5 A Day for Better Health Program Evaluation Report

Supported by NCI and the Produce for Better Health Foundation (PBH), 5 A Day for Better Health is a United-States-based initiative that approaches Americans with this message: Eat 5 or more servings of vegetables and fruit daily for better health. This evaluation of the programme includes 6 chapters. The final chapter, "Evaluation of the Program", is divided into these sections: (1) evaluation of the implementation of 5 A Day; (2) evaluation of the programme using process measures (primarily, communication of the 5 A Day message); (3) evaluation using outcome measures - namely, measures of dietary change and factors that mediate dietary change (such as knowledge of dietary recommendations); and (4) evaluation of randomised, controlled trials of dietary interventions.

Excerpts from the Executive Summary follow:

Conclusions of the Evaluation Group

Implementation and Process Measures

Collaborations and Partnerships

NCI's collaboration with private industry had a positive effect on expanding the impact of the 5 A Day message and bringing additional resources to the task. In addition, this partnership marked the first time that the producers and retailers of vegetables and fruit joined to undertake a common task. Key elements in ensuring the effectiveness of the partnership were the valuable in-kind contributions and the strong commitment of the industry. Beneficial outcomes of the partnership included an expanded communication base for the 5 A Day message and the promotion of national nutritional objectives. The public/private partnership, with its identifiable structure and modules, represents a model for the implementation of other public health endeavors.

The industry partnership approach may have been too vulnerable to market considerations which, if not balanced by public health considerations, could readily lead to ignoring segments of the population not viewed as attractive markets. Further, the social marketing strategies of the NCI and its media partners tended to exclude the most underserved populations. These reasons may explain why the Program was less successful in reaching minority and low-income populations, even though research indicates clearly that such populations can be reached effectively.

The 5 A Day Program developed successful collaborations with a range of Federal, state, and voluntary agencies. These collaborations provided mechanisms whereby the 5 A Day message was incorporated into a range of programs, from the school lunch program to statewide public-health interventions.

Message Delivery and Environment

...media relations strategies were less successful after the first 1-2 years of the campaign, and...advertising strategies dominated...

...Expenditures for the marketing of food, fast food, and beverages (nearly $10 billion in 1999 alone) dwarf the $1 million spent each year by the NCI during the first 10 years of the 5 A Day Program. The difference in magnitude is instructive and speaks in support of what the 5 A Day Program accomplished with modest means. It also speaks to the magnitude of the behavior-change problem in the United States in continued overconsumption of total calories and less healthful eating patterns.

Although new channels offer the possibility of more tailored communication to specific groups, the fragmentation of the communication system makes it more difficult to reach the majority of Americans consistently and inexpensively. The volume, inconsistency, and often contradictory nature of information in the marketplace have created less than ideal conditions for healthful behavior change...

Other Implementation and Process Measures

The 5 A Day Program was implemented in ways that differed substantially from what was planned; most importantly, neither the central capacity for outcome evaluation nor the senior leadership and administrative support for the Program was ever established effectively...

The redirection of resources from community/state capacity building to university-based research strengthened the opportunities to test well-designed intervention strategies for specific channels and targeted populations. This redirection, however, left little support for capacity building at the state and community level.

Changes in Nutrition Policy and Public Health Practice

...there has been a shift from the nutrient-based message - for example, eat more fiber - to the food-based message - eat more vegetables and fruit. This has been reflected, particularly, in an increased emphasis on eating vegetables and fruit in the Dietary Guidelines for Americans and in the U.S. Department of Agriculture's (USDA) Food Guide Pyramid. Though not necessarily a consequence solely of the 5 A Day Program, these shifts reflect the incorporation of the 5 A Day message into nutrition-related health promotion programs by Federal, state, and private agencies.

Dietary Change and Related Outcomes

Knowledge and Awareness

...Before the 5 A Day Program, a small proportion (8%) of the American public understood at least part of the 5 A Day message. Subsequently, there have been increases in knowledge of the 5 A Day Program (18%) and its message (20%). The message has reached more women than men, and more whites than Latinos or African Americans.

Consumption There has been a slow and steady increase in vegetable and fruit consumption in the United States during the period of the implementation of the 5 A Day Program and continuing through at least 1998. Possible inferences from these changes on the effectiveness of the 5 A Day Program are limited....

Even though safety is not an issue if vegetables and fruit are handled properly, the potentially undesirable sensory qualities of some vegetables and fruit (e.g., bitterness, sourness, pungency, astringency) may act as significant barriers to the adoption of a diet that is high in vegetables and fruit, especially among children. The dilemma here is that the strong-tasting compounds as a group overlap extensively with the compounds that are potentially protective against cancer; therefore, removing strong-tasting compounds may reduce the protective effect.

Randomized Trials and Other Experimental Studies

...The studies proved it is possible to change the elementary school environment and to reinforce the healthy dietary practices taught through the classroom curricula. The average effect increase was 0.62 servings per day, and the largest was 1.68 servings per day.

Among adults, changes in the worksite, church, or family social environment were found to be possible, and these changes led to increases in the availability and consumption of vegetables and fruit. The average effect size was 0.48 servings per day, and the largest effect was 0.85 servings per day. For both school-based and adult studies, larger effects were observed in fruit consumption than in vegetable consumption.

Surveillance

There are inadequacies in the surveillance and monitoring of vegetable and fruit intakes in the U.S. population...

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Source:

Executive Summary on the National Cancer Institute website.