[Senate Hearing 110-866]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 110-866

                      PROMOTING HEALTH, PREVENTING
                 CHRONIC DISEASE, AND FIGHTING HUNGER:
                   ASSESSMENT OF USDA FOOD ASSISTANCE
                      AND CHILD NUTRITION PROGRAMS
                        IN THE ECONOMIC DOWNTURN

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

                                HEARING

                               before the

                       COMMITTEE ON AGRICULTURE,
                        NUTRITION, AND FORESTRY

                          UNITED STATES SENATE


                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION


                               __________

                            DECEMBER 8, 2008

                               __________

                       Printed for the use of the
           Committee on Agriculture, Nutrition, and Forestry


  Available via the World Wide Web: http://www.agriculture.senate.gov





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           COMMITTEE ON AGRICULTURE, NUTRITION, AND FORESTRY



                       TOM HARKIN, Iowa, Chairman

PATRICK J. LEAHY, Vermont            SAXBY CHAMBLISS, Georgia
KENT CONRAD, North Dakota            RICHARD G. LUGAR, Indiana
MAX BAUCUS, Montana                  THAD COCHRAN, Mississippi
BLANCHE L. LINCOLN, Arkansas         MITCH McCONNELL, Kentucky
DEBBIE A. STABENOW, Michigan         PAT ROBERTS, Kansas
E. BENJAMIN NELSON, Nebraska         MIKE JOHANNS, Nebraska
SHERROD BROWN, Ohio                  CHARLES E. GRASSLEY, Iowa
ROBERT P. CASEY, Jr., Pennsylvania   JOHN THUNE, South Dakota
AMY KLOBUCHAR, Minnesota
KIRSTEN GILLIBRAND, New York
MICHAEL BENNET, Colorado

                Mark Halverson, Majority Staff Director

                    Jessica L. Williams, Chief Clerk

            Martha Scott Poindexter, Minority Staff Director

                 Vernie Hubert, Minority Chief Counsel

                                  (ii)








                            C O N T E N T S

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                                                                   Page

Hearing(s):

Promoting Health, Preventing Chronic Disease, and Fighting 
  Hunger: Assessment of USDA Food Assistance and Child Nutrition 
  Programs in the Economic Downturn..............................     1

                              ----------                              

                        Monday, December 8, 2008
                    STATEMENTS PRESENTED BY SENATORS

Harkin, Hon. Tom, U.S. Senator from the State of Iowa, Chairman, 
  Committee on Agriculture, Nutrition and Forestry...............     1
Casey, Hon. Robert P., Jr., U.S. Senator from the State of 
  Pennsylvania...................................................     4
Klobuchar, Hon. Amy, U.S. Senator from the State of Minnesota....     5
Lugar, Hon. Richard G., U.S. Senator from the State of Indiana...     4

                                Panel I

Chilton, Mariana, Ph.D., Mph, Co-Principal Investigator, 
  Children's Sentinel Nutrition Assessment Program, and Principal 
  Investigator, Philadelphia Grow Project, Department of Health 
  Management and Policy, Drexel University School of Public 
  Health, Philadelphia, Pennsylvania.............................    12
Duff, Carolyn L., RN, MS, NCSN, School Nurse, A.C. Moore 
  Elementary School, Columbia, South Carolina, on behalf of the 
  National Association of School Nurses..........................    14
Fox, Mary Kay, Senior Researcher, Mathematica Policy Research, 
  Cambridge, Massachusetts.......................................     9
Kennedy, Eileen, Dean, Friedman School of Nutrition Policy and 
  Science, Tufts University, Boston, Massachusetts...............     7
                              ----------                              

                                APPENDIX

Prepared Statements:
    Chambliss, Hon. Saxby........................................    38
    Grassley, Hon. Charles E.....................................    39
    Roberts, Hon. Pat............................................    41
    Chilton, Mariana.............................................    42
    Duff, Carolyn L..............................................    47
    Fox, Mary Kay................................................    53
    Kennedy, Eileen..............................................    58
Question and Answer:
Grassley, Hon. Charles E.:
    Written questions submitted to all panelists.................    64
    Written questions submitted to Eileen Kennedy................    64
Stabenow, Hon. Debbie:
    Written questions submitted to all panelists.................    66
    Written questions submitted to Mariana Chilton...............    66
    Written questions submitted to Eileen Kennedy................    66
    Written questions submitted to Carolyn L. Duff...............    66
Chilton, Mariana:
    Response to written questions from Hon. Charles E. Grassley..    67
    Response to written questions from Hon. Debbie Stabenow......    68
Duff, Carolyn L.:
    Response to written questions from Hon. Charles E. Grassley..    72
    Response to written questions from Hon. Debbie Stabenow......    72
Fox, Mary Kay:
    Response to written questions from Hon. Charles E. Grassley..    76
    Response to written questions from Hon. Debbie Stabenow......    76
Kennedy, Eileen:
    Response to written questions from Hon. Charles E. Grassley..    78
    Response to written questions from Hon. Debbie Stabenow......    79


 
                      PROMOTING HEALTH, PREVENTING
                 CHRONIC DISEASE, AND FIGHTING HUNGER:
                   ASSESSMENT OF USDA FOOD ASSISTANCE
                      AND CHILD NUTRITION PROGRAMS
                        IN THE ECONOMIC DOWNTURN

                              ----------                              


                        Monday, December 8, 2008

                                       U.S. Senate,
                                  Committee on Agriculture,
                                    Nutrition, and Forestry
                                                     Washington, DC
    The committee met, pursuant to notice, at 1:06 p.m., in 
room 328-A, Russell Senate Office Building, Hon. Tom Harkin, 
Chairman of the committee, presiding.
    Present or submitting a statement: Senators Harkin, Leahy, 
Lugar, Casey, and Klobuchar.

 STATEMENT OF HON. TOM HARKIN, U.S. SENATOR FROM THE STATE OF 
    IOWA, CHAIRMAN, COMMITTEE ON AGRICULTURE, NUTRITION AND 
                            FORESTRY

    Chairman Harkin. The Committee on Agriculture, Nutrition, 
and Forestry will come to order.
    Today, we begin a process to reauthorize what we call the 
Child Nutrition Programs. That is the School Lunch and the 
School Breakfast and, of course, the Women, Infants, and 
Children Supplemental Feeding Program.
    At the outset, I just want to say that what this hearing is 
about today, and what the other hearings will be about is not 
just about childhood nutrition or what our kids eat and how 
they get it and all that. What it really is a part of, is the 
debate, that this Congress will have and this new President 
will have on fundamentally reforming the health care system of 
America.
    There is nothing more important to the well-being of our 
people than their nutritional intake, especially when they are 
young, when they are kids, and not just kids in school. I mean 
even before that, during the times when their brains are 
forming, from birth through maybe 3 years of age.
    We are about this right now. We are starting it. I am on 
the Health Committee. Senator Kennedy has charged me with the 
responsibility of heading a working group on prevention, 
wellness, and public health. I have to tell you that prevention 
and wellness, public health, have been a footnote and an 
asterisk in all the debates we have had about health care in 
the past. I keep saying many times that we don't have a health 
care system in America, we have a sick care system. If you get 
sick, you get care, one way or the other--Medicare, Medicaid, 
Title 19, charity, emergency room, community health center, 
some way or another.
    We are very good at patching, fixing, and mending. We will 
spend billions, untold--no, trillions on patching, fixing, and 
mending. But what do we do up front to keep people healthy and 
out of the hospital, to keep them well? Where are the 
incentives? All the incentives are on the other side. Where are 
the incentives to keep people well and healthy?
    So this whole debate, I say to our witnesses and I say to 
others who are here and those who may be watching, that this is 
going to be a part of our health care debate, a big part of it, 
and it is going to be a part of the prevention and wellness 
part of that debate, how we get adequate nutritional foods to 
our kids in school and before school. I could go into our 
summer feeding programs and other things, too.
    But it seems that we are in this situation where it is not 
only just the lack of food that causes bad health care problems 
and hunger and malnourishment. Too much food, or too much of 
the wrong food, also leads to bad health problems. Or the 
ingestion of too much of things that aren't really listed as 
food.
    I am talking here about sodium. We have become a sodium-
saturated society, to the point where now kids are getting 
hypertension when they are ten, 11, 12 years old. Saturated 
fats, the American Academy of Pediatrics recently came out with 
guidelines for giving statins to kids as young as 8 years old 
with elevated cholesterol levels. Adult onset diabetes, which 
was unheard of in children until recently, is now growing at an 
alarming rate, kids as young as ten, 11, 12 years old with 
adult onset diabetes.
    And then you take a look at what our kids are eating in 
schools. I must say at the outset, I tried in 1996, I first 
offered an amendment to get vending machines taken out of 
schools. As you can see, I was a spectacular failure at that. 
They are still there. To some extent, some schools are putting 
better things in the vending machines, better foods, nutritious 
foods, but they are still there.
    And then we have these a la carte lines for kids in school. 
Why, they might as well be eating at McDonald's. They get all 
the kinds of fats and starches and sugars and sodium they need, 
they want. Go through the a la carte line.
    I just feel so strongly that we have to be thinking about 
the reauthorization of these Child Nutrition Programs, not just 
in the context of nutrition, but also in the context of the 
overall wellness of our society and health care reform. This is 
a big part, I submit to you, of all of our health care reform 
that we are going to be talking about.
    Again, I think today's hearing deals with a crucial part of 
this. Scientific studies are confirming what common sense has 
told us for generations, that good childhood nutrition, healthy 
eating habits when you are young determine your health for a 
lifetime.
    Now, we know there are a lot of factors. People say, well, 
Harkin, your folks think too much on what these kids eat. They 
are not getting enough exercise. Well, I agree with that. We 
are building elementary schools without playgrounds. That is 
beyond the purview of this committee, I think, at least right 
now, anyway. Sure, kids need more exercise, but that doesn't 
mean that they can't eat better even if they don't have the 
playgrounds to play on.
    Communities need wellness programs, too, walking paths, 
sidewalks to school so kids can walk to school, things like 
that.
    So again, I just make my statement a part of the record. I 
don't need to go on anymore on that. I don't need to read my 
statement at all, just make it a part of the record.
    But I just want to make it clear, and to my witnesses, I 
thank our witnesses. I have read all of your testimonies. They 
are right on target, every one of you. You are just right on 
target about what we have got to be doing with our kids in 
school. And I am going to ask provocative questions, not just 
of you, but as we go through this process, provocative 
questions. Why do we need so many starches, fats, and sugars in 
our foods that kids eat in school? Why do they need so much 
sodium?
    I have a little elevated blood pressure, Dick, so I am 
watching my salt intake. I have been watching my salt intake 
for a while. I have lunch at my desk, so I have my assistant go 
down and get me a low-sodium soup at the servery down there. 
Well, they have changed over. They no longer have low-sodium 
soup. So I said, well, go down and ask them what the lowest-
sodium soup is they have got. So she just brought it about an 
hour or so, so I had soup at my desk, and they said this is the 
lowest they have got. I had one spoon of that. One spoon, I 
think, is probably more salt than I take in the entire day.
    I say these things because we have really got to focus on 
what our kids are eating in school and the nutritious foods. 
Someone said, well, it costs more money. If you are going to 
have more nutritious food, it is going to cost more money. I am 
not certain. One of you, I forget which one of you had the 
testimony about the Minnesota deal, and I want to get into 
that. I don't know about that, about the Minnesota study.
    But my response is, if the nutritious foods cost a little 
bit more, so what? We ought to be willing to pay it as part of 
prevention and wellness and think about it in that context, of 
what it is going to mean for these kids to have better diets 
and better nutritious foods and what it is going to mean for 
the lack of the cost in our health care system later on.
    So with that, I welcome you. This is our first hearing on 
this issue. I wanted to get the ball rolling. I will chair a 
hearing on the Health Committee on Wednesday dealing with 
wellness and prevention, but Dick, I may have said this before 
you came in, but I see this whole debate and the 
reauthorization of this as not just singular, but as part of 
our health care reform debate and how we are going to look at 
wellness and prevention and getting to these issues finally and 
these issues in our school lunches, our WIC Programs, things 
like that, by providing more nutritious foods. I read our 
witnesses' testimony and they have got a lot of good 
suggestions and I look forward to those.
    Chairman Harkin. Well, I have gone on too long. I just 
wanted to thank you again. I will now yield to the first person 
that came here. I will yield to Senator Casey for any opening 
statement.

 STATEMENT OF HON. ROBERT P. CASEY, JR., U.S. SENATOR FROM THE 
                     STATE OF PENNSYLVANIA

    Senator Casey. Well, Mr. Chairman, thank you very much for, 
first of all, calling this hearing. Even at this time of the 
year when we are in transition, I think it is important we get 
a head start on such a critical issue for the country, not to 
mention the most important people that we are directing our 
attention to, and that is the children and the families that 
will benefit from the work that is done by our witnesses, the 
work that is done by the Congress, and the work that must be 
done by the new administration.
    I do want to thank you for taking this time to call the 
hearing, but I also want to thank you in a wider sense for the 
witness and the advocacy that you have provided over many years 
on these issues. These are issues that were neglected by the 
current administration, in my judgment. We don't need to get 
into that, but I think they were. That is not a news bulletin, 
I don't think, to some people in this room. But we can't look 
backwards. We have to look forward, and we have got a lot of 
work to do.
    I think there are certainly some priorities that we need to 
focus on. Certainly, one of them--I will mention four quickly--
increasing reimbursement rates to schools. Two, including more 
kids in both Lunch and Breakfast Programs. Three, decreasing 
administrative burdens and costs to schools. And four, 
maintaining service to children in the summer months.
    There is a lot more to talk about. I will submit my 
testimony for the record.
    But I think what summons us here, whether it is Senator 
Harkin or Senator Lugar or Senator Klobuchar or any of us, and 
certainly anyone in the room and especially our witnesses, I 
think what summons us here is our conscience and the moral 
gravity of this issue, especially at a time of economic crisis, 
but no matter what, even if it was a time of strong economy, 
which it isn't, it would still be an important and central 
issue to us.
    I was just handed by Dr. Chilton, who I am going to be 
talking about a little later, but she handed me a postcard 
entitled, ``Witness to Hunger,'' December 11-18, 2008, and it 
is a picture of a child in the city of Philadelphia, a 
beautiful child in that city, a city I know pretty well. There 
is a lot of hope in that child's face. Our obligation is to 
make sure that the spark and the life in that child is not 
diminished by our failure to do what is right with these 
programs. I don't think that is too grand or too broad a goal. 
I think this child reminds us more than anything else what our 
obligation is.
    Thank you, Mr. Chairman.
    Chairman Harkin. Thank you, Senator Casey.
    Senator Lugar.

STATEMENT OF HON. RICHARD G. LUGAR, U.S. SENATOR FROM THE STATE 
                           OF INDIANA

    Senator Lugar. Mr. Chairman, I appreciate very much your 
calling the hearing, likewise. I would just indicate that the 
authorization need for WIC and other child programs offers a 
bold opportunity which you have outlined and we will have to 
see how other committees progress on the problems of health for 
all Americans at all ages. But this is an important problem for 
adults as well as for children.
    I appreciate the fact that you have raised in previous 
years these standards with regard to sodium, calories, and 
various inputs of programs for which we bear some 
responsibility. Granted, this is a debate that will go on not 
only in this committee, but in our society for some time, it 
does offer an exemplary moment to try to even get the facts, 
the calorie count or the sodium count for the foods that we are 
putting into schools, sometimes an idea resisted by restaurants 
or other purveyors of food in our general society so that we 
begin to have some benchmark of what we are talking about, as 
opposed to too much or too little, a much more precise 
definition.
    At least we are beyond, I think, the debates that both of 
us have endured as to whether we should even have a National 
School Lunch Program. This was decided, thank goodness, about 
14 years ago during a tempestuous period in which new 
federalism had arisen and the thought was maybe States would do 
these programs and maybe they wouldn't. But at least we have a 
basis now of a national program, and we are going to be arguing 
about the specifics of it, so that is progress.
    I look forward to once again applauding the witnesses you 
have for excellent testimony and for a good start for our year.
    Chairman Harkin. Thank you, Senator Lugar, and I would be 
remiss if I didn't thank you for your leadership through all 
the years, as former Chair of this committee, and all your 
great leadership on nutrition and our School Lunch and School 
Breakfast Programs. You have been here a lot longer than I--
well, not a lot longer, but somewhat longer than I have been 
here anyway, Dick.
    Senator Lugar. Who is counting?
    [Laughter.]
    Chairman Harkin. And I thank you for your leadership and 
look forward to working with you on this issue next year.
    Senator Klobuchar.

STATEMENT OF HON. AMY KLOBUCHAR, U.S. SENATOR FROM THE STATE OF 
                           MINNESOTA

    Senator Klobuchar. Thank you very much, Chairman Harkin, 
and thank you for holding this hearing and the leadership of 
the other two Senators. I remember in the farm bill debates how 
Senator Lugar would always raise this issue, and how my friend, 
Senator Casey would, as well.
    I just came back from a 22-county tour of my State. As we 
remember, I made the promise that I would visit all 87 counties 
every year.
    Chairman Harkin. Have you thawed out yet?
    Senator Klobuchar. I am fine. There was a little snow. But 
it was just enlightening and somewhat inspiring to meet some of 
the people along the way and the struggles that they are 
facing. The woman we met at a cafe near Litchfield, Minnesota, 
that had told me that she was a teacher, but in order to make 
ends meet, because her husband had lost his job, that she was 
working as a waitress two nights a week and then she was 
stamping meat at the local butcher 1 day a week.
    The letters that we have received from people through our 
State, including the woman who wrote that she and her husband 
put their three daughters to bed and they kiss them goodnight 
and then they sit at their kitchen table and look at each other 
and wonder how they are going to pay the bills. Or the guy that 
wrote in that said that his wife had inherited some money from 
her father and they thought they were going to use that money 
for their daughter's wedding and now they have no money so they 
are using it for their expenses, including food and for their 
heating.
    And we heard these stories time and time again in our 
State. The statistics certainly bear it out in our State. The 
unemployment rate is at its highest in 22 years. The heating 
costs, despite the downward trend with oil, are expected to go 
up. And we know that on the national level, the number of 
individuals relying on Food Stamps has risen to an all-time 
high of over 31 million Americans, and that is one out of every 
ten people in the country.
    So what I am seeing in our State is that more and more 
people are skipping meals. In 2007, Minnesota had one of the 
largest increases in food insecurity in the country. It sounds 
like sort of an innocuous phrase, but the meaning is that 
someone doesn't know where their next meal is coming from. 
Nine-and-a-half percent of Minnesotans suffer from food 
insecurity. That is about one in ten. In 2008, a record number 
of people in our State have visited the food banks.
    The Iron Range of Northern Minnesota, where my Grandpa was 
an iron ore miner, has been especially hard hit by the economic 
downturn, especially recently, because some of the mines closed 
down because steel demand has gone down internationally. So far 
in 2008, food pantry visits up on the Iron Range are up 22 
percent, and 40 percent of the food distributed by the Duluth 
food bank, the largest town in Northern Minnesota, feeds 
children.
    That is what we know. We also know that getting kids 
breakfast and getting them meals in school is needed now more 
than ever. When I was county attorney, we would make this a 
major focus because we knew it helped to keep kids in school, 
that they did better when they were in school, and that they 
got the food that they need. The Center on Poverty and Hunger 
notes in their recent report, serving breakfast to school 
children who don't get it elsewhere significant improves their 
cognitive or mental abilities, enabling them to be more alert, 
pay better attention, and do better in terms of reading, math, 
and other standardized test scores.
    So as we go forward this year and talk about the education 
policy in this country and health policy, we have to remember 
the significant role that child nutrition plays.
    Thank you very much, Mr. Chairman.
    Chairman Harkin. Thank you, Senator Klobuchar.
    I thank our panel for coming. I will introduce you all. I 
will just go from my left to my right. I ask if each of you can 
sum up your statement in several minutes, we would appreciate 
it, and then we will get into an open discussion.
    First is Dr. Eileen Kennedy, the current dean of the 
Friedman School of Nutrition and Science and Policy at Tufts 
University. She worked at USDA in the late 1970's and early 
1980's, and I am also told in the 1990's, also, serving as 
Chief of the Nutrition Policy Branch in the Food and Nutrition 
Service. She is a recognized expert on child nutrition and 
public policy strategies for chronic disease prevention.
    Dr. Kennedy, thank you for being here. I will say this. All 
of your testimonies will be made a part of the record in their 
entirety. If you would just sum it up, I would be very pleased. 
Dr. Kennedy.

STATEMENT OF EILEEN KENNEDY, DEAN, FRIEDMAN SCHOOL OF NUTRITION 
  POLICY AND SCIENCE, TUFTS UNIVERSITY, BOSTON, MASSACHUSETTS

    Ms. Kennedy. Thank you, Mr. Chairman and committee members. 
I am delighted to be here. I have spent the past 30 years of my 
career conducting research, looking at the health and nutrition 
effects of government policies and programs, not just in the 
U.S. but worldwide. In a book we published last year, Richard 
Deckelbaum and myself looked at 60 years of nutrition in the 
United States, past, current, and what the future challenges 
are. Major problems of nutrient deficiencies, inadequate 
energy, poor growth, have been mitigated in part by the 
collective action of public- private sector agriculture, food 
and nutrition, but a part of the success is due to the 
nutrition programs.
    National evaluations of School Lunch and School Breakfast 
have shown that the programs have achieved their goals. WIC has 
demonstrated clearly positive impact on improving dietary 
patterns and nutritional status.
    So while problems of undernutrition and food security are 
still critical, we now have what I call the double burden of 
disease. We have undernutrition side by side in the United 
States with problems of overweight, obesity, and chronic 
diseases.
    My remarks today are focused on how can Federal Child 
Nutrition Programs afford potentially effective ways of 
promoting healthier lifestyle. Obviously, the economic downturn 
we are now experiencing makes the role of Child Nutrition 
Programs even more essential. I do quote some statistics from a 
report of only 2 weeks ago from the Center on Budget and Policy 
Priorities that projects that over the next little bit, child 
poverty will increase to the tune of about 2.6 to 3.3 million 
more children, and when we look at number of children in deep 
poverty, that is less than half the poverty-level income, 1.5 
to two million more children will be in deep poverty.
    So given these alarming statistics, the role of Child 
Nutrition Programs, School Lunch, School Breakfast, and WIC 
become even more essential, and let me start with School Lunch-
School Breakfast.
    Tufts University has been involved with the city of 
Somerville for the past 5 years in a project called Shape Up 
Somerville. Somerville is a small town outside of Boston, very 
racially, ethnically diverse, high participation of households 
on Food Stamps, high probability of free school lunches, and 
Shape Up Somerville was a joint effort with the city to look at 
ways of systematic change in school lunch and physical activity 
as a way of promoting healthier lifestyles. It is what I call 
an environmental change intervention including before, during, 
after school activities, school lunch, a la carte items, 
competitive food, walking to school with parents, after-school 
physical activity, in-school physical activity, let me quote 
something last week from the Boston Globe, and this is a quote.
    ``Pedestrians in this city of 77,500 stride onto bright, 
recently striped crosswalks. In school cafeteria, fresh produce 
has replaced canned fruits and vegetables and the high school 
retired its fryolator. The neighborhood restaurant now serves 
wheat oatmeal with bananas in addition to bacon and eggs.''
    Shape Up Somerville has been successful in a very rigorous 
evaluation. Children in first, second, and third grade gained 
significantly less weight than children in comparison schools, 
and we are in an environment where we are not worried about, on 
average, underweight. We are worried about heavy children.
    The school lunch now includes more fruits, vegetables, 
whole grains. Popular items in vending machines like chips and 
sodas were replaced by water, yogurts, healthier options. And I 
always get the question, what happened to revenue in schools? 
Initially, the revenue from vending machines went down. A year 
later, it was up. So I think it is the difference between 
short-term and long-term.
    We are now replicating Shape Up Somerville around the 
country in urban as well as rural areas to look at commonality 
of what are the core components that are important. I think 
this is clearly an example of retooling schools to have more 
emphasis on health and wellness policies.
    Availability of healthier competitive foods, I think has to 
be something which is addressed much more seriously in Child 
Nutrition Reauthorization in 2009. Federal standards are long 
overdue for competitive foods. The recent Institute of Medicine 
report on nutrition standards for foods that compete with 
school meals, provides a framework for developing such 
guidelines.
    I have some comments on WIC, looking at synergies between 
WIC and Child and Adult Care Food Programs. Rather than seeing 
them as distinct programs, the health benefits of both WIC and 
Child Care would be enhanced by coordination rather than 
competition.
    Let me just end, since my time is up, on a personal note. I 
am a product of school lunch throughout elementary and high 
school. My mother was what was affectionately called by my 
friends, ``a school lunch lady'', and she took pride in 
delivering healthy school meals to kids. My sister was formerly 
a Food Stamp recipient and is now a successful businesswoman in 
Massachusetts and a former elected town official for 
Winchester, Massachusetts. My own research relates to the WIC 
Program and how every dollar spent on WIC prenatally results in 
$3 in health care savings.
    And I bring this up because I have seen the Child Nutrition 
Programs up close and personal and I am a firm believer that 
investing in children is investing in the future, and I think 
we have the opportunity to look at in a bold, new, innovative 
direction repositioning the Child Nutrition Programs to be, 
more so than ever before, health nutrition programs. We can 
look at Child Nutrition Programs, but we also need to look at 
the other food security programs, like Food Stamps in tandem.
    Thank you, and I would be happy to answer questions.
    [The prepared statement of Ms. Kennedy can be found on page 
58 in the appendix.]
    Chairman Harkin. Thank you very much, Dr. Kennedy.
    And now we will turn to Ms. Fox. Mary Kay Fox is a senior 
researcher with Mathematica Policy Research. Her work is 
focused on the effects of food assistance and nutrition 
programs on child nutrition and health as well as analyzing the 
nutrition and health profiles of low-income populations.
    Welcome, Ms. Fox.

   STATEMENT OF MARY KAY FOX, SENIOR RESEARCHER, MATHEMATICA 
           POLICY RESEARCH, CAMBRIDGE, MASSACHUSETTS

    Ms. Fox. Thank you. Good afternoon, Mr. Chairman and 
members of the committee. I am very pleased to be invited here 
to testify today.
    As Senator Harkin said, I work with Mathematica Policy 
Research and I have done a lot of work over the past two 
decades on the school nutrition programs. I was asked today to 
give you a brief snapshot of what we know from this research 
about what is going well with the school meal programs and what 
might not be going so well in terms of the meals that are 
served to health care and actually how these meals might be 
influencing their diets and their overall health.
    So I have broken my main comments down into three 
questions. The first one is, what do we know about how school 
meals contribute to children's needs for essential nutrients? 
This is the overarching goal of the School Lunch Program back 
from when it was established in 1946. And the answer is that 
there is actually very convincing evidence that children who 
eat school meals have higher intakes of a range of essential 
nutrients and minerals than children who consume meals from 
other sources. And there is evidence that the difference is due 
to the fact that school meals have a more nutrient-dense mix of 
foods than other meals so that the nutrient density of the 
foods is contributing to the difference rather than the fact 
that school meal participants are just consuming more food.
    An important question in whether these differences in meal 
intakes actually translate into meaningful differences in 
children's overall diets, and for years, we really couldn't 
answer this question very well because the benchmarks that we 
had to use in assessing children's dietary intakes didn't allow 
us to do that very well.
    But the most recent national study of the school meal 
programs, the Third School Nutrition Dietary Assessment Study, 
or SNDA-III, was actually able to fill this gap by applying the 
most up-to-date reference standards for nutrient intakes and, 
using assessment methods recommended by the Institute of 
Medicine, and SNDA-III found that middle school and high 
school-age children who participated in the School Lunch 
Program were significantly less likely than comparable-aged 
children who didn't--comparable children on a number of socio-
demographic characteristics, not just their age, were 
significantly less likely to have inadequate intakes of a 
number of essential vitamins and minerals. The differences were 
most pronounced among high school-aged children and especially 
girls.
    And so these data document the important role that the 
Lunch Program plays in the diets of these older children who 
have the most autonomy in making food decisions. They have the 
greatest nutritional needs. And unfortunately, they often have 
the poorest diets.
    My second question is, what do we know about how well 
school meals promote the dietary guidelines for Americans, and 
this is getting into the comments that you made at the 
introduction, Senator Harkin, thinking more about overall 
health and reduction or prevention of chronic disease. And the 
answer here is that this is the area in which we know the 
school meal programs currently fall short.
    The standards for school meals never really referenced the 
dietary guidelines explicitly until 1994, when the Healthy 
Meals for Healthy Americans Act made compliance with the 
dietary guidelines a requirement. So they have been at it now 
for close to 12 years and they have made some improvements. 
There is evidence that the levels of fat and saturated fat in 
school meals have come down, but the current research shows 
that there is substantial room for additional improvement.
    For example, SNDA-III, which collected data 8 years after 
schools were supposed to be compliant with the dietary 
guidelines, found that only about a third of elementary schools 
and only about a quarter of secondary schools were providing 
lunches that were consistent with the dietary guidelines' 
recommendation for saturated fat. And following up on the 
sodium that you mentioned, Senator Harkin, only 1 percent of 
schools provided lunches that met the standard for sodium.
    So in looking past the meals to looking at children's 
diets, SNDA-III found no significant differences in total fat, 
saturated fat, or sodium intake of children who did and did not 
participate in the school meal programs. So despite high levels 
of saturated fat and sodium in the school meals, school meal 
participants did no worse than the non- participants, and the 
main reason for this is that both groups of children had 
excessively high intakes of both saturated fat and sodium. 
Roughly 80 percent of children had saturated fat intakes that 
exceeded the recommended levels in the dietary guidelines, and 
90 to 95 percent of children had sodium intakes that exceeded 
recommendations.
    My third question is what do we know--oops, I am over time. 
Can I go a little longer? What do we know about how school 
meals contribute to childhood obesity. I will go through this 
pretty quickly. And the answer there is there really isn't any 
convincing evidence that school meals contribute to childhood 
obesity. There have been studies done, but they have yielded 
conflicting results, and some of the studies that examined the 
relationship did not control for important factors that would 
influence both obesity and school meal participation, and so 
therefore they yielded conflicting results.
    Studies that have looked at the relationship between the 
Breakfast Program and obesity have also reported mixed results, 
but at least one of those studies reported that participation 
in the School Breakfast Program was associated with a decreased 
likelihood of obesity, so that perhaps the Breakfast Program 
may have some protective effect, perhaps by encouraging 
children to consume breakfast on a more regular basis. But the 
jury is out on that question.
    In my written testimony, I do have some observations about 
implications for these research findings, but I will stop now--
--
    Chairman Harkin. Take a couple more minutes.
    Ms. Fox. Take a couple more minutes? OK. Thank you. Scurry, 
scurry, scurry.
    So what are the implications of these research findings for 
the future of Child Nutrition Programs? Clearly, a No. 1 
priority for the future is making school meals healthier for 
children by improving the extent to which they conform to both 
the nutrient and food-based principles of the dietary 
guidelines. An ongoing Institute of Medicine panel is currently 
reviewing existing nutrients and standards and meal patterns 
with this exact goal in mind.
    The committee's final report, which is due out in late 
October 2009, will provide a foundation with recommended 
revisions to existing meal patterns and nutrient standards for 
both the School Lunch and Breakfast Programs and this will 
provide a framework for moving forward in improving the 
healthfulness of school meals. However, to be effective, the 
framework needs to be supported in several important ways, and 
I can't get into all of the ideas that I would have, but I 
wanted to mention three today.
    The first is that schools need support in promoting healthy 
food choices. The old adage that you can bring a horse to water 
but you can't make him drink comes to mind, and we have 
examples of this in the SNDA-III data. Nine out of ten schools' 
daily lunch menus in SNDA-III offered children a fruit or a 
juice or vegetables that were not French fries. But when you 
look at what children who consumed lunches took, only 45 
percent of kids included a fruit, and only 30 percent of kids 
included a vegetable that wasn't a French fry. So it has to be 
a collaborative and supportive process where nutrition reform 
efforts are supported by nutrition education and policies that 
support and promote healthy eating.
    I would encourage the committee to consider funding 
demonstration projects similar to the ones that are being 
funded for healthy eating initiatives in the C-SNAP Program, 
because there really isn't a lot of information out there about 
how you do this and do it well and get children to accept new 
and healthier menus.
    Finally, and this is also something else you mentioned, 
Senator Harkin, it is important to consider the potential 
impact of new meal standards on program costs. The IOM panel is 
looking at this issue, but it can only do it in a limited way. 
An ongoing FNS study will be collecting data on what schools 
are actually paying for food in the upcoming school year, 2009-
2010, and ideally, the new recommendations should be examined 
with the new cost data on what food purchases actually cost to 
look at the implications of the changes on the cost of school 
meals and potential implications for reimbursement rates before 
anything is implemented in a national fashion.
    Thank you.
    [The prepared statement of Ms. Fox can be found on page 53 
in the appendix.]
    Chairman Harkin. Thank you very much. Reset that clock for 
5 minutes. If you go over by a minute, that is fine.
    I will yield to Senator Casey for the next introduction.
    Senator Casey. Mr. Chairman, thank you very much. We are 
honored to have a Pennsylvanian here from Drexel University, 
Dr. Mariana Chilton, who is both co-principal investigator of 
the Children's Sentinel Nutrition Assessment Program as well as 
principal investigator of Philadelphia's GROW Project. She is 
at Drexel, as I mentioned. She has degrees from Harvard and 
Penn, great schools in their own right, maybe not as good as 
Drexel, but they are pretty good, I guess.
    In terms of her newest area of research, it includes 
assessing the health impacts of hunger and food insecurity in 
the Philadelphia area. This community-based research focuses on 
women and children, nutritional status, and human rights. She 
is currently teaching health behavior and community health in 
the full-time Master's of Public Health Program, and health and 
human rights in the doctoral program.
    Dr. Chilton, we are honored to have your testimony here and 
we are grateful for your willingness to be part of this 
hearing.

    STATEMENT OF MARIANA CHILTON, PH.D., MPH, CO-PRINCIPAL 
INVESTIGATOR, CHILDREN'S SENTINEL NUTRITION ASSESSMENT PROGRAM, 
    AND PRINCIPAL INVESTIGATOR, PHILADELPHIA GROW PROJECT, 
 DEPARTMENT OF HEALTH MANAGEMENT AND POLICY, DREXEL UNIVERSITY 
      SCHOOL OF PUBLIC HEALTH, PHILADELPHIA, PENNSYLVANIA

    Ms. Chilton. Thank you very much. Chairman Harkin and 
distinguished members of the committee, I am honored to speak 
to you as a research scientist at the Drexel University School 
of Public Health in Philadelphia, Pennsylvania, and also as a 
member of the National Network of Pediatric Researchers on the 
Children's Sentinel Nutrition Assessment Program. We call it C-
SNAP for short.
    I represent the States of Maryland, Massachusetts, 
Arkansas, Pennsylvania, and Minnesota, not to mention we use 
data from California and Washington, D.C., and I present to you 
today the scientific evidence from more than 30,000 children 
and their families across the nation. All 30,000 that we meet 
and touch in our emergency rooms and in our clinics are 
witnesses to hunger.
    One of these witnesses, Angela Sutton, a mother of two 
young children, struggles to feed her children in inner-city 
Philadelphia. When I asked her how she wanted to improve her 
children's health, she said, ``I want to march right down to 
Washington and put my babies on the steps of Congress.'' 
Senators, during this major economic recession, how you write 
policies for these children on your steps can make a remarkable 
difference in the health and well-being of the American 
population.
    With the Child Nutrition Reauthorization, we get two for 
one. We can prevent hunger and we can prevent nutrition-related 
diseases, such as diabetes, heart disease, and obesity.
    Let us start with hunger and food insecurity. We see in the 
USDA's recent release of data on hunger in America that 12.4 
million children were in food insecure households in 2007. My 
colleagues and I looked deeper into the numbers and we were 
stricken by the new rates among the youngest children in 
America, those who had yet to reach first grade. Among these 
young children, very low food security, what used to be known 
as food insecurity with hunger, doubled from 4 percent to 8 
percent between the years 2006 and 2007. This increase of 
124,000 persons is a sign of an impending national disaster.
    Committee members, you have the tools and the resources to 
handle this crisis. If you see the Child Nutrition 
Reauthorization and health care reform as one in the same, you 
will protect our youngest citizens from the ravages of the 
recession.
    Hunger is a major health problem. In the data on over 
30,000 families collected by C-SNAP, we demonstrate that 
children living in food insecure households were 30 percent 
more likely to have a history of hospitalization. They were 90 
percent more likely to be reported in fair or poor health. We 
have found that infants and toddlers who lived in food insecure 
circumstances were 73 percent more likely to be at 
developmental risk compared to infants and toddlers in food 
secure households. Clearly, we must intervene early in a 
child's life. Every child's brain architecture is laid down 
during the first 3 years of life, forming the foundation on 
which to build human capital. The Child Nutrition 
Reauthorization can build that capital.
    The Women, Infants, and Children Program and the Child and 
Adult Care Food Program should be considered two of the most 
important building blocks for the health and well-being of 
America's children. With approximately 50 percent of the 
children born in the United States participating in the WIC 
Program, the breadth and the reach of the WIC Program can, as 
our research shows, improve children's growth outcomes.
    Similarly, the Child and Adult Care Food Program can be 
considered one of the most effective tools to fight hunger and 
to promote early childhood health. We already know that child 
care helps the development and school readiness of a child. We 
applaud Senator Casey's initiative to improve the availability 
and the quality of child care. But an investment in child care 
without similar widespread attention to nutrition ultimately 
wastes that educational effort.
    The same goes for School Breakfast and School Lunch. 
Through these programs, you have an opportunity to infuse 
America's children with healthy diets that will prevent 
childhood obesity and thus prevent diabetes and cardiovascular 
disease. Because these programs can prevent disease, we must 
ensure that they work well administratively and are broadly 
available.
    We already have a great example from Philadelphia. 
Philadelphia has had a universal service School Lunch Program 
for the past 17 to 18 years. It has done away with individual 
applications in areas where the majority of the children are 
clearly eligible by population-based estimates of poverty. This 
program has reduced stigma and improved the nutritional health 
of children. We recommend universal service programs be 
replicated in major inner cities and low-income counties across 
the nation. The Senate ought to consider the same idea for the 
Child and Adult Care Food Program.
    Finally, the Child Nutrition Reauthorization process must 
take into account the true context of family poverty. Crystal 
Sears of Philadelphia has three children, all with major health 
problems. For her, it is a full-time job to keep her children 
and herself whole. From her perspective, Federal programs are 
good, but they don't go far enough. ``There are some 
benefits,'' she says. ``They provide our children with 
vaccinations. I can get some medical care. But the rest of me 
is just dangling out there, hanging on a rope.''
    Senators let us not leave this generation dangling and 
unmoored. A young child in its most critical moments of 
cognitive, social, and emotional development does not have time 
to wait. By treating the Child Nutrition Reauthorization as if 
it is medicine, an immunization against preventable chronic 
disease, you can boost the health and well-being of an entire 
generation.
    Thank you.
    [The prepared statement of Ms. Chilton can be found on page 
42 in the appendix.]
    Chairman Harkin. Thank you very much, Dr. Chilton.
    And for our final witness, we have Carolyn Duff, an RN, a 
practicing school nurse at A.C. Moore Elementary School in 
Columbia, South Carolina. Today, Ms. Duff will be sharing her 
experiences of the past 12 years in dealing with nutritional 
challenges of school children.
    Ms. Duff, welcome to the committee. Please proceed.

STATEMENT OF CAROLYN L. DUFF, RN, MS, NCSN, SCHOOL NURSE, A.C. 
MOORE ELEMENTARY SCHOOL, COLUMBIA, SOUTH CAROLINA, ON BEHALF OF 
           THE NATIONAL ASSOCIATION OF SCHOOL NURSES

    Ms. Duff. Thank you, Chairman Harkin and committee members. 
As Chairman Harkin said, I am a school nurse and I have 
practiced at A.C. Moore Elementary School in Columbia, South 
Carolina, for the past 12 years, and I am privileged to be here 
today representing the National Association of School Nurses.
    I commend the committee for bringing attention to the needs 
of school children at a time when there are so many pressing 
matters related to the downturn in our economy. Through my 
testimony, I hope to relay how school nurses have daily 
experiences with children who have severe nutrition issues by 
sharing stories from my own practice.
    In my school, over 50 percent of the students receive free 
or reduced meals. Given the country is in the middle of a 
recession, the number of eligible children is expected to 
increase in the coming year. More and more of the working poor 
are entering the ranks of the unemployed, impoverished, and 
homeless families. This reality is precisely why the USDA 
Breakfast and Lunch Programs are essential in curbing the 
hunger of school children.
    Many of the poor families I work with are from single- 
parent households. Usually the parent is a young and uneducated 
mother who struggles to make ends meet. Their lives are chaotic 
and things that most of us here take for granted, like 
transportation, child care, supportive extended families, a 
regular paycheck, and access to health care, are simply not 
there for them. They depend on school meals to feed their 
children.
    One young mother comes to mind, Mrs. J. She has two 
children, a boy in first grade and a little girl in second 
grade. I will call them Dan and Dora. The family is homeless. 
The children cannot ride the bus to school because they have no 
address, and where they slept last night will not be the same 
place where they will sleep tonight.
    Last week, first thing in the morning, Dora brought her 
little brother to me because he was crying inconsolably. I 
thought he had fever. His face was bright red. When I calmed 
him down, he told me that the reason he was crying is because 
he missed breakfast. Dora, his sister, explained that their 
mother overslept and hurried them off to school, but the 
cafeteria had already closed. The children couldn't get food 
and the mother had provided them nothing before school. She 
said that all they had eaten since lunch at school the day 
before was some chips at their cousin's house, where they had 
slept that night. Clearly, these children are not eating many 
full meals outside of school.
    I would like to tell you what I see routinely when students 
are not part of the meals program. Many students who visit my 
health office mid-morning are sent by teachers because the 
students are sleeping in class with their heads on the desks. 
Teachers can't tolerate that. The first question I usually ask 
the students is, what did you have for breakfast, and usually 
the answer is, nothing.
    That is the answer I got one morning from a fourth grade 
boy. I will call him John. John said he gets himself off to 
school in the morning because his dad, a single parent, gets 
himself off to work very early. When I called John's dad to let 
him know that John fell asleep in class, I suggested John be 
signed up for the breakfast program at school. After several 
attempts at sending the form home and trying to get it filled 
out, I called Mr. John again and I asked if I could fill out 
the form for him over the phone. He gave me the information, 
and then I sent the form home for his signature. I believe Mr. 
John cannot read. He was not going to tell me that, but he 
seemed grateful that I figured out a way to handle the 
situation. His son is now a much more energetic and attentive 
student.
    School nurses have a public health perspective and know 
well that prevention of chronic illnesses, such as 
cardiovascular disease and diabetes, must begin in childhood. I 
have a kindergarten student this year. I will call her Connie. 
I discovered during a health assessment that she has a BMI of 
99.5 percent, the top of the obese range. Just walking up a 
short flight of stairs, she is out of breath. Her poor 
nutritional status is obvious. She has four very deep cavities 
in her teeth and she has dark pigmented skin folds at the back 
of her neck, a condition called acanthosis nigricans, or AN. AN 
is related to obesity and is a reliable predictor of a 
progression to Type II diabetes, previously known to occur only 
in adults. This little girl is 5 years old. She will have a 
very short and poor quality of life if something is not done 
right now.
    I am working with her mother to connect her to services. 
Connie's mother is a single mother with four children and has 
multiple health, financial, and family issues of her own. I am 
hoping that Connie will stay at my school through the fifth 
grade so that I can see her progress toward improved health 
status as she eats a more nutritious diet and grows into her 
weight. The free school meals will be a key intervention in her 
health care plan.
    As a school nurse, my most important role is to support 
children in any way that will ensure that they are in school 
every day and are ready to learn. Both teachers and school 
nurses know from experience that healthy children learn better. 
Poverty and hunger are not hidden problems in schools.
    Speaking on behalf of our Association, I appreciate the 
opportunity to tell you what school nurses know about the 
important role school meals assistance plays in the lives of 
children and their families. Thank you, and I am happy to 
answer questions.
    [The prepared statement of Ms. Duff can be found on page 47 
in the appendix.]
    Chairman Harkin. Thank you very much, Ms. Duff. We thank 
you all for your testimonies.
    I was just asking Mr. Miller back here, who knows all of 
this stuff and has been involved in these issues for many 
years, about what you were just saying. I think a lot of times, 
Ms. Duff, we have looked upon hunger and obesity as two 
distinct kinds of things. It is hunger or it is obesity. As you 
pointed out, and I underlined it, you said they have got to be 
addressed jointly, that it is not a zero-sum kind of game. 
These both have to be looked at at the same time. I think that 
is very profound and I think that we have to be thinking of 
that. We maybe tend only to think about hunger and then obesity 
is over here. But the two go together very well and we have to 
address both of those.
    I would like to open it up for a general discussion here. 
Again, I will start with Dr. Kennedy. I think one of the things 
you pointed out was that there are other things that have to be 
involved. You talked about the Shape Up Somerville Program. Are 
you doing anything to replicate this anywhere? When you hear 
these, when I read it and when I heard you talk about it, it 
just sounds so common sense, but are we replicating this 
anyplace else?
    Ms. Kennedy. We are, Senator Harkin. Fortunately, we have 
the opportunity, and in a very rigorous way we are looking at 
urban areas in the United States in comparison to matched areas 
based on demographic characteristics that don't have this 
approach, and also we are looking at it in rural areas, because 
the infrastructural constraints may be different.
    As has already been pointed out, distance to services in 
rural areas are very different than urban areas. So, for 
instance, some of the Shape Up Somerville activities, like 
walking to school clubs, might not be as feasible in rural 
areas, so what is the counterpart of that? How do you, apropos 
to the earlier comment, how do you incorporate physical 
activity into schools that don't have a playground?
    We need to think about the core operating principles, and 
from the point of view of implementors, how do you actually get 
it done? I don't think anyone is against, or no one I have 
heard of, having healthier school meals and more physical 
activity. But within the constraints under which schools are 
operating, how do you do this, and that is going to vary 
somewhat by urban-rural. It also may vary by different locales 
based on constraints schools are facing.
    Obviously, schools that have the opportunity to have more 
parental and community involvement have resources added, but 
schools that don't have the luxury of having the backstopping 
of community organizations have to look at innovations, and 
this is where I think in Child Nutrition Reauthorization, to 
look at various kinds of pilots in order to move the school 
nutrition programs in the direction of more health and 
wellness.
    Chairman Harkin. The other thing you brought out in your 
testimony was that you mentioned that handing out pamphlets 
doesn't work, that there has to be more to it. Of course, I 
think about incentives. What kind of incentives can we build 
into the WIC Program, for example, to get better foods? Now, 
some of you mentioned in your testimonies--maybe you did, Dr. 
Kennedy--about that pilot program that we put in the Food Stamp 
Program that is just starting now to give incentives for Food 
Stamp recipients to buy healthier foods in stores. Is there 
something like that we could do in the WIC Program?
    Ms. Kennedy. The implementation now that USDA is undergoing 
of the new food package regulations that are based very heavily 
on the Institute of Medicine report, where there is more 
emphasis in the WIC food package on fruits, vegetables, whole 
grains, and low-fat dairy, is obviously a step in that 
direction. I think, again, in looking at gains we have made in 
the United States over the past 60 years, if you are targeting 
overweight and obesity as a primary problem both in children, 
and Senator Lugar's comment is well taken, and adults, the WIC 
food package or the school meals have to be part of the 
solution, but it is not the totality of the solution.
    This is why I made a plea in my testimony to look much more 
specifically at the potentiality of linking the WIC services to 
Child and Adult Care Food Program. Children, particularly low-
income children, are spending a disproportionate share of their 
day in child care. We are trying to achieve the same goals in 
WIC and Child Care, better dietary patterns, healthier 
lifestyles. We know from the point of view of the preschool age 
period it is developmentally so important, including the 
development of lifelong eating habits.
    What we found in the Shape Up Somerville experience, which 
was targeting first, second, and third graders, was that 44 
percent of those children, by the time they got in those early 
grades, were already either overweight or at risk of 
overweight. What this implies is you have to start earlier. If 
you want a healthy lifestyle, you have to start with the 
preschool years and one vehicle for that at the Federal level 
is this synergy between WIC and Child and Adult Care Food 
Program.
    Unfortunately, what we have seen since the means test was 
passed for homes and child care in 1996 and implemented in 
1997, what we have seen is a decline in the number of homes 
participating in Child Care, and again, Senator Casey, I think 
this is apropos to your point, where you talked about 
decreasing administrative burdens. If you have a woman who is 
running a child care facility with three or four children, they 
don't want to spend half their day doing paperwork to qualify. 
Without losing the essence of what we are trying to accomplish 
in Child Care, how do we make it more of a health program? I 
think you have the opportunity to think about this in the Child 
Nutrition 2009 Reauthorization.
    Chairman Harkin. Good suggestion. I just have one more 
before I yield to my colleagues. I want to know about this 
Minnesota study. People always told me these healthier foods 
cost more, and my response has always been, well, OK. It is 
still a good investment. It is still the best investment to get 
them healthier food. But you say the Minnesota study indicates 
that it didn't cost that much more, is that right?
    Ms. Fox. I will have to send you the paper. I don't want to 
misstate anything. Basically, it was a regression analysis that 
followed meal purchases and menu plans in 330 school districts 
in Minnesota, and what they found when they compared food 
prices to the healthfulness of the menus, that there wasn't the 
association that was expected, that the healthier meals cost 
more.
    And then they went back and did focus groups with food 
service directors to try to figure out why they got this 
counterintuitive result and they went back in and looked more 
closely at the components of the cost data and what they found 
was that many of these school districts that were serving 
healthier meals were spending more on labor because there was 
more chopping, slicing, dicing, and cooking, but they were 
spending a lot less on expensive pre-prepared, processed, 
packaged foods, so the per unit cost.
    Now, there are all kinds of caveats in the report, that 
obviously it is based on one State. They have got certain 
purchasing agreements in place and a menu that started in a 
certain place and so forth. But it is certainly something to 
look at, and I would be happy to send it to you.
    Chairman Harkin. I wish you would, because what I would 
like to do is see if we can't provide some support, read that 
as money, to other places around the country to do similar kind 
of studies, get a handle on this and find out. Maybe I have 
been wrong all along, that they just necessarily cost more. 
Maybe what you are pointing out, really that they balance each 
other off and that nutritious foods don't really cost that much 
more.
    Ms. Fox. I think there is probably a lot of variability, 
but this is at least one hopeful sign that it doesn't have to 
always be in one direction.
    Chairman Harkin. Thank you very much. I have questions for 
other witnesses, but I am trying to do a 7-minute round here 
and I will yield to Senator Casey, and then Senator Lugar and 
then Senator Klobuchar.
    Senator Casey. Mr. Chairman, thank you. I am yielding to 
Senator Klobuchar because of your schedule.
    Chairman Harkin. Okay.
    Senator Klobuchar. Thank you very much. I have to go train 
our new Senator on the nuts and bolts of setting up an office, 
so I will just take 5 minutes.
    Chairman Harkin. You have a new Senator?
    Senator Klobuchar. Well, incoming Senator Begich. He 
couldn't go to the orientation that we all did.
    Chairman Harkin. Oh.
    Senator Klobuchar. Oh, you thought that the Minnesota race 
had been determined?
    Chairman Harkin. I thought that was settled.
    [Laughter.]
    Senator Klobuchar. Oh, no, Chairman Harkin. I would let you 
know that.
    Chairman Harkin. Did I miss something here?
    Senator Klobuchar. No, no, no. OK. Sorry for throwing that 
in there.
    I want to thank all the witnesses, and I actually had some 
questions, Ms. Fox, that Senator Harkin, the Chairman, asked, 
but just about this Minnesota study, if you could send it, as 
well. I do think just intuitively, when you think of these 
packaged foods and some of them, they seem cheap but they are 
not always that cheap. It is cheaper to make a peanut butter 
sandwich, as I know from my daughter's lunches, and throw an 
apple in sometimes than the prepackaged things that you can 
buy.
    But I was thinking, Dr. Kennedy, of what you were saying 
about this relationship. I hadn't really thought of it so 
intensely until you brought it up, until yesterday when I saw 
an ad for a fast food restaurant that was clearly pushing this 
because of the economy and they were showing their basically 
basket of bad-looking food and they said that you could feed 
each family member of four, which I have never heard before on 
a fast food ad, because people are suffering, for $1.99 or 
something by using this. So it made me think about it, as I 
looked at this food and it looked really fattening. It made me 
think about how that it is going to get worse possibly because 
of the economy, that people are going to be getting more and 
more and more of the cheaper fast food, and so that will be an 
issue.
    I just wondered if you could just talk a little bit more 
about in the school lunch setting, the relationship here 
between the cheaper fried food and the obesity.
    Ms. Kennedy. Yes. Excellent observation. Clearly when one 
is income constrained, what you try to do with your food dollar 
is maximize caloric intake, and I am not suggesting that is 
good, but fast food restaurants are a great value for dollar on 
the calories you get per dollar spent.
    We have actually looked at this over the past 50 years, all 
of your nutrition programs, and see that particularly School 
Lunch, School Breakfast, and WIC, provide more nutrient-dense 
foods within the calorie allotment that is given. If you look 
at the last national evaluation of the WIC Program, what you 
see in children's diets, is that more expensive nutrients like 
calcium, iron, a range of vitamins, were increased while 
participating in the WIC Program. The same thing in School 
Lunch-School Breakfast. These programs effectively move 
participants to have more nutrient density in the diet because 
households can't afford to necessarily buy these more expensive 
foods.
    Nutrient-dense foods need not be more expensive, but it 
takes a lot more planning and thinking about how you get not 
only calories, but nutrients out of the dollar, which gets back 
to my earlier comment about information given to parents. In my 
testimony, I do talk about the fact that in interviews we did 
as part of a National Governors Association bipartisan project, 
that moms who really wanted to make the right choice reported 
over and over again that they were getting different messages 
from pediatricians, from WIC, from Head Start, from child care. 
We have the opportunity to think about how do we use our safety 
net to not only get across a consistent nutrition education 
message, but nest this in the concept of parenting skills.
    Senator Klobuchar. I mean, I was always looking for the 
easy way out when my daughter was in elementary school, but I 
finally decided bringing a lunch was so much better because of 
all these bad choices. There were some good choices, but there 
are some really bad choices that the kids would choose which 
really resonated with what you are talking.
    You talked about this national science-based standard for 
foods that compete with the lunches. How do you think we could 
do this, because the truth is, if they have got French fries to 
choose from or a yogurt, they are probably going to choose the 
French fries.
    I think what you have to do is move in the direction of 
having the healthy choices available in schools. I actually 
think we have an opportunity both for rigorous standards for 
the School Lunch-School Breakfast, but also national rigorous 
standards for competitive foods that the private sector will 
step up to the plate as they see consumer demand in schools and 
you will have a broader range of healthier products available.
    Senator Klobuchar. I just don't think we should have those 
bad choices, at least for elementary schools.
    Ms. Kennedy. Right, and this is what we did in Shape Up 
Somerville. We removed the chips and the sodas and replaced it 
with waters, yogurts, et cetera. Now, initially, revenues went 
down----
    Senator Klobuchar. Yes, I know.
    Ms. Kennedy [continuing]. But over the course of the first 
year, they bounced back up and schools were not adversely 
affected. The low-income schools rely on these revenues, so it 
is possible to do it.
    Senator Klobuchar. Right.
    Ms. Kennedy. I totally agree with you.
    Senator Klobuchar. Another thing along those same income 
lines, again, personal experience. My daughter was at a school 
in Minneapolis for 2 years that was 90 percent free and reduced 
lunch and it was an inner-city school, and now she is in the 
Arlington schools in Virginia, a very different population. So 
I don't see this as Minnesota versus Virginia schools but 
demographically, two very different situations.
    The Virginia schools, they have gym every single day. These 
kids are out there, no matter what. And this school she was in 
had a gym. It wasn't as good, like you said, but they could 
have been doing it. It was only 3 months out of the year, and 
there was no comparison between the physical actively. And in 
this school where she is now, they are giving them pedometers 
when they take health, so she is walking the stairs at home, 
the half-hour before she is going to bed, because she hasn't 
gotten enough steps in, running in place.
    But that kind of philosophy, if we could somehow get that 
across the board, could fit as a status thing to me, that at 
some of these urban schools that are doing less with the 
mandatory physical education, and I am someone who had like the 
second-to-the-worst softball throw in fourth grade. But my 
point is that somehow they have made gym something that my 
daughter looks forward to, even though she is not athletic----
    Ms. Kennedy. Making it fun.
    Senator Klobuchar. And so that has got to be a piece of 
this. Do you see, is there a demographic--I will ask someone 
else--demographic differences so that some of these poorer 
schools are getting less physical education, because that is 
what I saw. I don't know. Does anyone know?
    Ms. Duff. In South Carolina, recently, we have passed a law 
to increase the hours of physical education in all our schools. 
It is gradually being funded. Funding is part of the problem. 
We have to hire a lot more teachers and some of them have to be 
part-time teachers to cover more addition physical education 
classes.
    But in my own school district, our students have physical 
education twice a week, and they go outside. They engage in a 
variety of physical sports and activities and the students do 
look forward to it.
    Senator Klobuchar. I mean, I just would say that it seems 
the hour--the 45 minutes, not an hour, probably like 45 minutes 
a day, you really can't beat that because it sets up this 
routine, I think. But anyway, thank you very much.
    Chairman Harkin. Thank you, Senator Klobuchar.
    It kind of raises the question I am going to ask after I 
recognize Senator Lugar, but what you are talking about are 
competitive foods. I started thinking about this. Where did 
that name ever come from? Why are they called competitive foods 
and when did they come in?
    When I was a kid in school, when they started the School 
Lunch Program, we never had competitive foods. We never had 
vending machines, either. Anyway, I won't get into that, but 
why do we allow competitive foods? I make a provocative 
question. Should we just ban competitive foods? If you are 
getting part of the School Lunch and School Breakfast Program, 
you just can't have competitive foods, or whatever they are 
called, a la carte lines and vending machines and all those 
kinds of things like that. Maybe we ought to just say, enough. 
Anyway, I just throw that out there.
    Senator Lugar, I didn't mean to interrupt you, but thank 
you.
    Senator Lugar. Mr. Chairman, I will just follow along your 
idea. First of all, I liked the challenge in this 
reauthorization, which may come at a time that the new 
administration, the new Congress are discussing health care for 
all Americans, the more comprehensive approach there, that our 
role can be a very important one in talking about the 
nutritional part of it for our children, likewise for mothers 
in the WIC Program or for others who are involved in this. I 
like that idea and I am hoping we can draft something that 
would be consistent with this.
    It seems to me that we have discussed, certainly Ms. Duff 
has illustrated a dramatic example of the food safety net that 
still needs to be cast a good bit wider. This committee has 
made a lot of progress over the years with regard to summer 
feeding programs. We discovered a hiatus there of several 
months in which the children were not in a regular school 
operation, but there were park services, social groups, 
sometimes the schools themselves that regrouped so that there 
was not this gap.
    I am not certain how we phrase this, but essentially we 
know that the comprehensive medical changes are hugely 
expensive and our country is trying to grapple with how rapidly 
can you take this on, along with Social Security reform or 
other monumental tasks of this sort. But this is perhaps a less 
expensive part of that, and I mention that because whatever we 
do is going to be challenged in a budget way as to whose budget 
is paying for this. Is this United States Department of 
Agriculture or which situation, so that any increases we make 
are going to be challenged, as they will be in a period of 
deficit finance.
    What I want to get to, though, is the point that you were 
raising again, and this is from your testimony, Ms. Fox, about 
the fact that in some programs, in fact, the good fruits and 
the good vegetables and the other items that all of us believe 
are nutritious were presented to students. But I think you 
point out in one instance, only 45 percent of the choices were 
the good fruits and vegetables. In another case, 30 percent in 
some other choice people had to make.
    Senator Harkin is suggesting, I think, why is there a 
choice? Well, we say, my goodness, what kind of a country is 
this? We are Americans and we reserve the right to choose to 
eat whatever we want, whether we are children or adults or so 
forth. After all, what we ought to be doing, as everybody 
suggests, is presenting more information, more constructive 
advice as to why this is a good choice for a child who is six, 
seven, eight, nine, or what have you, presumably has the 
comprehension of all of this research, the argumentation, but 
also some familiarity with the habits of parents who may not 
share those thoughts, or even grandparents who have very strong 
ideas about what they like.
    And so again and again, we are going to be faced with this 
predicament that we present better and better information to 
people, and even have the food lying in front of them, but as 
you said, you can lead the horse to water and so forth, it 
really does pertain to this situation.
    What I am wondering is, first of all, what is your thought 
about how far choice ought to go in this predicament? Is this a 
case in, let us say elementary school feeding programs where, 
in fact, the only thing there on the counter happens to be in 
conformity with dietary guidelines? But then, second, the 
statistician in all of this sort of gropes with this thought. 
Can we at the same time begin to challenge students in the same 
way that the pedometer may challenge students to do the right 
thing with regard to steps and walking and so forth, to get 
better information about how many calories are in this or what 
is the Vitamin A content, or for that matter--and challenge 
students to do the math, to help construct for themselves a 
healthy pattern which may, in fact, be a source of discussion 
or debate with the family.
    In other words, I grope, as many of us do, for any 
information about some of the food that I have consumed in a 
restaurant or someplace that I don't control the situation, and 
there is debate in our society as to whether this information 
should be available at all. How do we make this kind of 
information universally available, and while we are involved 
with our courses with students, as you have been involved in 
the math of it, make this an attractive option for people to be 
doing the right thing and understand the reasons and have 
pride, really, in what their score may be? Can you make any 
comment about this?
    Ms. Fox. I think what you just said spells out how complex 
the whole situation is in terms of offering an individual 
decisions and the influence of the family and also the 
influence of what else is out there when they are making a 
decision.
    I think there clearly is evidence from programs like Shape 
Up Somerville and other programs that have been implemented 
sort of in a research setting that things can be changed in a 
way that children will adjust and move toward the healthier 
choices.
    I think when you are talking about trying to do that on a 
more broad-based way in schools that may have more or less 
motivation and resources, you know, physical and motivational 
resources to implement something like that, that there really 
is a need to try to put some models together and that is sort 
of what I was alluding to when I talked about having some 
demonstration projects, to put some models together that school 
districts that do want to make these changes from, whether it 
is eliminating competitive foods or making the not so great 
choices like French fries, instead of having them every day, 
offer them once a week. You know, instead of having pizza with 
pepperoni on it every day, offer pizza with no pepperoni once a 
week. I mean----
    Senator Lugar. So the district might make the choice.
    Ms. Fox. Right.
    Senator Lugar. In other words, to get to Somerville, that 
is a broad group of people, but so is a district.
    Ms. Fox. Right.
    Senator Lugar. So as opposed to the individual child making 
the choice or the nutrition director at the school, you do this 
in a geographic or organizational pattern.
    Ms. Fox. Right. Well, the school district would have to 
make choices about what they are going to make available and 
how they are going to market it and that sort of thing, and 
then there has to be support to help and encourage and provide 
encouragement and information to the children to be able to 
make those individual choices.
    I personally don't--I mean, competitive foods is a 
different story. But in terms of really limiting choice within 
the context of school meals, I think we should try to make them 
as healthy as they possibly can and allow students a variety of 
choices that they can mix and match in a variety of ways and 
still come out with a reasonably healthy meal.
    Senator Lugar. Thank you.
    Ms. Fox. That is sort of my opinion.
    Senator Lugar. Thank you, Mr. Chairman.
    Chairman Harkin. Well, Dick, you just again bring up an 
interesting thing about the choices that these kids have and 
why kids pick some of these bad foods and stuff. Again, it 
spills over into so many areas outside of our jurisdiction, but 
I think a lot of it has to do with marketing. I mean, they 
market to kids, and this goes back to a decision made back in 
1980 or 1981, somewhere in that range of time, by the FTC. The 
Federal Trade Commission right now has more authority to 
regulate advertising to you than to your grandkids because they 
exempted kids. There are two ways FTC can regulate advertising. 
One is on truthfulness and one is on unfairness. For you, for 
us as adults, they can regulate advertising based on both. For 
children, they can only do it based on truthfulness, but not on 
fairness.
    Some people have been saying that it is inherently unfair 
for people to market to kids because they don't understand the 
difference, but that jurisdiction was taken away from them 
around 1980, 1979, 1980, 1981, somewhere in that timeframe. So 
these kids get all this stuff marketed to them and of course 
then they are going to pick these foods because that is who 
their heroes tend to--see, Spiderman likes this stuff. I am 
talking about younger kids and things like that. So they come 
to school with all of that.
    I have made the statement before that it seems to me 
schools ought to be sanctuaries for kids, places where they 
come and they learn, they grow, they develop. They shouldn't 
just be another marketplace where vendors can market items, and 
sometimes to the extent where some vendors have exclusive 
marketing agreements with secondary schools, Coke, Pepsi. I 
have been to schools where they have got these exclusive 
contracts, and, of course, they provide money for band uniforms 
and sports and all that kind of stuff and they get these 
exclusive contracts, one soft drink over another.
    I was at one school once and they had seats, chairs for 
kids with the Coca-Cola emblem on them. They are sitting in 
school sitting on Coca-Cola seats. Well, you think at first, 
well, so what? But it is that brand identification that they 
instill in kids.
    I just, for some reason, I think that we have got to get 
away from that and come back to this idea of wholesome, 
nutritious foods, and at least if there is going to be a 
choice, it ought to be a choice among nutritional foods, 
perhaps not a choice between nutritional and non-nutritional 
foods. Maybe provide the choice, but at least put some 
guidelines out there that hopefully we can get before next 
October, anyway.
    I didn't mean to go on that. We are graced with the 
presence of Senator Leahy, another former Chairman of this 
distinguished committee. Senator Leahy?
    Senator Leahy. You see it is the former chairmen who show 
up here, the Chairman and former chairmen because we are the 
ones who understand how important it is.
    I was interested in listening to the conversations. I have 
been in some schools, maybe a couple of different schools, same 
demographics, same size, same budget, one with really good 
nutritional food and the education that goes with it, others 
with stuff that is scary, you know, green glop on Monday and 
blue glop on Tuesday, or the kinds of things you talked about 
before, other stuff.
    I think on this, the food assistance, it is a chance to 
learn how well equipped the Department is in helping the 
American people prevent chronic disease and fight hunger. It is 
a significant economic crisis in the country today and hunger 
becomes one of the first things that we see in the wealthiest 
nation on earth, a nation that spends millions of dollars to 
get rid of excess food. You see hungry people. So I am glad to 
see those who are here today, our friends from USDA who can try 
to work to respond to a growing demand.
    This is one of the most severe periods of economic turmoil 
in modern history, and as I said, when times are tough, more 
Americans go hungry. I think nobody has to be a genius to know 
that hunger is going to get worse. It is not going to get 
better as the recession goes on. Hunger is a leading indicator, 
an indicator during tough economic times, but it is a lot more 
than just statistics. It is deeply personal. It takes its toll 
one child at a time, one family at a time. Parents, as they are 
out there trying to get work, going without food because they 
want to at least feed their children, or children embarrassed 
to say when they go to school why they are hungry, because 
their family can't feed them.
    Right now, in my own home State of Vermont, nearly one in 
ten people are, as these statistics call it, hunger insecure. 
Hunger insecure. I cannot begin to tell you what they are going 
through. These people are running out of food. They reduce the 
quality of food their family eats. They feed their children 
unbalanced diets. They skip meals altogether so families can 
afford to feed their children. The current economic condition 
severely affects this food security. Then they show up at Food 
Stamp and food shelves, and the food shelves are strained far 
beyond their resources.
    My wife and I, one of the areas we prefer sending money for 
charity are food shelves, and I hope everybody else will do the 
same thing, because I talk to the heads of these food shelves. 
I know how they try to stretch every bit of food. They say they 
cannot begin to meet the demand. So we have to do a lot more to 
help that. The Agriculture Department has to be our partner in 
that.
    Hunger is just one of the problems--poor-quality diets, 
nutrition deficiencies, obesity,developmental delays, increases 
in aggression, depression, hyperactive behavior, poor 
academics. Any teacher will tell you, a hungry child is a child 
that can't learn. These are problems that face everybody in 
these hunger insecure homes.
    So that is the only thing I am going to talk about because 
I think that we will in the various committees be looking at 
things, everything from auto bailouts on through. Bailing out a 
hungry table with hungry children while parents try to find 
work, I think goes not just to the economics of this country, 
it goes to the morality of the United States.
    I think one of the ways that can stimulate that is the Food 
Stamp Program. I think there has to be an increase in Food 
Stamp benefits. Temporarily increase Federal reimbursement for 
school meals. We are in the school year. That might help. Find 
how to get more resources for our food banks around the 
country.
    Mr. Chairman, I would like to ask just a question about a 
point made in Dr. Kennedy's testimony. You had said, as I 
understand it, reading it, that you would like to see a 
temporary increase in the level of Food Stamp benefits to help 
low-income families. Do you have a level in mind, or how much 
of a bump the Food Stamp benefits should be? Am I putting you 
on the spot?
    Ms. Kennedy. No, no. Part of it has to be what is 
practical. The changes that have taken place in the level of 
reimbursement for the Thrifty Food Plan have gone in the 
negative direction over the past few years. The Thrifty Food 
Plan used to be at 103 percent of the value of the Thrifty Food 
Plan, because there is a lagged effect. That 3 percent was 
eliminated.
    So it is not simply increasing the level of the Thrifty 
Food Plan, the Food Stamp benefit, which I will get back to in 
a moment. We in Massachusetts, after a number of years of 
seeing downward trends in Food Stamp participation, suddenly 
are seeing this sharp uptick because of the economic downturn, 
but simultaneously, we are seeing increased participation in 
emergency feeding sites. And so if they are not getting it from 
Food Stamps, they need to get it from emergency sites.
    I will give you a number, and I know the reaction often is, 
oh, it is not possible because the Food Stamp Program is so 
expensive, but I would say a 10-percent increase. Now, what is 
the pragmatics in the current budgetary environment, but that 
is enough of a padding there that it would be significant. It 
would be expensive.
    Senator Leahy. Does anybody else want to add to that? Ms. 
Fox?
    Ms. Fox. I think that it would be terrific. The increases 
that we have seen in the past have been much, much smaller than 
that.
    Senator Leahy. I didn't expect you to jump up and disagree.
    [Laughter.]
    Senator Leahy. Dr. Chilton?
    Ms. Chilton. If I could say a few words about using Food 
Stamps as an economic stimulus, I think that would be 
incredibly important. I don't know what the percentage increase 
should be, but I have to tell you that based on our research 
that we have done in Boston and in Philadelphia, we have found 
that if a family is receiving the maximum allotment of Food 
Stamps, which used to be $542 for a family of four, even if 
they are receiving that maximum allotment, they still would not 
be able to afford everything that the Thrify Food Plan says 
that they can buy with that money.
    As a matter of fact, in Philadelphia, they would be about 
$2,000 in the hole trying to buy the Thrifty Food Plan with the 
maximum allotment of Food Stamps. So a 10-percent increase 
won't bring you up to what the Food Stamp Program is supposed 
to do.
    I also have to say that children who are on Food Stamps, 
there is a significant health effect. The more Food Stamps that 
a family receives, the better the developmental outcomes, the 
greater the reduction in hospitalization rates, and the greater 
the reduction in poor health. So you are not just getting a 
return on the dollar, but you are also stimulating and boosting 
the minds and the bodies of the very young children that need 
these Food Stamps the most.
    Senator Leahy. Thank you. Ms. Duff, did you want to add 
anything to that?
    Ms. Duff. I second that motion. Yes, I agree.
    Senator Leahy. Mr. Chairman, I think the reason here is 
that this is sort of important. I mean, none of us around this 
table are going to go hungry except by choice, and our children 
won't go and our grandchildren won't go hungry except by 
choice. But I can walk you out of here and I could say this in 
a hearing room in any city in this country and within a few 
blocks show you really severe hunger. And if you go into some 
of the rural areas, whether it is in Pennsylvania or Indiana or 
Iowa or Vermont, you have these real pockets of hunger, and 
with the hunger comes desperation. They don't know where to go, 
especially in families that have never faced that before. In 
the hard economic times, they are facing it for the first time 
in their lives and the difficulty of it.
    So thank you for holding the hearing, Mr. Chairman.
    Senator Lugar. Mr. Chairman, this is a point of query. Do 
we know or does staff know what the Federal budget is for Food 
Stamps now? In other words, what benchmark do we have to think 
about the 10 percent increase if that were to be a part of this 
economic stimulus package?
    Chairman Harkin. This is Derek Miller, who is my staff 
person on this. He knows all this stuff.
    Mr. Miller. A 10-percent increase in the Food Stamp 
allotment through the end of the fiscal year with a January 1 
effective date is about $4.3 or $4.4 billion. And that is what 
was included in the most recent stimulus bill that was brought 
before----
    Senator Lugar. It is included?
    Mr. Miller. Correct.
    Chairman Harkin. Thanks for asking the question. I didn't 
know the answer to that, either, Dick. Thank you.
    Senator Casey from Pennsylvania?
    Senator Casey. Mr. Chairman, thank you, and I am sorry I 
had to run out and I apologize to our witnesses.
    First of all, I want to thank our Chairman and both Senator 
Leahy and Senator Lugar, who all three have done decades of 
work on these subjects and on these priorities. So we want to 
thank them for their leadership on these important issues.
    I guess I wanted to start with Dr. Chilton on something 
that just leaped off the page of your testimony, where you 
talked about food insecurity and you said, and I am quoting 
from the first page of your testimony, ``Last year, 12.4 
million children,'' and you have highlighted that, ``were in 
food insecure households, according to the USDA. Yet again,'' 
you say, ``17 percent of households with children in the United 
States had lived in food insecure homes,'' unquote. But that 
12.4 million children, that is literally the entire population 
of the State of Pennsylvania, a very large State, as you know. 
That number alone, I think, tells the story. I can't even 
comprehend of that many children facing food insecurity, so you 
really put it into perspective when you highlighted that.
    I wanted to ask you, as I mentioned in my opening, the 
postcard that you showed me, the Witness to Hunger postcard. 
Can you give a sense of, from your research or from your own 
observations or from the testimony from others, what you are 
seeing in the last few months, kind of in real lives like these 
children's lives, versus what we were seeing a year ago or 5 
years ago? I mean, is there a way to define it beyond the 
numbers in terms of the kind of urgency to it or the kind of 
real world circumstances that we are seeing? I know it is hard 
to sum up without data, but is there another way to convey 
that?
    Ms. Chilton. Thank you very much for asking the question, 
and I think I can convey it. I will base it on my research with 
40 women, only 40 women in Philadelphia, but I have basically 
given them the opportunity to take photographs and to record 
their experiences with hunger and poverty in inner-city 
Philadelphia. The way they talk about it is having to reduce, 
or losing hours that they can put in at their jobs because of 
cuts that are happening in their workplaces and having to take 
on second and sometimes third jobs. This becomes very 
difficult, especially for a female head of household who needs 
to--who are doing janitorial services, for instance, between 9 
p.m. and 4 a.m. and how do they afford child care.
    So from these women's perspectives, I think it is really 
the reduction in hours at work. It is the extremely low pay and 
low wages that they actually earn. And also trying to arrange 
child care for their young children and trying to keep it 
together emotionally, financially, and just in their everyday 
lives. It creates an enormous sense of anxiety and depression 
in these women's lives, which then in turn makes it even worse 
for them to be able to find a job.
    So we are seeing that on the ground in Philadelphia. I am 
sure that we are seeing that in other cities, as well. We also 
have a clinic for children with failure to thrive at St. 
Christopher's Hospital up in North Philadelphia. Failure to 
thrive is severe undernutrition, and there we work with our 
families over the course of about 18 months to try to get a 
young child that has fallen off the growth curve to get back 
onto the growth curve so that they can develop well, socially, 
emotionally, and cognitively.
    And we have found that even in those families, with the 
economic downturn and also the hike in food prices, that 
families are stretching their food. They are watering down 
formula. They are taking on more jobs, which puts more strain 
on the household. Then again, the child begins to lose weight. 
And when you see food insecurity manifest in a loss of weight, 
you know that that food insecurity is very severe, because you 
can actually have food insecurity which affects a child's 
behavior and their emotional well-being and their cognitive 
performance, but when you see it have an effect on their growth 
and their growth potential, you know you are dealing with 
something very severe.
    And I have to say that if we do not boost Child Nutrition 
Programs, we will see a major downturn in child health and 
well-being and we would lose out on a generation. And this is 
an emergency. A young child between the ages of zero and three, 
any interruption in nutritional quality can have lifelong 
consequences. So this is our window of opportunity right now. 
Those first 3 years of life, that is where we can make a true 
difference.
    Senator Casey. Thank you. I know I may be plowing ground 
that has already been covered and questions that have been 
pursued before, but one of the near-term questions we have in 
front of the Congress, of course, is the stimulus legislation, 
which I have my own strong feelings about what should be in 
that and I believe that part of that should be Food Stamps, an 
increase in Food Stamp availability.
    Now, for those who aren't as concerned about or aren't 
convinced by the gravity of the situation for those who are 
food insecure, there is also a good taxpayer argument for it, 
which is always nice when you can help people and also do 
something that is efficient. In this case, Mark Zandy and, I 
guess, others, have told us that if you spend a buck on Food 
Stamps, you get $1.60, $1.70 back. So there is a good return on 
it.
    But talk to us--and this is for any of our witnesses--talk 
to us about the situation as you would perceive it, as you see 
it, if we don't act in January. Say we pass a stimulus bill and 
everyone pats each other on the back and says, yay, we have got 
a stimulus bill, and there is nothing in there for Food Stamps 
and we have to wait for the regular budget process to play out 
over the next year. Talk to us about that. I don't know whether 
Dr. Kennedy or Ms. Fox or Ms. Duff.
    Ms. Kennedy. We have looked at that and we know that 
households on the Food Stamp Program at a very low level of 
expenditures have a better dietary pattern than non-Food Stamp 
households at a similar level. However, having said that, most 
households at the spending of the Food Stamp level do not have 
a nutritionally adequate diet. I don't think any of us--long 
term, I am not talking about being on it for a week--long term 
at the spending level of the Thrifty Food Plan would have a 
nutritionally adequate diet. It is very, very difficult given 
the way--and when I was in USDA, I actually was involved in the 
revision of the Thrifty Food Plan to adhere to dietary 
guidelines. You almost have to have a Ph.D. in nutrition to 
make it work.
    So let us be realistic. Increments in the level of the 
Thrifty Food Plan would help income-constrained households.
    In my earlier comments, I talked about the fact that hunger 
tracks with poverty. Food Stamp participation tracks with 
poverty. Poverty rates are going up. Over the next year, there 
is going to be an exponential growth in demand for Food Stamps 
and I think we want to look at what is realistic in order to 
ensure food security of income- constrained households who are 
unemployed through no fault of their own. Companies have 
closed. So I would think about looking at, and I say temporary 
because I know this is not very popular, but a temporary 
increase in the level of funding of the Thrifty Food Plan 
because we are in a very dire situation.
    I would also look at ways of making sure that individuals 
who are eligible for Food Stamps maximize their participation 
in free School Lunch-School Breakfast, maximize their 
participation in the WIC Program, so you take the advantage of 
all of the programs that are there, the full mosaic of the 
safety net, so that you are not saying one or the other. You 
are looking at, through referrals, through advertisement, 
through community action, getting the multiple participation, 
which I think will help to the maximum extent curb food 
insecurity and hunger.
    Senator Casey. Anybody else?
    Ms. Duff. Increasingly we can expect greater dependence on 
free school meals for children. Families will depend on school 
meals more and more. Students who didn't qualify for meals 
assistance in the beginning of this school year will probably 
qualify now, and school nurses take an active role in that. We 
look at whether or not they qualified in the beginning of the 
school year. We try to go back and review that list and contact 
those families who did not qualify and assist them in 
reapplying so that they will have free school meals for their 
children.
    Senator Casey. Thank you very much.
    Chairman Harkin. Ms. Duff, first of all, I was startled to 
hear school nurses are serving students in 75 percent of U.S. 
public schools. Are you telling me one out of four schools 
don't even have a school nurse?
    Ms. Duff. That is correct.
    Chairman Harkin. What do they have?
    Ms. Duff. Nothing. They don't have anyone who attends to 
health care of children, not anyone trained, anyway. They have 
the secretary, who gives medicines that are controlled 
substances that have all sorts of side effects, and they are 
not trained in emergency care. They call 911 if they need 
something.
    Chairman Harkin. I think that is shocking. But I wanted to 
read something that you said here, which corresponds a lot with 
my thinking. You say, not only do the programs--you are talking 
about Breakfast and Lunch Programs--not only do the programs 
assist with the economic difficulties of poor families, they 
are part of a prevention strategy, an effort to protect the 
health of children. Prevention is the positive, logical, and 
cost-beneficial approach to achieve education goals and to 
prevent chronic diseases. Again, going back to what I alluded 
to in my opening statement, that this is all kind of part of 
the health care reform that we will be looking at.
    Dr. Chilton, let me ask you, it came to my mind when you 
were talking about the nutritional aspects of kids and what 
they are eating, some people have advised that perhaps one of 
the best things we could do for a lot of kids in our schools is 
just to provide them at least in the morning with a 
multivitamin.
    Ms. Chilton. That is hogwash.
    Chairman Harkin. Why? If they have a multivitamin, at least 
they have got the nutritional underpinnings of Vitamin A and D 
and B and the B-complex vitamins, maybe folates and other 
things like that you could put into a multivitamin. At least 
you would have that.
    Ms. Chilton. Right. Micronutrients are extremely important, 
but to suggest that you give a young child or a child that is 
supposed to learn a vitamin does not deal with having enough 
food and enough calories. So you need to have the energy 
balance in a child. You also need to have roughage. You need to 
have enjoyment with food. You need to teach a child good 
habits, color on the plate, five a day.
    To suggest that we would give a child a multivitamin and 
this would somehow enhance their cognitive potential of 
American society is absolutely backwards thinking. It goes 
against the CDC recommendations of fresh fruits and vegetables. 
It is going backwards. I highly recommend that we fight back on 
that argument to say that fresh fruits and vegetables, a 
nutritious, fully balanced meal with enough nutrient-dense 
calories is the best way to go for our young children and for 
the American people.
    Chairman Harkin. Let me see. Dr. Kennedy, you mentioned the 
school districts and the wellness policies that we put into our 
last reauthorization of this bill in which we mandated that by, 
I think it was 2005 or 2006, somewhere in there, that every 
school district had to have a wellness policy. I ask this of 
all of you. Have you looked at these? We didn't say exactly 
what they had to be. We wanted to have people think about their 
wellness policies and what the school districts would come up 
with. Do you have any knowledge of the different varieties of 
different wellness policies, and are they generally good, 
generally poor, or just do they run the gamut?
    Ms. Kennedy. Enormous variation in what is actually going 
on in health and wellness. Some school districts see this as an 
unfunded mandate. They have to have it, but there are no 
resources to come along with it. Others have taken it very 
seriously.
    I think, again, getting back to Somerville as an example, 
part of what was so exciting about--and it has been sustained 
even after the research dollars are gone--what was so exciting 
is looking at how you bring together the resources of the 
community, so we are not talking about incremental money, with 
the existing organizations of the community, existing staff. 
How do you make a community healthier?
    And part of it is charismatic personalities. I have to say, 
the Mayor of Somerville, Mayor Curtatone, wanted this to 
succeed, and we can get into a discussion of ``Are leaders born 
or created?'', but I think we can excite people when we show 
examples. We keep talking about prototypes or pilots. But when 
you can show in very diverse communities how it is possible to 
make this happen, it is not pie in the sky, you can actually do 
it in your community, can excite a community. I think the onus 
is on the Federal Government to try to provide some of the 
information, some of the models on, with these constraints, 
here is how you might do it. But at the moment, what I have 
seen, it is not just in Massachusetts but in other parts of the 
United States, there is enormous variability in what is going 
on.
    Chairman Harkin. There was some suggestion that perhaps, 
since have that out there, that perhaps we should have the 
wellness policies at least follow some guidelines that would be 
promulgated by the Institute of Medicine. Would that be a next 
step, to kind of standardize them a little bit?
    Ms. Kennedy. I think there is a wonderful resource there 
with the Institute of Medicine. Clearly, what you get from 
them, whether you are talking about nutrition standards for 
competitive foods or the current committee that is looking at 
nutrition for School Lunch-School Breakfast, or in this case 
health and wellness policies, you are getting rigor, science-
based--or a science-based framework that provides a national 
floor such that a child in State X is not disadvantaged vis-a-
vis a child in State Y. So I would think that would be one 
route to go that would be very promising.
    Chairman Harkin. Dr. Chilton, you said it is time to take 
lessons from public health where we consider population 
characteristics and socio-economic status to decide where to 
establish health centers and clinics. The Child Nutrition 
Programs ought to follow suit. What would that mean in 
practice? What kinds of Federal policy changes might you 
recommend if we were to implement that statement?
    Ms. Chilton. I think the first place to start would be with 
School Breakfast and School Lunch. Pretty much around the 
country, families have to individually apply in order to 
qualify for free school lunch. In the past 17 years in 
Philadelphia, we have done away with that, where in 
Philadelphia if the school is in a neighborhood that has 70 
percent or less--or it has 75 percent of the families that are 
living at the poverty line or below, then that child--that 
completely reduces the need for an individual application.
    What this has shown is it has reduced a stigma. It has 
enhanced the nutritional health of the children. It has made it 
easier in order to participate in the School Lunch Program. The 
same thing for School Breakfast.
    Sadly, this fall, there was some idea that this program 
might be threatened in the Philadelphia School District. We 
think you need to go the opposite way, that pretty much in 
every major inner city that has very high rates of poverty, it 
should be universal service. There should be no individual 
application for School Breakfast or for School Lunch. The 
application process and the administrative process for School 
Breakfast and School Lunch, and might I add, the Child and 
Adult Care Food Program, are true barriers to improving the 
health and wellness of children.
    And so I suggest that in public health, if you think about 
the Ryan White Care Act, where if you have a certain number of 
people who have been diagnosed with HIV or AIDS, then there are 
health centers that get put into place. There are therapies 
that get put into place automatically, no questions asked.
    In this same way, we have to think about our nutrition 
programs as actual public health programs that can truly 
prevent chronic disease. And if we really think about all of 
our welfare programs and the safety net programs in public 
health and started using some of our own tools, we would really 
enhance the health and well-being of children in the inner 
city, and might I also add in counties, in rural counties where 
poverty is very high.
    Chairman Harkin. Well, I guess that kind of brings us back 
to where we started, that really these programs are part of our 
public health environment and we ought to be considering them 
as such. If you are talking about public health, then you are 
looking at prevention and wellness and we ought to be focusing 
on that.
    I think it is time to make some fundamental changes in our 
health care system in America, but I also think it is time for 
some fundamental changes in our School Lunch and our School 
Breakfast and our WIC feeding programs. To the extent that we 
really promote nutritious foods, that we, again, not just think 
about our schools as marketplaces for vendors on which to hock 
or sell whatever they may have, but really as sanctuaries for 
kids to be healthy, where health is promoted and where it is 
stimulated and in an environment where kids can have these 
healthy choices.
    We started the School Snacks Program, the fresh fruit and 
vegetable snack program, and every school that has ever entered 
that program, not one school has asked to drop out, and it is 
all voluntary. We put that in the 2002 farm bill as a pilot 
program, to test it out in four States. In this last farm bill, 
we have gone nationwide with it. It is going to take a while to 
ramp it up.
    But what we found is when you provide free fresh fruits and 
vegetables to kids in schools as a snack, they will eat them. 
Now, if they have got to pay a buck for them, they might put 
their buck in the vending machine and get a Coke or something, 
or a Pepsi. I don't mean to pick on Coke here. A Pepsi or 
whatever, or they might get a bag of chips or whatever. But if 
they are free, they will eat them, and when they eat them, they 
find out the hunger pangs aren't there anymore and they don't 
go to that vending machine as often, and we have found this to 
be true. So kids are healthier.
    So we have to provide those kinds of environments in 
schools and we are going to continue on this committee and in 
this bill to try to make those changes that will move us in the 
direction of getting healthier foods and more nutritious foods, 
especially in the WIC Program, the Women, Infants, and Children 
Feeding Program.
    And I might digress a little bit here. I thought we had 
gotten away from this 20-some years ago. Twenty-seven years 
ago, I was the Honorary National Chairman of the Breastfeeding 
Coalition and we were making changes to promote nursing in the 
WIC Program and in hospitals and that kind of thing. Well, we 
did for a while and then it seems like we have backtracked a 
little bit now. How do we, while at the same time providing the 
necessary components of a WIC package, how do we really promote 
and enhance nursing, breastfeeding for infants? We know that is 
the best, it is the most wholesome, it is the most nutritious. 
It builds up immunities in babies.
    Of course, there are societal problems here, too. Many low-
income women who have babies find that the workplace they are 
working in does not provide the kind of support if they want to 
breastfeed their child. If they are working in the fast food 
industry or something like that, they just simply don't have 
that wherewithal.
    Some companies, larger companies, have provided those kinds 
of facilities for women, but as I said, a lot of low- income 
women who are working jobs that are minimum wage or slightly 
above just don't have that available. So we have to figure out 
societally how do we provide that kind of support, also.
    But to the maximum extent that a mother can nurse her 
child, how do we provide that in that WIC package? How do we 
promote that in that WIC package and give incentives in that 
WIC package? If you do this, you will get more of something 
else. See, it is all incentives, isn't it, to build the 
incentives in so they see some benefit that they will obtain 
above and beyond the health of the child, which if they have 
gotten all the information from the industry, they will be 
told, well, infant formula is every bit as good as mother's 
milk and all that kind of stuff, which we know is not so. So 
how do we build the incentives in that?
    I ask these questions so I hope that you will continue to 
think about these, the panel we have here, those of you. You 
are all experts. And continue to give us the benefit of your 
advice as we go through. This is obviously the first of our 
hearings and we are going to have a lot more early next year. 
We are open for any suggestions and advice that you might have 
in these areas.
    And the Child and Adult Care Food Program, which is sort 
of--not too many people know about it. They know about School 
Lunch, School Breakfast, Food Stamps, maybe a little bit about 
WIC, but not too many people know about the Child and Adult 
Care Food Program, which, again, more and more of our kids in 
day care centers, what are they eating? What kind of snacks are 
they having? These are kids in those early formative years, 
from one to three or 4 years of age, and they need nutritious 
food. So how do we change that program and how do we get more 
nutritious foods in that program on a reimbursable basis again?
    So these are the things that I think a lot about and how we 
provide the funding for it. Again, we are talking about budgets 
and everything and how tough the budget is. But again, it is 
that same thing. We can't afford to do it. Well, if we continue 
to do what we are doing, we are paying for the results of this 
later on in obesity and diabetes and chronic illnesses and 
chronic diseases and we pay a lot more for it later on than if 
we just decided to pay for a little bit more up front for these 
nutritious foods.
    So with that, I would thank you all for being here. I would 
just close this by asking if any of you have any final thoughts 
or suggestions or advice that you would have for us here. I 
would just go down the row again. Dr. Kennedy?
    Ms. Kennedy. Senator Harkin, I applaud your efforts to have 
the nutrition programs moved more in the direction of health 
programs. I think there is enormous potentiality for prevention 
with the basic underpinning that nutrition is a key part of 
preventive health strategies. I think whatever can be done to 
use Child Nutrition Reauthorization 2009 with much more of an 
emphasis on health and wellness is going to benefit children 
and all Americans.
    Chairman Harkin. Well, keep giving us the benefit of your 
wisdom and experience on this, Dr. Kennedy.
    Ms. Fox?
    Ms. Fox. I completely agree. I was very--I was thrilled 
with your opening comments. They were right on point and very 
compatible with my way of thinking. If this is the path you are 
going to take this over the next few months, I think good luck, 
and if there is anything we can do to help you with convincing 
some of your other colleagues--and I would just put in another 
plug for the Child and Adult Care Food Program. I really would 
like to see the focus on that program moved to the level that 
the school meal programs have received over the past 15 years, 
because that is the younger generation where they are forming 
their food habits and preferences and we really haven't done 
anything with that program. It is focused on nutrition and 
health.
    Chairman Harkin. Yes. Thank you.
    Dr. Chilton?
    Ms. Chilton. I, too, I am so amazed at the language that 
you use about public health, early childhood nutrition, and 
child development. It is so welcome to my ears, and to hear you 
talk about a school as being a sanctuary is extraordinary and I 
am so impressed. I think that if you keep on beating that drum, 
you will have enormous success.
    One of the things that I think hasn't been talked about as 
much here is that we have the USDA programs, then we have 
Health and Human Services, and then we have the Department of 
Education, and how about Labor? All of these agencies are so 
important to ensuring that there is a structure in place in 
which we can get good nutrition to children.
    And if I could suggest that we reinvigorate--I can't 
remember the name of this particular panel, but it is like a 
cross-agency nutrition assessment panel that has someone 
looking at nutrition in Health and Human Services, the USDA, 
the Department of Education, et cetera, that we set up 
benchmarks and goals in the same way that we have Healthy 
People 2010, we will have Healthy People 2020. We need to have 
some high standards for early childhood nutrition and for child 
nutrition and health, understanding that a school environment 
is just as important as the nutrition that we are going to 
infuse in there.
    And that is what public health is all about. It is about 
ensuring the conditions in which people can be healthy, and so 
I hope that we can have a very broad understanding of those 
conditions and how we can work to improve them. Thank you.
    Chairman Harkin. Thank you very much, Dr. Chilton. Again, 
you hit the point that--all of you have touched on this, and 
that is that, again, to the extent that we can on this 
committee, to the extent that I can as Chairman, get people to 
just not think about this just as a silo. Here is the School 
Lunch and here is the School Breakfast and here is this. This 
is all part of public health. It all blends into the whole 
public health spectrum of America and it has got to be 
addressed that way, without thinking about just, well, we are 
just going to provide food to kids in schools and not worry 
about the health aspects of it. So hopefully, we will start 
moving in that direction, I hope, anyway.
    Ms. Duff?
    Ms. Duff. Well, I appreciate very much the support for 
school meals assistance and the recognition that school meals 
is very much part of overall school health, and the health of 
children, and that school meals assistance is just one little 
thing that we can do to enhance the health of the family and 
that it shouldn't stop there. In schools, students that are 
connected to free and reduced meals have many, many problems. 
The fact that they qualify for meals assistance, for school 
nurses, anyway, is a red flag. We know that those families need 
many more services, and we don't just sit back and make sure 
they get their lunch. We actually make contact. We do 
assessments of the students and connect them to health 
services. I really appreciate the recognition of this committee 
that school health and school nursing is part of the public 
health system that we have in the United States.
    Chairman Harkin. A last provocative question. Do you think 
that perhaps we might build some incentives in, to the extent 
that if a school that is receiving Federal funds for breakfasts 
or lunches, that they would get a bump-up or a boost-up or 
something like that if, in fact, that school had a physical 
exercise program for each of their students that would involve 
so many hours a week of physical exercise?
    By the way, you notice I used physical exercise, not 
physical education. I have never understood physical education. 
I do understand physical exercise, and providing physical 
exercise for kids. If they do that and meet certain kinds of 
guidelines for that, they might get a boost.
    I don't know. I am trying to think of ways in which we 
blend these things together, incentive schools to do these 
kinds of things, so if you have any thoughts on that, let me 
know about it later on.
    I thank you all very much for taking time. I thought it was 
a very good session, a very good panel. I think this is really 
a good kickoff for our next year's work in reauthorizing the 
Child Nutrition Act.
    Thank you all very much, and the committee will stand 
adjourned, subject to the call of the Chair.
    [Whereupon, at 3:08 p.m., the committee was adjourned.]
      
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