Background of the 5 A Day Initiative

It has been approximately 15 years since the National Cancer Institute (NCI) instituted the National 5 A Day for Better Health Program to encourage Americans to eat 5 to 9 servings of fruits and vegetables every day^[1]. This initiative is a public-private partnership between the NCI and the Produce for Better Health Foundation and includes federal, state and local government agencies, industry and volunteer organizations. The community component of the program attempts to reach consumers at the local level through a variety of mechanisms, including the development of coalitions.

Overview of 5 A Day Research

The research component of the 5 A Day Initiative is an extension of the community component. When this initiative began, the NCI funded nine research studies in 1993 to be conducted at worksites, schools, churches, and food assistance programs^{[1, 2]}. The studies targeted specific channels (e.g., schools) and target populations (e.g., fourth-grade school children) for interventions designed to increase the consumption of fruit and vegetables. All of the interventions were based on one or more theories of behavior changes. Four projects targeted elementary school students in grades 4 and 5 (Alabama, Georgia, California, Minnesota), one program targeted high school students (Louisiana), one program targeted WIC participants (Maryland), three programs targeted worksites (Arizona, Massachusetts, Washington) and one program targeted adults through black churches (North Carolina). A number of countries have now adapted the “five-a-day” message. Since the completion of these intervention studies in 1997, scientists have made great strides in expanding behavior change research efforts targeting increased fruit and vegetable consumption of specific populations. Since the initiative began, there have been numerous research studies conducted in schools, communities, worksites, churches, supermarkets, and with large-scale populations. There are several articles that provide an excellent review of these studies^{[3, 4]}.

School-based interventions – What have they shown?

There have been a large number of school-based studies conducted with children and adolescents since 1993^[5-20], predominantly randomized controlled trials. A majority of the studies were developed based on Social Cognitive Theory with very few using a combination of behavioral theories. Although the population widely targeted was 4th and 5th grade students, there were large variations in sample size and number of schools. Among these 16 programs conducted in Europe and in the USA, two studies selected Boy/Girl Scouts as their target audience (“Girl Scouts Eat 5” (Texas) (1997)^[11] and “5-A-Day Achievement Badge” (Texas) (2002)^[13]) and none of the studies were conducted with preschool children. The intervention of choice included a curriculum, cafeteria component, and parental involvement. The length of the intervention and the content of the curriculum varied across the studies. There were a few intervention activities common across a number of studies, including taste testings, meal/recipe preparation skills and increased availability of FV. A particularly innovative approach was tested in two studies using a multimedia game [Squire’s Quest (Texas) (2003)]⁽¹⁶⁾ and a six-minute video episode [Food Dudes Healthy Eating Programme (UK) (2004)]⁽¹⁴⁾. The most commonly used behavioral change techniques were role modeling, selfmonitoring, goal-setting and problem-solving. Despite these noble efforts, most of the FV school-based interventions have not been especially successful. The obtained effect size ranged from 0.2 servings to 1.68 servings; majority being around 0.4 to 0.5 serving. The interventions appeared to be more successful in changing F consumption, particularly in school meals. Very little was shown in altering FV consumption in the home, which may reflect the very low dose of parental involvement. For most of the multicomponent interventions, it is unknown what caused most of the change in FV consumption and which of the “multi-components” really did work.

Two studies used a single component intervention: “Cafeteria Power Plus” (Minnesota) (2004)⁽¹⁷⁾ and “Squire’s Quest” (Texas) (2003)⁽¹⁶⁾. The cafeteria intervention (“Cafeteria Power Plus” Program) produced no significant intervention effect on FV consumption.

However, the multimedia game (“Squire’s Quest” Program) resulted in a 1.0 serving increase in FV consumption. Although the success of these interventions has been modest, we have come a long way since this initiative started 15 years ago. We have a better understanding of what does not work and maybe we need to refocus on trying to understand “why children eat the foods they do”^[21]. Understanding and intervening on the mediating variables related to FV consumption may be needed to successfully impact children’s FV consumption.

Conclusion

The classical “classroom, cafeteria, and parent” approach used in the past may need to be updated. Innovative, state of the art, channels for helping children and their families increase their FV consumption are indicated. We may need to move away from theory driven interventions all together^[22]; or, at the very least consider interventions that combine a number of behavioral theories.