Friday, December 10, 2010

5 A Day Campaign, How It Has Failed Much of the US Population – Erin Morehouse


Consumption of a high volume and a variety of fruits and vegetables each day has been shown to reduce the risk of cancer, cardiovascular disease, and other chronic diseases (1). Research of the association between fruit and vegetable consumption and cancer has been shown that increasing intake from 1-2 servings per day to 5 or more servings per day reduces the risk of cancer by half (1). Research done on cardiovascular disease risk and fruit and vegetable consumption it was found that dietary fruit and vegetables were significantly and inversely associated with cardiovascular disease risk factors (i.e. Low concentrations of total and low-density lipoproteins) (2). Other research has shown a 20-40% reduction in the prevalence of coronary heart disease associated with fruit and vegetable consumption (1).

Most people in the US do not meet the federal dietary recommendations for all nutrient rich food groups except for total grains, meat and beans (3). According to this study 79.6% and 88.7% of people’s usual intake of fruits and vegetables respectively are below the minimum recommended amounts (3). In a Morbidity and Mortality Weekly Report (MMWR) it was reported that only 32.5% of adults consumed 2 or more servings of fruits and 26.3% consumed 3 or more servings of vegetables per day in 2009 (4). The evidence makes it clear that strong campaigns encouraging fruit and vegetable consumption are needed in this country.

The national 5 A Day campaign began in the US in 1991 through a partnership between the private fruit and vegetable industries, and the US government (The National Cancer Institute: NCI). The program was modeled after a successful 5 A Day campaign from the California Department of Health Services, and aimed to increase average fruit and vegetable consumption to 5 servings per day or more. The 5 a day recommendation represents a minimum rather than a maximum target for consumption. The specific objectives of the campaign are to increase awareness of the importance of eating 5 or more fruits and vegetables per day and to provide information about how to reach that goal. The media rollout of the national program began in 1991 and the individual states began their intervention programs in 1994 (1). At baseline (a 1991 survey) the median intake of fruits and vegetables was 3.4 servings per day (5), and only 8% of people thought that they should be eating 5 or more servings of fruits and vegetables daily (1). As of 2009 the population of adults who met the recommended amount of fruit per day had declined slightly, but significantly from the year 2000 data, and vegetable consumption had not changed (4).

There are many reasons for the failure of the 5 A Day program to show appreciable results over the past 19 years. The first reason is people’s lack of confidence (self-efficacy) that they can eat 5 or more fruits and vegetables per day. Secondly, it can be a large and overwhelming jump for people starting from 1 serving of fruits or vegetables per day to 5 or more, and finally eating 5 or more fruits and vegetables per day for future health is a low priority for people who have other, more immediate concerns.

Critique #1, Self-Efficacy

Perceived self-efficacy is a person’s judgment about how well they can perform the course of action required to deal with prospective situations, it is a part of self-efficacy theory (6) and the theory of planned behavior (7). Level of self-efficacy also determines the amount of effort people will put into an action and how long they will persist through obstacles and adverse experiences (6). By focusing on media campaigns to spread the 5 A Day message the program assumed that the level of self-efficacy in the general population was adequate, and did not work to increase self-efficacy overall.

Due to low self-efficacy people may not believe that the action of eating 5 or more fruits and vegetables per day is possible for themselves, or they may not continue to try to achieve this goal after encountering obstacles. Therefore even after seeing the media campaign of the 5 A Day program this would likely not change the food they purchase or the food they prepare for themselves and their families. It has been shown that the most consistent variables predicting food behavior are habit, motivation and goals, beliefs about capabilities, knowledge and taste (8).

Providing straight facts and statistics to increase people’s knowledge about eating more servings per day of fruits and vegetables also does not increase self-efficacy. The 5 A Day campaign relies on this tactic for their media centered campaign. This is the basis of the Health Belief Model, where benefits of the action and barriers to achievement of the action are balanced with facts. Each person weighs the benefits and challenges, and then acts accordingly (9). Using this theory, if you give people the facts about how good it is for your future health to eat 5 or more servings of fruits and vegetables each day, they will see that it is true, and then do that action.

Being given facts can increase people’s intention to perform an action, but these intentions do not always translate into actually performing the action. Research has shown that nutrition knowledge is related to consumption of foods to only a small degree, and that taste plays a larger role in food consumption choices (10, 11). The discrepancy between intention to eat 5 or more fruits and vegetables each day and acting accordingly can stem from unforeseen barriers or temptation (12). Once self-efficacy is increased it is more likely that intention will lead to behavior. Whereas habit, motivation, goals, beliefs about capabilities, knowledge and taste are variables predicting behavior; intentions are predicted on belief about capabilities, beliefs of consequences, and perceived social influences. Therefore showing that self-efficacy is important in both intention as well as behavior. (8)

Critique #2, Access and Framing

The 5 A Day campaign was built on the simple message of “Eat 5 A Day for Better Health”, and the number 5 was chosen because it “was not so high as to be seen as impossible to attain by consumers” (1). The NCI assumed that people had access to fruits and vegetables, that they were already familiar with some fruits and vegetables, and that portion sizes were well known. For many people, eating five fruits and vegetables a day is a large stretch from their regular diet.

Large supermarkets generally have the highest amount, most variety, and best quality of fruits and vegetables as compared to neighborhood markets and convenience stores (13). Supermarkets generally carry 32 varieties of fresh produce to a corner stores’ 6 different produce items (14). Access to supermarkets, and therefore variety and quality of fruits and vegetables, is not standard for all populations in the United States. Research has shown that low-income households in cities, and households in sparsely populated rural areas have less access to supermarkets, and the markets they use generally have higher prices than those in larger supermarkets (14). When in-store food availability was studied, every meter of added shelf space in the stores correlated with a higher vegetable intake (14). Out of the shelf space allocated to produce in these stores supermarkets used 70% for fresh produce, while corner stores used 32% (14).

Store choices are greater, and prices are lower in suburban areas, and low-income populations are less likely to live in suburban areas (15). Low neighborhood socioeconomic status (SES) is also associated with increased incidence of obesity over time (16). Evidence shows that distance to a supermarket is associated with fruit and vegetable intake, the closer the supermarket is, the more fruits and vegetables people consume (13, 14, 17). In metropolitan areas as the odds of obesity increased and the odds of consuming 5 or more fruits and vegetables per day decreased as the distance to a supermarket increased (13). Thus, the 5 A Day campaign’s assumption that people have equal access to fruits and vegetables lead to the exclusion of populations in most need of the campaign.

The campaign also assumed that portion sizes were well understood in the population, and that it was clear what a serving of a fruit or vegetable was. According to the USDA Food Pyramid one serving of vegetables is generally 2 cups of raw leafy vegetables, 1 cup of any other vegetable cooked or raw, or ¾ cup of vegetable juice. One serving of fruit is generally one banana, apple, or orange, ½ -1 cup chopped, canned, or cooked fruit, or 1 cup of fruit juice, overall a serving of a fruit or vegetable is 80 grams (17, 18). However, these amounts are variable depending on the preparation of the fruit or vegetable (18). Poor knowledge of portion size was cited as a problem even within populations of well-educated healthcare students who were asked about portion sizes of various fruits and vegetables in a survey. When asked what the portion size of apricots was, only 11% answered correctly, three apricots (19).

Although the NCI believed that eating habits were an easy change, the framing of this message made it seem like a burden, or unattainable goal for some populations. Using a different frame for this campaign could have produced a shift in the way that the campaign was viewed (20). Being told to eat 5 or more fruits and vegetables per day could also elicit psychological reactance because the campaign is telling people what to do, and therefore is perceived to be taking away peoples control or freedom over their food choices (21). The 5 A Day campaign’s assumption that increasing people’s consumption of fruits and vegetables to a combined total of 5 each day “was not so high as to be seen as impossible to attain by consumers” (1) was misguided.

Critique #3, Hierarchy of Needs

According to Maslow’s Hierarchy of Need people can’t think about higher order needs until their lower order needs are sufficiently met (22). The basic physiological needs of a person include breathing, water, food, and sleep. Although food is listed here, it is referring to a basic need of food to prevent hunger. Being particular about which foods are eaten, and more specifically 5 fruits and vegetables each day, is a higher order need. So, people who don’t have their basic needs met, such as those mentioned above, or even safety needs such as security of body, employment, resources, health, and family (22), are not likely to be able to consider eating more volume and variety of fruits and vegetables in order to be more healthy in the future.

Within Maslow’s hierarchy of needs, a hierarchy of food needs has been formed, called the Satter Eating Competence Model (23). At each level of this hierarchy needs dictate food management behavior, and needs at each level must be satisfied before they can move onto the next level. These levels include ‘Enough Food’ which are people who have food insecurities and are driven by hunger and anxiety about where their food will come from. Those at the ‘Acceptable Food’ level are free enough from food insecurity to think about the subjective idea of acceptable food. The next level is ‘Reliable, Ongoing Access to Food’, these people can plan for upcoming meals, accumulate food stored for the future, and can budget for future purchases. The higher levels include ‘Good-Tasting Foods’, ‘Novel Food’, and ‘Instrumental Food’, where food choices are influenced by aesthetics, taste, and choosing food to achieve particular health outcomes (23).

Competent eaters have positive attitudes about eating and food, are accepting of eating new foods, and a variety of foods, they have internal regulation to allow for eating enough food to maintain weight and provide energy, and have skills to plan for meals and management of their food choices (24). The 5 A Day campaign has primarily focused on competent eaters by asking people to eat more, and a variety of fruits and vegetables, but non-competent eaters do not have these skills, and therefore they were not able to internalize and act on this message. Low-income restrictions are inversely associated with eating competence (25), so again low-income groups were not served by this campaign.

Solution #1, Self-Efficacy

The 5 A Day campaign is based on a very important premise, of encouraging people to eat more fruits and vegetables each day to improve their overall health. They missed their mark by glossing over self-efficacy, inducing psychological reactance, making assumptions about general US populations access to fruits and vegetables, and alienating low-income populations. In order to make this program more successful they should keep the shape of their current campaign, but make certain changes in order to overcome these shortcomings, and to better serve the many different populations of the US.

To increase the effectiveness of the 5 A Day campaign the program should focus on increasing people’s self-efficacy. Self-efficacy can be increased in various ways, depending on the groups you are targeting. The 5 A Day campaign could reach out to people using many different methods to increase their awareness, as well as their self-efficacy. Through the campaign’s website (, they can target youth, teens, or even college students with web based learning. Groups have shown that self-efficacy can be increased when web-based interventions are used (26, 27). This research showed that web based interactive nutrition education, along with classroom curriculum increased student’s self-efficacy (26). The second study focused on college students, and showed that using web-based, interactive nutrition interventions could increase self-efficacy as well (27). Since the 5 A Day campaign already has a website they could add a page for teachers to access with relevant information on bringing this information into their classrooms. They could also have an interactive module or game for people to access, and learn from, on their own.

Ways to increase self-efficacy in other populations hinge on the idea of bringing the information to where people are. One intervention used beauty salons to teach patrons, mostly African American women, about increasing fruit and vegetable intake. Their intervention included training the staff to use scripted motivational information along with leaving information packets and starter kits for the patrons at the salon (28). Although this is not as easy for the 5 A Day campaign since it covers the entire US population, it is necessary to bring the campaign to people instead of waiting for people to come to the campaign. It would increase self-efficacy if the 5 A Day campaign trained mentors who could then go out to bring this information to the beauty salons, places of worship, schools, and other places where people gather.

Solution #2, Social-Marketing and Access

To attract people back to this campaign, guide them to the website, and examine what is offered through the program, a strong social-marketing campaign should be used. This social-marketing campaign can be used to re-frame the current message, which focuses on eating fruits and vegetables for the betterment of their future health. The 5 A Day campaign has already changed its title to: “Fruits and Veggies, More Matters”, which is a good start, but its marketing campaign should focus on a core-value outcome instead of future health outcomes.

These core values could be control, freedom, and rebellion (i.e. Control over what you eat instead of allowing others to determine what is going into your food and therefore yours and your body), or youth (eating fruits and vegetables can keep you younger longer). Since they want to reach many different audiences, who may have different reactions to these core values, a few commercials should be made with these varying focuses. The commercials should also focus on how eating fruits and vegetables can help you achieve these core-values now, instead of focusing on future outcomes. This type of campaign can also reduce psychological reactance if people similar to the consumer are the ones giving the message.

Increasing access to fruits and vegetables will have an impact on the reach of this campaign as well. Smaller programs have worked with managers of corner stores to increase their knowledge of healthy foods, to stock more of these foods, and to promote these foods to their customers. In two initiatives researchers worked with corner-store owners to increase the knowledge of which foods are healthier, and how to display, and promote these items so that sales are increased. Through these efforts customer has more healthy items to purchase even if a large supermarket is far away (29-31).

Presentation is also a key to selling more fruits and vegetables in any store. Selling more produce is advantageous not just for the consumer, but for the store as well, because they will have less waste. According to research done on how to market produce better in stores, more fruits and vegetables were purchased when the produce was the first section that consumers passed through in the store, when it was lit with soft lights directed at the item, and when the healthiest items were placed at eye level. In smaller stores moving produce to the front of the store also helps it to improve sales (32).

Wider reaching point-of-purchase interventions have included work-site cafeterias, university dining halls, grocery stores, as well as restaurants, and focused on food availability, access, pricing and information (33). The 5 A Day campaign should work with grocery stores and corner stores, as well as other point-of-purchase food sources such as cafeterias and restaurants to stock and promote their fruit and vegetable items.

Solution #3, Hierarchy of needs

In order to reach people who are at a lower order of need than others, the 5 A Day campaign should tie their health behavior into a lower order need. Lowest order needs include water, air, sleep, and food, and higher order needs include safety and security needs. The 5 A Day campaign should tie fruits and vegetables into these lower order needs, such as basic food needs through their campaign.

According to the Satter eating competence model the focus should be on food seeking, not food avoidance to empower people to be positive and capable with eating. As people gain confidence in food acceptance, then they will push themselves along to gradually increase variety in their diet (34). This is a slow process, so the 5 A Day campaign should start with giving people basic information on a variety of fruits and vegetables and inexpensive simple recipes to use them. It should be noted in these recipes, at another point on their website or in their printed information, that fruits and vegetables come in many forms including canned, frozen, or dried. It should clarify the size of a general serving of fruits or vegetables. This can be done through using comparison sizing to every day items such as golf or tennis balls (35).


Overall the 5 A Day campaign should increase the populations’ self-efficacy around fruit and vegetable consumption by integrating web-based interventions for various age groups, as well as providing curricula for teachers and mentors. It is necessary for the campaign to be brought to populations, without waiting for them to eventually find their way to the program on their own.

The campaign should also use social marketing to reframe their campaign, and focus on outcomes associated with core values such as youth, control, freedom, or rebellion directing their efforts to the appropriate audience. Access to fruits and vegetables should be increased for people in areas where supermarket access is limited. This can be accomplished by working with stores and other point of service facilities to increase and promote their healthy options.

Finally the 5 A Day campaign should reach out to people on the lower tiers of the hierarchy of food competence. Tying together a lower order need, such as basic food needs with eating fruits and vegetables, would bring this behavior to the basic level. The information that the campaign makes available should also include basic fruit and vegetable facts, as well as simple recipes, and portion sizes. By making these changes to their campaign the 5 A Day campaign will be reaching out to a wider audience, and helping them to better internalize, and act upon this important message.


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