Challenging Dogma

...Using social sciences to improve the practice of public health

Friday, April 20, 2007

The Numbers Don’t Add Up: A Socio-Ecological Critique of CDC’s Five-A-Day Campaign’s Failure - Gerry Thomas

There is widespread agreement and evidence that adequate consumption of fresh fruits and vegetables on a regular basis are critical to overall health status, prevention of obesity and chronic diseases. Yet, following a 10-year, $27 million dollar campaign spearheaded by the National Cancer Institute (NCI), called Five a Day for Better Health Program, results showed an actual decline in the national average in following the recommendations. (1,2) The dismal outcomes produced demonstrate the campaign’s failure to employ appropriate social and behavioral sciences that incorporate a multi-factorial approach to the problem.

Identified Behavioral Theories and Concepts Used In 5 a Day
As part of the campaign, nine community research grants were awarded that utilized one or more of the following behavioral models or theories (1,2):
Health Belief Model (rational)
Trans-theoretical model (non-rational)
Social Cognitive Theory (rational)
Resiliency Theory
Social Networks/Supports (rational)
Community organization, organizational Change Theories
Diffusion of Innovations (rational)
PRECEDE-PROCEED Planning Process

Despite the fact that half of these models occur on an interpersonal or social level, a further review of the actual interventions corresponding to the stated behavioral theories show an overwhelming preference for individual level activities. Specifically these activities included education, dissemination of materials media campaigns, social marketing, and parental engagement.

The target locations and audiences of the research grants included worksites, school-age children, women receiving WIC, and African American churchgoers. Despite spending over two-thirds of its budget, $18m (1), to assess models on behavior change (1) no monies were directed to socio-ecological factors. Were the right models applied to right population?

In order to address root causes of problems there is too often a focus on the symptoms and a disregard for environmental and basic social conditions, and the socioeconomic factors that influence behavior and health outcomes. (3). Most of these models assume calculated rational thought and cannot account for environmental factors such as discrimination, marginalization or inadequate resources. (4) Lastly, a prevention focus such as Five-a-Day’s cancer prevention message requires not only access, but also delayed reward and gratification that do not resonate with everyone, particularly those facing more day to day survival issues. As Link notes “people of higher SES were more favorably situated to know the risks and to have the resources that allow them to engage in protective efforts to avoid them”. (3)

The Fruit and Vegetable Consumption Challenge…. where did we go wrong?

The campaign was unprepared to counter the prevailing marketing and messaging advertised by the fast food and soft drink industry(s).
It is noteworthy that the odds were stacked against the Campaign from the onset. The Five-a Day Campaign was vastly outspent by the fast food and soft drink industry, who spent $7 billion on food promotion in only one year, 1997 (1,2). The largest and most recognized vendor McDonald’s, alone spends $5B annually on advertising, and generates $5 for every dollar spent (1). Five-a–Day spent a grand total of $5 million on media.

In this David and Goliath environment, the campaign was unable to frame the campaign in a manner that would appeal to and engage the public. McDonalds, Coca-Cola, et al, market fun, taste, attractiveness, success and other core values utilizing advertising theory to win America’s hearts and minds. In contrast the Five-a-day message failed to connect with “core values” and its lack of appeal with consumers is apparent.

The intense and highly successful advertising campaigns by the soft drinks and fast food industries were well-designed and financed. The industry was also able to capitalize and even influence other environmental and social factors affecting the nation’s eating habits. For example, there is a strong correlation between consumption of sugar-sweetened beverages by children and overweight and obesity. (1995-2005) The amount of time children spend watching television and playing video games increased during this same time period (1, 5). Simultaneously radical changes in the food environment occurred (1,5), with food much more readily available (1,5), relatively cheap and inexpensive (1,5), and largely calorie-laden. (1,2,5) Five-a Day’s meager budget and lackluster prevention message could not compete.

The campaign did not address the barriers of availability, affordability and quality of fresh fruits and vegetables in low-income communities.
Several studies have found low-income neighborhoods do not have large supermarkets and thus residents of these areas can experience difficulties in obtaining fresh produce. In contrast liquor stores are more common in poorer neighborhoods and the “food environment is less diverse”(6, 7). There is also an abundance of high calorie food options through prepackaged and fast food. Ironically the most inexpensive foods and beverages available are often those that nutritionists warn us to consume only in moderation (6, 7). Consequently, many low-income communities have limited access to fresh produce and available produce is of poor quality.

The Five-a-Day did not address the social and community factors that interfere with a healthy lifestyle. In fact, research indicates that when faced with limited financial resources people increase their intake of higher calorie, less nutritious food over healthier items such as fruits and vegetables. (8) This “neglect of the social context of people’s lives’ and simply telling people to say yes to an option they have no control over is doomed to fail. (9)

Even when behavior change is made on an individual level decision, actual control lies in the environment. Two Boston-based studies reinforce this idea. The Boston Medical Center (BMC) and the Brigham and Women’s Hospital in separate projects assessed the cost associated with eating a healthy diet, which was defined as adhering to the recommendations of the American Heart Association and USDA (fruits and veggies included). BMC’s study also examined the feasibility of purchasing these items utilizing a family’s Food Stamps (a marker of low income status) allotment. Although the Thrifty Food Plan (TFP) is considered outdated, it remains the government’s measure of a sound diet and is based on a low-cost model food plan designed by the National Academy of Sciences. By either the healthy diet or TFP measure, the cost exceeds reach - TPF is $27 more per month and purchasing a healthier diet an additional $148 per month. These added costs thus make eating well unrealistic for those in lower-income situations. (10)

The Brigham and Women’s study examined barriers to Black women’s ability to follow nutritional guidelines. The biggest barrier found was cost. (8) In fact the federal government (11) and the Produce for Better Health Foundation (PBH) also reports price and lack of availability as barriers identified by consumers to increase fruit and vegetable consumption. (2) Not surprisingly, the PBH reports that professionals or retired professional and those with higher income (>$70,000/yr) have the highest level of fruit and vegetable intake. (2) The concept of self-efficacy is central to behavior change. Self-efficacy is the belief in being able to execute the behavior required, to produce the required outcome. Possessing adequate resources are by extension essential to self-efficacy in attaining a proper diet. Low-income people face steep barriers to realizing the Five-a-Day recommendations.

As a federally-sponsored program, NIH and CDC were positioned to advocate and support federal changes to eligibility rules, benefit level and simplified enrollment processes for the public nutrition programs such as food stamps, WIC and school lunch program. These were missed opportunities to create environmental level system change addressing important dimensions of behavior change such as moving the level of decision-making and control from the individual to the community level that adequately address environmental influences (12) There was a lack of systems and political analysis or they were discarded. The neglect of social, economic, cultural and other population factors (or socio-economical factors) and to address or not is a political decision. (12)

The campaign failed to account for distinct populations e.g. age (teens), and race/ethnicity, as well as differences in language, literacy, and cultural norms, and consequently did not tailor messages to key at-risk sub-populations.
In evaluations of the Campaign it was recognized there was a “failure to frame” a nutritional message, thus the public was left to grapple with complex and contradictory messages.(1) Questions arose such as what was a serving or portion size, and conflicting scientific research frequently reported in the media only confused matters. For those with low-literacy, these messages are particularly ineffective. The evaluators coined a descriptive phrase for the situation “dietary helplessness”. (1) Given the campaign could not engage the nation’s attention, it was little wonder that more vulnerable sub-populations would be further disenfranchised. Over the course of the campaign, Blacks/African Americans actually reduced consumption of fruit and vegetables.

Krieger stresses an eco-social framework for developing epidemiologic theory that requires situating the social context of such health behaviors if they were to be comprehended, let alone changed. (13) One such example used framing to design an intervention to increase the vegetables and fruit consumption among low-income, middle-aged Black and White women in California. In an ironic play on words, an intervention called “Little by Little” had promising success for replication. (14) Components of the intervention including dietary screening, individual feedback on self-selection modules and personal goal setting and commitment. Utilizing the Stages of Change model there was emphasis on self-sufficiency as demonstrated by creating more realistic milestones. (14) Success would build confidence for further success and maintenance. The intervention stressed personalization and participants also define their own goals allowing for participation and self-sufficiency more conducive to sustained behavior change. On the other hand, Five-a-Day was ineffective in raising self-efficacy by establishing unrealistic expectations for behavior change at the onset.

Another study incorporating promotion of healthy eating (increase in fruit and vegetable intake), tobacco cessation and occupational health made an unusual assumption that occupational status, education level, race and ethnicity were not barriers. (15) Instead measures of socio-economic status were considerations in the intervention design. Moreover, the intervention merged “consideration of health and safety condition as key features of the social-context environment in which workers make behavioral choices” (15) Unlike Five-A-Day that insisted on a generic, one-size-fits-all strategy, these researchers understood their subjects and designed the interventions based on the groups culture and social norms.

Asians and Hispanics and older adults had the highest level of fruit and vegetable consumption of sub-populations at the start of the campaign. (1) However, none of the pilot programs or educational materials targeted these sizable immigrant populations. The lack of cultural and linguistic materials showed a disregard for these potential positive and protective cultural and ethnic influences. Research shows that acculturation have a negative effect and consumption declines as acculturation occurs suggesting that factors aren’t on an individual level but more on a social level.

Lessons Learned
Recently the Centers for Disease Control (CDC) who assumed responsibility for the campaign in 2005 resisted (or ignored) most of the evidence and plowed ahead with the same strategies its predecessor utilized. Five-a-Day was renamed “More Matters”, and the recommended daily fruit and vegetable intake were increased. This may exacerbate the prevalence of “dietary helplessness” experienced in the earlier iteration.

All these efforts may not have been entirely futile. Increased attention and interest in healthy eating has opened the door to more environmental and social policy. As there is no universal cause to explain the lack of eating recommended fruits and vegetables, likewise, there is no one or answer. Given the multi-dimensional aspects of the goals a multi-pronged approach to redress is recommended if not required. (16, 17)

1. National Institutes of Health, National Cancer Institute. Monograph and Evaluation. 5 A Day for Better Health Program. Accessed by web
2. State of the Plate 2005 Study of America’s Consumption of Fruits and Vegetables. Produce for a Better Health Foundation. Accessed by web:
3. Link BG, Phelan J. Social conditions as fundamental causes of disease. Journal of Health and Social Behavior 1995; 35 (extra issue):80-94.
4. Choi K, Yep GA, Kumekawa E. HIV prevention among Asian and Pacific Islander men who have sex with men: a critical review of theoretical models and directions for future research. AIDS Education and Prevention 1998; 10 (Supplement A); 19-30.
5. The Massachusetts Health Policy Forum Overweight and Obesity in Massachusetts: Epidemic, Hype or Policy Opportunity? Issue Brief. No.30. 2007
6. Baker EA, Schootman M, Barnidge E, Kelly C. The role of race and poverty in access to foods that enable individuals to adhere to dietary guidelines. Prev Chronic Dis [serial online] 2006 Jul [date cited]. Available from: URL:
7. Moreland K, Wing S, Dietz Roux A, Poole C. Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine. 2002; 8(2):141-145.
8. Johnson P, Wilson R, Fulp R, et al. The Healthy Heart Initiative: Barriers to Eating a Heart Healthy Diet in a Low Income African American Community. A Special Report. Brigham and Women’s Hospital Connors Center for Women’s Health and Gender Biology.
9. Siegel M. The importance of formative research in public health campaigns: an example from the area of HIV prevention among gay men (Appendix 3-A), pg 66-69. In: Seil M, Doner L. Marketing Public Health: Strategies to Promote Social Change. Sudbury, MA: Jones and Barlett Publishers.
10. Neault N, Cook JT, Morris v, Frank DA. The Real Cost of a Healthy Diet: Healthful Foods Are Out Of Reach for Low-Income Families in Boston, Massachusetts. Report published 2005 by Boston Medical Center Department of Pediatrics.
11. Guthrie JF. Understanding Fruit and Vegetable Choices Economic and Behavioral Influences. United States Department of Agriculture. Agriculture Information Bulletin Number 792-1. October 2004. http://www.ers.usda/gov/AmberWaves/April05/Features/FruitAndVegChoices.htm
12. Pearce N. Traditional epidemiology, modern epidemiology, and public health. American Journal of Public Health 1996; 86:678-683.
13. Krieger N. Epidemiology and the web of causation: has anyone seen the spider? Social Sciences & Medicine 1994; 39:887-903.
14. Block, G, Wakimote P, Metz, D, et al. A Randomized Trial of the Little by Little CD-ROM: Demonstrated Effectiveness in Increasing Fruit and Vegetable Intake in a Low-Income Population. Preventing Chronic Disease 2004; 1:3: 1-12.
15. Sorensen G. Barbeau E. Stoddard AM. Hunt MK. Kaphingst K. Wallace L. Promoting behavior change among working-class, multiethnic workers: results of the healthy directions--small business study. American Journal of Public Health. 95(8):1389-95, 2005 Aug.
16. Department of Health and Human Services Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report. March 16, 2007. Vol 56 No 10.
17. Pomerleau J, Lock K, Knai C, McKee M. Interventions Designed to Increase Adult Fruit and Vegetable Intake Can Be Effective: A Systemic Review of the Literature. The Journal of Nutrition. 135:2486-2495, 2005.

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