[Senate Hearing 110-447]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-447

 CHILDHOOD OBESITY: THE DECLINING HEALTH OF AMERICA'S NEXT GENERATION--
                                 PART I

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

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON CHILDREN AND FAMILIES

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                                   ON

   EXAMINING CHILDHOOD OBESITY, FOCUSING ON THE DECLINING HEALTH OF 
                   AMERICA'S NEXT GENERATION (PART I)

                               __________

                             JULY 16, 2008

                               __________

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


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          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

               EDWARD M. KENNEDY, Massachusetts, Chairman

CHRISTOPHER J. DODD, Connecticut     MICHAEL B. ENZI, Wyoming
TOM HARKIN, Iowa                     JUDD GREGG, New Hampshire
BARBARA A. MIKULSKI, Maryland        LAMAR ALEXANDER, Tennessee
JEFF BINGAMAN, New Mexico            RICHARD BURR, North Carolina
PATTY MURRAY, Washington             JOHNNY ISAKSON, Georgia
JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York     ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois               PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont         WAYNE ALLARD, Colorado
SHERROD BROWN, Ohio                  TOM COBURN, M.D., Oklahoma

           J. Michael Myers, Staff Director and Chief Counsel

        Ilyse Schuman, Minority Staff Director and Chief Counsel

                                 ______

                 Subcommittee on Children and Families

               CHRISTOPHER J. DODD, Connecticut, Chairman

JEFF BINGAMAN, New Mexico            LAMAR ALEXANDER, Tennessee
PATTY MURRAY, Washington             JUDD GREGG, New Hampshire
JACK REED, Rhode Island              LISA MURKOWSKI, Alaska
HILLARY RODHAM CLINTON, New York     ORRIN G. HATCH, Utah
BARACK OBAMA, Illinois               PAT ROBERTS, Kansas
BERNARD SANDERS (I), Vermont         WAYNE ALLARD, Colorado
EDWARD M. KENNEDY, Massachusetts     MICHAEL B. ENZI, Wyoming (ex 
(ex officio)                         officio)

                   MaryEllen McGuire, Staff Director

                David P. Cleary, Minority Staff Director

                                  (ii)










                            C O N T E N T S

                               __________

                               STATEMENTS

                        WEDNESDAY, JULY 16, 2008

                                                                   Page
Dodd, Hon. Christopher J., Chairman, Subcommittee on Children and 
  Families, opening statement....................................     1
    Prepared statement...........................................     4
Levi, Jeff, Ph.D., Executive Director of Trust for America's 
  Health, Washington, DC.........................................     6
    Prepared statement...........................................     8
Kaufman, Francine, M.D., Past National President of the American 
  Diabetes Association, Distinguished Professor of Pediatrics and 
  Communications at the Keck School of Medicine and the Annenberg 
  School of Communications at the University of Southern 
  California, Los Angeles, CA....................................    13
    Prepared statement...........................................    15
Grey, Margaret, DrPH, R.N., FAAN, Dean and Annie Goodrich 
  Professor, Yale School of Nursing, New Haven, CT...............    18
    Prepared statement...........................................    20
Lesley, Bruce, President, First Focus, Washington, DC............    22
    Prepared statement...........................................    24
Harkin, Hon. Tom, a U.S. Senator from the State of Iowa, 
  statement......................................................    29
    Prepared statement...........................................    30
Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska, 
  statement......................................................    30
Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico, 
  statement......................................................    31

                                 (iii)

  

 
                    CHILDHOOD OBESITY: THE DECLINING
                        HEALTH OF AMERICA'S NEXT
                           GENERATION--PART I

                              ----------                              


                        WEDNESDAY, JULY 16, 2008

                                       U.S. Senate,
Subcommittee on Children and Families, Committee on Health, 
                            Education, Labor, and Pensions,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:31 p.m. in 
Room SD-430, Dirksen Senate Office Building, Hon. Christopher 
Dodd, chairman of the subcommittee, presiding.
    Present: Senators Dodd, Bingaman, and Murkowski.
    Also Present: Senator Harkin.

                   Opening Statement of Senator Dodd

    Senator Dodd. The committee will come to order.
    Well, first of all, let me thank our witnesses, and also I 
want to welcome the rather large audience here in this 
committee room. I am particularly pleased to see so many young 
people here. We have opened up the back room as well. For those 
of you standing here, as seats become available, the staff will 
try and make it more available.
    Had I known we were going to have this much interest in the 
subject matter, I would have tried to secure a larger room. I 
apologize to all of those of you who are standing and showed up 
for today's hearing, but I am very grateful to all of you.
    My colleague from Tennessee, Senator Lamar Alexander, I 
know is going to try and make it over here with us for this 
hearing, and I suspect we will be seeing Senator Harkin as 
well, who has a deep interest in the subject matter that is the 
theme of our hearing this afternoon.
    The subject, ``Childhood Obesity: The Declining Health of 
America's Next Generation--Part I.'' My intention is to have a 
series of hearings, at least two immediately and possibly more, 
on this subject matter as we examine the health condition of 
the next generation.
    As many have concluded, as I will share in my opening 
comments, this generation of the younger generation in this 
country may be the first generation of Americans in the history 
of our country that is less healthy than their parents. That is 
a statistic and a conclusion that is deeply troubling to all of 
us.
    I welcome you here today for what is the first, as I 
mentioned, of two important hearings on one of the most urgent 
threats to American children, the childhood obesity epidemic. 
The numbers are, quite frankly, stunning--absolutely stunning. 
No other word could be used other than that to describe it.
    Nearly one out of every three of America's children are 
obese or are at the risk of becoming obese--25 million children 
in all, with children in minority families at an even greater 
risk in our country. It is the most common disease of 
childhood, and we are told it is largely preventable.
    Nationally, the childhood obesity rate tripled between 1980 
and 2004. In many States, especially those in the South and the 
Midwest, the rates are even much worse. Even in States where 
childhood obesity rates are among the lowest in the Nation, 
like Colorado and my home State of Connecticut, the rates are 
appallingly high--even in relatively good States.
    As a parent, these findings are deeply troubling to me--as 
they should be, of course, to every parent, every person in 
this country--because this is about so much more than numbers 
and statistics. Most public health experts believe, and the New 
England Journal of Medicine recently warned, that unless we act 
as a nation, our children's generation may be the first in the 
modern era to live shorter, less healthy lives than those of 
their parents. That is a possibility we should all be ashamed 
of as Americans.
    Already the health consequences are crystal clear. Right 
now, children are increasingly being diagnosed with type 2, 
``adult-onset'' diabetes, high blood pressure, and high 
cholesterol levels. The list goes on: stroke, certain types of 
cancers, osteoarthritis--is that how you pronounce it?--certain 
liver diseases. You don't have to be a health expert to know 
that these are not diseases we normally associate with 
children.
    We all can point to reasons why this is happening. Junk 
food is rampant and marketed to children. Television has paved 
the way for children to have more sedentary lifestyles. We 
surround our public schools with soft drink machines and fast 
food restaurants, which local schools allow because they are 
often so underfunded they turn to corporate sponsors for 
financial assistance.
    It doesn't help that only 8 percent, only 8 percent of our 
elementary schools in this country even require daily physical 
activity, and only 6 percent of middle and high schools do as 
well. At the same time, our investment in public parks, bike 
paths, playgrounds, and other kinds of infrastructure that 
encourage physical activity has deteriorated.
    According to the 2004 National Survey of Children's Health, 
between 25 to 40 percent of children over the age of 9 get less 
than 1 hour of physical activity a week, depending upon the 
State they live in. A new report released by the National 
Institute of Child Health and Human Development and published 
in the Journal of the American Medical Association shows that 
the vast majority of 15-year-olds do not come close to getting 
the recommended 60 minutes of physical activity a day.
    Childhood obesity is a problem that affects all of us, 
whether we have children or not. One day every one of these 
children are going to grow into adulthood, and odds are that 
every one of the health problems that started when they were 
children are only going to get worse. We are all going to be 
paying the bill.
    If you are not impressed by the human dimension of this, 
then consider the financial costs. The obese spend 36 percent 
more on health care. They spend 77 percent more on medications. 
That means the costs for all of us are going to keep heading 
upwards.
    They already are. Health care spending has exploded, as 
many know, in the last 20 years, and 1 out of every 4 of those 
added dollars has gone to treat obesity-related problems. That 
is unsustainable as a nation. The question, of course, is what 
are we going to do about it as a nation?
    These hearings, these two hearings we will be holding are 
our first step in this subcommittee. Today, we will make sure 
we understand what is happening and why. Next week, I will hold 
a second hearing in which we will focus on what needs to be 
done to stem the current tide and who could and should be doing 
it, from the individual to the private sector, from State and 
local governments obviously to the national government as well.
    All of us--parents, schools, government, employers--need to 
see the rising childhood obesity rates for what they are. This 
is a medical emergency, and it is time that we worked together 
to do something about it.
    I am delighted that we are joined or will be joined by my 
colleague from Iowa, Senator Harkin, who I mentioned a moment 
ago, has devoted a great deal of his time to this issue. As the 
Chairman of the Agriculture Committee of the U.S. Senate and 
who sits on the Appropriations Committee, he has been working 
diligently over the last number of years to try and develop 
better nutrition programs, support more organic farming, and 
other issues which could help considerably to deal with some of 
the issues that are associated with obesity.
    I want to thank him and I want to thank again Senator 
Alexander, who is also very interested in the subject matter, 
for their support of this effort.
    With that, I want to turn to our witnesses and again thank 
them for being with us today. Let me introduce them for all of 
you.
    Jeff, is it ``Lee vee''--do you pronounce it ``Lee vee? 
''--Jeff Levi. Dr. Levi is the executive director of Trust for 
America's Health. He is also an associate professor at George 
Washington University's Department of Public Health, and he 
previously served as the deputy director of the White House 
Office of National AIDS Policy. He has a Master's from Cornell 
University and a Ph.D. from George Washington University.
    Trust for America's Health, or TFAH, advocates for a 
modernized public health system and addresses many of the 
critical problems threatening the health of our Nation. Each 
year, TFAH issues a remarkable report on obesity. It is called 
``F as in Fat.'' We look forward to sharing the findings of 
this report, and of course, thank you, Doctor, for being with 
us.
    Francine Kaufman, Dr. Kaufman, is a pediatric 
endocrinologist. Dr. Kaufman is a distinguished professor of 
pediatrics and communications at the Keck--is it Keck?--Keck 
School of Medicine and the Annenberg School of Communications 
at the University of Southern California. She also serves as 
the director of the Comprehensive Childhood Diabetes Center and 
is head of the Center for Endocrinology, Diabetes, Metabolism 
at Children's Hospital in Los Angeles.
    Dr. Kaufman served as national president of the American 
Diabetes Association from 2002 and 2003 and remains a very 
active volunteer in that effort. She is a foremost expert on 
the nexus of obesity and diabetes and is leading some of the 
world's largest studies on diabetes. She was elected to the 
Institute of Medicine in 2005 and has received numerous 
prestigious awards for her research and leadership. We thank 
you, Doctor, as well.
    Next we have Margaret Grey. She is from Connecticut, a 
constituent of mine. I am delighted she is with us. Dr. Grey is 
Dean at the Yale Nursing School, the Annie Goodrich Professor, 
and a pediatric nurse practitioner. She holds a master's of 
science in pediatric nursing from Yale University and a 
doctorate in public health and social psychology from Columbia 
University.
    Dr. Grey's work and leadership has been recognized by 
countless esteemed awards and honors. She was also elected to 
the Institute of Medicine in 2005. Her research focuses on 
behavioral aspects of children with diabetes and behavioral 
interventions that can help prevent and control diabetes in 
youth. We look forward to hearing from you as well, and thank 
you very much.
    Bruce Lesley is someone who needs little introduction to 
folks around here, and we thank you once again for being before 
us. He has spent 12 years on Capitol Hill working on the Senate 
Finance Committee and the HELP Committee, the very committee we 
are in today, as well as with numerous members, including our 
colleague Jeff Bingaman, who I hope will be able to get by a 
little later in this hearing.
    Long an advocate of the needs of children, he is currently 
the president of First Focus, a group that works to ensure that 
children and families remain on the agenda of the Federal 
Government. Bruce lives in Maryland with his wife and children. 
We welcome you back to the committee. Good to have you with us.
    Let me ask each of you, if you would, to make your opening 
statements. I want you all to know that whatever other 
supporting documentation you think would be helpful, as we 
start to build this record in the committee, will be made a 
part of the record.
    If you can--I am not going to wave a gavel around at you 
here, but if you could try and keep your remarks to 5 or 7 
minutes or so, so we can get through the opening statements and 
then have a good conversation.
    Since we are not overloaded with members here today, I want 
to encourage sort of the informality of talking back and forth 
without rudely interrupting each other. If you have additional 
thoughts, if I ask one question, don't be quiet about this. 
This is an opportunity for us to lay out a good record that I 
hope will be the beginning of some very positive developments 
on this issue as well.

                   Prepared Statement of Senator Dodd

    First, I want to welcome my colleagues and our 
distinguished witnesses, and thank them for being here today. 
Today we are holding the first of two important hearings on one 
of the most urgent threats to American children--the childhood 
obesity epidemic.
    The numbers are stunning. Nearly 1 out of every 3 of 
America's children are obese or are at risk of becoming obese--
25 million children in all, with children in minority families 
at an even greater risk. It is the most common disease of 
childhood and we're told it's largely preventable. Nationally, 
the childhood obesity rate tripled between 1980 and 2004. And 
in many States, especially those in the South and the Midwest, 
the rates are much worse. Even in States where childhood 
obesity rates are among the lowest in the Nation, like Colorado 
or my home State of Connecticut, the rates are appallingly 
high.
    As a parent, these findings deeply worry me--as they should 
every parent in America--because this is about so much more 
than numbers and statistics. Most public health experts 
believe, and the New England Journal of Medicine recently 
warned, that unless we act, our children's generation may be 
the first in the modern era to live shorter, less healthy lives 
than their parents. That is a possibility we should all be 
ashamed of.
    Already the health consequences are crystal clear. Right 
now, children are increasingly being diagnosed with type 2, 
``adult-onset'' diabetes, high blood pressure and high 
cholesterol. The list goes on--stroke, certain types of 
cancers, osteoarthritis, certain liver diseases. You don't have 
to be a health expert to know that these are not diseases we 
normally associate with children.
    We all can point to reasons why this is happening. Junk 
food is rampant and marketed to kids. Television has paved the 
way for kids to have a more sedentary lifestyle. We surround 
our public schools with soft drink machines and fast food 
restaurants--which local schools allow because they are often 
so underfunded they turn to corporate sponsors for financial 
assistance.
    It doesn't help that only 8 percent of elementary schools 
even require daily physical activity--only 6 percent of middle 
and high schools. At the same time, our investment in public 
parks--in bike paths, playgrounds and other kinds of 
infrastructure that encourage physical activity--has 
deteriorated. According to the 2004 National Survey of 
Children's Health, between 25 to 40 percent of children over 
the age of 9 get less than one hour of physical activity a 
week, depending on the State. And a new report released by the 
National Institute of Child Health and Human Development 
(NICHD) and published in the Journal of the American Medical 
Association today shows that the vast majority of 15 year olds 
do not come close to getting the recommended 60 minutes of 
physical activity a day.
    Childhood obesity is a problem that affects all of us--
whether we have kids or not. One day every one of these kids is 
going to grow into an adult--and odds are that every one of the 
health problems that started when they were kids is going to 
get worse.
    And we're all going to be paying the bill. The obese spend 
36 percent more on health care--they spend 77 percent more on 
medications. That means the costs for all of us are going to 
keep heading up. They already are. Health care spending has 
exploded in the last 20 years--and 1 out of every 4 of those 
added dollars has gone to treat obesity-related problems. That 
is unsustainable. The question is: what are we going to do 
about it?
    These hearings are our first step. Today we'll make sure we 
understand what is happening and why. Next week we will focus 
on what needs to be done to stem the current tide and who could 
and should be doing it, from the individual to the private 
sector, from State and local government to the Federal 
Government. All of us--parents, schools, government, 
employers--need to see the rising childhood obesity rates for 
what they are: a medical emergency. It is time we worked 
together to do something about it.
    I am delighted that we are joined by Senator Harkin. He has 
been tireless in his efforts to bring this issue to Congress' 
attention and find innovative solutions to this epidemic. I 
want to thank my partner in this venture, the Ranking Member of 
the Subcommittee, Senator Alexander, who also has a very real 
concern about these issues.
    Senator Dodd. With that, Dr. Levi, we thank you very much 
for joining us, and the floor is yours.

 STATEMENT OF JEFFREY LEVI, PH.D., EXECUTIVE DIRECTOR OF TRUST 
              FOR AMERICA'S HEALTH, WASHINGTON, DC

    Mr. Levi. Thank you, Mr. Chairman, and thank you very much 
for this opportunity to testify on this very serious issue of 
the declining health of America's children, which is closely 
linked to our Nation's obesity epidemic.
    As you noted, approximately 25 million children are obese 
or overweight, and rates of obesity have more than tripled 
since 1980. While a recent analysis from the National Health 
and Nutrition Examination Survey, known as NHANES, suggests 
that the number of U.S. children who are overweight or obese 
may have peaked after years of steady increases, scientists and 
public health officials are unsure if the data reflect real 
change or a statistical anomaly.
    Even if childhood obesity rates have peaked, the number of 
children with unhealthy BMIs remains unacceptably high, and the 
public health toll of childhood obesity will continue to grow 
as the problems related to overweight and obesity in children 
show up later in life. This will also threaten our economic 
competitiveness as a nation as our healthcare costs continue to 
rise, in part, due to obesity and overweight.
    How did this problem arise? In the simplest terms, one 
could argue this is just a matter of physics. Children today 
are eating more and moving less, which inevitably leads to 
increases in weight. That is true, but it is only a part of the 
story.
    We have also created a physical environment that re-
inforces a less-active lifestyle, and we have not compensated 
for this in the level of physical activity we promote in the 
schools. Thirty years ago, nearly half of American children 
walked or biked to school. Today, less than one in five do so.
    Children are also not getting enough activity in schools. 
According to CDC data, only 3.8 percent of elementary schools, 
7.9 percent of middle schools, and 2.1 percent of high schools 
provided daily physical education or its equivalent.
    We have also placed kids in a less nutritious environment. 
It is not just too much food, but too much bad food that kids 
are eating. We have not harnessed the opportunities of the 
school to compensate for the overall propensity among Americans 
to consume too much sugar and too few fruits and vegetables.
    What occurs in schools can be critical, given the number of 
children who depend on school breakfast and lunch for their 
meals and the patterns that school food access can create for 
all children. Current food and meal nutrition guidelines lack 
standards for sodium, trans fat and whole grains, and the fruit 
and vegetable content is too low. Yet new guidance from the 
USDA is not expected until 2010, despite a 2004 congressional 
requirement to issue new guidelines.
    We have placed a particular burden on our poor and minority 
children, who are disproportionately overweight and obese. 
Primarily because our poverty programs have not kept up with 
the rising cost of nutritious food, access to healthy food is 
often limited in poor neighborhoods, and physical activity may 
be limited because of safety concerns or inadequate 
recreational facilities.
    For example, African-American children are almost twice as 
likely to be obese. Similarly, the National Survey on 
Children's Health shows that rates of overweight decline as 
income rises. In 2003, 22.4 percent of kids below 100 percent 
of poverty were overweight, while only 9.1 percent of kids at 
400 percent or more of poverty were overweight.
    I think this outline of the problem shows that it will take 
more than telling kids to eat less and move more. We need a 
national commitment to change the physical and social 
environment in which children live, and all Americans will 
benefit from living in healthier communities. We must make 
healthy choices easy choices for all Americans, regardless of 
where they live or what school they attend. We need a cultural 
shift, one in which healthy environments, physical activity, 
and healthy eating become the norm.
    Tomorrow, Trust for America's Health will release a new 
report that examines how much the country could save by 
strategically investing in community disease prevention 
programs. The report concludes that an investment of $10 per 
person per year in proven community-based programs to increase 
physical activity, improve nutrition, and prevent smoking and 
other tobacco use could save the country more than $16 billion 
in healthcare costs annually within 5 years. This is a return 
of investment of $5.60 cents for every $1 invested.
    Harnessing this opportunity will require a true national 
strategy to combat obesity. At this time, we have no such 
national coordinated effort. It is time for a comprehensive, 
realistic plan that involves every department and agency of the 
Federal Government, State and local governments, businesses, 
communities, schools, families, and individuals.
    Our leaders should be challenged to do their part to 
improve our Nation's health. We know that even small changes 
can make big differences in people's health. The challenge is a 
big one, but we can make a difference together.
    Thank you again for the opportunity to testify, and I look 
forward to the discussion that follows.
    [The prepared statement of Dr. Levi follows:]
               Prepared Statement of Jeffrey Levi, Ph.D.
    Good afternoon. My name is Jeffrey Levi, and I am the Executive 
Director of Trust for America's Health (TFAH), a nonpartisan, nonprofit 
organization dedicated to saving lives by protecting the health of 
every community and working to make disease prevention a national 
priority. I would like to thank the Chairman, the Ranking Member and 
the members of the subcommittee for the opportunity to testify on a 
very serious issue--the declining health of America's children, which 
is closely linked to our Nation's obesity epidemic. Today I would like 
to discuss the scope of childhood obesity in America, the potential 
factors that may be contributing to it, the health and economic impacts 
of obesity, and the importance of developing a national strategy to 
coordinate our response to obesity. By focusing on the impact of 
obesity on the health of our children, we have a chance to reshape 
society--and assure that our children live healthier lives than we do. 
If we do it right, I believe we will also improve the health and well-
being of lots of adults in the process because the solutions to the 
obesity epidemic require a societal transformation that will benefit 
all of us.
                          scope of the problem
    Overall, approximately 23 million children are obese or overweight, 
and rates of obesity have more than nearly tripled since 1980, from 6.5 
percent to 16.3 percent.\1\ Eight of the 10 States with the highest 
rates of obese children are in the South.\2\
---------------------------------------------------------------------------
    \1\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass 
Index for Age among U.S. Children and Adolescents, 2003-2006.'' Journal 
of the American Medical Association 299, no. 20 (2008): 2401-2405.
    \2\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, Maternal and Child Health Bureau. National 
Survey of Children's Health 2003. Rockville, MD: U.S. Department of 
Health and Human Services, 2005, http://www.mchb.hrsa.gov/overweight/
techapp.htm (accessed April 22, 2008).
---------------------------------------------------------------------------
    According to a recent analysis from the National Health and 
Nutrition Examination Survey (NHANES), the number of U.S. children who 
are overweight or obese may have peaked, after years of steady 
increases. According to researchers from the Centers for Disease 
Control and Prevention (CDC), there was no statistically significant 
change in the number of children and adolescents (aged 2 to 19) with 
high BMI for age between 2003-2004 and 2005-2006.\3\ This is the first 
time the rates have not increased in over 25 years. Scientists and 
public health officials, however, are unsure if the data reflect the 
effectiveness of recent public health campaigns to raise awareness 
about obesity and increased physical activity and healthy eating among 
children and adolescents, or if this is a statistical abnormality. 
Scientists expect to know more when the 2007-2008 NHANES data are 
analyzed. The 2005-2006 National Survey on Children's Health, a large 
national survey with State-specific data, is also due out in late 2008 
and may offer another perspective on childhood obesity rates. Even if 
childhood obesity rates have peaked, the number of children with 
unhealthy BMIs remains unacceptably high, and the public health toll of 
childhood obesity will continue to grow as the problems related to 
overweight and obesity in children show up later in life. We should be 
setting a national goal to see childhood obesity rates return to 6.5 
percent, the level prior to the start of this epidemic.\4\
---------------------------------------------------------------------------
    \3\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass 
Index for Age among U.S. Children and Adolescents, 2003-2006.'' Journal 
of the American Medical Association 299, no. 20 (2008): 2401-2405. 
    \4\ U.S. Department of Health and Human Services, National Center 
for Health Statistics. Prevalence of Overweight Among Children and 
Adolescents: United States, 1999. Hyattsville, MD: National Center for 
Health Statistics; 2001. http://www.cdc.gov/nchs/products/pubs/pubd/
hestats/overwght99.htm (accessed July 14, 2008).
---------------------------------------------------------------------------
                 factors contributing to obesity rates
    How did this problem arise? In the simplest of terms, one could 
argue this is just a matter of physics--children today are eating more 
and moving less, which inevitably leads to increases in weight. That is 
true, but is only a part of the story.

     We have also created a physical environment that 
reinforces a less active lifestyle, and we have not compensated for 
this in the level of physical activity we promote in the schools.
     We have placed kids in a less nutritious environment--it 
is not just too much food, but too much bad food that kids are eating, 
and we have not harnessed the opportunities of the school to compensate 
for this.
     We have placed a particular burden on our poor and 
minority children, who are disproportionately overweight and obese, 
primarily because our poverty programs have not kept up with the rising 
cost of nutritious food; access to healthy foods is often limited in 
poor neighborhoods, and physical activity may be limited because of 
safety concerns or inadequate recreational facilities.

    To reverse this trend, we need a national commitment to change the 
physical and social environment in which children live. By doing so, we 
will also help adults--as all Americans benefit from living in 
healthier communities.
    The following is a sketch of the scope of the problem and some 
possible solutions. Our annual report on obesity, F as in Fat: How 
Obesity Policies Are Failing in America, is available at our Web site, 
www.healthyamericans.org, and provides a more comprehensive look at 
these issues. The 2008 edition will be released in August.
Food and Physical Activity
    Many American children are consuming more calories, eating less 
healthful foods, engaging in less physical activity and instead 
spending their time engaging in sedentary activities. Overall, ``added 
sugar'' consumption for Americans is nearly three times the U.S. 
Department of Agriculture's (USDA) recommended level,\5\ and adolescent 
females ages 12-15 consumed approximately 4 percent more calories in 
1999-2000 than they did in 1971-1974.\6\ In 2003, a USDA report 
characterized America's per capita fruit consumption as ``woefully 
low'' and noted that vegetable consumption ``tells the same story.'' 
\7\ Moreover, since the 1970s, fast food consumption in children has 
increased five-fold. In the late 1970s, children received approximately 
2 percent of their daily meals from fast food; by the mid-1990s, that 
increased to 10 percent. Children who consume fast food, as compared 
with those who do not, have higher caloric intake, more fat and 
saturated fat, and more added sugar.\8\
---------------------------------------------------------------------------
    \5\ Putnam, J., J. Allshouse, and L.S. Kantor. ``U.S. per Capita 
Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.'' 
Food Review 25, no. 3 (2002): 1-14.
    \6\ Briefel, R.R. and C.L. Johnson. ``Secular Trends in Dietary 
Intake in the United States.'' Annual Review of Nutrition 24, (2004): 
401-431.
    \7\ Putnam, J., J. Allshouse, and L.S. Kantor. ``U.S. per Capita 
Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.'' 
Food Review 25, no. 3 (2002): 1-14.
    \8\ Asche, K. ``Fast Foods May Increase Childhood Obesity Rates.'' 
University of Minnesota Extension. (2005). http://
www.extension.umn.edu/extensionnews/2005/fastfood.html (accessed July 
14, 2008).
---------------------------------------------------------------------------
    In addition to developing poor dietary habits, many children are 
becoming less physically active. For example, 30 years ago, nearly half 
of American children walked or biked to school; today, less than one in 
five either walk or bike to school.\9\ Increased screen time--whether 
television or computers--is associated with higher rates of overweight 
and obesity. Furthermore, according to the CDC's latest School Health 
Policies and Programs Study, only 3.8 percent of elementary schools, 
7.9 percent of middle schools and 2.1 percent of high schools provided 
daily physical education or its equivalent. Some attribute at least 
part of this decline in physical activity programs to the academic 
requirements of No Child Left Behind. That is unfortunate as there is 
growing evidence that fitter more active students perform better 
academically.
---------------------------------------------------------------------------
    \9\ McDonald, N.C. ``Active Transportation to School: Trends among 
U.S. Schoolchildren, 1969-2001.'' American Journal of Preventive 
Medicine 32, no. 6 (2007): 509-516.
---------------------------------------------------------------------------
Health Impacts
    The health impacts of obesity and physical inactivity are dire and 
can start at a young age. Physical inactivity is tied to heart disease 
and stroke risk factors in children and adolescents. A number of 
studies have documented how obesity increases a child's risk for a 
number of health problems, including the emerging onset of type 2 
diabetes, increased cholesterol and hypertension among children, and 
the danger of eating disorders among obese adolescents.\10\ Some 
studies have shown that obesity and overweight in children also 
negatively affect children's mental health and school performance. The 
recent recommendation by the American Academy of Pediatrics for 
cholesterol screening of kids--with the possibility of prescription of 
cholesterol lowering drugs for young children--is just another tragic 
example of how much obesity has affected the health of our children.
---------------------------------------------------------------------------
    \10\ U.S. Department of Health and Human Services (USDHHS). The 
Surgeon General's Call to Action to Prevent and Decrease Overweight and 
Obesity. Washington, DC: USDHHS, 2001.
---------------------------------------------------------------------------
Economic Impact
    These health impacts come at a great cost to our Nation. According 
to the Department of Health and Human Services, obese and overweight 
adults cost the United States anywhere from $69 billion to $117 billion 
per year.\11\ One study found that obese Medicare patients' annual 
expenditures were 15 percent higher than those of normal or overweight 
patients. The cost of childhood obesity is also growing. Between 1979 
and 1999, obesity-associated hospital costs for children (ages 6 to 17 
years) more than tripled, from $35 million to $127 million.\12\
---------------------------------------------------------------------------
    \11\ U.S. Centers for Disease Control and Prevention. ``Preventing 
Obesity and Chronic Diseases Through Good Nutrition and Physical 
Activity.'' U.S. Department of Health and Human Services, http://
www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm 
(accessed July 14, 2008).
    \12\ Ibid.
---------------------------------------------------------------------------
    The poor health of Americans of all ages is putting the Nation's 
economic security in jeopardy. More than a quarter of U.S.-health care 
costs are related to physical inactivity, overweight and obesity. 
Health care costs of obese workers are up to 21 percent higher than 
non-obese workers. Obese and physically inactive workers also suffer 
from lower worker productivity, increased absenteeism, and higher 
workers' compensation claims. To maintain our economic competitiveness 
and our general health and well-being, we must improve the health of 
America's next generation. To do that, we must improve diet and 
physical activity levels.
National Security Impact
    The problem of obesity and overweight has reduced the number of 
volunteers for military service who must meet height and weight 
requirements. At a time when military recruiters are struggling to meet 
the needs of our Armed Forces, we are finding more and more volunteers 
who are overweight and obese. In 1993, 25.6 percent of 18-year-old 
volunteers were overweight or obese; in 2006 that percentage rose to 
almost 34 percent.\13\ This problem continues during active duty. Each 
year between 3,000 and 5,000 service members are forced to leave the 
military because they are overweight.\14\
---------------------------------------------------------------------------
    \13\ Hsu, L.L., R.L. Nevin, S.K. Tobler, and M.V. Rubertone. 
``Trends in Overweight and Obesity among 18-Year-Old Applicants to the 
United States Military, 1993-2006.'' The Journal of Adolescent Health 
41, no. 6 (2007): 610-612.
    \14\ Cable News Network. ``Discharged Servicemen Dispute Military 
Weight Rules.'' CNN.com, September 6, 2000. http://www.cnn.com/2000/
HEALTH/09/06/military.obesity/index.html (accessed May 2, 2008).
---------------------------------------------------------------------------
An Environment That Discourages Physical Activity and Healthy Eating
    The built environment and community design can have a great impact 
on nutrition and physical activity levels. For children, the placement 
of schools and access to safe venues for physical activity are 
particularly important. One study found that the primary reason that 
children do not walk or bike to school is because their school is too 
far away. Other concerns included too much traffic, no safe route, fear 
of abduction, crime in the neighborhood, and lack of convenience.\15\ A 
Government Accountability Office study found that ``areas of low 
socioeconomic status and high minority populations had fewer venues for 
physical activity'' and ``adolescents in unsafe neighborhoods engage in 
less physical activity'' than their peers. Even where opportunities for 
physical activity may be available--such as school playgrounds--many 
communities are encountering liability concerns as an impediment to 
after-hours use of these community resources.
---------------------------------------------------------------------------
    \15\ U.S. Centers for Disease Control and Prevention (CDC). 
``Barriers to Children Walking and Biking to School--United States, 
1999.'' Morbidity and Mortality Weekly Report 51, no. 32 (2002): 701-
704.
---------------------------------------------------------------------------
    Access to nutritious foods is another important issue that can 
affect children's health. Everything from the foods sold in schools to 
the presence or absence of grocery stores and markets selling fresh 
fruits and vegetables in communities to the foods that parents serve to 
their children can influence obesity levels and ultimately health care 
costs.
    What occurs in schools can be critical--given the number of 
children who depend on school breakfast and lunch for their meals and 
the patterns that school food access can create for all children. In 
2004, the Child Nutrition and WIC Reauthorization Act of 2004 (P.L. 
108-265) required the U.S. Secretary of Agriculture to issue school 
nutrition guidelines that would ensure that American schoolchildren 
consume foods recommended in the most recent Dietary Guidelines for 
Americans (DGAs); however, USDA has issued no proposed regulations in 
the 3 years since the release of the 2005 DGAs.\16\ Instead, USDA 
contracted with the Institute of Medicine (IOM) to convene a panel of 
experts on child nutrition. In late 2009, the IOM Committee on 
Nutrition Standards for School Lunch and Breakfast Programs is expected 
to provide USDA with recommendations for updating the school meal 
programs' nutrition requirements. Once USDA receives the IOM 
recommendations, agency officials will then seek to incorporate them 
into formal USDA guidance, which is expected to be issued some time in 
2010. A final rule will take even longer to be issued. This turn of 
events effectively postpones the update of school meal nutrition 
standards by 5 years beyond when they were due. Given the fact that 
school meal nutrition standards lack standards for sodium, trans fat, 
and whole grains, and that the fruit and vegetable content is too low, 
this delay is of considerable public health concern.
---------------------------------------------------------------------------
    \16\ U.S. Department of Agriculture (USDA). Incorporating the 2005 
Dietary Guidelines for Americans into School Meals. SP 04-2008. 
Washington, DC: USDA, 2007.
---------------------------------------------------------------------------
Disparities
    Unfortunately, as with too many other health problems facing our 
Nation, obesity often disproportionately affects minorities and the 
poor. African-American children are almost twice as likely to be 
obese.\17\ Black and Hispanic adolescents have higher rates of physical 
inactivity (by 5-6 percentage points).\18\
---------------------------------------------------------------------------
    \17\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, Maternal and Child Health Bureau. National 
Survey of Children's Health 2003. Rockville, MD: U.S. Department of 
Health and Human Services, 2005.
    \18\ U.S. Centers for Disease Control and Prevention. ``Youth Risk 
Behavior Surveillance--United States, 2007.'' Morbidity and Mortality 
Weekly Report 57, no. SS-4 (2008): 1-136.
---------------------------------------------------------------------------
    Equally disturbing, is the apparent relationship between being 
overweight and poverty. The National Survey on Children's Health (2003) 
shows that rates of overweight decline as income rises (22.4 percent of 
kids below 100 percent of poverty were overweight; only 9.1 percent of 
kids at 400 percent or more of poverty were overweight). Similarly, 
rates of physical inactivity are greater for poor kids (17 percent who 
were under 100 percent of poverty engaged in no vigorous physical 
activity each week; only 7.8 percent of those at 400 percent of poverty 
fell into that category). Eating healthier can be very expensive. 
Calorie dense foods tend to be less expensive; supermarkets are less 
likely to be accessible in poor neighborhoods; and poor children are 
more dependent on school nutrition programs, which are not always 
meeting the highest standards. The current rise in food prices raises 
serious concerns about the impact on obesity among poor children. 
Programs such as food stamps are not keeping up with rising prices and 
do not provide adequate financial incentives to encourage healthier 
eating by providing larger benefits for healthier food, though some 
notable improvements were made through the passage of the Food, 
Conservation, and Energy Act of 2008 (P.L. 110-246).
                          community prevention
    As a nation, we tend to over-medicalize health problems. In fact, 
given the state of today's science--medicine can only address the 
consequences of overweight and obesity, not prevent it. Real prevention 
requires changing the communities in which children (and adults) live 
and approaching this as a community-wide, not just an individual, 
challenge. It will also be the most cost-effective way to mitigate this 
epidemic. To truly tackle the obesity epidemic, we must make healthy 
choices easy choices for all Americans, regardless of where they live 
or what school they attend. We need a cultural shift, one in which 
healthy environments, physical activity and healthy eating become the 
norm.
    Tomorrow Trust for America's Health will release a new report, 
Prevention for a Healthier America: Investments in Disease Prevention 
Yield Significant Savings, Stronger Communities, which examines how 
much the country could save by strategically investing in community 
disease prevention programs. The report concludes that an investment of 
$10 per person per year in proven community-based programs to increase 
physical activity, improve nutrition, and prevent smoking and other 
tobacco use could save the country more than $16 billion annually 
within 5 years. This is a return of $5.60 for every $1. The economic 
findings are based on a model developed by researchers at the Urban 
Institute and a review of evidence-based studies conducted by the New 
York Academy of Medicine. The researchers found that many effective 
prevention programs cost less than $10 per person, and that these 
programs have delivered results in lowering rates of diseases that are 
related to physical activity, nutrition, and smoking. The evidence 
shows that implementing these programs in communities reduces rates of 
type 2 diabetes and high blood pressure by 5 percent within 2 years; 
reduces heart disease, kidney disease, and stroke by 5 percent within 5 
years; and reduces some forms of cancer, arthritis, and chronic 
obstructive pulmonary disease by 2.5 percent within 10 to 20 years, 
which, in turn, can save money through reduced health care costs to 
Medicare, Medicaid and private payers.
                  examples of successful interventions
    Community and school-based approaches aimed at using reducing 
obesity in the United States have already shown to be successful. The 
Child and Adolescent Trial for Cardiovascular Health (CATCH) elementary 
school program provides education for students, modifications for 
improvements in school lunches and physical education, and increased 
education for staff and teachers. Results have shown that students in 
the program consumed healthier diets and engaged in more physical 
activity.
    The town of Somerville, MA developed a comprehensive program called 
``Shape Up Somerville'' to curtail childhood obesity rates. The project 
included partners across the community. Various restaurants started 
serving low-fat milk and smaller portion sizes; the school district 
nearly doubled the amount of fresh fruit at lunch and started using 
whole grain breads; the town expanded a local bike path and repainted 
crosswalks; and the town targeted crossing guards to areas where 
children are most likely to walk to school. Researchers evaluated the 
program after 1 year and found that children in Somerville gained less 
weight than children in surrounding communities. (Growing children are 
expected to gain some weight.)
    Another example of a coordinated approach to obesity reduction at 
the community level is the YMCA's Pioneering Healthier Communities. 
This project supports local communities in promoting healthy 
lifestyles. Examples of interventions have included offering fruits and 
vegetables and encouraging physical activity during after school 
programs; influencing policymakers to ``put physical education back in 
schools and include physical activity in after school programs''; 
building or enhancing bicycle and pedestrian trails; and increasing 
access to fresh produce in communities through community gardens, 
farmers markets and other activities.
                           national strategy
    Clearly, it has taken years for the childhood obesity epidemic to 
develop, and it will take a coordinated effort over time to begin to 
mitigate it. At this time, we have no national, coordinated effort to 
combat obesity. TFAH supports the development of a National Strategy to 
Combat Obesity. This needs to be a comprehensive, realistic plan that 
involves every department and agency of the Federal Government, State 
and local governments, businesses, communities, schools, families, and 
individuals. It must outline clear roles and responsibilities. Our 
leaders should challenge the entire Nation to share in the 
responsibility and do their part to help improve our Nation's health. 
All levels of government should develop and implement policies to make 
healthy choices easy choices--by giving Americans the tools they need 
to make it easier to engage in the recommended levels of physical 
activity and choose healthy foods, ranging from improving food served 
and increasing opportunities for physical activity in schools to 
securing more safe, affordable recreation places for all Americans.
    The ``National Strategy for Pandemic Influenza Planning'' provides 
a strong example for how this type of effort can be undertaken. With 
leadership and goals identified by health agencies and experts, every 
cabinet agency has taken charge of developing and implementing policies 
and programs in their jurisdiction that all contribute to our Nation's 
preparedness for a pandemic flu outbreak. Similarly, the United Kingdom 
has announced an anti-obesity strategy to ``transform the environment'' 
in which people in England live, including launching a campaign to 
promote healthy living and healthy towns with bicycle and pedestrian 
routes.
                               conclusion
    Our country needs to focus on developing policies that help 
Americans make healthier choices about nutrition and physical activity. 
We know that even small changes can make a big difference in people's 
health--and that individuals don't make decisions in a vacuum. If we 
want our children to lead healthy, productive lives, we need a strong 
partnership from the government, private and nonprofit sectors, as well 
as parents and teachers, to emphasize wellness and enhance nutrition 
and physical activity. The challenge is a big one, but we can make a 
difference together. Thank you again for the opportunity to testify.
                                 ______
                                 
                                Summary
    Overall, approximately 23 million children are obese or overweight, 
and rates of obesity have nearly tripled since 1980. According to a 
recent analysis from the National Health and Nutrition Examination 
Survey (NHANES), the number of U.S. children who are overweight or 
obese may have peaked, after years of steady increases. Scientists and 
public health officials, however, are unsure if this is a statistical 
abnormality. Even if childhood obesity rates have peaked, the number of 
children with unhealthy BMIs remains far too high, and the public 
health toll of childhood obesity will continue to grow as the problems 
related to overweight and obesity in children show up later in life.
    A number of factors have contributed to the Nation's childhood 
obesity epidemic. Children are eating more and moving less, which 
inevitably leads to increases in weight, but that is only a part of the 
story. We have also created a physical environment that reinforces a 
less active lifestyle, and we have not compensated for this in the 
level of physical activity we promote in the schools. We have placed 
kids in a less nutritious environment--it is not just too much food, 
but too much bad food that kids are eating, and we have not harnessed 
the opportunities of the school to compensate for this.
    The health and economic impacts of obesity are very serious. 
According to the Department of Health and Human Services, obese and 
overweight adults cost the United States anywhere from $69 billion to 
$117 billion per year. More than a quarter of U.S. health care costs 
are related to physical inactivity, overweight and obesity. To maintain 
our economic competitiveness and our general health and well-being, we 
must improve the health of America's next generation. To do that, we 
must improve diet and physical activity levels.
    Real prevention requires changing the communities in which children 
(and adults) live and approaching this as a community-wide, not just an 
individual challenge. It will also be the most cost-effective way to 
mitigate this epidemic. To truly tackle the obesity epidemic, we must 
make healthy choices easy choices for all Americans, regardless of 
where they live or what school they attend. We need a cultural shift, 
one in which healthy environments, physical activity and healthy eating 
become the norm.
    It has taken years for the childhood obesity epidemic to develop, 
and it will take a coordinated effort over time to begin to mitigate 
it. At this time, we have no national, coordinated effort to combat 
obesity. We need a National Strategy to Combat Obesity, a 
comprehensive, realistic plan that involves every department and agency 
of the Federal Government, State and local governments, businesses, 
communities, schools, families, and individuals. If we want our 
children to lead healthy, productive lives, we need a strong 
partnership from the government, private and nonprofit sectors, as well 
as parents and teachers, to emphasize wellness and enhance nutrition 
and physical activity.

    Senator Dodd. Thank you very, very much, and I have some 
questions for you, which I will raise in a few minutes.
    Dr. Levi. OK.
    Senator Dodd. Dr. Kaufman, thank you so much. Thank you 
very much. I attend every year, and am very active in the 
juvenile diabetes program in my home State of Connecticut. I 
have some wonderful friends with children who have diabetes, 
and we do a great effort in Connecticut. Thank you for your 
work.

STATEMENT OF FRANCINE KAUFMAN, M.D., PAST NATIONAL PRESIDENT OF 
 THE AMERICAN DIABETES ASSOCIATION, DISTINGUISHED PROFESSOR OF 
 PEDIATRICS AND COMMUNICATIONS AT THE KECK SCHOOL OF MEDICINE 
AND THE ANNENBERG SCHOOL OF COMMUNICATIONS AT THE UNIVERSITY OF 
              SOUTHERN CALIFORNIA, LOS ANGELES, CA

    Dr. Kaufman. Great. Thank you for your commitment.
    Chairman Dodd, it is truly an honor to be here, and I thank 
you for allowing me the opportunity to testify before you 
today.
    Examining the ravages of the obesity and diabetes epidemics 
in the United States and around the globe is not only what I do 
by my profession as a pediatric endocrinologist, but I do it as 
a passion. Obesity has reached epidemic proportions in the 
United States. It has increased in both genders and in all 
racial, ethnic, and socioeconomic groups.
    With 198 million Americans estimated to be obese or 
overweight and the prevalence of diabetes now at nearly 24 
million, it is urgent that Congress focus on this topic today.
    Since 1990, the prevalence of obesity has tripled among our 
children and adolescents. As you said, one in three in the 
United States are now classified as overweight or obese. Of 
great importance is that childhood obesity is a significant 
predictor of obesity in adulthood.
    Over the last 3 years, changes in demographics and societal 
norms have contributed to the rise of childhood obesity. We 
have seen dramatic changes in nutrition and physical activity 
habits of America's children. The vast majority of today's 
young children do not follow a nutritious diet, and only about 
a third get sufficient physical activity.
    That is why it is not unusual for me when I see infants 
coming to me at my center in Los Angeles with soda in their 
baby bottles and when I am told that the first solid food given 
to that child was a French fry. Children who are overweight, 
obese, and unfit are at increased risk of becoming seriously 
depressed. They have fatty liver disease, and they develop high 
blood pressure, abnormal lipid levels, inflammation in their 
blood vessels, and higher than normal blood sugar values.
    These last disorders are the precursors of adult-onset 
cardiovascular disease and type 2 diabetes. Dangerously, trends 
during the 1990s illustrate type 2 diabetes in youth, which was 
exclusively a disorder of the adult population when I began my 
career. Now type 2 diabetes has increased ten-fold in our 
youth, closely mirroring the childhood obesity epidemic.
    As these epidemics have unfolded, we have found that both 
obesity and type 2 diabetes disproportionately affect minority 
and poor children. The prevalence of childhood obesity and type 
2 diabetes among African-Americans, Mexican-Americans, and 
especially Native Americans exceeds that of other ethnic and 
racial groups. Estimates show that one in three children born 
in the year 2000 or beyond will develop diabetes at some point 
in their lives, but for minority children, this statistic is 
closer to one in two.
    On a personal level, I have seen heartbreaking examples of 
childhood obesity epidemic in my medical practice. In 1995, I 
saw one of the first children who heralded in the type 2 
diabetes epidemic in youth. She was a 13-year-old girl with a 
blood sugar value of 427 milligrams per deciliter, a value at 
least 5 times higher than normal. She weighed 267 pounds, and 
she was 5 foot, 1 inches tall.
    She came into my office with her mother and her 
grandmother, who each weighed over 250 pounds. Her diet 
consisted of fried foods, candy bars, and soda, most of which 
she obtained inside her school, and outside meals from fast 
food restaurants because there were few grocery stores in her 
neighborhood. Her school did not offer meaningful physical 
education, and there was no place safe to play in her 
neighborhood. So, she watched 5 hours of TV a day.
    Her grandmother had had uncontrolled type 2 diabetes and 
had suffered from a stroke and an amputation. The girl's mother 
had pre-diabetes, and even despite this strong family history, 
in 1995, it was hard to believe that a girl so young could have 
type 2 diabetes. It is not hard to believe it anymore.
    This young girl left my office taking five medications, but 
still remained at high risk for the complications of diabetes. 
I knew it would be hard for her to control her disease, and I 
knew that, as a result, 15 years would likely be taken from her 
life. Although that day I felt as if I had been in a battle, 
over the subsequent years, it has become clear that I and my 
colleagues are really in a war, and it is a war that we have 
yet to win.
    For my patient to do well, the world in which she lives 
will have to change. Her neighborhood, her school, her 
healthcare system that focuses on treatment rather than 
prevention, essentially the landscape of our country will have 
to transform so that it promotes and supports healthy lifestyle 
habits and makes healthy choices the easy choices and the 
accessible and affordable ones.
    My patient will need to make changes, too. Without a 
supportive environment, those changes--eating well, getting 
active, losing weight--which may sound easy, have been 
impossible for her to do. Today, there is no doubt that obesity 
and youth, along with its associated myriad of medical 
conditions, is a major health challenge of the century.
    There is no doubt that we have had some early efforts on 
the part of government, the private sector, and the medical and 
public health systems, but to date, they have not been 
sufficient to reverse the trend and control the number of 
children who are becoming overweight and obese and the number 
of children who are subsequently becoming ill. It is imperative 
that more be done to combat the ever-growing epidemics of 
obesity and diabetes.
    I thank you for the opportunity to speak before you today. 
I know we share the passion of enabling the children of America 
to grow up healthy and well.
    Thank you very much.
    [The prepared statement of Dr. Kaufman follows:]
              Prepared Statement of Francine Kaufman, M.D.
    Chairman Dodd, Ranking Member Alexander and members of the 
subcommittee, good afternoon. My name is Dr. Fran Kaufman and I am a 
pediatric endocrinologist and professor of Pediatrics and 
Communications at the Keck School of Medicine and the Annenberg School 
of Communications at the University of Southern California. Examining 
the ravages of the obesity and diabetes epidemics in the United States 
and around the globe is not only my specialty, but also my passion. I 
thank you for holding this hearing and allowing me the opportunity to 
testify before you today on the dangerous health consequences of 
childhood obesity.
    Obesity has reached epidemic proportions in the United States. It 
has increased in both genders, and in all racial, ethnic and 
socioeconomic groups. With 198 million Americans estimated to be 
overweight or obese according to the CDC and the prevalence of diabetes 
having risen to 23.6 million Americans--an increase of nearly 3 million 
people over the 2-year period from 2005 to 2007--it is especially 
valuable to be holding this hearing on this topic today.
    We have seen the prevalence of obesity triple among children 6 to 
11 years and adolescents 12 to 17 years since 1980.\1\ A total of 9 
million children ages 6 to 19 in the United States are now classified 
as overweight or obese. The overall prevalence of obesity in children 
was 17 percent in 2006. Alarmingly, we are seeing an increase in very 
young children, now over 1 in 5 young children 2 to 5 years of age are 
overweight or obese. Of great importance is the fact that obesity in 
childhood is a significant predictor of obesity in adulthood.
---------------------------------------------------------------------------
    \1\ National Health and Nutrition Examination Surveys (NHANES) 
(Ogden, C.L., Flegal, K.M., Carroll, M.D., Johnson, C.L.: Prevalence 
and Trends in Overweight Among United States Children and Adolescents, 
1999-2000. JAMA 288:1728-1732, 2002).
---------------------------------------------------------------------------
    Many researchers have placed the origin of the childhood obesity 
epidemic at the beginning of the 1980s. Since that time, we have seen 
dramatic changes in the nutrition and physical activity habits of 
American children, along with changes in demographics and societal 
norms that have all contributed to the rise in childhood obesity. 
According to the CDC only 20 percent of students eat the recommended 5 
servings of fruits and vegetables per day and only 2 percent of 
children currently meet the USDA's 5 main healthy diet recommendations. 
Additionally only 35 percent of students are physically active for at 
least 60 minutes per day meeting the recommended guidelines. Barely 
more than half of students, 54 percent, attend physical education 
classes at least 1 day a week.
    During childhood, obesity impairs psychosocial well-being and obese 
children are socially isolated. They perform poorly in school and have 
a poorer self-image than children who have a normal weight. Obesity in 
children is associated with severe impairments in quality of life. In 
fact, obese children have characterized their lives as being equal to 
those of children with cancer.
    Childhood obesity is associated with serious metabolic 
disturbances, obstructive sleep apnea, asthma, fatty liver disease, 
orthopedic problems, ovarian dysfunction, and chronic kidney ailments. 
Children who are overweight, obese and unfit are at an increased risk 
of developing high blood pressure, abnormal lipid levels, inflammation 
in their blood vessels, and higher than normal blood sugar levels.
    These factors are the precursors of adult-onset cardiovascular 
disease and diabetes. During the mid-1990s, type 2 diabetes in youth 
increased ten-fold in the United States, and mirrored the childhood 
obesity epidemic. Diabetes is a chronic condition in which the pancreas 
either does not create any insulin, which is type 1 diabetes, or the 
body doesn't create enough insulin and/or cells are resistant to 
insulin, which is type 2 diabetes.
    Diabetes is the leading cause of kidney disease, adult onset 
blindness, and lower limb amputations and can lead to heart disease and 
stroke.
    Childhood obesity disproportionately affects minority and poor 
children. The prevalence of childhood obesity among African-Americans, 
Mexican-Americans and Native Americans exceeds that of other ethnic 
groups. The Centers for Disease Control reported that in 2000 the 
prevalence of obesity was 19 percent for non-Hispanic black children 
and 20 percent for Mexican-American children, compared to 11 percent 
for non-Hispanic white children. The increase since 1980 is 
particularly evident among non-Hispanic black and Mexican-American 
adolescents.
    Similarly, type 2 diabetes in the pediatric population is 
disproportionately seen in Hispanic, Native American, and African-
American adolescents. Estimates show that one in three children born in 
the year 2000 will develop diabetes at some point in his or her life, 
but this statistic is nearly one in two for minority children. The 
SEARCH for Diabetes in Youth Population Study, sponsored by the CDC and 
NIH, found that the proportion of all diabetes that was diagnosed as 
type 2 varied by ethnicity among 10- to 19-year-olds: 6 percent for 
non-Hispanic whites, 22 percent for Hispanics, 33 percent for African-
Americans, 40 percent for Asians/Pacific Islanders, and 76 percent for 
Native Americans.\2\
---------------------------------------------------------------------------
    \2\ Liese, A.D., D'Agostino, R.B., Jr., Hamman, R.F., Kilgo, P.D., 
Lawrence, J.M., Liu, L.L., Loots, B., Linder, B., Marcovina, S., 
Rodriguez, B., Standiford, D., Williams, D.E.: The Burden of Diabetes 
Mellitus Among U.S. Youth: Prevalence Estimates from the SEARCH for 
Diabetes in Youth Study. Pediatrics 118:1510-1518, 2006.
---------------------------------------------------------------------------
    An extraordinary example of the rise of type 2 diabetes in youth is 
shown through the marked increase in the prevalence of type 2 diabetes 
in Pima Indian youth over the last 20 years. Before the 1990s, almost 
no younger children and less than 1 percent of older children in the 
Pima Indian community had type 2 diabetes. By the mid-90s, 2.2 percent 
of 10- to 14-year-olds and 5 percent of those 15- to 19-years-old had 
type 2 diabetes.\3\ As a result of diabetes, many young adults who 
developed the disease as adolescents are now suffering prematurely from 
the long-term complications of this devastating disease.
---------------------------------------------------------------------------
    \3\ Dabelea, D., Hanson, R.L., Bennett, P.H., Roumain, J., Knowler, 
W.C., Pettitt, D.J.: Increasing Prevalence of Type II Diabetes in 
American Indian Children. Diabetologia 41:904-910, 1998.
---------------------------------------------------------------------------
    Of further concern, the significant rise in obesity in children has 
been accompanied by an increase in the severity of obesity, and there 
are differences in the degree of obesity among racial groups. The 
prevalence of severe obesity (BMI > 30 kg/m2) in female adolescents was 
approximately 10 percent in non-Hispanic whites, 20 percent in non-
Hispanic blacks and 16 percent in Mexican-Americans.
    In one of the NIH studies of which I am the chair, called the 
HEALTHY middle-school trial, we have found that low-income, minority 
middle school students in 7 cities across the country have high rates 
of pre-diabetes associated with overweight and obesity. Pre-diabetes is 
a condition that is diagnosed when someone has a higher than normal 
fasting blood sugar level or a higher than normal value after a glucose 
tolerance test, but not one in the diabetes range. An estimated 57 
million Americans have pre-diabetes today.\4\ In adult studies the 
conversion rate is about 10 percent per year. In this particular study 
we found that 39 percent of 8th graders and 14 percent of 6th graders, 
these are 13- and 11-year-old children, respectively, had pre-diabetes, 
with the highest rates found in Hispanic and American Indian youth. Not 
only did these 13-year-old students have abnormal blood glucose levels, 
but 15 percent had high blood pressure, half had abnormal lipid levels, 
and 8 percent had fatty liver disease. Fatty liver disease is also a 
new phenomenon in youth, and there is an indication that this might 
lead to early liver failure, which if not treated with a liver 
transplant will result in death. Fatty liver disease is more common in 
obese boys than in obese girls, and differs significantly by race/
ethnicity. In obese children ages 2-19, 65 percent of Hispanics, 35 
percent of whites and 10 percent of blacks had fatty liver disease.\5\
---------------------------------------------------------------------------
    \4\ Centers for Disease Control and Prevention, 2007 National 
Diabetes Fact Sheet.
    \5\ Schwimmer, J.B., Deutsch, R., Kahen, T., Lavine, J.E., Stanley, 
C., Behling, C.: Prevalence of Fatty Liver in Children and Adolescents. 
Pediatrics 118:1388-1393, 2006.
---------------------------------------------------------------------------
    On a personal level, I have seen heart-breaking examples of the 
childhood obesity epidemic in my medical practice. I remember one of 
the first children I saw with type 2 diabetes just as this epidemic was 
beginning. It was in the middle of spring in 1995. She was a 13-year-
old girl with a blood sugar level of 427 mg/dl, at least five times 
higher than normal for a young teen. She weighed 267 pounds. She came 
to my office with her mother and grandmother, they each weighed about 
250 pounds. She had been drinking a lot of juice and soda throughout 
her life. Her diet consisted of fried foods, candy bars, and meals from 
fast food restaurants. She did not have access to meaningful physical 
education courses in her school curricula and there was nowhere safe to 
play in her neighborhood. She watched 5 hours or more of TV a day.
    Her grandmother had type 2 diabetes and had never controlled her 
blood sugar levels. Five years earlier she had suffered from a stroke 
and an amputation. My patient's mother had been diagnosed with pre-
diabetes. Despite her strong family history of diabetes, no one 
believed that this 13-year-old girl had this disease--because she was 
just too young.
    Her mother told me she watched diabetes destroy her own mother, and 
she did not want to see that happen to her child. To control her high 
blood sugar level, her high blood pressure, and her high cholesterol, 
this young girl left my office taking five medications. Even still, she 
remained at high risk and it would be hard to control her disease and 
all its attendant problems. I knew that at least 15 years would be 
peeled off this young woman's life.
    That day I felt as if I had been in a battle, but I am really in a 
war. A war we have yet to win. For my patient to do well, the world in 
which she lived would have to change. Her neighborhood, her school, the 
healthcare system that focuses more on treatment than prevention--our 
country--would have to transform so that it promotes and supports 
healthy lifestyle habits and make the healthy choices the easy 
choices--the accessible and affordable choices. My patient would need 
to make changes too, but without a supportive environment, those 
changes,--eating well, getting active and losing weight--might be 
impossible for her to make. In my office in 1995, I knew that a world 
of battles would have to be fought for my patient, and for too long 
that war has been going on. As I stand before you today, I am hopeful 
the time has come for the war to be won.
    Today, there is no doubt that obesity in youth, along with its 
associated medical conditions, is the major health challenge of this 
century. Although attention has been paid to this problem by government 
and public health officials, researchers, and health care providers, 
the number of overweight and obese youth continues to increase. More 
needs to be done to combat the ever growing epidemics of obesity and 
diabetes.
    Again, thank you for the opportunity to speak before you today. I 
look forward to the opportunity to answer any of your questions.

    Senator Dodd. Thank you very much, Dr. Kaufman.
    Dr. Grey, thank you very much for being with us as well.
    You will see, by the way, we have been joined by Senator 
Harkin and Senator Murkowski, and I thank you both for being 
here.
    We will let our witnesses finish, and then I am going to 
ask each of you to make some opening comments, if you would. Is 
that OK?
    Go ahead, Dr. Grey.

 STATEMENT OF MARGARET GREY, DrPH, R.N., FAAN, DEAN AND ANNIE 
   GOODRICH PROFESSOR, YALE SCHOOL OF NURSING, NEW HAVEN, CT

    Ms. Grey. Senator Dodd and Senators Harkin and Murkowski, 
thank you so much for the opportunity to speak with you today 
about childhood obesity.
    In my 30 years of experience, I have found that the obesity 
epidemic in youth is multifaceted, threatening not only their 
future health, but their quality of life, their potential for 
educational achievement, and ultimately, future employment 
potential.
    As a nurse with training in both public health and social 
psychology, my interest has always been in preventing illness 
and, in the case of obesity and diabetes, preventing 
complications. When I began working in this field in the 1970s, 
I never saw a child with type 2 diabetes. Now up to 50 percent 
of new cases of diabetes in children are type 2 diabetes, what 
we used to call ``adult-onset'' diabetes.
    While it is most common in teens, we have had children as 
young as 5 years old with type 2 diabetes in our service. 
Worse, it appears that this diabetes is very aggressive, and 
these youth develop the devastating complications of diabetes--
cardiovascular disease, kidney disease, blindness, and 
amputations--at an early age. Indeed, the early longitudinal 
studies of these youth suggest that while they are in their 
20s, they are already having heart attacks and on renal 
dialysis.
    Beyond physical complications, there are complications 
related to quality of life, depression, and academic 
achievement. Let me illustrate how serious these complications 
can be.
    Quality of life refers to self-reported physical, 
emotional, social, and school functioning. In 2003, a research 
study found that obese teens have lower quality of life than 
teens with cancer. If childhood overweight and obesity lead to 
a reduced quality of life, then these youth are at risk for 
psychological, social, and educational complications along with 
the medical ones.
    With funding from the National Institutes of Nursing 
Research, my colleagues and I have been studying approaches to 
prevent type 2 diabetes in youth who are overweight or obese 
and have a family history of type 2 diabetes. These are the 
youth who will be most likely to develop diabetes in the next 5 
to 10 years.
    In the New Haven middle schools where we conducted our 
work, we identified that at least 30 percent of these 
overweight high-risk youth had levels of depression requiring 
referral of treatment. This isn't minor sadness. This is 
serious depression. Those who were depressed also had much 
poorer dietary and activity behaviors, lower self-efficacy, 
higher body mass index, and higher fasting insulin levels.
    From studies of adults with diabetes, we know that 
depression is not uncommon and associated with poor physical 
health as well as poor self-care. We also know that the obesity 
epidemic is disproportionately affecting youth of racial and 
ethnic minorities and of lower income. These youth may be 
especially susceptible to depression, creating a situation of 
extremely high risk.
    We all know that depression is a risk factor for suicide, 
and a child who dies from the psychological complications of 
obesity is just as dead as the one who dies from the physical 
complications 10 years from now.
    The New Haven intervention to prevent type 2 diabetes was 
developed based on my own research with a behavioral 
intervention called coping skills training. Early on in this 
process, we found that these middle school youth had never 
learned basic nutrition. Many of these families had no access 
to quality fruits and vegetables, and physical education in the 
schools emphasize sports, not individual activity. So that, the 
youth who needed to participate the most were most often found 
on the sidelines.
    In addition, as has been stated earlier today, many of 
these children had no access to safe places to be active, nor 
did they have any confidence that they could change any of 
these health behaviors. The intervention that we did, targeted 
at seventh graders, included nutrition education, non-sports 
physical activities, and the behavioral skills necessary to 
implement what they learned.
    During the 12-month followup, youth who received the entire 
program had lower body mass index, decreased insulin 
resistance, improved dietary and activity behaviors, decreased 
depression, and improved confidence in their ability to sustain 
these behaviors.
    On the issue of school performance, a recent review found 
that overweight and obese youth had poorer performance than 
those of normal weight, with lower math and reading scores. 
They also were more likely to be held back, miss more days of 
school, and boys were more likely to expect to drop out of 
school.
    Even more disturbing is the finding that men and women who 
were obese as teenagers had significantly fewer levels of 
schooling by adulthood. The reasons for this are unclear. It 
may be due to the psychosocial complications of obesity, and it 
may be due to mildly high blood sugar levels through the day 
that affect cognitive abilities.
    The ramifications of these psychosocial and educational 
complications of obesity are clear. It is doubly hard to change 
lifestyle when children and youth are depressed, and poor 
school performance now predicts a lifetime of struggle later, 
not to mention the potential for absenteeism at work, affecting 
performance and the ability to stay employed.
    In this area of work, the need for more research into 
programs that can prevent obesity is critical. Once these 
habits are learned and engrained, it is much more difficult to 
change behavior. More studies of community-based approaches 
that reach children and families at a young age in their 
communities are needed.
    I would be remiss if I did not make the case that funding 
for NIH and CDC, as well as the National Institute of Nursing 
Research, which is the only institute at NIH focused on 
prevention and enhancement of self-management of chronic 
illness, needs to be increased to allow more of this kind of 
research to help us solve this problem.
    This generation of youth will not survive if we continue to 
pay for their heart attacks, but not for the intensive care 
that it will take to reduce this epidemic. None of us wishes 
for this generation to be the first to have a lifespan and 
quality of life that is lower than that of the previous 
generation.
    Thank you for your attention. Thank you for the invitation. 
I look forward to the discussion.
    [The prepared statement of Ms. Grey follows:]
         Prepared Statement of Margaret Grey, DrPH, R.N., FAAN
    Thank you for the opportunity to speak with you today about this 
very serious problem. My name is Margaret Grey, and I am a pediatric 
nurse practitioner with training in both public health and social 
psychology. For over 30 years, my area of research and practice has 
been pediatric diabetes. As you know, and as others on the panel have 
reiterated, the obesity epidemic in youth threatens not only the future 
of these children with chronic diseases and a decreased lifetime, this 
epidemic is multi-faceted and will ultimately affect the workforce and 
thus the economy.
    As a nurse, my interest has always been on prevention--preventing 
illness and, in the case of obesity and diabetes, preventing 
complications. The obesity epidemic has led to an entire generation of 
youth developing type 2 diabetes in childhood, not in adulthood or old 
age as we are more used to seeing. When I began in this field in the 
1970s, we never saw a child with type 2 diabetes. Now, depending on the 
clinic, up to 50 percent of new cases of diabetes in children are type 
2 diabetes as opposed to type 1 (which was formerly known as juvenile 
diabetes. While it is most common in teens, in our clinic, we have seen 
children as young as 5 years old with type 2 diabetes. Worse, it 
appears that this diabetes is very aggressive and these youth develop 
the devastating complications of diabetes--cardiovascular disease, 
kidney disease, blindness and amputations--at an early age. Indeed, the 
longitudinal studies of these youth suggest that while they are in 
their 20s, they are already having heart attacks and receiving 
dialysis.
    While these physical complications are critically important 
concerns, there are also complications related to quality of life, 
depression, and academic achievement. Let me illustrate how serious 
these complications can be. Quality of life refers to self-reported 
physical, emotional, social, and school functioning. In 2003, Schwimmer 
reported that in a comparative study that obese teens have lower 
quality of life than teens without a chronic condition or those with 
cancer! This finding was more recently replicated in a community 
sample. So why does quality of life matter? If childhood overweight and 
obesity lead to reductions in health-related functioning, then these 
youth are at risk for psychological, social, and educational 
complications. I will explain this further.
    Related to quality of life is depression. With funding from the 
National Institutes of Nursing Research, my colleagues and I have been 
studying approaches to preventing type 2 diabetes in youth at high risk 
for its development by virtue of overweight or obese status and a 
family history of type 2 diabetes. In our studies in the New Haven 
School System middle schools, we have identified that at least 30 
percent of these overweight, high risk youth have levels of 
depression--not temporary sadness or the ``blues''--but depression 
requiring referral and treatment. Those who were depressed had much 
poorer dietary and activity behaviors, lower self-efficacy, higher Body 
Mass Index (even among the already overweight), and higher fasting 
insulin levels (indicating a higher risk for type 2 diabetes). From 
studies of adults with diabetes, we know that depression is not 
uncommon and is associated with poorer physical health as well as 
poorer self-care. In addition, the obesity epidemic is 
disproportionately affecting youth of racial and ethnic minorities and 
of lower income. These youth may be especially susceptible to 
depression, creating a situation of extremely high risk. We all know 
that depression is a risk factor for suicide, and as I have often said, 
as much as we worry about the physical complications of obesity, a 
child who commits suicide is just as dead as one who suffers from the 
physical complications.
    Our intervention to prevent type 2 diabetes in high risk youth in 
the middle schools was developed based on my own research with a 
behavioral intervention called Coping Skills Training and with 
collaboration of teachers and school nurse practitioners. Early on in 
this process, we learned that these middle school youth had never 
learned basic nutrition, so that we had to teach the difference between 
starches, proteins, and fats. We also learned that many of these 
families have no access to quality fruits and vegetables in the inner 
city besides a head of old iceberg lettuce (and we wonder why they look 
at us funny when we suggest they eat salads every day!). Physical 
education programs in the schools emphasized sports, so that the youth 
who needed to participate the most were most often found watching and 
not playing. There was little to no emphasis on activity that could 
occur without a team. Finally, many of these children had no access to 
safe places to be active, nor did they have any confidence that they 
could change any of their health behaviors.
    The program was designed to be taught by the teachers in the 7th 
grade and included nutrition education, non-sports physical activity, 
and the behavioral skills (such as problem solving, social skills, 
assertiveness, and cognitive behavior modification) necessary to 
implement what they learned. Over the course of the 12 months of 
follow-up, we found that the youth who received the entire program, 
compared to just the nutrition education, had lower BMI, decreased 
insulin resistance (a marker of risk for diabetes), improved dietary 
and activity behaviors, decreased depression, and improved confidence 
in the ability to sustain these behaviors. We are now in the process of 
testing this program throughout the New Haven middle schools and in 
several other school districts.
    You may wonder if these concerns are confined to racial and ethnic 
minorities and the inner cities. They are not. While obesity rates in 
youth average 20 percent, they are merely higher in these communities. 
And, our recent studies tell us that concerns about school lunches 
being high in fat and low in fruits and vegetables are equally of 
concern in suburban middle class communities. One of our students 
recently analyzed school lunch menus in five Connecticut schools--both 
inner city and suburban--and found that while portion sizes were 
appropriate, percentage of calories from fat exceeded guidelines, even 
before the children went to the vending machines and purchased sodas 
and fried snacks.
    The final topic I will address is the effect of obesity on school 
performance. A recent review found that overweight and obese youth had 
poorer school performance than those of normal weight. Obese and 
overweight youth had lower math and reading scores, were more likely to 
be held back, missed more days of school, and boys were more likely to 
expect to quit school. Even more disturbing is the finding that men and 
women who were obese as teens had significantly fewer years of school 
by young adulthood. The reasons for this are unclear: the psychosocial 
complications of obesity may lead to decreased motivation, but it is 
also possible that there is a physiologic cause. We know from studies 
of youth with diabetes that even mildly elevated blood glucose levels 
are associated with cognitive declines, so it's possible that some of 
these youth have high glucose levels during the school day and just 
can't think the same way those of normal weight and glucose levels can.
    The ramifications of all of these psychosocial and educational 
complications of obesity are clear. It's doubly hard to change 
lifestyle when they are depressed. Depression may lead to suicide. Poor 
school performance often predicts a lifetime of struggle and lower 
income, not to mention the potential for absenteeism at work affecting 
performance and the ability to stay employed.
    In this area of work, the need for more research into programs that 
can prevent obesity before it happens is critical. Once habits are 
learned and ingrained, it is much more difficult to change behavior. 
For example, we are beginning a study to help pregnant women lose 
weight after pregnancy, because we know that children of these women 
are more likely to be overweight by age 2 than children of women who 
have lost their pregnancy weight. Such research will take longer than 
the usual NIH grant of 3-5 years to demonstrate convincingly that this 
kind of approach will reduce rates of childhood obesity. More studies 
of community-based approaches that reach children and families at a 
young age in their communities are needed. As important as these 
school-based studies are, they focus more on treatment of obesity that 
has already occurred than in prevention. And, I would be remiss if I 
did not make the case that the funding of NIH and NINR in particular, 
the only one with prevention and enhancement of self-management of 
chronic conditions as major focus areas, needs to be increased to allow 
for more of the studies I have described.
    With regard to health policy, I cannot emphasize enough that this 
generation of youth cannot survive if we continue to pay for the care 
of their heart attacks, but not for the intensive behavioral care that 
it will take to reverse this epidemic. I am sure that none of us wishes 
to be partially responsible for this being the first generation in many 
years to have a lifespan lower than the previous generation because we 
didn't act.
    Thank you for the invitation and your attention. I look forward to 
your comments and questions.
                               References
Grey, M. & Berry D. (2004). Coping skills training and problem solving 
    in diabetes. Current Diabetes Reports, 4(2), 126-133.
Grey, M., et al. (2004). Preliminary testing of a program to prevent 
    type 2 diabetes among high-risk youth. Journal of School Health, 
    74(1), 10-15.
Jaser, S.S., Grey, M., et al. (in press). Correlates of depressive 
    symptoms in youth at high risk for type 2 diabetes. Children's 
    Health Care.
Schwimmer, J.B. (2003). Health-related quality of life of severely 
    obese children and adolescents. Journal of the American Medical 
    Association, 289, 1813-1819.
Taras, H., & Potts-Datema, W. (2005). Obesity and student performance 
    at school. Journal of School Health, 75(8), 291-295.

    Senator Dodd. Doctor, thank you immensely and wonderful 
testimony. Thank you for your work over the years, more 
importantly.
    Bruce, welcome back to the committee.

STATEMENT OF BRUCE LESLEY, PRESIDENT, FIRST FOCUS, WASHINGTON, 
                               DC

    Mr. Lesley. Thank you. Good afternoon, Chairman Dodd, 
Senators Harkin and Murkowski, and staff of the Children and 
Families Subcommittee.
    Having served as staff for Senator Bingaman with this 
committee for 6 years, it is a real honor to be here today and 
to be before such champions for children's health generally and 
childhood obesity issues specifically.
    I am Bruce Lesley, president of First Focus, a bipartisan 
children's advocacy organization dedicated to making children 
and families a priority in Federal policy. Thank you for the 
opportunity to testify today on this issue and on the childhood 
obesity epidemic and its role in the rapidly declining health 
of our future generation.
    This is an American issue that affects not only our 
children, but all of our future. There is also a choice between 
investing now and improving the health and well-being of 
America's children or dealing with the effects of childhood 
obesity and related preventable diseases with today's young 
people as they become adults.
    Childhood obesity is a growing public health crisis. As you 
know, over the past 30 years, obesity rates have more than 
tripled for preschool children and adolescents, quadrupled for 
children ages 6 to 11. Today, one third of children in the 
United States are obese or at risk of becoming obese. Sadly, 
our adolescents are now the most obese teenagers in the world, 
and we have reason to be concerned. These teens have up to an 
80 percent chance of becoming overweight as adults.
    You have heard about the health consequences from my 
colleagues here, but also the costs of childhood obesity are 
staggering. A 2000 report of the U.S. Surgeon General estimated 
the cost at $117 billion annually, and all signs indicate that 
it will continue to grow. Treating an obese child is more 
costly than treating an average weight child, obviously. An 
overweight child is likely to visit an emergency room more 
frequently and two to three times more likely to be 
hospitalized.
    Estimates suggest that annual hospital costs associated 
with obese children and youth have more than tripled in less 
than 2 decades. Scientists, as discussed earlier, now forecast 
a 2- to 5-year drop in life expectancy for children of today 
unless we take aggressive actions to address and reverse the 
obesity epidemic.
    One of the interesting things is that we have conducted 
some polling that shows for the first time ever, American 
adults believe that the next generation will be worse off than 
the current generation. I think there are a lot of reasons that 
go into that, but one of them is the issues of the health of 
children.
    There was a national poll on children's health that was 
conducted by C.S. Mott Children's Hospital that shows that 
obesity is for the first time identified by adults as the top 
health problem for children after being rated third last year. 
It has been one of those issues that over time has gone up the 
scale.
    Concern with the high rate of obesity among U.S. children 
and the reality that they could face increased risk of heart 
disease as adults, the American Academy of Pediatrics recently 
recommended wider cholesterol screening for children and more 
aggressive use of cholesterol-lowering drugs for children as 
young as age 8. While we agree that we are in desperate need of 
solutions, this is hardly a viable one. Sadly, there will be no 
magic pill that can erase this problem.
    The fact of the matter is that despite all the research and 
these dismal statistics, our Nation's broader response to the 
childhood obesity epidemic has been woefully inadequate. While 
we invest heavily in the treatment and management of chronic 
diseases, in adults, we spend very little for the prevention 
and treatment of childhood obesity that would stave off the 
onset of conditions like heart disease and type 2 diabetes.
    As Julie Gerberding, director of the CDC, recently noted, 
we put way too much emphasis on treating disease rather than 
protecting health in the first place. According to Gerberding, 
today only a nickel out of every medical dollar spent in the 
United States goes toward keeping Americans healthy. This is 
part of a broader pattern of declining investments in our 
future.
    As a new First Focus report--Children's Budget 2008--
highlights, over the past 5 years, the share of Federal 
nondefense spending that goes to children and children's 
programs has declined by 10 percent. In fact, real Federal 
discretionary spending on children will be lower this year than 
it was 5 years ago.
    Kids' Share 2008, an Urban Institute report released at the 
Capitol Hill briefing last week, confirms this trend and 
details the overall decline in Federal spending on children 
over the past four and a half decades. It has found that since 
1960 the share of Federal spending that goes to children has 
dropped by more than 20 percent.
    The time for action is now. One thing just as a personal 
point, as I worked with all of your offices on an amendment a 
few years ago that was to the agriculture bill. As I recall, it 
was Bingaman, Dodd, Harkin, Murkowski, and I think even Senator 
Coburn as co-sponsors. It was an amendment that I worked on 
with all of your staffs, and ultimately, it resulted in an 
increase in a fresh fruits and vegetables program, which is a 
long-time initiative by Senator Harkin that has now become law 
in the Farm bill. It is those kinds of steps that we need to be 
taking.
    As the Institute of Medicine report ``Progress in 
Preventing Childhood Obesity: How Do We Measure Up? '' noted, 
addressing the childhood obesity epidemic is a collective 
responsibility involving multiple stakeholders in different 
sectors between the Federal Government, State and local 
governments, communities, schools, industry, media, and 
families.
    The Federal Government can--really it must--play a critical 
role in reversing this epidemic by providing leadership, 
coordinated efforts across agencies, and investing in research 
and sustained prevention and intervention strategies. We 
believe Congress can take several steps now to address this 
threat, and it is one of the things that we really want to 
emphasize that it is across areas. It is everything from public 
health programs. It is daily activities in schools.
    I note, for example, that Senator Dodd's bill on the 21st 
Century Community Learning Centers Act includes a provision 
that would add physical fitness and wellness programs as 
allowable activities. Under the 21st Century Community Learning 
Centers Act, we need to target investments in research, but it 
also includes coverage issues. The SCHIP program, for example, 
making sure that children have health coverage. Also, there was 
language in that bill that provided demonstration grants for 
childhood obesity efforts.
    It includes things like dealing with competitive foods and 
beverages in schools. We include a bunch of the recommendations 
in our testimony, and as those highlight childhood obesity is 
not just a healthcare issue, it is clearly an education issue, 
a transportation issue, an agriculture issue, an economics 
issue, and a public health issue.
    Given the complexity of the problem, it is easy to see why 
responsibility for addressing it is passed from one agency to 
the other. Unfortunately, no one in the Federal Government 
seems to own this issue. We must ensure that all Federal 
agencies with a role to play--including the CDC, NIH, 
Department of Agriculture, and Department of Transportation--
work together to address the childhood obesity epidemic.
    In a glimmer of good news, the data and research also shows 
that we can reverse the current trend and lower the incidence 
of a host of deadly diseases associated with obesity if we take 
action now.
    Thank you all for your leadership and for the opportunity 
to provide testimony. I welcome any questions.
    [The prepared statement of Mr. Lesley follows:]
                   Prepared Statement of Bruce Lesley
    Good morning Chairman Dodd, Ranking Member Alexander, and members 
and staff of the Children and Families Subcommittee. Having served as a 
staffer for Senator Bingaman, with this committee, it is a real honor 
to be here today.
    I am Bruce Lesley, President of First Focus, a bipartisan 
children's advocacy organization dedicated to making children and 
families a priority in Federal policy and budget decisions.
    Thank you for the opportunity to testify today on the childhood 
obesity epidemic and its role in the rapidly declining health of our 
next generation. This is an American issue that affects not only our 
children but all of our futures. It is also a choice between investing 
now in improving the health and well-being of America's children, or 
dealing with the effects of childhood obesity and related preventable 
diseases when today's young people become adults.
    Childhood obesity is a growing public health crisis. As you know, 
over the past 30 years, obesity rates have more than tripled for 
preschool children and adolescents, and quadrupled for children ages 6-
11.\1\ Today, one-third of children and youth in the United States are 
obese or at-risk of becoming obese.\2\ Sadly, our adolescents are now 
the most obese teenagers in the world. And we have reason to be 
concerned. These teens have up to an 80 percent chance of becoming 
overweight or obese adults.\3\
---------------------------------------------------------------------------
    \1\ Institute of Medicine of the National Academies. Progress in 
Preventing Childhood Obesity: How Do We Measure Up? Washington, DC: 
National Academies Press, 2006.
    \2\ Institute of Medicine of the National Academies. Progress in 
Preventing Childhood Obesity: How Do We Measure Up? Washington, DC: 
National Academies Press, 2006.
    \3\ Torgan, C. (2002). Childhood Obesity on the Rise. The NIH Word 
on Health. Downloaded from: http://www.nih.gov/news/WordonHealth/
jun2002/childhoodobesity.htm.
---------------------------------------------------------------------------
    Through our research and our advocacy, we know that the rates of 
obesity and related diseases are even more alarming for minority 
children. For instance:

     In the United States, Hispanic boys and African-American 
girls have the highest prevalence of obesity.\4\
---------------------------------------------------------------------------
    \4\ Institute of Medicine of the National Academies. Childhood 
Obesity in the United States: Fact and Figures. Fact Sheet. September 
2004.
---------------------------------------------------------------------------
     Overweight prevalence increased by 120 percent for 
African-American and Hispanic children between 1986 and 1998 in 
comparison to an increase of 50 percent for whites.\5\
---------------------------------------------------------------------------
    \5\ Stauss, R.S., Pollack, H.A. (2001). Epidemic Increase in 
Childhood Overweight. JAMA, 286:2845-8.
---------------------------------------------------------------------------
     A national survey of American Indian children ages 5 to 18 
found that 39 percent were overweight or at risk for becoming 
overweight.\6\
---------------------------------------------------------------------------
    \6\ Jackson, Yvonne. (1993). Height, weight, and body mass index of 
American Indian schoolchildren, 1990-1991. Journal of the American 
Dietetic Association, 93(10) 1136-1140.
---------------------------------------------------------------------------
    Obesity translates into more than just expanding waistlines. Obese 
children are being diagnosed with health problems once only seen in 
adults--such as type 2 diabetes, high cholesterol, high blood pressure, 
and even child gallstones. Overweight children are also at higher risk 
for heart disease, stroke, and several forms of cancer.\7\
---------------------------------------------------------------------------
    \7\ Freedman, D.S., Dietz, W.H., Srinivasan, S.R., Berenson, G.S. 
(1999). The Relation of Overweight to Cardiovascular Risk Factors Among 
Children and Adolescents: The Bogalusa Heart Study. Pediatrics, 103: 
1175-82.
---------------------------------------------------------------------------
    The direct and indirect costs associated with obesity in the United 
States are staggering. A 2000 report of the U.S. Surgeon General 
estimated the costs at $117 billion annually and all signs indicate 
that it will continue to grow.\8\ Treating an obese child is more 
costly than treating an average-weight child and an overweight child is 
likely to visit an emergency room more frequently and two to three 
times more likely to be hospitalized.\9\ Estimates suggest that annual 
hospital costs associated with obese children and youth have more than 
tripled in less than two decades.\10\
---------------------------------------------------------------------------
    \8\ U.S. Department of Health and Human Services. The Surgeon 
General's Call to Action to Prevent and Decrease Overweight and 
Obesity. U.S. Department of Health and Human Services, Public Health 
Service, Office of the Surgeon General. 2000.
    \9\ Marder, W.D. & Chang, S. (2005). Childhood Obesity: Costs, 
Treatment Patterns, Disparities in Care, and Prevalent Medical 
Conditions. Thomson Medstat Research Brief. Retrieved at http://
www.medstat.com/pdfs/childhood_obesity.pdf.
    \10\ Institute of Medicine of the National Academies. Preventing 
Childhood Obesity: Health in the Balance. Washington, DC: National 
Academies Press, 2005.
---------------------------------------------------------------------------
    Scientists now forecast a 2- to 5-year drop in life expectancy for 
children of today, unless we take aggressive action to address and 
reverse the obesity epidemic. In fact, a 2005 study published in The 
New England Journal of Medicine concluded that ``if childhood obesity 
continues unabated, people will have shorter lives because of the 
health toll of being heavy at such a young age.'' \11\ One of the study 
authors, pediatric endocrinologist David Ludwig describes childhood 
obesity as a ``massive tsunami headed toward the United States.'' 
Ludwig goes on to explain,
---------------------------------------------------------------------------
    \11\ Olshansky, S.J., Passaro, D.J., Hershow, R.C., Layden, J., 
Carnes, B.A., Brody, J., Hayflick, L., Butler, R.N., Allison, D.B., and 
Ludwig, D.S. (2005). A Potential Decline in Life Expectancy in the 
United States in the 21st Century. New England Journal of Medicine, 
Volume 352:1138-145, Number 11.

          ``It's like what happens if suddenly a massive number of 
        young children started chain smoking. At first you wouldn't see 
        much public health impact. But years later it would translate 
---------------------------------------------------------------------------
        into emphysema, heart disease, and cancer.''

    Concerned with the high rate of obesity among U.S. children and the 
reality that they could face increased risk of heart disease as adults, 
the American Academy of Pediatrics (AAP) recently recommended wider 
cholesterol screening for children and more aggressive use of 
cholesterol-lowering drugs for children as young as age 8. While we 
agree that we are in desperate need of solutions, this is hardly a 
viable one. Sadly, there will be no magic pill that can erase this 
problem.
    The fact of the matter is that despite all of the research and 
these dismal statistics, our Nation's broader response to the childhood 
obesity epidemic has been woefully inadequate. While we invest heavily 
in the treatment and management of chronic diseases in adults, we spend 
very little for the prevention and treatment of childhood obesity that 
would stave off the onset of conditions like heart disease and type 2 
diabetes. As Julie Gerberding, Director of the Centers for Disease 
Control and Prevention (CDC) recently noted, ``we put way too much 
emphasis on treating disease rather than protecting health in the first 
place.'' According to Gerberding, today, only a nickel out of every 
medical-care dollar spent in the United States goes toward keeping 
Americans healthy.
    This is part of a broader pattern of declining investments in our 
future. As a new First Focus report, Children's Budget 2008 highlights, 
over the past 5 years, the share of Federal non-defense spending that 
goes to children and children's programs has declined by 10 percent and 
in fact, real Federal discretionary spending on children will be lower 
this year than it was 5 years ago. Kids' Share 2008, a First Focus-
sponsored Urban Institute report released at a Capitol Hill briefing 
last week, confirms this trend, and details the overall decline in 
Federal spending on children over the past four and a half decades. 
Shockingly, it found that since 1960, the share of Federal spending 
that goes to children has dropped by more than 20 percent.
    The current Administration, for its part, has done little to avert 
the approaching tsunami. As a recent Washington Post series on 
childhood obesity highlighted, President Bush has repeatedly attempted 
to eliminate or cut several prominent Federal efforts aimed at 
overweight children and teens, including:

     The elimination of funding for the Carol M. White Physical 
Education Program (PEP). In its fiscal year 2009 budget request to 
Congress, the Administration proposed to zero out this $75 million 
program that helps schools and communities expand physical education 
offerings and purchase equipment.
     No new funding for the Centers for Disease Control and 
Prevention's (CDC) Division of Nutrition, Physical Activity and 
Obesity. Grants offered through this CDC program, which currently are 
up and running in less than half the States, allow State health 
departments to design, implement, evaluate and disseminate effective 
interventions, including those which support policy changes to 
encourage access to healthy foods and venues to be active.
     No new funding for the Department of Defense (DOD) Fresh 
Fruit and Vegetable Program, which helps schools provide a wider 
variety of fresh fruit and vegetables to students through federally 
sponsored breakfast and lunch programs.

    Not only has the Administration been meager in making investments 
in discretionary programs that could address childhood obesity, in 
longer-standing nutrition programs, change has been slow to come. The 
U.S. Department of Agriculture only recently modified the Women, 
Infants and Children (WIC) nutrition program to allow additional funds 
for low-income families to buy fresh fruits and produce, which are 
often more costly. In a bit of sad irony, traditional subsidies, which 
help low-income families purchase food staples like milk, eggs, and 
cheese, are contributing to our kids' expanding waistlines. In fact, in 
some communities, nearly half of toddler and preschool WIC recipients 
are overweight or obese. And, as The Post points out, the U.S. 
Department of Agriculture's (USDA) school breakfast and lunch programs 
continue to sell whole milk and sweetened flavored milk, instead of no-
fat alternatives.
    There are many interrelated factors that contribute to rapidly 
rising rates of obesity in children, chief among them poverty and food 
insecurity, which lead to lower food expenditures, limited fruit and 
vegetable consumption and poor diets.\12\ In fact, a recent Food Trust 
report found that ``people who live in lower-income areas without 
access to supermarkets appear to suffer from diet-related deaths at a 
rate higher than that experienced by the population as a whole.'' \13\ 
In another study, obesity rates were as high as 30 percent in the 
lowest income neighborhoods, compared to about 5 percent in the most 
affluent zip codes.\14\ The relatively low cost of foods containing 
refined grains, added sugars and fats is also a key factor in the 
rising obesity rate.\15\
---------------------------------------------------------------------------
    \12\ Drewnowski, A. and Specter, S.E. (2004). Poverty and Obesity: 
The Role of Energy Density and Energy Costs. American Journal of 
Clinical Nutrition, Vol. 79, No. 1, 6-16.
    \13\ The Food Trust (2001). The Need for More Supermarkets in 
Philadelphia. Retrieved at: http://www.thefoodtrust.org/pdf/
supermar.pdf.
    \14\ Drewnowski, A , Rehm, C.D., Solet, D. (2007). Disparities in 
Obesity Rates: Analysis by ZIP Code Area. Social Science and Medicine. 
65(12):2458-63.
    \15\ Drewnowski, A. and Specter, S.E. (2004). Poverty and Obesity: 
The Role of Energy Density and Energy Costs. American Journal of 
Clinical Nutrition, Vol. 79, No. 1, 6-16.
---------------------------------------------------------------------------
    Other factors also contribute to the childhood obesity epidemic. 
For instance, in recent decades, our society has experienced an influx 
of fast foods, bigger portion sizes, and the convenience of vending 
machines. Today, nearly one-third of children ages 4 to 19 eat fast 
food every day--that translates to 6 extra pounds per year for every 
child. And, children are eating more junk food in larger than-ever 
portion sizes. During the late 1990s, portion sizes increased more than 
60 times.\16\ Children today are also over-exposed to junk food 
marketing. A recent Kaiser Family Foundation study found that food is 
the top product seen advertised by children--and 34 percent of all the 
food ads targeting children or teens are for candy and snacks.\17\
---------------------------------------------------------------------------
    \16\ Anderson, P.M., and Butcher, K.F. (Spring 2006). Childhood 
Obesity: Trends and Potential Causes. Future of Children, Vol. 16, No. 
1.
    \17\ Gantz, W., Schwartz, N., Angelini, J.R., and Rideout, V. 
(March 2007). Food for Thought: Television Food Advertising to Children 
in the United States, A Kaiser Family Foundation Report.
---------------------------------------------------------------------------
    Unfortunately, the recent economic downturn has translated into 
rising food costs, and more Americans are turning to lower quality, 
frozen, bulk and processed foods for meals. And, as the economy 
worsens, America's poorest will be hit the hardest. As Dr. David Katz, 
a well-known authority on nutrition and the prevention of chronic 
disease notes, ``there's real cause for worry, because the data we do 
have, in general, indicates that more nutritious foods tend to be 
higher priced. It's only going to compound that problem [when] the food 
prices rise.''
    The time for action is now. As the recent 2006 Institute of 
Medicine (IOM) report, ``Progress in Preventing Childhood Obesity: How 
Do We Measure Up? '' noted, ``addressing the childhood obesity epidemic 
is a collective responsibility involving multiple stakeholders and 
different sectors--including the Federal Government, State and local 
governments, communities, schools, industry, media and families.'' \18\ 
The Federal Government can--really it must--play a critical role in 
reversing this epidemic by providing leadership, coordinating efforts 
across agencies, and investing in research and sustained prevention and 
intervention strategies.
---------------------------------------------------------------------------
    \18\ Institute of Medicine of the National Academies. Progress in 
Preventing Childhood Obesity: How Do We Measure Up? Washington, DC: 
National Academies Press, 2007.
---------------------------------------------------------------------------
    We believe Congress can take several critical steps now to help 
address this growing public health threat:

    (1) Improve Daily Physical Activity Requirements for All Students. 
In recent years, schools have cut back on physical education and 
recess. Although children need 60 minutes of moderate to vigorous 
exercise daily, national surveillance data tells us that only 35.8 
percent of high school students are meeting this measure.\19\ As the 
Campaign to End Obesity's Call to Action report highlights, the 
reauthorization of No Child Left Behind (NCLB) provides an important 
opportunity to improve physical education and activity standards. 
Congress should consider the following:
---------------------------------------------------------------------------
    \19\ 2005 Youth Risk Behavior Surveillance Results. Available at 
www.cdc.gov/healthyyouth.

     Support the 21st Century Community Learning Centers Act of 
2007 (S. 1557), sponsored by Senator Dodd, which would include the 
provision of physical fitness and wellness programs as allowable 
activities under 21st Century Community Learning Centers (CCLC);
     Amend Safe and Drug-Free Schools and Communities Act to 
allow for the promotion of Safe Routes to Schools (SRTS);
     Reauthorize the Carol M. White Physical Education Program 
and ensure it is adequately funded; and
     Provide incentives for schools that meet national 
standards for physical education.

    We would also like to urge support for the PLAY Every Day Act (S. 
651), sponsored by Senators Harkin and Bingaman, which would help 
children, families, and communities achieve the national recommendation 
of 60 minutes of physical activity every day.
    (2) Increase Our Federal Investment in Prevention and Public Health 
Programs Targeting Childhood Obesity. Congress should provide 
additional funding for the CDC's Division of Adolescent and School 
Health (DASH), which supports States in implementing Coordinated School 
Health Programs (CSHP). Currently, only 22 States and 1 tribal 
government are receiving grants, and overall funding for CSHP has 
followed a steady downward trend over the past 5 years.
    In addition, I'd like to highlight several promising proposals:

     The Prevention (HeLP) America Act (S. 1342/ H.R. 2633), 
sponsored by Senator Harkin, would provide for: (1) healthy school 
nutrition environment incentive grants; (2) establish a Baby-Friendly 
Hospital Initiative; (3) provide incentives for States to ensure the 
safety and convenience of all users of a transportation system, 
including pedestrians and bicyclists, and also includes provisions of 
the PLAY Every Day Act, Healthy Workforce Act of 2007, MEAL Act, and 
Child Nutrition and School Lunch Protection Act.
     The Healthy Places Act (S. 1067/ H.R. 398), sponsored by 
Senator Obama would among other provisions, require the Secretary of 
Health and Human Services to establish an interagency working group to 
discuss environmental health concerns, particularly concerns 
disproportionately affecting disadvantaged populations.
     In addition, we are pleased that Senator Bingaman will 
soon introduce comprehensive legislation that would effectively address 
the public health threats of overweight and obesity by requiring 
unprecedented collaboration and collective action across agencies, 
between private and public entities and industries, and involve 
individuals and communities in generating solutions and addressing the 
childhood obesity epidemic.

    (3) Enact a Strong Reauthorization of the State Children's Health 
Insurance Program (SCHIP). In order to be healthy, children need 
reliable access to routine health care. The research is clear that 
children without health coverage often lack the routine medical care 
that helps to prevent or address childhood obesity while in its early 
stages. Children in low-income working families--the very children who 
are eligible for coverage under SCHIP--are often those most at risk of 
becoming obese. We urge Congress to enact the strongest SCHIP 
reauthorization possible to improve access, coverage, and health 
outcomes for low-income children, with a particular focus on the 6 
million children who are eligible but unenrolled in SCHIP or Medicaid.
    We should also note that the SCHIP reauthorization language already 
passed by Congress on three occasions, included $25 million for 
demonstration grants to develop a comprehensive and systematic model 
for reducing childhood obesity. This is a small investment but, even if 
it is only a starting point, one that we hope to see included in any 
reauthorization bill.
    (4) Ensure Coverage for Obesity-Related Services in SCHIP. Because 
most private insurance plans do not provide explicit coverage for 
obesity-related services, these benefits may not be a part of benchmark 
plans from which stand-alone SCHIP coverage is developed. Basic anti-
obesity benefits should be covered under SCHIP for its beneficiaries. 
Precedent exists for this coverage; Medicaid currently covers medical 
nutrition therapy for beneficiaries with diabetes or renal disease, but 
that benefit may not be adequate for children.
    (5) Provide Guidelines for Childhood Obesity Health-Care Related 
Treatment Under Medicaid's Early and Periodic Screening & Diagnostic 
Treatment (EPSDT) Benefit. Children covered by Medicaid are nearly six 
times more likely to be treated for a diagnosis of obesity than 
children covered by private insurance.\20\ The George Washington 
University School of Public Health and Health Services and Center for 
Health Services Research and Policy recently reviewed existing Medicaid 
benefit codes, and found that Medicaid, under its EPSDT benefit, can 
cover comprehensive, obesity-related pediatric health care 
services.\21\ \22\ The researchers found that most State Medicaid 
manuals however, do not provide clear or adequate information about 
coverage levels and appropriate reimbursement codes for specific 
elements of care. Providers, therefore, remain uncertain about which 
services they can provide and if they can be reimbursed.
---------------------------------------------------------------------------
    \20\ Marder, W.D. & Chang, S. (2005). Childhood Obesity: Costs, 
Treatment Patterns, Disparities in Care, and Prevalent Medical 
Conditions. Thomson Medstat Research Brief. Retrieved at http://
www.medstat.com/pdfs/childhood_obesity.pdf.
    \21\ Rosenbaum, S., Wilensky, S., Cox, M., and Wright, D.B. (July, 
2005). Reducing Obesity Risks During Childhood: The Role of Public and 
Private Health Insurance. Retrieved at: http://www.gwumc.edu/sphhs/
departments/healthpolicy/chsrp/downloads/Obesity%20Report%20
Final.pdf.
    \22\ Wilensky, S., Whittington, R., Rosenbaum, S. (October, 2006). 
Strategies for Improving Access to Comprehensive Obesity Prevention and 
Treatment Services for Medicaid-Enrolled Children. Retrieved at http://
www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/
RWJ%20Medicaid%20Obesity%20Policy%20Brief.pdf.
---------------------------------------------------------------------------
    Given this lack of clarity, the Centers for Medicare & Medicaid 
Services (CMS) should take immediate action to:

     Disseminate information about the importance of childhood 
obesity risk to State Medicaid programs; and
     Augment existing CMS guidelines on EPSDT with special 
guidance on using managed care, integrated service delivery and 
disease-management techniques to develop comprehensive prevention 
programs for children at risk of obesity.

    (6) Improve Nutritional Standards for Competitive Foods and 
Beverages Served in Schools. Nutrition in school lunches is 
``substandard,'' and the only Federal regulation of the competitive 
food environment in schools is the restriction of ``Foods of Minimal 
Nutritional Value'' (FMNV) during meal times. This regulation is dated, 
and should be revised. The Child Promotion and School Lunch Protection 
Act (S. 771/H.R. 1363), sponsored by Senator Harkin, would require the 
Secretary to update the definition of FMNV to comply with nutrition 
science, and would set nutrition standards for all foods served in 
schools campus-wide and across the entire time span a school is open to 
children.
    As our recommendations highlight, childhood obesity is not just a 
health care issue--it is an education issue, a transportation issue, an 
agriculture issue, an economics issue, and a public health issue. Given 
the complexity of the problem, it is easy to see why responsibility for 
addressing it is passed from one agency to another. No one ``owns this 
issue.'' We must ensure that all Federal agencies with a role to play, 
including the Centers for Disease Control and Prevention, National 
Institutes of Health, Department of Agriculture, and Department of 
Transportation work together to address the childhood obesity epidemic.
    It is time for the Federal Government to stand up, take notice, and 
take action to address the childhood obesity epidemic. While the health 
of our children is our paramount concern, the costs associated with 
obesity-related diseases are too staggering to ignore. We urge Congress 
to back the kind of proactive, coordinated and sustained response the 
childhood obesity epidemic warrants. In a glimmer of good news, the 
data and research also show that we can reverse the current trend and 
lower the incidence of a host of deadly diseases associated with 
obesity if we take action now.
    Thank you for your leadership, and for the opportunity to provide 
this testimony. I welcome any questions you might have.

    Senator Dodd. Thank you very much. We have been joined by 
your former boss, Senator Bingaman.
    He did a good job, Jeff.
    Senator Bingaman. He did a good job.
    Senator Dodd. Yes. I will leave his testimony for you to 
read.
    Let me turn to my colleagues just for some opening 
comments, if they would like to make one. I mentioned earlier 
before you arrived, Tom, what a leader you have been on this 
issue and, as Chairman of the Committee on Agriculture, 
fighting all the time to see to it that there has been a 
greater emphasis on the quality of nutrition and food that 
children eat, efforts in our schools, and the like. Just a 
long-time champion of this issue.
    Do you have any opening comments?

                      Statement of Senator Harkin

    Senator Harkin. Well, thank you, Mr. Chairman.
    I would just say to my friend and my Chairman here that if 
you really want to find the person who has really been the 
leader on children's health and children's welfare for the last 
20 years, you need no further than to look in the mirror.
    Senator Dodd. Well, thank you.
    Senator Harkin. Because Chris Dodd is well known all over 
this country for being the champion of children and families. 
The Family and Medical Leave Act being perhaps one of the 
biggest highlights of his political career, getting that passed 
for families all over America and for our children.
    I just thank you very much for having this hearing and 
spearheading this. I know we are having another hearing next 
week, Mr. Chairman. I thank our witnesses for being here.
    I just ask that my statement be made a part of the record--
--
    Senator Dodd. Absolutely.
    Senator Harkin [continuing]. And would look forward to an 
interplay on questions and answers with the panel.
    [The prepared statement of Senator Harkin follows:]

                  Prepared Statement of Senator Harkin

    Thank you, Chairman Dodd and Senator Alexander, for calling 
this very timely hearing, this afternoon, to examine the impact 
of the childhood obesity epidemic on the child's well-being and 
next week to discuss real solutions that can be done to address 
this crisis. I have been looking forward to this hearing on 
this topic and appreciate this opportunity.
    Mr. Chairman, a number of leading health experts are now 
predicting that the generation of kids growing up today could 
be the first to live a shorter lifespan than their parents. One 
significant reason for this is the obesity epidemic.
    As we will hear from the panelist, obesity takes a 
frightening toll on a person's health. It can lead to diabetes, 
heart disease, high blood pressure, cancer, and numerous other 
chronic diseases--all of them major causes of death. It is a 
shocking fact that more rates of childhood obesity has nearly 
tripled since 1980.
    And the toll on children is especially disturbing. On the 
macro level, childhood obesity is a national public health 
crisis. But on the individual level . . . for each child 
afflicted with this condition . . . it is something else. It is 
a tragedy. A past Yale University study concluded that 
overweight children are stigmatized by their peers as early as 
age 3. They are subjected to teasing, rejection, and bullying, 
and are two to three times more likely to report suicidal 
thoughts as well as to suffer from high blood pressure and/or 
diabetes. The author of the study concluded: ``The quality of 
life for kids who are obese is comparable to the quality of 
life of kids who have cancer.''
    There have been several studies by the Institute of 
Medicine, Trust for America's Health and other that have 
reported on childhood obesity, and have offered excellent 
blueprints for a comprehensive national response to the obesity 
epidemic, with a strong emphasis on wellness and prevention. 
They all consistently call to individuals and families, as well 
as to schools, employers, communities and the food industry. 
Most of all it is a clarion call to Congress. It is time for us 
to act.
    I look forward to hearing from the witnesses today and next 
week to explore further areas where Congress should act. My 
broader ambition is to transform America into a genuine 
``wellness society'' and to bring this public health discussion 
into the larger health reform debate. How do we recreate 
America as a ``wellness society'' . . . a society focused on 
physical activity, good nutrition and disease prevention--
keeping people off pills and out of the hospital in the first 
place. And, as the Irish say, this isn't a private fight; 
anyone can join in. Schools, communities, Corporate America and 
government at every level--they all need to be part of the 
solution. And we need it now.
    So again, I am grateful to the Chairman for calling this 
important and timely hearing.
    Senator Dodd. Lisa, any opening comments?

                     Statement of Senator Murkowski

    Senator Murkowski. I want to thank you as well, Mr. 
Chairman.
    Listening to the panelists this afternoon, it has become 
frighteningly evident that we are talking about an epidemic in 
this Nation. When we think about how we treat other epidemics, 
we have a national strategy. We have a plan, and we are going 
to take control of whatever the epidemic may be.
    We are not focused on obesity as a nation as we should be, 
and I am very fearful that once you lose that first generation 
to this epidemic, it is going to be so difficult to later 
address it. I applaud you for your leadership. I have enjoyed 
the opportunity to work with you, Senator Harkin, on the issues 
of nutrition.
    I think we are starting to make some headway. We need to 
get parents, school administrators, teachers, families and 
policymakers engaged in this national epidemic because our 
children's health is at stake. As all of you have mentioned, 
the costs to us as a nation are staggering.
    Senator Dodd. Yes, I tell you, all the statistics can be 
numbing, I suppose, and it can end up glazing over your eyes if 
you let them. The two statistics that I kept on reading last 
night. In fact, I called the staff. I said this can't be right. 
You have the numbers wrong. This is a typo in the memo they 
wrote for me.
    The fact that only 8 percent of our elementary schools and 
less than 6 percent of our middle schools and high schools have 
any requirement of physical activity. It just--to me, it is one 
thing to understand what happens when people go out and make 
bad choices about the food they eat. But the school, you would 
think, the value of just the learning ability of a child to 
know that physical exercise is so important for so many other 
reasons, not to mention the one that is before the subject 
matter of the committee today.
    It is just hard to imagine that has happened. That many, 
that 92 percent of our elementary schools have no physical 
activity of their children.
    Senator Bingaman.

                     Statement of Senator Bingaman

    Senator Bingaman. Thanks very much for having the hearing, 
Mr. Chairman.
    It is a very important issue, and I particularly wanted to 
be here with Bruce Lesley here. He did guide me on these very 
issues for many years working here in the Senate and did a 
great job here and is doing a great job now.
    I am anxious, when we get to the question part, to explore 
what we can do with some of the specific Federal programs that 
are currently in place to try to deal with this issue--the 
SCHIP program, for example, Medicaid, some of these programs 
that ought to give us some leverage in reaching this group of 
young people that we are trying to help.
    At any rate, thank you again for having the hearing.
    Senator Dodd. Thank you very much.
    Let me start, if I can, Dr. Levi, with you. Just some 
questions that was noted in here. As I mentioned, the focus 
here will be on how to address the epidemic, but I wanted to 
ask you something about your testimony. You mentioned in your 
report--again, numbers just sort of jumped out at me last night 
reading your testimony in anticipation of the hearing today--
that an investment of $10 per person per year in proven 
community-based programs could save the country more than $16 
billion annually within 5 years.
    Let me ask you about four or five questions around this. 
Certainly what is community prevention? What types of 
interventions does this entail? Who would implement the 
interventions? Who would reap the benefits? I think that one 
may be more obvious. Can you give us some examples of 
community-based programs that have yielded some successful 
results to give us some idea of some models that are actually 
producing these kind of results?
    Dr. Levi. Sure, Senator.
    Senator Dodd. How did you get at these numbers? Where does 
that number come from?
    Mr. Levi. OK. This was a collaborative effort that Trust 
for America's Health engaged in with the Urban Institute, with 
economists there for a developed model. We worked in 
conjunction with the New York Academy of Medicine and 
Prevention Institute out in California as well. The goal here 
was really to look at how we can take on these problems before 
they become medicalized and see whether there actually is a 
value, an economic value to engaging in these programs and 
reducing healthcare costs.
    The process that we went through was really to identify the 
most expensive chronic diseases in the United States, and a lot 
of them relate to obesity, and what kind of community-level 
interventions are they amenable to. We sort of did a crosswalk 
of those.
    When you look at whether it is heart disease, diabetes, 
stroke, even some cancers, and arthritis, and you look at some 
of these very expensive conditions and you look at what sorts 
of interventions could actually prevent them or mitigate them, 
it ends up being physical activity, nutrition--how much we eat 
and what we eat--and also smoking cessation.
    What we discovered in reviewing the literature was that 
there are a lot of very effective community-level programs. By 
community-level programs, we mean things outside of the clinic. 
We don't have to medicalize the solution to all of these 
problems. It can be everything from making a community more 
walkable, improved street lighting, creating sidewalks, 
promoting programs like Safe Routes to Schools that encourage 
kids to walk to schools, improving the quality of school 
lunches, doing menu labeling so that people know what they are 
about to buy in a restaurant, doing some social marketing 
campaigns to encourage people to exercise more and to eat 
better.
    Usually it is a combination of several of these approaches 
that together make a community-level intervention. We have seen 
a number of very successful programs along those lines. Shape 
Up Somerville is one, where the community of Somerville, MA, 
came together and said here is the problem. Here are some of 
the things we can do, and they adopted a series of initiatives 
that targeted kids, targeted the physical environment, targeted 
adults, and together achieved some major changes.
    The YMCA is doing some phenomenal work in a number of 
cities around the country in bringing--you know, we talk about 
needing a plan to address this problem, and we do need a plan. 
We need a national plan, not just a Federal plan, though, 
because every sector of society has a role to play. The beauty 
of what the YMCA is doing is it is convening local communities, 
business, transportation, schools, health departments, everyone 
who could possibly--families, community-based and faith-based 
organizations--everyone who could play a role and getting them 
focused on this problem.
    I think that is what we mean by community-level prevention. 
What we did when we looked at the literature was we saw that 
these can have a dramatic impact on disease. In fact, the 
literature supported probably more than a 5 percent impact on 
things like diabetes and hypertension if you successfully 
implement these kinds of programs.
    With just a 5 percent effect, within 5 years, you are going 
to see a return on investment of $16 billion a year, and we 
looked at these programs and found that they were not 
expensive--$6 to $8 a year. We did the model based on $10 per 
person per year so that we could be relatively conservative.
    When you looked at it, it showed that if we provided more 
money for these kinds of programs, we would see a lot of 
savings. But who benefits? That is the challenge, the policy 
challenge that we face.
    Public health invests in these kinds of community-level 
prevention initiatives, but it is the Medicare system, it is 
the Medicaid system, it is private payers who benefit. The 
policy challenge we face then is to do the crosswalk back and 
say how are we going to find the resources for these kinds of 
interventions? If we find them, how can we get those who 
benefit to contribute to the solution?
    Senator Dodd. Yes, and it occurs to me, too, I don't know 
what Somerville is, the demographics of Somerville. Is it 
upscale?
    Mr. Levi. It is not an upscale community at all.
    Senator Dodd. Making the connection at the local level for 
the value because they are local investments you are talking 
about?
    Mr. Levi. That is right.
    Senator Dodd. Streetlights, sidewalks, you have got to make 
that nexus, it seems to me, for that local board of select men 
or city council, whoever makes those decisions on those 
investments is going to have to make the case to the taxpayers 
there that there is payback.
    Mr. Levi. That is right.
    Senator Dodd. How do they do that?
    Mr. Levi. Well, this report will show, on a state-by-state, 
basis how much private payers will save, how much Medicaid will 
save. You know, the private payers are really the employers of 
the local community.
    Senator Dodd. Yes.
    Mr. Levi. They have a vested interest in doing this. A lot 
of private employers are engaging in wellness programs, but 
those only----
    Senator Dodd. Would insurance companies be interested? For 
instance, if a community does these things, then the rates for 
people who live in that community might come down?
    Mr. Levi. One would hope that they would. Certainly the 
costs would come down, and the question is how can we harness 
some of those savings to promote these kinds of activities.
    Senator Dodd. You mentioned the U.K. Tell us about the U.K.
    Mr. Levi. United Kingdom has done what Senator Murkowski 
suggested, which is to take a look at this problem and actually 
did their own modeling and saw the projections of----
    Senator Dodd. Their problem was a serious one, was it?
    Mr. Levi. Very serious. Not quite as bad as ours, but on a 
very similar trajectory. They are just a few years behind.
    They made a decision that this required a national 
strategy, a national strategy that didn't just focus on medical 
intervention, though that certainly is part of it, and having 
appropriate medical counseling and access to appropriate 
services for people who are trying to control their weight and 
increase physical activity is important, but also literally 
remaking communities.
    They have made a commitment to remaking communities to 
promote physical activity, to improve the quality of food in 
any kind of public facility, whether it is schools or 
hospitals, to change the norms in a society, and that is what 
we are really talking about.
    Smoking cessation is probably a very good example of how we 
have, in a generation, dramatically changed people's attitudes 
and perceptions around smoking. Now, I don't want us to be 
stigmatizing people who are overweight or obese in the way, to 
some degree, we stigmatize people who smoke. But we can with 
social marketing, with education, with appropriate medical 
support, with changing the physical environment--that is what 
we do with smoking. We don't make it possible for people to 
smoke in certain places. If we can change the physical, social 
environment around issues of physical activity and eating, then 
we probably can see a similar change as we have with smoking.
    Senator Dodd. Thank you very much. I have a bunch more 
questions, but let me turn to my colleague.
    Senator Murkowski.
    Senator Murkowski. I wish it were easier. I am sitting here 
listening to all of this and thinking, we do a pretty good job 
in terms of incentives if you are an adult working for a 
company. Many companies have a wellness plan--in many instances 
the company helps pay for your club membership so that you can 
go and work out. It is limited to working people--adults. So, 
we are basically leaving kids on their own.
    There was a time when kids played. They were very physical, 
but now our children don't play the way they used to. I am 
convinced our children don't know how to play the way we did. I 
have a 15-year-old and a 17-year-old, and I make sure they know 
how to play. But they grew up in an outdoors environment which 
was relatively safe.
    I didn't have to worry about monitoring them like we do now 
with our children living in the cities. I didn't worry that 
they were going to fall off the monkey bars and break a leg, 
and I was going to end up going after the city for not 
maintaining the park. It is a different world that our children 
are growing up in, and they really don't spend time learning 
and understanding the physical aspect of playing.
    I worry about how we teach our children to accept exercise 
as something that is fun instead of something that you are 
forced to do. I absolutely support additional physical 
education within our schools. I, too, am stunned by the 
statistics.
    When you have physically active kids sitting in a classroom 
environment hour after hour, if they have a good recess, where 
they are out racing around, they can come back and focus--their 
education can benefit from that physical exercise. We don't 
want our kids to associate physical exercise with something 
that you have to do because, as adults, it will make it that 
much more difficult.
    Our problems are just overwhelming. I don't even know where 
to begin with a question. Keeping along the lines of physical 
education and the opportunities that we provide for our kids, I 
am told, when I go back to the State, that No Child Left Behind 
and the confines of that law are taking us away from the 
opportunity for more exercise in the school. We are focusing on 
the reading, writing, and arithmetic instead.
    I am also finding that it is not so much that there is not 
enough time in the school day, but we are having a real 
challenge finding P.E. teachers. We are having a real challenge 
finding health teachers. Much of it stems from the funding 
component, that we are not putting the money there. Am I right? 
Am I wrong? What is your experience?
    Dr. Kaufman. Well, I just wanted to mention that for the 
National Institutes of Health, I chair a study that is going on 
now called the Healthy Trial, and we are looking at a cohort of 
over 6,000 children in 42 middle schools in 7 cities across the 
country, and following them from sixth through eighth grade.
    Half of the schools we have intervened on, and part of that 
intervention, there is a food service component. There is a 
curriculum component. There is a social marketing component. 
There is also a physical activity, physical education 
component.
    When we got to these schools--so these schools all had to 
have at least 50 percent minority children and at least 50 
percent of the children eligible for free lunch. You can 
imagine what some of these schools were actually like. There 
was a gym area that was minute. They put 80 kids in there with 
one teacher.
    We have actually worked with the schools, found strategies. 
We have gotten a physical activity aide for the teacher. We 
couldn't actually hire more teachers, but we could hire an 
aide, a relatively low pay scale, most of them college kids who 
are looking for some outside work.
    We have been able to take these kids from, when we started, 
5 minutes of physical activity in a 45-minute P.E. class to 22 
minutes of moderate to vigorous physical activity without a 
huge change in what actually has been happening. These children 
have just finished seventh grade. In another year, they will 
finish eighth grade.
    There are hard outcomes, physical outcomes, medical 
outcomes that we are looking at in this cohort. If they have 
become healthier and less risk for diabetes and cardiovascular 
disease, we are hoping that this will serve as a model for how 
schools can fundamentally change comprehensively to enhance the 
health of our children.
    Mr. Levi. I think it is also important to point out, 
Senator, that this link to No Child Left Behind is, to some 
degree important, but in some respects specious in the sense 
that there is data now to show that kids who are more 
physically fit, more physically active will perform better 
academically.
    Part of complying with No Child Left Behind in some 
respects almost demands greater attention to physical activity 
so that the kids will score better. It is an indirect approach, 
but it really can make a difference.
    Now, ideally, if No Child Left Behind addressed physical 
activity, that probably would promote more attention as well. I 
also think, what Dr. Kaufman pointed out, that having P.E. 
alone is not sufficient. It is what happens in that P.E. class 
activity, and it doesn't even have to be a formal P.E. class, 
that you can introduce things into the school setting that 
encourage physical activity.
    Dr. Kaufman. Yes, they like hula hoop. They like dancing. I 
mean, it is not necessarily everybody who is going to go for a 
competitive sport. There are a lot of activities that the 
children want to do. When you give them a menu and they make 
some of the decisions, then they are much more engaged.
    Senator Murkowski. When you think about what we are trying 
to do in the schools, which is to teach you to be a lifetime 
learner, to make your life better every day by learning 
something new, we also should be teaching kids about their 
bodies and how to be healthy for a lifetime.
    It is not just talking about nutrition, although that is 
incredibly important, but the exercise component and how it 
makes you a better human being in the sense that everything is 
going well if your body is more physical and more fit.
    Mr. Chairman, I am over my time. We could spend all 
afternoon here.
    Senator Dodd. Thank you very much.
    Senator Harkin.
    Senator Harkin. I am like Senator Murkowski. It is hard to 
know where to begin on this.
    Jenelle Krishnamoorthy on my staff, whom I know works with 
some of you, just gave me this. The Journal of the American 
Medical Association today came out with a report on moderate to 
vigorous physical activity from ages 9 to 15 years and showed 
how it decreased in those years. You know, when you are 9 years 
old, you play more and you are active. By the time you are 15, 
you are not doing anything.
    Senator Dodd. Right.
    Senator Harkin. I haven't read the whole thing. I was just 
looking at the data here, but it said that expert opinion and 
empirical studies suggest that children need a minimum of 60 
minutes of moderate to vigorous physical activity per day, a 
standard proposed by the U.S. Department of Agriculture.
    Sixty minutes. When I was a kid, I remember we had 15 
minutes in the morning, a half hour at lunch, and 15 minutes in 
the afternoon recess. We had to go outside and play. Unless it 
was 20 below, maybe you stayed in at that point. That was about 
the only excuse----
    Senator Dodd. Which was about three quarters of the year.
    [Laughter.]
    Senator Harkin. That is Alaska. That is Alaska.
    How do we change the framework of the debate? I keep 
listening to candidates for President, no matter when. 
Everybody is running around, all the debate on healthcare in 
America is how do we pay the bills? In essence, when you boil 
it all down, that is all we are talking about. How do we pay 
the bills? National health insurance, single payer, all that 
kind of stuff is how do we pay?
    How do we change that framework to how do we prevent? How 
do we start changing the framework of that debate? Now part of 
the problem in the past has always been, well, you have to pay 
the bills because if you get into prevention, that just costs 
more money. It costs more money, and we can't take money out of 
the pot right now because there is not enough there to meet the 
needs of healthcare right now for low-income people.
    It has been kind of a catch-22 situation. We know we have 
to do prevention, but we don't have the money to do it.
    Now the report that you have just come out with, the Trust 
for America's Health that will be made public tomorrow, shows 
that the rate of return on that investment is about 1 for 1 in 
1 year, and that is at a very low investment rate of $10 per 
person. Think what it would be like if we invested $100 per 
person or more. It is a very timely study that the Trust for 
America's Health is coming out with.
    How do we change this framework? How do we start getting 
people, and our candidates who run for office on both sides of 
the aisle, to start thinking about how we change the framework 
of the debate?
    Yes?
    Senator Dodd. Dr. Grey.
    Ms. Grey. One of the major issues is we have spent most of 
the last 20 years blaming the people who are obese and say if 
you just wouldn't eat more, if you just would exercise more, 
then you wouldn't have this problem. Well, clearly, that hasn't 
worked.
    It is really about changing the perception and thinking 
about very early on how you bring the right people to the table 
to change things. I will give you an example.
    We know very clearly that children of pregnant women who do 
not lose their pregnancy weight are more likely to have 
children who are overweight or obese by the age of 2. The 
weight gain trajectory for those children will be like this 
compared to those children of those women who have not gained 
weight.
    We pay lots of money to take care of acutely ill babies, 
but we pay no money to help women postpartum lose pregnancy 
weight. We have to reframe the debate about not just healthcare 
and not just individual responsibility, but how do we create 
opportunities for communities and others to participate in 
this?
    One of the things we did in New Haven about 10 years ago--
in collaboration with your good friend Senator Toni Harp--we 
created a coalition to fight childhood obesity. It was a 
grassroots effort in New Haven that didn't engage the 
healthcare providers. I was the only healthcare provider 
involved.
    It was a group of parents, religious leaders, city 
officials, including the city planner, and others who said, 
``Oh, my gosh, this is a terrible problem. We really must do 
something about that.'' That coalition is the coalition that 
went to the schools and said, ``get the sodas out of here.'' 
There is a law in the State of Connecticut that says these 
should not be available during the school day.
    Well, we have the system where the schools can only pay 
their bills by collecting this information or paying for this 
soda. What they did was they put healthier choices in there, 
and guess what? They didn't lose any money.
    Senator Dodd. That is right.
    Ms. Grey. We started a system called Walking Buses. This is 
one of the things they do in England that is really wonderful 
for inner-city kids. You have adults who aren't getting much 
activity, who aren't working, who take a group of 5 or 10 kids 
from the neighborhood and walk them to school, and we create 
environments that are safe that allow them to walk 10 blocks to 
school every day and walk 10 blocks back.
    Those aren't huge changes, but it takes the community 
buying into this isn't just a self-responsibility problem. This 
is a societal problem.
    Mr. Lesley. Senator Harkin, I also think it is this issue 
of it is a national plan, as Dr. Levi talked about, but it is 
also kind of place-based policies. It is stuff that is 
reflected in all of the legislation you all work on in terms of 
if you look at the school, it isn't just the school lunch. It 
is the school lunch, but it is not just that.
    It is the school nutrition program. It is the P.E. program. 
It is also the afterschool program and the community 
involvement in that, and it is things like figuring out ways 
for kids to walk to school. It is also access to fruits and 
vegetables, which it is your bill that really did get fresh 
fruits and vegetables into the schools.
    There was a Washington Post series that talked about where 
in Fairfax County they got rid of the french fries in the 
schools, and 2 days later, it was the parents who had the 
revolt. We also need to get the community parents to understand 
why we are doing these kinds of things.
    In my neighborhood, the elementary school just happens to 
be on the other side of a major street. I would bet that 90 
percent of the parents in our neighborhood drive their kids to 
school, and it is just getting a crossing guard right there. 
That is all it would really take, and I would send my--but I 
drive my kids to school because of those kinds of things.
    It is really the community thinking about the issue and 
talking to one another. I profess that I have been part of the 
problem. Senator Bingaman came up to me one day when I was 
working in the Senate and said, ``The Ag bill is on the 
floor.'' I looked at him and said, ``Yes, I am your health L.A. 
So?''
    His point was, yes, and there is an obesity issue, and we 
worked with your office and all of your offices on kind of an 
amendment to the Ag bill to improve this issue. It is this 
transportation, healthcare, education, and health. It is very 
comprehensive, and people don't speak to one another about it.
    Senator Harkin. I guess I get frustrated because I watched 
all the debates of our candidates who are running for 
President. I watched all the debates----
    [Laughter.]
    Senator Dodd. One of those unique Americans.
    Senator Harkin. Whether it is on the Democratic side or the 
Republican side, I watched those, too. Every question that 
would come up on healthcare was always about how are we going 
to get health insurance to everyone? How are we going to cover 
everybody? How are we going to pay the bills?
    Senator Dodd. Yes.
    Senator Harkin. I kept waiting for one questioner to say, 
you know, we know that prevention works and we get the payback 
on it, what is your idea, so-and-so, about how we can change 
America to be a wellness society and prevent illness? No one is 
ever asking that question.
    Therefore, our candidates start thinking, well, I know the 
question is going to come, and it is going to be on how we pay 
the bills. And so, I will get up on that. It is very 
frustrating.
    I keep hoping that sometime the questioners of our 
presidential candidates will start grilling them on prevention 
and what it means and what community wellness means and how we 
get our communities to think about wellness programs and using 
examples. Like Portland, OR, who has done a great job as well 
as other cities and some schools, and what different schools 
are doing for activities.
    Then just talking about our school systems and our food 
programs, next year we have the reauthorization, Chris, of the 
child nutrition bill--school lunch and school breakfast. Well, 
I would like to have our candidates talking about what changes 
do you think we ought to have in the school lunch program so 
that our kids have better food in schools. To me, this is a key 
part of our wellness in society and how we are going to prevent 
illness in the future.
    But those questions don't get asked, and that is why I get 
kind of frustrated. That is why I ask you how do we change this 
paradigm?
    I am thinking Senator Murkowski and I worked very hard 
together to get a change in the foods minimal nutritional 
values done. We didn't get it on the Farm bill, but the child 
nutrition bill is our key to get it done next year. We tried to 
get it on the Farm bill but wasn't successful.
    What should we be thinking about in the child nutrition 
bill? What should we be thinking about and how should we change 
the school lunch and school breakfast programs?
    Mr. Lesley. Yes, I would also add that you also have 
opportunities next year with SCHIP coming back up for 
reauthorization in March, and in the final bill that all of you 
voted for in the Senate, it had a demonstration project on 
childhood obesity.
    It is interesting, on the Medicare side, I worked on a bill 
for Senator Bingaman on medical nutrition therapy in Medicare, 
but it seems to me that the emphasis you are putting on this 
hearing today is we should be thinking about all our public 
programs and including the child nutrition programs, the 
Children's Health Insurance Program.
    One of the things even we were looking at recently was the 
Maternal Child Health Program and the fact that in the Maternal 
Child Health Program there is no emphasis on this issue because 
it hasn't been reauthorized in a number of years.
    One thing, to speak to the issue you raised, is the WIC 
program still serves whole milk and sweet and flavored milk. 
Why are we not providing the no fat alternatives and those kind 
of things. We hope to work with you on things like that next 
year.
    Dr. Kaufman. In the reauthorization of the school lunch 
program, there is a lot of data, in a number of studies that I 
have looked at, of what some of those criteria should become. 
In this school study, we wanted to increase fiber. There is no 
real requirement for fiber. We put out first the high-fiber, 
high-grain buns, and the children had no idea what it was. 
First, we had to just put the one on the bottom and then the 
white one on the top. Then, eventually, they kind of got used 
to it. So it is not going to be an immediate shift.
    We are still looking at trays in our schools. I mean, these 
very vulnerable schools, and the schools we are in, 50 percent 
of these 11-year-olds had a BMI greater than the 85th 
percentile. Actually, we did a pilot in the eighth grade of the 
schools--it is not the same cohort--but in those eighth grade 
students, we actually found 39 percent had already an abnormal 
blood sugar level.
    These are incredibly vulnerable children, and they are 
still getting a Federal lunch program that is not weighted. The 
whole item, that whole tray for the week is kind of balanced 
out. Whatever they take, if it happens to be that 75 to 80 
percent of the choices are the higher fat containing burrito 
than we would like to see, it is still acceptable. We had to 
get waivers around the number of calories in some of those 
lunches in some of our schools.
    Senator Harkin. Or what they do is they cut down on the 
fat, and then they up the sodium. They pour the salt on.
    Dr. Kaufman. Right. Or they up the sugar.
    Senator Harkin. Or the sugar. Sugar, both.
    Mr. Levi. I think part of the message--and I think Dr. 
Kaufman could probably speak to this better, as more an expert 
than I, that part of the message that we need to communicate to 
folks is that relatively small changes can make a huge 
difference in terms of health outcomes. We don't have to 
suddenly have a nation of thin people in order to see dramatic 
changes in the quality of life and the length of life and how 
healthy people are.
    In fact, one of the things in doing this report that I 
think was particularly surprising to me, even though I have 
read a lot of this material, was how very small weight loss, 8 
to 10 pounds, can really dramatically reverse someone's course 
in diabetes.
    Dr. Kaufman. Right. The diabetes prevention program, which 
was a massive NIH study, showed that in a very high-risk group 
of multiethnic throughout the age span of adults, a modest 
weight--7 to 10 percent weight loss, 30 minutes 5 times a week 
of just walking reduced the progression to diabetes in those 
who had pre-diabetes by almost 60 percent.
    Now that is out in the community. There is a huge effort of 
translating this phenomenal NIH data and the components of the 
study out into community venues. Those kind of things don't 
belong inside the medical world. They belong inside the 
community and the workplace, where they are able to be done in 
a lot more effective and a lot more cost-savings way than 
inside a medical center.
    Senator Dodd. Let me ask you, we have an awful lot of young 
people here in the audience today, and I was thinking of going 
back to the smoking issue, seatbelts in cars. One of the 
reasons it worked wasn't because we just passed ordinances and 
laws, because actually children, in many cases, asked their 
parents to stop smoking, insisted they put on the seatbelt in 
the car, became a great advocacy group.
    The issues of weight and self-image, and Dr. Grey, you have 
done a lot of work in this area, the psychological effects of 
obesity. I couldn't help but think as well about the problem. I 
was with a good friend of mine today, and he knew I was going 
to conduct this hearing and has a child that is suffering from 
anorexia, the sort of antithesis of the issue, but, in effect, 
a manifestation of the same problem in some ways, self-image.
    All of the marketing techniques today, I mean, you open any 
popular magazine or what show it is, there is such a 
glorification in a way of a body type and style that I think it 
is difficult just in the sense of being a child and the kind of 
peer pressures associated with this that create its own 
dynamic. I regret not doing this, which I am tempted to do, I 
have never done this before in 27 years here. If any of these 
younger people in this audience have any ideas about this, you 
could become a witness in a congressional hearing if you would 
like to come up.
    [Laughter.]
    If you have any thoughts about this. Because, really, the 
audience in a way can do so much. We can do a lot of these 
things, and Tom has been terrific and Lisa on these issues. I 
was going to ask Tom--I have never done this either. I have 
never asked a colleague a question during a hearing. Normally, 
we ask the witnesses. The Food Stamp Program, I just have given 
a lot of thought to this and haven't come up with an answer for 
it because, obviously, we associate more expensive foods are 
more nutritious or the correlation is.
    Can't we incentivize that Food Stamp Program in some way, 
where we reward a family that will, in a sense, take those food 
stamps to buy more nutritious food? There ought to be a reward 
associated or some way to encourage, to incentivize people 
moving in that direction.
    I wonder, Doctor, if you could----
    Senator Harkin. Mr. Chairman, could I respond to that?
    Senator Dodd. Certainly, yes.
    Senator Harkin. In the Farm bill we just passed, I put a 
provision in there that--and we are going to test this out. It 
kind of comes from Michael Pollan's book. He was wondering why 
so many low-income people are so obese and why they have 
diabetes. He began looking into stores and finding out that 
low-income people use their food stamps to buy fast starches 
and sugars. They don't buy fruits and vegetables because they 
are the highest prices.
    Fast starches and sugars are the highest subsidized things 
that we do in this country. I got to thinking about that, and I 
thought, you know, we don't have food stamps anymore. We have 
an EBT card, electronic benefit transfer card, and it has a 
little black stripe on the back like your credit card.
    When you go through the counter, they swipe that card, and 
it deducts from your food stamp allotment whatever you bought, 
and then you know what you have left. You can encode on that 
stripe a lot of other things. For example, you can't buy beer 
or wine or cigarettes or nonfood items with the EBT card.
    If you go through and they have checked all the bar codes 
and stuff, and then you hand them the EBT card and they swipe 
it, and you have bought a six-pack of beer, that will come up 
and say that is not allowed. Or if you buy nonfood items, that 
is not allowed. They have to deduct that, and you have to pay 
cash for it. It can't come off of your food stamps.
    I got the idea that maybe what we could do is encode that 
for fruits and vegetables. We have in the Farm bill money to 
set up a study on providing EBT cards to people so that if they 
go in and they see fresh fruit, for example, or produce. Let us 
say it is $4, that is $4 per pound or something. They know that 
if they buy that, it is only going to cost them $2.
    And human nature being what it is, we all love a sale. We 
always like to buy things that are cheaper than what is marked 
on the thing. If I use my EBT card and I go to buy potato chips 
and it is $4, and I know it is still going to be $4, but if I 
buy this and it is not $4, it is going to be $2, maybe I will 
start buying it.
    We have this study that has just started. The Department of 
Agriculture is trying to get the rules and regs for it. 
Hopefully, this will show that if you give a benefit to people 
on that EBT card, they will start buying fresh fruits and 
vegetables, hopefully.
    Senator Dodd. Incentivizing.
    Senator Harkin. Incentivizing. That is what we are trying 
to do. I just wanted you to know that has started, and 
hopefully, by next year, we will have a little bit of data on 
this, I hope.
    Senator Dodd. Tell us, Dr. Grey, about the stigma and the 
psychological impacts. You have done a lot of work in this 
area. Is there a correlation between adults and children? I get 
the feeling from what you just said that it is obviously more 
pronounced among younger people than it is with adults that 
are----
    Ms. Grey. Well, it seems worse, I think, in children 
because depression is a serious problem amongst youth. While 
the elderly are the most likely to commit suicide, teenagers 
are the second most likely. When you put together kids who have 
health problems, depression, and difficult life circumstances, 
it is a witch's brew.
    Senator Dodd. More associated with girls than boys?
    Ms. Grey. Both. It is actually slightly higher--actually, 
girls make more attempts, but boys are more likely to be 
successful. Part of the reason for that is boys are likely to 
use more violent approaches. They have higher access to guns 
and may shoot themselves, whereas a girl may take an overdose 
of aspirin and get sick but not complete a suicide.
    The issues around self-esteem and all of those things are 
highly related to the communities in which people live, and one 
of the issues that we face now that in many inner-city 
communities, where we have done most of our work, we are 
talking about kids where being obese is normal. There are whole 
issues about if a kid wants to make a change and starts to lose 
weight, then they get teased for being different because they 
are losing weight.
    This whole issue, from my point of view, is really about 
how do we normalize what is healthy, not what is skinny? In the 
African-American community in which I work, the average 
teenager is overweight. When we start talking to them about 
weight loss, they think we want them to look like Halle Berry. 
Well, they are not going to look like Halle Berry.
    If they can lose 5 percent of their body weight or at least 
stop gaining weight for a while, while they kind of grow into 
this, then they feel much better about themselves. The fact is 
a lot of these kids can't be physically active because they are 
huge. These kids get mixed messages, boys in particular.
    We were talking earlier about kids playing football. In the 
junior high school, we are telling them, ``You are unhealthy.'' 
You weigh 280 pounds, and the football coach is saying, ``Keep 
packing on those pounds. You are a really good lineman on my 
football team.'' We have to stop the double message. We have to 
be talking about what is healthy from a mental and physical 
point of view and stop normalizing the fact that it is OK to be 
that heavy.
    Senator Dodd. Well, I am very interested as well in talking 
with you, Dr. Kaufman, about the link between obesity and 
diabetes. What proportion of people with obesity also have 
diabetes, and what proportion of people with diabetes is obese 
or overweight?
    Dr. Kaufman. Well, it is probably easiest with answering 
the second question. Those with type 2 diabetes, 90 percent are 
overweight or obese. In our pediatric group, it is 100 percent 
of these children.
    There is another trial that I chair for the NIH called the 
Today Trial--Margaret has been involved with it--which is 
looking at trying to really understand, characterize, and learn 
best treatment modalities from children who have already 
contracted type 2 diabetes. We have 15 sites across the 
country, and these children are--we had to buy new scales. I 
mean, a 350-pound child is almost close to our mean.
    Senator Dodd. If a child has pre-diabetes, what is the 
likelihood that child will develop type 2?
    Dr. Kaufman. Well, we are hoping to answer that question 
more scientifically. For adults, we know that once you have 
pre-diabetes, there is about a 10 percent conversion per year. 
We know there is 54 million Americans right now with pre-
diabetes. So you can start to imagine that math.
    We are watching, not only this last year, an increase to 
this 24 million, but at a higher rate of increase than had been 
seen before. One point three million more were added last year.
    We are still trying to sort out through a number of CDC and 
NIH efforts to characterize really what is happening in 
children, but we know that these children when they come to us, 
they are all overweight and obese. They come from families in 
which there is a very high prevalent rate of diabetes already. 
Most of the adults in their lives are failing in managing their 
disease.
    They are socioeconomically having a lot of issues attaining 
healthy lifestyle habits that we are working with them on. Of 
course, we are now providing healthcare, but a number of the 
children were having difficulty in access to healthcare.
    Senator Dodd. I am asking you a couple of these statistical 
questions, and I ask you to just go back and do this.
    Dr. Kaufman. Sure.
    Senator Dodd. Another one I had for you, I just was stunned 
and you referred to the healthy middle school study.
    Dr. Kaufman. Right.
    Senator Dodd. Thirty-nine percent of minority eighth 
graders were found to have pre-diabetes in your report. The 
question I have is how does this compare to the rate of 
diabetes in minority adults, No. 1, and what conclusions do you 
draw from the large disparity between the rate of pre-diabetes 
in the children you studied and the rate of diabetes in adult 
minorities?
    Dr. Kaufman. Well, we are applying adult criteria to these 
children. We are not sure they are the right criteria.
    Senator Dodd. Yes.
    Dr. Kaufman. These children actually have a blood sugar 
level clustering right at the cut point. We are not sure 
whether part of that may be due to when you are overweight and 
you are going through puberty--puberty is a time of insulin-
changing activity in your body, what we call insulin 
resistance. You know, puberty is a time of resistance, but 
insulin is one of the things that children are resistant to.
    We don't know whether as they come back out of puberty that 
might normalize at a lower rate so that they don't have pre-
diabetes anymore. I can't answer that question for you 
scientifically, but we will have the answers over time.
    We know that it is kind of a bad sign that you can't handle 
the stress of puberty without having too high a blood sugar. If 
they do come back down to a more normal range, they are 
likely--unless we do something about their weight and their 
health status--likely then to emerge again as adults with pre-
diabetes and then diabetes.
    Senator Dodd. Yes. I will ask you this and then turn to 
Lisa again.
    I talked about this as an epidemic, and I use the word 
``emergency'' carefully. We talk about--we use that word, we 
throw it around quite frequently to describe almost everything. 
It strikes me, looking at these numbers and looking at the 
studies that you have already done, even with the conclusions 
that you have drawn early on, that we are clearly in a medical 
emergency with this issue that is going to become exponentially 
larger.
    The point I think that Lisa made about--I think some of you 
did as well--that you let this generation slip into the next 
generation, because there is a direct correlation between obese 
parents and the likelihood of obesity among their children. So 
you start exponentially expanding that constituency. Then this 
problem becomes exponentially larger very quickly.
    Dr. Kaufman. Right.
    Senator Dodd. Am I exaggerating this conclusion?
    Dr. Kaufman. Not at all. I mean, from the psychological to 
the medical reasons as children, during childhood, these 
children are very, very fragile from a medical standpoint. Then 
their long-term health is in tremendous question.
    There is no doubt that unless we do something and they 
continue to track with overweight and obesity, they will be the 
cohort of adults with cardiovascular disease, diabetes, cancer, 
and a whole host of other medical conditions.
    Senator Dodd. Well, it is telling me so much that by 
looking at this, these are the kinds of problems you associate 
with adults. I mean, having children taking--I guess it is good 
maybe. Having cholesterol problems, having strokes, heart 
problems, these are all things we would normally just associate 
with aging, not with youth at all.
    Have you done anything, have we talked to the military at 
all about this? Are they showing any signs of problems in 
recruiting or people coming into the military?
    Dr. Kaufman. We are partly funded in some ways from some of 
the military grants because there is so much diabetes 
developing in their young adult cohort. Once they have 
developed diabetes, they have to then care for them. They are 
looking at ways to instill diabetes prevention programs inside 
the military.
    Mr. Levi. In fact, in terms of recruiting, it is a 
significant issue, and I mentioned this in my written 
testimony. In 1993, 25.6 percent of 18-year-old volunteers were 
overweight or obese. By 2006, that grew to 34 percent. Each 
year, between 3,000 and 5,000 service members are forced to 
leave the military because they are overweight. It is a huge 
problem, both in our being able to recruit people and also then 
the cost of retraining to replace people who are discharged.
    There is a certain irony, I think, in where we are today as 
opposed to 1965 when the Medicaid legislation was passed, and 
one of the things that compelled President Johnson to push for 
Medicaid was the difficulty--and this was during the period of 
the draft--that so many recruits were underweight and 
unhealthy, and today we have the reverse problem. It is a 
reverse national security problem.
    I think it also points to the comments that Bruce Lesley 
was talking about in terms of if you look at the populations 
who are probably volunteering for the military, were probably 
at some point touched by Medicaid in their lives, and maybe we 
also need to be looking at how Medicaid can address this issue 
so that when they do become of military age, they can 
successfully volunteer.
    Senator Dodd. What I am struck by in your testimony is 
that, one, the magnitude of the problem, but the nonmedical 
responses to this make this preventable.
    Mr. Levi. That is right.
    Senator Dodd. We could really make a huge difference.
    Mr. Levi. That is right.
    Senator Dodd. That is the positive and the silver lining in 
all of this, to identify the problem. To recognize that we can 
do something about this now that we know what to do.
    I have been dealing a lot with autism and done a lot of 
work at Yale as well on autism. One of the confounding 
problems, we don't really know what causes it. We don't even 
know how to successfully treat it. I mean, it is really in a 
spectrum what can happen.
    Here, we know what causes it. We know how to treat it. We 
know what we ought to be doing about it. Unlike other areas, 
such as autism, this is one we can handle.
    Lisa, any additional questions?
    Senator Murkowski. Just one final question to you. I am 
very active on the Energy Committee, and of course, what 
everybody in this country is talking about right now is the 
price of energy and what they are paying at the pump, and what 
their family is paying out of their pocketbook for their energy 
consumption.
    It would appear that in this country when you hit about $4 
at the pump, the American public started demanding action. Here 
in Congress, we are trying to figure out how we deliver on 
that. I am of the belief that it has to be a combination of 
increased production and increased renewables and less 
consumption, but this is a HELP hearing, and not an energy 
hearing.
    My point is, we have to identify what that tipping point is 
in this country when it comes to energy and how you have a 
public that is now demanding action. On the issue of obesity, 
are we at the tipping point yet?
    Do you think that Americans understand? Do you think that 
people understand--the statistics which you have all cited, 
which are phenomenal--that this is not just something that is 
happening in their town, but it is happening around the 
country?
    Do you think that people understand the connection between 
not only the consequences that you all have described--whether 
it is depression or other mental health issues--and then the 
cost to society and the medical costs? Do we sufficiently 
understand, as a nation, enough to push us over the edge so 
that we can have some definitive action? Are we there?
    Mr. Lesley. I would say that the polling on this kind of 
issue is pretty interesting in that there is this national poll 
on children's health that shows that adults definitely identify 
obesity as the top issue facing children. However, I don't 
think that they get the connection in terms of what is it that 
we need to do.
    I think that it is kind of a problem with children's issues 
generally of people care, but they don't then see the linkages 
to the public policy. If you ask people specifically, do you 
care about children's issues at the Federal level? They poll in 
the 80, 90 percent range. Then if you ask them is it a priority 
in what you are going to vote for, they don't list it. Then if 
you ask them in a focus group, so you don't care about these 
issues? They are like, of course, I do.
    There definitely needs to be a public education campaign, 
kind of like what we did around seatbelts and smoking and those 
kinds of issues, to really educate the public about--people get 
the issue. It is not an education of just stating that obesity 
is a bad thing, but it is what are all the things we need to do 
together as part of a national plan and commitment to 
addressing this issue and making people talk to one another? I 
think that is really one of the things missing.
    Senator Murkowski. But we are not there yet.
    Dr. Levi, you seem to indicate that we are there?
    Mr. Levi. Well, I think we are part of the way there. We 
just actually did some polling in conjunction with the release 
of our annual obesity report, which will be coming out shortly. 
We found that 63 percent of Americans now do believe the 
diseases related to obesity are a very important issue for 
government to focus on.
    I think translating from that to a specific agenda is the 
challenge, and I think, particularly with health problems, we 
have tended to want to look for magic bullets and for a pill or 
a vaccine. There isn't going to be a pill or a vaccine for 
obesity--at least not yet--and in the meantime, there is so 
much we can do.
    These behavioral changes are not easy and require really a 
lot of this norm changing that we have been talking about, the 
destigmatizing of changing what people value. That is going to 
take leadership from all of you, and it is going to take 
leadership from who is in the White House, and it is going to 
take leadership at the community level as well from every 
level.
    Senator Murkowski. I think also it is going to take a 
recognition that it is everyone's problem. None of you sitting 
here would be considered obese. I don't know what your 
background is, but is it your problem? Yes. It is everyone's 
problem.
    We are going to have to accept that we are all in this 
together. It is not the family next door that has an issue and 
they need to solve it on their own. We need to be changing our 
systems, changing the way that we think about diet and exercise 
and healthy lifestyles.
    In Alaska and our Native organizations, many of which have 
been pushing wellness initiatives to help deal with sobriety 
and drug abuse, and also the whole concept of wellness. As we 
talk about healthcare reform, as we talk about those ways that 
we can lower our healthcare costs--prevention, as Senator 
Harkin has mentioned, is just absolutely key. It is this 
greater concept of wellness, wellness of body, wellness of mind 
and attitude, and we are all part of the solution. It is not 
our next-door neighbor's problem.
    Thank you for your contributions. I appreciate it.
    Senator Dodd. I wonder if I made a mistake earlier in 
something I was suggesting. I was talking about eating 
disorders, and is bulimia and obesity--I have doctors here in 
front of me. What is the distinction in a sense, I mean?
    Dr. Kaufman. Well, in looking at weight issues, the very 
low weight, particularly woman, young adult woman, older 
teenager is a very distinct subset of the population who really 
are at risk for that, and they are quite distinct from the 
population who are at risk for obesity and obesity-related 
diseases.
    We have done a lot of evaluations in our community programs 
in Los Angeles, as well as in some of our school-based 
problems, to try to find out--because one of the big fears was 
would we be inducing anorexia now, with low weight and the 
medical issues associated with that, in these children as we 
were delivering school-based health programs. We are talking 
about health, talking about healthy behaviors.
    We have not seen any signal that that has changed at all. 
We don't think this is a risk for inducing low-weight medical 
issues.
    Senator Dodd. Do you agree with that, Dr. Grey?
    Ms. Grey. I do.
    Senator Dodd. Yes, I said earlier I am so impressed that we 
have so many younger people, Lisa, here in the audience that 
have come here today. I have never done this before.
    Would any of you young people have any ideas you would like 
to share with us on the subject matter? You have heard these 
official experts. I have never--in 27 years, I have never asked 
the audience a question at a congressional hearing.
    Yes, ma'am?
    Audience Member. I just want to say, I am a Ph.D. candidate 
at the Johns Hopkins Bloomberg School of Public Health in 
international health and nutrition, and I am also an intern 
here at the National [Off Mike]. I think it is a dual issue of 
changing our food system here in the United States and around 
the world and also looking at how we can change our messages.
    We are talking about individual behavior, but it is not 
just limited to behavior because if you look at those who are 
most at risk for overweight and obesity, it is children and 
adults with lower income status. You can't just ask the one 
person at their convenience and their time to join the gym or 
to eat healthier because it really is not possible. I think we 
need to really focus at a national level on environmental 
change as well.
    Senator Dodd. Some of the things Senator Harkin talked 
about in terms of how we incentivize dietary changes and so 
forth and making available foods that are far healthier and the 
like, I think, is what you are driving at on this issue.
    Well, thank you. Anybody else in these young people in the 
audience?
    Yes, ma'am? What is your name? Tell me where you are from.
    Audience Member. Hi, I am [Off Mike] resident at the 
University of Maryland in Baltimore. I think that the issue is 
multifactorial. We have families coming in that the parents are 
overweight, that the grandmother is overweight. Sometimes they 
don't see it as ``we are overweight.'' They just see it as ``we 
are all just big people.'' The family is looking at themselves 
like that, and they do not see it as an issue.
    When I show them the growth charts for the child to show 
that their child is above the 97th percentile and that it is an 
issue, when I try to tell them, well, let us think of different 
things you can do for your child. Just let us take out this 
little factor not just for the child, but for the whole 
household. Let us stop eating fast food two or three times a 
week. Let us have it once a week and then bring it down to once 
a month as more of a treat. Like, you did a good job at school 
today so this might be your treat.
    The fact that kids don't have physical education in school 
anymore, some kids also don't even get recess. Also another 
factor that is an issue is when I ask the parents, ``Well, do 
you feel safe in your household?'' They feel safe inside the 
house, but they don't feel safe outside. Therefore, their kids 
don't get the chance to go outside to play. They can't go 
outside to play. The parents' thinking might be, well, you know 
what? I would rather my kid be big than worry about whether 
they are going to get shot at when they are outside playing.
    The issue isn't just something of do we make sure that we 
have appropriate foods in the school, but we need to make sure 
that we also have physical activity for these kids, that they 
can feel safe in their local environment, but also that the 
parents understand that this is a problem. It isn't normal for 
your child to be this size, to be 50 pounds when you are 2 
years old. They need to understand this is an issue that is not 
just an issue for the child, but an issue for the whole family, 
and the whole family needs to be onboard.
    Because if we tell them, ``Well, this child needs to work 
on losing weight,'' I don't just say it is only for the child. 
The whole family has to make a lifestyle change. You take all 
of the cookies out of the household, and no one is eating 
cookies at home. And you take all of the soda out of the 
household. If you want soda, then it needs to be diet soda 
because there is no sugar in the diet soda.
    I think it is not just looking at one particular issue, but 
it is looking at everything within the household, within the 
community, within the environment.
    Senator Dodd. I think the next hearing we are going to 
invite both of you to be witnesses.
    [Laughter.]
    It is very good, excellent. It is encouraging to know you 
are thinking this way. We have people out there working this.
    Anybody else on a point they wanted to raise at all? Yes, 
ma'am, there is someone I can only see your hand. Yes?
    Audience Member. Hi. My name is [Off Mike]. I am from 
Glenwood, IA. My idea----
    Senator Dodd. Senator Harkin, did he know you were here?
    [Laughter.]
    Audience Member. I don't know if he knew I was here, but my 
idea would be to maybe increase the variety of physical 
activities in schools. I am also a dancer. I would say using 
dance as an option or just something else, so that if the kid 
isn't picked for kickball there are other avenues for physical 
activity. Making different kinds of programs more available, so 
the classes that they take are effective.
    Senator Dodd. That is a good idea. I have a 3-year-old and 
a 6-year-old daughter, and they love to dance.
    Audience Member. That is great, yes. It is good exercise.
    Senator Dodd. I think it is exercise. They make me do it 
with them.
    [Laughter.]
    With my knee replacement doing Irish step dancing. What a 
sight to behold, I will tell you.
    Well, this is very encouraging. It is very good.
    Anybody else in the audience want to say something? Hands? 
Yes, oh, we have a lot of hands now.
    Yes, I will start over here. Yes?
    Ms. Hoffman. Hi, I am Vanessa Hoffman. I just completed 
training to be a registered dietician.
    Senator Dodd. Where are you from?
    Ms. Hoffman. I am from Washington, DC. I wanted to commend 
Bruce Lesley's work in promoting medical nutrition therapy as a 
way to provide people with reimbursable ways to meet with 
registered dieticians, to talk with someone who is an expert 
about nutrition, answer their questions.
    Also improving resources, like Brian Wansink has been doing 
at the Center for Nutrition Policy and Promotion in terms of 
MyPyramid Tracker. People can go online for free and enter all 
the foods they have eaten and get feedback on how to improve 
their diet.
    Senator Dodd. That is terrific. That is great.
    On this side of the room someone had a point they wanted to 
make? Yes?
    Audience Member. Yes, we are both in high school, and it is 
really great to see so many of our generation here. That is 
really great to see.
    Senator Dodd. That is why I thought I ought to ask you 
since you are in the room.
    Audience Member. Yes, and it is really great to see in 
action. I think all of your plans are national in scope but 
local in application, and it is going to take a lot of local 
and, like you were saying, community-based action. It is good 
to see that the attention is going to create change, and it is 
great to see that starting, you know?
    Senator Dodd. Yes.
    Audience Member. Also, I would have to say that I think an 
interesting statistic would be if you look at the percentage of 
children in America with obesity, and actually, I think that 
would be very interesting if you figure out what percentage of 
those children have obese parents. Because I believe that you 
are a product of your environment. Sometimes that is not the 
case, but a lot of times that is true.
    Unless you have a conducive environment and parents that 
can support you and can instruct you, then you are not going to 
be--as a child, you look up to your parents. You do what--your 
parents are the producers. They provide for you, and we just 
consume. Like, if the parents aren't providing a healthy 
environment, then the children aren't living in a healthy 
environment. Therefore, we have this Nation of obese children 
because it all starts with the parents.
    I think that education programs should be geared first 
toward--more toward the parents. That is where it all starts.
    Senator Dodd. The families. That is what the young lady 
from Maryland was saying back here, too.
    What else? We have a couple more here. Yes, way in the 
back? Yes, go ahead. By the way, we have a microphone out here. 
We are going to give you a microphone.
    Audience Member. Mike [Off Mike] from Fargo, ND.
    Senator Dodd. You don't need a microphone. Go ahead.
    Audience Member. OK. This might just be a very small thing, 
and you were talking about before, Senator, you were talking 
about the energy crisis and you were talking about 
infrastructure with sidewalks and everything. I am an avid 
cyclist, so I love bicycling around town. DC is a great place 
to bike.
    If you could somehow create a Federal mandate, I know lots 
of roads are done on a State or local level, but sort of like 
speed limits, where you have to have this or you obviously 
don't get the funding. If you could say, you are not going to 
get this extra funding if you don't put bike lanes on the 
residential roads. Bike lanes are very, very helpful. They 
protect us a lot.
    I have ridden--I was in Florida--Tampa, FL, this past year. 
It was one of the worst places to bike in the country, and it 
was really, really dangerous, and I almost got run over a 
couple of times. You could solve two crises in one. Bike sales 
are going up. You could get people exercising, and you also 
lower people's cars' emissions.
    Senator Dodd. We have actually done that on some 
legislation. There has been--I know in my own State, I have 
done that in a number of instances. I actually got funding for 
bike paths in conjunction with highway programs. We actually 
have been doing some of it, probably do a lot more of it based 
on that suggestion.
    Audience Member. Yes, I thank you.
    Senator Dodd. Anyone else back there? I have opened up the 
door here, haven't I?
    [Laughter.]
    Anybody from Connecticut?
    Audience Member. Me.
    Senator Dodd. Nothing like a little local politics. Are you 
from Connecticut?
    Audience Member. I go to school at Yale.
    Senator Dodd. That is good. We will try. Do you vote in 
Connecticut?
    [Laughter.]
    I am only teasing. That is not serious.
    Mr. Talbott. My name is David Talbott [Off Mike] in my 
final year at Yale. I am, by no means, an expert on the issue, 
but one of the things that I did at school was I started up a 
program called Student Soccer Outreach. We go around to a lot 
of the local middle schools and teach them. Not only do we do 
mentoring, but we also do soccer and teach them what it means 
to be a fit and healthy younger adolescent.
    I guess, I have been interning for the HELP Committee.
    [Laughter.]
    I was reading some of the testimony, and I noticed that a 
lot of the talk today was focusing on prevention. I believe it 
was in Mr. Lesley's testimony that he mentioned that 95 percent 
of the money we are spending right now is on treatment rather 
than prevention. It seems like that money really isn't being 
effectively used.
    I am just not really making a statement. I am asking a 
question. Is there any way to make that 95 percent more 
efficient because it seems that while the prevention is where 
we are looking to go to the future, the current path has really 
been on treatment and that it is really not being effectively 
used.
    Senator Dodd. Bruce, do you have a comment on that?
    Mr. Lesley. No, I mean, other than to say I think that that 
is right on, in that we really do need to make a more concerted 
effort on the prevention side, and it is not just even 
government spending. It is private spending.
    It is also, to give kind of a shout-out to programs such as 
the one you worked in. It is also the Boys and Girls Clubs and 
the YMCAs of the world who are really providing another place, 
a safe place for children to engage in activities. There is 
also Congress, who does support a lot of those activities as 
well. It is very multifaceted.
    Senator Murkowski. Mr. Chairman, if I can just jump in 
here. Your mention of being a soccer club that reaches out to 
the younger kids--going back to my point earlier about kids not 
being able to play as much anymore, I think we overlook an 
incredible teaching resource when we don't allow our young 
people to be mentors.
    The eighth graders, I bet, look up to you all as heroes. To 
be able to play like you is something that makes them work hard 
and have fun at the same time. I am a huge supporter of what 
Boys and Girls Clubs do, and we keep trying to get more and 
more in the State along with the YMCA program. I think we have 
some real opportunities as we look to the local level to see 
how we can do more without necessarily huge increases in 
funding.
    We have a lot of volunteer opportunities if we use our 
young people, who have that level of energy and can be great 
role models for our kids. Thank you for what you are doing.
    Thank you, Mr. Chairman, for doing this. I am going to have 
to excuse myself.
    Senator Dodd. No, I understand that. I apologize. As I 
said, 27 years, I have never done this before. Take a couple 
more, a couple more comments. Can we get the microphone so you 
can be heard?
    Thank you, Lisa.
    Yes, go ahead. I will have to try and pick now. We have 
hands all over.
    Ms. Chambers. Hi, I am Cassie Chambers, also a Yale 
student, working on being able to vote in Connecticut.
    I think one of the things that kind of gets glossed over a 
lot is the importance of allowing people to own their own 
epidemic. I think it is important to allow people--when you are 
talking about such a comprehensive lifestyle change--to be 
individually empowered to make those decisions for themselves.
    I think looking at programs like providing grants to local 
schools, providing grants to parks and recreation centers, to 
work on a small scale, I think that is really important. I 
think programs in local schools, where local schools get 
evaluated on how they are doing on nutrition, tax incentives to 
give people money back if they make the choice to buy fresh 
produce or to invest in a gym membership or things like that.
    I think that empowering people on an individual level to 
make choices is really, really important.
    Senator Dodd. That is very good, and I agree. I think that 
is one way to describe it, too, to empower people themselves 
who are in that situation.
    Yes, what else? There was someone else back over there, 
too? Go ahead.
    Ms. Lewis. Hi, I am Dana Lewis from Huntsville, AL, and the 
University of Alabama, voting in Alabama.
    I think it is also important to realize that education can 
also be a barrier. It is one thing to lower the price or offer 
an incentive for somebody to buy fresh produce, vegetables, and 
things like that, but it is another thing to show people you 
don't have to clear your plate. It is important to know about 
the correct portion sizes.
    You don't need to always clear your plate. You need to know 
the nutrition labels, be able to read exactly how many 
carbohydrates or calories are in that meal, and just because 
your restaurant serves you this nice big plate, you don't need 
to clear it if it is triple the amount of calories or 
carbohydrates that you need.
    It is important to educate schoolchildren and adults as 
well to know the correct portion sizes and how to read 
nutrition labels as well.
    Senator Dodd. Yes, that is very good. Excellent.
    What else? We have some more over here, and then we will go 
over here.
    Ms. Singh. Hi. I am Ranu Singh. I am from Massachusetts, 
actually.
    I just wanted to make the point of it is really--I think 
the one group that can really make a difference here is 
children themselves. We were saying earlier that they can lead 
the way. Older children can lead the way for younger children.
    I also feel that if they have enough of a sense to know, if 
they are taught this either through like--I don't know--Sesame 
Street, they were saying now that the Cookie Monster is now the 
Veggie Monster, or something of the sort. Just silly things 
like that----
    Senator Dodd. Don't mess around with the Cookie Monster. I 
love the Cookie Monster.
    [Laughter.]
    Let us not get carried away here now.
    Ms. Singh. I mean, my point there is he is a monster so he 
can eat cookies. That is the point.
    Senator Dodd. Yes, right.
    Ms. Singh. I just feel that if they can be taught to 
believe that, if they can get that kind of inclination, they 
are going to drive it themselves. I feel like that is something 
that they will definitely do. They can change their parents, 
like you were saying earlier with the seatbelts, with not 
smoking. The children are the ones that will question that.
    Senator Dodd. Huge influence.
    Ms. Singh. That is a very big point.
    Senator Dodd. A question on this side of the room. I want 
to go back and forth. Can you get a microphone over to this 
side? Maybe you can walk toward him a little bit? We have a 
microphone for you.
    Ms. Johnson. Hi, my name is Laura Johnson. I am from 
Minnetonka, MN, College of St. Benedict, St. John's University.
    During the summer, I am a children's camp counselor for the 
YMCA, and I think one of the really important issues is 
encouraging children to get physical activity. Like what you 
were saying, I think that peer-to-peer encouragement is very 
important because what I have observed through my work is that 
the overweight and obese children are often the ones who are 
afraid to participate in physical activity because they are 
afraid that they are going to be the slow ones and the left-out 
ones. They really, really, really benefit from having positive 
encouragement.
    They are also the children who don't go swimming because 
they don't want to wear their swimsuits. I just think that 
among the peers and if you educate younger children to 
encourage their other overweight friends to participate in 
activities, that would greatly help.
    Senator Dodd. Yes, no question. Good for you for doing what 
you are doing.
    Come back over. I only have one microphone. Let us work our 
back way down. We will come down here and then come down this 
way. Yes? I could do this all afternoon.
    Ms. Farrell. Hi, my name is Caroline Farrell, and I am a 
second year--almost a second-year law student at the University 
of Maryland.
    Before coming to law school, I did my M.Ph. at G.W. During 
grad school, I was a spinning instructor, and that helped me 
pay the bills. I continue to teach spinning, and I teach at a 
couple of health clubs that offer children's or teen's spin. I 
know several fitness equipment lines also have special 
equipment for children.
    Obviously, not everyone is able to afford a gym membership, 
but I am sure that there are ways to subsidize those programs 
individually or perhaps other similar programs through the 
community.
    Senator Dodd. That is good. Great, great. One over here. 
Why don't you just use the microphone at the table? Go ahead. 
Right here.
    Ms. Quinn. OK. I am Abigail Quinn from Annandale, VA. I am 
at the University of Virginia doing elementary education, so 
this is all very interesting.
    I have been a camp counselor before, and we had a fruit and 
vegetable policy at each meal. We actually had a parent tell us 
that their kid did not eat fruits or vegetables. That was kind 
of awkward for us.
    The other point that I wanted to make is, I am interning 
this summer with National Wildlife Federation. We have a huge 
campaign trying to reconnect kids to nature, and obviously, 
getting kids outside, getting them active is all part of this. 
We have talked a lot about schools today. I know that recently 
in my research I have been looking at some studies that have 
suggested that kids are actually gaining weight over the summer 
because they are so inactive over the summer.
    While schools have a huge role to play, and obviously, as 
someone who wants to be in education, I think that is crucial. 
You really need to look at some of these other aspects, too.
    Senator Dodd. That is great. Yes, I will take one back 
here. Go ahead.
    Audience Member. First, I would like to say I am not from 
Connecticut. If I was, I would give you my vote, don't worry.
    Senator Dodd. Ah, smart guy. You take as long as you would 
like.
    [Laughter.]
    Audience Member. Well, Jenelle, I am sorry. I know you said 
you were going to tackle me, but I had to ask this.
    You were talking earlier about how seeing the marketing of 
body types and things like that increased anorexia amongst 
young people. Well, today, we have a lot of things that are 
beginning like plus-size modeling and all the commercials that 
you see all the time with, oh, lose weight fast, Slim Fast. You 
know, you can take these pills, and you will lose weight in 6 
months or whatever it is.
    I am just wondering what type of psychological affects do 
you think that has on the obesity of children? Do you suppose 
that they feel that this is becoming a societal norm because 
they see it now in the plus-size modeling, or in the 
commercials, you see people saying that you can lose this 
weight fast? Maybe they are saying, ``Well, I can eat this and 
I can do this, and then I take my Slim Fast and then I will 
lose that weight eventually'' or something like that?
    I was just wondering, as a question to any of you guys, 
what type of effects do you think that has?
    Senator Dodd. Is there an effect? Dr. Grey has done a lot 
of work in this area.
    Ms. Grey. This gets back to the whole issue of social 
marketing. The sense of normality about obesity is not from 
plus-size models. I mean, the reality, the role model for kids 
today are all these stick-thin, size 0 people. Plus-size models 
are for the middle-aged women who are the norm, wearing plus 
sizes.
    To be honest, in our work, I don't think most kids think 
about Slim Fast. I don't think they respond to those marketing 
approaches at all. Their parents might, but their children 
don't. The sense of being normal being overweight is if you are 
in a population like the inner city where I work, where 50 
percent of the kids in high school are obese or overweight, 
that is normal.
    Where I was in high school, there were 10 kids who were 
overweight out of a class of 650. Those who were overweight 
felt--they were teased. They were mocked. The physical activity 
was a problem because they were always chosen last, and they 
don't feel good about their ability to participate.
    These kids are all the same. While they still get teased 
and they still get mocked, they can look across a room and see 
50 percent of their classmates weigh 180 to 300 pounds. It is a 
very different mindset than what we think of as adults around 
this problem.
    Dr. Kaufman. Can I just add something? What really works 
best, I think, is to talk about behaviors rather than the 
outcome of weight. And that we are really--and if you are 
normative to the whole class, so everybody is learning, too. 
Even if you are the low-weight kid, soda isn't good for you.
    The most favorite food now unified, when we started doing 
our work in Los Angeles, was Flamin' Hot Cheetos. I mean, a 
couple bags of Flamin' Hot Cheetos for lunch aren't good for 
anybody. We are really trying to promote healthy behaviors on 
both the intake side and the energy expenditure side.
    Senator Dodd. That is very, very good.
    One right here, yes.
    Mr. Shevarro. I am trying to get rid of this, honestly.
    Senator Dodd. There you go.
    Mr. Shevarro. How are you doing? I am Keith Shevarro. I am 
from New York. I am also a second-year law student at the 
University of Maryland, and I was a physician before I went to 
law school.
    The question I have is do you see the rise in obesity 
correlating with the fall of the family? The divorce rate being 
so high, 50, 60 percent. People working two jobs. Single moms, 
single dads trying to do the best that they can, but can't 
really spend as much quality time with their child that they 
would like to. Have we seen in the numbers a correlation with 
the decline of the family, an increase of obesity?
    Senator Dodd. Anyone want to tackle that?
    Dr. Kaufman. Well, I mean, temporally probably some 
correlation. Exactly looking at is it greater in single parent 
families, and there are a lot of correlates, depending on what 
location you have done, there is a lot of data. It is just 
association. It is not really cause and effect.
    Senator Dodd. Yes. Anyone disagree with that?
    Ms. Grey. One of the things that we do know is that 
families who sit down to a meal together are more likely to eat 
a more balanced meal. Notice I didn't say ``healthier.'' At 
least a more balanced meal.
    If you look at the lives of many of these families, single 
parent or even dual parent, many of these families are working 
two and three hourly wage jobs just to be able to have a roof 
over their heads and pay the heating bills and those sorts of 
things. The stories we hear from these families about what we 
think of as a meal and what they think of as a meal is somebody 
puts something on the stove, and it is like the revolving 
door--in the kitchen, wolf it down, and back out again.
    Again, this is so tied to the economic reality in these 
poor families that I don't think it is just a family issue, it 
is about what are the structures in families, what are the 
structures in homes and communities that allow for these kinds 
of healthier behaviors?
    Senator Dodd. And the economics. Margaret Warren, who 
teaches at Harvard Law School, has done a lot of studies on 
just what is happening to middle-income families, the economic 
pressures. Close to 20 million Americans, heads of household in 
our country, spend half their disposable income on housing 
alone. That is leaving the rest of it to do everything else.
    When you start talking about all the other obligations, 
financial, again, it is cheap food, I suspect. And not a 
question of cheap, but the food that is less healthy certainly 
is going to fall into that category. It is not just shopping 
for the best price. It is also recognizing that, as we have 
learned painfully, less healthy food is, in many cases, less 
costly.
    I will take one more. We will take one right here. Yes?
    Audience Member. Hi. I am [Off Mike] from Great Falls, VA. 
I go to Thomas Jefferson High School.
    I just wanted to reiterate the point about portions of 
meals because that is really important. Even if it is a healthy 
mix of foods, if you are eating a ton of it, it doesn't matter. 
You are getting too many calories, too many carbohydrates.
    A lot of restaurants are really bad at that. You order a 
meal, and you end up with this huge plate piled with food. A 
lot of people feel obliged to finish off the plate. So portions 
are really important.
    Senator Dodd. Yes, just in terms of size of the plates that 
you buy for meals, your tendency, if you buy these--a lot of 
times they market these large plates, and putting a small 
amount of food on a large plate looks like you are getting very 
little. Just the size of the plate in proportion to the food 
that is on it can have an effect.
    I literally could do this the rest of the day. I can't do 
this to our witnesses. I have drawn them here for all 
afternoon. As I said, in 27 years in the Senate, I have never 
asked the audience to participate, but I just couldn't resist, 
looking at so many young people who are here, and you have been 
terrific. Give yourselves a round of applause.
    [Applause.]
    I find it rather encouraging in a sense that so many of you 
here have so many good ideas on how to address this. You can 
all call your parents tonight. You will be on C-Span.
    I thank our witnesses immensely. We will have some 
additional questions. I am going to leave the record open 
because other members, I think, will have some questions for 
you such as these detailed questions I was asking you, Dr. 
Kaufman, and I suspect we will have some more for you, Dr. 
Grey, as well.
    Just getting the data and the correlations between some of 
these questions here will be very helpful to us as we go 
forward.
    I would be remiss as well--where did she go? She left. Oh, 
Eva. A former staff member of mine was here this week, and one 
of the best children's advocates in Connecticut, Eva Bannell. 
Eva went someplace. I don't know where she went, but I was 
going to introduce her.
    Anyway, I thank Tom Harkin. I thank Lisa Murkowski, Senator 
Murkowski, and our witnesses as well. I appreciate all of you 
very much. This committee will meet again next week for the 
second panel on this issue.
    I thank all of you. The committee is adjourned.
    [Whereupon, at 4:31 p.m., the hearing was adjourned.]

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