[Senate Hearing 108-530]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 108-530

                    PREVENTION AND WELLNESS PROGRAM

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

                                HEARING

                                before a

                          SUBCOMMITTEE OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                      ONE HUNDRED EIGHTH CONGRESS

                             SECOND SESSION

                               __________

                            SPECIAL HEARING

                     APRIL 16, 2004--DES MOINES, IA

                               __________

         Printed for the use of the Committee on Appropriations


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                               __________
                      COMMITTEE ON APPROPRIATIONS

                     TED STEVENS, Alaska, Chairman
THAD COCHRAN, Mississippi            ROBERT C. BYRD, West Virginia
ARLEN SPECTER, Pennsylvania          DANIEL K. INOUYE, Hawaii
PETE V. DOMENICI, New Mexico         ERNEST F. HOLLINGS, South Carolina
CHRISTOPHER S. BOND, Missouri        PATRICK J. LEAHY, Vermont
MITCH McCONNELL, Kentucky            TOM HARKIN, Iowa
CONRAD BURNS, Montana                BARBARA A. MIKULSKI, Maryland
RICHARD C. SHELBY, Alabama           HARRY REID, Nevada
JUDD GREGG, New Hampshire            HERB KOHL, Wisconsin
ROBERT F. BENNETT, Utah              PATTY MURRAY, Washington
BEN NIGHTHORSE CAMPBELL, Colorado    BYRON L. DORGAN, North Dakota
LARRY CRAIG, Idaho                   DIANNE FEINSTEIN, California
KAY BAILEY HUTCHISON, Texas          RICHARD J. DURBIN, Illinois
MIKE DeWINE, Ohio                    TIM JOHNSON, South Dakota
SAM BROWNBACK, Kansas                MARY L. LANDRIEU, Louisiana
                    James W. Morhard, Staff Director
                 Lisa Sutherland, Deputy Staff Director
              Terrence E. Sauvain, Minority Staff Director
                                 ------                                

 Subcommittee on Departments of Labor, Health and Human Services, and 
                    Education, and Related Agencies

                 ARLEN SPECTER, Pennsylvania, Chairman
THAD COCHRAN, Mississippi            TOM HARKIN, Iowa
JUDD GREGG, New Hampshire            ERNEST F. HOLLINGS, South Carolina
LARRY CRAIG, Idaho                   DANIEL K. INOUYE, Hawaii
KAY BAILEY HUTCHISON, Texas          HARRY REID, Nevada
TED STEVENS, Alaska                  HERB KOHL, Wisconsin
MIKE DeWINE, Ohio                    PATTY MURRAY, Washington
RICHARD C. SHELBY, Alabama           MARY L. LANDRIEU, Louisiana
                                     ROBERT C. BYRD, West Virginia (Ex 
                                         officio)
                           Professional Staff
                            Bettilou Taylor
                              Jim Sourwine
                              Mark Laisch
                         Sudip Shrikant Parikh
                             Candice Rogers
                        Ellen Murray (Minority)
                         Erik Fatemi (Minority)
                      Adrienne Hallett (Minority)

                         Administrative Support
                             Carole Geagley



                            C O N T E N T S

                              ----------                              
                                                                   Page

Opening statement of Senator Tom Harkin..........................     1
Statement of Dr. Tom Baranowski, Ph.D., professor of pediatrics 
  behavioral nutrition and physical activity, Baylor College of 
  Medicine.......................................................     4
    Prepared statement...........................................     6
Statement of Rick Schupbach, co-director, P.E.4Life Institute, 
  and physical education teacher, Grundy Center Elementary 
  School, Grundy Center, IA......................................     9
    Prepared statement...........................................    11
Statement of Dr. Carolyn Cutrona, director, Institute for Social 
  and Behavioral Research, Iowa State University.................    14
    Prepared statement...........................................    17
Statement of Len Olsen, chief executive officer, Ottumwa Regional 
  Health Center..................................................    20
    Prepared statement...........................................    24
Statement of Rhonda E. Ruby, registered nurse, Webster County 
  Department of Public Health....................................    26
    Prepared statement...........................................    28
Statement of Thomas Oldham, president, Just Eliminate Lies (JEL), 
  Iowa Youth Tobacco Prevention Organization.....................    30
    Prepared statement...........................................    33

 
                    PREVENTION AND WELLNESS PROGRAM

                              ----------                              


                         FRIDAY, APRIL 16, 2004

                           U.S. Senate,    
    Subcommittee on Labor, Health and Human
     Services, and Education, and Related Agencies,
                               Committee on Appropriations,
                                                    Des Moines, IA.
    The subcommittee met at 9:30 a.m., at the AIB College of 
Business Activity Center, 2500 Fleur Drive, Des Moines, Iowa, 
Hon. Tom Harkin presiding.
    Present: Senator Harkin.


                opening statement of senator tom harkin


    Senator Harkin. Thank you all for being here this morning 
for one in a series of hearings that we're having on wellness 
and health. First let me recognize and thank some people. First 
I want to thank Nancy Williams, the president of AIB, and 
Marianne Nielsen, who is a director of advancement here at AIB, 
right here both, Marianne Nielsen and Nancy Williams, the 
president of AIB, thank you for having us here.
    Let me also thank Sarah O'Neill, director of activities at 
AIB too. Thank you, Sarah. Chris Schmidt, director of 
facilities at AIB for helping us get in here. Jay Byers, who is 
here, is representing Congress Leonard Boswell, and I talked to 
Leonard yesterday. He couldn't be here, he's in other places in 
his district, but thank you for being here, Jay.
    Some other people I want to recognize, Tom Coe, who is with 
the P.E.4LIFE group. We came out from Washington for this 
meeting. He has just put a heart monitor on me and I'm doing 
all right so far. Vernon Delapeace, CEO of the YMCA here in Des 
Moines, thank you for being here, Vernon. Mary Hanson, who's 
director of the Iowa Department of Public Health is here. Mary, 
thank you for being here. And Julie McMahon, who is the 
director of the Division of Community Health for the Iowa 
Department of Public Health, who is here. We thank all of you 
for being here.
    This morning, due to the shortage of available captioners, 
our captioning will be done by two AIB students--I hope I get 
these names right--Daria Shariari and Megan Caster. Thank you 
both for doing this and I appreciate your willingness to come 
and caption this event and I ask you all for your indulgence if 
they miss a word or two, but we'll try to speak plainly and 
clearly so you understand what we're talking about.
    Again, I want to thank you all for coming. Within the next 
several months, I, along with others, will be introducing 
legislation aimed at encouraging healthy lifestyles and 
preventing chronic disease. I've been soliciting ideas and 
gathering information all across the country for the last 
several months. But before I give final shape to this 
legislation, I wanted to get more input from people here in 
Iowa.
    Wellness is something that's difficult to define but easy 
to understand. It means eating right, exercising regularly, and 
developing healthy habits now in order to prevent major 
problems in the future. This is mostly just common sense. 
Iowans who take their cars in for regular maintenance 
understand the basic concept. You either pay a little now to 
keep things in good shape or you pay a whole lot later to fix 
and mend things.
    Well, it's the same with national health priorities. In the 
United States, we fail to make an up-front investment in 
prevention, so we end up spending hundreds of billions on 
hospitalization, treatment, and disability. This is foolish and 
it clearly is unsustainable. Right now we're spending more than 
$1.5 trillion each year on health care in the United States. 
Fully 75 percent of that total is accounted for by spending on 
chronic diseases, and what most of these chronic diseases have 
in common is that they are preventable.
    Overweight and obesity are fast becoming our Nation's 
leading public health threat. In fact, several weeks ago, the 
Centers for Disease Control said that poor diet and lack of 
physical activity is the number two leading cause of death in 
the United States, contributing to at least 400,000 deaths 
annually. It is a shocking fact that more than two-thirds of 
Americans are now overweight or obese, and more than 15 percent 
of our children are overweight.
    Obesity takes a terrible toll on an individual's health. It 
can lead to diabetes, heart disease, high blood pressure, 
cancer, and numerous other chronic diseases. Incredibly, 
obesity causes more chronic conditions than either smoking or 
alcoholism. In fact, being obese has an effect that is roughly 
comparable to aging 20 years.
    The costs are not only medical, they are economic as well. 
The Surgeon General estimates that direct and indirect costs of 
obesity in the United States come close to $120 billion 
annually. But obesity is by no means the only culprit. Tobacco 
use is still the number one killer of Americans. In 2002, 61 
million Americans, 26 percent of our population, smoked 
cigarettes. In Iowa the rate was a little lower, about 23 
percent. But despite decades of education efforts aimed at 
reducing tobacco use, nearly one in four Iowans still light up. 
Iowans know that this is bad for them and most want to quit, 
and we need to help them succeed.
    When it comes to tobacco use prevention, we need to refocus 
our efforts directly toward our children. Keep in mind that 90 
percent of all long-term smokers started as teenagers or 
younger. Every day in America more than 4,000 kids try their 
first cigarette. Another 2,000 children become daily smokers. 
One-third of these newly addicted smokers will eventually die 
from smoking-caused diseases.
    Mental health is also an important, but a very 
unacknowledged problem. The Surgeon General reports that mental 
disorders collectively account for 15 percent of the overall 
burden of disease from all causes. Under treated and untreated 
mental disorders cost the Nation more than $204 billion 
annually. Again, many of these disorders can be prevented, and 
millions of people living with mental illness can recover if 
provided treatment and support. This is one of the reasons I've 
worked so hard on what we call the Paul Wellstone Mental Health 
Parity Act, which will provide for mental health parity in our 
health systems along with physical health.
    Many people oppose a government role in this area. They say 
that preventable disease is a matter of personal 
responsibility. I agree that personal responsibility is 
critical, but I also believe that government has a 
responsibility to make sure that people have the information, 
the tools, and the support, and the means they need to make 
healthy choices.
    I interrupt my formal remarks here by saying that I wanted 
to have a little thing before the hearing this morning. I 
wanted to get some people and take a little walk around Gray's 
Lake and then walk up to AIB. I thought it would be a nice way 
to kick off the hearing. Well, you can walk around Gray's Lake, 
but you can't walk from Gray's Lake to here because there are 
no sidewalks. Think about how many streets are now being built 
in America, in our suburbs and everywhere else, and there are 
no sidewalks. Everything that the government now seems to be 
doing is discouraging you from exercising.
    I saw a figure not long ago, I forget it right now, but 
it's quite startling. As a kid, I grew up riding a bike 
everywhere. I rode a bike when I was in college. But I saw the 
figures indicating that today fewer kids and adults are 
bicycling than what they did in the past. Well, where are the 
bike paths? How can you ride a bike along a busy highway or a 
street with all those cars going by and you don't have any 
place to ride a bike? So again, I mention this as a government 
responsibility to begin to do things to encourage people or 
support people in trying to have a healthy lifestyle.
    As adults, we also have a responsibility to protect our 
children. Every year, kids are barraged with billions of 
dollars in tobacco, alcohol, and junk food marketing, all of it 
aimed at persuading them to make an unhealthy choice. I always 
say that the golden rule of holes is this. If you find yourself 
in a hole and it's getting up to your head, stop digging. Well, 
we've dug a big hole by failing to emphasize prevention and 
wellness, and it's time to stop digging and time to start 
climbing out of the hole. And it's going to take all sectors, 
it's going to take a comprehensive approach, everything from 
school-based, preschool, workplace-based, home-based, 
community-based, government-based, all of them working 
together.
    Today we'll hear from folks who are doing important and 
innovative work in encouraging individual wellness and healthy 
communities. I thank them for coming today. I look forward to 
their testimony and I'd like to say two more things. First, I 
want to thank the chairman of this subcommittee, my good friend 
Arlen Specter of Pennsylvania. Senator Specter and I have 
switched roles here numerous times over the last 14 years. I've 
been chairman, he's ranking member, he's chairman, I'm ranking 
member, back and forth. But as he is fond of saying, and I 
agree with him, it's been a seamless transfer. We have worked 
together very closely over all these years on health matters 
that pertain to the American people, and I want to thank him 
for allowing me this opportunity to have this hearing here in 
Des Moines.
    Second at the close of our formal remarks, I will engage in 
some questions with our panelists, but I'd also like to open it 
up to the audience, and time permitting, we'll have some 
questions, or if you want some statements or you have some 
input, some ideas, suggestions, we'd like to hear it. I would 
just ask that for the recorder's sake that you just give your 
name and please spell your name so that the recorder can get it 
right.
    So with that, let's go to our witnesses. I will introduce 
each one in the order that they will be making their testimony. 
First, we welcome Dr. Tom Baranowski. He's the professor of 
pediatrics and behavioral medicine at Baylor College of 
Medicine in Houston, Texas. Dr. Baranowski's research is 
directed toward understanding why children eat the foods and 
engage in the physical activities they do, as well as designing 
and evaluating programs to help change these dietary and 
physical activity behaviors. His areas of interest include 
fruit and vegetable consumption, obesity prevention, and 
physical activity. Dr. Baranowski will discuss chronic disease 
prevention and the cost to our economic health, specifically 
pertaining to physical inactivity and poor nutrition.
    After Dr. Baranowski, we'll go with Mr. Rick Schupbach and 
then we'll got to Dr. Carolyn Cutrona, then Mr. Len Olsen, Ms. 
Rhonda Ruby, and we got our clean-up hitter, someone you're 
really going to like to listen to, Tom Oldham right over there 
and what he's doing at Lincoln High School. So Dr. Baranowski, 
welcome, and the floor is yours.
STATEMENT OF DR. TOM BARANOWSKI, Ph.D., PROFESSOR OF 
            PEDIATRICS BEHAVIORAL NUTRITION AND 
            PHYSICAL ACTIVITY, BAYLOR COLLEGE OF 
            MEDICINE
    Dr. Baranowski. Senator Harkin, thank you for pronouncing 
my name properly, it was terrific. It's a great privilege to 
speak before this committee. I'll skip a couple of paragraphs 
that said who I was, being you did such a nice job of it.
    I'm here today to address the broader issues of chronic 
disease prevention, and of special interest to me, chronic 
disease prevention among children. As shown in table 1 in my 
testimony, 5 of the 10 leading causes of death in the United 
States are chronic diseases whose causes are largely or 
partially related to diet and physical inactivity.
    Accounting for fully two-thirds of deaths, the principal 
diseases of nutritional origin also account for an immense 
fraction of disability due to disease and the major share of 
medical costs for disease treatment as shown in table 2 in my 
testimony.
    Medical care costs for heart disease alone were $51.8 
billion in 1985. The cancers cost $41 billion. Type II diabetes 
cost $45.2 billion. These numbers are even higher in 2004 
because the population is larger and older. Further, in 
addition to these social economic costs, there are huge 
personal costs in terms of premature loss of loved ones, 
disruptions of gratifying lives, pain and sorrow, which are 
much more difficult to quantify.
    As I'm sure you are well aware, we are currently immersed 
in what can be termed an epidemic of obesity. However, you may 
be less aware of the fact that obesity is the principal 
underlying contributor to many of the major chronic diseases. 
Thus, for example, the dramatic rise in the incidence of 
diabetes in childhood and adolescence is directly the result of 
the increasing prevalence of obesity in children. In fact, the 
current prevalence rates of obesity and overweight are so high 
as to be alarming. Over half of all adults and approximately 
three-quarters of some ethnic/gender subgroups are overweight 
or obese. In middle schools in Houston among the minority 
students, half of the children are overweight or obese.
    The economic impact of obesity's role in the medical costs 
of the major chronic diseases of American adults has been 
calculated and it is frankly staggering. Today, most of the 
health care dollar is spent on treating these terrible 
diseases. While every effort should be maintained to treat 
existing cases of these diseases to minimize their burden, far 
more funding needs to be spent on prevention efforts upstream 
of the current treatment or downstream paradigms. Prevention is 
obviously always preferable to treatment in any circumstances, 
from both practical and fiscal perspectives. Prevention will 
serve to lessen the chronic disease burden on future 
generations, which, in turn, will minimize the social, 
economic, and personal costs.
    It's now abundantly clear that much of chronic disease 
morbidity and mortality is due to lifestyle behaviors. In fact, 
obesity is the result of an imbalance of two daily behaviors, 
calories consumed and an individual's level of physical 
activity. It's no surprise then that a recent report from the 
Centers for Disease Control and Prevention indicated that the 
two leading causes of death in 2000 were tobacco use and poor 
diet and physical activity. The other causes of death paled in 
comparison. The authors projected that poor diet and physical 
activity will soon overtake smoking as the leading cause of 
death, and urged a greater priority be placed on prevention.
    Thus, more than one-third of American deaths can be 
prevented by changing the smoking, diet, and physical activity 
practices of our children--of our citizens. Since poor diet and 
physical activity behaviors are the principal contributing 
causes of obesity, and since obesity is the leading underlying 
cause of nutritionally-related causes of death, a substantial 
investment is needed in obesity-related behavioral research to 
better understand how and why we have gotten where we are. In 
an annual NIH budget of $24 billion, approximately $379 million 
was spent on obesity in fiscal year 2003, about $400 million 
will be spent on obesity in fiscal year 2004, and $440 million 
in fiscal year 2005, and most of this will be spent on 
biological issues, not behavioral issues. Clearly, more funding 
must be spent on obesity and particularly on obesity 
prevention.
    Finally, why is a child's--why is a children's behavioral 
scientist speaking about chronic diseases of late adult life? 
All avenues of medical science now point to the fact that the 
prevention of chronic diseases should be initiated early in 
life among children. Diet and physical activity habits are 
learned in childhood. Chronic disease factors like blood 
pressure elevated among children tend to remain elevated into 
the adult years.


                           PREPARED STATEMENT


    There is some reason to believe that behaviors are more 
easily changed among children than among adults. Once excess 
weight is put on, it is almost impossible to take off. Despite 
these factors, many schools are minimizing or closing their 
physical education programs, high fat and high sugar foods are 
being marketed to children. National policy must carefully 
consider what can be done to enhance the diet and physical 
activity practices of our citizens and especially our children. 
This will have a huge impact on national health care costs and 
the quality of our children's lives.
    Thank you for your time and attention. I'd be happy to 
answer questions.
    [The statement follows:]

                Prepared Statement of Dr. Tom Baranowski

                       CHRONIC DISEASE PREVENTION

    Senator Harkin and members of the U.S. Senate Committee on 
Appropriations, it is a great privilege to speak before this committee.
    I am trained as a health psychologist, and do research on 
influences on children's diet and physical activity practices, and I 
design, implement and evaluate programs to change children's diet and 
physical activity practices.
    I am here, however, to address the broader issues of chronic 
disease prevention, and of especial interest to me, chronic disease 
prevention among children.
    As shown below in Table 1, five of the ten leading causes of death 
in the United States are chronic diseases whose causes are largely or 
partially related to diet and physical inactivity.

TABLE 1.--DEATHS AND PERCENTAGES OF TOTAL DEATHS FOR THE FIVE OF THE TOP
          10 LEADING CAUSES OF DEATH IN THE UNITED STATES, 2001
------------------------------------------------------------------------
                                                        Number   Percent
------------------------------------------------------------------------
Diseases of the Heart...............................    700,142     29.0
Malignant Neoplasms.................................    553,768     22.9
Cerebrovascular Diseases............................    163,538      6.8
Chronic lower respiratory Diseases..................    123,013      5.1
Diabetes Mellitus...................................     71,372      3.0
------------------------------------------------------------------------
Source: National Vital Statistics Reports, Vol. 52, #9, Nov. 7, 2003.

    Accounting for fully two-thirds of deaths, the principal diseases 
of nutritional origin also account for an immense fraction of 
disability due to disease and the major share of medical costs for 
disease treatment as shown in Table 2 below.

  TABLE 2.--HEALTH CARE COSTS FOR MAJOR CHRONIC DISEASES IN 1995 USING
                              2002 DOLLARS
                        [In billions of dollars]
------------------------------------------------------------------------
                                                               Estimated
                                                                 total
                                                                  cost
------------------------------------------------------------------------
Heart Disease................................................   51.8
Cancers......................................................   41.0
    Breast...................................................  .........
    Endometrial..............................................  .........
    Colon....................................................  .........
Type 2 Diabetes..............................................   45.2
Osteoarthritis...............................................  (64.0)
Hypertension.................................................   24.1
Obesity......................................................  117.0
------------------------------------------------------------------------
Source: Several NIH web sites.

    Medical care costs for heart disease alone were $51.8 billion in 
1995. The cancers cost $41 billion; Type 2 diabetes cost $45.2 billion. 
These numbers are even higher in 2004 because the population is larger 
and older. Further, in addition to these social economic costs, there 
are huge personal costs in terms of premature loss of loved ones, 
disruptions of gratifying lives, pain and sorrow, which are much more 
difficult to quantify.
    As I'm sure you are well aware, we are currently immersed in what 
can be termed an epidemic of obesity. However, you may be less aware of 
the fact that obesity is the principal underlying contributor to many 
of the major chronic diseases. Thus, for example, the dramatic rise in 
the incidence of diabetes in childhood and adolescence is directly the 
result of the increasing prevalence of obese children. In fact, the 
current prevalence rates of overweight and obesity are so high as to be 
alarming (see Table 3). Over half of all adults and approximately three 
quarters of some ethnic/gender subgroups are overweight or obese.

 TABLE 3.--PREVALENCE OF OVERWEIGHT AND OBESITY AMONG ADULTS (20+ YEARS
                OLD) BY MAJOR ETHNIC AND GENDER GROUPINGS
                              [In percent]
------------------------------------------------------------------------
                                                         Women     Men
------------------------------------------------------------------------
Non Hispanic Black....................................     77.3     60.7
Mexican American......................................     71.9     74.7
Non Hispanic White....................................     57.3     67.4 
------------------------------------------------------------------------
Source: NIDDK web site.

    Recently, the economic impact of obesity's role in the medical 
costs of the major chronic diseases of American adults has been 
calculated (Table 4 below) and it is frankly staggering.

      TABLE 4.--COSTS FOR CHRONIC ILLNESSES ATTRIBUTABLE TO OBESITY
------------------------------------------------------------------------
                                                    Directly  Indirectly
                                                     due to     due to
                                                     obesity    obesity
------------------------------------------------------------------------
Heart Disease (Billions)..........................      $8.8  ..........
Cancers:
    Breast (Billions).............................       1.1       $1.8
    Endometrial (Millions)........................     310.0      623.0
    Colon (Billions)..............................       1.3        2.2
Type 2 Diabetes (Billions)........................          52.8
Osteoarthritis (Billions).........................       5.3       15.9
Hypertension (Billions)...........................       4.1  ..........
Obesity (Billions)................................      61.0       56.0
------------------------------------------------------------------------
Source: Several NIH web sites.

    Today, most of the health care dollar is spent on treating these 
terrible illnesses. While every effort should be maintained to treat 
existing cases of these diseases to minimize their burden, far more 
funding needs to be spent on prevention efforts ``upstream'' of the 
current treatment or ``downstream'' paradigms. Prevention is obviously 
always preferable to treatment in any circumstance, from both practical 
and fiscal perspectives. Prevention will serve to lessen the chronic 
disease burden on future generations, which, in turn, will minimize the 
social, economic and personal costs.
    It's now abundantly clear that much of chronic disease morbidity 
and mortality is due to lifestyle behaviors. In fact, obesity is the 
result of an imbalance of two daily behaviors, calories consumed and an 
individual's level of physical activity. It's no surprise then that a 
recent report from the Centers for Disease Control and Prevention 
indicated that the two leading causes of death in 2000 were tobacco use 
and poor diet and physical activity. The other causes of death paled in 
comparison. The authors projected that poor diet and physical activity 
will soon overtake smoking as the leading cause of death, and urged a 
greater priority be placed on prevention.

     TABLE 5.--LEADING CAUSES OF DEATH IN THE UNITED STATES IN 2000
------------------------------------------------------------------------
                                                                 Percent
                                                       Numbers      of
                                                      of deaths   total
------------------------------------------------------------------------
Tobacco.............................................    435,000     18.1
Poor diet & physical activity.......................    400,000     16.6 
------------------------------------------------------------------------
Source: Mokdad, et al, Actual causes of death in the United States,
  2000. JAMA, 2004; 291:1238-1245.

    Thus, more than one-third of American deaths can be prevented by 
changing the smoking, diet and physical activity practices of our 
citizens.
    Since poor diet and physical activity behaviors are the principal 
contributing causes of obesity and since obesity is a leading 
underlying cause of nutritionally -related causes of death, a 
substantial investment is needed in obesity related behavioral research 
to better understand how and why we have gotten where we are. In an 
annual NIH Budget of $24 billion, approximately $379 million was spent 
on obesity in fiscal year 2003, about $400 million will be spent on 
obesity in fiscal year 20004, and $440 million in fiscal year 2005 
(source: www.nih.gov/news/fundingresearchareas.htm). Clearly more 
funding must be spent on obesity, and particularly on obesity 
prevention.
    Finally, why is a children's behavioral scientist speaking about 
chronic diseases of late adult life? All avenues of medical science now 
point to the fact that the prevention of chronic diseases should be 
initiated early in life among children. Diet and physical activity 
habits are learned in childhood. Chronic disease risk factors (like 
blood pressure) elevated among children, tend to remain elevated into 
adult years. Diet and physical activity practices learned in childhood 
tend to continue into the adult years. There is some reason to believe 
that behaviors are more easily changed among children than among 
adults. Once excess weight is put on it is almost impossible to take 
off. Despite these factors, many schools are minimizing or closing 
their physical education programs; high fat and high sugar foods are 
being marketed to children. National policy must carefully consider 
what can be done to enhance the diet and physical activity practices of 
our citizens and especially our children. This will have a huge impact 
on national health care costs and the quality of our children's lives.
    Thank you for your time an attention. I would be happy to answer 
questions.

                             LOB Questions

    Question. What research has been done on school based obesity 
prevention programs for children, and how are they working?
    Answer. First, there have been remarkably few school based or non-
school based, obesity prevention programs among children. Of those 
conducted, most have not changed some aspect of body composition. Of 
those that worked, most were pilot studies that do not normally work in 
more rigorous larger trials, or they worked for subsets, but not all of 
the students. There is no clear guidance from the published studies on 
what to do for school based obesity prevention.
    Question. Does this suggest that we should not fund more research 
in this area?
    Answer. No. The NIH has made an enormous investment in biological 
research over the last 50 years. It is only in the last 10 years or so 
where the treatments have been targeted at molecular systems, e.g. cell 
receptors, and have had substantial impact on disease without 
substantial side effects. The same investment must now be made in the 
behavioral sciences. We need to better understand why people eat the 
food they do, and are, or are not, physically active. Research must 
then be conducted to convert this knowledge into effective programs and 
evaluate them. This will require substantially more funding for 
behavioral science and related research.
    Question. What do you believe are the three highest priority issues 
for research in this area?
    Answer. First we need a clear picture of what are the major 
contributors to obesity. Some luminaries believe lack of physical 
activity is the major culprit; other equally admirable luminaries 
believe it is mostly diet. There are adherents for the contribution of 
TV, electronic games, fast food, enhanced portion sizes, etc. If we 
knew the five major causes of obesity, we would have clear guidance for 
the design of programs to maximize the effects. Of course the five 
major causes probably vary by age, and perhaps by gender.
    Second, we need a better understanding of why people do or don't 
do, the behaviors that are the major contributors to obesity. This 
knowledge will guide programs designers on what mediating variables to 
target.
    Third, we need research on controlled diet and physical activity. 
For example, most of national dietary guidance is based on the national 
dietary guidelines and food guide pyramid, but there has never been a 
study that assesses what happens when people eat a diet based on the 
dietary guidelines and food guide pyramid. What will it do for obese or 
moderately overweight people? for those with an elevated blood pressure 
or cholesterol? There are several recent versions of the food guide 
pyramid and more have been proposed. None have been compared for 
effects on outcomes. The same kind of research is needed with physical 
activity. What will 30 minutes of moderate to vigorous physical 
activity 6 days a week do for adults or children who are overweight? Is 
physical activity valuable primarily in longer doses, or do multiple, 
shorter doses have the same effect? While some of this research on 
physical activity has been done, this is very difficult research to do 
and much more is necessary.
    A number of my colleagues would argue that the primary research 
need is for more community-based interventions. In my opinion, since 
most of our community based interventions have not worked well, or not 
worked at all, these three kinds of research will provide much needed 
guidance to the community based interventions.

STATEMENT OF RICK SCHUPBACH, CO-DIRECTOR, P.E.4LIFE 
            INSTITUTE, AND PHYSICAL EDUCATION TEACHER, 
            GRUNDY CENTER ELEMENTARY SCHOOL, GRUNDY 
            CENTER, IA

    Senator Harkin. Dr. Baranowski, thank you very much for 
that testimony, and now we'll move to Mr. Schupbach, the Grundy 
Center Elementary physical education specialist is Mr. Rick 
Schupbach. He was selected the 1993 Iowa Elementary Physical 
Educator of the Year, and in 2001 was recognized as only the 
third Excellence in Education Award winner in Grundy Center 
Community School District history.
    On May 1, 2003, get this, the Grundy Center Elementary 
physical education program was recognized as the first 
P.E.4LIFE Institute at an elementary school in the entire 
Nation. Rick Schupbach.
    Mr. Schupback. Thank you, Senator Harkin, and if I could 
ask you to draw your attention to the screen, and the audience 
as well, and excuse me for having my back to you. It is indeed 
a pleasure to be here today and I thank you for this forum, and 
I want to thank you on behalf of all physical education 
teachers, not only in the State of Iowa but the Nation, for 
your visionary leadership in the area of not only health and 
wellness, but in physical education, especially with the PEP 
program legislation.
    Along with that, I'd like to take this opportunity, and I 
would be remiss if I did not recognize my school 
superintendent, Mr. John Stevens, who is here today with me. 
Mr. Stevens has been a visionary for health and wellness and 
physical education at the local level as you have on the 
national level, so it's very important that he is here with me 
today.
    As I begin my presentation, I want you to use your 
imagination. Dr. Baranowski did an excellent job of capturing 
the problem in our society today. What I would like to do is 
talk about what I perceive as a preventive, proactive, 
prescriptive solution, and that is quality physical education.
    So I'm going to ask you to use your imagination, and I want 
you to imagine a world where physical education just isn't 
another class to be completed, but a destination for a 
different kind of learning. Two such examples I have time to 
share with you today at the P.E.4LIFE Institute in Grundy 
Center that we do are the heart adventure challenge course 
where students represent red blood cells as they travel through 
the circulatory system. The SOS challenge course, where they 
have problem-solving teams and have to perform fitness tasks in 
order to be able to save themselves.
    At Grundy Center I'm proud to say that we believe in the 
mind body connection, that we believe that physical education 
represents the lifestyle learning lab. Unfortunately, No Child 
Left Behind has left physical education behind and it has 
concentrated solely on the mind at the expense of the body. And 
as a result of that, we have children today that are being 
educated not as a whole child, but only their mind. I am proud 
to say that at the Grundy Center P.E.4LIFE Institute, we 
believe in sound mind, sound body. There's more to education 
than math, reading, and science.
    To do that, you have to document your results. We have the 
opportunity and the vision to document our students' heart 
rates on a daily basis. We have revolutionized physical 
education with report card systems and meal planners and 
assessments where they can take what they do in fitness testing 
and track it over the lifetime that they are in school. We can 
document the effort that students put into physical education 
on a daily basis, providing printouts for every 5 seconds of 
their heart rate in P.E. They must invest in their own health 
to see a return, and we must be able to collect data like every 
other area of education.
    I want you to imagine a world where P.E. is articulated K-
12 and it expands outside the walls of the gymnasium and into 
the community. That's what we've been able to do at Grundy 
Center. One of the creative ways in which we've been able to do 
that is to put heart monitors on people in different careers. 
It's called ``the day in the life of,'' and as you look at this 
screen, you can see the different days in the life of, and what 
we've found out is that every career without exception is 
sedentary, and we know that 9 out of 10 teenagers if they are 
inactive as youth will become inactive as adults. So what we 
have to do is be able to get them active, get them to invest in 
their own health. Is it any wonder we have an obesity crisis 
when we know that all occupations are sedentary? It's part of 
how we can inspire one another.
    I want to welcome you to an awakening and to the new P.E., 
and it comes not a minute too soon for any kid who has been 
picked last, consigned to right field, or left dangling halfway 
up the climbing rope. The idea is to get away from the jock 
culture, the fastest, the strongest, the most athletic, instead 
start all kids on the road to lifelong fitness, and that starts 
with no humiliation.
    I believe that Grundy Center in some small way is serving 
as a beacon of light, as a lighthouse, not only for our 
students, but also for our community, also for our State, and 
as being named the second P.E.4LIFE Institute, for our Nation 
as we train people who come to our P.E.4LIFE Institute from 
around our Nation, in fact from around the world. We've had 
visitors from Finland.
    Our approach is a STAR-TEC P.E. approach, where we allow 
every child to be a star, and we provide success through 
assessing and reporting. We use technology, education, and 
community health. That's our physical education program. It 
starts with a design, and we must design what takes place in 
our classrooms. Many times physical educators are our own worst 
enemies and create our own black eyes. We must step up and we 
must be accountable for our actions, and so the design that I 
wish I had time to go through and show you all of the different 
things that are going on in the educational setting in the 
classroom setting in Grundy Center.
    I truly believe that we have the secret for healthy living. 
It is a lifestyle education approach. I would like to end and 
conclude my comments on the most personal and intimate level 
that I can. Seven years ago tomorrow, I was diagnosed with 
cancer. I had a tumor the size of my fist in my chest, and as I 
went to the Mayo Clinic to be treated, my doctor said to me 
that I was fortunate that I happened to be in as good a shape 
as I was, I was in training for my second half-marathon at the 
time. My regiment called for 120 hours of chemotherapy, IV, on 
four different occasions. Most of the time what killed people 
that had my type of cancer was the chemotherapy protocol. 
However, Dr. Ronald Richardson said to me, Rick, you are 
fortunate because you are in the best shape of your life.
    I know there are great teachers around this Nation in all 
subject matters, and I know they all think what they are doing 
is the most important thing. I want you to understand that I am 
passionate about what I teach and I want you to know that no 
matter how important those other subject matters seems, it's 
very important to understand that they could not stand in front 
of you today and say that by living their profession, it helped 
to save their life. By living my profession, I believe it 
helped to save my life.

                           PREPARED STATEMENT

    I thank you for your time and I thank you for your advocacy 
for our mission and our goal and I look forward to you visiting 
P.E.4LIFE Institute in Grundy Center shortly to join us in a 
living, breathing model. Thank you.
    [The statement follows:]

                  Prepared Statement of Rick Schupbach

    Thank you, Senator Harkin, for the opportunity to offer testimony 
here today. My name is Rick Schupbach and I am a Physical Education 
Teacher at Grundy Center Elementary School in Grundy Center, Iowa. I 
have been teaching physical education for 20 years, 14 of those in 
Grundy Center. I also serve as the Co-Director of the P.E.4LIFE 
Institute in Grundy Center.
    First, I would like to introduce my Superintendent, John Stevens, 
who is with me today. As you will hear in my testimony, transforming 
Physical Education programs so they are relevant and effective in the 
21st Century requires a partnership with the entire school system, not 
just the PE teachers. We need visionary administrators who understand 
and are committed to the healthy body, healthy mind connection. We are 
fortunate in Grundy Center to have John Stevens as that kind of 
educator.
    Before talking about the exciting things we are doing in Grundy 
Center, I would like to take a moment to commend you, Senator Harkin, 
for your exemplary leadership on the issue of promoting health, 
wellness and prevention, especially with regard to programs aimed at 
children. Your leadership in the success of the Carol White Physical 
Education Program (PEP) is making a tremendous difference in 
communities around the country. Now in its fourth year, the PEP program 
grants are invigorating PE programs and attracting more young people to 
healthy and active lifestyles. We are proud of the work you do and look 
forward to continuing together in the years ahead.
    My testimony today will focus on the importance of quality physical 
education in our nation's schools and specifically what we have been 
able to accomplish in Grundy Center. We believe quality PE must be part 
of any national strategy to promote health and wellness. Our 
understanding of physical education, which we call P.E.4LIFE, means 
meeting the needs of every student, not just the athletically inclined; 
it means grading students on effort and progress toward the goal, not 
on skills and innate abilities; it means using technology and 
innovative teaching to reach kids where they are, not pulling them to 
where we want them to be, only to lose them as soon as the bell rings; 
it means linking students, teachers, school administrators, business 
leaders and even senior citizens to build truly healthy communities. 
And perhaps most importantly, Grundy Center's P.E.4LIFE program means 
putting the fun back into sports, fitness, recreation and exercise in a 
way that inspires all students to want to be active every day of their 
lives.
    We have made tremendous progress in our community. Now, by serving 
as a P.E.4LIFE Institute, we attract and train others who come to see 
how to improve their physical education program.
    We have all heard the statistics about the health crisis facing our 
nation's youth. Probably one of the most widely used and significant is 
the Center for Disease report that the percentage of children ages 6 to 
11 who are overweight has increased nearly 300 percent during the past 
25 years. These numbers continue to astonish as one evaluates older 
demographics as well.
    As described in the news media, these numbers have reached epidemic 
proportions. It is an interesting paradox though. Never before have 
children and youth had better access to health care and have 
experienced lower rates of disease and disability. But the indicators 
of health status linked to physical activity are regressing. As a 
result children, for the first time in 100 years, may have a shorter 
life expectancy than their parents.
    The accompanying health problems as a result of this trend present 
a great problem in our society. Diseases like Type 2 diabetes, 
previously referred to as ``adult-onset diabetes,'' are on the rise 
among our children. It has been estimated that the health care cost of 
being overweight and obese now exceeds $100 billion annually. Just last 
month, newspaper headlines across the country reported new data 
attributing lack of physical activity and poor diet to 400,000 deaths 
per year. This makes physical inactivity and bad nutrition the second 
leading cause of preventable death in the country, just behind tobacco. 
The statistics go on and on.
    I am proud to say Grundy Center is at the forefront of a national 
movement to halt and reverse these trends, starting with our children 
and expanding into the whole community. One of the key aspects of this 
change has been the recognition led by organizations like P.E.4LIFE 
that our methods of teaching physical education needed to change. As a 
result, we have made our P.E.4LIFE program fun, innovative, integrated, 
motivational and accountable. With proper reinforcement and teaching, 
scores of kids who in traditional PE were scorned and turned off are 
becoming engaged and motivated. And these are the ones who make up the 
epidemic we are trying to fight.
    The P.E.4LIFE Physical Education program in Grundy Center is 
founded on the concept of lifestyle education. We developed our 
curriculum to educate students to meet the needs of their future 
lifestyles. My focus is to help students make healthy lifestyle choices 
they would not have made unless we intervened. Based on a lifestyle 
education model developed by Beth Kirkpatrick, a native Iowan, our 
program has been adapted specifically for the elementary school 
setting.
    We develop and implement innovative P.E.4LIFE activities that link 
to other educational concepts. We strive to integrate learning, 
starting inside the walls of the gymnasium and reaching out into the 
community. Let me mention a couple of examples:
  --Dance pads and game rider bikes using video technology to motivate 
        students to engage today's students' interest in investing in 
        their own health.
  --Community Fitness Center housed within the walls of the school.
  --Heart Adventure Challenge Course--Students take on a large scale 
        obstacle course by traveling as blood cells through the 
        circulatory system.
  --SOS Adventure Course--A game in which students, stranded on an 
        island, must work together through numerous physical and mental 
        challenges for the team to be saved.
  --Technology applications such as the pocket PC, the PE manager 
        report card program and the TriFit assessment program 
        integrated into the physical delivery system.
  --Math Projects--Using their own heart rate data, students learn 
        graphing and data collection skills, as well as trend analysis.
  --Music Education--Music is a constant in our PE classes. Coordinated 
        with our elementary music curriculum, different classical music 
        composers are introduced to fourth and fifth graders each month 
        during warm-ups. Contemporary music is cued to the aerobic 
        phases of our workouts.
    Not only are students learning valuable educational concepts, 
they're learning how to live active, healthy lives.
    Using a wide range of activities, unique class format design 
technology and interactive learning stations, Grundy Center has a 
program that addresses a different aspect and concept of lifestyle 
education in each PE class every day. In the fourth and fifth grade, 
students work throughout the year to design their personal lifestyle 
plans, with regular opportunities to revise their selections. 
Continually participating in thought-provoking activities requires our 
students to challenge their choices. This process also encourages 
parents to take an active role in their child's health through helping 
them work on obtaining their goals throughout the year.
    Technology can be a key determinant in getting kids healthy and 
active. Heart rate monitors, in particular, are transforming physical 
education. At the level of the individual student, heart rate monitors 
allow every child to be successful in PE. Use of monitors encourage 
students to set and attain goals that are appropriate for them. I teach 
kids that it doesn't matter how fast they run, as long as they meet 
their target heart rate. I can't emphasize how liberating this is for 
students, as well as for me. Technology like heart rate monitors can be 
the great equalizer, allowing everyone to be a winner and no one a 
loser.
    At the same time, the value of technology extends beyond 
motivation. Through immediate computer printouts of the every student's 
heart rate, I get verifiable feedback to see if I am indeed providing 
the class format and activities necessary to impact cardiovascular 
fitness. I can use objective data to make a fair assessment of 
individuals and the class as a whole.
    And it allows us to connect with families. We send heart rate 
printouts home to every parent. This has proven very positive, 
especially to encourage family discussion connecting fitness and 
health.
    I personally believe use of this kind of technology is absolutely 
critical to the future of physical education for another reason: 
Accountability. I can show--visually, graphically, objectively--how 
participating in physical education is improving our students' health 
and wellness. We are fully equipped to respond to our Superintendent, 
School Board and parents when they want to validate the critically 
important class time and resources our PE requires. In Grundy Center, 
we welcome the opportunity to demonstrate the cardiovascular benefits a 
quality physical education program has on students. We can show it. 
Cutting PE in Grundy Center would mean cutting the heart out of the 
child's education. I sincerely believe for our country to embrace PE 
the way it needs to, the physical education profession needs to embrace 
the accountability we can deliver through technology.
    A wonderful affirmation of our program's impact has been how Grundy 
Center's middle and high schools are embracing the Lifestyle Education 
approach to physical education. In 2001, we secured private foundation 
funding to create a state-of-the-art ``Community Fitness Center'' in 
our school. More than $130,000 was provided. Initially, aerobic and 
strength training equipment, along with heart rate monitors and fitness 
evaluation software, were made available to 6-12th graders. We have 
seen the quality of their PE experiences improve. Even more exciting, 
however, was the ability for us to expand physical education beyond the 
gym and into the community. On any day in Grundy Center, you may find a 
district judge, grocery clerk, firefighter or eighty year-old retiree 
working out and recording her heart rate in the Community Fitness 
Center.
    Let me mention one example of how we have extended beyond our 
school walls and engaged our community. We developed our ``A Day In The 
Life Of'' program to teach our students how different careers and 
lifestyles impact one's health. We went out to the community and put a 
heart rate monitor on various citizens, and asked each to wear it all 
day. After a full day's work, we downloaded the information to learn 
how heart rates fluctuated throughout a routine workday. The results 
demonstrably showed our students just how sedentary many career paths 
can become. Our students were shocked to see how few adults reached a 
target heart rate for any period of time, day after day. It made the 
point that every person has to consciously decide to be active, whether 
by riding a bike, walking to the grocery store, playing a sport or 
working out in a gym.
    In addition, this exercise spoke directly to many adults who had no 
idea of their own physical inactivity. Sue Havel, a local hairstylist, 
thought since she was on her feet all day she was getting valuable 
exercise. After seeing the heart rate data prove otherwise, Sue changed 
her life. She now is a regular at the Community Fitness Center, and 
happier and healthier for it.
    I can't tell you how proud it makes me to see young people 
inspiring adults and adults inspiring young people to take control of 
their health in this way. And when we see senior citizens on the 
treadmill alongside a middle school student, as I do in Grundy Center, 
it's hard to tell who is inspiring whom, which is even better!
    There is no doubt the change I am talking about takes time to 
realize. When I first began to develop the elementary school 
curriculum, which is called ``Energizing and Educating for Healthy 
Lifestyles'', our gymnasium was housed in the basement of a 70 year-old 
building. It wasn't anything special. Over time, we formed teams from 
the community to clean and restore the gym floor, I painted the gym 
myself one summer, and volunteers helped to build a student fitness 
area.
     Several years later, a new elementary school was built. Thanks in 
part to our collective roles in improving the old facility, community 
members and I were involved in designing the new gymnasium. This 
collaboration resulted in a truly effective teaching environment that 
today includes many child-centered learning ideas that allows our 
program to flourish:
  --PE teacher's office is central with windows for two way viewing;
  --Restrooms and drinking fountains are inside the gym so no child 
        leaves the teaching-learning setting;
  --Gymnasium is situated so that no one from outside class walks 
        through and distracts attention;
  --Gravionic bars are built into the walls for decompression exercises 
        that build strength and develop appropriate posture;
  --Equipment and heart monitor storage areas are built into facility 
        design;
  --Personal spaces are painted on gym floor and numbers are painted on 
        the wall to aid in class management protocols;
  --Student workstation to record concepts and heart rate data is 
        adjacent to gym;
  --Rock climbing wall was recently built within the gymnasium.
    Change takes time, and it takes vision. And if this country is to 
make the change toward health and fitness that we all know we have to, 
frankly, the physical education profession needs to change as well. We 
need to embrace P.E.4LIFE programs that promote technology, 
accountability, and community outreach. The University of Northern Iowa 
is attempting to revolutionize physical education training at the 
college level. Starting next year, eight top UNI graduate students will 
immerse themselves at the P.E4LIFE Institute in Grundy Center, teaching 
and living in the community to see firsthand how comprehensive health 
and wellness promotion can take hold. We believe Grundy Center is a 
national model that can be replicated across the country. We want more 
programs to come to the PE4LIFE Institute and then go back home and 
change they way they do things. Just last month, 10 people from Des 
Moines trained with us and returned here to transform their PE programs 
into P.E.4LIFE programs.
    We've all heard stories about humiliation in the old way of 
teaching PE. Being the last kid picked, suffering through elimination 
games, forced to compete in games that weren't fun--I acknowledge these 
perceptions hamper PE even today.
    Yet it is self evident that quality physical education, provided 
the right way, is an integral component to deal with obesity-related 
diseases, sedentary lifestyles and soaring health care costs that 
plague our country today. We can show people the old PE is out. We can 
prove to school boards that PE can and should be accountable just like 
other core subjects. Physical education can be a catalyst for entire 
communities to become active and healthy.
    Physical education in the 21st Century means educating every child 
in a way that is relevant to his or her life experiences. It means a 
STAR TECH PE approach where we provide Success Through Assessment, 
Reporting, Technology, Education and Community Health Physical 
Education. To truly take our PE programs where they have never gone 
before. We have the means and the experience to engage young people, to 
teach how and why to be active, and to give them the tools to live a 
healthy life. As a professional physical educator, I believe we are at 
a time of fundamental rethinking and retooling in what we do. I could 
not be more excited about the progress we are making in Grundy Center. 
It is revolutionary. And it is what is needed for us to address the 
challenges we face.
    Thank you for the opportunity to express my views. I am happy to 
answers any questions.

    Senator Harkin. Very good. Thank you. Who's taking care of 
my schedule, John? Make sure I get up there as soon as 
possible. I really do, and I mean that, I'm going to get up 
there very soon. Of course, you're going to be out of school 
pretty soon, darn it. Well, is it okay if I come in the 
summertime, anyway?
    Mr. Schupback. Any time you want. We'd be happy to have 
you.

STATEMENT OF DR. CAROLYN CUTRONA, DIRECTOR, INSTITUTE 
            FOR SOCIAL AND BEHAVIORAL RESEARCH, IOWA 
            STATE UNIVERSITY

    Senator Harkin. All right. Well, thank you very much, Rich. 
Now I'm going to go to Dr. Carolyn Cutrona, Professor of 
Psychology, Iowa State University. Dr. Cutrona has studied 
extensively rural mental health issues and the effects of 
economic stress on rural parents. Her areas of interest include 
coping with stress, social support, close relationships, health 
psychology and marital relationships. Dr. Cutrona will discuss 
the challenges we face regarding the current state of the 
mental health system and specifically rural mental health 
issues. In addition, Dr. Cutrona will also address how mental 
health and chronic disease are intertwined and can trigger one 
another, and will also address stress prevention. Dr. Cutrona, 
welcome.
    Dr. Cutrona. Thank you. Good morning, Senator Harkin, 
fellow Iowans. I am the director of the Institute for Social 
and Behavioral Research at Iowa State University and a 
professor of psychology. For 10 years the Institute for Social 
and Behavioral Research was home to an NIH-funded Center for 
Rural Mental Health. And we continued to conduct both applied 
and basic research in this area, so I'm very grateful for the 
opportunity to share information on mental health and wellness 
issues, especially as they apply to a rural America. I should 
note that in 1992 we were pleased to have Senator Harkin 
present to celebrate the opening of our facility when we first 
became a center for rural mental health.
    Nationally, as many Americans are hospitalized for severe 
mental disorders as for cancer. Over the course of their 
lifetime mental disorders affect one-third to one-half of the 
U.S. population. At any given time 20 percent of adults suffer 
from mental illness of some sort. Between 12 percent and 22 
percent of youth under the age of 18 are in need of mental 
health services. An estimated 7.5 million children and 
adolescents suffer from one or more mental disorders.
    Mental disorders are among the most disabling of chronic 
diseases. Furthermore, compared to other chronic diseases, 
mental disorders strike earlier in life, often in the teens to 
mid-20s. According to a report from the U.S. Surgeon General, 
depression is the leading cause of disability in the United 
States. Let me say that again. Depression is the leading cause 
of disability in the United States. In addition to the personal 
suffering of patients and their families, mental health 
disorders are very costly to society. According to the National 
Advisory Mental Health Council, in the year 1990 mental illness 
cost the United States an estimated $75 billion, and it's 
surely gone up considerably since then.
    Mental and physical health are closely intertwined. For 
example, depression and anxiety often accompany and complicate 
other diseases, like heart disease and cancer. One study found 
that the presence of depression among first heart attack 
survivors was linked to earlier death. The presence of 
depression among first heart attack survivors was associated 
with earlier death. Among all illnesses and health behaviors, 
mental disorders are among the leading contributors to what 
they call disease burden, defined as years of life lost to 
premature death and number of years weakened by disability. So 
clearly this is a very serious health issue.
    Let me talk briefly about mental illness in rural America. 
The prevalence of mental disorders are similar in rural and 
urban areas. The suicide rate, however, among adult males and 
children is higher in rural areas than in urban areas of the 
United States. Among Midwestern farmers, during the farm crisis 
of the 1980s, the suicide rates grew to four times the national 
average. Compared to urban dwellers, when you look at 
individuals who suffer from serious mental illness, 1-year 
symptom outcomes are worse among rural compared to urban 
residents. Youth between the ages of 15 and 24 are the most 
likely to receive inadequate treatment for serious mental 
illness than any other age group. This problem is more severe 
for rural than urban youth. Health officials in rural areas 
place mental health and mental disorders near the top of their 
list of health priorities.
    There is a severe shortage of mental health professionals 
in rural America. The most severe shortages in rural areas are 
of psychiatrists, especially child psychiatrists. Again, 
children with severe mental illnesses are the most underserved, 
especially in rural areas. Seventy-five percent of rural 
counties lack a psychiatrist, 95 percent lack a child 
psychiatrist. Fully 50 percent lack a doctoral level 
psychologist or master's level social worker. Only 1 in 14 
rural hospitals provide psychiatric services, and only 14 
percent of total rural hospital beds are designated for 
psychiatric care. Rural residents are more likely than urban 
residents to rely upon primary care physicians for mental 
health care. Primary care physicians often received inadequate 
training in the diagnosis and treatment of mental illness.
    There are many approaches to meeting the mental health 
needs of rural Americans. It is critically important to provide 
those who suffer from mental illness with state-of-the-art 
treatments that are affordable and accessible. In addition, we 
need to turn our attention to the prevention of mental 
disorders. There are a variety of strategies for doing this and 
perhaps we can discuss this in depth in the question and answer 
period. Let me stop for the time being.
    Senator Harkin. If you have a couple more minutes, I'm 
always willing to give.
    Dr. Cutrona. Well good, let me go ahead.
    Senator Harkin. Just a couple more minutes to wrap up, 
maybe.
    Dr. Cutrona. Very good. So, how do we increase access to 
mental health care? Incentives must be increased to encourage 
mental health professionals to locate in rural areas of the 
country.
    Senator Harkin. How do you do that?

                           PREPARED STATEMENT

    Dr. Cutrona. Federal reimbursement rates for Medicaid 
patients must be increased to lessen the income disparity for 
mental health providers who work in rural versus urban areas. 
Specialized training in rural mental health should be added to 
graduate training programs in psychology, social work and other 
mental health professions to increase the rural competence of 
mental health care providers. The ability of primary care 
physicians to provide competent mental health treatment should 
be increased through training, clinical practice guidelines, 
utilization, routinely a brief mental health screening 
instruments, and greater, stronger linkages between primary 
care physicians and mental health providers. Telemedicine, in 
which specialists at a distance provide consultation, training, 
supervision and even direct services via videophone technology 
is growing in popularity. A number of mental health 
telenetworks have been established to provide specialty 
consultation and training in the mental health area. We must 
reimburse critical aspects of mental health care, including 
thorough assessment, especially with children. It's very 
complex, assessing exactly what the nature of the child's 
mental health disorder or issue is. These are costly, they must 
be reimbursed. Treatment while problems are still small rather 
than waiting until problems are severe. Having these kinds of 
treatment reimbursable is critical.
    [The statement follows:]

                Prepared Statement of Carolyn E. Cutrona

    Good morning, Senator Harkin. My name is Carolyn Cutrona. I am the 
Director of the Institute for Social and Behavioral Research and a 
Professor of Psychology at Iowa State University. For ten years, the 
Institute for Social and Behavioral Research at Iowa State was home to 
an NIH-funded Center for Rural Mental Health and we continue to conduct 
both basic and applied research in this area. We are grateful for the 
opportunity to share information on mental health and wellness issues, 
especially as they apply to rural America.

                          SCOPE OF THE PROBLEM

    Nationwide, as many Americans are hospitalized for severe mental 
disorders as for cancer. Over the course of their lifetime, mental 
disorders affect approximately one-half of the U.S. population. At any 
given time, approximately 20 percent of adults and 25 percent of the 
elderly suffer from mental illness of some sort. Between 12 percent and 
22 percent of America's youth under age 18 are in need of mental health 
services. An estimated 7.5 million children and adolescents suffer from 
one or more mental disorders. Mental disorders are among the most 
disabling of chronic diseases. Compared to other chronic diseases, 
mental disorders strike earlier, often in the period extending from the 
teens to the mid-twenties. According to a report from the U.S. Surgeon 
General, depression is the leading cause of disability in the United 
States.
    In addition to the personal suffering of patients and their 
families, mental health disorders are very costly to society. According 
to the National Advisory Mental Health Council, in the year 1990 mental 
illness cost the United States an estimated $74.9 billion.
    Mental and physical health are closely intertwined. For example, 
depression and anxiety often accompany and complicate other diseases, 
like heart disease and cancer. One study links depression to early 
morality among first heart-attack survivors. Among all illnesses and 
health behaviors, mental disorders are among the leading contributors 
to disease burden, defined as years of life lost to premature death and 
number of years weakened by disability.

                    MENTAL ILLNESS IN RURAL AMERICA

    The prevalence of lifetime and recent mental disorders are similar 
in rural and urban areas. The suicide rate among adult males and 
children is higher in rural than in urban areas of the United States. 
Among Midwestern farmers during the farm crisis of the 1980s, the 
suicide rate grew to four times the national average. Compared to 
urban-dwellers, worse one-year symptom outcomes were found for rural 
residents with a serious mental illness, especially if the illness was 
accompanied by substance abuse. Youth between the ages of 15 and 24 are 
more likely to receive inadequate treatment for serious mental illness 
than any other age group. This problem is more severe for rural than 
urban youth. Health officials in rural areas place mental health and 
mental disorders near the top of their list of rural health priorities.

        AVAILABILITY OF MENTAL HEALTH RESOURCES IN RURAL AMERICA

    There is a severe shortage of mental health professionals in rural 
America. Although the supply of specialty mental health professionals 
in the United States grew substantially in the 1990s, the increase in 
rural areas has been minimal. In 1999, 87 percent of designated Mental 
Health Professional Shortage Areas in the United States were in non-
metropolitan counties, which are home to over 30 million people. The 
most severe shortages in rural areas are of psychiatrists, especially 
child psychiatrists. Seventy-five percent of rural counties lack a 
psychiatrist; 95 percent lack a child psychiatrist; 50 percent lack a 
master's or doctoral level psychologist or social worker. Twenty 
percent of non-metropolitan versus only 5 percent of metropolitan 
counties lack mental health services. Non-metropolitan counties have an 
average of less than two mental health clinics, compared to more than 
13 in metropolitan counties. Only 1 in 14 rural hospitals provide 
psychiatric services and only 14 percent of the total rural hospital 
beds are designated for psychiatric care.
    Rural residents are more likely than urban residents to rely upon 
primary care physicians for mental health needs. Studies have shown 
that primary care physicians do not always provide optimal treatment 
for mental illness. For example, patients treated for depression by 
primary care physicians are more likely than those treated by 
psychiatrists to have an incomplete recovery and to suffer a relapse. 
Primary care physicians often receive inadequate training in the 
diagnosis and treatment of mental illness. Their heavy case loads 
demand brief visits, in which mental health concerns cannot be 
adequately addressed. They may lack expertise regarding when to make 
referrals and they often lack local specialists to whom to refer 
seriously mentally ill patients.

            TWO APPROACHES TO THE PROMOTION OF MENTAL HEALTH

    There are many approaches to meeting the mental health needs of 
rural Americans. It is critically important to provide those who suffer 
from mental illness with state-of-the-art treatments that are both 
accessible and affordable. Increasingly, however, we should turn our 
attention to the prevention of mental. After a brief discussion of 
strategies for increasing the supply of mental health resources to 
rural Americans, attention will turn to preventive strategies that may 
be more cost effective in the long run.

                INCREASING ACCESS TO MENTAL HEALTH CARE

    Incentives must be increased to encourage mental health 
professionals to locate in rural areas of the country. Federal 
reimbursement rates for Medicaid patients must be increased, to lessen 
the income disparity for mental health providers who work in rural 
versus urban areas. Specialized training in rural mental health should 
be added to graduate training programs in psychology, social work, and 
other mental health professions to increase the cultural competence of 
mental health care providers. Rural-connected individuals should be 
recruited by graduate training programs in the mental health 
disciplines and encouraged to practice in their home communities. State 
and federal support should be available to students in these programs.
    The ability of primary care physicians to provide competent mental 
health treatment should be increased through training, clinical 
practice guidelines, utilization of screening instruments, and creating 
greater contact of primary care physicians with mental health 
professionals via a variety of linkages.
    Integrated treatment that addresses both psychological health and 
physical health may advance both cost and quality objectives in the 
system of care. The coordination of mental health services with primary 
health care has been found to contribute to reductions in health care 
costs. Improving the link between primary care physicians and mental 
health specialists is of great interest to rural mental health experts. 
A range of collaborative relationships can be envisioned, in which 
primary care physicians hire, share space with, or confer off-site with 
mental health specialists.
    Telemedicine, in which specialists at a distant site provide 
consultation, training, supervision, and direct services via videophone 
technology, has grown in popularity. A number of mental health 
telenetworks have been established. They have been used for direct 
psychiatric encounters (patient interviews), crisis response, 
medication management, and consultation on admission, commitment, and 
discharge. A recent survey of rural Iowans found that approximately 
two-thirds of respondents expressed willingness to use telemedicine for 
mental health services and three-fourths would recommend this service 
to a friend. As expected, older respondents were less willing than 
younger respondents to use telemedicine, and expressed concerns about 
confidentiality, impersonality, lack of knowledge about technology, and 
problems with vision or hearing.

                 THE NEED FOR PREVENTIVE INTERVENTIONS

    The last twenty years have seen an explosion in programs to prevent 
a wide range of mental illnesses and problem behaviors. Evidence has 
accumulated that preventive interventions are cost effective. Some 
mental health problems that are resistant to treatment in adulthood can 
be prevented through intensive preventive interventions in childhood. 
There is evidence that some disorders accelerate in severity over time. 
If their onset can be prevented, boundless suffering and years of lost 
productivity can be avoided.
    Relatively little is known about the precise causes of mental 
illness. Many types of mental illnesses result from a combination of 
genetic predispositions and life experiences. It is possible to inherit 
a tendency towards a disorder like depression, but only to succumb to 
the disorder if faced with overwhelmingly negative life conditions. 
Similarly, it is possible to inherit a tendency towards impulsivity and 
a short attention span, but with firm, consistent parenting, never to 
develop problem behaviors such as delinquency or drug abuse.
    Although we do not know the precise cause of most mental illnesses, 
we have learned a great deal about risk factors and protective factors 
associated with mental illness.
    Risk factors increase the probability over time that a mental 
illness will develop. Seven types of risk factors have been identified. 
These include constitutional handicaps (e.g., neurochemical imbalance 
or sensory disabilities), skill development delays (e.g., low 
intelligence or attentional deficits), emotional difficulties (e.g., 
emotional immaturity, low self-esteem), family circumstances (e.g., 
abuse, parental mental illness, poor parental supervision), 
interpersonal problems (e.g., peer rejection, social isolation), school 
problems (e.g., poor school performance, and alienation from school), 
and ecological risks (e.g., neighborhood poverty, racial prejudice).
    Protective factors decrease the probability that mental illness 
will develop, especially among persons who are subject to one or more 
risk factors. Protective factors include characteristics of the 
individual (e.g., intelligence, social skills, temperamental 
characteristics), the quality of the individual's interactions with 
others (e.g., a close relationship with parents and prosocial peers), 
and the quality of the larger environmental context (e.g., good quality 
schools, a good relationship between the family and the community).
    Preventive interventions that systematically decrease exposure to 
risk factors and increase access to protective factors have been the 
focus of concentrated research efforts for approximately two decades. 
These interventions closely parallel more familiar prevention efforts 
in the public health domain, such as anti-smoking campaigns or laws 
mandating the use of seat belts.
     principles of effective mental health preventive interventions
    Two decades of research on preventive mental health interventions 
yield the following general principles.
    1. Preventive interventions that start at an early age are the most 
effective. Some of the most effective preventive interventions begin in 
preschool.
    2. Short-term interventions produce only short-term results. Multi-
year programs are the most likely to produce enduring benefits.
    3. Preventive interventions are best directed at risk and 
protective factors rather than at specific symptoms or syndromes. 
Because the same risk and protective factors influence a wide range of 
mental illnesses, it is cost effective to target these factors and 
potentially influence multiple mental health outcomes.
    4. Preventive interventions should be aimed not only at building 
childrens' competencies and coping skills, but also at modifying their 
environments, including home, school, and community. Optimizing 
parenting quality is an especially important component of preventive 
interventions. A second critical component is optimizing the quality of 
the school climate for school-aged children.
    5. There is no single program component that can prevent mental 
illness and problem behavior. A package of coordinated, collaborative 
strategies and programs is required in each community.
    6. To create sustainability of preventive intervention programs, 
programs must be integrated into existing community structures. In this 
way, communities can develop common conceptual models, common language, 
and procedures that maximize the effectiveness of programs for 
individuals with varying levels of need. Schools, in coordination with 
community organizations (e.g., community mental health centers, 
Departments of Human Services, community youth organizations, County 
Extension Offices) can work together to offer sustained preventive 
programming to youth and families.

       TYPES OF PREVENTIVE INTERVENTIONS TO ENHANCE MENTAL HEALTH

    There are three different types of preventive mental health 
interventions: universal, selective, and indicated. Universal 
preventive interventions target the general public or a whole 
population group. Participants are not selected based on individual 
need. In the public health domain, childhood immunization programs are 
an example. In the mental health domain, a wide range of universal 
preventive interventions have shown good results. For example, 
preventive programs have been developed to prevent violence by exposing 
children to a school-based curriculum that teaches nonviolent conflict 
resolution, decision-making skills, and anger control. Programs to 
reduce drug and alcohol use have also been developed. One successful 
program included in-school programming on decision-making and 
resistance to peer pressure in addition to training for parents on 
effective parenting skills. Universal preventive interventions have 
been developed to ease the transition from elementary to middle school. 
These in-school programs focus on individual skill-building and 
creating a supportive school environment. One such program showed 
significant reductions in measures of maladjustment and mental illness, 
lower rates of alcohol and tobacco use, and less violent behavior six 
years after the program.
    Selective preventive interventions target individuals or subgroups 
based on the presence of biological or social risk factors that 
increase the probability of developing mental disorders. A number of 
selective preventive interventions have been designed to help children 
who are at increased risk for depression, either because they have a 
depressed parent, or because they have shown elevated depressive 
symptoms themselves. The interventions typically take place in schools 
and focus on the overly negative thought patterns and beliefs that 
often underlie depression. Such programs have been successful in 
lowering the rates of depression among youth. Other school-based 
preventive interventions have successfully targeted anxiety disorders 
or suicidal behavior. Preventive interventions have also been developed 
to serve children and families who have experienced family disruptions, 
including parental divorce and parental death. Such programs are 
successful in reducing future child depression and substance abuse.
    Finally, indicated preventive interventions target individuals who 
are identified as having early signs or symptoms related to mental 
disorders but who do not yet meet formal diagnostic criteria for a 
mental illness. An indicated preventive intervention is embedded in a 
larger universal intervention called Fast Track (Conduct Problems 
Prevention Research Group, 1999a). The program is designed to prevent 
conduct disorders and associated adolescent problem behaviors. This 
program involves 50 elementary schools in four urban and rural 
locations. The universal intervention includes a multi-grade curriculum 
throughout the elementary school years. The indicated intervention 
offers youth who are identified in kindergarten as manifesting a high 
level of problem behaviors a series of interventions that involve the 
family (e.g., home visiting, parenting skills, case management), the 
child (e.g., academic tutoring, social skills training), the school, 
the peer group, and the community. Results of the first three years 
indicate significant reductions in special education referrals and 
aggression both at home and at school for targeted children.

                                SUMMARY

    Residents of rural America suffer from mental illness at 
approximately the same rate as those of urban areas. However, rural 
residents have much lower access to mental health services. A variety 
of directions for reducing mental illness in rural America were 
suggested. Some of these include increasing the availability of mental 
health specialists. Another approach to mental illness, in both rural 
and urban settings, is to dedicate resources to the prevention of 
mental illness. When preventive interventions are implemented in early 
childhood and target the child's skills, the family environment, and 
the school environment, research shows that many kinds of mental health 
problems can be prevented or reduced in severity. A new model of 
collaboration among community organizations is needed in which programs 
with demonstrated effectiveness can be built into the structure and 
routines of community life.

    Senator Harkin. I'd like to go to some of the health 
prevention intervention, especially in early childhood with you 
during our question and answer sessions.
    Dr. Cutrona. Very good.

STATEMENT OF LEN OLSEN, CHIEF EXECUTIVE OFFICER, 
            OTTUMWA REGIONAL HEALTH CENTER

    Senator Harkin. Thank you, Dr. Cutrona.
    Now we will turn to Mr. Len Olsen. Mr. Olsen is the CEO of 
the Ottumwa Regional Health Center. This health center offers a 
comprehensive wellness program for their employees, and I also 
understand you're involved in providing wellness programs for 
the private sector and some businesses. And you can talk about 
that because I met one of those one time and was very intrigued 
by what you're doing there. Incentives include reduced health 
insurance premiums for participation and meeting individual 
health goals. So, welcome Len, and please tell us what you're 
doing in Ottumwa.
    Mr. Olsen. Well, thanks for the opportunity to be here 
again today, Senator Harkin. And I want to thank a couple of 
people that talked me into being here today and that's Elaine 
Leppard, our Wellness Coordinator. Elaine, if you could raise 
your hand. And Jo Ellen Randall, our vice president of Human 
Resources and who is in charge of wellness for our hospital and 
for the public program. So they really are responsible for the 
program.
    I'm speaking today more as a participate and an advocate 
rather than an architect of this program. But I want to go back 
a little bit to the Grundy Center presentation. You know, when 
I was growing up on a dairy farm in rural Minnesota, my 
exercise consisted of milking cows, shoveling things out of a 
gutter, cleaning calf pens, picking mustard weeds out of a 
field. And I stayed in pretty good shape doing that but I think 
I'd have rather gone to Grundy Center, however, because it 
looked like a lot more fun. But it points out how much our 
lifestyle's changed. I worked hard as a kid and now that's 
changed pretty dramatically.
    But to get to our program, as the head of a regional health 
center that employs some 960 people, I'm very much aware of the 
impact of increasing health costs on Iowa employers. It's a big 
problem. Over the last 8 years Ottumwa Regional has been 
instrumental in developing a work site wellness program that we 
call Healthy Choices. This program was not designed to be a 
quick fix. But over the last 8 years I think we are seeing the 
potential that the program has for helping contain health care 
costs and having our staff live a healthier lifestyle.
    The program was developed in 1997 in order to respond to 
rising health insurance costs, as many employers have 
experienced. We used a task force of employees to help develop 
ideas, and it was determined early on that it wasn't sufficient 
just to provide health insurance or sick coverage, as you said 
earlier, that we had to promote wellness and the individual 
health of employees and their families. I think one of the 
goals is that if we teach our employees how to live healthier 
lives they can help teach their kids how to lead healthier 
lives as well.
    When we looked at our claims history, 48 percent of our 
health insurance claims were related to lifestyle, or 
behavioral issues, such as drug and alcohol abuse, poor pre-
natal care, smoking, poor diet and lack of exercise. It was 
this resolution that led Ottumwa Regional to embark on the 
Healthy Choices journey. One of the key elements was creating a 
supportive rather than a punitive environment. A positive 
environment can help employees to turn healthy choices into 
healthy habits. Senior management's support for the program was 
essential in getting it off the ground, and my predecessor and 
Jo Ellen were a big part of that. Employees were encouraged, 
actively encouraged, to enroll in the program. Employee 
wellness games were formed to provide input on program design, 
encourage co-workers to participate and provide support to 
those who chose to make lifestyle changes. As one of the people 
that had to do that when I came to Ottumwa Regional, that 
support is important. Building a health culture is a big job, 
one that we continue to work on and improve upon to this day.
    Let's talk a little bit about the program design. From the 
beginning we were focusing on the individual through one-on-one 
counseling and education. You do have to sit down with Elaine, 
in a room, get weighed and do things, and respond to her 
questions. So it's a little tough at times. But what the staff 
does is help you set realistic goals for you. And they give you 
the tools to achieve these goals, and then there's a reward 
system if you make those--if you achieve those outcomes. One of 
the biggest is you get a cut on your health insurance premiums, 
a significant difference. In fact, from our highest health 
premium rate to our lowest, on a family plan, is about $3,000 a 
year difference, if you achieve those healthy lifestyle goals. 
So it's not insignificant.
    The goals initially, however, were to get as many people 
enrolled in the program as possible, whether or not they used 
our health insurance. We wanted to reward those who are willing 
to maintain or achieve a healthier lifestyle. Of course, you 
got a reduced health insurance premium if you did achieve your 
goals. And we also sought to reduce absenteeism, kind of a 
hidden cost of not having a healthy lifestyle. And we've got 
some statistics to prove that we've made improvements in that 
area. Initially the plan was only offered to employees but now 
it is extended to spouses.
    Some of the key components. It's a comprehensive program 
that has a number of health risk assessments. And our goal is 
to decrease risk factors that have been proven to increase the 
likelihood of chronic diseases, such as diabetes, heart 
disease, cancer, etcetera. So let me give you an idea of what 
some of those components are.
    Annually, you have to have a blood screening of 
cholesterol, blood sugar, also have your blood pressure taken, 
get weighed, have a body, this says body fat but we call it 
body composition, don't we Elaine? Makes it sound better. And 
now, waist to hip ratio measurements. So you have to go in and 
do this confidentially. You fill out a health risk appraisal, 
or a form that every participant has to fill out, and asks you 
a variety of questions. And then you sit down, the staff 
analyzes both the information from the laboratory work, their 
measurements and the self-assessment and they sit down and set 
goals with you.
    So, 4 years ago after I had sat down with Elaine, and I had 
the cholesterol challenge. I guess I had a choice to go on 
medication or to change some lifestyle issues, like eating 
better and exercising more. So I chose the latter. The health 
screenings allow employees and the wellness staff to identify 
and take corrective action on those health risks that could 
result in a major illness if they're left untreated. There are 
those who choose not to take corrective action and we provide 
awareness and education, and some materials for them to take 
home.
    To the incentives. There's really three parts to the 
incentive component. The core benefits, we provide a lot of 
things, screening devices, that are free of charge. Mammograms, 
nicotine patches if you want to stop smoking, the cholesterol 
screening, weight reduction programs and support and smoking 
cessation classes; don't cost you anything. Then, we've got a 
plan for our insurance, as a I said earlier. On the most 
expensive plan, for those folks who chose not to set a goal or 
not participate in the program, we pay 60 percent of the 
employee's premium, they pay the balance. That goes up to us 
paying 90 percent of the premium if an employee meets all of 
their health goals and criteria.
    Now, I'll give you a personal story. I think I was on Level 
B, partial compliance, and when I met the plan goals that we 
had established I saved $70 a paycheck, or about $1,800 a year. 
Now, imagine a dietary worker who may be making $8 or $10 an 
hour, $1,800 to $3,000 a year is a big deal. In fact, it's 
almost a car payment in some cases. So, that's the benefit you 
can get out of Healthy Choices.
    We also give something called Healthy Bucks, which is $100 
a year, per employee, to anybody who participates and completes 
a health risk assessment. And they can spend that on a variety 
of things that are health-related.
    Everybody wants to know about outcomes. And I want to 
stress that a wellness investment is not a short-term payoff; 
you've got to be in it for the long haul. The unhealthy habits 
that we see across the Nation today didn't happen overnight and 
they're rapidly reaching epidemic proportions, as we heard 
earlier. But through our Healthy Choices program we as an 
employer try to help our employees make better choices and live 
a healthier lifestyle. It will take years to pay off. But think 
about this one example--and I was close to this. One employee 
on a cholesterol-reducing drug would cost our health plan 
$1,300 a year and the employee $240 a year. By getting my 
cholesterol down, we both won. I don't pay out the $240 and my 
employer doesn't pay out the $1,300 a year. Pretty good 
investment, I'd say. That's a short run gain.
    For employees who already have healthy lifestyles, our 
wellness program assists with maintaining this lifestyle by the 
incentives I've talked about. And currently, 98 percent of our 
employees participate in our Healthy Choices program. Ninety-
eight percent.
    So, you want to talk about--we're going out in the 
community. This is something that we've begun to market as a 
product. Elaine goes out and spends a lot of time calling on 
businesses. But let's talk about some of our success stories 
that we can share with every business.
    In 1996, before the program started, 21 percent of our 
wellness participants at OHC used tobacco products. Currently, 
7 percent are using tobacco products. Employees who had body 
mass indexes of over 28 percent, which is close to the obesity 
limit, two-thirds of our people were at or exceeded this limit 
in 1996, compared to 37 percent today, a halving of that 
number. The health status of our employees began to show 
positive results in the first 3 years and it continues today. 
And I talked about absenteeism earlier; we've had a 24 percent 
reduction in absenteeism rates with participating Healthy 
Choices employees versus those who do not.
    So we're confident that healthier lifestyles are making a 
difference in our organization but we know our work is not 
done. We know that to remain competitive as an employer the 
health of our employees has to be part of our strategic plan. 
Instead of being a victim as a result of skyrocketing health 
care costs, organizations need to be a catalyst for creating 
healthy, innovative and productive employees.

                           PREPARED STATEMENT

    We have brought this out in the community. The city of 
Ottumwa and L-John Incorporated, both located in Ottumwa, have 
implemented our Healthy Choices program in their workplace. 
Musco Sports Lighting, with corporate headquarters in 
Oskaloosa, also came onboard with Healthy Choices, and we 
provide services to their locations in Iowa, along with 
regional offices across the United States. And Elaine gets to 
get on their private plane and fly around and do these things, 
so that's got to be fun.
    So, to close, we have about 1,800 area employees and their 
spouses participating in this program and we're very excited 
about it.
    [The statement follows:]

                    Prepared Statement of Lynn Olson

    Thank you for the opportunity to appear before you today to share 
with you the success of our wellness program at Ottumwa Regional Health 
Center. As President and CEO of a regional health center in 
southeastern Iowa, I am very much aware of the skyrocketing cost of 
health care costs and the impact on Iowa corporations.
    Over the past eight years, Ottumwa Regional Health Center (ORHC) 
has been instrumental in developing a worksite wellness program, known 
as Healthy Choice$. Currently, our participation rates in this program 
are at 98 percent. The success of this program did not happen in six 
months, a year or even two years; however, I can stand here today and 
tell you that we are beginning to enjoy the fruits of our hard work.
    The Healthy Choice$ wellness program was developed in 1997 by a 
group of employees participating in a benefit task force at Ottumwa 
Regional Health Center in Ottumwa, IA. The task force's purpose was to 
focus on what could be done to reverse the unfavorable upward trend in 
health claims resulting in significant premium increases. Because of 
the high cost of premiums, it was becoming more cost effective for the 
healthier employees to go elsewhere for health insurance coverage 
versus participating in the group plan. We were faced with the risk of 
offering a plan that was unaffordable, potentially driving employees to 
go elsewhere, or dropping the coverage and no longer being insured. It 
was determined that in addition to providing the coverage for illness 
and injuries, our organization needed to include an organized system to 
improve and maintain the individual health of our employees. An 
analysis of the claim history indicated that 48 percent of our claim 
dollars were spent on behavioral/lifestyle related cases (drug and 
alcohol, poor prenatal care, smoking, poor diet, lack of exercise, 
etc.) At this time, the initiation and implementation of a worksite 
wellness program occurred.

         STEPS IN BUILDING A WELLNESS PROGRAM IN THE WORKPLACE

    Healthy Choice$ is a program that focuses on lowering the health 
risks of the participants through education and one-on-one counseling. 
The plan measures a participant's health, helps them to establish 
realistic goals, provides the tools to achieve those goals and rewards 
them for achieving and maintaining those goals with significantly 
reduced premiums.
    The program was designed to achieve the following outcomes:
  --Increase the number of participants in the plan (spread the risk 
        over a greater number of people)
  --Reward those who were willing to maintain or achieve a healthier 
        lifestyle
  --Reduce the claims of that were related to lifestyle choices
  --Reduce the absenteeism rate by creating a ``healthier'' employee
    Initially, the plan was offered to employees. It is now offered to 
employees and their spouse.

                               INCENTIVES

    In order to meet the outcomes that were designed for this program, 
incentives surrounding wellness achievement were essential. Using 
national guidelines, the reduction in risk factors was the criterion 
that was implemented.
    The Healthy Choice$ program consists of three incentive components:
    Core Benefits.--Screening and wellness benefits made available to 
all employees. Mammograms, nicotine patches, cholesterol screening, 
weight reduction and smoking cessation classes.
    Health Allowance.--This is the incentive system that offers 
multiple levels of premium reductions offered to employees 
participating in the program.
  --Plan A: Employer pays 60 percent of premium.--Employee chooses not 
        to improve their health or to establish goals. Employees are 
        not rewarded or punished for their choice of non-participation.
  --Plan B: Employer pays 70 percent of premium.--Employee doesn't meet 
        the healthy criteria but establishes goals to be met within one 
        year.
  --Plan C: Employer pays 75 percent of premium.--Employees doesn't 
        meet the healthy criteria but has met a goal from the previous 
        year. Goals must again be established for the next year.
  --Plan D: Employer pays 90 percent of premium.--Employee meets/
        maintains the health criteria.
    Healthy Bucks.--Reimbursement of items/services that employees 
purchase to maintain or improve their health. At this time we allow 
$100.00 per employee and is given to any employee who participates and 
completes a health risk assessment.

                           PROGRAM COMPONENTS

    Healthy Choice$ is a comprehensive program that targets employee 
health risks. Decreasing risk factors that have been proven to increase 
the likelihood of chronic diseases such as diabetes, heart disease, 
cancer and diabetes is the focus of our program. The components of this 
program are:
  --Biometrics.--Annual screening of cholesterol, blood sugar, blood 
        pressure, weight, body fat levels and waist-hip ratios.
  --Data collection.--Health risk appraisals are completed by all 
        Healthy Choice participants in order to evaluate the 
        effectiveness of the program and to make changes as necessary.
  --Intervention/goal setting.--One on one with the employee and a 
        trained wellness professional. Review of the biometric 
        measurements and with the use of coaching, goals are set by the 
        employee. Every quarter, employees meet with the wellness staff 
        individually to assess their progress.
    The health screenings allow employees and the wellness staff to 
identify and take corrective action on health risks that could result 
in a major illness if left undetected and untreated. For those 
individuals who chose not to take corrective action, awareness and 
educational material is provided. One of the goals of Healthy Choice$ 
is to keep the employee coming back every year and eventually the 
decision is made by the individual to take action to improve his/her 
health. These are changes that do not occur overnight. It can take 
three to four years for an individual to begin making the behavior 
change.

                               BABY STEPS

    The unhealthy habits that we are seeing across the nation today did 
not happen in a day. We believe in taking small steps when helping 
employees set their annual health goals; and in some instances, we work 
towards preventing further erosion of the unhealthy lifestyle. Instead 
of a deficit approach, we build on the individual's strengths when 
helping them set their health goals. For those employees who already 
have healthy lifestyles, our wellness programs assists with maintaining 
this lifestyle by the incentives that are offered.

             CREATING A SUPPORTIVE AND HEALTHY ENVIRONMENT

    As Healthy Choice$ evolved over the last 8 years, it was evident 
that this wellness program included all of the elements of a 
comprehensive work site wellness program. However, in order to continue 
the vision of substance and growth of this program, creating a 
supportive environment was crucial to the overall success of Healthy 
Choice$. A positive environment can help employees to turn healthy 
choices into healthy habits. Senior management modeling and supporting 
healthy behavior is important in creating the well workplace. As the 
old cliche states, ``if you talk the talk, you have to walk the walk.'' 
Employee wellness teams provide the empowerment and peer role modeling 
in making lifestyle changes. Building a healthy culture is a big job 
and one that we currently are striving towards.

                  THE SUCCESS STORY OF HEALTHY CHOICE$

    In 1998, Ottumwa Regional Health Center marketed Healthy Choice$ to 
other employers in the community. The City of Ottumwa and Al-Jon, Inc. 
both located in Ottumwa, Iowa implemented the wellness program in their 
workplace. Masco Sports Lighting, with corporate headquarters in 
Oskaloosa, Iowa came on board with ORHC and we now provide services to 
their locations in Iowa along with their regional offices across the 
United States. Currently, we have over 1,800 individuals participating 
in Healthy Choice$.

          MAKING THE CONNECTION TO EMPLOYEE HEALTH IMPROVEMENT

    In 1996, 21 percent of the wellness participants at ORHC used 
tobacco products and currently 7 percent are using tobacco. Employees 
who had BMI's over 28 percent in 1996 were at 66 percent compared to 
current BMI rates at 37 percent. The health status of the employees 
started to show positive health behavior change within three years. 
ORHC employees who participated in Healthy Choice$ last year had a 24 
percent reduction in absenteeism rates when compared with non-
participating employees.
    We are confident that we are making progress in developing 
healthier lifestyles in our organization; however, we know that our 
work is not done. We know that if we are to remain competitive, the 
health of our employees has to be part of our strategic plan. Instead 
of being a victim as a result of the skyrocketing health care costs, 
organizations need to be the catalyst for creating healthy, innovative 

and productive employees.
STATEMENT OF RHONDA E. RUBY, REGISTERED NURSE, WEBSTER 
            COUNTY DEPARTMENT OF PUBLIC HEALTH
    Senator Harkin. Sounds great. Well, thank you very much, 
Len. That's great.
    Now we'll turn to Ms. Rhonda Ruby, Registered Nurse, 
Webster County Department of Public Health. Ms. Ruby started a 
joint seniors-HeadStart--interesting--mall walking program. 
Webster County created a mall walking program that has expanded 
into a community-wide effort to encourage healthier lifestyles 
among all ages and sectors of the county.
    Well, that sounds very interesting.
    Ms. Ruby. Okay. All right.
    Senator Harkin. Ms. Ruby.
    Ms. Ruby. Thank you. Can you hear me okay?
    Senator Harkin. Sure.
    Ms. Ruby. All right. Thank you for having us here today. 
This is so exciting, for us to be a part of----
    Senator Harkin. Pull that in a little bit closer maybe.
    Ms. Ruby. Closer?
    Senator Harkin. To you.
    Ms. Ruby. Okay. This is so exciting for us to be a part of 
this and I'm going to change the direction a little bit. 
Instead of a testimony I'd like to just have a brief 
conversation with you about what we've been doing in Webster 
County. It's really exciting for us to present this program 
because we've had so much success with it. We have several 
wellness programs, initiatives, policies in effect in Webster 
County that I would love to tell you about and I would love for 
you to come visit us so we can show you. But the big one we 
want to focus on is our Mall Walkers Program. And I just want 
to pre-empt that by saying we started this because in April 
2002 we did a community needs health assessment where our 
residents identified cardiovascular disease as their number one 
concern. We took that information and from that we instituted 
several wellness prevention paradigms. The big one that you 
guys are concerned with is our Mall Walkers and HeadStart 
Program. The reason this is so effective and so important is it 
truly is a comprehensive, family-centered wellness prevention 
paradigm. And this program is available to anybody in the 
community. It is available to all ages, all races, incomes, 
ethnicity and health disparities. We in fact have children in 
the program that are disabled and we have people in our Mall 
Walkers Program that are impaired.
    The format for the program is very simple. We have a Mall 
Walkers Club that people can walk at the mall at their 
convenience. Each month they turn in the minutes that are 
logged and the fruits and vegetables that are consumed. We 
monitor that information at the end of each month and each week 
we have a nurse at the mall that checks their blood pressure 
and continues to assess their cardiovascular status.
    How we tied in the HeadStart piece was, each month we'd 
bring a different class from our HeadStart population to walk 
with our mall walkers at the mall. So we have children from the 
age of 3 walking with mall walkers anywhere from age 18 to 80. 
And with our local HeadStart program we don't just bring the 
children, we bring the children, the day care staff, parents, 
foster grandparents; and each month we do a short educational 
piece with our mall walkers. It's been hugely successful in 
Webster County.
    We started it in 2000 and each year that program has grown. 
When we first started back in September 2000, I think we had 
something like 86 participants, which is great, that's 
progress. As of last year between our local HeadStart 
populations and our enrolled mall walkers we have 270 people in 
our program. We have been able to make huge, huge changes with 
this program. It was possible because of the community support 
that we have for it. In our program, we have the mayor enrolled 
as a mall walker; we have our local board of supervisors 
enrolled; we have legislatures enrolled; we have the entire 
community involved and embracing this program.

                           PREPARED STATEMENT

    The impact that we have been able to make has been 
tremendous. We have two of our local board of supervisors that 
we persuaded to join our Mall Walkers Club. One did not know he 
was diabetic and we did a screening and found him to be a 
diabetic and he has subsequently been treated for that. We had 
another board of supervisors member who was hypertensive and 
did not know that he was and has subsequently been treated for 
that. And just last week we performed a Wellness County Day 
where another board of supervisor was diagnosed as diabetic as 
well. So the impact for the community has been tremendous. 
We've been able to involve all facets of our community and it's 
been open to all the citizens, all ages, and we've had a 
tremendous amount of community support from it. It's been a 
huge success in Webster County.
    Senator Harkin. That's wonderful, too. You've got both, 
you've got the elderly and the young together.
    Ms. Ruby. Yep, uh-huh.
    Senator Harkin. Pretty interesting, I like that a lot. Well 
thank you very much.
    Ms. Ruby. You bet.
    Senator Harkin. You know, we'll have more to talk about 
this later on.
    Ms. Ruby. Uh-huh, Uh-huh.
    [The statement follows:]

                  Prepared Statement of Rhonda E. Ruby

    Senator Harkins, Ranking Member and other Members of the Committee: 
On behalf of all residents of Webster County, we would like to thank to 
everyone for allowing us the opportunity to share our stories of 
success and highlight our accomplishments. It is a privilege to offer 
our views and suggestions on how we feel it would be most beneficial to 
improve community wellness and institute disease prevention. We were 
pleased to read Senator Harkins comments from his Press Release, 
stating top legislative priority will be given to a Wellness and 
Disease Prevention Initiative. We too, have given this matter top 
priority. We believe by appearing before this committee, we have a 
wonderful opportunity to showcase the comprehensive efforts put forth 
by our agency to reduce cardiovascular and stroke risks by targeting 
Iowa's overweight and obesity conditions in Webster County.
    Our agency, along with the Iowa Department of Public Health has 
been waging a battle against the obesity epidemic for many years. As 
you know, staggering obesity rates have also coincided with increases 
in cardiovascular and stroke related illnesses. This was of great 
concern to us, and we decided it was essential to improve our own 
community's health and well-being. We did this by instituting several 
wellness prevention paradigms. Our goal was to empower citizens with 
information and resources that allowed them to take charge of their 
health and make informed decisions. With this in mind, we challenged 
the community to concentrate on nutrition and physical activity and 
make it a part of their daily lives. Our programs specifically focused 
on at risk individuals and stressed education, awareness, screening and 
prevention of obesity through worksites, busineses, and the community 
at large. The results have been phenomenal.
    We have witnessed first hand the remarkable success produced from a 
consistent focus on disease prevention and wellness promotion. The 
wellness paradigms implemented in this region are evidence of how 
powerful prevention and consistency can be when dealing with the 
complex issue of obesity. The programs were able to show direct, 
statistical outcomes that resulted in increased amounts of physical 
activity and proper nutrition among citizens, as well as decreased 
obesity rates and associated illness. Through the use of education, 
awareness, and screenings, our wellness investments in the community 
have paid off in the form of healthier, more knowledgeable citizens.

   WHY THE MALL WALKERS PROGRAM WAS INITIATED AND HOW IT HAS EVOLVED

    To understand the success of the wellness projects implemented in 
the last four years, it is important to recognize why these programs 
were vitally necessary for the community. One of the foremost reasons 
our agency focused on cardiovascular disease risk reductions, was due 
to Webster County residents identifying Cardiovascular Disease as their 
number one health concern in a Community Needs Assessment, completed in 
April of 2000. Since then the Webster County Health Department, along 
with the Iowa Department of Public Health have been committed to 
reducing the prevalence of Cardiovascular Disease, Stroke, Obesity, and 
Overweight in Webster County. Which benefits all of Iowa.
    Once the results of the needs assessment were compiled, we 
introduced several wellness initiatives to encourage people to engage 
physical activity and increase their consumption of fruits and 
vegetables daily. These simple behaviors changes could potentially 
impact hundreds of people and reduce cardiovascular risks dramatically. 
All of the health programs implemented over the past few years have 
been well received and highly successful in the community, especially 
our innovative program called the Mall Walker's Club, which named their 
group the Crossroads Pacers.
    This program was initiated in September of 2000, and the format was 
simple; participants could engage in exercise at their convenience in 
the comfort of a clean, safe mall environment, and use self-direction 
to consume the recommended amount of fruits and vegetables daily. Each 
month participants were required to log the amount of activity and 
proper nutrition engaged in and was asked to turn logs into the 
Wellness Coordinator for monitoring. This program has been hugely 
successful with citizens of all ages and the program has grown in leaps 
in bounds over the past four years. The kickoff for this program was a 
major community event that engaged many influential members. We had a 
legislator, city council members, the entire Webster County Board of 
Supervisors, and the mayor in attendance to show community support. We 
initially signed up 86 participants and have expanded the program since 
then to include 150 dedicated participants. We've had many success 
stories with the Mall Walker's Club, including a local board member who 
was unaware he was Hypertensive and Diabetic. Following a physician 
referral from our screening process, they were able to successfully 
treat his chronic diseases and he made the necessary lifestyle changes 
to stay healthy.
    The success of this program has been rooted in its fundamental but 
inventive design. To increase participation we launched an aggressive 
marketing campaign through the community by offering registration at 
different worksites and businesses to encourage sign up. Each week we 
placed a nurse at the mall to promote registration and also to monitor 
the cardiovascular status of enrolled participants. To keep interest in 
the program at a high level, we placed a new display table at the mall 
each month for participants to view a wide array of information. We 
exhibited fun and creative displays that promoted health and wellness. 
The topics ranged from signs and symptoms of a Heart Attack or Stroke, 
to extensive obesity related information, Diabetes awareness, and many 
other health related issues. This display table was well received from 
the community and we experienced positive responses from participants 
and other community members.
    These few simple strategies proved to be effective tools persuading 
citizens to join our club, and this program planted the seed for other 
wellness initiatives to follow that focused on a family centered 
approach to health. This lead to developing a family centered wellness 
prevention program for our local Head Start. This project focused on 
age directed preventative health by allowing the children enrolled in 
Head Start to walk each month at the mall with parents, foster 
grandparents, and other members of the Mall Walker's Club. This was a 
powerful alliance between young people and elderly citizens, and made 
age directed preventative health vital.

           WEBSTER COUNTY'S COMMUNITY'S APPROACH TO WELLNESS

    As mentioned, our wellness initiatives were in response to the 
community's concern about Cardiovascular Disease. Since that time we 
have made it paramount to involve the community in our wellness 
efforts. We have done this through a variety of grants, but also 
through a tremendous amount of community collaboration. This has been 
the cornerstone for success in constructing a community approach to 
wellness. We have built solid and strong relationships with entities 
that previously shied away from new and groundbreaking projects. We 
have been able to break the barrier between private and public industry 
to create a coexisting team that has served the entire community. Our 
highly successful Mall Walkers Club was a bi-product of the community's 
approach and belief in wellness. Through community participation and 
``buy in's'' from our citizens we have been able to effect many 
positive wellness changes. At the end of this report we have included 
several feature articles that have appeared in our local newspaper as 
evidence of the support and community embrace our programs have 
received. The following collaborations were a result of Webster 
County's community approach to wellness:
  --Creating the Webster County Cardiovascular Disease Coalition with 
        numerous community partners, including the public school 
        system, Community and Family Resources, and Trinity Regional 
        Medical Center. This group works cohesively to institutionalize 
        prevention programs and polices throughout Webster County and 
        meets each quarter.
  --Collaborating with local restaurants in Webster County to assess 
        healthy food choices available at each place. Following 
        collaboration we created the Webster County Dining Guide to 
        educate citizens on healthy food choices available at each 
        restaurant. A community policy was put in place requiring all 
        participating businesses to distribute the guide.
  --Collaborating with city and county officials to assess trail system 
        availability for outdoor physical activity in our region. 
        Following collaboration we created the Webster County Trail 
        Guide to inform citizens on sites available for outdoor 
        exercise. A community policy was implemented requiring 
        participating entities to maintain the trail system for usage 
        and to continue distribution of trail guides.
  --Screening 125 of the Mall Walker's Study Group for cardiovascular 
        risks including height, weight, blood pressure, BMI, waist 
        circumference, flexibility, glucose, and lipid profiles.
  --Collaborating with the Crossroads Mall and the local Head Start 
        program to conduct monthly walking sessions with children, 
        parents, foster grandparents, and other members of the Mall 
        Walker's Club.
  --Collaborating with the Crossroads Mall to conduct weekly blood 
        pressure assessments for Mall Walkers.
  --Collaborating with Crossroads Mall to assess water supply 
        availability and making water available to those walking in at 
        least three locations along the route.
  --Collaborating with seven licensed says in Webster County to arrange 
        visits to each to educate staff, parents, and children 
        regarding the benefits of healthy eating and exercise. 
        Educational information was kept on file each month at the 
        daycares for all parents and staff. A community policy was put 
        in place requiring all participating business to continue to 
        offer healthy food choices and exercise. A second environmental 
        policy was also implemented at the daycares requiring all keep 
        their sidewalks and playgrounds suitably maintained for usage.
  --Collaborating with seven licensed daycares in Webster County for 
        their children to plant and harvest miniature gardens at each 
        business.
  --Collaborating with the Crossroads Mall to exhibit a creative 
        display table each month promoting health and wellness.
  --Collaborating with five employers in Webster County to perform 
        1,600 wellness screening for employees that included height, 
        weight, BMI, blood pressure, glucose, and total lipid profiles.

                        IMPACT ON THE COMMUNITY

    One of the greatest achievements of our projects has been 
witnessing first hand the dramatic impact we've had on community health 
and well being. We have been able to reach large segments of the 
population that were at risk for cardiovascular related problems. We 
have received many accommodations from the community for our dedication 
to health and fitness. Although we understand all of efforts may not be 
measurable for many years, we have been able to directly measure the 
following outcomes:
  --500 children from seven licensed daycares were educated monthly 
        regarding the benefits of healthy eating and exercise. 
        Following education, 100 percent of participating children were 
        able to identify proper amounts of fruits and vegetables and 
        physical activity needed daily to be healthy.
  --500 parents of children from the seven licensed daycares were 
        educated on the benefits of healthy lifestyles, and symptoms of 
        heart attack and stroke. Following education, 95 percent of 
        parents and staff were able to identify heart attack and stroke 
        warning signs.
  --500 children from the seven licensed daycares in Webster County 
        planted and harvested miniature gardens at their daycare. 
        Following planting, 100 percent of participating daycares 
        reported success with garden harvesting.
  --200 employees and health care providers from all licensed daycares 
        received a power point presentation training session on the 
        hazards of adult and childhood obesity's education. Following 
        education, 100 percent of trainees were able to verbalize 
        hazards associated with obesity.
  --2,200 copies of the Webster County Dining Guide were distributed to 
        area restaurants. Following distribution, 13 percent of 
        citizens reported changing eating habits after viewing the 
        guide.
  --700 copies of the Webster County Trail Guides were distributed to 
        Webster County businesses. Following distribution, 10 percent 
        of citizens reported increased trail system usage.
  --125 Mall Walkers were screened for cardiovascular risk factors in 
        2001 and again in 2002. Following post assessments 10 percent 
        of enrollees had improved cardiovascular status in at least one 
        area.
  --125 Mall Walkers were screened monthly to assess amount of fruits 
        and vegetables consumed and amount of activity engaged in. 
        Following monthly monitoring, 25 percent reported increased 
        amounts of exercise.
    One of the success stories we use to promote community-impacted 
health was one that involved a preschool child we taught in the 
daycares about fruits and vegetables and exercise. This preschoolers' 
mother recently had a baby, and when we visited the mom for a routine 
post-partum visit, we asked the mother about the baby's eating habits. 
We were delighted to hear the preschool child tell the mom that the 
``the baby needs five fruits an vegetables everyday.'' This is a 
powerful of a statement about the impact our efforts can make, even 
with young children.

STATEMENT OF THOMAS OLDHAM, PRESIDENT, JUST ELIMINATE 
            LIES (JEL), IOWA YOUTH TOBACCO PREVENTION 
            ORGANIZATION

    Senator Harkin. Now we'll go to our last witness, Mr. 
Thomas Oldham. He is the president of something called Just 
Eliminate Lies. It's an Iowa youth tobacco prevention 
organization. Tom attends Lincoln High School here in Des 
Moines. Just Eliminate Lies raises awareness about the dangers 
of tobacco and organizes teens to fight the tobacco industry's 
efforts to manipulate them into using their products. Tom, tell 
us more.
    Mr. Oldham. Thank you. Well first of all, I just wanted to 
thank everyone for the chance to be here and talk about what 
JEL is and what can be done in the future for prevention across 
the United States of America. But I speak here on behalf of 
over 7,000 Iowa teenagers who are involved with the JEL 
program. It's a massive program with massive support all 
throughout the State and I think it's really an amazing thing 
to have so many teenagers come together, at such a young age, 
about one topic. And I really do not think that there's ever 
been quite the support for a program like this, at least in the 
youth base, as there is for ours.
    I also think I come here to speak on behalf of the over 
400,000 innocent Americans who die every year at the hands of 
Big Tobacco. And when I was 13 years old I was brought into the 
world of tobacco prevention. I was brought in at first on a 
different level though, of what I am now. At 13 years old I was 
a smoker. Me and some friends had started in 8th grade. I don't 
know why, I guess I probably will never know, but we just 
started smoking. And at the time, these youth-led movements, 
when I started to get in--when I was smoking were starting to 
get visible. And if it wasn't for the Iowa Tobacco Prevention 
Organization, I don't know where I'd be right now. I feel I was 
saved by becoming involved.
    Now, these youth organizations at the time were using 
tactics nobody had foreseen. They were using harsher 
advertisements and new kinds of direct action and so on. People 
had been taking notice and a clear line was drawn between the 
comprehensive tobacco control programs and the less than 
desirable have-to programs that are rampant in the tobacco 
industry. Change was taking place and lives were being saved 
and the State programs were getting recognition, not only for 
their actions but the results. But as the years passed so were 
the comprehensive State tobacco prevention programs. As more 
and more of them were forming and sounding the alarms their 
legs were cut out from underneath them. Successful programs 
were losing money rapidly with politicians dipping their hands 
into the tobacco settlement money like it was a rainy day fund. 
Not only this but the tobacco industry was increasing spending 
in the State with successful programs and by cutting out the 
funding for those successful programs you enhance the progress 
of the tobacco industry while curbing the efforts of the anti-
tobacco movement.
    The issue is clear and the right thing to do is extremely 
easy to do but across the United States not many people are 
doing anything about it. As Senator Harkin's Wellness and 
Disease Prevention Initiative is a step in the right direction, 
currently health care costs related to tobacco across the 
United States topples $75 billion annually. Because of this and 
other smoking-caused government spending, the average household 
tax burden because of tobacco problems is $525 a year. As a 
result, hardworking Americans, the majority of these non-
smokers, are paying big bucks for a preventable disease.
    Currently tobacco use is the number one killer. It kills 
more Americans annually than alcohol, AIDS, car crashes, drugs, 
fires, murders and suicide combined. It's inexcusable and 
outrageous especially when the situation is so easy to take 
care of.
    Now, I believe the first way to fix the problem is raising 
the funding of the State's tobacco control programs to CDC-
recommended levels. That way not only will the States have 
comprehensive prevention programs but comprehensive cessation 
programs too. All too often States are given money to have a 
prevention program and then when people see these funds and 
programs and want to quit, or want to know how they can quit, 
there's never any resources there for them to do so.
    The State's youth fund movements have a positive impact on 
young people all over. If we can raise the visibility of our 
programs and in turn raise awareness our programs will turn our 
colossal results. But when our lawmakers agree to cut funding 
for programs and either use our money for non-tobacco related 
issues, they curb our efforts to save lives and they become 
just as responsible for the death of thousands every year, as 
the tobacco industry. In order to combat the problem our 
lawmakers must act.
    Now, for a moment I'd like to talk about just the reason 
why that our movements are always under threat. There's always 
something that's trying to bring us down, or whether people 
realize that or not. For an example, I'd just like to mention 
something that's happening right now. Every year, or every 2 
years in Iowa we did the Iowa Youth Tobacco Survey, and that's 
how our program runs. If we don't have any new information how 
can we provide the results that we have? Well, this year that 
survey is in jeopardy of being cut. So if we do not do the 
survey this year, next year we're going to be going off of 
information from 2 years past. And that information is good. In 
2 years of being a program we lowered high school usage in the 
State of Iowa by 11 percent, and middle school usage by 23 
percent.
    Now, another way of prevention is raising the tobacco 
excise tax. In Iowa one of our initiatives this year was just 
that. The governor decided to raise the tax in time of crisis 
but this is exactly what prevention shouldn't be. We should be 
raising the tax in less needy times. That way we can prevent 
those times from ever occurring in the first place. Across the 
country, if we had significant, regular increases in the 
tobacco excise tax we would save thousands of lives, reduce 
health care spending by millions of dollars, and bring in 
millions of dollars for the States. It's a win-win-win 
situation.
    Passing smoke-free ordinances for workplaces across the 
country is another way we can reduce tobacco use. In passing 
these ordinances you can protect everyone from secondhand 
smoke, which kills over 53,000 innocent Americans every year. 
Along with cessation programs, smoke-free workplaces prove to 
be a winning strategy. FDA regulation, funding for the CDC's 
Office on Smoking and Health and a national cessation quit line 
are all of the ways we can work to prevent tobacco use and save 
lives.
    Now, the one way I think we can get all this done is very 
simple. And that is removing the tobacco industry's hands out 
of our lawmakers' pockets. Annually the tobacco industry spends 
over $5 million in campaign contributions around the country. 
Our lawmakers are influenced by these contributions and in turn 
are preventing comprehensive tobacco control programs from 
accomplishing the tasks that the settlement money was supposed 
to be used for.

                           PREPARED STATEMENT

    If we raise the State's prevention programs to CDC-
recommended funding, have regular significant increases in the 
tobacco excise tax, provide strong cessation services in every 
State and remove the tobacco industry's place in government, we 
will save thousands of lives and bring in millions upon 
millions of dollars to this country. If we don't, I believe 
that in 50 years we'll look back and be shocked as the world's 
greatest democracy that one industry had free reign on its 
citizens. I believe now is the time to do something about it 
while we still can and before the problem gets too out of hand 
and there's no looking back. Thank you.
    [The statement follows:]

                  Prepared Statement of Thomas Oldham

    Thank you for the chance to appear here and speak on behalf of the 
thousands of Iowa teenagers who are working to prevent tobacco use 
among their peers. I believe I come here not only on behalf of Iowa, 
but also for the 400,000 innocent Americans who die every year at the 
hands of Big Tobacco.
    At 13 years old, I was brought into the world of tobacco 
prevention, and at the time, the youth led movements were getting more 
and more powerful. They were using tactics nobody had foreseen; harsher 
advertisements, new kinds of direct action, and so on. People had been 
taking notice, and a clear line was drawn between the comprehensive 
tobacco prevention programs and the less than desirable ``have-to'' 
programs that the tobacco companies were running. Change was taking 
place, lives were being saved, and these state programs were getting 
recognition not only for their actions, but their results.
    But as the years passed, so we're these comprehensive state 
programs. As more and more were forming and sounding the alarms, their 
legs were cut out from underneath them. Successful programs were losing 
money rapidly, with politicians dipping their hands into the tobacco 
settlement money like it was a rainy day fund. Not only this, but the 
tobacco industry was increasing spending in states with successful 
programs, and by cutting out those programs you advance the progress of 
the tobacco industry while curbing the efforts of the prevention 
programs. The issue is clear, and the right thing to do is very easy, 
but across the United States, nothing is being done, and nobody is 
taking action.
    Senator Harkin's ``Wellness and Disease Prevention'' initiative is 
a step in the right direction. Currently, the Healthcare costs related 
to tobacco in this country topple $75 billion annually. Because of 
this, and other smoking caused government spending, the average 
household tax burden is $525. In result, hardworking Americans, the 
majority of these non-smokers, are paying big bucks for preventable 
disease. Currently, tobacco use is the number one cause of preventable 
death in this nation, killing more Americans annually than Alcohol, 
Aids, Car Crashes, Drugs, Fires, Murder, and Suicide combined. This is 
inexcusable and outrageous, especially when the situation is so easy to 
take care of.
    The first way is raising the funding of the states' tobacco control 
programs to CDC recommended levels. That way, not only will the states 
have comprehensive prevention programs, but comprehensive cessation 
programs. Too often states develop prevention programs that work, but 
have no aid for those who want to quit. The states' youth led movements 
have a positive impact on young people all over. If we can raise the 
visibility of our programs and in turn raise awareness, our programs 
will turn out colossal results. But when our lawmakers agree to cut 
funding for programs, and when they use our money for non-tobacco 
related issues, they curb our efforts to save lives, and become just as 
responsible for the death of thousands every year. In order to combat 
the problem, our lawmakers must act.
    Another way is raising the tobacco excise tax. In Iowa, one of our 
initiatives this year was just that. The weather was fair this year and 
our Governor decided to raise the tax in times of crisis, but this is 
exactly what prevention shouldn't be. We should be raising the tax in 
less needy times, that way we can prevent those times from ever 
occurring. Across the country, if we had significant regular increases 
in the tobacco excise tax we would save thousands of lives, reduce 
health care spending by millions of dollars, and bring in millions of 
dollars for the states. It's a win-win-win situation.
    Passing smoke-free ordinances for workplaces across the country is 
another way we can reduce tobacco use. In passing these ordinances, you 
can protect everyone from secondhand smoke, which kills over 53,000 Non 
smoking Americans every year. Along with cessation programs, smoke free 
work places proves to be a winning strategy. FDA regulation, funding 
the CDC's Office on Smoking and Health, and a national cessation 
quitline are all other ways we can work to prevent tobacco use and save 
lives.
    The one way we can get all of this done is simple. Remove the 
tobacco industry's hands out of our lawmaker's pockets. Annually, the 
tobacco industry spends over $5 million in campaign contributions 
around the country. Our lawmakers are influenced by these 
contributions, and in turn are preventing comprehensive tobacco control 
programs from accomplishing the task the settlement money was supposed 
to be used for.
    If we raise the states' prevention programs to CDC recommended 
funding, have regular significant increases in the tobacco excise tax, 
provide strong cessation services in every state, and remove the 
tobacco industry's place in government we will save thousands of lives 
and bring it millions upon millions of dollars to the country. If we 
don't, we'll look back 50 years from now and be shocked that the 
world's greatest democracy let one industry have free reign on it's 
citizens. I believe now is the time to do something about it while we 
still can, before the problem gets too out of hand and there's no 
looking back.

    Senator Harkin. Tom, thank you very much for that great 
testimony and thank you for being here today. Someone handed me 
a note, I didn't see him when I came in, but I want to 
recognize someone else who I've known for many years and who 
has always been a great leader in terms of physical fitness and 
making sure, as someone said there, it's not just the mind but 
also the body, because he's worked on both of those in so many 
ways. Bill Pulliam is here. Bill, where are you? Someone said 
you were back there. Bill Pulliam, right back there.
    One of our great basketball stars here in the history of 
the State of Iowa. Thank you for being here, Bill.
    Well listen, I again want to thank all of you for being 
here and for your testimonies. I'd like to just ask a few 
questions. And I guess we'll open it up for maybe a little bit 
of a general discussion. I don't know exactly how much time 
I've got here but we'll move ahead. Oh, yes. After our hearing 
concludes, we're going to do a little walk around the track. 
And, is that why I have this heart monitor on? Okay. All right. 
Okay. So we're going to take a little walk around the track 
just as a, you know, just as a little bit of exercise. I 
brought my walking shoes with me, nothing special.
    Let me start first with Doctor Baranowski. Again, you 
testified, others testified about the costs of fighting disease 
in this country, the health care costs associated with it. It's 
hard, to know exactly what steps we can take at the Federal 
level that will result in actual significant cost savings. A 
lot's being done on the local level; a lot of people here are 
doing things on their own. We have organizations like P.E. for 
Life and others, but is there anything else that you think that 
we can be doing on the Federal level? I'm looking for advice 
and suggestions.
    Dr. Baranowski. Yes sir. Thank you for the question. 
Without appearing to demean the very important efforts reported 
this morning, the existing programs that have been published to 
help people change their behaviors, even those designed by, 
implemented and evaluated by our best minds, are having, at 
best, modest effects and at worst no effect. This includes both 
programs designed to change the environment in which these 
behaviors occur and those designed to change the behaviors. 
This suggests we need more research. These are behavioral 
problems and they need behavioral solutions. The NIH has made 
an enormous investment in biological research over the least 50 
years. After 40 years of investment, it's only in the last 10 
years or so where the treatments have been targeted at 
molecular systems, for example, cell receptors, and have 
substantial impact on the disease without substantial side 
effects. The same investment must now be made in the behavioral 
sciences. We need to better understand why people eat the food 
that they do and are or are not physically active. Research 
must then be conducted to convert this knowledge into effective 
programs and evaluate them. This will require substantially 
more funding for behavioral science and related research. In 
fact, I think the solution or part of the solution is more 
research.
    Senator Harkin. Let me ask you this. I have discovered in 
the last couple of years that the number one reason why young 
women drop out of college, for varying periods of time, is 
because of eating disorders. I became interested in that and I 
started looking at some of the data surrounding eating 
disorders in this country and I become quite alarmed. It's 
growing rapidly. I've talked to a number of mental health 
people about this, others expert in the field, and on the one 
hand we have obesity, on the other hand we have anorexia, 
bulimia, binge eating, various and sundry other eating 
disorders. And most of it's centered around anorexia and 
bulimia. It just seems to be we're getting a couple of messages 
that are hitting our young people. One, you're getting all the 
ads for this food and that food and, I don't want to pick on 
McDonald's, but just all those unhealthy choices that you have 
for soda and everything else. On the other hand, every magazine 
you pick up, for young women, especially, has pictures of, 
extremely thin women. That's why I'm a little concerned about 
stressing this idea of obesity because I don't want young 
people to begin thinking that they've got to look like these 
sticks that pass for models in our society. But more and more I 
see young women thinking that that's how they've got to look if 
they want to be accepted. I just wonder if you have any 
thoughts on that.
    Dr. Baranowski. Yes sir, that's a very important question. 
I have to admit I'm not a specialist in eating disorders and I 
defer to Dr. Cutrona. Perhaps she has some insight on eating 
disorders that's ordinarily considered a mental health problem. 
Alternatively, most of the work that we do is in the inner-city 
with ethnic minority individuals. In the middle schools and the 
high schools, 50 percent of the kids are overweight or obese.
    Senator Harkin. 50?
    Dr. Baranowski. Five-zero. 50 percent.
    Senator Harkin. In high schools?
    Dr. Baranowski. In middle schools and high schools. This is 
a shocking, shocking problem and the eating disorders that 
aren't as prevalent in the minority community, although clearly 
we need to address the concerns for eating disorders in the 
majority community, that there's a huge need for obesity 
prevention in all high school kids but particularly in the 
minority community. If we don't the declines that have been 
occurring heart disease mortality and cancer mortality are all 
going to reverse and those are all going to start increasing 
enormously. The medical care costs associated with that are 
going to go out the window while we leave this problem 
unaddressed. We've got to address the obesity problem or we're 
going to pay for it in the long run.
    Senator Harkin. Do you have any thoughts on what I just 
brought up, Dr. Cutrona? Eating disorders among young women who 
are anorexic, bulimia, who think they've got to look like these 
sticks.
    Dr. Cutrona. I think that this can be used to illustrate a 
very important point, which is that you can't just address 
problems like this on the individual level. We have a young 
woman who's starving herself to death and we try to come up 
with a good treatment. We have to prevent this. We have to 
think about advertising, we have to think about the messages 
that young women receive. I think this is an appropriate 
context for public health campaigns that address our standards 
for young women, our standards for what is attractive, for what 
is healthy, making health what is our ideal rather than the 
stick-thin image that you're talking about. So I guess what I'm 
saying is this, along with most other mental health issues, has 
to be addressed on many levels, in the schools, in the home. 
You can't wait until the young woman is already perhaps on 
death's door. Women actually die from anorexia. We have to 
address this at the community level and it is a problem, 
although not as prevalent as Dr. Baranowski said as overweight. 
So a multi-tiered approach, I think.
    Senator Harkin. Well, I guess, getting back to the school-
based programs, I guess if kids learn early on, in elementary 
school, again, a healthy lifestyle. Not that you have to look 
like a stick but you don't have to be obese but you can 
maintain a decent weight, body fat percentage and be very 
healthy. I guess you got to start early with these kids.
    Dr. Cutrona. Well, obviously as an educator I believe that 
pretty strongly, preventive, proactive in nature. The reactive 
health care system that we have isn't working. I mean, that's 
pretty simply said. I really don't think it's health care, I 
think it's sick care. And what we need to do is be proactive in 
our--I think this young man's a great example. Even though he 
started, there was an intervention program that was very--it 
was preventive in nature and it got to him early. That type of 
education, he became more educated. That's the key. I mean, for 
me, that's the key. Where do we have every child? In school. So 
we have to capture their imagination, their interests, and get 
them to invest in their own, their value, investing in their 
own health to see a reward or a gain in the future. So yes, I 
feel very strongly that more money's into the physical quality, 
physical education programs is a key component if we're going 
to attack this problem. Because we can't do it on the back 
side. It's not working. David Chenoweth says, a health 
economist, by year 2020 the health care system's going to 
collapse because of the rise in health care costs. Can we 
prevent that? What have we always said? You know, prevention, 
an ounce of prevention's worth a pound of cure. But where's all 
the funding going into? Into reactive programming. We have to 
channel that. That's why I believe what you're doing with the 
PEP bill is so critically important. What you're doing in 
allowing funding to go into school systems to be able to do 
futuristic type of physical education programs, funding where 
there's lack of funding, because everything's saying and being 
mandated by No Child Left Behind. Math, reading and science. 
Math, reading, and science. At the expense of the child's 
health. And we believe, at Brittany Center, we believe it 
should be around the Nation, that if you cut physical education 
you're cutting the heart out of the child's education. And I 
don't think that, you know, we talked about the problem, we 
talk about it continuously, over and over and over, but then we 
need to come up with some viable solutions. And I believe, as 
an educator, that's what education's about. I think it worked 
for Tom and now, look at him. I mean, my goodness sakes. I feel 
honored to be sitting next to him. What an example he is for 
saying that something, you know, they intervened at a young age 
with him, some type of preventive program that helped change 
his life, change his healthy habits for a lifetime. Now look at 
him and look what he's doing. I cannot imagine at the age of 
18, sitting up here and doing what he's doing, and that's the 
type of young person that we need to have and that comes 
through education. And that's where I believe the funding needs 
to occur.
    Senator Harkin. Well Tom, since you've been brought into 
this right now, just out of curiosity, you said you were about, 
how old were you when you started smoking?
    Mr. Oldham. I was 13 years old.
    Senator Harkin. Do you have any, do you remember why? Was 
it peer pressure? What was it? Why did you start? I mean, 
because I can tell you, I was about maybe, let me think, I was 
probably around, oh, I suppose 12 or 13 when I started smoking.
    Mr. Oldham. I'm not sure if it was peer pressure because me 
and my friends all kind of started doing it at the same time. 
So I think it was just outside influences.
    Senator Harkin. Outside?
    Mr. Oldham. Like tobacco industry advertisements and things 
like that. As sad as it is, and it is often for a lot of 
teenagers still, is people think it's cool to, you know, light 
up a cigarette. They think it looks cool in their mouth or 
whatever. And I think that had a lot to do with it. We were 
very impressionable and the tobacco industry knows that. So 
they do what they can because they know if they do not target 
youth they'll be out of business in 30 years.
    Senator Harkin. Let me ask you this. How easy is it--how 
old are you right now?
    Mr. Oldham. I'm 18 right now.
    Senator Harkin. Eighteen. How easy is it for teenagers to 
get tobacco? Is it easy or not?
    Mr. Oldham. Oh, it's unbelievably easy.
    Senator Harkin. What?
    Mr. Oldham. It's unbelievably easy.
    Senator Harkin. But people aren't supposed to sell 
cigarettes.
    Mr. Oldham. Yeah, they're not supposed to sell cigarettes 
but I mean, that doesn't stop any teenager from going to 
someone who is 18 and--I mean, I'm even a perfect example. I've 
had people come up to me, of all people, and ask me to buy them 
cigarettes. I'm this--now granted, it's not often public 
knowledge what I do but I mean, it's just like, a lot of people 
my age will do that for someone.
    Senator Harkin. Do you think raising the cigarette tax 
would have an impact?
    Mr. Oldham. Absolutely.
    Senator Harkin. Just more expensive, kids won't--just, the 
money they have.
    Mr. Oldham. Yeah. That is one of the things that people say 
raising the cigarette tax, well people are still going to 
smoke. And that's true. People will still smoke. But many 
adults will quit and even more teenagers will quit. Teenagers 
don't have that anticipal funds as oftentimes more adults do. I 
mean, I've heard from many, many people my age that, if we 
raised the tobacco tax, because I, you know, I talk to people 
about it all the time, and they say if we raise the tobacco tax 
I'm not buying anymore. And I'm like, well hey, then we're 
successful. So studies have shown that with every ten percent 
increase in the tobacco tax you reduce consumption by 3 to 5 
percent.
    Senator Harkin. You know, Tom, I've been on the tobacco 
companies for years about their advertising. First there was 
Joe Camel, all the Joe Camel ads, how to be cool, geared 
towards young people. Then you had the Marlboro chits; you 
know, you get Marlboro points and you get all these gifts and 
stuff like that, anything to get young people into smoking. I 
came across one of the new ones here. First I thought these 
were candy when someone first gave them to me. It's called 
Liquid Zoo. I'll pass them around, you can look at them. It's 
strawberry flavored, kind of a fancy little box. I thought, my 
gosh, they're back to candy cigarettes again. And then I found 
out these are cigarettes. Liquid Zoo Flavored Cigarettes are an 
exotic blend of strawberry flavored, tobacco product that is 
sweet, fresh tasting and has a sweet aroma. Now who do you 
think they're marketing that to? Not to adults. Not to older 
people. Young people. And guess what? Made in the United States 
of America. Manufactured exclusively for Cretech International 
U.S.A. And in really small print it says, No underage smoking 
allowed. Have you ever seen these?
    Mr. Oldham. No sir.
    Senator Harkin. Pass them around. Here's another thing I 
wanted to hold up, Tom, I think you'd be interested in. You've 
all seen Kraft Macaroni and Cheese, right? It's FDA regulated. 
The FDA regulates the content of what's in that box. And guess 
what? Kraft is owned by Philip Morris. Philip Morris also owns 
Marlboro Cigarettes. This is not regulated by the FDA. That's 
regulated by the FDA, macaroni and cheese, tobacco, not 
regulated by the FDA. Anybody make any sense of that? That's 
why we keep pushing to have the FDA regulate cigarettes as a 
drug delivery mechanism. We know that tobacco is a drug, 
nicotine is a drug, it is a highly addictive drug. It contains 
things like hydrogen cyanide, ammonia, arsenic, butane, carbon 
monoxide, formaldehyde and 40 other chemicals known to cause 
cancer, yet the FDA does not regulate it. So again, this shows 
you the contrast in our FDA regulations and the problems that 
we have in trying to get the FDA to regulate them. So we're 
going to continue to press for FDA regulations so that they 
have to regulate it, plus stop this kind of nonsense here of 
how they're putting out these packages of strawberry flavored 
cigarettes.
    Some of you who are my age or maybe a little younger than I 
remember the little candy cigarettes that we all were given to 
practice on when we were younger and stuff. I thought they were 
coming back. That's even worse.
    I want to get back to you, Dr. Baranowski. You mentioned 
research.
    Dr. Baranowski. Yes sir.
    Senator Harkin. Give me some idea, can you give me two or 
three, four, whatever, what are the top areas that you believe 
that should be the highest priority research areas for 
childhood obesity.
    Dr. Baranowski. Thank you again for the question. First we 
need a clear picture of what are the major contributors to 
obesity. Some luminaries believe lack of physical activity is 
the major culprit. Other equally admirable luminaries believe 
it's most diet. There are adherents for the contribution of 
television, electronic games, fast food, enhanced portion 
sizes, etcetera. If we knew the five major causes of obesity we 
would have clear guidance for the design of programs to 
maximize the effects. Of course, the five major causes probably 
vary by age and perhaps by gender.
    Second, we need an understanding, a better understanding of 
why people do or don't do the behaviors that are the major 
contributors to obesity. This knowledge will guide program 
designers on what mediating variables to target.
    Third, we need control--we need research on controlled diet 
and physical activity. For example, most of the national 
dietary guidance is based on the national dietary guidelines 
and the food guide pyramid, but there has never been a study 
that assesses what happens when people eat a diet based on the 
dietary guidelines and the food guide pyramid. What will it do 
for the obese or the moderately overweight people? For those 
with an elevated blood pressure or elevated cholesterol? There 
are several recent versions of the food guide pyramid and more 
have been proposed. None have been compared for effects on 
outcomes.
    The same kind of research is needed with physical activity. 
What will 30 minutes of moderate to vigorous physical activity, 
6 days a week do for adults or children who are overweight? Is 
physical activity valuable primarily in longer doses or do 
multiple shorter doses have the same effect? While some of this 
research on physical activity has been done, this is very 
difficult research to do and much more is necessary.
    A number of my colleagues would argue that the primary 
research need is for more community-based interventions. In my 
opinion, since most of our community-based interventions have 
not worked well or not worked at all, these three kinds of 
research will provide much needed guidance to community-based 
interventions.
    Senator Harkin. Thank you. It was just brought to my 
attention the other day--I'm going to find out more about it 
because I'm not going to mention the place but I will mention 
what it was--a new elementary school that was just built that 
has no playground. An elementary school built without a 
playground. I'm going to look into it more. I assume there's no 
Federal money involved but probably just State and local money 
but there ought to be some thought given to that when schools 
are built that way.
    I wanted to get to Len Olsen here, because I met a person 
with A-John Company and what you're doing with them, right?
    Mr. Olsen. L-John, yes.
    Senator Harkin. L-John, I'm sorry, L-John. Now, what I was 
intrigued by your testimony was this idea of incentives.
    Mr. Olsen. Yep.
    Senator Harkin. So, you know, I believe in the carrot 
approach, I really do. I think, you know, there ought to be 
more incentives to push people to preventative health, to 
maintaining healthy lifestyles. You mentioned that in our 
testimony. I don't understand exactly how it works, but if 
you're in this program the company will pay 60 percent of your 
health premium but if you get certain indices up, what is that? 
You get up to 90 percent that they'll pay?
    Mr. Olsen. Right. I can give you a personal example of that 
one. Again, when I started, I needed to get my weight down a 
little bit, I needed to get my cholesterol down a lot. I had to 
set those goals. I didn't achieve them at first and I got 
bumped up to a higher--you get a little break for a while, kind 
of a grace period. Then I thought, well you know, I'll just do 
what I normally do and I'll be fine. I think a lot of people 
are that way, they don't want to change their behavior. I go 
back for the second test and don't pass, didn't meet the goals. 
Got bumped up, again. Eighteen hundred dollars a year. So now 
it gets your attention and your pride a little bit. Okay. So 
you make changes. And in my case--not everybody can do, some 
people need medication, their bodies are different. Sometimes 
you do have to exercise more, you do have to watch what you 
eat, how much and what kind. And so the next time I went back 
for an evaluation, and you get that down and what several 
people do, I think they're motivated, you know, we just had our 
more recent evaluation and I can tell you the buzz around the 
hospital was, my evaluation's coming up, I got to get my weight 
down, I got to behave, you know, I got to watch what I'm 
eating. And that's not false. I mean, they really are working 
at it. And I have a friendly rivalry with Danny Renfrew, one of 
our maintenance supervisors, and we have the same problem. 
We're both relatively okay on weight and physical activity but 
we struggle with cholesterol. So there's a little friendly 
rivalry and we talk about it. And so I believe incentives do 
work, with kids and with adults. I believe in personal 
responsibility. I think there is cause and effect. I think we 
are less active than we were 30 years ago. Talk about physical 
education, what the Federal Government can do. We used to have 
something called the Presidential Fitness Challenge when I was 
in elementary school. And we had to do tests. We had to get 
ready for doing the push ups and the sit ups and the chin ups 
and running the mile, girls and boys, this was egalitarian. And 
it's something you wanted to do well at and you were motivated 
to do well at. We had P.E. three times a week. We got to play 
games but we also did calisthenics. And yeah, there were the 
kids that were heavy and that suffered in that, and I do 
believe in no humiliation, I like to see the no jock approach, 
I think that's great. But you got to get people moving. 
Movement burns calories. And if we don't--if we're cutting that 
out with our kids, that's criminal.
    Senator Harkin. Are there other regional health center, at 
least in Iowa, that are doing anything like what you're doing? 
Do you know of any?
    Mr. Olsen. Arlene might know better than I do.
    (Extensive response by someone off-mike)
    Senator Harkin. Watch this.
    (Continuation of response by someone off-mike)
    Mr. Olsen. I think to add to that, what hospitals can do is 
kind of be beacons of healthy living. You know, Jo Ellen serves 
on our local Y board and they've started a program called Fit 
Kids. Is that what it's called, where we do after school 
programming for kids at risk? Getting them exercising, giving 
them better self esteem, and a lot of this is emotional health. 
I mean, it isn't just about the physical stuff, it's about why 
you're eating and dealing with what's going on up here. And the 
Y program tries to do that. And it's a partnership with the 
YMCA and the employers and the schools.
    (Interjection by someone off-mike)
    Senator Harkin. Oh wait, wait, wait. We got to get you a 
mike because I'm sorry, please identify yourself. Please 
identify yourself for the record.
    Jo Ellen Randall. Jo Ellen Randall. And this was a program 
that was started probably 3 years ago in Ottumwa where the YMCA 
is partnering with the school systems. And the Y has a bus and 
they go to the school systems, pick the kids up after school, 
they come back to the YMCA where they participate in fitness 
programs, also social programs, versus going home, watching TV, 
getting into the junk food. This keeps them active and it has 
been a very popular program. It continues to grow. We continue 
to look for funding to keep that program going because it is 
extremely important. And it also drives families in coming back 
to the YMCA to do things together because the kids want to be 
there. And then parents find that this is also an activity that 
they can participate in. So the healthiness of that is not only 
for the children but for the family also. So, an extremely good 
program.
    Senator Harkin. Maybe we ought to look at that as a source 
more for outreach. Ms. Ruby, you know, we're talking a lot 
about, you know, prevention in the first place, getting kids in 
school early on, but we have a whole generation of elderly 
people now who are leading sedentary lives, watching 
television. I think a lot of them were smokers or maybe still 
are smokers. Tell me about your getting elderly people 
involved. And it's my understanding, at least, that just with 
proper diet and proper exercise that a lot of the medical 
problems of the elderly kind of diminish, if you just get them 
on a good program. But how do you do that? I mean, you 
obviously have done it but how do we get more people involved, 
the elderly people involved?
    Ms. Ruby. Well, the number one thing is you have to be very 
creative in your thinking. We didn't just go to the mall to 
recruit people for our program. What we did was, we had days 
when we went to a senior citizen center and signed up people 
for our program. We also have many, many community 
partnerships, one in particular is with our local hospital, 
where we went to cardiac rehabilitation and we signed up 
people. We also went to the diabetes center to see if there 
were people that would be interested in our programs. So we 
approached several different programs within the community to 
join us and join our efforts and by being creative we have 
created a lot of community partnerships and we have been able, 
not just to get elderly people involved in our program but 
people who would really benefit from the physical activity, 
those people that are in cardiac rehabs, the diabetics. We've 
been able to get those health disparities by our community 
collaborations. And that's just from going out and being 
creative and working with the other programs within the 
community.
    Senator Harkin. As you, I don't know, you may not know 
this, but right now we have nutrition--we have a mandatory FDA 
requirement of nutritional labeling on packaged goods, when you 
go in the grocery store, right? You see all the packaged goods, 
you see what's on it, and anything, most of anything that's 
packaged has to have ingredients labeling. I have introduced 
legislation to also have the FDA mandate that certain 
restaurants and restaurant chains put on their menus certain 
information as to fats, trans fats, sodium, calories. It 
initially met with a wave of opposition. But I noticed that 
after we did this Ruby Tuesday's came out and said they were 
going to voluntarily do it, others have done it. But again, 
still kind of an opposition to this thing. Now, what's been the 
reaction? You established some kind of a dining guide. I'm not 
familiar with it, I know you mentioned it. What is it and how 
have you gotten--what's the public acceptance and the business 
acceptance been in the Fort Dodge area?
    Ms. Ruby. Well, one of the other programs that we have done 
in Webster County is we surveyed 67 restaurants in our area to 
see what they offer for healthy dining choices. And we took 
that information and we compiled it and we made a healthy 
dining guide for our citizens in Webster County, and it has all 
of the popular restaurants, Wendy's, Appleby's, all of the 
places that people would dine out. And I wish I would have 
brought one today but I did not. And it's a form that 
identifies what each restaurant has in the way of healthy 
foods, if they offer skim milk, if it's a non-smoking 
environment. There's just a list of information that we have on 
there for the residents of Webster County so they know where 
healthy places are to eat. And what we did was we distributed 
2,200 of those healthy dining guides to all of the restaurants 
in Fort Dodge and in the community and we took it one step 
further and we implemented a community policy with our 
restaurants, requiring them to post that information for 
citizens so it's available when they go there. And we have, 
like I said, we've distributed 2,200 dining guides and we are 
out of them; we're in the process of ordering more. So we've 
had great, great response from the community.
    Senator Harkin. And the restaurants too?
    Ms. Ruby. Yep. We had them sign the policy. Everybody that 
participated in the healthy dining guide, part of that program 
was that they had to have that dining guide posted for citizens 
to see. That was a piece of the program that they had to agree 
to participate in. And they all did.
    Senator Harkin. That's very good. Although I happened to 
read the paper this morning and I noticed that--I don't have it 
with me but--story in this morning's Register about McDonald's 
is now putting out an adult Happy Meal, and a kid's Happy Meal 
too, but it has a salad in it and fruit and a pedometer. And 
this is all well and good. And I think, you know, the more we 
can continue to encourage the McDonald's and the other fast 
food chains to do this the better off we're all going to be. So 
I applaud them for doing that and I hope they continue to do 
that. I ask the question, however, are they going to put as 
much advertising into that as they've put into a Big Mac? I 
mean, they start equalizing the advertising then maybe we'll 
make some progress here.
    Let's see. Was there any other thing that I wanted to cover 
here specifically? I think I got most of the--well, fruits and 
vegetables. You've been involved in that. And some others here 
also. You have been too, right?
    Ms. Ruby. Yep.
    Senator Harkin. You've been involved in fruits and 
vegetables. Well, children walk and bike 40 percent less now 
than they did 20 years ago. They don't get the daily 
recommended fruit and vegetable allowance. You know, again, 
what can we do about this, what kind of results have you seen 
in children after beginning your day care outreach? And I'm 
talking to you about that. What's happened when you do that? 
What's happened to the kids?
    Ms. Ruby. Well, another one of our wellness programs that 
we have is we went to the day cares each month and we talked to 
the children about eating fruits and vegetables and exercise. 
And what we did was we did monthly visits to educate them on 
the benefits of it and one of the things that we always look at 
when we do a program is sustainability. So after our program 
was completed we had all of the day cares, we signed another 
policy, community policy, where all of the day cares were 
required to continue to teach the children about fruits and 
vegetables and the importance of eating them. So we had buy-in 
from all of the day cares that we did, our education piece, but 
then they continued to do that.
    Senator Harkin. You may not be aware of this, in the 2002 
Farm bill, I happened to be chairman for a brief moment there, 
and I wanted to test a theory of mine, and that is that if kids 
had available free, fresh fruits and vegetables, not canned but 
free fresh fruits and vegetables that they would eat those and 
they would not be eating junk food and putting money into 
vending machines. So we picked four States, Iowa, Michigan, 
Ohio, Indiana were the four States. And two Indian 
reservations. We picked 25 schools--well, I didn't pick them 
but the Iowa Department of Public Education took in 
applications--so we had 25 schools in each State, 25 in Iowa, 
Ohio, Michigan, Indiana, 100 schools, some urban, some rural, 
some high income, some low income; we wanted to get a broad 
spectrum. And I put in just $4 million to do this. It's been 
existing now, it's been going on for just over a year now and 
the results have been fantastic. I mean, you'd be amazed at how 
many kids, especially low income kids, never eat fresh fruits 
and vegetables. It's one of the most expensive things in the 
grocery store. I mean, to go to some of the schools and see 
kids that have never eaten a fresh pear, kiwi fruit, bananas, 
apples, all these things. But it's just been phenomenal. But 
now again, this is just a pilot program, we added one more 
State this year, Mississippi, we added a couple more million 
dollars this year, a million dollars more for Iowa. But again, 
all the preliminary results after 1 year seems to be that--
well, we had one principal from where? Muscatine. Muscatine 
actually said they had to take a vending machine out of the 
school because it wasn't being used any more because the kids--
now, the idea was not that the kids had the fruits and 
vegetables just at lunch time but they had it when they came to 
school in the morning; if their stomach got the grumblies 
around ten in the morning they could get fresh fruit or 
vegetables. You got kids eating fresh broccoli, kids eating 
cauliflower.
    I went to this one school. I asked these kids what they 
like and this one kid said, he liked spinach. I thought that 
was pretty interesting. But, you know, obviously, who likes 
canned spinach? Is there anyone in this room who likes canned 
spinach? But fresh spinach is very good and these kids had 
never had fresh spinach. And so it just opened up a whole new 
world for them. And anecdotally we found a lot of kids that 
their parents now were coming into school and seeing them, and 
when they go grocery shopping they may take their kids with 
them; the kids were always, you know, they go to the fruits, 
they want this fruit and they want this vegetable, now they're 
making their parents buy this stuff. So again, I talk about 
that as a way, Dr. Baranowski, now you've done some--in this 
area, about getting kids started on fresh fruits and vegetables 
and how important that would be for, again, later on, for 
people to continue that kind of a lifestyle.
    Dr. Baranowski. Terrific. I honestly believe that the fruit 
and vegetable pilot program that you developed and implemented 
and funded was a remarkable program from many perspectives. The 
fruit and vegetable consumption is the single most important 
dietary behavior that needs to be encouraged for several 
reasons. The micro nutrients in fruits and vegetables have 
profound effects in regulating physiological systems and 
thereby helping prevent most cancers, heart disease, diabetes 
and a variety of other chronic illnesses. The high water and 
high fiber content tends to enhance a sense of fullness and 
thereby reduces caloric intake and fat and sugar intake, 
leading to weight loss. The evaluation that was done of the 
fruit and vegetable pilot was very promising but anecdotal, 
relying on participant testimonials. I believe you could have 
broader effect if you had a more thorough, systematic 
evaluation of the program. As a behavioral scientist I'd like 
to see harder data. Did the program lead to more fruit and 
vegetable consumption by the children or did just some children 
compensate by reducing their fruit and vegetable consumption 
outside the school? Which children increased? Were the children 
who needed it most among the ones to benefit? At what point is 
the optimal benefit achieved by a program such as this? At one 
serving of fruit and vegetable a week? At one serving a day? 
Two per day? At breakfast and lunch? At snack? What were the 
costs borne by the schools from such a program. I strongly 
encourage you to insert a line item in the next legislation 
funding this program to implement a thorough evaluation. A 
colleague of mine at the Children's Nutrition Research Center 
has submitted a grant to the NIH to begin such research but the 
peer reviewers seem to believe that the USDA should be the 
funding--the source of funding for the evaluation. My colleague 
is ready to do such research and I'm sure many others would 
like to have the opportunity to do so too. So while the program 
was an important first step it can have more pervasive effects 
on policy if it had a thorough evaluation.
    In a more direct response to your question, the highlights 
of my research reveal that children who have more fruit and 
vegetables available at home tend to eat more fruits and 
vegetables. That's not rocket science but we think it's an 
important finding so we've initiated research on the 
determinence of home fruit and vegetable availability and we're 
currently doing surveys in Houston on that factor.
    Also, we've designed electronic games based on behavior 
change principles and have shown that children who played our 
games twice a week for 5 weeks increased their fruit and 
vegetable consumption by a full serving a day. We have several 
funded studies pursuing this line of research, trying to find 
more effective ways within the game framework of helping 
children change their dietary behaviors.
    Finally, we've developed a computerized method for 
measuring children's daily food consumption. This opens the 
door to more extensive dietary research because it makes 
dietary data collection much less expensive. We think these are 
important contributions.
    Senator Harkin. Your point is that we need better research 
and data collection.
    Dr. Baranowski. Yes sir.
    Senator Harkin. I agree with that.
    I'm going to now open this up. I'm told we're going to 
start out walking in 10 minutes but I'd like to open up to the 
floor for anyone that has any questions, comments, suggestions. 
We're open for any observations that anyone might have. All I 
ask is that you just identify yourself for the record, is all. 
Yes, back here.
    Ms. Thomas. I'm Kathy Thomas from Iowa State University. 
And I think I have a couple of comments more than questions. 
With all due respect to Dr. Baranowski, I certainly agree that 
more money is necessary for research but one of the key points 
that I think, as we listen to Mr. Schupbach's program in Grundy 
Center, it's important to understand that his program is daily 
physical education. And if we look at the two most recent 
publications, one from NICHD and the Schifft Study that 
Burgeson and Paul Wexler published from CDC, both of those 
indicate that we are grossly behind the national 
recommendations in terms of daily P.E. In the elementary 
school, children are getting approximately 40 percent of daily 
physical education recommendations. In Iowa, it's about the 
same as it is nationwide, where children are getting 2.1 days 
of physical education per week when the recommendation is 
daily. They're getting approximately 62 minutes in the State of 
Iowa as opposed to 150 minutes. So----
    Senator Harkin. Let me ask a question. Sixty-two minutes 
per week?
    Ms. Thomas. Yes sir. Per week.
    Senator Harkin. In elementary school?
    Ms. Thomas. Yes sir.
    Senator Harkin. That's average?
    Ms. Thomas. That would be the national average, yes sir.
    Senator Harkin. The national average is 62 minutes per 
week?
    Ms. Thomas. It's 66 in third grade, in the NICHD study. If 
you look at the Schifft's data it's more like 62 minutes, which 
is about the Iowa average. Now, this is a systemic problem. And 
I think unfortunately a lot of the research that's done----
    Senator Harkin. Could you put the mike closer to your 
mouth?
    Ms. Thomas. This is a systemic problem that we look at 
research and we criticize instruction, curriculum, child 
behaviors, all sorts of things like that and we don't look at 
the systemic issue of how much physical education children are 
actually getting each day. One of the things, that if we look 
at the increase in obesity and overweight from the Enhans data 
from 1974 to 1999, it is almost parallel to the number of 
children since 1974 to 1999 who have no physical education. 
None.
    Senator Harkin. Now, I have to reconcile with what you just 
said with some data I saw recently that said 80 percent of 
elementary school kids in America don't even receive an hour of 
P.E. a week. Now, you say the average is an hour.
    Ms. Thomas. In elementary school. Now, it depends on how 
you read the data. If you look at high schools, for example, 
for students who are enrolled in physical education oftentimes 
they meet the 225 minutes per week requirement. But many 
children in high school are not enrolled in physical education; 
they meet their 1-year requirement for P.E. and then they're 
not enrolled the next 3 years. So if you look at 100 percent of 
the children in high school that are enrolled in physical 
education it looks more like 25 percent of the kids in high 
school are meeting that daily requirement. However, if you only 
report the students who are actually enrolled they become much 
closer. So it depends on how you want to interpret the data. 
But if you look at the data that CDC has presented for us and 
NICHD, they both are very consistent that the system is what's 
failing, not necessarily the teachers nor the curriculum. And I 
think that's a really important point because we see many 
wonderful teachers who are creative but who don't have the kind 
of support in their system that superintendents like the one in 
Grundy Center has offered. And I think that's an important 
problem.
    The other thing I'd just like to mention, I'm sure Dr. 
Baranowski is well familiar with Steve Blair's work from the 
Aerobics Institute which shows that obesity is less of an 
impact on morbidity and mortality than being physically active. 
And that may be one of the ways of dealing with your concern 
about people with eating disorders, that we want to make sure 
that people are active first and then we'll worry about 
overweight and obesity.
    Senator Harkin. Very good. Thank you.
    Yes.
    Mr. Layton. Senator Harkin, thank you for holding this 
hearing. My name is Tim Layton with the Iowa Department of 
Public Health. I want to share, number one, a story and just 
one or two statistics to shore up some of the presentations 
today. Some of them are rather recent.
    My personal background in this is that my father spent his 
life helping folks plan for their retirement, their financial 
well-being, their fiscal well-being at that stage of their 
life, and the greatest irony of my life was that when my father 
retired at the age of 65 a week later he died of a massive 
coronary. This impacted me and basically is my entire 
background and credentials that I've kind of based on my 
beliefs in. My father smoked, he was sedentary, his nutrition 
habits weren't good, that led to weight issues and he was a bit 
hypertensive. He's used to establish the animal standard for 
Iowa roads. Anybody that was driving slower than him was an old 
goat; anybody faster was a jackass. And if you weren't 
performing to my dad's standard when you were on the road it 
kind of would make him overly tense and again, those all 
contributed to his situation.
    I feel his outlook on life and the ability to overlook the 
physical as well as the fiscal planning for retirement is kind 
of analogous to America today. So I applaud your efforts to 
help us start addressing some issues that I, when I look down 
the road intently the three issues of one, the age of our State 
and the Nation, the cost of medical care and then also our 
sedentary trends and see that in the year 2020 we're not going 
to have money for anything else, it's frightening to me.
    I also wish to applaud you, you're kind of steering away 
from the term obesity, since we have a lot of individuals who 
are overweight and fit and a lot of individuals who are 
underweight and could be healthier. And also, perhaps framing 
it with those obesity terms is sometimes a little bit 
disturbing to me.
    But the two facts that I wanted to share with us today is 
that the youth screen time is now up to 4.5 hours a day and 
youth fracture rates have increased 1 percent a year over the 
last 30 years. We no longer just have frail elderly, we have 
frail youth. And that fracture rate isn't just coming from an 
increase in the TV show The Jackass and other things, it is 
coming from the diet and the lack of quality P.E. And by the 
way, the term for my P.E. program as a youth was P.E. for 
Strife. So I applaud the Grundy Center program. And at--trying 
to keep it short seeing that I have some quality individuals 
behind me, I'll just sum that up.
    Mr. Hensley. Thank you, Senator Harkin. My name is Larry 
Hensley. I'm a professor of health and physical education at 
the University of Northern Iowa and I serve as the director of 
our newly-established Youth Fitness and Obesity Institute. What 
I'd like to do is just comment and reinforce some of the 
statements that were made earlier.
    Dr. Baranowski talked about the imbalance that occurs 
relative to medical funding and expenditures for health 
services or sick care compared to prevention. The $1.5 trillion 
that's the national health care cost according to my figures, 
about 95 percent of that is directed towards sick care and only 
5 percent towards prevention. That needs to be changed. And 
along those areas we talked about obesity, it's important to 
recognize that both dietary behaviors and physical activity 
behaviors are important components and important factors in 
contributing to obesity. We also need to see balanced funding 
and balanced support for both areas. Dietary behaviors as well 
as physical activity.
    In the presentation that Mr. Schupbach made, and I must 
comment that Rick is a former student of mine and so I'm very 
proud of his work in Grundy Center. He talked about the 
potential that physical education programs have in helping 
arrest the overweight and obesity crisis. Unfortunately, and 
it's been mentioned previously, the current Federal education 
legislation, No Child Left Behind, does more to marginalize the 
physical education and as a result of this what we're seeing 
is, we're beginning to see dollars and funds shifted from 
physical education, I could talk about art education and music 
education as well, into other areas that are deemed to be more 
important. So this needs to be investigated and looked at very 
carefully.
    Last, I would suggest to you that with all the different 
health promotion initiatives that are underway, some very 
innovative initiatives, we certainly need policy to support 
these health initiatives and individual change initiatives.
    Thank you very much.
    Senator Harkin. Thank you very much.
     Ms. Kline. Susan Kline. I'm a nutrition and health field 
specialist for Iowa State University Extension. And I wanted to 
share something--I felt compelled to share something with you 
when you mentioned that vegetables and fruits are expensive, 
one of the most expensive things we can buy. At Extension, we 
go around trying to teach people about food selection and the 
importance of nutrition, and I want to share with you this 
little thought. If you bought a bag of taco chips, they often 
will cost $3. I'm not really sure how much they weigh but, for 
that same $3, if you bought bananas at 49 cents a pounds, which 
I guess is kind of expensive, if you ask me, and you figure 
there are about four bananas to a pound, you could buy, for 
that $3 of taco chips you could buy 24 bananas. So I don't 
really think, in comparing fresh fruits and vegetables and cost 
to other items that that's--we need to put away the myth that 
fresh fruits and vegetables or that fruits and vegetables are 
expensive. They aren't really expensive, they are just 
something that, when we buy them every week, maybe we have more 
spoilage is why we think it's expensive.
    Senator Harkin. Very good point. Thank you very much. 
That's good, that's good.
    Ms. Garrett-Hoffman. Hi. My name is Nida Garrett-Hoffman. 
I'm one of the diabetes nurses at Mercy Medical Center. And one 
of the things several of you mentioned about diabetes and the 
tremendous epidemic that we are having with diabetes, we have 
18 million people already who have diabetes; we have about 40 
million people who are at the stage of pre-diabetes or 
metabolic syndrome. At this particular time we don't have any 
diabetes education coverage for diabetes education for these 
people. We have found that if we don't get to these people they 
still have the risk of developing complications of diabetes 
that the people who have diabetes do. I'm asking that somehow 
we get some coverage, medical coverage for diabetes education, 
for pre-diabetes and metabolic syndrome. Thank you.
    Senator Harkin. Hmm. That's a good suggestion.
    Mr. Olsen. Just comment and I contrast that with the cost 
of dialysis, for one patient a year. And look at that versus 
diabetic treatment.
    Senator Harkin. Say it again?
    Mr. Olsen. I said contrast that with the cost of treating 
one dialysis patient for a year. Have your staff look that up.
    Senator Harkin. What?
    Mr. Olsen. Just how much it costs to treat one person on 
dialysis for 1 year. I can send it to you if you don't have it.
    Senator Harkin. Okay. All right.
    Ms. Heckenlaible. I'm Suzanne Heckenlaible. It's H-E-C-K-E-
N-L-A-I-B-L-E. And the director of Field Services Public 
Affairs for the March of Dimes, which is to improve the health 
of babies and their mothers by preventing birth defects and 
infant mortality. And Senator Harkin, we'd like to thank you 
for your support of Federal funding for the birth defects 
registry prevention programs and research. And as you know, in 
the State of Iowa we have a Center for Excellence here that 
does research with the Department of Public Health and we 
appreciate your support of that program. As you know, we have 
had significant reduction in neural tube defects, which is, the 
reduction is due to folic acid consumption. And we encourage 
you to continue to support the research and prevention programs 
in regards to birth defects in Federal funding. So thank you.
    Senator Harkin. Thank you.
    Ms. Huntington. I'm Jenny Huntington from Ames. I work for 
the Child Nutrition Programs at the Iowa Department of 
Education. I want to thank you for your support, your continued 
and long-term support, of the Child Nutrition Programs. These 
include programs for school children and also adults in day 
care and children in day care, both in homes and in child care 
centers. These are essential programs for our children and we 
really do appreciate your support, and the people of Iowa do.
    We also appreciate your support for Teen Nutrition, which 
is a grant program and a special nutrition education effort 
from USDA. Iowa has been fortunate enough to receive a number 
of Teen Nutrition grants for both schools and child care. From 
the beginning grant we have linked improved nutrition with 
increasing physical activity in our grant process, and we have 
also focused, in some of the grants, on efforts to work with 
child nutrition in early childhood programs. One of the things 
that we developed through these grants is a tool for people in 
early childhood to increase physical activity and increase 
healthy snacks is a set of 60 cards that have a physical 
activity on one side of each card and a healthy snack on the 
other side of each card. And they're held together with a ring. 
These cards are kind of expensive to print but they are all 
available through Iowa Public Television, on the Ready to Learn 
site. Anyone in Iowa and anyone in the Nation can download 
these cards and use them in their child development programs. 
We also have developed policy cards where we are encouraging 
child care organizations to not only serve healthy foods but 
make sure they're not selling candy for fundraising. And so 
we're looking at policies in child care and we have lessons. 
These are all sets of cards that we have developed through Teen 
Nutrition. Thank you very much. We've had at least 11 States 
that have requested reprinting of these cards; we're hoping the 
National Food Service Management Institute will take it on and 
distribute them for us.
    Senator Harkin. Thank you. I just want to mention one other 
thing. I've forgotten the ingredient but it was mentioned that 
the fractures in kids that have gone up 1 percent per year, the 
last several years; is that what you said?
    Mr. Layton. One percent a year, Senator, over the last 30 
years.
    Senator Harkin. I didn't know that exactly but I had heard 
about the increased fractures among kids; I sort of asked some 
questions about this at earlier hearings and different forums. 
And it was brought to my attention, Dr. Baranowski, that the 
increased consumption of sodas--soda contains phosphoric acid. 
Phosphoric acid leeches calcium out of your system. So the more 
phosphoric acid that you take in, the more calcium leeched out 
of your bones and that is one of the reasons why, some 
scientists believe that kids are having softer bones these 
days, because they're drinking so much soda pop.
    (Inaudible response off-mike)
    Senator Harkin. If what?
    (Inaudible response off-mike)
    Senator Harkin. No but----
    Mr. Layton. We brought one for you.
    Senator Harkin. I have a lot of pedometers. I just keep 
misplacing them, that's all. But thank you, anyway.
    Well listen. Thank you all very much. I want to thank all 
of you. Dr. Baranowski, thank you for coming all the way from 
Texas, and thank you for your continued work on a national 
basis on these issues. We appreciate it very much.
    We're going to do a little walk here, around the track up 
here at AIB I want to thank, again, I want to thank Vernon 
Delapeace, thank you very much, the C.E.O. of the YMCA of 
Greater Des Moines. I want to thank the staff of the YMCA, 
who's arrived; they're all back there in their tee-shirts. 
Thank you for being here. And they're going to join us on the 
walk. You're all invited to join us if you would like. We're 
just going to do a little walk around up there and I'll see if 
their pace is like my pace. And I have a heart monitor on; I 
don't know what that's all about.
    Dr. Baranowski. I'll explain it to you.
    Senator Harkin. What?
    Dr. Baranowski. I'll explain it to you.
    Senator Harkin. Oh, you're going to explain it to me?
    Dr. Baranowski. Yes, I am.
    Senator Harkin. Here or later?
    Dr. Baranowski. As you start.
    Senator Harkin. Oh, as I start you're going to explain it. 
All right. But again, I'd just close by just saying that this 
is--I don't think there really is a more important issue facing 
us as Americans, health-wise, than this issue of healthy 
lifestyles and prevention. If we keep going the way we're going 
there's just no way that we're going to be able to fund the 
sick care system we have in America; it's going to bust us. 
When we know. I mean, the science is there, the data's there. 
This is not just speculation; we know that if people eat right, 
exercise right they're going to be healthier, they're going to 
prevent chronic illnesses and diseases more often, and it's 
going to save us money plus people are just going to have 
better lives. I think we got off the track, some years ago, I 
guess when schools changed and stuff but I was like some of 
you, when I was in school, I mean, we had two recesses and a 
lunchtime and we could never stay inside. Well, maybe if it was 
20 degrees below and it was a blizzard maybe we could stay 
inside; otherwise we were out. And that was just our exercise, 
every week, when I was in grade school here in the State of 
Iowa. I don't think you find that any longer like that. And so 
we grew up and of course, being in the military and that helped 
too, promote physical activity and physical exercise. But we've 
just gotten so sedentary with everything, televisions and, as I 
said, now we don't, we no longer bike, we don't have bike 
paths, we don't even have sidewalks, we don't have walking 
paths for people. Everything we've done has been to encourage a 
more sedentary lifestyle. And now you can buy a Sequeway; you 
don't even have to walk anymore, you got to go to two-wheelers 
and just ride it wherever you want to go. It may have some 
benefits someplace but at a time when we're trying to encourage 
people to get out and walk more, I don't know.
    So I just don't think anything's more important than this 
in terms of both the health of our people and the health of our 
economy, and having a health care system that really is a 
health care system. We keep looking, I keep looking for 
suggestions, advice; I've gotten some good input here this 
morning on, you know, what needs to be done and steps to be 
taken. I think this may be another instance where the 
government, the government so to speak, those of us in 
government, are behind. I think we're seeing more of this 
coming from the grassroots up, people are demanding that they 
want a healthier lifestyle, they want to have physical 
activity, they want to have wellness programs and I think those 
in public office are going to have to start responding to that 
very, very soon and do what people want. And that is provide in 
workplaces, providing incentives for businesses to have 
wellness programs for all their employees; communities, on a 
community basis I mentioned schools, pre-school, but it has to 
be that kind of a comprehensive approach. And we can't put it 
off any longer. I think we've just got to have some real focus 
on this and we've got to bring this country together to move us 
as rapidly as possible in this direction.
    So again, I thank you all for being here. And you're all 
invited to join us on the walk if you like.
    With that, the subcommittee--unless I have anything else--I 
want to thank, first of all, Jenelle Krishnamoorthy right here 
behind me and Ellen Murray, my two staff people who do all this 
work and keep me advised and informed and get witnesses 
together and basically have been two of the great leaders in 
the U.S. Senate on health care. A lot of times we get the 
acclaim and we get the applause and stuff but they're really 
the ones that do the work and we want to publicly thank both of 
them for all their work.

                         CONCLUSION OF HEARING

    Thank you all very much for being here. That concludes our 
hearing.
    [Whereupon, at 11:40 a.m., Friday, April 16, the hearing 
was concluded, and the subcommittee was recessed, to reconvene 
subject to the call of the Chair.]

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