle programs, we can see substantial savings.”
HCA is also trying to cut costs by improving workers’ health. This year, the company, which insures 148,000 employees and 72,000 dependents around the country, began offering a $250 health care spending credit to those who complete an online health survey and assessment. So far 65 percent of workers have taken part. About 15,000 were found to have increased risk of a chronic disease; they were advised to see a doctor and to visit a company website with disease information.
The company is also testing a pilot program for people with pre-diabetes or diabetes. Once a month, about 350 workers receive individual coaching from a certified diabetes educator on how to reduce risks through exercise, healthy eating and medication. HCA researchers found that compared to a control group, those who were coached had a nearly 50 percent drop in emergency room visits, and a five percent drop in overall health care costs. None of the pre-diabetics who were coached became fully diabetic, and 57 percent stopped being pre-diabetic altogether.
Yonnie Chesley, who is in charge of HCA’s wellness efforts, said the pilot program will soon expand to 1,000 people. If that proves successful, the initiative will go company-wide next year; overall, the company has about 17,000 pre-diabetic or diabetic employees.
Improving Children’s Lives — and Saving Money
The city is also investing in ways to improve the health of the city’s future workforce, with efforts aimed at children and schools.
Improving the health of Nashville’s children will do more than reduce costs in decades to come; it will also help cut current costs. Childhood obesity is expensive: a recent study calculated that in the United States, each obese child costs the health care system nearly $300 a year more than a healthy weight child. The researchers calculated that reducing the rate of childhood obesity by just one percentage point would save at least $1.4 billion annually.
And because obese adults tend to use even more health care resources, helping obese children lose weight before they grow up will eventually save even more money. “Helping them learn healthy habits will really help down the road,” said Haushalter, the city’s obesity program director.
“It’s a long-term economic solution.” Last year, the Nashville school district lowered sugar levels in flavored milk, a reduction of 22 calories per carton. Because of the change, Nashville’s 77,000 public school students will ingest 50,000 fewer pounds of sugar a year. In conjunction with a local non-profit, the district is also working to improve the nutrition of products sold in school vending machines.
More than 40 schools have set up vegetable gardens, which are tended primarily by students. This summer, 20 of the district’s cafeteria managers, who together are responsible for food at more than 140 schools, received training on improving nutrition. Many of these schools are adding salad bars, and most are increasing the number of dishes that are prepared from scratch or with fresh fruits and vegetables.
Other changes are on the way too. “Nashville is like most places,” said Campbell. “The food you eat in a school is generally not very healthy — tater tots, hot dogs, french fries. We want to move to salads, fresh fruit and vegetables.”
In addition, the city is targeting children who aren’t yet old enough for school. The health department is working with eight Head Start programs, which together have nearly 2,000 students, to incorporate physical activity into learning and teach children about good nutrition.
Paul, the health commissioner, is confident that the combination of Nashvitality and private sector efforts will yield results. “If we can have even a small effect on health care costs,” he said, “it’s going to be a big payoff, for a relatively small investment.”
Haushalter agrees, but preaches patience. “We are in an epidemic that has occurred over several decades,” she said. “We have to be very diligent. This will take many years to change.”
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