QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Full Text (PDF) Online Supporting Material Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pomerleau, J. Articles by McKee, M. Search for Related Content PubMed PubMed Citation Articles by Pomerleau, J. Articles by McKee, M.

---

Nutritional Epidemiology

Interventions Designed to Increase Adult Fruit and Vegetable Intake Can Be Effective: A Systematic Review of the Literature^1,2,3

European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK

⁴To whom correspondence should be addressed. E-mail: Joceline.Pomerleau{at}lshtm.ac.uk.

	ABSTRACT

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
International recommendations advise increasing intakes of fruit and vegetables to help reduce the burden of chronic diseases worldwide. This project systematically reviewed evidence on the effectiveness of interventions and programs promoting fruit and/or vegetable intake in adults. In April 2004, we contacted experts in the field and searched 14 publication databases. We considered all papers published in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish, and reporting on interventions and promotion programs encouraging higher intakes of fruit and/or vegetables in free-living not acutely ill adults, with follow-up periods 3 mo, that measured change in intake and had a control group. Forty-four studies (mainly from developed countries) were included in the review and stratified by study setting. Larger effects were generally observed in individuals with preexisting health disorders. In primary prevention interventions in healthy adults, fruit and vegetable intake was increased by 0.1–1.4 serving/d. Consistent positive effects were seen in studies involving face-to-face education or counseling, but interventions using telephone contacts or computer-tailored information appeared to be a reasonable alternative. Community-based multicomponent interventions also had positive findings. This literature review suggests that small increases in fruit and vegetable intake are possible in population subgroups, and that these can be achieved by a variety of approaches. More research is required to examine the effectiveness of specific components of interventions in different populations, particularly less developed countries. There is also a need for a better assessment of the effectiveness and cost-effectiveness of large community-based interventions.

KEY WORDS: • review • fruit • vegetables • adult • randomized controlled trial

Cardiovascular diseases and cancer are major causes of morbidity and mortality worldwide, accounting for 29.3 and 12.5%, respectively, of all deaths and contributing to the rapidly growing epidemic of noncommunicable diseases in developing countries (1,2). The Global Strategy on Diet, Physical Activity and Health of the WHO urges healthier lifestyles to prevent this major threat, including eating more fruit and vegetables (3–5). However, survey data (6) and availability statistics from the FAO (7) suggest that most populations are not meeting currently recommended levels of fruit and vegetables (4) and that effective methods to promote dietary changes are urgently needed. In some developed countries (e.g., the United States, United Kingdom, Australia, Nordic countries), fruit and vegetable promotion initiatives are well established. In developing countries, a range of intersectoral projects has been established to encourage production and consumption, often as local food-based initiatives to reduce micronutrient deficiency. Various groups of researchers have also performed primary and secondary noncommunicable disease prevention trials.

Previous reviews of the literature suggested that a majority of the interventions that promote fruit and vegetable intake could increase consumption at least in the short term. However, these reviews have generally been limited in scope [e.g., focusing on community intervention programs (8), nutrition education (9), counseling in primary care units (10), school children (11), behavioral interventions (12)], or they have been geographically limited. This paper reports an up-to-date systematic review of evidence on the effectiveness of interventions and programs promoting fruit and vegetable intake among adults, to inform the joint WHO/FAO initiative on promoting fruit and vegetables for health (13,14).

	MATERIALS AND METHODS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
This review of the literature examined all individual and population-based interventions and promotion programs encouraging increased consumption of fruit and/or vegetables. It included all studies in free-living individuals who were not acutely ill, where the change in fruit and/or vegetable intake was measured, with at least 3 mo follow up, and with a control group.

    Search strategy. Fourteen databases were searched (from the earliest record to April 2004): PUBMED; CAB Abstracts (including nutritional abstracts and reviews); The Cochrane Library (including DARE: Database of Abstracts and Reviews of Effects); Web of Knowledge (including Web of Science and ISI database); IBSS (international bibliography of the Social Sciences); Psychinfo (BIDS); EMBASE; AGRICOLA; LILACS (Latin American and Caribbean Health Science Literature Database); ID21 (Development research reporting service); ERIC (Educational Resources Information Center); SIGLE (System for Information on Gray Literature); New York Academy of Medicine (Gray literature); INGENTA. The search strategy was developed in PUBMED and adapted to other databases. It was complemented by a comprehensive search for gray literature and other relevant material, and contacts with experts.

    Selection of documents. Documents in English, French, Spanish, Portuguese, Russian, Danish, Norwegian, and Swedish were considered. Articles were rejected on initial screening if the reviewer could determine from the title and abstract that the study was not a fruit and vegetable intervention study or promotion program, or if the study did not meet our selection criteria. When a paper could not be rejected with certainty from the title and abstract, the full text of the article was obtained for further evaluation. The suitability and quality of each selected paper were assessed independently by 2 assessors; differences between assessors’ results were resolved by discussion and, when necessary, in consultation with a third reviewer. Study quality was measured using a quality assessment tool developed on the basis of those used in previous reviews (9,14,15). Studies considered of poor quality were excluded from the review. Data abstraction was performed by one reviewer and checked by a second.

    Estimation of effect size. The effect size was estimated using 1 of 3 methods depending on data availability: 1) Net effect: difference between the change in fruit and vegetable intake in the intervention group (I) and control group (C) = [(Follow-up intake_I – Baseline intake_I) – (Follow-up intake_C – Baseline intake_C)]; 2) differences between groups at follow-up: difference in fruit and vegetable intake between the intervention and control groups at follow-up = [Follow-up intake_I – Follow-up intake_C]; 3) change in intakes within each group: assessment of the significance of the change in fruit and vegetable intake within each group (no statistical comparison between groups).

    Comparisons of study findings. Because of heterogeneity in the study populations, study settings, types of interventions, and outcome assessment measures (see above), and because some studies did not provide all of the information required (variability estimates for the outcomes) to obtain a statistically pooled effect, we did not attempt meta-analysis. We compared findings within and across 7 different study settings. Differences were considered significant at P < 0.05.

	RESULTS

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
    Retrieval of papers. A total of 3499 unduplicated records were identified; 306 of these reported on interventions designed to increase fruit and/or vegetable intake. Of these, 228 studies did not meet the eligibility criteria, and 8 were rated as methodologically weak. The remaining 70 articles reported results of 60 independent studies; of these, 44 were among adults (16–69).

    Results by study setting. Table 1 gives a general description of the 44 studies examined; 72.7% were from the United States, 15.9% were from Europe, 6.8% were from Asia (India), and 4.5% from the Western Pacific. Most included at least 500 participants, both genders, and had follow-up times of at least 6 mo. A majority of studies used personal counseling or education with or without other interventions. Dietary intake data were collected mainly by FFQ. Tables 2, 3, 4, 5 summarize the types of interventions used and study effects for each study, stratifying by study setting. Supplemental Tables 1 and 2 provide further details of the results of each study.

Three studies that targeted smaller focused communities, African American churches, had larger effects than general population interventions, i.e., +0.7 to +1.4 serving/d. These studies used ecological approaches with or without individual counseling. One intervention showed that culturally sensitive multicomponent self-help material with telephone motivational interviewing was more effective than the same material with 1 telephone cue call (+0.99 serving/d) or than standard nutrition education materials (+1.12 serving/d) (24).

In supermarket-based interventions, store-wide environmental changes (promotion and activities, e.g., to encourage sales) had no significant effect (26). However, a computer-based individualized education program demonstrated a significant net effect of approximately +1.3 servings after 8–10 mo (27).

Eight of 11 worksite interventions examined showed positive effects (2 only for vegetables): 7 studies reported effects ranging from +0.13 to +0.7 serving/d (29,31–35,39,41), and one showed an increase of 5.9% in the proportion of participants eating at least 2–3 servings of vegetables daily (28). The largest effects were observed in studies that incorporated social support activities using natural helpers (31), peer education (33), or family members (33). The "Treatwell ‘5-a-Day’ Study" (33) also found that the number of activities offered and greater participation both correlated with increased consumption.

Interventions in other study settings (Tables 4, and 5) used a combination of personalized education approaches reinforced by a range of other activities, mainly tailored or nontailored printed documents. Eight of 9 interventions in health care settings reported positive findings with effects ranged from +0.5 to +1.4 serving/d. Three studies delivered computer-tailored information (42–44). The 1st study showed the largest effect (+1.1 serving/d of fruit) with weekly communication over 6 mo with an interactive computer-based counseling voice system (44). The 2nd study suggested that printed computer-tailored information (particularly if participants were given the specific goal of increasing fruit and vegetable intake to 5 serving/d) was slightly more effective (but not significantly) than nontailored information; differences with the control group ranged from +0.6 to +0.8 serving/d (42). The 3rd study showed no significant difference between printed tailored or nontailored information (43). Telephone counseling with printed tailored information (45,46) was used in 2 studies. The simplest approach (computer-generated tailored newsletters and motivation phone call) had the least effect (45). The other study was more intensive (tailored letter, endorsement by health provider, 2 motivational telephone counseling sessions) but of shorter duration (46). Face-to-face individual or group counseling (47–50) had net effects ranging from +0.62 to +1.4 serving/d. The highest effect was observed in a study that used a brief negotiation method (50), the lowest in a study specifically examining the effect of behavioral counseling vs. no behavioral counseling (both targeting increased intake) (51).

All 5 trials targeting adults living on a low income increased fruit and vegetable intake. Four reported an effect ranging from approximately +0.42 to +1.1 serving/d (52–56). The other showed that individuals with a moderate fat intake at baseline who received a newly developed education curriculum focusing on the reduction of dietary fat increased their vegetable intake by 2.5 serving/d in 7–8 mo, compared with no significant increase in those receiving an existing general nutrition curriculum (57). Two studies showed that the effect could be maintained over 1 y after an initial follow-up time of 8 mo (54–56).

Trials conducted among individuals with preexisting health problems generally had greater effects than those targeting other populations. An intervention using only prompt sheets was the only one to report no significant effect (58). The other studies reported effects ranging from +0.27 serving/d (62,63) up to +4.9 serving/d (60); 2 studies showed an effect only for fruit (59,66). The highest effects were found in trials of individuals with cardiovascular risk factors (+3.9 or +4.2 serving/d) or suspected infarction in India (+4.9 serving/d) (59,60,65).

	DISCUSSION

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 
This systematic review identified various types of interventions used to promote and increase fruit and vegetable intake in adults, and most interventions had positive effects in spite of known difficulties in changing individual diets (70). The largest effects were generally observed among individuals already at higher risk of disease. This could reflect enhanced motivation to improve dietary intake, suggesting that these trials should be considered separately from studies targeting the general population. In healthy adult populations, increases in fruit and vegetable intake ranged from about +0.1 to +1.4 serving/d, but what constitutes a meaningful increase remains a subject for further research. Other interventions used less individualized approaches. This might seem intuitive but must be balanced against the high cost, time demands, and need for trained staff required by individualized counseling; in addition, such an approach is not feasible for whole populations. Conversely, printed individually tailored information and computer-based information (particularly if this was individually tailored) appeared to be a reasonable alternative to face-to-face or telephone contact, demonstrating significant effects. Clearly this is an easier and less expensive approach. Computer-tailored nutrition education is an innovative and promising tool to motivate people to make healthy dietary changes. It provides respondents with individualized feedback about their dietary behaviors, motivations, attitudes, norms, and skills, and mimics the process of "person-to-person" dietary counseling. Available evidence suggests that computer-tailored nutrition education is more effective in motivating people to make dietary changes than general nutrition information. However, we found no such trials outside the United States and Europe; thus, its effectiveness in other settings remains unevaluated and it is unlikely to be appropriate in developing countries particularly in poor and rural communities.

Workplaces are unique settings offering several advantages: they reach large audiences including some that traditionally do not come into contact with health services regularly (e.g., working-age men), interventions can be enhanced by co-worker support, and they provide opportunities for reinforcement and environmental support. However, they generally use a comprehensive, wide-ranging approach that is time and resource intensive and requires the collaboration of the company and many stakeholders (71). The effect sizes reported in such programs generally have not been very large, but this may reflect the diffuse nature of these multicomponent interventions.

The generalizability of our findings worldwide and the applicability of the interventions examined in developing countries are limited. The great majority of studies were conducted in industrialized countries, whereas in developing countries, fruit and vegetable promotion may focus on consumption of adequate micronutrients and high-quality protein, or improving methods used in the preparation of fruit/vegetable dishes (to conserve nutrients or control fat intakes), rather than promoting intake of fruits and vegetables as such. Although some countries now suffer the double burden of over- and undernutrition associated with the nutrition transition (72), deficiencies of micronutrients (e.g., vitamin A) remain a key issue for children and adults in developing countries (73), with fruit- and vegetable-promoting programs mainly part of food-based strategies to alleviate these conditions. In comparison, the focus of fruit and vegetable programs in developed countries is generally to reduce obesity and the risk of noncommunicable disease.

This review has some methodological limitations. First, some studies may have been missed (e.g., published in other languages, recent unpublished studies) and the possibility of publication bias could not be assessed. Second, because the analyses were restricted to studies with a control group, several studies were excluded, including some national or large-scale promotion interventions (74). A third limitation is that intake data relied in most cases on self-reported information and are thus subject to the limitations of dietary assessment methods, particularly for measuring small changes in intake (75,76). In addition, because the studies were not blinded, there may have been measurement bias with a possible overestimation of effect sizes. Most studies also failed to define the "fruit and vegetable" food group or what constituted a serving. Several studies included potatoes in the calculations, making comparisons with current international recommendations more difficult (4). Fourth, interventions had a relatively short follow-up time and did not provide information on the long-term effect on dietary changes or on the risk of major chronic diseases at a population level. Finally, we could not assess the cost effectiveness of the studies. However, an Australian study estimated that national campaigns to increase fruit and vegetable intake prevent 3626 disability adjusted life years each year with corresponding cost savings of AUS$125 million (US$163 million) each year over the implementation costs [estimated at $2.5 million (US$3.3 million) a year] (77).

Future research should pursue the promising results shown in this review and attempt to identify new cost-effective and efficient ways of increasing population fruit and vegetable intake. However, the effectiveness of all new interventions should be assessed, particularly in developing countries in which several programs have been initiated but without the evaluation of effectiveness. In addition, reports should give a better description of the methods used and include estimates of variability for the selected outcomes. Finally, studies are also required that examine in more depth the effectiveness of specific components of interventions, and how these effects vary in different populations. There is a need to understand better the factors influencing fruit and vegetable intake, including economic, social, and environmental factors that influence food availability and the ability of an individual to make healthy choices, and barriers to change.

	ACKNOWLEDGMENTS

 
We thank Dr. Ingrid Keller and Ms. Vanessa Candeias at the WHO for their support and help with identifying experts and obtaining research papers, and acknowledge the contribution of the many people worldwide who helped with this review by supplying information [a detailed list can be found elsewhere (14)].

	FOOTNOTES

 
¹ This paper summarizes and discusses part of the results of a review of the literature conducted as background material for the Joint WHO/FAO workshop on fruit and vegetable intake for health that took place in Kobe in September 2004. Full details of methods and results can be found in the more technical workshop report [Pomerleau, J., Lock, K., Knai, C. & McKee, M. (2005) Effectiveness of Interventions and Programmes Promoting Fruit and Vegetable Intake. WHO, Geneva, Switzerland].

² Funded by WHO. However, WHO cannot accept any responsibility for any information provided or views expressed. The authors have no conflict of interest.

³ Summary details of the studies included in the review (Supplemental Tables 1 and 2) are available as Online Supporting Material with the online posting of this paper at www.nutrition.org.

Manuscript received 10 March 2005. Initial review completed 17 May 2005. Revision accepted 20 July 2005.

	LITERATURE CITED

TOP ABSTRACT MATERIALS AND METHODS RESULTS DISCUSSION LITERATURE CITED

 

1. World Health Organization. The World Health Report 2002. Reducing risks, promoting healthy life. WHO Geneva, Switzerland.

2. Beaglehole R., Yach D. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Lancet. 2003;362:903-908.[Medline]

3. World Health Organization. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Global strategy on diet, physical activity and health. Fifty-seventh World Health Assembly. Resolution WHA57.17. 22 May 2004. WHO Geneva, Switzerland.

4. World Health Organization. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Diet, nutrition and the prevention of chronic diseases. Report of a joint FAO/WHO Expert Consultation. WHO Technical Report Series No. 916. World WHO Geneva, Switzerland.

5. World Cancer Research Fund, American Institute for Cancer Research. Globalisation and the prevention and control of non-communicable disease: the neglected chronic diseases of adults. Food, nutrition and the prevention of cancer: a global perspective. American Institute for Cancer Research Washington, DC.

6. Pomerleau J., Lock K., McKee M., Altmann D. R. The challenge of measuring global fruit and vegetable intake. J. Nutr. 2004;134:1175-1180.[Abstract/Free Full Text]

7. FAOstat database [Online]. The challenge of measuring global fruit and vegetable intake. Food and Agriculture Organization. http://faostat.fao.org/?language=EN 2004 [accessed March 2, 2005].

8. Ciliska D., Miles E., O’Brien M. A., Turl C., Tomasik H. H., Donovan U., Beyers J. The challenge of measuring global fruit and vegetable intake. The effectiveness of community interventions to increase fruit and vegetable consumption in people four years of age and older. Effective Public Health Practice Project. Ministry of Health, Public Health Research, Education and Development Program Ontario, Canada.

9. Contento I., Balch G., Bronner Y., Lytle L., Maloney S, Olson C., Swadener S. The effectiveness of nutrition education and implications for nutrition education policy, programs, and research: a review of research. J. Nutr. Educ. 1995;27:277-418.

10. Pignone M. P., Ammerman A., Fernandez L., Orleans C. T., Pender N., Woolf S., Lohr K. N., Sutton S. Counseling to promote a healthy diet in adults: a summary of the evidence for the US Preventive Services Task Force. Am. J. Prev. Med. 2003;24:75-92.[Medline]

11. Burchett H. Increasing fruit and vegetable consumption among British primary schoolchildren: a review. Health Educ. 2003;103:99-109.

12. Ammerman A. S., Lindquist C. H., Lohr K. N., Hersey J. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Prev. Med. 2002;35:25-41.[Medline]

13. Promoting Fruit and Vegetable Consumption around the World [Online]. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. World Health Organization. http://www.who.int/dietphysicalactivity/fruit/en/ [accessed March 2, 2005].

14. Pomerleau J., Lock K., Knai C., McKee M. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Effectiveness of interventions and programmes promoting fruit and vegetable intake. WHO Geneva, Switzerland.

15. Khan K. S. ter Riet G. Glanville J. Sowden A. J. Kleijnen J. eds. The efficacy of behavioral interventions to modify dietary fat and fruit and vegetable intake: a review of the evidence. Undertaking systematic reviews of research on effectiveness. CRD’s Guidance for those Carrying Out or Commissioning Reviews. CRD Report Number 4. 2nd ed. NHS Centre for Review and Dissemination, University of York York, UK.

16. Takashashi Y., Sasaki S., Takahashi M., Okubo S., Hayashi M., Tsugane S. A population-based dietary intervention trial in a high-risk area for stomach cancer and stroke: changes in intakes and related biomarkers. Prev. Med. 2003;37:432-441.[Medline]

17. Marcus A. C., Heimendinger J., Wolfe P., Rimer B. K., Morra M., Cox D., Lang P. J., Stengle W., Van Herle M. P., et al. Increasing fruit and vegetable consumption among callers to the CIS: results from a randomized trial. Prev. Med. 1998;27:S16-S28.[Medline]

18. Marcus A. C., Heimendinger J., Wolfe P., Fairclough D., Rimer B. K., Morra M., Warnecke R., Himes J. H., Darrow J. L., et al. A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS. Prev. Med. 2001;33:204-216.[Medline]

19. Backman D. R., Gonzaga G. C. A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS. Media, festival, farmers’/flea markets and grocery store interventions lead to improved fruit and vegetable consumption for California Latinos. California Department of Health Services, Public Health Institute Oakland, CA.

20. Department of Health. A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS. Five-a-day community pilot initiatives: key findings. Department of Health London, UK.

21. Department of Health. A randomized trial of a brief intervention to increase fruit and vegetable intake: a replication study among callers to the CIS. Five-a-day pilot initiatives. Executive summary of the pilot initiatives evaluation study. Department of Health London, UK.

22. Campbell M. K., Bernhardt J. M., Waldmiller M., Jackson B., Potenziani D., Weathers B., Demissie S. Varying the message source in computer-tailored nutrition education. Patient Educ. Couns. 1999;36:157-169.[Medline]

23. Campbell M. K., Demark-Wahnefried W., Symons M., Kalsbeek W. D., Dodds J., Cowan A., Jackson B., Motsinger B., Hoben K., et al. Fruit and vegetable consumption and prevention of cancer: the Black Churches United for Better Health project. Am. J. Public Health. 1999;89:1390-1396.[Abstract/Free Full Text]

24. Resnicow K., Jackson A., Wang T., De A. K., McCarty F., Dudley W. N., Baranowski T. A motivational interviewing intervention to increase fruit and vegetable intake through Black churches: results of the Eat for Life trial. Am. J. Public Health. 2001;91:1686-1693.[Abstract/Free Full Text]

25. Resnicow K., Campbell M. K., Carr C., McCarty F., Wang T., Periasamy S., Rahotep S., Doyle C., Williams A., Stables G. Body and Soul: a dietary intervention conducted through African-American churches. Am. J. Prev. Med. 2004;27:97-105.[Medline]

26. Kristal A. R., Goldenhar L., Muldoon J., Morton R. F. Evaluation of a supermarket intervention to increase consumption of fruits and vegetables. Am. J. Health Promot. 1997;11:422-425.[Medline]

27. Anderson E. S., Winett R. A., Wojcik J. R., Winett S. G., Bowden T. A computerized social cognitive intervention for nutrition behavior: direct and mediated effects on fat, fiber, fruits, and vegetables, self-efficacy, and outcome expectations among food shoppers. Ann. Behav. Med. 2001;23:88-100.[Medline]

28. Cook C., Simmons G., Swinburn B., Stewart J. Changing risk behaviours for non-communicable disease in New Zealand working men—is workplace intervention effective?. N. Z. Med. J. 2001;114:175-178.[Medline]

29. Buller D. B., Morrill C., Taren D., Aickin M., Sennott-Miller L., Buller M. K., Larkey L., Alatorre C., Wentzel T. M. Randomized trial testing the effect of peer education at increasing fruit and vegetable intake. J. Natl. Cancer Inst. 1999;91:1491-1500.[Abstract/Free Full Text]

30. Tilley B. C., Glanz K., Kristal A. R., Hirst K., Li S., Vernon S. W., Myers R. Nutrition intervention for high-risk auto workers: results of the Next Step Trial. Prev. Med. 1999;28:284-292.[Medline]

31. Campbell M. K., Tessaro I., DeVellis B., Benedict S., Kelsey K., Belton L., Sanhueza A. Effects of a tailored health promotion program for female blue-collar workers: Health Works for Women. Prev. Med. 2002;34:313-323.[Medline]

32. Hebert J. R., Stoddard A. M., Harris D. R., Sorensen G., Hunt M. K., Morris D. H.,, Ockene J. D. Measuring the effect of a worksite-based nutrition intervention on food consumption. Ann. Epidemiol. 1993;3:629-635.[Medline]

33. Sorensen G., Stoddard A., Peterson K., Cohen N., Hunt M. K., Stein E., Palombo R., Lederman R. Increasing fruit and vegetable consumption through worksites and families in the Treatwell 5-a-day study. Am. J. Public Health. 1999;89:54-60.[Abstract/Free Full Text]

34. Hunt M. K., Lederman R., Stoddard A., Potter S., Phillips J., Sorensen G. Process tracking results from the Treatwell 5-a-Day Worksite Study. Am. J. Health Promot. 2000;14:179-187.[Medline]

35. Sorensen G., Thompson B., Glanz K., Feng Z., Kinne S., DiClemente C., Emmons K., Heimendinger J., Probart C., Lichtenstein E. Work site-based cancer prevention: primary results from the Working Well Trial. Am. J. Public Health. 1996;86:939-947.[Abstract/Free Full Text]

36. Patterson R. E., Kristal A. R., Glanz K., McLerran D. F., Hebert J. R., Heimendinger J., Linnan L., Probart C., Chamberlain R. M. Components of the Working Well Trial intervention associated with adoption of healthful diets. Am. J. Prev. Med. 1997;13:271-276.[Medline]

37. Glanz K., Patterson R. E., Kristal A. R., Feng Z., Linnan L., Heimendinger J., Hebert J. R. Impact of work site health promotion on stages of dietary change: the Working Well Trial. Health Educ. Behav. 1998;25:448-463.[Abstract]

38. Emmons K. M., Linnan L. A., Shadel W. G., Marcus B., Abrams D. B. The Working Healthy Project: a worksite health-promotion trial targeting physical activity, diet, and smoking. J. Occup. Environ. Med. 1999;41:545-555.[Medline]

39. Sorensen G., Stoddard A., Hunt M. K., Hebert J. R., Ockene J. K., Avrunin J. S., Himmelstein J., Hammond S. K. The effects of a health promotion-health protection intervention on behavior change: the WellWorks Study. Am. J. Public Health. 1998;88:1685-1690.[Abstract/Free Full Text]

40. Sorensen G., Stoddard A. M., LaMontagne A. D., Emmons K., Hunt M. K., Youngstrom R, McLellan D., Christiani D. A comprehensive worksite cancer prevention intervention: behavior change results from a randomized controlled trial (United States). Cancer Causes Control. 2002;13:493-502.[Medline]

41. Beresford S. A., Thompson B., Feng Z., Christianson A., McLerran D., Patrick D. L. Seattle 5 a Day worksite program to increase fruit and vegetable consumption. Prev. Med. 2001;32:230-238.[Medline]

42. Lutz S. F., Ammerman A. S., Atwood J. R., Campbell M. K., DeVellis R. F., Rosamond W. D. Innovative newsletter interventions improve fruit and vegetable consumption in healthy adults. J. Am. Diet. Assoc. 1999;99:705-709.[Medline]

43. Campbell M. K., DeVellis B. M., Strecher V. J., Ammerman A. S., DeVellis R. F., Sandler R. S. Improving dietary behavior: the effectiveness of tailored messages in primary care settings. Am. J. Public Health. 1994;84:783-787.[Abstract/Free Full Text]

44. Delichatsios H. K., Friedman R. H., Glanz K., Tennstedt S., Smigelski C., Pinto B. M., Kelley H., Gillman M. W. Randomized trial of a "talking computer" to improve adults’ eating habits. Am. J. Health Promot. 2001;15:215-224.[Medline]

45. Kristal A. R., Curry S. J., Shattuck A. L., Feng Z., Li S. A randomized trial of a tailored, self-help dietary intervention: the Puget Sound Eating Patterns study. Prev. Med. 2000;31:380-389.[Medline]

46. Delichatsios H., Hunt M., Lobb R., Emmons K., Gillman M. EatSmart: efficacy of a multifaceted preventive nutrition intervention in clinical practice. Prev. Med. 2001;33:91-98.[Medline]

47. Stevens V. J., Glasgow R. E., Toobert D. J., Karanja N., Smith K. S. Randomized trial of a brief dietary intervention to decrease consumption of fat and increase consumption of fruits and vegetables. Am. J. Health Promot. 2002;16:129-134.[Medline]

48. Stevens V. J., Glasgow R. E., Toobert D. J., Karanja N., Smith K. S. One-year results from a brief, computer-assisted intervention to decrease consumption of fat and increase consumption of fruits and vegetables. Prev. Med. 2003;36:594-600.[Medline]

49. Coates R. J., Bowen D. J., Kristal A. R., Feng Z., Oberman A., Hall W. D., George V., Lewis C. E., Kestin M., et al. The Women’s Health Trial Feasibility Study in Minority Populations: changes in dietary intakes. Am. J. Epidemiol. 1999;149:1104-1112.[Abstract/Free Full Text]

50. John J. H., Ziebland S., Yudkin P., Roe L. S., Neil H. A. Effects of fruit and vegetable consumption on plasma antioxidant concentrations and blood pressure: a randomised controlled trial. Lancet. 2002;359:1969-1974.[Medline]

51. Steptoe A., Perkins-Porras L., McKay C., Rink E., Hilton S., Cappuccio F. P. Behavioural counselling to increase consumption of fruit and vegetables in low income adults: randomised trial. Br. Med. J. 2003;326:855..[Abstract/Free Full Text]

52. Del Tredici A. M., Joy A. B., Omelich C. L., Laughlin S. G. Evaluation study of the California Expanded Food and Nutrition Education Program: 24-hour food recall data. J. Am. Diet. Assoc. 1998;88:185-190.

53. Haire-Joshu D., Brownson R. C., Nanney M. S., Houston C., Steger-May K., Schechtman K., Auslander W. Improving dietary behavior in African Americans: the Parents As Teachers High 5, Low Fat Program. Prev. Med. 2003;36:684-691.[Medline]

54. Havas S., Anliker J., Damron D., Langenberg P., Ballesteros M., Feldman R. Final results of the Maryland WIC 5-A-Day Promotion Program. Am. J. Public Health. 1998;88:1161-1167.[Abstract/Free Full Text]

55. Langenberg P., Ballesteros M., Feldman R., Damron D., Anliker J., Havas S. Psychosocial factors and intervention-associated changes in those factors as correlates of change in fruit and vegetable consumption in the Maryland WIC 5 a day promotion program. Ann. Behav. Med. 2000;22:307-315.[Medline]

56. Havas S., Anliker J., Greenberg D., Block G., Block T., Blik C., Langenberg P., DiClemente C. Final results of the Maryland WIC Food for Life program. Prev. Med. 2003;37:406-416.[Medline]

57. Winkleby M. A., Howard-Pitney B., Albright C. A., Bruce B., Kraemer H. C., Fortmann S. P. Predicting achievement of a low-fat diet: a nutrition intervention for adults with low literacy skills. Prev. Med. 1997;26:874-882.[Medline]

58. Little P., Kelly J., Barnett J., Dorward M., Margetts B., Warm D. Randomised controlled factorial trial of dietary advice for patients with a single high blood pressure reading in primary care. Br. Med. J. 2004;328:1054-1060.[Abstract/Free Full Text]

59. de Lorgeril M., Renaud S., Mamelle N., Salen P., Martin J., Monjaud I., Guidollet J., Touboul P., Delaye J. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet. 1994;343:1454-1459.[Medline]

60. Singh R. B., Rastogi S. S., Verma R., Laxmi B., Singh R., Ghosh S., Niaz M. A. Randomised controlled trial of cardioprotective diet in patients with recent acute myocardial infarction: results of one year follow up. Br. Med. J. 1992;304:1015-1019.

61. Singh R. B., Dubnov G., Niaz M. A., Ghosh S., Singh R., Rastogi S. S., Manor O., Pella D., Berry E. M. Effect of an Indo-Mediterranean diet on progression of coronary artery disease in high risk patients (Indo-Mediterranean Diet Heart Study): a randomised single-blind trial. Lancet. 2002;360:1455-1461.[Medline]

62. Ness A. R., Ashfield-Watt P.A.L., Whiting J. M., Smith G. D., Hughes J., Burr M. L. The long-term effect of dietary advice on the diet of men with angina: the diet and angina randomized trial. J. Hum. Nutr. Diet. 2004;17:117-119.[Medline]

63. Burr M. L., Ashfield-Watt P. A., Dunstan F. D., Fehily A. M., Breay P., Ashton T., Zotos P. C., Haboubi N. A., Elwood P. C. Lack of benefit of dietary advice to men with angina: results of a controlled trial. Eur. J. Clin. Nutr. 2003;57:193-200.[Medline]

64. Appel L. J., Champagne C. M., Harsha D. W., Cooper L. S., Obarzanek E., Elmer P. J., Stevens V. J., Vollmer W. M., Lin P. H., et al. Effects of comprehensive lifestyle modification on blood pressure control: main results of the PREMIER clinical trial. J. Am. Med. Assoc. 2003;289:2083-2093.[Abstract/Free Full Text]

65. Singh R. B., Singh N. K., Rastogi S. S., Mani U. V., Niaz M. A. Effects of diet and lifestyle changes on atherosclerotic risk factors after 24 weeks on the Indian Diet Heart Study. Am. J. Cardiol. 1993;71:1283-1288.[Medline]

66. Bemelmans W. J., Broer J., de Vries J. H., Hulshof K. F., May J. F., Meyboom-De Jong B. Impact of Mediterranean diet education versus posted leaflet on dietary habits and serum cholesterol in a high risk population for cardiovascular disease. Public Health Nutr. 2000;3:273-283.[Medline]

67. Pierce J. P., Newman V. A., Flatt S. W., Faerber S., Rock C. L., Natarajan L., Caan B. J., Gold E. B., Hollenbach K. A., et al. Telephone counseling intervention increases intakes of micronutrient- and phytochemical-rich vegetables, fruit and fiber in breast cancer survivors. J. Nutr. 2004;134:452-458.[Abstract/Free Full Text]

68. Schatzkin A., Lanza E., Corle D., Lance P., Iber F., Caan B., Shike M., Weissfeld J., Burt R., et al. Lack of effect of a low-fat, high-fiber diet on the recurrence of colorectal adenomas. Polyp Prevention Trial Study Group. N. Engl. J. Med. 2000;342:1149-1155.[Abstract/Free Full Text]

69. Lanza E., Schatzkin A., Daston C., Corle D., Freedman L., Ballard-Barbash R., Caan B., Lance P., Marshall J., et al. Implementation 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.[Abstract/Free Full Text]

70. John J. H., Ziebland S. Reported barriers to eating more fruit and vegetables before and after participation in a randomized controlled trial: a qualitative study. Health Educ. Res. 2004;19:165-174.[Abstract/Free Full Text]

71. Fielding J. E. Worksite health promotion programs in the United States: progress, lessons and challenges. Health Promot. Int. 1990;5:75-84.[Abstract/Free Full Text]

72. Popkin B. M. The nutrition transition in the developing world. Dev. Policy Rev. 2003;21:581-597.

73. Faber M., Venter S. L., Benade A. J. Increased vitamin A intake in children aged 2–5 years through targeted home-gardens in a rural South African community. Public Health Nutr. 2002;5:11-16.[Medline]

74. World Health Organization. Increased vitamin A intake in children aged 2–5 years through targeted home-gardens in a rural South African community. Report of the Joint WHO/FAO workshop on fruit and vegetables for health. Kobe 1–3 September 2004. WHO Geneva, Switzerland.

75. Thomson C. A., Giuliano A., Rock C. L., Ritenbaugh C. K., Flatt S. W., Faerber S., Newman V., Caan B., Graver E., et al. Measuring dietary change in a diet intervention trial: comparing food frequency questionnaire and dietary recalls. Am. J. Epidemiol. 2003;157:754-762.[Abstract/Free Full Text]

76. Kristal A. R., Beresford S.A.A., Lazovich D. Assessing change in diet-intervention research. Am. J. Clin. Nutr. 1994;59(suppl.):185S-189S.[Abstract/Free Full Text]

77. Commonwealth Department of Health and Ageing. Assessing change in diet-intervention research. Priorities for Action in Cancer Control 2001–2003. Commonwealth of Australia Canberra, Australia.

This article has been cited by other articles:

				M.-C. Yeh, S. B. Ickes, L. M. Lowenstein, K. Shuval, A. S. Ammerman, R. Farris, and D. L. Katz Understanding barriers and facilitators of fruit and vegetable consumption among a diverse multi-ethnic population in the USA Health Promot. Int., March 1, 2008; 23(1): 42 - 51. [Abstract] [Full Text] [PDF]

				J. Goulet, B. Lamarche, and S. Lemieux Factors influencing the dietary response to a nutritional intervention promoting the Mediterranean food pattern in healthy women from the Quebec City metropolitan area Health Educ. Res., October 1, 2007; 22(5): 718 - 726. [Abstract] [Full Text] [PDF]

				J. P. Pierce, V. A. Newman, L. Natarajan, S. W. Flatt, W. K. Al-Delaimy, B. J. Caan, J. A. Emond, S. Faerber, E. B. Gold, R. A. Hajek, et al. Telephone Counseling Helps Maintain Long-Term Adherence to a High-Vegetable Dietary Pattern J. Nutr., October 1, 2007; 137(10): 2291 - 2296. [Abstract] [Full Text] [PDF]

				J. P. Pierce, L. Natarajan, S. Sun, W. Al-Delaimy, S. W. Flatt, S. Kealey, C. L. Rock, C. A. Thomson, V. A. Newman, C. Ritenbaugh, et al. Increases in Plasma Carotenoid Concentrations in Response to a Major Dietary Change in the Women's Healthy Eating and Living Study. Cancer Epidemiol. Biomarkers Prev., October 1, 2006; 15(10): 1886 - 1892. [Abstract] [Full Text] [PDF]

This Article Abstract Full Text (PDF) Online Supporting Material Purchase Article View Shopping Cart Alert me when this article is cited Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Pomerleau, J. Articles by McKee, M. Search for Related Content PubMed PubMed Citation Articles by Pomerleau, J. Articles by McKee, M.