terawatt hours of potential generation capacity, which is more than enough power to power the whole united states multiple times over, there are only two commercially scaled renewable energy part is operating on indian land. indian country can and should and must be brought to bear on the united states efforts to reduce its carbon emissions if they nation is going to succeed at meeting its commitment to future generations and the world in mitigating climate change. >> a look at the impact of climate change on native americans and how tribes are investing in clean energy technology to combat the threat. the climate crisis airs at 8:00 p.m. eastern on c-span. you can watch anytime online at c-span.org, or use our free video app, c-span now.

>> now, a senate hearing on nutrition, touching on a number of issues, including federal subsidies and food production and availability.

>> good morning everyone. i am so pleased to call this subcommittee on food and nutrition, especially crops, organics and research to order. i am privileged to be sitting next to the ranking member braun and on behalf of him and members of the subcommittee, i would like to just really welcome our witnesses and say thank you all for coming here. it's a lot of time and energy and effort to come to washington d.c. but this is so important and you all understand the urgency of this moment in american history. and i would say human history. i want to start off by stating the fact that all of our witnesses agree on this reality. this urgency, that today in america we are facing a massive, broad based nutrition crisis, a crisis where diet related diseases pose a serious threat to the health and well being of our country.

nearly one out of every $3 in the federal budget, i want to say that again. nearly one out of every $3 in the federal budget now goes to health care spending. with 80% of this money paying for the treatment of preventable diseases and these costs are rising at a staggering rate. currently in the united states, half of the u.s. population is prediabetic or has type two diabetes. in 1960, approximately 3% of the us population was obese. today, more than 40% of americans are obese and more than 70% of americans are either obese or overweight. even more shocking, one quarter of our teenagers today are prediabetic or have type 2 diabetes and obesity is the leading medical reason that 71%

of young americans are disqualified from military service. these data points are staggering and they need to be fully digested. now the numbers are worse in minority communities, dramatically so. communities. the risk of diabetes for example a 77% higher for black people in america and we are twice as likely to die from diabetes. as we will hear in today's testimony, the statistics are equally if not more so grim in our indigenous communities. the deadly nature of our nutrition crisis, which is in some of these diseases and epidemic levels has been tragically magnified by the pandemic. we have seen much higher hospitalization rates and death

rates for people with those diet-related diseases. so now let's be clear about something, the majority of our food system is now being controlled by a handful of multinational corporations. these were companies carefully formulate and market nutrient poor addictive ultra processed foods which now comprise two thirds of the calories in children and teenagers in their diets in the united states and these companies want us to believe the desired dash diet related diseases are somehow a moral failing. that they represent a lack of willpower or failure to get enough exercise. that is just a lie. the problem we have right now is not an individual moral failing, it is our collective policy failure.

it is a policy failure because the federal government is currently subsidizing easy access to the foods that are high in calories but have minimal nutritional value. while at the same time, too many communities lack access to the healthy foods they need to thrive. while the federal government tells us that our plates largely consist of fruits and vegetables, less than 2% of our federal agricultural subsidies in the united states go to these healthy foods. it's a policy failure because while other countries have begun to take on this crisis focusing on the problems with big food companies and banding marketing on junk food to children in the united states, however we continue to allow big corporations to spend billions

of dollars every year to advertise the least nutritious products such as fast food, candy, sugary drinks to our children. in august, the government accountability office released a report that analyzed efforts by the federal government to attract diet related chronic health conditions that are at epidemic levels. the gao concluded the federal government lacks a coordinated overarching strategy aimed at reducing americans risk of diet-related chronic diseases. how do we align our federal policy with our goal of addressing this nutrition crisis that's causing so much death and disease. we start by looking at history as a guide. in 1969, the year i was born naturally, president nixon convened the white house conference on food, nutrition and how to address the urgent national concern of widespread

hunger in the united states. what resulted was an unprecedented expansion in creation of vital programs dealing with that hunger crisis. programs that went on to tackle access to food. but fast forward 52 years and while we have made progress addressing hunger in america we are still grappling with food insecurity but now we face that second food crisis, one of nutrition insecurity were too many americans are overfed but undernourished and are seeing these staggering rates of disease and early death. despite being the wealthiest nation in the world we've crated a food system that relentlessly encourages the overeating of empty calories, literally making us sick and causing us to spend an ever-increasing amount of our taxpayer dollars literally trillions of dollars a year on

health care costs to treat diet-related diseases such as diabetes, heart disease, stroke, certain types of cancer and chronic kidney disease that are among the leading causes of preventable premature death in our country. i think we need to rethink the way we approach food and nutrition policy, our lives literally depend upon it. that's why last week we introduced legislation to create a second white house conference on food, nutrition, hunger and health which convenes public and private stakeholders to reimagine federal food and nutrition policies. the second white house conference needs to hear perspectives from a diverse set of stakeholders and communities such as we have here represented on our panel today. let me close with this, this

nutrition crisis we face is a threat. i would say it is the greatest threat the health and well-being of our country right now. millions and millions of americans see this and understand this threat in their communities and their homes and their families and their whole lives. it's also a threat to our economic security and our national security. we must act now. i will now turn to my friend and i'm deeply -- deeply grateful to have my partner with his opening statement.

>> goal in 1969 and one we are still chase the five decades later. as such i hope our hearing today will address both of successes and shortcomings and it will truly look at nutrition that's being made may be the thing we can use here to avoid entering the health care system because were healthy enough to be in shape day after day. since the white house conference and 69, american farmers have answered the call of growing population and malnutrition among poor american communities. farm level innovations, agriculture is now able to make more from less to help protect soil along the way. u.s. has made great progress to reduce food insecurity, nutritional deficits, a

foodborne illness over the course of the last five decades. our work is still far from over. until no american goes to sleep hungry or is unsure from where his or her next meal will come from, we have not successfully completed the task. a robust food security safety is supported by usda nutrition programs totaling more than $100 billion per year in federal spending. these programs were bolstered and fine-tuned to ensure caloric deficiencies were on the path to eradication in the u.s.. while the usda's nutrition program would help more americans during times and need, any discussion must include a discussion about quality of the foods that can be purchased through these programs. we all know an excess of low-quality foods can have

negative health outcomes for americans. empty calories, not one's making you stronger and healthier. obesity rates and 69 have increased 12% to over 42%. clearly not heading in the right direction. likewise preventable chronic illnesses like type two diabetes and coronary heart disease continue to play more and more -- plagued more and more americans print federal nutrition policies are still geared strictly to address caloric deficiencies. failing to prioritize the nutritional content for food rated as a result, reports show that programs are even making poor choices when it comes to americans nutrition. worse outcomes. our federal attrition program may be making poor nutritional outcomes worse for low income

american families. this is an irresponsible use of taxpayer dollars and its congresses responsibility lying in ensuring programs like snap are serving the best interest of both recipients and our nation as a whole. they have broader spillover effect. we spend way too much money the city the rest of the world. our health care expenses run between 18% and 20% of the gdp. finally we cannot have a conversation about the state of nutrition without discussing the harmful effects of unrestrained inflation has on the purchasing power of every american family. the new york times recently highlighted the damaging impact of inflation, showing in the

last year prices for key staples have risen by more than 10%. unsustainable and that's the cruelest of all taxes when we try to head in the other direction. these costs are driven by a multitude of factors not the least of which is irresponsible federal spending. as this subcommittee considers policies to help address nutrition insecurity we must remember that simply dumping more money into our economy will only exacerbate the issue of nutrition and desk insecurity for our most vulnerable, not to mention what inflation will do as well. nutrition insecurity is a challenging problem impacts our rural and urban communities alike. that's why i was proud to work with chairman booker to introduce legislation to convene a second white house conflict -- conference on food, nutrition,

hunger and health. a serious bipartisan analysis and effort will we make true headway. in my own life experience i've chosen to live through good nutrition. when you stick with it, it works. it should be the foundation for every american citizen. in my own company i was wrestling with high health care costs 13 years ago, i made that is a priority. changed our system into being enabling my employees to become health care consumers, giving them tools like free biometric screenings, telling them about good nutrition, putting a little skin in the game to incentivize that you do it. this is a topic for another day and another conversation. we did not get a premium increase in 13 years. and they enter into their

deductibles less now than they did 13 years ago because we are emphasizing prevention, not remediation. and making my employees and i think we can do it even in government where they invest in their own well-being and we give them the tools to do it. thank you mr. chair. >> you should put your placard up there someone might mistake you for a pragmatic minded businessperson and not a united states senator. senator lahey. it is an honor to have you here. i know you have to leave soon but we are excited you would like to come by. >> i appreciate the opening statement of both of you. when i was chair of this committee was called scented act culture and forestry -- agriculture and forestry. i changed it to agriculture,

nutrition and forestry. i wanted to bring back the word nutrition for exactly the reasons both of you have said. we are in the wealthiest nation in the world and we can handle our nutrition needs. that's a national security problem as well as anything else. i see in this pandemic, children are left behind. the needs of those struggling in our communities. it increases access for children but we need to do more than just

get the fork on the table. it needs to be health and nutrition. coming from a city like mine, in many cases this is not true. we need a coordinated effort on the federal government down to the local level to make sure all americans have access to nutritional foods and are also bolstering regional supply chains that can best deliver to these communities. particularly in our schools. i have looked at some of the statements that are going to be made and i'm sure our witnesses will tell us about how important it is for the health outcomes with the dietary habits of children. my staff will be here following this and i will actually listen to what you all say when i get

back for my appropriations meeting. providing healthy and local choices in our supermarkets, but even with that many in our schools still struggle to include these in school lunches. nearly 60% of usda school programs close to additional -- these corporations have been plagued by supply chain disruptions which caused food shortages in schools across the country. so we need more resilience -- resilient supply chains. we have to make it easier for local and small-scale producers to feed children. to ensure more schools have the

opportunity. all three of us can give a boost. at have also long championed the school program between local farmers and students. schools are affected and underutilized. i look forward to hearing from all of you. i am just so happy you are doing this. i would state to the witnesses, i have heard senator booker what he said about nutrition, he says that when the cameras are not on

and the ranking member, we have talked about this usually at our prayer meetings in the inner sanctum in the evening. in the need -- and the need we have to do this. parents or grandparents as citizens, if we do not do something about this issue, what are we leaving our children and the next generation so thank you mr. chairman. >> we understand you're going to an appropriations meeting and we hope you will remember new jersey. i would like to introduce the witnesses. i want to knowledge the presence of senator joni ernst, another person concerned about these issues. i would like to start off with introducing -- senator lahey: i did not see her come in. sen. booker: a cardiologist, a

dean and a professor at tufts friedman school of medicine. he aims to include a food system that is nutritious, equitable and sustainable. he has authored more than 450 scientific publications on dietary priorities for obesity, diabetes, cardiovascular disease and evidence based approaches in efforts to reduce these in the u.s. and globally. he has been featured in a wide array of media outlets. thomson reuters has named him as one of the worlds most influential scientific minds. i am grateful you are here today. dr. odom's young is director of

the food and nutrition education communities programs in new york state expanded food and education programs. in 2021 he joined the cornell faculty after spending 13 years of the university of illinois at the department of kinesiology and nutrition. dave -- the research explores social determinants of dietary behaviors and related self outcomes in low income populations in black indigenous people of color. it will -- the work settles on culturally responsive programs at policy to promote equity, food and community resilience. i want to thank them for being here as well. dr. donald -- serves as chair of

the department of indigenous health, director of the indians into medicine and public health program and professor of family and community medicine at the university of north dakota. he is the principal investigator for the indigenous trauma and resilience research center at u.n. d. he serves as a senior policy advisor to the great plains tribal leaders health board in rapid city, south dakota. he spent several years as a primary care physician. he is a member of the lakota tribe from pine ridge, south dakota and comes from a long line of traditional healers and medicine men. i want to thank you for being part of this today. i want to recognize the ranking member who will introduce our next two witnesses. sen. braun: our next witness is

vice chancellor and dean for agriculture and life sciences at texas a&m and director of the texas a&m search. earlier in his career he directed the division of nutritional sciences at cornell university and has advised policymakers at the centers for disease control and prevention world health organization and the united states food and drug administration. a testament to his leadership and biochemistry, nutrition and food systems, dr. stover is an elected member of the national academy of sciences and the former president of the american society of nutrition. the final witness this morning joins us remotely from wisconsin. she is a senior fellow and a rhodes scholar in poverty studies at the american enterprise institute where she

studies poverty and the effects of the federal safety net programs on low income people in america. it specializes in support programs for low income families including the temporary assistance for needy families. in the supplemental nutrition assistance program. she was a deputy commissioner for policy research in new york city department of social services. to each of our other witnesses for joining us this morning. >> fasten your seatbelts, these are extraordinary declarations of the state of american nutrition and i am excited about it. dr. mozaffarian, would you proceed with your testimony. dr. mozaffarian: chairman booker, ranking member braun, thank you for convening this hearing and for the opportunity to testify.

it's our experiences cardiologist and as a doctor i see first-hand people of all ages and background suffering from diet related illness. i see the incredible challenges americans face every day to obtain and eat nourishing foods. as a scientist i see the exciting advances on which food will help our bodies in which policy changes can support nutrition security health. we face a national nutrition crisis. costing us trillions of dollars and holding us back from achieving our goals as individuals and as a nation. the situation is dire. because of nutrition insecurity, more americans today are sick then are healthy. three in four have overweight or obesity. the recent report puts an exclamation point on this.

conditions are deadly, costly and largely preventable. during covid-19 americans with diet related conditions were 12 times more likely to die following infection. at the same time nearly 40 million americans experience food insecurity and in 2020 during the pandemic, food insecurity group for households and children. in every state in our nation, they also disproportionately afflict americans with the least advantage. those with low income, rural or racial or ethnic minorities. poor nutrition is harming our children, creating disability. among two to five-year-olds, one in 10 are already disease. among teens, one in five has prediabetes. shocking wake-up call to the future of our country. these diet-related diseases are also the top drivers at preventable health care spending.

it now accounts for most one in five dollars and our economy and one in three in our budget. 80% goes to treating preventable chronic diseases. this is not a path for balancing budgets, thriving u.s. businesses or a competitive national economy. it is largely ignored by the health care system. that simple but striking fact explain so much about where we are today. hundreds of thousands of sick americans and spiraling preventable health care costs. it also affects our national security. three in four young americans are ineligible to serve in the military and the top medical reason is obesity. these are daunting challenges but they are also opportunities, but today our country has no national strategy to address specifics. the science is available to create plans to address this national crisis.

practical, evidence-based and practical solutions per we have the ability to create nourishing sustainable -- which creates economic well-being and national security for our nation. as i hope we will discuss during this hearing, there are specific actions across six priority domains can catalyze a healthier citizen. one that ends hunger and reduces health. what do we need to do? we need to advance science and research. we need to leverage the power of food and medicine and health care. we need to strengthen our leverage on the federal nutrition programs in particular school meals. we have to catalyze business innovation, jobs in this area. we have to expand nutrition education in public health and

we have to actually coordinate all of this. including new leadership structure and authority to do so. we can only do this if we have a plan for a real national strategy. the two of you together with representatives in the house have called for hunger and health. it's been 52 years since our nation came together for a strategy. much has changed. we can make america the 21st century breadbasket for nourishing food for our country and the world. food that heals our bodies, reduces health care spending, supports our military, revitalizes rule america and creates new jobs and business. thank you for your leadership and i'm pleased to answer any questions. sen. booker: thank you so much.

i want to thank senator marshall, someone who's had a concern with these issues and i'm grateful for his leadership today. doctor, you are recognized. >> members of the agricultural subcommittee on nutrition, specialty crops and organics research, think you for allowing me the opportunity to speak with you about the state of nutrition in america with a specific focus on black communities. the social and economic consequences of suboptimal diets in the united states are well documented and -- as has been previously stated. this indicates poor nutrition is a major driver of americans high chronic disease burden and a sizable rate of death and disability from cardiovascular disease, hypertension and

certain cancers. it is exacerbating the national impact of poor nutrition is the reality its associated burden is not equally shared around all socioeconomic groups. in black population specifically have dietary intakes that fall short of the national recommendations and face higher rates of diseases. black americans are 60% more likely to be diagnosed with diabetes by a physician, 2.3 times more likely to be hospitalized and on what -- six times as likely to be diagnosed with diabetes by a physician. unfortunately in the last year we've seen racial inequity with health and nutrition worsen as a result of the covid-19 pandemic. the black white gaps in life expectancy is widening.

this can be partially explained by the high prevalence of nutrition related chronic disease among blacks as compared to white people. additionally, economic barriers including a greater likelihood of living in racially segregated dis-invested areas, higher rates of being uninsured and underinsured and a wage disparity where black americans earn almost half as white households also sets the stage for black communities to be more nutritionally vulnerable. although food security rates in the u.s. generally remained stable from 2019 to 2020, the prevalence of food insecurity for black households increased from 19.1% 21.7%. food insecurity not only contributes to higher disease rates but also the risk for maternal depression, and lower

academic achievement. consequently it's likely this increase have effects for years to come. traditionally researchers and practitioners focus attention on individual knowledge and motivation and key drivers of dietary behavior, science generated for more than three decades highlights the importance of social and structural determinants of health. many studies have shown this is not just about making hard choices. systemic and structural disadvantage moves good health out of their reach. a common thing in public health is this matters -- black americans are more likely to live in environments that promote obesity, specifically characterized by limited access to healthy options and

high-availability and in-store marketing of low cost energy dense foods and drinks. it is particularly striking that these inequities in healthy food environments exist at every level of income. the first white house conference on food nutrition and health resulted in landmark legislation that provided the foundation for the federal food infrastructure we know today and raised awareness about widespread malnutrition and hunger being experienced by families and communities throughout america. similar to 1969, the advance of 2020 -- events of 2020 amplifier level of consciousness about the ways in which social structures and political condition create different experiences and opportunities for people living in the u.s.. we did not get here by chance policies.

policies over centuries and every level of government such as redlining that restrict access to some but create opportunities for others. in closing we need to continue to prioritize nutrition security with the lens of racial equity. the time to leverage this policy is increased through hardship in black communities and increase opportunities for better access now. thank you for your attention in considering nutrition's role for promoting our nation's health. thank you so much. sen. booker: you are very welcome. thank you for your testimony. dr. warne, you are fortunate. my colleague from north dakota would like to introduce you. sen. braun: thank you mr. chairman and i admire your alliteration. i am very pleased i can take

just a minute to introduce dr. donald warne. he is here to share his insight in the health of american indians and alaska natives including the recognized tribes in north dakota. he is a member of the lakota tribe and is director of the indians into medicine program and the public health program at the university of north dakota medical center. this is one of the most amazing programs in the country, it encourages native americans to enter the field of medicine, doctors and nurses and everything else. we have such a need in this country to get more young people into medicine, particularly with our aging population. this is just a model and fabulous program that does that. not only making a difference in the lives of so many young

people, but think of what they do for all of us who need medical care and attention when we have such an acute shortage of people in the medical profession print thank you for your leadership of this incredible program. when i chaired the indian affairs last congress i invited dr. warne to participate in a discussion and i appreciated the insight you brought to that meeting and i look forward to your testimony here today as well. i'd like to think the chairman for that privilege. sen. booker: there is a bipartisan divide there. would you correct me with the cornet -- correct enunciation of your name. dr. warne: you make it sound cooler. [laughter] dr. warne: chairman booker, make -- ranking member braun, good

morning morning and thank you for the invitation to speak today and thank you for the kind words. in addressing the state of nutrition in 20 we need to recognize in american indians we have a crisis of nutritional disparities. less access to healthy foods and dependence on inexpensive processed foods leads to weight gain. obesity is at a critical level. 48% of the american indian and alaska native nation is 14 -- is obese. obesity is a significant risk factor as we deal with type two diabetes and heart disease as the leading cause of death for indigenous people in the united states. we have seen improvements but american indians and alaska natives have the highest prevalence of type two diabetes in the nation and alaska native children and adult -- adults are more likely than hispanic adults

to be diagnosed with type two diabetes. the prevalence of coronary heart disease is about 50% greater for indigenous peoples. my personal experience i served as a position in arizona for a number of years with among the highest rates of type 2 diabetes in the world. firsthand the challenges of a population with limited access to healthy food sources. on the pine ridge indian reservation, the supermarket is 90 miles away in rapid city. significant barriers to accessing healthy foods. many of them are suffering from diabetes and heart disease. many tribal communities, substantial expenditures manage complications such as dialysis for kidney failure, coronary artery bypass, amputation for diabetic neuropathy. with kidney failure people are automatic -- on medically eligible for care.

people are confined to wheelchairs due to amputations utilize social programs to build a ramp for them to access their homes. rather than the significant financial expenses and decreases in quality of life associated with the complications, would it not make more sense to invest in healthy food. one major historical consideration is the forced relocation of american indian people, restricting access to traditional food including regionally specific hunting, gathering, fishing and farming. a lot of traditional food source -- the lack of traditional sources relied on government programs such as the commodity food program and included the distribution of food such as lard, canned meats, salt and sugar. according to the north dakota department, the average age of death in the decades between 2009 and 2019, the average age

of death for american indians was 56.8 years. the average age of death for the white population was over 77 years. about a 20 year gap in the age of death. systems along with dachshund -- new moving forward a multipronged approach in collaboration with numerous stakeholders is needed to address the upstream social determination of health and increase access to healthier foods. promising best practices and strategies for american indian and native alaskan populations can include several areas including improving existing programs, promoting breast-feeding and early childhood nutrition, promoting food sovereignty and increasing access to traditional foods and expanding -- expanding local

foods and consider taxing unhealthy foods and subsidizing healthier options. food programs that work well in the city and suburbs may or may not work effectively in tribal communities. we have to recognize one size did not fit all for policy solutions. we need to recognize we have a crisis of nutritional disparities among american indians and alaska natives. we need to fundamentally change our approach to nutrition and develop new strategies to address inequities. i applaud the idea of a second white house conference on nutrition to gather community input on solutions and develop action items. we need a comprehensive policy and an approach that is well coordinated and the nuances of engaging tribes in these areas. ideally we will include stakeholders lived experiences moving forward. i am deeply honored to be here, indigenous voices are not always

at the table and i appreciate the opportunity to address each of you that look forward to further discussions and questions. sen. booker: i would like to recommend -- recognize dr. stover. dr. stover: chairman booker, ranking member braun and members of the subcommittee, thank you for the opportunity to testify today. i serve as vice chancellor, dean and director of research with the texas a&m university system in agriculture and life sciences. i am fortunate to lead one of the largest and most comprehensive agriculture programs in the nation encompassing 5000 people and a $400 million budget. agrilife covers a value chain from food production to consumer behavior. i want to provide my perspective

on the state of agriculture, the food system and its connection to hunger. i will provide some context for the enormous challenges we face. but more importantly give you a sense of the opportunity to reimagine the role of agriculture in transforming our lives. but first a little context. norman bohr log won the nobel peace prize for sparking the green revolution. his efforts transformed global systems to be abundant, affordable and high caloric density. his successful efforts dramatically reduced hunger. today we face a growing crisis of diet-related chronic disease which costs the u.s. economy over $1 trillion annually and affects nearly half of all adults. we need to build upon this legacy in a revolutionary new way by expanding our mission from simply using food to eliminate hunger and

undernutrition to using food to become healthier. this can only be done by achieving dachshund and advance rigorous science. what some deem to be healthy foods. with that said, urbanization, stark investment in agriculture research and the knowledge of agendas and a deficit of public trust all contribute to a deficit of public trust. that disconnect threatens agriculture, the food supply and the health of our society. fortunately agriculture is uniquely positioned to have a solution. we can tailor agriculture and food systems to support any and all desired outcomes. to that end, texas a&m agro life -- agrilife is happy to partner

with the usda centers. i am grateful for the new investments from congress, the state of texas and the usda that allowed texas a&m agrilife to launch two efforts. first the institute for advancing help desk health through agriculture will advance the search that connects agriculture with human environmental and economic outcomes. second, the agriculture food and nutrition scientific evidence center will be a global resource for policymakers and provide a nonbiased comprehensive scientific information concerning the human, environmental and economic effects of any proposed changes in the food system and agriculture system. these efforts are launching a first step in our collective efforts to solve some of the most pressing problems. equally important we must

bolster education and earn public trust. so individuals can make the best informed decisions for themselves. the land-grant university system is a network that's an extra ordinary resource and should be playing a much more active role across the nation. these are national treasure. with the mission of improving the quality for all embers of society. before i conclude i would be remiss if i did not acknowledge the efforts of leaders in this room to convene another white house conference on food and nutrition. as a nutrition scientist whose dedicated by career to advancing research between nutrition and disease i know these conversations are vitally important. with that said, agriculture was to have a seat at the table if we are going to be successful. the cost of the current situation cannot be overstated.

diet-related chronic diseases face a huge financial burden on individual and health care system, the american economy and our crippling quality of life -- and are crippling quality of life for most americans. hunger cannot be considered in the absence of agriculture health. with that, thank you for the opportunity to testify and a look forward to your questions. sen. booker: thank you for that testimony. i would like to recognize -- for her five minutes. >> members of the subcommittee, thank you for the opportunity to testify on the important issue of nutrition in america and thank you for allowing me to participate in today's hearing remotely. i am a senior fellow at poverty studies at the american enterprise institute where i spent the past several years researching policies aimed at reducing poverty.

before i joined i was deputy commissioner of the new york city department of social services for more than a decade where he oversaw the agency policy research. among other programs we administered, we oversaw snap which provided benefits for most 2 million new yorkers each month. my testimony covers three main points. first, a poor diet has created a major health crisis in the u.s. with serious health and financial ramifications. our nutrition assistance programs have mixed success. and in many ways contribute to the problem. instead of pursuing bipartisan recommendations with nutrition assistance programs. they've undermined these efforts. problems associated with poor diet puts millions of americans at a tremendous cost. we know from decades of research that obesity rates are at crisis

levels in the u.s.. we know poor diets contribute to very high rates of chronic diseases. these costs are staggering. although the aim of our food programs was originally to -- reduce hunger, this must now take priority. while the federal government nutrition assistance program cannot solve the problem of poor diet on its disease -- alone, it can play an important role. the usda operates 15 programs of the federal government spending more than $100 billion per year with assistance to u.s. households. evidence shows these programs effectively reduce hunger but they could do much more for better nutrition and help address poor health outcomes. one of the main problems with the usda nutrition assistance program is they lack a strategy.

according to my own research, the federal government added a level i project will remain high for several years to come. we knew that hunger from u.s. households constant -- was the worst month and yet federal lawmakers continue to expand -- extend benefits without addressing any of the underlying nutritional concerns associated with the program. this is concerning because research shows snap contributes to poor diet quality. usda recently increased snap benefit levels and determined households should consume more calories. this is counterproductive with research showing overconsumption of calories is a major contributor to the problem.

three of the five largest expenditure categories among snap households are sweet beverages, frozen prepared foods and prepared desserts. it is not to judge what they purchase, instead it is to acknowledge the reality that billions of federal dollars earmarked for nutrition among low income households are primarily being used to buy food and beverages that are major contributors to poor health. in 2010 i was part of an effort by the new york city mayor to pilot a project restricting sugary beverages from snap purchases. the usda denied our efforts and since then billions of snap dollars have supported the purchase of unhealthy products across the country in child obesity rates have increased to almost 20%. that is one in five children in the country are obese. in 2017i was part of a

bipartisan policy center task force on leveraging federal programs. we developed recommendations of the federal government could implement to improve nutrition among program participants. they all remain relevant today. the main point i want to make is the federal nutrition assistance program has a role to play in improving the health of americans. the largest of which involves a snap. problems of poor diet quality are bigger than snap. it can play a role in helping. this approach has received bipartisan support in the past and should be used as a framework moving forward. thank you, and i look forward to answering your questions. sen. booker: great testimony in

your experiences across the river from newark, new jersey was helpful watching you. i want to jump back into question and answering. the ranking member and i have worked out way the dutch ways that we can both vote so i will vote and run back and he will do the same. i want to start out with some of the staggering data that should appeal to everybody as you look at health-care costs, our nation spends more than any other segment of our economy, nearly one in every five dollars but one in every three government dollars almost. and yet the top because of public health, food is largely missing from the health care debate which seems to be more about access and not about demand. can you speak about the nation's

health care spending and the current trajectory we are on if we do nothing different? dr. mazaffarian: thank you, chairman booker, for that question. we are on a path to disaster. if three in four houses in our country were on fire and always did was build more firehouses, that would not be sensible. that's what we are doing with health. all we are doing is building systems to treat the downstream causes. with most houses on fire, we would figure out what is causing them and put them out rather than focusing on downstream treatment. a recent analysis by the rockefeller foundation found across the supply chain, we spend $1.1 trillion each year on food and at the same time, diet causes about $1.1 trillion worth of health care spending from diet-related illness.

every dollar we spend on food, our economies loses one -- economy loses one dollar. type two diabetes, we keep mentioning and will keep talking about this because it is the canary in the coal mine. it is a devastating disease, almost entirely treatable. the federal government, states, spend more than the entire budget of the usda. nationally, one in seven dollars overall is spent on diabetes. just one diabetes drug can cost 5000 to $10,000 a year with out-of-pocket costs of more than $2000 a year. diabetes costs for the governments have risen 25% in five years. this is not sustainable. rising health care costs are squeezing every other priority out of the federal government and u.s. businesses.

we have to get these health care costs under control and we are not going to do it until we address poor nutrition. sen. booker: i mean, that is staggering. the fact that we have seen spending go up just for one disease. so much diabetes and now is more than the entire department of agriculture. and as you said, i think that just to absorb that, that in five years alone, the last five five years, our spending on diabetes has gone up 25%. what could the next five years potentially bring if we do nothing. but i think the point that you made there that i want to ask you about is that we have enough evidence that we know some strategies that could interrupt this and make it better. and they're promising strategies. and i'm wondering you know, , there are strategies like food as medicine and access. and i think some of the other witnesses here testified that providing better access to healthy food dollars spent there could actually save health care dollars. you get the double bonus as

opposed to what we're seeing now is currently the dollars spent. we get a double loss. and so i'm wondering if you could maybe speak to some of those strategies that can integrate food and nutrition into our health care system and prevent what is the title wave? the tsunami that no one is talking about when they talk about our federal budget. again, the debates here are stuck in these debates about, as you said, how many more firehouses do we need as opposed to how do we stop the fire? dr. mazaffarian: well, this is what's really exciting about where we are today. there's some of the most exciting science has been about integrating food and nutrition into health care to reduce disease, increase equity and lower health care costs. i call that food is medicine kind of how do we get food into , the health care system? it's really a simple four part formula with every part really clear, easily addressed in a bipartisan fashion. the first is medically tailored meals. we have to have medicare, medicaid, test implement and

scale medically tailored meals. these are giving home nutritionally tailored meals to the sickest patients with severe chronic conditions like kidney failure, heart failure, poorly controlled diabetes, cancer. research has shown that giving medically tailored meals to these sick patients, reduces hospitalizations, reduces er visits reduces nursing home , visits and even accounting for the cost of the program actually saves money in one analysis, up to $10,000 per patient per year. the second part of the formula is produce prescriptions for people that have diet sensitive diseases but aren't quite that sick and they can still shop and cook. a doctor should be able to write a prescription for fruits, vegetables, beans, you know, other healthy foods that is partly or fully covered by insurance. and prescriptions seem from all the evidence at least as cost effective as other treatments like cholesterol lowering drugs for primary prevention of heart attacks. the third part of the formula is to actually leverage dietitians . today in medicare, dietitians can only be reimbursed for counseling of patients for a very small, limited set of diseases like diabetes or kidney disease, but not for many, many other major diet related

conditions like overweight or obesity, high blood pressure, heart disease, stroke, cancer or more. in a cardiology clinic, i can get reimbursed for having a genetic counselor on my staff, but i can't get reimbursed for having a nutritionist on on the staff. it's time to fix this and and part number four is nutrition education for doctors. the vast majority of doctors say in polls that they recognize nutrition is so crucial for their patients. they want to learn more and they're not learning enough in their training. the simple way to fix this is to change the tests. we have to change the u.s. medical licensing exam, the specialty boards tests and the continuing medical education test that every physician takes, for the top cause of poor health in our country shouldn't. all of the tests have five or 8% of questions on nutrition? if we change the tests will change medical education overnight. sen. booker: thank you for that. i'm going to run and vote and for now turn it over to the ranking member to chair.

thank you, mr. chairman. >> so we've been talking about health care costs nearly 20% of our gdp and we started this conversation 50 years ago. you know what our health care was as a percentage of our gdp 7%. so it's nearly tripled in the 50 years we've been having the discussion and then you hear testimony that what we do through snap through some of our , nutrition programs here in the government, might actually be adding to the issues of good nutrition because mostly what gets into diets would be probably highly processed food that may be inexpensive but would have empty calories. so what a dilemma we are in. i've got this question for dr. rashidi or mr. stover that what do we do to get the health care system to turn away from

remediation to prevention, number one? and what do we do through the usda and the one or two things that might be most salient to where we start actually recommending food that's going to help solve the problem, not exacerbate it. start with dr. rashidi. dr. rashidi: sure, thank you for the question. i'll address what are federal nutritionistance programs to do namely snap. i think the two main things that could happen in snap that could make a big difference is one to implement restrictions on what can be purchased with snap dollars. i think starting with sugary beverages is a very good step. it will reduce, likely reduce the amount of those beverages that are purchased by households and i think even more importantly it will send a very strong message that uh snap is serious about nutrition and serious about households wanting to improve nutrition. i think the second thing then that the usda could do within

snap is to leverage the restrictions with increases in funding for incentives to purchase fruits and vegetables. i think the combination of those two, so reducing the amount of money available for sweetened beverages, increasing the amount money -- amount of money available for fruit and vegetables can start to change the calculus and might actually increase access to those products in neighborhoods that are low income because there will be more money to purchase them. >> dr. stover? dr. stover. -- dr. stover: thank you for that question. i think that we have to take a systems approach to really connecting food and health. as i mentioned, there is a disconnect right now a major disconnect between food production and then our expectations around consumer health and we have to address this across the entire food system.

we heard about obesogenic environments. we talked about the relationship between diet and disease. we talked about incentive programs, we talked about other types of federal interventions. we need to approach this considering the entire food value chain from farm inputs all the way to consumer behavior and human nutrition. we saw during covid-19 that a change in consumer behavior, not eating at restaurants anymore, eating at home played havoc on the entire agriculture and food value chain. they are all connected. if we want to set the goal, the purpose of the food system, to lower health care costs to protect the environment or whatever goals we have we have , to focus on that goal and we have to make take advantage of every opportunity, all the knowledge we have today towards that specific goal. and we have to do it in a way that we acknowledge where our research gaps are and be very transparent about how certain we are, the knowledge we have so that we can engender public trust.

that's the only way we're going to get true prevention. if we deal with all the causes. when you talk about prevention there were two aspects to that ,. there is what you eat and how much you eat. francis collins started the precision nutrition initiative at nih for the sole purpose of trying to understand how individuals interact with food in the diet, chronic disease relationship. and we know we are heterogeneous. the data tells us that we all interact with food differently in terms of that chronic disease outcomes. one size doesn't fit all. so we need to better understand that science and how to better match people to diets and again consider the whole agriculture value chain in terms of dose. -- value chain. in terms of dose we need to , understand better human behaviors, these obesogenic

environments, etc. we need to try to work on dose so that people consume less. we have to work on both aspects, both the dose of consumption and what people eat. senator braun thank you and real : quickly how important , relatively is it that the obama would lead on this as opposed to trying to force solutions through government that always is a little trickier? why are we not hearing more in credentialing and so forth to where that ounce of prevention being worth a pound of cure. to me if that happens at where the rubber meets the road we actually start seeing things cascade in a favorable way. how important is it that the ama get on board with this? dr. stover: and as president of the american society for

nutrition we spent a lot of time , trying to focus on getting more nutrition into medical education. that's a tremendous challenge because every professional society once more of their type of education in the medical degree at texas a&m and we have a paper coming out on this. we are encouraging combined programs of nursing and dietetics. it's nurses who are the front line healthcare workers who see every patient especially in our disadvantaged communities. we need to have those front line workers have that nutrition education because there simply aren't enough dieticians in these health care facilities to educate about nutrition. and at the same time we need to expand what we do in the land grant system through extension. people trust us. people trust the information that we give them. we have community health programs. they have not kept up in terms of funding with the growth of population and the diversifying of the population. we need to take advantage of our extension system as well. senator braun: thank you. senator warren. senator warren: thank you so

much, ranking members, and senator braun, i'm grateful to you. and also to chairman booker for holding this important hearing. families across georgia's rural communities are facing added barriers to adequate nutrition including distance to a grocery store, limited transportation options and the availability of quality fresh products at an affordable price. for example second harvest of , south georgia estimates that one in five people in south georgia do not know where their next meal will come from, one in five. administrative flexibilities provided by usda have helped provide additional nutrition assistance throughout the pandemic. but i'm hearing from the folks back in georgia that the guidance coming from washington fails to fully reflect the challenges of administering assistance in rural communities. dr. warren, you both have

dedicated your career to underserved communities. what unique challenges do individuals in rural communities face regarding nutrition and how can this subcommittee better address those challenges as we look ahead to the 2023 farm bill? dr. warren i appreciate the : question very much, senator warnock and where i'm from in , south dakota originally and the communities i worked with in north dakota are very rural, particularly the tribal populations. and with the rural populations that i've worked with that are also underserved we tend to have , less access to health care, but also less access less easy access to healthy food. where i'm from originally in kyle, south dakota, for example, if we want to purchase healthy food, it costs more than what you would spend in a city or a suburb because it's perishable that it costs money to bring the food out to some of the rural communities. so in public health, we call that a poverty tax.

so it's not a tax per se where money is being collected by a government, but people have to pay more money for healthier options when they live in rural and underserved populations. so it also links them to the need for health education. and one of my challenges that i've seen when i was a full time clinician, i was also a certified diabetes educator. and what i recognize is all of this awareness, of education and theory is really not a value. if we can't implement it. if people don't have access to the things that we're recommending, then we're really not going to improve outcomes for diseases like diabetes. so when i look at the communities that i work with, there are so many challenges. we need to create opportunities and fundamentally rethink how we're doing this because we need more local, easy access to healthier choices. and in doing that, we also have to develop community champions. it's not easy to change behaviors just by changing a program or two. we actually have to do a lot of community engagement on the front end to make it more effective. senator warnock: thank you so much. in order to serve our rural

communities and i spend a lot of time in my state being certain to move around these rural communities, it seems to me that we have to center their unique concerns in order to get the policy right. and it's great to have folks like you here helping us helping this committee to think about how we best tailor the policy to the particular needs a rural communities. if i may, i want to pivot in my remaining time to another subject. since my first day in the senate, i've been laser focused with my colleagues on closing the medicaid coverage gap. in georgia, we got 646,000 georgians in the medicaid gap uh -- gap, millions of americans. this is a matter of life and death for people in my state all across the country, and congress must act immediately. according to the georgia food

bank association, approximately 66% of the families they serve have been forced to choose between food and medical care. so this issue affects everything including nutrition. dr. mozaffarian, in your testimony, you discuss how nutrition insecurity and diet related diseases disproportionately impact those who are low income, racial minorities or live in rural , areas. how would closing the medicaid coverage gap and expanding access to health insurance, reduce health disparities and improve nutrition for the 646,000 georgians. the 2.2 million americans who currently lack access to free and affordable health care. dr. mazaffarian: well as a as a physician, you know, i know and i see the power of the healthcare system when you get sick and if you get sick and have to use it and don't have insurance, you can be financially devastated. and so i think having access to health care insurance is as a

-- insurance as a financial support system is crucial. i'm not convinced that having health insurance per se makes us healthier. and there's lots of evidence that that's not not the case, it's a financial incentive, but you know, to get healthier, we also have to have that health insurance uh focus on prevention. and so i think that you'd get a double win if that policy of addressing the medicaid gap were paired with real programs and policies and medicaid, like the ones i mentioned, medically tailored meals, produce prescription programs, dietitians that can actually see patients who need them and physicians who are trained in nutrition so that those low income communities, rural communities, communities of color can get their insurance and go and actually get healthier food, get good counseling, get medically tailored meals if they need it and so on. so i think, you know, the health care system again is wonderful if you're sick, but it's very expensive and it doesn't do a whole lot for prevention. and so we need to both expand coverage and change the way we

think about health care so that it actually starts to really be a focus on prevention more than treatment. senator warnock: prevention, affordability, access to good nutritious food and access to health care. all caught up in a single web and there's no sort of one prescription for all of these things where they're caught up. thank you so much for your testimony. mr. ranking member, who's up next? sen. booker: dr. marshall. dr. marshall i appreciate you : holding this hearing. ranking member braun mentioned the cost of health care went from 7% of gdp to 20% of gdp gdp

-- gdp approximately. and often all i talk about driving the price of healthcare. i talk about what we need more transparency. we need more innovation. we need more consumerism. but the fourth leg of that stool is better nutrition. that's certainly one of the reasons that the cost of health care is went up is something i can't control is a position i can't prepare the diet for the folks that need it. the majority here gives us notes today. currently in the united states, nearly half of our adult population is pre diabetic or has type two diabetes. diabetes, half of our population. that's an epidemic. mr. chairman, in the spring of 2020, i volunteered in southwest kansas at an icu, and the covid virus was sweeping across kansas are packing plants in southwest kansas. we're just getting devastated. we set up testing stations and did everything we could. but i went to the icu in liberal kansas eight icu beds but there , was 11 patients and i think they were in their 50's.

every one of them had diabetes or probably prediabetes. and immediately i called the cdc and said, oh my gosh, this virus is going to assault this country. and people will ask why is our morbidity and mortality higher with the virus then say the african nations? and i assume that would be true for our friends in the far east who have better american diets as well. and i don't know about you all but i've been so frustrated that the cdc has not talked more about nutrition and building your own immunity. we've had a year and a half of this virus and i thought this might be an awakening for this country that if we had a better healthy immune system that's how , you fight viruses. i think i will start with dr. mozaffarian, forgive me. are you frustrated that the cdc hasn't been doing public service announcements on building up your own nutrition and how important nutrition is to

building a good immune system? dr. mozaffarian: i think this has been a lost opportunity this last year and a half. obviously we need to have worked , on and successfully developed vaccines. look for treatments for social distancing other things. but the huge, you know additional foundational effort , should have been to improve our overall metabolic health through through better nutrition. we published research this year that we we estimated 64% of covid hospitalizations could have been prevented if we had a metabolically healthy population. so every time, not just the cdc but but other leaders in the , federal government leaders in the states every time they talk about social distancing mask wearing a vaccine. -- getting a vaccine, nutrition, why wasn't it talked about? dr. marshall: i think that's a

great explanation point. i think about my own field of obstetrics and the morbidity mortality for this country's went up over the past decade or so. and we've done deep dives down why you know how come but i can share with you that the average starting wave weight of a patient in my practice from 25 years ago until i left my practice four years ago was up about 20 pounds. and this incidence of diabetes and prediabetes which is exacerbated from the hormones of pregnancy was i think that has to be contributing to it as well. and it's been frustrating, you know. we've been studying this for decades and i appreciate your comment. we had more education and medical school that would be helpful. but i'm telling you, i learned everything i need to know about nutrition to address this problem from my mother and my grandmother. and it's not doctors that give the nutrition education, it's the nurses, right? and i think it's just a matter of how do we use those assets the two and the time of the nurses to keep teaching that in as much as we need doctors learning more about vitamins a,

d, e, and k are fat-soluble and that's why we need to be drinking whole milk as opposed to just general general concepts. and i think the bottom line is this when the economy is bad, when people don't have a job, when you've got some some food stamps, whatever it is, carbohydrates are cheaper, processed food is cheaper. and that's why i've always thought the economy is so important to this issue as well. give a person a job where they can make these healthy choices. one big question i've got for anybody that can help me answer this. we pack our food banks with yesterday's donuts and yesterday's breads and it's expensive. we're making an effort. i think we are doing it better today in our food banks than we were a decade ago trying to get nutritious food in there. there is a multi trillion dollar vitamin industry out there. are you all aware any research that we should be putting vitamins in our food banks, or are vitamins different than you know, give me whole fruits and vegetables and give me a whole

milk and give me good protein sources over a bottle of vitamins. i think that most of us would agree that mother nature made it. it's better. but should we be adding vitamins to to those those types of situations? i know i'm open for anybody has any thoughts on that. dr. marshall i can comment on : that. what we are talking about today, diet-related chronic disease is , not driven by micronutrient deficiencies that you get out of a vitamin. certainly those do occur for those who do not have the best diet. certainly they can help fill gaps. but what we're talking about today at least in all of my experience and working on these dri panels is not related to vitamins. this is a broader question related to the food environment. it is related to health behaviors. it is related to public trust. and this is another issue where people -- pew research did a survey last year -- and people

don't trust nutrition researchers the way they do other areas of the health care system. and so we have a big challenge. we have the problem with covid and vaccinations. we have the problem in nutrition. if anyone thinks -- dr. marshall: go ahead. >> can i just add one comment, dr. marshall, on the cdc? the cdc's division of nutrition, physical activity and obesity, nutrition, physical activity and obesity. the foundation of health is that has $100 million a year budget. the government spends 160 billion on type two diabetes treatment and 100 million on prevention at cdc for physical activity, nutrition and obesity. let's get that division of $2 billion maybe 1/60 of the cost of diabetes so that you know, i think the city you can have. dr. marshall: i totally understand where you're coming from. my experience is throwing money

at it doesn't solve the problem. i would want no very specifically, what would they be doing different than they do today? mr. chairman, can i have another minute? nobody else is waiting? so i'm going to go ahead and you can have two more minutes. so i think my questions for for the doctor is again, i feel like we're just throwing money at things. we've tried this. i don't know why we need another conference to be honest. i think we all know exactly what what needs to happen. but much like me trying to convince a patient to stop smoking, they know they need to stop smoking. american knows they need to get on a better diet. american knows that that they need to be exercising more or we we certainly know what doesn't work. what would work. what are we not doing now? that if you were king that you would come in here and say here's something that we can do to really impact this problem tomorrow. so doctor you're on the line. , i think if you have any comments, i'd love to hear your

thoughts on that. dr. rachidi: yes. thank you and i couldn't agree more that just throwing money at the problem has not proven to be effective in the past and i don't think would necessarily be effective now, for example we , the federal government has increased efforts and spending on nutrition education for example and in snap and various other programs and while i think nutrition education can be useful, it certainly has not had a major impact um on any of the problems that we have talked about today. so we really need more of a holistic approach that looks at what we are already spending and figures out a better way to spend it. and again, i think the main point that i really want to emphasize today is that we need a cohesive nutrition strategy across all the federal agencies that makes it clear to the american public that this is a crisis and we have a strategy to try to fix it and that includes a whole range of things. i mentioned my area of expertise which is snap and what we could do there, but obviously there's many other ideas just today of what can be done. but the main thing is we have to pull it together and we have to develop a strategy and then we have to take action as a country and actually implement these strategies. dr. marshall: thank you so much.

mr. chairman if i would say my , experience in 25 years of medicine wic works. , the wic program is great. and one of the reasons that wic works is the people that are participating that are teaching and coaching up people, they're not just giving them vitamins, they're not just giving them healthy choices, but they're coaching them up. and it's that interaction between the real people and thee coached up to what a healthy diet looks like. so much. >> this is a wonderful form to engage with colleagues. you are one of the more informed people in the united states senate. you have tremendous experience with diverse populations. i agree with you. i'm one of these people who has witnessed a lot of knowledge, but it is not getting into our practice. the two things i would say, she said cohesive strategy. we are not working together to get it done. the vision for senator braun and

i -- and i would love to talk to you more about it -- we get stakeholders around the table. private sector, farmers, policymakers, to begin to talk while those evidence-based strategies, why are we not working together? the reality is, what can create change has to be folks like you and i agreeing on a strategy and executing it. there clearly are things we know work that we are not investing in, and things that are potentially making the situation worse. you are somebody i look forward to partnering with. you have when i would say cred on these issues. before you go i would like to ask this panel, and i want to turn to dr. odoms-young. because there are strategies. i was the mayor of a city. i kept my city government by 25%. i don't any -- i don't know any

governor in the senate that cut their budget is much as i did. the one cost i could not control with my health care costs. it will go up double percentages every year. senator braun, who is businessman extraordinaire, said he did creative things to bend his cost curve by providing healthier food options to people. if you could just put in! -- but an exclamation point, this is a fiscally conservative approach, right? we know if we do nothing wrong we are going to be doubling major increases in government spending, but we can invest in programs, we know, drive down government costs. if there is anything we can agree on, we are about to run government in the ground with one out of every three dollars being spent now on health-care costs, as opposed to if we do nothing, as you said, diabetes

along costs grew 25%. more money thing the entire department of agriculture. i know senator marshall is in great demand, probably has to go to another hearing and the floor vote, if there is one more thing you can say, you were talking to a fiscal conservative, what would you say, hey, these are some of the best dollar investments you can make in changing this nightmare for a lot of families and individuals? dr. mozaffarian: i consider myself a fiscal conservative as well. we need to invest money where we are going to get a return on investment. we need to invest money in nutrition science. we need to have health care pay for food, where we show it to be cost-effective. it was lots of great ways to do that. we need to strengthen our federal nutrition programs. improve snap so that snap leverages nutrition better. one thing we have not talked

about is to catalyze business innovation. the government has a role to play to help nurture and catalyze all of the disruption going on now from tag -- ag to retail. millions of dollars are going to create healthier products. the government could catalyze that with modest tax policy. other areas like that. i do think we need to expand public health. there is a return on investment for that. lastly, i agree with you, senator booker, that a low-cost thing to do is to convene to get dr. marshall, yourself, others with leaders in about an administration in the same room to say, we're going to fix this and we are not going to leave the room until we come up with a plan. sen. booker: thank you, sir. i want to jump to dr. odoms-young. this is an issue that affects rural areas, urban areas,

everywhere, but there are particular issues going on amongst native communities and black and brown communities that are -- that make this even more troubling and compound problems within those communities. dr. odoms-young, a recent report found that black and hispanic youth are exposed to more food advertising in the media, and their communities, compared to white youth, and that food companies target like and hispanic youth with advertising for their least healthy products. could you comment on that conclusion? are you familiar with these practices, and what impacts do you see them having in those communities? dr. odoms-young: thank you so much for that question, senator booker. i'm very familiar with the report, and also i have been part of several studies that look at the marketing that has been conducted through the council on black health. black americans, particularly youth, not only experience higher exposure to unhealthy

food marketing through television and advertising, but also through social media, print media, and in their communities. the report you mentioned found that junk food comprised 86% of the spending on black-targeted programming. and only 1% of healthy foods were marketed. i think what is particularly striking is in 2019 the report found that 23 restaurants spent $99 million to advertise on black television, or television that targets predominantly african americans. so, compared to white preschoolers, black preschoolers saw about 72% more fast food ads. if you look at teens, they saw

about 77% more fast food ads. this has implications when you look at dietary oppressions and eating behaviors. studies have shown that immediately after you see these ads, they have a desire for unhealthy foods, junk food, and fast food. if you look at lack, indigenous, and latin communities, where you have more available you can act on that marketing. the other issue that comes up is that when you are exposed to these ads in early life, it creates a lot of brand loyalty. and also you associate these foods with experiences. it is not just selling food, it is selling experiences. happiness, socialization.

these have major implications for obesity and chronic disease risk in these communities. sen. booker: it is neuro-associative conditioning. you think of a meal -- i may have thought of my grandmother's cooking, which is very different than you often see in black communities today, and that was happiness. now, i think the only senator who lives in a predominantly low income area, i am stunned with the messaging folks receive. maybe you can comment on this for a second. it is that, compounded with the fact of, you just don't have the availability of the kind of foods that when i talk to the elders in my community, that they used to cook with. i live in a neighborhood with a corner bodega. you have a limited healthy options. because of the way we subsidize certain foods and not others, with 98% of our ag subsidies

going to foods that are hyper processed, flown nutrition, you see kids walking into bodegas, with change, and a twinkie-like product costs less than an apple. you have that double hit. would you agree with that? dr. odoms-young: definitely. i have spent much of my career working on the south side of chicago with several community-based organizations, where we work alongside corner stores to change availability. part of the issue, as you mentioned, is not only availability, and also pricing. unhealthy food products cost lower. i was just in a corner store. it is funny you mention that. not only were unhealthy products marketed -- and this is in a store where we have partnership -- we also found there is a lot

of ultra-processed foods in stores not only corner stores, also grocery stores. it makes it difficult, because the pricing is -- the prices as compared to healthier food options make them more desirable, particularly when you have a limited budget to spend on food. i think that is very important, and if we can try to address and look at affordability, as well as accessibility, that is where we can see an -- a reduction in disparities and nutrition. dr. odoms-young: dr. warne, you mentioned that for family members still living on the pine ridge indian reservation in south dakota, that the nearest supermarket was 90 miles away. you know, can you speak to that? and what dr. odoms-young was

speaking about? that combination of access, issues to get healthy foods and how that is a disproportionate reality for native communities? we see this -- dr. warne: we see this across multiple reservation communities. we do not have access to healthy choices. if there are some perishable items that are healthier options, they are more expensive when we purchase those in our communities. we make it untenable for peak -- for people to make healthier choices. that is where investment needs to occur, to make the healthier choice the easier choice. there has been discussion about sugar-sweetened beverages, for example. i have worked with a tribe in minnesota where at the wellness center the bottled water is $.25 and the soda is $1.25. soda consumption went way down.

there are ways to invest in healthier options, make them accessible and inexpensive. right now if we put the food there and we provide education, if people cannot afford to purchase it then we are not going to implement the changes we need. sen. braun: -- sen. booker: we have done this in my city, having people access to make their snap dollars go further. if you spend it for processed food in a supermarket, but if you spend in a farmers market, you get double snap benefits. those are the kind of things you think would work? dr. warne: that would be very important. also looking at the value of traditional foods and locally-cultivated foods. that is what the fdpir has done. i would want to work with each community individually, because the one size does not fit all, but find those local preferences

and develop the local champions to do that. it would be a very important step. sen. booker: i'm going to yield to the ranking member to continue. sen. braun: we covered a lot of territory today about the health care system is almost triple than it was when we started the conversation. prior to becoming a senator -- and it was roughly 13 years ago -- as a ceo of a company that had 300 employees, i could put two and two together that i needed to change my own health care system. always believed in covering pre-existing conditions with no caps on coverage, my main interest was inducing health care costs and making my own employees health care consumers. i know we have two doctors on the panel here. i brought it into the c suite, that was very unusual. most individuals running

companies were paying for mediation when it costs a lot less, even 13 years ago. for the two mds on the panel, how important is it to foster a new paradigm based upon an engaged health care consumer, not one that is atrophied, with very little skin in the game, just wants government to remediate your bad behavior or illness or accident, and you have an industry that is based upon the business of remediation to me, knowledge and transparency are the two angst that have to drive all markets, and then you have to have things like competition, transparency. from an md's point of view, what do we do to fix the system from the bottom up for we turn it into a one payer system out of frustration? and even if the government pays

for more, wouldn't it make sense to reform health care first, regardless of what we do through nutrition, through usda? i would love to hear your thoughts each on that. dr. warne: i can go first. i appreciate the question and i also appreciated in your opening remarks, again, a holistic approach to doing this work. from a physician's position, working with tribal communities and recognizing that i have all of this knowledge about physiology and the understanding of things like diabetes education, one of my biggest challenges at that ground-level was that even if my patients wanted to make healthier choices did not have the means to make those choices were to purchase the healthier foods. we have to recognize that each population is different and will need unique strategies with each population we are engaging. the one thing i do know is our

populations want to be healthier. i think that having a community-engaged approach and recognizing that each group of patients in these populations will have their own strategies and we need to be flexible enough within that, and we talk about evidence-based practices, which are wonderful as a physician, but also training in public health. my question is always, whose evidence is it? if a program worked effectively in boston, it may or may not work effectively in pine ridge, south dakota. as we are building the evidence base, we need diversity in groups from which we are building the evidence. dr. mozaffarian: i think your instinct 13 years ago was spot on. it is spot on today. we need to reimagine the health care system as a preventative health care system that pays for value and prevention just as much, if not more, as it pays

for remediation. this is happening in private health care systems across the country, starting to think about, food is medicine, prevention. but they are doing it piece by piece, by bit. -- bit by bit. the federal government has a role to play. cmi's mandate is to reduce cost. i think congress asking cmmi to focus on prevention and integrating nutrition into the system in a way that empowers educated, knowledgeable consumers, gives them resources to purchase healthy food, is absolutely the way to go. i will give the example of john hancock life insurance in boston. and of the oldest in the nation. about five years ago they launched a program called john hancock vitality, which awarded their clients for the collectivity, for not smoking, and for healthier eating. all kinds of incentives for

healthier eating, including paying up to $50 a month out-of-pocket. john hancock pays up to $50 a month for their life insurance clients for purchasing healthy food. john hancock says, we will spend $600 a year for our clients, because we will make money. they will live longer. that is a model of health insurance for the future. most of our worksite wellness problem -- programs will pay for belonging to a gym, or buying tennis shoes or a treadmill. if you get your steps, programs will give you rewards. need to do the same thing for food. i think your model is right, and again, cmmi would be a great place to start. i would hope they would be investing in this testing to figure out what works best. sen. braun: one final comment. when you have a podium like this , for as long as i have been

asking the health-care industry to reform itself, when you've got bad stats, like costing three times as much as it did five decades ago, that soul-se arching and looking at how you might do a better job for the most important part of our economy, and agriculture and food processing to boot, see what you can do before you are in a pickle, to where you are forced by government to do things you are not happy with. i especially aimed that at the health care industry. embrace competition, transparency, get the health care consumer engaged, and may be less attention will be paid to it government. thank you. sen. booker: this is an interesting conversation. i love how you align as a business person the bottom line. you had to find creative ways to reduce costs. i'm wondering, maybe, a question

for dr. mozaffarian, but also you, do we have perverse incentives in government as opposed to the clarity that the senator had that we can do some changes to our policy that will align incentives? because right now it makes no sense. if you and i were running this with the goal of lowering costs -- and i have heard speeches on both sides of the aisle to the untenable, skyrocketing cost of health care, but the debate has been in providing health care, and not, why do we have so much demand? how do we get to aligning incentives in government that you as a businessperson had that resulted in success? sen. braun: real quickly. i have talked to chairman wyden, and if you are a problem solver you are looking ahead rather than being in a cul-de-sac where you are forced to do it.

my belief is that if you reform the system first, that even folks on your side of the aisle should be for more transparency, more competition. make the system better, regardless of whether the government pays for the health care or it is done through the private sector. so much is involved to have a broken system, almost like an unregulated utility on the health care provision side. i'm asking, as someone that believes in free markets, that maybe we need to pay more attention to creating the paradigm of competition, transparency, changing a consumer into one that is interested in his or her own well-being. and then if it is not moving in a way that we see things he evolving in a different direction, then i think it will cascade into the other option.

so many on my side of the aisle bemoan, but where were we when we were defending some of the stuff that was not working in the health care system and we had no answer like i'm trying to provide? sen. booker: there is so much agreement up here, which is i -- which i think is a rare thing in washington. i want to ask, may be, because i believe in the free market too. what i think the government is doing now is picking winners and losers. 98% of our ag subsidies are lowering the costs to the very foods -- the foods and another part of government tells you not to eat. only 2% of subsidies are going -- i've seen it go from the food pyramid to the food plate, but all along they have said to eat mostly these foods, but our ag subsidies are not allowing the free market to decide and for consumers. i live surrounded by fast food

restaurants. and i'm not having it my way, and i'm not having happiness in my meals. i'm having fast access to foods that when you go in and you see that dollar meal, that is heavily subsidized by the government. meanwhile, if i want to get a salad, the places that make them available, you walk in and there is a place down the street that charges $20 for vegetables. i guess that is my frustration. we are aligned on values. i believe in the free market. i believe that government needs to cut costs. i said to senator marshall, i am the only person who ran a government, who cut it 25%. i cannot control my health care costs. could you speak -- and maybe dr. stover, dr. mozaffarian, could you speak to this problem i see where we are not letting the free market rule?

we are investing heavily as a government dramatically on the things that are making us sick, and those small pilot programs that come in these farm bells, tiny amounts to incentivize the things that are making us well? it seems like a misalignment of government. we are not investing and getting a return, we are investing and compounding the problem during -- problem. dr. stover: let me state again that our farmers and ranchers are some of the hardest working people in the country. they feed america and they are proud of what they do. they respond to what the consumer demands, and with all of these things we have heard about influencing, advertisement, all of that, they respond to what the market is telling them to produce. we have the opportunity to change that.

then we have to look at all opportunities to do that. everything from nutrition education, everything from the frameworks we use in terms of what we subsidize, what we grow, how we process, how we then work within the cultural context of food systems and not alienate people from their food, but improve those food systems within the cultural context. there is no magic bullet to this. we need to take a systematic approach. if we know what to do, if we had the evidence right now, there would be complete consensus on what to do. we could fix this tomorrow. we know some things work, and they work at the margins. we need to address this systemically, again, looking at everything we do, from what we grow in the field, to how we are educating consumers and affecting behavior. sen. booker: dr. mozaffarian? dr. mozaffarian: there is no doubt the subsidy portion of the

farm bill is important for risk management for farmers across the country, but it is all going to five crops. if we took that away those farmers would go out of business. we would have severe problems. so we have to figure out how to shift without hurting those farmers, shift their profits and productivity toward health care crops. i agree with dr. stover that the farmers produce what the buyers buy. we have to both increase the market opportunities for those farmers and then help them shift toward healthier crops while still providing risk insurance, crop insurance for increasing threats from changes to climate and other things. the way to increase the market size, we have talked about it a bit. we need to leverage the power of our nutrition dollars to buy healthier foods. we need to leverage the power of the health care system and dollars that will change the market for those farmers, will give them incentives to make

specialty crops, organic crops, other healthier foods as well. we also need to catalyze entrepreneurship in this area. we work with many startups who are trying to make healthier foods, and they are actually at a disadvantage compared to their competitors, because they are buying more expensive ingredients, they are doing more to make the food healthier from local sources. that cost them more money. rather than having them be added disadvantage, the government should take up a policy to help catalyze entrepreneurs to help create or nutritious food and also create demand for farmers. i think, senator booker, it is complicated, but that $30 billion, if nothing else, is opportunity cost. i don't know that it lowers the price of those products, because we have a global commodities market. it is certainly opportunity costs. we could do more than we are doing now, and i think that is a serious conversation of how we

support our farmers and ranchers who are, again, champions in the united states. sen. booker: i have strange alliances in the senate. senator grassley and i are partnering on some challenges within the cattle industry. what cattle farmers are worried about is they are going to go the way of the dramatic changes in the chicken and pig industry. they were raised so differently than they were just 50 years ago. the way they are being raised is causing real concern for public health. the overuse of antibiotics is necessary because of the concentration in these industries. frankly, the farmers, if you talk to them, contract farmers

are living in deep debt and crisis. i was stunned in the hearing that i was being praised by a guy on conservative radio in alabama as being this northeast democrat that was talking to the concerns that the farmers have. i agree with both of you, that the farmers are my hope in america. i have gone out to the midwest to meet with republican farmers. and i was amazed at the concern we have, because they know the system as it is designed right now is benefiting more and more corporate concentration, farmers, their inputs are going up, i had one republican farmer from western illinois, if i remember correctly, is telling me their father had five people to sell their cattle to. now, one person. it is a system that is no longer working. the farmers share their consumer dollar. when my folks go to a supermarket, from their beef, to

the broccoli, the farmers share of the consumer dollar has gone down 50%. it is a food system where everyone is losing. talked about thewe talked aboutf our country, they are losing. we talked about the disappearance of family farmers. we talk about food workers, animals, the environmental issues. we have a system that is not making users healthy. we are as a government using tax dollars to incentivize behaviors that are driving pandemic like conditions. i understand what we are talking about, but this is not a free market. we are investing pneumatically in our own death -- dramatically in our own death.

farmers are being forced to respond to the way we structure the market. when a senator is a organic farmer who says i am more profitable, but there is no incentive to do that. 1 -- dr. mozaffarian, one more time, we all love farmers. they are not the problem. i believe in this case that decisions i policymakers -- and i do not want to vilify people. we were concerned in the 1940's and 50's about food scarcity. the thought back then it was to make low cost calories available. we transformed farm systems to deliver cheap food. but when you know better, you

should do better. we know of the crisis is not simply food availability. the crisis is that we are getting so sick. i shared values with my conservative friends. we have to figure out a way to align incentives with policy decisions, because it is so out of whack. we have the medical equivalent of a frog in boiling water. we are killing ourselves, but nobody seems to recognize the crisis. >> we do have a good conversation going. to me, i always look in terms of where i was going to implement the solution. there is a big distinction between food and health care. food is a bargain.

we just need to reconstitute the quality of the calories. in a paradigm that has commodity markets, we are the breadbasket of the world. that is going to be easier to do than a system that we have created to remediate health care issues when you enter the system. i think the task is going to be where we get better return on our investments by changing the health care side. when they go from remediation to prevention, heart the strategy will be to eat better, to have a better lifestyle. until we change the remediation paradigm, meeting health care, we are spending the percent of gdp on that, probably one third of that on food production.

it is a lot less. i think you get a twofer when you take on the health care industry by making them competitive, transparent, and selling wellness and prevention. it is going to bring the food system along with it. that would beat my global view of how that works. caller -- sen. booker: dr. mozaffarian, you seem to be, if i am reading your facial expressions right, you wanted to comment on something that ticked you off. dr. mozaffarian: my body language is thrilled that you guys are holding this hearing. you are sitting on the legacy of 50 years ago, the committee on nutrition with george mcgovern and opto. i wanted to agree with you and everything you said.

you perfectly summarized the current system. we have a legacy food system was built for 20th century goals. our goals were starchy, expensive, shelf stable set -- shelf stable calories. that food system was successful. we do not want to under messiah's the success of those goals. we probably prevented one billion people from starving. we have eliminated vitamin- deficient diseases that were common in the early part of the 20th century, but now we have 21st century problems and legacy players with a vested interest in keeping that system. but we also have disruption going on" new players.

i agreed that we have a system set up for 20th century goals and we need to say, how do we want to design our food system? the system we have today we consciously created. it was not the free market. we can do that again and leverage the power of private innovation, science, public health and redesign this in a short amount of time. caller -- sen. booker: to the further indulgence of deep ranking member, i have a question for dr. warren about minorities and specific strategies. my last question, mr. ranking member, was any -- i am going to start with dr. warren, because i

have read about historic, and the impact that it has on specific communities that have endured trauma associated with illnesses. i know you have spoken to that a lot. there are many opportunities through food to bring healing of bodies but also addressing that historic trauma. taste on your work, what do you feel are the most effective solution was to address these issues in the indigenous community through nutrition? dr. warren: i appreciate the question. we are looking at these exact questions and even at issues related to nutritional epi- genetics. we have to recognize that each population is unique, but there were policies like the indian removal act widget removed

tribal members from their homelands. they lost access to food sovereignty and to a traditional food systems. we have seen disruption of food systems based on historic policies. in terms of trauma, there is compelling evidence that looks at how a population that endures a significant amount of trauma can hand health disparities to the next generation. we do see an intergenerational impact that has been studied in american indian populations. we see a direct impact of loss of territory, but the other thing seat when we have unresolved trauma or adverse childhood experiences is more poverty in those populations. we also see people who are self-medicating, not always with drugs or alcohol. some self-medicating with food.

we have to look at this holistically and recognize that each population is different but the impact on health can have ripple effects that we do not see right away. it is vitally important to have diverse voices and experiences at the table. i am pleased and honored to be part of these discussions. sen. booker: we are honored that you are here. we talked already about the challenges unique to latino communities in terms of advertising targeted to them that is disproportionate to the population as a whole, but i want to ask what types of policies do you think would best address the specific nutrition challenges in black and latino communities? >> as dr. warne mentioned, it is

important that we ensure that all efforts take a comprehensive strategy. also that we focus on increasing economic development, as well as community cohesion. first, if we think about equity" food security, it needs to start in pregnancy. black babies die at three times the rate of white babies. if you look at the quote of kimberly fields that says food justice --, we need to think about how we expand support for milk feeding. we can do more to think about breast and human milk feeding. also, policy support can empower

those voices in the center of community and leadership of those with lived experiences. dr. warne mentioned food sovereignty, also an important piece. it is striking if we look at the traditional diet, which is rooted in vegetables and legumes and now we look at that black americans have the lowest intake of fiber. these environmental exposures have shifted the traditional diet. although he had some negative aspects that are always highlighted, there were always a a lot of positive aspects. i am from chicago, but by way of mississippi. i know what it is like to be in a community. we need people of color with businesses that are developed

and policies that help with creating a market opportunities for black, indigenous, and latin is this is. we also have to tailor our new christian education -- our nutrition education. we have programs that are doing excellent work, but the need for trauma-informed, culturally- specific nutrition education is the place where we can more within our land grant system. this is really the backbone of educating our community. also, we have the possibility of something like nutrition security corps, where we educate black, indigenous, latin and youth and put them in leadership roles. this has been at the center of

many of the policies that you have implemented. we need to focus on black farmers. black and indigenous farmers provide an opportunity for us to expand and produce cultural foods, but we have to make sure that they are supported. sen. booker: even though my ranking member is kind and generous, my staff is not. they are saying i need to wrap. i am going to do that and say, thank you. this is an extraordinary group. you have the richest of perspectives and experiences, not to mention more degrees than a thermometer. i want to say bank that we will welcome additional statements or questions that you may have for the records to be submitted to the committee clerk in five business days.

the one question i will ask is for advice as we look towards hopefully having a white house conference. in the meantime, i want to thank everybody. there is a lot dominating the headlines of our various news networks, but i do not think anybody is dealing with an issue in america right now that is of greater urgency than the one we have been talking about. i am grateful to my ranking member one more time for the common ground we have found and our commitment to do something about the problem. with that, this hearing is adjourned.

announcer: next week on c-span. wednesday, the senate rules committee holds a hearing on the capitol police since the january 6 attack. live coverage at 10:00 a.m. thursday at 7:00 a.m., coverage marking the one year anniversary of the attack. friday, the supreme court hears oral arguments in two cases dealing with the bite administration's vaccine mandate for health care workers and the vaccine or test mandate for larger private companies. life coverage beginning at 10:00 a.m. the house and senate return in january for the start of the second session of the 117th congress. the senate takes up the

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money once crisis hits." >> it is not if a another crisis hits, it is when. we want to set you up for the next crisis. it is not all about covid, but what recession is coming down the road. it may be long, it may be short, but life is going to happen. prepare now. i do a lot of financial seminars in my community. it is so hard to get people to save and prepare when they are doing well. because they are doing well. they do not think tomorrow is an issue. you need to save, and there are like, yeah i will get to it. in a crisis when everyone is in frugal mode and ready, that's too late. the time to do that is when you have the resources. it is easy to cut when you can't pay for anything, or things shut down.

i wanted to say, let's prepare. let's be like the fire woman next for the and -- ready for the next fire. hope it won't happen, but they are prepared. announcer: michelle single terry on her book, "what to do with your money when crisis hits." sunday on c-span's q&a. you can listen to our podcasts on our new c-spannow app. announcer: a new mobile video app from c-span. c-spannow. download today. announcer: next, a conversation with speechwriters for presidents bill clinton, george w. bush and barack obama. they discuss presidential rhetoric, their collaborations with the former presidents pivotal speeches by each of those presidents. this