4 fixes for the astonishing lack of vegetables in the American diet

Walk through your local grocery store, and you might discover, as Kentucky cardiologist John Mandrola did last year, that four apples cost $9 while a box of doughnuts costs 99 cents. "That’s nuts," Mandrola noted.

It is. And over the years, the American dinner plate has been stubbornly deficient in nutritious produce.

An analysis published in JAMA in June 2016 looked at US eating habits from 1999 to 2012 and found that while whole grain consumption went up and sugary drink consumption went down, there was no change in total fruits and vegetables consumed. (When Americans do eat vegetables, fully half of them are tomatoes and potatoes — often in the form of sugar-laden ketchup and greasy fries.)

The consequences of this pattern are serious: There’s a strong relationship between diets low in fruits and vegetables and obesity and diabetes — two chronic diseases that now rank among the nation’s gravest health concerns. Fruit and vegetable consumption also helps prevent a range of other diseases: "Eating more fruits and vegetables adds nutrients to diets, [and] reduces the risk for heart disease, stroke, and some cancers," as the Centers for Disease Control and Prevention puts it.

Doctors and health advocates have been urging Americans to choose broccoli over brownies for years, to no avail. So it’s abundantly clear that we now need to find other ways to incentivize and entice people to make different choices at the market.

There is some good news here. A variety of strategies — from subsidizing produce to enlisting celebrities to market it to enabling doctors to write prescriptions for it — are being tested across the nation.

We don’t yet know which ones are most effective. But some of the approaches, detailed below, look promising. They are worth testing for one simple reason: If Americans ate a greater quantity and a wider variety of fruits and vegetables, and less junk, they’d be healthier.

Why Americans eat so few vegetables

The Americans who aren’t eating broccoli don’t have a vendetta against it. Instead, there is a range of economic and social factors that make eating enough fruits and vegetables really hard.

Let’s start with cost: As you can see in the chart below, when it comes to how many calories you get per dollar, sugar, vegetable oils, and refined grains deliver a higher bang for buck than fruits and vegetables.

Javier Zarracina/Vox

As we know, in the long run nutrients in food (like fiber, vitamins, and minerals) matter more for health than calories alone. But if your household income is low, you’re probably going for the cheapest, highest-calorie options.

It’s not just cost that has doughnuts winning over lettuce in grocery baskets. It also has to do with access to information. People with higher levels of education — and perhaps more knowledge about health and nutrition — are likelier to choose healthier foods. (Having access to supermarkets actually doesn't have that big of an impact on health, as Jason Block, a physician and researcher at Harvard Medical School, explained to me last year, in our conversation about food deserts.)

Junk foods also have the marketing heft of multinational corporations behind them, and they’re engineered to get people hooked. This also makes it hard for Brussels sprouts and blueberries to compete.

To make things more complicated, there’s a supply problem. Researchers have pointed out that if Americans actually followed the US Dietary Guidelines and started to eat the volume and variety of produce health officials recommend, we wouldn’t have nearly enough to meet consumer demand.

USDA

As of 2013, potatoes and tomatoes made up half of the legumes and vegetables available in this country, according to the US Department of Agriculture. The USDA doesn’t subsidize leafy vegetable crops in the same way it supports crops like wheat, soy, and corn — two crops that make up a lot of the junk food that overwhelms the US diet. So products full of high-fructose corn syrup and soybean oil have an unfair advantage.

But as health advocates have reckoned with these realities, they’ve come up with several ways to fight back. Here are a few promising efforts underway across the US aimed at helping people to get more vegetables into their diets.

1) Subsidizing fruits and vegetables for the poor

Jameel Khaja/Wholesome Wave

To address the cost issue, programs to make fresh produce more affordable for lower-income people are springing up. And there’s government support through USDA grants to expand these programs.

One of the leaders in this arena is the nonprofit Wholesome Wave. As founder and celebrity chef Michel Nischan told Vox: "Affordability is the barrier that will prevent someone choosing a head of broccoli over an eight-pack of instant noodles."

The hallmark program at Wholesome Wave is called National Nutrition Incentives. The idea is simple: When people on food stamps (or SNAP) shop at farmers markets (and more recently, participating grocery stores), the food stamps double in value. So the program, mostly funded by private donors, is essentially a 2-for-1 match for farm-fresh food.

When the program launched in 2008, there were 10 farmers markets in three states participating. Now it’s a national network where local communities run their own programs in 40 states with more than 700 participating markets and retail stores.

Despite this rapid growth, it’s hard to measure how well the program is working. Much of the data evaluating Wholesome Wave is produced by Wholesome Wave itself, or it involves self-reported data and interviews with participants that only measure people's perceptions of fruit and vegetable consumption, and not their actual intake.

One of the more robust (and peer-reviewed) pilot studies looking at the effects of fruit and vegetable incentive programs — including Wholesome Wave’s — ran at farmers markets in three cities. The researchers found that people who participated in a financial incentive program over six months had marginally higher levels of fruit and vegetable consumption than when they started. But there were high dropout rates, and the study ended after just six months.

So what happened to those who discontinued the program midway through, or to the full participants in the long term? It’s not clear, nor is it clear whether these programs result in long-term changes to people's overall health status. And while the study was led by nutrition researchers at New York University and Penn State University, it also co-authored by one Wholesome Wave employee and funded by the organization — so it wasn't exactly independent research.

The nutrition and obesity researchers I spoke to were also skeptical about the cost-effectiveness and impact of fruit and vegetable incentive programs.

Brian Elbel, an obesity researcher at the New York University School of Medicine, said one big unknown is whether as people spend less money on their produce, they buy more junk food. He said we need more evidence to understand that potential replacement effect and how these programs change people's eating patterns over time. (As this randomized controlled trial from New Zealand found, both price discounts and tailored education programs didn’t change consumer habits.)

Block, of Harvard, agrees there isn’t enough good evidence to prove that subsidies work. "I like the concept that Wholesome Wave is putting forth," Block wrote in an email. "But, it hasn't been evaluated yet in a robust way."

Marion Nestle, an NYU food politics professor, called it "a lovely idea in principle." But she added: "In practice the data show small improvements in fruit and vegetable purchases for programs that are quite expensive."

Her main concern: The cost of produce is not the only obstacle to a better diet for people who are poor. "They may not be able to or have time to cook. They may not have grown up eating different kinds of vegetables. There may be transportation and cultural barriers."

Still, there may be other, more subtle changes at play. Nischan pointed out that surveys of participating farmers report positive effects: They put more land into production to respond to the increased demand at markets that offer the two-for-one program, and have more success in communities that wouldn’t necessarily have attracted farmers market shoppers in the first place.

2) Getting doctors to write "fruit and vegetable prescriptions"

Kendall Photo/Wholesome Wave

Another ways Wholesome Wave is trying to steer people toward eating more produce is through the Fruit and Vegetable Prescription Program, or FVRx.

Launched in 2010, it supports health care providers who’ve identified patients who need to change their diet to improve their health. Here’s how it works: Doctors give $1-a-day vouchers to patients for every family member in their family to be spent on fruits and vegetables at participating farmers markets, grocery stores, and other healthy food retailers.

But there’s a twist: As part of the program, patients also get nutrition advice from health care providers, set health goals, and check back at monthly clinic visits to collect more vouchers. Again, the idea here is to break down both cost and education barriers to eating more wholesome food.

An evaluation of the prescription program that rolled out in New York City in 2013 found measurable increases in people’s self-reported consumption of fruits and vegetables, and found that their knowledge about fresh produce increased. Interestingly, 40 percent of the participants also saw a decrease in their body mass index over the four-month program.

But again, these data were produced by Wholesome Wave, not by independent researchers, and the measures of fruit and vegetable intake were self-reported. From the report, it’s also not clear how significant the increases in produce consumption and decreases in BMI were — though this data at least suggests things are moving in the right direction.

3)  Sexy marketing of fruits and vegetables

FNV

It’s no secret that celebrities often put their star power behind marketing campaigns for junk foods and sugary drinks. Beyoncé signed a $50 million endorsement deal in 2012 to make Pepsi sexy, while Justin Timberlake got an estimated $6 million to sing the McDonald’s "I’m lovin’ it" tune. According to a recent study in the journal Pediatrics, food and drink campaigns were among the second most popular products celebrities endorsed (after consumer goods like perfume and makeup).

To counteract these efforts, the public-private Partnership for a Healthier America launched the FNV campaign last year with the goal of changing attitudes about fruits and vegetables. Since its inception, the organization has signed more than 70 celebrities to pose with delectable produce on posters that are shown in grocery and food stores and at produce stands. (Think Jessica Alba and Cindy Crawford sucking on citrus fruits, and Cam Newton cuddling with a bunch of carrots.)

According to survey data from PHA, the campaign has garnered hundreds of millions of media impressions. Among those who saw it, 72 percent said they purchased more produce after seeing the campaign, while 71 percent claimed the campaign inspired them to eat more of it.

But again, this wasn’t an independent study and it’s hard to know how well this approach will work over the long term.

4) Growing your own produce in a garden

As we wait for more data for these other programs, there is compelling evidence that suggests growing fruits and vegetables at community or home gardens can get people eating healthier without much investment.

A recent independent study out of the University of California looked at the effects of community and home gardening on vegetable consumption in a group of 135 mostly low-income gardeners in San Jose, California. Since the 1970s, the city has provided gardeners with spaces to grow food, so this study was measuring the impact of those and comparing those growers with people who gardened at home.

"Participants in this study reported doubling their vegetable intake to a level that met the number of daily servings recommended by the US Dietary Guidelines," the study reported. "Growing food in community and home gardens can contribute to food security by helping provide access to fresh vegetables and increasing consumption of vegetables by gardeners and their families."

Other researchers have come to similarly striking conclusions. A case study out of a high-poverty area in Toronto, for example, used focus group and interview feedback, as well as participant observation, to see how community gardens there impacted health. They found "growing one’s own fresh food was not only seen as cost-effective, but was also a way to access culturally appropriate foods." The gardens provided an opportunity for physical activity, and improved the nutrition of families who were eating more fresh foods while saving money at the grocery store.

A survey out of Denver found community gardeners consumed more fruits and vegetables about six times per day, compared with the four servings non-gardeners ate. "Moreover," the researchers concluded, "56% of community gardeners met national recommendations to consume fruits and vegetables at least 5 times per day, compared with 37% of home gardeners and 25% of non-gardeners."

Daniel Bowman Simon, a New York University food studies doctoral student, has been researching the effects of SNAP benefits and fruit and vegetable incentives. But he has been most impressed by gardening. "Gardening can have a phenomenal return on investment, particularly once fixed costs are accounted for," he told Vox.

But he, too, pointed out that before any of these programs are scaled, we need to better understand their relative benefits, especially through studies that compare efforts like fruit and vegetable incentives with community gardening plots.

"With scarce funding and urgent problems that need effective solutions," he added, "we ought to have better evidence."

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