Friday, December 21, 2012

2005 Dietary Guidelines (“9-A-day Campaign”): A Public Health Campaign Launched to Fail - Sandrine Batonga

 The 2005 Dietary guidelines: 9-A-Day Campaign

There is solid evidence that high fruit and vegetable consumption plays a major role in lowering risk of chronic illnesses such as heart disease and stroke, and contributes to lowering total mortality (1). Thus, in 2005, as they have been doing every 5 years since 1980, the US Department of Health and Human Services (HHS) and US Department of Agriculture (USDA) released the 2005 dietary guidelines which increased the recommended daily servings for fruits and vegetables from five to nine (based on a reference 2,000-kcal diet) (2). These dietary guidelines, also known as the “9-A- day campaign”, came after the “5-A-day campaign” which was not proven effective based on the expected outcomes and funding invested. Indeed, studies have shown that the 5-A-day campaign only increased food consumption by 30 points, well below the expected target (3). In 2007, only 40% of Americans met the former 5-A-Day guidelines, and fewer than 10% appeared to meet the 2005 guidelines and subgroup recommendations for fruits and vegetables (4).

Missing an opportunity to correct the previous campaign’s mistakes and missing the opportunity to examine in depth why only 40% of Americans were able to eat 5 servings of fruits and vegetables per day despite the generated investments, the 9-A-day campaign carries some of the same flaws of the preceding public health intervention. These flaws include incorrect assumptions on people’s access to fruits and vegetables, disregard of the influence of environmental factors, and price in particular, on Americans’ eating habits and flawed advertising approach.

Unequal access to fruits and vegetables
The 9-A-day campaign, as the 5-A-day campaign, dismissed the existence of a fruit residential distribution. Low-income, minority-dominated urban neighborhoods are often considered as food deserts, as supermarkets have vacated these communities (5). A lot of people do not consume fruit and vegetables not because they do not want to, but because they don’t have access to them and lack quality and variety of healthy products.

Research has shown that low-income and African American neighborhoods have fewer supermarkets but more liquor stores and convenience stores than higher income and White neighborhoods, respectively (6). Fewer healthy food options and lower quality foods, even after accounting for store type, in low-income and African American neighborhoods have also been documented (7). Thus, residents of African American and low-income neighborhoods tend to face more environmental barriers to healthy eating than residents of other neighborhoods.

A qualitative study by Zenk and colleagues sought to understand food acquisition behaviors and environmental factors that influence those behaviors among women in a low-income African American community with limited food resources. Women in the study described that material barriers to food acquisition included store availability, store upkeep and food availability and quality. Several women indicated that the lack of a full-service supermarket in their neighborhood was an obstacle in obtaining food. These women wanted a supermarket that was convenient and within walking distance especially women without a car (8).

The lack of availability and variety of some foods at neighborhood retailers (which include healthy foods) is evident in low-income neighborhoods. Fresh produce was commonly identified as missing from the neighborhood, among others, by the women in the study. Many felt that food options were particularly limited when compared with other types of neighborhoods, even among stores of the same type (8).

Of the foods available in the neighborhood, poor quality was another material impediment to obtaining products, especially for fresh foods, but sometimes for packaged foods as well. Women described withered fresh fruits and vegetables, rotting “green” fresh meats, and expired canned and packaged foods which definitely constitute a turn-off for visiting stores that provided them (8).

Lastly, another hindrance to healthy food access is safety. However, poor customer service or treatment, poor upkeep, crowding, and unsupportive sales practices also discourage families from seeking healthy products at available stores. The lack of safety was identified as a major social-interactional deterrent to food acquisition at local stores. Many safety concerns stemmed from problems with people hanging out in front of stores, panhandling, soliciting drugs, and harassing shoppers (8). Such issues are again prevalent in economically disadvantaged neighborhoods.

Price: a Major Environmental factor

Food price is yet another environmental factor that influences food consumption. Replacement of fats and sweets with vegetables and fruit has become a standard public health recommendation. However, little to no consideration has been given to diet costs. Whereas fats and sweets provide dietary energy at a very low cost, the energy cost of lean meats, fish, vegetables, and fruit is likely to be higher (9). Following advice to replace one with the other is far from being a simple public health application, and will most likely entail higher consumer diet costs (9).

Cassady and colleagues, in their study of 25 supermarkets in varying income-level neighborhoods in Sacramento and Los Angeles found that fruits and vegetables prices varied by neighborhood income and by store type. The cost of vegetables in the 2005 Dietary Guidelines market basket was significantly lower in supermarkets in higher-income neighborhoods than in middle-income neighborhoods. There was no significant difference between fruits and vegetables prices in stores located in very-low-income and low-income neighborhoods (10).

Fruits and vegetables from bulk stores costed 14% less than from independently owned supermarkets, and 17% less than traditional chain supermarkets. In addition, prices in very-low-income neighborhoods varied within the same city and supermarket chain by 17%, and within the same city and same bulk store chain by 52% (10).

Even when average price of fruits and vegetables were found to be surprisingly less in low-income neighborhoods, the cost of a complete market basket (i.e., one that contains breads, dairy, and meat in addition to fruits and vegetables) remains the greatest in very-low- compared to high-income neighborhoods (11). In places where on average low-income consumers would pay less for fruits and vegetables compared to their middle- and high-income neighbors, there are nevertheless several important cost barriers for the low-income consumers who wish to meet dietary guidelines (10).

First, only the careful selection of the store will guarantee that low-income shoppers pay less, because prices vary across stores in very-low-income areas, for instance by 65% in Los Angeles and 76% in Sacramento (10). Even within the same chain prices varied noticeably. Second, the cost of a 2005 Dietary Guidelines fruit and vegetable market basket will require substantial changes in the family food budget. As shown in the study by Drewnowski and colleagues (12), increasing the consumption of more healthful foods is not simply a matter of substituting grapes and broccoli for cupcakes and chips. This change also involves changing the food budget for consumers. American families spend 15% to 18% of their at-home food budget on fruits and vegetables. It seems unlikely that consumers would be able to increase their spending on fruits and vegetables by 200% to 400% without substantial changes elsewhere in the food budget, or from other household expenditures. For low-income consumers this may be especially challenging because there are few discretionary funds available in these other accounts (10).

A family of four shopping in a very-low-income neighborhood would pay on average $1,688 annually to meet the 2005 Dietary Guidelines recommendations. A family of four using food stamps in California receives on average $3,888 each year (13). Therefore, the 2005 Dietary Guidelines fruit and vegetable market basket would require 43% of the food stamp budget. According to the US Department of Labor, households in the lowest two income quintiles spend an average of $2,410 each year on food at home (14), which means lower income households would have to allocate 70% of their food-at-home budget to the 2005 Dietary Guidelines fruit and vegetable market basket (10).

Advertising techniques

Besides failing to take into account all the previous environmental factors, HHS and USDA failed to properly advertise the 2005 Dietary Guidelines. Although campaigns efforts included national mass media campaigns, activities in supermarkets, and community interventions in schools and at work sites (15), HHS and USDA invested substantially less in their campaign than what would be required to launch effective campaigns such as the ones the food industry do (15). Moreover, the advertising techniques used were defective in that they did not utilize empowering messages of control as suggested by the advertising theory.
Television has been cited as a contributing factor to higher dietary energy or fat intake (3). Exposure to food advertising, especially commercials for fast food or convenience foods, influence viewers' food choices toward higher-fat or higher-energy foods (3). The food industry also extensively uses new technologies for this purpose today. Food manufacturers, retailers, and food service spent $11 billion in 1997 on mass media advertising, second only to the automotive industry (15). In 1997, Coca Cola spent $277 million on advertising (3). In 1998, McDonald's spent $571.7 million and Burger King spent $407.5 million (3). These figure contrasts with the $29.8 million spent by the “milk mustache” and “got milk?” campaigns in 1996 and the $1 million spent in 1999 by the National Institutes of Health/National Cancer Institute to promote the “5-a-day” message (15). In 1997, the entire amount spent by the USDA on nutrition education, evaluation, and demonstration was $333.3 million, 3% of what the food industry spent in 1997 (15).
Relative to national dietary recommendations, foods that are most heavily advertised are those that are over-consumed, while those that receive less advertising are under-consumed (15). Confectionaries and snacks, prepared convenience foods, soft drinks, and alcoholic beverages are the most heavily advertised foods, whereas fruits and vegetables are among the least advertised foods (15). These data are consistent with overall food advertising expenditures, where in 1997 $792 million was spent on advertising breakfast cereals, $765 million on candy/gum, $728 million on beer, and $549 on carbonated soft drinks. By contrast, only $105 million was spent advertising fruits and vegetables (15).

Furthermore, the 9-A-day campaign does not send messages of empowerment and control to the public. This campaign is based on health benefits and promises of health instead of putting forth people’s deepest aspirations and dreams.

The HHS and USDA 9-A-day campaign is flawed in many ways as it fails to account several social and behavioral sciences theories including the advertising and marketing theories. Specific measures to address the specific flaws mentioned should be put in place in order to improve this campaign of great importance for Americans and the future of America. Ways to correct this campaign comprise making fruit and vegetables affordable for low-income populations who still struggle to meet the 5-A-Day campaign, increasing fruits and vegetables availability in neighborhoods where healthy products are scarce and not only considerably increase the advertising budget allocated to dietary guidelines but also completely reframe this issue.

The NO Limits Movement
To help the public meet dietary guidelines, a movement that promotes the absence of limits in life to fulfill dreams should be launched. This movement should rally motivated believers of freedom and justice as well as believers of the fact that dreams can come true and that anyone should have the possibilities to become who he/she wants to be.

The NO limits Movement will be about self-empowerment and justice. Its activities will include active advertising that merely refers to fruits and vegetables but with the subtle underlying message that all the roads to success pass by fruits and vegetables. Indeed, in order to freely achieve his or her goals, one must be in good physical shape as a healthy diet confers, one must have equal opportunities and equal access to promising routes as would confer a developed neighborhood where fruits, vegetables and transportation are readily available.

The NO limits movement will have a website to connect all NO limiters, and let them share their success stories as well as offer tips on various topics including job interviews and career advancement tips. The website will additionally advertise places who sell fruits and/or vegetables at affordable prices, and it will publicize creative (quick and elaborate) healthy menus in order for viewers to incorporate vegetables in daily meals. The site will also display locations and rotations of NO Limits trucks that provide free fruits donated to the organization as well as locations of where local sellers, with the help of NO Limiters, will periodically set their stands in neighborhoods with low healthy products access.

Farmers’ Markets and Free Fruits Trucks

In order to precisely address the unequal distribution of fruits and vegetables, their availability, quality, and transportation issues in low-income neighborhoods, the NO Limits movement will sponsor free fruits and vegetables distributions events as well as bring farmers’ markets to underserved communities. Although just a few well-designed studies have evaluated the influence of farmers' markets and community gardens on nutrition-related outcomes and further studies are recommended (16), these studies suggest evidence of a positive impact of bringing farmer’s market to low-resource communities.


Bringing fruits and vegetables to the communities in need does make a difference in their consumption. Caldwell and colleagues found that the perceived access to fruits and vegetables only - that a market or a truck for instance would procure - is associated with increased consumption (17). The average increase in fruit and vegetables consumption was 2.52 servings weekly from start to 1-year follow-up for 130 participants from nine communities participating in community-based programs emphasizing fruit and vegetable consumption in Colorado (17). Greater perceived access to fruits and vegetables was significantly associated with higher increases in fruit and vegetable consumption from program start to program end. Greater availability of produce was associated with greater increases in fruit and vegetable servings from program start to program end as measured by store assessments. Caldwell et al. recommend that interventions with the goal of increasing fruit and vegetable consumption consider focusing on increasing access to fresh fruits and vegetables in target communities (17). The latter are exactly the objectives of NO Limiters massive mobilization for the development of farmers’ markets all over the nation and expansion of distribution events.

NO Limits will strive for distributions of diverse and fresh fruits, as greater variety has been associated with increased fruits and vegetables intake (18). NO Limiters would also challenge through different types of actions including protests food chains to take their limits off, and be pioneers, bold enough to open branches in less affluent neighborhoods.

Cheaper Fruits and Vegetables
In addition to making fruits and vegetables available to communities that lack them to help them meet the dietary guidelines, the cost of these food items should also be reduced, if not free. Cost constitutes a tremendous barrier to meeting dietary guidelines. Farmers’ markets, in addition to improving access to healthy food items, have been proven to offer lower prices as foods are more expensive at small food retailers (19). Larsen and Gilliland demonstrated that the introduction of a farmers’ market in a food desert increased the availability of healthy food and lowered the overall food costs for households in the neighborhood. Although everyone in the neighborhood would not necessarily shops at the farmers’ market, a cost-saving opportunity should be made available (19).
NO Limits would actively reach out to local farmers, city/neighborhoods’ non-farmers markets sellers and local authorities to buy into this trend of open low-cost fruit markets everywhere. NO Limits will also advocate for extending existing or creating new voucher systems for fruits and vegetables to disadvantaged populations.

 The WIC (Women, Infants, and Children) Farmers' Market Nutrition Program already provides eligible individuals with vouchers redeemable for fresh fruits/vegetables at approved farmers' markets (20). It is a federal–state partnership that begun in 1992 by the USDA (20). The two primary objectives of the Farmers' Market Nutrition Program are to provide fresh produce to low-income women, infants, and children up to age 5 years; and expand awareness, use, and sales at farmers' markets. Local governments determine Farmers' Market Nutrition Program participation. USDA provides 100% of Farmers' Market Nutrition Program food costs and 70% of administrative costs; local governments are responsible for 30% of administrative costs (21). Local governments may elect not to participate in the Farmers' Market Nutrition Program because of costs or lack of farmers' markets in the area (22). NO Limits goals will then be to expand the list of approved farmers’ markets by the USDA’s program and again encourage markets implantation for increased access and actual usage of the vouchers when acquired.

Dollahite and colleagues found that the Farmers' Market Nutrition Program was associated with increased fruit/vegetable consumption among program participants (23). The average number of servings of fruit and vegetables per day, 7.5, was higher than the 4.4 servings reported among non-Hispanic African-American women in the 2000 National Health Interview Survey. In general, economic supplement for fruits and vegetables purchase whether at farmers’ markets or other types of vendors seems to improve consumption.  Herman et al. study of 454 low-income women (predominantly Hispanic) in Los Angeles confirmed this pattern. The women were provided vouchers for fresh fruit and vegetable purchase in the Special Supplemental Nutrition Program for WIC. They used the supplement provided almost fully, and purchased a wide variety of fresh fruits and vegetables for their families (24).

Additionally, it was found that participation to the Farmers' Market Nutrition Program increased the use of farmers' markets which support the previous argument of creating farmer’s market in the first place. The movement will thus organize protests in front of local governments that declined having the Farmers' Market Nutrition Program to encourage them to do so or put in place alternative vouchers systems for low-income citizens.

Powerful Advertising and Marketing
Last, but certainly not least as they will represent some of the most important components of this movement are the advertising and marketing of NO Limits. The NO Limits campaign will rely on extensive advertising and presence on the web, advertising on TV, posters on buses, transportation stops and billboards to name a few. The sentence NO Limits will appear on a picture of bright sky on posters. The meaning of NO Limits should become the new mystery in town each time the campaign is physically launched somewhere through inexplicit posters. NO Limits would be the new brand of success and the movement people who do not wish to be limited by others or circumstances identify with.

HHS and USDA as well as other public health and non-profit organizations will be solicited to generously invest in the marketing and advertising of the movement. As previously mentioned, substantial funding of high-quality, appealing and persistent marketing campaigns is key to success as shown by the food industry and illustrated by the “Truth” campaign (25).

As per the advertising theory, NO Limits’ message will include in addition to the promise that success is attainable, extensive support through bright images, catchy words, ideal music (when applicable) and the portray of different determined individuals achieving their goals in sports business, and/or school. The power of advertising and marketing through a promise and support has been proven effective many times including in the “Truth” campaign (25). NO Limit will be for NO Limiters who refuse to be limited by others and circumstances but work to attain success.

1.  Bazzano LA, He J, Ogden LG, et al. Fruit and vegetable intake and risk of cardiovascular disease in US adult: the first National Health and Nutrition Examination Survey epidemiologic follow-up study. Am J Clin Nutr. 2002; 76:93–99.

2. US Department of Health and Human Services and US Department of Agriculture. Dietary Guidelines for Americans, 2005. 6th edition.Washington, DC: US Government Printing Office, January 2005.

3. French A, Story M, Jeffrey RW. ENVIRONMENTAL INFLUENCES ON EATING AND PHYSICAL ACTIVITY - Annual Review of Public Health, 2001; 22(1):309.

4. Guenther PM, Dodd KW, Reedy J, Krebs-Smith SM. Most Americans eat much less than recommended amounts of fruits and vegetables. J Am Diet Assoc. 2006; 106:1371-1379.

5. Larsen K, Gilliland J. A farmers’ market in a food desert: Evaluating impacts on the price and availability of healthy food. 2009; 15(4):1158-1162.

6.  Beaulac J, Kristjansson E, Cummins S. A systematic review of food deserts, 1966-2007. Preventing Chronic Disease. 2009; 6: A105.

7. Cummins S, Smith DM, Taylor M, Dawson J, Marshall, D, Sparks, L, et al. Variations in Fresh fruit and vegetable quality by store type, urban–rural setting and Neighbourhood Deprivation in Scotland. Public Health Nutrition. 2009; 12: 2044-2050.

8. Zenk SN, Odoms-Young AM, Dallas C, Hardy E, Watkins A, Hoskins-Wroten J, Holland L.You have to hunt for the fruits, the vegetables": environmental barriers and adaptive strategies to acquire food in a low-income African American neighborhood. Health Educ Behav. 2011; 38(3):282-92.
9.  Drewnowski A, Darmon N,  Briend A. Replacing Fats and Sweets With Vegetables and Fruits—A Question of Cost. Am J Public Health. 2004; 94(9): 1555–1559.

10. Cassidy D, Jetter K, Culp J. Is Price a Barrier to Eating More Fruits and Vegetables For Low-income Families? J Am Diet Assoc. 2007; 107(11): 1909-1915.

11. Jetter KM, Cassady DL. The availability and cost of healthier food alternatives. Am J Prev Med. 2006; 30:38-44.

12. Drewnowski A, Darmon N, Briend A. Replacing fats and sweets with vegetables and fruits—A question of cost. Am J Public Health. 2004; 94:1555-1559.

 13. US Department of Agriculture. Food Stamp Program: Average monthly benefit per person.

14. US Department of Labor. Consumer Expenditures in 2002. Washington,DC: Bureau of Labor Statistics; 2004.

15. Gallo AE. 1999. Food advertising in the United States. See Ref. 16Bpp. 173–80

16. McCormack LA, Laska MN, Larson NI, Story M. Review of the nutritional implications of farmers' markets and community gardens: a call for evaluation and research efforts. J Am Diet Assoc. 2010; 110(3):399-408.

17. Caldwell EM, Miller Kobayashi M, DuBow WM, Wytinck SM. Perceived access to fruits and vegetables associated with increased consumption. Public Health Nutr. 2009; 12(10):1743-50.

18. Zenk SN, Schulz AJ, Hollis-Neely T, Campbell RT, Holmes N, Watkins G, Nwankwo R, Odoms-Young A. Fruit and vegetable intake in African Americans: income and store characteristics. Am J Prev Med. 2005; 29:1–9.
19.  J. Latham, T. Moffat. Determinants of variation in food cost and availability in two socioeconomically contrasting neighbourhoods of Hamilton, Ontario, Canada. 2007. Health and Place 2007; 13: 273–287.

20. WIC Farmers' Market Nutrition Act of 1992. 106 Stat. 281; Child Nutrition Act of 1966, as amended, Section 17(m), 42 U.S.C. 1786.

21. US Department of Agriculture, Food and Nutrition Services. WIC Farmers′ Market Nutrition Program. USDA Food and Nutrition Services Web site.

22. Racine EF, Smith Vaughn A, Laditka SB. Farmers' market use among African-American women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children. J Am Diet Assoc. 2010; 110(3):441-6.

23. J. Dollahite, J.A. Nelson, E.A. Frongillo, M.R. Griffin Building community capacity through enhanced collaboration in the farmers' market nutrition program. Agric Human Values, 22 (2005), pp. 330–354.

24. Herman DR, Harrison GG, Jenks E. Choices made by low-income women provided with an economic supplement for fresh fruit and vegetable purchase. J Am Diet Assoc. 2006; 106(5):740-4.

25. Hicks JJ. The strategy behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

Labels: , , ,


Post a Comment

Subscribe to Post Comments [Atom]

<< Home