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Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study

Miller V 1 , Yusuf S 1 , Chow CK 2 , Dehghan M 1 , Corsi DJ 3 , Lock K 4 Show all authors , Popkin B 5 , Rangarajan S 1 , Khatib R 6 , Lear SA 7 , Mony P 8 , Kaur M 9 , Mohan V 10 , Vijayakumar K 11 , Gupta R 12 , Kruger A 13 , Tsolekile L 14 , Mohammadifard N 15 , Rahman O 16 , Rosengren A 17 , Avezum A 18 , Orlandini A 19 , Ismail N 20 , Lopez-Jaramillo P 21 , Yusufali A 22 , Karsidag K 23 , Iqbal R 24 , Chifamba J 25 , Oakley SM 26 , Ariffin F 27 , Zatonska K 28 , Poirier P 29 , Wei L 30 , Jian B 30 , Hui C 30 , Xu L 30 , Xiulin B 30 , Teo K 1 , Mente A 31

Affiliations 

  • 1 Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
  • 2 Westmead Hospital and the George Institute for Global Health, Sydney University, Sydney, NSW, Australia
  • 3 Ottawa Hospital Research Institute, Ottawa, ON, Canada
  • 4 Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
  • 5 Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
  • 6 Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA; Institute of Community and Public Health, Birzeit University, Ramallah, Occupied Palestinian Territory
  • 7 Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada
  • 8 St John's Medical College & Research Institute, Bangalore, India
  • 9 School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  • 10 Madras Diabetes Research Foundation, Chennai, India
  • 11 Community Medicine, Health Action By People, Thiruvananthapuram, Kerala, India
  • 12 Department of Medicine, Fortis Escorts Hospital, Jaipur, India
  • 13 Faculty of Health Science North-West University, Potchefstroom Campus, Potchefstroom, South Africa
  • 14 University of the Western Cape, Bellville, South Africa
  • 15 Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran
  • 16 Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
  • 17 Sahlgrenska Academy and Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
  • 18 Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
  • 19 Estudios Clinicos Latino America, Rosario, Argentina
  • 20 Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur Malaysia
  • 21 Grupo Investigaciones FOSCAL, Fundacion Oftalmologica de Santander and Medical School, Universidad de Santander, Bucaramanga, Colombia
  • 22 Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
  • 23 Department of Internal Medicine, Istanbul University, Istanbul, Turkey
  • 24 Department of Community Health Sciences and Department of Medicine, Aga Khan University, Karachi, Pakistan
  • 25 Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
  • 26 Facultad de Medicina, Universidad de La Frontera, Temuco, Chile
  • 27 Faculty of Medicine, UiTM Sungai Buloh Campus, Selangor, Malaysia
  • 28 Department of Social Medicine, Medical University in Wroclaw, Wroclaw, Poland
  • 29 Laval University Heart and Lungs Institute, Quebec City, QC, Canada
  • 30 National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China
  • 31 Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. Electronic address: andrew.mente@phri.ca
Lancet Glob Health, 2016 10;4(10):e695-703.
PMID: 27567348 DOI: 10.1016/S2214-109X(16)30186-3

Abstract

BACKGROUND: Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability.

METHODS: We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost.

FINDINGS: Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040).

INTERPRETATION: The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.

FUNDING: Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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