NDSU Department of Child Development and Family Science
North Dakota Department of Human Services
October 1998
Theresa A. Nicklas, DrPH, LN, Department of Food and Nutrition, College of Human Development and Education, North Dakota State University, Fargo, North Dakota
Correspondence and Reprints: Theresa A. Nicklas, DrFH, LN, Department of Food and Nutrition, College of Human Development and Education, North Dakota State University, Fargo, North Dakota, (701) 231-7475, Fax (701) 231-7174
Gimme 5 was a multi-component intervention designed to increase consumption of fruits and vegetables by high school students by using the 5-A-Day message propagated and funded by the National Cancer Institute. Twelve high schools (six matched pairs) were selected to participate in the four-year nutrition intervention program. The longitudinal sample in the overall program design comprised students who were freshman in spring 1994 and who were later followed until they were seniors (spring 1997).
The Gimme 5 program followed the PRECEDE model and included four intervention components: workshops and supplementary subject activities; school meal modification; a school media-marketing campaign, and; parental involvement.
The purpose of this report is to describe the theoretical framework, design, intervention overview, and measurements of the Gimme 5 program.
Adolescents are often referred to as a "hard-to-reach" population, and they are identified repeatedly as a nutritionally vulnerable subgroup in the United States (Huenemann, Shapiro, Hampton, & Mitchell 1968; Fathing 1991; Skinner et al. 1985; Perry-Hunnicutt & Newman 1993; Skinner & Woodburn 1984; Story & Resnich; 1984; Schwartz 1975). Peer influences, effects of mass media, social and cultural norms, and a lack of nutrition knowledge influence an adolescent's food intake and behavior (Perry-Hunnicutt & Newman 1993; Skinner & Woodburn 1984; Story & Resnich 1984; Schwartz 1975). Eating disorders are common; adolescent obesity, as well as the unique and very diverse problems of pregnant teens and student athletes, often compound the nutritional problems of adolescents. Teens often skip meals (Fathing 1991; Skinner et al. 1985; Perry-Hunnicutt & Newman 1993) or choose foods of poor nutritional quality (Skinner et al. 1985; Perry-Hunnicutt & Newman 1993; Skinner & Woodburn 1984; Story & Resnich 1984; Schwartz 1975; Patterson, Block, Rosenberger, Pee, & Kahle 1990; U.S. Department of Health and Human Services Public Health Service, 1991). Dietary excesses of fat, saturated fat, and sodium are common among teens, as are lower-than-recommended intakes of fruits and vegetables (Zive, Nicklas, Busch, Myers, & Berenson 1996; Nicklas, Johnson, Myers, Webber, & Berenson 1995).
The National Cancer Institute (NCI) initiated the National 5-A-Day for Better Health Program to encourage Americans to eat five or more servings of fruits and vegetables daily as one of the nation's stated health promotion and disease prevention objectives (Produce for Better Health Foundation and National Cancer Institute 1991; Havas, Heimendinger, Reynolds, Baranowski, Nicklas, Bishop, Buller, Sorensen, Beresford, Cowan & Damron 1994; Havas, Heimendinger, Damron, Nicklas, Cowan, Beresford, Sorensen, Buller, Bishop, Baranowski, & Reynolds 1995). The 5-A-Day program includes retail, media, community, and research components. The research component was an extension of the community program. Nine 5-A-Day research programs were developed and implemented nationwide (Havas et al. 1994; Havas et al. 1995).
Gimme 5: A Fresh Nutrition Concept for Students was unique in that it was the only 5-A-Day program to target high school students. The Gimme 5 program followed the PRECEDE model (Green, Kreuter, Deeds, and Partridge 1980) and was designed to create an environment in which predisposing factors, enabling factors, and reinforcing factors addressed daily consumption of fruits and vegetables. The goal of the Gimme 5 program was to increase daily consumption of fruits and vegetables to five or more servings of high school students. Specific aims of the program were to: 1) increase awareness and positive attitudes for eating at least five servings of fruits and vegetables; 2) develop and evaluate environmental supports by offering more fruits and vegetables in the school cafeteria, snack outlets, and vending machines; and 3) evaluate the impact of increased fruit and vegetable consumption on total nutrient intake of high school students.
Nineteen of 22 high schools in the Archdiocese of New Orleans, LA, school system were recruited and agreed to participate. A paired design, matched on gender, ethnicity, school enrollment, and geographic location, was used to assign 12 of the schools (six pairs) to intervention or control conditions. The other seven schools served as pilot testing sites. The six school pairs were three female, two male, and one co-ed. The longitudinal sample in the overall program design comprised students who were freshman in spring 1994 and who were later followed until they were seniors (spring 1997). The demographics of the sample (n=2213) at baseline (58% female, 86% white, 4% black, 8% Hispanic) was similar throughout the intervention period.
The Gimme 5 high school program was designed to create an environment in which predisposing factors, enabling factors, and reinforcing factors, described in the PRECEDE Model of Health Education (Green et al 1980), influence increased daily consumption of fruits and vegetables. Consistent with the PRECEDE Model, the specific components of the Gimme 5 program addressed the following levels of behavior change: 1) Awareness Development - rationale for participation and strategies for exposure; 2) Interest Stimulation - efforts to have the audience shift into an information-collecting mode; 3) Skills Training - activities that provide practice of behaviors necessary for success; 4) Reinforcement - provision of external and development of internal reinforcement to increase the probability of long-term behavior change; 5) Application - mastery of behavioral skills and personal application through problem-solving; and 6) Maintenance - application, self-management strategies and modeling opportunities for long-term behavior adoption. Table 1 illustrates how the Gimme 5 intervention components addressed the levels of behavior change.
Table 1. "Gimme 5" activities by levels of behavior change.
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Awareness Information
Development/ Transfer/
Interest Skills Application/
Components Stimulation Training Reinforcement Maintenance
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Classroom Workshops
Supplemental
subject
activities
School staff
training
------------------------------------------------------------------------
Cafeteria Taste- Menu/recipe Taste-
testing of modification testings of
"Gimme 5" training "Gimme 5"
recipes and Food purchasing recipes and
food give- Food preparation food give-
aways Food service aways
staff
Training
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Media Marketing Faculty tip Faculty Student
stations sheets fruit/ recipes
Posters vegetable
Table tents baskets
Public Incentives
service Coupons
announcements
Point of
service signs
Faculty fruit/
vegetable
baskets
Student
contests
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Parent P.T.O. P.T.O. meetings: Newsletter
meetings: media displays P.T.O.
media and activities meetings:
displays "Gimme 5" media
and column in displays and
activities school activities
newspapers
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Four focus groups (n=55) were conducted in fall 1993 with high school students to elicit information helpful with program development. Details of the focus groups have been described previously (Nicklas, Johnson, Farris, Rice, Lyon, & Shi 1997). Briefly, the focus group summaries showed that students' attitudes were favorable regarding a school program aimed at improving diet; students were in favor of parental involvement to help support dietary changes; and consumption of fruits and vegetables was reported to be low. Information obtained from the focus groups generated three guiding words in program development: availability, variety and taste.
The intervention components included: 1) workshops and supplementary subject activities; 2) a school media-marketing campaign; 3) school meal and snack modification ("Fresh Choices"); and 4) parental involvement ("Raisin' Teens").
Five 55-minute workshops were developed and implemented with cohort students as part of the Gimme 5 program. Each workshop had a unique theme, included a variety of learning strategies, and focused on the individual student and issues that are important to students. The workshops shared a common goal of providing students with the learning opportunity to develop knowledge, attitudes, and skills to increase consumption of fruits and vegetables. Each workshop was designed to meet specific learning objectives that related to the theme.
In workshop 1, Fresh Start, students examined their individual eating habits and developed marketing strategies promoting healthy eating to their peers. Workshop 2, Body Works, focused of eating as it relates to appearance and athletic performance. Fast Food: Go for the Green, the third workshop, had students evaluate fast food menus to select healthy meals. In workshop 4, Fresh Snacks, students practiced reading nutrition labels and choosing healthy snack foods. In Microwave Magic, the final workshop, students explored microwave cooking techniques by preparing healthy vegetable recipes. Each workshop included a taste-test/new exposure.
The Transtheoretical Model (Prochaska, DiClemente, & Norcross 1992) describes behavior change as a series of stages through which a person progresses. This model provided a framework for developing educational strategies and identifying content for learning experiences. The educational strategies and progression of learning activities of the five Gimme 5 workshops was applied to the stages of change described in the model to demonstrate the movement along the continuum in adopting the new health behavior, increasing the consumption of fruits and vegetables. A diagram of the stages of the model and how the various Gimme 5 workshop activities complimented each stage is presented in Table 2.
Table 2. Transtheoretical model. Progression of Gimme 5 workshop activities and strategies
according to stages of change.
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Precontemplation Contemplation Action Maintenance
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(unaware of the (thinking (making some effort, (maintaining the
behavior not about/ taking specific steps positive
thinking about considering toward the behavior behavior change
eating more the behavior) change) over time)
fruits and
vegetables)
1. Fresh Start: 2. Body Works: 3. Fast Food: All 5 workshops
students students students evaluate reinforce
complete a food problem-solve fast food menus and behavior
record and issues of practice selecting adoption.
market the eating for healthy fast food
health behavior appearance and meals that include Workshops 3, 4
to peers. performance. fruits and and 5 include
Messages develop Topics vegetables. Students strategy
awareness, stimulate apply/demonstrate development
heighten interest by the behavior outside and self-
salience and focusing on of class; management
relevance of eating issues participate in for preventing
participating in that are contest for prizes relapses.
the behavior, relevant to (incentive/
and motivate. students. reinforcement).
Messages emphasize
balance; skill
training focuses on
evaluating options to
make the best choice.
4. Fresh Snacks:
students read and
evaluate food labels,
and practice choosing
healthy snacks
Activities demonstrate
fruits and vegetables
to be superior snack
foods. Skill training
focuses on developing
strategies for making
healthy choices.
5. Microwave Magic:
students prepare
healthy fruit and
vegetable recipes.
Skill training is
for actual food
preparation.
All 5 workshops include a taste-test/new exposure where
students demonstrate the behavior and receive reinforcement.
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Supplementary Subject Activities (SSA) were lessons to be included in required academic
course work which used fruits and/or vegetables in the lesson design. The purpose was to
increase and maintain awareness by teachers and students of the 5-a-Day message. All
faculty responsible for teaching the targeted cohort were requested to present at least
one SSA each semester in their subject area during the first year of intervention.
An SSA booklet of 85 activities in 10 academic areas that highlighted fruits and vegetables was developed for teacher use. The booklet contained three types of activities that related to three types of learning: 1) Adaptation - an alternative classroom lesson designed to address specific subject objectives and goals; 2) Sponge - a quick 10-20 minute exercise to "sop-up" extra class time designed to introduce, synthesize, or complete a subject topic or theme when applicable; and 3) Report - a reinforcement activity provided as an extra assignment and completed as a written or oral report. A user-friendly, one- to two-page lesson plan with objectives, an overview, materials needed and fact sheets for faculty and student reference comprised each SSA.
The goal of the school wide media-marketing campaign was to create and provide appealing messages and activities that would increase awareness and promote positive attitudes toward the consumption of fruits and vegetables. Because of the significance of peer influence and the modeling behavior of teenagers, the media-marketing campaign not only targeted the longitudinal sample (class of 1997) but extended to other grades as well. An intense focus on a media-marketing component, which included taste-testing, advertising, games, and contests, played a significant role in the Gimme 5 program.
In order to present a unified campaign, all media channels were coordinated to support monthly themes designed to stimulate and maintain student interest. During the first year of intervention (fall 1994 - spring 1995), media-marketing materials and activities were implemented, supporting the overall theme and message of each monthly fruit and/or vegetable promotion. For example, the September promotion utilized the theme "Grape Expectations" to promote grapes and, at the same time, featured students "back-to-school" photographs and their expectations concerning school work, relationships, and extra-curricular activities for the school year. Photographing the students participating in school activities and soliciting their expectations for the coming year provided an opportunity for Gimme 5 staff to get better acquainted with students and exhibit interest in and a connection with students' high school experiences.
During the second year of intervention (fall 1995 - spring 1996), a more global approach was used in the monthly promotions. Each month featured an ethnic theme during which two days were set aside to provide ethnic menus in school cafeterias. These menus included at least two vegetables, one fruit, and an entree containing vegetables. Prior to the development of the menus, recipes were developed and taste-tested at one of the pilot-testing schools. Examples of recipes were Calypso pasta salad, veggie pocket pizza, orange honey baked bananas, and green bean and tomato casserole.
The goal of the "Fresh Choices" component was to increase the availability, variety, and taste of fruits and vegetables meeting 5-A-Day serving size and nutrient criteria (Produce for Better Health Foundation and National Cancer Institute 1991) in the school cafeteria, vending machines, and snack outlets. This component had four objectives: a) to provide opportunities for students to increase consumption of fruits and vegetables by increased availability and portion size; b) to increase the variety of fruits and vegetables available to students; c) to offer fruit and vegetable recipes that were acceptable and appealing to students; and d) to conduct monthly marketing activities promoting increased fruit and vegetable consumption.
The "Fresh Choices" program involved four major intervention areas including: 1) planning the "Fresh Choices" menu; 2) purchasing fruits and vegetables as menu items and as recipe ingredients; 3) preparing foods that meet the 5-A-Day criteria; and, 4) promoting your "Fresh Choices" program. Thirty "Fresh Choices" guidelines were developed to assist food service personnel with implementation of the program (Table 3).
Table 3. Fresh choices guidelines.
------------------------------------------------------------------------
The guidelines listed below can be used to increase the use of fruits
and vegetables and reduce the amount of fat, saturated fat, cholesterol,
and sodium in the preparation of recipes containing fruits and
vegetables. Guidelines are grouped according to use.
------------------------------------------------------------------------
All recipes and food preparation —
1. Follow recipes, weighing or measuring all ingredients with
standardized equipment and utensils.
2. Serve menu items with standardized serving utensils.
3. Purchase and use foods that are lower in fat and/or sodium (vendor
products and recipe ingredients).
4. Gradually reduce the amount of salt in recipes or eliminate. Use
more garlic, onion powder, herbs, and spices without added salt.
5. Gradually reduce the amount of fat used in recipes. Replace butter
or shortening with vegetable oil or margarine whenever possible.
------------------------------------------------------------------------
Fruit and vegetable recipes and preparation —
6. Increase frequency and variety of fruit, fruit juices, and
vegetables on the menu.
7. Increase serving size of fruit, fruit juices, and vegetables
8. Increase frequency and amount of fruit, fruit juices, and
vegetables used as ingredients in recipes.
9. Increase use of recipes meeting the 5-A-Day criteria.
10. Drain canned vegetables to reduce sodium.
11. Reduce or eliminate salt added to vegetables.
12. Reduce or eliminate butter, oil, margarine, animal fat, or cheese
sauce added to vegetables.
13. Decrease or eliminate frequency of fried potatoes and other
vegetables on the menu.
14. Reduce the amount of mayonnaise, sour cream, and oil; or
substitute lowfat yogurt or lowfat mayonnaise in salad dressings
and other recipes.
15. Reduce, pre-portion, or eliminate use of high fat items in salads,
and on salad bars (e.g. olives, avocado, coconut, nuts, bacon bits,
regular cheese, egg yolks, sour cream).
------------------------------------------------------------------------
Mixed dishes and baked products containing fruits and vegetables —
16. Drain fat from cooked meat.
17. Rinse drained cooked ground meat with hot water and drain.
18. Trim all visible fat from meat before cooking it.
19. Bake, broil, roast, or stew beef, pork, chicken, or fish instead
of frying.
20. Remove skin and fat from chicken and turkey. Bake with no added fat.
21. Defat broth to be used in recipes.
22. Use water, beef base seasoning (low-sodium when possible) and flour;
or make a dry roux for gravy. Do not add meat drippings.
23. Use lower fat cheeses (e.g. part-skim mozzarella). Reduce the amount
of regular cheese or mix with lower fat cheese.
24. Use egg whites rather than whole eggs in salads and other recipes.
25. Use skim milk, lowfat, or nonfat dry milk instead of whole.
26. Use non-stick coating spray or pan liners instead of greasing pans.
27. If using butter, whip it before using in food preparation.
28. Reduce or eliminate butter or mayonnaise spread onto breads and
sandwiches.
29. Reduce or eliminate butter, oil, margarine, or animal fat added to
pasta or rice.
30. Reduce or eliminate salt added to pasta or rice
------------------------------------------------------------------------
The goal of the "Raisin' Teens" component was to provide education, stimulate awareness, and elicit parental support for the Gimme 5 program. The objective was to increase the availability and variety of fruits and vegetables in the home. Gimme 5 staff conducted taste-tests of Gimme 5 recipes, media displays, and activities at Parent Teacher Organization meetings and at family-related functions. Colorful brochures featuring pictures of individual fruits and vegetables with recipes were distributed to parents with school mailings at least once a semester during the first year of intervention. These leaflets included purchasing tips, recipes, and nutritional information on individual fruits and vegetables that corresponded with the monthly promotions taking place in the school. The initial mailing to parents included a Gimme 5 recipe holder with a magnet so that parents could attach the brochures to the refrigerator.
The "Gimme 5 Alive" newsletter was sent each semester to parents of the cohort students in the intervention schools. The newsletter provided information about Gimme 5 activities, recipes, discount coupons for produce, and information about the benefits and uses of fruits and vegetables. The "Ripeline" was a mail service that invited families to submit nutrition-related questions, and answers appeared in subsequent newsletter issues. School newspapers and newsletters also featured a Gimme 5 column to provide additional program information. It was anticipated that parental inclusion would encourage a receptive attitude in the homes of teenagers in the intervention schools.
A "Gimme 5 Calendar" for the school year 1995-96 was sent home to all parents of the intervention cohort. The ethnic foods calendar provided monthly healthy eating tips, eating out and dishing it out (for home cooking) tips, all related to the featured ethnic cuisine. Each monthly ethnic tips corresponded with the ethnic promotions that took place in the school. The fifth day of each calendar month was designated a Gimme 5 day to encourage home preparation of ethnic fruit and vegetable dishes. An entry form for a $50 gift certificate to an ethnic restaurant of choice as well as coupon clips and recipe pages were included to encourage parental involvement and support of the Gimme 5 message.
Program evaluation comprised process and outcome measurements. The usefulness of process evaluation was in documenting program implementation, program dose, fidelity to design, and external competing factors. Process evaluation measures included: 1) student awareness of and receptivity to intervention activities; 2) school meal participation; 3) student characteristics such as demographic and tracking data; and 4) intervention activities conducted in the classroom and food service components. A process media-marketing evaluation survey was administered each semester to intervention school cohort. The purpose of this survey was to obtain feedback from students on the media-marketing materials and activities. Specific items included a subjective rating of the marketing stations, table-tents, taste-testings, posters, Public Service Announcements and contests.
Outcome evaluation in Gimme 5 involved assessment of knowledge, attitudes, and practices related to program goals. These measures were collected annually over the four-year study to measure change. The self-administered questionnaire packet included measures of knowledge regarding fruits and vegetables, self-perception, social support, self-efficacy, stages of change and food frequency quantifying fruit and vegetable intake over the past month. Nutrient intakes were assessed via 24-hour dietary recall interviews, collected at baseline and post-intervention on a random subsample of 60 students (n=720) per school.
The importance of disease prevention and health promotion is being recognized by the general public and is beginning to influence lifestyles within the United States. The 21 nutrition objectives established as part of the Healthy People 2000 initiative (US Department of Health and Human Services, Healthy People 2000 1990) identify national goals for fostering the dietary changes needed to reduce the risk of chronic disease and to improve health status. Objective 2.6 targets increasing the consumption of fruits and vegetables to five or more daily servings of the general population. Gimme 5 is an example of a school-based program designed to meet this objective with adolescents.
The authors wish to thank Amy Cunningham, MS, RD, Marilyn Dantin, BS, Rosanne Farris, MsHyg, Carolyn Johnson, PhD, Lisa Lyon, MPH, Christina Reger, Rochelle Rice, MPH, Larry Webber, PhD, Marion White, MS, RD, and Gerald Berenson, MD for their support to the Gimme 5 program, and the Archdiocese School Food Service Office and Gimme 5 schools without whom this work could not be accomplished.
This research is supported by funds from the National Institutes of Health, National Cancer Institute, CA59803-01.
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Morgenstern, S. (1992). No sweat desktop publishing. New York: AMACOM.
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Wilficy, D.E. (1989). Interpersonal analyses of bulimia: Normal-weight and obese.
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The North Dakota Journal of Human Services, October 1998