Evidence-based promotion of fruit and vegetable consumption: the importance of socio-economic determinants

Over the last 15-20 years, campaigns have been made to Promote Fruit and Vegetables (F&V) in many countries in Europe and beyond, especially in school-aged children. Most of these campaigns have been school-based. The more recent campaigns combine educational activities with improving availability of F&V in schools by means of school fruit programs. Evidence suggests that such campaigns aiming to improve motivation and opportunities for increased F&V intakes among schoolchildren are effective. These campaigns remain very necessary particularly as recent trend analyses indicate that F&V intakes may be further declining among children from lower educated and lower income parents. The fact that prices of F&V have gone up much more than for the junk foods also does not help this situation. Promotion of F&V especially among children with a focus on socioeconomic status as a potential important factor is the main subject of this article. The following questions will be addressed:

  1. What are the important personal and environmental correlates and determinants of F&V intakes? In other words: who eats too little F&V and why?
  2. How can we target and tailor F&V promotion interventions to these potential determinants? In other words: how can we promote F&V intakes?

A special focus will be on school-aged childen.

Who eats too little F&V?

There are differences in F&V intake according to all kinds of sociodemographic variables, such as age, ethnicity, and gender. But the most consistent socio-demographic variable associated with F&V intakes is socioeconomic position. People from lower SocioEconomic Status (SES) groups eat fewer F&V. Socioeconomic position has been defined as an individual social and economic ranking within society, and it is based on access to resources, including income, educational status and also prestige. Most often the level of education is used as a proxy measure for SES. SES is associated with a broad range of health disparities. In the Netherlands for instance, there is quite a big gap in life expectancy between the highest educated groups and the lowest educated groups. This gap is also apparent in different life style behaviors such as smoking, physical inactivity and different unhealthy nutrition behaviors including low F&V intakes. However, this SES gap in F&V intakes may not be apparent for all age groups in all regions of Europe.

Ritva Prättälä and colleagues1, for example, showed for adults that there is a greater likelihood of daily use of vegetables for higher educated than people of lower education in the northern European countries. However, this was not true in the southern European countries like Italy or Spain. In France, an inverse relation was found as the lower educated people eat more F&V. Nevertheless, based on systematic reviews, SES comes out as maybe the most consistent correlate of F&V intakes, with lower SES people, and maybe even more consistently so among children, having lower F&V intakes2-5.

Why do people from lower socioeconomic status eat fewer F&V?

There are three main categories of determinants of health behaviors: motivation, ability, and opportunity6,7. Most health promotion campaigns have focused on improving motivation to live more healthily. However, such campaigns have had little success. In recent years more attention has been given to the environmental conditions for health behaviors, i.e. the environmental opportunities for adequate F&V intakes. This links to the WHO slogan ‘making the healthy choice the easy choice’. If the opportunities, i.e. the availability and accessibility of F&V are improved, then adequate F&V intake will become easier. Recent research indicates that availability and accessibility of F&V are indeed important determinants of F&V intakes, at least among children4,5.

The Pro Children Intervention Study, a cross-European project involving nine countries8 tried to build an evidence-based intervention package on these insights. The intervention package was tested in three different countries in Norway, the Netherlands, and Spain. This intervention included activities to improve motivation by means of classroom activities including taste-testing sessions and computer-tailored (web-based) F&V education, homework assignments, as well as newsletters and computer-tailored feedback for the parents. But the intervention also included a school F&V provision scheme, making F&V better available and accessible in the schools. The results showed an increased knowledge among children, a higher availability, and a higher intake of F&V9. Research conducted in Norway indicates that such F&V provisions should be for free and not by paid subscription in order to avoid having children from less affluent parents profit less from the activity10.

  1. Prättälä R. et al. Public Health Nutr. 2009 Nov;12(11):2174-82.
  2. Irala-Estévez JD. et al. Eur J Clin Nutr. 2000 Sep;54(9):706-14.
  3. Kamphuis CB. et al. Br J Nutr. 2006 Oct;96(4):620-35.
  4. Van der Horst K. et al. Health Educ Res. 2007 Apr;22(2):203-26.
  5. Rasmussen M. et al. Int J Behav Nutr Phys Act. 2006 Aug 11;3:22.
  6. Brug et al Am J Prev Med, 2006
  7. Brug et al. Proc Nutr Society 2008
  8. Pérez-Rodrigo C. et al. Ann Nutr Metab. 2005 Jul-Aug;49(4):267-77.
  9. Te Velde SJ. et al. Br J Nutr. 2008 Apr;99(4):893-903.
  10. Bere et al Int J Behav Nutr Phys Act 2007
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