Why the 5 A Day for Better Health Program was Ineffective: A Critique of a Public Health Intervention – Kathleen Meehan
The National Cancer Institute’s 5 A Day for Better Health Program is a national program that provides Americans with a seemingly clear and concise recommendation: Eat 5 or more servings of fruits and vegetables each day to achieve optimal nutrition and better health. This recommendation is supported by well-established principles of nutritional adequacy that suggest vegetables and fruits contain essential nutrients required for proper health (1). The Center for Disease Control and Prevention reports that the essential vitamins, minerals and fiber found in fruits and vegetables may help to protect individuals from chronic diseases. When comparing individuals who consume a diet lacking in fruits and vegetables to those who eat more generous portions, the latter are likely to have reduced risk of chronic diseases, including stroke, other cardiovascular diseases and certain cancers (2).
When the 5 A Day Program was initiated in 1991 as a public/private partnership between the vegetable and fruit industry and the U.S. Government, the program was expected to increase the average consumption of vegetables and fruit within the United States to 5 or more servings each day with long term goals to decrease the incidence of cancer and other chronic diseases (1). Increasing the percentage of Americans who consume enough fruits and vegetables each day is main objective (12). The program established a model for change by means of increasing public awareness and professional education while initiating a food-system change and an organizational change. According to population surveys gathered between 1989 and 1991, consumption of fruits and vegetables rose by 0.3 servings for both Caucasian and African American adults (1). In a study to determine the average fruit and vegetable consumption among adults in the United States, it was seen that between 1994 and 2000, the mean consumption of fruit and vegetables declined slightly (19). From 1994 to 2005, the proportion of men and women eating fruits and vegetables or both five or more times each day was virtually unchanged (9). There was little change seen amongst sociodemographic subgroups (19). In the year 2000, it was reported by Reeves and Rafferty that only 3% of United States adults adhered to four healthy lifestyle characteristics: five fruits and vegetables each day, regular physical activity, maintaining a healthy weight and not smoking (11). The 5 A Day Program was ineffective as it was implemented with the use of unsuccessful health models and it failed to acknowledge the determinants that prevent individuals from reaching the recommended consumption goals.
Disregard for the Disparity of Availability throughout US
When determining the problems associated with the 5 A Day Program and the reasons for its failure, one must consider socioeconomic status and the availability of fruit and vegetables within each population. When evaluating the diet quality of low-income and higher income Americans in 2003-2004, it was determined that people from low-income families had significantly lower intakes of total vegetables, dark green and orange vegetables, legumes and whole grains than those from higher income families (10). In a report conducted by the CDC regarding the prevalence of fruit and vegetable consumption and physical activity by race and ethnicity, specific racial and ethnic differences were significant determinants. While it was found that all populations should be targeted by interventions to increase the consumption of fruits and vegetables while simultaneously increasing regular physical activity, it was shown that both behaviors were particularly low amongst all racial and ethnic populations (3). It was concluded that interventions are most likely effective when they meet the needs of specific populations, especially Hispanics and non-Hispanic blacks (3). The greatest determinant of fruit and vegetable ingestion is socioeconomic position (15).
The 5 A Day Program did not take determinants of consumption into account. It is noted that to date, nutritional interventions have only been moderately successful in improving a lasting consumption of adequate fruits and vegetables as the important determinants are not considered when implementing the program (15). Low socioeconomic position is associated with low, or less frequent, intake of fruits and vegetables. Family income, parental occupation and parental education are all indicative consumption of fruits and vegetables as it was shown that the consumption of fruits and vegetables for high socioeconomic positioned students occurred mostly at home. Conversely, low socioeconomic positioned students obtained most of their fruits and vegetables from school (15).
Where are the Fruits and Vegetables?
There is a significant relationship between individual dietary practices and the grocery store environment (5). The influence of urbanization affects fruit and vegetable consumption. It was shown that intake of fruits and vegetables is higher among rural children and adolescents than amongst urban children and adolescents. A significant barrier for eating fruits and vegetables is ease of use and accessibility. (15). The 5 A Day Program fails to consider the availability and accessibility of fresh fruits and vegetables as it is targeted to entire communities without acknowledging that the availability of healthful foods in supermarkets may influence dietary behavior directly, while indirectly affecting nutrition related knowledge and attitudes (5). In the article “Neighborhood characteristics associated with the location of food stores and food service places,” it is noted that while the connection between diet and disease is well established and there are programs in place to reduce those risks, there is little acknowledgement of the notion that the availability of healthy foods will also affect individuals’ diets (13).
Individual dietary practice and store purchasing behavior is based on the socioeconomic status of the community residents. Higher education levels are associated with greater access and availability to healthful products (5). Due to a sharp decline of supermarkets in low-income areas, many residents of those areas must depend on smaller stores with limited selections of fruits and vegetables that are much higher priced (13). A study conducted in San Diego, California compared supermarkets, neighborhood groceries, health food stores and convenience stores. It was found that supermarkets had twice the amount of heart-healthy foods when compared to the neighborhood grocery stores and 4 times the average number of those foods when compared to convenience stores (18). It was seen that supermarkets are much more prevalent in neighborhoods that are predominately white and wealthy while smaller grocery stores are usually located in black or poor neighborhoods. The issue of transportation widens this disparity as it was seen to be less available in the poorer communities (13). For the 5 A Day Program to have been successful, it would have needed to effectively address the availability, cost and level of appeal of fruits and vegetables within all communities regardless of socioeconomic status.
The Use of Inappropriate Public Health Models
The 5 A Day Program was implemented with the use of public health models that are not shown to be effective. The intervention models used include the Health Belief Model, Social Cognitive Theory and the Transtheoretical Model (1). Concepts from these theories were applied across a range of settings and attempted to increase awareness and motivation, build skills, provide social support for behavioral change and establish environmental and political supports (1). It can be argued that the 5 A Day Program failed as these theories are less effective than initially expected.
The Health Belief Model
The Health Belief Model focuses on the thought processes that individuals go through before beginning a health-related action (6). The model assumes that human behavior is determined and objective (17). The theory relies heavily on the notion of motivation and the idea that health behaviors are motivated by perceived susceptibility, received severity, perceived benefits of an action and the perceived barriers to taking that action (6). Intention is also included in the model as it relates to behavior and ideally, ultimate success. In this individual level model, behavior is thought to be planned and reasoned as it is expected that individuals weight the costs and benefits of acting or not acting.
While the Health Belief Model may be beneficial for simple, one time decisions, it is less reasonable for decisions that must be made each and every day over time. Mark Edberg critiques the theory, arguing that it primarily focuses on individual decisions and fails to consider social and environmental factors (6). The model assumes that an internal, logical process occurs as individuals assess their degree of risk and then make a cost-benefit computation about whether to participate in health-oriented behavior. This notion completely disregards the element of external or social influence that is incorporated with decision-making. The model assumes behavior is determined individually and with intention. The model has limited ability to account for variance in behaviors that are related to attitudes, beliefs and situations (17). There are many barriers to action that the Health Belief Model fails to recognize.
Mark Edberg acknowledges a second problem with the Health Belief Model when he recognizes the fact that not everyone has equal access to information with which to make a rational calculation (6). The model does not account for disparities in knowledge. The element of perceived susceptibility may also be exaggerated, as many individuals truly believe “it won’t happen to me”. The model assumes that many hold their health in high regard. If this key factor is absent, the model is irrelevant (17). Convictions regarding the seriousness of a given health problem varies from individual to individual as the kinds of difficulties believed to be associated with a certain condition varies amongst individuals (16).
The Transtheoretical Model
The Transtheoretical Model is an individual behavioral change theory that suggests that behavior is planned. With it’s five stages, it acknowledges that not every individual is at the same place and ready for change at the same time. The model offers different interventions for different stages. The stages include precontemplation, contemplation, preparation, action and maintenance.
Stage one is precontemplation. This is the stage in which people do not intend to take action in the near future as they may be uninformed or under-informed about the consequences of their behavior. They are resistant, unmotivated clients who are disinterested in change (8). When considering the 5 A Day Program, it is possible that traditional health promotion programs relying on the transtheoretical model may categorize individuals as being in the precontemplation stage when really the promotion program is simply not meeting their needs (8).
In stage two, an individual experiences contemplation as they intend to change their behaviors (8). A person in contemplation weighs the pros and cons of making a change (6). In the transtheoretical model, the balance of weighing the pros and cons can lead to a cycle in which individuals are stuck in contemplation for long periods of time. These individuals are not ready for traditional, action-oriented programs that expect participants to take action immediately (8).
Stage three is preparation as a person is ready to change and has the intent to act soon (6). These people are prepared and should be recruited for action oriented programs that are made up of steps (8). Stage four is the stage in which people act, modifying their lifestyles to reduce the risks for the health problems being addressed (6). The fifth stage is maintenance in which a person has made specific changes in their behavior in terms of health risks and they are maintaining that change (6). They have successfully avoided relapse.
When the transtheoretical model is applied to public health interventions like the Five A Day Program, it falls very short. The program completely disregards the external barriers that exist and may prevent individuals from either actively choosing to make a change or from being able to make that change. A major flaw of the transtheoretical model is that it fails to acknowledge studies that have shown that unplanned decisions to quit or initiate a lifestyle change are more effective than actions that are based on planned quit attempts. While the transtheoretical model prides itself on flexibility to reenter the model at any stage if relapse were to occur, it disregards the notion that failed attempts cause very low self-efficacy.
Social Cognitive Theory
Social Cognitive Theory suggests that an individual’s knowledge acquisition can be directly affected by the observing the actions of others within the context of social interactions. Social Cognitive Theory incorporates self-efficacy beliefs, goals, outcome expectancies and perceived environmental impediments. According to Albert Bandura, the theory utilizes observational learning, which can resonate to help bring about a change in behavior (4). When applied to the 5 A Day Program, this theory is unsuccessful as it fails to acknowledge there are more factors that must be considered. While knowledge and self-efficacy are indeed important, social cognitive theory still ignores the social factors that make fruit and vegetables so unavailable.
The Effects of Parental Intake
The 5 A Day Program fails to acknowledge family related factors regarding the consumption of fruits and vegetables. A parent’s nutritional status will have a large effect on a child. There is a positive correlation between parental intake of fruits and vegetables and the child’s fruit and vegetable intake (15). In a three day diet recall of mothers and their children, it was established that children’s vegetable consumption was independently explained by the child’s liking of commonly eaten vegetables and the mother’s belief in the importance of disease prevention when choosing her food (15). Both parental and child intake is effected by home accessibility. In the study of Determinants of Fruit and Vegetable Consumption among Children and Adolescents, it was shown that there is a positive correlation between parental and children’s intake within families with a high availability of fruit and vegetables at home (19). The most important indicator of a child’s consumption of fruits and vegetables is a mother’s nutritional knowledge and her frequency of fruit consumption (15). If a parent is less occupied with the importance of proper nutrition and lacks the knowledge and accessibility to properly provide fruits and vegetables to their children, there has shown to be an association with less adherence to the suggestions in the 5 A Day Program.
Conclusion of Critique
The 5 A Day Program is a public health intervention with the best intentions and unimpressive outcomes. It fell short when it failed to acknowledge the true determinants of fruit and vegetable consumption while using ineffective public health models. The campaign does not consider the unavailability of fruits and vegetables in some communities. The use of the Health Belief Model, Social Cognitive Theory and Transtheoretical Model was a poor choice as these models fail to recognize the external constraints felt by each individual. They also address the individual rather than large groups of people, which is a method that has shown to be more effective in public health interventions. The program does not identify the effects of parental nutrition on the nutritional status of children. By acknowledging these shortcomings of the 5 A Day Program, the program can be improved and be much more effective to assure all Americans are receiving the healthful benefits associated with fruits and vegetables.
When the 5 A Day Program was first implemented in 1991, it was expected to provide Americans with the motivation to strive to increase their fruit and vegetable consumption. The program failed to properly acknowledge the many determinants that cause individuals to consume less than the recommended amounts of fruits and vegetables into account. Ineffective public health models were the basis of the program’s intervention methods. Use of the Health Belief Model, Social Cognitive Theory and the Transtheoretical Model was unsuccessful, as those models do not recognize external factors that can effect the consumption of healthful foods. Using public health models that are intended for intervention on an individual level are less useful as it has been shown that alternative models that focus on the group are much more effective in public health.
Education based on Needs of the Community
The 5 A Day Program would be significantly more effective if it helped to establish interventions that are tailored to the specific needs of each community. This is a daunting task as there must be many separate interventions involved. By using strategies like establishing programs in culturally relevant settings, promoting culturally appropriate foods and activities, and engaging members in the development of the intervention, consumption of fruits and vegetables may increase (3).
Interventions to address the behaviors regarding fruit and vegetable consumption should be implemented at the group level and include education and greater access to fruits and vegetables (3). Interventions to improve health related behaviors should be tailored to the specific determinants of those behaviors. The 5 A Day Program failed to acknowledge the social determinants that include inaccessibility to fresh fruits and vegetables in certain neighborhoods and the effect parental nutrition has on children. With the new program, fresh fruits and vegetables will be readily available in all neighborhoods as a result of a governmental subsidy to provide a uniform availability throughout all communities. Free sessions will be available at local demonstration kitchens that exhibit the ease of increasing intake of fruits and vegetables. Providing individuals with simple, healthful recipes while educating on the importance of incorporating fruits and vegetables into the diet will be a forward thinking solution. A new program would address these problems and work to effectively eradicate the issues seen in the 5 A Day Program.
Alternative Public Health Models
The 5 A Day Program utilized public health models that are based on the individual. Alternative models are much more effective as they work to change the group as a whole. With a group dynamic, less reason is required and the behavior of many individuals can be altered. Alternative models benefit from a “mob mentality” as it is recognized that you cannot simply break a group apart into individuals. When models are focused on affecting a single individual, many positive factors are excluded. The concept of herding is built upon the notion of a crowd’s mindset and therefore alternative models are powerful as they can affect groups as a whole. Alternative models are beneficial as they recognize that people are predictability irrational.
Social marketing is an extremely beneficial component in public health interventions. By implementing programs that incorporate the use of marketing to promote socially beneficial behavioral changes, public health interventions can be much more successful (9). With social marketing, target audiences can easily be segmented along several dimensions based on demographics (WALSH) Social marketing has enormous potential to affect health problems and has been successful regardless of disparities between members of ethnic minorities or majority groups (9).
Social Marketing Theory
To properly utilize social marketing theory in reference to increasing the mass consumption of fruits and vegetables within the United States, research and planning must precede design and implementation. Extensive research must begin with the segmentation of populations, determining the different groups that will be marketed to (21). Communication channels must be established and they must be realistic so that each target audience may meet their goals (21). In communities where it is reported mothers lack proper knowledge regarding fruits and vegetables, informational sessions should be available with demonstration kitchens to provide examples with how to incorporate healthful fruits and vegetables into the diet, which will help to easily increase consumption of those foods. In these same communities, it should be mandated that fruits and vegetables are readily available and provided to children during the school day. Several studies have shown that food preferences and eating habits established in childhood and adolescence tend to be maintained into adulthood (15). This reiterates the importance of providing fruits and vegetables to school children and educating young students on the healthful benefits of fruits and vegetables while providing parents with the proper outlets with which to purchase these foods. By introducing fruits and vegetables when children are young, they will be more likely to request them from their parents.
A better public health intervention to increase consumption of fruits and vegetables would acknowledge the important determinants that affect fruit and vegetable intake. Social marketing theory recognizes the importance of understanding target groups, noting that determining the physical, cultural and media environments of all consumers vary and therefore will affect what will messages capture their attention and to what extent those messages will be effective (21). With the use of social marketing theory to spread the message, large groups could benefit from programs that not only provide fruits and vegetables at a reduced cost but also educate individuals on their benefits and ease of use. If classes are offered in communities to develop self-efficacy amongst individuals who were previously unfamiliar with how to use and prepare formerly untried fruits and vegetables, changes in consumption may be imminent. Following program implementation, evaluations should occur to assess the impact of the intervention.
Acknowledgement of Availability
While new programs are implemented using a group model like social marketing theory, the availability of fruits and vegetables must also be acknowledged. In New Zealand, a program was developed that helped to aid low-income earners budget their incomes and specifically allocate their dollars to obtain healthful foods (7).
If initiated in lower socioeconomic neighborhoods, similar programs might prove to be helpful but there must be a shift in the ease of locating the healthful foods. Federal funding should be allocated to areas in need as there is a great disparity regarding the availability of fruits and vegetables in lower income areas. The food environment of a community has a large effect on the choices people will make. Fast food outlets and convenience stores are frequently located in lower-income areas and neighborhoods. It was found that these convenience stores are often stocked with fewer low-fat diary products, low-sugar beverages and healthy fruits and vegetables of acceptable quality (20). The characteristics of the physical environment can contribute to a less than optimal eating pattern that will affect the adherence to the 5 A Day Program’s recommendation (14). Food stores that are large enough to offer WIC benefits while providing healthful foods should be mandated in all communities to assure accessibility (20). Once it is mandated that healthful fruits and vegetables are readily available in all neighborhoods, demonstration kitchens will be extremely effective in increasing consumption.
Epidemiological evidence suggests that a diet high in fruits and vegetables will aid to promote good health and prevent chronic disease. In the United States, most individuals, including children and adolescents, do not meet the recommended amount of fruits and vegetables and in fact are consuming significantly less. As eating habits are established in early childhood, it is necessary to provide parents with the resources to provide fruits and vegetables to their children. By using a successful public health model to educate parents while working to narrow the disparities of inaccessibility, a public health intervention aiming to increase the consumption of fruits and vegetables will be possible.
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