Tuesday, May 4, 2010

MyPyramid: Has the United States Government Missed An Opportunity to Improve the Health of the Nation? – Laura Huber

MyPyramid is a public health intervention with the mission to improve the nutrition and health of the nation. The United States government has been the primary source of dietary and nutritional information for the nation since 1864, when it first published dietary recommendations as a guide to healthy eating (1). The first food pyramid was published in the 1960s by the United States Department of Agriculture (USDA), in response to an increase in the prevalence of heart disease (2). In 2005, The USDA published the latest version, MyPyramid, as the earlier version had been criticized as no longer consistent with current scientific evidence and difficult for individuals to comprehend (3). The intervention, which includes a graphic representation of the revised food pyramid and web-based interactive tools used to develop individualized dietary intake and physical activity plans, is designed to educate individuals about dietary guidelines and physical activity and to translate nutritional recommendations into the kinds and amounts of food to eat each day. The government’s mission is to reduce heart disease by improving the health and fitness of Americans through promotion of the MyPyramid Food Guidance System (4), which is the most visible source of U.S. nutrition policy and dietary guidelines (3).

The quality of dietary intake and physical activity plays a vital role in the prevention of cardiovascular and other chronic diseases (3). The American Heart Association defines ideal cardiovascular health by the presence of ideal health behaviors (such as non-smoking), 30 minutes of moderate to vigorous physical activity per day, and a diet consistent with current guideline recommendations together with ideal health factors, such as cholesterol, blood pressure, and blood glucose levels (5). Heart disease, stroke, and related vascular illnesses continue to be the leading causes of morbidity and mortality in the United States (5). Over the past four decades, there has been significant progress in the effectiveness of treatments to reduce cholesterol levels, blood pressure, and the prevalence of smoking, all of which contribute to cardiovascular health. However, trends in prevalence of obesity and diabetes have offset this progress and contribute to the persistent national burden related to cardiovascular disease (5). The prevalence of obesity among U.S. adults aged 20 years and over generally increased over time from 19.4% in 1997 to 27.9% in 2009 (6). Data shows that physical activity in adults, including occupational-related activity, is decreasing over time. In addition, physical activity in youths is also decreasing, including a lower level of activity in physical education classes. As a consequence, fitness levels continue to decline (7). The overall nutrition and fitness of Americans have not improved with the introduction of the dietary and physical activity guidelines and, in fact, continue to erode. Many would argue that the U.S. government has missed an opportunity with MyPyramid to direct Americans toward healthier nutrition and fitness and to directly impact the overall cardiovascular health of the nation (8).

My Pyramid, as a public health intervention, fails for a number of reasons. First, it fails because it intervenes primarily at the individual level and does not consider a population-based approach, such as the Social Ecological Model. Secondly, the content of the guidelines and recommendations for dietary intake are based on the influence of people with business interests in their messages rather than on the most current science (9). And lastly, the scope and breadth of its message is limited by a lack of accessibility and usability due to narrow communication channels and a lack of consideration for sociocultural variables such as health literacy and cultural influence on food intake and activity (10)

Critique #1: An Individual versus Population-Based Approach

The risk for cardiovascular disease is widely diffused throughout the population (5) and, for disease prevention, it is important to consider health as an issue for populations and not just for individuals (11). My Pyramid is flawed because it focuses on individual behavioral health change and fails to address the issue of the cardiovascular health of the nation through a population-wide strategy, such as the Social Ecological Model (SEM). A model such as the SEM considers the interrelationship between the individual and their environment and that there are multiple levels of influence on behavior, such as individual, interpersonal, community, and public policy (12).

Environmental and social influences on an individual’s health behaviors are not considered in MyPyramid. Access to the foods that are recommended in the MyPyramid guidelines may be limited based on socioeconomic status and affordability. Socioeconomic status and decisions about buying foods are found to be correlated, with those of lower socioeconomic status being less likely to buy high fiber, low fat, salt and sugar foods, as well as fruits and vegetables (13). The MyPyramid.gov website suggests looking for the USDA Organic Seal when food shopping and provides a link to the USDA site for information about organic food, although the cost of organic foods is typically higher than non-organic foods. The New York Times reported in April 2008 that organic food prices are 20 to 100% higher than their conventional counterparts and that sharp increases in prices are taking hold (14).

MyPyramid is designed to inform the individual about the amount of physical activity they should engage in each day, along with some specific ideas for types of activity, however, there is an assumption that simply providing this information will lead to action. It does not consider that the physical environment has an impact on physical activity level. Those who live in communities without access to walking paths, public parks and recreation areas are likely to have more limited activity levels (15).

Research also shows that there is a social influence on obesity with a correlation between obesity and one’s social network (16). This may be related to acceptability of obesity amongst friends and family members. MyPyramid ignores this relationship and influence on diet and activity.

Critique #2: Political Influence on the Content of the Pyramid

Whereas MyPyramid was developed with the intention of promoting a healthy diet, politics may have undermined the mission and diminished the opportunity for the government to improve the health of the nation. There is an inherent conflict of interest in the messages of the intervention, as the USDA, a government agency highly lobbied and influenced by the agriculture and food industries, publishes the guidelines. Since the 1930’s, the USDA has protected agricultural and dairy commodities (17). In the early 1900’s, the government began to develop food safety policies to protect the public from harm. Since that time, it has been in the position of balancing public safety with supporting a politically savvy and economically strong agricultural industry. In addition, the food industry relies heavily on attracting consumers by producing and marketing foods that are low cost and high in fat, sugar, and salt. Incentives to protect powerful industries can take precedence over public health (17).

There are several examples of industry influence on the U.S. government. In 1983, Congress signed The Dairy Product Stabilization Act, which emphasizes the importance of dairy in the human diet, the significance of the industry on the national economy, and that it is in the “public interest to finance and promote the U.S. dairy market to strengthen and expand its position in the marketplace” (18). There is no mention in the Congressional finding of the link between high-fat dairy products and heart disease and obesity (17). In 2002, Congress allocated an estimated $848,347,339 to the dairy industry in order to “ensure that the people of the United States receive adequate nourishment” (19). The current guidelines recommend three servings of dairy products per day, regardless of sex or age, when research has shown that lactose intolerance occurs in the majority of African-, Asian-, Hispanic-, and Native Americans (20). In 2006, the minority population, defined by the U.S. Census Bureau as Black, Asian, Hispanic, Native Alaskan, and Native American, totaled over 100 million (21), leaving one third of the population with guidelines that are inappropriate for them.

Despite research that directly correlates the extensive use of sugars and corn syrup with obesity (17), the U.S. spent $10 billion in 2003 on aid to U.S. corn subsidies, Congress proposed a bill to reduce the interest rates on loans to processors of sugar beets and sugar cane, and the 2004 US delegation to the World Health Organization objected to reducing the recommendations for sugar intake as not being scientifically sound (22,23).

The agricultural and food industries have influenced the content of the MyPyramid food guidelines, as evidenced by both what is included and that which is conspicuously absent. Not surprisingly, the recommendations do not appear to be an improvement over those of the food pyramid of 1992 (3).

Scientific evidence shows that replacing trans fats and saturated fats with unsaturated fats is one of the most important things to do to reduce heart disease (24). In addition, modest and achievable reductions in salt intake in populations can likely result in dramatic reductions in stroke (25), and there is a direct correlation between soft drinks, sweetened with nearly 100% high fructose corn syrup, and the obesity epidemic (17). The new pyramid places emphasis on whole grains and dairy consumption, makes no mention of salt intake or recommendations for limits on alcohol intake, and lacks the detail to adequately inform of the risks and benefits of consuming different types of fats (24). The guidelines encourage eating higher calorie forms of foods, specifically stating “You can use your discretionary calorie allowance to: eat more foods from any food group than the food guide recommends, eat higher calorie forms of foods—those that contain solid fats or added sugars (examples are whole milk, cheese, sausage, biscuits, sweetened cereal, and sweetened yogurt), add fats or sweeteners to foods (examples are sauces, salad dressings, sugar, syrup, and butter), eat or drink items that are mostly fats, caloric sweeteners, and/or alcohol, such as candy, soda, wine, and beer” (26). Although there is some information available regarding balancing calorie consumption and expenditure, there is no emphasis on weight management. In fact, the recommended intake actually represents an increase in the amount of daily food consumption (9). In addition, the guidelines do not consider the non-discretionary intake of trans fats and salts or the high calorie content of food that is eaten in fast foods, restaurants, and workplace cafeterias.

Critique #3: Limitations on the Dissemination of the Information

The primary mode of disseminating the food guideline recommendations to individuals is through a highly interactive website, MyPyramid.gov (27). The site is complex, with layers of links to access a wide variety of information. Accessing and navigating the site requires a high level of motivation on the part of the individual. The Transtheoretical Model (TTM), which defines five stages of change, might explain some of the theoretical basis of this intervention. Unlike the theories or models that focus on behavior change at a particular point in time, the TTM states that change occurs in stages and over time and that the individual can enter at any stage along the continuum (28). MyPyramid assumes that there is motivation to seek out this information and that there is intent to take action (the Preparation Stage). Once the individual engages in the process of utilizing the information and available tools, they have moved to a different stage (the Action Stage). The TTM assumes that behavior is predictable and that individuals will move in a continuum through the five stages. While MyPyramid provides a great deal of information, it does not provide motivators for this movement or tools for maintaining behaviors (28).

In addition, disparities in obesity exist in different subsets of the population, particularly in regards to minorities and those of lower socioeconomic status (29). Internet access and use are highly correlated with race, income level, education level, and geography (30). Whites are twice as likely to have Internet access at home than Blacks or Hispanics. Least usage occurs among those persons with an elementary school education or less and those with four-year college degrees have a usage rate more than nine times higher. 12.1% of those at the lower end of the income scale use the Internet, contrasted with 58.9% of those in the highest bracket and households of all races lag significantly in Internet access in rural areas (30,31). Another limitation of Internet-based interventions is that some non-users correspond to people at greater health risk (32). Because the Internet serves as the primary source of this information, accessibility may be limited to some of those who may be most vulnerable to poor health outcomes (29).

The current food pyramid guidelines have also been criticized for both their complexity and the knowledge required for users to understand the recommendations (33) and consumers have had difficulty understanding and adapting the pyramid to individual dietary needs and preferences (10). People with limited health literacy and nutrition literacy skills may have difficulty understanding concepts of healthful diets, reading nutrition information, and measuring a portion size. Health and nutrition literacy require the ability to read well and to understand health and nutrition concepts. In 2003, an estimated 43% of adults in the United States, or approximately 93 million, had “basic” or “below basic” literacy skills. (10). In addition, the readability of the information does not take into account the health literacy abilities required to understand science-based concepts and assess and track personal diet and physical activity (10). MyPyramid lacks a simple, effective public health message to improve the American diet (33).

The Intervention: A Population-Based Approach

The U.S. government has a great opportunity to improve upon the approach to guiding its citizens to healthy diet and activity levels that, when achieved by the majority of the population, will have a significant impact on the overall cardiovascular health of the nation. The best approach to achieve more effective outcomes is through a complement of interventions at each of the levels of influence described by The Social Ecological Model (individual, interpersonal, community, and public policy). This approach provides for a greater potential to impact and sustain change in the health of the population as it emphasizes the interrelatedness of the environment and individual behavior and that by intervention on any level will impact behavior change at each of the other levels (12).

Intervention at the Community Level

At the community level, there are opportunities for the government to promote the affordability of the recommended foods in the guidelines. First, through collaboration with national grocery store chains by providing incentives to buy less expensive, locally grown foods to be sold to consumers at lower prices. The incentive would be free marketing with national name recognition on the MyPyramid.gov website, educational materials, and any marketing initiatives, highlighting the grocery chain’s commitment to individual’s health and collaboration in the effort.

Secondly, community organizations could be mobilized to collaborate with local food producers to establish local farmer’s markets in low-income neighborhoods. Local growers could agree to sell at lower costs through incentives of ongoing participation as well as name recognition in community organization and local publications, acknowledging their community contribution. The Community Organizing Model emphasizes community-driven approaches to assessing and solving health and social problems and involves a process through which community groups are helped to identify common problems, mobilize resources, and develop and implement strategies to reach collective goal. The most successful community organizing projects consider the community’s priorities (28). As an adjunct to this community project, government subsidized ‘farmer’s market’ food vouchers for low-income individuals could promote participation by consumers and offer a mechanism to allow for low-income individuals to purchase healthy food. The general public wants to support local businesses and this would give these individuals an opportunity to do so (34).

Applying the same theoretical basis that draws the correlation between obesity and social networks can be used to promote positive health behaviors, such as physical activity (16). Information that explains this correlation and promotes specific recommendations for organizing and participating in group activities with friends, neighbors, and coworkers should be included in this intervention. This could include neighborhood walking groups, walk to school programs, and workplace fitness challenges. In addition, the website should include links to local biking, running, and hiking groups, amongst others.

Access to a supportive physical environment promotes participation in recommended levels of physical activity in the community. Walking in the community is popular, and parks and recreational areas located near home are used more frequently than those located elsewhere. Creating streetscapes, walking paths, bike paths, community parks, and recreation spaces will promote healthy physical behavior activities (15).

Intervention at the Public Policy Level

Measures need to be taken to better integrate the nutrition needs of the population with the economic growth and development of the agricultural and food industries (35). To mitigate some of the inherent conflicts of interest, the oversight of the recommendations for dietary intake and physical activity should transition from the USDA to the Food and Drug Administration’s Center for Food Safety and Applied Nutrition (CFSAN), which is responsible for promoting and protecting the public's health by ensuring that the nation's food supply is safe, sanitary, wholesome, and honestly labeled (36).

Public policies are indicated to reduce or eliminate the intake of non-discretionary food substances that are known to contribute to obesity and contribute to poor health outcomes and should consider only scientifically based information in their development. One-third of all calories are now eaten outside the home - in restaurants, cafeterias, convenience stores, snack bars, and fast-food outlets (37). Most often, the consumer is not aware of the specific content of what they are consuming. Dietary intake is often thought of as a personal, not a governmental, responsibility (23). However, there are societal, commercial, and institutional influences on food choices and consumption that can be addressed with public policy (38).

The FDA should ban artificial trans fat from the nations food supply. They are the most harmful fat and are linked to approximately 50,000 fatal heart attacks annually and researchers at the Harvard School of Public Health estimate that trans fat causes 72,000 to 228,000 heart attacks per year (37). The World Health Organization has recommended the upper limit of trans fat as 1% of daily dietary intake, and this from naturally occurring trans fat. The FDA estimates that the average daily intake of trans fat in the U.S. population is about 2.6% of calories per (37). A striking example of a public health policy intervention that supports a trans fat ban is one that occurred in the island nation of Mauritius in the late 1980s. The intervention included changing the composition of imported oils used for cooking from predominantly palm oil, which is very high in saturated fat, to almost exclusively soybean oil, which includes predominantly polyunsaturated fats. Within five years, the prevalence of hypercholestermia had decreased from 24.5% to 5.6 (5).

In addition to the trans fat ban, the FDA should limit the salt content of processed foods. Research shows that a modest and achievable reduction in salt intake in populations can likely result in dramatic reductions in stroke (25), and reducing sodium levels in packaged foods and restaurant foods by half could likely result in a 20 percent reduction in the prevalence of hypertension and 150,000 fewer deaths (39). Because 80% of salt intake is consumed from processed foods, lower salt intake would likely be achieved most effectively through food policy decisions and negotiation with the food industry rather than efforts focused on individuals (40).

Intervention at the Societal Level

The goal of MyPyramid is to improve the cardiovascular health of the nation through dietary intake and physical activity of individuals. This could be much more effectively accomplished through simplifying the message (33) and broadly communicating it with a marketing campaign.
Focusing on key aspects of diet and exercise, through simple catch phrases and slogans about food and exercise rules, would make the messages easier to understand and create a more meaningful and long-lasting association between the individual and the recommendations of the guidelines. Some examples of creative, catchy, and simple food rules are provided by Michael Pollan in his recently published book, “Food Rules”, and include “eat amounts of meats in this order: no feet, two feet, four feet” and “don't eat anything your great-grandmother wouldn't recognize as food” (41).

Catch phrases and slogans would play a key role in forming a link between long-term brand identity (MyPyramid) and behavior (healthy diet and exercise) (42). A brand is defined as a “set of associations linked to a name, mark, or symbol associated with a product or service” (43). Creating a brand and brand recognition are key components of marketing as they create associations that can transcend any one advertisement or promotional activity (43).
Public health communications increase knowledge and awareness of a health issue, and influence perceptions, beliefs, and attitudes. These then factor into social norms and prompt behavior changes (44). Disseminating information through a marketing campaign is a population-based approach that should be utilized to communicate the messages of MyPyramid. The media influences almost every aspect of our lives – political, social, and behavioral. A wide audience can be captured through many media outlets, both print and electronic. Some options include television, radio ads, public service announcements, billboards, messages in entertainment programs (such as situation comedies and soap operas), and a wide variety of magazines aimed at various age and cultural groups.


As an intervention that is focused on intervention only at the level of the individual, MyPyramid is unlikely to have a significant impact on the overall health of the population. The Social Ecological Model provides a framework to inform interventions that impact the various levels of influence, and it provides a strategy for developing a connection between behavioral strategies of health promotion and the strengthening of environmental supports within the community. Public health initiatives that are designed using traditional behavior models require voluntary and sustained effort by individuals to achieve desired health behavior goals. The Social Ecological Model differs as the focus is on the environment, where individuals and groups actively work to change their environment to promote health. It can also maximize the benefits of public health promotion as initiatives based on the Social Ecological Model have the potential for greater and more sustainable impact on health promoting behaviors by intervening simultaneously at multiple levels across multiple settings (12,29).

The government’s mission is to reduce heart disease by improving the health and fitness of Americans through promotion of the MyPyramid Food Guidance System. While the government has missed an opportunity to impact the overall health of the nation with the current MyPyramid campaign, it has a significant opportunity to do so with a comprehensive population-based approach. The Social Ecological Model provides the theoretical framework to accomplish its mission.


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