People with a lower socioeconomic position (SEP) meet the dietary guidelines less often than people with a higher SEP1-2. These SEP differences in dietary intake are also found among older adults3-4. To increase fruit, vegetable and fish intake in the general population barriers to healthy eating have been identified including; disliking, limited cooking skills, no time to prepare healthy food, perception of high costs, no availability, or no motivation to change eating habits5-8. SES differences in these barriers have also been described, where low income groups spend less money on healthy foods than higher income groups6, 9 and low education groups lack knowledge about healthy eating compared to higher education groups10. Despite the fact that it is important to investigate SES differences in barriers to healthy eating, research among older adults is scarce. Older adults may face specific age-related barriers such as loss of appetite, chewing problems, decreased mobility, limited transport that may all negatively influence food choice and food intake11-14. It is not clear from the literature if the impact of SEP on healthy eating and barriers is also present in older adults. Therefore, this study identified barriers for meeting the fruit, vegetable and fish guidelines in older Dutch adults and investigate SEP differences in these barriers. Furthermore, the mediating role of these barriers in the association between SEP and adherence to these guidelines.

1,057 community dwelling adults, aged 55-85 years

This cross sectional study used data from the Longitudinal Aging Study Amsterdam (LASA), an ongoing cohort study originally designed to investigate changes in autonomy and well-being in the aging population in the Netherlands15. We used data from 1,057 community dwelling adults, aged 55-85 years. SEP was measured by level of education and household income. A food frequency questionnaire was used to assess fruit, vegetables and fish intake and barriers to meet the guideline for fruit, vegetables and fish were measured with a selfreported lifestyle questionnaire. Respondents were asked to indicate, from a list of twelve barriers, the two barriers that were most important for their situation.

Based on the self-reported dietary intake data, we calculated adherence to the Dutch dietary guidelines for fruit, vegetable and for fish. The following criteria were used: two portions of fruit per day (a maximum of one glass of fruit juice (200 ml) to replace one portion of fruit), four serving spoons of vegetable per day (200 grams) and fish twice a week15. To assess the barriers as potential mediating variables in the association between SEP and adherence to the guidelines for fruit, vegetable and fish we conducted structural equation modeling.

48.9% of the respondents perceived a barrier to adhere to the fruit guideline, 40% for the vegetable

Overall, 48.9% of the respondents perceived a barrier to adhere to the fruit guideline, 40% for the vegetable and 51.1% for the fish guideline. The most frequently perceived barriers in the total sample were “the high price” of fruit and fish and “a poor appetite” for vegetables. Lower levels of income and education were statistically significant associated with a higher probability to perceive any barrier to meet the fruit, vegetable and fish guideline. Furthermore, lower income levels were statistically significant associated with lower adherence to the fruit guideline and the fish guideline. No association between income and adherence to the vegetable guideline was observed. Lower education levels were statistically significant associated with lower adherence to the vegetable guideline. Level of education was not associated with adherence to the guidelines for fruit and fish. The association between income and adherence to the fruit guideline was mediated by “perceiving any barrier to meet the fruit guideline” and the barrier “dislike fruit”. The association between income and adherence to the fish guideline was mediated by “perceiving any barrier to meet the fish guideline” and the barrier “fish is expensive”.

The findings of this large scale study in older Dutch adults suggests that focusing on barriers to meet the fruit and fish guideline and in particular taste preferences and cost concerns may be important in reducing income inequalities in fruit and fish intake among older adults. Affordable and accessible healthy foods and interventions aiming on improving liking of fruit, could potentially increase fruit and fish intake in older adults, especially in populations with lower incomes. Future studies in older persons should be conducted to test whether removal of these barriers in fact lead to better dietary adherence.