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More Matters And The Need For Supporting Research

In some ways Elizabeth Pivonka has the most thankless job in produce. The President and CEO of the Produce for Better Health Foundation, which ran the 5-a-Day program and now runs the Fruits & Veggies — More Matters effort, has the amorphous task of increasing produce consumption in the service of good health with a budget any marketer at Coke or Pepsi would laugh at.

She is battered from all sides. Some want her to be more scientific; others more promotional. She certainly is very busy, so we very much appreciate her taking the time to help enrich our industry conversation by responding to not one, not two, not three…but to five separate Pundit articles:

I can empathize with your Let’s Get Fat Together comment: “Here at the Pundit, we are having trouble keeping up with the volume of ridiculous research we are sent every day. Actually the research is not ridiculous, but the over-the-top claims made by the researchers often are ridiculous.”

Research certainly has to be taken in context. Unfortunately it’s the “study of the day” mentality consumers read about that creates confusion about what to eat! While each individual study may be interesting, it is the cumulative body of evidence that is most important; otherwise we’d be changing course every two seconds.

That said, PBH and Fruits & Veggies — More Matters and our core messages are in sync with scientific evidence today, and the strength of the science is such that Fruits & Veggies — More Matters will still be relevant tomorrow. Neither the Centers for Disease Control & Prevention, our lead federal partner in Fruits & Veggies — More Matters, nor PBH follow the latest fad… we watch the accumulation of scientific evidence, which evolves over years, not days.

That scientific evidence supports eating more fruits and vegetables for a variety of reasons. Fruits & Veggies — More Matters was not developed specifically as an anti-obesity message, as might be implied from your More Matters — Not When Counting Calories comments. Fruits and vegetables play an important role in preventing many diseases, of which obesity is only one. These diseases include coronary heart disease, stroke, diabetes, and certain types of cancer. (By the way, over the past decade the research between fruits and vegetables and cardiovascular disease is getting stronger and the cancer research a bit less so, Breast Cancer Study Shows No Improvement With Increased Produce Consumption. For example, the role of fruits and vegetables and reduced risk of breast cancer — let alone breast cancer reoccurrence in this most recent study — isn’t as strong as the link between fruits/vegetables and other cancers, including esophageal, lung, and stomach.)

Current science suggests that 100% juice is protective to health too, although certainly we wouldn’t want all servings of fruits and vegetables to be in liquid form. A brand can’t, all by itself, contain a two-page long disclaimer about all possible misuses of its product. Toyota doesn’t say “improper operation may cause death” as part of its brand identity or, more to the point, “Got Milk” doesn’t say that you can “drown in a bathtub full of the stuff.”

Likewise, we’re not going to say, “Fruits & Veggies — More Matters” but “limit intake of juice, limit high fat dressing on your salads, don’t fry your veggies.” We’ll address these specifics as appropriate on our web site, in our materials, or in “ask the expert” questions under the auspices of “education.”

Speaking of education, in your earlier Nutrition Education Doesn’t Work Says Associated Press Review of Literature comments, it’s important to point out that this review of the literature was not peer reviewed, published, or otherwise made available for our own assessment. I wonder, for example, if they looked at research supporting the successful nutrition education component of the WIC program.

Even how “nutrition education” is defined makes a difference. (It’s difficult to eat a mango, a kiwi, or even an orange if you don’t know how to cut it up… that’s all part of nutrition education.) Regardless, most don’t believe that nutrition education alone is going to change behavior, but it’s an important step. Case in point, social support, as you mentioned in Let’s Get Fat Together, is also important in changing behavior, along with availability, taste, price, promotions, convenience, and more.

Finally, in response to your cry for program evaluation in Evaluating Effectiveness in Childhood Eating Studies, evaluation is a very important part of what we do. In fact, NCI spent $16 million testing the impact of interventions in schools, WIC, farmers’ markets, and worksites. Frankly the end result from all of this research is that if you promote fruits and vegetables, consumption goes up.

It’s not rocket science. Would more research be helpful? Sure. Should we continue to build the case for greater government support? Absolutely. Are we doing more research? Constantly. Meanwhile, we are going to continue to do what we know is effective (education and encouraging industry promotions) specifically targeting “Gen X moms” and measuring success with her (and her family.)

Ok, so PBH doesn’t have the advertising dollars that we need. That’s why we rely on the collective industry (retailers, growers, processors), public relations, educators, our consumer website, and our public health partners to help get our Fruits & Veggies — More Matters message to consumers — a message that nearly 2/3 of the 1,000 consumers surveyed said would increase their interest in eating more fruits and vegetables either extremely well or very well just by seeing the brand logo itself.

For every $1 million we spend at PBH, we can leverage about $30 million from the industry and our public health partners combined. That’s more than $150 million each year, focused on a single message! And these are efforts that, in many cases, don’t cost a lot of additional money. Placing the Fruits & Veggies — More Matters brand logo on packaging, on supermarket role bags, or on tray liners that are already being printed provides this collective advertising in support of increased fruit and vegetable consumption with very little financial pain! By leveraging the industry’s investment we can have a significant impact.

Most definitely, More Matters Can Be a Rallying Cry for the Industry, and we encourage everybody to join us!

— Elizabeth Pivonka, Ph.D., R.D.
President & CEO
Produce for Better Health Foundation
Wilmington, Delaware

In ways not widely known, Elizabeth is an industry hero. We here at the Pundit have gotten notes from people upset with Elizabeth because PBH isn’t doing some kind of promotion that the writers think would be helpful. In almost every case, Elizabeth has held back because the science isn’t secure enough on that point. On issues ranging from the usefulness of produce consumption in extending lifespan to the efficacy of a vegetarian diet in curing cancer, she has stood solid, an industry firewall against claims unsupported by good research.

In so doing, she has sustained the alliance with governmental authorities, maintained the credibility of PBH and served well consumers who weren’t misled or given false hope. So we know Elizabeth and the Pundit share the frustration that comes not so much from a study every day purporting to prove, typically based on very little, that one or another produce item can cure this or that, but we share the frustration caused by an unholy alliance of researchers seeking fame, fortune and funding with journalists seeking much the same.

This transforms academic research, which might usefully lead to further research, into a public health problem as consumers are given preliminary and often contradictory information.

So perceiving Elizabeth as very much the bulwark of credibility for the produce industry on this kind of science, we confess it startles us a bit to read her making comparisons with Toyota or the “Got Milk” campaign.

We understand branding well enough, but Toyota and the dairy industry can say whatever they want — those are advertising messages. This would be comparable to the California Strawberry Commission promoting chocolate-dipped strawberries or strawberry short cake. There is no problem, no issue, because it is an ad, and in advertising, a vendor can promote whatever legal attribute of its product it wishes to promote.

However, Fruits & Veggies — More Matters is not solely an ad message… it is a public health message sponsored by a tax-exempt charitable foundation and thus will be held to a higher standard.

We bow to Elizabeth’s scientific expertise and are not so foolish as to start parsing research studies with her. We take, at her word, that the science behind Fruit and Veggies — More Matters is strong.

We will say that the message is unclear, however. We read all the PBH materials and strongly suspect we do so with more interest and motivation than any consumer can be expected to muster. We suspect that the number of consumer media editors who pay more attention is relatively few.

Yet we would like to gain clarification on the Fruits & Veggies — More Matters message:

  1. The logical consequence of saying that it would be desirable to consume “more” fruits and veggies regardless of one’s current level of consumption is that vegetarianism, from a health perspective, is the ideal diet. Is this the position of PBH? What about its government partner, CDC?
  2. The advisory that eating “more” produce is always good seems to imply that a person whose weight is maintained at 2,000 calories a day and whose consumption is currently 2,000 calories a day would benefit by forcing himself, though not hungry, to eat a few produce items before bed. To the Pundit, this sounds like a recipe for obesity. Is this the position of PBH?
  3. Elizabeth makes a point of saying that “…evidence supports eating more fruits and vegetables for a variety of reasons…” and that “Fruits & Veggies — More Matters was not developed specifically as an anti-obesity message.” These are extremely powerful points and have been communicated in a very minimal way. We understand Elizabeth to be saying that, even in studies in which people have not lost weight or changed their body mass index, there is strong science to support that merely eating more fruits and vegetables produces statistically significant health advantages. We wonder what, precisely, these health advantages are? Do the high produce consumers live longer? Live more vibrantly? Get disabled later in life?

    We have come across many studies that will find advantages to some particular element contained within certain produce items, such as folate — which has been found to be important for women who intend to have children, as it may reduce the incidence of spina bifida and anencephaly. But in many cases the advantages can be obtained elsewhere with more certainty, for example, with pre-natal vitamins or fortified grains. In fact the Federal government, effective January 1998, began requiring most grain products to be fortified with folic acid for exactly this reason.

    We are sure that Elizabeth is correct, and every survey we have seen shows that consumers, in some vague way, accept that produce is “healthy,” but we confess that if we were doing a consumer call-in show at the Pundit and a consumer said he consumed 2,000 calories a day of which 800 calories came from produce and said he was thinking of upping that to 1,000 from produce but wanted to see some good science regarding the health benefits he would receive by doing so, we would be hard pressed to know what to send him.

    If the case is as good as Elizabeth explains it is, that should not be the case.

  4. If everyone listened to the Fruits & Veggies — More Matters message, what is the expected public health benefit? An XX% decrease in colon cancer, an XX% decrease in the population with high blood pressure? An XX% increase in life expectancy? We know produce producers and vendors would like to see an increase of produce consumption, but how significant are the benefits for public health?

On broader points we agree with Elizabeth that the Associated Press article on the review of the literature on nutrition education was less rigorous than would be desirable. We have tried to compensate some by publishing much of the author’s source materials as part of our interview with Lorelei DiSogra, Vice President, Nutrition and Health for United Fresh.

Yet we must confess that the interesting thing we find is how often our requests for data are answered with anecdotes. We do appreciate Elizabeth’s suggestions for areas to look for successful outcomes of nutrition education and we promise to pursue each one — so keep one’s eyes peeled for future Pundits.

Although we accept Elizabeth’s explanation that Fruits and Veggies — More Matters is not an anti-obesity program, we wonder if the industry health effort shouldn’t be reconfigured in this vein. After all, obesity, especially childhood obesity, has been clearly identified as the Number One public health problem — with an enormous public cost due to diabetes, heart disease and other consequences.

Surely the most likely path to enhanced funding for a produce public health initiative is if we can tie it in to fighting obesity.

We also confess that to our ear, the whole More Matters slogan rings uncomfortably in an era when caloric restriction is the order of the day.

We sense that the public health authorities are thinking the same way. Virtually every state had a 5-a-Day coordinator and, typically, that was their title. In other words, there was a state public health authority in whose very title the tie-in with the national program of PBH was intrinsic.

Yet we do not see the states running to replace those 5 a Day coordinators with More Matters Coordinators. Now we see them adopting generic titles such as Fruit and Vegetable Nutrition Coordinators — moving clearly away from a tie-in with the national program. It is hard to see that as a big win for PBH.

We do not think PBH serves its cause well by utilizing those multiplier numbers that Elizabeth refers to in her letter. First, if it really was true that PBH spending $5 million a year is the same thing as spending $150 million a year, the industry would be completely in line at demanding a far better explanation for what has been achieved for the billions that were spent over the last 20 years. Second, although Elizabeth’s numbers are surely accurate, they are not revelatory of the situation. For example, a lot of that multiplier is Federal money going to the states to be spent on the program. But the states rarely get money just to “increase produce consumption.” More typically, they get money that is highly restricted — for example, it might have to be spent on very low consuming groups such as the impoverished.

It is marketing 101 that it is easier to sell one’s existing customers a little more than to convert non-users. That is not to say that these efforts on the state level aren’t important — only that the money is very ineffectively spent if the goal was simply to boost produce consumption.

When it comes to program evaluation, the very first letter this Pundit wrote to 5-a-Day was before Elizabeth was even there. The organization was trying to promote a retail signage program that “proved” that promoting 5-a-Day would allow a retailer to increase sales. We asked 5-a-Day for the control studies under which the same signage, aprons and promotions were done — just without the mention of 5-a-Day. In other words, we wanted to see how much, if any, of the boost in sales was caused by the use of the “5-a-Day” slogan as opposed to general promotion.

Well, there had been no control studies of an alternative slogan — the comparison was between a massive 5-a-Day promotion and doing nothing. We are reminded of all this by Elizabeth’s explanation that a lot of research wound up proving nothing more than the expected: “…the end result from all of this research is that if you promote fruits and vegetables, consumption goes up.”

Which brings us to the crux of the issue for the produce industry and its support of 5-a-Day and now, Fruits and Veggies — More Matters: We haven’t been able to noticeably move the needle on consumption.

Now this is always a difficult matter to evaluate. Perhaps consumption would have collapsed without 5-a-Day. It was a national program, and there was no control group, so there is just no way to know. But it is fair to say that we don’t have much evidence that all these years of 5-a-Day increased produce consumption — much less that the program has reduced obesity or decreased cancer or increased public health in some other way.

Still, if Elizabeth is correct and we have good research showing increased promotion results in increased consumption, then the question is, logically, how do we get to that point?

And this really is the crux of where we stand today: On one side is the argument that we have built this organization and national infrastructure and if it is underfunded, we just have to do the best we can with what we’ve got. And the hope, without having much evidence, is that we can do some incremental good. Perhaps one day, something will happen and we will be able to really do what needs to be done with the program.

The other view is that obtaining every goal has a cost. So if we want to bring in a big ad agency and tell them our goal is to move the needle on consumption nationally, we could prepare a budget sufficient to achieve that goal. If we do not have enough money to achieve that goal, spending what we do have just because we happen to have that much may just be a waste.

There are lots of options. We could geographically shrink the program to a pilot status with the goal of demonstrating effectiveness that would allow us to raise the needed budget. Alternatively we could change the nature of the program. For example, we could decide to build a database for each industry product so we could apply to get approved health claims for each produce item. The idea is that developing this “library” of approved health claims is within our budget to accomplish; it increases the intrinsic appeal of the product and can easily be promoted via public relations efforts.

Elizabeth Pivonka is a tireless warrior on behalf of produce and her program. The board members and executive committee are equally dedicated to boosting consumption and improving public health, and rest of the staff is enthusiastic and motivated.

Yet every program needs a metric of evaluation. Let us forget the past and just look at the future. It is 2007… how will we know in 2012, five years from now, whether we have been a success or not?

And what would we do if we failed?

These are difficult industry issues. Nobody wants to be seen as an enemy of efforts to increase consumption. Nobody wants to speak poorly of board members or staff trying their best to make this effort work.

However, as the funders of this effort, we have a responsibility to not allow precious industry resources to be poured into an effort that is not producing results. We need performance metrics so we will know when the program needs to be reformed.

Right now we are in a kind self-perpetuating cycle. If consumption were to increase that would “prove” the program to be working and would justify more funding, but if consumption does not increase that would “prove” we didn’t have enough money and would thus justify more funding. It is not a business-like way to operate.

We certainly hope for the best and thank Elizabeth. Her willingness to participate in this industry dialogue is the mark of a confident and gifted leader.

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