The south eastern region of the United States has some of the highest prevalence of chronic disease and poor health outcomes in the nation¹. The state of North Carolina (NC) reports higher than national average, age-adjusted death rates for heart disease, cancer, stroke, respiratory conditions and injury which account for almost two thirds of all annual deaths².

Physical inactivity and an unhealthy diet are documented health behaviors that lead to overweight and obesity³. In NC, the prevalence of adult overweight/obesity is 65%. Approximately 78% of adults do not consume the recommended daily intake of five or more servings of fruits and vegetables (F&V) and 56% do not engage in moderate and vigorous activity². These statistics highlight the prevalence of unhealthy behaviors in this region, yet they provide little information about the motivations and perceptions of residents relative to F&V consumption. In addition, qualitative descriptions of dietary behaviors in the context of one’s environment are rare. Of particular interest are research indications that lifestyle choices, including those relating to diet, are complex decisions affected by the interaction between people (attitudes, thoughts, behaviors, perceptions) and their external social and physical environments^4-6. We need to further our understanding of environment and behavior interactions in the context of diet.

Perceptions and behaviors toward fruits and vegetables are influenced by both internal and external environmental factors

Our work draws from a large study assessing social déterminants of chronic disease risk and health outcomes in adult North Carolinians. We surveyed 2,479 adults from 22 family practices in NC. A portion of the survey asked about participant perceptions of the variety, affordability, and quality of F&V at the grocery store where they regularly shopped. We also conducted focus groups, telephone interviews and used a photography activity with 32 of these individuals to further explore consumption of and perceived environmental influences on F&V intake. Participants were older (mean age 52.8), heavier (mean body mass index 29.4), averaged three3 chronic conditions, and were generally female, white, married, and high school graduates. Our findings revealed that a number of perceptions and environmental factors influenced F&V consumption, on both individual and community levels.

Individual-level barriers:

• personal food preferences,
  
• fatigue of taste buds for certain foods,
  
• life stresses (e.g. vocational and economic),
  
• lack of forethought in meal planning,
  
• current personal health status,
  
• perceived impact of food on chronic disease status.

Individual-level facilitators:

• presence of chronic disease,
  
• lifetime experience related to intake of F&V,
  
• preferences for certain F&V,
  
• personal or spousal health status.

Community-level barriers:

• contradictory media messages related to nutrition and health outcomes,
  
• limited worksite food options,
  
• food availability,
  
• food cost at grocery stores. Community-level facilitators:
  
• availability of home gardens, low cost of foods at farm stands,
  
• childhood exposure to F&V.

Participants took photographs to illustrate environmental factors. Images included farms, kitchen spaces, convenience stores, gardens, restaurants and buffet foods (Picture 1 and Picture 2).

How may fruit and vegetable consumption be enhanced?

Interventions targeting individuals and communities are effective tools in promoting healthy nutrition behaviors like F&V consumption. In fact, NC has a state-wide public health initiative called “Eat Smart, Move More.” This program has a multi-level approach that “encourages individuals to think differently about what they eat and how much they move and to make choices that will help them feel good and live better” while providing community resources to enable healthy behaviors (http://www.eatsmartmovemorenc.com). Our study highlights the importance of acknowledging the individual’s livedexperience, from personal attitudes and beliefs to social norms and resources available in the community for promoting F&V consumption. Individuals may be more likely to make healthy choices when armed with personally and culturally relevant intervention messages, which may lead to reduced chronic disease incidence and prevalence.