Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study
Creators: name: Miller, Victoria
name: Orlandini, Andrés
name: Rosengren, Annika
name: Karsidag, Kubilay
name: Oakley, Solange Martinez
name: Zatonska, Katarzyna
name: Mony, Prem
name: Mohammadifard, Noushin
name: Iqbal, Romaina
name: Khatib, Rasha
name: Teo, Koon
name: Corsi, Daniel J
name: Dehghan, Mahshid
name: Kaur, Manmeet
name: Popkin, Barry
name: Lock, Karen
name: Xiulin, Bai
name: Mohan, Viswanathan
name: Mente, Andrew
name: Rahman, Omar
name: Poirier, Paul
name: Ismail, Noorhassim
name: Lopez-Jaramillo, Patricio
name: Xu, Liu
name: Tsolekile, Lungiswa
name: Yusufali, Afzalhussein
name: Hui, Chen
name: Gupta, Rajeev
name: Ariffin, Farnaza
name: Jian, Bo
name: Chifamba, Jephat
name: Yusuf, Salim
name: Vijayakumar, Krishnapillai
name: Kruger, Annamarie
name: Chow, Clara K
name: Lear, Scott A
name: Avezum, Alvaro
name: Wei, Li
name: Rangarajan, Sumathy
Publisher: name: The University of North Carolina at Chapel Hill University Libraries
Year: 2016

description: 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.