The 5-a-Day for Better Health Program: a Critique of its Approach and Assumptions about Health Behavior – Alyson Cooper

History and Effectiveness of the 5-a-Day for Better Health Program

The 5-a-Day for Better Health Program was introduced in 1991 with a partnership between the National Cancer Institute and the vegetable and fruits industry (1). This national public health program was intended to encourage the consumption of five or more servings of fruits and vegetables each day in order to reduce the incidence of cancer (1). The 5-a-Day Program was largely based on the Health Belief Model (2). The program communicated a perceived health threat – poor health – with a beneficial, preventative behavior – eating five or more servings of fruits or vegetables per day (3). Success of the program relied on the notion that the intention to consume more fruits and vegetables to achieve better health would result in changed eating behaviors (3).

With a communications budget exceeding one million dollars per year, the simple and positive message of 5-a-Day was conveyed to Americans through supermarkets, schools, worksites, the media, and food assistance programs (1). Additional funding was allocated for research, evaluation, and supplemental programs, resulting in a 5-a-Day budget that exceeded twenty-seven million dollars from 1992-1997 (1).

The national effort, innovative partnership, and extensive funding continued to characterize the 5-a-Day program for over a decade. Over this ten-year period, average fruit and vegetable consumption increased from 3.8 to 3.9 servings per day and Americans that consumed five or more servings of fruits and vegetables per day increased from 19 to 22.7 percent (2). The program increased compliance with the consumption target by 3.7%. The minimal improvements in fruit and vegetable consumption are not necessarily attributable to the 5-a-Day Program. Awareness of the 5-a-Day Program may have led to social approval bias in self-report of consumption (4). Since more people began to recognize fruit and vegetable consumption as important and healthy, overstatement of consumption on dietary questionnaires became more likely. Researchers estimate that knowledge of the program accounts for 9.78% of the intervention effect (5).

Despite the time, money, and effort put into the campaign, the 5-a-Day for Better Health Program was not successful. Its lack of effectiveness can be attributed to numerous factors, including the use of an oversimplified message, treating heterogeneous populations as homogenous, overlooking environmental barriers to engaging in the desired behavior, and the theoretical assumptions about human behavior on which the intervention was based.

The Broad Message and Universal Approach of the 5-a-Day Progam.

The 5-A-Day for Better Health message was too simple to encourage the most beneficial dietary changes. Coupling fruits and vegetables in one serving size, suggests that consumption that lacks in variety still meets the recommendation. An adequate mix of fruits and vegetables and a variety in the types of fruits and vegetables must be consumed to maximize the nutritional benefits that improve health. However, there is a tendency for Americans to consume more fruits than vegetables (6), and, of the vegetables that are consumed, fifty percent are iceberg lettuce, frozen potatoes, fresh potatoes, potato chips and canned tomatoes (7). Since the program ignores these dietary preferences, it fails promote the proper intake of fruits and vegetables.

The new focus of the 5-a-Day Program suggests that the original message was too broad; the revised message, 5-a-Day the Color Way, encourages consumption of one fruit or vegetable from each of 5 color groups: blue/purple, green, white, yellow/orange and red (7). This message is still simple, but adds a necessary component to encourage the consideration of variety and ensure that a greater range of nutrients is consumed. The 5-a-Day for Better Heath message lacks the specificity to achieve the program’s goal of improving the health of the American population.

The 5-a-Day Program targets the entire nation with one message. This simplicity ignores variation in ethnicity, gender, age, and baseline eating habits that influence consumption of fruits and vegetables. Women were more likely than men to fall short of the 5-a-Day recommendation (7). Children, minorities, and low-income populations were also less likely to consume 5 servings of fruits and vegetables daily (7). These demographic groups hold unique views on diet and practice different eating habits, so in turn the program does not influence them in the same manner. Those that already ate fruits and vegetables were more responsive to the program’s message than those that did not (8). Fruit and vegetable eaters had already overcome the basic barriers to incorporating fresh produce into their diets and engaged in the food planning necessary to increase their consumption to the recommended serving size (8).

Despite the cultural and habitual difference in eating patterns, the 5-a-Day Program viewed the entire population similarly and expected everyone to share a positive response to the solitary campaign. The National Cancer Institute’s evaluation of the 5-a-Day Program claims that minority and low-income populations were not successfully targeted and thus did not experience improvements in fruit and vegetable consumption (2). This admission proves that program was too broad to target specialty populations and populations in need. The effectiveness of the 5-a-day program is compromised by the lack of acknowledgement and adaptation to a heterogeneous society.

The Focus on Improving Behavior, Rather than Improving Access, in the 5-a-Day Program.

In addition to the differences in the way in which certain populations respond to the 5-a-Day program, certain populations differ in their ability to incorporate its message into their daily lives. The 5-a-Day Program overlooked the greater difficulty urban populations experience in accessing fruits and vegetables. They are less likely to have a safe and easy route to obtain such foods. Common barriers include: the time cost and reliability of public transportation, traffic signals that do not allow enough time to cross, no marked cross walks, no stop signs or traffic lights at intersections, broken or missing sidewalks, and insufficient or no street lighting (9). Not only do urban populations encounter these barriers to purchase fruits and vegetables, but also there are fewer supermarkets in which to shop for them, because land is less available and more expensive (10). Since it takes more time to travel to supermarkets, purchasing fruits and vegetables is much more inconvenient and infrequent for urban populations than suburban populations.

Food stores that are available to urban populations charge higher prices for fresh produce to compensate for the higher land costs they must absorb (10). Therefore, urban populations, especially those that are low-income, are less likely to be able to afford fruits and vegetables necessary to meet the 5-a-Day recommendations. Produce price significantly influences the likelihood of its purchase; a 50% price decrease in fruits and vegetables is associated with a four-fold increase in fruit sales and a two-fold increase in vegetable sales (11). Similarly coupons for fruits and vegetables were more successful in altering their consumption than education about their health benefits (12). The higher price of fruits and vegetables makes them less desirable in comparison to other foods and less affordable to poorer consumers.

The 5-a-Day Program did not address the environmental barriers that urban populations face. They must commute farther, travel in less safe conditions, and pay more to access fresh produce than their suburban counterparts. Due to these characteristics that urban populations must overcome, they are not likely to attempt to achieve the 5-a-day program’s recommendation. Since the program did not acknowledge or offer solutions to these obstacles, the program inadvertently restricted the population that could respond to its message, improve eating habits, and benefit health.

The Use of the Health Belief Model to Structure the 5-a-Day Program.

Even in populations that could access fruits and vegetables, the 5-a-Day campaign did not ensure changed eating behavior. The program, as previously stated, was based on the Health Belief Model, which assumes that the intention to eat 5 servings of fruits and vegetables will result in the behavior of increased fruit and vegetable consumption. The message ‘5-a-Day for Better Health’ is flawed in creating the desired intentions. Immediate benefits, such as increased energy, are more likely to alter intentions and encourage adoption of the behavior than future benefits, such as reduced disease occurrence (8). Better health can be considered a future benefit, which is less likely to promote adoption of the 5-a-Day consumption goal. The chosen slogan was not attractive to the average population, indicating why many did not adopt its message.

Furthermore, research has showed that intention does not produce behavioral changes. A meta analysis of 47 studies on intention and behavior found that a medium-to-large change in intention results in a small-to-medium change in behavior (13). According to these results, if the 5-a-Day Program were very compelling, it would only increase fruit and vegetable consumption slightly. Due to the simplicity of the message and the lack of accompanying reasons to eat more fruits and vegetables, it is likely that the program did not produce the strong intentions needed to create even the slightest change. The Health Belief Model is not strongly representative of behavior change. The model structured the program in a way that contributed to its failure, indicating it was not an appropriate basis for the 5-a-Day Program.

Program designers ignored important elements from other behavioral theories that could have improved the program’s success. Self-efficacy was found to be the strongest predictor of fruit and vegetable consumption (14). An individual’s perception of his or her ability to carry out the 5-a-Day recommendations is very important. Knowledge of a means to implement a behavior increase feelings of self-efficacy and in turn increase the rate of acting on intentions (15). For example, when the 5-a-Day campaign was specialized to target low-income communities, consumption of fruits and vegetables did not change, but, when the program was accompanied by a cooking class which showed participants how to cook with more fruits and vegetables, the community increased consumption significantly (16). Other studies have shown that self-efficacy for dietary change improves when tips are offered to make eating fruits and vegetables quick and easy (8) and increasing the availability of fruits and vegetables in educational and occupational environments (17). Since the 5-a-Day Program did not address how to access or consume more fruits and vegetables, the intentions it produced would not successfully influence behavior change.

Conclusions

The 5-a-Day Program’s partnerships, longevity, and purpose were noteworthy. Although it improved knowledge about the serving size of fruits and vegetables necessary to improve health, it did not improve eating habits (18). The program’s approach lacked insight into the diversity of American culture, the complexity of built environments, and the application of theoretical models. The 5-a-Day Program should have delivered a more specific message for fruit and vegetable consumption, have been tailored to specific cultures and behavior traits, initiated changes in environments that did not support access to fruits and vegetables, taken advantages of alternative behavior change models, and provided knowledge and support to increase self efficacy. Future dietary interventions should consider the lessons of the 5-a-Day for Better Health Program to increase their likelihood of successful behavior change.

Targeted Improvements to the 5-a-Day for Better Health Program

– Alyson Cooper

Fruits and vegetables are an important dietary component that contain vital nutrients and offer significant health benefits. Unfortunately, most Americans do not consume enough fresh produce to acquire these benefits. Public health interventions, such as the 5-a-Day for Better Health program, have attempted to improve fruit and vegetable consumption. Despite inducing a four-fold increase the number of Americans that are aware of the recommended serving for fruits and vegetables, only 12% of the population actually consumes five fruits and vegetables daily after a decade of the 5-a-Day program (19). Drawing on the sources of the program’s failures can improve success of future public health campaigns that wish to encourage dietary change. Interventions should be multifaceted, such that programs address both individual and environmental factors. In doing so, the 5-a-Day program should expand upon its message, target this message to specific populations, and improve upon self-efficacy for dietary change in these populations.

Using a Specific Message and a Targeted Approach.

In order to promote the proper dietary changes the Targeted 5-a-Day program must not only specify how many fruits and vegetables to eat, but also which ones and in what proportions. The new program will utilize the 5-a-Day the Color Way slogan to increase the variety of fruits and vegetables consumed (7). Eating one fruit or vegetable from each of the five color groups is an easy way to encourage consumption of a wide range of vitamins, minerals, and phytochemicals in different colored fruits and vegetables (7). The new slogan will also have a component that endorses a balance between fruit and vegetable consumption to counteract the tendency to consume more fruits (6). The new program targets the combination and proportion of fruits and vegetables, in addition to serving size, in order to produce the health benefits desired from the campaign.

To facilitate dietary changes in the Targeted 5-a-Day program will address cultural and habitual differences in fruit and vegetable consumption. In doing so, the program will focus on women, children, minorities, low income, and urban populations who are less likely to meet the 5-a-Day serving requirement (8). The new program will tailor its approach to respond to the specific barriers and mentalities of each of these groups by adding components that appeal to younger children and adult women and having diversity present in the campaign. Treating the population as a heterogeneous body will make the Targeted 5-a-Day program more effective in reaching those that need dietary change.

Improving Access in Addition to Behavior.

One way to target populations in need is to improve their access to fruits and vegetables. The expense of fruits and vegetables limits access for low-income populations. Their access barrier will be targeted through coupons that discount the price of fruits and vegetables (12). The inconvenience (9) that urban populations face traveling to stores that stock fresh produce will be counteracted establishing farmers markets in inner-city neighborhoods. Prices of fruits and vegetables at the farmers markets will be subsidized if the cost is too high for consumers to absorb. Children’s access to fruits and vegetables is limited to those that their school and parents provide. Parents will be encouraged, through school newsletters, to have more fruits and vegetables available in the home (21). Schools will be encouraged to offer a greater variety of fruits and vegetables in cafeterias, and a snack program that distributes fruits and vegetables will be established in all elementary schools. The new 5-a-Day program targets the barriers to access that certain populations encounter to make obtaining fruits and vegetables possible.

Using Social Cognitive Theory

The new program will target obstacles for dietary change to ensure that individuals feel that they are able to consume five fruits and vegetables each day, not just that they should consume the recommended amount. The improvements in access to fruits and vegetables previously described increase self-efficacy (20) for obtaining fruits and vegetables. The program must also improve self-efficacy for incorporating fruits and vegetables into a daily diet. To begin consuming fruits and vegetables on a daily basis, individuals must engage in food planning (8). Consideration must be given to incorporating fruits and vegetables when planning meals, shopping for food, ordering food, and selecting recipes.

To assist with selecting recipes, the updated program will distribute 5-a-Day cookbooks to populations most in need in order to highlight ways to include fruits and vegetables in meals (21). The cookbook will also be accessible electronically, in food stores, and at farmers markets, in addition to being sent out in the program’s school newsletters. The schools will also be utilized for their cafeterias, in which cooking classes will be offered (16). These classes will be available to parents as well as community members to prove an interactive demonstration on how to prepare 5-a-Day recipes.

There is a trend to consume fruits and vegetables seasonally due to the fact that the availability, quality, and price of fresh produce vary by season (21). Therefore, is important that 5-a-Day recipes utilize both fresh and frozen vegetables. There is an ever-reducing emphasis on consuming full meals (7). As a result of fewer large dinners being prepared, vegetable-based side dishes have become less available. For that reason, it is also important that 5-a-Day recipes highlight the importance of having a variety of side dishes. This is especially necessary considering the fact that Americans favor fruit over vegetable consumption (6). It is also essential that recipes can be quickly prepared with a reasonable number of ingredients, since the majority of Americans have come to rely on convenience for their meals (7).

The disbursement of recipes offers ways for the target audience to add fruits and vegetables to meals they already prepare and discover new meals that make use of fresh produce at home. Offering a chance for individuals to engage in fruit and vegetable cooking in the classes may increase the likelihood that they will begin and continue such cooking habits on their own. By giving individuals new ideas on how to cook with fruits and vegetables, recipes and cooking classes increase the likelihood that these individuals feel able to incorporate fruits and vegetables into their diet.

There is an ever-increasing reliance in eating on-the-go. Almost three-quarters of Americans have indicated that they would be most likely to increase their consumption of fruits and vegetables in the form of snacks (19). The new 5-a-Day program will target today’s busy society by circulating fruit and vegetable snack tips in grocery stores, farmers markets, school newsletters, and on-line. The convenience of consuming fruit and vegetables as a snack will positively affect their incorporation into daily diets (7). Time constraints have led to greater reliance on eating out; one in six meals are obtained from restaurants (7). The new 5-a-Day program will target the source of one-sixth of American’s meals by encouraging restaurants to offer fruit and vegetable side items and individuals to take advantage of these side items. For example, individuals can choose to consume McDonalds’ apple slices instead of french fries, or ask for steamed vegetables instead of rice at a restaurant. Making consumers aware of alternative side items will increase their self-efficacy to obtain fruits and vegetables in meals consumed outside the home.

The target populations will be encouraged to plan their meals in advance and keep track of the fruits and vegetables they consume so that they will eat five servings a day. This tracking process will be made easier by the dietary ideas, which increase awareness of the amount of fruits and vegetables in snacks and meals. This awareness will also assist in knowing the type and quantity of fruits and vegetables to purchase when grocery shopping. The targeted 5-a-day approach increases the likelihood that individuals in need will be able to find and afford fresh produce, be aware of which fruits and vegetables to buy, and know how to prepare and consume them.

Conclusions

The Targeted 5-a-Day program continues to perpetuate the basic message of the 5-a-Day program: to consume at least five fruits and vegetables each day. Like the initial program, this 5-a-Day program hopes to increase consumption of fruits and vegetables to ultimately create a healthier society. The new program makes many targeted changes to improve the variety of, access to, and self-efficacy for consuming fruits and vegetables. By targeting the combination of fruits and vegetables to eat, the populations that need to eat more fruits and vegetables, and the individual and environmental barriers these populations face when attempting to consume fruits and vegetables, the Targeted 5-a-Day program counteracts the problems with the original and overly broad program. Hopefully the targeted approach will result in changed eating behaviors and produce the desired health benefits of a diet rich and fruits and vegetables.

REFERENCES

1. National Cancer Institute. 5 a Day for better health. Washington, DC: National Institutes of Heath: National Cancer Institute, 2001.

2. National Cancer Institute. 5 A Day for Better Health Program Evaluation Report. Washington, DC: National Institutes of Heath: National Cancer Institute, 2001. <http://www.cancercontrol.cancer.gov/5ad_exec.html>

3. Becker MH. The health belief model and personal health behavior. Health Education Monographs 1974; 2.

4. Miller TM, Abdel-Maksoud MF, Crane LA, Marcus AC, Byers TE. Effects of social approval bias on self-reported fruit and vegetable consumption: a randomized controlled trial. Journal of Nutrition 2008; 27:7-18.

5. Reynolds KD, Bishop DB, Chou CP, Xie B, Nebeling L, Perry CL. Contrasting mediating variables in two 5-a-day nutrition intervention programs. Journal of Preventive Medicine 2004; 39:882-893.

6. Trudeau E, Kristal AR, Li S, Patterson RE. Demographic and psychosocial predictors of fruit and vegetable intakes differ: implications for dietary interventions. Journal of the American Dietetic Association 1998; 98:1412-1417.

7. PR Newswire. American Families Eat Too Few Fruits and Vegetables; New '5 A Day The Color Way' National Campaign Uses Color to Encourage Healthier Eating. New York, NY: PR Newswire Association, 2002.

8. Balch GI, Loughrey K, Weinberg L, Lurie D, & Eisner E. Probing consumer benefits and barriers for the national 5 A Day Campaign: focus group findings. The Journal of Nutrition Education 1997; 29:178-183.

9. PR Newswire. California Latino 5 a Day Campaign Hosts Health Summit to Address Solutions to Latino Health Epidemic. New York, NY: PR Newswire Association, 2005.

10. Gentile A. Agencies move to close 'grocery gaps'. American City & County 2008; 123.3:341-344.

11. French SA. Pricing effects on food choices. The Journal of Nutrition 2003; 133.3:841-843.

12. Anderson JV, Bybee DI, Brown RM, McLean DF, Garcia EM, Breer ML, Schillo BA. 5 a day fruit and vegetable intervention improves consumption in a low income population. Journal of the American Dietetic Association 2001; 101:195-202.

13. Webb TL, Sheeran P. Does changing behavioral intentions engender behavior change? A Meta-Analysis of the Experimental Evidence. Psychological Bulletin 2006; 132:249-269.

14. Havas S, Treiman K, Langenberg P, Ballesteros M, Anliker J, Damron D, Feldman R. Factors associated with fruit and vegetable consumption among women participating in WIC. Journal of the American Dietetic Association 1998; 98:1141-1147.

15. Orbell S, Hodgkins S, Sheeran P. Implementation intentions and the theory of planned behavior. Personality & Social Psychology Bulletin 1997; 23: 945-954.

16. Weaver M, Poehlitz M, Hutchison S. 5 A Day for low income families: evaluation of an advertising campaign and cooking events. Journal of Nutrition Education 1999; 31:161-165.

17. Monge-Rojas R, Garita C, Sanchez M, & Munoz L. Barriers to and motivators for healthful eating as perceived by rural and urban Costa Rican adolescents. Journal of Nutrition Education and Behavior 2005; 37:33-40.

18. Ashfield-Watt PA. Fruits and vegetables, 5+ a day: are we getting the message across? Asia Pacific Journal of Clinical Nutrition 2006;15:245-252.

19. Tufts University Health and Nutrition Letter. Fruits and vegetables: five a day goal still needs work. Tufts University 2004; 11:2-3.

20. Bandura, A. Social Learning Theory. Prentice Hall: 1977; 247.

21. Thackeray R, Neiger BL, Leonard H, Ware J, Stoddard GJ. Comparison of a 5-a-day social marketing intervention and school-based curriculum. American Journal of Health Studies 2002; 18: 46-54.