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

GAO-02-657
Page i GAO-02-657 Fruits and Vegetables

Letter 1

Results in Brief 3

Background 6

Consuming the Recommended Servings of Fruits and Vegetables

Would Reduce the Risk for Some Chronic Diseases 10

Americans’ Consumption of Fruits and Vegetables Has Increased

Somewhat Under Federal Policy, Guidance, and Education

Programs for the General Public 12

Food Assistance Programs Have Had Mixed Effects on

Consumption of Fruits and Vegetables by Lower-Income

Citizens 20

Experts Have Identified Many Actions That Federal Agencies

Could Take to Further Increase Consumption of Fruits and

Vegetables 29

Conclusions 34

Recommendations for Executive Action 35

Agency Comments and Our Response 35

Appendix I Federal Obligations for Efforts Related to Fruit and

Vegetable Consumption 39

Appendix II Scope and Methodology 42

Appendix III Federal Agricultural, Trade, and Environmental

Programs and Regulations Can Affect Fruit and

Vegetable Consumption 44

Trade Restriction and Export Promotion Programs 44

Environmental Regulations 44

Agricultural Programs 45

Other Federal Activities 46

Appendix IV Fruits and Vegetables Help Protect Against Heart

Disease; Cancer; and, Potentially, Other Diseases 47

Contents
Page ii GAO-02-657 Fruits and Vegetables

Appendix V The U.S. Department of Agriculture’s Fruit and

Vegetable Categories 52

Appendix VI Serving Sizes by Food Group for Five Food Packages

for Women and Children in WIC 54

Appendix VII Comments from the Department of Health and

Human Services 55

Appendix VIII GAO Contacts and Staff Acknowledgments 61

Tables

Table 1: Recommended Daily Fruit and Vegetable Servings for

Men, Women, and Children, Based on Age and Activity

Level 7

Table 2: Participation, Total Funding, Nutrition Education Funding,

and Average Nutrition Education Funding per Participant

for Selected Food Assistance Programs, Fiscal Year 2001 8

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 13

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

Vegetable Consumption, Fiscal Years 1997-2001 40

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

Vegetable Consumption, Fiscal Years 1997-2001 40

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

Vegetable Consumption, Fiscal Years 1997-2001 41

Table 7: USDA’s Fruit Categories 52

Table 8: USDA’s Vegetable Categories 53

Table 9: Number and Percentage of Minimum Recommended

Servings by Food Group for Five WIC Packages for

Women and Children 54
Page iii GAO-02-657 Fruits and Vegetables

Figures

Figure 1: USDA’s Food Guide Pyramid 6

Figure 2: Percentage of Fruit Servings by Type, 1999 14

Figure 3: Percentage of Vegetable Servings by Type, 1999 15

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 21

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
Page 1 GAO-02-657 Fruits and Vegetables

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.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 diseasepreventing benefits of nutrients in different kinds of fruits and vegetables,

the 2000 edition of the guidelines included a specific recommendation that

consumers “choose a variety of fruits and vegetables daily” as part of a

healthy diet. The guidelines also included USDA’s Food Guide Pyramid,

which illustrates the recommended numbers of servings from each of the

food groups—grains, vegetables, fruits, milk, and meat/beans—that

together constitute a healthy diet. In 2000 HHS also released Healthy

People 2010, a report that set national health goals and objectives to be

achieved by the end of the decade, for use by federal agencies, states,

communities, professional organizations, and others to develop programs

to prevent disease and improve and maintain health. Two of the objectives

relate to fruits and vegetables: (1) increase, from 28 percent to 75 percent,

the proportion of Americans who consume at least 2 daily servings of fruit

and (2) increase, from 3 to 50 percent, the proportion of Americans who

consume at least 3 daily servings of vegetables, of which at least 1 serving

is a dark green or orange vegetable.

In addition to developing dietary guidelines and goals, federal agencies

provide nutrition education and intervention for the general public and for

 1

See 7 U.S.C. 5341 (2000).

United States General Accounting Office

Washington, DC 20548
Page 2 GAO-02-657 Fruits and Vegetables

participants in federal food assistance programs. The National Cancer

Institute, within HHS’s National Institutes of Health (NIH), administers the

5 A Day for Better Health Program—the only federal nutrition education

and intervention program focused exclusively on increasing the general

public’s consumption of fruits and vegetables to 5 to 9 servings daily. This

public-private partnership between federal/state/local governments, the

fruit and vegetable industry, and supermarkets uses a variety of strategies,

from national media campaigns to local programs in which, for example,

participants prepare new recipes with fruits and vegetables to reinforce

the 5 A Day message and influence dietary change. The Centers for

Disease Control and Prevention (CDC), also in HHS, works with states’ 5 A

Day programs and funds some states’ efforts to establish programs that

include nutrition education and intervention activities for the general

public. In April 2002, HHS and USDA signed a memorandum of

understanding that established a general framework for the two

departments’ agencies to work together to implement an enhanced

national 5 A Day Program.

USDA’s Food and Nutrition Service (FNS) funds and oversees federal food

assistance programs, many of which have nutrition education components

for program participants. Key federal food assistance programs, which are

administered by FNS and state governments, provide the following food

benefits:

• The Food Stamp Program provides low-income people with benefits

to supplement their food-purchasing ability.

• The National School Lunch and Breakfast Programs provide

schoolchildren with low-cost or free meals and snacks. USDA provides

food and funding and, under an agreement between USDA and the

Department of Defense (DOD), the DOD Fresh Fruit and Vegetable

Project (DOD Fresh) also purchases fresh fruits and vegetables with

USDA funds and delivers them to participating public and private

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

• The Special Supplemental Nutrition Program for Women,

Infants, and Children (WIC) provides low-income pregnant, breastfeeding, 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.
Page 3 GAO-02-657 Fruits and Vegetables

• 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.

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

Results in Brief
Page 4 GAO-02-657 Fruits and Vegetables

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
Page 5 GAO-02-657 Fruits and Vegetables

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
Page 6 GAO-02-657 Fruits and Vegetables

and research articles given to us by federal officials specifically for the

purpose of identifying such linkages.

USDA’s Food Guide Pyramid visually depicts federal guidance for the

number of servings needed in each of five food groups to provide a healthy

diet. (See fig. 1.) For example, the Pyramid recommends eating from 2 to

4 servings of fruit and 3 to 5 servings of vegetables daily.

Figure 1: USDA’s Food Guide Pyramid

Source: U.S. Department of Agriculture/U.S. Department of Health and Human Services

Background
Page 7 GAO-02-657 Fruits and Vegetables

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

Recommended servings

Type of person Vegetables Fruits

Children ages 2 to 6 years, most women, some older

adults 3 2

Children over 6, teen girls, active women, most men 4 3

Teen boys and active men 5 4

Source: Dietary Guidelines for Americans, 2000.

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.
Page 8 GAO-02-657 Fruits and Vegetables

Table 2: Participation, Total Funding, Nutrition Education Funding, and Average Nutrition Education Funding per Participant

for Selected Food Assistance Programs, Fiscal Year 2001

Program

Number of

participants

(in millions)

Total

program obligations

(dollars in millions)

Nutrition

education obligations

(dollars in millions)

Nutrition education

obligations per

participant

Food Stamp Program 17.3 $17,826.9 $148.3 $8.57

School Lunch and

Breakfast Programs

27.5

7.8 8,234.7 13.8a

<0.27a

WIC 7.3 4,199.1 235.9 32.32

WIC Farmers’ Market

Nutrition Program 2.1b

21.0 c c

Seniors Farmers’ Market

Nutrition Program <0.4 15.0 c 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: GAO’s analysis of data from USDA’s Food and Nutrition Service and the National

Association of Farmers’ Market Nutrition Programs.

USDA’s 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.2

 As a result of school meals, participants in these programs

consume greater amounts of several important nutrients, such as calcium.

 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.
Page 9 GAO-02-657 Fruits and Vegetables

WIC has seven food packages3—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.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 lion’s 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

USDA’s 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

 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.
Page 10 GAO-02-657 Fruits and Vegetables

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.

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.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

 5

See U.S. Department of Health and Human Services, Public Health Service, Office of the

Surgeon General, The Surgeon General’s Call to Action to Prevent and Decrease

Overweight and Obesity: 2001 (Rockville, Md.: 2001).

Consuming the

Recommended

Servings of Fruits and

Vegetables Would

Reduce the Risk for

Some Chronic

Diseases
Page 11 GAO-02-657 Fruits and Vegetables

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.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 one’s 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.7

 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.
Page 12 GAO-02-657 Fruits and Vegetables

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, HHS’s 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.

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.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, USDA’s

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.

 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.

Americans’

Consumption of

Fruits and Vegetables

Has Increased

Somewhat Under

Federal Policy,

Guidance, and

Education Programs

for the General Public

While Americans Have

Increased Their

Consumption of Fruits and

Vegetables, Most Consume

These Foods Below

Recommended Levels
Page 13 GAO-02-657 Fruits and 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

Average servings

consumed

Food 1989-91 1994-96

Percentage of

Americans consuming

minimum: 2 servings of

fruit, 3 servings of

vegetables, 1994-96

Percentage of

Americans meeting

their recommended

servings:a 2-4 servings

of fruit, 3-5 servings of

vegetables, 1994-96

Fruits 1.3 1.5 28 23

Vegetables 3.2 3.4 49 41

a

Adjusted for gender, age, and activity level.

Source: USDA Continuing Survey of Food Intakes by Individuals, 1989-91 and 1994-96.

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. USDA’s data for dark green or

orange vegetables indicates that consumption increased by less than onetenth 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.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

 9

USDA’s most recent consumption data from the 1994-96 Continuing Survey of Food

Intakes by Individuals (age adjusted to the standard population for 2000).
Page 14 GAO-02-657 Fruits and Vegetables

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

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.

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
Page 15 GAO-02-657 Fruits and Vegetables

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

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.
Page 16 GAO-02-657 Fruits and Vegetables

USDA’s 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.10 Although the Pyramid graphic

is based on analyses from more than 10 years ago, USDA’s 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.11 The

center plans to complete its assessment and any revisions before the 2005

update of the Dietary Guidelines for Americans.

 10See 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).

11Since 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.

The Food Guide Pyramid

Graphic Does Not Provide

Some Important Nutrition

Guidance About Fruits and

Vegetables
Page 17 GAO-02-657 Fruits and Vegetables

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 longrange 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: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

 12For 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).

5 A Day Appears to Be an

Effective Program, and

HHS and USDA Have

Announced Plans for Its

Expansion
Page 18 GAO-02-657 Fruits and Vegetables

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 NIH’s 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.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

 13See 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).
Page 19 GAO-02-657 Fruits and Vegetables

Disease Prevention and Health Promotion, CDC; and (3) USDA’s 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 1993,14 which provides

agencies with a systematic approach for managing programs. The results

act’s 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 other’s 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.15 With the NIH’s 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

 14See P.L. 107-76 (2001).

15HHS’ strategic plan identifies the percentage of Americans eating 5 servings daily of fruits

and vegetables as an indicator of a healthy diet.
Page 20 GAO-02-657 Fruits and Vegetables

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.

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 USDA’s strategic and performance

plans.

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 USDA’s 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.

Food Assistance

Programs Have Had

Mixed Effects on

Consumption of

Fruits and Vegetables

by Lower-Income

Citizens

Consumption of Fruits and

Vegetables by Participants

in Food Assistance

Programs Is Similar to or

Slightly Better Than That

of Low-Income

Nonparticipants
Page 21 GAO-02-657 Fruits and Vegetables

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

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,

Children’s Diets in the Mid-1990s: Dietary Intake and Its Relationship with School Meal Participation

(Alexandria, Va.: January 2001).

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.16

 16All 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.
Page 22 GAO-02-657 Fruits and Vegetables

• 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 lowincome 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 program’s 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.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)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.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

 17See 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).

18The USDA study found this 0.2 difference not statistically significant.

19The other two WIC packages are for infants.
Page 23 GAO-02-657 Fruits and Vegetables

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.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.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

 20See U.S. Department of Agriculture, Food and Nutrition Service, Children’s 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,

America’s Eating Habits: Changes and Consequences, Ag. Info. Bulletin No. 750

(Washington, D.C.: 1999).

21See U.S. Department of Agriculture, School Meal Initiative Implementation Study:

Second Year Report (Alexandria, Va.: July 2001).
Page 24 GAO-02-657 Fruits and Vegetables

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.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.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,

 22See U.S. Department of Agriculture, School Nutrition Dietary Assessment Study-II

(Washington, D.C.: April 2001).

23The 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.
Page 25 GAO-02-657 Fruits and Vegetables

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

DOD’s 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.24 Because DOD uses a decentralized system to purchase

produce from local vendors, we reported that it was able to provide highquality 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.25 In 2002 USDA reported that wasted food—

including fruits and vegetables—cost USDA $600 million annually.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 selfservice salad/meal bars.

 24See 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).

25See 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.

26See 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).
Page 26 GAO-02-657 Fruits and Vegetables

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.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, USDA’s 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

 27The three California school districts were Santa Monica-Malibu, Los Angeles, and

Vacaville Unified School District.
Page 27 GAO-02-657 Fruits and Vegetables

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.

USDA’s 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. USDA’s 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,

USDA’s 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

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
Page 28 GAO-02-657 Fruits and Vegetables

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 USDA’s Center for Nutrition

Policy and Promotion cited inadequate funding as a major factor limiting

the evaluation of USDA’s nutrition education efforts.28 In 1999 FNS

reported that the evaluation system was fragmented and minimal, and

lacked outcome measures.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.

 28See 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).

29See 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).
Page 29 GAO-02-657 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.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.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 industry’s annual

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

government’s 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.

 30Appendix II identifies the experts and organizations we interviewed.

31Other 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.

Experts Have

Identified Many

Actions That Federal

Agencies Could Take

to Further Increase

Consumption of

Fruits and Vegetables
Page 30 GAO-02-657 Fruits and Vegetables

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.32 CDC’s 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 state’s 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.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

 32CDC also conducts state-based surveillance for fruit and vegetable consumption.

33See 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).
Page 31 GAO-02-657 Fruits and Vegetables

the data and the financial resources that would be needed to conduct

such research.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.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. California’s

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.

 34See U.S. General Accounting Office, Food Assistance: WIC Faces Challenges in

Providing Nutrition Services, GAO-02-142 (Washington, D.C.: December 7, 2001).

35See U.S. Department of Agriculture, Report of the Dietary Guidelines Advisory

Committee on the Dietary Guidelines for Americans, 2000 (Washington, D.C.: August

2000).
Page 32 GAO-02-657 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.36 In

addition, USDA, the American Academy of Family Physicians,

American Academy of Pediatrics, American Dietetic Association,

 36See U.S. Department of Agriculture, USDA Food Distribution 2000: Transforming Food

Distribution for the Next Millennium (Washington, D.C.: November 2000).
Page 33 GAO-02-657 Fruits and Vegetables

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.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 lowincome 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 USDA’s 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

 37Officials of the National WIC Association support the expansion of farmers’ markets only

if separate funding is provided.
Page 34 GAO-02-657 Fruits and Vegetables

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.

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, USDA’s 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.

Conclusions
Page 35 GAO-02-657 Fruits and Vegetables

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 department’s 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.

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

and comment. We obtained USDA’s 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

Recommendations for

Executive Action

Agency Comments

and Our Response
Page 36 GAO-02-657 Fruits and Vegetables

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
Page 37 GAO-02-657 Fruits and Vegetables

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 USDA’s 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 General’s 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
Page 38 GAO-02-657 Fruits and Vegetables

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
Appendix I: Federal Obligations for Efforts

Related to Fruit and Vegetable Consumption

Page 39 GAO-02-657 Fruits and Vegetables

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.

Appendix I: Federal Obligations for Efforts

Related to Fruit and Vegetable Consumption
Appendix I: Federal Obligations for Efforts

Related to Fruit and Vegetable Consumption

Page 40 GAO-02-657 Fruits and Vegetables

Table 4: USDA Funding for Activities Related to Diet and Fruit and Vegetable Consumption, Fiscal Years 1997-2001

Constant 2001 dollars in thousands

Activity FY1997 FY1998 FY1999 FY2000 FY2001

Purchasing fruits and vegetables (except at

farmers’ markets) $7,524,861 $6,869,337 $6,659,353 $6,539,206 $6,667,931

Purchasing fruits and vegetables at farmers’

markets 7,809 13,383 15,616 19,762 35,921

Nutrition education related to total diet 355,121 368,748 393,870 422,793 474,656

Human nutrition research related to total diet 13,002a

18,022 22,084 34,900 16,250a

Agricultural research related to fruits and

vegetables 24,792a

81,174 78,273 97,436 64,402a

Other general nutrition activities (e.g., Healthy

Eating Index, Thrifty Food Plans, and Food

Supply Database) 202 309 517 537 532

Other agricultural activities (e.g., farmers’

market development and promotion, marketing

order administration, and market news) 395a

73,789 74,985 75,201 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: USDA’s 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.

Table 5: HHS Funding for Activities Related to Diet and Fruit and Vegetable Consumption, Fiscal Years 1997-2001

Constant 2001 dollars in thousands

Activity FY1997 FY1998 FY1999 FY2000 FY2001

NIH funding for nutrition education and/or

intervention and research related to fruits and

vegetables. $3,969 $4,972 $5,430 $5,627 $3,600

CDC funding for prevention research,

monitoring and surveillance, collaboration, and

evaluation, and other nutrition

education/intervention related to total diet 1,609 1,587 1,566 6,650 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.
Appendix I: Federal Obligations for Efforts

Related to Fruit and Vegetable Consumption

Page 41 GAO-02-657 Fruits and Vegetables

Table 6: DOD Funding for Activities Related to Diet and Fruit and Vegetable Consumption, Fiscal Years 1997-2001

Constant 2001 dollars in thousands

Activity FY1997 FY1998 FY1999 FY2000 FY2001

Purchasing fruits and vegetables $39,693 $47,605 $46,367 $55,350 $60,000

Nutrition education related to total diet 3,488 3,503 4,389 4,565 3,535

Human nutrition research related to total diet 4,348 6,304 6,236 4,740 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.
Appendix II: Scope and Methodology

Page 42 GAO-02-657 Fruits and Vegetables

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 USDA’s Center for Nutrition Policy and Promotion; HHS’s

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) HHS’s Office of the Secretary, including the Surgeon General, the Food

and Drug Administration and its Center for Food Safety and Nutrition;

(2) USDA’s Agricultural Marketing Service; Center for Nutrition Policy and

Promotion; Economic Research Service; and Cooperative State Research,

Education and Extension Service; (3) DOD’s 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, California’s Department of Health Services, the Food Research

and Action Center, and the National WIC Association.

Appendix II: Scope and Methodology
Appendix II: Scope and Methodology

Page 43 GAO-02-657 Fruits and Vegetables

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. USDA’s 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.
Appendix III: Federal Agricultural, Trade, and

Environmental Programs and Regulations Can

Affect Fruit and Vegetable Consumption

Page 44 GAO-02-657 Fruits and Vegetables

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 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.1

 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 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

 1

Some of these imports come from countries that are covered by regional trade agreements

that provide reduced or tariff-free entry for these commodities.

Appendix III: Federal Agricultural, Trade, and

Environmental Programs and Regulations

Can Affect Fruit and Vegetable Consumption

Trade Restriction and

Export Promotion

Programs

Environmental

Regulations
Appendix III: Federal Agricultural, Trade, and

Environmental Programs and Regulations Can

Affect Fruit and Vegetable Consumption

Page 45 GAO-02-657 Fruits and Vegetables

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.

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.2

 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.

 2

 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.

Agricultural Programs
Appendix III: Federal Agricultural, Trade, and

Environmental Programs and Regulations Can

Affect Fruit and Vegetable Consumption

Page 46 GAO-02-657 Fruits and Vegetables

• 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 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.

Other Federal

Activities
Appendix IV: Fruits and Vegetables Help

Protect Against Heart Disease; Cancer; and,

Potentially, Other Diseases

Page 47 GAO-02-657 Fruits and Vegetables

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 heart’s 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.1

 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.2

 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

 1

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).

2

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.

Appendix IV: Fruits and Vegetables Help

Protect Against Heart Disease; Cancer; and,

Potentially, Other Diseases
Appendix IV: Fruits and Vegetables Help

Protect Against Heart Disease; Cancer; and,

Potentially, Other Diseases

Page 48 GAO-02-657 Fruits and Vegetables

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.3

 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.4

 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.5

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.6

• 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

 3

See E. Obarzanek, F. M. Sacks, et al. Effects on Blood Lipids of a Blood PressureLowering 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).

4

See World Cancer Research Fund/American Institute of Cancer Research, Food, Nutrition

and the Prevention of Cancer: A Global Perspective (Washington, D.C.: 1997).

5

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).

6

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).
Appendix IV: Fruits and Vegetables Help

Protect Against Heart Disease; Cancer; and,

Potentially, Other Diseases

Page 49 GAO-02-657 Fruits and Vegetables

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.7

 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.8

 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.9

• 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.10 Specifically, the study found an

association between consuming 5 or more servings of fruits and

vegetables daily and a lower incidence of diabetes. Furthermore,

 7

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.

8

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.

9

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.

10See E.S. Ford, A.H. Mokdad. Fruit and Vegetable Consumption and Diabetes Mellitus

Incidence Among U.S. Adults (Preventive Medicine, 2001) 32:33-39.
Appendix IV: Fruits and Vegetables Help

Protect Against Heart Disease; Cancer; and,

Potentially, Other Diseases

Page 50 GAO-02-657 Fruits and Vegetables

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 General’s 2001

report on obesity estimated the total medical cost associated with

overweight- and obesity-related diseases at $117 billion in 2000.11

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.12 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

 11See U.S. Department of Health and Human Services, Public Health Service, Office of the

Surgeon General, The Surgeon General’s Call to Action to Prevent and Decrease

Overweight and Obesity: 2001 (Rockville, Md.: 2001).

12See 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.
Appendix IV: Fruits and Vegetables Help

Protect Against Heart Disease; Cancer; and,

Potentially, Other Diseases

Page 51 GAO-02-657 Fruits and Vegetables

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.13 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.

 13See 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.
Appendix V: The U.S. Department of

Agriculture’s Fruit and Vegetable Categories

Page 52 GAO-02-657 Fruits and Vegetables

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

(2) other fruits.1

Table 7: USDA’s Fruit Categories

Fruit category Fruits in category

Citrus, melons,

and berries

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

Other fruits 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.

 1

Apples, bananas and grapes are part of USDA’s “other fruits” category; because they

account for a large portion of fruit consumption, they are shown separately in figure 2 of

the report.

Appendix V: The U.S. Department of

Agriculture’s Fruit and Vegetable Categories
Appendix V: The U.S. Department of

Agriculture’s Fruit and Vegetable Categories

Page 53 GAO-02-657 Fruits and Vegetables

USDA classifies vegetables in three groups: (1) dark-green leafy and deepyellow vegetables; (2) starchy vegetables and dry beans, peas, and lentils;

and (3) other vegetables.2

Table 8: USDA’s Vegetable Categories

Vegetable category Vegetables in category

Dark-green leafy

(dark green)

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

Deep-yellow (orange)

vegetables

Carrots, carrot juice, pumpkin, sweet potato, and winter squash

Starchy vegetables Black-eyed peas (not dried), breadfruit, cassava, cowpeas (not

dried), green peas, hominy, lima beans (immature), parsnips,

sweet corn, white potato, rutabaga, and taro

Dry beans, peas, and

lentils

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

Other vegetables 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.

 2

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 USDA’s “other vegetables”

category—are shown separately.
Appendix VI: Serving Sizes by Food Group for

Five Food Packages for Women and Children

in WIC

Page 54 GAO-02-657 Fruits and Vegetables

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

Pyramid food group (WIC-allowed food)

Grain (cereal)

Vegetable

(carrots) Fruit (juice)

Dairy (milk,

cheese)

Protein (eggs,

tuna, beans,

peanut butter)

WIC package Number of servings (percentage of minimum recommended servingsa)

Package III

(for children 2-3 years of age) 1.8 (30%) 0 (0%) 2.3 (115%) 3.2 (160%)

0.64 (46%)b

0.68 (49%)c

Package IV

(for children 4 years of age) 1.2 (20%) 0 (0%) 1.5 (75%) 3.2 (160%)

0.64 (32%)b

0.68 (34%)c

Package V

(for women who are pregnant and

women who are breastfeeding and

receiving formula) 1.2 (13%) 0 (0%) 1.5 (50%) 3.7 (123%)

0.64 (27%)b

0.68 (28%)c

Package VI

(for nonbreastfeeding postpartum

women) 1.2 (20%) 0 (0%) 1 (50%) 3.2 (160%) 0.48 (24%)d

Package VII

(for women who are breastfeeding and

not receiving formula) 1.2 (13%) 0.28 (9%) 1.8 (60%) 4.1 (137%) 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.

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

Page 55 GAO-02-657 Fruits and Vegetables

Appendix VII: Comments from the

Department of Health and Human Services

Note: GAO’s comments

supplementing those in

the report’s text appear at

the end of this appendix.
Appendix VII: Comments from the

Department of Health and Human Services

Page 56 GAO-02-657 Fruits and Vegetables

See comment 3.

See comment 2.

See comment 1.
Appendix VII: Comments from the

Department of Health and Human Services

Page 57 GAO-02-657 Fruits and Vegetables

See comment 5.

See comment 6.

See comment 5.

See comment 4.
Appendix VII: Comments from the

Department of Health and Human Services

Page 58 GAO-02-657 Fruits and Vegetables

See comment 6.
Appendix VII: Comments from the

Department of Health and Human Services

Page 59 GAO-02-657 Fruits and Vegetables

The following are GAO’s comments on the Department of Health and

Human Services’ letter dated June 28, 2002.

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 General’s 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 USDA’s

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.

GAO’s Comments
Appendix VII: Comments from the

Department of Health and Human Services

Page 60 GAO-02-657 Fruits and Vegetables

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 CDC’s 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.
Appendix VIII: GAO Contacts and Staff

Acknowledgments

Page 61 GAO-02-657 Fruits and Vegetables

Lawrence J. Dyckman, (202) 512-5138

Erin Lansburgh, (202) 512-3017

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.

Appendix VIII: GAO Contacts and Staff

Acknowledgments

GAO Contacts

Acknowledgments

(360126)

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