[Senate Hearing 117-510]
[From the U.S. Government Publishing Office]



 


                                 ______



                                                        S. Hrg. 117-510
 
                 THE STATE OF NUTRITION IN AMERICA 2021

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

                                HEARING

                               before the

                            SUBCOMMITTEE ON
      FOOD AND NUTRITION, SPECIALTY CROPS, ORGANICS, AND RESEARCH

                                 of the

                       COMMITTEE ON AGRICULTURE,
                        NUTRITION, AND FORESTRY

                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION

                               __________

                            NOVEMBER 2, 2021

                               __________

                       Printed for the use of the
           Committee on Agriculture, Nutrition, and Forestry
           
           
           
  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]   
  
  
  

                  Available on http://www.govinfo.gov/
                  
                  
           COMMITTEE ON AGRICULTURE, NUTRITION, AND FORESTRY
           
           
           
                          ______
 
              U.S. GOVERNMENT PUBLISHING OFFICE 
 47-198PDF          WASHINGTON : 2023
           
           
           


                 DEBBIE STABENOW, Michigan, Chairwoman
PATRICK J. LEAHY, Vermont            JOHN BOOZMAN, Arkansas
SHERROD BROWN, Ohio                  MITCH McCONNELL, Kentucky
AMY KLOBUCHAR, Minnesota             JOHN HOEVEN, North Dakota
MICHAEL F. BENNET, Colorado          JONI ERNST, Iowa
KIRSTEN E. GILLIBRAND, New York      CINDY HYDE-SMITH, Mississippi
TINA SMITH, Minnesota                ROGER MARSHALL, Kansas
RICHARD J. DURBIN, Illinois          TOMMY TUBERVILLE, Alabama
CORY BOOKER, New Jersey              CHARLES GRASSLEY, Iowa
BEN RAY LUJAN, New Mexico            JOHN THUNE, South Dakota
RAPHAEL WARNOCK, Georgia             DEB FISCHER, Nebraska
                                     MIKE BRAUN, Indiana

               Joseph A. Shultz, Majority Staff Director
               Mary Beth Schultz, Majority Chief Counsel
                    Jessica L. Williams, Chief Clerk
               Fitzhugh Elder IV, Minority Staff Director
                 Fred J. Clark, Minority Chief Counsel
                              ----------                              

  Subcommittee on Food and Nutrition, Specialty Crops, Organics, and 
                                Research

                   CORY BOOKER, New Jersey, Chairman
PATRICK J. LEAHY, Vermont            MIKE BRAUN, Indiana
AMY KLOBUCHAR, Minnesota             MITCH McCONNELL, Kentucky
KIRSTEN E. GILLIBRAND, New York      JOHN HOEVEN, North Dakota
RAPHAEL WARNOCK, Georgia             JONI ERNST, Iowa
MICHAEL F. BENNET, Colorado          ROGER MARSHALL, Kansas
                                     DEB FISCHER, Nebraska
                            C O N T E N T S

                              ----------                              

                       Tuesday, November 2, 2021

                                                                   Page

Subcommittee Hearing:

The State of Nutrition in America 2021...........................     1

                              ----------                              

                    STATEMENTS PRESENTED BY SENATORS

Booker, Hon. Cory, U.S. Senator from the State of New Jersey.....     1
Braun, Hon. Mike, U.S. Senator from the State of Indiana.........     3
Leahy, Hon. Patrick J., U.S. Senator from the State of Vermont...     5

                               WITNESSES

Mozaffarian, Dariush, M.D., Dean, Friedman School of Nutrition 
  Science and Policy, Tufts University, Boston, MA...............     8
Odoms-Young, Angela, Ph.D., Associate Professor and Director, 
  Food and Nutrition Education in Communities Program and NYS 
  Expanded Food and Nutrition Education Program (EFNEP), Division 
  of Nutritional Sciences, Cornell University, Ithaca, NY........    10
Warne, Donald, M.D., Associate Dean and Director, Indians into 
  Medicine (INMED) and Public Health Programs, School of Medicine 
  and Heath Sciences, University of North Dakota, Grand Forks, ND    12
Stover, Patrick, Ph.D., Dean and Vice Chancellor for Agriculture 
  and Life Sciences, Texas A&M University, College Station, TX...    14
Rachidi, Angela, Ph.D., Senior Fellow and Rowe Scholar, American 
  Enterprise Institute (AEI), Washington, DC.....................    16
                              ----------                              

                                APPENDIX

Prepared Statements:
    Mozaffarian, Dariush, M.D....................................    42
    Odoms-Young, Angela, Ph.D....................................    54
    Warne, Donald, M.D...........................................    64
    Stover, Patrick, Ph.D........................................    88
    Rachidi, Angela, Ph.D........................................    95

Document(s) Submitted for the Record:
Boozman, Hon. John:
    The State of Nutrition in America 2021, prepared statement 
      for the record.............................................   104
Booker, Hon. Cory:
    The State of Obesity Report..................................   108
    Academy of Nutrition and Dietetics, statement for the record.   200
    Defeat malnutrition today, statement for the record..........   203
    The Food Industry Association, letter of support.............   205
    Mission Readiness, letter of support.........................   209
    National Association of Nutrition and Aging Services 
      Programs, letter of support................................   224
    Physicians Committee for Responsible Medicine, statement for 
      the record.................................................   226

Question and Answer:
Mozaffarian, Dariush, M.D.:
    Written response to questions from Hon. John Boozman.........   230
    Written response to questions from Hon. Amy Klobuchar........   237
    Written response to questions from Hon. Joni Ernst...........   239
Odoms-Young, Angela, Ph.D.:
    Written response to questions from Hon. John Boozman.........   246
    Written response to questions from Hon. Amy Klobuchar........   255
    Written response to questions from Hon. Joni Ernst...........   257
Warne, Donald, M.D.:
    Written response to questions from Hon. John Boozman.........   260
    Written response to questions from Hon. John Hoeven..........   263
    Written response to questions from Hon. Joni Ernst...........   264
Stover, Patrick, Ph.D.:
    Written response to questions from Hon. Cory Booker..........   266
    Written response to questions from Hon. John Hoeven..........   270
    Written response to questions from Hon. Joni Ernst...........   271
Rachidi, Angela, Ph.D.:
    Written response to questions from Hon. John Boozman.........   273
    Written response to questions from Hon. Joni Ernst...........   276


                 THE STATE OF NUTRITION IN AMERICA 2021

                              ----------                              


                       TUESDAY, NOVEMBER 2, 2021

                                       U.S. Senate,
         Committee on Agriculture, Nutrition, and Forestry,
    Subcommittee on Food and Nutrition, Specialty Crops, 
Organics, and Research,
                                                    Washington, DC.
    The Subcommittee met, pursuant to notice, at 10:07 a.m., 
via Webex and in room 216, Hart Senate Office Building, Hon. 
Cory Booker, Chairman of the Subcommittee, presiding.
    Present or submitting a statement: Senators Booker, Leahy, 
Warnock, Braun, Hoeven, Ernst, Marshall, and Fischer.

 STATEMENT OF HON. CORY BOOKER, U.S. SENATOR FROM THE STATE OF 
   NEW JERSEY, U.S. COMMITTEE ON AGRICULTURE, NUTRITION, AND 
                            FORESTRY

    Senator Booker. Good morning, everyone. I am so pleased to 
call this Subcommittee on Food and Nutrition, Specialty Crops, 
Organics, and Research to order.
    I am privileged to be sitting next to the Ranking Member 
Braun, and on behalf of him and members of the Subcommittee, I 
would like to just really welcome our witnesses and say thank 
you all for coming here. It is a lot of time and energy and 
effort to come to Washington, DC, but this is so important. You 
all understand the urgency of this moment in American history 
and, I would say, human history.
    I want to start off by stating the fact that all of our 
witnesses agree on this reality, this urgency, that today in 
America we are facing a massive broad-based nutrition crisis, a 
crisis where diet-related diseases pose a serious threat to the 
health and well-being of our country. Nearly one out of every 
three dollars in the Federal budget--I want to say that again. 
Nearly one out of every three dollars in the Federal budget now 
goes to healthcare spending, with 80 percent of this money 
paying for the treatment of preventable diseases, and these 
costs are rising at a staggering rate.
    Currently, in the United States, half--of the U.S. 
population is pre-diabetic or has type 2 diabetes. In 1960, 
approximately three percent of the U.S. population was obese. 
Today, more than 40 percent of Americans are obese, and more 
than 70 percent of Americans--70 percent of Americans--are 
either obese or overweight.
    Even more shocking, one-quarter of our teenagers today are 
pre-diabetic or have type 2 diabetes, and obesity is the 
leading medical reason that 71 percent of young Americans are 
disqualified for military service.
    These data points are staggering, and they need to be fully 
digested.
    Now the numbers are worse in minority communities, 
dramatically so. The risk of diabetes, for example, is 77 
percent higher for Black people in America, and we are twice as 
likely to die from diabetes. As we will hear in today's 
testimony, the statistics are equally, if not more so, grim in 
our indigenous communities.
    The deadly nature of our nutrition crisis, which is in some 
of these diseases at epidemic levels, has been tragically 
magnified by the pandemic, by COVID-19, where we have seen much 
higher hospitalization rates and death rates for people with 
those diet-related diseases.
    Now let us be clear about something. The majority of our 
food system is being now controlled by just a handful of big, 
multinational corporations. These food companies carefully 
formulate and market nutrient-poor, addictive, ultra-processed 
foods, ultra-processed foods which now comprise two-thirds of 
the calories in children and teens in their diets in the United 
States. These companies want us to believe that the resultant 
diet-related disease, such as obesity and diabetes, are somehow 
a moral failing, that they represent a lack of will power or 
failure to get enough exercise. That is just a lie. It is a 
lie.
    The problem we have right now is not an individual moral 
failing. It is our collective policy failure. It is a policy 
failure because the Federal Government is currently subsidizing 
easy access to the foods that are high in calories but have 
minimal nutritional value while at the same time too many 
communities, rural and urban alike, lack access to the healthy 
foods they need to thrive.
    It is a policy failure because while the Federal Government 
tells us that our plates should consist largely of fruits and 
vegetables, currently less than two percent of our Federal 
agricultural subsidies in the United States go to these healthy 
foods.
    It is a policy failure because while other countries have 
begun to take on this crisis, focusing on the problems with big 
food companies and banning the marketing of junk food to 
children, in the United States, however, we continue to allow 
big corporations to spend billions of dollars every year to 
advertise the least nutritious products, such as fast foods, 
candy, sugary drinks to our children.
    In August, the Government Accountability Office (GAO) 
released a report that analyzed efforts by the Federal 
Government to address diet-related chronic health conditions 
that, as I said, are at epidemic levels. The GAO concluded that 
the Federal Government lacks a coordinated, overarching 
strategy aimed at reducing Americans' risk of diet-related 
chronic diseases.
    How do we now align our Federal policy with our goal of 
addressing this nutrition crisis that is causing so much death 
and disease? We can start by looking at history as a guide. In 
1969, the year that I was born actually, President Nixon 
convened the White House Conference of Food, Nutrition, and 
Health to address the urgent national concern of widespread 
hunger in the United States. What resulted was an unprecedented 
expansion and creation of vital programs dealing with that 
hunger crisis, programs like WIC that went on to tackle access 
to food.
    Fast-forward 52 years, while we have made progress 
addressing hunger in America, we are still grappling with food 
insecurity. Now we face that second food crisis, one of 
nutrition insecurity, where too many Americans are overfed but 
undernourished and are seeing these staggering rates of disease 
and early death.
    Despite being the wealthiest nation in the world, we have 
created a food system that relentlessly encourages the 
overeating of empty calories, literally making us sick and 
causing us to spend an ever increasing amount of our taxpayer 
dollars, literally trillions of dollars a year, on healthcare 
costs to treat diet-related diseases such as type 2 diabetes, 
heart disease, stroke, certain types of cancer, and chronic 
kidney disease, that are among the leading causes of 
preventable, premature death in our country.
    I believe we need to rethink the way we approach food and 
nutrition policy. Our lives literally depend upon it. That is 
why last week Senator Braun and I, along with Congressman 
McGovern and others, introduced legislation to create a second 
White House Conference on Food, Nutrition, Hunger, and Health 
that convenes public and private stakeholders to reimagine our 
Federal food and nutrition policy. The second White House 
conference needs to hear perspectives from a diverse set of 
stakeholders and communities such as we have here represented 
on our panel today.
    Let me close with this: This nutrition crisis we face is a 
threat. In fact, I would say it is the greatest threat to the 
health and well-being of our country right now. Millions and 
millions of Americans see this and understand this threat in 
their communities and their homes and their families and their 
own lives. It is also a threat to our economic security and our 
national security. We must act now.
    I will now turn to my friend and deeply grateful partner--
who I am deeply grateful to have as my partner, the Ranking 
Member, Senator Braun, for his opening statement.

 STATEMENT OF HON. MIKE BRAUN, U.S. SENATOR FROM THE STATE OF 
INDIANA, U.S. COMMITTEE ON AGRICULTURE, NUTRITION, AND FORESTRY

    Senator Braun. Thank you, Mr. Chairman, and thank you for 
the witnesses joining us here today. The State of Nutrition in 
America, a very important topic.
    It has been 52 years since President Nixon convened the 
White House Conference on Food, Nutrition, and Health and vowed 
to put an end to hunger in America for all time. That was a 
lofty goal back in 1969 and one that, as we can see, we are 
still chasing to some degree five decades later. As such, I 
hope that our hearing today will address both the successes and 
shortcomings and it will truly look at nutrition as being maybe 
the thing that we can use here to avoid entering the healthcare 
system because you are healthy to be in shape day after day.
    Since the White House conference in 1969, America's farmers 
have answered the call of a growing population and malnutrition 
among poorer American communities. Through farm-level 
innovations, agriculture is now able to make more from less and 
help protect the soils along the way. The U.S. has made great 
progress to reduce food insecurity, nutritional deficits, food 
borne illness over the course of the last five decades. 
However, our work is still far from over. Until no American 
goes to sleep hungry or is unsure from where his or her next 
meal will come from, we have not successfully completed the 
task.
    Our robust food security safety net is support by USDA's 
nutrition programs, totaling more than $100 billion per year in 
Federal spending. Following the White House conference, these 
programs were bolstered and fine-tuned to ensure that caloric 
deficiencies were on the path to eradication in the U.S.
    While the USDA's nutrition programs have helped more 
Americans during times of need, any discussion about the state 
of nutrition in America today must include a discussion about 
the quality . . . the quality of the foods that can be 
purchased through these programs. We all know that an excess of 
low quality foods can have negative health outcomes for 
Americans, empty calories, not ones that are making you 
stronger and healthier. Since 1969, obesity rates in the U.S. 
have increased from 12 percent to over 42 percent, clearly not 
heading in the right direction. Likewise, preventable chronic 
illnesses, like type 2 diabetes and coronary heart disease, 
continue to plague more and more Americans.
    Federal nutrition policies are still geared strictly to 
address caloric deficiencies, failing to prioritize the 
nutritional content of our food. As a result, reports 
consistently show that programs are even making poorer choices 
when it comes to Americans' nutrition, worst outcomes. Let me 
repeat that; our Federal nutrition programs may be making poor 
nutritional outcomes worse for low-income American families. 
This is an irresponsible use of taxpayer dollars as Congress's 
responsibility lies in ensuring that nutrition programs like 
Supplemental Nutrition Assistance Program (SNAP) are serving 
the best interests of both the recipients and our Nation as a 
whole.
    Failing to address issues of nutrition have broader 
spillover effects, like increasing Federal outlays for 
healthcare, and that is already where we spend way too much 
money vis-a-vis the rest of the world. Our healthcare expenses 
run between 18 and 20 percent of our GDP. Most other countries 
with similar results do it for 11 to 13 percent.
    Finally, we cannot have a conversation about the state of 
nutrition without discussing the harmful effects that 
unrestrained inflation has on the purchasing power of every 
American family. The New York Times recently highlighted the 
damaging impact of inflation, showing that in the last year 
prices for key staples have risen by more than 10 percent, 
unsustainable, and that is the cruelest of all taxes when we 
are trying to head in the other direction.
    These rising costs are driven by a multitude of factors not 
least of which is irresponsible Federal spending, where we have 
got to get a better bang for our buck. As this Subcommittee 
considers policies to help address nutrition insecurity, we 
must remember that simply dumping more money into our economy 
will only exacerbate the issue of nutrition insecurity for our 
most vulnerable, not to mention what inflation will do as well.
    Nutrition insecurity is a challenging problem that impacts 
our rural and urban communities alike. That is why I was proud 
to work with Chairman Booker to introduce legislation to 
convene a second White House Conference on Food, Nutrition, 
Hunger, and Health. Only through a serious bipartisan analysis 
and effort will we make true headway.
    In my own life's experience, I have chosen to live 
holistically through good nutrition, and when you stick with 
it, it works. It should be the foundation for every American 
citizen. In my own company, when I was wrestling with high 
healthcare costs 13 years ago, I made that as a priority, 
changed our system into being enabling my employees to become 
healthcare consumers, giving them tools like free biometric 
screenings, telling them about good nutrition, putting a little 
skin in the game to incentivize that you do it.
    This is a topic for another day and another conversation. 
We have not had a premium increase for my employees' companies 
in 13 years, and they enter into their deductibles less now 
than they did 13 years ago because we are emphasizing 
prevention, not remediation, and making my employees--and I 
think we can do it even in government--to where they invest in 
their own well being, and we give them the tools to do it.
    Thank you, Mr. Chair.
    Senator Booker. Thank you, Senator Braun. Senator Braun, 
you should put your placard up there. Somebody might mistake 
you for a pragmatic-minded businessperson and not a United 
States Senator.
    Senator Braun. Thank you.
    Senator Booker. Senator Leahy.
    Senator Leahy. They will not mistake me for the----
    Senator Booker. Sir, it is an honor to have you here. I 
know you have to leave very soon, but we are excited that you 
would like to come and make an opening statement.

STATEMENT OF HON. PATRICK J. LEAHY, U.S. SENATOR FROM THE STATE 
   OF VERMONT, U.S. COMMITTEE ON AGRICULTURE, NUTRITION, AND 
                            FORESTRY

    Senator Leahy. I appreciate the opening statement of both 
of you. When I became Chairman of the Agriculture Committee 
quite a few years ago, it was called the Senate Agriculture and 
Forestry Committee. I changed the name to Agriculture and 
Nutrition and Forestry, which is what it had been originally. I 
wanted to bring back the word ``nutrition'' for exactly the 
reasons both of you have said.
    When we are the wealthiest nation on Earth and we cannot 
handle our nutrition needs, that is a national security problem 
as well as anything else. I see in this pandemic that food 
insecurity has risen, children are left behind. I am proud of 
the efforts we made to meet the needs of those struggling in 
our communities, the historic investment in child nutrition 
programs currently, including the Build Back Better Act, that 
will increase access to school and summer meals for millions of 
children.
    We need to do more than just get the food on the table. As 
you both said, it needs to be healthy and nutritious food. 
Coming from a State like mine, I think it particularly helps if 
it is grown locally. Unfortunately, in many cases, this is not 
true. We need a coordinated effort from the Federal Government, 
down to the local level, that makes sure all Americans have 
access to nutritious foods but also bolstering regional supply 
chains that can best deliver food to these communities, 
particularly in our schools.
    I have looked at some of the statements that are going to 
be made. I am sure our outstanding witnesses today will tell us 
about how important it is for the health outcomes and dietary 
habits of children that school meals include healthy and 
locally grown foods. My staff will be here following this, and 
I will be sure--I will actually read all you have said when I 
get back from my Appropriations meeting.
    My State of Vermont has the strong tradition of farmers 
providing healthy and local choices in our supermarkets, but 
even with that many of our schools still struggle to include 
these products in school lunches. In nearly--in fact, nearly 60 
percent of the USDA Foods in Schools program spending goes to 
15 multinational corporations, not to local producers. These 
corporations, we know, have been plagued by supply chain 
disruptions that have caused food shortages in schools across 
the country. We need more resilient supply chains. We need 
lower procurement barriers. We have to make it easier for local 
and small-scale producers to feed their children.
    Mr. Chairman, I thank your leadership on this issue, to 
work with USDA to ensure that more schools have the opportunity 
to work with their local farmers. All three of us can give a 
quick list of farmers who would be glad to work with them. I 
have also long championed the Farm to School program, which 
strengthens and supports this link between local farmers and 
students. Schools are effective and currently underutilized 
settings for nutrition policies, and so I am interested to hear 
what might be said about how Farm to School can help that.
    I look forward to hearing from all of you. I am just so 
happy you are doing this. I would state to the witnesses and 
the press who might be here I have heard what Senator Booker 
said about nutrition. He says that when the cameras are not on. 
The Ranking Member, we have talked about this, usually in our 
prayer meetings in the inner sanctum sometimes late in the 
evening, on the need that we have to do this. Whether we are 
parents or grandparents or citizens, if we do not get a hold of 
this, if we do not do something about this issue, what are we 
leaving our children in the next generation?
    Thank you, Mr. Chairman. I am so proud of this hearing.
    Senator Booker. Thank you very much. Again, we understand 
you are going to an Appropriations meeting, and we hope that 
you will remember New Jersey.
    I would like to now introduce the witnesses.
    I want to acknowledge the presence of Senator Joni Ernst, 
another person very concerned about these issues. It is so 
great to see you here.
    I would like to start off with introducing Dr. Mozaffarian.
    Senator Leahy. I am sorry. I did not see Senator Ernst come 
in. She is also from a State that knows how important this is.
    Senator Booker. Yes. Dr. Mozaffarian is a cardiologist. He 
has a heart, too. He is the Dean and the Jean Mayer Professor 
at Tufts Friedman School of Nutrition, Science, and Policy, and 
Professor of Medicine at Tufts School of Medicine. His work 
aims to create a food system that is nutritious, equitable, and 
sustainable. Dr. Mozaffarian has authored more than 450 
scientific publications on dietary priorities for obesity, 
diabetes, cardiovascular disease, and on evidence-based 
approaches and innovations to reduce these burdens in the U.S. 
and globally. He has served in numerous advisory roles, and his 
work has been featured in a wide array of media outlets. 
Thomson Reuters has named him as one of the world's most 
influential scientific minds.
    I am grateful that you are here today.
    Dr. Odoms-Young is an Associate Professor and Director of 
the Food and Nutrition Education in Communities Program and New 
York State Expanded Food and Nutrition Education Program. In 
2021, she joined the Cornell faculty after spending 13 years at 
the University of Illinois at Chicago in the Department of 
Kinesiology and Nutrition. Dr. Odoms-Young's research explores 
the social and structural determinants of dietary behaviors and 
related health outcomes in low-income populations in Black, 
indigenous, and people of color. Her work also centers on 
developing culturally responsive programs and policies that 
promote health equity, food, and community resilience.
    I want to thank Dr. Odoms-Young for being here as well, 
being a part of this hearing as well.
    Dr. Donald Warne serves as Associate Dean of Diversity, 
Equity, and Inclusion. He is Chair of the Department of 
Indigenous Health, Director of the Indians Into Medicine and 
Public Health programs and Professor of Family and Community 
Medicine at the School of Medicine and Health Sciences at the 
University of North Dakota. The doctor is the Principal 
Investigator for the Indigenous Trauma and Resilience Research 
Center at UND, and he also serves as the Senior Policy Advisor 
to the Great Plains Tribal Leaders Health Board in Rapid City, 
South Dakota. He also spent several years as a primary care 
physician. He is a member of the Oglala Lakota tribe from Pine 
Ridge, South Dakota, and comes from a long line of traditional 
healers and medicine men.
    I want to thank you so much for being a part today.
    I want to now recognize Ranking Member Braun who will 
introduce our next two witnesses.
    Senator Braun. Thank you, Mr. Chairman. Our next witness is 
Dr. Patrick Stover, who is Vice Chancellor and Dean for 
Agriculture and Life Sciences at Texas A&M AgriLife, and 
Director of Texas A&M AgriLife Research. Earlier in his career, 
he directed the Division of Nutritional Sciences at Cornell 
University and has advised policymakers from the Centers for 
Disease Control and Prevention, World Health Organization, and 
the United States Food and Drug Administration. A testament to 
his leadership in biochemistry, nutrition, and food systems, 
Dr. Stover is an elected member of the National Academy of 
Sciences and the former President of the American Society of 
Nutrition.
    Our final witness this morning, Dr. Angela Rachidi, is 
joining us remotely from Wisconsin. Dr. Rachidi is a Senior 
Fellow and the Rowe Scholar in Poverty Studies at the American 
Enterprise Institute (AEI), where she studies poverty and the 
effects of the Federal safety net programs on low-income people 
in America. She specializes in support programs for low-income 
families, including the Temporary Assistance for Needy 
Families, the Child Care and Development Block Grant, and the 
Supplemental Nutrition Assistance Program. Before joining AEI, 
she was a Deputy Commissioner for Policy Research at the New 
York City Department of Social Services.
    Thank you, Dr. Rachidi, and to each of our other witnesses 
for joining us this morning.
    Senator Booker. All right, everyone. Fasten your seatbelts. 
I have read all the testimonies. These are extraordinary 
declarations of the State of our American nutrition, and I am 
excited about them.
    Dr. Mozaffarian, would you please proceed with your 
testimony.

 STATEMENT OF DARIUSH MOZAFFARIAN, M.D., DEAN, FRIEDMAN SCHOOL 
  OF NUTRITION SCIENCE AND POLICY, TUFTS UNIVERSITY, BOSTON, 
                         MASSACHUSETTS

    Dr. Mozaffarian. Dear Chairman Booker, Ranking Member 
Braun, and other distinguished members of the Committee, thank 
you for convening this critical hearing today and for the 
opportunity to testify. My testimony reflects my expertise and 
experiences as a cardiologist, public health expert, and 
scientist.
    As a doctor, I see firsthand people of all ages and 
backgrounds suffering from diet-related illness. As a public 
health expert, I see the incredible challenges Americans face 
every day to obtain and eat nourishing food. As a scientist, I 
see the exciting advances on which foods help or harm our 
bodies and on which policy changes can support nutrition 
security and health.
    As has been outlined, we face a national nutrition crisis, 
one that is cutting lives short, costing us trillions of 
dollars, and holding us back from achieving our goals as 
individuals and as a Nation. The situation is dire. Because of 
nutrition insecurity and diet-related disease, more Americans 
today are sick than are healthy. One in two adults have 
diabetes or pre-diabetes, and three in four have overweight or 
obesity.
    The recent GAO report that Senator Booker mentioned puts an 
exclamation point on this, concluding that diet-related 
conditions are deadly, costly, and largely preventable. These 
diseases caused over half of U.S. deaths in 2018, and during 
COVID-19, Americans with diet-related conditions were 12 times 
more likely to die following infection. At the same time, 
nearly 40 million Americans experienced food insecurity in 
2018, and in 2020 during the pandemic, food insecurity grew for 
households with children.
    In every State in our Nation, nutrition insecurity and 
diet-related diseases also disproportionately afflict Americans 
who have the least advantage, those who are low-income, rural, 
or racial or ethnic minorities. Poor nutrition is harming our 
children, creating future suffering, disability, and lost human 
potential. Among two- to five-year-olds, one in ten are already 
obese. Among teens, one in five has pre-diabetes, a shocking 
wakeup call for the future of our country.
    These diet-related diseases are also the top drivers of 
preventable healthcare spending. Healthcare spending now 
accounts for almost one in five dollars in our economy and 
nearly one in three dollars in the Federal budget. Eighty 
percent of this goes to treat preventable, chronic diseases. 
This is not a path for balanced government budgets, thriving 
U.S. businesses or a competitive national economy.
    The top cause of poor health and nutrition is largely 
ignored by the healthcare system. That simple but striking fact 
explains so much about where we are today, hundreds of millions 
of sick Americans and spiraling, preventable healthcare costs.
    Poor nutrition also threatens our national security. Top 
military leaders at Mission: Readiness and elsewhere have 
talked about this. Three in four young Americans are ineligible 
to serve in the military, and the top medical reason is 
obesity.
    These are daunting challenges, but they are also 
opportunities. Today our country has no plan, no national 
strategy to address this, to fix food. The science is now 
available to create a plan to address this national crisis with 
practical, evidence-based, and cost-effective solutions. We 
have in our grasp the ability to create a nourishing, 
sustainable food system, one that promotes health and well-
being for all Americans and economic well-being and national 
security for our Nation.
    As I hope we will discuss more during this hearing, there 
are specific actions across six priority domains that can 
catalyze a healthier food system, one that advances nutrition, 
ends hunger, improves health and health equity, and reduce 
healthcare spending.
    What do we actually need to do? Six priority domains. No. 
1, we need to advance nutrition science and research. No. 2, we 
need to leverage the power of food as medicine in healthcare. 
No. 3, we need to strengthen and leverage our Federal nutrition 
programs, in particular, school meals, SNAP, and WIC. No. 4, we 
have to catalyze business innovation, entrepreneurship, new 
businesses, jobs in this area. No. 5, we have to expand 
nutrition education and public health. No. 6, we have to 
actually coordinate all of this, coordinate Federal food 
policy, including new leadership structure and authority to do 
so.
    It is time to fix food, but we can only do this if we 
actually have a plan, a real national strategy. Senators Booker 
and Braun, the two of you, together with Representatives 
McGovern and Walorski in the House, have called for the second 
White House Conference on Food, Nutrition, Hunger, and Health. 
It has been 52 years since our Nation came together to chart a 
national strategy around hunger. Much has changed in 52 years. 
It is time to bring everyone together again to reimagine our 
national food system for the next 50 years.
    We can make America the 21st century breadbasket for 
nourishing food for our country and for the world, food that 
heals our bodies, ends hunger, reduces healthcare spending, 
supports our military, revitalizes rural America, stewards our 
natural resources, and creates new jobs and businesses.
    Thank you for your leadership. I am pleased to answer any 
questions.

    [The prepared statement of Dr. Mozaffarian can be found on 
page 42 in the appendix.]

    Senator Booker. Thank you so much, Dr. Mozaffarian.
    Before I move to Dr. Odoms-Young, I want to just thank 
Senator Marshall, someone who has an obvious concern for these 
issues, and grateful for his leadership and presence here 
today.
    Dr. Odoms-Young, you are recognized for your five minutes.

STATEMENT OF ANGELA ODOMS-YOUNG, PH.D., ASSOCIATE PROFESSOR AND 
 DIRECTOR, FOOD AND NUTRITION EDUCATION IN COMMUNITIES PROGRAM 
AND NYS EXPANDED FOOD AND NUTRITION EDUCATION PROGRAM (EFNEP), 
 DIVISION OF NUTRITIONAL SCIENCES, CORNELL UNIVERSITY, ITHACA, 
                            NEW YORK

    Dr. Odoms-Young. Thank you. Chair Booker, Ranking Member 
Braun, and members of the Agriculture Subcommittee on Food and 
Nutrition, Specialty Crops, Organics, and Research, thank you 
for allowing me the opportunity to speak before you today about 
the state of nutrition in America with a specific focus on 
Black communities.
    The adverse health, social, and economic consequences of 
suboptimal diets in the United States are well documented. 
Extensive evidence indicates that poor nutrition is a major 
driver of America's high chronic disease burden, leading to 
sizable rates of death and disability from cardiovascular 
disease, hypertension, type 2 diabetes, and certain cancers. 
Further exacerbating the national impact of poor nutrition is 
the reality that its associated burden is not equally shared 
across all racial, ethnic, and socioeconomic groups.
    People of color overall and Black populations specifically 
have dietary intakes that fall short of the national 
recommendations and face higher rates of diet-related chronic 
diseases. For example, Black Americans are 60 percent more 
likely to be diagnosed with diabetes by a physician, 2.3 times 
more likely to be hospitalized for lower limb amputations, and 
almost four times as likely to develop kidney failure when 
compared to rates of White Americans.
    Unfortunately, in the last year, we have seen racial 
inequities in health and nutrition worsen as a result of the 
COVID-19 pandemic, with Black-White gaps in life expectancy 
widening. This disproportionate toll from COVID can be 
partially explained by the high prevalence of nutrition-related 
chronic diseases among Blacks as compared to Whites.
    Additionally, economic barriers, including a greater 
likelihood of living in racially segregated, disinvested areas, 
higher rates of being uninsured and underinsured, and a wage 
disparity where Black American households earn almost half that 
as of White households, also sets the stage for Black 
communities to be more nutritionally vulnerable. For example, 
although food security rates in the U.S. generally remained 
stable from 2019 to 2020, the prevalence of food insecurity for 
Black households increased from 19.1 percent to 21.7 percent.
    Food insecurity not only contributes to higher chronic 
disease rates but also increases the risk for maternal 
depression, developmental delays early in life, and lower 
academic achievement. Consequently, it is likely that this 
increase will have lingering effects for years to come.
    While, traditionally, researchers and practitioners focused 
attention on individual knowledge and motivation as key drivers 
of dietary behaviors, science generated for more than three 
decades highlights the importance of social and structural 
determinants of health. Many studies have shown that being 
healthy is not just about making smart choices or bad genes. 
For many Americans, systemic and structural disadvantage moves 
good health out of their reach.
    A common saying in public health is that ``your zip code 
matters more than your genetic code.'' Black Americans are more 
likely to live in neighborhoods that are considered obesogenic, 
environments that promote obesity, specifically characterized 
by limited access to healthy food options, and high 
availability and in-store marketing of low-cost, energy-dense 
foods and drinks of minimal nutritional value. It is 
particularly striking that these Black-White inequities in 
healthy food environments exist at every level of income.
    The first White House Conference on Food, Nutrition, and 
Health resulted in landmark legislation that provided the 
foundation for the Federal food and nutrition infrastructure we 
know today and raised awareness about widespread malnutrition 
and hunger being experienced by families and communities 
throughout America.
    Similar to 1969, the events of 2020 amplified our level of 
consciousness about the ways in which social, structural, and 
political conditions create different experiences and 
opportunities for people living in the U.S. We did not get here 
by chance but through policies, policies over centuries and at 
every level of government, such as redlining and yellowlining, 
that restrict access for some but create opportunities for 
others.
    In closing, we need to continue to prioritize nutrition 
security with the lens of racial equity. The time to leverage 
new policy and programmatic efforts to decrease food hardship 
in Black communities and increase opportunities for better 
access is now.
    Thank you for your attention in considering nutrition's 
pivotal role in promoting our Nation's health. I look forward 
to answering your questions. Thank you so much.

    [The prepared statement of Dr. Odoms-Young can be found on 
page 54 in the appendix.]

    Senator Booker. You are very, very welcome. Thank you for 
your testimony.
    Dr. Warne, you are very fortunate because you have one of 
our more esteemed Senators, the beneficent banker from 
Bismarck. My colleague from North Dakota would like to 
introduce you again.
    Senator Hoeven. Thank you, Mr. Chairman. I appreciate, also 
I admire, your alliteration.
    Senator Booker. Thank you very much, sir.
    Senator Hoeven. Fantastic. Thank you. I am very pleased 
that I can take just a minute to introduce Dr. Donald Warne. He 
is here with us today to share his insight into the health and 
well-being of American Indians and Alaska Natives, including 
those of the five federally recognized tribes located in North 
Dakota.
    Dr. Warne is a member of the Oglala Lakota tribe and is 
Director of the Indians Into Medicine Program and the Public 
Health Program at the University of North Dakota Medical 
School. I just have to tell you that this is one of the most 
amazing programs in the country. It encourages Native Americans 
to enter the field of medicine as doctors and nurses, med 
techs, and everything else.
    We have such a need in this country to get more young 
people into medicine, particularly with our aging population, 
that this is just a model of a fabulous program that does that, 
not only making a difference in the lives of so many young 
people, young Native Americans, but think of what they do for 
all of us who need medical care and attention and when we have 
such an acute shortage of people in the medical profession. 
Thank you for your leadership of this incredible program.
    I will just finish up by saying, when I chaired the Indian 
Affairs Committee last Congress, I invited Dr. Warne to 
participate in a roundtable discussion on advancing tribal 
public health partners, and I really appreciated the insight 
you brought to that meeting, and I very much look forward to 
your testimony here today as well.
    With that, again, I would like to thank the Chairman and 
Ranking Member for that point of privilege.
    Senator Booker. Thank you very much.
    Doctor, there is a bipartisan divide there. Would you 
correct me, please, with the correct pronunciation of your 
name? He was saying, ``Warne.'' I think he is usually right.
    Dr. Warne. It is Warne, yes, but you make it sound cooler.
    Senator Booker. You can call me ``Book-air,'' if you would 
like.
    Senator Hoeven. That is because Senator Booker is cooler.

 STATEMENT OF DONALD WARNE, M.D., ASSOCIATE DEAN AND DIRECTOR, 
   INDIANS INTO MEDICINE (INMED) AND PUBLIC HEALTH PROGRAMS, 
  SCHOOL OF MEDICINE AND HEATH SCIENCES, UNIVERSITY OF NORTH 
               DAKOTA, GRAND FORKS, NORTH DAKOTA

    Dr. Warne. Chairman Booker, Ranking Member Braun, members 
of the Subcommittee, Hihanni wast`e. Wopila.
    Good morning and thank you for the invitation to speak 
today. Senator Hoeven, thank you so much for the kind words.
    In addressing the state of nutrition in America in 2021, we 
need to recognize that for American Indians we have a crisis of 
nutritional disparities and subsequent health disparities. Less 
access to healthy foods and dependence on inexpensive processed 
foods leads to weight gain. Obesity rates for American Indians 
and Alaska Natives are at a critical level. According to the 
CDC, 48 percent of the American Indian and Alaska Native 
population over age 18 is obese, 48 percent, compared to 30 
percent of the non-Hispanic White population.
    Obesity is a significant risk factor, as we know, for type 
2 diabetes and heart disease, two of the leading causes of 
death for indigenous people in the United States. Although we 
have seen some modest improvements in recent years, American 
Indians and Alaska Natives still have the highest prevalence of 
type 2 diabetes in the Nation, and American Indian and Alaska 
Native adults are almost three times more likely than non-
Hispanic White adults to be diagnosed with diabetes. Heart 
disease is the leading cause of death for American Indians and 
Alaska Natives, and the prevalence of coronary heart disease is 
about 50 percent greater for indigenous peoples.
    In my personal experience, I served as a family physician 
with the Gila River Indian Community in Arizona for a number of 
years. This is a community with among the highest rates of type 
2 diabetes in the world. I have seen firsthand the challenges 
in managing diabetes in a population that has limited access to 
healthy food sources.
    Also, I am originally from Kyle, South Dakota, on the Pine 
Ridge Indian Reservation, and the nearest supermarket is 90 
miles away in Rapid City. As a result, many of my family 
members contend with significant barriers to accessing healthy 
foods, and many of them are suffering from diabetes and heart 
disease.
    In many of our tribal communities, substantial expenditures 
are made to manage the complications of diabetes, such as 
dialysis for kidney failure, coronary artery bypass grafting, 
and other surgical procedures for heart disease, amputations 
for diabetes neuropathy. With kidney failure, people are 
automatically eligible for Medicare, and in many of our 
communities, people who are confined to wheelchairs due to 
amputations utilize social programs that will build a ramp for 
them to access their homes. Rather than the significant 
financial expenses and decreases in quality of life associated 
with addressing just the complications of diabetes and heart 
disease, would it not make more sense to invest in healthy food 
in the first place?
    One major historical consideration is the forced relocation 
of American Indian people from their ancestral homelands, 
thereby severely restricting access to traditional food systems 
that historically included regionally specific hunting, 
gathering, fishing, and farming. The loss of traditional food 
sources also resulted in dependence on Federal Government 
programs such as the Commodity Food Program, the FDPIR, and 
that included historically the distribution of food such as 
lard, canned meats, white flour, salt, and sugar.
    According to the North Dakota Department of Health, the 
average age of death in the decade between 2009 and 2019, so 
the decade before the pandemic, the average age of death for 
American Indians was 56.8 years, and average age of death for 
the White population was over 77 years. Just a tremendous 
disparity, about 20 years, of average age of death.
    Loss of access to traditional food systems, combined with 
limited financial opportunities in many of our reservation 
communities, are important social determinants of health. The 
American Indian and Alaska Native population has significant 
health challenges. Moving forward, a multi-pronged approach, in 
collaboration with numerous stakeholders and organizations, is 
needed to address the upstream social determinants of health 
and to increase access to healthier foods.
    Promising best practices and strategies for American Indian 
and Alaska Native populations can be considered in several 
focus areas, including: one, improving existing food programs; 
two, promoting breastfeeding and early childhood nutrition; 
three, promoting food sovereignty and increasing access to 
traditional foods; four, expanding locally cultivated foods; 
and five, considering taxing unhealthy foods and subsidizing 
healthier options.
    Food programs that work well in cities or suburbs, where 
there is predominantly nonindigenous populations, may or may 
not work effectively in tribal communities. We do have to 
recognize that one size does not fit all when we are looking 
for policy solutions.
    In closing, we need to recognize that we have a crisis of 
nutritional disparities among American Indians and Alaska 
Natives. We need to fundamentally change our approach to 
nutrition and to develop new strategies to address nutrition 
and obesity-related health inequities. I applaud the idea of 
having a second White House Conference on Nutrition to gather 
more community-based input regarding the potential solutions 
and to develop action items. We also need a comprehensive 
policy approach that is well coordinated, and we need to 
understand the nuances of engaging tribes in these areas. 
Ideally, we will include stakeholders with lived experience as 
part of these important discussions moving forward.
    Finally, please know that I am deeply honored to be here. 
Indigenous voices are not always at the table, and I really 
appreciate this opportunity to address each of you. I look 
forward to further discussions and questions. Thank you so 
much.

    [The prepared statement of Dr. Warne can be found on page 
64 in the appendix.]

    Senator Booker. No, thank you, Dr. Warne, for your 
compelling testimony.
    I would like to now recognize Dr. Stover for his five 
minute remarks.

 STATEMENT OF PATRICK STOVER, PH.D., DEAN AND VICE CHANCELLOR 
   FOR AGRICULTURE AND LIFE SCIENCES, TEXAS A&M UNIVERSITY, 
                     COLLEGE STATION, TEXAS

    Mr. Stover. Chairman Booker, Ranking Member Braun, and 
members of the Subcommittee, thank you for the opportunity to 
testify before you today.
    My name is Patrick Stover, and I serve as Vice Chancellor, 
Dean, and Director of Research for the Texas A&M University 
System and Agriculture and Life Sciences, a Statewide 
organization known as AgriLife. I am fortunate to lead one of 
the largest and most comprehensive agriculture programs in the 
Nation, encompassing 5,000 people and a $400 million budget. 
AgriLife covers the entire agriculture value chain, from food 
production and farm inputs to consumer behavior and human 
nutrition.
    Today, I want to provide my perspective on the state of 
agriculture, the food system, and its connection to hunger. I 
will provide some context to the enormous challenges we face 
but, more importantly, give you a sense of the opportunities to 
reimagine the role of agriculture in transforming our lives.
    First, a little context. In 1970, Norman Borlaug won the 
Nobel Peace Prize for sparking the Green Revolution. His 
efforts transformed global food systems to be abundant, 
affordable, and high in caloric density. These successful 
efforts dramatically reduced hunger.
    Today, we face a growing crisis of diet-related chronic 
disease which costs the U.S. economy over $1 trillion annually 
and affects nearly half of all adults. We need to buildupon 
Borlaug's legacy in a revolutionary new way by expanding our 
mission from simply using food to eliminate hunger and 
undernutrition to using food to become healthier. This can only 
be achieved by innovating throughout the entire agriculture 
food supply chain and by advancing rigorous science, not merely 
focusing on what some deem to be healthy foods.
    With that said, urbanization, historic underinvestment in 
agriculture research, gaps in knowledge, competing agendas, and 
a deficit in public trust all contribute to the growing 
disconnect between people and the food they eat. To put it 
bluntly, that disconnect threatens agriculture, the food 
supply, and the health of our society.
    Fortunately, agriculture is uniquely positioned to be the 
solution. With current and emerging technologies, we can tailor 
agriculture and food systems to support any and all desired 
outcomes. To that end, Texas A&M AgriLife is well positioned to 
lead nationally, in partnership with other land grant 
universities and the USDA ARS centers.
    I am grateful for the new investments from Congress, the 
State of Texas, and the USDA ARS that enabled Texas A&M 
AgriLife to launch two long-term innovative efforts. First, the 
Institute for Advancing Health Through Agriculture will advance 
research that connects production agriculture with human, 
environmental, and economic health outcomes. Second, the 
Agriculture, Food and Nutrition Scientific Evidence Center will 
be a global resource for policymakers in providing nonbiased, 
comprehensive, scientific information concerning the human, 
environmental, and economic effects of any proposed changes to 
the food system and agriculture system. These efforts are now 
launching and mark an important first step in our collective 
efforts to solve some of the most pressing problems facing our 
Nation and the world.
    Equally important, we must bolster education and earn 
public trust so individuals can make the best informed 
decisions for themselves. The land grant university system is a 
network that is an extraordinary resource that should be 
playing a much more active role in nutrition education across 
the Nation. These institutions are a national treasure, 
publicly funded and therefore independent, with the mission of 
improving the quality of life for all members of society.
    Before I conclude, I would be remiss if I did not 
acknowledge the efforts of the leaders in this room to convene 
another White House Conference on Food, Nutrition, Hunger, and 
Health. As a nutrition scientist who has dedicated my entire 
career to advancing research between nutrition and disease, I 
know these conversations are vitally important. With that said, 
agriculture must have a seat at the table if we are going to be 
successful.
    The cost of the current situation cannot be overstated. 
Diet-related chronic diseases place a huge financial burden on 
individuals, the healthcare system, the American economy, and 
are crippling quality of life for most Americans. While 
historic efforts to eliminate hunger and food insecurity were 
important and well intentioned, hunger cannot be considered in 
the absence of agriculture and health.
    With that, thank you for the opportunity to testify, and I 
look forward to your questions.

    [The prepared statement of Dr. Stover can be found on page 
88 in the appendix.]

    Senator Booker. Thank you, sir, for that excellent 
testimony.
    I would like to now recognize Dr. Rachidi for her five 
minutes.

  STATEMENT OF ANGELA RACHIDI, PH.D., SENIOR FELLOW AND ROWE 
 SCHOLAR, AMERICAN ENTERPRISE INSTITUTE (AEI), WASHINGTON, D.C.

    Dr. Rachidi. Chairman Booker, Ranking Member Braun, and 
members of the Subcommittee, thank you for the opportunity to 
testify on the important issue of nutrition in America and 
thank you for allowing me to participate in today's hearing 
remotely.
    My name is Angela Rachidi, and I am a Senior Fellow in 
Poverty Studies at the American Enterprise Institute, where I 
have spent the past several years researching policy that is 
aimed at reducing poverty. As Senator Braun mentioned, before I 
joined AEI, I was a Deputy Commissioner for the New York City 
Department of Social Services for more than a decade, where I 
oversaw the agency's policy research. Among other programs that 
we administered, we oversaw SNAP, which provided benefits to 
almost two million New Yorkers each month.
    My testimony covers three main points. First, poor diet and 
overconsumption of food have created a major public health 
crisis in the U.S., with serious health and financial 
ramifications. Second, our nutrition assistance programs have 
mixed success in supporting nutrition among low-income 
households and in many ways contribute to the problem. Third, 
instead of pursuing bipartisan recommendations to improve our 
nutrition assistance programs, the Federal Government's actions 
over the past year have undermined these efforts.
    Problems associated with poor diet afflict millions of 
Americans at a tremendous public cost, as we have already heard 
today. We know from decades of research that obesity and rates 
of being overweight in the U.S. are at crisis levels. We know 
that poor diet is a leading cause of poor health and 
contributes to very high rates of chronic disease. As we have 
heard, the associated costs are staggering.
    Although the aim of our Federal food assistance programs 
was originally to reduce hunger, the public health crisis 
caused by poor diet and overconsumption of food must now take 
priority. While the Federal Government's nutrition assistance 
programs cannot solve the problems of poor diet and chronic 
disease alone, they can play an important role. The USDA 
operates 15 nutrition assistance programs, with the Federal 
Government spending more than $100 billion per year on food 
assistance to U.S. households. Evidence shows that these 
programs effectively reduce hunger, but they could do much more 
to support better nutrition and help address poor health 
outcomes.
    One of the main problems with the USDA's nutrition 
assistance programs is that they lack a cohesive nutrition 
strategy. SNAP is a prime example. According to my own 
research, the Federal Government added $50 billion to the 
program in 2020, a level that I project will remain this high 
for several years to come. However, as my colleague, AEI 
colleague, Scott Winship and I showed in October 2020, we knew 
that hunger among U.S. households held constant during the 
worst months of the pandemic for the U.S. economy. Yet, Federal 
lawmakers continued to expand SNAP benefits into this year and 
now permanently without addressing any of the underlying 
nutrition concerns associated with the program.
    This is concerning because research shows that SNAP 
actually contributes to poor diet quality. The USDA recently 
increased SNAP benefit levels because they determined that SNAP 
households should consume more calories. This is entirely 
counterproductive, with research showing that overconsumption 
of calories is a major contributor to the problem.
    Data on what SNAP households purchase add to these 
concerns. Three of the top five largest expenditure categories 
among SNAP households are sweetened beverages, frozen prepared 
foods, and prepared desserts. My point in mentioning this 
finding is not to judge what SNAP households purchase. Instead, 
it is to acknowledge the reality that billions of Federal 
dollars earmarked to improve nutrition among low-income 
households are primary being used on foods and beverages that 
are major contributors to poor health.
    More than a decade ago, in 2010, I was part of an effort by 
New York City Mayor Michael Bloomberg to pilot a project 
restricting sugary beverages from SNAP purchases. The USDA 
denied our efforts. Since then billions of SNAP dollars have 
supported the purchase of unhealthy products across the 
country, and child obesity rates nationally have increased to 
almost 20 percent. That is one in five children in this country 
are obese.
    In 2017, I was part of a bipartisan policy center task 
force on leveraging Federal programs to improve nutrition. We 
developed 15 recommendations that the Federal Government could 
implement to improve nutrition among program participants. They 
all remain relevant today.
    The main point I want to make is that the Federal nutrition 
assistance programs have a role to play in improving the diets 
and health of Americans. The Federal Government spends upwards 
of $100 billion per year on these programs, the largest of 
which involves SNAP. The problems of poor diet quality and 
health consequences in America are bigger than SNAP, but it can 
play a role in helping to address them. This includes a 
holistic approach that combines restrictions on purchases, 
incentives for healthy eating, and nutrition education. This 
approach has received bipartisan support in the past and should 
be used as a framework moving forward.
    Thank you, and I look forward to answering your questions.

    [The prepared statement of Dr. Rachidi can be found on page 
95 in the appendix.]

    Senator Booker. Thank you for that great testimony, and 
your experiences across the river from the metropolis of 
Newark, New Jersey, were really helpful to me, watching you.
    I want to jump right into question and answering. Votes 
have been called. The Ranking Member and I have worked out a 
way that we can both go vote. I am going to read my questions, 
run to vote, come back, relieve him to do the same.
    I want to start off, Dr. Mozaffarian, with some of the 
staggering data that should appeal to everybody in the Senate 
about as you look out at healthcare costs. You mentioned that 
our Nation spends more on healthcare than any other segment of 
our economy, as you said, nearly one in every five dollars 
within our economy but, staggeringly, one in every three 
government dollars almost. Yet, the top cause of poor health, 
our food, is largely missing from the healthcare debate. The 
healthcare debate in Washington seems to be more about access 
but not why is there so much demand.
    Can you speak to the impact of food on our Nation's 
healthcare spending and the current trajectory we are on with 
that spending if we do nothing different?
    Dr. Mozaffarian. Thank you, Chairman Booker for that 
question. I mean, we are on a path to disaster. If three in 
four houses in our country were on fire and all we did was 
build more firehouses and hire more firemen, right, that would 
not be sensible; and yet, that is what we are doing with 
health, right? The majority of Americans are sick, and all we 
are doing is building systems to treat the downstream causes. 
With most houses in the country on fire, we need to figure out 
what is causing the fires and put them out rather than only 
focusing on the downstream treatment.
    A recent analysis by The Rockefeller Foundation found that 
across the food supply chain we spend about $1.1 trillion each 
year on food, and at the same time poor diet causes about $1.1 
trillion in healthcare spending and lost productivity from 
diet-related illness. For every dollar we spend on food, our 
economy loses one dollar due to illness, due to healthcare 
costs and lost productivity. That is not a winning formula.
    As just one example: type 2 diabetes, we keep mentioning 
this. We will keep talking about this because it is really the 
canary in the coal mine for the nutritional health of our 
Nation. It is a devastating disease that is almost entirely 
preventable and treatable through better nutrition.
    The U.S. Government, States and Federal, spends $160 
billion each year in direct healthcare spending on diabetes, 
more than the entire budget of the USDA. Nationally, one in 
seven healthcare dollars overall is spent on diabetes. Just a 
single diabetes drug, just one drug, can cost $5,000 to $10,000 
per year with out-of-pocket costs of more than $2,000 per year. 
Diabetes costs for the government have risen 25 percent in five 
years--25 percent in five years.
    This is absolutely not sustainable. Rising healthcare costs 
are squeezing every other priority out of the Federal budget, 
States' budgets, and in the balance sheets of U.S. businesses. 
We have to get these healthcare costs under control, and we are 
absolutely not going to do it until we address the top cause, 
which is poor nutrition.
    Senator Booker. I mean, that is staggering, the fact that 
we have seen spending go up just for one disease so much, 
diabetes, and now it is more than the entire Department of 
Agriculture. As you said, I think that just to absorb that, 
that in five years alone, the last five years, our spending on 
diabetes has gone up 25 percent. What could the next five years 
potentially bring if we do nothing?
    I think the point that you made there that I want to ask 
you about is that we have enough evidence that we know some 
strategies that could interrupt this and make it better, and 
they are promising strategies. I am wondering. They are 
strategies like Food as Medicine and access. I think some of 
the other witnesses here testified that providing better access 
to healthy food, dollars spent there could actually save 
healthcare dollars, to get the double bonus as opposed to what 
we are seeing now as currently the dollars spent we get a 
double loss.
    I am wondering if you could maybe speak to some of those 
strategies that could integrate food and nutrition into our 
healthcare system and prevent what is the tidal wave, the 
tsunami, that no one is talking about when they talk about our 
Federal budget. Again, the debates here are stuck in these 
debates about, as you said, how many more firehouses do we need 
as opposed to how do we stop the fire.
    Dr. Mozaffarian. Well, this is what is really exciting 
about where we are today. Some of the most exciting science has 
been about integrating food and nutrition into healthcare to 
reduce disease, increase equity, and lower healthcare costs. I 
call that Food as Medicine: how do we get food into the 
healthcare system. It is really a simple four-part formula, 
with every part really clear, easily addressed, and in a 
bipartisan fashion.
    The first is medically tailored meals. We have to have 
Medicare/Medicaid test, implement, and scale medically tailored 
meals. These are giving home, nutritionally tailored meals to 
the sickest patients with severe chronic conditions like kidney 
failure or heart failure, poorly controlled diabetes, cancer. 
Research has shown that giving medically tailored meals to 
these sick patients reduces hospitalizations, reduces ER 
visits, reduces nursing home visits, and even accounting for 
the cost of the program, actually saves money: in one analysis 
up to $10,000 per patient per year.
    The second part of the formula is produce prescriptions, 
for people that have diet-sensitive diseases but are not quite 
that sick and they can still shop and cook. A doctor should be 
able to write a prescription for fruits, vegetables, beans, and 
other healthy foods that is partly or fully covered by 
insurance. Produce prescriptions seem, from all the evidence, 
at least as cost effective as other treatments like 
cholesterol-lowering drugs for primary prevention of heart 
attacks.
    The third part of the formula is to actually leverage 
dieticians. Today, in Medicare, dieticians can only be 
reimbursed for counseling of patients for a very small, limited 
set of diseases like diabetes or kidney disease but not for 
many, many other major diet-related conditions like overweight 
or obesity, high blood pressure, heart disease, stroke, cancer 
or more. In a cardiology clinic, I can get reimbursed for 
having a genetic counselor on my staff, but I cannot get 
reimbursed for having a nutritionist on the staff. It is time 
to fix this.
    Part four is nutrition education for doctors. The vast 
majority of doctors say in polls that they recognize nutrition 
as so crucial for their patients, they want to learn more, and 
they are not learning enough in their training. The simple way 
to fix this is to change the tests. We have to change the U.S. 
medical licensing exams, the specialty boards tests, and the 
continuing medical education tests that every physician takes. 
For the top cause of poor health in our country, should not all 
of the tests have five or eight percent of questions on 
nutrition? If we change the tests, we will change medical 
education overnight.
    Senator Booker. Thank you for that. I am going to run and 
vote and for now turn it over to the Ranking Member to chair.
    Senator Braun.
    [Presiding.] Thank you, Mr. Chairman. We have been talking 
about healthcare costs, nearly 20 percent of our GDP, and we 
have started this conversation 50 years ago. What healthcare 
was as a percentage of our GDP? Seven percent. It has nearly 
tripled in the 50 years we have been having the discussion.
    Then you hear testimony that what we do through SNAP, 
through some of our nutrition programs here in the government, 
might actually be adding to the issues of good nutrition 
because mostly what gets in the diets would be probably highly 
processed food that may be inexpensive but would have empty 
calories. What a dilemma we are in.
    I have got this question for Dr. Rachidi and Mr. Stover, 
that, what do we do to get the healthcare system to turn away 
from remediation to prevention, No. 1? Then what do we do 
through the USDA, the one or two things that might be most 
salient, to where we start actually recommending food that is 
going to help solve the problem, not exacerbate it? Start with 
Dr. Rachidi.
    Dr. Rachidi. Sure. Thank you for the question. I will 
address what our Federal nutrition assistance programs can do, 
namely, SNAP. I think the two main things that could happen in 
SNAP that could make a big difference is, one, to implement 
restrictions on what can be purchased with SNAP dollars. I 
think starting with sugary beverages is a very good step. It 
will reduce, likely reduce, the amount of those beverages that 
are purchased by households. I think even more importantly, it 
will send a very strong message that SNAP is serious about 
nutrition and serious about households wanting to improve 
nutrition.
    I think the second thing then that the USDA could do within 
SNAP is to leverage the restrictions with increases in funding 
for incentives to purchase fruits and vegetables.
    I think the combination of those two--so reducing the 
amount of money available for sweetened beverages, increasing 
the amount of money available for fruits and vegetables--can 
start to change the calculus and might actually increase access 
to those products in neighborhoods that are low-income because 
there will be more money to purchase them.
    Senator Braun. Dr. Stover.
    Mr. Stover. Thank you for that question. I think that we 
have to take a systems approach to really connecting food and 
health. As I mentioned, there is a disconnect right now, a 
major disconnect between food production and then our 
expectations around consumer health.
    We have to address this across the entire food system. We 
heard about obesogenic environments. We talked about the 
relationship between diet and disease. We talked about 
incentive programs. We talked about other types of Federal 
interventions. We need to approach this considering the entire 
food value chain, from farm inputs all the way to consumer 
behavior and human nutrition. We saw during COVID-19 that a 
change in consumer behavior, not eating at restaurants anymore, 
eating at home, played havoc on the entire agriculture and food 
value chain. They are all connected.
    If we want to set the goal, the purpose of the food system, 
to lower healthcare costs, to protect the environment or 
whatever goals we have, we have to focus on that goal, and we 
have to take advantage of every opportunity, all the knowledge 
we have today toward that specific goal. We have to do it in a 
way that we acknowledge where our research gaps are and be very 
transparent about how certain we are of the knowledge we have 
so that we can engender public trust. That is the only way we 
are going to get true prevention, if we deal with all the 
causes.
    When you talk about prevention, there are two aspects to 
that. There is what you eat and how much you eat. Francis 
Collins started the Precision Nutrition Initiative at NIH for 
the sole purpose of trying to understand how individuals 
interact with food and the diet-chronic disease relationship. 
We know we are heterogeneous. The data tells us that. We all 
interact with food differently in terms of that chronic disease 
outcome. One size does not fit all. We need to better 
understand that science and how to better match people to diets 
and again consider the whole agriculture value chain.
    In terms of dose, we need to understand better human 
behaviors, these obesogenic environments, et cetera. We need to 
try to work on dose so that people consume less. We have to 
work on both aspects, both the dose of consumption and what 
people eat.
    Senator Braun. Thank you. Real quickly, how important 
relatively is it that the AMA would lead on this as opposed to 
trying to force solutions through government? That always is a 
little trickier.
    Why are we not hearing more in credentialing and so forth 
to where that ounce of prevention being worth a pound of cure? 
To me, if that happens at where the rubber meets the road, we 
actually start seeing things cascade in a favorable way. How 
important is it that the AMA get on board with this?
    Mr. Stover. For years, and as President of the American 
Society for Nutrition, we spent a lot of time trying to focus 
on getting more nutrition into medical education. That is a 
tremendous challenge because every professional society wants 
more of their type of education in the medical degree.
    At Texas A&M--and we have a paper coming out on this--we 
are encouraging combined programs of nursing and dietetics. It 
is nurses who are the front-line healthcare workers who see 
every patient, especially in our disadvantaged communities. We 
need to have those front-line workers have that nutrition 
education because there simply are not enough dieticians in 
these healthcare facilities to educate about nutrition.
    At the same time, we need to expand what we do in the land 
grant system through extension. People trust us. People trust 
the information that we give them. We have community health 
programs. They have not kept up in terms of funding with the 
growth of the population and the diversifying of the 
population. We need to take advantage of our extension system 
as well.
    Senator Braun. Thank you.
    Senator Warnock.
    Senator Warnock. Thank you so very much, Ranking Member and 
Senator Braun. I am grateful to you and also to Chairman Booker 
for holding this important hearing.
    Families across Georgia's rural communities are facing 
added barriers to adequate nutrition, including distance to a 
grocery store, limited transportation options, and the 
availability of quality fresh products at an affordable price, 
for example, Second Harvest of south Georgia estimates that one 
in five people in south Georgia do not know where their next 
meal will come from. One in five.
    Administrative flexibilities provided by USDA have helped 
provide additional nutrition assistance throughout the 
pandemic, but I am hearing from the folks back in Georgia that 
the guidance coming from Washington fails to fully reflect the 
challenges of administering assistance in rural communities.
    Dr. Warne, you have dedicated your career to underserved 
communities. What unique challenges do individuals in rural 
communities face regarding nutrition, and how can this 
Subcommittee better address those challenges as we look ahead 
to the 2023 Farm Bill?
    Dr. Warne. I appreciate the question very much, Senator 
Warnock. Where I am from in South Dakota originally and the 
communities I work with in North Dakota are very rural, 
particularly the tribal populations. With the rural populations 
that I have worked with, that are also underserved, we tend to 
have less access to healthcare but also less access--less easy 
access to healthy food.
    Where I am from originally in Kyle, South Dakota, for 
example, if we want to purchase healthy food, it costs more 
than what you would spend in a city or a suburb because it is 
perishable and it costs money to bring the food out to some of 
the rural communities. In public health, we call that a poverty 
tax. Is not a tax per se, where money is being collected by a 
government, but people have to pay more money for healthier 
options when they live in rural and underserved populations.
    It also links then to the need for health education. One of 
my challenges that I have seen when I was a full-time clinician 
I was also a certified diabetes educator, and what I 
recognized, was all of this awareness of education and theory 
is really not of value if we cannot implement it. If people do 
not have access to the things that we are recommending, then we 
are really not going to improve outcomes for diseases like 
diabetes.
    When I look at the communities that I work with, there are 
so many challenges. We need to create opportunities and 
fundamentally rethink how we are doing this because we need 
more local, easy access to healthier choices. In doing that, we 
also have to develop community champions. It is not easy to 
change behaviors just by changing a program or two. We actually 
have to do a lot of community engagement on the front end to 
make it more effective.
    Senator Warnock. Thank you so much. In order to serve our 
rural communities--and I spend a lot of time in my State being 
certain to move around these rural communities--it seems to me 
that we have to center their unique concerns in order to get 
the policy right. It is great to have folks like you here 
helping us, helping this Committee to think about how we best 
tailor the policy to the particular needs of rural communities.
    If I may, I want to pivot in my remaining time to another 
subject. Since my first day in the Senate, I have been laser 
focused with my colleagues on closing the Medicaid coverage 
gap. In Georgia, we have got 646,000 Georgians in the Medicaid 
gap, millions of Americans. This is a matter of life and death 
for people in my State, all across the country, and Congress 
must act immediately.
    According to the Georgia Food Bank Association, 
approximately 66 percent of the families they serve have been 
forced to choose between food and medical care. This issue 
affects everything, including nutrition.
    Dr. Mozaffarian, in your testimony, you discuss how 
nutrition insecurity and diet-related diseases 
disproportionately impact those who are low-income, racial 
minorities or live in rural areas. How would closing the 
Medicaid coverage gap and expanding access to health insurance 
reduce health disparities and improve nutrition for the 646,000 
Georgians and 2.2 million Americans who currently lack access 
to free and affordable healthcare?
    Dr. Mozaffarian. Well, as a physician, I know and I see the 
power of the healthcare system when you get sick. If you get 
sick and have to use the healthcare system and do not have 
insurance, you can be financially devastated, and so I think 
having access to healthcare insurance as a financial support 
system is crucial.
    I am not convinced that having health insurance per se 
makes us healthier, and there is lots of evidence that this is 
not the case. It is a financial imperative, but to get 
healthier we also have to have that health insurance focus on 
prevention. I think that you would get a double win if that 
policy of addressing the Medicaid gap were paired with real 
programs and policies in Medicaid like the ones I mentioned--
medically tailored meals, produce prescription programs, 
dieticians that can actually see patients who need them, and 
physicians who are trained in nutrition--so that those low-
income communities, rural communities, communities of color can 
get their insurance and go and actually get healthier food, get 
good counseling, get medically tailored meals if they need it 
and so on.
    I think, the healthcare system again is wonderful if you 
are sick, but it is very expensive, and it does not do a whole 
lot for prevention. We need to both expand coverage and change 
the way we think about healthcare so that it actually starts to 
really have a focus on prevention more than treatment.
    Senator Warnock. Prevention, affordability, access to good, 
nutritious food, and access to healthcare are all caught up in 
a single web, and there is no sort of one prescription for all 
of these things that are caught up. Thank you so much for your 
testimony.
    Senator Booker.
    [Presiding.] Mr. Ranking Member, who is up next?
    Senator Braun. Dr. Marshall.
    Senator Booker. Dr. Marshall. Thank you, sir.
    Senator Marshall. Thank you, Chairman Booker, and 
appreciate you holding this hearing. Ranking Member Braun 
mentioned the cost of healthcare has went from 7 percent of GDP 
to 20 percent of GDP, approximately. Often, when I talk about 
driving the price of healthcare, I talk about, well, we need 
more transparency, we need more innovation, we need more 
consumerism, but the fourth leg of that stool is better 
nutrition. That is certainly one of the reasons that the cost 
of healthcare has went up and is something I cannot control as 
a physician. I cannot prepare the diet for the folks that need 
it.
    The Majority here gives us notes today: Currently, in the 
United States, nearly half of our adult population is pre 
diabetic or who has type 2 diabetes. Half of our population. 
That is an epidemic.
    Mr. Chairman, in the spring of 2020, I volunteered in 
southwest Kansas at an ICU and an ER. The COVID virus was 
sweeping across Kansas. Our packing plants in southwest Kansas 
were just getting devastated. We set up testing stations and 
did everything we could. I went to the ICU in Liberal, Kansas. 
Eight ICU beds, but there were 11 patients, and I think they 
were in their 50's. Every one of them had diabetes or probably 
pre-diabetes.
    Immediately I called the CDC and said, oh, my gosh, this 
virus is going to assault this country. People will ask, why is 
our morbidity/mortality higher with this virus than, say, the 
African nations? I assume that would be true for our friends in 
the Far East who have better American diets as well.
    I do not know about you all, but I have been so frustrated 
that the CDC has not talked more about nutrition and building 
your own immunity. We have had a year and a half of this virus, 
and I thought this might be an awakening for this country that 
if we had a better, healthy immune system that is how you fight 
viruses.
    I think I will start with Dr. Mozaffarian. Forgive me. Are 
you frustrated that the CDC has not been doing public service 
announcements on building up your own nutrition and how 
important nutrition is to building a good immune system?
    Dr. Mozaffarian. Well, I think that this has been a lost 
opportunity this last year and a half. Obviously, we need to 
have worked on and successfully developed vaccines, looked for 
treatments----
    Senator Marshall. Of course.
    Dr. Mozaffarian [continuing]. used social distancing, other 
things. The huge, huge additional foundational effort should 
have been to improve our overall metabolic health through 
better nutrition. We published research this year that we 
estimated 64 percent of COVID hospitalizations could have been 
prevented if we had a metabolically healthy population.
    Every time, not just the CDC, but other leaders in the 
Federal Government, leaders in the States, every time they 
talked about social distancing, mask-wearing, getting a 
vaccine, handwashing----
    Senator Marshall. Nutrition.
    Dr. Mozaffarian [continuing]. why weren't they talking 
about being healthy?
    Senator Marshall. Yes. I think that is a great explanation 
point. I think about my own field of obstetrics, and the 
morbidity/mortality for this country has went up over the past 
decade or so, and we have done deep dives down why. How come? I 
can share with you that the average starting weight of a 
patient in my practice, from 25 years ago until I left my 
practice four years ago, is up about 20 pounds. This incidence 
of diabetes and pre-diabetes, which is exacerbated from the 
hormones of pregnancy, I think that has to be contributing to 
it as well. It has been frustrating.
    We have been studying this for decades, and I appreciate 
your comment if we had more education in medical school that 
would be helpful. I am telling you I learned everything I need 
to know about nutrition to address this problem from my mother 
and my grandmother. It is not doctors that give the nutrition 
education; it is the nurses. Right? I think it is just a matter 
of how do we use those assets and the time of the nurses to 
keep teaching that inasmuch as we need doctors learning more 
about vitamins A, D, and K are fat-soluble and that is why we 
need to be drinking whole milk as opposed to just general 
concepts.
    I think the bottom line is this: when the economy is bad, 
when people do not have a job, when you have got some food 
stamps, whatever it is, carbohydrates are cheaper. Processed 
food is cheaper, and that is why I have always thought the 
economy is so important to this issue as well. Give a person a 
job where they can make these healthy choices.
    One big question I have got for anybody that can help me 
answer this: We pack our food banks with yesterday's donuts and 
yesterday's breads, and it is expensive. We are making an 
effort. I think we are doing it better today in our food banks 
than we were a decade ago, trying to get nutritious food in 
there.
    There is a multi-katrillion-dollar vitamin industry out 
there. Are you all aware of any research that we should be 
putting vitamins in our food banks? Are vitamins different 
than, give me whole fruits and vegetables and give me whole 
milk and give me good protein sources over a bottle of 
vitamins? I think that most of us would agree that if Mother 
Nature made it, it is better. Should we be adding vitamins to 
those types of situations? I know I am open for anybody who has 
any thoughts on that.
    Mr. Stover. I can comment on that. What we are talking 
about today, diet-related chronic disease, is not driven by 
micronutrient deficiencies that you get out of a vitamin. 
Certainly, those do occur for those who do not have the best 
diet. Certainly, they can help fill gaps. What we are talking 
about today, at least in all of my experience and working on 
these DRI panels, is not related to vitamins.
    This is a broader question related to the food environment. 
It is related to health behaviors. It is related to public 
trust. This is another issue where people--Pew Research did a 
survey last year, and people do not trust nutrition researchers 
the way they do other areas of the healthcare system.
    We have a big challenge. We have the problem with COVID and 
vaccinations. We have the problem in nutrition.
    Senator Marshall. If anyone thinks----
    Dr. Mozaffarian. Can I just add?
    Senator Marshall. Go ahead.
    Dr. Mozaffarian. Can I just add one comment, Dr. Marshall, 
on the CDC? The CDC's Division of Nutrition, Physical Activity, 
and Obesity--Nutrition, Physical Activity, and Obesity--the 
foundation of health, has a $100 million a year budget. The 
government spends $160 billion on type 2 diabetes treatment and 
$100 million on prevention at CDC for physical activity, 
nutrition, and obesity. Let's get that division up to a billion 
dollars maybe, one-sixtieth of the cost of diabetes, so that, I 
think the CDC can have a progressive----
    Senator Marshall. I totally, totally understand where you 
are coming from. My experience is throwing money at it does not 
solve the problem. I would want to know very specifically, what 
would they be doing different than they do today--Mr. Chairman, 
can I have another minute. Nobody else is waiting, so I am 
going to go ahead and----
    Senator Booker. Doctor, you can have two minutes.
    Senator Marshall. Okay. I think my question is for Dr. 
Rachidi. Again, I feel like we are just throwing money at 
things. We have tried this. I do not know why we need another 
conference, to be honest. I think we all know exactly what 
needs to happen. Much like me trying to convince a patient to 
stop smoking--they know they need to stop smoking. America 
knows they need to get on a better diet. America knows that 
they need to be exercising more.
    We certainly know what does not work. What would work? What 
are we not doing now, that if you were king that you would come 
in here and say, here is something that we can do to really 
impact this problem tomorrow.
    Dr. Rachidi, you are on the line, I think. If you have any 
comments, I would love to hear your thoughts on that.
    Dr. Rachidi. Yes, thank you. I could not agree more that 
just throwing money at the problem has not proven to be 
effective in the past, and I do not think would necessarily be 
effective now. For example, we, the Federal Government has 
increased efforts in spending on nutrition education, for 
example, in SNAP and various other programs. While I think 
nutrition education can be useful, it certainly has not had a 
major impact on any of the problems that we have talked about 
today. We really need more of a holistic approach that looks at 
what we are already spending and figures out a better way to 
spend it.
    Again, I think the main point that I really want to 
emphasize today is that we need a cohesive nutrition strategy 
across all the Federal agencies that makes it clear to the 
American public that this is a crisis and we have a strategy to 
try to fix it, and that includes a whole range of things. I 
mentioned my area of expertise which is SNAP and what we could 
do there, but obviously, there are many other ideas just today 
of what can be done. The main thing is we have to pull it 
together and we have to develop a strategy and then we have to 
take action as a country and actually implement these 
strategies.
    Senator Marshall. Thank you so much. Mr. Chairman, if I 
would say, my experience in 25 years of medicine, WIC works. 
The WIC program is great, and one of the reasons WIC works is 
the people that are participating in that are teaching and 
coaching up people. They are not just giving them vitamins. 
They are not just giving them healthy choices. They are 
coaching them up, and it is that interaction between the real 
people and the real WIC programs. Those are what we need to be; 
people need to be kind of coached up to what a healthy diet 
looks like.
    Thank you so much. I yield back.
    Senator Booker. Before you leave, because this is a 
wonderful forum to engage with colleagues, especially, frankly, 
you are one of the more informed people in the U.S. Senate. You 
are actually a medical doctor and have tremendous experience 
with diverse populations. I agree with you. I am one of these 
people that has witnessed a lot of knowledge out there, but it 
is not getting into our practice.
    The two things I would say is Dr. Rachidi, in her remarks, 
she said the words, ``cohesive strategy.'' We have so much 
accord, but we are not working together to get it done. The 
hope or the vision for Senator Braun and I--and I would love to 
talk to you more about it--is the idea if we get all 
stakeholders around the table in a bipartisan fashion, private 
sector, farmers, policymakers to begin to talk on those 
evidence-based strategies.
    Why are we not working together? Because the reality is 
what can create change, it has to be folks like you and I 
coming together and agreeing on a strategy and executing it 
because there clearly are, as Dr. Rachidi has been saying, 
things we know work that we are not investing in and things 
that are potentially making the situation worse.
    You are somebody I really look forward to partnering with. 
To have your sort of, what I would say, cred on these issues is 
really great. Maybe before you go I would like to ask this 
panel, then I want to turn to Dr. Odoms-Young, because there 
are evidence-based strategies.
    My experience in this is the fact that I was a mayor of a 
city. I cut my city government by 25 percent. I do not know any 
Governor or mayor that is in the Senate that cut their 
government size as much as I did, but one of the two costs I 
could not control was my healthcare cost.
    Senator Marshall. Yes.
    Senator Booker. It would go up double-digit percentages 
every single year.
    Senator Braun, who is a businessman extraordinaire, said 
that he did creative things to bend his cost curve by providing 
healthier food options to people.
    Dr. Mozaffarian, if you could just put an exclamation point 
perhaps on you were saying earlier that there are--this is 
not--this is a fiscally conservative approach. Right? We know 
that if we do nothing wrong we are going to be doubling major 
increases in government spending. We could actually invest in 
programs we know drive down government costs because if there 
is anything we can agree on in a bipartisan way we are about to 
run government into the ground with one of out of every three 
dollars now being spent on healthcare costs as opposed to--and 
if we do nothing, as you said, diabetes alone, costs grew 25 
percent, on that one disease more money than the entire 
Department of Agriculture, and it is going up in a stunning 
fashion.
    Maybe before--I know Senator Marshall is in great demand, 
has to probably go to another hearing and to the floor to vote.
    Senator Marshall. Go to vote.
    Senator Booker. If there is one more thing that you can say 
that is evidence-based programs and you were talking to a 
fiscal conservative, what would you say? Hey, these are some of 
the best dollar investments you can make in changing this 
nightmare for a lot of families and individuals.
    Dr. Mozaffarian. Yes, well, I consider myself a fiscal 
conservative as well, and I think, we need to invest money 
where we are going to get a return on investment. I think we 
need to invest money in nutrition science. There is huge return 
on investment. We can talk about that more, hopefully.
    We need to have healthcare pay for healthier food where we 
show it to be cost savings or cost-effective, and there are 
lots of great ways to do that. I absolutely agree we need to 
strengthen and leverage our Federal nutrition programs, 
strengthen school lunch. WIC is excellent. Improve SNAP so that 
SNAP leverages nutrition better.
    One thing we have not talked about which I would love to be 
able to talk about longer is to catalyze business innovation. 
The Federal Government has a role to play to help nurture and 
catalyze all of the disruption that is going on now, from 
agriculture to retail to consumer packaged goods. Tens of 
billions of dollars are going now into new jobs and new 
businesses to create healthier products. The Federal Government 
could catalyze this with modest tax policy, modest other 
investments, opportunity zones, other areas like that.
    I do think we need to expand public health. I think there 
is a return on investment for that. Then last, I agree with 
you, Senator Booker, that a low, low-cost thing to do is to 
convene a White House conference to get Dr. Marshall, yourself, 
others, along with the leaders in the Biden administration, in 
the same room to say, look, we are going to fix this, and we 
are not going to leave the room until we come up with a plan. I 
think it is all possible.
    Senator Booker. Thank you.
    Senator Marshall. I will go vote. Thank you.
    Senator Booker. Senator Marshall, thank you, sir, for 
giving a few extra minutes.
    I want to jump to Odoms-Young because this is an issue that 
affects rural areas, suburban areas, urban areas, everywhere, 
but there are particular issues going on amongst Native 
communities, Black and Brown communities, that are--make this 
even more troubling and compound the problems within those 
communities.
    Dr. Odoms-Young, a recent report from the Rudd Center found 
that Black and Hispanic youth are exposed to more food 
advertising in the media and their communities compared to 
White youth and that food companies target Black and Hispanic 
youth with advertising for their least healthy products. Could 
you comment on that Rudd conclusion? Are you familiar with 
these practices, and what impacts do you see them having in 
those communities?
    Dr. Odoms-Young. Yes. Thank you so much for that question, 
Senator Booker. I am very familiar with the report, and also, I 
have been part of several studies that look at food marketing 
in collaboration with the Council on Black Health. Black 
Americans, particularly youth, not only experience higher 
exposure to unhealthy food marketing through television and 
advertising but also through social media, print media, and in 
their communities.
    The Rudd report that you mentioned found that junk food 
comprised 86 percent of the spending on Black targeted 
programming and only one percent of healthy foods were 
marketed. I think what is particularly striking is that in 2019 
the report found that 23 restaurants spent $99 million to 
advertise on Black television or television programming that 
targets predominantly African Americans. As compared to White 
preschoolers, a Black preschooler saw about 72 percent more 
fast food ads, and if you look at teens, they saw about 77 more 
fast food ads.
    This has serious implications when you look at dietary 
preferences and eating behaviors. Several studies have shown 
that immediately after you see these ads they have a desire for 
unhealthy food, junk food, and fast food. If you look at Black, 
indigenous, and Latinx communities, where you have more of that 
food available, you can actually act on that marketing and that 
prompting.
    I think the other issue that comes up is that when youth 
are exposed to these ads in early life it creates a lot of 
brand loyalty and also youth start to associate these foods 
with experiences. It is not just selling food. It is selling 
experiences. It is selling value, happiness, socialization. 
These have major implications for obesity and chronic disease 
risk in these communities.
    Senator Booker. It is, I guess, neuro-associative 
conditioning. It is like you think of a meal, like I may have 
thought up about my grandmother's cooking, which was very 
different than often you see in Black communities today, and 
that was the happiness. Now, as I think the only Senator that 
lives in a predominantly African American, Latinx, low income 
area, I am just stunned with the messaging that folks receive.
    Maybe, Dr. Odoms-Young, you can comment on this for a 
second. It is that compounded with the fact of you just do not 
have the ease and availability of the kind of foods that when I 
talk to the elders in my community that they used to cook with. 
I live in a neighborhood with a corner bodega, and you have 
very limited healthy options. Then because of, I would say, the 
way we subsidize certain foods and not others, with 98 percent 
of our ag subsidies going to foods that are hyper-processed, 
low-nutrition, you see kids walking into bodegas and with--you 
know, with the kind of change. A Twinkie product, like product, 
costs less than an apple.
    You have that double hit. Right? The advertising and the 
availability. Would you agree with that?
    Dr. Odoms-Young. Definitely. I have spent much of my career 
working on the south side of Chicago with several community-
based organizations, where we worked alongside corner stores to 
change the availability. Part of the big issue, as you 
mentioned, is not only availability but also pricing. Unhealthy 
food products cost lower.
    I was just in a corner store--it is funny that you mention 
that--this week, and not only were unhealthy products 
marketed--and this is in a store where we have a partnership. 
We also found that there is a lot of ultra-processed foods in 
stores, not only corner stores but also grocery stores. It 
makes it difficult because the pricing is--the prices are--as 
compared to healthier food options, make them more desirable, 
particularly when you have a limited budget to spend on food.
    I think that is very important. If we can try to address 
and look at affordability, as well as accessibility, that is 
where we can see a reduction in dietary disparities and improve 
nutrition.
    Senator Booker. Thank you.
    Maybe, Dr. Warne, as the Ranking Member is coming back to 
the dais, you mentioned in your testimony that for you growing 
up and for many of the family members still living on the Pine 
Ridge Indian Reservation in South Dakota, that the nearest 
supermarket was 90 miles away. Can you speak to that and what 
Dr. Odoms-Young was just speaking about, that combination of 
access issues to get healthy foods and how that is a 
disproportionate reality for native communities?
    Dr. Warne. Yes. In my experience, particularly in the 
Northern Plains, we see this across multiple reservation 
communities, so not just my own community in South Dakota. As 
food deserts, we just do not have local access to healthy 
choices. If there are some perishable items that are healthier 
options, again, they are more expensive when we have to 
purchase those in our communities. We make it untenable for 
people to make healthier choices, and I think that is where 
investment really needs to occur is to make the healthier 
choice the easier choice.
    There has been discussion about sugar-sweetened beverages, 
for example. I have worked with a tribe in Minnesota, where at 
their wellness center the bottled water is 25 cents and the 
soda is $1.25. Well, guess what? Water consumption went way up; 
soda consumption went way down.
    There is ways we can try to invest in healthier options but 
make them easily accessible and inexpensive because right now 
even if we put the food there and we provide education 
regarding the value of healthy food, if people cannot afford to 
purchase it, then we are not going to implement the changes 
that we need.
    Senator Booker. Programs like--we have done this in my 
city, in Newark, giving people access to make their SNAP 
dollars go further. If you spend it for processed food in a 
supermarket, it is one thing, but if you spend it at a farmer's 
market, you get double SNAP benefits. Those are the kind of 
things that you think would work?
    Dr. Warne. Yes, that would be very important. Then also 
with engaging tribes, looking at the value of traditional foods 
and locally cultivated foods. That is one thing that the FDPIR, 
Food Distribution Program on Indian Reservations, has done 
better in recent years is to incorporate more culturally 
appropriate and traditional foods. I would want to work with 
each community individually, again because the one size does 
not fit all, but find those local preferences and develop the 
local champions to do that. That is--I think would be a very 
important step.
    Senator Booker. Fantastic. I am going to yield to the 
Ranking Member to continue questioning.
    Senator Braun. Thank you, Mr. Chairman. We covered a lot of 
territory today about the fact that the healthcare system is 
almost triple what it was 50 years ago when we started the 
conversation. Prior to becoming a Senator--and it was roughly 
13 years ago--as a CEO of a company that just had 300 
employees, now 1,200, I could put two and two together quickly 
that I needed to change my own healthcare system. I always 
believed in covering preexisting conditions with no caps on 
coverage, but my main interest was reducing healthcare costs 
and making my own employees healthcare consumers.
    I know we have two doctors, M.D.s on the panel here. When I 
brought it into the C-suite, that was very unusual because most 
individuals running companies were paying for remediation when 
it cost a lot less even 13 years ago.
    For the two M.D.s on the panel, how important is it to 
foster a new paradigm based upon an engaged healthcare 
consumer, not one that is atrophied, with very little skin in 
the game, just wants either government to remediate your bad 
behavior or your illness or your accident, and you have got an 
industry that is based upon the business of remediation?
    To me, knowledge and transparency are the two things that 
have to drive all markets, and then you have got to have things 
like competition, full transparency.
    From an M.D.'s point of view, what do we do to fix the 
system from the bottom-up before we maybe turn it into a one 
payer system out of frustration? Even if the government pays 
for more, wouldn't it make sense to reform healthcare first 
regardless of what we do through nutrition through USDA? I 
would love to hear your thoughts, each, on that.
    Dr. Warne. Okay. I can go ahead and go first. I appreciate 
the question, and I also appreciated in your opening remarks, 
again, a holistic approach to doing this work.
    I think from a physician's perspective, at least in my own 
experience working with tribal communities and recognizing that 
I have all of this knowledge about pathophysiology and the 
understanding of things like diabetes education, one of my 
biggest challenges really at that ground level was that even if 
my patients wanted to make healthier choices they did not have 
the means to make those choices to purchase the healthier 
foods. We just have to recognize that each population is 
different and we will need unique strategies with each 
population that we are engaging.
    One thing I do know is that our population, as diverse as 
they are, they want to be healthier; they really do. I think 
that having a community-engaged approach and recognizing that 
each group of patients and each population will have their own 
strategies, and we need to be flexible enough within that.
    We talk a lot about evidence-based practices, which are 
wonderful as a physician, but also training in public health. I 
recognize the need for evidence-based practice, but my question 
is always, whose evidence is it? I mean, if a program worked 
very effectively in Boston or New York City, it may or may not 
work effectively in Pine Ridge, South Dakota. As we are 
building the evidence base, from a physician's perspective, we 
need diversity in the groups from which are building the 
evidence.
    Dr. Mozaffarian. I would add, Senator Braun, I think your 
instinct 13 years ago was spot-on and it is spot-on today. It 
is really clear that we need to reimagine healthcare as a 
preventative healthcare system that pays for value and 
prevention just as much, if not more, as it pays for 
remediation, as you put it.
    This is happening. This is happening, and private 
healthcare systems across the country are really starting to 
think about food as medicine, prevention, social determinants 
of health. They are doing it in sort of fragmented fashion, 
piece by piece, bit by bit, learning.
    I think the Federal Government has an important role to 
play to catalyze this. The CMMI is--you know, CMMI's mandate is 
to test interventions that will improve health and reduce 
costs. I think Congress asking CMMI to really focus on 
nutrition and prevention and integrating food and nutrition 
into the system in a way that empowers educated, knowledgeable 
consumers, gives them systems, resources to purchase healthy 
food, is absolutely the way to go.
    I will give the example of John Hancock Life Insurance in 
Boston, one of the great and oldest life insurance companies in 
the Nation. About five years ago, they launched an insurance 
program called John Hancock Vitality, which rewarded their life 
insurance clients for physical activity, for not smoking, and 
for healthier eating--all kinds of gamification, incentives, 
rewards for healthier eating, including paying up to $50 a 
month. Out of pocket, John Hancock pays up to $50 a month to 
their life insurance clients for purchasing healthier food. 
Tufts is kind of their science partner to be sure that 
everything John Hancock is doing is credible science.
    John Hancock says, we will spend $600 a year on healthier 
food for our clients because we will make money. They will live 
longer. They will be healthier. That is a model of health 
insurance for the future.
    Most of our worksite wellness programs now today will pay 
for belonging to a gym or even buying equipment, buying tennis 
shoes or a treadmill. If you get your steps, many programs will 
give you some kind of rewards and other things. We need to do 
the same thing for food.
    I think your model is exactly right, and again, CMMI is an 
excellent place to start. I would hope they would be investing 
heavily in this kind of innovation testing to figure out what 
works best.
    Senator Braun. Thank you. One final comment, when you have 
got a podium like this and for as long as I have been asking 
the healthcare industry to reform itself. When you have got bad 
stats like costing three times as much as a part of our economy 
as it did five decades ago, that soul searching and looking at 
how you might do a better job for the most important part of 
our economy, and agriculture and food processing to boot, see 
what you can do before you are in a pickle to where you are 
maybe forced by government to do things that you are not happy 
with. I especially aim that at the healthcare industry. Embrace 
competition, transparency. Get the healthcare consumer engaged, 
and maybe less attention will be paid to it through government.
    Thank you.
    Senator Booker. Senator Braun, just for the sake of 
conversation, I love how you aligned as a businessperson your--
the bottom line. You saw that you had to find creative ways to 
reduce costs. I am wondering, maybe a question for Dr. 
Mozaffarian but also for you to the extent that you want to 
engage. Do we have perverse incentives in government as opposed 
to the clarity that the Senator had, that we could do some 
changes to our policy that align incentives? Because right now 
it makes no sense.
    If you and I were running this with the goal of lowering 
costs, which these are the--and I have heard speeches on both 
sides of the aisle to the untenable skyrocketing cost of 
healthcare, but again, the debate really has been in providing 
healthcare and not why do we have such a high demand. That is 
what I am wondering is how do we get at aligning incentives in 
government that you had so clearly as a businessperson that 
resulted in quicker success.
    Senator Braun. Real quickly, I have talked to Chairmen 
Wyden, and there, if you are a problem solver, like you have 
got to be to run a successful company, you are looking ahead 
rather than being in a cul-de-sac where you are forced to do 
it.
    My belief is that if you reform the system first that even 
folks on your side of the aisle should be for more 
transparency, more competition. Make the system better 
regardless of whether the government pays for the healthcare or 
it is done through the private sector. Much has evolved to have 
a broken system, almost like an unregulated utility out there, 
on the healthcare provision side.
    I am asking, as someone that believes in free markets, that 
maybe we need to pay more attention to creating the paradigm of 
competition, transparency, changing an atrophied consumer into 
one that is interested in his or her own well being. Then if it 
is not moving in a way that we see things evolving in a 
different direction, then I think it will cascade into the 
other option that so many on my side of the aisle bemoan. Where 
were we when we were defending some of the stuff that was not 
working in the healthcare system and we had no answer like I am 
trying to provide?
    Senator Booker. There is so much agreement up here, which I 
think is a rare thing in Washington. They might rush in soon 
and stop us from talking to each other, but I want to ask 
maybe--because I believe in a free market, too.
    What I think government is doing right now is picking 
winners and losers. Ninety-eight percent of our ag subsidies--
ninety-eight percent--of our ag subsidies are lowering the cost 
of the very foods another part of government tells you not to 
eat. Only two percent of ag subsidies are going to the things 
that we tell us--I have seen it go from the food pyramid to the 
food plate, but all along they have said eat mostly these 
foods. Yet, our ag subsidies are completely aligned, picking 
winners and losers, and not allowing the free market to decide 
and--for consumers.
    Again, I live surrounded by fast food restaurants, and I am 
not having it my way, and I am not having happiness in my 
meals. I am having fast access to foods that when I--when you 
go in and you see that dollar meal, it is--that is heavily 
subsidized by the government. Meanwhile, if I want to get a 
salad, the places that make them available, you walk in, and 
there is a place down the street. They charge like 20 bucks for 
a healthy salad with just vegetables.
    I guess that is my frustration because I think we are 
aligned on values. I believe in the free market. I believe that 
government needs to cut costs. I said to Senator Marshall, I am 
the only person here who actually ran a government that cut it 
25 percent. I could not control my healthcare costs.
    I am wondering that--could you speak--and maybe Dr. Stover, 
Dr. Mozaffarian, can you speak to this problem that I see, 
where we are not letting the free market rule? We are investing 
heavily as a government, dramatically, on the things that are 
making us sick. Those small pilot programs that come in these 
farm bills. Tiny, tiny amounts to try to incentivize the things 
that are making us well. It just seems like a misalignment of 
government. We are not investing and getting returns. We are 
investing, compounding the problem.
    Mr. Stover. I mean, certainly I understand what you are 
saying. Let me just first state again that our farmers and 
ranchers are some of the most devoted, hardest working people 
in the country. They feed America, and they are very proud of 
what they do. They respond to what the consumer demands. With 
all the things that we have heard about influencing, 
advertisement, all of that, they respond to what the market is 
telling them to produce.
    We have the opportunity to change that, and we have to look 
at all opportunities to do that, everything from nutrition 
education, everything from the frameworks we use in terms of 
what we subsidize, what we grow, how we process, how we then 
work within the cultural context of food systems and not 
alienate people from their food but improve those food systems 
within the cultural context. There is no magic bullet to this. 
We need to take a systematic approach.
    If we knew what do to, if we had the evidence right now, 
there would be complete consensus on what to do, and we could 
fix this tomorrow. We know some things work, and they work at 
the margins. We need to address this systemically again, 
looking at everything we do from what we grow in the field to 
what--how we are educating consumers and affecting behavior.
    Senator Booker. Dr. Mozaffarian?
    Dr. Mozaffarian. Yes, no doubt that the, subsidy portion of 
the farm bill is really important for risk management for, 
farmers across the country, but it is all going to five crops. 
If we took all that away, those farmers would go out of 
business. We would have severe, severe problems. We have to 
figure out how to shift without hurting those farmers, shift 
their profits and their productivity toward healthier crops.
    I agree with Dr. Stover that the farmers produce what the 
buyers buy, and so that is--they are producing those crops 
because that is where the market is. We have to both increase 
the market opportunities for those farmers and then find ways 
to help them shift toward healthier crops while still providing 
risk insurance, crop insurance for increasing, threats from 
changes in climate and other things.
    The way to increase the market side, we have talked about a 
little bit, right? We need to leverage the power of our 
nutrition dollars and particularly SNAP to buy healthier food. 
We need to leverage the power of the healthcare system and 
dollars to buy healthier food. That will change the market for 
those farmers. That will give them incentives to make locally 
grown specialty crops, organic crops, other healthier foods as 
well.
    We also need to catalyze business innovation and 
entrepreneurship in this area. We work with many startups who 
are trying to make healthier foods, and they are actually at a 
disadvantage compared to their competitors because they are 
buying more expensive ingredients. They are doing more to make 
the foods healthier, more authentic, from local sources. That 
costs them more money. Rather than having them be at a 
disadvantage, I think the government should really think about 
a policy to help catalyze small businesses and entrepreneurs 
who are creating more nutritious foods. That also creates 
demand for the farmers.
    I think Senator Booker, it is complicated, but that $30 
billion, if nothing else, is opportunity cost that we could be 
spending better. I do not know that it actually lowers the 
price of those products because we have a global commodities 
market. There is a lot of complexity into commodity prices. It 
is certainly opportunity cost. We could be doing more with that 
$30 billion than we are doing now.
    I think that is a very serious conversation of how we 
support our farmers and ranchers who are, again champions in 
the United States, support them, make sure they are going to be 
successful while letting them switch to healthier crops and 
create the markets for those crops.
    Senator Booker. I do not know if you want to respond. I 
have some thoughts about what was said.
    [No audible response.]
    Senator Booker. I agree with what both of you have said. I 
have strange alliances in the Senate. Senator Chuck Grassley 
and I are partnering, for example, on some challenges within 
the cattle industry because what cattle farmers are worried 
about is that they are going to go the way of the dramatic 
changes in the chicken and pig industry, for example. They are 
raised so differently than they were just 50 years ago, and the 
way they are being raised is causing real concern for public 
health. The overuse of antibiotics is necessary because of the 
concentration in the industries and the growth of CAFOs.
    Frankly, the farmers, if you talk to them, the contract 
farmers are living in deep debt and in real crisis.
    I was stunned in the hearing we had in the Ag Committee on 
the cattle industry that I was being praised by a guy on 
conservative radio in Alabama as being this northeast Democrat 
that was talking to the concerns that the farmers have.
    I agree with both of you that the farmers are my hope in 
America. I have gone out to the Midwest to meet with Republican 
farmers, as I told Dr. Stover, and was amazed at the concern we 
have because they know that the system as it is designed right 
now is benefiting more and more corporate concentration, that 
farmers, their inputs are going up. Instead of having--one 
Republican farmer from western Illinois, if I remember 
correctly, was telling me that they used to have--their father 
had five people to sell their cattle to, now one person.
    It is a system that is no longer working. The farmers' 
share of that consumer dollar--my folks in my city go to a 
supermarket from their beef to their broccoli. The farmers' 
share of that consumer dollar has gone down 50 percent.
    It is a food system where everyone is losing. We have 
talked about the health of our country right now; they are 
losing. We have talked about the challenges with farmers right 
now, the disappearance of family farmers; they are losing. You 
talk about food workers, what is happening with animals. You 
talk about the environmental issues that are all going on.
    We have a system that is not only making end users 
healthy--this is a nutrition conversation. We are, as a 
government, using our tax dollars to incentivize behaviors that 
are driving pandemic-like conditions and driving unhealth.
    I understand what we are talking about, but let us not be 
fooled. This is not a free market right now. We are investing 
dramatically in our own death.
    Farmers, yes, right now they are being forced to respond to 
the way we have structured the market. I agree with you. If we 
are changing--one of my alliances is with one Senator that is 
an organic farmer, who just says, I am more profitable that I 
am moving to more regenerative things, but there is no 
incentives to do that. People are stuck in the five, in the 
mono-cropping that is producing a lot of the foods that are 
making us so sick.
    Dr. Mozaffarian, I just want you to one more time--I mean, 
we all--we are an agrarian body. The Senate. We all love 
farmers. They are not the problem.
    I believe in this case the decisions by policymakers--and 
again, a lot of it--I do not want to vilify people. We were 
concerned in the 1940's and 1950's about food scarcity. We were 
really concerned about--the thought back then was make as many 
low-cost calories possibly available, and we transformed 
American farm systems to deliver toward that idea. Cheap food, 
get it to people as much as possible.
    When you know better, you should do better. We know America 
right now. The crisis is not simply food availability. The 
crisis is that we are getting so sick.
    I share the values of a lot of my conservative friends. I 
actually had to run something, a government. I tell you we have 
to figure out a way to align incentives with policy decisions 
because it is so out of whack right now. We have the virtual 
equivalent, the metaphorical equivalent, of a frog in boiling 
water right now. We are killing ourselves, but nobody seems to 
recognize the state and the degree of the crisis.
    Senator Braun. Mr. Chair?
    Senator Booker. Yes, sir.
    Senator Braun. I think we do have a good conversation going 
here. To me, in running a business, I always looked in terms of 
where I was going to try to implement the solution on where you 
are spending the most money.
    There is a big distinction between food and healthcare. 
Food is a bargain. We just need to reconstitute the quality of 
the calories. It is in a paradigm that has commodity markets. 
We are the breadbasket of the world. That is going to be easier 
to do than a system that we have created to remediate 
healthcare issues when you enter the healthcare system.
    I think the task is going to be where we get better return 
on our investment by changing the healthcare side of it because 
all of a sudden, when they go from remediation to prevention, 
part of the strategy will be to eat better and to have a better 
lifestyle. Until we change the remediation paradigm, meaning 
healthcare, we are spending 20 percent of our GDP on that. We 
are spending probably just one-third of that on food 
production. I think someone earlier mentioned maybe $1.5 
trillion. It is a lot less.
    I think that you get a two-fer when you take on the 
healthcare industry by making them competitive, transparent, 
and selling wellness and prevention. It is going to bring the 
food system along with it. Would be my global view of how that 
works.
    Senator Booker. All right. Dr. Mozaffarian, I am trying to 
read your body language. Did you want to--because I wanted to 
ask Dr. Warne about specific related issues to trauma. You seem 
to be champing at the bit if I am reading your facial 
expressions right, that you wanted to comment on something I 
said that ticked you off.
    Dr. Mozaffarian. No, no, no. I agreed with you. My body 
language has been just thrilled that you guys are holding this 
hearing. I mean, you are sitting on the legacy of 50 years ago, 
the Senate Select Committee on Nutrition with George McGovern 
and Bob Dole, and I think this Committee can have that same 
transformative impact.
    No, I just wanted to agree with you and everything you 
said. I think you really perfectly summarized the current 
system.
    The point I wanted to just emphasize was that we literally 
have a legacy food system that was built for 20th century 
goals, and we have 21st century problems. Our 20th century 
goals were starchy, inexpensive, shelf-stable calories that did 
not have foodborne bacteria and that were fortified with a 
handful of vitamins.
    That legacy food system was enormously successful. We do 
not want to underemphasize the success of those goals. We 
probably prevented a billion people from starving on the planet 
in the last century, and we pretty much have eliminated endemic 
vitamin deficiency diseases like pellagra and scurvy and 
rickets and other diseases that were very common in the early 
part of the last century.
    Now we have 21st century problems, and we still have this 
20th century food system. Then we have legacy players who, of 
course, have vested interests in keeping that system. We also 
have a lot of disruption going on, and new players coming in.
    I just wanted to agree with you that we have a system set 
up for 20th century goals, and we need to really sit down 
together as a nation and say, how do we want to design our food 
system? Because the food system we have today we consciously 
created very successfully. It was designed. It was not the free 
market. We designed the food system to be what it is today.
    We can do that again and leverage the power of private 
innovation, the power of science and academic institutions, 
public and private, the power of public health, and really 
redesign this in a pretty short amount of time if we set our 
minds to it.
    Senator Booker. To the further indulgence of my Ranking 
Member, who has been extraordinary in this hearing, I have a 
question for Dr. Warne and a question for Odoms-Young about 
minorities and specific strategies. Then my last question, Mr. 
Ranking Member, was just any advice the panel has for us, for 
what the White House strategies should be if we have this great 
summit meeting. Is that okay with you?
    Senator Braun. That would be fine.
    Senator Booker. All right. I am going to just start with 
Dr. Warne because I have read a lot about historic trauma and 
the impact it has on communities that have endured 
extraordinary trauma and trauma-associated illnesses. I know 
that you have studied that a lot and spoken to that a lot. I 
just think there are many opportunities perhaps through food to 
bring healing of not just body but also addressing those 
historic traumas. Based on your work, what do you feel are the 
most effective solutions to address these larger issues within 
the indigenous community through nutrition?
    Dr. Warne. I really appreciate the question. At University 
of North Dakota, I am the Principal Investigator for the 
Indigenous Trauma and Resilience Research Center funded through 
NIH, and we are looking at these exact questions and even 
looking at issues related to nutritional epigenetics.
    One of the things that we have seen historically--and we 
have to recognize that each population is unique. There were 
policies in the past like the Indian Removal Act, which removed 
tribal members from their homelands to other parts of the 
country, and in that process, they lost access to their food 
sovereignty and lost access to traditional food systems. In a 
very direct way, we have seen disruption of food systems based 
on some of those historic policies.
    In terms of historical trauma, there is very compelling 
evidence that looks at how a population that endures a 
significant amount of psychological and emotional trauma can 
hand health disparities to the next generation. We do see it an 
intergenerational impact. That has been studied in the Jewish 
populations after World War II and certainly been studied in 
the American Indian populations here. We see very direct impact 
of loss of territory because of the historical issues.
    The other thing that we see when we have unresolved trauma 
or adverse childhood experiences, we also tend to see more 
poverty in those populations, which then also has an impact on 
food access. We also see people who are self-medicating, and it 
is not always self-medicating with drugs or alcohol. Some 
people are self-medicating with food as well.
    We have to look at this holistically and recognize that 
each population is different, but the impact from the social 
determinants of health perspective can have ripple effects that 
we might not see right away.
    Just in terms of next steps, it is just so vitally 
important to have diverse voices and experiences at the table, 
and I am really just pleased and honored to be a part of these 
discussions.
    Senator Booker. I am honored that you are there. We are 
honored that you are here.
    Very quickly, Dr. Odoms-Young, we talked already about a 
lot of the challenges unique to lower-income African American 
and Latinx communities in terms of their--the levels of 
advertising that is targeted to them that is disproportionate 
to the population as a whole. I guess the general question I 
want to end with asking you is: What types of policies do you 
think would best address the specific nutrition challenges in 
Black and Latinx communities?
    Dr. Odoms-Young. Thank you so much, Senator Booker. As Dr. 
Warne mentioned, it is important that we ensure that all 
efforts take a comprehensive strategy to improve health 
outcomes and diets of Black populations and also that focus on 
increasing economic development as well as community cohesion.
    I think, first, if we think about equity in food security, 
it needs to start in pregnancy and infancy. Black babies die at 
three times the rate of White babies. If you look at the quote 
of Kimberly Seals Allers that says, ``First Food Justice'' is 
food justice. We need to first think about how do we expand 
those supports for breast and human milk feeding. I know WIC 
was mentioned. WIC is a key program. I think we could do more 
to think about breast and human milk feeding because this is 
really at the root of the health of our Nation.
    I think also policies to support and empower those voices 
in the center of communities and also leadership among those 
with the lived experience. Dr. Warne mentioned food 
sovereignty, which is also an important piece in the Black 
community as well. I mean, what is particularly striking, if we 
look at the traditional diet which is rooted in vegetables and 
legumes and then now we look at the intake where Black 
Americans have the lowest intake of fiber, we have seen that 
these environmental exposures have actually shifted the 
traditional diet. Although we have some negative aspects of 
diets always highlighted, there were always a lot of positive 
aspects of those diets.
    I am from Chicago, as I mentioned but, of course, by way of 
Mississippi. I know what it is like to be in a community where 
you have food that is produced, and I think we need to continue 
to support that. We need people of color, businesses that are 
developed, and also policies that help with scale-up of these 
businesses and creating new market opportunities for Black, 
indigenous, and Latino businesses.
    We also have to tailor our nutrition education to what Dr. 
Warne mentioned because we have massive nutrition education 
programs which are doing excellent work, but the need for 
trauma-informed, culturally specific nutrition education is a 
place where I think that we could do more within our land grant 
system because this is really the backbone of educating our 
communities.
    Also, we have the possibility of engaging youth of color 
through something like a nutrition security corps, where we 
educate Black, indigenous, and Latinx youth and put them in 
leadership roles. Then also--and I know that this has been at 
the center of many of the policies that you had implemented--is 
that we need to focus on Black farmers. Black farmers and 
indigenous farmers provide an opportunity for us to expand, 
produce cultural foods, but we also have to make sure that 
those farmers are supported.
    Senator Booker. I am grateful. I have been yelled at by my 
staff that even though my Ranking Member is kind and generous 
my staff is not, and they are saying I need to wrap. I am going 
to do that, and I am going to say that, first of all, thank you 
for the witnesses. This is an extraordinary group. I think you 
all have the richest of perspectives and experiences, not to 
mention more degrees than a thermometer between you all.
    I want to say to my fellow members, and their staffs for 
those members that are not here, we are going to welcome 
additional statements or questions that you may have for the 
record to be submitted to the committee clerk in five business 
days or by 5 p.m. that we can put to the panel. The one 
question for the record I will ask is for advice for us as we 
look toward hopefully having a White House conference.
    In the meantime, I want to thank everybody. There is a lot 
going on in Washington today, a lot that is dominating the 
headlines of our various 24-hour cable news networks, but in 
reality, I do not think anybody is dealing with any issue in 
America right now that is of greater urgency than the one we 
have been talking about. I am just grateful to my Ranking 
Member one more time for the common ground that we have found 
and both of our commitments to do something about the problem.
    With that, this hearing is adjourned.

    [Whereupon, at 12:17 p.m., the Subcommittee was adjourned.]

      
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                            A P P E N D I X

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                   DOCUMENTS SUBMITTED FOR THE RECORD

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                         QUESTIONS AND ANSWERS

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