Tuesday, June 28, 2011

Increasing fruit & veggie intake - the why and the how

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Today’s post focuses on why you should eat yer fruits and vegetables, and how it may be possible to get more of us to do so.  

At a population level, the evidence for increasing fruit and vegetable (F&V) consumption and decreasing obesity isn’t super strong [1]. But I still think that it’s at the heart of how to make a healthy population – coupled of course, with decreasing intake of crappy, energy dense, nutrient poor snack foods and sugar-sweetened beverages, as well as growing food in sustainable ways (e.g. sans pesticides). For instance, insufficient intake of F&Vs is estimated to be responsible for around 14% of gastrointestinal cancer deaths, about 11% of ischemic heart disease deaths and about 9% of stroke deaths worldwide [2]. They may even be able to make our immune systems healthier and decrease common communicable diseases [3].  

Fruits and vegetables have seemingly magical properties – they are abundant in vitamins and trace minerals, often are high in fibre, and are low in calories. But we don’t get enough of them – even in developed countries. Just to give you an idea, in 2004, only 30% of Canadian children (aged 4- 8 y) and 50% of adults met dietary recommendations for F&V intake [4]. More concerning is that children aged 4-18 years obtained a higher percentage of their calories (22.3%) from foods that are not recommended in the Canadian Food Guide (food high in sugar, fat and salt and low in nutrients) than from F&Vs (13.9%) [4].   

How can we increase intake? I think it’s all about making F&Vs easier to buy and prepare. This means that they are easily accessible, cheap, and offered in healthy, ready-to-eat meals (not only as whole foods).

Grocery stores have been identified as potential means to increase F&V intake – through their influence on availability, access, pricing, promotion and information on the health properties of F&Vs [5]. Churches, childcare centres and the broader community may also represent effective settings to implement environmental initiatives.

According to Glanz & colleagues:
"Policy and environmental approaches may have greater impact [on F&V consumption] because they influence the overall environment, reach many people, and are less costly and more enduring than clinical, individually oriented, or small-group educational interventions"

Unfortunately, the evidence for effectiveness in increasing F&V intake through these means is not strong (and even lacking with regard to obesity). But I don’t think that should be a deterring factor, especially given how difficult it is to actually implement an evaluation in this type of setting, let alone a rigorous one. 

There have been some innovative environmental initiatives that I have come across recently, which show great promise, but have not been formally evaluated (hopefully in some way soon). Descriptions and links can be found below:

The New Haven Health Corner Store (US) – member corner stores add healthier choices to the aisles of chips, soda and salty snacks, such as fresh produce and low-fat dairy products. Stores also have added advertising (including an easy to identify logo) and giveaways to increase awareness among consumers about healthier choices. The website highlights a study of why it might be important to target corner stores

Fruixi (Canada) – Mobile F&V bike carts operated by young volunteers around Montreal parks (kind of like getting street meat). All F&Vs sold are from local producers and at prices less than what you would have to pay in grocery stores. Fruixis will soon be available around University of Montreal affiliated hospitals. Unfortunately, the service is not available in winter.         

Fresh Moves Mobile Product Market (US) – A great idea – retrofitting a bus to become a one-aisle produce market for underserved communities in Chicago. Conventional as well as organic and local produce are available at affordable prices.

A healthy (for-profit) street food business called KeBal (Jakarta, Indonesia) – Targeted to children aged 5 years and under with branding, advertising, and health promotion initiatives. The menu was created by nutritionists and menu items are made from non-processed, whole foods. This is an interesting concept that could be translated to children and adults in developed countries.

Food Oasis, a virtual food market – a platform that works through consumers text messaging to communicate their individual needs. These messages go to a central system, where these small orders are aggregated by suppliers into economically-viable groups. Suppliers, including corner stores, local farmers or large grocery chains, can negotiate with consumers to agree on a price and central neighborhood delivery location (e.g., churches, day care centers, employment centers). This platform is still in preliminary stages of development.

Other environmental interventions that deserve further thought and investigation include making high calorie, nutrient poor foods harder to find and the display of fruits and vegetables more appealing and easier to access. A great example of this can be found here. Glanz and Yaroch also recommend establishing farm stands at large sports events; “cross-promotions” (e.g. bananas sold with cereal) and promotion of pre-packaged foods (including frozen) with high F&V content in grocery stores; as well as F&V sold in convenience stores as ready-to-eat or ready-to-heat food dishes.

Fruits and vegetables are good for us and we need to eat more of them. Environmental interventions can make the healthy choice the easier choice. For these initiatives to work they have to make F&Vs easier to choose over crappy food – so this means that they have to be convenient, at least the same price, easy to access, and tasty. And one intervention may not make a dent in our diets or our waistlines - this will require environmental interventions in multiple settings, making evaluation a tall, but necessary order.  


[1]Ledoux TA, Hingle MD, & Baranowski T (2011). Relationship of fruit and vegetable intake with adiposity: a systematic review. Obesity reviews : an official journal of the International Association for the Study of Obesity, 12 (5) PMID: 20633234

[2]  Mathers C, Stevens G, Mascarenhas M, for the World Health Organization. Global Health Risks: Mortality and burden of disease attributable to selected major risks. http://www.who.int/healthinfo/global_burden_disease/GlobalHealthRisks_report_full.pdf . 2009. Geneva, Switzerland, WHO.

[3] Villamor E, Fawzi WW: Effects of vitamin a supplementation on immune responses and correlation with clinical outcomes. Clin Microbiol Rev 2005, 18: 446-464.

[4] Garriguet D: Canadian's eating habits. Health Reports 2007, 18: 17-32. http://www.statcan.gc.ca/pub/82-620-m/82-620-m2006002-eng.pdf

[5] Glanz K & Yaroch AL. Strategies for increasing fruit and vegetable intake in grocery stores and communities: policy, pricing, and environmental change. Preventive Medicine. 2004; 39: S75-80 http://www.med.upenn.edu/nems/docs/Glanz_Yaroch_2004.pdf