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Pundit’s Pulse Of The Industry: Calif. Dept. of Public Health’s Sue Foerster

As part of our continuing efforts to explore the intersection between the industry and health and nutrition issues, we have run many pieces, including, most recently, an interview with Dr. Lorelei DiSogra, Vice President, Nutrition and Health, United Fresh, and a letter received from Elizabeth Pivonka, President and CEO of the Produce for Better Health Foundation.

Yet, in many ways, the mother of all the current efforts to improve public health through increased produce consumption is Sue Foerster. She was there at the beginning when 5-a-Day was first conceived as a California cancer-prevention effort and has stayed with the program through all its iterations through the present day..

The transition to Fruits & Veggies — More Matters on a national level is, in many ways, a decided break with the past, and we asked Pundit Investigator and Special Projects Editor, Mira Slott, to speak with Sue and update us on what they are doing in California and how the transition to More Matters is perceived:

Susan Foerster
MPH, RD, Chief Cancer Prevention and
Nutrition Section
California Department of Public Health
Sacramento, California

Q: How did Champions for Change come about, and what are the program’s key components and goals?

A: Champions for Change is our tag line for consolidation of 5-a-Day, which became obsolete, and California Nutrition Network for Healthy, Active Families. 5-a-Day was built into everything we did for the California Nutrition Network, but when 5-a-Day was re-branded to Fruits & Veggies More Matters, ownership shifted away from California.

From the time we developed 5-a-Day back in 1988, we also integrated physical activity. We understood from our research that everything we did needed to combine fruit and vegetable consumption with physical activity and incorporate a multi-faceted approach. In line with the Network for a Healthy California brand identity, the tone is about empowerment, champions and being agents of change.

Q: I’ve noticed there are still references to 5-a-Day on your websites [such as here and here]. Are you going to phase out 5-a-Day and if so, how will the transition be handled? Are you concerned that consumers will be getting mixed messages?

A: Because we have a brand new Department of Public Health, the organization has to invent a new web system, switching brands and nomenclature. We are waiting to get a Fruit and Veggies — More Matters license and are doing things to co-brand. We have a huge print order. It will involve a phase-out period. The license calls for a phase out in two years. We’re depleting our supplies.

We’re talking about champions and agents of change. We have a whole bunch of custom websites for employers, consumers, retailers, and partners with sections that provide a lot of data and reports, and where they can get right to where they are interested quickly.

The More Matters fruit and vegetable recommendation itself is throwing people, because it is no longer just a single number. We’ve developed a slide guide for consumers based on gender and age, so people can begin to feel more comfortable. People understand that fruits and vegetables and physical activity go together.

It’s a matter of changing over. It was difficult for me to let go of 5-a-Day after 20 years [you can read about her leadership role in its development in PRODUCE BUSINESS here]. It’s been a grieving process, but we have a more comprehensive approach now that integrates values and social change. The challenge now is execution.

Q: What trigger points drive the program and funding?

A: Since we are funded through the USDA food stamp program, we are focused on those families eligible for food stamps, or 185 percent of the federal poverty level for inclusion, which is higher than food stamps alone at 130 percent. Ten million Californians out of 38 million are estimated to have annual incomes that qualify. One of the challenges has been shaping all our programs through this USDA funding stream, channeling lower income audiences and particularly the 7 million parents and children. All media research for targeted campaigns tries to reach low-income families with kids.

More Matters is aimed at moms, but also Gen X or Gen Y and without an income target.

Part of our ability to build a comprehensive approach and intervention program for low-income families with children is a resource deal, from the way it’s funded through matching USDA food stamp funds. A lot you do is based on the resources you have. It’s perverse in a way that because of the obesity crisis, we are fortunate to be able to grow this program. We get our federal funds by raising state funds that qualify for matching federal financial participation. We were able to bring in $100 million in new money because our partners through state and local government have allocated equal or larger amounts, which qualify for matching USDA funds.

With the replacement of 5-a-Day nationally, we knew that there was going to be a whole new branding strategy. More Matters does not focus on physical activity. In addition, we focus on food security, but not in the way you may be defining it related to terrorism. In this sense, food insecurity is when people don’t get the right foods, whereas extreme insecurity would be when people go without food sometimes because they can’t afford to buy it.

Q: What challenges do you face in reversing childhood obesity, improving health and nutrition, and altering engrained lifestyle patterns and behaviors?

A: What we’re all about in our program is prevention, cancer and other disease prevention, and health and nutrition. We’ve been working for a very long time to help Californians reduce risk of cancer through diet and physical activity and alleviate food insecurity as a way to reduce chronic health problems. First will be combating obesity leading to reduction of Type 2 diabetes, and further out, heart and stroke, and last we’ll see results in the areas of cancer. Our planning sets goals that target significant change in the population by 2010, which is very, very ambitious. Nobody has yet done that.

How can we turn this health epidemic around? Our approach has to be comprehensive. We can’t just change school food, or just advertise to children, or insure grocery stores are carrying fresh fruits and vegetables. We have to pay attention to the social environment, the food environment, how fruits and vegetables are available, the cost and quality. And for our population, fruit and vegetable cost is a big deal. It’s a barrier to consumption. About 40 to 50 percent of the population report cost as a substantial barrier. That’s why this program is critical to our success.

The Institute of Medicine released three big reports on obesity and kids. In 2005, it established a real need to pay attention to upstream contributors to obesity; related to fresh fruit and vegetable consumption and its availability in school, the impact of fast food and eating habits at home, food advertising and pricing. Any program that wants to change obesity in kids, and this applies to adults as well, must develop an upstream factor set.

Q: How unique is the Champions for Change concept? Are you consulting with other state departments of health? Are other states adopting similar programs? How does this program gel with the other programs out there?

A: In developing the new brand, our consultant guided us in looking at obesity prevention/healthy living brands and logos from other states, and most said what it was they wanted people or communities to do — shape up, move more, and so forth. So, as far as we’ve seen for nutrition, physical activity and obesity prevention at least, this seems to be unique and, we hope, “evergreen”, as well as on-target with the emotional value that will result in normative change.

We also hope it will transcend the silo mentality that is so easy to slip into and be a big enough umbrella to allow lots of diverse stakeholders to buy in and participate. Consumers seem to love it. It speaks to them of community and joining efforts and commitment and respect.

We just launched it in late April, so we haven’t been beyond our own borders much yet. There’s a lot to do with the transition and learning how to build synergy, a principal purpose for making the change — there should be some good stories to tell over the coming months.

People carve off what they can do. With the National Partnership, we’ve developed a national action plan. It covers 10 different areas and is quite comprehensive.

Q: What is this national action plan? Is this a government or private program, and how long has it been around?

A: The National Action Plan to Promote Health Through Increased Fruit and Vegetable Consumption was pulled together by PBH with input from and on behalf of the entire National Partnership and reflects the broad approach that we partners believe is needed and that we’re working together to accomplish.

It involves the states, United Fresh, PMA, the canned and frozen food alliances, the diabetes and heart associations, National Cancer Institute (NCI), CDC and USDA, among others, and covers a wide scope of issues, such as marketing to schools, retail, health care research policies, etc. It’s the ability to execute that’s the challenge.

Coordinating all this is really a handful because we’re depending on voluntary efforts, and organizations each with their own timelines, expectations and demands. Trying to get things like this to work in one company is hard, and voluntarily is really tough.

Q: You’re certainly no stranger to overcoming such obstacles and building coalitions for change, as exemplified by your prowess in spearheading development and expansion of the California 5-a-Day program.

A: Initially 5-a-Day was headed by NCI, but then turned over to CDC about three years ago. There has always been coordination in the industry for this program. This is one initiative where all industry groups have come together to work with the federal government.

Fruits & Veggies — More Matters is the new brand replacing 5-a-Day. Because CDC didn’t feel it had authority to create a new brand, PBH developed and owns the brand and trademark. The government has always been the arm to license on the industry side. Now the role has flipped. PBH licenses the brand, and CDC, in turn, sublicenses it to the states, the Cancer Society, Heart and Diabetes Associations, etc.

We are still in discussions with PBH on the terms of the More Matters license. I believe 27 or 28 states now have interim licenses with PBH that are good for one year. They will eventually phase into the CDC license. PBH is taking very seriously the intellectual property aspects of the brand and using appropriate care so the integrity of the brand is maintained.

We are familiar with the style guide and brand ideology and how PBH is playing it out. Our agreement with them is consumer empowerment, to empower moms in this case to have control and put more fruits and vegetables into their family diet. For us, we remain The Network for a Healthy and Active California with our pillars of fruits and vegetables, physical activity, food security and chronic disease prevention starting with obesity.

This is the way we have our campaign laid out and what the public will see over the coming year. We have a comprehensive media campaign that includes T.V. in English and Spanish, in seven English and six Spanish media markets, and radio, billboard and transit ads in both languages. In addition, we have a totally new, drop mail bi-lingual DVD to almost 600,000 low income households in six counties, where moms talk about how they are making changes.

The emotional hook we’re building on is mom’s concern for her family and her environment; taking control of her home and kitchen, and working with other moms to change the community.

Q: The produce industry has always faced an uphill marketing/funding battle to compete with junk food manufacturers and fast food establishments. Now it seems in many schools physical education programs are being cut back, while kids get more sedentary off campus as well. What can be done to shake up established behaviors?

A: We’re creating a whole theme of champions, whether it’s kids speaking out, or a retailer or policy-maker or teacher who is a champion for change. That’s the tag line: Network for a Healthy California, Champions for Change.

We have about 160 local projects we fund, and about 2,000 partners, including regional organizations around the state. The challenge is to introduce this new approach in a way they will carry it through and capitalize on the will of the consumers to change their own environment, whether school, home, church, or community, wherever it happens to be.

We believe Californians have to change norms, what people expect and consider normal. They should expect fruits and vegetables at their children’s schools. They shouldn’t expect to have advertisers telling kids to eat bad food. They don’t want this. We did this as a state for tobacco control, wearing seatbelts, and putting on sunscreen. We tried and succeeded to de-normalize something unhealthy. That’s what has to happen with Champions of Change.

Q: How do you measure success of Champions for Change, and in a larger sense other health and nutrition programs? Do you have studies to document and validate the methodologies? Do you have examples you can share with us of how programs have evolved and changed?

A: We do our programs two ways. We develop at the state level based on research, test ideas and rollout programs on a pilot basis, test again, revise and rollout statewide. For example, on our Latino campaign, we found we could get an increase of one serving of fruit and one serving of vegetable a day from our pilot study, then tried to replicate the pilot in the real world with live partners, providing training and materials so they’d be able to implement the program according to the science we found and expected, while customizing it with community-based incentives.

At the local level, Latino campaign coordinators found the use of cultural festivals and flee markets important places large numbers of families gathered to build the program. As we roll out the program in other venues, such as schools and grocery stores, we look for changes in fruit and vegetable consumption at the state level. Now we have Latino campaigns in 9 of 11 regions. We do targeted surveys to understand our Latino audience. The other way is through evaluations that the partners have developed. The local agencies put their own money against ours.

Our Harvest of the Month program seemed to take off in schools like wildflowers; we stepped in and looked at evaluation results to see if it was doing what people thought it was doing. We now have three years of Harvest of the Month materials that can be used mainly in schools, but that extend to the home and community. Now we’re trying to carry the program into the retail environment. If the parent knows kids will be learning about kiwis, then the retailers can feature kiwis, and by working together we can increase consumption.

We have a high level of evaluation requirements to watch for what works and what doesn’t work as we roll out the program, and then we do surveys every two years; age 9 to 11 — 4th and 5th grades — done in odd years, as is our adult survey, and our teen survey in even years, age 12 to 17 — middle school and high school. The surveys are in-depth, with a focus on eating habits, physical activity what people know, as well as their opinions.

On our children’s survey, we had fabulous results showing huge increases in fruit and vegetable consumption, which we attributed to a combination of children’s T.V. promotion, our rollout of in school and after school programs and our ability to reach parents and their subsequent participation. Interestingly enough, the change in USDA rules in 2004 meant we could no longer do children’s T.V. in 2005. That same year we reported consumption did go down substantially. This was the main thing we could attribute the drop to. We know T.V. is very powerful with kids, resulting in very strong recall, and we were using child celebrities for normative change. We don’t know there’s a link; we can only speculate.

On the state level, we do compare our numbers against behavioral risk surveys by CDC that every state does roughly every two years targeting fruits and vegetables. We can compare how California does for adults using that survey. We come out high, but not the highest. It fluctuates. We thought it had to do with 5-a-Day programs. No one has actually analyzed this. It is very complicated work.

We are tracking low-income adults in our own survey, and we are seeing nice results. Numbers from 2005 have been showing steady increases, not any more than the high income group, but they are keeping up and the gap is not widening. We don’t know any other reason why, other than our work. We’re still doing number crunching to compare our results to national trends in this area.

Q: What are some valuable lessons you’ve discovered through your tenure?

A: There are many more influences on low-income populations that effect produce consumption. Their disposable income is shrinking all the time. It is complicated to know how much money they will have for food. Produce can be a risky and relatively costly food investment to someone on a strict budget when they don’t know what the quality, taste and freshness will be.

What we’ve learned in public health is that evaluation is very messy. We don’t have all the knowledge on the impact of all the countervailing forces, and it is very difficult to prove. Five billion dollars is spent on food advertising in California and two percent of that is on fruits and vegetables. By far most of the food advertising is not helping us. Only about 10 percent is for the healthier foods. We just know there is not as much advertising as there should be to turn these numbers around. We believe that by doubling or tripling, we’ll see reductions in obesity.

People who eat more fruits and vegetables have lower body weights. There is a correlation. But if all you’re doing is eating two additional food groups, the result could be counter-intuitive. One of the things we’ve learned is we need to tell people to eat less of other stuff, calorie-dense foods, soda, fried foods, portions and frequency and what the plate or snacks should be looking like.

Eating less is a shift from normal. Filling up on water-containing foods, such as soup, reduces caloric intake. When people go on Weight Watcher’s or South Beach, they do substantially increase the fruits and vegetables they eat to stave off hunger and stay on an eating plan for life. These are strategies to try and recalibrate our systems and expectations on a whole social level.

We appreciate the time Sue Foerster devoted to sharing her perspectives with the industry. What Sue and people like her in other states think about Fruits & Veggies — More Matters really matters. Because, to be blunt, they have the money. Note the reference to getting an extra 100 million dollars. PBH hasn’t spent $100 million dollars since it was started!

When Elizabeth Pivonka at PBH speaks about a multiplier effect in which small amounts of money spent by PBH pay off in larger amounts of in-kind promotion and government expenditures, a big chunk of that is what people like Sue Foerster spend.

The good news is that Sue is running an astounding program that is focused on poor people. Not only is the program about nutrition but also exercise; it has a behavioral component in which people are encouraged to see themselves as change agents and incorporates a focus on values and social change.

So many of the benefits that society could realize through a more fit populace come from the poorer sector of society. We can’t help think that, regardless of its impact on produce consumption, Sue’s laser-like focus on people at 185% or less of the federal poverty line is bound to do more good for the world than getting affluent people to boost their consumption slightly.

At the same time, we sense that there is a divergence today that didn’t exist when the national 5-a-Day program was established. Part of it may be the natural dynamic that comes about from a change of ownership of a program. After all, 5-a-Day was a California program that went national.

Now there is a national program and California has to be persuaded to use it.

And they will. Sue Foerster is not an enemy of Fruits & Veggies — More Matters. They will eventually get a license, co-brand and be supportive. But it is not going to be the same as 5-a-Day.

At best, Fruits & Veggies — More Matters can be useful as a nutritional component of a larger message such as Champions for Change.

Part of it is the sense that more than nutrition education is required, so any program so limited — as more Fruits & Veggies — More Matters is — can only be a part of the solution.

Part of it is the difference in focus. Sue is looking to help poor people; the More Matters program has no income focus.

Yet it also strikes us that there is a bigger issue. In answering Elizabeth Pivonka’s most recent letter, we wrote the following:

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.

Now we read Sue Forester’s comments:

…if all you’re doing is eating two additional food groups, the result could be counter-intuitive. One of the things we’ve learned is we need to tell people to eat less of other stuff, calorie-dense foods, soda, fried foods, portions and frequency…

Obviously, Sue has concerns that go well beyond the Fruits & Veggies — More Matters message.

Although Sue said nothing negative, intrinsic in the issues Sue raise is a real question about the compatibility of the More Matters message with the kind of low income focus Sue is responsible for.

More Matters might make sense if the problem is education. If the message we need to get out is that everyone, everywhere should increase their consumption of produce and if the only obstacle to doing that is understanding, then More Matters might make sense.

But Sue explains that there are substantive factors that block access to produce for the poor:

There are many more influences on low-income populations that effect produce consumption. Their disposable income is shrinking all the time. It is complicated to know how much money they will have for food. Produce can be a risky and relatively costly food investment to someone on a strict budget when they don’t know what the quality, taste and freshness will be.

If this is true and there is, for example, an economic barrier to consumption, then the More Matters slogan is almost cruel. It is like a psych on poor people. It is saying to poor people that More Matters — and you can’t afford it!

It is hard to see how programs focused on the poor are going to find that this general admonition to eat more fruits and vegetables should be the focus of their efforts.

This doesn’t mean that More Matters is a bad program, but there are clear signs that the old network of state groups has interests that are diverging from that of PBH.

In her recent letter, Elizabeth Pivonka said it clearly: Fruits & Veggies — More Matters was not developed specifically as an anti-obesity message…

But Sue Foerster tells us that a lot you do is based on the resources you have: It’s perverse in a way that because of the obesity crisis, we are fortunate to be able to grow this program. We get our federal funds by raising state funds that qualify for matching federal financial participation. We were able to bring in $100 million in new money because our partners through state and local government have allocated equal or larger amounts which qualify for matching USDA funds.

It makes you wonder if the produce industry isn’t missing the boat. The action is in anti-obesity efforts, and produce could play an important part but the particular program we’ve developed and slogan we’ve selected may lead to our marginalizing ourselves in a world focused on obesity.

We appreciate the insight Sue has provided into one of the most important public health efforts in America.

We wish her well and hope the produce industry, so important in the state of California, will find a way to be a true partner in Sue’s program to help the needy to lead more healthful lives.

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