their diets, thereby improving their health and increasing their chances of having a healthy baby."

Senator CLARK. Next, we are going to hear from Dr. Alvin Mauer, St. Jude's Research Hospital in Memphis, representing the American Academy of Pediatrics.

STATEMENT OF DR. ALVIN M. MAUER, MEDICAL DIRECTOR, ST. JUDE CHILDREN'S RESEARCH HOSPITAL, MEMPHIS, TENN., REPRESENTING THE COMMITTEE ON NUTRITION OF THE AMERICAN ACADEMY OF PEDIATRICS

Dr. MAUER. Thank you very much, Senator.

The American Academy of Pediatrics would like to speak in favor of this bill.

Senator CLARK. Is that S. 850?

Dr. MAUER. Yes, and I would like primarily to devote my time to talking about the need for such programs and the effectiveness of such programs. I think that there are no questions that there have been many surveys recently to indicate that malnutrition is still present in this country. I am going to talk about two of them, the 10-state survey which was published-and we have submitted results to youand also our own survey in Memphis conducted by the St. Jude Hospital.

There are in addition to the fact that malnutrition was found in these children two other important points from both of these surveys. One is there was a direct relationship to economic status. That is, malnutrition increased in frequency as the economic status decreased, and secondly that when one looked at the cause of malnutrition, it was because of limited food availability, not poor diets or for other reasons, and this was true in both surveys.

The consequences of malnutrition in these children could be most easily demonstrated in iron deficiency and iron deficiency anemia. The 10-state survey found iron deficiency in up to 70 percent of the children under the age of 3. In the Memphis survey actually a quarter of the children had severe iron-deficiency anemia as a consequence of their malnutrition.

Senator CLARK. Is this all the children?

Dr. MAUER. These are children-again the 10-state survey was of children in the lower economic status, and the same thing was true of the Memphis survey, so that there is a direct relationship to poverty. Now, beyond the iron-deficiency anemia, these children also demonstrated growth retardation in both of these surveys. In the Memphis study, half of the children were below the 25th percentile for weight and height.

Dr. MAUER. The major concern for malnutrition in infancy is its possible effect on brain development. It is certainly a relationship which is not yet clearly demonstrated, but I would just like to read the comment of the position paper of the Food and Nutrition Board of the National Academy of Science. It says that:

Present evidence indicates that malnutrition, per se, and as an integral part of the environmental complex, may adversely affect brain development and behavior, or both, directly and indirectly, so it must be for us a major concern for more nutrition.

Now, as I say, the surveys has demonstrated this to be present and consequences thereof. Can they be eliminated? That is, are food supplemental food programs effective? The WIC study reports, of course, are just now coming in, but I can give the results of our study in Memphis, in which infants were provided an iron-fortified formula during the first 6 months of life and were also given food supplementation by prescription during the first 5 years of life.

Now, the results of this study, which are now about 4 years old, indicate that, indeed, that with this iron-fortified formula, that iron deficiency anemia, and iron deficiency as we can measure it, has been climinated from the children who had the benefits of the program.

The growth of these children, both in height and weight, now is typical of those children of the middle class. That is, the growth retardation that we had seen before has, likewise, been eliminated. We are coming up in the next 3 years to an opportunity of evaluating the effectiveness of this program on school performance and will be doing this, but I think that as far as elimination of deficiencies, like iron deficiency, and effective growth, that there is no question that these programs are, indeed, effective.

We also favor a supplemental feeding program for schools and other institutions. It is much more difficult, of course, to document the effectiveness of these programs, but I think that it is not difficult to document the needs.

Again, the relationship of malnutrition to poverty is over and over and documented. Certainly we can find that if we find a child who has iron deficiency in infancy and then look at the family, that the family likewise has a high chance of being iron deficient, that is that there is malnutrition in the whole family, not just the infant. So, likewise, although it is more difficult to point to the effectiveness of the programs, we certainly see that there is a need.

We would finally close by making a recommendation that consideration be given to adding a small, but very important, group of children who need prescription foods, to this bill. They are children who have, some of them, inborn medical problems, such as phenylketonuria, who require prescription foods to prevent the development of severe brain damage. These foods are expensive and many of the people who require them, are families of children that cannot afford them. In addition, there are situations such as chronic renal failure. Some children have chronic diarrhea who require for a time special formulas, and, as I say, we would request that you consider adding prescription foods to this supplemental feeding program.

So, again, the Academy of Pediatrics feels that, indeed, there is a documented need and there has been quite adequate documentation of the effectiveness of these programs where they have been used. Thank you very much for this opportunity.

Senator CLARK. Thank you very much, Dr. Mauer. I am advised that you started a program identical to WIC or very close to it, some 3 years before the Federal program actually was funded, and you have done a lot of planning and work in this area. The legislation that was passed by the Congress was based upon your findings, and we are particularly happy to have your statement.

[The prepared statement of Dr. Mauer follows:]

STATEMENT OF DR. ALVIN M. MAUER, MEDICAL DIRECTOR, ST. JUDE CHILDREN'S RESEARCH HOSPITAL, MEMPHIS, TENN., REPRESENTING THE COMMITTEE ON NUTRITION OF THE AMERICAN ACADEMY OF PEDIATRICS

Mr. Chairman, I am Dr. Alvin M. Mauer, Medical Director of the St. Jude Children's Research Hospital, here today on behalf of the Committee on Nutrition for the American Academy of Pediatrics. The Academy is a professional organization of more than 17,000 Board certified physicians providing health care to infants, children, and adolescents.

Representing the committee, I wish to speak on behalf of the Senate Bill S-850 amending the National School Lunch and Child Nutrition Acts.

Several surveys of American children in the past few years have documented that malnutrition is still prevalent among children in this country. A nutrition survey conducted in ten states and including both urban and rural youngsters showed malnutrition as defined by iron deficiency is up to 70 percent of preschool children. In a study of urban-poor children in Memphis, reported in 1970,2 28 percent of the children less than three years of age had hemoglobin values below 10 g/100 ml, indicative of a rather severe degree of iron deficiency.

A most recent report published in 1974 by Dr. Teresa Haddy and her co-workers indicates in a similar group of children from a lower socioeconomic background that iron deficiency continues to be commonly seen.

Iron deficiency is an early and easily demonstrated manifestation of malnutrition in children. It is important to point out, however, that the clinical consequences of malnutrition in these children could be measured by other means as well. In the Memphis study, half of the children were found to be below the 25th percentile for both height and weight. Retardation of growth was also found in the Ten State Survey, as indicated by studies of height, weight, and skeletal, dental, and sexual development.

In addition to the retardation of growth, there is a further important and unresolved consideration concerning the significance of malnutrition during the early years of life and its relationship to brain development and behavior. Although the role of early malnutrition has not been clearly defined, the position paper of the Food and Nutrition Board of the National Academy of Sciences concludes that "present evidence indicates that malnutrition per se and as an integral part of the environmental complex may adversely affect brain development and behavior both directly and indirectly." This document stresses the need for continued studies in animal and man to identify and document more clearly the interacting effects between nutrition and other environmental factors in terms of brain development and behavior.

3

In further consideration of the problem of malnutrition among children in this country, one must, of course, look at the causative factors. Obviously, many elements contribute but there is one overriding issue which emerges from all of the surveys; that consistent finding is poverty. A clear relationship exists between economic level and state of nutrition. In the Ten State Survey, an attempt was made to find out whether dietary patterns affected the nutritional content of children's food. The answer was that the proportional content of nutrients in the diet did not vary. It was only the total amount of food available to the child that made the difference between the intakes of the low- and middle-income classes. The Memphis study, similarly, showed that lack of food was the main cause of growth retardation and anemia. Thus, educational campaigns alone without an expansion of food availability for these children would not seem to be an adequate approach to the problem.

The value of food supplementation intervention programs on malnutrition in children has been best documented during the first years of life. In the Memphis Study in which an iron containing formula was used during the first six months of life and supplemental food was available by prescription to the families during the first five years of life, the distribution of height and weight of children is now within the normal ranges for their ages. Furthermore, iron deficiency anemia has disappeared as a result of the early supplementation of their diets with iron. Many other studies also support the effectiveness of supplemental feeding pro

1 American Academy of Pediatrics-Committee Statement: The ten-state nutrition survey a pediatric perspective. Pediatrics 51: 1095, 1973.

2 Zee. Paul, Walters. T.. and Mitchell, Charles: Nutrition and poverty in preschool children Jama 213: 739. 1970.

3 The Subcommittee on Nutrition, Brain Development. and Behavior of the Committee on International Nutrition Programs: The Relationship of Nutrition to Brain Development and Behavior: National Academy of Sciences, National Research Council.

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grams in eliminating evidences of deficiency diseases in the children at risk. It will be of real interest to see the evaluation of the WIC Program in which supplemental feeding programs were made available to a much larger number of children throughout the country. One should certainly anticipate that a similar improvement in the state of nutrition would have been observed.

It is more difficult to provide documentation for the effectiveness of such programs as the School Breakfast and Lunch Programs and Summer Food Programs. However, it should be recalled that the relationship between poverty and malnutrition was clearly shown in the Ten State Survey and there is no reason to doubt that the older poor child is likewise at risk from malnutrition. Indeed, in a recent study Dr. Karp and his coworkers found that there was a good likelihood that families of poor children found to be iron deficient would also have evidence of iron deficiency as one manifestation of malnutrition.* The provision of supplemental food to these children, in the form of School and Summer Meal Plans, could hardly be without benefit in improving the state of nutrition.

There is one other small, but important, group of children who would benefit by having special supplemental food made available to them. There are a few children in this country who require special expensive diets. For example, children with phenylketonuria require a diet low in phenylalanine to prevent the development of progressive brain damage. These children and other children like them who are metabolically handicapped require formulas which can be of various degrees of expensiveness to prevent severe mental retardation. In other children, for example children with longstanding diarrhea, the temporary provision of a special formula will allow recovery from the diarrhea and return to a normal state of health. Without the help of these special foods the ultimate cost of care for this small group of children would be enormous. Therefore, the Committee on Nutrition of the American Academy of Pediatrics respectfully requests that the Bill be amended to make provision for special dietary supplementation for children with this small group of disorders who are otherwise unable to pay for these necessary formulas.

In closing, please let me thank the committee for the opportunity of appearing before it to represent the support of the Academy of Pediatrics for this Bill. Senator CLARK. Now, we are going to hear from Mike McManus, who is President, INTERACTION, Seattle, Wash.

STATEMENT OF MIKE MCMANUS, PRESIDENT, INTERACTION,

SEATTLE, WASH.

Mr. MCMANUS. Thank you very much, Senator Clark, members of the committee, ladies and gentlemen. My name is Mike McManus and I represent INTERACTION, a tax-exempt charitable and educational agency in the State of Washington, which is under contract to the Department of Social and Health Services, and which I believe is the only contractor of this sort in the Nation that is serving as the fiscal intermediary for the WIC program.

Just recently, we signed a contract to manage the State of Idaho as well.

I am here representing a consortium of business and industries that are working with us in the State of Washington to support the continuation of the legislation and departmentalization of the WIC program to meet the needs of this disadvantaged population.

Now. I am not here to speak on the social implications of WIC, although we are a social agency. since others obviously have already testified to the social and clinical values of this program. Rather, we thought in Washington State that it would be very important for you to hear the business implications of this program, since we have close

Karp, R. J., Haaz, W. S.. et al.: Iron deficiency in families of iron-deficient inner-city school children. Am. J. Dis. Child. 128: 18, 1974.

ties with the business community in Washington State. We therefore prepared this testimony.

INTERACTION is a rather unique corporation and is sometimes misunderstood. It represents a group of management-oriented people, accountants, auditors, ex-business and industrial leaders; in fact, one of the people with our group is the former State director of agriculture. And, it has been operating 3 years as a rather unique experiment to involve the private sector more thoroughly in a cooperative venture in administering and delivering governmental programs.

We have always felt that a combination of private sector-governmental sector work would reduce costs and, hopefully, even improve program delivery by reducing dependence upon the governmental mechanisms. We are still trying to prove that, and we think we have in WIC.

The following testimony details our experience in Washington State, the reasons why the business community in Washington State supports this program, and why we feel WIC should serve as, perhaps, a model for other governmental programs, at least the way we have been delivering it in Washington State.

As you know, for years businessmen and women have bitterly complained about governmental so-called giveaway programs. WIC, however, has the full endorsement of the business community in Washington State. From our experience, WIC represents the kind of governmental-private sector cooperation which produces more mileage for the taxpayer's dollars. This program appeals to the business community because of its business-like approach to feeding the disadvantaged, including its rather extensive fiscal and clinical controls, low overhead, simplicity of operation and minimization of abuses. We have put together in this consortium about six industries in the State, and I would like to read you the brief statements from them, although there are letters enclosed that are more lengthy.

The first one is from the Washington State Food Dealers Association, and it says this:

We strongly endorse the WIC program. Our membership, to a store-and that is over 3,000 supermarkets in our state-feels the program has been well set up and is working extremely well.

Senator DOLE. Would that not be sort of a self-serving statement? Mr. McMANUs. It may be in the sense we are all here with vested interests.

Senator DOLE. I can understand. I read your statement which said all those people would be for it because they are going to profit from it.

Mr. MCMANUS. But, let me tell you why they support it. Naturally, they are going to profit because the private sector is set up for profit. Senator DOLE. That does not tell me much, to have somebody say I am for it because I profit from it.

Mr. MCMANUS. But, they are not saying it just because they are profiting from it, and I want to make that quite clear. We are saying it because we believe that it is a better way of handling a program by using existing channels, and that in the long run it is being done more inexpensively anyway. We are still falling well within the 10 percent administrative cost in Washington State, which is the lid that has been put on this program.