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The Effect of Fruit and Vegetable Consumption on Cancer Incidence:

A Critical Approach to How the Scientific Knowledge Health !ecommendations and the "ublic "olic# Interact to Con$ert Efficientl# Knowledge into Social %ains

&os' (a#o)n Santiago Calder*n +,Southwestern .ni$ersit# Fall /0,1 Econometrics

Santiago Calder*n &os' (a#o)n Let food be thy medicine and medicine be thy food Hippocrates

,2 Introduction
The purpose of this stud# is to e$aluate the interaction among the scientific base recommendations and public polic# in the conte3t of fruits and $egetables consumption on cancer incidence rates2 Cancer is one of the leading causes of death in the world and the second leading one in the .nites States2 There are man# pla#ers in the multifaceted struggle to fight this pandemic2 The scientific communit# medical professionals the pertinent industr# non4 go$ernmental and the State ha$e all been coordinating and de$eloping wa#s to efficientl# promote the public health and minimi5e the effects of the disease2 In order to do so the# interact in se$eral wa#s2 6an# of these are based on the scientific understanding: to understand the nature of the disease wa#s to pre$ent it and wa#s to treat it2 Through this process the scientific base is con$erted into health recommendations and procedures emplo#ed b# medical professionals and in turn con$e#ed to the general public b# institutions associations guilds and agencies2 At this stage the message is redacted into a simpler form such that it can be understood b# the general public and eas# to communicate2 7astl# public polic# is designed to achie$e set goals that measure compliance of the recommendations in the public agenda2 This model is toda# more rele$ant than e$er2 In the absence of definite cures and treatments still with man# limitations pre$ention and alternati$es ha$e been the focus related to this epidemic2 The scientific understanding in this instance has concluded that the bul8 of the reasons of wh# cancer de$elops is mostl# contained in e3ogenous factors such as en$ironmental /

Santiago Calder*n &os' (a#o)n and beha$ioral concerns rather than more so in genetics2 9ue to this conclusion the recommendations and public polic# ha$e been dri$en b# the understood ris8 factors of the condition2 These recommendations comprise dietar# and lifest#le choices2 :ut of the dietar# concerns fruits and $egetables consumption is one widel# accepted and often pursued b# the public agenda2 ;hile there is a solid reasoning at the chemical le$el the effect of fruits and $egetables consumption on cancer incidence has not been as well established empiricall#2 ;hile there is no <con$incing= e$idence that fruits and $egetables diminishes the probabilit# of cancer occurring there is e$idence that suggest or ma8es a strong case for it to be li8el# that some fruits and some $egetables diminish the probabilit# of de$eloping certain 8inds of cancer2 "ublic polic# is then drafted around the assumption that achie$ing compliance of the recommendation in this case fruits and $egetable inta8e would lead to a lower cancer incidence rate when all things hold constant2 It is not far fetched that the public polic# ma8ers would tr# to achie$e an ideal social condition such that the ultimate goal is more feasible2 Howe$er we must ta8e precautions so that if we attempt to achie$e that ideal social condition through the compliance of said recommendation the desired effect follows2 In the case of fruits and $egetables consumption I will test whether it is correct to e3trapolate from the empirical findings and rel# on the general recommendation as our public polic# tool to ultimatel# create that ideal social condition fa$orable to our desired effect2 The model uses a linear regression with a cross section data with all $ariables at the count# le$el for ,>11 counties in the .nited States2 The data for most $ariables was collected from the national

Santiago Calder*n &os' (a#o)n (eha$ioral !is8 Factor Sur$eillance S#stem b# the Center for 9isease Control2 The regression used data computed for reported cancer incidence rate and the fruits and $egetables consumption from the food fre?uenc# ?uestionnaire2 6# control $ariables include the ris8 factors measured b# the national sur$e# and non4genetic demographic characteristics from the census2 The results pro$ided a significant coefficient for the $ariable of interest @p4$alue A 0200/B2 Howe$er the sign of the coefficient suggested the counter intuiti$e resultC indicating that the lower the percentage of people who compl# with the recommendation of consuming D or more rations of fruits and $egetables the higher the predicted cancer incidence rate for the population2 I concluded that the current polic# and recommendations are incorrectl# e3trapolated from the underl#ing scientific understanding and cannot predict or be used as tools to achie$e the desired effect under the established paradigm2 There is a need to harmoni5e our polic# ma8ing tools with the conclusions actuall# deri$ed from the empirical e$idence rather than wor8ing with the general recommendation2 7astl# I anal#5e how to impro$e the d#namic among the scientific base recommendations and public polic# to address these issues and establish better general recommendations and policies2

/2 7iterature !e$iew
6alignant neoplasm, cancer is the second leading cause of death in the .nited States @Center for 9isease Control /0,1B2 6alignant neoplasm refers to an# new and abnormal growth specificall# one in which cell multiplication is uncontrolled and progressi$e2 The four most
, 9efined b# the ;orld Health :rgani5ation as the rapid creation of abnormal cells that grow be#ond their usual boundaries2 @http:EEwww2who2intEcancerEenEB

Santiago Calder*n &os' (a#o)n prominent cancers nowada#s are: prostate @malesB breast @femalesB lung F bronchus and colon F rectumC with se3 dependent cancers leading in cancer incidence while lung F bronchus cancer leads in mortalit# rates for both se3es /2 According to the annual publication b# the American Cancer Societ# @/0,1B the ris8 factors $ar# across t#pe of cancer but some are pre$alent across $irtuall# all of them2 These ris8 factors are: age obesit# ph#sical acti$it# consumption of red meats consumption of fruit and $egetables smo8ing diabetes sunlight e3posure tobacco and certain 8inds of conditions or infections that wea8ens the immune s#stem such as the emotional state @high stress shoc8s traumas etcB2 The current medical understanding is that about ,0G of all cancers are probabl# due to genetics1 while H0G are due to en$ironmental factors related beha$ior or lifest#le choices2 :nl# about DG of cancers ma# be strongl# hereditar# @IbidB2 This is the reason wh# the field has e$ol$ed toward anal#5ing the beha$ior ris8 factors for this chronic epidemic2 The most common cancers are strongl# associated to aging2 As conse?uence de$eloped countries with longer life4 spans t#picall# ha$e higher cancer rates than countries where the lifespan is comparati$el# shorter2 Furthermore the older the population the higher the cancer incidence2 Howe$er it is important to notice that in the wealth# de$eloped world the sur$i$al rate for cancer is substantiall# higher than in those less economicall# prosperous -2 Sur$i$al rates are much higher in wealth# de$eloped countries not onl# because treatment might be more accessible but because cancer treatment is regarded as a lu3ur# goodD2
/ 1 D American Cancer Societ# <Cancer Facts F Figures I /0,1= %enes that are acti$e on the s#stem and e3cludes those who are inacti$e until triggered b# beha$ior2 Some cases de$iate from the ruleC in such cases the national healthcare s#stem generall# is the best e3planation for this2 ;ealthier patients are willing to de$ote a larger shares of their income to pa# for gains in cancer sur$i$al2

Santiago Calder*n &os' (a#o)n The .nited Kingdom is one of the countries who has studied cancer with an economic approach most profoundl# in part due to the Jational Healthcare S#stem >2 !esearch and polic# on cancer in the .nited States is generall# thought to ha$e started with "resident !ichard Ji3on+s declaration of war on cancer during the State of the .nion of ,HK,2 At this moment the Jational Cancer Act was signed into law2 The bill outlines the battle plan with a combination of different measures among them research for a cancer cureK2 Jutrition and medical research has been disco$ering new wa#s to fight cancer through a better understanding of cancer biolog#2 Some e3amples include: the role of sugar as the <food= for tumors to grow the relation between free radicals and malignanc# antio3idants and cancer pre$ention and the role of ph#tochemicals in pre$enting tumor growth L2 ;hile most of the research in these fields is focused on the chemical and biological processes the econometric approach to pandemic diseases is often not as well studied2 Some studies ha$e tried to e3plore the relation between fruit and $egetable inta8e with other maMor epidemics such as coronar# hearth diseases @CH9B2 A stud# to highlight is <Increased consumption of fruits and $egetables is related to a reduced ris8 of coronar# heart disease: meta4anal#sis of cohort studies= @He Feng &2 et al2 /00>B2 This research included twel$e studies with thirteen independent cohorts2 There were /KL -DH indi$iduals with a median follow4 up of ,, #ears2 The meta4anal#sis of prospecti$e cohort studies showed that increased consumption of fruit and $egetables from less than 1 to more than D ser$ingsEda# was related to a ,KG reduction in CH9 ris8 whereas increased inta8e to 1ID ser$ingsEda# was associated with a
> K L The Jational Health Ser$ice @JHSB is the publicl# funded healthcare s#stem for England2 It is the largest and the oldest single4pa#er healthcare s#stem in the world2 It was e3pected to find a cure for cancer within fi$e #ears2 These conclusions are widel# accepted in the field and are part of the .S F9A polic# recommendations2

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Santiago Calder*n &os' (a#o)n smaller and borderline significant reduction in CH9 ris8H2 Similar studies such as <Fruit and Vegetable Inta8es and "rostate Cancer !is8= @Cohen &ennifer H2 et al2 /0,0B studied the relation of fruit and $egetable inta8e with prostate cancer in a group stud# of men under the age of >D from King Count# @Seattle areaB ;A through self4 reported ?uestionnaires2 The stud# included >/L participants and >0/ men from the same underl#ing population and fre?uenc# as the control group2 The results of this stud# using odds ratios for prostate cancer ris8 associated with foods and nutrients were calculated b# use of unconditional logistic regression2 The stud# controlled onl# for demographic @ageB education bod# mass inde3 and dietar# $ariables2 These results suggested that high consumption of $egetables @not significant for fruitsB is associated with a reduced ris8 of prostate cancer2 6ost of the scientific 8nowledge and basis for health recommendations are the result of in $itro studies2 In contrast in $i$o studies are generall# not as widespread and comprehensi$e in the field2 This historical fact has led to man# claims being based on basic @labB science and not as robustl# confirmed b# social empirical data ,02 6uch of the science claims methodolog# and recommendations are communicated b# health agencies as well as institutes and medical professional guilds2 As a result man# researchers wor8 modeling wa#s to impro$e o$erall health b# ha$ing societ# engage in these recommended practices2 6an# studies propose models for optimi5ing ad$ertising campaigns and ma8ing sensible policies in order to ha$e a better population wellness2 :ne such stud# <An economic e$aluation of the war on cancer= @7a8dawalla et al2 /0,0B models the effect of a diminishing mortalit# rate in economic terms as

H Ta8en from the abstract of said publication2 ,0 Concern brought forth b# nutritionist 7cda2 Vilma %2 Calder*n2

Santiago Calder*n &os' (a#o)n a function of !F9 in$estment and from the patientsN $iew in terms of longer life e3pectanc#2 The results support the idea of cancer treatment being a lu3ur# good2 This idea has been supported b# $arious other publications such as <The Value of 7ife and the !ise in Health Spending= @Hall F &ones /00>BC these implications are the basis for the polic# regarding patents for cancer treatment and medicines a great deal of contemporar# polic# regarding the cancer epidemic2 :ther researchers focus on the health recommendations for fighting illnesses2 <A rational eating model of binges diets and obesit#= @9ragone /00HB attempts to measure the relation among different correlated choice beha$iors2 Studies b# 9ragone were a base to construct the methodolog# further discussed in that section2 7i8ewise <Thinness and obesit#: A model of food consumption health concerns and social pressure= @9ragone F Sa$orelli /0,/B is a stud# which models food consumption beha$ior as a function of health concerns and social pressure2 The implications of the research are that it presents choice beha$ior models in conte3t as opposed to Must a consumption choice or health consideration alone2 :ur obMecti$e as indi$iduals and as societ# is to pre$ent and treat this epidemic through all means possibles in the most efficient wa#s2 The a$ailable tools for the populace are mainl# their choices or beha$ior ris8 factors concerns2 The research in this area branches out ?uite a lot2 Some studies de$elop in the beha$ior models that helps us understand relations at the indi$idual le$el2 6eanwhile others e3plore factors that are not a direct function of choice such as wealth in the <The utilit# of health and wealth= @6oshe F !i5ans8# Jir /0,/B2 In this research the authors use health and wealth tradeoff ?uestionnaires for a sample of cancer and

Santiago Calder*n &os' (a#o)n diabetes patients2 .sing the formula .@h wB O hPu@wB where h represents health w wealth and u@wB the standard utilit# of wealth the stud# found that the .@h wB O hPlog@awB was the line of best fit for both samples suffering the different conditions2 The findings are consistent with pre$ious studies that claim that as health deteriorates the more willingness there is to trade wealth for health2 <6ortalit# lifest#le and socio4economic status= @(alia F &ones /00LB e3plores health ine?ualit# based on social4economic status but also with $arious beha$ior factors such as the use of tobacco2 <!ising educational gradients in mortalit#: The role of beha$ioral ris8 factors= presents a time stud# of the relation between education and $arious factors of ris8 @Cutler et2 al2 /0,,B2 The methodolog# of both studies was a part of the construction of the one used in this paper further e3plained in the methodolog# section2 I obser$ed a mar8ed tendenc# in the literature for including dietar# concerns to e3plain the ris8 of suffering common diseases or conditions that are epidemic in our societ#2 In other words diet is understood to be the most rele$ant factor in the research the health recommendations and the public polic#2 The literature on dietar# choices co$ers multiple dimensions2 Some aspects are: accessibilit# beha$ior modeling determination factors effect of its consumption etc2 <Fi$e4a4 da# a price to pa#: An e$aluation of the .K program impact accounting for mar8et forces= @Capacci F 6a55occhi /0,,B studies a polic# implemented to boost fruits and $egetables consumption in said countr#2 The results found a significant boost in consumption of fruit and $egetables of 021 rations on a$erage,,2 Such literature focuses on the effecti$eness of a polic# program in implementing a health recommendation2
,, ;hen di$iding the population b# income ranges the results ranged from 020/ 4 020K2

Santiago Calder*n &os' (a#o)n Some policies aim to create an en$ironment that promotes good li$ing practices2 :ne wa# it has been traditionall# studied are food desserts ,/ and fast food saturated communities,12 <The A$ailabilit# and Cost of Healthier Food Alternati$es= @&etter F Cassad# /00>B studies the presence of food desserts and how the absence of health# food options or restricti$e prices affect low income groups2 (# stud#ing the different mar8ets in terms of a$ailabilit# and prices the stud# concluded that the lac8 of small grocer# stores located in low income neighborhoods and higher costs for health# food bas8ets ma# be deterrents to eating healthier among $er# low income consumers2 According to the publication <Food Jutrition "h#sical Acti$it# and the "re$ention of Cancer: a %lobal "erspecti$e= @;orld Cancer !esearch Fund F The American Institute for Cancer !esearch /00KB there is no con$incing e$idence that fruits or $egetables consumption decrease the ris8 of cancer for an# cancer sites2 Howe$er there is e$idence at probable or limited suggested e$idence le$els that lin8 certain $arieties of fruits and $egetables to reduced probabilit# de$elopment of cancer for certain cancer sites2 It is the obMecti$e of this paper to shine light on how the scientific 8nowledge ,- health recommendations,D and the public polic#,> wor8 together to con$ert efficientl# 8nowledge into social gains2 This approach is not well researched in the literature and brings to the table $er# serious concerns about the current s#stem2 This paper will test the h#pothesis used in public
,/ A food desert is an area where affordable health# food is difficult to obtain particularl# for those without access to an automobile2 Food deserts are most li8el# to be found amid low4income communities2 ,1 Communit# with a food choice mar8et characteri5ed b# a well established presence of fast food options2 ,- The scientific base mostl# from in $itro e3periments2 ,D !ecommendations adapted from the scientific base propagated b# health professionals go$ernment agencies and institutes2 ,> The stance agenda decisions and programs of the go$ernment that deal with the issue2

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Santiago Calder*n &os' (a#o)n polic# and health recommendations that the consumption of at least fi$e rations of fruit and $egetables b# the public would lower the cancer incidence rate obser$ed in the population when controlling for the calculated ris8 factors2

12 9ata 9escription
The outcome $ariable measures the cancer incidence rate: new cases of cancer per capita per #ear o$er fi$e #ear inter$als ,K2 This particular data in the stud# uses the /00>4/0,0 time period2 The t#pes of cancers for calculating new cases of cancer account for all cancer sites e3cept for bladder cancer2 The incidence rates are age4adMusted to the /000 .S standard population @,H age groups: A, ,4- D4H Q L04L- LDRB2 !ates calculated using SEE!PStat ,L2 The population data used came from the Census (ureauC the ,H>H4/0,, .S "opulation 9ata File is used for SEE! and J"C!,H incidence rates2 The independent $ariable of Few Fruit and Vegetables is defined as the percentage of adults reporting an a$erage fruit and $egetable consumption of less than D ser$ings per da#2 In other words the population percentage who do not abide b# the recommended practice2 This percentage is calculated b# data collected through the (eha$ioral !is8 Factor Sur$eillance S#stem @(!FSSB sur$e#2 The data is at the count# le$el and was accessed through the Communit# Health Status Indicators @CHSIB /00L4/0,1 annual reports2 The control $ariables of the regression were: obesit# ph#sical inacti$it# mental health smo8ing drin8ing diabetes income and age2 :besit# was calculated b# the percentage obese /0
,K Standard practice in epidemiolog# and per capita based of ,00 000 people2 ,L The Sur$eillance Epidemiolog# and End !esults @SEE!B "rogram of the Jational Cancer Institute wor8s to pro$ide information on cancer statistics2 ,H Jational "rogram of Cancer !egistries @J"C!B /0 A calculated (6I greater than 102

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Santiago Calder*n &os' (a#o)n adults in the population2 "h#sical inacti$it# was defined b# the percent of adults that reported no leisure time ph#sical acti$it# in the past 10 da#s2 9iabetes reflected the percentage of adults diagnosed with diabetes2 The data for these two $ariables were pro$ided b# the Jational Center for Chronic 9isease "re$ention and Health "romotion 9i$ision of 9iabetes Translation2 6ental health was described b# the a$erage number of poor mental health da#s in past 10 da#s2 This $ariable onl# pro$ided data if at least D0 respondents answered the sur$e# per count#2 Smo8ing habits was included in the regression as the percentage of adults that smo8ed tobacco products2 The drin8ing $ariable was defined as the percentage of adults who reported hea$# drin8ing/,2 The data for these $ariables was collected from the (eha$ioral !is8 Factor Sur$eillance S#stem @/00-4/0,0B2 The demographic age $ariable was the percentage of the population with o$er si3t#4 fi$e #ears old accordingl# to the .S Census (ureau in the #ear /00H2 6edian household income was measured in .S9S and the data was from the Small Area Income and "o$ert# Estimates @/0,,B2 7astl# the data set used three I9 $ariables: FI"S State and Count#2 These pro$ided the name of the count# the state where the count# was located and the Federal Information "rocessing Standards Code for the count#2 The data sets and sur$e#s primaril# used for the data collection were the (eha$ioral !is8 Factor Sur$eillance S#stem @(!FSSB the Communit# Health Status Indicators !eport The Count# Health !an8ings F !oadmaps and the State Cancer "rofile2 The (eha$ioral !is8 Factor Sur$eillance S#stem @(!FSSB is a state4based s#stem of health sur$e#s that collects information on health ris8 beha$iors pre$enti$e health practices and health care access primaril# related to
/, Hea$# drin8ing defined as: if male two or more dail# drin8s and if female one or more drin8s per da#2

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Santiago Calder*n &os' (a#o)n chronic disease and inMur# @Healthdata2go$B2 The Communit# Health Status Indicators !eport is a collection of nationall# a$ailable indicators for counties representing se$eral areas of responsibilit# for public health2 It is the product of the Communit# Health Status Indicators @CHSIB "roMect a public4pri$ate collaboration of organi5ations committed to national support for local action to impro$e public health @/00HB2 The Count# Health !an8ings F !oadmaps program is a collaboration between the !obert ;ood &ohnson Foundation and the .ni$ersit# of ;isconsin "opulation Health Institute @www2count#healthran8ings2org AboutB2 The Jational Cancer Institute @JCIB is part of the Jational Institutes of Health @JIHB which is one of ,, agencies that compose the 9epartment of Health and Human Ser$ices @HHSB2 The State Cancer "rofile is an interacti$e data and statistical tool offered at their website2 The obser$ations used for the regression comprise all the counties in the .nited States for which data for all the selected $ariable was a$ailable in the data sets used2 These accounted for ,>11 counties out of the total 1,-, counties in the .nited States2 The counties obser$ed come from across all states and ;ashington 92C2 e3cept for the following: Alas8a Kansas 6innesota :hio and Virginia2 Those states did not ha$e the outcome $ariable data a$ailable2 In order to protect the research from bias b# ha$ing selected a non representati$e sample of the population I ran a summar# of statistics on basis of the outcome $ariable being a$ailable or not @Figures D F >B2 There were no alarming disparit# among the two summar# statistic present indicating that the obser$ations in the selection of the data seems to be random and should not bias the results2 The regression included one outcome $ariable one $ariable of interest and eight

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Santiago Calder*n &os' (a#o)n control $ariables2 9ue to the nature of the $ariable of interest as well as the control $ariables the data was compiled b# ?uestionnaires2 The data selections rests on the belief that the (!FSS is the most comprehensi$e and solid national sur$e# for these $ariables2 For an o$er$iew of the $ariables names definitions sources and co$erage refer to @figure ,B2 Form the summar# statistics @refer to figure /B we can see the profile of the aggregated counties2 (ased of the mean for the $ariables the a$erage count# could be described as following: a cancer incidence rate of -D, about ,ED of the population does compl# with the recommendation about , out of ,0 people suffers diabetes about ,DG of the population is >D #ears old or older the median income is around S-1 000 , out of D people is a smo8er about / out of K does not e3ercise ,DG are hea$# drin8ers ,E1 of the population is obese and in general people suffer around 1 da#s of poor mental health monthl#2 This statistics somewhat fit within the national statistics2 For e3ample in the case of the compliance with the recommendation of FFV consumption it has been historicall# low and nationall# less than ,E12 Furthermore the highest le$el of compliance with the recommendation obser$ed did not e3ceed the /EDC meanwhile the lowest le$el of compliance obser$ed was 12DG2 Some interesting results can be obser$ed from the co$ariance table @refer to figure 1B2 From the co$ariance summar# it can be seen a strong relation among ris8 factors such as obesit# diabetes smo8ing poor mental health and ph#sical inacti$it#2 Furthermore the $ariable of interest is positi$el# correlated to the almost all ris8 factors controlled for2 It has a negati$e correlation with income which is to be e3pectedC the higher #our income the more li8el# #ou can afford and might choose to consume fruits and $egetables2 Drink acts different than the other

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Santiago Calder*n &os' (a#o)n $ariables but is not surprising since it onl# measures e3treme consumption of alcohol2 For the most part the relations seem to be consistent with what it would be e3pected e3cept for one instance2 The $ariable of interest is negati$el# correlated with the outcome $ariables2 This hints to if significant the higher the proportion of people who do not eat as man# fruit and $egetables the lower the cancer incidence rate foreshadowing counter intuiti$e results2

-2 6ethodolog#
I test whether it is correct to generali5e the scientific 8nowledge some fruits and $egetables are lin8ed to diminish the probabilit# of certain t#pes of cancer into a broad health recommendation dail# inta8e of fruit and $egetable of at least D rations2 Furthermore base the public polic# on compliance of that recommendation as a wa# to predict or foster the achie$ement of the ultimate goal2 For this purpose I will use cross section data // for a linear regression/1 with the following e?uation: # O T0 R T,a R T/b R T1c R T-d R TDe R T>f R TKg R TLh R THi R T,0M R U Q where #:O outcome $ariable cancer incidence rate T0:O intercept a:O percentage of adults who do not follow the recommendation of a consumption le$el of at least D dail# rations of fruit and $egetables b:O percentage of adults diagnosed with diabetes c:O percentage of adults who are smo8ers of tobacco products d:O percentage of adults who are ph#sicall# inacti$e
// Time series data would show $er# small $ariation on our interest $ariable since the $alue are historical2 (ecause of this cross section data was determined to be the optimal choice2 /1 Jo reason or concerns rose up to challenge the assumption that the relation was not linear in nature2

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Santiago Calder*n &os' (a#o)n e:O percentage of adults who reported hea$# drin8ing f:O a$erage da#s of poor mental health per month g:O percentage of smo8ers h:O percentage of adults o$er >D #ears old i:O percentage of adults obese M:O median income in S The construction of this regression e?uation too8 into account the obMecti$e of this stud# and the surrounding scientific understanding2 In other words this regression uses the $ariables in the industr# standards measures uses the data collection methods that public polic# ma8er would ha$e access and would use to measure the le$el of compliance and controls for the current understood factors of ris8 measured within the statistic s#stem in place to address the issue2 This means that this regression does not tr# to unco$er the underl#ing effect of fruits and $egetables consumption on cancer incidence rate but to test whether if under the established framewor8 a higher compliance would predict the desired effect or not2 The control $ariables are those measured in the reports and understood as cancer ris8 e3cluding those genetic @race gender etc2B since the polic# and recommendation assume their role in predicting cancer is not significant/- in general for all cancer sites2 The scientific base has produced numerous stud#ing affirming the probabilit# that certain fruits and $egetables reduce the ris8 of certain cancers2 ;hile on the scientific communit# and man# health professionals close to the research can interpret the results into effecti$e medical ad$ice the public has limited capacities to do so on their own2 Health
/- It is accepted that around H0G of cancer is due to en$ironmental factors and not genetics2

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Santiago Calder*n &os' (a#o)n recommendations are then redacted in a more uni$ersal language so that the public might understand and commit to such practices2 6ost of the research is done in $itro e3periments while others are done in $i$o @mainl# in ratsB2 !esearch with humans has guided the medical field into obser$ing certain fruits for e3ample berries to ha$e an impact in decreasing the probabilit# of de$eloping certain t#pes of cancer2 It is mostl# for this reason that the go$ernment agencies institutions and professional guilds ma8e the less specific and more general recommendation of consuming fruits for cancer pre$ention2 This recommendation is generall# in the form of eating at least D rations of fruits and $egetables per da#2 :nce again the public polic# wor8s to use the recommendation and promote their implementation2 Following these assumptions I then choose as the $ariable of interest as the same measurement described b# the health recommendation2 For this stud# I will focus on the claim that this practice reduces the incidence of cancer2 This approach differs from the classical trial e3periments as I am not testing the effect of consumption of fruit and $egetables on cancer incidence but the compliance of the recommendation and its relation to the desired outcome within the recommendation+s framewor82 In order to control for other factors I will include the accepted ris8 factors of cancer2 From the literature I obser$ed that most cancer t#pes are not geneticall# determined but on the contrar# for the most part there are a function of en$ironmental factors2 The en$ironmental factors are then di$ided into choice beha$ior and those who are outside our power2 9ue to the nature of the disease I account for $ariable of age: those o$er >D #ears old are considered high

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Santiago Calder*n &os' (a#o)n ris8 population as cancer is a general age associated disease2 Since tumors grow when the immune s#stem is hampered I account for $ariables that are lin8ed to wea8ened immune s#stems namel# poor mental health da#s @stress depression etcB2 An indispensable $ariable to control for is the use of tobacco products and so I include the percentage of the population who are smo8ers2 For the same reasons I include drin8ing which is 8nown to increase the ris8 for a $ariet# of t#pes of Cancer /D2 7i8ewise strong e$idence has cataloged obesit# diabetes and ph#sical inacti$it# as factors of ris8 for man# t#pes of cancers/>2 Ha$ing included the control $ariables I ma8e the 8e# assumptions that cancer is a function of these accepted ris8 factors included and thus can belie$e that the 5ero conditional mean assumption will hold2 Howe$er I will address omitted $ariable bias concerns in the following paragraphs2 I belie$e that e$en to some e3pense other factors e3plain the outcome $ariable and are correlated to the $ariable of interest such as: famil# histor# e3posure to en$ironmental agents @asbestos air pollution trihalomethanes etcB second hand smo8ing Mob ha5ard @radiation chemical e3posure etc2B hormone disorders other immune s#stem debilitating conditions @H"V Herpes Hepatitis HIV etcB other dietar# choices @sugar fat meat processed food inta8eB etc2 Another concern is the fre?uenc# and ?ualit# of cancer screening that might create data error in our $alues2 The fre?uenc# and practice of regular cancer screenings among the different counties is probabl# not without $ariation2 9ata error is bound to be present in the stud# since the data is ?uestionnaires based2

/D Ke# point of the Jational Cancer Institute2 /> .nderl#ing science that supports it are the le$els of sugar in the blood and the state of the immune s#stem2

,L

Santiago Calder*n &os' (a#o)n Specific to this stud# it is well documented that Food Fre?uenc# Vuestionnaires @FFVB <contain onl# a limited list of precoded food items which tend to be grouped together unli8e the food diar# which is open ended the# ma# not be as suitable as food diaries for assessing $ariet# of food inta8e=/K @Cooper A2 &2 et al2 /0,/B2 The general tendenc# is for mean consumption of FFV to be o$erestimated b# FFV in comparison to the more precise method of a food diar#2 Je$ertheless due to data constrains to the polic# ma8ers and the purpose of this stud# these errors effects should be minimum2

D2 !esults
From running the regression corrected for heteroscedasticit# I obtained an !/ greater than 02H- and following results @refer to figure KB2 ;hen all pertinent factors held constant a ,G increase in the percentage of adults not compl#ing with the health recommendation predicts a @02H-/B decrease in the cancer incidence rate2 This coefficient is significant @p4$alue A 0200/B but when loo8ing at the practical effect ha$ing in consideration that the mean of cancer rate incidence is -D, and that it has pro$en historicall# $er# challenging to change this beha$ior it is more interesting the sign @refer to figure 1F-B2 ;hen comparing the h#pothesi5ed coefficient signs with those obtained from the results I obser$ed the intuiti$e conclusion with the e3ception of the $ariable of interest @refer to figure LB2 This was result was foreshadowed b# Must loo8ing at the co$ariance between the two $ariables2 9iabetes income smo8ing and ph#sical acti$it# all showed a positi$e correlation with cancer incidence2 9iabetes and smo8ing both had coefficients with significant @p4$alues A
/K <A "rospecti$e Stud# of the Association (etween Vuantit# and Variet# of Fruit and Vegetable Inta8e and Incident T#pe / 9iabetes=

,H

Santiago Calder*n &os' (a#o)n 0200,B and considerable economic effect2 Income on the other hand showed the same le$el of significance but with an economic effect of $irtuall# 5ero considering the mean of the outcome $ariable2 7astl# ph#sical inacti$it# showed a considerable economic effect but with a coefficient less significant @p4$alue A 020,B2 "ondering on the possible e3planations for this result is 8e# in accuratel# assessing the h#pothesis test2 The same drawbac8s that could potentiall# e3plain the sign of the coefficient could $er# well be the factors that ma8e the public polic# and general recommendation fault#2 The stud# is not accounting for pesticides in fruit and $egetables man# of which are classified as carcinogen2 Furthermore some studies suggest geneticall# modified products to pose health concerns2 E$en more other concerns not well addressed in the framewor8 are: whether the products are fresh or preser$ed in sugar pic8led or other mediumsC and how are the# prepared2 Eating a salad but drowning it in dressing will not bring the desired effect Must as for e3ample eating deep fried $egetables2 Some of the most popular fruits are e3tremel# contaminated b# pesticides in the effort to ma3imi5e their production due to their high demand in the mar8et2 7astl# the t#pe of fruits and $egetables are not being classified and lumped all together2 This is a concern since the nutritional components of all fruit and $egetables are not the same2 The pre$ious is an accepted drawbac8s of using FFV as opposed to food diaries2 ;hile these concerns would $iolate the 5ero mean condition in similar e3periments since the obMecti$e of this research is to understand whether not controlling for these in the recommendation affects the predicted outcome it is beneficial not to obser$e them2 This wa# we are finding out how the le$el of compliance is affecting our outcome $ariable with the

/0

Santiago Calder*n &os' (a#o)n specifications surrounding the message to the public and the specifications of the recommendation2

>2 Conclusion
I concluded that the interaction of the scientific base health recommendation and its transition to public polic# is at least partiall# fault#2 "ublic polic# that focuses in an e3trapolated recommendation e$en if once based in on empirical data ma# succeed at the compliance of the recommendation but not necessar# achie$e the desired effect which was the moti$ation2 In more specific terms the recommendations that fruits and $egetables consumption o$er D dail# ration is an e3trapolated conclusion2 The scientific understanding helps medical professional educate and treat patients2 Howe$er e$en if well intentioned actors wish to promote good health b# ma8ing claims e3trapolated from the research such as fruits and $egetables consumption @implies an# fruits and $egetables and no restrictions on which or how to consume themB to decrease cancer @impl#ing all t#pesB it does not necessaril# wor8 as intended2 The issue is more se$ere when it is adopted as a public polic# and the le$el of compliance is used to predict the outcome as the empirical e$idence showed incorrectl#2 This stud# b# no means discourages the consumption of fruits and $egetables or claims that the finding hold under a different setting @other condition or certain t#pes of cancer etcB2 It does howe$er ?uestions the current relationship among the scientific understanding

recommendations and policies2 :ne parallel obser$ation is made in <A "rospecti$e Stud# of the Association (etween Vuantit# and Variet# of Fruit and Vegetable Inta8e and Incident T#pe / 9iabetes= @Cooper A2 &2 et al2 /0,/B: <9espite the fact that $ariet# in FFV inta8e has been

/,

Santiago Calder*n &os' (a#o)n ad$ocated b# man# national and international bodies no studies that we are aware of ha$e e3plored associations between $ariet# in inta8e and ris8 of T/9=2 In order to harmoni5e and reconcile the scientific base with effecti$e recommendations and public polic# there has to be more in social studies in order to transfer the technical into tangible social e3perimentation2 E$en so there has to be a continuit# in studies that monitor how the recommendations are well designed in order to be clearl# understood b# the public2 7astl# there has to be a wa# to implement measure compliance and monitor the effect on the desired outcome2 That wa# recommendations can be at the border of simplicit# but ne$er step outside of what is supported b# the empirical e$idence2 If and onl# if this transition is reali5ed then we could accuratel# predict and foster public health through education and programs efficientl#2 E$en so this does not affect current policies uniforml#2 ;hile less than one third of the .nited States follows the recommendation FFV inta8e @see figure HB achie$ing a higher percentage of people eating health# is a good public polic#2 The problem arises for e3ample when based on assumptions one would e3pect such change to ha$e a miscalculated effect on cancer incidence rate2 The good news is that all the scientific 8nowledge alread# a$ailable is Must waiting to be properl# con$erted into effecti$e recommendations and public polic#2 It should be noted as well that people are loo8ing for new wa#s to sta# health# and gi$en the opportunit# to learn how to ta8e care of themsel$es it is $er# li8el# that the# will engage in healthier beha$ior and enMo# a better happier and longer life2

//

Santiago Calder*n &os' (a#o)n

K2 7ist of !eferences
Alemanno A2 F CarreWo I2 @/0,1B2 +Fat ta3es+ in Europe 4 A 7egal and "olic# Anal#sis under E. and ;T: 7aw2 European Food & Feed Law Review 8@/B HK4,,/2 Anand "2 F %ra# A2 @/00HB2 :besit# as 6ar8et Failure: Could a X9eliberati$e Econom#N :$ercome the "roblems of "aternalismY2 Kyklo !"@/B ,L/4,H02 doi:,02,,,,EM2,->K4 >-1D2/00H200-1023 (e#doun 62 A2 "owell 72 62 F ;ang Z2 @/00LB2 The association of fast food fruit and $egetable prices with dietar# inta8es among .S adults: Is there modification b# famil# incomeY2 #ocial #cience & $edicine !!@,,B //,L4///H2 doi:,02,0,>EM2socscimed2/00L20,20,L Cash S2 (2 Sunding 92 72 F [ilberman 92 @/00DB2 Fat ta3es and thin subsidies: "rices diet and health outcomes2 %cta %&riculturae #candinavica' #ection () Food Economic "@1E-B ,>K4,K-2 Clar8e %2 E#re H2 F %u# C2 @/00/B2 9eri$ing Indicators of Access to Food !etail "ro$ision in (ritish Cities: Studies of Cardiff 7eeds and (radford2 *rban #tudie +Routled&e, -.@,,B /0-,4/0>02 doi:,02,0L0E00-/0HL0//0000,,1D1 Cohen &ennifer H2 Kristal A2 !2 F Stanford &2 72 @/000B2 Fruit and Vegetable Inta8es and "rostate Cancer !is82 /ournal of the 0ational (ancer 1n titute Vol2 H/ Jo2 , &anuar# D /0002 H/ @,B: >,4>L2 doi: ,02,0H1EMnciEH/2,2>, Cooper A2 &2 4 :riginal !esearch @/0,/B 4 Epidemiolog#EHealth Ser$ices !esearch: Andrew &2 Cooper Stephen &2 Sharp 6arleen A2H2 7entMes !obert J2 7uben Ka#4Tee Khaw

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Santiago Calder*n &os' (a#o)n Jicholas &2 ;areham and Jita %2 Forouhi2 A "rospecti$e Stud# of the Association (etween Vuantit# and Variet# of Fruit and Vegetable Inta8e and Incident T#pe / 9iabetes2 Diabete (are &une /0,/ 1D:,/H14,100C published ahead of print April 1 /0,/ doi:,02/11KEdc,,4/1LL 9ana %oldman 9arius 7a8dawalla and Zuhui [heng2 \Food "rices and the 9#namics of (od# ;eight\ Economic Aspects of :besit#2 Ed2 6ichael %rossman Jaci 6ocan2 Chicago: .ni$ersit# of Chicago "ress /0,,2 >D4H02 A$ailable at: http:EEwor8s2bepress2comEdana]goldmanEKL 9owler E2 @/00LB2 Food and health ine?ualities: the challenge for sustaining Must consumption2 Local Environment 2-@LB KDH4KK/2 doi:,02,0L0E,1D-HL10L0/-KLK1> Franc8 C2 %randi S2 62 F Eisenberg 62 &2 @/0,1B2 Ta3ing &un8 Food to Counter :besit#2 %merican /ournal 3f 4ublic 5ealth 26-@,,B ,H-H4,HD12

doi:,02/,0DEA&"H2/0,1210,/KH %riep 72 Verschuren ;2 Kromhout 92 :c8' 62 F %eleiMnse &2 @/0,,B2 !aw and processed fruit and $egetable consumption and ,04#ear stro8e incidence in a population4based cohort stud# in the Jetherlands2 European /ournal 3f (linical 0utrition !7@KB KH,4KHH2 doi:,02,01LEeMcn2/0,,21>2 He Feng &2 Jowson C2 A2 6ac%regor %2 A2 @/00>B2 Fruit and $egetable consumption and stro8e: meta4anal#sis of cohort studies 8he Lancet) 9olume -!:) 1 ue .76:) "8 /anuary;February "66! "ages 1/041/> ISSJ 0,-04>K1> http:EEd32doi2orgE,02,0,>ES0,-04

>K1>@0>B>L0>H402 &ac?uier C2 (onthou3 F2 (aciu 62 F !uffieu3 (2 @/0,/B2 Impro$ing the

/-

Santiago Calder*n &os' (a#o)n effecti$eness of nutritional information policies: assessment of unconscious pleasure mechanisms in$ol$ed in food4choice decisions2 doi:,02,,,,EM2,KD14-LLK2/0,,200--K23 &etter K2 62 F Cassad# 92 72 @/00>B2 The A$ailabilit# and Cost of Healthier Food Alternati$es2 %merican /ournal 3f 4reventive $edicine -6@,B 1L4--2 doi:,02,0,>EM2amepre2/00D20H20,> Klein 6atthew &2 @/0,1B2 9iet and Health Capital: An American Case Stud# .ndergraduate Economic !e$iew: Vol2 ,0: Iss2 , Article 12 7ee H2 @/0,/B2 The role of local food a$ailabilit# in e3plaining obesit# ris8 among #oung school4aged children2 #ocial #cience & $edicine :<@LB ,,H14,/012 doi:,02,0,>EM2socscimed2/0,,2,/201> 6atti &osh and Kim Hansol @/0,1B2 Factors E3plaining :besit# in the 6idwest: E$idence from 9ata .ndergraduate Economic !e$iew: Vol2 ,0: Iss2 , Article ,2 A$ailable at: http:EEdigitalcommons2iwu2eduEuerE$ol,0Eiss,E, "owell 72 62 F Chaloup8a F2 &2 @/00HB2 Food "rices and :besit#: E$idence and "olic# Implications for Ta3es and Subsidies2 doi:,02,,,,EM2,->L4000H2/00H200DD-23 Sharma S2 "a8serescht 62 Cruic8shan8 K2 %reen 92 62 F Kolonel 72 J2 @/0,1B2 Adherence to the .S9A dietar# recommendations for fruit and $egetable inta8e and ris8 of fatal stro8e among ethnic groups: a prospecti$e cohort stud#2 >$( 0eurolo&y 2-@,B ,4L2 doi:,02,,L>E,-K,4/1KK4,14,/0 $ilbank =uarterly 8:@,B //H4/DK2 0utrition Review :6@/B ,,L4,1,2

/D

Santiago Calder*n &os' (a#o)n Von Tigerstrom (2 @/0,/B2 Ta3ing Sugar4Sweetened (e$erages For "ublic Health: 7egal And "olic# Issues in Canada2 %lberta Law Review 76@,B 1K4>-2 ;hite 62 @/00KB2 Food access and obesit#2 3be ity Review 8HH4,0K2

doi:,02,,,,EM2,->K4KLH^2/00K2001/K23 ;rigle# J2 @/00/B2 XFood 9esertsN in (ritish Cities: "olic# Conte3t and !esearch "riorities2 *rban #tudie +Routled&e, -.@,,B /0/H4/0-02 doi:,02,0L0E00-/0HL0//0000,,1-Zang [2 F Hall A2 %2 @/00LB2 The Financial (urden of :$erweight and :besit# among Elderl# Americans: The 9#namics of ;eight 7onge$it# and Health Care Cost2 5ealth #ervice Re earch <-@1B L-H4L>L2 doi:,02,,,,EM2,-KD4>KK12/00K200L0,23 A$ailable at: http:EEdigitalcommons2iwu2eduEuerE$ol,0Eiss,E1

L2 Anne3
Figure ,
Jame of Variable 9efinition Co$erage Source Jew cases of cancer per capita per #ear o$er fi$e #ear for all t#pes of Cancer]!ate Count# _ /00D4/0,0 State Cancer !egistr# cancers e3cept bladder "ercentage of adults reporting an a$erage fruit and $egetable consumption of Few]Fruit]Veg Count# _ /0,0 (!FSS less than D ser$ings per da# 9iabetes "ercentage of adults diagnosed with diabetes Count# _ /0,0 (!FSS Age "ercentage of residents o$er the age of >D #ears Count# _ /00H .2S2 Census (ureau Inc Household 6edian Income Count# _ /00H SAI"E Smo8e "ercentage of adults that smo8e tobacco Count# _ /00/4/00L (!FSS "h#s]Inact 9rin8 :bese 6.9 ]cons "ercent of adults that report no leisure time ph#sical acti$it# in past 10 da#s "ercent of adults who report hea$# drin8ing "ercentage of adults with (6I of o$er 10 A$erage number of poor mental health da#s in past 10 da#s Intercept Count# _ /00>4/00L Count# _ /00/4/00L Count# _ /00>4/00L Count# _ /00H JEA (!FSS (!FSS (!FSS (!FSS JEA

/>

Santiago Calder*n &os' (a#o)n Figure /


Variable Cancer_Rate 'e(_'ruit_Ve) Diabetes *)e +nc Smo,e -.ys_+nact Drin, Obese M/D Obs 268 #%$! &#!# &#!# &#!$ 2"&6 &#!# 262& &#!# 2%" Summary of Variables Mean Std. Dev. !"#.$2%& "%.!2%$& 8.%2&#6 ".#6$%2& #$.&8!"% 2.# 6%%! #"."!!&2 !.28"!#" !&86"."" ###$2.%2 2$."2!!" 6.$%&& 2 2 .%$!8# ".#" %68 #!.! 66 "."%!2# &$.&& 82 !.#6$"&! &.!86 #.$!2#8! Min #2&.# 6&.# & 2.% 2$%%$ $ #$ $ #&. $. Max ##6!.2 %6.! 2$ &6.2 ##%"2" !8 !! &6.8 ! .6 %.6

Figure 1

Covariance of variables Cancer0e 'e(_'r0) Diabetes *)e +nc Smo,e -.ys_+0t Drin, Obese M/D Cancer_Rate # 'e(_'ruit_0) 1$.$2%2 # Diabetes $.#6% $.&2 % # *)e 1$.$$ # $.$$8% $.2$# # +nc $.$2 ! 1$.&686 1$."% " 1$.&$"" # Smo,e $.#%2& $.&# 2 $."6!2 $.$6 1$."2&% # -.ys_+nact $.#! 2 $.!6"6 $. !82 $.2&"8 1$."%!# $.6$&% # Drin, 1$.$626 1$.#8# 1$.!82 $.$2!6 $.&% & 1$.2&2 1$.!#$ # Obese $.#$%6 $.!6#8 $. &6& $.$$"6 1$."28" $."2$2 $. "$ 1$.2 %# # M/D $.#"$# $.# 66 $."$#! 1$.$## 1$.!26& $."!6% $.!2 # 1$.!!& $.&2!" #
Figure 2$$ !$$ 6$$ 8$$ #$$$#2$$ 6$

8$ 'e(_'ruit_Ve)

%$ 'itted values

#$$

Cancer_Rate

/K

Santiago Calder*n &os' (a#o)n Figure D


Summary of variables for observations (it. Cancer Rate +ncidence data available Variable Obs Mean Std. Dev. Min Max 'e(_'2V # $6 8.%6"!2 ".2#&2"6 6&.# %6.! Diabetes 268 #$.!##2! 2.2"2"&% & 2$ *)e 268 #".!&" 6 !.2&"&#6 2.% &6.2 +nc 268 !&262.#! #$ 8 ." 2$%%$ ##$2$! Smo,e 2#86 2$.8#%& 6.$6 !#8 $ !8 -.ys_+nact 268 28.#%$%2 ".2!2&!2 #$ !! Drin, 228& #!.! $# ". 2$% 6 $ &6.8 Obese 268 &$.&&#"6 !.&&$&%! #&. ! .6 M/D 2"&6 &."&$28! #.$2888 $. %.6

Figure >
Summary of variables for observations (it. Cancer Rate +ncidence data not available Variable Obs Mean Std. Dev. Min Max 'e(_'2V #%8 8.""%$% !.682#8& 6!.% %&. Diabetes !"! #$.2268 #.6"!2&" 6 #" *)e !"! #6.#86 8 !."22!8& 6.# &#." +nc !"& ! !!!. 2 #222%. 6 28"$2 ##%"2" Smo,e &"$ #8.68286 ".%&8"$% $ &" -.ys_+nact !"! 26.2##!" !.2"!"#& #" &% Drin, &!$ #!."2 %! !.66#!&6 $ 28.8 Obese !"! &$.& !8% 2.%6"62# #%.& &%. M/D !2# &.22! $& #.$8&868 $. .&

/L

Santiago Calder*n &os' (a#o)n Figure K


3inear re)ression 4umber of obs ' 5%6 #62&7 -rob 8 ' R1s9uared Root MS: Cancer_Rate 'e(_'ruit_Ve) Diabetes *)e +nc Smo,e -.ys_+nact Drin, Obese M/D _cons Coef. 1$.%!#%$$6 &."&8%8" $.#22 "! $.$$#2$$2 #. 28!2# $.%"6!666 1$.$26$ !! 1$.#628#8 &."6$2 & &6%.%#6 Robust Std. :rr. $.&$ 62$ #.$"!8& $.&% %8!& $.$$$#"6 $.&" $86 $.!!$$!#6 $.&6!&#!# $."2&"8$2 #.%"&8#! 2%.$&"#2 t 1&.$6 &.&6 $.&# .66 !.8! 2.# 1$.$ 1$.&# #.82 #2. ! -8t $.$$2 $.$$# $. "8 $.$$$ $.$$$ $.$&$ $.%!& $. "6 $.$6% $.$$$ #6&& #%.$6 $.$$$$ $.%!& !%.#8! ;%"< Conf. +nterval= 1#."!"& #.! $$ 1$.6" 8 $.$$$% #.$28$ $.$%&! 1$. !$6 1#.#8%8 1$.2 2$ &#2.%66" 1$.&&8" ".6$8$ $.%$&! $.$$#" 2.!288 #.8#%6 $.688" $.86!# .&%2" !26.86 $

Figure L

Variable 'e(_'ruit_Ve)

>y?ot.esis @

Si)n and si)nificance 11

BCse

1$.%!2AA 5$.&#$7 Diabetes @ @@@ &."&%AAA 5#.$"$7 *)e @ $.#2& 5$.!$$7 +nc @ @@@ $.$$#AAA 5$.$$$7 Smo,e @ @@@ #. 28AAA 5$.&6$7 -.ys_+nact @ @ $.%"6A 5$.!!$7 Drin, @ 1$.$26 5$.&6$7 Obese @ 1$.#6& 5$."2$7 M/D @ &."6 5#.%"$7 Constant &6%.%# AAA 52%.$!$7 @ ?D$.$"6 @@ ?D$.$#6 @@@ ?D$.$$# and similary for 1

/H

Santiago Calder*n &os' (a#o)n Figure H


State District of Columbia Vermont Connecticut Maine 4e( >am?s.ire California Maryland Vir)inia 4e( Gor, 4e( Hersey Ore)on Massac.usetts R.ode +sland Montana Fas.in)ton Dela(are Colorado 'lorida +da.o Jeor)ia *riKona -ennsylvania Eexas 4evada >a(aii *las,a -ercent &#." 2%.& 28.& 28 2 .% 2 . 2 .6 2 .& 26.8 26.! 26.& 26.2 26.# 2". 2".# 2" 2!.8 2!.6 2!.6 2!." 2!.# 2!.# 2&.8 2&. 2&." 2&.! State Eennessee /ta. Fyomin) 4e( Mexico Fisconsin Mic.i)an +llinois 4ort. Da,ota Minnesota Ientuc,y O.io 4ebras,a +ndiana 4ort. Carolina *r,ansas *labama Missouri Iansas +o(a Sout. Carolina 3ouisiana Mississi??i Fest Vir)inia Sout. Da,ota O,la.oma -ercent 2&.& 2&.& 2&.& 2&.2 22. 22.6 22." 22." 2#.% 2#.# 2# 2$.% 2$.6 2$.6 2$.! 2$.& #%.% #8.6 #8." # .! #6.% #6.8 #6.2 #". #!.6

Jational Cancer State "rofile @C9CB generated est2 percentage of population that consumes D or more rations of fruitE$egetables b# state table `#ear /00Ha

10