[Senate Hearing 110-961]
[From the U.S. Government Printing 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.
---------------------------------------------------------------------------
    \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.
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    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:
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \6\ Trust for America's Health. Prevention for a Healthier America: 
Investments in Disease Prevention Yield Significant Savings, Stronger 
Communities, July 17, 2008.
---------------------------------------------------------------------------
    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:
---------------------------------------------------------------------------
    \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.]