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PREVENTION AND WELLNESS 

PROGRAM 

HEARING 

BEFORE A

SUBCOMMITTEE OF THE 

COMMITTEE ON APPROPRIATIONS 

UNITED STATES SENATE 

ONE HUNDRED EIGHTH CONGRESS 

SECOND SESSION 

SPECIAL HEARING 

APRIL 16, 2004—DES MOINES, IA 

Printed for the use of the Committee on Appropriations 

( 

Available via the World Wide Web: http://www.access.gpo.gov/congress/senate 
(II) 

COMMITTEE ON APPROPRIATIONS 

TED STEVENS, Alaska, Chairman 

THAD COCHRAN, Mississippi 

ARLEN SPECTER, Pennsylvania 

PETE V. DOMENICI, New Mexico 

CHRISTOPHER S. BOND, Missouri 

MITCH MCCONNELL, Kentucky 

CONRAD BURNS, Montana 

RICHARD C. SHELBY, Alabama 

JUDD GREGG, New Hampshire 

ROBERT F. BENNETT, Utah 

BEN NIGHTHORSE CAMPBELL, Colorado 

LARRY CRAIG, Idaho 

KAY BAILEY HUTCHISON, Texas 

MIKE DEWINE, Ohio 

SAM BROWNBACK, Kansas 

ROBERT C. BYRD, West Virginia 

DANIEL K. INOUYE, Hawaii 

ERNEST F. HOLLINGS, South Carolina 

PATRICK J. LEAHY, Vermont 

TOM HARKIN, Iowa 

BARBARA A. MIKULSKI, Maryland 

HARRY REID, Nevada 

HERB KOHL, Wisconsin 

PATTY MURRAY, Washington 

BYRON L. DORGAN, North Dakota 

DIANNE FEINSTEIN, California 

RICHARD J. DURBIN, Illinois 

TIM JOHNSON, South Dakota 

MARY L. LANDRIEU, Louisiana 

JAMES W. MORHARD, Staff Director 

LISA SUTHERLAND, Deputy Staff Director 

TERRENCE E. SAUVAIN, Minority Staff Director 

SUBCOMMITTEE ON DEPARTMENTS OF LABOR, HEALTH AND HUMAN SERVICES, AND

EDUCATION, AND RELATED AGENCIES

ARLEN SPECTER, Pennsylvania, Chairman 

THAD COCHRAN, Mississippi 

JUDD GREGG, New Hampshire 

LARRY CRAIG, Idaho 

KAY BAILEY HUTCHISON, Texas 

TED STEVENS, Alaska 

MIKE DEWINE, Ohio 

RICHARD C. SHELBY, Alabama 

TOM HARKIN, Iowa 

ERNEST F. HOLLINGS, South Carolina 

DANIEL K. INOUYE, Hawaii 

HARRY REID, Nevada 

HERB KOHL, Wisconsin 

PATTY MURRAY, Washington 

MARY L. LANDRIEU, Louisiana 

ROBERT C. BYRD, West Virginia (Ex officio) 

Professional Staff 

BETTILOU TAYLOR

JIM SOURWINE

MARK LAISCH

SUDIP SHRIKANT PARIKH

CANDICE ROGERS

ELLEN MURRAY (Minority) 

ERIK FATEMI (Minority) 

ADRIENNE HALLETT (Minority) 

Administrative Support 

CAROLE GEAGLEY
(III) 

C O N T E N T S 

Page 

Opening statement of Senator Tom Harkin .......................................................... 1 

Statement of Dr. Tom Baranowski, Ph.D., professor of pediatrics behavioral 

nutrition and physical activity, Baylor College of Medicine ............................. 4 

Prepared statement .......................................................................................... 6 

Statement of Rick Schupbach, co-director, P.E.4Life Institute, and physical 

education teacher, Grundy Center Elementary School, Grundy Center, IA ... 9 

Prepared statement .......................................................................................... 11 

Statement of Dr. Carolyn Cutrona, director, Institute for Social and Behavioral Research, Iowa State University ................................................................ 14 

Prepared statement .......................................................................................... 17 

Statement of Len Olsen, chief executive officer, Ottumwa Regional Health 

Center .................................................................................................................... 20 

Prepared statement .......................................................................................... 24 

Statement of Rhonda E. Ruby, registered nurse, Webster County Department 

of Public Health .................................................................................................... 26 

Prepared statement .......................................................................................... 28 

Statement of Thomas Oldham, president, Just Eliminate Lies (JEL), Iowa 

Youth Tobacco Prevention Organization ............................................................ 30 

Prepared statement .......................................................................................... 33 

(1) 

PREVENTION AND WELLNESS PROGRAM 

FRIDAY, APRIL 16, 2004 

U.S. SENATE,

SUBCOMMITTEE ON LABOR, HEALTH AND HUMAN

SERVICES, AND EDUCATION, AND RELATED AGENCIES, 

COMMITTEE ON APPROPRIATIONS, 

Des Moines, IA. 

The subcommittee met at 9:30 a.m., at the AIB College of Business Activity Center, 2500 Fleur Drive, Des Moines, Iowa, Hon. 

Tom Harkin presiding. 

Present: Senator Harkin. 

OPENING STATEMENT OF SENATOR TOM HARKIN

Senator HARKIN. Thank you all for being here this morning for 

one in a series of hearings that we’re having on wellness and 

health. First let me recognize and thank some people. First I want 

to thank Nancy Williams, the president of AIB, and Marianne 

Nielsen, who is a director of advancement here at AIB, right here 

both, Marianne Nielsen and Nancy Williams, the president of AIB, 

thank you for having us here. 

Let me also thank Sarah O’Neill, director of activities at AIB too. 

Thank you, Sarah. Chris Schmidt, director of facilities at AIB for 

helping us get in here. Jay Byers, who is here, is representing Congress Leonard Boswell, and I talked to Leonard yesterday. He 

couldn’t be here, he’s in other places in his district, but thank you 

for being here, Jay. 

Some other people I want to recognize, Tom Coe, who is with the 

P.E.4LIFE group. We came out from Washington for this meeting. 

He has just put a heart monitor on me and I’m doing all right so 

far. Vernon Delapeace, CEO of the YMCA here in Des Moines, 

thank you for being here, Vernon. Mary Hanson, who’s director of 

the Iowa Department of Public Health is here. Mary, thank you for 

being here. And Julie McMahon, who is the director of the Division 

of Community Health for the Iowa Department of Public Health, 

who is here. We thank all of you for being here. 

This morning, due to the shortage of available captioners, our 

captioning will be done by two AIB students—I hope I get these 

names right—Daria Shariari and Megan Caster. Thank you both 

for doing this and I appreciate your willingness to come and caption this event and I ask you all for your indulgence if they miss 

a word or two, but we’ll try to speak plainly and clearly so you understand what we’re talking about. 

Again, I want to thank you all for coming. Within the next several months, I, along with others, will be introducing legislation 
2 

aimed at encouraging healthy lifestyles and preventing chronic disease. I’ve been soliciting ideas and gathering information all across 

the country for the last several months. But before I give final 

shape to this legislation, I wanted to get more input from people 

here in Iowa. 

Wellness is something that’s difficult to define but easy to understand. It means eating right, exercising regularly, and developing 

healthy habits now in order to prevent major problems in the future. This is mostly just common sense. Iowans who take their cars 

in for regular maintenance understand the basic concept. You either pay a little now to keep things in good shape or you pay a 

whole lot later to fix and mend things. 

Well, it’s the same with national health priorities. In the United 

States, we fail to make an up-front investment in prevention, so we 

end up spending hundreds of billions on hospitalization, treatment, 

and disability. This is foolish and it clearly is unsustainable. Right 

now we’re spending more than $1.5 trillion each year on health 

care in the United States. Fully 75 percent of that total is accounted for by spending on chronic diseases, and what most of 

these chronic diseases have in common is that they are preventable. 

Overweight and obesity are fast becoming our Nation’s leading 

public health threat. In fact, several weeks ago, the Centers for 

Disease Control said that poor diet and lack of physical activity is 

the number two leading cause of death in the United States, contributing to at least 400,000 deaths annually. It is a shocking fact 

that more than two-thirds of Americans are now overweight or 

obese, and more than 15 percent of our children are overweight. 

Obesity takes a terrible toll on an individual’s health. It can lead 

to diabetes, heart disease, high blood pressure, cancer, and numerous other chronic diseases. Incredibly, obesity causes more chronic 

conditions than either smoking or alcoholism. In fact, being obese 

has an effect that is roughly comparable to aging 20 years. 

The costs are not only medical, they are economic as well. The 

Surgeon General estimates that direct and indirect costs of obesity 

in the United States come close to $120 billion annually. But obesity is by no means the only culprit. Tobacco use is still the number 

one killer of Americans. In 2002, 61 million Americans, 26 percent 

of our population, smoked cigarettes. In Iowa the rate was a little 

lower, about 23 percent. But despite decades of education efforts 

aimed at reducing tobacco use, nearly one in four Iowans still light 

up. Iowans know that this is bad for them and most want to quit, 

and we need to help them succeed. 

When it comes to tobacco use prevention, we need to refocus our 

efforts directly toward our children. Keep in mind that 90 percent 

of all long-term smokers started as teenagers or younger. Every 

day in America more than 4,000 kids try their first cigarette. Another 2,000 children become daily smokers. One-third of these 

newly addicted smokers will eventually die from smoking-caused 

diseases. 

Mental health is also an important, but a very unacknowledged 

problem. The Surgeon General reports that mental disorders collectively account for 15 percent of the overall burden of disease from 

all causes. Under treated and untreated mental disorders cost the 
3 

Nation more than $204 billion annually. Again, many of these disorders can be prevented, and millions of people living with mental 

illness can recover if provided treatment and support. This is one 

of the reasons I’ve worked so hard on what we call the Paul 

Wellstone Mental Health Parity Act, which will provide for mental 

health parity in our health systems along with physical health. 

Many people oppose a government role in this area. They say 

that preventable disease is a matter of personal responsibility. I 

agree that personal responsibility is critical, but I also believe that 

government has a responsibility to make sure that people have the 

information, the tools, and the support, and the means they need 

to make healthy choices. 

I interrupt my formal remarks here by saying that I wanted to 

have a little thing before the hearing this morning. I wanted to get 

some people and take a little walk around Gray’s Lake and then 

walk up to AIB. I thought it would be a nice way to kick off the 

hearing. Well, you can walk around Gray’s Lake, but you can’t 

walk from Gray’s Lake to here because there are no sidewalks. 

Think about how many streets are now being built in America, in 

our suburbs and everywhere else, and there are no sidewalks. Everything that the government now seems to be doing is discouraging you from exercising. 

I saw a figure not long ago, I forget it right now, but it’s quite 

startling. As a kid, I grew up riding a bike everywhere. I rode a 

bike when I was in college. But I saw the figures indicating that 

today fewer kids and adults are bicycling than what they did in the 

past. Well, where are the bike paths? How can you ride a bike 

along a busy highway or a street with all those cars going by and 

you don’t have any place to ride a bike? So again, I mention this 

as a government responsibility to begin to do things to encourage 

people or support people in trying to have a healthy lifestyle. 

As adults, we also have a responsibility to protect our children. 

Every year, kids are barraged with billions of dollars in tobacco, alcohol, and junk food marketing, all of it aimed at persuading them 

to make an unhealthy choice. I always say that the golden rule of 

holes is this. If you find yourself in a hole and it’s getting up to 

your head, stop digging. Well, we’ve dug a big hole by failing to emphasize prevention and wellness, and it’s time to stop digging and 

time to start climbing out of the hole. And it’s going to take all sectors, it’s going to take a comprehensive approach, everything from 

school-based, preschool, workplace-based, home-based, communitybased, government-based, all of them working together. 

Today we’ll hear from folks who are doing important and innovative work in encouraging individual wellness and healthy communities. I thank them for coming today. I look forward to their testimony and I’d like to say two more things. First, I want to thank 

the chairman of this subcommittee, my good friend Arlen Specter 

of Pennsylvania. Senator Specter and I have switched roles here 

numerous times over the last 14 years. I’ve been chairman, he’s 

ranking member, he’s chairman, I’m ranking member, back and 

forth. But as he is fond of saying, and I agree with him, it’s been 

a seamless transfer. We have worked together very closely over all 

these years on health matters that pertain to the American people, 
4 

and I want to thank him for allowing me this opportunity to have 

this hearing here in Des Moines. 

Second at the close of our formal remarks, I will engage in some 

questions with our panelists, but I’d also like to open it up to the 

audience, and time permitting, we’ll have some questions, or if you 

want some statements or you have some input, some ideas, suggestions, we’d like to hear it. I would just ask that for the recorder’s 

sake that you just give your name and please spell your name so 

that the recorder can get it right. 

So with that, let’s go to our witnesses. I will introduce each one 

in the order that they will be making their testimony. First, we 

welcome Dr. Tom Baranowski. He’s the professor of pediatrics and 

behavioral medicine at Baylor College of Medicine in Houston, 

Texas. Dr. Baranowski’s research is directed toward understanding 

why children eat the foods and engage in the physical activities 

they do, as well as designing and evaluating programs to help 

change these dietary and physical activity behaviors. His areas of 

interest include fruit and vegetable consumption, obesity prevention, and physical activity. Dr. Baranowski will discuss chronic disease prevention and the cost to our economic health, specifically 

pertaining to physical inactivity and poor nutrition. 

After Dr. Baranowski, we’ll go with Mr. Rick Schupbach and 

then we’ll got to Dr. Carolyn Cutrona, then Mr. Len Olsen, Ms. 

Rhonda Ruby, and we got our clean-up hitter, someone you’re really going to like to listen to, Tom Oldham right over there and what 

he’s doing at Lincoln High School. So Dr. Baranowski, welcome, 

and the floor is yours. 

STATEMENT OF DR. TOM BARANOWSKI, Ph.D., PROFESSOR OF PEDIATRICS BEHAVIORAL NUTRITION AND PHYSICAL ACTIVITY, 

BAYLOR COLLEGE OF MEDICINE 

Dr. BARANOWSKI. Senator Harkin, thank you for pronouncing my 

name properly, it was terrific. It’s a great privilege to speak before 

this committee. I’ll skip a couple of paragraphs that said who I 

was, being you did such a nice job of it. 

I’m here today to address the broader issues of chronic disease 

prevention, and of special interest to me, chronic disease prevention among children. As shown in table 1 in my testimony, 5 of the 

10 leading causes of death in the United States are chronic diseases whose causes are largely or partially related to diet and 

physical inactivity. 

Accounting for fully two-thirds of deaths, the principal diseases 

of nutritional origin also account for an immense fraction of disability due to disease and the major share of medical costs for disease treatment as shown in table 2 in my testimony. Medical care costs for heart disease alone were $51.8 billion in 

1985. The cancers cost $41 billion. Type II diabetes cost $45.2 billion. These numbers are even higher in 2004 because the population is larger and older. Further, in addition to these social economic costs, there are huge personal costs in terms of premature 

loss of loved ones, disruptions of gratifying lives, pain and sorrow, 

which are much more difficult to quantify. 

As I’m sure you are well aware, we are currently immersed in 

what can be termed an epidemic of obesity. However, you may be 

less aware of the fact that obesity is the principal underlying con-
5 

tributor to many of the major chronic diseases. Thus, for example, 

the dramatic rise in the incidence of diabetes in childhood and adolescence is directly the result of the increasing prevalence of obesity 

in children. In fact, the current prevalence rates of obesity and 

overweight are so high as to be alarming. Over half of all adults 

and approximately three-quarters of some ethnic/gender subgroups 

are overweight or obese. In middle schools in Houston among the 

minority students, half of the children are overweight or obese. 

The economic impact of obesity’s role in the medical costs of the 

major chronic diseases of American adults has been calculated and 

it is frankly staggering. Today, most of the health care dollar is 

spent on treating these terrible diseases. While every effort should 

be maintained to treat existing cases of these diseases to minimize 

their burden, far more funding needs to be spent on prevention efforts upstream of the current treatment or downstream paradigms. 

Prevention is obviously always preferable to treatment in any circumstances, from both practical and fiscal perspectives. Prevention 

will serve to lessen the chronic disease burden on future generations, which, in turn, will minimize the social, economic, and personal costs. 

It’s now abundantly clear that much of chronic disease morbidity 

and mortality is due to lifestyle behaviors. In fact, obesity is the 

result of an imbalance of two daily behaviors, calories consumed 

and an individual’s level of physical activity. It’s no surprise then 

that a recent report from the Centers for Disease Control and Prevention indicated that the two leading causes of death in 2000 were 

tobacco use and poor diet and physical activity. The other causes 

of death paled in comparison. The authors projected that poor diet 

and physical activity will soon overtake smoking as the leading 

cause of death, and urged a greater priority be placed on prevention. 

Thus, more than one-third of American deaths can be prevented 

by changing the smoking, diet, and physical activity practices of 

our children—of our citizens. Since poor diet and physical activity 

behaviors are the principal contributing causes of obesity, and since 

obesity is the leading underlying cause of nutritionally-related 

causes of death, a substantial investment is needed in obesity-related behavioral research to better understand how and why we 

have gotten where we are. In an annual NIH budget of $24 billion, 

approximately $379 million was spent on obesity in fiscal year 

2003, about $400 million will be spent on obesity in fiscal year 

2004, and $440 million in fiscal year 2005, and most of this will 

be spent on biological issues, not behavioral issues. Clearly, more 

funding must be spent on obesity and particularly on obesity prevention. 

Finally, why is a child’s—why is a children’s behavioral scientist 

speaking about chronic diseases of late adult life? All avenues of 

medical science now point to the fact that the prevention of chronic 

diseases should be initiated early in life among children. Diet and 

physical activity habits are learned in childhood. Chronic disease 

factors like blood pressure elevated among children tend to remain 

elevated into the adult years. 
6 

PREPARED STATEMENT

There is some reason to believe that behaviors are more easily 

changed among children than among adults. Once excess weight is 

put on, it is almost impossible to take off. Despite these factors, 

many schools are minimizing or closing their physical education 

programs, high fat and high sugar foods are being marketed to 

children. National policy must carefully consider what can be done 

to enhance the diet and physical activity practices of our citizens 

and especially our children. This will have a huge impact on national health care costs and the quality of our children’s lives. 

Thank you for your time and attention. I’d be happy to answer 

questions. 

[The statement follows:] 

PREPARED STATEMENT OF DR. TOM BARANOWSKI

CHRONIC DISEASE PREVENTION

Senator Harkin and members of the U.S. Senate Committee on Appropriations, 

it is a great privilege to speak before this committee. 

I am trained as a health psychologist, and do research on influences on children’s 

diet and physical activity practices, and I design, implement and evaluate programs 

to change children’s diet and physical activity practices. 

I am here, however, to address the broader issues of chronic disease prevention, 

and of especial interest to me, chronic disease prevention among children. 

As shown below in Table 1, five of the ten leading causes of death in the United 

States are chronic diseases whose causes are largely or partially related to diet and 

physical inactivity. 

TABLE 1.—DEATHS AND PERCENTAGES OF TOTAL DEATHS FOR THE FIVE OF THE TOP 10 LEADING 

CAUSES OF DEATH IN THE UNITED STATES, 2001 

Number Percent 

Diseases of the Heart ................................................................................................................................. 700,142 29 .0 

Malignant Neoplasms ................................................................................................................................. 553,768 22 .9 

Cerebrovascular Diseases ........................................................................................................................... 163,538 6 .8 

Chronic lower respiratory Diseases ............................................................................................................ 123,013 5 .1 

Diabetes Mellitus ........................................................................................................................................ 71,372 3 .0 

Source: National Vital Statistics Reports, Vol. 52, #9, Nov. 7, 2003. 

Accounting for fully two-thirds of deaths, the principal diseases of nutritional origin also account for an immense fraction of disability due to disease and the major 

share of medical costs for disease treatment as shown in Table 2 below. 

TABLE 2.—HEALTH CARE COSTS FOR MAJOR CHRONIC DISEASES IN 1995 USING 2002 DOLLARS 

[In billions of dollars] 

Estimated 

total cost 

Heart Disease ............................................................................................................................................................... 51 .8 

Cancers ........................................................................................................................................................................ 41 .0 

Breast .................................................................................................................................................................. ................

Endometrial ......................................................................................................................................................... ................

Colon ................................................................................................................................................................... ................

Type 2 Diabetes ........................................................................................................................................................... 45 .2 

Osteoarthritis ................................................................................................................................................................ (64 .0) 

Hypertension ................................................................................................................................................................. 24 .1 

Obesity .......................................................................................................................................................................... 117 .0 

Source: Several NIH web sites. 

Medical care costs for heart disease alone were $51.8 billion in 1995. The cancers 

cost $41 billion; Type 2 diabetes cost $45.2 billion. These numbers are even higher 
7 

in 2004 because the population is larger and older. Further, in addition to these social economic costs, there are huge personal costs in terms of premature loss of 

loved ones, disruptions of gratifying lives, pain and sorrow, which are much more 

difficult to quantify. 

As I’m sure you are well aware, we are currently immersed in what can be termed 

an epidemic of obesity. However, you may be less aware of the fact that obesity is 

the principal underlying contributor to many of the major chronic diseases. Thus, 

for example, the dramatic rise in the incidence of diabetes in childhood and adolescence is directly the result of the increasing prevalence of obese children. In fact, 

the current prevalence rates of overweight and obesity are so high as to be alarming 

(see Table 3). Over half of all adults and approximately three quarters of some ethnic/gender subgroups are overweight or obese. 

TABLE 3.—PREVALENCE OF OVERWEIGHT AND OBESITY AMONG ADULTS (20∂ YEARS OLD) BY 

MAJOR ETHNIC AND GENDER GROUPINGS 

[In percent] 

Women Men 

Non Hispanic Black ........................................................................................................................................ 77 .3 60 .7 

Mexican American ........................................................................................................................................... 71 .9 74 .7 

Non Hispanic White ........................................................................................................................................ 57 .3 67 .4 

Source: NIDDK web site. 

Recently, the economic impact of obesity’s role in the medical costs of the major 

chronic diseases of American adults has been calculated (Table 4 below) and it is 

frankly staggering. 

TABLE 4.—COSTS FOR CHRONIC ILLNESSES ATTRIBUTABLE TO OBESITY 

Directly 

due to 

obesity 

Indirectly 

due to 

obesity 

Heart Disease (Billions) .............................................................................................................................. $8 .8 ..............

Cancers: 

Breast (Billions) ................................................................................................................................. 1 .1 $1 .8 

Endometrial (Millions) ........................................................................................................................ 310 .0 623 .0 

Colon (Billions) ................................................................................................................................... 1 .3 2 .2 

Type 2 Diabetes (Billions) .......................................................................................................................... 52.8 

Osteoarthritis (Billions) ............................................................................................................................... 5 .3 15 .9 

Hypertension (Billions) ................................................................................................................................ 4 .1 ..............

Obesity (Billions) ......................................................................................................................................... 61 .0 56 .0 

Source: Several NIH web sites. 

Today, most of the health care dollar is spent on treating these terrible illnesses. 

While every effort should be maintained to treat existing cases of these diseases to 

minimize their burden, far more funding needs to be spent on prevention efforts 

‘‘upstream’’ of the current treatment or ‘‘downstream’’ paradigms. Prevention is obviously always preferable to treatment in any circumstance, from both practical and 

fiscal perspectives. Prevention will serve to lessen the chronic disease burden on future generations, which, in turn, will minimize the social, economic and personal 

costs. 

It’s now abundantly clear that much of chronic disease morbidity and mortality 

is due to lifestyle behaviors. In fact, obesity is the result of an imbalance of two 

daily behaviors, calories consumed and an individual’s level of physical activity. It’s 

no surprise then that a recent report from the Centers for Disease Control and Prevention indicated that the two leading causes of death in 2000 were tobacco use and 

poor diet and physical activity. The other causes of death paled in comparison. The 

authors projected that poor diet and physical activity will soon overtake smoking as 

the leading cause of death, and urged a greater priority be placed on prevention. 

TABLE 5.—LEADING CAUSES OF DEATH IN THE UNITED STATES IN 2000 

Numbers of 

deaths 

Percent 

of total 

Tobacco ......................................................................................................................................................... 435,000 18 .1 
8 

TABLE 5.—LEADING CAUSES OF DEATH IN THE UNITED STATES IN 2000—Continued 

Numbers of 

deaths 

Percent 

of total 

Poor diet & physical activity ........................................................................................................................ 400,000 16 .6 

Source: Mokdad, et al, Actual causes of death in the United States, 2000. JAMA, 2004; 291:1238–1245. 

Thus, more than one-third of American deaths can be prevented by changing the 

smoking, diet and physical activity practices of our citizens. 

Since poor diet and physical activity behaviors are the principal contributing 

causes of obesity and since obesity is a leading underlying cause of nutritionally –related causes of death, a substantial investment is needed in obesity related behavioral research to better understand how and why we have gotten where we are. In 

an annual NIH Budget of $24 billion, approximately $379 million was spent on obesity in fiscal year 2003, about $400 million will be spent on obesity in fiscal year 

20004, and $440 million in fiscal year 2005 (source: www.nih.gov/news/ 

fundingresearchareas.htm). Clearly more funding must be spent on obesity, and particularly on obesity prevention. 

Finally, why is a children’s behavioral scientist speaking about chronic diseases 

of late adult life? All avenues of medical science now point to the fact that the prevention of chronic diseases should be initiated early in life among children. Diet and 

physical activity habits are learned in childhood. Chronic disease risk factors (like 

blood pressure) elevated among children, tend to remain elevated into adult years. 

Diet and physical activity practices learned in childhood tend to continue into the 

adult years. There is some reason to believe that behaviors are more easily changed 

among children than among adults. Once excess weight is put on it is almost impossible to take off. Despite these factors, many schools are minimizing or closing their 

physical education programs; high fat and high sugar foods are being marketed to 

children. National policy must carefully consider what can be done to enhance the 

diet and physical activity practices of our citizens and especially our children. This 

will have a huge impact on national health care costs and the quality of our children’s lives. 

Thank you for your time an attention. I would be happy to answer questions. 

LOB QUESTIONS

Question. What research has been done on school based obesity prevention programs for children, and how are they working? 

Answer. First, there have been remarkably few school based or non-school based, 

obesity prevention programs among children. Of those conducted, most have not 

changed some aspect of body composition. Of those that worked, most were pilot 

studies that do not normally work in more rigorous larger trials, or they worked for 

subsets, but not all of the students. There is no clear guidance from the published 

studies on what to do for school based obesity prevention. 

Question. Does this suggest that we should not fund more research in this area? 

Answer. No. The NIH has made an enormous investment in biological research 

over the last 50 years. It is only in the last 10 years or so where the treatments 

have been targeted at molecular systems, e.g. cell receptors, and have had substantial impact on disease without substantial side effects. The same investment must 

now be made in the behavioral sciences. We need to better understand why people 

eat the food they do, and are, or are not, physically active. Research must then be 

conducted to convert this knowledge into effective programs and evaluate them. 

This will require substantially more funding for behavioral science and related research. 

Question. What do you believe are the three highest priority issues for research 

in this area? 

Answer. First we need a clear picture of what are the major contributors to obesity. Some luminaries believe lack of physical activity is the major culprit; other 

equally admirable luminaries believe it is mostly diet. There are adherents for the 

contribution of TV, electronic games, fast food, enhanced portion sizes, etc. If we 

knew the five major causes of obesity, we would have clear guidance for the design 

of programs to maximize the effects. Of course the five major causes probably vary 

by age, and perhaps by gender. 

Second, we need a better understanding of why people do or don’t do, the behaviors that are the major contributors to obesity. This knowledge will guide programs 

designers on what mediating variables to target. 

Third, we need research on controlled diet and physical activity. For example, 

most of national dietary guidance is based on the national dietary guidelines and 
9 

food guide pyramid, but there has never been a study that assesses what happens 

when people eat a diet based on the dietary guidelines and food guide pyramid. 

What will it do for obese or moderately overweight people? for those with an elevated blood pressure or cholesterol? There are several recent versions of the food 

guide pyramid and more have been proposed. None have been compared for effects 

on outcomes. The same kind of research is needed with physical activity. What will 

30 minutes of moderate to vigorous physical activity 6 days a week do for adults 

or children who are overweight? Is physical activity valuable primarily in longer 

doses, or do multiple, shorter doses have the same effect? While some of this research on physical activity has been done, this is very difficult research to do and 

much more is necessary. 

A number of my colleagues would argue that the primary research need is for 

more community-based interventions. In my opinion, since most of our community 

based interventions have not worked well, or not worked at all, these three kinds 

of research will provide much needed guidance to the community based interventions. 

STATEMENT OF RICK SCHUPBACH, CO-DIRECTOR, P.E.4LIFE INSTITUTE, AND PHYSICAL EDUCATION TEACHER, GRUNDY CENTER 

ELEMENTARY SCHOOL, GRUNDY CENTER, IA 

Senator HARKIN. Dr. Baranowski, thank you very much for that 

testimony, and now we’ll move to Mr. Schupbach, the Grundy Center Elementary physical education specialist is Mr. Rick 

Schupbach. He was selected the 1993 Iowa Elementary Physical 

Educator of the Year, and in 2001 was recognized as only the third 

Excellence in Education Award winner in Grundy Center Community School District history. 

On May 1, 2003, get this, the Grundy Center Elementary physical education program was recognized as the first P.E.4LIFE Institute at an elementary school in the entire Nation. Rick Schupbach. 

Mr. SCHUPBACK. Thank you, Senator Harkin, and if I could ask 

you to draw your attention to the screen, and the audience as well, 

and excuse me for having my back to you. It is indeed a pleasure 

to be here today and I thank you for this forum, and I want to 

thank you on behalf of all physical education teachers, not only in 

the State of Iowa but the Nation, for your visionary leadership in 

the area of not only health and wellness, but in physical education, 

especially with the PEP program legislation. 

Along with that, I’d like to take this opportunity, and I would be 

remiss if I did not recognize my school superintendent, Mr. John 

Stevens, who is here today with me. Mr. Stevens has been a visionary for health and wellness and physical education at the local 

level as you have on the national level, so it’s very important that 

he is here with me today. 

As I begin my presentation, I want you to use your imagination. 

Dr. Baranowski did an excellent job of capturing the problem in 

our society today. What I would like to do is talk about what I perceive as a preventive, proactive, prescriptive solution, and that is 

quality physical education. 

So I’m going to ask you to use your imagination, and I want you 

to imagine a world where physical education just isn’t another 

class to be completed, but a destination for a different kind of 

learning. Two such examples I have time to share with you today 

at the P.E.4LIFE Institute in Grundy Center that we do are the 

heart adventure challenge course where students represent red 

blood cells as they travel through the circulatory system. The SOS 

challenge course, where they have problem-solving teams and have 

to perform fitness tasks in order to be able to save themselves. 
10 

At Grundy Center I’m proud to say that we believe in the mind 

body connection, that we believe that physical education represents 

the lifestyle learning lab. Unfortunately, No Child Left Behind has 

left physical education behind and it has concentrated solely on the 

mind at the expense of the body. And as a result of that, we have 

children today that are being educated not as a whole child, but 

only their mind. I am proud to say that at the Grundy Center 

P.E.4LIFE Institute, we believe in sound mind, sound body. There’s 

more to education than math, reading, and science. 

To do that, you have to document your results. We have the opportunity and the vision to document our students’ heart rates on 

a daily basis. We have revolutionized physical education with report card systems and meal planners and assessments where they 

can take what they do in fitness testing and track it over the lifetime that they are in school. We can document the effort that students put into physical education on a daily basis, providing printouts for every 5 seconds of their heart rate in P.E. They must invest in their own health to see a return, and we must be able to 

collect data like every other area of education. 

I want you to imagine a world where P.E. is articulated K–12 

and it expands outside the walls of the gymnasium and into the 

community. That’s what we’ve been able to do at Grundy Center. 

One of the creative ways in which we’ve been able to do that is to 

put heart monitors on people in different careers. It’s called ‘‘the 

day in the life of,’’ and as you look at this screen, you can see the 

different days in the life of, and what we’ve found out is that every 

career without exception is sedentary, and we know that 9 out of 

10 teenagers if they are inactive as youth will become inactive as 

adults. So what we have to do is be able to get them active, get 

them to invest in their own health. Is it any wonder we have an 

obesity crisis when we know that all occupations are sedentary? It’s 

part of how we can inspire one another. 

I want to welcome you to an awakening and to the new P.E., and 

it comes not a minute too soon for any kid who has been picked 

last, consigned to right field, or left dangling halfway up the climbing rope. The idea is to get away from the jock culture, the fastest, 

the strongest, the most athletic, instead start all kids on the road 

to lifelong fitness, and that starts with no humiliation. 

I believe that Grundy Center in some small way is serving as a 

beacon of light, as a lighthouse, not only for our students, but also 

for our community, also for our State, and as being named the second P.E.4LIFE Institute, for our Nation as we train people who 

come to our P.E.4LIFE Institute from around our Nation, in fact 

from around the world. We’ve had visitors from Finland. 

Our approach is a STAR-TEC P.E. approach, where we allow 

every child to be a star, and we provide success through assessing 

and reporting. We use technology, education, and community 

health. That’s our physical education program. It starts with a design, and we must design what takes place in our classrooms. 

Many times physical educators are our own worst enemies and create our own black eyes. We must step up and we must be accountable for our actions, and so the design that I wish I had time to 

go through and show you all of the different things that are going 
11 

on in the educational setting in the classroom setting in Grundy 

Center. 

I truly believe that we have the secret for healthy living. It is a 

lifestyle education approach. I would like to end and conclude my 

comments on the most personal and intimate level that I can. 

Seven years ago tomorrow, I was diagnosed with cancer. I had a 

tumor the size of my fist in my chest, and as I went to the Mayo 

Clinic to be treated, my doctor said to me that I was fortunate that 

I happened to be in as good a shape as I was, I was in training 

for my second half-marathon at the time. My regiment called for 

120 hours of chemotherapy, IV, on four different occasions. Most of 

the time what killed people that had my type of cancer was the 

chemotherapy protocol. However, Dr. Ronald Richardson said to 

me, Rick, you are fortunate because you are in the best shape of 

your life. 

I know there are great teachers around this Nation in all subject 

matters, and I know they all think what they are doing is the most 

important thing. I want you to understand that I am passionate 

about what I teach and I want you to know that no matter how 

important those other subject matters seems, it’s very important to 

understand that they could not stand in front of you today and say 

that by living their profession, it helped to save their life. By living 

my profession, I believe it helped to save my life. 

PREPARED STATEMENT

I thank you for your time and I thank you for your advocacy for 

our mission and our goal and I look forward to you visiting 

P.E.4LIFE Institute in Grundy Center shortly to join us in a living, 

breathing model. Thank you. 

[The statement follows:] 

PREPARED STATEMENT OF RICK SCHUPBACH

Thank you, Senator Harkin, for the opportunity to offer testimony here today. My 

name is Rick Schupbach and I am a Physical Education Teacher at Grundy Center 

Elementary School in Grundy Center, Iowa. I have been teaching physical education 

for 20 years, 14 of those in Grundy Center. I also serve as the Co-Director of the 

P.E.4LIFE Institute in Grundy Center. 

First, I would like to introduce my Superintendent, John Stevens, who is with me 

today. As you will hear in my testimony, transforming Physical Education programs 

so they are relevant and effective in the 21st Century requires a partnership with 

the entire school system, not just the PE teachers. We need visionary administrators 

who understand and are committed to the healthy body, healthy mind connection. 

We are fortunate in Grundy Center to have John Stevens as that kind of educator. 

Before talking about the exciting things we are doing in Grundy Center, I would 

like to take a moment to commend you, Senator Harkin, for your exemplary leadership on the issue of promoting health, wellness and prevention, especially with regard to programs aimed at children. Your leadership in the success of the Carol 

White Physical Education Program (PEP) is making a tremendous difference in 

communities around the country. Now in its fourth year, the PEP program grants 

are invigorating PE programs and attracting more young people to healthy and active lifestyles. We are proud of the work you do and look forward to continuing together in the years ahead. 

My testimony today will focus on the importance of quality physical education in 

our nation’s schools and specifically what we have been able to accomplish in 

Grundy Center. We believe quality PE must be part of any national strategy to promote health and wellness. Our understanding of physical education, which we call 

P.E.4LIFE, means meeting the needs of every student, not just the athletically inclined; it means grading students on effort and progress toward the goal, not on 

skills and innate abilities; it means using technology and innovative teaching to 
12 

reach kids where they are, not pulling them to where we want them to be, only to 

lose them as soon as the bell rings; it means linking students, teachers, school administrators, business leaders and even senior citizens to build truly healthy communities. And perhaps most importantly, Grundy Center’s P.E.4LIFE program 

means putting the fun back into sports, fitness, recreation and exercise in a way 

that inspires all students to want to be active every day of their lives. 

We have made tremendous progress in our community. Now, by serving as a 

P.E.4LIFE Institute, we attract and train others who come to see how to improve 

their physical education program. 

We have all heard the statistics about the health crisis facing our nation’s youth. 

Probably one of the most widely used and significant is the Center for Disease report that the percentage of children ages 6 to 11 who are overweight has increased 

nearly 300 percent during the past 25 years. These numbers continue to astonish 

as one evaluates older demographics as well. 

As described in the news media, these numbers have reached epidemic proportions. It is an interesting paradox though. Never before have children and youth had 

better access to health care and have experienced lower rates of disease and disability. But the indicators of health status linked to physical activity are regressing. 

As a result children, for the first time in 100 years, may have a shorter life expectancy than their parents. 

The accompanying health problems as a result of this trend present a great problem in our society. Diseases like Type 2 diabetes, previously referred to as ‘‘adultonset diabetes,’’ are on the rise among our children. It has been estimated that the 

health care cost of being overweight and obese now exceeds $100 billion annually. 

Just last month, newspaper headlines across the country reported new data attributing lack of physical activity and poor diet to 400,000 deaths per year. This makes 

physical inactivity and bad nutrition the second leading cause of preventable death 

in the country, just behind tobacco. The statistics go on and on. 

I am proud to say Grundy Center is at the forefront of a national movement to 

halt and reverse these trends, starting with our children and expanding into the 

whole community. One of the key aspects of this change has been the recognition 

led by organizations like P.E.4LIFE that our methods of teaching physical education 

needed to change. As a result, we have made our P.E.4LIFE program fun, innovative, integrated, motivational and accountable. With proper reinforcement and 

teaching, scores of kids who in traditional PE were scorned and turned off are becoming engaged and motivated. And these are the ones who make up the epidemic 

we are trying to fight. 

The P.E.4LIFE Physical Education program in Grundy Center is founded on the 

concept of lifestyle education. We developed our curriculum to educate students to 

meet the needs of their future lifestyles. My focus is to help students make healthy 

lifestyle choices they would not have made unless we intervened. Based on a lifestyle education model developed by Beth Kirkpatrick, a native Iowan, our program 

has been adapted specifically for the elementary school setting. 

We develop and implement innovative P.E.4LIFE activities that link to other educational concepts. We strive to integrate learning, starting inside the walls of the 

gymnasium and reaching out into the community. Let me mention a couple of examples: 

—Dance pads and game rider bikes using video technology to motivate students 

to engage today’s students’ interest in investing in their own health. 

—Community Fitness Center housed within the walls of the school. 

—Heart Adventure Challenge Course—Students take on a large scale obstacle 

course by traveling as blood cells through the circulatory system. 

—SOS Adventure Course—A game in which students, stranded on an island, 

must work together through numerous physical and mental challenges for the 

team to be saved. 

—Technology applications such as the pocket PC, the PE manager report card 

program and the TriFit assessment program integrated into the physical delivery system. 

—Math Projects—Using their own heart rate data, students learn graphing and 

data collection skills, as well as trend analysis. 

—Music Education—Music is a constant in our PE classes. Coordinated with our 

elementary music curriculum, different classical music composers are introduced to fourth and fifth graders each month during warm-ups. Contemporary 

music is cued to the aerobic phases of our workouts. 

Not only are students learning valuable educational concepts, they’re learning 

how to live active, healthy lives. 

Using a wide range of activities, unique class format design technology and interactive learning stations, Grundy Center has a program that addresses a different 
13 

aspect and concept of lifestyle education in each PE class every day. In the fourth 

and fifth grade, students work throughout the year to design their personal lifestyle 

plans, with regular opportunities to revise their selections. Continually participating 

in thought-provoking activities requires our students to challenge their choices. This 

process also encourages parents to take an active role in their child’s health through 

helping them work on obtaining their goals throughout the year. 

Technology can be a key determinant in getting kids healthy and active. Heart 

rate monitors, in particular, are transforming physical education. At the level of the 

individual student, heart rate monitors allow every child to be successful in PE. Use 

of monitors encourage students to set and attain goals that are appropriate for 

them. I teach kids that it doesn’t matter how fast they run, as long as they meet 

their target heart rate. I can’t emphasize how liberating this is for students, as well 

as for me. Technology like heart rate monitors can be the great equalizer, allowing 

everyone to be a winner and no one a loser. 

At the same time, the value of technology extends beyond motivation. Through 

immediate computer printouts of the every student’s heart rate, I get verifiable feedback to see if I am indeed providing the class format and activities necessary to impact cardiovascular fitness. I can use objective data to make a fair assessment of 

individuals and the class as a whole. 

And it allows us to connect with families. We send heart rate printouts home to 

every parent. This has proven very positive, especially to encourage family discussion connecting fitness and health. 

I personally believe use of this kind of technology is absolutely critical to the future of physical education for another reason: Accountability. I can show—visually, 

graphically, objectively—how participating in physical education is improving our 

students’ health and wellness. We are fully equipped to respond to our Superintendent, School Board and parents when they want to validate the critically important class time and resources our PE requires. In Grundy Center, we welcome 

the opportunity to demonstrate the cardiovascular benefits a quality physical education program has on students. We can show it. Cutting PE in Grundy Center 

would mean cutting the heart out of the child’s education. I sincerely believe for our 

country to embrace PE the way it needs to, the physical education profession needs 

to embrace the accountability we can deliver through technology. 

A wonderful affirmation of our program’s impact has been how Grundy Center’s 

middle and high schools are embracing the Lifestyle Education approach to physical 

education. In 2001, we secured private foundation funding to create a state-of-theart ‘‘Community Fitness Center’’ in our school. More than $130,000 was provided. 

Initially, aerobic and strength training equipment, along with heart rate monitors 

and fitness evaluation software, were made available to 6–12th graders. We have 

seen the quality of their PE experiences improve. Even more exciting, however, was 

the ability for us to expand physical education beyond the gym and into the community. On any day in Grundy Center, you may find a district judge, grocery clerk, 

firefighter or eighty year-old retiree working out and recording her heart rate in the 

Community Fitness Center. 

Let me mention one example of how we have extended beyond our school walls 

and engaged our community. We developed our ‘‘A Day In The Life Of’’ program to 

teach our students how different careers and lifestyles impact one’s health. We went 

out to the community and put a heart rate monitor on various citizens, and asked 

each to wear it all day. After a full day’s work, we downloaded the information to 

learn how heart rates fluctuated throughout a routine workday. The results demonstrably showed our students just how sedentary many career paths can become. Our 

students were shocked to see how few adults reached a target heart rate for any 

period of time, day after day. It made the point that every person has to consciously 

decide to be active, whether by riding a bike, walking to the grocery store, playing 

a sport or working out in a gym. 

In addition, this exercise spoke directly to many adults who had no idea of their 

own physical inactivity. Sue Havel, a local hairstylist, thought since she was on her 

feet all day she was getting valuable exercise. After seeing the heart rate data prove 

otherwise, Sue changed her life. She now is a regular at the Community Fitness 

Center, and happier and healthier for it. 

I can’t tell you how proud it makes me to see young people inspiring adults and 

adults inspiring young people to take control of their health in this way. And when 

we see senior citizens on the treadmill alongside a middle school student, as I do 

in Grundy Center, it’s hard to tell who is inspiring whom, which is even better! 

There is no doubt the change I am talking about takes time to realize. When I 

first began to develop the elementary school curriculum, which is called ‘‘Energizing 

and Educating for Healthy Lifestyles’’, our gymnasium was housed in the basement 

of a 70 year-old building. It wasn’t anything special. Over time, we formed teams 
14 

from the community to clean and restore the gym floor, I painted the gym myself 

one summer, and volunteers helped to build a student fitness area. 

Several years later, a new elementary school was built. Thanks in part to our collective roles in improving the old facility, community members and I were involved 

in designing the new gymnasium. This collaboration resulted in a truly effective 

teaching environment that today includes many child-centered learning ideas that 

allows our program to flourish: 

—PE teacher’s office is central with windows for two way viewing; 

—Restrooms and drinking fountains are inside the gym so no child leaves the 

teaching-learning setting; 

—Gymnasium is situated so that no one from outside class walks through and distracts attention; 

—Gravionic bars are built into the walls for decompression exercises that build 

strength and develop appropriate posture; 

—Equipment and heart monitor storage areas are built into facility design; 

—Personal spaces are painted on gym floor and numbers are painted on the wall 

to aid in class management protocols; 

—Student workstation to record concepts and heart rate data is adjacent to gym; 

—Rock climbing wall was recently built within the gymnasium. 

Change takes time, and it takes vision. And if this country is to make the change 

toward health and fitness that we all know we have to, frankly, the physical education profession needs to change as well. We need to embrace P.E.4LIFE programs 

that promote technology, accountability, and community outreach. The University of 

Northern Iowa is attempting to revolutionize physical education training at the college level. Starting next year, eight top UNI graduate students will immerse themselves at the P.E4LIFE Institute in Grundy Center, teaching and living in the community to see firsthand how comprehensive health and wellness promotion can take 

hold. We believe Grundy Center is a national model that can be replicated across 

the country. We want more programs to come to the PE4LIFE Institute and then 

go back home and change they way they do things. Just last month, 10 people from 

Des Moines trained with us and returned here to transform their PE programs into 

P.E.4LIFE programs. 

We’ve all heard stories about humiliation in the old way of teaching PE. Being 

the last kid picked, suffering through elimination games, forced to compete in games 

that weren’t fun—I acknowledge these perceptions hamper PE even today. 

Yet it is self evident that quality physical education, provided the right way, is 

an integral component to deal with obesity-related diseases, sedentary lifestyles and 

soaring health care costs that plague our country today. We can show people the 

old PE is out. We can prove to school boards that PE can and should be accountable 

just like other core subjects. Physical education can be a catalyst for entire communities to become active and healthy. 

Physical education in the 21st Century means educating every child in a way that 

is relevant to his or her life experiences. It means a STAR TECH PE approach 

where we provide Success Through Assessment, Reporting, Technology, Education 

and Community Health Physical Education. To truly take our PE programs where 

they have never gone before. We have the means and the experience to engage 

young people, to teach how and why to be active, and to give them the tools to live 

a healthy life. As a professional physical educator, I believe we are at a time of fundamental rethinking and retooling in what we do. I could not be more excited about 

the progress we are making in Grundy Center. It is revolutionary. And it is what 

is needed for us to address the challenges we face. 

Thank you for the opportunity to express my views. I am happy to answers any 

questions. 

Senator HARKIN. Very good. Thank you. Who’s taking care of my 

schedule, John? Make sure I get up there as soon as possible. I 

really do, and I mean that, I’m going to get up there very soon. Of 

course, you’re going to be out of school pretty soon, darn it. Well, 

is it okay if I come in the summertime, anyway? 

Mr. SCHUPBACK. Any time you want. We’d be happy to have you. 

STATEMENT OF DR. CAROLYN CUTRONA, DIRECTOR, INSTITUTE FOR 

SOCIAL AND BEHAVIORAL RESEARCH, IOWA STATE UNIVERSITY 

Senator HARKIN. All right. Well, thank you very much, Rich. 

Now I’m going to go to Dr. Carolyn Cutrona, Professor of Psychology, Iowa State University. Dr. Cutrona has studied exten-
15 

sively rural mental health issues and the effects of economic stress 

on rural parents. Her areas of interest include coping with stress, 

social support, close relationships, health psychology and marital 

relationships. Dr. Cutrona will discuss the challenges we face regarding the current state of the mental health system and specifically rural mental health issues. In addition, Dr. Cutrona will also 

address how mental health and chronic disease are intertwined 

and can trigger one another, and will also address stress prevention. Dr. Cutrona, welcome. 

Dr. CUTRONA. Thank you. Good morning, Senator Harkin, fellow 

Iowans. I am the director of the Institute for Social and Behavioral 

Research at Iowa State University and a professor of psychology. 

For 10 years the Institute for Social and Behavioral Research was 

home to an NIH-funded Center for Rural Mental Health. And we 

continued to conduct both applied and basic research in this area, 

so I’m very grateful for the opportunity to share information on 

mental health and wellness issues, especially as they apply to a 

rural America. I should note that in 1992 we were pleased to have 

Senator Harkin present to celebrate the opening of our facility 

when we first became a center for rural mental health. 

Nationally, as many Americans are hospitalized for severe mental disorders as for cancer. Over the course of their lifetime mental 

disorders affect one-third to one-half of the U.S. population. At any 

given time 20 percent of adults suffer from mental illness of some 

sort. Between 12 percent and 22 percent of youth under the age of 

18 are in need of mental health services. An estimated 7.5 million 

children and adolescents suffer from one or more mental disorders. 

Mental disorders are among the most disabling of chronic diseases. Furthermore, compared to other chronic diseases, mental 

disorders strike earlier in life, often in the teens to mid-20s. According to a report from the U.S. Surgeon General, depression is 

the leading cause of disability in the United States. Let me say 

that again. Depression is the leading cause of disability in the 

United States. In addition to the personal suffering of patients and 

their families, mental health disorders are very costly to society. 

According to the National Advisory Mental Health Council, in the 

year 1990 mental illness cost the United States an estimated $75 

billion, and it’s surely gone up considerably since then. 

Mental and physical health are closely intertwined. For example, 

depression and anxiety often accompany and complicate other diseases, like heart disease and cancer. One study found that the 

presence of depression among first heart attack survivors was 

linked to earlier death. The presence of depression among first 

heart attack survivors was associated with earlier death. Among all 

illnesses and health behaviors, mental disorders are among the 

leading contributors to what they call disease burden, defined as 

years of life lost to premature death and number of years weakened by disability. So clearly this is a very serious health issue. 

Let me talk briefly about mental illness in rural America. The 

prevalence of mental disorders are similar in rural and urban 

areas. The suicide rate, however, among adult males and children 

is higher in rural areas than in urban areas of the United States. 

Among Midwestern farmers, during the farm crisis of the 1980s, 

the suicide rates grew to four times the national average. Com-
16 

pared to urban dwellers, when you look at individuals who suffer 

from serious mental illness, 1-year symptom outcomes are worse 

among rural compared to urban residents. Youth between the ages 

of 15 and 24 are the most likely to receive inadequate treatment 

for serious mental illness than any other age group. This problem 

is more severe for rural than urban youth. Health officials in rural 

areas place mental health and mental disorders near the top of 

their list of health priorities. 

There is a severe shortage of mental health professionals in rural 

America. The most severe shortages in rural areas are of psychiatrists, especially child psychiatrists. Again, children with severe 

mental illnesses are the most underserved, especially in rural 

areas. Seventy-five percent of rural counties lack a psychiatrist, 95 

percent lack a child psychiatrist. Fully 50 percent lack a doctoral 

level psychologist or master’s level social worker. Only 1 in 14 rural 

hospitals provide psychiatric services, and only 14 percent of total 

rural hospital beds are designated for psychiatric care. Rural residents are more likely than urban residents to rely upon primary 

care physicians for mental health care. Primary care physicians 

often received inadequate training in the diagnosis and treatment 

of mental illness. 

There are many approaches to meeting the mental health needs 

of rural Americans. It is critically important to provide those who 

suffer from mental illness with state-of-the-art treatments that are 

affordable and accessible. In addition, we need to turn our attention to the prevention of mental disorders. There are a variety of 

strategies for doing this and perhaps we can discuss this in depth 

in the question and answer period. Let me stop for the time being. 

Senator HARKIN. If you have a couple more minutes, I’m always 

willing to give. 

Dr. CUTRONA. Well good, let me go ahead. 

Senator HARKIN. Just a couple more minutes to wrap up, maybe. 

Dr. CUTRONA. Very good. So, how do we increase access to mental health care? Incentives must be increased to encourage mental 

health professionals to locate in rural areas of the country. 

Senator HARKIN. How do you do that? 

PREPARED STATEMENT

Dr. CUTRONA. Federal reimbursement rates for Medicaid patients 

must be increased to lessen the income disparity for mental health 

providers who work in rural versus urban areas. Specialized training in rural mental health should be added to graduate training 

programs in psychology, social work and other mental health professions to increase the rural competence of mental health care providers. The ability of primary care physicians to provide competent 

mental health treatment should be increased through training, 

clinical practice guidelines, utilization, routinely a brief mental 

health screening instruments, and greater, stronger linkages between primary care physicians and mental health providers. Telemedicine, in which specialists at a distance provide consultation, 

training, supervision and even direct services via videophone technology is growing in popularity. A number of mental health telenetworks have been established to provide specialty consultation and 

training in the mental health area. We must reimburse critical as-
17 

pects of mental health care, including thorough assessment, especially with children. It’s very complex, assessing exactly what the 

nature of the child’s mental health disorder or issue is. These are 

costly, they must be reimbursed. Treatment while problems are 

still small rather than waiting until problems are severe. Having 

these kinds of treatment reimbursable is critical. 

[The statement follows:] 

PREPARED STATEMENT OF CAROLYN E. CUTRONA

Good morning, Senator Harkin. My name is Carolyn Cutrona. I am the Director 

of the Institute for Social and Behavioral Research and a Professor of Psychology 

at Iowa State University. For ten years, the Institute for Social and Behavioral Research at Iowa State was home to an NIH-funded Center for Rural Mental Health 

and we continue to conduct both basic and applied research in this area. We are 

grateful for the opportunity to share information on mental health and wellness 

issues, especially as they apply to rural America. 

SCOPE OF THE PROBLEM

Nationwide, as many Americans are hospitalized for severe mental disorders as 

for cancer. Over the course of their lifetime, mental disorders affect approximately 

one-half of the U.S. population. At any given time, approximately 20 percent of 

adults and 25 percent of the elderly suffer from mental illness of some sort. Between 

12 percent and 22 percent of America’s youth under age 18 are in need of mental 

health services. An estimated 7.5 million children and adolescents suffer from one 

or more mental disorders. Mental disorders are among the most disabling of chronic 

diseases. Compared to other chronic diseases, mental disorders strike earlier, often 

in the period extending from the teens to the mid-twenties. According to a report 

from the U.S. Surgeon General, depression is the leading cause of disability in the 

United States. 

In addition to the personal suffering of patients and their families, mental health 

disorders are very costly to society. According to the National Advisory Mental 

Health Council, in the year 1990 mental illness cost the United States an estimated 

$74.9 billion. 

Mental and physical health are closely intertwined. For example, depression and 

anxiety often accompany and complicate other diseases, like heart disease and cancer. One study links depression to early morality among first heart-attack survivors. 

Among all illnesses and health behaviors, mental disorders are among the leading 

contributors to disease burden, defined as years of life lost to premature death and 

number of years weakened by disability. 

MENTAL ILLNESS IN RURAL AMERICA

The prevalence of lifetime and recent mental disorders are similar in rural and 

urban areas. The suicide rate among adult males and children is higher in rural 

than in urban areas of the United States. Among Midwestern farmers during the 

farm crisis of the 1980s, the suicide rate grew to four times the national average. 

Compared to urban-dwellers, worse one-year symptom outcomes were found for 

rural residents with a serious mental illness, especially if the illness was accompanied by substance abuse. Youth between the ages of 15 and 24 are more likely 

to receive inadequate treatment for serious mental illness than any other age group. 

This problem is more severe for rural than urban youth. Health officials in rural 

areas place mental health and mental disorders near the top of their list of rural 

health priorities. 

AVAILABILITY OF MENTAL HEALTH RESOURCES IN RURAL AMERICA

There is a severe shortage of mental health professionals in rural America. Although the supply of specialty mental health professionals in the United States 

grew substantially in the 1990s, the increase in rural areas has been minimal. In 

1999, 87 percent of designated Mental Health Professional Shortage Areas in the 

United States were in non-metropolitan counties, which are home to over 30 million 

people. The most severe shortages in rural areas are of psychiatrists, especially 

child psychiatrists. Seventy-five percent of rural counties lack a psychiatrist; 95 percent lack a child psychiatrist; 50 percent lack a master’s or doctoral level psychologist or social worker. Twenty percent of non-metropolitan versus only 5 percent of 

metropolitan counties lack mental health services. Non-metropolitan counties have 
18 

an average of less than two mental health clinics, compared to more than 13 in metropolitan counties. Only 1 in 14 rural hospitals provide psychiatric services and only 

14 percent of the total rural hospital beds are designated for psychiatric care. 

Rural residents are more likely than urban residents to rely upon primary care 

physicians for mental health needs. Studies have shown that primary care physicians do not always provide optimal treatment for mental illness. For example, patients treated for depression by primary care physicians are more likely than those 

treated by psychiatrists to have an incomplete recovery and to suffer a relapse. Primary care physicians often receive inadequate training in the diagnosis and treatment of mental illness. Their heavy case loads demand brief visits, in which mental 

health concerns cannot be adequately addressed. They may lack expertise regarding 

when to make referrals and they often lack local specialists to whom to refer seriously mentally ill patients. 

TWO APPROACHES TO THE PROMOTION OF MENTAL HEALTH

There are many approaches to meeting the mental health needs of rural Americans. It is critically important to provide those who suffer from mental illness with 

state-of-the-art treatments that are both accessible and affordable. Increasingly, 

however, we should turn our attention to the prevention of mental. After a brief discussion of strategies for increasing the supply of mental health resources to rural 

Americans, attention will turn to preventive strategies that may be more cost effective in the long run. 

INCREASING ACCESS TO MENTAL HEALTH CARE

Incentives must be increased to encourage mental health professionals to locate 

in rural areas of the country. Federal reimbursement rates for Medicaid patients 

must be increased, to lessen the income disparity for mental health providers who 

work in rural versus urban areas. Specialized training in rural mental health should 

be added to graduate training programs in psychology, social work, and other mental health professions to increase the cultural competence of mental health care providers. Rural-connected individuals should be recruited by graduate training programs in the mental health disciplines and encouraged to practice in their home 

communities. State and federal support should be available to students in these programs. 

The ability of primary care physicians to provide competent mental health treatment should be increased through training, clinical practice guidelines, utilization 

of screening instruments, and creating greater contact of primary care physicians 

with mental health professionals via a variety of linkages. 

Integrated treatment that addresses both psychological health and physical health 

may advance both cost and quality objectives in the system of care. The coordination 

of mental health services with primary health care has been found to contribute to 

reductions in health care costs. Improving the link between primary care physicians 

and mental health specialists is of great interest to rural mental health experts. A 

range of collaborative relationships can be envisioned, in which primary care physicians hire, share space with, or confer off-site with mental health specialists. 

Telemedicine, in which specialists at a distant site provide consultation, training, 

supervision, and direct services via videophone technology, has grown in popularity. 

A number of mental health telenetworks have been established. They have been 

used for direct psychiatric encounters (patient interviews), crisis response, medication management, and consultation on admission, commitment, and discharge. A recent survey of rural Iowans found that approximately two-thirds of respondents expressed willingness to use telemedicine for mental health services and three-fourths 

would recommend this service to a friend. As expected, older respondents were less 

willing than younger respondents to use telemedicine, and expressed concerns about 

confidentiality, impersonality, lack of knowledge about technology, and problems 

with vision or hearing. 

THE NEED FOR PREVENTIVE INTERVENTIONS

The last twenty years have seen an explosion in programs to prevent a wide range 

of mental illnesses and problem behaviors. Evidence has accumulated that preventive interventions are cost effective. Some mental health problems that are resistant 

to treatment in adulthood can be prevented through intensive preventive interventions in childhood. There is evidence that some disorders accelerate in severity over 

time. If their onset can be prevented, boundless suffering and years of lost productivity can be avoided. 

Relatively little is known about the precise causes of mental illness. Many types 

of mental illnesses result from a combination of genetic predispositions and life ex-
19 

periences. It is possible to inherit a tendency towards a disorder like depression, but 

only to succumb to the disorder if faced with overwhelmingly negative life conditions. Similarly, it is possible to inherit a tendency towards impulsivity and a short 

attention span, but with firm, consistent parenting, never to develop problem behaviors such as delinquency or drug abuse. 

Although we do not know the precise cause of most mental illnesses, we have 

learned a great deal about risk factors and protective factors associated with mental 

illness. 

Risk factors increase the probability over time that a mental illness will develop. 

Seven types of risk factors have been identified. These include constitutional handicaps (e.g., neurochemical imbalance or sensory disabilities), skill development delays 

(e.g., low intelligence or attentional deficits), emotional difficulties (e.g., emotional 

immaturity, low self-esteem), family circumstances (e.g., abuse, parental mental illness, poor parental supervision), interpersonal problems (e.g., peer rejection, social 

isolation), school problems (e.g., poor school performance, and alienation from 

school), and ecological risks (e.g., neighborhood poverty, racial prejudice). 

Protective factors decrease the probability that mental illness will develop, especially among persons who are subject to one or more risk factors. Protective factors 

include characteristics of the individual (e.g., intelligence, social skills, temperamental characteristics), the quality of the individual’s interactions with others (e.g., 

a close relationship with parents and prosocial peers), and the quality of the larger 

environmental context (e.g., good quality schools, a good relationship between the 

family and the community). 

Preventive interventions that systematically decrease exposure to risk factors and 

increase access to protective factors have been the focus of concentrated research efforts for approximately two decades. These interventions closely parallel more familiar prevention efforts in the public health domain, such as anti-smoking campaigns 

or laws mandating the use of seat belts. 

PRINCIPLES OF EFFECTIVE MENTAL HEALTH PREVENTIVE INTERVENTIONS

Two decades of research on preventive mental health interventions yield the following general principles. 

1. Preventive interventions that start at an early age are the most effective. Some 

of the most effective preventive interventions begin in preschool. 

2. Short-term interventions produce only short-term results. Multi-year programs 

are the most likely to produce enduring benefits. 

3. Preventive interventions are best directed at risk and protective factors rather 

than at specific symptoms or syndromes. Because the same risk and protective factors influence a wide range of mental illnesses, it is cost effective to target these 

factors and potentially influence multiple mental health outcomes. 

4. Preventive interventions should be aimed not only at building childrens’ competencies and coping skills, but also at modifying their environments, including 

home, school, and community. Optimizing parenting quality is an especially important component of preventive interventions. A second critical component is optimizing the quality of the school climate for school-aged children. 

5. There is no single program component that can prevent mental illness and 

problem behavior. A package of coordinated, collaborative strategies and programs 

is required in each community. 

6. To create sustainability of preventive intervention programs, programs must be 

integrated into existing community structures. In this way, communities can develop common conceptual models, common language, and procedures that maximize 

the effectiveness of programs for individuals with varying levels of need. Schools, 

in coordination with community organizations (e.g., community mental health centers, Departments of Human Services, community youth organizations, County Extension Offices) can work together to offer sustained preventive programming to 

youth and families. 

TYPES OF PREVENTIVE INTERVENTIONS TO ENHANCE MENTAL HEALTH

There are three different types of preventive mental health interventions: universal, selective, and indicated. Universal preventive interventions target the general public or a whole population group. Participants are not selected based on individual need. In the public health domain, childhood immunization programs are an 

example. In the mental health domain, a wide range of universal preventive interventions have shown good results. For example, preventive programs have been developed to prevent violence by exposing children to a school-based curriculum that 

teaches nonviolent conflict resolution, decision-making skills, and anger control. Programs to reduce drug and alcohol use have also been developed. One successful pro-
20 

gram included in-school programming on decision-making and resistance to peer 

pressure in addition to training for parents on effective parenting skills. Universal 

preventive interventions have been developed to ease the transition from elementary 

to middle school. These in-school programs focus on individual skill-building and 

creating a supportive school environment. One such program showed significant reductions in measures of maladjustment and mental illness, lower rates of alcohol 

and tobacco use, and less violent behavior six years after the program. 

Selective preventive interventions target individuals or subgroups based on the 

presence of biological or social risk factors that increase the probability of developing mental disorders. A number of selective preventive interventions have been 

designed to help children who are at increased risk for depression, either because 

they have a depressed parent, or because they have shown elevated depressive 

symptoms themselves. The interventions typically take place in schools and focus 

on the overly negative thought patterns and beliefs that often underlie depression. 

Such programs have been successful in lowering the rates of depression among 

youth. Other school-based preventive interventions have successfully targeted anxiety disorders or suicidal behavior. Preventive interventions have also been developed to serve children and families who have experienced family disruptions, including parental divorce and parental death. Such programs are successful in reducing 

future child depression and substance abuse. 

Finally, indicated preventive interventions target individuals who are identified 

as having early signs or symptoms related to mental disorders but who do not yet 

meet formal diagnostic criteria for a mental illness. An indicated preventive intervention is embedded in a larger universal intervention called Fast Track (Conduct 

Problems Prevention Research Group, 1999a). The program is designed to prevent 

conduct disorders and associated adolescent problem behaviors. This program involves 50 elementary schools in four urban and rural locations. The universal intervention includes a multi-grade curriculum throughout the elementary school years. 

The indicated intervention offers youth who are identified in kindergarten as manifesting a high level of problem behaviors a series of interventions that involve the 

family (e.g., home visiting, parenting skills, case management), the child (e.g., academic tutoring, social skills training), the school, the peer group, and the community. Results of the first three years indicate significant reductions in special education referrals and aggression both at home and at school for targeted children. 

SUMMARY

Residents of rural America suffer from mental illness at approximately the same 

rate as those of urban areas. However, rural residents have much lower access to 

mental health services. A variety of directions for reducing mental illness in rural 

America were suggested. Some of these include increasing the availability of mental 

health specialists. Another approach to mental illness, in both rural and urban settings, is to dedicate resources to the prevention of mental illness. When preventive 

interventions are implemented in early childhood and target the child’s skills, the 

family environment, and the school environment, research shows that many kinds 

of mental health problems can be prevented or reduced in severity. A new model 

of collaboration among community organizations is needed in which programs with 

demonstrated effectiveness can be built into the structure and routines of community life. 

Senator HARKIN. I’d like to go to some of the health prevention 

intervention, especially in early childhood with you during our 

question and answer sessions. 

Dr. CUTRONA. Very good. 

STATEMENT OF LEN OLSEN, CHIEF EXECUTIVE OFFICER, OTTUMWA 

REGIONAL HEALTH CENTER 

Senator HARKIN. Thank you, Dr. Cutrona. 

Now we will turn to Mr. Len Olsen. Mr. Olsen is the CEO of the 

Ottumwa Regional Health Center. This health center offers a comprehensive wellness program for their employees, and I also understand you’re involved in providing wellness programs for the private sector and some businesses. And you can talk about that because I met one of those one time and was very intrigued by what 

you’re doing there. Incentives include reduced health insurance 
21 

premiums for participation and meeting individual health goals. 

So, welcome Len, and please tell us what you’re doing in Ottumwa. 

Mr. OLSEN. Well, thanks for the opportunity to be here again 

today, Senator Harkin. And I want to thank a couple of people that 

talked me into being here today and that’s Elaine Leppard, our 

Wellness Coordinator. Elaine, if you could raise your hand. And Jo 

Ellen Randall, our vice president of Human Resources and who is 

in charge of wellness for our hospital and for the public program. 

So they really are responsible for the program. 

I’m speaking today more as a participate and an advocate rather 

than an architect of this program. But I want to go back a little 

bit to the Grundy Center presentation. You know, when I was 

growing up on a dairy farm in rural Minnesota, my exercise consisted of milking cows, shoveling things out of a gutter, cleaning 

calf pens, picking mustard weeds out of a field. And I stayed in 

pretty good shape doing that but I think I’d have rather gone to 

Grundy Center, however, because it looked like a lot more fun. But 

it points out how much our lifestyle’s changed. I worked hard as 

a kid and now that’s changed pretty dramatically. 

But to get to our program, as the head of a regional health center 

that employs some 960 people, I’m very much aware of the impact 

of increasing health costs on Iowa employers. It’s a big problem. 

Over the last 8 years Ottumwa Regional has been instrumental in 

developing a work site wellness program that we call Healthy 

Choices. This program was not designed to be a quick fix. But over 

the last 8 years I think we are seeing the potential that the program has for helping contain health care costs and having our staff 

live a healthier lifestyle. 

The program was developed in 1997 in order to respond to rising 

health insurance costs, as many employers have experienced. We 

used a task force of employees to help develop ideas, and it was determined early on that it wasn’t sufficient just to provide health insurance or sick coverage, as you said earlier, that we had to promote wellness and the individual health of employees and their 

families. I think one of the goals is that if we teach our employees 

how to live healthier lives they can help teach their kids how to 

lead healthier lives as well. 

When we looked at our claims history, 48 percent of our health 

insurance claims were related to lifestyle, or behavioral issues, 

such as drug and alcohol abuse, poor pre-natal care, smoking, poor 

diet and lack of exercise. It was this resolution that led Ottumwa 

Regional to embark on the Healthy Choices journey. One of the key 

elements was creating a supportive rather than a punitive environment. A positive environment can help employees to turn healthy 

choices into healthy habits. Senior management’s support for the 

program was essential in getting it off the ground, and my predecessor and Jo Ellen were a big part of that. Employees were encouraged, actively encouraged, to enroll in the program. Employee 

wellness games were formed to provide input on program design, 

encourage co-workers to participate and provide support to those 

who chose to make lifestyle changes. As one of the people that had 

to do that when I came to Ottumwa Regional, that support is important. Building a health culture is a big job, one that we continue 

to work on and improve upon to this day. 
22 

Let’s talk a little bit about the program design. From the beginning we were focusing on the individual through one-on-one counseling and education. You do have to sit down with Elaine, in a 

room, get weighed and do things, and respond to her questions. So 

it’s a little tough at times. But what the staff does is help you set 

realistic goals for you. And they give you the tools to achieve these 

goals, and then there’s a reward system if you make those—if you 

achieve those outcomes. One of the biggest is you get a cut on your 

health insurance premiums, a significant difference. In fact, from 

our highest health premium rate to our lowest, on a family plan, 

is about $3,000 a year difference, if you achieve those healthy lifestyle goals. So it’s not insignificant. 

The goals initially, however, were to get as many people enrolled 

in the program as possible, whether or not they used our health insurance. We wanted to reward those who are willing to maintain 

or achieve a healthier lifestyle. Of course, you got a reduced health 

insurance premium if you did achieve your goals. And we also 

sought to reduce absenteeism, kind of a hidden cost of not having 

a healthy lifestyle. And we’ve got some statistics to prove that 

we’ve made improvements in that area. Initially the plan was only 

offered to employees but now it is extended to spouses. 

Some of the key components. It’s a comprehensive program that 

has a number of health risk assessments. And our goal is to decrease risk factors that have been proven to increase the likelihood 

of chronic diseases, such as diabetes, heart disease, cancer, 

etcetera. So let me give you an idea of what some of those components are. 

Annually, you have to have a blood screening of cholesterol, blood 

sugar, also have your blood pressure taken, get weighed, have a 

body, this says body fat but we call it body composition, don’t we 

Elaine? Makes it sound better. And now, waist to hip ratio measurements. So you have to go in and do this confidentially. You fill 

out a health risk appraisal, or a form that every participant has 

to fill out, and asks you a variety of questions. And then you sit 

down, the staff analyzes both the information from the laboratory 

work, their measurements and the self-assessment and they sit 

down and set goals with you. 

So, 4 years ago after I had sat down with Elaine, and I had the 

cholesterol challenge. I guess I had a choice to go on medication or 

to change some lifestyle issues, like eating better and exercising 

more. So I chose the latter. The health screenings allow employees 

and the wellness staff to identify and take corrective action on 

those health risks that could result in a major illness if they’re left 

untreated. There are those who choose not to take corrective action 

and we provide awareness and education, and some materials for 

them to take home. 

To the incentives. There’s really three parts to the incentive component. The core benefits, we provide a lot of things, screening devices, that are free of charge. Mammograms, nicotine patches if you 

want to stop smoking, the cholesterol screening, weight reduction 

programs and support and smoking cessation classes; don’t cost you 

anything. Then, we’ve got a plan for our insurance, as a I said earlier. On the most expensive plan, for those folks who chose not to 

set a goal or not participate in the program, we pay 60 percent of 
23 

the employee’s premium, they pay the balance. That goes up to us 

paying 90 percent of the premium if an employee meets all of their 

health goals and criteria. 

Now, I’ll give you a personal story. I think I was on Level B, partial compliance, and when I met the plan goals that we had established I saved $70 a paycheck, or about $1,800 a year. Now, imagine a dietary worker who may be making $8 or $10 an hour, $1,800 

to $3,000 a year is a big deal. In fact, it’s almost a car payment 

in some cases. So, that’s the benefit you can get out of Healthy 

Choices. 

We also give something called Healthy Bucks, which is $100 a 

year, per employee, to anybody who participates and completes a 

health risk assessment. And they can spend that on a variety of 

things that are health-related. 

Everybody wants to know about outcomes. And I want to stress 

that a wellness investment is not a short-term payoff; you’ve got 

to be in it for the long haul. The unhealthy habits that we see 

across the Nation today didn’t happen overnight and they’re rapidly reaching epidemic proportions, as we heard earlier. But 

through our Healthy Choices program we as an employer try to 

help our employees make better choices and live a healthier lifestyle. It will take years to pay off. But think about this one example—and I was close to this. One employee on a cholesterol-reducing drug would cost our health plan $1,300 a year and the employee $240 a year. By getting my cholesterol down, we both won. 

I don’t pay out the $240 and my employer doesn’t pay out the 

$1,300 a year. Pretty good investment, I’d say. That’s a short run 

gain. 

For employees who already have healthy lifestyles, our wellness 

program assists with maintaining this lifestyle by the incentives 

I’ve talked about. And currently, 98 percent of our employees participate in our Healthy Choices program. Ninety-eight percent. 

So, you want to talk about—we’re going out in the community. 

This is something that we’ve begun to market as a product. Elaine 

goes out and spends a lot of time calling on businesses. But let’s 

talk about some of our success stories that we can share with every 

business. 

In 1996, before the program started, 21 percent of our wellness 

participants at OHC used tobacco products. Currently, 7 percent 

are using tobacco products. Employees who had body mass indexes 

of over 28 percent, which is close to the obesity limit, two-thirds 

of our people were at or exceeded this limit in 1996, compared to 

37 percent today, a halving of that number. The health status of 

our employees began to show positive results in the first 3 years 

and it continues today. And I talked about absenteeism earlier; 

we’ve had a 24 percent reduction in absenteeism rates with participating Healthy Choices employees versus those who do not. 

So we’re confident that healthier lifestyles are making a difference in our organization but we know our work is not done. We 

know that to remain competitive as an employer the health of our 

employees has to be part of our strategic plan. Instead of being a 

victim as a result of skyrocketing health care costs, organizations 

need to be a catalyst for creating healthy, innovative and productive employees. 
24 

PREPARED STATEMENT

We have brought this out in the community. The city of 

Ottumwa and L-John Incorporated, both located in Ottumwa, have 

implemented our Healthy Choices program in their workplace. 

Musco Sports Lighting, with corporate headquarters in Oskaloosa, 

also came onboard with Healthy Choices, and we provide services 

to their locations in Iowa, along with regional offices across the 

United States. And Elaine gets to get on their private plane and 

fly around and do these things, so that’s got to be fun. 

So, to close, we have about 1,800 area employees and their 

spouses participating in this program and we’re very excited about 

it. 

[The statement follows:] 

PREPARED STATEMENT OF LYNN OLSON

Thank you for the opportunity to appear before you today to share with you the 

success of our wellness program at Ottumwa Regional Health Center. As President 

and CEO of a regional health center in southeastern Iowa, I am very much aware 

of the skyrocketing cost of health care costs and the impact on Iowa corporations. 

Over the past eight years, Ottumwa Regional Health Center (ORHC) has been instrumental in developing a worksite wellness program, known as Healthy Choice$. 

Currently, our participation rates in this program are at 98 percent. The success 

of this program did not happen in six months, a year or even two years; however, 

I can stand here today and tell you that we are beginning to enjoy the fruits of our 

hard work. 

The Healthy Choice$ wellness program was developed in 1997 by a group of employees participating in a benefit task force at Ottumwa Regional Health Center in 

Ottumwa, IA. The task force’s purpose was to focus on what could be done to reverse the unfavorable upward trend in health claims resulting in significant premium increases. Because of the high cost of premiums, it was becoming more cost 

effective for the healthier employees to go elsewhere for health insurance coverage 

versus participating in the group plan. We were faced with the risk of offering a 

plan that was unaffordable, potentially driving employees to go elsewhere, or dropping the coverage and no longer being insured. It was determined that in addition 

to providing the coverage for illness and injuries, our organization needed to include 

an organized system to improve and maintain the individual health of our employees. An analysis of the claim history indicated that 48 percent of our claim dollars 

were spent on behavioral/lifestyle related cases (drug and alcohol, poor prenatal 

care, smoking, poor diet, lack of exercise, etc.) At this time, the initiation and implementation of a worksite wellness program occurred. 

STEPS IN BUILDING A WELLNESS PROGRAM IN THE WORKPLACE

Healthy Choice$ is a program that focuses on lowering the health risks of the participants through education and one-on-one counseling. The plan measures a participant’s health, helps them to establish realistic goals, provides the tools to achieve 

those goals and rewards them for achieving and maintaining those goals with significantly reduced premiums. 

The program was designed to achieve the following outcomes: 

—Increase the number of participants in the plan (spread the risk over a greater 

number of people) 

—Reward those who were willing to maintain or achieve a healthier lifestyle 

—Reduce the claims of that were related to lifestyle choices 

—Reduce the absenteeism rate by creating a ‘‘healthier’’ employee 

Initially, the plan was offered to employees. It is now offered to employees and 

their spouse. 

INCENTIVES

In order to meet the outcomes that were designed for this program, incentives 

surrounding wellness achievement were essential. Using national guidelines, the reduction in risk factors was the criterion that was implemented. 

The Healthy Choice$ program consists of three incentive components: 
25 

Core Benefits.—Screening and wellness benefits made available to all employees. 

Mammograms, nicotine patches, cholesterol screening, weight reduction and smoking cessation classes. 

Health Allowance.—This is the incentive system that offers multiple levels of premium reductions offered to employees participating in the program. 

—Plan A: Employer pays 60 percent of premium.—Employee chooses not to improve their health or to establish goals. Employees are not rewarded or punished for their choice of non-participation. 

—Plan B: Employer pays 70 percent of premium.—Employee doesn’t meet the 

healthy criteria but establishes goals to be met within one year. 

—Plan C: Employer pays 75 percent of premium.—Employees doesn’t meet the 

healthy criteria but has met a goal from the previous year. Goals must again 

be established for the next year. 

—Plan D: Employer pays 90 percent of premium.—Employee meets/maintains the 

health criteria. 

Healthy Bucks.—Reimbursement of items/services that employees purchase to 

maintain or improve their health. At this time we allow $100.00 per employee and 

is given to any employee who participates and completes a health risk assessment. 

PROGRAM COMPONENTS

Healthy Choice$ is a comprehensive program that targets employee health risks. 

Decreasing risk factors that have been proven to increase the likelihood of chronic 

diseases such as diabetes, heart disease, cancer and diabetes is the focus of our program. The components of this program are: 

—Biometrics.—Annual screening of cholesterol, blood sugar, blood pressure, 

weight, body fat levels and waist-hip ratios. 

—Data collection.—Health risk appraisals are completed by all Healthy Choice 

participants in order to evaluate the effectiveness of the program and to make 

changes as necessary. 

—Intervention/goal setting.—One on one with the employee and a trained 

wellness professional. Review of the biometric measurements and with the use 

of coaching, goals are set by the employee. Every quarter, employees meet with 

the wellness staff individually to assess their progress. 

The health screenings allow employees and the wellness staff to identify and take 

corrective action on health risks that could result in a major illness if left undetected and untreated. For those individuals who chose not to take corrective action, 

awareness and educational material is provided. One of the goals of Healthy 

Choice$ is to keep the employee coming back every year and eventually the decision 

is made by the individual to take action to improve his/her health. These are 

changes that do not occur overnight. It can take three to four years for an individual 

to begin making the behavior change. 

BABY STEPS

The unhealthy habits that we are seeing across the nation today did not happen 

in a day. We believe in taking small steps when helping employees set their annual 

health goals; and in some instances, we work towards preventing further erosion of 

the unhealthy lifestyle. Instead of a deficit approach, we build on the individual’s 

strengths when helping them set their health goals. For those employees who already have healthy lifestyles, our wellness programs assists with maintaining this 

lifestyle by the incentives that are offered. 

CREATING A SUPPORTIVE AND HEALTHY ENVIRONMENT

As Healthy Choice$ evolved over the last 8 years, it was evident that this 

wellness program included all of the elements of a comprehensive work site wellness 

program. However, in order to continue the vision of substance and growth of this 

program, creating a supportive environment was crucial to the overall success of 

Healthy Choice$. A positive environment can help employees to turn healthy choices 

into healthy habits. Senior management modeling and supporting healthy behavior 

is important in creating the well workplace. As the old cliche ́ states, ‘‘if you talk 

the talk, you have to walk the walk.’’ Employee wellness teams provide the empowerment and peer role modeling in making lifestyle changes. Building a healthy 

culture is a big job and one that we currently are striving towards. 

THE SUCCESS STORY OF HEALTHY CHOICE$

In 1998, Ottumwa Regional Health Center marketed Healthy Choice$ to other 

employers in the community. The City of Ottumwa and Al-Jon, Inc. both located in 
26 

Ottumwa, Iowa implemented the wellness program in their workplace. Masco Sports 

Lighting, with corporate headquarters in Oskaloosa, Iowa came on board with 

ORHC and we now provide services to their locations in Iowa along with their regional offices across the United States. Currently, we have over 1,800 individuals 

participating in Healthy Choice$. 

MAKING THE CONNECTION TO EMPLOYEE HEALTH IMPROVEMENT

In 1996, 21 percent of the wellness participants at ORHC used tobacco products 

and currently 7 percent are using tobacco. Employees who had BMI’s over 28 percent in 1996 were at 66 percent compared to current BMI rates at 37 percent. The 

health status of the employees started to show positive health behavior change within three years. ORHC employees who participated in Healthy Choice$ last year had 

a 24 percent reduction in absenteeism rates when compared with non-participating 

employees. 

We are confident that we are making progress in developing healthier lifestyles 

in our organization; however, we know that our work is not done. We know that 

if we are to remain competitive, the health of our employees has to be part of our 

strategic plan. Instead of being a victim as a result of the skyrocketing health care 

costs, organizations need to be the catalyst for creating healthy, innovative and productive employees. 

STATEMENT OF RHONDA E. RUBY, REGISTERED NURSE, WEBSTER 

COUNTY DEPARTMENT OF PUBLIC HEALTH 

Senator HARKIN. Sounds great. Well, thank you very much, Len. 

That’s great. 

Now we’ll turn to Ms. Rhonda Ruby, Registered Nurse, Webster 

County Department of Public Health. Ms. Ruby started a joint seniors-HeadStart—interesting—mall walking program. Webster 

County created a mall walking program that has expanded into a 

community-wide effort to encourage healthier lifestyles among all 

ages and sectors of the county. 

Well, that sounds very interesting. 

Ms. RUBY. Okay. All right. 

Senator HARKIN. Ms. Ruby. 

Ms. RUBY. Thank you. Can you hear me okay? 

Senator HARKIN. Sure. 

Ms. RUBY. All right. Thank you for having us here today. This 

is so exciting, for us to be a part of—— 

Senator HARKIN. Pull that in a little bit closer maybe. 

Ms. RUBY. Closer? 

Senator HARKIN. To you. 

Ms. RUBY. Okay. This is so exciting for us to be a part of this 

and I’m going to change the direction a little bit. Instead of a testimony I’d like to just have a brief conversation with you about what 

we’ve been doing in Webster County. It’s really exciting for us to 

present this program because we’ve had so much success with it. 

We have several wellness programs, initiatives, policies in effect in 

Webster County that I would love to tell you about and I would 

love for you to come visit us so we can show you. But the big one 

we want to focus on is our Mall Walkers Program. And I just want 

to pre-empt that by saying we started this because in April 2002 

we did a community needs health assessment where our residents 

identified cardiovascular disease as their number one concern. We 

took that information and from that we instituted several wellness 

prevention paradigms. The big one that you guys are concerned 

with is our Mall Walkers and HeadStart Program. The reason this 

is so effective and so important is it truly is a comprehensive, family-centered wellness prevention paradigm. And this program is 
27 

available to anybody in the community. It is available to all ages, 

all races, incomes, ethnicity and health disparities. We in fact have 

children in the program that are disabled and we have people in 

our Mall Walkers Program that are impaired. 

The format for the program is very simple. We have a Mall 

Walkers Club that people can walk at the mall at their convenience. Each month they turn in the minutes that are logged and 

the fruits and vegetables that are consumed. We monitor that information at the end of each month and each week we have a nurse 

at the mall that checks their blood pressure and continues to assess their cardiovascular status. 

How we tied in the HeadStart piece was, each month we’d bring 

a different class from our HeadStart population to walk with our 

mall walkers at the mall. So we have children from the age of 3 

walking with mall walkers anywhere from age 18 to 80. And with 

our local HeadStart program we don’t just bring the children, we 

bring the children, the day care staff, parents, foster grandparents; 

and each month we do a short educational piece with our mall 

walkers. It’s been hugely successful in Webster County. 

We started it in 2000 and each year that program has grown. 

When we first started back in September 2000, I think we had 

something like 86 participants, which is great, that’s progress. As 

of last year between our local HeadStart populations and our enrolled mall walkers we have 270 people in our program. We have 

been able to make huge, huge changes with this program. It was 

possible because of the community support that we have for it. In 

our program, we have the mayor enrolled as a mall walker; we 

have our local board of supervisors enrolled; we have legislatures 

enrolled; we have the entire community involved and embracing 

this program. 

PREPARED STATEMENT

The impact that we have been able to make has been tremendous. We have two of our local board of supervisors that we persuaded to join our Mall Walkers Club. One did not know he was 

diabetic and we did a screening and found him to be a diabetic and 

he has subsequently been treated for that. We had another board 

of supervisors member who was hypertensive and did not know 

that he was and has subsequently been treated for that. And just 

last week we performed a Wellness County Day where another 

board of supervisor was diagnosed as diabetic as well. So the impact for the community has been tremendous. We’ve been able to 

involve all facets of our community and it’s been open to all the 

citizens, all ages, and we’ve had a tremendous amount of community support from it. It’s been a huge success in Webster County. 

Senator HARKIN. That’s wonderful, too. You’ve got both, you’ve 

got the elderly and the young together. 

Ms. RUBY. Yep, uh-huh. 

Senator HARKIN. Pretty interesting, I like that a lot. Well thank 

you very much. 

Ms. RUBY. You bet. 

Senator HARKIN. You know, we’ll have more to talk about this 

later on. 

Ms. RUBY. Uh-huh, Uh-huh. 
28 

[The statement follows:] 

PREPARED STATEMENT OF RHONDA E. RUBY

Senator Harkins, Ranking Member and other Members of the Committee: On behalf of all residents of Webster County, we would like to thank to everyone for allowing us the opportunity to share our stories of success and highlight our accomplishments. It is a privilege to offer our views and suggestions on how we feel it 

would be most beneficial to improve community wellness and institute disease prevention. We were pleased to read Senator Harkins comments from his Press Release, stating top legislative priority will be given to a Wellness and Disease Prevention Initiative. We too, have given this matter top priority. We believe by appearing 

before this committee, we have a wonderful opportunity to showcase the comprehensive efforts put forth by our agency to reduce cardiovascular and stroke risks by targeting Iowa’s overweight and obesity conditions in Webster County. 

Our agency, along with the Iowa Department of Public Health has been waging 

a battle against the obesity epidemic for many years. As you know, staggering obesity rates have also coincided with increases in cardiovascular and stroke related 

illnesses. This was of great concern to us, and we decided it was essential to improve our own community’s health and well-being. We did this by instituting several 

wellness prevention paradigms. Our goal was to empower citizens with information 

and resources that allowed them to take charge of their health and make informed 

decisions. With this in mind, we challenged the community to concentrate on nutrition and physical activity and make it a part of their daily lives. Our programs specifically focused on at risk individuals and stressed education, awareness, screening 

and prevention of obesity through worksites, busineses, and the community at large. 

The results have been phenomenal. 

We have witnessed first hand the remarkable success produced from a consistent 

focus on disease prevention and wellness promotion. The wellness paradigms implemented in this region are evidence of how powerful prevention and consistency can 

be when dealing with the complex issue of obesity. The programs were able to show 

direct, statistical outcomes that resulted in increased amounts of physical activity 

and proper nutrition among citizens, as well as decreased obesity rates and associated illness. Through the use of education, awareness, and screenings, our wellness 

investments in the community have paid off in the form of healthier, more knowledgeable citizens. 

WHY THE MALL WALKERS PROGRAM WAS INITIATED AND HOW IT HAS EVOLVED

To understand the success of the wellness projects implemented in the last four 

years, it is important to recognize why these programs were vitally necessary for 

the community. One of the foremost reasons our agency focused on cardiovascular 

disease risk reductions, was due to Webster County residents identifying Cardiovascular Disease as their number one health concern in a Community Needs Assessment, completed in April of 2000. Since then the Webster County Health Department, along with the Iowa Department of Public Health have been committed to reducing the prevalence of Cardiovascular Disease, Stroke, Obesity, and Overweight 

in Webster County. Which benefits all of Iowa. 

Once the results of the needs assessment were compiled, we introduced several 

wellness initiatives to encourage people to engage physical activity and increase 

their consumption of fruits and vegetables daily. These simple behaviors changes 

could potentially impact hundreds of people and reduce cardiovascular risks dramatically. All of the health programs implemented over the past few years have 

been well received and highly successful in the community, especially our innovative 

program called the Mall Walker’s Club, which named their group the Crossroads 

Pacers. 

This program was initiated in September of 2000, and the format was simple; participants could engage in exercise at their convenience in the comfort of a clean, safe 

mall environment, and use self-direction to consume the recommended amount of 

fruits and vegetables daily. Each month participants were required to log the 

amount of activity and proper nutrition engaged in and was asked to turn logs into 

the Wellness Coordinator for monitoring. This program has been hugely successful 

with citizens of all ages and the program has grown in leaps in bounds over the 

past four years. The kickoff for this program was a major community event that engaged many influential members. We had a legislator, city council members, the entire Webster County Board of Supervisors, and the mayor in attendance to show 

community support. We initially signed up 86 participants and have expanded the 

program since then to include 150 dedicated participants. We’ve had many success 

stories with the Mall Walker’s Club, including a local board member who was un-
29 

aware he was Hypertensive and Diabetic. Following a physician referral from our 

screening process, they were able to successfully treat his chronic diseases and he 

made the necessary lifestyle changes to stay healthy. 

The success of this program has been rooted in its fundamental but inventive design. To increase participation we launched an aggressive marketing campaign 

through the community by offering registration at different worksites and businesses to encourage sign up. Each week we placed a nurse at the mall to promote 

registration and also to monitor the cardiovascular status of enrolled participants. 

To keep interest in the program at a high level, we placed a new display table at 

the mall each month for participants to view a wide array of information. We exhibited fun and creative displays that promoted health and wellness. The topics ranged 

from signs and symptoms of a Heart Attack or Stroke, to extensive obesity related 

information, Diabetes awareness, and many other health related issues. This display table was well received from the community and we experienced positive responses from participants and other community members. 

These few simple strategies proved to be effective tools persuading citizens to join 

our club, and this program planted the seed for other wellness initiatives to follow 

that focused on a family centered approach to health. This lead to developing a family centered wellness prevention program for our local Head Start. This project focused on age directed preventative health by allowing the children enrolled in Head 

Start to walk each month at the mall with parents, foster grandparents, and other 

members of the Mall Walker’s Club. This was a powerful alliance between young 

people and elderly citizens, and made age directed preventative health vital. 

WEBSTER COUNTY’S COMMUNITY’S APPROACH TO WELLNESS

As mentioned, our wellness initiatives were in response to the community’s concern about Cardiovascular Disease. Since that time we have made it paramount to 

involve the community in our wellness efforts. We have done this through a variety 

of grants, but also through a tremendous amount of community collaboration. This 

has been the cornerstone for success in constructing a community approach to 

wellness. We have built solid and strong relationships with entities that previously 

shied away from new and groundbreaking projects. We have been able to break the 

barrier between private and public industry to create a coexisting team that has 

served the entire community. Our highly successful Mall Walkers Club was a biproduct of the community’s approach and belief in wellness. Through community 

participation and ‘‘buy in’s’’ from our citizens we have been able to effect many positive wellness changes. At the end of this report we have included several feature 

articles that have appeared in our local newspaper as evidence of the support and 

community embrace our programs have received. The following collaborations were 

a result of Webster County’s community approach to wellness: 

—Creating the Webster County Cardiovascular Disease Coalition with numerous 

community partners, including the public school system, Community and Family Resources, and Trinity Regional Medical Center. This group works cohesively to institutionalize prevention programs and polices throughout Webster 

County and meets each quarter. 

—Collaborating with local restaurants in Webster County to assess healthy food 

choices available at each place. Following collaboration we created the Webster 

County Dining Guide to educate citizens on healthy food choices available at 

each restaurant. A community policy was put in place requiring all participating businesses to distribute the guide. 

—Collaborating with city and county officials to assess trail system availability 

for outdoor physical activity in our region. Following collaboration we created 

the Webster County Trail Guide to inform citizens on sites available for outdoor 

exercise. A community policy was implemented requiring participating entities 

to maintain the trail system for usage and to continue distribution of trail 

guides. 

—Screening 125 of the Mall Walker’s Study Group for cardiovascular risks including height, weight, blood pressure, BMI, waist circumference, flexibility, glucose, and lipid profiles. 

—Collaborating with the Crossroads Mall and the local Head Start program to 

conduct monthly walking sessions with children, parents, foster grandparents, 

and other members of the Mall Walker’s Club. 

—Collaborating with the Crossroads Mall to conduct weekly blood pressure assessments for Mall Walkers. 

—Collaborating with Crossroads Mall to assess water supply availability and 

making water available to those walking in at least three locations along the 

route. 
30 

—Collaborating with seven licensed says in Webster County to arrange visits to 

each to educate staff, parents, and children regarding the benefits of healthy 

eating and exercise. Educational information was kept on file each month at the 

daycares for all parents and staff. A community policy was put in place requiring all participating business to continue to offer healthy food choices and exercise. A second environmental policy was also implemented at the daycares requiring all keep their sidewalks and playgrounds suitably maintained for usage. 

—Collaborating with seven licensed daycares in Webster County for their children 

to plant and harvest miniature gardens at each business. 

—Collaborating with the Crossroads Mall to exhibit a creative display table each 

month promoting health and wellness. 

—Collaborating with five employers in Webster County to perform 1,600 wellness 

screening for employees that included height, weight, BMI, blood pressure, glucose, and total lipid profiles. 

IMPACT ON THE COMMUNITY

One of the greatest achievements of our projects has been witnessing first hand 

the dramatic impact we’ve had on community health and well being. We have been 

able to reach large segments of the population that were at risk for cardiovascular 

related problems. We have received many accommodations from the community for 

our dedication to health and fitness. Although we understand all of efforts may not 

be measurable for many years, we have been able to directly measure the following 

outcomes: 

—500 children from seven licensed daycares were educated monthly regarding the 

benefits of healthy eating and exercise. Following education, 100 percent of participating children were able to identify proper amounts of fruits and vegetables 

and physical activity needed daily to be healthy. 

—500 parents of children from the seven licensed daycares were educated on the 

benefits of healthy lifestyles, and symptoms of heart attack and stroke. Following education, 95 percent of parents and staff were able to identify heart attack and stroke warning signs. 

—500 children from the seven licensed daycares in Webster County planted and 

harvested miniature gardens at their daycare. Following planting, 100 percent 

of participating daycares reported success with garden harvesting. 

—200 employees and health care providers from all licensed daycares received a 

power point presentation training session on the hazards of adult and childhood 

obesity’s education. Following education, 100 percent of trainees were able to 

verbalize hazards associated with obesity. 

—2,200 copies of the Webster County Dining Guide were distributed to area restaurants. Following distribution, 13 percent of citizens reported changing eating 

habits after viewing the guide. 

—700 copies of the Webster County Trail Guides were distributed to Webster 

County businesses. Following distribution, 10 percent of citizens reported increased trail system usage. 

—125 Mall Walkers were screened for cardiovascular risk factors in 2001 and 

again in 2002. Following post assessments 10 percent of enrollees had improved 

cardiovascular status in at least one area. 

—125 Mall Walkers were screened monthly to assess amount of fruits and vegetables consumed and amount of activity engaged in. Following monthly monitoring, 25 percent reported increased amounts of exercise. 

One of the success stories we use to promote community-impacted health was one 

that involved a preschool child we taught in the daycares about fruits and vegetables and exercise. This preschoolers’ mother recently had a baby, and when we visited the mom for a routine post-partum visit, we asked the mother about the baby’s 

eating habits. We were delighted to hear the preschool child tell the mom that the 

‘‘the baby needs five fruits an vegetables everyday.’’ This is a powerful of a statement about the impact our efforts can make, even with young children. 

STATEMENT OF THOMAS OLDHAM, PRESIDENT, JUST ELIMINATE LIES 

(JEL), IOWA YOUTH TOBACCO PREVENTION ORGANIZATION 

Senator HARKIN. Now we’ll go to our last witness, Mr. Thomas 

Oldham. He is the president of something called Just Eliminate 

Lies. It’s an Iowa youth tobacco prevention organization. Tom attends Lincoln High School here in Des Moines. Just Eliminate Lies 

raises awareness about the dangers of tobacco and organizes teens 
31 

to fight the tobacco industry’s efforts to manipulate them into using 

their products. Tom, tell us more. 

Mr. OLDHAM. Thank you. Well first of all, I just wanted to thank 

everyone for the chance to be here and talk about what JEL is and 

what can be done in the future for prevention across the United 

States of America. But I speak here on behalf of over 7,000 Iowa 

teenagers who are involved with the JEL program. It’s a massive 

program with massive support all throughout the State and I think 

it’s really an amazing thing to have so many teenagers come together, at such a young age, about one topic. And I really do not 

think that there’s ever been quite the support for a program like 

this, at least in the youth base, as there is for ours. 

I also think I come here to speak on behalf of the over 400,000 

innocent Americans who die every year at the hands of Big Tobacco. And when I was 13 years old I was brought into the world 

of tobacco prevention. I was brought in at first on a different level 

though, of what I am now. At 13 years old I was a smoker. Me and 

some friends had started in 8th grade. I don’t know why, I guess 

I probably will never know, but we just started smoking. And at 

the time, these youth-led movements, when I started to get in— 

when I was smoking were starting to get visible. And if it wasn’t 

for the Iowa Tobacco Prevention Organization, I don’t know where 

I’d be right now. I feel I was saved by becoming involved. 

Now, these youth organizations at the time were using tactics nobody had foreseen. They were using harsher advertisements and 

new kinds of direct action and so on. People had been taking notice 

and a clear line was drawn between the comprehensive tobacco 

control programs and the less than desirable have-to programs that 

are rampant in the tobacco industry. Change was taking place and 

lives were being saved and the State programs were getting recognition, not only for their actions but the results. But as the years 

passed so were the comprehensive State tobacco prevention programs. As more and more of them were forming and sounding the 

alarms their legs were cut out from underneath them. Successful 

programs were losing money rapidly with politicians dipping their 

hands into the tobacco settlement money like it was a rainy day 

fund. Not only this but the tobacco industry was increasing spending in the State with successful programs and by cutting out the 

funding for those successful programs you enhance the progress of 

the tobacco industry while curbing the efforts of the anti-tobacco 

movement. 

The issue is clear and the right thing to do is extremely easy to 

do but across the United States not many people are doing anything about it. As Senator Harkin’s Wellness and Disease Prevention Initiative is a step in the right direction, currently health care 

costs related to tobacco across the United States topples $75 billion 

annually. Because of this and other smoking-caused government 

spending, the average household tax burden because of tobacco 

problems is $525 a year. As a result, hardworking Americans, the 

majority of these non-smokers, are paying big bucks for a preventable disease. 

Currently tobacco use is the number one killer. It kills more 

Americans annually than alcohol, AIDS, car crashes, drugs, fires, 
32 

murders and suicide combined. It’s inexcusable and outrageous especially when the situation is so easy to take care of. 

Now, I believe the first way to fix the problem is raising the 

funding of the State’s tobacco control programs to CDC-recommended levels. That way not only will the States have comprehensive prevention programs but comprehensive cessation programs too. All too often States are given money to have a prevention program and then when people see these funds and programs 

and want to quit, or want to know how they can quit, there’s never 

any resources there for them to do so. 

The State’s youth fund movements have a positive impact on 

young people all over. If we can raise the visibility of our programs 

and in turn raise awareness our programs will turn our colossal results. But when our lawmakers agree to cut funding for programs 

and either use our money for non-tobacco related issues, they curb 

our efforts to save lives and they become just as responsible for the 

death of thousands every year, as the tobacco industry. In order to 

combat the problem our lawmakers must act. 

Now, for a moment I’d like to talk about just the reason why that 

our movements are always under threat. There’s always something 

that’s trying to bring us down, or whether people realize that or 

not. For an example, I’d just like to mention something that’s happening right now. Every year, or every 2 years in Iowa we did the 

Iowa Youth Tobacco Survey, and that’s how our program runs. If 

we don’t have any new information how can we provide the results 

that we have? Well, this year that survey is in jeopardy of being 

cut. So if we do not do the survey this year, next year we’re going 

to be going off of information from 2 years past. And that information is good. In 2 years of being a program we lowered high school 

usage in the State of Iowa by 11 percent, and middle school usage 

by 23 percent. 

Now, another way of prevention is raising the tobacco excise tax. 

In Iowa one of our initiatives this year was just that. The governor 

decided to raise the tax in time of crisis but this is exactly what 

prevention shouldn’t be. We should be raising the tax in less needy 

times. That way we can prevent those times from ever occurring 

in the first place. Across the country, if we had significant, regular 

increases in the tobacco excise tax we would save thousands of 

lives, reduce health care spending by millions of dollars, and bring 

in millions of dollars for the States. It’s a win-win-win situation. 

Passing smoke-free ordinances for workplaces across the country 

is another way we can reduce tobacco use. In passing these ordinances you can protect everyone from secondhand smoke, which 

kills over 53,000 innocent Americans every year. Along with cessation programs, smoke-free workplaces prove to be a winning 

strategy. FDA regulation, funding for the CDC’s Office on Smoking 

and Health and a national cessation quit line are all of the ways 

we can work to prevent tobacco use and save lives. 

Now, the one way I think we can get all this done is very simple. 

And that is removing the tobacco industry’s hands out of our lawmakers’ pockets. Annually the tobacco industry spends over $5 million in campaign contributions around the country. Our lawmakers 

are influenced by these contributions and in turn are preventing 
33 

comprehensive tobacco control programs from accomplishing the 

tasks that the settlement money was supposed to be used for. 

PREPARED STATEMENT

If we raise the State’s prevention programs to CDC-recommended funding, have regular significant increases in the tobacco excise tax, provide strong cessation services in every State 

and remove the tobacco industry’s place in government, we will 

save thousands of lives and bring in millions upon millions of dollars to this country. If we don’t, I believe that in 50 years we’ll look 

back and be shocked as the world’s greatest democracy that one industry had free reign on its citizens. I believe now is the time to 

do something about it while we still can and before the problem 

gets too out of hand and there’s no looking back. Thank you. 

[The statement follows:] 

PREPARED STATEMENT OF THOMAS OLDHAM

Thank you for the chance to appear here and speak on behalf of the thousands 

of Iowa teenagers who are working to prevent tobacco use among their peers. I believe I come here not only on behalf of Iowa, but also for the 400,000 innocent Americans who die every year at the hands of Big Tobacco. 

At 13 years old, I was brought into the world of tobacco prevention, and at the 

time, the youth led movements were getting more and more powerful. They were 

using tactics nobody had foreseen; harsher advertisements, new kinds of direct action, and so on. People had been taking notice, and a clear line was drawn between 

the comprehensive tobacco prevention programs and the less than desirable ‘‘haveto’’ programs that the tobacco companies were running. Change was taking place, 

lives were being saved, and these state programs were getting recognition not only 

for their actions, but their results. 

But as the years passed, so we’re these comprehensive state programs. As more 

and more were forming and sounding the alarms, their legs were cut out from underneath them. Successful programs were losing money rapidly, with politicians dipping their hands into the tobacco settlement money like it was a rainy day fund. 

Not only this, but the tobacco industry was increasing spending in states with successful programs, and by cutting out those programs you advance the progress of 

the tobacco industry while curbing the efforts of the prevention programs. The issue 

is clear, and the right thing to do is very easy, but across the United States, nothing 

is being done, and nobody is taking action. 

Senator Harkin’s ‘‘Wellness and Disease Prevention’’ initiative is a step in the 

right direction. Currently, the Healthcare costs related to tobacco in this country 

topple $75 billion annually. Because of this, and other smoking caused government 

spending, the average household tax burden is $525. In result, hardworking Americans, the majority of these non-smokers, are paying big bucks for preventable disease. Currently, tobacco use is the number one cause of preventable death in this 

nation, killing more Americans annually than Alcohol, Aids, Car Crashes, Drugs, 

Fires, Murder, and Suicide combined. This is inexcusable and outrageous, especially 

when the situation is so easy to take care of. 

The first way is raising the funding of the states’ tobacco control programs to CDC 

recommended levels. That way, not only will the states have comprehensive prevention programs, but comprehensive cessation programs. Too often states develop prevention programs that work, but have no aid for those who want to quit. The states’ 

youth led movements have a positive impact on young people all over. If we can 

raise the visibility of our programs and in turn raise awareness, our programs will 

turn out colossal results. But when our lawmakers agree to cut funding for programs, and when they use our money for non-tobacco related issues, they curb our 

efforts to save lives, and become just as responsible for the death of thousands every 

year. In order to combat the problem, our lawmakers must act. 

Another way is raising the tobacco excise tax. In Iowa, one of our initiatives this 

year was just that. The weather was fair this year and our Governor decided to 

raise the tax in times of crisis, but this is exactly what prevention shouldn’t be. We 

should be raising the tax in less needy times, that way we can prevent those times 

from ever occurring. Across the country, if we had significant regular increases in 

the tobacco excise tax we would save thousands of lives, reduce health care spending 
34 

by millions of dollars, and bring in millions of dollars for the states. It’s a win-winwin situation. 

Passing smoke-free ordinances for workplaces across the country is another way 

we can reduce tobacco use. In passing these ordinances, you can protect everyone 

from secondhand smoke, which kills over 53,000 Non smoking Americans every 

year. Along with cessation programs, smoke free work places proves to be a winning 

strategy. FDA regulation, funding the CDC’s Office on Smoking and Health, and a 

national cessation quitline are all other ways we can work to prevent tobacco use 

and save lives. 

The one way we can get all of this done is simple. Remove the tobacco industry’s 

hands out of our lawmaker’s pockets. Annually, the tobacco industry spends over $5 

million in campaign contributions around the country. Our lawmakers are influenced by these contributions, and in turn are preventing comprehensive tobacco control programs from accomplishing the task the settlement money was supposed to 

be used for. 

If we raise the states’ prevention programs to CDC recommended funding, have 

regular significant increases in the tobacco excise tax, provide strong cessation services in every state, and remove the tobacco industry’s place in government we will 

save thousands of lives and bring it millions upon millions of dollars to the country. 

If we don’t, we’ll look back 50 years from now and be shocked that the world’s greatest democracy let one industry have free reign on it’s citizens. I believe now is the 

time to do something about it while we still can, before the problem gets too out 

of hand and there’s no looking back. 

Senator HARKIN. Tom, thank you very much for that great testimony and thank you for being here today. Someone handed me a 

note, I didn’t see him when I came in, but I want to recognize 

someone else who I’ve known for many years and who has always 

been a great leader in terms of physical fitness and making sure, 

as someone said there, it’s not just the mind but also the body, because he’s worked on both of those in so many ways. Bill Pulliam 

is here. Bill, where are you? Someone said you were back there. 

Bill Pulliam, right back there. 

One of our great basketball stars here in the history of the State 

of Iowa. Thank you for being here, Bill. 

Well listen, I again want to thank all of you for being here and 

for your testimonies. I’d like to just ask a few questions. And I 

guess we’ll open it up for maybe a little bit of a general discussion. 

I don’t know exactly how much time I’ve got here but we’ll move 

ahead. Oh, yes. After our hearing concludes, we’re going to do a little walk around the track. And, is that why I have this heart monitor on? Okay. All right. Okay. So we’re going to take a little walk 

around the track just as a, you know, just as a little bit of exercise. 

I brought my walking shoes with me, nothing special. 

Let me start first with Doctor Baranowski. Again, you testified, 

others testified about the costs of fighting disease in this country, 

the health care costs associated with it. It’s hard, to know exactly 

what steps we can take at the Federal level that will result in actual significant cost savings. A lot’s being done on the local level; 

a lot of people here are doing things on their own. We have organizations like P.E. for Life and others, but is there anything else that 

you think that we can be doing on the Federal level? I’m looking 

for advice and suggestions. 

Dr. BARANOWSKI. Yes sir. Thank you for the question. Without 

appearing to demean the very important efforts reported this morning, the existing programs that have been published to help people 

change their behaviors, even those designed by, implemented and 

evaluated by our best minds, are having, at best, modest effects 

and at worst no effect. This includes both programs designed to 
35 

change the environment in which these behaviors occur and those 

designed to change the behaviors. This suggests we need more research. These are behavioral problems and they need behavioral solutions. The NIH has made an enormous investment in biological 

research over the least 50 years. After 40 years of investment, it’s 

only in the last 10 years or so where the treatments have been targeted at molecular systems, for example, cell receptors, and have 

substantial impact on the disease without substantial side effects. 

The same investment must now be made in the behavioral 

sciences. We need to better understand why people eat the food 

that they do and are or are not physically active. Research must 

then be conducted to convert this knowledge into effective programs and evaluate them. This will require substantially more 

funding for behavioral science and related research. In fact, I think 

the solution or part of the solution is more research. 

Senator HARKIN. Let me ask you this. I have discovered in the 

last couple of years that the number one reason why young women 

drop out of college, for varying periods of time, is because of eating 

disorders. I became interested in that and I started looking at some 

of the data surrounding eating disorders in this country and I become quite alarmed. It’s growing rapidly. I’ve talked to a number 

of mental health people about this, others expert in the field, and 

on the one hand we have obesity, on the other hand we have anorexia, bulimia, binge eating, various and sundry other eating disorders. And most of it’s centered around anorexia and bulimia. It 

just seems to be we’re getting a couple of messages that are hitting 

our young people. One, you’re getting all the ads for this food and 

that food and, I don’t want to pick on McDonald’s, but just all those 

unhealthy choices that you have for soda and everything else. On 

the other hand, every magazine you pick up, for young women, especially, has pictures of, extremely thin women. That’s why I’m a 

little concerned about stressing this idea of obesity because I don’t 

want young people to begin thinking that they’ve got to look like 

these sticks that pass for models in our society. But more and more 

I see young women thinking that that’s how they’ve got to look if 

they want to be accepted. I just wonder if you have any thoughts 

on that. 

Dr. BARANOWSKI. Yes sir, that’s a very important question. I 

have to admit I’m not a specialist in eating disorders and I defer 

to Dr. Cutrona. Perhaps she has some insight on eating disorders 

that’s ordinarily considered a mental health problem. Alternatively, 

most of the work that we do is in the inner-city with ethnic minority individuals. In the middle schools and the high schools, 50 percent of the kids are overweight or obese. 

Senator HARKIN. 50? 

Dr. BARANOWSKI. Five-zero. 50 percent. 

Senator HARKIN. In high schools? 

Dr. BARANOWSKI. In middle schools and high schools. This is a 

shocking, shocking problem and the eating disorders that aren’t as 

prevalent in the minority community, although clearly we need to 

address the concerns for eating disorders in the majority community, that there’s a huge need for obesity prevention in all high 

school kids but particularly in the minority community. If we don’t 

the declines that have been occurring heart disease mortality and 
36 

cancer mortality are all going to reverse and those are all going to 

start increasing enormously. The medical care costs associated with 

that are going to go out the window while we leave this problem 

unaddressed. We’ve got to address the obesity problem or we’re 

going to pay for it in the long run. 

Senator HARKIN. Do you have any thoughts on what I just 

brought up, Dr. Cutrona? Eating disorders among young women 

who are anorexic, bulimia, who think they’ve got to look like these 

sticks. 

Dr. CUTRONA. I think that this can be used to illustrate a very 

important point, which is that you can’t just address problems like 

this on the individual level. We have a young woman who’s starving herself to death and we try to come up with a good treatment. 

We have to prevent this. We have to think about advertising, we 

have to think about the messages that young women receive. I 

think this is an appropriate context for public health campaigns 

that address our standards for young women, our standards for 

what is attractive, for what is healthy, making health what is our 

ideal rather than the stick-thin image that you’re talking about. So 

I guess what I’m saying is this, along with most other mental 

health issues, has to be addressed on many levels, in the schools, 

in the home. You can’t wait until the young woman is already perhaps on death’s door. Women actually die from anorexia. We have 

to address this at the community level and it is a problem, although not as prevalent as Dr. Baranowski said as overweight. So 

a multi-tiered approach, I think. 

Senator HARKIN. Well, I guess, getting back to the school-based 

programs, I guess if kids learn early on, in elementary school, 

again, a healthy lifestyle. Not that you have to look like a stick but 

you don’t have to be obese but you can maintain a decent weight, 

body fat percentage and be very healthy. I guess you got to start 

early with these kids. 

Dr. CUTRONA. Well, obviously as an educator I believe that pretty 

strongly, preventive, proactive in nature. The reactive health care 

system that we have isn’t working. I mean, that’s pretty simply 

said. I really don’t think it’s health care, I think it’s sick care. And 

what we need to do is be proactive in our—I think this young 

man’s a great example. Even though he started, there was an 

intervention program that was very—it was preventive in nature 

and it got to him early. That type of education, he became more 

educated. That’s the key. I mean, for me, that’s the key. Where do 

we have every child? In school. So we have to capture their imagination, their interests, and get them to invest in their own, their 

value, investing in their own health to see a reward or a gain in 

the future. So yes, I feel very strongly that more money’s into the 

physical quality, physical education programs is a key component 

if we’re going to attack this problem. Because we can’t do it on the 

back side. It’s not working. David Chenoweth says, a health economist, by year 2020 the health care system’s going to collapse because of the rise in health care costs. Can we prevent that? What 

have we always said? You know, prevention, an ounce of prevention’s worth a pound of cure. But where’s all the funding going 

into? Into reactive programming. We have to channel that. That’s 

why I believe what you’re doing with the PEP bill is so critically 
37 

important. What you’re doing in allowing funding to go into school 

systems to be able to do futuristic type of physical education programs, funding where there’s lack of funding, because everything’s 

saying and being mandated by No Child Left Behind. Math, reading and science. Math, reading, and science. At the expense of the 

child’s health. And we believe, at Brittany Center, we believe it 

should be around the Nation, that if you cut physical education 

you’re cutting the heart out of the child’s education. And I don’t 

think that, you know, we talked about the problem, we talk about 

it continuously, over and over and over, but then we need to come 

up with some viable solutions. And I believe, as an educator, that’s 

what education’s about. I think it worked for Tom and now, look 

at him. I mean, my goodness sakes. I feel honored to be sitting next 

to him. What an example he is for saying that something, you 

know, they intervened at a young age with him, some type of preventive program that helped change his life, change his healthy 

habits for a lifetime. Now look at him and look what he’s doing. 

I cannot imagine at the age of 18, sitting up here and doing what 

he’s doing, and that’s the type of young person that we need to 

have and that comes through education. And that’s where I believe 

the funding needs to occur. 

Senator HARKIN. Well Tom, since you’ve been brought into this 

right now, just out of curiosity, you said you were about, how old 

were you when you started smoking? 

Mr. OLDHAM. I was 13 years old. 

Senator HARKIN. Do you have any, do you remember why? Was 

it peer pressure? What was it? Why did you start? I mean, because 

I can tell you, I was about maybe, let me think, I was probably 

around, oh, I suppose 12 or 13 when I started smoking. 

Mr. OLDHAM. I’m not sure if it was peer pressure because me and 

my friends all kind of started doing it at the same time. So I think 

it was just outside influences. 

Senator HARKIN. Outside? 

Mr. OLDHAM. Like tobacco industry advertisements and things 

like that. As sad as it is, and it is often for a lot of teenagers still, 

is people think it’s cool to, you know, light up a cigarette. They 

think it looks cool in their mouth or whatever. And I think that 

had a lot to do with it. We were very impressionable and the tobacco industry knows that. So they do what they can because they 

know if they do not target youth they’ll be out of business in 30 

years. 

Senator HARKIN. Let me ask you this. How easy is it—how old 

are you right now? 

Mr. OLDHAM. I’m 18 right now. 

Senator HARKIN. Eighteen. How easy is it for teenagers to get tobacco? Is it easy or not? 

Mr. OLDHAM. Oh, it’s unbelievably easy. 

Senator HARKIN. What? 

Mr. OLDHAM. It’s unbelievably easy. 

Senator HARKIN. But people aren’t supposed to sell cigarettes. 

Mr. OLDHAM. Yeah, they’re not supposed to sell cigarettes but I 

mean, that doesn’t stop any teenager from going to someone who 

is 18 and—I mean, I’m even a perfect example. I’ve had people 

come up to me, of all people, and ask me to buy them cigarettes. 
38 

I’m this—now granted, it’s not often public knowledge what I do 

but I mean, it’s just like, a lot of people my age will do that for 

someone. 

Senator HARKIN. Do you think raising the cigarette tax would 

have an impact? 

Mr. OLDHAM. Absolutely. 

Senator HARKIN. Just more expensive, kids won’t—just, the 

money they have. 

Mr. OLDHAM. Yeah. That is one of the things that people say 

raising the cigarette tax, well people are still going to smoke. And 

that’s true. People will still smoke. But many adults will quit and 

even more teenagers will quit. Teenagers don’t have that anticipal 

funds as oftentimes more adults do. I mean, I’ve heard from many, 

many people my age that, if we raised the tobacco tax, because I, 

you know, I talk to people about it all the time, and they say if we 

raise the tobacco tax I’m not buying anymore. And I’m like, well 

hey, then we’re successful. So studies have shown that with every 

ten percent increase in the tobacco tax you reduce consumption by 

3 to 5 percent. 

Senator HARKIN. You know, Tom, I’ve been on the tobacco companies for years about their advertising. First there was Joe 

Camel, all the Joe Camel ads, how to be cool, geared towards young 

people. Then you had the Marlboro chits; you know, you get Marlboro points and you get all these gifts and stuff like that, anything 

to get young people into smoking. I came across one of the new 

ones here. First I thought these were candy when someone first 

gave them to me. It’s called Liquid Zoo. I’ll pass them around, you 

can look at them. It’s strawberry flavored, kind of a fancy little box. 

I thought, my gosh, they’re back to candy cigarettes again. And 

then I found out these are cigarettes. Liquid Zoo Flavored Cigarettes are an exotic blend of strawberry flavored, tobacco product 

that is sweet, fresh tasting and has a sweet aroma. Now who do 

you think they’re marketing that to? Not to adults. Not to older 

people. Young people. And guess what? Made in the United States 

of America. Manufactured exclusively for Cretech International 

U.S.A. And in really small print it says, No underage smoking allowed. Have you ever seen these? 

Mr. OLDHAM. No sir. 

Senator HARKIN. Pass them around. Here’s another thing I wanted to hold up, Tom, I think you’d be interested in. You’ve all seen 

Kraft Macaroni and Cheese, right? It’s FDA regulated. The FDA 

regulates the content of what’s in that box. And guess what? Kraft 

is owned by Philip Morris. Philip Morris also owns Marlboro Cigarettes. This is not regulated by the FDA. That’s regulated by the 

FDA, macaroni and cheese, tobacco, not regulated by the FDA. 

Anybody make any sense of that? That’s why we keep pushing to 

have the FDA regulate cigarettes as a drug delivery mechanism. 

We know that tobacco is a drug, nicotine is a drug, it is a highly 

addictive drug. It contains things like hydrogen cyanide, ammonia, 

arsenic, butane, carbon monoxide, formaldehyde and 40 other 

chemicals known to cause cancer, yet the FDA does not regulate it. 

So again, this shows you the contrast in our FDA regulations and 

the problems that we have in trying to get the FDA to regulate 

them. So we’re going to continue to press for FDA regulations so 
39 

that they have to regulate it, plus stop this kind of nonsense here 

of how they’re putting out these packages of strawberry flavored 

cigarettes. 

Some of you who are my age or maybe a little younger than I 

remember the little candy cigarettes that we all were given to practice on when we were younger and stuff. I thought they were coming back. That’s even worse. 

I want to get back to you, Dr. Baranowski. You mentioned research. 

Dr. BARANOWSKI. Yes sir. 

Senator HARKIN. Give me some idea, can you give me two or 

three, four, whatever, what are the top areas that you believe that 

should be the highest priority research areas for childhood obesity. 

Dr. BARANOWSKI. Thank you again for the question. First we 

need a clear picture of what are the major contributors to obesity. 

Some luminaries believe lack of physical activity is the major culprit. Other equally admirable luminaries believe it’s most diet. 

There are adherents for the contribution of television, electronic 

games, fast food, enhanced portion sizes, etcetera. If we knew the 

five major causes of obesity we would have clear guidance for the 

design of programs to maximize the effects. Of course, the five 

major causes probably vary by age and perhaps by gender. 

Second, we need an understanding, a better understanding of 

why people do or don’t do the behaviors that are the major contributors to obesity. This knowledge will guide program designers on 

what mediating variables to target. 

Third, we need control—we need research on controlled diet and 

physical activity. For example, most of the national dietary guidance is based on the national dietary guidelines and the food guide 

pyramid, but there has never been a study that assesses what happens when people eat a diet based on the dietary guidelines and 

the food guide pyramid. What will it do for the obese or the moderately overweight people? For those with an elevated blood pressure or elevated cholesterol? There are several recent versions of 

the food guide pyramid and more have been proposed. None have 

been compared for effects on outcomes. 

The same kind of research is needed with physical activity. What 

will 30 minutes of moderate to vigorous physical activity, 6 days a 

week do for adults or children who are overweight? Is physical activity valuable primarily in longer doses or do multiple shorter 

doses have the same effect? While some of this research on physical 

activity has been done, this is very difficult research to do and 

much more is necessary. 

A number of my colleagues would argue that the primary research need is for more community-based interventions. In my 

opinion, since most of our community-based interventions have not 

worked well or not worked at all, these three kinds of research will 

provide much needed guidance to community-based interventions. 

Senator HARKIN. Thank you. It was just brought to my attention 

the other day—I’m going to find out more about it because I’m not 

going to mention the place but I will mention what it was—a new 

elementary school that was just built that has no playground. An 

elementary school built without a playground. I’m going to look 

into it more. I assume there’s no Federal money involved but prob-
40 

ably just State and local money but there ought to be some thought 

given to that when schools are built that way. 

I wanted to get to Len Olsen here, because I met a person with 

A-John Company and what you’re doing with them, right? 

Mr. OLSEN. L-John, yes. 

Senator HARKIN. L-John, I’m sorry, L-John. Now, what I was intrigued by your testimony was this idea of incentives. 

Mr. OLSEN. Yep. 

Senator HARKIN. So, you know, I believe in the carrot approach, 

I really do. I think, you know, there ought to be more incentives 

to push people to preventative health, to maintaining healthy lifestyles. You mentioned that in our testimony. I don’t understand exactly how it works, but if you’re in this program the company will 

pay 60 percent of your health premium but if you get certain indices up, what is that? You get up to 90 percent that they’ll pay? 

Mr. OLSEN. Right. I can give you a personal example of that one. 

Again, when I started, I needed to get my weight down a little bit, 

I needed to get my cholesterol down a lot. I had to set those goals. 

I didn’t achieve them at first and I got bumped up to a higher— 

you get a little break for a while, kind of a grace period. Then I 

thought, well you know, I’ll just do what I normally do and I’ll be 

fine. I think a lot of people are that way, they don’t want to change 

their behavior. I go back for the second test and don’t pass, didn’t 

meet the goals. Got bumped up, again. Eighteen hundred dollars 

a year. So now it gets your attention and your pride a little bit. 

Okay. So you make changes. And in my case—not everybody can 

do, some people need medication, their bodies are different. Sometimes you do have to exercise more, you do have to watch what you 

eat, how much and what kind. And so the next time I went back 

for an evaluation, and you get that down and what several people 

do, I think they’re motivated, you know, we just had our more recent evaluation and I can tell you the buzz around the hospital 

was, my evaluation’s coming up, I got to get my weight down, I got 

to behave, you know, I got to watch what I’m eating. And that’s not 

false. I mean, they really are working at it. And I have a friendly 

rivalry with Danny Renfrew, one of our maintenance supervisors, 

and we have the same problem. We’re both relatively okay on 

weight and physical activity but we struggle with cholesterol. So 

there’s a little friendly rivalry and we talk about it. And so I believe incentives do work, with kids and with adults. I believe in 

personal responsibility. I think there is cause and effect. I think we 

are less active than we were 30 years ago. Talk about physical education, what the Federal Government can do. We used to have 

something called the Presidential Fitness Challenge when I was in 

elementary school. And we had to do tests. We had to get ready for 

doing the push ups and the sit ups and the chin ups and running 

the mile, girls and boys, this was egalitarian. And it’s something 

you wanted to do well at and you were motivated to do well at. We 

had P.E. three times a week. We got to play games but we also did 

calisthenics. And yeah, there were the kids that were heavy and 

that suffered in that, and I do believe in no humiliation, I like to 

see the no jock approach, I think that’s great. But you got to get 

people moving. Movement burns calories. And if we don’t—if we’re 

cutting that out with our kids, that’s criminal. 
41 

Senator HARKIN. Are there other regional health center, at least 

in Iowa, that are doing anything like what you’re doing? Do you 

know of any? 

Mr. OLSEN. Arlene might know better than I do. 

(Extensive response by someone off-mike) 

Senator HARKIN. Watch this. 

(Continuation of response by someone off-mike) 

Mr. OLSEN. I think to add to that, what hospitals can do is kind 

of be beacons of healthy living. You know, Jo Ellen serves on our 

local Y board and they’ve started a program called Fit Kids. Is that 

what it’s called, where we do after school programming for kids at 

risk? Getting them exercising, giving them better self esteem, and 

a lot of this is emotional health. I mean, it isn’t just about the 

physical stuff, it’s about why you’re eating and dealing with what’s 

going on up here. And the Y program tries to do that. And it’s a 

partnership with the YMCA and the employers and the schools. 

(Interjection by someone off-mike) 

Senator HARKIN. Oh wait, wait, wait. We got to get you a mike 

because I’m sorry, please identify yourself. Please identify yourself 

for the record. 

JO ELLEN RANDALL. Jo Ellen Randall. And this was a program 

that was started probably 3 years ago in Ottumwa where the 

YMCA is partnering with the school systems. And the Y has a bus 

and they go to the school systems, pick the kids up after school, 

they come back to the YMCA where they participate in fitness programs, also social programs, versus going home, watching TV, getting into the junk food. This keeps them active and it has been a 

very popular program. It continues to grow. We continue to look for 

funding to keep that program going because it is extremely important. And it also drives families in coming back to the YMCA to 

do things together because the kids want to be there. And then 

parents find that this is also an activity that they can participate 

in. So the healthiness of that is not only for the children but for 

the family also. So, an extremely good program. 

Senator HARKIN. Maybe we ought to look at that as a source 

more for outreach. Ms. Ruby, you know, we’re talking a lot about, 

you know, prevention in the first place, getting kids in school early 

on, but we have a whole generation of elderly people now who are 

leading sedentary lives, watching television. I think a lot of them 

were smokers or maybe still are smokers. Tell me about your getting elderly people involved. And it’s my understanding, at least, 

that just with proper diet and proper exercise that a lot of the medical problems of the elderly kind of diminish, if you just get them 

on a good program. But how do you do that? I mean, you obviously 

have done it but how do we get more people involved, the elderly 

people involved? 

Ms. RUBY. Well, the number one thing is you have to be very creative in your thinking. We didn’t just go to the mall to recruit people for our program. What we did was, we had days when we went 

to a senior citizen center and signed up people for our program. We 

also have many, many community partnerships, one in particular 

is with our local hospital, where we went to cardiac rehabilitation 

and we signed up people. We also went to the diabetes center to 

see if there were people that would be interested in our programs. 
42 

So we approached several different programs within the community 

to join us and join our efforts and by being creative we have created a lot of community partnerships and we have been able, not 

just to get elderly people involved in our program but people who 

would really benefit from the physical activity, those people that 

are in cardiac rehabs, the diabetics. We’ve been able to get those 

health disparities by our community collaborations. And that’s just 

from going out and being creative and working with the other programs within the community. 

Senator HARKIN. As you, I don’t know, you may not know this, 

but right now we have nutrition—we have a mandatory FDA requirement of nutritional labeling on packaged goods, when you go 

in the grocery store, right? You see all the packaged goods, you see 

what’s on it, and anything, most of anything that’s packaged has 

to have ingredients labeling. I have introduced legislation to also 

have the FDA mandate that certain restaurants and restaurant 

chains put on their menus certain information as to fats, trans fats, 

sodium, calories. It initially met with a wave of opposition. But I 

noticed that after we did this Ruby Tuesday’s came out and said 

they were going to voluntarily do it, others have done it. But again, 

still kind of an opposition to this thing. Now, what’s been the reaction? You established some kind of a dining guide. I’m not familiar 

with it, I know you mentioned it. What is it and how have you gotten—what’s the public acceptance and the business acceptance 

been in the Fort Dodge area? 

Ms. RUBY. Well, one of the other programs that we have done in 

Webster County is we surveyed 67 restaurants in our area to see 

what they offer for healthy dining choices. And we took that information and we compiled it and we made a healthy dining guide for 

our citizens in Webster County, and it has all of the popular restaurants, Wendy’s, Appleby’s, all of the places that people would 

dine out. And I wish I would have brought one today but I did not. 

And it’s a form that identifies what each restaurant has in the way 

of healthy foods, if they offer skim milk, if it’s a non-smoking environment. There’s just a list of information that we have on there 

for the residents of Webster County so they know where healthy 

places are to eat. And what we did was we distributed 2,200 of 

those healthy dining guides to all of the restaurants in Fort Dodge 

and in the community and we took it one step further and we implemented a community policy with our restaurants, requiring 

them to post that information for citizens so it’s available when 

they go there. And we have, like I said, we’ve distributed 2,200 dining guides and we are out of them; we’re in the process of ordering 

more. So we’ve had great, great response from the community. 

Senator HARKIN. And the restaurants too? 

Ms. RUBY. Yep. We had them sign the policy. Everybody that 

participated in the healthy dining guide, part of that program was 

that they had to have that dining guide posted for citizens to see. 

That was a piece of the program that they had to agree to participate in. And they all did. 

Senator HARKIN. That’s very good. Although I happened to read 

the paper this morning and I noticed that—I don’t have it with me 

but—story in this morning’s Register about McDonald’s is now putting out an adult Happy Meal, and a kid’s Happy Meal too, but it 
43 

has a salad in it and fruit and a pedometer. And this is all well 

and good. And I think, you know, the more we can continue to encourage the McDonald’s and the other fast food chains to do this 

the better off we’re all going to be. So I applaud them for doing 

that and I hope they continue to do that. I ask the question, however, are they going to put as much advertising into that as they’ve 

put into a Big Mac? I mean, they start equalizing the advertising 

then maybe we’ll make some progress here. 

Let’s see. Was there any other thing that I wanted to cover here 

specifically? I think I got most of the—well, fruits and vegetables. 

You’ve been involved in that. And some others here also. You have 

been too, right? 

Ms. RUBY. Yep. 

Senator HARKIN. You’ve been involved in fruits and vegetables. 

Well, children walk and bike 40 percent less now than they did 20 

years ago. They don’t get the daily recommended fruit and vegetable allowance. You know, again, what can we do about this, what 

kind of results have you seen in children after beginning your day 

care outreach? And I’m talking to you about that. What’s happened 

when you do that? What’s happened to the kids? 

Ms. RUBY. Well, another one of our wellness programs that we 

have is we went to the day cares each month and we talked to the 

children about eating fruits and vegetables and exercise. And what 

we did was we did monthly visits to educate them on the benefits 

of it and one of the things that we always look at when we do a 

program is sustainability. So after our program was completed we 

had all of the day cares, we signed another policy, community policy, where all of the day cares were required to continue to teach 

the children about fruits and vegetables and the importance of eating them. So we had buy-in from all of the day cares that we did, 

our education piece, but then they continued to do that. 

Senator HARKIN. You may not be aware of this, in the 2002 Farm 

bill, I happened to be chairman for a brief moment there, and I 

wanted to test a theory of mine, and that is that if kids had available free, fresh fruits and vegetables, not canned but free fresh 

fruits and vegetables that they would eat those and they would not 

be eating junk food and putting money into vending machines. So 

we picked four States, Iowa, Michigan, Ohio, Indiana were the four 

States. And two Indian reservations. We picked 25 schools—well, 

I didn’t pick them but the Iowa Department of Public Education 

took in applications—so we had 25 schools in each State, 25 in 

Iowa, Ohio, Michigan, Indiana, 100 schools, some urban, some 

rural, some high income, some low income; we wanted to get a 

broad spectrum. And I put in just $4 million to do this. It’s been 

existing now, it’s been going on for just over a year now and the 

results have been fantastic. I mean, you’d be amazed at how many 

kids, especially low income kids, never eat fresh fruits and vegetables. It’s one of the most expensive things in the grocery store. I 

mean, to go to some of the schools and see kids that have never 

eaten a fresh pear, kiwi fruit, bananas, apples, all these things. 

But it’s just been phenomenal. But now again, this is just a pilot 

program, we added one more State this year, Mississippi, we added 

a couple more million dollars this year, a million dollars more for 

Iowa. But again, all the preliminary results after 1 year seems to 
44 

be that—well, we had one principal from where? Muscatine. 

Muscatine actually said they had to take a vending machine out of 

the school because it wasn’t being used any more because the 

kids—now, the idea was not that the kids had the fruits and vegetables just at lunch time but they had it when they came to school 

in the morning; if their stomach got the grumblies around ten in 

the morning they could get fresh fruit or vegetables. You got kids 

eating fresh broccoli, kids eating cauliflower. 

I went to this one school. I asked these kids what they like and 

this one kid said, he liked spinach. I thought that was pretty interesting. But, you know, obviously, who likes canned spinach? Is 

there anyone in this room who likes canned spinach? But fresh 

spinach is very good and these kids had never had fresh spinach. 

And so it just opened up a whole new world for them. And 

anecdotally we found a lot of kids that their parents now were coming into school and seeing them, and when they go grocery shopping they may take their kids with them; the kids were always, 

you know, they go to the fruits, they want this fruit and they want 

this vegetable, now they’re making their parents buy this stuff. So 

again, I talk about that as a way, Dr. Baranowski, now you’ve done 

some—in this area, about getting kids started on fresh fruits and 

vegetables and how important that would be for, again, later on, 

for people to continue that kind of a lifestyle. 

Dr. BARANOWSKI. Terrific. I honestly believe that the fruit and 

vegetable pilot program that you developed and implemented and 

funded was a remarkable program from many perspectives. The 

fruit and vegetable consumption is the single most important dietary behavior that needs to be encouraged for several reasons. The 

micro nutrients in fruits and vegetables have profound effects in 

regulating physiological systems and thereby helping prevent most 

cancers, heart disease, diabetes and a variety of other chronic illnesses. The high water and high fiber content tends to enhance a 

sense of fullness and thereby reduces caloric intake and fat and 

sugar intake, leading to weight loss. The evaluation that was done 

of the fruit and vegetable pilot was very promising but anecdotal, 

relying on participant testimonials. I believe you could have broader effect if you had a more thorough, systematic evaluation of the 

program. As a behavioral scientist I’d like to see harder data. Did 

the program lead to more fruit and vegetable consumption by the 

children or did just some children compensate by reducing their 

fruit and vegetable consumption outside the school? Which children 

increased? Were the children who needed it most among the ones 

to benefit? At what point is the optimal benefit achieved by a program such as this? At one serving of fruit and vegetable a week? 

At one serving a day? Two per day? At breakfast and lunch? At 

snack? What were the costs borne by the schools from such a program. I strongly encourage you to insert a line item in the next legislation funding this program to implement a thorough evaluation. 

A colleague of mine at the Children’s Nutrition Research Center 

has submitted a grant to the NIH to begin such research but the 

peer reviewers seem to believe that the USDA should be the funding—the source of funding for the evaluation. My colleague is ready 

to do such research and I’m sure many others would like to have 

the opportunity to do so too. So while the program was an impor-
45 

tant first step it can have more pervasive effects on policy if it had 

a thorough evaluation. 

In a more direct response to your question, the highlights of my 

research reveal that children who have more fruit and vegetables 

available at home tend to eat more fruits and vegetables. That’s 

not rocket science but we think it’s an important finding so we’ve 

initiated research on the determinence of home fruit and vegetable 

availability and we’re currently doing surveys in Houston on that 

factor. 

Also, we’ve designed electronic games based on behavior change 

principles and have shown that children who played our games 

twice a week for 5 weeks increased their fruit and vegetable consumption by a full serving a day. We have several funded studies 

pursuing this line of research, trying to find more effective ways 

within the game framework of helping children change their dietary behaviors. 

Finally, we’ve developed a computerized method for measuring 

children’s daily food consumption. This opens the door to more extensive dietary research because it makes dietary data collection 

much less expensive. We think these are important contributions. 

Senator HARKIN. Your point is that we need better research and 

data collection. 

Dr. BARANOWSKI. Yes sir. 

Senator HARKIN. I agree with that. 

I’m going to now open this up. I’m told we’re going to start out 

walking in 10 minutes but I’d like to open up to the floor for anyone that has any questions, comments, suggestions. We’re open for 

any observations that anyone might have. All I ask is that you just 

identify yourself for the record, is all. Yes, back here. 

Ms. THOMAS. I’m Kathy Thomas from Iowa State University. And 

I think I have a couple of comments more than questions. With all 

due respect to Dr. Baranowski, I certainly agree that more money 

is necessary for research but one of the key points that I think, as 

we listen to Mr. Schupbach’s program in Grundy Center, it’s important to understand that his program is daily physical education. 

And if we look at the two most recent publications, one from 

NICHD and the Schifft Study that Burgeson and Paul Wexler published from CDC, both of those indicate that we are grossly behind 

the national recommendations in terms of daily P.E. In the elementary school, children are getting approximately 40 percent of daily 

physical education recommendations. In Iowa, it’s about the same 

as it is nationwide, where children are getting 2.1 days of physical 

education per week when the recommendation is daily. They’re getting approximately 62 minutes in the State of Iowa as opposed to 

150 minutes. So—— 

Senator HARKIN. Let me ask a question. Sixty-two minutes per 

week? 

Ms. THOMAS. Yes sir. Per week. 

Senator HARKIN. In elementary school? 

Ms. THOMAS. Yes sir. 

Senator HARKIN. That’s average? 

Ms. THOMAS. That would be the national average, yes sir. 

Senator HARKIN. The national average is 62 minutes per week? 
46 

Ms. THOMAS. It’s 66 in third grade, in the NICHD study. If you 

look at the Schifft’s data it’s more like 62 minutes, which is about 

the Iowa average. Now, this is a systemic problem. And I think unfortunately a lot of the research that’s done—— 

Senator HARKIN. Could you put the mike closer to your mouth? 

Ms. THOMAS. This is a systemic problem that we look at research 

and we criticize instruction, curriculum, child behaviors, all sorts 

of things like that and we don’t look at the systemic issue of how 

much physical education children are actually getting each day. 

One of the things, that if we look at the increase in obesity and 

overweight from the Enhans data from 1974 to 1999, it is almost 

parallel to the number of children since 1974 to 1999 who have no 

physical education. None. 

Senator HARKIN. Now, I have to reconcile with what you just 

said with some data I saw recently that said 80 percent of elementary school kids in America don’t even receive an hour of P.E. a 

week. Now, you say the average is an hour. 

Ms. THOMAS. In elementary school. Now, it depends on how you 

read the data. If you look at high schools, for example, for students 

who are enrolled in physical education oftentimes they meet the 

225 minutes per week requirement. But many children in high 

school are not enrolled in physical education; they meet their 1- 

year requirement for P.E. and then they’re not enrolled the next 3 

years. So if you look at 100 percent of the children in high school 

that are enrolled in physical education it looks more like 25 percent 

of the kids in high school are meeting that daily requirement. However, if you only report the students who are actually enrolled they 

become much closer. So it depends on how you want to interpret 

the data. But if you look at the data that CDC has presented for 

us and NICHD, they both are very consistent that the system is 

what’s failing, not necessarily the teachers nor the curriculum. And 

I think that’s a really important point because we see many wonderful teachers who are creative but who don’t have the kind of 

support in their system that superintendents like the one in 

Grundy Center has offered. And I think that’s an important problem. 

The other thing I’d just like to mention, I’m sure Dr. Baranowski 

is well familiar with Steve Blair’s work from the Aerobics Institute 

which shows that obesity is less of an impact on morbidity and 

mortality than being physically active. And that may be one of the 

ways of dealing with your concern about people with eating disorders, that we want to make sure that people are active first and 

then we’ll worry about overweight and obesity. 

Senator HARKIN. Very good. Thank you. 

Yes. 

Mr. LAYTON. Senator Harkin, thank you for holding this hearing. 

My name is Tim Layton with the Iowa Department of Public 

Health. I want to share, number one, a story and just one or two 

statistics to shore up some of the presentations today. Some of 

them are rather recent. 

My personal background in this is that my father spent his life 

helping folks plan for their retirement, their financial well-being, 

their fiscal well-being at that stage of their life, and the greatest 

irony of my life was that when my father retired at the age of 65 
47 

a week later he died of a massive coronary. This impacted me and 

basically is my entire background and credentials that I’ve kind of 

based on my beliefs in. My father smoked, he was sedentary, his 

nutrition habits weren’t good, that led to weight issues and he was 

a bit hypertensive. He’s used to establish the animal standard for 

Iowa roads. Anybody that was driving slower than him was an old 

goat; anybody faster was a jackass. And if you weren’t performing 

to my dad’s standard when you were on the road it kind of would 

make him overly tense and again, those all contributed to his situation. 

I feel his outlook on life and the ability to overlook the physical 

as well as the fiscal planning for retirement is kind of analogous 

to America today. So I applaud your efforts to help us start addressing some issues that I, when I look down the road intently the 

three issues of one, the age of our State and the Nation, the cost 

of medical care and then also our sedentary trends and see that in 

the year 2020 we’re not going to have money for anything else, it’s 

frightening to me. 

I also wish to applaud you, you’re kind of steering away from the 

term obesity, since we have a lot of individuals who are overweight 

and fit and a lot of individuals who are underweight and could be 

healthier. And also, perhaps framing it with those obesity terms is 

sometimes a little bit disturbing to me. 

But the two facts that I wanted to share with us today is that 

the youth screen time is now up to 4.5 hours a day and youth fracture rates have increased 1 percent a year over the last 30 years. 

We no longer just have frail elderly, we have frail youth. And that 

fracture rate isn’t just coming from an increase in the TV show The 

Jackass and other things, it is coming from the diet and the lack 

of quality P.E. And by the way, the term for my P.E. program as 

a youth was P.E. for Strife. So I applaud the Grundy Center program. And at—trying to keep it short seeing that I have some quality individuals behind me, I’ll just sum that up. 

Mr. HENSLEY. Thank you, Senator Harkin. My name is Larry 

Hensley. I’m a professor of health and physical education at the 

University of Northern Iowa and I serve as the director of our 

newly-established Youth Fitness and Obesity Institute. What I’d 

like to do is just comment and reinforce some of the statements 

that were made earlier. 

Dr. Baranowski talked about the imbalance that occurs relative 

to medical funding and expenditures for health services or sick care 

compared to prevention. The $1.5 trillion that’s the national health 

care cost according to my figures, about 95 percent of that is directed towards sick care and only 5 percent towards prevention. 

That needs to be changed. And along those areas we talked about 

obesity, it’s important to recognize that both dietary behaviors and 

physical activity behaviors are important components and important factors in contributing to obesity. We also need to see balanced 

funding and balanced support for both areas. Dietary behaviors as 

well as physical activity. 

In the presentation that Mr. Schupbach made, and I must comment that Rick is a former student of mine and so I’m very proud 

of his work in Grundy Center. He talked about the potential that 

physical education programs have in helping arrest the overweight 
48 

and obesity crisis. Unfortunately, and it’s been mentioned previously, the current Federal education legislation, No Child Left 

Behind, does more to marginalize the physical education and as a 

result of this what we’re seeing is, we’re beginning to see dollars 

and funds shifted from physical education, I could talk about art 

education and music education as well, into other areas that are 

deemed to be more important. So this needs to be investigated and 

looked at very carefully. 

Last, I would suggest to you that with all the different health 

promotion initiatives that are underway, some very innovative initiatives, we certainly need policy to support these health initiatives 

and individual change initiatives. 

Thank you very much. 

Senator HARKIN. Thank you very much. 

Ms. KLINE. Susan Kline. I’m a nutrition and health field specialist for Iowa State University Extension. And I wanted to share 

something—I felt compelled to share something with you when you 

mentioned that vegetables and fruits are expensive, one of the most 

expensive things we can buy. At Extension, we go around trying to 

teach people about food selection and the importance of nutrition, 

and I want to share with you this little thought. If you bought a 

bag of taco chips, they often will cost $3. I’m not really sure how 

much they weigh but, for that same $3, if you bought bananas at 

49 cents a pounds, which I guess is kind of expensive, if you ask 

me, and you figure there are about four bananas to a pound, you 

could buy, for that $3 of taco chips you could buy 24 bananas. So 

I don’t really think, in comparing fresh fruits and vegetables and 

cost to other items that that’s—we need to put away the myth that 

fresh fruits and vegetables or that fruits and vegetables are expensive. They aren’t really expensive, they are just something that, 

when we buy them every week, maybe we have more spoilage is 

why we think it’s expensive. 

Senator HARKIN. Very good point. Thank you very much. That’s 

good, that’s good. 

Ms. GARRETT-HOFFMAN. Hi. My name is Nida Garrett-Hoffman. 

I’m one of the diabetes nurses at Mercy Medical Center. And one 

of the things several of you mentioned about diabetes and the tremendous epidemic that we are having with diabetes, we have 18 

million people already who have diabetes; we have about 40 million 

people who are at the stage of pre-diabetes or metabolic syndrome. 

At this particular time we don’t have any diabetes education coverage for diabetes education for these people. We have found that 

if we don’t get to these people they still have the risk of developing 

complications of diabetes that the people who have diabetes do. I’m 

asking that somehow we get some coverage, medical coverage for 

diabetes education, for pre-diabetes and metabolic syndrome. 

Thank you. 

Senator HARKIN. Hmm. That’s a good suggestion. 

Mr. OLSEN. Just comment and I contrast that with the cost of dialysis, for one patient a year. And look at that versus diabetic 

treatment. 

Senator HARKIN. Say it again? 

Mr. OLSEN. I said contrast that with the cost of treating one dialysis patient for a year. Have your staff look that up. 
49 

Senator HARKIN. What? 

Mr. OLSEN. Just how much it costs to treat one person on dialysis for 1 year. I can send it to you if you don’t have it. 

Senator HARKIN. Okay. All right. 

Ms. HECKENLAIBLE. I’m Suzanne Heckenlaible. It’s H-E-C-K-E-NL-A-I-B-L-E. And the director of Field Services Public Affairs for 

the March of Dimes, which is to improve the health of babies and 

their mothers by preventing birth defects and infant mortality. And 

Senator Harkin, we’d like to thank you for your support of Federal 

funding for the birth defects registry prevention programs and research. And as you know, in the State of Iowa we have a Center 

for Excellence here that does research with the Department of Public Health and we appreciate your support of that program. As you 

know, we have had significant reduction in neural tube defects, 

which is, the reduction is due to folic acid consumption. And we encourage you to continue to support the research and prevention 

programs in regards to birth defects in Federal funding. So thank 

you. 

Senator HARKIN. Thank you. 

Ms. HUNTINGTON. I’m Jenny Huntington from Ames. I work for 

the Child Nutrition Programs at the Iowa Department of Education. I want to thank you for your support, your continued and 

long-term support, of the Child Nutrition Programs. These include 

programs for school children and also adults in day care and children in day care, both in homes and in child care centers. These 

are essential programs for our children and we really do appreciate 

your support, and the people of Iowa do. 

We also appreciate your support for Teen Nutrition, which is a 

grant program and a special nutrition education effort from USDA. 

Iowa has been fortunate enough to receive a number of Teen Nutrition grants for both schools and child care. From the beginning 

grant we have linked improved nutrition with increasing physical 

activity in our grant process, and we have also focused, in some of 

the grants, on efforts to work with child nutrition in early childhood programs. One of the things that we developed through these 

grants is a tool for people in early childhood to increase physical 

activity and increase healthy snacks is a set of 60 cards that have 

a physical activity on one side of each card and a healthy snack on 

the other side of each card. And they’re held together with a ring. 

These cards are kind of expensive to print but they are all available through Iowa Public Television, on the Ready to Learn site. 

Anyone in Iowa and anyone in the Nation can download these 

cards and use them in their child development programs. We also 

have developed policy cards where we are encouraging child care 

organizations to not only serve healthy foods but make sure they’re 

not selling candy for fundraising. And so we’re looking at policies 

in child care and we have lessons. These are all sets of cards that 

we have developed through Teen Nutrition. Thank you very much. 

We’ve had at least 11 States that have requested reprinting of 

these cards; we’re hoping the National Food Service Management 

Institute will take it on and distribute them for us. 

Senator HARKIN. Thank you. I just want to mention one other 

thing. I’ve forgotten the ingredient but it was mentioned that the 
50 

fractures in kids that have gone up 1 percent per year, the last several years; is that what you said? 

Mr. LAYTON. One percent a year, Senator, over the last 30 years. 

Senator HARKIN. I didn’t know that exactly but I had heard 

about the increased fractures among kids; I sort of asked some 

questions about this at earlier hearings and different forums. And 

it was brought to my attention, Dr. Baranowski, that the increased 

consumption of sodas—soda contains phosphoric acid. Phosphoric 

acid leeches calcium out of your system. So the more phosphoric 

acid that you take in, the more calcium leeched out of your bones 

and that is one of the reasons why, some scientists believe that 

kids are having softer bones these days, because they’re drinking 

so much soda pop. 

(Inaudible response off-mike) 

Senator HARKIN. If what? 

(Inaudible response off-mike) 

Senator HARKIN. No but—— 

Mr. LAYTON. We brought one for you. 

Senator HARKIN. I have a lot of pedometers. I just keep misplacing them, that’s all. But thank you, anyway. 

Well listen. Thank you all very much. I want to thank all of you. 

Dr. Baranowski, thank you for coming all the way from Texas, and 

thank you for your continued work on a national basis on these 

issues. We appreciate it very much. 

We’re going to do a little walk here, around the track up here 

at AIB I want to thank, again, I want to thank Vernon Delapeace, 

thank you very much, the C.E.O. of the YMCA of Greater Des 

Moines. I want to thank the staff of the YMCA, who’s arrived; 

they’re all back there in their tee-shirts. Thank you for being here. 

And they’re going to join us on the walk. You’re all invited to join 

us if you would like. We’re just going to do a little walk around up 

there and I’ll see if their pace is like my pace. And I have a heart 

monitor on; I don’t know what that’s all about. 

Dr. BARANOWSKI. I’ll explain it to you. 

Senator HARKIN. What? 

Dr. BARANOWSKI. I’ll explain it to you. 

Senator HARKIN. Oh, you’re going to explain it to me? 

Dr. BARANOWSKI. Yes, I am. 

Senator HARKIN. Here or later? 

Dr. BARANOWSKI. As you start. 

Senator HARKIN. Oh, as I start you’re going to explain it. All 

right. But again, I’d just close by just saying that this is—I don’t 

think there really is a more important issue facing us as Americans, health-wise, than this issue of healthy lifestyles and prevention. If we keep going the way we’re going there’s just no way that 

we’re going to be able to fund the sick care system we have in 

America; it’s going to bust us. When we know. I mean, the science 

is there, the data’s there. This is not just speculation; we know that 

if people eat right, exercise right they’re going to be healthier, 

they’re going to prevent chronic illnesses and diseases more often, 

and it’s going to save us money plus people are just going to have 

better lives. I think we got off the track, some years ago, I guess 

when schools changed and stuff but I was like some of you, when 

I was in school, I mean, we had two recesses and a lunchtime and 
51 

we could never stay inside. Well, maybe if it was 20 degrees below 

and it was a blizzard maybe we could stay inside; otherwise we 

were out. And that was just our exercise, every week, when I was 

in grade school here in the State of Iowa. I don’t think you find 

that any longer like that. And so we grew up and of course, being 

in the military and that helped too, promote physical activity and 

physical exercise. But we’ve just gotten so sedentary with everything, televisions and, as I said, now we don’t, we no longer bike, 

we don’t have bike paths, we don’t even have sidewalks, we don’t 

have walking paths for people. Everything we’ve done has been to 

encourage a more sedentary lifestyle. And now you can buy a 

Sequeway; you don’t even have to walk anymore, you got to go to 

two-wheelers and just ride it wherever you want to go. It may have 

some benefits someplace but at a time when we’re trying to encourage people to get out and walk more, I don’t know. 

So I just don’t think anything’s more important than this in 

terms of both the health of our people and the health of our economy, and having a health care system that really is a health care 

system. We keep looking, I keep looking for suggestions, advice; 

I’ve gotten some good input here this morning on, you know, what 

needs to be done and steps to be taken. I think this may be another 

instance where the government, the government so to speak, those 

of us in government, are behind. I think we’re seeing more of this 

coming from the grassroots up, people are demanding that they 

want a healthier lifestyle, they want to have physical activity, they 

want to have wellness programs and I think those in public office 

are going to have to start responding to that very, very soon and 

do what people want. And that is provide in workplaces, providing 

incentives for businesses to have wellness programs for all their 

employees; communities, on a community basis I mentioned 

schools, pre-school, but it has to be that kind of a comprehensive 

approach. And we can’t put it off any longer. I think we’ve just got 

to have some real focus on this and we’ve got to bring this country 

together to move us as rapidly as possible in this direction. 

So again, I thank you all for being here. And you’re all invited 

to join us on the walk if you like. 

With that, the subcommittee—unless I have anything else—I 

want to thank, first of all, Jenelle Krishnamoorthy right here behind me and Ellen Murray, my two staff people who do all this 

work and keep me advised and informed and get witnesses together and basically have been two of the great leaders in the U.S. 

Senate on health care. A lot of times we get the acclaim and we 

get the applause and stuff but they’re really the ones that do the 

work and we want to publicly thank both of them for all their 

work. 

CONCLUSION OF HEARING

Thank you all very much for being here. That concludes our 

hearing. 

[Whereupon, at 11:40 a.m., Friday, April 16, the hearing was 

concluded, and the subcommittee was recessed, to reconvene subject to the call of the Chair.] 

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