[Senate Hearing 110-961]
[From the U.S. Government Publishing Office]
S. Hrg. 110-961
CHILDHOOD OBESITY: THE DECLINING HEALTH OF AMERICA'S NEXT GENERATION--
NATIONAL PROBLEM, SOUTHERN CRISIS
=======================================================================
FIELD 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--NATIONAL PROBLEM, SOUTHERN CRISIS
__________
OCTOBER 23, 2008 (Nashville, TN)
__________
Printed for the use of the Committee on Health, Education, Labor, and
Pensions
Available via the World Wide Web: http://www.gpoaccess.gov/congress/
senate
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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)
David P. Cleary, Minority Staff Director
(ii)
C O N T E N T S
__________
STATEMENTS
THURSDAY, OCTOBER 23, 2008
Page
Alexander, Hon. Lamar, a U.S. Senator from the State of
Tennessee, opening statement................................... 1
Riley, Wayne, M.D., M.P.H., MBA, FACP, President, Meharry Medical
College, Nashville, TN, statement.............................. 1
Cooper, Susan R., M.S.N., R.N., Commissioner, Tennessee
Department of Health, Nashville, TN............................ 5
Prepared statement........................................... 8
Barkin, Shari, M.D., MSHS, Director of Pediatric Obesity
Research, Diabetes Research Training Center Professor of
Pediatrics, Monroe Carell, Jr. Children's Hospital at
Vanderbilt, Nashville, TN...................................... 12
Prepared statement........................................... 14
Tropez-Sims, Susanne, M.D., M.P.H., Associate Dean of Clinical
Affiliations and Professor of Pediatrics, Meharry Medical
College, Nashville, TN......................................... 16
Prepared statement........................................... 18
Griffin, David, Participant, Season 4 of NBC's `` The Biggest
Loser,'' Cedar Hill, TN........................................ 20
Prepared statement........................................... 23
(iii)
CHILDHOOD OBESITY: THE DECLINING HEALTH OF AMERICA'S NEXT GENERATION
--NATIONAL PROBLEM, SOUTHERN CRISIS
----------
THURSDAY, OCTOBER 23, 2008
U.S. Senate,
Subcommittee on Children and Families, Committee on Health,
Education, Labor, and Pensions,
Nashville, TN.
The subcommittee met, pursuant to notice, at 10:10 a.m., at
Meharry Medical College Library, S.S. Kresge Learning Resource
Center, 1005 Dr. D.B. Todd Jr. Boulevard, Nashville, TN, Hon.
Lamar Alexander, presiding.
Present: Senator Alexander.
Opening Statement of Senator Alexander
Senator Alexander. The Subcommittee on Children and
Families will come to order.
We're delighted to be at Meharry. First, I'd like to
recognize Dr. Wayne Riley, who is the president of Meharry, who
is a friend, and who is here.
Thank you for letting us be here, Dr. Riley.
STATEMENT OF WAYNE RILEY, M.D., M.P.H., MBA, FACP, PRESIDENT,
MEHARRY MEDICAL COLLEGE
Dr. Riley. I'm very honored--well, good morning, all.
Senator, we're honored to have you with us. I just want to
thank you for being here, but also thank you for your support
of Meharry Medical College.
Senator Alexander has been very instrumental in securing
funds through the earmark process for the renovation of this
library, and I hope that the next time you come, Senator, we
will have transformed this library, with the support that you
were able to secure for us, plus our own resources. This is one
of my major capital projects since becoming president on
January 1, 2007, which is to transform Meharry Medical College
Library. I'd like to thank you and your staff for the excellent
support.
We're proud of Meharry. We are delighted that we could play
a role in discussing a major issue facing Americans, and that
is the increasing incidence and prevalence of obesity,
particularly with emphasis on children.
Senator, we appreciate your leadership in the U.S. Senate,
and we look forward to working with you for many years.
Thank you.
Senator Alexander. Thank you, Dr. Riley. I appreciate your
leadership.
One of my favorite stories is that people sometimes ask me,
``What is more difficult, being Governor of a State, a member
of the President's Cabinet, or president of a university?'' and
I always say, ``Obviously, you've never been president of a
university, or you wouldn't ask a question like that''----
[Laughter.]
Senator Alexander [continuing]. Because it's a real
challenge. And you do a great job. We're tremendously proud of
Meharry and its history and reputation and service to our
community and to our country every year.
Before we start, I want to thank Mary-Sumpter Johnson and
Sarah Rittling, of my staff, who have worked hard on this
hearing and done a great job. I want to observe that, while
we're going to do a lot of changing, here--this is a great
place to have a hearing like this--here's the way we'll
proceed. I'd like to make a brief opening statement, and then
I'll go to our four distinguished witnesses and ask them to
summarize their testimony in 5 or 6 minutes, and then we'll
have a conversation back and forth on the subject we're talking
about today.
This is the third hearing by the Senate Subcommittee on
Children and Families on this subject. Senator Dodd of
Connecticut is the chairman of the committee, and I am the
ranking Republican member, and we've worked together on
children and family issues over the last 6 years. Part of that
time, I was chairman, and part of the time he was ranking
member. It depends upon what the voters have to say in
elections. We work in a bipartisan way, and one of the issues
that we worked on successfully was the so-called PREEMIE bill,
which we worked on with the March of Dimes, to advance research
and study and support for the question of premature babies and
why they're born. It struck me, in studying for this hearing--
and I was talking with some of our witnesses about it--in the
case of premature babies, in about half the cases, we don't
know why they're born premature. A lot of what we have to do is
to try to understand that. In the case of childhood obesity and
why the children are likely to live less longer than their
parents today, we pretty well know the problem, and we know
what's happening, and we're going to talk about that today. So,
we have to figure out, then, what to do about the problem.
In a way, we should be a little ahead of the curve if we
understand the problem. I think I'm right about that, at least;
we'll find out in the testimony. A lot of the effort that we
have to make is, then, What do we do about the problem? What
are the tactics that we need?
We're at a time in our history--and I remember about 2
years ago, a physician said to me that this is the first
generation of children who are expected to live shorter lives
than their parents. It made me stop--it was such a dramatic
statement that I went back to my staff, to Sarah and to Mary-
Sumpter and said, ``Go check that. I don't want to go say that
in public if that's an exaggeration or inaccurate or something
that might not be true.'' What we've found is that that's
exactly the case. In the New England Journal of Medicine, and
the publications of the Institute of Medicine, and the Trust
for America's Health, say that, generally speaking, for the
last 1,000 years, children have lived longer lives than their
parents, but children born in the year 2000 are expected to
live shorter lives.
It's a real healthcare crisis. One of the biggest reasons
for this crisis is what we call ``childhood obesity.'' The
increasing rate of diseases that normally have been associated
with adults--type-2 diabetes--are now being found in children.
I'm hopeful that--Commissioner Cooper, I think you're the first
witness--maybe you can take a minute at the beginning and just
explain what type-2 diabetes is and why it's different. Others
may want to talk about that. I don't want to jump right into
this subject, just assuming everybody knows what we're talking
about, when, in fact, many people don't.
It's especially important in Tennessee, because Tennessee
is the third most obese State in the year 2007, and one out of
every three children born are likely to be overweight. Twenty
percent of Tennessee's children, overall, are overweight.
We'll hear from our witnesses about the significant
increases in this condition. One is that, over the last 40
years, obesity rates have quadrupled for children from the ages
of 6 to 11 years, and tripled for adolescent ages 12 to 19
years. It's prevalent among children and youth throughout the
entire population. Everybody's children. Hispanic, nonHispanic,
black, and Native-American children and adolescents are
disproportionately affected when compared to the general
population.
This affects, of course, millions of children, and
potentially will cost billions of dollars for us to deal with.
What we're doing here today, in this third of a series of
hearings, is to explore, ``What can the Federal Government do
to create solutions to this healthcare crisis? '' Let's get on
the upside of it and see if, over the next 10 years, we may
begin to reduce it as a crisis and save millions of lives, help
them live longer than their parents, and save billions of
dollars, which we could use in this country for other purposes.
One of the things that struck me in the hearing was
Commissioner Cooper's goal--and it may be the goal of others,
as well----a good goal would be for high-school students to
graduate in the year 2018 with a healthy weight. You have a
report card for physics, and you have a report card for
chemistry. You would know what a healthy weight would be, and
you could aim for that goal. As the late Chet Atkins used to
tell us, ``You have to be mighty careful, in this life, where
you aim, because you're likely to get there.'' I like that a
lot better than talking about obesity, because you don't want
to just walk up to someone and say, ``You're overweight, you're
too fat, you're obese.'' That's not a good way to start a
conversation. That's not a good way to challenge people to
improve very much. The same with illiteracy; we don't just walk
around labeling people with illiteracy. Or, take the issue of
the No Child Left Behind law; it's caused us to label schools,
although they're not officially labeled in the law this way, as
failing schools. You pick up the newspaper, and you hear that a
school in Nashville is failing. I'd like to change the way we
talk about schools in No Child Left Behind, to say, ``Here are
the schools that have succeeded, and here are the schools that
have succeeded even more. Then there are some with more work to
do.'' That's the way we do everything else. We give you an A or
a B or a C, and then some people have a little extra work to
do.
In the case of obesity, I think we need to find a way to
talk about it to each other on the street and in the school or
in the home. I can see families and public policymakers and
elected officials talking about, ``Let's have a healthy weight
for every child. We know the importance of it. Let's marshal
every single thing we can think of to do to cause that.''
Our witnesses today are a very distinguished group. One
reason we're having this hearing is because Tennesseans are
such good examples and--well, all of you are good examples and
are experts on our subject. I won't go through the whole
history of each witness, but let me introduce all four, in
brief to start with, and then we'll go right down the line with
their comments, and then have a conversation.
Susan Cooper is commissioner of the Tennessee Department of
Health here. Tennessee is one of the three States with the
biggest problem in obesity, and it's also one of a handful of
States that is doing the most about it. A lot of that is due to
Commissioner Cooper and Governor Bredesen, and I commend them
for that. She is a special--she made a little history, because
she became the first nurse to serve as the commissioner of the
Tennessee Department of Health, and she assumed leadership of
Project Diabetes, a program of Governor Bredesen created to
address type-2 diabetes. She'll tell us more about their
initiatives. She was born and raised in west Tennessee.
Dr. Shari Barkin is director of Pediatric Obesity Research
at the Diabetes Research Training Center at Monroe Carell
Children's Hospital at Vanderbilt University. Dr. Barkin is
also a National Institute of Health-funded researcher. She's
made many contributions there. She's focused much of her work
on pediatric obesity, children who are overweight, looking at
prevention and early intervention approaches. She's also a
clinician, which means she works every day with children and
families who are trying to deal with this problem. We look
forward to her contribution.
Dr. Susanne Tropez-Sims is associate dean of clinical
affiliations and professor of pediatrics at Meharry Medical
College, where we are today. She's focused her research on
faculty development, HIV/AIDS prevention in adolescents, and
correlations of infant obesity as related to the mother's
obesity. She's received her M.D. at Chapel Hill, where she
continued her internship and residency in pediatrics. She's a
native of New Orleans.
David Griffin is the celebrity here today. David Griffin
was a participant on Season 4 of NBC's ``The Biggest Loser.''
He's currently the spokesman for ``Get Fit Tennessee.''
Originally from Cedar Hill, TN, his role as husband and father
of four children inspired him to appear on the show. David is
about 6 feet tall, and he went from weighing 368 pounds to,
today, it says here, 228 pounds. That's losing a total of 140
pounds and 38 percent of his total body weight. All of us are
envious, and I'll look forward to hearing more from him----
[Laughter.]
Senator Alexander [continuing]. And congratulate him on his
excellent example.
Commissioner Cooper, let's begin with you and go right down
the line, then we'll go forward.
STATEMENT OF SUSAN R. COOPER, M.S.N., R.N., COMMISSIONER,
TENNESSEE DEPARTMENT OF HEALTH, NASHVILLE, TN
Ms. Cooper. Thank you, Senator Alexander. I'm certainly
thrilled to be with you today to really have a conversation
about the leading health risk facing the children of Tennessee
and our Nation, pediatric or childhood obesity.
As you said, I'm a registered nurse and the commissioner of
health, and I'm also a mother of three and a grandmother of
three. Nothing is more important to me than the health of our
children.
As commissioner, my job is to protect, promote, and improve
the health of all that live in, work in, or visit our great
State. It's really important for us to have this conversation
about our children.
We're facing a public health threat of an unprecedented
nature. It is absolutely unacceptable to me that of the
children born in the year 2000, that they would be the first
generation in history not to live as long as their parents.
We've heard some of the statistics today. Certainly, I think,
we've talked about the obesity rate, but also, when you start
thinking about type-2 diabetes, those same children born in the
year 2000, one in three are anticipated to develop type-2
diabetes, a disease that used to be called ``adult-onset
diabetes,'' because we never saw it in children. Then, if you
happen to be African-American or Hispanic, that number is one
in two. Think about walking through a cafeteria line in any of
our schools in Tennessee and looking at the children standing
there, and say, ``One, two, three, you're it.''
Let me tell you what a life with type-2 diabetes would look
like. You will become blind. You may lose a leg. You may have
end-stage renal disease that will require you to receive kidney
dialysis or have need for a transplant. Oh, by the way, heart
attacks and strokes are just going to be part of the norm.
Unacceptable. Not for these children.
Unfortunately, 8 of the 10 States with the highest obesity
rates are found in the South. Twenty percent of our 10- to 17-
year-olds are overweight, the fourth highest rate in the
Nation. We believe that number is really under-reported. We've
done screening, through our coordinated school health program,
and it looks like 42 percent of our children are either
overweight or at risk of being overweight. Again, that is
unacceptable.
This epidemic, if left untreated or partially treated, as
we do sometimes in our clinical work, will result in
substantial costs to the State and to the Nation, both in
health and economic terms. Obesity is associated, as we've
said, with a number of chronic diseases, along with, not just
the physical diseases--we see effects to the mental health of
our children, as well.
From an economic perspective, overweight and obese adults
cost the United States between $69 and $117 billion on an
annual basis. The costs of childhood obesity are growing, as
well. Between 1979 and 1999, that grew from $35 million to $127
million spent on hospitalization costs. This State and this
country cannot sustain the economic or health impacts, and we
must take action immediately to halt this epidemic. Please
understand that stemming the tide of childhood obesity requires
that we start to shift our conversation solely from a focus on
the care end of healthcare to the health end of healthcare.
There's a difference between health and healthcare, and we must
take a proactive prevention-focused approach to health.
As a Nation, if we were to make just a modest investment
into preventive health strategies, if we invested $10 per
person in this Nation each year in proven community-based
programs to increase physical activity, improve nutrition, and
prevent smoking and other tobacco use, we could save this
country more than $16 billion a year. Of course, that's about a
return of $5.60 for every dollar we spend. I would respectfully
say that, you know, if you invested just 1 percent of that $16
billion into health--health, not healthcare--we could really
change the tide of what we're looking at today.
As you said, the Department of Health really does believe
that we can reach the goal of every child graduating in 2018 of
being at a healthy weight. No one agency or entity can be
responsible, in isolation, for finding the remedies that we
need to address the issue. We're going to have to have
governmental responses, industry responses, media, community,
schools, and individuals all to commit to prevention efforts
and to dissemination of promising practices.
I want to just briefly speak about Tennessee's approach. I
have my chief medical officer, who's going to be the computer-
whiz extraordinaire over here, in just a moment.
Tennessee's approach has really been to look at programs,
policies, partnerships, and innovation, and the efforts tend to
be paying off. In 2006, the Obesity Initiative from the
University of Baltimore gave six States in this Nation a grade
of A--and I love talking about good news--for their legislative
and public policy work around childhood obesity, and Tennessee
actually was one of those six States.
Some of our policies are found across a multitude of our
agencies in--that's the collaborative focus we're taking. In
health, we have the Childhood Wellness and Nutrition Act, where
we have developed an Office of Childhood Wellness and Nutrition
within the Department of Health, and our goal is really to
create a State plan for addressing the childhood obesity
efforts here. We also have the Diabetes Prevention and Health
Improvement Act, and we've invested $22 million of State-only
dollars to fund community-based initiatives that will focus on
the prevention and/or treatment of type-2 diabetes.
In finance and administration, we are the only State in the
Nation that has insurance plans that said, ``You know,
preventive health is important, so instead of risking you on
what you pay, based on--do you have heart disease or do you
have diabetes--we use age, weight, and tobacco usage to
determine what your premium cost will be.''
In education, the Coordinated School Health Program is
mandated for all school systems. Well, that's not necessarily
unique across States, but what is unique, we are the first
State in the Nation that has fully funded it for every school
system in the State.
The transportation department----
Senator Alexander. Now, you've fully funded what?
Ms. Cooper. Coordinated school health----
Senator Alexander. OK.
Ms. Cooper [continuing]. For each of the school systems.
Our transportation department has invested almost $5
million in the Safe Routes to Schools Programs.
Economic and community development has a three-star
community program to help bring new business in. And one of the
indicators is health.
Also, we're working with Human Services to work with our
licensed childcare facilities to set activity and nutrition
standards.
We're really excited about this. We have broken down the
silos that exist in State government, and we have reached out,
not just to our State partners, but to our community partners,
as well.
With our innovative approaches, I want to talk to you
briefly about Project Diabetes.
Next slide.
In two initiatives in particular, our Get Fit Tennessee
Initiative, which is an online, interactive fitness community
for youth and adults that is really a program to help us all
start where we are. When you think about that messaging, there
is something that everybody can do to improve the health of
themselves, their families, their communities. This is free
online too, not only to anybody in this State, but anybody in
this Nation, where you can set your own fitness and nutrition
goals, you can track your progress, you can create challenges,
as you can see, for Child Health Week.
Next slide.
Last week, we set a Child Health Week Challenge, for
children across this State, to look at fitness points. There
are dropdown boxes of about 100 different activities, built on
the Governor's Physical Fitness Challenge, where everybody can
get points for health and fitness. We really believe that this
is a very innovative tool that helps everyone find something
that they can do. It also helps in setting realistic health and
fitness goals.
The second program that I want to briefly show--oh, there's
our food journal. I'll just say, about food journaling, we had
this up before the report came out that said, ``If you journal
what you eat, you will lose up to 50 percent more than if you
don't journal.'' It's a very effective tool, and it links to
the USDA database for calorie content.
Again, Get Fit Tennessee, we've spent a lot of time across
the State. We've been to hundreds and hundreds, and almost
thousands of community events now, really acknowledging what's
happening at the grassroots effort. Every moment becomes a
teachable moment. What we've found is that fitness can be fun
and everybody can do something.
Those are just pictures of folks from across the State that
have participated in our opportunities, and what you'll see is
that folks are smiling as we're doing this. I think that's just
the visualization of the hope that exists for families today.
Now, GoTrybe is an online physical fitness program,
physical education program that we now have in 17 school
systems in the East and Northeast, in 33 different high
schools, and it's the culmination of a unique public/private
partnership funded by Project Diabetes. This Web site was
designed by health and fitness professionals, we'll talk a
little bit--the Zoo-Do's are for grades 1 through 5. Tribe 180
is for grades 6 through 8. And Next Tribe are for our high
school students, 9 through 12. We've got a 1-minute video clip
explaining what this does.
[Video presentation.]
Ms. Cooper. Little--in there.
Senator Alexander. Better--we want to keep going here so we
stay within our time.
Ms. Cooper. Just--every child has an--and I think what's
interesting is, we're beginning to see the results of our
efforts here.
I want to say that we are committed to this. We appreciate
your attention in everything you've done for all of us, and
we'll turn it to Dr. Barkin.
[The prepared statement of Dr. Cooper follows:]
Prepared Statement of Susan R. Cooper, M.S.N., R.N.
Chairman Dodd, Ranking Member Alexander, and members of the
subcommittee, thank you for the opportunity to be with you today to
testify about the leading health threat facing the children of
Tennessee and our Nation both today and for generations to come--
childhood obesity.
I am Susan Cooper, M.S.N., R.N., Commissioner of the Tennessee
Department of Health, a registered nurse, mother of three and a
grandmother of three. As Commissioner, my job is to protect, promote,
and improve the health of all that live in, work in, and visit our
great State. The health of our children is of utmost importance to me
and to the future of Tennessee and the Nation. Today, I would like to
briefly speak to the scope of the problem, the potential contributing
factors, and give examples of Tennessee's response to this national
emergency.
background and scope of problem
We are facing a public health threat to our children of an
unprecedented nature. It is unacceptable to me that the children born
in the year 2000 are the first generation in history not expected to
live as long as their parents. You have heard the statistics many
times, but they are worth repeating. Today, almost 32 percent of
American children and adolescents--more than 23 million--ages 2-19 are
overweight or obese.\1\ Rates of obesity have more than tripled since
1980, from 6.5 percent to 16.3 percent. One in three children born in
the year 2000 is anticipated to develop type 2 diabetes,\2\ a disease
that was once called adult onset diabetes because it was not seen in
children. The likelihood is one in two if you are an African-American
or Hispanic child.
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\1\ Ogden, CL, Carroll MD, Flegal KM. High Body Mass Index for Age
Among US Children and Adolescents, 2003-2006. Journal of the American
Medical Association 2008;299(20):2401-2405.
\2\ Ibid.
---------------------------------------------------------------------------
Unfortunately, 8 of the 10 States with the highest obesity rates
are found in the South. In Tennessee, 20 percent of our 10- to 17-year-
olds are overweight, the fourth highest rate in the Nation.\3\ The most
recent numbers from BMI screening through the Coordinated School Health
Program in Tennessee reveal an even deeper problem. Of the 16,513
students 7 through 16 years of age screened in the first year of the
program, the findings show:
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\3\ Trust for America's Health. F as in Fat 2007: How Obesity
Policies are Failing in America. www.healthyamericans.org. (accessed
June 24, 2008).
24 percent overweight (above 95th percentile),
18 percent at risk for overweight (85th-95th percentile),
42 percent total overweight and at risk,
56 percent normal weight, and
2 percent underweight.
Detailed analysis of Tennessee data reflects the national trends:
More boys (26 percent) were overweight than girls (22
percent);
A greater proportion of African-American students (29
percent) were overweight than Caucasian (24 percent);
African-American females had the highest proportion of
overweight or at risk for overweight (50 percent);
Caucasian females had the lowest proportion of overweight
or at risk for overweight (40 percent); and
The only age group with combined proportion of overweight
and at risk for overweight less than 40 percent: Students under age 7.
The proportions of overweight and at risk for overweight were
considerably higher than those reported for Tennessee high school
students in the 2005 Youth Risk Behavior Surveillance System (YRBSS)--
42 percent BMI Screening Program versus 32.1 percent YRBSS. These
findings are limited as the African-American student population and
urban student populations were underrepresented in the BMI program
sample.
This epidemic, if left untreated or partially treated, will result
in substantial costs to the State and Nation both in health and
economic terms. Obesity is associated with a number of chronic
conditions and diseases such as type 2 diabetes, increased cholesterol
and hypertension, heart disease, kidney disease, neurovascular disease,
and some cancers. Some studies also suggest that overweight and obesity
negatively affect the mental health of children and their performance
in school. From an economic perspective, overweight and obese adults
cost the United States between $69 and $117 billion per year.\4\ The
costs of childhood obesity are growing as well. Obesity-related
hospital costs for children ages 6 though 17 more than tripled between
1979 and 1999, from $35 million to $127 million.\5\ This country, and
our State, cannot sustain this economic or health impact. Action must
be taken immediately to halt this epidemic.
---------------------------------------------------------------------------
\4\ U.D. 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 August 2008).
\5\ Ibid.
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Please understand that stemming the tide of childhood obesity
requires that we start to shift our conversation solely from a focus on
healthcare delivery to a proactive, prevention-focused approach to
health. If we as a Nation made a modest investment in the prevention of
obesity and its related chronic diseases, rather than treating or
paying for its subsequent health consequences, we could avert much
greater costs later. A recent report demonstrated that for an
investment of just $10 a person, every 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 a year within 5 short years. This is a return of $5.60 for
every dollar.\6\
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\6\ Trust for America's Health. Prevention for a Healthier America:
Investments in Disease Prevention Yield Significant Savings, Stronger
Communities, July 17, 2008.
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With this focus on health promotion in mind, the Tennessee
Department of Health has set as its vision that every child completing
high school in 2018 will graduate at a healthy weight.
national response
No one agency or entity is, or can be, responsible in isolation for
finding the remedies we need to address this issue. In the 2006 report,
Progress in Preventing Childhood Obesity: How do We Measure Up?, the
Institute of Medicine issued a call to action to all key stakeholders--
including government, industry, media, communities, schools and
individuals--to commit to leading childhood obesity prevention
interventions, evaluation and dissemination of promising practices.
Government-specific IOM recommendations included establishing a high-
level interdepartmental task force to set priorities and coordinate
Federal, State, local and public-private actions; developing nutrition
standards for foods and beverages sold in schools; applying for State-
based nutrition and physical activity grants with strong evaluation
components; expanding and promoting opportunities for physical activity
in the community through changes to ordinances, capital improvement
programs, and other planning practices; and working with communities to
support partnerships and networks that expand the availability of and
access to healthful foods. In recent years, Tennessee has undertaken
many of these steps toward developing a coordinated response to
childhood obesity prevention.
tennessee's approach
Initiatives to address childhood obesity are grounded in four
areas: policies, programs, partnerships and innovation. The efforts
appear to be paying off. In 2006, the Obesity Initiative, found at the
Schaefer Center for Public Policy at the University of Baltimore, gave
six States the grade of ``A'' for their legislative and public-policy
work in the past year to control childhood obesity.\7\ Tennessee was
among the six. Eight types of legislative activities were evaluated to
determine the grades:
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\7\ Cotten, A., Stanton, K.R., Acs, Z.J. and Lovegrove, M. The UB
Obesity Report CardTM: An Overview 2006. http://www.ubalt.edu/experts/
obesity/index.html. October 20, 2008.
Nutrition standards--controlling the types of foods and
beverages offered during school hours.
Vending machine usage--prohibiting types of foods and
beverages sold in school and prohibiting access to vending machines at
certain times.
Body mass index measured in school.
Recess and physical education--State-mandated additional
recess and physical education time.
Obesity programs and education--programs established as
part of curriculum.
Obesity research--legislative support for other
institutions or groups to study obesity.
Obesity treatment in health insurance--expanding health
insurance to cover obesity treatment where applicable.
Obesity commissions--legislature-established commissions
designed to study obesity.
In Tennessee, many State policies have been developed, and
collaborative efforts among State and local entities have been
implemented to address the childhood obesity epidemic. Efforts have
focused on developing policies and infrastructure that enable youth and
their families to make healthier choices. Specifically, policy
development has been focused on the promotion of health across State
agencies and designed to influence children and their families where
they learn, work and live.
Health
In 2006, the Child Wellness and Nutrition Act, created the Office
of Child Wellness and Nutrition within the Department of Health. This
Office interacts with other State and local partners to develop and
evaluate activities related to child health with particular attention
to improving childhood nutrition. The Diabetes Prevention and Health
Improvement Act of 2006 established a Center within State government
for the purpose of developing, implementing and promoting a statewide
effort to reduce the incidence of type 2 diabetes. The Center is
authorized to issue grants to community and faith-based organizations,
not-for-profits, local education authorities and other health service
providers for programs designed to prevent and/or treat type 2 diabetes
in children and adults. Furthermore, the Department of Health has
collaborated on a number of innovative programs designed to increase
physical activity and nutrition, which I will describe in a moment.
Finance and Administration
One of the State's insurance programs, Cover Tennessee, uses age,
weight and tobacco use information to assign risk for their insurance
products. TennCare, Tennessee's Medicaid waiver program, requires its
MCOs to have disease management models for obesity, and has policies
that support Weight Watchers and other healthy weight programs for
children and their parents. In addition, TennCare issues a child and
teen newsletter which includes information on healthy food choices and
exercise.
Education
The Coordinated School Health (CSH) program is required for all
school systems and is fully funded; Tennessee is the first State in the
Nation to fully fund its CSH program. The CSH program collects BMI and
other health information for youth in elementary school through high
school. The Department of Education, with input from the Department of
Health, has established nutritional standards for all meals and
nutritional standards for all competitive foods, including those
purchased from vending machines. In addition, legislation passed in
2006 requires 90 minutes of physical activity per week for all students
in grades K-12.
Transportation
Tennessee supports a Safe Routes to School program which focuses on
the benefits of children walking and biking to school. Its primary
purpose is to encourage elementary and middle school children to safely
walk and bike to school, thereby promoting a healthier lifestyle,
reducing traffic congestion and minimizing air pollution. In 2007, the
Department of Transportation provided $4.5 million for these local
programs that promote collaboration with schools, the community, and
local government to create a healthy lifestyle for children and a
safer, cleaner environment for everyone.
Economic and Community Development
The Department of Economic and Community Development's Three Star
Program is an initiative designed to preserve existing employment,
create new employment opportunities, increase Tennessee family income,
improve health and quality of life and create a strong leadership base.
A detailed plan that promotes access to health care is a required
component of community development in order for a community to achieve
Three Star designation.
Human Services
The Gold Sneaker initiative was developed to enhance policy related
to physical activity and nutrition within licensed child care
facilities across Tennessee, and represents collaboration among the
Department of Health, Department of Human Services and Child Care
Resource & Referral system. Enacted policies must include minimum
requirements on physical activity (or ``active play'' ), sedentary
activities, breastfeeding, meal time and portion sizes. Child care
facilities that implement the proposed enhanced physical activity and
nutrition policies will earn a ``Gold Sneaker'' award which designates
them as a ``Gold Sneaker'' child care facility.
innovative projects
Tennessee has utilized many innovative approaches to improving
health behaviors that rely on partnerships between State and local
government and private entities. These initiatives acknowledge to
critical role that local communities play in the development,
implementation and evaluation of effective programs for that community.
We recognize that what works to improve child health in Northwest
Tennessee, for example, may not be the same program that works in South
Central Tennessee. These innovative programs and initiatives challenge
traditional approaches to community-based interventions, and all have
an evaluation component. Examples include the following:
Project Diabetes is a statewide initiative focusing on
innovative education, prevention, and treatment programs for diabetes
and obesity. The fundamental goals of Project Diabetes are to:
Decrease the prevalence of overweight/obesity across
the State and, in turn, prevent or delay the onset of type 2
diabetes and/or the consequences of this devastating disease.
Educate the public about current and emerging health
issues linked to diabetes and obesity.
Promote community, public-private partnerships to
identify and solve regional health problems related to obesity
and diabetes.
Advise and recommend policies and programs that
support individual and community health improvement efforts.
Evaluate effectiveness of improvement efforts/
programs that address overweight, obesity, pre-diabetes, and
diabetes.
Disseminate best practices for diabetes prevention
and health improvement.
Over $10 million in local efforts have been funded through
Project Diabetes grants. Sixty-three Project Diabetes grants have been
awarded; of these, twenty-nine have a child health focus, with goals to
improve physical activity, nutrition and health literacy, or to provide
culturally and developmentally appropriate activities. An example of
one such activity is the Step Up to Health program. Step Up to Health
is a collaboration between State and local government agencies, the
Historically Black Colleges and Universities' Wellness Project, and the
National Step Show Alliance. This program works with youth at risk for
diabetes to improve their physical fitness, health knowledge and
awareness, self-efficacy and self-esteem through the performance of
step shows with integrated health messages. This program will reach 300
youth ages 11-15 years; baseline and post-intervention health,
nutrition, and fitness data will be collected to determine program
effectiveness.
GoTrybe is an online, interactive fitness community for
youth that is the culmination of a unique public-private partnership.
Designed by health and fitness professionals, GoTrybe seeks to
transform sedentary screen time to active screen time for participants
to ultimately improve child health. GoTrybe focuses on enhancing
wellness through increased physical activity, improved motivation, and
improved nutritional awareness. The tool allows the user to create an
individually tailored fitness routine. Built-in data collection tools
allow for tracking of individual, school or regional-level process
measures.
Get Fit TN is a statewide program to raise awareness of
the risk factors for type 2 diabetes and steps that Tennesseans can
take to reduce their risk. This free online tool combines a personal
fitness tracker and nutrition tracker which allow the user to set
realistic fitness and/or nutrition goals, and provides useful
information to facilitate changes in health behaviors.
closing
In closing, I want to again thank the members of this committee for
your past and ongoing commitment to improving the health, safety and
well-being of our Nation. We know that so much more can be and must be
done to protect, promote and improve our Nation's health as we
continually anticipate and prepare for a myriad of public health
threats. We welcome the opportunity to continue to work with you in
pursuit of that goal.
Thank you for your attention. I will be pleased to answer any
questions you may have.
Senator Alexander. Thank you. Thank you, Commissioner
Cooper. That's exciting testimony.
Dr. Barkin.
STATEMENT OF SHARI BARKIN, M.D., MSHS, DIRECTOR OF PEDIATRIC
OBESITY RESEARCH, DIABETES RESEARCH TRAINING CENTER PROFESSOR
OF PEDIATRICS, MONROE CARELL, JR. CHILDREN'S HOSPITAL AT
VANDERBILT, NASHVILLE, TN
Dr. Barkin. Senator, thank you for the opportunity to
discuss this growing epidemic, and, really, thank you for your
leadership and interest in doing something now to make a
difference.
My name is Dr. Shari Barkin. I'm the division chief of
general pediatrics at Monroe Carell, Jr. Children's Hospital at
Vanderbilt. Additionally, I'm an NIH-funded researcher with
extensive experience conducting national research trials and
the proud recipient of State-supported Project Diabetes grant
funding, as well, to address this problem.
My focus is in the area of prevention and early
intervention for pediatric obesity. As you mentioned, I'm a
pediatrician and work with families who are dealing and
struggling with this issue every day.
My testimony will be summarizing recent findings on the
causes of pediatric obesity. I then will provide some insights
from the National Forum on Pediatric Obesity that was held here
in conjunction with the FCC last week. And last, I would like
to recommend some suggestions on the role of the Federal
Government to address this critical public health problem.
You heard the statistics. I would just add to that, that
childhood obesity is linked to adult obesity and, via
prevention, science says we could have the greatest impact on
this problem. For example, rapid weight gain in infancy is
associated with excessive weight at age 4. If you are an
overweight toddler, you're five times as likely to be an
overweight adolescent. If you're an overweight adolescent, you
have a 70-percent likelihood that you'll be an overweight
adult. They're linked.
So, what's going on? What are the major causes? What does
science have to tell us to try to explain the causes of this
epidemic? I'm breaking this down into three general categories.
The first category is that we live in a fast-paced society,
and the problem with this is that we're out of balance. We
consume too much, and we exercise too little. Our bodies were
not made to do this every day; we were designed to move enough
and feed our needs for movement with an agrarian society. In
fact, we know that now we are more inactive than we have ever
been in recorded history. The average American child spends 45
hours a day [sic] in sedentary media-related activities. That's
more time than they spend in school, more time than they might
even spend sleeping, and certainly more time than they're
spending with their parents.
We also know that we respond to our environment. There has
been some interesting science on this. In a study published in
2007, the easy availability of supermarkets, where consumers
have access to healthy foods, was associated with a lower body
mass index, the index that we use to determine if you're
overweight or obese. While the availability of convenience
stores, where there are fewer healthy choices instead of
supermarkets, was associated with a higher BMI. We have
scientists working right here at Vanderbilt looking at
geographic informational systems data, showing where we have
food deserts, for example, in north Nashville. Those are areas
where we see higher BMIs. This study supports the science to
explain that. We are responding, our behavior response, to our
environment.
The third category that I'd like to bring up is that
children's behavior is greatly influenced by their family and
peers. We're meant to be that way. We were meant to be social
creatures. We influence each other by how we act.
In a recent study in the New England Journal of Medicine,
obesity appears to be socially contagious. If your spouse is
obese, you have a 37-percent likelihood of being obese
yourself. If an adult sibling is obese, you have a 41-percent
likelihood of being obese. Importantly, if your friends are
obese, you have a 57-percent likelihood of being obese. Very
important study that was done in a longitudinal way using the
Framingham heart study to look over what happens over a 30-year
period. This was done with adults, not with children.
I'd like to move us now to some insights that were
generated from the forum.
We know that the FCC has had a very dedicated effort
bringing together a joint task force on media and childhood
obesity. We were fortunate to host the FCC commissioners here,
and, with the leadership of Commissioner Tate, look at some of
the recommendations that several of our media outlets and food
and beverage advertisers have considered.
They noted, for example, in the task force, that during
children's programming, advertisers typically have about 80-
percent unhealthy foods that are advertised during that period,
and a suggestion was made to create more of a balance in
advertising. If we are influenced by what we see, and science
shows that that is so, that we should promote things that
children see that promote a healthy lifestyle.
Second, through self-regulation, media can use common
childhood characters to promote healthy lifestyles, and
voluntarily, media giants like Sesame Street and Disney and
Nickelodeon have taken on this challenge so that the content
reveals positive role modeling with this popular culture.
Third, we discussed at the forum that behavior plays a
larger role in obesity than genetics. Genetics is an important
contributor, but behavior contributes largely to whether you'll
become obese.
We were fortunate to hear about some of our efforts here in
Tennessee. Easy access to recreational facilities, for example,
allows the promotion of healthier active lifestyles.
Last, we talked about the importance of creating linkages
between multiple stakeholders, and these stakeholders include
policymakers, scientists, media, food and beverage companies,
schools, communities, and, of course, parents.
Here's an example of some things that have already been
tried that seem to be promising. The vice president of Disney
Channels Worldwide, Kelly Pena, presented some initiatives that
they put into place, just about a year ago, in the Disney theme
parks. Disney, I was surprised to learn, is the seventh largest
restaurateur in the world. People consume a lot of food there.
What they did with their attention to nutrition and change is
that they changed how they offered children's menus. Rather
than automatically getting fries and a soda with your
children's meal, you would automatically--the default was set
at getting fruits, vegetables, and milk. You could always
request replacing that with soda and french fries, but 80
percent of people didn't; they ate what they were given.
Based on the recommendations of the Institute of Medicine
and the National Forum on Pediatric Obesity, I would like to
respectfully put forth the following recommendations for
governmental consideration. Here are some suggestions.
Government could provide coordinated leadership to truly
make pediatric obesity prevention a clear national priority,
echoing the sentiments of Commissioner Cooper, focusing our
efforts on prevention.
Second, government can provide significant funding for
research on childhood obesity and, importantly, the translation
of those effective successful findings into sustainable
programs designed to impact large populations of children.
Third, government could address the issue of food
advertising imbalance for both children's and adults'
programming through a combination of self-regulation and
perhaps legislation
And last, government could consider incentives that would
support built environments that encourage healthy living.
Once again, I'd like to thank you, Senator Alexander, for
your leadership, for your focus, for your clear dedication to
action. I look forward to serving as a resource to your
committee in the future.
Thank you.
[The prepared statement of Dr. Barkin follows:]
Prepared Statement of Shari Barkin, M.D., MSHS
Chairman Alexander and members of the committee, thank you for the
opportunity to discuss the growing epidemic of childhood obesity and
its impact on our Nation. My name is Dr. Shari Barkin. I am the
Division Chief of General Pediatrics at the Monroe Carell Jr.
Children's Hospital at Vanderbilt University. In addition, I am a NIH-
funded researcher with extensive experience conducting national
research trials. My focus is in the area of pediatric obesity,
developing and testing prevention and early intervention approaches. I
also work as a clinician with children and families battling obesity
every day.
My testimony will summarize recent findings on the causes of
pediatric obesity, provide insights from the National Forum on
Pediatric Obesity held this month at Monroe Carell Jr. Children's
Hospital, and offer recommendations on the role that government should
play to address this critical public health problem.
Longitudinal studies demonstrate that childhood obesity is
inextricably linked to health outcomes later in life. For instance,
rapid infant weight gain often leads to excessive weight gain by age 4.
Overweight toddlers are 5 times as likely to be overweight adolescents.
Overweight adolescents have a 70 percent risk of becoming overweight
adults. Furthermore, 60 percent of overweight children aged 5-10
already have one or more risk factors for heart disease and diabetes.
In fact, the CDC predicts that without aggressive intervention, over 30
percent of children born in the year 2000 will go on to have type two
diabetes.
This will likely be the first generation where a child's life
expectancy is less than their parents due to obesity-related health
problems.
What has led to this emergence of pediatric obesity? Studies show
there are three major factors:
First, we live in a fast-paced society. More families eat
on the run than sit down together. More children sit in front of TV
than play outside. The problem is that we are out of balance. We
consume too much and exercise too little. In fact, we are more inactive
than we've ever been in recorded history. The average American child
watches 45 hours of media per week. That is more time than they spend
in school or with their parents. Media has become a full time job for
our children.
The second factor is that our bodies are adapting to this
new lifestyle. We are born into this world with very little hardwiring.
Instead, we adapt to our environment. For example, in a study published
in 2007, the easy availability of supermarkets (where consumers have a
greater abundance of healthy food choices) was associated with a lower
body mass index (BMI) while the availability of convenience stores
(where there are fewer healthy choices) instead of supermarkets was
associated with a higher BMI.
The third and final factor is that children's behavior is
greatly influenced by their family and peers. We are meant to be social
creatures. Children live in the context of their families; families
live in the context of their communities; and communities live in the
context of society. We influence each other by how we act. In a study
in the New England Journal of Medicine, obesity appears to be socially
contagious. If your spouse is obese, you have a 37 percent likelihood
of being obese. If your sibling is obese, you have a 41 percent
likelihood of being obese. And, importantly, if your friend is obese,
you have a 57 percent likelihood of being obese. The challenge is to
make being healthy socially contagious.
On October 15, 2008, the Monroe Carell Jr. Children's Hospital at
Vanderbilt and Department of Pediatrics in conjunction with the Federal
Communication Commission hosted a conference entitled, ``The National
Forum on Pediatric Obesity: Developing Unique Partnerships to Halt the
Epidemic.'' The Forum was structured on The Institute of Medicine's
(IOM) blueprint for action. The IOM report stressed that pediatric
obesity can only be addressed effectively if multiple stakeholders act
together, including: Government at all levels, Food and beverage
companies, Advertising and marketing companies, Multimedia industry,
Communities, Schools, Health providers, and Parents.
With the IOM recommendations as our guide, the National Forum on
Pediatric Obesity concluded the following: We live in a media-saturated
world and media exposure influences both children's and adults'
behavior. During children's programming, advertisers should be
responsible for presenting a balance of healthy to unhealthy food ads.
Currently, 80 percent of the advertising is for unhealthy foods. FCC
Commissioner and Forum participant Deborah Tate is leading the effort
to encourage media to improve advertising for healthy food options.
The media through self-regulation should encourage the use of
common characters (such as Elmo and Mickey Mouse) to promote healthy
choices. Senior executives from Sesame Workshop and Disney who
participated at the Forum spoke of how their companies have voluntarily
made important changes in both their programming and advertising
approaches to focus on healthy lifestyles.
While genetics is important, behavior plays a larger role in
determining obesity outcomes. Easy access to recreational facilities is
one area in which government can positively impact children's health.
Forum participant and Nashville Mayor Karl Dean discussed efforts to
create built environments such as more green space for outdoor
activities. Nashville has also built more community centers thereby
increasing access to recreational facilities in all communities.
Stakeholders should discuss how they could partner together in
innovative ways. One suggestion discussed was partnering media,
scientists, food vendors and policymakers to create what are called
``healthy default environments.'' For example, children who request
meals at Disney theme parks are now automatically provided with fruit
as a side item instead of French fries. The great majority eat what
they are given, rather than requesting anything different. Another
example could be policymakers at the local level working with grocery
chains to create incentives to build supermarkets in communities with
limited access to food.
Based on the recommendations of the IOM and the National Forum on
Pediatric Obesity, I would like to respectfully put forth the following
recommendations for governmental action. Government could:
Provide coordinated leadership to make pediatric obesity
prevention a clear national priority.
Provide significant funding for research on childhood
obesity and translation of these findings into sustainable programs
designed to impact large populations of children.
Address the issue of food advertising imbalance for both
children's and adult programming through a combination of legislation
and self-regulation.
Consider incentives to support built environments that
encourage healthy living.
Once again I would like to thank you Mr. Chairman and the other
members of the committee for allowing me to appear before you today and
for your strong leadership on this very critical issue. I look forward
to serving as a resource to your committee, if ever you need me, in the
future.
Senator Alexander. Thank you, Dr. Barkin.
Dr. Tropez-Sims, thank you for being here.
STATEMENT OF SUSANNE TROPEZ-SIMS, M.D., M.P.H., FAAP, ASSOCIATE
DEAN OF CLINICAL AFFILIATIONS AND PROFESSOR OF PEDIATRICS,
MEHARRY MEDICAL COLLEGE, NASHVILLE, TN
Dr. Tropez-Sims. Thank you for inviting me to be here. I'm
proud to represent Meharry.
As has been stated already, most of the statistics--one
statistic that has not been mentioned is that Tennessee ranks
first in deaths due to heart disease and strokes. If this is
so, and most of our children are becoming obese, does that mean
that we will have serious consequences of early heart disease
and strokes in young adults? I believe it is so.
The other thing, too, is that in African-Americans in
Tennessee, 43 percent are higher to die of strokes than our
Caucasian partners, and for diabetes, the rate of death due to
it in Tennessee is 146 percent higher among African-Americans
than in Caucasians. Hispanic Americans are also one of the
fastest growing minority groups, and they, too, are obese and
are having alarming rates of type-2 diabetes.
Dr. Nicholas Stiffler, from the University of Pennsylvania,
hypothesizes that rapid weight gain during early infancy is
associated with obesity, especially in African-American young
adults. The critical period is proposed to be between birth and
4 months of age, where there is a rapid increase in weight for
age greater than one standard deviation.
I don't want to repeat everything that has been said
previously, so I'm running through this.
Senator Alexander. No, no, we're interested in whatever you
have to say.
Dr. Tropez-Sims. All right.
One of the major contributing factors--they're really
multifactorial in this disease or problem--it's environmental,
behavioral, genetic, metabolic, cultural, socioeconomic status,
and energy imbalance, which has been mentioned, where we
consume more than the physical activity.
Other health risk behaviors also play a major role. In
Tennessee, 36 percent of our Caucasian high-school students and
12 percent of African-American students smoked in 2001. As I
see patients, most of them state that they smoke to keep from
eating, because they do not want to become obese. They don't
realize that this causes them to be at risk for other health
diseases, but it still increases their risk for heart disease
and strokes.
Fifty-eight percent of our students in Tennessee in 2001
were not enrolled in an organized physical education class.
With our high rates of crimes and drive-by shootings, this
hampers outside play for most of our children in this entire
country. These students are prime set-ups for obesity and its
consequences.
One of the other things that I want to discuss is that the
socioeconomic status plays a major role in obesity. For all
racial and ethnic groups combined, women of lower socioeconomic
status--that's income less than 130 percent of poverty
threshold--are approximately 50 percent more likely to be obese
than of higher socioeconomic status. African-American girls
from lower socioeconomic status experience a higher prevalence
of overweight--obesity--than those from a higher socioeconomic
status. The exact etiology is not known, but I hypothesize that
the high cost of nutritious fresh fruits, vegetables, and lean
meats prohibit the possibility of improving eating habits.
In the past, the increase in television viewing or use of
electronic games was proposed as the key factor. In McMurray's
study, he says it may play role, but it's not the total answer.
At Meharry, we have several programs that are looking at
obesity. It ranges from pregnancy in mothers to adolescents to
looking at communities and how, working with community
agencies, that we can make a hallmark in changing the obesity
rate.
In conclusion, thus far we have learned that obesity is a
multifactoral issue, and it will take everyone to become a part
of the solution. As we see from some studies, the battle
against obesity and its consequences begin as soon as we are
born. It must be stated that not only overweight and obese
children and adolescents are at risk for these consequences,
but even non-obese individuals run similar outcomes, albeit
lower rates secondary to inappropriate dietary consumption,
smoking, and lack of physical activity.
In our schools, not only the three R's must be taught, but
preventive and healthy lifestyles must be integrated as a
lifelong learning experience. Good nutrition is not a diet, and
changing the mindset of the population of this aspect is
usually overlooked.
Research must look at all aspects of obesity, including the
psychological aspects. Going back to basics, as growing one's
own vegetables and fruits, even in a city, can assist in
improving one's health. Children and adolescents need guidance
in lifestyle healthy behavior. Parents need to increase their
knowledge first to allow children to inherit their example.
Tennessee has multiple guidelines and plans in place to
implement a change in behavior of its constituents. It's a
daunting task, but with everyone playing a major role, the
State can be successful.
Thank you.
[The prepared statement of Dr. Tropez-Sims follows:]
Prepared Statement of Susanne Tropez-Sims, M.D., M.P.H., FAAP
abstract
Tennessee is one of three States in the United States with an
Obesity rate of greater than 30. It is the State who has the leading
cause of death due to heart disease and strokes in the Nation. In
Tennessee, deaths from strokes are reported 43 percent higher in
African-Americans than Caucasians. The rate of death due to diabetes in
Tennessee is 146 percent higher among African-Americans than among
Caucasians. Hispanic Americans are one of the fast growing minority
group and they are obese at an alarming rate and suffer similar
consequences.
Children and adolescents are not unscathed in this dilemma. Obesity
has risen threefold in this age group. In children, the prevalence
increased from 5.0 percent to 13.9 percent; aged 6-11 years increased
from 6.5 percent to 18.8 percent; and those aged 12-19 years increased
from 5.0 percent to 17.4 percent. These children and adolescents are at
increase risk of dyslipidemia, hypertension, metabolic syndrome and
type 2 diabetes. In addition, CDC reports 80 percent of children
between the ages of 10-15 years who are overweight or obese will
persist to adulthood. Yet only 25 percent of obese adults were
overweight as children. If a child of 8 years of age is obese, they
will suffer severe obesity as adult. Metabolic syndrome is a useful
tool in assisting to diagnose adults but it has not been documented to
diagnose children and adolescents at risk. A serious consequence to
early obesity is the risk of early heart disease and strokes.
Children and adolescents have a multifactorial reason for their
obesity. Contributing factors are environmental, behavioral, genetic,
metabolic, cultural, socioeconomic status, energy imbalance (consuming
more than physical activity). Other health risky behaviors also play a
major role. In Tennessee, 36 percent of Caucasian high school students
and 12 percent of African-American students smoked in 2001. Fifty-eight
percent of high school students are not enrolled in an organized
physical education class, but with the high rate of crime, as
kidnapping of children, outside play is also hampered. These students
are prime set-up for obesity and its health consequences.
Children and adolescents need guidance in lifestyle healthy
behavior. Parents need to increase their knowledge first to allow
children to inherit their examples. Tennessee has multiple guidelines
and plans in place to implement a change in behavior of its
constituents. It is a daunting task but with everyone playing a major
role the State can be successful.
childhood obesity
Obesity is a growing dilemma in the United States and specifically
three States have the highest rate greater than 30 percent. They are
Alabama (30.3), Mississippi (32) and Tennessee (30.1). However, the
increase in health adversity is of major concern. Diseases such as
coronary heart disease, stroke, dyslipidemia (high blood cholesterol
and triglycerides), type 2 diabetes, some cancers (breast, colon and
endometrial), osteoarthritis and sleep apnea are hallmark consequences.
The National Vital Statistics report these diseases contributed $117
billion to the medical cost in the year 2000. According to the Center
for Disease Control (CDC), Tennessee has the leading cause of deaths
due to heart disease in this country. In 2002, 29 percent of the States
deaths were due to heart disease and in addition, stroke ranked 3rd
causing 7 percent of the States deaths. Cancer caused 22 percent of the
deaths. Despite the above statistics, in 2005 the Behavior Risk Factor
Surveillance System revealed adults continue to have increase in health
risk factors as 30 percent screened reported increase blood pressure,
which ultimately leads to strokes and heart disease, and 32 percent of
those screened had high blood cholesterol. In Tennessee, deaths from
strokes are reported 43 percent higher in African-Americans then
Caucasians. The rate of death due to diabetes in Tennessee is 146
percent higher among African-Americans than among Caucasians. Hispanic
Americans are one of the fast growing minority groups and they are
obese at an alarming rate and suffer similar consequences.
Children and adolescents are not unscathed in this dilemma. Obesity
has risen threefold in this age group. In children, the prevalence
increased from 5.0 percent to 13.9 percent; aged 6-11 years increased
from 6.5 percent to 18.8 percent; and those aged 12-19 years increased
from 5.0 percent to 17.4 percent. These children and adolescents are at
increase risk of dyslipidemia, hypertension, metabolic syndrome and
type 2 diabetes. In addition, CDC reports 80 percent of children
between the ages of 10-15 years who are overweight or obese will
persist to adulthood. Yet only 25 percent of obese adults were
overweight as children. If a child of 8 years of age is obese, they
will suffer severe obesity as an adult. Metabolic syndrome is a useful
tool in assisting to diagnose adults but it has not been documented to
diagnosing children and adolescents at risk. A serious consequence to
early obesity is the risk of early heart disease and strokes.
Dr. Nicolas Stittler out of the University of Pennsylvania School
of Medicine
``hypothesized rapid weight gain during early infancy is associate with
obesity in
African-American young adults, a group at increase risk of obesity.''
The critical period that he proposes, is between birth and 4 months
where there is a rapid increase in weight for age greater than one
standard deviation. Of the 29 percent patients with rapid weight gain,
8 percent were obese by age 20 years. This proposal requires further
investigations.
Contributing factors are multifactorial, environmental, behavioral,
genetic, metabolic, cultural, socioeconomic status, energy imbalance
(consuming more than physical activity). Other health risky behaviors
also play a major role. In Tennessee, 36 percent of Caucasian high
school students and 12 percent of African-American students smoked in
2001. Fifty-eight percent of high school students are not enrolled in
an organized physical education class, but with the high rate of crime,
as kidnapping of children, outside play is also hampered. These
students are prime set-up for obesity and its health consequences.
In addition to behavioral and risky behaviors, socioeconomic status
has shown a relationship to obesity. ``For all racial and ethnic groups
combined, women of lower socioeconomic status (income < 130 percent of
poverty threshold) are approximately 50 percent more likely to be obese
than those of higher socioeconomic status. African-American girls from
lower SES experience a higher prevalence of overweight/obesity than
those from higher SES families'' (American Journal of Clinical
Nutrition 2006 October; 84(4) 707-16). The exact etiology is not known,
but the high cost of nutritious fresh foods as fruits and vegetables
and lean meats prohibit the possibility to improve eating habits. In
the past, the increase in television viewing or use of electric games
was proposed as key factors. These items may play a role but it is not
the total answer. (McMurray, et al., 2000).
Tennessee has mounted a tremendous response to assist its
constituents to decrease their risk of heart disease and stroke. It has
partnered or collaborated with multiple agencies to improve the quality
of care and institute preventive measures. The State is a part of the
Delta States Stroke Consortium which is led by Arkansas Department of
Health; the State formed a Heart Disease and Stroke Prevention Program
(HDSP) Advisory Council Task force which has implemented guidelines for
treatment of strokes, heart failure and coronary heart disease in 40
hospitals, as well as a comprehensive preventive plan for the entire
State. HDSP has collaborated with Joint Commission on Accreditation of
Healthcare Organization (JCAHO) to certify hospitals as primary stroke
centers. HDSP has also partnered with American Heart Association to
increase awareness of signs and symptoms and institute ways to decrease
Tennesseans risk factors of heart disease and stroke.
Meharry Medical College has two programs underway to address some
of these issues. One is in Obstetrics and Gynecology where Dr. Sandra
Torrente is the Project Investigator. She is investigating overweight
and obese women who are pregnant to denote if they can safely go on a
diet and have a good birthing outcome. Dr. Xylina Bean is beginning a
project on overweight and obese adolescents by providing a mentor in
addition to nutritional counseling and exercise to improve a successful
outcome. Dr. Tropez-Sims has completed a study reviewing if overweight
or obese mothers during pregnancy transfer their poor eating habits and
produce overweight and obese infants during the first year of life. The
conclusion of this study is there is no clear relationship in the first
year of life.
In conclusion, thus far, we have learned that obesity is a
multifactorial issue and it will take everyone to become a part of the
solution. As we see from some studies the battle against obesity and
its consequences begins as soon as we are born. It must be stated that
not only overweight and obese children and adolescents are at risk for
these consequences but even non-obese individuals run similar outcomes
albeit lower rates secondary to inappropriate dietary consumptions,
smoking and lack of physical activity. In our schools not only the
three ``R's'' must be taught but preventive and healthy life styles
must be integrated as a life-long learning experience. Good nutrition
is not a diet and changing the mindset of the population of this issue
is required. Research must continue to look at all aspects of obesity
including the psychological aspects, which is mostly overlooked. Going
back to basics as growing ones own vegetables and fruits even in a city
can assist in improving ones health. Children and adolescents need
guidance in lifestyle healthy behavior. Parents need to increase their
knowledge first to allow children to inherit their examples. Tennessee
has multiple guidelines and plans in place to implement a change in
behavior of its constituents. It is a daunting task but with everyone
playing a major role the State can be successful.
Bibliography
Baba Reizo, Kokotsdu, Masaaki, et al. Role of Exercise in the
Prevention of Obesity of Homodynamic Abnormalities in Adolescents,
Pediatric International 2008 Oct. 8.
Bray, Jablonski Fajnoto, et al. Am J Clin Nut 2008 May; 87(5): 1212-8.
Arch Pediatr Adoles Med 2007 July; 161 (7): 677-83.
Chronic Diseases, Risk Factors, and Preventive Services, Tennessee,
Burden of Chronic Diseases, CDC 2004; 1-4.
Gianna Perez Gomez and Fatma G. Huffman. Risk Factors for Type 2
Diabetes and Cardiovascular Diseases in Hispanic Adolescents,
Journal of Adolescent Health 2008; 444-449.
Gordon-Larsen P., Adair L.S., Papkin B.M. UNC Chapel Hill, The
Relationship of Ethnicity, Socioeconomic Factors and Overweight in
U.S. Adolescents, Obese Res 2003 Jan; 11(1): 121-9.
McMurray R.G., Harrell J.S., Ding S., Bradley C.B., Cox R.M. and
Bangdewala S.I. The Influence of Physical Activity, Socioeconomic
Status and Ethnicity on the Weight Status of Adolescents, Obese Res
2000 Mar; 8(2): 130-9.
Moore D.B., Howell P.B., Treibis FA. Changes in Overweight Youth Over a
Period of 7 Years Impact of Ethnicity, Gender and Socioeconomic
Status, Eth Dis 2002 Winter; 12(1): 51-83-6.
Wang Y. and Zhang O. SEC and American Children and Adolescents of Low
Socioeconomic Status of Obesity at Risk 1971-2002, Am J Clin Nutri
2006 Oct; 84(4) 707-16.
Senator Alexander. Thank you, Dr. Tropez-Sims.
David Griffin, we appreciate your coming and look forward
to hearing more about your story, which by now is pretty well
known across the country.
STATEMENT OF DAVID GRIFFIN, PARTICIPANT, SEASON 4 OF NBC'S ``
THE BIGGEST LOSER ,'' CEDAR HILL, TN
Mr. Griffin. Unfortunately, sometimes it is a little too
known.
[Laughter.]
Senator Alexander, I'd like to thank you for what you are
doing for our great State and for inviting me to be involved in
this witness panel.
I'd like to make one thing clear, and I want this on the
record. It's not fair to put the former fat kid with all the
smart people.
[Laughter.]
I definitely don't have the statistics to prove what the
epidemic is, but I do have eyes. All we have to do is take a
walk through a shopping mall, we have to go to a school, and we
can see what our problems are. They lie more than just in
economic regions, more--more, to me, profoundly, is with our
children's health and the health of their parents.
So, briefly, about me, I am 33 years old. I'm from Cedar
Hill, TN. I was an obese child. I was the fat kid. I was the
kid that was ridiculed. Even though I was an athlete, I was
always heavier than all of my peers. It was important, growing
up, you know, for the football coach to keep the defensive
linemen heavy, ``Give the kid an extra hot dog.'' You know, I
remember baseball coaches even saying, ``I'll buy you a hot dog
for every home run you hit.'' It wasn't even about the hot dog.
It didn't hurt.
Those habits of eating unhealthy--because I grew up in the
South, like most people here did. My grandmother could fry a
banana, and it tasted good, so we ate it.
[Laughter.]
We knew nothing, you know, about healthy nutrition. I
didn't know, really, anything about healthy nutrition until I
started my journey to get healthy.
I grew up eating poorly. I exercised during the school year
during athletics, but I did nothing outside of that. With all
the knowledge that we have now--I mean, we have more knowledge
about obesity, about health and fitness and nutrition,
available to us in the world than we ever have, and we're in a
poorer State of health than our country's ever been.
With that being said, my weight continued to escalate. I
stayed around 275 all through high school. I remember that,
because I wrestled heavyweight, and there was a weight limit of
280 pounds. I didn't cut weight. I just didn't gain any. I
remember laughing at the skinnier guys, the lighter-weight guys
that would run around the gym with trash bags on and not eat
for 3 days so they could make weight. I was eating an extra
piece of pizza in the lunchroom. There again, that bad
nutrition was available. It was readily there. I didn't know
any better. I could do it. It was comfortable. I got away with
it.
From graduating high school at 275 to age 31, I was 400
pounds. That was my heaviest. I know it's kind of rude to
correct a Senator, but, you know, leave it to the fat kid.
[Laughter.]
I went to the doctor as a scared adult. I was a heavy
smoker. I never really passed by a fast-food restaurant without
at least visiting to say hello.
[Laughter.]
I was on a first-name basis with most of the people at
McDonald's in the area. I didn't exercise at all. We have a
small place in Robertson County where we raise some livestock,
and we are very physical in our daily lives, along with being,
you know, full-time career people, my wife and myself. Even
that work ethic never kept me slim, it never put me on the
right direction to healthy life.
At the point of 31, I didn't go to a doctor, ever. I never
got on a scale. That would be a joke. I fooled myself for a lot
of years that, ``Maybe I'm 300 pounds.'' Maybe. Then, when I
went to the doctor and realized--you know, my doctor told me
that I had two choices. I was 31. I could do one of two things.
He said, ``Your blood pressure is high, your sugar is
borderline.'' You know, I was a borderline diabetic. He said,
``You can leave today and make a decision to change
your life and make gradual changes and lose some weight
here and there and get active, do something besides
what you do on a normal basis, because your body gets
used to that. Talk to a dietician, talk to a
nutritionist, get a personal trainer, go to the Y,
workout, make it inexpensive,''
because there are means in most communities that you can go to
a facility fairly inexpensive, as a family. If not, there are a
lot of parks that I have not seen a ticket booth at yet to get
in to take advantage of the playgrounds and the basketball
courts. He said,
``You can either start now, or you can do nothing. In
5 years from now, when you fall dead on the sidewalk,
it'll be no medical mystery why.''
That was a huge wake-up call for me. Being a father of four
and a dedicated husband, it was important to me to do the right
thing for my family.
Even though I was extremely unhealthy--I didn't watch a lot
of television, I knew nothing about ``The Biggest Loser.'' But,
I did get started. The only thing I did in the beginning was
change my diet. From January 2007, I changed my diet. An old
friend of mine, in February, suggested trying out for the show,
``The Biggest Loser.'' I'd never seen it, had no clue what it
was. One--if I could give you guys any advice besides that
obesity epidemic, if you're going to try out for a reality
show, just find out what it's all about.
[Laughter.]
I went down in Nashville, went to an open casting call,
stood in line with everybody, and was fortunate enough to be
selected to go to Season 4. It wasn't like we went out there
and we just had a little medical test and they said,
``OK, you guys need to lose weight, and our chef's
going to cook this for you every day, and, you know,
we'll go to the spa after you work out, and you'll get
a back rub.''
It was horrible.
[Laughter.]
Everybody thinks that being on television's a great thing,
you know, and it's--it's a flashy-type deal. There was nothing
flashy about what I did. We trained 6 or 8 hours a day, boot-
camp style. We were in the gym, we were in the sand, we were
outside, were on the beach, we were in the mountains, whatever
it took. The way we lost our weight there is not necessarily
that I condone losing weight. It's not healthy to work out 6 or
8 hours a day. It's not healthy to lose 140 pounds in 6 months.
It wasn't about a game for me. I never played the game. I never
focused on the cash prize. I do a lot of speaking, and people
ask me, all the time, if I'm upset that I didn't win the
$250,000 or I didn't win the $100,000. I did end up in the top
5 percent out of 18 people that were on our season. My answer
to that is, I didn't win a monetary prize, but what I did win
was my health. And you can never put a dollar figure on that.
Now I can lead the example for my children, what it is to
be healthy, what we can do. Even though all my children are
fit, were fit, have always been fit, I want to show them how
their parents should live fit, the foods that should be in our
cupboard at home. And yes, my kids hate me sometimes, because
we don't have Pop-Tarts anymore, we don't have sugary cereal at
my house anymore. We all treat ourselves, from time to time,
but it can't be a daily treat, because then it becomes a habit,
and those habits, along with the more sedentary lifestyles that
we have in our new age, have put us where we are.
I want to give you guys one example. I have recently passed
my personal training certification, and, as a study--I'm not
necessarily focused on children, but I have a niece who's 10,
who is about 45 pounds overweight. That's a lot of extra weight
for a 10-year-old, especially a little girl. For some reason,
men have always been able to get away with a little extra
weight, more than women.
She's, of course, close to my heart, because she was
family. She always struggled--socially, personally--with her
weight. All I did was sit her down, and I sat her mom and dad
down, and we basically talked about nutrition. I'm not a
dietician, I'm not a nutritionist, but what I've learned, I can
give you commonsense advice. I gave her a cookbook. I told her,
``Three days a week, do something different than just sit on
the couch and watch television or play video games.'' They have
a park right across the street from their house, so I said,
``Three days a week, it's your job, 45 minutes you spend at
that park.'' It's not like they're just going to sit over there
for 45 minutes on the ground and twiddle their thumbs; they're
going to find something to do. In the last 6 months, she's lost
25 of those 45 pounds. That's pretty fast. She's a child, she
can lose it faster and get away with it. Just simply changing
her diet and getting her out of the house, it's changed her
whole life.
That's what we can do to change the lives of the children
that we affect. I do my spokeswork with Get Fit Tennessee
because it is important to me to get in front of the children.
We're going to win our war with obesity with this generation.
We need to affect their parents, because that's going to affect
what they have in their homes, that's going to affect their
lifestyle, that's where their examples are going to come from.
As adults, it's our job to reach out to these children
personally and try to find a way to help. We can't move them
all in our house, we can't save them, necessarily, we can't
capture them, but we can help them. We can lead by good
examples, and we can continue with the great programs that
we've started in this State and reach more people.
I do think some of the things in this panel--well,
actually, everything that I've heard were great examples, but
one thing that's really near and dear to my heart is the
nutrition in our schools. I know there are budgetary concerns,
but I know that buying in mass quality [sic], you can get
better rates on anything. There are a lot of schools, even
where my children go to school, in Robertson County, that
physical education is not mandatory. I think it's 90 minutes a
week for our kids. I think we're focusing a lot on their formal
education, which is extremely important, but if we don't focus
on their health education, it doesn't matter how much book
smarts they have, because without their health, they're not
going to go anywhere.
And that's about as smart as I get. Thank you, guys.
[Laughter.]
[The prepared statement of Mr. Griffin follows:]
Prepared Statement of David Griffin
Good morning. My name is David Griffin. I am 33 year's old and live
in Cedar Hill, TN in Robertson County with my wife, Sheri and four
beautiful children.
I know what it feels like to deal with childhood obesity. As a
child, around age 9 or 10, I started to rapidly gain weight. I didn't
receive nutritional education from my parents. And although I was in
athletics, I didn't exercise outside of athletics. As a child, I was
ridiculed for being the big kid, the fat kid.
During my childhood I developed stressed eating habits. I turned to
food for comfort, and I continued to gain weight throughout my high
school years. I graduated high school weighing 275 pounds. The problems
didn't stop when I left high school, and at 31, I weighed 400 pounds.
I went to see my doctor and he gave me the bad news--my blood
pressure was borderline high, my blood sugar was borderline, and it was
a wake-up call for me. As I mentioned, I have four children, and I knew
I needed to get busy getting healthy, so I could spend time with my
children and be here to see them grow up.
My children were all fit, but I wanted to lose the weight and get
healthy to set a positive example for them. I wanted to form the
healthy habits I wanted to see in them, and set them up for a healthy
future.
An old friend of mine suggested trying out for the television show,
`` The Biggest Loser.'' I had never watched the show before. I went
down, tried out, and I was lucky enough to be selected for Season Four.
I lost 30 pounds before the show, because my doctor said I needed to
get healthy, and there was no guarantee that I would get on the show,
so I began working even before being accepted for the show.
We began filming the show in May 2007. From that time until
December 2007, when it ended, I lost 140 pounds. After the show, I lost
about another 10 pounds. To date, my total weight loss is about 180
pounds!
Losing the weight and getting healthy has transformed my whole
life. It wasn't about a diet; it was about learning what to do to be
healthy, for my family to be healthy. We restructured our lives
together. We removed sodas, teas and junk food from our home. Our
children are not exposed to it because they know it's not healthy for
them.
For me it was a choice to get healthy. Everyone has to make the
decision for themselves. Knowing what I know now, I have learned that
you can treat yourself from time to time and it's important to do that
so you don't binge eat. If you are training hard and staying on track
with your exercise, you feel it when you eat unhealthy foods.
I went from not working out at all before ``The Biggest Loser,'' to
spending 6 to 8 hours a day working out on the show. Today, I do an
hour every day, 6 days a week. No excuses. In moments of weakness I try
to remind myself that nothing tastes as good as fit feels.
Since the show it's been important to me to sign on with Get Fit
Tennessee, and get in front of children to talk about healthy choices.
I recently passed my certification exam to be a trainer to teach people
to be healthy, and I am starting a boot camp aerobics class in the
middle Tennessee area in November.
In my opinion the war with obesity will be won with this generation
of children. As you know, statistics show us this generation of
children is the first that won't outlive the life expectancy of their
parents. Our society and our government must push for more physical
education testing in our school systems. I believe children need
physical education 5 days a week.
I think moving soft drink and vending machines from schools will be
very effective. If they want it that badly they can bring it to school.
And to the critics who say they need these vending machines for
revenues to pay for things at school, I say put water and sugar-free
drinks or juices in them. Work with vendors to offer healthier
alternatives.
Our children's health should be a priority in school systems.
School nutrition also needs to be addressed. The menu choices should be
healthier. Again, working with vendors to make healthier selections to
offer to children is an important step we can take. As far as children
go, a healthy mind is an open mind.
Now that I am healthy, I can do so much more with my children. We
play outside, I can run and play touch football, go for a walk, or roll
around on the floor with my children. My wife and I are closer, too,
because we can get closer. We take cycling class together, walks, and
those are things we couldn't do together for a long time. I wouldn't
trade these things I have now for any food out there today.
Senator Alexander. Thank you, David. That's very
impressive. Thank you. Thank you.
Let's talk a little bit more. To let you know, we're
recording all of this, so your testimony will be given to all
the other Senators on the committee, and it'll be a part of the
public record, and they'll have a chance to review it. This
builds our record for what we're hoping to do later.
Let's talk about ways to make a difference. I've always
been curious about--money seems to be a pretty good incentive
in our society. How has the insurance plan worked? Has it been
in effect long enough--you said--it's part of Cover Tennessee,
right?
Ms. Cooper. That's correct.
Senator Alexander. And Cover Tennessee is the State of
Tennessee's program to spend Federal--well, explain what Cover
Tennessee is and who's a part of it.
Ms. Cooper. There are three different components to the
overall Cover Tennessee program. There's the CoverKids Program,
which is the SCHIP Program.
Senator Alexander. Right.
Ms. Cooper. There is Access Tennessee, which is----
Senator Alexander. Which is a combination of Federal and
State money.
Ms. Cooper. Correct. Then, there's Access Tennessee, which
is a high-risk pool for those persons who are classified as
uninsurable by insurance standards. Then, there's CoverTN,
which is a limited benefits plan for the working uninsured, so
small businesses or those folks that had worked sometime in the
past year----
Senator Alexander. These all are part of Cover Tennessee.
Ms. Cooper [continuing]. That's correct--and now would be
unemployed.
The way it works for CoverTN, which is the working
uninsured program, the average premium is about $150 a month; a
third is paid by the person, a third is paid by the employer,
and then a third is paid for by the State. And your premium,
based on your age, which, unfortunately, we haven't figured out
what to do with, but your weight or tobacco use either--it
comes down, basically, if you are at a healthy weight or if you
do not use tobacco products.
Senator Alexander. Now, how do you determine healthy
weight?
Ms. Cooper. A healthy weight is a BMI under 30, so it's not
that we're asking everybody to be marathon runners and all be
very lean.
Senator Alexander. Well, how do you determine that, even?
Ms. Cooper. The BMI?
Senator Alexander. Yes.
Ms. Cooper. Through a physical screening----
Senator Alexander. OK.
Ms. Cooper [continuing]. A physical exam.
Senator Alexander. So, you go in for a physical exam, and
they measure your body mass.
Ms. Cooper. Correct. It's self-reported at first, and then
everyone has a physical exam during that first year, to verify
that. Same way with tobacco usage. Self-reported, ``Do you
smoke? Yes or no.'' Then, if you do or if your weight is above
30--if you're enrolled in a program and you're taking action to
reduce your rate, and the healthcare provider can see a change
over the first year, you'll pay a lower premium the next year.
Senator Alexander. Does this--the insurance is a factor in
one of the three----
Ms. Cooper. Yes. Well----
Senator Alexander. Cover Tennessee----
Ms. Cooper [continuing]. Also in Access Tennessee. The kids
program, you can't use weight and tobacco usage as a modifier,
it's just--everybody qualifies if their income is less than 250
percent of the Federal poverty level.
Senator Alexander. Now, you can't because of the Federal
rules?
Ms. Cooper. Right.
Senator Alexander. Although, Dr. Barkin, what we've heard,
or what both of you said, I think, was that there's this link
between babies who are overweight and--and one of you said it
was the first 4 months. How pronounced is that?
Dr. Tropez-Sims. Dr. Stiffler said that if you were
overweight or if you gained weight at a rapid pace between the
first 4 months of life, then 8 percent of those will be obese
by the time they're 20.
Senator Alexander. Well, now, what is a way to get at that?
I remember when I was Governor, my wife was working on a--we
were working on prenatal healthcare, because it made so much
sense to do it that way. Probably the most effective thing we
did was to form an alliance with pediatricians and try to make
it possible for every mother--every pregnant woman to find a
pediatrician before the baby's born, if we could. We made a lot
of progress with that. Is that--does the profession of
pediatrics use a healthy weight as part of its advice to young
mothers?
Dr. Tropez-Sims. Yes, we do. We follow a growth chart,
that's national, from out of the CDC, and we're able to plot--
and it's expected that every child, for every visit, whether
it's a well or a sick visit, that they--we plot their weights,
their heights, and their head circumferences, so we can tell if
a child is gaining weight more rapidly than they should.
Senator Alexander. I guess I've heard that, my own children
and many of my grandchildren, but I'm not sure I had heard
before about the link. Is that a new understanding, or do
mothers and fathers of babies know that now?
Dr. Barkin. The link actually has been shown in
longitudinal studies, many of them done in other States, such
as----
Senator Alexander. Yes.
Dr. Barkin [continuing]. Finland, over 30 years. I believe
when we're counseling our families, we know, and through our
research, that families see a chubby baby. And I work with a
lot of Latino families--we call these ``gordito babies,''
they're chubby babies--that equals health. While information is
an important part, it is a necessity, but not sufficient for
changing behavior, so that while we might both, in our clinic
settings, talk, as we do every time we see families, on growth
and what is healthy growth, our perception versus parental
perception is quite different, and that has been shown over and
over again in studies.
Senator Alexander. Well, going back to the insurance for a
minute, that would seem such an obvious thing to do. Has it
been in place long enough where you can make any judgment now
about whether it has any effect or not?
Ms. Cooper. I think it's still very new. It's about 2 years
old. We've got our first year of data, and I think it's made
some difference. Whether it's replicable across other
populations, it's too early to tell.
Senator Alexander. It seems to me like Governor Huckabee in
Arkansas were doing some of the same kind of thing, were they
not?
Ms. Cooper. They were. They actually have quite a bit of
interest, in Arkansas, around our Cover Tennessee program----
Senator Alexander. Yes.
Ms. Cooper [continuing]. The way we've stratified and
identified risk.
Senator Alexander. Maybe he had a program for State
employees insurance, where he tried to introduce healthy weight
into that.
Ms. Cooper [continuing]. I can't speak to that. I know, in
Alabama, they're getting ready to charge State employees if
they're not at a healthy weight or if they use tobacco. There's
some type of an increase in premium. I can't speak to Arkansas.
Senator Alexander. We would have to introduce that into
various insurance policies for a few years and see what
difference it makes.
Ms. Cooper. I think, look at the data. I also think, again,
a lot of our solutions are community-based. I think insurance
will come, down the road. It gets back to some of the cultural
differences we see. When you talk about money, one of the
things we hear is, ``It costs too much to be healthy.'' You
know, it costs too much to eat healthy. It costs too much to
join a gym. I think David hit on something that was really
important. This ability to create a healthy environment for
people, where they eat, where they work, where they play, where
they live, where they study. This ability to link all of that,
to open school playgrounds at night, where families could go,
to make linkages with the great State parks we have in--
certainly in our State--to create healthy grocery stores in
these food deserts that we have, to create healthy foods in
schools--as David said, you know, when you look at the foods
that come down from the USDA in the free breakfast and lunch
programs, there are some limits to the healthfulness of the
food, because of the trans fats and the calorie count that all
come down. I think, to be able to incent schools to have
healthier meals is certainly important.
Senator Alexander. David, let me ask you--a lot of this is
about changing behavior, which is something the government has
a hard time doing, at least in a relatively free society. What
was the one thing that turned you around? Was it that visit to
the doctor? What caused you to make the visit to the doctor?
Mr. Griffin. My health was poor. I was constantly out of
breath. Like I said before, I was a heavy smoker, which was a
no-brainer why I was out of breath. I just continually got more
sluggish and was worried about my activity. I couldn't even go
outside and play with my kids. You know,--get on the floor----
Senator Alexander. So, that took you to the doctor.
Mr. Griffin. It really did.
Senator Alexander. Then the doctor's message is what got
you turned around?
Mr. Griffin. Yes, that was a big part of it. And, too, it
was important to me--I had made a promise to my wife, a long
time before, that, you know, ``I'll get healthy.'' I just
kept--like, I had lost 100 pounds one time before, and I gained
160 back. So, to me, it was a trend. And----
Senator Alexander. Yes.
Mr. Griffin [continuing]. All the history and all the
studies will show that changing human behavior is never easy.
Senator Alexander. No, it's not. Now, you've talked to a
lot of people since then, and----
Mr. Griffin. Yes, sir.
Senator Alexander [continuing]. People have talked to you.
What's your guess about what are the most effective ways to
change human behavior in this case?
Mr. Griffin. The things that I've found in my studies is,
people change when it becomes easier to change than it does to
stay the same.
Senator Alexander. Easier to change.
Mr. Griffin. Yes. When it's easier----
Senator Alexander. Oh, easier----
Mr. Griffin [continuing]. For them to change their behavior
or their habit than it is to stay the same. The medical studies
show that people change when they get to that point that if
they don't do something, they're going to die.
Senator Alexander. Yes.
Mr. Griffin. It's easier for them to get healthy then, or
to try to attempt it, when, I think, we're going to win the
battles more on the forefront when we're getting in front of
our children and we're getting in front of our adults with
healthier programs. I think, too, if--I don't have a vision for
this. As a thought, I think if we could find more programs that
put our children and adults together--parents, families doing
healthier activities, doing things--you know, there's always
these walks, these 5K's and these runs, and--but, there are so
many other things that, as communities and as a State, I think
we can try to create some programs to keep our families closer.
Senator Alexander. Well, you all have emphasized that there
are a multitude of factors. As someone my age can look back to
an era where there was no television, no video games, walk to
school, Boy Scouts every week, hiking on the weekends, playing
every day. I had to do my piano lessons--practice the piano in
the morning so I could play all afternoon. That was sort of the
incentive--I didn't want to be practicing the piano while all
the boys were out playing in the afternoon. There was an
incentive to be outside. Now today, we've gone a couple of
generations, and we have parents who know so little about the
outdoors, they're even afraid to take their children outdoors,
they're afraid they'll see a bear or something and won't know
what to do.
[Laughter.]
No, really. I grew up in an area where all the adults had
outdoor experiences, and so, they were eager to teach them to
us, and then we became confident in the outdoors.
Dr. Barkin, you were about to say something.
Dr. Barkin. May I comment on something?
Senator Alexander. Yes.
Dr. Barkin. First, I see that David, to me, is the biggest
winner, not the biggest loser. And you hear his story, which is
so compelling, because he found his own motivation to change,
and then he was pushed over, he was nudged toward action by
both his family and his physician and, I'm sure, every time he
looked at his children. He made a lot of choices, and it was
hard, but he kept striving for it. We see--at our weight
management clinic, we see 3-year-olds who weigh 200 pounds, who
have fatty livers.
Senator Alexander. Three-year-olds?
Dr. Barkin. Three-year-olds. We see families who don't see
this as a problem. We show them our growth curves and the body
mass index is determined by a weight-to-height ratio, so we're
able to give them that information, show them the curves that
you heard Dr. Tropez-Sims discuss, and show them that they are
way outside of the curve, that they're far away from health.
When they look at their child, they see an active child who
looks cherubic and healthy to them. While we provide them with
information, at that stage--so, David tells a very important
story as an engaged adult, an engaged father--for these
families, they see health. The problem with so many of these
diseases, like hypertension and diabetes, which we are
diagnosing right and left in our clinic, for young children, is
that you can't see them, they're invisible.
Senator Alexander. Has anything been successful? What's
been most successful for you in changing the minds of these
parents?
Dr. Barkin. It's something very important that David said
and what the literature shows. If obesity is socially
contagious, how can you create health to be socially
contagious? Much of that is done through social networks, by
developing programs that are sustainable in communities and in
schools that bring the community together--the child, in the
context of their family; and the family, in the context of
their community.
Dr. Tropez-Sims. I was going to add that I've found that,
especially with my adolescents, the more children that lose
weight, it's because the mother was also overweight and they
worked together to try to lose the weight. If they can make it
a family affair, they can be much more successful. If you have
parents who say, ``Well, you know, I'm not changing my cooking
habits, they can just not eat the foods that I buy,'' those
children have no support, and, therefore, they do not lose
weight.
Sometimes the adolescents don't even see themselves as
being overweight. You have to get them to the mindset to
understand that they are overweight and they need to do
something about it.
Senator Alexander. I wonder if any of you want to comment
on the--I was very attracted to the idea of healthy weight
being a goal that every child have by the year 2018. It's
always a conflict between whether you scare people to death or
whether you tell them, ``Here's a goal. We can do this
together.'' I know, in my case, I stopped smoking when my
friend John showed me a picture of a pair of lungs of a smoker.
The next day, I quit. Some nice-sounding goal probably wouldn't
have done it for me before. It would seem to me that having
such a goal would at least be a good way to start, and then,
after that, you can develop various horrible stories about 300-
pound 3-year-olds and the consequences of that, to help people
see it. Tell me what you're doing with that goal.
Ms. Cooper. What we've found is--we've traveled across the
State and talked to Tennesseans, mothers and their kids, dads
and their kids--is that people want to do the right thing, but
they're bombarded by the media, by the restaurants, supersize,
biggie-size, value-size. They get all of this information
coming at them, and they don't necessarily know what the right
thing is. You have to put something out there that's achievable
for them. You know, if you came to me and said, ``You've got to
lose 100 pounds,'' I wouldn't hear anything else you said. If
you came to me and said, ``Look, let's just start where we are.
Did you get up and move at all today? Did you do any physical
activity? '' Well, if the answer is no, then you can say,
``Well, how about 5 minutes of playing with your kids in the
backyard,'' or, ``Are you willing to go out for a walk? ''
Then, what we've found is, 5 minutes becomes 10 minutes, 10
becomes 30, 30 becomes and hour. It's something that families
can do together.
We also hear that people want to know that they're valued.
I mean, as we've traveled across the State, again, people
appreciate that you go out and spend time with them, with a
message that, again, is attainable: get fit, healthy ways. Not,
`` You're fat, you don't do this, you don't do that, you don't
do that.'' The message just doesn't resonate. You take those
teachable moments, and then you build upon that. As you said,
we've seen this in the literature with tobacco, over and over
again, about creating the environment of health. If you take
tobacco out of a restaurant, more people tend not to smoke,
because it becomes what is known. I think the same thing works
for obesity.
Think about the labels on food, as you drive through your
favorite fast-food restaurant. If you saw, on a kid's meal,
that that kid's meal--not an adult meal--contained 1,400
calories, that's 1,400, not 140--you know, for an average
adult--I mean, I need about 1,500 calories a day; getting it in
one kid's meal, think what it's doing to a child. Unacceptable.
Thinking about what we could do with our restaurant foods is
important.
Senator Alexander. Let me do this. We've about gotten to
the point where we should conclude, but I want to ask each of
you if you have a minute or two, any other thought that you'd
like to add to the record or something you'd like to say.
This has been a very important discussion. I think it's
enough of a startling thought to say to anybody that this is
the first generation of children that may live a shorter life
than their parent, and that we know what the cause is. We've
got to figure out how to deal with it, and each of you, in your
own ways, have made a very significant contribution to this.
I'll do my best to make it a part of the Senate record and a
part of how the Federal Government supports what you're doing.
As a former Governor, you know, I'm very skeptical of the
Federal Government's ability to change behavior. I really think
we do more, locally and individually and in our families.
Obviously, the Federal Government can help create an
environment in which it's easier for this to happen. You've
mentioned two or three examples, school lunches as an example.
That is certainly a very important place, where we're in
everybody's face with that, so we ought to be very careful
about what is served there.
Let me thank you for your work and for taking your time
today, and thank Meharry for being such a great host. Let me
start at the other end, if I may this time, and start with
David Griffin and go back to Commissioner Cooper and see if you
have any last word you'd like to leave with us here.
Mr. Griffin. Just a couple of things. Thank you, again, for
allowing me to be here today. It's been a pleasure. It's nice
to be on the good side of the law for a change. No.
[Laughter.]
When I was talking about nutritional education before, and
me not really knowing, and--I'm sorry, Dr. Barkin--I can't see
your name tags, it's not fair--Dr. Barkin had talked about the
food deserts north of Nashville. We live in Robertson County.
There's two grocery stores in Springfield, a Kroger and a Wal-
Mart. And I, still today, shop there, but when I learned what
to read on labels and what to look for in the grocery store and
how to eat healthy and how to feed my body, to train the way I
was trained--because all that 140 pounds was not lost in that 6
months in California; 2 months of it was there, the other 4 was
home, after I was eliminated from the show. I did my healthy
eating from a Wal-Mart shelf. It can be done if we educate our
people. They can shop where they have the means. It can be done
more cost-effectively than eating at McDonald's 4 to 5 days a
week. It really can. A can of tuna fish is, like, 80 cents. You
know? Tuna's healthy.
The other thing that--when we were talking about school
lunches, it's not just the school lunches, it's also the
unhealthy things that they have available to them at schools. I
don't think that I've walked through a high school that I've
done a talk at that I didn't see at least four soda machines. I
mean, they're a treat from time to time, and kids can get away
with a lot more than adults can. That's where we're going to
have to start their healthy education, in their schools.
Senator Alexander. Thank you, David. And your----
Mr. Griffin. Thank you.
Senator Alexander [continuing]. Comment about the
availability of food, Wal-Mart's the largest seller of
groceries in the country. The percentage they sell is--I heard
it the other day, and I don't remember it, but it's
surprisingly high, maybe 15 or 20 percent or 10 percent of all
the groceries in the country.
Dr. Tropez-Sims.
Dr. Tropez-Sims. Yes, two comments I wanted to make. One is
that I think we need to make sure that people no longer think
that eating fruits and vegetables is a diet, that that is just
normal food that should be incorporated in daily life, and that
we need to try to change our perception of a diet.
The other thing is, is that, a lot of times, with parents,
especially new parents, when they take their children home,
when the baby cries--they think that every time the baby cries,
they need to feed them. We need to try to encourage them that
every time a child cries does not mean they need to eat. Every
time that child, as a toddler, asks for something to eat does
not mean that you need to give them the junk food that they're
requesting. We need to make sure that, as adults, we feel more
self-assured, ourselves, that we're not starving our children,
but they do not have to eat every time we think that they are
hungry.
Senator Alexander. Thank you.
Dr. Barkin.
Dr. Barkin. Thank you, again, Senator Alexander, for
allowing us to have this kind of really engaged discussion.
I would like to focus that information is necessary, but
not sufficient. It's not that people don't know. For example,
smokers know they shouldn't smoke. It's not that parents don't
know that their children shouldn't be eating every meal in a
fast-food place. Knowledge is necessary, but not sufficient.
What is sufficient?
When we look at behavior-change theory, people do what's
easy. If you can find ways to support healthy default
environments, such as the examples made about school lunches--
if we're not offering tater tots or french fries there, our
children won't be eating it. Considering how we create those
healthy default environments is really critical for changing
behavior that is sustainable.
And last, this notion of affordable and accessible food--
because if we say, for example, for insurance, you will get a
lower premium if you are a lower weight, but, as you heard from
Dr. Tropez-Sims, that lower socio-economic-strata individuals
have a harder time with weight, and they don't have access or
affordability, then we've given them a goal that's
unattainable, which we don't want to set forth as a precedent.
Here's just an example. I know that our surgeon general has
been working with the National Institute of Child Health and
Human Development. One of the things that they're looking at is
the economics of obesity. I just have a picture here of a plate
of broccoli and a tiny little dollop of peanut butter. They
have exactly the same amount of calories, 200 calories. For
that dollop of peanut butter, it costs 17 cents. For this plate
full of broccoli, it costs almost $2. We have to consider
affordable and accessible access to food.
Senator Alexander. Commissioner Cooper.
Ms. Cooper. Well, I'm going to take it, I guess, a
different place.
We're going to move Tennessee, and we're going to move it
from being one of the unhealthiest States in this Nation to
becoming one of the healthiest States in this Nation. And I
will tell you, it's also not really a goal that is sufficient,
because our Nation is not the healthiest Nation in this world,
and there's no excuse for us not to be. We need to build health
in all of our policies, whether they're health policies,
education policies, transportation policies. Health should be
included in all of them.
We should address those areas where we eat, where we learn,
where we play, where we work, how we commute, where we live. I
would challenge us to find the world that we move, to close our
eyes and remember the time when it was OK to turn off the
television, where it was great to go out to the backyard and
play. Do you remember lying down on the ground and looking up
at the sky and seeing these great, wonderful things you made
out of clouds? Kids don't know how to do that today. You've got
to figure out how to influence their behavior to get them
outside more.
You know, I believe, fundamentally, we have to make a
commitment in this Nation to change, to say that this is
unacceptable, and to move, not just our State, but every State
in this Nation to look at those children born in the year 2000
and their graduation date in 2018 and say, ``All children, not
just Tennessee children, will graduate at healthy weight in
2018.''
Senator Alexander. Thank you very much, Commissioner
Cooper.
Thanks, to each one of you. Thanks, to all of you for
coming. And, Dr. Riley, thank you, again, for making Meharry's
great facilities available.
The hearing is adjourned.
[Whereupon, at 11:21 a.m., the hearing was adjourned.]