Challenging Dogma - Fall 2008

Thursday, December 18, 2008

5 A Day Campaign: Are We Really Addicted To Bad Eating? - Jessica Spiegel

Eating a diet full of fruits and vegetables will promote good health and will help to protect individuals from chronic diseases such as heart disease, diabetes and some cancers (22). In an effort to encourage individuals around the world to increase their fruit and vegetable intake, the National Caner Institute and the Produce for a Better Health Foundation formed a coalition and developed the ‘5 a Day’ campaign . It quickly became the largest partnership for nutrition and, in 2005, the Centers for Disease Control became the national healthy authority on the ‘5 a Day’ program (22). The ‘5 a Day’ campaign uses media as well as educational programming to promote eating five servings of both fruits and vegetables daily in order to improve health status. In March 2007, the ‘5 a Day’ campaign launched a new initiative called ‘More Matters’ to try to encourage even greater improvements in healthy eating. The previous dietary guidelines recommended eating 5 to 9 servings of fruits and vegetables every day. The new ‘More Matters’ guidelines recommend 2 to 6.5 cups of fruits and vegetables a day which is the equivalent of 4 to 13 servings. The ‘5 a Day’ campaign has been emphasized in schools through teachers and in school cafeterias. Teachers in primary schools encourage students to eat as many servings of fruits and vegetables as they possibly can and cafeterias try to accommodate these new guidelines by offering more of the ‘healthy’ options for the students to choose (7). There has also been a big push in lower income areas to try to encourage families to choose fruits and salads over the other fast food options (7)
The development of the ‘5 a Day’ program can be contributed to the Health Belief Model of health behavior change. The Health Belief Model is the most widely used theory of health behavior. The basis of the Health Belief Model has two parts, ‘Perceived Benefits’ and ‘Perceived Barriers’. Two components are involved in the “Perceived Benefits’ of a health behavior. One component is the individual’s ‘Perceived Susceptibility’ to the disease that would be inevitable if they do not change their behavior. It is formally defined as “the degree to which the person feels at risk for a health problem” (4). The other contributing component to an individual’s ‘Perceived Benefits’ is the ‘Perceived Severity of the Disease’. This can be described as the degree to which a person believes the disease they will develop will be detrimental to their life. The ‘Perceived Benefits’ of making a change to a health behavior weighed against the Barriers to making that change determines the individuals intent to act. In the Health Belief Model a person’s intent to act directly precedes a person’s behavior. According to the Heath Belief Model, individuals plan to act in a certain way and, as a result, they behave in the way they planned (4). The ‘5 a Day’ campaign used the outline of the Health Belief model as a way to encourage individuals to increase their healthy food consumption. The ‘5 a Day’ plan appeals to a person’s perceived susceptibility by using the media to convey the image that ‘if you do not eat the recommended amount of vegetables you are at an increased risk for heart disease and obesity’. The media also conveys the severity of heart disease, cerebriovascular disease and obesity by defining these issues as the leading causes of death in the United States (23). According to the Health Belief Model these educational aspects of the ‘5 a Day’ campaign should be enough to encourage all individuals to increase the number of servings of fruits and vegetables they eat. Unfortunately there are many weaknesses to the Health Belief Model and to the ‘5 a Day’ program that prevent the campaign from revolutionizing the eating habits of the population.
Self Efficacy: Can I really eat that many vegetables?
The ‘5 a Day’ campaign encourages all individuals to eat five servings of each fruits and vegetables a day. Current data suggests that the average adult eats fewer than three servings of fruits and vegetables a day. The data also illustrates that 42 percent of the population eats fewer than two servings of vegetables daily (3).Asking people to eat two or three more servings of healthy foods a day may seem unattainable to a vast majority of the population. Most people think that it’s completely impossible to reach the goal of five servings a day. A majority of the ‘5 a Day’ campaign is targeted towards youths, whom have very little control over the food they eat. If the food these kids are given does not coincide with the guidelines of the campaign, these kids may begin to believe that it is impossible for them to eat a healthy diet. If they believe this, when they can make their own food and diet decisions they will continue to make poor choices because they already assume that they aren’t capable of eating five servings of fruits and vegetables. The ‘5 a Day’ campaign is also targeted toward lower socio-economic groups who do not have ideal eating patterns. In these groups, fresh fruits and vegetables are not accessible due to their high prices and their availability. Although many families may understand that healthy eating is important, they may not have the tools necessary to achieve the goals set by the ‘5 a Day’ campaign. In terms of the ‘5 a Day’ campaign; individuals have a very low self efficacy. Self efficacy is a belief held by an individual that they are capable of performing in a certain manner or of achieving a set goal (16). The Social Learning Theory developed by Bandura, tells us that a persons decision to change behavior is dependant on the persons expectations of the outcomes of the behavior change and their self efficacy in the situation (2). The ‘5 a Day’ campaign fails to address this concept of self efficacy. If an individual feels that they are not capable of reaching a goal they will be discouraged from pursuing the behavior change at all (16). If the ‘5 a Day’ campaign had simply encouraged people to increase their fruits and vegetable consumptions they may have been more successful. By not specifying a specific serving goal that individuals need to reach, people will feel more capable of achieving the program goal. Research supports this idea, and confirms that if people have an increased sense of self efficacy they will increase the number of fruits and vegetables they consume daily (16). Therefore, in order for a campaign to successfully encourage individuals to eat more healthy foods, the program needs to support the population’s perception of self efficacy for the behavior change.
Culturally Fruits & Vegetables are not satisfying
A large focus of the ‘5 a Day’ campaign was in lower socio-economic, urban areas (11). These regions of focus have a very different cultural diversity then the rest of the country. For example, in Bronx, New York the demographics consist of 36% African Americans and 48% Hispanics. Over 50% of the population in the Bronx over the age of five does not speak English as their native language (12). In an area with a demographic diversity such as the Bronx, we can conclude that their poor diet habits are directly linked to their varying culture. Individuals that are from other nations have vastly different beliefs on what types of food are important. The typical diet of a native Caribbean consists of stewed, fried vegetables, and processed meats and fishes (26). African Americans also have very culturally based diets. Chitterlings is one of the foods that African Americans typically eat as well as fried chicken and items high in oil and butter (5).The ‘5 a Day’ campaign that was integrated into these communities through media, billboards and educational agendas, failed to address the fact that diet is very closely related to culture. People from many different nationalities do not weigh the importance of healthy eating decisions against the decision to eat their culturally designed diets. By failing to acknowledge the different cultural determinants of diet, the ‘5 a Day’ program failed to convert many to more healthy foods. If the campaign had provided culturally diverse areas, such as the Bronx, with recipes that are a healthier version of their culturally desired foods, there may have been more people that made the choice to eat more fruits and vegetables. This would also show individuals that it is possible to eat foods that they enjoy while also incorporating more fruits and vegetables into their diet.
It is also possible that adults, who were not educated in the United States, do not know the importance of eating a healthy diet rich in fresh vegetables. The native countries of most of the immigrants seen in the lower socio-economic areas are developing nations that do not have the resources available to promote healthy eating patterns. Instead these countries simply promote eating for calories. When these cultures come to America and see the ‘5 a Day’ campaign they may not be excited to change their eating habits because they do not understand its importance. The ‘5 a Day’ program failed to incorporate an educational facet for adults and for individuals who are not native English speakers. While the media did express the susceptibility of individuals who do not eat a healthy diet, those who need to hear these facts do not have access to news in a language they comprehend. Also, the educational aspects of the current ‘5 a Day’ campaign are focused on school aged children and not adults; neglecting to take into account that it’s the adults who ultimately make the household food decisions. A program such as the ‘5 a Day’ needs to address a lack of knowledge in these areas before suggesting that people increase their fruit and vegetable consumption. If the ‘5 a Day’ campaign incorporated an adult education campaign in multiple language there would be an increase in the number of people eating five fruits and vegetables a day.
Ronald McDonald vs. Apples & Oranges
In the lower socioeconomic areas that the ‘5 a Day’ campaign emphasized, financing five servings of fruits and vegetables a day for an entire family is a serious setback. In low socio-economic areas, such as the Bronx, the median household income was around $27,551 (15). People living in poorer areas have less dispensable income and can spend far less money on food then people living in wealthier areas. The monetary constraints on these families competes with the dietary guidelines sent out by the ‘5 a Day’ program. Many families have to choose between paying their rent and buying ‘healthy’ foods. In this situation almost everyone can agree that paying for rent is a higher priority then buying fruits and vegetables. Based on prices found at a Shaws supermarket, two heads of lettuce which would be enough to feed a family of four one meal cost around $6.00.This, of course, is not enough food for one meal and additional items need to be incorporated. Tomatoes cost an additional $3.50, Bell Peppers cost $3.39 a pound and Broccoli costs $4.00 a head. A meal that incorporates these four servings of vegetables for a family of four would cost upwards of $21.00 per family just for the salad. A meal at McDonalds which includes a hamburger, french fries and a beverage costs around $5.00 for each meal. For a family of four, a full meal can cost around $20.00.
Another reason why individuals in poorer communities find it difficult to get five servings of vegetables a day is because mothers cannot afford the time to go to the local store on a regular basis and buy fresh fruits and vegetables. Unfortunately, fresh foods have a short lifespan and spoil quickly. Because of this, keeping fruits and vegetable around requires a commitment to go to the food store once or twice a week. In these poorer neighborhoods mothers who work multiple jobs and are overwhelmed with responsibilities cannot set time aside to go to the store. Instead they keep frozen and canned foods on hand or rely on fast food to go.
A third barrier to healthy eating in poorer neighborhoods is the availability of fresh fruits and vegetables in the local bodegas. Because many people in these communities do not purchase the healthier foods options it is economically impractical for store owners to stock the items in their stores. As a result, even if someone wanted to purchase fruits and vegetables they are unable to do so. The ‘5 a Day’ campaign fails to recognize the economic barriers to consuming fruits and vegetables in lower socio-economic areas. Therefore, it is unrealistic to expect people to change their diets to incorporate a healthier option since it requires extra funds
What’s a better way to get your ‘5 a Day’?
The ‘5 a Day’ campaign fails to address some of the major forces that encourage health behavior change. By labeling the recommended daily serving of fruits and vegetables as five servings of each, the program is setting people up for failure. Currently the average adult consumes around 3 servings of fruits and/ or vegetables daily. Asking them to increase their intake so drastically seems impossible to most. Thus, the self efficacy relating to this campaign is very low and as a result very few individuals will make the healthy decision to follow the ‘5 a Day’ plan. The campaign also fails to incorporate the cultural basis of diets into their program. If the program advertised ways to change recipes for traditional foods to include more fresh vegetables, there would be more people eating healthy. The biggest failure of the ‘5 a Day’ campaign is the avoidance of the economic basis behind people’s diet choices. Because many people cannot afford these healthier food items, and they are not widely available in many poorer neighborhoods, few people make the necessary changes to their diets. If the ‘5 a Day’ campaign wants to improve their success rate they will first need to take the number 5 out of their program. If we do not make the goal of healthier eating seem unattainable, more individuals will modify their diets to include more of the fruits and vegetables. Also, if the ‘5 a Day’ campaign begins to addresses the cultural basis behind diets as well as the economic factors that act as barrier to healthier eating, there will be an increase in fruit and vegetable consumption. In order for a healthy eating program to be as successful as possible, it needs to address the barriers to diet change that are ignored by the “5 a Day” campaign. A possible solution to the failure of the “5 a Day” program is an intervention called “Grassroots Fruits & Vegetables”. This intervention is a three pronged approach to encourage healthier eating habits among the population.
“Grassroots Fruits & Vegetables”
More a Day the Fun Way
The first component to the Grassroots campaign involves taking over the current “5 a Day” program and changing its name to the “More a Day” program. By removing the five from the title, the campaign simply encourages individuals to eat more fruits and vegetables a day. The “More a Day” doesn’t set a very high goal for consumption, and as a result, it will not challenge self efficacy. Eating even just one more fruit or vegetable is not an overwhelming task and thus people will be more inclined to attempt to eat healthier (18). Studies have shown that self efficacy is a very strong predictor of the degree of behavior change that will result (2). This further supports the idea that if the “More a Day” campaign improves people’s self efficacy in healthy eating, we will see a greater number of individuals making the behavior change to increased vegetable consumption. Changing the campaign title to “More a Day” will also allow the Health Belief Model basis of the program to have a greater impact on the programs success. Without the factor of individual’s self efficacy, the program will lead individuals towards weighing the benefits of healthy eating against the barriers to doing so. They can then make an informed decision about their healthy eating behavior. By increasing self efficacy, the overall barriers to healthy eating are few for most individuals. The benefits of increased fruits and vegetable consumption include the severity of the disease that will result if the behavior is not changed, as well as the person’s susceptibility to the resulting illness. The focus of the “More a Day” program is to prevent obesity and obesity related illnesses such as heart disease, stroke, and some cancers. These illnesses are currently some of the leading causes of death in the United States (23). With the media presenting the severity of obesity-related illnesses daily, the susceptibility and severity of the resulting diseases are very clear. Under the “More a Day’ campaign the benefits of healthy eating appear to outweigh the barriers. According to the Health Belief Model, this will result in more individuals incorporating more fruits and vegetables into their current diets (4).
Learn to Love Your Fruits & Vegetables
The second facet of the “Grassroots Fruits & Vegetables” campaign is the educational component of the project. One of the problems with the “5 a Day” program was that it wasn’t culturally sensitive. Diet and food choice are very closely related to cultural and traditional beliefs (5). One of the proposed reasons why the “5 a Day” campaign has not been successful is because it does not show people how to incorporate fresh fruits and vegetables into their everyday diets without having to completely change their every day cultural ties. The ‘Grassroots Fruits & Vegetables’ program will go into very culturally diverse areas where many immigrants live and will offer free cooking classes that focus on how to take traditional dishes and use more vegetables and less fat. There will be a class offered for each different culture including Caribbean natives, African Americans who cook in a traditionally southern manner, and Hispanics Americans. Currently a program in Louisiana is attempting to encourage the same sort of behavior. “Stay Healthy Louisiana” is a program developed by the Louisiana Public Health Institution that encourages smoking cessation and health eating. On their website they have a section that lists the recipes for healthier versions of traditional southern foods such as cornbread, fried fish and chicken, and collard greens. They hope that by publicizing that it is possible to make healthier versions of the foods you enjoy, more people will change their diet (25). Under the “Grassroots Fruits & Vegetables” program there will also be a website that contains recipes for healthy versions of foods from all cultures and nationalities. However, under the grassroots program there will also be available a cookbook of all of these recipes that will be held in libraries and in food stores including local corner stores and bodegas. The cookbook will be free to eliminate any economic barrier to this part of the program. Making the health conscious recipes available will make it easier for more families to alter their diets to include more fruits and vegetables.
A Market for Healthy Eating
The third and most important component of the “Grassroots Fruits & Vegetables” campaign is the economics facet. One of the biggest barriers to healthy eating is the availability of fresh fruits and vegetables in local stores at a reasonable price (10). The economic part of the grassroots campaign hopes to combat this barrier through a three step process. The first part of this component will be to go to local corner stores and bodegas in lower socioeconomic areas and convince the store owners of the importance of carrying fresh produce for their patrons. As an incentive to the store owners we will offer them a subsidy to cover the initial costs of carrying these foods such as costs for displays and proper refrigeration units. We will also provide them with a subsidy so that they can keep the prices of the produce low. If fruits and vegetables are readily available in these areas for an equal or lesser price than unhealthy foods, it is more likely that people will make the change to fresh fruits and vegetables. This step of the economics project will also address the time commitment barrier to healthier eating. Having fresh produce readily available in local corner stores requires less of a time commitment to purchase vegetables on the way home each day. The second step of the economics component to the Grassroots campaign is Farmers Markets. By encouraging local farmers to sell their produce in these poorer neighborhoods you will be able to sell the vegetables for less than you would have to if they had been shipped form other parts of the country or world. Typically programs of this nature are run by the government and are, therefore, able to bypass typical food distribution policies to work directly with farmers (6). The aim of our farmers markets will be to get the local community involved in the health food market. This way they will be able to create a ‘local food system’ and local food economy that these people can continue to use after our intervention period is over (6). The third step of the economic component to the grassroots campaign is banning fast foods in poorer communities. This appears to be an unrealistic idea, however many public health organizations have been able to get restrictions on future fast food chains entering poorer areas (24). This restriction means that there will not be a saturated fast food market in these neighborhoods giving residents more freedom to choose from healthier options. The fewer fast food restaurants available the less chances people will consume fast food on a daily basis. Hopefully, they will consume increased healthier options that, at this point, are readily available to them (24). This step of the economics program is based off of the Social Learning Theory. People are influenced to make healthy decisions based on their environment, and their outcome expectancy (14). If they see fewer fast food restaurants, they will assume that there is a smaller demand for fast food in their neighborhood and they will be influenced to stay out of the fast food restaurants. All three steps coordinated together will help to combat the current economic barriers to healthy eating in lower socioeconomic communities.
The current “5 a Day” campaign for healthier eating has proven to be unsuccessful in really impacting the eating behaviors in the United States. It is really important that we have an appropriate public health intervention that works to encourage more fruits and vegetables and fewer fats. Obesity is a serious concern of today’s society because it increases a person’s risk of heart disease, diabetes, stroke and some cancer which are currently the leading causes of death. A campaign that would target obesity through changing eating habits would also be reducing the health risks of the population. The “Grassroots Fruits & Vegetables” campaign is an improvement to the current “5 a Day” program. It takes over the current program and changes its tagline to “More a Day” which will improve self efficacy in healthy eating decisions. As a result, more people will increase their fruits and vegetable consumption. The “Grassroots Fruits & Vegetables” program will also reach out the cultural diverse areas and encourage them to incorporate more fresh produce into the traditional meals through cooking lessons and free cookbooks. The most important improvement that the Grassroots campaign makes is in its economics component. By offering subsidies to local corner stores and bodegas, the program will make fresh fruits and vegetables accessible to poorer communities. Farmer’s markets in these neighborhoods will permit fresh produce to be sold at a remarkably low price as well. It will also create a community and local economy based on the market which will allow the healthy eating to continue long after our intervention. The “ Grassroots Fruits and Vegetables” campaign is merely just an addition to the current “ 5 a Day’ campaign for healthier eating, but the few changes to the program address some of the major barrier to health eating that the initial program failed to recognize. Through increased self efficacy, cultural sensitivity and economic considerations, the “ Grassroots Fruits and vegetables” programs hopes to have a deep impact on the food choices of the population as well as on the obesity epidemic that is currently the leading cause of death among our residents.

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