Challenging Dogma - Spring 2008

...Using social sciences to improve the practice of public health

Thursday, April 17, 2008

The 5 A Day Campaign: An Unrealistic Approach to Increasing Fruit and Vegetable Consumption - Natalie Dell

The Obesity Epidemic
As of 2007, there were 58 million overweight Americans, 40 million obese Americans, and another 3 million morbidly obese individuals (1). Many public health and nutritional experts view this problem as an epidemic. One of the major contributors to obesity is a poor diet that is low in healthy items like fruits and vegetables and high in fattening or sweet items (1). To help solve this problem and the growing epidemic in the United States, the National Cancer Institute combined forces in 1991 with public health groups and Produce for Better Health to promote the consumption of 5 servings of fruits and vegetables a day through various advertisements and promotions (2). In 2004, the campaigns spent 9.55 million dollars to promote the message (3).

A Poorly Planned Campaign
The campaign promoted a message that encouraged people to eat at least 5 fruits and vegetables a day to enable Americans to lead healthier lives. The 5 A Day message has good intentions; everyone can benefit from a healthier diet, not to mention the millions who are obese. In fact, about 40% of Americans, or 68 million people, will be obese by 2010 if people keep gaining at the current rate, scientists estimate (2). However, data collected before and after the campaign revealed that there was no improvement in fruit or vegetable consumption. Still, the campaign continues, even as the daily requirement escalated to 7 a day, aiming for nine. This goal is incredibly unrealistic since most people, from poor to wealthy, do not eat the suggested 5 a day servings, despite the campaign’s extensive promotional efforts.

The campaign misses the boat on several key social and behavioral theories. It does not understand how the target audience perceives the severity of the outcomes associated with not eating 5 fruits and vegetables a day. The campaign also fails to connect with its target audience and understanding the real reasons why they are not eating enough produce. By setting unrealistic expectations for fruit and vegetable consumption, misinterpreting the public’s perceived severity and taking a broad, blanket-statement approach, the 5 A Day campaign is unable to effectively increase fruit and vegetable consumption by Americans.

Reasons for Failure
Misinterpreting perceived severity
First of all, in a social and behavioral context and according to the Health Belief Model (HBM). This model functions by focusing on the attitudes and beliefs of individuals to explain and also predict health behaviors. It was created to clarify health-related behavior at an individual, decision-maker level. Its main concepts include "perceived susceptibility," "severity," and "social consequence" (5).

The campaign has a skewed perception of its target audience and assumes the perceived susceptibility of inadequate nutrition is such a serious concern to the audience that it will motivate them to eat at least 5 produce items a day. In other words, the campaign is structured to appeal to someone who is concerned about their health and wants to improve it through produce consumption. However, it seems that many people simply do not care if they do not eat fruits and vegetables (6). When a person’s core values do not include disease prevention, they need to be targeted in a different way. The campaign is structured to only succeed with a target audience who cares deeply about disease prevention and perceive low produce consumption levels to be severe to their health.

In other words, the 5 A Day campaign overlooks the perceived severity, that is, how severe the target audience perceives the effects of not eating 5 items of produce a day. If people do not view low fruit and vegetable consumption levels as a problem, they will not care to fix it. The campaign assumes that the audience perceives not eating 5 a day to be a problem but in reality, this issue is not at the forefront of the audience’s concerns (2). This oversight creates a disconnect between perceived susceptibility/severity of the audience and the campaign’s strategy and is one of the reasons why the campaign has resulted in stagnant consumption levels.

Setting unrealistic expectations and ignoring fundamentals of the Communication Theory

In addition to misinterpreting the perceived severity, the campaign focuses on the number of servings a day, as opposed to specific foods. This approach is unrealistic for many people, regardless of SES. This is evidenced in the data collected from a large sample of U.S. adults between 1994 and 2000 (before and after the 5 A Day campaign) (4). The mean frequency of fruit and vegetable consumption within this study population declined, and proportion of respondents consuming fruits and vegetables 5 or more times a day did not change (4). The campaign lacks an effective, specific message to advise people on what exactly they need to eat, if they can only eat a few servings a day. Such a message would help people prioritize and would inform consumers about what are the most important fruits/vegetables to eat.

To actually improve consumption without setting unrealistic expectations, the campaign should have utilized the fundamentals of the communications theory by focusing on what consumers are currently doing and communicating ways of improving the quality of the food they are already eating (5). If the campaign would have considered the communications model, it would have emphasized the following message: "If you only have time for three servings, make sure at least one of them is spinach or an orange." The current message that challenges people to eat at least 5 produce items a day is not what the audience needs to hear to engage in the desired action. Although the campaign’s extensive media coverage may reach its audience, it is incorrectly encoding the information. The implications of continuing this way are static fruit and vegetable consumption and a less healthy population, despite the millions being spent on the campaign.

Ignoring cultural and SES differences and the Anthropology and Cultural Theory
In addition to setting unrealistic expectations for consumption, the current campaign does not consider SES status or cultural differences in its target audience. Culture and SES affect consumption levels in three ways: access, affordability and cultural values. To contemplate these issues, the Anthropology and Cultural Theory should be referenced (5). The theory suggests that consumption patterns and opinions regarding fruit/vegetable consumption will vary between different cultural groups and SES status. This theory allows us to ask the question: What do people in a culture or social group think about the components of a good meal and what are the common expectations about healthy lifestyles (5)?

The 5 A Day campaign should have used this theory when developing its promotional strategy. Instead, the campaign ignores the socioeconomic and cultural differences in communities that lead to decreased consumption. There are some places where fresh fruit and vegetables are not readily available or are too expensive (6). Even if the desire to eat fruits and vegetables is present, those lacking the resources to purchase produce are left with few options. The campaign should have implemented an intervention that would considered the prices of fruits and recommend ones that are give the most "bang for their buck." A successful strategy would have also considered how to raise people’s expectations about healthy lifestyles, across all cultures. Additionally, the campaign should have also added an intervention to assist people who live in communities with little or no access to produce items (like the Roxbury community in Boston).

To date, $9.55 million has been spent to advertise and promote the notion of eating five servings a day (3). The campaign’s budget has consisted of advertising and promotion as opposed to addressing the core problems of fruit/vegetable consumption: prices, access, cultural issues and the people’s personal priorities regarding eating.

The 5 A Day campaign, meant to increase fruit and vegetable consumption, has failed not only culturally but also structurally. The campaign doesn’t align its strategy with the actual perceived susceptibility and severity of the problem among its target audience. By setting unrealistic expectations for produce consumption, the campaign doesn’t focus on what the consumers are actually doing and ignores the fundamentals of the Communications Theory. The success of the 5 A Day Campaign relies heavily on selecting target populations, since produce consumption differs among different socioeconomic strata (8). The campaign just used a blanket-statement to get its message out and did not tailor it to certain cultures and socioeconomic groups or rely on these social groups to communicate the importance of eating fruits and vegetables. This principle explains why there are such disproportionate produce consumption rates among the poor, minority, and urban communities. Consequently, the campaign’s failure is rooted in its very broad focus. The campaign failed to understand the fundamental causes of the lack of fruit and vegetables in Americans’ diets and how consumption varies with social economic status. The campaign released a blanket-statement to all social groups and networks but since these groups have different needs and priorities, such an approach will not work (7). If the campaign would have considered these questions and reviewed the Anthropology and Cultural Theory, it may have resulted in far better outcomes.

For a recommendation for the future, the campaign should use specialized grassroots methods to facilitate behavior change. More money could be devoted to a grassroots intervention, such as a "bookmobile" style fruit stand that travels into communities that have little access to produce. Although awareness does need to be raised about fruit and vegetable consumption, access to and cost of produce items need to be considered as well.

The campaign’s delivery is poorly structured and does not effectively reach those who most likely have the worst produce consumption rates. By adopting a "one message fits all" strategy, the campaign does not address many of the realities present in its target audience.

(1 ) Bray, G. Primary Care: Clinics in Office Practice, Volume 30, Issue 2, Pages xi-xii.
(2) Serdula M, Gillespsie C, Kettel-Kahn L, Farris R, Symour J, & Denny C. Trends in Fruit and Vegetable Consumption Among Adults in the United States: Behavioral Risk Factor Surveillance System, 1994–2000. American Journal of Public Health. 2004, Volume 24, Pages 1014-1018.
(3) Imholz, Betsy. New Report Shows Food Industry Advertising Overwhelms Government’s "5 A Day" Campaign to Fight Obesity and Promote Healthy Eating. Consumer Union, September 2005.
(4) Stables, G.J., et al. Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association, Volume 102, Pages 809-817.
(5) Edberg, Mark, Ph.D. Essentials of Health Behavior, social and behavioral theory in public health. 2007, Pages 65-69.
(6) Ard, J.D., et al. Informing Cancer Prevention Strategies for African Americans: The Relationship of African American Acculturation to Fruit, Vegetable, and Fat Intake. Journal of Behavioral Medicine, Volume 28, Pages 239-247.
(7) Adewale Troutman. Creating Health Equity Through Social Justice. Satellite broadcast originally aired February 20, 2003. 
(8) Lu, Ning. Samuels, Michael E. Wilson, Richard. Socioeconomic Differences in Health: How Much Do Health Behaviors and Health Insurance Coverage Account For? Journal of Health Care for the Poor and Underserved , Volume 15, Number 4, November 2004, Pages 618-630.
(9) New Report Shows Food Industry Advertising Overwhelms Government’s "5 A Day" Campaign to Fight Obesity and Promote Healthy Eating, September 2005.

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