[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]
HEARING TO REVIEW THE STATE OF OBESITY IN THE UNITED STATES
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON DEPARTMENT OPERATIONS,
OVERSIGHT, NUTRITION, AND FORESTRY
OF THE
COMMITTEE ON AGRICULTURE
HOUSE OF REPRESENTATIVES
ONE HUNDRED ELEVENTH CONGRESS
FIRST SESSION
__________
MARCH 26, 2009
__________
Serial No. 111-5
Printed for the use of the Committee on Agriculture
agriculture.house.gov
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COMMITTEE ON AGRICULTURE
COLLIN C. PETERSON, Minnesota, Chairman
TIM HOLDEN, Pennsylvania, FRANK D. LUCAS, Oklahoma, Ranking
Vice Chairman Minority Member
MIKE McINTYRE, North Carolina BOB GOODLATTE, Virginia
LEONARD L. BOSWELL, Iowa JERRY MORAN, Kansas
JOE BACA, California TIMOTHY V. JOHNSON, Illinois
DENNIS A. CARDOZA, California SAM GRAVES, Missouri
DAVID SCOTT, Georgia MIKE ROGERS, Alabama
JIM MARSHALL, Georgia STEVE KING, Iowa
STEPHANIE HERSETH SANDLIN, South RANDY NEUGEBAUER, Texas
Dakota K. MICHAEL CONAWAY, Texas
HENRY CUELLAR, Texas JEFF FORTENBERRY, Nebraska
JIM COSTA, California JEAN SCHMIDT, Ohio
BRAD ELLSWORTH, Indiana ADRIAN SMITH, Nebraska
TIMOTHY J. WALZ, Minnesota ROBERT E. LATTA, Ohio
STEVE KAGEN, Wisconsin DAVID P. ROE, Tennessee
KURT SCHRADER, Oregon BLAINE LUETKEMEYER, Missouri
DEBORAH L. HALVORSON, Illinois GLENN THOMPSON, Pennsylvania
KATHLEEN A. DAHLKEMPER, BILL CASSIDY, Louisiana
Pennsylvania CYNTHIA M. LUMMIS, Wyoming
ERIC J.J. MASSA, New York
BOBBY BRIGHT, Alabama
BETSY MARKEY, Colorado
FRANK KRATOVIL, Jr., Maryland
MARK H. SCHAUER, Michigan
LARRY KISSELL, North Carolina
JOHN A. BOCCIERI, Ohio
EARL POMEROY, North Dakota
TRAVIS W. CHILDERS, Mississippi
WALT MINNICK, Idaho
______
Professional Staff
Robert L. Larew, Chief of Staff
Andrew W. Baker, Chief Counsel
April Slayton, Communications Director
Nicole Scott, Minority Staff Director
______
Subcommittee on Department Operations, Oversight, Nutrition, and
Forestry
JOE BACA, California, Chairman
HENRY CUELLAR, Texas JEFF FORTENBERRY, Nebraska,
STEVE KAGEN, Wisconsin Ranking Minority Member
KURT SCHRADER, Oregon STEVE KING, Iowa
KATHLEEN A. DAHLKEMPER, JEAN SCHMIDT, Ohio
Pennsylvania CYNTHIA M. LUMMIS, Wyoming
TRAVIS W. CHILDERS, Mississippi
Lisa Shelton, Subcommittee Staff Director
(ii)
C O N T E N T S
----------
Page
Baca, Hon. Joe, a Representative in Congress from California,
opening statement.............................................. 1
Prepared statement........................................... 2
Dahlkemper, Hon. Kathleen A., a Representative in Congress from
Pennsylvania, opening statement................................ 6
Fortenberry, Hon. Jeff, a Representative in Congress from
Nebraska, opening statement.................................... 3
Kagen, Hon. Steve, a Representative in Congress from Wisconsin,
opening statement.............................................. 4
Lummis, Hon. Cynthia M., a Representative in Congress from
Wyoming, opening statement..................................... 5
Peterson, Hon. Collin C., a Representative in Congress from
Minnesota, prepared statement.................................. 6
Schmidt, Hon. Jean, a Representative in Congress from Ohio,
opening statement.............................................. 6
Schrader, Hon. Kurt, a Representative in Congress from Oregon,
opening statement.............................................. 5
Witnesses
Dietz, M.D., Ph.D., William H., Director, Division of Nutrition,
Physical Activity, and Obesity, National Center for Chronic
Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, U.S. Department of Health and Human
Services, Atlanta, GA.......................................... 7
Prepared statement........................................... 10
Wolf, M.S., R.D., Anne M., Instructor of Research and ICAN
Intervention Team Leader, University of Virginia School of
Medicine, Charlottesville, VA.................................. 31
Prepared statement........................................... 33
Hamburg, Richard S., Director of Government Relations, Trust for
America's Health, Washington, D.C.............................. 35
Prepared statement........................................... 37
Yadrick, M.S., M.B.A., R.D., F.A.D.A., Martin M., President,
American Dietetic Association, Washington, D.C................. 43
Prepared statement........................................... 44
Mazyck, R.N., M.S., N.C.S.N., Donna J., Board President, National
Association of School Nurses; School Health Services
Specialist, Maryland State Department of Education, Silver
Spring, MD..................................................... 47
Prepared statement........................................... 49
Submitted Material
Barnard, M.D., Neal D., President, Physicians Committee for
Responsible Medicine, submitted statement...................... 59
Campaign to End Obesity, submitted statement..................... 86
Heinen, M.P.P., LuAnn, Director, Institute on the Costs & Health
Effects of Obesity; Vice President, National Business Group on
Health, submitted statement.................................... 60
HEARING TO REVIEW THE STATE OF OBESITY IN THE UNITED STATES
----------
THURSDAY, MARCH 26, 2009
House of Representatives,
Subcommittee on Department Operations, Oversight,
Nutrition, and Forestry
Committee on Agriculture,
Washington, D.C.
The Subcommittee met, pursuant to call, at 10:05 a.m., in
Room 1300 of the Longworth House Office Building, Hon. Joe Baca
[Chairman of the Subcommittee] presiding.
Members present: Representatives Baca, Cuellar, Kagen,
Schrader, Dahlkemper, Childers, Fortenberry, Schmidt, and
Lummis.
Staff present: Adam Durand, Tyler Jameson, John Konya,
Robert L. Larew, Lisa Shelton, April Slayton, Rebekah Solem,
Patricia Barr, Pam Miller, and Jamie Mitchell.
OPENING STATEMENT OF HON. JOE BACA, A REPRESENTATIVE IN
CONGRESS FROM CALIFORNIA
The Chairman. This hearing to review the state of obesity
in the United States will now come to order. Thank you very
much to those of you for being here this morning. What we will
do is begin with opening statements by myself, and then with
the Minority Ranking Member, and other Members as they arrive,
if they wish to give an opening statement.
Again, good morning. I want to thank all of you for being
here before the Subcommittee to review the impact on obesity in
the United States. I think it is an important topic that
affects a lot of us. The issue is one of pressing concern to
all Members of the Subcommittee. We are all anxious to hear the
testimony of the outstanding witnesses to learn all that we can
about the disease. And I say the disease of obesity, because
that is what it is.
Also, I would like to acknowledge our new Ranking Member,
Congressman Fortenberry, and thank him for his interest in this
hearing. Thank you very much, Jeff. I look forward to working
with you on this and other issues before this Subcommittee,
because we want to work on a bipartisan manner on issues that
impact us on all subject matters that we have the
responsibility for.
I have purposely kept this hearing small in numbers to
promote dialogue on this topic. We are here to listen, to
learn, to see how we can make good policies. We will likely
have other hearings to educate us on the problem of obesity.
This isn't the only one we are going to have, but hopefully, we
can explore the problems of access to healthy food as we look
at obesity and its effects, and look to explore ways to
eliminate food deserts. Also, we hope to explore the impact of
obesity on many of the underrepresented communities,
particularly the effects on tribal and Native American
communities, the impact it has there. Also, I encourage Members
of the Subcommittee to share their thoughts in future hearings
on this or any other topic that we should be addressing.
So with that in mind, I hope that we are--that our capable
witnesses and Members will not hesitate to share their
thoughts, and their expertise on obesity in America.
The problem of obesity plagues all Americans, and I state
all Americans, either directly or indirectly. Statistics
indicate that more than \1/3\ of our population is considered
obese. That is, in and of itself, a shocking number. It has an
impact on us financially. It has an impact on us health-wise,
and it also has an impact in terms of relationships with one
another. However, the consequences of that number need to be
examined and need to be understood.
Like any disease, obesity affects many more than just those
who suffer from it. Today's hearing will give us a better
insight as to the very real impact that obesity has on our
whole society. How does obesity affect the family? How does it
specifically affect American women? How does obesity affect
children and their ability to learn? How does obesity affect
businesses? How does obesity affect the cost of health care?
How does obesity affect the American culture?
These are the questions that must be taken into account,
and which we will begin to address today. We know that
prevention--that prevention and nutrition education are key to
success in combating obesity. We must find out what works, what
does not work, and why. Hopefully, your insight will best
inform us as to how to make realistic and substantive policy
changes.
As a father, grandfather, and an American, I am depressed
by the harmful effects of obesity on our health and on our
society. But as a legislator, I am also troubled by the
economic consequences our nation faces due to obesity. So
today, we will listen and learn from excellent panels of
witnesses about their work to determine the impact of obesity
on America.
I hope this hearing will build on an important body of
evidence, so that we can continue to work together to fight
obesity and create a healthier nation.
[The prepared statement of Mr. Baca follows:]
Prepared Statement of Hon. Joe Baca, a Representative in Congress from
California
Good morning, and thank you all for being here before this
Subcommittee--to review the impact of obesity in the United States.
This issue is one of common concern to all Members of the
Subcommittee--so we are anxious to hear the testimony of our
outstanding witnesses and to learn all we can about this ``disease''.
Also, I would like to acknowledge our new Ranking Member,
Congressman Fortenberry, and thank him for his interest in this
hearing.
I look forward to working with you on this and other issues before
our Subcommittee.
We are a small Subcommittee with a very large interest in the
health and welfare of the people in this country.
I have purposely kept this hearing small in numbers to promote real
dialogue on this topic.
We are here to listen and to learn so we can make good policy
choices.
Also, we will likely have other hearings to educate us on the
problem of obesity.
We plan to explore the problem of access to healthy food--and look
to explore ways to eliminate ``food deserts''.
I also hope to explore the impact of obesity on many of our
underrepresented communities--and particularly its effects on our
tribal and Native American communities.
Once staff is in place at USDA's Food and Nutrition Service, I'm
sure they could also add to the discussion.
And, as always, I encourage Members of the Subcommittee to share
their thoughts on future hearings on this, or any, topic.
So, with that in mind, I hope our capable witnesses--and Members--
will not hesitate to share their thoughts and expertise on obesity in
America.
The problem of obesity plagues all Americans--either directly or
indirectly.
Statistics indicate more than \1/3\ of our population is considered
obese.
That, in and of itself--is a shocking number.
However, it is the consequences of that number that we need to
examine and understand.
Like any disease, obesity affects many more than just those who
suffer from it.
Today's hearing will give us better insight into the very real
impact that obesity has on our whole society.
How does obesity affect a family? How does it specifically
affect America's women?
How does obesity affect children, and their ability to
learn?
How does obesity affect a business?
How does obesity affect the cost of health care?
How does obesity affect the American culture?
These are all questions that must be taken into account--and which
we will begin to address today.
We know that prevention and nutrition education are keys to success
in combating obesity--but we must find out what works; what does not
work; and why.
Hopefully--your insight will best inform us on how to make
realistic and substantive policy changes.
As a father, grandfather, and an American, I am distressed by the
harmful effects of obesity on the health of our society.
But as a legislator, I am also troubled by the economic
consequences our nation faces due to obesity.
So, today we will listen and learn from our excellent panel of
witnesses about their work to determine the impact of obesity on
America.
I hope this hearing will build on this important body of evidence,
so we can continue to work together to fight obesity and create a
healthier nation.
I now yield to our Ranking Member--Congressman Fortenberry, for his
opening statement; and after that will open the hearing up to any other
Subcommittee Members who wish to make a brief opening statement.
The Chairman. I now yield to the Ranking Member,
Congressman Fortenberry, for his opening statements, and after
that, I will have other Members give their comments as well.
OPENING STATEMENT OF HON. JEFF FORTENBERRY, A REPRESENTATIVE IN
CONGRESS FROM NEBRASKA
Mr. Fortenberry. Thank you, Mr. Chairman, for your kind
introduction and for holding this hearing today on the state of
obesity in the United States. I appreciate all of you who are
witnesses, your time and willingness to come before us as well
on this important subject, and I look forward to our discussion
today.
Like many of my colleagues, I am very concerned about the
rising rate of obesity among Americans, and the costs are not
only great in terms of economics, but also in terms of health
and well-being of our people. As our witnesses will testify
today, obesity is contributing to rising health care costs, the
loss of productivity in the workplace, and various life-
threatening conditions such as diabetes, cardiovascular
disease, as well as stroke. I am also very concerned about the
rising trend of overweight and obesity statistics among
America's children. I strongly believe that we need to link the
nutrition our children receive to their wellness for the
purpose of preventing the onset of debilitating chronic
diseases. By doing so, we should also see improved health
outcomes as well as lowered heath care costs. I am personally
committed to exploring ways to encourage good nutrition and
wellness, and ultimately, as we all know, for these statistics
to change, persons must take more personal responsibility,
choose a more informed and well-balanced diet, as well as
increase their activity level. But to encourage people to get
on the right track, I believe access to good nutrition, as well
as nutritional education, is the key.
I would also like to note, Mr. Chairman, that Dr. Kagen,
from Wisconsin, and I successfully amended the farm bill last
year to empower local school systems, as well as other public
institutions, to purchase locally raised, nutritious foods from
local farmers as a way to strengthen local food programs while
adding healthful options to school menus.
I am anxious to hear all of your testimony today, as we
unpack these various aspects of the obesity problem in our
country, as well as to hear your helpful suggestions about the
most effective ways to provide information on combating this
growing trend.
Mr. Chairman, again, I thank you for holding this hearing,
and I look forward to our dialogue today.
The Chairman. Thank you very much. Next, I will call on
Congressman Kagen.
OPENING STATEMENT OF HON. STEVE KAGEN, A REPRESENTATIVE IN
CONGRESS FROM WISCONSIN
Mr. Kagen. Thank you, Mr. Chairman, for holding this very
important hearing. I expect this morning to hear from experts
in the field to help document the state of this epidemic of
being overweight. America is overweight, no question about it.
I look forward to your suggestions at what we can do to begin
to solve this difficult challenge that we face.
As the Ranking Member, Jeff Fortenberry, indicated, we have
in the Farm Bill of 2009--we put in some good things, didn't
we, Jeff? You can grow local food and put it into local school
systems: Grow local, buy local.
I will just remind everybody, pollution begins at your
lips. You are what you eat, and from the Kagen point of view,
you ought to weigh today what you did as a senior in high
school. I am working on it.
I will yield back my time.
The Chairman. I think we are all headed to the gym right
now. Thank you. Congresswoman Lummis.
OPENING STATEMENT OF HON. CYNTHIA M. LUMMIS, A REPRESENTATIVE
IN CONGRESS FROM WYOMING
Mrs. Lummis. Thank you very much, Mr. Chairman. Although I
haven't any prepared remarks for opening, I would like to thank
you, is it Dr. Dietz, for being here, and our other witnesses.
Every time that a TV ad runs on our cable television
station at home that says don't just do something, sit there, I
go springing out of my seat because I realize all Americans
watch too much TV, and we are all insufficiently exercised. And
of course, our children learn those behaviors from us. Growing
up and having been in 4-H where we worked on food pyramids, we
worked on making sure we had a balanced meal in front of us,
and that we had different colors of food to make it a pleasing-
looking meal, it seems that those things, to me, come as second
nature. However, I realize that in this day and age, not all
kids are in 4-H. Not all kids learn about the food groups,
about nutrition, and we need to return to that. And that is why
I have been so encouraged to see, for example, ads by the
National Football League encouraging kids to get off the couch
and go out and exercise. There are a lot of groups that are
pitching in to this effort, and it is important that we who are
lawmakers, policy makers, acknowledge the public-private
partnerships that are so positive that could further nutrition
in this country.
Additionally, I would like to echo Mr. Fortenberry's
remarks. It seems to me there is such a natural alliance
between slow food, as we are calling it now, and home-grown
food in areas that can help young people learn about
agriculture, learn about selecting appropriate foods, and the
connection where their food comes from and their community,
their health, their body, their lives. This seems like a very
good time to be pursuing this subject. I commend you on your
willingness to inform us today and to inform the debate today.
Thank you, Mr. Chairman.
The Chairman. Thank you. Congressman Schrader.
OPENING STATEMENT OF HON. KURT SCHRADER, A REPRESENTATIVE IN
CONGRESS FROM OREGON
Mr. Schrader. Thank you, Mr. Chairman. I was going to take
a point of personal privilege with Mr. Kagen's remarks about
pollution starting at the lips. I thought he was talking about
us, but he was actually talking about food in general. I
appreciate his clarification there.
I just hope that the panel would focus on how we can
encourage these behaviors. There has been a lot of talk about
health care, health care reform, and a lot of talk about
prevention being the real key to developing these healthier
lifestyles. So if any of the panelists could really direct us
to some solutions or things they may want to include, as we
move forward in health care discussion, to encourage healthy
lifestyles in a most productive way. We like to mandate things,
and that doesn't usually get the job done, so I would be very
interested in the panel's remarks along those lines.
Thank you.
The Chairman. Congresswoman Schmidt.
OPENING STATEMENT OF HON. JEAN SCHMIDT, A REPRESENTATIVE IN
CONGRESS FROM OHIO
Mrs. Schmidt. Thank you, Mr. Chairman. First off, I would
just want to say to Dr. Kagen, I actually do weigh the same as
I did in high school, but it was a lifestyle change that
occurred with me 30 years ago.
What I hope this panel will present is ways that we can
encourage our young children to not only get off the couch and
get outside and do some physical activity, but make smart
choices on the food that they eat, because it is a lifestyle
process, as you and I know, but we are speaking inside the
room. We are on a dangerous course in the United States where
our children will no longer outlive our lifetime on Earth, but
we may outlive theirs. With the obesity rates that continue to
climb, with the health concerns, especially with high blood
pressure, heart disease, and diabetes, which are now growing at
alarming rates with our youth, it is not just up to us in
Congress to mandate a better way to have a lifestyle, but for
all of us in the United States to promote a better lifestyle.
While I will have to leave in a few minutes for another
meeting, I am very encouraged by this panel and this action. I
look forward to this great deliberation.
The Chairman. Thank you very much. Congresswoman
Dahlkemper.
OPENING STATEMENT OF HON. KATHLEEN A. DAHLKEMPER, A
REPRESENTATIVE IN CONGRESS FROM PENNSYLVANIA
Mrs. Dahlkemper. Thank you, Mr. Chairman. As a new Member
of Congress and someone who was a registered dietician for over
25 years, I just want to thank the Chairman for bringing this
topic up as actually the first Committee hearing of this
Congress.
I think one of the aspects of this whole issue that
sometimes gets buried is the whole emotional and psychological
aspect of eating. Having worked in Early Intervention with the
birth to 3 years of age population for many years, and knowing
that connection and that parental/child connection, that is an
aspect to this whole problem that also needs to be addressed. I
hope today that that is, along with so many other great parts--
not great, but so many important parts of this discussion.
So I am just grateful to the Chairman for holding this, and
I really look forward to the testimony in front of us today.
The Chairman. Thank you very much. The Chairman requests
that other Members submit their opening statements for the
record.
[The prepared statement of Mr. Peterson follows:]
Prepared Statement of Hon. Collin C. Peterson, a Representative in
Congress from Minnesota
Thank you, Chairman Baca for calling today's hearing and for
raising this timely and important issue, which is a serious public
health concern.
This hearing will look at the obesity problem in the United States,
particularly among low income Americans, many of whom participate or
have participated in SNAP--the Supplemental Nutrition Assistance
Program, which was previously known as the food stamp program.
In the 2008 Farm Bill, we created and expanded a number of programs
that will address obesity by expanding access to healthy food choices
and increasing nutrition education efforts aimed at SNAP participants.
The farm bill expanded the USDA Snack Program, which provides fresh
fruit and vegetable snacks for school children and includes curricula
to promote healthy eating. It also included a pilot project to
encourage SNAP participants to purchase more fruits and vegetables and
a demonstration project to evaluate strategies to address obesity in
low income communities.
When looking at the problem of obesity in America, there are often
more questions than answers. But one thing is clear--the number of
obese Americans is growing, and the cost of this problem, to the
individuals facing obesity, their families, and their communities must
be addressed.
This is a serious, multifaceted problem with few simple answers,
and I appreciate the Subcommittee's work on this issue and look forward
to the testimony of the witnesses here today.
The Chairman. We would like to welcome our first panel to
the table. Dr. William Dietz, who is Director of the Division
of Nutrition and Physical Activity and Obesity in the Center
for Chronic Disease Control and Prevention right here in
Washington, D.C. Dr. Dietz, could you please begin when you are
ready, and you have 5 minutes. Then afterwards, we will have
questions and answers from each of the Members here, based on
when they arrive.
STATEMENT OF WILLIAM H. DIETZ, M.D., Ph.D., DIRECTOR,
DIVISION OF NUTRITION, PHYSICAL ACTIVITY, AND
OBESITY, NATIONAL CENTER FOR CHRONIC DISEASE
PREVENTION AND HEALTH PROMOTION, CENTERS FOR
DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ATLANTA, GA
Dr. Dietz. Thank you, Mr. Chairman, Mr. Fortenberry,
Members of the Subcommittee. Thank you for the opportunity to
address the epidemic of childhood obesity. I will limit my
comments to childhood obesity, because the entire scope of the
epidemic is well beyond 5 minutes.
I am Bill Dietz. I am the Director of the Division of
Nutrition, Physical Activity, and Obesity located in CDC's
National Center for Chronic Disease Prevention and Health
Promotion in Atlanta. I would like to provide you with the
latest data on the breadth of the epidemic, the health
implications of the epidemic, and the progress that is
occurring, as well as what remains to be accomplished.
I have given you six slides.
The first of these slides shows the changes in prevalence
over the last 30 years. If you look at 1976 to 1980 and compare
that with 1999 to 2000, you will see that there has been a two-
fold increase in the prevalence of obesity among 6 to 11 year-
olds, and a three-fold increase among adolescents, 12 to 19
years old. The latest data suggests that among 2 to 19 year-
olds, 16 percent are obese, 15 percent are overweight. So there
is a total of 31 percent of children and adolescents in the
United States at risk for the complications of obesity. Those
consequences include an increase in cardiovascular disease risk
factors. Seventy percent of obese youth have at least one
additional cardiovascular disease risk factor, like elevated
insulin levels, elevated blood pressure, or elevated lipid
levels. Thirty-nine percent of those children and adolescents
have two or more of those complications. Type 2 diabetes
mellitus, a disease previously limited to adults, is now
occurring in children and adolescents. In some cities, it
accounts for 50 percent of all new cases of type 2 diabetes.
We know from the natural history of obesity that children
who are overweight go on to become obese adults. As obese
adults, they are much more severely obese than adults who
become obese in adulthood, and therefore, have an increased
risk of the diseases associated with obesity. There has been a
recent paper that suggests that the deaths from obesity in
adolescence are approximately equivalent to those deaths
attributable to smoking, so this is not a trivial disease in
any means.
Now, although the costs of obesity in children and
adolescents rate in the millions, those costs are in the
billions for adults. In adults, those cardiovascular disease
risks factors in children become hypertension, become
atherosclerosis, become cardiovascular disease, and become
cancer. The prevalence of these diseases in adults portends a
further increase in the future costs of obesity and medical
costs in the United States. Obesity-related diseases accounted
for 25 percent of the increase in medical costs between 1987
and 2001. We have a choice here. We can pay for the care of
these diseases, or we can choose to prevent these diseases. But
if we are to control these medical costs, prevention is
essential. There is no way that these diseases, obesity and its
associated diseases can be treated in medical settings. Sixty
percent of adults are overweight or obese, 31 percent of
children and adolescents are overweight or obese. That far
exceeds the capacity of the medical system. We really need to
look beyond that.
Now, there is some modest cause for optimism. If you look
at the second slide, this shows the changes in obesity
prevalence by race ethnicity for boys 2 to 19 years old. There
are a couple of observations here. The first is that among all
three major ethnic groups studied in the National Health and
Nutrition Examination Survey, the prevalence of obesity has
flattened. We are at a plateau. Notice also on this figure that
among boys, Mexican American boys are disproportionately
affected.
If you look at the next slide, the same thing is true for
girls. But among girls, African American girls are
disproportionately affected. That alone emphasizes the
important cultural basis and linkages of obesity in children
and adolescents.
Coming back to this plateau, this is true for children and
adolescents between the 85th and 95th percentile, that is
overweight children and adolescents, obese children and
adolescents, and also severely obese children and adolescents.
However, this is not a cause for complacency. Thirty-one
percent of the pediatric population is overweight or obese.
Thirty-one percent are destined--some proportion of that 31
percent are destined to become obese adults, and therefore
suffer the medical consequences.
Now, the next slide indicates the states that we are
funding. Many of those are your states. Our challenge has been
to figure out what we should recommend that our state programs
do. Obesity didn't result from active decisions on the part of
the population to eat more or exercise less. Recent
calculations suggest that the imbalance necessary to account
for obesity in adolescents amounts to about 150 calories per
day. That is an easy remediable and accomplishable imbalance to
address. But as I said before, behavior changes in large
proportions of the pediatric and adult populations are highly
unlikely, unless they are supported by changes in the
environment that provide access to healthy eating and active
living. People must make good choices, but they must have good
choices to make.
Place matters: Children can't walk to school in our suburbs
because of the lack of sidewalks and centrally located schools.
Inner city populations are surrounded by fast food restaurants
and lack access to grocery stores. If our population is to make
good choices, there must be good choices to make.
Like tobacco, our focus is on policy and environmental
changes which will change diet and physical activity, many of
which will change practices or behaviors, but not necessarily
be driven by increased costs. I would like to point to a few of
those policy initiatives.
New York City regulates group day care: About 18 months
ago, they passed a new regulation which called for limits on
television veiwing over the age of 2, no television veiwing for
children under the age of 2, which is consistent with the
recommendations the American Academy of Pediatrics. They banned
sugar-sweetened beverages, they called for the provision of
low-fat and no-fat milk, and they called for 60 minutes of
physical activity a day. In a group day care, that regulation
is likely to have a substantial impact on the prevalence of
obesity.
In Mississippi, the Department of Education worked with
CDC, the Bower Foundation, and the Alliance for a Healthier
Generation, the alliance between the Clinton Foundation and the
American Heart Association, to develop new standards for
snacks, they banned sugar-sweetened beverages, and replaced
deep fryers with steamers. The school-based fresh fruit and
vegetable snack program that was part of the farm bill makes a
major contribution to the improved nutrition of children and
adolescents. Among communities, the CDC funded an intervention
in Somerville, Massachusetts, which included multiple changes
in schools in the community, such as increasing low energy
density foods, discouraging high fat and high sugar foods,
enhancing the school food service, expanding pedestrian safety
policy, and promoting a walk to school campaign. This program
resulted in a lower rate of increase in BMI among children in
the targeted schools than among control schools.
One additional problem which is worth mentioning is the
food insecurity in underserved populations may contribute to
obesity. Hunger seems clearly associated with restricted growth
in children and adolescents, but food insecurity may contribute
to obesity. That is, families may make decisions to eat more
when food is available to account for the deficits of food when
it is not. In an era of financial instability, this becomes an
important potential contributing problem.
Now, the plateau is encouraging in the prevalence of
obesity in children, but it is not enough. Thirty-one percent
of our youth population are overweight or obese, and the
estimates are, as you are aware, that if we don't in some way
control medical costs and the medical costs that are
increasingly driven by obesity, the costs of our medical system
is going to account for 20 percent of our gross domestic
product. We already know that insurance companies are
struggling and employers are struggling to support these costs.
Those are only going to increase as these children and
adolescents go on to become obese adults. We need an integrated
approach across multiple sectors, collaboration across agencies
and departments, and coordinated efforts among national, state,
and local authorities.
In closing, I would like to thank the Committee for its
leadership and commitment to the health of our nation's youth.
We know that the young can achieve long-term health benefits
from better nutrition, increased physical activity, and other
preventive efforts. Environmental changes to make good
nutrition and regular activity a routine part of their lives
will take a committed, coordinated effort that must endure for
decades to come.
Thank you again for the opportunity to share these views
with you.
[The prepared statement of Dr. Dietz follows:]
Prepared Statement of William H. Dietz, M.D., Ph.D., Director, Division
of Nutrition, Physical Activity, and Obesity, National Center for
Chronic Disease Prevention and Health Promotion, Centers for Disease
Control and Prevention, U.S. Department of Health and Human Services,
Atlanta, GA
Current Status and Activities to Decrease the Prevalence of Obesity
Among U.S. Children and Adolescents
Introduction
Chairman Baca and Members of the Subcommittee, thank you for the
opportunity to provide this statement for the record for today's
hearing on the nation's childhood obesity epidemic. I am Dr. Bill
Dietz, Director, Division of Nutrition, Physical Activity, and Obesity,
located in CDC's National Center for Chronic Disease Prevention and
Health Promotion. My statement provides you with an overview of the
childhood obesity epidemic including updated surveillance data on youth
overweight and obesity; the financial cost that treating overweight and
obesity places on our healthcare system; and a description of
integrated activities illustrating the implementation of policy
approaches supported by the CDC to combat the childhood obesity
epidemic.
Background
In order to improve the health and quality of life of Americans,
now and for the next generation, while keeping our healthcare budget
under control, we need to invest in prevention. At every stage of life,
eating a nutritious, balanced diet and staying physically active are
essential for health and well-being. This is especially true for
children and adolescents who are developing the habits they will likely
maintain throughout their lifetime. Thus, developing effective
population-level interventions that create supportive healthful
environments for young people and their families is an opportunity to
affect positive health outcomes throughout the life span.
Childhood obesity is an epidemic in the United States, one that is
negatively impacting the physical and emotional health of our children,
their families and society as a whole. The multiple, complex causes of
childhood obesity present a compelling case for integrating multiple
disciplines in a coordinated, comprehensive effort to halt and reverse
the epidemic. Obesity in children is defined using the Body Mass Index
(BMI), a calculation of a child's height and weight as adjusted for
gender and age based on CDC's Growth Charts for the United States. A
child is considered overweight if his or her BMI is between the 85th
and 95th percentiles, and obese if his or her BMI is greater than or
equal to the 95th percentile.
The prevalence of obesity among American youth increased radically
between the 1980's and the present decade. Between 1976 and 1980,
approximately five percent of youth 2 to 19 years of age were obese.\1\
In 2006, the rate had increased to 16.3 percent. In fact, obesity among
children aged 2 to 5 years doubled, increasing from five percent to
12.4 percent; among children 6 to 11 had doubled, increasing from 6.5
percent in 1980 to 17.0 percent in 2006; and tripled among adolescents
aged 12 to 19, increasing from five percent in 1980 to 17.6 percent in
2006.\2\ Furthermore, 11.3 percent of children and adolescents aged 2
through 19 years were found to be severely obese, that is, their BMI
was above the 97th percentile.\3\
There are disparities by race, ethnicity and socioeconomic status
in the prevalence of obesity among youth. In 2004, 14.8 percent of
children 5 and under from low-income families were obese compared to
10.4 percent of those from moderate to high income families.\4\ Among
males aged 12 to 19, more than 25 percent of Mexican American were
obese, compared with 15.5 percent of non-Hispanic whites. Among females
aged 12 to 19 years, the obesity prevalence was higher among non-
Hispanic Blacks (27.7 percent) and Mexican Americans (19.9 percent)
compared to non-Hispanic whites (14.5 percent).\5\
As noted previously, recent trends reveal that among all youth, the
rate of obesity appears to have leveled; there has been no
statistically significant increase or decrease for either boys or girls
2-19 years of age between survey years 1999-2000 and 2005-2006. Recent
data also show a plateau of obesity rates among U.S. children and
adolescents that participate in the Women, Infants and Children (WIC)
Supplemental Nutrition Program.\6\ We cannot, however, become
complacent about this plateau. Sixteen percent of our youth remain
obese, and we have not achieved a reduction in obesity among this
population group.
Obesity in adults is associated with serious health concerns that
we are now beginning to see in children. A 2007 study reported that 70
percent of obese young people already had at least one additional risk
factor for cardiovascular disease, while 39 percent had at least two
additional risk factors.\7\ And consider Type 2 Diabetes Mellitus
(T2DM), historically referred to as `adult-onset' diabetes. Type 2
Diabetes Mellitus was virtually unknown in children and adolescents 10
years ago; now children and adolescents account for almost 50 percent
of new cases of T2DM in some communities.\8\
Childhood obesity can become a chronic condition affecting the
individual and their families throughout their lifetime. Children and
adolescents, who are overweight, are more likely to be overweight or
obese as adults. One study found that after age 6, obese children have
a greater than 50 percent chance of becoming obese adults, regardless
of parental obesity status.\9\ In another study, obese adults who
experienced childhood obesity before the age of 8 were more severely
obese (had higher adult BMI) than were individuals who became obese as
teenagers or adults.\10\ Adults who were obese as children may have
earlier onset of co-morbidities (e.g., diabetes, cardiovascular
disease, some cancers) and prolonged health effects from these co-
morbidities and other conditions (e.g., arthritis, reproductive health
complications, memory loss).\11\
The care and treatment of obesity and its co-morbidities over the
life span can be costly. Economic data show that in 2001 dollars,
obesity-associated annual hospital costs among youth were estimated to
have more than tripled from $35 million in 1979-1981 to $127 million in
1997-1999.\12\ More than 25 percent of the rise in medical costs
between 1987 and 2001 has been attributed to obesity.\13\ Between 1987
and 2002, the cost of obesity to private insurers increased tenfold,
from $3.6 billion to $36.5 billion.\14\ In 2003, approximately half the
cost of treating obesity was paid through Medicare or Medicaid.\15\ One
reason for the higher medical costs is the prevalence of obesity-
associated co-morbidities, such as diabetes and cardiovascular disease,
which also require treatment and management.\16\ Another contributing
factor may be inconsistent use of and lack of uniformity in applying
billing codes to obesity-related treatments such that bill coding
attributes the cost of care to a co-morbidity (e.g., diabetes) rather
than to obesity as an underlying condition).
Some youth-targeted obesity interventions have been shown to have a
positive return on investment. For example, Planet Health, a school-
based obesity prevention program, cost $33,677 for 1200 middle school
students over 2 years, or $14 per student per year. An economic
evaluation of the program found that it would prevent an estimated 1.9%
of the female students from becoming overweight or obese adults. As a
result, for every dollar spent on the program, $1.20 would be saved in
future medical costs and loss of productivity costs.\17\
Monitoring Physical Activity and Nutrition
Several sources of CDC-funded surveillance or monitoring data allow
us to track obesity related behaviors and other risk factors among the
nation's youth.\18\ Behaviors and risk factors monitored by CDC
tracking systems include rates of physical activity and critical
indicators of nutrition (e.g., fruit and vegetable consumption,
maternal breast-feeding practices). We use these data to assess the
health of our youth and develop relevant interventions designed to
integrate multiple settings (i.e., communities, medical care and
schools) in efforts to support healthier behaviors for children and
their families.
Recent tracking data indicate that for too many children and their
families, proper nutrition and physical activity are not part of their
daily lives. For example, the recently released Physical Activity
Guidelines for Americans from the Department of Health and Human
Services recommends that all young people ages 6 to 19 engage in
moderate to vigorous activity that add up to 60 minutes of physical
activity daily.\19\ Unfortunately, more than 60 percent of our young
people do not meet this recommendation. On most days of the week, only
34.7 percent of young people in grades nine through 12 report that they
regularly engage in vigorous physical activity.\20\ Further, the 2005
Dietary Guidelines for Americans encourages all Americans to daily
consume fruits and vegetables in amounts sufficient to meet their
caloric needs based on age, height, weight, gender, and level of
physical activity. However, between 1999 and 2007, the percentage of
U.S. youth in grades nine through 12 who reported eating fruits and
vegetables five or more times per day declined from 23.9 to 21.4
percent.\21\ These factors may have had a direct impact on the nation's
childhood obesity rate. That students cannot meet these physical
activity and nutrition recommendations illustrates the need to develop
public policies that create and support environments that allow for
regular and routine physical activity and access to healthful foods for
our youth.
What has Contributed to the Leveling of Obesity Rates?
The recent data showing a plateau of obesity rates among U.S.
children and adolescents are encouraging. The cause of this plateau has
not been scientifically determined. However, CDC notes that greater
public awareness resulting from press and media attention to the
problem likely contributed to the present leveling of obesity rates.
Yet, we strive not simply to stop the increase in obesity rates, but to
reverse the epidemic. Implementing policy and environmental change
initiatives at the national, state and community level that have the
potential to decrease the prevalence of youth obesity may help reverse
the epidemic among youth and adults. Such initiatives can include:
seeking to eliminate so-called ``food deserts'' in urban and
underserved areas where there is little or no access to healthy
foods;
expanding public transportation services and improve road
conditions to allow for non-vehicle transit;
expanding physical activity opportunities for youth; and
improving and increasing access to healthy foods in schools
and communities.
CDC Activities to Prevent and Control Obesity Through Population-Level
Interventions
Currently, CDC's efforts to address the obesity epidemic are
focused on policy and environmental strategies that can improve the
health of all U.S. children and adults by making the places in which we
live, learn, work, play, and pray, more supportive of healthy eating
and physical activity. Through innovative partnerships and funded state
programs, we are identifying, implementing and evaluating a variety of
policy and environmental strategies in order to prioritize best and
promising practices at the community, state and national level. Our
efforts revolve around six target areas, prioritized because they
address a significant disease burden, are supported by reasonable or
logical evidence, and can prevent and control obesity at the
population-level. These six strategies include:
1. increasing physical activity;
2. increasing fruit and vegetable consumption;
3. increasing breast-feeding initiation, duration, and exclusivity;
4. decreasing television viewing;
5. decreasing consumption of sugar-sweetened beverages; and
6. decreasing consumption of foods high in calories and low in
nutritional value.
Because some barriers to nutrition and physical activity are
specific to particular settings (e.g., workplaces, communities, medical
care, and schools and childcare centers), CDC seeks to develop
strategies, tools and resources that can assist practitioners in
providing integrated health messages and coordinated interventions to
prevent and control childhood obesity. CDC's major program areas to
address childhood obesity include grants for state-based Nutrition and
Physical Activity, Coordinated School Health, as well as for Healthy
Communities.
Nutrition, Physical Activity and Obesity State Plans: CDC provides
funding to twenty-three states to coordinate statewide efforts to
address obesity through policy and environmental changes focused on
CDC's six strategies mentioned above. The program also addresses health
disparities and requires a comprehensive state plan. A good example of
one of these initiatives is from Washington State. A series of
initiatives, now known as Healthy Communities Moses Lake, have
encouraged good nutrition and physical activity behaviors through
environmental and policy change. Accomplishments include widening of
sidewalks, creating an interconnected system of paths for pedestrians
and bicyclists, and fostering an environment conducive to outdoor
physical activity. The project also developed a community garden which
provides residents and participants with greater access to fresh,
nutritious produce as well as opportunities to engage in physical
activity through gardening. In addition, to encourage good nutrition
from birth, Healthy Communities informs residents about proper breast-
feeding practices and creates supportive environments for nursing
mothers throughout the community.
Coordinated School Health: CDC also funds twenty-two state-based
education and health agencies and one tribal government to implement
coordinated school health programs. These programs bring together
school administrators, teachers, other staff, students, families, and
community members to assess health needs; set priorities; and plan,
implement, and evaluate school health activities, including those
focused on physical activity and healthy eating among school-aged
youth. This program fosters collaboration between state and local
authorities, as well as between state departments of health and
education. In Mississippi, for example, the Department of Education
worked with CDC, the Bower Foundation, the Alliance for a Healthier
Generation, and other partners to set new nutritional standards for
school snacks and meal programs, and impose a ban on sugar-sweetened
beverages. Forty-one school districts purchased 104 combination oven
steamers, replacing the traditional deep-fat fryers and thereby
substantially decreasing the amount of high-calorie, fatty foods eaten
by almost 65,000 of the state's school children. Additionally,
Wisconsin's ``Movin' and Munchin' Schools'' campaign to promote
physical activity and healthy eating as lifetime habits resulted in
101,641 students, 39,143 parents, and 9,265 staff reporting increases
in physical activity and fruit and vegetable consumption.
Healthy Communities: Since 2003, Healthy Communities (formerly
referred to as Steps to a HealthierUS) has supported local communities
in implementing evidence-based interventions in community-based
settings including schools, workplaces, community organizations, health
care settings, and municipal planning, and in achieving local changes
necessary to prevent obesity and related risk factors. Special focus
has been directed toward populations with disproportionate burden of
disease. Communities receive funds to spark local-level action, change
community conditions to reduce risk factors for obesity, establish and
sustain state-of-the-art programs, test new models of intervention,
create models for replication, and help train and mentor additional
communities.
Examples of Integrated Approaches to Address Childhood Obesity
We know that any effort to combat childhood obesity will take a
multi-pronged approach aimed at improving population-level indicators
of health and include not just CDC and the Federal Government, but
states, localities and our national and local partner organizations.
Coordinating our efforts across sectors, including education,
agriculture, and transportation, and leveraging our resources to affect
policy and environmental changes is necessary if we want to see obesity
trends decrease. One such partnership is between CDC, the United States
Department of Agriculture, and the United States Department of
Education in a joint project called Making It Happen! School Nutrition
Success Stories. This report tells the stories of 32 schools and school
districts from across the United States (grades K-12) that have
implemented innovative strategies to improve the nutritional quality of
foods and beverages sold outside of Federal meal programs. Another
partner in our efforts is the Alliance for a Healthier Generation, a
joint partnership between the Clinton Foundation and the American Heart
Association. The Alliance has worked with industry and school districts
to develop guidelines on the provision of competitive foods and
beverages in schools, and most recently began a new campaign working
with national medical associations, insurers and employers to provide
comprehensive health benefits to obese children and their families.\22\
In addition to our partners, many cities and localities have
started their own childhood obesity initiatives including New York
City's Department of Health and Mental Hygiene. The city developed and
implemented a regulation that specifically improves the nutritional and
physical activity habits of children in the city childcare programs.
The regulation prohibits the availability of sugar-sweetened beverages;
permits only 6 oz. of 100% juice for children 8 months or older;
permits children 12 months to under 2 years to have whole milk and then
limits milk to 1% or less for children 2 years of age or older;
requires water to be available and accessible to children throughout
the day; requires children 12 months and older to participate in 60
minutes of physical activity per day and for children 3 years or older
to participate in 30 to 60 minutes of structured physical activity per
day; and restricts television viewing for children under 2 years of
age, and limits television viewing to no more than 60 minutes per day
of educational programming or programs that actively engage children in
movement to children 2 years of age or older.
Another example can be found in Florida, where the Pinellas County
Childcare Licensing Board requires a minimum of 30 minutes of physical
activity, 5 days per week, for all children as a condition of childcare
licensure. And in 2008, the state of Florida passed a law requiring
each school district to provide 150 minutes per week of physical
education for students in grades K to 5, and for students in the 6th
grade when the school has one or more elementary grades. Beginning in
2009, school districts will have to expand the physical education
requirement so students in grades six to eight receive one physical
education class per day each semester. The effect of these policies is
a coordinated effort across jurisdictions and sectors to increase daily
physical activity for all children from pre-school through the 6th
grade. As a result, many children in Pinellas County now meet the
national recommendation of 60 minutes of physical activity daily.
And in California, to create healthy environments where people can
thrive, the California Convergence has convened leaders from 26
communities to collaboratively develop a common policy agenda, build a
statewide communication infrastructure, influence funding strategies,
and generate public revenue to support their work. As a result,
officials have identified the need to improve nutrition standards in
those places where children spend most of their time, (including
schools, after school and childcare environments), and a broad range of
strategies that focus on local, state and national level health impact.
Given the challenges ahead, CDC will continue to develop and
evaluate policy and environmental strategies to determine effective
population-level interventions that will provide a positive impact on
the health of our nation's youth. We applaud recent changes in Federal
policy to support healthier eating; updating WIC program requirements
to be more in line with the Dietary Guidelines for Americans, and the
inclusion in the 2008 Farm Bill (Food, Conservation and Energy Act of
2008, Public Law 110-246) of the Healthy Urban Food Enterprise
Development Center and the school-based Fresh Fruit and Vegetables
Program provisions. These provisions, like others implemented through
the 2008 Farm Bill, will help incentivize the consumption of fruits and
vegetables. Agricultural policies like these support American families
in making healthy food choices, thereby ensuring healthier diets among
some of our most at-risk children.
Further, we cannot forget the impact of physical activity and
proper nutrition on student academic achievement and classroom
participation. A 2008 elementary school study found that physical
activity may be associated with improved academic performance for girls
and had no negative effect on academic achievement for elementary
school children.\23\ And, among children living in the urban areas of
Baltimore, Maryland and Philadelphia, Pennsylvania, those who
participated in the School Breakfast Program increased their nutrient
intake and were more likely to improve their academic and psychosocial
functioning than those who did not participate in the program.\24\
Last, we are compelled to acknowledge the causal relationship
between food insecurity and obesity.\25\ Though it may appear
paradoxical, families faced with food insecurity are more likely to
augment their diet with high energy density, low nutritional value
foods and, therefore, have high rates of obesity. Obesity is not a
symptom of eating well but an indicator of poor diet. Persons living in
low income communities often do not have access to fresh produce making
foods of low nutritional value an affordable option to satiate their
hunger. With increasing unemployment and concurrent demand on public
and privately funded food service facilities, it is imperative that we
pursue policies that ensure proper nutrition among persons experiencing
the greatest obesity- related health disparities.
Conclusion
In closing, I would like to thank the Committee for its leadership
and commitment to the health of our nation's youth. Making balanced
nutrition and regular activity a routine part of life will take a
committed, coordinated effort that will need to endure for decades to
come.
Positively impacting the health of our youth offers promising
prevention opportunities. We know that the young can benefit from
better nutrition, and increased physical activity, as well as from
other preventive efforts. While medical treatment for disease
management is essential, our nation needs a better balance between
treating diseases and preventing them.
There is much we can do to prevent disease and conditions related
to obesity that contribute so heavily to disability and death, the need
for long-term care, and escalating health care costs. Our youth have an
urgent need for more and better prevention policies and environmental
change initiatives. I look forward to working with my colleagues in the
United States Department of Agriculture to further discuss agriculture
policies and their impact on the public's health.
Thank you.
Endnotes
\1\ Obesity Prevalence, Centers for Disease Control and Prevention,
Division of Nutrition, Physical Activity and Obesity, (children 2-5
years, 5%, children 6-11 years, 6.5%, children 12-19 years, 5%). http:/
/www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm, last
visited March 20, 2009.
\2\ Ogden C.L., Carroll M.D., Flegal K.M. High Body Mass Index for
Age Among U.S. Children and Adolescents, 2003-2006. JAMA.
2008;299(20):2401-2405.
\3\ C.L. Ogden, M.D. Carroll, K.M. Flegal. High Body Mass Index for
Age Among U.S. Children and Adolescents, 2003-2006. JAMA.
2008;299(20):2401-2405.
\4\ Polhamus B., Thompson D., Dalenius K., Borland E., Smith B.,
Grummer-Strawn L. Pediatric Nutrition Surveillance 2004 Report.
Atlanta: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention; 2006.
\5\ Ogden C.L., Flegal K.M., Carroll M.D., Johnson C.L. Prevalence
and trends in overweight among U.S. children and adolescents, 1999-
2000. JAMA 2002;288:1728-1732.
\6\ Polhamus B., Dalenius K., Borland E., Mackintosh H., Smith B.,
Grummer-Strawn L. Pediatric Nutrition Surveillance 2007 Report.
Atlanta: U.S. Department of Health and Human Services, Centers for
Disease Control and Prevention; 2009.
\7\ Freedman D.S., Mei Z., Srinivasan S.R., Berenson G.S., Dietz
W.H. Cardiovascular risk factors and excess adiposity among overweight
children and adolescents: The Bogalusa Heart Study. J. Pediatr. 2007
Jan; 150:12-17.e2.
\8\ American Diabetes Association (ADA). 2000. Type 2 Diabetes in
Children and Adolescents. Pediatrics 105:671-80.
\9\ Whitaker R.C., Wright J.A., Pepe M.S., Seidel K.D., Dietz W.H.
Predicting Obesity in young adulthood from childhood and parental
obesity. N. Engl. J. Med. 1997;337(13): 869-73.
\10\ Relationship of Childhood Obesity to Coronary Heart Disease
Risk Factors in Adulthood: The Bogaluse Heart Study. Pediatrics,
2001;108(3): 712-718.
\11\ Ferraro, K.S., R.J. Thorpe, Jr., and J.A. Wilkinson. 2003. The
Life Course of Severe Obesity: Does Childhood Overweight Matter?
Journals of Gerontology, Series B, Psychological Sciences and Social
Sciences 58(2):S110-19.
\12\ Wang G. and Dietz W.H. Economic Burden of Obesity in Youths
Aged 6 to 17 years: 1979-1999. Pediatrics. 2002;109;e81.
\13\ Thorpe, K.E., C.S. Florence, D.H. Howard, and P. Joski. 2004.
The Impact of Obesity on the Rise in Medical Spending. Health Affairs,
July-December (suppl. web excl.):W4-480-86.
\14\ Thorpe, K.E., C.S. Florence, D.H. Howard, and P. Joski. 2005.
The Rising Prevalence of Treated Disease: Effects on Private Health
Insurance Spending. Health Affairs, January-June (suppl. web excl.):W5-
317-25.
\15\ Finkelstein, E., et al. State-Level Estimates of Annual
Medical Expenditures Attributable to Obesity. Obesity Research, January
2004: V12. No 1: 18-24.
\16\ Thorpe, K.E. 2006. Factors Accounting for the Rise in Health-
Care Spending in the United States: The Role of Rising Disease
Prevalence and Treatment Intensity. Journal of the Royal Institute of
Public Health 120:1002-7.
\17\ Wang, L.Y., Yang, Q., Lowry, R, Wechsler, H. Economic analysis
of a school-based obesity prevention program. Obesity Research 2003;
11:1313-1324.
\18\ Pediatric and Pregnancy Nutrition Surveillance System
(PedNSS); Youth Risk Behavior Surveillance System (YRBSS); National
Health and Nutrition Examination Survey (NHANES).
\19\ 2008 Physical Activity Guidelines for Americans, at http://
www.health.gov/PAGuidelines/, last visited March 20, 2009.
\20\ CDC. Youth Risk Behavior Surveillance--United States (http://
www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf), 2007 [pdf 1M]
Morbidity & Mortality Weekly Report 2008;57(No.SS-4).
\21\ CDC. Youth Risk Behavior Surveillance--United States (http://
www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm), 2007. Morbidity &
Mortality Weekly Report 2008;57(SS-05):1-131.
\22\ http://www.healthiergeneration.org.
\23\ Carlson S.A., Fulton J.E., Lee S.M., Maynard L.M., Brown D.R.,
Kohl H.W., Dietz W.H. Physical Education and Academic Achievement in
Elementary Schools: Data From the Early Childhood Longitudinal Study.
Am. J. Public Health, 2008;98(4):721-727.
\24\ Murphy J.M., Pagano M.E., Nachmani J., Sperling P., Kane S.,
Kleinman R.E. The Relationship of school breakfast to psychosocial and
academic functioning: Cross-sectional and longitudinal observations in
an inner-city school sample. Archives of Pediatrics and Adolescent
Medicine 1998; 152(9); 899-907.
\25\ Tufts University School of Medicine, Case Report, Does Hunger
Cause Obesity. Pediatrics 1995;95:766-7; Freedman D.S., Ogden C.L.,
Flegal K.M., Kettel-Khan L., Serdula M.K., Dietz W.H. Childhood
Overweight and Family Income. Medscape General Medicine, 2007;9(2):26.
Attachment
Slide 1
Thank you very much, Dr. Dietz, for your testimony and for the work
you are doing to quantify the crisis of obesity. So on behalf of all of
us, we would like to thank you.At this time we will begin with
questions. Each of the Members will have 5 minutes if they wish to, and
if not, they can yield back the balance of the time. I will begin,
first of all, by asking a couple of questions myself, then turn it over
to the Ranking Member.
In your expert opinion, Dr. Dietz, of all the methods of obesity
prevention you have seen, what type of nutrition education methods are
most effective and why?
Dr. Dietz. I am not very optimistic that additional nutrition
education is going to make a big difference. It may prompt people to
make better choices, but only if those choices are available. Many of
the patients that I saw, when I was treating childhood obesity in
Boston, knew the choices they should make. Those choices weren't often
available.
The Chairman. Okay. In part of your comment you mentioned food
insecurity as part of it, that is why the question is there. Sometimes
people have a tendency, not just because of having more finances, but
in the sense when they have more finances buying a lot of the bad food
or food that they shouldn't be buying versus because of a lack of
security, not buying, therefore, the effects it has on them.
Dr. Dietz. If I could interrupt, let me tell you the story of what
prompted my interest in food insecurity. When I was in Boston, I had a
patient, a 13 year-old girl, who lived with a single mother who was on
welfare. Their first check of the month went for housing. By mid-month,
they were hungry and this mother was so concerned that her daughter not
go to bed hungry that she was feeding her pasta with added oil or
butter. That was instrumental in causing that girl's obesity. When we
restructured that family's diet and gave them some additional options,
that problem began to resolve.
So in that case, it wasn't a question of education, it was a
question of food availability, and a uniform distribution of that food
availability throughout the month.
The Chairman. Thank you. As you know, this Committee has
jurisdiction over the SNAP, which is a food stamp program.
I am curious to know if in your research you have any data that
might show positive effects of state nutrition educational programs
through SNAP?
Dr. Dietz. I am not aware of such research, but we can certainly
let you know if we are able to identify some of that.
The Chairman. Okay, thank you. In statistics you cite showing the
racial increase of obesity rates from 1980 to the present day, which
are, of course, very troubling, but it does seem like there is some
positive news. The rate of obesity among children seemed to level off
from the year 2000 to the present. Can we point to positive steps we
started to take in education prevention that have led to this leveling
of obesity rates? And then, can you also elaborate on programs that we
used to have that also dealt with obesity, such as with physical
education, physical exercise?
Dr. Dietz. Sure. The principle factor influencing the plateau, in
my opinion, is the awareness of the epidemic, in part driven by the
maps the CDC published showing the rapid increase in adult obesity. But
there were other positive changes that paralleled this. One is an
increased awareness on the part of pediatric providers and changes in
the way care is delivered. Some notable examples of that include Kaiser
Permanente in northern California and the American Academy of
Pediatrics initiative in the State of Maine.
A second change was that a number of schools began to make changes
in the period between 2000 and 2006, according to the CDC study that is
called ``School Health Policy and Programs Survey,'' and schools began
to reduce the availability of soft drinks and increase the availability
of lower fat foods. That was certainly a contributing factor.
Furthermore, we know that a number of communities have initiated
efforts around childhood obesity. By our last count, it is in the
neighborhood of 100 communities around the country, spontaneously,
often supported by philanthropic organizations, have begun to intervene
at the community level on this problem.
The decline of physical activity and physical education in schools
is certainly an important contributor, because schools may be one of
the last safe places for children to be physically active, and we know
that part of that is driven by the No Child Left Behind program. We
recently published a paper showing that in girls, not boys, physical
education programs in young children increased test performance,
improved test performance. It is widely believed by teachers, whose
judgment I trust, that physical activity improves classroom behavior. I
think we need more data on that, but my belief is that physical
activity improves the capacity for learning and will improve test
performance, just as the school breakfast program does. We know that in
order to improve test scores, many schools provide school breakfast on
the days of testing to assure that children would perform better.
The Chairman. Okay, thank you. I know that my time has expired, but
one final question that I have is in reference to obesity and diabetes.
What effect does obesity have on diabetes, and what can be done for
prevention?
Dr. Dietz. Obesity is a major driver of the diabetes epidemic. That
is one of the major consequences, and if I could show you maps of the
change in the prevalence of diabetes, they would exactly parallel
changes in the prevalence of obesity.
One important strategy for the prevention of type 2 diabetes in
children and adolescents is healthier pregnancies. About 50 percent of
type 2 diabetes that occurs in adolescence, which is where the peak of
type 2 diabetes occurs, 50 percent of those children were exposed in
utero to either obesity or gestational diabetes or diabetes in the
mother during pregnancy. So a huge chunk of that diabetes could be
prevented by more attention to pregnancy related weight gain or control
of diabetes during pregnancy.
That is only half of the problem. The other half comes from the
occurrence of diabetes, particularly among minority populations. It is
much more prevalent among Hispanic youth and African American youth.
The Chairman. Thank you. Next, I will call on Congressman
Fortenberry.
Mr. Fortenberry. Thank you, Mr. Chairman, and thank you, Dr. Dietz,
for your helpful testimony. It is packed with information, so I want to
go back to a few statistics that should be highlighted.
You had mentioned that approximately 25 percent of our medical
costs either now, or in the future, will be related to this problem?
Dr. Dietz. Twenty-five percent of the rise in medical costs between
1987 and 2001 was attributable to obesity. These are data from Ken
Thorpe at Emory University. The implications are that that is going to
increase further, if you think abut what the prevalence was in 1987 and
what it is now, and the impact that the wave of childhood onset obesity
is going to have on adult disease.
Mr. Fortenberry. Do you have--let us say we could cut that increase
or the total prevalence of that statistic in half by the variety of
things that will be suggested today, or a national awareness that this
is serious, and an implementation of both old and new ideas about
nutrition education access as you are suggesting. What would the
potential health care cost savings be to our overall system? A number
that is actually attainable in the short run.
Dr. Dietz. We know that from a paper that we published several
years ago that the adult--annual adult costs of obesity are about $117
billion per year. If we were to halt the rise in prevalence, I think we
would begin to see a decline in those costs. If we could cut obesity in
half, I am not sure that we could reduce those costs by half, but we
could certainly have a big impact in that reduction.
Mr. Fortenberry. I think as we move forward, particularly in a
legislative year, this is going to be a very important number to try to
quantify. What is the potential improvement of health outcomes as
related to health care costs reductions, particularly in public
programs, that we could see if there were broader investments like we
are all going to talk about today in nutritional outcome.
So if you could continue to parse your data to come down to some
number that--of course, it will depend on a lot of factors, I
understand that--that will be helpful to quantify to get our mind
around what the potential here is, not only just in terms of well-being
of our population, but health care cost outcome.
Another statistic you had mentioned, and you actually addressed it
a bit with Chairman Baca's question, you said 60 percent of adults are
either overweight or obese, 31 percent of children. Now, type 2
diabetes or the rise in it--if I understood you correctly, was
basically unheard of in this particular category of children just a few
short years ago--related directly to the obesity problem, or are there
other factors there?
Dr. Dietz. The main driver is obesity. In the adolescents that I
saw clinically when I was still in Boston, there was generally a family
history which predisposes those individuals to type 2 diabetes----
Mr. Fortenberry. But something must trigger that.
Dr. Dietz. Yes, if they hadn't been obese, that would not have
happened.
Coming back to your question about costs, it occurs to me that we
can provide you with some data from the Diabetes Prevention Program,
which showed that clinical interventions for preventing diabetes were
quite effective, that they lowered the rate of new onset diabetes by
about 60 percent, which was more effective than medication. And I
believe that a cost calculation was done on the cost benefits of that
intervention, but I don't know those data off the top of my head.
Mr. Fortenberry. That would be helpful for us as a Committee. I
think, if I can be presumptuous and suggest that, Mr. Chairman, that we
drive towards some number like that that gives Congress a quantifiable
goal as a measure to potentially reduce costs in the name of health and
well-being.
I want to end--one more question and I will make some editorial
comments. Could you address the benefits of local food markets as
related to a trend toward--or a growing paradigm as we--a new paradigm
as we look to combat obesity and the problem of being overweight? How
helpful will this be?
Dr. Dietz. Well, two slides that I didn't address that are in your
handout include the six target behaviors that we think are going to
change the prevalence of obesity. Chief among those is fruit and
vegetable consumption. We know that people who eat fruits and
vegetables tend to have an earlier satiety, because satiety--fullness--
is regulated by the volume of food, not by the calories in the food,
and fruits and vegetables, because they have a high water content, are
more filling.
One of our interests is in how do we increase fruit and vegetable
consumption, and one key strategy is increasing access. A great example
of that occurred with Kaiser Permanente in northern California, which
instituted fruit and vegetable farmers' markets in all of its major
clinics, and these were located between the parking lot and the clinic.
So employees who passed by could buy fruits and vegetables, patients
who passed by could buy fruits and vegetables, and those fruits and
vegetables were produced by small farms in the Sacramento area. So it
was a ``three-for.'' It benefited employees, it benefited patients, and
it benefits those small farmers.
We believe that farm-to-market programs are an important strategy
for increasing fruit and vegetable intake, and your initiatives in this
regard are to be applauded.
Mr. Fortenberry. Well again, thank you very much for your
testimony. Mr. Chairman, if I could add just right quick, I want to
point out that the gentlelady from Wyoming made some very important
observations. When I was growing up, my mother was an extension
educator, 4-H club leader, and some of these processes that we are
trying to turn the clock back to are so normalized and with lack of
continuity in family life, disconnection from roots in any particular
community, the stresses in modern life, and the sociological factors as
well that are underlying this problem.
Thank you very much for your testimony.
Dr. Dietz. You are welcome.
The Chairman. Thank you. Next, I will call on Dr. Kagen.
Mr. Kagen. Thank you. Thank you for your testimony. I am certain we
shouldn't interpret your testimony to mean that we should blame our
mothers if we are overweight. My mother and father used to tell me that
if it tastes good, it is probably not good for you. I have learned a
great deal on the Agriculture Committee. There are no more hayseeds on
the farm. The farmers will only grow what people are willing and able
to eat. You can't blame someone for trying to make a living producing
food that is good for our economy and good for their businesses,
because if it is not good for business, it will not happen.
A couple of questions for you have to do with your opinion or
perhaps the CDC's opinion about obesity and child abuse. Is it a form
of child abuse to continue to feed children things that are not good
for them?
Dr. Dietz. Yes. Where one draws the line is the challenge, and I am
thinking now about several patients I had when I was in Boston who had
a very significant adverse consequence of their obesity, and those
families, the failure of the family to implement strategies around
weight loss, in my opinion, constituted abuse, and I filed on those
patients.
It is an odd form of abuse because it comes from giving too much
rather than giving too little, and the impact of impaired parenting.
These were parents who generally couldn't set limits on their children.
But the abuse side was that they were overfeeding them, or failing to
regulate their feeding. So yes, at some point, it does become abuse.
There is another interesting relationship in adult obesity related
to your question, and that is that among severely obese adults, there
is a very high prevalence of early abusive behavior, such as physical,
verbal, or sexual abuse. And that suggests that for some core of
severely overweight patients, the kinds of policy initiatives or even
the routine medical therapies are not going to work, that these people
need much more intensive----
Mr. Kagen. Well, this legislative body cannot legislate morality.
It hasn't worked with regard to AIG or the financial markets, so we
have a hard time when it comes to legislating things about good
behavior. We can't legislate how food should taste. We can make
suggestions about what might be good for people, but we also have the
capability and the power to reward people financially for doing the
right thing, and punish people financially for not doing the right
thing.
In that regard, we have taxed cigarettes because they are harmful
to human health, and very costly to our society; we have banned
cigarette advertisements from television. Do you think that same sort
of approach should be taken with regard to the ``fat foods'' or foods
that are not good for our society?
Dr. Dietz. There are a number of states that already are taxing
snacks and sugar-sweetened beverages. Those taxes go into the general
revenue fund. They are not taxes that are designed to discourage
consumption, but there have been proposals to allocate those funds to
improve nutrition and physical activity.
The issue of one of the relationships that is causal, in my
opinion, for childhood obesity is television time. It appears that the
effects of television on childhood obesity are mediated through the
effects of television on childhood food consumption. The more
television a child watches, the more likely they are to consume foods
while watching television, and the more likely those foods are foods
advertised on television. There is an initiative by the--a voluntary
initiative on the part of businesses conducted through the Council for
Better Business Bureaus to limit advertising directed to children and
to establish standards for the products that are advertised to
children. At the moment--and that is to be applauded, and that is
worthwhile, beginning to look at what impact that has.
Mr. Kagen. The other thing we could consider doing, and I would
like to hear your suggestions either now or in writing later, is to
reward families or people who purchase health insurance products or
insurance companies that offer products to reward people financially
for joining the YMCA for exercising. They have been very successful. We
have a Medicare Advantage plan in the Appleton, Wisconsin region that
actually provides for $65 a month savings if you join and attend the
YMCA and actually get some exercise. So I am looking at your point of
view in terms of rewarding people financially for their purchase, or
maybe rewarding people the opposite way for their cigarette smoking and
for their weight.
So I would appreciate your opinion on that.
Dr. Dietz. Sure. We would be happy to give you some feedback on
that. There are two recent papers that were published in the Journal of
the American Medical Association which looked at financial incentives
for weight loss and financial incentives for smoking cessation, both of
which were associated with very positive outcomes. I am not aware that
that has been as carefully studied in the kind of programs that you are
discussing. It has been studied in a more controlled fashion.
Mr. Kagen. Thank you very much.
The Chairman. Thank you very much. The gentlewoman from Wyoming,
Congresswoman Lummis.
Mrs. Lummis. Thank you, Mr. Chairman, and again, Dr. Dietz, thank
you for being here. I want to start by asking you some questions about
the CDC's studies.
Do your CDC studies differentiate between urban and rural areas? Do
you have good data to show the level of activity in rural areas versus
urban areas, and how that may affect obesity, or other factors that
differentiate young people especially in rural and urban areas that
might affect obesity?
Dr. Dietz. Yes. I must confess, we have not done as many of those
analyses as we should, but we do have those data and we can provide you
with data from the adult population on physical activity and fruit and
vegetable consumption.
Our ability to study that is quite limited. There are studies that
demonstrate that people in urban areas do tend to walk more, they are
more physically active, when you think about New York versus rural
Wyoming. And the dietary history, I used to think that while people in
rural areas were more likely to have gardens, more likely to consume
fruits and vegetables, I don't think that is the case, but we can
provide you with more up-to-date statistics on that problem.
Mrs. Lummis. Okay. Thank you, I would appreciate that. That would
be helpful.
What about best practices? Do you have examples around the country
of public-private partnerships that are working, or states or local
communities that have initiated a best practice that you can share with
us?
Dr. Dietz. Sure. That is a critical area, and if you look at our
target behaviors, that is exactly the direction we are following. Those
target behaviors are increased physical activity, breast-feeding, fruit
and vegetable consumption, reductions in sugar-sweetened beverages,
reduction in high energy density foods, and reductions in television
time. The process that we are engaged in, which we hope to complete in
the next couple of months, is to identify policy or environmental
strategy that address those behaviors, and many of those would fall
into your promising practices or best practices category. Some of them,
like the New York City group daycare policy, we are in the process of
evaluating, so we will have some really hard data.
The Guide for Community Preventive Services, which is a CDC
publication, has identified recommended practices in the area of
physical activity. We have very sound data on best practices within--to
promote breast-feeding, like baby-friendly hospitals, lactation
consultants, strategies like that. Our strategies in the other areas
are less well-developed, but that is what we are trying to accomplish.
To your public-private partnership question, one of the most
notable is that my division at CDC is the Federal authority on the new
Fruits and Veggies, More Matters campaign, and that is a public-private
partnership with the Produce for Better Health Foundation representing
the industry side. There are also a number of non-governmental
organizations like the American Cancer Society and American Heart
Association that are members of that, and it is a natural partnership
because we are all interested in promoting increased fruit and
vegetable intake.
Mrs. Lummis. Thank you. Mr. Chairman, a couple more questions.
In Wyoming, we had a terrible methamphetamine problem, terrible,
and some substance abuse problems, unrelated to meth, that were rising,
alcohol being the largest. And so Wyoming went on this incredible
message campaign to just bombard people where they get their messages
about the hazards of, particularly, drunk driving and of meth, and the
hazards of trying meth once. And they really have had a dramatic impact
on meth use, meth arrests, and they are beginning to have an effect on
drunk driving because we saw such a positive response with regard to
this intensive meth campaign. But now we are seeing it with regard to
drunk driving as well.
I wonder if that might work for food, where every time you turn on
the TV or a radio or a billboard or you drive by a building that has a
wall, you are bombarded with that message. Any response to that idea?
Dr. Dietz. Sure. One of the best public health campaigns ever was
the VERB campaign conducted by the CDC. This was a paid advertising
campaign to promote physical activity in 'tweens, that is, 9 to 13
year-olds. That program was successful in increasing the physical
activity levels of the target population, but it was a very expensive
campaign. And as with any behavior change information campaign, it has
to be continuous, because the population is constantly cycling.
Although the VERB campaign was a fabulous piece of work, our focus on
policy and environment, we think, will be just as effective because
once a policy is in place, you don't have to continually put money into
the implementation of that policy. It changes behavior long-term. I
would love to have the capacity to do a campaign around food,
particularly fruits and vegetables.
Mrs. Lummis. Thank you.
The Chairman. Thank you very much for the question. Next, the
gentleman from Oregon, Congressman Schrader.
Mr. Schrader. Thank you, Mr. Chairman.
I guess just mostly following up on some of my colleagues, I see a
trend, at least it seems, in some of the questions about best practices
and trying to identify where the biggest bang for the buck is. You have
alluded to it yourself, and to the extent you can provide this panel
over the course of this session and sessions to come, it would be very
helpful. I know in the State of Oregon, we have a tremendous obesity
problem, despite our outdoor mantra, and that has been a great concern.
And as a state legislator, it was always difficult to choose among all
these different strategies, which ones were to be most cost effective,
and certainly right now, we face some budgetary issues. So, the more
direction CDC and others can provide us, that would be very helpful.
A question I have for you, and perhaps some of the other panelists
to come, would be about some of the programs that we do have in terms
of nutrition and trying to provide the nutrition, such as our SNAP
program, such as WIC. Are there some suggestions you would have for us
in terms of the types of food and access to beverages, and what have
you, that we should put into these programs where you can get some
things, can't get others? You said you can't even control that,
frankly, but I would be curious about your thoughts.
Dr. Dietz. There was an important report issued by the Institute of
Medicine 2 years ago called ``Nutrition Standards for Foods in Schools:
Leading the Way Toward Healthier Youth,'' which had a number of
recommendations about how school nutrition programs should be changed.
One of the most important recommendations was to make the competitive
foods consistent with the dietary guidelines for Americans. This would
encourage fruits and vegetables, 100 percent fruit and vegetable
juices, whole grain products, and non-fat or low-fat dairy products,
and limit foods sold after school to those that meet certain standards
consistent with the dietary guidelines, like those with less than 200
calories per serving, less than 35 percent of calories from fat, free
of trans fat, less than 35 percent of total sugars, and sodium of less
than 200 milligrams per portion. If those were implemented, they would
go a long way towards improving the nutrition in schools.
The revision of the WIC food package is also an important step
forward to make that package much more consistent with the dietary
guidelines as well.
Mr. Schrader. Very good. I yield back the rest of my time, Mr.
Chairman.
The Chairman. Thank you very much. Next, I have the gentlewoman
from Pennsylvania, Mrs. Dahlkemper.
Mrs. Dahlkemper. Thank you, Mr. Chairman.
Mr. Dietz, I wanted to ask you about the correlation between obese
children and their parents, and what you see in terms of the genetic
versus the environmental aspects of that.
Dr. Dietz. Well, there certainly is an association. Part of it is
genetic, part of it is the shared environment. We did a study of
patients and families that were in group health a number of years ago,
and showed that the highest risk for adult obesity--there was a higher
risk for adult obesity among children who were born to two obese
parents. There was about a five-fold increased risk. There was also, on
the individual side, a rising risk as those children grew that
eventually exceeded the risk of parental obesity. So both are in play.
Some estimates suggest that as much as 60 percent of the family
association of obesity is genetically mediated. That doesn't mean that
the solution is changed. The number of genes that affect obesity seems
to increase almost daily, and I am not sure that an investment in the
medications that address those gene products is going to be any
cheaper. In fact, it is likely to be much more expensive than a focus
on the environment that promotes increased food intake and reduced
physical activity.
Mrs. Dahlkemper. I guess part of my question is as we have seen the
level of obesity rise in our adult population, how has that correlated
with our rise in childhood obesity? Did it take some time for it to
catch up where you see that correlation?
Dr. Dietz. The rise among certain groups of adults has paralleled
that in the pediatric population. It is not--only about 25 percent of
adult obesity, according to one of our studies, is accounted for by
childhood obesity. The disproportionate contribution of childhood
obesity is to the severity of adult disease, so even though it is a
minority of adult disease, it accounts for a much greater proportion of
severe adult obesity. Five percent of the adult population have a BMI
over 40, which is 100 pounds or more overweight, and about \1/2\ of
that population is attributable to childhood onset obesity.
Mrs. Dahlkemper. Okay. One of your recommendations--in fact, the
first one here was to increase breast-feeding initiation and duration
and exclusivity with early intervention, that was the birth to 3 years
of age population. But by the time I would see that parent and that
child, this issue was off the table. They had either decided to breast-
feed or they had not. So, what do you see as some initiatives we could
take in that area? What have you seen successfully done here in terms
of----
Dr. Dietz. Well, baby-friendly hospitals, those which don't
routinely make formula available to mothers immediately following the
birth of their infants have a higher rate of ongoing breast-feeding,
both initiation and duration. A major falloff in breast-feeding occurs
about the time that women go back to work, so equipping worksites with
lactation rooms and fostering opportunities for new mothers to pump
their breasts to store the milk are essential.
As you undoubtedly know, in many places women use the ladies' room
as a place to pump their breasts and to store breast milk. I can't
think of any other food that is prepared in a restroom. To me, that is
criminal.
So those types of strategies, peer support, lactation consultants,
because although breast-feeding is the natural way to feed infants, it
is often unnatural for mothers to initiate breast-feeding, particularly
with their first infant. So additional support and counseling, both
within delivery rooms and the delivery wards, and as well as following
discharge is essential.
Those are all policy initiatives that would promote breast-feeding.
Mrs. Dahlkemper. I think it is a very important piece here, and as
a mother of five, I can tell you it often was not convenient and it
often was not well-accepted or encouraged, and that is very central to
the issue of so many new mothers. If they don't have that support
there, either in the hospital or shortly thereafter, then they only
breast-feed for a very short time. And having some kind of support
system available to them shortly after, because that becomes the
toughest time, and then as you say, once they return to work--and I am
one of those mothers who went back to work and continued to breast-feed
for a year, so I am a very big proponent of this, but I wanted to have
you address that, so I appreciate that.
I have just a few seconds left here in my time, and I have a lot of
other questions. I guess one of the things I want to make a comment on,
I heard a report of a mother who let her child walk \9/10\ of a mile to
a sporting event and was met by the police at that field when she
showed up 20 minutes later, because she had let her 10 year-old walk
and supposedly endangered her child. I think this is a huge issue as we
go forward. I am in a community where most people drive everywhere,
whether it is three blocks to the convenience store, and when you are
in a city like Washington or New York City people walk more. So I go
back to Ms. Lummis's point on that, that we really need to look at
that.
Anyway, my time is up. Thank you.
The Chairman. Thank you very much. Next, I will recognize the
gentleman, for 5 minutes, from Mississippi, Mr. Childers.
Mr. Childers. Thank you, Mr. Chairman, and Dr. Dietz, thank you for
being here. Before I begin what I wanted to ask you, you made a comment
earlier and I wanted you to repeat that. I missed part of it. You
mentioned something about people's BMI index over 40--would you repeat
what you said? I missed it.
Dr. Dietz. Yes. About five percent of the adult population have a
body mass index over 40; that is about 100 pounds overweight, and about
\1/2\ of that group were obese as young children. So early childhood
obesity or childhood obesity, even though it accounts for only about 25
percent of adult disease, is associated with an increase in the
severity of adult disease.
Mr. Childers. What portion of that five percent--is that only of
adults or children today--how many children, I guess, are we seeing as
a society with that high of a BMI?
Dr. Dietz. Very few, because the cut point for obesity in children
and adolescents is based on percentiles rather than an absolute number,
because children are growing and their BMI increases with age. But one
of the useful cut points is the 99th percentile for BMI, maybe a more
robust cut point is the 97th percentile. There about eight percent of
the pediatric population somewhere in that neighborhood, and I can
assure you that we are actually working on the precise number, are in
that category which would correspond to the severe adult obesity. So
that bodes ill for the future. Those are the kids that are going to
be--that already have multiple complications, because we know that even
in childhood the more severe obesity, the more likely you are to have
those cardiovascular disease risk factors that I mentioned, and those
are only going to increase and become diseases as those children grow
and as their obesity becomes more severe.
Mr. Childers. Thank you. I want to just state this, for the third
year in a row, my state, Mississippi, has the highest rate of obesity
in the nation. That is not something I am proud of, but it is a fact
nevertheless. And almost 70 percent of our state's adult population is
overweight. One quarter of the state's school age children are
overweight.
Over the past several years, our state, recognizing that, has
implemented several programs in schools and communities, quite frankly,
to try to combat childhood obesity, and they have had varying degrees
of success. I guess the question I wanted to ask you was which types of
programs are you finding to be the most successful in reducing
childhood obesity, especially in rural communities, because we are a
rural state and my district is rural.
Dr. Dietz. I can't answer that question for rural communities. In
fact, Mississippi is a place where we hope to learn some of those
answers. As you know, CDC is funded to develop a project in the Delta.
I mentioned earlier the work that the Bowers Foundation is doing in
northern Mississippi. What those programs need is a careful evaluation
to determine what works.
We know from other community studies that multi-disciplinary and
multi-sectoral approach with more than just one strategy is most likely
to be effective, and I mentioned Somerville, Massachusetts, as one good
example of that. But if you target any single one of the behaviors that
we think are relevant, we don't believe that that alone is going to
turn the tide of obesity. It is not going to make a difference. You
have to have a comprehensive, multi-sectoral program if we are going to
succeed at this. And the experience from communities which are
successfully beginning to control obesity worked. Another good example
is El Paso, Texas, which was supported by the Paso del Norte Health
Foundation, and they coupled a catch program, an intervention within
schools with a walking program in the community and cooking lessons for
moms. In this predominantly Hispanic population, they showed a
successful reduction in the prevalence of obesity, particularly among
younger children who were exposed to that program for a longer period
of time.
Mr. Childers. On a lighter note, it has been within only my adult
lifetime in Mississippi that we learned you can cook chicken in a
manner that is not frying it. We have learned that.
The Chairman. Thank you very much. I noted the time and I would
like to thank Dr. Dietz for your testimony here today. I think it was
very informative for a lot of us, especially as we address the area of
obesity. One of the areas that we would love to follow up on, because
as we look at the bill that we are going to have on health issues, and
looking at the cost factors and looking at how we may be able to reduce
that. Ultimately we, the taxpayers, end up having to pay for someone
else. And if we can do more of the prevention and education that needs
to be done, especially, at different ages, and diversity and the impact
they have, it tells us that we still need to do a lot more in these
areas.
Again, Dr. Dietz, thank you very much for coming here.
What we will do now is call on the next panel to come up, because
they will be calling votes shortly. What we will do is we will have the
panelists go through and give their testimony, and each one of you will
have 5 minutes, and then after that, we will proceed with any kinds of
questions if a vote is not called.
So if the other panelists can come forward? And in the interest of
time, we will start with Anne Wolf, and introduce yourself and who you
represent, and then we will do the same with each one when we get to
you, in the interest of time.
STATEMENT OF ANNE M. WOLF, M.S., R.D., INSTRUCTOR OF
RESEARCH AND ICAN INTERVENTION TEAM LEADER,
UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE,
CHARLOTTESVILLE, VA
Ms. Wolf. My name is Anne Wolf. I am from the University of
Virginia School of Medicine. Thank you for inviting me to speak today,
Congressman Baca and Members of the Subcommittee. Testifying before
this Subcommittee is particularly important for me, because as one of
three children, raised by a single mother, we relied on food stamps
during a couple times. I am particularly grateful to the government for
really helping our family out during tough times, because it really did
make a difference. While we didn't have much, I never went hungry and I
was really able to focus on my schoolwork, and that eventually led me
into Cornell University and the Harvard School of Public Health, and
into the career of fighting obesity. And so I am honored today to
testify in front of you about the economic costs of obesity.
There are now well over 120 published studies on the cost of
obesity and the cost effectiveness of treatment of obesity. Studies
consistently demonstrate five important things.
The first is that the cost of obesity is significant to our health
care bill in the United States.
Second, the cost is driven by obesity severity, its prevalence, as
well as its relationship to chronic disease.
Third, the government is paying a huge percentage of this health
care bill.
Fourth, employers are hit particularly hard, because not only does
obesity increase health care costs, but it impacts productivity and
disability.
And fifth, there is treatment that is effective and cost effective.
The direct cost of obesity inflated to 2008 dollars is
approximately $77 to $118 billion a year. This is approximately 1.7
times the cost of stroke and 1.4 times the cost of hypertension in the
United States. Obesity outranks both smoking and problem drinking in
its deleterious effects on health and on health care costs. In
addition, 39 million workdays are lost, 239 million restricted activity
days, and 89 million bed days are lost or attributable to obesity in
1994.
Higher medical expenses are associated with the severity of excess
weight. As body weight increases from overweight to obese, severe
obesity, health care costs rise. Per capita medical spending for people
who are overweight are 14 percent higher, for people who are obese, it
was 47 percent higher, and for those who are severely obese, their
health care expenses were doubled compared to people with a healthy
body weight.
The rise in health care expenditures is found across every single
type of service, from inpatient utilization to outpatient services, to
procedures, to increased pharmaceutical use. Among children, the
proportion of hospital discharges with obesity-related diseases
increased dramatically from 1979 to 1999. A recent report identified
that the growing prevalence of obesity as a primary factor responsible
for the growth of private health care spending between 1987 and 2002
were the primary factors.
The cost of obesity is not due to treatment costs. Obesity is not
systematically treated in our medical care setting. One of the reasons
for that is that it is not systematically reimbursed by CMS or any
major health insurance companies. Most people who seek treatment have
to pay for the majority of their expenses out-of-pocket right now.
If we want to look at the costs by the type of payer, Medicare and
Medicaid are paying the largest percentage, 48 percent of the cost of
obesity that the government is paying. These costs are particularly
high among the older population, because obesity is so highly
associated with chronic diseases. For instance, in basic terms, obesity
plus age is equal to chronic illness.
If you look at excess medical care expenditures for a mildly obese
person from age 65 to the time that they die, that person will incur an
additional $20,000 to $50,000 of excess medical expenditures, compared
to someone who had a healthy body weight. Again, it is Medicare that is
picking this up.
Now, employers are hit particularly hard. Employers as diverse as
General Motors, Bank One, and Shell Oil have all demonstrated within
their populations that excess weight has increased their direct medical
care costs as well as impacted productivity and disability. The
combined direct and indirect per capita costs of obesity to the
employer range from approximately $175 to $2,000 among men, and
approximately $600 to $2,200 in women; that is per person costs.
Worksite injuries are also significantly increased. For instance, low
back injuries were 1.4 times higher, and musculoskeletal injuries were
1.5 times higher among obese employees compared to healthy weight
employees.
As Members of this Subcommittee, you really want to know what type
of legislation would help address the obesity epidemic in a cost
effective manner. Legislation to encourage positive food choices by
targeting food stamp benefits towards healthy but under-consumed foods
like fruits and vegetables----
The Chairman. Ann, if you can sort of wrap it up. Each one has 5
minutes, and we are about ready to get out and vote.
Ms. Wolf. Yes, this is it--would encourage consumption of more
fruits and vegetables.
Last, there is evidence of intervention and medical nutrition
therapy is not only effective, but cost effective in high risk
populations.
In summary, the cost of obesity is--in terms of both financial and
human costs. The financial costs are born disproportionately by the
Federal Government, but are felt keenly by employers. Most important
are the personal costs incurred by the obese patient. There is a
desperate need to disseminate programs with proven effectiveness to
combat the financial, medical, and personal costs of obesity.
[The prepared statement of Ms. Wolf follows:]
Prepared Statement of Anne M. Wolf, M.S., R.D., Instructor of Research
and ICAN Intervention Team Leader, University of Virginia School of
Medicine, Charlottesville, VA
The Economic Impact of Obesity
Congressman Baca and Congressional Members of the Subcommittee on
Department Operations, Oversight, Nutrition, and Forestry,
Thank you for inviting me to testify today on the economic impact
of obesity in the United States. Testifying before this Subcommittee is
particularly important to me. As one of three children raised by a
single mother, I and my family relied on both food stamps as well as
the free school lunch program. I am deeply grateful to the government
for helping our family during those tough times, and it did make a
difference. While we didn't have much, I never went hungry and was able
to focus on my school work, which eventually gained me entrance into
Cornell University and the Harvard School of Public Health, and from
there into the fight against obesity. So, I am honored today to testify
in front of you about the economic impact of obesity.
Government, health care, and business leaders are concerned by the
marked increase of overweight and obesity in the United States and the
resulting impact on our nation's health, health care costs, and
productivity. Most concerning is that excess weight carries major
health risks. These conditions are associated with high costs,
including both the direct costs of medical care and the indirect costs
of lost productivity and disability. A recent report identified the
growing prevalence of obesity as one of the primary factors responsible
for the growth of private health care spending between 1987 and 2002.
There are over 120 articles published in peer-reviewed, scientific
journals related to the cost of obesity and cost effectiveness of
treatment. These studies consistently demonstrate five important
findings: first, the direct cost of obesity is dramatic and contributes
significantly to our rising health care costs; second, the cost is
driven by obesity's high prevalence and its relationship to chronic
disease; third, the government is paying the largest percentage of the
health care bill related to obesity; fourth, employers are hit
particularly hard because obesity impacts both health care costs and
productivity; and fifth, some treatments are both effective and cost-
effective.
The most recent direct cost, inflated to 2008 dollars, estimates
that at a national level, obesity (including overweight) costs the
United States $77.3 to $117.8 \1\ billion a year, accounting for 9.1%
of the national health care expenditure (in 1998, the year the analysis
was undertaken). This is approximately 1.7 times the cost of stroke and
1.4 times the cost of hypertension in America. Obesity outranks both
smoking and problem drinking in it deleterious effects on health and
health care costs. In addition, 39.2 million work days, 239 million
restricted activity days and 89.5 million bed days were attributable to
obesity in 1994, the last time this analysis was undertaken.
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\1\ Includes nursing home costs.
---------------------------------------------------------------------------
Higher medical expenses are associated with the severity of excess
weight--as body weight increases from overweight to obese to severe
obesity, health care expenses rise. Per capita medical spending
increases among the overweight by 14.5%, among the obese by 37.4% and
by 100%--or doubled--among the severely obese, compared to people with
a healthy body weight. The rise in health care expenditures with higher
weight occurs across all of the major categories of health care
services. Obesity has been associated with higher inpatient utilization
as well as more outpatient services, procedures and prescription
medication use. Among children (age 6-17 years), the proportion of
hospital discharges with obesity-related diseases increased
dramatically from 1979 to 1999. The cost of obesity is not due to
direct treatment costs--obesity is not systematically treated in the
medical setting because it is not systemically reimbursed by CMS or
health insurance companies. Most people who seek treatment have to pay
out of pocket for the majority of their expenses.
If one looks at cost by type of payer (private, out-of-pocket, and
government-sponsored), Medicaid and Medicare combined pay the largest
percentage--48%--of the cost of obesity. The costs of obesity are
particularly high among the older population because chronic medical
conditions such as diabetes and heart disease are so highly associated
with excess weight and advancing age. In basic terms, obesity + age =
chronic illness. If you look at excess Medicare expenditures for a
mildly obese person [among a person with a body mass index (BMI)
between 30-35 kg/m2,] from age 65 to death, that person will
incur approximately $20,000-$50,000 additional dollars compared to
someone with a healthy body weight.
The costs of obesity to the employer are even more substantial
since obesity is associated not only with higher health care costs but
also with greater rates of lost productivity, disability and earlier
mortality. Employers as diverse as General Motors, Bank One and Shell
Oil have all demonstrated that excess weight is associated with lost
productivity and greater medical and disability costs. Aggregating the
direct and indirect costs of obesity to the employer the additional per
capita costs to the employer due to excess weight ranged from $175
[(overweight)] to $2,027 [(class III obesity)] in men and $588
[(overweight)] to $2,164 [(class III obesity)] in women, depending on
the degree of overweight and obesity. Obesity also imposes limitations
while at work. Data from the 2002 National Health Interview Survey
(NHIS) show that 6.9% of obese workers have work limitations, compared
with 3.0% of workers with a healthy body weight. Worksite injuries are
also significantly higher among overweight employees; low back injuries
were 1.42 times higher and non-back musculoskeletal injuries were 1.53
times higher among overweight and obese employees compared with
employees with a healthy body weight. Last, overweight and obesity is a
significant predictor of transition from short-term to chronic back
pain. Overweight employees have a 56% greater chance for developing
chronic back pain and obese employees have an 85% greater risk compared
with healthy-weight employees.
As Members of this Subcommittee, you may want to know what type of
legislation would help address the obesity epidemic in a cost effective
manner, given your charge with food stamps and oversight of
agriculture. There is evidence that lifestyle intervention--education
and behavior change programs to improve diet quality and increase
physical activity with resultant weight loss--is cost effective in high
medical risk populations. There is also evidence that the addition of
medical nutrition therapy to usual medical care can reduce health care
costs, improve absenteeism and disability, and have a positive return
on investment. For example, from the work we have done at the
University of Virginia, for every dollar spent on lifestyle
intervention with a registered dietitian among people with obesity and
diabetes, there is a $14.58 return on investment.
In summary, the cost of the obesity epidemic is enormous, in terms
of both the financial costs and human costs. The financial costs are
borne disproportionately by the Federal Government, but are felt keenly
by employers as well. Most important are the personal costs to the
individual suffering from obesity. There is a desperate need to
promulgate programs with proven effectiveness to combat the financial,
medical, and personal costs of obesity.
Relevant Published Papers
1. Daviglus M.L., Liu K.L., Yan L.L., Pirzada A., Manheim L.,
Manning W., Garside D.B., Wang R., Dyer A.R., Greenland P.,
Stamler J. Relation of body mass index in young adulthood and
middle age to Medicare expenditures in older age. JAMA.
2004;292(22):2743-2749.
2. Finkelstein E.A., Fiebelkorn I.C., Wang G. National medical
spending attributable to overweight and obesity: How much, and
who's paying? Health Aff. 2003;W3:219-226.
3. Finkelstein E.A., Fiebelkorn I.C., Wang G. State-level estimates
of annual medical expenditures attributable to obesity. Obes.
Res. 2004;12(1):18-24.
4. Sturm R. The Effects of Obesity, Smoking and drinking on medical
problems and costs. Obesity outranks both smoking and drinking
in its deleterious effects on health and health costs. Health
Aff. 2002;21:245-253.
5. Thorpe K.E., Florence C.S., Howard D.H., Joski P. The impact of
obesity on rising medical spending. Health Aff. 2004;W4:480-
486.
6. Wee C.C., Phillips R.S., Legedza A.T.R., Davis R.B.; Soukup
J.R., Colditz G.A., Hamel M.B. Health care expenditures
associated with overweight and obesity among U.S. adults:
importance of age and race. Am. J. Public Health.
2005;95(1):159-165.
7. Wolf A.M., Colditz G.A. Current estimates of the economic cost
of obesity in the United States. Obes. Res. 1998;6:97-106.
8. Wang G., Dietz W.H. Economic burden of obesity in youths aged 6
to 17 years: 1979-1999. Pediatrics. 2002;109(5):E81-1.
9. Wang G., Dietz W.H. Economic Burden of Obesity in Youth age 6-17
years: 1979-1999. Pediatrics 2002;109:81-87.
Indirect Cost Related To Obesity
1. Burton W.N., Chen C.Y., Schultz A.B., Edington D.W. The Economic
Costs Associated With Body Mass Index in a Workplace. J. Occup.
Environ. Med. 1998;40(9):786-792.
2. Tucker L.A., Friedman G.M. Obesity and absenteeism: An
epidemiologic study of 10,825 employed adults. Am. J. Health
Promot. 1998;12:202-207.
3. Finnkelstein E.A., Fiebelkorn I.C., Wang G. The Costs of Obesity
among Full-time Employees. Am. J. Health Promot. 2005;20:45-51.
Obesity Intervention: Lifestyle Intervention Cost Analyses
1. Herman W.H., Hoerger T.J., Brandle M., et al; Diabetes
Prevention Program Research Group. The cost-effectiveness of
lifestyle modification or metformin in preventing type 2
diabetes in adults with impaired glucose tolerance. Ann.
Intern. Med. 2005;142:323-332.
2. Wolf, A.M., Siadity, M., Yaeger, B., Conaway, M.R., Crowther
J.Q., Nadler, J.L., Bovbjerg, V.E. Effects of Lifestyle
Intervention on Health Care Costs: The ICAN Project. J. Am.
Diet. Assoc. 2007;107(8):1365-73.
3. Wolf, A.M., Siadity, M., Crowther J.Q., Nadler, J.L., Wagner
D.L., Cavalieri S., Elward K., Bovbjerg, V.E.: Impact of
Lifestyle Intervention on Lost Productivity and Disability:
Improving Control with Activity and Nutrition (ICAN) JOEM
2009;51:139-145.
4. Wolf A.M., Crowther J.Q., Nadler J.L., Bovbjerg V.E. The Return
on Investment of a Lifestyle Intervention: The ICAN Program.
Accepted for presentation at the American Diabetes Association
69th Scientific Sessions (169-OR), 7 June, 2009, New Orleans,
Louisiana.
Food Stamps and Obesity
1. Food Stamps and Obesity: What We Know and What It Means at
http://www.ers.usda.gov/AmberWaves/June08/Features/
FoodStampsObesity.htm.
2. Improving Food Choices--Can Food Stamps Do More? at http://
www.ers.usda.gov/AmberWaves/May07SpecialIssue/Features/
Improving.htm.
3. Gleason, Philip M., Allison Hedley Dodd. School Breakfast
Program but not School Lunch Program participation is
associated with lower body mass index. Journal of the American
Dietetic Association, 2009. Vol. 109 (2,S1):S118-128.
4. Ver Ploeg, M., L. Mancino, B-H. Lin and J.F. Guthrie. U.S. Food
Assistance Programs and Trends in Children's Weight.
International Journal of Pediatric Obesity, 3(1):22-30, 2008.
The Chairman. Thank you very much. Next, we will have
Richard Hamburg, Director of Governmental Relations, Trust for
America's Health, in Washington, DC.
STATEMENT OF RICHARD S. HAMBURG, DIRECTOR OF
GOVERNMENT RELATIONS, TRUST FOR AMERICA'S HEALTH, WASHINGTON,
D.C.
Mr. Hamburg. Good morning, everyone. I would like to thank
the Chairman, Ranking Member, and Members of the Subcommittee
for the opportunity to testify on a very serious issue, our
nation's obesity epidemic. Glad to see it was the first hearing
of the year for this panel.
To examine obesity rates and policies each year, Trust for
America's Health publishes a report on obesity entitled ``F as
in Fat, How Obesity Policies Are Failing in America.'' Our 2008
report found that adult obesity rates increased in 37 states in
the past year. No state saw a decrease. In addition to the
serious health impacts associated with this disease, for
example, type 2 diabetes rates, rose in 26 states. According to
the Department of Health and Human Services, obese and
overweight adults cost the U.S. anywhere between $70 and $117
billion each year.
The current rise in food prices, coupled with the economic
recession, raises serious concerns about obesity as the high
cost of many healthful foods can be prohibitive for some
Americans. In fact, nutritionists are now worried that
Americans will put on so-called ``recession pounds,'' pointing
to studies linking obesity and unhealthy eating habits to low
income.
The problem is so far reaching it is becoming a problem for
our overstretched military. Just this week, the Department of
Defense reported that one in five military-aged Americans are
too overweight to qualify for the Armed Services. That is
48,000 overweight recruits that have been turned away, just
since 2005.
Unfortunately, as in many other health problems for our
nation, obesity often disproportionately affects minorities and
the poor, partly due to the fact that calorie-dense foods tend
to be less expensive. In addition, access is a serious problem,
as many families live in communities as we have heard referred
to as food deserts, because they do not have access to healthy
foods and mainstream grocery outlets.
To address this problem, innovative organizations, such as
the Food Trust, have been working to increase access to
nutritious foods in underserved communities. The Food Trust
provided policy recommendations that led to the creation of the
Pennsylvania Fresh Food Financing Initiative, a grant and loan
program to encourage supermarket development in underserved
neighborhoods throughout the state. The initiative has
committed more than $67 million for 69 supermarket projects in
27 Pennsylvania counties, also creating and preserving 3,900
jobs.
We must continue to build upon this progress and build upon
the work of this Committee by providing financial incentives
for supermarkets in low-income neighborhoods with little access
to healthy foods, encouraging farmer's markets to accept SNAP
electronic benefits cards, WIC vouchers and senior farmers
market nutrition program vouchers, and work with schools to
improve healthy options.
Obesity is a multi-faceted problem with diverse causes and
impacts across all sectors of society that has taken decades to
become a full-fledged epidemic. To begin to mitigate and
ultimately reverse this epidemic, we will need a sustained
commitment over time to invest in population-based prevention
strategies and coordinate our efforts. We need a cultural
shift, one in which healthy environments, physical activity and
healthy eating become the norm.
This past July, Trust for America's Health released a
report entitled ``Prevention for Healthy America,'' which
examined how much the country could save by strategically
investing in community disease prevention programs. The report
concludes that an investment of $10 per person each year,
improving community-based programs to increase physical
activity, prevent smoking and other tobacco use, sound
nutrition could save the country more than $16 billion annually
within 5 years. We must invest in effective evidence-based
community-based prevention programs, promote increased physical
activity, and sound nutrition.
Now, while states and localities have been hard at work,
and currently, 40 states have plans and strategies to lower the
prevalence of overweight and obesity-related chronic diseases,
no such national strategy currently exists at the Federal
level. We strongly support 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. In fact,
Representatives Towns and Granger will be reintroducing a bill
that encompasses this recommendation in the coming weeks, and I
encourage support for this approach.
In 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 difference in people's health, and that
individuals don't make decisions in a vacuum. If we want
Americans to lead healthy, productive lives, we need a strong
partnership with government, private, and non-profit sectors as
well as parents and teachers to emphasize wellness and enhanced
physical activity. We need to remove barriers to healthful
living by making healthy choices easy choices by creating
opportunities for exercise and healthy living. The challenge is
a big one, but we can make a difference together.
Thank you again for the opportunity to testify here today.
[The prepared statement of Mr. Hamburg follows:]
Prepared Statement of Richard S. Hamburg, Director of Government
Relations, Trust for America's Health, Washington, D.C.
Good afternoon. My name is Richard Hamburg, and I am the Director
of Government Relations for 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--our nation's obesity epidemic.
Today I would like to discuss the scope of 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.
Scope of the Problem
Adult Obesity
Approximately \2/3\ of American adults are obese or overweight. To
examine obesity trends each year, TFAH publishes a report on obesity
entitled ``F as in Fat: How Obesity Policies Are Failing in America.''
The 2008 report, based on the Centers for Disease Control and
Prevention's (CDC's) Behavioral Risk Factor Surveillance Survey (BRFSS)
2005-2007 data, found that adult obesity rates increased in 37 states
in the past year. No state saw a decrease. More than 25 percent of
adults are obese in 28 states, and more than 20 percent of adults are
obese in every state except Colorado. A study published in the July
edition of Obesity estimates that 86 percent of Americans will be
overweight or obese by 2030.
Childhood Obesity
Overall, approximately 23 million children are obese or overweight,
and rates of obesity have nearly tripled since 1980, from 6.5 percent
to 16.3 percent.\1\ Eight of the ten states with the highest rates of
obese children are in the South.\2\ 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 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. 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.\4\
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\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).
\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).
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Impacts of Obesity
Health Impacts
Obesity and overweight are associated with a number of serious
chronic conditions. More than 80 percent of people with type 2 diabetes
are overweight. People who are overweight are more likely to suffer
from high blood pressure, high levels of blood fats, and high LDL
(``bad'') cholesterol--all risk factors for heart disease and stroke.
Obesity is a known risk factor for the development and progression of
knee osteoarthritis and possibly osteoarthritis of other joints.
Obesity may increase adults' risk for dementia and may increase the
risk of developing several types of cancer.
The health impacts of obesity 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.\5\ Some studies have shown that obesity and
overweight in children also negatively affect children's mental health
and school performance.
---------------------------------------------------------------------------
\5\ U.S. Department of Health and Human Services (USDHHS). The
Surgeon General's Call to Action to Prevent and Decrease Overweight and
Obesity. Washington, D.C.: USDHHS, 2001.
---------------------------------------------------------------------------
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 U.S. anywhere from $69 billion to $117 billion per
year.\6\ 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.\7\
---------------------------------------------------------------------------
\6\ 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).
\7\ 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.
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.\8\ 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.\9\
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\8\ 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.
\9\ 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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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--Americans 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 placed kids in a less nutritious environment--it is
not just too much food, but too much unhealthy 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
Americans, 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.
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 and
in the workplace.
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 website,
www.healthyamericans.org, and provides a more comprehensive look at
these issues. The 2009 edition will be released in a few months.
Nutrition
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,\10\ and
adolescent females ages 12-15 consumed approximately four percent more
calories in 1999-2000 than they did in 1971-1974.\11\ In 2003, a USDA
report characterized America's per capita fruit consumption as
``woefully low'' and noted that vegetable consumption ``tells the same
story.'' \12\ Moreover, since the 1970's, fast food consumption in
children has increased five-fold. In the late 1970s, children received
approximately two percent of their daily meals from fast food; by the
mid-1990s, that increased to ten 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.\13\
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\10\ 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.
\11\ Briefel, R.R. and C.L. Johnson. ``Secular Trends in Dietary
Intake in the United States.'' Annual Review of Nutrition 24, (2004):
401-431.
\12\ 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.
\13\ 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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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. 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).\14\ USDA contracted
with the Institute of Medicine (IOM) to convene a panel of experts on
child nutrition. The IOM Committee on Nutrition Standards for School
Lunch and Breakfast Programs will 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. A final rule will take even
longer to be issued. This delay is of considerable public health
concern. As this process develops, TFAH urges schools to begin to work
towards implementation of the most recent DGAs.
---------------------------------------------------------------------------
\14\ U.S. Department of Agriculture (USDA). Incorporating the 2005
Dietary Guidelines for Americans into School Meals. SP 04-2008.
Washington, D.C.: 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.\15\ Black and Hispanic adolescents have higher rates of physical
inactivity (by 5-6 percentage points).\16\
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\15\ 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.
\16\ 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% 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 children (17% who were under
100 percent of poverty engaged in no vigorous physical activity each
week; only 7.8% of those at 400% of poverty fell into that category).
Lack of access to nutritious foods is one obstacle to healthy
eating in some low-income communities. Supermarkets are less likely to
be accessible in poor neighborhoods, and many families live in
communities referred to as ``food deserts'' because they do not have
access to healthy foods and mainstream grocery outlets. To address this
problem, innovative organizations such as the Food Trust have been
working to increase access to nutritious foods in underserved
communities. The Food Trust provided policy recommendations to the
Pennsylvania legislature regarding access to supermarkets in low-income
communities. As a result, the legislature created the Pennsylvania
Fresh Food Financing Initiative, a grant and loan program to encourage
supermarket development in underserved neighborhoods throughout the
state. The Fresh Food Financing Initiative has committed more that $67
million in funding for 69 supermarket projects in 27 Pennsylvania
counties, creating or preserving 3,900 jobs.\17\ We must continue to
build on this progress by providing financial incentives for
supermarkets in low-income neighborhoods with little access to healthy
foods; encouraging farmers' markets to accept SNAP Electronic Benefits
cards, WIC vouchers and Senior Farmers' Market Nutrition Program
vouchers; and working with schools to improve healthy options through
Federal meal programs.
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\17\ The Food Trust. ``Supermarket Campaign.'' http://
www.thefoodtrust.org/php/programs/super.market.campaign.php.
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Even when healthy foods are readily available, eating healthier can
be very expensive, whereas calorie dense foods tend to be less
expensive. The current rise in food prices, coupled with the economic
recession, raises serious concerns about obesity. For example, a recent
study in the UK by Which?, a consumer group, found that 24 percent of
UK adults feel healthier eating is now less important, with 56% saying
price has overtaken as a priority when choosing food.\18\ Similarly, in
the U.S. nutritionists are worried that Americans will put on
``recession pounds,'' pointing to studies linking obesity and unhealthy
eating habits to low incomes.\19\
---------------------------------------------------------------------------
\18\ BBC News. ``Recession Thwarts Healthy Efforts.'' (March 11,
2009). http://news.bbc.co.uk/1/hi/health/7934242.stm.
\19\ Reuters. ``Will Americans Put on Recession Pounds?'' (January
9, 2009). http://www.reuters.com/article/newsOne/idUSTRE50805W20090109.
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To help address this problem, it is important that we provide
incentives for Americans to purchase healthy foods. TFAH was pleased
with the inclusion of the provision in the Food, Conservation, and
Energy Act of 2008 (P.L. 110-246), which provides funding to carry out
a point-of-purchase pilot program to encourage households participating
in the Supplemental Nutrition Assistance Program (SNAP) to purchase
fruits, vegetables or other healthy foods. Further, the American
Recovery and Reinvestment Act of 2009 included a 13.6 percent increase
in the value of benefits provided through the SNAP. During these
difficult economic times, we hope Congress will continue to support the
nutrition needs of all Americans, particularly those who are
economically disadvantaged.
In particular, as Congress considers Child Nutrition and WIC
reauthorization, we hope that Congress will increase reimbursement
rates for school meals. As schools are faced with increasing food and
energy costs, we must ensure that they are serving healthy meals to
America's children and recognize that this requires a higher level of
investment in school meal programs. Moreover, TFAH hopes that Congress
will consider updating the national nutritional standards for school
foods sold outside of the school meal program so that strong
nutritional standards based on current science will apply across a
school campus. TFAH also hopes that Congress will strengthen
requirements for local school wellness policies, strengthen nutrition
education, and support the implementation of the new WIC food packages,
as well as the technology needs of the WIC program. These actions would
help promote access to nutritious foods and increase understanding of
the importance of nutrition, which are all necessary to mitigate the
obesity epidemic.
An Environment That Discourages Physical Activity
In addition to developing poor dietary habits, many children are
becoming less physically active, which is also contributing to obesity
and overweight. 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.\20\ 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.\21\ TFAH hopes that Congress considers making
improvements to the built environment and promoting non-motorized
transit option in upcoming transportation reauthorization legislation.
---------------------------------------------------------------------------
\20\ 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.
\21\ 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.
---------------------------------------------------------------------------
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.
When Congress considers reauthorization of No Child Left Behind, TFAH
urges Congress to include provisions that promote physical education
and physical activity throughout the school day.
Recommendations
It is clear that obesity is a multi-faceted issue with diverse
causes and impacts across all sectors of society. Progress can be made
by adopting some of the provisions referenced above in various
reauthorization bills. However, to truly begin to mitigate and
ultimately reverse this epidemic, we will need a sustained commitment
over time to investing in population-based prevention strategies and
coordinating our efforts to combat obesity.
Strengthening Our Investment in Community Prevention
Real prevention requires changing the communities in which we 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.
Last July TFAH released 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 five percent within 2 years; reduces heart disease, kidney
disease, and stroke by five 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, Massachusetts 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.
TFAH urges Congress to build upon these successes and to make a
sustained investment in population-based disease prevention. If we are
serious about combating this epidemic, we must invest in our future by
strengthening communities and promoting prevention.
Implementing a National Strategy to Combat Obesity
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 Americans 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.
The Chairman. Thank you very much. Next we will have Martin
Yadrick, President of American Dietetic Association,
Washington, DC.
STATEMENT OF MARTIN M. YADRICK, M.S., M.B.A., R.D., F.A.D.A.,
PRESIDENT, AMERICAN DIETETIC ASSOCIATION,
WASHINGTON, D.C.
Mr. Yadrick. Good morning, Mr. Chairman, and thank you. My
name is Marty Yadrick. I am registered dietician and President
of the American Dietetic Association. I am honored to be here,
and I am acutely aware that we are sitting below the portrait
of former Chairman Kika de la Garza. Chairman de la Garza
proudly and frequently would tell the story of getting to take
a short trip on a U.S. nuclear submarine, part of the vanguard
of the nation's defense. It was a long story the way the
Chairman would tell it, so I am told, and the tale would always
conclude with him asking his listeners what was the single
greatest limitation on the submarine's voyages? The thing that
brought a nuclear submarine back was running low on its supply
of food. I can tell you that the person who decided what foods
went on that submarine was a registered dietician. The
registered dietician is the chosen nutrition professional of
the U.S. military. The RD's selections would be premised on
meeting the food's safety and nutritional requirements, and the
pleasure of the crew. That Chairman's story seems to be a good
starting point for my testimony today to the Committee.
Food availability has traditionally been the concern of
nations and of families; however, in the last 20 or so years,
we have a new concern: overweight and obesity. They have become
epidemic in the United States and the world. Millions of people
are getting sick with diseases and conditions associated with
over consumption of food. Dire related deaths are soaring. It
is time to get serious about obesity. It is time to become
alarmed when nearly \1/2\ of the people in the United States
suffer from preventable chronic conditions, and when we see the
life expectancy of our children declining from our own, largely
due to overweight and obesity.
Obesity is a problem that defies an easy cure. We know that
it is a better strategy to prevent overweight and obesity,
rather than simply attempting to treat them. That means we
should pay particular attention to the issue of childhood
obesity.
ADA's own research illuminates the challenge ahead. There
are barriers due to nutrition literacy, lack of access to
nutrition services, and other causes. This Subcommittee is in a
position to address barriers to better public nutrition and
nutrition care. We recommend the Committee focus on research,
nutrition labeling and education, and child nutrition.
First, research. This Committee can make an enormous
contribution by focusing on and investing in food and
agricultural research. After all, research was a key reason
that President Lincoln established the United States Department
of Agriculture. Unfortunately, what once was the gold standard
for government research has atrophied. We all have a role in
bringing our food and agricultural research programs back so
that they can lead the U.S. food and agricultural sector
successfully in the 21st century.
Government funded research is especially imperative. It is
the basis for nearly everything we know about food, nutrition,
and human health. The private sector does little of this kind
of research, and the public is skeptical of much of it. Only
the Federal Government has a public mandate to carry out
research on human nutrition needs and motivators. The Federal
Government has a unique responsibility to evaluate nutrition
policies and programs.
The second issue is nutrition education and labeling. Some
have observed that there is a reason why we call this the
information age, not the knowledge age or wisdom age. Consumers
are drowning in nutrition information, yet the consumer cannot
easily evaluate the quality of this information. As often as
not, on their own, consumers are likely to end up misinformed.
The United States has a statute on the books called ``The
Nutrition Labeling and Education Act,'' a fine law that has
never lived up to its promise. Labels are everywhere, but if
consumers don't know how to use them and what they mean, then
we must ask how to bridge the gap.
The good news is that nutrition education is a worthwhile
investment. Research documents that nutrition education has
helped people chose and prepare healthier food options, but the
education component of the NLEA has been chronically under-
funded by Congress and virtually ignored. Nutrition education
has been integrated into some of the food assistance programs,
such as SNAP and WIC, but support for nutrition education lags
behind that for school meals and childcare settings.
The third is child nutrition. Children need to learn, early
in life, about choices and behaviors that will keep them
healthy for life. They need to be taught nutrition, how to
choose and enjoy food, and they need to be taught how and
encouraged to engage in physical activity. They need
reinforcement of healthy eating and activity in order to make
healthy living a habit.
Speaking for the American Dietetic Association, I am asking
our elected leaders to make a paradigm shift in which
prevention plays a more balanced role in our health system.
Nutrition is the cornerstone of prevention.
Thank you for holding this important hearing, and I honored
that we have been invited to speak.
[The prepared statement of Mr. Yadrick follows:]
Prepared Statement of Martin M. Yadrick, M.S., M.B.A., R.D., F.A.D.A.,
President, American Dietetic Association, Washington, D.C.
Good morning. My name is Marty Yadrick. I am a Registered Dietitian
from Los Angeles and the President of the American Dietetic
Association.
ADA is the world's largest organization of food and nutrition
professionals, with more than 69,000 registered dietitians, dietetic
technicians, registered and advanced-degree nutritionists. Every day,
the members of our professional association work with Americans in all
walks of life--from before birth through old age--providing care,
services and knowledge to help people optimize their health through
food and nutrition.
Others at this hearing are clearly identifying the national
imperative to address obesity and the overall health of our population.
I will not repeat statistics or the conclusions. I do ask that you add
my name and that of the American Dietetic Association to the list of
Americans who are committed to improving the health of our citizens.
Let me urge that we begin by focusing on prevention.
Nutrition and diet are known to be associated with seven of the top
ten leading causes of death in the United States today, including the
Big Three: heart disease, cancer and stroke.
Diet and nutrition are also factors in other chronic conditions
such as pulmonary disease, diabetes, liver disease, arteriosclerosis
and kidney disease. Seven of every ten Americans who die each year--
more than 1.7 million people--die of chronic disease.
Furthermore, diet and nutrition affect the mortality rates
associated with pneumonia and influenza, septicemia, prenatal
complications and other conditions that are leading causes of death in
our country.
How best to reduce the incidence of these diseases and conditions
that take so many lives? A big step would be to re-frame our
understanding of the role of nutrition and health in the United States
and the world.
Traditionally, we have tended to view nutrition in terms of the
adequacy of the diet. And hunger remains an issue for millions of
Americans.
But now, the primary manifestation of malnutrition in the United
States has become excess weight and obesity. These conditions coexist
with and at times overshadow hunger as the most significant nutrition
problem facing the nation.
For those of you wondering about ``dietetics,'' there are a few
specifics you should know. Dietetics is the science that directly
connects food to nutrition and health. Registered dietitians study
multiple hard and social sciences, including those that quantify
nutrients that people need and nutrients' effects on health. But RDs
become experts in dietetics in order to help people optimize their
health by choosing foods in a healthful pattern of eating. Of course,
to stay healthy, food choices need to be matched with physical activity
and a series of personal decisions--like choosing not to smoke and
refraining from high-risk behaviors.
ADA is guided by a philosophy of sound science. Our association
analyzes, publishes and disseminates scientific breakthroughs and
information that is applied in dietetics practice every day throughout
the nation. ADA was one of the first professional groups to embrace
evidence-based practice, creating the world's first evidence-analysis
nutrition library and producing guides for condition-specific nutrition
care. ADA strongly believes that, as the public becomes knowledgeable
and informed about food, nutrition and health, our profession can
contribute more significantly to make Americans healthier. It is time
that we as a nation take action to address food, nutrition and health.
It is time to become alarmed when nearly half the people in the
United States suffer from preventable chronic conditions and when we
see the life expectancy of our children declining from our own--largely
due to overweight and obesity.
Obesity is a problem that defies an easy cure. We know that it is a
better strategy to prevent overweight and obesity, rather than simply
attempt to treat them. And that means that we should pay particular
attention to the issue of childhood obesity.
ADA's own research illuminates the challenge ahead. American
parents have erroneous perceptions of their children's nutritional
condition and frequently, they are disengaged from their kids' eating
habits. Parents are reluctant to help their children because they don't
know how to help. It has been only the luckiest of families who are
able to see a Registered Dietitian for nutrition assessment and
intervention where families' insurance plans will provide coverage.
ADA's research also documents that most Americans have no idea of
their own nutritional status, weight or eating patterns. Even when a
diet-linked condition as serious as pre-diabetes is identified, a
patient is likely to encounter very real barriers to professional
nutrition care and services. To explain: Medicare is the template for
most insurance plans. Medicare currently covers screening for pre-
diabetes. A beneficiary can be tested as frequently as every 6 months
to check his or her status. However, there is no referral--no covered
care by Medicare or most private insurance--until pre-diabetes
deteriorates to full blown diabetes. Only once the diagnosis has
reached a dire situation will Medicare meet beneficiaries' needs
through covered diabetes services. If the patient is very lucky his or
her physician may send them to a Registered Dietitian for Medical
Nutrition Therapy or an accredited Diabetes Self Management Training
program.
So why would I call patients ``lucky'' to be referred? Fewer than
five percent of Medicare beneficiaries eligible for MNT are referred,
as doctors' offices frequently pass out literature rather than
encourage the patient to get proven-effective, intensive nutrition
assessment, personalized intervention and ongoing counseling. DSMT
reflects similarly dismal referral statistics.
Fortunately we have just seen the development of a pilot program to
help overweight children see their physicians and then Registered
Dietitians to learn better nutrition and activity habits. Several
health insurance organizations are part of this ground-breaking effort
which will reach nearly one million children during the first year. The
long-term goal of the initiative is that within the first 3 years, 25
percent of all overweight children (approximately 6.2 million) will
have access to the benefit. This is thanks to the work of the Alliance
for a Healthier Generation.
This Subcommittee also is in a position to address barriers to
better public nutrition and nutrition care. We recommend the Committee
focus on research, nutrition labeling and education, and child
nutrition.
Research
The first is research. This Committee can make an enormous
contribution by focusing on and investing in food and agricultural
research across the board. ADA is a member of National C-FAR which
educates how Federal research contributes to improved standards of
living. After all, research was a key reason that President Lincoln
established the U.S. Department of Agriculture. Unfortunately, what was
once the gold standard for government research has atrophied. We all
have a role in bringing our food and agriculture research programs back
so that they can lead the U.S. food and agricultural sector
successfully in the 21st century.
Government-funded nutrition research is especially imperative. It
is the basis for nearly everything we know about food, nutrition and
human health. The private sector does little of this kind of research--
and the public is skeptical of much of it. Only the Federal Government
has the public mandate to carry out research on human nutrition needs
and motivators, as well as biological, epidemiological, social and
environmental factors. The Federal Government has a unique
responsibility to evaluate nutrition policies and programs. It's time
to invest much needed resources into our Human Nutrition Research
Centers. I can only imagine how much healthier we might be today if we
had invested as much in human nutrition as we have spent for bovine,
swine, poultry, aquaculture and other animal nutrition research over
the years!
Nutrition Education and Labeling
The second is nutrition education and labeling. Some have observed
that there is a reason why we call this the ``information age'' and not
the ``knowledge age'' or ``wisdom age.'' Consumers are drowning in
nutrition ``information.'' Related to that is that the consumer cannot
easily evaluate the quality of the information. As often as not, on
their own, consumers are likely to end up misinformed.
The United States has a statute on the books called the Nutrition
Labeling and Education Act--a fine law that has never lived up to its
promise. Labels are everywhere, but if consumers don't know how to use
them and what they mean--then we must ask how to bridge the gap.
Nutrition information does not translate into knowledge or
knowledge necessarily into appropriate action. If labels and pamphlets
do not lead to behavior change, then people have to be taught.
The good news is that nutrition education is a worthwhile
investment. Research documents that nutrition education can help people
choose and prepare healthier food options, but the education components
of NLEA are chronically under-funded by Congress and virtually ignored.
Nutrition education has been integrated into some of the food
assistance programs such as SNAP and WIC, but support for nutrition
education lags behind for school meals and child care settings.
Child Nutrition
Children need to learn early in life about choices and behaviors
that will keep them healthy for life. They need to be taught nutrition,
how to choose and enjoy food and they need to be taught how and
encouraged to engage in physical activity. They need reinforcement of
healthy eating and activity in order to make healthy living a habit. We
need to teach nutrition in a way that is meaningful, culturally aware,
individualized and personal. PSAs and motivational messages have short-
lived impact, if any.
School environments may not be teaching healthful nutrition or even
offering healthful choices beyond the reimbursable school meal. Rushed
meal times, pressure to increase revenues, calorically dense vending
and elimination of physical education all send the message that health
is not really a priority.
ADA recommends amendments be made to the Child Nutrition Act to:
1. Ensure the Dietary Guidelines are the foundation of Federal food
assistance and nutrition programs. The Secretary of Agriculture
should have the authority to extend nutrition standards to all
foods and beverages sold on school campuses throughout the day
for schools that are participating in the school breakfast,
lunch and after school programs. You can help that happen by
supporting H.R. 1324, The Child Nutrition Promotion and School
Lunch Protection Act.
2. Provide adequate funding for program implementation. School
reimbursements have fallen far behind the costs of production
and are inadequate to maintain the high nutrition standards
established in law. And adequate funding is needed to ensure
implementation of the new WIC food packages.
3. Strengthen nutrition education and promotion. In the last Child
Nutrition Reauthorization, Congress approved the Team Nutrition
Network, a state-level infrastructure and networking component
to coordinate nutrition education activities across child
nutrition programs, conduct evaluations and enhance program
operations. Funding is now needed for the benefits of that
infrastructure to be realized. Nutrition education must
continue to be a key component of the WIC program services.
4. Increase funding for Child Nutrition Program research. Funding
would allow USDA to conduct and fund research on and evaluation
of their programs and allow USDA's Food and Nutrition Service
to collaborate with research agencies in USDA and extramurally
to develop and implement a comprehensive research agenda.
5. Place trained professionals in roles where they make policies.
Directors of the School Nutrition Program at the district level
should be certified as Registered Dietitians, Dietetic
Technicians, Registered or School Nutrition Association School
Nutrition Specialists. It is not simple to balance student
satisfaction with nutritional needs and to do so cost-
effectively. The extension of nutrition standards to all foods
and beverages sold in schools, in conjunction with the local
wellness policy requirement, will only increase the need for
trained professionals in schools. Planning for nutritious
intakes for children with special food and nutrition needs
requires the biochemical and food science knowledge that only
registered dietitians possess in school settings. Registered
dietitians have the expertise needed to provide education to
high-risk WIC recipients.
Speaking for the American Dietetic Association, I am asking our
elected leaders to make the paradigm shift in which prevention plays a
more balanced role in our health system. Nutrition is the cornerstone
of prevention.
As a Registered Dietitian, I can tell you that many of the most-
costly disabling conditions can be prevented through nutrition
strategies. And with proper nutrition support, many complications can
be averted or delayed. Federal attention to public nutrition and
investment in nutrition care, education and research is essential. From
these small, practical steps, great benefits may accrue to people,
their families and the nation.
Thank you for holding this important hearing. I am honored that I
have been invited to speak and to learn from you and my fellow
panelists.
The Chairman. Thank you very much. Next we have Donna
Mazyck, President of the Board, National Association of Nurses
in Silver Spring, Maryland. Donna?
STATEMENT OF DONNA J. MAZYCK, R.N., M.S., N.C.S.N., BOARD
PRESIDENT, NATIONAL ASSOCIATION OF SCHOOL NURSES; SCHOOL HEALTH
SERVICES SPECIALIST, MARYLAND STATE DEPARTMENT OF EDUCATION,
SILVER SPRING, MD
Ms. Mazyck. Mr. Chairman, Mr. Fortenberry, and Members of
the Subcommittee, I am privileged to be here today representing
the National Association of School Nurses to speak about the
state of obesity in our country. Through my testimony, I hope
to relay to the Subcommittee Members how school nurses have
daily experiences with children with severe nutrition issues,
and other health conditions related to obesity.
School nurses are fully aware that the fastest rising
public health problem in our nation is obesity. Let me give you
an example of what school nurses are addressing, drawing from
my days as a high school nurse. One of my students went to the
back of the health room one day to weigh herself. Before I
could get back there to assist her, she exclaimed, this scale
doesn't work. I had to help her understand that her weight was
beyond the 250 pound capacity of the scale. Her weight was
clearly a source of embarrassment to her as she endured teasing
by classmates for her large size. I continued to work with her
because not only was she experiencing dangerous physical
consequences, but she was also suffering with adolescent
emotional distress.
Knowing that obese adolescents have up to an 80 percent
chance of becoming obese adults, a major investment in
prevention must take place from multiple sectors of society to
become a healthier America. Prevention is the positive,
logical, and most cost beneficial approach to achieve education
goals and to prevent chronic diseases.
I want to share with you a true story from one of our
members that accentuates the gravity of the generational issues
involved with obesity. It is about a current Kindergarten
student whom I will call Connie B. It was discovered during a
health assessment that she has a BMI in the 99.5 percentile.
Connie is always out of breath. She has four very deep cavities
in her teeth, and she had dark-pigmented skin folds at the back
of her neck, a condition called Acanthosis nigricans, a
reliable predictor of an over-production of insulin that is a
known precursor to type 2 diabetes. This little girl is only 5
years old. The school nurse spoke with her mother and found
that that mother had difficulty with Medicaid coverage for her
family of four children. There were three children younger than
Connie, including a severely autistic child. As a single
mother, she was overwhelmed with life, did not have access to
medical care, and said she wished that Connie was not so fat.
When the school nurse met Ms. B in person, she observed that
the mother was also obese. The school nurse helped this parent
to obtain Medicaid coverage for her child with the partnership
of a local hospital. The school nurse helped that mother
complete a meals assistance application, and encouraged the
mother to allow Connie to eat her meals in school, where they
were carefully planned and nutritionally balanced meals.
This type of preventive approach is the best way to ensure
that Connie won't become part of the up to 80 percent of
adolescents who will take obesity into an adulthood filled with
chronic, life-altering diseases.
Schools can also contribute significantly to the other
major factor which leads to obesity, the lack of physical
activity. Therefore, NASN recommends a stronger emphasis on
school wellness policies that include necessary physical
activity for all students. Many school nurses throughout the
country take a leadership role in the development and
implementation of school wellness policies. NASN recommends
that school nurses serve on every school and district wellness
policy committee.
I want to assure the Subcommittee that our association has
taken on the responsibility of educating school nurses about
childhood obesity. In fact, with seed money from the CDC and a
cooperative agreement addressing type 2 diabetes, NASN
developed a program known as S.C.O.P.E. It stands for School
Nurse Childhood Obesity Prevention Education. The goal is to
provide strategies for every school nurse to assist not only
the students, but also the families and school community in
addressing the challenges related to obesity. With a very
limited budget, NASN has been able to educate about 1,200
school nurses since 2006. We are hoping public and private
partners will recognize the importance of school nurse
involvement in obesity prevention, and help us increase the
number of school nurses completing that training. We believe
that school nurses are in a unique position to be liaisons with
schools, parents, community members, health care professionals,
and Federal, state, and local governments to help stop the rise
in childhood obesity. Part of the solution is to employ school
nurses to effectively work on a daily basis with students to
increase their understanding of how to achieve healthy
lifestyles.
Thank you for this opportunity.
[The prepared statement of Ms. Mazyck follows:]
Prepared Statement of Donna J. Mazyck, R.N., M.S., N.C.S.N., Board
President, National Association of School Nurses; School Health
Services Specialist, Maryland State Department of Education, Silver
Spring, MD
Mr. Chairman, Mr. Fortenberry, and Members of the Subcommittee, my
name is Donna Mazyck, and I am President of the National Association of
School Nurses (NASN) and I serve the Maryland State Department of
Education as a school health services specialist. I am privileged to be
here today representing NASN to speak about the critical importance of
the rise in obesity throughout the United States. I commend the
Committee for reviewing this issue at a time when there are so many
pressing issues. Unfortunately, obesity is an issue which can no longer
be ignored. It is a factor related to multiple issues, including the
economy, health care, chronic disease, nutrition, hunger, and national
security.
Through my testimony, I hope to relay to the Subcommittee Members
how school nurses have daily experiences with children who have severe
nutrition issues and other health conditions related to obesity. I will
share stories from when I practiced as a school nurse in two Maryland
high schools and from my current policy role as President of an
association with nearly 14,000 members.
School nurses are serving students in 75 percent of the U.S. public
schools. We know first-hand that school nurses are performing duties
today that go well beyond what school nursing was like 30-40 years ago
when health care costs were affordable, and school children with
complex health needs did not come to school. School nurses do not
simply wait in their offices for a sick child to appear; rather they
provide health services for all the students, but especially for the
uninsured. They also provide health education, with special attention
to nutrition and obesity. They serve children with chronic conditions
which previously were extremely rare in children, such as type 2
diabetes, heart disease, high blood pressure, and food allergy.
School nurses have knowledge and expertise in the areas of
nutrition, weight maintenance and exercise. This knowledge can be
applied to intervention and prevention programs that help students live
healthy and active lifestyles. The school nurse collaborates with
students, parents, school personnel, health care providers and members
of the community to identify students who are overweight and obese. In
addition, the school nurse is involved with support programs,
counseling services, referrals, and follow-up activities.
For clarification of terminology, body mass index (BMI) is a
practical measure used to determine overweight and obesity. BMI is a
measure of weight in relation to height that is used to determine
weight status. While BMI is an accepted screening tool for the initial
assessment of body fatness in children and adolescents, it is not a
diagnostic measure because BMI is not a direct measure of body fatness.
The Centers for Disease Control and Prevention (CDC) defines overweight
as a BMI at or above the 85th percentile and lower than the 95th
percentile. Obesity is defined as a BMI at or above the 95th percentile
for children of the same age and sex.
NASN's membership is fully aware that the fastest rising public
health problem in our nation is obesity because their eyes and their
work with today's students tell them so. Over the past 3 decades,
obesity rates have soared among all age groups, increasing more than
four times among children ages 6 to 11. According to the Robert Wood
Johnson Foundation (RWJF), today, more than 23 million children and
teenagers are overweight or obese. That's nearly one in three young
people. In fact, 16.3 percent of children and adolescents from ages 2
to 19 are obese; with 11 percent considered extremely obese--above the
97th percentile. Given these statistical realities, the complex medical
issues facing school nurses are imaginable. School nurses are now
addressing the typical adult ailments of high blood pressure, type 2
diabetes, sleep apnea, and gallstones in their elementary and
adolescent students.
Let me give you an example of what school nurses are addressing--
drawing from my days as a high school nurse. One day a student entered
the health room and asked if she could weigh herself on the scale in
the back of the room. I directed her to the scale, but before I could
get back there to assist her, she exclaimed. ``This scale doesn't
work!'' When I walked over to her, I realized that her weight was over
250 pounds, which was the highest measure registered on the scale. Her
weight was a source of embarrassment for this student as she endured
teasing by classmates for her large size. Not only was she experiencing
dangerous physical consequences, such as shortness of breath when
walking through the school hallways, but she also was suffering with
adolescent psychological distress.
Even our national security is threatened as we learned from the
United States Military this week that since 2005, 48,000 overweight
recruits had to be turned away from serving our country. The obesity
epidemic is a major contributor to the national crisis of filling the
military's ranks. These young people are products of an environment who
have been driven to school for 18 years, and when in school, they had
little or no daily physical education. When out of school, they spent
on average four or more hours per day using electronic media; and the
foods they've grown accustomed to eating have been unhealthy and in
larger sizes. Even in schools, due to antiquated guidelines for foods
sold outside of the meals, students have been consuming on a daily
basis high-calorie, low-nutrient foods, snacks, and beverages.
According to RWJF, it's estimated that the obesity epidemic costs
our nation $117 billion annually in direct medical expenses and
indirect costs, including lost productivity. Childhood obesity alone
has a tremendous and unnecessary cost of up to $14 billion annually in
direct medical expenses. There are many societal explanations for these
alarming statistics which translate into health care expenses and lower
life expectancies of the present and future generations. The questions
facing us all, are what can be done to turn this epidemic around and
who is going to be a major contributor to the solution?
Knowing that obese adolescents have up to an 80 percent chance of
becoming obese adults, a major investment in prevention must take place
from multiple sectors of society to become a healthier America.
Prevention is the positive, logical, and cost beneficial approach to
achieve education goals and to prevent chronic diseases.
School nurses have an individual and public health perspective and
know well that prevention of chronic illnesses such as cardiovascular
disease and diabetes must begin in childhood to be efficacious. School
nurses identify at-risk students through periodic assessments, and then
intervene through referrals to connect students to health services and
to educate students and parents about nutrition and the availability of
school meals assistance.
I want to share with you a true story from one of our members that
accentuates the gravity of the generational issues involved with
obesity. It is about a current kindergarten student whom I will call
Connie B. It was discovered during a health assessment that she has a
BMI of 99.5 percent--the top of the obese range. Just walking up a
short flight of stairs causes her to be out of breath. She has four
very deep cavities in her teeth, and she has dark pigmented skin folds
at the back of her neck, a condition called Acanthosis nigricans.
Acanthosis nigricans is a reliable predictor of hyperinsulinemia, an
over production of insulin and a known precursor to type 2 diabetes,
previously only known to occur in adults. This little girl is only 5
years old. She will have a very short and poor quality of life if
something is not done now.
The nurse spoke with her mother and found that she has not been to
the doctor for awhile because her Medicaid ``ran out.'' In other words,
the mother did not complete the annual renewal process. Mrs. B, a
single mother, said she has three children younger than Connie,
including a 4 year old who is severely autistic and who takes up most
of her time. She said she cannot easily take the children for health
visits and has a very hard time doing most household duties, including
cooking regular meals. She said she wishes that Connie was not ``so
fat.''
When the school nurse met Ms. B in person, she observed that she is
also obese. The services available through the school were explained
and using a partnership with a local hospital, Medicaid coverage was
re-established. The nurse helped her complete the meals assistance
application and encouraged Ms. B to allow Connie to eat breakfast at
school where meals are carefully planned and nutritionally balanced.
Our dedicated nurse is hoping Connie will stay at the school for 6
years so that she can work with her and her family. Connie's progress
toward improved health status will be monitored as she eats a more
nutritious diet and grows into her weight. This type of preventive
approach is the best way to ensure that Connie won't become part of the
80 percent of adolescents who take their obesity into an adulthood
filled with chronic, life altering diseases.
Critical to helping students break the cycle and develop good
decision-making skills related to nutrition, is the modeling which
occurs in the school meals program. Currently, the National School
Lunch Program is serving nutritious meals to more than 28 million
children and the School Breakfast Program is reaching more than eight
million children daily. The meals eaten at school are meals that they
can count on. In contrast to the students who pay full price for
lunches, students on assistance are generally so hungry that their
plates are clean when they finish. We have to ask ourselves, what would
our schools be like if these children did not receive these vitally
important meals? In addition, if the Department of Agriculture
nutrition standards for school foods sold outside of meals would be
updated, our nation's schools (not just the meals program) could become
a place where children's nutritional health is taken seriously.
Schools can also contribute significantly to the other major factor
which leads to obesity--the lack of physical activity. Therefore, NASN
recommends a stronger emphasis on school wellness policies that include
necessary physical activity for all students. Throughout Maryland
schools, the school nurses are joining with the physical education
teachers in urging parents to ``Take 15 for the Health of It!'' Parents
and guardians are encouraged to devote 15 minutes every day with their
children in some form of physical activity.
Since the Child Nutrition and WIC Reauthorization Act of 2004, all
school districts are required to have local school wellness policies.
School nurses have a critical role in teaching about and providing
healthy food choices and teaching skills and knowledge to motivate
participation in lifelong physical activity. Many school nurses
throughout the country are the lead person in the school for
development and implementation of the wellness policy. NASN recommends
that school nurses serve on every school and district wellness policy
committee. With the help of the Congress, this could become a reality.
The child nutrition and learning link must be considered, if
wellness is the goal. Longstanding and ongoing research in the area of
nutrition and learning informs 21st century policymakers that the link
between nutrition and academic achievement is evident and strong.
Schools should be responsive to the evidence and provide all students
with highly nutritious meals at school regardless of their ability to
pay. Ninety-seven percent of school-age students attend school, and
clearly, there is no better way to insure that children in poverty get
fed foods they need to thrive and grow than to provide meals assistance
and well-planned, nutritious meals at school. In addition, a recent
study found that obese children have more absences than normal weight
students. The school nurse role is to support children in any way that
will insure that they are in school everyday and ready, even eager, to
learn. Teachers and school nurses know from experience that healthy
children learn better!
Conclusion
Speaking on behalf of NASN, I appreciate the opportunity to share
experiences from my practice and what school nurses know about obesity
and how to prevent it amongst school children. Our Association is happy
to assist the Subcommittee further as it addresses the issues in the
context of nutrition, health care and education reforms.
I also want to ensure the Subcommittee that as a national
association, NASN is doing what it can to take on the responsibility of
training school nurses about childhood obesity. In working on a
demonstration project related to type 2 diabetes funded by CDC and the
National Institutes of Health, it was recognized that school nurses are
in key positions to impact this problem and to serve as catalysts for
better care. Therefore, with seed money from the cooperative agreement,
NASN developed a program known as S.C.O.P.E. It stands for School Nurse
Childhood Obesity Prevention Education. The program has been designated
a ``program to watch'' by the Partnership to Fight Chronic Disease
because it covers the assessment, treatment, and prevention of
childhood obesity and the case assessment and management for children
with type 2 diabetes. The goal is to provide strategies for every
school nurse to assist not only the students, but also the families and
the school community in addressing the challenges related to obesity.
Within a very limited budget, NASN has been able to train about 1,200
school nurses since the program's inception in 2006. Having public and
private partners recognize the importance of school nurse involvement
in obesity prevention, hopefully will allow for increased numbers of
school nurses completing the training.
The childhood obesity epidemic in the United States continues to
seriously threaten the health and future of our nation's youth. Working
towards a solution will involve the collaboration of schools, parents,
community members, health care professionals and Federal, state, and
local governments. All are responsible for addressing the epidemic and
serving as advocates to protect children. However, school nurses are in
the unique position to serve as liaisons with the various groups to
help stop the rise in childhood obesity while working on a daily basis
with students to increase their understanding of how to achieve healthy
lifestyles.
The Chairman. Thank you, and I want to thank all of the
witnesses for being here this morning, and for your testimony.
What we will do, then, is take a recess break and convene
back in an hour from now, which makes it around 12:40, and then
we will proceed with the answering of questions. So at this
time, we will be in recess until then, for voting. We have
about 2 minutes left. We are in recess.
[Recess.]
The Chairman. The meeting will come to order. I want to
begin, first of all, thank you very much for your testimony.
I have used food stamps to feed my family during difficult
times, and I also appreciate you for sharing your story with
us, those of us who have used food stamps or SNAP to provide
for our families.
You have given us some very interesting statistics. It is
truly amazing--you said that 48 percent of those with obesity
utilize Medicare and Medicaid----
Ms. Wolf. No, can I clarify that?
The Chairman. Sure.
Ms. Wolf. Forty-eight percent of the costs of obesity are
paid for by Medicaid and Medicare.
The Chairman. Thank you very much for clarifying that. It
is still pretty high, the amount that is on the taxpayers.
Just to clarify what you said in your testimony that the
benefit of education is the best way to prevent obesity. Every
dollar that is spent on lifestyle intervention for people with
obesity and diabetes, there is a $14.58 return on investment.
In your opinion, how prevalent should lifestyle intervention
for obesity be in our attempt to focus more on prevention
healthcare?
Ms. Wolf. Congressman Baca, I believe that preventive
effort is what we really need to put into the medical care
system, and of course, we have to look at the environment and
we need to do public health messaging. But right now if you
look at the state of medical care, it is focused on treatment
and not on the preventive part of medical care, such as
lifestyle care.
In the study that was quoted right there, there was a very
high return on investment. It was a smaller study, 150 people
that were at high risk for diabetes and obesity, but on every
major qualifier, just giving them a moderate lifestyle
intervention decreased patient admissions. There was 18
admissions during a 1 year period, 16 of those were the people
who had regular, usual, medical care. Only two of those
admissions were people who actually got the lifestyle. You see
a decrease in pharmaceutical use, you saw a decrease in
absenteeism. That was significant and robust and saves dollars
at every single level, and that is why you saw that positive
return on investment.
Typically when we do intervene in this--in lifestyle
interventions with a high-risk population, you see that it is
cost effective. You may not see that high of a return on an
investment, that is only one study, but you will see that it is
cost effective.
The Chairman. Okay, thank you. The next question, and any
one of the three can respond to this. One would go back, of
course, to Ms. Wolf, and then the other one would be for Mr.
Yadrick and then Ms. Mazyck as well.
What are the developmental effects of obesity in children?
Ms. Mazyck. The developmental effects of obesity in
children?
The Chairman. Yes.
Ms. Mazyck. So you are addressing----
The Chairman. Anyone or all three of you, if you could
address that, ma'am.
Ms. Wolf. Mr. Chairman, when children are developing, and
they have issues with obesity, they begin to develop some of
those risk factors that we heard from Dr. Dietz that generally
will lead to issues with hypertension. Some of them are
developing type 2 diabetes, we have heard. One of the untold--
and I don't have a percentage--were the number of children who
deal with bullying and the emotional effects of being
overweight. That is a factor, indeed, that impacts children
when they are overweight. They are unable to physically move
like they would want to, and they have to suffer the teasing
and the bullying from friends and schoolmates.
Mr. Yadrick. And the other thing, Mr. Chairman, is they are
just setting the stage for chronic problems throughout the rest
of their life. As my colleague mentioned, the inactivity that
obesity often leads to is going to prevent them from having a
healthy lifestyle, and starts that out early on in life, the
pattern towards all the chronic diseases that are going to be a
consequence of that.
The Chairman. Part of the follow-up, and Ms. Wolf, you can
probably add to that, what kind of data is there on the long-
term cost of these developmental problems.
Ms. Wolf. There is evidence that children who are
overweight and obese later on have lower wages, there is--let
me see. Of course, they have higher chronic problems which
means they have higher amounts of medical expenditures and
things like that. Basically what Dr. Dietz was saying, and what
we find, is that when you are overweight and obese as a child,
it does track along. Remember that the health care costs for
obesity increase along with the severity of obesity, so these
kids are tracking along all the way through. They are having a
long-term level of obesity, which means they are going to have
more chronic diseases. That really translates into higher
medical expenses, absenteeism, and then problems with
disabilities.
The Chairman. Okay, thank you. Mr. Hamburg, I appreciate
the big picture, the point of view you offered in your
testimony. It is critical that we on the Subcommittee remember
that there are many ways that health and obesity affect Federal
law and policies as a whole.
With your outlook in mind, could you expand on your ideas
of a national strategy to combat obesity?
Mr. Hamburg. Well, sure. I mean, it has become clear,
certainly, in the last few years that this is a problem that
affects all aspects of society, all aspects of government. So,
just looking at what you all are able to insert into the farm
bill, some of the decisions that need to be made around
reauthorization of the education programs, transportation bill
that is coming back up. You know, there are significant funds
for a program called Safe Foods for Schools.
I think to best look at it from the community level--YMCA
has a program called Pioneering Healthier Communities, and what
they do is try to address the obesity issue in a community-wide
fashion. They bring together leaders from the community that
includes everyone from the police chief to the Chamber of
Commerce and the schools, and public health and voluntary
health associations, and try to figure out what can be done in
a cumulative way to try to fight an epidemic that, again, took
30 years to manifest.
So at the Federal level, the idea that we have--first, we
should have a national plan on public health overall, but
specifically on obesity, we need to make sure that policies
match up, that we don't have counter-intuitive policies between
different agencies.
One issue that was addressed very well in a government-wide
fashion in the last couple of years was pandemic flu, the
possibility for a worldwide pandemic flu. The past
Administration and Congress decided we need a full plan, multi-
agency plan to address that. We think that is the case for
addressing obesity as well.
The Chairman. Thank you. I know that my time has expired,
but have you presented these ideas to the Administration?
Mr. Hamburg. Yes, we have. We have been pushing these
ideas, both in this report and also a report called ``The
Blueprint for a Healthier America.'' It is a whole blueprint of
recommendations relative to how the Federal Government needs to
address public health broadly, and we can certainly forward the
recommendations on to this Committee. So yes, we are talking to
whoever will listen, and we are certainly talking to the
individuals in both Houses who are currently drafting health
reform legislation. This is, indeed, a health reform and we
need to make sure that prevention initiatives are front and
center.
The Chairman. Thank you. I am going to turn it over to
Congressman Fortenberry to ask any additional questions.
Mr. Fortenberry. Thank you, Mr. Chairman. I am sorry for
the disruption. Thank you all for staying. All of your
testimony has been very insightful and informative. It is
packed with a lot of statistics, and to highlight a couple of
those key findings, going back to what Chairman Baca had
mentioned regarding 48 percent of the costs of obesity are born
by government programs. Is this across a spectrum of Medicare/
Medicaid, veterans' programs, other types of health care
subsidies that are out there through the public sector of
financing, or is it concentrated among Medicare and Medicaid
populations?
Ms. Wolf. The analysis could only look at Medicaid/Medicare
recipients, and most of that is Medicare, because of chronic
illness.
Mr. Fortenberry. So you would suggest it is fair to say
that the majority of that cost is in the Medicare program?
Ms. Wolf. It absolutely is, and there has been a more
recent paper that has really shown that it is worth the
government's effort to invest in preventive efforts, because
the costs down the line to the government are so large, so
huge, and will continue to grow.
Remember, you are paying Medicare costs this high right
now. We didn't have the population of obese children that we
have now, back then.
Mr. Fortenberry. Can you correlate, again--set your own
parameters about what nutritional increase and access to
nutritional education and programs in food could do in terms of
combating this problem: how that is correlated to a decrease in
obesity and overweight issues, correlated to better health
outcomes, correlated to better disease management, correlated
to increased savings. It is the same question I had for Dr.
Dietz. Give us a number, if we did this, it would translate to
this in terms of cost savings, because clearly, the trajectory
we are on in terms of government financed health care programs,
as well as private sector is unsustainable. This is a common
sense way to get underneath some of that trajectory so--yes,
sir, did you want to----
Mr. Hamburg. Yes, in a report that we put out that
basically is a return on investment report and investing in
community-based interventions, we need to be mindful that there
are clinically-based interventions, one to one, and then
community-based interventions. Most of the interventions we
looked at related to obesity. There were some tobacco
interventions included as well, but it was primarily nutrition,
physical activity. So we looked at all of these studies for
close to 80 or 90 local and national studies, and what we found
was that if we invested just $10 per person--that was a
conservative number, because a lot of these programs only cost
a few dollars per person--but if we invested $10 per person,
that is $3 billion. And that is actually what was in the
initial wellness fund in the stimulus bill that came through
this House. So if we put $10 per person, $3 billion, within a
year or 2, we would see, first of all, a five percent decrease
in a lot of these associated diseases, and in 1 to 2 years, an
immediate return in investment of that $3 billion. Within 5
years, we would see $16 billion a year in savings, and those
savings are to Medicare, Medicaid--actually, the biggest one
was in private health insurance and out-of-pocket expense.
Mr. Fortenberry. That is an aggregate savings, $16 billion,
or just a public----
Mr. Hamburg. That is each year, so it builds up to a point
where it is, approximately, 5.6 return for every dollar
invested.
Mr. Fortenberry. This is anecdotal, and it is related to a
question that one of our other Members had asked earlier. But
in terms of rethinking a health insurance model--the largest
employer in Nebraska is a health care provider, but for their
own employees, they incent healthy behaviors. In other words,
if you--they pay you to go to the doctor for a checkup. If you
quit smoking you get, say, $500 for your health savings
account. If you are 20 pounds overweight you get--I asked the
CEO of that company if they had run a calculation based upon
the present value of the long-term cost savings, expecting
their initial cost to actually rise as they invested in these
long-term measures to reduce costs, and he said yes, that is
what we did and justified doing it. But ironically, we actually
saw short-term costs drop as well. So their increases have
basically been cut in half. They are not saving money; it is
still going up, but the rate of increase of their own health
care programs has been halved, compared to the national
average.
So again, we tended to focus the hearing on just trying to
unpack the nature of the problem, and I think we have done a
good job of that. Now, the next phase is to take the testimony
that we have heard here, both in terms of public programs, but
also in terms of rethinking some of the mechanisms out there in
the private sector that have been set up a particular way, but
there might be more productive ends to it.
Do any of you have any comments on that?
Ms. Wolf. It has been shown in a couple of studies that
incentives really do help promote healthy behavior, and we know
that subsidies are incentives. So right now, people are paying
a certain amount of money for their health care, which is very
expensive to the family. If that was reduced if they had
healthy behaviors, that has been proven that that is effective
in getting them to create healthy behaviors, with the result of
improved diet, increased physical activity, and weight loss as
well. So absolutely, those studies are few and far between. We
would love to see more of the health insurance companies--we
have seen in North Carolina where their Blue Cross/Blue Shield
has taken us on, they too have invested immediately and are
spending more, however, they are finding great returns at this
point.
Mr. Fortenberry. I think that it is an important point.
There is positive data out there to quantify these potential
outcomes would be helpful to spurring this type of innovation
across the country.
Thank you, Mr. Chairman.
The Chairman. Thank you. Since there are no other panelists
here, we can ask some additional questions and then adjourn.
I just want to ask Mr. Hamburg one thing. In your testimony
you referred to a community health program that costs as little
as $10 per person, yet has the potential to save our nation
over $16 billion in the long term. Can you explain in more
detail about what this program entails, and why is it so
effective?
Mr. Hamburg. Well, what we looked at were, first of all,
successful interventions, and it wasn't any one particular
program. It included school health programs, efforts like Dr.
Dietz talked about in educating the public through the media,
putting in bike paths, stop smoking help lines, those sorts of
things. So we looked at all of those and had those costed out.
On average, most of those interventions, frankly, only cost $5
or $6 per person, so it is an idea that just with a small
investment in trying to educate the public, trying to change
some norms around physical activity and nutrition, both in
schools and the worksite, is equally important. You can see
these large returns on investment if you look at diabetes, for
example, and the incredible rise in type 2 diabetes.
I mean, if you just have an intervention that puts more
physical activities into the schools and more healthful foods
within the lunch and breakfast programs, and also competitive
foods through vending machines, if kids or adults lost 10
pounds, that is a dramatic change at times. And that is why you
see a lot of the return in investment early on, because within
a year or 2, you can take somebody pretty quickly from type 2
diabetes back to pre-diabetes or pre-diabetes even farther back
just by making some very small interventions. I think that is
the concept that we need to have out there, you know. You don't
have to lose the 50 pounds, you don't have to run 5 miles a
day. It would be nice, but you do what you can do, and small
interventions can have great effects, both in health, and we
are finding in economics. That is just gravy on top if we can
have reduced chronic disease and save money. That is a win-win.
The Chairman. That is true. I need to lose 20 pounds, so I
am going to do it a little at a time.
I know that we are running out of time. I really appreciate
your patience and your time and willingness to wait for us, but
as you can see, this is exit time for many of the Members. Your
testimony is very important to a lot of us. Your knowledge and
your research have given us a lot of hope in terms of trying to
develop some good policies as we look to end obesity in
America. It also helps make us more aware of both the economic
and the human effects of obesity in our communities and our
neighborhoods and our schools.
I want to thank each and every one of you for coming and
sharing your expertise with us here. This will not be the end.
We have a lot of work ahead of us, I think that we can begin,
jointly, to develop in partnership and collaboration the kind
of programs that we need to reshape America. I think it is our
responsibility with the kind of programs and development and
the kind of legislation, kind of educational programs that we
can develop, and the kind of research that also needs to be
done. So I thank you for being here.
And with that, I would like to say that under the rules of
the Committee, the record of today's hearing will remain open
for 10 calendar days to receive additional materials and
supplemental written responses from the witnesses, and any
questions posed by Members, which means some of us may have
some questions we didn't get an opportunity to ask, so we will
submit those. The hearing of the Subcommittee of the Department
Operations, Oversight, Nutrition, and Forestry is now
adjourned. Again, thank you very much.
[Whereupon, at 1:00 p.m., the Subcommittee was adjourned.]
[Material submitted for inclusion in the record follows:]
Submitted Statement of Neal D. Barnard, M.D., President, Physicians
Committee for Responsible Medicine
Mr. Chairman, thank you for the opportunity to submit testimony to
the Subcommittee on the state of obesity in the United States. The
Physicians Committee for Responsible Medicine (PCRM) is a nonprofit
organization founded in 1985 and based in Washington, D.C. PCRM is
comprised of more than 120,000 members across the country, including
some 7,000 physicians, working together for preventive medicine,
nutrition, and higher ethical standards in research.
For many years PCRM has worked hard to educate Americans about good
nutrition and has also conducted numerous studies on nutrition. For
example, in 2006, PCRM completed an NIH-funded study on the link
between diet and type 2 diabetes. The findings of that study were
published in Diabetes Care, a journal published by the American
Diabetes Association, with subsequent findings published in the Journal
of the American Dietetic Association and elsewhere.
I would like to focus my testimony on the effect that poor
nutrition is having on America's children and ways Federal policy can
address this growing health crisis.
Kids need healthier diets. If you could look into the arteries of
children in schools, you would find that many have early signs of
atherosclerosis before they pick up their high school diplomas. One in
five is overweight by the end of elementary school. According to the
Centers for Disease Control and Prevention, one in three children born
in the year 2000 will develop diabetes at some point in his or her
life.
As children grow into adulthood, cancer will eventually strike one
in three females, one in two males. And as they reach older age, the
same fatty, high-calorie diets that caused these health problems will
increase their risk of developing Alzheimer's disease.
There are many proposed solutions to children's health problems:
more exercise, less TV, more vegetables and fruits, less meat and
cheese, more meals at home, and less fast food. But there is one thing
everyone agrees on: Children need healthful choices at school. People
who learn about healthful foods in childhood are much more likely to
choose them as adults.
But schools are in a tough spot. As food prices rise, many schools
rely on inexpensive commodities--many of which are high in fat and
cholesterol--and may not be able to expand their menus in healthier
directions. A major part of the problem is the fact that U.S.
agricultural policies continue to make those foods highest in fat and
cholesterol relatively cheap.
Unfortunately, the last farm bill did not adequately address the
many problems with Federal commodity subsidies. Despite record
deficits, Federal taxpayers continue to provide billions of dollars in
subsidies to agribusinesses for the production of the unhealthiest of
food products.
From a medical standpoint, I would ask the Subcommittee to help us
in tackling the obesity epidemic, and to revisit the farm bill and
eliminate or dramatically reduce direct and indirect Federal subsidies
for high-fat, high-cholesterol foods.
Nutrition policy is another area where Congress can make a
substantive impact, particularly through the re-authorization of the
Child Nutrition Act. Some common-sense changes at the Federal level
will help stem the rise in obesity among our children.
The most important change is a need for healthful options in school
lunch lines. A few simple choices would do a world of good.
Take a veggie burger, for example. It provides exactly the same
amount of protein as a typical cheeseburger--15 grams. But while a
cheeseburger harbors 10 grams of fat, a veggie burger has only five,
and it has no saturated fat, no cholesterol, and fewer calories.
Vegetarian chili has exactly the same protein content as chicken
nuggets--10 grams per serving. But while the nuggets have 18 grams of
fat, the veggie chili has only 3 grams. It, too, has essentially no
saturated fat, no cholesterol, and fewer calories. Unfortunately, most
school children never see these healthful vegetarian options.
President Obama's children, Sasha and Malia, attend Sidwell
Friends, a private school in Washington. On February 10, 2009, Sidwell
Friends' menu featured beef chili, and students looking for a healthier
choice could choose vegetarian chili. However, that same day, the
Washington, D.C., public schools served meatloaf with gravy, and
children who wanted a healthy vegetarian option were offered nothing at
all.
On February 13, 2009, Sidwell Friends served regular pizza, and
roasted vegetable pizza for students who wanted a vegetarian choice.
But children in the public schools were served chicken nuggets with
barbecue sauce. If they wanted a vegetarian option, they got nothing.
On February 25, 2009, Sidwell Friends served regular shepherd's pie
and vegetarian shepherd's pie. Public school children were served
bologna and cheese sandwiches. If they wanted a healthy, vegetarian
option, they got nothing.
A child in public school has a right to a healthful lunch, just as
a child in private school does. But most schools will only provide
these choices if Congress pushes them to do so--and provides the
wherewithal to make it happen. Schools should offer vegetarian choices
every day, and they should also have the funding that makes it feasible
for them to do so.
The following changes should be part of the new legislation:
1. All schools participating in the National School Lunch Program
(NSLP) and School Breakfast Program (SBP) must provide a
nondairy, vegetarian meal option and a healthful nondairy
beverage.
2. Calcium-rich nondairy beverages should be considered as
satisfying the milk requirement in fulfilling the definition of
reimbursable meals. Whether due to lactose intolerance,
allergy, ethics, or taste preference, a student who desires soy
milk instead of cow's milk should not need a note from home or
a doctor.
3. Reimbursement rates for NSLP and SBP should be increased by 20
percent for exemplary schools with meal averages as follows:
saturated fat <7%, cholesterol <100 milligrams, and fiber
>7grams.
4. Commodities should be selected based on current scientific
evidence about the role of diet in health and illness. The
commodity program should include no products with more than 7%
energy from saturated fat.
5. In order to allow schools to provide more healthful meals, the
calorie minimum required for meals shall be reduced. Currently,
meals for grades K through 3 must average at least 633
calories. For grades 4-12, these figures are 785 calories.
These figures are too high.
These changes would go a long way in improving the health of our
children and addressing the obesity epidemic.
Thank you for your consideration.
______
Submitted Statement of LuAnn Heinen, M.P.P., Director, Institute on the
Costs & Health Effects of Obesity; Vice President, National Business
Group on Health
The Cost of Obesity to U.S. Business
The National Business Group on Health (Business Group) thanks the
Subcommittee on Department Operations, Oversight, Nutrition and
Forestry of the House Committee on Agriculture for the opportunity to
submit these recommendations as our written testimony for the public
hearing to review the state of obesity in the United States on March
26, 2009.
Founded in 1974, the Business Group is a member organization
representing over 300 members, mostly large employers, who provide
coverage to more than 55 million U.S. employees, retirees and their
families and is the nation's only non-profit organization devoted
exclusively to finding innovative and forward-thinking solutions to
large employers' most important health care and related benefits
issues. Business Group members are primarily Fortune 500 companies and
large public sector employers, with 64 members in the Fortune 100.
Employers and employees fund health care in the U.S. by (1) paying
claims (larger, self-insured employers) or insurance premiums (smaller,
fully insured employers), and (2) paying corporate and individual
income taxes for Medicare and other public programs. The costs to both
employers and employees are significantly higher because of obesity, a
key factor in escalating health costs due to type 2 diabetes, heart
disease, some cancers, and many other conditions.
The great majority of employers want to continue sponsoring health
care for employees and their families, a key feature of leading health
reform proposals. However, a recent survey of nearly 500 large
employers identified ``employees' poor health habits'' (physical
inactivity, poor diet, tobacco use) as by far their greatest challenge
in providing affordable health coverage.\1\ This helps explain why the
great majority of members of the National Business Group on Health
(representing Fortune 500 employers) offer wellness and health
promotion programs at work.
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\1\ The Keys to Continued Success: Lessons Learned from Consistent
Performers. 14th Annual National Business Group on Health/Watson Wyatt
Employer Survey, 2009.
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Direct and Indirect Costs of Obesity to Employers Are Substantial
Obesity costs employers about $45 billion annually in medical costs
and lost productivity.\2\ The Federal Centers for Disease Control and
Prevention estimate that obese employees cost employers at least $4
billion each year in lost productivity alone, and that these employees
typically are absent from work twice as often as other employees. In
total, the obesity contributes to nearly 10% of healthcare spending in
the U.S., or as much as $93 billion annually.\3\
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\2\ Finkelstein, E., Fiebelkorn, I. and Wang, G. National Medical
Spending Attributable to Overweight and Obesity: How Much, and Who's
Paying? Health Affairs Web Exclusive, May 14, 2003.
\3\ cdc.gov/nccdphp/dnpa/Obesity/economic_consequences.htm.
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The direct medical costs of obesity are significant and measurable;
several published studies and employers' own data easily demonstrate an
increase in spending roughly correlated with increasing Body Mass Index
(BMI). It is especially noteworthy that an estimated 27% of the year-
over-year increase in health costs to private employers is attributable
to obesity; \4\ obesity is thus one of the key reasons why the trend in
U.S. health costs is persistently steeper than the CPI or even the
medical inflation index.
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\4\ Thorpe, K. et al. Trends: The Impact of Obesity on Rising
Medical Spending. Health Affairs Web Exclusive, October 20, 2004.
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Obesity is the leading ``lifestyle-related'' or ``modifiable'' risk
factor; it is more significantly associated with chronic medical
conditions, reduced health-related quality of life, and increased
health and medication spending than either smoking or problem
drinking.\5\
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\5\ Sturm, R. The Effects of Obesity, Smoking and Drinking on
Medical Problems and Costs. Health Affairs 21(2): 245-53, 2002.
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This helps explain the impact of obesity on productivity; when
quantified, these so-called indirect costs of obesity are as much as
three times as great as the direct medical costs. Obesity generates
indirect costs for employers by increasing workers' compensation claims
and related lost workdays,\6\ absenteeism,\7\ presenteeism,\8\ and
disability in people aged 50-69.\9\ Even without counting the cost of
presenteeism (a self-reported measure of diminished on-the-job work
performance due to health or life problems) which is not universally
measured, productivity costs attributable to obesity are highly
significant.
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\6\ Osbye, T. et al. Results from the Duke Health and Safety
System. Archives of Internal Medicine 166(8):766-73, 2007.
\7\ Finkelstein, E. et al. The Costs of Obesity Among Full-Time
Employees. American Journal of Health Promotion 20(1):45-51, 2005.
\8\ Ricci, J. and Chee, E. Lost Productive Time Associated with
Excess Weight in the U.S. Workforce. Journal of Occupational and
Environmental Medicine 47(12): 1227-34, 2005.
\9\ Sturm, R. et al. Increasing Obesity Rates and Disability
Trends. Health Affairs 23(2): 199-205, 2004.
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Obesity Rates Becoming a Workforce Differentiator
A Texas legislator tells the story of an employer who refused to
relocate to his Congressional district because of the high rate of
obesity in those counties. By contrast, the Metro Denver website
promotes Colorado as the state with the lowest rate of obesity,
claiming ``while no state is immune to rising obesity rates, we're
curbing the gradual expansion of our waistlines by re-adjusting our
culture. Under the leadership of the Metro Denver Health and Wellness
Commission, Metro Denver is aiming to become America's Healthiest
Community by instituting strategies that support worksite wellness,
school policy, and the creation of interlinked, walkable communities.''
\10\
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\10\ www.metrodenver.org/market-differentiators/health-
wellness.html.
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In addition to competing at the macro level, we see plenty of
competition among employers at the individual employer level for
recognition as employers of choice. The National Business Group on
Health has given 148 ``Best Employer for Healthy Lifestyles'' awards to
some of America's healthiest corporations over the last 4 years. Major
strategies employed by employers to improve employee and family health
include: comprehensive benefits with healthy lifestyle incentives;
environmental (nutrition and physical activity) support for healthy
lifestyles; the fostering of an organizational culture of health; and
outreach to family members and the community. These strategies are
fully described in a recent publication provided to the Subcommittee
(The Milbank Quarterly March 2009 special edition on Obesity; see
especially Heinen and Darling, ``Addressing Obesity in the Workplace:
The Role of Employers'').\11\
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\11\ Heinen, L. and Darling, H. Addressing Obesity in the
Workplace: The Role of Employers. The Milbank Quarterly 87(1):101-122,
2009.
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The Next Generation: Impact on Employers (and Society) Will Be
Significant
As concerned as employers are about the health and cost
consequences of America's lifestyle today, the problems of tomorrow's
workforce may eclipse anything seen to date. The Millennial generation
(born between 1980 and 2000) is one of the largest ever--and they are
the unhealthiest in modern history. Seventy-five million strong, this
generation is now entering the workforce. Commonly described as
ambitious, confident, and ``not willing to take no for an answer,''
they also overwhelmingly sedentary, choosing the array of high-tech
entertainment options available to them over regular, vigorous physical
activity. Raised with low-cost calories freely available 24/7, they
consume more calories per day on average than previous generations.
Currently 32 percent of children and adolescents are overweight or
obese, with 16.3 percent possessing a BMI in the obese range.\12\ As
the Millennials age and these trends continue, it is projected that a
staggering 86 percent of Americans will be overweight or obese by
2030.\13\
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\12\ Ogden, C. et al. High Body Mass Index for Age Among U.S.
Children and Adolescents, 2003-2006. Journal of the American Medical
Association 299 (20):2401-2405, 2008.
\13\ Wang, Y. Will All Americans Become Overweight or Obese?
Obesity 16(10): 2323-2330, 2008.
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According to the 2007 Youth Risk Behavior Survey,\14\ among U.S.
high school students:
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\14\ www.cdc.gov/HealthyYouth/yrbs/pdf/yrbs07_us_obesity.pdf.
13% are obese; adolescent obesity has more than tripled in
---------------------------------------------------------------------------
the past 25 years.
Nearly 80% do not consume the recommended amount of fruits
and vegetables.
More than \1/3\ drink at least one can of soda each day.
65% do not achieve the recommended amount of daily physical
activity.
More than 10% do not engage in any physical activity.
35% watch 3 or more hours of television each day.
25% play video games or use a computer recreationally for
more than 3 hours each day.
45% are attempting to lose weight.
It is sobering to realize that this generation will comprise a
significant portion of the workforce in a few short years and is on
track to further burden U.S. employers and health care payers, whether
they be public or private, with their poor health status and associated
costs.
The evidence so far suggests the Millenials will carry their risky
health habits into the workforce. A 2007 Nationwide Better Health
survey \15\ found:
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\15\ www.nationwidebetterhealth.com/docs/media-kit/obesity-in-
workplace.pdf.
22 percent of 18-27 year-old employees eat an unhealthy
snack at work at least five times each week. This compares to
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nine percent of those over age 45.
27 percent of those 18-27 report a sedentary job, sitting at
a desk most of the day.
35 percent of those under age 27 indicate that stress leads
to adverse nutritional choices.
Due to declining health status over the course of this century,
life expectancy in the U.S. could drop by 5 years or more.\16\ Further,
a Rand Corporation analysis revealed that, in recent years, 30-39 year
olds have experienced the sharpest rise in disability rates of any age
group--increases upwards of 50 percent.\17\ New research projects an
additional 100,000 annual cases of heart disease by 2035 if obesity
rates are not brought under control.\18\
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\16\ Olshansky, S.J. et al. A Potential Decline in Life Expectancy
in the United States in the 21st Century. New England Journal of
Medicine 352(11): 1138-1145, 2005.
\17\ Lakdawalla, D. et al. Are the Young Becoming More Disabled?
Health Affairs 23(1): 168-176, 2004.
\18\ Bibbens-Domingo, K. Adolescent Overweight and Future Adult
Coronary Heart Disease, New England Journal of Medicine 357(23): 2371-
9, 2007.
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All of this translates into an additional $956 billion each year in
medical costs by about 2030. Simply put, within two decades, one of
every $6 spent on health care in the United States could be
attributable to overweight and obesity.\19\
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\19\ Wang, Y. et al., op. cit.
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Policy Can Support Healthier Weight, and a Healthier Economy
To change course and avert these dismal scenarios, we must
acknowledge the threat posed by obesity to our common purpose and react
accordingly. Every employer and policymaker should understand that as a
nation we are already paying for the medical costs and lost
productivity costs of serous overweight and obesity. Thus it is
directly in our financial interest to support policy to improve the
health of employees and families.
In general, policymakers should view proposed policies and programs
through the lens of ``obesity impact.'' Just as environmental
assessment is often part of laws and regulations at the state and
Federal level for new energy projects, a required obesity impact
assessment could focus the attention of lawmakers and organizations
seeking Federal funding on this problem. Obesity impact assessments
would be especially relevant to food and farm policies along with
housing, urban development, public works, transportation and other
projects affecting the built environment and the promotion of
``livable'' communities which offer walking, biking and recreational
opportunities.
We must reform the tax code to reward and incentivize health and
wellness and not just subsidize treatment of disease as our current tax
laws do. We must make it easier for employees to participate in
employee wellness programs, including weight management and weight loss
programs, and to make it easier for employers of all sizes--small,
medium, and large--to administer employee wellness programs by making a
small change in the tax code to treat out-of-pocket expenses for health
and wellness the same as it does for expenses for medical care.
While current tax law allows employers to deduct all of their costs
toward employee wellness as business expenses, generally the value of
employer contributions to employees for these purposes must be reported
as income subject to taxation by employees--including payment for
fitness, nutrition, and weight management programs--unless they are
part of medical treatment.
Employees should be able to use pre-tax dollars (including through
Section 125 cafeteria plans, HSAs, and FSAs) to pay for health and
wellness activities, programs and purchases, including for fitness,
nutrition, and weight-management programs. Employer contributions
toward employee expenses for health and wellness, activities, programs
and purchases should be excludable from income for tax purposes. People
should be allowed to deduct post-tax out-of-pocket expenses for health
and wellness activities, programs, and purchases from their taxes
irrespective of whether it is for medical and treatment or for
wellness, health maintenance or disease prevention if their total
health care expenses meet the 7.5 percent adjusted gross income
threshold for health care expenses.
Extending favorable tax treatment for employer-contributions to pay
for employee health and wellness programs would remove a major barrier
to more widespread adoption of these programs and lead to a healthier
America.
Just as employers who subsidize employee cafeterias should only
subsidize fruits, vegetables and other foods that would otherwise not
be consumed at the recommended levels of daily intake, so should the
Federal Government limit its subsidies to the types and classes of
foods essential to a healthy diet that are currently under-consumed,
particularly fruits and vegetables. Food stamp, WIC and other Federal
aid should encourage the purchase of healthy, nutrient-rich foods and
beverages; unprocessed or minimally processed foods; whole grains;
fruits; and vegetables.
Support for locally grown produce (e.g., in school lunch programs),
farmers markets, tax subsidies for inner city grocery stores and other
approaches to eliminate so-called ``food deserts'' where access to
healthful foods is lacking are particularly worthwhile and should be
encouraged.
Thank you for the opportunity to share the perspective of large
employers on the obesity cost crisis. We believe it is essential to
combat the tsunami of obesity that threatens to overwhelm us. In terms
of lifetime and generational impact, obesity has ramifications that go
even beyond those associated with the current economic crisis. The
National Business Group on Health welcomes further dialogue with the
Subcommittee on this or related matters.
National Business Group on Health contacts:
LuAnn Heinen,
Vice President, Obesity Institute,
[Redacted] or [Redacted];
Steve Wojcik,
Vice President, Public Policy,
[Redacted] or [Redacted];
Helen Darling,
President,
[Redacted] or [Redacted].
______
Submitted Statement of Campaign to End Obesity
The Campaign to End Obesity (``The Campaign'') is a nonprofit,
nonpartisan organization dedicated to reversing the rising rates of
obesity through Federal policy action. The Campaign is the only
organization that brings together leaders in public health, academia,
and industry to promote common policy goals for stemming the nation's
obesity epidemic (a list of our Board and Advisory Board Members are
attached). We commend the Health, Education, Labor, and Pensions
Committee for its commitment to helping Americans live healthier lives.
The Campaign looks forward to continuing to work with the Committee to
assist in developing and advancing policies that enable better
prevention, identification, management and treatment of obesity.
A Crisis We Cannot Afford to Ignore
Obesity is now the most costly and prevalent chronic disease
affecting American adults and children, and the single most dangerous
driver of every other chronic disease afflicting our nation. Eighty-
three cents of every dollar spent on U.S. health care costs is
associated with obesity, and that number continues to grow as the
epidemic triggers greater incidence of costly chronic diseases like
heart disease, cancer and diabetes. Today, nearly 33 percent of the
American adult population is obese, more than double what it was in
1980.\1\ Likewise, an astonishing 16.3 percent of children are
considered overweight or obese.\2\
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\1\ Fox, Maggie. ``Obese Americans Now Outweigh the Merely
Overweight.'' Reuters. January 9, 2009. http://www.reuters.com/article/
domesticNews/idUSTRE50863H20090109.
\2\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass
Index for Age among U.S. Children andAdolescents, 2003-2006.'' Journal
of the American Medical Association 299, no. 20 (2008): 2401-2405.
---------------------------------------------------------------------------
The obesity epidemic has brought other tolls as well: children with
obesity suffer from a growing list of emotional disorders such as
depression, social stigmatization, and poor academic performance;
employees with obesity cost private employers $45 billion a year due to
medical expenses and excessive absenteeism; \3\ and, Americans with
obesity face lower quality medical care as the current infrastructure
may be inadequate to diagnose, monitor and treat them.
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\3\ Rosen, B. and L. Barrington. Weights & Measures: What Employers
Should Know about Obesity. New York, NY: The Conference Board, April
2008.
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Working Together Toward Solutions
How can we begin to reverse the tide on rising obesity rates across
the country? Families, communities, local, state, and the Federal
Government all must take a leadership role to fight this perilous
epidemic to improve the health of the American people and reduce the
ever-growing costs of this deadly disease on our health care system.
The Campaign's leadership believes that, if powerful interests work
together, we can drive the national policy change needed to achieve the
goal of reducing obesity rates. The Campaign urges policymakers to work
actively in the current Congress to adopt the following new and
aggressive policies that will create a framework to encourage better
nutrition and more healthful living:
Improve the Federal Apparatus for Addressing Obesity
Prompt the Executive Branch to convene one or more
high profile events or commissions to highlight the
importance of a Federal response to U.S. rates of obesity.
Create an Executive Branch function to focus on
obesity, i.e., a coordinator across health agencies.
Launch public awareness efforts to educate key
constituencies about risks, resources and prevention/
treatment options.
Mandate that Executive Branch and/or legislative
actions be considered with respect to their impact on
efforts to reduce obesity.
Bolster Access for Americans to an Environment That Helps
Reduce Their Prospects of Becoming Obese
Expand the infrastructure to facilitate and encourage
increased physical activity in communities and schools;
Incent or require increased physical activity for
children during the school day; and
Increase access to healthy nutrition for children by
providing incentives.
We commend Congress for already acting this year on one of the
Campaign's priorities: including a childhood obesity demonstration
project in the SCHIP reauthorization bill. Authorizing grants to
community organizations across the nation to develop programs that
encourage healthy living is a step in the right direction to preventing
obesity, particularly as it affects one of our most vulnerable
populations--children of economically disadvantaged homes.
The Campaign believes that the 111th Congress is presented with a
unique opportunity to make real reforms to give Americans a chance for
a better, healthier weight and life. We look forward to working with
Congress and the new Administration to achieve these reforms. Please
contact Noelle Lundberg ([Redacted]) or Jennifer Conklin ([Redacted])
with any questions.
Attachment 1