[Senate Hearing 110-792]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-792

               WATCH WHAT YOU EAT: FOOD MARKETING TO KIDS

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

                             JOINT HEARING

                               before the

   SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN SERVICES, EDUCATION, AND 
                            RELATED AGENCIES

                                AND THE

       SUBCOMMITTEE ON FINANCIAL SERVICES AND GENERAL GOVERNMENT

                                 OF THE

            COMMITTEE ON APPROPRIATIONS UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                            SPECIAL HEARING

                   SEPTEMBER 23, 2008--WASHINGTON, DC

                               __________

         Printed for the use of the Committee on Appropriations


  Available via the World Wide Web: http://www.gpoaccess.gov/congress/
                               index.html

                               __________


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                      COMMITTEE ON APPROPRIATIONS

                ROBERT C. BYRD, West Virginia, Chairman
DANIEL K. INOUYE, Hawaii             THAD COCHRAN, Mississippi
PATRICK J. LEAHY, Vermont            TED STEVENS, Alaska
TOM HARKIN, Iowa                     ARLEN SPECTER, Pennsylvania
BARBARA A. MIKULSKI, Maryland        PETE V. DOMENICI, New Mexico
HERB KOHL, Wisconsin                 CHRISTOPHER S. BOND, Missouri
PATTY MURRAY, Washington             MITCH McCONNELL, Kentucky
BYRON L. DORGAN, North Dakota        RICHARD C. SHELBY, Alabama
DIANNE FEINSTEIN, California         JUDD GREGG, New Hampshire
RICHARD J. DURBIN, Illinois          ROBERT F. BENNETT, Utah
TIM JOHNSON, South Dakota            LARRY CRAIG, Idaho
MARY L. LANDRIEU, Louisiana          KAY BAILEY HUTCHISON, Texas
JACK REED, Rhode Island              SAM BROWNBACK, Kansas
FRANK R. LAUTENBERG, New Jersey      WAYNE ALLARD, Colorado
BEN NELSON, Nebraska                 LAMAR ALEXANDER, Tennessee

                    Charles Kieffer, Staff Director
                  Bruce Evans, Minority Staff Director
   Subcommittee on Departments of Labor, Health and Human Services, 
                    Education, and Related Agencies

                       TOM HARKIN, Iowa, Chairman
DANIEL K. INOUYE, Hawaii             ARLEN SPECTER, Pennsylvania
HERB KOHL, Wisconsin                 THAD COCHRAN, Mississippi
PATTY MURRAY, Washington             JUDD GREGG, New Hampshire
MARY L. LANDRIEU, Louisiana          LARRY CRAIG, Idaho
RICHARD J. DURBIN, Illinois          KAY BAILEY HUTCHISON, Texas
JACK REED, Rhode Island              TED STEVENS, Alaska
FRANK R. LAUTENBERG, New Jersey      RICHARD C. SHELBY, Alabama
ROBERT C. BYRD, West Virginia, (ex 
    officio)
                           Professional Staff
                              Ellen Murray
                              Erik Fatemi
                              Mark Laisch
                            Adrienne Hallett
                             Lisa Bernhardt
                       Bettilou Taylor (Minority)
                    Sudip Shrikant Parikh (Minority)

                         Administrative Support
                              Teri Curtin
                         Jeff Kratz (Minority)
                                 ------                                

       Subcommittee on Financial Services and General Government

                 RICHARD J. DURBIN, Illinois, Chairman
PATTY MURRAY, Washington             SAM BROWNBACK, Kansas
MARY L. LANDRIEU, Louisiana          CHRISTOPHER S. BOND, Missouri
FRANK R. LAUTENBERG, New Jersey      RICHARD C. SHELBY, Alabama
BEN NELSON, Nebraska                 WAYNE ALLARD, Colorado
ROBERT C. BYRD, West Virginia (ex    THAD COCHRAN, Mississippi (ex 
    officio)                             officio)

                           Professional Staff

                             Marianne Upton
                         Diana Gourlay Hamilton
                        Mary Dietrich (Minority)
                        Rachel Jones (Minority)

                         Administrative Support

                              Michael Bain
                       LaShawnda Smith (Minority)












                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Tom Harkin..........................     1
Statement of Senator Sam Brownback...............................     3
Statement of Senator Richard J. Durbin...........................     5
    Prepared Statement of........................................     6
Statement of Julie Gerberding, M.D., M.P.H., Director, Centers 
  for Disease Control and Prevention, Department of Health and 
  Human Services.................................................     7
    Prepared Statement of........................................     9
Statement of Hon. Kevin J. Martin, Chairman, Federal 
  Communications Commission......................................    14
    Prepared Statement of........................................    16
Statement of Hon. Jon D. Leibowitz, Commissioner, Federal Trade 
  Commission.....................................................    19
    Prepared Statement of........................................    20
FTC's Authority and History on Food Marketing to Children........    21
The 2005 Workshop on Marketing, Self-Regulation, and Childhood 
  Obesity........................................................    21
The 2007 Forum and Current Assessment of Industry Efforts........    22
The 2008 Food Marketing Study and Report.........................    23
Health Systems Reports...........................................    29
Reducing Children's Television Viewing to Prevent Obesity........    31
A Randomized Controlled Trial....................................    31
Methods..........................................................    32
Intervention.....................................................    32
Outcome Measurements.............................................    33
Statistical Analysis.............................................    34
Results..........................................................    34
Participation in the Intervention................................    35
Effects on Adiposity.............................................    35
Effects on Media Use, Diet, and Physical Activity................    37
Comment..........................................................    39
References.......................................................    40
A Randomized Trial of the Effects of Reducing Television Viewing 
  and Computer Use on Body Mass Index in Young Children..........    42
Methods..........................................................    44
Results..........................................................    47
Comment..........................................................    51
Physical Education in the Schools................................    54
Statement of J. Michael McGinnis, M.D., MPP, Institute of 
  Medicine, Washington, DC.......................................    57
    Prepared Statement of........................................    59
Food Marketing to Children and Youth.............................    61
2008 Status of Recommendations in the 2005 IOM Report............    61
Statement of Marc Firestone, Executive Vice President, Corporate 
  and Legal Affairs, and General Counsel, Kraft Foods, 
  Northfield, Illinois...........................................    64
    Prepared Statement of........................................    65
Statement of Marva Smalls, Executive Vice President and Chief of 
  Staff, MTV Network, IDS and Family Group (Nickelodeon), New 
  York,
  New York.......................................................    67
    Prepared Statement of........................................    68
Childhood Obesity: A Multi-Dimensional Problem...................    69
Nickelodeon's Approach...........................................    69
Nickelodeon's Health & Wellness Initiatives......................    70
Licensed Characters..............................................    71
Collaboration with Advertisers and Food Companies................    72
Statement of Patti Miller, Vice President, Children and the 
  Media, Children NOW............................................    72
    Prepared Statement of........................................    73

 
               WATCH WHAT YOU EAT: FOOD MARKETING TO KIDS

                              ----------                              


                      TUESDAY, SEPTEMBER 23, 2008

        U.S. Senate, Subcommittee on Labor, Health and 
            Human Services, Education, and Related 
            Agencies, and Subcommittee on Financial 
            Services and General Government, Committee on 
            Appropriations,
                                                    Washington, DC.
    The subcommittees met at 10:35 a.m., in room SD-192, 
Dirksen Senate Office Building, Hon. Tom Harkin (chairman of 
the Labor-HHS Subcommittee) presiding.
    Present: Senators Harkin, Durbin, and Brownback.


                opening statement of senator tom harkin


    Senator Harkin. Good morning, everyone. The two 
subcommittees of the Appropriations Committee will come to 
order.
    This is the Subcommittee on Labor, Health, and Human 
Services, Education, and Related Agencies, and the Subcommittee 
on Financial Services and General Government, subcommittee of 
the Committee on Appropriations.
    I'd like to thank everyone for coming today to examine the 
role of media and marketing food, beverages, and lifestyles to 
children. I especially want to thank my ranking member, Senator 
Arlen Specter, and also the Financial Services Subcommittee, 
Senator Brownback, Senator Durbin, for working with us to have 
this kind of a joint hearing. We don't often get to work across 
jurisdictions, so I'm gratified that this epidemic of childhood 
obesity has inspired this rare meeting of two subcommittees of 
the Appropriations Committee.
    I just want to say that, because of the number of 
witnesses, we've had to shorten the statements; I'll get right 
to the point. I'm convinced that the food and beverage industry 
and the--and kids media industry, with all of their creativity 
and resourcefulness, can be a powerful force for change and 
doing good. Therefore, today's hearing is to discuss media and 
marketing.
    Now, I'm going to have other hearings on school nutrition 
as we do the--as I wear my other hat, on agriculture, as we do 
the reauthorization of the childhood--the Child Nutrition Act 
for next year. But, I want to hear from you here today on how 
media and advertising can be a part of the solution.
    Senator Brownback and I have worked together on this a lot 
in the past, and looking at the FCC and how we can try to get a 
handle on this, with the help and assistance of the industry.
    Now, I must say, in this regard, some within the food and 
beverage industry, and several media companies, have really 
tried to do the right thing. In the second panel, we're going 
to hear from Kraft. Kraft Foods took the lead, back in 2005. 
They announced that all TV, radio, and print advertising viewed 
primarily by children ages 6 to 11 would feature only Kraft 
products that meet specific nutrition criteria. And then, in 
2006, Kraft extended this policy to their Web sites. So, I 
personally want to applaud Kraft's work in this area, and hope 
to hear, today, how we can build on those advancements.
    Also, in November 2006, the Council of Better Business 
Bureaus formed the Children's Food and Beverage Advertising 
Initiative. Fifteen food companies have joined the initiative 
and pledged to limit their marketing to children to foods that 
meet company-developed nutrition standards. In addition, 
several media companies, including Disney, Sesame Workshop, and 
Cartoon Network, announced that they will only license their 
characters on foods that meet their own nutrition standards. 
Nickelodeon has also announced a licensed-character program 
that relies on individual food company nutritional standards.
    So, I look forward to learning more about these programs 
from our second panel, and I'll be asking if all of Viacom's 
characters are included.
    You know, kids are powerfully influenced by these 
characters. I mean, you know, to me, Nemo is a cartoon 
character, but to kids, he's an authority figure. So, you know, 
just the way you look at it.
    Now, again, there are some great examples of how these 
characters can assist in marketing good food to our kids. And 
here, I have some props. What's good if you don't have a prop, 
right? Here are mandarin oranges with Disney characters on it, 
on the front of it. Yeah, Nemo. Thanks for telling me that.
    Senator Harkin. Nemo's on the front of the mandarin 
oranges. That's good. And here's--I never thought I'd live to 
say the--they see this Mickey Mouse on a head of lettuce.
    Now, to me, that's the direction we ought to be going.
    So, again--it looks good. So, what's the problem? Well, 
here are some of the problems. Studies have found that about 50 
percent of commercial advertisements targeted to young people 
during Saturday morning programming are for food and beverage 
products, but few commercials are viewed for dairy products, 
fruits, or vegetables. In 2007, a study published in Pediatrics 
reviewed approximately 98,000 advertisements from a sample of 
television programs that were top-rated among kids under 17, 
found that nearly all of them--98 percent--viewed by the kids, 
and 89 percent viewed by adolescents, were for products that 
were high in fat, sugar, or sodium. That was in 2007, a year 
after Kraft changed its guidelines, and after the creation of 
the Better Business Bureau initiative.
    A 2008 study by the Kaiser Family Foundation found that 
little television airtime was devoted to the promotion of 
healthy food choices. The study examined 1,680 hours of 
television content on ten major broadcasting cable networks. It 
reported that, across all of the ten networks, paid public 
service announcements were shown for an average of 10 seconds 
per hour, but none of them promoted good nutrition. Now, that's 
28 minutes a week. Donated PSAs--public service announcements--
represented only one-half of 1 percent of all airtime, and, 
within that, an average of 28 seconds per week was on promoting 
good nutrition. Twenty-eight seconds per week on public service 
announcements.
    So, again, I think this is where the problem lies. Now, 
again, I don't want to be misunderstood. It's television, but 
now a lot of kids are now on the Internet and social networking 
on the Internet. I thought I was doing pretty good, Sam, I've 
got 1,500 friends on my Facebook.
    Senator Brownback. Yeah, very good.
    Senator Harkin. Yes, until I found out Obama had 8.1 
million.
    I've got 1,500. Okay? I've got 100 friends on my Facebook.
    But--so, anyway, but more and more kids are doing that. So, 
again, we need to think about that, also.
    Expenditures for advertising on social-network Web sites 
are expected to reach $1.8 billion by 2010. Markets such as 
Wendy's, Burger King, and Pepsi have created profiles on My 
Space, where visitors can interact with the brand, just as they 
would with the profiles of their other friends. So, again, this 
is the wave of the future. The question for us is, Will it just 
be foods that are high in sugar, fat, and sodium, or will we, 
kind of, redirect this towards other ways? Will the companies 
do that?
    So, again, these are the questions I think we need to be 
exploring. I applaud what's happening on some of these things, 
but we've got to think about what's happening both on 
television and on the Internet, where kids are spending a lot 
of their time and where they're getting a lot of influence.
    So, I guess I look forward to hearing today from the 
witnesses on how we can change the landscape of what our kids 
see on TV, on the Internet, grocery items, and on and on. We're 
going to be discussing, a lot in the next year or two, 
healthcare. I don't care--well, maybe I do care who gets 
elected President, but regardless who gets elected President, 
this Congress and the next administration are going to be 
working on healthcare reform. If all we're going to be doing is 
talking about how we pay the bills, it's not going to get us 
anywhere. We've got to get ahead of the curve with prevention 
and wellness programs, and that starts with our kids, getting 
our kids started off early in life, eating the right kind of 
foods, enjoying the right kind of foods, developing the kind of 
tastes for the right kind of foods, so that they won't be 
developing diabetes and obesity, and the other things that are 
plaguing our kids today. So, I see this as sort of the front 
end, the most important part of what we're going to be doing in 
healthcare reform in the next couple of years.
    And I have talked way too long, and I would yield to my 
good friend, Senator Brownback.


                   statement of senator sam brownback


    Senator Brownback. Thank you very much. Mr. Chairman, I 
couldn't agree more with your statement, and I really 
appreciate working with you and with Chairman Martin.
    We started a process about a 1\1/2\ years ago to try and 
get some voluntary compliance with these issues. We didn't get 
far enough, and that's the genesis of the hearing. I would like 
to know what else we can do to move this process on forward.
    We are on the verge of a nationwide crisis that threatens 
to create, for the first time ever, a generation of kids who 
will have a shorter life span than their parents. That's a 
breathtaking statement. That's where we are today. And if we 
don't start to do something about it, that's where we're going 
to be, and that's why we have to get at these prevention 
programs you mentioned.
    You had some samples, I've got charts. They're dull, but 
they do drive the point. The past 30 years, childhood obesity 
rates have risen nearly 300 percent; from 5 percent in the mid-
1970s to over 17 percent of our children are obese in 2004. For 
children, 2 to 5, it's gone from 5 to nearly 15 percent; for 
adolescents, it's gone from 6\1/2\ to nearly 19 percent; for 
teenagers, 17.4 percent. Wow. These are very, very troubling 
figures.
    While we all agree that there are myriad of different 
factors that comprise childhood obesity, we cannot ignore that 
our children live in a saturated media environment with 
advertisers eager to make impressions on young minds. A 2004 
Kaiser Family Foundation report found that children are exposed 
to approximately 40,000 advertisements per year. And I want to 
show that on this next chart.
    A 2007 Kaiser Family report found that, in terms of 
minutes, children ages 2 to 7 see an average of 17 minutes 
worth of commercials per day; adolescents, 37 minutes; 
teenagers, 35 minutes. Now, that same report, in the next 
chart, also showed that, among all TV genres, children's shows 
have the highest proportion of food ads--50 percent--versus 
dramas, with 25 percent; sitcoms, with 23; and reality shows, 
with 16 percent.
    The recently released FTC report on marketing food to 
children and adolescents, found that, in total, $1.6 billion 
was spent on food and beverage advertising to children in 2006. 
You can say, ``Well, okay, that maybe neither is good nor 
bad,'' but, in the next chart, of that $1.6 billion, 34 percent 
of the ads were for candy and snacks--here comes Halloween--28 
percent were for cereals, and 10 percent were for fast foods. 
We simply must do better, and we can do better.
    We all know that there are serious long-term health 
consequences to obesity, including an increased risk for 
cardiovascular disease, high blood pressure, and type-2 
diabetes. In fact--and this, I found just stunning--in July 
2008 of this year, the American Academy of Pediatricians said 
that more children, as young as 8, should be given cholesterol-
lowering drugs. As young as 8. According to the Centers for 
Disease Control and Prevention--we'll hear from them today--
almost 60 percent of overweight children had at least one 
cardiovascular disease risk factor, while 25 percent of 
overweight children had two or more risk factors. American 
Heart Association found that more than 6 million children in 
the United States have nonalcoholic fatty liver disease 
attributed to overweight or obesity. Six million. Already we 
have pharmaceutical companies reformatting drugs for children 
for such health conditions as type-2 diabetes, cardiovascular 
disease, and hypertension.
    Indeed, we have an enormous challenge before us, one I'm 
hopeful we can address together an in expeditious way, when it 
works with our spirit of a free society, but also places the 
best interests of our Nation's children first.
    And toward that end, Mr. Chairman, what I'm looking for, 
from the testimony for the witnesses today, is, How do we 
proceed forward with addressing this? This is an enormous 
problem that's right on us, and we've got to do something about 
it. And we can't just debate, in our healthcare policy, about 
who's going to pay the bill, but how do we get out ahead of it? 
And clearly this is a big one we've got to get out ahead of.
    Thank you for holding the hearing.
    Senator Harkin. Thank you, Senator Brownback, for working 
with us and working together, and our staffs working together 
on this. I think, again, this crosses party lines, crosses 
regional lines. I mean, this is a national problem, and I look 
forward to working with you on this as we move ahead, also. So, 
I thank you very much.
    And I yield to the chairman of the Financial Services and 
General Government Subcommittee, Senator Durbin.


                 statement of senator richard j. durbin


    Senator Durbin. Thank you very much.
    I want to thank both Senators Harkin and Brownback for this 
hearing and ask that my opening statement be placed in the 
record in its entirety.
    I also would like to make a note that we--we had a call to 
arms on this issue in 2001. A fellow named Eric Schlosser wrote 
a book called ``Fast Food Nation.'' And if you read it, you 
couldn't help but realize how life had changed so dramatically, 
in terms of the way we eat, the way we advertise for the food 
that is purchased. And it means that generations, since the 
1960s, have really been raised in a much different world than 
some of us at this table. And their notion of what is healthy 
and what is normal is a lot different than we had, growing up.
    I tried to address one small part of this. I thought, well, 
let's go after something the Federal Government has a special 
responsibility for. How about school lunches? I started 
visiting schools, and looking at what they serve, and listening 
to the menus that are announced on a lot of radio shows back in 
Iowa and Kansas and Illinois. It's disturbing. You know, choice 
today is between corndogs and pizza, tater tots on the side, 
you know, and you start thinking to yourself, ``Is this as good 
as it gets?''
    So, we started to try to work out a way to develop school 
lunches that were healthy, that kids would actually eat. It 
doesn't do us any good to put out the salad bar and watch the 
kids go for the tater tots, so we had to figure out how to put 
this food in front of kids at an age where they start choosing 
the right thing, and choosing the right amount of the right 
thing.
    It's not easy. Any parent can tell you it's not easy. But 
it works if you work at it. And we've had a dozen schools in 
Chicago that have started with salad bars for kindergartners 
and grade-school kids, and we've started trying to build this 
appetite for the right kind of foods. We are doing this, 
against this tidal wave of advertising, which says: supersize 
carbos and salt and sugar. And it's tough.
    But, if we're serious about it at the Federal level, we've 
got to do more than just complain about advertising. Let's get 
our own house in order. Let's make the school lunch program and 
the school breakfast program a model for the Nation. Let's 
prove that we can put nutritious foods in front of these kids 
and they'll eat them. But, we're going to have to work at it.
    One thing we found, for example, Mr. Chairman, was, milk 
wasn't that appealing to these kids--they would go for those 
sugar-filled juices, in a second--unless you put it in the 
right container. Give them those little jugs, they grab them. 
It's about packaging and marketing. And I hate to concede that 
point, because it seems like an unnecessary expense and more 
plastic in the environment, but, at the end of the day, it 
worked.


                           prepared statement


    So, we have to start thinking more sensibly about how we 
move the Federal programs, whether it's the WIC program or the 
school lunch program. Our feeding--we feed a lot of people in 
this country through the Federal Government, and we can do a 
much better job.
    I'm glad we're having this hearing. Thank you.
    [The statement follows:]

            Prepared Statement of Senator Richard J. Durbin

    Chairman Harkin, Senator Brownback, I am pleased to join you today 
to discuss the important issue of childhood obesity. There's been 
considerable upheaval in the world the last few days and weeks, but the 
issue of children's health should always be a priority for us.
    I welcome Chairman Martin of the FCC and Commissioner Leibowitz of 
the FTC, two agencies under the jurisdiction of the Financial Services 
and General Government Appropriations Subcommittee. I also welcome Dr. 
Gerberding of the CDC and the witnesses on our second panel, 
particularly Mark Firestone, Vice President of Illinois-based Kraft 
Foods.
    Childhood obesity in the Unites States has tripled in the last 40 
years, putting children at unprecedented risk for lifetime struggles 
with an array of chronic diseases. The problem of obesity in America 
will not be solved overnight. But slowly, we're starting to see adults 
and children making efforts to be more active and to eat healthier 
foods.
    For example, in 2003, I worked with Illinois schools to provide 
healthier lunch choices for students. The schools used different 
strategies to promote better food choices among students. The schools:
  --Introduced healthier food choices,
  --Changed packaging and pricing,
  --Promoted fruits and vegetables, and
  --Increased accessibility of school breakfast.
    Before the changes, kids could choose between pizza and burgers for 
lunch--too often their first meal of the day. After the changes, 
students in 12 different Chicago-area schools had the option of a salad 
bar with healthy fruits and vegetables or a warm breakfast to start 
their day.
    These small changes made a tremendous impact on kids' food choices. 
With support from the Robert Wood Johnson Foundation and Action for 
Healthy Kids, these changes made Illinois schools a model for other 
schools. Since then, Action for Healthy Kids continues to help schools 
in Illinois and nationwide to implement changes promoting healthier 
eating.
    It would be a mistake, though, to ignore the rest of the 
environment kids are growing up in. The environment is a part of the 
problem--but ultimately it can also be a part of the solution.
    Marketing and advertising is inescapable in our day-to-day lives. 
We're no longer just talking about commercial breaks between kid's 
cartoons. We're seeing product placement in video games and movies, 
Internet content flooded with commercial messages, and even ads on cell 
phones.
    The pervasiveness of advertising in America has a huge influence on 
kids. They simply haven't developed the cognitive skills to tell the 
difference between advertising and entertainment. As we all know, kids 
are also are more easily persuaded by sophisticated ads, celebrity 
endorsements, and flashy packaging.
    Since the Surgeon General issued a health warning about smoking in 
1964, the number of smokers in the United States has decreased by 50 
percent. We have taken many steps in our fight against tobacco: looking 
at what companies are doing, limiting advertisements, providing 
cessation services, and educating families and communities. A similar 
comprehensive approach may be useful in our fight against childhood 
obesity. It is going to take the commitment of government, communities, 
families, and industry to make a dent in this alarming trend.
    Recent industry efforts are encouraging. Several companies have 
come together with the Better Business Bureau to make commitments to 
change the way they market food to children.
    Kraft and McDonald's, two Illinois companies, have made promising 
commitments under that initiative to limit advertising to children to 
only the healthiest foods. I welcome Kraft here today as part of our 
second panel. I think Kraft and other companies deserve recognition for 
voluntarily changing the way they do business in the interest of 
children's health.
    Viacom, also a witness before us today, devotes air time to 
encourage kids to be active. In fact, this Saturday Nickelodeon will 
actually go completely off the air for 3 hours to encourage kids to get 
outside and play. Let's all hope for good weather on Saturday!
    These efforts are clearly a big step in the right direction. But 
the question we're here to answer today is--will it be enough to make a 
difference? How can we work together to make even stronger commitments 
to limiting kids' exposure to unhealthy messages and promoting healthy 
lifestyles?
    I look forward to hearing our witnesses' testimony today and 
hearing the views of my colleagues. Thank you.

    Senator Harkin. I'm glad you mentioned the WIC program, 
because, again, in our reauthorization bill next year, I can 
tell you that there are forces at work to get white potatoes to 
put into the WIC program. Be on guard.
    Senator Durbin. Can I mention one? I forgot to mention the 
Robert Wood Johnson Foundation and Action for Healthy Kids have 
really been helpful on the school lunch program.
    Senator Harkin. Yeah. Very good.
    Well, thank you all very much. As you can see, there is a 
great deal of interest on our committee and among others on 
this issue. And I can tell you, just from talking to other 
Senators and stuff, I know that their--the interest level and 
the attention is going to be focused very high on this.
    So, we have two panels. The first panel, we're honored to 
have Dr. Julie Gerberding, the head of the Centers for Disease 
Control and Prevention; Kevin Martin, the Chairman of the 
Federal Communications Commission; and Mr. Jon Leibowitz, 
Commissioner of the Federal Trade Commission.
    We thank you all for being here. Again, your statements 
will all be made a part of the record.
    I will go in, just, the order I just announced here, so 
we'll start with Dr. Gerberding, go to Mr. Martin, and then go 
to Mr. Leibowitz.
    And, Dr. Gerberding, welcome again to the subcommittee 
here----
    Dr. Gerberding. Thank you.
    Senator Harkin [continuing]. Subcommittees, I should say.
STATEMENT OF JULIE GERBERDING, M.D., M.P.H., DIRECTOR, 
            CENTERS FOR DISEASE CONTROL AND PREVENTION, 
            DEPARTMENT OF HEALTH AND HUMAN SERVICES
    Dr. Gerberding. Thank you. It is a privilege to appear in 
front of both of these committees and to have a chance to 
address an issue that's important. And I really thank you all 
for making this visible, especially when there are so many 
other important things on your agenda this week. And I 
especially thank Senator Harkin for his fruits and vegetable 
program on the desktops of children in school. You know, that's 
one of our favorite projects.
    As a CDC Director, I wake up every morning with one issue 
on my mind, and that is, Why aren't we the healthiest Nation? 
We spend the most money, but we're not the healthiest. We're 
37th in the world in health, and we spend more than virtually 
every other developed country to earn that pitifully poor 
ranking.
    One of the reasons why we're not the healthiest is because 
our children are at high risk for chronic diseases, and they 
are moving in a direction where, as Senator Brownback said, we 
may see children whose life expectancies are shorter than our 
own.
    You've presented the statistics already, just showing the 
percentage of our children who are obese over the past several 
years. I also want to emphasize that this is not something that 
affects all children equally. We see health disparities here--
significantly greater rates of obesity in children of Mexican-
American and African-American origin compared to white 
children--but all children are affected by this problem.
    We have lots of statistics, and we can describe this in 
great detail, some horrifying statistics about the poor health 
status of our children. But, I think it's important to think of 
this as more than statistics; these are about individual 
children, the children that I see when I visit schools, and the 
children across America--12 million children, to be exact--who 
are obese.
    If you're an 8-year-old today, you have more than a 30-
percent chance of having diabetes in your life. If you are an 
obese 8-year-old today, you have a 70 percent chance of having 
a second risk factor for cardiovascular disease, and a 25-
percent chance of having a third risk factor for cardiovascular 
disease. So, we are conditioning our children's health status 
now at a point where they don't even have a chance to look 
forward to a healthy life. And it a national catastrophe and a 
major reason for our national health shortage.
    So, children have poor health and poor health prognosis in 
America, but what they don't have is the maturity and judgment 
to make decisions about healthy foods, themselves. You've shown 
this graphic that reveals the toxic food environment present on 
our children's television viewing, but this is just a piece of 
the picture. Children are exposed to these kinds of 
advertisements on the Internet, and their parents are exposed 
to them through a variety of channels and media; and, of 
course, that influences food choices available in the home, as 
well.
    So, we've got our work cut out. And one of the things that 
CDC is doing is to create a comprehensive approach to 
children's health. We will be soon rolling out our Children's 
Health Goal Plan, which lays out what we think are the 
priorities for action. But, those actions do include, number 
one, finding the evidence, understanding what is the 
relationship between advertising choices and obesity; more 
importantly, what is the effect of changing that and doing 
something about it?
    We also need standards and agreement across all of our 
government agencies on what constitutes a healthy choice so 
that we're all identifying and thinking about the same thing. 
And we can use that consistently across industry and families.
    We need regulation. Whether or not that's self-regulation 
or imposed regulation, I understand, is the big debate and the 
subject of this committee. But, there's clear indicators that 
we've got to do more than we're doing, and we need to have 
those apply not just to the television industry or the food and 
beverage industry, but across a much broader swath, where 
children are exposed. And, of course, if we do that, we have to 
have a means of accountability and enforcement. And, I think, 
most importantly, we need to have measures of success so that 
we can see what's working, what isn't working, and act 
effectively on behalf of our children.

                           PREPARED STATEMENT

    So, from a CDC perspective, I'll just summarize by saying 
this is job one for our Nation, this is our future. We owe it 
to our children, and we've got to do a lot more than we've been 
doing to get this problem under control.
    [The statement follows:]

             Prepared Statement of Dr. Julie L. Gerberding

Introduction
    Distinguished Chairmen, Members of the Committees, thank you for 
the opportunity to provide this statement for the record for today's 
hearing on food marketing to youth. I am Dr. Julie Louise Gerberding, 
Director of the Centers for Disease Control and Prevention (CDC), and 
Administrator of the Agency for Toxic Substances and Disease Registry 
(ATSDR), within the U.S. Department of Health and Human Services. My 
statement provides you with an overview of the obesity epidemic 
including updated surveillance data on youth overweight and obesity; 
the role of a healthful diet in obtaining and maintaining healthy 
weight; the effects of food marketing on youth dietary habits; and a 
description of CDC's resources to combat the childhood obesity 
epidemic.
Youth Obesity Epidemic
    To understand the extent of the youth obesity epidemic, we need to 
grasp the trend in youth weight gain over the past few decades. 
National Health and Nutrition Examination Survey (NHANES) data revealed 
that between 1976 and 1980 the prevalence of overweight among youth 
aged 2-5 years was 5 percent, for youth 6-11 years it was 6.5 percent, 
and for youth aged 12-19 year it was 5 percent. The most recent data 
available from NHANES (2003-2006) show the prevalence of overweight 
among America's youth to be 12.4 percent for 2-5 year olds, 17 percent 
for 6-11 year olds and 17.6 percent for 12-19 year olds. These data 
point to an alarming rate of obesity among youth in all age groups. To 
determine whether a child was overweight CDC determined their body mass 
index (BMI), which is a number calculated from a child's weight and 
height.
    BMI is an accepted screening tool for the initial assessment of 
body fatness for children, but it is not a diagnostic measure. It is 
also an acceptable tool to determine overweight status of children and 
youth at the population level. If a child's BMI was at or above the 
95th percentile the child was classified as overweight or at risk for 
obesity. Recently, however, an expert Committee on Assessment, 
Prevention and Treatment, of Child and Adolescent overweight and 
Obesity \1\ has recommended classifying children whose BMI is at or 
above the 95th percentile for age and gender on the CDC growth charts 
as obese. This is only a change in the terminology.
---------------------------------------------------------------------------
    \1\ The committee was supported by the American Medical 
Association, the Health Resources and Service Administration and the 
Centers for Disease Control and Prevention, to figure out solutions for 
the growing number of children who are severely overweight. It included 
representatives from 15 medical societies such as the American Academy 
of Pediatrics and the National Medical Association.
---------------------------------------------------------------------------
    Obesity among youth has emotional, social and physical consequences 
and is associated with early onset of chronic diseases such as 
arthritis, asthma, type 2 diabetes, and heart disease. In fact, 61 
percent of obese children aged 5-10 years old have one or more risk 
factors for heart disease and 27 percent have two or more risk factors 
for heart disease. (Freedman DS et al. Pediatrics 1999;103:1175-8.)
    Further, high childhood BMI is associated with an increased 
likelihood of adult obesity. Adult overweight and obesity increases the 
risk of many diseases and chronic health conditions, including coronary 
heart disease, stroke, type 2 diabetes, and some cancers. In 2001 
dollars, obesity-associated annual hospital costs among youth were 
estimated to have more than tripled from $35 million in 1979-1981 to 
$127 million in 1997-1999. (Wang G and Dietz WH. Economic Burden of 
Obesity in Youths Aged 6 to 17 years: 1979-1999. Pediatrics. 
2002;109;e81.) In 2000, the total direct and indirect healthcare costs 
(which include medical costs and days lost because of illness, 
disability, or premature death) from obesity for all ages was estimated 
to be $117 billion. (Wolf, AM, Manson JE, Colditz GA. The Economic 
Impact of Overweight, Obesity and Weight Loss. In: Eckel R, ed. 
Obesity: Mechanisms and Clinical Management. Lippincott, Williams and 
Wilkins; 2002)
    One of the national Healthy People 2010 objectives is to ``reduce 
the proportion of children and adolescents who are overweight or 
obese'' to the target of 5 percent. Not since 1980 has the prevalence 
of overweight and obesity among youth been at or near this target.
    Obesity is often the result of an improper balance between energy/
calories consumed (poor diet) and energy expended (physical 
inactivity). The increasing rate of obesity among the Nation's youth 
demonstrates the necessity of engaging in a comprehensive approach 
focused on policy and environmental changes that help make the healthy 
choice the easy choice when it comes to nutrition and physical 
activity. Appropriate policy and environmental changes can be effective 
in increasing the consumption of fruits and vegetables, increasing 
physical activity, increasing the initiation and duration of 
breastfeeding, reducing television viewing, reducing the consumption of 
sugar sweetened beverages, and reducing calorie dense-nutrient poor 
food intake.
Role of Healthy Diet
    Healthy eating in childhood and adolescence is important for 
overall healthy growth and development and can prevent health problems 
such as obesity, dental caries, and iron deficiency anemia as well as 
positively affect mental acuity and academic performance. The diets of 
most young people, however, do not meet the recommendations set forth 
in the Dietary Guidelines for Americans. Of U.S youth aged 12-18, only 
39.1 percent meet the total grain recommendation and only 3.4 percent 
meet the recommendations for whole grain intake. (USDA, Grain 
Consumptions by Americans, Nutrition Insights 32, August 2005.) 
According to CDC's National Youth Risk Behavior Survey, in 2007, only 
21.4 percent of high school students reported eating five or more 
servings of fruits and vegetables (when fried potatoes and potato chips 
are excluded) per day during the past 7 days. Only 14.1 percent drank 
three or more glasses per day of milk (Morbidity and Mortality Weekly 
Report 2006; 57 SS04; 1-131.)
CDC Efforts to Address Food Marketing to Youth and Childhood Obesity
    In 2004, CDC commissioned IOM to conduct a study on food marketing 
to children. One of the conclusions of the study was that, ``public 
policy programs and incentives do not currently have the support or 
authority to address many of the current and emerging marketing 
practices that influence the diets of children and youth.'' CDC is 
exploring options to identify and assess the feasibility of 
implementing policy and environmental change strategies aimed at both 
reducing television viewing as well as positively influencing those 
products that are marketed to youth. CDC is working closely with the 
Academy for Educational Development (AED) to develop a research plan 
around marketing to children. Based on recommendations from the IOM 
committee members, the plan will focus on 8-12 year olds and on 
vegetables, in particular, because consumption of vegetables is lower 
than consumption of fruits.
    In 2005, CDC created the National Center for Health Marketing in 
response to communication innovations to revolutionize the way people 
receive and use health information and interventions to make healthy 
decisions. To increase the reach and impact of health information by 
understanding when, where, and how people need it, CDC is exploring the 
potential for conducting health literacy and content analysis research 
on food marketing to youth on television and through other 
communication channels including the Web, social networks, and new 
media.
    In 2007, CDC and partners launched Fruits & Veggies--More 
MattersTM, a marketing and communication strategy designed 
to influence healthy dietary choices to replace high calorie dense 
foods. The National Fruit and Vegetable Alliance, CDC and Produce for 
Better Health Foundation (PBH) are leading Fruits & Veggies--More 
MattersTM, which is a health initiative that consumers will 
see in stores, online, at home, and on packaging. It replaces the 
existing 5 A Day awareness program and will leverage the 5 A Day 
heritage and success to further inspire and support consumers to eat 
more fruits and vegetables, showcasing the unrivaled combination of 
great taste, nutrition, abundant variety, and various product forms 
(fresh, frozen, canned, dried, and 100 percent juice). It also will 
build upon the body of science that indicates increased daily 
consumption of fruits and vegetables may help prevent many chronic 
diseases.
    CDC's School Health Policies and Program Study is a national survey 
conducted to assess school health policies and practices at the State, 
district, school, and classroom levels. The 2006 study showed that many 
schools are taking a leadership role in marketing healthy food options 
to their students. A majority of the schools in the study gave menus to 
their students to promote the school nutrition services program (95.6 
percent), placed posters or other materials promoting healthy eating 
practices in the cafeteria area (82.7 percent), included articles about 
the school nutrition services program in their school publications 
(68.0 percent), and included nutrition services topics during school-
wide announcements (53.3 percent). However, one third of all school 
districts allowed soft drink companies to advertise soft drinks in 
school buildings (35.8 percent) and almost half of all school districts 
allowed soft drink companies to advertise on school grounds, including 
on the outside of school buildings and on playing fields (46.6 
percent). Additionally, less than 25 percent of school districts 
prohibit schools from advertising for candy, fast food restaurants, or 
soft drinks on school property.
    In addition to these efforts, CDC has a number of initiatives and 
programs under way to address childhood obesity. They include programs 
in education, surveillance of youth nutrition behaviors and obesity 
rates, surveillance of school policies and programs, translation and 
promotion of effective intervention strategies, and policy and Web-
based tools for healthy eating, physical activity, and obesity.
CDC's National Coordinated School Health Program to Improve Physical 
        Activity, Nutrition, and Prevent Tobacco Use Among Youth
    CDC provides funding for 22 State education agencies (average 
award: $411,000) and 1 tribal government ($275,000) to help school 
districts and schools implement a Coordinated School Health Program 
(CSHP), and, through this approach, increase effectiveness of policies, 
programs, and practices to promote physical activity, nutrition, and 
tobacco-use prevention among students.
    A CSHP is a planned, organized set of health-related programs, 
policies, and services coordinated to meet the health and safety needs 
of K-12 students at both the school district and individual school 
building levels. CSHP is comprised of multiple components that can 
influence health and learning. These include physical education; health 
education; health services; nutrition services; counseling and 
psychological services; a healthy school environment; family/community 
involvement; and health promotion for staff. Active coordination is 
needed to engage school staff, implement district/school priority 
actions; assess programs and policies; create a plan based on data and 
sound science; establish goals; and evaluate efforts.
CDC's National Nutrition and Physical Activity Program to Prevent 
        Obesity
    CDC is funding 23 States (average award $750,000) to improve 
healthful eating and physical activity to prevent and control obesity 
and other chronic diseases by building and sustaining statewide 
capacity and implementing population-based strategies and 
interventions. Funded State programs develop strategies to leverage 
resources and coordinate statewide efforts with multiple partners to 
address all of the following principal target areas: increase physical 
activity; increase the consumption of fruits and vegetables; increase 
breastfeeding initiation, duration and exclusivity; reduce the 
consumption of high energy dense foods; decrease the consumption of 
sugar sweetened beverages; and decrease television viewing.
    From individual behavior change to changes in public policy, State 
efforts aim to engage multiple levels of society including individual, 
family and community settings. Each State funded by the Nutrition and 
Physical Activity Program to Prevent Obesity and Other Chronic Diseases 
uses the Social-Ecological Model to more fully understand the obesity 
problem in that State. This model serves as a reminder to look at all 
levels of influence that can be addressed to support long-term, 
healthful lifestyle choices. State efforts include making policy and 
environmental changes to encourage access to healthy foods and places 
to be active, and strengthening obesity prevention and control programs 
in preschools, child care centers, work sites, and other community 
settings. All funded States will continue to evaluate their 
interventions to determine their effectiveness and to guide future 
efforts.
Supporting Communities through the Steps Program
    The Steps Program is a critical part of CDC's national efforts to 
address the urgent realities of chronic disease and obesity. Since 
2003, Steps has supported local communities to implement evidence-based 
interventions in community-based settings including schools, 
workplaces, community organizations, health care settings, and 
municipal [city/county] planning, to achieve local changes necessary to 
prevent chronic diseases and their risk factors. Special focus has been 
directed toward populations with disproportionate burden of disease and 
lack of preventive services. In fiscal year 2008, CDC is supporting 21 
communities through cooperative agreements with three States (average 
award $1.580 million), five local urban health departments (average 
award $1.256 million), and two tribal organizations (average award 
$747,000). In addition, CDC is supporting 14 communities through new 
cooperative agreements with two States, two local urban health 
departments, and two tribal organizations and 40 additional communities 
through new cooperative agreements with national organizations.
    As part of the new grant strategy, CDC will support 50 Steps 
Community Grants in fiscal year 2009. Communities will receive funds to 
spark local-level action, change community conditions to reduce risk 
factors, establish and sustain state-of-the-art programs, test new 
models of intervention, create models for replication, and help train 
and mentor additional communities. Tools, resources, and training will 
be provided to community leaders and public health professionals to 
equip these entities to effectively confront the urgent realities of 
the growing national crisis in obesity and other chronic diseases in 
their communities.
CDC Surveillance Programs
    CDC monitors the Nation's health through surveillance programs in 
order to accomplish its mission to promote health and quality of life 
by preventing and controlling disease, injury, and disability.
    Through its ongoing National Health and Nutrition Examination 
Survey, CDC produces nationally representative surveillance data on the 
prevalence of overweight and obesity among children and adolescents 
based on measured height and weight, as well as on their physical 
activity and dietary behaviors. (Additional information available at 
www.cdc.gov/nchs/nhanes.htm.)
    In addition, CDC's biennial Youth Risk Behavior Survey provides 
national, State, and city data on self-reported height and weight, 
physical activity, physical education, and dietary behaviors among high 
school students. (Additional information available at http://
www.cdc.gov/HealthyYouth/yrbs/)
    CDC's School Health Policies and Program Study (SHPPS) is a 
national survey periodically conducted to assess school health policies 
and programs of State education agencies and of nationally 
representative samples of school districts, schools, and physical 
education and health education classrooms. SHPPS provides national data 
on what schools are doing in relation to physical education, after 
school physical activity programs, recess, nutrition education, school 
food service, and vending machine policies and practices. (Additional 
information available at http://www.cdc.gov/HealthyYouth/shpps/)
    CDC's School Health Profiles survey, conducted every other year, 
tells us about the extent to which schools are implementing physical 
education, physical activity, and nutrition-related policies and 
practices in different States and cities. (Additional information 
available at http://www.cdc.gov/HealthyYouth/profiles/)
    CDC's Pediatric Nutrition Surveillance System (PedNSS) is a child-
based public health surveillance system that describes the nutritional 
status of low-income U.S. children who attend federally-funded maternal 
and child health and nutrition programs. PedNSS provides data on the 
prevalence and trends of nutrition-related indicators. (http://
www.cdc.gov/pednss/index.htm)
Tools to Help Schools and Community-based Organizations Promote Healthy 
        Eating
    CDC has developed, and is continuing to develop, a variety of tools 
that schools and community based organizations can use to implement 
policies and practices. Examples include:
  --The Guide to Community Preventative Services: Review of 
        Interventions that Support Healthy Weight, which is a 
        systematic review of the effectiveness of selected population-
        based interventions aimed at supporting healthful weight among 
        children, adolescents, and adults; http://
        www.thecommunityguide.org/obese/.
  --Guidelines for School and Community Programs to Promote Lifelong 
        Healthy Eating Among Young People that identify the most 
        effective policies and practices schools can implement to help 
        young people adopt and maintain healthy eating habits; http://
        www.cdc.gov/mmwr/preview/mmwrhtml/00042446.htm.
  --CDC's School Health Index for Physical Activity and Healthy Eating, 
        a widely used self-assessment and planning tool, enables 
        schools to identify the strengths and weaknesses of their 
        health promotion policies and programs, develop an action plan 
        for improving student health, and involve teachers, parents, 
        students, and the community in improving school policies and 
        programs; http://apps.nccd.cdc.gov/shi/default.aspx.
  --Fit Healthy and Ready to Learn, a school health policy guide, 
        developed by the National Association of State Boards of 
        Education with CDC support, that provides education 
        policymakers and administrators with sample physical activity 
        and nutrition policies and information to support the policies;
  --Making It Happen--School Nutrition Success Stories (MIH), a joint 
        product of CDC and USDA, tells the stories of 32 schools and 
        school districts that have implemented innovative strategies to 
        improve the nutritional quality of foods and beverages offered 
        and sold on school campuses. The most consistent theme emerging 
        from these case studies is that students will buy and consume 
        healthful foods and beverages--and schools can make money from 
        healthful options; http://www.cdc.gov/healthyyouth/nutrition/
        Making-It-Happen/about.htm.
  --The Health Education Curriculum Analysis Tool which is a user-
        friendly checklist designed by CDC to help schools select or 
        develop curricula based on the extent to which they have 
        characteristics that research has identified as being critical 
        for leading to positive effects on youth health behaviors. The 
        companion Healthy Eating Curriculum Analysis Tool will help 
        school districts promote healthy eating, sound nutrition, and 
        healthy dietary practices based on insights gained from 
        research and best practice, and; http://www.cdc.gov/
        HealthyYouth/HECAT/index.htm.
  --The CDC Program Technical Assistance Manual, was created to serve 
        CDC's State and community partners as they develop, implement, 
        and evaluate an array of nutrition and physical activity 
        initiatives that aim to prevent and control obesity and other 
        chronic diseases.
  --We Can! (Ways to Enhance Children's Activity & Nutrition), a 
        national NIH-supported public education program for reaching 
        parents and caregivers of children ages 8-13 in home and 
        community settings--provides educational materials and 
        activities to encourage healthy eating, increase physical 
        activity, and reduce ``screen-time'' among youth. NIH and CDC 
        are working together to promote We Can! and CDC's school health 
        tools (e.g., the School Health Index) and resources to 
        partners; nongovernmental organizations; State departments of 
        education and departments of health; schools; and community 
        sites.
    I have briefly described the efforts of CDC in this area; we are 
but one of many programs within the Department of Health and Human 
Services focusing on this epidemic. For example, CDC is an active 
member in ``Healthy Youth for a Healthy Future,'' the Secretary's 
Childhood Overweight and Obesity Prevention Initiative that is 
spearheaded by the Acting Surgeon General, Rear Admiral Steven Galson. 
Uniting programs from across the Department, the Childhood Overweight 
and Obesity Prevention Council has implemented an action plan that 
leverages and enhances programs that prevent childhood overweight and 
obesity. The Council synergizes Department-wide prevention efforts, 
including community interventions and evaluation, outreach and 
services, and education and research. The Council's efforts have 
broadened the reach of individual agency campaigns.
    CDC also supports the Surgeon General's Outreach Tour under the 
``Healthy Youth for a Healthy Future'' campaign which is traveling from 
State to State, meeting with communities to recognize and bring 
attention to effective prevention programs that motivate organizations 
and families to work together on this issue. The tour focuses on three 
themes: Help Children Stay Active, Encourage Health Eating Habits, and 
Promote Healthy Choices. During the visits, the focus is not only about 
the importance of childhood overweight and obesity prevention, but also 
on model healthy behaviors for children of all ages realizing these are 
significant teaching moments that will help them develop healthy habits 
to last a lifetime.
Conclusion
    No single cause or factor is to blame for the epidemic of obesity 
among children and adolescents. Indeed, many factors have contributed 
to the unfavorable trends in physical activity and nutrition that have 
fueled the obesity epidemic.
    We have learned a great deal about effective strategies for 
promoting physical activity and healthy eating among young people. We 
know that no one strategy alone will be sufficient to slow or reduce 
the obesity epidemic. Our chances for success will be greater if we use 
multiple strategies to address multiple factors that contribute to the 
imbalance between calorie consumption and physical activity and if we 
involve multiple sectors of society at the community, State, and 
national levels.
    CDC is committed to doing all that we can to help our young people 
enjoy good health now and for a lifetime. I thank you for your interest 
and the opportunity to share information about the childhood obesity 
epidemic, the importance of good nutrition in combating the epidemic 
and an overview of CDC's activities. I would be happy to answer your 
questions.

    Senator Harkin. Thank you very much, Dr. Gerberding, and I 
look forward to working with you and the CDCP in the next 
couple of years as we do this healthcare reform, and to make 
sure that this is up front, a big part, an important part of 
this healthcare reform that we're talking about.
    Now we'll turn to Mr. Martin, the head of the--Chairman of 
the Federal Communications Commission, the FCC, before we go to 
the FTC.
    Mr. Martin.
STATEMENT OF HON. KEVIN J. MARTIN, CHAIRMAN, FEDERAL 
            COMMUNICATIONS COMMISSION
    Mr. Martin. Thank you. Good morning, Chairman Durbin, 
Chairman Harkin, and Senator Brownback. I appreciate the 
opportunity to speak to you today about this important issue 
that is facing American families, the impact of media on the 
rising rate of childhood obesity.
    In recent years, the rate of childhood obesity has gone in 
only one direction, and that is up. And, understandably, the 
concerns of parents, medical experts, and public officials has 
risen, as well.
    Last September, the Institute of Medicine found that one-
third of American children are either obese or at risk for 
obesity. And this is consistent with the Centers for Disease 
Control's findings that, since 1980, the number of overweight 
children ages 6 to 11 has doubled, and the number of overweight 
adolescents has tripled. Childhood obesity has gone from a 
national problem to a point of crisis.
    Parents, of course, are the first line of defense, but we, 
in the government and in the industry, must make sure that they 
have the tools that they need to ensure their children's 
welfare. As a parent, I already know the enormous influence 
that media has on our children. Its impact really can't be 
overstated.
    According to Nielsen Media Research for the 2004-2005 
season, an average American household has the television turned 
on more than 8 hours a day, with children watching between 2 
and 4 hours every day. And recent studies have found that even 
the youngest children are exposed to a lot of television. 
Almost one-half--43 percent--of children under the age of two 
watch TV every day. According to Kaiser Family Foundation, by 
the time a child enters the first grade, they will have spent 
the equivalent of 3 school years in front of the television.
    In the Children's Television Act, Congress recognized the 
unique role television and the media can have on children. 
Specifically, Congress noted that by the time the average child 
is 18, he or she will have spent between 10,000 and 15,000 
hours watching television and will have been exposed to more 
than 200,000 commercials. Congress also noted that it is well 
established by scientific research that children are uniquely 
susceptible to the persuasive messages contained in television 
advertising.
    Given the enormous impact of the media--specifically, 
television--on children, the Commission, along with Senator 
Harkin and Senator Brownback, convened the Joint Task Force on 
Media and Childhood Obesity. The task force sought to bring 
together government officials, media companies, advertisers, 
and the food and beverage industry to work on behalf of 
America's children. I appreciate the leadership of Senators 
Brownback and Harkin and all my colleagues on the Commission. 
And I particularly want to recognize the hard work and many 
hours volunteered by Gary Knell, of Sesame Workshop, who led 
the task force efforts.
    While the task force succeeded in producing some 
significant voluntary commitments, ultimately it did not reach 
an agreement on two key issues: one, a uniform standard for 
what constitutes healthy versus unhealthy foods; and, two, the 
willingness of most media companies to place any limit on the 
advertising of unhealthy foods on children's programming.
    Several good companies did make significant voluntary 
commitments. For example, 15 of the largest food companies and 
manufacturers--beverage manufacturers, including Kraft and 
Kellogg--agreed to curtail advertising of ``unhealthy food'' to 
children under age 12. As described in more detail by some of 
the other witnesses, although the food and beverage industry 
have made some significant steps in the right direction, there 
is no uniform agreement among the companies as to the 
definition of what constitutes ``healthy foods.''
    On the media side, Disney and Ion have made the most 
aggressive commitments. The Disney Company's Healthy Kids 
Initiative set a new standard for the food served in the Disney 
parks, they disallowed the licensing of Disney characters to 
foods that do not meet strict nutritional standards, and they 
disallowed the promotion of foods on the Disney Channel that do 
not meet these same standards.
    Ion media's Qubo was referred to as the ``gold standard'' 
by the children's advocates, for their leadership. Ion has 
committed to licensing their characters for use with healthy 
foods, and they agreed to no longer accept advertising for any 
unhealthy foods targeted at children.
    Unfortunately, not all of the participants in the Obesity 
Task Force were as forthcoming in their effort to protect 
American children. I was particularly disappointed at the media 
companies who made no solid commitments in this area. For 
example, some companies only agreed to limit character usage 
while leaving a major loophole for special occasions. That 
leads one to wonder, ``What is a special occasion?'' May a 
character that endorses candy or cakes for birthdays, 
President's Day, Valentine's Day, St. Patrick's Day, Easter, 
Halloween, Thanksgiving, Christmas, and Hanukkah all be 
exempted from their voluntary commitment?
    Even more troubling was the majority of media companies' 
refusal to agree to any kind of limit on advertising toward our 
children. Patty Miller summarizes the majority of media 
companies as being, quote, ``absent from any attempt to solve 
this problem, and refusing to play a role in protecting 
children from the advertising of unhealthy food.''
    As a result, all of the public-health and child-advocacy 
groups have asked Congress to adopt legislation mandating that 
at least 50 percent of all food advertising to children on 
broadcast and cable television be devoted to healthy food 
products.
    In the past, Congress has anticipated that children would 
be particularly susceptible to advertising, and put certain 
protections in place. Indeed, in the Children's Television Act, 
Congress enacted specific limits on the amount of advertising 
that could be shown during children's programming. The 
Children's Television Act requires that commercial TV 
broadcasters and cable operators limit the amount of 
commercials in children's programming to no more than 10\1/2\ 
minutes per hour on weekends and 12 minutes per hour on 
weekdays.
    Finally, the lack of action by the media industry creates a 
disincentive for those companies that have volunteered for such 
limits, like Ion and Kraft. Without a broader commitment from 
our media companies, these companies are actually put at a 
competitive disadvantage.
    While it was, and always is, my hope that we will not have 
to resort to actual requirements--and I strongly encouraged the 
media companies involved in the task force to propose some 
voluntary limits on advertising targeted at our children--in 
the end, no widespread voluntary commitment on behalf of the 
media industry was forthcoming. On the voluntary side, I am 
left to conclude that, sadly, no limit was even close to being 
presented.
    In reference to Senator Brownback's comments about wanting 
to ask what the solution should be, I would highlight that I 
think that there's one key ingredient: any remedy must be 
targeted to both broadcast and cable outlets on the media side. 
According to a recent Kaiser Family Foundation study, the three 
ad-supported children's cable networks have 32 percent of their 
advertising time dedicated towards advertising for food, 
compared to only 13 percent of broadcast networks, and they 
have twice as many ads--8.8 versus 4.8 ads--again, targeted for 
foods per hour. So, I think that leaves us with the absolute 
conclusion that any kind of a solution must be comprehensive as 
you look forward to what the Congress should now be addressing.

                           PREPARED STATEMENT

    Again, I want to thank you all for your leadership on these 
efforts and your support for the Commission and its attempt on 
the Childhood Obesity Task Force, and I look forward to working 
with you all as you go forward to try to improve the health of 
our children.
    [The statement follows:]

               Prepared Statement of Hon. Kevin J. Martin

    Good morning, Chairman Durbin, Chairman Harkin, Ranking Member 
Brownback, Ranking Member Specter, and Members of the Committee.
    I appreciate the opportunity to speak to you today about an 
important issue facing American families; the impact of the media on 
the rising rate of childhood obesity.
    I particularly want to thank Senator Harkin and Senator Brownback 
for their leadership, support and dedication to these issues.
    In recent years the rate of childhood obesity has gone in only one 
direction--up. Understandably, the concern of parents, medical experts 
and public officials has risen as well.
    Last September, the Institute of Medicine found that one-third of 
American children are either obese or at risk for obesity. This is 
consistent with the Center for Disease Control's finding that since 
1980 the number of overweight children ages 6-11 has doubled and the 
number of overweight adolescents has tripled. To quote the American 
Academy of Pediatrics, the trends of children becoming overweight and 
inactive ``pose an unprecedented burden in terms of children's health 
as well as present and future health care costs.'' Childhood Obesity 
has gone from a national problem to a point of crisis.
    Parents of course are the first line of defense. But we in 
government and in industry must make sure they have the tools they need 
to ensure their children's welfare.
    A study in the Journal of the American Dietetic Association 
recently outlined two important ways to reduce childhood obesity. The 
first is that parents should become more aware of children's 
nutritional needs. And the second, which goes to the heart of this 
hearing today, is that parents should reduce the amount of time their 
children spend watching television.
    As a parent, I already know the enormous influence the media has on 
our children. Its impact can't really be overstated. According to 
Nielsen Media Research (for the 2004-2005 season), an average American 
Household has the television turned on more than 8 hours a day, with 
children watching between 2 and 4 hours every day.
    And recent studies have found that even the youngest children are 
exposed to a lot of television. Almost one-half (43 percent) of 
children under the age of two watch TV every day. One-quarter (26 
percent) of these youngest children even have a television in their 
bedroom.
    According to the Kaiser Family Foundation, by the time children 
enter the first grade, they will have spent the equivalent of three 
school years in front of the TV.
    In the Children's Television Act, Congress recognized the unique 
role television and the media can have on children. Specifically, 
Congress noted that, by the time the average child is 18 years old, he 
or she has spent between 10,000 to 15,000 hours watching television and 
has been exposed to more than 200,000 commercials. Congress also noted 
that it is well established by scientific research that children are 
uniquely susceptible to the persuasive messages contained in television 
advertising. Indeed, the Kaiser Family Foundation found that children 
under 6 cannot distinguish between programming content and advertising. 
In addition, these kids cannot distinguish between marketing messages 
and their favorite show, especially when the ad campaigns feature 
favorite TV characters like Sponge Bob. And a report by the Institute 
of Medicine concluded that there is strong evidence that television 
advertising influences short-term food consumption patterns in children 
between the ages of 2 and 11.
    Given the enormous impact of the media--specifically television on 
children, the FCC along with Senators Harkin and Brownback convened the 
Joint Task Force on Media and Childhood Obesity (the ``Task Force''). 
The ``Task Force'' sought to bring together government officials, media 
companies, advertisers and the food and beverage industry to work on 
behalf of America's children.
    I appreciate the leadership of Senators Brownback and Harkin and my 
colleagues on the Commission, Commissioners Tate and Copps. I also want 
to thank all of the Task Force participants for dedicating their time, 
energy and efforts. In particular I want to recognize the hard work and 
many hours volunteered by Gary Knell of Sesame Workshop who led the 
Task Force's efforts.
    We cannot hope to truly address this problem without the 
participation of all those involved, the media, advertisers and the 
food and beverage industry. Indeed, this task force was founded on the 
notion that we all have a responsibility to promote and protect our 
children's welfare.
    While the Task Force succeeded in producing some significant 
voluntary commitments aimed at reducing the negative impact of the 
media on children's eating habits and increasing its positive influence 
on their behavior, ultimately it did not reach an agreement on two key 
issues: (1) a uniform standard of what constitutes healthy versus 
unhealthy foods; and (2) the willingness of most media companies to 
place any limit on the advertising of unhealthy foods on children's 
programs.
    Several food companies made significant voluntary commitments. For 
example, fifteen of the Nation's largest food and beverage 
manufacturers including Kraft Foods and Kellogg agreed to curtail 
advertising of ``unhealthy food'' to children under age twelve and 
others are reformulating current products. As described in more detail 
by some other witnesses, although the food and beverage industry have 
made some significant steps in the right direction there is no uniform 
agreement among the companies as to the definition of ``healthy 
foods.''
    On the media side, Disney and Ion have made the most aggressive 
commitments. The Disney company's Healthy Kids Initiative set new 
standards for the food served in Disney's parks, disallowed the 
licensing of Disney characters to foods that did not meet strict 
nutritional standards and disallowed the promotion of foods on the 
Disney Channel that do not meet those same standards.
    Ion media's Qubo was referred to as the ``gold standard'' by 
children's advocates for their leadership. Ion has committed to only 
licensing their characters for use with healthy foods and they agreed 
to no longer accept advertising for unhealthy food targeted at 
children.
    Several companies took significant steps to limit the licensing of 
their characters for use to promote unhealthy foods. Companies like 
Discovery Kids, Cartoon Network and Sesame Workshop announced 
commitments to license characters only to promote food and beverages 
that meet specific nutritional standards.
    Other media companies agreed to telecast public service 
announcements promoting healthy lifestyles. I applaud these 
developments.
    Unfortunately, not all participants in the Obesity Task Force were 
as forthcoming in their efforts to protect American children. I am 
particularly disappointed in those media companies who made no solid 
commitments in these areas.
    For example, some companies only agreed to limit character usage 
while leaving a major loop hole for ``special occasions.'' That leads 
one to wonder what is a special occasion? May a character then endorse 
candy or cakes for birthdays, President's Day, Valentine's Day, Saint 
Patrick's Day, Easter, Halloween, Thanksgiving, Christmas, and 
Chanukah?
    Even more troubling was the majority of media companies refused to 
agree to any kind of limit on advertising targeted toward our children. 
Patti Miller summarizes the majority of media companies as being 
``absent from any attempt to solve this problem'' and ``refusing to 
play a role in protecting children from the advertising of unhealthy 
food. As a result, all of the public health and child advocacy groups 
have asked Congress to adopt legislation mandating that at least 50 
percent of all food advertising to children on broadcast and cable 
television programming be devoted to healthy food products.
    In the past, Congress has anticipated that children would be 
particularly susceptible to advertising and thus put certain 
protections in place. Indeed, in the Children's Television Act, 
Congress enacted specific limits on the amount of advertising that 
could be shown during children's programming. The Children's Television 
Act requires that commercial TV broadcasters and cable operators limit 
the amount of commercials in children's programs to no more than 10 
minutes per hour on weekends and 12 minutes per hour on weekdays.
    In the United Kingdom, Ofcom has gone a step further than we have 
here in the United States. They recently implemented rules targeted at 
reducing the impact of advertising of high fat, salt and sugar (HFSS) 
food and beverages to children by banning such ads on children's 
television channels. In recent weeks, there has been some question as 
to whether children are still being exposed to these ads under the 
existing restrictions. Ofcom is reviewing the rules and will be 
releasing a report on how they might improve regulations to better 
accomplish their goals of reducing unhealthy advertising towards 
children.
    Finally, the lack of action creates a disincentive for those 
companies that have volunteered to such limits, like Ion and Kraft. 
Without a broader commitment from our media companies, these companies 
are actually put at a competitive disadvantage.
Conclusion
    A study published in the Official Journal of the American Academy 
of Pediatrics last year found that the overwhelming majority of food 
product advertisements seen on television were of poor nutritional 
content. The article stated that ``these findings will provide a 
benchmark against which future research can evaluate the commitments by 
food companies to change the nature of food advertising directed at 
America's children.'' As a result we will be able to measure our 
progress.
    While it was--and always is--my hope that we will not have to 
resort to actual requirements, and I strongly encouraged the media 
companies to propose some voluntary limitations on advertising 
targeting our children, in the end no widespread voluntary commitment 
on behalf of the media industry was forthcoming. On the voluntary side, 
I am left to conclude that, sadly, no limit was even close to being 
presented.
    Thank you again for your leadership on this issue. I look forward 
to working with you to improve the health of our children.

    Senator Harkin. Thank you very much, Mr. Martin, for a very 
profound statement. I've got some things that I'll come back to 
questioning you on some--very good. Really appreciate it very, 
very much.
    And now we turn to Mr. Leibowitz--Jon D. Leibowitz, 
Commissioner, Federal Trade Commission.
    Mr. Leibowitz.
STATEMENT OF HON. JON D. LEIBOWITZ, COMMISSIONER, 
            FEDERAL TRADE COMMISSION
    Mr. Leibowitz. Thank you, Chairman Harkin, Chairman Durbin, 
Ranking Member Brownback. I am pleased to be here to testify 
today about childhood obesity and food marketing to children.
    As you know, at your request we issued this comprehensive 
report in July. It is called, ``Marketing Food to Children and 
Adolescents: A Review of Industry Expenditures, Activities, and 
Self-Regulation.'' It examines food marketing expenditures, 
reviews new self-regulatory initiatives, and recommends 
additional steps.
    Simply put, whether or not food and beverage marketers are 
part of the problem--and in my view, we all share some 
responsibility--they have to be part of the solution. As you 
pointed out, Senator Harkin, industry can play an instrumental 
role in influencing children's food choices and helping to curb 
the obesity epidemic.
    To obtain data for our FTC report, we sent subpoenas to 44 
major food, beverage, and fast-food companies. And, as you can 
see from the charts that are going up, and from the chart that 
Senator Brownback put up earlier, in 2006 these companies spent 
approximately $1.6 billion to advertise to children and 
adolescents, or almost $2 billion if we include the cost of 
toys provided with fast-food children's meals.
    Let me go to the second chart.
    Our report details what foods were advertised and how they 
were promoted in 2006, just as industry self-regulatory 
initiatives were starting up, so it is going to serve as a 
benchmark to measure future progress.
    Perhaps most striking is the fully integrated, cross-
platform nature of the campaigns directed to children and 
teens, and the cross-promotional marketing that links food, 
drinks, and restaurants with popular entertainment.
    Television advertising still dominates landscape, but it is 
not like what you see in, say, Mad Men. Modern ad campaigns 
carry over to product packaging, displays in supermarkets and 
restaurants, Internet sites with online advergames, contests, 
and e-cards to send to friends. New digital media is becoming a 
major and a very efficient marketing tool.
    Our report also assesses industry self-regulatory efforts. 
In 2006, after we held the workshop with HHS, the Better 
Business Bureau created the Children's Food and Beverage 
Advertising Initiative. To date, 15 major food and beverage 
companies, including one today, have joined and pledged to 
restrict their child-directed TV, print, and Internet 
advertising to healthy dietary choices, or to simply stop 
advertising to children under 12.
    In addition, the Alliance for a Healthier Generation 
secured marketers agreements to stop selling high-calorie foods 
and drinks in schools--and it sounds like you're making some 
progress with nutritional lunches in schools in Illinois, 
Senator Durbin.
    Our report concludes with a list of recommendations. For 
example, all food marketers should adopt meaningful, nutrition-
based standards for promoting their products to children under 
12. Those standards should apply to all child-directed 
marketing, not only to broadcast, print, and Internet 
advertising, but also to product packaging and other 
promotions. And media companies should develop their own 
programs to impose nutritional standards for both the licensing 
of characters--and, as Chairman Martin pointed out, they are 
starting to do this--and the advertising placed on children's 
programming.

                           PREPARED STATEMENT

    Mr. Chairman, your hearing comes at a propitious moment in 
the debate over self-regulation and how far it can take us. We 
are encouraged that some industry members are stepping up to 
the plate. Still, these promising first efforts need to be 
expanded and replicated. To that end, we are committed to 
monitoring industry progress and to issuing a followup report, 
and we'll use our subpoena power to do that.
    Hopefully, by working together, we can go a long way toward 
ensuring the healthier future for our young people that all of 
us want to see.
    Thank you, and I'd be happy to answer questions.
    [The statement follows:]

                 Prepared Statement of Jon D. Leibowitz

                              introduction
    Chairman Durbin, Chairman Harkin, Ranking Member Brownback, Ranking 
Member Specter, and Members of the Subcommittees, I am Jon Leibowitz, 
Commissioner of the Federal Trade Commission (``FTC'' or 
``Commission'').\1\ The Commission is pleased to have this opportunity 
to provide testimony on our efforts to address childhood obesity. 
Today, I would like to provide some context to the Commission's 
efforts, describe the agency's various initiatives to advocate for 
responsible marketing and enhanced self-regulation, and then turn more 
specifically to a discussion of the Commission's July 2008 Report to 
Congress: ``Marketing Food to Children and Adolescents: A Review of 
Industry Expenditures, Activities, and Self- Regulation.'' \2\ The full 
text of the Report has been submitted to the subcommittees for the 
record.
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    \1\ The written statement presents the views of the Federal Trade 
Commission. My oral testimony and responses to questions reflect my 
views, and do not necessarily reflect the views of the Commission or 
any other Commissioner.
    \2\ Federal Trade Commission, Marketing Food to Children and 
Adolescents: A Review of Industry Expenditures, Activities, and Self-
Regulation (2008) (2008 Report), available at http://www.ftc.gov/os/
2008/07/P064504foodmktingreport.pdf. See also Concurring Statement of 
Commissioner Jon Leibowitz, available at http://www.ftc.gov/speeches/
leibowitz/080729foodmarketingtochildren.pdf.
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    The Commission believes that this Report will provide an important 
benchmark for measuring the future progress of self-regulatory 
initiatives. In addition to describing the state of food marketing to 
children and adolescents in 2006 and analyzing industry initiatives to 
date, the Report also sets forth a number of recommendations. For 
example, the Commission recommends that all companies engaged in 
marketing food to children limit such marketing to products that meet 
meaningful, nutrition-based standards and that such standards apply to 
all forms of advertising and promotion. A good first step would be for 
all such companies to join the self-regulatory initiative established 
by the Council of Better Business Bureaus.\3\ In addition, the 
Commission recommends that the media and entertainment companies 
develop their own self-regulatory program to impose meaningful 
nutrition standards for both the licensing of characters and the 
advertising placed on programming directed to children. After allowing 
a reasonable time for response to these recommendations, the Commission 
will issue a follow-up report assessing the extent to which the 
recommendations have been implemented and identifying what, if any, 
additional measures may be warranted.
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    \3\ See pp. 6-7, infra.
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       ftc's authority and history on food marketing to children
    The Federal Trade Commission is the Nation's consumer protection 
agency and has a broad mandate under Section 5 of the Federal Trade 
Commission Act to stop deceptive or unfair acts and practices in 
commerce.\4\ The Commission fulfills this mandate primarily through law 
enforcement, but also engages in rulemaking, research, policy 
development, consumer and business education, and promotion of industry 
self-regulatory initiatives. Issues that relate to health and well-
being have always been a priority of our consumer protection mission, 
and in recent years, the Commission has devoted substantial resources 
to addressing childhood overweight and obesity.
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    \4\ 15 U.S.C. Sec. 45(a).
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    The prevalence and seriousness of this public health problem have 
been well documented by the Centers for Disease Control and Prevention 
(CDC).\5\ The causes of the problem are complex, and there is ongoing 
vigorous debate over the social and economic factors that may 
contribute to the problem. Poor city planning that makes it difficult 
for children to walk or bike ride, cuts in school physical education 
classes, increased television viewing, computer use, and video gaming, 
fewer hours of sleep, and more frequent restaurant meals have all been 
cited as factors. Much of the public attention has naturally focused on 
what and how much children consume and what types of foods and 
beverages they are encouraged to eat and drink by marketers.
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    \5\ According to the CDC, the prevalence of overweight youth has 
increased about three-fold over the last 25 or 30 years, with 19 
percent of children ages 6 to 11 and 17 percent of teenagers 12 to 19 
now overweight or obese. The long-term health consequences for these 
children are serious and include increased risk of cardiovascular 
disease and increased prevalence of type 2 diabetes. Centers for 
Disease Control and Prevention, Obesity and Overweight: Childhood 
Overweight, available at http://www.cdc.gov/nccdphp/dnpa/obesity/
childhood/index.htm.
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    The Commission has concluded that, at this point, the most 
effective means of addressing childhood obesity, and particularly the 
food marketing issue, is through industry initiatives that include 
vigorous self-regulation.\6\ Under the right circumstances, industry-
generated solutions have the potential to address a public health 
problem of this magnitude quickly, creatively, and flexibly.
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    \6\ In 1978, the Commission embarked on a rulemaking effort to 
address concerns about marketing of sugary foods to children. In 1980, 
Congress enacted restrictions that prohibited the Commission from 
adopting any rule regarding children's advertising that relies on a 
legal basis that the advertising is unfair under the FTC Act. FTC 
Improvements Act of 1980, Public Law No. 96-252, Sections 11(a)(1), 
11(a)(3), 94 Stat. 374 (1980) (current version codified at 15 U.S.C. 
Sec. 57a(h)). For this and other reasons, the Commission ultimately 
terminated the rulemaking proceeding. 46 Fed. Reg. 48,710 (Oct. 2, 
1981). An effort by government to ban or restrict food marketing could 
also face significant constitutional constraints. Any government 
regulation of truthful commercial speech must pass three tests: (1) 
there must be a substantial government interest to be achieved by 
restricting the speech; (2) the regulation must directly advance that 
interest; and (3) the restriction must be narrowly tailored. Cent. 
Hudson Gas & Elec. Corp. v. Pub. Serv. Comm'n, 447 U.S. 557, 564 
(1980).
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    For these reasons, the Commission has focused its efforts in recent 
years on encouraging, guiding, and pushing the private sector in the 
right direction. We have explored how the food industry can contribute 
to reversing obesity trends through product and packaging innovations 
and responsible marketing practices that emphasize healthier food 
choices for children. The Commission has also looked at ways that the 
media and entertainment industries can use their considerable creative 
know-how and strong appeal to children to encourage healthier diets and 
lifestyles. The FTC has kept a close watch on industry progress and has 
been candid in its assessments. We are encouraged by what we have seen 
so far, but we are also recommending that industry take additional 
steps.
 the 2005 workshop on marketing, self-regulation, and childhood obesity
    The Commission's push for industry solutions to childhood obesity 
began in July 2005, when the FTC and the Department of Health and Human 
Services (HHS) jointly convened a 2-day Workshop on Marketing, Self-
Regulation, and Childhood Obesity.\7\ This event brought together some 
of the largest food manufacturers and entertainment companies, as well 
as government officials, health experts, and consumer advocates. The 
purpose of the workshop was neither to determine the causes of 
childhood obesity nor to assess blame; rather, the goal was to focus 
attention on positive initiatives that industry members and others 
could take to encourage healthier eating and living by the Nation's 
young people.
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    \7\ Marketing, Self-Regulation, and Childhood Obesity: A Joint 
Workshop of the Federal Trade Commission and the Department of Health 
and Human Services (July 14-15, 2005). Agenda and transcript of 
proceedings available at http://www.ftc.gov/bcp/workshops/
foodmarketingtokids/index.htm.
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    The workshop yielded a number of important findings, which are 
detailed in an April 2006 joint report of the FTC and HHS.\8\ The 
report identified several steps that food and beverage companies were 
already taking to respond to childhood obesity, including the 
introduction of new, lower-calorie products and smaller-portion 
packages; use of icons and seals to provide simple nutrition 
information; and an increase in use of popular characters to deliver 
nutrition and health messages to children.\9\ In addition, two 
companies \10\ had committed to shift their children's advertising to 
products meeting certain nutrition standards.
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    \8\ Federal Trade Commission & Department of Health and Human 
Services, Perspectives on Marketing, Self-Regulation, & Childhood 
Obesity (2006) (2006 Report), available at http://www.ftc.gov/os/2006/
05/PerspectivesOnMarketingSelf-
Regulation&ChildhoodObesityFTCandHHSReportonJointWorkshop.pdf.
    \9\ See id. at 11-23.
    \10\ Kraft Foods, Inc. and PepsiCo, Inc.
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    The 2006 Report included a series of specific recommendations for 
the food and media industries. The FTC and HHS called on industry to 
implement self-regulatory initiatives to change the way food is 
marketed to children. The agencies also encouraged food marketers to: 
create more nutritious food choices for children through product 
innovation and reformulation; expand product packaging efforts to 
control portion size and calories; explore labeling initiatives to help 
consumers identify lower-calorie, more nutritious foods; improve the 
nutritional profile of foods marketed to children; educate consumers 
about nutrition and fitness; and improve the nutritional quality of 
foods and beverages sold in schools outside of the meal program. In 
addition, the 2006 Report recommended that media and entertainment 
companies incorporate nutrition and fitness messages into programming 
and revise their practices with respect to licensing popular children's 
characters for use in food marketing.\11\
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    \11\ See 2006 Report at 48-54.
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       the 2007 forum and current assessment of industry efforts
    In July 2007, the FTC and HHS conducted a follow-up forum to review 
progress in the implementation of these self-regulatory and educational 
initiatives.\12\ The agencies were encouraged to learn that the 2005 
Workshop and 2006 Report had provided a stimulus for many individual 
company efforts as well as broad industry programs. One notable program 
is the Children's Food and Beverage Advertising Initiative, established 
by the Council of Better Business Bureaus (CBBB) and the CBBB's 
National Advertising Review Council.\13\ To date, 14 of the largest 
food and beverage companies--estimated to represent more than two-
thirds of children's food and beverage television advertising 
expenditures \14\--have joined the Initiative, making pledges that, 
when fully implemented, will significantly improve the landscape of 
food marketing to children. Most of these companies have committed 
either not to direct television, radio, print, and Internet advertising 
to children under 12 or to limit such advertising to foods that qualify 
as ``healthy dietary choices'' by meeting specified nutritional 
standards, such as limitations on calories, fat, sugar, and sodium and/
or providing certain nutritional benefits to children. In addition, the 
companies have pledged to limit the use of licensed characters to 
promote ``healthy dietary choices'' or healthy lifestyles, not to seek 
product placements in child-directed media, not to advertise food or 
beverages in elementary schools, and to use only their ``healthy 
dietary choices'' in interactive games directed to children.
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    \12\ FTC/HHS Forum on Marketing, Self-Regulation, and Childhood 
Obesity (July 18, 2007). Agenda and transcript of proceedings available 
at http://www.ftc.gov/bcp/workshops/childobesity/index.shtml.
    \13\ See About the Initiative, available at www.us.bbb.org/
advertisers4healthykids.
    \14\ That estimate was made with reference to the initial ten 
program members. Four additional major companies subsequently 
subscribed to the Initiative. See Press Release, Council of Better 
Business Bureaus, New Food, Beverage Initiative to Focus Kids' Ads on 
Healthy Choices; Revised Guidelines Strengthen CARU's Guidance to Food 
Advertisers (Nov. 14, 2006), available at www.us.bbb.org/
advertisers4healthykids (More Information, item 7).
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    The forum also highlighted another industry program directed 
specifically at the sale of foods and beverages in schools. Created in 
2006 under the auspices of the Alliance for a Healthier Generation, the 
program brings together several food and beverage companies who have 
committed to limit the sale of ``competitive foods''--those sold 
outside of the school meal program--to lower-calorie, more nutritious 
products.\15\ Although not yet fully implemented, the program has 
already begun to have a significant impact, resulting in a 58 percent 
decrease in total calories for beverages shipped to schools between 
2004 and the 2007-08 school year.\16\
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    \15\ See Competitive Foods Guidelines for K-12 Schools and Alliance 
School Beverage Guidelines, Alliance for a Healthier Generation, 
available at www.healthiergeneration.org. The Alliance is a partnership 
of the American Heart Association and the William J. Clinton 
Foundation.
    \16\ See American Beverage Association, School Beverage Guidelines 
Progress Report 2007-2008 (Sept. 2008), available at http://
www.schoolbeverages.com/download.aspx?id=111.
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                the 2008 food marketing study and report
    The Commission's 2008 Report assesses the industry's self-
regulatory initiatives undertaken since our last report and identifies 
areas where we believe more needs to be done. In addition, this Report 
provides the results of the agency's comprehensive study of food and 
beverage industry marketing expenditures and activities directed to 
children and adolescents.
    Until now, research on food and beverage marketing to children has 
consisted largely of studies of television advertising and, to a lesser 
extent, other forms of traditional, measured media. The FTC's Bureau of 
Economics, for example, issued a study in 2007 comparing children's 
exposure to food advertising on television in 1977 with their exposure 
in 2004. The study concluded that children's exposure to food ads had 
fallen modestly from 6,100 ads seen by children ages 2-11 in 1977, to 
5,500 ads in 2004. In 2004, however, children's ad exposure was more 
concentrated on children's programming; about half of the food ads seen 
by children were during programs in which they were at least 50 percent 
of the audience, compared to about one quarter of the ads seen in 
1977.\17\ Although children's exposure to food advertising on 
television has remained fairly constant over the past 30 years, 
marketing to children has become omnipresent, and promotional campaigns 
have become more integrated because of the Internet, other new 
electronic media, and the burgeoning of cross-promotions with products, 
movies, and characters popular with children and teens. Previously, 
however, there has been little information quantifying children's 
exposure to these newer, more integrated marketing venues and 
techniques.
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    \17\ Children's Exposure to TV Advertising in 1977 and 2004: 
Information for the Obesity Debate, FTC Bureau of Economics Staff 
Report (June 2007), available at www.ftc.gov/os/2007/06/cabecolor.pdf.
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    The FTC's new study, which was conducted at the request of 
Congress,\18\ addresses not only marketing activities in traditional 
measured media--television, radio, and print--but also analyzes the 
Internet and other new media, as well as older, but mostly unmeasured, 
forms of promotional activities directed to youth. This Report presents 
a great deal of information not previously collected and not otherwise 
available to the research community. Significantly, the study analyzes 
data from 2006--a year just before, or very early in the inception of, 
industry self-regulatory activities. The Commission believes, 
therefore, that the study will serve as a benchmark for measuring the 
future effects of voluntary efforts to reduce the amount or improve the 
nutritional profile of food and beverage marketing to children.
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    \18\ The Conference Report (H.R. Rep. No. 109-272 (2005)) for the 
Commission's fiscal year 2006 appropriation legislation (Public Law No. 
109-108) incorporated by reference language from the Senate Report 
directing the FTC to submit a report to the Committee regarding: 
marketing activities and expenditures of the food industry targeted 
toward children and adolescents. The report should include an analysis 
of commercial advertising time on television, radio, and in print 
media; in-store marketing; direct payments for preferential shelf 
placement; events; promotions on packaging; all Internet activities; 
and product placements in television shows, movies, and video games. S. 
Rep. No. 109-88, at 108 (2005).
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Study Design and Scope
    The study analyzes data from both public and non-public sources to 
provide a comprehensive picture of expenditures and activities directed 
toward children and adolescents by 44 food and beverage producers, 
marketers, and quick-service restaurants (QSRs) in the United States 
during 2006. Those 44 companies, which provided data in response to 
compulsory process issued by the Commission, were generally selected 
based on their status as the top advertisers during children's 
programming and as the companies with the largest sales shares for 
selected food categories. The Commission sought information from these 
companies for marketing of brands in 11 categories of food products 
ranging from breakfast cereals, candy, and carbonated beverages, to 
fruits and vegetables. Companies were required to report their 
marketing expenditures across 20 categories of promotional activities 
including traditional media like television, newer media like the 
Internet and mobile phones, and other promotional techniques like 
product placement, event sponsorship, character licensing, and in-
school marketing. In each category, spending was broken down between 
activities targeted to children (ages 2-11) and adolescents (ages 12-
17). In addition to reporting spending, companies were also asked to 
provide samples or descriptions of their marketing in various 
categories.\19\
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    \19\ Appendix A to the Report describes the research methods in 
detail and identifies the specific companies, food categories, and 
promotional activities that were included in the study.
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    Although the study does not include the entire universe of 
companies marketing food to children and adolescents, or the entire 
range of foods promoted to them, the Commission believes that it covers 
a substantial majority of such expenditures and activities for the 
relevant time frame. It should provide an accurate picture of the scope 
and variety of food marketing to American youth in 2006.
Key Findings
    The Report provides a detailed breakdown of spending for both 
children and teenagers for each type of marketing activity and across 
each food category. It also provides examples and descriptions of the 
various promotional techniques used by the companies. This testimony 
will highlight only a few key findings.
    Total spending on food and beverage marketing to children and teens 
(together described as ``youth'') by the 44 reporting companies 
slightly exceeded $1.6 billion, with approximately $870 million of that 
spent on marketing directed to children under 12.\20\ Not surprisingly, 
television advertising, one of the more expensive media, accounted for 
nearly half (46 percent) of the total reported youth-directed marketing 
expenditures. With a total of $745 million spent, television 
advertising ranked at the top of promotional techniques. In-store 
display materials and packaging ranked second in youth-directed 
spending at 12 percent ($195 million), closely followed by in-school 
marketing at 11 percent ($186 million).\21\ The Internet and other new 
media and techniques, such as digital media and viral marketing, 
represented a combined 5 percent of youth-directed expenditures ($77 
million). Youth-directed premiums were reported as representing only 4 
percent of total expenditures ($67 million).\22\
---------------------------------------------------------------------------
    \20\ 2008 Report, supra note 2, at 7. The cost of youth marketing 
reported here is significantly lower than some previous estimates. 
There are several reasons for this disparity. Other researchers have 
not had access to the confidential company financial data obtained by 
the Commission. Moreover, prior estimates have included advertising 
directed to children for products other than food and also have 
included price promotions, which generally are targeted to adults and 
therefore were not included in the FTC data.
    \21\ The FTC defined the in-school marketing category to include 
the commissions paid to schools and school districts by beverage 
companies and bottlers pursuant to vending machine contracts. Thus, the 
majority of the expenditures reported in this category were not for 
traditional advertising or marketing activities. The Commission 
included these expenses because the payments afford the companies 
access to young people in school. We recognize that many schools rely 
on these payments to support athletic and other school programs.
    \22\ 2008 Report at 8, 12-13.
---------------------------------------------------------------------------
    The low level of spending on premiums may seem surprising at first 
glance. The figure, however, does not tell the whole story because it 
excludes toys distributed by QSRs with children's meals--an expense 
that is recouped by the cost of the meal and thus not reported as a 
marketing expenditure by the companies. If the cost of QSR toys is 
added to premium expenditures, this marketing technique jumps from $67 
million to $427 million, ranking second only to television in youth-
directed expenditures.\23\
---------------------------------------------------------------------------
    \23\ Id. at 8.
---------------------------------------------------------------------------
    The foods most heavily marketed to all youth were carbonated 
beverages, restaurant foods, and breakfast cereals, with these three 
categories comprising 63 percent of all youth-directed spending.\24\ 
For children under 12, the top marketed food categories, ranked in 
order, were breakfast cereals ($229 million), restaurant food ($161 
million), and snack foods ($113 million).\25\ Again, this ranking 
changes dramatically if the cost of toys included in QSR kids' meals is 
added to expenditures for children under 12. With these toys included, 
QSR food becomes the most heavily marketed category to children, at 
$521 million--more than twice that spent in any other food and beverage 
category.\26\
---------------------------------------------------------------------------
    \24\ Id. at 10.
    \25\ Id.
    \26\ Id.
---------------------------------------------------------------------------
    In addition to providing these figures, the Report describes the 
various ways in which food is marketed to children. A principal finding 
is that many marketing campaigns are fully integrated, weaving together 
a sweeping net of repeated product exposure across multiple venues and 
techniques. A typical campaign, for example, may begin with a child 
seeing an ad on television. The child is then likely to encounter 
promotional displays and product packaging at the grocery store or 
restaurant and perhaps receive a toy or other premium upon purchase of 
the product. Often, that toy or premium will be tied to a popular movie 
release, for which there will be additional advertising exposure. The 
child also might be directed to a website to enter a package UPC or 
other code to participate in a sweepstakes or earn points toward 
prizes. Once on the website, the child may interact with the brand 
through online games or participate in viral marketing by sending an e-
card to a friend.
    The extensive cross-promotion of food and beverage products with 
popular movie releases illustrates the integration of marketing 
methods. The PG-13-rated movie, Pirates of the Caribbean: Dead Man's 
Chest, for example, was released in July 2006.\27\ Coinciding with the 
release, food, beverage, and restaurant companies ran cross promotions 
for QSR meals, frozen waffles, fruit snacks, breakfast cereals, 
popcorn, lunch kits, candy, and fresh fruit. The food products tied to 
Pirates were promoted by television ads, in-theater ads, Internet 
``advergames,'' specially marked packaging, and in-store displays and 
tags for pineapples and bananas. Limited edition line extensions were 
created, including candy that turned gold in the mouth, fruit snacks in 
treasure shapes, and frozen waffles stamped with movie images. 
Promotions also included premiums and prizes like skull-shaped cereal 
bowls, bandanas, and skull strobe light key chains.\28\ Pirates was 
just one of approximately 80 films, television programs, and video 
games used in cross promotion of food and beverages to children and 
teens in 2006.\29\
---------------------------------------------------------------------------
    \27\ In October 2006, the Walt Disney Company announced new food 
guidelines stating that its name and characters would be used only for 
food products that meet specific nutritional requirements, including 
limits on calories, fat, and sugar. This and other initiatives by media 
and entertainment companies are described in the 2008 Report at 78-79.
    \28\ 2008 Report at 37-38.
    \29\ Id. at 29-32.
---------------------------------------------------------------------------
    The Report also provides illustrations of many other youth-directed 
marketing techniques used by the industry. It describes, for example, 
the variety of methods that the industry uses to market in schools--
vending machines, contests, team sponsorship, event advertising, and 
others. The Report also describes the branding of clothing, toys, and 
other children's merchandise with food, beverage, and QSR logos; 
digital marketing that includes downloadable podcasts, ``webisodes,'' 
and ringtones; viral marketing; word-of-mouth marketing that recruits 
youth as ``ambassadors'' to hand out product samples and promotional 
items; event marketing; celebrity endorsements; product placement; 
philanthropic activities, and more.
Key FTC Recommendations
    Drawing from the findings of our study as well as from our 
assessment of the industry's progress on self-regulation since our 
first report, the 2008 Report concludes with several new and stronger 
recommendations designed to further strengthen and expand on all 
aspects of the industry's self-regulatory efforts and company 
initiatives.
    First, the Commission recommends that all food and beverage 
companies adopt and adhere to meaningful nutrition-based standards for 
marketing their products to children under 12. A useful first step 
would be to join the CBBB Initiative. In other words, all companies 
should take measures to limit their food and beverage promotions 
directed to children to those for healthier products.
    Second, given the integrated nature of most marketing campaigns, 
the Commission also recommends that these nutrition-based standards be 
extended beyond television, radio, print, and Internet advertising, to 
cover the full spectrum of marketing activities to children, including 
product packaging, advertising displays at the retail site, premium 
distribution, celebrity endorsements, and other promotional activities.
    Third, the Commission also recommends that all companies stop in-
school promotion of foods and beverages that do not meet meaningful 
nutrition-based standards. In addition, all companies that sell 
``competitive'' food or beverage products in schools (outside of the 
school meal program) should join the Alliance for a Healthier 
Generation or otherwise adopt and adhere to meaningful nutrition-based 
standards for foods and beverages sold in schools, such as those 
recommended by the Institute of Medicine.
    Fourth, the Report contains many other specific recommendations for 
the food industry, which address the nutritional profile of product 
offerings, nutrition labeling, healthy messages, and marketing in 
schools.
    Finally, in light of the character licensing and extensive cross 
promotion of foods with films and children's televison programs, the 
Report also recommends actions by media and entertainment companies. 
Included among these is a recommendation that media and entertainment 
companies should consider instituting their own self-regulatory 
initiative and working with the CBBB in this endeavor.\30\
---------------------------------------------------------------------------
    \30\ The complete list of recommendations is set forth in the 
Executive Summary. 2008 Report at ES-8-ES-11.
---------------------------------------------------------------------------
Conclusion
    The Commission is hopeful that continued and expanded efforts by 
all stakeholders will yield more progress in addressing the issue of 
childhood obesity. Going forward, the Commission will continue to 
monitor developments in this area. In particular, we will be looking at 
the progress of the food and media industries' self-regulatory 
initiatives and examining the impact on marketing to children. At an 
appropriate point in the future, the Commission is committed to issuing 
a follow-up report assessing the extent to which the recommendations in 
the 2008 Report have--or have not--been implemented.
    On behalf of the Commission, I would like to thank the 
subcommittees for the opportunity to present testimony on this 
important topic.

    Senator Harkin. Thank you all very much for your 
statements.
    First, Mr. Leibowitz, let me start with you.
    Mr. Leibowitz. Sure.
    Senator Harkin. If you look at that chart that both Senator 
Brownback had and, I think, that Dr. Gerberding had, where it 
showed the increase in obesity rates among kids, it had a line 
going up--there were three or four lines there.
    Mr. Leibowitz. Uh-huh.
    Senator Harkin. You notice those lines, like this one 
here--it's odd, isn't it, that they all started a precipitous 
increase right around 1980, 1981? Now, I remember, back in the 
1970s, there was this proposal to regulate advertising to kids. 
I was in the House at the time. I was on the Agriculture 
Committee. We had a little bit of it. But, I remember, there 
was a big hue and cry went up about nanny government and this 
and that, and I remember those. But then, I kind of forgot 
about it, because it kind of went away.
    Well, what happened was, in 1981 the Congress--the Congress 
passed a law that took away the authority of the Federal Trade 
Commission to regulate children's advertising, in this way. 
Right now, the FTC has the authority to regulate advertising to 
adults on the basis of deception or unfairness.
    Mr. Leibowitz. That is right. We usually do it with our 
enforcement power by going after deceptive advertisements, but 
that is exactly right.
    Senator Harkin. But you have both of those----
    Mr. Leibowitz. Right.
    Senator Harkin [continuing]. For adults.
    Mr. Leibowitz. We do have those, that's right.
    Senator Harkin. But, for kids, only on deception. Now, why 
is it the FTC has more authority to regulate advertising to me 
than to my grandkids? Now, that's an interesting statement. 
But, it is true, is it not, Mr. Leibowitz?
    Mr. Leibowitz. It is absolutely correct.
    Senator Harkin. So, therefore, taking it a step further, 
since they took away--the Congress took away the power of the 
FTC to regulate advertising to kids based on unfairness, they 
can only do it on deception. Well, most ads are probably--
they're not deceptive, but I would propose this, that a--an ad 
targeted to a child--and there have been studies that have 
shown this, that they can't tell the difference between program 
content and advertising content--that that kind of advertising 
to children is inherently unfair. Inherently unfair, because 
they can't distinguish. We have studies that show that. Yet, 
the Federal Trade Commission, Mr. Leibowitz, if I'm right----
    Mr. Leibowitz. You are right.
    Senator Harkin [continuing]. Can't do anything about it.
    Mr. Leibowitz. Well, I would say that was the motivation 
for the rulemakings that we did in the Pertschuk Commission in 
the late 1970s. It has also, I think, driven what some European 
countries have done to ban food marketing to children. On the 
other hand--that is also part of the reason why we have worked 
so vigorously to use our bully pulpit at the FTC and to push 
companies to do a better job using self-regulatory measures. We 
think they have really improved.
    You are absolutely right, as you described the history and 
the restrictions that we are under now. The only other point I 
would make is probably that even if you regulate in that area, 
you still have First Amendment concerns, depending on what that 
regulation is, as Chairman Martin knows. And so, you want to be 
very, very careful, if you could regulate, about what you would 
do. And we do think that one of the benefits of self-
regulation--and we have seen a lot of progress through the 
Better Business Bureau initiative, and through the work that 
the Clinton Foundation and the American Heart Association have 
done in the schools on beverages. One of the advantages, I 
would say, of the self-regulatory approach is that you avoid 
litigation. And if you can get companies to do the right thing, 
then they do it much more quickly.
    But, yes, you described the history of the FTC and of our 
rulemaking initiative very clearly.
    Senator Harkin. I'd also make a note, also, that that 
precipitous incline also started at about the time that we saw 
the huge influx of vending machines in our schools. Go back and 
look at it. That's when it--that's when--and I don't think it's 
just coincidental, by the way, that the obesity rates and 
everything else started and has gone up since both of those 
things took place, this law that we passed and also the influx 
of----
    Mr. Leibowitz. Well, with vending machines----
    Senator Harkin [continuing]. The vending----
    Mr. Leibowitz [continuing]. In the schools, again, in the 
last couple of years, particularly with the Clinton 
Foundation's involvement, we have seen a lot of progress there 
to have reduced-calorie juices and diet sodas in the schools, 
replacing high-calorie drinks.
    Senator Harkin. But, on a case-by-case basis, some--some 
school districts have done magnificent jobs.
    Mr. Leibowitz. That's right.
    Senator Harkin. And others have done it.
    Mr. Leibowitz. That's right.
    Senator Harkin. So, it's sort of spotty. But then, from 
what you said about self-regulation, that's where we've all 
been headed, to try to get all these companies to do this.
    But then, Mr. Martin, as you point out in your statement, 
that some of these companies agreed to limit character usage, 
leaving the loophole open for these special occasions that you 
mentioned in your verbal statement. And then, as you point out 
in your written statement, even more troubling was, the 
majority of media companies refused to agree to any kind of 
limit on advertising targeted toward our children. And then you 
go on to say that, as a result, all of the public health and 
child advocacy groups have asked Congress to adopt legislation 
mandating that at least 50 percent of all food advertising to 
children on broadcast and cable television programming be 
devoted to healthy food products. So, you know, yes, as I said, 
I applaud those companies that have done that.
    Mr. Martin. Yes.
    Senator Harkin. I mentioned Kraft. There are others. But, I 
just singled them out because they really were moving ahead 
and--but, the problem that I saw over the last few years with, 
really, conscientious companies doing this--and I have examples 
of this, of other companies coming in and trying to invade 
their market share. So, the good companies basically are giving 
up, maybe, some of their market share to those that don't much 
care about this. As you say, they aren't adhering to this, and 
so, they come in with, again, the high sugar, high salt, high 
fat foods, advertising them to kids, to take away from the 
companies that are doing good things. So, how do we get around 
this problem?
    Mr. Martin. Well, the same thing is true even on the media 
company side, to the extent that any company--or in this case--
a company like Ion--that agreed to this kind of a commitment, 
they're put at a competitive disadvantage in trying to get 
advertising dollars----
    Senator Harkin. Sure.
    Mr. Martin [continuing]. So, it has a negative impact on 
them, as well. So, that's why I would speak more from the media 
company side of it, which is where the Commission ends up 
having its regulatory authority, but I would say that I think 
the voluntary efforts of trying to get them to put limits on 
their advertising of unhealthy products has probably run its 
course.
    There was no question that over the last 1\1/2\year and a 
half to 2 years we spent on the task force, the vast majority 
of media companies were unwilling to place any kind of limit on 
the advertising of unhealthy products to our children. And 
that's why I think this is a significant problem, and I think 
Congress should consider, what limits should be placed on them. 
And, as I indicated in my testimony, I think that the solution 
must be one that's comprehensive and involves all media 
companies.
    Senator Harkin. Well, I'd like to pursue that just a little 
bit further, but----
    Mr. Martin. Sure.
    Senator Harkin [continuing]. My time's gone--run way over.
    And, with that, I'd yield to Senator Brownback.

                         HEALTH SYSTEMS REPORTS

    Senator Brownback. Thank you all, for being here.
    Dr. Gerberding, you've mentioned that we're 37th on health, 
and yet, we spend the most. What countries are doing the best 
job, and what practices do you think we should import to help 
us improve our health?
    Dr. Gerberding. I can answer that generically, and I 
appreciate what Senator Harkin said about healthcare reform. 
But, I would like to ask that we think of this as ``health 
system reform,'' because this kind of health isn't going to 
happen in the healthcare delivery system, it's going to happen 
in schools and communities and homes. And I know that's what 
you mean, but we're trying to really emphasize ``health 
system,'' not just ``healthcare system.''
    What we can say, in comparison to the other developed 
countries that are spending far less of their GDP on managing 
their health, is that they put much more emphasis on things 
going on in schools, on physical fitness and good nutrition, on 
environments that support exercising and access to healthy 
choices. I can't comment specifically on what they're doing 
about advertising to children, so I would leave that to my 
colleagues to address.
    But, in general, their portfolio of health dollars is 
invested much differently than ours is. We put our emphasis on 
end-of-life care, in complex biomedical interventions, they're 
more willing to spend upstream, where health really happens.
    Senator Brownback. So, on school nutrition programs, 
physical education in school----
    Dr. Gerberding. Absolutely.
    Senator Brownback [continuing]. Key items that you look 
at----
    Dr. Gerberding. Absolutely. They----
    Senator Brownback [continuing]. When you look at this 
chart, here, why the spike in 1980? Chairman Harkin mentioned a 
couple of things that seem probable. I presume you guys have 
studied this and you have several factors that you think are 
likely.
    Dr. Gerberding. Well, we can make correlations. That is the 
same time at which television viewing increased. There are a 
lot of things that happened along those same times. The decline 
in school physical ed programs began in the 1980s as school 
districts became less and less able to afford those activities. 
So, there's a confluence of things. But, I think the sharp 
change at 1981 is highly correlated with the policy change that 
the Senator mentioned.
    Senator Brownback. Either of the other gentlemen--Chairman 
Martin, same question--are there practices in other countries 
that would be very helpful if we would do?
    Mr. Martin. In the United Kingdom, Ofcom has much more 
direct regulations limiting the advertising of unhealthy 
products during any children's programming. And they actually--
have instituted a series of rules and requirements and 
regulations restricting that. And they're actually going 
through a process of reviewing them and seeing if they need 
even additional restrictions or regulations. But, they've been 
the most aggressive of any country in trying to actually 
restrict the advertising of unhealthy foods to children.
    Senator Brownback. At up to a certain age, what's the age 
that they target?
    Mr. Martin. I think----
    I'll have to get back to you, but I thought it was 16, but 
I'll have to get back to you on the exact age.
    Mr. Leibowitz. Yes, we can----
    Senator Brownback. Mr. Leibowitz.
    Mr. Leibowitz [continuing]. Find that, too.
    [The information follows:]

    Ofcom targets children under 16 (that is up to and including 15) 
with respect to the regulations on food advertising. The restrictions 
apply to ads for foods and drinks that are high in fat, salt, and sugar 
(HFSS). HFSS ads are not permitted in or around programs made for 
children and on dedicated children's channels. In addition, they are 
not permitted in or around programs ``likely to be of particular appeal 
to children aged 4-15.'' Whether a program has ``particular appeal'' to 
those under 16 is determined by a statistical index. If the proportion 
of children 4-15 watching a program is more than 20 percent higher than 
their proportion of the general population, the program is defined as 
having ``particular appeal'' to that age group. The regulations were 
phased in and became fully effective January 1, 2009.

    Mr. Leibowitz. The Europeans have gone much further than we 
have in regulating the types of advertisements that children 
can see, and particularly young children.
    But, I would also say this, it is complicated, in the 
United States, by the First Amendment. Under Central Hudson, 
which is the major commercial speech case, there is a three-
part test, and you have to have substantial government 
interest, and the regulation has to directly advance that 
interest, and has to be narrowly tailored. So, it would 
complicate rulemaking, and it would certainly complicate 
legislating in this area. That doesn't mean it can't be done, 
but you would have to be, very careful and cautious if you do 
it. And, again, that is part of the reason why we have pushed 
very hard for robust, strong, self-regulatory initiatives.
    Senator Brownback. Dr. Gerberding----
    Mr. Leibowitz. Plus, the ban.
    Senator Brownback. What's that?
    Mr. Leibowitz. As Chairman Harkin pointed out, we have a 
ban on our rulemaking authority here.
    Senator Brownback. Would these limitations in media 
advertising get at the heart of the issue, in your estimation? 
Or, are these useful, but we need to really get more at school 
nutrition programs, the health system, physical education? 
What's your thought?
    Dr. Gerberding. I don't believe there'll be a simple fix. 
This is going to take a comprehensive set of interventions that 
involves schools and nutrition and activity. But, the Institute 
of Medicine has specifically looked at the relationship between 
advertisement and what children choose to eat, and there's no 
question that the media influence is strong, that this exposure 
to this toxic environment really does influence what kids want, 
what they eat, what they won't eat, and that it is a major 
influence.
    What we don't know is, if we take that away, how much 
weight change will occur. But, we've seen evidence that when 
you do reduce exposure to advertisements, that children's 
weight drops, even if they don't increase their physical 
activity. So, that's some pretty direct evidence that there is 
a logic model here that would suggest that removing this 
influence would have beneficial health impact.
    Senator Brownback. You have direct studies that show that.
    Dr. Gerberding. If you remove the exposure, you see weight 
loss.
    Senator Brownback. Mr. Leibowitz, you're familiar with 
these studies, as well, and agree with----
    Mr. Leibowitz. I am aware of some of these studies. I mean, 
I defer to the healthcare expert here, the director of CDC. 
But, yes, we are aware of them.
    Senator Brownback. Well, I think that's quite a strong and 
clear statement. I'm hopeful, actually, that CDC can submit 
that study, or the citation for those studies, to us so that we 
can have that.
    [The information follows:]

  [From the Journal of the American Medical Association, October 27, 
                                 1999]

       Reducing Children's Television Viewing to Prevent Obesity

                     (Thomas N. Robinson, MD, MPH)
 [available on the web at: http://jama-ama-assn.org/cgi/reprint/282/16/
                                 1561]
                     a randomized controlled trial
    Context.--Some observational studies have found an association 
between television viewing and child and adolescent adiposity.
    Objective.--To assess the effects of reducing television, 
videotape, and video game use on changes in adiposity, physical 
activity, and dietary intake.
    Design.--Randomized controlled school-based trial conducted from 
September 1996 to April 1997.
    Setting.--Two sociodemographically and scholastically matched 
public elementary schools in San Jose, Calif.
    Participants.--Of 198 third- and fourth-grade students, who were 
given parental consent to participate, 192 students (mean age, 8.9 
years) completed the study.
    Intervention.--Children in 1 elementary school received an 18-
lesson, 6-month classroom curriculum to reduce television, videotape, 
and video game use.
    Main Outcome Measures.--Changes in measures of height, weight, 
triceps skinfold thickness, waist and hip circumferences, and 
cardiorespiratory fitness; self-reported media use, physical activity, 
and dietary behaviors; and parental report of child and family 
behaviors. The primary outcome measure was body mass index, calculated 
as weight in kilograms divided by the square of height in meters.
    Results.--Compared with controls, children in the intervention 
group had statistically significant relative decreases in body mass 
index (intervention vs control change: 18.38 to 18.67 kg/m\2\ vs 18.10 
to 18.81 kg/m\2\, respectively; adjusted difference -0.45 kg/m\2\ [95% 
confidence interval (CI), -0.73 to -0.17]; P=.002), triceps skinfold 
thickness (intervention vs control change: 14.55 to 15.47 mm vs 13.97 
to 16.46 mm, respectively; adjusted difference, -1.47 mm [95% CI, -2.41 
to -0.54]; P=.002), waist circumference (intervention vs control 
change: 60.48 to 63.57 cm vs 59.51 to 64.73 cm, respectively; adjusted 
difference, -2.30 cm [95% CI, -3.27 to -1.33]; P<.001), and waist-to-
hip ratio (intervention vs control change: 0.83 to 0.83 vs 0.82 to 
0.84, respectively; adjusted difference, -0.02 [95% CI, -0.03 to 
-0.01]; P<.001). Relative to controls, intervention group changes were 
accompanied by statistically significant decreases in children's 
reported television viewing and meals eaten in front of the television. 
There were no statistically significant differences between groups for 
changes in high-fat food intake, moderate-to-vigorous physical 
activity, and cardiorespiratory fitness.
    Conclusions.--Reducing television, videotape, and video game use 
may be a promising, population-based approach to prevent childhood 
obesity.
                              introduction
    The United States has experienced alarming increases in obesity 
among children and adolescents. [1] However, most available treatments 
for obese children have yielded only modest, unsustained effects. [2] 
Consequently, prevention is considered to hold the greatest promise. 
[3] Unfortunately, most prevention programs that specifically attempt 
to reduce fat and energy intake and increase physical activity have 
been ineffective at changing body fatness. [4] [5] As a result, there 
is a need for innovative approaches to prevent obesity.
    There is widespread speculation that television viewing is one of 
the most easily modifiable causes of obesity among children. American 
children spend more time watching television and videotapes and playing 
video games than doing anything else except sleeping. [6] Two primary 
mechanisms by which television viewing contributes to obesity have been 
suggested: reduced energy expenditure from displacement of physical 
activity and increased dietary energy intake, either during viewing or 
as a result of food advertising.
    Cross-sectional epidemiological studies have consistently found 
relatively weak positive associations between television viewing and 
child and adolescent adiposity. [7-21] Prospective studies are less 
common and have produced mixed results. [7] [14] The consistently weak 
associations found in epidemiological studies may be due to the 
measurement error in self-reports of television viewing. As a result, 
additional epidemiological studies would not be expected to clarify the 
true nature of this relationship. [22]
    A causal relationship can only be demonstrated in an experimental 
trial, in which manipulation of the risk factor changes the outcome. 
[23] Therefore, we conducted a randomized, controlled, school-based 
trial of reducing third- and fourth-grade children's television, 
videotape, and video game use to assess the effects on adiposity and 
the hypothesized mechanisms of physical activity and dietary intake. We 
hypothesized that compared with controls, children exposed to the 
television reduction intervention would significantly decrease their 
levels of adiposity.
                                methods
    All third- and fourth-grade students in 2 public elementary schools 
in a single school district in San Jose, Calif, were eligible to 
participate. Schools were sociodemographically and scholastically 
matched by district personnel. School principals and teachers agreed to 
participate prior to randomization. Parents or guardians provided 
signed written informed consent for their children to participate in 
assessments and for their own participation in telephone interviews. 
One school was randomly assigned to implement a program to reduce 
television, videotape, and video game use. The other school was 
assigned to be an assessments-only control. Participants and school 
personnel, including classroom teachers, were informed of the nature of 
the intervention but were unaware of the primary hypothesis. The study 
was approved by the Stanford University Panel on Human Subjects in 
Research, Palo Alto, Calif.
                              intervention
    To test the specific role of television, videotape, and video game 
use in the development of body fatness, as well as effects on dietary 
intake and physical activity, it was necessary to design an 
intervention that decreased media use alone without specifically 
promoting more active behaviors as replacements. This was accomplished 
by limiting access to television sets and budgeting use while 
simultaneously becoming more selective viewers or players.
    The intervention, which was based in Bandura's social cognitive 
theory, [24] consisted of incorporating 18 lessons of 30 to 50 minutes 
into the standard curriculum that was taught by the regular third- and 
fourth-grade classroom teachers. The teachers were trained by the 
research staff, and the majority of lessons were taught during the 
first 2 months of the school year. Early lessons included self-
monitoring and self-reporting of television, videotape, and video game 
use to motivate children to want to reduce the time they spent in these 
activities. These lessons were followed by a television turnoff, [25] 
during which children were challenged to watch no television or 
videotapes and play no video games for 10 days. After the turnoff, 
children were encouraged to follow a 7-hour per week budget. Additional 
lessons taught children to become ``intelligent viewers'' by using 
their viewing and video game time more selectively. Several final 
lessons enlisted children as advocates for reducing media use. The 
entire curriculum consisted of approximately 18 hours of classroom 
time. Newsletters that were designed to motivate parents to help their 
children stay within their time budgets and that suggested strategies 
for limiting television, videotape, and video game use for the entire 
family were distributed to parents.
    To help with budgeting, each household also received an electronic 
television time manager (TV Allowance, Mindmaster, Inc, Miami, Fla). 
This device locks onto the power plug of the television set and 
monitors and budgets viewing time for each member of the household 
through use of personal identification codes. Because it controls power 
to the television, it also controls video cassette recorder (VCR) and 
video game use. Families could request additional units for every 
television in their homes, at no cost.
                          outcome measurements
    Assessments were performed by trained staff, blinded to the 
experimental design, at baseline (September 1996) and after the 
completion of the intervention (April 1997). At each time point, on the 
same days in both schools, children completed self-report 
questionnaires on 2 non-Monday weekdays. A research staff member read 
each question out loud. Classroom teachers did not participate in the 
assessments. Physical measures were performed during 2 physical 
education periods at each time point, by the same staff in both 
schools. Parents were interviewed by telephone at baseline and after 
the intervention by trained interviewers following a standardized 
protocol. Parents, children, and teachers were not aware that the 
primary outcome was adiposity.
    Body mass index (BMI), defined as the weight in kilograms divided 
by the square of the height in meters, was the primary measure of 
adiposity. [26] [27] Standing height was measured using a portable 
direct-reading stadiometer and body weight was measured using a digital 
scale, according to established guidelines. [28] [29] Test-retest 
reliabilities were high (intraclass Spearman r>0.99 for height, r>0.99 
for weight). Triceps skinfold thickness was included as a measure of 
subcutaneous fat and was measured on the right arm, according to 
established guidelines. [28] [29] Test-retest reliability was r>0.99 
and skinfold thickness was highly correlated with BMI (r=0.82).
    Waist and hip circumferences were measured with a nonelastic tape 
at the level of the umbilicus and the maximal extension of the 
buttocks, respectively, according to established guidelines.[28] [29] 
Test-retest reliabilities were r>0.99. Waist and hip circumferences 
were correlated with BMI (r=0.87, r=0.90, respectively) and triceps 
skinfold thickness (r=0.72, r=0.78, respectively). The waist-to-hip 
ratio was calculated as a measure of body fat distribution.
    Children reported the time they spent ``watching television,'' 
``watching movies or videos on a VCR,'' and ``playing video games,'' 
separately for before school and after school, ``yesterday'' and ``last 
Saturday'' on the first assessment day, and ``yesterday'' on the second 
assessment day. Prior to reading these items, the research staff led 
children through several participatory time-estimating exercises. This 
instrument was adapted from a similar instrument previously used in 
young adolescents with high test-retest reliability (r=0.94). [15]
    Parents estimated the amount of time their child spent watching 
television, watching videotapes on the VCR, and playing video games on 
a typical school day and on a typical weekend day. Similar items have 
produced accurate estimates compared with videotaped observation. [30] 
There was moderate agreement between parent and child reports of 
children's media use (Spearman r=0.31, P<.001 for television viewing; 
r=0.17, P=.03 for videotape viewing; r=0.49, P<.001 for video game 
playing). A previously validated 4-item instrument was used to assess 
overall household television viewing. [31]
    Children and parents also estimated the amount of time the child 
spent in other sedentary behaviors, including, using a computer, doing 
homework, reading, listening to music, playing a musical instrument, 
doing artwork or crafts, talking with parents, playing quiet games 
indoors, and at classes or clubs (parent-child agreement Spearman 
r=0.16, P<.05).
    On both days children reported their previous day's out-of-school 
physical activities, using a previously validated activity checklist. 
[32] Responses from the 2 days were averaged and weighted for levels of 
intensity using standard energy expenditure estimates.[33] Parents 
estimated the amount of time their child spent in organized physical 
activities (such as teams or sports classes) and nonorganized physical 
activities (such as playing sports, bicycling, rollerblading, etc) 
(parent-child agreement Spearman r=0.16, P=.05).
    On both days, children completed 1-day food frequency recalls for 
60 foods in 26 food categories, based on instruments previously 
validated in third- through sixth-grade children. [34] [35] High-fat 
foods were those previously identified as the major contributors of fat 
in the diets of children [35] and adults, [36] and were identified 
through focus groups with children, parents, and school lunch 
personnel. Highly advertised foods included 3 categories representing 
sugary cereals, carbonated soft drinks, and foods from fast-food 
restaurants.
    Children also reported how often they ate breakfast and dinner in a 
room with the television turned on during the past week, on 4-point 
scales ranging from never to every day, and they reported the 
proportion of time they were eating or drinking a snack (not including 
meals) while watching television or videotapes or playing video games, 
on a 3-point scale. Parents responded to the same questions about their 
children, reporting the number of days in the last week for meals 
(parent-child agreement Spearman r=0.24, P=.003) and the percentage of 
time for snacking (parent-child agreement Spearman r=0.02, P>.05).
    The maximal, multistage, 20-m, shuttle run test (20-MST) was used 
to assess cardiorespiratory fitness. [37] The 20-MST has been found to 
be reliable (test-retest r=0.73-0.93), [37] a valid measure of maximum 
oxygen consumption as measured by treadmill testing (r=0.69-0.87), [38- 
42] and sensitive to change &2] in children.
                          statistical analysis
    Baseline comparability of intervention and control groups was 
assessed using nonparametric Wilcoxon rank sum tests for scaled 
variables and 2 tests for categorical variables. As a primary 
prevention program, the intervention was designed to target the entire 
sample. Effects were expected and intended to occur throughout the 
entire distribution of adiposity in the sample-not just around a 
defined threshold. Thus, for purposes of establishing the efficacy of 
this intervention, it is most appropriate to compare the full 
distributions of BMI between intervention and control groups. 
Therefore, to test the primary hypothesis, accounting for the design 
with school as the unit of randomization (adjusting for intraclass 
correlation), a mixed-model analysis of covariance approach was used, 
with postintervention BMI as the dependent variable; the intervention 
group (intervention vs control) as the independent variable; and 
baseline BMI, age, and sex as covariates (SAS MIXED procedure, SAS 
version 6.12, SAS Institute Inc, Cary, NC). [43] The same analysis 
approach was used for all secondary outcome variables, triceps skinfold 
thickness, waist and hip circumferences, waist-to-hip ratio, and 
measures of dietary intake and physical activity. Each outcome also was 
tested for intervention by sex and intervention by age interactions. 
All analyses were completed on an intention-to-treat basis, and all 
tests of statistical significance were 2-tailed with =.05.
    With an anticipated sample size of approximately 100 participants 
per group and using the above analysis, the study was designed to have 
80 percent power to detect an effect size of 0.20 or greater. This 
corresponded to estimated differences between groups of about 0.75 BMI 
units, 1.2 mm of triceps skinfold, 1.8 cm of waist circumference, and 2 
hours per week of television, videotape, and video game use.
    In children of this age, BMI, triceps skinfold thickness, waist 
circumference, and hip circumference were all expected to increase over 
the course of the experiment, as part of normal growth, in both the 
intervention and control groups. Therefore, effect sizes are reported 
as changes in the intervention group relative to changes in the 
controls (relative differences). A negative difference is termed a 
relative decrease in comparison with the controls, even if the actual 
value increased as a result of normal growth and development.
                                results
    The study design and participation are shown in Figure 1. Ninety-
two (86.8 percent) of 106 eligible children in the intervention school 
and 100 (82.6 percent) of 121 eligible children in the control school 
participated in baseline and postintervention assessments. Intervention 
and control participants, respectively, were comparable in age (mean 
[SD], 8.95 [0.64] vs 8.92 [0.70] years, P=.69), sex (44.6 percent vs 
48.5 percent girls, P=.59), mean (SD) number of televisions in the home 
(2.7 [1.3] vs 2.7 [1.1], P=.56), mean (SD) number of video game players 
(systems) (1.5 [2.3] vs 1.2 [1.7], P=.49) and percentage of children 
with a television in their bedroom (43.5 percent vs 42.7 percent, 
P=.92). Physical measures but not self-reports were included in the 
analysis for 11 children who were classified by their teachers as 
having limited English proficiency or having a learning disability.
    Baseline and postintervention telephone interviews were completed 
by 68 (71.6 percent) and 75 (72.8 percent) of the parents of 
participating children in the intervention and control schools, 
respectively. Intervention school parents reported greater maximum 
household education levels than participating control school parents 
(45 percent vs 21 percent college graduates, P=.01) but did not differ 
significantly in ethnicity (80 percent vs 70 percent white, P=.19), sex 
of respondent (82 percent vs 88 percent female, P=.33) or marital 
status (77 percent vs 67 percent married, P=.22). 



              Figure 1.--Study Design and Participant Flow

                   participation in the intervention
    Teachers reported teaching all lessons, although we did not collect 
detailed data determining whether the lessons were delivered as they 
were intended. Ninety-five (90 percent) of 106 students in the 
intervention school participated in at least some of the television 
turnoff and 71 (67 percent) completed the entire 10 days without 
watching television or videotapes or playing video games. During the 
budgeting phase of the intervention, 58 (55 percent) of the students 
turned in at least 1 signed parent confirmation that they had stayed 
below their television and videotape viewing and video game playing 
budget for the previous week. Forty-four parents (42 percent) returned 
response cards reporting they had installed the TV Allowance and 29 
families (27 percent) requested 1 or more additional TV Allowances.
                          effects on adiposity
    Results of anthropometric measures are presented in Table 1. At 
baseline, both groups were comparable (P>.10) on all baseline measures 
of body composition. As expected for children of this age, BMI, triceps 
skinfold thickness, waist circumference, and hip circumference all 
increased in both intervention and control children during the course 
of the school year. However, compared with controls, children in the 
intervention group had statistically significant relative decreases in 
BMI, triceps skinfold thickness, waist circumference, and waist-to-hip 
ratio (Table 1). There were no significant interventions by sex or 
intervention by age interactions for any of the body composition 
outcomes. The results did not change when ethnicity and parent 
education were included as additional covariates for children with 
completed parent interviews.

                                                    TABLE 1.--CHILDREN'S ANTHROPOMETRIC MEASURES \1\
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                               Baseline                      Postintervention
                                  --------------------------------------------------------------------    Adjusted Change (95% CI) \2\        P Value
                                     Intervention       Control        Intervention       Control
--------------------------------------------------------------------------------------------------------------------------------------------------------
Body cross index, kg/m\2\........     18.38 (3.67)      1810 (3.77)     18.67 (3.77)     18.81 (3.76)              -0.45 (-0.73 to -0.17)           .002
Triceps skinfold thickness, mm...     14.35 (6.06)     13.97 (5.43)     15.47 (5.95)     16.46 (5.27)              -1.47 (-2.41 to -0.54)           .002
Waist circumference, cm..........     60.48 (9.91)     59.51 (8.91)     63.57 (8.96)     64.73 (8.91)              -2.30 (-3.27 to -1.33)          <.001
Hip circumference, cm............     72.78 (8.91)     72.70 (8.78)     76.53 (7.94)     76.79 (8.37)               -0.27 (-1.08 to 0.53)           .50
Waist-to-hip ratio...............      0.83 (0.05)      0.82 (0.05)      0.83 (0.06)      0.84 (0.05)               -0.02 (0.03 to -0.01)          <.001
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Baseline and postintervention values are unadjusted mean (SD). At baseline, both groups were comparable (P>.10) on all measures of body composition.
\2\ Change estimates and 95 percent confidence intervals (CIs) are the differences between intervention group and control group after adjustment by
  mixed-model analysis of covariance for the baseline value, age, and sex.

    Although the sample size was insufficient to formally test for 
effects within subgroups, it was desirable to further characterize the 
effects of the intervention on participants with varying levels of 
adiposity, with a descriptive analysis. Intervention and control group 
changes were compared within strata defined by baseline levels of BMI, 
triceps skinfold, waist circumference, and waist-to-hip ratio. For all 
body composition measures, effects of the intervention occurred across 
the entire distribution of baseline adiposity, with greater 
intervention vs control differences evident among the middle and higher 
strata of body fatness.
           effects on media use, diet, and physical activity
    Child measures are presented in Table 2 and parent measures are 
presented in Table 3. Both groups were well matched at baseline, 
although intervention group children reported eating significantly more 
meals while watching television, and participating intervention group 
parents reported significantly less overall household television use 
and that their children spent significantly more time in other 
sedentary behaviors at baseline.

                                TABLE 2.--CHILD MEASURES OF TELEVISION VIEWING. DIET AND PHYSICAL ACTIVITY AND FITNESS \1\
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                               Baseline                      Postintervention
                                  --------------------------------------------------------------------    Adjusted Change (95% CI) \2\        P Value
                                     Intervention       Control        Intervention       Control
--------------------------------------------------------------------------------------------------------------------------------------------------------
Hours per week:
    Television...................    15.35 (13.17)    15.46 (15.02)     8.80 (10.41)    14.46 (13.82)              -5.53 (-8.64 to -2.42)          <.001
    Videotapes...................      4.74 (6.57)     5.52 (10.44)      3.46 (4.86)      5.21 (8.41)               -1.53 (-3.39 to 0.33)           .11
    Video games..................      2.57 (5.10)      3.85 (9.17)      1.32 (2.72)     4.24 (10.00)              -2.54 (-4.48 to -0.60)           .01
Meals in front of television, 0-3      2.38 (1.75)  \3\ 1.84 (1.78)      1.70 (1.49)       1.99 (178)              -0.54 (-0.98 to -0.12)           .01
 scale...........................
Frequency of snacking in front of      2.20 (0.56)      2.15 (0.61)      1.94 (0.51)      2.05 (0.59)               -0.11 (-0.27 to 0.04)           .16
 the television. 1-3 scale.......
Daily servings of high-fat foods.      6.15 (3.63)      6.62 (5.85)      5.14 (3.50)      6.17 (4.88)               -0.82 (-1.87 to 0.23)           .12
Daily serving of highly                1.36 (0.96)      1.55 (1.20)      1.47 (1.10)      1.48 (1.06)                 0.06 (-024 to 0.36)           .71
 advertised foods................
Other sedentary behaviors, h/d...      4.66 (3.81)      4.47 (6.37)      3.81 (2.66)      4.05 (4.53)               -0.34 (-1.21 to 0.52)           .44
Physical activity, metabolic         396.8 (367.8)    310.2 (250.7)    362.3 (235.2)    337.8 (277.3)               -16.7 (-78.6 to 45.3)           .60
 equivalent-weighted, min/wk.....
20-m shuttle test, laps..........     15.21 (9.60)     14.80 (8.56)    19.72 (11.40)    18.18 (10.72)                0.87 (-1.41 to 3.15)           .45
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Baseline and postintervention values are unadjusted mean (SD).
\2\ Change estimates and 95 percent confidence intervals (CIs) are the differences between groups after adjustment by mixed-model analysis of covariance
  for the baseline value, age, and sex.
\3\ Groups were significantly different (P<.05) at baseline by a nonparametraic Willcoxon rank sum test.


                               TABLE 3.--PARENT REPORTS OF CHILDREN'S TELEVISION VIEWING. DIET, AND PHYSICAL ACTIVITY \1\
--------------------------------------------------------------------------------------------------------------------------------------------------------
                                               Baseline                      Postintervention
                                  --------------------------------------------------------------------    Adjusted Change (95% CI) \2\        P Value
                                     Intervention       Control        Intervention       Control
--------------------------------------------------------------------------------------------------------------------------------------------------------
Children's hours per week:
    Television...................     12.43 (5.65)     14.90 (7.10)      8.86 (4.91)     14.75 (7.37)              -4 29 (-5.89 to -2.70)           .001
    Videotapes...................    (4.96) (4.21)      4.41 (3.72)      3.87 (2.87)      3.91 (3.21)               -0.25 (-1.19 to 0.69)           .60
    Video games..................      1.84 (2.73)      2.71 (3.78)      1.44 (1.96)      2.57 (4.41)               -0.76 (-1.75 to 0.22)           .13
Overall household television use,      7.09 (3.97)  \3\ 8.60 (3.51)      6.09 (3.64)      7.76 (3.26)               -0.77 (-1.69 to 0.14)           .10
 0-16 scale......................
No. of children's meals eaten in       3.18 (3.69)      3.53 (3.71)      2.19 (2.95)      3.43 (3.64)                -1.07(-1.96 to 0.18)           .02
 front of the television, 0-14
 meals...........................
Percentage of children's viewing     17.28 (20.91)    18.83 (41.24)    19.54 (22.43)    20.25 (22.70)               -1.94 (-9.06 to 5.17)           .59
 when snacking...................
Children's other sedentary           44.89 (19.76)    39.79 (20.27)    41.31 (20.89)    43.37 (26.75)              -4.88 (-11.69 to 1.93)           .16
 behaviors, h/wk.................                               \3\
Children's physical activity, h/      11.19 (7.16)      9.19 (5.77)     16.08 (8.45)     17.21 (9.32)               -2 00 (-4.58 to 0.59)           .13
 wk..............................
--------------------------------------------------------------------------------------------------------------------------------------------------------
\1\ Baseline and postintervention values are unadjusted mean (SD).
\2\ Change estimates and 95 percent confidence intervals (CIs) are the differences between groups after adjustment by mixed-model analysis on covariance
  for the baseline value, age, and sex.
\3\ Groups were significantly different (P<.05) at baseline by a nonparametric Willcoxon rank sum test.

    The intervention significantly decreased children's television 
viewing, compared with controls, according to both child and parent 
reports (relative reductions of about one third from baseline). 
Intervention group children also reported significantly greater 
reductions in video game use than controls. The intervention also 
resulted in greater, but not statistically significant, decreases in 
parent reports of children's video game use, parent and child reports 
of videotape viewing, and parent reports of overall household 
television viewing. There were no significant intervention by sex or 
intervention by age interactions for any of the media use outcomes.
    The intervention significantly reduced the frequency of children 
eating meals in a room with the television turned on. Intervention 
group children also reported relative reductions in servings of high-
fat foods compared with controls, although these differences were not 
statistically significant. There were no significant intervention 
effects on reports of children's physical activity levels or 
performance on the 20-MST of physical fitness. There were no 
significant intervention by sex or intervention by age interactions for 
any of the diet or activity outcomes.
                                comment
    This is the first experimental study to demonstrate a direct 
association between television, videotape, and video game use and 
increased adiposity. Because the intervention targeted reduction of 
media use alone, without substituting alternative behaviors, a causal 
inference might be made. [23] In one previous obesity treatment study, 
obese children who were reinforced (ie, rewarded) for decreasing 
sedentary activity (including television viewing and computer games, as 
well as imaginative play, talking on the telephone, playing board 
games, etc) along with following an energy-restricted diet lost 
significantly more weight than obese children reinforced for increasing 
physical activity or those reinforced for both. [44] Although that 
study did not directly test the role of television, videotape, and 
video game use, the similar findings support our results.
    This experiment was designed to overcome the dependence of 
epidemiological studies on error-prone measures of television viewing 
behaviors by using BMI as the primary outcome. However, the 
intervention did produce statistically significant decreases in 
reported television viewing and video game use, compared with controls. 
Previous studies of reducing children's television viewing have been 
uncontrolled and limited to a small number of families. [45] [46] [47] 
This study, therefore, also represents a promising model for studying 
other hypothesized effects of television and videotape viewing and 
video game use.
    Because this study involved children in only 2 elementary schools, 
the possibility that the results were due to differences in the groups 
that were unrelated to the intervention cannot be ruled out completely. 
This possibility is made less likely, however, because the schools were 
in a single school district and participants were comparable at 
baseline on almost all measured variables. In addition, the patterns of 
the results strengthen the case for causal inference. The crossover 
patterns of the changes in BMI, triceps skinfold thickness, waist 
circumference, and waist-to-hip ratio lessen the likelihood of scaling 
(a ``ceiling effect''), regression, and selection-maturation biases as 
alternative interpretations of the results. [48] [49]
    Effects of the intervention on diet and activity were less clear. 
Compared with controls, children in the intervention group 
significantly reduced the number of meals they reportedly ate in front 
of the television set. There were no significant effects on reports of 
snacking while watching television or intake of high-fat and highly 
advertised foods. However, because snacking while watching television 
was assessed as a proportion, even no change in this variable might 
result in decreased energy intake as total viewing was decreased. 
Epidemiological studies have found associations among hours of 
television viewing and children's fat and energy intakes, [15] [50] and 
experimental studies have shown that food advertising affects 
children's snack choices and consumption. [51] [52]
    Some epidemiological studies have found weak inverse associations 
between hours of television viewing and physical activity [14] [18] and 
fitness. [8] [16] Our intervention did not result in a significant 
change in physical activity or cardiorespiratory fitness. However, 
because only moderate- and vigorous-intensity activities were assessed, 
it is also possible that reductions in television viewing resulted in 
increased energy expenditure via more low-intensity activity. This is 
consistent with the finding that reductions in television, videotape, 
and video game use did not result in compensatory increases in other 
sedentary pursuits. Larger experimental studies and improved measures 
of diet and activity are needed to more definitively assess the 
specific mechanisms that account for changes in adiposity in response 
to reduced television, videotape, and video game use.
    With a few exceptions, previous prevention interventions that have 
attempted to increase physical activity and decrease dietary fat and 
energy intake have been relatively ineffective at reducing body 
fatness. [4] [5] In contrast, this intervention targeting only 
television, videotape, and video game use produced statistically 
significant and clinically significant relative changes in BMI, triceps 
skinfold thickness, waist circumference, and waist-to-hip ratio over a 
period of 7 months. These changes occurred over the entire sample, 
shifting the entire distribution of adiposity downward. Even a small 
shift downward in the population distribution of adiposity would be 
expected to have large effects on obesity-related morbidity and 
mortality. [53] Additional experimental studies with larger and more 
sociodemographically diverse samples are needed to evaluate the 
generalizability of these findings. However, this study indicates that 
reducing television, videotape, and video game use may be a promising, 
population-based approach to help prevent childhood obesity.
    Funding/Support.--This work was funded by a grant from the American 
Heart Association, California Affiliate, and by grant RO1 HL54102 from 
the National Heart, Lung, and Blood Institute, Bethesda, Md. The study 
was completed during the tenure of a Clinician-Scientist Award from the 
American Heart Association.
    Acknowledgment.--I thank Marta Luna Wilde, MA, Joel D. Killen, PhD, 
Dina L. G. Borzekowski, EdD, K. Farish Haydel, Ann Varady, MS, Sally 
McCarthy, and the students, teachers, and administrators who 
participated in this project.
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    [32] Sallis JF, Strikmiller PK, Harsha DW, et al. Validation of 
interviewer- and self-administered physical activity checklists for 
fifth grade students. Med Sci Sports Exerc. 1996;28:840-851.
    [33] Ainsworth BE, Haskell WL, Leon AS, et al. Compendium of 
physical activities: classification of energy costs of human physical 
activities. Med Sci Sports Exerc. 1993;25:71-80.
    [34] Baranowski T, Dworkin R, Henske JC, et al. The accuracy of 
children's self reports of diet: family health project. J Am Diet 
Assoc. 1986;86:1381-1385.
    [35] Simons-Morton BG, Baranowski T, Parcel GS, O'Hara NM, Matteson 
RC. Children's frequency of consumption of foods high in fat and 
sodium. Am J Prev Med. 1990;6:218-227.
    [36] Block G, Clifford C, Naughton MD, Henderson M, McAdams M. A 
brief dietary screen for high fat intake. J Nutr Educ. 1989;21:199-207.
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metre shuttle run test for aerobic fitness. J Sports Sci. 1988;6:93-
101.
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of the 20-meter shuttle test in American students 12 to 15 years old. 
Res Q Exerc Sport. 1992;63:360-365.
    [39] Mahoney C. 20-MST and PWC170 validity in non-Caucasian 
children in the UK. Br J Sports Med. 1992;26:45-47.
    [40] Boreham CAG, Paliczka VJ, Nichols AK. A comparison of the 
PWC170 and 20-MST tests of aerobic fitness in adolescent 
schoolchildren. J Sports Med Phys Fitness. 1990;30:19-23.
    [41] van Mechelen W, Hlobil H, Kemper HCG. Validation of two 
running tests as estimates of maximal aerobic power in children. Eur J 
Appl Physiol. 1986;55:503-506.
    [42] Ahmaidi SB, Varray AL, Savy-Pacaux AM, Prefaut CG. 
Cardiorespiratory fitness evaluation by shuttle test in asthmatic 
subjects during aerobic training. Chest. 1993;103:1135-1141.
    [43] Murray DM. Design and Analysis of Group-Randomized Trials. New 
York, NY: Oxford University Press; 1998.
    [44] Epstein LH, Valoski AM, Vara LS, et al. Effects of decreasing 
sedentary behavior and increasing activity on weight change in obese 
children. Health Psychol. 1995;14:109-115.
    [45] Wolfe DA, Mendes MG, Factor D. A parent-administered program 
to reduce children's television viewing. J Appl Behav Anal. 
1984;17:267-272.
    [46] Jason LA. Using a token-actuated timer to reduce television 
viewing. J Appl Behav Anal. 1985;18:269-272.
    [47] Jason LA, Johnson SZ, Jurs A. Reducing children's television 
viewing with an inexpensive lock. Child Fam Behav Ther. 1993;15:45-54.
    [48] Bracht GH, Glass GV. The external validity of experiments. Am 
Educ Res J. 1968;5:437-474.
    [49] Cook TD, Campbell DT. Quasi-Experimentation: Design & Analysis 
Issues for Field Settings. Boston, Mass: Houghton Mifflin Co; 1979.
    [50] Taras HL, Sallis JF, Patterson TL, Nader PR, Nelson JA. 
Television's influence on children's diet and physical activity. J Dev 
Behav Pediatr. 1989;10:176-180.
    [51] Gorn GJ, Goldberg ME. Behavioral evidence for the effects of 
televised food messages on children. J Consumer Res. 1982;9:200-205.
    [52] Jeffrey DB, McLellarn RW, Fox DT. The development of 
children's eating habits: the role of television commercials. Health 
Educ Q. 1982;9:78-93.
    [53] Rose G. Strategies of prevention: the individual and the 
population. In: Marmot M, Elliott P, eds. Coronary Heart Disease 
Epidemiology: From Aetiology to Public Health. Oxford, England: Oxford 
University Press; 1992.
                                 ______
                                 

[From the Archives of Pediatrics of Adolescent Medicine, Vol. 162 (No. 
                            3), March 2008]

 A Randomized Trial of the Effects of Reducing Television Viewing and 
           Computer Use on Body Mass Index in Young Children

 (Leonard H. Epstein, PhD, James N. Roemmich, PhD, Jodie L. Robinson, 
MA, MBA, Rocco A. Paluch, MA, Dana D. Winiewicz, Janene H. Fuerch, and 
                      Thomas N. Robinson, MD, MPH)
 [available on the web at: http://archpedi.ama-assn.org/content/vo1162/
                           issue3/index.dt1]
    Objective.--To assess the effects of reducing television viewing 
and computer use on children's body mass index (BMI) as a risk factor 
for the development of overweight in young children.
    Design.--Randomized controlled clinical trial.
    Setting.--University children's hospital.
    Participants.--Seventy children aged 4 to 7 years whose BMI was at 
or above the 75th BMI percentile for age and sex.
    Interventions.--Children were randomized to an intervention to 
reduce their television viewing and computer use by 50 percent vs a 
monitoring control group that did not reduce television viewing or 
computer use.
    Main Outcome Measures.--Age- and sex-standardized BMI (zBMI), 
television viewing, energy intake, and physical activity were monitored 
every 6 months during 2 years.
    Results.--Children randomized to the intervention group showed 
greater reductions in targeted sedentary behavior (P<.001), zBMI 
(P<.05), and energy intake (P<.05) compared with the monitoring control 
group. Socioeconomic status moderated zBMI change (P=.01), with the 
experimental intervention working better among families of low 
socioeconomic status. Changes in targeted sedentary behavior mediated 
changes in zBMI (P<.05). The change in television viewing was related 
to the change in energy intake (P<.001) but not to the change in 
physical activity (P=.37).
    Conclusions.--Reducing television viewing and computer use may have 
an important role in preventing obesity and in lowering BMI in young 
children, and these changes may be related more to changes in energy 
intake than to changes in physical activity.
    Trial Registration.--Clinical trials.gov Identifier: NCT00065052
                              introduction
    Television viewing is cross-sectionally and prospectively related 
to obesity in children.\1\ \2\ There is limited research assessing the 
effect of reducing television viewing on the development of obesity.\3\ 
\4\ \5\ School-based interventions have shown that reducing television 
viewing in third- and fourth-grade students slowed the increase in body 
mass index (BMI) (calculated as weight in kilograms divided by height 
in meters squared) \3\ and that reduction in television viewing was 
related to success of a multicomponent obesity prevention program.\4\ 
Reducing television viewing in preschool children was associated with a 
reduction in parent-reported television viewing, but no changes in BMI 
were observed.\5\ Little research has involved children aged 4 to 7 
years as they transition into their early school years.
---------------------------------------------------------------------------
    \1\ Dietz, WH, Jr; Gortmaker, SL. Do we fatten our children at the 
television set? obesity and television viewing in children and 
adolescents. Pediatrics. 1985;75(5):807-812.
    \2\ Gortmaker, SL; Must, A; Sobol, AM; Peterson, K; Colditz, GA; 
Dietz, WH. Television watching as a cause of increasing obesity among 
children in the United States, 1986-1990. Arch Pediatr Adolesc Med. 
1996;150(4):356-362.
    \3\ Robinson, TN. Reducing children's television viewing to prevent 
obesity: a randomized controlled trial. JAMA. 1999;282(16):1561-1567.
    \4\ Gortmaker, SL; Peterson, K; Wiecha, J, et al. Reducing obesity 
via a school-based interdisciplinary intervention among youth: Planet 
Health. Arch Pediatr Adolesc Med. 1999;153(4):409-418.
    \5\ Dennison, BA; Russo, TJ; Burdick, PA; Jenkins, PL. An 
intervention to reduce television viewing by preschool children. Arch 
Pediatr Adolesc Med. 2004;158(2):170-176.
---------------------------------------------------------------------------
    Reducing sedentary behavior could affect body weight by modifying 
energy intake or energy expenditure in several ways. Television viewing 
is related to consumption of fast food \6\ and foods and beverages that 
are advertised on television.\7\ Viewing cartoons with embedded food 
commercials can increase choice of the advertised item in 
preschoolers,\8\ and television commercials may prompt eating.\9\ \10\ 
\11\ Television viewing or related sedentary behavior may prompt eating 
by the association of these behaviors with eating, and television 
viewing and related behavior may impair the development of satiety by 
interfering with habituation to gustatory and olfactory cues.\12\ \13\ 
\14\ \15\ Reducing television viewing decreased energy and fat intake 
in lean adolescents.\16\ Television viewing and related sedentary 
behavior can compete with physical activity, lowering energy 
expenditure.\11\ \17\ \18\ When sedentary behavior is reduced, children 
may choose to engage in other sedentary behavior or to reallocate time 
to be more physically active,\19\ \20\ \21\ \22\ although the 
reallocation depends on child characteristics.\23\
---------------------------------------------------------------------------
    \6\ Taveras, EM; Sandora, TJ; Shih, MC; Ross-Degnan, D; Goldmann, 
DA; Gillman, MW. The association of television and video viewing with 
fast food intake by preschool-age children. Obesity (Silver Spring). 
2006;14(11):2034-2041.
    \7\ Utter, J; Scragg, R; Schaaf, D. Associations between television 
viewing and consumption of commonly advertised foods among New Zealand 
children and young adolescents. Public Health Nutr. 2006;9(5):606-612.
    \8\ Borzekowski, DL; Robinson, TN. The 30-second effect: an 
experiment revealing the impact of television commercials on food 
preferences of preschoolers. J Am Diet Assoc. 2001;101(1):42-46.
    \9\ Jeffrey, DB; McLellam, RW; Fox, DT. The development of 
children's eating habits: the role of television commercials. Health 
Educ Q. 1982;9(2-3):174-189.
    \10\ Galst, JP. Television food commercials and pro-nutritional 
public service announcements as determinants of young children's snack 
choices. Child Dev. 1980;51(3):935-938.
    \11\ Taras, HL; Sallis, JF; Patterson, PR; Nader, PR; Nelson, JA. 
Television's influence on children's diet and physical activity. J Dev 
Behav Pediatr. 1989;10(4):176-180.
    \12\ Epstein, LH; Rodefer, JS; Wisniewski, L; Caggiula, AR. 
Habituation and dishabituation of human salivary response. Physiol 
Behav. 1992;51(5):945-950.
    \13\ Epstein, LH; Paluch, R; Smith, JD; Sayette, M. Allocation of 
attentional resources during habituation to food cues. 
Psychophysiology. 1997;34(1):59-64.
    \14\ Wisniewski, L; Epstein, LH; Caggiula, AR. Effect of food 
change on consumption, hedonics, and salivation. Physiol Behav. 
1992;52(1):21-26.
    \15\ Temple, JL; Giacomelli, AM; Kent, KM; Roemmich, JN; Epstein, 
LH. Television watching increases motivated responding and energy 
intake in children. Am J Clin Nutr. 2007;85(2):355-361.
    \16\ Epstein, LH; Roemmich, JN; Paluch, RA; Raynor, HA. The 
influence of changes in sedentary behavior on energy and macronutrient 
intake in youth. Am J Clin Nutr. 2005;81(2):361-366.
    \17\ Buchowski, MS; Sun, M. Energy expenditure, television viewing 
and obesity. Int J Obes Relat Metab Disord. 1996;20(3):236-244.
    \18\ DuRant, RH; Baranowski, T; Johnson, M; Thompson, WO. The 
relationship among television watching, physical activity, and body 
composition of young children. Pediatrics. 1994;94(4 pt 1):449-455.
    \19\ Epstein, LH; Valoski, AM; Vara, LS, et al. Effects of 
decreasing sedentary behavior and increasing activity on weight change 
in obese children. Health Psychol. 1995;14(2):109-115.
    \20\ Epstein, LH; Saelens, BE; O'Brien, JG. Effects of reinforcing 
increases in active behavior versus decreases in sedentary behavior for 
obese children. Int J Behav Med. 1995;2(1):41-50.
    \21\ Epstein, LH; Smith, JA; Vara, LS; Rodefer, JS. Behavioral 
economic analysis of activity choice in obese children. Health Psychol. 
1991;10(5):311-316.
    \22\ Saelens, BE; Epstein, LH. The rate of sedentary activities 
determines the reinforcing value of physical activity. Health Psychol. 
1999;18(6):655-659.
    \23\ Epstein, LH; Roemmich, JN; Paluch, RA; Raynor, HA. Physical 
activity as a substitute for sedentary behavior in youth. Ann Behav 
Med. 2005;29(3):200-209.
---------------------------------------------------------------------------
    The primary objective of this study was to determine the effects of 
reducing television viewing and computer use on age- and sex-
standardized BMI (zBMI) changes in a sample of children aged 4 to 7 
years who were at or above the 75th BMI percentile. Because BMI is 
positively associated with chronic disease risk factors in children 
\24\ and because childhood BMI predicts adult BMI,\25\ these young at-
risk children are an appropriate target group for prevention programs. 
Secondary aims were to assess the effects of television viewing on 
energy intake and on energy expenditure. The study was approved by the 
Social and Behavioral Sciences Institutional Review Board at the State 
University of New York at Buffalo.
---------------------------------------------------------------------------
    \24\ Freedman, DS; Dietz, WH; Srinivasan, SR; Berenson, GS. The 
relation of overweight to cardiovascular risk factors among children 
and adolescents: the Bogalusa Heart Study. Pediatrics. 1999;103(6 pt 
1):1175-1182.
    \25\ Whitaker, RC; Wright, JA; Pepe, MS; Seidel, KD; Dietz, WH. 
Predicting obesity in young adulthood from childhood and parental 
obesity. N Engl J Med. 1997;337(13):869-873.
---------------------------------------------------------------------------
                                methods
Participants
    Families were recruited through newspaper advertisements, flyers, 
and direct mailings targeting families with children aged 4 to 7 years. 
Inclusion criteria were a child aged 4 to 7 years at or above the 75th 
BMI percentile for age and sex,\26\ participation in at least 14 hours 
of television viewing and computer game playing per week in the primary 
household, no medical conditions that prevented or interfered with 
regular physical activity, unlimited access to television or 
television-related sedentary activities, and family agreement to have 
television monitoring devices (TV Allowance; Mindmaster Inc, Miami, 
Florida) attached to every television and computer monitor in the home 
for the duration of the study.
---------------------------------------------------------------------------
    \26\ Kuczmarski, RJ; Ogden, CL; Guo, SS, et al. 2000 CDC Growth 
Charts for the United States: methods and development. Vital Health 
Stat 11. 2002;246(246):1-90.
---------------------------------------------------------------------------
Procedures
    After completing a telephone screen, families attended an 
orientation, and, if interested, parents read and signed the informed 
consent and then completed a questionnaire that assessed the numbers of 
televisions, television video game units, VCR and DVD players, and 
computers in the home. Approximately 1 week later, a TV Allowance was 
attached to each television and computer monitor in the home by a 
research assistant (D.D.W. or J.H.F.), who recorded the numbers of 
televisions and computers and their locations in the home. The TV 
Allowance is an automated device that controls and monitors the use of 
televisions or computer monitors, including television, video game 
systems, DVD players, VCRs, and computers. The appliance was plugged 
into the TV Allowance, the plug was locked in, and the device was 
plugged into the wall. To turn on the television or computer monitor, 
each family member used an individually selected 4-digit code. To 
protect against the participating child watching television or playing 
a computer game on other family members' time, the participating child 
was not informed of the codes of other family members. If the child 
learned the codes of another family member, these codes were changed. 
The TV Allowance sums the minutes of use for each code to objectively 
determine use of that device.
    Baseline television and computer use was measured during a 3-week 
period. Seventy families met eligibility criteria and were randomized 
into intervention and control groups (Figure 1). Families were 
recruited in cohorts, were stratified by child sex, and were randomized 
by the study statistician (R.A.P.) in blocks of 2 without replacement 
using a random number generator limited to 2 numbers. Group assignments 
were provided to the project coordinator (J.L.R.).



                   Figure 1.--Overview of Study Flow

    Study staff (D.D.W. and J.H.F.) set the weekly time budgets for 
television viewing, computer use, and associated behaviors. Budgets 
were reduced by 10 percent of their baseline amount per month for 
children in the intervention group until the budget was reduced by 50 
percent. When the budget was reached, the television or computer 
monitor could not be turned on for the remainder of the week. Study 
staff could set different amounts of time for each child in a 
household, if desired, to reduce conflict if another child was not on 
the program. Parents and non-participating family members could use 
their code to watch television or to use computers without being on a 
budget.
    Children in the intervention group earned $.25 for each half hour 
under budget, up to $2 per week. Parents were instructed to praise the 
participating child for reducing television viewing and for engaging in 
alternative behaviors. Decreases were also reinforced by a star chart. 
At each home visit, a study staff member reviewed the star chart and 
praised the child for the number of stickers earned. When the child 
reached the 50 percent decrease at 6 months, the star charts were 
discontinued, and changes were supported through monthly newsletters 
and by parental praise for behavior change. The intervention group 
received ideas for alternatives to sedentary behavior, a tailored 
monthly newsletter with parenting tips to reduce sedentary behavior, 
and information about how to rearrange the home environment to reduce 
access to sedentary behavior. Children in the control group were 
provided free access to television and computers and received $2 per 
week for participating, independent of their behavior change. Control 
families received a newsletter to provide parenting tips, sample praise 
statements, and child-appropriate activities and recipes.
Measures
    Television and computer time were measured using the TV Allowance. 
Body mass index was calculated based on weight measured using a digital 
or calibrated balance beam scale and height measured using a calibrated 
stadiometer. The zBMI was calculated using age- (to the nearest month) 
and gender-specific median, standard deviation, and power of the Box-
Cox transformation (LMS method).\26\ Physical activity was monitored 
using an activity monitor (ActiGraph; ActiGraph, LLC, Pensacola, 
Florida), a unidirectional accelerometer validated for children.\27\ 
\28\ \29\ Physical activity was recorded in 1-minute epochs on 3 
randomly selected weekdays from after school until bedtime and all day 
for 1 randomly selected weekend day. The mean counts per minute during 
the 4 days was the measure of physical activity. Energy intake (in 
kilocalories per day) was measured for the month before the assessment 
using a validated \30\ 85-item food frequency questionnaire completed 
by the participating parent. The numbers of televisions, computers, and 
pieces of exercise equipment were measured by interviews with the 
participating parent and child, as were the characteristics of the 
neighborhood environment (including distance in miles to the nearest 
park or playground, number of activities the child engaged in per week 
in the neighborhood environment, and perceived safety of the 
neighborhood on a scale of 1 to 5 [1, unsafe; 5, very safe]). 
Socioeconomic status (SES) was measured using the Four Factor Index of 
Social Status by Hollingshead,\31\ which provides a continuous measure 
based on parental occupation and education.
---------------------------------------------------------------------------
    \27\ Pate, RR; Baranowski, T; Dowda, M; Trost, SG. Tracking of 
physical activity in young children. Med Sci Sports Exerc. 
1996;28(1):92-96.
    \28\ Trost, SG; Ward, DS; Moorehead, SM; Watson, PD; Riner, W; 
Burke, JR. Validity of the Computer Science and Applications (CSA) 
activity monitor in children. Med Sci Sports Exerc. 1998;30(4):629-633.
    \29\ Ekelund, U; Sjostrom M; Yngve, A, et al. Physical activity 
assessed by activity monitor and doubly labeled water in children. Med 
Sci Sports Exerc. 2001;33(2):275-281.
    \30\ Blum, RE; Wei, EK; Rockett, HR, et al. Validation of a food 
frequency questionnaire in Native American and Caucasian children 1 to 
5 years of age. Matern Child Health J. 1999;3(3):167-172.
    \31\ Hollingshead, AB. Four Factor Index of Social Status. New 
Haven, CT: Yale University; 1975.
---------------------------------------------------------------------------
Data Analysis Plan
    t Tests and x \2\ tests were used to assess comparability of 
groups. Mixed-effects regression models (MRMs) were used to assess 
zBMI, television viewing, energy intake, and physical activity over 
time. The MRMs do not assume compound symmetry but use separate 
estimates of variance at each measurement, which is important because 
variability often increases as follow-up is extended, and MRMs use all 
available data.\32\ The models for targeted sedentary behavior, energy 
intake, and physical activity included group, SES, and child age and 
sex as time-invariant fixed effects, as well as a random intercept. 
Child age and sex were excluded from the zBMI model because the zBMI 
values were standardized for age and sex. The usual pattern of change 
in behavioral studies is a decrease during the initial phases of 
intervention, followed by maintenance of change or relapse. To capture 
these patterns of change, linear (months) and quadratic (months  
months) interactions with group were tested. Linear and quadratic 
interactions with group were evaluated for improvement of fit for the 
overall model by 2-tailed log likelihood tests using 2 df. If adding 
the quadratic term did not improve the fit of the model, it was not 
included to test the interaction of group  months. Group  months 
interactions were explored by examining between-group differences from 
baseline to 6, 12, 18, or 24 months.
---------------------------------------------------------------------------
    \32\ Hedeker, D; Gibbons, RD. Longitudinal Data Analysis. Hoboken, 
NJ: John Wiley & Sons; 2006.
---------------------------------------------------------------------------
    Three families moved out of state during the 2-year measurement 
period, so the primary analysis was based on 67 of 70 families (96 
percent). Complete data were available for 66 of 67 families because 1 
family withdrew before the 2-year follow-up, but all available data 
were included in the MRM analysis. The primary analysis was based on 
families who did not move because families who moved could not be 
provided with the intervention, as it required implementation of the TV 
Allowance and regular home monitoring. Intent-to-treat MRM analyses 
were also completed, including the 3 families who moved.
    The MRMs were used to evaluate moderators, mediators of outcome, 
and nonspecific predictors.\33\ Moderators are baseline variables that 
differentially predict outcomes of the groups and were evaluated by the 
interaction of group  potential moderator  months (linear and 
quadratic models as appropriate). Potential moderators included sex, 
age, SES, energy intake, physical activity, baseline levels of targeted 
sedentary behavior, and the numbers of televisions and computers in the 
home and in the child's bedroom. Moderators were chosen to represent 
baseline characteristics that could affect change but were not based on 
specific theoretical hypotheses.
---------------------------------------------------------------------------
    \33\ Kraemer, HC; Wilson, GT; Fairburn, CG; Agras, WS. Mediators 
and moderators of treatment effects in randomized clinical trials. Arch 
Gen Psychiatry. 2002;59(10):877-883.
---------------------------------------------------------------------------
    Mediators are variables that differentially change between groups, 
and the differential change is related to change in the dependent 
variable. Only time-variant predictors that show between-group 
differences can be considered mediators, and these were tested by the 
interaction of group  potential mediator  months (linear and 
quadratic models as appropriate).
    Nonspecific predictors are baseline or time variant variables that 
predict change in the dependent variable but do not interact with the 
group. Nonspecific predictors included variables assessed as moderators 
and mediators. The MRMs are particularly useful for studying mediators 
or nonspecific predictors over time because the MRM allows for time-
variant (repeated) measures as independent and dependent variables.
    The MRMs were used to estimate the elasticity between changes in 
television viewing and physical activity or energy intake. Elasticity 
is an economic construct that represents the relationships between 
proportional changes in television viewing and physical activity or 
energy intake. Elasticity coefficients are determined using log values 
in the regression models.\34\ \35\ The finding of a statistically 
significant positive relationship suggests that the 2 behaviors are 
complements. For example, energy intake would be a complement to 
television viewing and computer game playing if there was a 
statistically significant positive relationship between the change in 
television and computer use and energy intake. The finding of a 
statistically significant negative relationship suggests that the 2 
behaviors are substitutes. Physical activity would be considered a 
substitute for watching television or playing computer games if 
physical activity increased in association with a reduction in 
television viewing and computer game playing.
---------------------------------------------------------------------------
    \34\ Epstein, LH; Raja, S; Gold, SS; Paluch, RA; Pak, Y; Roemmich, 
JN. Reducing sedentary behavior: the relationship between park area and 
the physical activity of youth. Psychol Sci. 2006;17(8):654-659.
    \35\ Epstein, LH; Handley, EA; Dearing, KK, et al. Purchases of 
food in youth: influence of price and income. Psychol Sci. 
2006;17(1):82-89.
---------------------------------------------------------------------------
    Sample size estimates were based on research about the effects of 
reducing sedentary behavior on BMI changes.\3\ We estimated that with 
30 subjects per group we had 80 percent power to detect a standardized 
effect size (Cohen d) of at least 0.23 at a 2-sided a level of .05 for 
the primary outcome variable of zBMI using a repeated-measures analysis 
of variance with 5 repeated measures (0, 6, 12, 18, and 24 months). 
Analyses were performed using commercially available software (SYSTAT 
11.0; Systat Software, Inc, Richmond, California).\36\
---------------------------------------------------------------------------
    \36\ Systat Software, Inc. SYSTAT 11.0. Richmond, CA: Systat 
Software Inc; 2004.
---------------------------------------------------------------------------
                                results
    There were no statistically significant differences in baseline 
characteristics among the participants (Table). Fifty-six of 70 
children (80 percent) were above the 85th BMI percentile, and 31 of 
them (44 percent) were above the 95th BMI percentile.

                     CHARACTERISTICS OF PARTICIPANTS
------------------------------------------------------------------------
                                           Control Group   Intervention
             Characteristic                   (n=34)       Group (n=36)
------------------------------------------------------------------------
Age, mean (SD), y.......................       6.1 (1.3)       5.8 (1.2)
Male to female ratio....................           18:16           19:17
BMI (SD)................................      19.1 (3.5)      19.3 (2.5)
Age- and sex-standardized BMI, mean (SD)     1.51 (0.57)     1.69 (0.58)
Television viewing and computer use,         26.1 (10.1)     24.2 (10.8)
 mean (SD), h/wk........................
Physical acitivity counts per min, mean    783.5 (249.1)   757.0 (256.4)
 (SD) \1\...............................
Energy intake per day, mean (SD), kcal..         1,562.6         1,551.4
                                                 (474.0)         (515.3)
Socioeconomic status, mean (SD) \2\.....     42.0 (13.0)     44.3 (10.6)
Minority race/ethnicity, No. (%) \3\....       9/34 (27)       8/36 (22)
Home environment, No. (%):
    Television..........................       2.9 (1.4)       2.9 (1.2)
    Computers...........................       1.0 (0.6)       1.1 (0.6)
Pieces of home exercise equipment, mean        1.4 (1.2)       1.8 (1.1)
 (SD)...................................
Neighborhood environment, mean (SD):
    Blocks to nearest park or playground       3.7 (2.8)       3.3 (2.2)
    Activities per wk in the                   6.6 (3.6)       6.4 (3.8)
     neighborhood.......................
    Perceived safety on a scale of 1           3.4 (1.5)       3.9 (1.2)
     (safe) to 5 (dangerous)............
------------------------------------------------------------------------
Abbreviation: BMI, body mass index (calculated as weight in kilograms
  divided by height in meters squared).
\1\ Based on accelerometer counts per minute.
\2\ Based on parental occupation and education.
\3\ Includes families of Hispanic, African American, Native American,
  and multiple races/ethnicities.

    In the control group, the mean (SEM) number of hours of television 
viewing and computer games declined by -5.2 (11.1) hours per week at 24 
months (Figure 2). In contrast, the mean (SEM) number of hours of 
television viewing and computer games in the intervention group 
declined by -17.5 (7.0) hours per week at 6 months and remained about 
the same through 24 months (P<.001 for group  months interaction). 
Statistically significant between-group differences (P<.001) were 
observed at 6 through 24 months.



   Figure 2.--Reduction from baseline in targeted sedentary behavior 
(television viewing and computer use) for the intervention and control 
groups over time. A statistically significant difference in the rate of 
  change by group was observed (P<.001). Data are given as mean (SEM).

    A statistically significant interaction of group x months was 
observed for zBMI (P<.05), as zBMI decreased a mean (SEM) of -0.24 
(0.32) at 24 months for the intervention group, while the control group 
demonstrated a mean (SEM) zBMI increase of 0.05 (0.29) at 6 months, a 
return to baseline at 12 months, and a gradual mean (SEM) zBMI decrease 
of -0.13 (0.37) at 24 months after baseline (Figure 3). Statistically 
significant between-group differences were observed from baseline to 6 
months (P=.02) and 12 months (P=.03).





   Figure 3.--Reduction in age- and sex-standardized body mass index 
  (zBMI) values relative to baseline for the intervention and control 
groups over time. A statistically significant difference in the rate of 
 change in zBMI by group was observed (P<.05). Data are given as mean 
                                 (SEM).

    Energy intake data showed a greater reduction for the intervention 
group than for the control group (P<.05), with statistically 
significant between-group differences from baseline to 18 months and 24 
months (P=.047) (Figure 4). No statistically significant between-group 
changes over time were observed for changes in physical activity, as 
the control group demonstrated mean (SEM) changes in physical activity 
counts per minute of 43.7 (302.2), 7.8 (316.9), -23.5 (262.4), and -
62.7 (189.7) at 6, 12, 18, and 24 months, respectively, while the 
intervention group demonstrated mean (SEM) changes in physical activity 
counts per minute of 36.2 (381.3), 63.7 (288.8), 111.8 (603.0), and 
31.4 (275.4) at the same time points, respectively.



Figure 4.--Reduction in energy intake for the intervention and control 
groups over time. A statistically significant difference in the rate of 
 change in energy intake by group was observed (P<.05). Data are given 
                             as mean (SEM).

    Socioeconomic status was a statistically significant moderator of 
zBMI change (group xSES  months; P=.01) (Figure 5). This effect was 
explored by dividing the sample based on SES into 2 groups at the mean 
SES and by examining changes in zBMI by group. For the low SES group, 
statistically significant between-group differences were observed from 
baseline to 6 months (P=.002), 12 months (P=.02), 18 months (P=.04), 
and 24 months (P=.05), while no statistically significant between-group 
differences in zBMI change were observed for the high SES group. Tele 
vision and computer use mediated the effect of group on zBMI values 
over time (group xtargeted sedentary behavior x months; P<.05). 
Baseline zBMI was a nonspecific predictor of zBMI change (coefficient, 
0.008; P<.001), with lower zBMI baseline values associated with greater 
change. However, care should be used in interpreting the direction of 
the relationship between baseline zBMI values and zBMI change over time 
because of the distribution of zBMI values.\37\ Log changes in targeted 
sedentary behavior were complemented by log changes in energy intake 
(coefficient [SE], 0.10 [0.03]; P<.001), while physical activity was 
not a substitute for targeted sedentary behavior (coefficient [SE], -
0.03 [0.03]; P=.37).
---------------------------------------------------------------------------
    \37\ Paluch, RA; Epstein, LH; Roemmich, JN. Comparison of methods 
to evaluate changes in relative body mass index in pediatric weight 
control. Am J Hum Biol. 2007;19(4):487-494. 



 Figure 5.--Change in age- and sex-standardized body mass index (zBMI) 
  values relative to baseline for the intervention and control groups 
over time. A statistically significant difference in the rate of change 
  in zBMI by group for families divided into lower (A) and higher (B) 
socioeconomic status (SES) was observed (P=.01). Data are given as mean 
                                 (SEM).

                                comment
    This randomized controlled trial showed a statistically significant 
and sustained reduction in television viewing and computer use that was 
associated with decreases in zBMI for children whose BMI was at or 
above the 75th percentile for age and sex. Results of the mediator 
analyses suggest that zBMI changes were mediated by targeted sedentary 
behavior changes. Our findings show that television viewing and 
computer use can be modified in young children using behavioral 
engineering technology that provides parental control over a child's 
screen time budget while giving the child the opportunity to choose how 
to spend this budget.
    The trend for zBMI in the intervention group was a gradual 
reduction during the 2 years of observation, while the control group 
demonstrated an increase followed by gradual decreases. Differential 
changes from baseline to 6 and 12 months were statistically 
significant. The largest zBMI difference between groups was -0.19 at 6 
months, which decreased to -0.13, -0.10, and -0.11 at 12, 18, and 24 
months, respectively. Although the changes were modest, a small effect 
of this simple and inexpensive intervention (approximately $100 for 
each TV Allowance) magnified across the population may produce 
important reductions in the prevalence of obesity and obesity-related 
comorbidities.\38\
---------------------------------------------------------------------------
    \38\ Rose, G. Strategy of prevention: lessons from cardiovascular 
disease. Br Med J (Clin Res Ed). 1981;282(6279):1847-1851.
---------------------------------------------------------------------------
    The changes in zBMI were moderated by child SES, with the 
intervention working best for families of lower SES. Children from 
families of higher SES showed reductions in zBMI whether they were in 
the intervention group or the control group. Families of lower SES 
showed large and sustained zBMI differences between the intervention 
and control families throughout the 2 years of measurement of -0.17, 
-0.20, -0.17 and -0.26 at 6, 12, 18 and 24 months, respectively. The 
observation that the intervention worked better for families of lower 
SES than of higher SES is important because children of low SES are at 
greater risk of becoming obese adults than children of higher SES.\39\ 
\40\ Perhaps families of higher SES were more aware than families of 
lower SES of information linking television viewing to weight in 
children, and perhaps families of higher SES had the familial resources 
and parenting skills needed to modify television viewing without use of 
the TV Allowance. No differences in family characteristics between 
groups of lower SES vs higher SES were found, including no differences 
in the breakdown among families of minority races/ethnicities in the 
lower (22.6 percent) and higher (22.2 percent) SES groups. Future re 
search should explore differences between SES groups that may mediate 
these effects.
---------------------------------------------------------------------------
    \39\ Parsons, TJ; Power, C; Logan, S; Summerbell, CD. Childhood 
predictors of adult obesity: a systematic review. Int J Obes Relat 
Metab Disord. 1999;23(suppl 8):S1-S107.
    \40\ Janssen, I; Boyce, WF; Simpson, K; Pickett, W. Influence of 
individual- and area-level measures of socioeconomic status on obesity, 
unhealthy eating, and physical inactivity in Canadian adolescents. Am J 
Clin Nutr. 2006;83(1):139-145.
---------------------------------------------------------------------------
    Changes in energy intake, but not changes in physical activity, 
were differentially related to changes in the targeted sedentary 
behavior. Reducing television viewing could affect energy intake by 
minimizing cues to eat and by decreasing exposure to television 
advertising.\6\ \7\ \8\ \9\ \10\ \11\ Patterns of change in energy 
intake \16\ and physical activity \23\ were consistent with findings of 
experimental research in which targeted sedentary behavior was modified 
in older children. If the intervention works primarily by complementary 
changes in energy intake, then youth who eat while watching television 
would benefit more from the intervention. Previous research showed that 
decreases in energy intake were not observed for youth who infrequently 
ate in association with television viewing, while a decrease in energy 
intake of more than 600 kcal was observed for youth who ate in 
association with television viewing for at least 50 percent of their 
eating episodes.\16\ Television viewing reduction technology can also 
be used as part of a comprehensive obesity treatment program.\19\ \41\ 
The association of television viewing with eating supports the need to 
explore the reduction of television advertising as a way to avoid 
overeating and obesity in youth.\42\
---------------------------------------------------------------------------
    \41\ Epstein, LH; Paluch, RA; Gordy, CC; Dorn, J. Decreasing 
sedentary behaviors in treating pediatric obesity. Arch Pediatr Adolesc 
Med. 2000;154(3):220-226.
    \42\ Caraher, M; Landon, J; Dalmeny, K. Television advertising and 
children: lessons from policy development. Public Health Nutr. 
2006;9(5):596-605.
---------------------------------------------------------------------------
    The behavioral engineering technology of the TV Allowance may 
simplify the modification of child television viewing. It is possible 
that family rules regarding television viewing could have similar 
effects, but there may be important differences in technology vs 
parental control. Using technology to modify television viewing 
eliminates parental vigilance needed to enforce family rules and 
reduces the disciplinary action needed if a child exceeds his or her 
sedentary behavior limits. Perhaps most important, the device puts the 
choice of when to watch television in the child's control, as opposed 
to a rule such as no television time until homework is completed. 
Although the TV Allowance and family rules can reduce sedentary 
behavior, there may be child differences in the perception of control 
that may relate to intervention effectiveness.
    The TV Allowance was placed on all televisions and computers in the 
home. Without this technology, there would be additional parental 
demands to monitor use, especially in the case of televisions in 
children's bedrooms. Placement of a television in a child's bedroom may 
increase the risk of obesity more than televisions in family spaces 
\43\ and may make parental monitoring difficult.\44\
---------------------------------------------------------------------------
    \43\ Dennison, BA; Erb, TA; Jenkins, PL. Television viewing and 
television in bedroom associated with overweight risk among low-income 
preschool children. Pediatrics. 2002;109(6):1028-1035.
    \44\ Robinson, JL; Winiewicz, DD; Fuerch, JH; Roemmich, JN; 
Epstein, LH. Relationship between parental estimate and an objective 
measure of child television watching. Int J Behav Nutr Phys Act. 2006. 
[May 3, 2007]. p. e43. http://www.ijnpa.org/content/3/1/43.
---------------------------------------------------------------------------
    The intervention used in children aged 4 to 7 years is applicable 
to older children. It has previously been shown that the TV Allowance 
can be used to reduce home television viewing and computer use among 
older children and adolescents just as among younger children in the 
present study.\3\ \16\ \45\ \46\ A major difference is that older 
children may have more opportunities to visit friends and to accumulate 
additional television viewing and computer use at friends' homes.
---------------------------------------------------------------------------
    \45\ Ford, BS; McDonald, TE; Owens, AS; Robinson, TN. Primary care 
interventions to reduce television viewing in African-American 
children. Am J Prev Med. 2002;22(2):106-109.
    \46\ Robinson, TN; Killen, JD; Kraemer, HC, et al. Dance and 
reducing television viewing to prevent weight gain in African-American 
girls: the Stanford GEMS pilot study. Ethn Dis. 2003;13(1 suppl 1):S65-
S77.
---------------------------------------------------------------------------
    This study included children who were at or above the 75th BMI 
percentile; therefore, the results cannot be generalized to the 
prevention of at-risk children who were less overweight. Data on use of 
the television and computer, such as to entertain children or for 
educational purposes, may provide insight into how reducing television 
and computer use moderated the effects of the intervention among 
families of lower SES. There were limitations to the measurement of 
television viewing and energy intake. The TV Allowance accumulates 
television time until it is reset but does not provide downloadable 
information about when the television is watched. Energy intake data 
were collected using a food frequency questionnaire that assesses 
eating during the past month. Food diaries would be more labor 
intensive for subjects, but they would provide a detailed assessment of 
how television viewing affects behaviors that influence energy balance 
and body weight.
    These results show that changes in the home environment may be 
important targets for reducing BMI in children and that the home 
environment as arranged by parents may contribute to the risk of 
pediatric obesity.\47\ In addition to complementary changes in energy 
intake that may accompany reductions in television viewing,\16\ an 
environment in which parents provide easy access to fruits and 
vegetables is related to children's fruit and vegetable 
consumption,\48\ and parent and sibling models can maximize occasions 
to teach healthy eating habits to young children.\49\ There may be 
unique advantages to environmental manipulations that modify the shared 
family environment, including television and computer use, in which 
children develop positive behaviors that provide the basis for lifetime 
good eating and physical activity habits and a healthy body weight.
---------------------------------------------------------------------------
    \47\ Davison, KK; Birch, LL. Obesigenic families: parents' physical 
activity and dietary intake patterns predict girls' risk of overweight. 
Int J Obes Relat Metab Disord. 2002;26(9):1186-1193.
    \48\ Baranowski, T; Cullen, KW; Baranowski, J. Psychosocial 
correlates of dietary intake: advancing dietary intervention. Annu Rev 
Nutr. 1999;19:17-40.
    \49\ Harper, LV; Sanders, KM. The effect of adults' eating on young 
children's acceptance of unfamiliar foods. J Exp Child Psychol. 
1975;20(2):206-214.
---------------------------------------------------------------------------
    Accepted for Publication. September 5, 2007.
    Correspondence.--Leonard H. Epstein, PhD, Behavioral Medicine 
Laboratory, Department of Pediatrics, School of Medicine and Biomedical 
Sciences, State University of New York at Buffalo, Farber Hall, 3435 
Main St, Room G56, Bldg 26, Buffalo, NY 14214-3000 
([email protected]).
    Author Contributions.--Study concept and design: Epstein, Roemmich, 
and J. Robinson. Acquisition of data: Epstein, J. Robinson, Paluch, 
Winiewicz, and Fuerch. Analysis and interpretation of data: Epstein, J. 
Robinson, Paluch, and T. Robinson. Drafting of the manuscript: Epstein. 
Critical revision of the manuscript for important intellectual content: 
Epstein, Roemmich, J. Robinson, Paluch, Winiewicz, Fuerch, and T. 
Robinson. Statistical analysis: Epstein and Paluch. Obtained funding: 
Epstein and Roemmich. Administrative, technical, and material support: 
Epstein, J. Robinson, Winiewicz, and Fuerch.
    Financial Disclosure.--Dr. Epstein is a consultant to Kraft Foods.
    Funding/Support.--This study was supported by grant DK63442 from 
the National Institute of Diabetes and Digestive Diseases (Dr. Epstein) 
and by the Behavioral Medicine Laboratory, Department of Pediatrics, 
School of Medicine and Biomedical Sciences, State University of New 
York at Buffalo (Dr. Roemmich).

    Senator Brownback. One final question, and I'm not sure who 
to ask this of, but if I'm recalling correctly on the 
advertising area, the younger the person, the more susceptible 
to being persuaded by the advertising. Therefore, there would 
be some thought that you really want to guard the most the 
youngest--that's six and under.
    Mr. Martin. Sure.
    Senator Brownback. Is that correct, Mr. Martin?
    Mr. Martin. That's right. The Kaiser Family Foundation has 
determined that children six and under are not really able to 
distinguish between advertising and the programming itself. So, 
they're obviously much more susceptible to the impact of 
advertising.
    And I would just add that, while, obviously, there are 
always First Amendment concerns whenever you're talking about 
any kind of restriction broadcasters are subject to a lesser 
standard on First Amendment restrictions; it's only moderate 
scrutiny instead of the strict scrutiny. And even for the paid 
programming in the area of children's programming, the 
Children's Television Act that Congress passed actually has 
limits on paid programming. Children can be susceptible to 
advertising and for this very reason, there is certainly a 
compelling governmental interest to protect our children. I 
think it could be narrowly tailored to address it. So, I'm not 
convinced that there would be a prohibition on us taking 
action.
    Senator Brownback. Thank you.
    Senator Harkin. Thank you very much.
    Chairman Durbin.

                   PHYSICAL EDUCATION IN THE SCHOOLS

    Senator Durbin. Dr. Gerberding, you talked a little bit 
about physical activity, which is the other side of this 
equation--nutrition, good food, and the amount of exercise and 
activity that kids get. And I noticed, in your testimony, that 
you have given grants to 23 States, $750,000 grants, to deal 
with these issues of nutrition and physical activity. That 
sounds like about $18 million, if I did my math correctly here. 
And I noticed that, on the FTC proposal here, we find that 
we're currently seeing expenditures of $185 million in schools 
by these folks promoting food and such. So, it appears you're 
being outgunned pretty dramatically here, 10 to 1, when it 
comes to this, which I think puts you at a decided 
disadvantage.
    It reminds me, Chairman Harkin, of our battle against 
tobacco, when we would put out a couple of public service 
announcements, they would swamp us with Joe Camel.
    But, let me ask you this. On the physical activity, 
Illinois takes false pride in the fact that it's the only State 
in the Nation that requires physical activity from kindergarten 
through 12th grade. It's false pride, because I've seen it, and 
it isn't what it should be. In high school, it's a joke. Two of 
those years are driver's ed and driver's training, and high 
school students, in 40-minute periods, are supposed to leave 
the classroom, get into their tennis shoes or whatever it is, 
exercise, and get back to the next class, all within 40 
minutes. It doesn't work.
    So, let me ask you about that aspect of it. Is there a 
better way to approach this, in terms of encouraging physical 
activity during the schoolday, that might be consistent with 
all the testing that we're doing and all the other demands that 
schools face?
    Dr. Gerberding. Well, first of all, we need to learn more 
about exactly how to do this well. And the school wellness 
programs that were required in the agriculture bill have 
required school districts to create plans for promoting fitness 
and better nutrition in the schools. But, right now we don't 
have any resource to evaluate where the best examples are and 
how that really is playing out so that we can say, ``Here's the 
best-case scenario. Do it this way and everyone will benefit.''
    But, having said that, I think we have learned some best 
practices. There's a wonderful Web site at CDC, where schools 
can go. The problem is the competing priorities that the school 
districts are experiencing. And when they put more money here, 
it has to come out of some other part of their budget. And so, 
the real strategy is, How can we do this efficiently at low 
cost?
    And some school districts have been able to figure this 
out, with very little increase in the school budget. I visited 
a school in Titusville, Pennsylvania, where every child in the 
school has what I would consider to be an optimal exercise 
program, and they were able to incorporate that by clever 
changes in scheduling and rearranging the way students move 
from one classroom to another, et cetera. So, it can be done, 
but we've got to accelerate the pace. And I think we need to 
require it.
    Senator Durbin. One of the charter schools in Chicago has 
what they call ``walking school buses,'' where they have some 
parents who take on the responsibility of rounding up kids in a 
neighborhood and walking to school, picking up other kids on 
the way so that they actually do walk to school instead of send 
the buses out. But, that--that works in a city, it wouldn't 
work in a rural area in--necessarily, in Iowa or Illinois.
    Dr. Gerberding. It doesn't work in January, either.
    Senator Durbin. No, it--true. The weather can be a real 
problem with that, as well.
    Mr. Martin, what about this embedded product advertising--
Seinfeld's Junior Mints and things like that--what are we doing 
about that, in terms of products that pop up in television 
shows that kids are going to spot and obviously the advertisers 
or the people making the product believe might be of some value 
in marketing?
    Mr. Martin. The Children's Television Act actually has 
limits on the ability of embedding advertising in the program. 
There is actually a requirement to have a bumper between the 
programming and any commercials on children's programming. So, 
on the children's side, actually that issue is addressed.
    There is the issue of product placement that is occurring 
in commercial programming, just in general, even as targeted 
for adults, in large part because of the changes in the way the 
media companies are selling their product. They no longer have 
as much advertising revenue because of the way people are 
recording their programs and then fast-forwarding through some 
of the commercials. So, they are embedding more of those. We 
have certain rules and requirements about the way that 
advertising is supposed to be disclosed, so consumers are 
aware, at the end of the program, that these certain products 
were paid to be placed, although the Commission has been 
investigating whether or not those companies are complying with 
those rules and/or whether we need to update our rules, as that 
is becoming more and more of a prevalent practice.
    Senator Durbin. The chairman asked Mr. Leibowitz about FTC 
rules and how they've changed when it came to advertising for 
children. It seems to me that there are some real parallels 
between our debate that's going on in another part of the 
Capitol now, about regulation in the banking industry, and what 
happened when we removed it and let the free market work its 
will, and we find ourselves in a pretty dangerous situation 
today. Do you feel that we've gone too far when it comes to 
reducing the role of the Federal Communications Commission, 
when it comes to program content and advertising on issues like 
this?
    Mr. Martin. I've certainly been concerned about many of the 
different content issues as it relates to the role of 
protecting our children, whether it is talking about indecent 
content, violent content, or content that relates to healthy 
foods. I worked with my colleagues, and we made a 
recommendation to Congress, in part to respond to Senator 
Rockefeller's concern, about violent programming about what 
Congress could do to help restrict violent programming.
    I think that we do need to be more concerned about that, 
particularly in an environment in which families are asked to 
contribute to, and pay for, these ever-larger and ever-
increasing packages of channels that have programming that they 
may not want, but yet we are still forced to subsidize and pay 
for. I think that if we really wanted to have a free-market 
solution, we would allow people to pick and choose the channels 
they wanted, and then their choices would have economic meaning 
so that you could tell families, ``If you don't like what's 
going on, on this particular children's programming, then you 
should not subscribe to it any longer,'' and that would have an 
impact on both their advertising and on their subscription 
dollars.
    Today, those are not meaningful choices, because you're 
forced, as a family, to pay for those channels anyway. So, 
without an implementation of a true market mechanism to allow 
families to pick and choose the channels they want through an 
a-la-carte system, to be able to opt out of channels that they 
object to, then I do think there needs to be some kind of 
standard that is applied to the channels that are included in 
those packages.
    Senator Durbin. And, just for the record, can you tell why 
there's resistance to your idea?
    Mr. Martin. Well, there is tremendous resistance to that 
idea from all of the media companies, because of the 
significant amount of money they receive, from their 
subscription revenues. As I said, families are required to pay 
for channels, even if they object to them. And as a result they 
are not able to send an adequate market message. This is a 
concern for families that are concerned about violence, that 
are concerned about potentially indecent content, and also 
about these unhealthy food products. So, I think that that 
would be the market solution. But, in the absence of the 
ability for families to make meaningful choices and have those 
choices have economic meaning, then I think that there should 
be some kind of standard.
    Senator Durbin. Thanks.
    Thanks, Mr. Chairman.
    Senator Harkin. Thank you very much, Chairman Durbin.
    And thank you all very much. I thank the first panel. We 
have a vote coming up here at noon, so I'm going to have to 
dismiss this panel and bring our second panel up. But, thank 
you very much. Thanks, Dr. Gerberding.
    All right, we'd call our second panel up, and that would be 
J. Michael McGinnis, M.D., from the Institute of Medicine; Marc 
Firestone, executive vice president, corporate and legal 
affairs, general counsel, Kraft Foods; Marva Smalls, executive 
vice president and chief of staff, MTV Network----
    Again, I'm sorry, I was--the last person, I had not 
introduced, was Patti Miller, vice president of the Children 
and the Media, Children NOW. And, again, as I said to the first 
panel, all of your statements will be made a part of the record 
in their entirety, and I will start, as I did the list--first, 
Dr. McGinnis, Mr. Firestone, Ms. Smalls, Ms. Miller--in that 
order.
    And if you could just give us a brief summary of your 
testimony, I'd appreciate that.
    And we'll start with Dr. McGinnis--thank you very much for 
being here, Dr. McGinnis--from the Institute of Medicine.
STATEMENT OF J. MICHAEL McGINNIS, M.D., MPP, INSTITUTE 
            OF MEDICINE, WASHINGTON, DC
    Dr. McGinnis. Thank you very much, Chairman Harkin. Thank 
you very much, Senator Brownback.
    And I'd like to begin with a note of thanks to the 
committees for sponsoring the attention on this issue. It's 
clearly an important question and challenge for the Nation, and 
I'm pleased to be here to speak to you in my capacity as the 
chair of the study committee that you initiated, the Study 
Committee for the Institute of Medicine on Food and Marketing 
and the Diets of Children and Youth.
    This report, ``Food and Marketing, Children and Youth: 
Threat or Opportunity,'' was issued as a result of that study 
in December 2005, and I would like, briefly, to touch on just 
three items and submit, as you suggested, the full text of the 
testimony for the record.
    First item is to review, quickly, the key elements of those 
2005 report findings; secondly, to mention the many positive 
developments, in brief, that have transpired since the release 
of that report; and the third is to note the status, as of 
September 2008, vis-a-vis the recommendations in that report.
    On the first issue, the key elements of our report, we were 
charged with reviewing, literally, the world's literature on 
the relationship between food marketing and the diets of 
children and youth, and the first lesson of our findings was 
that marketing works. It clearly does. And I'll come back to 
that in a second.
    The second key element was that the dominant focus of 
marketing to children is on foods that are high in calories and 
low in nutrients.
    And the third is that marketing itself is changing, and 
changing rather dramatically. It is a moving target.
    With respect to the first charge, we reviewed over 2,000 
articles, and reviewed extensively, with a rigorous analytic 
framework, the 123 that met our standards of evidence, and we 
found, quite clearly, that there's a strong causal relationship 
between marketing practices and the food preferences, purchase 
requests, and short-term consumption of dietary food products.
    There was, we found, a statistical association between 
marketing and the prevalence of obesity, but not a causal 
relationship, because the timeframe of the studies that we 
assessed was too short to identify a causal relationship.
    We also note that marketing works, not only with respect to 
the relationship to adverse dietary patterns, but also that 
marketing can work positively in a sustained social marketing 
context.
    With respect to the dominant focus of marketing of food 
products on foods that are high in calories and low in 
nutrients, we did an independent analysis, for example, of the 
recent products, in the decade prior to the report, that were 
introduced into the market, found the slope for those products 
that were high in calories and low in fats targeted to children 
to be much greater than for the rest of the food supply.
    Thirdly, to emphasize the fact that marketing, itself, is 
changing. With the notion of advergames, Internet, the combined 
marketing strategies that Mr. Leibowitz mentioned, quite 
clearly we have a very different and rapidly changing marketing 
environment which requires ever more vigilance to its impact 
and its strategies.
    In essence, what we found was that the subtitle here, 
``Threat or Opportunity,'' the answer is: both. It's both a 
threat, but it is an opportunity, and it's the opportunity 
piece that we need to focus on, I think, more extensively in 
the time ahead.
    To some extent there have been a number of positive actions 
undertaken since the release of the report. Mr. Chairman, you 
and Senator Brownback both mentioned some of those. The work of 
the Council of Better Business Bureaus, several food company 
initiatives, the American Beverage Association, some of the 
cartoon character producers, both the FTC and the FCC 
initiatives that you've heard about, HHS and USDA have had ad 
hoc activities that are positive in this domain, and that 
you've mentioned also; the Robert Wood Johnson Foundation 
committed about half a billion dollars to the arena.
    It is clear that there is interest and activity in this 
domain, but the question is the extent to which the actions 
have translated into progress, or when they will translate into 
progress. And that gets me to the last point I want to 
underscore, and that is, the assessment of the extent of 
progress as of today. And our take on the ten recommendations 
that were included in our report--and this is a matter of 
personal opinion, because they--we have not subjected them to 
systemic analysis, so I have to underscore, this is my personal 
opinion--is that, for the most part, there has been relatively 
limited progress; at best, the progress has been positive in 
the general sense, but there are a few areas in which it's 
actually reversed.
    Just quickly, the ten areas of our recommendations ranged 
from the policies of individual food and beverage companies, 
the commercial meal establishments, the trade associations that 
are crosscutting standards that are applied to food and 
beverage products, and the media and entertainment industries. 
Those are, sort of, half of the recommendations that focused on 
industry practices. The remaining half focused on potential 
government actions, including the potential establishment of a 
sustained public/private social marketing effort, the policies 
related to marketing in schools, the issues available--levers 
available to government at all levels, such as the one that you 
mentioned on fruits and vegetable promotion, as well as a 
variety of other possible government actions; the research 
capacity--expanding the research capacity to understand how 
these marketing influences work; and finally, the monitoring 
issue.

                           PREPARED STATEMENT

    In the review of the progress--and I'll mention this in the 
last 10 seconds--we found that much of the progress that's been 
undertaken have been more in the category of individual 
actions, actions that are, for the most part, ad hoc and 
fragmented, and some of them even counterproductive in their 
net effect. Without slighting the solid efforts of the Council 
on Better Business Bureaus and those of individual companies, 
or even the efforts of individual agencies in government, it's 
very clear that as long as the efforts are as fragmented as 
they are, as long as they are relatively unsupervised and they 
aren't part of a broader strategy, we're going to fall short of 
meeting that opportunity.
    Thank you, Mr. Chairman.
    [The statement follows:]

               Prepared Statement of J. Michael McGinnis

    Good morning, Chairman Harkin, Chairman Durbin, and members of the 
subcommittees. I am Dr. Michael McGinnis, Senior Scholar and Executive 
Director of the Roundtable on Evidence-Based Medicine at the Institute 
of Medicine (IOM) of the National Academies in Washington, DC. Thank 
you for your kind invitation to appear before this joint subcommittee 
hearing.
    First a word about the Institute of Medicine, which is my current 
employer but my responsibilities lie outside this arena, and I am 
appearing here as an individual expert to address issues related to my 
prior responsibilities as an IOM committee chair. Established in 1970 
under the Congressionally-granted Charter of the National Academy of 
Sciences, the IOM provides independent, objective, evidence-based 
advice to policymakers, health professionals, the private sector, and 
the public. That advice is developed through committees comprised of 
leading national and international experts from relevant fields 
convened by the IOM to conduct rigorous reviews of problems at hand. I 
join you today in the context a previous capacity, as Chair of the IOM 
Committee on Food Marketing and the Diets of Children and Youth. Our 
Committee produced the 2005 report, Food Marketing to Children and 
Youth: Threat or Opportunity? I appreciate the opportunity to speak to 
the findings of that report, the activities it has helped catalyze, and 
the current state of play in the field. Most of my comments will be 
oriented to matters of fact or interpretation of findings and 
recommendations from the report, and I will be clear when opinions 
expressed are personal and based solely on my individual expertise.
    Against the backdrop of pressing public concern over the rapid and 
widespread increase in the prevalence of childhood obesity, Congress, 
in the fiscal year 2004 appropriation, directed the Centers for Disease 
Control and Prevention (CDC) to undertake a study of the influence of 
food and beverage marketing on the diets and health of children and 
youth. The CDC requested that the IOM undertake the study, and the 
Committee on Food Marketing and the Diets of Children and Youth was 
formed. The committee charge included exploring what is known about 
current food and beverage marketing to children and youth in the United 
States, the scientific evidence on the relationship between these 
marketing practices and the diets and health of children and youth, and 
the strategies that have been, or could be, used to promote healthful 
food and beverage choices among children and youth.
    The committee's report on Food Marketing to Children and Youth was 
released in December 2005 and published in 2006. It is one of several 
recent IOM examinations of various aspects of childhood obesity 
prevention, most notably Preventing Childhood Obesity: Health in the 
Balance, Congressionally mandated and published in 2005, and Progress 
in Preventing Childhood Obesity: How Do We Measure Up? published in 
2007. Each highlights, from different perspectives, the urgent need for 
attention to obesity in children and for multi-sectoral approaches to 
addressing it.
    Befitting the breadth of the topic, the food marketing committee 
was comprised of experts of unusually varied disciplines, experience, 
and perspective. The 16 members brought to the committee expertise not 
only in child and adolescent development, epidemiology, public health, 
and nutrition, but also in food production, marketing, children's 
television, causal reasoning, constitutional law, and business ethics.
    The Food Marketing report represented the most comprehensive review 
undertaken of the scientific literature on the influence of marketing 
on the diets of children at that time--and remains so today. In 
conducting the study, the committee developed and applied a rigorous 
analytic framework to the systematic review of the relevant scientific 
literature. We also undertook an extensive review of the nutritional 
status of and trends for children and youth, what is known about the 
full range of factors that influence the dietary patterns of this 
population, the broad and evolving food and beverage marketing 
environment, and the policy measures that might improve the nutrition 
of young people. Since our report was published, the continuing 
improvement in identifying and understanding the influences of 
marketing on diets of children and youth, is encouraging and a 
reflection of the importance of this subject.
    What did we find? In short, we found that marketing works. First, 
we found that there is strong evidence that television advertising of 
foods and beverages has a direct influence on what children choose to 
eat. Second, the dominant focus of food and beverage marketing to 
children and youth is for products high in calories and low in 
nutrients, and this is sharply out of balance with healthful diets. 
Third, marketing approaches have become multifaceted and sophisticated, 
moving far beyond television advertising to include the Internet, 
advergames, strategic product placement, and much more.
    We also found that turning around the current trends in children's 
diets and in marketing will require strong and active leadership and 
cooperation, from both the public and private sectors. Industry 
resources and creativity must be harnessed on behalf of healthier diets 
for children. The food industry needs to be a substantial part of the 
solution to a problem to which it has been a contributor. The committee 
had limited access to proprietary marketing research, which might have 
shed additional light on some of the research and marketing patterns 
and strategies for child- and youth-oriented foods and beverages. Hence 
the importance of the focus of today's hearing and the work of the 
Federal Trade Commission.
    The 2005 IOM Food Marketing report presented recommendations for 
different segments of society to guide the development of effective 
marketing strategies that promote healthier food, beverage, and meal 
options to children and youth. Recommendations were also offered for 
research necessary to chart the path of future improvements, and the 
capacity to monitor and track improving in marketing practices that 
have an influence on children's and youth's diets and diet-related 
conditions.
    With respect to strategy, one thing is very clear: the turnaround 
required is so substantial, and the issues are so complex, that the 
full involvement and leadership of food and beverage industries is 
essential. The report identified a number of ways in which food, 
beverage, and restaurant companies, food retailers, and advertising and 
marketing firms can and should shift their child- and youth-oriented 
product development and marketing. It also suggested ways they can and 
should work with government, scientific, and public health groups to 
develop and enforce marketing standards for healthful foods and for 
marketing of products, to develop and implement an empirically tested 
rating system and graphic representation for front of package labeling, 
to develop a way to access propriety data, and to develop and implement 
a sustained public-private cooperative social marketing effort aimed at 
achieving better diets among our children. The report recommended that 
Congress consider legislative mandates, should voluntary efforts fail 
to shift the emphasis of television advertising to healthier products.
    Since the release of our report, a number of interesting and 
important developments have occurred which hold promise for progress in 
improving the influence of marketing on children's diets. Several 
individual food companies have committed to alter their marketing 
practices in various ways to give greater emphasis to children's 
products that are lower in calories and higher in nutrient density; 
Disney, Nickelodeon, and the Cartoon Network all have announced some 
limitations in licensing of their cartoon characters for use in 
marketing to children; the soft drink industry announced cessation of 
soda sales in elementary schools, with phased extension of that policy; 
the industry-wide voluntary self-regulatory guidelines administered by 
the Children's Food and Beverage Advertising Initiative were 
strengthened and expanded; the American Academy of Pediatrics called 
for rigorous standards on marketing food a beverages to children; in a 
settlement with CSPI, Kellogg's agreed to stronger standards in 
marketing healthier products; the Kaiser Family Foundation released the 
most comprehensive survey to date of the magnitude and trends for food 
advertising to children and youth; and the Federal Trade Commission 
undertook its study on food marketing and industry practices, and 
discussions here in Congress have included consideration of ways for 
the FTC to engage standards for foods marketed to children. Outside of 
the marketing arena, but important to overall progress is the pledge by 
my former colleagues at the Robert Wood Johnson Foundation to commit 
over $500 million in the coming years to combating childhood obesity. 
These are all important developments. Still, as noted in the 2007 IOM 
report Progress in Preventing Childhood Obesity: How Do We Measure Up?, 
they are just beginnings and the fundamental gains for children are 
still to be realized.
    Challenges of the scope and potential national impact of obesity in 
general, and childhood obesity in particular, require aggressive 
government leadership, hence our Committee recommendations that 
government explore the various incentives it has available to: 
encourage and reward companies that develop and promote healthier 
products for young people; use marketing resources in social marketing 
for healthier lifestyles for children; and develop the type of 
monitoring capacity required for a health challenge of this magnitude. 
On the monitoring activity, we specifically recommended that the 
Secretary of Health and Human Services, in consultation with other key 
officials, designate an agency to monitor the progress of various 
entities in doing their part to promote more healthful diets, and 
report to Congress on the progress made and needed actions. To our 
knowledge, that recommendation, among others, has yet to be addressed. 
At the end of this statement is a list of our 10 Committee 
recommendations \1\ with an informal status assessment. I emphasize 
that this is my personal and preliminary view, offered without benefit 
of the rigorous and regular scrutiny warranted for an issue of this 
importance.
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    \1\ The recommendations are summarized at http://www.iom.edu/CMS/
3788/21939/31330/31337.aspx.
---------------------------------------------------------------------------
    In summary, there is substantial and compelling concern about the 
prospects for future health gains if the epidemic of obesity is not 
reversed, beginning with its disturbing presence among children--our 
Nation's future. This is a matter of truly compelling urgency, and 
requires sustained and intense attention befitting any epidemic of 
potentially widespread and generation-changing lethality. We thank you 
for the attention and emphasis that you and your colleagues are drawing 
to this issue, and hope that it will help catalyze the changes 
necessary to transform the current threats into future opportunities.
    That concludes my statement. Thank you again for the opportunity to 
appear before you today, and for your leadership on this vital issue 
for the health of Americans--now and in the years to come. I would be 
happy to address any questions you may wish to ask.
                  food marketing to children and youth
         2008 status of recommendations in the 2005 iom report
    Food and beverage companies should use their creativity, resources, 
and full range of marketing practices to promote and support more 
healthful diets for children and youth.\2\
---------------------------------------------------------------------------
    \2\ Note for emphasis: This status summary reflects personal and 
preliminary opinion, offered without benefit of the rigorous, regular, 
and formal scrutiny warranted for an issue of this importance. JMM.
---------------------------------------------------------------------------
  --2008 Status.--Limited progress, initiatives beginning. The 
        components of this recommendation include shifting portfolio 
        balance toward more healthful products; reversing marketing 
        emphasis in child- and youth-oriented products so that 
        healthful products predominate; public-private collaboration to 
        develop industrywide rating system and graphic representation 
        for child- and youth-oriented products; and marshal marketing 
        capacity for broad promotion of healthier foods and beverages. 
        Activities such as those underway through the Council of Better 
        Business Bureaus (CBBB) pledge program represent incentives for 
        positive movement, and there may be some increase in 
        development and marketing more healthful products. But we are 
        far short of a reversal in the balance. The plethora of rating 
        systems and graphic representations continues, potentially 
        adding to consumer confusion. Despite ongoing discussion of the 
        issue through the Keystone dialogue process on common labeling 
        approaches to healthful products, the utility for children's 
        products is unclear and neither government nor industry has 
        specifically identified addressing this issue as a priority.
    Full serve restaurant chains, family restaurants, and quick serve 
restaurants should use their creativity, resources, and full range of 
marketing practices to promote healthful meals for children and youth.
  --2008 Status.--Very limited progress, growing interest and focus. 
        The components of this recommendation include expanding 
        healthier options for children and youth in commercial meal 
        establishments, and providing key nutrition information at the 
        point of choice and use. A number of national chains are 
        conducting research and experimenting with approaches, and 
        several States and localities have initiated legislative or 
        regulatory efforts on restaurant menu labeling, which may step 
        up the pace.
    Food beverage, restaurant, retail and marketing industry trade 
associations should assume transforming leadership roles in harnessing 
industry creativity, resources, and marketing on behalf of healthful 
diets for children and youth.
  --2008 Status.--Very limited progress. The components of this 
        recommendation include trade association leadership and 
        technical assistance for the initiatives of individual 
        companies to develop creative approaches to healthful product 
        lines, marketing strategies, and public-private partnerships. 
        Although effects are still to be determined, the American 
        Beverage Association initiated certain member efforts to shift 
        sales and marketing efforts in schools. The Grocery 
        Manufacturers Association has been focused, appropriately, on 
        food safety issues, leaving leadership on healthful content 
        largely to the initiative of individual companies. And the 
        National Restaurant Association has opposed menu labeling 
        initiatives. To date, none has worked to spearhead the 
        collaborative development of the sort of sustained social 
        marketing effort noted in recommendation #6.
    The food, beverage, restaurant, and marketing industries should 
work with government, scientific, public health, and consumer groups to 
establish and enforce the highest standards for the marketing of foods, 
beverages, and meals to children and youth.
  --2008 Status.--Some progress, pending assessment. The components of 
        this recommendation include work of the Children's Advertising 
        Review Unit (CARU) to strengthen self-regulatory guidelines; 
        eliminate of use of licensed cartoon characters for products 
        other than those that promote healthful diets; and FTC-CARU 
        cooperation on guideline monitoring and enforcement. 
        Advertising guidelines have been strengthened, and the joint 
        FTC/HHS conference and Better Business Bureau initiatives 
        report progress in reducing advertising to children. Impact on 
        broader marketing strategies is unclear. Other efforts, such as 
        the FCC-sponsored task force on food marketing to children have 
        not yet reported their progress. Announcement by Disney, 
        Nickelodeon, and the Cartoon Network to impose limitations of 
        their cartoon characters in marketing high calorie/low nutrient 
        foods to children represents progress that needs evaluation.
    The media and entertainment industry should direct its extensive 
power to promote healthful foods and beverages for children and youth.
  --2008 Status.--No apparent progress. The components of this 
        recommendation include incorporation of promotion of healthful 
        foods through multiple media platforms, and close scrutiny and 
        reporting by news organizations of the activities of public and 
        private organizations on the level of effort in executing 
        responsibilities and engaging opportunities. Information is not 
        available on the trends on either dimension.
    Government, in partnership with the private sector, should create a 
long-term, multifaceted, and financially sustained social marketing 
program supporting parents, caregivers and families in promoting 
healthful diets for children and youth.
  --2008 Status.--Some reversal of progress, with respect to the notion 
        of a sustained public-private effort. The components of this 
        recommendation include development of a mechanism for a 
        sustained public-private support stream for long-term social 
        marketing efforts to improve the diets and activity patterns of 
        children and youth; draw upon the marketing research and 
        expertise accumulated by industry to shape strategies; give 
        initial emphasis to skills building for parents and caregivers 
        of young children. Although there are notable ad hoc activities 
        under way (e.g. HHS and Advertising Council initiatives, Small 
        Steps obesity prevention campaign, America on the Move, 
        Alliance for a Healthier Generation, Action for Healthy Kids), 
        no government agency, company, association, or philanthropic 
        organization has taken the initiative to create the public-
        private vehicle necessary for sustained conduct of the long-
        term strategic social marketing necessary for progress against 
        the epidemic. In fact, public funding has ceased for the Verb 
        Campaign of the Centers for Disease Control and Prevention, 
        which showed some initial success in promoting physical 
        activity among young teens.
    State and local educational authorities, with support from parents, 
health authorities, and other stakeholders, should educate about and 
promote healthful diets for children and youth in all aspects of the 
school environment (e.g., commercial sponsorships, meals and snacks, 
curriculum).
  --2008 Status.--Some progress. The components of this recommendation 
        include implementation of nutrition standards for the school 
        environment; promotion of more healthful foods in schools; and 
        prominent leadership by all levels of public and private sector 
        influence over school environments. Amendments through Public 
        Law 108-265 to the Richard Russell National School Lunch Act 
        and the Child Nutrition Act of 1966 have established a basis 
        from which substantial changes can be made in the influence of 
        school meals and school centered initiatives on children's diet 
        and health, although effecting those changes has not received 
        the top to bottom emphasis necessary. A 2007 IOM report focused 
        on nutrition standards for food in schools, has been adopted 
        and used in several States, and both CDC and USDA are working 
        on related best practices for wider dissemination. Many 
        industry marketing practices in schools are undergoing 
        revision.
    Government at all levels should marshal the full range of public 
policy levers to foster the development and promotion of healthful 
diets for children and youth.
  --2008 Status.--Little apparent progress, despite some increase in ad 
        hoc public education campaigns (see #6). The components of this 
        recommendation include government incentives (e.g. subsidies, 
        tax policies, awards) to promote availability and family use of 
        fruits and vegetables; USDA use of school and other low-income 
        food programs to promote healthier meals, and Congressional 
        legislation on children's television advertising if industry-
        led initiatives do not turn around the marketing emphasis. 
        Increased focus on school meals, as well as nutrition standards 
        for other USDA food programs, but little information available 
        on current status and trends; reliable updated information is 
        also not yet available on which Congress might base legislation 
        on children's broadcast and cable television advertising; and 
        economic incentive programs are not yet widely in place to 
        increase fruit and vegetable consumption.
    The Nation's formidable research capacity should be substantially 
better directed to sustained, multidisciplinary work on how marketing 
influences the food and beverage choices of children and youth.
  --2008 Status.--No apparent progress. The components of this 
        recommendation include expanded research capacity to learn more 
        about the ways marketing influences children's attitudes and 
        behaviors, especially related to new and emerging multifaceted 
        marketing strategies; and development of a means for commercial 
        marketing research to be made available as a publicly-available 
        resource for the design of broad social marketing strategies 
        targeting diet and activity patterns of children and youth. 
        Little research capacity has been developed to assess either 
        the broader impact of new media marketing strategies, or the 
        targeted impact on children's diets. No government agency, 
        company, association, or philanthropic organization has taken 
        the initiative to create the public-private vehicle necessary 
        for the receipt, mining, and application of insights of 
        commercial marketing research on behalf of strategies for pro-
        social marketing on children's diets and activity patterns.
    The Secretary of the U.S. Department of Health and Human Services 
(HHS) should designate a responsible agency, with adequate and 
appropriate resources, to formally monitor and report regularly on the 
progress of the various entities and activities related to the 
recommendations include in this report.
  --2008 Status.--No apparent progress. The components of this 
        recommendation included consultation by the HHS Secretary with 
        counterparts from USDA, Education, FTC and FCC to develop 
        monitoring and reporting on progress on findings and 
        recommendations of the report, and issuance by December 2007 of 
        a report to Congress on the progress. Public knowledge is not 
        available to indicate that a formal collaborative effort of 
        this sort has been undertaken, nor has the report to Congress 
        been submitted.

    Senator Harkin. Thank you very much, Dr. McGinnis.
    I'm sorry the way--the seating arrangement--but the way 
it's lined up here is, next we turn to Mr. Firestone, executive 
vice president of corporate and legal affairs of Kraft Foods. 
Then we'll go to Ms. Smalls and to Ms. Miller.
STATEMENT OF MARC FIRESTONE, EXECUTIVE VICE PRESIDENT, 
            CORPORATE AND LEGAL AFFAIRS, AND GENERAL 
            COUNSEL, KRAFT FOODS, NORTHFIELD, ILLINOIS
    Mr. Firestone. Good morning, Mr. Chairman and Senator 
Brownback. Thank you so much for the privilege to appear before 
you today and to give me a chance to thank both of you 
personally for the tremendous and engaging leadership you've 
shown on behalf of the children of this country and their 
health and well-being.
    Childhood obesity is, indeed, a serious public health 
issue, and it's one for which there's no simple answer. As 
experts, including IOM, have emphasized, we need a national 
effort that is comprehensive in scope, with active, coordinated 
participation by government and communities, the food and 
beverage industry, the entertainment and media industry, 
schools, and parents.
    The consistent recommendation by experts for action 
specifically by food companies has been to change the mix of 
advertising to children to emphasize better-for-you choices and 
more physical activity. And, in that spirit, I'd like to share 
examples of what Kraft has been doing.
    In 2003, we announced a worldwide initiative that focused 
on product nutrition, consumer information, marketing 
practices, and public policy engagement. Then, in 2005, Kraft 
took a bold step when it created what has become a model for 
limiting children's advertising. We announced that we would no 
longer advertise products that don't meet our better-for-you 
nutrition criteria in mass media primarily directed to children 
under the age of 12.
    As a result, we stopped advertising many well-known, well-
loved products to kids. It wasn't an easy decision for the 
company's management to take, but we heard, loud and clear from 
policymakers and consumers alike, that among the dozen or so 
actions that society should take to address this issue, 
changing food advertising was the one most directly under our 
control. Other food companies have since adopted a similar 
approach under the auspices of the Council of Better Business 
Bureaus. We were pleased to be a founding member of this 
initiative, and applaud the progress that's taken place in the 
last year and a half.
    In addition, Kraft created the portion-controlled 100-
calorie packaging that is now common throughout the industry, 
and we were the first to use dual-column nutrition labeling on 
small packages with multiple servings.
    The FTC's recent report on food marketing recommended 
several important next steps, many of which Kraft already has 
in place. For example, we don't engage in product placement in 
children's media or in any in-school marketing.
    Further, Kraft is participating with other food companies 
in a Keystone Roundtable to develop uniform nutritional 
criteria and labeling for better-for-you products.
    To conclude, I'd like to share Kraft's perspective on the 
overall effort to address youth marketing and childhood 
obesity.
    First, we view self-regulation as a means to an end, not an 
end unto itself. Voluntary action by industry can, indeed, be 
effective, and often is faster than regulation or legislation. 
In all instances, though, we are looking for approaches that 
make sense for our consumers, and therefore, our company and 
our shareholders.
    Second, Kraft has shown it's willing to lead, even if there 
is a competitive disadvantage, but we certainly prefer a level 
playing field, both for our business and for making a 
difference socially. Fifteen major food companies have now 
pledged to follow the BBB advertising principles, and we think 
other companies that advertise food or beverages to children 
should do the same.

                           PREPARED STATEMENT

    Third, although food companies absolutely have major 
contributions to make to this effort, we are only one part of 
the equation. A nationwide approach that covers all areas, from 
community intervention to food marketing to physical education 
in schools, is critical. We value the leadership and the 
encouragement--what we think of as the forceful encouragement--
that the Congress, the agencies, and other bodies can bring to 
bear to ensure continued momentum in the right direction, 
including over areas over which we, as a food company, have 
little or no control.
    Thank you, again, Senator Harkin and Senator Brownback. We 
look forward to answering your questions.
    [The statement follows:]

                Prepared Statement of Marc S. Firestone

    Good morning Mr. Chairman and members of the Appropriations 
Committee. I am Marc Firestone, Executive Vice President of Kraft 
Foods.\1\ It is a privilege to address you today on behalf of the more 
than 100,000 people who work at Kraft, the country's largest food 
company.
---------------------------------------------------------------------------
    \1\ For more than a century, Kraft (www.kraft.com) has offered 
delicious foods and beverages that fit the way consumers live, 
including Kraft cheeses, dinners and dressings; Oscar Mayer meats; 
Philadelphia cream cheese; Maxwell House coffee; Nabisco cookies and 
crackers and its Oreo brand; Jacobs coffees; Milka chocolates; and LU 
biscuits. The company's stock (NYSE: KFT) is included in the Dow Jones 
Industrial Average and listed on the Standard & Poor's 100 and 500 
indexes as well as the Dow Jones Sustainability Index and Ethibel 
Sustainability Index.
---------------------------------------------------------------------------
    Thank you for holding this hearing and for your leadership on 
topics related to the well-being of children. You have set a tone that 
encourages people to work together, to find pragmatic solutions and to 
show real progress.
    We recognize that childhood obesity is a serious public health 
issue. For any one person, the key is to find the right balance between 
calories in and calories out, but individual choices all take place 
within a broader context. Unfortunately, there's no simple way to 
improve diets and increase physical activity.
    Economic conditions and access to nutritious foods; government 
policies and food company practices; parental involvement and school 
food programs; urban planning and building design: These and other 
factors all influence obesity rates. Therefore, as the FTC, the IOM and 
others have emphasized, we need a national effort that is comprehensive 
in addressing each of those factors.
    A national commitment takes national leadership, which is what I 
believe you are providing through your encouragement--your forceful 
encouragement--to all participants in pursuing opportunities and 
addressing concerns within areas under their control. This includes 
government, the food and beverage industry, the entertainment and media 
industry, schools and parents. The consistent recommendation by experts 
for action on the part of food companies has been to change the mix of 
advertising to children to emphasize better-for-you choices and 
physical activity.
What Kraft is Doing
    In that spirit, I'd like to share examples of Kraft's leadership 
within the food industry.
    In response to concerns over obesity rates, we announced in 2003 an 
11-point initiative. We focused on product nutrition, consumer 
information, marketing practices and public policy engagement.
    Then, in 2005, Kraft took a bold step when it created what has 
become a model for limiting children's advertising. Kraft already had a 
long-standing policy not to advertise our products in media primarily 
directed to children under the age of six. In 2005, we voluntarily 
adjusted our advertising practices globally, so that all TV, radio and 
print advertising viewed primarily by children ages 6-11 would feature 
only Kraft products that meet specific nutrition criteria. These 
products are labeled with our Sensible Solution flag, so consumers can 
easily identify the better-for-you options in our product line. In 
2006, we extended this policy to our websites.
    We phased out advertising primarily directed to children 6-11 for 
products that do not meet the Sensible Solution criteria. As a result, 
a number of well known, well loved Kraft products, including Oreo, 
Chips Ahoy! and the original versions of Kool-Aid, are no longer 
advertised to children.
    It wasn't an easy decision for the company's management to take. 
But we heard loud and clear from policy makers and consumers alike that 
among the dozen or so actions that society should take, changing our 
advertising was the one most directly under our control as a food 
company.
    Many of our competitors and other companies have since adopted a 
similar approach to their advertising under the auspices of the Council 
of Better Business Bureaus. We were pleased to be a founding member of 
this initiative and applaud the progress that's taken place in the last 
year and a half.
    As part of the BBB initiative, most major food and beverage 
companies have committed to advertise to children only those products 
that meet specific nutrition standards. And advertising content 
increasingly encourages active behaviors and aims to model appropriate 
meals, eating behaviors and portion control.
    In addition, we created the type of 100 calorie, portion-control 
packaging that is now common throughout the industry. In most cases, we 
didn't simply put the same product in a smaller package. We created 
special recipes for making cookies, crackers and other items in a 
single serving of 100 calories. This gives consumers another choice.
    And we were the first to use dual-column nutrition labeling on 
small packages with multiple servings. These labels do the math for 
consumers by showing calories and other data both on a per-serving 
basis, as FDA requires, and for the whole package. This helps consumers 
make informed choices in managing their diets.
    The FTC's recent report on food marketing has recommendations for 
next steps, many of which Kraft already has in place. For example, we 
don't engage in product placement in children's media or in-school 
marketing. Further, consistent with the FTC's recommendations, Kraft is 
participating with other food companies in the Keystone Roundtable to 
develop more uniform nutritional criteria and labeling for ``better-
for-you'' products.
Conclusion
    To conclude, I'd like to share Kraft's perspective on the overall 
effort to address youth marketing and childhood obesity.
    First, we view self-regulation as a means to an end, not an end 
unto itself. Voluntary action by industry can indeed produce results, 
often faster than regulation or legislation. The shift in food 
advertising is a great example. From our perspective, the issue is less 
about the means and more about the substance: We are looking for 
approaches that make sense for our consumers and therefore for our 
company and our shareholders.
    Second, we remain eager to find common sense approaches. Kraft has 
shown it's willing to lead, even if there's a competitive disadvantage, 
but we certainly prefer a level playing field, both for our business 
and for making an impact socially. Fourteen major food companies have 
now pledged to follow the BBB advertising principles, which goes a long 
way in that direction. We think other companies that advertise food or 
beverages to children should do the same.
    Third, enduring change comes when there is proportionally equal 
effort by all those who can influence the calories in/calories out 
equation. I believe that Kraft and other food companies have made major 
contributions to the effort. But we're only one part of the equation. A 
nationwide approach that covers all key areas, from community 
intervention to food marketing to physical education in schools, and so 
on, is critical. We value the leadership and forceful encouragement 
that Members of Congress, the agencies and other bodies can bring to 
bear to ensure continued momentum in the right direction, including in 
areas over which we, as a food company, have little control.
    In closing, I thank you again for inviting Kraft here today. We are 
honored to be part of an effort that has shown progress is possible. I 
look forward to answering your questions.

    Senator Harkin. Thank you again, Mr. Firestone. And thank 
you again, publicly, for Kraft working with us through the 
years. I thought probably the boldest step of all was when 
Kraft decided not to advertise Oreo cookies to kids. I mean, 
whooo, that was quite a step----
    Mr. Firestone. Thank you, sir.
    Senator Harkin [continuing]. And we applaud you for it.
    Now we turn to Ms. Smalls, executive vice president, public 
affairs, chief of staff of Nickelodeon, MTV Network's Kids and 
Family Group.
    Ms. Smalls, welcome.
STATEMENT OF MARVA SMALLS, EXECUTIVE VICE PRESIDENT AND 
            CHIEF OF STAFF, MTV NETWORK, IDS AND FAMILY 
            GROUP (NICKELODEON), NEW YORK, NEW YORK
    Ms. Smalls. Thank you. And thank you for holding this 
hearing today, and for your leadership on this issue.
    And let me just add, on a personal level, I've had a long-
time interest, in that I was chief of staff to Congress when 
Robin Tallon, who chaired the House Subcommittee on Food, 
Nutrition, and Marketing--we actually had the first hearing on 
establishing the pyramid. But, at Nickelodeon our mantra has 
always been, ``What is good for kids is good for business.'' 
And because of that, we were compelled to confront the 
childhood issue on obesity, and our approach was to make 
ourselves as smart as possible.
    So, over the past 5 years, we've conducted research, we've 
reached out to advocates, food industry CEOs, government 
agencies, and academics. We've participated in public and 
private forums. We've partnered with organizations like the 
Boys and Girls Club, the Clinton Foundation, and the American 
Heart Association. And, based on all that we've learned through 
this around-the-world meeting with the stakeholders, we've 
committed more than $30 million in annual resources and 10 
percent of our airtime to balanced lifestyle messages. We've 
given more than $2.5 million in grants in schools--to schools 
and community-based organizations, direct cash, many in the 
States you represent. We've launched the Let's Just Play 
Campaign and our annual Worldwide Day of Play, when all of our 
TV and Web sites go dark. And this year, the fifth annual 
Worldwide Day of Play will take place on this upcoming 
Saturday. We've pledged to limit the use of our licensed 
character, and we've put--characters--and we've put more 
resources into our long-form programming. And not to leave 
parents behind, we've launched Nick at Night's Family Table, 
encouraging families to share more quality meals together, and, 
just in January, we launched the Kick One, Pick One Campaign, 
asking families to exchange a bad habit for a good one on a 
monthly basis.
    So, in conclusion, we agree with the Institute of 
Medicine's assessment that media can be an integral part of the 
childhood obesity solution, but advertising and media are not 
the only solution. Fighting obesity is a marathon, not a 
sprint. And while we've made great strides toward empowering 
kids and families with the tools they need to navigate this 
issue, we are determined to go the distance to empower our 
audience to make balanced choices.
    I'd like to just roll a tape that briefly summarizes all of 
the various programs we've done on air and off air, and then 
I'll be happy to answer any questions.
    Thank you.
    Senator Harkin. How long is this?
    Ms. Smalls. It's one minute.
    [The statement follows:]

                   Prepared Statement of Marva Smalls

    Good Morning. My name is Marva Smalls and I am the Executive Vice 
President of Public Affairs and Chief of Staff at the Nickelodeon Kids 
and Family Group.
    At the outset, I want to thank Chairman Harkin, Chairman Durbin and 
Senators Brownback and Specter for holding this hearing today. I'd also 
like to acknowledge Senators Harkin and Brownback for leading the FCC 
Media and Childhood Obesity Task Force, a forum in which Nickelodeon 
was heavily engaged for more than a year and a half.
    Nickelodeon's Kids and Family Group is comprised of four television 
networks. The Kids and Family Group also includes online, digital, 
consumer products and recreation businesses focused on children and 
families. Nickelodeon was launched 30 years ago and it has been the #1 
cable network for the past 14 years, reaching over 83 million viewers 
per week. It is the most widely distributed channel in the world and 
can be viewed in over 175 countries.
    During my 15 year tenure at Nickelodeon, `what is good for kids is 
good for business' has been a guiding principle of the company. Year 
round, we work to ensure that our corporate responsibility and 
engagement upholds and honors that core value. It extends not only to 
the quality content we create for kids, but also to what we leave with 
them when they turn the TV off, put down their magazine or log off the 
internet.
    As discussed in greater detail herein, Nickelodeon's ongoing 
efforts to promote health and wellness and combat childhood obesity 
demonstrate our commitment to kids, parents and families.
    For kids:
  --Let's Just Play, Nickelodeon's long-term, multimedia campaign 
        designed to help kids make healthy lifestyle choices.
  --Nickelodeon's commitment to license its characters only on ``better 
        for you'' foods.
  --The annual Worldwide Day of Play when Nickelodeon, Nicktoons, 
        Noggin, The N and their corresponding websites go off the air 
        and Nickelodeon partners with community-based organizations and 
        schools to encourage kids to get up, go outside and play here 
        in the United States and in ten countries around the world.
  --Programming devoted to health and wellness like My Family's Got 
        GUTS, Lazytown and the Let's Just Play Go Healthy Challenge and 
        other short form content including PSAs.
  --Partnerships with the American Heart Association and the W.J. 
        Clinton Foundation's Alliance for a Healthier Generation, the 
        NFL, the LeBron James Family Foundation and the Boys and Girls 
        Clubs of America, which reaches millions kids in diverse 
        communities and clubs.
  --$2.5 million in grants to schools and communities to promote 
        physical fitness and nutrition education.
  --Regular features in Nick Magazine highlighting healthy activities 
        and options for kids
    For parents and families:
  --Nick at Nite and TV Land's Family Table, an initiative to raise 
        awareness about the benefits of quality, uninterrupted family 
        time especially at meals.
  --Nick at Nite's Kick One, Pick One, a new PSA campaign promoting 
        kids and parents joining together to eliminate one unhealthy 
        habit and choose a positive new one every 21 days.
  --ParentsConnect.com, an on-line community for parents which features 
        experts and advice on all matters related to health, fitness 
        and good nutrition.
  --Nicktrition, an effort with our fruit and vegetable licensing 
        partners to introduce families to the produce aisle in retail 
        stores and to provide healthy on-pack tips on packaged foods.
    These commitments are ongoing, but they must be viewed in the 
context of the larger, multi-dimensional problem of childhood obesity.
             childhood obesity: a multi-dimensional problem
    Nothing matters more than the health of kids. Good health is the 
first key that opens the door to learning, to proper development, and a 
happy childhood. Unfortunately, despite some evidence that the obesity 
crisis has leveled off, far too many kids are getting too little 
nutrition and consuming too many calories while burning too few. Making 
matters worse, too many of these kids are African American, Latino, or 
from low-income families, which adds good health to an already long 
list of closed doors they face.
    We all know the disturbing statistics about childhood obesity, so 
there is no need to repeat them here. The point I want to make is this: 
Childhood obesity is a challenge all of us must address because no 
matter what we do for a living, all adults are collectively responsible 
for the well-being of America's kids. Each of us must do our part. Each 
of us must connect kids to an active, healthy life-style.
    We know that obesity has many complex causes: poor nutrition at 
home and at school, lack of access to safe recreational facilities, 
confusion about what is a healthy food and what is not. It is foolish 
to cite one factor and claim that changing it alone will solve the 
problem. There is no magic bullet solution. Fighting obesity is a 
process of evolution, not revolution. It is a marathon, not a sprint.
    We wholeheartedly concur with the Institute of Medicine's 
assessment that media can be an integral part of the obesity solution, 
but advertising and media are not the only solution. We also know that 
at the end of the day, it is a personal commitment and responsibility. 
Anything we do must recognize that kids and parents need tools and 
messages from all stakeholders to help them make the daily choices that 
will change their lives.
                         nickelodeon's approach
    It is helpful to understand Nickelodeon's approach to confronting 
challenging social issues with our audience. When an issue becomes so 
prevalent that it impacts the well-being of kids, our approach is to do 
the necessary due diligence to ensure that our programming, initiatives 
and messaging will help serve our audience. Kids need to have command 
of information they can use and actions they can take so they are 
empowered to control their lives.
    The company's current commitment to health and wellness is in line 
with its pro-social legacy. For example in the 1990s, we launched The 
Big Help campaign, an initiative to inspire and equip the Nation's 
youngest citizens to volunteer in their communities. The campaign moved 
beyond the traditional mold of linear public service campaigns to build 
a grassroots, in-community infrastructure in partnership with 28 
national service organizations (e.g. Big Brothers/Big Sisters, National 
4-H, Second Harvest, YMCA, the Boys & Girls Clubs of America, etc) to 
give kids service projects on the local level. Over an 8 year span, 33 
million kids pledged and fulfilled more than 383 million hours of 
volunteering. Based on our success with The Big Help, the Centers for 
Disease Control invited us to help craft the direction of the VERB 
campaign in 2001.
    Long before the media frenzy started about childhood obesity, we 
were compelled to confront it. The results were beginning to have 
disastrous implications especially for African American, Latino as well 
as other challenged communities in urban areas and regions such as the 
southern United States.
    Our approach was to do what we've always done: to make ourselves as 
smart as possible on the issue and collaborate with willing 
stakeholders with the ultimate goal of empowering kids with 
information. We could have opted out, but that would have violated 
every principle that guides us. We opted in because that's how we 
operate.
    We met folks who market to kids and those who believe it is wrong 
to do so. We did this to see and understand the whole picture because 
what is at stake is too important for anything less. We wanted all the 
facts and every opinion because everything was under review. We wanted 
to act smartly and effectively. What we learned helped guide the 
company in our health and wellness campaigns and craft content to help 
kids lead the way.
    Our outreach on childhood obesity included advocates, food industry 
CEOs, government agencies and academics from Yale, New York University, 
Tufts University, and the University of Colorado, all of which are 
well-respected leaders in this field, to help formulate best practices 
and create scalable change. We have sought out and willingly 
participated in both public and private forums, sometimes in very 
heated debate, including the Institute of Medicine, the Kaiser Family 
Foundation, the Department of Health and Human Services, the Federal 
Trade Commission and most recently the FCC Task Force on Media and 
Childhood Obesity. As the issue has spread around the world, we have 
worked with groups in other countries to discover more and more options 
to address the issue.
    In collaboration with a leading academic institution, we conducted 
a national survey to identify kids and parents' attitudes and behaviors 
on eating, food, media and marketing.
    What did we learn? Perhaps most telling, our research found that 
most parents feel overstressed and overscheduled. They are working 
longer outside of the house than ever before, so they have less time to 
spend with their kids and less time to prepare nutritious meals. This 
impacts how they make decisions and how they take responsibility. They 
are most likely to choose one of the following four options in orders 
of preference.
  --One, what makes their life easier?
  --Two, what makes their kids happy?
  --Three, what helps them raise their kids to be ``good'' people?
  --And four, what stays within their financial means?
    Anyone here who has school-aged kids can understand why this is the 
case. For better or worse, these priorities are a natural outgrowth of 
modern life. If letting Johnny eat a frosted donut or danish for 
breakfast makes him happy, gets him off to school on time without fuss, 
and makes mom and dad's lives simpler, that's a trade-off many parents 
are understandably, if reluctantly, willing to make.
    This reality speaks volumes about how stakeholders must work very 
specifically to address how children and parents can take 
responsibility. It is incumbent upon all stakeholders to acknowledge 
the reality of this important family dynamic, and the role parental 
responsibility must play, so that meaningful steps can be made.
    Allow me to share with you in specific terms how we deliver on that 
promise to promote health and wellness and combat childhood obesity.
              nickelodeon's health & wellness initiatives
    For the past 6 years, Nickelodeon has championed health and 
wellness as its premier pro-social initiative. It represents a 
commitment of more than $30 million in resources of the company. This 
unprecedented campaign involves engaging a leading registered 
dietitian/nutritionist and consulting with an advisory committee of 
experts on child nutrition, exercise and fitness, psychology and civic 
engagement. In addition, the company commits resources externally, 
partnering to build a national grassroots infrastructure for kids to be 
leaders in making healthy and balanced lifestyle choices in their 
homes, schools and communities.
Let's Just Play
    Let's Just Play has been Nickelodeon's long-term campaign to help 
kids make healthy lifestyle choices. The Let's Just Play Go Healthy 
Challenge, a television program and website challenging children to 
make the changes necessary to lead healthier lives, launched the W.J. 
Clinton Foundation and the American Heart Association's Alliance for a 
Healthier Generation's outreach program to combat childhood obesity. In 
2007, over 1 million kids signed up to take the Challenge and to follow 
a nine month healthy living program mirroring two role model kids. Our 
partnership with The Boys & Girls Clubs of America extends the reach of 
the program to millions more in diverse communities and clubs.
    The Go Healthy Challenge does not just talk about calories in and 
energy out. It also helps kids understand the underlying causes of 
overweight and obesity, such as lack of physical education in schools, 
families not spending quality time together, regional demographic 
challenges, and insufficient safe play-space in communities, to name a 
few. By understanding the causes and giving them solutions to confront 
the obstacles they encounter, we are connecting the dots between 
information and action.
    The campaign also offers a personal training game and tracking log 
for kids online so that they can follow their progress and celebrate 
their success. Nickelodeon delivers this and other Let's Just Play 
content through all multi-media platforms including Nickelodeon 
Magazine, www.nick.com, our broadband site www.TurboNick.com, wireless 
phones, video on demand and iTunes. We provide standards-based 
curriculum materials to teachers through our Cable in the Classroom 
website for educators at www.teachers.nick.com.
    Activation of community events and programs has been the 
cornerstone of Nickelodeon's Let's Just Play campaign. Millions of kids 
and families in all 50 states have participated in Let's Just Play 
activities and community-wide events created with our partners as well 
as the National Football League, the National PTA, schools, mayors, and 
other community-based organizations. Nickelodeon provides tool-kits to 
100,000 local organizers so that they can take advantage of 
Nickelodeon's connection with kids to generate more attention and 
support for their in-community health, nutrition and fitness programs. 
The kits feature Let's Just Play Go Healthy Challenge and include how-
to information on organizing programs and events with kids, monthly 
themes based on goal-setting and health, and health information for 
parents. Additional resources, such as customizable banner, flyer and 
poster art are offered online to local organizations.
Local Grants for Under-resourced Programs
    Since 2005, Nickelodeon has given $2.5 million in local seed 
funding for health, nutrition, physical education and other fitness 
programs through the Let's Just Play Give-Away, a kid-driven grants 
program. Kids partner with their school or community-based organization 
to apply for the grants for much needed resources where physical 
education and nutrition education are lacking. Over 450 communities in 
all 50 states and the District of Columbia have benefited from these 
resources, including Iowa ($45,000), Illinois ($45,000), Kansas 
($42,000) and Pennsylvania ($85,000). Winners are announced on-air and 
on-line, thereby raising awareness to kids about the lack of resources 
in schools and communities for nutrition, fitness and physical 
education programs.
    Nickelodeon's Worldwide Day of Play serves as an annual culmination 
for Let's Just Play, as well as Family Table and Kick One, Pick One, 
our health and wellness initiatives on Nick at Nite and TV Land. In 
addition to suspending programming and ``going dark'' on air and 
online, Nickelodeon and its national and local partners generate 
thousands of local events to celebrate the accomplishments of kids and 
to hit home the powerful message of tuning out to play.
    Make no mistake, this is not a one day effort or investment. This 
programming is a constant part of our content throughout the year. 
Let's Just Play daily messaging has included a growing library of 
short-form PSAs and interstitials. In addition, our long-form 
programming that features healthy messages include:
  --My Family's Got GUTS,
  --Nick News with Linda Ellerbee,
  --The Let's Just Play Go Healthy Challenge,
  --Lazy Town,
  --Dance on Sunset, and
  --The N's Student Body.
Initiatives to Engage Parents
    What we have learned through our work on Let's Just Play is that 
kids cannot succeed without positive encouragement from their parents 
and others in their home. We launched Kick One, Pick One on Nick at 
Nite to involve the whole family with humor, simplicity and no guilt. 
This campaign is designed for kids and parents to write and sign a 
family contract committing to eliminate a bad habit and to pick up a 
newer healthier habit. In this way, kids and parents can support each 
other and keep each other honest in the process. Families can track 
their progress at www.nickatnite.com/kopo.
    Kick One, Pick One is a natural extension of our 4 year effort with 
Family Table on Nick at Nite and TV Land, which promotes uninterrupted 
family dinner as a way for parents and children to discuss all sorts of 
topics of importance in their lives like work, school, difficult 
situations and healthy living.
    Kick One, Pick One and Family Table messages are extended through 
Nickelodeon's online outreach to parents. On ParentsConnect.com and 
NickJr.com, you will find a host of resources for parents to find ways 
that they can help their kids with good nutrition, fitness and overall 
healthy living. ParentsConnect in particular is a community site where 
parents openly share advice as well as challenges on keeping healthy.
                          licensed characters
    In 2007, Nickelodeon announced that it will limit the use of its 
licensed characters to food packaging that meets ``better for you'' 
criteria as established by our marketing partners in accordance with 
governmental dietary guidelines. We will continue to allow characters 
to be used on a limited number of seasonal treats, such as Halloween 
candy. This policy will become effective with all new agreements 
beginning in 2009.
    This announcement follows more than three years of pro-active 
efforts by Nickelodeon to seek and secure partners to license 
Nickelodeon's most popular characters for ``better for you'' food 
products. We've changed our licensing model so that we could establish 
on-going programs with a growing list of fruit and vegetable partners 
who otherwise would not have the financial means to market their 
products. These now include, but are not limited to SpongeBob Carrots 
and Spinach; SpongeBob and Dora clementines, mandarin oranges and 
tangelos; Dora and Diego peaches, plums, and nectarines; SpongeBob and 
Dora Frozen Edamame. All Nickelodeon licensed food products are 
marketed with ``Nicktrition'' on-label food tips, which highlight 
portion control, valuable nutrients and healthful preparations.
           collaboration with advertisers and food companies
    Nickelodeon actively engages its business partners to encourage 
improvements in how they market to kids and parents. These 
conversations have yielded changes in food labels, product re-
formulations involving fat, sugar and sodium content, and kid-friendly 
portion sizes and information. These conversations have also led to the 
introduction of healthy options in kids' meals offered by Nickelodeon's 
quick service restaurant partners. In addition, all advertising must 
adhere to the advertising guidelines established by the Children's 
Advertising Review Unit (CARU).
    Since last summer, 14 of the major food companies that market to 
kids took the unprecedented step of launching a major new self-
regulatory initiative to complement the Children's Advertising Review 
Unit (CARU) guidelines. It is important to note that companies that are 
party to the agreement have announced pledges which exceed the 
agreement to devote at least 50 percent of all advertising primarily 
directed to children under 12 and to reduce use of third-party licensed 
characters in advertising directed to children under 12. In addition, 
most companies are well ahead of schedule in terms of full 
implementation by January 1, 2009.
                             in conclusion
    The media and food industries have demonstrated their commitment to 
fighting childhood obesity. Now, the government must step in to address 
the main causes of childhood obesity, including the lack of recess and 
physical education in schools and proper nutrition in school lunches.
    I am confident that a fair review over the past few years shows 
that the children's media landscape has changed for the better. On its 
own since 2002, Nickelodeon has made childhood obesity a filter by 
which we review all our business initiatives, whether television, 
online, digital, consumer products or recreation, and we will continue 
to do so.

    Senator Harkin. Thank you very much, Ms. Small.
    Now we'll turn to our last witness, Patti Miller, vice 
president of Children NOW.
STATEMENT OF PATTI MILLER, VICE PRESIDENT, CHILDREN AND 
            THE MEDIA, CHILDREN NOW
    Ms. Miller. Thank you, Senator Harkin and Senator 
Brownback, for holding this hearing today.
    Our Nation's children face an unprecedented public health 
crisis. While a confluence of factors contribute to this 
crisis, food marketing is a significant one. In 2005, the 
Institute of Medicine recommended that the industry voluntarily 
shift marketing and advertising targeted to kids to products 
that are lower in calories, fat, salt, and added sugars and 
higher in nutrient content. If the industry was not able to 
achieve significant reform, the IOM recommended that Congress 
intervene.
    More than 2 years have passed since the IOM's call to 
action, and, unfortunately, voluntary industry action has 
fallen considerably short of the goal. Industry leaders assert 
that the Children's Food and Beverage Advertising Initiative 
will address concerns about food advertising to children, yet 
the initiative is insufficient, for three main reasons:
    Number one, food and beverage companies participating in 
the initiative lack a uniform nutrition standard for defining 
healthy foods. This poses numerous problems. It's confusing to 
parents. It creates situations where similar food products will 
be classified as healthy by one company, but will be considered 
unhealthy by another. This absence of a level playing field 
allows companies to maneuver their product portfolios and their 
definitions of ``better for you'' to best serve their own 
economic interests. For any industry initiative to be 
effective, there must be a uniform nutrition standard.
    Number two, food and beverage companies have created a huge 
loophole that allows non-nutritious foods to be categorized as 
``better for you.'' They take products loaded with added sugar 
and fat, and then label them as ``better for you'' because they 
have a modest proportion of the unhealthy ingredients removed. 
Yes, it's true that it's better for you to eat Fruit Loops or 
Cocoa Puffs with less sugar than in the original formula, but 
it's also true that these types of products remain non-
nutritious. We must close the ``better for you'' food loophole 
and focus on shifting food advertising to children to actual 
healthy products.
    Number three, media companies that deliver children's 
programming are absent from any attempt to solve this problem. 
They point to the food and beverage companies, hoping they will 
fix it. Yet, without media company participation, another 
loophole is created. What do you do about the food and beverage 
companies that refuse to participate in the industry 
initiative? They will be allowed to continue to advertise junk 
food to children. That's hardly a solution to this problem.
    That's why media companies must play a critical gatekeeper 
role by monitoring their advertising environments to ensure 
that unhealthy food advertising is significantly reduced, while 
healthy food advertising is enhanced.

                           PREPARED STATEMENT

    Children NOW believes that media companies should be 
required to devote either equivalent time or a majority of 
their total time--advertising time--for the promotion of 
healthy food products. To accomplish this, Congress should, 
one, adopt legislation mandating that at least 50 percent of 
all food advertising to children on broadcast and cable TV 
programming be devoted to healthy food products, and, two, 
delegate to appropriate agencies the task of devising criteria 
for a uniform nutrition standard. It's essential that we 
intervene on behalf of the Nation's children. The stakes are 
too high to sell their needs short.
    Thank you, Senators, for your leadership on this issue. We 
look forward to working with you to improve the health of the 
Nation's kids.
    [The statement follows:]

                   Prepared Statement of Patti Miller

    Children Now thanks Senators Harkin, Specter, Durbin and Brownback 
for hosting this hearing today to address the influence of food 
marketing on children's health. It could not come at a more critical 
time.
    Our Nation's children are facing an unprecedented public health 
crisis. For the first time in modern history, we have a generation of 
children whose life expectancy may be lower than that of their 
parents.\1\ The U.S. Surgeon General has identified overweight and 
obesity as ``the fastest growing cause of disease and death in 
America.'' \2\
---------------------------------------------------------------------------
    \1\ S. Jay Olshanksy, et al, ``A Potential Decline in the Life 
Expectancy in the United States in the 21st Century,'' New England 
Journal of Medicine: 352: 11: 1138-1145.
    \2\ Richard H. Carmona, ``The Obesity Crisis in America,'' 
Testimony of the United States Surgeon General before the Subcommittee 
on Education Reform, Committee on Education and the Workforce, United 
States House of Representatives, July 19, 2003. http://
www.surgeongeneral.gov/news/testimony/obesity07162003.html.
---------------------------------------------------------------------------
    While a confluence of factors contribute to childhood obesity, 
advertising and marketing clearly are very significant ones. Children 
are exposed to tens of thousands of ads each year on television alone, 
the majority of which are for fast food, junk food and sugared 
cereals.\3\
---------------------------------------------------------------------------
    \3\ Kaiser Family Foundation, Food for Thought: Television Food 
Advertising to Children in the United States, March 2007, http://
www.kff.org/entmedia/7618.cfm.
---------------------------------------------------------------------------
    In 2005, the Institute of Medicine released a report which found 
compelling evidence that television advertising influences the food and 
beverage preferences, purchase requests and consumption habits of 
children. The IOM recommended that the food industry voluntarily shift 
advertising and marketing targeted to kids to products and beverages 
that are lower in calories, fat, salt and added sugars and higher in 
nutrient content. If the industry was not able to achieve significant 
reform, the IOM recommended that Congress intervene.\4\
---------------------------------------------------------------------------
    \4\ Institute of Medicine, Food Marketing to Children and Youth: 
Threat or Opportunity, National Academy of Sciences Press, December 
2005, http://books.nap.edu/openbook.php?record_id=11514&page=1.
---------------------------------------------------------------------------
    Children Now was hopeful that the industry--both the food/beverage 
companies and the media companies--would respond to the IOM's call to 
action. Yet more than two years have already passed and unfortunately, 
voluntary industry action has fallen considerably short of the goal.
    Industry leaders assert that the Children's Food and Beverage 
Advertising Initiative, a voluntary self-regulatory program that 
includes 14 food and beverage companies, has sufficiently addressed the 
concerns about unhealthy food advertising to children. They tell 
advocates to give the Initiative a chance to work. Yet the Initiative 
is insufficient for three main reasons:
  --The food/beverage companies participating in the Initiative say 
        they will advertise ``healthier products'' to children--but the 
        companies lack a uniform nutrition standard for defining 
        healthy foods. This poses numerous problems. It will be 
        confusing to parents. It creates situations where similar food 
        products will be classified as ``healthy'' for kids by one 
        company but will be considered ``unhealthy'' for kids by 
        another company's standards. This absence of a level playing 
        field allows companies to maneuver both their product 
        portfolios and their definitions of ``better for you'' food to 
        best serve their own economic interests. For the industry 
        initiative to effectively address the concerns about childhood 
        obesity, there must be a uniform nutrition standard for 
        defining healthy foods that food/beverage companies adopt.
  --Food/beverage companies have created a huge loophole that allows 
        non-nutritious foods to be categorized as ``better for you'' 
        for children. They take products loaded with added sugar and 
        fat, and then label the item as ``better for you'' because it 
        has a modest proportion of the unhealthy ingredients removed. 
        It's true that it is ``better for you'' to eat Fruit Loops or 
        Cocoa Puffs with less sugar than the original formula with all 
        of the added sugar. But it's also true that these types of 
        products remain non-nutritious and that regular consumption 
        poses a risk of obesity. ``Better for you'' foods are not the 
        same as ``healthy'' foods. We must close the ``better for you'' 
        food loophole and focus on the goal of shifting food and 
        beverage advertising to children to actual healthy products.
  --Media companies that deliver children's programming are absent from 
        any attempt to solve this problem. They refuse to take the 
        necessary steps to reduce unhealthy food advertising to 
        children. They simply point toward the food and beverage 
        companies, hoping they will fix it. Yet without the 
        participation of media companies, another loophole is created. 
        Food/beverage companies that do not participate in the industry 
        initiative will be allowed to continue to advertise junk food 
        to children. That's hardly a solution to the problem. Media 
        companies must play a critical gatekeeper role by monitoring 
        their advertising environments to ensure that unhealthy food 
        advertising is significantly reduced, while advertising for 
        healthy food products is enhanced.
    Because there is no uniform nutrition standard;
    Because unhealthy products creatively labeled as ``better for you'' 
are being passed off as healthy food for children;
    And because the media companies refuse to play a role in protecting 
children from the advertising of unhealthy food products, all of the 
public health and child advocacy groups involved with the Joint Senate/
FCC Task Force have refused to accept the industry initiative as a 
viable solution to the problem we face here.
    Children Now believes that media companies (both broadcast and 
cable) should be required to devote either equivalent time or a 
majority of their total advertising time for the promotion of healthy 
and nutritious food products, as judged by basic scientific standards. 
To accomplish this, Congress should:
  --Adopt legislation mandating that at least 50 percent of all food 
        advertising to children on broadcast and cable television 
        programming be devoted to healthy food products;
  --Delegate to an appropriate agency or agencies the task of devising 
        criteria for a uniform nutrition standard that would identify 
        healthy, nutritious foods.
    It is essential that we intervene on behalf of the Nation's 
children. Industry is privileging their profits over the health and 
nutrition concerns of the Nation's children. The stakes are too high to 
sell children's needs short.
    Thank you Senators Harkin, Brownback, Durbin and Specter for your 
leadership on this issue. We look forward to working with you to 
improve the health and well-being of our Nation's children.

    Senator Harkin. Thank you very much, Ms. Miller.
    I thank the panel for being here today.
    Let me just start--first, I'll start with Ms. Smalls. I'm 
thrilled you're here today to represent Nickelodeon. When we're 
talking solutions, we must have Nickelodeon at the table. As 
you state in your testimony, Nick reaches over 84 million 
viewers per week. It's the number-one cable network. And so, 
I'm very happy to learn about the many initiatives that your 
network's been involved in over the last several years, and 
your collaboration with leading academics and experts in the 
field.
    So, again--but, we have to take a realistic look at what's 
happening. Now, I was--looked at a statement that just came out 
for--the Center for Science and the Public Interest, that just 
did a study of Nickelodeon. And it said here, ``In early 2008, 
the Center for Science and the Public Interest undertook a 
second assessment of Nickelodeon food marketing to children. 
The 2008 assessment indicates that Nickelodeon continues to 
market primarily foods of poor nutritional quality to children. 
The vast majority--79 percent--of food ads, products, and meals 
marketed to children by Nickelodeon are too high in fats, 
salts, and sugars. This is just a little lower than in 2005, 
when 88 percent were of poor nutritional quality.'' So, they're 
saying that, really, not much has changed at Nickelodeon.
    And it went on to point out that--and there's some data 
here--they did 28 hours, on Friday and Saturday, of Nickelodeon 
programming--they reviewed that--during which a total of 819 
advertisements and PSAs and promos were shown. Of the 185 food 
ads, 177 had nutrition information available; 138--78 percent--
of those ads were for foods of poor nutritional quality. Four--
out of all of this, four nutrition-related public service 
announcements were observed, probably similar to what you just 
showed, one for every 34 ads for foods high in fats, salts, and 
sugar. So, you get 34 ads on Nickelodeon that are for foods 
that are high in fats, salts, and sugar, and you get one public 
service announcement.
    And then they looked at the Nickelodeon magazine. Seven 
issues--August 2007 to March 2008--of Nickelodeon were 
reviewed. Of the 31 food ads, 24--or 77 percent--were for foods 
of poor nutritional quality. And use of licensed characters on 
food packages, nine food products containing Viacom marketing 
were found at the Georgetown Safeway grocery store in 
Washington, DC--7 or 78 percent--of the products were foods of 
poor nutritional quality.
    Last, they go to the promotional tie-ins between 
Nickelodeon and fast-food restaurants. During the study period, 
three restaurants featured Viacom tie-in promotions: 
McDonald's, with the Spiderwick Chronicles; Subway, with the 
Naked Brothers Band; and Chuck E. Cheese, with Bee Movie. 
Listen to this. Of 24 Happy Meal combos at McDonald's using 
this tie-in, 92 percent are of poor nutritional quality. Of 18 
Fresh Fit Combos at Subway--much better--56 percent are of poor 
nutritional quality; 89 percent of Chuck E. Cheese's menu items 
are of poor nutritional quality.
    So, with all of this, don't we think Nickelodeon has got a 
ways to go?
    Ms. Smalls. Well, sir, I'm very proud of the efforts 
Nickelodeon has made, and I think what's missing from that 
press release is the fine--footnotes and the fine print. For 
example, I believe that press release--I saw it only briefly 
before I sat down--was that 81 percent of our advertising is 
covered by the CBBB food pledges. So, let me begin by saying 
that only 20 percent of our advertising comes from food. The 
majority of that advertise--food advertising is covered by the 
CBBB pledges.
    So, part of the issue here is not being sure what standards 
that CSPI has used in analyzing the food criteria, because 
we've attempted nutritional standards ourselves, and it is a 
challenging and daunting task. We used it to engage on our on-
pack foods. But, for every one nutritionist or dietician we 
spoke to, there is a different nutritionist or dietician who 
had a different point of view. When we met with our individual 
food and marketing partners--if you take the 15 that have 
agreed to the pledge, they each have a different nutritional 
standard, based on their foods.
    So, what I'm saying is, our air is balanced. So, if 80---if 
the majority--or if they--if we use their number, 81 percent of 
our air is covered by better-for-you food advertising, we 
believe we've closed the gap----
    Senator Harkin. Well, Ms.----
    Ms. Smalls [continuing]. A long way. And----
    Senator Harkin. So, Ms. Smalls, what you're saying is, 
you're relying upon the companies----
    Ms. Smalls. No, I haven't----
    Senator Harkin [continuing]. Themselves. That's--yeah.
    Ms. Smalls. Sir, we are----
    Senator Harkin. Eighty-one percent are covered by current 
CFBI pledges, remaining ads not subject to any company 
nutrition standards.
    Ms. Smalls. We--again, Senator, we have to rely on the 
experts, the people who are closest to the food product. We're 
an entertaining and media company, we aren't in the business of 
food. We could not begin, with any credibility, to develop 
nutritional standards for food for the diversity of products or 
manufacturers or the diversity of age groups that apply--that 
they would apply to.
    We have a very balanced air. Even the CBBB pledges 
establish a 50-percent threshold. We give more than 30 
percent--or, more than 10 percent of our airtime to balanced 
messaging, $30 million in resources, direct grants, long-form 
programming. We go dark on the air. We have engaged 
stakeholders, up and down--excuse the pun--the food chain. But, 
when the majority of our advertisers, who are closest to the 
product, and they have the experts who know what the 
nutritional standards makes most sense for their food, we've 
learned--we've learned, by attempting to establish the food 
standards, that we can't do it. We don't have the expertise to 
be a gatekeeper on nutritional standards.
    Senator Harkin. Well, there are standards that are out 
there that are widely accepted. The Institute of Medicine has 
come up with standards.
    Dr. McGinnis.
    Dr. McGinnis. We do have standards for nutrition products 
in schools. But, the fact is that the sort of standard that--
across the board, as to what constitute a healthy food for 
children has not been subjected to a consensus study of that 
sort. It's doable, I think. The issues are very complex, but 
it's doable. And this is a very important issue. There do need 
to be--there needs to be a common understanding, across the 
board, about the standards for the labels, and there needs to 
be a more consistent approach, in terms of the graphics used to 
portray the food content so that the consumer is aided and not 
confused.
    Ms. Smalls. And just----
    Senator Harkin. See, that's the idea----
    Ms. Smalls [continuing]. Just to follow up--if we----
    Senator Harkin [continuing]. That if--that Nick will only 
license their characters for foods that meet an individual food 
company's nutritional standard. I don't know what that means. 
What does Mars candy--I mean, what's their nutritional 
standard?
    Ms. Smalls. Well, Mars candy--well, let me back up. We said 
we will only license our characters to healthier better-for-you 
products, in keeping with the U.S. dietary guidelines, as 
filtered through the individual company's better-for-you 
standards. Again, the issue is, there is no uniform food 
standard across the 15 companies who've accepted the pledge, or 
even if you line up our--the other kids' networks in--who've 
made commitments, and you lined up all of the standards that 
they've committed to, none of them are uniform. In contrast, if 
you look at what has been committed to in the United Kingdom by 
our channel there, the government, Ofcom, took the initiative 
and laid out uniform standards, and those are the standards we 
used.
    So, if--between USDA, HHS, whoever established the pyramid, 
the dietary guidelines, or the industry themselves, if a 
baseline of uniform food standards can be established--because, 
as a media company--I assure you, it--we tried--it's a 
challenging task. We don't have the expertise, nor would we be 
credible in this space. But, if the industry or the government 
or something similar to Ofcom came up with uniform standards by 
which we could use to engage our advertising and marketing 
partners, we would be there. But, we cannot credibly come up 
with those standards to cover all of the food manufacturers and 
their products----
    Senator Harkin. Ms. Smalls----
    Ms. Smalls [continuing]. Or the agents.
    Senator Harkin [continuing]. Will Nick support uniform 
standards if they are adopted?
    Ms. Smalls. Sir, if uniform standards are adopted, and they 
apply to all of the industries we deal with, absolutely, we 
will use that as a filter for all of our----
    Senator Harkin. And----
    Ms. Smalls [continuing]. Marketing and advertising 
relationships.
    Senator Harkin. And in the meantime, could you do a better 
job--when you have 34 ads for foods high in fats, salt, and 
sugar, and only one for a public service announcement, that 
does not seem to me to be a balanced approach.
    Ms. Smalls. Again, sir, I don't know the statistics they 
used, but what you saw in that tape is the diversity of our air 
that our audience sees on a regular----
    Senator Harkin. I don't know. All I can tell----
    Ms. Smalls [continuing]. And consistent basis.
    Senator Harkin. All I can tell is, this is what they said 
of watching it over----
    Ms. Smalls. And I would----
    Senator Harkin [continuing]. A 2-day period----
    Ms. Smalls [continuing]. And I will----
    Senator Harkin [continuing]. Of time.
    Ms. Smalls [continuing]. Be happy to provide you and your 
staff more information----
    Senator Harkin. Thank you.
    [The information follows:]

    The Center for Science in the Public Interest (CSPI) hastily 
presented Nickelodeon with a report entitled ``Nickelodeon: Food 
Marketing Little Improved between 2005 & 2008'' just moments before the 
September 23 hearing. Although the two-page report was unscientific and 
lacked substantiation, it nevertheless generated interest among Members 
of the Committee. I feel compelled to set the record straight.
    As an initial matter, the report actually undercuts the CSPI 
premise that food marketing to children has not improved by noting that 
just 20 percent of ads on Nickelodeon are for foods and ``[e]ighty-one 
percent of the Nickelodeon food ads are covered by current [Children's 
Food and Beverage Advertising Initiative (CFBAI)] pledges.'' The 
balance of the report suffers serious flaws and should be rejected.
    First, CSPI conducted its analysis in February 2008, almost a full 
year before the CFBAI food advertising pledges went into effect on 
January 1, 2009. CFBAI self-regulation must be given a chance to work, 
particularly since even CSPI has praised the program as ``historic.'' 
\1\ For CSPI to ignore the pending implementation of the pledges is 
disingenuous at best. Nickelodeon expects the landscape of food 
advertising on Nickelodeon television and in Nickelodeon Magazine to be 
very different in 2009 than it was in February 2008.\2\ As more food 
and beverage marketers join the CFBAI pledge program, as Nestle did 
last July, the scale of the change will be even more dramatic.
---------------------------------------------------------------------------
    \1\ See http://www.cspinet.org/new/200707181.html.
    \2\ In the absence of a uniform nutritional standard, the 
qualitative measurement of food advertising is inherently subjective. 
As a media company, Nickelodeon cannot and does not assess the 
nutritional content of food and beverages featured in advertising. 
Nevertheless, Nickelodeon expects a shift in the types of food 
advertisements in all media after January 1, 2009.
---------------------------------------------------------------------------
    Second, CSPI developed a unique and arbitrary standard for 
``nutritionally poor'' foods in ads aired on Nickelodeon. In some 
instances, the CSPI standards are stricter than industry and government 
standards. In other instances, they are less strict or unclear, such as 
in defining portion size. This lack of consistency, and the unhelpful 
confusion it adds for parents, underscores the need for a uniform 
nutritional standard.
    The CSPI standard is one of at least 20 different non-governmental 
guidelines for nutritional content in children's foods. In addition, 
there are competing U.S governmental standards, including the U.S. 
Department of Agriculture's MyPyramid and the Food and Drug 
Administration's Dietary Guidelines for Americans. Using CSPI's unique 
guidelines to measure food marketing on Nickelodeon makes little sense 
if the goal is to evaluate the effectiveness of self-regulation. CSPI 
should direct their apparent concern with the CFBAI food standards to 
the food and beverage companies that created them.
    It also makes little sense for Nickelodeon to add yet another set 
of nutritional standards, as CSPI suggests. Setting aside the practical 
difficulty in having a media company develop nutritional standards, how 
would more than 20 sets of standards help kids and parents navigate 
what is ``healthy'' and what is not? Plainly, it would not.
    Finally, the CSPI report failed to provide proper perspective on 
the children's media industry. Nickelodeon is the largest, but not the 
only, children's media company. Time Warner Inc., The Walt Disney 
Company and Discovery Communications Inc. each accept food advertising 
and sponsorships directed to children. If CSPI had surveyed these 
companies, they would have discovered similar food products and 
promotions likewise not yet subject to fully implemented CFBAI pledges.

    Ms. Smalls [continuing]. That counters that, sir.
    Senator Harkin. Thank you.
    Senator Brownback.
    Senator Brownback. Thank you very much, Mr. Chairman.
    Ms. Miller, you put forward a proposal to have half the 
advertising time being put toward something healthy. If you're 
going to advertise junk food, okay, but of 100 percent of your 
budget, half of it has to go to some healthy product or 
setting.
    Dr. McGinnis, do you agree or like that proposal?
    Dr. McGinnis. Yes. The committee that issued the report in 
2005 recommended that the proportion of food products that are 
marketed be reversed, in terms of the relative emphasis on 
foods now that are high in calories and low in other nutrients, 
toward a--marketing products that were more helpful. We didn't 
set a specific percent, but, in fact, some of the members, as I 
mentioned, were, in fact, focused on a reversal, which would be 
a much greater proportion change.
    Senator Brownback. Mr. Firestone, first, thank you guys for 
what Kraft has done, and done voluntarily. And I'm sure that's 
come at some market dislocation for some of your products.
    And I'd note, just parenthetically, chairman, when I was 
there to help present that BBB award. That was the last time I 
saw Tim Russert. He was there at that award presentation, the 
last time I saw him, was a strong proponent and supporter of 
it, as well.
    I sense, in what you're saying, though, that you're saying, 
``Look, we've got to have a level playing field on this.'' Now, 
what do you mean by that?
    Mr. Firestone. Well, Senator, I'd say that I think--two 
things I'd mention. One is that these are difficult commercial 
decisions that we make, and will continue to make because of 
the broader social policies. The question of 50 percent versus 
100 percent, for example, is one that's come up, where 
basically our rule is 100 percent. So, 100 percent of the 
products we advertise meet the sensible-solutions standards, 
and zero of the products that we advertise don't. So, we've 
basically made it an all-or-nothing standard, as opposed to the 
50 percent. And some other companies have started to come 
along.
    So, one would be a degree of uniformity and consistency in 
the standards, including the nutritional criteria and the other 
practices.
    And then, second, and more broadly, as everybody has been 
saying, this morning and in your July hearing, this whole issue 
takes place in a broader ecosystem, of which marketing is a 
hugely important part, and we want to do our part, but 
community intervention, for example, is something that can be 
very powerful.
    So, ideally, what we, from the food companies, do, and the 
others, all interrelate in the broader program. So, it's the 
level playing field within our industry, and the integration of 
what we're doing with what the other five or six components of 
the ecosystem are doing.
    Senator Brownback. Well, let me get sharper to the point, 
then.
    Mr. Firestone. Yes, sir.
    Senator Brownback. Is it that you believe all food 
companies should be required, 100 percent, to do what you're 
doing, to level that playing field?
    Mr. Firestone. Well, yes, Senator, as I said in my opening 
remarks, we certainly hope that all of the food companies will 
follow the BBB standards, along with us and the other 14 
companies that have done so. So, yes, we would like to see the 
entire industry following a similar approach.
    Senator Brownback. And required to follow?
    Mr. Firestone. Well, I think that what we've seen over the 
last few years really is a huge change in the mix of 
advertising, in a relatively short time. We announced, in 2005; 
we're now 2008. There's been a huge change in the mix of 
advertising. So, I think self-regulation has shown that it has 
the advantage of speed, so--and, as Commissioner Leibowitz was 
saying, it avoids questions of litigation. So, to the extent 
that the pace remains as impressive as it's been, we would 
certainly support, through your forceful encouragement and your 
encouraging companies to participate, that--everybody to do so.
    And I'd defer, to the broader question of whether, at this 
point, there should be legislation. I think we've seen the 
speed and the effectiveness of these voluntary measures that 
has proven----
    Senator Brownback. Well, and that's what I certainly 
support. And I've started down this road--gosh, this has been a 
couple of years ago. I think Kaiser Family Foundation had a 
meeting I presented and said that where we need to do this on a 
voluntary basis.
    This is a problem. It's a big problem. It's well documented 
that it's a problem. It is in a broader environment, as we 
heard from Dr. Gerberding. But, this is a piece that can be 
gotten at, and I think we've got to do our job on the school 
nutrition and physical education, as well. There's no question 
about it. But, here's one that you can get right at.
    And as a parent of five children and two 10-year-olds, I've 
witnessed the power of advertising, and I know it's very 
strong.
    And, Ms. Smalls, I think that's what the chairman's really 
getting at with you, where you've got a powerful set of 
characters in it, so that anything you can do would be helpful. 
My 10-year-old son is a real fan of SpongeBob, which I didn't 
know existed until he started watching him. And then you put 
SpongeBob on a product of fruit-flavored snacks--now, I don't 
know that he sees SpongeBob as an authority figure, but it 
certainly is attractive to him.
    And this was purchased yesterday. I don't think my next-
door neighbor, who's a dentist, would like these at all. They 
really stick to the teeth, and the lead ingredient in this--
sugar, modified corn syrup, cornstarch, just a number of not 
particularly healthy items. And we got this yesterday.
    And I think that's what the chairman is pointing out, that 
I'm concerned about, too, is that you do have a big impact in a 
youngster's mind. And you know that. And you entertain them. 
You spend a lot of time with them. In many cases, you spend 
more time with them than most parents do, unfortunately, given 
the way things have evolved in our society. And so we're really 
saying to you, and pleading with you, that you've got to get it 
better for us to be able to move this forward, given your 
presence in their lives. And I'm sure you can appreciate that.
    And I would just really press you that, to the degree you 
can, that you go back to your company and you press within the 
corporation, that we've got to do better, because we are at a 
crisis stage on this. And self-regulation is the better route 
to go. But, if it doesn't work then the other steps move on 
forward. And you've heard the testimony here today, as well. 
So, we'd really plead with you on that.
    Ms. Smalls. Well, Senator, I was the one who engaged with 
you, 2 years ago at the Kaiser study, and encouraged the 
formulation of a task force, a safe-space kind of environment 
that did take place with a task force. And since that time, we 
have--the industry, most all, have agreed to limit the use of 
licensed characters. Fifteen companies have signed the CBBB 
pledges, all to take----
    Senator Brownback. But, what about this guy?
    Ms. Smalls [continuing]. Effect in January 2009. Our 
agreements that are----
    Senator Brownback. Not until 2009, this guy comes off?
    Ms. Smalls. Well, we also have SpongeBob Dora on edamame 
grapes, vegetables, Clementines----
    Senator Brownback. When does he come off of this?
    Ms. Smalls [continuing]. Oranges----
    Ms. Smalls. He--effective January 2009, our licensed 
characters will only be used on better-for-you products. In 
addition to that, most of the food companies--15 of the major 
food manufacturers have said they will only market their 
better-for-you products to our core audience. So, I think, in 
January--the pledges aren't fully in effect yet, and we've 
already seen tremendous movement. I think that we're going to 
continue to see even more movement when all of the pledges, by 
both the food companies, the media companies, are fully loaded 
in. But, we----
    Senator Brownback. Okay.
    Ms. Smalls [continuing]. Are also--created partnerships 
with the Fresh Food and Marketing Association and Vegetable 
Association. So, our characters on--are on a variety of 
products. And, you know, but it is this whole intervention 
across many platforms.
    The other----
    Senator Brownback. May I get to----
    Ms. Smalls [continuing]. Thing you said----
    Senator Brownback.--Ms. Miller, too, here? We've given you 
quite a bit of time to respond, and we appreciate that.
    Ms. Miller.
    Ms. Miller. Yes. I just want to make sure everyone is clear 
on the advocates and public health groups' position on this 
issue. Better-for-you foods does not mean healthy foods. You 
can take out a couple of grams of sugar, you can take out a 
couple of, you know, parts of the salt; that does not mean--
then you're putting characters on something--that that, in 
fact, is advertising a healthy food to kids.
    Senator Brownback. That's where we've got to get the 
standard----
    Ms. Miller. That's what we----
    Senator Brownback [continuing]. Developed----
    Ms. Miller. That's why we need a standard here. You can 
talk all about--you know, companies saying, ``We have 100 
percent of better-for-you''--that doesn't work for us. We need 
at least 50 percent of foods advertised to children to be 
healthy. And that should be judged by a uniform nutrition 
criteria that we all agree to accept, that can be devised, you 
know, across agencies, across government agencies, that, you 
know, people who have expertise in determining what good 
nutrition criteria would be, sit down, and it's evidence-based, 
that it's based on good scientific criteria.
    But, better-for-you foods does not equal healthy foods, and 
that's where the advocates and public health groups come down 
on this issue. So, you can put characters on some products, and 
that doesn't necessarily mean we're getting to the root of the 
problem.
    Senator Brownback. Thanks, chairman.
    Senator Harkin. Thank you very much, Senator Brownback.
    I thank the panel for being here today and for your 
involvement in this issue. We are going to continue to, 
obviously--both Senator Brownback and I have been working 
together on this for a long time, we're going to continue to 
work on this issue.
    I would ask consent that the hearing record be left open 
for 1 week, and for the addition of other statements to be 
included in the record.

                         CONCLUSION OF HEARING

    Senator Harkin. Thank you all very much. The subcommittees 
will stand recessed.
    [Whereupon, at 12:16 p.m., Tuesday, September 23, the 
hearing was concluded, and the subcommittee was recessed, to 
reconvene subject to the call of the Chair.]

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