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Pundit’s Mailbag — Evaluating Effectiveness In Childhood Eating Studies

Jim Prevor’s Perishable Pundit, July 10, 2007

Our piece, ‘Nutrition-Education Doesn’t Work’ Says Associated Press Review Of Literature, brought a spirited response. That response included several correspondents whose work we’ve mentioned before in our coverage of the Food Dudes program. This program, after lengthy testing in the U.K. and Ireland, is now being rolled out across Ireland and there have been discussions about rolling it out across Europe.

We published an interview, which we ran under the title pundit Pulse of The Industry: Fyffes’ Dr. Laurence Swan, in which we discussed how and why Dr. Swan and Fyffe’s had gotten so involved in the Food Dudes program. Now Dr. Swan sent along this pithy note about our nutrition-education article:

Dear Perishable Pundit,

I have just one word for this piece:

"Bravo"

— Dr. L Swan
Managing Director for R&D
Fyffes plc
Ireland

Our main review of the Food Dudes program, entitled Food Dudes Beat Junk Punks And Kids Eat More Produce, included an interview with Fergus Lowe, Deputy Vice-Chancellor of the University of Wales Bangor and co-founder of the Food Dude Programme. Our piece on the failures of nutrition education brought this substantive response:

You make some very valuable points in your piece on the Associated Press review of literature dealing with attempts to change children’s eating habits. It certainly never ceases to surprise me that huge sums of government money are spent on schemes for which there is, at best, no evidence or even negative indicators of effectiveness.

Take, as an illustration of this, the schemes, covered in the Associated Press Review, that do no more than make fruit and vegetables available to children and leave it at that. In several studies we have conducted (see, for example, Increasing Children’s Fruit and Vegetable Consumption: AA Peer-Modelling And Rewards-Based Intervention, Horne et al., 2004; and http://www.Fooddudes.co.uk), making fruit and vegetables available to school kids over several months did not lead to any increase in consumption of these foods.

Indeed, consumption levels remained very low. The UK has carried out one of the largest and costliest free-fruit-in-school schemes in the world, but evaluations of it (by NFER) have shown that it has been wholly unsuccessful in bringing about changes in eating habits.

As your article makes clear, what is needed is not simply to make these foods available, nor more dull education, which may in fact turn kids off, but instead programs that really change eating habits. We need to motivate children to learn to like the taste of fruit and vegetables. These are great foods that previous generations of kids have eaten, and we must now help this generation to enjoy them too.

The bottom line in this regard is actual consumption of fruit and vegetables and this should be the key behavioral measure. It has been the main focus of the Food Dudes program that we have been developing over past 15 years or so, and which has been subject to controlled experimental evaluation in the UK, with the findings published in peer-reviewed journals.

This is a program that has now been piloted in Ireland (funded by the European Union, Irish Government, and the Fresh Produce Industry), and evaluated by University College, Dublin. Such was its effectiveness in bringing about large and long-lasting changes in children’s eating habits that the Irish Government has decided to make the program available to all primary schools in Ireland.

The Irish project seems to offer an appropriate paradigm that can be followed in other countries such as the US. It entails, as you have proposed, an evaluation of the evidence and an effective trial of the Food Dudes program to see whether it really can change the behavior of US kids (can they be that different from their European counterparts?).

This is not rocket science and it does not require a great deal of resources to establish whether a program can change what children eat and whether these changes can be sustained over time. If a fraction of the money currently spent on the implementation of untested governmental and other schemes were to be spent instead on the establishing what really does change behavior, then we might begin to make progress. The cost of not doing so will be the continued rapid growth of the obesity problem.

— Fergus Lowe
Professor of Psychology and
Director of the Food Dudes

When people do not do things that are eminently sensible, we would be flattering ourselves to think it is because we and only we see the good sense of it. One has to confront the horrible truth that these types of programs become self-perpetuating industries.

It is good that Dr. Lowe is a professor of psychology as he could doubtless speak to the powerful ability of human beings to persuade themselves of whatever they want to do. In the piece we wrote regarding the Associated Press review of the literature education, we included two quotes from the AP article that lay this out so perfectly:

Kate Houston, deputy under secretary of the USDA’s Food, Nutrition and Consumer Services, oversees most federal funds, $696 million this year, spent on childhood nutrition education in this country. Funding has steadily increased in recent years, up from $535 million in 2003. Houston insists the programs are successful.

“I think the question here is how are we measuring success and there are certainly many ways in which you can do so and the ways in which we’ve been able to measure have shown success,” she said.

But isn’t the goal of these programs to change the way kids eat?

“Absolutely that’s the goal,” she said.

And they’re successfully reaching that goal?

“We’re finding success in things in which we have been able to measure, which are more related to knowledge and skill. It is more difficult for us to identify success in changing children’s eating patterns.”

When asked about the many studies that don’t show improvement, Houston asked for copies of the research. And she said the USDA doesn’t have the resources to undertake “long term, controlled, medical modeled studies” necessary to determine the impact of its programs.

At least she acknowledges the goal — changing consumption patterns. But how ridiculous is it for her to say that “…the USDA doesn’t have the resources to undertake long term, controlled, medical modeled studies necessary to determine the impact of its programs”?

She should be before Congress every week demanding that no program ever be done without a mechanism set up to determine if it is achieving its goal. If there is no more money available, better to do half as many programs and study them for efficacy than to do a bunch of random programs and spend billions and billions over the years with not the foggiest idea of whether the goal is being accomplished.

Some of the contractors have talked themselves into forgetting the goal of changing consumption patterns:

Their teacher, Jenkins, offers fact-filled and engaging nutrition lessons as part of a $7 million USDA program which reaches about 388,000 students a year in the Los Angeles Unified School District.

The most recent evaluation of the 8-year-old program was disheartening: no difference in the amount of fruits and vegetables eaten by kids participating in the program and those who weren’t. Teachers who spent more hours on nutrition education had no greater impact than those who didn’t. And parent behavior didn’t change either.

“It’s true, it didn’t change what they actually eat. But the program really made a difference in how kids were feeling about fruits and vegetables. They really had a more positive attitude toward fruits and vegetables,” said Dr. Mike Prelip, a UCLA researcher who headed up the evaluation.

Is it possible that Dr. Prelip thinks the taxpayers care about how children are “feeling” about fruits and vegetables? The children have a more ‘positive attitude’ towards fruit and vegetables? Who is this guy, the Dr. Norman Vincent Peale of produce? It would be nice to hear him say something scientific, such as that he has an ongoing study that he believes will show that thinking positively about produce at age 9 correlates to higher consumption at age 12.

What is revealing about these quotes is that the people who taxpayers would hope would stop ineffective programs — the government, in the person of Kate Houston, deputy under secretary of the USDA’s Food, Nutrition and Consumer Services, and the private contractor hired by the taxpayer’s representatives to evaluate the program, in this caseDr. Mike Prelip, a UCLA researcher who headed up the evaluation — did not attack the programs. Instead they conveniently changed the criteria from those that matter — are children healthier, has this changed their diet, etc. — to completely irrelevant ones — do children have a more “positive attitude” toward produce items?

In fairness, this is a cultural problem that goes far beyond nutrition education. In the recent immigration bill, there were “triggers” put in by which certain policies would not be implemented until the border had been secured. How would we ascertain when the border had been secured? Would someone, such as the head of the Immigration and Naturalization Service or the President, be required to certify that illegal border crossings had fallen to a set level?

No, not at all, the certification required was simply that money had been spent on border security. This may or may not have been effective in securing the border.

Beyond nutrition education, education in general suffers from a desire to be evaluated based on inputs. So all those accreditation bodies go in and measure things such as the number of teachers per pupil, the number of books in the library per student, the percentage of the faculty with PhDs… they measure everything except what the students actually learn. And when some propose to pay teachers based not on their number of years standing there but based on the actual improvement of their students on test score — in other words, paying them based on what they were hired to accomplish — the teacher’s unions wail in outrage.

Within our own industry, we are equally guilty. We so desperately want to believe that if we contribute money to the Produce for Better Health Foundation we will increase produce consumption. Yet we continue to contribute without any evidence that we are achieving our goals.

In fact, we do the same thing these government people do. If we have no data to indicate our programs increase consumption, we convince ourselves that other questions are important — What percentage of people know how many servings they ought to eat? These questions are typically nothing more than diversions.

And, in fact, we set up our own programs, intentionally or unintentionally, with the effect of avoiding testing for effectiveness.

The Pundit must have been asked a thousand times what do we think about the new Fruits & Veggies — More Matters! campaign that has replaced the old 5 a Day program. The answer is that it sounds pretty good to us, but so what? Who cares? Why is our opinion important? Why is anyone’s opinion important?

The goal of adopting Fruit & Veggies — More Matters! was to increase consumption — an eminently testable proposition.

You go to one little city and adopt Fruits & Veggies — More Matters! Then, in the control city you test it against whatever you want to test it against. For example, the continuation of the national 5 a Day program.

You do rigorous measurements of the things you are looking to measure. The obvious one is produce consumption. Although we question if that really is the goal as opposed to say, decreased obesity. In any case, you test what you want to test, then you compare results.

It would have been a relatively easy matter to ascertain if Fruits & Veggies — More Matters! will obtain our goals. But we had to test it.

By just rolling it out nationally, we lose the ability to easily do comparative studies. As a result we just have no idea and will never have an idea if the More Matters! program helps or hurts or is a neutral.

We simply must get away from doing stuff because it “feels good.” Our piece, School Nutrition Success Cries For Research, told the story of Nurse Abodeely and her school. The nurse received an award from the Produce for Better Health Foundation for instituting a whirlwind of activity to help her school and her students.

Yet the award was in some sense curious, as the activity left us lacking in two things: First, we cannot go to the federal government and say “Mr. President, look how effective Nurse Abodeely’s program was in reducing childhood obesity. This merits being rolled out on an expanded 50-state trial.” We cannot do this because no statistics have been kept to ascertain the effect of the program on the health of children..

And, secondly, we have absolutely no factual basis to judge whether Nurse Abodeely is doing important work or just wasting her time. Without research, we just don’t know.

Now our letter-writer today must be frustrated. With the Food Dudes program, they have at least tried to do the right thing. Yet, so far, nobody in the U.S. has leapt to try the program in America. That is a shame.

The research we have seen is encouraging, but more is needed. As Professor Lowe acknowledges, we certainly need research cross-culturally. A program might work in Ireland and fail in New Zealand. So a U.S. pilot is needed.

Additionally, longer term research is required. We have learned from programs such as “Head Start” in the U.S. that sometimes a program can show “results” — a Head Start graduate will be ahead of control groups in reading at completion of the program and for several years thereafter — but students revert to the level of the control group prior to high school graduation.

Even if Food Dudes does “work” in the short run, we have, as of yet, no research telling us what, if any, is its long-term effect.

Still, the research is sufficiently compelling to think that we should try a model program here in the U.S. Getting one funded should be a top priority for the Produce for Better Health Foundation and the government relations efforts of United Fresh and others.

And insuring that all our efforts — by government, non-profits and private industry — are subjected to proper evaluation for effectiveness is a requirement for progress in the 21st century.

Many thanks to Fergus Lowe for fighting hard to do the right thing and for sharing his findings with us in America.

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