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. 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. 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. 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. As a result of school meals, participants in these programs consume greater amounts of several important nutrients, such as calcium. WIC has seven food packages—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. 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 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.Studying the relationship between diet and chronic diseases is challenging because, among other things, it is difficult to measure and account for all potential risk factors; this challenge is compounded because chronic diseases may take many years to develop. However, extensive and consistent evidence shows that diet is one of the leading risk factors for these diseases. Although no diet can guarantee full protection against any disease, the recommendations from HHS and USDA and health organizations such as the American Cancer Society and American Heart Association indicate that consuming the recommended 5 to 9 daily servings of fruits and vegetables as part of a healthy diet provides some of the best dietary protection against disease. Research links increased fruit and vegetable consumption to reduction in the risk of heart disease and many types of cancer. Research also suggests their potential benefits for reducing the risk of stroke, diabetes, diverticulosis, and obesity, according to reviews by NIH, CDC, and academic experts. Fruits and vegetables are among the most concentrated natural sources of over 100 beneficial vitamins, minerals, and other dietary compounds such as fiber and antioxidants important to disease prevention. With regard to the specific health benefits of fruits and vegetables, studies show that people who consume 5 or more servings daily have about one-half the cancer risk of those who consume 2 or fewer servings, according to a National Institutes of Health report. 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. 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. 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. 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 one- tenth of a serving between the 1989-91 and 1994-96 surveys. Indeed, only about 8 percent of Americans get the recommended daily 1 or more servings of dark green or orange vegetables. Moreover, only 3 percent of Americans get both the recommended number of servings of vegetables and at least 1 serving daily of a dark green or orange vegetable. There may be many reasons why the consumption of fruits and vegetables, particularly deeply colored ones, is low. For example, many people may not be aware of the importance of eating deeply colored fruits and vegetables. In addition, taste, price, and seasonal availability, among other factors, may affect consumption, as might the ready availability of other foods. Many Americans do not incorporate adequate variety into their daily diet. As noted earlier, eating a wide variety of fruits and vegetables is important because different fruits and vegetables are rich in different nutrients. For example, fruits such as apricots and blueberries, are excellent sources of protective phytochemicals and, although most citrus is consumed as juice, a fresh orange has 27 times the fiber content of orange juice. As shown in figure 2, three fruit sources—citrus (fresh and juice), apples (fresh and juice), and bananas—accounted for 52 percent of total fruit servings in 1999. While these provide important nutrients, they do not supply all the nutrients important for disease prevention and health promotion. (See app. V for a detailed listing of fruits in each of the categories for fig. 2.) Americans’ vegetable consumption tells a similar story. Although federal dietary guidance recommends eating a variety of vegetables—including dark green or orange; starchy (e.g., potatoes, dry beans, peas, and lentils); and others—consumers eat a limited variety. As shown in figure 3, three foods—white potatoes, iceberg lettuce, and canned tomatoes—accounted for 53 percent of total vegetable servings in 1999. Although white potatoes are an excellent source of potassium and vitamin C and are naturally low in fat, frozen potatoes (mostly french fries) and potato chips together accounted for 43 percent of starchy vegetable servings and 17 percent of total vegetable servings. The added-fat in french fries and potato chips carries calories that contribute to overweight and obesity. Moreover, the consumption of dark green or orange vegetables most likely to prevent disease and promote health totaled only 0.4 serving per day, well below the 1 or more daily servings suggested for the average person. (See app. V for a detailed listing of vegetables in each of the categories for fig. 3.) 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. 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. The center plans to complete its assessment and any revisions before the 2005 update of the Dietary Guidelines for Americans. The 5 A Day program—a public-private partnership between federal/state/local governments, the fruit and vegetable industry, and supermarkets—is the only federal nutrition education and intervention effort focused on increasing fruit and vegetable consumption. Its long- range purpose is to help reduce the incidence of cancer and other chronic diseases through dietary improvements—specifically by getting Americans to consume 5 to 9 servings of fruits and vegetables daily. The National Cancer Institute coordinates and provides the funding for the federal side of the partnership, CDC develops and manages state-level programs, and the Produce for Better Health Foundation, a nonprofit organization of approximately 800 members of the fruit and vegetable industry and supermarkets, coordinates the private side of the partnership. To support a variety of 5 A Day program and research activities, the National Cancer Institute spent $3.6 million in fiscal year 2001. In fiscal year 2002, the Institute expects to spend $4.5 million; California, Florida, and Arizona have committed to providing $3 million, $1.7 million, and $0.3 million, respectively; and industry has committed about $3 million. The success of 5 A Day may be due to its use of a combination of strategies, including hands-on experiences (e.g., food preparation and field-trips), visual cues (signs on cafeteria doors and at registers), and media campaigns (TV, radio, and print). Following are three examples of 5 A Day community-based programs that have had sustained results in improving fruit and vegetable consumption: An 8-week program of activities for 4th- and 5th-grade children in three California communities increased the consumption of fruits and vegetables by over 1.5 servings after the first year and about 1 serving after the second year, compared with consumption by children who did not receive the activities. The program included classroom activities (lessons, problem-solving, and taste testing), cafeteria/food service activities (promotion of fruits and vegetables), and parent activities (homework assignments, brochures, refrigerator magnets). That program was subsequently expanded statewide. A 2-year study in 28 small- to medium-sized businesses in Seattle, Washington, provided half the sites with 5 A Day signs in the work environment to provide constant reminders about eating fruits and vegetables and worked with food-service staff to make more fruits and vegetables available as part of the regular menus. Nutrition education was provided through a specialist who visited the work sites, and an employee advisory board was used to encourage behavior change. Two years after the program concluded, the employees who received the 5 A Day program averaged about a third of a serving more of fruits and vegetables than the control group. A 20-month program involving 49 predominantly African-American churches in North Carolina resulted in a 0.85-serving increase in fruit and vegetable consumption at the 2-year follow-up. According to study participants, having more fruit and vegetables served at church functions, having the pastor promote the 5 A Day message from the pulpit, and receiving personalized printed materials were influential in increasing their consumption. The American Cancer Society has begun a nationwide program based on the design of this study. In November 2000, the 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. In response to those recommendations, in April 2002, the Secretaries of Agriculture and Health and Human Services announced plans to expand 5 A Day. A memorandum of understanding signed by (1) the Director, National Cancer Institute; (2) the Director, National Center for Chronic Disease Prevention and Health Promotion, CDC; and (3) 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, 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. 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 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. 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. The Food Stamp Program. Food stamp recipients receive on average less than $80 monthly to help them purchase foods of their choice. They consume about the same amounts of fruits and vegetables as similar low-income nonparticipants. According to USDA, program participants consumed 1.3 servings of fruits and 3.0 servings of vegetables as compared with 1.3 and 3.1 servings, respectively, for low- income nonparticipants. Both low-income groups fall short of the national average of 1.5 servings of fruits and 3.3 servings of vegetables, as well as the recommended number of servings—2-4 of fruits and 3-5 of vegetables. Furthermore, both participants and low-income nonparticipants consumed only 0.1 serving each of deep green or orange vegetables—those most important to disease prevention. According to USDA, the 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.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) 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. Only one WIC food package includes vegetables, and it provides only about one-quarter serving—all in carrots. In contrast, the five WIC packages for women and children provide far more servings of other food groups. For example, all five WIC packages for women and children provide from 3.2 to 4.1 of the recommended 3 to 5 daily servings of dairy products. Appendix VI shows the foods in the five WIC packages for women and children. The National School Lunch and Breakfast Programs. The millions of children who participate in School Lunch consume daily, on average, twice as many servings of vegetables as nonparticipants for lunch (1.3 servings versus 0.6); however, most of that difference is in the form of white potatoes—mostly french fries. 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. However, it is unclear whether the increased overall purchases or offerings resulted in increased consumption because purchases or offerings per student or meal were not reported. Although participation in the School Lunch and Breakfast Programs has been shown to improve dietary quality, 40 percent of children do not eat the School Lunch and 83 percent do not eat School Breakfast in schools where the meals are offered. USDA reported that participation might be affected by other meal options available to students such as foods sold a la carte, in vending machines, and school stores or snack bars. Those foods do not have to meet the nutrition standards required for the USDA-reimbursable meals of School Lunch and Breakfast. USDA reported that a la carte sales are higher in higher-income schools and that as a la carte sales increase, school meal participation decreases. 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.Over 2 million WIC participants receive farmers’ market coupons; only about 60 percent redeem them, annually. According to FNS, eligible individuals may not participate because, among other things, farmers’ markets are often not located in or near low-income areas and they may not be familiar with farmers’ markets or with the program. The Seniors Farmers’ Market Nutrition Program. Established in 2001, the seniors program serves about 380,000 low-income elderly people. This small program is based on the WIC farmers’ market program and the two farmers’ market programs are often run by the same state and local agencies. Although national data are not available, one county in Washington State surveyed 87 homebound participants, who reported increasing their consumption of fruits and vegetables by one serving daily. Under the school meal programs, USDA has increased its spending for canned, frozen, and fresh fruits and vegetables from $140 million in 1996 to $243 million in 2001. In addition, under an agreement between USDA and DOD, DOD Fresh provides about $31 million in fresh produce to schools in 39 states, Puerto Rico, and Guam. Participating schools benefit from 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. Because DOD uses a decentralized system to purchase produce from local vendors, we reported that it was able to provide high- quality fresh produce. According to USDA, many school food authorities can purchase fresh produce of similarly high-quality from distributors and, seasonally, from local sources. Nonetheless, fruits and vegetables are the most frequently wasted (e.g., thrown away) food items in the School Lunch Program, ranging from 21- percent to 42-percent waste. In 2002 USDA reported that wasted food— including fruits and vegetables—cost USDA $600 million annually.Studies have shown that this waste can be decreased by such factors as (1) scheduling recess before lunch, (2) increasing the use of fresh produce and local foods, (3) involving students in meal planning, (4) introducing new fruits and vegetables to students before they appear in school meals, and (5) allowing students to serve themselves—for example, using self- service salad/meal bars. Over the past few years, FNS has helped fund some innovative programs implemented by local and state agencies that have been found to promote fruit and vegetable consumption. One such program—Food Sense—is under way in two counties in Washington State. Food Sense provides 1,300 low-income adults with handouts, recipes, and information about the Food Guide Pyramid and the Dietary Guidelines for Americans, and how to select and prepare fresh produce. The program also serves 2,000 children from low-income households and uses storytelling, games, and healthy snack tasting to reinforce healthy food choices. State data on the program show that 75 percent of the adults and 31 percent of the children participating in Food Sense ate more fruits and vegetables daily as a result of the program. Another initiative, funded jointly by USDA and three California school districts, also appears to have increased the consumption of fruits and vegetables in the School Lunch and School Breakfast Programs. 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 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 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. In 1999 FNS reported that the evaluation system was fragmented and minimal, and lacked outcome measures. 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. 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. 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. 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. 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. 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. FNS officials and others agreed that adequate and reliable evaluations are needed to determine which program components improve diet so that FNS and state and local agencies administering the programs can plan effective nutrition education strategies. In a 2001 report on WIC, we recommended that FNS work with stakeholders to develop a strategic plan to evaluate the impacts of specific WIC nutrition services and include in the plan information on the types of research that could be done to evaluate the impacts of specific nutrition services as well as the data and the financial resources that would be needed to conduct such research. 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. 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. 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. In addition, USDA, the American Academy of Family Physicians, American Academy of Pediatrics, American Dietetic Association, National Hispanic Medical Association, and the National Medical Association have suggested that (1) foods that compete with school lunches be required to follow the same nutritional regulations as the school meals; (2) all students have designated lunch periods as near the middle of the school day as possible and of sufficient length to enjoy eating healthy foods with friends; and (3) schools provide enough serving areas to ensure student access to school meals with a minimum of wait time, among other things. Also, the Farm Security and Rural Investment Act of 2002 includes a provision to pilot a program to offer free fruits and vegetables to school children in about 100 schools—25 schools in each of four states—and on an Indian reservation. This same act also includes a provision for mandatory spending on fruits and vegetables. The provision directs USDA to spend not less than $50 million for fresh fruits and vegetables for schools through DOD Fresh. Expand farmers’ market programs for WIC participants and the elderly. The American Public Health Association, the National WIC Association, the Center for Science in the Public Interest, and others support increasing farmers’ market programs for WIC and elderly participants. In addition, a few representatives noted that USDA agencies should collaborate to increase the number of markets in areas where WIC participants and other low-income people live. Such collaboration is needed because initiating farmers’ markets in low- income areas is hindered by several factors including difficulties with finding space in a large city and farmers’ lack of familiarity with the redemption of WIC coupons, according to one university researcher. He further stated that 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 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. 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 for Americans, which includes the Food Guide Pyramid. USDA also said that its approach is to address total diet by promoting overall balanced nutrition and the principles of the Dietary Guidelines for Americans, which includes, but is not limited to, increasing fruit and vegetable consumption and other dietary improvements that support all of the Healthy People 2010 nutrition objectives and the 5 A Day targets. USDA said it has not considered the Healthy People 2010 nutrition objectives as goals that must be directly incorporated into its strategic plan, but that it could consider the merits of including components directly supporting the Healthy People 2010 objectives and 5 A Day in its strategic and performance plans. We believe the Healthy People 2010 objectives—which USDA was a major participant in developing—present a national agenda for improving the health of Americans and that USDA should incorporate these measurable targets and time frames into the food assistance programs. We further believe that the 5 A Day partnership presents a reasonable framework for addressing the objectives related to increasing fruit and vegetable consumption. With regard to the Food Guide Pyramid graphic, USDA noted that consumer research showed that the graphic communicates the messages of proportionality, moderation, and variety among the food groups. USDA stated that the Pyramid graphic does not convey all nutrition messages and that the Pyramid booklet provides more detailed information on how to make appropriate fruit and vegetable selections. Nonetheless, USDA agreed with the merits of our recommendation that, as it considers revising the Pyramid graphic and related materials, it will explore appropriate ways to effectively communicate information on the need for a variety of fruits and vegetables, especially deeply colored ones. USDA also pointed out that its efforts to promote fruits and vegetables extend beyond food assistance and nutrition education to include agricultural, economic, and behavioral research; agricultural extension; and market development and support. We added this information in the report. HHS stated that our draft report was too definitive in its statements about the relationship between fruit and vegetable consumption and the reduction of diseases, and that the scientific evidence does not support the statements we made concerning the reduction of disease rates and the dollar savings that would result from increased intakes of fruits and vegetables alone. HHS was particularly concerned about the information we present in appendix IV—which describes some of the evidence that links fruit and vegetable consumption to reducing the risk for certain diseases. We qualified the language in appendix IV to clarify the strength of the linkages between consuming fruits and vegetables and specific diseases and added citations for our sources throughout the report. With regard to the cost data, we deleted the reference to 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 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. 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. 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. 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. 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. 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 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. In general, the promotional activities of marketing orders can increase consumer demand and, therefore, the consumption of some fruits and vegetables. However, a few marketing orders restrict the quantity of a particular fruit or vegetable that can be marketed, particularly during periods of oversupply. In general, these quantity restrictions could be expected to raise prices compared with free market levels and, thereby, reduce consumption. Also, some marketing orders impose quality restrictions. While some economists have suggested that these orders might also be used to restrict quantity—by increasing the quality requirements during periods of strong supply—other economists have noted that such action might not affect supply because major purchasers (wholesalers and retailers) set quality requirements higher than those imposed by federal marketing orders. Commodity Programs. The provisions of commodity programs that provide producers of other commodities, such as grains and cotton, with income and price supports can affect fruit and vegetable consumption. For example, during the past several years, grain and cotton farmers who received direct payments from USDA under production flexibility contracts were restricted from increasing their acreage devoted to fruits and vegetables if they wanted to remain eligible for these payments. This restriction may have reduced the supply of certain fruits and vegetables, thereby raising prices and lowering the consumption of those fruits and vegetables. In addition, because consumers have to choose how to spend their food dollars— on fruits and vegetables or on other foods—anything that influences the consumption of other foods by influencing their prices, including government income and price support programs, can also affect fruit and vegetable consumption. Crop Insurance. By providing subsidized crop insurance for certain crops, USDA reduces the risk to farmers of growing those crops— which would generally lead to greater supplies and lower prices for those crops. Not all fruits and vegetables are covered under federal crop insurance. To the extent that the availability of crop insurance affects the supply of certain fruits and vegetables, it may also affect their prices and, hence, their consumption. Other federal activities 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. 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. 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. The lowest risks were observed for the men and women with the highest consumption of green leafy vegetables and vitamin-C-rich fruits and vegetables, such as strawberries, oranges and orange juice, Brussels sprouts, and red cabbage. That study found a 4 percent lower risk of coronary heart disease for each serving-per-day-increase in fruits and vegetables. Another study looked at the effect of a diet high in fruits and vegetables and low in fat—the Dietary Approaches to Stop Hypertension (DASH) diet—on plasma lipid levels and found reductions in plasma levels of total cholesterol, LDL and HDL, in all races and both sexes compared with the control diet. 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. 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.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. Stroke. Stroke is the third leading cause of death in the United States. CDC reports that about 600,000 Americans have a stroke each year, of which about 160,000 will die. Studies have shown that the consumption of fruits and vegetables may decrease the risk of stroke through their effect on reducing hypertension (high blood pressure), an important risk factor for stroke. These studies show that the lowest risks for stroke are associated with high consumption of cruciferous vegetables (e.g., broccoli and cabbage), green leafy vegetables, citrus fruits, and vitamin-C-rich fruits and vegetables. For example, a recent analysis of 14 years of data from the Nurses’ Health Study and 8 years of data from the Health Professionals’ Follow-Up Study disclosed that each additional daily serving of fruits or vegetables was associated with a 4 to 7 percent reduction in the risk of stroke. 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. 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. 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. Specifically, the study found an association between consuming 5 or more servings of fruits and vegetables daily and a lower incidence of diabetes. Furthermore, women who consumed 5 or more servings of fruits and vegetables per day were 39 percent less likely to develop diabetes compared with women who consumed little or no fruits and vegetables. There are a number of possible mechanisms by which fruit and vegetable consumption could affect diabetes, and additional studies will be needed to conclusively determine the relationship between fruit and vegetable consumption and diabetes. For example, fiber and magnesium in fruits and vegetables have positive effects on the primary manifestations of diabetes—the control of glucose and peripheral insulin sensitivity. The potential benefits in preventing diabetes also may stem from antioxidant vitamins and phytochemicals found in high levels in fruits and vegetables. Obesity. The link between obesity and the consumption of fruits and vegetables is receiving considerable attention from scientists, especially as the prevalence of obesity has increased. Over 60 percent of American adults are overweight, and about 13 percent of children and adolescents are seriously overweight. Overweight and obesity are important risk factors for a number of diseases, including heart disease, cancer, stroke, and diabetes. The Surgeon General’s 2001 report on obesity estimated the total medical cost associated with overweight- and obesity-related diseases at $117 billion in 2000.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. Importantly, consuming meals with the added fruit and vegetables resulted in a 30 percent reduction in total caloric intake for the day. That study, and others like it, suggests that consuming foods of low-energy density, such as vegetables and some fruits, may be a useful strategy for weight loss and control. Adding fruits and vegetables to the diet was also explored as a weight loss strategy in a recent study of obese parents, whose normal-weight children are at risk for becoming obese. 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. USDA classifies fruits in two groups: (1) citrus, melons, and berries and (2) other fruits. USDA classifies vegetables in three groups: (1) dark-green leafy and deep- yellow vegetables; (2) starchy vegetables and dry beans, peas, and lentils; and (3) other vegetables. 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. 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. 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. 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.

Summary: Fruits and vegetables are a critical source of nutrients and other substances that help protect against chronic diseases. Yet fewer than one in four Americans consumes the 5 to 9 daily servings of fruits and vegetables recommended by the federal Dietary Guidelines for Americans. Fruit and vegetable consumption by the general public as a whole has increased by about half a serving under key federal nutritional policy, guidance, and educational programs, as shown by the national consumption data compiled by federal agencies. But key federal food assistance programs have had mixed effects on fruit and vegetables consumption, as shown by national consumption data. However, increasing fruit and vegetable consumption is not a primary focus of these programs, which are intended to reduce hunger and support agriculture. A number of actions the federal government could take to encourage more Americans to consume the recommended daily servings have been identified. These include expanding nutrition education efforts, such as the 5 A Day Program; modifying the special supplemental Nutrition Program for Women, Infants, and Children to allow participants to choose from more of those fruits and vegetables; expanding the use of the Department of Defense Fresh Fruit and Vegetable Project in schools; and expanding farmers' market programs for food assistance participants. These options could require additional resources or redirecting resources from other programs.