5 a day Q&A with Public Health England

Many of you have sent in questions about the 5 a day message and what the evidence is to back it up. Public Health England has been kind enough to answer them for us.

“The advice to eat at least five 80g portions (400g) of a variety of fruit and vegetables per day (excluding potatoes) was developed based on a recommendation from the World Health Organisation (WHO)[1]. This arises from epidemiological studies which show an association between the consumption of more than 400g of fruit and vegetables and lower levels of death from chronic diseases such as heart disease, stroke and some cancers by up to 20%[2]. A further reference to this association can be found in a paper by Bazzano and Israel[3].“

“In the UK, the Committee on Medical Aspects of Food Policy and Nutrition (COMA), reviewed the evidence and endorsed the WHO recommendation in 1998. This advice has since been endorsed by the Scientific Advisory Committee on Nutrition (SACN), which succeeded COMA in 2001.“ 

“The 5 A DAY programme was launched in March 2003 as part of the health promotion activity by the Department of Health to encourage people to eat at least 5 portions of a variety of fruit and vegetables a day.”

2. With the traffic light labelling lots of fruits are recorded as having ‘red’ for their sugar content. Should I still be eating them? (Lee Williamson)

“The sugars found in whole fruits and vegetables are classified as intrinsic sugars. Non-milk extrinsic sugars, such as those found in fruit juices and honey are added to foods, and may lead to tooth decay and excess calorie intake.” 

“The Scientific Advisory Committee on Nutrition (SACN) are currently reviewing the scientific literature to clarify the relationship between sugars and health as part of their review on carbohydrates. This report will be published for consultation later this year.”

“In regard to labelling of fruit/fruit products, Front of Pack guidelines state that the red, amber and green colour coding for sugars are determined based on total sugars, in accordance with European Union policy. This may include both naturally occurring and added sugars. As such it may be possible for fruit/fruit products to be labelled as high in total sugars.”

3. Different countries around the world have variations of the 5-a-day campaign. Is there any evidence looking at how different populations respond to [public health messages on] fruit and vegetable consumption? (Toria Harding)

“We do not hold any information on the impact of fruit and vegetable campaigns on consumption in other countries although there may be individual studies in the scientific literature. Different methods are used for measuring fruit and vegetable consumption in different countries which can make inter-country comparisons difficult. The Organisation for Economic Co-operation and Development (OECD) in 2012 published data on the percentage of adults in European countries who report eating fruit and vegetables on a daily basis[4]. This report stated that across 18 countries, 63% of adults reported eating fruit daily. The average daily consumption of vegetables by adults was the same as fruit, 63%. This is based on data from national health interview surveys in each country.”

4. Is the 5 a day campaign working? Are people eating more fruit and vegetables now compared to when the campaign launched? (Dan Curtis)

“The consumption and purchase of fruit and vegetables may be driven by a range of factors. However, awareness of the 5 A DAY message is high.”

“The 5-a-day campaign was launched in 2003.  Annual national data from the Health Survey for England,[5] which asks participants about the amount of fruit and vegetables they ate in the previous 24 hours, shows that the average number of portions consumed by adults increased slightly from 3.4 portions per day in 2001-2003 to peak at 3.8 portions per day in 2006-2007. Since then it has declined slightly and was 3.6 portions per day in 2010 and 2011. The same pattern is seen in the percentage of adults consuming five or more portions a day.”

“The Food Standards Agency (FSA) published the results of a ‘Food and You’ survey in 2011[6], which collected data on the UK public’s attitude, beliefs and values towards food issues. This report stated that the majority of respondents were aware of the recommended 5 portions of fruit and vegetables a day. However, it cannot be determined if this is as a result of the campaign.”

“We can also look at annual national data on household purchases of fruit and vegetables from the Family Food Survey[7]. These data show a similar picture.  Purchases of both fruit and vegetables peaked in 2005/2006 but declined from 2007. Fruit purchases declined by 14% between 2007 and 2012 and vegetable purchases by 5%.”

“The most accurate method of assessing fruit and vegetable consumption is that used in the National Diet and Nutrition Survey (NDNS)[8] which includes the contribution of fruit and vegetables in composite foods such as homemade recipe dishes, ready meals and other manufactured products which also include other ingredients (such as tomatoes in a bolognese sauce) and calculates portions according to the 5-a-day criteria (see Q4).  This method has only been in place since 2008 and it is too early to look at changes over time. An earlier national survey of adults aged 19-64 years in 2000/01 used a similar but cruder method to estimate consumption which did not fully take account of consumption from composite dishes. Comparing these results with more recent data from NDNS 2008/10 re-analysed using the earlier method suggests that there has been a small increase in consumption in adults over this period. We do not have any data points in the middle of this period so we cannot say if there was a peak in consumption in 2006 as shown by the other surveys.”

“Of course it is not possible to determine to what extent changes in consumption are due to the 5-a-day programme compared to factors, such as price, which are likely to have an influence.”

5. How difficult is it to work out how many portion of fruit and vegetables people are eating? Is the method of finding this out accurate? (James Clarke)

“It is relatively straightforward to ask people taking part in a survey how many portions of fruit and vegetables they ate the previous day. This is the method used in the Health Survey for England.  It is important to explain what is included in the definition of fruit and vegetables (potatoes for example are excluded) and to describe what is meant by a portion of different fruit and vegetables (e.g. two plums, three heaped tablespoons of peas). It is better to ask about different types of fruit and vegetables separately rather than just asking a single question covering all consumption.”

“One problem with estimating consumption is that most people consume some fruit and vegetables in composite foods such as homemade recipe dishes, ready meals and other manufactured products which also include other ingredients (such as tomatoes in a bolognese sauce). It is difficult for people to estimate how many portions of fruit and vegetables they eat in this form. The most accurate method of working out the number of portions consumed is to collect detailed information about what people eat over a day or more including the amounts of manufactured products, ready meals and any homemade dishes containing fruit and vegetables.  In the National Diet and Nutrition Survey (NDNS) this information is collected by asking participants to keep a detailed food diary. From this information the number of portions of fruit and vegetables (including the contribution from composite foods) can be calculated accurately according to the 5-a-day criteria so that only one portion or fruit juice and one portion of beans / pulses is counted. The NDNS provides the most accurate measure of fruit and vegetable consumption data. Latest results show that adults aged 19-64 years consume 4.1 portions of fruit and vegetables a day on average and 31% eat 5 or more portions a day.”

6. What about fruit smoothies? All the newspapers at the moment seem to be saying they are full of sugar and I’m not sure what to believe. (Chris Peters)

“Smoothies are made of fruit juice and fruit pulp and can count as more than 1 portion a day. When using the Department of Health 5 A DAY logo, smoothies only count as a maximum of 2 portions. When fruit is juiced and pulped, sugars are released from fruit, which may cause damage to teeth, compared to the sugars in whole fruits, which are less like to cause tooth decay.”

“Sugar can be classified into intrinsic and extrinsic sugars. Intrinsic sugars are contained within the cell walls of food, e.g. in whole fruits and vegetables. Extrinsic sugars are not incorporated within the cellular structure of the food/drink, but are free in the food/drink or are added to it. Extrinsic sugars include: milk sugars (such as lactose) contained in milk; and non-milk extrinsic sugars (NMES) which include sugars found in fruit juices, honey and sugars added to foods.”

“NMES (often called added sugars) should be consumed in small amounts and infrequently. This is because they can lead to tooth decay and excess calories intake, which can in turn lead to weight gain and obesity. Obesity increases the risk of type 2 diabetes, cardiovascular disease and some cancers.”

“The Scientific Advisory Committee on Nutrition (SACN) are currently reviewing the scientific literature to clarify the relationship between sugars and health as part of their review on carbohydrates. This draft report will be published for consultation later this year.”  

7. Fruit and vegetable prices have been going up much quicker than other foods. Is this going to have an impact on the 5 a day campaign in the future? In the US there are food stamps for example. (Prateek Buch)

“It is not possible to determine to what extent the price of fruit and vegetables will have on the campaign. However we can consider the annual national data on household purchases of fruit and vegetables from the Family Food Survey[9]. These data showed that the purchase of both fruit and vegetables peaked in 2005/2006 but declined from 2007. Fruit purchases declined by 14% between 2007 and 2012 and vegetable purchases by 5%.”

“The Department of Health have an ongoing Healthy Start scheme, which aims to provide pregnant women and children in low income families, throughout the UK, with vouchers towards the cost of buying fruit and vegetables along with milk and formula milk. This scheme will continue to exist, working alongside Universal Credit, to help the most vulnerable to access these foods.”

“In 2011, this scheme was extended to include frozen, as well as fresh fruit and vegetables as a convenient and cost effective way to provide a balanced diet.”

“The School Fruit and Vegetable Scheme provides a free piece of fruit or vegetable daily to children aged 4 – 6 years attending primary schools and some nurseries in England. The purpose of this scheme is to encourage children to enjoy eating fruit and vegetables as part of a daily balanced diet. Access to this scheme has been extended to free schools and academies whose term dates coincide with those of Local Authority schools.”

“Public Health England recommends people eat at least 5 portions of a variety of fruit and vegetables a day, as per government guidelines. By adding these into your meals, substituting for some of the meat and fish, for example having a vegetable based curry rather than meat based, it is possible to increase fruit and vegetable intake and limit cost.

"Public Health England will continue to promote healthier eating messages, including 5 A DAY, aimed at helping people continue to meet dietary recommendations, e.g. through our flagship Change4Life campaign.”

"Tips on meeting 5 A DAY on a budget and on how to save money and healthier swaps are available."

8. Can you balance your 5 a day over a week? I struggle to eat my 5 a day during the week so can I compensate on the weekends? (Alex Borthwick)

“With a busy lifestyle, it may seem hard to eat 5 portions of a variety of fruit and vegetables a day. The advice to eat at least 5 portions of a variety of fruit and vegetables a day (excluding potatoes) was based on epidemiological evidence of an association between the consumption of more than 400g of fruit and vegetables a day and lower levels of death from chronic diseases such as heart disease, stroke and some cancers. It is important to keep in mind that it would be easier to eat the recommended 5 portions a day compared to a larger number of portions on subsequent or alternate days to meet the request.”

“By making small changes, it can become easy to include your 5 A DAY as part of your day, for example, having a 150ml glass of 100% pure fruit juice and adding sliced banana to cereal at breakfast.”

“It is important to note that variety is the key to 5 A DAY and therefore we should all try to eat five portions of a variety of different types of fruits and vegetables a day, including fresh, frozen, tinned, dried and juice.”

“There is a wealth of information, including tips and a tool to get 5 A DAY into your meals on the NHS livewell website:”

9. Are there benefits to eating vegetables over fruit? Fruit still seems to contain lots of sugar. (Lydia Le Page)

“Fruit and vegetables are a good source of vitamins and minerals, including vitamin C, folate and potassium. They are also an excellent source of fibre and help maintain a healthy gut and digestive system.”

“The evidence base does not distinguish between fruit or vegetables. Different fruit and vegetables have different levels and types of nutrient components. It is important to have both fruit and vegetables, in order to meet the Department of Health recommendation of at least 5 portions a day. This can be achieved by eating a variety of fresh, frozen, tinned, dried and juiced fruit and vegetables every day to ensure you get all the different nutrients needed.”

10. Is there a difference between what adults and children should be eating? Or should both be trying to eat 5 a day? (Adam Gillett)

“There is no epidemiological evidence to support determination of fruit and vegetable portion sizes for children, although it is acknowledged that pragmatic approaches have been developed by industry and the voluntary sector. The Department of Health recommends both children and adults consume at least 5 portions of a variety of fruit and vegetables every day.”

11. Do tomatoes really reduce the risk of prostate cancer? (James Boyle)

"The publication Food, Nutrition, Physical Activity and the Prevention of Cancer: Global Perspective reports probable evidence linking lycopene, a component of tomatoes that is activated on juicing, with a reduced risk of prostate cancer[10]. This finding was reached by reviewing the evidence of cohort and case-control studies. However, additional epidemiological studies would be needed to explore this association further."

"The government recommends that people consume at least five portions of a variety of fruit and vegetables every day. This advice is based on epidemiological evidence indicating an association between the consumption of more than 400g a day of fruit and vegetables (excluding potatoes) with a reduced risk of certain diet related chronic diseases, including coronary heart disease and certain cancers."