[Senate Hearing 110-447]
[From the U.S. Government Publishing Office]
S. Hrg. 110-447
CHILDHOOD OBESITY: THE DECLINING HEALTH OF AMERICA'S NEXT GENERATION--
PART I
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON CHILDREN AND FAMILIES
OF THE
COMMITTEE ON HEALTH, EDUCATION,
LABOR, AND PENSIONS
UNITED STATES SENATE
ONE HUNDRED TENTH CONGRESS
SECOND SESSION
ON
EXAMINING CHILDHOOD OBESITY, FOCUSING ON THE DECLINING HEALTH OF
AMERICA'S NEXT GENERATION (PART I)
__________
JULY 16, 2008
__________
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Pensions
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COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS
EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico RICHARD BURR, North Carolina
PATTY MURRAY, Washington JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio TOM COBURN, M.D., Oklahoma
J. Michael Myers, Staff Director and Chief Counsel
Ilyse Schuman, Minority Staff Director and Chief Counsel
______
Subcommittee on Children and Families
CHRISTOPHER J. DODD, Connecticut, Chairman
JEFF BINGAMAN, New Mexico LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington JUDD GREGG, New Hampshire
JACK REED, Rhode Island LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont WAYNE ALLARD, Colorado
EDWARD M. KENNEDY, Massachusetts MICHAEL B. ENZI, Wyoming (ex
(ex officio) officio)
MaryEllen McGuire, Staff Director
David P. Cleary, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
WEDNESDAY, JULY 16, 2008
Page
Dodd, Hon. Christopher J., Chairman, Subcommittee on Children and
Families, opening statement.................................... 1
Prepared statement........................................... 4
Levi, Jeff, Ph.D., Executive Director of Trust for America's
Health, Washington, DC......................................... 6
Prepared statement........................................... 8
Kaufman, Francine, M.D., Past National President of the American
Diabetes Association, Distinguished Professor of Pediatrics and
Communications at the Keck School of Medicine and the Annenberg
School of Communications at the University of Southern
California, Los Angeles, CA.................................... 13
Prepared statement........................................... 15
Grey, Margaret, DrPH, R.N., FAAN, Dean and Annie Goodrich
Professor, Yale School of Nursing, New Haven, CT............... 18
Prepared statement........................................... 20
Lesley, Bruce, President, First Focus, Washington, DC............ 22
Prepared statement........................................... 24
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa,
statement...................................................... 29
Prepared statement........................................... 30
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska,
statement...................................................... 30
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico,
statement...................................................... 31
(iii)
CHILDHOOD OBESITY: THE DECLINING
HEALTH OF AMERICA'S NEXT
GENERATION--PART I
----------
WEDNESDAY, JULY 16, 2008
U.S. Senate,
Subcommittee on Children and Families, Committee on Health,
Education, Labor, and Pensions,
Washington, DC.
The subcommittee met, pursuant to notice, at 2:31 p.m. in
Room SD-430, Dirksen Senate Office Building, Hon. Christopher
Dodd, chairman of the subcommittee, presiding.
Present: Senators Dodd, Bingaman, and Murkowski.
Also Present: Senator Harkin.
Opening Statement of Senator Dodd
Senator Dodd. The committee will come to order.
Well, first of all, let me thank our witnesses, and also I
want to welcome the rather large audience here in this
committee room. I am particularly pleased to see so many young
people here. We have opened up the back room as well. For those
of you standing here, as seats become available, the staff will
try and make it more available.
Had I known we were going to have this much interest in the
subject matter, I would have tried to secure a larger room. I
apologize to all of those of you who are standing and showed up
for today's hearing, but I am very grateful to all of you.
My colleague from Tennessee, Senator Lamar Alexander, I
know is going to try and make it over here with us for this
hearing, and I suspect we will be seeing Senator Harkin as
well, who has a deep interest in the subject matter that is the
theme of our hearing this afternoon.
The subject, ``Childhood Obesity: The Declining Health of
America's Next Generation--Part I.'' My intention is to have a
series of hearings, at least two immediately and possibly more,
on this subject matter as we examine the health condition of
the next generation.
As many have concluded, as I will share in my opening
comments, this generation of the younger generation in this
country may be the first generation of Americans in the history
of our country that is less healthy than their parents. That is
a statistic and a conclusion that is deeply troubling to all of
us.
I welcome you here today for what is the first, as I
mentioned, of two important hearings on one of the most urgent
threats to American children, the childhood obesity epidemic.
The numbers are, quite frankly, stunning--absolutely stunning.
No other word could be used other than that to describe it.
Nearly one out of every three of America's children are
obese or are at the risk of becoming obese--25 million children
in all, with children in minority families at an even greater
risk in our country. It is the most common disease of
childhood, and we are told it is largely preventable.
Nationally, the childhood obesity rate tripled between 1980
and 2004. In many States, especially those in the South and the
Midwest, the rates are even much worse. Even in States where
childhood obesity rates are among the lowest in the Nation,
like Colorado and my home State of Connecticut, the rates are
appallingly high--even in relatively good States.
As a parent, these findings are deeply troubling to me--as
they should be, of course, to every parent, every person in
this country--because this is about so much more than numbers
and statistics. Most public health experts believe, and the New
England Journal of Medicine recently warned, that unless we act
as a nation, our children's generation may be the first in the
modern era to live shorter, less healthy lives than those of
their parents. That is a possibility we should all be ashamed
of as Americans.
Already the health consequences are crystal clear. Right
now, children are increasingly being diagnosed with type 2,
``adult-onset'' diabetes, high blood pressure, and high
cholesterol levels. The list goes on: stroke, certain types of
cancers, osteoarthritis--is that how you pronounce it?--certain
liver diseases. You don't have to be a health expert to know
that these are not diseases we normally associate with
children.
We all can point to reasons why this is happening. Junk
food is rampant and marketed to children. Television has paved
the way for children to have more sedentary lifestyles. We
surround our public schools with soft drink machines and fast
food restaurants, which local schools allow because they are
often so underfunded they turn to corporate sponsors for
financial assistance.
It doesn't help that only 8 percent, only 8 percent of our
elementary schools in this country even require daily physical
activity, and only 6 percent of middle and high schools do as
well. At the same time, our investment in public parks, bike
paths, playgrounds, and other kinds of infrastructure that
encourage physical activity has deteriorated.
According to the 2004 National Survey of Children's Health,
between 25 to 40 percent of children over the age of 9 get less
than 1 hour of physical activity a week, depending upon the
State they live in. A new report released by the National
Institute of Child Health and Human Development and published
in the Journal of the American Medical Association shows that
the vast majority of 15-year-olds do not come close to getting
the recommended 60 minutes of physical activity a day.
Childhood obesity is a problem that affects all of us,
whether we have children or not. One day every one of these
children are going to grow into adulthood, and odds are that
every one of the health problems that started when they were
children are only going to get worse. We are all going to be
paying the bill.
If you are not impressed by the human dimension of this,
then consider the financial costs. The obese spend 36 percent
more on health care. They spend 77 percent more on medications.
That means the costs for all of us are going to keep heading
upwards.
They already are. Health care spending has exploded, as
many know, in the last 20 years, and 1 out of every 4 of those
added dollars has gone to treat obesity-related problems. That
is unsustainable as a nation. The question, of course, is what
are we going to do about it as a nation?
These hearings, these two hearings we will be holding are
our first step in this subcommittee. Today, we will make sure
we understand what is happening and why. Next week, I will hold
a second hearing in which we will focus on what needs to be
done to stem the current tide and who could and should be doing
it, from the individual to the private sector, from State and
local governments obviously to the national government as well.
All of us--parents, schools, government, employers--need to
see the rising childhood obesity rates for what they are. This
is a medical emergency, and it is time that we worked together
to do something about it.
I am delighted that we are joined or will be joined by my
colleague from Iowa, Senator Harkin, who I mentioned a moment
ago, has devoted a great deal of his time to this issue. As the
Chairman of the Agriculture Committee of the U.S. Senate and
who sits on the Appropriations Committee, he has been working
diligently over the last number of years to try and develop
better nutrition programs, support more organic farming, and
other issues which could help considerably to deal with some of
the issues that are associated with obesity.
I want to thank him and I want to thank again Senator
Alexander, who is also very interested in the subject matter,
for their support of this effort.
With that, I want to turn to our witnesses and again thank
them for being with us today. Let me introduce them for all of
you.
Jeff, is it ``Lee vee''--do you pronounce it ``Lee vee?
''--Jeff Levi. Dr. Levi is the executive director of Trust for
America's Health. He is also an associate professor at George
Washington University's Department of Public Health, and he
previously served as the deputy director of the White House
Office of National AIDS Policy. He has a Master's from Cornell
University and a Ph.D. from George Washington University.
Trust for America's Health, or TFAH, advocates for a
modernized public health system and addresses many of the
critical problems threatening the health of our Nation. Each
year, TFAH issues a remarkable report on obesity. It is called
``F as in Fat.'' We look forward to sharing the findings of
this report, and of course, thank you, Doctor, for being with
us.
Francine Kaufman, Dr. Kaufman, is a pediatric
endocrinologist. Dr. Kaufman is a distinguished professor of
pediatrics and communications at the Keck--is it Keck?--Keck
School of Medicine and the Annenberg School of Communications
at the University of Southern California. She also serves as
the director of the Comprehensive Childhood Diabetes Center and
is head of the Center for Endocrinology, Diabetes, Metabolism
at Children's Hospital in Los Angeles.
Dr. Kaufman served as national president of the American
Diabetes Association from 2002 and 2003 and remains a very
active volunteer in that effort. She is a foremost expert on
the nexus of obesity and diabetes and is leading some of the
world's largest studies on diabetes. She was elected to the
Institute of Medicine in 2005 and has received numerous
prestigious awards for her research and leadership. We thank
you, Doctor, as well.
Next we have Margaret Grey. She is from Connecticut, a
constituent of mine. I am delighted she is with us. Dr. Grey is
Dean at the Yale Nursing School, the Annie Goodrich Professor,
and a pediatric nurse practitioner. She holds a master's of
science in pediatric nursing from Yale University and a
doctorate in public health and social psychology from Columbia
University.
Dr. Grey's work and leadership has been recognized by
countless esteemed awards and honors. She was also elected to
the Institute of Medicine in 2005. Her research focuses on
behavioral aspects of children with diabetes and behavioral
interventions that can help prevent and control diabetes in
youth. We look forward to hearing from you as well, and thank
you very much.
Bruce Lesley is someone who needs little introduction to
folks around here, and we thank you once again for being before
us. He has spent 12 years on Capitol Hill working on the Senate
Finance Committee and the HELP Committee, the very committee we
are in today, as well as with numerous members, including our
colleague Jeff Bingaman, who I hope will be able to get by a
little later in this hearing.
Long an advocate of the needs of children, he is currently
the president of First Focus, a group that works to ensure that
children and families remain on the agenda of the Federal
Government. Bruce lives in Maryland with his wife and children.
We welcome you back to the committee. Good to have you with us.
Let me ask each of you, if you would, to make your opening
statements. I want you all to know that whatever other
supporting documentation you think would be helpful, as we
start to build this record in the committee, will be made a
part of the record.
If you can--I am not going to wave a gavel around at you
here, but if you could try and keep your remarks to 5 or 7
minutes or so, so we can get through the opening statements and
then have a good conversation.
Since we are not overloaded with members here today, I want
to encourage sort of the informality of talking back and forth
without rudely interrupting each other. If you have additional
thoughts, if I ask one question, don't be quiet about this.
This is an opportunity for us to lay out a good record that I
hope will be the beginning of some very positive developments
on this issue as well.
Prepared Statement of Senator Dodd
First, I want to welcome my colleagues and our
distinguished witnesses, and thank them for being here today.
Today we are holding the first of two important hearings on one
of the most urgent threats to American children--the childhood
obesity epidemic.
The numbers are stunning. Nearly 1 out of every 3 of
America's children are obese or are at risk of becoming obese--
25 million children in all, with children in minority families
at an even greater risk. It is the most common disease of
childhood and we're told it's largely preventable. Nationally,
the childhood obesity rate tripled between 1980 and 2004. And
in many States, especially those in the South and the Midwest,
the rates are much worse. Even in States where childhood
obesity rates are among the lowest in the Nation, like Colorado
or my home State of Connecticut, the rates are appallingly
high.
As a parent, these findings deeply worry me--as they should
every parent in America--because this is about so much more
than numbers and statistics. Most public health experts
believe, and the New England Journal of Medicine recently
warned, that unless we act, our children's generation may be
the first in the modern era to live shorter, less healthy lives
than their parents. That is a possibility we should all be
ashamed of.
Already the health consequences are crystal clear. Right
now, children are increasingly being diagnosed with type 2,
``adult-onset'' diabetes, high blood pressure and high
cholesterol. The list goes on--stroke, certain types of
cancers, osteoarthritis, certain liver diseases. You don't have
to be a health expert to know that these are not diseases we
normally associate with children.
We all can point to reasons why this is happening. Junk
food is rampant and marketed to kids. Television has paved the
way for kids to have a more sedentary lifestyle. We surround
our public schools with soft drink machines and fast food
restaurants--which local schools allow because they are often
so underfunded they turn to corporate sponsors for financial
assistance.
It doesn't help that only 8 percent of elementary schools
even require daily physical activity--only 6 percent of middle
and high schools. At the same time, our investment in public
parks--in bike paths, playgrounds and other kinds of
infrastructure that encourage physical activity--has
deteriorated. According to the 2004 National Survey of
Children's Health, between 25 to 40 percent of children over
the age of 9 get less than one hour of physical activity a
week, depending on the State. And a new report released by the
National Institute of Child Health and Human Development
(NICHD) and published in the Journal of the American Medical
Association today shows that the vast majority of 15 year olds
do not come close to getting the recommended 60 minutes of
physical activity a day.
Childhood obesity is a problem that affects all of us--
whether we have kids or not. One day every one of these kids is
going to grow into an adult--and odds are that every one of the
health problems that started when they were kids is going to
get worse.
And we're all going to be paying the bill. The obese spend
36 percent more on health care--they spend 77 percent more on
medications. That means the costs for all of us are going to
keep heading up. They already are. Health care spending has
exploded in the last 20 years--and 1 out of every 4 of those
added dollars has gone to treat obesity-related problems. That
is unsustainable. The question is: what are we going to do
about it?
These hearings are our first step. Today we'll make sure we
understand what is happening and why. Next week we will focus
on what needs to be done to stem the current tide and who could
and should be doing it, from the individual to the private
sector, from State and local government to the Federal
Government. All of us--parents, schools, government,
employers--need to see the rising childhood obesity rates for
what they are: a medical emergency. It is time we worked
together to do something about it.
I am delighted that we are joined by Senator Harkin. He has
been tireless in his efforts to bring this issue to Congress'
attention and find innovative solutions to this epidemic. I
want to thank my partner in this venture, the Ranking Member of
the Subcommittee, Senator Alexander, who also has a very real
concern about these issues.
Senator Dodd. With that, Dr. Levi, we thank you very much
for joining us, and the floor is yours.
STATEMENT OF JEFFREY LEVI, PH.D., EXECUTIVE DIRECTOR OF TRUST
FOR AMERICA'S HEALTH, WASHINGTON, DC
Mr. Levi. Thank you, Mr. Chairman, and thank you very much
for this opportunity to testify on this very serious issue of
the declining health of America's children, which is closely
linked to our Nation's obesity epidemic.
As you noted, approximately 25 million children are obese
or overweight, and rates of obesity have more than tripled
since 1980. While a recent analysis from the National Health
and Nutrition Examination Survey, known as NHANES, suggests
that the number of U.S. children who are overweight or obese
may have peaked after years of steady increases, scientists and
public health officials are unsure if the data reflect real
change or a statistical anomaly.
Even if childhood obesity rates have peaked, the number of
children with unhealthy BMIs remains unacceptably high, and the
public health toll of childhood obesity will continue to grow
as the problems related to overweight and obesity in children
show up later in life. This will also threaten our economic
competitiveness as a nation as our healthcare costs continue to
rise, in part, due to obesity and overweight.
How did this problem arise? In the simplest terms, one
could argue this is just a matter of physics. Children today
are eating more and moving less, which inevitably leads to
increases in weight. That is true, but it is only a part of the
story.
We have also created a physical environment that re-
inforces a less-active lifestyle, and we have not compensated
for this in the level of physical activity we promote in the
schools. Thirty years ago, nearly half of American children
walked or biked to school. Today, less than one in five do so.
Children are also not getting enough activity in schools.
According to CDC data, only 3.8 percent of elementary schools,
7.9 percent of middle schools, and 2.1 percent of high schools
provided daily physical education or its equivalent.
We have also placed kids in a less nutritious environment.
It is not just too much food, but too much bad food that kids
are eating. We have not harnessed the opportunities of the
school to compensate for the overall propensity among Americans
to consume too much sugar and too few fruits and vegetables.
What occurs in schools can be critical, given the number of
children who depend on school breakfast and lunch for their
meals and the patterns that school food access can create for
all children. Current food and meal nutrition guidelines lack
standards for sodium, trans fat and whole grains, and the fruit
and vegetable content is too low. Yet new guidance from the
USDA is not expected until 2010, despite a 2004 congressional
requirement to issue new guidelines.
We have placed a particular burden on our poor and minority
children, who are disproportionately overweight and obese.
Primarily because our poverty programs have not kept up with
the rising cost of nutritious food, access to healthy food is
often limited in poor neighborhoods, and physical activity may
be limited because of safety concerns or inadequate
recreational facilities.
For example, African-American children are almost twice as
likely to be obese. Similarly, the National Survey on
Children's Health shows that rates of overweight decline as
income rises. In 2003, 22.4 percent of kids below 100 percent
of poverty were overweight, while only 9.1 percent of kids at
400 percent or more of poverty were overweight.
I think this outline of the problem shows that it will take
more than telling kids to eat less and move more. We need a
national commitment to change the physical and social
environment in which children live, and all Americans will
benefit from living in healthier communities. We must make
healthy choices easy choices for all Americans, regardless of
where they live or what school they attend. We need a cultural
shift, one in which healthy environments, physical activity,
and healthy eating become the norm.
Tomorrow, Trust for America's Health will release a new
report that examines how much the country could save by
strategically investing in community disease prevention
programs. The report concludes that an investment of $10 per
person per year in proven community-based programs to increase
physical activity, improve nutrition, and prevent smoking and
other tobacco use could save the country more than $16 billion
in healthcare costs annually within 5 years. This is a return
of investment of $5.60 cents for every $1 invested.
Harnessing this opportunity will require a true national
strategy to combat obesity. At this time, we have no such
national coordinated effort. It is time for a comprehensive,
realistic plan that involves every department and agency of the
Federal Government, State and local governments, businesses,
communities, schools, families, and individuals.
Our leaders should be challenged to do their part to
improve our Nation's health. We know that even small changes
can make big differences in people's health. The challenge is a
big one, but we can make a difference together.
Thank you again for the opportunity to testify, and I look
forward to the discussion that follows.
[The prepared statement of Dr. Levi follows:]
Prepared Statement of Jeffrey Levi, Ph.D.
Good afternoon. My name is Jeffrey Levi, and I am the Executive
Director of Trust for America's Health (TFAH), a nonpartisan, nonprofit
organization dedicated to saving lives by protecting the health of
every community and working to make disease prevention a national
priority. I would like to thank the Chairman, the Ranking Member and
the members of the subcommittee for the opportunity to testify on a
very serious issue--the declining health of America's children, which
is closely linked to our Nation's obesity epidemic. Today I would like
to discuss the scope of childhood obesity in America, the potential
factors that may be contributing to it, the health and economic impacts
of obesity, and the importance of developing a national strategy to
coordinate our response to obesity. By focusing on the impact of
obesity on the health of our children, we have a chance to reshape
society--and assure that our children live healthier lives than we do.
If we do it right, I believe we will also improve the health and well-
being of lots of adults in the process because the solutions to the
obesity epidemic require a societal transformation that will benefit
all of us.
scope of the problem
Overall, approximately 23 million children are obese or overweight,
and rates of obesity have more than nearly tripled since 1980, from 6.5
percent to 16.3 percent.\1\ Eight of the 10 States with the highest
rates of obese children are in the South.\2\
---------------------------------------------------------------------------
\1\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass
Index for Age among U.S. Children and Adolescents, 2003-2006.'' Journal
of the American Medical Association 299, no. 20 (2008): 2401-2405.
\2\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, Maternal and Child Health Bureau. National
Survey of Children's Health 2003. Rockville, MD: U.S. Department of
Health and Human Services, 2005, http://www.mchb.hrsa.gov/overweight/
techapp.htm (accessed April 22, 2008).
---------------------------------------------------------------------------
According to a recent analysis from the National Health and
Nutrition Examination Survey (NHANES), the number of U.S. children who
are overweight or obese may have peaked, after years of steady
increases. According to researchers from the Centers for Disease
Control and Prevention (CDC), there was no statistically significant
change in the number of children and adolescents (aged 2 to 19) with
high BMI for age between 2003-2004 and 2005-2006.\3\ This is the first
time the rates have not increased in over 25 years. Scientists and
public health officials, however, are unsure if the data reflect the
effectiveness of recent public health campaigns to raise awareness
about obesity and increased physical activity and healthy eating among
children and adolescents, or if this is a statistical abnormality.
Scientists expect to know more when the 2007-2008 NHANES data are
analyzed. The 2005-2006 National Survey on Children's Health, a large
national survey with State-specific data, is also due out in late 2008
and may offer another perspective on childhood obesity rates. Even if
childhood obesity rates have peaked, the number of children with
unhealthy BMIs remains unacceptably high, and the public health toll of
childhood obesity will continue to grow as the problems related to
overweight and obesity in children show up later in life. We should be
setting a national goal to see childhood obesity rates return to 6.5
percent, the level prior to the start of this epidemic.\4\
---------------------------------------------------------------------------
\3\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass
Index for Age among U.S. Children and Adolescents, 2003-2006.'' Journal
of the American Medical Association 299, no. 20 (2008): 2401-2405.
\4\ U.S. Department of Health and Human Services, National Center
for Health Statistics. Prevalence of Overweight Among Children and
Adolescents: United States, 1999. Hyattsville, MD: National Center for
Health Statistics; 2001. http://www.cdc.gov/nchs/products/pubs/pubd/
hestats/overwght99.htm (accessed July 14, 2008).
---------------------------------------------------------------------------
factors contributing to obesity rates
How did this problem arise? In the simplest of terms, one could
argue this is just a matter of physics--children today are eating more
and moving less, which inevitably leads to increases in weight. That is
true, but is only a part of the story.
We have also created a physical environment that
reinforces a less active lifestyle, and we have not compensated for
this in the level of physical activity we promote in the schools.
We have placed kids in a less nutritious environment--it
is not just too much food, but too much bad food that kids are eating,
and we have not harnessed the opportunities of the school to compensate
for this.
We have placed a particular burden on our poor and
minority children, who are disproportionately overweight and obese,
primarily because our poverty programs have not kept up with the rising
cost of nutritious food; access to healthy foods is often limited in
poor neighborhoods, and physical activity may be limited because of
safety concerns or inadequate recreational facilities.
To reverse this trend, we need a national commitment to change the
physical and social environment in which children live. By doing so, we
will also help adults--as all Americans benefit from living in
healthier communities.
The following is a sketch of the scope of the problem and some
possible solutions. Our annual report on obesity, F as in Fat: How
Obesity Policies Are Failing in America, is available at our Web site,
www.healthyamericans.org, and provides a more comprehensive look at
these issues. The 2008 edition will be released in August.
Food and Physical Activity
Many American children are consuming more calories, eating less
healthful foods, engaging in less physical activity and instead
spending their time engaging in sedentary activities. Overall, ``added
sugar'' consumption for Americans is nearly three times the U.S.
Department of Agriculture's (USDA) recommended level,\5\ and adolescent
females ages 12-15 consumed approximately 4 percent more calories in
1999-2000 than they did in 1971-1974.\6\ In 2003, a USDA report
characterized America's per capita fruit consumption as ``woefully
low'' and noted that vegetable consumption ``tells the same story.''
\7\ Moreover, since the 1970s, fast food consumption in children has
increased five-fold. In the late 1970s, children received approximately
2 percent of their daily meals from fast food; by the mid-1990s, that
increased to 10 percent. Children who consume fast food, as compared
with those who do not, have higher caloric intake, more fat and
saturated fat, and more added sugar.\8\
---------------------------------------------------------------------------
\5\ Putnam, J., J. Allshouse, and L.S. Kantor. ``U.S. per Capita
Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.''
Food Review 25, no. 3 (2002): 1-14.
\6\ Briefel, R.R. and C.L. Johnson. ``Secular Trends in Dietary
Intake in the United States.'' Annual Review of Nutrition 24, (2004):
401-431.
\7\ Putnam, J., J. Allshouse, and L.S. Kantor. ``U.S. per Capita
Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.''
Food Review 25, no. 3 (2002): 1-14.
\8\ Asche, K. ``Fast Foods May Increase Childhood Obesity Rates.''
University of Minnesota Extension. (2005). http://
www.extension.umn.edu/extensionnews/2005/fastfood.html (accessed July
14, 2008).
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In addition to developing poor dietary habits, many children are
becoming less physically active. For example, 30 years ago, nearly half
of American children walked or biked to school; today, less than one in
five either walk or bike to school.\9\ Increased screen time--whether
television or computers--is associated with higher rates of overweight
and obesity. Furthermore, according to the CDC's latest School Health
Policies and Programs Study, only 3.8 percent of elementary schools,
7.9 percent of middle schools and 2.1 percent of high schools provided
daily physical education or its equivalent. Some attribute at least
part of this decline in physical activity programs to the academic
requirements of No Child Left Behind. That is unfortunate as there is
growing evidence that fitter more active students perform better
academically.
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\9\ McDonald, N.C. ``Active Transportation to School: Trends among
U.S. Schoolchildren, 1969-2001.'' American Journal of Preventive
Medicine 32, no. 6 (2007): 509-516.
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Health Impacts
The health impacts of obesity and physical inactivity are dire and
can start at a young age. Physical inactivity is tied to heart disease
and stroke risk factors in children and adolescents. A number of
studies have documented how obesity increases a child's risk for a
number of health problems, including the emerging onset of type 2
diabetes, increased cholesterol and hypertension among children, and
the danger of eating disorders among obese adolescents.\10\ Some
studies have shown that obesity and overweight in children also
negatively affect children's mental health and school performance. The
recent recommendation by the American Academy of Pediatrics for
cholesterol screening of kids--with the possibility of prescription of
cholesterol lowering drugs for young children--is just another tragic
example of how much obesity has affected the health of our children.
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\10\ U.S. Department of Health and Human Services (USDHHS). The
Surgeon General's Call to Action to Prevent and Decrease Overweight and
Obesity. Washington, DC: USDHHS, 2001.
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Economic Impact
These health impacts come at a great cost to our Nation. According
to the Department of Health and Human Services, obese and overweight
adults cost the United States anywhere from $69 billion to $117 billion
per year.\11\ One study found that obese Medicare patients' annual
expenditures were 15 percent higher than those of normal or overweight
patients. The cost of childhood obesity is also growing. Between 1979
and 1999, obesity-associated hospital costs for children (ages 6 to 17
years) more than tripled, from $35 million to $127 million.\12\
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\11\ U.S. Centers for Disease Control and Prevention. ``Preventing
Obesity and Chronic Diseases Through Good Nutrition and Physical
Activity.'' U.S. Department of Health and Human Services, http://
www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm
(accessed July 14, 2008).
\12\ Ibid.
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The poor health of Americans of all ages is putting the Nation's
economic security in jeopardy. More than a quarter of U.S.-health care
costs are related to physical inactivity, overweight and obesity.
Health care costs of obese workers are up to 21 percent higher than
non-obese workers. Obese and physically inactive workers also suffer
from lower worker productivity, increased absenteeism, and higher
workers' compensation claims. To maintain our economic competitiveness
and our general health and well-being, we must improve the health of
America's next generation. To do that, we must improve diet and
physical activity levels.
National Security Impact
The problem of obesity and overweight has reduced the number of
volunteers for military service who must meet height and weight
requirements. At a time when military recruiters are struggling to meet
the needs of our Armed Forces, we are finding more and more volunteers
who are overweight and obese. In 1993, 25.6 percent of 18-year-old
volunteers were overweight or obese; in 2006 that percentage rose to
almost 34 percent.\13\ This problem continues during active duty. Each
year between 3,000 and 5,000 service members are forced to leave the
military because they are overweight.\14\
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\13\ Hsu, L.L., R.L. Nevin, S.K. Tobler, and M.V. Rubertone.
``Trends in Overweight and Obesity among 18-Year-Old Applicants to the
United States Military, 1993-2006.'' The Journal of Adolescent Health
41, no. 6 (2007): 610-612.
\14\ Cable News Network. ``Discharged Servicemen Dispute Military
Weight Rules.'' CNN.com, September 6, 2000. http://www.cnn.com/2000/
HEALTH/09/06/military.obesity/index.html (accessed May 2, 2008).
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An Environment That Discourages Physical Activity and Healthy Eating
The built environment and community design can have a great impact
on nutrition and physical activity levels. For children, the placement
of schools and access to safe venues for physical activity are
particularly important. One study found that the primary reason that
children do not walk or bike to school is because their school is too
far away. Other concerns included too much traffic, no safe route, fear
of abduction, crime in the neighborhood, and lack of convenience.\15\ A
Government Accountability Office study found that ``areas of low
socioeconomic status and high minority populations had fewer venues for
physical activity'' and ``adolescents in unsafe neighborhoods engage in
less physical activity'' than their peers. Even where opportunities for
physical activity may be available--such as school playgrounds--many
communities are encountering liability concerns as an impediment to
after-hours use of these community resources.
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\15\ U.S. Centers for Disease Control and Prevention (CDC).
``Barriers to Children Walking and Biking to School--United States,
1999.'' Morbidity and Mortality Weekly Report 51, no. 32 (2002): 701-
704.
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Access to nutritious foods is another important issue that can
affect children's health. Everything from the foods sold in schools to
the presence or absence of grocery stores and markets selling fresh
fruits and vegetables in communities to the foods that parents serve to
their children can influence obesity levels and ultimately health care
costs.
What occurs in schools can be critical--given the number of
children who depend on school breakfast and lunch for their meals and
the patterns that school food access can create for all children. In
2004, the Child Nutrition and WIC Reauthorization Act of 2004 (P.L.
108-265) required the U.S. Secretary of Agriculture to issue school
nutrition guidelines that would ensure that American schoolchildren
consume foods recommended in the most recent Dietary Guidelines for
Americans (DGAs); however, USDA has issued no proposed regulations in
the 3 years since the release of the 2005 DGAs.\16\ Instead, USDA
contracted with the Institute of Medicine (IOM) to convene a panel of
experts on child nutrition. In late 2009, the IOM Committee on
Nutrition Standards for School Lunch and Breakfast Programs is expected
to provide USDA with recommendations for updating the school meal
programs' nutrition requirements. Once USDA receives the IOM
recommendations, agency officials will then seek to incorporate them
into formal USDA guidance, which is expected to be issued some time in
2010. A final rule will take even longer to be issued. This turn of
events effectively postpones the update of school meal nutrition
standards by 5 years beyond when they were due. Given the fact that
school meal nutrition standards lack standards for sodium, trans fat,
and whole grains, and that the fruit and vegetable content is too low,
this delay is of considerable public health concern.
---------------------------------------------------------------------------
\16\ U.S. Department of Agriculture (USDA). Incorporating the 2005
Dietary Guidelines for Americans into School Meals. SP 04-2008.
Washington, DC: USDA, 2007.
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Disparities
Unfortunately, as with too many other health problems facing our
Nation, obesity often disproportionately affects minorities and the
poor. African-American children are almost twice as likely to be
obese.\17\ Black and Hispanic adolescents have higher rates of physical
inactivity (by 5-6 percentage points).\18\
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\17\ U.S. Department of Health and Human Services, Health Resources
and Services Administration, Maternal and Child Health Bureau. National
Survey of Children's Health 2003. Rockville, MD: U.S. Department of
Health and Human Services, 2005.
\18\ U.S. Centers for Disease Control and Prevention. ``Youth Risk
Behavior Surveillance--United States, 2007.'' Morbidity and Mortality
Weekly Report 57, no. SS-4 (2008): 1-136.
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Equally disturbing, is the apparent relationship between being
overweight and poverty. The National Survey on Children's Health (2003)
shows that rates of overweight decline as income rises (22.4 percent of
kids below 100 percent of poverty were overweight; only 9.1 percent of
kids at 400 percent or more of poverty were overweight). Similarly,
rates of physical inactivity are greater for poor kids (17 percent who
were under 100 percent of poverty engaged in no vigorous physical
activity each week; only 7.8 percent of those at 400 percent of poverty
fell into that category). Eating healthier can be very expensive.
Calorie dense foods tend to be less expensive; supermarkets are less
likely to be accessible in poor neighborhoods; and poor children are
more dependent on school nutrition programs, which are not always
meeting the highest standards. The current rise in food prices raises
serious concerns about the impact on obesity among poor children.
Programs such as food stamps are not keeping up with rising prices and
do not provide adequate financial incentives to encourage healthier
eating by providing larger benefits for healthier food, though some
notable improvements were made through the passage of the Food,
Conservation, and Energy Act of 2008 (P.L. 110-246).
community prevention
As a nation, we tend to over-medicalize health problems. In fact,
given the state of today's science--medicine can only address the
consequences of overweight and obesity, not prevent it. Real prevention
requires changing the communities in which children (and adults) live
and approaching this as a community-wide, not just an individual,
challenge. It will also be the most cost-effective way to mitigate this
epidemic. To truly tackle the obesity epidemic, we must make healthy
choices easy choices for all Americans, regardless of where they live
or what school they attend. We need a cultural shift, one in which
healthy environments, physical activity and healthy eating become the
norm.
Tomorrow Trust for America's Health will release a new report,
Prevention for a Healthier America: Investments in Disease Prevention
Yield Significant Savings, Stronger Communities, which examines how
much the country could save by strategically investing in community
disease prevention programs. The report concludes that an investment of
$10 per person per year in proven community-based programs to increase
physical activity, improve nutrition, and prevent smoking and other
tobacco use could save the country more than $16 billion annually
within 5 years. This is a return of $5.60 for every $1. The economic
findings are based on a model developed by researchers at the Urban
Institute and a review of evidence-based studies conducted by the New
York Academy of Medicine. The researchers found that many effective
prevention programs cost less than $10 per person, and that these
programs have delivered results in lowering rates of diseases that are
related to physical activity, nutrition, and smoking. The evidence
shows that implementing these programs in communities reduces rates of
type 2 diabetes and high blood pressure by 5 percent within 2 years;
reduces heart disease, kidney disease, and stroke by 5 percent within 5
years; and reduces some forms of cancer, arthritis, and chronic
obstructive pulmonary disease by 2.5 percent within 10 to 20 years,
which, in turn, can save money through reduced health care costs to
Medicare, Medicaid and private payers.
examples of successful interventions
Community and school-based approaches aimed at using reducing
obesity in the United States have already shown to be successful. The
Child and Adolescent Trial for Cardiovascular Health (CATCH) elementary
school program provides education for students, modifications for
improvements in school lunches and physical education, and increased
education for staff and teachers. Results have shown that students in
the program consumed healthier diets and engaged in more physical
activity.
The town of Somerville, MA developed a comprehensive program called
``Shape Up Somerville'' to curtail childhood obesity rates. The project
included partners across the community. Various restaurants started
serving low-fat milk and smaller portion sizes; the school district
nearly doubled the amount of fresh fruit at lunch and started using
whole grain breads; the town expanded a local bike path and repainted
crosswalks; and the town targeted crossing guards to areas where
children are most likely to walk to school. Researchers evaluated the
program after 1 year and found that children in Somerville gained less
weight than children in surrounding communities. (Growing children are
expected to gain some weight.)
Another example of a coordinated approach to obesity reduction at
the community level is the YMCA's Pioneering Healthier Communities.
This project supports local communities in promoting healthy
lifestyles. Examples of interventions have included offering fruits and
vegetables and encouraging physical activity during after school
programs; influencing policymakers to ``put physical education back in
schools and include physical activity in after school programs'';
building or enhancing bicycle and pedestrian trails; and increasing
access to fresh produce in communities through community gardens,
farmers markets and other activities.
national strategy
Clearly, it has taken years for the childhood obesity epidemic to
develop, and it will take a coordinated effort over time to begin to
mitigate it. At this time, we have no national, coordinated effort to
combat obesity. TFAH supports the development of a National Strategy to
Combat Obesity. This needs to be a comprehensive, realistic plan that
involves every department and agency of the Federal Government, State
and local governments, businesses, communities, schools, families, and
individuals. It must outline clear roles and responsibilities. Our
leaders should challenge the entire Nation to share in the
responsibility and do their part to help improve our Nation's health.
All levels of government should develop and implement policies to make
healthy choices easy choices--by giving Americans the tools they need
to make it easier to engage in the recommended levels of physical
activity and choose healthy foods, ranging from improving food served
and increasing opportunities for physical activity in schools to
securing more safe, affordable recreation places for all Americans.
The ``National Strategy for Pandemic Influenza Planning'' provides
a strong example for how this type of effort can be undertaken. With
leadership and goals identified by health agencies and experts, every
cabinet agency has taken charge of developing and implementing policies
and programs in their jurisdiction that all contribute to our Nation's
preparedness for a pandemic flu outbreak. Similarly, the United Kingdom
has announced an anti-obesity strategy to ``transform the environment''
in which people in England live, including launching a campaign to
promote healthy living and healthy towns with bicycle and pedestrian
routes.
conclusion
Our country needs to focus on developing policies that help
Americans make healthier choices about nutrition and physical activity.
We know that even small changes can make a big difference in people's
health--and that individuals don't make decisions in a vacuum. If we
want our children to lead healthy, productive lives, we need a strong
partnership from the government, private and nonprofit sectors, as well
as parents and teachers, to emphasize wellness and enhance nutrition
and physical activity. The challenge is a big one, but we can make a
difference together. Thank you again for the opportunity to testify.
______
Summary
Overall, approximately 23 million children are obese or overweight,
and rates of obesity have nearly tripled since 1980. According to a
recent analysis from the National Health and Nutrition Examination
Survey (NHANES), the number of U.S. children who are overweight or
obese may have peaked, after years of steady increases. Scientists and
public health officials, however, are unsure if this is a statistical
abnormality. Even if childhood obesity rates have peaked, the number of
children with unhealthy BMIs remains far too high, and the public
health toll of childhood obesity will continue to grow as the problems
related to overweight and obesity in children show up later in life.
A number of factors have contributed to the Nation's childhood
obesity epidemic. Children are eating more and moving less, which
inevitably leads to increases in weight, but that is only a part of the
story. We have also created a physical environment that reinforces a
less active lifestyle, and we have not compensated for this in the
level of physical activity we promote in the schools. We have placed
kids in a less nutritious environment--it is not just too much food,
but too much bad food that kids are eating, and we have not harnessed
the opportunities of the school to compensate for this.
The health and economic impacts of obesity are very serious.
According to the Department of Health and Human Services, obese and
overweight adults cost the United States anywhere from $69 billion to
$117 billion per year. More than a quarter of U.S. health care costs
are related to physical inactivity, overweight and obesity. To maintain
our economic competitiveness and our general health and well-being, we
must improve the health of America's next generation. To do that, we
must improve diet and physical activity levels.
Real prevention requires changing the communities in which children
(and adults) live and approaching this as a community-wide, not just an
individual challenge. It will also be the most cost-effective way to
mitigate this epidemic. To truly tackle the obesity epidemic, we must
make healthy choices easy choices for all Americans, regardless of
where they live or what school they attend. We need a cultural shift,
one in which healthy environments, physical activity and healthy eating
become the norm.
It has taken years for the childhood obesity epidemic to develop,
and it will take a coordinated effort over time to begin to mitigate
it. At this time, we have no national, coordinated effort to combat
obesity. We need a National Strategy to Combat Obesity, a
comprehensive, realistic plan that involves every department and agency
of the Federal Government, State and local governments, businesses,
communities, schools, families, and individuals. If we want our
children to lead healthy, productive lives, we need a strong
partnership from the government, private and nonprofit sectors, as well
as parents and teachers, to emphasize wellness and enhance nutrition
and physical activity.
Senator Dodd. Thank you very, very much, and I have some
questions for you, which I will raise in a few minutes.
Dr. Levi. OK.
Senator Dodd. Dr. Kaufman, thank you so much. Thank you
very much. I attend every year, and am very active in the
juvenile diabetes program in my home State of Connecticut. I
have some wonderful friends with children who have diabetes,
and we do a great effort in Connecticut. Thank you for your
work.
STATEMENT OF FRANCINE KAUFMAN, M.D., PAST NATIONAL PRESIDENT OF
THE AMERICAN DIABETES ASSOCIATION, DISTINGUISHED PROFESSOR OF
PEDIATRICS AND COMMUNICATIONS AT THE KECK SCHOOL OF MEDICINE
AND THE ANNENBERG SCHOOL OF COMMUNICATIONS AT THE UNIVERSITY OF
SOUTHERN CALIFORNIA, LOS ANGELES, CA
Dr. Kaufman. Great. Thank you for your commitment.
Chairman Dodd, it is truly an honor to be here, and I thank
you for allowing me the opportunity to testify before you
today.
Examining the ravages of the obesity and diabetes epidemics
in the United States and around the globe is not only what I do
by my profession as a pediatric endocrinologist, but I do it as
a passion. Obesity has reached epidemic proportions in the
United States. It has increased in both genders and in all
racial, ethnic, and socioeconomic groups.
With 198 million Americans estimated to be obese or
overweight and the prevalence of diabetes now at nearly 24
million, it is urgent that Congress focus on this topic today.
Since 1990, the prevalence of obesity has tripled among our
children and adolescents. As you said, one in three in the
United States are now classified as overweight or obese. Of
great importance is that childhood obesity is a significant
predictor of obesity in adulthood.
Over the last 3 years, changes in demographics and societal
norms have contributed to the rise of childhood obesity. We
have seen dramatic changes in nutrition and physical activity
habits of America's children. The vast majority of today's
young children do not follow a nutritious diet, and only about
a third get sufficient physical activity.
That is why it is not unusual for me when I see infants
coming to me at my center in Los Angeles with soda in their
baby bottles and when I am told that the first solid food given
to that child was a French fry. Children who are overweight,
obese, and unfit are at increased risk of becoming seriously
depressed. They have fatty liver disease, and they develop high
blood pressure, abnormal lipid levels, inflammation in their
blood vessels, and higher than normal blood sugar values.
These last disorders are the precursors of adult-onset
cardiovascular disease and type 2 diabetes. Dangerously, trends
during the 1990s illustrate type 2 diabetes in youth, which was
exclusively a disorder of the adult population when I began my
career. Now type 2 diabetes has increased ten-fold in our
youth, closely mirroring the childhood obesity epidemic.
As these epidemics have unfolded, we have found that both
obesity and type 2 diabetes disproportionately affect minority
and poor children. The prevalence of childhood obesity and type
2 diabetes among African-Americans, Mexican-Americans, and
especially Native Americans exceeds that of other ethnic and
racial groups. Estimates show that one in three children born
in the year 2000 or beyond will develop diabetes at some point
in their lives, but for minority children, this statistic is
closer to one in two.
On a personal level, I have seen heartbreaking examples of
childhood obesity epidemic in my medical practice. In 1995, I
saw one of the first children who heralded in the type 2
diabetes epidemic in youth. She was a 13-year-old girl with a
blood sugar value of 427 milligrams per deciliter, a value at
least 5 times higher than normal. She weighed 267 pounds, and
she was 5 foot, 1 inches tall.
She came into my office with her mother and her
grandmother, who each weighed over 250 pounds. Her diet
consisted of fried foods, candy bars, and soda, most of which
she obtained inside her school, and outside meals from fast
food restaurants because there were few grocery stores in her
neighborhood. Her school did not offer meaningful physical
education, and there was no place safe to play in her
neighborhood. So, she watched 5 hours of TV a day.
Her grandmother had had uncontrolled type 2 diabetes and
had suffered from a stroke and an amputation. The girl's mother
had pre-diabetes, and even despite this strong family history,
in 1995, it was hard to believe that a girl so young could have
type 2 diabetes. It is not hard to believe it anymore.
This young girl left my office taking five medications, but
still remained at high risk for the complications of diabetes.
I knew it would be hard for her to control her disease, and I
knew that, as a result, 15 years would likely be taken from her
life. Although that day I felt as if I had been in a battle,
over the subsequent years, it has become clear that I and my
colleagues are really in a war, and it is a war that we have
yet to win.
For my patient to do well, the world in which she lives
will have to change. Her neighborhood, her school, her
healthcare system that focuses on treatment rather than
prevention, essentially the landscape of our country will have
to transform so that it promotes and supports healthy lifestyle
habits and makes healthy choices the easy choices and the
accessible and affordable ones.
My patient will need to make changes, too. Without a
supportive environment, those changes--eating well, getting
active, losing weight--which may sound easy, have been
impossible for her to do. Today, there is no doubt that obesity
and youth, along with its associated myriad of medical
conditions, is a major health challenge of the century.
There is no doubt that we have had some early efforts on
the part of government, the private sector, and the medical and
public health systems, but to date, they have not been
sufficient to reverse the trend and control the number of
children who are becoming overweight and obese and the number
of children who are subsequently becoming ill. It is imperative
that more be done to combat the ever-growing epidemics of
obesity and diabetes.
I thank you for the opportunity to speak before you today.
I know we share the passion of enabling the children of America
to grow up healthy and well.
Thank you very much.
[The prepared statement of Dr. Kaufman follows:]
Prepared Statement of Francine Kaufman, M.D.
Chairman Dodd, Ranking Member Alexander and members of the
subcommittee, good afternoon. My name is Dr. Fran Kaufman and I am a
pediatric endocrinologist and professor of Pediatrics and
Communications at the Keck School of Medicine and the Annenberg School
of Communications at the University of Southern California. Examining
the ravages of the obesity and diabetes epidemics in the United States
and around the globe is not only my specialty, but also my passion. I
thank you for holding this hearing and allowing me the opportunity to
testify before you today on the dangerous health consequences of
childhood obesity.
Obesity has reached epidemic proportions in the United States. It
has increased in both genders, and in all racial, ethnic and
socioeconomic groups. With 198 million Americans estimated to be
overweight or obese according to the CDC and the prevalence of diabetes
having risen to 23.6 million Americans--an increase of nearly 3 million
people over the 2-year period from 2005 to 2007--it is especially
valuable to be holding this hearing on this topic today.
We have seen the prevalence of obesity triple among children 6 to
11 years and adolescents 12 to 17 years since 1980.\1\ A total of 9
million children ages 6 to 19 in the United States are now classified
as overweight or obese. The overall prevalence of obesity in children
was 17 percent in 2006. Alarmingly, we are seeing an increase in very
young children, now over 1 in 5 young children 2 to 5 years of age are
overweight or obese. Of great importance is the fact that obesity in
childhood is a significant predictor of obesity in adulthood.
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\1\ National Health and Nutrition Examination Surveys (NHANES)
(Ogden, C.L., Flegal, K.M., Carroll, M.D., Johnson, C.L.: Prevalence
and Trends in Overweight Among United States Children and Adolescents,
1999-2000. JAMA 288:1728-1732, 2002).
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Many researchers have placed the origin of the childhood obesity
epidemic at the beginning of the 1980s. Since that time, we have seen
dramatic changes in the nutrition and physical activity habits of
American children, along with changes in demographics and societal
norms that have all contributed to the rise in childhood obesity.
According to the CDC only 20 percent of students eat the recommended 5
servings of fruits and vegetables per day and only 2 percent of
children currently meet the USDA's 5 main healthy diet recommendations.
Additionally only 35 percent of students are physically active for at
least 60 minutes per day meeting the recommended guidelines. Barely
more than half of students, 54 percent, attend physical education
classes at least 1 day a week.
During childhood, obesity impairs psychosocial well-being and obese
children are socially isolated. They perform poorly in school and have
a poorer self-image than children who have a normal weight. Obesity in
children is associated with severe impairments in quality of life. In
fact, obese children have characterized their lives as being equal to
those of children with cancer.
Childhood obesity is associated with serious metabolic
disturbances, obstructive sleep apnea, asthma, fatty liver disease,
orthopedic problems, ovarian dysfunction, and chronic kidney ailments.
Children who are overweight, obese and unfit are at an increased risk
of developing high blood pressure, abnormal lipid levels, inflammation
in their blood vessels, and higher than normal blood sugar levels.
These factors are the precursors of adult-onset cardiovascular
disease and diabetes. During the mid-1990s, type 2 diabetes in youth
increased ten-fold in the United States, and mirrored the childhood
obesity epidemic. Diabetes is a chronic condition in which the pancreas
either does not create any insulin, which is type 1 diabetes, or the
body doesn't create enough insulin and/or cells are resistant to
insulin, which is type 2 diabetes.
Diabetes is the leading cause of kidney disease, adult onset
blindness, and lower limb amputations and can lead to heart disease and
stroke.
Childhood obesity disproportionately affects minority and poor
children. The prevalence of childhood obesity among African-Americans,
Mexican-Americans and Native Americans exceeds that of other ethnic
groups. The Centers for Disease Control reported that in 2000 the
prevalence of obesity was 19 percent for non-Hispanic black children
and 20 percent for Mexican-American children, compared to 11 percent
for non-Hispanic white children. The increase since 1980 is
particularly evident among non-Hispanic black and Mexican-American
adolescents.
Similarly, type 2 diabetes in the pediatric population is
disproportionately seen in Hispanic, Native American, and African-
American adolescents. Estimates show that one in three children born in
the year 2000 will develop diabetes at some point in his or her life,
but this statistic is nearly one in two for minority children. The
SEARCH for Diabetes in Youth Population Study, sponsored by the CDC and
NIH, found that the proportion of all diabetes that was diagnosed as
type 2 varied by ethnicity among 10- to 19-year-olds: 6 percent for
non-Hispanic whites, 22 percent for Hispanics, 33 percent for African-
Americans, 40 percent for Asians/Pacific Islanders, and 76 percent for
Native Americans.\2\
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\2\ Liese, A.D., D'Agostino, R.B., Jr., Hamman, R.F., Kilgo, P.D.,
Lawrence, J.M., Liu, L.L., Loots, B., Linder, B., Marcovina, S.,
Rodriguez, B., Standiford, D., Williams, D.E.: The Burden of Diabetes
Mellitus Among U.S. Youth: Prevalence Estimates from the SEARCH for
Diabetes in Youth Study. Pediatrics 118:1510-1518, 2006.
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An extraordinary example of the rise of type 2 diabetes in youth is
shown through the marked increase in the prevalence of type 2 diabetes
in Pima Indian youth over the last 20 years. Before the 1990s, almost
no younger children and less than 1 percent of older children in the
Pima Indian community had type 2 diabetes. By the mid-90s, 2.2 percent
of 10- to 14-year-olds and 5 percent of those 15- to 19-years-old had
type 2 diabetes.\3\ As a result of diabetes, many young adults who
developed the disease as adolescents are now suffering prematurely from
the long-term complications of this devastating disease.
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\3\ Dabelea, D., Hanson, R.L., Bennett, P.H., Roumain, J., Knowler,
W.C., Pettitt, D.J.: Increasing Prevalence of Type II Diabetes in
American Indian Children. Diabetologia 41:904-910, 1998.
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Of further concern, the significant rise in obesity in children has
been accompanied by an increase in the severity of obesity, and there
are differences in the degree of obesity among racial groups. The
prevalence of severe obesity (BMI > 30 kg/m2) in female adolescents was
approximately 10 percent in non-Hispanic whites, 20 percent in non-
Hispanic blacks and 16 percent in Mexican-Americans.
In one of the NIH studies of which I am the chair, called the
HEALTHY middle-school trial, we have found that low-income, minority
middle school students in 7 cities across the country have high rates
of pre-diabetes associated with overweight and obesity. Pre-diabetes is
a condition that is diagnosed when someone has a higher than normal
fasting blood sugar level or a higher than normal value after a glucose
tolerance test, but not one in the diabetes range. An estimated 57
million Americans have pre-diabetes today.\4\ In adult studies the
conversion rate is about 10 percent per year. In this particular study
we found that 39 percent of 8th graders and 14 percent of 6th graders,
these are 13- and 11-year-old children, respectively, had pre-diabetes,
with the highest rates found in Hispanic and American Indian youth. Not
only did these 13-year-old students have abnormal blood glucose levels,
but 15 percent had high blood pressure, half had abnormal lipid levels,
and 8 percent had fatty liver disease. Fatty liver disease is also a
new phenomenon in youth, and there is an indication that this might
lead to early liver failure, which if not treated with a liver
transplant will result in death. Fatty liver disease is more common in
obese boys than in obese girls, and differs significantly by race/
ethnicity. In obese children ages 2-19, 65 percent of Hispanics, 35
percent of whites and 10 percent of blacks had fatty liver disease.\5\
---------------------------------------------------------------------------
\4\ Centers for Disease Control and Prevention, 2007 National
Diabetes Fact Sheet.
\5\ Schwimmer, J.B., Deutsch, R., Kahen, T., Lavine, J.E., Stanley,
C., Behling, C.: Prevalence of Fatty Liver in Children and Adolescents.
Pediatrics 118:1388-1393, 2006.
---------------------------------------------------------------------------
On a personal level, I have seen heart-breaking examples of the
childhood obesity epidemic in my medical practice. I remember one of
the first children I saw with type 2 diabetes just as this epidemic was
beginning. It was in the middle of spring in 1995. She was a 13-year-
old girl with a blood sugar level of 427 mg/dl, at least five times
higher than normal for a young teen. She weighed 267 pounds. She came
to my office with her mother and grandmother, they each weighed about
250 pounds. She had been drinking a lot of juice and soda throughout
her life. Her diet consisted of fried foods, candy bars, and meals from
fast food restaurants. She did not have access to meaningful physical
education courses in her school curricula and there was nowhere safe to
play in her neighborhood. She watched 5 hours or more of TV a day.
Her grandmother had type 2 diabetes and had never controlled her
blood sugar levels. Five years earlier she had suffered from a stroke
and an amputation. My patient's mother had been diagnosed with pre-
diabetes. Despite her strong family history of diabetes, no one
believed that this 13-year-old girl had this disease--because she was
just too young.
Her mother told me she watched diabetes destroy her own mother, and
she did not want to see that happen to her child. To control her high
blood sugar level, her high blood pressure, and her high cholesterol,
this young girl left my office taking five medications. Even still, she
remained at high risk and it would be hard to control her disease and
all its attendant problems. I knew that at least 15 years would be
peeled off this young woman's life.
That day I felt as if I had been in a battle, but I am really in a
war. A war we have yet to win. For my patient to do well, the world in
which she lived would have to change. Her neighborhood, her school, the
healthcare system that focuses more on treatment than prevention--our
country--would have to transform so that it promotes and supports
healthy lifestyle habits and make the healthy choices the easy
choices--the accessible and affordable choices. My patient would need
to make changes too, but without a supportive environment, those
changes,--eating well, getting active and losing weight--might be
impossible for her to make. In my office in 1995, I knew that a world
of battles would have to be fought for my patient, and for too long
that war has been going on. As I stand before you today, I am hopeful
the time has come for the war to be won.
Today, there is no doubt that obesity in youth, along with its
associated medical conditions, is the major health challenge of this
century. Although attention has been paid to this problem by government
and public health officials, researchers, and health care providers,
the number of overweight and obese youth continues to increase. More
needs to be done to combat the ever growing epidemics of obesity and
diabetes.
Again, thank you for the opportunity to speak before you today. I
look forward to the opportunity to answer any of your questions.
Senator Dodd. Thank you very much, Dr. Kaufman.
Dr. Grey, thank you very much for being with us as well.
You will see, by the way, we have been joined by Senator
Harkin and Senator Murkowski, and I thank you both for being
here.
We will let our witnesses finish, and then I am going to
ask each of you to make some opening comments, if you would. Is
that OK?
Go ahead, Dr. Grey.
STATEMENT OF MARGARET GREY, DrPH, R.N., FAAN, DEAN AND ANNIE
GOODRICH PROFESSOR, YALE SCHOOL OF NURSING, NEW HAVEN, CT
Ms. Grey. Senator Dodd and Senators Harkin and Murkowski,
thank you so much for the opportunity to speak with you today
about childhood obesity.
In my 30 years of experience, I have found that the obesity
epidemic in youth is multifaceted, threatening not only their
future health, but their quality of life, their potential for
educational achievement, and ultimately, future employment
potential.
As a nurse with training in both public health and social
psychology, my interest has always been in preventing illness
and, in the case of obesity and diabetes, preventing
complications. When I began working in this field in the 1970s,
I never saw a child with type 2 diabetes. Now up to 50 percent
of new cases of diabetes in children are type 2 diabetes, what
we used to call ``adult-onset'' diabetes.
While it is most common in teens, we have had children as
young as 5 years old with type 2 diabetes in our service.
Worse, it appears that this diabetes is very aggressive, and
these youth develop the devastating complications of diabetes--
cardiovascular disease, kidney disease, blindness, and
amputations--at an early age. Indeed, the early longitudinal
studies of these youth suggest that while they are in their
20s, they are already having heart attacks and on renal
dialysis.
Beyond physical complications, there are complications
related to quality of life, depression, and academic
achievement. Let me illustrate how serious these complications
can be.
Quality of life refers to self-reported physical,
emotional, social, and school functioning. In 2003, a research
study found that obese teens have lower quality of life than
teens with cancer. If childhood overweight and obesity lead to
a reduced quality of life, then these youth are at risk for
psychological, social, and educational complications along with
the medical ones.
With funding from the National Institutes of Nursing
Research, my colleagues and I have been studying approaches to
prevent type 2 diabetes in youth who are overweight or obese
and have a family history of type 2 diabetes. These are the
youth who will be most likely to develop diabetes in the next 5
to 10 years.
In the New Haven middle schools where we conducted our
work, we identified that at least 30 percent of these
overweight high-risk youth had levels of depression requiring
referral of treatment. This isn't minor sadness. This is
serious depression. Those who were depressed also had much
poorer dietary and activity behaviors, lower self-efficacy,
higher body mass index, and higher fasting insulin levels.
From studies of adults with diabetes, we know that
depression is not uncommon and associated with poor physical
health as well as poor self-care. We also know that the obesity
epidemic is disproportionately affecting youth of racial and
ethnic minorities and of lower income. These youth may be
especially susceptible to depression, creating a situation of
extremely high risk.
We all know that depression is a risk factor for suicide,
and a child who dies from the psychological complications of
obesity is just as dead as the one who dies from the physical
complications 10 years from now.
The New Haven intervention to prevent type 2 diabetes was
developed based on my own research with a behavioral
intervention called coping skills training. Early on in this
process, we found that these middle school youth had never
learned basic nutrition. Many of these families had no access
to quality fruits and vegetables, and physical education in the
schools emphasize sports, not individual activity. So that, the
youth who needed to participate the most were most often found
on the sidelines.
In addition, as has been stated earlier today, many of
these children had no access to safe places to be active, nor
did they have any confidence that they could change any of
these health behaviors. The intervention that we did, targeted
at seventh graders, included nutrition education, non-sports
physical activities, and the behavioral skills necessary to
implement what they learned.
During the 12-month followup, youth who received the entire
program had lower body mass index, decreased insulin
resistance, improved dietary and activity behaviors, decreased
depression, and improved confidence in their ability to sustain
these behaviors.
On the issue of school performance, a recent review found
that overweight and obese youth had poorer performance than
those of normal weight, with lower math and reading scores.
They also were more likely to be held back, miss more days of
school, and boys were more likely to expect to drop out of
school.
Even more disturbing is the finding that men and women who
were obese as teenagers had significantly fewer levels of
schooling by adulthood. The reasons for this are unclear. It
may be due to the psychosocial complications of obesity, and it
may be due to mildly high blood sugar levels through the day
that affect cognitive abilities.
The ramifications of these psychosocial and educational
complications of obesity are clear. It is doubly hard to change
lifestyle when children and youth are depressed, and poor
school performance now predicts a lifetime of struggle later,
not to mention the potential for absenteeism at work, affecting
performance and the ability to stay employed.
In this area of work, the need for more research into
programs that can prevent obesity is critical. Once these
habits are learned and engrained, it is much more difficult to
change behavior. More studies of community-based approaches
that reach children and families at a young age in their
communities are needed.
I would be remiss if I did not make the case that funding
for NIH and CDC, as well as the National Institute of Nursing
Research, which is the only institute at NIH focused on
prevention and enhancement of self-management of chronic
illness, needs to be increased to allow more of this kind of
research to help us solve this problem.
This generation of youth will not survive if we continue to
pay for their heart attacks, but not for the intensive care
that it will take to reduce this epidemic. None of us wishes
for this generation to be the first to have a lifespan and
quality of life that is lower than that of the previous
generation.
Thank you for your attention. Thank you for the invitation.
I look forward to the discussion.
[The prepared statement of Ms. Grey follows:]
Prepared Statement of Margaret Grey, DrPH, R.N., FAAN
Thank you for the opportunity to speak with you today about this
very serious problem. My name is Margaret Grey, and I am a pediatric
nurse practitioner with training in both public health and social
psychology. For over 30 years, my area of research and practice has
been pediatric diabetes. As you know, and as others on the panel have
reiterated, the obesity epidemic in youth threatens not only the future
of these children with chronic diseases and a decreased lifetime, this
epidemic is multi-faceted and will ultimately affect the workforce and
thus the economy.
As a nurse, my interest has always been on prevention--preventing
illness and, in the case of obesity and diabetes, preventing
complications. The obesity epidemic has led to an entire generation of
youth developing type 2 diabetes in childhood, not in adulthood or old
age as we are more used to seeing. When I began in this field in the
1970s, we never saw a child with type 2 diabetes. Now, depending on the
clinic, up to 50 percent of new cases of diabetes in children are type
2 diabetes as opposed to type 1 (which was formerly known as juvenile
diabetes. While it is most common in teens, in our clinic, we have seen
children as young as 5 years old with type 2 diabetes. Worse, it
appears that this diabetes is very aggressive and these youth develop
the devastating complications of diabetes--cardiovascular disease,
kidney disease, blindness and amputations--at an early age. Indeed, the
longitudinal studies of these youth suggest that while they are in
their 20s, they are already having heart attacks and receiving
dialysis.
While these physical complications are critically important
concerns, there are also complications related to quality of life,
depression, and academic achievement. Let me illustrate how serious
these complications can be. Quality of life refers to self-reported
physical, emotional, social, and school functioning. In 2003, Schwimmer
reported that in a comparative study that obese teens have lower
quality of life than teens without a chronic condition or those with
cancer! This finding was more recently replicated in a community
sample. So why does quality of life matter? If childhood overweight and
obesity lead to reductions in health-related functioning, then these
youth are at risk for psychological, social, and educational
complications. I will explain this further.
Related to quality of life is depression. With funding from the
National Institutes of Nursing Research, my colleagues and I have been
studying approaches to preventing type 2 diabetes in youth at high risk
for its development by virtue of overweight or obese status and a
family history of type 2 diabetes. In our studies in the New Haven
School System middle schools, we have identified that at least 30
percent of these overweight, high risk youth have levels of
depression--not temporary sadness or the ``blues''--but depression
requiring referral and treatment. Those who were depressed had much
poorer dietary and activity behaviors, lower self-efficacy, higher Body
Mass Index (even among the already overweight), and higher fasting
insulin levels (indicating a higher risk for type 2 diabetes). From
studies of adults with diabetes, we know that depression is not
uncommon and is associated with poorer physical health as well as
poorer self-care. In addition, the obesity epidemic is
disproportionately affecting youth of racial and ethnic minorities and
of lower income. These youth may be especially susceptible to
depression, creating a situation of extremely high risk. We all know
that depression is a risk factor for suicide, and as I have often said,
as much as we worry about the physical complications of obesity, a
child who commits suicide is just as dead as one who suffers from the
physical complications.
Our intervention to prevent type 2 diabetes in high risk youth in
the middle schools was developed based on my own research with a
behavioral intervention called Coping Skills Training and with
collaboration of teachers and school nurse practitioners. Early on in
this process, we learned that these middle school youth had never
learned basic nutrition, so that we had to teach the difference between
starches, proteins, and fats. We also learned that many of these
families have no access to quality fruits and vegetables in the inner
city besides a head of old iceberg lettuce (and we wonder why they look
at us funny when we suggest they eat salads every day!). Physical
education programs in the schools emphasized sports, so that the youth
who needed to participate the most were most often found watching and
not playing. There was little to no emphasis on activity that could
occur without a team. Finally, many of these children had no access to
safe places to be active, nor did they have any confidence that they
could change any of their health behaviors.
The program was designed to be taught by the teachers in the 7th
grade and included nutrition education, non-sports physical activity,
and the behavioral skills (such as problem solving, social skills,
assertiveness, and cognitive behavior modification) necessary to
implement what they learned. Over the course of the 12 months of
follow-up, we found that the youth who received the entire program,
compared to just the nutrition education, had lower BMI, decreased
insulin resistance (a marker of risk for diabetes), improved dietary
and activity behaviors, decreased depression, and improved confidence
in the ability to sustain these behaviors. We are now in the process of
testing this program throughout the New Haven middle schools and in
several other school districts.
You may wonder if these concerns are confined to racial and ethnic
minorities and the inner cities. They are not. While obesity rates in
youth average 20 percent, they are merely higher in these communities.
And, our recent studies tell us that concerns about school lunches
being high in fat and low in fruits and vegetables are equally of
concern in suburban middle class communities. One of our students
recently analyzed school lunch menus in five Connecticut schools--both
inner city and suburban--and found that while portion sizes were
appropriate, percentage of calories from fat exceeded guidelines, even
before the children went to the vending machines and purchased sodas
and fried snacks.
The final topic I will address is the effect of obesity on school
performance. A recent review found that overweight and obese youth had
poorer school performance than those of normal weight. Obese and
overweight youth had lower math and reading scores, were more likely to
be held back, missed more days of school, and boys were more likely to
expect to quit school. Even more disturbing is the finding that men and
women who were obese as teens had significantly fewer years of school
by young adulthood. The reasons for this are unclear: the psychosocial
complications of obesity may lead to decreased motivation, but it is
also possible that there is a physiologic cause. We know from studies
of youth with diabetes that even mildly elevated blood glucose levels
are associated with cognitive declines, so it's possible that some of
these youth have high glucose levels during the school day and just
can't think the same way those of normal weight and glucose levels can.
The ramifications of all of these psychosocial and educational
complications of obesity are clear. It's doubly hard to change
lifestyle when they are depressed. Depression may lead to suicide. Poor
school performance often predicts a lifetime of struggle and lower
income, not to mention the potential for absenteeism at work affecting
performance and the ability to stay employed.
In this area of work, the need for more research into programs that
can prevent obesity before it happens is critical. Once habits are
learned and ingrained, it is much more difficult to change behavior.
For example, we are beginning a study to help pregnant women lose
weight after pregnancy, because we know that children of these women
are more likely to be overweight by age 2 than children of women who
have lost their pregnancy weight. Such research will take longer than
the usual NIH grant of 3-5 years to demonstrate convincingly that this
kind of approach will reduce rates of childhood obesity. More studies
of community-based approaches that reach children and families at a
young age in their communities are needed. As important as these
school-based studies are, they focus more on treatment of obesity that
has already occurred than in prevention. And, I would be remiss if I
did not make the case that the funding of NIH and NINR in particular,
the only one with prevention and enhancement of self-management of
chronic conditions as major focus areas, needs to be increased to allow
for more of the studies I have described.
With regard to health policy, I cannot emphasize enough that this
generation of youth cannot survive if we continue to pay for the care
of their heart attacks, but not for the intensive behavioral care that
it will take to reverse this epidemic. I am sure that none of us wishes
to be partially responsible for this being the first generation in many
years to have a lifespan lower than the previous generation because we
didn't act.
Thank you for the invitation and your attention. I look forward to
your comments and questions.
References
Grey, M. & Berry D. (2004). Coping skills training and problem solving
in diabetes. Current Diabetes Reports, 4(2), 126-133.
Grey, M., et al. (2004). Preliminary testing of a program to prevent
type 2 diabetes among high-risk youth. Journal of School Health,
74(1), 10-15.
Jaser, S.S., Grey, M., et al. (in press). Correlates of depressive
symptoms in youth at high risk for type 2 diabetes. Children's
Health Care.
Schwimmer, J.B. (2003). Health-related quality of life of severely
obese children and adolescents. Journal of the American Medical
Association, 289, 1813-1819.
Taras, H., & Potts-Datema, W. (2005). Obesity and student performance
at school. Journal of School Health, 75(8), 291-295.
Senator Dodd. Doctor, thank you immensely and wonderful
testimony. Thank you for your work over the years, more
importantly.
Bruce, welcome back to the committee.
STATEMENT OF BRUCE LESLEY, PRESIDENT, FIRST FOCUS, WASHINGTON,
DC
Mr. Lesley. Thank you. Good afternoon, Chairman Dodd,
Senators Harkin and Murkowski, and staff of the Children and
Families Subcommittee.
Having served as staff for Senator Bingaman with this
committee for 6 years, it is a real honor to be here today and
to be before such champions for children's health generally and
childhood obesity issues specifically.
I am Bruce Lesley, president of First Focus, a bipartisan
children's advocacy organization dedicated to making children
and families a priority in Federal policy. Thank you for the
opportunity to testify today on this issue and on the childhood
obesity epidemic and its role in the rapidly declining health
of our future generation.
This is an American issue that affects not only our
children, but all of our future. There is also a choice between
investing now and improving the health and well-being of
America's children or dealing with the effects of childhood
obesity and related preventable diseases with today's young
people as they become adults.
Childhood obesity is a growing public health crisis. As you
know, over the past 30 years, obesity rates have more than
tripled for preschool children and adolescents, quadrupled for
children ages 6 to 11. Today, one third of children in the
United States are obese or at risk of becoming obese. Sadly,
our adolescents are now the most obese teenagers in the world,
and we have reason to be concerned. These teens have up to an
80 percent chance of becoming overweight as adults.
You have heard about the health consequences from my
colleagues here, but also the costs of childhood obesity are
staggering. A 2000 report of the U.S. Surgeon General estimated
the cost at $117 billion annually, and all signs indicate that
it will continue to grow. Treating an obese child is more
costly than treating an average weight child, obviously. An
overweight child is likely to visit an emergency room more
frequently and two to three times more likely to be
hospitalized.
Estimates suggest that annual hospital costs associated
with obese children and youth have more than tripled in less
than 2 decades. Scientists, as discussed earlier, now forecast
a 2- to 5-year drop in life expectancy for children of today
unless we take aggressive actions to address and reverse the
obesity epidemic.
One of the interesting things is that we have conducted
some polling that shows for the first time ever, American
adults believe that the next generation will be worse off than
the current generation. I think there are a lot of reasons that
go into that, but one of them is the issues of the health of
children.
There was a national poll on children's health that was
conducted by C.S. Mott Children's Hospital that shows that
obesity is for the first time identified by adults as the top
health problem for children after being rated third last year.
It has been one of those issues that over time has gone up the
scale.
Concern with the high rate of obesity among U.S. children
and the reality that they could face increased risk of heart
disease as adults, the American Academy of Pediatrics recently
recommended wider cholesterol screening for children and more
aggressive use of cholesterol-lowering drugs for children as
young as age 8. While we agree that we are in desperate need of
solutions, this is hardly a viable one. Sadly, there will be no
magic pill that can erase this problem.
The fact of the matter is that despite all the research and
these dismal statistics, our Nation's broader response to the
childhood obesity epidemic has been woefully inadequate. While
we invest heavily in the treatment and management of chronic
diseases, in adults, we spend very little for the prevention
and treatment of childhood obesity that would stave off the
onset of conditions like heart disease and type 2 diabetes.
As Julie Gerberding, director of the CDC, recently noted,
we put way too much emphasis on treating disease rather than
protecting health in the first place. According to Gerberding,
today only a nickel out of every medical dollar spent in the
United States goes toward keeping Americans healthy. This is
part of a broader pattern of declining investments in our
future.
As a new First Focus report--Children's Budget 2008--
highlights, over the past 5 years, the share of Federal
nondefense spending that goes to children and children's
programs has declined by 10 percent. In fact, real Federal
discretionary spending on children will be lower this year than
it was 5 years ago.
Kids' Share 2008, an Urban Institute report released at the
Capitol Hill briefing last week, confirms this trend and
details the overall decline in Federal spending on children
over the past four and a half decades. It has found that since
1960 the share of Federal spending that goes to children has
dropped by more than 20 percent.
The time for action is now. One thing just as a personal
point, as I worked with all of your offices on an amendment a
few years ago that was to the agriculture bill. As I recall, it
was Bingaman, Dodd, Harkin, Murkowski, and I think even Senator
Coburn as co-sponsors. It was an amendment that I worked on
with all of your staffs, and ultimately, it resulted in an
increase in a fresh fruits and vegetables program, which is a
long-time initiative by Senator Harkin that has now become law
in the Farm bill. It is those kinds of steps that we need to be
taking.
As the Institute of Medicine report ``Progress in
Preventing Childhood Obesity: How Do We Measure Up? '' noted,
addressing the childhood obesity epidemic is a collective
responsibility involving multiple stakeholders in different
sectors between the Federal Government, State and local
governments, communities, schools, industry, media, and
families.
The Federal Government can--really it must--play a critical
role in reversing this epidemic by providing leadership,
coordinated efforts across agencies, and investing in research
and sustained prevention and intervention strategies. We
believe Congress can take several steps now to address this
threat, and it is one of the things that we really want to
emphasize that it is across areas. It is everything from public
health programs. It is daily activities in schools.
I note, for example, that Senator Dodd's bill on the 21st
Century Community Learning Centers Act includes a provision
that would add physical fitness and wellness programs as
allowable activities. Under the 21st Century Community Learning
Centers Act, we need to target investments in research, but it
also includes coverage issues. The SCHIP program, for example,
making sure that children have health coverage. Also, there was
language in that bill that provided demonstration grants for
childhood obesity efforts.
It includes things like dealing with competitive foods and
beverages in schools. We include a bunch of the recommendations
in our testimony, and as those highlight childhood obesity is
not just a healthcare issue, it is clearly an education issue,
a transportation issue, an agriculture issue, an economics
issue, and a public health issue.
Given the complexity of the problem, it is easy to see why
responsibility for addressing it is passed from one agency to
the other. Unfortunately, no one in the Federal Government
seems to own this issue. We must ensure that all Federal
agencies with a role to play--including the CDC, NIH,
Department of Agriculture, and Department of Transportation--
work together to address the childhood obesity epidemic.
In a glimmer of good news, the data and research also shows
that we can reverse the current trend and lower the incidence
of a host of deadly diseases associated with obesity if we take
action now.
Thank you all for your leadership and for the opportunity
to provide testimony. I welcome any questions.
[The prepared statement of Mr. Lesley follows:]
Prepared Statement of Bruce Lesley
Good morning Chairman Dodd, Ranking Member Alexander, and members
and staff of the Children and Families Subcommittee. Having served as a
staffer for Senator Bingaman, with this committee, it is a real honor
to be here today.
I am Bruce Lesley, President of First Focus, a bipartisan
children's advocacy organization dedicated to making children and
families a priority in Federal policy and budget decisions.
Thank you for the opportunity to testify today on the childhood
obesity epidemic and its role in the rapidly declining health of our
next generation. This is an American issue that affects not only our
children but all of our futures. It is also a choice between investing
now in improving the health and well-being of America's children, or
dealing with the effects of childhood obesity and related preventable
diseases when today's young people become adults.
Childhood obesity is a growing public health crisis. As you know,
over the past 30 years, obesity rates have more than tripled for
preschool children and adolescents, and quadrupled for children ages 6-
11.\1\ Today, one-third of children and youth in the United States are
obese or at-risk of becoming obese.\2\ Sadly, our adolescents are now
the most obese teenagers in the world. And we have reason to be
concerned. These teens have up to an 80 percent chance of becoming
overweight or obese adults.\3\
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\1\ Institute of Medicine of the National Academies. Progress in
Preventing Childhood Obesity: How Do We Measure Up? Washington, DC:
National Academies Press, 2006.
\2\ Institute of Medicine of the National Academies. Progress in
Preventing Childhood Obesity: How Do We Measure Up? Washington, DC:
National Academies Press, 2006.
\3\ Torgan, C. (2002). Childhood Obesity on the Rise. The NIH Word
on Health. Downloaded from: http://www.nih.gov/news/WordonHealth/
jun2002/childhoodobesity.htm.
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Through our research and our advocacy, we know that the rates of
obesity and related diseases are even more alarming for minority
children. For instance:
In the United States, Hispanic boys and African-American
girls have the highest prevalence of obesity.\4\
---------------------------------------------------------------------------
\4\ Institute of Medicine of the National Academies. Childhood
Obesity in the United States: Fact and Figures. Fact Sheet. September
2004.
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Overweight prevalence increased by 120 percent for
African-American and Hispanic children between 1986 and 1998 in
comparison to an increase of 50 percent for whites.\5\
---------------------------------------------------------------------------
\5\ Stauss, R.S., Pollack, H.A. (2001). Epidemic Increase in
Childhood Overweight. JAMA, 286:2845-8.
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A national survey of American Indian children ages 5 to 18
found that 39 percent were overweight or at risk for becoming
overweight.\6\
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\6\ Jackson, Yvonne. (1993). Height, weight, and body mass index of
American Indian schoolchildren, 1990-1991. Journal of the American
Dietetic Association, 93(10) 1136-1140.
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Obesity translates into more than just expanding waistlines. Obese
children are being diagnosed with health problems once only seen in
adults--such as type 2 diabetes, high cholesterol, high blood pressure,
and even child gallstones. Overweight children are also at higher risk
for heart disease, stroke, and several forms of cancer.\7\
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\7\ Freedman, D.S., Dietz, W.H., Srinivasan, S.R., Berenson, G.S.
(1999). The Relation of Overweight to Cardiovascular Risk Factors Among
Children and Adolescents: The Bogalusa Heart Study. Pediatrics, 103:
1175-82.
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The direct and indirect costs associated with obesity in the United
States are staggering. A 2000 report of the U.S. Surgeon General
estimated the costs at $117 billion annually and all signs indicate
that it will continue to grow.\8\ Treating an obese child is more
costly than treating an average-weight child and an overweight child is
likely to visit an emergency room more frequently and two to three
times more likely to be hospitalized.\9\ Estimates suggest that annual
hospital costs associated with obese children and youth have more than
tripled in less than two decades.\10\
---------------------------------------------------------------------------
\8\ U.S. Department of Health and Human Services. The Surgeon
General's Call to Action to Prevent and Decrease Overweight and
Obesity. U.S. Department of Health and Human Services, Public Health
Service, Office of the Surgeon General. 2000.
\9\ Marder, W.D. & Chang, S. (2005). Childhood Obesity: Costs,
Treatment Patterns, Disparities in Care, and Prevalent Medical
Conditions. Thomson Medstat Research Brief. Retrieved at http://
www.medstat.com/pdfs/childhood_obesity.pdf.
\10\ Institute of Medicine of the National Academies. Preventing
Childhood Obesity: Health in the Balance. Washington, DC: National
Academies Press, 2005.
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Scientists now forecast a 2- to 5-year drop in life expectancy for
children of today, unless we take aggressive action to address and
reverse the obesity epidemic. In fact, a 2005 study published in The
New England Journal of Medicine concluded that ``if childhood obesity
continues unabated, people will have shorter lives because of the
health toll of being heavy at such a young age.'' \11\ One of the study
authors, pediatric endocrinologist David Ludwig describes childhood
obesity as a ``massive tsunami headed toward the United States.''
Ludwig goes on to explain,
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\11\ Olshansky, S.J., Passaro, D.J., Hershow, R.C., Layden, J.,
Carnes, B.A., Brody, J., Hayflick, L., Butler, R.N., Allison, D.B., and
Ludwig, D.S. (2005). A Potential Decline in Life Expectancy in the
United States in the 21st Century. New England Journal of Medicine,
Volume 352:1138-145, Number 11.
``It's like what happens if suddenly a massive number of
young children started chain smoking. At first you wouldn't see
much public health impact. But years later it would translate
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into emphysema, heart disease, and cancer.''
Concerned with the high rate of obesity among U.S. children and the
reality that they could face increased risk of heart disease as adults,
the American Academy of Pediatrics (AAP) recently recommended wider
cholesterol screening for children and more aggressive use of
cholesterol-lowering drugs for children as young as age 8. While we
agree that we are in desperate need of solutions, this is hardly a
viable one. Sadly, there will be no magic pill that can erase this
problem.
The fact of the matter is that despite all of the research and
these dismal statistics, our Nation's broader response to the childhood
obesity epidemic has been woefully inadequate. While we invest heavily
in the treatment and management of chronic diseases in adults, we spend
very little for the prevention and treatment of childhood obesity that
would stave off the onset of conditions like heart disease and type 2
diabetes. As Julie Gerberding, Director of the Centers for Disease
Control and Prevention (CDC) recently noted, ``we put way too much
emphasis on treating disease rather than protecting health in the first
place.'' According to Gerberding, today, only a nickel out of every
medical-care dollar spent in the United States goes toward keeping
Americans healthy.
This is part of a broader pattern of declining investments in our
future. As a new First Focus report, Children's Budget 2008 highlights,
over the past 5 years, the share of Federal non-defense spending that
goes to children and children's programs has declined by 10 percent and
in fact, real Federal discretionary spending on children will be lower
this year than it was 5 years ago. Kids' Share 2008, a First Focus-
sponsored Urban Institute report released at a Capitol Hill briefing
last week, confirms this trend, and details the overall decline in
Federal spending on children over the past four and a half decades.
Shockingly, it found that since 1960, the share of Federal spending
that goes to children has dropped by more than 20 percent.
The current Administration, for its part, has done little to avert
the approaching tsunami. As a recent Washington Post series on
childhood obesity highlighted, President Bush has repeatedly attempted
to eliminate or cut several prominent Federal efforts aimed at
overweight children and teens, including:
The elimination of funding for the Carol M. White Physical
Education Program (PEP). In its fiscal year 2009 budget request to
Congress, the Administration proposed to zero out this $75 million
program that helps schools and communities expand physical education
offerings and purchase equipment.
No new funding for the Centers for Disease Control and
Prevention's (CDC) Division of Nutrition, Physical Activity and
Obesity. Grants offered through this CDC program, which currently are
up and running in less than half the States, allow State health
departments to design, implement, evaluate and disseminate effective
interventions, including those which support policy changes to
encourage access to healthy foods and venues to be active.
No new funding for the Department of Defense (DOD) Fresh
Fruit and Vegetable Program, which helps schools provide a wider
variety of fresh fruit and vegetables to students through federally
sponsored breakfast and lunch programs.
Not only has the Administration been meager in making investments
in discretionary programs that could address childhood obesity, in
longer-standing nutrition programs, change has been slow to come. The
U.S. Department of Agriculture only recently modified the Women,
Infants and Children (WIC) nutrition program to allow additional funds
for low-income families to buy fresh fruits and produce, which are
often more costly. In a bit of sad irony, traditional subsidies, which
help low-income families purchase food staples like milk, eggs, and
cheese, are contributing to our kids' expanding waistlines. In fact, in
some communities, nearly half of toddler and preschool WIC recipients
are overweight or obese. And, as The Post points out, the U.S.
Department of Agriculture's (USDA) school breakfast and lunch programs
continue to sell whole milk and sweetened flavored milk, instead of no-
fat alternatives.
There are many interrelated factors that contribute to rapidly
rising rates of obesity in children, chief among them poverty and food
insecurity, which lead to lower food expenditures, limited fruit and
vegetable consumption and poor diets.\12\ In fact, a recent Food Trust
report found that ``people who live in lower-income areas without
access to supermarkets appear to suffer from diet-related deaths at a
rate higher than that experienced by the population as a whole.'' \13\
In another study, obesity rates were as high as 30 percent in the
lowest income neighborhoods, compared to about 5 percent in the most
affluent zip codes.\14\ The relatively low cost of foods containing
refined grains, added sugars and fats is also a key factor in the
rising obesity rate.\15\
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\12\ Drewnowski, A. and Specter, S.E. (2004). Poverty and Obesity:
The Role of Energy Density and Energy Costs. American Journal of
Clinical Nutrition, Vol. 79, No. 1, 6-16.
\13\ The Food Trust (2001). The Need for More Supermarkets in
Philadelphia. Retrieved at: http://www.thefoodtrust.org/pdf/
supermar.pdf.
\14\ Drewnowski, A , Rehm, C.D., Solet, D. (2007). Disparities in
Obesity Rates: Analysis by ZIP Code Area. Social Science and Medicine.
65(12):2458-63.
\15\ Drewnowski, A. and Specter, S.E. (2004). Poverty and Obesity:
The Role of Energy Density and Energy Costs. American Journal of
Clinical Nutrition, Vol. 79, No. 1, 6-16.
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Other factors also contribute to the childhood obesity epidemic.
For instance, in recent decades, our society has experienced an influx
of fast foods, bigger portion sizes, and the convenience of vending
machines. Today, nearly one-third of children ages 4 to 19 eat fast
food every day--that translates to 6 extra pounds per year for every
child. And, children are eating more junk food in larger than-ever
portion sizes. During the late 1990s, portion sizes increased more than
60 times.\16\ Children today are also over-exposed to junk food
marketing. A recent Kaiser Family Foundation study found that food is
the top product seen advertised by children--and 34 percent of all the
food ads targeting children or teens are for candy and snacks.\17\
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\16\ Anderson, P.M., and Butcher, K.F. (Spring 2006). Childhood
Obesity: Trends and Potential Causes. Future of Children, Vol. 16, No.
1.
\17\ Gantz, W., Schwartz, N., Angelini, J.R., and Rideout, V.
(March 2007). Food for Thought: Television Food Advertising to Children
in the United States, A Kaiser Family Foundation Report.
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Unfortunately, the recent economic downturn has translated into
rising food costs, and more Americans are turning to lower quality,
frozen, bulk and processed foods for meals. And, as the economy
worsens, America's poorest will be hit the hardest. As Dr. David Katz,
a well-known authority on nutrition and the prevention of chronic
disease notes, ``there's real cause for worry, because the data we do
have, in general, indicates that more nutritious foods tend to be
higher priced. It's only going to compound that problem [when] the food
prices rise.''
The time for action is now. As the recent 2006 Institute of
Medicine (IOM) report, ``Progress in Preventing Childhood Obesity: How
Do We Measure Up? '' noted, ``addressing the childhood obesity epidemic
is a collective responsibility involving multiple stakeholders and
different sectors--including the Federal Government, State and local
governments, communities, schools, industry, media and families.'' \18\
The Federal Government can--really it must--play a critical role in
reversing this epidemic by providing leadership, coordinating efforts
across agencies, and investing in research and sustained prevention and
intervention strategies.
---------------------------------------------------------------------------
\18\ Institute of Medicine of the National Academies. Progress in
Preventing Childhood Obesity: How Do We Measure Up? Washington, DC:
National Academies Press, 2007.
---------------------------------------------------------------------------
We believe Congress can take several critical steps now to help
address this growing public health threat:
(1) Improve Daily Physical Activity Requirements for All Students.
In recent years, schools have cut back on physical education and
recess. Although children need 60 minutes of moderate to vigorous
exercise daily, national surveillance data tells us that only 35.8
percent of high school students are meeting this measure.\19\ As the
Campaign to End Obesity's Call to Action report highlights, the
reauthorization of No Child Left Behind (NCLB) provides an important
opportunity to improve physical education and activity standards.
Congress should consider the following:
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\19\ 2005 Youth Risk Behavior Surveillance Results. Available at
www.cdc.gov/healthyyouth.
Support the 21st Century Community Learning Centers Act of
2007 (S. 1557), sponsored by Senator Dodd, which would include the
provision of physical fitness and wellness programs as allowable
activities under 21st Century Community Learning Centers (CCLC);
Amend Safe and Drug-Free Schools and Communities Act to
allow for the promotion of Safe Routes to Schools (SRTS);
Reauthorize the Carol M. White Physical Education Program
and ensure it is adequately funded; and
Provide incentives for schools that meet national
standards for physical education.
We would also like to urge support for the PLAY Every Day Act (S.
651), sponsored by Senators Harkin and Bingaman, which would help
children, families, and communities achieve the national recommendation
of 60 minutes of physical activity every day.
(2) Increase Our Federal Investment in Prevention and Public Health
Programs Targeting Childhood Obesity. Congress should provide
additional funding for the CDC's Division of Adolescent and School
Health (DASH), which supports States in implementing Coordinated School
Health Programs (CSHP). Currently, only 22 States and 1 tribal
government are receiving grants, and overall funding for CSHP has
followed a steady downward trend over the past 5 years.
In addition, I'd like to highlight several promising proposals:
The Prevention (HeLP) America Act (S. 1342/ H.R. 2633),
sponsored by Senator Harkin, would provide for: (1) healthy school
nutrition environment incentive grants; (2) establish a Baby-Friendly
Hospital Initiative; (3) provide incentives for States to ensure the
safety and convenience of all users of a transportation system,
including pedestrians and bicyclists, and also includes provisions of
the PLAY Every Day Act, Healthy Workforce Act of 2007, MEAL Act, and
Child Nutrition and School Lunch Protection Act.
The Healthy Places Act (S. 1067/ H.R. 398), sponsored by
Senator Obama would among other provisions, require the Secretary of
Health and Human Services to establish an interagency working group to
discuss environmental health concerns, particularly concerns
disproportionately affecting disadvantaged populations.
In addition, we are pleased that Senator Bingaman will
soon introduce comprehensive legislation that would effectively address
the public health threats of overweight and obesity by requiring
unprecedented collaboration and collective action across agencies,
between private and public entities and industries, and involve
individuals and communities in generating solutions and addressing the
childhood obesity epidemic.
(3) Enact a Strong Reauthorization of the State Children's Health
Insurance Program (SCHIP). In order to be healthy, children need
reliable access to routine health care. The research is clear that
children without health coverage often lack the routine medical care
that helps to prevent or address childhood obesity while in its early
stages. Children in low-income working families--the very children who
are eligible for coverage under SCHIP--are often those most at risk of
becoming obese. We urge Congress to enact the strongest SCHIP
reauthorization possible to improve access, coverage, and health
outcomes for low-income children, with a particular focus on the 6
million children who are eligible but unenrolled in SCHIP or Medicaid.
We should also note that the SCHIP reauthorization language already
passed by Congress on three occasions, included $25 million for
demonstration grants to develop a comprehensive and systematic model
for reducing childhood obesity. This is a small investment but, even if
it is only a starting point, one that we hope to see included in any
reauthorization bill.
(4) Ensure Coverage for Obesity-Related Services in SCHIP. Because
most private insurance plans do not provide explicit coverage for
obesity-related services, these benefits may not be a part of benchmark
plans from which stand-alone SCHIP coverage is developed. Basic anti-
obesity benefits should be covered under SCHIP for its beneficiaries.
Precedent exists for this coverage; Medicaid currently covers medical
nutrition therapy for beneficiaries with diabetes or renal disease, but
that benefit may not be adequate for children.
(5) Provide Guidelines for Childhood Obesity Health-Care Related
Treatment Under Medicaid's Early and Periodic Screening & Diagnostic
Treatment (EPSDT) Benefit. Children covered by Medicaid are nearly six
times more likely to be treated for a diagnosis of obesity than
children covered by private insurance.\20\ The George Washington
University School of Public Health and Health Services and Center for
Health Services Research and Policy recently reviewed existing Medicaid
benefit codes, and found that Medicaid, under its EPSDT benefit, can
cover comprehensive, obesity-related pediatric health care
services.\21\ \22\ The researchers found that most State Medicaid
manuals however, do not provide clear or adequate information about
coverage levels and appropriate reimbursement codes for specific
elements of care. Providers, therefore, remain uncertain about which
services they can provide and if they can be reimbursed.
---------------------------------------------------------------------------
\20\ Marder, W.D. & Chang, S. (2005). Childhood Obesity: Costs,
Treatment Patterns, Disparities in Care, and Prevalent Medical
Conditions. Thomson Medstat Research Brief. Retrieved at http://
www.medstat.com/pdfs/childhood_obesity.pdf.
\21\ Rosenbaum, S., Wilensky, S., Cox, M., and Wright, D.B. (July,
2005). Reducing Obesity Risks During Childhood: The Role of Public and
Private Health Insurance. Retrieved at: http://www.gwumc.edu/sphhs/
departments/healthpolicy/chsrp/downloads/Obesity%20Report%20
Final.pdf.
\22\ Wilensky, S., Whittington, R., Rosenbaum, S. (October, 2006).
Strategies for Improving Access to Comprehensive Obesity Prevention and
Treatment Services for Medicaid-Enrolled Children. Retrieved at http://
www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/
RWJ%20Medicaid%20Obesity%20Policy%20Brief.pdf.
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Given this lack of clarity, the Centers for Medicare & Medicaid
Services (CMS) should take immediate action to:
Disseminate information about the importance of childhood
obesity risk to State Medicaid programs; and
Augment existing CMS guidelines on EPSDT with special
guidance on using managed care, integrated service delivery and
disease-management techniques to develop comprehensive prevention
programs for children at risk of obesity.
(6) Improve Nutritional Standards for Competitive Foods and
Beverages Served in Schools. Nutrition in school lunches is
``substandard,'' and the only Federal regulation of the competitive
food environment in schools is the restriction of ``Foods of Minimal
Nutritional Value'' (FMNV) during meal times. This regulation is dated,
and should be revised. The Child Promotion and School Lunch Protection
Act (S. 771/H.R. 1363), sponsored by Senator Harkin, would require the
Secretary to update the definition of FMNV to comply with nutrition
science, and would set nutrition standards for all foods served in
schools campus-wide and across the entire time span a school is open to
children.
As our recommendations highlight, childhood obesity is not just a
health care issue--it is an education issue, a transportation issue, an
agriculture issue, an economics issue, and a public health issue. Given
the complexity of the problem, it is easy to see why responsibility for
addressing it is passed from one agency to another. No one ``owns this
issue.'' We must ensure that all Federal agencies with a role to play,
including the Centers for Disease Control and Prevention, National
Institutes of Health, Department of Agriculture, and Department of
Transportation work together to address the childhood obesity epidemic.
It is time for the Federal Government to stand up, take notice, and
take action to address the childhood obesity epidemic. While the health
of our children is our paramount concern, the costs associated with
obesity-related diseases are too staggering to ignore. We urge Congress
to back the kind of proactive, coordinated and sustained response the
childhood obesity epidemic warrants. In a glimmer of good news, the
data and research also show that we can reverse the current trend and
lower the incidence of a host of deadly diseases associated with
obesity if we take action now.
Thank you for your leadership, and for the opportunity to provide
this testimony. I welcome any questions you might have.
Senator Dodd. Thank you very much. We have been joined by
your former boss, Senator Bingaman.
He did a good job, Jeff.
Senator Bingaman. He did a good job.
Senator Dodd. Yes. I will leave his testimony for you to
read.
Let me turn to my colleagues just for some opening
comments, if they would like to make one. I mentioned earlier
before you arrived, Tom, what a leader you have been on this
issue and, as Chairman of the Committee on Agriculture,
fighting all the time to see to it that there has been a
greater emphasis on the quality of nutrition and food that
children eat, efforts in our schools, and the like. Just a
long-time champion of this issue.
Do you have any opening comments?
Statement of Senator Harkin
Senator Harkin. Well, thank you, Mr. Chairman.
I would just say to my friend and my Chairman here that if
you really want to find the person who has really been the
leader on children's health and children's welfare for the last
20 years, you need no further than to look in the mirror.
Senator Dodd. Well, thank you.
Senator Harkin. Because Chris Dodd is well known all over
this country for being the champion of children and families.
The Family and Medical Leave Act being perhaps one of the
biggest highlights of his political career, getting that passed
for families all over America and for our children.
I just thank you very much for having this hearing and
spearheading this. I know we are having another hearing next
week, Mr. Chairman. I thank our witnesses for being here.
I just ask that my statement be made a part of the record--
--
Senator Dodd. Absolutely.
Senator Harkin [continuing]. And would look forward to an
interplay on questions and answers with the panel.
[The prepared statement of Senator Harkin follows:]
Prepared Statement of Senator Harkin
Thank you, Chairman Dodd and Senator Alexander, for calling
this very timely hearing, this afternoon, to examine the impact
of the childhood obesity epidemic on the child's well-being and
next week to discuss real solutions that can be done to address
this crisis. I have been looking forward to this hearing on
this topic and appreciate this opportunity.
Mr. Chairman, a number of leading health experts are now
predicting that the generation of kids growing up today could
be the first to live a shorter lifespan than their parents. One
significant reason for this is the obesity epidemic.
As we will hear from the panelist, obesity takes a
frightening toll on a person's health. It can lead to diabetes,
heart disease, high blood pressure, cancer, and numerous other
chronic diseases--all of them major causes of death. It is a
shocking fact that more rates of childhood obesity has nearly
tripled since 1980.
And the toll on children is especially disturbing. On the
macro level, childhood obesity is a national public health
crisis. But on the individual level . . . for each child
afflicted with this condition . . . it is something else. It is
a tragedy. A past Yale University study concluded that
overweight children are stigmatized by their peers as early as
age 3. They are subjected to teasing, rejection, and bullying,
and are two to three times more likely to report suicidal
thoughts as well as to suffer from high blood pressure and/or
diabetes. The author of the study concluded: ``The quality of
life for kids who are obese is comparable to the quality of
life of kids who have cancer.''
There have been several studies by the Institute of
Medicine, Trust for America's Health and other that have
reported on childhood obesity, and have offered excellent
blueprints for a comprehensive national response to the obesity
epidemic, with a strong emphasis on wellness and prevention.
They all consistently call to individuals and families, as well
as to schools, employers, communities and the food industry.
Most of all it is a clarion call to Congress. It is time for us
to act.
I look forward to hearing from the witnesses today and next
week to explore further areas where Congress should act. My
broader ambition is to transform America into a genuine
``wellness society'' and to bring this public health discussion
into the larger health reform debate. How do we recreate
America as a ``wellness society'' . . . a society focused on
physical activity, good nutrition and disease prevention--
keeping people off pills and out of the hospital in the first
place. And, as the Irish say, this isn't a private fight;
anyone can join in. Schools, communities, Corporate America and
government at every level--they all need to be part of the
solution. And we need it now.
So again, I am grateful to the Chairman for calling this
important and timely hearing.
Senator Dodd. Lisa, any opening comments?
Statement of Senator Murkowski
Senator Murkowski. I want to thank you as well, Mr.
Chairman.
Listening to the panelists this afternoon, it has become
frighteningly evident that we are talking about an epidemic in
this Nation. When we think about how we treat other epidemics,
we have a national strategy. We have a plan, and we are going
to take control of whatever the epidemic may be.
We are not focused on obesity as a nation as we should be,
and I am very fearful that once you lose that first generation
to this epidemic, it is going to be so difficult to later
address it. I applaud you for your leadership. I have enjoyed
the opportunity to work with you, Senator Harkin, on the issues
of nutrition.
I think we are starting to make some headway. We need to
get parents, school administrators, teachers, families and
policymakers engaged in this national epidemic because our
children's health is at stake. As all of you have mentioned,
the costs to us as a nation are staggering.
Senator Dodd. Yes, I tell you, all the statistics can be
numbing, I suppose, and it can end up glazing over your eyes if
you let them. The two statistics that I kept on reading last
night. In fact, I called the staff. I said this can't be right.
You have the numbers wrong. This is a typo in the memo they
wrote for me.
The fact that only 8 percent of our elementary schools and
less than 6 percent of our middle schools and high schools have
any requirement of physical activity. It just--to me, it is one
thing to understand what happens when people go out and make
bad choices about the food they eat. But the school, you would
think, the value of just the learning ability of a child to
know that physical exercise is so important for so many other
reasons, not to mention the one that is before the subject
matter of the committee today.
It is just hard to imagine that has happened. That many,
that 92 percent of our elementary schools have no physical
activity of their children.
Senator Bingaman.
Statement of Senator Bingaman
Senator Bingaman. Thanks very much for having the hearing,
Mr. Chairman.
It is a very important issue, and I particularly wanted to
be here with Bruce Lesley here. He did guide me on these very
issues for many years working here in the Senate and did a
great job here and is doing a great job now.
I am anxious, when we get to the question part, to explore
what we can do with some of the specific Federal programs that
are currently in place to try to deal with this issue--the
SCHIP program, for example, Medicaid, some of these programs
that ought to give us some leverage in reaching this group of
young people that we are trying to help.
At any rate, thank you again for having the hearing.
Senator Dodd. Thank you very much.
Let me start, if I can, Dr. Levi, with you. Just some
questions that was noted in here. As I mentioned, the focus
here will be on how to address the epidemic, but I wanted to
ask you something about your testimony. You mentioned in your
report--again, numbers just sort of jumped out at me last night
reading your testimony in anticipation of the hearing today--
that an investment of $10 per person per year in proven
community-based programs could save the country more than $16
billion annually within 5 years.
Let me ask you about four or five questions around this.
Certainly what is community prevention? What types of
interventions does this entail? Who would implement the
interventions? Who would reap the benefits? I think that one
may be more obvious. Can you give us some examples of
community-based programs that have yielded some successful
results to give us some idea of some models that are actually
producing these kind of results?
Dr. Levi. Sure, Senator.
Senator Dodd. How did you get at these numbers? Where does
that number come from?
Mr. Levi. OK. This was a collaborative effort that Trust
for America's Health engaged in with the Urban Institute, with
economists there for a developed model. We worked in
conjunction with the New York Academy of Medicine and
Prevention Institute out in California as well. The goal here
was really to look at how we can take on these problems before
they become medicalized and see whether there actually is a
value, an economic value to engaging in these programs and
reducing healthcare costs.
The process that we went through was really to identify the
most expensive chronic diseases in the United States, and a lot
of them relate to obesity, and what kind of community-level
interventions are they amenable to. We sort of did a crosswalk
of those.
When you look at whether it is heart disease, diabetes,
stroke, even some cancers, and arthritis, and you look at some
of these very expensive conditions and you look at what sorts
of interventions could actually prevent them or mitigate them,
it ends up being physical activity, nutrition--how much we eat
and what we eat--and also smoking cessation.
What we discovered in reviewing the literature was that
there are a lot of very effective community-level programs. By
community-level programs, we mean things outside of the clinic.
We don't have to medicalize the solution to all of these
problems. It can be everything from making a community more
walkable, improved street lighting, creating sidewalks,
promoting programs like Safe Routes to Schools that encourage
kids to walk to schools, improving the quality of school
lunches, doing menu labeling so that people know what they are
about to buy in a restaurant, doing some social marketing
campaigns to encourage people to exercise more and to eat
better.
Usually it is a combination of several of these approaches
that together make a community-level intervention. We have seen
a number of very successful programs along those lines. Shape
Up Somerville is one, where the community of Somerville, MA,
came together and said here is the problem. Here are some of
the things we can do, and they adopted a series of initiatives
that targeted kids, targeted the physical environment, targeted
adults, and together achieved some major changes.
The YMCA is doing some phenomenal work in a number of
cities around the country in bringing--you know, we talk about
needing a plan to address this problem, and we do need a plan.
We need a national plan, not just a Federal plan, though,
because every sector of society has a role to play. The beauty
of what the YMCA is doing is it is convening local communities,
business, transportation, schools, health departments, everyone
who could possibly--families, community-based and faith-based
organizations--everyone who could play a role and getting them
focused on this problem.
I think that is what we mean by community-level prevention.
What we did when we looked at the literature was we saw that
these can have a dramatic impact on disease. In fact, the
literature supported probably more than a 5 percent impact on
things like diabetes and hypertension if you successfully
implement these kinds of programs.
With just a 5 percent effect, within 5 years, you are going
to see a return on investment of $16 billion a year, and we
looked at these programs and found that they were not
expensive--$6 to $8 a year. We did the model based on $10 per
person per year so that we could be relatively conservative.
When you looked at it, it showed that if we provided more
money for these kinds of programs, we would see a lot of
savings. But who benefits? That is the challenge, the policy
challenge that we face.
Public health invests in these kinds of community-level
prevention initiatives, but it is the Medicare system, it is
the Medicaid system, it is private payers who benefit. The
policy challenge we face then is to do the crosswalk back and
say how are we going to find the resources for these kinds of
interventions? If we find them, how can we get those who
benefit to contribute to the solution?
Senator Dodd. Yes, and it occurs to me, too, I don't know
what Somerville is, the demographics of Somerville. Is it
upscale?
Mr. Levi. It is not an upscale community at all.
Senator Dodd. Making the connection at the local level for
the value because they are local investments you are talking
about?
Mr. Levi. That is right.
Senator Dodd. Streetlights, sidewalks, you have got to make
that nexus, it seems to me, for that local board of select men
or city council, whoever makes those decisions on those
investments is going to have to make the case to the taxpayers
there that there is payback.
Mr. Levi. That is right.
Senator Dodd. How do they do that?
Mr. Levi. Well, this report will show, on a state-by-state,
basis how much private payers will save, how much Medicaid will
save. You know, the private payers are really the employers of
the local community.
Senator Dodd. Yes.
Mr. Levi. They have a vested interest in doing this. A lot
of private employers are engaging in wellness programs, but
those only----
Senator Dodd. Would insurance companies be interested? For
instance, if a community does these things, then the rates for
people who live in that community might come down?
Mr. Levi. One would hope that they would. Certainly the
costs would come down, and the question is how can we harness
some of those savings to promote these kinds of activities.
Senator Dodd. You mentioned the U.K. Tell us about the U.K.
Mr. Levi. United Kingdom has done what Senator Murkowski
suggested, which is to take a look at this problem and actually
did their own modeling and saw the projections of----
Senator Dodd. Their problem was a serious one, was it?
Mr. Levi. Very serious. Not quite as bad as ours, but on a
very similar trajectory. They are just a few years behind.
They made a decision that this required a national
strategy, a national strategy that didn't just focus on medical
intervention, though that certainly is part of it, and having
appropriate medical counseling and access to appropriate
services for people who are trying to control their weight and
increase physical activity is important, but also literally
remaking communities.
They have made a commitment to remaking communities to
promote physical activity, to improve the quality of food in
any kind of public facility, whether it is schools or
hospitals, to change the norms in a society, and that is what
we are really talking about.
Smoking cessation is probably a very good example of how we
have, in a generation, dramatically changed people's attitudes
and perceptions around smoking. Now, I don't want us to be
stigmatizing people who are overweight or obese in the way, to
some degree, we stigmatize people who smoke. But we can with
social marketing, with education, with appropriate medical
support, with changing the physical environment--that is what
we do with smoking. We don't make it possible for people to
smoke in certain places. If we can change the physical, social
environment around issues of physical activity and eating, then
we probably can see a similar change as we have with smoking.
Senator Dodd. Thank you very much. I have a bunch more
questions, but let me turn to my colleague.
Senator Murkowski.
Senator Murkowski. I wish it were easier. I am sitting here
listening to all of this and thinking, we do a pretty good job
in terms of incentives if you are an adult working for a
company. Many companies have a wellness plan--in many instances
the company helps pay for your club membership so that you can
go and work out. It is limited to working people--adults. So,
we are basically leaving kids on their own.
There was a time when kids played. They were very physical,
but now our children don't play the way they used to. I am
convinced our children don't know how to play the way we did. I
have a 15-year-old and a 17-year-old, and I make sure they know
how to play. But they grew up in an outdoors environment which
was relatively safe.
I didn't have to worry about monitoring them like we do now
with our children living in the cities. I didn't worry that
they were going to fall off the monkey bars and break a leg,
and I was going to end up going after the city for not
maintaining the park. It is a different world that our children
are growing up in, and they really don't spend time learning
and understanding the physical aspect of playing.
I worry about how we teach our children to accept exercise
as something that is fun instead of something that you are
forced to do. I absolutely support additional physical
education within our schools. I, too, am stunned by the
statistics.
When you have physically active kids sitting in a classroom
environment hour after hour, if they have a good recess, where
they are out racing around, they can come back and focus--their
education can benefit from that physical exercise. We don't
want our kids to associate physical exercise with something
that you have to do because, as adults, it will make it that
much more difficult.
Our problems are just overwhelming. I don't even know where
to begin with a question. Keeping along the lines of physical
education and the opportunities that we provide for our kids, I
am told, when I go back to the State, that No Child Left Behind
and the confines of that law are taking us away from the
opportunity for more exercise in the school. We are focusing on
the reading, writing, and arithmetic instead.
I am also finding that it is not so much that there is not
enough time in the school day, but we are having a real
challenge finding P.E. teachers. We are having a real challenge
finding health teachers. Much of it stems from the funding
component, that we are not putting the money there. Am I right?
Am I wrong? What is your experience?
Dr. Kaufman. Well, I just wanted to mention that for the
National Institutes of Health, I chair a study that is going on
now called the Healthy Trial, and we are looking at a cohort of
over 6,000 children in 42 middle schools in 7 cities across the
country, and following them from sixth through eighth grade.
Half of the schools we have intervened on, and part of that
intervention, there is a food service component. There is a
curriculum component. There is a social marketing component.
There is also a physical activity, physical education
component.
When we got to these schools--so these schools all had to
have at least 50 percent minority children and at least 50
percent of the children eligible for free lunch. You can
imagine what some of these schools were actually like. There
was a gym area that was minute. They put 80 kids in there with
one teacher.
We have actually worked with the schools, found strategies.
We have gotten a physical activity aide for the teacher. We
couldn't actually hire more teachers, but we could hire an
aide, a relatively low pay scale, most of them college kids who
are looking for some outside work.
We have been able to take these kids from, when we started,
5 minutes of physical activity in a 45-minute P.E. class to 22
minutes of moderate to vigorous physical activity without a
huge change in what actually has been happening. These children
have just finished seventh grade. In another year, they will
finish eighth grade.
There are hard outcomes, physical outcomes, medical
outcomes that we are looking at in this cohort. If they have
become healthier and less risk for diabetes and cardiovascular
disease, we are hoping that this will serve as a model for how
schools can fundamentally change comprehensively to enhance the
health of our children.
Mr. Levi. I think it is also important to point out,
Senator, that this link to No Child Left Behind is, to some
degree important, but in some respects specious in the sense
that there is data now to show that kids who are more
physically fit, more physically active will perform better
academically.
Part of complying with No Child Left Behind in some
respects almost demands greater attention to physical activity
so that the kids will score better. It is an indirect approach,
but it really can make a difference.
Now, ideally, if No Child Left Behind addressed physical
activity, that probably would promote more attention as well. I
also think, what Dr. Kaufman pointed out, that having P.E.
alone is not sufficient. It is what happens in that P.E. class
activity, and it doesn't even have to be a formal P.E. class,
that you can introduce things into the school setting that
encourage physical activity.
Dr. Kaufman. Yes, they like hula hoop. They like dancing. I
mean, it is not necessarily everybody who is going to go for a
competitive sport. There are a lot of activities that the
children want to do. When you give them a menu and they make
some of the decisions, then they are much more engaged.
Senator Murkowski. When you think about what we are trying
to do in the schools, which is to teach you to be a lifetime
learner, to make your life better every day by learning
something new, we also should be teaching kids about their
bodies and how to be healthy for a lifetime.
It is not just talking about nutrition, although that is
incredibly important, but the exercise component and how it
makes you a better human being in the sense that everything is
going well if your body is more physical and more fit.
Mr. Chairman, I am over my time. We could spend all
afternoon here.
Senator Dodd. Thank you very much.
Senator Harkin.
Senator Harkin. I am like Senator Murkowski. It is hard to
know where to begin on this.
Jenelle Krishnamoorthy on my staff, whom I know works with
some of you, just gave me this. The Journal of the American
Medical Association today came out with a report on moderate to
vigorous physical activity from ages 9 to 15 years and showed
how it decreased in those years. You know, when you are 9 years
old, you play more and you are active. By the time you are 15,
you are not doing anything.
Senator Dodd. Right.
Senator Harkin. I haven't read the whole thing. I was just
looking at the data here, but it said that expert opinion and
empirical studies suggest that children need a minimum of 60
minutes of moderate to vigorous physical activity per day, a
standard proposed by the U.S. Department of Agriculture.
Sixty minutes. When I was a kid, I remember we had 15
minutes in the morning, a half hour at lunch, and 15 minutes in
the afternoon recess. We had to go outside and play. Unless it
was 20 below, maybe you stayed in at that point. That was about
the only excuse----
Senator Dodd. Which was about three quarters of the year.
[Laughter.]
Senator Harkin. That is Alaska. That is Alaska.
How do we change the framework of the debate? I keep
listening to candidates for President, no matter when.
Everybody is running around, all the debate on healthcare in
America is how do we pay the bills? In essence, when you boil
it all down, that is all we are talking about. How do we pay
the bills? National health insurance, single payer, all that
kind of stuff is how do we pay?
How do we change that framework to how do we prevent? How
do we start changing the framework of that debate? Now part of
the problem in the past has always been, well, you have to pay
the bills because if you get into prevention, that just costs
more money. It costs more money, and we can't take money out of
the pot right now because there is not enough there to meet the
needs of healthcare right now for low-income people.
It has been kind of a catch-22 situation. We know we have
to do prevention, but we don't have the money to do it.
Now the report that you have just come out with, the Trust
for America's Health that will be made public tomorrow, shows
that the rate of return on that investment is about 1 for 1 in
1 year, and that is at a very low investment rate of $10 per
person. Think what it would be like if we invested $100 per
person or more. It is a very timely study that the Trust for
America's Health is coming out with.
How do we change this framework? How do we start getting
people, and our candidates who run for office on both sides of
the aisle, to start thinking about how we change the framework
of the debate?
Yes?
Senator Dodd. Dr. Grey.
Ms. Grey. One of the major issues is we have spent most of
the last 20 years blaming the people who are obese and say if
you just wouldn't eat more, if you just would exercise more,
then you wouldn't have this problem. Well, clearly, that hasn't
worked.
It is really about changing the perception and thinking
about very early on how you bring the right people to the table
to change things. I will give you an example.
We know very clearly that children of pregnant women who do
not lose their pregnancy weight are more likely to have
children who are overweight or obese by the age of 2. The
weight gain trajectory for those children will be like this
compared to those children of those women who have not gained
weight.
We pay lots of money to take care of acutely ill babies,
but we pay no money to help women postpartum lose pregnancy
weight. We have to reframe the debate about not just healthcare
and not just individual responsibility, but how do we create
opportunities for communities and others to participate in
this?
One of the things we did in New Haven about 10 years ago--
in collaboration with your good friend Senator Toni Harp--we
created a coalition to fight childhood obesity. It was a
grassroots effort in New Haven that didn't engage the
healthcare providers. I was the only healthcare provider
involved.
It was a group of parents, religious leaders, city
officials, including the city planner, and others who said,
``Oh, my gosh, this is a terrible problem. We really must do
something about that.'' That coalition is the coalition that
went to the schools and said, ``get the sodas out of here.''
There is a law in the State of Connecticut that says these
should not be available during the school day.
Well, we have the system where the schools can only pay
their bills by collecting this information or paying for this
soda. What they did was they put healthier choices in there,
and guess what? They didn't lose any money.
Senator Dodd. That is right.
Ms. Grey. We started a system called Walking Buses. This is
one of the things they do in England that is really wonderful
for inner-city kids. You have adults who aren't getting much
activity, who aren't working, who take a group of 5 or 10 kids
from the neighborhood and walk them to school, and we create
environments that are safe that allow them to walk 10 blocks to
school every day and walk 10 blocks back.
Those aren't huge changes, but it takes the community
buying into this isn't just a self-responsibility problem. This
is a societal problem.
Mr. Lesley. Senator Harkin, I also think it is this issue
of it is a national plan, as Dr. Levi talked about, but it is
also kind of place-based policies. It is stuff that is
reflected in all of the legislation you all work on in terms of
if you look at the school, it isn't just the school lunch. It
is the school lunch, but it is not just that.
It is the school nutrition program. It is the P.E. program.
It is also the afterschool program and the community
involvement in that, and it is things like figuring out ways
for kids to walk to school. It is also access to fruits and
vegetables, which it is your bill that really did get fresh
fruits and vegetables into the schools.
There was a Washington Post series that talked about where
in Fairfax County they got rid of the french fries in the
schools, and 2 days later, it was the parents who had the
revolt. We also need to get the community parents to understand
why we are doing these kinds of things.
In my neighborhood, the elementary school just happens to
be on the other side of a major street. I would bet that 90
percent of the parents in our neighborhood drive their kids to
school, and it is just getting a crossing guard right there.
That is all it would really take, and I would send my--but I
drive my kids to school because of those kinds of things.
It is really the community thinking about the issue and
talking to one another. I profess that I have been part of the
problem. Senator Bingaman came up to me one day when I was
working in the Senate and said, ``The Ag bill is on the
floor.'' I looked at him and said, ``Yes, I am your health L.A.
So?''
His point was, yes, and there is an obesity issue, and we
worked with your office and all of your offices on kind of an
amendment to the Ag bill to improve this issue. It is this
transportation, healthcare, education, and health. It is very
comprehensive, and people don't speak to one another about it.
Senator Harkin. I guess I get frustrated because I watched
all the debates of our candidates who are running for
President. I watched all the debates----
[Laughter.]
Senator Dodd. One of those unique Americans.
Senator Harkin. Whether it is on the Democratic side or the
Republican side, I watched those, too. Every question that
would come up on healthcare was always about how are we going
to get health insurance to everyone? How are we going to cover
everybody? How are we going to pay the bills?
Senator Dodd. Yes.
Senator Harkin. I kept waiting for one questioner to say,
you know, we know that prevention works and we get the payback
on it, what is your idea, so-and-so, about how we can change
America to be a wellness society and prevent illness? No one is
ever asking that question.
Therefore, our candidates start thinking, well, I know the
question is going to come, and it is going to be on how we pay
the bills. And so, I will get up on that. It is very
frustrating.
I keep hoping that sometime the questioners of our
presidential candidates will start grilling them on prevention
and what it means and what community wellness means and how we
get our communities to think about wellness programs and using
examples. Like Portland, OR, who has done a great job as well
as other cities and some schools, and what different schools
are doing for activities.
Then just talking about our school systems and our food
programs, next year we have the reauthorization, Chris, of the
child nutrition bill--school lunch and school breakfast. Well,
I would like to have our candidates talking about what changes
do you think we ought to have in the school lunch program so
that our kids have better food in schools. To me, this is a key
part of our wellness in society and how we are going to prevent
illness in the future.
But those questions don't get asked, and that is why I get
kind of frustrated. That is why I ask you how do we change this
paradigm?
I am thinking Senator Murkowski and I worked very hard
together to get a change in the foods minimal nutritional
values done. We didn't get it on the Farm bill, but the child
nutrition bill is our key to get it done next year. We tried to
get it on the Farm bill but wasn't successful.
What should we be thinking about in the child nutrition
bill? What should we be thinking about and how should we change
the school lunch and school breakfast programs?
Mr. Lesley. Yes, I would also add that you also have
opportunities next year with SCHIP coming back up for
reauthorization in March, and in the final bill that all of you
voted for in the Senate, it had a demonstration project on
childhood obesity.
It is interesting, on the Medicare side, I worked on a bill
for Senator Bingaman on medical nutrition therapy in Medicare,
but it seems to me that the emphasis you are putting on this
hearing today is we should be thinking about all our public
programs and including the child nutrition programs, the
Children's Health Insurance Program.
One of the things even we were looking at recently was the
Maternal Child Health Program and the fact that in the Maternal
Child Health Program there is no emphasis on this issue because
it hasn't been reauthorized in a number of years.
One thing, to speak to the issue you raised, is the WIC
program still serves whole milk and sweet and flavored milk.
Why are we not providing the no fat alternatives and those kind
of things. We hope to work with you on things like that next
year.
Dr. Kaufman. In the reauthorization of the school lunch
program, there is a lot of data, in a number of studies that I
have looked at, of what some of those criteria should become.
In this school study, we wanted to increase fiber. There is no
real requirement for fiber. We put out first the high-fiber,
high-grain buns, and the children had no idea what it was.
First, we had to just put the one on the bottom and then the
white one on the top. Then, eventually, they kind of got used
to it. So it is not going to be an immediate shift.
We are still looking at trays in our schools. I mean, these
very vulnerable schools, and the schools we are in, 50 percent
of these 11-year-olds had a BMI greater than the 85th
percentile. Actually, we did a pilot in the eighth grade of the
schools--it is not the same cohort--but in those eighth grade
students, we actually found 39 percent had already an abnormal
blood sugar level.
These are incredibly vulnerable children, and they are
still getting a Federal lunch program that is not weighted. The
whole item, that whole tray for the week is kind of balanced
out. Whatever they take, if it happens to be that 75 to 80
percent of the choices are the higher fat containing burrito
than we would like to see, it is still acceptable. We had to
get waivers around the number of calories in some of those
lunches in some of our schools.
Senator Harkin. Or what they do is they cut down on the
fat, and then they up the sodium. They pour the salt on.
Dr. Kaufman. Right. Or they up the sugar.
Senator Harkin. Or the sugar. Sugar, both.
Mr. Levi. I think part of the message--and I think Dr.
Kaufman could probably speak to this better, as more an expert
than I, that part of the message that we need to communicate to
folks is that relatively small changes can make a huge
difference in terms of health outcomes. We don't have to
suddenly have a nation of thin people in order to see dramatic
changes in the quality of life and the length of life and how
healthy people are.
In fact, one of the things in doing this report that I
think was particularly surprising to me, even though I have
read a lot of this material, was how very small weight loss, 8
to 10 pounds, can really dramatically reverse someone's course
in diabetes.
Dr. Kaufman. Right. The diabetes prevention program, which
was a massive NIH study, showed that in a very high-risk group
of multiethnic throughout the age span of adults, a modest
weight--7 to 10 percent weight loss, 30 minutes 5 times a week
of just walking reduced the progression to diabetes in those
who had pre-diabetes by almost 60 percent.
Now that is out in the community. There is a huge effort of
translating this phenomenal NIH data and the components of the
study out into community venues. Those kind of things don't
belong inside the medical world. They belong inside the
community and the workplace, where they are able to be done in
a lot more effective and a lot more cost-savings way than
inside a medical center.
Senator Dodd. Let me ask you, we have an awful lot of young
people here in the audience today, and I was thinking of going
back to the smoking issue, seatbelts in cars. One of the
reasons it worked wasn't because we just passed ordinances and
laws, because actually children, in many cases, asked their
parents to stop smoking, insisted they put on the seatbelt in
the car, became a great advocacy group.
The issues of weight and self-image, and Dr. Grey, you have
done a lot of work in this area, the psychological effects of
obesity. I couldn't help but think as well about the problem. I
was with a good friend of mine today, and he knew I was going
to conduct this hearing and has a child that is suffering from
anorexia, the sort of antithesis of the issue, but, in effect,
a manifestation of the same problem in some ways, self-image.
All of the marketing techniques today, I mean, you open any
popular magazine or what show it is, there is such a
glorification in a way of a body type and style that I think it
is difficult just in the sense of being a child and the kind of
peer pressures associated with this that create its own
dynamic. I regret not doing this, which I am tempted to do, I
have never done this before in 27 years here. If any of these
younger people in this audience have any ideas about this, you
could become a witness in a congressional hearing if you would
like to come up.
[Laughter.]
If you have any thoughts about this. Because, really, the
audience in a way can do so much. We can do a lot of these
things, and Tom has been terrific and Lisa on these issues. I
was going to ask Tom--I have never done this either. I have
never asked a colleague a question during a hearing. Normally,
we ask the witnesses. The Food Stamp Program, I just have given
a lot of thought to this and haven't come up with an answer for
it because, obviously, we associate more expensive foods are
more nutritious or the correlation is.
Can't we incentivize that Food Stamp Program in some way,
where we reward a family that will, in a sense, take those food
stamps to buy more nutritious food? There ought to be a reward
associated or some way to encourage, to incentivize people
moving in that direction.
I wonder, Doctor, if you could----
Senator Harkin. Mr. Chairman, could I respond to that?
Senator Dodd. Certainly, yes.
Senator Harkin. In the Farm bill we just passed, I put a
provision in there that--and we are going to test this out. It
kind of comes from Michael Pollan's book. He was wondering why
so many low-income people are so obese and why they have
diabetes. He began looking into stores and finding out that
low-income people use their food stamps to buy fast starches
and sugars. They don't buy fruits and vegetables because they
are the highest prices.
Fast starches and sugars are the highest subsidized things
that we do in this country. I got to thinking about that, and I
thought, you know, we don't have food stamps anymore. We have
an EBT card, electronic benefit transfer card, and it has a
little black stripe on the back like your credit card.
When you go through the counter, they swipe that card, and
it deducts from your food stamp allotment whatever you bought,
and then you know what you have left. You can encode on that
stripe a lot of other things. For example, you can't buy beer
or wine or cigarettes or nonfood items with the EBT card.
If you go through and they have checked all the bar codes
and stuff, and then you hand them the EBT card and they swipe
it, and you have bought a six-pack of beer, that will come up
and say that is not allowed. Or if you buy nonfood items, that
is not allowed. They have to deduct that, and you have to pay
cash for it. It can't come off of your food stamps.
I got the idea that maybe what we could do is encode that
for fruits and vegetables. We have in the Farm bill money to
set up a study on providing EBT cards to people so that if they
go in and they see fresh fruit, for example, or produce. Let us
say it is $4, that is $4 per pound or something. They know that
if they buy that, it is only going to cost them $2.
And human nature being what it is, we all love a sale. We
always like to buy things that are cheaper than what is marked
on the thing. If I use my EBT card and I go to buy potato chips
and it is $4, and I know it is still going to be $4, but if I
buy this and it is not $4, it is going to be $2, maybe I will
start buying it.
We have this study that has just started. The Department of
Agriculture is trying to get the rules and regs for it.
Hopefully, this will show that if you give a benefit to people
on that EBT card, they will start buying fresh fruits and
vegetables, hopefully.
Senator Dodd. Incentivizing.
Senator Harkin. Incentivizing. That is what we are trying
to do. I just wanted you to know that has started, and
hopefully, by next year, we will have a little bit of data on
this, I hope.
Senator Dodd. Tell us, Dr. Grey, about the stigma and the
psychological impacts. You have done a lot of work in this
area. Is there a correlation between adults and children? I get
the feeling from what you just said that it is obviously more
pronounced among younger people than it is with adults that
are----
Ms. Grey. Well, it seems worse, I think, in children
because depression is a serious problem amongst youth. While
the elderly are the most likely to commit suicide, teenagers
are the second most likely. When you put together kids who have
health problems, depression, and difficult life circumstances,
it is a witch's brew.
Senator Dodd. More associated with girls than boys?
Ms. Grey. Both. It is actually slightly higher--actually,
girls make more attempts, but boys are more likely to be
successful. Part of the reason for that is boys are likely to
use more violent approaches. They have higher access to guns
and may shoot themselves, whereas a girl may take an overdose
of aspirin and get sick but not complete a suicide.
The issues around self-esteem and all of those things are
highly related to the communities in which people live, and one
of the issues that we face now that in many inner-city
communities, where we have done most of our work, we are
talking about kids where being obese is normal. There are whole
issues about if a kid wants to make a change and starts to lose
weight, then they get teased for being different because they
are losing weight.
This whole issue, from my point of view, is really about
how do we normalize what is healthy, not what is skinny? In the
African-American community in which I work, the average
teenager is overweight. When we start talking to them about
weight loss, they think we want them to look like Halle Berry.
Well, they are not going to look like Halle Berry.
If they can lose 5 percent of their body weight or at least
stop gaining weight for a while, while they kind of grow into
this, then they feel much better about themselves. The fact is
a lot of these kids can't be physically active because they are
huge. These kids get mixed messages, boys in particular.
We were talking earlier about kids playing football. In the
junior high school, we are telling them, ``You are unhealthy.''
You weigh 280 pounds, and the football coach is saying, ``Keep
packing on those pounds. You are a really good lineman on my
football team.'' We have to stop the double message. We have to
be talking about what is healthy from a mental and physical
point of view and stop normalizing the fact that it is OK to be
that heavy.
Senator Dodd. Well, I am very interested as well in talking
with you, Dr. Kaufman, about the link between obesity and
diabetes. What proportion of people with obesity also have
diabetes, and what proportion of people with diabetes is obese
or overweight?
Dr. Kaufman. Well, it is probably easiest with answering
the second question. Those with type 2 diabetes, 90 percent are
overweight or obese. In our pediatric group, it is 100 percent
of these children.
There is another trial that I chair for the NIH called the
Today Trial--Margaret has been involved with it--which is
looking at trying to really understand, characterize, and learn
best treatment modalities from children who have already
contracted type 2 diabetes. We have 15 sites across the
country, and these children are--we had to buy new scales. I
mean, a 350-pound child is almost close to our mean.
Senator Dodd. If a child has pre-diabetes, what is the
likelihood that child will develop type 2?
Dr. Kaufman. Well, we are hoping to answer that question
more scientifically. For adults, we know that once you have
pre-diabetes, there is about a 10 percent conversion per year.
We know there is 54 million Americans right now with pre-
diabetes. So you can start to imagine that math.
We are watching, not only this last year, an increase to
this 24 million, but at a higher rate of increase than had been
seen before. One point three million more were added last year.
We are still trying to sort out through a number of CDC and
NIH efforts to characterize really what is happening in
children, but we know that these children when they come to us,
they are all overweight and obese. They come from families in
which there is a very high prevalent rate of diabetes already.
Most of the adults in their lives are failing in managing their
disease.
They are socioeconomically having a lot of issues attaining
healthy lifestyle habits that we are working with them on. Of
course, we are now providing healthcare, but a number of the
children were having difficulty in access to healthcare.
Senator Dodd. I am asking you a couple of these statistical
questions, and I ask you to just go back and do this.
Dr. Kaufman. Sure.
Senator Dodd. Another one I had for you, I just was stunned
and you referred to the healthy middle school study.
Dr. Kaufman. Right.
Senator Dodd. Thirty-nine percent of minority eighth
graders were found to have pre-diabetes in your report. The
question I have is how does this compare to the rate of
diabetes in minority adults, No. 1, and what conclusions do you
draw from the large disparity between the rate of pre-diabetes
in the children you studied and the rate of diabetes in adult
minorities?
Dr. Kaufman. Well, we are applying adult criteria to these
children. We are not sure they are the right criteria.
Senator Dodd. Yes.
Dr. Kaufman. These children actually have a blood sugar
level clustering right at the cut point. We are not sure
whether part of that may be due to when you are overweight and
you are going through puberty--puberty is a time of insulin-
changing activity in your body, what we call insulin
resistance. You know, puberty is a time of resistance, but
insulin is one of the things that children are resistant to.
We don't know whether as they come back out of puberty that
might normalize at a lower rate so that they don't have pre-
diabetes anymore. I can't answer that question for you
scientifically, but we will have the answers over time.
We know that it is kind of a bad sign that you can't handle
the stress of puberty without having too high a blood sugar. If
they do come back down to a more normal range, they are
likely--unless we do something about their weight and their
health status--likely then to emerge again as adults with pre-
diabetes and then diabetes.
Senator Dodd. Yes. I will ask you this and then turn to
Lisa again.
I talked about this as an epidemic, and I use the word
``emergency'' carefully. We talk about--we use that word, we
throw it around quite frequently to describe almost everything.
It strikes me, looking at these numbers and looking at the
studies that you have already done, even with the conclusions
that you have drawn early on, that we are clearly in a medical
emergency with this issue that is going to become exponentially
larger.
The point I think that Lisa made about--I think some of you
did as well--that you let this generation slip into the next
generation, because there is a direct correlation between obese
parents and the likelihood of obesity among their children. So
you start exponentially expanding that constituency. Then this
problem becomes exponentially larger very quickly.
Dr. Kaufman. Right.
Senator Dodd. Am I exaggerating this conclusion?
Dr. Kaufman. Not at all. I mean, from the psychological to
the medical reasons as children, during childhood, these
children are very, very fragile from a medical standpoint. Then
their long-term health is in tremendous question.
There is no doubt that unless we do something and they
continue to track with overweight and obesity, they will be the
cohort of adults with cardiovascular disease, diabetes, cancer,
and a whole host of other medical conditions.
Senator Dodd. Well, it is telling me so much that by
looking at this, these are the kinds of problems you associate
with adults. I mean, having children taking--I guess it is good
maybe. Having cholesterol problems, having strokes, heart
problems, these are all things we would normally just associate
with aging, not with youth at all.
Have you done anything, have we talked to the military at
all about this? Are they showing any signs of problems in
recruiting or people coming into the military?
Dr. Kaufman. We are partly funded in some ways from some of
the military grants because there is so much diabetes
developing in their young adult cohort. Once they have
developed diabetes, they have to then care for them. They are
looking at ways to instill diabetes prevention programs inside
the military.
Mr. Levi. In fact, in terms of recruiting, it is a
significant issue, and I mentioned this in my written
testimony. In 1993, 25.6 percent of 18-year-old volunteers were
overweight or obese. By 2006, that grew to 34 percent. Each
year, between 3,000 and 5,000 service members are forced to
leave the military because they are overweight. It is a huge
problem, both in our being able to recruit people and also then
the cost of retraining to replace people who are discharged.
There is a certain irony, I think, in where we are today as
opposed to 1965 when the Medicaid legislation was passed, and
one of the things that compelled President Johnson to push for
Medicaid was the difficulty--and this was during the period of
the draft--that so many recruits were underweight and
unhealthy, and today we have the reverse problem. It is a
reverse national security problem.
I think it also points to the comments that Bruce Lesley
was talking about in terms of if you look at the populations
who are probably volunteering for the military, were probably
at some point touched by Medicaid in their lives, and maybe we
also need to be looking at how Medicaid can address this issue
so that when they do become of military age, they can
successfully volunteer.
Senator Dodd. What I am struck by in your testimony is
that, one, the magnitude of the problem, but the nonmedical
responses to this make this preventable.
Mr. Levi. That is right.
Senator Dodd. We could really make a huge difference.
Mr. Levi. That is right.
Senator Dodd. That is the positive and the silver lining in
all of this, to identify the problem. To recognize that we can
do something about this now that we know what to do.
I have been dealing a lot with autism and done a lot of
work at Yale as well on autism. One of the confounding
problems, we don't really know what causes it. We don't even
know how to successfully treat it. I mean, it is really in a
spectrum what can happen.
Here, we know what causes it. We know how to treat it. We
know what we ought to be doing about it. Unlike other areas,
such as autism, this is one we can handle.
Lisa, any additional questions?
Senator Murkowski. Just one final question to you. I am
very active on the Energy Committee, and of course, what
everybody in this country is talking about right now is the
price of energy and what they are paying at the pump, and what
their family is paying out of their pocketbook for their energy
consumption.
It would appear that in this country when you hit about $4
at the pump, the American public started demanding action. Here
in Congress, we are trying to figure out how we deliver on
that. I am of the belief that it has to be a combination of
increased production and increased renewables and less
consumption, but this is a HELP hearing, and not an energy
hearing.
My point is, we have to identify what that tipping point is
in this country when it comes to energy and how you have a
public that is now demanding action. On the issue of obesity,
are we at the tipping point yet?
Do you think that Americans understand? Do you think that
people understand--the statistics which you have all cited,
which are phenomenal--that this is not just something that is
happening in their town, but it is happening around the
country?
Do you think that people understand the connection between
not only the consequences that you all have described--whether
it is depression or other mental health issues--and then the
cost to society and the medical costs? Do we sufficiently
understand, as a nation, enough to push us over the edge so
that we can have some definitive action? Are we there?
Mr. Lesley. I would say that the polling on this kind of
issue is pretty interesting in that there is this national poll
on children's health that shows that adults definitely identify
obesity as the top issue facing children. However, I don't
think that they get the connection in terms of what is it that
we need to do.
I think that it is kind of a problem with children's issues
generally of people care, but they don't then see the linkages
to the public policy. If you ask people specifically, do you
care about children's issues at the Federal level? They poll in
the 80, 90 percent range. Then if you ask them is it a priority
in what you are going to vote for, they don't list it. Then if
you ask them in a focus group, so you don't care about these
issues? They are like, of course, I do.
There definitely needs to be a public education campaign,
kind of like what we did around seatbelts and smoking and those
kinds of issues, to really educate the public about--people get
the issue. It is not an education of just stating that obesity
is a bad thing, but it is what are all the things we need to do
together as part of a national plan and commitment to
addressing this issue and making people talk to one another? I
think that is really one of the things missing.
Senator Murkowski. But we are not there yet.
Dr. Levi, you seem to indicate that we are there?
Mr. Levi. Well, I think we are part of the way there. We
just actually did some polling in conjunction with the release
of our annual obesity report, which will be coming out shortly.
We found that 63 percent of Americans now do believe the
diseases related to obesity are a very important issue for
government to focus on.
I think translating from that to a specific agenda is the
challenge, and I think, particularly with health problems, we
have tended to want to look for magic bullets and for a pill or
a vaccine. There isn't going to be a pill or a vaccine for
obesity--at least not yet--and in the meantime, there is so
much we can do.
These behavioral changes are not easy and require really a
lot of this norm changing that we have been talking about, the
destigmatizing of changing what people value. That is going to
take leadership from all of you, and it is going to take
leadership from who is in the White House, and it is going to
take leadership at the community level as well from every
level.
Senator Murkowski. I think also it is going to take a
recognition that it is everyone's problem. None of you sitting
here would be considered obese. I don't know what your
background is, but is it your problem? Yes. It is everyone's
problem.
We are going to have to accept that we are all in this
together. It is not the family next door that has an issue and
they need to solve it on their own. We need to be changing our
systems, changing the way that we think about diet and exercise
and healthy lifestyles.
In Alaska and our Native organizations, many of which have
been pushing wellness initiatives to help deal with sobriety
and drug abuse, and also the whole concept of wellness. As we
talk about healthcare reform, as we talk about those ways that
we can lower our healthcare costs--prevention, as Senator
Harkin has mentioned, is just absolutely key. It is this
greater concept of wellness, wellness of body, wellness of mind
and attitude, and we are all part of the solution. It is not
our next-door neighbor's problem.
Thank you for your contributions. I appreciate it.
Senator Dodd. I wonder if I made a mistake earlier in
something I was suggesting. I was talking about eating
disorders, and is bulimia and obesity--I have doctors here in
front of me. What is the distinction in a sense, I mean?
Dr. Kaufman. Well, in looking at weight issues, the very
low weight, particularly woman, young adult woman, older
teenager is a very distinct subset of the population who really
are at risk for that, and they are quite distinct from the
population who are at risk for obesity and obesity-related
diseases.
We have done a lot of evaluations in our community programs
in Los Angeles, as well as in some of our school-based
problems, to try to find out--because one of the big fears was
would we be inducing anorexia now, with low weight and the
medical issues associated with that, in these children as we
were delivering school-based health programs. We are talking
about health, talking about healthy behaviors.
We have not seen any signal that that has changed at all.
We don't think this is a risk for inducing low-weight medical
issues.
Senator Dodd. Do you agree with that, Dr. Grey?
Ms. Grey. I do.
Senator Dodd. Yes, I said earlier I am so impressed that we
have so many younger people, Lisa, here in the audience that
have come here today. I have never done this before.
Would any of you young people have any ideas you would like
to share with us on the subject matter? You have heard these
official experts. I have never--in 27 years, I have never asked
the audience a question at a congressional hearing.
Yes, ma'am?
Audience Member. I just want to say, I am a Ph.D. candidate
at the Johns Hopkins Bloomberg School of Public Health in
international health and nutrition, and I am also an intern
here at the National [Off Mike]. I think it is a dual issue of
changing our food system here in the United States and around
the world and also looking at how we can change our messages.
We are talking about individual behavior, but it is not
just limited to behavior because if you look at those who are
most at risk for overweight and obesity, it is children and
adults with lower income status. You can't just ask the one
person at their convenience and their time to join the gym or
to eat healthier because it really is not possible. I think we
need to really focus at a national level on environmental
change as well.
Senator Dodd. Some of the things Senator Harkin talked
about in terms of how we incentivize dietary changes and so
forth and making available foods that are far healthier and the
like, I think, is what you are driving at on this issue.
Well, thank you. Anybody else in these young people in the
audience?
Yes, ma'am? What is your name? Tell me where you are from.
Audience Member. Hi, I am [Off Mike] resident at the
University of Maryland in Baltimore. I think that the issue is
multifactorial. We have families coming in that the parents are
overweight, that the grandmother is overweight. Sometimes they
don't see it as ``we are overweight.'' They just see it as ``we
are all just big people.'' The family is looking at themselves
like that, and they do not see it as an issue.
When I show them the growth charts for the child to show
that their child is above the 97th percentile and that it is an
issue, when I try to tell them, well, let us think of different
things you can do for your child. Just let us take out this
little factor not just for the child, but for the whole
household. Let us stop eating fast food two or three times a
week. Let us have it once a week and then bring it down to once
a month as more of a treat. Like, you did a good job at school
today so this might be your treat.
The fact that kids don't have physical education in school
anymore, some kids also don't even get recess. Also another
factor that is an issue is when I ask the parents, ``Well, do
you feel safe in your household?'' They feel safe inside the
house, but they don't feel safe outside. Therefore, their kids
don't get the chance to go outside to play. They can't go
outside to play. The parents' thinking might be, well, you know
what? I would rather my kid be big than worry about whether
they are going to get shot at when they are outside playing.
The issue isn't just something of do we make sure that we
have appropriate foods in the school, but we need to make sure
that we also have physical activity for these kids, that they
can feel safe in their local environment, but also that the
parents understand that this is a problem. It isn't normal for
your child to be this size, to be 50 pounds when you are 2
years old. They need to understand this is an issue that is not
just an issue for the child, but an issue for the whole family,
and the whole family needs to be onboard.
Because if we tell them, ``Well, this child needs to work
on losing weight,'' I don't just say it is only for the child.
The whole family has to make a lifestyle change. You take all
of the cookies out of the household, and no one is eating
cookies at home. And you take all of the soda out of the
household. If you want soda, then it needs to be diet soda
because there is no sugar in the diet soda.
I think it is not just looking at one particular issue, but
it is looking at everything within the household, within the
community, within the environment.
Senator Dodd. I think the next hearing we are going to
invite both of you to be witnesses.
[Laughter.]
It is very good, excellent. It is encouraging to know you
are thinking this way. We have people out there working this.
Anybody else on a point they wanted to raise at all? Yes,
ma'am, there is someone I can only see your hand. Yes?
Audience Member. Hi. My name is [Off Mike]. I am from
Glenwood, IA. My idea----
Senator Dodd. Senator Harkin, did he know you were here?
[Laughter.]
Audience Member. I don't know if he knew I was here, but my
idea would be to maybe increase the variety of physical
activities in schools. I am also a dancer. I would say using
dance as an option or just something else, so that if the kid
isn't picked for kickball there are other avenues for physical
activity. Making different kinds of programs more available, so
the classes that they take are effective.
Senator Dodd. That is a good idea. I have a 3-year-old and
a 6-year-old daughter, and they love to dance.
Audience Member. That is great, yes. It is good exercise.
Senator Dodd. I think it is exercise. They make me do it
with them.
[Laughter.]
With my knee replacement doing Irish step dancing. What a
sight to behold, I will tell you.
Well, this is very encouraging. It is very good.
Anybody else in the audience want to say something? Hands?
Yes, oh, we have a lot of hands now.
Yes, I will start over here. Yes?
Ms. Hoffman. Hi, I am Vanessa Hoffman. I just completed
training to be a registered dietician.
Senator Dodd. Where are you from?
Ms. Hoffman. I am from Washington, DC. I wanted to commend
Bruce Lesley's work in promoting medical nutrition therapy as a
way to provide people with reimbursable ways to meet with
registered dieticians, to talk with someone who is an expert
about nutrition, answer their questions.
Also improving resources, like Brian Wansink has been doing
at the Center for Nutrition Policy and Promotion in terms of
MyPyramid Tracker. People can go online for free and enter all
the foods they have eaten and get feedback on how to improve
their diet.
Senator Dodd. That is terrific. That is great.
On this side of the room someone had a point they wanted to
make? Yes?
Audience Member. Yes, we are both in high school, and it is
really great to see so many of our generation here. That is
really great to see.
Senator Dodd. That is why I thought I ought to ask you
since you are in the room.
Audience Member. Yes, and it is really great to see in
action. I think all of your plans are national in scope but
local in application, and it is going to take a lot of local
and, like you were saying, community-based action. It is good
to see that the attention is going to create change, and it is
great to see that starting, you know?
Senator Dodd. Yes.
Audience Member. Also, I would have to say that I think an
interesting statistic would be if you look at the percentage of
children in America with obesity, and actually, I think that
would be very interesting if you figure out what percentage of
those children have obese parents. Because I believe that you
are a product of your environment. Sometimes that is not the
case, but a lot of times that is true.
Unless you have a conducive environment and parents that
can support you and can instruct you, then you are not going to
be--as a child, you look up to your parents. You do what--your
parents are the producers. They provide for you, and we just
consume. Like, if the parents aren't providing a healthy
environment, then the children aren't living in a healthy
environment. Therefore, we have this Nation of obese children
because it all starts with the parents.
I think that education programs should be geared first
toward--more toward the parents. That is where it all starts.
Senator Dodd. The families. That is what the young lady
from Maryland was saying back here, too.
What else? We have a couple more here. Yes, way in the
back? Yes, go ahead. By the way, we have a microphone out here.
We are going to give you a microphone.
Audience Member. Mike [Off Mike] from Fargo, ND.
Senator Dodd. You don't need a microphone. Go ahead.
Audience Member. OK. This might just be a very small thing,
and you were talking about before, Senator, you were talking
about the energy crisis and you were talking about
infrastructure with sidewalks and everything. I am an avid
cyclist, so I love bicycling around town. DC is a great place
to bike.
If you could somehow create a Federal mandate, I know lots
of roads are done on a State or local level, but sort of like
speed limits, where you have to have this or you obviously
don't get the funding. If you could say, you are not going to
get this extra funding if you don't put bike lanes on the
residential roads. Bike lanes are very, very helpful. They
protect us a lot.
I have ridden--I was in Florida--Tampa, FL, this past year.
It was one of the worst places to bike in the country, and it
was really, really dangerous, and I almost got run over a
couple of times. You could solve two crises in one. Bike sales
are going up. You could get people exercising, and you also
lower people's cars' emissions.
Senator Dodd. We have actually done that on some
legislation. There has been--I know in my own State, I have
done that in a number of instances. I actually got funding for
bike paths in conjunction with highway programs. We actually
have been doing some of it, probably do a lot more of it based
on that suggestion.
Audience Member. Yes, I thank you.
Senator Dodd. Anyone else back there? I have opened up the
door here, haven't I?
[Laughter.]
Anybody from Connecticut?
Audience Member. Me.
Senator Dodd. Nothing like a little local politics. Are you
from Connecticut?
Audience Member. I go to school at Yale.
Senator Dodd. That is good. We will try. Do you vote in
Connecticut?
[Laughter.]
I am only teasing. That is not serious.
Mr. Talbott. My name is David Talbott [Off Mike] in my
final year at Yale. I am, by no means, an expert on the issue,
but one of the things that I did at school was I started up a
program called Student Soccer Outreach. We go around to a lot
of the local middle schools and teach them. Not only do we do
mentoring, but we also do soccer and teach them what it means
to be a fit and healthy younger adolescent.
I guess, I have been interning for the HELP Committee.
[Laughter.]
I was reading some of the testimony, and I noticed that a
lot of the talk today was focusing on prevention. I believe it
was in Mr. Lesley's testimony that he mentioned that 95 percent
of the money we are spending right now is on treatment rather
than prevention. It seems like that money really isn't being
effectively used.
I am just not really making a statement. I am asking a
question. Is there any way to make that 95 percent more
efficient because it seems that while the prevention is where
we are looking to go to the future, the current path has really
been on treatment and that it is really not being effectively
used.
Senator Dodd. Bruce, do you have a comment on that?
Mr. Lesley. No, I mean, other than to say I think that that
is right on, in that we really do need to make a more concerted
effort on the prevention side, and it is not just even
government spending. It is private spending.
It is also, to give kind of a shout-out to programs such as
the one you worked in. It is also the Boys and Girls Clubs and
the YMCAs of the world who are really providing another place,
a safe place for children to engage in activities. There is
also Congress, who does support a lot of those activities as
well. It is very multifaceted.
Senator Murkowski. Mr. Chairman, if I can just jump in
here. Your mention of being a soccer club that reaches out to
the younger kids--going back to my point earlier about kids not
being able to play as much anymore, I think we overlook an
incredible teaching resource when we don't allow our young
people to be mentors.
The eighth graders, I bet, look up to you all as heroes. To
be able to play like you is something that makes them work hard
and have fun at the same time. I am a huge supporter of what
Boys and Girls Clubs do, and we keep trying to get more and
more in the State along with the YMCA program. I think we have
some real opportunities as we look to the local level to see
how we can do more without necessarily huge increases in
funding.
We have a lot of volunteer opportunities if we use our
young people, who have that level of energy and can be great
role models for our kids. Thank you for what you are doing.
Thank you, Mr. Chairman, for doing this. I am going to have
to excuse myself.
Senator Dodd. No, I understand that. I apologize. As I
said, 27 years, I have never done this before. Take a couple
more, a couple more comments. Can we get the microphone so you
can be heard?
Thank you, Lisa.
Yes, go ahead. I will have to try and pick now. We have
hands all over.
Ms. Chambers. Hi, I am Cassie Chambers, also a Yale
student, working on being able to vote in Connecticut.
I think one of the things that kind of gets glossed over a
lot is the importance of allowing people to own their own
epidemic. I think it is important to allow people--when you are
talking about such a comprehensive lifestyle change--to be
individually empowered to make those decisions for themselves.
I think looking at programs like providing grants to local
schools, providing grants to parks and recreation centers, to
work on a small scale, I think that is really important. I
think programs in local schools, where local schools get
evaluated on how they are doing on nutrition, tax incentives to
give people money back if they make the choice to buy fresh
produce or to invest in a gym membership or things like that.
I think that empowering people on an individual level to
make choices is really, really important.
Senator Dodd. That is very good, and I agree. I think that
is one way to describe it, too, to empower people themselves
who are in that situation.
Yes, what else? There was someone else back over there,
too? Go ahead.
Ms. Lewis. Hi, I am Dana Lewis from Huntsville, AL, and the
University of Alabama, voting in Alabama.
I think it is also important to realize that education can
also be a barrier. It is one thing to lower the price or offer
an incentive for somebody to buy fresh produce, vegetables, and
things like that, but it is another thing to show people you
don't have to clear your plate. It is important to know about
the correct portion sizes.
You don't need to always clear your plate. You need to know
the nutrition labels, be able to read exactly how many
carbohydrates or calories are in that meal, and just because
your restaurant serves you this nice big plate, you don't need
to clear it if it is triple the amount of calories or
carbohydrates that you need.
It is important to educate schoolchildren and adults as
well to know the correct portion sizes and how to read
nutrition labels as well.
Senator Dodd. Yes, that is very good. Excellent.
What else? We have some more over here, and then we will go
over here.
Ms. Singh. Hi. I am Ranu Singh. I am from Massachusetts,
actually.
I just wanted to make the point of it is really--I think
the one group that can really make a difference here is
children themselves. We were saying earlier that they can lead
the way. Older children can lead the way for younger children.
I also feel that if they have enough of a sense to know, if
they are taught this either through like--I don't know--Sesame
Street, they were saying now that the Cookie Monster is now the
Veggie Monster, or something of the sort. Just silly things
like that----
Senator Dodd. Don't mess around with the Cookie Monster. I
love the Cookie Monster.
[Laughter.]
Let us not get carried away here now.
Ms. Singh. I mean, my point there is he is a monster so he
can eat cookies. That is the point.
Senator Dodd. Yes, right.
Ms. Singh. I just feel that if they can be taught to
believe that, if they can get that kind of inclination, they
are going to drive it themselves. I feel like that is something
that they will definitely do. They can change their parents,
like you were saying earlier with the seatbelts, with not
smoking. The children are the ones that will question that.
Senator Dodd. Huge influence.
Ms. Singh. That is a very big point.
Senator Dodd. A question on this side of the room. I want
to go back and forth. Can you get a microphone over to this
side? Maybe you can walk toward him a little bit? We have a
microphone for you.
Ms. Johnson. Hi, my name is Laura Johnson. I am from
Minnetonka, MN, College of St. Benedict, St. John's University.
During the summer, I am a children's camp counselor for the
YMCA, and I think one of the really important issues is
encouraging children to get physical activity. Like what you
were saying, I think that peer-to-peer encouragement is very
important because what I have observed through my work is that
the overweight and obese children are often the ones who are
afraid to participate in physical activity because they are
afraid that they are going to be the slow ones and the left-out
ones. They really, really, really benefit from having positive
encouragement.
They are also the children who don't go swimming because
they don't want to wear their swimsuits. I just think that
among the peers and if you educate younger children to
encourage their other overweight friends to participate in
activities, that would greatly help.
Senator Dodd. Yes, no question. Good for you for doing what
you are doing.
Come back over. I only have one microphone. Let us work our
back way down. We will come down here and then come down this
way. Yes? I could do this all afternoon.
Ms. Farrell. Hi, my name is Caroline Farrell, and I am a
second year--almost a second-year law student at the University
of Maryland.
Before coming to law school, I did my M.Ph. at G.W. During
grad school, I was a spinning instructor, and that helped me
pay the bills. I continue to teach spinning, and I teach at a
couple of health clubs that offer children's or teen's spin. I
know several fitness equipment lines also have special
equipment for children.
Obviously, not everyone is able to afford a gym membership,
but I am sure that there are ways to subsidize those programs
individually or perhaps other similar programs through the
community.
Senator Dodd. That is good. Great, great. One over here.
Why don't you just use the microphone at the table? Go ahead.
Right here.
Ms. Quinn. OK. I am Abigail Quinn from Annandale, VA. I am
at the University of Virginia doing elementary education, so
this is all very interesting.
I have been a camp counselor before, and we had a fruit and
vegetable policy at each meal. We actually had a parent tell us
that their kid did not eat fruits or vegetables. That was kind
of awkward for us.
The other point that I wanted to make is, I am interning
this summer with National Wildlife Federation. We have a huge
campaign trying to reconnect kids to nature, and obviously,
getting kids outside, getting them active is all part of this.
We have talked a lot about schools today. I know that recently
in my research I have been looking at some studies that have
suggested that kids are actually gaining weight over the summer
because they are so inactive over the summer.
While schools have a huge role to play, and obviously, as
someone who wants to be in education, I think that is crucial.
You really need to look at some of these other aspects, too.
Senator Dodd. That is great. Yes, I will take one back
here. Go ahead.
Audience Member. First, I would like to say I am not from
Connecticut. If I was, I would give you my vote, don't worry.
Senator Dodd. Ah, smart guy. You take as long as you would
like.
[Laughter.]
Audience Member. Well, Jenelle, I am sorry. I know you said
you were going to tackle me, but I had to ask this.
You were talking earlier about how seeing the marketing of
body types and things like that increased anorexia amongst
young people. Well, today, we have a lot of things that are
beginning like plus-size modeling and all the commercials that
you see all the time with, oh, lose weight fast, Slim Fast. You
know, you can take these pills, and you will lose weight in 6
months or whatever it is.
I am just wondering what type of psychological affects do
you think that has on the obesity of children? Do you suppose
that they feel that this is becoming a societal norm because
they see it now in the plus-size modeling, or in the
commercials, you see people saying that you can lose this
weight fast? Maybe they are saying, ``Well, I can eat this and
I can do this, and then I take my Slim Fast and then I will
lose that weight eventually'' or something like that?
I was just wondering, as a question to any of you guys,
what type of effects do you think that has?
Senator Dodd. Is there an effect? Dr. Grey has done a lot
of work in this area.
Ms. Grey. This gets back to the whole issue of social
marketing. The sense of normality about obesity is not from
plus-size models. I mean, the reality, the role model for kids
today are all these stick-thin, size 0 people. Plus-size models
are for the middle-aged women who are the norm, wearing plus
sizes.
To be honest, in our work, I don't think most kids think
about Slim Fast. I don't think they respond to those marketing
approaches at all. Their parents might, but their children
don't. The sense of being normal being overweight is if you are
in a population like the inner city where I work, where 50
percent of the kids in high school are obese or overweight,
that is normal.
Where I was in high school, there were 10 kids who were
overweight out of a class of 650. Those who were overweight
felt--they were teased. They were mocked. The physical activity
was a problem because they were always chosen last, and they
don't feel good about their ability to participate.
These kids are all the same. While they still get teased
and they still get mocked, they can look across a room and see
50 percent of their classmates weigh 180 to 300 pounds. It is a
very different mindset than what we think of as adults around
this problem.
Dr. Kaufman. Can I just add something? What really works
best, I think, is to talk about behaviors rather than the
outcome of weight. And that we are really--and if you are
normative to the whole class, so everybody is learning, too.
Even if you are the low-weight kid, soda isn't good for you.
The most favorite food now unified, when we started doing
our work in Los Angeles, was Flamin' Hot Cheetos. I mean, a
couple bags of Flamin' Hot Cheetos for lunch aren't good for
anybody. We are really trying to promote healthy behaviors on
both the intake side and the energy expenditure side.
Senator Dodd. That is very, very good.
One right here, yes.
Mr. Shevarro. I am trying to get rid of this, honestly.
Senator Dodd. There you go.
Mr. Shevarro. How are you doing? I am Keith Shevarro. I am
from New York. I am also a second-year law student at the
University of Maryland, and I was a physician before I went to
law school.
The question I have is do you see the rise in obesity
correlating with the fall of the family? The divorce rate being
so high, 50, 60 percent. People working two jobs. Single moms,
single dads trying to do the best that they can, but can't
really spend as much quality time with their child that they
would like to. Have we seen in the numbers a correlation with
the decline of the family, an increase of obesity?
Senator Dodd. Anyone want to tackle that?
Dr. Kaufman. Well, I mean, temporally probably some
correlation. Exactly looking at is it greater in single parent
families, and there are a lot of correlates, depending on what
location you have done, there is a lot of data. It is just
association. It is not really cause and effect.
Senator Dodd. Yes. Anyone disagree with that?
Ms. Grey. One of the things that we do know is that
families who sit down to a meal together are more likely to eat
a more balanced meal. Notice I didn't say ``healthier.'' At
least a more balanced meal.
If you look at the lives of many of these families, single
parent or even dual parent, many of these families are working
two and three hourly wage jobs just to be able to have a roof
over their heads and pay the heating bills and those sorts of
things. The stories we hear from these families about what we
think of as a meal and what they think of as a meal is somebody
puts something on the stove, and it is like the revolving
door--in the kitchen, wolf it down, and back out again.
Again, this is so tied to the economic reality in these
poor families that I don't think it is just a family issue, it
is about what are the structures in families, what are the
structures in homes and communities that allow for these kinds
of healthier behaviors?
Senator Dodd. And the economics. Margaret Warren, who
teaches at Harvard Law School, has done a lot of studies on
just what is happening to middle-income families, the economic
pressures. Close to 20 million Americans, heads of household in
our country, spend half their disposable income on housing
alone. That is leaving the rest of it to do everything else.
When you start talking about all the other obligations,
financial, again, it is cheap food, I suspect. And not a
question of cheap, but the food that is less healthy certainly
is going to fall into that category. It is not just shopping
for the best price. It is also recognizing that, as we have
learned painfully, less healthy food is, in many cases, less
costly.
I will take one more. We will take one right here. Yes?
Audience Member. Hi. I am [Off Mike] from Great Falls, VA.
I go to Thomas Jefferson High School.
I just wanted to reiterate the point about portions of
meals because that is really important. Even if it is a healthy
mix of foods, if you are eating a ton of it, it doesn't matter.
You are getting too many calories, too many carbohydrates.
A lot of restaurants are really bad at that. You order a
meal, and you end up with this huge plate piled with food. A
lot of people feel obliged to finish off the plate. So portions
are really important.
Senator Dodd. Yes, just in terms of size of the plates that
you buy for meals, your tendency, if you buy these--a lot of
times they market these large plates, and putting a small
amount of food on a large plate looks like you are getting very
little. Just the size of the plate in proportion to the food
that is on it can have an effect.
I literally could do this the rest of the day. I can't do
this to our witnesses. I have drawn them here for all
afternoon. As I said, in 27 years in the Senate, I have never
asked the audience to participate, but I just couldn't resist,
looking at so many young people who are here, and you have been
terrific. Give yourselves a round of applause.
[Applause.]
I find it rather encouraging in a sense that so many of you
here have so many good ideas on how to address this. You can
all call your parents tonight. You will be on C-Span.
I thank our witnesses immensely. We will have some
additional questions. I am going to leave the record open
because other members, I think, will have some questions for
you such as these detailed questions I was asking you, Dr.
Kaufman, and I suspect we will have some more for you, Dr.
Grey, as well.
Just getting the data and the correlations between some of
these questions here will be very helpful to us as we go
forward.
I would be remiss as well--where did she go? She left. Oh,
Eva. A former staff member of mine was here this week, and one
of the best children's advocates in Connecticut, Eva Bannell.
Eva went someplace. I don't know where she went, but I was
going to introduce her.
Anyway, I thank Tom Harkin. I thank Lisa Murkowski, Senator
Murkowski, and our witnesses as well. I appreciate all of you
very much. This committee will meet again next week for the
second panel on this issue.
I thank all of you. The committee is adjourned.
[Whereupon, at 4:31 p.m., the hearing was adjourned.]