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Consumption Could Yield Health Benefits for Americans' which was 
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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 Agricultures 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:



GAOs 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: USDAs Fruit Categories:



Table 8: USDAs 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: USDAs 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 USDAs 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 HHSs 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 publics 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.



USDAs 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:



USDAs 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: USDAs 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: ; <0.27[A].



Program: WIC; Number of participants: 7.3; Total 

program obligations: 4,199.1; Nutrition 

education obligations: 235.9; Nutrition education obligations per 

participant: 32.32.



Program: WIC Farmers Market Nutrition Program; Number of participants: 
; 

2.1[B]; Total 

program obligations: ; 21.0; Nutrition 

education obligations: [C]; Nutrition education obligations per 

participant: [C].



Program: Seniors Farmers Market Nutrition Program; Number of 
participants: ; 

<0.4; Total 

program obligations: ; 15.0; Nutrition 

education obligations: [C]; Nutrition education obligations per 

participant: [C].



Legend:



< means less than.



[A] This number reflects the obligations divided by 50.5 million 

children (47.9 million eligible for school meals and 2.6 million in the 

Child and Adult Care Food Program).



[B] Total WIC recipients to whom farmers market coupons were issued 

with either federal or nonfederal funds or both.



[C] Farmers market programs provide a small nutrition education 

benefit; however, the amount is not tracked.



Source: GAOs analysis of data from USDAs Food and Nutrition Service 

and the National Association of Farmers Market Nutrition Programs.



[End of table]



USDAs food assistance programs serve one in six Americans each year. 

As table 2 shows, in terms of funding, the Food Stamp Program is by far 

the largest, having over $17.8 billion in funding in fiscal year 2001. 

Slightly over half of the recipients are children, and about 20 percent 

are elderly or disabled. In terms of participation, the School Lunch 

and Breakfast Programs serve the greatest number of people (27.5 

million and 7.8 million, respectively)--and are available to nearly 48 

million school children.[Footnote 2] As a result of school meals, 

participants in these programs consume greater amounts of several 

important nutrients, such as calcium.



WIC has seven food packages[Footnote 3]--three for pregnant or 

postpartum women, two for children, and two for infants. Depending on 

the package, WIC benefits may be used to purchase cereals, 100 percent 

fruit (or vegetable) juice, eggs, milk, cheese, peanut butter, dried 

beans, infant formula, tuna, and carrots. WIC serves about half of all 

infants and a quarter of all children from 1 through 4 years old in the 

United States.[Footnote 4] WIC is considered one of the most successful 

nutrition interventions, increasing birth weights and providing other 

health benefits.



Regarding nutrition education, USDA provides the lions share of 

federal funding, although HHS, DOD, and other federal agencies fund 

nutrition education efforts as well. For food assistance participants, 

USDA obligated about $398 million toward nutrition education in fiscal 

year 2001. Nutrition education for WIC participants accounted for about 

half of USDAs total nutrition education funding. As table 2 shows, 

funding per participant for nutrition education varied greatly--from 

$32 per WIC participant to less than $0.27 per child in the school meal 

programs. In fiscal year 2001 CDC spent $16.2 million for nutrition, 

obesity, and physical activity efforts; the National Cancer Institute 

spent $3.6 million for 5 A Day initiatives; DOD spent $3.5 million for 

nutrition education activities for the services.



In addition to food assistance and nutrition education programs, other 

federal programs and policies--such as trade restrictions and 

environmental regulations--have the potential for affecting the 

consumption of fruits and vegetables. For example, trade restrictions 

in the form of tariffs on some fruits and vegetables result in higher 

prices that could reduce U.S. consumption of those fruits and 

vegetables. Likewise, environmental regulations limiting pesticides 

use may increase farm costs, which can reduce the quantities of fruits 

and vegetables sent to market, thereby increasing price and lowering 

consumption. However, the effect of trade restrictions and 

environmental regulations on farm-level prices would have to be 

substantial to have a large impact on consumption, because farm-level 

prices account for about one-third of retail prices for fruits and 

vegetables. Appendix III provides more detail on how these programs and 

regulations can affect fruit and vegetable consumption.



The food environment is a major factor that affects the consumption 

of fruits and vegetables. The food environment includes prices set by 

retailers; access to and availability (year-round or seasonal) in local 

groceries, markets, and restaurants; the quality of fresh produce; the 

time available for shopping, preparation, and eating; and the ready 

availability, appeal, and advertising for and prices of other foods. 

Taste preferences and familiarity with foods of a particular culture 

are other important factors in food choices.



Consuming the Recommended Servings of Fruits and Vegetables Would 

Reduce the Risk for Some Chronic Diseases:



Heart disease, cancer, stroke, and diabetes are among the leading 

causes of death for Americans. In fact, 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.[Footnote 5] Studying the relationship between diet and 

chronic diseases is challenging because, among other things, it is 

difficult to measure and account for all potential risk factors; this 

challenge is compounded because chronic diseases may take many years to 

develop. However, extensive and consistent evidence shows that diet is 

one of the leading risk factors for these diseases.



Although no diet can guarantee full protection against any disease, the 

recommendations from HHS and USDA and health organizations such as the 

American Cancer Society and American Heart Association indicate that 

consuming the recommended 5 to 9 daily servings of fruits and 

vegetables as part of a healthy diet provides some of the best dietary 

protection against disease. Research links increased fruit and 

vegetable consumption to reduction in the risk of heart disease and 

many types of cancer. Research also suggests their potential benefits 

for reducing the risk of stroke, diabetes, diverticulosis, and obesity, 

according to reviews by NIH, CDC, and academic experts. Fruits and 

vegetables are among the most concentrated natural sources of over 100 

beneficial vitamins, minerals, and other dietary compounds such as 

fiber and antioxidants important to disease prevention. With regard to 

the specific health benefits of fruits and vegetables, studies show 

that people who consume 5 or more servings daily have about one-half 

the cancer risk of those who consume 2 or fewer servings, according to 

a National Institutes of Health report.[Footnote 6] That report also 

stated that, according to studies, diets high in fruits and vegetables 

are associated with a 20 to 40 percent reduction in the occurrence of 

coronary heart disease. Appendix IV describes some of the evidence that 

links fruit and vegetable consumption to reducing the risk for heart 

disease and cancer as well as possible links to reducing the risk for 

stroke, diabetes, obesity, and diverticulosis.



Because it is not clear how single nutrients, combinations of 

nutrients, the over consumption of nutrients, or age affect ones risk 

of specific diseases such as cancer, experts advise consuming a variety 

of fruits and vegetables to ensure an adequate intake of all known and 

as yet unidentified dietary compounds. A variety of deeply colored 

fruits, such as apricots, blueberries, and citrus fruits, and dark 

green or orange vegetables, such as spinach and carrots, are 

particularly rich in vitamins, minerals, antioxidants, other 

phytochemicals, and fiber.[Footnote 7]



Americans Consumption of Fruits and Vegetables Has Increased Somewhat 

Under Federal Policy, Guidance, and Education Programs for the General 

Public:



Under current federal policy, guidance, and nutrition education 

programs, the consumption of fruits and vegetables by the general 

public as a whole has increased somewhat, yet most Americans consume 

fruits and vegetables below recommended levels. The most widely 

recognized nutrition guidance--the Food Guide Pyramid graphic--does not 

clearly convey some important nutrition guidance that could help 

Americans close this consumption gap, and USDA is currently assessing 

the Pyramid for possible updates. In recognition of the diet shortfall 

in fruits and vegetables, HHSs strategic plan identifies 5 A Day as 

one strategy for achieving its objective of improving the diet of 

Americans. Moreover, the April 2002 announcement by HHS and USDA to 

expand 5 A Day may further encourage Americans to consume the 

recommended 5 to 9 daily servings.



While Americans Have Increased Their Consumption of Fruits and 

Vegetables, Most Consume These Foods Below Recommended Levels:



Under federal policy and guidance--Dietary Guidelines for Americans, 

Healthy People 2010, and the Food Guide Pyramid--the consumption of 

fruits and vegetables has improved somewhat.[Footnote 8] Between the 

1989-91 and 1994-96 time frames, the most recent years for which 

consumption data are available, fruit and vegetable consumption each 

increased by 0.2 serving (or nearly half a serving in total), such that 

the average consumption of fruits and vegetables is near the minimum 

recommended 5 servings a day. In addition to federal policy and 

guidance, USDAs Economic Research Service points to the increased 

year-round availability of fruits and vegetables as another factor 

influencing consumption. Nonetheless, most Americans still fall short 

of consuming the recommended levels for health promotion and disease 

prevention. As table 3 shows, even with the increase, only 23 percent 

of Americans get their recommended servings of fruits, and 41 percent, 

their recommended servings of vegetables.



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:



Food: Fruits; Average servings consumed: 1989-91: 1.3; Average servings 

consumed: 1994-96: 1.5; Percentage of Americans consuming minimum: 2 

servings of fruit, 3 servings of vegetables, 1994-96: 28; Percentage of 

Americans meeting their recommended servings:[A] 2-4 servings of fruit, 

3-5 servings of vegetables, 1994-96: 23.



Food: Vegetables; Average servings consumed: 1989-91: 3.2; Average 

servings consumed: 1994-96: 3.4; Percentage of Americans consuming 

minimum: 2 servings of fruit, 3 servings of vegetables, 1994-96: 49; 

Percentage of Americans meeting their recommended servings:[A] 2-4 

servings of fruit, 3-5 servings of vegetables, 1994-96: 41.



[A] Adjusted for gender, age, and activity level.



Source: USDA Continuing Survey of Food Intakes by Individuals, 1989-91 

and 1994-96.



[End of table]



According to USDA and NIH researchers, consumption of the deeply 

colored fruits and deep green or orange vegetables falls far short of 

what is recommended for disease prevention. USDAs data for dark green 

or orange vegetables indicates that consumption increased by less than 

one-tenth of a serving between the 1989-91 and 1994-96 surveys. Indeed, 

only about 8 percent of Americans get the recommended daily 1 or more 

servings of dark green or orange vegetables.[Footnote 9] Moreover, only 

3 percent of Americans get both the recommended number of servings of 

vegetables and at least 1 serving daily of a dark green or orange 

vegetable. There may be many reasons why the consumption of fruits and 

vegetables, particularly deeply colored ones, is low. For example, many 

people may not be aware of the importance of eating deeply colored 

fruits and vegetables. In addition, taste, price, and seasonal 

availability, among other factors, may affect consumption, as might the 

ready availability of other foods.



Many Americans do not incorporate adequate variety into their daily 

diet. As noted earlier, eating a wide variety of fruits and vegetables 

is important because different fruits and vegetables are rich in 

different nutrients. For example, fruits such as apricots and 

blueberries, are excellent sources of protective phytochemicals and, 

although most citrus is consumed as juice, a fresh orange has 27 times 

the fiber content of orange juice. As shown in figure 2, three fruit 

sources--citrus (fresh and juice), apples (fresh and juice), and 

bananas--accounted for 52 percent of total fruit servings in 1999. 

While these provide important nutrients, they do not supply all the 

nutrients important for disease prevention and health promotion. (See 

app. V for a detailed listing of fruits in each of the categories for 

fig. 2.):



Figure 2: Percentage of Fruit Servings by Type, 1999:



[See PDF for image]



Note: Other includes cherries, peaches, pears, plums, pineapple, 

prunes, and raisins, among others. (See app. V for a complete list.) 

The percentages do not add to 100 percent because of rounding.



Source: USDA, Economic Research Service food supply data.



[End of figure]



Americans vegetable consumption tells a similar story. Although 

federal dietary guidance recommends eating a variety of vegetables--

including dark green or orange; starchy (e.g., potatoes, dry beans, 

peas, and lentils); and others--consumers eat a limited variety. As 

shown in figure 3, three foods--white potatoes, iceberg lettuce, and 

canned tomatoes--accounted for 53 percent of total vegetable servings 

in 1999. Although white potatoes are an excellent source of potassium 

and vitamin C and are naturally low in fat, frozen potatoes (mostly 

french fries) and potato chips together accounted for 43 percent of 

starchy vegetable servings and 17 percent of total vegetable servings. 

The added-fat in french fries and potato chips carries calories that 

contribute to overweight and obesity. Moreover, the consumption of dark 

green or orange vegetables most likely to prevent disease and promote 

health totaled only 0.4 serving per day, well below the 1 or more daily 

servings suggested for the average person. (See app. V for a detailed 

listing of vegetables in each of the categories for fig. 3.):



Figure 3: Percentage of Vegetable Servings by Type, 1999:



[See PDF for image]



Note: Other includes artichoke, asparagus, cabbage, eggplant, olives, 

and onions, among others. (See app. V for a complete list.) The 

percentages do not add to 100 percent because of rounding.



Source: USDA, Economic Research Service food supply data.



[End of figure]



The Food Guide Pyramid Graphic Does Not Provide Some Important 

Nutrition Guidance About Fruits and Vegetables:



USDAs Food Guide Pyramid graphic--the most widely recognized nutrition 

guidance--does not communicate the need to consume a variety of fruits 

and vegetables, particularly the deeply colored ones that the Dietary 

Guidelines for Americans identifies as important for disease prevention 

and health promotion. (See fig. 1 on page 6.) USDA pointed out that the 

Pyramid graphic, introduced in 1992, was not intended to stand alone 

but, rather, it was to be used along with the information in the 

Pyramid brochure. However, the Pyramid graphic is typically displayed 

alone--on food packages and in classrooms, grocery stores, and 

cafeterias. The Pyramid brochure, which was modified slightly in 1996, 

provides selection tips for a variety of fruits and vegetables, 

including dark green or orange vegetables. According to HHS officials, 

a diet based on the Pyramid graphic provides adequate nutrient intake 

when people consume a variety of the recommended servings of fruits and 

vegetables, for example half of fruit servings from citrus, melons, or 

berries and one-third of vegetable servings from dark green or orange 

vegetables.



Furthermore, a 2001 publication by the National Cancer Institute stated 

that the inadequacies and imbalances in the current American diet--such 

as the low consumption of dark green or orange vegetables--relate to 

issues that were integral to the development of the Food Guide Pyramid 

but not captured in the Pyramid graphic.[Footnote 10] Although the 

Pyramid graphic is based on analyses from more than 10 years ago, 

USDAs Center for Nutrition Policy and Promotion reanalyzed it in the 

mid-1990s and determined that it was consistent with the 1995 Dietary 

Guidelines for Americans and met most nutrient objectives. The center 

recently initiated a reassessment of the Food Guide Pyramid to ensure 

that it is consistent with the 2000 Dietary Guidelines for Americans 

and new nutrient intake recommendations released by the National 

Academy of Sciences.[Footnote 11] The center plans to complete its 

assessment and any revisions before the 2005 update of the Dietary 

Guidelines for Americans.



5 A Day Appears to Be an Effective Program, and HHS and USDA Have 

Announced Plans for Its Expansion:



The 5 A Day program--a public-private partnership between federal/

state/local governments, the fruit and vegetable industry, and 

supermarkets--is the only federal nutrition education and intervention 

effort focused on increasing fruit and vegetable consumption. Its long-

range purpose is to help reduce the incidence of cancer and other 

chronic diseases through dietary improvements--specifically by getting 

Americans to consume 5 to 9 servings of fruits and vegetables daily. 

The National Cancer Institute coordinates and provides the funding for 

the federal side of the partnership, CDC develops and manages state-

level programs, and the Produce for Better Health Foundation, a 

nonprofit organization of approximately 800 members of the fruit and 

vegetable industry and supermarkets, coordinates the private side of 

the partnership. To support a variety of 5 A Day program and research 

activities, the National Cancer Institute spent $3.6 million in fiscal 

year 2001. In fiscal year 2002, the Institute expects to spend $4.5 

million; California, Florida, and Arizona have committed to providing 

$3 million, $1.7 million, and $0.3 million, respectively; and industry 

has committed about $3 million.



The success of 5 A Day may be due to its use of a combination of 

strategies, including hands-on experiences (e.g., food preparation and 

field-trips), visual cues (signs on cafeteria doors and at registers), 

and media campaigns (TV, radio, and print). Following are three 

examples of 5 A Day community-based programs that have had sustained 

results in improving fruit and vegetable consumption:[Footnote 12]



* An 8-week program of activities for 4th-and 5th-grade children in 

three California communities increased the consumption of fruits and 

vegetables by over 1.5 servings after the first year and about 1 

serving after the second year, compared with consumption by children 

who did not receive the activities. The program included classroom 

activities (lessons, problem-solving, and taste testing), cafeteria/

food service activities (promotion of fruits and vegetables), and 

parent activities (homework assignments, brochures, refrigerator 

magnets). That program was subsequently expanded statewide.



* A 2-year study in 28 small-to medium-sized businesses in Seattle, 

Washington, provided half the sites with 5 A Day signs in the work 

environment to provide constant reminders about eating fruits and 

vegetables and worked with food-service staff to make more fruits and 

vegetables available as part of the regular menus. Nutrition education 

was provided through a specialist who visited the work sites, and an 

employee advisory board was used to encourage behavior change. Two 

years after the program concluded, the employees who received the 5 A 

Day program averaged about a third of a serving more of fruits and 

vegetables than the control group.



* A 20-month program involving 49 predominantly African-American 

churches in North Carolina resulted in a 0.85-serving increase in fruit 

and vegetable consumption at the 2-year follow-up. According to study 

participants, having more fruit and vegetables served at church 

functions, having the pastor promote the 5 A Day message from the 

pulpit, and receiving personalized printed materials were influential 

in increasing their consumption. The American Cancer Society has begun 

a nationwide program based on the design of this study.



In November 2000, the NIHs National Cancer Institute reported the 

results of an independent review of the science underlying the 5 A Day 

program, its implementation and accomplishments, and the degree to 

which its goals and objectives were achieved. The evaluation found that 

the evidence was convincing and that the program contributed to the 

small increases in fruit and vegetable consumption over the past 

decade. It recommended that the National Cancer Institute, among other 

things, increase resources, staffing, and expertise available to the 

states for the dissemination, monitoring, and evaluation of the 5 A Day 

program; expand 5 A Day by partnering with CDC to manage states 5 A 

Day programs and develop a surveillance plan to monitor fruit and 

vegetable consumption; and partner with USDA to better focus dietary 

guidelines and promote research in agriculture and economic policies. 

The evaluation further recommended that the National Cancer Institute 

partner with other NIH institutes to promote fruit and vegetable 

research.[Footnote 13]



In response to those recommendations, in April 2002, the Secretaries of 

Agriculture and Health and Human Services announced plans to expand 5 A 

Day. A memorandum of understanding signed by (1) the Director, National 

Cancer Institute; (2) the Director, National Center for Chronic Disease 

Prevention and Health Promotion, CDC; and (3) USDAs Under Secretaries 

for Food, Nutrition, and Consumer Services; Research, Education, and 

Economics; and Marketing and Regulatory Programs, formalized 

commitments to enhance and more effectively coordinate the national 5 A 

Day partnership. It also established a framework for cooperation 

between the agencies to promote 5 A Day, whereby each agency pledges 

its commitment to encourage all Americans to eat 5 to 9 servings of 

fruits and vegetables daily.



To be successful, however, any crosscutting, multiagency efforts such 

as the new 5 A Day initiative depend on certain key elements, including 

clear leadership, an overarching strategy, and effective partnerships 

between the federal and state agencies. These are critical elements 

that underpin the Government Performance and Results Act of 

1993,[Footnote 14] which provides agencies with a systematic approach 

for managing programs. The results acts principles include developing 

a strategy, identifying goals and objectives, and establishing 

performance measures. The act states that performance goals should be 

sufficiently precise to allow for a determination of performance. When 

participants in a crosscutting program understand how their missions 

contribute to a common goal--such as achieving the Healthy People 2010 

nutrition objectives--they can develop specific goals and objectives 

and implementation plans to reinforce each others efforts. We 

recognize the difficulties associated with making changes in dietary 

habits. However, we believe that if HHS and USDA work together in a 

comprehensive strategic approach, they are more likely to be 

successful.



Since it released Healthy People 2010, HHS has identified 5 A Day in 

its strategic plan for 2001-2006 as one strategy for achieving its 

objective of improving the diet of Americans.[Footnote 15] With the 

NIHs National Cancer Institute as the lead federal agency for the new 

5 A Day initiative, a steering committee--composed of the National 

Cancer Institute, CDC, USDA, the American Cancer Society, Produce for 

Better Health Foundation, and others--was created to plan and 

collaborate on specific activities to achieve the 5 A Day goal. The 

memorandum of understanding specified activities for each agency and 

supported, among other things, comprehensive planning at the federal, 

state, and local levels, and improved the availability of high-quality 

data related to fruit and vegetable consumption. If translated into 

specific strategies and targets in agencies annual performance plans, 

these commitments could provide a framework to guide HHS efforts to 

help Americans achieve the Healthy People 2010 objectives for fruits 

and vegetables.



Food Assistance Programs Have Had Mixed Effects on Consumption of 

Fruits and Vegetables by Lower-Income Citizens:



Fruit and vegetable consumption by food stamp participants and women in 

WIC is similar to that of low-income individuals who do not participate 

in these programs; both low-income groups have lower consumption than 

the general public. However, children in WIC and participants in the 

school meal programs and farmers market programs have begun to show 

some improvement. In the April 2002 announcement by USDA and HHS to 

expand 5 A Day, USDA pledged to support 5 A Day in its food assistance 

programs. The 5 A Day commitments could provide a framework for 

incorporating the 2010 objectives in USDAs strategic and performance 

plans.



Consumption of Fruits and Vegetables by Participants in Food Assistance 

Programs Is Similar to or Slightly Better Than That of Low-Income 

Nonparticipants:



The key purposes of the food assistance programs are to reduce hunger, 

increase food security, and improve nutrition and health, while 

supporting American agriculture. Increasing fruit and vegetable 

consumption is not a primary focus, yet it is part of USDAs nutrition 

education efforts under these programs. Nonetheless, the consumption of 

fruits and vegetables by food stamp participants and women in WIC 

differs little from that of similar nonparticipants, and consumption by 

children in the school meal programs is greater than that of 

nonparticipants, as shown in the right column of figure 4. In addition, 

according to data covering 1994-96 and 1998--different time frames from 

those presented in figure 4--children in WIC also have increased their 

consumption of fruits and vegetables. The limited information on 

farmers market participants--in WIC and in the seniors program--

suggests that they too consume more fruits and vegetables than 

nonparticipants.



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:



[See PDF for image]



Note: According to USDA, the 0.2 difference in fruit serving between 

women in WIC and similar nonparticipants is not statistically 

significant. The WIC data presented here are USDA projections for a 30-

year-old participant and similar nonparticipant.



Source: Food stamp participant data are from the Continuing Survey of 

Food Intakes by Individuals; WIC data are from the U.S. Department of 

Agriculture, Economic Research Service, The Effect on Dietary Quality 

of Participation in the Food Stamp and WIC Programs (Washington, D.C.: 

September 2000); School meal data are from U.S. Department of 

Agriculture, Food and Nutrition Service, Childrens Diets in the Mid-

1990s: Dietary Intake and Its Relationship with School Meal 

Participation (Alexandria, Va.: January 2001).



[End of figure]



Our analysis of fruit and vegetable consumption, food benefits, and 

related initiatives for the Food Stamp Program, WIC, the National 

School Lunch and Breakfast Programs, and the WIC and Seniors Farmers 

Market Nutrition Programs are as follows.[Footnote 16]



* The Food Stamp Program. Food stamp recipients receive on average less 

than $80 monthly to help them purchase foods of their choice. They 

consume about the same amounts of fruits and vegetables as similar low-

income nonparticipants. According to USDA, program participants 

consumed 1.3 servings of fruits and 3.0 servings of vegetables as 

compared with 1.3 and 3.1 servings, respectively, for low-income 

nonparticipants. Both low-income groups fall short of the national 

average of 1.5 servings of fruits and 3.3 servings of vegetables, as 

well as the recommended number of servings--2-4 of fruits and 3-5 of 

vegetables. Furthermore, both participants and low-income 

nonparticipants consumed only 0.1 serving each of deep green or orange 

vegetables--those most important to disease prevention. According to 

USDA, the programs electronic benefit payment system may discourage 

participants from shopping at farmers markets because many markets do 

not have the technology needed to access payments. In 2002, New York 

State received $100,000 in federal funds to support a pilot program in 

the state to implement wireless and other innovative electronic 

solutions that will allow farmers markets to accept food stamp and WIC 

benefits.



* WIC. As with food stamp participants, women in WIC have about the 

same low fruit and vegetable consumption as similar 

nonparticipants.[Footnote 17] For example, according to USDA data, a 

30-year-old woman in WIC would consume 0.2 serving more fruit (1.3 

versus 1.1)[Footnote 18] and the same number of servings of vegetables 

(3.5) as a similar nonparticipant, according to USDA estimates. 

Children ages 2 through 4 in WIC consume 0.3 more serving of fruit (1.4 

versus 1.1) and 0.1 serving more of vegetables (1.2 versus 1.1). The 

five WIC packages for women and children designate allowable foods 

selected to improve nutrient intake.[Footnote 19] Only one WIC food 

package includes vegetables, and it provides only about one-quarter 

serving--all in carrots. In contrast, the five WIC packages for women 

and children provide far more servings of other food groups. For 

example, all five WIC packages for women and children provide from 3.2 

to 4.1 of the recommended 3 to 5 daily servings of dairy products. 

Appendix VI shows the foods in the five WIC packages for women and 

children.



* The National School Lunch and Breakfast Programs. The millions of 

children who participate in School Lunch consume daily, on average, 

twice as many servings of vegetables as nonparticipants for lunch (1.3 

servings versus 0.6); however, most of that difference is in the form 

of white potatoes--mostly french fries.[Footnote 20] With respect to 

fruit consumption, there is no difference between the participants of 

School Lunch and similar nonparticipants. The millions of children who 

participate in School Breakfast consume daily, on average, 0.4 more 

serving of fruit than nonparticipants for breakfast (0.7 serving versus 

0.3).



FNS officials pointed out that their most significant initiative to 

improve school meals (the School Meals Initiative) was begun in 1995 

and that the most current consumption data (for 1994-96) would not 

capture potential increases in consumption that may have occurred after 

1996. The School Meals Initiative included new nutrition standards for 

school meals and educational and technical resources to assist food 

service personnel in preparing nutritious and appealing meals. In 2001 

USDA reported, from a survey of school food service authorities, that 

schools reported an increase in (1) the numbers of fruits and/or 

vegetables offered, (2) the purchases of fruits and vegetables, and (3) 

plate waste for cooked vegetables.[Footnote 21] However, it is unclear 

whether the increased overall purchases or offerings resulted in 

increased consumption because purchases or offerings per student or 

meal were not reported.



Although participation in the School Lunch and Breakfast Programs has 

been shown to improve dietary quality, 40 percent of children do not 

eat the School Lunch and 83 percent do not eat School Breakfast in 

schools where the meals are offered. USDA reported that participation 

might be affected by other meal options available to students such as 

foods sold a la carte, in vending machines, and school stores or snack 

bars. Those foods do not have to meet the nutrition standards required 

for the USDA-reimbursable meals of School Lunch and Breakfast. USDA 

reported that a la carte sales are higher in higher-income schools and 

that as a la carte sales increase, school meal participation 

decreases.[Footnote 22]



* WIC Farmers Market Nutrition Program. A USDA-funded evaluation of a 

1991 pilot program that became the WIC Farmers Market program found, 

from a survey, that participants daily consumed an average of 0.2 

serving more of both fresh fruits and vegetables than low-income 

nonparticipants. According to the survey, which was based on a random 

statistical sample, participants consumed an average of 3.6 servings of 

fruit and 4.1 servings of vegetables daily, compared with 3.4 and 3.9 

servings, respectively, for nonparticipants. In surveys developed by 

the National Farmers Market Association and conducted by states 

annually from 1996 to 2000, most of the over 20,000 participants 

surveyed reported that they had increased their consumption of fresh 

fruits and vegetables. In the 2000 survey, 71 percent reported that 

they ate more fresh fruits and vegetables than usual and 80 percent 

reported that they planned to eat more year round. Surveys for each of 

the previous 4 years had similar results.[Footnote 23] Over 2 million 

WIC participants receive farmers market coupons; only about 60 percent 

redeem them, annually. According to FNS, eligible individuals may not 

participate because, among other things, farmers markets are often not 

located in or near low-income areas and they may not be familiar with 

farmers markets or with the program.



* The Seniors Farmers Market Nutrition Program. Established in 2001, 

the seniors program serves about 380,000 low-income elderly people. 

This small program is based on the WIC farmers market program and the 

two farmers market programs are often run by the same state and local 

agencies. Although national data are not available, one county in 

Washington State surveyed 87 homebound participants, who reported 

increasing their consumption of fruits and vegetables by one serving 

daily.



Under the school meal programs, USDA has increased its spending for 

canned, frozen, and fresh fruits and vegetables from $140 million in 

1996 to $243 million in 2001. In addition, under an agreement between 

USDA and DOD, DOD Fresh provides about $31 million in fresh produce to 

schools in 39 states, Puerto Rico, and Guam. Participating schools 

benefit from DODs purchasing power and distribution network. According 

to the American School Food Service Association, DOD Fresh generally 

provides lower-priced, more-varied, and better-quality fruits and 

vegetables than are otherwise available to schools and may result in 

increased consumption. Dark green or orange vegetables are among the 10 

most popular items ordered by schools through DOD Fresh. In 1997 we 

identified states use of DOD Fresh as a best practice for improving 

the nutritional content of school meals.[Footnote 24] Because DOD uses 

a decentralized system to purchase produce from local vendors, we 

reported that it was able to provide high-quality fresh produce. 

According to USDA, many school food authorities can purchase fresh 

produce of similarly high-quality from distributors and, seasonally, 

from local sources.



Nonetheless, fruits and vegetables are the most frequently wasted 

(e.g., thrown away) food items in the School Lunch Program, ranging 

from 21-percent to 42-percent waste.[Footnote 25] In 2002 USDA reported 

that wasted food--including fruits and vegetables--cost USDA $600 

million annually.[Footnote 26] Studies have shown that this waste can 

be decreased by such factors as (1) scheduling recess before lunch, (2) 

increasing the use of fresh produce and local foods, (3) involving 

students in meal planning, (4) introducing new fruits and vegetables to 

students before they appear in school meals, and (5) allowing students 

to serve themselves--for example, using self-service salad/meal bars.



Over the past few years, FNS has helped fund some innovative programs 

implemented by local and state agencies that have been found to promote 

fruit and vegetable consumption. One such program--Food Sense--is under 

way in two counties in Washington State. Food Sense provides 1,300 low-

income adults with handouts, recipes, and information about the Food 

Guide Pyramid and the Dietary Guidelines for Americans, and how to 

select and prepare fresh produce. The program also serves 2,000 

children from low-income households and uses storytelling, games, and 

healthy snack tasting to reinforce healthy food choices. State data on 

the program show that 75 percent of the adults and 31 percent of the 

children participating in Food Sense ate more fruits and vegetables 

daily as a result of the program.



Another initiative, funded jointly by USDA and three California school 

districts, also appears to have increased the consumption of fruits and 

vegetables in the School Lunch and School Breakfast Programs.[Footnote 

27] That effort provided salad bars as an alternative to the standard 

hot meal, along with hands-on nutrition education in the classroom, 

contests, and tours of local farms and farmers markets. Students who 

consumed the salad bar and were surveyed, reported increasing their 

daily consumption of fresh fruits and vegetables by an average of 1 to 

2 servings. To meet USDA requirements for meal reimbursement, the 

schools salad bars offered items from each of the five food groups 

(grain, milk, protein, fruit, and vegetables), and students were 

required to take a minimum of one serving from three groups.



In addition to the FNS efforts, USDAs Cooperative State Research, 

Education and Extension Service administers a nutrition education 

effort--the Expanded Food and Nutrition Education Program--to improve 

the dietary habits of low-income children and families with children. 

In 2001 about 447,000 children and 164,000 adults were in the program, 

which was funded at $58.6 million. At a cost of about $96 per 

participant, the program includes a series of lessons taught by peer 

instructors over several months and uses hands-on approaches, such as 

cooking new recipes, that enable participants to gain the practical 

skills necessary to make positive behavioral change. Nearly three 

quarters of the participants entering the program in 2001 were 

receiving federal food assistance; an additional 8 percent were on food 

assistance by the time they left the program. For about a decade, the 

program has tracked participants consumption levels for each food 

group when participants enter and exit the program. The 106,000 adult 

participants who completed the program in fiscal year 2001 increased 

their fruit and vegetable consumption by more than 62 percent (from 2.9 

to 4.7 servings), according to program evaluation data. According to 

USDA, evaluation data from participants has led to improvements in 

curriculum, staff development and training, new community partnerships, 

and increased cooperation with researchers who are studying diet-

related behavior.



In commenting on a draft of this report, USDA pointed out that its 

efforts to promote fruits and vegetables extend beyond food assistance 

and nutrition education to include agricultural, economic, and 

behavioral research; agricultural extension; and market development and 

support. For example, USDA sponsors research investigating the health-

promoting properties of fruits and vegetables, as well as the 

motivations and barriers to their consumption.



Opportunities Exist for USDA to Better Use Its Strategic and 

Performance Plans to Help Achieve the Healthy People 2010 Objectives 

for Fruits and Vegetables and Meet New 5 A Day Commitments:



USDAs strategic and performance plans do not specifically address the 

Healthy People 2010 objectives for increasing the proportion of 

Americans in food assistance programs who consume at least 2 servings 

of fruit and 3 of vegetables daily. USDAs strategic plan for 2000 to 

2005 has a goal and related targets for improving the overall diet of 

food assistance program participants through nutrition education and 

education-related research. To help achieve that goal, USDA recently 

launched the national EAT SMART. PLAY HARD.TM nutrition education and 

promotion campaign to convey motivational messages regarding nutrition 

and physical activity aimed at changing dietary behavior, among other 

things. In addition, USDAs 2003 revision to its 2002 performance plan 

includes a goal of improving access to fruits and vegetables, which it 

will measure by the funding provided to purchase fruits and vegetables 

for schools, and by the number of sites on Indian reservations 

receiving fresh fruits and vegetables.



According to an FNS planning official, the strategic and performance 

plans include a focus on overall dietary quality. Although these plans 

do not specifically address the Healthy People 2010 objectives related 

to fruits and vegetables, officials told us that USDA is working to 

increase fruit and vegetable consumption through improvements in 

nutrition education efforts, such as the EAT SMART. PLAY HARD.TM 

campaign. However, USDA has reported for several years that limited 

funding hinders nutrition education efforts and evaluation of those 

efforts. The current strategic plan also acknowledges that inadequate 

funding for nutrition education is the key factor that could hinder 

plans to improve Americans diet, including the diet of food assistance 

program participants. With regard to evaluating these efforts, a 1996 

report by USDAs Center for Nutrition Policy and Promotion cited 

inadequate funding as a major factor limiting the evaluation of USDAs 

nutrition education efforts.[Footnote 28] In 1999 FNS reported that the 

evaluation system was fragmented and minimal, and lacked outcome 

measures.[Footnote 29] Agriculture appropriations acts for the past 

several years have generally prohibited the use of food stamp, WIC, and 

school meal program funds for such evaluations.



Those funding constraints notwithstanding, in the April 2002 memorandum 

of understanding between USDA and HHS regarding 5 A Day, USDA pledged 

to plan and support the delivery of the 5 A Day message to food 

assistance participants. USDA has not yet identified what additional 

resources, if any, will be needed to accomplish this effort; however, 

the Secretary of Agriculture pledged to commit the necessary resources 

to meet the 5 A Day goals. As noted earlier, the strategic planning 

process is designed to address crosscutting, multiagency/government 

issues such as the expanded 5 A Day initiatives in the memo of 

understanding. In fact, the 5 A Day commitments could provide a 

framework for USDA to incorporate the 2010 objectives in strategic and 

performance plans. Identifying strategies and targets could help USDA 

implement its 5 A Day commitments, which in turn could help food 

assistance participants achieve national Healthy People 2010 objectives 

for fruits and vegetables.



Experts Have Identified Many Actions That Federal Agencies Could Take 

to Further Increase Consumption of Fruits and Vegetables:



Federal officials, academic nutrition experts, and representatives from 

industry, food advocacy, and consumer groups have identified a number 

of actions they believe the federal government could take to help 

people make better dietary choices and increase their consumption of 

fruits and vegetables.[Footnote 30] The actions most frequently 

identified include (1) expanding and improving federal nutrition 

education programs, (2) emphasizing the importance of program 

evaluation and related behavioral research efforts to maximize the 

impact of nutrition education, (3) providing incentives to encourage 

food stamp recipients to purchase fruits and vegetables, (4) including 

more fruits and vegetables in WIC packages, (5) expanding the 

availability of salad bars and access to DOD Fresh in schools, and (6) 

expanding farmers market programs for WIC participants and low-income 

seniors.[Footnote 31]



* Expand and improve federal nutrition education programs. To promote 

better nutrition, particularly fruit and vegetable consumption, USDA 

and HHS officials, university professors, and the Center for Science in 

the Public Interest emphasized to us the value of nutrition education 

programs for the general public and the need to expand federal 

investment in programs shown to be effective at changing dietary 

behavior. Several contrasted the food industrys annual advertising 

expenditures (about $11 billion, annually) to the federal governments 

nutrition education expenditures (under $500 million, annually). 

According to FNS, it is unrealistic to expect consumer behavior to be 

consistent with national nutrition goals in an environment that 

provides a barrage of messages that encourage poor nutrition. The 1999 

FNS report to Congress stated that an ongoing investment reinforcing 

the importance of nutrition education is essential to counter the 

environment that has been moving the general population toward poorer 

nutrition. The report further stated that adequate nutrition education 

for the general population--not just FNS program participants--is an 

essential component of an overall strategy because FNS program 

participants are influenced by trends that affect the population as a 

whole.



In addition, the Surgeon General recommended a national campaign to 

foster public awareness of the benefits of healthful dietary choices 

and physical activity. With regard to food assistance programs, the 

Surgeon General recommended expanding these nutrition education efforts 

as well. Likewise, the 1999 FNS report to Congress noted that nutrition 

education should be an integral benefit of all FNS programs. According 

to FNS, dependable funding for nutrition education is needed to support 

planning, program delivery, and the integration of services, and for 

the federal government to provide the necessary leadership and support. 

FNS also reported that the child nutrition programs--the largest of 

which are the School Lunch and Breakfast Programs--serve more 

participants, and yet have less funding per participant for nutrition 

education, than any other FNS program. The report noted that uneven 

nutrition education funding and reductions in program funding have 

decreased the capacity of state and local agencies to effectively 

deliver nutrition education to children. Similarly, CDC noted the need 

to improve the capacity of state programs that promote healthy 

behaviors to reduce the risk of chronic disease.[Footnote 32] CDCs 

long-term goal is to establish a nationwide network of state-based 

comprehensive nutrition and physical activity programs for the 

prevention and control of obesity and related chronic diseases, and to 

include 5 A Day activities as an essential component of every states 

nutrition education effort.



* Emphasize the importance of evaluating programs and conducting 

behavioral research to maximize the impact of nutrition education. In 

the 1999 report to Congress, FNS pointed out the need to invest in 

improved nutrition education evaluation.[Footnote 33] FNS officials and 

others agreed that adequate and reliable evaluations are needed to 

determine which program components improve diet so that FNS and state 

and local agencies administering the programs can plan effective 

nutrition education strategies. In a 2001 report on WIC, we recommended 

that FNS work with stakeholders to develop a strategic plan to evaluate 

the impacts of specific WIC nutrition services and include in the plan 

information on the types of research that could be done to evaluate the 

impacts of specific nutrition services as well as the data and the 

financial resources that would be needed to conduct such 

research.[Footnote 34] In addition to program evaluation, a number of 

experts, including the 2000 Dietary Guidelines Advisory Committee and 

the Surgeon General, recommended increasing behavioral research efforts 

to gain a greater understanding of what motivates people to make 

healthy food choices.[Footnote 35] Research findings could be used to 

improve the design of new, or make improvements in existing, nutrition 

education efforts. Officials from CDC also noted the need for more 

fruit-and vegetable-related economic, marketing, and consumer 

research, as well as research to clarify the roles of nutrients and 

other compounds found in fruits and vegetables that may be beneficial 

to health.



* Provide incentives to encourage food stamp recipients to purchase 

more fruits and vegetables. Academic nutrition experts and officials 

from the American Public Health Association, the state of California, 

food advocacy groups, the Center for Science in the Public Interest, 

and the Produce for Better Health Foundation suggested the use of 

incentives, such as double coupons or discounts, to encourage food 

stamp recipients to purchase fruits and vegetables. Californias 

Department of Health Services, in conjunction with three grocery chains 

that are 5 A Day partners, has proposed a pilot project to FNS to see 

how food stamp recipients respond to three different approaches for 

providing incentives to buy fruit and vegetables. These include coupons 

at checkout for free or discounted items, buy one, get one free 

promotions, and store discount cards that can be used with electronic 

benefit transfer cards. For example, stores have agreed to allow 

recipients to buy one, get one free for certain fruits and 

vegetables. The stores will feature different fruits and vegetables for 

which local food stamp participants have expressed preferences, and 

community partners will promote the program as part of a nutrition 

message. The grocery receipt would show the value of the free item as 

an additional incentive. The stores and the other industry partners in 

the pilot have agreed to pay for the free fruits and vegetables.



* Include more fruits and vegetables in WIC packages. The National WIC 

Association (formerly the National Association of WIC Directors), 

several health associations, and others have suggested that USDA 

broaden the WIC food package to include fruits and vegetables, because 

the current packages are inconsistent with the Dietary Guidelines for 

Americans. In a November 2000 letter to the Secretary of Agriculture, 

the American Cancer Society, American College of Preventive Medicine, 

other health associations, and industry groups urged USDA to broaden 

the WIC food package to include a variety of fresh produce. In 

addition, the National WIC Association, in a 2000 position paper, 

recommended that WIC packages offer a proportional balance of foods 

from each group in the Food Guide Pyramid. The association further 

stated that WIC should offer fresh, frozen, or canned fruits and 

vegetables, such as citrus fruits, tomatoes, sweet potatoes, greens, 

and broccoli.



USDA recognizes that revisions to the food packages are vital to 

bringing the WIC packages in line with current scientific dietary 

recommendations--the Dietary Guidelines for Americans. FNS had planned 

to publish a proposed rule in The Federal Register in September 2000 

that would add nutrient-dense leafy and other dark green or orange 

vegetables to five food packages, allow the substitution of canned 

legumes for dry legumes in four food packages, and reduce the servings 

of juice for three food packages. The final rule was to be effective 

September 2002. However, USDA decided to delay proposing the rule until 

after the 2000 election, because of concerns over potential opposition 

by industries that may lose revenue as a result of changes in the 

packages. The rule has yet to be published.



* Expand the availability of salad bars and DOD Fresh in schools. 

Federal and association officials in the 5 A Day partnership have 

called for the introduction of salad bars as part of all school meal 

programs. USDA has funded DOD Fresh at about $31 million per year for 

schools. Schools and state agencies have asked USDA to increase funding 

to make DOD Fresh available to more schools. Increased funding for DOD 

Fresh could also help provide produce for school salad bars.[Footnote 

36] In addition, USDA, the American Academy of Family Physicians, 

American Academy of Pediatrics, American Dietetic Association, National 

Hispanic Medical Association, and the National Medical Association have 

suggested that (1) foods that compete with school lunches be required 

to follow the same nutritional regulations as the school meals; (2) all 

students have designated lunch periods as near the middle of the school 

day as possible and of sufficient length to enjoy eating healthy foods 

with friends; and (3) schools provide enough serving areas to ensure 

student access to school meals with a minimum of wait time, among other 

things. Also, the Farm Security and Rural Investment Act of 2002 

includes a provision to pilot a program to offer free fruits and 

vegetables to school children in about 100 schools--25 schools in each 

of four states--and on an Indian reservation. This same act also 

includes a provision for mandatory spending on fruits and vegetables. 

The provision directs USDA to spend not less than $50 million for fresh 

fruits and vegetables for schools through DOD Fresh.



* Expand farmers market programs for WIC participants and the elderly. 

The American Public Health Association, the National WIC Association, 

the Center for Science in the Public Interest, and others support 

increasing farmers market programs for WIC and elderly 

participants.[Footnote 37] In addition, a few representatives noted 

that USDA agencies should collaborate to increase the number of markets 

in areas where WIC participants and other low-income people live. Such 

collaboration is needed because initiating farmers markets in low-

income areas is hindered by several factors including difficulties with 

finding space in a large city and farmers lack of familiarity with the 

redemption of WIC coupons, according to one university researcher. He 

further stated that USDAs Agricultural Marketing Service, which is 

responsible for promoting farmers markets, could work with extension 

agents as well as public service agencies to find suitable locations 

for these markets. In addition, some experts noted that most farmers 

markets do not have the technology, electricity, and telephone 

equipment needed to process the magnetic electronic benefit cards 

provided to food stamp recipients.



Some of these efforts--such as expanding nutrition education--would 

require additional federal resources, while others--such as emphasizing 

an evaluation of nutrition education efforts, expanding DOD Fresh, 

promoting salad bars in schools, and expanding farmers markets for WIC 

and the elderly--may only require redirecting existing federal 

resources. Adding more choices of fruits and/or vegetables to the WIC 

package without reducing other food items would require additional 

funding. However, if USDA reduces the servings of other foods, then 

additional resources may not be required, but industries that stand to 

lose revenue are likely to oppose the proposal.



Conclusions:



Although federal nutrition policy and guidance--the Dietary Guidelines 

for Americans and the Healthy People 2010 nutrition objectives--

recognize the importance of consuming a variety of fruits and 

vegetables as part of a healthy diet, the Food Guide Pyramid graphic 

does not convey this important guidance. The Pyramid graphic--the most 

widely recognized and disseminated nutrition guide--does not direct 

Americans to the best dietary choices, particularly to choosing a 

variety fruits and vegetables high in nutrients that science has linked 

to promoting health and reducing the risk for chronic diseases. While 

we recognize that USDA intended the Pyramid graphic to be used in the 

context of the information in the Pyramid brochure, in reality, the 

Pyramid graphic typically stands alone. Moreover, when HHS issued 

Healthy People 2010 with specific national objectives for fruit and 

vegetable consumption, it did so with the expectation that those 

objectives would be reflected in federal programs. However, USDAs 

strategic plan does not specifically address how it will help food 

assistance program participants achieve the objectives--despite the 

fact that one in six Americans is on food assistance and half of 

American babies are on WIC.



The memorandum of understanding between HHS and USDA provides a 

framework for expanding 5 A Day across all food assistance programs and 

to all Americans. Incorporating the new 5 A Day commitments into the 

agencies performance plans and establishing performance measures is a 

logical next step. We recognize the difficulty involved in changing 

Americans dietary habits. However, if USDA and HHS develop strategies 

with specific targets and milestones emphasizing the importance of 

fruits and vegetables--particularly deeply colored fruits and 

vegetables--in all their programs, they are more likely to be 

successful in influencing Americans to follow healthier diets.



Finally, nutrition experts and others have identified a number of 

actions--such as increasing salad bars in schools and expanding 

farmers market programs--that hold promise for improving fruit and 

vegetable consumption for Americans and may warrant further evaluation.



Recommendations for Executive Action:



To give Americans the most current, science-based guidance for making 

dietary choices, we recommend that, as USDA considers revisions to the 

Food Guide Pyramid, the Secretary of Agriculture, in consultation with 

the Secretary of Health and Human Services, ensure that the Pyramid 

graphic communicates information on the need for a variety of fruits 

and vegetables, especially deeply colored fruits and vegetables, in 

accordance with the Dietary Guidelines for Americans and in support of 

the Healthy People 2010 objective for vegetables.



To ensure that federal nutrition education/intervention and food 

assistance programs promote federal goals and guidelines on the 

consumption of fruits and vegetables, we further recommend that:



* the Secretary of Agriculture include in the departments strategic 

and performance plans, strategies and targets supporting the Healthy 

People 2010 objectives for fruit and vegetable consumption,



* the Secretary of Health and Human Services direct the National 

Institutes of Health, CDC, and other relevant agencies to include in 

their performance plans, strategies and targets for supporting the 

Healthy People 2010 objectives for fruit and vegetable consumption, 

and:



* the Secretaries of Agriculture and Health and Human Services consider 

the actions that experts and others have identified to increase the 

consumption of fruits and vegetables and, for those deemed most 

promising, assess the merits, feasibility, and costs to determine 

whether the actions should be implemented.



Lastly, to provide accountability for implementing the commitments in 

the April 2002 memorandum of understanding for 5 A Day, we recommend 

that the Secretaries of Agriculture and Health and Human Services, in 

their strategic and performance plans, develop specific strategies and 

targets for implementing the 5 A Day commitments made in the April 2002 

memorandum of understanding.



Agency Comments and Our Response:



We provided USDA and HHS with a draft of this report for their review 

and comment. We obtained USDAs comments in a meeting with department 

officials; HHS provided written comments. (See app. VII.) USDA said it 

understood the basis for our recommendations and generally concurred 

with our treatment of the issues relating to its programs. USDA said 

that the science base for its nutrition efforts is the Dietary 

Guidelines for Americans, which includes the Food Guide Pyramid. USDA 

also said that its approach is to address total diet by promoting 

overall balanced nutrition and the principles of the Dietary Guidelines 

for Americans, which includes, but is not limited to, increasing fruit 

and vegetable consumption and other dietary improvements that support 

all of the Healthy People 2010 nutrition objectives and the 5 A Day 

targets.



USDA said it has not considered the Healthy People 2010 nutrition 

objectives as goals that must be directly incorporated into its 

strategic plan, but that it could consider the merits of including 

components directly supporting the Healthy People 2010 objectives and 5 

A Day in its strategic and performance plans. We believe the Healthy 

People 2010 objectives--which USDA was a major participant in 

developing--present a national agenda for improving the health of 

Americans and that USDA should incorporate these measurable targets and 

time frames into the food assistance programs. We further believe that 

the 5 A Day partnership presents a reasonable framework for addressing 

the objectives related to increasing fruit and vegetable consumption.



With regard to the Food Guide Pyramid graphic, USDA noted that consumer 

research showed that the graphic communicates the messages of 

proportionality, moderation, and variety among the food groups. USDA 

stated that the Pyramid graphic does not convey all nutrition messages 

and that the Pyramid booklet provides more detailed information on how 

to make appropriate fruit and vegetable selections. Nonetheless, USDA 

agreed with the merits of our recommendation that, as it considers 

revising the Pyramid graphic and related materials, it will explore 

appropriate ways to effectively communicate information on the need for 

a variety of fruits and vegetables, especially deeply colored ones. 

USDA also pointed out that its efforts to promote fruits and vegetables 

extend beyond food assistance and nutrition education to include 

agricultural, economic, and behavioral research; agricultural 

extension; and market development and support. We added this 

information in the report.



HHS stated that our draft report was too definitive in its statements 

about the relationship between fruit and vegetable consumption and the 

reduction of diseases, and that the scientific evidence does not 

support the statements we made concerning the reduction of disease 

rates and the dollar savings that would result from increased intakes 

of fruits and vegetables alone. HHS was particularly concerned about 

the information we present in appendix IV--which describes some of the 

evidence that links fruit and vegetable consumption to reducing the 

risk for certain diseases. We qualified the language in appendix IV to 

clarify the strength of the linkages between consuming fruits and 

vegetables and specific diseases and added citations for our sources 

throughout the report. With regard to the cost data, we deleted the 

reference to USDAs estimate of total diet-related costs for heart 

disease, cancer, stroke, and diabetes because it was not limited to 

costs solely for low fruit and vegetable consumption. HHS further 

stated, There is no comprehensive recent detailed review by a 

recognized authoritative body from which such a summary of the evidence 

could be based that would reflect the totality of recent evidence and 

that has undergone appropriate clearance. Our sources for information 

included September 2001 and November 2000 National Institutes of Health 

reports summarizing the evidence on the relationship between fruits and 

vegetables and disease prevention; The Surgeon Generals Call to Action 

to Prevent and Decrease Overweight and Obesity: 2001; articles 

published in the Journal of the American Medical Association, the New 

England Journal of Medicine, and the Annals of Internal Medicine; and 

documents from CDC; the National Institutes of Health; the National 

Cancer Institute; and other HHS offices. The reports, documents, and 

information from HHS agencies were represented to us as reflecting 

current research; HHS did not identify evidence that we should cite 

that might be contradictory to any links between fruit and vegetable 

consumption and prevention of diseases cited in the report.



HHS further stated that dietary messages for the consumer can be 

confusing, particularly when the public receives conflicting reports or 

isolated parts of the total diet message. While our report focuses on 

fruits and vegetables, it does so in the context of a healthy diet. 

With regard to our recommendation--to include in agencies annual 

performance plans, strategies and targets for supporting the Healthy 

People 2010 objectives for fruits and vegetables--HHS noted that 

performance measures based on relevant Healthy People 2010 objectives 

are already included in the strategic plans of many HHS agencies. 

However, the annual performance plans of the National Institutes of 

Health and CDC do not address the objectives on fruits and vegetables. 

We recommend that they do so.



USDA and HHS also provided technical comments that we incorporated as 

appropriate.



As agreed with your offices, unless you publicly announce its contents 

earlier, we plan no further distribution of this report until 30 days 

from the date of this report. At that time, we will send copies to the 

Secretaries of Agriculture, Defense, and Health and Human Services; the 

Director, Office of Management and Budget; and other interested 

parties. We will make copies available to others upon request. In 

addition, the report will be available at no charge on the GAO web site 

at the following address: http://www.gao.gov:



If you have any questions about this report, please contact me or 

Erin Lansburgh at (202) 512-3841. Key contributors to this report are

listed in appendix VIII.



Lawrence J. Dyckman

Director, Natural Resources

 and Environment:



Signed by Lawrence J. Dyckman:



[End of section]



Appendix I: Federal Obligations for Efforts Related to Fruit and 

Vegetable Consumption:



The largest federal activities related to fruit and vegetable 

consumption are the purchase of fruits and vegetables and nutrition 

education. The U.S. Department of Agriculture (USDA) estimated that it 

obligated $6.7 billion for these activities in fiscal year 2001. In 

arriving at this figure, USDA estimated that 20 percent of the total 

food stamp and school meal expenditures were for the purchase of fruits 

and vegetables. Funding information for the Department of Health and 

Human Services (HHS) includes funding for the Centers for Disease 

Control and Prevention (CDC) and the National Institutes of Health 

(NIH) only, and reflects 5 A Day activities carried out by the 

agencies, as well as CDC grants to states for 5 A Day efforts and other 

diet-related efforts. Department of Defense (DOD) funding goes 

primarily to purchase fruits and vegetables for military personnel and 

to support 5 A Day initiatives in each military service branch. USDA, 

HHS, and DOD nutrition education and/or intervention, human nutrition 

research, and other activities include activities related to fruits 

and vegetables, as well as those focused on general nutrition or other 

diet-related issues, because agencies generally do not track nutrition 

education/intervention funding related to fruits and vegetables 

separately from funding related to other foods.



Funding information provided by USDA, HHS, and DOD are presented below 

in 2001 dollars in tables 4, 5, and 6, respectively.



Table 4: USDA Funding for Activities Related to Diet and Fruit and 

Vegetable Consumption, Fiscal Years 1997-2001:



Constant 2001 dollars in thousands.



Activity: Purchasing fruits and vegetables (except at farmers 
markets); FY1997: 

$7,524,861; FY1998: $6,869,337; FY1999: $6,659,353; FY2000: 

$6,539,206; FY2001: $6,667,931.



Activity: Purchasing fruits and vegetables at farmers markets; FY1997: 
7,809; 

FY1998: 13,383; FY1999: 15,616; FY2000: 19,762; FY2001: 35,921.



Activity: Nutrition education related to total diet; FY1997: 355,121; 
FY1998: 

368,748; FY1999: 393,870; FY2000: 422,793; FY2001: 474,656.



Activity: Human nutrition research related to total diet; FY1997: 
13,002[A]; 

FY1998: 18,022; FY1999: 22,084; FY2000: 34,900; FY2001: 16,250[A].



Activity: Agricultural research related to fruits and vegetables; 
FY1997: 

24,792[A]; FY1998: 81,174; FY1999: 78,273; FY2000: 97,436; FY2001: 

64,402[A].



Activity: Other general nutrition activities (e.g., Healthy Eating 
Index, Thrifty 

Food Plans, and Food Supply Database); FY1997: 202; FY1998: 309; 

FY1999: 517; FY2000: 537; FY2001: 532.



Activity: Other agricultural activities (e.g., farmers market 
development and 

promotion, marketing order administration, and market news); FY1997: 

395[A]; FY1998: 73,789; FY1999: 74,985; FY2000: 75,201; FY2001: 79,686.



[A] The Cooperative State Research, Education and Extension Service did 

not provide funding data for fiscal years 1997 and 2001; the 

Agricultural Marketing Service and Economic Research Service did not 

provide data for fiscal year 1997.



Source: USDAs Food and Nutrition Service; Center for Nutrition Policy 

and Promotion; Cooperative State Research, Education, and Extension 

Service; Agricultural Marketing Service; Economic Research Service; and 

Agricultural Research Service.



[End of table]



Table 5: HHS Funding for Activities Related to Diet and Fruit and 

Vegetable Consumption, Fiscal Years 1997-2001:



Constant 2001 dollars in thousands.



Activity: NIH funding for nutrition education and/or intervention and 
research 

related to fruits and vegetables.; FY1997: $3,969; FY1998: $4,972; 

FY1999: $5,430; FY2000: $5,627; FY2001: $3,600.



Activity: CDC funding for prevention research, monitoring and 
surveillance, 

collaboration, and evaluation, and other nutrition education/

intervention related to total diet; FY1997: 1,609; FY1998: 1,587; 

FY1999: 1,566; FY2000: 6,650; FY2001: 16,200.



Note: Data do not include Medicare reimbursements for nutrition 

counseling provided in medical care. Some administrative costs related 

to 5 A Day are not included.



Source: Centers for Disease Control and Prevention and National 

Institutes of Health.



[End of table]



Table 6: DOD Funding for Activities Related to Diet and Fruit and 

Vegetable Consumption, Fiscal Years 1997-2001:



Constant 2001 dollars in thousands.



Activity: Purchasing fruits and vegetables; FY1997: $39,693; FY1998: 
$47,605; 

FY1999: $46,367; FY2000: $55,350; FY2001: $60,000.



Activity: Nutrition education related to total diet; FY1997: 3,488; 
FY1998: 

3,503; FY1999: 4,389; FY2000: 4,565; FY2001: 3,535.



Activity: Human nutrition research related to total diet; FY1997: 
4,348; FY1998: 

6,304; FY1999: 6,236; FY2000: 4,740; FY2001: 3,619.



Note: Data do not include nutrition counseling provided as part of 

medical care.



Source: Budget data were provided by the Army, Navy, Air Force, Defense 

Supply Center, and Defense Commissary Agency.



[End of table]



[End of section]



Appendix II: Scope and Methodology:



To identify the health-related benefits associated with the consumption 

of the recommended servings of fruits and vegetables, we reviewed 

research studies and/or obtained expert views from medical and 

nutritional scientists at USDAs Center for Nutrition Policy and 

Promotion; HHSs National Institutes of Health, including the National 

Cancer Institute and the National Heart, Lung, and Blood Institute, and 

CDC; the National Academy of Sciences; and academic research 

institutions, including Harvard University, the Mayo Clinic, Cornell 

University, New York University, and the University of California at 

Davis. We also considered federal dietary guidance and the two health 

claims for fruits and vegetables authorized by the Food and Drug 

Administration. We also analyzed published data on the costs to the 

nation, including deaths, associated with poor diets, including diets 

low in fruits and vegetables, from these agencies and experts.



To assess whether the general public has improved its consumption of 

fruits and vegetables under key federal nutrition policy, guidance, and 

programs, we interviewed officials with and analyzed documents from 

(1) HHSs Office of the Secretary, including the Surgeon General, the 

Food and Drug Administration and its Center for Food Safety and 

Nutrition; 

(2) USDAs Agricultural Marketing Service; Center for Nutrition Policy 

and Promotion; Economic Research Service; and Cooperative State 

Research, Education and Extension Service; (3) DODs Office of the 

Secretary and representatives with nutrition responsibilities from each 

of the armed services; (4) industry groups, including United Fresh 

Fruit and Vegetable Association; and (5) consumer and health 

associations, including the Center for Science in the Public Interest; 

the American Public Health Association; the American Cancer Society; 

and the American Heart Association. We also interviewed former USDA and 

HHS officials with responsibilities for nutrition policies and programs 

to obtain historical information on certain programs.



To assess whether key federal food assistance programs have achieved 

improvements in the fruit and vegetable consumption of program 

participants, we analyzed data on consumption for program participants 

and similar nonparticipants; documents related to the requirements for 

providing fruits and vegetables in food assistance programs; and 

internal and external program evaluations of food assistance and 

nutrition programs. We discussed this information with the officials 

previously identified, Californias Department of Health Services, the 

Food Research and Action Center, and the National WIC Association.



To identify federal actions that experts recommend for increasing the 

consumption of fruits and vegetables, as well as the implications of 

those actions, we analyzed documents and interviewed officials from the 

aforementioned federal and state agencies, universities, and consumer 

and health associations. Documents included reports to Congress and the 

Secretaries of Agriculture and Health and Human Services, published 

articles, internal and external program evaluations, and position 

papers.



To determine funding information for federal programs that may promote 

fruit and vegetable consumption, we developed a data collection 

instrument to identify federal obligations for efforts to promote fruit 

and vegetable consumption for a 5-year period. We requested from USDA, 

HHS, and DOD information on purchases of fruits and vegetables, human 

nutrition research, nutrition education, and other activities. In some 

instances, agency officials estimated funding information when precise 

information was not available.



With regard to information on the numbers of servings of fruits and 

vegetables, we used consumption data that USDA calculates by surveying 

a sample of Americans in its Continuing Survey of Food Intakes by 

Individuals (CSFII). The most recent CSFII data are based on 1994-96 

surveys. USDA also estimates food available for consumption by 

adjusting annual food supply data for spoilage, waste, and other losses 

accumulated throughout the marketing system. USDAs Economic Research 

Service reports these data in terms of Food Guide Pyramid servings. 

While these data are more current, food supply data may overestimate 

actual consumption, according to USDA. Therefore, unless otherwise 

stated, we used CSFII data throughout this report.



Finally, 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 work was conducted in accordance with generally accepted government 

auditing standards from August 2001 through June 2002.



[End of section]



Appendix III: Federal Agricultural, Trade, and Environmental Programs 

and Regulations Can Affect Fruit and Vegetable Consumption:



The federal government influences the consumption of fruits and 

vegetables in many ways besides through food assistance and nutrition 

programs. Any government program or regulation that affects either 

consumers preferences for consuming fruits and vegetables or 

producers ability or willingness to supply fruits and vegetables to 

the market can influence U.S. consumption, although these effects may 

be small. Such programs and regulations include trade-restriction and 

export-promotion programs, environmental regulations, and agricultural 

programs. However, the effects on farm-level prices of such programs or 

regulations would have to be fairly substantial to have a large impact 

on consumption, because farm-level prices generally account for about 

one-third of the retail prices for fruits and vegetables.



Trade Restriction and Export Promotion Programs:



Trade restrictions, in the form of tariffs, on some fruits and 

vegetables result in higher prices that could reduce U.S. consumption 

of those fruits and vegetables. Although tariffs on most fruits and 

vegetables are low--less than 10 percent of the price--tariffs of 20 

percent or more are sometimes applied to some imported fruits and 

vegetables, such as certain types of melons, asparagus, and 

broccoli.[Footnote 38] In addition, when domestic marketing orders are 

in place, some imports, including tomatoes, potatoes, and grapes, are 

subject to minimum quality requirements. Some foreign suppliers and 

others claim that these requirements keep out lower-priced imports to 

maintain higher prices for domestic producers, which can reduce 

consumption. Proponents of the standards claim that the standards 

ensure high quality, which encourages consumption.



The U.S. government also promotes exports of U.S.-grown fruits and 

vegetables to increase the demand for these products in other 

countries. Increasing exports through such promotions may divert fruits 

and vegetables from domestic markets, raising their price and lowering 

fruit and vegetable consumption by U.S. consumers.



Environmental Regulations:



Environmental regulations regarding the use of pesticides, as well as 

the protection of water and air quality, can affect fruit and vegetable 

consumption in a variety of ways. For example, complying with 

regulations on pesticides may increase farm costs, which can reduce the 

quantities of fruits and vegetables supplied to the market, thereby 

increasing prices and lowering consumption. On the other hand, 

pesticide regulation may reduce consumers concerns about the safety of 

pesticides and other chemicals used on fruits and vegetables. To the 

extent that these concerns decrease, consumption may increase, 

particularly the consumption of those fruits and vegetables often eaten 

fresh, such as apples and broccoli. Similarly, consumers perceptions 

that lax environmental controls in other countries make imported 

produce less safe may affect the consumption of fruits and vegetables.



Agricultural Programs:



Several agricultural programs administered by USDA can affect U.S. 

consumption of fruits and vegetables. These programs include (1) 

marketing orders, which advertise and promote certain crops and, in 

some instances, limit the quantity or specify the quality that can be 

marketed; (2) commodity programs, in which USDA provides farmers with 

price and income supports; and (3) crop insurance, through which USDA 

indemnifies farmers, in part or in whole, against the loss of certain 

crops.



* Marketing Orders. Marketing orders are agreements among producers of 

a particular commodity on actions designed to provide an orderly 

market that would reduce fluctuations in farm and retail prices and 

assure consumers of a steady supply of quality products.[Footnote 39] 

In general, the promotional activities of marketing orders can increase 

consumer demand and, therefore, the consumption of some fruits and 

vegetables. However, a few marketing orders restrict the quantity of a 

particular fruit or vegetable that can be marketed, particularly during 

periods of oversupply. In general, these quantity restrictions could be 

expected to raise prices compared with free market levels and, thereby, 

reduce consumption. Also, some marketing orders impose quality 

restrictions. While some economists have suggested that these orders 

might also be used to restrict quantity--by increasing the quality 

requirements during periods of strong supply--other economists have 

noted that such action might not affect supply because major purchasers 

(wholesalers and retailers) set quality requirements higher than those 

imposed by federal marketing orders.



* Commodity Programs. The provisions of commodity programs that provide 

producers of other commodities, such as grains and cotton, with income 

and price supports can affect fruit and vegetable consumption. For 

example, during the past several years, grain and cotton farmers who 

received direct payments from USDA under production flexibility 

contracts were restricted from increasing their acreage devoted to 

fruits and vegetables if they wanted to remain eligible for these 

payments. This restriction may have reduced the supply of certain 

fruits and vegetables, thereby raising prices and lowering the 

consumption of those fruits and vegetables. In addition, because 

consumers have to choose how to spend their food dollars--on fruits and 

vegetables or on other foods--anything that influences the consumption 

of other foods by influencing their prices, including government income 

and price support programs, can also affect fruit and vegetable 

consumption.



* Crop Insurance. By providing subsidized crop insurance for certain 

crops, USDA reduces the risk to farmers of growing those crops--which 

would generally lead to greater supplies and lower prices for those 

crops. Not all fruits and vegetables are covered under federal crop 

insurance. To the extent that the availability of crop insurance 

affects the supply of certain fruits and vegetables, it may also affect 

their prices and, hence, their consumption.



Other Federal Activities:



Other federal activities may also affect the prices of fruits and 

vegetables and their consumption.



* Restrictions on legally importing seasonal workers when domestic 

workers are not available can reduce the amount of fruits and 

vegetables that farmers can harvest, which can result in higher prices, 

which, in turn, can reduce consumption.



* Laws that subsidize the cost of the water that some farmers use for 

irrigation can lower those farmers costs of growing fruits and 

vegetables. To the extent that the lower cost results in lower prices 

to consumers, consumption may increase.



* Federal efforts to ensure food safety can increase consumer 

confidence in the safety of fruits and vegetables and, perhaps, 

increase the quantities consumed.



[End of section]



Appendix IV: Fruits and Vegetables Help Protect Against Heart Disease; 

Cancer; and, Potentially, Other Diseases:



The following describes some of the evidence that links fruit and 

vegetable consumption to reducing the risk for heart disease and 

cancer. It also discusses the evidence suggesting links to reducing the 

risk for stroke, diabetes, obesity, and diverticulosis. Studying the 

relationship between diet and chronic diseases is challenging for many 

reasons, including the difficulty in accounting for all potential risk 

factors and the fact that chronic diseases may develop over a long 

period of time.



* Heart Disease. Heart disease is the leading cause of death in the 

United States, killing about 725,000 people each year, according to 

CDC. A healthy lifestyle, including a healthy diet, has great potential 

to reduce disease and death associated with coronary heart disease--the 

manifestation of heart disease that afflicts the hearts blood vessels. 

A diet low in saturated fat and cholesterol and rich in fruits, 

vegetables, and grains has been found to be associated with lower rates 

of coronary heart disease. According to an NIH report, diets high in 

fruits and vegetables are associated with a 20 to 40 percent reduction 

in the occurrence of coronary heart disease.[Footnote 40] An array of 

substances in fruits and vegetables, including antioxidants, folate, 

fiber, potassium, flavonoids, and other phytochemicals, may be 

responsible for the decreased risk. Recent studies have added to the 

growing evidence that diets high in fruits and vegetables reduce 

important risk factors associated with coronary heart disease, 

hypertension, and high plasma lipid levels in particular. For example, 

a recent report combining data from women in the Nurses Health Study 

with men in the Health Professionals Follow-Up Study showed that men 

who ate an average of 10 servings and women who ate an average of 9 

servings per day of fruits and vegetables had a 20-percent lower risk 

of coronary heart disease than men and women who ate an average of 2.5 

to 3 servings a day.[Footnote 41] The lowest risks were observed for 

the men and women with the highest consumption of green leafy 

vegetables and vitamin-C-rich fruits and vegetables, such as 

strawberries, oranges and orange juice, Brussels sprouts, and red 

cabbage. That study found a 4 percent lower risk of coronary heart 

disease for each serving-per-day-increase in fruits and vegetables. 

Another study looked at the effect of a diet high in fruits and 

vegetables and low in fat--the Dietary Approaches to Stop Hypertension 

(DASH) diet--on plasma lipid levels and found reductions in plasma 

levels of total cholesterol, LDL and HDL, in all races and both sexes 

compared with the control diet.[Footnote 42] Furthermore, the DASH diet 

is also effective in lowering blood pressure. The beneficial effect of 

fruits and vegetables on coronary heart disease risk is also likely 

due, in part, to their high fiber and antioxidant activity.



* Cancer. Cancer is the second leading cause of death in the United 

States according to CDC. Over 550,000 cancer deaths are expected in 

2002, and estimates are that about one-third of those deaths will be 

related to poor nutrition, a preventable cause of death. Indeed, 

reviews of more than 200 studies by the American Institute for Cancer 

Research and others indicate that the link between the consumption of 

fruits and vegetables and some cancers is consistent and 

strong.[Footnote 43] People who consume 5 or more servings daily have 

about one-half the cancer risk of those who consume 2 or fewer 

servings, according to an NIH report.[Footnote 44] Although there are 

still many unresolved questions regarding the association between 

cancer risk and the consumption of fruits and vegetables, ample 

scientific evidence indicates that the frequent consumption of a 

variety of fruits and vegetables protects against some cancers, 

particularly cancers of the mouth, pharynx, esophagus, stomach, colon, 

and rectum. The evidence also suggests reductions in the risk for 

cancers of the breast, pancreas, larynx, and bladder.[Footnote 45]



* Stroke. Stroke is the third leading cause of death in the United 

States. CDC reports that about 600,000 Americans have a stroke each 

year, of which about 160,000 will die. Studies have shown that the 

consumption of fruits and vegetables may decrease the risk of stroke 

through their effect on reducing hypertension (high blood pressure), an 

important risk factor for stroke. These studies show that the lowest 

risks for stroke are associated with high consumption of cruciferous 

vegetables (e.g., broccoli and cabbage), green leafy vegetables, citrus 

fruits, and vitamin-C-rich fruits and vegetables. For example, a recent 

analysis of 14 years of data from the Nurses Health Study and 8 years 

of data from the Health Professionals Follow-Up Study disclosed that 

each additional daily serving of fruits or vegetables was associated 

with a 4 to 7 percent reduction in the risk of stroke.[Footnote 46] A 

2001 study confirmed the blood-pressure-reducing effect of the DASH 

diet (high in fruits, vegetables, and low-fat dairy products and low in 

saturated fat and cholesterol) and found further decreases in blood 

pressure when the DASH diet was combined with low sodium 

intake.[Footnote 47] In addition, a 2002 study of a representative 

sample of the U.S. population added support for the association between 

fruit and vegetable consumption and lower risk of stroke incidence and 

mortality.[Footnote 48]



* Diabetes. Diabetes is the sixth leading cause of death in Americans 

and is associated with a range of other serious, chronic ailments, 

including coronary heart disease, stroke, hypertension, blindness, 

kidney disease, and amputation. CDC reported that, during the last 10 

years, diabetes increased 49 percent among adults, and that over 

800,000 new cases and over 200,000 deaths were from diabetes-related 

complications each year. An analysis of 20-year follow-up data from 

nearly 10,000 men and women who participated in a 1970s study showed 

that individuals who developed diabetes had a lower average consumption 

of fruits and vegetables.[Footnote 49] Specifically, the study found an 

association between consuming 5 or more servings of fruits and 

vegetables daily and a lower incidence of diabetes. Furthermore, women 

who consumed 5 or more servings of fruits and vegetables per day were 

39 percent less likely to develop diabetes compared with women who 

consumed little or no fruits and vegetables. There are a number of 

possible mechanisms by which fruit and vegetable consumption could 

affect diabetes, and additional studies will be needed to conclusively 

determine the relationship between fruit and vegetable consumption and 

diabetes. For example, fiber and magnesium in fruits and vegetables 

have positive effects on the primary manifestations of diabetes--the 

control of glucose and peripheral insulin sensitivity. The potential 

benefits in preventing diabetes also may stem from antioxidant vitamins 

and phytochemicals found in high levels in fruits and vegetables.



* Obesity. The link between obesity and the consumption of fruits and 

vegetables is receiving considerable attention from scientists, 

especially as the prevalence of obesity has increased. Over 60 percent 

of American adults are overweight, and about 13 percent of children and 

adolescents are seriously overweight. Overweight and obesity are 

important risk factors for a number of diseases, including heart 

disease, cancer, stroke, and diabetes. The Surgeon Generals 2001 

report on obesity estimated the total medical cost associated with 

overweight-and obesity-related diseases at $117 billion in 

2000.[Footnote 50] Although the link is not direct, fruits and 

vegetables may affect obesity through their relatively low-calorie 

level, high water content, palatability, and fiber content. The 

inclusion of fruits and vegetables in the diet has the potential to 

affect each of those factors. A study looking at the short-term effects 

of diet on calorie intake found that adding fruits and vegetables to 

lunch or dinner meals lowered the calories in the meal but did not 

affect palatability or feelings of fullness and hunger.[Footnote 51] 

Importantly, consuming meals with the added fruit and vegetables 

resulted in a 30 percent reduction in total caloric intake for the day. 

That study, and others like it, suggests that consuming foods of low-

energy density, such as vegetables and some fruits, may be a useful 

strategy for weight loss and control. Adding fruits and vegetables to 

the diet was also explored as a weight loss strategy in a recent study 

of obese parents, whose normal-weight children are at risk for becoming 

obese.[Footnote 52] In that study, some families were encouraged to 

increase fruit and vegetable consumption while others were encouraged 

to decrease high-fat/high-sugar foods. The families that increased 

fruit and vegetable consumption had greater weight reduction. These 

data support the positive benefits of including fruits and vegetables 

in weight loss diets and suggest that an effective approach to weight 

loss might focus on increasing the consumption of healthy foods rather 

than emphasizing dietary restriction.



* Diverticulosis. Diverticulosis occurs when small out-pouches called 

diverticula develop in the large intestine (colon), a condition that 

affects an estimated one-half of Americans age 60 to 80, and almost 

everyone over age 80 according to the National Institutes of Health. An 

estimated 10 to 25 percent of individuals with diverticulosis develop 

diverticulitis--an infection or inflammation of these out-pouches--

that can result in tearing, blockages, or bleeding if left untreated. 

High-fiber diets--especially those high in insoluble cellulose fiber--

have been found to reduce the risk of diverticulosis and 

diverticulitis. Because fruits and vegetables are excellent sources of 

cellulose fiber--accounting for over 30 percent of the insoluble fiber 

in fruits and 50 percent or more in vegetables--an increase in the 

consumption of fruits and vegetables may be particularly important in 

helping prevent diverticulosis and its complications.



[End of section]



Appendix V: The U.S. Department of Agricultures Fruit and Vegetable 

Categories:



USDA classifies fruits in two groups: (1) citrus, melons, and berries 

and (2) other fruits.[Footnote 53]



Table 7: USDAs Fruit Categories:



Fruit category: Citrus, melons, and berries; Fruits in category: 

Acerola, blackberries, blueberries, boysenberries, calamondin, 

cantaloupe, casaba melon, cranberries, elderberries, gooseberries, 

grapefruit, honeydew melon, juneberries, kiwifruit, kumquat, lemon, 

lime, loganberries, mulberries, orange, raspberries, strawberries, 

tangelo, tangerine, ugli fruit, watermelon, and juices made from these 

fruits.



Fruit category: Other fruits; Fruits in category: Apple, apricot, Asian 

pear, avocado, banana, cherries, currants, dates, figs, genip, grapes, 

guava, jackfruit, Japanese pear, jobo, lychee, mamey, mango, nectarine, 

papaya, passion fruit, peach, pear, persimmon, plantain, pineapple, 

plum, pomegranate, prickly pear, prunes, quince, raisins, rhubarb, 

sapodilla, soursop, star fruit, sweetsop, tamarind, wi-apple, and 

juices made from these fruits.



Source: USDA, Economic Research Service.



[End of table]



USDA classifies vegetables in three groups: (1) dark-green leafy and 

deep-yellow vegetables; (2) starchy vegetables and dry beans, peas, and 

lentils; and (3) other vegetables.[Footnote 54]



Table 8: USDAs Vegetable Categories:



Vegetable category: Dark-green leafy (dark green); Vegetables in 

category: Arugula, beet greens, broccoli, chard, chicory, collard 

greens, dandelion greens, endive, escarole, grape leaves, kale, 

lambsquarters, mustard greens, parsley, poke greens, romaine lettuce, 

spinach, taro leaves, turnip greens, and watercress.



Vegetable category: Deep-yellow (orange) vegetables; Vegetables in 

category: Carrots, carrot juice, pumpkin, sweet potato, and winter 

squash.



Vegetable category: Starchy vegetables; Vegetables in category: Black-

eyed peas (not dried), breadfruit, cassava, cowpeas (not dried), green 

peas, hominy, lima beans (immature), parsnips, sweet corn, white 

potato, rutabaga, and taro.



Vegetable category: Dry beans, peas, and lentils; Vegetables in 

category: Bayo beans, black beans, black-eyed peas, broadbeans, calico 

beans, chickpeas (garbanzos), cowpeas, kidney beans, lentils, lima 

beans (mature), mung beans, navy beans, pinto beans, pink beans, red 

Mexican beans, split peas, soybeans (mature), and white beans.



Vegetable category: Other vegetables; Vegetables in category: 

Artichoke, asparagus, balsam-pear pods, bamboo shoots, bean and alfalfa 

sprouts, broccoflower, beets, Brussels sprouts, cabbage (green and 

red), cactus, capers, cauliflower, celery, chayote, Chinese cabbage, 

chives, christophene, coriander, cucumber, eggplant, garlic, ginger 

root, green beans, horseradish, iceberg lettuce, leek, mushrooms, okra, 

olives, onions (mature and green), peppers (green, red, hot, banana), 

pimiento, radicchio, radishes, sauerkraut, seaweed, snow peas, summer 

squash, tomatillos, tomatoes, tomato juice, turnips, water chestnuts, 

wax beans, and zucchini.



Source: USDA, Economic Research Service.



[End of table]



[End of section]



Appendix VI: Serving Sizes by Food Group for Five Food Packages for 

Women and Children in WIC:



All five packages for women and children in the Special Supplemental 

Nutrition Program for Women, Infants, and Children (WIC) provide foods 

for four of the food groups--grain, fruit, dairy, and protein; one 

package also provides a partial serving of the fifth food group--

vegetable.



Table 9: Number and Percentage of Minimum Recommended Servings by Food 

Group for Five WIC Packages for Women and Children:



WIC package: Package III; (for children 2-3 years of age); Pyramid food 

group (WIC-allowed food): Grain (cereal): Number of servings 

(percentage of minimum recommended servings[A] ): ; 1.8 (30%); Pyramid 

food group (WIC-allowed food): Vegetable (carrots): Number of servings 

(percentage of minimum recommended servings[A] ): ; 0 (0%); Pyramid 

food group (WIC-allowed food): Fruit (juice): Number of servings 

(percentage of minimum recommended servings[A] ): ; 2.3 (115%); Pyramid 

food group (WIC-allowed food): Dairy (milk, cheese): Number of servings 

(percentage of minimum recommended servings[A] ): ; 3.2 (160%); Pyramid 

food group (WIC-allowed food): Protein (eggs, tuna, beans, peanut 

butter): Number of servings (percentage of minimum recommended 

servings[A] ): 0.64 (46%)[B]; 0.68 (49%)[C].



WIC package: Package IV; (for children 4 years of age); Pyramid food 

group (WIC-allowed food): Grain (cereal): Number of servings 

(percentage of minimum recommended servings[A] ): ; 1.2 (20%); Pyramid 

food group (WIC-allowed food): Vegetable (carrots): Number of servings 

(percentage of minimum recommended servings[A] ): ; 0 (0%); Pyramid 

food group (WIC-allowed food): Fruit (juice): Number of servings 

(percentage of minimum recommended servings[A] ): ; 1.5 (75%); Pyramid 

food group (WIC-allowed food): Dairy (milk, cheese): Number of servings 

(percentage of minimum recommended servings[A] ): ; 3.2 (160%); Pyramid 

food group (WIC-allowed food): Protein (eggs, tuna, beans, peanut 

butter): Number of servings (percentage of minimum recommended 

servings[A] ): 0.64 (32%)[B]; 0.68 (34%)[C].



WIC package: Package V; (for women who are pregnant and women who are 

breastfeeding and receiving formula); Pyramid food group (WIC-allowed 

food): Grain (cereal): Number of servings (percentage of minimum 

recommended servings[A] ): ; ; ; 1.2 (13%); Pyramid food group (WIC-

allowed food): Vegetable (carrots): Number of servings (percentage of 

minimum recommended servings[A] ): ; ; ; 0 (0%); Pyramid food group 

(WIC-allowed food): Fruit (juice): Number of servings (percentage of 

minimum recommended servings[A] ): ; ; ; 1.5 (50%); Pyramid food group 

(WIC-allowed food): Dairy (milk, cheese): Number of servings 

(percentage of minimum recommended servings[A] ): ; ; ; 3.7 (123%); 

Pyramid food group (WIC-allowed food): Protein (eggs, tuna, beans, 

peanut butter): Number of servings (percentage of minimum recommended 

servings[A] ): ; ; 0.64 (27%)[B]; 0.68 (28%)[C].



WIC package: Package VI; (for nonbreastfeeding postpartum women); 

Pyramid food group (WIC-allowed food): Grain (cereal): Number of 

servings (percentage of minimum recommended servings[A] ): ; ; 1.2 

(20%); Pyramid food group (WIC-allowed food): Vegetable (carrots): 

Number of servings (percentage of minimum recommended servings[A] ): ; 

; 0 (0%); Pyramid food group (WIC-allowed food): Fruit (juice): Number 

of servings (percentage of minimum recommended servings[A] ): ; ; 1 

(50%); Pyramid food group (WIC-allowed food): Dairy (milk, cheese): 

Number of servings (percentage of minimum recommended servings[A] ): ; 

; 3.2 (160%); Pyramid food group (WIC-allowed food): Protein (eggs, 

tuna, beans, peanut butter): Number of servings (percentage of minimum 

recommended servings[A] ): ; ; 0.48 (24%)[D].



WIC package: Package VII; (for women who are breastfeeding and not 

receiving formula); Pyramid food group (WIC-allowed food): Grain 

(cereal): Number of servings (percentage of minimum recommended 

servings[A] ): ; ; 1.2 (13%); Pyramid food group (WIC-allowed food): 

Vegetable (carrots): Number of servings (percentage of minimum 

recommended servings[A] ): ; ; 0.28 (9%); Pyramid food group (WIC-

allowed food): Fruit (juice): Number of servings (percentage of minimum 

recommended servings[A] ): ; ; 1.8 (60%); Pyramid food group (WIC-

allowed food): Dairy (milk, cheese): Number of servings (percentage of 

minimum recommended servings[A] ): ; ; 4.1 (137%); Pyramid food group 

(WIC-allowed food): Protein (eggs, tuna, beans, peanut butter): Number 

of servings (percentage of minimum recommended servings[A] ): ; ; 1.2 

(50%)[E].



Note: Packages I and II are for infants only.



[A] The Food Guide Pyramid is the source for minimum recommended 

servings.



[B] Eggs and beans.



[C] Eggs and peanut butter.



[D] Eggs.



[E] Eggs, peanut butter, beans, and tuna.



Source: National WIC Association.



[End of table]



[End of section]



Appendix VII: Comments from the Department of Health and Human 
Services:



Note: GAOs comments supplementing those in the reports text appear at 

the end of this appendix.



DEPARTMENT OF HEALTH & HUMAN SERVICES:



Office of Inspector General:



Washington, D.C. 20201:



JUN 28 2002:



Mr. Lawrence J. Dyckman Director, Natural Resources and Environment:



United States General Accounting Office Washington, D.C. 20548:



Dear Mr. Dyckman:



Enclosed are the Departments comments on your draft report entitled, 

Fruits and Vegetables: Enhanced Federal Efforts to Increase 

Consumption Would Yield Health Benefits for Americans. The comments 

represent the tentative position of the Department and are subject to 

reevaluation when the final version of this report is received.



The Department also provided numerous technical comments directly to 

your staff.



The Department appreciates the opportunity to comment on this draft 

report before its publication.



Sincerely,



Janet Rehnquist Inspector General:



Signed by an official for Janet Rehnquist:



Enclosure:



COMMENTS OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES ON THE U. S. 

GENERAL ACCOUNTING OFFICE (GAO) DRAFT REPORT, FRUITS AND VEGETABLES: 

ENHANCED FEDERAL EFFORTS TO INCREASE CONSUMPTION WOULD YIELD HEALTH 

BENEFITS FOR AMERICANS (GAO-02-657):



The Department of Health and Human Services (HHS) appreciates the 

opportunity to review and comment on this draft report, which addresses 

Federal efforts to increase consumption of fruits and vegetables.



General Comments:



As identified in the Dietary Guidelines for Americans, which is issued 

by HHS and the United States Department of Agriculture (USDA), choosing 

a variety of fruits and vegetables daily is a key element of a healthy 

diet. Healthy People 2010 set objectives based on the Dietary 

Guidelines to stimulate action and to provide a way to measure progress 

toward meeting the recommendations. Performance measures based on 

relevant Healthy People 2010 objectives are already included in the 

strategic plans of many HHS agencies and offices.



The HHS agrees that continued emphasis on consumption of increased 

amounts and variety of fruits and vegetables is an important part of 

the national total diet message.However, HHS feels that dietary 

messages for the consumer can be confusing particularly when the public 

receives conflicting reports or isolated parts of the total diet 

message. The emerging science in the area of fruit and vegetable 

consumption is consistent with the total diet message promulgated by 

the USDA/HHS Dietary Guidelines for Americans, the National Heart, 

Lung, and Blood Institutes (NHLBI) National Cholesterol Education 

Program, National High Blood Pressure Education Program, and Obesity 

Education Initiative. The HHS believes it is essential to present 

recommendations for increased consumption of fruits and vegetables in 

the context of a total diet that is low in saturated fat and 

cholesterol and moderate in total fat, lower in salt, with levels of 

energy intake and physical activity to maintain or lose weight as 

needed for health. Also, evidence is emerging of a strong link between 

genetics, diet and health outcomes that is not addressed in this 

document.



In general, the draft report is too definitive in its statements about 

the relationship between fruit and vegetable consumption and the 

reduction of disease. The scientific evidence does not support such 

firm statements concerning the reduction of disease rates and the 

dollar savings attached that would result from increased intakes of 

fruits and vegetables alone. Notation of the differing strengths of 

scientific evidence for the different diseases and conditions covered 

by the draft report would greatly enhance its utility for its diverse 

readership. In addition, HHS believes that presentation of the 

scientific evidence for the health effects of fruits and vegetables in 

the draft report would be substantially strengthened by including 

references. Statements based on a few studies should be qualified as 

reporting any health effects to ensure that the statements do not 

imply scientific consensus.



Finally, the review of the scientific literature in Appendix IV does 

not reflect the totality of the evidence relating fruit and vegetable 

consumption with health. Moreover, there is no comprehensive recent 

detailed review by a recognized authoritative body from which such a 

summary of the evidence could be based that would reflect the totality 

of recent evidence and that has undergone appropriate clearance. For 

example, the GAO draft report does not present the totality of the 

evidence and contains inaccuracies in the report text for the bullet 

Heart Disease and the bullet Stroke.:



The Food and Drug Administration (FDA), under provisions of the Federal 

Food, Drug, and Cosmetic Act (the Act) (section 403) of the Act), has 

established provisions for truthful and non-misleading nutrient content 

and health claims that may be used to encourage consumption of fruits 

and vegetables. Implementing regulations for nutrient content claims 

establish definitions for claims that fruits and vegetables may use to 

highlight the levels of the many nutrients they contain. Likewise, 

regulations for health claims establish the requirements to be met 

before claims characterizing the relationship between a substance in 

the diet to a disease or health-related condition can be used in food 

labeling. These regulations provide that FDA may authorize a health 

claim only when it determines, based on the totality of publicly 

available scientific evidence, that there is significant scientific 

agreement among experts qualified by scientific training and experience 

to evaluate such claims that the claim is supported by such evidence.



Based on these standards, FDA has provided for two health claims that 

pertain to fiber-containing fruits and vegetables. Sample claims that 

may be made for these two health claims are: Low fat diets rich in 

fiber-containing grain products, fruits, and vegetables may reduce the 

risk of some types of cancer, a disease associated with many factors 

(21 CFR 101.76) and Diets low in saturated fat and cholesterol and 

rich in fruits, vegetables, and grain products that contain some types 

of dietary fiber, particularly soluble fiber, may reduce the risk of 

heart disease, a disease associated with many factors (21 CFR 101.77). 

These claims are written to clearly identify the dietary factors that 

must be present with the fruits and vegetables in order to have the 

claimed effect and to point out that the etiology of these diseases is 

multi-factorial.



The Centers for Disease Control and Prevention (CDC) supports 

population-based public health efforts to promote healthy personal 

behaviors associated with prevention of premature death and disability 

from chronic diseases. The CDC does this in part by providing funding 

and technical assistance to State Departments of Health to support 

development and implementation of programs for the general population. 

The CDC has developed goals and objectives specific to 5 A Day, and 

with the National Cancer Institute (NCI) has completed a major round of 

5 A Day strategic planning activities with every state. Currently there 

is no specific 5 A Day funding for States, even though every State has 

designated a 5 A Day coordinator. States that receive current or future 

funding for nutrition and physical activity programs for prevention and 

control of obesity and related chronic diseases will have opportunities 

to incorporate 5 A Day components into programs as they develop and 

test or adopt effective interventions, promote policies and 

environmental changes, conduct surveillance, and implement social 

marketing strategies. Current capacity is dependent on a variety of 
local, 

state, and federal government as well as private and non-profit 
resources, 

and is very limited in many states.



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. The 

CDC has partnered with NO in the past to provide a mechanism for NCI to 

distribute funds to support state-based program evaluation projects. 

Now, CDC is assuming an expanded role in the 5 A Day for Better Health 

Program by working with State Departments of Health to promote 5 A Day 

in all funded chronic disease prevention programs. The CDCs long-term 

goal is to establish a nationwide network of state-based comprehensive 

nutrition and physical activity programs for prevention and control of 

obesity and related chronic diseases, and to include 5 A Day activities 

as an essential component in every State. The CDC also conducts and 

supports state-based surveillance of fruit and vegetable consumption 

and is in the process of developing questions on barriers to and 

determinants of fruit and vegetable consumption.



The following are GAOs comments on the Department of Health and Human 

Services letter dated June 28, 2002.



GAOs Comments:



1. While performance measures based on relevant Healthy People 2010 

objectives may be in the strategic plans of many HHS agencies, the 

objectives for fruit and vegetable consumption are not in the 

performance plans for the National Institutes of Health and the Centers 

for Disease Control and Prevention (CDC). Our recommendation addresses 

the need for strategies and targets specifically for the National 

Institutes of Health and the Centers for Disease Control and Prevention 

(CDC).



2. HHS agrees that continued emphasis on fruit and vegetable 

consumption is important to the total diet message, but that 

recommendations for increasing consumption should be in the context of 

a healthy diet and physical activity. Our report acknowledges the 

importance of a healthy diet and physical activity; however, because we 

were asked to examine fruit and vegetable consumption, our study and 

recommendations focus on that aspect of a healthy diet.



3. HHS stated that the draft report was too definitive in its 

statements about the relationship between fruit and vegetable 

consumption and the reduction of disease, and that including references 

would substantially strengthen the presentation. The sources for our 

information include September 2001 and November 2000 NIH reports 

summarizing the evidence on the relationship between fruits and 

vegetables and disease prevention, The Surgeon Generals Call to Action 

to Prevent and Decrease Overweight and Obesity: 2001, articles 

published in the Journal of the American Medical Association and the 

Annals of Internal Medicine, and documents from CDC, NIH, National 

Cancer Institute, and other HHS offices. In many instances, our 

statements are more conservatively couched than in the source 

documents. We have also added--and repeated--references throughout the 

report to clarify the sources of our information. The reports, 

documents, and information we received from HHS agencies were 

represented as reflecting current research. HHS did not identify 

evidence that might be contradictory to any links between fruit and 

vegetable consumption and prevention of diseases cited in our report. 

With regard to the cost data, we deleted the reference to USDAs 

estimate of total diet-related costs for heart disease, cancer, stroke, 

and diabetes because it was not limited to costs solely for low fruit 

and vegetable consumption.



4. While HHS states that appendix IV does not reflect the totality of 

evidence, HHS did not identify evidence that we should cite that might 

be contradictory to any links between fruit and vegetable consumption 

and the prevention of diseases cited in the appendix. HHS further 

states that there is no comprehensive recent detailed review by a 

recognized authoritative body from which such a summary of the evidence 

could be based Our sources included, among others, the November 2000 

NIH/NCI report--5 A Day for Better Health Program Evaluation Report 

(NIH Pub. No. 01-4904)--and the September 2001 NIH/NCI report--5 A Day 

for Better Health Program Monograph (NIH Pub. No. 01-5019)--both of 

which review the relevant research demonstrating the linkages between 

fruit and vegetable consumption and disease prevention. We modified the 

appendix to clarify the strength of the linkages and added specific 

citations for the sources of our information. We also made revisions to 

the appendix bullets on stroke and heart disease, based on technical 

comments from HHS.



5. HHS describes the role and responsibility of the Food and Drug 

Administration for approving health claims that industry can make on 

food labels. To address HHS concerns that we may be perceived as a 

scientific body making authoritative statements that can be used by 

industry to seek approval for health claims, we have added a statement 

in the front of the report and in our scope and methodology appendix. 

That statement clarifies that 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.:



6. Our report cites the agreements that CDC, NCI, and USDA agencies 

have initiated to expand 5 A Day and that the memorandum of 

understanding establishes a framework for cooperation among the 

agencies to promote their commitment to encourage all Americans to eat 

5 to 9 servings of fruits and vegetables daily. We believe that, if 

carried out, these commitments could provide a framework for helping 

Americans achieve the Healthy People 2010 nutrition objectives for 

fruits and vegetables. In addition, based on technical comments from 

HHS, we added information to the report regarding CDCs surveillance of 

fruit and vegetable consumption and its concern for the need to improve 

the capacity of state programs that promote healthy behaviors to reduce 

the risk of chronic disease.



[End of section]



Appendix VIII: GAO Contacts and Staff Acknowledgments:



GAO Contacts:



Lawrence J. Dyckman, (202) 512-5138:



Erin Lansburgh, (202) 512-3017:



Acknowledgments:



In addition to those named above, Beverly A. Peterson,

Terrance N. Horner, Jr., Nancy Bowser, Jay Cherlow, and Cynthia Norris 

made key contributions to this report.



FOOTNOTES



[1] See 7 U.S.C. 5341 (2000).



[2] Almost all public and some private nonprofit schools are subsidized 

by USDA for each complete school meal served regardless of household 

income; lunches and breakfasts for children from low-income households 

receive greater subsidies.



[3] In the WIC program, the term package refers to the group of foods 

that the benefits can be used to purchase.



[4] Unlike the food stamp program, which is an entitlement program, 

participation in WIC is limited by the available funding.



[5] See U.S. Department of Health and Human Services, Public Health 

Service, Office of the Surgeon General, The Surgeon Generals Call to 

Action to Prevent and Decrease Overweight and Obesity: 2001 (Rockville, 

Md.: 2001).



[6] See National Institutes of Health, National Cancer Institute, 5 A 

Day for Better Health Program Evaluation Report, NIH Pub. No. 01-4904 

(Bethesda, Md.: November 2000).



[7] Fruits and vegetables have also been linked to pathogens, such as 

Salmonella and E. coli, that cause foodborne illnesses. However, the 

cause of contamination is often unknown. While contamination may be 

carried in the seeds or the fruit/vegetable, diseases also have been 

linked to contamination during harvesting, packing, transporting, or 

preparation. Fruits and vegetables may also contain pesticide residues; 

however, the American Cancer Society, World Cancer Research Fund, and 

American Institute for Cancer Research reported that the benefits of 

fruits and vegetables in terms of cancer risks far outweigh the 

potential pesticides risks.



[8] There are 18 objectives in the Healthy People 2010 nutrition focus 

area, including ones for weight status and growth; food and nutrient 

consumption; iron deficiency and anemia; schools, work sites, and 

nutrition counseling; and food security.



[9] USDAs most recent consumption data from the 1994-96 Continuing 

Survey of Food Intakes by Individuals (age adjusted to the standard 

population for 2000).



[10] See National Institutes of Health, National Cancer Institute, 5 A 

Day for Better Health Program Evaluation Report, NIH Pub. No. 01-4904 

(Bethesda, Md.: November 2000).



[11] Since 1997, the National Academy of Sciences has been replacing 

the Recommended Dietary Allowances for nutrients with Dietary 

Reference Intakes. Dietary Reference Intakes have been completed for 

most nutrients.



[12] For more information on these examples, see National Institutes of 

Health, National Cancer Institute, 5 A Day for Better Health Monograph, 

NIH Pub. No. 01-5019, (Bethesda, Md.: September 2001).



[13] See National Institutes of Health, National Cancer Institute, 5 A 

Day for Better Health Program Evaluation Report, NIH Pub. No. 01-4904 

(Bethesda, Md.: November 2000).



[14] See P.L. 107-76 (2001).



[15] HHS strategic plan identifies the percentage of Americans eating 

5 servings daily of fruits and vegetables as an indicator of a healthy 

diet. 



[16] All consumption data, unless otherwise noted, are for 1994-96--the 

most recent years for which data are available from the Continuing 

Survey of Food Intakes by Individuals.



[17] See U.S. Department of Agriculture, Economic Research Service, The 

Effects on Dietary Quality of Participation in the Food Stamp and WIC 

Programs (Washington, D.C.: September 2000).



[18] The USDA study found this 0.2 difference not statistically 

significant.



[19] The other two WIC packages are for infants.



[20] See U.S. Department of Agriculture, Food and Nutrition Service, 

Childrens Diets in the Mid-1990s: Dietary Intake and Its Relationship 

with School Meal Participation (Alexandria, Va.: 2001) and U.S. 

Department of Agriculture, Economic Research Service, Americas Eating 

Habits: Changes and Consequences, Ag. Info. Bulletin No. 750 

(Washington, D.C.: 1999).



[21] See U.S. Department of Agriculture, School Meal Initiative 

Implementation Study: Second Year Report (Alexandria, Va.: July 2001).



[22] See U.S. Department of Agriculture, School Nutrition Dietary 

Assessment Study-II (Washington, D.C.: April 2001).



[23] The over 20,000 survey resopndents each year did not represent the 

entire population of nearly 2 million participants because they are not 

selected randomly as part of a statistical sample. In addition, the 

wording of questions in this survey may overestimate the reporting of 

increased comsumption.



[24] See U.S. General Accounting Office, School Meals Programs: Sharing 

Information on Best Practices May Improve Programs Operations, GAO/

RCED-97-126 (Washington, D.C.: May 21, 1997).



[25] See U.S. General Accounting Office, School Lunch Program: 

Cafeteria Managers Views on Food Wasted by Students, GAO/RCED-96-191 

(Washington, D.C.: July 18, 1996). Cafeteria managers estimated the 

amount of waste on the basis of observation.



[26] See U.S. Department of Agriculture, Economic Research Service, 

Plate Waste in School Nutrition Programs: Final Report to Congress, ERS 

Pub. No. E-FAN-02-009 (Washington, D.C.: March 2002).



[27] The three California school districts were Santa Monica-Malibu, 

Los Angeles, and Vacaville Unified School District.



[28] See U.S. Department of Agriculture, Center for Nutrition Policy 

and Promotion, The State of Nutrition Education in USDA: A Report to 

the Secretary (Washington, D.C.: October 1996).



[29] See U.S. Department of Agriculture, Food and Nutrition Service, 

Promoting Healthy Eating: An Investment in the Future, A Report to 

Congress (Alexandria, Va.: December 1999).



[30] Appendix II identifies the experts and organizations we 

interviewed.



[31] Other options that were identified but not as frequently mentioned 

included (1) requiring nutrition education training for medical 

students, (2) increasing the availability of nutrition information for 

foods eaten away from home, (3) levying taxes on unhealthful foods, and 

(4) increasing agricultural research on fruits and vegetables.



[32] CDC also conducts state-based surveillance for fruit and vegetable 

consumption.



[33] See U.S. Department of Agriculture, Food and Nutrition Service, 

Promoting Healthy Eating: An Investment in the Future, A Report to 

Congress (Alexandria, Va.: December 1999).



[34] See U.S. General Accounting Office, Food Assistance: WIC Faces 

Challenges in Providing Nutrition Services, GAO-02-142 (Washington, 

D.C.: December 7, 2001).



[35] See U.S. Department of Agriculture, Report of the Dietary 

Guidelines Advisory Committee on the Dietary Guidelines for Americans, 

2000 (Washington, D.C.: August 2000).



[36] See U.S. Department of Agriculture, USDA Food Distribution 2000: 

Transforming Food Distribution for the Next Millennium (Washington, 

D.C.: November 2000).



[37] Officials of the National WIC Association support the expansion of 

farmers markets only if separate funding is provided.



[38] Some of these imports come from countries that are covered by 

regional trade agreements that provide reduced or tariff-free entry for 

these commodities.



[39] Once marketing order agreements are voted in by the industry and 

approved by the Secretary of Agriculture, they are issued as federal 

regulations and have the force of law.



[40] See National Institutes of Health, National Cancer Institute, 5 A 

Day for Better Health Program Evaluation Report, NIH Pub. No. 01-4904 

(Bethesda, Md.: November 2000).



[41] See K.J. Joshipura, F.B. Hu, et al. Effect of Fruit and Vegetable 

Intake on Risk for Coronary Heart Disease (Philadelphia, Pa: Annals of 

Internal Medicine, June 2001) 134:1106-1114. This prospective cohort 

study followed female nurses for 14 years and male health professionals 

for 8 years.



[42] See E. Obarzanek, F. M. Sacks, et al. Effects on Blood Lipids of a 

Blood Pressure-Lowering Diet: The Dietary Approaches to Stop 

Hypertension (DASH) Trial (American Journal of Clinical Nutrition, 

2000) 74:80-89. See also U.S. General Accounting Office, Food Stamp 

Program: Information on the Costs of Special Diets, GAO/RCED-00-144R 

(Washington, D.C.: May 8, 2000).



[43] See World Cancer Research Fund/American Institute of Cancer 

Research, Food, Nutrition and the Prevention of Cancer: A Global 

Perspective (Washington, D.C.: 1997).



[44] See National Institutes of Health, National Cancer Institute, 5 A 

Day for Better Health Program Evaluation Report, NIH Pub. No. 01-4904 

(Bethesda, Md.: November 2000).



[45] See U.S. Department of Health and Human Services, Public Health 

Service, National Institutes of Health, National Cancer Institute, 

Cancer Progress Report: 2001, NIH Pub. No. 02-5045 (Bethesda, Md.: 

2001).



[46] See K.J. Joshipura, A. Asherio, et al. Fruit and Vegetable Intake 

in Relation to Risk of Ischemic Stroke (Journal of the American Medical 

Association, 1999) 282:1233-1239.



[47] See F.M. Sacks, L.P. Svetkey, et al. Effects on Blood Pressure of 

Reduced Dietary Sodium and the Dietary Approaches to Stop Hypertension 

(DASH) Diet (New England Journal of Medicine, 2001) 344:3-10.



[48] See L.A. Bazzano, J. He, et al. Fruit and Vegetable Intake and 

Risk of Cardiovascular Disease in US Adults: The First National Health 

and Nutrition Examination Survey Epidemiological Follow-Up Study 

(American Journal of Clinical Nutrition, 2002) 76:93-99.



[49] See E.S. Ford, A.H. Mokdad. Fruit and Vegetable Consumption and 

Diabetes Mellitus Incidence Among U.S. Adults (Preventive Medicine, 

2001) 32:33-39.



[50] See U.S. Department of Health and Human Services, Public Health 

Service, Office of the Surgeon General, The Surgeon Generals Call to 

Action to Prevent and Decrease Overweight and Obesity: 2001 (Rockville, 

Md.: 2001).



[51] See E.A. Bell, V.H. Castellanos, et al. Energy Density of Foods 

Affects Energy Intake in Normal-Weight Women. (American Journal of 

Clinical Nutrition, 1998) 67:412-420.



[52] See L.H. Epstein, C.C. Gordy, et al. Increasing Fruit and 

Vegetable Intake and Decreasing Fat and Sugar Intake in Families at 

Risk for Childhood Obesity. (Obesity Research, 2000) 9:171-178.



[53] Apples, bananas and grapes are part of USDAs other fruits 

category; because they account for a large portion of fruit 

consumption, they are shown separately in figure 2 of the report.



[54] In figure 3 of the report, white potatoes are shown separately 

from the other starchy vegetables because they account for a large 

portion of starchy vegetable consumption. Similarly, canned tomatoes 

and iceberg lettuce--included in USDAs other vegetables category--

are shown separately.



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