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The Scottish Health Survey: Volume 1: Main Report

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Chapter 5 Fruit and Vegetable Consumption

5 FRUIT AND VEGETABLE CONSUMPTION

Linsay Gray and Alastair Leyland

SUMMARY

  • In 2010, 22% of adults (20% of men and 23% of women) met the recommended daily intake of five or more portions of fruit and vegetables. The proportion of adults meeting the recommendation has not changed significantly over time.
  • In 2010, adults consumed 3.2 mean portions of fruit and vegetables. Mean daily consumption was higher for women (3.3) than for men (3.1).
  • Adults aged 16-24 and those aged 75+ were the least likely to consume five or more portions a day (17% and 19% respectively).
  • The mean portions of fruit and vegetables consumed per day by all children aged 5-15, and the proportions of children meeting the recommended daily intake (five or more portions a day), were not significantly different in 2010 compared with 2003.
  • In 2010, children aged 2-15 consumed 2.6 mean portions of fruit and vegetables per day (2.6 for boys and 2.7 for girls). 12% of children aged 2-15 met the recommended daily intake of five or more portions.
  • Children's mean daily consumption of fruit and vegetables varied significantly with age, from 2.9 portions among those aged 2-4 to 2.4 for those aged 13-15. 6% of children aged 2-4 consumed no portions compared with 16% of those aged 13-15.
  • 6% of adults living in households that ate together more than 7 times in the previous week had eaten no portions of fruit and vegetables, compared with 15%-16% of adults in households who did not eat together or did so only 1 or 2 times.
  • The mean number of portions of fruit and vegetables consumed was higher in children in households that had eaten together more than 7 times (3.0 portions) than those in households that only ate together 1-2 times (2.3 portions).
  • Children in households that ate together 1-2 times were the most likely to have eaten no fruit and vegetables (17% compared with 7%-11% among those in households eating together more often than this).

5.1 INTRODUCTION

Much of Scotland's poor health can be attributed to its unhealthy diet. Low consumption of fruit and vegetables is a risk factor for cardiovascular disease, cancer, hypertension, type 2 diabetes and obesity. The World Health Organisation ( WHO) recommends eating at least five varied portions - where a portion is defined as 80g - of fruit and vegetables a day.

The fruit and vegetable consumption chapter in the 2008 report [1] and the diet chapter in the 2009 report [2] provided overviews of the policy context from the mid 1990s onwards. They outlined a number of actions taken by the Government and NHS Scotland to improve diets in Scotland, including initiatives designed to encourage more fruit and vegetable consumption, in line with the recommendation to eat at least five portions of fruit and vegetables a day. These included:

  • The Scottish Diet Action Plan, [3] which outlined the Scottish Dietary Targets. [4]
  • The White Paper Towards a Healthier Scotland.[5]
  • The Scottish Executive's Improving Health in Scotland - the Challenge paper. [6]
  • The Hungry for Success initiative. [7]
  • A framework for implementing the Diet Action Plan: Eating for health meeting the challenge.[8]
  • The Scottish Government's Better Health, Better Care Action Plan. [9]
  • Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011).[10]
  • The Scottish Government's Obesity Route Map. [11]
  • The Schools (Health Promotion and Nutrition) (Scotland) Act. [12]

The Scottish Government published its Obesity Route Map Action Plan[13] in 2011. This includes actions to reduce energy consumption and encourage active living with the long-term goal to reduce overweight and obesity in the Scottish population. It outlines strategies for liaising with the food and drink industries, consumer groups, schools and the public sector, and using social marketing and licensing to address food product reformulation, portion sizes, stocking policies, pricing, labelling and packaging, and marketing. Allied to the Action Plan, a set of 16 indicators and associated desired outcomes will help monitor its progress. [14] The Scottish Health Survey provides data for a number of the indicators, including one to monitor the short-term outcome of increased awareness, knowledge, skills and empowerment in relation to healthy eating. This will be assessed using the Survey's measure of the proportion of adults who have tried making a positive change to their behaviour to improve their dietary habits. Progress on this will be reported in the Knowledge, Attitudes and Motivations module report to be published by Health Scotland in Autumn 2011.

The detailed measures of fruit and vegetable consumption included for the first time in the 2003 Scottish Health Survey were repeated in 2008, 2009 and 2010. This chapter updates the trends in fruit and vegetable consumption among adults and children since 2003 by age and sex. The association between fruit and vegetable consumption and the frequency of household members eating their meals together is also examined.

5.2 METHODOLOGY

5.2.1 Measures of eating habits

Two different modules of questions were used to assess eating habits. One of these assessed fruit and vegetable consumption, and was designed with the aim of providing sufficient detail to monitor the '5-a-day' policy effectively. This module was asked of all adults and children aged 2 and over. The second was asked of all children in 2008 and 2009, and a sub-sample of adults in 2008. It used a modified version of the Dietary Instrument of Nutrition Education ( DINE) questionnaire developed by the Imperial Cancer Research Fund's General Practice Research Group to assess participants' usual intake of a wide range of nutrients, including protein, starch, fat and fibre. [15] This chapter reports the findings from the fruit and vegetable module for adults and children.

To determine the total number of portions that had been consumed in the 24 hours preceding the interview, the fruit and vegetable module asked about the following food types: vegetables (fresh, frozen or canned); salads; pulses; vegetables in composites ( e.g. vegetable chilli); fruit (fresh, frozen or canned); dried fruit; and fruit in composites ( e.g. apple pie). A portion was defined as the conventional 80g of a fruit or vegetable. As 80g is difficult to visualise, a 'portion' was described using more everyday terms, such as tablespoons, cereal bowls and slices. Examples were given in the questionnaire to aid the recall process, for instance, tablespoons of vegetables, cereal bowls full of salad, pieces of medium sized fruit ( e.g. apples) or handfuls of small fruits ( e.g. raspberries). In spite of this, there may be some variation between participants' interpretation of 'a portion'. These everyday measures were converted back to 80g portions prior to analysis. The following table shows the definitions of the portion sizes used for each food item included in the survey:

Food item

Portion size

Vegetables (fresh, frozen or canned)

3 tablespoons
Pulses (dried)
3 tablespoons
Salad

1 cereal bowlful

Vegetables in composites, such as vegetable chilli

3 tablespoons

Very large fruit, such as melon

1 average slice

Large fruit, such as grapefruit

Half a fruit

Medium fruit, such as apples

1 fruit

Small fruit, such as plum

2 fruits

Very small fruit, such as blackberries

2 average handfuls

Dried fruit
1 tablespoon

Fruit in composites, such as stewed fruit in apple pie

3 tablespoons

Frozen fruit/canned fruit

3 tablespoons
Fruit juice

1 small glass
(150 ml)

Since the five a day policy stresses both volume and variety, the number of portions of fruit juice, pulses and dried fruit was capped so that no more than one portion could contribute to the total number of portions consumed. Interviewers recorded full or half portions, but nothing smaller.

5.2.2 Measure of communal eating

In 2008 the survey introduced a new measure of communal eating which has been included every year to date. In all households containing more than one person, the following question is asked:

How many times in the last week, that is the seven days ending (date last Sunday), did all or most of the people who live in this household eat a main meal together not including breakfast?

The answer options are: never, one or two times, three or four times, five or six times, seven times, more than this. The association between fruit and vegetable consumption and communal eating is explored at the end of this chapter.

5.3 FRUIT AND VEGETABLE CONSUMPTION

5.3.1 Trends in adult consumption of fruit and vegetables

Table 5.1 presents information on the quantity of fruit and vegetables men and women aged 16 and over had consumed in the 24 hours prior to the interview for 2003, 2008, 2009 and 2010. It shows the mean and median number of portions consumed, and the proportions who met the daily recommended consumption of five or more portions.

The small, but statistically significant, change over time in adults' fruit and vegetable consumption reported last year, 2 from 3.1 portions in 2003 to 3.3 in 2009, was not sustained in 2010 when the mean number of portions consumed by all adults aged 16 and over was 3.2. However, the 2009 and 2010 figures are not significantly different so there are clearly dangers when comparing single figures within a time series rather than assessing the nature of the underlying trend. Once the 2011 data have been collected it will be possible to perform a more sophisticated analysis of the trend over the 2003-2011 period. Men consumed fewer portions than women in each year (3.0 versus 3.2 in 2003, 3.1 and 3.4 in 2008 and 2009, 3.1 and 3.3 in 2010).

The proportion of adults meeting the recommended intake of at least five portions of fruit and vegetables has not changed significantly over time. 21% of adults met the recommendations in 2003 compared with 22% in 2008, 23% in 2009, and 22% again in 2010. The proportion of men meeting the recommendations has remained fairly static across the years (22% in 2009 and 20% in all others). The small upward trend in the proportion of women meeting the recommendations (from 22% to 25% between 2003 and 2009) was not continued in 2010 when the figure was 23%. Table 5.1

5.3.2 Portions of fruit and vegetables consumed by adults in 2010

More detailed figures for the quantity of fruit and vegetables consumed in the 24 hours prior to the interview by age and sex for adults aged 16 and over in 2010 are also presented in Table 5.1. Figures 5A and 5B show the summary measures of five or more portions, no portions and the mean number, by age and sex.

As noted above, adults consumed 3.2 portions of fruit and vegetables per day on average in 2010. The difference between men and women's consumption (3.1 portions versus 3.3) was statistically significant. The mean number of portions consumed generally increased with age. Consumption was lowest in adults aged 16-24 (2.6), rose to 3.3-3.4 portions among those aged 45-74, before declining to 3.2 among those aged 75 and over. The patterns for men and women were broadly the same as for all adults, as shown in Figures 5A and 5B.

The proportion of adults in 2010 who met the recommended daily intake of five or more portions of fruit and vegetables (20% of men, 23% of women and 22% overall) also varied by age. The proportion consuming five or more portions was highest in the 65-74 age group (25%) and lowest among those aged 16-24 (17%) and 75 and over (19%). This pattern of lower consumption in the youngest and oldest age groups has been apparent in all survey years with the exception of 2009. At the other extreme, one in ten adults (12% of men and 9% of women) had consumed no portions of fruit or vegetables at all during the previous day. The proportion consuming no fruit or vegetables decreased with age. A fifth of adults aged 16-24 (19%) consumed no fruit and vegetables (22% of men and 16% of women). This dropped to 8%-11% among those aged 25-64 and was lower again for the two oldest age groups at 6%. Table 5.1, Figure 5A, Figure 5B

Figure 5A

Figure 5B

5.3.3 Trends in child consumption of fruit and vegetables

Table 5.2 presents information on the quantity of fruit and vegetables consumed by children in the 24 hours prior to the interview for 2003, 2008, 2009 and 2010. The fruit and vegetable questions were asked of children aged 5-15 in 2003 and 2-15 from 2008 onwards. For this reason, the trends in consumption since 2003 are based on children aged 5-15. The findings for children aged 2-15 from 2008 onwards are also discussed below.

There were no statistically significant changes in fruit and vegetable consumption among all children aged 5-15 between 2003 and 2010. The mean number of portions consumed by children per day was 2.6 in 2003, 2.7 in both 2008 and 2009, and 2.6 in 2010. The separate figures for boys and girls followed the same pattern: for boys, the mean number of portions consumed was 2.6 in 2003, 2008 and 2009, and 2.5 in 2010. The figures for girls were 2.6 portions in 2003, 2.8 in 2008 and 2009, and 2.6 in 2010. Last year's report noted a small and marginally significant change between 2003 and 2008/2009 in mean consumption for girls aged 5-15 (from 2.6 to 2.8). Although the 2010 figure of 2.6 appears to negate this trend, the difference between the years is not statistically significant so it remains to be seen whether the latest figure represents a plateau, the start of a downward trend or simply fluctuation over the years.

The equivalent figures for all children aged 2-15 from 2008 onwards are similar to those for children aged 5-15, the mean portions consumed were 2.8 in 2008 and 2009, and 2.6 in 2010.

The proportion of children aged 5-15 meeting the recommended daily intake of five or more portions of fruit and vegetables was not significantly different in 2003 (12%), 2008, 2009 (both 14%) and 2010 (12%). The figures for children aged 2-15 have not changed significantly between 2008 and 2010 and it remains the case that only around one in eight children in Scotland aged 2-15 are eating the recommended five or more portions of fruit and vegetables. Table 5.2

5.3.4 Portions of fruit and vegetables consumed by children in 2010

Table 5.2 presents more detailed information on the quantity of fruit and vegetables children aged 2-15 had consumed in the 24 hours prior to the interview by age and sex in 2010. A more accurate picture of children's consumption patterns is gained by combining more than one year, as was the case in the chapter published last year. 2 The figures presented below therefore provide an overview of the patterns in 2010, but analyses based on a larger sample are necessary to provide more robust estimates of the figures for sub-groups of children.

For all children aged 2-15 in 2010, the mean number of portions of fruit and vegetables consumed per day was 2.6 portions (2.6 for boys and 2.7 for girls). Table 5.2 and Figure 5C show that the figures varied slightly across age, with higher values in the youngest age groups. For instance, the mean number of portions was 2.9 for those aged 2-4 and 2.7 for those aged 5-7, and continued to decline successively in each age group to 2.4 for those aged 13-15; these patterns were also evident in the separate figures for boys and girls.

12% of children aged 2-15 in 2010 met the recommended daily intake of five or more portions of fruit and vegetables and 11% had consumed none at all. Again, the individual figures for boys and girls were very similar to those for all children. The proportion consuming the recommended five or more portions was highest in children aged 2-4 (15%) compared with those aged 5-15 (11% to 12%). Children aged 2-4 also had the lowest prevalence of consuming no portions of fruit and vegetables (6%) compared with those aged 5-15 (9% to 16%). Patterns for consuming no portions and consumption of five or more portions of fruit and vegetables were similar for boys and girls. This reinforces the message in last year's report that teenagers are a key group for initiatives to increase fruit and vegetable consumption, but also suggests that all children from 5 years upwards should be targeted.

Table 5.2, Figure 5C

Figure 5C

5.4 FRUIT AND VEGETABLE CONSUMPTION BY COMMUNAL EATING

5.4.1 Adult consumption by number of times householdate together

Table 5.3 shows the number of portions of fruit and vegetables consumed per day by adults according to how many times people in their household had eaten a meal together in the past week (adults in single person households are excluded from this analysis). Adults in households who ate together the most frequently (7 times or more) consumed more portions (3.2-3.4) than those in households who ate together on 6 occasions or fewer (2.8-3.0 portions). However, it is worth noting that the median number of portions, a figure less prone to extreme values in the distribution, was the same for adults in households who had never eaten together and those that had done so the most often (3.0 portions), which suggests that the association between portions and the frequency of communal meals is somewhat weak.

The percentage consuming the recommended five or more portions of fruit and vegetables per day did not vary significantly across the different groups, for example 22% of people in households who never ate together consumed five or more portions, as did 23% of adults in households that ate together more often than 7 times. However, there was a much clearer pattern for the prevalence of eating no portions of fruit and vegetables at all. 15%-16% of adults in households with a low number of communal meals in the previous week (0-2) $1consumed no fruit or vegetables, compared with 12% in households eating together 3-6 times, 9% in households eating together 7 times, and 6% of those in households that had shared more than 7 meals. Table 5.3

5.4.2 Child consumption by number of times householdate together

Children's fruit and vegetable consumption broadly increased with increasing frequency of their household eating meals together. As with adults, the largest differences tended to be evident between households that ate together the most and least often (note that very few children lived in households that never ate together so these figures are not cited here). Children in households that ate together 1-2 times in the past week consumed 2.3 portions compared with 3.0 portions for those in households that ate together more than 7 times (the intervening figures ranged between 2.5 and 2.8 portions with a less clear pattern). Unlike adults, the difference in the median number of portions between the groups that ate together the most and least often followed the same pattern for the mean number.

The pattern for the proportion meeting the recommendations was less clear: 16% of children living in households who ate together more than 7 times consumed five or more portions, compared with 10%-14% of those who ate together between 1-2 and 7 times. The figures for no fruit and vegetable consumption followed a similar pattern to that found in adults. Children in households that ate together the most often were the least likely to have eaten no fruit and vegetables (7%), while children in households that only ate together 1-2 times were the most likely (17%).

The more detailed analysis of the association between fruit and vegetable consumption and communal eating presented in the 2009 report, based on the combined 2008 and 2009 child samples, found that the frequency of communal meals was independently associated with higher fruit and vegetable consumption, even after controlling for household socio-economic status measures. 2 Future reports will be able to repeat this more detailed analysis, and could potentially assess whether communal household meals have a greater impact on children's diets than adults'. Table 5.4