Scientific Rationale for the Program
In 1981, Doll and Peto concluded that about 35 percent of all cancer deaths were related to nutrition, with a plausible range of 10 to 70 percent.26 This conclusion was driven largely by data on dietary behaviors that might increase risk. Evidence for the role of plant foods in cancer risk coalesced in the late 1980s and early 1990s, based on summaries of the epidemiologic literature specific to the relationship between vegetables and fruit and cancer.27-35
The evidence supporting the role of vegetables and fruit in cancer prevention provided a foundation for several documents that were the basis of national nutrition policy in the 1980s and 1990s. In 1982, the National Research Council (NRC) published the seminal document, Diet, Nutrition and Cancer, which summarized the research literature on the relationship between various chronic diseases and dietary patterns.36 Other Federal documents followed such as Healthy People 2000,37 the first Surgeon General's Report on Nutrition,27 Dietary Guidelines for Americans,38 and the Food Guide Pyramid.39,b Despite the strong evidence linking vegetable and fruit consumption with protection from cancer, national surveys showed that vegetable and fruit consumption remained low. National survey data available in 1991 included the 1976-80 National Health and Nutrition Examination Survey (NHANES) II40 and the 1985 CSFII,41 which found a mean intake of vegetables and fruit of 2.9 servings, including french fries.42,43
CSFII data for 1989 showed that mean intake was 3.9 servings, excluding french fries, with only 32 percent consuming 5 or more servings a day.44 Similarly, the 5 A Day Program baseline survey conducted in October 1991 found a mean intake of 3.8 servings a day, with 23 percent consuming 5 or more servings a day. Though there were substantial differences in estimates of vegetable and fruit consumption due to differences in survey methods,c all of the surveys showed vegetable and fruit consumption well below the 5 A Day goal.
Policy Background
The National Cancer Act of 1971 mandated that the NCI "…shall establish programs as necessary for cooperation with State and other health agencies in the diagnosis, prevention, and treatment of cancer." Amended in 1996, the Public Health Service Act stated, "… the NCI shall establish and support demonstration, education, and other programs for the detection, diagnosis, prevention, and treatment of cancer and shall include locally initiated education and demonstration programs (and regional networks of such programs) to transmit research results and to disseminate information."
NCI's Cancer Control Objectives for the Nation: 1985-200045 projected that 30,000 lives could be saved annually through modification of dietary habits. NCI's cancer control objectives called for the population to reduce fat consumption to 30 percent or less of calories and increase fiber consumption (including vegetables and fruit) to 20-30 g per day. The appropriate roles for the NCI, as stated in the document, included guiding and supporting research on the cancer-related effects of dietary fat and fiber, chemoprevention, and dietary behavior, and conducting public education programs on the health advantages and cancer risks of relevant dietary components. A list of recommended actions for state and local health agencies also was provided and included (1) reviewing school menus and educational programs in relation to NCI's dietary recommendations, (2) assisting private-sector groups in modifying health promotion programs to include cancer risk reduction, (3) encouraging restaurants to provide sufficient information to consumers on choosing nutritious foods, (4) coordinating activities with state departments of agriculture and aging, (5) working with local mass media to educate the public, and (6) addressing the needs of high-risk populations.45 These roles for state health agencies were incorporated into the state component of the national 5 A Day Program.
Program Origins
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 aimed to increase the average consumption of vegetables and fruit in the United States to 5 or more servings every day, with the long-range goal of reducing the incidence of cancer and other chronic diseases through dietary improvements. The specific program objectives were to increase public awareness of the importance of eating 5 or more servings of vegetables and fruit every day and to provide consumers with specific information about ways to incorporate more servings of vegetables and fruit into their daily eating patterns.
The NCI Program was built on an initiative of the California Department of Health Services, which was funded in 1988 by an NCI capacity-building grant.46 The California 5 A Day Program established a model for statewide dietary-change efforts with three types of simultaneous activities: public awareness and professional education, food-system change, and organizational change. According to statewide population surveys conducted in 1989 and 1991, vegetable and fruit consumption rose by 0.3 servings for both Caucasian and African American adults, a rate four times higher than secular trends.47
The recommendation to target a minimum of 5 servings of vegetables and fruit had its origins in the California program and was based on an extensive review of the scientific literature. In addition, (1) at least 5 servings represented a considerable increase in consumption, nearly doubling the 1987 estimated level of about 2.5 servings; (2) at least 5 servings provided health benefits by improving the quality of the overall diet for problem nutrients, such as folic acid, and possibly also by displacing less healthful foods; (3) although epidemiologic studies rarely specified how many servings were optimal, at least 5 servings allowed for a daily mix of items high in provitamin A and vitamin C, fiber, and from plant families such as cruciferous vegetables and citrus fruits, and therefore seemed likely to include choices associated with reduced cancer risk; (4) at least 5 servings was not so high as to be seen as impossible to attain by consumers, and the number was consistent with other dietary recommendations; and (5) the number 5 was memorable and provided a platform for creative message and program development.48 The recommendation to eat 5 or more servings a day was made in several relevant policy documents at this time, for example, by the NRC in its Diet and Health report,28 USDA/Department of Health and Human Services (DHHS) in their dietary guidelines,38 DHHS in Healthy People 2000,37 and USDA in its Food Guide Pyramid.39
The planning for a national program began with discussions in 1990 among representatives of industry, the California program, and the NCI. The PBH Foundation was formed in May 1991 with contributions from about 60 companies and commodity groups totaling $415,000. The nonprofit PBH was conceived as a partner with the NCI to oversee industry participation, thus enabling the NCI to interface with only one industry organization. California negotiated an agreement to assign legal rights to the program logo, slogan, and program standards to the NCI. As a result, NCI's Board of Scientific Counselors approved the concept proposal for the program in October 1991 with a budget of $27 million for 5 years and the option of continuing the program for a second 5-year period. The concept formed the basis of a Request For Applications (RFA) totaling $16 million and designed to fund research on the impact of 5 A Day interventions on dietary behaviors in controlled trials.
Intervention Models
The techniques of social marketing guided the communications strategies for the program. Various studies had shown that the media played a vital role in increasing consumer awareness of health issues and, in some instances, even in changing individual patterns of behavior.49-51 Data suggested that, while members of the public were concerned about diet and health, they lacked sufficient knowledge to act effectively on these concerns.52
Although use of the media alone can produce behavioral change, research had shown that the effect may be increased when supplemented by other community-based educational efforts.53-55 Three major theories used in the cardiovascular health promotion trials guided the national 5 A Day Program: the Health Belief Model,56 Social Cognitive Theory,57,58 and the Transtheoretical Model or Stages of Change Model.59,60 Key constructs from these theories were applied across a range of settings, including the media, supermarkets, schools, worksites, food assistance programs, churches, food service/restaurants, and health care settings. The theoretical models suggested targeting increasing awareness and motivation, building skills, providing social support for behavior change, and establishing environmental and policy supports.61 These theoretical constructs were incorporated into the guidelines for licensed 5 A Day Program participants, and some were used in the community-based research grants.
Collaborations and Sponsorship
The partnership between the NCI and the PBH promoted national nutrition objectives using media and campaign strategies to promote and reinforce appropriate messages. The formation of the PBH provided a vehicle for building collaborations within the vegetable and fruit industry and provided an infrastructure for the national program. The roles of the NCI were to maintain the scientific credibility of the program, plan and conduct evaluations, create an RFA for developing community interventions, and develop materials and training through NCI's Office of Cancer Communications (NCI/OCC). The roles of the PBH were defined as performing public relations functions, fundraising and providing in-kind support, implementing the point-of-purchase plan, recruiting additional partners, and monitoring implementation of the campaign. Through the community component of the 5 A Day Program, the NCI began licensing state and territorial health agencies in 1993 to coordinate and deliver 5 A Day activities through community channels. The roles of funded state health departments included developing coalitions with the food industry, monitoring implementation and conducting evaluations of state programs, and providing local placement of mass media. Statewide coalitions included state and county health agencies; state departments of education and agriculture; cooperative extension; Special Supplemental Nutrition Program for Women, Infants, and Children (WIC); voluntary agencies; businesses; media organizations; health care organizations; and state dietetic associations, although the structure and composition of these coalitions were left to the discretion of the state program coordinators. This flexibility enabled the coordinators to tailor program design to the needs of each state.
In 1996, the NCI expanded the 5 A Day Program to other Federal government health-promotion programs by licensing the U.S. Uniformed Services (Air Force, Army, Navy, Marines, and Coast Guard) and the Indian Health Service. The NCI also developed an agreement with the USDA Food and Nutrition Service (Team Nutrition) to promote 5 A Day in school classrooms and cafeterias across the Nation. 5 A Day messages also were integrated into the nutrition education efforts of the WIC Program, the Farmer's Market Nutrition Program (FMNP), the Commodity Supplemental Food Program (CSFP), and the Child and Adult Care Food Program (CACFP). NCI's partnership with the CDC, Division of Nutrition, was developed based on an interagency agreement to evaluate, award, and monitor grants to state health agencies. In 1994 and 1995, the CDC funded 38 intervention grants for 1 year addressing 5 A Day project areas in new and relatively untested community channels. In coordination with the CDC, the NCI in 1995, 1996, 1997, 1998, and 1999 also funded 31 grants to evaluate 5 A Day interventions implemented at the state level within specific community channels.
NCI's 5 A Day Program also developed partnerships with a variety of voluntary associations. The collaboration with the ACS included the participation of 32 representatives from state and local ACS chapters in 23 state coalitions affiliated with the 5 A Day Program. The ACS partnered with NCI's 4-year research grants—contributing to research in black churches in North Carolina, worksites in Arizona, elementary schools in Alabama, and high schools in Louisiana. Recently, the NCI and the ACS began collaborating on a project to diffuse and disseminate the approach used in the black churches study. The NCI 5 A Day Program also established an alliance with the American Dietetic Association (ADA). This alliance included collaborating on ADA nutrition month activities, 5 A Day communication training for ADA media advisors, and collaborating on 5 A Day Fact Sheets in the Journal of the American Dietetic Association. The 5 A Day Program also linked with the American School Foodservice Association and the USDA to undertake 5 A Day activities for School Lunch Week.d
b In addition, the accumulating scientific evidence contributed to strengthening the focus on vegetable and fruit messages in these documents. In the 2000 U.S. Dietary Guidelines and Healthy People 2010, vegetable and fruit objectives have been expanded and strengthened. The Healthy People 2010 includes two nutrition objectives focusing on vegetables and fruit, as opposed to only one in 2000. In the recently released 2000 U.S. Dietary Guidelines, there is a stand-alone, prominently placed vegetable and fruit guideline, versus a combined fruit, vegetable, and grain guideline in 1990.
c Measures of vegetable and fruit consumption will differ based on the definition of serving size, whether or not small amounts of vegetables and fruit in mixed foods are disaggregated and included in the total, whether or not fried and high-fat vegetables and fruit included in baked goods and candy are included, and whether or not information on portion sizes and mixed foods is captured.d This section is derived extensively from Chapter 2 of the forthcoming 5 A Day monograph by Stables, G., J. Heimendinger, E. Pivonka, S. Foerster. "National Program Structure Components" (in press).
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