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The Health
of Children and Young People
 3 Fruit and vegetable consumption
3.1 Background
It is widely accepted that fruit and vegetables have a protective effect against chronic disease such as cancer and coronary heart disease. The World Health Organisation (WHO) recommends the consumption of at least 400g (five 80g portions) of fruit and vegetables a day, with the aim of reducing the risk of death from chronic disease by up to 20%.1,2 An increase in fruit consumption in childhood is thought to have a long term protective effect against cancer risk later in life.3
Fruit and vegetable consumption in England falls below the recommended level of 400g a day. The 2001 Health Survey for England (HSE) reported that adults ate on average 3.6 portions a day. Studies of children have also found that fruit and vegetable consumption is less than five portions a day. The National Diet and Nutrition Survey (1997) reported that less than half of those aged 4-18 ate the recommended amount and the 2001 Health Survey for England reported that one in ten informants aged 5-15 had eaten no fruit or vegetables the previous day. 4,5
The 5-A-Day programme was introduced in July 2000 with the aim of increasing the consumption of fruit and vegetables in the population, by raising awareness of the health benefits and improving access to fruit and vegetables through targeted action.6 As part of this programme, a series of initiatives has been introduced to increase awareness of the 5-A-Day message, including the introduction of the 5-A-Day logo. The National School Fruit Scheme was introduced to increase fruit and vegetable consumption specifically among children, and provides schoolchildren aged 4-6 with a piece of fruit each school day. It was initiated in autumn 2000 in a number of pilot areas, and is being expanded throughout England with a view to being nationwide by 2004. The expansion began in the West Midlands in summer term 2002, followed by London in the autumn term, the North West in spring 2003 and the East Midlands in summer 2003.7 3.2 Methodology 3.2.1 Fruit and vegetable module
Informants aged 5 and over were asked questions about a range of food items to determine the overall amounts of fruit, vegetables and pulses consumed in a single day (defined as the 24 hours ending the previous midnight). The questions were asked as part of a face to face interview. Parents of children aged 12 and under answered questions on behalf of the child, those aged 13-15 answered the questions themselves. Any seasonal or weekly variation in eating habits is minimised in the aggregate data, as interviewing for the survey is carried out throughout the year and on every day of the week. For each type of food item, the informant was asked whether they had consumed that foodstuff and, if so, how much. Separate questions were asked for vegetables (fresh, frozen, canned), vegetables in composites (for example vegetable curry), salads, pulses, fresh, canned and frozen fruit, dried fruit, and fruit in composites (such as apple pie). Measurement of the amount of different food items differed according to the type of food (see Section 3.2.2). 3.2.2 Portions The questions and analysis were based on the nominal definition of 80g for a portion, which was defined in terms of everyday measures, such as tablespoons, cereal bowls and slices. The everyday definitions of portions were included in the question wording. For example, informants were asked how many tablespoons of vegetables, cereal bowls of salad, pieces of medium sized fruit (such as apples) or handfuls of small fruit (such as raspberries) they had eaten in the previous 24 hours. The following table shows the portion size defined for each of the different food items included in the survey.
Each question provided a clear definition of which foods were to be included: for example, informants were told not to count potatoes as vegetables. Interviewers were able to record full and half units, such as teaspoons or handfuls, consumed. No smaller fractions could be recorded. Each informant could obtain no more than one portion of their daily intake from fruit juice, pulses or dried fruit: if more was consumed only one portion was shown for each of these food items. These restrictions are in line with the 5-A-Day message, which emphasises that a variety of fruit and vegetables should be consumed. In the absence of defined portion sizes for children, fruit and vegetable consumption was measured using the same definition of portion sizes as those for adults. 3.2.3 Interpretation of the data This chapter looks in detail at fruit and vegetable consumption among those aged 5-24 using combined data from the 2001 and 2002 surveys, investigating the relationship between fruit and vegetable consumption and socio-economic indicators such as household income, as well as lifestyle indicators such as smoking, drinking and obesity. Results are presented separately for children (aged 5-15) and young adults (aged 16-24). Data from 2001 was reanalysed using the revised definitions of fruit and vegetable portions as outlined in section 3.2.2.8 The data are based on self-reported information given by the informant for a 24-hour recall period. Although portions were clearly defined in every day terms, there may be some variation in the way that informants interpreted the definitions. Also, the data may be subject to recall error and the social desirability of responses.9 There may also be particular problems in assessing the amount of fruit or vegetables contained within composite foods such as apple pie or vegetable chilli. Mean amounts consumed are based on the total sample, not on those consuming any of the food types concerned. Within specific groups, mean levels of consumption may be increased by a small number of informants who consume unusually large amounts of fruit and vegetables. To compensate for this, medians are shown in addition to means to provide the user with a fuller picture of fruit and vegetable consumption. 3.3 Comparison of fruit and vegetable consumption between 2001 and 2002 3.3.1 Consumption by children Among children aged 5-15, there was no significant difference in the overall mean or median levels of consumption between 2001 and 2002, or in the proportion eating five or more portions. Table 3.1
3.3.2 Consumption by young adults Comparisons of 2001 and 2002 in respect of fruit and vegetable consumption in young adults (aged 16-24) showed that the overall mean and median number of portions, and the proportion eating five or more portions a day, increased slightly (see table below), though this difference was not statistically significant. Table 3.2
3.4 Fruit and vegetable consumption by age and sex 3.4.1 Consumption by children The analysis in this chapter from this point on is based on the combined data from 2001 and 2002. Table 3.3 shows fruit and vegetable consumption by sex and age for those aged 5 to 15. There was some increase with age in the proportion of boys and girls eating five or more portions a day, but the pattern was not clear. Mean fruit and vegetable consumption was slightly higher among girls (2.6) than boys (2.5) but there was no significant difference between the sexes in the proportion eating five or more portions (though boys were more likely than girls not to have eaten any fruit and vegetables (12% compared with 8%)). Table 3.3, Figure 3A 3.4.2 Consumption by young adults Table 3.4 shows fruit and vegetable consumption by sex for informants aged 16-24. Young men aged 16-24 ate significantly fewer portions of fruit and vegetables (mean: 2.6 portions, median: 2.0 portions) than young women (mean: 2.9, median: 2.3). There was some increase with age in the proportion eating five or more portions a day, and in the mean number of portions eaten. Young women were more likely than young men to have eaten five or more portions the previous day. Nearly one fifth (18%) of young women, aged 16-24, reported eating five or more portions, compared with 15% of young men. Correspondingly, the proportion eating no portions of fruit and vegetables was significantly higher among young men (15%) than young women (12%). Table 3.4, Figure 3B
3.5.1 Consumption of different food items Tables 3.5 and 3.6 show the proportion of informants eating each of the different food items, including fresh fruit, dried fruit, vegetables and pulses. Tables 3.7 and 3.8 show the mean number of these different food items eaten by 5-24 year olds. In all tables data from all informants, both consumers and non-consumers, are included. Children Table 3.5 shows the proportion of children eating different food items. The pattern of results was very similar for boys and girls overall, with the latter being slightly more likely to eat most of the items. There were significant differences between girls and boys in the proportion eating fresh fruit (62% of girls compared with 56% of boys) and the proportion eating salad (22% of girls compared with 16% of boys). Fresh fruit consumption tended to decrease with age among
girls (from 71% among those aged 5 through to 57% of those aged 15) and
boys (from 66% of those aged 5 to 47% of those aged 15). Consumption of
vegetables showed no clear pattern with age.Table 3.5, Figure 3C
Young adults Table 3.6 shows the proportion of young adults aged 16-24 eating different food items. As with children, young women were more likely than young men to have eaten each of the different categories of food. Overall, young women were significantly more likely than men to eat fresh fruit (52% compared with 43%), vegetables (44% of young women compared with 40% of young men), salad (28% of young women compared with 21% of young men). The exception was pulses (37% of young men compared with 33% of young women). Table 3.6, Figure 3D
Tables 3.7 and 3.8 show the mean quantities of different food items consumed. The tables also show three summary categories - total portions of fruit and vegetables, all vegetables, and all fruit. The category 'all fruit' includes fresh fruit, frozen fruit, canned fruit and fruit in composites while 'all vegetables' includes fresh, frozen and canned vegetables, vegetables in composites and salad. Fruit juice, pulses and dried fruit are not included in the summary variables as the number of portions counted are capped at one portion per person (regardless of the amount consumed) for all three of these items. Children Table 3.7 shows the average amount of fruit and vegetables eaten the previous day, separated into food types, for children aged 5 to 15. Overall, girls ate more portions of fruit and vegetables in total than boys (2.6 compared with 2.5 portions). The largest proportion (just under half) of daily consumption was accounted for by fruit (1.2 portions for girls and 1.1 boys). For both sexes, mean vegetable consumption increased with age, rising from an average of 0.5 portions a day at age 5 to 0.8 portions at age 15. Table 3.7, Figure 3E
On average, young women, aged 16-24, ate significantly more portions of fruit and vegetables than young men (2.9 compared with 2.6 portions). In contrast with children, total consumption of fruit and vegetables was spread more evenly across the two main categories among young men (0.9 portions of both vegetables and fruit) and young women (1.0 vegetable portions and 1.1 fruit portions). The average number of portions of vegetables eaten by young men increased with age from 0.7 at age 16 to 1.1 portions at age 24. Among young women, mean vegetable consumption also tended to increase with age but the pattern was less clear. Table 3.8, Figure 3F
3.6 Fruit and vegetable consumption, by socio-demographic group 3.6.1 Socio-economic classification (NS-SEC)NS-SEC is a classification of social position that was introduced in the 2001 census. It has similarities to Registrar General's Social Class. Informants are assigned to an NS-SEC category based on the current or former occupation of the household reference person. The five categories presented here are managerial and professional, intermediate (e.g. clerical, administrative, sales), small employers and self-employed workers, lower supervisory and technical, and semi-routine and routine occupations. Children Table 3.9 shows children's fruit and vegetable consumption by the NS-SEC of the household reference person. Children in managerial and professional households were the most likely to eat five or more portions of fruit and vegetables (14% both boys and girls) and ate the highest mean number of portions (2.8 boys, 2.9 girls), although median portions for boys showed little variation. Boys and girls in semi-routine and routine households and in lower supervisory and technical households were the least likely to eat five portions a day and ate the smallest mean number of portions. The table shows mean and median portions and the proportion of children eating five or more portions on the previous day. Table 3.9, Figure 3G
Young adults As with children, young adults in managerial and professional households were the most likely to eat five or more portions (18% young men, 20% young women) and to eat on average the largest number of portions (2.9 young men, 3.3 young women). The differences between the remaining four groups were less marked. The table summarises the means and medians, and the proportion eating five or more portions a day. Table 3.10, Figure 3H
3.6.2 Equivalised household income quintile Equivalised household income is a measure of household income that takes account of the number of persons in the household.10 Children Mean values of fruit and vegetable consumption for children tended to increase with increased equivalised household income. The proportion eating five or more portions per day was highest in the highest income quintile. Around one in ten children in the lowest three income quintiles ate five or more portions a day compared with one in six in the highest income group. Girls in the lowest income quintile were nearly three times more likely to eat no fruit or vegetables than those in the highest (11% compared with 4%). Similarly, boys in the lowest income quintile were almost twice as likely to eat no fruit or vegetables (14% lowest income quintile, 8% highest). The table compares the mean and median portions and the proportion of children eating five or more portions between the highest and lowest household income quintiles. Table 3.11, Figure 3I
Young adults Among young adults, as among children, fruit and vegetable consumption was highest in the highest income quintile. The table compares the highest and lowest income quintiles.
The gap in fruit and vegetable consumption between the highest and lowest income quintiles was substantial. For example, over a fifth of young women in the highest quintile (22%) ate five or more portions a day, compared with a sixth in the lowest (16%). The gap between the highest and lowest quintiles was greater for young men, with nearly twice the proportion eating five or more portions (22% compared with 12%). But there was no difference between the sexes in the other measures: in both sexes, the amount consumed in the highest income quintile was about half as large again as in the lowest income quintile. Young women in the lowest two income quintiles were more than twice as likely to have eaten no fruit or vegetables as those in the highest income quintile (14% compared with 6%). Similarly, nearly a fifth (18%) of young men in the lowest two quintiles had eaten no fruit or vegetables during the previous day, compared with one in ten in the highest income quintile. Table 3.12, Figure 3J
The Index of Multiple Deprivation (IMD) ranks areas from most deprived to least deprived. This classification is based upon area characteristics in six domains: income, employment, health deprivation and disability, education, housing, and access to services. The analysis is based on IMD quintiles. Children Table 3.13 shows children's daily fruit and vegetable consumption by IMD quintile. In the least deprived quintile, girls ate on average 2.9 portions and boys ate 2.7 portions. This decreased to 2.5 (girls) and 2.3 (boys) in the most deprived quintile. One in seven (14%) boys and 13% of girls in the least deprived quintile ate five or more portions of fruit and vegetables, compared with one in ten boys and girls (10% and 11% respectively) in the most deprived quintile. Table 3.13, Figure 3K
Young adults Among young adults fruit and vegetable consumption was lower in the most deprived quintile and highest in the least deprived, but no smooth gradient was observed from one quintile to another. The number of portions of fruit and vegetables eaten by young men in the least deprived quintile was higher (2.9) than those in the other quintiles. Among young women, those in the second quintile ate the most fruit and vegetables (mean:3.3, proportion five or more: 20%). Young women in the most deprived quintile ate the fewest portions of fruit and vegetables, consuming 2.6 portions. Table 3.14, Figure 3L 3.6.4 Government Office Region Government Office Regions have been the primary classification for the presentation of regional statistics since 1996. There are currently nine Government Office Regions.11 Children Table 3.15 shows fruit and vegetable consumption among children by region and sex. Boys and girls living in London were significantly more likely than those living in other regions to report eating at least five portions a day (19% and 17%, compared with the overall average of 11% and 12% respectively for boys and girls). The mean number of portions consumed was also highest among those living in London (3.1 for both sexes) compared with the overall average (2.5 boys, 2.6 girls). No significant differences from the overall average were found in any other regions. The table below compares mean and median portions and
the proportion of children eating five or more portions on the previous
day for London against the countrywideaverage.
Table 3.15, Figure 3M
Young adults As with children, young adults in London were more
likely than those in all other regions to eat five or more portions
of fruit and vegetable per day (19% of young men and 22% of young women,
compared with an overall average of 15% and 18% respectively). The mean
number of portions was also higher in London for young men (3.0) and
young women (3.2) compared with the overall average (2.6 young men and
2.9 young women). Table 3.16, Figure 3N
3.7 Fruit and vegetable consumption, by alcohol consumption and cigarette smoking 3.7.1 Alcohol consumption Children Alcohol questions were only asked of children aged 8 to 15 and therefore table 3.17 shows the fruit and vegetable consumption analysed by alcohol consumption only for this age range. There was no association between fruit and vegetable consumption and alcohol consumption for boys or girls. Table 3.17 Young adults The main series of questions in the Health Survey has been designed to estimate average weekly consumption rather than daily drinking patterns. The results in this section are based on weekly consumption estimates.12 The definition of the three categories of alcohol consumption are: non-drinkers (ex-drinkers or those who have never drunk alcohol), moderate drinkers (up to 21 units a week for males, and up to 14 units a week for females) and heavy drinkers (more than 21 (males) and 14 (females) units a week). Table 3.18 shows young adults' fruit and vegetable
consumption by alcohol consumption and sex. Fruit and vegetable consumption
decreased as the amount of alcohol consumed increased. Among young men,
the mean number of fruit and vegetable portions consumed was 3.3 for
non-drinkers compared with 2.6 for moderate drinkers and 2.4 for heavy
drinkers. The pattern was similar among young women with non-drinkers
eating 3.2 portions, on average, compared with 2.9 among moderate and
heavy drinkers. Approximately one quarter of non-drinkers of both sexes
(23%) ate five or more portions a day compared with 17% of female heavy
drinkers and 12% of male heavy drinkers.Table 3.18, Figure 3O
3.7.2 Cigarette smoking status Children As with alcohol, smoking questions were only asked of children aged 8 to 15 and so table 3.19 shows fruit and vegetable consumption among children by cigarette smoking status for this age range. The 'non-smokers' category includes children who have never smoked, those who have only smoked once or twice and those who used to smoke sometimes but do not currently smoke. Children in the 'smokers' category are those who reported that they currently smoke, including those who do not smoke every week. There was no association between fruit and vegetable consumption and cigarette smoking for boys or girls. Table 3.19 Young adults Table 3.20 shows fruit and vegetable consumption by smoking status among informants aged 16 to 24. Current smokers are defined as those who smoke at least one cigarette a day. The category 'used to smoke regularly' includes those who used to smoke at least one cigarette a day. Fruit and vegetable consumption was higher among all three 'non-smoking' groups, than among current smokers. Among young women, current smokers reported a mean of 2.6 portions of fruit and vegetables a day, compared with 2.9 among those who used to smoke regularly, 3.3 among those who used to smoke occasionally and 3.1 among those who have never smoked. A similar pattern was found among young men, where current smokers reported an average consumption of 2.2 portions, compared with 2.8 for those who had never smoked and who used to smoke occasionally, and 2.9 for those who used to smoke regularly. Similarly, the proportion of young adults who consumed
five or more portions a day was significantly lower for current smokers
than for any of the non-smoking groups. 14% of young women who currently
smoked ate five or more portions a day compared with a fifth (20%) of
those who had never smoked and 23% of those who used to smoke occasionally.
For young men the pattern was the same, with 11% of current cigarette
smokers eating five or more portions compared with 17-18% of the three
non-smoking groups.Table 3.20, Figure 3P 3.8 Fruit and vegetable consumption, by body mass index and perception of weight 3.8.1 Body mass index Body mass index (BMI) is defined as weight in kg divided by the square of height in metres. Children Overweight and obesity prevalence for children was estimated using the age and sex-specific International classification standards11(see chapter 9 for more details). The calculations for these estimates were based on the exact age of children and were produced using the published table with the age (at 0.5 years intervals) and sex-specific BMI cut-off values for overweight and obesity. Table 3.21 shows fruit and vegetable consumption for children by BMI status for those aged 5-15. Children's fruit and vegetable consumption showed no clear association with BMI status. Table 3.21 Young adults For young adults aged 16-24, prevalence estimates were made using the standard adult BMI definition, classified into the following groups:
Table 3.22 shows fruit and vegetable consumption by BMI status and sex. No clear pattern emerged for either young men or young women. Table 3.22 3.8.2 Perception of weight and attempted weight change Children's self perception of weight In 2002 only, informants aged 8 and over were asked to indicate self perception of weight in terms of whether they perceived themselves to be 'about the right weight', 'too heavy' or 'too light'. They were also asked whether they weretrying to change their weight at the time of interview. Significant differences were found in boys' fruit and vegetable consumption when analysed by self-perception of weight. One in five (19%) of those who stated that they were too heavy ate five or more portions compared with one in ten of those who perceived themselves to be 'too light' (9%), and those who were 'not sure' (10%). Table 3.23, Figure 3Q
Children's attempted weight change Children who stated that they were 'trying to lose weight' ate more portions of fruit and vegetables on average (2.7 boys, 2.9 girls) than those not trying to change weight (2.5 boys, 2.6 girls). Around a sixth of children, 17% of boys and 16% of girls, who were trying to lose weight ate more than five portions of fruit and vegetables compared with one in ten (10%) of both sexes who were trying to put on weight. Table 3.24, Figure 3R Tables 3.25 and 3.26 show fruit and vegetable consumption
by self-perception of weight and attempted weight change for young adults
in 2002. The proportion of informants eating five or more portions of
fruit and vegetables a day was higher among those who considered themselves
to be 'about the right weight' (17% young men, 18% young women) than
among those who considered themselves to be 'too light' (12% young men,
15% young women). Table 3.25, Figure 3S Young adults' attempted weight change Table 3.26 shows fruit and vegetable consumption by attempted weight change. As with children, young adults who were 'trying to lose weight' ate more portions of fruit and vegetables (young men 2.8 portions, young women 3.0 portions) than those not trying to change weight (2.5 and 2.8 respectively). Table 3.26 3.9 Logistic regression of factors associated with eating five or more portions of fruit and vegetables per day Multivariate logistic regression has been used to examine the independent factors that are associated with eating five or more portions of fruit and vegetables per day. Unlike simple standardisation, which only adjusts for one variable, such as age, this regression technique adjusts for several explanatory variables simultaneously. Forward stepwise regression models were used to identify variables that were significantly related to the outcome. Separate models were run for males and females aged 8 to 24 years. This age range was used in the regression model as smoking and drinking questions were only asked of those informants aged 8 and over. Table 3.27 shows the adjusted odds ratios for factors that are associated with eating five or more portions of fruit and vegetables. All odds ratios are compared with a reference category (OR=1). They show how many times greater (if more than 1.0) or less (if less than 1.0) the odds are than for the reference category. 95% confidence intervals are shown for each odds ratio. If the interval does not include one, there is a significant difference between that odds ratio and that for the reference category. The p-value shown indicates whether, taken as a whole, the variable is a significant predictor of fruit and vegetable consumption. Among males and females, after controlling for all the other variables in the models, age, smoking status, alcohol consumption (males only), whether currently trying to change weight (females only), equivalised household income, NS-SEC of the household reference person and Government Office Region were significantly associated with consuming five or more portions of fruit and vegetables. Body mass index, perception of current weight and area deprivation (IMD) were not significant for either males or females and were subsequently removed from the models. The likelihood of consuming five or more portions of fruit and vegetable varied by: Age - The odds of consuming five or more portions increased with age. Relative to those aged 8-10, males and females aged 20-24 were, respectively, 2.84 times and 2.61 times more likely to consume five or more portions. Smoking - Non-smokers (both males and females) were about one and a half times more likely than smokers to consume five or more portions. Alcohol consumption - Compared with males who drank almost every day, those who have never drunk or did not currently drink alcohol were almost twice as likely to eat five or more portions a day. Weight change - Female informants who were not trying to change their weight were less likely to consume five or more portions than those who were trying to change their weight. Equivalised household income - Compared with males in the lowest income quintile, those in the highest income quintile were significantly more likely to consume five or more portions. There was no clear pattern for females. NS-SEC of the household reference person - Informants, of both sexes, in managerial & professional households, were more likely than those in most other classes to consume five or more portions of fruit and vegetables. Government Office Region - With reference to London,
males and females living in most other regions in England were less
likely to consume five or more portions of fruit and vegetables. Table
3.27
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