Challenging Dogma - Spring 2009

Thursday, May 7, 2009

Critique of CDC 5-A-Day Campaign-Tiffany Chua

Infectious diseases have been replaced by chronic diseases as the major contributors to mortality in the United States (1). Cardiovascular disease is at the top of the list (1). It is largely considered a preventable disease and, because of this, has been the topic of many epidemiologic studies (1-4). Nutrition studies have investigated the effect of diet on cardiovascular disease and have found an inverse relationship between fruit and vegetable intake and cardiovascular disease (2-4). Along with the heightened focus on diet and nutrition, researchers have noticed the growing obesity rates in the United States, especially in children (5,6). As researchers have accumulated evidence supporting the protective effect of a healthy diet on such problems as cardiovascular disease and obesity, public health practitioners have designed programs to help fight these diseases. This critique will discuss a public health intervention that has attempted to improve people’s health by encouraging consumption of more fruits and vegetables. However, it is unlikely that the program will be able to realize its goals due to innate flaws in its design.

Fruits and Veggies: More Matters
Fruits and Veggies: More Matters is a public health intervention program that is run by the Centers for Disease Control and Prevention (CDC), Produce for Better Health (PBH), and several other entities including industry and nonprofit organizations (7). It launched on March 19, 2007 as part of the National Fruit and Vegetable Program and replaced the 5 A Day program under the National Fruit & Vegetable for Better Health (7). The 5 A Day program had been in effect since 1988, but in 2005 the Dietary Guidelines for Americans published a report that increased the recommended daily servings of fruits and vegetables from 5 servings to 5-13 servings (8,9). The mission of the Fruits and Veggies: More Matters program is to encourage people to eat more fruits and vegetables through awareness and education (7). An interactive website is available at (7). The website includes a program that helps people calculate their personalized fruit and vegetable needs based on one’s age, sex, and activity level. There are printable resources such as recipes and tips for eating healthy that attempt to help people incorporate more fruits and vegetables into their daily meals. Links to other websites that promote healthy eating are provided as well.

The Health Belief Model
The failures of this public health intervention stem mainly from its basis upon the Health Belief Model (HBM). The HBM was the first model that was developed to explain behavior change (10). In brief, it proposes that a person’s decision to change a health behavior is dependent upon whether the perceived benefits outweigh the perceived costs (10). Although there are several weaknesses of the model, it is frequently used to design public health interventions. Additional details of this traditional model have been described previously, however the relevant aspects to this critique will be highlighted again. Three major pitfalls of this public health intervention are related to three negative aspects of the health belief model. One negative aspect is the HBM’s exclusion of social and environmental factors. A second negative aspect is one that the HBM has in common with other traditional social behavior models - it is designed to address behavior change on an individual level. A third negative aspect is arguably one of the strongest negatives of the HBM – it assumes that people behave rationally.

Ignores Socioeconomic Factors that Affect Access
The Fruits and Veggies: More Matters program promotes a nutritious diet, but does not address any social or environmental factors that could prevent people from eating nutritiously. The program’s website includes a plethora of information, from the nutritional content of a wide variety of different fruits and vegetables to different ways to incorporate more fruits and vegetables in a diet. However, all of this useful information is available mainly to those who have a computer and internet access as well as the motivation to visit the website. Studies have shown that the demographic population in the United States that is least likely to eat sufficient amounts of fruits and vegetables are those with the lowest household income levels (11). These families are probably also the least likely to have internet access much less their own computer. If economically disadvantaged people do manage to access the website and are interested in eating more fruits and vegetables, they may not be able to buy the fruits and vegetables that the website suggests for two reasons: due to the lack of supermarkets in their neighborhood that carry high quality, fresh produce or due to the financial inability to afford high prices of fresh produce. In general, large supermarkets tend to have a wider selection of produce that is more reasonably priced when compared to small grocery or convenience stores (11). Studies have shown that there are fewer large supermarkets in areas with greater populations of low-socioeconomic families and that high price is a major reason why low-income families choose not to eat fresh fruits and vegetables (11-13). These are critical issues, because people will not be able to take advantage of the information provided by the program if they cannot find a market from which to buy fresh fruits and vegetables or if they cannot afford to buy those fresh fruits and vegetables for their family. The program does not address the fact that fresh fruits and vegetables cost more than processed and fast food, nor does it address the additional inconvenience that may accompany more frequent trips to the supermarket.
These social and environmental factors are significant forces that may work against a person’s ability to adhere to the advice of the Fruits and Veggies: More Matters program. Additionally, the program may fail to reach the very population that needs the most encouragement by heavily relying on their website to educate people. These failures were demonstrated in a study that analyzed the success of the HBM in increasing fruit and vegetable consumption in urban black men, a low socioeconomic status population at increased risk of cardiovascular disease (14).

Targets Individual Adults
The Fruits and Veggies: More Matters program should reach out to both adults and children. With the increasing utilization of computers in children’s education, children have been spending more of their time on the Internet (15). However, the Fruits and Veggies: More Matters website is geared towards adult education. In one sense this is beneficial since studies have shown that there is a significant correlation between a mother’s nutrition knowledge and their child’s nutrition knowledge. This is mostly due to the fact that mothers are their children’s primary care givers and play a major role in shaping their eating habits (16). This serves as evidence to support ensuring that accurate knowledge is readily available to children’s parents to take advantage of this strong, positive relationship.
In another sense, it would be prudent to ensure that children, whose parents do not play a role in encouraging their children to develop healthy eating habits, are given the chance to learn about the nutritional benefits of fruits and vegetables for themselves. One reason why this is so important is because childhood and adolescence are crucial times during which children develop habits that will influence their health behavior throughout adulthood (17). As previously discussed, this development of a healthy diet into adulthood may have long-run beneficial health effects with respect to cardiovascular disease.

In addition to excluding children as part of their target population, the program addresses health behavior change on an individual level. As we have learned from Dr. Michael Siegel’s lectures, the program could be more effective and efficient if it were designed to address behavior change on a group level. The benefits from such an approach would not only be reaped by the individuals who adopt healthier eating habits, but also by society as a whole. The costs related to cardiovascular disease in the United States are expected to exceed $475 billion in 2009 (18). Since fruit and vegetable consumption has been shown to be negatively related to cardiovascular disease as well as obesity (5,6), health care costs associated with these diseases could potentially decrease substantially.

Disregards Irrational Behavior
The Fruits and Veggies: More Matters program assumes that people behave rationally. It believes that simply telling consumers that fruits and vegetables are healthier and that they potentially prevent various diseases will result in their making the choice to seek out and purchase fresh fruits and vegetables. This, however, is not the case with most people. As we have learned from Dr. Siegel, even if people intend to follow through with the behavior – in this case buying fresh fruits and vegetables – it still does not mean that the behavior change will occur.
Studies have shown that even when people are aware of the nutritional content of fruits and vegetables and the positive health effects a nutritious diet can have, they still do not change their eating habits. In children, this relationship has been observed mostly due to the fact they have trouble perceiving the future and thus the relevance of fruits and vegetables to disease prevention (19). In a population of adult black men, perceived health benefits were not associated with fruit and vegetable consumption either (14). Another study investigating the influences on eating habits in adults, taste was the top predictor of what people chose to eat, followed by cost. Only in those people that the study categorized as members of a “health lifestyle cluster” was importance of nutrition a predictor of eating healthful foods (19). Thus, by attempting to promote healthful eating based on benefits from disease prevention, the Fruits and Veggies: More Matters program may only be influencing the decisions of those people who are already attuned to living a healthy lifestyle.


The Fruits and Veggies: More Matters program is a national public health initiative that promotes the benefits of fruit and vegetable consumption, but suffers from three flaws that may prevent it from reaching its goals. It does not address socioeconomic factors that influence fruit and vegetable consumption. It also fails to appeal to children, and falls into the all-too-familiar trap of assuming that people behave rationally. Being supported by a wide variety of institutions, including the government, industry and nonprofit organizations, the program possesses great potential to reach its goals due to its access to financial and political resources through its contributors. These advantages put the well-intentioned program in a position to create positive change in the American population. Having been launched a little more than 2 years ago, the program has been re-evaluated at a critical time. There is little question about the growing obesity problem in the United States. A program could have a big impact in the lives of adults, but most especially in the generation of current youths who are still in the position to adopt healthy eating behaviors. In order for this program to effectively improve people’s nutrition across all ages and levels of socioeconomic status, changes will need to be made to improve upon the three critical flaws.


These three critical flaws can be addressed by structuring the design 0f the Fruits and Veggies: More Matters program around the Social Marketing Theory (SMT), including aspects of the Advertising Theory (AT), and the Social Expectations Theory (SET). These are population-level models that are ideal for addressing a wide-spread issue like fruit and vegetable consumption. The improvements that should be made include enacting policies that impose restrictions on supermarkets, implementing school programs, and incorporating media advertisement to promote the program.

Increase Access
A solution which takes social and environmental factors into account has two parts: increased access to education and increased access to fruits and vegetables. The problem with heavily relying on a website to educate people is its assumption that its target population has access to a computer and the Internet. Even fliers distributed at the grocery store do not address this problem since people first have to get to the grocery store in order to see the fliers. Instead of waiting for people to come to the information, the information should come to the people. This can be achieved through mailed pamphlets. Pamphlets should minimize the amount of text and maximize the use of charts and pictures to make them attention-grabbing. They will provide exposure to the benefits of eating more fruits and vegetables, the costs involved with eating more fruit and vegetables, and ways to access them.
The solution to the second part of the access problem adheres to the SET and focuses on changing current social norms, wealth and inconvenience, around fruit and vegetable consumption among the low-income population to affordability and accessibility. Two policy changes can help achieve this goal: one to increase physical access to large-scale supermarkets and one to increase financial access to fresh fruits and vegetables. Supermarkets should be required to locate their stores so that the average income level in the regions of all their stores within a state must not exceed a specified maximum. This would require them to locate their stores in lower income areas thant they normally would avoid.

The second part of this policy change proposes a tax on so-called junk food due to their lack of nutritional content. The taxes will subsidize the cost of fresh fruits and vegetables to lower the price of healthy produce in relation to junk food and make nutritious diets financially feasible to low-income populations. Industries affected by these policies will be adverse to these proposals. There will likely be heated discussion concerning which foods to consider junk food and thus liable to the tax. Thorough research will need to be conducted to determine a minimum nutritional content for certain foods. Supporting institutions behind the program will need to harness their political influence to compete against lobbyists that may dispute these policy changes.

Target Children in Addition to Mothers
Policy change, in addition to education, should be used to include children in the target population. The main reasoning behind the original program’s focus on mothers is because, for the most part, they are responsible for buying the family’s groceries and preparing the meals. However, the program should directly target children in addition to mothers so as not to rely on mothers to instill nutrition values. Some mothers may not provide their children with the environment or resources conducive to developing nutritious eating habits. This should not prevent the children of these mothers from having the same opportunity to learn about nutrition as other children.

A Fruits and Veggies: More Matters educational program should be developed and implemented in schools for first through eighth graders. In an article that reviewed the successfulness of obesity interventions based on several different theoretical models, population-level interventions that were tailored to specific groups were the most successful (20). School programs containing two key components will certainly achieve this goal. One component is interactive classroom learning. The Fruits and Veggies: More Matters program should not take the form of another lecture to which children must passively listen. The same article that reviewed obesity interventions found that interactive intervention is more successful than its counterpart; therefore the program should use hands-on activities to teach kids about healthy eating habits (20).

In accordance with the “four Ps” of the SMT, formative research should be done among the different age groups since a six-year-old in first grade will respond to an activity differently than a thirteen-year old in eighth grade. This research should illuminate how one can benefit from changing his/her eating habits, what costs are involved in changing eating habits, and the best ways to gain access to fresh produce. The second component of this educational program is requiring school lunch programs to provide multiple fresh fruit and vegetable options. Provision of these options will give children who eat school lunches the opportunity to choose, and thus practice, actually making healthful decisions.
One may ask where the program plans to get the financial resources to implement this educational program and policy change. Since these changes will only apply to public schools, a portion of school budgets that state governments allocate to public schools will need to be used for this program. Additionally, funding from the health care sector will be sought as Fruits and Veggies: More Matters is a heath promotion program that will result in cost savings in the long-run due to prevention of chronic diseases associated with obesity.

Appeal to People’s Emotions

The solution to the third critique of the Fruits and Veggies: More Matters program utilizes the AT. People’s irrational behavior concerning their food choices should be addressed in ways similar to those that conventional industries use to market their products. In a paper highlighting use of advertisements to promote conventional consumer products, successful advertisements have utilized the emotions of the consumer to help sell their goods (21). There is no reason why public health intervention should not adopt the same tactic for promoting health behavior change. The way that the Fruits and Veggies: More Matters program should achieve this is by creating a brand, a slogan, and a promise. The brand will be a set of values that appeal to both youths and mothers, including physical attractiveness and carefree fun. Commercials, billboards, and magazine spreads will feature a young, attractive woman. She will be doing something as simple as posing on a beach. A fresh fruit or vegetable will appear in her hand or beside her, but not as the focus of the advertisement. The slogan will read “You are what you eat.” The promise of being beautiful and carefree will resonate with youths and young mothers alike. The slogan will brand the program by associating it with physical attractiveness. In a sizeable portion of the advertisements certain celebrities such as musicians and actors will be used to tie the program in with mainstream values. These advertisements will promise consumers that they can look and feel attractive if they eat nutritious fruits and vegetables.

One criticism of this solution highlights the issue of finances. Instead of being funded by the government, these media advertisements will have to be paid for with money from the program’s contributors – more specifically, the industry groups that have deeper pockets than the non-profit or government organizations. Although they will be expensive, these advertisements represent a significant component of the program.

The Fruits and Veggies: More Matters program should be structured around the Social Marketing Theory and include elements from the Advertising Theory and Social Expectations Theory. Implementing policy change is an effective and efficient way to create behavior change on the population level. Modeling advertisements after successful tactics used in conventional product promotion will help the program appeal to the emotional side of the predictably irrational population. Incorporation of all the changes discussed in this paper will help the Fruits and Veggies: More Matters program become a strong public health intervention that will improve the health and wellness of our current population as well as of future generations.
1. Bodenheimer T, Grumbach K. Understanding Health Policy: A Clinical Approach. New York: McGraw-Hill Companies, Inc., 2009.
2. Hung HC, Joshipura KJ, Jiang R. Fruit and Vegetable Intake and Risk of Major Chronic Disease. Journal of the National Cancer Institute 2004;96:1577-1584.
3. Panagiotakos DB, Pitsavos C, Kokkions P. Consumption of fruits and vegetables in relation to the risk of developing acute coronary syndromes; the CARDIO2000 case-control study. Nutrition Journal 2003;2:1-6.
4. Veer P, Jansen M, Klerk M. Fruits and Vegetables in the Prevention of Cancer and Cardiovascular Disease. Public Health Nutrition 1999;3:103-107.
5. Wang Y, Beydoun M. The Obesity Epidemic in the United States—Gender, Age, Socioeconomic, Racial/Ethnic, and Geographic Characteristics: A Systematic Review and Meta-Regression Analysis. Epidemiologic Reviews 2007;29:6-28.
6. Dehghan M, Akhtar-Danesh N, Merchant A. Childhood Obesity, Prevalence and Prevention. Nutrition Journal 2005;4:24-31.
7. Fruits and Veggies Matter. Q&A. Atlanta, GA: Centers for Disease Control and Prevention.
8. Dietary Guidelines for Americans, 2005. Food Groups to Encourage. Washington, D.C.: U.S. Department of Health and Human Services.
9. 5 A Day For Better Health Program USA. Origin of 5 A Day Program. Geneva, Switzerland: World Health Organization.
10. Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Boston, MA: Jones and Bartlett Publishers, 2007.
11. Cassady D, Jetter K, Culp J. Is Price a Barrier to Eating More Fruits and Vegetables for Low-Income Families. Journal of the American Dietetic Association 2007;107:1909-1915.
12. Moore LV, Roux A. Associations of Neighborhood Characteristics with the Location and Type of Food Stores. American Journal of Public Health 2006;96:325-331.
13. Powell LM, Slater S, Mirtcheva D. Food Store Availability and Neighborhood Characteristics in the United States. Preventive Medicine 2007;44:189-195.
14. Wolf RL, Lepore SJ, Vandergrift JL, et. al. Knowledge, Barriers, and Stage of Change as Correlates of Fruit and Vegetable Consumption among Urban and Mostly Immigrant Black Men. Journal of the American Dietetic Association 2008;108:1315-1322.
15. Becker HJ. Who's Wired and Who's Not: Children's Access to and Use of Computer Technology. Children and Computer Technology 2000;10:44-75.
16. Gibson EL, Wardle J, Watts CJ. Fruit and Vegetable Consumption, Nutritional Knowledge and Beliefs in Mothers and Children. Appetite 1998;31:205-228.
17. Douglas L. Children’s Food Choice. Nutrition and Food Science 1998;98:14-18.
18. Chronic Disease Prevention and Health Promotion. Heart Disease and Stroke Prevention. Atlanta, GA: Centers for Disease Control and Prevention.
19. Glanz K, Basil M, Maibach E, et. al. Why Americans Eat What They Do: Taste, Nutrition, Cost, Convenience, and Weight Control Concerns as Influences on Food Consumption. Journal of the American Dietetic Association 1998;98:1118-1126.
20. Tufano JT, Karras BT. Mobile eHealth Interventions for Obesity: A Timely Opportunity to Leverage Convergence Trends. Journal of Medical Internet Research 2005;7:e58.
21. David SP, Geer DS. Social Marketing: Application to Medical Education. Annals of Internal Medicine 2001; 134:125-127.


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