Examination of the Adherence to the “5 a Day the

HJCE

Color Way” Campaign Among Parents and Their

Preschool Children
MARILYN S. NANNEY, PHD, MPH, RD, REBECCA SCHERMBECK, RD,
Adherence to the “5 a Day the Color Way” Campaign

DEBRA HAIRE-JOSHU, PHD

Abstract—Background. The evidence of health benefits associated with the consumption of a vari-
ety fruits and vegetables (FV) is well known. The “5 A Day Color Way” campaign is a national
effort to translate the science with a message of increased colorful FV consumption for the public.
The extent of the translation and adherence to these recommendations among families in a com-
munity setting is an important public health question. Methods. Parents enrolled in 8 rural Mis-
souri county parent education programs answered surveys for their preschool children (n = 1658)
about FV consumption and barriers to purchasing them by color. Results. Of parents, 40% (n =
668) and 26% (n = 425) of children ate from all 5 colors some time the previous week. However,
no parents and only 1 child attained perfect adherence to the guidelines (all 5 colors most days of
the week). Disliking the taste and not in the habit of purchasing colorful FV were significant pre-
dictors for not meeting recommendations for red, yellow/orange, and green FV. Conclusions. Inter-
ventions targeting young children and their families (ie, child care settings, elementary schools)
that establish preference for color specific FV may be ideal in rural communities to encourage
movement toward adherence to the campaign. J Cancer Educ. 2007; 22:177-180.

I
t is well known that compounds found in fruits and veg-
etables (FV) play an integral protective role in the pre-
vention of many cancers, heart disease, and stroke.1,2
Evidence is surfacing that supports the role of FV in the
prevention of cataracts, chronic obstructive pulmonary dis-
ease, diverticulosis, and hypertension.3 The “5 A Day for
Better Health” program, a national cancer prevention cam-
paign, has communicated to Americans to eat a variety of 5
or more servings of fruits and vegetables daily for more than
10 years with great success.4 The newly revised and current
campaign, “5 A Day the Color Way,” expands on the previ-
ous message and encourages consumers to “sample the com-
plete color spectrum every day”5 Consuming red, green,
yellow/orange, white, and blue/purple FV daily assures con-
sumption of compounds responsible for disease prevention.1
Center for Disease Control data from 2003 reports only
23% of Americans claim to eat 5 or more FV serving/day.6
However, these data do not document the distribution of
intake as defined by color. This is particularly intriguing
given the concerted national FV campaign to the public.
Received from University of Utah, Salt Lake City, (MSN); and Saint
Louis University, St Louis, MO (RS, DH-J).
Supported by the National Cancer Institute (5 R01 CA68398).
Address correspondence and reprint requests to: Marilyn S. Nanney,
PhD, MPH, RD, University of Utah, Health Promotion & Education,
1901 E. So Campus Drive Annex 2115, Salt Lake City, Utah 84112;
phone: (801) 585-5679; fax: (801) 585-3646; e-mail: <susie.nanney@
hsc.utah.edu>.
In this article, we examine the degree to which this
national message has been translated to parents and pre-
school children in a rural community setting by examining
their consumption patterns and barriers to purchasing
color-specific FV.
METHODS
This study was conducted in collaboration with Parents
As Teachers (PAT), a national parenting and child devel-
opment program serving families in all 50 states. PAT is
committed to assisting parents in preparing their 0 to 5
years children for kindergarten through social, emotional,
cognitive, and motor skills development. The philosophy of
the organization is that “parents are a child’s first and most
influential teacher.”7 Program sites across the United States
self report that they are mostly located in rural communi-
ties (55%) and further classify themselves as small towns
(33%). Fewer program sites identify themselves as located
in urban (20%) and suburban (15%) areas. According to
the 2001 annual report, rural programs served 87,985 fami-
lies and urban programs served 52,387 families.
Sample/Setting
Parents (n = 1658) of preschool children (2 to 5 years)
enrolled in 1 of 16 PAT program sites located in 8 rural
Southeast Missouri counties were recruited by their parent

177
educator to participate in the study. These 8 counties repre-
sent a distinct geographic region for PAT services, and
overall, residents experience the poorest chronic disease
health outcomes in the state.8 Recruitment strategies
included personal invitations and flyers. All families
enrolled in PAT with a child who would be 2 to 5 years old
sometime during the following school year were eligible to
participate. Data was collected over 3 years during the fall
(2002-2004). The Institutional Review Board of Saint
Louis University approved this study, and informed consent
was obtained from all participants.
Survey Instrument
Trained, professional interviewers assessed eating habits
and determining factors. Parents completed a telephone
interview answering questions for themselves and their pre-
school child about their FV intake during the past 7 days
using a 29-item food frequency questionnaire. Develop-
ment of the Saint Louis University for Kids Food Frequency
Questionnaire (SLU4Kids FFQ) included a systematic
approach to determine the foods relevant to parents (20-49
years) and children (2-5 years) living in the rural Midwest9
for inclusion. Development and validation of SLU4Kids
FFQ is described in detail elsewhere.10,11 Parents were asked
“did you have cantaloupe in the past seven days?” If yes,
how often? One time, 2 times, 3 to 4 times, 5 to 6 times, 7
or more times? Each question/food was repeated using the
child’s name. FV intake over the 7 days was converted into
the number of times consumed per day for each individual
food item. The test-retest reliability for the summed mea-
sures of FV intake showed excellent reliability, with an
intraclass correlation coefficient (ICC) of .82.
Personal and community factors determining FV intake
by color was assessed with the following question: “What is
the main reason that you don’t buy more orange fruits or
vegetables like cantaloupe and carrots?” The question was
repeated for green, red, and purple FV. Response choices
were not read to the participants and included common
personal (don’t like the way they taste, take too long to pre-
pare) and community barriers (too expensive, not avail-
able/not high enough quality where I shop). The test-retest
reliability for the measures of determining factors also
showed good reliability, with a 76% agreement (n = 127).
Parents were given a $20 gift card for completing the sur-
vey, with a response rate of 82%.
General demographic characteristics such as age, educa-
tional attainment, height, and weight were self-reported by
the parent.
DATA PREPARATION AND ANALYSIS
Two registered dietitians (MSN, RMS) independently
categorized each SLU4Kids FFQ FV as either red, green,
orange/yellow, white, or purple/blue using the “5 a Day
Color Way” color categories (98% agreement). Where
questions concerning the specific color of foods was in
178
question (green, red, or black grapes), the national Con-
tinuing Food Survey Intake Interview data (1994, 1996-
1997) was used to determine which was mostly eaten by
this age group within this geographic setting. This resulted
in 5-color categories: red (n = 3; strawberries, tomatoes,
apples), orange/yellow (n = 6; cantaloupe, pineapple,
peach, corn, carrots, orange), green (n = 5; lettuce, green
beans, peas, broccoli, other vegetables), white (n = 3; pears,
banana, nonfried potatoes), and purple/blue (n = 2; grapes,
other fruits). Consistent with the “5 a Day Color Way”
color specifications, juice, beans, and fried potatoes were
not included.
Initial analyses were performed by creating summary
scores or counts of total FV eaten by color for the parent
and child. The dependent variable, number of times that
FV were eaten in the previous week, was dichotomized to
reflect those who ate them most days of the week versus
fewer days (≥ 3.5 vs ≤ 3 days). The independent variables,
main reason identified as to why those FV were not pur-
chased (taste, habit, skill, expense, availability), was
recoded to compare to the referent group only (taste vs. I do
buy them; expense vs I do buy them). All data were cate-
gorical data, and logistic regression was performed. To iden-
tify to what extent determining factors influenced FV
intake by color, odds ratios (OR) with 95% confidence
intervals were conducted. An OR of 1.00 would indicate no
difference in rates between the group of interest and the
reference group. Lack of statistical significance of these OR
is determined by the presence of 1.00 in the 95% confi-
dence intervals.
RESULTS
Color Adherence
Adherence to the 5 A Day the Color Way recommenda-
tions was examined by frequency of consuming FV color
categories the previous week among a sample of mostly
young (mean age = 29 years), White (76%), married (69%)
females (98%) with at least a high school education (84%)
and their preschool children (52% males; mean age, 3.2
years) living in 8 rural Missouri counties. Most answering
parents worked for wages (58%), with 39% earning
between $15,000 and $35,000 annually. Parents report eat-
ing fast food a little more than twice per week (mean times
per month, 7.2). Most parents were trying to lose weight
(60%) but were not very concerned that their child would
become overweight (17%).
As depicted by Table 1, 40% (n = 668) of parents and
26% (n = 425) of children ate from all 5 colors. Parents
consuming from all 5 colors some time the previous week
(vs <5 colors) were more likely to be older (28 vs 30 years),
more educated, and have a higher income (data not
shown). There were no differences between parent groups
for body mass index (mean, 27.1 ± 6.4 vs 27.2 ± 6.4, P =
.72). Children consuming from all 5 colors some time the
previous week were slightly older, weighed 1 lb more (35.7
NANNEY et al. ■ Adherence to the “5 a Day the Color Way” Campaign
 TABLE 1. Number of Fruits and Vegetables (FV) Colors Factors That Influence Color Adherence
Consumed the Previous Week*
Barriers to purchasing FV by color were examined by
Parents Children personal (taste preference, purchasing habits, and prepara-
Color Count % n n % tion skills) and community (expense, availability and qual-
ity of produce where they usually shop) factors. Disliking
Only 1 FV color .7 11 7.1 117 the taste was cited most often for all colors as the main rea-
At least 2 FV colors 4.4 73 13.6 225 son for not buying them, and lack of preparation skill was
At least 3 FV colors 15 249 22.2 368 the least cited. Those identifying taste as the main reason
At least 4 FV colors 39.6 656 28.1 466 that they did not buy red, yellow/orange, or green FV were
All 5 FV colors 40.3 668 25.6 425 45% to 60% less likely to eat those colors most days of the
*Counts exclude fried potatoes, beans, and juice. week compared to those who reportedly do purchase them
(Table 3). Similarly, those “not in the habit of buying
them” were 20% to 58% less likely to meet recommenda-
tion of eating their colors (red, yellow/orange, green) most
TABLE 2. Fruits and Vegetables (FV) Colors Consumed days of the week. Community factors did not significantly
Most Days the Previous Week* impede meeting recommendations.
Parents Children
CONCLUSIONS
Color (>3.5 times) % n % n
This study is the first of its kind to examine FV intake by
Any Green FV 1 16 3) 42 colors in a large community setting. Although colorful FV
Any Yellow/Orange FV 0.4 6 0.1 2 consumption in rural Missouri families is inadequate, our
Any Red FV 5 79 3 53
study identifies that eating from all 5 colors most days of
Any White FV 9 152 4 58
the week is associated with about a 1½ increase in total
Any Purple FV 7 123 4 66
daily servings among parents and their preschool children.
*Counts exclude fried potatoes, beans, and juice. Community-based FV interventions that promote a general
“5 A Day” report an average increase of 0.1 to 1.4 FV serv-
ings/day for adults12 and 0.3 to 0.99 FV servings/day for
children.13 Several color specific FV interventions have
vs 36.7 lb), and parent reported more FV as the child’s been conducted with success among highly motivated indi-
favorite. Eating from all 5 colors was associated with higher viduals (ie, cancer patients) in clinical settings and have
overall FV intake for parents (5.0 ± 2.2 vs 3.5 ± 1.8, P = reported significant increases by total servings and color.14-17
<.01) and children (6.0 ± 2.5 vs 4.6 ± 2.2, P = <.01). Personal preference continues to be an issue, at least among
No parents and only 1 child attained perfect adherence this rural population. Surprisingly, price and quality of the
to the guidelines (all 5 colors most days of the week; data produce where parents usually shop did not significantly
not shown). Table 2 identifies that specific color adherence predict intakes. Although generalizing these findings to
was greatest for white (4%-9%) and purple (4%-7%; ie, nonrural settings is inappropriate at this time, these data
grapes, raisins, plums) and the least for yellow/orange FV are consistent with national data18 and other studies19,20
(<1%). Among the white FV, baked, mashed, or boiled that identify taste as the lead predictor of FV consumption
potatoes were most commonly consumed. among adults and youth. The best available evidence to

TABLE 3. Factors Impeding Colorful Fruit and Vegetable Consumption Adherence*

Red FV Yellow/Orange FV Green FV

N Odds Ratio 95% CI N Odds Ratio 95% CI N Odds Ratio 95% CI

Personals Factors
Taste 381 .456 .349, .596 745 .604 .472, .773 984 .614 .484, .780
Purchasing Habits 86 .525 .330, .835 107 .579 .377, .889 71 .200 .111, .362
Preparation Skill 1 .975 .215, 4.416 7 0 14 8.952 1.159, 69.126
Community Factors
Expense 128 1.136 .769, 1.678 57 1.131 .708, 1.419 47 1.469 .770, 2.803
Availability/Quality 304 .991 .748, 1.314 199 1.002 .638, 2.730 35 1.320 .638, 2.730
I Do Purchase Them 548 R R 400 R R 385 R R

*Bold indicates P < .05. R indicates Reference group.

Journal of Cancer Education 2007, Volume 22, Number 3 179

affect lifelong preference for FV is early exposure (ie, pre-
school years) and often21,22 and parental role model-
ing.20,23 The “5 a Day the Color Way” campaign is the
next generation of public messaging designed to promote
awareness of the specific health benefits of each fruit and
vegetable by color. Evidence suggests that interventions
promoting a colorful FV diet targeting families with young
children (ie, child care settings, elementary schools) may
be ideal.
References
1. Nanney M, Haire-Joshu D, Brownson R. Rationale for a “power-
house” approach to vegetable and fruit interventions. Am J Diet.
2004;104:352-356.
2. Van Duyn MAS, Pivonka E. Overview of the health benefits of fruit
and vegetable consumption for dietetics profesional: selected litera-
ture. J Am Diet Assoc. 2000;100:1511-1521.
3. Lui R. Health benefits of fruit and vegetables are from additive and
synergistic combination of phytochmeicals. Am J Clin Nutr.
2003;73(suppl 3):517S-520S.
4. Heimendinger J, Van Duyn MA, Chapelski D, Foerster S, Stables G.
The national 5 A Day for Better Health program: a large-scale nutri-
tion intervention. J Public Health Manag Pract. 1996;2:27-35.
5. 5 a Day the Color Way. Why 5 a Day the Color Way. 5 a Day Web
site. Available at: http://www.5aday.com. Accessed October 16, 2006.
6. Center for Disease Control and Prevention. 5 a Day: Data and Statis-
tics Display. 2005. Available at: www.apps.nccd.cdc.gov/
5ADaySurveillance/displayV.asp. Accessed March 29, 2006.
7. 2001 Annual Report. Parents as Teachers National Center, Inc.
St. Louis, Missouri. Parents as Teachers Web site. Available at:
http://www.parentsasteachers.org. Accessed October 16, 2006.
8. Brownson RC, Smith CA, Pratt M, et al. Preventing cardiovascular
disease through community-based risk reduction: the Bootheel Heart
Health Project. Am J Public Health. 1996;86:206-213.
9. Nanney M, Haire-Joshu D, Hessler K, Elliott M, Brownson R. Evalu-
ating changeability to improve fruits and vegetables intake among
school aged children. Nutr J. 2005;4:34.
10. Linneman C, Hessler K, Nanney S, Steger-May K, Haire-Joshu D.
Parents are accurate reporters of their preschoolers’ fruit and
180
vegetable consumption under limited conditions. J Nutr Educ Behav.
2004;36:305-308.
11. Nanney MS, Johnson S, Elliott M, Haire-Joshu D. Eating home grown
produce is associated with higher intake and less costs for parents and
their preschool children in rural Missouri. J Am Diet Assoc. In press.
12. Pomerleau J, Lock K, Knai C, McKee M. Interventions designed to
increase adult fruit and vegetable intake can be effective: a systematic
review of the literature. J Nutr. 2005;135:2486-2495.
13. Knai C, Pomerleau J, Lock K, McKee M. Getting children to eat more
fruit and vegetables: a systematic review. J Prev Med. 2006;42:85-95.
14. Noakes M, Clifton P, Ntanios F, Shrapnel W, Record I. An increase
in dietary carotenoids when consuming plant sterols or stanols is
effective in maintaining plasma carotenoid concentrations. Am J
Clin Nutr. 2002;75:79-86.
15. Lanza E, Schatzkin A, Daston C, Corle D, Freedman L. Implementa-
tion of a 4-y, high-fiber, high-fruit-and-vegetable, low-fat dietary
intervention: results of dietary changes in the Polyp Prevention Trial.
Am J Clin Nutr. 2001;74:387-401.
16. Rock CL, Moskowitz A, Huizar B, Saenz CC, Clark JT, Daly TL.
High vegetable and fruit diet intervention in premenopausal women
with cervical intraepithelial neoplasia. J Am Diet Assoc.
2001;101:1167-1174.
17. Smith-Warner S, Elmer P, Tharp T, et al. Increasing vegetable and
fruit intake: randomized intervention and monitoring in an at-risk
population. Cancer Epidemiol Biomarkers Prev, 2000;9:307-317.
18. Glanz K, Basil M, Maibach E, Goldberg J, Snyder D. Why Americans
eat what they do: taste, nutrition, cost, convenience, and weight con-
trol concerns as influences on food consumption. J Am Diet Assoc.
1998;98:1118-1126.
19. Blanchette L, Brug J. Determinants of fruit and vegetable consump-
tion among 6 12 year old children and effective interventions to
increase consumption. J Hum Nutr Diet. 2005;18:431-443.
20. Cullen K, Baranowski T, Owens E, Marsh T, Rittenberry L, de Moor
C. Availability, accessibility, and preferences for fruit, 100% fruit
juice, and vegetable influence children’s dietary behaviors. Health
Educ Behav. 2003;30:615-626.
21. Birch L. Development of food preferences. Annu Rev Nutr.
1999;19:41-62.
22. Birch L. What kind of exposure reduces children’s food neophobia?
Looking vs tasting. Appetite. 1987;9:171-178.
23. Nicklas T, Johnson R. Dietary guidance for healthy children aged 2 to
11 years. J Am Diet Assoc. 2004;104:660-677.
NANNEY et al. ■ Adherence to the “5 a Day the Color Way” Campaign