The Five-a-Day campaign has spread throughout the world and is undoubtedly a resounding success, is this reality or merely public perception?

The five-a-day campaign started in the early 1990’s making it one of the first public health campaigns, it is certainly the longest running and as a consequence many people are aware of its existence, even if they are oblivious to its meaning.

The essay will look back at the long history of this health scheme, to a time before its introduction in to the United Kingdom (UK) and ascertain the reason for its initiation; following through with a review of its successes and known failures. An investigation will explain why it was necessary to recently clarify what could be included in your five-a-day recommendations, and whether there were any specific guidelines for children. It will look at other developed countries of “five-a-day” recommendations and how they differ from the UK.

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The five-a-day health promotion was initially implemented in the United States of America (USA) in 1991 by the National Cancer Institute and the Produce for Better Health Foundation (Obesity Epidemiology, 2010). The promotion advised that to limit the occurrence of cancer, diabetes or cardiovascular disease we should eat a minimum of five portions of fruit and vegetables per day. This was deemed necessary as cancer accounts for around 20% of deaths in the developed world and is the second most common cause of death. It is thought that much of this is triggered by environmental influences rather than genetic effects. Studies have proved that migrants moving from low to high risk countries adopt their host countries cancer patterns within a short space of time.

Epidemiology estimates demonstrate that a healthier choice of food in our diet could prevent 32-35% of some cancers in the developed world (Human Nutrition and Dietetics, 2000). Our present history of western diseases has made health initiative schemes essential to educate or remind the population on what constitutes good food choices. The power of epidemiological study is vital in our understanding of public health. The Framingham Heart Study carried out in the United States of America is an excellent example of the incredible worth of systematic gathering and analysis of data from medical professionals.

The long-term epidemiological study involved a cohort of 5000 men and women from 1948 until the present day. The analysis of the study group has given the world invaluable information to the many risk factors of cardiovascular disease. Very little was known of the common features of coronary heart disease before the findings of these studies. Coronary heart disease is the number one cause of death in the UK and the Framingham heart study is repeatedly referred to in peer viewed articles, this only emphasizes its vital worth.

The five-a-day initiative was launched during a time in history just prior to the information explosion with the development of many new media sources which have been continually increasing in both number and sophistication. From early media such as newsprint and television to the present day when via the internet and numerous readily accessible “gadgets” the general public have easy access to vast amounts of health and nutritional information such as British dietary survey reports, carried out by the Scientific Advisory Committee on Nutrition (SACN) in 2008. These surveys are undertaken at regular intervals from a cross section of the UK population, with a view to giving us a general analysis of our nutritional status and attempting to target those more in need of essential nutrients for better health.

The name of the report is, “The Nutritional Wellbeing of the British Population, an analysis of British dietary surveys.” The nature of these types of reports has given rise to opportunities for a huge amount of journalistic criticism, especially of the five-a-day plan since it was endorsed by the Department of Health in 2002. And rightly so, as the 2008 SACN report tells us that there has been a decline in fruit and vegetable consumption since 2002 by elderly people in institutions, young adults, people on benefits and young children. These groups of society are in obvious need of a boost to their micronutrient intake and should be a priority for the government’s health agency.

The useful report also highlighted that it is necessary to take into account an individual’s biochemical status to get a true picture of their nutritional health. With regard to the efficient functioning of micronutrients, additional factors need to be taken into consideration, such as a person’s genotype, possible smoking habits and lack of sunshine (vitamin D), all of which could affect efficient functioning and absorption of particular micronutrients. This is a valid point, but would be at great cost to society as blood tests would be required. The costs could be even greater if rickets or osteoporosis developed in our high risk cohorts of the population. Thus, prevention would be less costly than cure.

Despite these findings and regardless of our British passion for roast beef and Yorkshire pudding the overall population does have a healthier eating pattern. So, the impact of five a day for the rest of the UK population seems to have had a positive effect on lives. From the onslaught of sophisticated media in the twenty first century the British are less gastronomically illiterate. In general, if we have the time, we do seek out to and eat a greater variety of interesting foods, not just the ones’ in neat dull packets on supermarket shelves. The five-a-day campaign has contributed to this increased interest in food and helped to brush off our image of a “meat and two veg” nation.

“The fruit vegetable task force” (August 2010) report shown on the Department of Environment, Food and Rural Affairs (Defra) website informs us that poor nutrition costs the NHS approximately £6-7 billion in 2002. Drastic measures needed to be carried out and the five-a-day promotion no doubt seemed the obvious choice to the government’s healthcare advisors, but it could have been conducted differently.

The UK agencies responsible for the scheme’s introduction and management appeared to ignore mistakes made in the American model. A national survey was conducted in the USA in 1997 with the objective to review the impact of five-a-day since its inception in 1991. The US survey reported a significant increase from 3.75 to 3.98 portions per day. However, at a later date it was proved that these figures were demographically incorrect as they failed to take into account the sub-groups of society.

Maybe the UK campaign should have assessed the fruit and vegetable consumption of the high risk groups of our own society before investing millions of pounds into its promotion. The money could have been put to better use if specific groups of society were targeted and helped in improving their diets and therefore able to develop better health habits. Improved health habits could subsequently reduce the colossal cost to the United Kingdom tax payer for poor dietary health related diseases.

The task force also confirmed a decrease in fruit consumption, but a definite increase in the purchase of fruit juice. An average carton of commercialised fruit juice will contain 10g of sugar per 100ml and decreases by an average of 40% with freshly squeezed unpasteurised orange juice. Extraction of juice from fruits will reduce the fibre content and release non-milk extrinsic sugars. The non-milk extrinsic sugars can help to cause tooth decay so most dentists instruct children not to consume more than one glass of fruit juice per week while wearing retainers.

It is healthier to eat an intact whole orange, as this will moderate the release of fructose into the bloodstream therefore regulating a sensible insulin release. The numbers of confirmed Diabetics in the UK population have increased to 3 million in the UK and are expected to reach 5 million people by the year 2025. So, this sort of valuable information should be made clearer through the five-a-day campaign. Increasing public awareness of specific problem areas should be the key to health initiatives to subsequently improving overall public health.

The European Prospective Investigation into Cancer and Nutrition (EPIC) study in 2010 proved that out of the 200 cancer diseases only a handful of them such as mouth, larynx, oesophagus, bowel and lung can be reduced with an increase of fruit and vegetables. Five-a-day campaign will have no effect on breast, prostate, ovarian or lymphoma cancers. Breast cancer is more associated with a diet high in saturated fat and alcohol and lack of exercise, more than the absence of fruit and vegetable.

Officials at Cancer Research UK are keen to express that there are of course many other benefits to eating fruit and vegetables, for example the consumption of fruit and vegetables instead of high energy foods would increase our fibre intake; which could decrease chances of obesity, heart disease and of course bowel cancer. It is important that the five-a-day initiative should emphasize the prominence of a varied diet which takes into account all the main food groups. Some fruits and vegetables are being branded as ‘super-foods’ and that leads people to the misconception that once consumed they are a cure to cancer, but as the EPIC study shows; they may only play a small part towards some cancer preventions.

A better campaign than five-a-day would have been to encourage the population to simply include vegetables or fruit with every meal. Building this lifetime habit of thought can only benefit all of society with long-term good health. An increase in detailed information is needed to express the importance of vegetable and fruit consumption to our daily diet in relation to the prevention of early stroke, heart diseases and some cancers. Any new campaign should also focus on children during their early years in order to be most effective. So, fruit and vegetables images should be prominent in nurseries, schools and health clinics or any establishments that children frequent. If healthy food images were an everyday visible image in a child’s life it would only help to enforce good dietary messages. The awareness of sensible dietary choices should be prominent through-out a child’s school career, not just as a short unit of the current national curriculum.

It is widely known that the United Kingdom recommends five portions of fruit and vegetables per day and many European countries also advise the same, but the other countries such as Greece along with the USA proposes 9 portions and the Irish government 4 portions daily. Each of these countries has a pyramid or plate for illustrating a balanced healthy diet aimed at the general public. However, people with particular health conditions should be told to seek medical help and not rely totally on the pyramid guidelines.

The German government’s health agency produces an impressive three-dimensional pyramid that gives space of four sides allowing for quantitative as well as qualitative dietary information. The pyramid could be adopted in the United Kingdom and turned into a tactile object such as a soft toy which would be of more interest to young children, especially if the illustrations on sides were to be in vibrant colours of five-a-day recommendations for daily fruit and vegetables. With some imagination it could be transformed into a mathematical style puzzle toy to sit alongside other similar based toys in a classroom setting to emphasize its importance to older pupils.

Children all learn in different ways, while book based illustrations and posters are very useful to emphasise five-a-day, an additional tactile form of health diet education may be something that will also stick with them for life.

Young children need to eat more frequently than adults so, having a classroom reminder that illustrates possible health snacks, i.e. raw vegetables or fruit shown on a three dimensional food pyramid would be a way of building beneficial lifelong habits.

The National Health Service’s “Livewell” campaign gives an indication of a child’s five-a-day portion size; it is roughly the amount they can fit into the palm of one hand. Unfortunately, this information is not displayed on their posters or eatwell plate or the UK pyramid! If this information was made clearer it could help towards reducing the danger of a child eating in excess of their needs, and possibly developing an unhealthy weight or dental problems if too much fruit is consumed. It is predicted in the USA that a possible source of obesity is that obese people are eating their five-a-day recommendations as well as what they have always consumed in the daily diet, so just adding to their overall calorie intake. In the UK it should be emphasized that fruit and vegetables ought to replace high calorific or fatty foods.

It appears as if the message of ‘five’ per day was originally a marketing tool, as five is a memorable number; however, there has never been any scientific evidence to back up this theory. A better message would be to encourage parents to keep their children healthy by avoiding processed foods and drinks as much as possible, as these are seen to be significantly a big contributor to ever increasing levels of obesity amongst both the UK adult population and in particular young children and teenagers. This last point should be of serious concern to the current and future governments.

Obesity has been on the rise in the UK since the mid-1990s and very worryingly among children between 4 to 5 years old, statistics show that 9.5% were obese in 2011 (National Obesity Observatory). By the time they leave primary school the current mean percentage of boys and girls overweight or obese is 34%. A future prediction from the National Obesity Observatory (NOO) estimates that a quarter of our children will be obese by the year 2050, if current trends persist.

There have been various speculations with the reason for childhood obesity. NOO statistics tell us that child obesity is dominant in areas of the United Kingdom that are socioeconomically deprived. Childhood obesity needs be addressed with the utmost urgency, because if allowed to continue into adulthood, it will have even wider reaching health consequences such as depression, low self-confidence, diabetes 2, cardiovascular diseases and cancers.

There is also a huge prediction of cost to society for obesity of £50 billion per year by the year 2050, (as per UK government Foresight Programme report, 2007). With all these facts in mind it is important that five-a-day does not promote the consumption of more processed food (as the easy solution).

Defra reported that by the end of 2010 families of low-income earners were reducing their fruit and vegetable consumption to half of what five-a-day recommends, due to the increasing cost of food prices during the recession. In answer to this the Food Services Agency (FSA) advised a credit crunching five-a-day plan. The plan’s advice included; buying from local markets, buy in season vegetables and the use of frozen or tinned fruit and vegetables can be included in your five-a-day recommended daily consumption as well. The advice given is very useful but it should clarify that when purchasing tinned varieties or fruit and vegetables one should ensure that they are not laden with syrup, salt and added sugar.

In conclusion, Five-a-day may not be a resounding success and it certainly is not free of faults, but to those who were ready to listen, it has highlighted the awareness of their mortality and the devastating effect that a poor nutrient diet can bring. These people will hopefully avoid or delay the onset of diet related diseases.

The scheme has brought forward a good grounding for many other health department initiatives and hopefully these new and improved promotions will be more effective, especially in the fight to reduce obesity in the UK amongst our very young and vulnerable children.

Reference List

Annie S. Anderson, David Cox, (2000) “Five a day – challenges and achievements”, Nutrition & Food Science, Vol. 30 Iss: 1, pp.30 – 34 [Online]. Available from: Emerald Insight

http://www.emeraldinsight.com/journals.htm?articleid=866078 [Accessed 10th April 2013]

Crawford, D, Jeffrey R.W., Ball, K and Brug J. (ed.) (2010) Obesity Epidemiology from aetiology to public health, 2nd edition. Oxford University Press.

Department of Environment, Food & Rural affairs (2010): Fruit and vegetable task force report

Food Standards Agency, (2008), Manual of Nutrition, (11th edition).

Garrow, J.S., James, W.P.T. and Ralph A. (2000) Human Nutrition and Dietetics, (10th Edition)

http://www.nhs.uk/Livewell/5ADAY [Accessed 12th April 2013].

The Public Health England Obesity Knowledge and Intelligence team, formerly the National Obesity Observatory (NOO)

[Online]. Available from:

http://www.noo.org.uk/ [Accessed 11th April 2013]

The Scientific Advisory Committee on Nutrition (SACN) (2008).Report on the nutritional wellbeing of the British population.

[Online]. Available from:

www.sacn.gov.uk/reports_position_statements/reports/the_nutritional_wellbeing_of_the_british_population.html [Accessed 14th April 2013].

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