Chapter 3 Consumption, Availability and Food Policies

Chapter 3 Consumption, availability and food policies

Fruit and vegetable others used weighed or estimated food consumption intake records over a variable number of days (for more information, see http://www.fao.org/es/esn/nutrition/pro- This section reviews quantitative infor- files—en.stm). Finally, the FAO food mation on consumption of fruit and balance sheets (see Chapter 2) were vegetables from published and unpub- used to obtain an overview of the situ- lished surveys. Most of the survey ation worldwide, as well as to detect results were published in the interna- trends over time (FAOSTAT, 2000). tional scientific literature, but some From the above, it is apparent that were retrieved from national journals the data reported in this chapter have with limited circulation and from gov- been generated by a variety of meth- ernment reports. Studies and reports ods, some of which are known to pro- presenting information on the fre- vide only a crude estimate of dietary quency of consumption only were intake. A detailed description of the excluded. Another selection criterion diverse approaches is provided in was the level of representativity of the Chapter 2. The limitations encountered study sample, at the national or subna- in trying to provide a general picture of tional level, although in special cases, the consumption of fruit and vegeta- data on smaller, selected groups of bles are detailed below, and should be populations were retained for the pur- kept in mind when considering the data pose of highlighting specific points. and drawing conclusions. The review focuses on surveys conducted in the last couple of decades; Categories of fruit and of earlier data are considered only if they agencies global data banks, comple- vegetables are of special significance or if they mented by information from national The presentation of data-sets on con- document specific aspects, such as institutions and independent experts sumption of fruit and vegetables as time trends. from the countries. The quality of the aggregated groups is an important In view of the paucity of information information on food consumption is issue that can seriously limit their com- on food consumption in the developing highly variable between countries, but parison and interpretation. In some regions of the world, recourse was is mostly rather crude. Only overall fruit cases, only values for combined fruit made to the series of Nutrition Country and vegetable consumption data are and vegetables are provided. More fre- Profiles (NCP5) of the Food and reported, and little, if any, methodolog- quently, separate values are given for Agriculture Organization (FAO) to ical information (sampling technique, the two categories, but these are not obtain a glimpse, albeit crude, of the survey methods, individual food items homogeneous across studies, as they situation in these countries. NCPs are included under either category, general may or may not include individual prepared in a standard format and pro- context of the survey) is provided. items such as potatoes, starchy fruit vide information on the food and nutri- Some surveys used the household (e.g., bananas), dry and/or fresh tional situation in individual countries. budget survey method, others used pulses, or fruit and vegetable juices. Data are derived from the UN food frequency questionnaires, yet Unfortunately, it has not been possible

35 IARC Handbooks of Cancer Prevention Volume & Fruit and Vegetables to fully harmonize the data and the around the reported values. A further advanced old age), it cannot be errors introduced when comparing two problem is the fact that certain items assumed that the same pattern applies non-identical food aggregations can be are country-specific. Thus, inclusion or to the intake of fruit and vegetables. neither corrected nor controlled for. exclusion of a food item here was Indeed, an age-associated increase in Indeed, the most serious and wide- determined with the purpose of maxi- fruit and vegetable consumption can spread limitation is that reports only mizing the comparability of the data- be seen in some but not all data-sets. seldom specify the individual fruit and Sets. As a rule, potatoes, pulses and More important might be the possible vegetable items included in or canned beans were excluded from the change in the spectrum of individual excluded from their analyses. vegetable category, while 'beans", food items consumed at various ages. Examples of detailed descriptions of "peas", "fresh legumes" and "canned A clear case is that of consumption of the food items included within the fruit vegetables" were included. "Other root fruit juices and nectars that increases and vegetable categories are the vegetables" were also included. Olives sharply in the second to third years of CSFII surveys (USDA Food Surveys were excluded. For the category of life, remains high during childhood, Research Group, 2003a) and the mul- fruit, the following items were and then declines with advancing age. ticentre European Prospective Investi- excluded: jams, preserves, dates, gation into Cancer and Nutrition bananas, plantains, nuts and dry fruits. National surveys (EPIC) (Agudo et aI., 2002). The lack The fruit category includes fruit juices, Nationally representative data on fruit of detail in the reports from developing fruit nectars and canned fruits. An and vegetable consumption were countries may be accounted for by the exception was made with the food bal- available for 21 countries including fact that the focus of these surveys ance sheet data, where bananas were China, India, Israel and the has been food security and therefore included in the fruit category, in view of Philippines. The remaining 17 coun- the emphasis was placed on staple the important position of bananas in tries include 14 within the WHO foods rather than the low-energy con- the diet of large regions in Africa and European Region and Australia, Japan tent fruits and vegetables. However, a Latin America. This inclusion is not and the USA. similar paucity of data on food group- based on evidence of any potential Figure 1 shows the data obtained ings is shared by several reports from health-protective effect. in Australia (McLennan & Podger, developed countries. In conclusion, an attempt was 1999), the Baltic republics (Pomerleau The problem is compounded by made to harmonize the categories of et aI., 2001), Belgium (Kornitzer & the loose and sometimes imprecise fruit and vegetables across the various Bara, 1989), China (Institute of use of botanical classification of fruit surveys. However, this process has Nutrition and Food Hygiene, 2002), and vegetables. Thus, roots and been possible only to a limited extent Denmark (National Food Agency of tubers' may or may not be included in and no presumption can be made Denmark, 1990), Finland (National the vegetable category; potatoes are about the homogeneity of the cate- Public Health Institute of Finland, sometimes, but not always, included in gories in the various studies. 1998), France (Volatier & Verger, roots and tubers; olives may be 1999), India (Department of Women & specified as fruits; starchy fruits and Age and sex groupings Child Development, 1998), Ireland vegetables (bananas, yams, bread- Another factor that limits the compara- (Irish Nutrition & Dietetic Institute, fruit) may or may not be listed in their bility of food intake data from the van - 1990), Israel (D.N. Kaluski, personal respective categories; the category of eus sources derives from the disparity communication), Italy (Turrini et al., pulses is sometimes given separately in the sex and age composition of the 2001), Japan (Office for Life-style but it is almost never specified whether study samples. Often data are given Related Disease Control, 2002), the fresh pods are included or not in the as averages for both sexes combined. Netherlands (Netherlands Nutrition vegetable category. The term In some cases, age groups do not Centre, 1998), Norway (Johansson & "legumes" is used in a loose manner, overlap, in other cases the range is Sovoll, 1999), the Philippines (Food especially in the non-English literature, wide and no information on the median and Nutrition Research Institute, where it sometimes refers to fresh or mean age of the entire group is pro- 2001), Spain (Institute Nacional de vegetables in general. Fruit and vided. While age has a bearing on the Estadistica, 1991), Sweden (Becker, vegetable juices and nectars may or total volume of food consumed as well 2001), the United Kingdom (Gregory may not be listed separately, as may as on total energy intake (increasing et al., 1990) and the USA (USDA Food canned and preserved fruits. This may with age from childhood to maturity Surveys Research Group, 2003b). introduce a large margin of uncertainty and levelling off later to fall in

Consumption, availability and food policies

500

400

3 00

w C = - 200

100

il!!

-' -. >. >. > > > -. > > CI) > >, >, > > > > > > + + U) C) C) C) C U) CC C) C) + + C) + + C C) Ct) C) C) Cr) U) C) 'C C C) Cr C) C) C) 4 C) (C (C C) (D (C (C) (D C) (C (C Co (C (CC (C C) C) N- N- (C (D N- (C C) (C (D (C N- N- N- C) C) co N- C I I I CC) I I I J I I C I I I I I I I C) (D 3) C) (C C) C) C) U) (C C) I) C) CC !!!!lIl!!!l!l!!I!!M ! Co W >> LL. -0 4- 4- C') LL C C U- C _ C (C) C C U- (I) .E - . lu CL E < O U) C D CD OD U) Z r Z

Figure 1 Overview of the fruit (yellow) and vegetable (blue) consumption in 21 selected countries, as reported by the most recently conducted national surveys

There are obvious limitations to this of well over 300 g/d. Developing coun- for developed countries to have higher comparison, such as the different age tries have the lowest intake, for exam- proportions of fruit consumption. In ranges used, the survey methods, the ple 128-148 g/d in India and 183 g/d in particular, Scandinavian countries dates of the survey and the items the Philippines. In most European (Norway, Sweden, Finland) have very included in the categories of fruit and countries, consumption is between high fruit intake. vegetables. Where the data permitted, 250 and 350 g/d of total fruit and values shown in Figure 1 are for vegetables, but there is wide diversity Selected multi-centre studies adults, but in some cases the range between European regions. Japan has A multi-country survey on the preva- includes children and/or the elderly. one of the highest levels of overall con- lence of non-insulin-dependent dia- About half of the surveys give data for sumption (almost 400 g/d), while the betes mellitus and related risk factors men and women separately. USA and Australia have about 300 g/d. was carried out in Algeria, Bulgaria, The picture that emerges shows a Fruit consumption in individual coun- Egypt, Greece and Italy on small wide disparity in intake across coun- trïes appears to fluctuate indepen- homogeneous groups of non-diabetic tries, with a four-fold difference dently of vegetable consumption and men and women aged 35-60 years between the lowest intake of just over may represent between less than a (Karamanos et al., 2002) (Figure 2). 100 g of fruit and vegetables per day in fifth of the total intake (India, China) up Food consumption was assessed by a India and the highest intake of almost to more than half (Finland, Spain). validated dietary history method. The 500 g/d in Israel, a difference in intake There seems to be a slight tendency results indicate that consumption of

37 IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables fruit and vegetables is similar in North Netherlands, Poland, Portugal, Spain, g/d) and lowest in Denmark (120 g/d), African countries and in European Switzerland and the United Kingdom and followed a pattern of increasing Mediterranean countries, with intakes (Trichopoulou et al., 1995b; Schroll et consumption from northern to south- ranging from 416 g/d to 501 g/d of total al., 1996, 1997). ern Europe. In most sites, fruits repre- fruit and vegetables. The data from A surprisingly high consumption of sented well under half of the overall Italy are in good agreement with the vegetables was recorded everywhere, amount of fruit and vegetables con- national results. Interestingly, the high- but potatoes and other roots were sumed, but reached about 50% in est intake was recorded in Bulgaria included in the vegetable category, Greece and Portugal and over 60% in (536-594 g/d). For all countries except thus inflating the total amount to a Italy and Spain (Schroll et al., 1997). Egypt, fruits represented half or more degree that differs depending on the For Denmark, the Netherlands, Spain of the total amount. study site. The proportion covered by and Switzerland, data are available on The multi-country SENECA project potatoes appears to range roughly the same subjects assessed four years (Survey in Europe on Nutrition and the from over two thirds in Denmark and earlier (Schroll et al., 1997). The Elderly, a Concerted Action) collected Poland to less than one third in Italy changes over the intervening four information on the diet of elderly peo- and one French site (Schroll et at., years were negligible and within the ple (born between 1913 and 1918) in 1996). Therefore, these data should be methodological error. 11 European countries in an initial sur- considered only within the context of The dietary pattern of 519 878 vey in 1988-89 and in a follow-up in the SENECA project. For women and healthy adult men and women was 1993 on a smaller sample. Dietary men, the highest overall consumption assessed by food frequency question- intake was assessed by a three-day of fruit and vegetables was recorded in naire in 27 cohorts recruited in ten food record in household measures, Spain (766 g/d for women, 935 g/d for European countries within the frame- followed by an interview with a dietitian men), followed by Portugal and work of the EPIC project. Details on the to establish the weight of portion sizes. France, Belgium, the Netherlands, background, rationale and design The method was strictly standardized Greece and Italy. The lowest intakes of the study, on population characteris- across all study sites, affording a set of were recorded in Denmark (347 g/d for tics, the selection process, data collec- uniquely comparable data. The data women and 371 g/d for men) and tion and some preliminary results are reviewed here are those for people Switzerland (about 420 g/d for both given elsewhere (Riboli, 1992; Slimani aged 74-79 years in Belgium, men and women). Fruit consumption et aL, 2000, 2002; Riboli et al., 2002), Denmark, France, Greece, Italy, the was also highest in Spain (about 550 along with detailed information on the food items included in the categories of fruit and vegetables. The diet of a sub- sample of 35 955 men and women aged 35-74 years (mean age, 55 years for women, 57 years for men) randomly selected from each EPIC cohort was assessed by a standardized 24-hour recall method (Agudo et al., 2002). The cohorts are located in Denmark (two sites), France (four sites), Germany (two sites), Greece (one site), Italy (five sites), the Netherlands (two sites), Norway (two sites), Spain (five sites), Sweden (two sites) and the United Kingdom (two populations). Men and women partici- pate in the study in 19 centres, and only women in eight. The data pre- sented are adjusted for age, season and day of the week, thus providing an Figure 2 Fruit (yellow) and vegetable (blue) consumption in the Mediterranean coun- internally comparable set of data tries participating in the Mediterranean Group for the Study of Diabetes (MCSD) (Figure 3), although these data differ

Intake (gld) Intake (gid) N) Cl) P. 01 C) J Cl) o (D O C' (D C' C) (D (D (D C) O O O O O M CO 41 C) O (D C) (D O O (D Q C Q C) Q Copenhagen M z Copenhagen D Aarhus I Aarhus I

North West Heidelberg - North East South ______z Potsdam o Coast

Heidelberg I ni Potsdam rfl C) rn Varese

Florence Naples r Varese Ragusa Florence I rn Ragusa O Turin Z I Turin I m

Biithoven Bilthoven z o FT1 ED rr Utrecht C/) z North &West o Asturias South & East Navarra Asturias Granada Navarra Granada San Sebastian I San Sebastian Murcia I Murcia Cl) Malmd Ci) ni Umeâ Umeâ niz Malmö z IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables only very slightly from the unadjusted rather than as edible portion, possible the spectrum, with intakes below 200 values. For both sexes, the highest stores present in the household, data g/d. At the higher end of the spectrum, overall consumption of fruit and representing availability rather con- the Middle Eastern and North African vegetables was seen in Spain (721 g/d sumption), the harmonized household countries (Morocco, Turkey and Iran) for men in Murcia) and Italy, while the budget surveys permit cross-country have intakes of over 350 g/d. lowest consumption was found in comparisons. Fruit and vegetable Sweden (225 g/d for men in Umeâ), availability ranged from 217 g/d in Availability and time trends in followed by the Netherlands, Norway, Ireland, almost equally divided large regions the United Kingdom and Denmark. between the two categories, to the val- The food balance sheets of the FAO Where the information is available, ues recorded in Spain (463 g/d) and in (FAOSTAT, 2000), collected with a uni- women seem to consume similar Greece (613 g/d), which include higher fied and unchanging technique since amounts of fruit and vegetables to proportions of fruit. As data for eastern 1961, offer a unique opportunity to men, except in Greece, Italy and Europe are scarce, it is interesting to examine time trends worldwide. The Spain, where men have appreciably note the values recorded in Poland data are more correctly referred to as higher consumption. (302 g/d in 1988) and Hungary (354 disappearance or availability figures, Besides the notable variations in g/d in 1991), the difference being and thus are not directly comparable total intake between countries, there mainly a result of higher availability of with the data obtained from dietary are also wide variations within coun- fruit in Hungary than in Poland. The surveys. An additional difference is that tries, particularly in those countries highest availability of fruit is again bananas are included in the fruit cate- where consumption is highest (Italy, recorded in Greece (346 g/d) and gory. Spain). The intake of fruit generally Spain (283 g/d). Data from Greece for Figures 5 and 6 provide an represents about half the total intake, 1988 and 1994 show an unexpected overview of the availability of fruit and but rises to two thirds in countries decline in availability of both fruit and vegetables in major regions of the where the total intake is high. Thus, the vegetables, which dropped from 613 world and of changes over the last 40 lowest consumption of fruit was g/d in 1988 to 496 g/d in 1994. On the years. A six-fold difference in fruit and recorded in Sweden (122-159 g/d) whole, the ranking of the DAFNE data vegetable availability is apparent and the highest in Spain (454 g/d) and on the basis of fruit and vegetable across the world (Figure 5). The four Italy (448 g/d). The data from this study availability is in good agreement with regions in sub-Saharan Africa have the indicate that the countries with the the results of national surveys (Figure lowest levels overall, with countries in highest total intake have the largest 1) and the EPIC (Figure 3) and eastern Africa having less than 100 within-country variation and the high- SENECA studies on food consump- g/d. Western Europe, the Asian Near est consumption of fruit. Similar high tion, with Ireland and the United East and North America at the upper variability is shared by other studies, Kingdom at the Lower end and Greece end have over 600 g/d. and is reflected in the large difference and Spain at the higher end. In most developing regions, the between the intake of individual con- availability of vegetables is higher than sumers and the mean intake of the Developing countries that of fruit, except in those regions entire group. For a small number of developing where bananas represent a large per- The European DAFNE project, countries, information on fruit and centage of the fruit (central Africa, designed to harmonize the data of the vegetable consumption was retrieved Latin America and the Caribbean). In household budget surveys of diverse from the Nutrition Country Profiles contrast, in the developed regions countries, produced comparable data series (FAO NCPs). Data for Iran, Mali, where the total availability of fruit and for ten European countries: Belgium, Morocco, Pakistan, Sri Lanka, Turkey, vegetables is highest (western Europe Germany, Greece, Hungary, Ireland, Venezuela and Viet Nam are shown in and North America), there is similar Luxembourg, Norway, Poland, Spain Figure 4. The data available do not availability of fruit and of vegetables. and the United Kingdom. All surveys separate fruit and vegetable consump- Eastern European countries have very were conducted between 1987 and tion. While the quality of the data may low intake of fruit compared with that of 1995 (Naska et al., 2000). Despite lim- be questionable, the picture that vegetables and compared with itations inherent to the nature of the emerges is one of great disparity western Europe. data (level of aggregation of the data, between countries. Asian countries Different trends over time are household level of the information, (Pakistan, Sri Lanka, Viet Nam), Mali observed between regions. in eastern foods being reported as crude values and Venezuela are at the lower end of and central Africa, availability of both

40 Consumption, availability and food policies

00 vegetable intakes reveals great 450 interindividual variation in patterns of TURKEY IRAN consumption. Figure 7 displays within- 400 MOROCCO country variations of fruit and - 350 vegetable intake in selected developed 300 countries. The largest interregional dif- W 2E0 ference is seen in the USA (USDA 200 Food Surveys Research Group, ISO PAKISTAN 2003c), where it reaches 112 g/d, fol- 100 MALI Ï NÏilI lowed by Finland (87 g/d in men). 50 Elsewhere, the differences are smaller, O ranging between 36 g/d in Norway and 67 g/d in Finland for women. In those Figure 4 Total fruit and vegetable intake in selected developing countries for which countries for which data are available, recent, nationally representative data were available there appear to be larger differences between men than between women. In the United Kingdom, a four-fold difference was found between the 1st and the 4th quartiles in the amount of fruit 700 I and vegetables consumed by adults: - 6001 105 and 448 g/d respectively (Billson 5001 etal., 1999). In the data from the EPIC project (Agudo et al., 2002), the range 4001 observed within one country varies £ 3001 from non-existent or minimal (Sweden 200 or Norway) up to 200 g/d as seen 100 across the five sites in Spain (Figure ! 3). The SENECA study confirms the persistence of within-country variation CX (n '-( 2 < 2 w 2 in the elderly (data not shown). (n . .e

41 IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables

Sub-Saharan Africa Northern Africa & Near East

45t3 .. 120 400 350

w 100 CU ~Wu El C5 250 Ç 80 200 150 0 oo e: ;~ ~~

40------1961- 1066- 1971- 1976- 1091- 1986- 1091- 1996- A 65 70 75 80 85 90 95 2000

Latin America & Caribbean Europe & America 350 300

-300 250 250 w 200 . 200 u i 150 150 100 -Fa 00 o o I— 50 1— 59 o o ...... 1961- 1968- 1971- 1976- 1981- 1986- 1001- 1696- 1961- 1996- 1971- 1976- 1981- 198e- 1991- 1996- C 65 70 75 80 85 90 95 2000 D 65 70 75 80 85 90 95 2000

Asia 400 —g-- Fruits Woolon —W-- Fruits NW Air --F0515 Wool. E. 350 --4-- Fruits Control Fruits N Air — é— Fruits Lasi. E —S-- FruFto Eastern —4--- Fruits North Am. 300 —4--- Fruits NE AsIa ---FruIts Southern -a--- va- i-iw Ate -.---- Fteits L. AOl/Ce 250 w --y-- Veg. WOlsiOlO H /eg NE Afr —8—W9 West, E. —é--Vi. Central —1--Veg East. E , 200 --+--Ve NE Asi. Eastern —*--Veg North An. 150 • - Va- Seattrerrr —S--Veq L Am/Car. 1:0 L A B C 50

—8--S Am Vug —A— Froitu Sooth Sols E 1961- 1966- 1971- 1978- 1951- 1986- 1991- 1996- —a---5 Am Fruits ----Froilu EEEE Asia 65 70 75 50 85 90 05 2000 ----Ceriir An Va- - - Fi - Erses Jopar - Cer5r An Fruits —A— Va- Eoth Ave —0--Carib. Va- —X—Va- EaSE Asia Carrib. Emits —a-- Vuy Sapas D E

Figure 6 Time trends in fruit and vegetable consumption in large regions worldwide: Data retrieved from the FAQ Food Balance Sheets (FAOSTAT, 2000). Except where mentioned, the same regions as for Figure 5 were selected.

42 Consumption, availability and food policies over 200 g/d among illiterates and survey also revealed a seasonal trend, (FAO NCPs). Similarly in Ireland, from 75 g/d to over 300 g/d among the with values of 518 g/d in summer and intakes were slightly higher (30 g/d) in college-educated. A 3-4-fold interre- 482 g/d in winter. In Iran, the the rural population, among both men gional difference is observed at all lev- urban/rural difference was very and women (Irish Nutrition & Dietetic els of education attained, from illiteracy marked, 523 g/d versus 389 g/d (FAO Institute, 1990). through primary, secondary and high NCP5). Data from India (Department Another very likely determinant of school to college education (see also of Women & Child Development, fruit and vegetable intake is income. In below). 1998) and Pakistan (FAQ NCPs) indi- the USA, intake is positively income- A large number of factors may cate very small, non-significant associated in both sexes and at all account for the diverse food patterns urban/rural differences. In China, a dif- ages (USDA Food Surveys Research observed within a country. For some ference of 65 g/d was reported, from Group, 2003d) (Figure 9). The greatest countries, separate data are available 345 g/d in the rural population to 410 effect appears to be in adolescent for urban and rural populations. Almost g/d in the cities, the difference being women, with a difference of about 100 everywhere, urban populations tend to related predominantly to fruit con- g/d between the strata of highest and consume more fruit and vegetables sumption (FAQ NCPs; Institute of lowest income; for the other age than rural ones, but the difference is Nutrition and Food Hygiene, 2002). In groups the difference between the often negligible (FAQ NCP5). A Chile, in contrast, a nationwide survey poorest and the richest amounts to national survey conducted in Turkey in in 1969 recorded intakes of relatively 35-60 g/d. National data from the 1984 indicated an average consump- high amounts of fruit and vegetables 1992 survey in China also indicate an tion of 408 g/d of fruit and vegetables, (about 435 g/d), while later surveys appreciable positive income-associ- with an urban/rural difference of 425 conducted mostly in the Santiago area ated gradient in total intake of fruit and g/d versus 392 g/d (FAQ NCP5). The found lower intakes (around 300 g/d) vegetables, the higher-income group

Figure 7 Regional differences in fruit (yellow) and vegetable (blue) consumption within selected developed countries

43 IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables consuming three times more fruit than amount of fruit and vegetables con- Greece, Hungary and Poland, while the lower-income group, while the dif- sumed by the college-level households the relationship with education is less ference in vegetable consumption was in certain states may be lower than that clear in Belgium and Spain. minimal (Institute of Nutrition and Food of illiterate households in other states. These data are generally not Hygiene, 2002). A positive association between adjusted for possible confounders, so Educational level, taken as a proxy educational level and consumption of that the relationship between intake for socioeconomic status, has been fruit and vegetables has also been and various parameters may be con- shown in several surveys to influence found in developed countries, such as founded by lifestyle covariant parame- fruit and vegetable intake. The national the USA (Devine et al., 1999; Xie et al., ters such as smoking, alcohol-drinking data from India (Department of Women 2003) and Australia (Turrell et al., habits or culture as well as by the eco- & Child Development, 1998) indicate 2002). In Europe, the situation seems logical niche. Care must therefore be that only part of the variation in fruit to be less clear, as the DAFNE data do exercised in interpreting these associa- and vegetable consumption across the not confirm a positive trend in the total tions. For example, stratification by country can be accounted for by edu- amount consumed with increasing ethnic group (Mexican American, other cational level (Figure 10); the differ- level of education. For the total con- Hispanic origin, non-Hispanic blacks ences in intake between regions are sumption of fruit and vegetables, the and non-Hispanic whites) in the USA greater than those associated with the trend, albeit slight, is for consumption has revealed differences in the pattern education attained within any given to be higher at the lower levels of edu- of fruit and vegetable consumption state, which reach a maximum of 183 cation (elementary level or less), a (USDA Food Surveys Research g/d (2.5-fold) in Daman & Diu. The decrease of consumption in the sec- Group, 2003e). Although the differ- clear positive association with educa- ondary level of education, and an ences are neither systematic nor very tional level found in several states increase again at the university educa- large, it appears that non-Hispanic (7/17) appears to be independent of tion level. However, looking at con- blacks, who are likely to have lower the absolute intake, as it occurs in sumption of fruit and vegetables sepa- educational attainment and lower regions of both low and high total rately reveals an inexplicable decrease income, tend also to be lower con- intake. In other regions, education was of fruit consumption with increasing sumers. In Ireland, the unemployed not associated with fruit and vegetable education in Spain, but an increase in and the unskilled have systematically consumption. In yet other regions, fruit Greece. The other three countries for lower consumption than profession- and vegetable intake steeply increases which values are available, Poland, als and "non manuals" (Irish Nutrition only at college educational level Hungary and Belgium, present a & Dietetic Institute, 1990). (Meghalaya, Chandigarh, Dadra & U-shaped trend. Vegetable consump- Such diverse behaviour and the Nagar Daveli, Daman & Diu). Thus, the tion decreases with education in variety of forces responsible for it have

A. Illiterate population B. College educated 350 350 300 300 250 250 200 200 !150 J 150 100 100 50 50 0 M I I I~ nflaflI 111111111. k . _ k rn _ . . . (L' J E a .- ' c- 70 E2 I L3 ED C Figure 8 Geographical differences in fruit (yellow) and vegetable (blue) consumption in India, according to the education level attained

Consumption, availability and food policies

350 1-5 years 6-11 years 12-19 years > 20 years Polo 300

250 :a 200 TEL H • 150 - - Ii I - 100

0 ---.. .. - -.-- -.. '.- '- -..- - - - e - o o o o - o o - o e - o e U) e e €' It) L) U) U) L) U) U) L) U) U) L) It) It) L) L) U) U) L) Cl) - Cl) ,- L) Cl)C') Cl) C') L) C') A C') A y A V A V i. A V A V y A

female male female male female male

Figure 9 Differences in fruit (yellow) and vegetable (blue) consumption by household income and age class in the USA

started to be investigated, and are osteoporosis and other noncommuni- els of fruit and vegetable consumption revealing that consumers' choices cable diseases. During the 1970s and are associated with reduced risk of are shaped by an amazingly wide and 1980s, dietary fat was a major focus of some cancers (see Chapter 4). complex array of factors, that include research and policy, and later in this Several comprehensive reviews of market forces, physical access, price, period the roles of dietary fibre and data regarding diet in relation to traditions, availability and many others. antioxidants were addressed. More cancer, chronic disease and health recent epidemiological, clinical and concerns in general have identified laboratory research has been focused foods, nutrients and other dietary Nutrition and food policies on foods and food groups, particularly components as being potentially and special campaigns fruit and vegetables. During the past important for cancer prevention 25 years, research findings suggesting (Assembly of Life Sciences, 1982; Historical perspective an inverse association between fruit National Cancer Institute, 1986; Nutritional research, programmes and and vegetables and cancer have con- James, 1988; US Public Health food policy have shifted focus over the tributed to the development of interna- Service and Office of the Surgeon last hundred years. In the early 1900s, tional and national policy statements General, 1988; WHO, 1990, 2003). the focus was on identifying and about cancer and the consumption of These also provided estimates of the preventing nutrient deficiency dis- fruit and vegetables. potential effects of cancer-prevention eases, while in the 1940s and 1950s, Doll and Pete (1981) estimated that efforts and recommendations and pri- attention moved to the identification of approximately 35% of cancer deaths orities for dietary change, including nutrient requirements. Subsequently, were related to diet (from tO to reducing the intake of total fats, espe- investigations were directed to the role 70%, depending on the type of can- cially saturated fat, maintaining desir- of diet in maintaining health and reduc- cer). Since then, a growing body of evi- able weight and improving diet quality. ing the risk of cancer, heart disease, dence has suggested that higher lev- The earlier dietary guidelines included

45 IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables

Figure 10 Fruit (yellow) and vegetable (blue) consumption by educational level in four representative States in India few specific recommendations for solely on nutrient intakes and nutrient quences in terms of unfavourable fruits and vegetables. In the USA, the adequacy to recommendations that dietary patterns and decreased physi- National Research Council (1989) pro- are more food-based and aimed cal activity. Fruit and vegetable intake vided a quantitative recommendation towards health maintenance and food still varies considerably between coun- to every day eat five or more servings safety. In 2002, the WHO issued tries, in large part reflecting the pre- of a combination of vegetables and guidelines and policies for national vailing economic, cultural and agricul- fruit, especially green and yellow cancer control programmes (WHO, tural environments. The WHO/FAO vegetables and citrus fruits. The 2002). These emphasized improved report emphasized the need for con- recommended number of servings of diet and increased fruit and vegetable certed efforts to improve diet, with fruit and vegetables was derived by intake as essential parts of the increasing intake of fruit and vegeta- calculating nutritionally balanced diets approach to cancer prevention. A joint bles, and for a lifelong approach to that would meet the overall dietary WHO/FAO Technical Report (WHO, healthy eating. recommendations (Cronin etaL, 1987). 2003) made it clear that a growing Recent reports from international These reports taken together provided epidemic of chronic diseases, includ- and nongovernmental organizations a focus on dietary patterns containing ing obesity, diabetes mellitus, cardio- have included recommendations for a variety of foods, rich in plant foods vascular disease, hypertension and fruit and vegetable intake, as summa- including fruits, vegetables, cereals stroke, and some types of cancer, rized in Table 9. The World Cancer and whole grains, while being gener- afflicting both developed and develop- Research Fund review (WCRF!AICR, ally low in energy, fat, especially satu- ing countries, is related to dietary and 1997) estimated that a simple rated fat, cholesterol and sodium. lifestyle changes, often linked to change, such as eating the recom- industrialization, urbanization, eco- mended five servings of fruit and Current policy and dietary guide- nomic development and market global- vegetables each day, could by itself lines ization. While standards of living and reduce cancer rates more than 20 per- Over the years, nutrition and dietary food availability have improved, there cent. The first recommendation of the guidelines have moved from focusing have also been negative conse- American Cancer Society's Guidelines

46 Consumption, availability and food policies on Nutrition and Physical Activity for The WHO European Regional Office states (Kafatos & Codrington, 2003). Cancer Prevention (Byers et al., 2002) has provided Member States with a Other groups of countries also work is to eat a variety of healthful foods Regional Food and Nutrition Action together to develop nutrition plans, with an emphasis on plant sources" Plan, which refers to fruit and dietary guidelines and educational and specifically to 'eat five or more vegetable consumption as a priority efforts. The examples in Figures 11-14 servings of a variety of vegetables and (WHO/EURO, 2000). WHO also pro- show how food-based dietary guide- fruits each day". The WHO/FAO vides information and assistance for lines for different countries or regions Expert Consultation on Diet, Nutrition developing food-based guidance sys- translate the recommendations for fruit and the Prevention of Chronic Disease tems (WHO, 1998). and vegetable intake and how they (WHO, 2003) recommends consuming The International Conference on reflect cultural food patterns. Other at least 400 grams of fruit and vegeta- Nutrition in 1992 called upon countries pictorial representations of dietary bles per day. to develop national food and nutrition guidelines have been reported (Painter action plans (http://www.fao.org/- etal., 2002). Programmes to implement es/esn/nutrition/ICN/ICNCONTS.htm). dietary guidelines and nutrition To date about 150 countries have such Recommended amounts of fruit policy plans and another 20 have them under and vegetables National and regional health organiza- development. Many of these plans in Recommendations for fruit and tions translate these international developed countries, and to a lesser vegetable intake are fairly similar policy statements into food-based extent in developing countries, include across international and national dietary guidelines that reflect the cul- goals for prevention of noncommuni- guidelines, and are generally desig- tural food patterns and the prevalence cable diseases through population- nated as servings of fruit and vegeta- of noncommunicable diseases in indi- based dietary strategies. bles per day specified in household vidual populations (WHO, 1998). Such The EURODIET project (1998- units, serving sizes or grams. Most guidelines aim at disease prevention, 2000) established a broad network and publications specify consuming at taking into account local economic, a strategy and action plan for the least 400 grams or five or more serv- food availability and food safety con- development of European dietary ings daily of fruit and vegetables, with siderations (Becker, 1999; Löwik et al., guidelines and outlined ways for effec- a range for the daily intake provided to 1999; Valsta, 1999; US Department of tive promotion of diet and healthy allow for varying energy intakes. Health and Human Services, 2000). lifestyles in European Union member Several guidelines make separate

Agency Recommendations Fruit and Suggestions for (reference) vegetables implementation

World Cancer Promote year-round 400-800 g!day or 5 servings/day Research Fund/ consumption of a variety of or more. Not included: pluses! American Institute fruit and vegetables, providing fruit and vegetables (tubers. for Cancer Research 7% or more total energy starchy roots and plantains (WCRF/AICR, 1997)

American Cancer Eat a variety of healthful 5 servings/day or more Include vegetables and fruits Society foods, with an emphasis on at every meal and for snacks. (Byers et al., 2002) plant foods Eat a variety of vegetables and fruits. Limit french fries, snack chips and other fried vegetable products. Choose 100% juice if you drink fruit or vegetable juices

WHO 400 g/day or more (WHO, 2003) Not included: tubers

47 IARC Handbooks of Cancer Prevention Volume & Fruit and Vegetables recommendations for fruit and Campaigns to increase fruit and programmes (WHO, 1998). During the vegetables (Chinese Nutrition Society, vegetable intake late 1980s, state projects were con- 2000; see Figure 14). Over the past twenty years, a variety of ducted in California, Australia, Guidelines differ in what items are campaigns have been conducted to Canada, and some European coun- included in the food list for fruits and inform individuals of the benefits of fruit tries to develop programmes and cam- vegetables or in what are counted as and vegetable consumption. Health paigns on fruit and vegetables; these a fruit or vegetable (see Chapter 1). policy objectives and international and provided valuable experience for fur- There are also differences in what national dietary guidelines have ther development and national expan- specific types of preparation or manu- served as the foundation for these sion of fruit and vegetable campaigns facture of fruits and vegetables are campaigns (see above). The cam- (Foerster et al., 1995; Miller et al., encouraged or emphasized. Potatoes paigns have included large national 1996; Dixon et al., 1998; Farrell et al., may or may not be included in the food programmes, regional efforts and Local 2000). Recent campaigns have list for fruit and vegetables. For programmes to develop and imple- expanded social marketing approaches example, the World Cancer Research ment dietary guidelines in order to and community-based implementation Fund report (WCRF/AICR, 1997) does increase fruit and vegetable intake. methods and draw on the scientific not include potatoes (or other starchy The campaigns have used informa- credibility of sponsorship by national, roots or plantains) in its list of fruits and tion developed in earlier community state and local health institutions. A vegetables, nor do the food guides for intervention studies (Puska et al., major element is partnerships between several countries (Denmark, Germany, 1983; Farquhar et al., 1990; Luepker health agencies, nongovernmental Ireland, the Netherlands) (Flynn & et al., 1994) and recommendations organizations for cancer or heart dis- Kearney, 1999; Haraldsdottir, 1999; about implementing community-based ease prevention and the fruit and veg- Hermann-Kunz & Thamm, 1999; Ltwik etable industry and agricultural groups. et al., 1999). Potatoes are included in The first national initiative was the US the food lists for fruit and vegetables of National Cancer Institute's 5-A-Day Australia, the USA and the American For Better Health Program, initiated in Cancer Society (Miller et al., 1997; US 1991 (see below). The methods in this Department of Health and Human programme and the experience gained Services, 2000; Byers et al., 2002). have provided a model for many Soy products are usually not programmes to develop national part- included as fruit and vegetables, but nerships for development and imple- other legumes may be included. mentation of fruit and vegetable cam- Pickled vegetables and fruit-based- paigns (National Institutes of Health jams, jellies, preserves, candies and and National Cancer Institute, 2001). A fruit-based soft drinks are frequently variety of campaigns conducted pre- not included on the lists of fruits and dominantly in Europe and North vegetables. To ensure compatibility America have focused on the five - with guidelines that address fat intake, a-day theme for recommendation of some fruit and vegetable dishes that fruit and vegetable intake. In these, are prepared with fat, salt or sugar programme partners work together to may be excluded from the food list, or develop, implement and evaluate inter- individuals may be cautioned to ventions. Such campaigns dissemi- limit intake of these dishes. Most nate messages and conduct activities guidelines indicate that individuals aimed at behavioural change in rela- should limit chips, snack chips and tion to fruit and vegetable intake, other fried vegetables. Many of the Figure 11 CINDI dietary guide from the involving a variety of components: national guidelines also encourage WHO Regional Office for Europe (pyra- media and communications; point-of- consumption of specific fruits and mid) (WHO/EURO, 2000).The recommen- sale interventions; community-level vegetables, such as dark green leafy programmes, including public health dation is to eat a variety of vegetables and vegetables, red-orange fruit, citrus fruit agencies, school-based and worksite fruits, preferably fresh and local, several and cruciferous vegetables. programmes; partnership activities times per day (at least 400 g per day) with the food industry, retailers and

48 Consumption, availability and food policies

I.. public side and the Produce for Better Health Foundation (PBH) as the private side (Produce for Better Health Foundation and National Cancer Institute, 1999). PBH is a non-profit organization supported by approximately 1000 donors from the fruit and vegetable industry, supermarkets and other organizations and individuals interested in health promotion. The goal is to increase the average consumption of fruit and vegetables per capita to five or more servings every day by providing consumers with information about how to incorporate more servings of these foods into their daily eating patterns and by creating a healthy food environment wherever people eat, in schools, at workplaces or at home. After a favourable national evalua- Figure 12 Canada's Food Guide to Health Eating (rainbow) (Health Canada, 2002) tion of the first decade of the pro- The advice is to eat 5-10 portions of frut and vegetables per day gramme in 2000, the National 5 A Day Partnership was formalized and expanded in April 2001. This partnership increased the number of both pri- A2OCMV GRASAS vate and public stakeholders in the US programme. New partners formally

POO added included the Centers for Disease Control and Prevention (CDC), the American Cancer Society (ACS) and several mission areas within the US Department of Agriculture (USDA). These new part- i: ners provided more federal and local GRANOS r support. CDC now funds several state Y PAPA 5 A Day research and demonstration protects. USDA has launched a pilot project in four states to bring fresh fruit Figure 13 Guatemalan Dietary Guide (pot) (INCAP/OPS, 2000) and vegetables into school class- rooms. Coordinators from each of the The recommendation is to eat fruit and vegetables including leafy vegetables, every day 50 states, plus all the US Territories and military branches, form the rest of fruit and vegetable producers; and 5 A Day Program—USA the National 5 A Day Partnership, research efforts. Media components The Eat 5 A Day—for Better Health! which is now the largest public-private are implemented in complementary Program originated as a pilot pro- partnership promoting health in the ways at the national or state level and gramme in 1988 in the state of USA. at the local level. Examples of such California through the California The partners are also targeting campaigns are described below. Department of Health. It was initiated specific population sectors. NCI targets nationally in the USA in 1991 by the African American men with a National Cancer Institute (NCI) as the message to Eat 5 to 9 A Day PBH,

49 IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables

NANA is a coalition of over 200 organizations promoting public policy changes to improve both nutrition and Fat and oils 25 g physical fitness. NANA leaders include the Center for Science in the Public Milk and dairy products 100 g Interest, American Public Health Beans and bean products 50 g Association, American Heart Associa- tion, American College of Preventive Medicine and many state departments Meat 50-100g fish 50 g, eggs of health. In addition to participating in 25-50 g the NANA coalition, United and PBH are pressing to expand the USDA free fresh fruit/vegetable pilot programme Vegetables 400-500 g into other schools nationwide. Fruits 100-200 g At the community level, coordinators in each state health department help to implement the 5 A Day programme by targeting their own audi- Cereals 300-500 g ences with their own materials or materials available through the national partners. State and local coali- tions involve both the public and pri- Figure 14 Dietary guidelines from the Chinese Nutrition Society (2000) (pagoda) vate sectors to implement activities at The recommendation is to eat 400-500 g of vegetables/day and 100-200g of fruits the local level. Local partners include industry as well as local ACS divisions, focusing on female shoppers, has variety of vegetables and fruit in cultur- regional USDA offices, schools and launched a campaign called 5 A Day ally appropriate ways and in the con- others. The Color Way. The American Cancer text of a low-fat diet; the use of whole A great strength of the programme Society's 5 A Day Body and Soul grains and minimal use of salt and has been its focus on organizing and programme is targeting African sugars are also strongly suggested. expanding the number and reach of American women through the black NCI and PBH have established the 5 A Day National Partnership, as church networks. To reach Spanish- criteria to define promotable products much as promoting the actual 5 a day speaking consumers, both NCI and that may be promoted as part of the 5 message. The programme has shown PBH materials have been adapted A Day Program. These criteria are the feasibility of health agencies work- with appropriate ethnic food choices intended to keep the 5 A Day Program ing in partnership with agricultural and visuals promoting Coma 5 al d(a y consistent with US federal nutrition boards and commissions, fruit and Sea Active (Eat 5 A Day and be Active) objectives, dietary guidelines and food vegetable companies and supermar- and 5 A Day—Coma Sus Colores labelling regulations (US Department kets to deliver wide-reaching mass- Cada DIa! (5 A Day—Eat Your Colors of Health and Human Services, 1990, media messages with modest govern- Every Day!). California 5 A Day has 2000). These criteria are now being ment resources (National Cancer taken the lead in developing many of re-evaluated to take into account the Institute, 2002). these materials in their Latino 5 A Day latest knowledge about fruits and A survey of 2544 adults conducted programme. vegetables and new fruit/vegetable in 1997 showed that general aware- In all cases, the goal is to promote products in the US food supply. At the ness of the recommended daily serv- a positive message about diet and a national level, 5 A Day partners also ings of fruits and vegetables had healthy lifestyle. Eating low-fat meals include the United Fresh Fruit & increased from 7.7% in 1991 to 19.2% that include five to nine servings of fruit Vegetable Association and the National and knowledge of the 5 A Day and vegetables every day is a corner- Alliance for Nutrition and Physical programme had increased from 2.0% stone of a healthy life plan. Care is Activity (NANA). The former is a trade to 17.8% (Stables et al., 2002). taken not to disparage other food organization representing the fresh Preli-minary data showed a modest groups, and to promote a colourful fruit and vegetable industry, while increase in the mean intake of total

50 Consumption, availability and food policies fruit and vegetables (from 3.75 serv- Europe Food, Agriculture and Fisheries (Fagt ings per day in 1991 to 3.98 in 1998) Several campaigns have been con- et aL, 2002) confirmed 600 g/d in (National Institutes of Health and ducted in Europe. The European addition to potatoes as a recom- National Cancer Institute, 2001). Partnership for Fruits, Vegetables and mended target for public health. Better Health (EPBH) is a voluntary Since 1999, the Danish 6 A Day Australia network set up in May 2003 involving programme has conducted a number Several campaigns aimed at improving Denmark, Finland, France, Germany, of research projects on how to increase fruit and vegetable consumption have Holland, Norway, Poland, Slovenia fruit and vegetable consumption. A par- been conducted in Australia, initiated and the United Kingdom. The mem- ent-paid subscription programme for at the state level. The Western bers are bodies promoting health or fruit in schools was shown to increase Australia Health Department directed a fruit and vegetable consumption. students' fruit intake by 0.4 servings campaign with the slogan "Fruit 'n' Veg National members should ideally per day. Non-subscribers too showed with Every Meal' (Health Department include both health organizations and a significant increase in fruit consump- of Western Australia, 1990). Following non-profit organizations representing tion in schools where the programme an evaluation showing a limited impact the fruit and vegetable industry, such was introduced (Eriksen et al., 2003). of this slogan, the department moved in as growers, importers, shippers, Supplying free fruit in workplace 1991 to using a quantitative message, processors, wholesalers and retailers. settings has also proven very effective. '2 Fruit 'n' 5 Veg Every Day' (National Where such national partnerships do In an intervention study, a total of 283 Health and Medical Research Council, not exist, countries are encouraged to employees at 12 workplaces increased 1991). Surveys conducted in Western form such an alliance. The overall their average fruit intake by 0.7 Australia identified barriers to increas- objective of EPBH is to assist mem- servings per day and the men's intake ing consumption of fruit and vegetables bers to increase the consumption of of unhealthy snacks was cut in half including habit, lack of knowledge fruit and vegetables in their countries. (Morten Strunge Meyer, Denmark, about the amount of fruit and vegeta- This should be achieved by facilitating personal communication). The number bles to eat for good health, concern exchange of documentation and expe- of workplaces offering free fruit to about high prices and poor quality, par- rience on effective strategies and employees has greatly increased from ticularly of fruit; and boredom with and actions and by collaboration and coor- 1998 to 2002. lack of preparation ideas for vegeta- dination of research activities on fruit Since 1998, the awareness of 6 A bles. On the basis of the Western and vegetable promotion across Day has been monitored twice a year. Australian experience, Victoria con- Europe. EPBH will formulate and com- Unpublished data show that 40% of all ducted a "2 Fruit n' 5 Veg Every Day" municate suggestions for policy Danes now know that they should eat campaign between 1992 and 1995, changes at both national and Euro- 6 A Day or 600 g/d, and 66% have placing greater emphasis on formal pean levels, coordinate pan-European heard or read about the 6 A Day cam- industry partnerships. promotions and actions and stimulate paign. More important, the average per Surveys at the state level indicated national partnerships between health capita intake of fruit and vegetables for increased awareness of the recom- partners and organizations represent- adults increased from 279 to 379 g/d mended daily amounts of fruit and ing the fruit and vegetable industry. from 1995 to 2000/01, according to the vegetables, improved attitudes and The EPBH web site (www.epbh. national dietary survey (Fagt at al., increased consumption (Dixon et al., org) provides information on cam- 2002). Unpublished data from the 6 A 1998; Farrell et al., 2000). A telephone paigns already implemented in Euro- Day telephone surveys suggest that survey of 2602 subjects in November pean countries. As an example, the this increase took place after the year 2000 showed an increase in reported experience in Denmark, including 2000, when the 6 A Day-campaign was consumption of fresh fruit and some evaluation results, is summa- launched (Figure 15). vegetables from 4.1 servings per day in rized below. The 6 A Day research projects 1998 to 4.5 (Reeve, 2000). In addition, In 1998, a broad consensus was have shown that enhancing determi- respondents were aware of the health reached in Denmark to adopt the nants such as availability and ready- benefits of fruit and vegetable con- message 6 A Day - Eat more fruits to-eat-ness' can be very effective in sumption and believed they should be and vegetables' as the official national increasing fruit and vegetable con- eating seven or more servings per day. recommendation for fruit and sumption in a population that already vegetable consumption. A 2002 follow- knows that fruit and vegetables are up report from the Danish Ministry of good for health. Health information has

51 IARC Handbooks of Cancer Prevention Volume 8: Fruit and Vegetables

Figure 15 Self reported intake of Fruits and vegetables in Denmark Each bar is based on 500 phone interviews. Potatoes are excluded not been entirely abandoned, continu- gies. 6 A Days future strategy will have ing to target, for instance, key profes- an increased locus on influencing sionals, but for interventions to be health-oriented public policies and effective the many and complex continued strengthening of effective determinants must be adequately public—private partnerships. addressed when developing strate-