Thursday, May 6, 2010

Does MyPyramid Improve My Health? – Emily Hashim

Over the past 20 years there has been a dramatic increase in obesity rates in the United States. In 2008 only one state had an obesity prevalence of less than 20%, with 32 states having a prevalence of greater than or equal to 25% (1). There are many associated risk factors linked to obesity some include coronary heart disease, type two diabetes, breast cancer, colon cancer, hypertension, dyslipidemia, stroke, liver disease, gallbladder disease, sleep apnea, osteoarthritis, and infertility (1). The economic consequences in the United States related to obesity are staggering, it has been estimated that in 2002 $92.6 billion was spent on overweight and obesity related medical expenses which continue to rise as the obesity epidemic expands (1).
On April 19, 2005 a new symbol entitled MyPyramid was released by agriculture secretary Mike Johanns (2). MyPyramid, developed by the United States Department of Agriculture (USDA), replaced the 1992 food guide pyramid. The central message, “Steps to a Healthier You,” is based on the 2005 Dietary Guidelines for Americans. These guidelines are published by the USDA and United States Department of Health and Human Services (HHS) every five years and are applicable for people two years of age and older (2-4).
The overall goal of MyPyramid is to improve American’s diet and lifestyle by providing individualized information (2, 3, 5-7). This can be accomplished by using the interactive food guidance system on the Internet at The pyramid itself was designed to look simple and includes eight divisions. The first division is physical activity which is represented by a person appearing to walk up the pyramid stairs. Divisions two through seven are the six colored sections in the pyramid representing the six food groups; grains, vegetables, fruits, oils, milk, and meat and beans. The last division is the uncolored tip at the top of the pyramid stemming from the six food groups which represents discretionary calories (2, 3, 5-7). Discretionary calories are the leftover balance of calories after you subtract the calories used to meet nutritional needs from your calorie allotment for the day. Typical foods considered to be “non-nutritional” include soda, added sugars, butter, and salad dressing which fall into the discretionary calorie category (2, 3, 5, 6).
Each division has its own set of recommendations. Physical activity includes at least 30 minutes per day of moderate exercise for adults and 60 minutes of moderate exercise per day for children and teenagers (3, 6). The actual food intake volume for all six food groups are custom tailored to the individual on the website but there are some general recommendations for all consumers to follow. At least half of the daily grains consumed should be whole grain. Dark green and orange vegetables with a variety of whole fruits are emphasized, with a de-emphasis on fruit juices. In the oil food group fish, nut, and vegetable sources are recommended and in the milk group fluid milk is suggested as well as other dairy sources. Finally, in the meat and bean group low-fat and lean meats are encouraged with other suggestions such as fish, nuts, seeds, and beans (3, 6).
By looking at the new symbol representing MyPyramid American’s are supposed to understand several fundamental themes underlying the new pyramid according to the USDA (2, 3, 5, 7). Personalization is depicted by directing consumers to the website Gradual improvement is shown by the slogan “Steps to a Healthier You,” this suggests that American’s can take small steps towards improving their overall health. Physical activity is represented by the person climbing the steps. Variety of foods is represented by the six different colored sections of the pyramid. Moderation is demonstrated by the gradual narrowing of all six food groups as they approach the top of the pyramid. The wider base represents food with little or no solid fats, added sugars, or caloric sweeteners. Finally, a consumer should see the importance or proportionality; this is demonstrated by the different widths of each food group division or band. The larger the width suggests a larger portion of that food group should make up a person’s daily intake of food (2, 3, 5, 7).
To obtain recommendations for how much to eat of each food group and the allotted calorie amount per day the consumer must go to the main website. Once selecting, “Get a personalized plan” on the right hand side of the screen, the consumer is prompted to enter their age, sex, height, weight, and physical activity. When this is completed they are given a, “MyPyramid Plan.” This is composed of the total daily calorie allotment and also the breakdown of how much they should eat in each food group. In the new pyramid “servings” are not provided and quantities are listed in actual cups or ounces. This was changed due to consumer confusion with the 1992 food guide pyramid and the lack of understanding of what a “serving” was in each food group category (2, 4).
Following the determination of nutritional needs the consumer can enter a typical days worth of food they consume and assess how their actual intake reflects their recommended needs. If desired the consumer can then select one or more area they would like to improve on and a list of suggestions will appear on the screen. There are also many other interactive tools and information on the website, all which center around a healthier lifestyle specifically focusing on diet and exercise.
The new pyramid was developed due to the high criticism of the 1992 food guide pyramid (4). Estimations suggest that only about 3-4% of American’s follow all of the Dietary Guideline recommendations (8). During the 2005 press release statement by Johanns it was mentioned that the overall purpose of the revisions was, “to improve the effectiveness in motivating consumers to make healthier food choices and ensure that the USDA food guidance system reflects the latest nutritional science (2).” They included five benefits with the new system which are as followed:
1) It enables the use of a symbol as a stand-alone visual to represent the overall food guidance system without being cluttered by specific messages.
2) It more effectively teaches consumers what and how much to eat through clear, tailored nutrition messages and diet personalization.
3) It helps combat obesity by encouraging healthier eating patterns.
4) It helps to improve the overall health and well-being of Americans
5) It more effectively reaches consumers through the use of multiple channels including the Internet (2).
Despite the technical research and focus groups for consumer input (2, 4), the new pyramid still contains some fundamental flaws.

Critique Argument 1: If the question is who are we really targeting? The answer is the Caucasian, middle to upper class, well educated American. – MyPyramid is not generalizable to the public.

The USDA intends to target all American’s over two years of age, as these are the consumers who qualify for the 2005 Dietary Guidelines for Americans (2-4). The USDA also clearly stated in their press release that MyPyramid should help decrease the obesity epidemic in the United States. Knowing this one can assume they are ideally targeting overweight and obese individuals. Unfortunately, low-income communities have higher rates of overweight and obesity and tend to have a disproportionately higher prevalence of racial and ethnic minority populations (9). Therefore, low-income and racial and ethnic minorities would be essential to educate.
The MyPyramid intervention is through the Internet only because of this a major concern is for those consumers who have little access to the Internet (5, 10-13). Approximately 77% of American adults used the Internet as of 2006 (14). Already one can see that the USDA has closed the door on 23% of American’s and low-income American’s are more likely to have limited access to a computer. Also, all of the information provided online is in English with some translation to Spanish. This again is worrisome as it limits the use for many non-English speaking American’s (14). Even American’s with different racial and ethnic backgrounds that are able to read English unless their diet is the typical American/Western diet the website will realistically not contain any information regarding their cultural foods, food habits, preferences, or family/community food norms and support (14). There is also a lack of culturally tailored message as it does not provide information as to the relationship of diet or physical activity to health issues for racial and ethnic groups (14).
Readability is a measure of the ease with which a passage or text may be read (15). Estimates have suggested that the average American reads between the seventh and ninth grade reading level and approximately 20% of American adults read at or below the fifth grade level (14). What is even more alarming is studies have suggested that 15-55% of the general population is illiterate (16). The USDA’s website was tested for readability and the results ranged from a reading level of 8.8 to 10.8 (14). In other words the readability on the MyPyramid website is more advanced than the average level an American can read at. With the increasing use of the Internet an additional literacy requirement was developed called “computer literacy” (14). This includes but is not limited to the ease of locating and searching the site, the interactive features, and links to other sites. only received a 50% for computer literacy. Some areas that scored low were font size, active graphics, ability to search site, and homepage layout (14).
The USDA has developed an Internet only, primarily English only content, high reading level, poor cultural sensitivity health intervention. I do not feel this meets the criteria for consumers the USDA intended to target, do you?

Critique Argument 2: Carrot Cake Counts as a Vegetable? I’ll Take Two Slices Then Please! – Lack of Useful Information

As mentioned earlier the new pyramid was designed to look simple (2, 3, 5-7). I would argue it looks so simple that you are unable to learn anything by looking at it. I asked my husband, who is a physician, to look at the symbol of MyPyramid and tell me what he thinks it is telling him. He was able to see that they are encouraging exercise and assumed each color was for a different food group but he wasn’t sure which color was for which food. He was unable to recognize the personalization, moderation, proportionality, and gradual improvement messages the pyramid is supposed to demonstrate. I also have to be honest and admit that I am a dietitian and did not see all of those messages either, although I did a little better than my husband. My point has been validated by a large study in south-east Texas where 972 participants filled out a 4-page questionnaire examining consumer’s knowledge and comprehension of MyPyramid. The results showed that the majority of the participants reported a 0-10% level of understanding of the tool (17). Even if consumers are given detailed instruction about MyPyramid using a non-computerized teaching tool, they still have trouble using and understanding the main concepts (18).
One also must question the value of the information given. Many items that we eat, such as pizza, contain several different food groups which lead to the development of composite nutrient profiles (19, 20). The actual process of MyPyramid breaking down the food into the food group components is called disaggregation (20). For example if a consumer enters into the MyPyramid Tracker beef stew, MyPyramid assumes that for every 100 grams eaten the consumer receives 0.74 servings of meat, 0.13 servings of orange vegetables, 0.08 servings of “other” vegetables, 0.41 servings of starchy vegetables, and 0.08 servings of grains. This also implies that carrot cake you had after dinner last night will count towards your vegetable intake. I’m not arguing that carrots shouldn’t be counted as vegetables, my concern lies in what message this portrays to the public. We should really only be allowing fruits and vegetables to count as part of our daily intake if they are coming from a healthy source, not allowing them to come from cake.
Another large concern about the information MyPyramid provides stems from the heavy lobbying of the food industry during the development of MyPyramid (3, 10, 11). There are claims that the dairy and meat industry had a heavy hand in influencing the high number of portions that are recommended in those two food groups (3). With the disaggregation of foods there is no education to the consumer about “good” or “bad” foods, including a lack of discussion about trans fatty acids or omega-3 fatty acids (10, 11). This was speculated to be due to the USDA’s interest and hope to avoid upsetting any particular commodity group or food company (10, 11).
If all this hasn’t made you angry enough, catsup counts as a vegetable on On a bottle of Heinz Tomato Ketchup the ingredients are as followed; tomato concentrate from red ripe tomatoes, distilled vinegar, high fructose corn syrup, corn syrup, salt, spice, onion powder, and natural flavoring. If your “vegetable” has more than one ingredient in it and the third one says high fructose corn syrup, as a dietitian I would tell you we really shouldn’t count that as a vegetable. But according to the USDA if you or your children are a little short on your vegetables for the day, run out to a fast food restaurant and order a large fry with catsup and you will have just increased your vegetable intake by 1 ¼ cups or go have a couple slices of that carrot cake! I may be a little dramatic here but honestly, what is this teaching American’s?

Critique Argument 3: Another intervention using individual and rational behavior change models.

MyPyramid can be described as an individual model because the main goal is to provide personalized information about nutritional need to each individual American and it is up to the consumer to make the change themselves. Once the nutritional needs are established, the consumer can evaluate their own diet and get specific advice to help improve their diet. MyPyramid is a rational model because it assumes once we educate the consumer they will consider the information and make an informed decision based on the facts provided. Overall, individual and rational level models assume the consumer is the sole person responsible for their own health, that the consumer values good health, and that they make cognitive decision that drive their health behaviors (21).
The problem with these types of models is that they do not address social and environmental factors (22) such as access to fruits and vegetables or socioeconomic status. They also tend to overlook family and community dynamics and health disparities (23) all which play vital roles in dietary intake decisions. Some researchers have also questioned the consumer’s ability to sustain the behavior change over time using these theories due to social pressures (21).

Proposed Intervention:

Despite the negative aspects of the new pyramid there are some redeeming qualities. Compared to the food guide pyramid from 1992 physical activity is now included as part of a healthy lifestyle. American’s who desire a customized recommendation about how many calories to eat daily and how much in each food group to eat can obtain this by going to the main webpage. Finally, consumers complained of being confused with the concept of “servings” using the old food guide pyramid. The new one has eliminated the word serving and uses concrete measurable amounts such as cups and ounces (4).
I believe overall, the public health community has been approaching nutrition education the wrong way. Although MyPyramid does have its place for educating consumers, it will truly only work for motivated individuals who are able to seek out the information (5, 11). I would keep MyPyramid as an online tool but provide additional simple, core, concrete messages such as, “eat more whole grains” or “eat fruits and vegetables from all colors of the rainbow.” This will help to not overwhelm Americans with information but, the main proposed intervention involves taking a look at our competitors such as the fast food industry and soft drink companies for advice.
I would propose we turn to the media and create a series of five short commercials. The commercials would NOT discuss the health benefits of eating healthy or mention what will happen if the consumer does not take our advice. We instead would focus our messages on family, tradition, power, strength, freedom, and other core values Americans hold. Depending on what time of day the commercial will air, we would run the appropriate commercials to fit the demographic watching the show. For example during sports shows our commercials would focus on strength, freedom, and power but during family oriented shows the focus would shift to family and tradition.
Each commercial would have one simple central message or slogan at the end, with the website at the bottom. An example of a 20-30 second commercial would be clips or pictures of a family at a dinner table, grandma and grandpa at the park with the grandchildren, mom and dad cooking in the kitchen, the kids walking the dog, sisters laughing and running outside, and any other positive and relatable family oriented clip. Once these have completed a message, “Love life, love family, love fruits” or “Fruits, bring sweetness to your life” will appear on the television screen with the website.
Another example commercial again would be clips or pictures of a boxer punching a boxing bag, a football player tackling another, a tennis player serving the tennis ball, a marathon runner crossing the finish line, and other various intense sport moments. After these clips a message would appear as, “Grains, fuel the fight” or “Produce Power” with two meanings for produce. The first definition of produce referring to fruits and vegetables, and the second definition refers to generate or to make. Again the website would be at the bottom of the television screen.
We also need to address our environment by first working with the food industry and lobby for them to take more responsibility. There needs to be more bans on unhealthy vending machines in our school systems. I wouldn’t ask them to remove them but take out the soda and replace it with 100% fruit juices, milk, and water. Unhealthy snack choices should be replaced by healthy alternatives. Secondly, governmental services and public health clinicians need to make fruit and vegetables more accessible in low-income inner city areas. If we make healthier foods easier to buy our messages may be followed.

Defense of Intervention 1: Simplify and take a step back.

The MyPyramid website took an eighty plus page document, the Dietary Guidelines for Americans, and put it into one symbol. This leaves many consumers overwhelmed and confused. By providing simple, single sentence, messages on the website as an alternative to a customized program we will help consumers who are either too busy to take the time or just starting to learn the nutritional basics. It also provides a starting point or helps sets goal for nutrition educators with their clients.
Complex public health messages are associated with poor adherence to the targeted behavior change, which in turn decreases the effectiveness of your intervention (24). Several studies have tested the effectiveness of simple concrete nutritional message compared to a more complex detailed education. The overall conclusion is one or two simple dietary messages can improve diet outcomes and this was seen in both young and old adults (24, 25).

Defense of Intervention 2: It’s all about the promise - Marketing Theory

Images, emotions, and core values are more likely to influence a consumer’s behavior than statistics and data (26). We must take away the traditional public health model of telling consumers what steps to take, but add images with core values such as family, tradition, power, and freedom. This will help keep the product of eating healthier turn into a great promise. A promise “is the soul of an advertisement (27)” as this can develop into a brand. Branding forms a relationship between the product and its consumer (26) and most top selling products in the United States are branded such as Nike. Can you imagine if in the produce isle at the grocery store people start to feel connected to the apple and immediately think of their family? Or the runner walks by brown rice and remembers crossing the marathon finish line for the first time? This is how we want to connect our consumers to healthy eating.
What is also positive about using an intervention such as commercials is you are able to reach more consumers. A study by Espinosa et al tested the awareness of MyPyramid among college students and only 37% actually knew the food guide pyramid had changed (28). This supports that argument that MyPyramid was not a successful intervention as solely an Internet based tool.

Defense of Intervention 3: Let’s go upstream instead of down – Framing

MyPyramid focuses all of its information onto the individual person. The website helps to analyze the individuals diet and then provides personalized advice to improve the consumers well being, this is looking downstream. Public health professionals need to change their thinking to include looking upstream. This includes assessing environmental factors and targeting the companies that are producing the “unhealthy” foods. Framing issues correctly will not only help to define the issue but also aid in the determination of the solution (26). If we target the companies that supply the vending machine products in our children’s schools we can help decrease soda drinking at school. If we are asking people who have limited access to fresh produce to eat more produce it becomes a futile intervention. This is why we need to look upstream and first get the fruits and vegetables to those people and then ask them to eat more.
By simplifying some of our education messages on and connecting healthy foods and physical activity to core values that American’s respect through television commercials, we start to develop a public health brand. But we must also stand up to food companies to demand healthier schools, prevent false information or influences to our Dietary Guidelines for Americans, and improve access to fruit and vegetables for low-income, inner-city Americans. Although this is a huge and expensive task to undertake, in 2002 the United States was paying an estimated $92.6 billion in obesity related costs. From 2002 to 2006 that cost rose to over $100 billion (9), if only that $7 billion went to interventions such as the one proposed in this paper, maybe we could have been in a different place today.

1. Center for Disease Control and Prevention. Overweight and Obesity. Atlanta, Georgia.
2. United States Department of Agriculture. Johanns Reveals USDA’s Steps to a Healthier You. Alexandria, VA: News and Media Press Release.
3. Wikipedia the Free Encyclopedia. MyPyramid.
4. Britten P, Haven J, Davis C. Consumer Research for Development of Educational Messages for the MyPyramid Food Guidance System. J Nutr Educ Behav. 2006;38:S108-S123.
5. Muth ND. Getting Personal with MyPyramid: Anatomy of MyPyramid. IDEA Fitness Journal. 2005;October.
6. United States Department of Agriculture. MyPyramid Food Intake Patterns. Alexandria, VA.
7. United States Department of Agriculture. Anatomy of MyPyramid. Alexandria, VA: News and Media Press Release.
8. Hornick BA, Krester AJ, Nicklas TA. Menu Modeling with MyPyramid Food Patterns Incremental Dietary Changes Lead to Drastic Improvements in Diet Quality of Menus. J Am Diet Assoc. 2008;108:2077-2083.
9. Townsend MS. Obesity in Low-Income Communities: Prevalence, Effects, a Place to Begin. J Am Diet Assoc. 2006;106:34-37.
10. Wendling P. Revamped Federal Food Pyramid Draws Mixed Reviews. Internal Medicine News. 2005;38:6.
11. Critics and Supporters Weigh in on “MyPyramid” Nutrition Guide. Food and Drink Weekly. April 25, 2005.;col1.
12. Peregrin T. Making MyPyramid for Kids a Successful Tool in Nutrition Education. J Am Diet Assoc. 2006;106:656-658.
13. Peregrin T. Getting to Know the Modified MyPyramid for Older Adults. J Am Diet Assoc. 2008;108:937-938.
14. Rothschild R, Rodriguez FM. Assessment of Literacy, Cultural and Linguistic Factors in the USDA Food Pyramid Web Site. J Nutr Educ Behav. 2007;39:219-225.
15. Encarta World English Dictionary. Readability.
16. Davis TC, Crouch MA, Miller S, et al. The Gap Between Patient Reading Comprehension and the Readability of Patient Education Materials. J Fam Prac. 1990;31:533-536.
17. Sealy-Potts C, Bockhorn BM, Mahoney K, et al. Consumers’ Knowledge and Perceived Understanding of MyPyramid 2005: A Need for Nutrition Education in Texas. J Am Diet Assoc. 2007;107:A101.
18. Zoladia M, Taylor UR. Is a Non-Computerized Teaching Tool Useful to Convey the Basic Principles of MyPyramid to African American and Latino Adults in an Urban Setting? J Am Diet Assoc. 2006;106:A74.
19. Reedy J, Krebs-Smith SM. A Comparison of Food-Based Recommendations and Nutrient Values of Three Food Guides: USDA’s MyPyramid, NHLBI’s Dietary Approaches to Stop Hypertension Eating Plan, and Harvard’s Healthy Eating Pyramid. J Am Diet Assoc. 2008;108:522-528.
20. Marcoe K, Juan WY, Yamini S, et al. Development of Food group Composites and Nutrient Profiles for the MyPyramid Food Guidance System. J Nutr Educ Behav. 2006;38:S93-S107.
21. Crosby RA, Kegler MC, DiClemente RJ. Understanding and Applying Theory in Health Promotion Practice and Research (Chapter 1). In: DiClemente RJ, Crosby RA, Kegler MC, eds. Emerging Theories in Health Promotion Practice and Research: Strategies for Improving Public Health. San Francisco, CA: John Wiley & Sons, Inc., 2002, pp.1-15.
22. Individual Health Behavior Theories (chapter 4). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007, pp.35-49.
23. Choi K, Yep GA, Kumekawa E. HIV Prevention Among Asian and Pacific Islander Men Who Have Sex With Men: A Critical Review of Theoretical Models and Directions for Future Research. AIDS Education and Prevention. 1998;10 (Supplement A):19-30.
24. Olendzki BC, Ma Y, Schneider KL, et al. A Simple Dietary Message to Improve Dietary Quality: Results from a Pilot Investigation. Nutrition. 2009;25:736-744.
25. Sahyoun NR, Pratt CA, Anderson A. Evaluation of Nutrition Education Interventions for Older Adults: A Proposed Framework. J Am Diet Assoc. 2004;104:58-69.
26. Marketing Public Health – An Opportunity for the Public Health Practitioner (Chapter 6). In: Siegel M, Donor L. Marketing Public Health: Strategies to Promote Social Change (2nd Edition). Sudbury, MA: Jones & Bartlett Publishers, Inc., 2007, pp.127-152.
27. How to Build Great Campaigns (Chapter 5). In: Ogilvy D. Confessions of an Advertising Man. New York: Atheneum, 1964, pp.89-103.
28. Espinosa C, Rassas EH, Kim BM. Testing the Awareness of MyPyramid Among College Students Through Nutritional Booths Conducted in Campus Dining Halls. J Am Diet Assoc. 2007;107:A102.

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