Fruits and Vegetables
Enhanced Federal Efforts to Increase Consumption Could Yield Health Benefits for Americans Gao ID: GAO-02-657 July 25, 2002Fruits and vegetables are a critical source of nutrients and other substances that help protect against chronic diseases. Yet fewer than one in four Americans consumes the 5 to 9 daily servings of fruits and vegetables recommended by the federal Dietary Guidelines for Americans. Fruit and vegetable consumption by the general public as a whole has increased by about half a serving under key federal nutritional policy, guidance, and educational programs, as shown by the national consumption data compiled by federal agencies. But key federal food assistance programs have had mixed effects on fruit and vegetables consumption, as shown by national consumption data. However, increasing fruit and vegetable consumption is not a primary focus of these programs, which are intended to reduce hunger and support agriculture. A number of actions the federal government could take to encourage more Americans to consume the recommended daily servings have been identified. These include expanding nutrition education efforts, such as the 5 A Day Program; modifying the special supplemental Nutrition Program for Women, Infants, and Children to allow participants to choose from more of those fruits and vegetables; expanding the use of the Department of Defense Fresh Fruit and Vegetable Project in schools; and expanding farmers' market programs for food assistance participants. These options could require additional resources or redirecting resources from other programs.
RecommendationsOur recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
Director: Team: Phone:GAO-02-657, Fruits and Vegetables: Enhanced Federal Efforts to Increase Consumption Could Yield Health Benefits for Americans
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Report to Congressional Requesters:
United States General Accounting Office:
GAO:
July 2002:
FRUITS AND VEGETABLES:
Enhanced Federal Efforts to Increase Consumption Could Yield Health
Benefits for Americans:
Fruits and Vegetables:
GAO-02-657:
Contents:
Letter:
Results in Brief:
Background:
Consuming the Recommended Servings of Fruits and Vegetables Would
Reduce the Risk for Some Chronic Diseases:
Americans‘ Consumption of Fruits and Vegetables Has Increased Somewhat
Under Federal Policy, Guidance, and Education Programs for the General
Public:
Food Assistance Programs Have Had Mixed Effects on Consumption of
Fruits and Vegetables by Lower-Income Citizens:
Experts Have Identified Many Actions That Federal Agencies Could Take
to Further Increase Consumption of Fruits and Vegetables:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Response:
Appendix I: Federal Obligations for Efforts Related to Fruit and
Vegetable Consumption:
Appendix II: Scope and Methodology:
Appendix III: Federal Agricultural, Trade, and Environmental Programs
and
Regulations Can Affect Fruit and Vegetable Consumption:
Trade Restriction and Export Promotion Programs:
Environmental Regulations:
Agricultural Programs:
Other Federal Activities:
Appendix IV: Fruits and Vegetables Help Protect Against Heart Disease;
Cancer; and, Potentially, Other Diseases:
Appendix V: The U.S. Department of Agriculture‘s Fruit and Vegetable
Categories:
Appendix VI: Serving Sizes by Food Group for Five Food Packages
for Women and Children in WIC:
Appendix VII: Comments from the Department of Health and
Human Services:
GAO‘s Comments:
Appendix VIII: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Acknowledgments:
Tables:
Table 1: Recommended Daily Fruit and Vegetable Servings for Men, Women,
and Children, Based on Age and Activity Level:
Table 2: Participation, Total Funding, Nutrition Education Funding, and
Average Nutrition Education Funding per Participant for Selected Food
Assistance Programs, Fiscal Year 2001:
Table 3: Average Servings of Fruits and Vegetables Consumed in 1989-91
and 1994-96, and Percentage of Americans Consuming the Minimum and
Recommended Servings in 1996:
Table 4: USDA Funding for Activities Related to Diet and Fruit and
Vegetable Consumption, Fiscal Years 1997-2001:
Table 5: HHS Funding for Activities Related to Diet and Fruit and
Vegetable Consumption, Fiscal Years 1997-2001:
Table 6: DOD Funding for Activities Related to Diet and Fruit and
Vegetable Consumption, Fiscal Years 1997-2001:
Table 7: USDA‘s Fruit Categories:
Table 8: USDA‘s Vegetable Categories:
Table 9: Number and Percentage of Minimum Recommended Servings by Food
Group for Five WIC Packages for Women and Children:
Figures:
Figure 1: USDA‘s Food Guide Pyramid:
Figure 2: Percentage of Fruit Servings by Type, 1999:
Figure 3: Percentage of Vegetable Servings by Type, 1999:
Figure 4: Fruit and Vegetable Consumption by Food Stamp Participants,
Women in WIC, and Children in School Meal Programs Compared With
Consumption By Similar Nonparticipants, 1994-96:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
CSFII: Continuing Survey of Food Intakes by Individuals:
DASH: Dietary Approaches to Stop Hypertension:
DOD: U.S. Department of Defense:
DOD Fresh: Department of Defense Fresh Fruit and Vegetable Project:
FNS: Food and Nutrition Service:
GAO: General Accounting Office:
HHS: U.S. Department of Health and Human Services:
NIH: National Institutes of Health:
USDA: U.S. Department of Agriculture:
WIC: Special Supplemental Nutrition Program for Women,
Infants, and Children:
Letter:
July 25, 2002:
The Honorable Jo Ann Emerson
House of Representatives:
The Honorable Sam Farr
House of Representatives:
Fruits and vegetables are a critical source of nutrients and other
substances that help protect against chronic diseases, including heart
disease and cancer. Yet fewer than one in four Americans consumes the
daily 5 to 9 servings of fruits and vegetables recommended by the
federal Dietary Guidelines for Americans.
The Departments of Agriculture (USDA) and Health and Human Services
(HHS) are required by law to update and publish the Dietary Guidelines
for Americans at least every 5 years.[Footnote 1] The guidelines
contain nutritional and dietary information and guidance for the
general public, on the basis of current scientific and medical
knowledge. To emphasize the disease-preventing benefits of nutrients in
different kinds of fruits and vegetables, the 2000 edition of the
guidelines included a specific recommendation that consumers ’choose a
variety of fruits and vegetables daily“ as part of a healthy diet. The
guidelines also included USDA‘s Food Guide Pyramid, which illustrates
the recommended numbers of servings from each of the food groups--
grains, vegetables, fruits, milk, and meat/beans--that together
constitute a healthy diet. In 2000 HHS also released Healthy People
2010, a report that set national health goals and objectives to be
achieved by the end of the decade, for use by federal agencies, states,
communities, professional organizations, and others to develop programs
to prevent disease and improve and maintain health. Two of the
objectives relate to fruits and vegetables: (1) increase, from 28
percent to 75 percent, the proportion of Americans who consume at least
2 daily servings of fruit and (2) increase, from 3 to 50 percent, the
proportion of Americans who consume at least 3 daily servings of
vegetables, of which at least 1 serving is a dark green or orange
vegetable.
In addition to developing dietary guidelines and goals, federal
agencies provide nutrition education and intervention for the general
public and for participants in federal food assistance programs. The
National Cancer Institute, within HHS‘s National Institutes of Health
(NIH), administers the 5 A Day for Better Health Program--the only
federal nutrition education and intervention program focused
exclusively on increasing the general public‘s consumption of fruits
and vegetables to 5 to 9 servings daily. This public-private
partnership between federal/state/local governments, the fruit and
vegetable industry, and supermarkets uses a variety of strategies, from
national media campaigns to local programs in which, for example,
participants prepare new recipes with fruits and vegetables to
reinforce the 5 A Day message and influence dietary change. The Centers
for Disease Control and Prevention (CDC), also in HHS, works with
states‘ 5 A Day programs and funds some states‘ efforts to establish
programs that include nutrition education and intervention activities
for the general public. In April 2002, HHS and USDA signed a memorandum
of understanding that established a general framework for the two
departments‘ agencies to work together to implement an enhanced
national 5 A Day Program.
USDA‘s Food and Nutrition Service (FNS) funds and oversees federal food
assistance programs, many of which have nutrition education components
for program participants. Key federal food assistance programs, which
are administered by FNS and state governments, provide the following
food benefits:
* The Food Stamp Program provides low-income people with benefits to
supplement their food-purchasing ability.
* The National School Lunch and Breakfast Programs provide
schoolchildren with low-cost or free meals and snacks. USDA provides
food and funding and, under an agreement between USDA and the
Department of Defense (DOD), the DOD Fresh Fruit and Vegetable Project
(DOD Fresh) also purchases fresh fruits and vegetables with USDA funds
and delivers them to participating public and private nonprofit schools
in 39 states, Guam, and Puerto Rico.
* The Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) provides low-income pregnant, breast-feeding, and
postpartum women, infants, and children ages 1 through 4, with benefits
for the purchase of specific food items, including juice and carrots.
Some WIC participants also receive $10 to $20 annually to use at
farmers‘ markets in the WIC Farmers‘ Market Nutrition Program.
* The Seniors Farmers‘ Market Nutrition Program, new in fiscal year
2001, provides about 380,000 low-income elderly Americans with an
average of $28 each to use at farmers‘ markets.
As you requested, this report (1) examines the health-related benefits
associated with consuming the recommended servings of fruits and
vegetables; (2) determines the extent to which overall fruit and
vegetable consumption by Americans has improved under key federal
nutrition policy, guidance, and education programs for the general
public; (3) assesses the impact of key federal food assistance programs
on fruit and vegetable consumption by program participants; and (4)
identifies federal actions that experts recommend for increasing the
consumption of fruits and vegetables, as well as some of the
implications of those actions. As agreed with your offices, the key
federal food assistance programs we reviewed are the Food Stamp
Program, WIC, the School Lunch and Breakfast Programs, and the farmers‘
market programs for WIC participants and for seniors. You also asked us
to provide funding information for key USDA, HHS, and DOD programs that
may promote fruit and vegetable consumption. This information, which we
obtained by surveying the three departments, is incorporated throughout
the report and presented in appendix I. In addition, because we are not
a scientific body, we did not conduct an independent study of the
health benefits of various foods; rather, we reviewed existing
literature and are reporting information contained in that literature.
Therefore, nothing in this report would constitute an authoritative
statement that could be used, under section 403(r)(2) of the Federal
Food, Drug, and Cosmetic Act, to support a claim of a health benefit of
any food; nor would anything in this report constitute valid support
for a petition under section 403(r)(4) of the act to allow such a claim
to be made. Our scope and methodology are presented in appendix II.
Results in Brief:
Scientific evidence shows that consuming the recommended 5 to 9 daily
servings of fruits and vegetables helps protect against heart disease
and cancer. For example, studies show that people who consume 5 or more
servings of fruits and vegetables daily have about one-half the cancer
risk of those who consume fewer than 2 servings, according to NIH.
Fruits and vegetables provide more than 100 dietary compounds,
including vitamins and minerals, that may also have the potential to
reduce the risk of obesity and many other chronic diseases including
stroke, diabetes, and diverticulosis, according to reviews of the
research by NIH, CDC, and academic experts. Deeply colored fruits, such
as apricots and blueberries, and dark green or orange vegetables, such
as spinach and carrots, are particularly high in these compounds. While
there is no estimate for disease-related costs or number of deaths
attributable to low fruit and vegetable consumption, medical experts,
including the Surgeon General, have noted that physical inactivity and
poor diet--of which low consumption of fruits and vegetables is a key
component--cause diseases that result in the death of more than 300,000
Americans each year.
Fruit and vegetable consumption by the general public as a whole has
increased by about half a serving under key federal nutrition policy,
guidance, and education programs, as shown by national consumption data
compiled by federal agencies. In particular, 5 A Day, the one education
and intervention program that encourages Americans to eat 5 to 9
servings of fruits and vegetables daily, has shown some success in
improving consumption. However, most Americans still do not consume the
5 to 9 daily servings recommended in the Dietary Guidelines for
Americans. Moreover, the consumption of the dark green or orange
vegetables beneficial for disease prevention remains far below the
Healthy People 2010 objectives. This low consumption of fruits and
vegetables may be due to factors such as taste preferences, cost, and
the ready availability of other foods. Moreover, the Food Guide Pyramid
graphic--the most widely recognized nutrition guidance--does not
communicate the need to consume a variety of fruits and vegetables,
particularly deeply colored ones that the Dietary Guidelines for
Americans identifies as high in nutrients important for disease
prevention and health promotion. The April 2002 commitment by USDA and
HHS to promote a comprehensive national 5 A Day program could provide a
framework for helping Americans meet the 2010 nutrition objectives for
fruits and vegetables.
Key federal food assistance programs have had mixed effects on fruit
and vegetable consumption by participants, as shown by national
consumption data. However, increasing fruit and vegetable consumption
is not a primary focus of these programs, which are intended to, among
other things, reduce hunger and support agriculture. Food stamp
participants and women in WIC consume about the same number of servings
as nonparticipating low-income people and fewer servings than the
general public. However, children in WIC and in the School Lunch and
Breakfast Programs have shown some improvement. WIC children consume
0.3 serving more of fruit than similar nonparticipants; school meal
children consume 0.7 serving more of vegetables (largely french fries)
than nonparticipants at lunch and 0.4 serving more of fruit at
breakfast. The consumption of fruits and vegetables at schools that use
DOD Fresh may be higher because the produce available to the schools is
generally lower priced, greater in variety, and higher in quality than
otherwise available to schools, according to the American School Food
Service Association. In addition, participants in farmers‘ market
programs may consume more fruits and vegetables. However, DOD Fresh and
farmers‘ market programs are relatively small components of all food
assistance programs. USDA also supports nutrition education and
intervention, as well as research, to improve dietary habits of low-
income Americans. In the April 2002 announcement regarding the
expansion of 5 A Day, the Secretary of Agriculture noted that the food
assistance programs enable USDA to reach millions of Americans and that
USDA will commit the necessary resources to meet 5 A Day goals.
However, USDA has not yet identified specific strategies for this 5 A
Day commitment or for helping food assistance participants meet the
Healthy People 2010 objectives related to fruits and vegetables.
Federal officials and academic nutrition experts, as well as food
advocacy and consumer groups, have identified a number of actions the
federal government could take to encourage more Americans to consume
the recommended 5 to 9 daily servings of fruits and vegetables. These
actions include expanding nutrition education efforts, such as 5 A Day;
modifying the WIC program to allow participants to choose from more of
those fruits and vegetables important to disease prevention; expanding
the use of DOD Fresh in schools; and expanding farmers‘ market programs
for food assistance participants. These options could require
additional resources or redirecting existing resources from other
programs. That notwithstanding, USDA and HHS have committed to
expanding 5 A Day, and USDA is already considering changes in WIC to
allow more choices of vegetables.
This report makes recommendations to USDA and HHS to encourage
Americans to increase their consumption of fruits and vegetables
important in disease prevention as part of a healthy diet. In
commenting on a draft of this report, USDA and HHS generally concurred
with our recommendations, although both pointed out that fruit and
vegetable consumption should be addressed in the context of total diet.
We agree. While the report focuses on fruits and vegetables, it
discusses their importance as part of a healthy diet. In addition, HHS
stated that we were too definitive about linking disease prevention to
fruit and vegetable consumption and that we failed to consider the
totality of the scientific evidence. We modified the report language to
clarify the strength of the linkages and added citations for the
sources of our information throughout the report. The information we
present on health benefits came from NIH and CDC reports summarizing
the related research and from documents and research articles given to
us by federal officials specifically for the purpose of identifying
such linkages.
Background:
USDA‘s Food Guide Pyramid visually depicts federal guidance for the
number of servings needed in each of five food groups to provide a
healthy diet. (See fig. 1.) For example, the Pyramid recommends eating
from 2 to 4 servings of fruit and 3 to 5 servings of vegetables daily.
Figure 1: USDA‘s Food Guide Pyramid:
[See PDF for image]
Source: U.S. Department of Agriculture/U.S. Department of Health and
Human Services:
[End of figure]
The specific number of servings of fruits and vegetables is based on
nutrient requirements and energy needs, which are associated with
gender, age, and activity level. (See table 1.) For example, most
children and many teenagers and adults should consume 7 servings daily-
-4 of vegetables and 3 of fruit.
Table 1: Recommended Daily Fruit and Vegetable Servings for Men, Women,
and Children, Based on Age and Activity Level:
Type of person: Children ages 2 to 6 years, most women, some older
adults; Recommended servings: Vegetables:
3; Recommended servings: Fruits: 2.
Type of person: Children over 6, teen girls, active women, most men;
Recommended servings: Vegetables: 4; Recommended servings: Fruits: 3.
Type of person: Teen boys and active men; Recommended servings:
Vegetables: 5; Recommended servings: Fruits: 4.
Source: Dietary Guidelines for Americans, 2000.
[End of table]
All federal nutrition education and food assistance programs are
required to promote the Dietary Guidelines for Americans. USDA uses the
guidelines and the Food Guide Pyramid as the science base for nutrition
education efforts in the food assistance programs. Table 2 provides
information on participation, benefits, and nutrition education funding
for the Food Stamp Program, WIC, and the School Lunch and Breakfast
Programs, as well as the WIC and seniors farmers‘ market programs.
Table 2: Participation, Total Funding, Nutrition Education Funding, and
Average Nutrition Education Funding per Participant for Selected Food
Assistance Programs, Fiscal Year 2001:
Program: Food Stamp Program; Number of participants: 17.3; Total
program obligations: $17,826.9; Nutrition
education obligations: $148.3; Nutrition education obligations per
participant: $8.57.
Program: School Lunch and; Breakfast Programs; Number of participants:
27.5;
7.8; Total
program obligations: ; 8,234.7; Nutrition
education obligations: ; 13.8[A]; Nutrition education obligations per
participant: ;
