Monday, December 13, 2010

Flaws of The 5-a-day Campaign –Sungeun Kim

The effects of diet on health have been emphasized over a few decades, and research has shown that a high intake of fruits and vegetables has a role in protecting against the development of chronic diseases and obesity. Healthy People 2010 recommends consuming ≥2 servings of fruits and ≥3 servings of vegetables a day for children (1). However, according to National Health and Nutrition Examination Survey (NHANES) data, average daily intake of fruits and vegetables for children is 3.7 servings, and only 18 to 20% of children consume 5 or more than 5 servings (2).
First of all, a higher intake of fruits and vegetables is related to a decrease in the incidence of obesity. Obesity is a rapidly growing health problem that is not just threat to adults. Childhood obesity has been grown dramatically over a few decades (3). Overweight or obese children are more likely to become obese adults. There are several negative effects of obesity on health, such as increased risk of heart disease, high blood pressure, diabetes, breathing problems, and trouble sleeping. Emotional problems are another consequence of childhood obesity because obese children tend to have lower self-esteem (4).
With development of new technologies, people tend to be less physically active and to eat more. These days, there are numerous processed or convenient foods that contain high amounts of calories, sugar, salts, and saturated fats. These foods are also available in schools. . Vegetables and fruits have high amounts of water and fiber and low energy density. Research has shown that dietary fiber increases satiety and decreases later hunger, resulting in less eating and weight loss in the long term (5). If children feel more satiety, there is a lower chance they will eat from unhealthy sources such as vending machines and snack bars. The high content of water in vegetables and fruits leads children to eat less food that is high energy. This means that filling up the stomach with vegetables and fruits can help control hunger and reduce energy intake (2). Since one of the contributing factors to obesity is a diet of high energy density and low nutrition density foods, adding vegetables and fruits to one’s diet can help to prevent and treat obesity and weight problems.
There are many campaigns to convince people to eat more vegetables and fruits. One well-known campaign is the 5-a-day campaign. This campaign has been initiated by the government targeting the general population, particularly children. It emphasizes the importance of having at least five servings of vegetables and fruits every day. However, according to the national diet and nutrition survey published by the Food Standards Agency, it was found that children eat less vegetables and fruits compared with the past (6). It turns out that the 5-a-day has not been successful in persuading people to have a healthier eating habit. There are several flaws in this campaign that makes it inefficient.

1. The 5-a-day campaign does not take into account the fact that target population is composed of various socio-economic, cultural, and racial backgrounds.
According to the social contextual model of health behavior change, social context is important to make health behavioral changes. Socio-economic, race, and culture impacts health behaviors widely, such as dietary patterns and physical activity (7). Many diverse groups have low amounts of vegetables and fruit consumption: Female adolescents, American Indian (low fruit intake), African-American (low vegetable intake), and those in the middle and lower socio-economic level (8). However, the 5-a-day campaign does not consider the characteristic difference in the population. Instead, it delivers the same message to all of the population. National data suggest that school-aged children consume lower amounts of vegetables and fruits than the 2005 diet guidelines recommendations. This is particularly significant among children from low income families (2). Children and adolescents from low income families are most likely to have the fewest servings of fruit and vegetables. According to Consumer Expenditure Survey data, while a person from an average socio-economic household spends $5.02 to buy fruit and vegetable, a person from low socio-economic households only spends $3.50 for vegetables and fruits per week (2).
According to Abraham maslow’s hierarchy of needs theory, there is a hierarchy of five levels of basic needs, which are physiological needs, safety, love/belonging, esteem, and self-actualization. In the hierarchy of five basic needs, one does not want the second need until the first need is satisfied. Humans are motivated to the next higher level of need once lower needs are met (9). Children who are from a low income family do not worry about eating five servings of fruit and vegetables per day, although it would improve their future health. They would rather focus on physiological needs. Because vegetables and fruits are more expansive than other foods, like high calorie foods, it is often inevitable that low socio-economic parents buy unhealthy foods. In addition, the recent depressed economy may lead low income families buy fewer vegetables and fruits. Because these children’s lower needs are not met, the message about various benefits of eating fruits and vegetables is not going to change their dietary habits.
A population’s characteristics, such as income and culture that might influence dietary intake should be considered for the intervention (7). Understanding different patterns of healthy behaviors between different socioeconomic positions and other aspects of the social environment is crucial for creating a successful intervention. Therefore, the intervention should be designed to reduce the gap among children’s differences. A different approach should be made to communicate effectively with all the population. For example, for African American, green leafy vegetables are popular, and cooked vegetables are more preferred. Cooking demonstrations with teachers at schools could be one approach. Cooking healthy foods with other friends and teachers could increase their interest and they will be more likely to eat vegetables and fruits. Bringing that recipe home may lead their mothers cook for them. For low income family children, their situation should be taken into account and incorporated into an intervention. For those children, school meals might be the only source where they can obtain fruits and vegetables. Because their physiological needs are not met, their priority of resource allocation is not health related (9). Their parents would not care about buying fresh fruits and vegetables for their family’s health. Intervention should focus on improving school meals, since school meals are accessible to most children with a low socio-economic status. Research done by the Food and Nutrition Services of the United States Department of Agriculture shows that students in the National Lunch School Program are more likely to have fruit juice and more vegetables than those who do not participate in school meals. This result demonstrates the importance of school meals for low income children in terms of having enough vegetables and fruits (2)

2. 5-a-day neglects one of the most important components in changing one’s behaviors: motivation.

Because motivation leads a person to make behavioral changes, it is a critical aspect that should be considered in an intervention designed to change behaviors. Self-Determination Theory suggests that making and maintaining a behavioral change is related to motivation (10). To obtain motivation to initiate and maintain new behavioral patterns, autonomy should be developed. Motivation is differentiated into two categories, controlled motivation and autonomous motivation (11). Controlled motivation occurs when a person is under pressure and an environment is controlled. With controlled motivation, one is likely to fail to persist with behavioral changes over the long-term. Contrary to controlled motivation, autonomous motivation does not come from external pressure, rather from internal worth that one considers important. One feels satisfaction from the activity. Self-Determination Theory suggests much higher success rates for maintaining a behavioral change than controlled motivation (11). Self-Determination theory proposes that pressure and control have negative effects on autonomy, leading to a lower quality of motivation (12). Therefore, it is important to respect one’s opinions and values to encourage autonomous motivation to support this need. However, 5-a-day campaign focuses on increasing the awareness about the importance of eating vegetables and fruits by using controlled motivation.
According to Self-Determination Theory, the problem with the 5-a-day campaign is that it is based on controlled motivation. It gives both negative effects of not having five servings of fruits and vegetables per day and positive effects of having them, and pushes children to eat more of them. If children have eaten vegetables and fruits because a teacher or parents tells them to do so, it is unlikely one will maintain that eating habit because that behavior comes from controlled motivation (13). This theory proposes a lack of autonomos motivation as the main reason for failure to keep healthy eating habits because controlled motivation is associated with poor performance
A successful intervention can be created by applying Self-Determination Theory to it. The best way to motivate children to eat more vegetables and fruits should be considered before the intervention is initiated. First of all, an autonomy supportive environment should be created (10). Each person has to make their own decisions and be encouraged to make choices by themselves. Since children spend most of their time at shools, schools can have a huge impact on children’s eating habits. Schools have been considered as a main location to lower obesity rates and promote healthy eating habits for children (1). A possible intervention could be that children learn about vegetables and fruits. Teachers would introduce a variety of vegetables and fruits in colors and taste. Once a week, there would be a list of choices of fruits and vegetables on the table in class. Each child would pick whatever they like, eat them, and share what they feel and what they like about them. They will talk about what values are important to them, and the connection between their values and a healthy diet. Some children think healthy behaviors are boring and no fun. But in this way, children will find having vegetables and fruits can be fun and interesting. Once they find autonomous motivation, it may lead them to eat more of vegetables and fruits even outside of school. Finding out that healthy eating habits are intriguing will help to encourage children to keep doing it for a lifetime.

3. 5-a-day campaign does not explain the issue of self efficacy.

In the self-efficacy theory, how people think, motivate, and behave themselves depends on their self-efficacy. People who have higher self- efficacy are more confident about completing a task and willing to try and overcome it. In contrast, people who do not trust their abilities to succeed at something are more likely to avoid and give up rather than putting efforts actively (14). Therefore, self -efficacy is one of the most important factors in determining one’s behaviors for achieving a goal. One of the flaws that the 5-a-day has is that it ignores the impact on self efficacy on behavior changes. Eating 5 servings of fruits and vegetables could be impossible for some people, particularly on those who do not eat vegetables and fruits now. At least 5 servings of fruits and vegetables every day for adults is difficult to achieve, and it is even more difficult for children to have this amount. According to the self-efficacy theory, children may give up having a healthy diet because it seems to be hard and out of their scope. Therefore, self-efficacy should be taken into account as the main factor in an intervention. Because the average consumption of vegetables and fruits among children is about 3 servings, it is not practical to persuade them to have at least 5servings.
To make an intervention effective, the campaign should encourage children’s perceptions that a goal is achievable. Instead of delivering the message to consume at least 5 servings of fruits and vegetables, tell children to increase consumption by half or one serving, and gradually increase them as they reach their goals. Increasing by half to one serving is not threatened to most children, and therefore they are more likely to achieve a goal and maintain it due to higher self-efficacy.
Self-efficacy theory suggests that seeing people similar to oneself succeed increases observers’ beliefs that they have abilities to complete that task as well. Children’s self-efficacy changes substantially depending upon the peers that they are surrounded by (14). A great amount of social learning occurs from peers. Thus, self-efficacy can be enhanced through peer influences (14). This can be used to create an effective intervention. One possible intervention would be that each child writes a goal at school related to increasing vegetables and fruits consumption once a week, and after a week, they will share their experience and feelings, how they achieved their goals and what obstacles they had to achieve a goal. Whether or not they achieve a goal, there will be no prize or punishment. After sharing, they will set another goal. As children observe their peers who are similar to them succeed to complete a goal, they would obtain higher self-efficacy that leads them to feel more confident about accomplishing a task, and therefore encourages them to put more efforts on it.


The 5-a-day campaign has been initiated to help all people, particularly children, to have healthy eating habits. However, it turns out that this campaign does not have huge effects on peoples’ diets. First of all, it does not reflect different characteristics of population in terms of culture, race, and racial backgrounds. Because social context determines peoples’ diets, various approaches for different people should be done to persuade them to make behavioral changes. Another flaw of the 5-a-day campaign is that it ignores the importance of autonomous motivation. Controlled motivation seems to work at first, but behavioral changes cannot be maintained with controlled motivation. Intervention should be designed to increase children’s interest about eating vegetables and fruits and help them to relate their own values for a healthy diet. Lastly, the 5-a-day campaign does not include the concept of self-efficacy. Children are more likely to attempt a task when it is more achievable and realistic. Because at least having 5 servings of vegetables and fruits per day is difficult to accomplish for most children, increasing a mild to moderate amount of their current consumption would have more powerful influence on their diets. The importance of having vegetables and fruits has been emphasized for a few decades and there are many campaigns encouraging eating them. The 5-a-day campaign has been shown to be inefficient, even though a tremendous amount of money has spent. Because the majority of habits are determined during childhood, it is important to have a healthy diet from an early age. School is the place where children spend the most time, and therefore it can be the most potent venue to encourage them to eat more fruits and vegetables. Therefore, there is a strong need to implement an effective intervention that takes place at school.

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