Challenging Dogma - Fall 2009

Sunday, December 13, 2009

“5- A – Day” Intervention Program Targeting Obesity in the African- African Population in the Southern states of USA-Asween Marco

“Eat 5 servings of fruits and vegetables a day”. This slogan was born out of a private- public nutrition education initiative partnership between the National Cancer Institute (NCI) and the Produce for Better Health Foundation in 1991 [1].The purpose of this partnership was to increase the consumption of fruits and vegetables in the people living in United States. The target of the organizers was that by 2010, 75% of Americans would eat at least 5 servings of fruit and vegetables in a day [2]. Studies have found an association between higher intakes of fruits and vegetables and lower risks of cardiovascular disease [3], reduced risks of many cancers [1], and reduced risk of obesity [4].
Obesity can be defined having a Body Mass Index (BMI) greater than 30.[5] Results from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) indicate that an estimated 32.7 percent of U.S. population, 20 years and older is overweight, 34.3 percent is obese and 5.9 percent is extremely obese[5]. These growing numbers of obese individuals are also susceptible to a wide variety of diseases like hypertension and diabetes which are known to be greatly affected by dietary influences. The Southern states of USA have the maximum number of obese people. In 2000, the highest obesity levels for men were found in Texas (31%) and Mississippi (30%). For women, Texas (37%), Louisiana (37%), Mississippi (37%), District of Columbia (37%), Alabama (37%) and South Carolina (36%) led the pack [6].African Americans constituted 56% of these obese individuals in the Southern States [6].


Lack of access to cheap fruits and vegetables:
It is an easier option on the pocket to pick up cheap, ready- to- eat foodstuffs rather than fresh fruits and vegetables. The CDC has been working in close association with supermarkets to increase the popularity of the campaign. However, a major factor which has not been addressed by the CDC is the availability and presence of cheap, wholesale supermarkets in lower SES areas [7]. Several studies investigating the association between socioeconomic status and fruit and vegetable intake reported higher consumption of fruit and vegetables among people of higher socioeconomic status [8-11] .These studies however only used individual level measures of socioeconomic status and thus may not have captured the potential influence of the area where the people live. Evidence also supports the fact the more the number of supermarkets in a neighborhood, the healthier is the diet of the residents.[12] However the number of supermarkets reported in higher income neighborhoods as compared to their availability in low-income neighborhoods is two – four times [13]. There are also studies done which clearly indicate a heavy concentration of fast food and other unhealthy food options in lower SES areas [14]. There is also a documented evidence of higher concentration of fast food restaurants in predominantly African-American neighborhoods. [15]

Lack of knowledge about food labels:
The CDC has laid emphasis on eating at least 5 servings of fruits and vegetables in its campaign [1]. However, it includes canned food products also in this list in an effort to make people believe that five servings is not a difficult goal to achieve. Promotion of canned products without taking into account all the other harmful additives like preservatives, high sodium content, flavoring agents, coloring agents, defeats the whole purpose of the campaign. Without any knowledge about what could be the harmful implications of these additives, the whole point of the campaign is lost. Also, these food items have high calorific content and huge servings which tend to encourage their use as it seems to make them more economically viable.
It is generally believed that fresh food is better than the frozen food provided it has not been over cooked and has its nutrient content intact [16]. However, the general population would always prefer the canned option as that is quicker and more convenient. But canned foods contain higher percentage of added salts and sugars. In fact, most dietary salt or sodium is added to foods during processing or preparation with smaller amounts being added to food by the consumer.[17,18] Meanwhile, frozen foods require a lot of additives (for example: Emulsifiers and binders present in desserts) [16]. Also, food processed a year or more before being consumed cannot have the same nutritious value as fresh produce.
Each nutrition label on canned or processed foods provides a lot of factual information and variables which is difficult for a consumer to understand in a glance. Also lack of ability to do math and read the information aggravates the problem.
A specific phenomenon was demonstrated by Rothman et al [19] in his study. He divided education factors into two: Literacy and Numeracy. Literacy was a measure of the subjects’ ability to read while Numeracy was measure of his basic mathematical abilities.He found that sometimes even people who had a high level of education experienced problems doing basic mathematical calculations. Thus they were at a disadvantage of deciphering what the nutritional labels on processed foods said. He concluded by saying that currently the numeracy and literacy skills of the public are not adequate to understanding the labels due to a lack of education [19]. Even if emphasis was laid on policy and regulation, this would remain a big hindrance. Newer ways need to be developed for organizing such information.


Campaign unable to address cultural differences in communities:
The 5 a day campaign is run on the “one-size fits all” theory. It does not take into account the social factors which could be the factor deciding the success or failure of this campaign. This could explain the lack of success of this campaign in specific communities. Some communities like Haitians focus on a high carbohydrate diet and there is no importance given to dietary intake of fruits and vegetables [20]. In the southern states, especially in Texas, the chief crop being grown is corn. Fruit and vegetable consumption here is not as high due to more emphasis being placed on a high carbohydrate diet. African American community-in the southern states as elsewhere, are known to have diets rich in fat content. Their staple diet, which is typical of African American culture is “soul-food” [21] which consists of combination of the following: grits, ham or bacon, homemade biscuits, country-smothered steak or pork-chops ,fresh milk and eggs, fried chicken A lot of emphasis is laid on fried foods even though their nutrition content is low. When low physical activity is combined with a diet of fried “soul food”, it results in a high rate of obesity especially in this ethnic group.
This data on communities and their link with individual eating habits proves the failure of the health belief model and the other individual level models like the transtheoretical model used to describe it [22]. Human behavior is not rational but predictable irrational [23].However, the five a day campaign goes against this basic principle. The health belief model[24] is an individual level model which works on the belief that once an individual knows what it is that is harmful or useful for them, they make informed choices based on that. Everyone knows fruits and green vegetables are good for health. It is drummed into us since we are kids by our mothers that eating that green leafy vegetables would make us big and strong. However, this message gets lost along the way someplace and does not remain a consideration when we are buying groceries. The CDC has been marketing the 5 a day campaign in a way that it believes in the individual role that knowledge and perceptions play in personal responsibility. They have taken for granted that once people are told that fruits and vegetables are good for them, they would definitely eat them .However, planned intention is not what always makes a person act the way they do. The primary focus of the CDC campaign has been promoting the belief in “health” which has been proven not to work in a community based program like the five a day program.

In the 15 years of its existence, the “5 a day campaign” proved to be a failure. However, the incentives of eating fresh fruits and vegetables cannot be ignored. Community gardening is one of the effective ways of growing them in a convenient and economical way. According to the American Gardening Association, a Community Garden [25]can be defined as “Any piece of land gardened by a group of people”. It usually refers to growing of fruits and vegetables in urban settings and hence complements the aim of the 5 a day campaign. Mark Francis, a professor at the University of California at Davis (and past Board member of the ACGA) has done numerous studies [25] of the community benefits and perceptions of parks and gardens. He found that the gardens which are built and maintained by the community residents have “unique social and economic benefits.” He further elaborates in his statement by saying that “The spaces provide opportunities for neighborhood residents to develop and control part of their neighborhood, an advantage not afforded by traditional parks”. This he noted from a 1987 study of park and garden users in Sacramento, California.
Community gardening also helps us address the failure of 5 a day campaign with support of the social learning theory. SLT states that an individual’s behavior depends on his/her expectation of health outcomes and his/her perspective of self-efficacy. Growing fruits and vegetables in your own local community helps overcome the problem of self – efficacy.
Promotion of community gardening can also be supported by the advertising theory [33]. A campaign promising attractive body can be initiated along with 5 a day campaign. The advertising campaign can also work on the principle of “substitution”-that is substituting the heavier and unhealthy component of Soul food with a healthier food component. This is known to work better than disregarding their cultural tradition of cooking food and expect them to suddenly adopt a newer, different cooking habit. Also community gardening can provide financial independence to individuals in lower income group by selling extra fruits and vegetables in local farmers market [27].

Defense 1:
Lack of access to fresh food and vegetables is one of the key issues which made 5 – a day campaign a failure. A lot of changes in policy as well as marketing strategy need to be implemented to correct this problem. There can be incentives or subsidies like cheaper land or lesser tax given to supermarkets if they open their stores in low income neighborhoods. People can be informed of the existence of farmers produce markets which are close to their area of residence.
An innovative and simpler approach to tackle the problem of lack of access would be to promote community gardening. These community gardens are then a convenient source of fresh fruits and vegetable to local people at significantly lower cost.
These three ways can help in making cheaper fruits and vegetables accessible to a wider number of people.

Defense 2:
The campaign should not include canned foods. If they are being included, to prevent misinformation and canned foods being given precedence over the fresh variety, people need to be informed about how to balance the two. The community farming venture would be encouraging weekly lunches where people would get together to maintain the garden and meet each other. Over these weekly lunches, recipes could be exchanged. Competitions could be held and the tastiest recipe involving the maximum amount of fresh fruits and vegetables would win. The members of the community would be given information via pamphlets or printouts of what to avoid and how to read food labels more carefully before buying them. These pamphlets would also be distributed to nearby grocery stores, supermarkets and shopping areas. They can be put up in prominent areas for easy visibility. Other than providing basic information in these pamphlets, information can also be provided about online resources available which can make food labels easily comprehensible to the consumer. Based on the 2005 Dietary Guidelines [35] for Americans recommendations, the FDA has made available an easily downloadable “Nutrition Facts Label” brochure (PDF, 350Kb) on its website. The brochure is useful for both consumers and health professionals. For consumers, it provides a step –by –step guide on how to read the nutrition facts label and use it to shop and plan their meals each day. Health professionals can use it to counsel their patients on healthy eating. Thus, by making food labels easy to understand, consumers can make informed food choices which can contribute to life-long healthy eating habits. Supermarkets should be encouraged to stock lower calorific content and reasonable servings of food items in order to achieve a balance between calorific and nutritional content of food items.

Defense 3:
The 5 a day campaign needs to take into account cultural factors. No individual can take a decision alone without taking into account cultural factors like race along with individual factors. The five a day work could be a success if we implement group level models to make it work. Community gardening provides an opportunity for an individual to be in a group level setting where he is interacting with not just people of his own ethnicity or racial group but with a diverse population of different ethnicities. This encourages interaction between them when they are performing a task like gardening [25]. Using the concept of ‘herd behavior’, we are better able to appreciate how such an interaction can bring about desired behavioral change. [27]Community gardening would increase interaction between African Americans and the other communities in their neighborhood. Research by Jill Roper, a graduate student at Rutgers University, confirms the theory that community gardens improve the interaction between people in the neighborhood. As Charles Lewis says: “A community activity such as gardening can be used to break the isolation, creating a sense of neighborliness among residents. Until this happens, there is no community, but rather separate people who happen to live in the same place.” [31]It would allow them to learn and appreciate the differences in their diet and that of people around them. Sharing of recipes also would encourage them to appreciate the varied cultures and tastes. It would also allow them to appreciate that food can be tasty even without frying it.
Low physical exercise is also a factor compounding the problem of unhealthy diet in this community. This can also be tackled when we consider that gardening is a great form of exercise [31] while interacting with new people.

The five – a – day campaign was a much hyped public health venture which has failed drastically. There are various reasons for it failure. They organizers not taking into account cultural and economic differences between various sections of the population is an important reason. Also, basing a community based intervention program on an individual level model like the Health Belief Model does not help the case either. Lack of information about ways to comprehend food labels further aggravates the problem. Till the time these factors are taken into account for designing an intervention program like community gardening, and basing the campaign on theories like the advertising theory, social learning theory and the social marketing theory can help in effectively tackling a problem like obesity .

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