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Pundit’s Mailbag — PBH’s Effectiveness May Best Be Seen At State Levels

Jim Prevor’s Perishable Pundit, June 16, 2009

As part of our extensive coverage of the efforts by top executives at PBH to establish a Generic Promotion Board for the produce industry, we ran a piece titled, Got Produce? Has PBH Been Effective At Boosting Produce Consumption? The piece questioned if all the talent and money invested in PBH had actually helped achieve its professed aim of increasing consumption of produce.

Because the piece questioned an industry and public health “sacred cow,” it brought a number of responses, including this thoughtful letter from a public health official with the title of Nutrition Education Advisor for the state of Arizona:

I think you’re missing some important information about how PBH has contributed to changes in fruit and vegetable consumption over the years. They have been very strategic in using their limited dollars to reach audiences in creative ways. First with 5 a Day and now with Fruits and Veggies — More Matters, PBH has positioned information on fruits and vegetables to be used in a variety of settings that have a much more extensive reach than they could expect to accomplish with the funding they have available.

For a fair assessment, you need to look at the populations and settings where the PBH messages have had the most extensive reach in order to see a change in consumption.

Here in Arizona, PBH’s messages and materials have been used primarily with low income individuals reached through USDA programs such as WIC, Food Stamp Nutrition Education, and Farmers’ Market Nutrition Program. We know that since the early 1990s, while the overall number of people reporting that they eat five or more servings of fruits and vegetables has remained about the same, the numbers for low income individuals (where the PBH messages have been used) has steadily increased and now equals that of people with higher incomes.

When the new WIC food package is implemented in October, we think this trend will accelerate and intake of fruits and vegetables among low income individuals will surpass that of people with higher incomes. In Arizona, the new WIC food package will provide for the purchase of $750,000 of fresh fruits and vegetables each month. Fruits and Veggies — More Matters is an important part of the promotion and education we are doing about the fruits and vegetables that will soon be available to WIC clients.

The PBH website for moms that provides information on how to pick, store, and cook fruits and vegetables is something state health departments couldn’t provide on their own. I think you are underestimating the value and the impact of the tools that PBH provides for consumers.

I would love to talk more with you about the successes we’ve seen in using the PBH common messages here in Arizona, and I’m sure many other states have similar success stories.

Take a look at some of the creative ways the Arizona Nutrition Network has used the PBH messages and information by visiting www.eatwellbewell.org. Be sure to take time to view the videos!

— Sharon Sass, R.D.
Nutrition Education Advisor
Arizona Department of Health Services
Phoenix, Arizona

We greatly appreciate the letter from Sharon Sass. Both 5-a-Day and, now, Fruits & Veggies — More Matters are unusual programs because much of the messaging gets carried out through a myriad of state and federal efforts, often focused on the poor.

What Ms. Sass is basically arguing is that the correct evaluation metric is not general consumption in the US, but, rather, the consumption of certain subgroups that have been more substantially exposed to the messaging that the Produce for Better Health Foundation promulgates.

This is a brilliant notion and corresponds perfectly with what we have been suggesting for years. We felt that Fruits & Veggies — More Matters needed to be test marketed… that we would have seen more value in doing the program in one small city with proper evaluation mechanisms established. If by spending $10 a person per year (by comparison the proposed generic promotion program proposes to spend less than 10 cents per person per year), we could actually get people to consume a produce-rich diet resulting in fewer diseases of obesity, this data would allow us to go to The Department of Health and Human Services and Congress with a budget proposal that would dramatically improve public health while reducing federal expenditures on medical care. That is exciting.

Ms. Sass is suggesting, though, that instead of doing the evaluation on a city, we could do it on a specific demographic that has had more intensive exposure to the Fruit & Veggies — More Matters messaging. The proposal is not without its difficulties; there is no assurance, for example, that a program that is effective with a particular demographic combination, say, poor, Hispanic ethnicity, young, Catholic, females will be equally effective with, say, middle class, German ethnicity, middle-aged, Protestant, males.

Still, if there is evidence that Fruits & Veggies — More Matters is increasing consumption among various subgroups, this would indeed be very exciting and point the way to a possible massive expansion of the program.

We are still cautious. Ms. Sass wrote a great letter but we immediately saw two possible challenges:

First, she seems to include a lot of programs, such as giving vouchers to people to buy fruits and vegetables through the WIC program along with the Fruits & Veggies — More Matters messaging. This strikes us as analytically problematic. Although some may question whether the WIC vouchers are sufficient in size to raise produce consumption — as recipients may just use the small vouchers to replace other money they were already spending on produce — all agree that at some level, giving away free produce will encourage more consumption. Yet giving away the product doesn’t actually have much to do with the effectiveness of generic promotion.

Second, although we were glad to read it, this line from Ms. Sass’ letter gives us pause: “We know that since the early 1990s, while the overall number of people reporting that they eat five or more servings of fruits and vegetables has remained about the same, the numbers for low income individuals (where the PBH messages have been used) has steadily increased and now equals that of people with higher incomes.”Survey data is notoriously unreliable when it comes to measuring produce consumption. The other day, we ran an interview with Rhonda Reed, Marketing Director at Dole Fresh Vegetables; you can read the interview here. In the interview, Ms. Reed stated the matter clearly in reference to a category she knows more than a little about:

“Consumers say they are eating more packaged salads by far — 55 percent of consumers think they are eating more bagged salads, 37 percent about the same, and 7 percent less often. That is coming from our September 2008 consumer attitudes and usage study, focusing on added-value products. It was conducted by a specialized independent research company.

Consumers only fantasize that they’re eating a lot more salads in line with the trends toward nutrition and health. However, if you look at IRI trends, excluding Wal-Mart and the Clubs, the bagged salad category was down 4 percent in 2006, flat in 2007, down 3 percent in 2008, and down 3 percent year-to-date.”

It is exceedingly possible that highly effective nutrition education and communication has taught the consumers enough that they now feel shame at not eating the right number of servings and so now lie about it. Whether that has anything to do with consumption is hypothetical..

Still Ms. Sass was gracious enough to say she would let us in on what Arizona is doing to utilize the Fruit & Veggies — More Matters program, and we certainly wanted to take her up on that.

We asked Pundit Investigator and Special Projects Editor, Mira Slott, to find out more:

Sharon Sass, R.D.
Nutrition Education Advisor
Arizona Department of Health Services
Office of Chronic Disease Prevention and Nutrition Services
Phoenix, Arizona

Q: Thank you for your feedback on efforts to increase produce consumption. Could you tell us more about the targeted work you do at the state level to help low-income Arizonians address health and nutrition issues and stave off the obesity epidemic? How are the programs funded and resourced? What are the goals, and how do you measure success?

A: One of the things I want to acknowledge upfront is that the fruit and vegetable programs we have in Arizona only existing because of Sue Foerster [MPH, RD, Chief, California Department of Public Health] and Elizabeth Pivonka [President and CEO of the Produce for Better Health Foundation (PBH)]. Sue Foerster instigated and led the 5-a-Day movement. We watch what California does and we follow a year or two after.[Editor’s note: See Pundit’s Pulse of the Industry with Sue Foerster here.]

Q: Could you clarify the distinctions and interplay between government-run programs and those of the PBH?

A: Our efforts are really built on the foundation of the original 5-a-Day project. Back in 1991, we met with the California Department of Health Services, Arizona Department of Agriculture and Western Growers Association to start a 5-a-Day program in Arizona. We ended up not going ahead with the plan because we didn’t have the money for implementation.

Instead, we focused on childcare centers, developing educational activity books that emphasized the importance of eating fruits and vegetables for better health. We distributed 150,000 copies over the years, but the first one didn’t have the 5-a-Day logo on it. In 1993, we were one of the first states licensed by the National Cancer Institute (NCI) [as the 5-a-Day State Health Authority for Arizona].[Editor’s note: Sharon Sass was appointed Arizona 5-a-Day Coordinator).

Q: How did you capitalize on the 5-a-Day license? What programs did you institute, and where did you get the resources?

A: PBH is one of the constants in our efforts, providing the messages and materials, the scientific basis for the work we do, and all kinds of support for coordinators in the state.

Other resources have come from the fruit and vegetable industry. Arizona Iceberg Lettuce Promotion Council funded us the first few years, and we partnered with grocery stores, media and community to facilitate the 5-a-Day message.

PBH was giving us the information and tools we needed and the public relations. The two entities, Arizona Department of Agriculture (ADA) and then the Arizona Department of Health Services (ADHS), jointly ran the Arizona Grown/ 5-a-Day for Better Health Program. But in 1999, it was discontinued when the Arizona Grown promotion took a different strategic direction. We continued to work on special projects and events, such as national tours. PBH got involved and we received lots of support from industry and retailers, as well as from ADA and ADHS.

Q: PBH and the industry propagate a broad, general mandate to increase produce consumption. Isn’t the primary work you do concentrated on low-income groups with specific projects, which generate the bulk of your funding via government-assisted programs? Doesn’t the continued stream of government funding require that focus?

A: Incorporating the food stamp programs into PBH work allowed us to extend funding. It really expanded opportunity for different efforts to increase produce consumption, especially at the community level and in schools, among other things. Food stamp nutrition education is funded through USDA. Last year, Food Stamps changed its name to Supplemental Nutrition Assistance Program or SNAP. SNAP-Ed represents the nutrition education programs provided to SNAP participants.

Q: Could you provide a time line of how programs for low-income individuals unfolded, and highlight some examples?

A: In 1996, we formed the Arizona Nutrition Network and partners selected 5-a-Day as a common message for nutrition education efforts targeting low-income Hispanic women and their children. Other projects included developing a 5-a-Day component for the Arizona WISE-Woman project, a screening program for older women, funded by CDC. We implemented standardized 5-a-Day classes for low-income third-grade students in 12 rural counties through the Community Nutrition Program. [This program was discontinued last year due to budget cuts].

In 1999, we aggressively moved forward on our 5-a-Day interventions for Hispanic low-income mothers and their children, using social marketing and community education. In 2002, we expanded the Arizona Nutrition Network target audience to a general low-income audience and we broadened common messages to include 5-a-Day but also incorporate new messages for low-fat milk and physical activity. Paid media expanded to English and Spanish stations statewide.

Even today we continue social marketing approaches in our three campaigns: one for fruits and vegetables, now with the new message, Fruits and Veggies — More Matters; a second campaign promoting low-fat milk, and a third called Grow a Healthy Child, integrating obesity-prevention messages tied to family meals and appropriate beverages.

Q: In the California program, Champions for Change, there is an emphasis on a comprehensive, multi-faceted approach to address health and nutrition issues and battle the childhood obesity epidemic. Sue Foerster emphasizes the need to combine fruit and vegetable consumption with physical activity and to stimulate an environment of self-empowerment for change.

A: Physical activity is a component in every campaign and is woven into all we do. We have an animated spokesperson, Bobby B. Well, who promotes a healthy lifestyle and teaches kids that nutrition and exercise are cool and fun.

The most exciting thing about our fruit and vegetable promotion is implementing Champions for Change, not just in SNAP-Ed and food stamps, but in all programs. The one percent/fat-free milk program is the first one to incorporate the concept. Champions for Change is a different approach, and we didn’t just take the phrase and retag it. We are customizing the concept to fit with our specific programs.

Representing Hispanic mothers, we have put together really powerful ads. Here mothers are talking about how good their children are and how physical activity and eating well has made them healthier and happier. Whether it’s SNAP or WIC, or the Farmers Nutrition Program, we are implementing the same common messages in all these programs. We reach nearly a million participants through our efforts.

In the WIC programs, it is often one-to-one consultations, and it might include a demo.

SNAP-Ed is much more community-based. We might have a public nutritionist going into classrooms or offer cooking demos at a senior center. The SNAP-Ed programs vary from state to state. The state pays half the expenses for that program, so it is often tailored to particular needs. USDA has done a lot of work on messaging and good formative research around fruits and vegetables.

Funding at this time is all for low income individuals, up to 130 percent of poverty level.

For SNAP-Ed, it is dollar-for-dollar and the state has to provide half the funding.

WIC is 100 percent federally funded up to 185 percent of the poverty level.

Q: Is there any government funding available for other income levels?

A: To have some state and federal money for other income levels, CDC had provided funds, but those funds have gone away. [Editors Note: see information on budget cuts later in the interview]

The USDA funding does have a tremendous reach. In March, 791,244 people were receiving benefits in Arizona, averaging $112 per person. Food stamps provide $9 million to grocery stores for food, and people are buying more fruits and vegetables and low-fat milk.

Q: How do you accurately measure results of your program? In studies based on surveys, what people say they are doing doesn’t necessarily mean much. It is often difficult to accurately measure whether people’s intentions or memories parallel reality.

A: For changes in fruits and vegetable consumption, we rely, like every other state, on a behavioral risk factor survey conducted by CDC, the largest health risk appraisal done in world. Usually questions are collected every other year, but here in Arizona, we have conducted them every year. A new Arizona Nutrition Status Report was just published in 2008, looking at fruit and vegetable consumption. Link to the Arizona Nutrition Status Report 2008 (Fruit and vegetable info begins on page 18).

The report covers 2001 to 2007, and if you go back to 1993 it appears overall trends are the same: Still, only 11 percent of people are reporting they are eating more fruits and vegetables. What is different is that lower income people are reporting increases in consumption reaching the levels of higher income people. We are expecting that trend to accelerate with the implementation of the new WIC food package, and intake of produce among low income individuals to exceed that of adults not in poverty.

For the first time in 30 years, WIC has significantly changed the package to include fruits and vegetables. [See New WIC Food Package for Arizona.] There was juice before, and carrots for mothers who are breast feeding, but now people are receiving WIC benefits for fruits and vegetables and also canned fruits and vegetables for infants. We’re going to provide cash value vouchers for fruits and vegetables, and depending on whether for a child, pregnant mother, etc., the amount will vary between $6 and $10. This might not sound like much, but for perspective, we serve 185,000 WIC clients a month, amounting to $750,000 a month for fruits and vegetables.

I also think this will lead to big changes in grocery stores. A lot of Arizona is rural, and a good selection of fresh produce is not always readily available. We think many retailers will be able to offer more fruits and vegetables to WIC customers and see opportunity to expand produce offerings. We will be using the Fruits & Veggies — More Matters materials.

One thing we know from our research is that WIC mothers understand the importance of eating fruits and vegetables but don’t always know how to pick and cook them. PBH provides the educational tools, including 97 videos on food items. We could never afford to offer these kinds of programs. PBH provides tremendous support, coupled with the education we do in clinics. We just finished training 400 WIC employees, including a WIC chef who conducts food demos. Retail partners also do sampling in stores to assist people with cash-value vouchers.

We find the benefits come from eating a wide variety of fruits and vegetables, and if people just take the three they’re used to, they may not get all the nutritional value. We really want to be sure to maximize the benefits. Mothers have told us in focus groups they watch food dollars so carefully. If they are not sure their child will eat the item, they won’t risk buying it. If the child has sampled the item in the SNAP-Ed program or at a WIC clinic, we think they’ll be more likely to eat it.

Q: How do you know the food stamp recipients will actually increase their produce purchases and not just move their allotted food money around, using the produce cash-value voucher to buy the same amount of produce they did before?

A: WIC is very specific for food items. There are defined vouchers for cereals high in iron. Those foods come in a list; they can buy so many dozen eggs, so much milk; all very specific down to the ounces of cereal. For the first time in 30 years, the new WIC package also will be receiving whole grains, and soy products are being added.

The dollar impact is three quarters of a million dollars every month, and this is just in Arizona.

Industry support of this program is vital. You can’t sell produce without dedicated suppliers and committed retail grocers. Retailers are bringing in dietitians. A dietitian for a grocery store in Arizona is featured on PBH’s Fruit & Veggies — More Matters website.

Q: What you describe here could be intended for a much broader audience than the one WIC serves…

A: This program won’t just impact low-income people. It will lead to a greater reach. Our funding has increased specifically for the SNAP-Ed and WIC programs. With SNAP-Ed, we’ve worked with partners in local communities resulting in more money and resources coming to the table. It may be a teacher devoting more of her time to promoting messages of healthy eating. WIC is different because it is specific on who it serves, but with tough economic times, those eligible for the program are increasing.

In Arizona, SNAP-Ed reaches one in five preschoolers, 30 percent of school-age children and teenagers, and 40 percent of their mothers. Less than 10 percent are adults or elderly people. We have a lot more people unemployed, so we may see a shift on who is receiving SNAP. In Arizona, those eligible for food stamps increased 30 percent in the last year.

Q: What connection, if any, does SNAP have with USDA’s fresh fruit and vegetable snack program (FFVP) at schools?

A: In the early stages, that program was piloted at eight schools on Indian reservations, and nutrition education was provided by the Arizona Nutrition Network. Last year it expanded to an additional 25 schools, and nutrition education messages coordinated with Arizona Nutrition Network and Farmers Market Nutrition Program, with schools encouraged to buy locally grown produce.

When we look at problems of obesity and the role fruit and vegetable consumption plays in counteracting that, we know access is critical. We‘ve seen that evidenced in the free fresh fruit and vegetable snack program, as Lorelei DiSogra can attest to based on its successes. [See interview with Lorelei DiSogra in the Pundit here]. That free snack program doesn’t include money for nutrition education.

We’ve linked our SNAP-Ed programs with that program, and we can bring the nutrition education piece. Unfortunately, if the grocery store is not close by, if the family lives in a food desert and can’t get to a store that has affordable fruits and vegetables, all the education in the world doesn’t matter.

There is a lot of coordination going on, and I’ve been remiss on not emphasizing the role of CDC. They license Fruit and Veggies — More Matters and conduct the effort in all states. Previously it was done at the National Cancer Institute. There is collaboration for the PBH to license Fruit and Veggies — More Matters, but no funding. Use of the license will be different in different states and may go through the chronic disease program. CDC doesn’t fund all programs.

Q: With so many variables impacting the consumption of fresh fruits and vegetables, have there been any studies to monitor the impact of generic produce campaigns? Has there been an assessment comparing 5-a-Day to Fruits and Veggies — More Matters?

A: CDC published a report “5 a Day Works” in 2005. [Read the report here. Arizona Info begins on page 42):

NCI in 2001 put out a study highlighting examples of 5-a-Day’s effectiveness. It discussed the affect of our Bobby B. Well character. It also underscored our program launched in 1998 through the Community Nutrition Program, appropriating state money for rural services we provided for third graders, although cuts in funding forced us to shutter the program last year. Lorelei DiSogra was right when she said if you make produce available to children they’ll eat it.

Fruits and Veggies — More Matters comes to states through PBH and CDC with no funding, but with a scientific base and reliable tools, and collaborations we would not be able to do on our own. PBH was instrumental in linking us with retailers. They have licenses with retailers nationwide — 27,000 stores use Fruits and Veggies — More Matters.

When NCI handled licensing, it arranged individual consultations with public relations/marketing/promotions firms. One of the most important things they told us is to know when moving from a small program to a larger one, look to the successes and good partnerships. For 5-a-Day, we had been focusing on people already at two or three servings of vegetables a day.

When selecting our strategy, we need to be practical on what we could do based on our budget. For the first three years, we only focused on Hispanic children, getting our message out on Spanish television stations, and in print in two languages. For our WIC county health and school programs, we focused where we already had success. Then we moved to broader advertising at a later time. When you have limited funds, don’t start with a new population or unproven concept.

Q: In other words, if you have limited funds, spreading them out too thin could result in a watered-down approach, where no one individual project gets enough resources for success.

A: Because our funding comes from USDA and SNAP, we have to show exact percentage of low-income mothers reached by that advertising, and it has to be approved by USDA. If you look at overall data, it probably won’t show a big change, but when you examine the impact to the specific group targeted, it can make a significant difference. If you look at the Arizona numbers for fruit and vegetable consumption, they haven’t changed for the whole population. When you pull out the numbers for the low-income groups we devoted our funding and resources to, the change is strong.

Support from industry over the years has been tremendous. Look at produce sections at grocery stores… it’s been doubled from the early 90s… and you see industry making fruits and vegetables more accessible. In convenience stores you see a bowl of fresh fruit. Ten years ago that was unheard of. We don’t have a way to measure our contribution exactly because there are so many pieces to the puzzle.

The two constants are PBH and the industry, as well as CDC and previously NCI. PBH came to the table when the reigns were changed to CDC. PBH stepped up to the plate and issued to each state licenses for Fruits and Veggies — More Matters. At a time when there could have been a lapse in promotion without 5-a-Day, we were able to continue our promotion without a break. In 2007, we incorporated it into all Arizona Nutrition Network and Arizona WIC materials.

Q: But can you demonstrate that this flow of messaging actually leads to increased consumption?

A: In 2006 part of our evaluation involved sending trained interviewers to our food stamp offices, WIC clinics, and places where people should be reached with our messages. We conducted an in-depth survey. One question showed recognition of the 5-a-Day logo or perhaps our network logo that included 5-a-Day of over 50 percent, which is tremendous.

Recognition of the Arizona Grown logo in conjunction with 5-a-Day went from 0 to 40 percent recognition in a year and a half. We’ve been using Fruits and Veggies — More Matters since 2007. People see it in grocery stores, on WIC materials, and it’s a reminder to eat more fruits and vegetables; it is a reinforcement of the message.

Q: Earlier you discussed the necessity of concentrating funds on targeted projects to get the most bang for the buck. Some industry executives wonder whether generic produce promotions are the best use of limited funds. Basically, unless you can afford to blast your message and saturate the market, the message will get lost in the sea of junk food marketers and it’s a waste of money. Could you share more thoughts here?

A: Back to generic promotion, we talked a lot about this with Arizona Grown/5-a-Day. Arizona had to put up matching funds with the Department of Agriculture. I came out of the experience with the belief that the best ways to promote fruits and vegetables is through a team approach. It is not helpful to pit one fruit or vegetable against another.

Q: Sue Foerster said she went through somewhat of a grievance period when 5-a-Day was retired in favor of Fruits and Veggies — More Matters. What feelings did you go through?

A: I’m an experienced public health nutritionist. Fruits & Veggies — More Matters came out of the revised 2005 USDA nutrition guidelines. I don’t’ think people recognized the significance of those changes in the guidelines. Getting my mind around them at first was difficult. I want one recommendation for everyone; 5-a-Day was one size fits all.

Those guidelines made a fundamental shift in that philosophy. It was an important change but as a nutritionist hard for me to embrace. We no longer say 5 to 9 servings of fruits and vegetables. Now recommendations to individuals are based on gender, age and physical activity. We serve over 1 million people a year; how can we make individual recommendations?

USDA developed tools for consumers. On the mypyramid.gov website, consumers can develop their own personal plans; who gets two cups and who gets three. Consumers can enter their daily intake and physical activity and track progress over time.

Q: The concept of More Matters as a health message to consume more produce doesn’t address the need for overweight and obese people to reduce overall calorie intake and eat smaller portions of food. Do you think it may create a mixed message?

A: Families that include more fruits and vegetables will have less incidents of overweight. If you look at nutrition education, we spent many years telling people to eat this and cut out this. The beauty of the Fruits and Veggies — More Matters message is that consumers won’t overeat fruits and vegetables, and now with the WIC package of whole grains, it balances out.

Parents who restrict eating find the children tend to become overweight. [Encouraging people to eat] more fruits and vegetables is part of an overall healthy message. Higher calorie foods with empty calories need to be replaced with low-fat milk and appropriate quantities of 100 percent fruit. We’re following national recommendations.

I think the change to Fruits and Veggies — More Matters came from science. If we’re going to impact the obesity epidemic, this is one positive strategy. I think we’re seeing a leveling off of obesity. We’re certainly seeing much more interest in addressing obesity from state and city governments, and many efforts in the schools. Again, there is no one answer. PBH, along with support from industry and CDC, is helping to alleviate the problems.

Q: What are the most important developments going forward?

A: I think I’m most excited about implementing Champions for Change throughout all our nutritional programs. And taking the new WIC package and really assisting mothers in serving a variety of fruits and vegetables to their families.

Q: How will the uncertain economic environment come into play?

A: We lost significant funding and support from CDC as well as state government funding. Our former coordinator was supported by state funds that went away in January. We transferred the duties to Laura Astbury, M.S., R.D., State Fruit and Vegetable Nutrition Coordinator.

Our former coordinator had flexibility to work with other income levels, so we lost those.

This is a challenge, I’ll be honest. We’ve looked at consolidating. We’ve looked internally at what funds we have to address the obesity epidemic. I can assure you Fruits & Veggies — More Matters will be used to address this. These are difficult times and with those limited resources, maybe it’s good to use common messages like we’ve done across government programs. The effects of the stimulus money remain to be seen.

CDC funded a nutrition and physical activity program for five years, and did provide at least four employees in that effort, including a physical activity coordinator and epidemiologist. That was a five-year agreement, and in a round of competition with Arizona and other states, the program was approved but not funded. We had that program doing a lot of work, including promotion of fruits and vegetables with partners around the state. Funding stopped in September. And later we lost program employees.[Editor’s note: See most recent list from Association of State & Territorial Public Health Nutrition Directors on contracted state directors, and administrative coordinators.]

We’re going to work to reach as many people as we can with the limitations confronting us. We have a $3 to $4 billion deficit in Arizona, and we are working to preserve programs. The way we deal with these difficult times is by building on existing efforts with the resources we have. We are talking about targeting, which goes back to the Hispanic program. As our budget grew, we were able to expand reach.

Q: So are you reassessing plans to fit your reduced budget?

A: We have clear plans going forward. We submitted our WIC plan for next year, and our SNAP plan is about to go in. We are talking about public health prevention services within the department. Our finding from USDA is very specific; the budget reassessment is part of the department’s efforts. Are there other programs where we can take a common message like we did for 5-a-Day and build on that message?

The license to use Fruits and Veggies — More Matters comes without designated funding, and in some ways that’s the beauty because we are not tied to a cookie-cutter approach. Given my druthers, obviously I would like money for Fruits & Veggies — More Matters because we could take successes with our low-income program and move to other population groups or work on policy to get more grocery stores in underserved areas.

There are projects underway to help grocery stores get started in food deserts. There have been a number of new stores that have become successful when offering fruits and vegetables with state money. We can do the most innovative program to increase consumption, but if people don’t have access to the produce, it’s pointless.

Editor’s note: Sharon provides the following links on food deserts and policy change to promote access to healthy foods:

Bringing Healthy Foods Home: Examining Inequalities in Access to Food Stores

USDA ERS — Food Deserts

Food Deserts — Nonmetropolitan South

The Food Trust (Philadelphia)

The Food Trust (Other States)

Rural Food Deserts

The new Leadership for Healthy Communities: Advancing Policies to Support Healthy Eating and Active Living Toolkit indicates that research shows that policy change to increase local sources of food will provide consumers with healthier choices, farmers with marketing opportunities, and communities with powerful economic development opportunities. Policy options to accomplish this include development of farmers’ markets, expanding of community gardens, and the procurement of locally grown food. To see a summary of the toolkit, look here.

How inspiring! As industry members but, more importantly, as Americans, how fortunate are we to have people like Sharon Sass out there fighting the good fight and trying to help people be healthy and live better lives. We hear her story and we want to give her an award or a garland of roses. How does one say thank you enough to public servants who approach their work with such passion?

Yet when we review the copious materials Ms. Sass offers, we see her efforts as only marginally related to increased fruit and vegetable consumption. More exercise, increased consumption of low-fat as opposed to full-fat dairy products, a focus on the poor plus many other initiatives — Ms. Sass, quite appropriately, is looking to enhance the health and well being of the citizenry, and increasing produce consumption is just one facet of that effort.

We note that Ms. Sass seems very concerned with access to produce: “Unfortunately, if the grocery store is not close by, if the family lives in a food desert and can’t get to a store that has affordable fruits and vegetables, all the education in the world doesn’t matter.”

We wish there was more quantification of this problem. Knowing the industry and the availability of canned, frozen and fresh, it is hard to imagine that this is really a major obstacle to consumption. Still, if access is the problem, then it is doubtful that generic promotion is the answer.

Mostly, though, we are frustrated that so many good people work so hard and we just have no hard data to indicate we are accomplishing the professed goal of increasing produce consumption. Sometimes we get survey data that shows people saying they are consuming more, but sales and disappearance data don’t support the survey responses. To us, this exchange from the discussion is both telling and typical:

Q: But can you demonstrate that this flow of messaging actually leads to increased consumption?

A: In 2006 part of our evaluation involved sending trained interviewers to our food stamp offices, WIC clinics, and places where people should be reached with our messages. We conducted an in-depth survey. One question showed recognition of the 5-a-Day logo or perhaps our network logo that included 5-a-Day of over 50 percent, which is tremendous.

Recognition of the Arizona Grown logo in conjunction with 5-a-Day went from 0 to 40 percent recognition in a year and a half. We’ve been using Fruits and Veggies — More Matters since 2007. People see it in grocery stores, on WIC materials and it’s a reminder to eat more fruits and vegetables. It is a reinforcement of the message.

This is what we find time and time again. We ask for evidence that a program has been successful at boosting consumption and we are given evidence that a program boosted awareness of a logo. These are just not the same things.

To us, people like Sharon Sass are heroes, delving in with limited budgets and limited information about what will work and they try to solve serious public health problems. It’s the type of thing one would like to make a donation to support or urge public officials to better fund.

But this all has little to do with the produce industry assessing itself to fund a generic marketing program. In the end, that is a business decision. It requires estimates of what consumption would be in the absence of a program, estimates of how the promotional effort would increase demand, assessments of how supply will respond to increased demand, calculations of the return to various commodity growers and industry segments from the intersection of the demand and supply response and an evaluation of returns available from alternative investment opportunities. Our coverage has been, and continues to be, an attempt to explore all these matters.

Many thanks to Sharon Sass and the Arizona Department of Health Services for helping the industry to better understand the important work they, and their peers in other states, are doing to help people live healthier, happier and more productive lives.

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