[House Hearing, 111 Congress]
[From the U.S. Government Publishing Office]





      HEARING TO REVIEW THE STATE OF OBESITY IN THE UNITED STATES

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

                                HEARING

                               BEFORE THE

                 SUBCOMMITTEE ON DEPARTMENT OPERATIONS,
                   OVERSIGHT, NUTRITION, AND FORESTRY

                                 OF THE

                        COMMITTEE ON AGRICULTURE
                        HOUSE OF REPRESENTATIVES

                     ONE HUNDRED ELEVENTH CONGRESS

                             FIRST SESSION

                               __________

                             MARCH 26, 2009

                               __________

                            Serial No. 111-5


          Printed for the use of the Committee on Agriculture
                         agriculture.house.gov





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                        COMMITTEE ON AGRICULTURE

                COLLIN C. PETERSON, Minnesota, Chairman

TIM HOLDEN, Pennsylvania,            FRANK D. LUCAS, Oklahoma, Ranking 
    Vice Chairman                    Minority Member
MIKE McINTYRE, North Carolina        BOB GOODLATTE, Virginia
LEONARD L. BOSWELL, Iowa             JERRY MORAN, Kansas
JOE BACA, California                 TIMOTHY V. JOHNSON, Illinois
DENNIS A. CARDOZA, California        SAM GRAVES, Missouri
DAVID SCOTT, Georgia                 MIKE ROGERS, Alabama
JIM MARSHALL, Georgia                STEVE KING, Iowa
STEPHANIE HERSETH SANDLIN, South     RANDY NEUGEBAUER, Texas
Dakota                               K. MICHAEL CONAWAY, Texas
HENRY CUELLAR, Texas                 JEFF FORTENBERRY, Nebraska
JIM COSTA, California                JEAN SCHMIDT, Ohio
BRAD ELLSWORTH, Indiana              ADRIAN SMITH, Nebraska
TIMOTHY J. WALZ, Minnesota           ROBERT E. LATTA, Ohio
STEVE KAGEN, Wisconsin               DAVID P. ROE, Tennessee
KURT SCHRADER, Oregon                BLAINE LUETKEMEYER, Missouri
DEBORAH L. HALVORSON, Illinois       GLENN THOMPSON, Pennsylvania
KATHLEEN A. DAHLKEMPER,              BILL CASSIDY, Louisiana
Pennsylvania                         CYNTHIA M. LUMMIS, Wyoming
ERIC J.J. MASSA, New York
BOBBY BRIGHT, Alabama
BETSY MARKEY, Colorado
FRANK KRATOVIL, Jr., Maryland
MARK H. SCHAUER, Michigan
LARRY KISSELL, North Carolina
JOHN A. BOCCIERI, Ohio
EARL POMEROY, North Dakota
TRAVIS W. CHILDERS, Mississippi
WALT MINNICK, Idaho

                                 ______

                           Professional Staff
                    Robert L. Larew, Chief of Staff
                     Andrew W. Baker, Chief Counsel
                 April Slayton, Communications Director
                 Nicole Scott, Minority Staff Director

                                 ______

   Subcommittee on Department Operations, Oversight, Nutrition, and 
                                Forestry

                     JOE BACA, California, Chairman

HENRY CUELLAR, Texas                 JEFF FORTENBERRY, Nebraska, 
STEVE KAGEN, Wisconsin               Ranking Minority Member
KURT SCHRADER, Oregon                STEVE KING, Iowa
KATHLEEN A. DAHLKEMPER,              JEAN SCHMIDT, Ohio
Pennsylvania                         CYNTHIA M. LUMMIS, Wyoming
TRAVIS W. CHILDERS, Mississippi

               Lisa Shelton, Subcommittee Staff Director

                                  (ii)















                             C O N T E N T S

                              ----------                              
                                                                   Page
Baca, Hon. Joe, a Representative in Congress from California, 
  opening statement..............................................     1
    Prepared statement...........................................     2
Dahlkemper, Hon. Kathleen A., a Representative in Congress from 
  Pennsylvania, opening statement................................     6
Fortenberry, Hon. Jeff, a Representative in Congress from 
  Nebraska, opening statement....................................     3
Kagen, Hon. Steve, a Representative in Congress from Wisconsin, 
  opening statement..............................................     4
Lummis, Hon. Cynthia M., a Representative in Congress from 
  Wyoming, opening statement.....................................     5
Peterson, Hon. Collin C., a Representative in Congress from 
  Minnesota, prepared statement..................................     6
Schmidt, Hon. Jean, a Representative in Congress from Ohio, 
  opening statement..............................................     6
Schrader, Hon. Kurt, a Representative in Congress from Oregon, 
  opening statement..............................................     5

                               Witnesses

Dietz, M.D., Ph.D., William H., Director, Division of Nutrition, 
  Physical Activity, and Obesity, National Center for Chronic 
  Disease Prevention and Health Promotion, Centers for Disease 
  Control and Prevention, U.S. Department of Health and Human 
  Services, Atlanta, GA..........................................     7
    Prepared statement...........................................    10
Wolf, M.S., R.D., Anne M., Instructor of Research and ICAN 
  Intervention Team Leader, University of Virginia School of 
  Medicine, Charlottesville, VA..................................    31
    Prepared statement...........................................    33
Hamburg, Richard S., Director of Government Relations, Trust for 
  America's Health, Washington, D.C..............................    35
    Prepared statement...........................................    37
Yadrick, M.S., M.B.A., R.D., F.A.D.A., Martin M., President, 
  American Dietetic Association, Washington, D.C.................    43
    Prepared statement...........................................    44
Mazyck, R.N., M.S., N.C.S.N., Donna J., Board President, National 
  Association of School Nurses; School Health Services 
  Specialist, Maryland State Department of Education, Silver 
  Spring, MD.....................................................    47
    Prepared statement...........................................    49

                           Submitted Material

Barnard, M.D., Neal D., President, Physicians Committee for 
  Responsible Medicine, submitted statement......................    59
Campaign to End Obesity, submitted statement.....................    86
Heinen, M.P.P., LuAnn, Director, Institute on the Costs & Health 
  Effects of Obesity; Vice President, National Business Group on 
  Health, submitted statement....................................    60

 
      HEARING TO REVIEW THE STATE OF OBESITY IN THE UNITED STATES

                              ----------                              


                        THURSDAY, MARCH 26, 2009

                  House of Representatives,
 Subcommittee on Department Operations, Oversight, 
                            Nutrition, and Forestry
                                  Committee on Agriculture,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to call, at 10:05 a.m., in 
Room 1300 of the Longworth House Office Building, Hon. Joe Baca 
[Chairman of the Subcommittee] presiding.
    Members present: Representatives Baca, Cuellar, Kagen, 
Schrader, Dahlkemper, Childers, Fortenberry, Schmidt, and 
Lummis.
    Staff present: Adam Durand, Tyler Jameson, John Konya, 
Robert L. Larew, Lisa Shelton, April Slayton, Rebekah Solem, 
Patricia Barr, Pam Miller, and Jamie Mitchell.

    OPENING STATEMENT OF HON. JOE BACA, A REPRESENTATIVE IN 
                    CONGRESS FROM CALIFORNIA

    The Chairman. This hearing to review the state of obesity 
in the United States will now come to order. Thank you very 
much to those of you for being here this morning. What we will 
do is begin with opening statements by myself, and then with 
the Minority Ranking Member, and other Members as they arrive, 
if they wish to give an opening statement.
    Again, good morning. I want to thank all of you for being 
here before the Subcommittee to review the impact on obesity in 
the United States. I think it is an important topic that 
affects a lot of us. The issue is one of pressing concern to 
all Members of the Subcommittee. We are all anxious to hear the 
testimony of the outstanding witnesses to learn all that we can 
about the disease. And I say the disease of obesity, because 
that is what it is.
    Also, I would like to acknowledge our new Ranking Member, 
Congressman Fortenberry, and thank him for his interest in this 
hearing. Thank you very much, Jeff. I look forward to working 
with you on this and other issues before this Subcommittee, 
because we want to work on a bipartisan manner on issues that 
impact us on all subject matters that we have the 
responsibility for.
    I have purposely kept this hearing small in numbers to 
promote dialogue on this topic. We are here to listen, to 
learn, to see how we can make good policies. We will likely 
have other hearings to educate us on the problem of obesity. 
This isn't the only one we are going to have, but hopefully, we 
can explore the problems of access to healthy food as we look 
at obesity and its effects, and look to explore ways to 
eliminate food deserts. Also, we hope to explore the impact of 
obesity on many of the underrepresented communities, 
particularly the effects on tribal and Native American 
communities, the impact it has there. Also, I encourage Members 
of the Subcommittee to share their thoughts in future hearings 
on this or any other topic that we should be addressing.
    So with that in mind, I hope that we are--that our capable 
witnesses and Members will not hesitate to share their 
thoughts, and their expertise on obesity in America.
    The problem of obesity plagues all Americans, and I state 
all Americans, either directly or indirectly. Statistics 
indicate that more than \1/3\ of our population is considered 
obese. That is, in and of itself, a shocking number. It has an 
impact on us financially. It has an impact on us health-wise, 
and it also has an impact in terms of relationships with one 
another. However, the consequences of that number need to be 
examined and need to be understood.
    Like any disease, obesity affects many more than just those 
who suffer from it. Today's hearing will give us a better 
insight as to the very real impact that obesity has on our 
whole society. How does obesity affect the family? How does it 
specifically affect American women? How does obesity affect 
children and their ability to learn? How does obesity affect 
businesses? How does obesity affect the cost of health care? 
How does obesity affect the American culture?
    These are the questions that must be taken into account, 
and which we will begin to address today. We know that 
prevention--that prevention and nutrition education are key to 
success in combating obesity. We must find out what works, what 
does not work, and why. Hopefully, your insight will best 
inform us as to how to make realistic and substantive policy 
changes.
    As a father, grandfather, and an American, I am depressed 
by the harmful effects of obesity on our health and on our 
society. But as a legislator, I am also troubled by the 
economic consequences our nation faces due to obesity. So 
today, we will listen and learn from excellent panels of 
witnesses about their work to determine the impact of obesity 
on America.
    I hope this hearing will build on an important body of 
evidence, so that we can continue to work together to fight 
obesity and create a healthier nation.
    [The prepared statement of Mr. Baca follows:]

Prepared Statement of Hon. Joe Baca, a Representative in Congress from 
                               California
    Good morning, and thank you all for being here before this 
Subcommittee--to review the impact of obesity in the United States.
    This issue is one of common concern to all Members of the 
Subcommittee--so we are anxious to hear the testimony of our 
outstanding witnesses and to learn all we can about this ``disease''.
    Also, I would like to acknowledge our new Ranking Member, 
Congressman Fortenberry, and thank him for his interest in this 
hearing.
    I look forward to working with you on this and other issues before 
our Subcommittee.
    We are a small Subcommittee with a very large interest in the 
health and welfare of the people in this country.
    I have purposely kept this hearing small in numbers to promote real 
dialogue on this topic.
    We are here to listen and to learn so we can make good policy 
choices.
    Also, we will likely have other hearings to educate us on the 
problem of obesity.
    We plan to explore the problem of access to healthy food--and look 
to explore ways to eliminate ``food deserts''.
    I also hope to explore the impact of obesity on many of our 
underrepresented communities--and particularly its effects on our 
tribal and Native American communities.
    Once staff is in place at USDA's Food and Nutrition Service, I'm 
sure they could also add to the discussion.
    And, as always, I encourage Members of the Subcommittee to share 
their thoughts on future hearings on this, or any, topic.
    So, with that in mind, I hope our capable witnesses--and Members--
will not hesitate to share their thoughts and expertise on obesity in 
America.
    The problem of obesity plagues all Americans--either directly or 
indirectly.
    Statistics indicate more than \1/3\ of our population is considered 
obese.
    That, in and of itself--is a shocking number.
    However, it is the consequences of that number that we need to 
examine and understand.
    Like any disease, obesity affects many more than just those who 
suffer from it.
    Today's hearing will give us better insight into the very real 
impact that obesity has on our whole society.

   How does obesity affect a family? How does it specifically 
        affect America's women?

   How does obesity affect children, and their ability to 
        learn?

   How does obesity affect a business?

   How does obesity affect the cost of health care?

   How does obesity affect the American culture?

    These are all questions that must be taken into account--and which 
we will begin to address today.
    We know that prevention and nutrition education are keys to success 
in combating obesity--but we must find out what works; what does not 
work; and why.
    Hopefully--your insight will best inform us on how to make 
realistic and substantive policy changes.
    As a father, grandfather, and an American, I am distressed by the 
harmful effects of obesity on the health of our society.
    But as a legislator, I am also troubled by the economic 
consequences our nation faces due to obesity.
    So, today we will listen and learn from our excellent panel of 
witnesses about their work to determine the impact of obesity on 
America.
    I hope this hearing will build on this important body of evidence, 
so we can continue to work together to fight obesity and create a 
healthier nation.
    I now yield to our Ranking Member--Congressman Fortenberry, for his 
opening statement; and after that will open the hearing up to any other 
Subcommittee Members who wish to make a brief opening statement.

    The Chairman. I now yield to the Ranking Member, 
Congressman Fortenberry, for his opening statements, and after 
that, I will have other Members give their comments as well.

OPENING STATEMENT OF HON. JEFF FORTENBERRY, A REPRESENTATIVE IN 
                     CONGRESS FROM NEBRASKA

    Mr. Fortenberry. Thank you, Mr. Chairman, for your kind 
introduction and for holding this hearing today on the state of 
obesity in the United States. I appreciate all of you who are 
witnesses, your time and willingness to come before us as well 
on this important subject, and I look forward to our discussion 
today.
    Like many of my colleagues, I am very concerned about the 
rising rate of obesity among Americans, and the costs are not 
only great in terms of economics, but also in terms of health 
and well-being of our people. As our witnesses will testify 
today, obesity is contributing to rising health care costs, the 
loss of productivity in the workplace, and various life-
threatening conditions such as diabetes, cardiovascular 
disease, as well as stroke. I am also very concerned about the 
rising trend of overweight and obesity statistics among 
America's children. I strongly believe that we need to link the 
nutrition our children receive to their wellness for the 
purpose of preventing the onset of debilitating chronic 
diseases. By doing so, we should also see improved health 
outcomes as well as lowered heath care costs. I am personally 
committed to exploring ways to encourage good nutrition and 
wellness, and ultimately, as we all know, for these statistics 
to change, persons must take more personal responsibility, 
choose a more informed and well-balanced diet, as well as 
increase their activity level. But to encourage people to get 
on the right track, I believe access to good nutrition, as well 
as nutritional education, is the key.
    I would also like to note, Mr. Chairman, that Dr. Kagen, 
from Wisconsin, and I successfully amended the farm bill last 
year to empower local school systems, as well as other public 
institutions, to purchase locally raised, nutritious foods from 
local farmers as a way to strengthen local food programs while 
adding healthful options to school menus.
    I am anxious to hear all of your testimony today, as we 
unpack these various aspects of the obesity problem in our 
country, as well as to hear your helpful suggestions about the 
most effective ways to provide information on combating this 
growing trend.
    Mr. Chairman, again, I thank you for holding this hearing, 
and I look forward to our dialogue today.
    The Chairman. Thank you very much. Next, I will call on 
Congressman Kagen.

  OPENING STATEMENT OF HON. STEVE KAGEN, A REPRESENTATIVE IN 
                    CONGRESS FROM WISCONSIN

    Mr. Kagen. Thank you, Mr. Chairman, for holding this very 
important hearing. I expect this morning to hear from experts 
in the field to help document the state of this epidemic of 
being overweight. America is overweight, no question about it. 
I look forward to your suggestions at what we can do to begin 
to solve this difficult challenge that we face.
    As the Ranking Member, Jeff Fortenberry, indicated, we have 
in the Farm Bill of 2009--we put in some good things, didn't 
we, Jeff? You can grow local food and put it into local school 
systems: Grow local, buy local.
    I will just remind everybody, pollution begins at your 
lips. You are what you eat, and from the Kagen point of view, 
you ought to weigh today what you did as a senior in high 
school. I am working on it.
    I will yield back my time.
    The Chairman. I think we are all headed to the gym right 
now. Thank you. Congresswoman Lummis.

 OPENING STATEMENT OF HON. CYNTHIA M. LUMMIS, A REPRESENTATIVE 
                    IN CONGRESS FROM WYOMING

    Mrs. Lummis. Thank you very much, Mr. Chairman. Although I 
haven't any prepared remarks for opening, I would like to thank 
you, is it Dr. Dietz, for being here, and our other witnesses.
    Every time that a TV ad runs on our cable television 
station at home that says don't just do something, sit there, I 
go springing out of my seat because I realize all Americans 
watch too much TV, and we are all insufficiently exercised. And 
of course, our children learn those behaviors from us. Growing 
up and having been in 4-H where we worked on food pyramids, we 
worked on making sure we had a balanced meal in front of us, 
and that we had different colors of food to make it a pleasing-
looking meal, it seems that those things, to me, come as second 
nature. However, I realize that in this day and age, not all 
kids are in 4-H. Not all kids learn about the food groups, 
about nutrition, and we need to return to that. And that is why 
I have been so encouraged to see, for example, ads by the 
National Football League encouraging kids to get off the couch 
and go out and exercise. There are a lot of groups that are 
pitching in to this effort, and it is important that we who are 
lawmakers, policy makers, acknowledge the public-private 
partnerships that are so positive that could further nutrition 
in this country.
    Additionally, I would like to echo Mr. Fortenberry's 
remarks. It seems to me there is such a natural alliance 
between slow food, as we are calling it now, and home-grown 
food in areas that can help young people learn about 
agriculture, learn about selecting appropriate foods, and the 
connection where their food comes from and their community, 
their health, their body, their lives. This seems like a very 
good time to be pursuing this subject. I commend you on your 
willingness to inform us today and to inform the debate today.
    Thank you, Mr. Chairman.
    The Chairman. Thank you. Congressman Schrader.

 OPENING STATEMENT OF HON. KURT SCHRADER, A REPRESENTATIVE IN 
                      CONGRESS FROM OREGON

    Mr. Schrader. Thank you, Mr. Chairman. I was going to take 
a point of personal privilege with Mr. Kagen's remarks about 
pollution starting at the lips. I thought he was talking about 
us, but he was actually talking about food in general. I 
appreciate his clarification there.
    I just hope that the panel would focus on how we can 
encourage these behaviors. There has been a lot of talk about 
health care, health care reform, and a lot of talk about 
prevention being the real key to developing these healthier 
lifestyles. So if any of the panelists could really direct us 
to some solutions or things they may want to include, as we 
move forward in health care discussion, to encourage healthy 
lifestyles in a most productive way. We like to mandate things, 
and that doesn't usually get the job done, so I would be very 
interested in the panel's remarks along those lines.
    Thank you.
    The Chairman. Congresswoman Schmidt.

  OPENING STATEMENT OF HON. JEAN SCHMIDT, A REPRESENTATIVE IN 
                       CONGRESS FROM OHIO

    Mrs. Schmidt. Thank you, Mr. Chairman. First off, I would 
just want to say to Dr. Kagen, I actually do weigh the same as 
I did in high school, but it was a lifestyle change that 
occurred with me 30 years ago.
    What I hope this panel will present is ways that we can 
encourage our young children to not only get off the couch and 
get outside and do some physical activity, but make smart 
choices on the food that they eat, because it is a lifestyle 
process, as you and I know, but we are speaking inside the 
room. We are on a dangerous course in the United States where 
our children will no longer outlive our lifetime on Earth, but 
we may outlive theirs. With the obesity rates that continue to 
climb, with the health concerns, especially with high blood 
pressure, heart disease, and diabetes, which are now growing at 
alarming rates with our youth, it is not just up to us in 
Congress to mandate a better way to have a lifestyle, but for 
all of us in the United States to promote a better lifestyle.
    While I will have to leave in a few minutes for another 
meeting, I am very encouraged by this panel and this action. I 
look forward to this great deliberation.
    The Chairman. Thank you very much. Congresswoman 
Dahlkemper.

      OPENING STATEMENT OF HON. KATHLEEN A. DAHLKEMPER, A 
          REPRESENTATIVE IN CONGRESS FROM PENNSYLVANIA

    Mrs. Dahlkemper. Thank you, Mr. Chairman. As a new Member 
of Congress and someone who was a registered dietician for over 
25 years, I just want to thank the Chairman for bringing this 
topic up as actually the first Committee hearing of this 
Congress.
    I think one of the aspects of this whole issue that 
sometimes gets buried is the whole emotional and psychological 
aspect of eating. Having worked in Early Intervention with the 
birth to 3 years of age population for many years, and knowing 
that connection and that parental/child connection, that is an 
aspect to this whole problem that also needs to be addressed. I 
hope today that that is, along with so many other great parts--
not great, but so many important parts of this discussion.
    So I am just grateful to the Chairman for holding this, and 
I really look forward to the testimony in front of us today.
    The Chairman. Thank you very much. The Chairman requests 
that other Members submit their opening statements for the 
record.
    [The prepared statement of Mr. Peterson follows:]

  Prepared Statement of Hon. Collin C. Peterson, a Representative in 
                        Congress from Minnesota
    Thank you, Chairman Baca for calling today's hearing and for 
raising this timely and important issue, which is a serious public 
health concern.
    This hearing will look at the obesity problem in the United States, 
particularly among low income Americans, many of whom participate or 
have participated in SNAP--the Supplemental Nutrition Assistance 
Program, which was previously known as the food stamp program.
    In the 2008 Farm Bill, we created and expanded a number of programs 
that will address obesity by expanding access to healthy food choices 
and increasing nutrition education efforts aimed at SNAP participants. 
The farm bill expanded the USDA Snack Program, which provides fresh 
fruit and vegetable snacks for school children and includes curricula 
to promote healthy eating. It also included a pilot project to 
encourage SNAP participants to purchase more fruits and vegetables and 
a demonstration project to evaluate strategies to address obesity in 
low income communities.
    When looking at the problem of obesity in America, there are often 
more questions than answers. But one thing is clear--the number of 
obese Americans is growing, and the cost of this problem, to the 
individuals facing obesity, their families, and their communities must 
be addressed.
    This is a serious, multifaceted problem with few simple answers, 
and I appreciate the Subcommittee's work on this issue and look forward 
to the testimony of the witnesses here today.

    The Chairman. We would like to welcome our first panel to 
the table. Dr. William Dietz, who is Director of the Division 
of Nutrition and Physical Activity and Obesity in the Center 
for Chronic Disease Control and Prevention right here in 
Washington, D.C. Dr. Dietz, could you please begin when you are 
ready, and you have 5 minutes. Then afterwards, we will have 
questions and answers from each of the Members here, based on 
when they arrive.

     STATEMENT OF WILLIAM H. DIETZ, M.D., Ph.D., DIRECTOR,
         DIVISION OF NUTRITION, PHYSICAL ACTIVITY, AND
          OBESITY, NATIONAL CENTER FOR CHRONIC DISEASE
          PREVENTION AND HEALTH PROMOTION, CENTERS FOR
 DISEASE CONTROL AND PREVENTION, U.S. DEPARTMENT OF HEALTH AND 
                  HUMAN SERVICES, ATLANTA, GA

    Dr. Dietz. Thank you, Mr. Chairman, Mr. Fortenberry, 
Members of the Subcommittee. Thank you for the opportunity to 
address the epidemic of childhood obesity. I will limit my 
comments to childhood obesity, because the entire scope of the 
epidemic is well beyond 5 minutes.
    I am Bill Dietz. I am the Director of the Division of 
Nutrition, Physical Activity, and Obesity located in CDC's 
National Center for Chronic Disease Prevention and Health 
Promotion in Atlanta. I would like to provide you with the 
latest data on the breadth of the epidemic, the health 
implications of the epidemic, and the progress that is 
occurring, as well as what remains to be accomplished.
    I have given you six slides.
    The first of these slides shows the changes in prevalence 
over the last 30 years. If you look at 1976 to 1980 and compare 
that with 1999 to 2000, you will see that there has been a two-
fold increase in the prevalence of obesity among 6 to 11 year-
olds, and a three-fold increase among adolescents, 12 to 19 
years old. The latest data suggests that among 2 to 19 year-
olds, 16 percent are obese, 15 percent are overweight. So there 
is a total of 31 percent of children and adolescents in the 
United States at risk for the complications of obesity. Those 
consequences include an increase in cardiovascular disease risk 
factors. Seventy percent of obese youth have at least one 
additional cardiovascular disease risk factor, like elevated 
insulin levels, elevated blood pressure, or elevated lipid 
levels. Thirty-nine percent of those children and adolescents 
have two or more of those complications. Type 2 diabetes 
mellitus, a disease previously limited to adults, is now 
occurring in children and adolescents. In some cities, it 
accounts for 50 percent of all new cases of type 2 diabetes.
    We know from the natural history of obesity that children 
who are overweight go on to become obese adults. As obese 
adults, they are much more severely obese than adults who 
become obese in adulthood, and therefore, have an increased 
risk of the diseases associated with obesity. There has been a 
recent paper that suggests that the deaths from obesity in 
adolescence are approximately equivalent to those deaths 
attributable to smoking, so this is not a trivial disease in 
any means.
    Now, although the costs of obesity in children and 
adolescents rate in the millions, those costs are in the 
billions for adults. In adults, those cardiovascular disease 
risks factors in children become hypertension, become 
atherosclerosis, become cardiovascular disease, and become 
cancer. The prevalence of these diseases in adults portends a 
further increase in the future costs of obesity and medical 
costs in the United States. Obesity-related diseases accounted 
for 25 percent of the increase in medical costs between 1987 
and 2001. We have a choice here. We can pay for the care of 
these diseases, or we can choose to prevent these diseases. But 
if we are to control these medical costs, prevention is 
essential. There is no way that these diseases, obesity and its 
associated diseases can be treated in medical settings. Sixty 
percent of adults are overweight or obese, 31 percent of 
children and adolescents are overweight or obese. That far 
exceeds the capacity of the medical system. We really need to 
look beyond that.
    Now, there is some modest cause for optimism. If you look 
at the second slide, this shows the changes in obesity 
prevalence by race ethnicity for boys 2 to 19 years old. There 
are a couple of observations here. The first is that among all 
three major ethnic groups studied in the National Health and 
Nutrition Examination Survey, the prevalence of obesity has 
flattened. We are at a plateau. Notice also on this figure that 
among boys, Mexican American boys are disproportionately 
affected.
    If you look at the next slide, the same thing is true for 
girls. But among girls, African American girls are 
disproportionately affected. That alone emphasizes the 
important cultural basis and linkages of obesity in children 
and adolescents.
    Coming back to this plateau, this is true for children and 
adolescents between the 85th and 95th percentile, that is 
overweight children and adolescents, obese children and 
adolescents, and also severely obese children and adolescents. 
However, this is not a cause for complacency. Thirty-one 
percent of the pediatric population is overweight or obese. 
Thirty-one percent are destined--some proportion of that 31 
percent are destined to become obese adults, and therefore 
suffer the medical consequences.
    Now, the next slide indicates the states that we are 
funding. Many of those are your states. Our challenge has been 
to figure out what we should recommend that our state programs 
do. Obesity didn't result from active decisions on the part of 
the population to eat more or exercise less. Recent 
calculations suggest that the imbalance necessary to account 
for obesity in adolescents amounts to about 150 calories per 
day. That is an easy remediable and accomplishable imbalance to 
address. But as I said before, behavior changes in large 
proportions of the pediatric and adult populations are highly 
unlikely, unless they are supported by changes in the 
environment that provide access to healthy eating and active 
living. People must make good choices, but they must have good 
choices to make.
    Place matters: Children can't walk to school in our suburbs 
because of the lack of sidewalks and centrally located schools. 
Inner city populations are surrounded by fast food restaurants 
and lack access to grocery stores. If our population is to make 
good choices, there must be good choices to make.
    Like tobacco, our focus is on policy and environmental 
changes which will change diet and physical activity, many of 
which will change practices or behaviors, but not necessarily 
be driven by increased costs. I would like to point to a few of 
those policy initiatives.
    New York City regulates group day care: About 18 months 
ago, they passed a new regulation which called for limits on 
television veiwing over the age of 2, no television veiwing for 
children under the age of 2, which is consistent with the 
recommendations the American Academy of Pediatrics. They banned 
sugar-sweetened beverages, they called for the provision of 
low-fat and no-fat milk, and they called for 60 minutes of 
physical activity a day. In a group day care, that regulation 
is likely to have a substantial impact on the prevalence of 
obesity.
    In Mississippi, the Department of Education worked with 
CDC, the Bower Foundation, and the Alliance for a Healthier 
Generation, the alliance between the Clinton Foundation and the 
American Heart Association, to develop new standards for 
snacks, they banned sugar-sweetened beverages, and replaced 
deep fryers with steamers. The school-based fresh fruit and 
vegetable snack program that was part of the farm bill makes a 
major contribution to the improved nutrition of children and 
adolescents. Among communities, the CDC funded an intervention 
in Somerville, Massachusetts, which included multiple changes 
in schools in the community, such as increasing low energy 
density foods, discouraging high fat and high sugar foods, 
enhancing the school food service, expanding pedestrian safety 
policy, and promoting a walk to school campaign. This program 
resulted in a lower rate of increase in BMI among children in 
the targeted schools than among control schools.
    One additional problem which is worth mentioning is the 
food insecurity in underserved populations may contribute to 
obesity. Hunger seems clearly associated with restricted growth 
in children and adolescents, but food insecurity may contribute 
to obesity. That is, families may make decisions to eat more 
when food is available to account for the deficits of food when 
it is not. In an era of financial instability, this becomes an 
important potential contributing problem.
    Now, the plateau is encouraging in the prevalence of 
obesity in children, but it is not enough. Thirty-one percent 
of our youth population are overweight or obese, and the 
estimates are, as you are aware, that if we don't in some way 
control medical costs and the medical costs that are 
increasingly driven by obesity, the costs of our medical system 
is going to account for 20 percent of our gross domestic 
product. We already know that insurance companies are 
struggling and employers are struggling to support these costs. 
Those are only going to increase as these children and 
adolescents go on to become obese adults. We need an integrated 
approach across multiple sectors, collaboration across agencies 
and departments, and coordinated efforts among national, state, 
and local authorities.
    In closing, I would like to thank the Committee for its 
leadership and commitment to the health of our nation's youth. 
We know that the young can achieve long-term health benefits 
from better nutrition, increased physical activity, and other 
preventive efforts. Environmental changes to make good 
nutrition and regular activity a routine part of their lives 
will take a committed, coordinated effort that must endure for 
decades to come.
    Thank you again for the opportunity to share these views 
with you.
    [The prepared statement of Dr. Dietz follows:]

Prepared Statement of William H. Dietz, M.D., Ph.D., Director, Division 
   of Nutrition, Physical Activity, and Obesity, National Center for 
 Chronic Disease Prevention and Health Promotion, Centers for Disease 
 Control and Prevention, U.S. Department of Health and Human Services, 
                              Atlanta, GA
Current Status and Activities to Decrease the Prevalence of Obesity 
        Among U.S. Children and Adolescents
Introduction
    Chairman Baca and Members of the Subcommittee, thank you for the 
opportunity to provide this statement for the record for today's 
hearing on the nation's childhood obesity epidemic. I am Dr. Bill 
Dietz, Director, Division of Nutrition, Physical Activity, and Obesity, 
located in CDC's National Center for Chronic Disease Prevention and 
Health Promotion. My statement provides you with an overview of the 
childhood obesity epidemic including updated surveillance data on youth 
overweight and obesity; the financial cost that treating overweight and 
obesity places on our healthcare system; and a description of 
integrated activities illustrating the implementation of policy 
approaches supported by the CDC to combat the childhood obesity 
epidemic.
Background
    In order to improve the health and quality of life of Americans, 
now and for the next generation, while keeping our healthcare budget 
under control, we need to invest in prevention. At every stage of life, 
eating a nutritious, balanced diet and staying physically active are 
essential for health and well-being. This is especially true for 
children and adolescents who are developing the habits they will likely 
maintain throughout their lifetime. Thus, developing effective 
population-level interventions that create supportive healthful 
environments for young people and their families is an opportunity to 
affect positive health outcomes throughout the life span.
    Childhood obesity is an epidemic in the United States, one that is 
negatively impacting the physical and emotional health of our children, 
their families and society as a whole. The multiple, complex causes of 
childhood obesity present a compelling case for integrating multiple 
disciplines in a coordinated, comprehensive effort to halt and reverse 
the epidemic. Obesity in children is defined using the Body Mass Index 
(BMI), a calculation of a child's height and weight as adjusted for 
gender and age based on CDC's Growth Charts for the United States. A 
child is considered overweight if his or her BMI is between the 85th 
and 95th percentiles, and obese if his or her BMI is greater than or 
equal to the 95th percentile.
    The prevalence of obesity among American youth increased radically 
between the 1980's and the present decade. Between 1976 and 1980, 
approximately five percent of youth 2 to 19 years of age were obese.\1\ 
In 2006, the rate had increased to 16.3 percent. In fact, obesity among 
children aged 2 to 5 years doubled, increasing from five percent to 
12.4 percent; among children 6 to 11 had doubled, increasing from 6.5 
percent in 1980 to 17.0 percent in 2006; and tripled among adolescents 
aged 12 to 19, increasing from five percent in 1980 to 17.6 percent in 
2006.\2\ Furthermore, 11.3 percent of children and adolescents aged 2 
through 19 years were found to be severely obese, that is, their BMI 
was above the 97th percentile.\3\
    There are disparities by race, ethnicity and socioeconomic status 
in the prevalence of obesity among youth. In 2004, 14.8 percent of 
children 5 and under from low-income families were obese compared to 
10.4 percent of those from moderate to high income families.\4\ Among 
males aged 12 to 19, more than 25 percent of Mexican American were 
obese, compared with 15.5 percent of non-Hispanic whites. Among females 
aged 12 to 19 years, the obesity prevalence was higher among non-
Hispanic Blacks (27.7 percent) and Mexican Americans (19.9 percent) 
compared to non-Hispanic whites (14.5 percent).\5\
    As noted previously, recent trends reveal that among all youth, the 
rate of obesity appears to have leveled; there has been no 
statistically significant increase or decrease for either boys or girls 
2-19 years of age between survey years 1999-2000 and 2005-2006. Recent 
data also show a plateau of obesity rates among U.S. children and 
adolescents that participate in the Women, Infants and Children (WIC) 
Supplemental Nutrition Program.\6\ We cannot, however, become 
complacent about this plateau. Sixteen percent of our youth remain 
obese, and we have not achieved a reduction in obesity among this 
population group.
    Obesity in adults is associated with serious health concerns that 
we are now beginning to see in children. A 2007 study reported that 70 
percent of obese young people already had at least one additional risk 
factor for cardiovascular disease, while 39 percent had at least two 
additional risk factors.\7\ And consider Type 2 Diabetes Mellitus 
(T2DM), historically referred to as `adult-onset' diabetes. Type 2 
Diabetes Mellitus was virtually unknown in children and adolescents 10 
years ago; now children and adolescents account for almost 50 percent 
of new cases of T2DM in some communities.\8\
    Childhood obesity can become a chronic condition affecting the 
individual and their families throughout their lifetime. Children and 
adolescents, who are overweight, are more likely to be overweight or 
obese as adults. One study found that after age 6, obese children have 
a greater than 50 percent chance of becoming obese adults, regardless 
of parental obesity status.\9\ In another study, obese adults who 
experienced childhood obesity before the age of 8 were more severely 
obese (had higher adult BMI) than were individuals who became obese as 
teenagers or adults.\10\ Adults who were obese as children may have 
earlier onset of co-morbidities (e.g., diabetes, cardiovascular 
disease, some cancers) and prolonged health effects from these co-
morbidities and other conditions (e.g., arthritis, reproductive health 
complications, memory loss).\11\
    The care and treatment of obesity and its co-morbidities over the 
life span can be costly. Economic data show that in 2001 dollars, 
obesity-associated annual hospital costs among youth were estimated to 
have more than tripled from $35 million in 1979-1981 to $127 million in 
1997-1999.\12\ More than 25 percent of the rise in medical costs 
between 1987 and 2001 has been attributed to obesity.\13\ Between 1987 
and 2002, the cost of obesity to private insurers increased tenfold, 
from $3.6 billion to $36.5 billion.\14\ In 2003, approximately half the 
cost of treating obesity was paid through Medicare or Medicaid.\15\ One 
reason for the higher medical costs is the prevalence of obesity-
associated co-morbidities, such as diabetes and cardiovascular disease, 
which also require treatment and management.\16\ Another contributing 
factor may be inconsistent use of and lack of uniformity in applying 
billing codes to obesity-related treatments such that bill coding 
attributes the cost of care to a co-morbidity (e.g., diabetes) rather 
than to obesity as an underlying condition).
    Some youth-targeted obesity interventions have been shown to have a 
positive return on investment. For example, Planet Health, a school-
based obesity prevention program, cost $33,677 for 1200 middle school 
students over 2 years, or $14 per student per year. An economic 
evaluation of the program found that it would prevent an estimated 1.9% 
of the female students from becoming overweight or obese adults. As a 
result, for every dollar spent on the program, $1.20 would be saved in 
future medical costs and loss of productivity costs.\17\
Monitoring Physical Activity and Nutrition
    Several sources of CDC-funded surveillance or monitoring data allow 
us to track obesity related behaviors and other risk factors among the 
nation's youth.\18\ Behaviors and risk factors monitored by CDC 
tracking systems include rates of physical activity and critical 
indicators of nutrition (e.g., fruit and vegetable consumption, 
maternal breast-feeding practices). We use these data to assess the 
health of our youth and develop relevant interventions designed to 
integrate multiple settings (i.e., communities, medical care and 
schools) in efforts to support healthier behaviors for children and 
their families.
    Recent tracking data indicate that for too many children and their 
families, proper nutrition and physical activity are not part of their 
daily lives. For example, the recently released Physical Activity 
Guidelines for Americans from the Department of Health and Human 
Services recommends that all young people ages 6 to 19 engage in 
moderate to vigorous activity that add up to 60 minutes of physical 
activity daily.\19\ Unfortunately, more than 60 percent of our young 
people do not meet this recommendation. On most days of the week, only 
34.7 percent of young people in grades nine through 12 report that they 
regularly engage in vigorous physical activity.\20\ Further, the 2005 
Dietary Guidelines for Americans encourages all Americans to daily 
consume fruits and vegetables in amounts sufficient to meet their 
caloric needs based on age, height, weight, gender, and level of 
physical activity. However, between 1999 and 2007, the percentage of 
U.S. youth in grades nine through 12 who reported eating fruits and 
vegetables five or more times per day declined from 23.9 to 21.4 
percent.\21\ These factors may have had a direct impact on the nation's 
childhood obesity rate. That students cannot meet these physical 
activity and nutrition recommendations illustrates the need to develop 
public policies that create and support environments that allow for 
regular and routine physical activity and access to healthful foods for 
our youth.
What has Contributed to the Leveling of Obesity Rates?
    The recent data showing a plateau of obesity rates among U.S. 
children and adolescents are encouraging. The cause of this plateau has 
not been scientifically determined. However, CDC notes that greater 
public awareness resulting from press and media attention to the 
problem likely contributed to the present leveling of obesity rates. 
Yet, we strive not simply to stop the increase in obesity rates, but to 
reverse the epidemic. Implementing policy and environmental change 
initiatives at the national, state and community level that have the 
potential to decrease the prevalence of youth obesity may help reverse 
the epidemic among youth and adults. Such initiatives can include:

   seeking to eliminate so-called ``food deserts'' in urban and 
        underserved areas where there is little or no access to healthy 
        foods;

   expanding public transportation services and improve road 
        conditions to allow for non-vehicle transit;

   expanding physical activity opportunities for youth; and

   improving and increasing access to healthy foods in schools 
        and communities.
CDC Activities to Prevent and Control Obesity Through Population-Level 
        Interventions
    Currently, CDC's efforts to address the obesity epidemic are 
focused on policy and environmental strategies that can improve the 
health of all U.S. children and adults by making the places in which we 
live, learn, work, play, and pray, more supportive of healthy eating 
and physical activity. Through innovative partnerships and funded state 
programs, we are identifying, implementing and evaluating a variety of 
policy and environmental strategies in order to prioritize best and 
promising practices at the community, state and national level. Our 
efforts revolve around six target areas, prioritized because they 
address a significant disease burden, are supported by reasonable or 
logical evidence, and can prevent and control obesity at the 
population-level. These six strategies include:

    1. increasing physical activity;

    2. increasing fruit and vegetable consumption;

    3. increasing breast-feeding initiation, duration, and exclusivity;

    4. decreasing television viewing;

    5. decreasing consumption of sugar-sweetened beverages; and

    6. decreasing consumption of foods high in calories and low in 
        nutritional value.

    Because some barriers to nutrition and physical activity are 
specific to particular settings (e.g., workplaces, communities, medical 
care, and schools and childcare centers), CDC seeks to develop 
strategies, tools and resources that can assist practitioners in 
providing integrated health messages and coordinated interventions to 
prevent and control childhood obesity. CDC's major program areas to 
address childhood obesity include grants for state-based Nutrition and 
Physical Activity, Coordinated School Health, as well as for Healthy 
Communities.
    Nutrition, Physical Activity and Obesity State Plans: CDC provides 
funding to twenty-three states to coordinate statewide efforts to 
address obesity through policy and environmental changes focused on 
CDC's six strategies mentioned above. The program also addresses health 
disparities and requires a comprehensive state plan. A good example of 
one of these initiatives is from Washington State. A series of 
initiatives, now known as Healthy Communities Moses Lake, have 
encouraged good nutrition and physical activity behaviors through 
environmental and policy change. Accomplishments include widening of 
sidewalks, creating an interconnected system of paths for pedestrians 
and bicyclists, and fostering an environment conducive to outdoor 
physical activity. The project also developed a community garden which 
provides residents and participants with greater access to fresh, 
nutritious produce as well as opportunities to engage in physical 
activity through gardening. In addition, to encourage good nutrition 
from birth, Healthy Communities informs residents about proper breast-
feeding practices and creates supportive environments for nursing 
mothers throughout the community.
    Coordinated School Health: CDC also funds twenty-two state-based 
education and health agencies and one tribal government to implement 
coordinated school health programs. These programs bring together 
school administrators, teachers, other staff, students, families, and 
community members to assess health needs; set priorities; and plan, 
implement, and evaluate school health activities, including those 
focused on physical activity and healthy eating among school-aged 
youth. This program fosters collaboration between state and local 
authorities, as well as between state departments of health and 
education. In Mississippi, for example, the Department of Education 
worked with CDC, the Bower Foundation, the Alliance for a Healthier 
Generation, and other partners to set new nutritional standards for 
school snacks and meal programs, and impose a ban on sugar-sweetened 
beverages. Forty-one school districts purchased 104 combination oven 
steamers, replacing the traditional deep-fat fryers and thereby 
substantially decreasing the amount of high-calorie, fatty foods eaten 
by almost 65,000 of the state's school children. Additionally, 
Wisconsin's ``Movin' and Munchin' Schools'' campaign to promote 
physical activity and healthy eating as lifetime habits resulted in 
101,641 students, 39,143 parents, and 9,265 staff reporting increases 
in physical activity and fruit and vegetable consumption.
    Healthy Communities: Since 2003, Healthy Communities (formerly 
referred to as Steps to a HealthierUS) has supported local communities 
in implementing evidence-based interventions in community-based 
settings including schools, workplaces, community organizations, health 
care settings, and municipal planning, and in achieving local changes 
necessary to prevent obesity and related risk factors. Special focus 
has been directed toward populations with disproportionate burden of 
disease. Communities receive funds to spark local-level action, change 
community conditions to reduce risk factors for obesity, establish and 
sustain state-of-the-art programs, test new models of intervention, 
create models for replication, and help train and mentor additional 
communities.
Examples of Integrated Approaches to Address Childhood Obesity
    We know that any effort to combat childhood obesity will take a 
multi-pronged approach aimed at improving population-level indicators 
of health and include not just CDC and the Federal Government, but 
states, localities and our national and local partner organizations. 
Coordinating our efforts across sectors, including education, 
agriculture, and transportation, and leveraging our resources to affect 
policy and environmental changes is necessary if we want to see obesity 
trends decrease. One such partnership is between CDC, the United States 
Department of Agriculture, and the United States Department of 
Education in a joint project called Making It Happen! School Nutrition 
Success Stories. This report tells the stories of 32 schools and school 
districts from across the United States (grades K-12) that have 
implemented innovative strategies to improve the nutritional quality of 
foods and beverages sold outside of Federal meal programs. Another 
partner in our efforts is the Alliance for a Healthier Generation, a 
joint partnership between the Clinton Foundation and the American Heart 
Association. The Alliance has worked with industry and school districts 
to develop guidelines on the provision of competitive foods and 
beverages in schools, and most recently began a new campaign working 
with national medical associations, insurers and employers to provide 
comprehensive health benefits to obese children and their families.\22\
    In addition to our partners, many cities and localities have 
started their own childhood obesity initiatives including New York 
City's Department of Health and Mental Hygiene. The city developed and 
implemented a regulation that specifically improves the nutritional and 
physical activity habits of children in the city childcare programs. 
The regulation prohibits the availability of sugar-sweetened beverages; 
permits only 6 oz. of 100% juice for children 8 months or older; 
permits children 12 months to under 2 years to have whole milk and then 
limits milk to 1% or less for children 2 years of age or older; 
requires water to be available and accessible to children throughout 
the day; requires children 12 months and older to participate in 60 
minutes of physical activity per day and for children 3 years or older 
to participate in 30 to 60 minutes of structured physical activity per 
day; and restricts television viewing for children under 2 years of 
age, and limits television viewing to no more than 60 minutes per day 
of educational programming or programs that actively engage children in 
movement to children 2 years of age or older.
    Another example can be found in Florida, where the Pinellas County 
Childcare Licensing Board requires a minimum of 30 minutes of physical 
activity, 5 days per week, for all children as a condition of childcare 
licensure. And in 2008, the state of Florida passed a law requiring 
each school district to provide 150 minutes per week of physical 
education for students in grades K to 5, and for students in the 6th 
grade when the school has one or more elementary grades. Beginning in 
2009, school districts will have to expand the physical education 
requirement so students in grades six to eight receive one physical 
education class per day each semester. The effect of these policies is 
a coordinated effort across jurisdictions and sectors to increase daily 
physical activity for all children from pre-school through the 6th 
grade. As a result, many children in Pinellas County now meet the 
national recommendation of 60 minutes of physical activity daily.
    And in California, to create healthy environments where people can 
thrive, the California Convergence has convened leaders from 26 
communities to collaboratively develop a common policy agenda, build a 
statewide communication infrastructure, influence funding strategies, 
and generate public revenue to support their work. As a result, 
officials have identified the need to improve nutrition standards in 
those places where children spend most of their time, (including 
schools, after school and childcare environments), and a broad range of 
strategies that focus on local, state and national level health impact.
    Given the challenges ahead, CDC will continue to develop and 
evaluate policy and environmental strategies to determine effective 
population-level interventions that will provide a positive impact on 
the health of our nation's youth. We applaud recent changes in Federal 
policy to support healthier eating; updating WIC program requirements 
to be more in line with the Dietary Guidelines for Americans, and the 
inclusion in the 2008 Farm Bill (Food, Conservation and Energy Act of 
2008, Public Law 110-246) of the Healthy Urban Food Enterprise 
Development Center and the school-based Fresh Fruit and Vegetables 
Program provisions. These provisions, like others implemented through 
the 2008 Farm Bill, will help incentivize the consumption of fruits and 
vegetables. Agricultural policies like these support American families 
in making healthy food choices, thereby ensuring healthier diets among 
some of our most at-risk children.
    Further, we cannot forget the impact of physical activity and 
proper nutrition on student academic achievement and classroom 
participation. A 2008 elementary school study found that physical 
activity may be associated with improved academic performance for girls 
and had no negative effect on academic achievement for elementary 
school children.\23\ And, among children living in the urban areas of 
Baltimore, Maryland and Philadelphia, Pennsylvania, those who 
participated in the School Breakfast Program increased their nutrient 
intake and were more likely to improve their academic and psychosocial 
functioning than those who did not participate in the program.\24\
    Last, we are compelled to acknowledge the causal relationship 
between food insecurity and obesity.\25\ Though it may appear 
paradoxical, families faced with food insecurity are more likely to 
augment their diet with high energy density, low nutritional value 
foods and, therefore, have high rates of obesity. Obesity is not a 
symptom of eating well but an indicator of poor diet. Persons living in 
low income communities often do not have access to fresh produce making 
foods of low nutritional value an affordable option to satiate their 
hunger. With increasing unemployment and concurrent demand on public 
and privately funded food service facilities, it is imperative that we 
pursue policies that ensure proper nutrition among persons experiencing 
the greatest obesity- related health disparities.
Conclusion
    In closing, I would like to thank the Committee for its leadership 
and commitment to the health of our nation's youth. Making balanced 
nutrition and regular activity a routine part of life will take a 
committed, coordinated effort that will need to endure for decades to 
come.
    Positively impacting the health of our youth offers promising 
prevention opportunities. We know that the young can benefit from 
better nutrition, and increased physical activity, as well as from 
other preventive efforts. While medical treatment for disease 
management is essential, our nation needs a better balance between 
treating diseases and preventing them.
    There is much we can do to prevent disease and conditions related 
to obesity that contribute so heavily to disability and death, the need 
for long-term care, and escalating health care costs. Our youth have an 
urgent need for more and better prevention policies and environmental 
change initiatives. I look forward to working with my colleagues in the 
United States Department of Agriculture to further discuss agriculture 
policies and their impact on the public's health.
    Thank you.
Endnotes
    \1\ Obesity Prevalence, Centers for Disease Control and Prevention, 
Division of Nutrition, Physical Activity and Obesity, (children 2-5 
years, 5%, children 6-11 years, 6.5%, children 12-19 years, 5%). http:/
/www.cdc.gov/nccdphp/dnpa/obesity/childhood/prevalence.htm, last 
visited March 20, 2009.
    \2\ Ogden C.L., Carroll M.D., Flegal K.M. High Body Mass Index for 
Age Among U.S. Children and Adolescents, 2003-2006. JAMA. 
2008;299(20):2401-2405.
    \3\ C.L. Ogden, M.D. Carroll, K.M. Flegal. High Body Mass Index for 
Age Among U.S. Children and Adolescents, 2003-2006. JAMA. 
2008;299(20):2401-2405.
    \4\ Polhamus B., Thompson D., Dalenius K., Borland E., Smith B., 
Grummer-Strawn L. Pediatric Nutrition Surveillance 2004 Report. 
Atlanta: U.S. Department of Health and Human Services, Centers for 
Disease Control and Prevention; 2006.
    \5\ Ogden C.L., Flegal K.M., Carroll M.D., Johnson C.L. Prevalence 
and trends in overweight among U.S. children and adolescents, 1999-
2000. JAMA 2002;288:1728-1732.
    \6\ Polhamus B., Dalenius K., Borland E., Mackintosh H., Smith B., 
Grummer-Strawn L. Pediatric Nutrition Surveillance 2007 Report. 
Atlanta: U.S. Department of Health and Human Services, Centers for 
Disease Control and Prevention; 2009.
    \7\ Freedman D.S., Mei Z., Srinivasan S.R., Berenson G.S., Dietz 
W.H. Cardiovascular risk factors and excess adiposity among overweight 
children and adolescents: The Bogalusa Heart Study. J. Pediatr. 2007 
Jan; 150:12-17.e2.
    \8\ American Diabetes Association (ADA). 2000. Type 2 Diabetes in 
Children and Adolescents. Pediatrics 105:671-80.
    \9\ Whitaker R.C., Wright J.A., Pepe M.S., Seidel K.D., Dietz W.H. 
Predicting Obesity in young adulthood from childhood and parental 
obesity. N. Engl. J. Med. 1997;337(13): 869-73.
    \10\ Relationship of Childhood Obesity to Coronary Heart Disease 
Risk Factors in Adulthood: The Bogaluse Heart Study. Pediatrics, 
2001;108(3): 712-718.
    \11\ Ferraro, K.S., R.J. Thorpe, Jr., and J.A. Wilkinson. 2003. The 
Life Course of Severe Obesity: Does Childhood Overweight Matter? 
Journals of Gerontology, Series B, Psychological Sciences and Social 
Sciences 58(2):S110-19.
    \12\ Wang G. and Dietz W.H. Economic Burden of Obesity in Youths 
Aged 6 to 17 years: 1979-1999. Pediatrics. 2002;109;e81.
    \13\ Thorpe, K.E., C.S. Florence, D.H. Howard, and P. Joski. 2004. 
The Impact of Obesity on the Rise in Medical Spending. Health Affairs, 
July-December (suppl. web excl.):W4-480-86.
    \14\ Thorpe, K.E., C.S. Florence, D.H. Howard, and P. Joski. 2005. 
The Rising Prevalence of Treated Disease: Effects on Private Health 
Insurance Spending. Health Affairs, January-June (suppl. web excl.):W5-
317-25.
    \15\ Finkelstein, E., et al. State-Level Estimates of Annual 
Medical Expenditures Attributable to Obesity. Obesity Research, January 
2004: V12. No 1: 18-24.
    \16\ Thorpe, K.E. 2006. Factors Accounting for the Rise in Health-
Care Spending in the United States: The Role of Rising Disease 
Prevalence and Treatment Intensity. Journal of the Royal Institute of 
Public Health 120:1002-7.
    \17\ Wang, L.Y., Yang, Q., Lowry, R, Wechsler, H. Economic analysis 
of a school-based obesity prevention program. Obesity Research 2003; 
11:1313-1324.
    \18\ Pediatric and Pregnancy Nutrition Surveillance System 
(PedNSS); Youth Risk Behavior Surveillance System (YRBSS); National 
Health and Nutrition Examination Survey (NHANES).
    \19\ 2008 Physical Activity Guidelines for Americans, at http://
www.health.gov/PAGuidelines/, last visited March 20, 2009.
    \20\ CDC. Youth Risk Behavior Surveillance--United States (http://
www.cdc.gov/HealthyYouth/yrbs/pdf/yrbss07_mmwr.pdf), 2007 [pdf 1M] 
Morbidity & Mortality Weekly Report 2008;57(No.SS-4).
    \21\ CDC. Youth Risk Behavior Surveillance--United States (http://
www.cdc.gov/mmwr/preview/mmwrhtml/ss5704a1.htm), 2007. Morbidity & 
Mortality Weekly Report 2008;57(SS-05):1-131.
    \22\ http://www.healthiergeneration.org.
    \23\ Carlson S.A., Fulton J.E., Lee S.M., Maynard L.M., Brown D.R., 
Kohl H.W., Dietz W.H. Physical Education and Academic Achievement in 
Elementary Schools: Data From the Early Childhood Longitudinal Study. 
Am. J. Public Health, 2008;98(4):721-727.
    \24\ Murphy J.M., Pagano M.E., Nachmani J., Sperling P., Kane S., 
Kleinman R.E. The Relationship of school breakfast to psychosocial and 
academic functioning: Cross-sectional and longitudinal observations in 
an inner-city school sample. Archives of Pediatrics and Adolescent 
Medicine 1998; 152(9); 899-907.
    \25\ Tufts University School of Medicine, Case Report, Does Hunger 
Cause Obesity. Pediatrics 1995;95:766-7; Freedman D.S., Ogden C.L., 
Flegal K.M., Kettel-Khan L., Serdula M.K., Dietz W.H. Childhood 
Overweight and Family Income. Medscape General Medicine, 2007;9(2):26.
                               Attachment
                                Slide 1


  Thank you very much, Dr. Dietz, for your testimony and for the work 
you are doing to quantify the crisis of obesity. So on behalf of all of 
    us, we would like to thank you.At this time we will begin with 
questions. Each of the Members will have 5 minutes if they wish to, and 
if not, they can yield back the balance of the time. I will begin, 
first of all, by asking a couple of questions myself, then turn it over 
to the Ranking Member.
    In your expert opinion, Dr. Dietz, of all the methods of obesity 
prevention you have seen, what type of nutrition education methods are 
most effective and why?
    Dr. Dietz. I am not very optimistic that additional nutrition 
education is going to make a big difference. It may prompt people to 
make better choices, but only if those choices are available. Many of 
the patients that I saw, when I was treating childhood obesity in 
Boston, knew the choices they should make. Those choices weren't often 
available.
    The Chairman. Okay. In part of your comment you mentioned food 
insecurity as part of it, that is why the question is there. Sometimes 
people have a tendency, not just because of having more finances, but 
in the sense when they have more finances buying a lot of the bad food 
or food that they shouldn't be buying versus because of a lack of 
security, not buying, therefore, the effects it has on them.
    Dr. Dietz. If I could interrupt, let me tell you the story of what 
prompted my interest in food insecurity. When I was in Boston, I had a 
patient, a 13 year-old girl, who lived with a single mother who was on 
welfare. Their first check of the month went for housing. By mid-month, 
they were hungry and this mother was so concerned that her daughter not 
go to bed hungry that she was feeding her pasta with added oil or 
butter. That was instrumental in causing that girl's obesity. When we 
restructured that family's diet and gave them some additional options, 
that problem began to resolve.
    So in that case, it wasn't a question of education, it was a 
question of food availability, and a uniform distribution of that food 
availability throughout the month.
    The Chairman. Thank you. As you know, this Committee has 
jurisdiction over the SNAP, which is a food stamp program.
    I am curious to know if in your research you have any data that 
might show positive effects of state nutrition educational programs 
through SNAP?
    Dr. Dietz. I am not aware of such research, but we can certainly 
let you know if we are able to identify some of that.
    The Chairman. Okay, thank you. In statistics you cite showing the 
racial increase of obesity rates from 1980 to the present day, which 
are, of course, very troubling, but it does seem like there is some 
positive news. The rate of obesity among children seemed to level off 
from the year 2000 to the present. Can we point to positive steps we 
started to take in education prevention that have led to this leveling 
of obesity rates? And then, can you also elaborate on programs that we 
used to have that also dealt with obesity, such as with physical 
education, physical exercise?
    Dr. Dietz. Sure. The principle factor influencing the plateau, in 
my opinion, is the awareness of the epidemic, in part driven by the 
maps the CDC published showing the rapid increase in adult obesity. But 
there were other positive changes that paralleled this. One is an 
increased awareness on the part of pediatric providers and changes in 
the way care is delivered. Some notable examples of that include Kaiser 
Permanente in northern California and the American Academy of 
Pediatrics initiative in the State of Maine.
    A second change was that a number of schools began to make changes 
in the period between 2000 and 2006, according to the CDC study that is 
called ``School Health Policy and Programs Survey,'' and schools began 
to reduce the availability of soft drinks and increase the availability 
of lower fat foods. That was certainly a contributing factor. 
Furthermore, we know that a number of communities have initiated 
efforts around childhood obesity. By our last count, it is in the 
neighborhood of 100 communities around the country, spontaneously, 
often supported by philanthropic organizations, have begun to intervene 
at the community level on this problem.
    The decline of physical activity and physical education in schools 
is certainly an important contributor, because schools may be one of 
the last safe places for children to be physically active, and we know 
that part of that is driven by the No Child Left Behind program. We 
recently published a paper showing that in girls, not boys, physical 
education programs in young children increased test performance, 
improved test performance. It is widely believed by teachers, whose 
judgment I trust, that physical activity improves classroom behavior. I 
think we need more data on that, but my belief is that physical 
activity improves the capacity for learning and will improve test 
performance, just as the school breakfast program does. We know that in 
order to improve test scores, many schools provide school breakfast on 
the days of testing to assure that children would perform better.
    The Chairman. Okay, thank you. I know that my time has expired, but 
one final question that I have is in reference to obesity and diabetes. 
What effect does obesity have on diabetes, and what can be done for 
prevention?
    Dr. Dietz. Obesity is a major driver of the diabetes epidemic. That 
is one of the major consequences, and if I could show you maps of the 
change in the prevalence of diabetes, they would exactly parallel 
changes in the prevalence of obesity.
    One important strategy for the prevention of type 2 diabetes in 
children and adolescents is healthier pregnancies. About 50 percent of 
type 2 diabetes that occurs in adolescence, which is where the peak of 
type 2 diabetes occurs, 50 percent of those children were exposed in 
utero to either obesity or gestational diabetes or diabetes in the 
mother during pregnancy. So a huge chunk of that diabetes could be 
prevented by more attention to pregnancy related weight gain or control 
of diabetes during pregnancy.
    That is only half of the problem. The other half comes from the 
occurrence of diabetes, particularly among minority populations. It is 
much more prevalent among Hispanic youth and African American youth.
    The Chairman. Thank you. Next, I will call on Congressman 
Fortenberry.
    Mr. Fortenberry. Thank you, Mr. Chairman, and thank you, Dr. Dietz, 
for your helpful testimony. It is packed with information, so I want to 
go back to a few statistics that should be highlighted.
    You had mentioned that approximately 25 percent of our medical 
costs either now, or in the future, will be related to this problem?
    Dr. Dietz. Twenty-five percent of the rise in medical costs between 
1987 and 2001 was attributable to obesity. These are data from Ken 
Thorpe at Emory University. The implications are that that is going to 
increase further, if you think abut what the prevalence was in 1987 and 
what it is now, and the impact that the wave of childhood onset obesity 
is going to have on adult disease.
    Mr. Fortenberry. Do you have--let us say we could cut that increase 
or the total prevalence of that statistic in half by the variety of 
things that will be suggested today, or a national awareness that this 
is serious, and an implementation of both old and new ideas about 
nutrition education access as you are suggesting. What would the 
potential health care cost savings be to our overall system? A number 
that is actually attainable in the short run.
    Dr. Dietz. We know that from a paper that we published several 
years ago that the adult--annual adult costs of obesity are about $117 
billion per year. If we were to halt the rise in prevalence, I think we 
would begin to see a decline in those costs. If we could cut obesity in 
half, I am not sure that we could reduce those costs by half, but we 
could certainly have a big impact in that reduction.
    Mr. Fortenberry. I think as we move forward, particularly in a 
legislative year, this is going to be a very important number to try to 
quantify. What is the potential improvement of health outcomes as 
related to health care costs reductions, particularly in public 
programs, that we could see if there were broader investments like we 
are all going to talk about today in nutritional outcome.
    So if you could continue to parse your data to come down to some 
number that--of course, it will depend on a lot of factors, I 
understand that--that will be helpful to quantify to get our mind 
around what the potential here is, not only just in terms of well-being 
of our population, but health care cost outcome.
    Another statistic you had mentioned, and you actually addressed it 
a bit with Chairman Baca's question, you said 60 percent of adults are 
either overweight or obese, 31 percent of children. Now, type 2 
diabetes or the rise in it--if I understood you correctly, was 
basically unheard of in this particular category of children just a few 
short years ago--related directly to the obesity problem, or are there 
other factors there?
    Dr. Dietz. The main driver is obesity. In the adolescents that I 
saw clinically when I was still in Boston, there was generally a family 
history which predisposes those individuals to type 2 diabetes----
    Mr. Fortenberry. But something must trigger that.
    Dr. Dietz. Yes, if they hadn't been obese, that would not have 
happened.
    Coming back to your question about costs, it occurs to me that we 
can provide you with some data from the Diabetes Prevention Program, 
which showed that clinical interventions for preventing diabetes were 
quite effective, that they lowered the rate of new onset diabetes by 
about 60 percent, which was more effective than medication. And I 
believe that a cost calculation was done on the cost benefits of that 
intervention, but I don't know those data off the top of my head.
    Mr. Fortenberry. That would be helpful for us as a Committee. I 
think, if I can be presumptuous and suggest that, Mr. Chairman, that we 
drive towards some number like that that gives Congress a quantifiable 
goal as a measure to potentially reduce costs in the name of health and 
well-being.
    I want to end--one more question and I will make some editorial 
comments. Could you address the benefits of local food markets as 
related to a trend toward--or a growing paradigm as we--a new paradigm 
as we look to combat obesity and the problem of being overweight? How 
helpful will this be?
    Dr. Dietz. Well, two slides that I didn't address that are in your 
handout include the six target behaviors that we think are going to 
change the prevalence of obesity. Chief among those is fruit and 
vegetable consumption. We know that people who eat fruits and 
vegetables tend to have an earlier satiety, because satiety--fullness--
is regulated by the volume of food, not by the calories in the food, 
and fruits and vegetables, because they have a high water content, are 
more filling.
    One of our interests is in how do we increase fruit and vegetable 
consumption, and one key strategy is increasing access. A great example 
of that occurred with Kaiser Permanente in northern California, which 
instituted fruit and vegetable farmers' markets in all of its major 
clinics, and these were located between the parking lot and the clinic. 
So employees who passed by could buy fruits and vegetables, patients 
who passed by could buy fruits and vegetables, and those fruits and 
vegetables were produced by small farms in the Sacramento area. So it 
was a ``three-for.'' It benefited employees, it benefited patients, and 
it benefits those small farmers.
    We believe that farm-to-market programs are an important strategy 
for increasing fruit and vegetable intake, and your initiatives in this 
regard are to be applauded.
    Mr. Fortenberry. Well again, thank you very much for your 
testimony. Mr. Chairman, if I could add just right quick, I want to 
point out that the gentlelady from Wyoming made some very important 
observations. When I was growing up, my mother was an extension 
educator, 4-H club leader, and some of these processes that we are 
trying to turn the clock back to are so normalized and with lack of 
continuity in family life, disconnection from roots in any particular 
community, the stresses in modern life, and the sociological factors as 
well that are underlying this problem.
    Thank you very much for your testimony.
    Dr. Dietz. You are welcome.
    The Chairman. Thank you. Next, I will call on Dr. Kagen.
    Mr. Kagen. Thank you. Thank you for your testimony. I am certain we 
shouldn't interpret your testimony to mean that we should blame our 
mothers if we are overweight. My mother and father used to tell me that 
if it tastes good, it is probably not good for you. I have learned a 
great deal on the Agriculture Committee. There are no more hayseeds on 
the farm. The farmers will only grow what people are willing and able 
to eat. You can't blame someone for trying to make a living producing 
food that is good for our economy and good for their businesses, 
because if it is not good for business, it will not happen.
    A couple of questions for you have to do with your opinion or 
perhaps the CDC's opinion about obesity and child abuse. Is it a form 
of child abuse to continue to feed children things that are not good 
for them?
    Dr. Dietz. Yes. Where one draws the line is the challenge, and I am 
thinking now about several patients I had when I was in Boston who had 
a very significant adverse consequence of their obesity, and those 
families, the failure of the family to implement strategies around 
weight loss, in my opinion, constituted abuse, and I filed on those 
patients.
    It is an odd form of abuse because it comes from giving too much 
rather than giving too little, and the impact of impaired parenting. 
These were parents who generally couldn't set limits on their children. 
But the abuse side was that they were overfeeding them, or failing to 
regulate their feeding. So yes, at some point, it does become abuse.
    There is another interesting relationship in adult obesity related 
to your question, and that is that among severely obese adults, there 
is a very high prevalence of early abusive behavior, such as physical, 
verbal, or sexual abuse. And that suggests that for some core of 
severely overweight patients, the kinds of policy initiatives or even 
the routine medical therapies are not going to work, that these people 
need much more intensive----
    Mr. Kagen. Well, this legislative body cannot legislate morality. 
It hasn't worked with regard to AIG or the financial markets, so we 
have a hard time when it comes to legislating things about good 
behavior. We can't legislate how food should taste. We can make 
suggestions about what might be good for people, but we also have the 
capability and the power to reward people financially for doing the 
right thing, and punish people financially for not doing the right 
thing.
    In that regard, we have taxed cigarettes because they are harmful 
to human health, and very costly to our society; we have banned 
cigarette advertisements from television. Do you think that same sort 
of approach should be taken with regard to the ``fat foods'' or foods 
that are not good for our society?
    Dr. Dietz. There are a number of states that already are taxing 
snacks and sugar-sweetened beverages. Those taxes go into the general 
revenue fund. They are not taxes that are designed to discourage 
consumption, but there have been proposals to allocate those funds to 
improve nutrition and physical activity.
    The issue of one of the relationships that is causal, in my 
opinion, for childhood obesity is television time. It appears that the 
effects of television on childhood obesity are mediated through the 
effects of television on childhood food consumption. The more 
television a child watches, the more likely they are to consume foods 
while watching television, and the more likely those foods are foods 
advertised on television. There is an initiative by the--a voluntary 
initiative on the part of businesses conducted through the Council for 
Better Business Bureaus to limit advertising directed to children and 
to establish standards for the products that are advertised to 
children. At the moment--and that is to be applauded, and that is 
worthwhile, beginning to look at what impact that has.
    Mr. Kagen. The other thing we could consider doing, and I would 
like to hear your suggestions either now or in writing later, is to 
reward families or people who purchase health insurance products or 
insurance companies that offer products to reward people financially 
for joining the YMCA for exercising. They have been very successful. We 
have a Medicare Advantage plan in the Appleton, Wisconsin region that 
actually provides for $65 a month savings if you join and attend the 
YMCA and actually get some exercise. So I am looking at your point of 
view in terms of rewarding people financially for their purchase, or 
maybe rewarding people the opposite way for their cigarette smoking and 
for their weight.
    So I would appreciate your opinion on that.
    Dr. Dietz. Sure. We would be happy to give you some feedback on 
that. There are two recent papers that were published in the Journal of 
the American Medical Association which looked at financial incentives 
for weight loss and financial incentives for smoking cessation, both of 
which were associated with very positive outcomes. I am not aware that 
that has been as carefully studied in the kind of programs that you are 
discussing. It has been studied in a more controlled fashion.
    Mr. Kagen. Thank you very much.
    The Chairman. Thank you very much. The gentlewoman from Wyoming, 
Congresswoman Lummis.
    Mrs. Lummis. Thank you, Mr. Chairman, and again, Dr. Dietz, thank 
you for being here. I want to start by asking you some questions about 
the CDC's studies.
    Do your CDC studies differentiate between urban and rural areas? Do 
you have good data to show the level of activity in rural areas versus 
urban areas, and how that may affect obesity, or other factors that 
differentiate young people especially in rural and urban areas that 
might affect obesity?
    Dr. Dietz. Yes. I must confess, we have not done as many of those 
analyses as we should, but we do have those data and we can provide you 
with data from the adult population on physical activity and fruit and 
vegetable consumption.
    Our ability to study that is quite limited. There are studies that 
demonstrate that people in urban areas do tend to walk more, they are 
more physically active, when you think about New York versus rural 
Wyoming. And the dietary history, I used to think that while people in 
rural areas were more likely to have gardens, more likely to consume 
fruits and vegetables, I don't think that is the case, but we can 
provide you with more up-to-date statistics on that problem.
    Mrs. Lummis. Okay. Thank you, I would appreciate that. That would 
be helpful.
    What about best practices? Do you have examples around the country 
of public-private partnerships that are working, or states or local 
communities that have initiated a best practice that you can share with 
us?
    Dr. Dietz. Sure. That is a critical area, and if you look at our 
target behaviors, that is exactly the direction we are following. Those 
target behaviors are increased physical activity, breast-feeding, fruit 
and vegetable consumption, reductions in sugar-sweetened beverages, 
reduction in high energy density foods, and reductions in television 
time. The process that we are engaged in, which we hope to complete in 
the next couple of months, is to identify policy or environmental 
strategy that address those behaviors, and many of those would fall 
into your promising practices or best practices category. Some of them, 
like the New York City group daycare policy, we are in the process of 
evaluating, so we will have some really hard data.
    The Guide for Community Preventive Services, which is a CDC 
publication, has identified recommended practices in the area of 
physical activity. We have very sound data on best practices within--to 
promote breast-feeding, like baby-friendly hospitals, lactation 
consultants, strategies like that. Our strategies in the other areas 
are less well-developed, but that is what we are trying to accomplish.
    To your public-private partnership question, one of the most 
notable is that my division at CDC is the Federal authority on the new 
Fruits and Veggies, More Matters campaign, and that is a public-private 
partnership with the Produce for Better Health Foundation representing 
the industry side. There are also a number of non-governmental 
organizations like the American Cancer Society and American Heart 
Association that are members of that, and it is a natural partnership 
because we are all interested in promoting increased fruit and 
vegetable intake.
    Mrs. Lummis. Thank you. Mr. Chairman, a couple more questions.
    In Wyoming, we had a terrible methamphetamine problem, terrible, 
and some substance abuse problems, unrelated to meth, that were rising, 
alcohol being the largest. And so Wyoming went on this incredible 
message campaign to just bombard people where they get their messages 
about the hazards of, particularly, drunk driving and of meth, and the 
hazards of trying meth once. And they really have had a dramatic impact 
on meth use, meth arrests, and they are beginning to have an effect on 
drunk driving because we saw such a positive response with regard to 
this intensive meth campaign. But now we are seeing it with regard to 
drunk driving as well.
    I wonder if that might work for food, where every time you turn on 
the TV or a radio or a billboard or you drive by a building that has a 
wall, you are bombarded with that message. Any response to that idea?
    Dr. Dietz. Sure. One of the best public health campaigns ever was 
the VERB campaign conducted by the CDC. This was a paid advertising 
campaign to promote physical activity in 'tweens, that is, 9 to 13 
year-olds. That program was successful in increasing the physical 
activity levels of the target population, but it was a very expensive 
campaign. And as with any behavior change information campaign, it has 
to be continuous, because the population is constantly cycling. 
Although the VERB campaign was a fabulous piece of work, our focus on 
policy and environment, we think, will be just as effective because 
once a policy is in place, you don't have to continually put money into 
the implementation of that policy. It changes behavior long-term. I 
would love to have the capacity to do a campaign around food, 
particularly fruits and vegetables.
    Mrs. Lummis. Thank you.
    The Chairman. Thank you very much for the question. Next, the 
gentleman from Oregon, Congressman Schrader.
    Mr. Schrader. Thank you, Mr. Chairman.
    I guess just mostly following up on some of my colleagues, I see a 
trend, at least it seems, in some of the questions about best practices 
and trying to identify where the biggest bang for the buck is. You have 
alluded to it yourself, and to the extent you can provide this panel 
over the course of this session and sessions to come, it would be very 
helpful. I know in the State of Oregon, we have a tremendous obesity 
problem, despite our outdoor mantra, and that has been a great concern. 
And as a state legislator, it was always difficult to choose among all 
these different strategies, which ones were to be most cost effective, 
and certainly right now, we face some budgetary issues. So, the more 
direction CDC and others can provide us, that would be very helpful.
    A question I have for you, and perhaps some of the other panelists 
to come, would be about some of the programs that we do have in terms 
of nutrition and trying to provide the nutrition, such as our SNAP 
program, such as WIC. Are there some suggestions you would have for us 
in terms of the types of food and access to beverages, and what have 
you, that we should put into these programs where you can get some 
things, can't get others? You said you can't even control that, 
frankly, but I would be curious about your thoughts.
    Dr. Dietz. There was an important report issued by the Institute of 
Medicine 2 years ago called ``Nutrition Standards for Foods in Schools: 
Leading the Way Toward Healthier Youth,'' which had a number of 
recommendations about how school nutrition programs should be changed. 
One of the most important recommendations was to make the competitive 
foods consistent with the dietary guidelines for Americans. This would 
encourage fruits and vegetables, 100 percent fruit and vegetable 
juices, whole grain products, and non-fat or low-fat dairy products, 
and limit foods sold after school to those that meet certain standards 
consistent with the dietary guidelines, like those with less than 200 
calories per serving, less than 35 percent of calories from fat, free 
of trans fat, less than 35 percent of total sugars, and sodium of less 
than 200 milligrams per portion. If those were implemented, they would 
go a long way towards improving the nutrition in schools.
    The revision of the WIC food package is also an important step 
forward to make that package much more consistent with the dietary 
guidelines as well.
    Mr. Schrader. Very good. I yield back the rest of my time, Mr. 
Chairman.
    The Chairman. Thank you very much. Next, I have the gentlewoman 
from Pennsylvania, Mrs. Dahlkemper.
    Mrs. Dahlkemper. Thank you, Mr. Chairman.
    Mr. Dietz, I wanted to ask you about the correlation between obese 
children and their parents, and what you see in terms of the genetic 
versus the environmental aspects of that.
    Dr. Dietz. Well, there certainly is an association. Part of it is 
genetic, part of it is the shared environment. We did a study of 
patients and families that were in group health a number of years ago, 
and showed that the highest risk for adult obesity--there was a higher 
risk for adult obesity among children who were born to two obese 
parents. There was about a five-fold increased risk. There was also, on 
the individual side, a rising risk as those children grew that 
eventually exceeded the risk of parental obesity. So both are in play. 
Some estimates suggest that as much as 60 percent of the family 
association of obesity is genetically mediated. That doesn't mean that 
the solution is changed. The number of genes that affect obesity seems 
to increase almost daily, and I am not sure that an investment in the 
medications that address those gene products is going to be any 
cheaper. In fact, it is likely to be much more expensive than a focus 
on the environment that promotes increased food intake and reduced 
physical activity.
    Mrs. Dahlkemper. I guess part of my question is as we have seen the 
level of obesity rise in our adult population, how has that correlated 
with our rise in childhood obesity? Did it take some time for it to 
catch up where you see that correlation?
    Dr. Dietz. The rise among certain groups of adults has paralleled 
that in the pediatric population. It is not--only about 25 percent of 
adult obesity, according to one of our studies, is accounted for by 
childhood obesity. The disproportionate contribution of childhood 
obesity is to the severity of adult disease, so even though it is a 
minority of adult disease, it accounts for a much greater proportion of 
severe adult obesity. Five percent of the adult population have a BMI 
over 40, which is 100 pounds or more overweight, and about \1/2\ of 
that population is attributable to childhood onset obesity.
    Mrs. Dahlkemper. Okay. One of your recommendations--in fact, the 
first one here was to increase breast-feeding initiation and duration 
and exclusivity with early intervention, that was the birth to 3 years 
of age population. But by the time I would see that parent and that 
child, this issue was off the table. They had either decided to breast-
feed or they had not. So, what do you see as some initiatives we could 
take in that area? What have you seen successfully done here in terms 
of----
    Dr. Dietz. Well, baby-friendly hospitals, those which don't 
routinely make formula available to mothers immediately following the 
birth of their infants have a higher rate of ongoing breast-feeding, 
both initiation and duration. A major falloff in breast-feeding occurs 
about the time that women go back to work, so equipping worksites with 
lactation rooms and fostering opportunities for new mothers to pump 
their breasts to store the milk are essential.
    As you undoubtedly know, in many places women use the ladies' room 
as a place to pump their breasts and to store breast milk. I can't 
think of any other food that is prepared in a restroom. To me, that is 
criminal.
    So those types of strategies, peer support, lactation consultants, 
because although breast-feeding is the natural way to feed infants, it 
is often unnatural for mothers to initiate breast-feeding, particularly 
with their first infant. So additional support and counseling, both 
within delivery rooms and the delivery wards, and as well as following 
discharge is essential.
    Those are all policy initiatives that would promote breast-feeding.
    Mrs. Dahlkemper. I think it is a very important piece here, and as 
a mother of five, I can tell you it often was not convenient and it 
often was not well-accepted or encouraged, and that is very central to 
the issue of so many new mothers. If they don't have that support 
there, either in the hospital or shortly thereafter, then they only 
breast-feed for a very short time. And having some kind of support 
system available to them shortly after, because that becomes the 
toughest time, and then as you say, once they return to work--and I am 
one of those mothers who went back to work and continued to breast-feed 
for a year, so I am a very big proponent of this, but I wanted to have 
you address that, so I appreciate that.
    I have just a few seconds left here in my time, and I have a lot of 
other questions. I guess one of the things I want to make a comment on, 
I heard a report of a mother who let her child walk \9/10\ of a mile to 
a sporting event and was met by the police at that field when she 
showed up 20 minutes later, because she had let her 10 year-old walk 
and supposedly endangered her child. I think this is a huge issue as we 
go forward. I am in a community where most people drive everywhere, 
whether it is three blocks to the convenience store, and when you are 
in a city like Washington or New York City people walk more. So I go 
back to Ms. Lummis's point on that, that we really need to look at 
that.
    Anyway, my time is up. Thank you.
    The Chairman. Thank you very much. Next, I will recognize the 
gentleman, for 5 minutes, from Mississippi, Mr. Childers.
    Mr. Childers. Thank you, Mr. Chairman, and Dr. Dietz, thank you for 
being here. Before I begin what I wanted to ask you, you made a comment 
earlier and I wanted you to repeat that. I missed part of it. You 
mentioned something about people's BMI index over 40--would you repeat 
what you said? I missed it.
    Dr. Dietz. Yes. About five percent of the adult population have a 
body mass index over 40; that is about 100 pounds overweight, and about 
\1/2\ of that group were obese as young children. So early childhood 
obesity or childhood obesity, even though it accounts for only about 25 
percent of adult disease, is associated with an increase in the 
severity of adult disease.
    Mr. Childers. What portion of that five percent--is that only of 
adults or children today--how many children, I guess, are we seeing as 
a society with that high of a BMI?
    Dr. Dietz. Very few, because the cut point for obesity in children 
and adolescents is based on percentiles rather than an absolute number, 
because children are growing and their BMI increases with age. But one 
of the useful cut points is the 99th percentile for BMI, maybe a more 
robust cut point is the 97th percentile. There about eight percent of 
the pediatric population somewhere in that neighborhood, and I can 
assure you that we are actually working on the precise number, are in 
that category which would correspond to the severe adult obesity. So 
that bodes ill for the future. Those are the kids that are going to 
be--that already have multiple complications, because we know that even 
in childhood the more severe obesity, the more likely you are to have 
those cardiovascular disease risk factors that I mentioned, and those 
are only going to increase and become diseases as those children grow 
and as their obesity becomes more severe.
    Mr. Childers. Thank you. I want to just state this, for the third 
year in a row, my state, Mississippi, has the highest rate of obesity 
in the nation. That is not something I am proud of, but it is a fact 
nevertheless. And almost 70 percent of our state's adult population is 
overweight. One quarter of the state's school age children are 
overweight.
    Over the past several years, our state, recognizing that, has 
implemented several programs in schools and communities, quite frankly, 
to try to combat childhood obesity, and they have had varying degrees 
of success. I guess the question I wanted to ask you was which types of 
programs are you finding to be the most successful in reducing 
childhood obesity, especially in rural communities, because we are a 
rural state and my district is rural.
    Dr. Dietz. I can't answer that question for rural communities. In 
fact, Mississippi is a place where we hope to learn some of those 
answers. As you know, CDC is funded to develop a project in the Delta. 
I mentioned earlier the work that the Bowers Foundation is doing in 
northern Mississippi. What those programs need is a careful evaluation 
to determine what works.
    We know from other community studies that multi-disciplinary and 
multi-sectoral approach with more than just one strategy is most likely 
to be effective, and I mentioned Somerville, Massachusetts, as one good 
example of that. But if you target any single one of the behaviors that 
we think are relevant, we don't believe that that alone is going to 
turn the tide of obesity. It is not going to make a difference. You 
have to have a comprehensive, multi-sectoral program if we are going to 
succeed at this. And the experience from communities which are 
successfully beginning to control obesity worked. Another good example 
is El Paso, Texas, which was supported by the Paso del Norte Health 
Foundation, and they coupled a catch program, an intervention within 
schools with a walking program in the community and cooking lessons for 
moms. In this predominantly Hispanic population, they showed a 
successful reduction in the prevalence of obesity, particularly among 
younger children who were exposed to that program for a longer period 
of time.
    Mr. Childers. On a lighter note, it has been within only my adult 
lifetime in Mississippi that we learned you can cook chicken in a 
manner that is not frying it. We have learned that.
    The Chairman. Thank you very much. I noted the time and I would 
like to thank Dr. Dietz for your testimony here today. I think it was 
very informative for a lot of us, especially as we address the area of 
obesity. One of the areas that we would love to follow up on, because 
as we look at the bill that we are going to have on health issues, and 
looking at the cost factors and looking at how we may be able to reduce 
that. Ultimately we, the taxpayers, end up having to pay for someone 
else. And if we can do more of the prevention and education that needs 
to be done, especially, at different ages, and diversity and the impact 
they have, it tells us that we still need to do a lot more in these 
areas.
    Again, Dr. Dietz, thank you very much for coming here.
    What we will do now is call on the next panel to come up, because 
they will be calling votes shortly. What we will do is we will have the 
panelists go through and give their testimony, and each one of you will 
have 5 minutes, and then after that, we will proceed with any kinds of 
questions if a vote is not called.
    So if the other panelists can come forward? And in the interest of 
time, we will start with Anne Wolf, and introduce yourself and who you 
represent, and then we will do the same with each one when we get to 
you, in the interest of time.

          STATEMENT OF ANNE M. WOLF, M.S., R.D., INSTRUCTOR OF
              RESEARCH AND ICAN INTERVENTION TEAM LEADER,
               UNIVERSITY OF VIRGINIA SCHOOL OF MEDICINE,
                          CHARLOTTESVILLE, VA

    Ms. Wolf. My name is Anne Wolf. I am from the University of 
Virginia School of Medicine. Thank you for inviting me to speak today, 
Congressman Baca and Members of the Subcommittee. Testifying before 
this Subcommittee is particularly important for me, because as one of 
three children, raised by a single mother, we relied on food stamps 
during a couple times. I am particularly grateful to the government for 
really helping our family out during tough times, because it really did 
make a difference. While we didn't have much, I never went hungry and I 
was really able to focus on my schoolwork, and that eventually led me 
into Cornell University and the Harvard School of Public Health, and 
into the career of fighting obesity. And so I am honored today to 
testify in front of you about the economic costs of obesity.
    There are now well over 120 published studies on the cost of 
obesity and the cost effectiveness of treatment of obesity. Studies 
consistently demonstrate five important things.
    The first is that the cost of obesity is significant to our health 
care bill in the United States.
    Second, the cost is driven by obesity severity, its prevalence, as 
well as its relationship to chronic disease.
    Third, the government is paying a huge percentage of this health 
care bill.
    Fourth, employers are hit particularly hard, because not only does 
obesity increase health care costs, but it impacts productivity and 
disability.
    And fifth, there is treatment that is effective and cost effective.
    The direct cost of obesity inflated to 2008 dollars is 
approximately $77 to $118 billion a year. This is approximately 1.7 
times the cost of stroke and 1.4 times the cost of hypertension in the 
United States. Obesity outranks both smoking and problem drinking in 
its deleterious effects on health and on health care costs. In 
addition, 39 million workdays are lost, 239 million restricted activity 
days, and 89 million bed days are lost or attributable to obesity in 
1994.
    Higher medical expenses are associated with the severity of excess 
weight. As body weight increases from overweight to obese, severe 
obesity, health care costs rise. Per capita medical spending for people 
who are overweight are 14 percent higher, for people who are obese, it 
was 47 percent higher, and for those who are severely obese, their 
health care expenses were doubled compared to people with a healthy 
body weight.
    The rise in health care expenditures is found across every single 
type of service, from inpatient utilization to outpatient services, to 
procedures, to increased pharmaceutical use. Among children, the 
proportion of hospital discharges with obesity-related diseases 
increased dramatically from 1979 to 1999. A recent report identified 
that the growing prevalence of obesity as a primary factor responsible 
for the growth of private health care spending between 1987 and 2002 
were the primary factors.
    The cost of obesity is not due to treatment costs. Obesity is not 
systematically treated in our medical care setting. One of the reasons 
for that is that it is not systematically reimbursed by CMS or any 
major health insurance companies. Most people who seek treatment have 
to pay for the majority of their expenses out-of-pocket right now.
    If we want to look at the costs by the type of payer, Medicare and 
Medicaid are paying the largest percentage, 48 percent of the cost of 
obesity that the government is paying. These costs are particularly 
high among the older population, because obesity is so highly 
associated with chronic diseases. For instance, in basic terms, obesity 
plus age is equal to chronic illness.
    If you look at excess medical care expenditures for a mildly obese 
person from age 65 to the time that they die, that person will incur an 
additional $20,000 to $50,000 of excess medical expenditures, compared 
to someone who had a healthy body weight. Again, it is Medicare that is 
picking this up.
    Now, employers are hit particularly hard. Employers as diverse as 
General Motors, Bank One, and Shell Oil have all demonstrated within 
their populations that excess weight has increased their direct medical 
care costs as well as impacted productivity and disability. The 
combined direct and indirect per capita costs of obesity to the 
employer range from approximately $175 to $2,000 among men, and 
approximately $600 to $2,200 in women; that is per person costs. 
Worksite injuries are also significantly increased. For instance, low 
back injuries were 1.4 times higher, and musculoskeletal injuries were 
1.5 times higher among obese employees compared to healthy weight 
employees.
    As Members of this Subcommittee, you really want to know what type 
of legislation would help address the obesity epidemic in a cost 
effective manner. Legislation to encourage positive food choices by 
targeting food stamp benefits towards healthy but under-consumed foods 
like fruits and vegetables----
    The Chairman. Ann, if you can sort of wrap it up. Each one has 5 
minutes, and we are about ready to get out and vote.
    Ms. Wolf. Yes, this is it--would encourage consumption of more 
fruits and vegetables.
    Last, there is evidence of intervention and medical nutrition 
therapy is not only effective, but cost effective in high risk 
populations.
    In summary, the cost of obesity is--in terms of both financial and 
human costs. The financial costs are born disproportionately by the 
Federal Government, but are felt keenly by employers. Most important 
are the personal costs incurred by the obese patient. There is a 
desperate need to disseminate programs with proven effectiveness to 
combat the financial, medical, and personal costs of obesity.
    [The prepared statement of Ms. Wolf follows:]

Prepared Statement of Anne M. Wolf, M.S., R.D., Instructor of Research 
  and ICAN Intervention Team Leader, University of Virginia School of 
                     Medicine, Charlottesville, VA
The Economic Impact of Obesity
    Congressman Baca and Congressional Members of the Subcommittee on 
Department Operations, Oversight, Nutrition, and Forestry,

    Thank you for inviting me to testify today on the economic impact 
of obesity in the United States. Testifying before this Subcommittee is 
particularly important to me. As one of three children raised by a 
single mother, I and my family relied on both food stamps as well as 
the free school lunch program. I am deeply grateful to the government 
for helping our family during those tough times, and it did make a 
difference. While we didn't have much, I never went hungry and was able 
to focus on my school work, which eventually gained me entrance into 
Cornell University and the Harvard School of Public Health, and from 
there into the fight against obesity. So, I am honored today to testify 
in front of you about the economic impact of obesity.
    Government, health care, and business leaders are concerned by the 
marked increase of overweight and obesity in the United States and the 
resulting impact on our nation's health, health care costs, and 
productivity. Most concerning is that excess weight carries major 
health risks. These conditions are associated with high costs, 
including both the direct costs of medical care and the indirect costs 
of lost productivity and disability. A recent report identified the 
growing prevalence of obesity as one of the primary factors responsible 
for the growth of private health care spending between 1987 and 2002.
    There are over 120 articles published in peer-reviewed, scientific 
journals related to the cost of obesity and cost effectiveness of 
treatment. These studies consistently demonstrate five important 
findings: first, the direct cost of obesity is dramatic and contributes 
significantly to our rising health care costs; second, the cost is 
driven by obesity's high prevalence and its relationship to chronic 
disease; third, the government is paying the largest percentage of the 
health care bill related to obesity; fourth, employers are hit 
particularly hard because obesity impacts both health care costs and 
productivity; and fifth, some treatments are both effective and cost-
effective.
    The most recent direct cost, inflated to 2008 dollars, estimates 
that at a national level, obesity (including overweight) costs the 
United States $77.3 to $117.8 \1\ billion a year, accounting for 9.1% 
of the national health care expenditure (in 1998, the year the analysis 
was undertaken). This is approximately 1.7 times the cost of stroke and 
1.4 times the cost of hypertension in America. Obesity outranks both 
smoking and problem drinking in it deleterious effects on health and 
health care costs. In addition, 39.2 million work days, 239 million 
restricted activity days and 89.5 million bed days were attributable to 
obesity in 1994, the last time this analysis was undertaken.
---------------------------------------------------------------------------
    \1\ Includes nursing home costs.
---------------------------------------------------------------------------
    Higher medical expenses are associated with the severity of excess 
weight--as body weight increases from overweight to obese to severe 
obesity, health care expenses rise. Per capita medical spending 
increases among the overweight by 14.5%, among the obese by 37.4% and 
by 100%--or doubled--among the severely obese, compared to people with 
a healthy body weight. The rise in health care expenditures with higher 
weight occurs across all of the major categories of health care 
services. Obesity has been associated with higher inpatient utilization 
as well as more outpatient services, procedures and prescription 
medication use. Among children (age 6-17 years), the proportion of 
hospital discharges with obesity-related diseases increased 
dramatically from 1979 to 1999. The cost of obesity is not due to 
direct treatment costs--obesity is not systematically treated in the 
medical setting because it is not systemically reimbursed by CMS or 
health insurance companies. Most people who seek treatment have to pay 
out of pocket for the majority of their expenses.
    If one looks at cost by type of payer (private, out-of-pocket, and 
government-sponsored), Medicaid and Medicare combined pay the largest 
percentage--48%--of the cost of obesity. The costs of obesity are 
particularly high among the older population because chronic medical 
conditions such as diabetes and heart disease are so highly associated 
with excess weight and advancing age. In basic terms, obesity + age = 
chronic illness. If you look at excess Medicare expenditures for a 
mildly obese person [among a person with a body mass index (BMI) 
between 30-35 kg/m2,] from age 65 to death, that person will 
incur approximately $20,000-$50,000 additional dollars compared to 
someone with a healthy body weight.
    The costs of obesity to the employer are even more substantial 
since obesity is associated not only with higher health care costs but 
also with greater rates of lost productivity, disability and earlier 
mortality. Employers as diverse as General Motors, Bank One and Shell 
Oil have all demonstrated that excess weight is associated with lost 
productivity and greater medical and disability costs. Aggregating the 
direct and indirect costs of obesity to the employer the additional per 
capita costs to the employer due to excess weight ranged from $175 
[(overweight)] to $2,027 [(class III obesity)] in men and $588 
[(overweight)] to $2,164 [(class III obesity)] in women, depending on 
the degree of overweight and obesity. Obesity also imposes limitations 
while at work. Data from the 2002 National Health Interview Survey 
(NHIS) show that 6.9% of obese workers have work limitations, compared 
with 3.0% of workers with a healthy body weight. Worksite injuries are 
also significantly higher among overweight employees; low back injuries 
were 1.42 times higher and non-back musculoskeletal injuries were 1.53 
times higher among overweight and obese employees compared with 
employees with a healthy body weight. Last, overweight and obesity is a 
significant predictor of transition from short-term to chronic back 
pain. Overweight employees have a 56% greater chance for developing 
chronic back pain and obese employees have an 85% greater risk compared 
with healthy-weight employees.
    As Members of this Subcommittee, you may want to know what type of 
legislation would help address the obesity epidemic in a cost effective 
manner, given your charge with food stamps and oversight of 
agriculture. There is evidence that lifestyle intervention--education 
and behavior change programs to improve diet quality and increase 
physical activity with resultant weight loss--is cost effective in high 
medical risk populations. There is also evidence that the addition of 
medical nutrition therapy to usual medical care can reduce health care 
costs, improve absenteeism and disability, and have a positive return 
on investment. For example, from the work we have done at the 
University of Virginia, for every dollar spent on lifestyle 
intervention with a registered dietitian among people with obesity and 
diabetes, there is a $14.58 return on investment.
    In summary, the cost of the obesity epidemic is enormous, in terms 
of both the financial costs and human costs. The financial costs are 
borne disproportionately by the Federal Government, but are felt keenly 
by employers as well. Most important are the personal costs to the 
individual suffering from obesity. There is a desperate need to 
promulgate programs with proven effectiveness to combat the financial, 
medical, and personal costs of obesity.
Relevant Published Papers

    1. Daviglus M.L., Liu K.L., Yan L.L., Pirzada A., Manheim L., 
        Manning W., Garside D.B., Wang R., Dyer A.R., Greenland P., 
        Stamler J. Relation of body mass index in young adulthood and 
        middle age to Medicare expenditures in older age. JAMA. 
        2004;292(22):2743-2749.

    2. Finkelstein E.A., Fiebelkorn I.C., Wang G. National medical 
        spending attributable to overweight and obesity: How much, and 
        who's paying? Health Aff. 2003;W3:219-226.

    3. Finkelstein E.A., Fiebelkorn I.C., Wang G. State-level estimates 
        of annual medical expenditures attributable to obesity. Obes. 
        Res. 2004;12(1):18-24.

    4. Sturm R. The Effects of Obesity, Smoking and drinking on medical 
        problems and costs. Obesity outranks both smoking and drinking 
        in its deleterious effects on health and health costs. Health 
        Aff. 2002;21:245-253.

    5. Thorpe K.E., Florence C.S., Howard D.H., Joski P. The impact of 
        obesity on rising medical spending. Health Aff. 2004;W4:480-
        486.

    6. Wee C.C., Phillips R.S., Legedza A.T.R., Davis R.B.; Soukup 
        J.R., Colditz G.A., Hamel M.B. Health care expenditures 
        associated with overweight and obesity among U.S. adults: 
        importance of age and race. Am. J. Public Health. 
        2005;95(1):159-165.

    7. Wolf A.M., Colditz G.A. Current estimates of the economic cost 
        of obesity in the United States. Obes. Res. 1998;6:97-106.

    8. Wang G., Dietz W.H. Economic burden of obesity in youths aged 6 
        to 17 years: 1979-1999. Pediatrics. 2002;109(5):E81-1.

    9. Wang G., Dietz W.H. Economic Burden of Obesity in Youth age 6-17 
        years: 1979-1999. Pediatrics 2002;109:81-87.
Indirect Cost Related To Obesity
    1. Burton W.N., Chen C.Y., Schultz A.B., Edington D.W. The Economic 
        Costs Associated With Body Mass Index in a Workplace. J. Occup. 
        Environ. Med. 1998;40(9):786-792.

    2. Tucker L.A., Friedman G.M. Obesity and absenteeism: An 
        epidemiologic study of 10,825 employed adults. Am. J. Health 
        Promot. 1998;12:202-207.

    3. Finnkelstein E.A., Fiebelkorn I.C., Wang G. The Costs of Obesity 
        among Full-time Employees. Am. J. Health Promot. 2005;20:45-51.
Obesity Intervention: Lifestyle Intervention Cost Analyses 
    1. Herman W.H., Hoerger T.J., Brandle M., et al; Diabetes 
        Prevention Program Research Group. The cost-effectiveness of 
        lifestyle modification or metformin in preventing type 2 
        diabetes in adults with impaired glucose tolerance. Ann. 
        Intern. Med. 2005;142:323-332.

    2. Wolf, A.M., Siadity, M., Yaeger, B., Conaway, M.R., Crowther 
        J.Q., Nadler, J.L., Bovbjerg, V.E. Effects of Lifestyle 
        Intervention on Health Care Costs: The ICAN Project. J. Am. 
        Diet. Assoc. 2007;107(8):1365-73.

    3. Wolf, A.M., Siadity, M., Crowther J.Q., Nadler, J.L., Wagner 
        D.L., Cavalieri S., Elward K., Bovbjerg, V.E.: Impact of 
        Lifestyle Intervention on Lost Productivity and Disability: 
        Improving Control with Activity and Nutrition (ICAN) JOEM 
        2009;51:139-145.

    4. Wolf A.M., Crowther J.Q., Nadler J.L., Bovbjerg V.E. The Return 
        on Investment of a Lifestyle Intervention: The ICAN Program. 
        Accepted for presentation at the American Diabetes Association 
        69th Scientific Sessions (169-OR), 7 June, 2009, New Orleans, 
        Louisiana.
Food Stamps and Obesity
    1. Food Stamps and Obesity: What We Know and What It Means at 
        http://www.ers.usda.gov/AmberWaves/June08/Features/
        FoodStampsObesity.htm.

    2. Improving Food Choices--Can Food Stamps Do More? at http://
        www.ers.usda.gov/AmberWaves/May07SpecialIssue/Features/
        Improving.htm.

    3. Gleason, Philip M., Allison Hedley Dodd. School Breakfast 
        Program but not School Lunch Program participation is 
        associated with lower body mass index. Journal of the American 
        Dietetic Association, 2009. Vol. 109 (2,S1):S118-128.

    4. Ver Ploeg, M., L. Mancino, B-H. Lin and J.F. Guthrie. U.S. Food 
        Assistance Programs and Trends in Children's Weight. 
        International Journal of Pediatric Obesity, 3(1):22-30, 2008.

    The Chairman. Thank you very much. Next, we will have 
Richard Hamburg, Director of Governmental Relations, Trust for 
America's Health, in Washington, DC.

          STATEMENT OF RICHARD S. HAMBURG, DIRECTOR OF
 GOVERNMENT RELATIONS, TRUST FOR AMERICA'S HEALTH, WASHINGTON, 
                              D.C.

    Mr. Hamburg. Good morning, everyone. I would like to thank 
the Chairman, Ranking Member, and Members of the Subcommittee 
for the opportunity to testify on a very serious issue, our 
nation's obesity epidemic. Glad to see it was the first hearing 
of the year for this panel.
    To examine obesity rates and policies each year, Trust for 
America's Health publishes a report on obesity entitled ``F as 
in Fat, How Obesity Policies Are Failing in America.'' Our 2008 
report found that adult obesity rates increased in 37 states in 
the past year. No state saw a decrease. In addition to the 
serious health impacts associated with this disease, for 
example, type 2 diabetes rates, rose in 26 states. According to 
the Department of Health and Human Services, obese and 
overweight adults cost the U.S. anywhere between $70 and $117 
billion each year.
    The current rise in food prices, coupled with the economic 
recession, raises serious concerns about obesity as the high 
cost of many healthful foods can be prohibitive for some 
Americans. In fact, nutritionists are now worried that 
Americans will put on so-called ``recession pounds,'' pointing 
to studies linking obesity and unhealthy eating habits to low 
income.
    The problem is so far reaching it is becoming a problem for 
our overstretched military. Just this week, the Department of 
Defense reported that one in five military-aged Americans are 
too overweight to qualify for the Armed Services. That is 
48,000 overweight recruits that have been turned away, just 
since 2005.
    Unfortunately, as in many other health problems for our 
nation, obesity often disproportionately affects minorities and 
the poor, partly due to the fact that calorie-dense foods tend 
to be less expensive. In addition, access is a serious problem, 
as many families live in communities as we have heard referred 
to as food deserts, because they do not have access to healthy 
foods and mainstream grocery outlets.
    To address this problem, innovative organizations, such as 
the Food Trust, have been working to increase access to 
nutritious foods in underserved communities. The Food Trust 
provided policy recommendations that led to the creation of the 
Pennsylvania Fresh Food Financing Initiative, a grant and loan 
program to encourage supermarket development in underserved 
neighborhoods throughout the state. The initiative has 
committed more than $67 million for 69 supermarket projects in 
27 Pennsylvania counties, also creating and preserving 3,900 
jobs.
    We must continue to build upon this progress and build upon 
the work of this Committee by providing financial incentives 
for supermarkets in low-income neighborhoods with little access 
to healthy foods, encouraging farmer's markets to accept SNAP 
electronic benefits cards, WIC vouchers and senior farmers 
market nutrition program vouchers, and work with schools to 
improve healthy options.
    Obesity is a multi-faceted problem with diverse causes and 
impacts across all sectors of society that has taken decades to 
become a full-fledged epidemic. To begin to mitigate and 
ultimately reverse this epidemic, we will need a sustained 
commitment over time to invest in population-based prevention 
strategies and coordinate our efforts. We need a cultural 
shift, one in which healthy environments, physical activity and 
healthy eating become the norm.
    This past July, Trust for America's Health released a 
report entitled ``Prevention for Healthy America,'' which 
examined how much the country could save by strategically 
investing in community disease prevention programs. The report 
concludes that an investment of $10 per person each year, 
improving community-based programs to increase physical 
activity, prevent smoking and other tobacco use, sound 
nutrition could save the country more than $16 billion annually 
within 5 years. We must invest in effective evidence-based 
community-based prevention programs, promote increased physical 
activity, and sound nutrition.
    Now, while states and localities have been hard at work, 
and currently, 40 states have plans and strategies to lower the 
prevalence of overweight and obesity-related chronic diseases, 
no such national strategy currently exists at the Federal 
level. We strongly support the development of a national 
strategy to combat obesity. This needs to be a comprehensive, 
realistic plan that involves every department and agency of the 
Federal Government, state and local governments, businesses, 
communities, schools, families, and individuals. In fact, 
Representatives Towns and Granger will be reintroducing a bill 
that encompasses this recommendation in the coming weeks, and I 
encourage support for this approach.
    In conclusion, our country needs to focus on developing 
policies that help Americans make healthier choices about 
nutrition and physical activity. We know that even small 
changes can make a difference in people's health, and that 
individuals don't make decisions in a vacuum. If we want 
Americans to lead healthy, productive lives, we need a strong 
partnership with government, private, and non-profit sectors as 
well as parents and teachers to emphasize wellness and enhanced 
physical activity. We need to remove barriers to healthful 
living by making healthy choices easy choices by creating 
opportunities for exercise and healthy living. The challenge is 
a big one, but we can make a difference together.
    Thank you again for the opportunity to testify here today.
    [The prepared statement of Mr. Hamburg follows:]

   Prepared Statement of Richard S. Hamburg, Director of Government 
        Relations, Trust for America's Health, Washington, D.C.
    Good afternoon. My name is Richard Hamburg, and I am the Director 
of Government Relations for Trust for America's Health (TFAH), a 
nonpartisan, nonprofit organization dedicated to saving lives by 
protecting the health of every community and working to make disease 
prevention a national priority. I would like to thank the Chairman, the 
Ranking Member and the Members of the Subcommittee for the opportunity 
to testify on a very serious issue--our nation's obesity epidemic. 
Today I would like to discuss the scope of obesity in America, the 
potential factors that may be contributing to it, the health and 
economic impacts of obesity, and the importance of developing a 
national strategy to coordinate our response to obesity.
Scope of the Problem
Adult Obesity
    Approximately \2/3\ of American adults are obese or overweight. To 
examine obesity trends each year, TFAH publishes a report on obesity 
entitled ``F as in Fat: How Obesity Policies Are Failing in America.'' 
The 2008 report, based on the Centers for Disease Control and 
Prevention's (CDC's) Behavioral Risk Factor Surveillance Survey (BRFSS) 
2005-2007 data, found that adult obesity rates increased in 37 states 
in the past year. No state saw a decrease. More than 25 percent of 
adults are obese in 28 states, and more than 20 percent of adults are 
obese in every state except Colorado. A study published in the July 
edition of Obesity estimates that 86 percent of Americans will be 
overweight or obese by 2030.
Childhood Obesity
    Overall, approximately 23 million children are obese or overweight, 
and rates of obesity have nearly tripled since 1980, from 6.5 percent 
to 16.3 percent.\1\ Eight of the ten states with the highest rates of 
obese children are in the South.\2\ According to a recent analysis from 
the National Health and Nutrition Examination Survey (NHANES), the 
number of U.S. children who are overweight or obese may have peaked, 
after years of steady increases. According to researchers from the CDC, 
there was no statistically significant change in the number of children 
and adolescents (aged 2 to 19) with high BMI for age between 2003-2004 
and 2005-2006.\3\ This is the first time the rates have not increased 
in over 25 years. Scientists and public health officials, however, are 
unsure if the data reflect the effectiveness of recent public health 
campaigns to raise awareness about obesity and increased physical 
activity and healthy eating among children and adolescents, or if this 
is a statistical abnormality. Scientists expect to know more when the 
2007-2008 NHANES data are analyzed. Even if childhood obesity rates 
have peaked, the number of children with unhealthy BMIs remains 
unacceptably high, and the public health toll of childhood obesity will 
continue to grow as the problems related to overweight and obesity in 
children show up later in life.\4\
---------------------------------------------------------------------------
    \1\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass 
Index for Age among U.S. Children and Adolescents, 2003-2006.'' Journal 
of the American Medical Association 299, no. 20 (2008): 2401-2405.
    \2\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, Maternal and Child Health Bureau. National 
Survey of Children's Health 2003. Rockville, MD: U.S. Department of 
Health and Human Services, 2005, http://www.mchb.hrsa.gov/overweight/
techapp.htm (accessed April 22, 2008).
    \3\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass 
Index for Age among U.S. Children and Adolescents, 2003-2006.'' Journal 
of the American Medical Association 299, no. 20 (2008): 2401-2405.
    \4\ U.S. Department of Health and Human Services, National Center 
for Health Statistics. Prevalence of Overweight Among Children and 
Adolescents: United States, 1999. Hyattsville, MD: National Center for 
Health Statistics; 2001. http://www.cdc.gov/nchs/products/pubs/pubd/
hestats/overwght99.htm. (accessed July 14, 2008).
---------------------------------------------------------------------------
Impacts of Obesity
Health Impacts
    Obesity and overweight are associated with a number of serious 
chronic conditions. More than 80 percent of people with type 2 diabetes 
are overweight. People who are overweight are more likely to suffer 
from high blood pressure, high levels of blood fats, and high LDL 
(``bad'') cholesterol--all risk factors for heart disease and stroke. 
Obesity is a known risk factor for the development and progression of 
knee osteoarthritis and possibly osteoarthritis of other joints. 
Obesity may increase adults' risk for dementia and may increase the 
risk of developing several types of cancer.
    The health impacts of obesity can start at a young age. Physical 
inactivity is tied to heart disease and stroke risk factors in children 
and adolescents. A number of studies have documented how obesity 
increases a child's risk for a number of health problems, including the 
emerging onset of type 2 diabetes, increased cholesterol and 
hypertension among children, and the danger of eating disorders among 
obese adolescents.\5\ Some studies have shown that obesity and 
overweight in children also negatively affect children's mental health 
and school performance.
---------------------------------------------------------------------------
    \5\ U.S. Department of Health and Human Services (USDHHS). The 
Surgeon General's Call to Action to Prevent and Decrease Overweight and 
Obesity. Washington, D.C.: USDHHS, 2001.
---------------------------------------------------------------------------
Economic Impact
    These health impacts come at a great cost to our nation. According 
to the Department of Health and Human Services, obese and overweight 
adults cost the U.S. anywhere from $69 billion to $117 billion per 
year.\6\ One study found that obese Medicare patients' annual 
expenditures were 15 percent higher than those of normal or overweight 
patients. The cost of childhood obesity is also growing. Between 1979 
and 1999, obesity-associated hospital costs for children (ages 6 to 17 
years) more than tripled, from $35 million to $127 million.\7\
---------------------------------------------------------------------------
    \6\ U.S. Centers for Disease Control and Prevention. ``Preventing 
Obesity and Chronic Diseases Through Good Nutrition and Physical 
Activity.'' U.S. Department of Health and Human Services, http://
www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm. 
(accessed July 14, 2008).
    \7\ Ibid.
---------------------------------------------------------------------------
    The poor health of Americans of all ages is putting the nation's 
economic security in jeopardy. More than a quarter of U.S. health care 
costs are related to physical inactivity, overweight and obesity. 
Health care costs of obese workers are up to 21 percent higher than 
non-obese workers. Obese and physically inactive workers also suffer 
from lower worker productivity, increased absenteeism, and higher 
workers' compensation claims.
National Security Impact
    The problem of obesity and overweight has reduced the number of 
volunteers for military service who must meet height and weight 
requirements. At a time when military recruiters are struggling to meet 
the needs of our armed forces, we are finding more and more volunteers 
who are overweight and obese. In 1993, 25.6 percent of 18 year-old 
volunteers were overweight or obese; in 2006 that percentage rose to 
almost 34 percent.\8\ This problem continues during active duty. Each 
year between 3,000 and 5,000 service members are forced to leave the 
military because they are overweight.\9\
---------------------------------------------------------------------------
    \8\ Hsu, L.L., R.L. Nevin, S.K. Tobler, and M.V. Rubertone. 
``Trends in Overweight and Obesity among 18-Year-Old Applicants to the 
United States Military, 1993-2006.'' The Journal of Adolescent Health 
41, no. 6 (2007): 610-612.
    \9\ Cable News Network. ``Discharged Servicemen Dispute Military 
Weight Rules.'' CNN.com, September 6, 2000. http://www.cnn.com/2000/
HEALTH/09/06/military.obesity/index.html  (accessed May 2, 2008).
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Factors Contributing to Obesity Rates
    How did this problem arise? In the simplest of terms, one could 
argue this is just a matter of physics--Americans today are eating more 
and moving less, which inevitably leads to increases in weight. That is 
true, but is only a part of the story.

   We have placed kids in a less nutritious environment--it is 
        not just too much food, but too much unhealthy food that kids 
        are eating, and we have not harnessed the opportunities of the 
        school to compensate for this.

   We have placed a particular burden on our poor and minority 
        Americans, who are disproportionately overweight and obese, 
        primarily because our poverty programs have not kept up with 
        the rising cost of nutritious food; access to healthy foods is 
        often limited in poor neighborhoods, and physical activity may 
        be limited because of safety concerns or inadequate 
        recreational facilities.

   We have also created a physical environment that reinforces 
        a less active lifestyle, and we have not compensated for this 
        in the level of physical activity we promote in the schools and 
        in the workplace.

    The following is a sketch of the scope of the problem and some 
possible solutions. Our annual report on obesity, F as in Fat: How 
Obesity Policies Are Failing in America, is available at our website, 
www.healthyamericans.org, and provides a more comprehensive look at 
these issues. The 2009 edition will be released in a few months.
Nutrition
    Many American children are consuming more calories, eating less 
healthful foods, engaging in less physical activity and instead 
spending their time engaging in sedentary activities. Overall, ``added 
sugar'' consumption for Americans is nearly three times the U.S. 
Department of Agriculture's (USDA) recommended level,\10\ and 
adolescent females ages 12-15 consumed approximately four percent more 
calories in 1999-2000 than they did in 1971-1974.\11\ In 2003, a USDA 
report characterized America's per capita fruit consumption as 
``woefully low'' and noted that vegetable consumption ``tells the same 
story.'' \12\ Moreover, since the 1970's, fast food consumption in 
children has increased five-fold. In the late 1970s, children received 
approximately two percent of their daily meals from fast food; by the 
mid-1990s, that increased to ten percent. Children who consume fast 
food, as compared with those who do not, have higher caloric intake, 
more fat and saturated fat, and more added sugar.\13\
---------------------------------------------------------------------------
    \10\ Putnam, J., J. Allshouse, and L.S. Kantor. ``U.S. per Capita 
Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.'' 
Food Review 25, no. 3 (2002): 1-14.
    \11\ Briefel, R.R. and C.L. Johnson. ``Secular Trends in Dietary 
Intake in the United States.'' Annual Review of Nutrition 24, (2004): 
401-431.
    \12\ Putnam, J., J. Allshouse, and L.S. Kantor. ``U.S. per Capita 
Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.'' 
Food Review 25, no. 3 (2002): 1-14.
    \13\ Asche, K. ``Fast Foods May Increase Childhood Obesity Rates.'' 
University of Minnesota Extension. (2005). http://
www.extension.umn.edu/extensionnews/2005/fastfood.html (accessed July 
14, 2008).
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    Everything from the foods sold in schools to the presence or 
absence of grocery stores and markets selling fresh fruits and 
vegetables in communities to the foods that parents serve to their 
children can influence obesity. What occurs in schools can be 
critical--given the number of children who depend on school breakfast 
and lunch for their meals and the patterns that school food access can 
create for all children. In 2004, the Child Nutrition and WIC 
Reauthorization Act of 2004 (P.L. 108-265) required the U.S. Secretary 
of Agriculture to issue school nutrition guidelines that would ensure 
that American schoolchildren consume foods recommended in the most 
recent Dietary Guidelines for Americans (DGAs).\14\ USDA contracted 
with the Institute of Medicine (IOM) to convene a panel of experts on 
child nutrition. The IOM Committee on Nutrition Standards for School 
Lunch and Breakfast Programs will provide USDA with recommendations for 
updating the school meal programs' nutrition requirements. Once USDA 
receives the IOM recommendations, agency officials will then seek to 
incorporate them into formal USDA guidance. A final rule will take even 
longer to be issued. This delay is of considerable public health 
concern. As this process develops, TFAH urges schools to begin to work 
towards implementation of the most recent DGAs.
---------------------------------------------------------------------------
    \14\ U.S. Department of Agriculture (USDA). Incorporating the 2005 
Dietary Guidelines for Americans into School Meals. SP 04-2008. 
Washington, D.C.: USDA, 2007.
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Disparities
    Unfortunately, as with too many other health problems facing our 
nation, obesity often disproportionately affects minorities and the 
poor. African American children are almost twice as likely to be 
obese.\15\ Black and Hispanic adolescents have higher rates of physical 
inactivity (by 5-6 percentage points).\16\
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    \15\ U.S. Department of Health and Human Services, Health Resources 
and Services Administration, Maternal and Child Health Bureau. National 
Survey of Children's Health 2003. Rockville, MD: U.S. Department of 
Health and Human Services, 2005.
    \16\ U.S. Centers for Disease Control and Prevention. ``Youth Risk 
Behavior Surveillance--United States, 2007.'' Morbidity and Mortality 
Weekly Report 57, no. SS-4 (2008): 1-136.
---------------------------------------------------------------------------
    Equally disturbing, is the apparent relationship between being 
overweight and poverty. The National Survey on Children's Health (2003) 
shows that rates of overweight decline as income rises (22.4 percent of 
kids below 100% of poverty were overweight; only 9.1 percent of kids at 
400 percent or more of poverty were overweight). Similarly, rates of 
physical inactivity are greater for poor children (17% who were under 
100 percent of poverty engaged in no vigorous physical activity each 
week; only 7.8% of those at 400% of poverty fell into that category).
    Lack of access to nutritious foods is one obstacle to healthy 
eating in some low-income communities. Supermarkets are less likely to 
be accessible in poor neighborhoods, and many families live in 
communities referred to as ``food deserts'' because they do not have 
access to healthy foods and mainstream grocery outlets. To address this 
problem, innovative organizations such as the Food Trust have been 
working to increase access to nutritious foods in underserved 
communities. The Food Trust provided policy recommendations to the 
Pennsylvania legislature regarding access to supermarkets in low-income 
communities. As a result, the legislature created the Pennsylvania 
Fresh Food Financing Initiative, a grant and loan program to encourage 
supermarket development in underserved neighborhoods throughout the 
state. The Fresh Food Financing Initiative has committed more that $67 
million in funding for 69 supermarket projects in 27 Pennsylvania 
counties, creating or preserving 3,900 jobs.\17\ We must continue to 
build on this progress by providing financial incentives for 
supermarkets in low-income neighborhoods with little access to healthy 
foods; encouraging farmers' markets to accept SNAP Electronic Benefits 
cards, WIC vouchers and Senior Farmers' Market Nutrition Program 
vouchers; and working with schools to improve healthy options through 
Federal meal programs.
---------------------------------------------------------------------------
    \17\ The Food Trust. ``Supermarket Campaign.'' http://
www.thefoodtrust.org/php/programs/super.market.campaign.php.
---------------------------------------------------------------------------
    Even when healthy foods are readily available, eating healthier can 
be very expensive, whereas calorie dense foods tend to be less 
expensive. The current rise in food prices, coupled with the economic 
recession, raises serious concerns about obesity. For example, a recent 
study in the UK by Which?, a consumer group, found that 24 percent of 
UK adults feel healthier eating is now less important, with 56% saying 
price has overtaken as a priority when choosing food.\18\ Similarly, in 
the U.S. nutritionists are worried that Americans will put on 
``recession pounds,'' pointing to studies linking obesity and unhealthy 
eating habits to low incomes.\19\
---------------------------------------------------------------------------
    \18\ BBC News. ``Recession Thwarts Healthy Efforts.'' (March 11, 
2009). http://news.bbc.co.uk/1/hi/health/7934242.stm.
    \19\ Reuters. ``Will Americans Put on Recession Pounds?'' (January 
9, 2009). http://www.reuters.com/article/newsOne/idUSTRE50805W20090109.
---------------------------------------------------------------------------
    To help address this problem, it is important that we provide 
incentives for Americans to purchase healthy foods. TFAH was pleased 
with the inclusion of the provision in the Food, Conservation, and 
Energy Act of 2008 (P.L. 110-246), which provides funding to carry out 
a point-of-purchase pilot program to encourage households participating 
in the Supplemental Nutrition Assistance Program (SNAP) to purchase 
fruits, vegetables or other healthy foods. Further, the American 
Recovery and Reinvestment Act of 2009 included a 13.6 percent increase 
in the value of benefits provided through the SNAP. During these 
difficult economic times, we hope Congress will continue to support the 
nutrition needs of all Americans, particularly those who are 
economically disadvantaged.
    In particular, as Congress considers Child Nutrition and WIC 
reauthorization, we hope that Congress will increase reimbursement 
rates for school meals. As schools are faced with increasing food and 
energy costs, we must ensure that they are serving healthy meals to 
America's children and recognize that this requires a higher level of 
investment in school meal programs. Moreover, TFAH hopes that Congress 
will consider updating the national nutritional standards for school 
foods sold outside of the school meal program so that strong 
nutritional standards based on current science will apply across a 
school campus. TFAH also hopes that Congress will strengthen 
requirements for local school wellness policies, strengthen nutrition 
education, and support the implementation of the new WIC food packages, 
as well as the technology needs of the WIC program. These actions would 
help promote access to nutritious foods and increase understanding of 
the importance of nutrition, which are all necessary to mitigate the 
obesity epidemic.
An Environment That Discourages Physical Activity
    In addition to developing poor dietary habits, many children are 
becoming less physically active, which is also contributing to obesity 
and overweight. For example, 30 years ago, nearly half of American 
children walked or biked to school; today, less than one in five either 
walk or bike to school.\20\ The built environment and community design 
can have a great impact on nutrition and physical activity levels. For 
children, the placement of schools and access to safe venues for 
physical activity are particularly important. One study found that the 
primary reason that children do not walk or bike to school is because 
their school is too far away. Other concerns included too much traffic, 
no safe route, fear of abduction, crime in the neighborhood, and lack 
of convenience.\21\ TFAH hopes that Congress considers making 
improvements to the built environment and promoting non-motorized 
transit option in upcoming transportation reauthorization legislation.
---------------------------------------------------------------------------
    \20\ McDonald, N.C. ``Active Transportation to School: Trends among 
U.S. Schoolchildren, 1969-2001.'' American Journal of Preventive 
Medicine 32, no. 6 (2007): 509-516.
    \21\ U.S. Centers for Disease Control and Prevention (CDC). 
``Barriers to Children Walking and Biking to School--United States, 
1999.'' Morbidity and Mortality Weekly Report 51, no. 32 (2002): 701-
704.
---------------------------------------------------------------------------
    Furthermore, according to the CDC's latest School Health Policies 
and Programs Study, only 3.8 percent of elementary schools, 7.9 percent 
of middle schools and 2.1 percent of high schools provided daily 
physical education or its equivalent. Some attribute at least part of 
this decline in physical activity programs to the academic requirements 
of No Child Left Behind. That is unfortunate as there is growing 
evidence that fitter more active students perform better academically. 
When Congress considers reauthorization of No Child Left Behind, TFAH 
urges Congress to include provisions that promote physical education 
and physical activity throughout the school day.
Recommendations
    It is clear that obesity is a multi-faceted issue with diverse 
causes and impacts across all sectors of society. Progress can be made 
by adopting some of the provisions referenced above in various 
reauthorization bills. However, to truly begin to mitigate and 
ultimately reverse this epidemic, we will need a sustained commitment 
over time to investing in population-based prevention strategies and 
coordinating our efforts to combat obesity.
Strengthening Our Investment in Community Prevention
    Real prevention requires changing the communities in which we live 
and approaching this as a community-wide, not just an individual 
challenge. It will also be the most cost effective way to mitigate this 
epidemic. To truly tackle the obesity epidemic, we must make healthy 
choices easy choices for all Americans, regardless of where they live 
or what school they attend. We need a cultural shift, one in which 
healthy environments, physical activity and healthy eating become the 
norm.
    Last July TFAH released Prevention for a Healthier America: 
Investments in Disease Prevention Yield Significant Savings, Stronger 
Communities, which examines how much the country could save by 
strategically investing in community disease prevention programs. The 
report concludes that an investment of $10 per person per year in 
proven community-based programs to increase physical activity, improve 
nutrition, and prevent smoking and other tobacco use could save the 
country more than $16 billion annually within 5 years. This is a return 
of $5.60 for every $1. The economic findings are based on a model 
developed by researchers at the Urban Institute and a review of 
evidence-based studies conducted by the New York Academy of Medicine. 
The researchers found that many effective prevention programs cost less 
than $10 per person, and that these programs have delivered results in 
lowering rates of diseases that are related to physical activity, 
nutrition, and smoking. The evidence shows that implementing these 
programs in communities reduces rates of type 2 diabetes and high blood 
pressure by five percent within 2 years; reduces heart disease, kidney 
disease, and stroke by five percent within 5 years; and reduces some 
forms of cancer, arthritis, and chronic obstructive pulmonary disease 
by 2.5 percent within 10 to 20 years, which, in turn, can save money 
through reduced health care costs to Medicare, Medicaid and private 
payers.
Examples of Successful Interventions
    Community and school-based approaches aimed at using reducing 
obesity in the United States have already shown to be successful. The 
Child and Adolescent Trial for Cardiovascular Health (CATCH) elementary 
school program provides education for students, modifications for 
improvements in school lunches and physical education, and increased 
education for staff and teachers. Results have shown that students in 
the program consumed healthier diets and engaged in more physical 
activity.
    The town of Somerville, Massachusetts developed a comprehensive 
program called ``Shape Up Somerville'' to curtail childhood obesity 
rates. The project included partners across the community. Various 
restaurants started serving low-fat milk and smaller portion sizes; the 
school district nearly doubled the amount of fresh fruit at lunch and 
started using whole grain breads; the town expanded a local bike path 
and repainted crosswalks; and the town targeted crossing guards to 
areas where children are most likely to walk to school. Researchers 
evaluated the program after 1 year and found that children in 
Somerville gained less weight than children in surrounding communities. 
(Growing children are expected to gain some weight.)
    Another example of a coordinated approach to obesity reduction at 
the community level is the YMCA's Pioneering Healthier Communities. 
This project supports local communities in promoting healthy 
lifestyles. Examples of interventions have included offering fruits and 
vegetables and encouraging physical activity during after school 
programs; influencing policymakers to ``put physical education back in 
schools and include physical activity in after school programs''; 
building or enhancing bicycle and pedestrian trails; and increasing 
access to fresh produce in communities through community gardens, 
farmers markets and other activities.
    TFAH urges Congress to build upon these successes and to make a 
sustained investment in population-based disease prevention. If we are 
serious about combating this epidemic, we must invest in our future by 
strengthening communities and promoting prevention.
Implementing a National Strategy to Combat Obesity
    Clearly, it has taken years for the childhood obesity epidemic to 
develop, and it will take a coordinated effort over time to begin to 
mitigate it. At this time, we have no national, coordinated effort to 
combat obesity. TFAH supports the development of a National Strategy to 
Combat Obesity. This needs to be a comprehensive, realistic plan that 
involves every department and agency of the Federal Government, state 
and local governments, businesses, communities, schools, families, and 
individuals. It must outline clear roles and responsibilities. Our 
leaders should challenge the entire nation to share in the 
responsibility and do their part to help improve our nation's health. 
All levels of government should develop and implement policies to make 
healthy choices easy choices--by giving Americans the tools they need 
to make it easier to engage in the recommended levels of physical 
activity and choose healthy foods, ranging from improving food served 
and increasing opportunities for physical activity in schools to 
securing more safe, affordable recreation places for all Americans.
    The ``National Strategy for Pandemic Influenza Planning'' provides 
a strong example for how this type of effort can be undertaken. With 
leadership and goals identified by health agencies and experts, every 
cabinet agency has taken charge of developing and implementing policies 
and programs in their jurisdiction that all contribute to our nation's 
preparedness for a pandemic flu outbreak. Similarly, the United Kingdom 
has announced an anti-obesity strategy to ``transform the environment'' 
in which people in England live, including launching a campaign to 
promote healthy living and healthy towns with bicycle and pedestrian 
routes.
Conclusion
    Our country needs to focus on developing policies that help 
Americans make healthier choices about nutrition and physical activity. 
We know that even small changes can make a big difference in people's 
health--and that individuals don't make decisions in a vacuum. If we 
want Americans to lead healthy, productive lives, we need a strong 
partnership from the government, private and nonprofit sectors, as well 
as parents and teachers, to emphasize wellness and enhance nutrition 
and physical activity. The challenge is a big one, but we can make a 
difference together. Thank you again for the opportunity to testify.

    The Chairman. Thank you very much. Next we will have Martin 
Yadrick, President of American Dietetic Association, 
Washington, DC.

 STATEMENT OF MARTIN M. YADRICK, M.S., M.B.A., R.D., F.A.D.A., 
           PRESIDENT, AMERICAN DIETETIC ASSOCIATION,
                        WASHINGTON, D.C.

    Mr. Yadrick. Good morning, Mr. Chairman, and thank you. My 
name is Marty Yadrick. I am registered dietician and President 
of the American Dietetic Association. I am honored to be here, 
and I am acutely aware that we are sitting below the portrait 
of former Chairman Kika de la Garza. Chairman de la Garza 
proudly and frequently would tell the story of getting to take 
a short trip on a U.S. nuclear submarine, part of the vanguard 
of the nation's defense. It was a long story the way the 
Chairman would tell it, so I am told, and the tale would always 
conclude with him asking his listeners what was the single 
greatest limitation on the submarine's voyages? The thing that 
brought a nuclear submarine back was running low on its supply 
of food. I can tell you that the person who decided what foods 
went on that submarine was a registered dietician. The 
registered dietician is the chosen nutrition professional of 
the U.S. military. The RD's selections would be premised on 
meeting the food's safety and nutritional requirements, and the 
pleasure of the crew. That Chairman's story seems to be a good 
starting point for my testimony today to the Committee.
    Food availability has traditionally been the concern of 
nations and of families; however, in the last 20 or so years, 
we have a new concern: overweight and obesity. They have become 
epidemic in the United States and the world. Millions of people 
are getting sick with diseases and conditions associated with 
over consumption of food. Dire related deaths are soaring. It 
is time to get serious about obesity. It is time to become 
alarmed when nearly \1/2\ of the people in the United States 
suffer from preventable chronic conditions, and when we see the 
life expectancy of our children declining from our own, largely 
due to overweight and obesity.
    Obesity is a problem that defies an easy cure. We know that 
it is a better strategy to prevent overweight and obesity, 
rather than simply attempting to treat them. That means we 
should pay particular attention to the issue of childhood 
obesity.
    ADA's own research illuminates the challenge ahead. There 
are barriers due to nutrition literacy, lack of access to 
nutrition services, and other causes. This Subcommittee is in a 
position to address barriers to better public nutrition and 
nutrition care. We recommend the Committee focus on research, 
nutrition labeling and education, and child nutrition.
    First, research. This Committee can make an enormous 
contribution by focusing on and investing in food and 
agricultural research. After all, research was a key reason 
that President Lincoln established the United States Department 
of Agriculture. Unfortunately, what once was the gold standard 
for government research has atrophied. We all have a role in 
bringing our food and agricultural research programs back so 
that they can lead the U.S. food and agricultural sector 
successfully in the 21st century.
    Government funded research is especially imperative. It is 
the basis for nearly everything we know about food, nutrition, 
and human health. The private sector does little of this kind 
of research, and the public is skeptical of much of it. Only 
the Federal Government has a public mandate to carry out 
research on human nutrition needs and motivators. The Federal 
Government has a unique responsibility to evaluate nutrition 
policies and programs.
    The second issue is nutrition education and labeling. Some 
have observed that there is a reason why we call this the 
information age, not the knowledge age or wisdom age. Consumers 
are drowning in nutrition information, yet the consumer cannot 
easily evaluate the quality of this information. As often as 
not, on their own, consumers are likely to end up misinformed.
    The United States has a statute on the books called ``The 
Nutrition Labeling and Education Act,'' a fine law that has 
never lived up to its promise. Labels are everywhere, but if 
consumers don't know how to use them and what they mean, then 
we must ask how to bridge the gap.
    The good news is that nutrition education is a worthwhile 
investment. Research documents that nutrition education has 
helped people chose and prepare healthier food options, but the 
education component of the NLEA has been chronically under-
funded by Congress and virtually ignored. Nutrition education 
has been integrated into some of the food assistance programs, 
such as SNAP and WIC, but support for nutrition education lags 
behind that for school meals and childcare settings.
    The third is child nutrition. Children need to learn, early 
in life, about choices and behaviors that will keep them 
healthy for life. They need to be taught nutrition, how to 
choose and enjoy food, and they need to be taught how and 
encouraged to engage in physical activity. They need 
reinforcement of healthy eating and activity in order to make 
healthy living a habit.
    Speaking for the American Dietetic Association, I am asking 
our elected leaders to make a paradigm shift in which 
prevention plays a more balanced role in our health system. 
Nutrition is the cornerstone of prevention.
    Thank you for holding this important hearing, and I honored 
that we have been invited to speak.
    [The prepared statement of Mr. Yadrick follows:]

Prepared Statement of Martin M. Yadrick, M.S., M.B.A., R.D., F.A.D.A., 
       President, American Dietetic Association, Washington, D.C.
    Good morning. My name is Marty Yadrick. I am a Registered Dietitian 
from Los Angeles and the President of the American Dietetic 
Association.
    ADA is the world's largest organization of food and nutrition 
professionals, with more than 69,000 registered dietitians, dietetic 
technicians, registered and advanced-degree nutritionists. Every day, 
the members of our professional association work with Americans in all 
walks of life--from before birth through old age--providing care, 
services and knowledge to help people optimize their health through 
food and nutrition.
    Others at this hearing are clearly identifying the national 
imperative to address obesity and the overall health of our population. 
I will not repeat statistics or the conclusions. I do ask that you add 
my name and that of the American Dietetic Association to the list of 
Americans who are committed to improving the health of our citizens.
    Let me urge that we begin by focusing on prevention.
    Nutrition and diet are known to be associated with seven of the top 
ten leading causes of death in the United States today, including the 
Big Three: heart disease, cancer and stroke.
    Diet and nutrition are also factors in other chronic conditions 
such as pulmonary disease, diabetes, liver disease, arteriosclerosis 
and kidney disease. Seven of every ten Americans who die each year--
more than 1.7 million people--die of chronic disease.
    Furthermore, diet and nutrition affect the mortality rates 
associated with pneumonia and influenza, septicemia, prenatal 
complications and other conditions that are leading causes of death in 
our country.
    How best to reduce the incidence of these diseases and conditions 
that take so many lives? A big step would be to re-frame our 
understanding of the role of nutrition and health in the United States 
and the world.
    Traditionally, we have tended to view nutrition in terms of the 
adequacy of the diet. And hunger remains an issue for millions of 
Americans.
    But now, the primary manifestation of malnutrition in the United 
States has become excess weight and obesity. These conditions coexist 
with and at times overshadow hunger as the most significant nutrition 
problem facing the nation.
    For those of you wondering about ``dietetics,'' there are a few 
specifics you should know. Dietetics is the science that directly 
connects food to nutrition and health. Registered dietitians study 
multiple hard and social sciences, including those that quantify 
nutrients that people need and nutrients' effects on health. But RDs 
become experts in dietetics in order to help people optimize their 
health by choosing foods in a healthful pattern of eating. Of course, 
to stay healthy, food choices need to be matched with physical activity 
and a series of personal decisions--like choosing not to smoke and 
refraining from high-risk behaviors.
    ADA is guided by a philosophy of sound science. Our association 
analyzes, publishes and disseminates scientific breakthroughs and 
information that is applied in dietetics practice every day throughout 
the nation. ADA was one of the first professional groups to embrace 
evidence-based practice, creating the world's first evidence-analysis 
nutrition library and producing guides for condition-specific nutrition 
care. ADA strongly believes that, as the public becomes knowledgeable 
and informed about food, nutrition and health, our profession can 
contribute more significantly to make Americans healthier. It is time 
that we as a nation take action to address food, nutrition and health.
    It is time to become alarmed when nearly half the people in the 
United States suffer from preventable chronic conditions and when we 
see the life expectancy of our children declining from our own--largely 
due to overweight and obesity.
    Obesity is a problem that defies an easy cure. We know that it is a 
better strategy to prevent overweight and obesity, rather than simply 
attempt to treat them. And that means that we should pay particular 
attention to the issue of childhood obesity.
    ADA's own research illuminates the challenge ahead. American 
parents have erroneous perceptions of their children's nutritional 
condition and frequently, they are disengaged from their kids' eating 
habits. Parents are reluctant to help their children because they don't 
know how to help. It has been only the luckiest of families who are 
able to see a Registered Dietitian for nutrition assessment and 
intervention where families' insurance plans will provide coverage.
    ADA's research also documents that most Americans have no idea of 
their own nutritional status, weight or eating patterns. Even when a 
diet-linked condition as serious as pre-diabetes is identified, a 
patient is likely to encounter very real barriers to professional 
nutrition care and services. To explain: Medicare is the template for 
most insurance plans. Medicare currently covers screening for pre-
diabetes. A beneficiary can be tested as frequently as every 6 months 
to check his or her status. However, there is no referral--no covered 
care by Medicare or most private insurance--until pre-diabetes 
deteriorates to full blown diabetes. Only once the diagnosis has 
reached a dire situation will Medicare meet beneficiaries' needs 
through covered diabetes services. If the patient is very lucky his or 
her physician may send them to a Registered Dietitian for Medical 
Nutrition Therapy or an accredited Diabetes Self Management Training 
program.
    So why would I call patients ``lucky'' to be referred? Fewer than 
five percent of Medicare beneficiaries eligible for MNT are referred, 
as doctors' offices frequently pass out literature rather than 
encourage the patient to get proven-effective, intensive nutrition 
assessment, personalized intervention and ongoing counseling. DSMT 
reflects similarly dismal referral statistics.
    Fortunately we have just seen the development of a pilot program to 
help overweight children see their physicians and then Registered 
Dietitians to learn better nutrition and activity habits. Several 
health insurance organizations are part of this ground-breaking effort 
which will reach nearly one million children during the first year. The 
long-term goal of the initiative is that within the first 3 years, 25 
percent of all overweight children (approximately 6.2 million) will 
have access to the benefit. This is thanks to the work of the Alliance 
for a Healthier Generation.
    This Subcommittee also is in a position to address barriers to 
better public nutrition and nutrition care. We recommend the Committee 
focus on research, nutrition labeling and education, and child 
nutrition.
Research
    The first is research. This Committee can make an enormous 
contribution by focusing on and investing in food and agricultural 
research across the board. ADA is a member of National C-FAR which 
educates how Federal research contributes to improved standards of 
living. After all, research was a key reason that President Lincoln 
established the U.S. Department of Agriculture. Unfortunately, what was 
once the gold standard for government research has atrophied. We all 
have a role in bringing our food and agriculture research programs back 
so that they can lead the U.S. food and agricultural sector 
successfully in the 21st century.
    Government-funded nutrition research is especially imperative. It 
is the basis for nearly everything we know about food, nutrition and 
human health. The private sector does little of this kind of research--
and the public is skeptical of much of it. Only the Federal Government 
has the public mandate to carry out research on human nutrition needs 
and motivators, as well as biological, epidemiological, social and 
environmental factors. The Federal Government has a unique 
responsibility to evaluate nutrition policies and programs. It's time 
to invest much needed resources into our Human Nutrition Research 
Centers. I can only imagine how much healthier we might be today if we 
had invested as much in human nutrition as we have spent for bovine, 
swine, poultry, aquaculture and other animal nutrition research over 
the years!
Nutrition Education and Labeling
    The second is nutrition education and labeling. Some have observed 
that there is a reason why we call this the ``information age'' and not 
the ``knowledge age'' or ``wisdom age.'' Consumers are drowning in 
nutrition ``information.'' Related to that is that the consumer cannot 
easily evaluate the quality of the information. As often as not, on 
their own, consumers are likely to end up misinformed.
    The United States has a statute on the books called the Nutrition 
Labeling and Education Act--a fine law that has never lived up to its 
promise. Labels are everywhere, but if consumers don't know how to use 
them and what they mean--then we must ask how to bridge the gap.
    Nutrition information does not translate into knowledge or 
knowledge necessarily into appropriate action. If labels and pamphlets 
do not lead to behavior change, then people have to be taught.
    The good news is that nutrition education is a worthwhile 
investment. Research documents that nutrition education can help people 
choose and prepare healthier food options, but the education components 
of NLEA are chronically under-funded by Congress and virtually ignored. 
Nutrition education has been integrated into some of the food 
assistance programs such as SNAP and WIC, but support for nutrition 
education lags behind for school meals and child care settings.
Child Nutrition
    Children need to learn early in life about choices and behaviors 
that will keep them healthy for life. They need to be taught nutrition, 
how to choose and enjoy food and they need to be taught how and 
encouraged to engage in physical activity. They need reinforcement of 
healthy eating and activity in order to make healthy living a habit. We 
need to teach nutrition in a way that is meaningful, culturally aware, 
individualized and personal. PSAs and motivational messages have short-
lived impact, if any.
    School environments may not be teaching healthful nutrition or even 
offering healthful choices beyond the reimbursable school meal. Rushed 
meal times, pressure to increase revenues, calorically dense vending 
and elimination of physical education all send the message that health 
is not really a priority.
    ADA recommends amendments be made to the Child Nutrition Act to:

    1. Ensure the Dietary Guidelines are the foundation of Federal food 
        assistance and nutrition programs. The Secretary of Agriculture 
        should have the authority to extend nutrition standards to all 
        foods and beverages sold on school campuses throughout the day 
        for schools that are participating in the school breakfast, 
        lunch and after school programs. You can help that happen by 
        supporting H.R. 1324, The Child Nutrition Promotion and School 
        Lunch Protection Act.

    2. Provide adequate funding for program implementation. School 
        reimbursements have fallen far behind the costs of production 
        and are inadequate to maintain the high nutrition standards 
        established in law. And adequate funding is needed to ensure 
        implementation of the new WIC food packages.

    3. Strengthen nutrition education and promotion. In the last Child 
        Nutrition Reauthorization, Congress approved the Team Nutrition 
        Network, a state-level infrastructure and networking component 
        to coordinate nutrition education activities across child 
        nutrition programs, conduct evaluations and enhance program 
        operations. Funding is now needed for the benefits of that 
        infrastructure to be realized. Nutrition education must 
        continue to be a key component of the WIC program services.

    4. Increase funding for Child Nutrition Program research. Funding 
        would allow USDA to conduct and fund research on and evaluation 
        of their programs and allow USDA's Food and Nutrition Service 
        to collaborate with research agencies in USDA and extramurally 
        to develop and implement a comprehensive research agenda.

    5. Place trained professionals in roles where they make policies. 
        Directors of the School Nutrition Program at the district level 
        should be certified as Registered Dietitians, Dietetic 
        Technicians, Registered or School Nutrition Association School 
        Nutrition Specialists. It is not simple to balance student 
        satisfaction with nutritional needs and to do so cost-
        effectively. The extension of nutrition standards to all foods 
        and beverages sold in schools, in conjunction with the local 
        wellness policy requirement, will only increase the need for 
        trained professionals in schools. Planning for nutritious 
        intakes for children with special food and nutrition needs 
        requires the biochemical and food science knowledge that only 
        registered dietitians possess in school settings. Registered 
        dietitians have the expertise needed to provide education to 
        high-risk WIC recipients.

    Speaking for the American Dietetic Association, I am asking our 
elected leaders to make the paradigm shift in which prevention plays a 
more balanced role in our health system. Nutrition is the cornerstone 
of prevention.
    As a Registered Dietitian, I can tell you that many of the most-
costly disabling conditions can be prevented through nutrition 
strategies. And with proper nutrition support, many complications can 
be averted or delayed. Federal attention to public nutrition and 
investment in nutrition care, education and research is essential. From 
these small, practical steps, great benefits may accrue to people, 
their families and the nation.
    Thank you for holding this important hearing. I am honored that I 
have been invited to speak and to learn from you and my fellow 
panelists.

    The Chairman. Thank you very much. Next we have Donna 
Mazyck, President of the Board, National Association of Nurses 
in Silver Spring, Maryland. Donna?

   STATEMENT OF DONNA J. MAZYCK, R.N., M.S., N.C.S.N., BOARD 
PRESIDENT, NATIONAL ASSOCIATION OF SCHOOL NURSES; SCHOOL HEALTH 
 SERVICES SPECIALIST, MARYLAND STATE DEPARTMENT OF EDUCATION, 
                       SILVER SPRING, MD

    Ms. Mazyck. Mr. Chairman, Mr. Fortenberry, and Members of 
the Subcommittee, I am privileged to be here today representing 
the National Association of School Nurses to speak about the 
state of obesity in our country. Through my testimony, I hope 
to relay to the Subcommittee Members how school nurses have 
daily experiences with children with severe nutrition issues, 
and other health conditions related to obesity.
    School nurses are fully aware that the fastest rising 
public health problem in our nation is obesity. Let me give you 
an example of what school nurses are addressing, drawing from 
my days as a high school nurse. One of my students went to the 
back of the health room one day to weigh herself. Before I 
could get back there to assist her, she exclaimed, this scale 
doesn't work. I had to help her understand that her weight was 
beyond the 250 pound capacity of the scale. Her weight was 
clearly a source of embarrassment to her as she endured teasing 
by classmates for her large size. I continued to work with her 
because not only was she experiencing dangerous physical 
consequences, but she was also suffering with adolescent 
emotional distress.
    Knowing that obese adolescents have up to an 80 percent 
chance of becoming obese adults, a major investment in 
prevention must take place from multiple sectors of society to 
become a healthier America. Prevention is the positive, 
logical, and most cost beneficial approach to achieve education 
goals and to prevent chronic diseases.
    I want to share with you a true story from one of our 
members that accentuates the gravity of the generational issues 
involved with obesity. It is about a current Kindergarten 
student whom I will call Connie B. It was discovered during a 
health assessment that she has a BMI in the 99.5 percentile. 
Connie is always out of breath. She has four very deep cavities 
in her teeth, and she had dark-pigmented skin folds at the back 
of her neck, a condition called Acanthosis nigricans, a 
reliable predictor of an over-production of insulin that is a 
known precursor to type 2 diabetes. This little girl is only 5 
years old. The school nurse spoke with her mother and found 
that that mother had difficulty with Medicaid coverage for her 
family of four children. There were three children younger than 
Connie, including a severely autistic child. As a single 
mother, she was overwhelmed with life, did not have access to 
medical care, and said she wished that Connie was not so fat. 
When the school nurse met Ms. B in person, she observed that 
the mother was also obese. The school nurse helped this parent 
to obtain Medicaid coverage for her child with the partnership 
of a local hospital. The school nurse helped that mother 
complete a meals assistance application, and encouraged the 
mother to allow Connie to eat her meals in school, where they 
were carefully planned and nutritionally balanced meals.
    This type of preventive approach is the best way to ensure 
that Connie won't become part of the up to 80 percent of 
adolescents who will take obesity into an adulthood filled with 
chronic, life-altering diseases.
    Schools can also contribute significantly to the other 
major factor which leads to obesity, the lack of physical 
activity. Therefore, NASN recommends a stronger emphasis on 
school wellness policies that include necessary physical 
activity for all students. Many school nurses throughout the 
country take a leadership role in the development and 
implementation of school wellness policies. NASN recommends 
that school nurses serve on every school and district wellness 
policy committee.
    I want to assure the Subcommittee that our association has 
taken on the responsibility of educating school nurses about 
childhood obesity. In fact, with seed money from the CDC and a 
cooperative agreement addressing type 2 diabetes, NASN 
developed a program known as S.C.O.P.E. It stands for School 
Nurse Childhood Obesity Prevention Education. The goal is to 
provide strategies for every school nurse to assist not only 
the students, but also the families and school community in 
addressing the challenges related to obesity. With a very 
limited budget, NASN has been able to educate about 1,200 
school nurses since 2006. We are hoping public and private 
partners will recognize the importance of school nurse 
involvement in obesity prevention, and help us increase the 
number of school nurses completing that training. We believe 
that school nurses are in a unique position to be liaisons with 
schools, parents, community members, health care professionals, 
and Federal, state, and local governments to help stop the rise 
in childhood obesity. Part of the solution is to employ school 
nurses to effectively work on a daily basis with students to 
increase their understanding of how to achieve healthy 
lifestyles.
    Thank you for this opportunity.
    [The prepared statement of Ms. Mazyck follows:]

   Prepared Statement of Donna J. Mazyck, R.N., M.S., N.C.S.N., Board
    President, National Association of School Nurses; School Health
  Services Specialist, Maryland State Department of Education, Silver 
                               Spring, MD
    Mr. Chairman, Mr. Fortenberry, and Members of the Subcommittee, my 
name is Donna Mazyck, and I am President of the National Association of 
School Nurses (NASN) and I serve the Maryland State Department of 
Education as a school health services specialist. I am privileged to be 
here today representing NASN to speak about the critical importance of 
the rise in obesity throughout the United States. I commend the 
Committee for reviewing this issue at a time when there are so many 
pressing issues. Unfortunately, obesity is an issue which can no longer 
be ignored. It is a factor related to multiple issues, including the 
economy, health care, chronic disease, nutrition, hunger, and national 
security.
    Through my testimony, I hope to relay to the Subcommittee Members 
how school nurses have daily experiences with children who have severe 
nutrition issues and other health conditions related to obesity. I will 
share stories from when I practiced as a school nurse in two Maryland 
high schools and from my current policy role as President of an 
association with nearly 14,000 members.
    School nurses are serving students in 75 percent of the U.S. public 
schools. We know first-hand that school nurses are performing duties 
today that go well beyond what school nursing was like 30-40 years ago 
when health care costs were affordable, and school children with 
complex health needs did not come to school. School nurses do not 
simply wait in their offices for a sick child to appear; rather they 
provide health services for all the students, but especially for the 
uninsured. They also provide health education, with special attention 
to nutrition and obesity. They serve children with chronic conditions 
which previously were extremely rare in children, such as type 2 
diabetes, heart disease, high blood pressure, and food allergy.
    School nurses have knowledge and expertise in the areas of 
nutrition, weight maintenance and exercise. This knowledge can be 
applied to intervention and prevention programs that help students live 
healthy and active lifestyles. The school nurse collaborates with 
students, parents, school personnel, health care providers and members 
of the community to identify students who are overweight and obese. In 
addition, the school nurse is involved with support programs, 
counseling services, referrals, and follow-up activities.
    For clarification of terminology, body mass index (BMI) is a 
practical measure used to determine overweight and obesity. BMI is a 
measure of weight in relation to height that is used to determine 
weight status. While BMI is an accepted screening tool for the initial 
assessment of body fatness in children and adolescents, it is not a 
diagnostic measure because BMI is not a direct measure of body fatness. 
The Centers for Disease Control and Prevention (CDC) defines overweight 
as a BMI at or above the 85th percentile and lower than the 95th 
percentile. Obesity is defined as a BMI at or above the 95th percentile 
for children of the same age and sex.
    NASN's membership is fully aware that the fastest rising public 
health problem in our nation is obesity because their eyes and their 
work with today's students tell them so. Over the past 3 decades, 
obesity rates have soared among all age groups, increasing more than 
four times among children ages 6 to 11. According to the Robert Wood 
Johnson Foundation (RWJF), today, more than 23 million children and 
teenagers are overweight or obese. That's nearly one in three young 
people. In fact, 16.3 percent of children and adolescents from ages 2 
to 19 are obese; with 11 percent considered extremely obese--above the 
97th percentile. Given these statistical realities, the complex medical 
issues facing school nurses are imaginable. School nurses are now 
addressing the typical adult ailments of high blood pressure, type 2 
diabetes, sleep apnea, and gallstones in their elementary and 
adolescent students.
    Let me give you an example of what school nurses are addressing--
drawing from my days as a high school nurse. One day a student entered 
the health room and asked if she could weigh herself on the scale in 
the back of the room. I directed her to the scale, but before I could 
get back there to assist her, she exclaimed. ``This scale doesn't 
work!'' When I walked over to her, I realized that her weight was over 
250 pounds, which was the highest measure registered on the scale. Her 
weight was a source of embarrassment for this student as she endured 
teasing by classmates for her large size. Not only was she experiencing 
dangerous physical consequences, such as shortness of breath when 
walking through the school hallways, but she also was suffering with 
adolescent psychological distress.
    Even our national security is threatened as we learned from the 
United States Military this week that since 2005, 48,000 overweight 
recruits had to be turned away from serving our country. The obesity 
epidemic is a major contributor to the national crisis of filling the 
military's ranks. These young people are products of an environment who 
have been driven to school for 18 years, and when in school, they had 
little or no daily physical education. When out of school, they spent 
on average four or more hours per day using electronic media; and the 
foods they've grown accustomed to eating have been unhealthy and in 
larger sizes. Even in schools, due to antiquated guidelines for foods 
sold outside of the meals, students have been consuming on a daily 
basis high-calorie, low-nutrient foods, snacks, and beverages.
    According to RWJF, it's estimated that the obesity epidemic costs 
our nation $117 billion annually in direct medical expenses and 
indirect costs, including lost productivity. Childhood obesity alone 
has a tremendous and unnecessary cost of up to $14 billion annually in 
direct medical expenses. There are many societal explanations for these 
alarming statistics which translate into health care expenses and lower 
life expectancies of the present and future generations. The questions 
facing us all, are what can be done to turn this epidemic around and 
who is going to be a major contributor to the solution?
    Knowing that obese adolescents have up to an 80 percent chance of 
becoming obese adults, a major investment in prevention must take place 
from multiple sectors of society to become a healthier America. 
Prevention is the positive, logical, and cost beneficial approach to 
achieve education goals and to prevent chronic diseases.
    School nurses have an individual and public health perspective and 
know well that prevention of chronic illnesses such as cardiovascular 
disease and diabetes must begin in childhood to be efficacious. School 
nurses identify at-risk students through periodic assessments, and then 
intervene through referrals to connect students to health services and 
to educate students and parents about nutrition and the availability of 
school meals assistance.
    I want to share with you a true story from one of our members that 
accentuates the gravity of the generational issues involved with 
obesity. It is about a current kindergarten student whom I will call 
Connie B. It was 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 causes her to be out of breath. 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. 
Acanthosis nigricans is a reliable predictor of hyperinsulinemia, an 
over production of insulin and a known precursor to type 2 diabetes, 
previously only known to occur in adults. This little girl is only 5 
years old. She will have a very short and poor quality of life if 
something is not done now.
    The nurse spoke with her mother and found that she has not been to 
the doctor for awhile because her Medicaid ``ran out.'' In other words, 
the mother did not complete the annual renewal process. Mrs. B, a 
single mother, said she has three children younger than Connie, 
including a 4 year old who is severely autistic and who takes up most 
of her time. She said she cannot easily take the children for health 
visits and has a very hard time doing most household duties, including 
cooking regular meals. She said she wishes that Connie was not ``so 
fat.''
    When the school nurse met Ms. B in person, she observed that she is 
also obese. The services available through the school were explained 
and using a partnership with a local hospital, Medicaid coverage was 
re-established. The nurse helped her complete the meals assistance 
application and encouraged Ms. B to allow Connie to eat breakfast at 
school where meals are carefully planned and nutritionally balanced. 
Our dedicated nurse is hoping Connie will stay at the school for 6 
years so that she can work with her and her family. Connie's progress 
toward improved health status will be monitored as she eats a more 
nutritious diet and grows into her weight. This type of preventive 
approach is the best way to ensure that Connie won't become part of the 
80 percent of adolescents who take their obesity into an adulthood 
filled with chronic, life altering diseases.
    Critical to helping students break the cycle and develop good 
decision-making skills related to nutrition, is the modeling which 
occurs in the school meals program. Currently, the National School 
Lunch Program is serving nutritious meals to more than 28 million 
children and the School Breakfast Program is reaching more than eight 
million children daily. The meals eaten at school are meals that they 
can count on. In contrast to the students who pay full price for 
lunches, students on assistance are generally so hungry that their 
plates are clean when they finish. We have to ask ourselves, what would 
our schools be like if these children did not receive these vitally 
important meals? In addition, if the Department of Agriculture 
nutrition standards for school foods sold outside of meals would be 
updated, our nation's schools (not just the meals program) could become 
a place where children's nutritional health is taken seriously.
    Schools can also contribute significantly to the other major factor 
which leads to obesity--the lack of physical activity. Therefore, NASN 
recommends a stronger emphasis on school wellness policies that include 
necessary physical activity for all students. Throughout Maryland 
schools, the school nurses are joining with the physical education 
teachers in urging parents to ``Take 15 for the Health of It!'' Parents 
and guardians are encouraged to devote 15 minutes every day with their 
children in some form of physical activity.
    Since the Child Nutrition and WIC Reauthorization Act of 2004, all 
school districts are required to have local school wellness policies. 
School nurses have a critical role in teaching about and providing 
healthy food choices and teaching skills and knowledge to motivate 
participation in lifelong physical activity. Many school nurses 
throughout the country are the lead person in the school for 
development and implementation of the wellness policy. NASN recommends 
that school nurses serve on every school and district wellness policy 
committee. With the help of the Congress, this could become a reality.
    The child nutrition and learning link must be considered, if 
wellness is the goal. Longstanding and ongoing research in the area of 
nutrition and learning informs 21st century policymakers that the link 
between nutrition and academic achievement is evident and strong. 
Schools should be responsive to the evidence and provide all students 
with highly nutritious meals at school regardless of their ability to 
pay. Ninety-seven percent of school-age students attend school, and 
clearly, there is no better way to insure that children in poverty get 
fed foods they need to thrive and grow than to provide meals assistance 
and well-planned, nutritious meals at school. In addition, a recent 
study found that obese children have more absences than normal weight 
students. The school nurse role is to support children in any way that 
will insure that they are in school everyday and ready, even eager, to 
learn. Teachers and school nurses know from experience that healthy 
children learn better!
Conclusion
    Speaking on behalf of NASN, I appreciate the opportunity to share 
experiences from my practice and what school nurses know about obesity 
and how to prevent it amongst school children. Our Association is happy 
to assist the Subcommittee further as it addresses the issues in the 
context of nutrition, health care and education reforms.
    I also want to ensure the Subcommittee that as a national 
association, NASN is doing what it can to take on the responsibility of 
training school nurses about childhood obesity. In working on a 
demonstration project related to type 2 diabetes funded by CDC and the 
National Institutes of Health, it was recognized that school nurses are 
in key positions to impact this problem and to serve as catalysts for 
better care. Therefore, with seed money from the cooperative agreement, 
NASN developed a program known as S.C.O.P.E. It stands for School Nurse 
Childhood Obesity Prevention Education. The program has been designated 
a ``program to watch'' by the Partnership to Fight Chronic Disease 
because it covers the assessment, treatment, and prevention of 
childhood obesity and the case assessment and management for children 
with type 2 diabetes. The goal is to provide strategies for every 
school nurse to assist not only the students, but also the families and 
the school community in addressing the challenges related to obesity. 
Within a very limited budget, NASN has been able to train about 1,200 
school nurses since the program's inception in 2006. Having public and 
private partners recognize the importance of school nurse involvement 
in obesity prevention, hopefully will allow for increased numbers of 
school nurses completing the training.
    The childhood obesity epidemic in the United States continues to 
seriously threaten the health and future of our nation's youth. Working 
towards a solution will involve the collaboration of schools, parents, 
community members, health care professionals and Federal, state, and 
local governments. All are responsible for addressing the epidemic and 
serving as advocates to protect children. However, school nurses are in 
the unique position to serve as liaisons with the various groups to 
help stop the rise in childhood obesity while working on a daily basis 
with students to increase their understanding of how to achieve healthy 
lifestyles.

    The Chairman. Thank you, and I want to thank all of the 
witnesses for being here this morning, and for your testimony.
    What we will do, then, is take a recess break and convene 
back in an hour from now, which makes it around 12:40, and then 
we will proceed with the answering of questions. So at this 
time, we will be in recess until then, for voting. We have 
about 2 minutes left. We are in recess.
    [Recess.]
    The Chairman. The meeting will come to order. I want to 
begin, first of all, thank you very much for your testimony.
    I have used food stamps to feed my family during difficult 
times, and I also appreciate you for sharing your story with 
us, those of us who have used food stamps or SNAP to provide 
for our families.
    You have given us some very interesting statistics. It is 
truly amazing--you said that 48 percent of those with obesity 
utilize Medicare and Medicaid----
    Ms. Wolf. No, can I clarify that?
    The Chairman. Sure.
    Ms. Wolf. Forty-eight percent of the costs of obesity are 
paid for by Medicaid and Medicare.
    The Chairman. Thank you very much for clarifying that. It 
is still pretty high, the amount that is on the taxpayers.
    Just to clarify what you said in your testimony that the 
benefit of education is the best way to prevent obesity. Every 
dollar that is spent on lifestyle intervention for people with 
obesity and diabetes, there is a $14.58 return on investment. 
In your opinion, how prevalent should lifestyle intervention 
for obesity be in our attempt to focus more on prevention 
healthcare?
    Ms. Wolf. Congressman Baca, I believe that preventive 
effort is what we really need to put into the medical care 
system, and of course, we have to look at the environment and 
we need to do public health messaging. But right now if you 
look at the state of medical care, it is focused on treatment 
and not on the preventive part of medical care, such as 
lifestyle care.
    In the study that was quoted right there, there was a very 
high return on investment. It was a smaller study, 150 people 
that were at high risk for diabetes and obesity, but on every 
major qualifier, just giving them a moderate lifestyle 
intervention decreased patient admissions. There was 18 
admissions during a 1 year period, 16 of those were the people 
who had regular, usual, medical care. Only two of those 
admissions were people who actually got the lifestyle. You see 
a decrease in pharmaceutical use, you saw a decrease in 
absenteeism. That was significant and robust and saves dollars 
at every single level, and that is why you saw that positive 
return on investment.
    Typically when we do intervene in this--in lifestyle 
interventions with a high-risk population, you see that it is 
cost effective. You may not see that high of a return on an 
investment, that is only one study, but you will see that it is 
cost effective.
    The Chairman. Okay, thank you. The next question, and any 
one of the three can respond to this. One would go back, of 
course, to Ms. Wolf, and then the other one would be for Mr. 
Yadrick and then Ms. Mazyck as well.
    What are the developmental effects of obesity in children?
    Ms. Mazyck. The developmental effects of obesity in 
children?
    The Chairman. Yes.
    Ms. Mazyck. So you are addressing----
    The Chairman. Anyone or all three of you, if you could 
address that, ma'am.
    Ms. Wolf. Mr. Chairman, when children are developing, and 
they have issues with obesity, they begin to develop some of 
those risk factors that we heard from Dr. Dietz that generally 
will lead to issues with hypertension. Some of them are 
developing type 2 diabetes, we have heard. One of the untold--
and I don't have a percentage--were the number of children who 
deal with bullying and the emotional effects of being 
overweight. That is a factor, indeed, that impacts children 
when they are overweight. They are unable to physically move 
like they would want to, and they have to suffer the teasing 
and the bullying from friends and schoolmates.
    Mr. Yadrick. And the other thing, Mr. Chairman, is they are 
just setting the stage for chronic problems throughout the rest 
of their life. As my colleague mentioned, the inactivity that 
obesity often leads to is going to prevent them from having a 
healthy lifestyle, and starts that out early on in life, the 
pattern towards all the chronic diseases that are going to be a 
consequence of that.
    The Chairman. Part of the follow-up, and Ms. Wolf, you can 
probably add to that, what kind of data is there on the long-
term cost of these developmental problems.
    Ms. Wolf. There is evidence that children who are 
overweight and obese later on have lower wages, there is--let 
me see. Of course, they have higher chronic problems which 
means they have higher amounts of medical expenditures and 
things like that. Basically what Dr. Dietz was saying, and what 
we find, is that when you are overweight and obese as a child, 
it does track along. Remember that the health care costs for 
obesity increase along with the severity of obesity, so these 
kids are tracking along all the way through. They are having a 
long-term level of obesity, which means they are going to have 
more chronic diseases. That really translates into higher 
medical expenses, absenteeism, and then problems with 
disabilities.
    The Chairman. Okay, thank you. Mr. Hamburg, I appreciate 
the big picture, the point of view you offered in your 
testimony. It is critical that we on the Subcommittee remember 
that there are many ways that health and obesity affect Federal 
law and policies as a whole.
    With your outlook in mind, could you expand on your ideas 
of a national strategy to combat obesity?
    Mr. Hamburg. Well, sure. I mean, it has become clear, 
certainly, in the last few years that this is a problem that 
affects all aspects of society, all aspects of government. So, 
just looking at what you all are able to insert into the farm 
bill, some of the decisions that need to be made around 
reauthorization of the education programs, transportation bill 
that is coming back up. You know, there are significant funds 
for a program called Safe Foods for Schools.
    I think to best look at it from the community level--YMCA 
has a program called Pioneering Healthier Communities, and what 
they do is try to address the obesity issue in a community-wide 
fashion. They bring together leaders from the community that 
includes everyone from the police chief to the Chamber of 
Commerce and the schools, and public health and voluntary 
health associations, and try to figure out what can be done in 
a cumulative way to try to fight an epidemic that, again, took 
30 years to manifest.
    So at the Federal level, the idea that we have--first, we 
should have a national plan on public health overall, but 
specifically on obesity, we need to make sure that policies 
match up, that we don't have counter-intuitive policies between 
different agencies.
    One issue that was addressed very well in a government-wide 
fashion in the last couple of years was pandemic flu, the 
possibility for a worldwide pandemic flu. The past 
Administration and Congress decided we need a full plan, multi-
agency plan to address that. We think that is the case for 
addressing obesity as well.
    The Chairman. Thank you. I know that my time has expired, 
but have you presented these ideas to the Administration?
    Mr. Hamburg. Yes, we have. We have been pushing these 
ideas, both in this report and also a report called ``The 
Blueprint for a Healthier America.'' It is a whole blueprint of 
recommendations relative to how the Federal Government needs to 
address public health broadly, and we can certainly forward the 
recommendations on to this Committee. So yes, we are talking to 
whoever will listen, and we are certainly talking to the 
individuals in both Houses who are currently drafting health 
reform legislation. This is, indeed, a health reform and we 
need to make sure that prevention initiatives are front and 
center.
    The Chairman. Thank you. I am going to turn it over to 
Congressman Fortenberry to ask any additional questions.
    Mr. Fortenberry. Thank you, Mr. Chairman. I am sorry for 
the disruption. Thank you all for staying. All of your 
testimony has been very insightful and informative. It is 
packed with a lot of statistics, and to highlight a couple of 
those key findings, going back to what Chairman Baca had 
mentioned regarding 48 percent of the costs of obesity are born 
by government programs. Is this across a spectrum of Medicare/
Medicaid, veterans' programs, other types of health care 
subsidies that are out there through the public sector of 
financing, or is it concentrated among Medicare and Medicaid 
populations?
    Ms. Wolf. The analysis could only look at Medicaid/Medicare 
recipients, and most of that is Medicare, because of chronic 
illness.
    Mr. Fortenberry. So you would suggest it is fair to say 
that the majority of that cost is in the Medicare program?
    Ms. Wolf. It absolutely is, and there has been a more 
recent paper that has really shown that it is worth the 
government's effort to invest in preventive efforts, because 
the costs down the line to the government are so large, so 
huge, and will continue to grow.
    Remember, you are paying Medicare costs this high right 
now. We didn't have the population of obese children that we 
have now, back then.
    Mr. Fortenberry. Can you correlate, again--set your own 
parameters about what nutritional increase and access to 
nutritional education and programs in food could do in terms of 
combating this problem: how that is correlated to a decrease in 
obesity and overweight issues, correlated to better health 
outcomes, correlated to better disease management, correlated 
to increased savings. It is the same question I had for Dr. 
Dietz. Give us a number, if we did this, it would translate to 
this in terms of cost savings, because clearly, the trajectory 
we are on in terms of government financed health care programs, 
as well as private sector is unsustainable. This is a common 
sense way to get underneath some of that trajectory so--yes, 
sir, did you want to----
    Mr. Hamburg. Yes, in a report that we put out that 
basically is a return on investment report and investing in 
community-based interventions, we need to be mindful that there 
are clinically-based interventions, one to one, and then 
community-based interventions. Most of the interventions we 
looked at related to obesity. There were some tobacco 
interventions included as well, but it was primarily nutrition, 
physical activity. So we looked at all of these studies for 
close to 80 or 90 local and national studies, and what we found 
was that if we invested just $10 per person--that was a 
conservative number, because a lot of these programs only cost 
a few dollars per person--but if we invested $10 per person, 
that is $3 billion. And that is actually what was in the 
initial wellness fund in the stimulus bill that came through 
this House. So if we put $10 per person, $3 billion, within a 
year or 2, we would see, first of all, a five percent decrease 
in a lot of these associated diseases, and in 1 to 2 years, an 
immediate return in investment of that $3 billion. Within 5 
years, we would see $16 billion a year in savings, and those 
savings are to Medicare, Medicaid--actually, the biggest one 
was in private health insurance and out-of-pocket expense.
    Mr. Fortenberry. That is an aggregate savings, $16 billion, 
or just a public----
    Mr. Hamburg. That is each year, so it builds up to a point 
where it is, approximately, 5.6 return for every dollar 
invested.
    Mr. Fortenberry. This is anecdotal, and it is related to a 
question that one of our other Members had asked earlier. But 
in terms of rethinking a health insurance model--the largest 
employer in Nebraska is a health care provider, but for their 
own employees, they incent healthy behaviors. In other words, 
if you--they pay you to go to the doctor for a checkup. If you 
quit smoking you get, say, $500 for your health savings 
account. If you are 20 pounds overweight you get--I asked the 
CEO of that company if they had run a calculation based upon 
the present value of the long-term cost savings, expecting 
their initial cost to actually rise as they invested in these 
long-term measures to reduce costs, and he said yes, that is 
what we did and justified doing it. But ironically, we actually 
saw short-term costs drop as well. So their increases have 
basically been cut in half. They are not saving money; it is 
still going up, but the rate of increase of their own health 
care programs has been halved, compared to the national 
average.
    So again, we tended to focus the hearing on just trying to 
unpack the nature of the problem, and I think we have done a 
good job of that. Now, the next phase is to take the testimony 
that we have heard here, both in terms of public programs, but 
also in terms of rethinking some of the mechanisms out there in 
the private sector that have been set up a particular way, but 
there might be more productive ends to it.
    Do any of you have any comments on that?
    Ms. Wolf. It has been shown in a couple of studies that 
incentives really do help promote healthy behavior, and we know 
that subsidies are incentives. So right now, people are paying 
a certain amount of money for their health care, which is very 
expensive to the family. If that was reduced if they had 
healthy behaviors, that has been proven that that is effective 
in getting them to create healthy behaviors, with the result of 
improved diet, increased physical activity, and weight loss as 
well. So absolutely, those studies are few and far between. We 
would love to see more of the health insurance companies--we 
have seen in North Carolina where their Blue Cross/Blue Shield 
has taken us on, they too have invested immediately and are 
spending more, however, they are finding great returns at this 
point.
    Mr. Fortenberry. I think that it is an important point. 
There is positive data out there to quantify these potential 
outcomes would be helpful to spurring this type of innovation 
across the country.
    Thank you, Mr. Chairman.
    The Chairman. Thank you. Since there are no other panelists 
here, we can ask some additional questions and then adjourn.
    I just want to ask Mr. Hamburg one thing. In your testimony 
you referred to a community health program that costs as little 
as $10 per person, yet has the potential to save our nation 
over $16 billion in the long term. Can you explain in more 
detail about what this program entails, and why is it so 
effective?
    Mr. Hamburg. Well, what we looked at were, first of all, 
successful interventions, and it wasn't any one particular 
program. It included school health programs, efforts like Dr. 
Dietz talked about in educating the public through the media, 
putting in bike paths, stop smoking help lines, those sorts of 
things. So we looked at all of those and had those costed out. 
On average, most of those interventions, frankly, only cost $5 
or $6 per person, so it is an idea that just with a small 
investment in trying to educate the public, trying to change 
some norms around physical activity and nutrition, both in 
schools and the worksite, is equally important. You can see 
these large returns on investment if you look at diabetes, for 
example, and the incredible rise in type 2 diabetes.
    I mean, if you just have an intervention that puts more 
physical activities into the schools and more healthful foods 
within the lunch and breakfast programs, and also competitive 
foods through vending machines, if kids or adults lost 10 
pounds, that is a dramatic change at times. And that is why you 
see a lot of the return in investment early on, because within 
a year or 2, you can take somebody pretty quickly from type 2 
diabetes back to pre-diabetes or pre-diabetes even farther back 
just by making some very small interventions. I think that is 
the concept that we need to have out there, you know. You don't 
have to lose the 50 pounds, you don't have to run 5 miles a 
day. It would be nice, but you do what you can do, and small 
interventions can have great effects, both in health, and we 
are finding in economics. That is just gravy on top if we can 
have reduced chronic disease and save money. That is a win-win.
    The Chairman. That is true. I need to lose 20 pounds, so I 
am going to do it a little at a time.
    I know that we are running out of time. I really appreciate 
your patience and your time and willingness to wait for us, but 
as you can see, this is exit time for many of the Members. Your 
testimony is very important to a lot of us. Your knowledge and 
your research have given us a lot of hope in terms of trying to 
develop some good policies as we look to end obesity in 
America. It also helps make us more aware of both the economic 
and the human effects of obesity in our communities and our 
neighborhoods and our schools.
    I want to thank each and every one of you for coming and 
sharing your expertise with us here. This will not be the end. 
We have a lot of work ahead of us, I think that we can begin, 
jointly, to develop in partnership and collaboration the kind 
of programs that we need to reshape America. I think it is our 
responsibility with the kind of programs and development and 
the kind of legislation, kind of educational programs that we 
can develop, and the kind of research that also needs to be 
done. So I thank you for being here.
    And with that, I would like to say that under the rules of 
the Committee, the record of today's hearing will remain open 
for 10 calendar days to receive additional materials and 
supplemental written responses from the witnesses, and any 
questions posed by Members, which means some of us may have 
some questions we didn't get an opportunity to ask, so we will 
submit those. The hearing of the Subcommittee of the Department 
Operations, Oversight, Nutrition, and Forestry is now 
adjourned. Again, thank you very much.
    [Whereupon, at 1:00 p.m., the Subcommittee was adjourned.]
    [Material submitted for inclusion in the record follows:]
      
  Submitted Statement of Neal D. Barnard, M.D., President, Physicians 
                   Committee for Responsible Medicine
    Mr. Chairman, thank you for the opportunity to submit testimony to 
the Subcommittee on the state of obesity in the United States. The 
Physicians Committee for Responsible Medicine (PCRM) is a nonprofit 
organization founded in 1985 and based in Washington, D.C. PCRM is 
comprised of more than 120,000 members across the country, including 
some 7,000 physicians, working together for preventive medicine, 
nutrition, and higher ethical standards in research.
    For many years PCRM has worked hard to educate Americans about good 
nutrition and has also conducted numerous studies on nutrition. For 
example, in 2006, PCRM completed an NIH-funded study on the link 
between diet and type 2 diabetes. The findings of that study were 
published in Diabetes Care, a journal published by the American 
Diabetes Association, with subsequent findings published in the Journal 
of the American Dietetic Association and elsewhere.
    I would like to focus my testimony on the effect that poor 
nutrition is having on America's children and ways Federal policy can 
address this growing health crisis.
    Kids need healthier diets. If you could look into the arteries of 
children in schools, you would find that many have early signs of 
atherosclerosis before they pick up their high school diplomas. One in 
five is overweight by the end of elementary school. According to the 
Centers for Disease Control and Prevention, one in three children born 
in the year 2000 will develop diabetes at some point in his or her 
life.
    As children grow into adulthood, cancer will eventually strike one 
in three females, one in two males. And as they reach older age, the 
same fatty, high-calorie diets that caused these health problems will 
increase their risk of developing Alzheimer's disease.
    There are many proposed solutions to children's health problems: 
more exercise, less TV, more vegetables and fruits, less meat and 
cheese, more meals at home, and less fast food. But there is one thing 
everyone agrees on: Children need healthful choices at school. People 
who learn about healthful foods in childhood are much more likely to 
choose them as adults.
    But schools are in a tough spot. As food prices rise, many schools 
rely on inexpensive commodities--many of which are high in fat and 
cholesterol--and may not be able to expand their menus in healthier 
directions. A major part of the problem is the fact that U.S. 
agricultural policies continue to make those foods highest in fat and 
cholesterol relatively cheap.
    Unfortunately, the last farm bill did not adequately address the 
many problems with Federal commodity subsidies. Despite record 
deficits, Federal taxpayers continue to provide billions of dollars in 
subsidies to agribusinesses for the production of the unhealthiest of 
food products.
    From a medical standpoint, I would ask the Subcommittee to help us 
in tackling the obesity epidemic, and to revisit the farm bill and 
eliminate or dramatically reduce direct and indirect Federal subsidies 
for high-fat, high-cholesterol foods.
    Nutrition policy is another area where Congress can make a 
substantive impact, particularly through the re-authorization of the 
Child Nutrition Act. Some common-sense changes at the Federal level 
will help stem the rise in obesity among our children.
    The most important change is a need for healthful options in school 
lunch lines. A few simple choices would do a world of good.
    Take a veggie burger, for example. It provides exactly the same 
amount of protein as a typical cheeseburger--15 grams. But while a 
cheeseburger harbors 10 grams of fat, a veggie burger has only five, 
and it has no saturated fat, no cholesterol, and fewer calories.
    Vegetarian chili has exactly the same protein content as chicken 
nuggets--10 grams per serving. But while the nuggets have 18 grams of 
fat, the veggie chili has only 3 grams. It, too, has essentially no 
saturated fat, no cholesterol, and fewer calories. Unfortunately, most 
school children never see these healthful vegetarian options.
    President Obama's children, Sasha and Malia, attend Sidwell 
Friends, a private school in Washington. On February 10, 2009, Sidwell 
Friends' menu featured beef chili, and students looking for a healthier 
choice could choose vegetarian chili. However, that same day, the 
Washington, D.C., public schools served meatloaf with gravy, and 
children who wanted a healthy vegetarian option were offered nothing at 
all.
    On February 13, 2009, Sidwell Friends served regular pizza, and 
roasted vegetable pizza for students who wanted a vegetarian choice. 
But children in the public schools were served chicken nuggets with 
barbecue sauce. If they wanted a vegetarian option, they got nothing.
    On February 25, 2009, Sidwell Friends served regular shepherd's pie 
and vegetarian shepherd's pie. Public school children were served 
bologna and cheese sandwiches. If they wanted a healthy, vegetarian 
option, they got nothing.
    A child in public school has a right to a healthful lunch, just as 
a child in private school does. But most schools will only provide 
these choices if Congress pushes them to do so--and provides the 
wherewithal to make it happen. Schools should offer vegetarian choices 
every day, and they should also have the funding that makes it feasible 
for them to do so.
    The following changes should be part of the new legislation:

    1. All schools participating in the National School Lunch Program 
        (NSLP) and School Breakfast Program (SBP) must provide a 
        nondairy, vegetarian meal option and a healthful nondairy 
        beverage.

    2. Calcium-rich nondairy beverages should be considered as 
        satisfying the milk requirement in fulfilling the definition of 
        reimbursable meals. Whether due to lactose intolerance, 
        allergy, ethics, or taste preference, a student who desires soy 
        milk instead of cow's milk should not need a note from home or 
        a doctor.

    3. Reimbursement rates for NSLP and SBP should be increased by 20 
        percent for exemplary schools with meal averages as follows: 
        saturated fat <7%, cholesterol <100 milligrams, and fiber 
        >7grams.

    4. Commodities should be selected based on current scientific 
        evidence about the role of diet in health and illness. The 
        commodity program should include no products with more than 7% 
        energy from saturated fat.

    5. In order to allow schools to provide more healthful meals, the 
        calorie minimum required for meals shall be reduced. Currently, 
        meals for grades K through 3 must average at least 633 
        calories. For grades 4-12, these figures are 785 calories. 
        These figures are too high.

    These changes would go a long way in improving the health of our 
children and addressing the obesity epidemic.
    Thank you for your consideration.
                                 ______
                                 
Submitted Statement of LuAnn Heinen, M.P.P., Director, Institute on the 
 Costs & Health Effects of Obesity; Vice President, National Business 
                            Group on Health
The Cost of Obesity to U.S. Business
    The National Business Group on Health (Business Group) thanks the 
Subcommittee on Department Operations, Oversight, Nutrition and 
Forestry of the House Committee on Agriculture for the opportunity to 
submit these recommendations as our written testimony for the public 
hearing to review the state of obesity in the United States on March 
26, 2009.
    Founded in 1974, the Business Group is a member organization 
representing over 300 members, mostly large employers, who provide 
coverage to more than 55 million U.S. employees, retirees and their 
families and is the nation's only non-profit organization devoted 
exclusively to finding innovative and forward-thinking solutions to 
large employers' most important health care and related benefits 
issues. Business Group members are primarily Fortune 500 companies and 
large public sector employers, with 64 members in the Fortune 100.
    Employers and employees fund health care in the U.S. by (1) paying 
claims (larger, self-insured employers) or insurance premiums (smaller, 
fully insured employers), and (2) paying corporate and individual 
income taxes for Medicare and other public programs. The costs to both 
employers and employees are significantly higher because of obesity, a 
key factor in escalating health costs due to type 2 diabetes, heart 
disease, some cancers, and many other conditions.
    The great majority of employers want to continue sponsoring health 
care for employees and their families, a key feature of leading health 
reform proposals. However, a recent survey of nearly 500 large 
employers identified ``employees' poor health habits'' (physical 
inactivity, poor diet, tobacco use) as by far their greatest challenge 
in providing affordable health coverage.\1\ This helps explain why the 
great majority of members of the National Business Group on Health 
(representing Fortune 500 employers) offer wellness and health 
promotion programs at work.
---------------------------------------------------------------------------
    \1\ The Keys to Continued Success: Lessons Learned from Consistent 
Performers. 14th Annual National Business Group on Health/Watson Wyatt 
Employer Survey, 2009.
---------------------------------------------------------------------------
Direct and Indirect Costs of Obesity to Employers Are Substantial
    Obesity costs employers about $45 billion annually in medical costs 
and lost productivity.\2\ The Federal Centers for Disease Control and 
Prevention estimate that obese employees cost employers at least $4 
billion each year in lost productivity alone, and that these employees 
typically are absent from work twice as often as other employees. In 
total, the obesity contributes to nearly 10% of healthcare spending in 
the U.S., or as much as $93 billion annually.\3\
---------------------------------------------------------------------------
    \2\ Finkelstein, E., Fiebelkorn, I. and Wang, G. National Medical 
Spending Attributable to Overweight and Obesity: How Much, and Who's 
Paying? Health Affairs Web Exclusive, May 14, 2003.
    \3\ cdc.gov/nccdphp/dnpa/Obesity/economic_consequences.htm.
---------------------------------------------------------------------------
    The direct medical costs of obesity are significant and measurable; 
several published studies and employers' own data easily demonstrate an 
increase in spending roughly correlated with increasing Body Mass Index 
(BMI). It is especially noteworthy that an estimated 27% of the year-
over-year increase in health costs to private employers is attributable 
to obesity; \4\ obesity is thus one of the key reasons why the trend in 
U.S. health costs is persistently steeper than the CPI or even the 
medical inflation index.
---------------------------------------------------------------------------
    \4\ Thorpe, K. et al. Trends: The Impact of Obesity on Rising 
Medical Spending. Health Affairs Web Exclusive, October 20, 2004.
---------------------------------------------------------------------------
    Obesity is the leading ``lifestyle-related'' or ``modifiable'' risk 
factor; it is more significantly associated with chronic medical 
conditions, reduced health-related quality of life, and increased 
health and medication spending than either smoking or problem 
drinking.\5\
---------------------------------------------------------------------------
    \5\ Sturm, R. The Effects of Obesity, Smoking and Drinking on 
Medical Problems and Costs. Health Affairs 21(2): 245-53, 2002.
---------------------------------------------------------------------------
    This helps explain the impact of obesity on productivity; when 
quantified, these so-called indirect costs of obesity are as much as 
three times as great as the direct medical costs. Obesity generates 
indirect costs for employers by increasing workers' compensation claims 
and related lost workdays,\6\ absenteeism,\7\ presenteeism,\8\ and 
disability in people aged 50-69.\9\ Even without counting the cost of 
presenteeism (a self-reported measure of diminished on-the-job work 
performance due to health or life problems) which is not universally 
measured, productivity costs attributable to obesity are highly 
significant.
---------------------------------------------------------------------------
    \6\ Osbye, T. et al. Results from the Duke Health and Safety 
System. Archives of Internal Medicine 166(8):766-73, 2007.
    \7\ Finkelstein, E. et al. The Costs of Obesity Among Full-Time 
Employees. American Journal of Health Promotion 20(1):45-51, 2005.
    \8\ Ricci, J. and Chee, E. Lost Productive Time Associated with 
Excess Weight in the U.S. Workforce. Journal of Occupational and 
Environmental Medicine 47(12): 1227-34, 2005.
    \9\ Sturm, R. et al. Increasing Obesity Rates and Disability 
Trends. Health Affairs 23(2): 199-205, 2004.
---------------------------------------------------------------------------
Obesity Rates Becoming a Workforce Differentiator
    A Texas legislator tells the story of an employer who refused to 
relocate to his Congressional district because of the high rate of 
obesity in those counties. By contrast, the Metro Denver website 
promotes Colorado as the state with the lowest rate of obesity, 
claiming ``while no state is immune to rising obesity rates, we're 
curbing the gradual expansion of our waistlines by re-adjusting our 
culture. Under the leadership of the Metro Denver Health and Wellness 
Commission, Metro Denver is aiming to become America's Healthiest 
Community by instituting strategies that support worksite wellness, 
school policy, and the creation of interlinked, walkable communities.'' 
\10\
---------------------------------------------------------------------------
    \10\ www.metrodenver.org/market-differentiators/health-
wellness.html.
---------------------------------------------------------------------------
    In addition to competing at the macro level, we see plenty of 
competition among employers at the individual employer level for 
recognition as employers of choice. The National Business Group on 
Health has given 148 ``Best Employer for Healthy Lifestyles'' awards to 
some of America's healthiest corporations over the last 4 years. Major 
strategies employed by employers to improve employee and family health 
include: comprehensive benefits with healthy lifestyle incentives; 
environmental (nutrition and physical activity) support for healthy 
lifestyles; the fostering of an organizational culture of health; and 
outreach to family members and the community. These strategies are 
fully described in a recent publication provided to the Subcommittee 
(The Milbank Quarterly March 2009 special edition on Obesity; see 
especially Heinen and Darling, ``Addressing Obesity in the Workplace: 
The Role of Employers'').\11\
---------------------------------------------------------------------------
    \11\ Heinen, L. and Darling, H. Addressing Obesity in the 
Workplace: The Role of Employers. The Milbank Quarterly 87(1):101-122, 
2009.
---------------------------------------------------------------------------
The Next Generation: Impact on Employers (and Society) Will Be 
        Significant
    As concerned as employers are about the health and cost 
consequences of America's lifestyle today, the problems of tomorrow's 
workforce may eclipse anything seen to date. The Millennial generation 
(born between 1980 and 2000) is one of the largest ever--and they are 
the unhealthiest in modern history. Seventy-five million strong, this 
generation is now entering the workforce. Commonly described as 
ambitious, confident, and ``not willing to take no for an answer,'' 
they also overwhelmingly sedentary, choosing the array of high-tech 
entertainment options available to them over regular, vigorous physical 
activity. Raised with low-cost calories freely available 24/7, they 
consume more calories per day on average than previous generations.
    Currently 32 percent of children and adolescents are overweight or 
obese, with 16.3 percent possessing a BMI in the obese range.\12\ As 
the Millennials age and these trends continue, it is projected that a 
staggering 86 percent of Americans will be overweight or obese by 
2030.\13\
---------------------------------------------------------------------------
    \12\ Ogden, C. et al. High Body Mass Index for Age Among U.S. 
Children and Adolescents, 2003-2006. Journal of the American Medical 
Association 299 (20):2401-2405, 2008.
    \13\ Wang, Y. Will All Americans Become Overweight or Obese? 
Obesity 16(10): 2323-2330, 2008.
---------------------------------------------------------------------------
    According to the 2007 Youth Risk Behavior Survey,\14\ among U.S. 
high school students:
---------------------------------------------------------------------------
    \14\ www.cdc.gov/HealthyYouth/yrbs/pdf/yrbs07_us_obesity.pdf.

   13% are obese; adolescent obesity has more than tripled in 
---------------------------------------------------------------------------
        the past 25 years.

   Nearly 80% do not consume the recommended amount of fruits 
        and vegetables.

   More than \1/3\ drink at least one can of soda each day.

   65% do not achieve the recommended amount of daily physical 
        activity.

   More than 10% do not engage in any physical activity.

   35% watch 3 or more hours of television each day.

   25% play video games or use a computer recreationally for 
        more than 3 hours each day.

   45% are attempting to lose weight.

    It is sobering to realize that this generation will comprise a 
significant portion of the workforce in a few short years and is on 
track to further burden U.S. employers and health care payers, whether 
they be public or private, with their poor health status and associated 
costs.
    The evidence so far suggests the Millenials will carry their risky 
health habits into the workforce. A 2007 Nationwide Better Health 
survey \15\ found:
---------------------------------------------------------------------------
    \15\ www.nationwidebetterhealth.com/docs/media-kit/obesity-in-
workplace.pdf.

   22 percent of 18-27 year-old employees eat an unhealthy 
        snack at work at least five times each week. This compares to 
---------------------------------------------------------------------------
        nine percent of those over age 45.

   27 percent of those 18-27 report a sedentary job, sitting at 
        a desk most of the day.

   35 percent of those under age 27 indicate that stress leads 
        to adverse nutritional choices.

    Due to declining health status over the course of this century, 
life expectancy in the U.S. could drop by 5 years or more.\16\ Further, 
a Rand Corporation analysis revealed that, in recent years, 30-39 year 
olds have experienced the sharpest rise in disability rates of any age 
group--increases upwards of 50 percent.\17\ New research projects an 
additional 100,000 annual cases of heart disease by 2035 if obesity 
rates are not brought under control.\18\
---------------------------------------------------------------------------
    \16\ Olshansky, S.J. et al. A Potential Decline in Life Expectancy 
in the United States in the 21st Century. New England Journal of 
Medicine 352(11): 1138-1145, 2005.
    \17\ Lakdawalla, D. et al. Are the Young Becoming More Disabled? 
Health Affairs 23(1): 168-176, 2004.
    \18\ Bibbens-Domingo, K. Adolescent Overweight and Future Adult 
Coronary Heart Disease, New England Journal of Medicine 357(23): 2371-
9, 2007.
---------------------------------------------------------------------------
    All of this translates into an additional $956 billion each year in 
medical costs by about 2030. Simply put, within two decades, one of 
every $6 spent on health care in the United States could be 
attributable to overweight and obesity.\19\
---------------------------------------------------------------------------
    \19\ Wang, Y. et al., op. cit.
---------------------------------------------------------------------------
Policy Can Support Healthier Weight, and a Healthier Economy
    To change course and avert these dismal scenarios, we must 
acknowledge the threat posed by obesity to our common purpose and react 
accordingly. Every employer and policymaker should understand that as a 
nation we are already paying for the medical costs and lost 
productivity costs of serous overweight and obesity. Thus it is 
directly in our financial interest to support policy to improve the 
health of employees and families.
    In general, policymakers should view proposed policies and programs 
through the lens of ``obesity impact.'' Just as environmental 
assessment is often part of laws and regulations at the state and 
Federal level for new energy projects, a required obesity impact 
assessment could focus the attention of lawmakers and organizations 
seeking Federal funding on this problem. Obesity impact assessments 
would be especially relevant to food and farm policies along with 
housing, urban development, public works, transportation and other 
projects affecting the built environment and the promotion of 
``livable'' communities which offer walking, biking and recreational 
opportunities.
    We must reform the tax code to reward and incentivize health and 
wellness and not just subsidize treatment of disease as our current tax 
laws do. We must make it easier for employees to participate in 
employee wellness programs, including weight management and weight loss 
programs, and to make it easier for employers of all sizes--small, 
medium, and large--to administer employee wellness programs by making a 
small change in the tax code to treat out-of-pocket expenses for health 
and wellness the same as it does for expenses for medical care.
    While current tax law allows employers to deduct all of their costs 
toward employee wellness as business expenses, generally the value of 
employer contributions to employees for these purposes must be reported 
as income subject to taxation by employees--including payment for 
fitness, nutrition, and weight management programs--unless they are 
part of medical treatment.
    Employees should be able to use pre-tax dollars (including through 
Section 125 cafeteria plans, HSAs, and FSAs) to pay for health and 
wellness activities, programs and purchases, including for fitness, 
nutrition, and weight-management programs. Employer contributions 
toward employee expenses for health and wellness, activities, programs 
and purchases should be excludable from income for tax purposes. People 
should be allowed to deduct post-tax out-of-pocket expenses for health 
and wellness activities, programs, and purchases from their taxes 
irrespective of whether it is for medical and treatment or for 
wellness, health maintenance or disease prevention if their total 
health care expenses meet the 7.5 percent adjusted gross income 
threshold for health care expenses.
    Extending favorable tax treatment for employer-contributions to pay 
for employee health and wellness programs would remove a major barrier 
to more widespread adoption of these programs and lead to a healthier 
America.
    Just as employers who subsidize employee cafeterias should only 
subsidize fruits, vegetables and other foods that would otherwise not 
be consumed at the recommended levels of daily intake, so should the 
Federal Government limit its subsidies to the types and classes of 
foods essential to a healthy diet that are currently under-consumed, 
particularly fruits and vegetables. Food stamp, WIC and other Federal 
aid should encourage the purchase of healthy, nutrient-rich foods and 
beverages; unprocessed or minimally processed foods; whole grains; 
fruits; and vegetables.
    Support for locally grown produce (e.g., in school lunch programs), 
farmers markets, tax subsidies for inner city grocery stores and other 
approaches to eliminate so-called ``food deserts'' where access to 
healthful foods is lacking are particularly worthwhile and should be 
encouraged.
    Thank you for the opportunity to share the perspective of large 
employers on the obesity cost crisis. We believe it is essential to 
combat the tsunami of obesity that threatens to overwhelm us. In terms 
of lifetime and generational impact, obesity has ramifications that go 
even beyond those associated with the current economic crisis. The 
National Business Group on Health welcomes further dialogue with the 
Subcommittee on this or related matters.
National Business Group on Health contacts:
LuAnn Heinen,
Vice President, Obesity Institute,
[Redacted] or [Redacted];

Steve Wojcik,
Vice President, Public Policy,
[Redacted] or [Redacted];

Helen Darling,
President,
[Redacted] or [Redacted].
                                 ______
                                 
             Submitted Statement of Campaign to End Obesity
    The Campaign to End Obesity (``The Campaign'') is a nonprofit, 
nonpartisan organization dedicated to reversing the rising rates of 
obesity through Federal policy action. The Campaign is the only 
organization that brings together leaders in public health, academia, 
and industry to promote common policy goals for stemming the nation's 
obesity epidemic (a list of our Board and Advisory Board Members are 
attached). We commend the Health, Education, Labor, and Pensions 
Committee for its commitment to helping Americans live healthier lives. 
The Campaign looks forward to continuing to work with the Committee to 
assist in developing and advancing policies that enable better 
prevention, identification, management and treatment of obesity.
A Crisis We Cannot Afford to Ignore
    Obesity is now the most costly and prevalent chronic disease 
affecting American adults and children, and the single most dangerous 
driver of every other chronic disease afflicting our nation. Eighty-
three cents of every dollar spent on U.S. health care costs is 
associated with obesity, and that number continues to grow as the 
epidemic triggers greater incidence of costly chronic diseases like 
heart disease, cancer and diabetes. Today, nearly 33 percent of the 
American adult population is obese, more than double what it was in 
1980.\1\ Likewise, an astonishing 16.3 percent of children are 
considered overweight or obese.\2\
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    \1\ Fox, Maggie. ``Obese Americans Now Outweigh the Merely 
Overweight.'' Reuters. January 9, 2009. http://www.reuters.com/article/
domesticNews/idUSTRE50863H20090109.
    \2\ Ogden, C.L., M.D. Carroll, and K.M. Flegal. ``High Body Mass 
Index for Age among U.S. Children andAdolescents, 2003-2006.'' Journal 
of the American Medical Association 299, no. 20 (2008): 2401-2405.
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    The obesity epidemic has brought other tolls as well: children with 
obesity suffer from a growing list of emotional disorders such as 
depression, social stigmatization, and poor academic performance; 
employees with obesity cost private employers $45 billion a year due to 
medical expenses and excessive absenteeism; \3\ and, Americans with 
obesity face lower quality medical care as the current infrastructure 
may be inadequate to diagnose, monitor and treat them.
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    \3\ Rosen, B. and L. Barrington. Weights & Measures: What Employers 
Should Know about Obesity. New York, NY: The Conference Board, April 
2008.
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Working Together Toward Solutions
    How can we begin to reverse the tide on rising obesity rates across 
the country? Families, communities, local, state, and the Federal 
Government all must take a leadership role to fight this perilous 
epidemic to improve the health of the American people and reduce the 
ever-growing costs of this deadly disease on our health care system.
    The Campaign's leadership believes that, if powerful interests work 
together, we can drive the national policy change needed to achieve the 
goal of reducing obesity rates. The Campaign urges policymakers to work 
actively in the current Congress to adopt the following new and 
aggressive policies that will create a framework to encourage better 
nutrition and more healthful living:

   Improve the Federal Apparatus for Addressing Obesity 

     Prompt the Executive Branch to convene one or more 
            high profile events or commissions to highlight the 
            importance of a Federal response to U.S. rates of obesity.

     Create an Executive Branch function to focus on 
            obesity, i.e., a coordinator across health agencies.

     Launch public awareness efforts to educate key 
            constituencies about risks, resources and prevention/
            treatment options.

     Mandate that Executive Branch and/or legislative 
            actions be considered with respect to their impact on 
            efforts to reduce obesity.

   Bolster Access for Americans to an Environment That Helps 
        Reduce Their Prospects of Becoming Obese

     Expand the infrastructure to facilitate and encourage 
            increased physical activity in communities and schools;

     Incent or require increased physical activity for 
            children during the school day; and

     Increase access to healthy nutrition for children by 
            providing incentives.

    We commend Congress for already acting this year on one of the 
Campaign's priorities: including a childhood obesity demonstration 
project in the SCHIP reauthorization bill. Authorizing grants to 
community organizations across the nation to develop programs that 
encourage healthy living is a step in the right direction to preventing 
obesity, particularly as it affects one of our most vulnerable 
populations--children of economically disadvantaged homes.
    The Campaign believes that the 111th Congress is presented with a 
unique opportunity to make real reforms to give Americans a chance for 
a better, healthier weight and life. We look forward to working with 
Congress and the new Administration to achieve these reforms. Please 
contact Noelle Lundberg ([Redacted]) or Jennifer Conklin ([Redacted]) 
with any questions.
                              Attachment 1




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