Challenging Dogma - Fall 2007

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

Wednesday, December 12, 2007

Does an Apple a Day Keep the Doctor Away? – Vanessa Holley

Does an Apple a Day Keep the Doctor Away? The Failure of the 9 a Day Campaign to Reduce the Risk of Diet Related Diseases in African Americans.


The Center for Disease and Control reports that everyone should consume fruits and vegetables because they contain essential vitamins and minerals needed to protect against chronic diseases such as cardiovascular disease and certain cancers (1). Vitamin A and C, fiber, and potassium are just some of the many nutrients found in fruits and vegetables that may help protect people against these chronic diseases. Studies suggest that those who do not eat fruits and vegetables daily are twice as likely to get cancer and increasing the intake of fruits and vegetables can reduce cancer rates by more than 25% (2). Eating fruits and vegetables is important, but it is the amount you consume that theoretically reduces the risk of certain diseases.

According to the National Institute of Health, on average people consume 2.9 servings of fruits and vegetables daily (2). As an association was clear between fruit and vegetable intake and chronic diseases, the National Institute of Health and the National Cancer Institute developed a program, 5 a Day for Better Health, to increase the awareness of eating more fruits and vegetables daily to reduce the risk of diseases. The 5 a Day program recommends everyone to eat at least 5-9 fruits and vegetables daily to reduce the incidence of chronic diseases. People were encouraged to maintain a healthy lifestyle, diet regularly, and consume at least 5 fruits and vegetables daily to reduce the risk of diseases. As the campaign progressed and continued to address the issue of fruit and vegetable intake and chronic diseases, small populations of Americans were still disproportionately affected by diet related and chronic diseases, especially African American men.

African American men suffer disproportionately in numerous health conditions. African American men have the highest rates of cancer and mortality rates among any other ethnic group (3). They develop diabetes and high blood pressure very young and suffer severe side effects (3). They are also twice as likely to get diabetes than whites. Overall, African American men are 140% more likely to die from cancer than whites (4). African Americans are severely affected by diet related diseases, yet they have the lowest consumption of fruit and vegetable intake overall (4). On average, African American men eat 3.1 fruits and vegetables daily (4). The 5 a Day campaign became concerned with the high rates of diseases among African American men so they extended their program to a 9 a Day campaign, a program designed for African American men to eat 9 fruits and vegetables daily to reduce their risk of diet related disease. The 9 a Day campaign needs to ultimately change the eating habits of African American men to reduce their risk of disease. The U.S. Department of Health and Human Services and the National Cancer Institute 9 a Day Campaign to reduce chronic disease among African American men fails in its attempt to recognize factors that influence eating habits.

Accessibility of Fruits and Vegetables

The 9 a Day campaign does not take into account accessibility of fruits and vegetables. African American men will be unable to eat at least 9 fruits and vegetables daily if they are not readily accessible to them. Geographic location of healthy food stores, lack of transportation and affordability of fruits and vegetables are main components that prohibit African American men from having access to fruits and vegetables.

The campaign fails in its’ attempt to understand how the local environment can influence consumption of fruits and vegetables. Low-income neighborhoods are made up of a disproportionate number of African Americans and predominately white neighborhoods tend to have higher average incomes. Lower income neighborhoods have fewer healthy food stores compared to higher income neighborhoods and therefore is not accessible to many African American men (5). Higher income neighborhoods have 5 times more supermarkets compared to only 8 % of low-income communities made up of African Americans living near at least one supermarket (5). Supermarkets carry more variety of fruits and vegetables than local grocery stores and would be a resource of obtaining needed fruits and vegetables. As more supermarkets continue to migrate to the suburbs and more independently own grocery stores are being built in low-income neighborhoods, a greater proportion of African American households will not have access to essential fruits and vegetables. It is impossible for African American men to eat 9 fruits and vegetables daily if resources (healthy food stores and supermarkets) are not readily available within their specific neighborhoods.

Transportation would also have to be readily accessible to get access of fruits and vegetables needed. If healthy food stores are not located in African American neighborhoods, African Americans would be forced to travel across town to get the food they need. Those without a car rely on public transportation to get around. What father of 3 would waste 2 hours of their time to get on the bus with children in tow to get the necessary 9 fruits and vegetables needed to maintain a healthy lifestyle. Whites have 3 times greater access to transportation than African Americans and have a better chance of purchasing the food they need (5). Those with limited transportation are forced to shop nearby in grocery stores where supermarkets are generally smaller in size, carry a narrower range of products, and are usually more expensive (6). The program cannot be effective unless African American men have access to purchase the fruits and vegetables needed to reduce diet related diseases.

African American men will be unable to eat at least 9 fruits and vegetables daily if they cannot afford to purchase these items. Increasing fruit and vegetable consumption is very difficult because consumer food choice is closely linked to food costs (7). Fruit and vegetable availability decreases in the home as the costs per serving for fruits and vegetables increases (7). As prices steadily rise for fruits and vegetables, African American men will not be able to afford them. The 9 a Day campaign expects all African American men to eat 9 fruits and vegetables daily, but they can eat that many servings if they are unable to afford these items. There is also an association between income and fruits and vegetables. Lower socioeconomic status is linked to the consumption of fruits and vegetables because many cannot afford to purchase fruits and vegetables. There are more African Americans considered within the lower socioeconomic class than whites, which would affect African American men food consumpti0n even more.

Lower income households spend little on fruits and vegetables because they allocate their limited income to other items they deem desirable such as housing, clothing, and other foods (8). Many African American men find that providing for their families essential needs is more important than buying 9 fruits and vegetables a day. A father would first pay rent to provide a roof over his families head than to purchase numerous fruits and vegetables. Although they make less than higher income households, lower income households spend more of their income on food (5). Food is a big part of their budget and they would prefer to buy the necessary food items to feed their family. Many consider fruits and vegetables as an additional expense, and would prefer not to exchange usual food items for healthier options (8). The 9 a Day campaign cannot expect African American men to buy 9 fruits and vegetables if they do not have enough disposable income to actually buy the food items. The campaign cannot be effective unless the men can actually afford to purchase the fruits and vegetables needed to reduce diet related diseases.

Thus, the 9 a Day campaign does not take into account accessibility of fruits and vegetables to African American men. Lower income neighborhoods made up of a disproportionate number of African Americans have fewer healthy food stores. Those without access to transportation are unable to go to the store and buy the recommended fruits and vegetables. Also, many African Americans are unable to afford these items due to their limited incomes, and may opt to prioritize other resources over fruits and vegetables.

Cultural Norms and Fruits and Vegetables

The 9 a Day campaign does not take into account differences in cultural norms of African American men. African American men will not eat 9 fruits and vegetables daily if it is not part of their normal diet. Many cultural differences exist between food consumption and Social Expectations Theory explains how it would be hard for African Americans who are used to consuming the same foods to change their daily eating habits.

African American families purchase fruits and vegetables based on preference, cultural significance and family traditions (7). Food patterns vary according to regional and social influences of each community. African American food patterns have drawn on eating habits of several cultures including seventeenth and eighteenth century West African culture associated with American slavery and post-civil war rural South (9). Slaves had limited access to ingredients and preparation tools to cook food (9). Fruits and vegetables were not readily accessible to many slaves. As a result, many traditional African American families do not eat fruits and vegetables as there food patterns are similar to that of slaves. Many other cultures such as the Haitian community have a high intake of meat, rice, plantains, and beans. Those of Caribbean descent have a high intake of jerk and curry chicken, rice and peas, and sugar cane. Different foods associate with different cultures. Many of these cultures simply may not know how to prepare the fruits and vegetables you find here. These cultures are used to preparing the food of their specific culture. These cultures also have these specific items because they are cash crops of these countries and are easily available to the people of that land (9). Those that migrate to the states are still going to consume those foods of cultural significance. There is deep ethnic variation in the consumption of fruits and vegetables.

The 9 a Day campaign does not consider cultural differences in African American men. The Social Expectations Theory in which behavior is dictated by social norms shows how cultural differences in the consumption of food will change how people feel about consuming 9 fruits and vegetables daily. Those who are used to consuming the same foods within their specific culture will not want to change their daily behavior. Those cultures are not susceptible to change if they are use to their specific social norms. The 9 a Day campaign would have to change the cultural norms of a community in order to change their specific eating habits. The 9 a Day campaign falls short in changing the daily norms of these deeply enriched cultures.

Thus, the 9 a Day campaign does not take into account differences in cultural norms of African American men. Ethnic variations exist between eating habits and fruit and vegetable consumption may not be a big part in their diet. The Social Expectations Theory helps to explain that if the men are use to their specific social norms then consequently they will not be inclined to change their daily diet.

Self-Efficacy and Fruits and Vegetables

African American men will not eat fruits and vegetables if they do not think they can consume 9 fruits and vegetables daily. Social Cognitive Theory helps to address this failure of the 9 a Day campaign. Social Cognitive Theory provides a framework for understanding what influences the mens’ human behavior through self-efficacy.

Within the theory, self-efficacy is a person’s notion that they are capable of performing certain behaviors (10). Those who believe they have the power to change will ultimately change their behavior. People are more inclined to take on a task if they believe they can do it. Likewise, those who believe they cannot change are not inclined to perform a specific task. In Social Cognitive Theory, perceived self-efficacy is a key determinant in changing and inflicting behavior (10). The problem with the 9 a Day campaign is that it does not take into account self-efficacy as a means of changing behavior. African American men will not eat fruits and vegetables if they do not think they can consume 9 fruits and vegetables daily. Many African American men may find that eating 9 servings a day an unattainable goal (11). Simply put, 9 fruits and vegetables are a lot to eat in one day, especially if a person works a 9-5 job and takes care of their children. People may find that they have no time to eat so many fruits and vegetables and opt not to eat any fruits and vegetables all together. Studies indicate that men appear to need increased confidence in their ability to include fruit in their diets as they consider and commit to such a change (11). The 9 a Day campaign fails to recognize the actual ability of these men to change their diets to include 9 fruits and vegetables. Also, accounting for accessibility and affordability, African American men will find it even harder to eat 9 fruits and vegetables. Those who face the barriers to fruit and vegetable access and affordability are discouraged from pursing a healthy behavior according to the Social Cognitive Theory (11). Increased consumption of fruits and vegetables is associated with high levels of self-efficacy (12) and the 9 a Day campaign fails to boost people’s perception that eating 9 fruits and vegetables is an achievable goal. The 9 a Day campaign should just focus on the importance of consuming fruits and vegetables versus mandating 9 fruits and vegetables daily to achieve a healthy lifestyle. Requiring 9 fruits and vegetables seems unattainable to many.

Thus, the 9 a Day Campaign does not take into account self-efficacy as a means of changing behavior. African American men simply do not think that they can consume 9 fruits and vegetables daily. 9 fruits and vegetables is a lot to consume in one day and many African American men find this an unachievable goal.

Conclusion

Overall, the U.S. Department of Health and Human Services and the National Cancer Institute 9 a Day campaign to reduce chronic disease among African American men fails in its attempt to recognize factors that influence eating habits. The 9 a Day campaign does not consider accessibility of fruits and vegetables. A systematic geographic difference exists between those who simply do not have access to healthy food stores and supermarkets. Accessibility is an issue when many do not have transportation to healthy foods stores and supermarkets. Many also simply cannot afford to purchase numerous fruits and vegetables. The 9 a Day campaign does not consider cultural norms of African American men. Ethnic variations exist between eating habits and fruit and vegetable consumption may not be a big part in their diet. The 9 a Day campaign also does not consider self-efficacy as a means of changing behavior. African Americans simply do not believe that they can eat 9 fruits and vegetables daily. The 9 a Day campaign will continue to be a failure unless these factors that influence eating habits are recognized. The 9 a Day campaign can become effective if they work to change the underlying social conditions that cause differences in access, cultural differences, and motivation.

REFERENCES

1. Centers for Disease Control and Prevention. Fruits and Veggies Matter. Atlanta, GA: Centers for Disease Control and Prevention. http://www.fruitsandveggiesmatter.gov/benefits/index.html

2. Produce for Better Health Foundation. 5 a Day for a Better Health Program

Monograph. Wilmington, DE: Produce for Better Health Foundation. http://www.pbhfoundation.org/pdfs/pulse/research/5adayresearch/NCImonograph.pdf

3. The University of Texas MD Anderson Cancer Center. Cancer Wise. Houston, TX: The University of Texas MD Anderson Cancer Center. http://www.cancerwise.org/June_2003/display.cfm?id=D9F10E7A-FCE4-4AF6-9329DF2B425D18D6&method=displayFull&color=green

4. US Department of Health and Human Services. HHS News. Washington D.C.:

http://www.nih.gov/news/pr/apr2003/nci-24.htm

5. Roux A., Moreland K., Wing S. The Contextual Effect of the Local

Food Environment on Residents’ Diets: The Atherosclerosis Risk in Communities Studies. American Journal of Public Health 2002; 92:1761-1767.

6. Krebs-Smith S., Kantor L. Choose a Variety of Fruits and Vegetables

Daily: Understanding the Complexities. The Journal of Nutrition 2001; 22:487-501.

7. Ard J., Fitzpatrick S., Desmond P., et al. The Impact of Cost on

the Availability of Fruits and Vegetables in the Homes of Schoolchildren in Birmingham, Alabama. American Journal of Public Health 2007; 97:376-372.

8. Blisard N., Jolliffe D., Stewart H. Low-Income Households’

Expenditures on Fruits and Vegetables. Agriculture Information Bulletin 2004; 792:1-2.

9. Klassen A., Shankar S. Influences on Fruit and Vegetable Procurement

and Consumption among Urban African-American Public Housing Residents, and Potential Strategies for Intervention. Family Economics and Nutrition Review 2001; 13:34-46.

10. Bandura A. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall,

1977.

11. Betts N., Greene G., Hoerr Sharon., et al. Self-Efficacy, Perceived

Benefits, and Weight Satisfaction Discriminate Among Stages of Change for Fruit and Vegetable Intakes for Young Men and Women. Journal of the American Dietetic Association 2002; 102:1466-1470.

12. Barbeau E., Dubowitz T., Stoddard A., et al. The Influence of

Social Context on Changes in Fruit and Vegetable Consumption: Results of the Health Directions Studies. American Journal of Public Health 2007; 97: 1216-1227.

Labels: , , , ,

1 Comments:

  • At December 18, 2007 at 7:09 PM , Anonymous Sarah said...

    Nice article, although there are a lot of articles on this. Are there any programs that actually increase fruit & vegetable consumption? I'm curious about what actually works.

     

Post a Comment

Subscribe to Post Comments [Atom]

<< Home