[Senate Hearing 107-477]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 107-477



                     GETTING FIT, STAYING HEALTHY:

                   STRATEGIES FOR IMPROVING NUTRITION

                    AND PHYSICAL ACTIVITY IN AMERICA

=======================================================================

                                HEARING

                               BEFORE THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS
                          UNITED STATES SENATE

                      ONE HUNDRED SEVENTH CONGRESS

                             SECOND SESSION

                                   ON

EXAMINING STRATEGIES FOR IMPROVING NUTRITION AND PHYSICAL ACTIVITY, IN 
         AN EFFORT TO STAVE OFF THE OBESITY EPIDEMIC IN AMERICA

                               __________

                              MAY 21, 2002

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman
CHRISTOPHER J. DODD, Connecticut     JUDD GREGG, New Hampshire
TOM HARKIN, Iowa                     BILL FRIST, Tennessee
BARBARA A. MIKULSKI, Maryland        MICHAEL B. ENZI, Wyoming
JAMES M. JEFFORDS (I), Vermont       TIM HUTCHINSON, Arkansas
JEFF BINGAMAN, New Mexico            JOHN W. WARNER, Virginia
PAUL D. WELLSTONE, Minnesota         CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             PAT ROBERTS, Kansas
JACK REED, Rhode Island              SUSAN M. COLLINS, Maine
JOHN EDWARDS, North Carolina         JEFF SESSIONS, Alabama
HILLARY RODHAM CLINTON, New York     MIKE DeWINE, Ohio

           J. Michael Myers, Staff Director and Chief Counsel
             Townsend Lange McNitt, Minority Staff Director


                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                         Tuesday, May 21, 2002

                                                                   Page
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico.     1
Frist, Hon. Bill, a U.S, Senator from the State of Tennessee.....     2
Dietz, William H., M.D., Director, Division of Nutrition and 
  Physical Activity, National Center for Chronic Disease 
  Prevention and Health Promotion, Centers for Disease Control 
  and Prevention, U.S. Department of Health and Human Services...     5
    Prepared statement...........................................     7
Dodd, Hon. Christopher J., a U.S. Senator from the State of 
  Connecticut....................................................    16
Austin, Ms. Denise, on behalf of P.E.4Life, accompanied by Ann 
  Flannery, Executive Director, P.E.4Life........................    19
    Prepared statement...........................................    22
Davis, Sally M., Director, Center for Health Promotion and 
  Disease Prevention, University of New Mexico...................    27
    Prepared statement...........................................    29
Brownell, Kelley D., Director, Yale Center for Eating and Weight 
  Disorders, Yale University.....................................    30
Katic, Ms. Lisa, Senior Food and Health Policy Advisory, Grocery 
  Manufacturers of America.......................................    34
    Prepared statement...........................................    35
Dickey, Richard A., M.D., Wake Forest University School of 
  Medicine, on behalf of the Endocrine Society...................    40
    Prepared statement...........................................    42

                          Additional Material

Statements, articles, publications, letters, etc.:
    Senator Enzi.................................................    49
    Senator Clinton..............................................    49
    Response to questions of Senator Clinton from Kelley Brownell    50
    Response to questions of Senator Clinton from Lisa Katic.....    51
    John McCarthy................................................    52
    Katherine E. Tallmadge.......................................    54
    Myrna Johnson................................................    58
    Connie Tipton................................................    59
    American Dietetic Association................................    61
    National Soft Drink Association..............................    63

 
                     GETTING FIT, STAYING HEALTHY:
                   STRATEGIES FOR IMPROVING NUTRITION
                    AND PHYSICAL ACTIVITY IN AMERICA

                              ----------                              


                         TUESDAY, MAY 21, 2002

                                       U.S. Senate,
       Committee on Health, Education, Labor, and Pensions,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 2:30 p.m., in 
room SD-430, Dirksen Senate Office Building, Senator Bingaman, 
presiding.
    Present: Senators Bingaman, Dodd, Reed, and Frist.

                 Opening Statement of Senator Bingaman

    Senator Bingaman [presiding]. The hearing will come to 
order. Thank you all for coming.
    Today's hearing is on the issue of obesity and the epidemic 
of obesity and the problems associated with it, particularly in 
young people.
    Obesity has reached epidemic proportions and has become a 
major public health problem in our country. It is estimated 
that about 61 percent of American adults are overweight or 
obese. Obesity rates have increased by 61 percent during the 
last decade.
    The epidemic is particularly alarming when you look at how 
it affects our young people. The percentage of overweight 
children has nearly doubled, from 7 percent to 13 percent, 
while the percentage of overweight adolescents has almost 
tripled, from 5 percent to 14 percent, over the past two 
decades.
    Although obesity has increased among all populations, this 
increase is occurring at disproportionate rates among at-risk, 
medically underserved populations which include racial and 
ethic minority groups and persons of lower income status.
    In my home State of New Mexico, 62 percent of American 
Indian adults and 63 percent of Hispanic adults are overweight 
according to the statistics that we have been given
    Nationwide, obesity among black and Hispanic children 
increased by more than 120 percent compared to about 50 percent 
among white children from 1996 to 1998.
    One-third of children from lower income households are 
obese compared to 19 percent of children from higher income 
households.
    These rising rates of obesity are accompanied by a host of 
other health consequences, including heart disease, Type II 
diabetes, some types of cancer, stroke, arthritis, breathing 
problems, and psychological problems, and many health problems 
that are typically thought of in the context of adults, 
including early warning signs of heart disease such as high 
cholesterol and high blood pressure and Type II diabetes, are 
becoming prevalent among children as well.
    I think we are all in agreement that there is no one right 
way to address this problem. It is a problem that will require 
a comprehensive, multifaceted approach that will have to take 
into account a wide array of factors that contribute to it. 
Improved nutrition and increased physical activity have been 
defined as key factors associated with this issue.
    Scientifically, it is well-established that healthy diets 
and adequate levels of physical activity can reduce the risk of 
becoming overweight and obese and help reduce morbidity and 
mortality associated with obesity-related diseases.
    I worked closely with Senator Frist and Senator Dodd on 
legislation that we have entitled ``The Improved Nutrition and 
Physical Activity Act.'' That legislation focuses on strategies 
for preventing and decreasing overweight and obesity in 
families and communities. The legislation includes programs of 
evidence-based approaches as well as innovative strategies 
designed to get people moving, eating well, engaged in leading 
healthy lifestyles across their life span, with a particular 
emphasis on youth and school health programs.
    Very recently, I worked with Senator Leahy and others on 
legislation to impose restrictions on soda machines in schools, 
and I received a letter at that point from a substitute teacher 
in Albuquerque who said, ``Dear Jeff, I sincerely hope you will 
continue to pursue legislation to improve the nutrition of our 
Nation's students. As a substitute teacher and parent, I see 
firsthand the awful diets that our kids are existing on while 
at school. The snack bars which many middle and high school 
students purchase their lunches from have plenty of chips, 
candy, sports drinks and pizza, but nutritious snacks such as 
yogurt and fruit are missing. I have also found that there is 
not an easy way for a student to purchase a carton of milk in 
many schools. One of my students jokingly told me one day that 
he had had a balanced lunch--all the colors were in the bag of 
Skittles.''
    It is humorous, but in many ways it is unfortunate that we 
have students eating bags of Skittles and claiming that that is 
lunch.
    So I think this legislation is important, and I know that 
this issue is extremely important to our country and appreciate 
all of you being here.
    Let me defer to Senator Frist for his opening comments, and 
then we will hear from Dr. Dietz.

                   Opening Statement of Senator Frist

    Senator Frist. Thank you, Mr. Chairman.
    The number of Americans who are overweight and obese has 
grown steadily during the past decade. The problem is real, and 
the problem is one that is increasing. Today, more than 38 
million Americans are obese; an estimated 61 percent of adults 
are overweight or obese, and 13 percent of children and 
adolescents and children are overweight.
    The prevalence of being overweight and obese is indeed 
increasing among both men and women and indeed all age groups. 
The problem is real, and the problem is getting worse.
    In the first chart here--and these are charts which have 
really been imprinted in my own mind as I address this problem, 
because I think they do tell the story of the problem and what 
we need to do is see what the appropriate Federal, State and 
local response should be.
    The first chart covers 1991 in the upper left-hand corner, 
1995 in the upper right-hand corner, and 2000 down below. The 
Centers for Disease Control and Prevention have tracked risk 
factors for chronic disease. In the States colored dark blue, 
over 30 percent of adults are classified as obese. As you can 
see, this epidemic of obesity is real; it has already across 
the country in the past 20 years since 1991, and again, just 
for those of you in the back, you can see the increasing blue, 
but also the red, which you can clearly see, is greater than 20 
percent. You can see that there was no red in 1991, in 1995 no 
red--and look at where we are in the year 2000 as the 
percentage of adults who are obese is increasing.
    In my own State of Tennessee, Tennessee has the seventh-
highest percentage of adults who report no leisure time 
physical activity and the 12th-highest percentage of adults who 
are overweight.
    Perhaps most disturbing to me are the increases among 
America's young people. In my own State of Tennessee, nearly 12 
percent of high school students are overweight and 82 percent 
reported eating fewer than the five recommended servings of 
fruits and vegetables per day.
    Nationwide, the number of overweight children has doubled, 
and the number of overweight adolescents has tripled in the 
past decade. Again, for those of you in the back who cannot see 
the chart and read along the X axis there, on the far left is 
1973 to 1970, and it moves all the way across to 1999. The blue 
line is 6 to 9 years of age, and the red line is 12 to 19 years 
of age. And again it defines, at least for me, the importance 
of us acting, responding, and working together to develop an 
appropriate response to this increase.
    The Surgeon General wrote last year in his ``Call to 
Action'' that ``the prevalence of overweight and obesity in the 
United States has truly reached epidemic proportions. An 
estimated 300,000 deaths a year are associated with being 
overweight or obese, and people who are obese have a 50 to 100 
percent increased risk of premature death.'' That is a doubling 
of the risk of premature death. ``Being overweight or obese 
increases the risk of disease, including heart disease, 
diabetes, musculoskeletal disorders, and many other 
conditions.''
    The third chart uses 1990 data, and the CDC and others are 
working to update or modernize that data, and if anything, the 
data is likely to be worse rather than better than in 1990. But 
this is the leading study in the area, and it shows that poor 
nutrition and physical inactivity are the second leading causes 
of death in the United States, resulting in about 14 percent of 
all deaths.
    Again along the X axis is the percentage of all deaths, and 
along the top is tobacco, and the second, in red, is poor diet/
exercise, and then comes alcohol, infectious agents, 
pollutants, firearms, sexual behavior, motor vehicles, illicit 
drug use. Again, that is dramatic.
    We have a responsibility to do something about that, and 
that something, again, as the Chairman mentioned, we are all 
working to decide exactly what that is, and that is why this 
hearing today is so important.
    The good thing is that it is preventable, and we know it is 
preventable; therefore, we know that there is something that we 
can do to prevent this dramatic impact that poor diet and lack 
of exercise has.
    There is not a single solution, but we know that progress 
can be made by educating people, by providing more information, 
by making better known and more broadly known the healthier 
options and increased opportunities for physical activity.
    People ask me all the time, ``Do you really want the 
Federal Government in this business?'' and the answer is yes, 
because we can demonstrate both leadership and, through 
legislation, a coordination, a highlighting and a spotlighting 
of the problem and potential solutions.
    More research, for example, is needed to help us find 
solutions and better target interventions. More resources are 
needed to expand those programs that we know are successful. 
Enhanced oversight, better coordination of existing programs, 
and limited pilot programs can help us find innovative, cost-
effective ways to produce and prevent obesity, which will 
translate into a reduction in death and premature death.
    I do appreciate the Bush Administration's commitment to 
making improvements in this area. I applaud Secretary 
Thompson's personal commitment to reducing the incidence of 
overweight and obesity. As we finished an annual road race here 
about 3 weeks ago, I mentioned to him what we were going to be 
doing in terms of addressing the issue of obesity and had the 
opportunity to thank him, but it also imprinted in my mind the 
importance of having somebody like him out there, running, 
watching his own weight, watching his own diet, as a real model 
for us all.
    Today we have made available a summary of the draft 
legislation that we are working on, that Senator Bingaman 
mentioned, along with Senators Dodd, Collins, Stevens, and many 
others. I think today's hearing will help us refine that 
legislation with what we hear.
    We do plan to introduce bipartisan legislation in the near 
future, probably right after the upcoming Memorial Day recess.
    In addition, we plan to ask the GAO to look at the way that 
nutrition and physical activity programs are organized 
throughout the Federal Government and to suggest ways that 
coordination and effectiveness could be improved.
    Legislation can go a long way, yet we cannot change the 
trends of the past two decades through laws and legislation 
alone. The Government does not have all the answers. The 
private sector has a crucial role to play. The food and 
restaurant industries have demonstrated significant leadership. 
Already we are seeing an increasing number of advertisements 
for fast food restaurants touting healthier options. All of us 
have seen that change over the last couple of years. One 
national chain has designed its entire advertising strategy 
around its low-fat menu options.
    There will be new collaborative efforts which we will 
promote in the legislation between the Government and the 
private sectors so that Americans do have better information 
and are equipped to make those healthier choices. We need to 
avoid stigmatizing or demonizing any one sector of society and 
to build on a coalition of public and private interest to begin 
to address this problem on multiple fronts.
    Mr. Chairman, I thank you for holding this hearing and look 
forward to working with you and others on this committee as we 
address a problem which has now reached epidemic proportions.
    Senator Bingaman. Thank you very much, Senator Frist.
    We have three panels this afternoon. Our first panel 
consists of Dr. William Dietz, who is Director of the Division 
of Nutrition and Physical Activity in the National Center for 
Chronic Disease Prevention and Health Promotion at the Centers 
for Disease Control.
    Dr. Dietz has been a leader in examining the causes and 
consequences of obesity, particularly among children. We 
welcome you as a witness today, and we are anxious to hear 
whatever you can tell us about how to solve this problem.
    Please take a few minutes and summarize your testimony if 
you would, and we will include your entire written statement in 
the record.

  STATEMENT OF WILLIAM H. DIETZ, M.D., DIRECTOR, DIVISION OF 
 NUTRITION AND PHYSICAL ACTIVITY, NATIONAL CENTER FOR CHRONIC 
 DISEASE PREVENTION AND HEALTH PROMOTION, CENTERS FOR DISEASE 
  CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND HUMAN 
                            SERVICES

    Dr. Dietz. Thank you, Senator Bingaman, Senator Frist.
    It is a great honor and pleasure to be here, and thank you 
for inviting me to comment on this important problem.
    I can do little to improve on the epidemiology which you 
have summarized so well, but I just want to expand on a couple 
of points.
    First, 8 million children and teenagers in the United 
States are now overweight.
    Second, although childhood obesity only accounts for about 
one-quarter of adult obesity, childhood-onset obesity in obese 
adults tends to be more severe, so it exerts a disproportionate 
contribution to morbidity and mortality.
    Even so, 60 percent of overweight children have at least 
one additional cardiovascular disease risk factor, and 25 
percent have two or more.
    As you pointed out, we have already begun to see the impact 
of childhood obesity on disease. Type II diabetes, a disease 
previously limited only to adults, now accounts for as much as 
50 percent of new cases of diabetes in some communities.
    We pointed out in an article last week that hospitalization 
rates for overweight children have tripled over the last 30 
years. And as you pointed out, in adults, obesity accounts for 
300,000 deaths annually, second only to tobacco-related deaths.
    Last year, the Surgeon General's report suggested that 
obesity and its complications were already costing $117 billion 
annually. The rapid increases in obesity across the population 
suggest that these costs are only going to increase.
    The CDC has made efforts to develop effective prevention 
and treatment strategies through our State programs, State-
coordinated school health programs, and applied research agenda 
to develop and refine new approaches and partnerships with 
other organizations.
    Currently, the CDC funds 12 States to prevent and reduce 
obesity and its related chronic diseases through policy and 
environmental changes. Most of the State programs have focused 
on youth, and with a modest increase in funds this year, some 
States will begin to fund community programs.
    For example, CDC funds the North Carolina Healthy Weight 
Initiative which involves communities in a Statewide task force 
comprised of community leaders and health professionals. The 
CDC-funded program is a curriculum for 4- and 5-year-olds 
called ``Color Me Healthy,'' which focuses on eating healthy 
and being active and is being implemented in 71 counties 
through cooperative extension and WIC. States could clearly do 
more.
    One of the most efficient means of impacting the greatest 
numbers of children and adolescents and shaping our Nation's 
future health is through school health programs. The CDC 
through its coordinated school health programs reaches students 
in elementary and secondary schools during their formative 
years, when many health habits are formed.
    CDC and coordinated school health programs are working to 
increase physical activity and improve nutrition among our 
Nation's young people. While we currently fund 20 State-
coordinated school health programs, much more must be done to 
establish healthy eating and physical activity patterns in 
young people.
    At least four behavior change strategies are currently 
justified to reduce obesity and the chronic diseases associated 
with it. These include the promotion of breast feeding and 
efforts to increase its duration; reduced television viewing in 
children and adolescents; increased fruit and vegetable 
consumption, and increased physical activity for the 
population. Because of time constraints, I will only focus on 
physical activity.
    Increased physical activity prevents weight gain, maintains 
weight after weight loss, and reduces many of the comorbidities 
associated with obesity such as hypertension and diabetes.
    In addition, physical activity may also displace other 
health risk behaviors in youth. In fiscal year 2001, Congress 
appropriated $125 million to develop the CDC Youth Media 
Campaign which will be launched in June. The campaign will be 
directed at 9- to 13-year-olds, and we use the best principles 
of marketing and communication to get children excited about 
increasing the amount of physical activity in their lives and 
helping their parents see the importance of physical activity 
to the overall health of their children.
    We also for the first time have six evidence-based 
strategies around the promotion of physical activity that we 
are beginning to incorporate into State programs. These 
approaches represent strategies that we can pursue today while 
we do the research necessary to identify additional effective 
prevention approaches for States and communities.
    In summary, obesity in the United States is epidemic. The 
consequent increase in diabetes and other diseases caused by 
obesity are likely to break the health care bank. Although CDC 
programs and strategies have started to address obesity, we 
have only begun. We must invest in comprehensive nutrition and 
physical activity approaches that link changes in families, 
schools, worksites and health care settings to successfully 
halt this epidemic.
    Thank you, Mr. Chairman.
    [The prepared statement of Dr. Dietz follows:]

              Prepared Statement of William H. Dietz, M.D.

    Good morning. I am Dr. William Dietz, Director of the Division of 
Nutrition and Physical Activity at Centers for Disease Control and 
Prevention. I am pleased to be here today to participate in this 
important discussion of the obesity epidemic.
                           burden of obesity
    The burden placed on our society by obesity and related chronic 
diseases is enormous. In the last 20 years, obesity rates have 
increased by more than 60 percent in adults. Since 1980, rates have 
doubled in children and tripled in adolescents. More than 25 percent of 
the adult population in the United States is obese, or approximately 50 
million adults. Almost 15 percent of our children and adolescents are 
overweight, or approximately eight million youth. Rates of obesity have 
increased more rapidly among African Americans and Mexican Americans 
than among Caucasians. Obesity in the United States is truly epidemic.
    We have already begun to see the impact of the obesity epidemic on 
other diseases. For example, Type II diabetes, a major consequence of 
obesity, also has increased rapidly over the last 10 years. Although 
Type II diabetes was virtually unknown in children and adolescents 10 
years ago, it now accounts for almost 50 percent of new cases of 
diabetes in some communities. Obesity is also a major contributor to 
heart disease, arthritis, and some types of cancer. Recent estimates 
suggest that obesity accounts for 300,000 deaths annually, second only 
to tobacco related deaths.
    The contribution of childhood onset obesity to adult disease is 
even more worrisome. Although onset of obesity in childhood only 
accounts for 25 percent of adult obesity, obese adults who were 
overweight children have much more severe obesity than adults, who 
became obese in adulthood. Sixty percent of overweight children have at 
least one additional cardiovascular disease risk factor, and 25 percent 
have two or more. Hospitalization rates for the complications of 
obesity in children and adolescents have tripled.
    The combination of chronic disease death and disability accounts 
for roughly 75 percent of the $1.3 trillion spent on health care each 
year in the United States. Last year, the Surgeon General's Call to 
Action on Obesity suggested that obesity and its complications were 
already costing the Nation $117 billion annually. By way of comparison, 
obesity has roughly the same association with chronic health conditions 
as does 20 years of aging, and the costs of obesity were recently 
estimated to exceed the health care costs of smoking and problem 
drinking.
    The rapid increases in obesity across the population and the burden 
of costly diseases that accompany obesity indicate that we should not 
ignore. The rapidity with which obesity has increased can only be 
explained by changes in the environment that have modified calorie 
intake and energy expenditure. Fast food consumption now accounts for 
more than 40 percent of a family's budget spent on food. Soft drink 
consumption supplies the average teenager with over 10 percent of their 
daily caloric intake. The variety of foods available has multiplied, 
and portion size has increased dramatically. Fewer children walk to 
school, and the lack of central shopping areas in our communities means 
that we make fewer trips on foot than we did 20 years ago. Hectic work 
and family schedules allow little time for physical activity. Schools 
struggling to improve academic achievement are dropping physical 
education and assigning more homework, which leaves less time for 
sports and physical activity. Television viewing has increased. 
Neighborhoods can be unsafe for walking, and parks may be unsafe for 
playing. Many office buildings tend to have inaccessible and uninviting 
stairwells that are seldom used, and many communities are built without 
sidewalks or bike trails to support physical activity.

                         PUBLIC HEALTH APPROACH

    Given the size of the population that we are trying to reach, we 
cannot rely solely upon individual interventions that target one person 
at a time. Instead, the prevention of obesity will require coordinated 
policy and environmental changes that affect large populations 
simultaneously. The CDC has made efforts to develop effective 
prevention and treatment strategies through our State obesity programs, 
State coordinated school health programs, partnerships with other 
organizations, and an applied research agenda to develop and refine new 
approaches.

         A COORDINATED STRATEGY TO ADDRESS THE OBESITY EPIDEMIC

    Currently CDC funds 12 States to prevent and reduce obesity and its 
chronic related diseases. Our support permits States to develop and 
test nutrition and physical activity interventions to prevent obesity 
through strategies that focus on policy-level changes (e.g., States 
assess and rate childcare centers for nutrition and active play) or a 
supportive environment (e.g., competitive pricing of fruits and 
vegetables in school cafeterias). Examples of these approaches can be 
illustrated by the experience in three States.
    In Massachusetts, The National Institutes of Health (NIH) funded a 
school-based obesity curriculum known as Planet Health. This 
curriculum, which integrated reduced fat, increased fruit and vegetable 
intake, increased physical activity, and reduced television, messages 
in science, math, language and social studies classes significantly 
reduced obesity in adolescent girls. The CDC is now supporting the 
expansion of this program into public, charter, and parochial school 
systems in Boston.
    The State of Rhode Island has selected racial and ethnic minority 
children enrolled in public elementary schools as the target for 
lifelong healthy eating and physical activity behaviors to promote 
healthy weight, based on the CDC guidelines for school health, which 
were developed with input from the Department of Education. After 
surveying half of all elementary schools (including all schools with at 
least 25 percent or more Hispanic enrollment) to assess existing 
nutrition and physical activity programs, policies, and environmental 
supports in schools, the State is developing a systems-level, nutrition 
and physical activity intervention that will increase the number of 
environmental and policy supports in schools based upon the CDC 
guidelines for school health programs to promote lifelong physical 
activity and healthy eating. Selected communities with schools where at 
least 40 percent of the students are Hispanic/Latino and 50 percent or 
more of the student population is eligible for free or reduced lunch 
programs will be involved in the program beginning in September. Each 
school will tailor intervention components to fit with their school 
structure and population while maintaining a common purpose and shared 
activities across schools. Program expectations include goals for 
student consumption of fruits and vegetables to five daily servings and 
participation in moderate physical activity for 30 minutes at least 
five times a week.
    The North Carolina Healthy Weight Initiative has involved 
communities and an energetic statewide task force comprised of 
community leaders and health professionals. The group has developed a 
curriculum known as ``Color Me Healthy'' for 4- and 5-year-olds that 
focuses on interactive, innovative learning opportunities on eating 
healthy and being active. Through an innovative collaboration with the 
U.S. Department of Agriculture (USDA), implementation of ``Color Me 
Healthy'' is underway in 71 counties through cooperative extension and 
the Special Supplemental Nutrition Program for Women, Infants and 
Children (WIC). These programs help illustrate how CDC-funded programs 
translate research findings into practice, and integrate HHS activities 
with those of other departments.
    In addition to the collaboration with State health departments, CDC 
also funds 20 State educational agencies through the Coordinated School 
Health Program. This program reaches students in elementary and 
secondary schools and strives to increase physical activity and improve 
the nutrition among our Nation's young people. Through this program, 
the CDC awards competitive grants to State, tribal, and territorial 
educational agencies to:
    Plan, implement, and evaluate programs, including curricula, to 
promote a healthy lifestyle, including programs that increase physical 
activity and improve the nutrition of the students at elementary and 
secondary schools;
    Provide education and training to education professionals, 
including physical education, health education, and food service 
professionals, in State and local educational agencies; monitor youth 
lifestyle behaviors and/or programs to influence them; develop and 
implement policies to support effective implementation of school health 
programs at the local level; and build effective partnerships with 
other Government agencies and non-governmental organizations to support 
effective implementation of school health programs.
    Examples of these approaches can be illustrated by the experience 
in three States. West Virginia has adopted one of the strongest 
standards in the Nation for school nutrition. The West Virginia Board 
of Education prohibits the sale or serving of the following foods at 
school: chewing gum, flavored ice bars, and candy bars; foods or drinks 
containing 40 percent or more, by weight, of sugar or other sweeteners; 
juice or juice products containing less than 20 percent real fruit or 
vegetable juice; and food(s) with more than eight grams of fat per one-
ounce serving. At elementary and middle schools, soft drinks are 
prohibited. In addition to implementing effective policies, the West 
Virginia Department of Education Office of Healthy Schools collaborated 
with the Office of Child Nutrition and the West Virginia Nutrition 
Coalition plan and delivered a week-long nutrition symposium for school 
food service, health education, and school health services 
professionals. These programs impact more than 300,000 students in a 
State where over 25 percent of the children ages 5-17 live in poverty.
    In California, the State has focused on collaborative efforts. The 
California Department of Education serves a population exceeding six 
million students, and 63 percent of these students identify themselves 
as a minority (42 percent Hispanic, 11 percent Asian Pacific, 9 percent 
African American, and 1 percent American Indian/Alaskan Native). To 
support collaborative efforts in California, the State's Department of 
Education and Department of Health Services formed a joint effort 
called School Health Connections (SHC). SHC coordinates funding, 
policies, and programs within both agencies and with local school 
districts and health departments. SHC accomplishments include:
    Collaboration with partners, leading to the passage of legislation 
which establishes nutrition standards for food sold in elementary 
schools, prohibits the sale of carbonated beverages in middle schools, 
until 30 minutes after lunch is served, requires schools to post State 
and local laws and policies related to nutrition and physical activity, 
and establishes a pilot program for middle and high schools to 
implement nutrition standards; the inclusion of health in new statewide 
standards for teacher training; added physical fitness test results to 
local school districts' accountability report cards; provided training 
in school health, including CDC's School Health Index, reaching 
approximately 1200 parents and professionals in the fields of 
education, public health, and school health; and obtained $6 million 
for school outreach for Healthy Families and Medi-Cal for Families.
    Finally, the Wisconsin Department of Public Instruction (DPI), in 
collaboration with several University of Wisconsin departments, 
instituted an annual Best Practices in Physical Activity and Health 
Education Symposium. This two-day staff development experience for 
teachers showcases exemplary school-based physical activity, physical 
education, and health education. Information and resources on physical 
education and health education, including health literacy assessment 
tools, were provided to all 426 school districts to guide program 
improvement. In addition, all Wisconsin school districts received 
nutrition education information and training opportunities. More than 
3,200 staff were trained on the Dietary Guidelines for Americans 2000, 
the importance of a good breakfast, and the relationship of nutrition 
to learning.
    CDC's coordinated school health program enables State departments 
of education and health to work together efficiently, respond to 
changing health priorities, and effectively use limited resources to 
meet a wide range of health needs among the State's school-aged 
population.

                              PARTNERSHIPS

    National or State programs alone will not succeed unless they are 
supported by a wide array of partnerships. Nutrition and physical 
activity programs must be integrated across other CDC funded State 
programs aimed at cancer, diabetes, and cardiovascular disease. In 
addition, as the North Carolina program emphasizes, nutrition and 
physical activity programs must be linked to other departments, such as 
the USDA. Groups that share concerns about the impact of obesity on 
other diseases, such as the American Heart Association and the American 
Cancer Society are natural allies in obesity prevention efforts. For 
example, the CDC is exploring joint training activities with the 
American Cancer Society around nutrition and physical activity 
strategies within States.

                          PRIORITY STRATEGIES

    At least four behavior change strategies appear justified by the 
current State of our knowledge. These include the development of 
sophisticated marketing messages designed to increase health behaviors 
among youth, the promotion of breast feeding and efforts to increase 
its duration, reduced television viewing in children and adolescents, 
and increased physical activity for the population. In FY2001, Congress 
appropriated $125 million to develop and launch the CDC Youth Media 
Campaign using the same strategies used by commercial marketers to 
reach our target audience of 9-13 year olds. The campaign will use the 
best principles of marketing and communications to deliver important 
messages to young people about the importance of building healthy 
habits early in life with the full knowledge that today's youth are 
very savvy about the messages they receive. The Youth Media Campaign 
will be launched in June of 2002 with the focus on getting kids excited 
about increasing the amount of physical activity in their lives, and 
helping their parents to see the importance of physical activity to the 
overall health of their kids.
    Breast feeding is unquestionably the most appropriate form of 
feeding for most infants, and clearly reduces the incidence of acute 
diseases of infancy and early childhood. Recent studies of breast-
feeding indicate that children who are breast-fed appear to have a 
reduced risk of obesity later in life. Nonetheless, only 64 percent of 
new mothers initiate breast feeding, and only about 29 percent have 
continued breast feeding six months after birth. A major research 
objective is to understand how to increase breast feeding rates and 
duration through strategies such as spouse support or worksite 
modifications that permit mothers to continue to feed their children 
breast milk after they return to work.
    The prevalence of obesity has been directly related to the amount 
of time children and adolescents watch television, and therefore 
reducing television time appears to be an effective strategy to treat 
and prevent obesity. Nonetheless, incentives for parents to reduce the 
amount of time their children watch television must still be 
identified. Some research suggests that parental concerns about 
televised violence or sexuality may be more persuasive reasons than 
obesity prevention to control children's television time.
    Increased physical activity for overweight patients reduces many of 
the co-morbidities associated with obesity such as hypertension, 
hyperlipidemia, and glucose tolerance. We now have six evidence based 
strategies around the promotion of physical activity. These include 
recommendations for physical education programs in schools, promotion 
of stairwell use, access and promotion of recreation facilities, social 
supports for physical activity, individually adapted behavior change, 
and community-wide campaigns.
    Medical approaches are an integral part of the battle against the 
bulge. When 25 percent of adults are affected with obesity, the 
effective translation of proven strategies into approaches that can be 
used in primary care settings must become a high priority. We recently 
calculated what it would cost if all obese Americans were started on 
one of the two available drugs for the treatment of obesity. The costs 
of drug therapy were approximately the same as the direct costs of 
obesity. This observation indicates that conventional medical therapy 
for the treatment of obesity is extremely expensive. However, last year 
an NIH clinical trial demonstrated that diet, exercise, and modest 
weight loss decreased the incidence of diabetes by almost 60 percent--a 
far greater improvement than the pharmaceutical therapy in the 
comparison group. These results emphasize the importance of lifestyle 
modification in the treatment of prediabetes. We are currently working 
with several managed care organizations to begin the process of 
translating these approaches into strategies that can be used in 
primary care. In a meeting to be held this summer, we will begin the 
process of identifying simple and effective counseling techniques that 
can be used by physicians, nurse practitioners and nutritionists to 
help obese patients. Evaluation of these approaches will be critical.
    In summary, this hearing could not have come at a more opportune 
time. Obesity in the United States is epidemic. The diseases caused by 
obesity like diabetes have also begun to increase, and are already 
adding to health care costs. CDC programs have begun to address the 
problem of obesity, but are small and just beginning. Nonetheless, 
comprehensive nutrition and physical activity approaches to prevent and 
treat obesity appear the most cost-effective strategy to reduce obesity 
and its complications.
    Thank you for the opportunity to talk about this very critical 
issue. I would be happy to answer any questions the Committee may have.

    Senator Bingaman. Thank you very much.
    You do indicate that we need a comprehensive approach, and 
I certainly agree with that. Let me go on and read another 
couple of sentences from the letter that Cindy Anderson, the 
substitute teacher from Albuquerque wrote me. She says: ``I 
wonder if it could not improve student achievement, not to 
mention behavior and disease risk, simply by not allowing the 
sale of candy, soda, and other empty-calory foods in our 
schools. It seems so silly to spend time teaching our kids 
about nutrition and then not provide nutritious foods for 
them.''
    You are funding a bunch of initiatives around the country 
to teach kids about nutrition as I understand it. Are you doing 
anything with regard to the actual providing of nutritious 
foods at schools?
    Dr. Dietz. That is not the role of the CDC, but we are very 
interested in alternative strategies around the provision of 
nutritious foods in school lunch lines. For example, we 
recently became part of a memo of understanding between USDA 
and HHS around the promotion of fruits and vegetables in lunch 
lines, and it has already been shown that reducing the price of 
fresh fruits and vegetables increases consumption. What we are 
trying to look for are sustainable strategies such as 
increasing the prices on less healthful items in the lunch 
line, thereby sustaining subsidies on fruits and vegetables. 
That is one alternative to making other choices available to 
children and teenagers.
    Senator Bingaman. The idea of funding a lot of these State 
initiatives is, as I understand it--and I have always thought--
not just in this area, but in all areas, is to figure out which 
strategies work and then replicate them around the country.
    How far are we from knowing which of these strategies work 
and being in a position to say this should be a national 
program, or this should be something that every State 
implements, or whatever?
    Dr. Dietz. With respect to our State programs, I think we 
are still several years away from knowing whether the 
strategies which States have initiated are going to be 
effective or not. We have set them up in such a way that they 
have employed a very careful design; they have often partnered 
with universities or prevention research centers and schools of 
public health, and in order to not only design the best program 
but employ a very careful evaluation to determine whether it 
works or not.
    But as I said, I think we do have four strategies which we 
can employ today. They are the promotion of breast feeding, 
reduction in television time, increase in fruit and vegetable 
consumption, and increases in physical activity. I think we 
have the best data around physical activity, where we know that 
there are evidence-based recommendations that suggest that 
increases in physical education programs in schools will 
increase rates of physical activity and thereby reduce many of 
the obesity-associated comorbidities.
    Senator Bingaman. I guess I am still not clear as to--now 
that we know that exercise is something that we should be 
promoting in our schools, what is the extent of the effort that 
is being made either by the CDC or by Health and Human Services 
more generally or by anyone else, any of the other Federal 
agencies, to actually bring this about? Are resources being 
provided? I know that we have the PEP bill, but I do not know 
how many States that is getting into, how many kids are 
actually being allowed or encouraged to participate in physical 
activity because of that funding.
    Dr. Dietz. I cannot supply you with those data, although I 
think we could probably come up with them from the Department 
of Education or others who are here in the room testifying 
later.
    I think that the CDC cannot make schools change, nor do I 
think the Federal Government can. Schools are locally 
controlled, as you know. I think our job is to provide schools 
and communities with the best evidence, the best suggestions 
that we know, and rely on them to take those suggestions 
forward.
    Senator Bingaman. So you think that providing the 
suggestions is probably the extent of what we can do, rather 
than providing any resources?
    Mr. Dietz. If we were to give resources directly to 
communities, I would be concerned that those communities 
utilize those resources in such a way that they can learn from 
what they do, because my concern about throwing money at a 
problem without an evaluation is that we are going to spend a 
lot of money, and at the end of that, we are not going to have 
any better idea of what works or what doesn't than when we 
started.
    One of the reasons that I have chosen to emphasize State 
programs is that I think funds for communities channelled 
through State programs at least assures that the communities 
will have the best recommendations that we know of programs 
that work and can couple those with an evaluation to determine 
which of those programs are effective, and those can then be 
disseminated to other communities.
    Senator Bingaman. You did refer, I believe, to six 
evidence-based strategies for increasing physical activity.
    Dr. Dietz. Correct.
    Senator Bingaman. And presumably those are six evidence-
based strategies, each of which is recommended?
    Dr. Dietz. Yes.
    Senator Bingaman. So that we have six ways in which we know 
that schools can deal with this problem if they will just do 
it.
    Dr. Dietz. Those recommendations were not limited to 
schools. I cited the physical education recommendation as most 
applicable to schools. Promotion of stairwell use is one of 
those strategies. This is a ready made opportunity for physical 
activity to walk up and down stairs. Stairs are rarely in a 
convenient place and are rarely attractive.
    Access and promotion of recreational facilities is another 
recommended strategy which suggests the importance of 
partnerships with groups like the park and recreation 
department; social supports for physical activity; individually 
adapted behavior change, which is more of a clinical strategy; 
and community-wide campaigns to promote physical activity.
    What we do not yet have is a clear understanding of how to 
translate those effectively into community-based programs.
    Senator Bingaman. Okay. Let me defer to my colleagues. Both 
Senator Reed and Senator Dodd are very focused on this set of 
issues and are working with us on this legislation.
    Let me call on Senator Reed since he arrived first.
    Senator Reed. Thank you very much, Mr. Chairman, and thank 
you for holding this hearing.
    This is a vitally important topic, and CDC has taken a 
leadership role, and I thank you, Dr. Dietz, for your efforts.
    The Children's Health Act of 2000 incorporated some 
provisions that I suggested with respect to a competitive grant 
program for CDC that could be used for intervention models and 
prevention strategies for obesity; it could be used in terms of 
applied research, public education, provider education and 
training.
    I realize that all of these provisions are not under your 
auspices, but could you give an outline of the implementation 
to date of the Children's Health Act?
    Dr. Dietz. The Children's Health Act has not directly 
impacted our programs, but as I said earlier, we are funding 12 
States now, and those States have principally focused on youth. 
Rhode island is one of those States, as you know. They are 
adopting a variety of strategies. Some are using a WIC-based 
approach. Some are targeting African American or other minority 
youth. I believe Rhode Island is using a WIC-based approach, as 
well as North Carolina.
    I think the importance of those programs is that they be 
designed in such a way that we know clearly what the target 
audience is, and we have good pre and post measures to evaluate 
which of those programs is effective, and those can then be 
expanded.
    I think that is not the question that you asked. You are 
asking about the Children's Health Act, which has not, as I 
said, impacted on our programs.
    Senator Reed. But you deduced my second question, which is 
how well we are doing in Rhode Island, one of your 12 States, 
and I thank you for your response.
    I notice that in conjunction with your efforts, the budget 
proposed for the CDC Center for Chronic Disease Prevention and 
Health Promotion is going to be proposed to be reduced by 8 
percent, less than the fiscal year 2002 funding level. Could 
you describe how that reduction would impact on the efforts 
that you just talked about and others?
    Dr. Dietz. I think the reduction applies almost exclusively 
to the Youth Media Campaign. That is currently funded at about 
$68.5 million in the 2002 budget and has been eliminated from 
the 2003 budget.
    Senator Reed. I presume that when it was included in 
previous budgets, there was some logic to do that, that there 
was some data or at least instinct that it would be good to 
tell youngsters not to eat certain things, and certainly, since 
there is such a constant barrage of what to eat from every fast 
food restaurant in America, do you have any thoughts about the 
reduction or elimination of this program?
    Dr. Dietz. I think the Youth Media Campaign is a unique 
attempt to influence physical activity behaviors of children. 
As you know, when Congressman Porter introduced that 
legislation, it was with the intent of displacing other high-
risk behaviors like sexual behavior, drug use, alcohol use, and 
tobacco use. The choice of physical activity I think is a sound 
one--physical activity and other activities--particularly those 
that children, in this case, 9- to 13-year-olds, participate in 
after school, because that is when these other high-risk 
behaviors begin.
    I think that to know clearly whether that program is 
effective or not is going to require 3 to 5 years of work. The 
program will only come out, or the media delivery will only be 
at the end of June, and I think there are enough funds in it 
for media buys for a year.
    The expectation is that that may well change attitudes but 
will not likely change behavior because it is such a short run.
    Senator Reed. Thank you.
    Thank you, Mr. Chairman.
    Senator Bingaman. Thank you, Senator Reed.
    Senator Frist.
    Senator Frist. Thank you, Mr. Chairman.
    Dr. Dietz, CDC has gained a great deal of experience 
working with States and communities over the years on the issue 
of improved nutrition and physical activity, and on the charts 
that I showed, it was ``nutrition/activity'' in essence. I know 
you mentioned a little bit about this, but what do you think 
are the key components or elements of an effective program, and 
as we put together legislation or a Federal model and program, 
specific things like provider training and education--again, 
you mentioned it a little bit--designing environments to allow 
increased activities in terms of physical education or just 
physical activity and the right sort of environment, and also, 
physical education and nutrition education actually in school, 
in terms of what you are actually exposed to.
    Dr. Dietz. I think there are several important elements of 
a comprehensive program. One is that there has to be a 
repository of expertise related to nutrition and physical 
activity. Those I do not think are the same person in States. I 
think that somebody with physical activity expertise is not 
likely to share nutrition expertise.
    Second, the program needs to be integrated. As you know, we 
are funding a number of categorical programs like cancer, 
cardiovascular disease, and diabetes. Nutrition and physical 
activity strategies to prevent obesity will also influence 
those other chronic diseases. So that part of a comprehensive 
program is a physical activity and nutrition strategy that is 
cross-cutting and engages the secondary prevention efforts that 
those categorical diseases are already involved in.
    Third, there needs to be integration across agencies. For 
example, the USDA EFNEP program and the USDA WIC program all 
need to be linked into preventive efforts because they address 
particularly vulnerable populations, and it is unlikely and 
needless for HHS programs to replicate the tremendous job of 
education that a program like EFNEP does. But if we do not link 
to those programs, we are going to miss an opportunity.
    Third, there need to be partnerships with other 
organizations within States, like the American Cancer Society, 
like the American Heart Association, which have a vested 
interest in the prevention of obesity and its consequences.
    Fourth, I think there need to be strategies that explore 
what works. We have already talked about that briefly. My model 
for that would be funding going through State programs to 
communities where small amounts of funding can make an enormous 
difference in getting programs off the ground. My concern is 
that those State-based programs be coupled with a good 
evaluation effort so that we learn what works, so that those 
communities themselves can learn what works.
    Fifth, I think we need a stronger science base. The 
strategies I mentioned--physical activity, breast feeding, 
reduction in TV time--are probably just the beginning of those 
strategies. They will significantly impact the problem, but it 
is not going to eliminate it. And there is a wide range of 
applied research that needs to be done and augmented by survey 
work.
    For example, several recent focus group studies have 
demonstrated that parents do not define obesity by where a 
child fits on the growth chart. That is very perplexing to 
primary care providers, because if they cannot point out where 
a child fits on the growth chart and say to a parent, ``This is 
a problem,'' and the parent says, ``What are you talking about? 
This is not a problem,'' then, we have a problem. What is the 
language that we use?
    It turns out that parents do not define being overweight as 
a problem unless where the child fits on a growth chart has an 
adverse impact on the child's self-esteem.
    So I think there is a lot of work that needs to be done 
around the language that we use to talk to parents about their 
child's weight problem. I also think that for the vast majority 
of parents, overweight is considered a cosmetic issue, not a 
health issue. That conversation has to change.
    Senator Frist. Has my time expired, Mr. Chairman.
    Senator Bingaman. Well, we do not have the timer on. Why 
don't you go ahead with another question?
    Senator Frist. Thank you.
    Very briefly--and I appreciate the comprehensive nature of 
your last answer--extending from the parents' view of what 
obesity is, this committee deals with a lot of public health 
issues broadly, and public health people think of all sorts of 
things, like infectious disease--infectious disease, people can 
relate to--when we think of obesity being a public health 
issue, it takes some explaining, and part of the reason might 
be that many people view being overweight or obese as a matter 
of personal choice. It may affect one individual because of 
certain behavior, but it does not affect other people.
    Could you respond to that?
    Dr. Dietz. Sure. I think that to a certain extent, that is 
true. While we focus on the prevention of obesity in the 
majority of population, we cannot neglect the 25 percent of 
adults and 15 percent of children and teenagers who are already 
overweight.
    One of the things that we are doing this summer is 
convening a conference with Kaiser Permanente to look at how to 
translate the efficacious recommendations that came out of the 
NHLBI Report on the Assessment and Treatment of Obesity into 
practical approaches that can be used in primary care.
    We are doing something similar around the prevention of 
obesity in children through a collaborative project with the 
American Academy of Pediatrics and the American Dietetic 
Association to try to prevent the development of obesity in 
young children, 3- to 7-year-olds, through a focus on the 
division of responsibility between parents and children around 
food choices and the limitation of television time to one to 2 
hours per day.
    I think you are absolutely right that clinical strategies 
do have to focus on those issues, and what I think we need the 
most are approaches which make physicians feel more effective 
when they are confronted with an overweight patient.
    Senator Frist. Thank you.
    Thank you, Mr. Chairman.
    Senator Bingaman. Thank you very much.
    Senator Dodd.

                   Opening Statement of Senator Dodd

    Senator Dodd. Thank you very much, Mr. Chairman, and let me 
begin by thanking you for holding this hearing, and Senator 
Frist and Senator Reed for their support of this.
    This is a very, very important issue, and it is getting 
some attention in the last little bit, but it really deserves 
much, much more. I want to begin by thanking you for doing 
this.
    I was stunned to read the statistics on the number of 
children, the number of adults, the number of deaths, and the 
costs associated with this. On Senator Frist's last point, 
talking about this being a matter of choice--there may be 
choice, but there are tremendous effects that we all pay for as 
a result of these decisions, so beyond just the individual 
effects, obviously, there are effects that go far beyond that.
    We are going to introduce shortly--Senator Bingaman may 
have raised this before I came in--Senator Bingaman and Senator 
Frist are the lead sponsors and I am a supporter of their 
efforts on the Improved Nutrition and Physical Activity Act, 
the IMPACT bill which I am sure you have already addressed.
    We focus on children. The piece that I added was on the 
children, because the numbers just stun me, when we start 
talking about a tripling of this problem in the last decade--or 
is it two decades?
    Dr. Dietz. Twenty years.
    Senator Dodd. Twenty years. I was stunned to see the amount 
of activity--let me just focus on the activity side of this, 
even though the diet issue deserves attention--I was stunned to 
see that in the last 10 years, I believe, we saw the number of 
children involved in activities went from 42 percent to 29 
percent, and the trend lines continue to go down.
    What is going on here? Why is this happening? Have you 
analyzed what is going on in schools? Are school budgets such 
that they are cutting back on after-school athletic programs 
and during the day? Is that a feature of this? Are schools 
reducing significantly the amount of physical activities that 
were normally part of the curriculum at the elementary and 
secondary levels?
    Dr. Dietz. I think that physical activity around schools 
has declined in two ways. The numbers that you are citing have 
to do with the physical education programs offered by schools, 
which amount to 42 percent of schools in 1991 and declined to 
29 percent of schools by 1999.
    Senator Dodd. Is this a budgetary--have you analyzed this?
    Dr. Dietz. Well, we do not have terrific data, but on an 
anecdotal basis--and I think this is a pretty widespread 
anecdote--most schools have reduced P.E. programs because of 
cost and the need to meet performance standards, and that P.E. 
is seen as a luxury, one which detracts from school 
performance.
    I think a clear research need is to demonstrate that 
physical activity has an impact on both classroom behavior and 
performance. That is something that we do not know.
    Senator Dodd. We know it has an effect on the other 
behaviors--smoking, drugs, and the like--isn't that true?
    Dr. Dietz. That is true. Those adverse risk behaviors 
cluster. But the other factor which has influenced physical 
activity around schools is that today, far fewer children walk 
to school. In part, that is a consequence of community design, 
and in part, it reflects perceptions of neighborhood safety.
    In fact, when I talk to audiences around the country, 90 
percent of those audiences walked to school when they were 
children, and only about 20 percent of their children and 
grandchildren walk to school.
    So not only have schools eliminated their physical 
education programs, but the opportunities to include physical 
activity as part of a child's day have also diminished.
    Senator Dodd. Have you looked over the children-specific 
provisions of the proposed legislation that we are offering?
    Dr. Dietz. I am not permitted to comment on legislation; I 
am sorry. I have looked it over.
    Senator Dodd. Do you want to just give me a little wink or 
something?
    [Laughter.]
    Dr. Dietz. I thought that was what I did.
    Senator Dodd. Okay. I will take that as a wink. I 
appreciate it very much.
    We just passed the Elementary and Secondary Education Act; 
in fact, we were involved in it in this committee. Correct me 
if I am wrong, Bill, but I do not think we did anything on this 
particular aspect.
    Tell me about these contracts that schools have with some 
of our producers of less-than-nutritional-value products. Is 
this a growing problem, where, to get exclusive rights, you 
give schools a check for a certain amount if they will give you 
exclusivity to some of these products, and you also have to 
agree to have them available to the kids during the school day. 
Tell us about some of those contracts.
    Dr. Dietz. I think that what you are describing is 
euphemistically called a ``pouring contract,'' which is an 
exclusive contract with a soft drink company to stock vending 
machines. That is an increasingly widespread practice that is 
driven by schools' need for financial resources. They play a 
very important role in keeping schools afloat as the tax base 
for schools has diminished.
    So my professional opinion is that I would not agree that 
those vending machines should be replaced in schools unless the 
financial support can be replaced. But that does not mean that 
all the choices in those machines have to be--
    Senator Dodd. What does a contract amount to? Can you give 
me a typical--
    Dr. Dietz. I do not actually know what a typical contract 
is. I was reading something the other day that suggested that a 
town outside Atlanta signed a contract over a 5-year period for 
$200,000, or an income of about $40,000 to $50,000 a year. That 
pays for things like scoreboards, things that a school board 
might not choose to fund.
    But in any case, the vending machines need not be all 
negative. For example, we know from our experience and a study 
that we are funding that if those vending machines are stocked 
with healthful products, kids will buy them, and that maintains 
the bottom line while allowing healthful alternatives like 
flavored milk or even water as something in a vending machine 
offers a positive alternative for children and still maintains 
the level of financial support that schools need.
    Senator Dodd. And your concern is that the nutritional 
value of these products is substantially lacking.
    Dr. Dietz. But it need not be so.
    Senator Dodd. Yes. There was a piece by Tim Eagan in the 
New York Times yesterday or the day before--did you see that?
    Dr. Dietz. Yes, I did.
    Senator Dodd. Do you agree with the conclusions in that 
story?
    Dr. Dietz. I thought the principal conclusion was that 
trial lawyers were moving on to prosecute food rather than 
tobacco, and I did not agree with that. But perhaps you could 
remind me of the other points.
    Senator Dodd. They talked about what goes on in the 
schools, and they cited lunch time at Fremont High, the largest 
school district in the Nation to enact a statewide ban on junk 
food. In fact, the two biggest States, Texas and California, 
are moving toward phasing out junk food in schools.
    What you are suggesting is that there might be an 
alternative here, and that is to eliminate junk food but 
provide them vending opportunities with more nutritional 
products.
    Dr. Dietz. Provide choices, and there are strategic ways to 
increase consumption of the healthful choices by competitive 
pricing, for example.
    The other conclusion that I remember that that article 
reached was that if adolescents cannot find what they want in 
schools, they can leave the open campus and go to the ring of 
fast food chains that generally surround many of those high 
schools.
    So I think that it is not a simple solution, but schools 
could do a better job in offering more healthful alternatives 
and pricing them competitively.
    Senator Dodd. Or, of course, alternatively, we could come 
up with better funding schemes to help schools so they do not 
have do this in the first place.
    Dr. Dietz. Absolutely.
    Senator Dodd. Thank you, Mr. Chairman.
    Senator Bingaman. Thank you very much.
    We have a vote that has already started, so we will need to 
adjourn before we start with Panel 2.
    Does any Senator have one additional question to put to Dr. 
Dietz before we recess?
    [No response.]
    Senator Bingaman. If not, let us take about a 10-minute 
break, and we will resume with Panel 2.
    Thank you very much.
    [Recess.]
    Senator Bingaman. The hearing will resume.
    I am sure some other Senators will be coming back in a few 
minutes, but to move this along, we will go ahead with our 
second panel.
    Our witness on this panel is Ms. Denise Austin, who is 
nationally known and respected as an expert in fitness. She 
offers expert advice and has hosted her own television show on 
physical fitness for the past two decades, and she is also a 
tremendous example for the rest of us to follow in physical 
fitness.
    It is a pleasure to have you here. Thank you very much for 
coming.
    Please go right ahead.

STATEMENT OF DENISE AUSTIN, ON BEHALF OF P.E.4LIFE, ACCOMPANIED 
         BY ANN FLANNERY, EXECUTIVE DIRECTOR, P.E.4LIFE

    Ms. Austin. Thank you. Mr. Chairman and distinguished 
Members of the committee, I thank you for the opportunity to 
talk about the role that exercise and fitness play in the 
healthy development of our children.
    Joining me today is Ann Flannery, who is Executive Director 
of P.E.4Life.
    I am here to talk about physical education in the schools. 
I am a mom. I have my degree in physical education, and I have 
been in the fitness industry for 23 years. I travel to schools 
all over the Nation, giving lectures, trying to motivate kids 
to get in better shape. And I have physically seen these kids 
who are so out of shape they cannot even run a lap. So I am 
here to help promote physical education in the schools, and I 
truly believe that if we can get kids doing physical education 
three to five times a week, a lot of these problems will be 
diminished.
    As you can tell, so many of the budget cuts happened about 
14 to 16 years ago, and this is when the decline began.
    I receive about 2,000 letters and emails each week from 
moms all over the country, because I am a mom, and I can 
relate. They ask me, Denise, what can I do--my child is 
overweight, or my grand-daughter is overweight--what can I do?
    The first thing I tell people is to find out how many days 
a week they have in physical education. Ask your children. I 
ask my kids, ``How many days a week do you have?'' I make sure 
that they have at least 3 days a week of physical education. 
That way, I know that they are physically active while they are 
at school.
    Also, of course, as a mom, you do have to instill in them a 
healthy lifestyle when they get home, do some activities, too. 
But my goal for everybody is to have healthy, happy children 
and make sure they get exercise in three to five times as week.
    A lot of mothers tell me, ``Denise, I asked my daughter, 
and she said she only gets physical education once a week. What 
do I do?'' That is why I am here.
    Our joint passion to fight obesity and reverse the lack of 
physical exercise in our Nation's youth is bolstered by 
troubling research finding a corresponding rise in obesity and 
diabetes rates.
    Dr. William Klish, head of pediatric gastroenterology at 
Baylor College of Medicine, found that children today have a 
shorter life expectancy than their parents for the first time 
in 100 years.
    Beyond the physical trials of being overweight, the 
psychological effects and social stigma attached to childhood 
and adolescent obesity are of equal concern. Self-esteem is so 
important for kids.
    Most important, the correlation between increased childhood 
obesity and decreased school-based physical education is all 
too clear. Here are some statistics.
    During the 1990s, the percentage of high school students 
enrolled in daily gym classes fell by 31 percent. Today, only 8 
percent of elementary schools, 6.4 percent of middle schools, 
and 5.8 percent of high schools provide daily physical 
education. Overall, 25 percent of our school children today do 
not attend any physical education class at all.
    Here is some good news. With an increase in physical 
activity three to five times per week, studies have found a 20 
percent increase in improvement in physical fitness, in self-
esteem, school attendance, and academic performance, and a 50 
percent reduction in smoking and a 60 percent reduction in drug 
and alcohol use.
    That is why I am here today. I would like to introduce to 
you Ann Flannery, who will speak in behalf of P.E.4Life.
    Senator Bingaman. Thank you for being here, Ms. Flannery. 
Go right ahead.
    Ms. Flannery. Thank you, Mr. Chairman, and thank you, 
Denise.
    PE4Life was formed just 2 short years ago in recognition 
that our Nation's most efficient delivery system for teaching 
children how to lead physically active lives, school-based P.E. 
programs, has largely been under siege over the past 15 years. 
A comprehensive school-based physical education program is one 
that includes not only classroom instruction--what we all know 
as gym class--but also intramurals, after school activity 
clubs, and athletics.
    PE is not the same thing as sports. That is one of the 
misconceptions that we need to educate people about. Most 
parents and community stakeholders are shocked to learn today 
that so many of our children do not receive daily P.E. in our 
Nation's schools.
    We believe that the solution to getting our children 
physically active is to foster more public-private partnerships 
with schools. Toward that end, we created the P.E.4Life 
Institute. It is a partnership with the Naperville Community 
Unit School District 203, and it provides in-service training 
for community stakeholders throughout the Nation on techniques 
to transform their physical education programs from the more 
traditional skill-based instruction to more fitness-based 
curriculums.
    The Naperville Public Schools Physical Education Program 
has been named and recognized as a model program by the Centers 
for Disease Control and is perhaps the prime example of what as 
been coined as ``the new P.E.'' And let me tell you, this is 
probably not the P.E. that you had when you were in school, 
Senator.
    The new P.E. engages every student and stresses lifetime 
fitness in addition to introducing children to traditional 
games, activities, and individual and team sports, and it 
rewards all students for personal improvement. In the new P.E. 
today, a P.E. professional is highly likely to use a heart rate 
monitor to score a student's success and levels of improvement, 
rather than looking at them and asking are they working hard 
enough.
    This is really the transition that we are talking about 
that is going on in physical education that once parents and 
communities find out about, their immediate response is: How do 
we get that in our own community?
    PE4Life commends the Committee and Senators Frist, Bingaman 
and Dodd in particular for your work in crafting comprehensive 
legislation to address obesity and fitness. We understand that 
a bill is likely and appreciate the opportunity to be afforded 
to review a draft version.
    In particular we applaud the key elements contained in the 
draft version, including the community grants and the 
coordinated school health program of which physical education 
is a part. We have been working hand-in-hand with Dr. Dietz and 
Dr. Colby at CDC in their Coordinated School Health Program to 
understand how valuable we need to make a physical education 
program. We also commend the community nutrition and physical 
activity education and the Youth Media Campaign.
    But as you proceed with crafting the final bill, there are 
three additional focal points that we would encourage for 
inclusion. The first is local partnership models. We have seen 
the demonstrated success of the P.E.4Life Institute model, and 
we are very pleased that the CDC recognizes its efficacy. 
Fundamentally, it involves a 30-year teaching professional 
named Phil Lawler. He is the director, and he is credited with 
being what we are calling the ``guru'' of the new P.E. He 
taught the old way, the way that, unfortunately, some of our 
teacher prep programs still teach physical education. We need 
to move them along. If it is a supply chain management issue, 
we need to address the teacher prep programs in physical 
education, and they are ready to do that, to learn all the new 
technology that is going on in physical education and to learn 
fundamentally how to be a community advocate.
    So we would like you to take a look at the P.E.4Life 
Institute as the model. People over the country in around 200 
communities have come to visit in the last 18 months examples 
like Owensboro, KY, where the hospital CEO recognized that all 
of these outcomes in their community are preventable. He found 
out about the Institute, and he took the mayor, the head of the 
school board, the head of the PTA, a prominent cardiologist and 
P.E. professionals in the community, and they traveled to the 
Institute to learn how to do this in their own community. They 
got energized, and now you have this community-school 
partnership where everyone in that community believes that 
every child in our school needs a daily physical education 
program.
    The next aspect we would recommend is a national study on 
school physical education. As Dr. Dietz referred to earlier, we 
do not have enough information on what is going on out there. 
Forty-seven out of 50 States have something on the books about 
physical education, but that does not translate into what is 
actually happening at the local level, and we need that; it is 
essential.
    We are concerned. The CDC's own SHIPS data confirms that 
what is required is not necessarily what is happening on the 
ground. Such a study should include the physical education 
requirements, the extent to which classes are available and/or 
mandatory at the elementary, middle, and high school level, and 
a comparative evaluation on the curriculum, including the 
length of time of classes, the teacher qualifications, the 
existence of standards, and the class size.
    And then, finally, what we need more than anything, 
Senator, is a national fitness test. We need to be able to 
assess our children's fitness levels.
    The CDC used to conduct the Youth Risky Behavior Survey, 
which was a terrific study. We would suggest that we need to 
fund that again to track children particularly at the K through 
6 level. If we wait until high school and beyond, it will be 
too late.
    We are encouraged by California's leadership using the 
Fitness Gram, a national test developed by the Cooper 
Institute. This comprehensive youth assessment includes a 
variety of health-related physical fitness tests designed to 
assess cardiovascular fitness, muscle strength, muscular 
endurance, flexibility, and body composition.
    We appreciate the opportunity to be here with you today. 
Denise and I are both committed. It is personal to me as well. 
My mother was a 30-year physical education professional and 
very proud to say that. She made a huge impact of the health of 
children's lives.
    Physical education is a great delivery system. We just need 
to reinvigorate it.
    Thank you.
    [The prepared statement of Ms. Austin follows:]

                  Prepared Statement of Denise Austin

    Chairman Kennedy, Ranking Member Gregg, Senator Bingaman, and 
distinguished Members of the Committee, I thank you for the opportunity 
to testify on behalf of P.E.4LIFE--a non-profit organization dedicated 
to reestablishing quality physical education programs in our Nation's 
schools while promoting the tangible benefits of daily physical 
education programs in the healthy development of our children. Also I'm 
pleased to be joined here today by Anne Flannery, Executive Director of 
P.E.4LIFE.

                   A PERSONAL MISSION ROOTED IN FACT

    Your commitment to addressing the United States' obesity epidemic 
is evidenced by today's hearing, and your individual and collective 
efforts on this crisis is a common bond we share. Beyond my current 
work as the host of Lifetime TV's Denise Austin's Daily Workout, my 
personal mission always has been to share the joys of fitness with the 
widest possible audience. For ten years, my previous show on ESPN 
reached homes in over 82 nations.
    Our joint passion to fight obesity and reverse the lack of physical 
activity in our Nation's youth is bolstered by troubling research 
finding a corresponding rise in obesity rates. Dr. William Klish, head 
of pediatric gastroentorology at Baylor College of Medicine, has found 
that children today have a shorter life expectancy than their parents 
for the first time in one hundred years. Currently, over 13 percent of 
children and adolescents are overweight, which is nearly double late-
1970s levels.
    Being overweight during childhood, and particularly adolescence, 
directly relates to increased morbidity and mortality later in life. 
Overweight and obese children have higher rates of asthma, Type II 
diabetes, hypertension, and orthopedic complications--conditions that 
have emerged only as the onset of this epidemic has accelerated. Beyond 
the physical trials, the psychological effects and social stigma 
attached to child and adolescent obesity are of equal concern.
    And the correlation between increased childhood obesity and 
decreased school-based physical education is all too clear. During the 
1990s, the percentage of high school students enrolled in daily gym 
classes fell by 31 percent. Today, only 8 percent of elementary 
schools, 6.4 percent of middle schools, and 5.8 percent of high schools 
provide daily physical education or its equivalent for the entire 
school year for students in all grades. Overall, 25 percent of school 
children do not attend any physical education class at all.
    These are disturbing statistics, and I only hope that a comparative 
review in 2010 will paint a far different picture.
    According to the U.S. Department of Health and Human Services, all 
children--from pre-kindergarten through grade 12--should participate in 
quality physical education classes every school day. In physical 
education class, students develop the knowledge, attitude, skills, 
behavior, and confidence needed to be physically active for life. With 
an increase in physical activity 3 to 5 times per week, studies have 
found a 20 percent improvement in physical fitness, in self esteem, 
school attendance, and academic performance--and impressively, a 50 
percent reduction in smoking and 60 percent decrease in drug and 
alcohol use.

                   P.E.4LIFE: ACCEPTING THE CHALLENGE

    This is why I am honored to be with you today with P.E.4LIFE. I am 
proud to be an active P.E.4LIFE supporter, joining noted athletes 
Billie Jean King, Herschel Walker, Martina Navratilova, Dominique 
Dawes, Stephen Davis, Payton Manning and Steve Young, among others, in 
helping this fight. In addition, top companies in the sporting goods 
industry, including Adidas, New Balance, Nike, Reebok, Spalding and 
Wilson, have joined together with the American Heart Association, the 
American Academy of Pediatrics, and other voluntary health organization 
to support P.E.4LIFE's mission. Now I would like to have Anne Flannery 
discuss several points regarding P.E.4LIFE and the Committee's Obesity 
Agenda.
    P.E.4LIFE believes that physical education is the beginning of a 
lifelong learning process in which schools can play a central role in 
teaching our children how to live as active, responsible, and healthy 
adults. Our main goals include:
    Raising awareness about the physical inactivity of America's youth 
and the unfortunate state of physical education across the Nation;
    Promoting the need for educational policies that include mandatory 
daily physical education classes for children in grades K-12;
    Advancing quality model physical education programs in every State;
    Empowering physical educators, parents, and community leaders with 
the knowledge to become key advocates for quality, daily physical 
education; and
    Stimulating private and public funding for quality physical 
education.
    This year, on May 1st, P.E.4LIFE celebrated National Physical 
Education Day by visiting over 60 Members of Congress, including 
Senators Bond, Frist, Harkin, Reed, Roberts, and Wellstone of the HELP 
Committee. We also joined U.S. Secretary of Health and Human Services 
Tommy Thompson and U.S. Secretary of Education Rod Paige in promoting 
the importance of childhood physical activity as a means of preventing 
many of the diseases this young generation is facing.

                     PEP--ONE PART OF THE SOLUTION

    In particular, P.E.4LIFE thanks the Members of this Committee for 
authorizing the Carol M. White Physical Education Program, known as 
PEP, which was included in the comprehensive education reform bill 
recently enacted. Promoting PEP, a competitive Federal grant program 
providing grants to schools and school districts for equipment and 
teacher training, has been among our top priorities.
    PEP grants have allowed us to support and highlight good programs 
that are constrained by a lack of resources. While we are very pleased 
that PEP received an appropriation of $50 million in Fiscal Year 2002, 
P.E.4LIFE does not believe that PEP funding is the exclusive answer to 
the problem of lack of physical education problem in America. Overall, 
we believe the solution must take hold and be driven at the local 
level.

THE P.E.4LIFE INSTITUTE AND NAPERVILLE, ILLINOIS: A CASE STUDY OF LOCAL 
                              PARTNERSHIP

    Placing our belief in local leadership and involvement to the test, 
we have created the P.E.4LIFE Institute. I have visited the Institute, 
which trains communities throughout the Nation on techniques to 
transform their physical education curriculum into model programs. By 
providing in-service training for community stakeholders on 
contemporary physical education curriculum measures, the Institute is 
providing strong, grassroots support and continuing education 
opportunities for community leaders and is creating advocates for 
quality, daily physical education programs within communities 
nationwide.
    Just one example of how P.E.4LIFE is partnering with local 
leadership is the P.E.4LIFE Institute established with the Naperville 
Community Unit School District 203.
    The Naperville public schools physical education program has been 
named a model program by the Centers for Disease Control and Prevention 
(CDC), and is perhaps the prime example of what has been coined the 
``New P.E.'' This movement engages every student and stresses fitness, 
and is beginning to take hold in schools nationwide. Daily, quality 
physical education can replace failing or non-existent programs. The 
New P.E. stresses lifetime fitness, in addition to traditional games, 
activities, team sports, and rewards all students for personal 
improvement. More likely to use a heart monitor than a score sheet to 
gauge a student's success, New P.E. engages every student--not simply 
the relatively small percentage of outstanding athletes.
    It has worked in Naperville, and like many success stories, the 
movement is spreading. About 30 percent of Illinois schools have 
changed to the new model, and officials from over 200 schools around 
the country have visited the Institute in the last two years. Two such 
examples are Owensboro, Kentucky and Titusville, Pennsylvania. In 
Owensboro, Hospital CEO Greg Neelson recognized that most of the 
conditions that affected their community's health were preventable. He 
read about the P.E.4LIFE Institute and arranged for ten leaders in his 
community--including the Mayor, head of the school board, PTA members 
and P.E. professionals--to travel to Naperville to learn how to 
implement the New P.E. They were so energized that they came back and 
put together the same kind of public/private sector partnership whereby 
the business community matches the monies pledged by both the hospital 
and the school districts, to implement a daily P.E. program in every 
school for every Owensboro Child. To date, they have underwritten 6 
schools programs and are well on their way to having every child 
receive the New P.E. every day. In Titusville, it was the inspiration 
of one P.E. professional who recognized that his teaching methods were 
no longer sufficient to engaging today's children; Tim McCord called 
the Institute, arranged for a visit and in two short years has 
completed an overhaul of his school district's P.E. program that has 
gotten the attention of both the local media and educators statewide.

                      CONGRESS' ROLE IN THE BATTLE

    P.E.4LIFE commends the Committee, and Senators Frist, Bingaman, and 
Dodd in particular, for your work in crafting comprehensive legislation 
to address obesity and fitness. We understand that a bill will likely 
be introduced in the next few weeks, and appreciate the opportunity 
afforded by the Committee to review a draft version.
    In particular, we applaud the following key elements contained in 
the draft version and encourage their retention as the bill is 
introduced:
    Community Grants. Local community grants, as outlined in Title II, 
to promote increased physical activity in the community are essential. 
P.E.4LIFE supports the grassroots focus of this provision. The creation 
of parks, bike paths, and recreational centers under this proposed 
provision will significantly enhance opportunities to exercise. In 
addition, the focus on encouraging business coalitions to increase 
workplace activity levels, starting of exercise programs in nursing 
homes, leveraging school-based facilities for broader recreational 
activities is appropriately targeted.
    School Health Program. P.E.4LIFE looks forward to working with you 
to implement the School Health Program of Title III, which authorizes 
and expands the work of the CDC in encouraging schools to implement 
physical education courses and nutrition classes. We are especially 
pleased that funding may be provided for staff physical education 
training, after hours physical activity programs, and physical 
education class planning and implementing. This program would 
complement both the PEP program and CDC's school health program by 
working directly with schools or school districts.
    Community Nutrition and Physical Activity Education. States should 
be permitted to use Preventive Services Block Grant funds for community 
education on nutrition and increased physical activity.
    Health Center Obesity Programs. P.E.4LIFE supports the use of funds 
for community health centers, rural health clinics, Indian Health 
Center facilities to carry out programs to address obesity and 
overweight among their clientele.
    Youth Media Campaign. It is very appropriate that the bill devotes 
resources to the CDC Youth Media Campaign--an initiative that will all 
contribute to increasing physical activity.
    As you proceed with crafting the final bill, there are three 
additional focal points that P.E.4LIFE would encourage for inclusion.
    Local Partnership Models. We have seen the demonstrated success of 
the P.E.4LIFE Institute model, are very pleased that the CDC views this 
initiative as a model P.E. program. P.E.4LIFE strongly encourages the 
Committee to include the tenants of the P.E.4LIFE Institute in Title 
III as an ideal model for the training of physical education personnel 
and the designing of physical education curricula.
    National Study on School Physical Education. P.E.4LIFE also believe 
that a comprehensive review on the state of physical education programs 
is essential. Topics for a study or GAO Report addressing the level of 
physical education in schools should include, at minimum: each State's 
physical education requirements; the extent to which physical education 
classes are available and/or mandatory at the elementary, middle, and 
high school levels in each State; comparative evaluation on physical 
education curricula, including the length of time of classes, physical 
education teacher qualification, the existence of standards for 
physical education, and class size; and measures of accountability for 
student achievement.
    National Fitness Testing. To enhance our continued understanding of 
the obesity epidemic and the role that increasing physical activity 
plays in achieving change, P.E.4LIFE recommends that additional 
measures for assessing the fitness of our Nation's youth be 
established. Creating incentives to States for the conducting of 
statewide fitness testing should be considered as the Committee 
proceeds.
    While fitness testing in schools is not new, we are encouraged by 
California's leadership in using ``Fitness Gram,'' a national test 
battery developed by The Cooper Institute. This comprehensive youth 
assessment protocol includes a variety of health-related physical 
fitness tests designed to assess cardiovascular fitness, muscle 
strength, muscular endurance, flexibility, and body composition. 
Criterion-referenced standards associated with good health have been 
established for children and youth for each of these fitness 
components. We view Fitness Gram as a model for other States to follow, 
and encourage you to include language in the bill that would 
incentivize States to conduct fitness testing.
    On behalf of P.E.4LIFE, I thank you for the opportunity to testify 
today. As one person whose life work has centered on helping all 
Americans adopt healthy lifestyle fitness practices and habits, I 
greatly appreciate the time that each of you is investing. The 
comprehensive agenda that the Committee is forming for the forthcoming 
legislation is heartening and appropriate as we together remedy the 
obesity epidemic facing America today. Please know that both P.E.4LIFE 
and I are willing to work side-by-side with you in the coming days.

    Senator Bingaman. Thank you both very much for your 
testimony.
    Let me try to understand a little more. If I gin up a trip 
of school administrators and P.E. professionals and public 
officials to come and see your Institute, what do we learn?
    Ms. Flannery. You are going to learn a number of things 
about how to implement a daily P.E. program. First of all, it 
is not the old P.E., and I think we need to raise awareness 
about that. The equipment has changed tremendously. You see a 
lot of, fundamentally in some ways, health club situations in 
the schools--climbing walls--you are seeing all sorts of 
activities that children get a chance to learn. But you are 
also seeing the adoption of new technology like heart rate 
monitors, software programs like FitLinks that allow children 
to develop their cognitive skills about what is it like to be 
in their target heart rate zone, what is healthy, and what is 
appropriate--because we do not just want to train the athletes. 
We want to train all of our children to understand how to be 
physically active their entire lives.
    Senator Bingaman. Denise, do you try to do anything 
involving proselytizing on diet and what people eat as well as 
the exercise that you are so identified with?
    Ms. Austin. Yes, but I am not a nutritionist. My degree is 
in physical education. I am a big believer in getting out there 
and moving, even it is kids at whatever age, to teach people 
the joys of fitness and how much better you can feel about 
yourself. I am a big believer that you should eat well 80 
percent of the time, have some treats 20 percent of the time--
but the key thing here is that I believe that food is not our 
enemy--it is standing still, sitting still--doing nothing is 
our enemy.
    We need to get kids out there and more active. They are 
sitting, watching too much TV, in front of the computer games. 
I get my kids out there, and we play tag, ball, anything to 
keep them moving. Everyone needs to implement exercise now into 
their lives because we sit for 8\1/2\ hours a day. We need to 
get up and move.
    Senator Bingaman. All right. I am encouraged.
    On your Institute, do you worry about nutrition in the 
schools, or do you leave that to someone else?
    Ms. Flannery. I think the 21st century P.E. professional 
also needs training in nutrition. Phil Lawler has an 
opportunity with children to address what is calorie intake, 
calorie output, in very real situations with the kids. When 
someone is learning on the exercise machine and seeing how many 
calories they are burning, he can right there say, ``What did 
you eat today?'' or ``What are you planning to eat between now 
and dinner?'' and it gives very real life examples and teaching 
moments, which is what you want so that the child can learn on 
a real life basis what good nutrition is all about and what 
choices he or she can make.
    Senator Bingaman. Thank you. Thank you both very much. I 
think your testimony has been great, and I compliment you for 
your lifelong commitment to solving this problem.
    Thank you very much.
    Let me ask the third panel to come forward now and we will 
hear from them.
    We welcome Sally Davis from the University of New Mexico, 
Kelley Brownell from Yale University, Lisa Katic from the 
Grocery Manufacturers of America, and Richard Dickey, M.D., 
with Wake Forest University School of Medicine.
    Thank you all very much for being here. I appreciate it. I 
will give a little more elaborate introduction of each of the 
four of you.
    Dr. Sally Davis is a Professor in the Department of 
Pediatrics and Director of the Center for Health Promotion and 
Disease Prevention at the University of New Mexico School of 
Medicine. She has 30 years of experience in health promotion 
and disease prevention programs, especially in the areas of 
physical activity, nutrition, and obesity prevention.
    Dr. Kelley Brownell is a Professor of Psychology at Yale 
University, where he also serves as Professor of Epidemiology 
and Public Health and as Director of the Yale Center for Eating 
and Weight Disorders. He is an internationally known expert on 
eating disorders, obesity, and body weight regulation.
    We also have Dr. Richard Dickey who is both a physician and 
a Professor of Medicine at Wake Forest University School of 
Medicine and has practiced medicine for more than four decades. 
He has focused much of his efforts on the study and treatment 
of obesity and obesity-related health complications. He is one 
of the Nation's foremost experts on the subject of obesity and 
metabolism.
    Ms. Lisa Katic is the Senior Food and Health Policy Advisor 
to the Grocery Manufacturers of America in Washington, DC. She 
is responsible for developing and implementing policies and 
programs related to fitness and nutrition. She is also a 
registered dietician and is considered an expert on nutrition 
policy.
    Why don't we start with Dr. Davis and go right across. As I 
said earlier, we will take your full statement and include it 
in the record as if you read it, so if you could summarize the 
main points that we think we should be aware of and do that in 
5 or 6 minutes each, that would be great.
    Dr. Davis.

   STATEMENT OF SALLY M. DAVIS, DIRECTOR, CENTER FOR HEALTH 
   PROMOTION AND DISEASE PREVENTION, UNIVERSITY OF NEW MEXICO

    Ms. Davis. Thank you, Mr. Chairman, for the opportunity to 
testify today.
    I come before you to share some of our experience in the 
battle against the growing epidemic of obesity. For the past 30 
years, I have worked in partnership with underrepresented 
communities in New Mexico and throughout the Southwest. For the 
most part, these communities are rural and culturally diverse, 
with Native American, Hispanic, and Anglo families often living 
near or below the poverty level.
    During these 30 years, I have seen lifestyle diseases such 
as obesity and diabetes increase at alarming rates and at 
younger ages than ever before. Paralleling these health trends 
is a decrease in school physical education and recess, an 
increase in the availability of calorie-dense foods, and a less 
active lifestyle.
    Our Center has been actively engaged in developing, 
implementing, and evaluating various interventions to address 
the health concerns of this medically underserved population in 
the Southwest. I would like to highlight a few of those 
interventions specifically related to physical activity, 
nutrition, and obesity.
    One of our first projects was the Checkerboard 
Cardiovascular Curriculum funded by the National Heart, Lung, 
and Blood Institute, which was a culturally and developmentally 
appropriate classroom intervention that focused on healthy 
eating and a balanced diet and on being physically active. For 
example, we used stories about healthy Native foods, such as 
the story about corn, beans, and squash called ``The Three 
Sisters.'' We also taught Native games to reinforce being 
physically active.
    It was during this project that we learned the importance 
of including families in school-based interventions. When 
included in the intervention activities, families serve as an 
important role model and as powerful reinforcers of the 
knowledge and behavior children learn at school.
    An example of this from one of our projects is that 
grandparents were concerned that their grandchildren were not 
as active as they had been when they were growing up and that 
the children were eating too much. Elders are honored to come 
into the classroom and share their experiences about a time 
when physical activity was a part of everyday life.
    These stories about the healthy habits they once practiced, 
such as running to the East in the morning when they woke up, 
and eating with one hand so they would not eat too much, 
provide inspiration and cultural pride.
    Three other school-based projects also funded by NIH 
followed, the most recent of these being Pathways, in which we 
partnered with four universities and seven Native tribes. Since 
the completion of Pathways, we have had more than 300 requests 
from across the country for the intervention materials and 
training in their use. Unfortunately, at this time, we do not 
have the funds for dissemination, often a problem associated 
with research of this kind; once it is developed and lessons 
learned, we do not have the resources to share with others.
    Although much of our work has been done in schools, as they 
are important gathering places in rural communities and a focal 
point for reaching children and their families, we believe that 
interventions to promote a healthy lifestyle and prevent 
disease should be addressed across the life span.
    For example, we were approached by the Navajo Agency on 
Aging, which was concerned that prevention programs were 
overlooking the needs of the elders. This collaboration has 
resulted in our providing training and technical assistance on 
nutrition and physical activity specific to senior citizens to 
the staff of senior centers across the Navajo Nation.
    On the other end of the age spectrum is the collaborative 
project that we have with Dine College, which is a Navajo 
community college, to assess the nutritional status of 
preschool children participating in the Navajo Head Start 
program.
    Yet another study that we recently completed assessed the 
availability, affordability, and variety of healthful foods on 
the Navajo reservation by conducting an inventory of the foods 
available in trading posts and convenience stores. Zuni Healthy 
Foods First is another project currently underway that promotes 
the intake of selected fruits, vegetables, and other healthy 
foods that includes partnering with local grocery stores. We 
are also involved in developing a nutritional training module 
for the March of Dimes Birth Defects Prevention Task Force 
aimed at preconception health education through motivational 
counseling.
    On the national level, we are the lead center for a CDC 
Division of Nutrition and Physical Activity-funded network of 
11 universities and 12 State health departments who are working 
together to identify innovative approaches to increasing 
physical activity, improving nutrition, and preventing obesity.
    All the projects that I have presented were made possible 
through Federal funding. The science of what we know about 
increasing physical activity and improving nutrition and 
particularly preventing obesity is very new and therefore, very 
limited. If we are to identify solutions to the growing 
problems associated with obesity, it is important that programs 
like these and others that are innovative, that meet local 
needs and are rigorously evaluated be supported through funding 
and legislation. We need more programs designed to educate and 
support families, including the aging population. Schools and 
communities need support in creating healthy and safe 
environments for physical activity.
    We need to find out what works and what does not work. This 
bill to establish grants to provide health services for 
improved nutrition, increased physical activity, and obesity 
prevention is an important and much needed move in the right 
direction to meeting a critical health need of this country.
    Thank you.
    Senator Bingaman. Thank you very much, Dr. Davis.
    [The prepared statement of Ms. Davis follows:]

                  Prepared Statement of Sally M. Davis

    Thank you, Mr. Chairman and distinguished Members of the Committee 
for the opportunity to testify today. I am Dr. Sally Davis, Director of 
the Center for Health Promotion and Disease Prevention at the 
University of New Mexico. I come before you to share some of our 
experience in the battle against the growing epidemic of obesity. For 
the past 30 years, I have worked in partnership with under-represented 
communities in New Mexico and throughout the Southwest. For the most 
part these communities are rural, and culturally diverse (Native 
American, Hispanic and Anglo) with families often living near or below 
the poverty level. During these 30 years, I have seen lifestyle 
diseases such as obesity and diabetes increase at alarming rates and in 
younger ages than ever before. Paralleling these health trends is a 
decrease in school physical education and recess, an increase in the 
availability of calorie dense foods and a less active lifestyle.
    The University of New Mexico Center for Health Promotion and 
Disease Prevention, one of the Centers for Disease Control's (CDC) 
Prevention Research Centers (PRC) has been actively engaged in 
developing, implementing, and evaluating various interventions to 
address the health concerns of this medically underserved population in 
the Southwest. I would like to highlight those interventions 
specifically related to physical activity, nutrition and obesity.
    One of our first projects was the Checkerboard Cardiovascular 
Curriculum (CCC) Project named for a vast land area of New Mexico with 
a checkered patterned of land ownership that includes Navajo 
homesteads, ranches that were once Spanish land grants; other private 
land; and public lands administered by the Bureau of Land Management 
(BLM) and U.S. Forest Service. The CCC project, funded by the National 
Heart Lung and Blood Institute, was a culturally and developmentally 
appropriate classroom intervention that focused on eating a healthy and 
balanced diet and being physically active. For example, we used 
traditional stories about healthy Native foods such as the story about 
corn, beans, and squash called ``The Three Sisters.'' We also taught 
Native games to re-enforce being physically active. It was during this 
project that we learned the importance of including families in school-
based interventions. When included in intervention activities, families 
serve as important role models and powerful re-enforcers of the 
knowledge and behaviors children learn at school. An example of this 
from our projects is that grandparents are concerned that their 
grandchildren are not as active as they had been when they were growing 
up and that the children are eating too much. The elders are honored to 
come into the classroom to share their experiences about a time when 
physical activity was a part of every day life. The stories about the 
healthy habits they once practiced such as running to the East each 
morning when they woke and eating with one hand so they would not eat 
too much, provide inspiration and cultural pride. Traditional food 
preparation is a favorite activity of both the grandparents and 
students and leads to discussions of ways to make food healthier during 
preparation. Stories of foot races and long distance running is also a 
favorite and remind children of their heritage. A video documentary of 
local Native people who have chosen to live a healthy lifestyle 
continues to be very popular.
    Taking what we learned from the Checkerboard Cardiovascular 
Curriculum project and at the invitation of the communities and schools 
over the years we developed the Southwest Cardiovascular Project and 
the Pathways to Health projects. Our most recent intervention, 
Pathways, was with tribes and universities across the country. For 
eight years, we worked with schools and communities located in seven 
Indian Nations. Using a participatory approach, researchers from five 
universities, seven Indian Nations and the National Heart Lung and 
Blood Institute developed, implemented and evaluated a physical 
activity and nutrition intervention for students in grades three 
through five. Pathways was designed by building on a foundation of 
previous experience, social learning theory, community-based formative 
assessment and cultural concepts representative of the participating 
population. The four components of Pathways include classroom 
curriculum, family activities, physical activity and school food 
service. Family Fun Night includes booths where families can taste 
foods such as low fat milk and healthy snacks. Families also learn 
things they can do with their children to be physically active and 
receive prizes for participating in active games. Short physically 
active games designed for the classroom, called exercise breaks, re-
enforce the importance of movement. In the curriculum, students 
correspond with other students from other tribes in the Pathways 
project and share information about healthy foods and activities common 
to each participating tribe. Food service workers learn ways to make 
school lunches and breakfasts healthier. Pathways was successful in 
increasing children's knowledge about nutrition, physical activity, and 
health in general and positively affecting their nutrition and physical 
activity behaviors. Parents, school administration and staff were very 
positive about the project and especially appreciated the training that 
accompanied each of the components. Parents often told us how much they 
enjoyed the activities and how much the program had influenced them to 
make changes in their daily habits relating to eating and being active. 
Since the completion of Pathways, we have had more than 300 requests 
from across the country for the intervention materials and training in 
their use. Unfortunately, at this time we do not have the funds for 
dissemination.
    Although much of our work has been done in schools, as they are an 
important gathering place in rural communities and a focal point for 
reaching children and their families, we believe that interventions to 
promote a healthy lifestyle and prevent disease should be addressed 
across the life span. For example we were approached by the Navajo 
Agency on Aging and a community health educator who were concerned that 
prevention programs were overlooking the needs of the elders. This 
collaboration has resulted in our providing training and technical 
assistance on nutrition and physical activity specifically for senior 
citizens to the staff of Senior Centers across the Navajo Nation. On 
the other end of the age spectrum is a collaborative project with Din 
College (Navajo Community College) to assess the nutritional status of 
preschool children participating in the Navajo Head Start program. The 
results of this study will provide a data set that can be used to 
inform discussion of policy and effectiveness of food assistance 
programs and nutritional interventions among Navajo families. Yet 
another study assessed the availability, affordability, and variety of 
healthful foods on the Navajo reservation by conducting an inventory of 
the difference sources, such as trading posts and convenience store, 
for purchasing food throughout the Navajo reservation. This project 
helps to better understand what foods are realistic to recommend to 
families and what food stores should be encouraged to carry. ``Zuni 
Healthy Foods First'' is another project currently underway that 
promotes the intake of selected fruit, vegetables, and other healthy 
foods through a practical, multi-dimensional approach that includes 
partnering with the local grocery stores. They have agreed to stock 
foods recommended in nutrition classes and take incentive coupons from 
those families attending the nutrition/cooking classes.
    Nutritionists from the Prevention Research Center are also 
developing a nutritional training module for the March of Dimes Birth 
Defects Prevention Task Force aimed at ``Preconception Health Education 
through Motivational Counseling''.
    Since our Prevention Research Center is university-based and we are 
located within the Health Sciences Center we have a wonderful 
opportunity to reach students and residents in training for the health 
professions. We provide hands-on experiences and one-on-one mentoring 
for a diverse group of students and residents of all levels. We believe 
it is important to include these individuals to better prepare them as 
prevention researchers and health care providers of the future.
    All of these projects I have presented were made possible with 
Federal funding. The science of what we know about increasing physical 
activity and improving nutrition and particularly preventing obesity is 
very new and therefore limited. If we are to identify solutions to the 
growing problems associated with obesity it is important that programs 
like these and others that are innovative, meet local needs, and are 
rigorously evaluated be supported through funding and legislation. We 
need more programs designed to educate and support families including 
the aging population. Schools and communities need support in creating 
healthy and safe environments for physical activity. We need to find 
out what works and what doesn't work in the prevention of obesity and 
the improvement of physical activity and nutrition. This means more 
funding for prevention research and training of researchers. Pre-
service and continuing education must be provided to health 
professionals if they are to provide state-of the-art counseling and 
treatment for their patients. The ``Improved Nutrition and Physical 
Activity Act'' (IMPACT), to establish grants to provide health services 
for improved nutrition, increased physical activity, and obesity 
prevention is an important and much needed move in the right direction 
to meeting a critical health need of our country.

    Senator Bingaman. Dr. Brownell.

  STATEMENT OF KELLEY D. BROWNELL, DIRECTOR, YALE CENTER FOR 
          EATING AND WEIGHT DISORDERS, YALE UNIVERSITY

    Mr. Brownell. Thank you for the opportunity to speak.
    I love the fact that this bill exists. As much as the 
content in it, the fact that this bill is before the country 
now, is something quite striking and marks a very important 
point in the history of our dealing with an important health 
problem.
    The folks who have spoken so far today have talked a lot 
about physical activity, and that is very important--do not get 
me wrong--but we are ignoring the food part of this, and the 
food part of it is at least as important as the physical 
activity, and it is easy to ignore because of pressure from the 
food industry.
    I am going to make the point that the epidemic of obesity 
exists because of a toxic food and physical inactivity 
environment and that until we recognize this cause and do 
something bold and innovative about it, we are going to be 
losing this battle.
    The programs we have heard about today, programs in 
communities, are innovative and absolutely need to be done, but 
for every case of obesity this prevents, there are probably 
more thousands more coming on line because of this toxic food 
and physical inactivity environment.
    We simply cannot get rid of this problem by traditional 
medical treatment or by community programs, because the toxic 
forces are so overwhelming. By a ``toxic'' environment, I mean 
the physical inactivity that has been explained in great detail 
already, but also the fact that food is available everywhere, 
all the time, in places where it never used to be. You can eat 
a meal in a gas station now. You can eat a meal in a drugstore. 
You can eat a meal in a shopping mall. This was never the case 
before.
    Portion sizes have grown out of control. What used to be 
the large is now the small; portion sizes have been manipulated 
up, up, and up until the default sizes are absolutely 
astronomical.
    The food industry pounds away relentlessly at our psyche, 
and this is especially true of children in a way that I will 
mention in just a minute. This is a David and Goliath contest. 
This is a drop against a tidal wave, if you will. Let me give a 
few examples.
    The National Cancer Institute has $1 million per year to 
spend on advertising the Five A Day program to encourage people 
to eat fruits and vegetables--$1 million. McDonald's alone 
spent $500 million on the ``We Love to See Your Smile'' 
campaign. One company, one campaign, 500 times what the NCI 
spends.
    The entire Government budget now for nutrition education is 
one-fifth the annual advertising budget for Altoids mints. It 
is not surprising, therefore, that one-fourth of all vegetables 
served in the United States come as french fries.
    The picture with children is especially appalling. The 
average American child sees 10,000 food advertisements a year. 
A mother or father who gives a compelling media-based lecture 
to their child every day of the year would deliver 365 messages 
compared to the 10,000 from the food industry.
    We are engineering physical activity out of schools. We 
feed our children terrible school lunches. We allow the soft 
drink companies and the snack food companies to put machines in 
our schools. The schools become dependent on this money, but 
logos for Coke and other companies show up on scoreboards and 
on uniforms and in other places, and more and more, schools are 
beginning to look like 7-Elevens with books.
    The question is what do we do. First, we have to make a 
philosophical judgment ourselves as to how much of our 
resources can we contribute to trying to help people who have 
the problem already versus trying to prevent it. Helping people 
with a problem already smacks of compassion and is obviously an 
important thing to do, but it costs a lot, because the 
treatments that we have are not terribly effective, although 
there are some promising things out there, and they tend to be 
fairly expensive. So from a public health point of view, we are 
not going to be able to treat this problem away.
    This, of course, leads us naturally to the issue of 
prevention, and that leads us, of course, to the issue of 
children. I think that children are to the obesity field what 
secondhand smoke was to tobacco. You can always make the 
individual responsibility argument for adults, but when you see 
8-year-old children with what used to be called adult-onset 
diabetes, probably needing cardiovascular bypass surgery by the 
time they are 30, it is very hard to make a personal 
responsibility argument.
    I think we need to make bold, decisive moves on the level 
of public policy, and specifically, I would suggest the 
following. One is to make physical activity more available to 
the population. This has been discussed in detail.
    Second, I believe we need to regulate food advertising 
aimed at children. The 10,000 food commercials, by the way, 95 
percent of which are for fast food, sugared cereals, soft 
drinks and candy, have to be combatted by something, and what I 
would suggest specifically is some kind of equal time 
legislation that would mandate equal time for pro-nutrition 
messages, and money should be put behind developing pro-
nutrition messages.
    What happens in our schools has to be changed. Fast foods, 
snack foods, and soft drinks should be banned from the schools. 
Dr. Dietz is correct--it is not the machines that we are 
concerned about; it is what is in the machines. So if children 
have healthy foods available, they will eat healthy foods; if 
they have unhealthy foods available, they will eat those. It is 
a simple matter. Animals will do the same thing when put in a 
cage. If children have fast foods available, the snack foods 
and the soft drinks, they are going to consume them, and we are 
going to have trouble.
    Finally, I would recommend that we consider some ways to 
reverse the economic picture of food. The fact is that 
unhealthy food is easy to get, and it costs relatively little; 
healthy food is harder to get, and it costs too much. And as 
long as the economics are set up like this, we are bound to 
have a society that is going to overeat the unhealthy foods.
    If you go to poor neighborhoods especially--this has been 
quite well-documented--healthy foods are not available, and 
when one does find them, they tend to cost an awful lot, 
whereas there are lots of choices of soft drinks, snack foods, 
candy, and the like.
    I am going to end with a discussion of how we interact with 
the food industry around this, and I think this is a very 
important philosophical decision that the folks making the 
policy will have to deal with.
    There is much talk these days of stakeholders, of 
coalitions, and words like ``partnership'' get used a good bit. 
The way I see our field going is that the food industry is 
becoming a part of the decisionmaking progress. Now, I am a 
collaborative person by nature, and generally, partnerships and 
coalitions are a good thing rather than a bad thing, but we 
have to be cautious here, and I think there is a dear price to 
pay if we are not careful about how we move ahead. We have to 
take some knowledge from what happened with tobacco and the way 
the tobacco industry dealt with these issues, too.
    This is what I believe the food industry is going to do, 
and they have shown many signs of this already. First of all, 
they are going to stay and say ``We need more research''; 
recommendations that come out of committee meetings and so on 
will be watered down and will end up looking like pablum more 
than anything bold and decisive.
    Second, they have the opportunity to deny, distort and 
ignore both the science and common sense. I will give you an 
example in a moment. They will say that parents and families 
must do the job. Well, if parents and families could do the 
job, we would not have this problem in the first place. They 
will also make straw man arguments and say things like we 
cannot blame the epidemic on one food, we should not make 
demons of certain parts of the industry, and that things like a 
soft drink tax which several States are considering now will 
not wipe away this problem. Of course, they will not wipe away 
the problem. It is an enormous, complex problem, and no one 
thing is going to get the job done. But those are straw man 
arguments.
    As an example of this, let us look at soft drinks. The most 
authoritative recent study that has been done on soft drink 
consumption which was published in a good medical journal, The 
Lancet, by Ludwig and colleagues concluded the following, and I 
quote: ``Consumption of sugar-sweetened drinks is associated 
with obesity in children.'' Common sense will tell you that 
that is the case, and data tell you that is the case. However, 
the website from Saturday from the National Soft Drink 
Association said the following: ``Soft drinks do not cause 
pediatric obesity, and further, the soft drink industry has a 
long commitment to promoting a healthy lifestyle for 
individuals, especially children.'' How can anybody with an IQ 
over 8 believe that to be the case?
    They also say--and this is actually true, but sad--that 
``The revenue generated from the sale of beverages in schools 
is an important part of the education funding equation in the 
United States.'' If the schools need the money, and if they 
need to sign on with corporate America in order to survive, why 
can't they sign on with computer companies, with fitness 
equipment companies--something other than food, which is 
basically helping to poison our children.
    It took 40 years to get where we are today with the fight 
against tobacco. The industry stalled, ignored the data, denied 
the data, and did all the things that are now well-known. You 
can just see it coming with the food companies. If they are on 
the team, we are going to crawl up the field inch by inch by 
inch and make very slow progress. I believe that it is better 
to have them on defense than it is to have them sabotaging your 
offense.
    Thank you.
    Senator Bingaman. Thank you, Dr. Brownell.
    Ms. Katic, please go ahead.

    STATEMENT OF LISA KATIC, SENIOR FOOD AND HEALTH POLICY 
           ADVISORY, GROCERY MANUFACTURERS OF AMERICA

    Ms. Katic. Thank you, Mr. Chairman.
    My name is Lisa Katic. I am a registered dietician, as you 
pointed out earlier, and I am the Senior Food and Health Policy 
Advisor to the Grocery Manufacturers of America.
    GMA is very pleased to be before you today. We want to 
share our views on food and nutrition. We are the world's 
largest association of food, beverage, and consumer product 
companies. We employ more than 2.5 million people in all 50 
States.
    First of all, let me begin by commending the Committee for 
focusing on solutions today rather than scapegoats. The 
problems that we are addressing today are the result of a 
complex combination of factors. That is why we believe the 
title for this hearing is appropriate--``Getting Fit, Staying 
Healthy: Strategies for Improving Nutrition and Physical 
Activity.''
    We believe that effective solutions demand a comprehensive 
strategy, one that avoids blaming individuals, food companies, 
or societal trends. As a nutritionist, I can tell you that this 
issue is about calories in versus calories out. The source of 
calories does not affect this equation.
    The American Dietetic Association says that a healthy 
lifestyle involves a well-proportioned, balanced diet and 
physical activity. You cannot have one without the other.
    With every passing decade, there seems to be a new diet 
that focuses on a single food group or nutrient, such as 
carbohydrates, proteins, or fats, and these diets profess to be 
the answer to all of our weight gain woes. The Atkins diet 
first gained popularity in the 1970s. In the 1980s, the 
nutrition culprit was fat. Today, obesity rates are rising, and 
once again, Americans are turning to failed diets of the past, 
and consumers are as confused as ever.
    My point is that none of these have worked in the past. 
They are not going to work now. Consumers need consistent and 
understandable messages about food and health, based on the 
best available science. We must take a total diet approach and 
forever abandon blaming a single food or nutrient as the cause 
of America's weight gain.
    Many people come to this hearing today with differing 
perspectives, but no one disagrees that physical activity is 
the leading cause of health in America. I did say that physical 
activity is the leading cause of health in America.
    Last year, the Surgeon General called for 30 minutes of 
daily physical activity for every school-age child. Sadly 
today, we are not even close to meeting this goal. The goal 
must be to make physical fitness a part of our culture. Habits 
that are learned early stay with us for a lifetime.
    Mr. Chairman, it is time to get Americans moving again. GMA 
recognizes that our industry has a very important role to play 
in improving fitness and nutrition. Our industry has long 
supported nutrition education and physical activity programs, 
like Take 10, Activate, the Five-a-Day campaign, and Colorado 
on the Move, just to name a few.
    Our member companies also place a very high priority on 
researching and developing new ways to make people's favorite 
foods even healthier without sacrificing taste. We know that 
taste is the number one reason why people choose food. Many 
companies provide financial, technical, and personnel support 
for local food banks and community-based wellness programs.
    Although we have some suggestions, GMA believes that 
legislation currently being drafted by this Committee is headed 
in the right direction, particularly the focus on research, on 
physical activity, and on nutrition education.
    In the area of improving nutrition education, I cannot 
emphasize enough that quality research is needed to determine 
what actually changes behavior and changes behavior for the 
long term. There is a tremendous amount of nutrition 
information available, but it is just not always getting 
through to the people who need it, like parents, teachers, and 
community leaders.
    Equally important, the information is not always culturally 
appropriate. It is not always available to help at-risk or 
minority populations.
    Let me just say a word or two about some of the punitive 
measures that have been offered as solutions today. Efforts to 
tax, ban, or restrict the consumption of certain food are 
scientifically unsound and in fact quite counterproductive. 
Such proposals lull people into thinking that something complex 
can be solved by something simple. Quite simply, they do not 
work, and Congress should reject them.
    In fact, a study published in the Journal of the American 
Dietetic Association states that overly restrictive diets can 
lead to enhanced food cravings, overindulgence, and even eating 
disorders.
    Finally, let us not forget the critical role that 
individuals and families play in combatting obesity. While the 
Government provides information to help consumers make informed 
choices, and the food and beverage industry provides variety, 
neither of these is as important as the role that parents play 
in establishing proper eating habits for their children. 
Parents must also show a good example by engaging in regular 
physical activity themselves.
    Mr. Chairman, we look forward to working with you as you 
progress on your legislation. We have a lot of expertise in 
this area, we have a lot of suggestions, and we are also very 
committed to helping Americans get fit and stay healthy.
    Senator Bingaman. Thank you very much.
    [The prepared statement of Ms. Katic follows:]

                    Prepared Statement of Lisa Katic

    Good afternoon Mr. Chairman and Members of the Committee. My name 
is Lisa Katic. I am a registered dietitian and a Senior Food & Health 
Policy Advisor to the Grocery Manufacturers of America (GMA).
    GMA is pleased to appear before the Committee today to share our 
views on the issue of fitness and nutrition. GMA is the world's largest 
association of food, beverage and consumer product companies. With U.S. 
sales of more than $460 billion, GMA members employ more than 2.5 
million workers in all 50 States. The organization applies legal, 
scientific and political expertise from its member companies to vital 
food, nutrition and public policy issues affecting the industry. Led by 
a Board of 42 Chief Executive Officers, GMA speaks for food and 
consumer product manufacturers at the State, Federal and international 
levels on legislative and regulatory issues.
    GMA and its member companies believe the topic for today's hearing 
is critically important. The food and beverage industry we represent 
has long advocated for comprehensive, long-term strategies for 
improving the health and wellness of all Americans by promoting 
science-based solutions focused on the critical balance between fitness 
and nutrition. We have done so as individual companies and trade 
associations and, more recently, in cooperation with other industry 
allies, not-for-profit organizations, public health professionals and 
others who are committed to promoting the balance between fitness and 
nutrition. Many of these groups and individuals have joined with GMA to 
form the American Council for Fitness and Nutrition, an organization 
dedicated to these ideals.
    GMA thinks the ``Improved Nutrition and Physical Activity Act'' is 
the perfect title for the legislation being developed by Members of 
this Committee because it sets the right framework for this discussion. 
The lack of a balanced diet coupled with the lack of regular, daily 
physical activity can lead to many physical and mental conditions--
including depression, heart disease, diabetes and overweight.
    These conditions emerge because of a complex combination of factors 
and cannot be solved solely by blaming individuals, food companies or 
societal trends and events. It is well documented that people become 
overweight from a variety of dietary, socio-economic, genetic and life-
style risk factors. Therefore, finding effective, long-term solutions 
requires (1) a thorough understanding of the science of fitness and 
nutrition, (2) a recognition of the benefits of a well portioned and 
balanced diet, and (3) a commitment to promoting physical activity.
    I would like to discuss these three topics in turn and then offer 
some insights into the contributions the food and beverage industry is 
making to help improve general wellness. Finally, I will close with 
observations on the draft legislation and what more can be done by 
individuals, the food and beverage companies and Government entities to 
improve nutrition and physical activity for all Americans.

I. The Science of Fitness and Nutrition

    History has taught us that there can be no single solution to 
improving our children's nutrition and fitness. Although our need for 
food is basic, the interaction between nutrition, exercise and health 
is complex. To help our kids lose weight and get in shape, we must 
understand the evolution of food and the latest developments in 
nutrition science to avoid repeating past mistakes in nutrition advice 
offered by Government, health professionals or the media.
    As a nutritionist, I can tell you that there is a consensus that at 
its core, this issue is about calories in versus calories out. In 
scientific terms, obesity is a disease with a multifactorial etiology. 
In addition to diet and physical activity, incidence of overweight and 
obesity are also affected by sociocultural factors, socioeconomic 
status, and an individual's unique genetics and physiology. To 
understand how a poor diet and the lack of physical activity in 
particular contribute to overweight and obesity, the fundamentals of 
thermodynamics must be understood and applied: calories consumed = 
calories expended. The source of calories consumed does not affect the 
equation. Total diet (calories in) and physical activity (calories 
out), therefore, are the critical controllable factors in today's 
weight loss and in weight maintenance.
    Overweight and obesity among Americans are linked to several major 
chronic diseases affecting Americans, such as cardiovascular disease, 
cancer, and diabetes. Overweight children are more likely to become 
overweight adults, and, therefore, they may be at increased risk of 
developing these chronic diseases later in life. There is general 
scientific agreement that parents and healthcare professionals should 
stress to adolescents the benefits of eating a healthy diet, as 
outlined in the U.S. Department of Agriculture's Food Guide Pyramid. 
The American Dietetic Association has stated that the entire diet, 
rather than specific foods, should be scrutinized. Identifying the 
extra calories that might be contributing to an adolescent being 
overweight or obese will probably be more effective in changing his or 
her diet than portraying individual foods as good or bad.
    Simply put, the science is too much in flux to declare a final 
answer today. For instance, we have been told to monitor cholesterol to 
prevent coronary heart disease, which is the leading cause of death in 
the United States. More recent studies have identified homocysteine, 
not cholesterol, as a culprit in producing arteriosclerosis. Scientists 
are also now divided on the role of saturated fats in causing coronary 
heart disease. That linkage, once thought ironclad, is now being 
reassessed. Retrospective epidemiological studies are now calling into 
question the practical benefits of avoiding saturated fats for an 
entire lifetime. What is clear is that the keys to a healthy lifestyle 
involve following the American Dietetic Association's (ADA) guidance on 
a well proportioned, balanced diet and physical activity. Doing just 
one is not enough: we need to do both.
    In addition to scientific research, the amount of general nutrition 
information available to the public is at an all time high. However, 
consumers are potentially more confused about food and its role in 
enhancing health than ever before. This is especially true when it 
comes to losing or maintaining weight.
    With every passing decade, there seems to be a new ``diet'' that 
focuses on a single food group or nutrient, such as carbohydrates, 
proteins and fats, and professes to be the answer to all our weight 
gain woes. The Atkins diet was popular in the 1970s, developed in 
response to the targeting of sugar and carbohydrates. In the 1980s, the 
nutrient culprit of the decade was fat. Now, in the new millennium, 
obesity rates are rising and, once again, many Americans are turning to 
the anti-sugar and anti-carbohydrate diets of the past and consumers 
are as confused as ever.
    My point is that none of these fads worked in the past and, as a 
nutritionist I can tell you, they will not work this time either. We 
have an opportunity to get it right this time. Consumers need 
consistent and understandable messages about food and health based on 
the best available science--not quick fixes that promise to deliver 
unrealistic benefits. We must take a total diet approach and forever 
abandon blaming one nutrient or food as the cause of America's weight 
gain.

II. A Well Proportioned and Balanced Diet

    The Government has recognized that a balanced approach to diet is 
the right approach, as opposed to characterizing certain foods as 
``good'' or ``bad.'' In the preambles to the proposed and final 
regulations implementing the 1990 Nutrition Labeling and Education Act 
(NLEA), FDA emphasized that there is no such thing as a good food or a 
bad food. Similarly, the USDA Food Guide Pyramid focuses on a well 
portioned and balanced diet. This is the same approach embraced by one 
of the most successful diet-assistance groups, Weight Watchers.
    The Weight Watchers POINTs program uses a positive system that 
allows consumers to build their own diet, complete with ample food 
choices, including ice cream, pizza and ``fast food.'' The program does 
not prohibit any food or nutrient; it just teaches people to balance 
the amounts of their consumption. It doesn't mandate, tax or prohibit, 
it measures and recommends. Since introducing the points program, 
Weight Watchers members have lost a combined 79.9 million pounds.
    Other examples support that position. Although the number and type 
of reduced-fat, low-fat, and non-fat foods has increased dramatically 
over the last twenty years, more Americans are overweight today than in 
1990. We know that people are buying and reading the labels on low-fat 
foods; but we are still gaining weight as a population. Some non-fat 
and low-fat foods may have as many calories as their regular variety. 
Other studies have demonstrated that both obese and non-obese 
adolescents who exercise consume similar amounts of calorie-dense snack 
foods, items of minimal nutritional value, and food with highly 
saturated fat. So simply avoiding fat or sugar is not the magic some 
think. We have lost sight of the simple fact that calories still count.
    Moreover, if Congress focuses on ``bad'' foods, it will find that 
opinions about those foods change radically over time. Ten years ago, 
we were most concerned about the propensity of dietary cholesterol to 
raise serum triglyceride levels. Accordingly, people were advised not 
to consume animal fats. Today, scientists have uncovered some 
components found in animal products called conjugated linoleic acids 
that may provide exciting health benefits. We also now know that 
calcium, which is abundant in dairy products, can deliver health 
benefits beyond building strong bones. Calcium is now linked to 
providing potential protective effects against colon cancer and may 
help those with diabetes.
    In looking at the total diet, we should identify the amount of 
excess calories in an individual's diet, rather than declaring 
individual foods are ``good'' or ``bad.'' Restricting, taxing or 
prohibiting certain foods will almost certainly not work. In fact, a 
study published in the Journal of the American Dietetic Association 
states that overly restrictive diets may lead to enhanced food 
cravings, overindulgence, eating disorders or a preoccupation with food 
and eating. Moreover, selective food taxes are arbitrary, 
discriminatory and regressive. Such taxes hinder free choice by 
consumers and disproportionately affect households with lower incomes 
that may have fewer affordable snack options.
    Some studies have been completed which develop this point, but more 
research needs to be done, especially with children. Many of the 
existing studies have focused on the role of exercise and diet in 
extending an adult's life. We need to review existing studies and 
determine what additional studies might be helpful in focusing on 
childhood and adolescent nutrition and fitness. For example, we should 
be looking at the role of nutrition and fitness in the development of 
diabetes, respiratory or skeletal problems and other conditions that 
are problematic for children, pre-teens and adolescents. Similarly, we 
should focus on the balance between fitness and nutrition to promote 
overall wellness--instead of focusing too much attention on weight 
loss.

III. The Benefits of Physical Activity

    Many people came to this hearing today with many competing 
perspectives, but no one disagrees that physical activity is the 
leading cause of health in America.
    According to the American Heart Association, daily physical 
activity helps reduce the risk of heart disease by improving blood 
circulation throughout the body, keep weight under control, improve 
blood cholesterol levels, prevent and manage high blood pressure, 
prevent bone loss, boost energy level, manage stress, improve the 
ability to fall asleep quickly and sleep well, improve self-esteem, 
counter anxiety and depression, increase muscle strength, provide a way 
to share activity with family and friends, establish good heart-healthy 
habits in children.
    Physical activity among children is especially important. Studies 
have also shown that children who participate in quality physical 
education programs fare better physically and mentally than children 
who are not physically active. The National Association for Sport and 
Physical Education reported that a quality physical education program 
will help children improve self-esteem and interpersonal skills, gain a 
sense of belonging through teamwork, handle adversity through winning 
and losing, learn discipline, improve problem solving skills and 
increase creativity.
    But it is clear that fitness is becoming less of a personal issue 
and more of a societal concern. It is important to stress individual 
solutions toward fitness but at the same time we need to examine all 
the environmental changes in our lives that have reduced fitness.
    Time spent on computers and televisions have overtaken sports; 
driving has overtaken walking; technology and automation reduce on-the-
job activity--and people around the world are becoming more sedentary.
    More alarming is the lack of quality daily physical activity in our 
Nation's schools. According to a report issued by the International 
Life Sciences Institute (ILSI), about one in four children do not get 
any physical education in school. Physical education requirements in 
our public schools have been declining over the last twenty years. 
Today, only the State of Illinois has a daily physical education 
requirement for grade K-12, but it allows schools to be exempted from 
this requirement. During the 1990s, the percentage of high school 
students enrolled in daily gym classes dropped from 42 percent to 29 
percent and only 19 percent of those high school students taking daily 
physical education courses are physically active for 20 minutes or more 
a day. Outside of school, the statistics are equally concerning. 
According to ILSI, fewer than one in four children get 20 minutes of 
vigorous activity every day of the week and fewer than one in four get 
at least half an hour of any type of physical activity every single 
day.
    The Surgeon General, many leading researchers and well-respected 
health organizations, the FDA and USDA have all said the risks of 
inactivity are too great regardless of your diet. Mr. Chairman, it is 
time to get Americans moving again.
    Last year, Congress approved $50 million in funding for the 
Physical Education for Progress (PEP) program. The PEP Act authorizes 
the U.S. Department of Education to award grants to help initiate, 
expand and improve physical education programs in schools. Funds 
awarded under PEP can be used for a variety of purposes including the 
purchasing of equipment, hiring of staff and developing curriculum. The 
PEP program provides vitally needed funds to local communities and 
schools and can serve as a catalyst for communities across America to 
address physical activity issues. GMA supports the PEP program and 
urges you to encourage your constituents to apply for grants. We would 
also urge Congress to support full funding for PEP in the FY2003 
appropriations process and beyond.
    For children, we agree with the standards set by the Surgeon 
General: at least 30 minutes of physical activity for all grades K-12. 
The goal here, Mr. Chairman, should be to make physical fitness a 
cultural habit that catches on early. Like all habits, the ones that 
start early tend to stay with us for a long time. Quite simply, to make 
physical fitness a habit for life it will need to become part of 
American culture.

IV. Industry's Contributions

    GMA believes the food and beverage industry has a very important 
role to play in helping to improve fitness and nutrition. The industry 
has introduced tens of thousands of products that provide options for 
consumers looking for ways to incorporate variety, balance and 
moderation in their diets. Food and beverage companies also place a 
high priority on researching and developing new ways to make people's 
favorite foods even healthier without sacrificing taste. For example, 
large numbers of products are fortified with calcium and other 
essential vitamins and minerals and many items have been reformulated 
to provide reduced or lower calorie, fat or salt content while 
delivering good taste.
    What is done in the home and in the community is also important to 
combating this problem. GMA members and many other companies in the 
industry support a wide variety of nutrition education and physical 
activity programs designed to help individuals and their communities. 
Here are just a few examples:
    TAKE 10! is a classroom-based program focused on the promotion of 
physical activity designed to reduce periods of inactivity during the 
school day. The program integrates 10-minute intervals of physical 
activity into the school day combined with age-appropriate lessons of 
math, science, language and arts.
    The 5 A Day Better Health Program is a national program to 
encourage all Americans to eat 5 to 9 servings of fruits and vegetables 
every day for good health. The national 5 A Day for Better Health 
Program, established in 1991 as a partnership between the National 
Cancer Institute and the Produce for Better Health Foundation, is the 
largest public-private partnership for nutrition and health in the 
United States and in the world.
    ACTIVATE--a communications and web-based program designed to 
provide important nutrition and physical activity information for 
children and their families.
    Colorado on the Move is a new program developed by the University 
of Colorado's Center for Human Nutrition in response to the national 
obesity epidemic. The program proposes easy to implement strategies to 
increase physical activity in the population that will be sufficient 
enough to prevent positive energy balance and weight gain.
    GMA and its member companies have also been long-standing promoters 
of health and wellness in the communities in which we operate. Many 
companies have provided financial, technical and personnel support for 
local food banks, community-based wellness programs (e.g. diabetes 
prevention programs, ``heart healthy'' education programs) and school-
based nutrition education and physical activity programs.
    Closer to home, the GMA Board of Directors recently approved a set 
of corporate wellness principles to promote the creation of prevention-
based initiatives at our companies that are designed to improve the 
health and wellness of our workforce.

V. Observations and Suggestions

    There is a growing understanding in Congress and across the United 
States that food, itself, is not the problem. It is the lack of a 
balanced diet and not enough exercise that is the root cause of today's 
concern.
    Imprecise solutions and unfounded rhetoric have sent many consumers 
down the wrong paths. Punitive measures and quick fixes such as snack 
taxes, advertising and sales restrictions are unproductive and 
potentially dangerous. Such proposals lull people into thinking that 
these complex problems can be solved with one simple measure. As a 
dietitian, I feel compelled to reinforce the need for measured, 
balanced approaches to this complicated issue. This is not just my 
opinion, but a position supported by many clinical and dietary science 
professionals. Congress should not criticize people's willpower or food 
choices; instead it should promote positive program focused on the 
balance between diet and exercise. This is nothing new. Most leading 
health associations, well-respected weight loss programs and fitness 
experts support this philosophy.
    GMA believes the legislation is heading in the right direction by 
focusing on improving nutrition education, increasing physical 
activity, and calling for additional research. We strongly support the 
provisions calling for a cataloguing of existing research to better 
understand what is currently being done and in which areas additional 
research may be necessary. In addition, we encourage the Committee to 
look at existing programs that might be able to accomplish some of 
these activities without having to create new organizations and 
bureaucracies. As with any piece of legislation, it is important that 
all definitions be precise, and that grants are well tailored to their 
purpose and given to the most meritorious applicants. We have some 
additional suggestions that we look forward to working on with you as 
this proposal progresses.
    In the area of research, I cannot emphasize enough the importance 
of quality research on behavioral factors. Currently, the research that 
is available is inadequate. We need to investigate more fully what 
actions change behavior so that we can develop programs that actually 
work.
    Another area that must be improved is nutrition education. GMA 
supports the professional guidance of the American Dietetic 
Association, which states all foods fit within the U.S. Dietary 
Guidelines. We support additional research to determine the best way to 
introduce and teach these concepts to parents and their children. While 
tremendous amounts of information currently exists, much of it is not 
produced or distributed in a way that gets it into the hands of those 
who need it most--parents, their children, educators and community 
leaders. We also need a better commitment to provide up-to-date 
nutrition education programs that are culturally appropriate. These 
nutrition education programs should build on the ADA's recommendations 
and teach our children the value of variety, moderation and balance. 
Much more research is needed to enable us to do so effectively.
    Speaking broadly, we must empower individuals through education and 
awareness. We need to improve the public's understanding of the 
consequences of too little exercise and unbalanced diets and urge 
Americans to view obesity as more than a cosmetic issue. After we raise 
awareness, we must offer access to effective programs and educational 
tools that people can actually use. These programs should embrace the 
science of fitness and nutrition mentioned earlier and identify ways to 
achieve a balanced diet and quality daily physical activity in the 
workplace, our community, home and school environments.
    On the public policy front, we pledge to work with Congress to look 
for additional ways to adopt the Surgeon General's recommendation for 
physical activity for all school aged children, K-12 and find ways to 
improve the quality and accessibility of nutrition education 
underscoring how all foods eaten in moderation can fit into a healthy 
diet. In addition, we look forward to working with you to increase 
funding for research on the behavioral factors that contribute to 
America's weight gain; identify and support effective and culturally 
appropriate health interventions to reach at-risk and minority 
populations; and provide incentives for schools, communities and 
companies to develop and adopt physical fitness and general wellness 
programs.
    Finally, a discussion on fitness and nutrition would not be 
complete without mentioning the critical role individuals and families 
play in combating obesity. Ultimately, individuals have to make a 
choice about the foods they eat and the level of physical activity they 
engage in. Governments can and should provide information to help 
consumers make informed choices. The food and beverage industry also 
plays an important role in providing choice and variety and promoting 
its products in a truthful and non-misleading fashion. None of these 
actions are as important, however, as the role parents play in 
establishing food eating patterns and preferences for their children.
    Parents must set a good example of eating a moderate amount of a 
wide variety of foods. Most weight management experts agree that food 
should not be withheld or used as a reward. At the same time, foods 
should not be forced on children. Children need to see their parents 
setting a good example by enjoying and engaging regularly in physical 
activity. As studies have shown, people who learn appropriate eating 
habits early in life continue to eat responsibly throughout their 
lifetime and pass these good habits onto their children.
    The ability for individuals to exercise choice and make responsible 
decisions will be aided or hindered by the outcomes of this hearing and 
the actions taken by Congress from this point forward. Let me reiterate 
the importance of endorsing policy proposals that are positive, 
comprehensive and address the problems surrounding the fitness and 
nutrition debate in a responsible manner.
    GMA is very pleased by the willingness of the Senate, and 
particularly the Members and staff of this Committee to engage in a 
dialogue with the food industry. We believe our expertise can be an 
asset in this on-going effort. We look forward to working with the 
Committee on this important subject, and thank the Committee for its 
constructive and positive approach to this matter.

    Senator Bingaman. Dr. Dickey, please go ahead.

 STATEMENT OF RICHARD A. DICKEY, M.D., WAKE FOREST UNIVERSITY 
     SCHOOL OF MEDICINE, ON BEHALF OF THE ENDOCRINE SOCIETY

    Dr. Dickey. Thank you, Mr. Chairman, and good afternoon.
    My name is Richard Dickey, and I am a newly-retired 
physician. I practiced endocrinology for over 30 years and 
still practice as a volunteer at an indigent clinic in North 
Carolina. I also continue to teach at Wake Forest University 
School of Medicine and have participated in People-to-People 
Ambassadors programs leading endocrinologists to China and Cuba 
to study problems with obesity and metabolic syndrome in those 
cultures.
    I am pleased to testify before you today on behalf of the 
Endocrine Society, where I serve on the Clinical Affairs 
Committee. We commend the Members of the HELP Committee for 
their leadership and support in bringing the issue of obesity 
to the attention of both the Congress and the American public.
    The Endocrine Society, founded in 1916, consists of over 
10,000 physicians and scientists who are dedicated to the study 
of endocrinology. Endocrinology is the study of hormone 
disorders including diabetes, obesity, thyroid disease, 
osteoporosis, infertility, menopause, pituitary tumors, and 
hypertension.
    I am also here as a representative of the Hormone 
Foundation, the Endocrine Society's patient education 
organization. This foundation plans to launch a major 
initiative over the next year to address the growing epidemic 
of obesity and help educate patients and physicians on the 
metabolic syndrome.
    The Endocrine Society strongly supports the Senate HELP 
Committee's development of the Improved Nutrition and Physical 
Activity Act. The efforts of this Senate Committee to address 
and raise the visibility of obesity and its negative impact on 
the health of our Nation is truly commendable. As an 
organization dedicated to the advancement of research and 
knowledge and the care of patients, the Endocrine Society urges 
the Committee to take this opportunity to address the impact of 
research and the mechanisms responsible for the diagnosis and 
treatment of obesity and its complications, including the 
metabolic syndrome.
    In 2002, obesity is a national epidemic, as we have heard, 
with the number of obese and overweight Americans nearly 
doubling over the past 10 years. Estimates from the U.S. 
Surgeon General indicate that over half of all Americans are 
now overweight. Adipose tissue, or fat, hunger, weight, and 
metabolism are all regulated by hormones. Research by 
endocrinologists has shown that obesity, especially in 
children, can lead to numerous medical problems later in life, 
including diabetes, heart disease, and infertility.
    You have identified a number of excellent programs to 
address this epidemic. I would like to expand on several areas 
that the Endocrine Society believes to be imperative. The first 
is to recognize the medical risks of obesity. We define the 
most debilitating and costly complications of obesity as the 
metabolic syndrome.
    The Centers for Disease Control estimates that a decade 
ago, approximately one in five United States adults had the 
metabolic syndrome, which is defined as a person having three 
or more of the following: abdominal or visceral central 
obesity, high blood fat levels, low HDL or so-called ``good'' 
cholesterol, high blood pressure, or high blood sugar or 
glucose.
    The NCEP expert panel concluded, because the root causes of 
the metabolic syndrome for the overwhelming majority of 
patients are improper nutrition and inadequate physical 
activity, that the high prevalence of this syndrome underscores 
the urgent need to develop comprehensive efforts directed at 
controlling the obesity epidemic and improving physical 
activity levels in the United States.
    But besides the American adult population, obesity, 
diabetes, and the metabolic syndrome also affect American 
children. Our health care system is simply not prepared for the 
epidemic explosion of diabetes and other metabolic 
complications of obesity in our younger generation of 
Americans. The costs to the American public of the medical 
complications of obesity are substantial and may increase 
health care costs to a greater extent than tobacco use and 
smoking.
    Annual health care costs of diabetes alone are 
approximately $100 billion now and are expected to double over 
the next 10 to 20 years. The costs of medical complications of 
obesity and the metabolic syndrome in terms of pain, suffering, 
and loss of productivity are also important and include 
blindness, kidney failure, limb amputations, stroke, heart 
attack, cancer, and death.
    To address the medical complications and health care costs 
of an epidemic of this proportion, we will need a new arsenal 
of tools and new therapies to supplement the nutritional and 
exercise approaches. The internal signals that control body 
weight and metabolism are very complex and need much more 
study. Research to determine the mechanisms responsible for 
obesity and the metabolic syndrome, as well as for the 
prevention of and treatment for obesity and related clinical 
conditions such as diabetes and cardiovascular disease is 
essential. Research also should include funding for a 
significant genomics component to expedite the identification 
of genes with mutations or polymorphisms linked to obesity and 
the metabolic syndrome, to expedite the development of more 
effective therapies.
    The Endocrine Society appreciates this opportunity to 
testify before the Senate HELP Committee on the very important 
issue of obesity. It is not a simple problem with a simple 
answer. Obesity is a devastating and extremely costly epidemic, 
an epidemic which is robbing and ruining the lives and health 
of millions. We must confront it, and we must stop it. To date, 
we have failed to fully acknowledge, to understand, to develop 
and implement, effective and adequate means to prevent and 
treat the cancer of obesity in our Nation. The Endocrine 
Society believes that the Committee is headed in the right 
direction by focusing on improving nutrition education and 
increasing physical activity. In addition, significant progress 
can be achieved toward preventing obesity through research to 
better determine and understand the mechanisms responsible for 
this national and, in fact, international problem.
    The Society looks forward to continuing to work closely 
with the Senate and particularly the Members and staff of this 
Committee to achieve meaningful progress in the battle against 
obesity.
    Thank you.
    [The prepared statement of Dr. Dickey follows:]

             Prepared Statement of Richard A. Dickey, M.D.

    Good afternoon Mr. Chairman and Members of the Committee. My name 
is Richard Dickey and I am a newly retired physician. I practiced 
endocrinology for over 30 years, and still practice as a volunteer at a 
local indigent clinic. I also continue to teach at Wake Forest 
University. I participated in the People to People Ambassador program, 
and have led groups of physicians to China and to Cuba to study obesity 
and metabolic syndrome in these cultures.
    I am pleased to testify before you today on behalf of The Endocrine 
Society, where I serve on the Clinical Affairs Committee. We commend 
the Members of this Committee for their leadership and support in 
bringing the issue of obesity to the attention of both the Congress and 
the American public.
    The Endocrine Society, founded in 1916, consists of over 10,000 
physicians and scientists who are dedicated to the advancement, 
promulgation, and clinical application of knowledge related to 
endocrinology. Our members include academic researchers and educators 
as well as clinicians involved in the daily treatment of patients with 
hormone disorders including diabetes, obesity, hyperthyroidism, 
hypothyroidism, osteoporosis, infertility, menopause, pituitary tumors, 
hypertension and other endocrine disorders. We publish four peer-
reviewed journals: Endocrinology, Endocrine Reviews, The Journal of 
Clinical Endocrinology and Metabolism, and Molecular Endocrinology.
    I am also here as a representative of The Hormone Foundation, The 
Endocrine Society's patient education organization. The Hormone 
Foundation is dedicated to improving the quality of life by promoting 
the prevention, diagnosis, and treatment of human disease in which 
hormones play a role. The Hormone Foundation plans to launch a major 
initiative over the next year to address the growing epidemic of 
obesity, and educate patients and physicians on the metabolic syndrome.
    The Endocrine Society strongly supports the Senate HELP Committee's 
development of the ``Improved Nutrition and Physical Activity Act.'' 
The efforts of this Senate Committee to address and raise the 
visibility of obesity and its negative impact on the health of our 
Nation is truly commendable. As an organization dedicated to the 
advancement of research and knowledge and the care of patients, The 
Endocrine Society urges the Committee to take this opportunity to 
address the impact of research in the mechanisms responsible for the 
diagnosis and the treatment of obesity and its complications, including 
the metabolic syndrome.
    In 2002 obesity is a national epidemic with the number of obese and 
overweight Americans nearly doubling over the last 10 years. Estimates 
from the U.S. Surgeon General indicate that over one-half of all 
Americans are overweight. Adipose tissue or fat, hunger, weight, and 
metabolism are all regulated by hormones. Research by endocrinologists 
has shown that obesity, especially in children, can lead to numerous 
medical problems later in life, including diabetes, heart disease, and 
infertility.
    You have identified a number of excellent programs to address this 
epidemic. I would like to expand on several areas that The Endocrine 
Society believes to be imperative. The first is to recognize the 
medical risks of obesity. We define the most debilitating and costly 
complications of obesity as the metabolic syndrome.
    Metabolic Syndrome: The Center for Disease Control estimates that 
approximately one in five U.S. adults have the metabolic syndrome. The 
Third Report of the National Cholesterol Education Program (NCEP) 
Expert Panel on Detection, Evaluation and Treatment of High Blood 
Cholesterol in Adults (ATPIII) defined individuals with the metabolic 
syndrome as having 3 or more of the following:

        Abdominal obesity (waist circumference >102 cm, or 40 inches, 
        in men, >88 cm, or 35 inches, in women)
        High blood fat levels (triglyceridemia > 150 mg/dl)
        Low HDL cholesterol (<40 mg/dl in men, <50 mg/dl in women)
        High blood pressure (>130/85 mm Hg)
        High blood sugar (fasting glucose >110 mg/dl).

    The researchers concluded, ``Because the root causes of the 
metabolic syndrome for the overwhelming majority of patients are 
improper nutrition and inadequate physical activity, the high 
prevalence of this syndrome underscores the urgent need to develop 
comprehensive efforts directed at controlling the obesity epidemic and 
improving the physical activity levels in the United States.'' The 
problem of improper nutrition is related to the ``Western Diet'', 
characterized by higher consumption of red meat, processed meat, french 
fries, high-fat dairy products, refined grains, and sweets and 
desserts; the ``Prudent Diet'', a far healthier choice, is 
characterized by higher consumption of vegetables, fruit, fish, poultry 
and whole grains. According to a new study from the Harvard School of 
Public Health that followed more than 42,000 male health professionals 
for 12 years, men who consumed a typical ``Western Diet'' were 60 
percent more likely to develop diabetes than those whose diets center 
on vegetables, fruits, whole grains, fish and poultry. Besides the 
American adult population, the metabolic syndrome also affects American 
children. A recent estimate revealed that 1 in 4 obese children may 
show signs of pre-diabetes (NEJM ref). Our health care system is not 
prepared for the epidemic explosion of diabetes and metabolic 
complications of obesity in our younger generations of Americans.
    The costs to the American public of the medical complications of 
obesity are substantial. Obesity may increase health care costs to a 
greater extent than smoking. Annual health care costs of diabetes alone 
are approximately $98 billion now and are expected to double over the 
next 10-20 years. The costs of the medical complications of obesity in 
terms of pain, suffering, and loss of productivity also are important. 
Medical complications of obesity and the metabolic syndrome include 
blindness, kidney failure, amputations, strokes, heart attacks, and 
death.
    Funding for basic and clinical research: To address the medical 
complications and health care costs of an epidemic of this proportion 
we will need a new arsenal of tools and new therapies to supplement the 
nutritional and exercise approaches. The internal signals that control 
body weight and metabolism are very complex and need much more study. 
Research to determine the mechanisms responsible for obesity and the 
metabolic syndrome as well as for the prevention of and the treatment 
for obesity and related clinical conditions, such as diabetes and 
cardiovascular disease, is essential. Research also should include 
funding for a significant genomics component to expedite the 
identification of genes with mutations or polymorphisms linked to 
obesity and the metabolic syndrome to expedite the development of more 
effective therapies.
    Clinical Funding: In the long term, to address this epidemic, we 
will also need to develop creative new strategies to ensure funding for 
the clinical care of obesity, including expanding multidisciplinary 
clinical obesity centers, and assuring access to medical care for the 
prevention and treatment of obesity prevention and the metabolic 
syndrome.
    Funding for and development of public school-based educational 
programs in nutrition and exercise targeted at children and adolescents 
and funding for and development of community-based educational programs 
in nutrition and exercise: This needs to go a step further than issuing 
block grants. The development of web-based educational tools marketed 
and made available to schools would ensure a consistent message, and 
provide all educators the opportunity to work these issues into their 
curriculum.

                               CONCLUSION

    The Endocrine Society appreciates this opportunity to testify 
before the Senate HELP Committee on the very important issue of 
obesity. It is not a simple problem with a simple answer. The Endocrine 
Society believes that the Committee is headed in the right direction by 
focusing on improving nutritional education and increasing physical 
activity. In addition, significant progress can be achieved toward 
preventing obesity through research to better determine and understand 
the mechanisms responsible for this national problem.
    The Society looks forward to continuing to work closely with the 
Senate, and particularly the Members and staff of this Committee to 
achieve meaningful progress in the battle against obesity.

    Senator Bingaman. I thank all of you very much for your 
testimony. Let me ask a few questions about trying to zero in 
on some practical steps that could be taken and that Congress 
could assist with.
    Obviously, this problem is societal, the problem of 
inadequate activity and poor diet. But it seems to me that the 
portion of that that is actually most susceptible to change 
would be in the school setting. It seems like you could have a 
big impact there, because you are dealing with young people. 
Clearly, we have had a lot of testimony this afternoon about 
physical activity and the need to get physical education back 
into our schools and the right kind of physical education, and 
I certainly agree with that.
    On the issue of diet in the schools, it would seem that two 
fairly straightforward approaches, if they are done in 
parallel, would make a lot of sense. One is to substantially 
improve school lunches so that they are better and more 
appealing to kids. I think a lot of kids look at the school 
lunch and figure this is a loss and go to the vending machines 
or outside, across the street, to the burger joint. So one is 
improved school lunches, but at the same time to get the junk 
foods out of the schools so that kids really do have an option 
of eating good food while they are being kept in the school.
    Do you agree with that approach, Dr. Brownell? Is that a 
good place for us to concentrate our efforts so as to really be 
able to have a measurable impact?
    Mr. Brownell. That would be an absolutely wonderful place 
to start. As long as the bad foods are present, there are 
biological and, of course, social reasons why kids will eat 
them, so the more you can minimize the presence of unhealthy 
foods and maximize the presence of healthy ones, the better you 
will do.
    I would take what you said one stop further and somehow 
develop the philosophy that what the kids are eating and their 
physical activity gets integrated with the educational mission 
of the school. Right now, food service in most schools is sort 
of a stand-alone operation, like custodial services, where you 
just do not want them to lose money, keep the customers happy, 
get them to buy as much of whatever as you can just so you do 
not lose money.
    If all of these things get integrated, and health 
education, physical education and the school lunch program all 
go together because the schools believe this will ultimately be 
in the best interests of their children--even their academic 
performance--I think you will have more hope.
    Senator Bingaman. Thank you.
    Do any of the rest of you have a comment on that?
    Ms. Katic, did you have a view on that?
    Ms. Katic. Absolutely. I really want to emphasize first of 
all that there has been an attempt to improve the school lunch 
program over the last several years. USDA has a program in 
place called Team Nutrition that has been implemented in many 
schools across the country. It meets the dietary guidelines for 
Americans--for instance, 30 percent of calories from fat, and 
so forth. They are still trying to implement that program 
across the country. It has been effective in a lot of schools. 
At the same time, they have tried to market the school lunch 
program to make it appealing for kids, because historically, 
that has really been a challenge and a problem.
    I want to say something obviously about the junk foods in 
schools. I feel very strongly that ``just saying no'' to these 
kinds of foods in schools does not give children the tools they 
need to make choices throughout their lives. It is something 
that they really need to be educated about, and that needs to 
start in the classroom.
    If you take foods away--you heard it said earlier in the 
New York Times article--they are going to go somewhere else and 
get it. These foods are available all the time, and they are 
going to be available for the rest of their lives. So if they 
do not learn how to include it in the diet, they never learn. 
They have to learn when, how much, when it is appropriate, and 
if that is not offered in the schools, they do not have the 
right tools to navigate the food environment as they get older.
    Senator Bingaman. I would certainly agree that teaching 
kids to ``just say no'' is not the solution, but it would seem 
to me that if you have a good nutrition education program in 
the school, it would make sense to complement that by not 
having a vending machine right outside the door that is selling 
junk food.
    Ms. Katic. Sixty percent of schools today offer water and 
100 percent juice as options in vending machines. All soft 
drink companies provide diet soft drinks.
    Senator Bingaman. But there is not the kind of advertising 
campaign directed at kids saying go out and buy yourself a 
bottle of water that there is to buy Coke or Pepsi.
    Ms. Katic. Water is the fastest-growing item in the 
beverage category. It is being driven by consumer demand. And 
yes, we do see advertising for water.
    Senator Bingaman. Well, maybe you will solve the problem 
for us, and we will not have the problem of kids drinking too 
many sodas.
    Dr. Dickey.
    Dr. Dickey. Yes, I would agree that the education of the 
kids is important, but I think the education of the parents and 
the education of medical professionals, as well as the 
teachers, is important. It has to be a comprehensive program, 
and it has to be integrated with the physical activity and the 
nutrition program.
    We tend to eat what tastes good. We tend to choose what 
tastes good, what we like, not necessarily what is healthy for 
us, and that behavior is very difficult to change. It has been 
mentioned earlier that changing behavior takes a lot longer and 
a lot more persistence than just educating.
    So I think that we need an educational program to help make 
better choices and then provide those better choices is the 
key.
    Senator Bingaman. Thank you.
    Ms. Davis.
    Ms. Davis. In Pathways, we actually worked with the school 
food service personnel, and I will mention three things that 
they were eager to learn and did in their school breakfast and 
lunch programs. Those were offering choices to the kids as they 
came through the lunch line. It made it much more appealing if 
they had several different vegetables or fruits to choose from 
in the lunch line. Second was working with them in their food 
preparation to prepare the food in a more healthy way, with 
less saturated fat, less fat, and in a more appealing way to 
the children as well, and sharing that from school to school 
what the school lunch workers were learning. We found it to be 
extremely successful, they enjoyed doing it, and the children 
liked it as well.
    The other problem that we worked with them on is that they 
were giving seconds of the main course rather than seconds of 
the fruits and vegetables, so we worked with them on that. So 
they were small changes, but they were important changes, and 
they were changes in the whole lunch program.
    Senator Bingaman. Let me ask about one other subject and 
that is the contracts that many schools and school districts 
have entered into with various food vendors to provide 
exclusive rights to sell a particular soft drink. I do not know 
how extensive those are, but I have spoken with people in 
school administration in my State, and they say we need those 
funds. We have gotten a deal here where we have become addicted 
to having the fast food vending machines in the schools because 
the schools get a cut of everything that is sold.
    How do we unscramble that egg and get to a situation where 
we are not hamstrung in our ability to make rational policy 
judgments because of some contractual agreement that we have 
entered into?
    Dr. Dickey, do you have a point of view on that?
    Dr. Dickey. I was shocked to learn about these contracts 
within the past year and the great impact that they have. I 
think the answer is that we have to find some way to provide 
the funds that are being supplied by those alternatives, 
because that is not the way we should be deciding what our 
choices are.
    So providing an alternative source of funds and in an 
incremental fashion, withdrawing those, or providing 
alternative choices, even under contract, which are healthier 
choices--that is a choice that we can make--whether we are 
going to continue to sign contracts to fund schools and 
education by forcing changes in the offerings that we think or 
healthier choices, or whether we are simply going to replace 
those funds with other funds which are already short. But that 
is a hard choice to make, and it is one of the choices we are 
going to have to make.
    Senator Bingaman. Ms. Katic, did you have a point of view?
    Ms. Katic. Absolutely. I think Dr. Dietz said it best 
earlier when you asked him the same question. I support what he 
said. He inferred, as Dr. Dickey just mentioned, that offering 
choice is very important and then backing up with nutrition 
education in the classroom what the proper choices are that 
should be made is extremely important.
    So that instead of taking those kinds of foods away, I 
think it is really important to add alternatives, as was just 
suggested. And I mentioned earlier and will say it again that 
water and juice are definitely sold in the schools, and like I 
said, water is the fastest growing category. Diet drinks are 
offered as well. So there are already existing choices in 
vending machines, and I think we need to highlight the ones 
that we want our children to choose.
    Senator Bingaman. Dr. Brownell.
    Mr. Brownell. I think these contracts are quite pernicious. 
There is a famous case in Colorado Springs where the school 
district there was given millions of dollars, not just hundreds 
of thousands, to sign a 10-year contract with Coca-Cola. If I 
remember the numbers right, the contract stipulated that the 
school system would sell 70,000 cases of Coke products in one 
of the first 3 years of the contract. In the year prior to the 
contract, they had sold 21,000 cases of Coke products. So the 
school system basically entered into a contract agreeing to 
triple the sales of Coca-Cola products in their school system 
in order to get this many millions of dollars. It is hard to 
argue that that is good.
    And the issue about choices sound like ``mom and apple 
pie,'' but you would not want to put cigarette machines in the 
schools so kids can get real world experience in making 
choices.
    The sad fact is that the way America is now, if the bad 
food is there, kids are going to eat it. Some kids will go next 
door to the 7-Eleven, some will go to the Burger King down the 
street, but this will have enough of a public health impact 
that it would really make a significant dent, I think, in the 
weight problem, and then, at least the schools become an 
opportunity for the kids to learn positive things rather than 
to walk past the soft drink machines, the vending machines, and 
go into a cafeteria that either has a fast food franchise in 
it, which is the case with thousands of schools, or basically 
makes the same foods themselves.
    Senator Bingaman. Dr. Davis, do you have any comment on 
this?
    Ms. Davis. No, but I agree with Dr. Brownell.
    Senator Bingaman. Thank you all very much. It has been 
useful testimony and a very useful hearing, and we will 
continue to work on this legislation and refine it and 
hopefully introduce it in a couple of weeks.
    Thank you all very much.
    [Whereupon, at 4:35 p.m., the hearing was adjourned.]
    [Additional material follows.]

                          ADDITIONAL MATERIAL

                   Prepared Statement of Senator Enzi
    Thank you Mr. Chairman. I join you in welcoming the witnesses in 
our panels today. I look forward to listening to your comments and 
proposals for a strategy to improve physical activity and nutritional 
practices in America.
    On the surface, getting fit and maintaining a healthy body seems 
like a simple issue. Our bodies run on a simple equation; when energy 
intake is greater than energy expenditure, the object gains mass. When 
energy expenditure is greater than energy intake, the object, our body, 
loses mass. However, the equation in the American culture is 
complicated by recliners and king-sized snack packs.
    Our mission today is very serious. We will seek information from 
you to form strategies that encourage healthier eating and exercising, 
but more importantly, we will discuss how to change our culture. 
Throughout these discussions, we must not villainize the wrong actor.
    In recent years, sugar has been booed off the stage of our national 
diet. Sugar-free diets are marketed as the best way to lose weight. We 
need to consider scientific evidence before we suggest limiting access 
to a food which, in moderation, has no negative health implications.
    A recently published U.S. Department of Agriculture (USDA) research 
brief on current scientific knowledge concluded that intake of added 
sugars is not associated with diabetes, heart disease, obesity and 
hyperactivity. First of all, sugars are not ``empty calories.'' Humans 
transform all digestible carbohydrates into the simple sugars the body 
needs. All simple sugars are chemically identical. It follows that the 
body does not distinguish sugars added to foods from the same naturally 
occurring sugars or sugars broken down from complex carbohydrates.
    The report indicated that Food and Drug Administration's Sugars 
Task Force and the National Research Council concur: there is no 
conclusive evidence citing sugar consumption as an independent risk 
factor for coronary artery disease in the general population.
    Evidence does not single out dietary sugar as the cause of obesity; 
many factors contribute to this disease. A number of studies actually 
show an inverse relationship between reported sugar consumption and 
overweight. Mr. Chairman, I would like to request that a copy of this 
report from the USDA Center for Nutrition Policy and Promotion be 
included in the record.
    As the Committee considers today what strategies we should initiate 
to increase the health of the American people, I suggest we evaluate 
all factors that contribute to obesity and adopt a well-rounded 
approach to our health.
    Thank you Mr. Chairman.
                                 ______
                                 

                 Prepared Statement of Senator Clinton

    For years, we have listed chronic diseases like heart 
disease, cancer, stroke, diabetes as some of the leading causes 
of mortality, yet we have not done enough to address the causes 
of these chronic conditions. It is now recognized that 
individual behaviors and environmental factors are responsible 
for 70 percent of all premature deaths in the United States. 
While we must learn more about the other factors that 
contribute to these diseases, there are some factors that we 
clearly know to target. Physical inactivity, poor diet, tobacco 
use are at the top of the list. These behaviors lead to the 
diseases that ultimately kill us. We don't have to sit idly by 
waiting for some deadly disease to strike. Our own behavior can 
help protect us or put us at increased risk.
    Unfortunately we have not always done a good job educating 
ourselves and the public about the importance of our own health 
behaviors. We have begun to tackle the problem with smoking, 
but still have a long way to go. American diet and exercise 
habits have deteriorated to a record low. Obesity is reaching 
epidemic proportions: 27 percent of U.S. adults are obese and 
13 percent of children and 14 percent of adolescents are 
seriously overweight. Daily physical activity has declined for 
both children and adults. After school sports are reserved for 
the elite athlete and physical education (PE) is no longer 
required. Even when youngsters take P.E., they rarely actively 
participate. The consequence of this sedentary behavior is 
taking its toll. Type II diabetes is increasing at an alarming 
rate. Type II diabetes used to be a disease of older overweight 
adults. It is now being diagnosed in children.
    It is time that we recognize the cost of poor dietary 
behaviors and physical inactivity to our own health and the 
health of our Nation. Studies have shown that Type II diabetes 
is preventable in both children and adults by careful attention 
to diet and exercise. We need to help our young people develop 
healthy eating and exercise behaviors that they can carry with 
them though out their lives. Fad diets and simple messages to 
be thin will not work and have unintended consequences of their 
own.
    Recent data from the 1999 Youth Risk Behavior Survey 
indicated that 7 percent of young women who were very thin 
(body mass index < 15 percentile) reported taking laxatives or 
vomiting to lose weight or to avoid gaining weight. An even 
larger percentage (9 percent) of these very thin young women 
reported using diet pills.
    Poor eating habits have also led to a ``calcium crisis'' 
among American youth. Very few adolescent girls (14 percent) 
get the recommended daily amount of calcium, placing them at 
serious risk for osteoporosis and other bone diseases. Because 
nearly 90 percent of adult bone mass is established by the end 
of adolescent growth period, the Nation's youth's insufficient 
calcium intake is truly a calcium crisis. The consequence of 
this crisis will be seen years later, when we are likely to 
face an unprecedented incidence of osteoporosis in women.
    We need a comprehensive approach to promoting healthy 
eating habits and regular exercise. Senator Bingaman and I have 
introduced S. 2249, Promoting Healthy Eating Behaviors in 
Youth, that would attempt to prevent the serious array of 
eating-related health problems now common in our Nation, by 
supporting research to identify the best ways to help young 
people develop healthy eating habits. However, this bill is 
just a small beginning. We need more research to guide both 
prevention and treatment efforts and we need communities of all 
types--families, schools, work settings--to create the 
supportive environments necessary to make a real change in what 
we eat and how often we exercise.
                                ------                                

 Response to Written Questions of Senator Clinton from Kelley Brownell
    Question 1: Do we know the best ways to help children develop 
healthy eating habits?
    Answer 1. Biology drives most people toward a diet high in fat, 
calories, and variety. This would be adaptive if food was scarce, but 
this drive intersects with a food environment that is relentless in 
making problem foods accessible, cheap, good tasting, and ubiquitous. 
It will take powerful efforts to reverse this situation.
    Children are a logical place to begin. Eating habits are 
established early, so programs in elementary schools would be helpful, 
and Government programs such as WIC, Head Start, and food stamps could 
be central to the effort. The object would be to offer children healthy 
and attractive food, integrate eating with education (so children are 
learning about good nutrition), and to create programs that make the 
material fun and educational. Research shows that children can learn to 
like healthy foods when presented in the right context.
    Another key issue with children is learning about portion sizes. 
The ``more is better'' philosophy is ingrained in American consumer 
habits. Words like big, super, and mega describe serving sizes of many 
foods. What was once the large soft drink is now the small (16 oz.), 
the large fries of yesterday are now the small size, and things like 
``value meals'' may be teaching children that large sizes are good, 
even necessary. ``Supersize'' is now a verb. Eating to the point where 
hunger is satisfied, understanding reasonable portions, and avoiding 
inducements to eat large sizes must be taught to children.
    Physical activity is also important. The activity itself will help 
with weight control and overall health, but can also lead to healthier 
eating. The food industry is pushing hard to focus the spotlight on 
physical activity, saying consensus exists on the importance of 
exercise. It would be a mistake to leave activity out of the picture, 
but it would be grave mistake also to let attention be diverted from 
food.

    Question 2: Are eating disorders and obesity related?
    Answer 2. There is fear among eating disorders specialists that 
increased focus on weight and obesity will drive more people toward 
disordered eating (pressure to be thin would be even more intense). 
This would be a special concern in children, who are developing their 
adult body image and can fall into unhealthy dieting practices.
    Eating disorders can be crippling, and should not be ignored, but 
because obesity dwarfs these disorders in public health significance, 
the obesity effort should not get hamstrung by critics in the eating 
disorders field. Perhaps the way to be sensitive to this constituency 
is to address the issue in legislation or other places, perhaps with 
language like:
    ``Obesity prevention programs should be implemented in ways to 
prevent the onset or exacerbation of disordered eating and body image 
problems. Focusing on nutrition and physical activity in the service of 
health, vitality, and well-being, educating children on natural 
variations in body size, and avoiding images of thin ideals such as 
models is essential.''
                                 ______
                                 
    Response to Written Questions of Senator Clinton from Lisa Katic
    Question 1. You mentioned in your testimony that ``overly 
restrictive diets may lead to enhanced food cravings, overindulgence, 
eating disorders or a preoccupation with foods and eating.'' I have 
heard from many young women who have started diets to lose weight and 
``be healthy'' only to develop an eating disorder. How can we 
discourage obesity and not encourage eating disorders?
    Answer 1. Your first question about how to address obesity without 
encouraging eating disorders is a critical one. The best way to do this 
with a young population is to be positive about food and nutrition 
education in the school and home environments. Some schools have 
attempted to implement eating disorder prevention programs only to find 
they were more harmful than helpful. Programs that introduce young 
people to disordered eating may inadvertently create negative outcomes 
by raising awareness about weight issues among this vulnerable 
population who may have been otherwise uninterested in losing weight. 
Education programs then show young people new and suggestive weight 
control methods such as laxative use, diuretics, smoking, or binging. 
Students may become more aware about the need to diet and now know how 
to achieve a result. Some other potential adverse effects of eating 
disorder prevention programs are: glamorization of eating disorders 
often depicted in the media by highlighting famous people who have 
suffered from eating problems; prevention programs can give children 
the idea that everybody is doing it, therefore it is socially 
acceptable; and negative messages about ``bad'' foods such as sugar or 
fat contribute to fear of food.
    The first step in establishing positive nutrition messages in 
school-based education is to change the focus from highlighting 
negative, problem-based approaches to focusing on building self-esteem 
and showing children how to enjoy food and regular physical activity 
without developing a fear of food. This can be achieved by conducting 
cooking classes where children learn about all of the ingredients that 
go into certain foods. Supermarket tours can provide practical 
application of nutrition information, as can visits to students' 
favorite restaurants.
    Also, nutrition educators, teachers and parents must examine the 
important role they play in modeling positive eating behavior. Those 
that interact with young people on food and nutrition issues must 
consider their own body image and self-esteem. Specialized training for 
teachers, health educators and dietitians is needed in this area and 
should not only provide factual information about food and nutrition, 
but must also provide information and activities that focus on healthy 
body image, shape and normal growth patterns throughout the lifespan. 
The primary focus of this training should be to encourage educators to 
abandon the common negative approach to food, which uses terms like 
``junk food'' or ``bad food'' and not use terms such as overweight and 
obesity. Children and adolescents must learn how to fit their favorite 
foods into an overall balanced diet and feel good about doing so in the 
process.

    Question 2. I know many young women who have given up milk products 
entirely in order to avoid the calories and stay thin. Many of these 
women have successfully avoided the effects of obesity but will end up 
with a different health problem: osteoporosis. What kind of media 
campaign should be direct at our youth? I am concerned that a campaign 
that emphasizes the importance of being thin may have some unintended 
consequences.
    Answer 2. If the approach outlined above were successfully 
incorporated into a school's curriculum, then your second question 
would not be an issue. The same positive approach to food is needed in 
this case as well.
    If young women perceive milk products as being ``bad'' because they 
contribute to weight gain, then young women have a constant uphill 
battle with food. They will potentially struggle for a lifetime to 
achieve a happy medium between consuming foods with the nutrients they 
need to maintain health and desiring to meet an unrealistic set of 
goals for their weight. Unfortunately, the unrealistic set of weight 
goals usually wins in the end. Nutrition is compromised and women or 
men will suffer health consequences if a negative approach to food and 
nutrition is adopted.
    Any campaign targeted at this population must be positive and focus 
on health not the importance of being thin. Messages delivered to a 
target audience in any campaign must be tested with that audience first 
to determine their impact and acceptability.
    I hope this helps answer your questions, I would be happy to 
provide additional information if needed on any of your food or 
nutrition questions.
                                 ______
                                 
                  Prepared Statement of John McCarthy

    Mr. Chairman and Members of the Committee: On behalf of the 
International Health, Racquet & Sportsclub Association (IHRSA), I want 
to commend the Committee for focusing legislative attention on the 
major public health problem of obesity in the United States today. Two 
of the largest contributing factors to obesity are poor nutrition and 
inadequate physical activity. IHRSA, representing 5,000 of our Nation's 
health and fitness facilities, is dedicated to improving the public's 
health through physical activity, and we strongly support legislative 
focus on this problem.
    It is important to note that framing this issue as a public health 
problem is correct and essential. Almost \2/3\ of all adults are 
seriously overweight or obese and the percentage of obese children has 
doubled in the last two decades. The World Health Organization has 
declared that obesity is set to become the largest disease of the 
century. It is appropriate for the Government to carefully examine the 
causes of the problem, and to enact programs and incentives which will 
encourage healthy eating and healthy levels of physical activity. To do 
otherwise is to tolerate the continuing increases, in heart disease, 
cancer, stroke, and diabetes, as well as the associated fiscal costs of 
obesity.
    We cite two of the many recent research reports which document the 
problem of obesity. In June 2001, RAND issued a report analyzing the 
costs and scope of obesity. It concluded that obesity was now the 
number one public health problem in the United States, even greater 
than the health effects of smoking, poverty, or problem drinking. The 
RAND study demonstrated how obesity is linked to very high rates of 
chronic illness. Not surprisingly, obese individuals spend 36 percent 
more on health services and 77 percent more on medications. In 
addition, the March 14, 2002 issue of the New England Journal of 
Medicine reports that physical fitness is the single most important 
factor, aside from age, which predicts life expectancy. The New England 
Journal of Medicine authors explicitly call upon physicians to 
encourage their patients to improve their exercise capacity.
    Obesity costs are estimated at $117 billion annually. The Committee 
and Congress should be aware that these costs represent direct costs of 
medical care and loss of income to our citizens who suffer from obesity 
and related medical conditions. There are further losses to the 
employer community which supports most health insurance costs for their 
employees as well as the cost of turnover and lack of productivity 
accompanying significant illnesses. There is, of course, a loss to the 
Federal and State governments, whose Medicare and Medicaid programs 
will increasingly be taxed by the costs of these disease conditions 
which are a consequence of obesity.
    To allow our citizens to enjoy long and productive lives, to avoid 
the drag of immense and preventable obesity-related health costs on our 
economy, and to focus our scarce Government health resources on the 
most intractable health problems, we should as a Nation make every 
effort to improve our nutrition and fitness.

                 ROLE OF HEALTH AND FITNESS FACILITIES

    Health and fitness facilities have become critically important 
players in the national effort to promote health and prevent disease.
    Approximately 34 million Americans utilize the Nation's health, 
sports and fitness clubs. They range in age from youth to senior 
citizens, with particularly strong growth in participation in the 55+ 
age group over the past few years. In the whole population, only about 
10 percent judge their health to be ``excellent,'' but one third of 
fitness club members believe they have excellent health.
    The health and fitness clubs of today are a long way from the old 
gym. There have been genuine advances in understanding exercise 
physiology and development of equipment which efficiently aids exercise 
and fitness development. More importantly, most private health clubs 
have been developing ongoing relations with health care industry 
professionals. To cite a few relevant developments:
    89 percent of IHRSA members offer initial fitness assessments.
    73 percent offer body composition analysis.
    66 percent offer nutritional counseling.
    63 percent offer weight management programs.
    61 percent offer exercise prescriptions.
    55 percent offer wellness education.
    Health and fitness facilities play an essential role for millions 
of Americans who are interested in fitness and maintaining a healthy 
lifestyle. In doing so, they also are an essential resource in 
controlling the costs of poor nutrition and fitness.

                           ROLE OF EMPLOYERS

    The key question is what motivates a person to exercise and 
maintain a healthy level of physical activity. Although there are many 
factors, it is IHRSA member experience that the involvement of an 
employer through programs centered at or sponsored through the 
workplace are successful. Just as most private health insurance is 
provided through the employer, we need to create a system in which 
fitness benefits and services may be promoted through the employer. 
This connection may be direct, with facilities located on site. It may 
be through an employer offering a health plan in which a fitness 
program is an available benefit. Or it may be through an employer 
contributing to or subsidizing employee utilization of health club 
facilities.
    The Healthy People 2010 report from the Department of Health and 
Human Services details how obesity and the resulting chronic conditions 
cost employers more than 39 million days of work time annually. At the 
top of employers' worries are the controlling health care costs, 
gaining efficient employee performance, and recruiting and retaining 
qualified workers. These issues are all the more intense for small 
employers, which often cannot afford large health insurance premiums, 
or afford to lose proven and productive employees.
    Most adults spend half or more of their waking hours at worksites. 
Both from the standpoint of the costs to employers, and the healthy 
impact on employees, connecting employees with concepts of health and 
fitness at the worksite is essential.
    Just as the schools are the logical starting point for 
encouragement of healthy lifestyles and nutrition habits for children, 
the worksite is the most logical platform from which to build more 
effective programs and personal activity habits.

                ENCOURAGING ACTIVITY AND SOUND NUTRITION

    We know that Senator Frist and others are preparing proposals which 
can focus resources on these important priorities. The schools have an 
essential role to play, given their prominence in our children's lives 
and their educational responsibilities. Governmental and local entities 
should be encouraged to grant tax relief and incentivize physical 
activity and nutrition counseling activities at the local level, 
including activities sponsored by business.
    Yet we believe it is essential to enlist the five million small 
employers who employ 70 percent of the private workforce with fitness 
programs which can be clearly and easily used by employers and 
employees. The Surgeon General's Call to Action to Prevent and Decrease 
Overweight and Obesity 2001 cited that ``the worksite provides the many 
opportunities to reinforce the adoption and maintenance of healthy 
lifestyle behaviors.'' Furthermore, the report recommends creating 
incentives for employees to join local fitness centers. Accordingly, we 
suggest that the Congress include in any legislation the ``Healthy 
Workforce Incentive'' concept.
    In 1984, the Congress enacted Internal Revenue Code Section 132, 
relating to the non-taxation to employees of certain fringe benefits 
received from employers. That section allows employers to maintain on-
premises health and fitness facilities, and allow employee use of such 
facilities without additional income or tax consequences to the 
employee receiving the benefit of these services. This tax incentive, 
however, is of no use to those millions of businesses which do not have 
the resources (space and/or capital) to create and maintain fitness 
facilities for their employees.
    To encourage health and fitness and control the costs associated 
with the chronic conditions arising out of obesity, the Congress can 
make a very simple modification of IRC Section 132. By simply removing 
the ``onsite'' requirement, employers, especially small employers, 
would be encouraged to contribute to their employee use of fitness 
facilities, regardless of the location of the employee or the 
availability of a ``company gym.'' Smaller employers, in particular, 
for the first time would be able to incentivize employee physical 
activity with no negative tax consequences to the employee. The change 
would require no additional bureaucracy, no detailed rulemaking, no 
complicated tax accounting.
    This change would give employers a very important additional 
technique to work with their employees on healthy lifestyle and 
nutrition habits. We firmly believe that whatever the minor cost of 
this program in non-taxed benefits would be more than made up by 
increased productivity, lowered health insurance premiums, and lowered 
medical expenditures for employees, employers and ultimately the 
Government.
                                Summary
    IHRSA commends the Committee, Senator Frist, and those other 
Senators who will join him on his legislative proposal. Obesity and 
lack of physical activity are truly national problems. There is no one 
solution to the problem. Focusing on schools and workplaces may provide 
efficient and effective platforms from which to improve child and adult 
health status. Legislation should also provide the simple healthy 
workforce incentive of tax free employer provision of fitness benefits. 
These steps would be modest, but would result in real and successful 
progress in our fight against the Nation's number one public health 
problem.
                                 ______
                                 
              Prepared Statement of Katherine E. Tallmadge
    The devastating problem of childhood obesity shatters lives, 
diverts scarce public resources and causes heartbreaking suffering to 
millions of our Nation's youth.
    It has become an epidemic that demands careful study and urgent 
action. As a nutritionist in private practice in Washington, D.C. for 
20 years I have seen obesity in our youth evolve into something 
approaching a national tragedy.
    As a health care professional I have seen this problem up close.

                         I. BIOGRAPHICAL SKETCH

    I first started thinking about weight problems when I was a child 
in Ohio. A vivid memory from childhood was finding my mother weighing 
peas at the kitchen counter before dinner. The peas were scattering all 
over the counter and floor and I helped her pick them up.
    ``Mom, what are you doing?'' I asked. Weighing peas, after all, 
seemed like a very strange thing to do.
    ``I'm fat,'' she replied. ``I'm on a diet and I have to lose 
weight.''
    Now, you have to understand that my mother was--and is--a beautiful 
Swedish woman. She is artistic, funny and has always had tons of 
friends.
    But all she could think about was how fat she was. She hid behind 
us kids in photographs and always put off doing things for herself, 
like buying new dresses, until she would ``lose weight''--which she 
never seemed to do. The shame and disappointment she felt was something 
that stayed deep inside me.
    Years later, when faced with choosing a major in college, I picked 
nutrition in undergraduate school and behavioral sciences in graduate 
school. I wasn't even aware of the inner voices affecting my decisions 
at the time. It's only now, after years of reflection, that I realize 
why I'm so passionate about my work. I chose this as my life's vocation 
so that I could help people like my mother.
    When my own weight problem developed and caught me by surprise in 
college, and it eventually turned into an eating disorder, I was 
determined to solve my own problem so that I could help myself avoid 
the pain my mother experienced and be a better counselor in my career.
    My professional career has evolved in response to my desire to make 
a real difference in people's lives. While studying nutrition in 
college, I was dismayed at the overwhelmingly negative results in 
weight loss studies. People who went on diets gained their weight back 
95 percent of the time. I thought, what good is all this nutrition 
knowledge if people aren't benefiting?
    I was determined to make a difference, so I decided to study 
behavioral sciences in graduate school to help me figure out what makes 
people tick and how to best help them change. My graduate studies also 
helped me become a better counselor which, I believe, has been 
necessary for my clients' success.
    But the real reason I've been able to help so many people over the 
years is the time I've spent listening to and understanding my clients, 
becoming intimately involved in their day to day routines, and 
analyzing their many successes and failures. Solving my own eating 
disorder and weight problem has also given me empathy and insight into 
their unique needs and has convinced me that anyone can conquer this 
problem.
    The bottom line is that I'm no sanctimonious preacher looking down 
at a congregation of sinners. I've been there! And I know what it takes 
to come back from those depths of despair.
    I'm passionate about helping people solve their weight problems, 
which, I believe, saps them of health, energy and happiness. Let alone 
all of the horrible and preventable diseases which inevitably occur.
    When I learned how easy and positive weight loss could be and how 
it could transform lives, I wanted to scream it from the rooftops. Diet 
Simple is my way of screaming from the rooftops!

                        II. SCOPE OF THE PROBLEM

    One out of every five children in this country is overweight or 
obese, resulting in severe social, emotional, and medical problems for 
these youngsters. And 70 percent of overweight children between 10 and 
13 will go on to become obese as adults, leading to skyrocketing health 
costs, misery, and early death for many.
    This is expected to further burden a health care system already 
spending, some recent studies have concluded, as much as $293 billion 
annually on obesity and its related diseases. This is particularly 
startling when one realizes the overweight and obese adults of today 
most likely were not overweight as children. This new generation of 
overweight children promises a record number going into adulthood with 
skyrocketing health care costs.
    ``The greatest health risk of childhood obesity is the risk of 
becoming an overweight adult,'' argued Dr. Thomas Robinson, Assistant 
Professor of Pediatrics and Medicine at Stanford University School of 
Medicine at the Washington, D.C. conference.
    But whether or not obesity continues into adulthood, childhood 
obesity presents many serious health risks to the child. Type II 
diabetes, for instance, which is normally diagnosed in obese adults, is 
becoming increasingly evident in children.
    A study of children aged 19 and under in Cincinnati showed that 
prior to 1982, 4 percent of all cases of diabetes diagnosed were Type 
II or non-insulin-dependent. However, by 1996, that rate jumped to 16 
percent, a 10-fold increase in little over 10 years. Obesity and 
inactivity were major risk factors for this diagnosis in children which 
occurred at a mean body mass index of 37 (higher than 25 is 
overweight). The highest prevalence was in African American females.
    Overweight children are not immune from other adult-style diseases 
either. Cardiovascular risk factors such as elevated triglycerides and 
LDL cholesterol, along with lowered HDL cholesterol are often observed 
in overweight children. These children also suffer from higher rates of 
hypertension, sleep apnea, liver and gallbladder disease, and even 
orthopedic complications including Blount disease, characterized by 
bowed legs.
    Because of these potentially serious health complications, 
overweight children should be routinely screened for levels of fasting 
insulin and glucose, and a fasting lipoprotein profile should be 
obtained regularly, according to Dr. William Dietz of the Centers for 
Disease Control and Prevention in the March 1998 issue of Pediatrics.
    But experts believe the social consequences of childhood obesity 
are just as serious as the physical. Obese children become targets of 
early and systematic discrimination. By the time they are teens, a 
negative self image is developed, and increased behavioral and learning 
difficulties are observed, according to Dr. Dietz at the conference in 
Washington, D.C.
    The National Longitudinal Survey of Youth, designed to examine the 
effects of obesity in adolescence on social achievement in early 
adulthood, found women who were obese in late adolescence and early 
adulthood achieved less years of advanced education, had lower family 
incomes, lower rates of marriage, and higher rates of poverty. These 
effects were found only in women, and even when controlled for the 
income and education of the family of origin.
    ``These results suggest that obesity was a cause rather than a 
consequence of socioeconomic status,'' said Dr. Dietz, in Pediatrics. 
``Adolescent obesity may be the worst socioeconomic handicap that women 
can suffer,'' he added.
    Studies demonstrate clearly that obesity can ravage a life from 
youth to death. There are complex factors that interact to cause poor 
nutrition and limited physical activity which lead to obesity in young 
people.
    The problem of obesity effects children of all races and economic 
backgrounds, however a disproportionate number of overweight or obese 
children come from low income Caucasian families, or African American, 
Mexican American, and Native American families of all income levels. 
Although genetic factors play a role in obesity development, 
researchers are skeptical that this explains the current problem. Human 
genetics have probably not altered in the last several decades while 
the incidence of obesity has risen dramatically.
    Childhood obesity is obviously a result of the consumption of too 
much high calorie, low nutrient foods and too little physical activity. 
But why children are eating too much and exercising too little is 
multifaceted.

                  III. FAMILY AND SOCIETAL INFLUENCES

    One of the most influential factors is the parenting the youngster 
receives, and the family environment in which he or she develops.
    For many reasons, today's parents are less able or available for 
effective guidance. Often parents are struggling to deal with increased 
economic pressures. Many households are headed by single women. Or if 
there are two parents, they both likely work and have less time to 
guide their children's lifestyles and food choices. Several studies 
show parental neglect is a strong predictor of the development of 
childhood obesity.
    The care givers are so overburdened with work responsibilities that 
they don't have time for the kids. The children fend for themselves 
with food. Television becomes the child care provider.
    In recent decades, family meal times have changed in quality and 
quantity. Parents have become less likely to prepare all meals for 
their children and are resorting more to the purchase of fast foods or 
the use of frozen foods that children can choose and microwave 
themselves. Often families aren't eating meals together, which means 
children may be grazing on their favorite high calorie snack foods all 
afternoon while skipping family dinners and breakfasts. In fact, 
missing breakfast is a key risk factor for obesity in children. Nearly 
80 percent of heavier girls fail to eat breakfast regularly, studies 
show. Also, families who eat dinner together are less likely to have 
obese children.
    This suggests that the initial focus of preventive efforts should 
be on the obese parents of the young child, regardless of the weight 
status of the child.
    When parents of overweight children were treated for obesity, the 
children were more likely to lose weight than if the children were 
directly treated, in a study published in the American Journal of 
Clinical Nutrition in 1998. Other studies show positive long term 
effects of treating the whole family.
    What the parent eats and makes available in the house profoundly 
effects what the child eats and prefers.
    Studies show that children will develop food preferences based on 
what is provided in the home by their parents. In studies conducted at 
Pennsylvania State University, kids' fat preferences and fat intakes 
were linked to parental fatness, so the heavier parents had kids who 
were preferring and eating diets that were higher in fat, said Dr. 
Leann Birch, Professor and Head of the Department of Human Development 
and Family Studies at Pennsylvania State University at the Washington, 
D.C. conference.
    ``Kids learn to prefer calorie-dense foods, and this could, in 
fact, be one of the factors that contributes to diets that are too high 
in calories and too high in fat,'' said Dr. Birch.
    Birch's studies demonstrate that parents can teach children to love 
healthy food if it is presented positively.
    ``If we work at it, we should be able to help children to learn to 
eat what we think is good for them,'' says Birch. But, she warns, 
children naturally reject new foods, so parents must be patient, 
positive and vigilant and may need to present a new food at least 10 
times before the child accepts it. Children have a natural love for 
sweets, so introducing sweets takes little or no effort.
    Studies show that providing information that new foods taste good 
(not that it's ``good for you!''), opportunities to sample good-tasting 
novel foods, or observing others enjoy foods can increase acceptance 
for both adults and children. Children's preferences for ``disliked'' 
vegetables were enhanced when they had opportunities to observe peers 
and parents selecting and eating those vegetables. But it may take up 
to twenty exposures to the foods for a child to prefer them.
    Food preferences are learned and modifiable. Children eat what is 
available to them and learn to prefer vegetables and healthy foods if 
they are frequently and positively offered.
    The level of a child's physical activity is also influenced by 
parents in many ways.
    Without parental supervision, today it often isn't safe for 
children to be outdoors playing with friends or walking to and from 
school. Even when there is adequate supervision for children, today's 
youth are inclined toward more sedentary activities, such as watching 
television and playing on computers or video games.
    Studies have shown clearly that there is a direct relationship 
between hours of television watched and obesity levels in children. 
It's up to families and care givers to encourage children to be active 
and to be role models for regular physical activity.
    Most children are very receptive to going on walks, going hiking or 
swimming, or simply shooting some hoops with Mom or Dad. With strong 
family connections, these activities are more likely to be perceived as 
positive and valuable to the child and those values can be carried over 
into habits as an adult.
    But as children move into their teenage years, parental influence 
over their behavior diminishes and they are more deeply influenced by 
peers and other broader societal factors. Even the best of parents are 
given little assistance by the larger culture which influences the 
behaviors and attitudes of the children, especially as they become 
teens.
    Unfortunately, the environment of many of our teenagers reinforces 
the over consumption of calorie-dense foods, snacks, and sodas, and 
doesn't encourage physical activity.
    Schools are increasingly relying on selling calorie-dense sodas, 
snack foods, and fast foods to children to increase school revenues. 
Portion sizes for many foods and beverages have grown to absurdly large 
proportions. For example, she notes, the 7-11 ``Big Gulp'' contains 64 
ounces and 600-800 calories. A bottle of soda now contains up to 20 
ounces, when 20 years ago, the standard Coke was 6 oz.
    In the past 20 years, teens' milk consumption has decreased while 
soda consumption has increased. Two-thirds of teenage boys are drinking 
3 sodas per day, with two-thirds of girls drinking 2 sodas per day, 
according to the USDA. Studies have shown a link between soft drink 
consumption and obesity in teenagers.
    Children are less active because of safety concerns, particularly 
low income children in urban areas. In some communities, there are no 
sidewalks to walk on, just roads to drive on. And to make matters 
worse, schools are offering and requiring less gym classes with recess 
quickly disappearing.
    The 1997 Youth Risk Behavior Surveillance study administered by the 
Centers for Disease Control and Prevention found that half of all U.S. 
high school students did not meet basic exercise needs. It also found 
that substantially fewer girls exercised on a regular basis. Another 
trend is the decline in physical activity with increasing age. Between 
the 9th and 12th grades, boys exercised 10 percent less, while girls 
exercised 23 percent less. Black girls exercised even less than their 
white counterparts.
    The report goes on to say that children have a natural need for 
more daily physical activity than adults. Elementary school children 
should be encouraged to accumulate more than 60 minutes and up to 
several hours per day of age- and developmentally-appropriate activity. 
The report emphasizes the importance of variety and that the majority 
of activity should be in play that is intermittent in nature. It adds 
that ``extended periods of inactivity are inappropriate for children.''
    For adolescents, the guidelines are similar to those for adults. 
The report recommends that adolescents engage in three or more sessions 
per week of activities that last 20 minutes or more at a time and 
require moderate to vigorous levels of exertion.

                                SUMMARY

    If parents don't eat vegetables and fruits, kids don't
    If parents don't drink milk, kids don't
    Kids can't lose weight unless their parents are eating healthy or 
are also on a weight loss program
    Badgering the kids doesn't work.
    Telling kids one thing and doing another is not working. Parents 
must model what they want their kids to do
    Kids eat and learn to prefer the foods which are available in their 
homes. Hence, overweight parents have children who prefer fatty foods
    When parents skip breakfast, kids skip breakfast--putting them at 
risk for poor school performance and obesity
    When parents over-emphasize sodas, sweets and desserts, their 
children are more likely to develop sweet addictions. And even if the 
children don't have weight problems now, they will later
    When parents don't exercise, kids don't do it or value it--and this 
stays with them for a life time
    If parents don't teach their kids to cook, their children will rely 
on high calorie/low nutrient junk food and take-out
    Studies demonstrate 50 percent of 5-year-old girls know what 
dieting is. And this is related to if their parents are dieting. This 
puts these children at risk of developing eating disorders and weight 
problems later.
    Even though kids are overweight, they're nutritionally deficient 
and malnourished because of the poor quality of food they're eating.
    Being overweight is causing serious self-image problems, lack of 
confidence in children, which will have profound effects on them their 
whole lives.
    Overweight girls achieve less later in life.

                             IV. SOLUTIONS

    The solution to solving the childhood obesity problem is complex. 
Where parents are having problems providing appropriate role modeling, 
society and schools may have to step in.
    Increasing youngsters' physical activity levels may need to be 
addressed in society so children have safe environments in which to 
play and get around. Schools are a part of the answer as they need to 
place a higher value on time for physical activity and presenting 
nutritious foods in positive ways. And families need to understand the 
important role they play by setting better examples for their children 
and being physically fit and enjoying eating healthy together.
    In my private nutritional counseling practice in Washington, DC, I 
have helped many overweight children gain control over their bodies by 
advocating a whole-family approach.
    My own personal story illustrates how adult modeling affected my 
own body image, eating and weight problems later in life. But also how 
these problems can be overcome.
                                 ______
                                 
                  Prepared Statement of Myrna Johnson

    On behalf of the Outdoor Industry Association, I want to thank the 
bipartisan leadership of the Health, Education, Labor and Pensions 
Committee for your commitment to addressing our Nation's obesity 
epidemic. Data compiled by the Center for Disease Control points to 
obesity as one of the single greatest health challenges facing our 
Nation. Today, 50 percent of adults, 16 percent of children aged 6-11 
and 14 percent of adolescents are overweight and are at increased risk 
of chronic diseases such as diabetes, heart disease and cancer.
    However, there is reason for great hope on the obesity front. 
Studies have also shown that regular exercise and a healthy diet can 
dramatically reduce obesity.
    The time has come to get America's youth off the couch and 
outdoors. As an industry, we have identified educating young Americans 
on the physical and mental health benefits of outdoor recreation as one 
of our top public policy objectives. Specifically, we are supporting:
    1. Legislation that ensures physical education in schools--full 
funding for the PEP initiative.
    2. Greater outdoor recreation activities in schools.
    3. Greater access to affordable recreation.
    Outdoor recreation is one of the most effective tools we have in 
combating childhood obesity and we are committed to making this tool 
available to more Americans.
    Upon careful review of ``Improved Nutrition and Physical Activity 
Act,'' the Outdoor Industry Association is prepared to offer its strong 
and enthusiastic support for this legislation. This measure represents 
a thoughtful and comprehensive approach to addressing an enormously 
complex societal health problem. As one of America's fastest growing 
industries, we look forward to working with this Committee at each step 
of the legislative process.
    The Outdoor Industry Association
    The Outdoor Industry Association is the trade association of the 
$18 billion human-powered outdoor recreation industry. Our members 
include 1,100 manufacturers, retailers, and distributors of outdoor 
products associated with hiking, backpacking, climbing, canoeing, 
kayaking, fly fishing, and backcountry skiing. In 2000, Outdoor 
Industry Association's Participation Study found that hiking and 
mountain biking each had over 70 million participants and that 149 
million Americans participated in basic outdoor recreation activities.
    The events and aftermath of September 11th have also brought 
renewed focus on outdoor recreation. According to the Outdoor Industry 
Association Special Report: ``The effects of September 1lth on 
Recreation, Travel and Leisure,'' 29 percent of Americans changed their 
travel plans for the 6 months following September 11th. When exploring 
the types of vacations or activities that Americans will take in future 
months, 91 percent of Americans say they would feel safest visiting 
national parks. Clearly, Americans are seeking outdoor experiences in 
these uncertain times.
    Combating Obesity Through Outdoor Recreation
    The ``Improved Nutritional and Physical Activity Act'' recognizes 
and emphasizes the critical nexus between recreation and reducing the 
prevalence of obesity. The Outdoor Industry Association is very 
supportive of Title II of this Act, ``Community Demonstration Grants,'' 
which authorizes $40 million in fiscal year 1903 for an array of 
community-based recreation initiatives.
    We would recommend language be included in Section 201 (b) that 
recognizes the potential to significantly leverage Federal dollars for 
recreation through community/business partnerships. We look forward to 
working with you and your staff on this potential win-win measure.
    The Outdoor Industry Association is also embarking on a health 
oriented campaign similar to that described in Title X, ``Youth Media 
Campaign.'' During June of 2003, the Outdoor Industry Association will 
be launching a campaign highlighting the health benefits of outdoor 
recreation. Themes the industry will be emphasizing include: Eat 
Healthy, Play Healthy (the importance of diet and exercise) and 
Thinking Outside the School (motivational posters and or learning 
modules to encourage the discovery of nearby outdoor resources).
    Again, our industry believes there is an opportunity for real 
synergy between our efforts and those policies being advanced in the 
``Improved Nutrition and Physical Activity Act.'' The American public 
will frequently pursue the physical activities that provide the most 
enjoyment. Human-powered outdoor recreation offers a myriad of funds 
and affordable sports activities for persons of all ages, and any 
fitness level. We look forward to working with you and your staff on 
this important component of the legislation.
    Support for Obesity Legislation
    The Outdoor Industry Association greatly appreciates the 
opportunity to work with this Committee in crafting and advancing 
meaningful obesity legislation. We stand ready to support your efforts 
with both technical drafting suggestions and the development of 
nationwide support for your legislation.
    Outdoor Industry Association was founded in 1989 and provides trade 
services for over 4,000 manufacturers, distributors, suppliers, 
retailers, sales representatives and climbing gyms in the outdoor 
industry. Outdoor Industry Association programs include: industry 
research; representation in Washington, D.C.; educational programs and 
cost-saving benefits. OIA (www.outdoorindustry.org) is headquartered in 
Boulder, Colorado.
                                 ______
                                 
                  Prepared Statement of Connie Tipton

    These comments are submitted on behalf of the member companies of 
the International Dairy Foods Association (IDFA) and its three 
constituent organizations, the Milk Industry Foundation, National 
Cheese Institute, and International Ice Cream Association. Members 
range from large multi-national corporations to single plant 
operations, and represent more than 85 percent of the total volume of 
milk, cultured products, cheese, and ice cream and frozen desserts 
produced in the United States. IDFA represents more than 600 dairy food 
manufacturers, marketers, distributors and industry suppliers across 
the United States and Canada, and in 20 other countries.
    The dairy industry in the U.S. has made a significant investment 
and commitment over many years to research and fact development about 
the role of dairy products in diet and health. There also has been a 
major commitment by the dairy industry to educating consumers about the 
importance of a balanced, nutritious diet along with exercise to 
maintain good health. Long-standing alliances between the dairy 
industry and a broad range of recognized medical and scientific 
professionals and related organizations have provided the research and 
confirmation of dairy's key role in a healthy lifestyle. The IDFA 
organizations are committed to continuing and expanding these efforts.
    As the Committee embarks on an exploration of issues related to 
improved nutrition and fitness, the dairy foods industry seeks to be a 
partner in providing existing information and research that may be 
helpful to your consideration.
    The following messages about dairy products and their role in a 
nutritious diet provide an overview of some of the existing information 
that may be of interest. We would be happy to provide more detailed 
information about any of the research related to these messages, if the 
Committee is interested.
    The Good News About Milk & Dairy
    General Milk Statements
     Dairy products are available in a wide range of varieties 
to suit consumers' individual tastes and nutrition needs.
     People choose different milks for different reasons, and 
the different varieties of milk--fat-free, lowfat, whole, flavored and 
lactose-free--all deliver the same powerful package of nine essential 
nutrients: calcium, vitamin D, potassium, phosphorus, protein, vitamin 
B-12, vitamin A, riboflavin and carbohydrates.
     Dairy's role in a nutritious diet has been established and 
lauded by the nutrition and science community, including the American 
Dietetic Association, the National Institutes of Health, the U.S. 
Department of Agriculture, the National Osteoporosis Foundation, the 
American Academy of Pediatrics and many other reputable health 
organizations.
     Milk is doctor recommended. The American Academy of 
Pediatrics recognizes widespread low calcium intake among children, 
which remains one of the most pressing public health problems. The AAP 
notes that because of these low intakes, pediatricians should recommend 
a daily diet that includes milk and other calcium-rich dairy foods. 
Further, children are more likely to consume more milk in place of soft 
drinks or other beverages if they have the option of flavored milk.\1\
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    \1\ American Academy of Pediatrics. Calcium requirements of 
infants, children, and adolescents. Pediatrics. 1999; 104(5):1152.
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     Studies show that many who are lactose intolerant, 
regardless of ethnic background, can drink up to two 8-ounce glasses of 
milk with food or in small quantities throughout the day without side 
effects. For those who cannot, lactose-free milk is widely 
available.\2\
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    \2\ Inman-Felton, AE. Overview of lactose maldigestion (lactase 
non-persistence). Journal of American Dietetic Association.1999; 
99:481.
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    Weight Loss/Weight Management
     Emerging studies suggest that dairy products may play a 
role in maintaining a healthy weight. Researchers have found that those 
individuals who consumed more milk and milk products were least likely 
to be overweight.\3\ \8\
---------------------------------------------------------------------------
    \3\ Zemel, MB et al. Regulation of adiposity by dietary calcium. 
FASEB J. 2000; 14:1132.
    \8\ Davies, KM et al. Calcium intake and body weight. Journal of 
Clinical Endocrinology & Metabolism. 2000; 85:4635.
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     This protection from obesity found with increasing 
calcium/dairy intakes was not limited to fat-free or lowfat dairy 
products. The reported weight control benefits may be associated with a 
variety of dairy products.\3\ \8\
---------------------------------------------------------------------------
    \3\ Zemel, MB et al. Regulation of adiposity by dietary calcium. 
FASEB J. 2000; 14:1132.
    \8\ Davies, KM et al. Calcium intake and body weight. Journal of 
Clinical Endocrinology & Metabolism. 2000; 85:4635.
---------------------------------------------------------------------------
     Milk may also play a role in reducing the risk of obesity 
in children.\5\ Researchers analyzed the diets of preschool children 
and found that those consuming four servings of a variety of dairy 
products per day was associated with less body weight compared to 
children who consumed the same number of calories but fewer servings of 
dairy products.\6\
---------------------------------------------------------------------------
    \5\ Chan, GM et al. Journal of the American College of Nutrition, 
2001.
    \6\ Carruth, BR and Skinner, JD. The role of dietary calcium and 
other nutrients in moderating body fat in preschool children. 
International Journal of Obesity. 2001; 25:559.
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     Compelling evidence found in animal studies suggest that 
the calcium from dairy is more effective in weight control than non-
dairy sources or calcium supplements.\3\ To date, emerging research in 
human subjects has shown similar results.
---------------------------------------------------------------------------
    \3\ Zemel, MB et al. Regulation of adiposity by dietary calcium. 
FASEB J. 2000; 14:1132.
---------------------------------------------------------------------------
     Research in animal studies indicates those with a high 
calcium intake had an increase in the breakdown of fat, thereby burning 
more fat for energy, and required the use of less insulin.\3\
---------------------------------------------------------------------------
    \3\ Zemel, MB et al. Regulation of adiposity by dietary calcium. 
FASEB J. 2000; 14:1132.
---------------------------------------------------------------------------
     Researchers at the University of Tennessee analyzed the 
diets of Americans using Government food consumption surveys (NHANES 
III) and found that body fat was significantly lower in people who 
consumed more dairy (after controlling for calorie intake, physical 
activity and other factors.)\3\
---------------------------------------------------------------------------
    \3\ Zemel, MB et al. Regulation of adiposity by dietary calcium. 
FASEB J. 2000; 14:1132.
---------------------------------------------------------------------------
     Researchers at Purdue University found in women ages 18 to 
31 years who consumed a diet containing at least 780 mg of calcium and 
1,900 calories or less per day lost, or had less of an increase in, 
body weight over a 2-year period, compared to women who consumed the 
same number of calories but less calcium.\7\
---------------------------------------------------------------------------
    \7\ Teegarden, D et al. Calcium related to change in body weight in 
young women. Federation of American Societies of Experimental Biology 
Journal.1999; 13:A873.
---------------------------------------------------------------------------
     Researchers at Creighton University in Omaha found that 
women who consumed 1,000 mg of calcium (the amount in at least three 8-
ounce glasses of milk) weighed about 18 pounds less than those who 
didn't. The researchers speculate that calcium may help turn off one of 
the mechanisms responsible for storing fat.
     A recent study published in JAMA found that overweight 
young adults who consume more dairy products--such as milk, yogurt and 
cheese--may be less likely to become obese and develop insulin 
resistance syndrome, a key risk factor for Type II diabetes and heart 
disease.\9\
---------------------------------------------------------------------------
    \9\ Pereira, MA et al. Dairy consumption, obesity, and the insulin 
resistance syndrome in young adults: The CARDIA study. Journal of the 
American Medical Association. 2002; 287:2081.
---------------------------------------------------------------------------
     A number of studies have shown that the intake of calcium 
(particularly from dairy products) is inversely associated with body 
weight in children, adult men and women, Caucasians and African 
Americans.\9\
---------------------------------------------------------------------------
    \9\ Pereira, MA et al. Dairy consumption, obesity, and the insulin 
resistance syndrome in young adults: The CARDIA study. Journal of the 
American Medical Association. 2002; 287:2081.
---------------------------------------------------------------------------
    Milk & Kids
     A growing body of evidence suggests that a decline in milk 
consumption may have serious, long-term detrimental effects on the bone 
health of today's youth.
     Milk consumption in school lunch increases when chocolate 
or other flavored milk is offered, significantly increasing calcium and 
riboflavin intakes. \10\
---------------------------------------------------------------------------
    \10\ Guthrie, HA. Effect of a flavored milk option in a school 
lunch program. Journal of American Dietetic Association. 1977; 71:35.
---------------------------------------------------------------------------
    Flavored milks also offer a way to satisfy cravings without the 
guilt.
     Chocolate milk is a great way to satisfy chocolate 
cravings.
     Additional flavors found in dairy cases across the country 
include Caramel, Mocha Cappuccino, Vanilla, Banana, Orange, Strawberry 
and Cookies and Cream. Besides tasting great, the new milk flavors have 
the same amount of calcium and the eight other essential nutrients.
     Children and adolescents who are high consumers of soft 
drinks have lower intakes of riboflavin, folate, vitamins A and C, 
calcium and phosphorus.
                                 ______
                                 
        Prepared Statement of the American Dietetic Association

    Lifestyles that support and sustain the maintenance of a healthy 
weight, for both individuals and the population as a whole, are a major 
focus of the American Dietetic Association and its members. The rapid 
rise in the prevalence of overweight and obesity among all segments of 
the U.S. population is of grave concern as the health and quality of 
life of those afflicted plummets and health care costs and societal 
burdens continue to soar.
    Dietetic professionals translate complex nutrition principles into 
a vast array of healthful and appealing food options for millions of 
Americans daily. Our unique education, supervised pre-practice 
experience, and mandated continuing professional education equip us to 
identify and address overweight, obesity and its health consequences at 
all stages of the life cycle and in a myriad of educational, community, 
medical, commercial, and research environments. We commend the 
Committee's pursuit of legislation that represents a community-based, 
thoughtful approach to the prevention and treatment of obesity for the 
American public. Federal legislation should focus on strategies to 
encourage local screening and intervention programs, and encompass the 
consensus achieved through the Surgeon General's ``Call to Action'' 
related to obesity and overweight. The public health focus of 
legislative proposals is extremely important. We recommend it be paired 
with a number of additional elements that will maximize its success.
    Obesity is a complex disease state. Its definition must be 
evidence-based and appropriate to each segment of the population 
characterized. Modifiers such as age and ethnicity must be considered 
as general parameters for the U.S. population are established.
    Not everyone who falls outside the upper limit of normal for 
defined parameters is obese even though their body weight may be higher 
than is recommended. We must be sure that weight reduction is promoted 
for those in whom weight loss would be of benefit. Individuals who make 
healthful food choices the majority of the time, who are physically 
active/physically fit, and at low risk for the development of diet-
related disease should be urged to maintain the weight and lifestyle 
that is best for them.
    The American Dietetic Association urges that obesity be designated 
a disease by Federal agencies and institutions (i.e., Centers for 
Medicare & Medicaid Services, Social Security Administration, Centers 
for Disease Control and Prevention, etc.) with all of the attendant 
ramifications that such a designation implies--including sanctioned 
insurance coverage for obesity treatment. Coverage will facilitate the 
timely provision of health services to treat obesity and its attendant 
commodities; i.e., hypertension, lipid abnormalities, diabetes 
mellitus. As interventions are implemented, parameters, in addition to 
weight change, must be identified as outcomes to be assessed. Examples 
include but are not limited to:
     Normalization of blood pressure, blood sugar, lipid 
parameters
     Normalization of respiratory rate, improved exercise 
tolerance
     Reduced rates of admission or length of stay in 
institutional settings
     Reductions in medications use
     Reductions in frequency of visits to health care providers
     Decreased incidence of obesity-related comorbidities.
    Our knowledge of the genetic, environmental, cultural, behavioral, 
and emotional contributors to overweight and obesity is limited; 
current approaches to prevent or treat overweight and obesity are 
simplistic at best. An evidence-based approach to the development and 
implementation of strategies to prevent and treat overweight and 
obesity is necessary. Further, adequate annual appropriation of funds 
must accompany any demonstration project or research authorizations 
that are legislated.
    Coordination among the numerous stakeholders--government, academia, 
medicine, industry and others---is vital if rapid progress is to be 
made. Within Government institutions, we recommend strengthening the 
network of public officials who design and implement Federal, State and 
local projects and programs so that nutrition and physical activity are 
fully integrated within them. The Secretaries of Agriculture and Health 
and Human Services would benefit from having senior advisors on 
nutrition and health involved in the design and review of broad array 
of agency programs--not just those programs traditionally viewed as 
food, nutrition and health related. A deputy level position within the 
Surgeon General's office should ensure that nutrition and physical 
activity are fully integrated into Federal health and research agendas. 
Within the States, individuals with expertise in food, nutrition, and/
or physical activity, are needed at top levels with the authority to 
coordinate information and resources and make public health initiatives 
in nutrition and physical activity effective.
    Losing weight and maintaining a healthy weight in our American 
society is difficult, and ADA has several science-based positions on 
healthful eating, the balance between energy intake and expenditure, 
weight management, and medical nutrition therapy for diet-related 
medical conditions.
    While a number of individuals with moderate to morbid obesity 
studied in clinical research settings are able to loose weight, few--
perhaps only 5 percent of those studied--maintain their weight loss 
over time. A recent University of Pittsburgh study suggests that in the 
general adult population, planned modest weight loss of 10 percent or 
more maintained for at least 5 years occurs at a rate of approximately 
25-27 percent. Data such as this are promising, but our ability to 
replicate them will depend on our willingness to understand and then 
act individually and as a Nation.
    The best way to combat overweight and obesity is to prevent it. We 
support efforts to prevent or to reduce the incidence of childhood 
obesity, and in fact, have directed the ADA Foundation to turn its 
attention toward this issue. When working with children, we also must 
work with their families. Family members, of all ages, must become 
involved and must practice the dogmas that they preach.
    Prevention and intervention modalities targeted to children must 
incorporate the development of healthful eating practices and daily 
physical activity. As promising programs or programmatic elements are 
identified, school and community-based nutrition and physical education 
initiatives can be tested and those that are effective expanded through 
grants and appropriations. A preventive approach, rather than an 
approach that targets weight management only after one or more disease-
specific consequences have become established, offers the opportunity 
for restoration of a healthy weight before the comorbidities associated 
with obesity become entrenched and target organ damage occurs.
    ADA urges the Committee to emphasize the importance of innovative 
approaches to the prevention and treatment of obesity throughout the 
lifecycle. This includes proactive work with adolescents and women of 
childbearing age to maintain a healthy weight prior to conception. It 
encompasses the promotion of weight gain during pregnancy according to 
established guidelines, and encourages breastfeeding during the first 
year of the infant's life. This type of approach should help to stem 
the tide of increased incidence gestational diabetes and Type II 
diabetes in our Nation's mothers and children.
    Finally, we want to emphasize that increased awareness, education 
and action are needed to ensure positive health outcomes. Opportunity 
and incentives to pursue a healthy lifestyle must be supported with
     Reasonable access to a variety of low-cost nutritious 
foods for all Americans but especially for its children
     Nutrition education and/or behavioral counseling to 
facilitate food choices that support optimal weight maintenance and 
life-long healthful eating habits
     Physical activity curricula, programs and facilities that 
accommodate a broad range of individual interests and abilities and 
that are part of the established curriculum in elementary and secondary 
schools.
     Public and private insurance coverage for weight 
management programs initiated prior to the development of diet-related 
disease.
    The emphasis on the identification of individuals who would benefit 
from prevention and/or treatment must be matched with a comparable 
effort to ensure that there is adequate funding to support sufficient 
numbers of sound, multidisciplinary weight management options once 
obesity has been diagnosed. Obesity is multifactorial by nature; its 
management will require a team approach. Registered dietitians and 
dietetic technicians, physicians, nurses, psychologists, exercise 
physiologists, pharmacists and others will need to work collaboratively 
to ensure success. The nature and depth of counseling required to 
effectively intervene in youth and adults with moderate to morbid 
obesity greatly exceeds that which can be provided in the context of 
the routine office visit.
    As a society, we must acknowledge the effect that our national 
``culture'' has on the food and activity choices of the individual. We 
must collectively seek to improve it and to shift toward it toward 
health.
    In summary, ADA and its members are uniquely positioned to assist 
in the development and delivery of individualized prevention and 
treatment programs, to participate in community and school-based 
programs, and to conduct basic and applied research related to 
overweight and obesity.
    Federal legislation to address overweight, obesity, nutrition and 
physical activity must have a public health focus at the community, 
school, family and individual levels; promote research to better 
understand contributing factors and solutions; and create opportunities 
for education and behavioral counseling for weight management, 
prevention, and treatment. Further, Federal and private health programs 
should provide coverage for medical nutrition therapy and behavior 
modification to reduce obesity and diet-related disease.
    We commend the Committee for its work in bringing this issue to the 
forefront. Thank you, Mr. Chairman and Members of the Committee, for 
giving the American Dietetic Association the opportunity to share our 
views toward seeking and defining solutions to the epidemic of obesity 
that jeopardizes the health and well being of all.
                                 ______
                                 
       Prepared Statement of the National Soft Drink Association

    NSDA is pleased to submit a statement to the Committee today to 
share our views on the issue of fitness and nutrition, and in 
particular, its role in combating child overweight and obesity. NSDA is 
the major trade association representing the United States soft drink 
industry. Our members produce a wide array of beverage products 
including carbonated soft drinks, fruit juices, fruit drinks, bottled 
waters, iced teas and coffees, sports drinks and herbal and energy 
drinks. The U.S. soft drink industry has sales of over $72 billion a 
year and employs more than 183,000 workers in all fifty States.
    NSDA and its member companies commend the Committee for exploring 
ways to reverse rising obesity rates. Today's hearing is an important 
first step in understanding a very complex public health problem. There 
are three important components of any effort to reverse current obesity 
trends. First, Congress should take steps to implement the Surgeon 
General's most recent recommendation that all school-aged children 
receive 30 minutes of physical activity each day. We strongly believe 
that without this first critical step, any approach is likely to fail.
    Second, we need to improve the level and quality of nutrition 
education. Nutrition information used for education purposes should be 
based on fact, not emotion. There is a great deal of misinformation 
masquerading as evidence regarding soft drink consumption and soft 
drinks and health. For example, teen soft drink consumption is often 
misrepresented. An analysis of Federal Government data by researchers 
at Virginia Tech shows the average adolescent consumes about a can of 
soda a day, nearly one-fourth of teens do not drink regular carbonated 
soft drinks and only 5 percent consumed more than three per day. This 
level of consumption falls within the USDA/HHS Dietary Guidelines for 
Americans and the dietary advice of the American Dietetic Association.
    And third, the Committee should reject any recommendation to ban, 
tax, restrict or forbid the consumption of any particular food or 
beverage. Weight management professionals who work with patients know 
that efforts to prohibit foods in diet do not work, and may reinforce 
the negative behaviors they are trying to change.
    With regard to the Surgeon General's recommendation about daily 
physical activity, we note with dismay that the physical education 
requirements in our public schools have been declining over the last 20 
years. During the 1990s, the percentage of high school students 
enrolled in daily gym classes dropped from 42 percent to 29 percent and 
only one State today requires daily physical education for grades K-12. 
There are many reasons for this decline including new mandates on 
schools like standardized testing, time constraints, liability 
concerns, and lack of adequate financial resources. NSDA believes that 
the ``Improved Nutrition and Physical Activity Act (IMPACT)'' being 
developed by the Committee is a step in the right direction toward the 
successful implementation of the Surgeon General's recommendation. We 
also believe that the Committee should urge the Congress to support 
full funding for the Physical Education for Progress (PEP) program in 
the FY2003 appropriations process and beyond.
    NSDA believes however, that the private sector can also help 
schools address their revenue problems. Soft drink companies have had a 
strong and long-lasting commitment to America's education process for 
more than fifty years. Like many local businesses, beverage companies 
have developed successful partnerships with schools that provide value 
in the form of grants, scholarships and employee volunteer programs. 
These partnerships also generate revenue from the sale of beverages 
that help fund important educational programming, such as sports and 
physical education equipment, arts and theater programs, foreign 
language classes and computers and other technology.
    These business partnerships are a ``win-win.'' Beverage companies, 
schools, students and taxpayers all benefit. Educators are empowered to 
make decisions that best benefit their schools, students and 
communities. In fact, local control is the key to making these public-
private partnerships work for schools. That is why the soft drink 
industry opposes further Federal legislative intervention in the issue.
    The revenue generated from the sale of beverages in schools in an 
important part of the education funding equation in the United States. 
According to a March 2001 Survey by the National Association of 
Secondary School Principals (NASSP), 30 percent of schools report that 
their funding situation is worse than it was 5 years ago. The need for 
additional revenue is greater among the Nation's rural and urban 
schools.
    In 1996, the Carnegie Foundation for the Advancement of Teaching 
and NASSP produced a report evaluation America's school entitled, 
``Breaking Ranks, Changing an American Institution.'' The report 
recommended that schools reach out to the business community to form 
alliances that enhance academic programs on behalf of students. The 
March 2001 NASSP survey on business relationships with schools shows 
that educators have embraced the recommendation, as over 90 percent of 
school principals support public-private partnerships with soft drink 
companies to improve education. Other key findings from the study show:
    1. Over 60 percent of schools offer a wide variety of beverages in 
their vending machines, including water, 100 percent juice, sports 
drinks and juice drinks.
    2. The number one use of the revenue generated by the sale of 
beverages in schools is to purchase sports and physical education 
equipment (66 percent of schools), followed by after-school student 
activities (59 percent), instructional materials (48 percent) field 
trips (46 percent) arts and theater programs (44 percent) and computers 
and other technology (42 percent).
    It is important to remember the basic elements of achieving and 
maintaining a healthy lifestyle:
    1. Establish a daily diet that is balanced and has variety and 
moderation for all foods and beverages consumed.
    2. Engage in 30 minutes of physical activity daily.
    Too many calories consumed from all sources, combined with a lack 
of physical activity are fueling rising obesity rates. The American 
Dietetic Association (ADA) counsels that there are no ``good foods'' or 
``bad foods'' just good diet and bad diets. In addition, ADA says all 
foods have a place in a balanced diet.
    Opponents to beverage sales in schools base their objections on 
their own allegations that consumption of soft drinks and other foods 
of minimal nutritional value are causing obesity and other health 
problems. Not only do these allegations ignore an ever-growing body of 
scientific evidence (see attachment) but they also defy logic and 
common sense. NSDA knows of no data or evidence that suggests that 
children and teenagers in States, cities, or school districts that 
restrict the sale of soft drinks in their schools are any less 
overweight or obese then those in states that allow the sales of 
competitive foods like soft drinks.
    In closing, NSDA again commends the Committee for its efforts in 
developing legislation intended to evaluate the success of existing 
Federal nutrition programs and to encourage the development of physical 
fitness programs and education at the local level. We stand ready to 
work with the Committee in furtherance of these goals.

   ATTACHMENT TO THE STATEMENT OF THE NATIONAL SOFT DRINK ASSOCIATION
  RECENT ADVANCES IN SCIENTIFIC KNOWLEDGE CHALLENGE MANY COMMON VIEWS 
                      ABOUT SOFT DRINKS AND HEALTH

    There is one simple truth in all the data about rates of overweight 
and obesity--if we consume more calories than we expend, we will gain 
weight.\1\ Rising rates of obesity, especially pediatric obesity, 
present the Nation with a serious health challenge. As parents, 
educators, Government officials and healthcare professionals look for 
answers, accurate information is critical. In many instances, the facts 
challenge common misperceptions.
---------------------------------------------------------------------------
    \1\ ``Straight Facts About Beverage Choices,'' Journal of the 
American Dietetic Association, September, 2001.
---------------------------------------------------------------------------
     Did you know that a November 2001 journal article by a 
leading researcher at the United States Department of Agriculture 
Center for Nutrition Policy and Promotion stated that sugar consumption 
is not associated with chronic diseases such as diabetes, obesity and 
hyperactivity in children? The author, Dr. Anne Mardis, MD currently at 
the National Institute for Occupational Safety and Health, Centers for 
Disease Control and Prevention advises that the ``focus on sugar as an 
independent risk factor for chronic disease and hyperactivity should be 
de-emphasized.'' \2\
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    \2\ Mardis, Anne, ``Current Knowledge of the Health Effects of 
Sugar Intake,'' Family Economics and Nutrition Review, United States 
Department of Agriculture, Center for Nutrition Policy and Promotion, 
volume 13, number 1, 2001.
---------------------------------------------------------------------------
    Did you know that according to research conducted by the Georgetown 
University Center for Food & Nutrition Policy, presented at a major 
scientific conference in April 2001, 20 percent of teens 12 to 16 years 
of age do not consume regular carbonated soft drinks, 67 percent 
consume one 12-ounce can of regular carbonated soft drink per day or 
less and only 5 percent consume three or more cans per day. The simple 
message here is that most children are not ``guzzling'' soft drinks. 
Rather, they are finding a way to fit soda, milk, juice, water and 
sports drinks into their diets.\3\
---------------------------------------------------------------------------
    \3\ Storey, M. & Forshee, R., ``Relationship Between Soft Drink 
Consumption and BMI Among Teens,'' Experimental Biology 2001.
---------------------------------------------------------------------------
     Did you know that according to research using the very 
latest Federal Government health data, conducted by Virginia Tech and 
presented to the American College of Nutrition annual conference in 
October 2001, soft drink consumption does not contribute to increases 
in dental cavities in children? \4\ A recent University of Michigan 
study showed that soft drinks do not cause increased cavities in people 
under the age of 25.\5\ Also, according to the National Institutes of 
Health, the number of dental cavities continues to decline and dental 
health has been improving for years, due to many factors, including 
water fluoridation and better oral hygiene.\6\
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    \4\ Storey, M. & Forshee, R., ``Beverage Consumption and Dental 
Caries,'' American College of Nutrition, 2001.
    \5\ Burt, B.A., ``Is Sugar Consumption Still A Major Determinant of 
Dental Caries? A Systematic Review,'' www.lib.umich.edu/dentlib/nihcdc/
abstracts burt2.html 2001.
    \6\ National Institutes of Health Consensus Development Conference 
Statement, ``Diagnosis and Management of Dental Caries Throughout 
Life,'' March 26-28, 2001.
---------------------------------------------------------------------------
     Did you know that a recent study, funded by the dairy 
industry and published in the American Journal of Clinical Nutrition, 
showed that neither the caffeine nor the phosphorus found in some soft 
drinks contributes to poor bone health? \7\
---------------------------------------------------------------------------
    \7\ Heaney, R. & Rafferty, K., ``Carbonated Beverages and Urinary 
Calcium Excretion,'' American Journal of Clinical Nutrition, 2001, 
74:343-7
---------------------------------------------------------------------------
     Did you know that the September 2001 Journal of the 
American Dietetic Association contains an official Nutrition Fact Sheet 
stating, ``Regular carbonated soft drinks contain calories; milk and 
juice contain calories, vitamins and minerals--all beverages can have a 
place in a well-balanced eating pattern''? Further, the American 
Dietetic Association counsels that restricting foods or food 
ingredients is not a viable strategy for weight management.\8\
---------------------------------------------------------------------------
    \8\ ``Straight Facts About Beverage Choices,'' Journal of the 
American Dietetic Association, September 2001.
---------------------------------------------------------------------------
     Did you know that virtually no school system in the 
country provides daily physical activity for its students\9\ despite 
the fact that the rate of pediatric and childhood obesity in this 
country has reached an alarming level? Today's school children receive 
less physical activity today than their counterparts did 5 years 
ago.\10\
---------------------------------------------------------------------------
    \9\ ``Shape of the Nation Report,'' National Association for Sport 
& Physical Education, pp. 3-5.
    \10\ National Association for Sport & Physical Education, ``Public 
Attitudes Toward Physical Education,'' March 22, 2000.
---------------------------------------------------------------------------
     Did you know that low physical activity levels are 
associated with increasing obesity? According to a new study conducted 
by the National Public Health institute in Helsinki and published in 
the American Journal of Clinical Nutrition,\11\ among various 
behaviors, low levels of leisure exercise over time have the strongest 
relationship with obesity. The authors conclude that a physically 
active lifestyle, together with abstention from smoking, moderate 
alcohol consumption and a variety of healthy foods, provide the 
greatest likelihood of avoiding obesity. The results of the study of 
24,604 Finnish men and women underscore the importance of regular 
exercise in maximizing the chances of maintaining a normal weight.
---------------------------------------------------------------------------
    \11\ Am J Clin Nutr 2002: 5,809-817
---------------------------------------------------------------------------
     Did you know that a National Institutes of Health (NIH) 
analysis of daily calorie consumption, published in the American 
Journal of Clinical Nutrition \12\ concludes, ``The lack of evidence of 
a general increase in energy intake among youths despite an increase in 
the prevalence of overweight suggests that physical inactivity is a 
major public health challenge for this group?'' The study suggests that 
although some have tried to blame the over-consumption of food for 
rising obesity rates, the evidence does not support that position. The 
study suggests lack of exercise is a major contributor to obesity.
---------------------------------------------------------------------------
    \12\ Am J Clin Nutr 2000:72(suppl):1343S-53S.
---------------------------------------------------------------------------
     Did you know that a new study from the University of 
Washington presented at the Experimental Biology 2002 Annual Meeting in 
April 2002 demonstrates that cola soft drinks have the same effect on 
satisfying hunger and thirst as orange juice and 1 percent milk? Adam 
Drewnowski, Ph.D., Professor of Epidemiology and Medicine and Director 
of the University of Washington's Nutritional Science Program said, 
``Some nutritionists believe that colas act only as thirst quenching 
liquids and have no influence on hunger or fullness, and that fruit 
juices and milk are said to be foods that you drink. In our study with 
healthy college-age men and women, we found nothing of the sort.''

                                
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