bioactive foods in promoting health || trends in us adult fruit and vegetable consumption

mtpa

1. EVIDENCE SUMMARY

1.1 Fruit and Vegetable Consumption

[19]. This was done through advertising campaigns, education, and school and workplace interventions. In 2005, the USDA Guidelines were revised to emphasize fruit and vegetable Consuming a diet high in fruits and vegetables is associated with a decreased risk of certain chronic diseases including cardiovascular disease [14], cancer [1,5], and diabetes [69]. Previous literature indicates that US adult fruit and vegetable consumption is below recommendations [1016]. Beginning in 1985, the United States Department of Agriculture (USDA) Dietary Guidelines for Healthy Americans (Guidelines hereafter) recommended consuming at least two servings of fruit and three servings of vegetables daily [17,18]. In 1991, the 5-A-Day Program for Better Health was initiated by the National Cancer Institute and the Produce for Better Health Foundation to increase public awareness of the importance of eating at least five fruits and vegetables daily

intakes based on individual energy requirements and recommended 59 servings per day. Lastly, in 2007, the Produce for Better Health Foundation launched the Fruits and Veggies More Matters campaign to reflect the 2005 Guideline revisions.

Previous research indicates that only a small proportion of Americans meet the USDA Guidelines for daily servings of fruits and vegetables [13,20,21]. An evidence table summarizing fruit and vegetable consumption studies is referenced in Table 8.1. Twenty-four hour dietary recall data from the Second National Health and Nutrition Examination Survey (NHANES) (19761980) estimated that only 27% of adults consumed the three or more servings of vegetables and 29% of adults

Bioactive Foods in Promoting Health: Fruits and Vegetables 111 r 2010 Elsevier Inc. All rights reserved. C H A

8Trends in US Adult

ConsuSarah Stark Casagrande1 an

1Department of Epidemiology, Jof Public Health, Bal

2Welch Center for Prevention, EMedical Institutions, BP T E R

Fruit and Vegetable ption

d Tiffany L. Gary-Webb1,2 ohns Hopkins Bloomberg School imore, Maryland, USA idemiology, and Clinical Medicine, ltimore, Maryland, USA

112 8. TRENDS IN US ADULT FRUIT AND VEGETABLE CONSUMPTION

1095 white adults whites

Patterson 1987 National Health 20,143 adults Food Frequency Females consumed more F&V, fewer et al. [14] Interview Survey Questionnaire meats and high-fat foods (NHIS) Whites consumed a more varied diet than African Americans or Hispanics Hispanics consumed the lowest amounts of high-fat foods; African Americans the most

Basiotis [16] NHANES 19992002 8070 age > 2 yrs Healthy Eating Index 28% consumed Z3 servings vegetables 17% consumed Z2 servings fruit

Few met F&V recommendations

Gary et al. Project DIRECT 2172 African Modified Block 8% met fruit recommendations (Z2) [12] American adults Questionnaire 16% met vegetable recommendations

(Z3)

Intake increased with higher income and more education

Casagrande NHANES III, 1988 NHANES III: 24-hour dietary recall 11% met USDA Guidelines for F&V et al. [11] 1994 and NHANES 14,997 adults in both study periods

19992002

NHANES 1999 Non-Hispanic blacks less likely to 2002: 8910 adults meet Guidelines compared to non-

Hispanic whites

consumed the two or more servings of fruit recommended by USDA and DHHS [13]. Only 9% of adults met both fruit and vegetable recommendations.

Demographic patterns for fruit and vegetable consumption have been varied. Racial differences in consumption patterns are inconsistent depending on the region, sample size, and the method of measurement. One study

demonstrated that whites tend to eat a more varied diet than African Americans and Mexican Americans, but that Mexican Americans consume the lowest amounts of high-fat foods while African Americans eat the most [14]. A second study reported that African Americans have low consumption of fruits and vegetables with only 8% meeting the recommendations for fruit and 16% meeting TABLE 8.1 Evidence Summary for Fruit and Vegetable (

Reference Study Population Me

Patterson NHANES II, 1976 11,648 adults 24-et al. [13] 1980 adm

inte

Swanson Population survey in 881 African Fooet al. [15] three areas of US Americans and A. FRUIT AND VEGETABLEF&V) Consumption

asures Results

hour dietary recall 45% no fruit servings inistered by a trained rviewer

22% no vegetable servings 27% consumed 3 + vegetables

29% consumed 2 + fruits

9% consumed both

Consumption low

d frequency data African Americans were more frequent consumers of F&V than S IN HEALTH PROMOTION

113 2. DIETARY GUIDELINES the recommendations for vegetable intake [12]. A third study reported that African Americans consumed more fruits and vegetables (citrus, cruciferous, and vegetables rich in vitamin A and C) and slightly less total and saturated fat than whites [15]. Finally, a fourth study among African Americans reported that fruit intake was higher among participants with higher income and more education [12]. Females have been shown to consume a more diverse diet than males and consume more fruits and vegetables, less meat, and fewer high-fat foods [14].

1.2 Fruit and Vegetable Trends

Table 8.2 summarizes evidence of trends in fruit and vegetable consumption. Using the National Health Interview Survey (NHIS) between 1987 and 1992, the proportion of fruit and vegetable consumption and the mean number of servings per week remained stable over time [10]. Similarly, results from the Behavioral Risk Factor Surveillance System (BRFSS) examining F&V consumption at intervals between 1994 and 2000 found that the proportion of individuals consuming fruits and vegetables five or more times per day remained constant at 25% [21]. The BRFSS survey conducted from 1990 to 1996 indicated 19%, 22%, and 23% of adults in 1990, 1994, and 1996, respectively, consumed at least five fruits and vegetables per day which indicated slightly higher consumption over time [20]. These results indicate a slight increase in consumption over relatively the same time period as the 19942000 BRFFS survey.

1.3 Trends by Race/Ethnicity

A cross-sectional study identified quality of diet trends between 1965 and 1991 using data from the Nationwide Food Consumption Surveys and the Continuing Survey of Food A. FRUIT AND VEGETABLESIntake by Individuals using the Diet Quality Index [22]. In 1965 whites of high socioeconomic status were eating the least healthful diet and African Americans of low socioeconomic status were eating the most healthful. By 1991, the diets among all groups had improved and were relatively similar.

Cross-sectional data from NHANES I (1971 1975), II (19761980), III (19881994), and NHANES 20012002 indicated that dietary trends were similar between blacks and whites across the study periods [23]. There was a significant trend toward lower fruit consumption among whites and a significant trend toward higher vegetable consumption among black females. Black males and females reported lower intakes of vegetables compared to their white counterparts.

2. DIETARY GUIDELINES

2.1 Background

Since 1980, the Guidelines have been jointly published by the Department of Health and Human Services (DHHS) and the United States Department of Agriculture (USDA). The Guidelines are reviewed and revised as needed every five years. The purpose of this publication is to provide scientific evidence for beneficial nutrients to promote health and reduce disease risk through nutrition and healthy lifestyles.

The Guidelines are developed through a three-stage process involving advisory committees from both DHHS and USDA. An external scientific Advisory Committee is appointed by the two Departments. The Advisory Committee is responsible for compiling new scientific information relating to nutrition, disease, and physical activity and preparing a summarized report of the findings. The report is available for public and Government agencies for comment and then the two Departments join to develop Key IN HEALTH PROMOTION


[20] Surveillance System (BRFFS) 99

1994: 32,076 1996: 37,581 adults

6-item Food Frequency Questionnaire

F&V consumption Z5 was 19%, 22%, 23% in 1990, 1994, 1996, respectively Slight increase in

consumption

Serdula et al. [21]

19942000 Behavioral Risk Factor Surveillance System (BRFSS)

1994: 87,582 1996: 96,511 1998: 114,129 2000: 135,899 adults


F&V consumption Z5 was 25% for each year No trend in consumption

Kant et al. [23]

NHANES I (19711975), II (1976 1980), III (19881994), NHANES 20012002

Non-Hispanic black (N = 7099) and white (N = 23,314) adults

24-hour dietary recall administered by a trained interviewer

Black men and women reported lower intakes of vegetables compared to white counterparts

Dietary trends were similar between blacks and whites

Significant decreased trend in fruit reporting among whites

Significant increased trend in vegetable reporting among black women

Recommendations based on the Advisory Committees initial report and the comments made by other agencies. The final Guidelines contain the details of the science-based Key Recommendations and, finally, the two Departments develop messages to communicate the Guidelines to the public.

The Guidelines are the basis for national nutrition education programs, intervention

programs, and federal food programs. Federal dietary guidance publications are, by law, required to follow the Guidelines. Examples include the USDA Food Guide, the food label, and the Nutrition Facts Panel. Policies for nutrition-related programs such as the National Child Nutrition Programs or the Women, Infants and Children Program are based on the Guidelines. TABLE 8.2 Evidence Summary for Trends in Fruit and

Reference Study Populatio

Popkin et al. [22]

1965, 197778 Nationwide Food Consumption Survey (NFCS) and 19891991 Continuing Survey of Food Intake (CSFI)

1965: 6061197778: 1

19891991adults

Breslow et al. [50]

1987 and 1992 National Health Interview Survey (NHIS) Cancer Control Supplements

10,000 aduresponden

Li et al. 19901996 Behavioral Risk Factor 1990: 25,4A. FRUIT AND VEGETABLVegetable Consumption

n Measures Results

6,425

: 9920

Diet Quality Index (DQI)

Overall dietary quality improved

Racial differences decreased over time

lt ts


Proportion of F&V consumers remained stable over time ES IN HEALTH PROMOTION

115 2. DIETARY GUIDELINES the Guidelines in daily food choices, the 1985 edition outlined suggested servings from each of the major food groups. Specifically, the USDA suggested a minimum of at least two daily servings of fruits and at least three daily servings of vegetables. In 1990 the Advisory Committee revised the statement to Choose a diet with plenty of fruits, vegetables, and grain products which explicitly targeted the food groups to choose from in an effort to make the Guidelines clearer to Americans.

2.3 The Food Guide Pyramid

The development of the USDA Food Guide Pyramid spans over six decades. The first National Nutrition Conference, prompted by President Franklin D. Roosevelt, was held in 1941. As a result of this conference, the USDA developed Recommended Dietary Allowances (RDAs) and specified caloric intakes and essential nutrients. In 1943, the USDA announced the Basic Seven which was a special modification of the nutritional guidelines to alleviate the shortage of food supplies during the

TABLE 8.3 The 2005 Dietary Guidelines for Number of Sfrom Total and Saturated Fat, and Fiber

Energy Daily Servings of Fruits % of E(kcal) and Vegetables To

1200 5

2000 9

3200 13 A. FRUIT AND VEGETABLEbe consumed in moderation. Although the USDAs food guide, A Pattern for Daily Food Choices, was published annually beginning in the 1980s, it was not well known. Beginning in 1988, the USDA began to represent the Guidelines graphically to convey the messages of variety, proportionality, and moderation. The Food Guide Pyramid was released in 1992 and in 1994 the Nutrition Labeling and Education Act required all grocery items to have a nutritional label.

2.4 2005 Guidelines: The Current Guidelines

Unlike past revisions, the 2005 Guidelines emphasized nutrient intakes based on individual energy requirements for weight maintenance (Table 8.3). Fiber-rich fruits and vegetables were one of the food groups strongly encouraged in the Guidelines. Two cups of fruit and 2 cups of vegetables per day (9 servings) were recommended as a reference for a 2000-calorie intake; an increase from the recommended five

ervings of Fruits and Vegetables, Percentage of Calories

nergy from % of Energy from Fiber (g) tal Fat Saturated Fat

r30


daily servings that began in 1985. These intakes should be adjusted depending on specific

3. FRUIT AND VEGETABLE INITIATIVES energy needs. Intakes would equate to 2 to 6 cups of fruits and vegetables per day (513 servings) for 12003200 calorie levels. The Key Recommendations emphasized choosing a wide variety of fruits and vegetables each day and selecting from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week [17]. The Guidelines recommended three cups per week of dark green vegetables, up to 11 cups per week of starchy and other vegetables, and three cups per week of legumes.

2.5 MyPyramid: The Current Food Guide

Along with the release of the 2005 Dietary Guidelines, the USDA and DHHS released the revised Food Guide Pyramid. In past years, the Food Guide Pyramid displayed the major food groups proportional to consumption recommendations. Grains and cereals formed the base of the pyramid, fruits and vegetables formed the next layer followed by dairy and meat, beans, and nuts, and the tip of the pyramid included fats, oils and sweets to be used sparingly. The 2005 edition had a similar pyramid shape but contained a vertical rainbow of colors, with each color identifying a specific food group and the proportion of total intake. In addition, a color segment for physical activity was included. The 2005 Food Guide Pyramid was promoted as being interactive on the internet by allowing individuals to tailor their daily intakes depending on their age, gender, and activity levels. Unfortunately, those populations without internet access were disadvantaged in becoming educated about the importance of a healthy diet and ways to incorporate nutritious foods into daily intakes. A. FRUIT AND VEGETABLEThe 5-A-Day for Better Health Program was the first large-scale program aimed at increasing fruit and vegetable consumption by promoting the consumption of five fruit and vegetable servings per day; in 2005 the 5-A-Day began to encourage 59 servings per day to reflect changes in the Dietary Guidelines [24]. The 5-A-Day began in 1991 as a public/private partnership between the National Cancer Institute (NCI) and Produce for Better Health (PBH), a non-profit organization. The mission of the program was to increase public awareness of the importance of eating at least five fruits and vegetables daily through education and advertising campaigns. The 5-A-Day has initiated several successful local intervention initiatives in schools and the workplace [2528] (Table 8.4). These multicomponent interventions were based on the stages of behavioral change model and included interactive activities involving F&V, education, cooking demonstrations, and involving the family and community. Although many 5-A-Day interventions were successful, whether individuals maintained fruit and vegetable consumption after the intervention was removed has not been well established. Research does indicate that demographic and psychosocial determinants have a strong bearing on sustained consumption [29]; whether 5-A-Day interventions had a positive effect on predictors of consumption has yet to be determined.

The 5-A-Day logo, placed on grocery items, was developed to educate consumers on which grocery items counted towards the 5-A-Day goal. Advertising funding has been low with total funding for public communication under $3 million in 1999, which is a miniscule amount compared to the advertising spent on fast food and junk food [30]. S IN HEALTH PROMOTION

4. TRENDS IN FRUIT AND VEGETABLE CONSUMPTION: DATA FROM NHANES III (19881994) AND NHANES 19992002 117

TABLE 8.4 Evidence Summary of Interventions Implemented for the 5-A-Day for Better Health Program

m

tla

b

b

&w

e

Health Foundation launched the Fruit and Veggies More Matters campaign to replace

VEGETABLE CONSUMPTION: DATA FROM NHANES III (1988 the 5-A-Day Program [31]. The new campaign relies heavily on internet access but provides a multitude of online resources including recipes, individualized serving calculators, lessons for kids, shopping tips, and the ability to post questions for experts and the community. The Fruit and Veggies More Matters campaign is part of the Produce for Better Health Foundations National Action Plan to increase fruit and vegetable consumption among Americans [32]. Marketing to children, targeting worksites, supermarket retailers, fruit and vegetable growers and processors, health-care industries and organizations, communities, research, and federal policies are some of the strategies outlined to meet fruit and vegetable intake goals. We now present a recent fruit and vegetable trend study among US adults.

1994) AND NHANES 19992002

4.1 Introduction

To determine if national efforts to increase F&V consumption were successful, F&V consumption trends were examined using data from NHANES III (19881994) and NHANES 19992002. Data from NHANES III (19881994) coincided with the initiation of the 5-A-Day Program in 1991, and data from NHANES 19992002 were used as the most recently available data for comparison with NHANES III. This analysis compared consumption to the USDA Dietary Guidelines that were implemented from 1985 to 2005, which explicitly recommended eating at least two servings of fruits and at least three servings of vegetables daily. Reference Population Measures

Beech et al. [25]

Beresford et al. [26]

Stables et al. [27]

Stables et al. [28]

2213 students in parochial school in New Orleans

2828 adults at 28 work-sites in Seattle

2755 and 2544 adults in 1991 and 1997

Seven 5-A-Day school-based intervention studies funded by 1-year grants

22 nutrition-related iteknowledge of F&V

Food Frequency Quesrecalls, fiber and fat-reior questions, usual d

Intervention followedof change model

Random digit dialing low-up survey Questions regarding Fand attitudes and knoF&V

F&V consumption basup; measures varied

In March 2007, the Produce for Better A. FRUIT AND VEGETABLESResults

s to assess

ionnaire, 24-hour ated diet behavy checklist

ehavioral stages

aseline and fol

V consumption ledge about

line vs. follow-

Knowledge and consumption low

Attitudes toward learning about healthier eating practices favorable

At 2 years, significant increase in F&V consumption (0.2 baseline vs. 0.5 follow-up)

Mean F&V consumption significantly higher at follow-up; null findings when data adjusted for demographic shifts Weighted only: Z5 servings F&V, 27% in 1997 and 23% in 1991

Average effect size of 0.4 servings of F&V

Results similar to larger scale trials

4. TRENDS IN FRUIT AND IN HEALTH PROMOTION


4.4 Dietary Measures 4.2 Methods

The National Health and Nutrition Examination Survey (NHANES) is a stratified multistage probability survey conducted in the non-institutionalized population, aged Z6 months administered by the National Center for Health Statistics (NCHS). The NHANES survey has two parts: 1) an in-home interview for demographic and basic health information, and 2) a health examination in a mobile examination center (MEC). Household interviews are conducted by trained staff and the MEC is staffed by physicians, medical and health technicians, and dietary and health interviewers. All survey information is confidential and approved by the NCHS Institutional Review Board [33].

4.3 Study Population

This study included 14,997 adults (Z18 years) from 1988 to 1994 and 8910 adults from 1999 to 2002 with complete demographic and dietary data. For 19881994, the number of missing values for variables ranged from 108 (0.6% missing) for education to 1582 (9%) for poverty income ratio (PIR). Individuals with missing PIR tended to be slightly older, more often Mexican American, and have less education than individuals not missing PIR (data not shown). For 19992002, missing values for variables ranged from 19 (0.2%) for education to 1031 (10%) for PIR. Individuals with missing PIR tended to be slightly older, more often non-Hispanic Black or Mexican American, and have less education than individuals having PIR. There were no differences in F&V consumption overall or by socio-demographic indicators when individuals with missing PIR were included in analysis in either NHANES dataset. Therefore, individuals with missing socio-demographic data were excluded. A. FRUIT AND VEGETABLEAs part of the standard NHANES data collection protocol, 24-hour dietary recalls (24HR) were conducted and were used to estimate the number of daily F&V servings. The main F&V variable used in these analyses was the 7- and 8-digit food coding scheme developed by the USDA for NHANES III and NHANES 1999 2002, respectively, which categorized items by food group and subgroup [34]. If the main ingredient of a mixed dish was a fruit or vegetable, the item was categorized according to the main fruit or vegetable. Sweets containing fruit where fruit was not the main ingredient were excluded from analysis. Serving sizes for each recorded F&V were determined using serving size estimations from USDA/DHHS Dietary Guidelines [35] and a previous NHANES study [13]. Fruit servings included whole fruit, dried and mixed fruit dishes, and 100% fruit juice. Vegetable servings included white potatoes, fried potatoes, garden vegetables (dark leafy greens, yellow vegetables, tomatoes, green beans, starchy vegetables), salad, and legumes. Although fried potatoes have been criticized as a vegetable, this subcategory was included in analyses to be consistent with previously published NHANES II data [13]. Additional analyses were conducted to estimate the proportion of individuals consuming fried potatoes. Reporting a salad on a single occasion was coded as being equal to one serving rather than multiple servings for each ingredient.

For each vegetable, one serving consisted of 30149 g and two servings consisted of Z150 g. For each fruit, one serving consisted of 30239 g and two servings consisted of Z240 g. For fruit juice, one serving was 62 371 g (212 ounces), two servings 372587 g (1218 ounces), and three servings Z588 g (Z18 ounces). To minimize the impact of reported overestimation, an upper limit of two servings for F&V and an upper limit of three S IN HEALTH PROMOTION

4. TRENDS IN FRUIT AND VEGETABLE CONSUMPTION: DATA FROM NHANES III (19881994) AND NHANES 19992002 119 servings for fruit juice were established. The lower limit for one serving was equal to one ounce to capture consumption for individuals with lower energy intakes. Although portions less than one ounce could sum to a serving over the day, and consequently result in underestimation, the bias would be minimal since the lower limit reflects very small intake amounts.

Individuals with total caloric intakes 7000 kcal were considered to have unreliable consumption patterns and were excluded from our final analysis [N = 195 (1.0%) and N = 67 (0.7%) for 19881994 and 19992002, respectively] [36,37].

4.5 Statistical Analysis

All analyses were conducted using survey weighting to account for the complex survey design, which consisted of multistage, stratified, clustered samples. Probability sampling weights were used in conjunction with strata and primary sampling units (psu) to weight the analysis. Mean servings of F&V, the proportion of individuals consuming specific types of F&V, and the proportion of individuals meeting the Dietary Guidelines (Z2 servings of fruit and Z3 servings of vegetables based on an average 2000 kcal daily intake) were reported [35]. To explore demographic shifts over time between NHANES datasets, secondary analyses were conducted adjusted for age, ethnicity, and gender. Previously published data from NHANES II, 19761980 [13] were used to assess trends across three NHANES surveys.

Logistic regression analysis was used to compare F&V consumption patterns across socio-demographic groups. Mean intakes of total energy, percentage of energy from total and saturated fat, and fiber were stratified by F&V intake and adjusted for age, gender, and ethnicity using multiple regression A. FRUIT AND VEGETABLEmodels. To assess differences in consumption between 19881994 and 19992002, 2 tests for significance were performed. All analyses were conducted using STATA 9.0 statistical software (StatCorp. 2005 Stata Statistical Software: Release 9. College Station, TX; StataCorp LP).

4.6 Results

4.6.1 Population Characteristics

Sixty-eight percent and 65% of the study population was


s for NHANES III (19881994) and NHANES 1999

9

Gender

Female 52.2 (0.5) 51.9 (0.5) 0.693 Ethnicity

Non-Hispanic White 76.8 (1.3) 72.4 (1.7) 0.055

Non-Hispanic Black 10.8 (0.6) 10.3 (1.2)

Mexican American 5.0 (0.4) 6.9 (0.9)

Other 7.4 (0.8) 10.4 (1.7)

Poverty Income Ratio (PIR)

r1.0 (poor) 12.9 (0.8) 14.9 (0.9) 0.008 1.01.25 (near poor) 4.9 (0.3) 6.7 (0.7)

1.252.5 (moderately poor) 26.3 (1.0) 22.2 (0.9)

> 2.5 (not poor) 55.9 (1.4) 56.2 (1.8)

Education

< High school 23.9 (1.1) 21.3 (0.9) High school 41.5 (1.3) 52.5 (1.5)

aSurvey weighted percentage and standard error. bP-value for Pearson 2 test for difference between NHANES III and NHANES 19992002.

servings vegetables) in 19881994 and in 1999 2002 (P = 0.963), indicating no change in consumption. Mean daily serving intakes for fruits and vegetables were 3.06 and 3.04 for 1988 1994 and 19992002, respectively (P = 0.754). For both study periods, roughly half of the participants reported no fruit servings, about 25% reported no vegetable servings, and 14% reported no vegetable and no fruit servings (Table 8.7). Fruit and vegetable intakes adjusted for age, sex, and ethnicity did not

significantly change consumption patterns (data not shown).

4.6.3 Fruit and Vegetable Patterns by Demographics

In both study periods, recommended consumption frequencies for fruits (Z2) and vegetables (Z3) were significantly different by age, ethnicity, poverty income ratio, and education level (data not shown). In 19881994 TABLE 8.5 Adult (Z18 years) Population Characteristic2002

NHANES III, 19881(N = 14,997) % (SE)a

Age

1829 25.3 (0.9)

3039 24.1 (0.7)

4049 18.7 (0.7)

5059 12.0 (0.7)

6069 10.6 (0.5)

Z70 9.4 (0.6) A. FRUIT AND VEGETABLE94 NHANES 19992002 (N = 8910) % (SE) P-valueb

21.6 (0.8)


TABLE 8.6 Mean Servings (SE) of Fruits and Vegetables and Percentage (SE) of Adults (Z18 Years) Meeting

Daily Serving Recommendations for Fruits and Vegetables

Servings per day NHANES III, 19881994 NHANES 19992002 P-valuea

(N = 14,997) (N = 8910) % (SE) % (SE)

Fruit

Total Fruit

Mean servings (SE) 0.99 (0.03) 1.07 (0.04) 0.081

Whole Fruit

0 63.1 (0.9) 61.3 (1.2) 0.290

Z1 36.9 (0.9) 38.7 (1.2)

Fruit Juice

0 75.4 (0.8) 75.4 (0.9) 0.983 Z1 24.6 (0.8) 24.6 (0.9)

Recommended (Z2) 26.7 (0.8) 28.4 (1.2) 0.196

Vegetables

Total Vegetables

Mean servings (SE) 2.08 (0.03) 1.97 (0.03) 0.029

White Potatoes

0 79.3 (0.8) 82.1 (0.6) 0.004

Z1 20.7 (0.8) 17.9 (0.6) Fried Potatoes

0 80.2 (0.6) 79.4 (1.0) 0.402

Z1 19.8 (0.6) 20.6 (1.0)

Salad

0 70.8 (0.9) 72.0 (0.7) 0.335

Z1 29.2 (0.8) 28.0 (0.7)

Garden Vegetables

0 46.2 (0.9) 48.9 (1.0) 0.033 Z1 53.7 (0.9) 51.1 (1.0)

Legumes

0 88.7 (0.6) 87.1 (0.5) 0.059

Z1 11.2 (0.6) 12.9 (0.5)

Recommended (Z3) 35.0 (0.7) 32.5 (0.7) 0.026

Total Fruit and Vegetable

Mean Servings of Fruit and Vegetables

Mean (SE) 3.06 (0.04) 3.04 (0.06) 0.754 Recommended Fruit (Z2) and Vegetable (Z3)

Yes 10.9 (0.4) 10.8 (0.6) 0.963

Z5 Servings Fruits and Vegetables

Yes 24.3 (0.6) 23.6 (0.8) 0.544

aPearson 2 test for difference between NHANES III and NHANES 19992002. A. FRUIT AND VEGETABLES IN HEALTH PROMOTION


1994 compared to non-Hispanic Whites

(OR = 0.75, CI = 0.690.83); there was no difference in NHANES 19992002. Non-Hispanic Blacks were less likely to meet vegetable recommendations in 19881994 and 19992002 compared to non-Hispanic Whites (OR = 0.52, 0.0.61, respectively, P

y Age, Gender, Ethnicity, Poverty

4. T

REN

DS

IN FR

UIT

AND

VEG

ETABLE

CONSU

MPT

ION: DATA

FROM

NHANES

III (1988

1994) A

ND

NHANES

19992002

123

A. FR

UIT

AND

VEGETABLES

IN H

EALTH

PROMOTIO

N

Recommended Fruits (Z2) and Vegetables (Z3)

NHANES III NHANES

19881994 19992002

Ref Ref

1.18 (0.991.41) 1.23 (0.991.54)

1.22* (1.011.48) 1.25 (1.001.56)

1.84* (1.512.23) 1.45* (1.141.83)

1.71* (1.422.06) 1.80* (1.452.23)

2.10* (1.782.49) 1.74* (1.422.14)

0.97 (0.881.08) 1.00 (0.881.14)

Ref Ref

0.45* (0.390.53) 0.57* (0.460.70)

0.76* (0.680.88) 0.95 (0.821.11)

0.92 (0.711.20) 0.94 (0.741.21)

Ref Ref

1.40* (1.101.77) 0.89 (0.651.22)

1.44* (1.221.69) 1.31* (1.061.61)

2.06* (1.772.39) 1.65* (1.372.00)

Ref Ref

1.14 (1.001.31) 1.21* (1.001.47)

1.78* (1.572.02) 1.90* (1.622.22) TABLE 8.8 Odds Ratios (95% CI) for Meeting Fruit and Vegetable Serving Recommendations Stratified bIncome Ratio, and Education for Adults (Z18 Years)

Recommended Fruit Recommended Vegetables (Z2 servings) (Z3 servings)

NHANES III NHANES NHANES III NHANES

19881994a 19992002 19881994 19992002

Age

1829 Ref Ref Ref Ref

3039 1.18* (1.051.33) 1.04 (0.901.21) 1.07 (0.971.19) 1.15* (1.001.33)

4049 1.22* (1.071.38) 1.12 (0.971.30) 1.13* (1.011.27) 1.10 (0.951.27)

5059 1.80* (1.582.06) 1.33* (1.141.57) 1.10 (0.971.24) 1.24* (1.061.45)

6069 2.11* (1.862.39) 1.67* (1.441.94) 1.03 (0.921.16) 1.27* (1.091.46)

Z70 2.96* (2.643.32) 2.10* (1.822.41) 0.94 (0.841.05) 0.96 (0.831.11)

Gender

Female (vs. male) 1.12* (1.041.20) 1.20* (1.091.31) 0.83* (0.770.89) 0.95 (0.871.04)

Ethnicity

Non-Hispanic White Ref Ref Ref Ref

Non-Hispanic Black 0.63* (0.570.69) 0.68* (0.600.77) 0.52* (0.470.57) 0.61* (0.530.69)

Mexican American 0.75* (0.690.83) 0.93 (0.831.03) 1.04 (0.961.13) 1.01 (0.911.13)

Other 1.02 (0.851.23) 0.97 (0.821.15) 0.90 (0.751.08) 0.83* (0.701.00)

Poverty Income Ratio (PIR)

r1.0 (poor) Ref Ref Ref Ref 1.01.25 (near poor) 1.30* (1.111.51) 0.88 (0.731.07) 1.01 (0.871.17) 1.03 (0.851.25)

1.252.5 (moderately 1.40* (1.261.56) 1.17* (1.021.34) 1.14* (1.031.25) 1.22* (1.071.40) poor)

> 2.5 (not poor) 1.77* (1.611.96) 1.38* (1.221.56) 1.50* (1.371.64) 1.57* (1.391.78)

Education

< High school Ref Ref Ref Ref

High school diploma 0.98 (0.901.07) 1.12 (0.991.27) 1.12* (1.031.22) 1.20* (1.061.35)

> High school 1.60* (1.471.74) 1.52* (1.371.69) 1.31* (1.211.43) 1.62* (1.461.80)

aNHANES III (N = 14,997); NHANES 19992002 (N = 8910). *P


potatoes (P = 0.51) and 44% in 19881994 and with far fewer consuming any combination con

2 servings of

r

o 0mbe

r

2 se

Nu

Sa

0 5 10 15 20 25 30 35 40 45 Perentage (%)

1 vegetable servings

FIGURE 8.1 Percentage of adults consuming zero, one, twsumed in NHANES 19881994 and NHANES 19992002.A. FRUIT AND VEGETABLE white potato

vings garden

lad & garden

0 5 10 15 20 25

Legumes

garden

Salad

Fried potato

White potato

0 5 10 15 20 25 30 35 40 45

Percentage (%)

, or Z3 daily vegetable servings and types of vegetables con43% in 19992002 consumed garden vegetables (P = 0.53) (Fig. 8.1). In both study periods, as vegetable servings increased and vegetable combinations became more varied, garden vegetables and salads were more frequently consumed. For individuals consuming 2 servings of vegetables, roughly 22% consumed a salad and a garden vegetable and roughly 19% consumed 2 servings of garden vegetables. Among individuals consuming Z3 servings in 19881994 and 19992002, roughly 12% consumed 3 servings of garden vegetables and 14% consumed 2 servings of garden and a salad

taining fried potatoes. The combination of vegetables individuals consumed over the two study periods did not change significantly (data not shown).

4.6.5 Trends in Consumption Between NHANES II, NHANES III, and NHANES 19992002

Previously published data from NHANES II (19761980) was used to compare fruit and vegetable consumption over the past three NHANES surveys [39] (Fig. 8.2). The

Salad, garden legume 2 garden & 1 fried potato

2 garden & 1 white potato Fried potato, salad, garden

2 fried potato & 1 garden 2 white potato & 1 salad

White potato, salad, garden White potato, fried potato, garden

>3 vegetable servings 2 White potato, & 1 fried garden

2 White potato, & 1 garden 2 garden & 1 salad

0 5 10 15

3

gser

vin

2 servings legume

2 vegetable servings Fried potato & salad

2

ble

Set

a 2 servings fried potato

Veg Fried potato & garden

1

Dai

ly White potato & garden S IN HEALTH PROMOTION


e

9

i

[%

30

25

20

15

10

5

0 Fruit V

NHANES II, 1976-1

NHA

FIGURE 8.2 Percentage of adults (Z18 years) meeting daby NHANES study periods. (NHANES II from previously published data; Patterson et al. A. FRUIT AND VEGETABLEgetable Fruit and vegetable

80 NHANES III, 1988-1994

NES 1999-2002

ly recommended servings of fruits (Z2) and vegetables (Z3)

13]). percentage of individuals meeting fruit and vegetable recommendations increased only slightly from 9% in 19761980 to 11% in 1988 1994 and remained constant at 11% in 1999 2002. Fruit consumption decreased slightly from 29% in 19761980 to 27% in 19881994 and 28% in 19992002. Vegetable consumption increased from 27% in 19761980 to 35% in 19881994 and then decreased slightly to 33% in 19992002.

4.6.6 Energy and Macronutrient Consumption by Fruit and Vegetable Intake

The USDA Dietary Guidelines recommend 14 g of fiber per 1000 kcal consumed [40]. After adjusting for age, gender, and ethnicity, mean energy and fiber intakes were higher for those consuming more F&V (Table 8.9), but remained below recommendations in both

40

35

study periods. The Dietary Guidelines recommend 2035% of energy from total fat and


e0

(

((

(

(

(

Hispanic Whites (7% vs. 11%). These results the analyses indicated that consumption at the

are consistent with previous NHANES findings [41], although published literature is varied [12,14,15]. The results that F&V consumption was positively associated with income and education are also consistent with findings in other studies [12,20,21,42,43]. This result suggests that poverty continues to be a barrier for purchasing and consuming F&V, and could be one reason for low F&V consumption. In addition to the general population, behavioral interventions should target demographic groups that are less likely to meet the national Dietary Guidelines such as African Americans and low socioeconomic status groups.

In contrast to study expectations, the analysis indicated little change in F&V consumption

national level has not changed (Table 8.2). Similar results have been documented in the BRFSS, which examined trends over a shorter period. The BRFSS data collected between 1994 and 2000 showed that the proportion of individuals consuming F&V five or more times per day remained constant at 25% [47]; another BRFSS analysis indicated 19%, 22%, and 23% of adults in 1990, 1994, and 1996, respectively, consumed at least five daily F&V servings [48]. Most recently, a report from 2005 BRFSS data indicated that 32.6% of the US adult population consumed fruit two or more times per day and 27.2% ate vegetables three or more times per day; results for Z5 servings of fruits and vegetables was not reported [49]. TABLE 8.9 Mean Intakes (SE) of Energy, Total and Satfor American Adults, Adjusted for Age, Gender and Ethnic

NHANES III, 1988994 (N = 14,997)

Energy Intake % of % of Energy Fib(kcal) Energy from 100

from Total Saturated Fat Fat

F&V Servings

0 1818 (37) 32.4 (0.4) 11.4 (0.2) 6.1

1 1922 (27) 33.1 (0.3) 11.3 (0.1) 6.9 2 2075 (37) 33.8 (0.3) 11.3 (0.1) 7.7

3 2091 (28) 32.7 (0.3) 10.8 (0.1) 8.5

4 2253 (39) 33.3 (0.3) 10.8 (0.1) 9.4

Z5 2372 (29) 32.4 (0.3) 10.3 (0.1) 10.2

32% in 19992002 consumed Z3 servings of vegetables per day on average, many individuals consumed multiple servings of the same vegetable, which reflects a lack of balance and variety. These results are similar to other studies that have estimated fruit and vegetable intake among American adults.

In both surveys, non-Hispanic Blacks were less likely to meet F&V Guidelines than non-A. FRUIT AND VEGETABLEurated Fat, and Fiber by Fruit and Vegetable Consumption ity

NHANES 19992002 (N = 8910)

r (g/ Energy % of % of Energy Fiber (g/ kcal) Intake (kcal) Energy from 1000 kcal)

from Total Saturated Fat Fat

0.1) 1813 (32) 31.9 (0.4) 10.7 (0.1) 5.5 (0.1)

0.1) 1985 (29) 33.1 (0.3) 10.8 (0.1) 6.4 (0.1) 0.1) 2090 (27) 33.7 (0.3) 10.9 (0.1) 7.0 (0.1)

0.1) 2164 (22) 33.1 (0.3) 10.7 (0.1) 7.8 (0.1)

0.1) 2269 (36) 33.0 (0.5) 10.5 (0.2) 8.1 (0.1)

0.1) 2453 (24) 32.1 (0.4) 10.0 (0.1) 10.0 (0.2)

between 19881994 and 19992002. A slight increase in consumption was expected as a result of national initiatives such as the 5-A-Day for Better Health Program launch in 1991 and increased media attention on the importance of a healthy, balanced diet, which includes a variety of F&V. Although the 5-A-Day Campaign has produced some immediate successful results in local interventions [4446], S IN HEALTH PROMOTION

5. CONCLUSION 127 These estimates are slightly higher for fruits and slightly lower for vegetables than reported estimates from NHANES III and NHANES 19992002. The differences are likely to be a result of the BRFSS using a brief self-reported fruit and vegetable screener and NHANES using a 24-hour dietary recall as reporting methods. The 19871992 NHIS found that F&V consumption and the mean number of servings per week remained stable over time [50]. Although the trends in BRFSS and NHIS are similar to the current study, the difference in the actual proportion meeting the Guidelines is likely due to inaccurate portion size estimation and limiting F&V consumption to the specific combination of 2 fruits and 3 vegetables. In these analyses, when any combination of F&V was considered, 24% of individuals consumed Z5 F&V.

There are limitations of this study worth noting. First, NHANES provides only one 24-hour dietary recall. Four 24-hour recalls are optimal to measure individuals usual intake, however, some research has indicated that food intake data based on 1-day dietary recall can be reliable measures of usual intakes of population groups [51]. Second, it is likely that there may be inaccuracies in converting grams to servings. Nevertheless, the implemented method follows protocols used in the USDA Dietary Guidelines and is interpretable by the public. Even though small portions (


against preventable chronic diseases including be expected to meet the 2005 Guidelines, theseanalyses stress the point that the proportion of individuals meeting current Guidelines is likely even lower and the need for further nutritional education is warranted.

Consistent reports of low F&V consumption with no indication of improvement as well as consumption disparities across ethnic, income, and educational groups over the past several decades should alarm public health officials and professionals. With two-thirds of the US adult population overweight or obese, the implications of a diet low in F&V are extensive [58]. Actions to improve the availability, accessibility, and affordability of fresh produce and to increase consumption through federally funded food programs, such as the Food Stamp Program, should be components for implementation. Schools and worksites provide an avenue in which to reach the general public about the importance of fruits and vegetables in a healthy diet. Successful components of the 5-A-Day Program, such as information sessions, cooking demonstrations, and community and family involvement, are starting points for future interventions. The new Fruit and Veggies More Matters campaign aims to increase consumption by targeting the primary household food purchasers and by educating on the health benefits of fruit and vegetables and ways to incorporate them in the daily diet. Despite these campaigns, new strategies may be necessary to help Americans make desirable behavioral changes to consume a healthy diet that includes a variety of fruits and vegetables.

6. SUMMARY

Consumption of fruits and vegetables among US adults is below USDA recommended servings. Low consumption has a negative effect on a healthy diet. A healthy diet that includes a variety of fruits and vegetables may protect A. FRUIT AND VEGETABLEcardiovascular disease and diabetes. To increase consumption, concerted efforts must address individual behaviors and the social and physical environments in which individuals interact and obtain fruits and vegetables.

References 1. Genkinger, J. M., Platz, E. A., Hoffman, S. C., Comstock,

G. W., & Helzlsouer, K. J. (2004). Fruit, vegetable, and antioxidant intake and all-cause, cancer, and cardiovascular disease mortality in a community-dwelling population in Washington County, Maryland. American Journal of Epidemiology, 160, 12231233.

2. He, F. J., Nowson, C. A., & MacGregor, G. A. (2006). Fruit and vegetable consumption and stroke: Metaanalysis of cohort studies. Lancet, 367, 320326.

3. He, K., Hu, F. B., Colditz, G. A., Manson, J. E., Willett, W. C., & Liu, S. (2004). Changes in intake of fruits and vegetables in relation to risk of obesity and weight gain among middle-aged women. International Journal of Obesity Related Metabolism Disorder, 28, 15691574.

4. Hung, H. C., Joshipura, K. J., Jiang, R., Hu, F. B., Hunter, D., Smith-Warner, S. A., Colditz, G. A., Rosner, B., Spiegelman, D., & Willett, W. C. (2004). Fruit and vegetable intake and risk of major chronic disease. Journal of National Cancer Institute, 96, 15771584.

5. Ziegler, R. G., Mason, T. J., Stemhagen, A., Hoover, R., Schoenberg, J. B., Gridley, G., Virgo, P. W., & Fraumeni, J. F., Jr. (1986). Carotenoid intake, vegetables, and the risk of lung cancer among white men in New Jersey. American Journal of Epidemiology, 123, 10801093.

6. Feskens, E. J., Virtanen, S. M., Rasanen, L., Tuomilehto, J., Stengard, J., Pekkanen, J., Nissinen, A., & Kromhout, D. (1995). Dietary factors determining diabetes and impaired glucose tolerance. A 20-year follow-up of the Finnish and Dutch cohorts of the Seven Countries Study. Diabetes Care, 18, 11041112.

7. Ford, E. S., & Mokdad, A. H. (2001). Fruit and vegetable consumption and diabetes mellitus incidence among U.S. adults. Preventive Medicine, 32, 3339.

8. Sargeant, L. A., Khaw, K. T., Bingham, S., Day, N. E., Luben, R. N., Oakes, S., Welch, A., & Wareham, N. J. (2001). Fruit and vegetable intake and population glycosylated haemoglobin levels: The EPIC-Norfolk Study. European Journal of Clinical Nutrition, 55, 342348.

9. Williams, D. E., Wareham, N. J., Cox, B. D., Byrne, C. D., Hales, C. N., & Day, N. E. (1999). Frequent salad vegetable consumption is associated with a reduction in the risk of diabetes mellitus. Journal of Clinical Epidemiology, 52, 329335. S IN HEALTH PROMOTION

REFERENCES 129

10. Breslow, R. A., Subar, A. F., Patterson, B. H., & Block, and socioeconomic groups in the United States. New

G. (1997). Trends in food intake: the 1987 and 1992 National Health Interview Surveys. Nutrition and Cancer, 28, 8692.

11. Casagrande, S. S., Wang, Y., Anderson, C., & Gary, T. L. (2007). Have Americans increased their fruit and vegetable intake? The trends between 1988 and 2002. American Journal of Preventive Medicine, 32, 257263.

12. Gary, T. L., Baptiste-Roberts, K., Gregg, E. W., Williams, D. E., Beckles, G. L., Miller, E. J., III, & Engelgau, M. M. (2004). Fruit, vegetable and fat intake in a population-based sample of African Americans. Journal of National Medicine Association, 96, 15991605.

13. Patterson, B. H., Block, G., Rosenberger, W. F., Pee, D., & Kahle, L. L. (1990). Fruit and vegetables in the American diet: Data from the NHANES II survey. American Journal of Public Health, 80, 14431449.

14. Patterson, B. H., Harlan, L. C., Block, G., & Kahle, L. (1995). Food choices of whites, blacks, and Hispanics: Data from the 1987 National Health Interview Survey. Nutrition and Cancer, 23, 105119.

15. Swanson, C. A., Gridley, G., Greenberg, R. S., Schoenberg, J. B., Swanson, G. M., Brown, L. M., Hayes, R., Silverman, D., & Pottern, L. (1993). A comparison of diets of blacks and whites in three areas of the United States. Nutrition and Cancer, 20, 153165.

16. Basiotis, P. P. (2004). Healthy eating index: NHANES 19992002. Washington, DC: USDA Center for Nutrition and Policy Promotion.

17. HHS/USDA (2005). Dietary guidelines for Americans (pp. 184). Washington, DC: United States Department of Human Services and US Department of Agriculture.

18. Davis, C., & Saltos, E. (1998). Dietary recommendations and how they have changed over time. (pp. 3350). Washington, DC: United States Department of Agriculture, Center for Nutrition Policy Promotion.

19. Heimendinger, J., Van Duyn, M. A., Chapelsky, D., Foerster, S., & Stables, G. (1996). The national 5 A Day for Better Health Program: A large-scale nutrition intervention. Journal of Public Health Management Practice, 2, 2735.

20. Li, R., Serdula, M., Bland, S., Mokdad, A., Bowman, B., & Nelson, D. (2000). Trends in fruit and vegetable consumption among adults in 16 US states: Behavioral Risk Factor Surveillance System, 19901996. American Journal of Public Health, 90, 777781.

21. Serdula, M. K., Gillespie, C., Kettel-Khan, L., Farris, R., Seymour, J., & Denny, C. (2004). Trends in fruit and vegetable consumption among adults in the United States: Behavioral risk factor surveillance system, 19942000. American Journal of Public Health, 94, 10141018.

22. Popkin, B. M., Siega-Riz, A. M., & Haines, P. S. (1996). A comparison of dietary trends among racial A. FRUIT AND VEGETABLESEngland Journal of Medicine, 335, 716720. 23. Kant, A. K., Graubard, B. I., & Kumanyika, S. K.

(2007). Trends in black-white differentials in dietary intakes of U.S. adults, 19712002. American Journal of Preventive Medicine, 32, 264272.

24. The National Cancer Institute. (2006). The 5-A-day for better health program. .

25. Beech, B. M., Rice, R., Myers, L., Johnson, C., & Nicklas, T. A. (1999). Knowledge, attitudes, and practices related to fruit and vegetable consumption of high school students. Journal of Adolescent Health, 24, 244250.

26. Beresford, S. A., Thompson, B., Feng, Z., Christianson, A., McLerran, D., & Patrick, D. L. (2001). Seattle 5 a Day worksite program to increase fruit and vegetable consumption. Preventive Medicine, 32, 230238.

27. Stables, G. J., Subar, A. F., Patterson, B. H., Dodd, K., Heimendinger, J., Van Duyn, M. A., & Nebeling, L. (2002). Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association, 102, 809817.

28. Stables, G. J., Young, E. M., Howerton, M. W., Yaroch, A. L., Kuester, S., Solera, M. K., Cobb, K., & Nebeling, L. (2005). Small school-based effectiveness trials increase vegetable and fruit consumption among youth. Journal of the American Dietetic Association, 105, 252256.

29. Trudeau, E., Kristal, A. R., Li, S., & Patterson, R. E. (1998). Demographic and psychosocial predictors of fruit and vegetable intakes differ: Implications for dietary interventions. Journal of the American Dietetic Association, 98, 14121417.

30. Nestle, M. (2002). Food politics: How the food industry influences nutrition and health. (pp. 130132). Berkeley and Los Angeles, CA: University of California Press.

31. Produce for Better Health Foundation. (2008). Fruit and veggies more matters.

32. Produce for a Better Health Foundation. (2005). National action plan: To promote health through increased fruit and vegetable consumption. Produce for a Better Health Foundation..

33. National Center for Health Statistics. (1999). National health and nutrition examination survey: Overview 1999 2002. Hyattsville, MD: NCHS.

34. US Department of Agriculture. (2004). USDA food and nutrient database for dietary studies, 1.0-documentation and user guide. Beltsville, MD: Agricultural Research Service, Food Surveys Research Group.

35. Cronin, F., Shaw, A., Krebs-Smith, S. M., Marsland, P., & Light, L. (1987). Developing a food guidance system to implement the dietary guidelines. Journal of Nutrition Education, 19, 281302. IN HEALTH PROMOTION


36. Krebs-Smith, S. M., Cleveland, L. E., Ballard-Barbash, R., Cook, D. A., & Kahle, L. L. (1997). Characterizing food intake patterns of American adults. American

and vegetable consumption among adults in the United States: Behavioral risk factor surveillance system, 19942000. American Journal of Public Health, 94, 10141018. Journal of Clinical Nutrition, 65, 1264S1268S.

37. Thompson, F. E., Midthune, D., Subar, A. F., McNeel, T., Berrigan, D., & Kipnis, V. (2005). Dietary intake estimates in the National Health Interview Survey, 2000: Methodology, results, and interpretation. Journal of the American Dietetic Association, 105, 352363.

38. US Census Bureau. (2005). Poverty income ratio. Washington, DC: U.S. Department of Commerce.


40. US Department of Health and Human Services and US Department of Agriculture. (2006). Dietary guidelines for Americans, 2005. Washington, DC: US Government Printing Office.


42. Dibsdall, L. A., Lambert, N., Bobbin, R. F., & Frewer, L. J. (2003). Low-income consumers attitudes and behaviour towards access, availability and motivation to eat fruit and vegetables. Public Health Nutrition, 6, 159168.

43. Miller, R. R., Sales, A. E., Kopjar, B., Fihn, S. D., & Bryson, C. L. (2005). Adherence to heart-healthy behaviors in a sample of the U.S. population. Prevention Chronical Disease, 2, A18.

44. Beresford, S. A., Thompson, B., Feng, Z., Christianson, A., McLerran, D., & Patrick, D. L. (2001). Seattle 5 a Day worksite program to increase fruit and vegetable consumption. Preventive Medicine, 32, 230238.

45. Stables, G. J., Subar, A. F., Patterson, B. H., Dodd, K., Heimendinger, J., Van Duyn, M. A., & Nebeling, L. (2002). Changes in vegetable and fruit consumption and awareness among US adults: Results of the 1991 and 1997 5 A Day for Better Health Program surveys. Journal of the American Dietetic Association, 102, 809817.

46. Stables, G. J., Young, E. M., Howerton, M. W., Yaroch, A. L., Kuester, S., Solera, M. K., Cobb, K., & Nebeling, L. (2005). Small school-based effectiveness trials increase vegetable and fruit consumption among youth. Journal of the American Dietetic Association, 105, 252256.

47. Serdula, M. K., Gillespie, C., Kettel-Khan, L., Farris, R., Seymour, J., & Denny, C. (2004). Trends in fruit A. FRUIT AND VEGETABL48. Li, R., Serdula, M., Bland, S., Mokdad, A., Bowman, B., & Nelson, D. (2000). Trends in fruit and vegetable consumption among adults in 16 US states: Behavioral Risk Factor Surveillance System, 19901996. American Journal of Public Health, 90, 777781.

49. Blanck, H. M., Galuska, D. A., Gillespie, C., Kettel Kahn, L., Serdula, M. K., Solera, M. K., & Mokdad, A. K. (2007). Fruit and vegetable consumption among adults United States 2005. MMWR, 56, 213217.

50. Breslow, R. A., Subar, A. F., Patterson, B. H., & Block, G. (1997). Trends in food intake: The 1987 and 1992 National Health Interview Surveys. Nutrition Cancer, 28, 8692.

51. Basiotis, P. P., Welsh, S. O., Cronin, F. J., Kelsay, J. L., & Mertz, W. (1987). Number of days of food intake records required to estimate individual and group nutrient intakes with defined confidence. Journal of Nutrition, 117, 16381641.

52. Shepherd, R. (2005). Influences on food choice and dietary behavior. Forum Nutrition, 57, 3643.

53. Tucker, K. L., Maras, J., Champagne, C., Connell, C., Goolsby, S., Weber, J., Zaghloul, S., Carithers, T., & Bogle, M. L. (2005). A regional food-frequency questionnaire for the US Mississippi Delta. Public Health Nutrition, 8, 8796.

54. Van Duyn, M. A., Kristal, A. R., Dodd, K., Campbell, M. K., Subar, A. F., Stables, G., Nebeling, L., & Glanz, K. (2001). Association of awareness, intrapersonal and interpersonal factors, and stage of dietary change with fruit and vegetable consumption: A national survey. American Journal of Health Promotion, 16, 6978.

55. French, S. A., Harnack, L., & Jeffery, R. W. (2000). Fast food restaurant use among women in the Pound of Prevention study: Dietary, behavioral and demographic correlates. International Journal of Obesity Related Metabolism Disorder, 24, 13531359.

56. Morland, K., Wing, S., Diez, R. A., & Poole, C. (2002). Neighborhood characteristics associated with the location of food stores and food service places. American Journal of Preventive Medicine, 22, 2329.

57. Brown, D. (2005). New dietary guidelines need dietetic interpretation. Journal of the American Dietetic Association, 105, 13561357.

58. Hedley, A. A., Ogden, C. L., Johnson, C. L., Carroll, M. D., Curtin, L. R., & Flegal, K. M. (2004). Prevalence of overweight and obesity among US children, adolescents, and adults, 19992002. JAMA, 291, 28472850. ES IN HEALTH PROMOTION

Trends in US Adult Fruit and Vegetable ConsumptionEvidence summaryFruit and Vegetable ConsumptionFruit and Vegetable TrendsTrends by Race/Ethnicity

Dietary guidelinesBackgroundHistory of Dietary GuidelinesThe Food Guide Pyramid2005 Guidelines: The Current GuidelinesMyPyramid: The Current Food Guide

Fruit and vegetable initiativesTrends in fruit and vegetable consumption: data from NHANES III (1988-1994) and NHANES 1999-2002IntroductionMethodsStudy PopulationDietary MeasuresStatistical AnalysisResultsPopulation CharacteristicsFruit and Vegetable PatternsFruit and Vegetable Patterns by DemographicsTypes of Vegetables ConsumedTrends in Consumption Between NHANES II, NHANES III, and NHANES 1999-2002Energy and Macronutrient Consumption by Fruit and Vegetable IntakeDiscussion

ConclusionSummaryReferences

bioactive foods in promoting health || trends in us adult fruit and vegetable consumption

Documents