[Senate Hearing 113-560] [From the U.S. Government Publishing Office] S. Hrg. 113-560 A NATIONAL PRIORITY: THE IMPORTANCE OF CHILD NUTRITION PROGRAMS TO OUR NATION'S HEALTH, ECONOMY AND NATIONAL SECURITY ======================================================================= HEARING BEFORE THE COMMITTEE ON AGRICULTURE, NUTRITION AND FORESTRY UNITED STATES SENATE ONE HUNDRED THIRTEENTH CONGRESS SECOND SESSION __________ JUNE 12, 2014 __________ Printed for the use of the Committee on Agriculture, Nutrition and Forestry [GRAPHIC NOT AVAILABLE IN TIFF FORMAT] Available via the World Wide Web: http://www.fdsys.gov/ ____________ U.S. GOVERNMENT PUBLISHING OFFICE 93-031 PDF WASHINGTON : 2015 ________________________________________________________________________________________ For sale by the Superintendent of Documents, U.S. Government Publishing Office, http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center, U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free). E-mail, [email protected]. COMMITTEE ON AGRICULTURE, NUTRITION AND FORESTRY DEBBIE STABENOW, Michigan, Chairwoman PATRICK J. LEAHY, Vermont THAD COCHRAN, Mississippi TOM HARKIN, Iowa MITCH McCONNELL, Kentucky SHERROD BROWN, OHIO PAT ROBERTS, Kansas AMY KLOBUCHAR, MINNESOTA SAXBY CHAMBLISS, Georgia MICHAEL BENNET, COLORADO JOHN BOOZMAN, Arkansas KIRSTEN GILLIBRAND, NEW YORK JOHN HOEVEN, North Dakota JOE DONNELLY, INDIANA MIKE JOHANNS, Nebraska HEIDI HEITKAMP, NORTH DAKOTA CHARLES E. GRASSLEY, Iowa ROBERT P. CASEY, Jr., PENNSYLVANIA JOHN THUNE, South Dakota JOHN WALSH, MONTANA Christopher J. Adamo, Majority Staff Director Jonathan J. Cordone, Majority Chief Counsel Jessica L. Williams, Chief Clerk Thomas Allen Hawks, Minority Staff Director Anne C. Hazlett, Minority Chief Counsel and Senior Advisor (ii) C O N T E N T S ---------- Page Hearing(s): A National Priority: The Importance of Child Nutrition Programs to Our Nation's Health, Economy, and National Security......... 1 ---------- Thursday, June 12, 2014 STATEMENTS PRESENTED BY SENATORS Stabenow, Hon. Debbie, U.S. Senator from the State of Michigan, Chairwoman, Committee on Agriculture, Nutrition and Forestry... 1 Gillibrand, Hon. Kirsten E., U.S. Senator from the State of New York........................................................... 2 Witnesses Hawley, General Richard E., United States Air Force (Ret.), Mission: Readiness, Newport News, Virginia..................... 4 Thornton, Otha, President, National Parent Teacher Association, Fort Stewart, Georgia.......................................... 6 Cook, Stephen R., M.D., Physician, Associate Professor, School of Medicine and Dentistry, University of Rochester Medical School, Rochester, New York............................................ 7 Stanislaus, Yolanda, Principal, Francis Scott Key Middle School, Silver Spring, Maryland........................................ 9 ---------- APPENDIX Prepared Statements: Casey, Hon. Robert, Jr....................................... 30 Cochran, Hon. Thad........................................... 31 Leahy, Hon. Patrick J........................................ 33 Cook, Stephen R.............................................. 35 Hawley, Richard.............................................. 40 Stanislaus, Yolanda.......................................... 44 Thornton, Otha, Jr........................................... 46 Document(s) Submitted for the Record: Stabenow, Hon. Debbie: ``A National Priority: The Importance of Child Nutrition Programs to our Nation's Health, Economy and National Security", Hon. Martin O'Malley, State of Maryland, Office of the Governor............................................ 50 National Education Association, prepared statement........... 52 Question and Answer: Stephen Cook: Written response to questions from Hon. Debbie Stabenow...... 56 Written response to questions from Hon. Patrick J. Leahy..... 59 Written response to questions from Hon. Amy Klobuchar........ 59 Written response to questions from Hon. Michael Bennet....... 60 Written response to questions from Hon. Robert Casey, Jr..... 63 Hawley, Richard: Written response to questions from Hon. Debbie Stabenow...... 66 Written response to questions from Hon. Michael Bennet....... 66 Written response to questions from Hon. Robert Casey, Jr..... 68 Written response to questions from Hon. John Boozman......... 70 Stanislaus, Yolanda: Written response to questions from Hon. Debbie Stabenow...... 71 Written response to questions from Hon. Amy Klobuchar........ 71 Written response to questions from Hon. Michael Bennet....... 72 Written response to questions from Hon. Robert Casey, Jr..... 73 Thornton, Otha, Jr.: Written response to questions from Hon. Debbie Stabenow...... 75 Written response to questions from Hon. Patrick J. Leahy..... 75 Written response to questions from Hon. Amy Klobuchar........ 76 Written response to questions from Hon. Michael Bennet....... 77 Written response to questions from Hon. Robert Casey, Jr..... 79 A NATIONAL PRIORITY: THE IMPORTANCE OF CHILD NUTRITION PROGRAMS TO OUR NATION'S HEALTH, ECONOMY, AND NATIONAL SECURITY ---------- Thursday, June 12, 2014 United States Senate, Committee on Agriculture, Nutrition and Forestry, Washington, DC The committee met, pursuant to notice, at 10:07 a.m., in room 328A, Russell Senate Office Building, Hon. Debbie Stabenow, Chairwoman of the committee, presiding. Present or submitting a statement: Senators Stabenow, Brown, Klobuchar, Gillibrand, Donnelly, Casey, Boozman, and Thune. STATEMENT OF HON. DEBBIE STABENOW, U.S. SENATOR FROM THE STATE OF MICHIGAN, CHAIRWOMAN, COMMITTEE ON AGRICULTURE, NUTRITION AND FORESTRY Chairwoman Stabenow. Well, good morning. The committee meeting will come to order. We are so pleased that all of you are here today. I want to welcome everyone to the committee's first hearing as we begin the process of reauthorizing Child Nutrition Programs. These conversations could not come at a more critical time. Today, more than 16 million children in this country do not have enough to eat. At the same time, childhood obesity rates have tripled over the past 30 years. Something is wrong with this picture. These trends are not just a threat to the health of America's young people, they are a threat to the future of our national security, and we want to talk about that today. For generations, the U.S. military has depended on the strength and courage of young Americans to form the world's most elite fighting force. Our military leaders recognize this, and historically, when they have asked Congress for help, we have responded. Near the end of World War II, General Lewis Hershey came before the Congress to explain that malnutrition and underfeeding were to blame for recruits being rejected for service in the Armed Forces. In response to the General's concerns, Congress launched the National School Lunch Program, calling it a measure of national security. Today, as we will hear, our military leaders have a similar request for Congress, and it is the same request we will hear from pediatricians and school leaders and parents. They ask that we protect and strengthen school nutrition programs so that we can strengthen our nation's military preparedness and improve the long-term health of the next generation of Americans. This request has even more urgency today than it had 70 years ago. That is because roughly 27 percent of Americans between the ages of 17 and 24 are too overweight to serve in the military. The proportion of new recruits who failed physical exams during the past 13 years rose by nearly 70 percent. Childhood obesity and weight-related diseases weaken our nation's financial security, as well. It is estimated that the nation spends about $14 billion a year to treat obesity and preventable weight-related diseases in children alone, not counting adults. Yet, for 14 cents, we can give a child an apple in school. Fourteen billion a year or 14 cents. That reminds me of what Benjamin Franklin once said. An ounce of prevention is worth a pound of cure. These are the critical types of investments that we can make now to save billions down the road, reducing many of the high costs associated with treating preventable diseases, like Type 2 diabetes, hypertension, and liver disease. In the classroom, a school breakfast can spur a lifetime of learning and achievement. We know that children who receive a healthy breakfast are likely to have better math scores and are less likely to be absent from class. For many children, a healthy lunch can form the foundation for a lifetime of good health. Making sure children have healthy, nutritious food will mean they can focus on what is important--learning, growing, and ultimately becoming productive and successful in future years. While it is often easy to think of programs in terms of a six-month budget or the annual appropriations, this hearing is really about the big picture. School breakfasts and school lunch are key components of child nutrition, but it is also important to remember that child nutrition is also about wellness policies, it is about WIC--Women, Infants, and Children's Programs, it is about Farm to School efforts, and day care. It is about reducing hunger for children after school and during the summer months. The authorization of Child Nutrition Programs is important. Investing in our children's nutritional health is not only about the cost of a meal, it is about investing in our nation's future and our most critical priorities: Stronger national security, long-term economic strength, educational success, and the health and happy lives of our families. I am pleased we have a great panel of witnesses today with us who can discuss the big picture impact of investing in the health of our children. We welcome everyone today. Our Ranking Member is not able to be with us. I know we will be joined by others as we proceed. If either of my colleagues want to make a brief comment, we would be happy to have it. Otherwise, we will go to our witnesses. Senator Gillibrand. STATEMENT OF HON. KIRSTEN GILLIBRAND, U.S. SENATOR FROM THE STATE OF NEW YORK Senator Gillibrand. I have a statement to introduce one of our witnesses. Is that all right? Chairwoman Stabenow. Absolutely. I will let you proceed. Senator Gillibrand. Okay. Well, I would like to introduce Dr. Stephen Cook. He is trained in pediatrics and adult internal medicine. He currently serves as an attending physician at the Golisano Children's Hospital at the University of Rochester Medical Center. Dr. Cook has served as a member of my Healthy Children's Working Group and he has shared his research with us on child and adolescent obesity and his work has been a resource to me as I have developed my legislative agenda with respect to children's health. Dr. Cook's research focuses on children and childhood and adolescent obesity by examining cardiovascular risk factors in clinical studies on prevention intervention. Dr. Cook has been an integral part of the Greater Rochester Obesity Collaborative, which serves as a national model for obesity prevention and treatment. The Rochester team was among ten teams chosen to participate in the Healthy Weight Collaborative, which is aimed at curbing the obesity rate in the U.S. Dr. Cook received his M.D. from SUNY at Buffalo School of Medicine and completed his residency and a chief resident year in Buffalo, New York. He has completed an academic pediatric fellowship, during which he focused on research in clinical aspects on nutrition, physical activity, obesity, and metabolic complications that arise. Dr. Cook has received a number of medical and research awards and honors and has been recognized by the American Heart Association for being the National Science Advocate of the Year in 2011. He currently serves on the Governor's Anti-Hunger Task Force in New York State as well as the Chairman and Membership Committee for the Obesity Society. We welcome him to the Senate Agriculture Committee today and we look forward to his testimony. Chairwoman Stabenow. Thank you very much, Senator Gillibrand---- Senator Gillibrand. Thank you, Madam Chairwoman. Chairwoman Stabenow. --and thank you for your advocacy and leadership. We are very fortunate to have both Senator Brown and Senator Gillibrand, who are strong advocates for the Child Nutrition Programs, and I look forward to working with you in partnership as we proceed to reauthorize in the coming year. Let me proceed with our other witnesses. I am so pleased to introduce our first witness on the panel, General Richard Hawley, a retired four-star general in the Air Force who serves on the Executive Advisory Council on Mission: Readiness, Military Leaders for Kids, which is a nonprofit, nonpartisan national security organization of hundreds of retired military officers committed to strengthening future generations through smart policy. During General Hawley's military career, he served in a variety of command and staff positions in the United States and overseas. He commanded a group, wing, Numbered Air Force, and two major commands. His assignments as a flag staff officer included duty as the Air Force Director of Operations during the First Gulf War, Commander of U.S. Forces Japan, and Fifth Air Force, Principal Deputy Assistant Secretary of the Air Force for Acquisition, and Commander United States Air Force in Europe and Allied Air Forces Central. We welcome you. Our second witness is Mr. Otha Thornton, President of the National Parent Teacher Association, who is also a Senior Operations Analyst with General Dynamics in Fort Stewart, Georgia. Mr. Thornton is a retired United States Army Lieutenant Colonel, and his last two assignments were with the White House Communications Agency and United States Forces Iraq and Baghdad. Mr. Thornton earned the Bronze Star Medal for exceptional performance in combat operations during Operation Iraqi Freedom in 2009-2010. As a PTA leader, Mr. Thornton's military background has allowed him to volunteer throughout the country and the world at various State, local, and council levels, and we are so pleased to have you with us. Let me now turn to Ms. Yolanda Stanislaus--we are so pleased to have you--who is the Principal of Francis Scott Key Middle School in Silver Spring, Maryland. She is an educator for 21 years, starting her career as a high school earth science and chemistry teacher in New York City Public Schools. She also taught at Bethesda-Chevy Chase High School and served as teacher and assistant principal at Silver Spring International Middle School. Prior to becoming Principal at Francis Scott Key, she was Principal of Galway Elementary School. Ms. Stanislaus has spent several years in the Montgomery County Public School System, and the Montgomery County Schools participate in the National School Lunch and Breakfast Programs. In addition to providing meals, the schools participate in other healthy food and hunger mitigation programs, including After School Snack, Summer Meals, and Farm to School activities. We are so pleased to have all of you here with your experiences and expertise to share with us. I would remind you, we are asking for five minutes' worth of testimony. We are very happy to accept whatever you would like to give us in writing, as well. We will start with General Hawley. Welcome. STATEMENT OF GENERAL RICHARD E. HAWLEY, UNITED STATES AIR FORCE (RET.), MISSION: READINESS, NEWPORT NEWS, VIRGINIA General Hawley. Well, thank you, Chairwoman Stabenow and members of the committee. First of all, thanks for holding this hearing and for including me. I appreciate the opportunity to join and give our perspective as a retired military flag. It may seem odd to some here that a retired general officer would be here talking about childhood nutrition, not exactly our line of expertise. But, as the Chairwoman pointed out, the National School Lunch Program was established in 1946, in large measure in response to our experiences during World War II, when we discovered that of those who were not qualified for military service, about 40 percent of those were malnourished. The Congress took action, established the School Lunch Program, and it has had a great effect on the health of our potential recruits upon who we depend to defend the nation. Unfortunately, 70 years later, nutrition remains a national problem and a problem for our military, but the pendulum has swung a little and the issue is now we have too many children and candidate recruits who are obese or overweight and, hence, unfit to perform the service that we require for our nation in the military. About 75 percent of young Americans today are unfit for military service, and that is a tragic figure. As the Chairwoman pointed out, more than one in five of our youth are too fat, overweight, obese, to meet the demands of military service. Others cannot meet the educational requirements or have a criminal background which disqualifies them. Just to put a number on this, for the six years from 2006 to 2011, young men and women were denied enlistment at the rate of 62,000. Sixty-two-thousand young Americans during that period who could not qualify for military service because of their weight. Just to put a little easier number on it, that would man about 30 Air Force combat wings. It is an astounding figure and one that demands action. Twelve-hundred first-term enlistees are discharged every year because of weight problems, 1,200. The military has to then go out and recruit and train replacements. I do not know how this adds up to the 14-cent apple, Chairwoman, but it is $90 million a year that we spend to recruit and train those replacements. That would buy a lot of apples. DOD spends another $1.1 billion each year to treat obesity- related illnesses through our military medicine and TRICARE programs. The military is responding to these problems. They have launched a number of initiatives to deal with the issues, but they need help, and that is why the school nutrition environment is so important. A child who is overweight in his preteen years has an 80 percent chance of being obese by age 25, and those are the ones who cannot meet the requirements for military service. In 2010, our group released a report, ``Too Fat to Fight,'' and another in 2012, ``Still Too Fat to Fight,'' and they examine how obesity affects our military and highlight the need for standards in our School Lunch Program. When ``Too Fat to Fight'' was released in 2010, our children were consuming way too many junk food calories, the equivalent of two billion candy bars a year. By the way, two billion candy bars weighs more than the Aircraft Carrier Midway. But, the revised standards that this committee endorsed in 2010 are beginning to show results. The steady upward march in rates of obesity is slowing, and in some age groups has been reversed. Cultural change does not happen quickly, but if given time to work their magic, the changes set forth in 2010 will give us a stronger military in 2030 and a healthier nation, as well. On behalf of the 450 generals and admirals of Mission: Readiness, I thank you for this opportunity to highlight the link between childhood nutrition and national security. We look forward to working with the committee as you continue this important work. Thank you. [The prepared statement of General Hawley can be found on page XX in the appendix.] Chairwoman Stabenow. Thank you very much for that testimony. Mr. Thornton, welcome again. STATEMENT OF OTHA THORNTON, JR., PRESIDENT, NATIONAL PARENT TEACHER ASSOCIATION, FORT STEWART, GEORGIA Mr. Thornton. Chairman Stabenow, committee members, and my fellow distinguished panelists, I am honored to have the opportunity to speak before you on behalf of over four million members of the National Parent Teacher Association. With more than 24,000 local units, PTA exists in all 50 States, the District of Columbia, Puerto Rico, the U.S. Virgin Islands, and the Department of Defense Schools in Europe. I currently serve as President of the National PTA, an elected volunteer position that I assumed in June of last year. In addition to my involvement with National PTA, I have been active in State and local PTAs in Georgia, Maryland, Texas, Michigan, and Kaiserslautern, Germany. I am currently employed as a Senior Operations Analyst with General Dynamics at Fort Stewart, Georgia, and I am a retired Lieutenant Colonel. Most importantly, I have over two decades of experience as a father of my two wonderful children with my wife, Caryn, Candice and Tre. PTA was founded in 1897 and is the oldest and largest volunteer child advocacy organization in the United States. PTA's legacy of influencing policy to protect the education, health, and overall well-being of children has made an indelible impact in the lives of millions of children and their families. This legacy includes the creation of kindergarten classes, a juvenile justice system, child labor laws, and mandatory immunizations for school children. Our mission is to be a powerful voice for every child. With regards to today's hearing, one of the fundamental purposes of PTA is to preserve children's health and protect them from harm. PTA has been at the table from the beginning, piloting a hot lunch program in schools in the 1920s that led to PTA's advocacy for a National School Lunch Program, and each subsequent reauthorization of the Richard B. Russell National School Lunch Act. Most recently, the PTA and our coalition partners fought for the passage of the Healthy, Hunger-Free Kids Act, which has made significant updates to our nation's Child Nutrition Programs. PTA viewed this as both a win for the kids and also the parents, because parents knew that, for the first time, no matter what our kids purchased in the cafeteria, it was going to be good for them. As for the primary decision makers in our kids' lives, it also provided us as parents a stronger role through local wellness policy development, implementation, and evaluation. As I always say, if you are not at the table, you are on the menu. I mention these accomplishments not only to underscore PTA's commitment to the well-being of our nation's children, but also to provide a historical context for where we are today. We have made a commitment to our children for over 70 years to do the right thing in the cafeteria and we cannot turn our backs now. I know some of my fellow panelists will address the reality of our nation's obesity crisis as it relates to our overall health and national security, so as a PTA leader and father, I am here today to tell you that our parents and families are committed to working together to ensure the continued success of our nation's Child Nutrition Programs. Where are we today? Schools are making exceptional progress in the nutritional quality of the meals that they are serving to our kids. There have been challenges along the way, but that is to be expected. We are parents, after all. When was the last time you changed rules for your kids in the interest of their well-being and your kids were happy about it? Do we have anyone here? As a partner in the school building, PTA and parents understand there are certain challenging realities. There is never enough time, seldom enough money, and oftentimes minimum resources, but that has never and can never be a free pass not to do the right thing for our kids. For parents, it means that we need to step up to the plate and support our schools, the board, the administration, the school food service, the teachers, the students to make sure that the school meals are successful. That means having a seat at the table and finding solutions to the challenges. Do we need updated kitchen equipment to serve fresh food? Well, how are we going to secure funding? Do we need volunteers so breakfast can be served in the classroom? Well, let us get some parents and grandparents together. Do we need to taste test some of the new items? How can we help? Do we need to adjust our fundraising practices? Let's do this. One of the most common questions that we hear as we travel around the country is, will our kids have enough time to eat lunch? How can we solve this problem? We can do this together. It may take a little bit of time and a lot of effort, but we can do it. In closing, thank you for having me here for this testimony. [The prepared statement of Mr. Thornton can be found on page XX in the appendix.] Chairwoman Stabenow. Thank you very much. Dr. Cook, welcome. STEPHEN R. COOK, M.D., ASSOCIATE PROFESSOR, SCHOOL OF MEDICINE AND DENTISTRY, UNIVERSITY OF ROCHESTER MEDICAL SCHOOL, ROCHESTER, NEW YORK Dr. Cook. Thank you very much, Chairwoman Stabenow and distinguished members of the committee. I am both a pediatrician and adult internist from Upstate New York and an American Heart Association volunteer. The unintended benefit of my dual training is now being realized in the current childhood obesity epidemic. Today, I see young patients with Type 2 diabetes, high cholesterol and fatty liver disease. These are conditions which I am familiar with as an internist treating adult patients, but my pediatric colleagues never saw before. In other words, our children are developing adult diseases accelerated by their poor diets and developing obesity. The statistics are grim. Today, one in three kids or teens are overweight or obese, nearly tripled from the 1960s. Hypertension, high cholesterol, Type 2 diabetes are affecting children and adolescents at unprecedented levels. Not surprisingly, more than 90 percent of children meet none or only one of the five components the American Heart Association uses to define a healthy diet, such as eating more fruits and vegetables or more whole grains. Beyond the toll and human suffering, obesity is associated with diseases with a steep price tag. The cost of treating obesity-related illnesses in the U.S. tripled just over a decade, from $78 billion in 1998 to $270 billion in 2009. Let me tell you a story behind some of these statistics. I currently work in a pediatric practice at the Children's Hospital at the University of Rochester and I am on the front line of the war against childhood obesity. Almost half the students in the Rochester City School District are considered overweight or obese, and nearly 80 percent of these students qualify for Free and Reduced Lunch, in many instances, that being the only healthy meal they receive all day. It was during my fellowship training in Rochester that I learned a very important lesson I would like to share with you. I learned that I, as a pediatrician, must care for children and families beyond the four walls of my office. I could provide life-saving vaccines or medications, but what good would it do if these very same children were doomed to a life of chronic disease and early death brought upon in part by unhealthy diets? On a positive note, I have seen firsthand how children's eating and activity habits are established very early in life. It is a critical window when eating habits and healthy lifestyles are imprinted behaviorally and biologically. It provides a great, and, I would argue, unique opportunity for improving the health of our nation's children, lowering medical costs, and improving productivity. I would like to illustrate the delicate balance of a small change and consistent change in the life of a child and how, if made correctly at the right times, allow for prevention and treatment really to overlap. A colleague of mine and I had a three-year-old patient who, during his annual check-up, was found to have a BMI in the obese range, actually, 97th percentile. She discussed with the child's mother the boy's beverage habits and drinking, and which the mom did not think was a problem until he returned for his four-year check-up in which he was still obese, now at the 98th percentile for age. They discussed cutting back on the sugary beverages along with instituting some behavior changes related to nutrition and his inactivity level. He came in for regular visits over the next two-and-a-half years and his weight continued to increase, but more slowly. Over his last two visits, his weight actually decreased by just over a pound. This was over seven months. But, by now, his BMI percentile was 69th percentile for age, right where it should be, right in the normal change. These changes in behavior we discussed were not of a high intensity level, like a treatment level needed for older children or those more severely affected by obesity, but the consistent message as part of well child visits, with age- appropriate recommendations for nutrition, physical activity, screen time, and sleep. This is also a motivated parent who sought out resources, including ensuring her son attended a high-quality child care center that was moving to improve policies around meals and snacks. The patient is now on the right path for a healthy life. Programs authorized by the Healthy, Hunger-Free Kids Act set the stage for millions of children to also get a head start for a lifetime of healthy habits. Based on solid clinical research, I urge the committee and Congress to continue the good work with school districts to prioritize Child Nutrition Programs. It is great up-front investment in our children and our nation's future. To do less is unacceptable. I also believe that we cannot let perfect be the enemy of good. The USDA and schools can work through challenges while at the same time applying evidence-based strategies for altering the food environment and the presentation with minimal cost. Let me conclude by noting that the programs in child nutrition reauthorization play a critical role in improving the health of our nation's children, their future, and our nation's future. It is one of the many strategies that, while alone will not be enough, must be implemented to turn the tide on obesity and the many other chronic obesity-related conditions among America's youth. The very lives of our children are at stake. Thank you. [The prepared statement of Dr. Cook can be found on page XX in the appendix.] Chairwoman Stabenow. Well, thank you very much, Doctor, for that testimony. Principal Stanislaus, welcome. STATEMENT OF YOLANDA STANISLAUS, PRINCIPAL, FRANCIS SCOTT KEY MIDDLE SCHOOL, SILVER SPRING, MARYLAND Ms. Stanislaus. Welcome, and thank you for having me. Good morning, Chairwoman Stabenow and members of the committee, and thank you for this opportunity to share my experience and views on the importance of Child Nutrition Programs like School Breakfast and School Lunch. When I think about this issue of school nutrition from the perspective of a principal and parent of both a middle school and elementary-age child, the benefits of universal or Free and Reduced Meals Programs is obvious. In addition, I was a child of two working-class parents who worked tirelessly to clothe, feed, and nurture five children. As a child, I participated in the meal program at my school. I recall looking forward to going to school every day and wondering what was going to be served for breakfast and lunch. I can testify firsthand that the School Meal Program had a positive impact on my life and my learning. There are children in classrooms all over this nation, in cities, in suburbs, and in communities, who are coming to school extremely eager to learn. In order for students to learn at high levels, they must be prepared and ready to concentrate by starting their day off with a nutritious breakfast. The numbers show that one out of five school-age children struggle with hunger in this country. I can tell you that on a more personal note, I have 65 percent of my students who receive Free and Reduced Breakfast and Lunch daily, and they are still struggling with having enough to eat at home. I can also tell you that this makes it harder for them to learn. I am not alone. There are teachers and principals all over this country who will tell you the same thing. There are children in classrooms all over the nation, cities and suburbs, who are coming to school too hungry to learn. In some cases, the nutritious school breakfast and lunch are the only meals the students have on a daily basis. Children who consistently do not get enough to eat tend to go to the nurse more often, have trouble focusing on lessons, which often result in off-task behavior and difficulties with sharing their best thinking on their tests. Research shows that students who do get enough nutrition on a daily basis feel better, learn more, develop good eating habits, and grow up stronger. We spend so much time and thought and money in this nation around educating our children. We ask questions like, how do we improve our test scores? How do we ensure that students graduate? There are some wonderful programs and innovations to educate our kids, but if they are too hungry to learn, we have lost them before we have begun. There are two really key times I see hunger as a widespread problem, in the mornings and after the summer and the start of the school year. For students of low-income families, their nutrition comes from school meals. Without school breakfast and lunch, these students would not get the nutrition they need. You can really see it in the morning. I have seen students come to school and they have not eaten since lunch the day before. They are irritable. They cannot focus. They are only able to think about where their next meal is coming from. I am grateful that my school has a universal Free Breakfast Program. This program enables all of my students to receive nutritious breakfast and start their day off right. Another danger time is over the summer vacation. Students do not get school meals when school is out of session. You can see a real difference at the start of the school year between students who had enough to eat over the breaks and those who struggled. The ones who may not have been getting consistent meals are more stressed out. They take longer to get into the swing of the school year. They have forgotten a lot of what they have learned the year before, and it makes a real difference with their progress. As a principal, I make it my duty to greet my students every morning. This is an opportunity for me to quickly gauge my students' current social-emotional state. This particular morning, I noticed a student who appeared tired and unhappy. Before I could ask him what was wrong, he asked me, ``Ms. Stanislaus, are we going to be getting breakfast this morning? I do not have any money.'' I quickly reassured him that breakfast was waiting for him in his first period classroom. A sense of relief came over his face and he quickly proceeded into the building. This and many other stories similar to this one confirms for me how important it is that schools have a nutritious Breakfast and Lunch Program for students and how much they rely on them on a daily basis. I would like to share with you some current research conducted by the nonprofit organization, No Kid Hungry, and the consulting firm Deloitte. They analyzed the ways hunger affects a child's ability to learn. Their research focused primarily on what happens when students from low-income families get the breakfast every day. Here are some of their findings. Their attendance rate went up. Tardiness and absences went down. On average, students scored 17.5 percent higher on math assessments. Higher attendance and higher test scores are closely tied to graduation rates. Students who attend school regularly and receive better grades are 20 percent more likely to graduate from high school. This has a huge potential impact on their futures and ours. High school graduates are more likely to find better employment, make higher salaries, and become self- sufficient. I thank you for this time. Once again, I am the proud Principal of Francis Scott Key Middle School. [The prepared statement of Ms. Stanislaus can be found on page XX in the appendix.] Chairwoman Stabenow. Well, thank you so much. Thank you to each of you for your important testimony. First, let me start, General Hawley, with you. I know that, as you have said, since 2012, the Department of Defense has really expanded its efforts to combat obesity, and I think, as you indicated, as well, people would be surprised that we start this whole process of reauthorization talking about what is happening in our military and Department of Defense, but it is a very real, concrete example of what is happening in terms of obesity in our country. I know you are investing--the DOD is investing a lot of time and funding to prevent obesity. Could you talk a little bit more about those investments versus the amount of money being spent to treat obesity? General Hawley. I retired some years ago, so I cannot claim to be an expert on everything going on in DOD today, but I do know that they have instituted a number of trial programs--the Healthy Base Initiative, which includes all of the services--to institute programs to increase awareness of the problem among our soldiers, sailors, airmen, Marine, and Coast Guardsmen, because, as some of the testimony pointed out, sometimes people do not even understand what their diet is doing to them. They are doing things like color-coding items in the commissary and in the dining hall, dining facilities, red, green, yellow. The green says, hey, you can eat all that you want. It is good for you. It will help you be a better person in the military, a better soldier, sailor, airman. If it is yellow, well, maybe not so much. If it is red, hey, why do you not avoid that? That is full of sugar and that is not good for you. The Air Force, I know, has instituted a program recently on a trial basis that they hope to expand, Better Food, Better Body, again, trying to increase awareness among our airmen to let them know that, hey, your nutrition is important. It is going to affect how you perform. Of course, your performance is going to affect how well you do in your career in our service. There is a lot going on and I know it is going to expand because this is a very important item. The cost of those programs is insignificant compared to the cost of treating the problem. I think I cited the number $1.1 billion to treat obesity and overweight-related illnesses in our military medical system and the TRICARE program that supports people like me and others. It is--you cited 14 cents, I think, versus $14 billion. There is just no comparison. Chairwoman Stabenow. Well, thank you. Principal Stanislaus, could you talk a little bit about, as a principal, how your school is working to ensure that kids are receiving healthy breakfasts and healthy lunches. What kinds of things are you doing? Ms. Stanislaus. We were fortunate enough this year to receive a grant from the State that allowed us to have a Free Breakfast Program for not only the 65 percent of our students who would receive a Free and Reduced Meals Breakfast, but for all students. It is--we already had in place what we called a Sustained Silent Reading in the morning, and once we received the Breakfast Program, we were able to bring the breakfast items into the first period classroom. Now we call it Books and Breakfast and it works out really nicely. The students--I have seen an increase in my attendance rate. I have seen--and I check it every week. We are certain to check if students are coming in on time and are there at school and ready to learn. We have seen some great increases. Another partnership that I formed was a partnership with the University of Maryland at my former school, where they would come in and actually have lessons with the students on the importance of nutrition. I really think that it starts with the advocacy of the principal and tapping into the resources. I work very, very closely with our Food Services Director and our program in my county and I am consistently asking for opportunities for my students and my community. We were selected for this summer, one of 12 schools to receive a Summer Lunch Program. Not only will my students benefit, but students who live in that community up to age 18 are welcome to come to my school for a free lunch. Chairwoman Stabenow. Thank you. One more question here before my time is up. Mr. Thornton, could you talk from the parent standpoint about working together to make the school programs a success, a little bit more about how you see parents in the involvement. Mr. Thornton. Madame Chairwoman, first of all, we believe, and we really push for a solid wellness policy around our school systems. PTA uses six standards for effective school partnerships in working on issues such as nutrition. One, welcoming all families into the school and communicating effectively around these particular programs are two of the standards. Just to give you an example, at home we understand the importance of the family meal. Sometimes, families do not have the time to properly plan and we understand that. One of the tools that we have is a partnership with the Healthy Weight Commitment Foundation to provide grants to a lot of local PTA units around the country to help parents work on nutrition and educate them on nutrition within the schools. What does a healthy plate look like? What does a healthy grocery shopping trip look like? Those are some of the grants we've provided to assist our parents; one of the strategies that we use. Chairwoman Stabenow. Thank you very much. Senator Brown. Senator Brown. Thank you, Madam Chair. I thank you all for your testimony. It was terrific. Thank you for that. I want to make three quick comments before I get to my questions. First, I really appreciate General Hawley's comment and Chairwoman Stabenow's comment about the National School Lunch Program, created after World War II in response to far too many recruits being malnourished. I think it is always important to put anything this government does in historical context because it teaches us for the future, so thank you for that. I wanted to mention, in Ohio, ProMedica, a health care provider in Northwest Ohio, out of Toledo, and provides also in Southeast Michigan, as the Chairwoman knows, announced a plan to reduce hunger and improve childhood nutrition. They view ending hunger not just as the moral issue that all of you view it as, I think, but also as one of the most important ways to lower health care costs. The third point I wanted to make before directing some questions to Ms. Stanislaus is the Summer Feeding Program in my State, we have about 600,000 students every day that--in any single day, on the average, and getting the School Free or Reduced Breakfast or Lunch Program, 600,000 during the school year. In the summer, and we are maybe slightly above the national average, only about 60,000 students on any single day are participating in the Summer Feeding Program. You think of the difference there, 600,000 in a particular day in March or April, and in July and August, it is one-tenth of that, and what that says about what we are doing, where we need to go. My questions are for Ms. Stanislaus. I would first say, if I had teenage children, I would want them to go to Francis Scott Key Middle School because I know the leadership that principals show and what a difference that makes in the whole school environment. Teachers are better. The students are better. The custodians are better. Everything is better. Thank you. I held a conference call to Ohio reporters yesterday on the issue of summer feeding and asking them to help--I usually do not ask reporters or suggest what they write, but I asked them to help get the word out for these Summer Feeding Programs. Part of it is we only have about 1,700 sites, which is more than we have had some other summers. We get AmeriCorps and some other groups and individuals helping us build the sites. You have got to build them in May or June and then take them down in September, and you have got to find people to do it, churches and schools and libraries and all. But, talk to me, if you would, talk to the committee, Ms. Stanislaus, what that means in terms of the huge drop-off, not just weekends--do not talk the weekends and during the school year, but in the summer, what that actually means to children, to their development, to their physical and mental development, to their preparation the next fall for school, all that means. Ms. Stanislaus. Thank you. When I look into their faces, that is where I start. I can see immediately if a student has been really taken care of over the summer, has had nutritious meals. You can tell by their physical appearance, by their level of energy when they come back, just even--it does not even take a summer. You can see over, like, a spring break, if they come back, very often, it takes them a lot longer to get ready for their school day, for their school week. If school starts on a Monday, they may be ready by Wednesday. What I have noticed was just a drop in their socialization. I have noticed them misbehaving more, where when they have a level of consistency, when they know that, they have eaten every day and it is a nutritious breakfast, lunch, their anxiety does not go up. Right now is the second-to-last day of school in my school and many other middle schools, and as principals talk, we are noticing that the anxiety in our children are really increasing. I think a part of it is because they know that they are not going to be able to come in and get that free breakfast and free lunch. I am fortunate to have a school that will have that this summer, but not all schools in my system have it, only 12. So-- -- Senator Brown. Talk to me--if I could take another few seconds---- Chairwoman Stabenow. Sure. Senator Brown. Understanding, probably in the State of Maryland, the Summer Feeding Program is roughly ten or 12 or 15 percent of those during the year. How does that compare? If you have an active middle school like yours with however many students that you said it is a universal free breakfast, how many of them are there in the summer and what can we learn from what you do there in your geographic location to reach into communities and do better everywhere? Ms. Stanislaus. Thank you. It starts with communicating. That is first. I--this summer will be my actual first summer with this school to see exactly how this program works. I do have over 900 students. It is us really reaching out to the parents---- Senator Brown. You have 900 during the school year---- Ms. Stanislaus. Yes. Senator Brown. --or 900 in the summer---- Ms. Stanislaus. During this current school year. Senator Brown. Okay. How many do you have in the summer feeding? You do not know yet. Ms. Stanislaus. Well, it is open to everyone, and I am not sure yet, because this will be the first summer---- Senator Brown. But, last year, do you know how many they had? Ms. Stanislaus. We did not have the summer program---- Senator Brown. You did not have it last year. Ms. Stanislaus. --and that is where, you know. We are really excited to have it this year, and I will--I can get back to you and let you know the success of it. Senator Brown. Will you--if I can interrupt again. I apologize. Ms. Stanislaus. Sure. No problem. Senator Brown. Sorry, Madam Chair. Do you use the same--I know in most--it seems most that I have watched and been part, I mean, been part as an observer, the breakfasts and lunches and the snacks in the summer are pretty much pre-prepared in boxes and all that. Will you, in the Summer Feeding Program, because you are using the middle school's cafeteria, I assume-- -- Ms. Stanislaus. Mm-hmm. Senator Brown. --will you prepare these lunches and breakfasts the same way you do during the school year? Ms. Stanislaus. Yes. They will get warm lunches. Breakfast is usually a cold breakfast, a cereal and a bagel, a fruit. But, for the lunch package, it is going to be prepared the same way it would be prepared during the school year. Senator Brown. So---- Ms. Stanislaus. They are actually going to have--hire staff to come in and ensure that the teachers are teaching and the staff who are working in our cafeteria---- Ms. Stanislaus. The reimbursement for this is enough to fund the same kind of feeding program that you do during the school year? Ms. Stanislaus. Hmm? Senator Brown. The same kind of preparation of food that you do during the school year? Ms. Stanislaus. Uh, yes. Senator Brown. The funding---- Ms. Stanislaus. The county is handling the funding. Senator Brown. The county is going beyond what USDA does. Ms. Stanislaus. Yes. Senator Brown. Okay. Ms. Stanislaus. Yes. Senator Brown. Sorry for the length of that, Madam Chair. Chairwoman Stabenow. No, thank you very much. That is an important question we are going to get into in reauthorization, and breakfasts versus lunch. Another great children's advocate--we are so lucky on this committee to have Senator Brown and Senator Casey. Welcome. Thank you. Senator Casey. Madam Chair, thank you, and thank you for having this hearing and we have great testimony here and great witnesses. Senator Brown was asking a lot of the questions that are on the minds of each of us when it comes to kind of a general point, the drop-off between the children that get either a breakfast or a lunch or both during the school year, and then in the summer, a huge drop-off. In Pennsylvania, we have more than 1.8 million children enrolled in the School Lunch Program. A fraction of that are getting help in the summer, and that is one of our big challenges. Just at the outset, I just want to make a brief statement about kind of a philosophy of mine, or a guiding principle for me. I think one of the problems we have nationally in terms of our national programs, national efforts--what you might even call a national strategy, which I do not think we have for children, but I think what we need--this question that we are examining in this hearing is, I think, at least one of the four pillars or one of the four parts of the strategy. If we are doing the right thing--and we are not, we are a long way from this--we should make sure that every child has health insurance, every child has a quality early learning opportunity--and when I say every child, I mean every single one, that has to be the goal--that every child has the kinds of basic protections from predators, and then, number four, and not in this order, is the issue we are talking about today, that children have access to enough food to eat, but making sure that it is nutritious food. If we did those four things for every child, we would be a much better country and our national security would be enhanced. This is one of those four, and I know we do not have time for every question, but I wanted to ask--I wanted to start with Dr. Cook. The WIC Program, talk to me about that in terms of the Women, Infants, and Children Program as a preventative step to cut back on the potential that child will be obese down the road, if you can talk about that one particular program. Dr. Cook. Sure, and thank you very much for the question. The Women, Infants, and Children Program represents a great opportunity. In New York, they piloted some of the first changes and we were able to see in our community how the offerings to the mothers were changing, more whole grains, better variety of foods for the mothers who are breastfeeding as well as for the infants and children, more culturally diverse food offerings, as well, which we also know is very appropriate. If a family comes from a certain cultural background, yet what they are offered is not relative to the parents who are preparing and serving these meals, it is not really going to work. I think it also represents a great window, as pediatricians, where we look at another way to outreach to the families. If we can get WIC workers in our office, in our waiting rooms two days a month, where they can be there and make available the information to families, we feel that is a huge advantage. I had mentioned before, 80 percent of children in our community--in the City of Rochester qualify for Free and Reduced Lunch, and because of that, the whole city school district has universal Lunch Program, as well. In the two largest practices in the city, ours and the other training practice that is affiliated with another hospital in our system, we have about 13,000 patients in each of them. Sixty- five percent, if not more, are Medicaid/Medicaid-eligible, and we know that just with those two practices, we reach approximately 45 percent of the children in the city. Just with those two sites, linking access to WIC and WIC enrollment represents a great opportunity to get the information out. For the past couple of years, we have been working with our food pantry agency that is organizing the Summer Meal Programs, as well as some of the advocacy agencies, to get the information about where summer meals are into the pediatric practices. We do not see every kid, but when kids are coming in for a summer camp physical or for illness, we have that information available. We always try to think a season or two ahead, and that has been one of the strategies we have looked at specifically. I am very fortunate, because where I trained in Rochester, the concept of community pediatrics was born because we felt we had to really reach out to children and families. We have done a great job with vaccines preventing so many illnesses in kids that we are now seeing this wave of new morbidity, and nutrition, physical inactivity, mental health issues are the core of that wave, and so we really have to think outside the four walls of our office. Senator Casey. I was going to ask you a question, but I will answer the question in my own way. I think if you just looked at one indicator of how we are doing in terms of national policy that undergirds a national strategy for helping pregnant women, I do not think we would get a very high letter grade, maybe a D. That is my opinion, but I think we have a long way to go, and WIC plays a role in that, as you know. I know we are almost out of time, but I wanted to ask our principal, Principal Stanislaus, maybe just on a lighter note, when you talked about irritability in the morning and Sustained Silent Reading periods, that might help in the Senate. [Laughter.] Senator Casey. We do not need more irritability. We have got plenty of that. But, Sustained Silent Reading, I think we should consider for Senators. We are pretty irritable when we are not eating. But, just this whole question, which is so central to the life of a child. I like to say that if kids learn more now, they are going to earn more later, but you cannot really learn if you are hungry. You cannot really learn if you have got a lot of other things happening to you. But, just this basic, fundamental question about the trouble that children have concentrating---- Ms. Stanislaus. Mm-hmm. Senator Casey. --because of lack of access to food or nutritious food. Talk about that for a moment. I know you spoke to it, but---- Ms. Stanislaus. Right. I think for me, personally, because I was one of those children and I have a personal connection to what that really feels like if you do not have your breakfast because--or you do not have dinner because there is nothing at home to eat and you are truly waiting to come to school for that meal, I can get it because I can just kind of envision what that feels like because I have lived it. I understand. Even when my students are--it is middle schoolers. We all know at times they say, ``Oh, I am fine,'' or try to be too proud. I know what that really, really means. It may just mean taking them into another location and saying, oh, here. Here is your breakfast. Yes, it plays a very, very heavy role. That is why, I think, as a principal, you really need to be in touch with the social-emotional side of where your children are and really get to know them and get to know their families. Unfortunately, there is a really big stigma with being a student who receives Free and Reduced Meals. For some reason, they just know that, oh, I am a student who receives Free and Reduced Meals. But, having my Breakfast Program, it made such a difference because now everyone, any child, it does not matter of the income of their parent, can get their meal in the morning and it is no stigma attached. It is really pushing students past that in order to help them unlock their best thinking, because if you cannot--if you are hungry, you are not going to concentrate. You may get some of the information, but you are going to miss most of the information. At times, the hunger and the misbehavior tend to go hand-in-hand. Once you take care of that fundamental need, you often find that students are able to elevate their progress throughout the course of the day, throughout the course of the year. Senator Casey. Thanks very much. Thank you, Madam Chair. Chairwoman Stabenow. Thank you. Senator Klobuchar. Senator Klobuchar. Well, thank you very much. I am sorry I was late. I was at a Judiciary hearing where we had some votes. But, I knew I was at the right hearing when I saw Senator Gillibrand's orange peels right here. [Laughter.] Senator Klobuchar. Thank you so much to our witnesses, and thank you to the Chairman for holding this hearing. In 2010, we overwhelmingly approved major reforms to the Child Nutrition Programs through the Healthy, Hunger-Free Kids Act, and I supported that legislation, felt very strongly about it, and I oppose some of the current efforts to roll it back. I think that we have shown a bit of progress with some stability in the numbers and the rates of childhood obesity, but I think we all know that there is a lot more work to be done. I guess I would start with you, General Hawley. In your testimony, you included an anecdote about school kids and the consumption of nearly two million candy bars. I think you said it weighed more than the U.S.S. Midway Aircraft Carrier. That is quite a picture. I have worked closely with Senator Harkin to change the standards for vending machines and a la carte lines, and the Smart Snacks in school provision takes effect, as you know, July 1st. In your view, what role do vending machines and a la carte lines play in medical disqualifications in recruitment? General Hawley. Well, I think they play a huge role. We all know that sugar is a primary contributor to this problem, the over-consumption of sugar. I am not an expert on what is going on in today's schools, because my kids grew up a long time ago, but I can relate a tale from one of my partners in this effort who related the fact that when he was a child growing up in North Carolina, they had cigarette machines in the schools. This is a place where kids go to get---- Senator Klobuchar. Okay. General Hawley. --bad habits reinforced. Our experience in the military is that by the time we get them as recruits, it is almost too late to influence their habits, because we all know that we develop eating habits early. I like the things that my mother fed me when I was a child. I am 72 years old and nothing has changed. These habits that our children form by accessing these vending machines with unhealthy foods, sugary drinks, Twinkies, you name it, shape their habits going forward---- That affects our ability as military services to recruit adequately. It contributes to the fact that only 25 percent of enlistment-eligible youth could join the military if they walked into a recruiter's office today. We need to get a handle on that. Senator Klobuchar. Okay. Ms. Stanislaus, thanks for your work as a principal. My mom taught second grade until she was 70 years old. She had 30 second graders at age 70, so I really appreciate your work. As implementation of the Healthy, Hunger-Free Kids Act continues, USDA, as you know, has provided additional technical assistance, including $25 million in grant funding to help schools purchase kitchen equipment that will allow them to provide healthier meals. As an administrator who works closely with the cafeteria in your school, do you think that there is going to be more investment in kitchen equipment in order to provide healthier meals? Ms. Stanislaus. I think that for my county, the Food Services Administrators, they often visit our school to monitor and ensure that the lunches that we are serving are healthy. I have to say that my county has done a really great job with giving our school and all of the schools across the county kind of a guideline as to what is acceptable nutritional values. Days of pizza parties are gone, because we want to ensure that the foods that we are serving are of really high nutritional value. I think about the vending machine. We do have a vending machine. It is on a timer, and I thank you for ensuring that we do have healthy snacks in the vending machine that are not only befitting what the expectation here is for this committee, but also the expectation for my county. Students, yes, they are allowed to go to the vending machines, but after they have eaten their meals. Getting back to the equipment in the kitchen, everything for our kitchen, we are really, I would say, pretty much doing okay. But, if there is ever anything that we need, the county is right there to support my staff. Senator Klobuchar. Thank you, and our State has actually been a leader in bringing the Farm to School Programs in place. I am out of time here, but I will ask you about that in writing. Thank you very much for all your work, and---- Ms. Stanislaus. Thank you. Senator Klobuchar. --we know that change is not easy, but I think these standards are very important and I do not think now is the time to roll them back. Thank you. Chairwoman Stabenow. Thank you very much. Senator Thune. Senator Thune. Thank you, Madam Chairwoman, and thank you all for being here and for providing great insights on this important subject. General, thank you for your service. Welcome back. It is nice to see you again. I am interested in the fact that 25 percent of our young people 17 to 24 are eligible, and you listed academic preparedness, obesity, and criminal records as the three, and I guess--where does obesity fit into that, and how has that changed in the time that you were in the service relative to those other factors? General Hawley. Well, on the first point, our best--people are disqualified sometimes for multiple reasons, so it is a little hard to pin down exactly what percentage is due to overweight or obesity, but better than one in five of the disqualified applicants are attributable to overweight or obesity. Senator Thune. Okay. General Hawley. The change is dramatic, of course, over the course of my service. I became a Second Lieutenant in 1964. It was a very different country then and obesity was not nearly the problem that we have today. I cannot give you the number, but I would guess it was below ten percent were rejected from service because of their weight. Senator Thune. Well, and you said 1,200 a year are discharged because of that. Is that--when they are discharged, we assume that when they came in, they met the weight requirements, and then what contributes to that while they are in the service? How do they---- General Hawley. I think most of them were borderline when they came in, and, of course, we feed them very well. [Laughter.] Senator Thune. Right. General Hawley. We exercise a lot, but we offer a lot of food. Sometimes it is due to other factors. They have consumed so many sugary drinks rather than milk and too few vegetables so their bones are brittle and we wind up with--it is both a weight-related problem and a diet-related problem, so they suffer fractures, serious sprains, whatever. But, there is a lot of issues with those, and every time we have to discharge one for these problems, we spend about $75,000 to go recruit a replacement and train them, to the tune of about $90 million a year. Senator Thune. Let me just--I can direct this to anybody on the panel, but, just, what can be done to encourage parents to do a better job, take more responsibility for providing healthy, nutritious meals for children? I mean, people kind of hearken back to their younger days. When I was growing up, I grew up in a small town. We did not have a School Lunch Program, so everybody either went home or they brought a sack lunch to school. We, fortunately, lived close enough to the school that we would go home, but my parents both worked, and somehow, my mother managed to get up in the morning and get something for us for breakfast and then put something in the oven for lunch. It is a very different world today, but what can we do to encourage, better incentivize parents to complement the meals that are provided at the schools and ensure that our kids are getting the nutrition that they need? Dr. Cook. I can speak on that topic from the standpoint of I have yet to meet a parent that does not want to try to provide the basic necessities, as we have heard. Feeding and sleeping are probably the most important things to the parent of a newborn. It is really important to craft that message and think about that message very early. We are even looking at and seeing research that it is at the time of conception and during pregnancies, when mothers are planning what they are going to do for their child--where they sleep, how they feed, if they breastfeed, a number of things that go on that actually sustain those behaviors very early. It is really important to understand, and when I say parents, unfortunately, this does become much a burden of mothers because of their role. I think it is really important to understand that identifying these issues very early at the health of pregnancy can be one of the early windows to try to identify where parents feel is normal and not normal, what is really healthy versus perceived healthy. We have hit on history a lot here and I find that very important, and one of the best advocates I have often found is when grandma is in the room, because that can be a great resource for the family. Unfortunately, many of the families I see, not really the traditional nuclear family are very disconnected. They may not have the same type of social support and social structure that can give that type of beneficial anecdotal evidence. I think it is important to understand, the evidence is very difficult to figure out in kids because you cannot do a research study in a child the same way you can in an adult. They are a protected population. It is using history, using families, and in this case, providing those resources at really critical times, and in infancy and childhood, getting families to adopt these behaviors is really an important time because it can imprint these behaviors throughout their lifetime. Senator Thune. Do you think that we put too much--I mean, is it a disincentive to parents when you increase the number of meals and parents start shifting that responsibility to the schools and say, well, the school is going to take care of that? Dr. Cook. I think it is a really important balance to try to strike, because the parents are assuming, and parents do have a respect for the school to protect their child, and so I think it represents that balance of they are assuming that it is the right thing that is being done there. As we have had parents engage schools around the PTA, around school wellness policies, they become very concerned and shocked when they are actually in there seeing what is available. I think it is a balance of the responsibility of the parent as well as the school, and that is why having parents involved in the process actually is moving this forward very well. Senator Thune. My time has expired, so thank you, Madam Chairman. Thank you all. Chairwoman Stabenow. Thank you very much. Senator Gillibrand. Senator Gillibrand. Thank you. Thank you, Madam Chairwoman, for holding this hearing. I am very grateful. Mr. Thornton, with the start of summer upon us, I am reminded that many of our low-income students and children will lose access to school breakfasts and lunches that they rely on during the school year and that both hunger and obesity go up during summer vacation. The Summer Nutrition Program ensures that low-income children have access to healthy food throughout the summer. Most Summer Nutrition Programs occur in tandem with education enrichment programs that keep kids learning, engaged, and safe during the summer months. However, despite these benefits, summer meals only reach a fraction of eligible children and many children often do not have adequate access and go hungry during the summertime. Can you talk a little bit about the need to ensure access to healthy meals year-round so that children are returning for the school year healthy and ready to learn. Mr. Thornton. Senator, thank you for the question. Quickly, to address the former, Senator, one of the things I talk about to our over four million parents around the country is personal accountability. Education begins at home. Dr. Cook mentioned earlier, different people come from different stages in life. I am one of those kids who did not always have access to food during the summers. I mean, my family did the best they could, but, again, we have to keep that in mind as we look at the public school system its, use as a public good and that these type of programs help kids that may not have the same privilege or opportunity as other kids have had. Senator, as for the programs we are looking at and working on for our children, we are working with Secretary Vilsack and the Department of Agriculture and other organizations to help find those resources to get additional food for those kids in the summer, recognizing, as we heard the principal talk about today, the impact that it has on their academic performance and coming back to school after having to deal with that. Very directly, we are working with government agencies and our advocates to try to get those programs in the communities. Senator Gillibrand. Thank you. Dr. Cook, in New York, we talk a lot about the intersection of childhood obesity and actual hunger, that the quality of the nutrition that some of our most obese children are receiving is so low that they are actually obese but still starving. We address this a bit in the farm bill with food deserts, trying to make sure that inner cities or remote areas have access to affordable fruits and vegetables. You would be surprised. There are food deserts in the Bronx, in Brooklyn, in the North Country. In a State as wealthy and rich as New York, it seems outrageous. But, can you talk a little bit about the intersection of hunger and obesity and what are the dynamics at play, and what are your best ideas for the School Nutrition Program to combat both, or any other programs that you think are worth mentioning. Dr. Cook. Thank you very much for the question, Senator. The interaction of hunger and obesity is a really important and complex one. As research has actually really shown, the body physiologically adapts to these different states. Anecdotally, the story is always that at the beginning of the month, families have more food. Near the end of the month, there is less. We have seen evidence that shows that the eating patterns, the foods available in the home are different at the beginning of the month versus the end of the month. The problem is that metabolically, physiologically, that actually has an impact on the body, and biologically, we are still cavemen. When we put on calories, the body's metabolism when we store that alters to hold on to that, to defend that weight, because we know we need to survive. Even though it is not the Stone Age, our bodies physiologically still respond that way, which makes weight loss extremely difficult. You have a person, especially a child, who has gained a tremendous amount of weight for whatever reason, whether the origins are hunger, stress, depression, overfeeding and cyclic feeding patterns that you would see if you are having more calories at the beginning of the month versus the end. That makes it more difficult to lose weight. The stress that comes with hunger also drives up hormones that drive up appetite. The distress that goes on in some of our children is obesity is just one of the manifestations of that. The hunger is always there. As we look at these children metabolically, even though their weight may be normal or high, they are nutrient deficient. We still see many children, obese children, who are iron deficient, who are borderline Vitamin D deficient, because while they get excess calories, they are not getting the important nutrients. We know in childhood, especially in infancy and toddlerhood when the brain is growing, just like it is more susceptible to a small level of a toxin like lead--a small amount of lead fed to a child or a child is exposed to lead as a toddler has a big impact on the brain. Very concerning that the nutrition science is coming along that is suggesting some of the same findings. Are we imprinting eating behaviors, or because of nutritional deficiencies, affecting the developmental growth, the brain growth in children. Senator Gillibrand. Thank you, Doctor. Ms. Stanislaus, can you talk about ways to increase participation in School Nutrition Programs, such as offering breakfast or lunch for free for all students, allowing students eligible for reduced price school meals to participate for free, or implementing a Breakfast Program. Ms. Stanislaus. I still struggle every year with having my parents complete a form that will make them eligible for their students to receive Free and Reduced Meals. As stated earlier, I currently have slightly over 65 percent of my students who are eligible for that, but I can assure you that I have more children in my building whose parents may not have felt comfortable filling out that form because it, in a sense, stigmatizes them. Once we received the Free Breakfast Program for all students, it took that stigma away. Wow, would it not be amazing to have a Free Breakfast Program and a Free Lunch Program so that it would take away the stigmatism that goes with having to fill out that form and turn it in and, oh my gosh, what are they going to think about me. I struggle with that every year. Sometimes, it is me calling a parent into my office and kind of having a heart-to- heart and letting them know, it is okay. I will take the form. I will personally turn it in. It makes that difference, but that is the difference, and the time that I am willing to take, and many of my colleagues, to ensure that the children get what they need. In saying that, I think if it does not change, just exciting students about learning about nutrition, like Dr. Cook was saying, using food as fuel as opposed to, I just want to eat it because it really tastes good. They may--trying different things will excite them. In turn, I have found as a principal, often it excites the parents. But, going back to if it were free for all, I can imagine that everyone would partake in the program. Senator Gillibrand. Thank you, Madam Chair. Ms. Stanislaus. Thank you. Chairwoman Stabenow. Thank you very much. Senator Boozman, we are so glad to see you. Senator Boozman. Thank you, Madam Chair. Thank you very much. Ms. Stanislaus, I really do not have a question for you, but I do want to thank you. As a principal, I know how hard you all work. I was on the school board for seven years, and I tell my colleagues, it does not matter what issue we are discussing here, there are many school board issues that are much more tougher. We do appreciate all that you represent and the people that work with you to get this done. Dr. Cook, in your testimony, you told the story about a small change in beverage consumption that made a huge difference for a young person and got them back into the normal BMI range. Is there any other low-hanging fruit out there that we can do in the same manner? Dr. Cook. The area that we look at in terms of low-hanging fruit---- Senator Boozman. Maybe it is fruit. [Laughter.] Dr. Cook. Low-hanging vegetables, I would add. [Laughter.] Dr. Cook. I think both of those are part of the key points, and it is really important to find where the evidence is and then what is feasible. I can give patients all kinds of advice, but if it is not going to fit in their lifestyle, in their day, in their routine, it is not going to work. Relative in terms of the low-hanging fruit, early and often. Giving the message seven times is kind of a joke, but really a useful strategy. If we have some of these same messages that we are using in our offices are being used in schools and day care centers around screen time, physical activity, active play, where they are running around--not necessarily has to be structured sports. Fruits and vegetables are really important and really tough, probably the toughest of all the behaviors because of access, taste, presentation, so many steps that can go into it. But, liquid calories really are very occult, and I say that because you could drink this package full of water or it could be a sugary beverage and the amount of fullness you will feel will be the same, and will probably be minimal. Yet, you could have 600 calories in there or you could have zero. Senator Boozman. Right. Dr. Cook. The amount of time a parent or a child--actually, the amount of time a child needs to be active to burn 600 calories would probably drive a parent nuts---- [Laughter.] Dr. Cook. --because of the amount of activity. I mean, a big misperception is that children are very active and it burns a lot of the calories. As liquid calories, being, really, an important first step. Screen time and---- Senator Boozman. You run into--and I do not mean to interrupt you---- Dr. Cook. No, go ahead. Senator Boozman. But, you run into the same problem besides the Coke-type beverages. You would run into the same problem with some of the juice, high-calorie sugar---- Dr. Cook. Absolutely. I mean---- Senator Boozman. --or carbohydrates. Dr. Cook. Yes. I mean, virtually almost all the liquid calories we drink will fall into that range and it has a very similar pattern. The low-hanging fruit, a lot of times, can be liquid calories. Again, screen time, very important. When we can bring in more evidence to reinforce it to parents--the screen time is bad because it is mindless time. They are not active. It is actually more time for consumption. If you sit in front of a screen for five or six hours, you may not burn 100 calories, but you may eat 250 calories, and it is that occult eating that you do not catch. The same thing with kids, and it becomes a repetitive type of behavior. It also does not allow kids to relax and fall asleep easier, and that, again, is a very important concern for our parents. Having the stealth type of intervention, or having the collateral type of advantage of these small steps can be really beneficial, and if we can give these in age-appropriate simple steps in our office and in other settings that reach families and children, like school, early child care programs, after school programs, then we are hitting them with multiple messages--the same message multiple times. Senator Boozman. In your testimony, you equated that to a normal BMI range. The BMI, it has some problems with it in the sense that there are body types and things. I hear from parents occasionally that you have a kid that is just a good, healthy, normal looking kid, and yet the BMI says that they are obese. Our body types are different. Is there another test that is coming out that perhaps will do a better job of identifying people that truly are in need? Dr. Cook. I think that is a very important point, because BMI is a useful tool on a population level, and if measuring a thousand people, the top third fall in this range for health, on the individual level, it can be more limiting because it measures weight either as fat or as muscle. I always caution pediatricians to think about it. When we try to use the data, the higher the cut-off, the worse concern I have. But, in a young child, I will also ask a pediatrician, if they are asking for advice, what is the parent's weight, because having two obese parents as a three-year-old is actually a much bigger risk factor for that child to be an obese adult than their actual weight at the time. Additional measures really comes out of the research that we are trying to develop and the importance of continuing this research and looking in children, because children are a group that are not studied as closely. We are putting more attention to it, and we need to understand what is the really normal physiological growth. I think the sad point is that we do not have as many children going through normal physiologic growth in our modern era than we would have even 30 years ago. I would also add the point that, when parents will say, well, they are big boned, or they are pretty large, most toddlers, three-, four-, five-year-olds, do not have that much muscle mass. Even when their BMI is high, it is more likely going to have more components of body fat. Now, when it is teenagers and body and muscle mass and fat mass are changing, it is a different story and it can be very difficult. But, I agree. It really does need to look at a mix of when we can identify BMI as the first step. Senator Boozman. Right. Dr. Cook. What I like to say is, like not every tumor is cancer, not every high BMI is obesity---- Senator Boozman. Right. Dr. Cook. --and, so, we really do have to work on that. Senator Boozman. I think you make a good point. Even among the pediatric community, that is so well educated in this, my concern is that at the school level, where you have an administrator or whoever is doing these programs, and in many of our smaller schools, there are people like that. They simply look at a number, chart that in, and it is automatically that way without using any common sense along with it. Dr. Cook. I agree, and I think schools have a lot of things on their plate, and doing fitness testing, we know, is beneficial, and increased cardiovascular fitness is beneficial for all kids. But, as we have seen in Rochester when asking parents and doing surveys, they want to hear about this and talk about this with their primary care provider. Even if we can off-load some of those burdens from schools of doing it, because that is where we are hearing---- Senator Boozman. I agree. Dr. Cook. --the few but loud stories of, this is not really an accurate measure of my child, well, that may or may not be true. But, maybe if we put it in a different context when health can be presented, it can take some of the burden off of schools and can put it in a setting where parents may be more comfortable to discuss it. Senator Boozman. Right. Thank you, Madam Chair. Chairwoman Stabenow. Thank you very much. Really important questions and discussions. We are going to be wrapping up, but I would like to ask each of you a closing question, the same question, that would be very helpful to us because we have been talking about child nutrition and the impact both within the school, but also more broadly for our country. If you could give the committee a piece of advice as we consider reauthorizing Child Nutrition Programs, what would you say is the most important thing we could do to address some of the concerns and the ideas that you have raised today. I will start with General Hawley. General Hawley. Well, I learned during my career that probably the most valuable trait you can have is persistence. As they say, persistence will out. I guess my advice would be, stay with it. This is an important program. I am sure it is not perfect and it can be improved. But, I think it is beginning to work. My view is that this is a cultural issue in our country and cultures take a long time to change. We should not expect instant results from any program, least of all one that tries to change the nation's eating habits. I give my advice, stay with it. Keep up the good work. I think, in time, we will see the results. Chairwoman Stabenow. Okay. Great advice. Mr. Thornton. Mr. Thornton. Thank you, Chairwoman. As we talk about these nutrition needs of our children, they remain the same whether you live in Iowa or Georgia. It is impractical to try to force parents to fight for access to healthier foods one school at a time. Instead of reinventing the wheel while facing the same obstacles, this is the way the reauthorization of these programs can continue to make a difference. PTA has worked very hard throughout the history to ensure that kids had access to equal education, proper nutrition, proper fitness, and it is very, very important. I just thank you and the committee and all the panelists for engaging this topic, which is critical to the future of our children and our country. Make no mistake. The decisions during this reauthorization will have a definite impact on our schools, our hospitals, our economy, our military, our homes, and most importantly, our kids. I thank you for this time. Chairwoman Stabenow. Thank you very much. Dr. Cook. Dr. Cook. Thank you very much for the question. I find it a persistent question that we get a lot related to this as I give presentations, and sometimes it is the, what is the one thing I would do if I could do something, would be to get everyone to realize there is not one thing you can do. Everything is part of the problem. Each one of these strategies and proposals represents one percent of the solution. It cannot be left off. It is not the magic bullet. We need to include all of these. We need to think global and act local, because that is where I find, like, a lot of social change occurs. It is going to occur at the grassroots level where it really can take hold and have that local relevant context that is really important. I thank you for the question. Just to conclude, with obesity and with hunger, we discuss this a lot, and I think it is really important that obesity has come up as a disease, but it is probably the one disease that still exists that does not carry the dignity of other chronic diseases, and that is even more so a problem for children and adolescents. I think it is really important to make this about health, about health at any size, and promoting the health across all children and all families. Chairwoman Stabenow. Thank you very much. Principal Stanislaus. Ms. Stanislaus. Thank you, Chairwoman. We have mentioned a few times today that how the schools are really on the front lines. I thank you for this opportunity to share my thinking and my experiences with our school and my school system. The partnership is definitely something that I would say, let us continue this conversation and think about what actions that we will take and that we can take back to our schools and our school districts, continued opportunities to increase the education for parents. What--just as a one principal schoolhouse, I often find that we struggle with funding to have different events for families, after school events. It does take money to put these things together. At times, we are robbing Peter to pay Paul in order to make this happen for our local communities. If we can think about opportunities for these partnerships with universities, as I mentioned earlier, or increased funding so we can have buses after school so that we can not only have the nutritious After School Program and Snack Program, but also physical activities and clubs that students can be a part of so they are not sitting in front of the screen at home. I think this continued conversation, this conversation does not need to stop here. Getting feedback from other principals and schools would be a great welcome to different educators and all educators. Thank you. Chairwoman Stabenow. Thanks to each of you, and this discussion does not stop here. This is just the beginning. It was important to me that we start with the big picture of why we have these programs, why should we care about this. We are going to be hearing from all perspectives and working with everyone to make sure that the way things are done makes sense and are workable, and we certainly want to move forward, not backward. We do not intend to move backward, so we are going to move forward. But, we think it is very, very important that we talk about why, as a country, why, as a community, why, as parents and family members, that we need to care. Thank you again to everyone. Let me just remind colleagues that any additional questions for the record should be submitted to the Committee Clerk five business days from today. That is 5:00 p.m. on Friday, June 20. The hearing is adjourned. [Whereupon, at 11:34 a.m., the committee was adjourned.] ======================================================================= A P P E N D I X JUNE 12, 2014 ======================================================================= [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] ======================================================================= DOCUMENTS SUBMITTED FOR THE RECORD JUNE 12, 2014 ======================================================================= [GRAPHICS NOT AVAILABLE IN TIFF FORMAT] ======================================================================= QUESTIONS AND ANSWERS JUNE 12, 2014 ======================================================================= [GRAPHICS NOT AVAILABLE IN TIFF FORMAT]