Environmental impact and nutritional quality of adult diet in France based on fruit and vegetable intakes

PURPOSE

To describe the nutritional quality and environmental impact of self-selected diets of adults in France in relation to their fruit and vegetable (FV) intakes.

METHODS

Estimates of food and nutrient intakes were taken from the national INCA3 Survey on food intakes carried out in France in 2014-2015. The population (n = 2121 adults) was split into five quintiles of FV intakes, in g/d (Q1 representing the lowest intake, and Q5 the highest). The nutritional quality of diets was assessed through 4 indicators: mean adequacy ratio (MAR), solid energy density, mean excess ratio (MER) and Programme National Nutrition Santé guideline score 2 (PNNS-GS2). The environmental impacts were measured with environmental footprint (EF) scores and 4 additional indicators: climate change, ozone depletion, fine particulate matter and water use. Indicators were compared between quintiles. Analysis was conducted on diets adjusted to 2000 kcal.

RESULTS

MAR and PNNS-GS2 increased with increased FV quintiles, while solid energy density decreased. Fibre, potassium, vitamin B9 and vitamin C densities increased with increasing FV intakes. Climate change, ozone depletion and fine particulate matter impacts of diets decreased with increasing quintiles of FV consumption. Conversely, water use impact increased.

CONCLUSION

Higher intake of FV is associated with higher nutritional quality of diets and lower environmental impact, except for water use. Given the benefits of fruit and vegetables for human health and the environment, their negative impact on water use could be improved by working on the agricultural upstream, rather than by changing individuals' food choices and reducing their consumption.

Mediators and moderators of the effects of a school-based intervention on adolescents' fruit and vegetable consumption: the HEIA study

OBJECTIVE

To examine whether targeted determinants mediated the effects of the HEalth In Adolescents (HEIA) intervention on fruit and vegetable (FV) consumption and explore if these mediating effects were moderated by sex, parental education or weight status.

DESIGN

Cluster-randomised controlled trial.

SETTING

The HEIA study (2007-2009) was a Norwegian 20-month multi-component school-based intervention to promote healthy weight development. FV consumption and targeted determinants were self-reported at baseline, mid-way (8 months) and post-intervention (20 months).

PARTICIPANTS

Adolescents (11-13-year-old) in twenty-five control schools (n 746) and twelve intervention schools (n 375).

RESULTS

At post-intervention, more adolescents in the intervention group compared with the control group had knowledge of the FV recommendations (OR: 1·4, 95 % CI 1·1, 1·9) and reported a decreased availability of vegetables at home (β: -0·1, 95 % CI -0·2, 0·0). Availability/accessibility of FV at home, availability of vegetables at dinner, taste preferences for different types of FV and knowledge of the FV recommendations were positively associated with the consumption of FV. However, none of the post-intervention determinants significantly mediated the intervention effects on FV consumption. Although no moderating influences by sex, parental education or weights status were observed on the mediating effects, exploratory analyses revealed significant moderations in the b-paths.

CONCLUSIONS

Since none of the targeted determinants could explain the increase in FV consumption, it remains unclear why the intervention was effective. Reporting on a wide range of mediators and moderators in school-based interventions is needed to reveal the pathways through which intervention effects are achieved.

Does fruit and vegetable consumption impact mental health? Systematic review and meta-analyses of published controlled intervention studies

Associations between fruit and vegetable (FV) consumption and mental health are suggested, largely from observational studies. This systematic review aimed to identify and summarise all published controlled intervention studies investigating the effects of FV consumption on mental health in adults. Four academic databases (Medline, PsycINFO, PubMed, Web of Science) were searched on 16 September 2022, over all years, for studies that used an intervention design; included FV consumption; included an appropriate non-FV-consumption control; used a validated measure of mental health and were conducted in healthy adults or adults with solely a depressive or anxiety-related condition. Study details were tabulated and combined using meta-analyses. Risk of bias was assessed using the domains of the Cochrane Collaboration. Six studies, enrolling 691 healthy adults and reporting on one or more mental health outcomes, were found. Meta-analyses found small and imprecise effects of FV consumption for: psychological well-being (4 studies, 289 participants) standardised mean difference (SMD) = 0·07 (95 % CI -0·17, 0·30), P = 0·58, I2 = 0 %; depressive symptomology (3 studies, 271 participants) SMD = -0·15 (95 % CI -0·40, 0·10), P = 0·23, I2 = 47 % and anxiety-related symptomology (4 studies, 298 participants) SMD = -0·15 (95 % CI -0·39, 0·08), P = 0·20, I2 = 71 %. Some benefit for psychological well-being was found in change-from-baseline data: SMD = 0·28 (95 % CI 0·05, 0·52), P = 0·02, I2 = 0 %. Risk of bias was high in many studies. Limitations include the consideration only of published studies and stem from the studies found. Given the few, limited studies available and the small size of effects, stronger evidence is needed before recommending FV consumption for mental health.

Geographical and sociodemographic disparities in fruit and vegetables consumption among adults in Burkina Faso: baseline results from the 2013 WHO STEPS survey

BACKGROUND

Evidence on sociodemographic determinants and spatial variations in the fruit and/or vegetable (FV) consumption was reported. This study aimed to explore geographical and sociodemographic disparities in the level of FV consumption among adults in Burkina Faso, using the national baseline data.

METHODS

This was a cross-sectional secondary study of primary data obtained by the 2013 (September to October) World Health Organization Stepwise Approach to Surveillance survey conducted in Burkina Faso. The participants were 4402 women and men aged 25-64 years and living in all 13 Burkinabè Regions. Descriptive and analytical analyses were performed using Student's t test, ANOVA, the chi-square test, Fisher's exact test and logistic regressions.

RESULTS

The prevalence of a typical daily consumption of at least three servings was 4.1% (95% CI: 3.6-4.8) for fruits and 6.6% (95% CI: 5.9-7.3) for vegetables. The national prevalence of adequate FV intake was 5.1% (95% CI: 4.4-5.8), and for two Regions ("Centre-Ouest" and "Nord") the pooled prevalence was 22.4%, while in the other eleven Regions its was significantly lower, 2.4% (p = 0.0001). Using quartiles derived from the national level of consumption, each of these two Regions had a higher proportion (about 50%) of their participants in the fourth quartile (the higher level). The associated sociodemographic factors with the adequate intake were being rural residents (aOR = 1.7, p = 0.011) and women (aOR = 1.3; p = 0.03).

CONCLUSION

Except for the Regions of "Centre-Ouest" and "Nord" of Burkina Faso, the prevalence of adequate consumption of FV was very low in its other eleven Regions. Measures to increase consumption in urban people are urgent while women should be the key actor in the family-based approaches implementation and the nutrition education promoting FV consumption.

Role of fruit and vegetables in sustaining healthy cognitive function: evidence and issues

Modifiable lifestyle factors, such as improved nutrition, are crucial in maintaining cognitive health in older age. Fruit and vegetables represent healthy and sustainable sources of nutrients with the potential to prevent age-related cognitive decline. The aim of this review is to synthesise the available evidence, from epidemiological and randomised controlled trials (RCT), regarding the role of fruit and vegetables in sustaining healthy cognitive function. Epidemiological studies of combined fruit and vegetable intake suggest that increased consumption may sustain cognition in later life. The evidence appears to be stronger for an association between vegetables and cognition, particularly for green leafy and cruciferous vegetables. Specific benefits shown for berries, citrus fruits, avocado and nuts suggest fruit is worthy of further investigation in relation to cognition. Data from RCT indicate benefits to differing aspects of cognition following citrus and berry fruits, cocoa and peanuts, but the data are limited and there are a lack of studies exploring effects of vegetables. There is growing evidence for an association between fruit and vegetable intake and cognitive function, but this is not always consistent and the data from RCT are limited. Issues in previous research are highlighted, such as strict exclusion criteria, absence of baseline nutritional status data and lack of consideration of individual differences, which may explain the weaker findings from RCT. Inclusion of those most at risk for cognitive decline is recommended in future nutrition and cognition research.

Total carotene plasma concentrations are inversely associated with atherosclerotic plaque burden: A post-hoc analysis of the DIABIMCAP cohort

BACKGROUND AND AIMS

Atherosclerosis is the major risk factor for cardiovascular disease (CVD), the first cause of death worldwide. Chronic low-grade inflammation and a sustained oxidative milieu are causatively related to atherosclerosis onset and progression, and therefore, dietary patterns rich in bioactive compounds with anti-inflammatory and antioxidant activities might likely contribute to revert or slowing the progression of atherosclerosis. The aim of this study is to analyse the association between fruit and vegetables intake, quantitatively measured through carotene plasma concentrations, and atherosclerotic burden, as a surrogate biomarker of CVD, in free-living subjects from the DIABIMCAP cohort study.

METHODS

The 204 participants of the DIABIMCAP Study cohort (Carotid Atherosclerosis in Newly Diagnosed Type 2 Diabetic Individuals, ClinicalTrials.gov Identifier: NCT01898572), were included in this cross-sectional study. Total, α-, and β-carotenes were quantified by HPLC-MS/MS. Lipoprotein analysis in serum was performed by 2D- 1H NMR- DOSY, and atherosclerosis and intima media thickness (IMT) were measured through standardized bilateral carotid artery ultrasound imaging.

RESULTS

Subjects with atherosclerosis (n = 134) had lower levels of large HDL particles than subjects without atherosclerosis. Positive associations were found between α-carotene and both large and medium HDL particles, and inverse associations were found between β- and total carotene, and VLDL and its medium/small particles. Subjects with atherosclerosis presented significantly lower plasma concentrations of total carotene compared with subjects without atherosclerosis. Plasma concentrations of carotene decreased as the number of atherosclerotic plaques increased, although after multivariate adjustment, the inverse association between β- and total carotene with plaque burden remained significant only in women.

CONCLUSIONS

A diet rich in fruit and vegetables results in higher plasmatic carotene concentrations, which are associated with a lesser atherosclerotic plaque burden.

Bioaccessibility of Cu, Mn, Fe, and Zn in Fruit and Vegetables by the In Vitro UBM and Statistical Evaluation of the Results

The total, gastric, and gastro-intestinal Cu, Mn, Fe, and Zn concentrations in eight fruit and vegetable samples were investigated. The unified bioaccessibility method (UBM) developed by BARGE (Bioaccessibility Research Group of Europe) was performed for in vitro bioaccessibility experiments. Total and bioaccessible concentrations of Cu, Mn, Fe, and Zn were determined by ICP-OES and ICP-MS, respectively. The accuracy of the methods was verified using BGS 102 for the BARGE UBM and SRM 1573a for total analysis. The mean BF (%) order for Cu, Mn, Fe, and Zn was Mn (101) > Zn (88) > Fe (60) > Cu (30) in gastric phase and Mn (78) > Zn (69) > Fe (46) > Cu (29) in gastro-intestinal phase. The results show that Mn and Zn in all the samples have the greatest bioaccessible values, while the values for Cu are much lower. The relationships among total, gastric, and gastro-intestinal element concentrations were investigated using statistical analysis such as correlation analysis, principal component analysis (PCA), and cluster analysis (CA). Total and bioaccessible Cu, Mn, and Zn concentrations were significantly correlated with each other.

Implementation of four strategies in Dutch day-care centres to stimulate young children's fruit and vegetable consumption

The day-care setting is an ideal place to encourage children's fruit and vegetable (=F&V) eating. Whereas many studies have focused on the effectiveness to increase F&V consumption, little is known about how to successfully implement effective strategies in daily practice. This study aimed to investigate how day-care professionals evaluated the implementation of a self-chosen strategy to support children's F&V eating. Thirteen day-care locations chose one out of five promising strategies and implemented this strategy for 10-12 weeks. Before (N = 98) and after the study (N = 49), day-care professionals completed a questionnaire to assess their implementation experiences, the impact on children's F&V eating as well as their future intention to use the strategy (on a 5-point scale). Parents (N = 152) completed a short questionnaire at the end of the study to capture their experiences and potential transfer effects to the home situation. Results showed that acceptability, appropriateness, feasibility and sustainability of the strategies were generally satisfactory (scores ≥3.5 on a 5-point scale), but the strategy of cooking scored less favourable on appropriateness and sustained implementation. Children's willingness to taste F&V varieties (3.4 ± 0.7 vs. 2.8 ± 0.8; p < 0.001) and eating pleasure for vegetables (3.4 ± 0.6 vs. 3.1 ± 0.8; p = 0.01) increased, whereas children's F&V consumption did not change (p > 0.14). Parents valued the day-cares' efforts to encourage children's F&V consumption and a small group (∼20%) experienced positive effects at home. This study shows that implementing a self-chosen F&V strategy at the day-care is acceptable, appropriate and feasible for day-care professionals and has potential to positively impact children's F&V eating behaviour. Future research should investigate the effects of long-term implementation on children's eating behaviour and examine how structural implementation can be further supported.

Effects of the DAGIS randomized controlled trial on home environment and children's food consumption according to the degree of implementation

BACKGROUND

Combining process evaluation data with effectiveness data and examining the possible mediators of intervention effects elicits valuable knowledge about how and for whom these interventions are effective. The aim of this study was to examine whether the parental degree of implementation (DOI) of a home-involving preschool intervention affected children's food consumption via home mediators.

METHODS

The five-month Increased Health and Wellbeing in Preschools (DAGIS) intervention involved 476 participating children aged 3-6 years and was conducted in 2017-2018. Parents reported children's food consumption (g/day) outside childcare hours, the availability of foods at home, role modelling of food consumption, and the norms related to food consumption. In addition, parents reported the extent to which they had implemented the intervention program at home. Mediation analyses were conducted to examine the effect of low and high DOI compared to control group on the change in children's consumption of fruit and vegetables (FV), sugary everyday foods, sugary treats, and sugar-sweetened beverages (SSB) via food availability in the home, parental role modelling and parental norms.

RESULTS

Compared to the control group, there was a direct effect of a high DOI on diminishing consumption of SSB (B -27.71, 95% CI -49.05, -4.80). No indirect effects were detected. In the high DOI group, a change in parental norm was associated with increased FV consumption showing an indirect effect (B 4.31, 95% CI 0.23, 10.59). In the low DOI group, there was an indirect effect via decreased food availability leading to decreased sugary everyday food consumption (B -2.17, 95% CI -5.09,  -0.09).

CONCLUSIONS

Combining process evaluation and effectiveness data revealed a decrease in children's SSB consumption only in the high DOI group, as well as indirect effects on children's consumption of FV and sugary everyday foods. In order to gain more intervention effects, further studies are required in order to examine parental facilitators and barriers to the implementation of interventions and how to impact effectively the determinants of the targeted behavior.

TRIAL REGISTRATION

ISRCTN57165350 (8 January, 2015).

Pay (for it) as you go: Prepaid energy meters and the heat-or-eat dilemma

The "heat-or-eat" dilemma, a trade-off typically between food consumption and heating, may elevate public health concerns during the 2022 energy-price crisis. Our paper contributes to the literature by exploring the role of domestic energy prepayment meters (PPMs) in the heat-or-eat dilemma, focusing on the association between PPM use and fruit and vegetable consumption. Using a representative sample of 24,811 individuals residing in Great Britain (January 2019-May 2021), we find robust evidence of lower fruit and vegetable consumption amongst individuals using PPMs, compared to those using post-payment energy bill payment methods. On average, our point estimates suggest that individuals using a PPM consume 2.7 fewer portions of fruit and vegetables per week. Our findings hold when bounding analysis is employed to account for omitted variable bias. Using a suite of IV approaches to further alleviate endogeneity concerns we found that our ordinary least squares results are consistent as opposed to IV models. Further robustness analyses highlight the deleterious impact of PPMs on people's healthy eating habits relevant to the consumption of enough fruit and vegetables. Our results suggest that targeted support for PPM users may have beneficial effects on people's fruit and vegetable consumption patterns.

Causes and prevention practices of food waste in fruit and vegetable supply chains: How is Brazil dealing with these issues?

This study aims to identify the main causes of food waste (especially fruit and vegetables) and their relationship with prevention practices at supermarket and supplier levels. To do so, we conducted case studies in four Brazilian supermarket chains and their suppliers. Our findings show that although supermarkets seem to be concerned about avoiding food waste, they mostly focus on internal prevention actions, reflecting the lack of collaboration and information between supermarkets and suppliers. The low investment of supermarkets in actions to prevent food waste is focused only on their internal operations and, despite this, training is inefficient due to the high level of staff turnover and lack of involvement of suppliers in participating in this training. The use of technologies such as packaging, traceability, refrigeration, and transport equipment is insufficient, it increases production costs. A lack of strict legislation in Brazil makes it difficult for supermarkets and suppliers to donate food. Cultural issues specific to Brazil, such as consumer overhandling fruit and vegetables before buying these products, generate a great deal of waste. The paper contributes to the literature by identifying the main root causes of food waste and providing a list of prevention practices that supermarkets and suppliers can benefit from. Managerially, it can help supermarket managers spot the causes of food waste within their operations, and hence change, improve or implement practices and behavior to prevent food waste.

Study protocol: Evaluation of the 'Flavour School' sensory food education programme: a cluster-randomised controlled trial in UK primary school children, aged 4-7 years, to determine impact on confidence and curiosity in tasting vegetables and fruit

BACKGROUND

Many children would benefit from a diet richer in vegetables and fruit. 'Flavour School' is a programme of 'sensory food education', which aims to increase children's confidence and curiosity in exploring foods and flavours, especially vegetables and fruit. This study will conduct a cluster-randomised controlled trial to assess the outcomes of the Flavour School programme in primary school children aged 4-7 years.

METHODS

Four hundred plus children from 4+ schools will either complete the Flavour School programme (experimental group) or have no intervention with normal school teaching (control group), cluster-randomised within-schools, by school class. Baseline data collection will consist of video recorded behavioural observation during a tasting activity, and post-intervention data collection will repeat this activity after the experimental group have completed the intervention. Process measures will be assessed using a teacher engagement feedback questionnaire.

DISCUSSION

This study will provide causal data on the efficacy of a sensory food education intervention for increasing children's confidence and curiosity in exploring foods and flavours, especially vegetables and fruit. This new knowledge will help educators and policy makers to make evidence based decisions on uptake of sensory food education.

TRIAL REGISTRATION

ISRCTN: 40249947 Date assigned 17 March 2020 Last edited 22 September 2021 Version 1.2 Trial Acronym OASES (Outcomes Assessment of Sensory Education in Schools).

Metabolic impact of a nutrition education program for the promotion of fruit and vegetable consumption with people with severe mental disorders (DIETMENT)

OBJECTIVES

The aim of this study is to determine the metabolic impact of a nutrition education program on metabolic parameters and the presence of metabolic syndrome (MetS).

RESULTS

Seventy-four patients were included (mean age, 48.7 years [Standard deviation, SD: 10.8], 55.4% men). The diagnoses of SMD were 37.8% schizophrenia and related disorders; 29.7% bipolar disorder; 25.7% depressive disorder; 4.1% personality disorders; and 2.7% obsessive compulsive disorders. Thirty-seven individuals were distributed in both the intervention group (IG) and the control group (CG). In the IG the presence of MetS was 56.3% and in the CG 46.7%, with no statistically significant difference (p = 0.309). At the end of the study, glomerular filtrate decreased in the IG, body mass index and abdominal perimeter increased in both groups, and there were no changes in metabolic parameters between the groups. Between the baseline and the end of the study, there was no increase in the number of patients diagnosed with MetS (14 at both points); and in the CG the increase was from 8 to 12 (p = 0.005). An intervention based on fruit and vegetable intake could prevent progression to MetS in individuals with SMD, decreasing the likelihood of cardiovascular disease. Trial registration The trial was retrospectively registered on International Standard Randomised Controlled Trial Number (ISRCTN) Register on 11 March 2022 (ISRCTN12024347).

Effect of the multicomponent healthy high school intervention on meal frequency and eating habits among high school students in Denmark: a cluster randomized controlled trial

Background

Previous studies have shown that multicomponent interventions may improve meal frequency and eating habits in children, but evidence among young people is limited. This study evaluated the effect of the Healthy High School (HHS) intervention on daily intake of breakfast, lunch, water, fruit, and vegetables at 9-month follow-up.

Methods

The study included first-year students (≈16 years) attending high school in Denmark. Participating schools were randomized into the HHS intervention (N = 15) or control group (operating as usual) (N = 15). The intervention was designed to promote well-being (primary outcome) by focusing on healthy habits including meals, stress prevention, and strong peer relations. It included a curriculum, structural and organisational initiatives, a workshop, and a smartphone application. Students completed self-administered online questionnaires at the beginning of the school year and nine months later. To account for clustering of data, we used multilevel logistic regression analyses to estimate odds ratios (OR). We applied an intention-to-treat approach with multiple imputations of missing data.

Results

At baseline 4577 of 5201 students answered the questionnaire and 4512 at follow-up. In both groups the proportion of students eating breakfast decreased from approximately 50% to 40% from baseline to follow-up, and lunch frequency decreased from approximately 50% to 47%. Daily water intake, intake of fresh fruit and intake of vegetables remained unchanged from baseline to follow-up. There were no significant between group differences on any of the outcomes at first follow-up: breakfast: OR = 0.85 (95% CI: 0.65;1.10), lunch: OR = 0.96 (95% CI: 0.75;1.22), water intake: OR = 1.14 (95% CI: 0.92;1.40), intake of fresh fruit: (OR = 1.07, 95% CI: 0.84;1.37), vegetables: (OR = 1.01, 95% CI: 0.77;1.33).

Conclusion

No evidence of an effect of the HHS intervention was found for any of the outcomes. Future studies are warranted to explore how health promoting interventions can be integrated in further education to support educational goals. Moreover, how to fit interventions to the lives and wishes of young people, by also including systems outside of the school setting.

Trial registration

ISRCTN, ISRCTN43284296. Registered 28 April 2017 - retrospectively registered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12966-021-01228-2.

A pilot study of a school lunchroom intervention in a predominately Latinx sample

OBJECTIVE

The purpose of the study was to assess the feasibility of an environmental school lunchroom intervention ('Smarter Lunchrooms') and test initial efficacy within a predominately Latinx population.

DESIGN

We collected baseline and intervention lunchroom food consumption and waste data in a pre-post, single group design. Meal consumption data was analyzed using Nutrition Data System for Research software to obtain estimates of nutritional content.

MAIN OUTCOME MEASURES

Feasibility.

SECONDARY MEASURES

Plate Waste, Nutrient Intake.

RESULTS

Participants were 88 1st-4th graders (51% female; 77% Latinx). Our recruitment rate was 45%, we were able to implement 8 Smarter Lunchroom strategies, and we were able to collect 82 baseline plate photos (93%) and 80 intervention photos (90%) of school lunches. On average, students threw away more than half of their meals on both days. Fruit consumption and fiber per 1000 kcal were significantly poorer at intervention compared to baseline.

CONCLUSIONS

Our findings highlight challenges in collecting consumption data in a real-world setting. We describe directions for future research taking into consideration our "lessons learned" from this formative work.

Integrative programming for simulation of packaging headspace and shelf life of fresh produce

Fresh horticultural products are exposed to different environmental conditions from farm to fork. Barrier properties of packaging and physiological behaviour of produce, namely respiration and transpiration can affect headspace conditions surrounding produce and consequently remaining shelf life. Packaging material also plays a role in heat and mass transfer, such as thermal conduction and permeation of O2, CO2 and water vapour. All of these behaviours are integrated together in the form of ordinary differential equations and solved using numerical methods in MATLAB. • The simulation program is useful for designing the size and number of perforations to achieve equilibrium modified atmosphere alone or in combination with packaging material having a higher water transmission rate or active moisture absorber. • The simulation program is also useful for predicting the shelf life of fresh produce under the actual supply chain conditions. • The simulation program provides a flexible system to input predefined supply chain conditions and the properties of fresh produce and packaging material, thus, minimizing the costly and time consuming experimental procedures for selecting the optimum packaging material for fresh produce.

Identifying individuals with multiple non-communicable disease risk factors in Kenya: a latent class analysis

OBJECTIVES

Non-communicable diseases (NCDs) are the leading causes of death globally. In Kenya, the number of deaths resulting from NCDs is projected to surpass malaria and tuberculosis by 2030. Studies in Kenya show increasing NCDs; the aim of the present study is to examine the clustering of NCDs and risk factors in Kenya.

STUDY DESIGN

This is a cross-sectional study using data from the 2015 Kenya STEPwise Survey.

METHODS

This study examined relationships between NCDs (e.g. obesity, hypertension and diabetes) and health behaviours (e.g. sedentary activity, and fruit and vegetable consumption). Survey probability weights, which estimated the sampling design effect, were applied to consider the sampling units, and stratifications were used during sampling so that the results could be generalisable to the national adult Kenyan population. In total, 4350 adults were included in the study sample.

RESULTS

Overall, 24.43% of participants were classified as having hypertension, 1.88% as having type 2 diabetes, and 27.94% were classified as being overweight or obese. The best-fit model was a four-class solution. Class 1 is best described as 'young with high NCD risk' and had the highest sedentary activity. Class 2 is best described as 'poor rural with lower NCD risk' with a high chance of smoking and alcohol consumption. Class 3 is best described as 'rural with high NCD risk' and had the highest fruit and vegetable consumption. Class 4 is best described as 'wealthy young urban dwellers with high NCD risk' with a high chance of alcohol consumption and smoking. Individuals in Class 4 had the highest chance (40%) of being overweight/obese, a 2% chance of type 2 diabetes and a 23% chance of having hypertension.

CONCLUSIONS

NCDs are clustered in groups with high-risk behaviours. The group with the highest chance of having NCDs also had the highest chance of engaging in high-risk behaviours. The findings of this study suggest that smoking and alcohol consumption increase NCD risk in rural areas. Tailored and targeted interventions are needed to curb the increasing NCD prevalence in Kenya.

Older age, smoking, tooth loss and denture-wearing but neither xerostomia nor salivary gland hypofunction are associated with low intakes of fruit and vegetables in older Danish adults

Xerostomia and salivary gland hypofunction are prevalent conditions in older people and may adversely influence the intake of certain foods, notably fruit and vegetables. Here, we aimed to investigate whether xerostomia and salivary gland hypofunction were associated with a lower intake of fruit and vegetables. The study included 621 community-dwelling adults, mean age 75⋅2 ± 6⋅4 years, 58⋅9 % female, who had participated in the Copenhagen City Heart Study follow-up, and undergone interviews regarding food intake (preceding month), oral and general health (xerostomia, taste alterations, diseases, medication, alcohol consumption and smoking), clinical oral examination and measurements of unstimulated and chewing-stimulated whole saliva flow rates. The average total energy intake (8⋅4 ± 2⋅7 MJ) and protein energy percentage (14⋅8 ± 3⋅1 %) were slightly below recommendations. The average fruit (234⋅7 ± 201⋅2 g/d) and vegetables (317⋅3 ± 157⋅4 g/d) intakes were within recommendations. Xerostomia and hyposalivation were more prevalent in women than in men (16⋅4 v. 7⋅1 %, P < 0⋅001 and 40⋅7 v. 27⋅5 %, P < 0⋅001). Multiple linear regression analyses revealed that older age (β -0⋅009, se 0⋅003, P = 0⋅005), smoking (β -0⋅212, se 0⋅060, P = 0⋅0005) and wearing complete dentures/being partially or fully edentulous (β -0⋅141, se 0⋅048, P = 0⋅003), but neither xerostomia nor salivary flow rates were associated with an inadequate fruit and vegetable intake, after adjustment for covariates. Older age, smoking, tooth loss and denture-wearing were stronger determinants of low fruit and vegetable intakes than xerostomia and salivary hypofunction supporting the importance of dietary counselling and maintenance of oral health and an adequate masticatory performance.

Examining fruit and vegetable intake in low-income older adults using the Veggie Meter®

BACKGROUND

Older adults report low fruit and vegetable (FV) intake. The lack of objective, field-based assessments of FV intake is a limitation when assessing the effectiveness of interventions.

AIM

To examine if self-reported FV intake was correlated with Veggie Meter® scores among low-income older adults. The Veggie Meter® is a portable tool that uses pressure-mediated reflection spectroscopy to estimate skin carotenoid measurements.

METHODS

A cross-sectional assessment of FV intake, food security, and Veggie Meter® score in low-income older adults was conducted. Bivariate analyses quantified the association between FV intake and Veggie Meter® score.

RESULTS

Participants (n = 154) were mostly female (69.3%), non-white (66.2%) and at risk for food insecurity (65.6%). Mean Veggie Meter® score was 172.3 ± 77.2 and had a small significant positive correlation with FV intake (r= 0.192, p = 0.018).

CONCLUSION

The Veggie Meter® may objectively indicate FV intake. Research to validate the Veggie Meter® in older, diverse populations is needed.

Changes in the nutritional content of children's lunches after the Food Dudes healthy eating programme

Previous research into the effectiveness of healthy eating programmes has shown increases in healthful eating behaviour in primary schools; however, data collection methods have not been sufficiently sensitive to detect micronutrient changes. The present study extends the literature by measuring individual children's intake of macro- and micronutrients at lunchtime, before and after a programme targeting children's consumption of fruit and vegetables, to identify evidence-based health benefits of programme participation. Baseline data were collected over 4 d at lunchtime in two primary schools. The Food Dudes programme was then implemented in the intervention school. Follow-up data were collected over 4 d in each school 2 months after baseline. We employed a validated and sensitive photographic method to estimate individual children's (N 112) consumption of fruit, vegetables, and their intake of calories, macro- and selected micronutrients. Significant changes were observed in the intervention school but not in the control school: Children's consumption of fruit, vegetables, vitamin C and E intake increased, while their total energy consumption, fat, saturated fat, and sodium intake decreased. The present results show that the Food Dudes programme produced a positive nutritional change, with implications for its application as a healthy eating and obesity prevention intervention. These optimistic conclusions should be tested by further research to establish the longevity of the positive effects presented here.

Optimization and application of QuEChERS and SPE methods followed by LC-PDA for the determination of triazines residues in fruits and vegetables from Pietermaritzburg local supermarkets

QuEChERS and solid phase extraction (SPE) methods were optimized and applied for the extraction of triazines in fruit and vegetables. These extraction methods are easy, effective, rugged and safe. Also, they have the ability to purify the extracts which leads to lower detection limits and higher recoveries of the analytes. The analysis were conducted using liquid chromatography coupled to photodiode array detector. The limits of detection and quantification ranged from 0.4 -1.4 µg/kg and 1.5 - 4.5 µg/kg, respectively, for QuEChERS and 0.3 - 1.8 µg/kg and 1.4 - 4.9 µg/kg respectively, for SPE. The recoveries ranged from 84 to 102% for QuEChERS and 76-119% for SPE, with relative standard deviation less than 20% for both methods. The fruits and vegetables analysed were apples, pears, carrots, potatoes, tomatoes, avocado, cucumber, spinach, bananas, and oranges. The concentrations detected ranged between 6 and 46 µg/kg in fruits and 4 - 84 µg/kg in vegetables. Simazine was detected in all fruits and vegetable samples except in pear, while terbutylazine was not detected in all samples analysed. Propazine and ametryn were only found in carrot while pear sample only had atrazine. The proposed methods proved to be sensitive and accurate indicating their applicability for detection and monitoring of the selected triazines in fruits and vegetables. However, QuEChERS can be recommended for routine analysis of these triazines due to its fewer extraction steps compared to SPE which is important for turn-around time.

Human health risk assessment of dichlorodiphenyltrichloroethane (DDT) and hexachlorocyclohexane (HCH) pesticide residues in fruits and vegetables in Nigeria

The residues of dichlorodiphenyltrichloroethanes (DDTs) and hexachlorocyclohexanes (HCHs) in forty-eight (48) composite fruit and vegetable samples (carrot, cucumber, tomato, and watermelon) were qualitatively and quantitatively determined using gas chromatography equipped with electron capture detector (GC-ECD). Safety indices such as the estimated average daily intake (EADI), cancer benchmark concentration (CBC), hazard quotient (HQ) and index (HI), and hazard ratio (HR) were also estimated. Results showed the predominance of HCH and its isomers in the fruits and vegetables as compared with the DDTs. The most predominant HCHs in all the fruits was α-HCH with mean concentrations of 2.704 ± 2.488 mg kg-1 (carrot), 1.536 ± 1.036 mg kg-1 (cucumber), 6.814 ± 2.967 mg kg-1 (tomato), and 9.241 ± 2.735 mg kg-1 (watermelon). The analysis showed that the levels of pesticide residues detected in 25 to 100% of the fruit and vegetable samples were above the UK/European Commission Maximum Residue Limits (MRLs). The non-carcinogenic health risk estimates showed that only α-HCH in tomatoes and watermelon had HQ > 1 which indicates the possibility of systemic health risk in children consumers. The carcinogenic health risk showed that only α-HCH and γ-HCH in children and α-HCH in adults had HR > 1 for tomato and watermelon which implies the possibility of carcinogenic health risk from its consumption. It is therefore paramount to institute a policy and regulatory framework for regular monitoring of pesticide residues in fruits and vegetables in Nigeria in order to ensure food safety for consumers and protect human health.

Phytohormones in postharvest storage of fruit and vegetables: mechanisms and applications

As a ubiquitous and essential part of phytophysiology, phytohormones have attracted tremendous attention for effective regulation of development and senescence of agricultural products. However, the postharvest mechanisms of phytohormones have not been thoroughly understood. This review provides an overview of common phytohormones for extending the shelf life of fruit and vegetables. The modulation principles are discussed in detail based on defence gene expression activation, sensitivity of senescence-related phytohormones inhibition, antioxidant enzymes activity stimulation, and cell membrane integrity maintenance. The applications of jasmonates, salicylic acids, cytokinins, gibberellins, polyamines, and brassinosteroids in preserving fruit and vegetables based on defence signaling network stimulation, senescence-related phytohormones expression or sensitivity repression, as well as antioxidant system enhancement and cell membrane integrity sustentation are introduced. The challenges and problems to be solved are discussed, and new trends of expanding lifespan by combining phytohormones with other treatments are also suggested. Although phytohormones have been demonstrated to have promising efforts in maintaining agricultural products, more novel and effective combination treatments should be developed to complement each other.

Use of a deactivated PTV injector liner and GCMS/MS for the quantitative determination of multiple pesticide residues in fruit and vegetables

The quantitative determination of multiple pesticide residues in food is an iterative process given the frequent changes in monitoring specifications set by regulatory authorities, introduction of new pesticide active ingredients, variety of commodities encountered and advances in the capability of analytical instrumentation and software platforms. The method described here:•replaces our previous methodology [1] that was based on an ethyl acetate extraction [2], two different sample extract clean-up regimes depending on the commodity; either Gel Permeation Chromatography (GPC) or Solid Phase Extraction (SPE) and GC/MSMS analysis using cool on-column injection and permits higher throughput using the same QuEChERS extraction method used for LCMS/MS analysis [3]•uses PTV injection incorporating a deactivated (baffled) injection liner required to improve performance for 'difficult to analyse' pesticides e.g. captan, dichlofluanid, folpet, tolylfluanid.•has been validated for the quantitative determination of 113 different pesticides and their metabolites in a range of fruit and vegetables of high water content and high acid and high water content i.e. cabbage, lemon, pepper, plum and spinach and complies with requirements of European Commission guidance document on Analytical Quality Control and Method Validation Procedures for Pesticides Residues Analysis in food and feed - SANTE/12682/2019 [4].

Process evaluation of fruit and vegetables distribution interventions in school-based settings: A systematic review

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Assesses how school fruit & vegetable distribution interventions are implemented.

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Child fruit & vegetable intake is influenced by how intervention is implemented.

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Recommendations for implementing fruit & vegetable interventions in schools.

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Studies should also consider sustainability, cost-effectiveness and implementation.

Despite the importance of process evaluation in program evaluations, research has focused primarily on the effectiveness of fruit and vegetables (FVs) distribution interventions on children’s consumption, with little attention given to how these interventions achieve their outcomes. Five bibliographic databases (Embase, PubMed, ProQuest, Scopus, and Web of Science Core Collection) were searched in June 2019 for studies of interventions where the main focus was the implementation of distributed FVs to school-aged children as a snack. The Critical Appraisal Skills Programme (CASP) tool was used to appraise the risk of bias within included studies. Data were extracted based on study characteristics and findings. Results identified 24 studies reporting on 11 interventions and 1 policy. The findings of this systematic review indicate that the majority of the studies included limited references to implementation research. Recurring limitations include an absence of an evaluation theoretical framework and the data collection methods used. Also, several factors were identified as informing the success of snack-based FVs distribution programs, including participation of the school community, school characteristics, background knowledge, and parental engagement. Lack of timely FVs delivery, limited funding, inadequate awareness about the program, insufficient teachers’ time, and food waste were identified as challenges to successful programming. Findings indicate that distributing FVs to school-aged children as a snack can increase their consumption, but only with proper implementation. Further evaluative research is required to better inform future implementation of snack-based FV distribution interventions in school settings.

Food availability and advertising within food outlets around primary healthcare services in Brazil

The consumer food environment is changing: an extensive variety of foods are now available in most markets, offering palatability, convenience and novelty. However, little is known about the availability and advertising of food items within food outlets, especially among developing countries. The present study examined these dimensions in 281 food outlets located around eighteen primary healthcare services in Belo Horizonte, Brazil, in 2013. These establishments were classified as large-chain supermarkets; specialised fruits and vegetable (F&V) markets; and local grocery stores, convenience stores or bakeries. Availability of F&V, availability of ultra-processed foods (UPF) and food advertising were compared across the food outlet categories by applying the χ² test. Almost 60 % of the food outlets were specialised F&V markets, 21⋅4 % were large-chain supermarkets and 19⋅2 % were local grocery stores, convenience stores or bakeries. Almost 80 % contained at least eight types of fruits and vegetables, and 60 % contained UPF. Food advertisement was absent in 59⋅8 % of the food outlets, 19⋅6 % were advertising only F&V and 17⋅4 % were advertising only UPF. Higher F&V availability was noted inside specialised F&V markets and large-chain supermarkets than local grocery stores, convenience stores or bakeries. Advertising of F&V was more common within specialised F&V markets. However, large-chain supermarkets and local grocery stores, convenience stores or bakeries contained more frequent UPF food advertising isolated: 38⋅3 and 35⋅2 %, respectively. Therefore, the availability and advertising of food items within food outlets around primary healthcare services are different according to the type of food outlet.

Multi-residue analysis of pesticide residues and polychlorinated biphenyls in fruit and vegetables using orbital ion trap high-resolution accurate mass spectrometry

With the increasing demand on pesticide residue laboratories to increase their scope of analysis, high-resolution accurate mass (HRAM) systems have found increasing popularity in this area. The systems have the advantage of much more reliable confirmation as high resolution increases the ability to distinguish between masses which are close together and the mass accuracy achieved limits the number of structural formulae. To date, much of the work involving these systems has revolved around developing screening methods and little has been done on use of these systems for quantitative methods. Here we describe the development and validation of a quantitative method for the analysis of 167 pesticide residues and polychlorinated biphenyls (PCBs) in samples of fruit and vegetables according to the protocol described in EU SANTE guidance document. The determination method involves analysis using a GC QExactive orbitrap in full scan mode using EI. The samples were then extracted using the standard mini-Luke method. After extraction with acetone/dichloromethane/petroleum ether 40-60 °C, a solvent exchange into ethyl acetate is carried out. Recovery work was carried out in cucumber, lemon and broccoli representing high water content, high acid content and high chlorophyll content commodity groups. The results show that the default MRL of 10 ppb can be achieved for more than 93% of the pesticides studied. Mass accuracy, ion ratio and matrix effect studies show that the method is robust and provides a viable alternative to triple quadrupole mass spectrometer systems for the quantification of pesticide residues in fruit and vegetable samples.

Ethylene scavengers for the preservation of fruits and vegetables: A review

The phytohormone ethylene is the main cause of postharvest spoilage of fruit and vegetables (F&V). To address the global challenge of reducing postharvest losses of F&V, effective management of ethylene is of great importance. This review summarizes the various ethylene scavengers/inhibitors and emerging technologies recently developed for the effective removal of ethylene released, paying particular attention to the ethylene scavenger/inhibitors containing catalysts to promote the in-situ oxidation of ethylene without inducing further pollution. Packing ethylene scavengers, such as zeolite, titanium dioxide and transition metals, in a small sachet has been practically used and widely reported. However, incorporating ethylene scavenger into food packaging materials or films along with the in-situ oxidation of ethylene has been rarely reviewed. The current review fills up this gap, covering the latest research progress on ethylene scavengers/inhibitors and discussion on the mechanisms of ethylene elimination and oxidation associated with F&V packaging.

Fruit and vegetable consumption is associated with lower prevalence of asymptomatic diverticulosis: a cross-sectional colonoscopy-based study

Background

Previous studies of the relationship between dietary factors and risk of diverticulosis have yielded inconsistent results. We therefore sought to investigate the association between consumption of fruit and vegetables and prevalent diverticulosis.

Methods

Our study population included participants in the Gastrointestinal Disease and Endoscopy Registry (GIDER), a colonoscopy-based longitudinal cohort at the Massachusetts General Hospital, who provided comprehensive information on dietary intake and lifestyle factors using validated questionnaires prior to colonoscopy. Information on presence and location of diverticula was obtained from the endoscopist at the end of each procedure. We used Poisson regression modeling to calculate the prevalence ratios (PRs) and 95% confidence intervals (CIs).

Results

Among 549 participants with a mean age of 61 years enrolled in GIDER, we confirmed diverticulosis in 245 (44.6%). The prevalence of diverticulosis appeared to decrease with higher consumption of fruit and vegetables (P_trend = 0.007 for fruit and 0.008 for vegetables, respectively). Compared to participants with less than five servings of vegetables per week, the multivariable-adjusted PRs of diverticulosis were 0.84 (95% CI, 0.60–1.17) with five to seven servings per week and 0.62 (95% CI, 0.44–0.89) with greater than one serving per day. Similarly, compared to participants with less than five servings per week of fruit, the multivariable-adjusted PR of diverticulosis was 0.60 (95% CI, 0.41–0.87) with greater than one serving per day. These associations were not modified by age, BMI, smoking, or red meat intake (All P_interaction > 0.055).

Conclusion

In a colonoscopy-based longitudinal cohort study, we show that higher consumption of fruit and vegetables is associated with lower risk of prevalent diverticulosis.

Keiki Produce Prescription (KPRx) Program Feasibility Study to Reduce Food Insecurity and Obesity Risk

One in 6 US children experience food insecurity, signifying that at some time during the last year their household did not have sufficient food, money, or resources to feed their family. These children experience little intake of fresh fruits and vegetables (FV), a risk factor for chronic disease, including obesity. Produce prescription programs provide vouchers to purchase fresh FV at participating retailers. The Keiki Produce Prescription (KPRx) Program feasibility study was conducted through a partnership between the Waianae Coast Comprehensive Health Center's Pediatrics and Health Promotion Department's Farmers'Market and the University of Hawai'i nutrition faculty. Pediatricians provided patients with a prescription (Rx) to purchase FV from the Farmers' Market ($24 per month for three months). Of the 193 Rx distributed, 125 patients participated in part of the program, while 34 completed the full program. Parents, pediatricians, clinic staff, and community members expressed overwhelming support of the program. Parents of participating children completed an exit interview that identified themes surrounding motivation to participate, benefits to child and family, and future recommendations. It identified the need to improve program retention efforts. Participants reported lifestyle benefits for both the child and family and recommended educational resources. Aresearch protocol was developed to address the following objectives: (1) streamline referrals, (2) enhance retention, (3) quantify program impact, and (4) identify barriers to participation. Subsidies have the potential to increase FV consumption, improve overall health, reduce chronic diseases in adulthood, and result in substantial healthcare cost savings.

A pilot food prescription program promotes produce intake and decreases food insecurity

Food insecurity is associated with limited food resources that may lead to poor nutritional intake and diet-related chronic disease. Food prescription programs offer an avenue for facilitating access to fresh and healthy nonperishable food while reducing food insecurity. The purpose of this pilot study is to examine the feasibility, perceptions, and impact of a collaborative food prescription program in an area with a high rate of food insecurity. The study was a single group pre-post evaluation design. Participants were recruited from two school-based clinics and one Federally Qualified Health Center in north Pasadena, an area with a high rate of food insecurity in Harris County, TX. Adult, food insecure participants were screened at health clinics for eligibility. Participants received nutrition education materials and 30 pounds of a variety of fresh produce plus four healthy, nonperishable food items every 2 weeks for up to 12 visits at a local food pantry. Surveys and tracking tools monitored food insecurity, program dosage, reach, fidelity, acceptability, and program costs. Surveys and key informant interviews assessed perceptions of health care providers, implementation staff, and participants. Participants (n = 172) in the program reported a 94.1% decrease in the prevalence of food insecurity (p < .01) at the end of the program. An average of 29.2 pounds of fruits and vegetables were distributed per family per distribution, and 99% of participants reported eating "all" or "most" of the food provided. Program costs were $12.20 per participant per redemption. Interviews revealed that providers and participants felt the program was well received and highly needed. This pilot study demonstrates the framework and feasibility of a collaborative clinic-based food prescription program to address food insecurity. Future research should examine the sustained impact of such programs on behavioral and health outcomes.

A free-produce stand on campus: impact on fruit and vegetable intake in Dutch university students

OBJECTIVE

To investigate the effects of providing free fruit and snack vegetables at a university on students' fruit intake, snack vegetable intake and total vegetable intake.

DESIGN

Free fruit and raw snack vegetables (e.g. bite-sized tomatoes) were provided in a stand in the form of a miniature wooden house located in the central hall of the university's main building, which students regularly pass through on their way to lectures and the cafeteria. Three interventions tested with a pre-test/post-test design were performed. In these three interventions, small changes to the appearance of the stand were made, such as placing potted plants around it. Demographic characteristics and fruit and vegetable intakes were assessed with questionnaires.

SETTING

A Dutch university of applied science.

PARTICIPANTS

Intervention 1 included 124 students; Intervention 2 included ninety-two students; Intervention 3 included 237 students.

RESULTS

Longitudinal linear regression analyses showed that post-test snack vegetable intake was consistently higher compared with pre-test. In the three interventions, post-test snack vegetable intakes were between 11 and 14 g/d higher than at the pre-test, which is comparable to three bite-sized tomatoes. No differences in fruit intake or total vegetable intake were found. Subgroup analyses showed that, in all three interventions, students with the lowest pre-test fruit intake and total vegetable intake reported the largest increase in fruit intake and snack vegetable intake after the interventions.

CONCLUSIONS

Providing free fruit and vegetables to students at their university might be beneficial for those with low habitual intakes.

Systematically testing the effects of promotion techniques on children's fruit and vegetables intake on the long term: a protocol study of a multicenter randomized controlled trial

Background

Eating a diet rich in fruit and vegetables is essential for healthy development, protects against chronicle diseases, and increases mental well-being. Numerous studies have consistently shown that children do not consume enough fruit and vegetables, especially among children from low socioeconomic status, while foods high in fat, sugar and salt are over-consumed. In order to improve children’s eating behavior, there is an urgent need to systematically test novel and effective methods to make fruit and vegetables more appealing and increase the intake among children. Therefore, the main aim of the proposed project is to test if food promotion techniques increase children’s fruit and vegetable intake, both on the short- and long-term.

Methods

Three studies will be conducted. First, to develop the vlogs in co-creation, multiple focus groups will be held with (1) children (N = 25, between 8 and 13 years), (2) parents (N = 10), (3) vloggers (N = 5), and (4) fruit and vegetable producers and marketers (N = 5). Second, a multicenter randomized clinical trial will be conducted among 10 primary schools. A mixed repeated measure design with three different conditions will be used: (1) control, (2) a vlog unboxing fruit and vegetables (preparing and tasting), and (3) a vlog doing a challenge with the fruit and vegetables (e.g., contests, tricks, games). Children between 7 and 13 will participate in the experiments (N = 350). Third, after 6 and 12 months follow-up measurements will take place.

Discussion

HFSS foods have higher intrinsically rewarding properties that make them more “wanted” and “liked” than fruit and vegetables, thereby inducing unhealthy eating behavior among children. Additionally, promotion for HFSS foods is omnipresent and increases the rewarding value of these foods. Moreover, some studies showed that the promotion of fruit and vegetables affects the intake, although a recent systematic review shows that evidence is inconclusive and a theoretical understanding for the underlying mechanism is missing. The current study aims to improve the existing knowledge by experimentally testing a newly developed theoretical model.

Trial registration

Netherlands Trial registration:NL8077, received on 12 October 2019.

Low intake of commonly available fruits and vegetables in socio-economically disadvantaged communities of South Africa: influence of affordability and sugary drinks intake

BACKGROUND

Consumption of fruits and vegetables reduces the risk of obesity, diabetes, cancer, cardiovascular mortality and all-cause mortality. The study assessed the pattern of intake and the factors that influence daily intake of commonly available fruits and vegetables in economically disadvantaged South African communities.

METHODS

This is a cross-sectional study nested on an ongoing longitudinal study in South Africa. Two communities (a rural and urban) of low socio-economic status were purposely selected from two of the nine provinces. A sample of 535 participants aged 30-75 years was randomly selected from the longitudinal cohort of 1220; 411 (78%) women. Data were collected using validated food frequency and structured interviewer-administered questionnaires. Descriptive and multivariate regression analysis were undertaken.

RESULTS

A higher proportion of participants in the urban township compared to their rural community counterparts had purchased fruits (93% vs. 51%) and vegetables (62% vs. 56%) either daily or weekly. Only 37.8% of the participants consumed at least two portions of commonly available fruits and vegetables daily, with no differences in the two communities. Daily/weekly purchase of sugar sweetened beverages (SSBs) was associated with daily intake of fruits and vegetables (p = 0.014). Controlling for age and gender, analysis showed that those who spent R1000 (USD71.4) and more on groceries monthly compared to those who spent less, and those who travelled with a personal vehicle to purchase groceries (compared to those who took public transport) were respectively 1.6 times (AOR, 95% CI: 1.05-2.44; p = 0.030) and 2.1 times (AOR, 95% CI: 1.06-4.09; p = 0.003) more likely to consume at least two or more portions of fruits and vegetables daily. Those who purchased SSBs daily or weekly were less likely (AOR, 95% CI: 0.54, 0.36-0.81, p = 0.007) to consume two or more portions of fruits and vegetables daily. The average household monthly income was very low (only 2.6% of households earned R5000 (US$357.1); and education level, attitude towards fruits and vegetables and owning a refrigerator had no significant association with fruits and vegetable daily intake.

CONCLUSION

These findings indicate that affordability and frequency of purchase of sugary drinks can influence daily intake of fruits and vegetables in resource-limited communities.

Fruit and vegetable consumption and mental health across adolescence: evidence from a diverse urban British cohort study

BACKGROUND

Evidence on the relationship between fruit and vegetable consumption (FV) and mental health in adolescence is sparse and inconsistent. Social determinants of FV include ethnicity, family environments and economic disadvantage. We investigated the relationship between FV and mental health in the British multi-ethnic Determinants of Adolescents (now young Adult) Social well-being and Health (DASH) longitudinal study.

METHODS

A longitudinal study of 4683 adolescents living in London at age 11-13 years and followed up at 14-16 years. FV was measured using validated questions on the number of portions consumed daily. Mental health was measured by the Strengths and Difficulties Questionnaire as mean Total Difficulties Score (TDS) and by classification as a 'probable clinical case' (TDS > 17). Social measures included ethnicity, parenting and socioeconomic circumstances. Multilevel modelling was used to investigate the association between FV and mental health throughout adolescence.

RESULTS

Low FV was common among adolescents, with approximately 60-70% of adolescents reporting < 5 portions/day and 20-30% reporting < 1 portion/day. In late adolescence, most ethnic minority groups reported lower FV than their White peers. In fully adjusted models, < 1 portion/day remained a significant correlate with mean TDS (Coef: 0.55, 0.29-0.81, P < 0.001) and TDS > 17 (Odds Ratio: 1.43, 1.11-1.85, P = 0.007). Gender- or ethnic-specific effects were not observed. Low parental care partly attenuated the association between FV and mental health.

CONCLUSIONS

Low FV is a longitudinal correlate of poor mental health across adolescence. A focus on FV in parenting interventions could yield interrelated benefits across developmental outcomes given its importance to both physical and socioemotional health.

Comparison of Parent and Child Ratings of Fruit and Vegetable Liking to Assess Parent Accuracy as Proxy Reporters

This study examined the accuracy of parent-report child fruit/vegetable (FV) liking. Child/parent dyads (n = 24) were recruited from six Head Start preschools in North Carolina. Liking for 10 FVs was assessed using a validated pictorial tool for children; a similar scale was used for parents. Negative relationships were observed between parent/child for one fruit (grapes) and one vegetable (broccoli). Positive relationships were observed among oranges, grapes, and overall fruit rankings. Parents tended to rank children's liking of fruits higher than their children, while children ranked liking vegetables higher. Findings suggest parents may not be accurate respondents for preschool children's FV liking.

Lettuce be happy: A longitudinal UK study on the relationship between fruit and vegetable consumption and well-being

Rationale

While the role of diet in influencing physical health is now well-established, some recent research suggests that increased consumption of fruits and vegetables could play a role in enhancing mental well-being. A limitation with much of this existing research is its reliance on cross-sectional correlations, convenience samples, and/or lack of adequate controls.

Objective

We aim to add to the emerging literature on the relationship between fruit and vegetable consumption and well-being by using longitudinal data from a study in the United Kingdom (UK).

Method

We employ panel data analytical techniques on three waves collected between 2010 and 2017 (i.e., following the same individuals over time) in the UK Household Longitudinal Survey. We also control for time-variant confounders such as diet, health, and lifestyle behaviours.

Results

Fixed effects regressions show that mental well-being (GHQ-12) responds in a dose-response fashion to increases in both the quantity and the frequency of fruit and vegetables consumed. This relationship is robust to the use of subjective well-being (life satisfaction) instead of mental well-being. We also document a hump-shaped relationship between fruit and vegetable consumption and age.

Conclusion

Our findings provide further evidence that persuading people to consume more fruits and vegetables may not only benefit their physical health in the long-run, but also their mental well-being in the short-run.

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Increased fruit & vegetable consumption can enhance mental well-being.

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Increasing frequency and increasing quantity of consumption both matter.

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The relationship is robust to different measures of well-being.

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A hump-shaped relationship appeared between age and fruit and vegetable consumption.

The impact of a multilevel childhood obesity prevention intervention on healthful food acquisition, preparation, and fruit and vegetable consumption on African-American adult caregivers

OBJECTIVE

To evaluate the secondary impact of a multilevel, child-focused, obesity intervention on food-related behaviours (acquisition, preparation, fruit and vegetable (FV) consumption) on youths' primary caregivers.

DESIGN

B'More Healthy Communities for Kids (BHCK) group-randomized controlled trial promoted access to healthy foods and food-related behaviours through wholesaler and small store strategies, peer mentor-led nutrition education aimed at youths, and social media and text messaging targeting their adult caregivers. Measures included caregivers' (n 516) self-reported household food acquisition frequency for FV, snacks and grocery items over 30 d, and usual FV consumption in a sub-sample of 226 caregivers via the NCI FV Screener. Hierarchical models assessed average treatment effects (ATE). Treatment-on-the-treated-effect (TTE) analyses evaluated correlation between behavioural change and exposure to BHCK. Exposure scores at post-assessment were based on self-reported viewing of BHCK materials and participating in activities.

SETTING

Thirty Baltimore City low-income neighbourhoods, USA.ParticipantsAdult caregivers of youths aged 9-15 years.

RESULTS

Of caregivers, 90·89 % were female; mean age 39·31 (sd 9·31) years. Baseline mean (sd) intake (servings/d) was 1·30 (1·69) fruits and 1·35 (1·05) vegetables. In ATE, no significant intervention effect was found on caregivers' food-related behaviours. In TTE, each point increase in BHCK exposure score (range: 0-6·9) increased caregivers' daily fruit consumption by 0·2 servings (0·24 (se 0·11); 95 % CI 0·04, 0·47). Caregivers reporting greater social media exposure tripled their daily fruit intake (3·16 (se 0·92); 95 % CI 1·33, 4·99) and increased their frequency of unhealthy food purchasing v. baseline.

CONCLUSIONS

Child-focused community-based nutrition interventions may also benefit family members' fruit intake. Child-focused interventions should involve adult caregivers and intervention effects on family members should be assessed. Future multilevel studies should consider using social media to improve reach and engage caregiver participants.

Choice architecture modifies fruit and vegetable purchasing in a university campus grocery store: time series modelling of a natural experiment

Background

In developed countries, adolescent and young adult diets have been found to be nutritionally poor. The aim of this study was to examine whether a choice architecture intervention, re-arrangement of produce within a grocery store to increase the accessibility of fruit and vegetables, affected purchasing behaviour on a university campus.

Methods

A database of daily sales data from January 2012 to July 2017 was obtained from a campus grocery store. Two changes to the layout were made during this time period. In January 2015, fruit and vegetables were moved from the back of the store, furthest from the entrance, to the aisle closest to the entrance and an entrance-facing display increasing their accessibility. In April 2016, the entrance-facing display of fruit and vegetables was replaced with a chiller cabinet so that fruit and vegetables remained more accessible than during the baseline period, but less accessible than in the period immediately previously. A retrospective interrupted time series analysis using dynamic regression was used to model the data and to examine the effect of the store re-arrangements on purchasing. All analyses were carried out both for sales-by-quantity and for sales-by-money.

Results

The first shop re-arrangement which made fruit and vegetables more prominent, increased the percentage of total sales that were fruit and vegetables, when analysed by either items purchased or money spent. The second rearrangement also had a positive effect on the percentage of total sales that were fruit and vegetables compared to baseline, however this was not significant at the 5% level. Over the five year period, the percentage of sales that were fruit and vegetables declined both in terms of items purchased, and money spent.

Conclusions

Increasing accessibility of fruit and vegetables in a grocery store is a feasible way to improve the diet of students in tertiary education. There is evidence of declining fruit and vegetable consumption among the studied population, which should be further investigated.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-6063-8) contains supplementary material, which is available to authorized users.

5-a-day fruit and vegetable food product labels: reduced fruit and vegetable consumption following an exaggerated compared to a modest label

BACKGROUND

Food product labels based on the WHO 5-a-day fruit and vegetable (FV) message are becoming increasingly common, but these labels may impact negatively on complementary or subsequent FV consumption. This study aimed to investigate the impact of a '3 of your 5-a-day' versus a '1 of your 5-a-day' smoothie product label on subsequent FV consumption.

METHODS

Using an acute experimental design, 194 participants (90 males, 104 females) were randomised to consume a smoothie labelled as either '3 of your 5-a-day' (N = 97) or '1 of your 5-a-day' (N = 97) in full, following a usual breakfast. Subsequent FV consumption was measured for the rest of the day using 24-h recall. Usual FV consumption was also assessed via 24-h recall for the day before the study.

RESULTS

Regression analyses revealed a significantly lower subsequent FV consumption following smoothies displaying the '3 of your 5-a-day' label compared to the '1 of your 5-a-day' label (Beta = - 0.15, p = 0.04). Secondary analyses revealed these effects to be driven mainly by changes to consumption in usual high FV consumers, in females and in vegetable as opposed to fruit consumption.

CONCLUSIONS

These findings demonstrate a role for label information in food intake, and the potential negative impacts of an exaggerated food product label on healthy food consumption and healthy dietary profiles.

Colon Cancer: What We Eat

A higher incidence of colorectal cancer (CRC) is observed in Oceania and Europe, whereas Africa and Asia have a lower incidence. CRC is largely preventable by adapting a healthy lifestyle, such as healthy diet, adequate physical activity, and avoiding obesity. This review summarizes the latest work available, mainly epidemiologic studies, to examine the relationship between diet and CRC. Higher intake of red/processed meat could increase the CRC risk, whereas fibers, especially from whole grains and cereals, as well as fruit and vegetables may decrease the CRC risk. Heterogeneity and inconsistency among studies or individuals, however, need to be taken into consideration.

Associations between fruit and vegetables intake and abnormal glucose tolerance among women with prior gestational diabetes mellitus

PURPOSE

Women with prior gestational diabetes mellitus (GDM) are at higher risk of type 2 diabetes (T2D). The aim of this study was to investigate the association between fruit and vegetables (FV) intake and abnormal glucose tolerance (AGT) among women with prior GDM.

METHODS

A total of 281 women with prior GDM have been recruited a mean of 6 years after their pregnancy in this cohort study. FV intake was obtained with a validated food frequency questionnaire (FFQ). Anthropometric and glycemic components were measured during their clinical visit and women were stratified according to normal glucose tolerance (NGT) or AGT.

RESULTS

A cross-sectional analysis showed that a total of 155 women had NGT and 126 AGT. Women with AGT had significantly lower FV (6.5 ± 0.2) and vegetables servings (3.9 ± 0.2) and tended to have lower fruit servings (2.6 ± 0.2) than women with NGT (7.4 ± 0.2, 4.5 ± 0.2 and 3.0 ± 0.1, respectively) (p = 0.001, p = 0.04 and p = 0.10, respectively, adjusted for age and BMI). FV intake, per one serving increase, was associated with a reduced likelihood of having AGT [OR = 0.88 (0.81-0.97) after adjustment for age and BMI]. Vegetables or fruit intake tended to be associated with a reduced likelihood of having AGT [OR = 0.88 (0.78-1.00) and OR = 0.88 (0.76-1.02), respectively, after adjustment for age and BMI].

CONCLUSIONS

Higher intake of FV may be associated with a lower likelihood of AGT among women with prior GDM. Further studies are needed to confirm these results in this high-risk population.

The association of fruit and vegetable consumption with changes in weight and body mass index in Chinese adults: a cohort study

OBJECTIVES

Findings regarding the benefits of fruit and vegetables (FV) on weight control are inconsistent and little is known among Chinese populations. Therefore, we examined the relationship between change in FV consumption, weight, and change in body mass index (BMI) among Chinese adults, participants of the China Health and Nutrition Survey (CHNS).

STUDY DESIGN

A prospective cohort study.

METHODS

Two waves of CHNS conducted in 2006 and 2011 were used. Continuous FV consumption increase was considered as the exposure and changes in weight and BMI as outcomes. Change in FV consumption was categorized into quintiles. Analysis of covariance and multiple linear regression models, after controlling for potential confounders such as energy intake, physical activity, and smoking, were used to describe the relationship between change in FV consumption and change in weight and BMI.

RESULTS

A total of 4357 participants aged 18-65 years were included in this study. The respective weight and BMI gains in male individuals were 1.81 kg and 0.73 kg/m² in the fifth quintile of FV change relative to individuals in the first quintile (3.67 kg for weight gain and 1.48 kg/m² for BMI gain). An increase in FV consumption by 100 g was associated with a 211 g weight loss (B = -2.11; 95% confidence interval [CI], -3.34, -0.89, P < 0.001) and a decrease in BMI by 0.94 kg/m² (B = -0.94; 95% CI, -1.36, -0.46, P < 0.001) in men; and a 140 g weight loss (B = -0.14; 95% CI, -0.97, 0.69, P = 0.74) and a decrease in BMI by 0.29 kg/m² BMI (B = -0.29; 95% CI, -0.63, 0.06, P = 0.11) in women.

CONCLUSIONS

Increase in FV consumption was associated with statistically significant weight loss and decrease in BMI among Chinese men, and, although suggested, weight loss among women was not significant. Considering the protective effect of FV on human health, increasing FV consumption in the Chinese population is recommended.

The value of facial attractiveness for encouraging fruit and vegetable consumption: analyses from a randomized controlled trial

BACKGROUND

An effect of increased fruit and vegetable (FV) consumption on facial attractiveness has been proposed and recommended as a strategy to promote FV intakes, but no studies to date demonstrate a causal link between FV consumption and perceived attractiveness. This study investigated perceptions of attractiveness before and after the supervised consumption of 2, 5 or 8 FV portions/day for 4 weeks in 30 low FV consumers. Potential mechanisms for change via skin colour and perceived skin healthiness were also investigated.

METHODS

Faces were photographed at the start and end of the 4 week intervention in controlled conditions. Seventy-three independent individuals subsequently rated all 60 photographs in a randomized order, for facial attractiveness, facial skin yellowness, redness, healthiness, clarity, and symmetry.

RESULTS

Using clustered multiple regression, FV consumption over the previous 4 weeks had no direct effect on attractiveness, but, for female faces, some evidence was found for an indirect impact, via linear and non-linear changes in skin yellowness. Effect sizes, however, were small. No association between FV consumption and skin healthiness was found, but skin healthiness was associated with facial attractiveness.

CONCLUSIONS

Controlled and objectively measured increases in FV consumption for 4 weeks resulted indirectly in increased attractiveness in females via increases in skin yellowness, but effects are small and gradually taper as FV consumption increases. Based on the effect sizes from this study, we are hesitant to recommend the use of facial attractiveness to encourage increased FV consumption.

TRIAL REGISTRATION

Clinical trial Registration Number NCT01591057 ( www.clinicaltrials.gov ). Registered: 27th April, 2012.

A randomised controlled intervention study investigating the efficacy of carotenoid-rich fruits and vegetables and extra-virgin olive oil on attenuating sarcopenic symptomology in overweight and obese older adults during energy intake restriction: protocol paper

Background

Weight loss interventions have not been advocated for overweight/obese older adults due to potential loss of skeletal muscle and strength impacting on physical function with potential loss of independence. Carotenoids and polyphenols are inversely associated with sarcopenic symptomology. This paper reports the protocol of a study evaluating the efficacy of a high-protein, energy restricted diet rich in carotenoids and polyphenols on body composition, muscle strength, physical performance and quality of life in overweight and obese older adults.

Methods

This randomised controlled clinical trial will recruit community-dwelling, healthy overweight and obese older adults (≥60 years) for a 12-week weight loss intervention. Seventy-three participants will be recruited and randomized to an energy restricted (~30% restriction), isocaloric diet (30% protein; 30% carbohydrate; 40% fat) enriched with either: a) 375 g/d of high carotenoid vegetables, 300 g/d high carotenoid fruit, and 40-60 ml extra-virgin olive oil (EVOO); or b) 375 g/d of lower carotenoid vegetables, 300 g/d lower carotenoid fruit, and 40-60 ml Polyunsaturated fatty acid (PUFA) based oil. All participants will receive individual dietary counselling each fortnight for the duration of the study and will be asked to maintain their habitual level of physical activity throughout the study. The primary outcome will be appendicular skeletal muscle (ASM) assessed by dual energy X-ray absorptiometry (DXA). Secondary outcomes will include body weight, fat-free mass (FFM), fat mass (FM), muscle strength (Isometric hand-grip strength), physical performance (Short Physical Performance Battery), physical activity (International Physical Activity Questionnaire) and health related quality of life (SF-36). Outcomes will be measured at baseline and at week 12.

Discussion

The results of this study will provide a novel insight relating to the potential influence of high carotenoid and polyphenol intakes on attenuation of ASM during dietary energy-restricted weight loss in overweight and obese older adults.

Trial registration

The trial was registered on the Australia New Zealand Clinical Trials Register (ACTRN12616001400459); Trial registration date: 10th October, 2016.

Growth kinetics of Escherichia coli O157:H7 on the epicarp of fresh vegetables and fruits

Despite the increasing reports on the incidence of fresh vegetables and fruits as a possible vehicle for human pathogens, there is currently limited knowledge on the growth potential of Escherichia coli O157:H7 on different plant substrates. This study analyzed the selective adhesion and growth of E. coli O157:H7 on chili habanero (Capsicum chinense L.), cucumber (Cucumis sativus), radish (Raphanus sativus), tomato (Lycopersicon esculentum), beet (Beta vulgaris subsp. vulgaris), and onion (Allium cepa L.) under laboratory conditions. The Gompertz parameters were used to determine the growth kinetics. Scanning electron microscopy was used to visualize the adhesion of E. coli O157:H7 on the epicarp of the samples. Predictive models were constructed to compare the growth of E. coli O157:H7 on the samples with different intrinsic factors and to demonstrate the low selectivity of the pathogen. No significant difference was observed in the lag-phase duration (LPD), generation time (GT), and exponential growth rate (EGR) of the pathogen adhered to the samples. The interaction between the microorganism and the substrate was less supportive to the growth of E. coli O157:H7 for onion, whereas for tomato and cucumber, the time for the microorganism to attain the maximum growth rate (M) was significantly longer than that recorded for other samples.

Associations between fruit and vegetable, and antioxidant nutrient intake and age-related macular degeneration by smoking status in elderly Korean men

Background

Age-related macular degeneration (AMD) is one of the major causes of irreversible blindness. The objective of this study was to determine whether there is any relationship between dietary intake of fruits and vegetables (F&V) and antioxidant nutrients including carotenoids and AMD according to smoking status in elderly men.

Methods

We performed a cross-sectional analysis using nationally representative samples of elderly aged ≥ 65 years (n = 1414) from the Korea National Health and Nutrition Examination Survey (KNHANES, 2010–2012).

Results

The current smokers consumed less food in total, and, in particular, less cereals/potatoes/sugar products, fruits and vegetables than the nonsmokers and former smokers (p < 0.05). Intake of energy, thiamin, vitamin C, vitamin A, and β-carotene were significantly lower in the current smokers than in the nonsmokers and the former smokers. For current smokers, the ORs of the highest tertile compared with the lowest tertile were 0.36 (95% CI: 0.14–0.96, p for trend = 0.0576) for F&V, 0.32 (95% CI: 0.12–0.85, p for trend = 0.0561) for vitamin C, 0.23 (95% CI: 0.08–0.67, p for trend = 0.0038) for α-carotene, 0.13 (95% CI: 0.04–0.46, p for trend = 0.0003) for β-carotene after adjusting for confounding factors. In contrast, there was no association between antioxidant nutrient intake and AMD among the nonsmokers and former smokers.

Conclusions

These results suggest that increased consumption of fruits and vegetables containing antioxidant components such as vitamin C, α-carotene, and β-carotene may have a protective effect on AMD. These effects may be more evident among current smokers.

Investigating the importance of the local food environment for fruit and vegetable intake in older men and women in 20 UK towns: a cross-sectional analysis of two national cohorts using novel methods

BACKGROUND

Local neighbourhood environments can influence dietary behavior. There is limited evidence focused on older people who are likely to have greater dependence on local areas and may suffer functional limitations that amplify any neighbourhood impact.

METHODS

Using multi-level ordinal regression analysis we investigated the association between multiple dimensions of neighbourhood food environments (captured by fine-detail, foot-based environmental audits and secondary data) and self-reported frequency of fruit and vegetable intake. The study was a cross-sectional analysis nested within two nationally representative cohorts in the UK: the British Regional Heart Study and the British Women's Heart and Health Study. Main exposures of interest were density of food retail outlets selling fruits and vegetables, the density of fast food outlets and a novel measure of diversity of the food retail environment.

RESULTS

A total of 1124 men and 883 women, aged 69 - 92 years, living in 20 British towns were included in the analysis. There was strong evidence of an association between area income deprivation and fruit and vegetable consumption, with study members in the most deprived areas estimated to have 27% (95% CI: 7, 42) lower odds of being in a higher fruit and vegetable consumption category relative to those in the least deprived areas. We found no consistent evidence for an association between fruit and vegetable consumption and a range of other food environment domains, including density of shops selling fruits and vegetables, density of premises selling fast food, the area food retail diversity, area walkability, transport accessibility, or the local food marketing environment. For example, individuals living in areas with greatest fruit and vegetable outlet density had 2% (95% CI: -22, 21) lower odds of being in a higher fruit and vegetable consumption category relative to those in areas with no shops.

CONCLUSIONS

Although small effect sizes in environment-diet relationships cannot be discounted, this study suggests that older people are less influenced by physical characteristics of neighbourhood food environments than is suggested in the literature. The association between area income deprivation and diet may be capturing an important social aspect of neighbourhoods that influence food intake in older adults and warrants further research.

Participation in a farmers' market fruit and vegetable prescription program at a federally qualified health center improves hemoglobin A1C in low income uncontrolled diabetics

Fruit and vegetable prescription programs have been shown to increase consumption of fresh produce, but whether they have an impact on medical outcomes is unknown. The purpose of this study was to examine the role of participation in a farmers' market and fruit and vegetable prescription program on changes in hemoglobin A1C (HbA1C), blood pressure (BP) and weight in patients with uncontrolled type 2 diabetes at a federally qualified health center (FQHC) in Detroit, MI.

The 13-week Fresh Prescription program (June 2015–October 2015) was designed to improve access and consumption of produce among low-income patients with uncontrolled type 2 diabetes. The program allotted up to $40 ($10 per week for up to four weeks) for purchase of produce from a FQHC located farmers' market. Adult, non-pregnant patients with a history of type 2 diabetes that had an elevated HbA1C > 6.5 within three months before Fresh Prescription program were eligible to participate. HgA1c, BP and weight were collected within three months of program start and within three months of completion.

There were 65 eligible participants with complete biometric data. A statistically significant (p = 0.001) decrease in HbA1C was found (9.54% to 8.83%). However, weight (208.3 lbs. to 209.0 lbs.) and BP (135.1/79.3 mm Hg to 135.8/77.6 mm Hg) did not change from pre- to post-study (p > 0.05).

Access to a fruit and vegetable prescription program over a 13-week period led to decreased HbA1C concentrations in uncontrolled type 2 diabetic patients living in an urban area of predominately-lower socioeconomic status.

•

We evaluated efficacy of a fruit and vegetable prescription program.

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To date, there has been no research investigating the quantitative health benefits.

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A significant decrease in hemoglobin A1C was found in diabetics after program.

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There was no change in weight and blood pressure.

Fruit and vegetable intake and the risk of cardiovascular disease, total cancer and all-cause mortality-a systematic review and dose-response meta-analysis of prospective studies

Background

Questions remain about the strength and shape of the dose-response relationship between fruit and vegetable intake and risk of cardiovascular disease, cancer and mortality, and the effects of specific types of fruit and vegetables. We conducted a systematic review and meta-analysis to clarify these associations.

Methods

PubMed and Embase were searched up to 29 September 2016. Prospective studies of fruit and vegetable intake and cardiovascular disease, total cancer and all-cause mortality were included. Summary relative risks (RRs) were calculated using a random effects model, and the mortality burden globally was estimated; 95 studies (142 publications) were included.

Results

For fruits and vegetables combined, the summary RR per 200 g/day was 0.92 [95% confidence interval (CI): 0.90-0.94, I 2  = 0%, n  = 15] for coronary heart disease, 0.84 (95% CI: 0.76-0.92, I 2  = 73%, n  = 10) for stroke, 0.92 (95% CI: 0.90-0.95, I 2  = 31%, n  = 13) for cardiovascular disease, 0.97 (95% CI: 0.95-0.99, I 2  = 49%, n  = 12) for total cancer and 0.90 (95% CI: 0.87-0.93, I 2  = 83%, n  = 15) for all-cause mortality. Similar associations were observed for fruits and vegetables separately. Reductions in risk were observed up to 800 g/day for all outcomes except cancer (600 g/day). Inverse associations were observed between the intake of apples and pears, citrus fruits, green leafy vegetables, cruciferous vegetables, and salads and cardiovascular disease and all-cause mortality, and between the intake of green-yellow vegetables and cruciferous vegetables and total cancer risk. An estimated 5.6 and 7.8 million premature deaths worldwide in 2013 may be attributable to a fruit and vegetable intake below 500 and 800 g/day, respectively, if the observed associations are causal.

Conclusions

Fruit and vegetable intakes were associated with reduced risk of cardiovascular disease, cancer and all-cause mortality. These results support public health recommendations to increase fruit and vegetable intake for the prevention of cardiovascular disease, cancer, and premature mortality.