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CHILDHOOD OBESITY: THE DECLINING HEALTH 

OF AMERICA’S NEXT GENERATION—PART I 

HEARING 

BEFORE THE

SUBCOMMITTEE ON CHILDREN AND FAMILIES 

OF THE

COMMITTEE ON HEALTH, EDUCATION, 

LABOR, AND PENSIONS 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

ON

EXAMINING CHILDHOOD OBESITY, FOCUSING ON THE DECLINING 

HEALTH OF AMERICA’S NEXT GENERATION (PART I) 

JULY 16, 2008 

Printed for the use of the Committee on Health, Education, Labor, and Pensions 

( 

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

COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS 

EDWARD M. KENNEDY, Massachusetts, Chairman 

CHRISTOPHER J. DODD, Connecticut 

TOM HARKIN, Iowa 

BARBARA A. MIKULSKI, Maryland 

JEFF BINGAMAN, New Mexico 

PATTY MURRAY, Washington 

JACK REED, Rhode Island 

HILLARY RODHAM CLINTON, New York 

BARACK OBAMA, Illinois 

BERNARD SANDERS (I), Vermont 

SHERROD BROWN, Ohio 

MICHAEL B. ENZI, Wyoming 

JUDD GREGG, New Hampshire 

LAMAR ALEXANDER, Tennessee 

RICHARD BURR, North Carolina 

JOHNNY ISAKSON, Georgia 

LISA MURKOWSKI, Alaska 

ORRIN G. HATCH, Utah 

PAT ROBERTS, Kansas 

WAYNE ALLARD, Colorado 

TOM COBURN, M.D., Oklahoma 

J. MICHAEL MYERS, Staff Director and Chief Counsel 

ILYSE SCHUMAN, Minority Staff Director and Chief Counsel 

SUBCOMMITTEE ON CHILDREN AND FAMILIES

CHRISTOPHER J. DODD, Connecticut, Chairman 

JEFF BINGAMAN, New Mexico 

PATTY MURRAY, Washington 

JACK REED, Rhode Island 

HILLARY RODHAM CLINTON, New York 

BARACK OBAMA, Illinois 

BERNARD SANDERS (I), Vermont 

EDWARD M. KENNEDY, Massachusetts (ex 

officio) 

LAMAR ALEXANDER, Tennessee 

JUDD GREGG, New Hampshire 

LISA MURKOWSKI, Alaska 

ORRIN G. HATCH, Utah 

PAT ROBERTS, Kansas 

WAYNE ALLARD, Colorado 

MICHAEL B. ENZI, Wyoming (ex officio) 

MARYELLEN MCGUIRE, Staff Director 

DAVID P. CLEARY, Minority Staff Director 

(II) 

C O N T E N T S 

STATEMENTS 

WEDNESDAY, JULY 16, 2008 

Page 

Dodd, Hon. Christopher J., Chairman, Subcommittee on Children and Families, opening statement ........................................................................................ 1 

Prepared statement .......................................................................................... 4 

Levi, Jeff, Ph.D., Executive Director of Trust for America’s Health, Washington, DC ............................................................................................................. 6 

Prepared statement .......................................................................................... 8 

Kaufman, Francine, M.D., Past National President of the American Diabetes 

Association, Distinguished Professor of Pediatrics and Communications at 

the Keck School of Medicine and the Annenberg School of Communications 

at the University of Southern California, Los Angeles, CA ............................. 13 

Prepared statement .......................................................................................... 15 

Grey, Margaret, DrPH, R.N., FAAN, Dean and Annie Goodrich Professor, 

Yale School of Nursing, New Haven, CT ........................................................... 18 

Prepared statement .......................................................................................... 20 

Lesley, Bruce, President, First Focus, Washington, DC ....................................... 22 

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

Harkin, Hon. Tom, a U.S. Senator from the State of Iowa, statement ............... 29 

Prepared statement .......................................................................................... 30 

Murkowski, Hon. Lisa, a U.S. Senator from the State of Alaska, statement ..... 30 

Bingaman, Hon. Jeff, a U.S. Senator from the State of New Mexico, statement ...................................................................................................................... 31 

(III) 

(1) 

CHILDHOOD OBESITY: THE DECLINING 

HEALTH OF AMERICA’S NEXT 

GENERATION—PART I 

WEDNESDAY, JULY 16, 2008 

U.S. SENATE, 

SUBCOMMITTEE ON CHILDREN AND FAMILIES, COMMITTEE ON

HEALTH, EDUCATION, LABOR, AND PENSIONS, 

Washington, DC. 

The subcommittee met, pursuant to notice, at 2:31 p.m. in Room 

SD–430, Dirksen Senate Office Building, Hon. Christopher Dodd, 

chairman of the subcommittee, presiding. 

Present: Senators Dodd, Bingaman, and Murkowski. 

Also Present: Senator Harkin. 

OPENING STATEMENT OF SENATOR DODD

Senator DODD. The committee will come to order. 

Well, first of all, let me thank our witnesses, and also I want to 

welcome the rather large audience here in this committee room. I 

am particularly pleased to see so many young people here. We have 

opened up the back room as well. For those of you standing here, 

as seats become available, the staff will try and make it more 

available. 

Had I known we were going to have this much interest in the 

subject matter, I would have tried to secure a larger room. I apologize to all of those of you who are standing and showed up for today’s hearing, but I am very grateful to all of you. 

My colleague from Tennessee, Senator Lamar Alexander, I know 

is going to try and make it over here with us for this hearing, and 

I suspect we will be seeing Senator Harkin as well, who has a deep 

interest in the subject matter that is the theme of our hearing this 

afternoon. 

The subject, ‘‘Childhood Obesity: The Declining Health of America’s Next Generation—Part I.’’ My intention is to have a series of 

hearings, at least two immediately and possibly more, on this subject matter as we examine the health condition of the next generation. 

As many have concluded, as I will share in my opening comments, this generation of the younger generation in this country 

may be the first generation of Americans in the history of our country that is less healthy than their parents. That is a statistic and 

a conclusion that is deeply troubling to all of us. 

I welcome you here today for what is the first, as I mentioned, 

of two important hearings on one of the most urgent threats to 

2 

American children, the childhood obesity epidemic. The numbers 

are, quite frankly, stunning—absolutely stunning. No other word 

could be used other than that to describe it. 

Nearly one out of every three of America’s children are obese or 

are at the risk of becoming obese—25 million children in all, with 

children in minority families at an even greater risk in our country. 

It is the most common disease of childhood, and we are told it is 

largely preventable. 

Nationally, the childhood obesity rate tripled between 1980 and 

2004. In many States, especially those in the South and the Midwest, the rates are even much worse. Even in States where childhood obesity rates are among the lowest in the Nation, like Colorado and my home State of Connecticut, the rates are appallingly 

high—even in relatively good States. 

As a parent, these findings are deeply troubling to me—as they 

should be, of course, to every parent, every person in this country— 

because this is about so much more than numbers and statistics. 

Most public health experts believe, and the New England Journal 

of Medicine recently warned, that unless we act as a nation, our 

children’s generation may be the first in the modern era to live 

shorter, less healthy lives than those of their parents. That is a 

possibility we should all be ashamed of as Americans. 

Already the health consequences are crystal clear. Right now, 

children are increasingly being diagnosed with type 2, ‘‘adult-onset’’ 

diabetes, high blood pressure, and high cholesterol levels. The list 

goes on: stroke, certain types of cancers, osteoarthritis—is that how 

you pronounce it?—certain liver diseases. You don’t have to be a 

health expert to know that these are not diseases we normally associate with children. 

We all can point to reasons why this is happening. Junk food is 

rampant and marketed to children. Television has paved the way 

for children to have more sedentary lifestyles. We surround our 

public schools with soft drink machines and fast food restaurants, 

which local schools allow because they are often so underfunded 

they turn to corporate sponsors for financial assistance. 

It doesn’t help that only 8 percent, only 8 percent of our elementary schools in this country even require daily physical activity, 

and only 6 percent of middle and high schools do as well. At the 

same time, our investment in public parks, bike paths, playgrounds, and other kinds of infrastructure that encourage physical 

activity has deteriorated. 

According to the 2004 National Survey of Children’s Health, between 25 to 40 percent of children over the age of 9 get less than 

1 hour of physical activity a week, depending upon the State they 

live in. A new report released by the National Institute of Child 

Health and Human Development and published in the Journal of 

the American Medical Association shows that the vast majority of 

15-year-olds do not come close to getting the recommended 60 minutes of physical activity a day. 

Childhood obesity is a problem that affects all of us, whether we 

have children or not. One day every one of these children are going 

to grow into adulthood, and odds are that every one of the health 

problems that started when they were children are only going to 

get worse. We are all going to be paying the bill. 

3 

If you are not impressed by the human dimension of this, then 

consider the financial costs. The obese spend 36 percent more on 

health care. They spend 77 percent more on medications. That 

means the costs for all of us are going to keep heading upwards. 

They already are. Health care spending has exploded, as many 

know, in the last 20 years, and 1 out of every 4 of those added dollars has gone to treat obesity-related problems. That is 

unsustainable as a nation. The question, of course, is what are we 

going to do about it as a nation? 

These hearings, these two hearings we will be holding are our 

first step in this subcommittee. Today, we will make sure we understand what is happening and why. Next week, I will hold a second hearing in which we will focus on what needs to be done to 

stem the current tide and who could and should be doing it, from 

the individual to the private sector, from State and local governments obviously to the national government as well. 

All of us—parents, schools, government, employers—need to see 

the rising childhood obesity rates for what they are. This is a medical emergency, and it is time that we worked together to do something about it. 

I am delighted that we are joined or will be joined by my colleague from Iowa, Senator Harkin, who I mentioned a moment ago, 

has devoted a great deal of his time to this issue. As the Chairman 

of the Agriculture Committee of the U.S. Senate and who sits on 

the Appropriations Committee, he has been working diligently over 

the last number of years to try and develop better nutrition programs, support more organic farming, and other issues which could 

help considerably to deal with some of the issues that are associated with obesity. 

I want to thank him and I want to thank again Senator Alexander, who is also very interested in the subject matter, for their 

support of this effort. 

With that, I want to turn to our witnesses and again thank them 

for being with us today. Let me introduce them for all of you. 

Jeff, is it ‘‘Lee vee’’—do you pronounce it ‘‘Lee vee? ’’—Jeff Levi. 

Dr. Levi is the executive director of Trust for America’s Health. He 

is also an associate professor at George Washington University’s 

Department of Public Health, and he previously served as the deputy director of the White House Office of National AIDS Policy. He 

has a Master’s from Cornell University and a Ph.D. from George 

Washington University. 

Trust for America’s Health, or TFAH, advocates for a modernized 

public health system and addresses many of the critical problems 

threatening the health of our Nation. Each year, TFAH issues a remarkable report on obesity. It is called ‘‘F as in Fat.’’ We look forward to sharing the findings of this report, and of course, thank 

you, Doctor, for being with us. 

Francine Kaufman, Dr. Kaufman, is a pediatric endocrinologist. 

Dr. Kaufman is a distinguished professor of pediatrics and communications at the Keck—is it Keck?—Keck School of Medicine and 

the Annenberg School of Communications at the University of 

Southern California. She also serves as the director of the Comprehensive Childhood Diabetes Center and is head of the Center 

4 

for Endocrinology, Diabetes, Metabolism at Children’s Hospital in 

Los Angeles. 

Dr. Kaufman served as national president of the American Diabetes Association from 2002 and 2003 and remains a very active 

volunteer in that effort. She is a foremost expert on the nexus of 

obesity and diabetes and is leading some of the world’s largest 

studies on diabetes. She was elected to the Institute of Medicine in 

2005 and has received numerous prestigious awards for her research and leadership. We thank you, Doctor, as well. 

Next we have Margaret Grey. She is from Connecticut, a constituent of mine. I am delighted she is with us. Dr. Grey is Dean 

at the Yale Nursing School, the Annie Goodrich Professor, and a 

pediatric nurse practitioner. She holds a master’s of science in pediatric nursing from Yale University and a doctorate in public health 

and social psychology from Columbia University. 

Dr. Grey’s work and leadership has been recognized by countless 

esteemed awards and honors. She was also elected to the Institute 

of Medicine in 2005. Her research focuses on behavioral aspects of 

children with diabetes and behavioral interventions that can help 

prevent and control diabetes in youth. We look forward to hearing 

from you as well, and thank you very much. 

Bruce Lesley is someone who needs little introduction to folks 

around here, and we thank you once again for being before us. He 

has spent 12 years on Capitol Hill working on the Senate Finance 

Committee and the HELP Committee, the very committee we are 

in today, as well as with numerous members, including our colleague Jeff Bingaman, who I hope will be able to get by a little 

later in this hearing. 

Long an advocate of the needs of children, he is currently the 

president of First Focus, a group that works to ensure that children 

and families remain on the agenda of the Federal Government. 

Bruce lives in Maryland with his wife and children. We welcome 

you back to the committee. Good to have you with us. 

Let me ask each of you, if you would, to make your opening 

statements. I want you all to know that whatever other supporting 

documentation you think would be helpful, as we start to build this 

record in the committee, will be made a part of the record. 

If you can—I am not going to wave a gavel around at you here, 

but if you could try and keep your remarks to 5 or 7 minutes or 

so, so we can get through the opening statements and then have 

a good conversation. 

Since we are not overloaded with members here today, I want to 

encourage sort of the informality of talking back and forth without 

rudely interrupting each other. If you have additional thoughts, if 

I ask one question, don’t be quiet about this. This is an opportunity 

for us to lay out a good record that I hope will be the beginning 

of some very positive developments on this issue as well. 

PREPARED STATEMENT OF SENATOR DODD

First, I want to welcome my colleagues and our distinguished 

witnesses, and thank them for being here today. Today we are 

holding the first of two important hearings on one of the most urgent threats to American children—the childhood obesity epidemic. 

5 

The numbers are stunning. Nearly 1 out of every 3 of America’s 

children are obese or are at risk of becoming obese—25 million children in all, with children in minority families at an even greater 

risk. It is the most common disease of childhood and we’re told it’s 

largely preventable. Nationally, the childhood obesity rate tripled 

between 1980 and 2004. And in many States, especially those in 

the South and the Midwest, the rates are much worse. Even in 

States where childhood obesity rates are among the lowest in the 

Nation, like Colorado or my home State of Connecticut, the rates 

are appallingly high. 

As a parent, these findings deeply worry me—as they should 

every parent in America—because this is about so much more than 

numbers and statistics. Most public health experts believe, and the 

New England Journal of Medicine recently warned, that unless we 

act, our children’s generation may be the first in the modern era 

to live shorter, less healthy lives than their parents. That is a possibility we should all be ashamed of. 

Already the health consequences are crystal clear. Right now, 

children are increasingly being diagnosed with type 2, ‘‘adult-onset’’ 

diabetes, high blood pressure and high cholesterol. The list goes 

on—stroke, certain types of cancers, osteoarthritis, certain liver 

diseases. You don’t have to be a health expert to know that these 

are not diseases we normally associate with children. 

We all can point to reasons why this is happening. Junk food is 

rampant and marketed to kids. Television has paved the way for 

kids to have a more sedentary lifestyle. We surround our public 

schools with soft drink machines and fast food restaurants—which 

local schools allow because they are often so underfunded they turn 

to corporate sponsors for financial assistance. 

It doesn’t help that only 8 percent of elementary schools even require daily physical activity—only 6 percent of middle and high 

schools. At the same time, our investment in public parks—in bike 

paths, playgrounds and other kinds of infrastructure that encourage physical activity—has deteriorated. According to the 2004 National Survey of Children’s Health, between 25 to 40 percent of 

children over the age of 9 get less than one hour of physical activity 

a week, depending on the State. And a new report released by the 

National Institute of Child Health and Human Development 

(NICHD) and published in the Journal of the American Medical Association today shows that the vast majority of 15 year olds do not 

come close to getting the recommended 60 minutes of physical activity a day. 

Childhood obesity is a problem that affects all of us—whether we 

have kids or not. One day every one of these kids is going to grow 

into an adult—and odds are that every one of the health problems 

that started when they were kids is going to get worse. 

And we’re all going to be paying the bill. The obese spend 36 percent more on health care—they spend 77 percent more on medications. That means the costs for all of us are going to keep heading 

up. They already are. Health care spending has exploded in the 

last 20 years—and 1 out of every 4 of those added dollars has gone 

to treat obesity-related problems. That is unsustainable. The question is: what are we going to do about it? 

6 

These hearings are our first step. Today we’ll make sure we understand what is happening and why. Next week we will focus on 

what needs to be done to stem the current tide and who could and 

should be doing it, from the individual to the private sector, from 

State and local government to the Federal Government. All of us— 

parents, schools, government, employers—need to see the rising 

childhood obesity rates for what they are: a medical emergency. It 

is time we worked together to do something about it. 

I am delighted that we are joined by Senator Harkin. He has 

been tireless in his efforts to bring this issue to Congress’ attention 

and find innovative solutions to this epidemic. I want to thank my 

partner in this venture, the Ranking Member of the Subcommittee, 

Senator Alexander, who also has a very real concern about these 

issues. 

Senator DODD. With that, Dr. Levi, we thank you very much for 

joining us, and the floor is yours. 

STATEMENT OF JEFFREY LEVI, PH.D., EXECUTIVE DIRECTOR 

OF TRUST FOR AMERICA’S HEALTH, WASHINGTON, DC 

Mr. LEVI. Thank you, Mr. Chairman, and thank you very much 

for this opportunity to testify on this very serious issue of the declining health of America’s children, which is closely linked to our 

Nation’s obesity epidemic. 

As you noted, approximately 25 million children are obese or 

overweight, and rates of obesity have more than tripled since 1980. 

While a recent analysis from the National Health and Nutrition 

Examination Survey, known as NHANES, suggests that the number of U.S. children who are overweight or obese may have peaked 

after years of steady increases, scientists and public health officials 

are unsure if the data reflect real change or a statistical anomaly. 

Even if childhood obesity rates have peaked, the number of children with unhealthy BMIs remains unacceptably high, and the 

public health toll of childhood obesity will continue to grow as the 

problems related to overweight and obesity in children show up 

later in life. This will also threaten our economic competitiveness 

as a nation as our healthcare costs continue to rise, in part, due 

to obesity and overweight. 

How did this problem arise? In the simplest terms, one could 

argue this is just a matter of physics. Children today are eating 

more and moving less, which inevitably leads to increases in 

weight. That is true, but it is only a part of the story. 

We have also created a physical environment that re-inforces a 

less-active lifestyle, and we have not compensated for this in the 

level of physical activity we promote in the schools. Thirty years 

ago, nearly half of American children walked or biked to school. 

Today, less than one in five do so. 

Children are also not getting enough activity in schools. According to CDC data, only 3.8 percent of elementary schools, 7.9 percent of middle schools, and 2.1 percent of high schools provided 

daily physical education or its equivalent. 

We have also placed kids in a less nutritious environment. It is 

not just too much food, but too much bad food that kids are eating. 

We have not harnessed the opportunities of the school to comVerDate Nov 24 2008 14:45 Jan 26, 2010 Jkt 035165 PO 00000 Frm 00010 Fmt 6633 Sfmt 6601 S:\DOCS\43703.TXT DENISE
7 

pensate for the overall propensity among Americans to consume too 

much sugar and too few fruits and vegetables. 

What occurs in schools can be critical, given the number of children who depend on school breakfast and lunch for their meals and 

the patterns that school food access can create for all children. Current food and meal nutrition guidelines lack standards for sodium, 

trans fat and whole grains, and the fruit and vegetable content is 

too low. Yet new guidance from the USDA is not expected until 

2010, despite a 2004 congressional requirement to issue new guidelines. 

We have placed a particular burden on our poor and minority 

children, who are disproportionately overweight and obese. Primarily because our poverty programs have not kept up with the 

rising cost of nutritious food, access to healthy food is often limited 

in poor neighborhoods, and physical activity may be limited because of safety concerns or inadequate recreational facilities. 

For example, African-American children are almost twice as likely to be obese. Similarly, the National Survey on Children’s Health 

shows that rates of overweight decline as income rises. In 2003, 

22.4 percent of kids below 100 percent of poverty were overweight, 

while only 9.1 percent of kids at 400 percent or more of poverty 

were overweight. 

I think this outline of the problem shows that it will take more 

than telling kids to eat less and move more. We need a national 

commitment to change the physical and social environment in 

which children live, and all Americans will benefit from living in 

healthier communities. We must make healthy choices easy choices 

for all Americans, regardless of where they live or what school they 

attend. We need a cultural shift, one in which healthy environments, physical activity, and healthy eating become the norm. 

Tomorrow, Trust for America’s Health will release a new report 

that examines how much the country could save by strategically investing in community disease prevention programs. The report concludes that an investment of $10 per person per year in proven 

community-based programs to increase physical activity, improve 

nutrition, and prevent smoking and other tobacco use could save 

the country more than $16 billion in healthcare costs annually 

within 5 years. This is a return of investment of $5.60 cents for 

every $1 invested. 

Harnessing this opportunity will require a true national strategy 

to combat obesity. At this time, we have no such national coordinated effort. It is time for a comprehensive, realistic plan that involves every department and agency of the Federal Government, 

State and local governments, businesses, communities, schools, 

families, and individuals. 

Our leaders should be challenged to do their part to improve our 

Nation’s health. We know that even small changes can make big 

differences in people’s health. The challenge is a big one, but we 

can make a difference together. 

Thank you again for the opportunity to testify, and I look forward to the discussion that follows. 

[The prepared statement of Dr. Levi follows:] 

8 

1Ogden, C.L., M.D. Carroll, and K.M. Flegal. ‘‘High Body Mass Index for Age among U.S. 

Children and Adolescents, 2003–2006.’’ Journal of the American Medical Association 299, no. 20 

(2008): 2401–2405. 2 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. National Survey of Children’s Health 2003. Rockville, 

MD: U.S. Department of Health and Human Services, 2005, http://www.mchb.hrsa.gov/overweight/techapp.htm (accessed April 22, 2008). 3Ogden, C.L., M.D. Carroll, and K.M. Flegal. ‘‘High Body Mass Index for Age among U.S. 

Children and Adolescents, 2003–2006.’’ Journal of the American Medical Association 299, no. 20 

(2008): 2401–2405. 4 U.S. Department of Health and Human Services, National Center for Health Statistics. Prevalence of Overweight Among Children and Adolescents: United States, 1999. Hyattsville, MD: 

National Center for Health Statistics; 2001. http://www.cdc.gov/nchs/products/pubs/pubd/ 

hestats/overwght99.htm (accessed July 14, 2008). 

PREPARED STATEMENT OF JEFFREY LEVI, PH.D. 

Good afternoon. My name is Jeffrey Levi, and I am the Executive Director of 

Trust for America’s Health (TFAH), a nonpartisan, nonprofit organization dedicated 

to saving lives by protecting the health of every community and working to make 

disease prevention a national priority. I would like to thank the Chairman, the 

Ranking Member and the members of the subcommittee for the opportunity to testify on a very serious issue—the declining health of America’s children, which is 

closely linked to our Nation’s obesity epidemic. Today I would like to discuss the 

scope of childhood obesity in America, the potential factors that may be contributing 

to it, the health and economic impacts of obesity, and the importance of developing 

a national strategy to coordinate our response to obesity. By focusing on the impact 

of obesity on the health of our children, we have a chance to reshape society—and 

assure that our children live healthier lives than we do. If we do it right, I believe 

we will also improve the health and well-being of lots of adults in the process because the solutions to the obesity epidemic require a societal transformation that 

will benefit all of us. 

SCOPE OF THE PROBLEM

Overall, approximately 23 million children are obese or overweight, and rates of 

obesity have more than nearly tripled since 1980, from 6.5 percent to 16.3 percent.1

Eight of the 10 States with the highest rates of obese children are in the South.2

According to a recent analysis from the National Health and Nutrition Examination Survey (NHANES), the number of U.S. children who are overweight or obese 

may have peaked, after years of steady increases. According to researchers from the 

Centers for Disease Control and Prevention (CDC), there was no statistically significant change in the number of children and adolescents (aged 2 to 19) with high BMI 

for age between 2003–2004 and 2005–2006.3 This is the first time the rates have 

not increased in over 25 years. Scientists and public health officials, however, are 

unsure if the data reflect the effectiveness of recent public health campaigns to raise 

awareness about obesity and increased physical activity and healthy eating among 

children and adolescents, or if this is a statistical abnormality. Scientists expect to 

know more when the 2007–2008 NHANES data are analyzed. The 2005–2006 National Survey on Children’s Health, a large national survey with State-specific data, 

is also due out in late 2008 and may offer another perspective on childhood obesity 

rates. Even if childhood obesity rates have peaked, the number of children with 

unhealthy BMIs remains unacceptably high, and the public health toll of childhood 

obesity will continue to grow as the problems related to overweight and obesity in 

children show up later in life. We should be setting a national goal to see childhood 

obesity rates return to 6.5 percent, the level prior to the start of this epidemic.4

FACTORS CONTRIBUTING TO OBESITY RATES

How did this problem arise? In the simplest of terms, one could argue this is just 

a matter of physics—children today are eating more and moving less, which inevitably leads to increases in weight. That is true, but is only a part of the story. 

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

• We have placed kids in a less nutritious environment—it is not just too much 

food, but too much bad food that kids are eating, and we have not harnessed the 

opportunities of the school to compensate for this. 

• We have placed a particular burden on our poor and minority children, who are 

disproportionately overweight and obese, primarily because our poverty programs 

9 

5Putnam, J., J. Allshouse, and L.S. Kantor. ‘‘U.S. per Capita Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.’’ Food Review 25, no. 3 (2002): 1–14. 6 Briefel, R.R. and C.L. Johnson. ‘‘Secular Trends in Dietary Intake in the United States.’’ Annual Review of Nutrition 24, (2004): 401–431. 7Putnam, J., J. Allshouse, and L.S. Kantor. ‘‘U.S. per Capita Food Supply Trends: More Calories, Refined Carbohydrates, and Fats.’’ Food Review 25, no. 3 (2002): 1–14. 8 Asche, K. ‘‘Fast Foods May Increase Childhood Obesity Rates.’’ University of Minnesota Extension. (2005). http://www.extension.umn.edu/extensionnews/2005/fastfood.html (accessed 

July 14, 2008). 9McDonald, N.C. ‘‘Active Transportation to School: Trends among U.S. Schoolchildren, 1969– 

2001.’’ American Journal of Preventive Medicine 32, no. 6 (2007): 509–516. 10 U.S. Department of Health and Human Services (USDHHS). The Surgeon General’s Call 

to Action to Prevent and Decrease Overweight and Obesity. Washington, DC: USDHHS, 2001. 

have not kept up with the rising cost of nutritious food; access to healthy foods is 

often limited in poor neighborhoods, and physical activity may be limited because 

of safety concerns or inadequate recreational facilities. 

To reverse this trend, we need a national commitment to change the physical and 

social environment in which children live. By doing so, we will also help adults— 

as all Americans benefit from living in healthier communities. 

The following is a sketch of the scope of the problem and some possible solutions. 

Our annual report on obesity, F as in Fat: How Obesity Policies Are Failing in 

America, is available at our Web site, www.healthyamericans.org, and provides a 

more comprehensive look at these issues. The 2008 edition will be released in August. 

Food and Physical Activity 

Many American children are consuming more calories, eating less healthful foods, 

engaging in less physical activity and instead spending their time engaging in sedentary activities. Overall, ‘‘added sugar’’ consumption for Americans is nearly three 

times the U.S. Department of Agriculture’s (USDA) recommended level,5 and adolescent females ages 12–15 consumed approximately 4 percent more calories in 1999– 

2000 than they did in 1971–1974.6 In 2003, a USDA report characterized America’s 

per capita fruit consumption as ‘‘woefully low’’ and noted that vegetable consumption ‘‘tells the same story.’’ 7 Moreover, since the 1970s, fast food consumption in 

children has increased five-fold. In the late 1970s, children received approximately 

2 percent of their daily meals from fast food; by the mid-1990s, that increased to 

10 percent. Children who consume fast food, as compared with those who do not, 

have higher caloric intake, more fat and saturated fat, and more added sugar.8

In addition to developing poor dietary habits, many children are becoming less 

physically active. For example, 30 years ago, nearly half of American children 

walked or biked to school; today, less than one in five either walk or bike to school.9

Increased screen time—whether television or computers—is associated with higher 

rates of overweight and obesity. Furthermore, according to the CDC’s latest School 

Health Policies and Programs Study, only 3.8 percent of elementary schools, 7.9 percent of middle schools and 2.1 percent of high schools provided daily physical education or its equivalent. Some attribute at least part of this decline in physical activity programs to the academic requirements of No Child Left Behind. That is unfortunate as there is growing evidence that fitter more active students perform better 

academically. 

Health Impacts 

The health impacts of obesity and physical inactivity are dire and can start at a 

young age. Physical inactivity is tied to heart disease and stroke risk factors in children and adolescents. A number of studies have documented how obesity increases 

a child’s risk for a number of health problems, including the emerging onset of type 

2 diabetes, increased cholesterol and hypertension among children, and the danger 

of eating disorders among obese adolescents.10 Some studies have shown that obesity and overweight in children also negatively affect children’s mental health and 

school performance. The recent recommendation by the American Academy of Pediatrics for cholesterol screening of kids—with the possibility of prescription of cholesterol lowering drugs for young children—is just another tragic example of how much 

obesity has affected the health of our children. 

Economic Impact 

These health impacts come at a great cost to our Nation. According to the Department of Health and Human Services, obese and overweight adults cost the United 

10 

11 U.S. Centers for Disease Control and Prevention. ‘‘Preventing Obesity and Chronic Diseases 

Through Good Nutrition and Physical Activity.’’ U.S. Department of Health and Human Services, http://www.cdc.gov/nccdphp/publications/factsheets/Prevention/obesity.htm (accessed 

July 14, 2008). 12 Ibid. 13 Hsu, L.L., R.L. Nevin, S.K. Tobler, and M.V. Rubertone. ‘‘Trends in Overweight and Obesity 

among 18-Year-Old Applicants to the United States Military, 1993–2006.’’ The Journal of Adolescent Health 41, no. 6 (2007): 610–612. 14 Cable News Network. ‘‘Discharged Servicemen Dispute Military Weight Rules.’’ CNN.com, September 6, 2000. http://www.cnn.com/2000/HEALTH/09/06/military.obesity/index.html 

(accessed May 2, 2008). 15 U.S. Centers for Disease Control and Prevention (CDC). ‘‘Barriers to Children Walking and 

Biking to School—United States, 1999.’’ Morbidity and Mortality Weekly Report 51, no. 32 

(2002): 701–704. 16 U.S. Department of Agriculture (USDA). Incorporating the 2005 Dietary Guidelines for 

Americans into School Meals. SP 04–2008. Washington, DC: USDA, 2007. 

States anywhere from $69 billion to $117 billion per year.11 One study found that 

obese Medicare patients’ annual expenditures were 15 percent higher than those of 

normal or overweight patients. The cost of childhood obesity is also growing. Between 1979 and 1999, obesity-associated hospital costs for children (ages 6 to 17 

years) more than tripled, from $35 million to $127 million.12

The poor health of Americans of all ages is putting the Nation’s economic security 

in jeopardy. More than a quarter of U.S.-health care costs are related to physical 

inactivity, overweight and obesity. Health care costs of obese workers are up to 21 

percent higher than non-obese workers. Obese and physically inactive workers also 

suffer from lower worker productivity, increased absenteeism, and higher workers’ 

compensation claims. To maintain our economic competitiveness and our general 

health and well-being, we must improve the health of America’s next generation. To 

do that, we must improve diet and physical activity levels. 

National Security Impact 

The problem of obesity and overweight has reduced the number of volunteers for 

military service who must meet height and weight requirements. At a time when 

military recruiters are struggling to meet the needs of our Armed Forces, we are 

finding more and more volunteers who are overweight and obese. In 1993, 25.6 percent of 18-year-old volunteers were overweight or obese; in 2006 that percentage 

rose to almost 34 percent.13 This problem continues during active duty. Each year 

between 3,000 and 5,000 service members are forced to leave the military because 

they are overweight.14

An Environment That Discourages Physical Activity and Healthy Eating 

The built environment and community design can have a great impact on nutrition and physical activity levels. For children, the placement of schools and access 

to safe venues for physical activity are particularly important. One study found that 

the primary reason that children do not walk or bike to school is because their 

school is too far away. Other concerns included too much traffic, no safe route, fear 

of abduction, crime in the neighborhood, and lack of convenience.15 A Government 

Accountability Office study found that ‘‘areas of low socioeconomic status and high 

minority populations had fewer venues for physical activity’’ and ‘‘adolescents in unsafe neighborhoods engage in less physical activity’’ than their peers. Even where 

opportunities for physical activity may be available—such as school playgrounds— 

many communities are encountering liability concerns as an impediment to afterhours use of these community resources. 

Access to nutritious foods is another important issue that can affect children’s 

health. Everything from the foods sold in schools to the presence or absence of grocery stores and markets selling fresh fruits and vegetables in communities to the 

foods that parents serve to their children can influence obesity levels and ultimately 

health care costs. 

What occurs in schools can be critical—given the number of children who depend 

on school breakfast and lunch for their meals and the patterns that school food access can create for all children. In 2004, the Child Nutrition and WIC Reauthorization Act of 2004 (P.L. 108–265) required the U.S. Secretary of Agriculture to issue 

school nutrition guidelines that would ensure that American schoolchildren consume 

foods recommended in the most recent Dietary Guidelines for Americans (DGAs); 

however, USDA has issued no proposed regulations in the 3 years since the release 

of the 2005 DGAs.16 Instead, USDA contracted with the Institute of Medicine (IOM) 

to convene a panel of experts on child nutrition. In late 2009, the IOM Committee 

on Nutrition Standards for School Lunch and Breakfast Programs is expected to 

provide USDA with recommendations for updating the school meal programs’ nutriVerDate Nov 24 2008 14:45 Jan 26, 2010 Jkt 035165 PO 00000 Frm 00014 Fmt 6633 Sfmt 6621 S:\DOCS\43703.TXT DENISE
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17 U.S. Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. National Survey of Children’s Health 2003. Rockville, MD: U.S. Department of Health and Human Services, 2005. 18 U.S. Centers for Disease Control and Prevention. ‘‘Youth Risk Behavior Surveillance— 

United States, 2007.’’ Morbidity and Mortality Weekly Report 57, no. SS–4 (2008): 1–136. 

tion requirements. Once USDA receives the IOM recommendations, agency officials 

will then seek to incorporate them into formal USDA guidance, which is expected 

to be issued some time in 2010. A final rule will take even longer to be issued. This 

turn of events effectively postpones the update of school meal nutrition standards 

by 5 years beyond when they were due. Given the fact that school meal nutrition 

standards lack standards for sodium, trans fat, and whole grains, and that the fruit 

and vegetable content is too low, this delay is of considerable public health concern. 

Disparities 

Unfortunately, as with too many other health problems facing our Nation, obesity 

often disproportionately affects minorities and the poor. African-American children 

are almost twice as likely to be obese.17 Black and Hispanic adolescents have higher 

rates of physical inactivity (by 5–6 percentage points).18

Equally disturbing, is the apparent relationship between being overweight and 

poverty. The National Survey on Children’s Health (2003) shows that rates of overweight decline as income rises (22.4 percent of kids below 100 percent of poverty 

were overweight; only 9.1 percent of kids at 400 percent or more of poverty were 

overweight). Similarly, rates of physical inactivity are greater for poor kids (17 percent who were under 100 percent of poverty engaged in no vigorous physical activity 

each week; only 7.8 percent of those at 400 percent of poverty fell into that category). Eating healthier can be very expensive. Calorie dense foods tend to be less 

expensive; supermarkets are less likely to be accessible in poor neighborhoods; and 

poor children are more dependent on school nutrition programs, which are not always meeting the highest standards. The current rise in food prices raises serious 

concerns about the impact on obesity among poor children. Programs such as food 

stamps are not keeping up with rising prices and do not provide adequate financial 

incentives to encourage healthier eating by providing larger benefits for healthier 

food, though some notable improvements were made through the passage of the 

Food, Conservation, and Energy Act of 2008 (P.L. 110–246). 

COMMUNITY PREVENTION

As a nation, we tend to over-medicalize health problems. In fact, given the state 

of today’s science—medicine can only address the consequences of overweight and 

obesity, not prevent it. Real prevention requires changing the communities in which 

children (and adults) live and approaching this as a community-wide, not just an 

individual, challenge. It will also be the most cost-effective way to mitigate this epidemic. To truly tackle the obesity epidemic, we must make healthy choices easy 

choices for all Americans, regardless of where they live or what school they attend. 

We need a cultural shift, one in which healthy environments, physical activity and 

healthy eating become the norm. 

Tomorrow Trust for America’s Health will release a new report, Prevention for a 

Healthier America: Investments in Disease Prevention Yield Significant Savings, 

Stronger Communities, which examines how much the country could save by strategically investing in community disease prevention programs. The report concludes 

that an investment of $10 per person per year in proven community-based programs 

to increase physical activity, improve nutrition, and prevent smoking and other tobacco use could save the country more than $16 billion annually within 5 years. 

This is a return of $5.60 for every $1. The economic findings are based on a model 

developed by researchers at the Urban Institute and a review of evidence-based 

studies conducted by the New York Academy of Medicine. The researchers found 

that many effective prevention programs cost less than $10 per person, and that 

these programs have delivered results in lowering rates of diseases that are related 

to physical activity, nutrition, and smoking. The evidence shows that implementing 

these programs in communities reduces rates of type 2 diabetes and high blood pressure by 5 percent within 2 years; reduces heart disease, kidney disease, and stroke 

by 5 percent within 5 years; and reduces some forms of cancer, arthritis, and chronic 

obstructive pulmonary disease by 2.5 percent within 10 to 20 years, which, in turn, 

can save money through reduced health care costs to Medicare, Medicaid and private payers. 

12 

EXAMPLES OF SUCCESSFUL INTERVENTIONS

Community and school-based approaches aimed at using reducing obesity in the 

United States have already shown to be successful. The Child and Adolescent Trial 

for Cardiovascular Health (CATCH) elementary school program provides education 

for students, modifications for improvements in school lunches and physical education, and increased education for staff and teachers. Results have shown that students in the program consumed healthier diets and engaged in more physical activity. 

The town of Somerville, MA developed a comprehensive program called ‘‘Shape Up 

Somerville’’ to curtail childhood obesity rates. The project included partners across 

the community. Various restaurants started serving low-fat milk and smaller portion sizes; the school district nearly doubled the amount of fresh fruit at lunch and 

started using whole grain breads; the town expanded a local bike path and repainted crosswalks; and the town targeted crossing guards to areas where children 

are most likely to walk to school. Researchers evaluated the program after 1 year 

and found that children in Somerville gained less weight than children in surrounding communities. (Growing children are expected to gain some weight.) 

Another example of a coordinated approach to obesity reduction at the community 

level is the YMCA’s Pioneering Healthier Communities. This project supports local 

communities in promoting healthy lifestyles. Examples of interventions have included offering fruits and vegetables and encouraging physical activity during after 

school programs; influencing policymakers to ‘‘put physical education back in schools 

and include physical activity in after school programs’’; building or enhancing bicycle and pedestrian trails; and increasing access to fresh produce in communities 

through community gardens, farmers markets and other activities. 

NATIONAL STRATEGY

Clearly, it has taken years for the childhood obesity epidemic to develop, and it 

will take a coordinated effort over time to begin to mitigate it. At this time, we have 

no national, coordinated effort to combat obesity. TFAH supports the development 

of a National Strategy to Combat Obesity. This needs to be a comprehensive, realistic plan that involves every department and agency of the Federal Government, 

State and local governments, businesses, communities, schools, families, and individuals. It must outline clear roles and responsibilities. Our leaders should challenge the entire Nation to share in the responsibility and do their part to help improve our Nation’s health. All levels of government should develop and implement 

policies to make healthy choices easy choices—by giving Americans the tools they 

need to make it easier to engage in the recommended levels of physical activity and 

choose healthy foods, ranging from improving food served and increasing opportunities for physical activity in schools to securing more safe, affordable recreation 

places for all Americans. 

The ‘‘National Strategy for Pandemic Influenza Planning’’ provides a strong example for how this type of effort can be undertaken. With leadership and goals identified by health agencies and experts, every cabinet agency has taken charge of developing and implementing policies and programs in their jurisdiction that all contribute to our Nation’s preparedness for a pandemic flu outbreak. Similarly, the 

United Kingdom has announced an anti-obesity strategy to ‘‘transform the environment’’ in which people in England live, including launching a campaign to promote 

healthy living and healthy towns with bicycle and pedestrian routes. 

CONCLUSION

Our country needs to focus on developing policies that help Americans make 

healthier choices about nutrition and physical activity. We know that even small 

changes can make a big difference in people’s health—and that individuals don’t 

make decisions in a vacuum. If we want our children to lead healthy, productive 

lives, we need a strong partnership from the government, private and nonprofit sectors, as well as parents and teachers, to emphasize wellness and enhance nutrition 

and physical activity. The challenge is a big one, but we can make a difference together. Thank you again for the opportunity to testify. 

SUMMARY

Overall, approximately 23 million children are obese or overweight, and rates of 

obesity have nearly tripled since 1980. According to a recent analysis from the National Health and Nutrition Examination Survey (NHANES), the number of U.S. 

children who are overweight or obese may have peaked, after years of steady inVerDate Nov 24 2008 14:45 Jan 26, 2010 Jkt 035165 PO 00000 Frm 00016 Fmt 6633 Sfmt 6621 S:\DOCS\43703.TXT DENISE
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creases. Scientists and public health officials, however, are unsure if this is a statistical abnormality. Even if childhood obesity rates have peaked, the number of children with unhealthy BMIs remains far too high, and the public health toll of childhood obesity will continue to grow as the problems related to overweight and obesity 

in children show up later in life. 

A number of factors have contributed to the Nation’s childhood obesity epidemic. 

Children are eating more and moving less, which inevitably leads to increases in 

weight, but that is only a part of the story. We have also created a physical environment that reinforces a less active lifestyle, and we have not compensated for this 

in the level of physical activity we promote in the schools. We have placed kids in 

a less nutritious environment—it is not just too much food, but too much bad food 

that kids are eating, and we have not harnessed the opportunities of the school to 

compensate for this. 

The health and economic impacts of obesity are very serious. According to the Department of Health and Human Services, obese and overweight adults cost the 

United States anywhere from $69 billion to $117 billion per year. More than a quarter of U.S. health care costs are related to physical inactivity, overweight and obesity. To maintain our economic competitiveness and our general health and wellbeing, we must improve the health of America’s next generation. To do that, we 

must improve diet and physical activity levels. 

Real prevention requires changing the communities in which children (and adults) 

live and approaching this as a community-wide, not just an individual challenge. It 

will also be the most cost-effective way to mitigate this epidemic. To truly tackle 

the obesity epidemic, we must make healthy choices easy choices for all Americans, 

regardless of where they live or what school they attend. We need a cultural shift, 

one in which healthy environments, physical activity and healthy eating become the 

norm. 

It has taken years for the childhood obesity epidemic to develop, and it will take 

a coordinated effort over time to begin to mitigate it. At this time, we have no national, coordinated effort to combat obesity. We need a National Strategy to Combat 

Obesity, a comprehensive, realistic plan that involves every department and agency 

of the Federal Government, State and local governments, businesses, communities, 

schools, families, and individuals. If we want our children to lead healthy, productive lives, we need a strong partnership from the government, private and nonprofit 

sectors, as well as parents and teachers, to emphasize wellness and enhance nutrition and physical activity. 

Senator DODD. Thank you very, very much, and I have some 

questions for you, which I will raise in a few minutes. 

Dr. LEVI. OK. 

Senator DODD. Dr. Kaufman, thank you so much. Thank you 

very much. I attend every year, and am very active in the juvenile 

diabetes program in my home State of Connecticut. I have some 

wonderful friends with children who have diabetes, and we do a 

great effort in Connecticut. Thank you for your work. 

STATEMENT OF FRANCINE KAUFMAN, M.D., PAST NATIONAL 

PRESIDENT OF THE AMERICAN DIABETES ASSOCIATION, 

DISTINGUISHED PROFESSOR OF PEDIATRICS AND COMMUNICATIONS AT THE KECK SCHOOL OF MEDICINE AND THE 

ANNENBERG SCHOOL OF COMMUNICATIONS AT THE UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CA 

Dr. KAUFMAN. Great. Thank you for your commitment. 

Chairman Dodd, it is truly an honor to be here, and I thank you 

for allowing me the opportunity to testify before you today. 

Examining the ravages of the obesity and diabetes epidemics in 

the United States and around the globe is not only what I do by 

my profession as a pediatric endocrinologist, but I do it as a passion. Obesity has reached epidemic proportions in the United 

States. It has increased in both genders and in all racial, ethnic, 

and socioeconomic groups. 

14 

With 198 million Americans estimated to be obese or overweight 

and the prevalence of diabetes now at nearly 24 million, it is urgent that Congress focus on this topic today. 

Since 1990, the prevalence of obesity has tripled among our children and adolescents. As you said, one in three in the United 

States are now classified as overweight or obese. Of great importance is that childhood obesity is a significant predictor of obesity 

in adulthood. 

Over the last 3 years, changes in demographics and societal 

norms have contributed to the rise of childhood obesity. We have 

seen dramatic changes in nutrition and physical activity habits of 

America’s children. The vast majority of today’s young children do 

not follow a nutritious diet, and only about a third get sufficient 

physical activity. 

That is why it is not unusual for me when I see infants coming 

to me at my center in Los Angeles with soda in their baby bottles 

and when I am told that the first solid food given to that child was 

a French fry. Children who are overweight, obese, and unfit are at 

increased risk of becoming seriously depressed. They have fatty 

liver disease, and they develop high blood pressure, abnormal lipid 

levels, inflammation in their blood vessels, and higher than normal 

blood sugar values. 

These last disorders are the precursors of adult-onset cardiovascular disease and type 2 diabetes. Dangerously, trends during 

the 1990s illustrate type 2 diabetes in youth, which was exclusively 

a disorder of the adult population when I began my career. Now 

type 2 diabetes has increased ten-fold in our youth, closely mirroring the childhood obesity epidemic. 

As these epidemics have unfolded, we have found that both obesity and type 2 diabetes disproportionately affect minority and poor 

children. The prevalence of childhood obesity and type 2 diabetes 

among African-Americans, Mexican-Americans, and especially Native Americans exceeds that of other ethnic and racial groups. Estimates show that one in three children born in the year 2000 or beyond will develop diabetes at some point in their lives, but for minority children, this statistic is closer to one in two. 

On a personal level, I have seen heartbreaking examples of childhood obesity epidemic in my medical practice. In 1995, I saw one 

of the first children who heralded in the type 2 diabetes epidemic 

in youth. She was a 13-year-old girl with a blood sugar value of 427 

milligrams per deciliter, a value at least 5 times higher than normal. She weighed 267 pounds, and she was 5 foot, 1 inches tall. 

She came into my office with her mother and her grandmother, 

who each weighed over 250 pounds. Her diet consisted of fried 

foods, candy bars, and soda, most of which she obtained inside her 

school, and outside meals from fast food restaurants because there 

were few grocery stores in her neighborhood. Her school did not 

offer meaningful physical education, and there was no place safe to 

play in her neighborhood. So, she watched 5 hours of TV a day. 

Her grandmother had had uncontrolled type 2 diabetes and had 

suffered from a stroke and an amputation. The girl’s mother had 

pre-diabetes, and even despite this strong family history, in 1995, 

it was hard to believe that a girl so young could have type 2 diabetes. It is not hard to believe it anymore. 

15 

1 National Health and Nutrition Examination Surveys (NHANES) (Ogden, C.L., Flegal, K.M., 

Carroll, M.D., Johnson, C.L.: Prevalence and Trends in Overweight Among United States Children and Adolescents, 1999–2000. JAMA 288:1728–1732, 2002). 

This young girl left my office taking five medications, but still remained at high risk for the complications of diabetes. I knew it 

would be hard for her to control her disease, and I knew that, as 

a result, 15 years would likely be taken from her life. Although 

that day I felt as if I had been in a battle, over the subsequent 

years, it has become clear that I and my colleagues are really in 

a war, and it is a war that we have yet to win. 

For my patient to do well, the world in which she lives will have 

to change. Her neighborhood, her school, her healthcare system 

that focuses on treatment rather than prevention, essentially the 

landscape of our country will have to transform so that it promotes 

and supports healthy lifestyle habits and makes healthy choices 

the easy choices and the accessible and affordable ones. 

My patient will need to make changes, too. Without a supportive 

environment, those changes—eating well, getting active, losing 

weight—which may sound easy, have been impossible for her to do. 

Today, there is no doubt that obesity and youth, along with its associated myriad of medical conditions, is a major health challenge 

of the century. 

There is no doubt that we have had some early efforts on the 

part of government, the private sector, and the medical and public 

health systems, but to date, they have not been sufficient to reverse the trend and control the number of children who are becoming overweight and obese and the number of children who are subsequently becoming ill. It is imperative that more be done to combat the ever-growing epidemics of obesity and diabetes. 

I thank you for the opportunity to speak before you today. I know 

we share the passion of enabling the children of America to grow 

up healthy and well. 

Thank you very much. 

[The prepared statement of Dr. Kaufman follows:] 

PREPARED STATEMENT OF FRANCINE KAUFMAN, M.D. 

Chairman Dodd, Ranking Member Alexander and members of the subcommittee, 

good afternoon. My name is Dr. Fran Kaufman and I am a pediatric endocrinologist 

and professor of Pediatrics and Communications at the Keck School of Medicine and 

the Annenberg School of Communications at the University of Southern California. 

Examining the ravages of the obesity and diabetes epidemics in the United States 

and around the globe is not only my specialty, but also my passion. I thank you 

for holding this hearing and allowing me the opportunity to testify before you today 

on the dangerous health consequences of childhood obesity. 

Obesity has reached epidemic proportions in the United States. It has increased 

in both genders, and in all racial, ethnic and socioeconomic groups. With 198 million 

Americans estimated to be overweight or obese according to the CDC and the prevalence of diabetes having risen to 23.6 million Americans—an increase of nearly 3 

million people over the 2-year period from 2005 to 2007—it is especially valuable 

to be holding this hearing on this topic today. 

We have seen the prevalence of obesity triple among children 6 to 11 years and 

adolescents 12 to 17 years since 1980.1 A total of 9 million children ages 6 to 19 

in the United States are now classified as overweight or obese. The overall prevalence of obesity in children was 17 percent in 2006. Alarmingly, we are seeing an 

increase in very young children, now over 1 in 5 young children 2 to 5 years of age 

are overweight or obese. Of great importance is the fact that obesity in childhood 

is a significant predictor of obesity in adulthood. 

16 

2Liese, A.D., D’Agostino, R.B., Jr., Hamman, R.F., Kilgo, P.D., Lawrence, J.M., Liu, L.L., 

Loots, B., Linder, B., Marcovina, S., Rodriguez, B., Standiford, D., Williams, D.E.: The Burden 

of Diabetes Mellitus Among U.S. Youth: Prevalence Estimates from the SEARCH for Diabetes 

in Youth Study. Pediatrics 118:1510–1518, 2006. 3Dabelea, D., Hanson, R.L., Bennett, P.H., Roumain, J., Knowler, W.C., Pettitt, D.J.: Increasing Prevalence of Type II Diabetes in American Indian Children. Diabetologia 41:904–910, 1998. 

Many researchers have placed the origin of the childhood obesity epidemic at the 

beginning of the 1980s. Since that time, we have seen dramatic changes in the nutrition and physical activity habits of American children, along with changes in demographics and societal norms that have all contributed to the rise in childhood 

obesity. According to the CDC only 20 percent of students eat the recommended 5 

servings of fruits and vegetables per day and only 2 percent of children currently 

meet the USDA’s 5 main healthy diet recommendations. Additionally only 35 percent of students are physically active for at least 60 minutes per day meeting the 

recommended guidelines. Barely more than half of students, 54 percent, attend 

physical education classes at least 1 day a week. 

During childhood, obesity impairs psychosocial well-being and obese children are 

socially isolated. They perform poorly in school and have a poorer self-image than 

children who have a normal weight. Obesity in children is associated with severe 

impairments in quality of life. In fact, obese children have characterized their lives 

as being equal to those of children with cancer. 

Childhood obesity is associated with serious metabolic disturbances, obstructive 

sleep apnea, asthma, fatty liver disease, orthopedic problems, ovarian dysfunction, 

and chronic kidney ailments. Children who are overweight, obese and unfit are at 

an increased risk of developing high blood pressure, abnormal lipid levels, inflammation in their blood vessels, and higher than normal blood sugar levels. 

These factors are the precursors of adult-onset cardiovascular disease and diabetes. During the mid-1990s, type 2 diabetes in youth increased ten-fold in the United 

States, and mirrored the childhood obesity epidemic. Diabetes is a chronic condition 

in which the pancreas either does not create any insulin, which is type 1 diabetes, 

or the body doesn’t create enough insulin and/or cells are resistant to insulin, which 

is type 2 diabetes. 

Diabetes is the leading cause of kidney disease, adult onset blindness, and lower 

limb amputations and can lead to heart disease and stroke. 

Childhood obesity disproportionately affects minority and poor children. The prevalence of childhood obesity among African-Americans, Mexican-Americans and Native Americans exceeds that of other ethnic groups. The Centers for Disease Control 

reported that in 2000 the prevalence of obesity was 19 percent for non-Hispanic 

black children and 20 percent for Mexican-American children, compared to 11 percent for non-Hispanic white children. The increase since 1980 is particularly evident 

among non-Hispanic black and Mexican-American adolescents. 

Similarly, type 2 diabetes in the pediatric population is disproportionately seen 

in Hispanic, Native American, and African-American adolescents. Estimates show 

that one in three children born in the year 2000 will develop diabetes at some point 

in his or her life, but this statistic is nearly one in two for minority children. The 

SEARCH for Diabetes in Youth Population Study, sponsored by the CDC and NIH, 

found that the proportion of all diabetes that was diagnosed as type 2 varied by ethnicity among 10- to 19-year-olds: 6 percent for non-Hispanic whites, 22 percent for 

Hispanics, 33 percent for African-Americans, 40 percent for Asians/Pacific Islanders, 

and 76 percent for Native Americans.2

An extraordinary example of the rise of type 2 diabetes in youth is shown through 

the marked increase in the prevalence of type 2 diabetes in Pima Indian youth over 

the last 20 years. Before the 1990s, almost no younger children and less than 1 percent of older children in the Pima Indian community had type 2 diabetes. By the 

mid-90s, 2.2 percent of 10- to 14-year-olds and 5 percent of those 15- to 19-yearsold had type 2 diabetes.3 As a result of diabetes, many young adults who developed 

the disease as adolescents are now suffering prematurely from the long-term complications of this devastating disease. 

Of further concern, the significant rise in obesity in children has been accompanied by an increase in the severity of obesity, and there are differences in the 

degree of obesity among racial groups. The prevalence of severe obesity (BMI > 30 

kg/m2) in female adolescents was approximately 10 percent in non-Hispanic whites, 

20 percent in non-Hispanic blacks and 16 percent in Mexican-Americans. 

In one of the NIH studies of which I am the chair, called the HEALTHY middleschool trial, we have found that low-income, minority middle school students in 7 

cities across the country have high rates of pre-diabetes associated with overweight 

and obesity. Pre-diabetes is a condition that is diagnosed when someone has a highVerDate Nov 24 2008 14:45 Jan 26, 2010 Jkt 035165 PO 00000 Frm 00020 Fmt 6633 Sfmt 6621 S:\DOCS\43703.TXT DENISE
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4 Centers for Disease Control and Prevention, 2007 National Diabetes Fact Sheet. 

5Schwimmer, J.B., Deutsch, R., Kahen, T., Lavine, J.E., Stanley, C., Behling, C.: Prevalence 

of Fatty Liver in Children and Adolescents. Pediatrics 118:1388–1393, 2006. 

er than normal fasting blood sugar level or a higher than normal value after a glucose tolerance test, but not one in the diabetes range. An estimated 57 million 

Americans have pre-diabetes today.4 In adult studies the conversion rate is about 

10 percent per year. In this particular study we found that 39 percent of 8th graders 

and 14 percent of 6th graders, these are 13- and 11-year-old children, respectively, 

had pre-diabetes, with the highest rates found in Hispanic and American Indian 

youth. Not only did these 13-year-old students have abnormal blood glucose levels, 

but 15 percent had high blood pressure, half had abnormal lipid levels, and 8 percent had fatty liver disease. Fatty liver disease is also a new phenomenon in youth, 

and there is an indication that this might lead to early liver failure, which if not 

treated with a liver transplant will result in death. Fatty liver disease is more common in obese boys than in obese girls, and differs significantly by race/ethnicity. In 

obese children ages 2–19, 65 percent of Hispanics, 35 percent of whites and 10 percent of blacks had fatty liver disease.5

On a personal level, I have seen heart-breaking examples of the childhood obesity 

epidemic in my medical practice. I remember one of the first children I saw with 

type 2 diabetes just as this epidemic was beginning. It was in the middle of spring 

in 1995. She was a 13-year-old girl with a blood sugar level of 427 mg/dl, at least 

five times higher than normal for a young teen. She weighed 267 pounds. She came 

to my office with her mother and grandmother, they each weighed about 250 

pounds. She had been drinking a lot of juice and soda throughout her life. Her diet 

consisted of fried foods, candy bars, and meals from fast food restaurants. She did 

not have access to meaningful physical education courses in her school curricula and 

there was nowhere safe to play in her neighborhood. She watched 5 hours or more 

of TV a day. 

Her grandmother had type 2 diabetes and had never controlled her blood sugar 

levels. Five years earlier she had suffered from a stroke and an amputation. My patient’s mother had been diagnosed with pre-diabetes. Despite her strong family history of diabetes, no one believed that this 13-year-old girl had this disease—because 

she was just too young. 

Her mother told me she watched diabetes destroy her own mother, and she did 

not want to see that happen to her child. To control her high blood sugar level, her 

high blood pressure, and her high cholesterol, this young girl left my office taking 

five medications. Even still, she remained at high risk and it would be hard to control her disease and all its attendant problems. I knew that at least 15 years would 

be peeled off this young woman’s life. 

That day I felt as if I had been in a battle, but I am really in a war. A war we 

have yet to win. For my patient to do well, the world in which she lived would have 

to change. Her neighborhood, her school, the healthcare system that focuses more 

on treatment than prevention—our country—would have to transform so that it promotes and supports healthy lifestyle habits and make the healthy choices the easy 

choices—the accessible and affordable choices. My patient would need to make 

changes too, but without a supportive environment, those changes,—eating well, 

getting active and losing weight—might be impossible for her to make. In my office 

in 1995, I knew that a world of battles would have to be fought for my patient, and 

for too long that war has been going on. As I stand before you today, I am hopeful 

the time has come for the war to be won. 

Today, there is no doubt that obesity in youth, along with its associated medical 

conditions, is the major health challenge of this century. Although attention has 

been paid to this problem by government and public health officials, researchers, 

and health care providers, the number of overweight and obese youth continues to 

increase. More needs to be done to combat the ever growing epidemics of obesity 

and diabetes. 

Again, thank you for the opportunity to speak before you today. I look forward 

to the opportunity to answer any of your questions. 

Senator DODD. Thank you very much, Dr. Kaufman. 

Dr. Grey, thank you very much for being with us as well. 

You will see, by the way, we have been joined by Senator Harkin 

and Senator Murkowski, and I thank you both for being here. 

We will let our witnesses finish, and then I am going to ask each 

of you to make some opening comments, if you would. Is that OK? 

18 

Go ahead, Dr. Grey. 

STATEMENT OF MARGARET GREY, DrPH, R.N., FAAN, DEAN 

AND ANNIE GOODRICH PROFESSOR, YALE SCHOOL OF 

NURSING, NEW HAVEN, CT 

Ms. GREY. Senator Dodd and Senators Harkin and Murkowski, 

thank you so much for the opportunity to speak with you today 

about childhood obesity. 

In my 30 years of experience, I have found that the obesity epidemic in youth is multifaceted, threatening not only their future 

health, but their quality of life, their potential for educational 

achievement, and ultimately, future employment potential. 

As a nurse with training in both public health and social psychology, my interest has always been in preventing illness and, in 

the case of obesity and diabetes, preventing complications. When I 

began working in this field in the 1970s, I never saw a child with 

type 2 diabetes. Now up to 50 percent of new cases of diabetes in 

children are type 2 diabetes, what we used to call ‘‘adult-onset’’ diabetes. 

While it is most common in teens, we have had children as young 

as 5 years old with type 2 diabetes in our service. Worse, it appears 

that this diabetes is very aggressive, and these youth develop the 

devastating complications of diabetes—cardiovascular disease, kidney disease, blindness, and amputations—at an early age. Indeed, 

the early longitudinal studies of these youth suggest that while 

they are in their 20s, they are already having heart attacks and 

on renal dialysis. 

Beyond physical complications, there are complications related to 

quality of life, depression, and academic achievement. Let me illustrate how serious these complications can be. 

Quality of life refers to self-reported physical, emotional, social, 

and school functioning. In 2003, a research study found that obese 

teens have lower quality of life than teens with cancer. If childhood 

overweight and obesity lead to a reduced quality of life, then these 

youth are at risk for psychological, social, and educational complications along with the medical ones. 

With funding from the National Institutes of Nursing Research, 

my colleagues and I have been studying approaches to prevent type 

2 diabetes in youth who are overweight or obese and have a family 

history of type 2 diabetes. These are the youth who will be most 

likely to develop diabetes in the next 5 to 10 years. 

In the New Haven middle schools where we conducted our work, 

we identified that at least 30 percent of these overweight high-risk 

youth had levels of depression requiring referral of treatment. This 

isn’t minor sadness. This is serious depression. Those who were depressed also had much poorer dietary and activity behaviors, lower 

self-efficacy, higher body mass index, and higher fasting insulin 

levels. 

From studies of adults with diabetes, we know that depression 

is not uncommon and associated with poor physical health as well 

as poor self-care. We also know that the obesity epidemic is disproportionately affecting youth of racial and ethnic minorities and 

of lower income. These youth may be especially susceptible to depression, creating a situation of extremely high risk. 

19 

We all know that depression is a risk factor for suicide, and a 

child who dies from the psychological complications of obesity is 

just as dead as the one who dies from the physical complications 

10 years from now. 

The New Haven intervention to prevent type 2 diabetes was developed based on my own research with a behavioral intervention 

called coping skills training. Early on in this process, we found that 

these middle school youth had never learned basic nutrition. Many 

of these families had no access to quality fruits and vegetables, and 

physical education in the schools emphasize sports, not individual 

activity. So that, the youth who needed to participate the most 

were most often found on the sidelines. 

In addition, as has been stated earlier today, many of these children had no access to safe places to be active, nor did they have 

any confidence that they could change any of these health behaviors. The intervention that we did, targeted at seventh graders, included nutrition education, non-sports physical activities, and the 

behavioral skills necessary to implement what they learned. 

During the 12-month followup, youth who received the entire 

program had lower body mass index, decreased insulin resistance, 

improved dietary and activity behaviors, decreased depression, and 

improved confidence in their ability to sustain these behaviors. 

On the issue of school performance, a recent review found that 

overweight and obese youth had poorer performance than those of 

normal weight, with lower math and reading scores. They also 

were more likely to be held back, miss more days of school, and 

boys were more likely to expect to drop out of school. 

Even more disturbing is the finding that men and women who 

were obese as teenagers had significantly fewer levels of schooling 

by adulthood. The reasons for this are unclear. It may be due to 

the psychosocial complications of obesity, and it may be due to 

mildly high blood sugar levels through the day that affect cognitive 

abilities. 

The ramifications of these psychosocial and educational complications of obesity are clear. It is doubly hard to change lifestyle when 

children and youth are depressed, and poor school performance 

now predicts a lifetime of struggle later, not to mention the potential for absenteeism at work, affecting performance and the ability 

to stay employed. 

In this area of work, the need for more research into programs 

that can prevent obesity is critical. Once these habits are learned 

and engrained, it is much more difficult to change behavior. More 

studies of community-based approaches that reach children and 

families at a young age in their communities are needed. 

I would be remiss if I did not make the case that funding for 

NIH and CDC, as well as the National Institute of Nursing Research, which is the only institute at NIH focused on prevention 

and enhancement of self-management of chronic illness, needs to be 

increased to allow more of this kind of research to help us solve 

this problem. 

This generation of youth will not survive if we continue to pay 

for their heart attacks, but not for the intensive care that it will 

take to reduce this epidemic. None of us wishes for this generation 

20 

to be the first to have a lifespan and quality of life that is lower 

than that of the previous generation. 

Thank you for your attention. Thank you for the invitation. I 

look forward to the discussion. 

[The prepared statement of Ms. Grey follows:] 

PREPARED STATEMENT OF MARGARET GREY, DRPH, R.N., FAAN 

Thank you for the opportunity to speak with you today about this very serious 

problem. My name is Margaret Grey, and I am a pediatric nurse practitioner with 

training in both public health and social psychology. For over 30 years, my area of 

research and practice has been pediatric diabetes. As you know, and as others on 

the panel have reiterated, the obesity epidemic in youth threatens not only the future of these children with chronic diseases and a decreased lifetime, this epidemic 

is multi-faceted and will ultimately affect the workforce and thus the economy. 

As a nurse, my interest has always been on prevention—preventing illness and, 

in the case of obesity and diabetes, preventing complications. The obesity epidemic 

has led to an entire generation of youth developing type 2 diabetes in childhood, not 

in adulthood or old age as we are more used to seeing. When I began in this field 

in the 1970s, we never saw a child with type 2 diabetes. Now, depending on the 

clinic, up to 50 percent of new cases of diabetes in children are type 2 diabetes as 

opposed to type 1 (which was formerly known as juvenile diabetes. While it is most 

common in teens, in our clinic, we have seen children as young as 5 years old with 

type 2 diabetes. Worse, it appears that this diabetes is very aggressive and these 

youth develop the devastating complications of diabetes—cardiovascular disease, 

kidney disease, blindness and amputations—at an early age. Indeed, the longitudinal studies of these youth suggest that while they are in their 20s, they are already having heart attacks and receiving dialysis. 

While these physical complications are critically important concerns, there are 

also complications related to quality of life, depression, and academic achievement. 

Let me illustrate how serious these complications can be. Quality of life refers to 

self-reported physical, emotional, social, and school functioning. In 2003, 

Schwimmer reported that in a comparative study that obese teens have lower quality of life than teens without a chronic condition or those with cancer! This finding 

was more recently replicated in a community sample. So why does quality of life 

matter? If childhood overweight and obesity lead to reductions in health-related 

functioning, then these youth are at risk for psychological, social, and educational 

complications. I will explain this further. 

Related to quality of life is depression. With funding from the National Institutes 

of Nursing Research, my colleagues and I have been studying approaches to preventing type 2 diabetes in youth at high risk for its development by virtue of overweight or obese status and a family history of type 2 diabetes. In our studies in the 

New Haven School System middle schools, we have identified that at least 30 percent of these overweight, high risk youth have levels of depression—not temporary 

sadness or the ‘‘blues’’—but depression requiring referral and treatment. Those who 

were depressed had much poorer dietary and activity behaviors, lower self-efficacy, 

higher Body Mass Index (even among the already overweight), and higher fasting 

insulin levels (indicating a higher risk for type 2 diabetes). From studies of adults 

with diabetes, we know that depression is not uncommon and is associated with 

poorer physical health as well as poorer self-care. In addition, the obesity epidemic 

is disproportionately affecting youth of racial and ethnic minorities and of lower income. These youth may be especially susceptible to depression, creating a situation 

of extremely high risk. We all know that depression is a risk factor for suicide, and 

as I have often said, as much as we worry about the physical complications of obesity, a child who commits suicide is just as dead as one who suffers from the physical complications. 

Our intervention to prevent type 2 diabetes in high risk youth in the middle 

schools was developed based on my own research with a behavioral intervention 

called Coping Skills Training and with collaboration of teachers and school nurse 

practitioners. Early on in this process, we learned that these middle school youth 

had never learned basic nutrition, so that we had to teach the difference between 

starches, proteins, and fats. We also learned that many of these families have no 

access to quality fruits and vegetables in the inner city besides a head of old iceberg 

lettuce (and we wonder why they look at us funny when we suggest they eat salads 

every day!). Physical education programs in the schools emphasized sports, so that 

the youth who needed to participate the most were most often found watching and 

not playing. There was little to no emphasis on activity that could occur without 

21 

a team. Finally, many of these children had no access to safe places to be active, 

nor did they have any confidence that they could change any of their health behaviors. 

The program was designed to be taught by the teachers in the 7th grade and included nutrition education, non-sports physical activity, and the behavioral skills 

(such as problem solving, social skills, assertiveness, and cognitive behavior modification) necessary to implement what they learned. Over the course of the 12 

months of follow-up, we found that the youth who received the entire program, compared to just the nutrition education, had lower BMI, decreased insulin resistance 

(a marker of risk for diabetes), improved dietary and activity behaviors, decreased 

depression, and improved confidence in the ability to sustain these behaviors. We 

are now in the process of testing this program throughout the New Haven middle 

schools and in several other school districts. 

You may wonder if these concerns are confined to racial and ethnic minorities and 

the inner cities. They are not. While obesity rates in youth average 20 percent, they 

are merely higher in these communities. And, our recent studies tell us that concerns about school lunches being high in fat and low in fruits and vegetables are 

equally of concern in suburban middle class communities. One of our students recently analyzed school lunch menus in five Connecticut schools—both inner city and 

suburban—and found that while portion sizes were appropriate, percentage of calories from fat exceeded guidelines, even before the children went to the vending machines and purchased sodas and fried snacks. 

The final topic I will address is the effect of obesity on school performance. A recent review found that overweight and obese youth had poorer school performance 

than those of normal weight. Obese and overweight youth had lower math and reading scores, were more likely to be held back, missed more days of school, and boys 

were more likely to expect to quit school. Even more disturbing is the finding that 

men and women who were obese as teens had significantly fewer years of school 

by young adulthood. The reasons for this are unclear: the psychosocial complications 

of obesity may lead to decreased motivation, but it is also possible that there is a 

physiologic cause. We know from studies of youth with diabetes that even mildly 

elevated blood glucose levels are associated with cognitive declines, so it’s possible 

that some of these youth have high glucose levels during the school day and just 

can’t think the same way those of normal weight and glucose levels can. 

The ramifications of all of these psychosocial and educational complications of obesity are clear. It’s doubly hard to change lifestyle when they are depressed. Depression may lead to suicide. Poor school performance often predicts a lifetime of struggle and lower income, not to mention the potential for absenteeism at work affecting 

performance and the ability to stay employed. 

In this area of work, the need for more research into programs that can prevent 

obesity before it happens is critical. Once habits are learned and ingrained, it is 

much more difficult to change behavior. For example, we are beginning a study to 

help pregnant women lose weight after pregnancy, because we know that children 

of these women are more likely to be overweight by age 2 than children of women 

who have lost their pregnancy weight. Such research will take longer than the usual 

NIH grant of 3–5 years to demonstrate convincingly that this kind of approach will 

reduce rates of childhood obesity. More studies of community-based approaches that 

reach children and families at a young age in their communities are needed. As important as these school-based studies are, they focus more on treatment of obesity 

that has already occurred than in prevention. And, I would be remiss if I did not 

make the case that the funding of NIH and NINR in particular, the only one with 

prevention and enhancement of self-management of chronic conditions as major 

focus areas, needs to be increased to allow for more of the studies I have described. 

With regard to health policy, I cannot emphasize enough that this generation of 

youth cannot survive if we continue to pay for the care of their heart attacks, but 

not for the intensive behavioral care that it will take to reverse this epidemic. I am 

sure that none of us wishes to be partially responsible for this being the first generation in many years to have a lifespan lower than the previous generation because 

we didn’t act. 

Thank you for the invitation and your attention. I look forward to your comments 

and questions. 

REFERENCES

Grey, M. & Berry D. (2004). Coping skills training and problem solving in diabetes. 

Current Diabetes Reports, 4(2), 126–133. 

Grey, M., et al. (2004). Preliminary testing of a program to prevent type 2 diabetes 

among high-risk youth. Journal of School Health, 74(1), 10–15. 

22 

Jaser, S.S., Grey, M., et al. (in press). Correlates of depressive symptoms in youth 

at high risk for type 2 diabetes. Children’s Health Care. Schwimmer, J.B. (2003). Health-related quality of life of severely obese children and 

adolescents. Journal of the American Medical Association, 289, 1813–1819. 

Taras, H., & Potts-Datema, W. (2005). Obesity and student performance at school. 

Journal of School Health, 75(8), 291–295. 

Senator DODD. Doctor, thank you immensely and wonderful testimony. Thank you for your work over the years, more importantly. 

Bruce, welcome back to the committee. 

STATEMENT OF BRUCE LESLEY, PRESIDENT, FIRST FOCUS, 

WASHINGTON, DC 

Mr. LESLEY. Thank you. Good afternoon, Chairman Dodd, Senators Harkin and Murkowski, and staff of the Children and Families Subcommittee. 

Having served as staff for Senator Bingaman with this committee for 6 years, it is a real honor to be here today and to be before such champions for children’s health generally and childhood 

obesity issues specifically. 

I am Bruce Lesley, president of First Focus, a bipartisan children’s advocacy organization dedicated to making children and 

families a priority in Federal policy. Thank you for the opportunity 

to testify today on this issue and on the childhood obesity epidemic 

and its role in the rapidly declining health of our future generation. 

This is an American issue that affects not only our children, but 

all of our future. There is also a choice between investing now and 

improving the health and well-being of America’s children or dealing with the effects of childhood obesity and related preventable 

diseases with today’s young people as they become adults. 

Childhood obesity is a growing public health crisis. As you know, 

over the past 30 years, obesity rates have more than tripled for 

preschool children and adolescents, quadrupled for children ages 6 

to 11. Today, one third of children in the United States are obese 

or at risk of becoming obese. Sadly, our adolescents are now the 

most obese teenagers in the world, and we have reason to be concerned. These teens have up to an 80 percent chance of becoming 

overweight as adults. 

You have heard about the health consequences from my colleagues here, but also the costs of childhood obesity are staggering. 

A 2000 report of the U.S. Surgeon General estimated the cost at 

$117 billion annually, and all signs indicate that it will continue 

to grow. Treating an obese child is more costly than treating an average weight child, obviously. An overweight child is likely to visit 

an emergency room more frequently and two to three times more 

likely to be hospitalized. 

Estimates suggest that annual hospital costs associated with 

obese children and youth have more than tripled in less than 2 decades. Scientists, as discussed earlier, now forecast a 2- to 5-year 

drop in life expectancy for children of today unless we take aggressive actions to address and reverse the obesity epidemic. 

One of the interesting things is that we have conducted some 

polling that shows for the first time ever, American adults believe 

that the next generation will be worse off than the current generation. I think there are a lot of reasons that go into that, but one 

of them is the issues of the health of children. 

23 

There was a national poll on children’s health that was conducted by C.S. Mott Children’s Hospital that shows that obesity is 

for the first time identified by adults as the top health problem for 

children after being rated third last year. It has been one of those 

issues that over time has gone up the scale. 

Concern with the high rate of obesity among U.S. children and 

the reality that they could face increased risk of heart disease as 

adults, the American Academy of Pediatrics recently recommended 

wider cholesterol screening for children and more aggressive use of 

cholesterol-lowering drugs for children as young as age 8. While we 

agree that we are in desperate need of solutions, this is hardly a 

viable one. Sadly, there will be no magic pill that can erase this 

problem. 

The fact of the matter is that despite all the research and these 

dismal statistics, our Nation’s broader response to the childhood 

obesity epidemic has been woefully inadequate. While we invest 

heavily in the treatment and management of chronic diseases, in 

adults, we spend very little for the prevention and treatment of 

childhood obesity that would stave off the onset of conditions like 

heart disease and type 2 diabetes. 

As Julie Gerberding, director of the CDC, recently noted, we put 

way too much emphasis on treating disease rather than protecting 

health in the first place. According to Gerberding, today only a 

nickel out of every medical dollar spent in the United States goes 

toward keeping Americans healthy. This is part of a broader pattern of declining investments in our future. 

As a new First Focus report—Children’s Budget 2008—highlights, over the past 5 years, the share of Federal nondefense 

spending that goes to children and children’s programs has declined by 10 percent. In fact, real Federal discretionary spending 

on children will be lower this year than it was 5 years ago. 

Kids’ Share 2008, an Urban Institute report released at the Capitol Hill briefing last week, confirms this trend and details the 

overall decline in Federal spending on children over the past four 

and a half decades. It has found that since 1960 the share of Federal spending that goes to children has dropped by more than 20 

percent. 

The time for action is now. One thing just as a personal point, 

as I worked with all of your offices on an amendment a few years 

ago that was to the agriculture bill. As I recall, it was Bingaman, 

Dodd, Harkin, Murkowski, and I think even Senator Coburn as cosponsors. It was an amendment that I worked on with all of your 

staffs, and ultimately, it resulted in an increase in a fresh fruits 

and vegetables program, which is a long-time initiative by Senator 

Harkin that has now become law in the Farm bill. It is those kinds 

of steps that we need to be taking. 

As the Institute of Medicine report ‘‘Progress in Preventing 

Childhood Obesity: How Do We Measure Up? ’’ noted, addressing 

the childhood obesity epidemic is a collective responsibility involving multiple stakeholders in different sectors between the Federal 

Government, State and local governments, communities, schools, 

industry, media, and families. 

The Federal Government can—really it must—play a critical role 

in reversing this epidemic by providing leadership, coordinated efVerDate Nov 24 2008 14:45 Jan 26, 2010 Jkt 035165 PO 00000 Frm 00027 Fmt 6633 Sfmt 6601 S:\DOCS\43703.TXT DENISE
24 

1 Institute of Medicine of the National Academies. Progress in Preventing Childhood Obesity: 

How Do We Measure Up? Washington, DC: National Academies Press, 2006. 2 Institute of Medicine of the National Academies. Progress in Preventing Childhood Obesity: 

How Do We Measure Up? Washington, DC: National Academies Press, 2006. 

forts across agencies, and investing in research and sustained prevention and intervention strategies. We believe Congress can take 

several steps now to address this threat, and it is one of the things 

that we really want to emphasize that it is across areas. It is everything from public health programs. It is daily activities in 

schools. 

I note, for example, that Senator Dodd’s bill on the 21st Century 

Community Learning Centers Act includes a provision that would 

add physical fitness and wellness programs as allowable activities. 

Under the 21st Century Community Learning Centers Act, we 

need to target investments in research, but it also includes coverage issues. The SCHIP program, for example, making sure that 

children have health coverage. Also, there was language in that bill 

that provided demonstration grants for childhood obesity efforts. 

It includes things like dealing with competitive foods and beverages in schools. We include a bunch of the recommendations in 

our testimony, and as those highlight childhood obesity is not just 

a healthcare issue, it is clearly an education issue, a transportation 

issue, an agriculture issue, an economics issue, and a public health 

issue. 

Given the complexity of the problem, it is easy to see why responsibility for addressing it is passed from one agency to the 

other. Unfortunately, no one in the Federal Government seems to 

own this issue. We must ensure that all Federal agencies with a 

role to play—including the CDC, NIH, Department of Agriculture, 

and Department of Transportation—work together to address the 

childhood obesity epidemic. 

In a glimmer of good news, the data and research also shows 

that we can reverse the current trend and lower the incidence of 

a host of deadly diseases associated with obesity if we take action 

now. 

Thank you all for your leadership and for the opportunity to provide testimony. I welcome any questions. 

[The prepared statement of Mr. Lesley follows:] 

PREPARED STATEMENT OF BRUCE LESLEY

Good morning Chairman Dodd, Ranking Member Alexander, and members and 

staff of the Children and Families Subcommittee. Having served as a staffer for 

Senator Bingaman, with this committee, it is a real honor to be here today. 

I am Bruce Lesley, President of First Focus, a bipartisan children’s advocacy organization dedicated to making children and families a priority in Federal policy and 

budget decisions. 

Thank you for the opportunity to testify today on the childhood obesity epidemic 

and its role in the rapidly declining health of our next generation. This is an American issue that affects not only our children but all of our futures. It is also a choice 

between investing now in improving the health and well-being of America’s children, 

or dealing with the effects of childhood obesity and related preventable diseases 

when today’s young people become adults. 

Childhood obesity is a growing public health crisis. As you know, over the past 

30 years, obesity rates have more than tripled for preschool children and adolescents, and quadrupled for children ages 6–11.1 Today, one-third of children and 

youth in the United States are obese or at-risk of becoming obese.2 Sadly, our adolescents are now the most obese teenagers in the world. And we have reason to be 

25 

3Torgan, C. (2002). Childhood Obesity on the Rise. The NIH Word on Health. Downloaded 

from: http://www.nih.gov/news/WordonHealth/jun2002/childhoodobesity.htm. 4 Institute of Medicine of the National Academies. Childhood Obesity in the United States: 

Fact and Figures. Fact Sheet. September 2004. 5Stauss, R.S., Pollack, H.A. (2001). Epidemic Increase in Childhood Overweight. JAMA, 286:2845–8. 6 Jackson, Yvonne. (1993). Height, weight, and body mass index of American Indian schoolchildren, 1990–1991. Journal of the American Dietetic Association, 93(10) 1136–1140. 7Freedman, D.S., Dietz, W.H., Srinivasan, S.R., Berenson, G.S. (1999). The Relation of Overweight to Cardiovascular Risk Factors Among Children and Adolescents: The Bogalusa Heart 

Study. Pediatrics, 103: 1175–82. 8 U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to 

Prevent and Decrease Overweight and Obesity. U.S. Department of Health and Human Services, 

Public Health Service, Office of the Surgeon General. 2000. 9Marder, W.D. & Chang, S. (2005). Childhood Obesity: Costs, Treatment Patterns, Disparities 

in Care, and Prevalent Medical Conditions. Thomson Medstat Research Brief. Retrieved at 

http://www.medstat.com/pdfs/childhoodlobesity.pdf. 10 Institute of Medicine of the National Academies. Preventing Childhood Obesity: Health in 

the Balance. Washington, DC: National Academies Press, 2005. 11Olshansky, S.J., Passaro, D.J., Hershow, R.C., Layden, J., Carnes, B.A., Brody, J., Hayflick, 

L., Butler, R.N., Allison, D.B., and Ludwig, D.S. (2005). A Potential Decline in Life Expectancy 

in the United States in the 21st Century. New England Journal of Medicine, Volume 352:1138– 

145, Number 11. 

concerned. These teens have up to an 80 percent chance of becoming overweight or 

obese adults.3

Through our research and our advocacy, we know that the rates of obesity and 

related diseases are even more alarming for minority children. For instance: 

• In the United States, Hispanic boys and African-American girls have the highest prevalence of obesity.4

• Overweight prevalence increased by 120 percent for African-American and Hispanic children between 1986 and 1998 in comparison to an increase of 50 percent 

for whites.5

• A national survey of American Indian children ages 5 to 18 found that 39 percent were overweight or at risk for becoming overweight.6

Obesity translates into more than just expanding waistlines. Obese children are 

being diagnosed with health problems once only seen in adults—such as type 2 diabetes, high cholesterol, high blood pressure, and even child gallstones. Overweight 

children are also at higher risk for heart disease, stroke, and several forms of cancer.7

The direct and indirect costs associated with obesity in the United States are staggering. A 2000 report of the U.S. Surgeon General estimated the costs at $117 

billion annually and all signs indicate that it will continue to grow.8 Treating an 

obese child is more costly than treating an average-weight child and an overweight 

child is likely to visit an emergency room more frequently and two to three times 

more likely to be hospitalized.9 Estimates suggest that annual hospital costs associated with obese children and youth have more than tripled in less than two decades.10

Scientists now forecast a 2- to 5-year drop in life expectancy for children of today, 

unless we take aggressive action to address and reverse the obesity epidemic. In 

fact, a 2005 study published in The New England Journal of Medicine concluded 

that ‘‘if childhood obesity continues unabated, people will have shorter lives because 

of the health toll of being heavy at such a young age.’’ 11 One of the study authors, 

pediatric endocrinologist David Ludwig describes childhood obesity as a ‘‘massive 

tsunami headed toward the United States.’’ Ludwig goes on to explain, 

‘‘It’s like what happens if suddenly a massive number of young children started chain smoking. At first you wouldn’t see much public health impact. But 

years later it would translate into emphysema, heart disease, and cancer.’’ 

Concerned with the high rate of obesity among U.S. children and the reality that 

they could face increased risk of heart disease as adults, the American Academy of 

Pediatrics (AAP) recently recommended wider cholesterol screening for children and 

more aggressive use of cholesterol-lowering drugs for children as young as age 8. 

While we agree that we are in desperate need of solutions, this is hardly a viable 

one. Sadly, there will be no magic pill that can erase this problem. 

The fact of the matter is that despite all of the research and these dismal statistics, our Nation’s broader response to the childhood obesity epidemic has been woefully inadequate. While we invest heavily in the treatment and management of 

chronic diseases in adults, we spend very little for the prevention and treatment of 

childhood obesity that would stave off the onset of conditions like heart disease and 

type 2 diabetes. As Julie Gerberding, Director of the Centers for Disease Control 

26 

12Drewnowski, A. and Specter, S.E. (2004). Poverty and Obesity: The Role of Energy Density 

and Energy Costs. American Journal of Clinical Nutrition, Vol. 79, No. 1, 6–16. 13The Food Trust (2001). The Need for More Supermarkets in Philadelphia. Retrieved at: 

http://www.thefoodtrust.org/pdf/supermar.pdf. 14Drewnowski, A , Rehm, C.D., Solet, D. (2007). Disparities in Obesity Rates: Analysis by ZIP 

Code Area. Social Science and Medicine. 65(12):2458–63. 15Drewnowski, A. and Specter, S.E. (2004). Poverty and Obesity: The Role of Energy Density 

and Energy Costs. American Journal of Clinical Nutrition, Vol. 79, No. 1, 6–16. 

and Prevention (CDC) recently noted, ‘‘we put way too much emphasis on treating 

disease rather than protecting health in the first place.’’ According to Gerberding, 

today, only a nickel out of every medical-care dollar spent in the United States goes 

toward keeping Americans healthy. 

This is part of a broader pattern of declining investments in our future. As a new 

First Focus report, Children’s Budget 2008 highlights, over the past 5 years, the 

share of Federal non-defense spending that goes to children and children’s programs 

has declined by 10 percent and in fact, real Federal discretionary spending on children will be lower this year than it was 5 years ago. Kids’ Share 2008, a First 

Focus-sponsored Urban Institute report released at a Capitol Hill briefing last week, 

confirms this trend, and details the overall decline in Federal spending on children 

over the past four and a half decades. Shockingly, it found that since 1960, the 

share of Federal spending that goes to children has dropped by more than 20 percent. 

The current Administration, for its part, has done little to avert the approaching 

tsunami. As a recent Washington Post series on childhood obesity highlighted, President Bush has repeatedly attempted to eliminate or cut several prominent Federal 

efforts aimed at overweight children and teens, including: 

• The elimination of funding for the Carol M. White Physical Education Program 

(PEP). In its fiscal year 2009 budget request to Congress, the Administration proposed to zero out this $75 million program that helps schools and communities expand physical education offerings and purchase equipment. 

• No new funding for the Centers for Disease Control and Prevention’s (CDC) Division of Nutrition, Physical Activity and Obesity. Grants offered through this CDC 

program, which currently are up and running in less than half the States, allow 

State health departments to design, implement, evaluate and disseminate effective 

interventions, including those which support policy changes to encourage access to 

healthy foods and venues to be active. 

• No new funding for the Department of Defense (DOD) Fresh Fruit and Vegetable Program, which helps schools provide a wider variety of fresh fruit and vegetables to students through federally sponsored breakfast and lunch programs. 

Not only has the Administration been meager in making investments in discretionary programs that could address childhood obesity, in longer-standing nutrition 

programs, change has been slow to come. The U.S. Department of Agriculture only 

recently modified the Women, Infants and Children (WIC) nutrition program to 

allow additional funds for low-income families to buy fresh fruits and produce, 

which are often more costly. In a bit of sad irony, traditional subsidies, which help 

low-income families purchase food staples like milk, eggs, and cheese, are contributing to our kids’ expanding waistlines. In fact, in some communities, nearly half 

of toddler and preschool WIC recipients are overweight or obese. And, as The Post 

points out, the U.S. Department of Agriculture’s (USDA) school breakfast and lunch 

programs continue to sell whole milk and sweetened flavored milk, instead of nofat alternatives. 

There are many interrelated factors that contribute to rapidly rising rates of obesity in children, chief among them poverty and food insecurity, which lead to lower 

food expenditures, limited fruit and vegetable consumption and poor diets.12 In fact, 

a recent Food Trust report found that ‘‘people who live in lower-income areas without access to supermarkets appear to suffer from diet-related deaths at a rate higher than that experienced by the population as a whole.’’ 13 In another study, obesity 

rates were as high as 30 percent in the lowest income neighborhoods, compared to 

about 5 percent in the most affluent zip codes.14 The relatively low cost of foods containing refined grains, added sugars and fats is also a key factor in the rising obesity rate.15

Other factors also contribute to the childhood obesity epidemic. For instance, in 

recent decades, our society has experienced an influx of fast foods, bigger portion 

sizes, and the convenience of vending machines. Today, nearly one-third of children 

ages 4 to 19 eat fast food every day—that translates to 6 extra pounds per year for 

every child. And, children are eating more junk food in larger than-ever portion 

27 

16 Anderson, P.M., and Butcher, K.F. (Spring 2006). Childhood Obesity: Trends and Potential 

Causes. Future of Children, Vol. 16, No. 1. 17Gantz, W., Schwartz, N., Angelini, J.R., and Rideout, V. (March 2007). Food for Thought: 

Television Food Advertising to Children in the United States, A Kaiser Family Foundation Report. 18 Institute of Medicine of the National Academies. Progress in Preventing Childhood Obesity: 

How Do We Measure Up? Washington, DC: National Academies Press, 2007. 19 2005 Youth Risk Behavior Surveillance Results. Available at www.cdc.gov/healthyyouth. 

sizes. During the late 1990s, portion sizes increased more than 60 times.16 Children 

today are also over-exposed to junk food marketing. A recent Kaiser Family Foundation study found that food is the top product seen advertised by children—and 34 

percent of all the food ads targeting children or teens are for candy and snacks.17

Unfortunately, the recent economic downturn has translated into rising food costs, 

and more Americans are turning to lower quality, frozen, bulk and processed foods 

for meals. And, as the economy worsens, America’s poorest will be hit the hardest. 

As Dr. David Katz, a well-known authority on nutrition and the prevention of chronic disease notes, ‘‘there’s real cause for worry, because the data we do have, in general, indicates that more nutritious foods tend to be higher priced. It’s only going 

to compound that problem [when] the food prices rise.’’ 

The time for action is now. As the recent 2006 Institute of Medicine (IOM) report, 

‘‘Progress in Preventing Childhood Obesity: How Do We Measure Up? ’’ noted, ‘‘addressing the childhood obesity epidemic is a collective responsibility involving multiple stakeholders and different sectors—including the Federal Government, State 

and local governments, communities, schools, industry, media and families.’’ 18 The 

Federal Government can—really it must—play a critical role in reversing this epidemic by providing leadership, coordinating efforts across agencies, and investing in 

research and sustained prevention and intervention strategies. 

We believe Congress can take several critical steps now to help address this growing public health threat: 

(1) Improve Daily Physical Activity Requirements for All Students. In recent years, schools have cut back on physical education and recess. Although children need 60 minutes of moderate to vigorous exercise daily, national surveillance 

data tells us that only 35.8 percent of high school students are meeting this measure.19 As the Campaign to End Obesity’s Call to Action report highlights, the reauthorization of No Child Left Behind (NCLB) provides an important opportunity to 

improve physical education and activity standards. Congress should consider the following: 

• Support the 21st Century Community Learning Centers Act of 2007 (S. 1557), 

sponsored by Senator Dodd, which would include the provision of physical fitness 

and wellness programs as allowable activities under 21st Century Community 

Learning Centers (CCLC); 

• Amend Safe and Drug-Free Schools and Communities Act to allow for the promotion of Safe Routes to Schools (SRTS); 

• Reauthorize the Carol M. White Physical Education Program and ensure it is 

adequately funded; and 

• Provide incentives for schools that meet national standards for physical education. 

We would also like to urge support for the PLAY Every Day Act (S. 651), sponsored by Senators Harkin and Bingaman, which would help children, families, and 

communities achieve the national recommendation of 60 minutes of physical activity 

every day. 

(2) Increase Our Federal Investment in Prevention and Public Health 

Programs Targeting Childhood Obesity. Congress should provide additional 

funding for the CDC’s Division of Adolescent and School Health (DASH), which supports States in implementing Coordinated School Health Programs (CSHP). Currently, only 22 States and 1 tribal government are receiving grants, and overall 

funding for CSHP has followed a steady downward trend over the past 5 years. 

In addition, I’d like to highlight several promising proposals: 

• The Prevention (HeLP) America Act (S. 1342/ H.R. 2633), sponsored by Senator 

Harkin, would provide for: (1) healthy school nutrition environment incentive 

grants; (2) establish a Baby-Friendly Hospital Initiative; (3) provide incentives for 

States to ensure the safety and convenience of all users of a transportation system, 

including pedestrians and bicyclists, and also includes provisions of the PLAY Every 

Day Act, Healthy Workforce Act of 2007, MEAL Act, and Child Nutrition and School 

Lunch Protection Act. 

28 

20Marder, W.D. & Chang, S. (2005). Childhood Obesity: Costs, Treatment Patterns, Disparities 

in Care, and Prevalent Medical Conditions. Thomson Medstat Research Brief. Retrieved at 

http://www.medstat.com/pdfs/childhoodlobesity.pdf. 21 Rosenbaum, S., Wilensky, S., Cox, M., and Wright, D.B. (July, 2005). Reducing Obesity 

Risks During Childhood: The Role of Public and Private Health Insurance. Retrieved at: http:// 

www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/Obesity%20Report%20 

Final.pdf. 22Wilensky, S., Whittington, R., Rosenbaum, S. (October, 2006). Strategies for Improving Access to Comprehensive Obesity Prevention and Treatment Services for Medicaid-Enrolled Children. Retrieved at http://www.gwumc.edu/sphhs/departments/healthpolicy/chsrp/downloads/ 

RWJ%20Medicaid%20Obesity%20Policy%20Brief.pdf. 

• The Healthy Places Act (S. 1067/ H.R. 398), sponsored by Senator Obama would 

among other provisions, require the Secretary of Health and Human Services to establish an interagency working group to discuss environmental health concerns, particularly concerns disproportionately affecting disadvantaged populations. • In addition, we are pleased that Senator Bingaman will soon introduce comprehensive legislation that would effectively address the public health threats of 

overweight and obesity by requiring unprecedented collaboration and collective action across agencies, between private and public entities and industries, and involve 

individuals and communities in generating solutions and addressing the childhood 

obesity epidemic. 

(3) Enact a Strong Reauthorization of the State Children’s Health Insurance Program (SCHIP). In order to be healthy, children need reliable access to 

routine health care. The research is clear that children without health coverage 

often lack the routine medical care that helps to prevent or address childhood obesity while in its early stages. Children in low-income working families—the very 

children who are eligible for coverage under SCHIP—are often those most at risk 

of becoming obese. We urge Congress to enact the strongest SCHIP reauthorization 

possible to improve access, coverage, and health outcomes for low-income children, 

with a particular focus on the 6 million children who are eligible but unenrolled in 

SCHIP or Medicaid. 

We should also note that the SCHIP reauthorization language already passed by Congress on three occasions, included $25 million for demonstration grants to develop a comprehensive and systematic model for reducing childhood obesity. This is 

a small investment but, even if it is only a starting point, one that we hope to see 

included in any reauthorization bill. 

(4) Ensure Coverage for Obesity-Related Services in SCHIP. Because most 

private insurance plans do not provide explicit coverage for obesity-related services, 

these benefits may not be a part of benchmark plans from which stand-alone SCHIP 

coverage is developed. Basic anti-obesity benefits should be covered under SCHIP 

for its beneficiaries. Precedent exists for this coverage; Medicaid currently covers 

medical nutrition therapy for beneficiaries with diabetes or renal disease, but that 

benefit may not be adequate for children. 

(5) Provide Guidelines for Childhood Obesity Health-Care Related Treatment Under Medicaid’s Early and Periodic Screening & Diagnostic Treatment (EPSDT) Benefit. Children covered by Medicaid are nearly six times more 

likely to be treated for a diagnosis of obesity than children covered by private insurance.20 The George Washington University School of Public Health and Health Services and Center for Health Services Research and Policy recently reviewed existing 

Medicaid benefit codes, and found that Medicaid, under its EPSDT benefit, can 

cover comprehensive, obesity-related pediatric health care services.21 22 The researchers found that most State Medicaid manuals however, do not provide clear 

or adequate information about coverage levels and appropriate reimbursement codes 

for specific elements of care. Providers, therefore, remain uncertain about which 

services they can provide and if they can be reimbursed. 

Given this lack of clarity, the Centers for Medicare & Medicaid Services (CMS) 

should take immediate action to: 

• Disseminate information about the importance of childhood obesity risk to State 

Medicaid programs; and 

• Augment existing CMS guidelines on EPSDT with special guidance on using 

managed care, integrated service delivery and disease-management techniques to 

develop comprehensive prevention programs for children at risk of obesity. 

(6) Improve Nutritional Standards for Competitive Foods and Beverages 

Served in Schools. Nutrition in school lunches is ‘‘substandard,’’ and the only Federal regulation of the competitive food environment in schools is the restriction of 

‘‘Foods of Minimal Nutritional Value’’ (FMNV) during meal times. This regulation 

is dated, and should be revised. The Child Promotion and School Lunch Protection 

29 

Act (S. 771/H.R. 1363), sponsored by Senator Harkin, would require the Secretary to 

update the definition of FMNV to comply with nutrition science, and would set nutrition standards for all foods served in schools campus-wide and across the entire 

time span a school is open to children. 

As our recommendations highlight, childhood obesity is not just a health care 

issue—it is an education issue, a transportation issue, an agriculture issue, an economics issue, and a public health issue. Given the complexity of the problem, it is 

easy to see why responsibility for addressing it is passed from one agency to another. No one ‘‘owns this issue.’’ We must ensure that all Federal agencies with a 

role to play, including the Centers for Disease Control and Prevention, National Institutes of Health, Department of Agriculture, and Department of Transportation 

work together to address the childhood obesity epidemic. 

It is time for the Federal Government to stand up, take notice, and take action 

to address the childhood obesity epidemic. While the health of our children is our 

paramount concern, the costs associated with obesity-related diseases are too staggering to ignore. We urge Congress to back the kind of proactive, coordinated and 

sustained response the childhood obesity epidemic warrants. In a glimmer of good 

news, the data and research also show that we can reverse the current trend and 

lower the incidence of a host of deadly diseases associated with obesity if we take 

action now. 

Thank you for your leadership, and for the opportunity to provide this testimony. 

I welcome any questions you might have. 

Senator DODD. Thank you very much. We have been joined by 

your former boss, Senator Bingaman. 

He did a good job, Jeff. 

Senator BINGAMAN. He did a good job. 

Senator DODD. Yes. I will leave his testimony for you to read. 

Let me turn to my colleagues just for some opening comments, 

if they would like to make one. I mentioned earlier before you arrived, Tom, what a leader you have been on this issue and, as 

Chairman of the Committee on Agriculture, fighting all the time to 

see to it that there has been a greater emphasis on the quality of 

nutrition and food that children eat, efforts in our schools, and the 

like. Just a long-time champion of this issue. 

Do you have any opening comments? 

STATEMENT OF SENATOR HARKIN

Senator HARKIN. Well, thank you, Mr. Chairman. 

I would just say to my friend and my Chairman here that if you 

really want to find the person who has really been the leader on 

children’s health and children’s welfare for the last 20 years, you 

need no further than to look in the mirror. 

Senator DODD. Well, thank you. 

Senator HARKIN. Because Chris Dodd is well known all over this 

country for being the champion of children and families. The Family and Medical Leave Act being perhaps one of the biggest highlights of his political career, getting that passed for families all 

over America and for our children. 

I just thank you very much for having this hearing and spearheading this. I know we are having another hearing next week, Mr. 

Chairman. I thank our witnesses for being here. 

I just ask that my statement be made a part of the record—— 

Senator DODD. Absolutely. 

Senator HARKIN [continuing]. And would look forward to an 

interplay on questions and answers with the panel. 

[The prepared statement of Senator Harkin follows:] 

30 

PREPARED STATEMENT OF SENATOR HARKIN

Thank you, Chairman Dodd and Senator Alexander, for calling 

this very timely hearing, this afternoon, to examine the impact of 

the childhood obesity epidemic on the child’s well-being and next 

week to discuss real solutions that can be done to address this crisis. I have been looking forward to this hearing on this topic and 

appreciate this opportunity. 

Mr. Chairman, a number of leading health experts are now predicting that the generation of kids growing up today could be the 

first to live a shorter lifespan than their parents. One significant 

reason for this is the obesity epidemic. 

As we will hear from the panelist, obesity takes a frightening toll 

on a person’s health. It can lead to diabetes, heart disease, high 

blood pressure, cancer, and numerous other chronic diseases—all of 

them major causes of death. It is a shocking fact that more rates 

of childhood obesity has nearly tripled since 1980. 

And the toll on children is especially disturbing. On the macro 

level, childhood obesity is a national public health crisis. But on 

the individual level . . . for each child afflicted with this condition 

. . . it is something else. It is a tragedy. A past Yale University 

study concluded that overweight children are stigmatized by their 

peers as early as age 3. They are subjected to teasing, rejection, 

and bullying, and are two to three times more likely to report suicidal thoughts as well as to suffer from high blood pressure and/or 

diabetes. The author of the study concluded: ‘‘The quality of life for 

kids who are obese is comparable to the quality of life of kids who 

have cancer.’’ 

There have been several studies by the Institute of Medicine, 

Trust for America’s Health and other that have reported on childhood obesity, and have offered excellent blueprints for a comprehensive national response to the obesity epidemic, with a strong 

emphasis on wellness and prevention. They all consistently call to 

individuals and families, as well as to schools, employers, communities and the food industry. Most of all it is a clarion call to Congress. It is time for us to act. 

I look forward to hearing from the witnesses today and next 

week to explore further areas where Congress should act. My 

broader ambition is to transform America into a genuine ‘‘wellness 

society’’ and to bring this public health discussion into the larger 

health reform debate. How do we recreate America as a ‘‘wellness 

society’’ . . . a society focused on physical activity, good nutrition 

and disease prevention—keeping people off pills and out of the hospital in the first place. And, as the Irish say, this isn’t a private 

fight; anyone can join in. Schools, communities, Corporate America 

and government at every level—they all need to be part of the solution. And we need it now. 

So again, I am grateful to the Chairman for calling this important and timely hearing. 

Senator DODD. Lisa, any opening comments? 

STATEMENT OF SENATOR MURKOWSKI

Senator MURKOWSKI. I want to thank you as well, Mr. Chairman. 

31 

Listening to the panelists this afternoon, it has become frighteningly evident that we are talking about an epidemic in this Nation. 

When we think about how we treat other epidemics, we have a national strategy. We have a plan, and we are going to take control 

of whatever the epidemic may be. 

We are not focused on obesity as a nation as we should be, and 

I am very fearful that once you lose that first generation to this 

epidemic, it is going to be so difficult to later address it. I applaud 

you for your leadership. I have enjoyed the opportunity to work 

with you, Senator Harkin, on the issues of nutrition. 

I think we are starting to make some headway. We need to get 

parents, school administrators, teachers, families and policymakers 

engaged in this national epidemic because our children’s health is 

at stake. As all of you have mentioned, the costs to us as a nation 

are staggering. 

Senator DODD. Yes, I tell you, all the statistics can be numbing, 

I suppose, and it can end up glazing over your eyes if you let them. 

The two statistics that I kept on reading last night. In fact, I called 

the staff. I said this can’t be right. You have the numbers wrong. 

This is a typo in the memo they wrote for me. 

The fact that only 8 percent of our elementary schools and less 

than 6 percent of our middle schools and high schools have any requirement of physical activity. It just—to me, it is one thing to understand what happens when people go out and make bad choices 

about the food they eat. But the school, you would think, the value 

of just the learning ability of a child to know that physical exercise 

is so important for so many other reasons, not to mention the one 

that is before the subject matter of the committee today. 

It is just hard to imagine that has happened. That many, that 

92 percent of our elementary schools have no physical activity of 

their children. 

Senator Bingaman. 

STATEMENT OF SENATOR BINGAMAN

Senator BINGAMAN. Thanks very much for having the hearing, 

Mr. Chairman. 

It is a very important issue, and I particularly wanted to be here 

with Bruce Lesley here. He did guide me on these very issues for 

many years working here in the Senate and did a great job here 

and is doing a great job now. 

I am anxious, when we get to the question part, to explore what 

we can do with some of the specific Federal programs that are currently in place to try to deal with this issue—the SCHIP program, 

for example, Medicaid, some of these programs that ought to give 

us some leverage in reaching this group of young people that we 

are trying to help. 

At any rate, thank you again for having the hearing. 

Senator DODD. Thank you very much. 

Let me start, if I can, Dr. Levi, with you. Just some questions 

that was noted in here. As I mentioned, the focus here will be on 

how to address the epidemic, but I wanted to ask you something 

about your testimony. You mentioned in your report—again, numbers just sort of jumped out at me last night reading your testimony in anticipation of the hearing today—that an investment of 

32 

$10 per person per year in proven community-based programs 

could save the country more than $16 billion annually within 5 

years. 

Let me ask you about four or five questions around this. Certainly what is community prevention? What types of interventions 

does this entail? Who would implement the interventions? Who 

would reap the benefits? I think that one may be more obvious. 

Can you give us some examples of community-based programs that 

have yielded some successful results to give us some idea of some 

models that are actually producing these kind of results? 

Dr. LEVI. Sure, Senator. 

Senator DODD. How did you get at these numbers? Where does 

that number come from? 

Mr. LEVI. OK. This was a collaborative effort that Trust for 

America’s Health engaged in with the Urban Institute, with economists there for a developed model. We worked in conjunction with 

the New York Academy of Medicine and Prevention Institute out 

in California as well. The goal here was really to look at how we 

can take on these problems before they become medicalized and see 

whether there actually is a value, an economic value to engaging 

in these programs and reducing healthcare costs. 

The process that we went through was really to identify the most 

expensive chronic diseases in the United States, and a lot of them 

relate to obesity, and what kind of community-level interventions 

are they amenable to. We sort of did a crosswalk of those. 

When you look at whether it is heart disease, diabetes, stroke, 

even some cancers, and arthritis, and you look at some of these 

very expensive conditions and you look at what sorts of interventions could actually prevent them or mitigate them, it ends up 

being physical activity, nutrition—how much we eat and what we 

eat—and also smoking cessation. 

What we discovered in reviewing the literature was that there 

are a lot of very effective community-level programs. By community-level programs, we mean things outside of the clinic. We don’t 

have to medicalize the solution to all of these problems. It can be 

everything from making a community more walkable, improved 

street lighting, creating sidewalks, promoting programs like Safe 

Routes to Schools that encourage kids to walk to schools, improving 

the quality of school lunches, doing menu labeling so that people 

know what they are about to buy in a restaurant, doing some social 

marketing campaigns to encourage people to exercise more and to 

eat better. 

Usually it is a combination of several of these approaches that 

together make a community-level intervention. We have seen a 

number of very successful programs along those lines. Shape Up 

Somerville is one, where the community of Somerville, MA, came 

together and said here is the problem. Here are some of the things 

we can do, and they adopted a series of initiatives that targeted 

kids, targeted the physical environment, targeted adults, and together achieved some major changes. 

The YMCA is doing some phenomenal work in a number of cities 

around the country in bringing—you know, we talk about needing 

a plan to address this problem, and we do need a plan. We need 

a national plan, not just a Federal plan, though, because every secVerDate Nov 24 2008 14:45 Jan 26, 2010 Jkt 035165 PO 00000 Frm 00036 Fmt 6633 Sfmt 6601 S:\DOCS\43703.TXT DENISE
33 

tor of society has a role to play. The beauty of what the YMCA is 

doing is it is convening local communities, business, transportation, 

schools, health departments, everyone who could possibly—families, community-based and faith-based organizations—everyone 

who could play a role and getting them focused on this problem. 

I think that is what we mean by community-level prevention. 

What we did when we looked at the literature was we saw that 

these can have a dramatic impact on disease. In fact, the literature 

supported probably more than a 5 percent impact on things like diabetes and hypertension if you successfully implement these kinds 

of programs. 

With just a 5 percent effect, within 5 years, you are going to see 

a return on investment of $16 billion a year, and we looked at 

these programs and found that they were not expensive—$6 to $8 

a year. We did the model based on $10 per person per year so that 

we could be relatively conservative. 

When you looked at it, it showed that if we provided more money 

for these kinds of programs, we would see a lot of savings. But who 

benefits? That is the challenge, the policy challenge that we face. 

Public health invests in these kinds of community-level prevention initiatives, but it is the Medicare system, it is the Medicaid 

system, it is private payers who benefit. The policy challenge we 

face then is to do the crosswalk back and say how are we going to 

find the resources for these kinds of interventions? If we find them, 

how can we get those who benefit to contribute to the solution? 

Senator DODD. Yes, and it occurs to me, too, I don’t know what 

Somerville is, the demographics of Somerville. Is it upscale? 

Mr. LEVI. It is not an upscale community at all. 

Senator DODD. Making the connection at the local level for the 

value because they are local investments you are talking about? 

Mr. LEVI. That is right. 

Senator DODD. Streetlights, sidewalks, you have got to make that 

nexus, it seems to me, for that local board of select men or city 

council, whoever makes those decisions on those investments is 

going to have to make the case to the taxpayers there that there 

is payback. 

Mr. LEVI. That is right. 

Senator DODD. How do they do that? 

Mr. LEVI. Well, this report will show, on a state-by-state, basis 

how much private payers will save, how much Medicaid will save. 

You know, the private payers are really the employers of the local 

community. 

Senator DODD. Yes. 

Mr. LEVI. They have a vested interest in doing this. A lot of private employers are engaging in wellness programs, but those 

only—— 

Senator DODD. Would insurance companies be interested? For instance, if a community does these things, then the rates for people 

who live in that community might come down? 

Mr. LEVI. One would hope that they would. Certainly the costs 

would come down, and the question is how can we harness some 

of those savings to promote these kinds of activities. 

Senator DODD. You mentioned the U.K. Tell us about the U.K. 

34 

Mr. LEVI. United Kingdom has done what Senator Murkowski 

suggested, which is to take a look at this problem and actually did 

their own modeling and saw the projections of—— 

Senator DODD. Their problem was a serious one, was it? 

Mr. LEVI. Very serious. Not quite as bad as ours, but on a very 

similar trajectory. They are just a few years behind. 

They made a decision that this required a national strategy, a 

national strategy that didn’t just focus on medical intervention, 

though that certainly is part of it, and having appropriate medical 

counseling and access to appropriate services for people who are 

trying to control their weight and increase physical activity is important, but also literally remaking communities. 

They have made a commitment to remaking communities to promote physical activity, to improve the quality of food in any kind 

of public facility, whether it is schools or hospitals, to change the 

norms in a society, and that is what we are really talking about. 

Smoking cessation is probably a very good example of how we 

have, in a generation, dramatically changed people’s attitudes and 

perceptions around smoking. Now, I don’t want us to be stigmatizing people who are overweight or obese in the way, to some degree, we stigmatize people who smoke. But we can with social marketing, with education, with appropriate medical support, with 

changing the physical environment—that is what we do with smoking. We don’t make it possible for people to smoke in certain places. 

If we can change the physical, social environment around issues of 

physical activity and eating, then we probably can see a similar 

change as we have with smoking. 

Senator DODD. Thank you very much. I have a bunch more questions, but let me turn to my colleague. 

Senator Murkowski. 

Senator MURKOWSKI. I wish it were easier. I am sitting here listening to all of this and thinking, we do a pretty good job in terms 

of incentives if you are an adult working for a company. Many companies have a wellness plan—in many instances the company helps 

pay for your club membership so that you can go and work out. It 

is limited to working people—adults. So, we are basically leaving 

kids on their own. 

There was a time when kids played. They were very physical, but 

now our children don’t play the way they used to. I am convinced 

our children don’t know how to play the way we did. I have a 15- 

year-old and a 17-year-old, and I make sure they know how to play. 

But they grew up in an outdoors environment which was relatively 

safe. 

I didn’t have to worry about monitoring them like we do now 

with our children living in the cities. I didn’t worry that they were 

going to fall off the monkey bars and break a leg, and I was going 

to end up going after the city for not maintaining the park. It is 

a different world that our children are growing up in, and they 

really don’t spend time learning and understanding the physical 

aspect of playing. 

I worry about how we teach our children to accept exercise as 

something that is fun instead of something that you are forced to 

do. I absolutely support additional physical education within our 

schools. I, too, am stunned by the statistics. 

35 

When you have physically active kids sitting in a classroom environment hour after hour, if they have a good recess, where they are 

out racing around, they can come back and focus—their education 

can benefit from that physical exercise. We don’t want our kids to 

associate physical exercise with something that you have to do because, as adults, it will make it that much more difficult. 

Our problems are just overwhelming. I don’t even know where to 

begin with a question. Keeping along the lines of physical education and the opportunities that we provide for our kids, I am 

told, when I go back to the State, that No Child Left Behind and 

the confines of that law are taking us away from the opportunity 

for more exercise in the school. We are focusing on the reading, 

writing, and arithmetic instead. 

I am also finding that it is not so much that there is not enough 

time in the school day, but we are having a real challenge finding 

P.E. teachers. We are having a real challenge finding health teachers. Much of it stems from the funding component, that we are not 

putting the money there. Am I right? Am I wrong? What is your 

experience? 

Dr. KAUFMAN. Well, I just wanted to mention that for the National Institutes of Health, I chair a study that is going on now 

called the Healthy Trial, and we are looking at a cohort of over 

6,000 children in 42 middle schools in 7 cities across the country, 

and following them from sixth through eighth grade. 

Half of the schools we have intervened on, and part of that intervention, there is a food service component. There is a curriculum 

component. There is a social marketing component. There is also 

a physical activity, physical education component. 

When we got to these schools—so these schools all had to have 

at least 50 percent minority children and at least 50 percent of the 

children eligible for free lunch. You can imagine what some of 

these schools were actually like. There was a gym area that was 

minute. They put 80 kids in there with one teacher. 

We have actually worked with the schools, found strategies. We 

have gotten a physical activity aide for the teacher. We couldn’t actually hire more teachers, but we could hire an aide, a relatively 

low pay scale, most of them college kids who are looking for some 

outside work. 

We have been able to take these kids from, when we started, 5 

minutes of physical activity in a 45-minute P.E. class to 22 minutes 

of moderate to vigorous physical activity without a huge change in 

what actually has been happening. These children have just finished seventh grade. In another year, they will finish eighth grade. 

There are hard outcomes, physical outcomes, medical outcomes 

that we are looking at in this cohort. If they have become healthier 

and less risk for diabetes and cardiovascular disease, we are hoping 

that this will serve as a model for how schools can fundamentally 

change comprehensively to enhance the health of our children. 

Mr. LEVI. I think it is also important to point out, Senator, that 

this link to No Child Left Behind is, to some degree important, but 

in some respects specious in the sense that there is data now to 

show that kids who are more physically fit, more physically active 

will perform better academically. 

36 

Part of complying with No Child Left Behind in some respects almost demands greater attention to physical activity so that the 

kids will score better. It is an indirect approach, but it really can 

make a difference. 

Now, ideally, if No Child Left Behind addressed physical activity, 

that probably would promote more attention as well. I also think, 

what Dr. Kaufman pointed out, that having P.E. alone is not sufficient. It is what happens in that P.E. class activity, and it doesn’t 

even have to be a formal P.E. class, that you can introduce things 

into the school setting that encourage physical activity. 

Dr. KAUFMAN. Yes, they like hula hoop. They like dancing. I 

mean, it is not necessarily everybody who is going to go for a competitive sport. There are a lot of activities that the children want 

to do. When you give them a menu and they make some of the decisions, then they are much more engaged. 

Senator MURKOWSKI. When you think about what we are trying 

to do in the schools, which is to teach you to be a lifetime learner, 

to make your life better every day by learning something new, we 

also should be teaching kids about their bodies and how to be 

healthy for a lifetime. 

It is not just talking about nutrition, although that is incredibly 

important, but the exercise component and how it makes you a better human being in the sense that everything is going well if your 

body is more physical and more fit. 

Mr. Chairman, I am over my time. We could spend all afternoon 

here. 

Senator DODD. Thank you very much. 

Senator Harkin. 

Senator HARKIN. I am like Senator Murkowski. It is hard to 

know where to begin on this. 

Jenelle Krishnamoorthy on my staff, whom I know works with 

some of you, just gave me this. The Journal of the American Medical Association today came out with a report on moderate to vigorous physical activity from ages 9 to 15 years and showed how it 

decreased in those years. You know, when you are 9 years old, you 

play more and you are active. By the time you are 15, you are not 

doing anything. 

Senator DODD. Right. 

Senator HARKIN. I haven’t read the whole thing. I was just looking at the data here, but it said that expert opinion and empirical 

studies suggest that children need a minimum of 60 minutes of 

moderate to vigorous physical activity per day, a standard proposed 

by the U.S. Department of Agriculture. 

Sixty minutes. When I was a kid, I remember we had 15 minutes 

in the morning, a half hour at lunch, and 15 minutes in the afternoon recess. We had to go outside and play. Unless it was 20 

below, maybe you stayed in at that point. That was about the only 

excuse—— 

Senator DODD. Which was about three quarters of the year. 

[Laughter.] 

Senator HARKIN. That is Alaska. That is Alaska. 

How do we change the framework of the debate? I keep listening 

to candidates for President, no matter when. Everybody is running 

around, all the debate on healthcare in America is how do we pay 

37 

the bills? In essence, when you boil it all down, that is all we are 

talking about. How do we pay the bills? National health insurance, 

single payer, all that kind of stuff is how do we pay? 

How do we change that framework to how do we prevent? How 

do we start changing the framework of that debate? Now part of 

the problem in the past has always been, well, you have to pay the 

bills because if you get into prevention, that just costs more money. 

It costs more money, and we can’t take money out of the pot right 

now because there is not enough there to meet the needs of 

healthcare right now for low-income people. 

It has been kind of a catch-22 situation. We know we have to do 

prevention, but we don’t have the money to do it. 

Now the report that you have just come out with, the Trust for 

America’s Health that will be made public tomorrow, shows that 

the rate of return on that investment is about 1 for 1 in 1 year, 

and that is at a very low investment rate of $10 per person. Think 

what it would be like if we invested $100 per person or more. It 

is a very timely study that the Trust for America’s Health is coming out with. 

How do we change this framework? How do we start getting people, and our candidates who run for office on both sides of the aisle, 

to start thinking about how we change the framework of the debate? 

Yes? 

Senator DODD. Dr. Grey. 

Ms. GREY. One of the major issues is we have spent most of the 

last 20 years blaming the people who are obese and say if you just 

wouldn’t eat more, if you just would exercise more, then you 

wouldn’t have this problem. Well, clearly, that hasn’t worked. 

It is really about changing the perception and thinking about 

very early on how you bring the right people to the table to change 

things. I will give you an example. 

We know very clearly that children of pregnant women who do 

not lose their pregnancy weight are more likely to have children 

who are overweight or obese by the age of 2. The weight gain trajectory for those children will be like this compared to those children of those women who have not gained weight. 

We pay lots of money to take care of acutely ill babies, but we 

pay no money to help women postpartum lose pregnancy weight. 

We have to reframe the debate about not just healthcare and not 

just individual responsibility, but how do we create opportunities 

for communities and others to participate in this? 

One of the things we did in New Haven about 10 years ago—in 

collaboration with your good friend Senator Toni Harp—we created 

a coalition to fight childhood obesity. It was a grassroots effort in 

New Haven that didn’t engage the healthcare providers. I was the 

only healthcare provider involved. 

It was a group of parents, religious leaders, city officials, including the city planner, and others who said, ‘‘Oh, my gosh, this is a 

terrible problem. We really must do something about that.’’ That 

coalition is the coalition that went to the schools and said, ‘‘get the 

sodas out of here.’’ There is a law in the State of Connecticut that 

says these should not be available during the school day. 

38 

Well, we have the system where the schools can only pay their 

bills by collecting this information or paying for this soda. What 

they did was they put healthier choices in there, and guess what? 

They didn’t lose any money. 

Senator DODD. That is right. 

Ms. GREY. We started a system called Walking Buses. This is one 

of the things they do in England that is really wonderful for innercity kids. You have adults who aren’t getting much activity, who 

aren’t working, who take a group of 5 or 10 kids from the neighborhood and walk them to school, and we create environments that 

are safe that allow them to walk 10 blocks to school every day and 

walk 10 blocks back. 

Those aren’t huge changes, but it takes the community buying 

into this isn’t just a self-responsibility problem. This is a societal 

problem. 

Mr. LESLEY. Senator Harkin, I also think it is this issue of it is 

a national plan, as Dr. Levi talked about, but it is also kind of 

place-based policies. It is stuff that is reflected in all of the legislation you all work on in terms of if you look at the school, it isn’t 

just the school lunch. It is the school lunch, but it is not just that. 

It is the school nutrition program. It is the P.E. program. It is 

also the afterschool program and the community involvement in 

that, and it is things like figuring out ways for kids to walk to 

school. It is also access to fruits and vegetables, which it is your 

bill that really did get fresh fruits and vegetables into the schools. 

There was a Washington Post series that talked about where in 

Fairfax County they got rid of the french fries in the schools, and 

2 days later, it was the parents who had the revolt. We also need 

to get the community parents to understand why we are doing 

these kinds of things. 

In my neighborhood, the elementary school just happens to be on 

the other side of a major street. I would bet that 90 percent of the 

parents in our neighborhood drive their kids to school, and it is just 

getting a crossing guard right there. That is all it would really 

take, and I would send my—but I drive my kids to school because 

of those kinds of things. 

It is really the community thinking about the issue and talking 

to one another. I profess that I have been part of the problem. Senator Bingaman came up to me one day when I was working in the 

Senate and said, ‘‘The Ag bill is on the floor.’’ I looked at him and 

said, ‘‘Yes, I am your health L.A. So?’’ 

His point was, yes, and there is an obesity issue, and we worked 

with your office and all of your offices on kind of an amendment 

to the Ag bill to improve this issue. It is this transportation, 

healthcare, education, and health. It is very comprehensive, and 

people don’t speak to one another about it. 

Senator HARKIN. I guess I get frustrated because I watched all 

the debates of our candidates who are running for President. I 

watched all the debates—— 

[Laughter.] 

Senator DODD. One of those unique Americans. 

Senator HARKIN. Whether it is on the Democratic side or the Republican side, I watched those, too. Every question that would 

come up on healthcare was always about how are we going to get 

39 

health insurance to everyone? How are we going to cover everybody? How are we going to pay the bills? 

Senator DODD. Yes. 

Senator HARKIN. I kept waiting for one questioner to say, you 

know, we know that prevention works and we get the payback on 

it, what is your idea, so-and-so, about how we can change America 

to be a wellness society and prevent illness? No one is ever asking 

that question. 

Therefore, our candidates start thinking, well, I know the question is going to come, and it is going to be on how we pay the bills. 

And so, I will get up on that. It is very frustrating. 

I keep hoping that sometime the questioners of our presidential 

candidates will start grilling them on prevention and what it 

means and what community wellness means and how we get our 

communities to think about wellness programs and using examples. Like Portland, OR, who has done a great job as well as other 

cities and some schools, and what different schools are doing for activities. 

Then just talking about our school systems and our food programs, next year we have the reauthorization, Chris, of the child 

nutrition bill—school lunch and school breakfast. Well, I would like 

to have our candidates talking about what changes do you think we 

ought to have in the school lunch program so that our kids have 

better food in schools. To me, this is a key part of our wellness in 

society and how we are going to prevent illness in the future. 

But those questions don’t get asked, and that is why I get kind 

of frustrated. That is why I ask you how do we change this paradigm? 

I am thinking Senator Murkowski and I worked very hard together to get a change in the foods minimal nutritional values 

done. We didn’t get it on the Farm bill, but the child nutrition bill 

is our key to get it done next year. We tried to get it on the Farm 

bill but wasn’t successful. 

What should we be thinking about in the child nutrition bill? 

What should we be thinking about and how should we change the 

school lunch and school breakfast programs? 

Mr. LESLEY. Yes, I would also add that you also have opportunities next year with SCHIP coming back up for reauthorization in 

March, and in the final bill that all of you voted for in the Senate, 

it had a demonstration project on childhood obesity. 

It is interesting, on the Medicare side, I worked on a bill for Senator Bingaman on medical nutrition therapy in Medicare, but it 

seems to me that the emphasis you are putting on this hearing 

today is we should be thinking about all our public programs and 

including the child nutrition programs, the Children’s Health Insurance Program. 

One of the things even we were looking at recently was the Maternal Child Health Program and the fact that in the Maternal 

Child Health Program there is no emphasis on this issue because 

it hasn’t been reauthorized in a number of years. 

One thing, to speak to the issue you raised, is the WIC program 

still serves whole milk and sweet and flavored milk. Why are we 

not providing the no fat alternatives and those kind of things. We 

hope to work with you on things like that next year. 

40 

Dr. KAUFMAN. In the reauthorization of the school lunch program, there is a lot of data, in a number of studies that I have 

looked at, of what some of those criteria should become. In this 

school study, we wanted to increase fiber. There is no real requirement for fiber. We put out first the high-fiber, high-grain buns, and 

the children had no idea what it was. First, we had to just put the 

one on the bottom and then the white one on the top. Then, eventually, they kind of got used to it. So it is not going to be an immediate shift. 

We are still looking at trays in our schools. I mean, these very 

vulnerable schools, and the schools we are in, 50 percent of these 

11-year-olds had a BMI greater than the 85th percentile. Actually, 

we did a pilot in the eighth grade of the schools—it is not the same 

cohort—but in those eighth grade students, we actually found 39 

percent had already an abnormal blood sugar level. 

These are incredibly vulnerable children, and they are still getting a Federal lunch program that is not weighted. The whole item, 

that whole tray for the week is kind of balanced out. Whatever 

they take, if it happens to be that 75 to 80 percent of the choices 

are the higher fat containing burrito than we would like to see, it 

is still acceptable. We had to get waivers around the number of calories in some of those lunches in some of our schools. 

Senator HARKIN. Or what they do is they cut down on the fat, 

and then they up the sodium. They pour the salt on. 

Dr. KAUFMAN. Right. Or they up the sugar. 

Senator HARKIN. Or the sugar. Sugar, both. 

Mr. LEVI. I think part of the message—and I think Dr. Kaufman 

could probably speak to this better, as more an expert than I, that 

part of the message that we need to communicate to folks is that 

relatively small changes can make a huge difference in terms of 

health outcomes. We don’t have to suddenly have a nation of thin 

people in order to see dramatic changes in the quality of life and 

the length of life and how healthy people are. 

In fact, one of the things in doing this report that I think was 

particularly surprising to me, even though I have read a lot of this 

material, was how very small weight loss, 8 to 10 pounds, can really dramatically reverse someone’s course in diabetes. 

Dr. KAUFMAN. Right. The diabetes prevention program, which 

was a massive NIH study, showed that in a very high-risk group 

of multiethnic throughout the age span of adults, a modest 

weight—7 to 10 percent weight loss, 30 minutes 5 times a week of 

just walking reduced the progression to diabetes in those who had 

pre-diabetes by almost 60 percent. 

Now that is out in the community. There is a huge effort of 

translating this phenomenal NIH data and the components of the 

study out into community venues. Those kind of things don’t belong 

inside the medical world. They belong inside the community and 

the workplace, where they are able to be done in a lot more effective and a lot more cost-savings way than inside a medical center. 

Senator DODD. Let me ask you, we have an awful lot of young 

people here in the audience today, and I was thinking of going back 

to the smoking issue, seatbelts in cars. One of the reasons it 

worked wasn’t because we just passed ordinances and laws, because actually children, in many cases, asked their parents to stop 

41 

smoking, insisted they put on the seatbelt in the car, became a 

great advocacy group. 

The issues of weight and self-image, and Dr. Grey, you have done 

a lot of work in this area, the psychological effects of obesity. I 

couldn’t help but think as well about the problem. I was with a 

good friend of mine today, and he knew I was going to conduct this 

hearing and has a child that is suffering from anorexia, the sort 

of antithesis of the issue, but, in effect, a manifestation of the same 

problem in some ways, self-image. 

All of the marketing techniques today, I mean, you open any popular magazine or what show it is, there is such a glorification in 

a way of a body type and style that I think it is difficult just in 

the sense of being a child and the kind of peer pressures associated 

with this that create its own dynamic. I regret not doing this, 

which I am tempted to do, I have never done this before in 27 

years here. If any of these younger people in this audience have 

any ideas about this, you could become a witness in a congressional 

hearing if you would like to come up. 

[Laughter.] 

If you have any thoughts about this. Because, really, the audience in a way can do so much. We can do a lot of these things, and 

Tom has been terrific and Lisa on these issues. I was going to ask 

Tom—I have never done this either. I have never asked a colleague 

a question during a hearing. Normally, we ask the witnesses. The 

Food Stamp Program, I just have given a lot of thought to this and 

haven’t come up with an answer for it because, obviously, we associate more expensive foods are more nutritious or the correlation 

is. 

Can’t we incentivize that Food Stamp Program in some way, 

where we reward a family that will, in a sense, take those food 

stamps to buy more nutritious food? There ought to be a reward 

associated or some way to encourage, to incentivize people moving 

in that direction. 

I wonder, Doctor, if you could—— 

Senator HARKIN. Mr. Chairman, could I respond to that? 

Senator DODD. Certainly, yes. 

Senator HARKIN. In the Farm bill we just passed, I put a provision in there that—and we are going to test this out. It kind of 

comes from Michael Pollan’s book. He was wondering why so many 

low-income people are so obese and why they have diabetes. He 

began looking into stores and finding out that low-income people 

use their food stamps to buy fast starches and sugars. They don’t 

buy fruits and vegetables because they are the highest prices. 

Fast starches and sugars are the highest subsidized things that 

we do in this country. I got to thinking about that, and I thought, 

you know, we don’t have food stamps anymore. We have an EBT 

card, electronic benefit transfer card, and it has a little black stripe 

on the back like your credit card. 

When you go through the counter, they swipe that card, and it 

deducts from your food stamp allotment whatever you bought, and 

then you know what you have left. You can encode on that stripe 

a lot of other things. For example, you can’t buy beer or wine or 

cigarettes or nonfood items with the EBT card. 

42 

If you go through and they have checked all the bar codes and 

stuff, and then you hand them the EBT card and they swipe it, and 

you have bought a six-pack of beer, that will come up and say that 

is not allowed. Or if you buy nonfood items, that is not allowed. 

They have to deduct that, and you have to pay cash for it. It can’t 

come off of your food stamps. 

I got the idea that maybe what we could do is encode that for 

fruits and vegetables. We have in the Farm bill money to set up 

a study on providing EBT cards to people so that if they go in and 

they see fresh fruit, for example, or produce. Let us say it is $4, 

that is $4 per pound or something. They know that if they buy 

that, it is only going to cost them $2. 

And human nature being what it is, we all love a sale. We always like to buy things that are cheaper than what is marked on 

the thing. If I use my EBT card and I go to buy potato chips and 

it is $4, and I know it is still going to be $4, but if I buy this and 

it is not $4, it is going to be $2, maybe I will start buying it. 

We have this study that has just started. The Department of Agriculture is trying to get the rules and regs for it. Hopefully, this 

will show that if you give a benefit to people on that EBT card, 

they will start buying fresh fruits and vegetables, hopefully. 

Senator DODD. Incentivizing. 

Senator HARKIN. Incentivizing. That is what we are trying to do. 

I just wanted you to know that has started, and hopefully, by next 

year, we will have a little bit of data on this, I hope. 

Senator DODD. Tell us, Dr. Grey, about the stigma and the psychological impacts. You have done a lot of work in this area. Is 

there a correlation between adults and children? I get the feeling 

from what you just said that it is obviously more pronounced 

among younger people than it is with adults that are—— 

Ms. GREY. Well, it seems worse, I think, in children because depression is a serious problem amongst youth. While the elderly are 

the most likely to commit suicide, teenagers are the second most 

likely. When you put together kids who have health problems, depression, and difficult life circumstances, it is a witch’s brew. 

Senator DODD. More associated with girls than boys? 

Ms. GREY. Both. It is actually slightly higher—actually, girls 

make more attempts, but boys are more likely to be successful. 

Part of the reason for that is boys are likely to use more violent 

approaches. They have higher access to guns and may shoot themselves, whereas a girl may take an overdose of aspirin and get sick 

but not complete a suicide. 

The issues around self-esteem and all of those things are highly 

related to the communities in which people live, and one of the 

issues that we face now that in many inner-city communities, 

where we have done most of our work, we are talking about kids 

where being obese is normal. There are whole issues about if a kid 

wants to make a change and starts to lose weight, then they get 

teased for being different because they are losing weight. 

This whole issue, from my point of view, is really about how do 

we normalize what is healthy, not what is skinny? In the AfricanAmerican community in which I work, the average teenager is 

overweight. When we start talking to them about weight loss, they 

43 

think we want them to look like Halle Berry. Well, they are not 

going to look like Halle Berry. 

If they can lose 5 percent of their body weight or at least stop 

gaining weight for a while, while they kind of grow into this, then 

they feel much better about themselves. The fact is a lot of these 

kids can’t be physically active because they are huge. These kids 

get mixed messages, boys in particular. 

We were talking earlier about kids playing football. In the junior 

high school, we are telling them, ‘‘You are unhealthy.’’ You weigh 

280 pounds, and the football coach is saying, ‘‘Keep packing on 

those pounds. You are a really good lineman on my football team.’’ 

We have to stop the double message. We have to be talking about 

what is healthy from a mental and physical point of view and stop 

normalizing the fact that it is OK to be that heavy. 

Senator DODD. Well, I am very interested as well in talking with 

you, Dr. Kaufman, about the link between obesity and diabetes. 

What proportion of people with obesity also have diabetes, and 

what proportion of people with diabetes is obese or overweight? 

Dr. KAUFMAN. Well, it is probably easiest with answering the 

second question. Those with type 2 diabetes, 90 percent are overweight or obese. In our pediatric group, it is 100 percent of these 

children. 

There is another trial that I chair for the NIH called the Today 

Trial—Margaret has been involved with it—which is looking at trying to really understand, characterize, and learn best treatment 

modalities from children who have already contracted type 2 diabetes. We have 15 sites across the country, and these children are— 

we had to buy new scales. I mean, a 350-pound child is almost 

close to our mean. 

Senator DODD. If a child has pre-diabetes, what is the likelihood 

that child will develop type 2? 

Dr. KAUFMAN. Well, we are hoping to answer that question more 

scientifically. For adults, we know that once you have pre-diabetes, 

there is about a 10 percent conversion per year. We know there is 

54 million Americans right now with pre-diabetes. So you can start 

to imagine that math. 

We are watching, not only this last year, an increase to this 24 

million, but at a higher rate of increase than had been seen before. 

One point three million more were added last year. 

We are still trying to sort out through a number of CDC and NIH 

efforts to characterize really what is happening in children, but we 

know that these children when they come to us, they are all overweight and obese. They come from families in which there is a very 

high prevalent rate of diabetes already. Most of the adults in their 

lives are failing in managing their disease. 

They are socioeconomically having a lot of issues attaining 

healthy lifestyle habits that we are working with them on. Of 

course, we are now providing healthcare, but a number of the children were having difficulty in access to healthcare. 

Senator DODD. I am asking you a couple of these statistical questions, and I ask you to just go back and do this. 

Dr. KAUFMAN. Sure. 

Senator DODD. Another one I had for you, I just was stunned and 

you referred to the healthy middle school study. 

44 

Dr. KAUFMAN. Right. 

Senator DODD. Thirty-nine percent of minority eighth graders 

were found to have pre-diabetes in your report. The question I have 

is how does this compare to the rate of diabetes in minority adults, 

No. 1, and what conclusions do you draw from the large disparity 

between the rate of pre-diabetes in the children you studied and 

the rate of diabetes in adult minorities? 

Dr. KAUFMAN. Well, we are applying adult criteria to these children. We are not sure they are the right criteria. 

Senator DODD. Yes. 

Dr. KAUFMAN. These children actually have a blood sugar level 

clustering right at the cut point. We are not sure whether part of 

that may be due to when you are overweight and you are going 

through puberty—puberty is a time of insulin-changing activity in 

your body, what we call insulin resistance. You know, puberty is 

a time of resistance, but insulin is one of the things that children 

are resistant to. 

We don’t know whether as they come back out of puberty that 

might normalize at a lower rate so that they don’t have pre-diabetes anymore. I can’t answer that question for you scientifically, but 

we will have the answers over time. 

We know that it is kind of a bad sign that you can’t handle the 

stress of puberty without having too high a blood sugar. If they do 

come back down to a more normal range, they are likely—unless 

we do something about their weight and their health status—likely 

then to emerge again as adults with pre-diabetes and then diabetes. 

Senator DODD. Yes. I will ask you this and then turn to Lisa 

again. 

I talked about this as an epidemic, and I use the word ‘‘emergency’’ carefully. We talk about—we use that word, we throw it 

around quite frequently to describe almost everything. It strikes 

me, looking at these numbers and looking at the studies that you 

have already done, even with the conclusions that you have drawn 

early on, that we are clearly in a medical emergency with this issue 

that is going to become exponentially larger. 

The point I think that Lisa made about—I think some of you did 

as well—that you let this generation slip into the next generation, 

because there is a direct correlation between obese parents and the 

likelihood of obesity among their children. So you start exponentially expanding that constituency. Then this problem becomes exponentially larger very quickly. 

Dr. KAUFMAN. Right. 

Senator DODD. Am I exaggerating this conclusion? 

Dr. KAUFMAN. Not at all. I mean, from the psychological to the 

medical reasons as children, during childhood, these children are 

very, very fragile from a medical standpoint. Then their long-term 

health is in tremendous question. 

There is no doubt that unless we do something and they continue 

to track with overweight and obesity, they will be the cohort of 

adults with cardiovascular disease, diabetes, cancer, and a whole 

host of other medical conditions. 

Senator DODD. Well, it is telling me so much that by looking at 

this, these are the kinds of problems you associate with adults. I 

45 

mean, having children taking—I guess it is good maybe. Having 

cholesterol problems, having strokes, heart problems, these are all 

things we would normally just associate with aging, not with youth 

at all. 

Have you done anything, have we talked to the military at all 

about this? Are they showing any signs of problems in recruiting 

or people coming into the military? 

Dr. KAUFMAN. We are partly funded in some ways from some of 

the military grants because there is so much diabetes developing 

in their young adult cohort. Once they have developed diabetes, 

they have to then care for them. They are looking at ways to instill 

diabetes prevention programs inside the military. 

Mr. LEVI. In fact, in terms of recruiting, it is a significant issue, 

and I mentioned this in my written testimony. In 1993, 25.6 percent of 18-year-old volunteers were overweight or obese. By 2006, 

that grew to 34 percent. Each year, between 3,000 and 5,000 service members are forced to leave the military because they are overweight. It is a huge problem, both in our being able to recruit people and also then the cost of retraining to replace people who are 

discharged. 

There is a certain irony, I think, in where we are today as opposed to 1965 when the Medicaid legislation was passed, and one 

of the things that compelled President Johnson to push for Medicaid was the difficulty—and this was during the period of the 

draft—that so many recruits were underweight and unhealthy, and 

today we have the reverse problem. It is a reverse national security 

problem. 

I think it also points to the comments that Bruce Lesley was 

talking about in terms of if you look at the populations who are 

probably volunteering for the military, were probably at some point 

touched by Medicaid in their lives, and maybe we also need to be 

looking at how Medicaid can address this issue so that when they 

do become of military age, they can successfully volunteer. 

Senator DODD. What I am struck by in your testimony is that, 

one, the magnitude of the problem, but the nonmedical responses 

to this make this preventable. 

Mr. LEVI. That is right. 

Senator DODD. We could really make a huge difference. 

Mr. LEVI. That is right. 

Senator DODD. That is the positive and the silver lining in all of 

this, to identify the problem. To recognize that we can do something about this now that we know what to do. 

I have been dealing a lot with autism and done a lot of work at 

Yale as well on autism. One of the confounding problems, we don’t 

really know what causes it. We don’t even know how to successfully 

treat it. I mean, it is really in a spectrum what can happen. 

Here, we know what causes it. We know how to treat it. We 

know what we ought to be doing about it. Unlike other areas, such 

as autism, this is one we can handle. 

Lisa, any additional questions? 

Senator MURKOWSKI. Just one final question to you. I am very 

active on the Energy Committee, and of course, what everybody in 

this country is talking about right now is the price of energy and 

46 

what they are paying at the pump, and what their family is paying 

out of their pocketbook for their energy consumption. It would appear that in this country when you hit about $4 at 

the pump, the American public started demanding action. Here in 

Congress, we are trying to figure out how we deliver on that. I am 

of the belief that it has to be a combination of increased production 

and increased renewables and less consumption, but this is a 

HELP hearing, and not an energy hearing. 

My point is, we have to identify what that tipping point is in this 

country when it comes to energy and how you have a public that 

is now demanding action. On the issue of obesity, are we at the tipping point yet? 

Do you think that Americans understand? Do you think that people understand—the statistics which you have all cited, which are 

phenomenal—that this is not just something that is happening in 

their town, but it is happening around the country? 

Do you think that people understand the connection between not 

only the consequences that you all have described—whether it is 

depression or other mental health issues—and then the cost to society and the medical costs? Do we sufficiently understand, as a nation, enough to push us over the edge so that we can have some 

definitive action? Are we there? 

Mr. LESLEY. I would say that the polling on this kind of issue 

is pretty interesting in that there is this national poll on children’s 

health that shows that adults definitely identify obesity as the top 

issue facing children. However, I don’t think that they get the connection in terms of what is it that we need to do. 

I think that it is kind of a problem with children’s issues generally of people care, but they don’t then see the linkages to the 

public policy. If you ask people specifically, do you care about children’s issues at the Federal level? They poll in the 80, 90 percent 

range. Then if you ask them is it a priority in what you are going 

to vote for, they don’t list it. Then if you ask them in a focus group, 

so you don’t care about these issues? They are like, of course, I do. 

There definitely needs to be a public education campaign, kind 

of like what we did around seatbelts and smoking and those kinds 

of issues, to really educate the public about—people get the issue. 

It is not an education of just stating that obesity is a bad thing, 

but it is what are all the things we need to do together as part of 

a national plan and commitment to addressing this issue and making people talk to one another? I think that is really one of the 

things missing. 

Senator MURKOWSKI. But we are not there yet. 

Dr. Levi, you seem to indicate that we are there? 

Mr. LEVI. Well, I think we are part of the way there. We just actually did some polling in conjunction with the release of our annual obesity report, which will be coming out shortly. We found 

that 63 percent of Americans now do believe the diseases related 

to obesity are a very important issue for government to focus on. 

I think translating from that to a specific agenda is the challenge, and I think, particularly with health problems, we have 

tended to want to look for magic bullets and for a pill or a vaccine. 

There isn’t going to be a pill or a vaccine for obesity—at least not 

yet—and in the meantime, there is so much we can do. 

47 

These behavioral changes are not easy and require really a lot 

of this norm changing that we have been talking about, the 

destigmatizing of changing what people value. That is going to take 

leadership from all of you, and it is going to take leadership from 

who is in the White House, and it is going to take leadership at 

the community level as well from every level. 

Senator MURKOWSKI. I think also it is going to take a recognition 

that it is everyone’s problem. None of you sitting here would be 

considered obese. I don’t know what your background is, but is it 

your problem? Yes. It is everyone’s problem. 

We are going to have to accept that we are all in this together. 

It is not the family next door that has an issue and they need to 

solve it on their own. We need to be changing our systems, changing the way that we think about diet and exercise and healthy lifestyles. 

In Alaska and our Native organizations, many of which have 

been pushing wellness initiatives to help deal with sobriety and 

drug abuse, and also the whole concept of wellness. As we talk 

about healthcare reform, as we talk about those ways that we can 

lower our healthcare costs—prevention, as Senator Harkin has 

mentioned, is just absolutely key. It is this greater concept of 

wellness, wellness of body, wellness of mind and attitude, and we 

are all part of the solution. It is not our next-door neighbor’s problem. 

Thank you for your contributions. I appreciate it. 

Senator DODD. I wonder if I made a mistake earlier in something 

I was suggesting. I was talking about eating disorders, and is 

bulimia and obesity—I have doctors here in front of me. What is 

the distinction in a sense, I mean? 

Dr. KAUFMAN. Well, in looking at weight issues, the very low 

weight, particularly woman, young adult woman, older teenager is 

a very distinct subset of the population who really are at risk for 

that, and they are quite distinct from the population who are at 

risk for obesity and obesity-related diseases. 

We have done a lot of evaluations in our community programs 

in Los Angeles, as well as in some of our school-based problems, 

to try to find out—because one of the big fears was would we be 

inducing anorexia now, with low weight and the medical issues associated with that, in these children as we were delivering schoolbased health programs. We are talking about health, talking about 

healthy behaviors. 

We have not seen any signal that that has changed at all. We 

don’t think this is a risk for inducing low-weight medical issues. 

Senator DODD. Do you agree with that, Dr. Grey? 

Ms. GREY. I do. 

Senator DODD. Yes, I said earlier I am so impressed that we 

have so many younger people, Lisa, here in the audience that have 

come here today. I have never done this before. 

Would any of you young people have any ideas you would like 

to share with us on the subject matter? You have heard these official experts. I have never—in 27 years, I have never asked the audience a question at a congressional hearing. 

Yes, ma’am? 

48 

AUDIENCE MEMBER. I just want to say, I am a Ph.D. candidate 

at the Johns Hopkins Bloomberg School of Public Health in international health and nutrition, and I am also an intern here at the 

National [Off Mike]. I think it is a dual issue of changing our food 

system here in the United States and around the world and also 

looking at how we can change our messages. 

We are talking about individual behavior, but it is not just limited to behavior because if you look at those who are most at risk 

for overweight and obesity, it is children and adults with lower income status. You can’t just ask the one person at their convenience 

and their time to join the gym or to eat healthier because it really 

is not possible. I think we need to really focus at a national level 

on environmental change as well. 

Senator DODD. Some of the things Senator Harkin talked about 

in terms of how we incentivize dietary changes and so forth and 

making available foods that are far healthier and the like, I think, 

is what you are driving at on this issue. 

Well, thank you. Anybody else in these young people in the audience? 

Yes, ma’am? What is your name? Tell me where you are from. 

AUDIENCE MEMBER. Hi, I am [Off Mike] resident at the University of Maryland in Baltimore. I think that the issue is multifactorial. We have families coming in that the parents are overweight, 

that the grandmother is overweight. Sometimes they don’t see it as 

‘‘we are overweight.’’ They just see it as ‘‘we are all just big people.’’ 

The family is looking at themselves like that, and they do not see 

it as an issue. 

When I show them the growth charts for the child to show that 

their child is above the 97th percentile and that it is an issue, 

when I try to tell them, well, let us think of different things you 

can do for your child. Just let us take out this little factor not just 

for the child, but for the whole household. Let us stop eating fast 

food two or three times a week. Let us have it once a week and 

then bring it down to once a month as more of a treat. Like, you 

did a good job at school today so this might be your treat. 

The fact that kids don’t have physical education in school anymore, some kids also don’t even get recess. Also another factor that 

is an issue is when I ask the parents, ‘‘Well, do you feel safe in 

your household?’’ They feel safe inside the house, but they don’t 

feel safe outside. Therefore, their kids don’t get the chance to go 

outside to play. They can’t go outside to play. The parents’ thinking 

might be, well, you know what? I would rather my kid be big than 

worry about whether they are going to get shot at when they are 

outside playing. 

The issue isn’t just something of do we make sure that we have 

appropriate foods in the school, but we need to make sure that we 

also have physical activity for these kids, that they can feel safe 

in their local environment, but also that the parents understand 

that this is a problem. It isn’t normal for your child to be this size, 

to be 50 pounds when you are 2 years old. They need to understand 

this is an issue that is not just an issue for the child, but an issue 

for the whole family, and the whole family needs to be onboard. 

Because if we tell them, ‘‘Well, this child needs to work on losing 

weight,’’ I don’t just say it is only for the child. The whole family 

49 

has to make a lifestyle change. You take all of the cookies out of 

the household, and no one is eating cookies at home. And you take 

all of the soda out of the household. If you want soda, then it needs 

to be diet soda because there is no sugar in the diet soda. 

I think it is not just looking at one particular issue, but it is looking at everything within the household, within the community, 

within the environment. 

Senator DODD. I think the next hearing we are going to invite 

both of you to be witnesses. 

[Laughter.] 

It is very good, excellent. It is encouraging to know you are 

thinking this way. We have people out there working this. 

Anybody else on a point they wanted to raise at all? Yes, ma’am, 

there is someone I can only see your hand. Yes? 

AUDIENCE MEMBER. Hi. My name is [Off Mike]. I am from Glenwood, IA. My idea—— 

Senator DODD. Senator Harkin, did he know you were here? 

[Laughter.] 

AUDIENCE MEMBER. I don’t know if he knew I was here, but my 

idea would be to maybe increase the variety of physical activities 

in schools. I am also a dancer. I would say using dance as an option 

or just something else, so that if the kid isn’t picked for kickball 

there are other avenues for physical activity. Making different 

kinds of programs more available, so the classes that they take are 

effective. 

Senator DODD. That is a good idea. I have a 3-year-old and a 6- 

year-old daughter, and they love to dance. 

AUDIENCE MEMBER. That is great, yes. It is good exercise. 

Senator DODD. I think it is exercise. They make me do it with 

them. 

[Laughter.] 

With my knee replacement doing Irish step dancing. What a 

sight to behold, I will tell you. 

Well, this is very encouraging. It is very good. 

Anybody else in the audience want to say something? Hands? 

Yes, oh, we have a lot of hands now. 

Yes, I will start over here. Yes? 

Ms. HOFFMAN. Hi, I am Vanessa Hoffman. I just completed training to be a registered dietician. 

Senator DODD. Where are you from? 

Ms. HOFFMAN. I am from Washington, DC. I wanted to commend 

Bruce Lesley’s work in promoting medical nutrition therapy as a 

way to provide people with reimbursable ways to meet with registered dieticians, to talk with someone who is an expert about nutrition, answer their questions. 

Also improving resources, like Brian Wansink has been doing at 

the Center for Nutrition Policy and Promotion in terms of 

MyPyramid Tracker. People can go online for free and enter all the 

foods they have eaten and get feedback on how to improve their 

diet. 

Senator DODD. That is terrific. That is great. 

On this side of the room someone had a point they wanted to 

make? Yes? 

50 

AUDIENCE MEMBER. Yes, we are both in high school, and it is 

really great to see so many of our generation here. That is really 

great to see. 

Senator DODD. That is why I thought I ought to ask you since 

you are in the room. 

AUDIENCE MEMBER. Yes, and it is really great to see in action. 

I think all of your plans are national in scope but local in application, and it is going to take a lot of local and, like you were saying, 

community-based action. It is good to see that the attention is 

going to create change, and it is great to see that starting, you 

know? 

Senator DODD. Yes. 

AUDIENCE MEMBER. Also, I would have to say that I think an interesting statistic would be if you look at the percentage of children 

in America with obesity, and actually, I think that would be very 

interesting if you figure out what percentage of those children have 

obese parents. Because I believe that you are a product of your environment. Sometimes that is not the case, but a lot of times that 

is true. 

Unless you have a conducive environment and parents that can 

support you and can instruct you, then you are not going to be— 

as a child, you look up to your parents. You do what—your parents 

are the producers. They provide for you, and we just consume. 

Like, if the parents aren’t providing a healthy environment, then 

the children aren’t living in a healthy environment. Therefore, we 

have this Nation of obese children because it all starts with the 

parents. 

I think that education programs should be geared first toward— 

more toward the parents. That is where it all starts. 

Senator DODD. The families. That is what the young lady from 

Maryland was saying back here, too. 

What else? We have a couple more here. Yes, way in the back? 

Yes, go ahead. By the way, we have a microphone out here. We are 

going to give you a microphone. 

AUDIENCE MEMBER. Mike [Off Mike] from Fargo, ND. 

Senator DODD. You don’t need a microphone. Go ahead. 

AUDIENCE MEMBER. OK. This might just be a very small thing, 

and you were talking about before, Senator, you were talking about 

the energy crisis and you were talking about infrastructure with 

sidewalks and everything. I am an avid cyclist, so I love bicycling 

around town. DC is a great place to bike. 

If you could somehow create a Federal mandate, I know lots of 

roads are done on a State or local level, but sort of like speed limits, where you have to have this or you obviously don’t get the 

funding. If you could say, you are not going to get this extra funding if you don’t put bike lanes on the residential roads. Bike lanes 

are very, very helpful. They protect us a lot. 

I have ridden—I was in Florida—Tampa, FL, this past year. It 

was one of the worst places to bike in the country, and it was really, really dangerous, and I almost got run over a couple of times. 

You could solve two crises in one. Bike sales are going up. You 

could get people exercising, and you also lower people’s cars’ emissions. 

51 

Senator DODD. We have actually done that on some legislation. 

There has been—I know in my own State, I have done that in a 

number of instances. I actually got funding for bike paths in conjunction with highway programs. We actually have been doing 

some of it, probably do a lot more of it based on that suggestion. 

AUDIENCE MEMBER. Yes, I thank you. 

Senator DODD. Anyone else back there? I have opened up the 

door here, haven’t I? 

[Laughter.] 

Anybody from Connecticut? 

AUDIENCE MEMBER. Me. 

Senator DODD. Nothing like a little local politics. Are you from 

Connecticut? 

AUDIENCE MEMBER. I go to school at Yale. 

Senator DODD. That is good. We will try. Do you vote in Connecticut? 

[Laughter.] 

I am only teasing. That is not serious. 

Mr. TALBOTT. My name is David Talbott [Off Mike] in my final 

year at Yale. I am, by no means, an expert on the issue, but one 

of the things that I did at school was I started up a program called 

Student Soccer Outreach. We go around to a lot of the local middle 

schools and teach them. Not only do we do mentoring, but we also 

do soccer and teach them what it means to be a fit and healthy 

younger adolescent. 

I guess, I have been interning for the HELP Committee. 

[Laughter.] 

I was reading some of the testimony, and I noticed that a lot of 

the talk today was focusing on prevention. I believe it was in Mr. 

Lesley’s testimony that he mentioned that 95 percent of the money 

we are spending right now is on treatment rather than prevention. 

It seems like that money really isn’t being effectively used. 

I am just not really making a statement. I am asking a question. 

Is there any way to make that 95 percent more efficient because 

it seems that while the prevention is where we are looking to go 

to the future, the current path has really been on treatment and 

that it is really not being effectively used. 

Senator DODD. Bruce, do you have a comment on that? 

Mr. LESLEY. No, I mean, other than to say I think that that is 

right on, in that we really do need to make a more concerted effort 

on the prevention side, and it is not just even government spending. It is private spending. 

It is also, to give kind of a shout-out to programs such as the one 

you worked in. It is also the Boys and Girls Clubs and the YMCAs 

of the world who are really providing another place, a safe place 

for children to engage in activities. There is also Congress, who 

does support a lot of those activities as well. It is very multifaceted. 

Senator MURKOWSKI. Mr. Chairman, if I can just jump in here. 

Your mention of being a soccer club that reaches out to the younger 

kids—going back to my point earlier about kids not being able to 

play as much anymore, I think we overlook an incredible teaching 

resource when we don’t allow our young people to be mentors. 

The eighth graders, I bet, look up to you all as heroes. To be able 

to play like you is something that makes them work hard and have 

52 

fun at the same time. I am a huge supporter of what Boys and 

Girls Clubs do, and we keep trying to get more and more in the 

State along with the YMCA program. I think we have some real 

opportunities as we look to the local level to see how we can do 

more without necessarily huge increases in funding. 

We have a lot of volunteer opportunities if we use our young people, who have that level of energy and can be great role models for 

our kids. Thank you for what you are doing. 

Thank you, Mr. Chairman, for doing this. I am going to have to 

excuse myself. 

Senator DODD. No, I understand that. I apologize. As I said, 27 

years, I have never done this before. Take a couple more, a couple 

more comments. Can we get the microphone so you can be heard? 

Thank you, Lisa. 

Yes, go ahead. I will have to try and pick now. We have hands 

all over. 

Ms. CHAMBERS. Hi, I am Cassie Chambers, also a Yale student, 

working on being able to vote in Connecticut. 

I think one of the things that kind of gets glossed over a lot is 

the importance of allowing people to own their own epidemic. I 

think it is important to allow people—when you are talking about 

such a comprehensive lifestyle change—to be individually empowered to make those decisions for themselves. 

I think looking at programs like providing grants to local schools, 

providing grants to parks and recreation centers, to work on a 

small scale, I think that is really important. I think programs in 

local schools, where local schools get evaluated on how they are 

doing on nutrition, tax incentives to give people money back if they 

make the choice to buy fresh produce or to invest in a gym membership or things like that. 

I think that empowering people on an individual level to make 

choices is really, really important. 

Senator DODD. That is very good, and I agree. I think that is one 

way to describe it, too, to empower people themselves who are in 

that situation. 

Yes, what else? There was someone else back over there, too? Go 

ahead. 

Ms. LEWIS. Hi, I am Dana Lewis from Huntsville, AL, and the 

University of Alabama, voting in Alabama. 

I think it is also important to realize that education can also be 

a barrier. It is one thing to lower the price or offer an incentive 

for somebody to buy fresh produce, vegetables, and things like that, 

but it is another thing to show people you don’t have to clear your 

plate. It is important to know about the correct portion sizes. 

You don’t need to always clear your plate. You need to know the 

nutrition labels, be able to read exactly how many carbohydrates 

or calories are in that meal, and just because your restaurant 

serves you this nice big plate, you don’t need to clear it if it is triple 

the amount of calories or carbohydrates that you need. 

It is important to educate schoolchildren and adults as well to 

know the correct portion sizes and how to read nutrition labels as 

well. 

Senator DODD. Yes, that is very good. Excellent. 

53 

What else? We have some more over here, and then we will go 

over here. 

Ms. SINGH. Hi. I am Ranu Singh. I am from Massachusetts, actually. 

I just wanted to make the point of it is really—I think the one 

group that can really make a difference here is children themselves. We were saying earlier that they can lead the way. Older 

children can lead the way for younger children. 

I also feel that if they have enough of a sense to know, if they 

are taught this either through like—I don’t know—Sesame Street, 

they were saying now that the Cookie Monster is now the Veggie 

Monster, or something of the sort. Just silly things like that—— 

Senator DODD. Don’t mess around with the Cookie Monster. I 

love the Cookie Monster. 

[Laughter.] 

Let us not get carried away here now. 

Ms. SINGH. I mean, my point there is he is a monster so he can 

eat cookies. That is the point. 

Senator DODD. Yes, right. 

Ms. SINGH. I just feel that if they can be taught to believe that, 

if they can get that kind of inclination, they are going to drive it 

themselves. I feel like that is something that they will definitely 

do. They can change their parents, like you were saying earlier 

with the seatbelts, with not smoking. The children are the ones 

that will question that. 

Senator DODD. Huge influence. 

Ms. SINGH. That is a very big point. 

Senator DODD. A question on this side of the room. I want to go 

back and forth. Can you get a microphone over to this side? Maybe 

you can walk toward him a little bit? We have a microphone for 

you. 

Ms. JOHNSON. Hi, my name is Laura Johnson. I am from 

Minnetonka, MN, College of St. Benedict, St. John’s University. 

During the summer, I am a children’s camp counselor for the 

YMCA, and I think one of the really important issues is encouraging children to get physical activity. Like what you were saying, 

I think that peer-to-peer encouragement is very important because 

what I have observed through my work is that the overweight and 

obese children are often the ones who are afraid to participate in 

physical activity because they are afraid that they are going to be 

the slow ones and the left-out ones. They really, really, really benefit from having positive encouragement. 

They are also the children who don’t go swimming because they 

don’t want to wear their swimsuits. I just think that among the 

peers and if you educate younger children to encourage their other 

overweight friends to participate in activities, that would greatly 

help. 

Senator DODD. Yes, no question. Good for you for doing what you 

are doing. 

Come back over. I only have one microphone. Let us work our 

back way down. We will come down here and then come down this 

way. Yes? I could do this all afternoon. 

54 

Ms. FARRELL. Hi, my name is Caroline Farrell, and I am a second year—almost a second-year law student at the University of 

Maryland. 

Before coming to law school, I did my M.Ph. at G.W. During grad 

school, I was a spinning instructor, and that helped me pay the 

bills. I continue to teach spinning, and I teach at a couple of health 

clubs that offer children’s or teen’s spin. I know several fitness 

equipment lines also have special equipment for children. 

Obviously, not everyone is able to afford a gym membership, but 

I am sure that there are ways to subsidize those programs individually or perhaps other similar programs through the community. 

Senator DODD. That is good. Great, great. One over here. Why 

don’t you just use the microphone at the table? Go ahead. Right 

here. 

Ms. QUINN. OK. I am Abigail Quinn from Annandale, VA. I am 

at the University of Virginia doing elementary education, so this is 

all very interesting. 

I have been a camp counselor before, and we had a fruit and vegetable policy at each meal. We actually had a parent tell us that 

their kid did not eat fruits or vegetables. That was kind of awkward for us. 

The other point that I wanted to make is, I am interning this 

summer with National Wildlife Federation. We have a huge campaign trying to reconnect kids to nature, and obviously, getting 

kids outside, getting them active is all part of this. We have talked 

a lot about schools today. I know that recently in my research I 

have been looking at some studies that have suggested that kids 

are actually gaining weight over the summer because they are so 

inactive over the summer. 

While schools have a huge role to play, and obviously, as someone who wants to be in education, I think that is crucial. You really 

need to look at some of these other aspects, too. 

Senator DODD. That is great. Yes, I will take one back here. Go 

ahead. 

AUDIENCE MEMBER. First, I would like to say I am not from Connecticut. If I was, I would give you my vote, don’t worry. 

Senator DODD. Ah, smart guy. You take as long as you would 

like. 

[Laughter.] 

AUDIENCE MEMBER. Well, Jenelle, I am sorry. I know you said 

you were going to tackle me, but I had to ask this. 

You were talking earlier about how seeing the marketing of body 

types and things like that increased anorexia amongst young people. Well, today, we have a lot of things that are beginning like 

plus-size modeling and all the commercials that you see all the 

time with, oh, lose weight fast, Slim Fast. You know, you can take 

these pills, and you will lose weight in 6 months or whatever it is. 

I am just wondering what type of psychological affects do you 

think that has on the obesity of children? Do you suppose that they 

feel that this is becoming a societal norm because they see it now 

in the plus-size modeling, or in the commercials, you see people 

saying that you can lose this weight fast? Maybe they are saying, 

‘‘Well, I can eat this and I can do this, and then I take my Slim 

55 

Fast and then I will lose that weight eventually’’ or something like 

that? 

I was just wondering, as a question to any of you guys, what type 

of effects do you think that has? 

Senator DODD. Is there an effect? Dr. Grey has done a lot of work 

in this area. 

Ms. GREY. This gets back to the whole issue of social marketing. 

The sense of normality about obesity is not from plus-size models. 

I mean, the reality, the role model for kids today are all these 

stick-thin, size 0 people. Plus-size models are for the middle-aged 

women who are the norm, wearing plus sizes. 

To be honest, in our work, I don’t think most kids think about 

Slim Fast. I don’t think they respond to those marketing approaches at all. Their parents might, but their children don’t. The 

sense of being normal being overweight is if you are in a population 

like the inner city where I work, where 50 percent of the kids in 

high school are obese or overweight, that is normal. 

Where I was in high school, there were 10 kids who were overweight out of a class of 650. Those who were overweight felt—they 

were teased. They were mocked. The physical activity was a problem because they were always chosen last, and they don’t feel good 

about their ability to participate. 

These kids are all the same. While they still get teased and they 

still get mocked, they can look across a room and see 50 percent 

of their classmates weigh 180 to 300 pounds. It is a very different 

mindset than what we think of as adults around this problem. 

Dr. KAUFMAN. Can I just add something? What really works best, 

I think, is to talk about behaviors rather than the outcome of 

weight. And that we are really—and if you are normative to the 

whole class, so everybody is learning, too. Even if you are the lowweight kid, soda isn’t good for you. 

The most favorite food now unified, when we started doing our 

work in Los Angeles, was Flamin’ Hot Cheetos. I mean, a couple 

bags of Flamin’ Hot Cheetos for lunch aren’t good for anybody. We 

are really trying to promote healthy behaviors on both the intake 

side and the energy expenditure side. 

Senator DODD. That is very, very good. 

One right here, yes. 

Mr. SHEVARRO. I am trying to get rid of this, honestly. 

Senator DODD. There you go. 

Mr. SHEVARRO. How are you doing? I am Keith Shevarro. I am 

from New York. I am also a second-year law student at the University of Maryland, and I was a physician before I went to law school. 

The question I have is do you see the rise in obesity correlating 

with the fall of the family? The divorce rate being so high, 50, 60 

percent. People working two jobs. Single moms, single dads trying 

to do the best that they can, but can’t really spend as much quality 

time with their child that they would like to. Have we seen in the 

numbers a correlation with the decline of the family, an increase 

of obesity? 

Senator DODD. Anyone want to tackle that? 

Dr. KAUFMAN. Well, I mean, temporally probably some correlation. Exactly looking at is it greater in single parent families, and 

there are a lot of correlates, depending on what location you have 

56 

done, there is a lot of data. It is just association. It is not really 

cause and effect. 

Senator DODD. Yes. Anyone disagree with that? 

Ms. GREY. One of the things that we do know is that families 

who sit down to a meal together are more likely to eat a more balanced meal. Notice I didn’t say ‘‘healthier.’’ At least a more balanced meal. 

If you look at the lives of many of these families, single parent 

or even dual parent, many of these families are working two and 

three hourly wage jobs just to be able to have a roof over their 

heads and pay the heating bills and those sorts of things. The stories we hear from these families about what we think of as a meal 

and what they think of as a meal is somebody puts something on 

the stove, and it is like the revolving door—in the kitchen, wolf it 

down, and back out again. 

Again, this is so tied to the economic reality in these poor families that I don’t think it is just a family issue, it is about what are 

the structures in families, what are the structures in homes and 

communities that allow for these kinds of healthier behaviors? 

Senator DODD. And the economics. Margaret Warren, who teaches at Harvard Law School, has done a lot of studies on just what 

is happening to middle-income families, the economic pressures. 

Close to 20 million Americans, heads of household in our country, 

spend half their disposable income on housing alone. That is leaving the rest of it to do everything else. 

When you start talking about all the other obligations, financial, 

again, it is cheap food, I suspect. And not a question of cheap, but 

the food that is less healthy certainly is going to fall into that category. It is not just shopping for the best price. It is also recognizing that, as we have learned painfully, less healthy food is, in 

many cases, less costly. 

I will take one more. We will take one right here. Yes? 

AUDIENCE MEMBER. Hi. I am [Off Mike] from Great Falls, VA. 

I go to Thomas Jefferson High School. 

I just wanted to reiterate the point about portions of meals because that is really important. Even if it is a healthy mix of foods, 

if you are eating a ton of it, it doesn’t matter. You are getting too 

many calories, too many carbohydrates. 

A lot of restaurants are really bad at that. You order a meal, and 

you end up with this huge plate piled with food. A lot of people feel 

obliged to finish off the plate. So portions are really important. 

Senator DODD. Yes, just in terms of size of the plates that you 

buy for meals, your tendency, if you buy these—a lot of times they 

market these large plates, and putting a small amount of food on 

a large plate looks like you are getting very little. Just the size of 

the plate in proportion to the food that is on it can have an effect. 

I literally could do this the rest of the day. I can’t do this to our 

witnesses. I have drawn them here for all afternoon. As I said, in 

27 years in the Senate, I have never asked the audience to participate, but I just couldn’t resist, looking at so many young people 

who are here, and you have been terrific. Give yourselves a round 

of applause. 

[Applause.] 

57 

I find it rather encouraging in a sense that so many of you here 

have so many good ideas on how to address this. You can all call 

your parents tonight. You will be on C-Span. 

I thank our witnesses immensely. We will have some additional 

questions. I am going to leave the record open because other members, I think, will have some questions for you such as these detailed questions I was asking you, Dr. Kaufman, and I suspect we 

will have some more for you, Dr. Grey, as well. 

Just getting the data and the correlations between some of these 

questions here will be very helpful to us as we go forward. 

I would be remiss as well—where did she go? She left. Oh, Eva. 

A former staff member of mine was here this week, and one of the 

best children’s advocates in Connecticut, Eva Bannell. Eva went 

someplace. I don’t know where she went, but I was going to introduce her. 

Anyway, I thank Tom Harkin. I thank Lisa Murkowski, Senator 

Murkowski, and our witnesses as well. I appreciate all of you very 

much. This committee will meet again next week for the second 

panel on this issue. 

I thank all of you. The committee is adjourned. 

[Whereupon, at 4:31 p.m., the hearing was adjourned.] 

Æ