Americans were eating 3.06 servings of fruits and vegetables a day when the initiatives began and are eating 3.04 servings today. These unfavorable findings were also confirmed in a CDC report issued last week, using random telephone survey data from the 2005 Behavioral Risk Factor Surveillance System.
There was “no indication of improvement,” said the John Hopkins researchers. “New strategies are necessary to help Americans make desirable behavioral changes to consume a healthy diet that includes a variety of fruits and vegetables.”
To coincide with this report, the Produce for Better Health Foundation (PBH) issued a press release announcing another new program called “Fruit & Veggies—More Matters.” It’s the next rendition of their 5-A-Day program.
Once upon a time…
Before we delve into the evidence on this issue, to help us think critically and understand the significance of all of this, let’s trace back 15 years. The National Cancer Institute began a program to promote the 5-A-Day message to increase consumption of fruits and vegetables as part of a low-fat, high fiber diet. It sent out notices that NIH research grant money was available for programs that implemented and evaluated these interventions and put up $4 million for each of the first four years. Grants would only be issued, said the NCI’s Guide, to applicants whose interventions used “a model of behavioral change, integrating constructs from appropriate theories such as...social marketing, social cognitive theory, health belief model, stages of change and diffusion of innovations.” Part of every plan was supposed to include evaluating the effectiveness of the objectives to increase daily consumption of fruits and vegetables among the target populations.
A nonprofit group was formed in May, 1991, consisting of 76 produce-related interests, such as growers, shippers, producers, suppliers, commodity boards, supermarkets and manufacturers. Calling itself the Produce for Better Health Foundation, it co-sponsored 5-A-Day with the NCI which gave it the license to use the 5-A-Day logo and trademarked materials. In turn, PBH could issue sublicenses to their partners. By February 1992, according to the NCI, more than 80 retailers, representing more than 25, 000 stores, had signed licensing agreements, and more than 50 merchandisers were licensed.
PBH says it is now the country’s largest public-private nutrition education initiative with coordinators in every state, territory, and the military. PBH coordinators are also part of state food stamp programs, U.S. Dept. of Agriculture-funded school classroom nutrition curriculums, and school lunch initiatives. PBH has grown to become an organization with over 700 members that now include trade associations, food industry organizations, health insurers, medical and nutrition professional groups, and retailers for 30,000 national supermarkets. Members pay a minimum of $1,000 to use the 5-A-Day logo and graphics, with Platinum members paying upwards of $100,000. PBH also receives contributions from various interests, which this year total $7,753,626. In addition, its 90-member Board represents every produce-related interest imaginable, from ConAgra Foods, Inc. to Alberts Organics; Wild Oats Markets, Inc. to Safeway, Inc.; Gerber Products Co. to Wegmans Food Markets.
PBH also now chairs a National 5-D-Day Partnership, consisting of government agencies, non-profit organizations and industry groups. Its national partners include the CDC and U.S. Dept. of Agriculture; trade and lobbying organizations such as the American Cancer Society, American Diabetes Association and American Heart Association; and the National Alliance for Nutrition and Activity (NANA). NANA may be unfamiliar to many, although it may be the most influential. PBH partners support NANA’s initiatives, which include national and state nutrition, physical activity and obesity programs; and School Wellness Policies under the Child Nutrition and WIC Reauthorization Act of 2005, which mandated that schools receive federal funds to address nutrition and physical activity. NANA has been a key lobbying group for national policies and programs to promote healthy eating and exercise in order to reduce “diet and inactivity-related diseases,” such as heart disease, cancer, high blood pressure, diabetes and obesity. NANA’s nutrition policy initiatives were founded and coordinated by Margo Wootan, director of nutrition policy at CSPI (Center for Science in the Public Interest), who is also on the Steering Committee and co-chair of the Policy Subcommittee for the National 5-A-Day Partnership. A recent PBH National Excellence Awards honored Ms Wootan’s leadership as being “largely responsible for elevating nutrition and physical activity policy to today’s current position as major components in the ongoing national health care debate.”
The lobbying has paid off. In a 2001 statement, Ms Wootan said NANA had successfully lobbied to increase the budget of the CDC’s Division of Nutrition and Physical Activity 8-fold in just 2 years: from $2 million in 1999 to $16 million in 2001. They were urging Congress for $50 million for 2002.
In 2005, the CDC rather than the NCI, became the lead federal agency for Better Produce for Health programs and its national fruit and vegetable initiatives. In addition to the 5-A-Day program, the CDC’s Division of Nutrition and Physical Activity now funds programs promoting healthy eating and physical activities, obesity prevention, public health research, communication campaigns and national surveys.
NANA has grown now to more than 300 state and national organizations, agencies and nonprofit groups all interested in promoting healthy lifestyles, exercise and fitness, nutrition and wellness. The vast moneys these nonprofits have collected and poured into healthy eating and exercise initiatives is incomprehensible. NANA has also led the way to increasing current CDC funding to $41 million a year. Its 2007 National Health Priorities paper, available through CSPI here, has asked Congress to appropriate $65 million for 2008, with $5 million specifically for fruit and vegetable programs.
Since 1999, the CDC budget for healthy eating and activity initiatives has grown 2,000 percent. PBH’s programs, membership and partnerships have grown along with it, as have an enormous throng of organizations revolving around healthy eating and exercise..
The point here is not to demonize anyone. Ad hominum attacks are for junk scientists. The point is to help us realize that it’s not just direct financial ties to industry that can bring conflicts of interest or bias. Professional careers, growing budgets and staff, prestige and recognition, and being part of a group perceived as doing good important work, can all cloud objectivity even more than financial rewards alone. Many come to passionately believe in the right and good of what they are doing.
But now that we understand the bigger picture, we can ask ourselves: How likely is it that this massive machine and momentum might suddenly grind to a halt, disband, end careers, and say “Never mind, we were wrong?”
Not likely at all — no matter how flawed the evidence for their initiatives and how many decades it is shown to be ineffective. And because we’ve come to believe these nonprofit groups, professionals and agencies are the good guys, we’ve also come to believe that eating “right” and having a healthy lifestyle is the right and necessary thing to do. So we similarly fail to question or consider if they are presenting the science objectively, or if they might have an interest in spinning the research, exaggerating or putting the best light on things possible.
In the beginning
The fact that no healthy eating and lifestyle educational effort has been effective in changing behavior is not surprising at all, given the evidence, as we’ll see in a moment. But how strong was the evidence for such an initiative from the very beginning?
A review of available case-control and prospective epidemiological studies on fruits and vegetables and healthy eating, published through 1991, was done for the NCI. Back then, the reviewers found a very large body of evidence showing a relationship between fruit and vegetable intake and cancer risks, but they noted that few investigators had looked at the strength of the evidence and had, instead, tried to identify some special factor in the food. But it is impossible to be confident that benefits come from a particular food or factor, they cautioned in the paper. They found that the vast majority of studies reported their results in terms of relative risks and while many found strong associations, others had found none. But because a biological rationale for a possible protective effect of fruits and vegetables was believed to be strong — such as antioxidants like vitamin C and vitamin E, and folate and fiber — they concluded it wasn’t necessary to understand the science before taking action for public health.
A later examination of the scientific literature published since 1999 to 2001 was done for PBH by Dianne Hyson, Ph.D., MS, RD. Her report, “The Health Benefits of Fruits and Vegetables —A Scientific Overview for Health Professionals,” was carefully written, but the actual evidence to support the special benefits of produce continued to be built on a series of correlations found in case-control studies. However, “the results of the new prospective trials have been less conclusive,” she concluded in her overview. On breast cancer, for example, “data from 8 prospective trials found no association between intake of fruits and vegetables and reduced risk of breast cancer.” Throughout the report are notes finding that some population and case controlled studies have found positive correlations, but confounding factors, such as socioeconomic status, that might influence health discrepancies might explain the findings. “It will be important to see if dietary intervention studies confirm the potential benefits,” she cautioned repeatedly. The trials to date suggesting benefits have looked at biomarkers associated with risks for certain diseases (surrogate endpoints), rather than actual diseases, health outcomes or mortality. And that, as we've seen, is what matters most.
She also reported on the inconsistency of various findings looking for correlations among populations. “However, results from several recent prospective investigations have not consistently shown this effect...in reducing risk of colorectal cancers...stomach cancers...” For instance, while a small number of studies have suggested that fruit and vegetable consumption is associated with reduced risk of developing diabetes and improved control of blood sugar levels, she writes, these analyses “must be viewed cautiously...these results are in contrast to another prospective study published recently in which fruit and vegetable intake was not directly associated with incidence of type 2 diabetes in older women followed prospectively for 6 years.”
Examining the conflicting studies on produce and bone health, she concluded, “current available data suggest that there may be a link between bone health and fruit and vegetable consumption, although further investigation is needed to confirm the mechanisms and specific constituents in fruits and vegetables that might account for the association. [italics added] One can almost read the difficult tightrope she was walking.
Looking at longevity claims, she examined a 26-year prospective study of longevity among men in Sweden. She notes it found “no relationship between vegetable consumption and mortality or other major diseases... and at 26 year, the protective association with fruits was no longer statistically significant.” Her lengthy paper references 125 papers, all with similar findings and caveats. She concluded:
The most convincing data for a relationship between fruit and vegetable intake and disease prevention would be provided by large randomized trial or intervention studies providing fruits and vegetables to defined populations for a period of time and assessing health-related outcomes....such trials have not been conducted...Collectively, the current evidence supports a significant association between fruit and vegetable intake and health.
While a varied diet, complete with a beautiful array of fruits and vegetables, has been soundly shown to help prevent nutritional deficiencies, have we perhaps exaggerated the magical abilities of certain foods, diets and ingredients to help keep us youthful, healthy and prevent diseases? The evidence continues to appear to suggest so. Dare we even consider the possibility?
Looking back at the NCI’s original 5-A-Day for Better Health guide to NIH grants, the “Scientific Rationale” included the review already noted above, as well as a 1990 review conducted by Walter Willet, M.D., DrPH, professor of epidemiology and nutrition at Harvard School of Public Health in Boston, MA. Dr. Willet was also one of the individuals who wrote the PBH’s current National Action Plan. The NCI wrote that according to Willet “the inverse relationship between the intake of vegetables and fruits and the risk of lung cancer represents one of the best established associations in the field of nutritional epidemiology.” But looking at the study itself, which was actually a study of vitamin A and lung cancer, it appears the author’s enthusiasm was considerably more tempered:
Although initial studies suggested that persons with lower levels of serum retinol have higher future rates of lung cancer, this idea was not confirmed in subsequent investigations. Prediagnostic levels of beta-carotene in blood, however, have been inversely related with risk of lung cancer. Available data thus strongly support the hypothesis that dietary carotenoids reduce the risk of lung cancer, but the data are also compatible with the possibility that some other factor in these foods is responsible for the lower risk. Even if ultimately shown to be casual, the relation between diet and lung cancer is modest compared with the deleterious effect of cigarette smoking.
And most of us heard nothing of the latest NCI study, led by Dr. Willet in 2004, which set out to better define the relationship between fruits and vegetables and risks for major chronic diseases. Prior to beginning their study, the authors wrote that to date, “studies of fruit and vegetable consumption in relation to overall health are limited.” After examining the data on 71,910 women and 37,725 men followed for 15 years, they found no relationship between fruits and vegetables and cancer and no statistically significant associations with major chronic disease or cardiovascular disease.
Evidence in action
It appears, however, that evidence alone might not be enough to deter today’s growing fixation with “healthy” eating and exercise.
Over the past 15 years, as the fruit and vegetable public health education strategies have repeatedly been shown to be ineffective, the result has been larger budgets and bigger, more comprehensive programs. Each time a national health survey has found that consumption of fruits and vegetables among Americans has failed to change, or has even declined slightly, calls have gone out that “additional efforts and new strategies are needed.” For example, a CDC study published in the American Journal of Public Health in 2004 found little change in product consumption from 1994 to 2000.
According to its most recent National Action Plan, PBH’s 5-A-Day and healthy eating strategies have expanded to include innumerable programs and encompass over 75 strategies, targeting every conceivable setting:
• Marketing to children
• Supermarkets and retailers
• Fruit and vegetables growers, processors and shippers
• Cafeterias, restaurants and other food establishments
• Schools, daycare centers and youth camps
• Health care industry and health organizations
• Research entities
• Federal policies
- Food and nutrition assistance programs
- Centers for Disease Control and Prevention
- Food and Drug Administration
5-A-Day related programs continue to grow and it’s hard to imagine something that hasn’t been tried. In 2005, PBH partnered with the USDA and 30 industry groups to unveil its Phytochemical Information Center, to encourage consumers to eat more produce by promoting special qualities and emerging science on phytochemicals, making it a top nutrition news story, and creating an online food composition database. PBH partnered with Sesame Street for programming for preschoolers, and Dreamworks and Walmart to create its Over the Hedge programs to teach kids to eat more colorful produce.
Marketing to children and initiatives that include billboards, direct mailings, supermarket and retailer messagings, restaurant and food establishment merchandizing and promotions, and school programs fill their action plan. Yet, their own paper noted (and ignored) that the 2003 Roper Youth Report found that among all ages of children and teens, parents have the primary influence on their food choices, with advertisements and teachers almost none.
Which brings us to the latest $3.5 million campaign: “Fruits & Veggies — More Matters.” There’s an interesting story behind its creation that was described in a publication of PBH Board member, the Florida Fruit and Vegetable Association. In 2005, realizing that their 5-A-Day campaign was no longer working or viable, PBH looked to create a new campaign to motivate people to eat more fruits and vegetables. PBH partners brought in experts from leading professional branding agencies across the country. They chose Sterling Brands, based in New York. A task force of PBH representatives working with Sterling shadowed families for days. They reported that: “the moms told us, ‘we think we’re doing okay for our families. We don’t want you to preach to us.’” Their research found that most mothers already know the benefits of eating fruits and vegetables and a healthy diet. So, when developing their new brand, did they acknowledge the evidence their own research found? You decide.
The Washington Post described the just-released campaign in an article this week titled, “Look for a juggler:”
Despite this effort, the public is not consuming the recommended amount of fruits and vegetables...Yet research clearly shows that a diet rich in fruits and vegetables can help control blood pressure, reduce risk of heart disease and stroke, cut the incidence of diabetes and lower the odds of developing some types of cancer. ...Eating more fruits and vegetables may help prevent some age-related vision problems, and it even helps improve bone density, key to staving off osteoporosis....
A bright green juggler tossing colorful fruits and vegetables through the air is likely to make it a bit easier for consumers to spot healthy foods and drinks that can help them meet their nutritional goals. The icon will appear on fresh produce as well as canned, frozen and dried products that meet nutritional criteria set by the CDC. About 21,000 supermarkets and 170 companies are already licensed to use the icons, according to PBH. To earn the juggler icon, a product needs to contain at least one serving of fruit or vegetables per portion....The program sets strict limits on the amounts of added sugars or sugar substitutes, fat and sodium.
While the new program is designed to boost fruit and vegetable intake throughout the population, it specifically targets mothers who make the most food choices for their families....“All are designed to make healthy choices easier choices,” said William Dietz, director of the CDC's Division of Nutrition and Physical Activity.
The overwhelming message I hear in these initiatives, and the claims made in the article in support of them, is a paternalistic belief that we are all making bad choices, eating wrong, and unable to feed ourselves or our children without the growing involvement of experts to help us make the right choices. Eating right is a matter of good versus bad foods, and the “healthy” choice is perceived as the good one. The pursuit of health must be our paramount concern in everything we do.
But can the need for this popular imperative and the intense fixation on healthism be credibly supported?
We’ve already examined that, contrary to beliefs and fears about junk food and our modern diets, we have the safest and most abundant supply of wholesome food ever in our country’s history.
And every annual report on the actual health of Americans that’s been issued over recent decades by the CDC has brought better and better news. Headline were made in 2002 as the CDC reported that in the past fifty years, death rates among children and adults had been cut in half and even dropped by a third among our eldest citizens. By the year 2000, Americans enjoyed the longest life expectancy in U.S. history. And the most recent report,Health United States 2006, reported that life expectancy for our population has continued to rise from 1990, reaching a record of 77.9 years.
Since 2000, age-adjusted mortality from heart disease had dropped another 16% and cancer another 8%.
The actual evidence on the state of our health is good news! It calls into question any apparent health crisis because we haven’t increased our fruits and vegetables, or complied sufficiently with some other prescribed lifestyle choice, for the past 15 years.
According to the CDC data, however, certain health inequities are still in evidence, notably among the poorer, minority members of our society. Interestingly, this past week’s study by the John Hopkins epidemiologists also found that fewer poor people met national recommendations for fruits and vegetables. But it is a fallacy in logic to conclude that produce or poor diet is, therefore, the cause for those health inequities. As is common with many associations between health and certain foods, diets and lifestyles, they often turn out to be markers for socioeconomic status, social inequities, stress or other life factors that impact health. This highlights the harm and waste of limited resources when associations are mistakenly taken as causations. Of course, it is far easier to direct energies to a nonproblem that sounds good, is fashionable and makes loads of money, than to face really hard problems such as food insecurity, discrimination and poverty.
The biggest failure of all
Is there any evidence for the effectiveness of efforts to counsel, advise, educate and motivate people into eating more fruits and vegetables or eat “healthy”? The answer may surprise you.
Remember the U.S. Preventive Services Task Force? As we’ve noted, it is sponsored by the Agency for Healthcare Research and Quality, the Federal government’s lead agency under the U.S. Health and Services Department, and is charged with examining the soundest research and issuing careful, evidence-based findings that are supposed to be used in all aspects of government healthcare spending and public health policies. But, as we’ve seen, its findings and recommendations aren’t always followed.
What has the USPSTF advised about counseling to promote a healthy diet?
The USPSTF, in updating its 1996 findings, again concluded in 2003 that there is insufficient evidence to recommend routine behavioral counseling to promote a healthy diet in adults.
They found that the evidence was only fair that even medium-intensity dietary counseling could produce small to medium changes in diet. “The strength of this evidence, however, is limited by reliance on self-reported diet outcomes, limited use of measures corroborating reported changes in diet, limited followup data beyond 6 to 12 months, and enrollment of study participants who may not be fully representative of primary care patients. In addition, there is limited evidence to assess possible harms.”
And concerning even high-intensity interventions, they found studies showing changes in the diet among patients with specific diet-related diseases or highly selected patient populations with specially trained providers, but that these findings couldn’t point to effective interventions addressing diet or broader lifestyle interventions for wider use in the general population. They concluded that “existing studies do not provide sufficient evidence to recommend these interventions for widespread use due to a number of limitations such as modest overall patient recruitment/participation rates, reliance on self-reported outcome measures, relatively short followup periods, uncertainty about the health effects of small and medium changes in diet, and the lack of evidence about possible adverse effects of counseling.” They found no controlled trials of routine behavioral dietary counseling of any intensity for children or adolescents to indicate effectiveness in the primary care setting.
If decades of research had presented any convincing evidence for the benefit and long-term effectiveness of behavioral counseling to get people to eat healthfully, it would have caught the attention of experts by now. So, it was actually not surprising — even after 15 years and throwing every possible tactic into the efforts — that the 5-A-Day campaign has continued to demonstrate no success in increasing fruit and vegetable consumption.
Despite this lack evidence, however, professionals working in medicine, preventive health, nutrition, education, and public agencies are being especially targeted and encouraged to be agents of change in compelling healthy eating and behaviors — by the government, our professional organizations and even insurers (compliance used as reimbursement measures). As the PBH action plan advises:
Train health care providers such as pediatricians, nurses and family pracitioners [sic] to deliver effective, behaviorally-focused programs and messages about fruits and vegetables to all populations and subgroups. Provide appropriately tailored messages for specific populations such as children and persons with particular health conditions such as overweight, hypertension, high cholesterol and/or diabetes.
• Include consistent, behaviorally-focused messages about dietary recommendations for fruits and vegetables and practical tips for increasing consumption in guidelines and materials produced by professional and health voluntary organizations
• Develop an incentive-based approach for public and private health insurers to promote fruit and vegetable intake among subscribers (Medicaid, Medicare, state children’s health insurance programs, and federal, state and local, and private insurers).
As professionals, we might ask ourselves if our credibility is jeopardized among those we care for and advise when we become messengers in social agendas that may not be sound or in the best interest of our patients. Beyond making available basic nutritional information and guidance when medical needs dictate, do we damage people’s trust when we try and tell them how they must eat and live their lives? Might most people be perfectly capable of feeding themselves without our intervention? This isn’t a political question, but one of people’s welfare. Today's pervasive message of panic over “bad” foods, beliefs surrounding “good” foods, and urgency in the admonitions that we all must eat healthy and exercise a certain way lest we become diseased and doomed to an early grave, or that there is some ideal diet everyone must abide by before good health is even possible, have simply gone beyond the available science and into speculation and myth. A worrisome effect is that growing numbers of people are afraid for their health, fear for the safety and wholesomeness of their food and its ability to provide adequate nourishment unless every morsel is proper, and are scared that every “bad” thing they do might be a reason for blame, guilt and condemnation. Choices made in fear and emotion are less apt to use careful reasoning. Yet nowhere in public discussion has the harm resulting from these incessant messages even been considered. In this climate, less is more. It may be most helpful and healthful for ourselves and everyone if we step back and let our own common sense guide us.
There's another result from today's healthism. By furthering the idea that only experts and authorities know what’s best and fostering a sense of dependence, rather than empowerment, these messages also have a slow, steady effect of undermining people’s confidence in their own ability to decide what is best for themselves.
So this past week, we were presented with more evidence of 15 years of failure of a massive public health initiative that was based on well-intentioned, but unresolved medical evidence, and utilized methods with no evidence at all. Now, what will we do with it?
© 2007 Sandy Szwarc