Image Credit: Iñigo De la Maza / Unsplash. This image has been modified.

The Crowding Out Strategy to Eating Healthier

It may be more expedient politically to promote an increase in consumption of healthy items rather than a decrease in consumption of unhealthy items, but it may be far less effective.

The World Health Organization has estimated that more than a million deaths “worldwide are linked to low fruit and vegetable consumption.” What can be done about it? I explore this in my video Is it Better to Advise More Plants or Less Junk?

There’s always appealing to vanity. A daily smoothie can give you a golden glow as well as a rosy glow, both of which have been shown to “enhance healthy appearance” in Caucasian, Asian, and African skin tones, as you can see at 0:24 in my video.

What about giving it away for free?

A free school fruit scheme was introduced in Norway for grades 1 through 10. Fruit consumption is so powerfully beneficial that if kids ate only an additional 2.5 grams of fruit a day, the program would pay for itself in terms of saving the country money. How much is 2.5 grams? The weight of half of a single grape. However, that cost-benefit analysis assumed this minuscule increased fruit consumption would be retained through life. It certainly seemed to work while the program was going on, with a large increase in pupils eating fruit, but what about a year after the free fruit program ended? The students were still eating more fruit. They were hooked! Three years later? Same thing. Three years after they had stopped getting free fruit, they were still eating about a third of a serving more, which, if sustained, is considerably more than necessary for the program to pay for itself.

There were also some happy side effects, including a positive spillover effect where not only the kids were eating more fruit, but their parents started eating more, too. And, although the “intention of these programs was not to reduce unhealthy snack intakes,” that’s exactly what appeared to happen: The fruit replaced some of the junk. Increasing healthy choices to crowd out the unhealthy ones may be more effective than just telling kids not to eat junk, which could actually backfire. Indeed, when you tell kids not to eat something, they may start to want it even more, as you can see at 2:20 in my video.

Which do you think worked better? Telling families to increase plants or decrease junk? Families were randomly assigned to one of two groups, either receiving encouragement to get at least two servings of fruits and veggies a day, with no mention of decreasing junk, or being encouraged to get their junk food intake to less than ten servings a week, with no mention of eating more fruits and veggies. What do you think happened? The Increase Fruit and Vegetable intervention just naturally “reduced high-fat/high-sugar intake,” whereas those in the Decrease Fat and Sugar group cut back on junk but didn’t magically start eating more fruits and vegetables.

This crowding out effect may not work on adults, though. As you can see at 3:12 in my video, in a cross-section of over a thousand adults in Los Angeles and Louisiana, those who ate five or more servings of fruits and veggies a day did not consume significantly less alcohol, soda, candy, cookies, or chips. “This finding suggests that unless the excessive consumption of salty snacks, cookies, candy, and sugar-sweetened beverages”—that is, junk—“is curtailed, other interventions…[may] have a limited impact….It may be politically more expedient to promote an increase in consumption of healthy items rather than a decrease in consumption of unhealthy items, but it may be far less effective.” In most public health campaigns, “messages have been direct and explicit: don’t smoke, don’t drink, and don’t take drugs.” In contrast, food campaigns have focused on eat healthy foods rather than cut out the crap. “Explicit messages against soda and low-nutrient [junk] foods are rare.”

In the United States, “if one-half of the U.S. population were to increase fruit and vegetable consumption by one serving each per day, an estimated 20,000 cancer cases might be avoided each year.” That’s 20,000 people who would not have gotten cancer had they been eating their fruits and veggies. The U.S. Department of Agriculture recommends we “fill half [our] plate with colorful fruits and vegetables,” but less than 10 percent of Americans hit the recommended daily target. Given this sorry state of affairs, should we even bother telling people to strive for “5 a day,” or might just saying “get one more serving than you usually do” end up working better? Researchers thought that “the more realistic ‘just 1 more’ goal would be more effective than the very ambitious ‘5 a day’ goal,” but they were wrong.

As you can see at 4:56 in my video, those told to eat one more a day for a week, ate about one more a day for a week, and those told to eat five a day for a week did just that, eating five a day for a week. But here’s the critical piece: One week after the experiment was over, the group who had been told to eat “5 a day” was still eating about a serving more, whereas the “just 1 more” group went back to their miserable baseline. So, more ambitious eating goals may be more motivating. Perhaps this is why “in the US ‘5 a day’ was replaced by the ‘Fruits and Veggies—More Matters’ campaign…in which a daily consumption of 7–13 servings of fruits and vegetables – FVs –  is recommended.” However, if the recommendation is too challenging, people may just give up. So, instead of just sticking with the science, policy makers evidently need to ask themselves questions like “How many servings are regarded as threatening?”


For more on appealing to vanity to improve fruit and vegetable consumption, see my videos Eating Better to Look Better and Beauty Is More Than Skin Deep.

What does the science say about smoothies? See:

The flipside of free fruit programs is to tax instead of subsidize. Learn more by checking out my video Would Taxing Unhealthy Foods Improve Public Health?

For more on the paternalistic attitude that you don’t care enough about your health to be told the truth, see my videos Everything in Moderation? Even Heart Disease? and Optimal Diet: Just Give It to Me Straight, Doc.

I explore this same patronizing attitude when it comes to physical activity in How Much Should You Exercise?

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

 

Discuss

Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.


24 responses to “The Crowding Out Strategy to Eating Healthier

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  1. ‘The World Health Organization has estimated that more than a million deaths “worldwide are linked to low fruit and vegetable consumption.” ‘

    The click-through link at ‘estimated’ appears o be the wrong one.

  2. I would have to agree with the 7th paragraph in this article in that fruit/veg and junk food are two different animals so to speak. As perfectly healthy as my diet is, cramming fruit and veg into my day has little to do with my desire for, or my capacity to eat junk food… if only it were that simple.
    Making the determined effort to eat consistently well on a daily basis year in, year out, has certainly paid dividends however.

    1. Barb,

      I have friends and acquaintances who tell me that I’m exceptional, in that I am able to eat whole plant foods and avoid animal products as well as processed and prepared foods. There are lots of benefits — including that my weight is now about what it was in high school, which wasn’t always the case. I was a vegetarian for almost 50 years, but before dropping the dairy and eggs, I also ate some processed food. It probably helps that I also try to avoid added sugar, oil, and salt.

      These same friends and acquaintances complain about weighing too much, not being able to lose weight, or keep it off. At the same time, they comment and post about “comfort foods,” and desserts, snacks, generally rich foods, all the weight gained during the pandemic, etc. And most are probably horrified at the thought of giving up animals products. Yet they can see the results of doing so.

      So I wonder: what persuades you to continue to eat this way?

      For me, it was primarily health reasons; I was researching the effects of diet on breast cancer after my diagnosis when I stumbled upon this site. At the same time, I learned more about how animals are treated, and about the contributions of the livestock industry to GHG emissions and development of antibiotic resistance. Now I also know about the potential pandemic pathogens circulating amidst livestock. I stopped eating meat initially primarily for sustainability and environmental reasons.

      I know one person who had a heart attack, and after learning about the benefits of whole plant foods, switched to them. But I know several more who wouldn’t consider it. The same is true for people with cardiovascular disease. For other diseases, such as diabetes, kidney disease, high BP, high cholesterol, etc I don’t know anybody who would change how they eat.

      So I wonder, as always: what is persuasive? What persuades people to change their eating habits?

    2. Barb,

      That is interesting.

      I read Dr. Greger’s paragraph that crowding out the junk food doesn’t work for adults and I would agree, but I have had 3 years – not all consecutive, but those years, I stopped wanting junk food entirely and I am still trying to figure it out.

      I do know that if I eat until I am full, I do have less desire for junk food. And that if I don’t eat any sugar, and do eat fruit, there is less of a junk food craving.

      For sure, eating foods like white potatoes seems to cause a sugar craving, but it didn’t last time. I still did get hungry a few hours later and I think I did eat the same Lara bar that I would have had if I had a sugar craving, but I am really trying to stop the sugar cravings again because it made life so much easier.

      Eating until I am full hasn’t helped for losing weight, but residual hunger and blood sugar spikes are the combination that I think causes the seasons of junk food hunger for me. Not sure.

      1. I got Chef AJ’s book about Ultimate Weight Loss. Calorie density is crucial. But I noticed a distinct reduction in my cravings for sugary, processed stuff when I started eating vegetables for breakfast instead of oat groats, or brown rice, with fruit (and sometimes maple syrup).
        If you haven’t tried vegetables for breakfast, give it a go!

        1. Dharma, thank you for your suggestion of veggies at breakfast! I remember Marlyn Kaye mentioning that she enjoys a savory breakfast (if I remember incorrectly, pls forgive me Marilyn!) and thought at the time that it might just shake me out of my rut and do me some good too. I will try it.

          1. Barb, you remember correctly. Breakfast today was aduki beans, broccoli, brussel sprouts, beets, yellow squash and kimchi. Grapefruit for dessert.

      2. Deb, I thought of you yesterday as I was batch-watching Krocks in the kitchen vids. You mentioned you bought potatoes, and I watched their chili recipe video thinking the chili thrown on top of a baked potato might be something you would enjoy. https://m.youtube.com/watch?v=uq9Se0HwKvY

        The chili looks terrific, and easy too, though I will make a small pot of it this weekend first.

        Good luck with the infrared.. who knows!? Could be good. Meditation helps too.

        1. Thanks, Barb.

          Yes, as a Christian, meditation is one of the disciplines we do, and I do have a Christian meditation app. It is easy though to have such a full schedule or a cat jumping on me to not really do the process properly. I do better when either I am in total silence or I combine it with an ambient sound. Decades ago, I had a brain device that brought the brain into alpha, beta, delta, gamma. I can approximate it with YouTube videos or with Christian soaking room music.

          My ICES PEMF does do the same thing, so I can use that now that the cat is gone.

          But the infrared was helping. I didn’t pull it out during the time of the cat, but I did pull it out yesterday and I am going to try the potato experiment again.

          It is supposed to help with insulin issues and blood sugar issues, so it is worth it to try it because that is a good enough logic.

          1. Strange, I always thought that christianity emphasized on belief and blind acceptance of authority, that is: the denial of scepticism.

            Meditation without scepticism is not meditation at all, but rather mere hypnosis and self-satisfaction. And how could meditation be put into an app ?

            Nowadays, most people seem to confound meditation with so-called mindfulness, a concept cooked with many organized religious sauces.

  3. Dr J, I am surrounded by people with similar attitudes and eating habits as your friends. One friend is terrified… she has learned that that some cardiac intervention might be necessary and even the testing scares her half to death. She has seen my successes, and yet she was arguing the other day for an 80% rule. I don’t argue, and frankly, I don’t care…if only because she has to find the motivation within herself.

    I was blessed with regular healthy meals and discussions around the benefits of maintaining healthy weight as a kid. I have never been overweight ( though I would consider a bmi of 23 to be 20 lbs overweight) preferring to stay around bmi of 18 to 20. This does not come easily or naturally for me, even eating wfpb.

    I have eaten this way a long long time. Several factors have come into play and help with staying motivated.
    1. As mentioned above, I intend to stay slim for my lifetime. That’s a daily work.
    2. I love my exercise and being mobile. Able to ride, swim, run, walk the dogs, bicycle, paint the kitchen, whatever.
    3. My health..I survived a quintuple bypass operation, and I only take 3 little pills per day. Great, but not really a strong motivator for me, not as strong as
    4. I really do not want any any animal to die for me today. Not today, not tomorrow.

    I do believe however that the elephant in the room is addiction. wfpb and addiction are 2 distinct topics, and it’s my belief that a person can embrace wfpb, while taking on the (spiritual) work of addiction and experience success in both areas. It’s just my view.

    1. Barb,

      My BMI is 21.3; I’ve been shrinking in height, so it’s going up.

      At my highest weight, it was 25.8. I lost about 25 lbs when I was vegetarian by practicing portion control and making healthier choices. I lost another 10 without trying when I switched to eating whole plant foods, dropping dairy and eggs, and avoiding processed foods as well as prepared and processed food. (Though I still do eat a little; that’s where I practice portion control. Oh, and for nuts, too: I love them!! Otherwise, I eat as much as I want to.) I also try to avoid added sugar, oil, and salt.

      But, wow! A quintuple bypass! That must have been a huge wake-up call. My brother suffered a heart attack about 5 years ago (1 stent in a lateral artery), and he switched to eating whole plant foods — once he learned about it. And it wasn’t from his doctor, it was from a billboard advertising a chip health program (which advocates a whole healthy lifestyle: whole plant foods, exercise, stress reduction, etc) That makes me think that too few people know about the benefits from eating whole plants. And their doctors aren’t telling them about these benefits. I wonder why?

      But, I don’t understand those who do know about the benefits, but won’t change.

      But I also agree with you: why bother arguing? “Just the facts, ma’am.” What folks do with the facts and evidence is up to them.

      btw, I agree with you about animals dying. But my bigger motivator is this planet earth, which cannot sustain our current lifestyles. Which includes eating huge amounts of animal products. So wrong, for so many reasons.

  4. I think if people were encouraged to “crowd out” their meat intake then it would be more appealing to most. When the vegans and plant based converts get on their cases they switch off…
    I always encourage my friends/family and FB community to “move towards” a more plant-based diet…
    I for one am very pleased at how my junk food cravings are seriously reduced since I moved towards a more wholefood plant based diet!

    So much of today’s food and food production is all about convenience.
    Stuffing food full of sugar and other preservatives because it’s more convenient if it lasts longer… once you break that cycle it’s pretty compelling because real food tastes so good!

  5. My experience has been that eating more vegetables and less meat did not make a difference until I eliminated eggs, dairy, and fat. I have been eating the Dr. G 12 for 18 months–lost 45 pounds, got off injectable insulin (60U/day). My A1c went down temporarily but is back above 7; I am stuck at my present weight. I take the maximum Metformin and added Glimiperide reluctantly to control my blood sugar. Unfortunately, Glimiperide encourages weight gain. I have tried many things–eliminating oils, fasting after 7P.M., no junk, 40 min. of aerobic exercise every day. I am enjoying this new weight but frustrated with my inability to reverse the diabetes more. I am 69 and have been type 2 diabetic for almost 20 years.

    1. Congratulations on your weight loss, Nancy!  You might try two 40 min exercise sessions daily and adding more fiber with each meal to see if this helps with A1c.

      My cardiologist said that 45 min of walking is for people already at their ideal weight, while those who need to lose weight should walk 90 minutes. My insurance company suggested 7,500 to 10,000 steps, which is more than a 45 minute walk.

      A friend with insulin resistance was told by her physician that increasing fiber is the key to reversing that condition. Eliminate drinkable calories like smoothies and fruit juice in favor of food that needs to be chewed. As an aside, we were told in elementary school half a century ago that each mouthful of food needs to be chewed fifty times before you swallow. If everyone did that, few people would be overweight. John Harvey Kellogg, the Seventh-day Adventist physician to celebrities of his time and inventor of corn flakes, preached this same message about the importance of chewing.

      Have you tried the Esselstyn and Ornish diet? Both claim that this diet prevents and reverses both heart disease and diabetes. The diet is very low in fat and high in fiber. PCRM: “Studies show that eating a diet high in fatty foods can cause fat particles to build up inside our cells. These fat particles interfere with insulin’s ability to move sugar out from our bloodstream and into our cells. Instead of powering our cells, the glucose remains in our bloodstream, eventually leading to diabetes. A plant-based diet low in fat allows insulin to function properly. Here’s how to tackle diabetes in a few simple steps:

      1. Eat a plant-based diet.Evidence shows a diet of fruits, vegetables, whole grains, and legumes can prevent and reverse diabetes.
      2. Limit high-fat foods. Diets high in animal products and added oils are linked to increased diabetes risk.
      3. Eat foods that are low on the glycemic index. Beans, oats, sweet potatoes, and other low-GI foods do not spike blood sugar.
      4. Eat about 40 grams of fiber per day.”
      5. Download diet and diabetes fact sheet at https://www.pcrm.org/health-topics/diabetes

      Another good resource for diabetics is https://www.brendadavisrd.com/articles/diet-and-disease/

  6. Crowding out is an excellent strategy. Worth also mentioning, indeed stressing, FIBRE! Once I’ve eaten my beans or lentils or oats, I don’t usually have room for the usual meat or cheese feel full fillers, which are of course fibre free and make no contribution to the gut microbiome either. I’ve read many articles on improving gut health, which make zero mention of the word “fibre”. Sometimes the words veggies and plants can be off-putting, but people should be prompted to look for fibre content on packaging, because that is also half the battle to eating better and feeling fuller and crowding out the lesser stuff :)

    1. Excellent point, Rosy. My friend, prediabetic with insulin resistance, was given a goal for daily fiber intake by the physician as treatment. Hopefully more physicians will stress how important increasing dietary fiber is. Another benefit of managing blood sugar spikes (with fiber and by eliminating all sugary drinks and limiting simple carbs) is a lower risk of cancer. https://www.pcf.org/c/prostate-cancers-sweet-tooth/

  7. I want to mention that I am impressed with the quality of the imagery in the photos.

    I am not sure which one of you has such a good eye but the lighting and flow of the lines and the painterly quality of that image are exquisite. If I was an artist, that sight would cause me to want to paint a still life. That is interesting to me because I have always hated fruit, but I still knew that it was beautiful to behold. It would be interesting to have an art installation of fruit and light.

    When you do this, I end up going to the website and looking and it is hard to find that quality image on that site. It takes a while to find anything that stands up to it.

    https://unsplash.com/photos/jAHy1_59KkA

  8. Dr. Greger, Researchers at Johns Hopkins have confirmed that COVID-19 droplets have receptors which can attach to our tears and enter the body through our eyes. They describe the possibility that the virus lodge in the back of the nose where the germs replicate. If this is true, wouldn’t it be prudent to, first of all, warn people to wear goggles or face shields? This would prevent infections. Secondly, shouldn’t everyone be advised to flush their nasal cavity on a regular basis? This would insure that if a person were infected, he or she could reduce the possibility of allowing the virus to replicate?

  9. Don,

    You’re correct on the eye exposure hence the use of eye shields is the norm in medical settings.
    Is this practical or necessary for most given a 6-foot perimeter…. up for debate and could be all about the situation.

    As an example, talking vs singing or other activities has shown dramatically different droplet formations and spread. And let’s not forget the air flow where your located. https://flip.it/PrPDuO

    Nasal and pharyngeal washing would potentially reduce the number of viral particles but not eliminate them and would add a burdensome level to the already intrusive masks, distancing and washing regimes. So perhaps practicality is the key here ?

    Dr. Alan Kadish moderator for Dr. Greger http://www.Centerofhealth.com

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