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In 1993, an estimated 1,170,000 new cases of cancer were diagnosed and 526,000 people died of cancer in the United States (1). Cancer accounts for 23% of all deaths in the United States, 35% or more of which may be attributable to unhealthful dietary patterns (2,3). Diets that are high in fat, low in fiber, and/or low in fruits and vegetables have been associated with increased incidence and mortality from various cancers (4-6).
The scientific rationale for increasing consumption of fruits and vegetables is compelling. Two recent reviews of up to 200 studies on this subject found that the majority have shown an increased intake of fruits and vegetables to be associated with a reduced risk of various cancers (7-9). Such cancers include those of the pharynx, esophagus, oral cavity, stomach, pancreas, colon, rectum, larynx, lung, bladder, endometrium, cervix, and ovary. These studies have been performed in different countries using a variety of dietary assessment methods. They include case-control, cohort, and within-country and between-country correlation studies.
On the basis of the strength and consistency of this association, in 1991 the National Cancer Institute (NCI) instituted the national 5 A Day for Better Health Program to encourage Americans to eat 5 or more servings of fruits and vegetables every day, which is one of the nation's health promotion and disease prevention objectives (10). The program is a public-private partnership between the NCI and the Produce for Better Health Foundation (PBH), a nonprofit foundation representing the fruit and vegetable industry. Industry participants include supermarkets, independent grocery stores, merchandisers, suppliers, commodity groups, marketers, and foodservice operations. The 5 A Day Program represents a model for public-private partnerships and community nutrition education.
Surveys indicate that Americans fall far short of the five or more servings recommended in the US Dietary Guidelines (11), the Food Guide Pyramid (12), and the Diet and Health report (13). In 1991, at the beginning of the 5 A Day Program, only 2395 of the population were consuming the recommended level of fruits and vegetables (14).
The 5 A Day Program includes retail, media, community, and research components. Supermarkets and foodservice retailers advertise the program in local media and provide consumers with brochures, recipes, and interactive events such as food demonstrations. The NCI and PBH are working together to develop a comprehensive media campaign to obtain consistent coverage of the 5 A Day Program. The community component of the program attempts to reach consumers at the local level through the cooperative efforts of health, educational, agricultural, and voluntary agencies and the private sector. Participating state health agencies coordinate 5 A Day activities for their states through a variety of mechanisms, including the development of coalitions. The research component is an extension of the community component. After the review of a large number of proposals submitted in response to a request for applications, the NCI funded nine studies in the spring of 1993. The studies, which will be conducted at worksites, schools, churches, and food assistance programs, will be completed in the spring of 1997. The purpose of the research is to develop, implement, and evaluate interventions in specific community channels to increase the consumption of fruits and vegetables in specific target populations.
The 5 A Day projects have chosen specific channels (eg, schools) and target populations (eg, fourth-grade schoolchildren) for intervention. The projects will randomize a large number of units (eg, worksites) to either intervention or control status. All have based their interventions on one or …