The Scottish Health Survey 2008

5 FRUIT AND VEGETABLE CONSUMPTION

Linsay Gray and Alastair Leyland

SUMMARY

• On average, women consumed 3.4 portions of fruit and vegetable per day and men consumed 3.1 portions. A fifth of men (20%) and a quarter of women (24%) consumed the recommended amount of five or more portions per day.
• There were no statistically significant changes in fruit and vegetable consumption between 2003 and 2008.
• Consumption of five or more portions of fruit and vegetables increased with age in men until the age of 74, and in women up to the age of 64, then declined thereafter. Although those aged 75 and over were the least likely to have eaten no portions at all, they were less likely to have eaten as many as five.
• 73% of men and 79% of women had eaten any vegetables or salad on the previous day; the figures for any fruit (except fruit juice) were 73% for men and 80% for women. Over half of men and around two-thirds of women had consumed fresh fruit with similar but slightly lower proportions having also eaten fresh, raw, tinned or frozen vegetables. More women (31%) than men (23%) had eaten salad and consumption of dried fruit was also significantly more common in women than men. Around 40% of men and women had consumed fruit juice and just under 30% had pulses. Frozen or tinned fruit, and vegetables or fruit in composites were each consumed by around 6%.
• The age-standardised prevalence of fruit and vegetable consumption varied by socio-economic classification. 26% of men and 31% of women in managerial and professional households consumed five or more portions a day compared with 14% of men and 17% of women in semi-routine and routine households. Mean portions per day were highest among those in managerial and professional households (3.6 portions for men, 3.9 for women) and lowest among those in semi-routine and routine households (2.6 and 2.8 portions, respectively).
• Similar patterns were found when looking at the age-standardised prevalence of fruit and vegetable consumption by household income and area deprivation. Consumption of fruit and vegetables decreased as household income decreased. 28% of men and 35% of women in the highest income quintile ate five or more portions a day dropping to 12% of men and 18% of women in the lowest income quintile. Mean portions per day showed a similar decline, from 3.8 and 4.3 portions for men and women in the highest quintile to 2.5 and 2.8 in the lowest.
• The age-standardised prevalence of consuming five or more portions a day was 25% for men and 31% for women in the least deprived areas, the corresponding figures for those in the most deprived areas were just 9% and 16%, respectively. Those in the most deprived areas also consumed, on average, fewer portions per day than those in the least deprived communities (2.2 versus 3.5 portions among men, and 2.7 versus 4.0 among women, respectively).
• Regression analysis was used to explore the relationship between a range of factors and the odds of consuming five or more portions a day. The odds of eating five or more portions a day were associated with age, area deprivation, parental socio-economic classification, smoking and physical activity. For women, eating five or more a day was also associated with household socio-economic classification.

5.1 INTRODUCTION

Much of Scotland's poor health record can be attributed to its unhealthy eating habits. As set out in the 1993 report of the Scottish Office working party on diet, excess consumption of saturated fat, salt, and sugar, and low consumption of fruit and vegetables are all risk factors associated with one or more of cardiovascular disease, cancer, hypertension, type 2 diabetes and obesity. ¹ In response the Scottish Office published the Scottish Diet Action Plan ² in 1996. This outlined the Scottish Dietary Targets, a series of targets for dietary improvement to be achieved by 2005. Policy initiatives in support of the Scottish Diet Action Plan were further outlined in the 1999 White Paper Towards a Healthier Scotland³ and in the Scottish Executive's 2003 health improvement paper Improving Health in Scotland - the Challenge. ⁴ The latter document included a commitment to continue implementing the recommendations of the Diet Action Plan with the aim of seeing tangible results each year up to 2010. This was followed up in 2004 by Eating for health meeting the challenge⁵ a framework for implementing the Diet Action Plan. However, an independent review of the Diet Action Plan carried out in 2005 concluded that the rate of progress towards many of the targets was too slow for them to be met by 2010. ⁶

The Scottish Government's 2007 Better Health, Better Care Action Plan,⁷ sets out a strategy for a healthier Scotland and outlines how funding will be allocated to tackle obesity through dietary and physical activity programmes. The Scottish Government's overall strategy relating to diet, physical activity and obesity is set out in the 2008 publication Healthy Eating, Active Living: An action plan to improve diet, increase physical activity and tackle obesity (2008-2011). ⁸ This includes a series of actions aimed at all levels: individuals, schools, care and community settings, workplaces, industry and food producers. The document also contains a commitment to the underlying principles of the original Diet Action Plan while suggesting a need to consider developing a more pragmatic set of longer term dietary goals to replace the existing ones that expire in 2010. A new policy document on food and drink, due to be published in late 2009, will begin this process.

A social marketing campaign 'Take Life On' was launched in June 2008 ⁹ with ten key health messages, one of which is try to eat five varied portions - where a portion is defined as 80g - of fruit and vegetables a day. This recommendation is aligned with the Scottish Dietary Target of increasing daily fruit and vegetable consumption to 400g. This '5 a day' recommendation is common throughout the UK and is increasingly used in food labelling and marketing. It is also a World Health Organisation recommendation, based on the well documented evidence that low fruit and vegetable consumption in particular is a key risk factor in chronic diseases, such as cancer and cardiovascular disease. ¹⁰ The 2003 Scottish Health Survey included detailed measures of fruit and vegetable consumption for the first time; these have been repeated in 2008.

The chapter examines fruit and vegetable consumption in Scotland, with particular reference to the five portions a day target. Fruit and vegetable consumption by age and sex is presented, followed by socio-demographic differences in consumption rates and comparisons with the 2003 data.

5.2 METHODOLOGY

5.2.1 Measures of eating habits

Two different modules of questions were used to assess eating habits. One of these assessed fruit and vegetable consumption, and was designed with the aim of providing sufficient detail to monitor the '5-a-day' policy effectively. This module was asked of all adults and children. The second was asked of all children and a sub-sample of adults. It used a modified version of the Dietary Instrument of Nutrition Education ( DINE) questionnaire developed by the Imperial Cancer Research Fund's General Practice Research Group to assess participants' usual intake of a wide range of foods, including protein, starch, fat and fibre. ¹¹ This chapter reports the findings from the fruit and vegetable module; tables based on the adapted DINE questionnaire will be published on the web at: www.scotland.gov.uk/Topics/Statistics/Browse/Health/scottish-health-survey/Publications.

To determine the total number of portions that had been consumed in the 24 hours preceding the interview, the fruit and vegetable module asked about the following food types: vegetables (fresh, frozen or canned); salads; pulses; vegetables in composites (e.g. vegetable chilli); fruit (fresh, frozen or canned); dried fruit; and fruit in composites (e.g. apple pie). A portion was defined as the conventional 80g of a fruit or vegetable. As 80g is difficult to visualise, a 'portion' was described using more everyday terms, such as tablespoons, cereal bowls and slices. Examples were given in the questionnaire to aid the recall process, for instance, tablespoons of vegetables, cereal bowls full of salad, pieces of medium sized fruit (e.g. apples) or handfuls of small fruits (e.g. raspberries). In spite of this, there may be some variation between participants' interpretation of 'a portion'. These everyday measures were converted back to 80g portions prior to analysis. The following table shows the definitions of the portion sizes used for each food item included in the survey:

Food item	Portion size
Vegetables (fresh, frozen or canned)	3 tablespoons
Pulses (dried)	3 tablespoons
Salad	1 cereal bowlful
Vegetables in composites, such as vegetable chilli	3 tablespoons
Very large fruit, such as melon	1 average slice
Large fruit, such as grapefruit	Half a fruit
Medium fruit, such as apples	1 fruit
Small fruit, such as plum	2 fruits
Very small fruit, such as blackberries	2 average handfuls
Dried fruit	1 tablespoon
Fruit in composites, such as stewed fruit in apple pie	3 tablespoons
Frozen fruit/canned fruit	3 tablespoons
Fruit juice	1 small glass (150 ml)

Since the five a day policy stresses both volume and variety, the number of portions of fruit juice, pulses and dried fruit was capped so that no more than one portion could contribute to the total number of portions consumed. Interviewers recorded full or half portions, but nothing smaller.

5.3 FRUIT AND VEGETABLE CONSUMPTION

5.3.1 Portions of fruit and vegetables consumed, by age and sex

Table 5.1 presents information on the quantity of fruit and vegetables men and women aged 16 and over had consumed in the 24 hours prior to the interview for both 2003 and 2008.

In 2008, the mean number of portions of fruit and vegetables consumed per day was 3.1 for men and 3.4 for women - this difference was statistically significant. The figures varied significantly across the age groups, with peak values around middle-age. For instance, the mean number of portions rose steadily from 2.5 in men and 2.9 in women for those aged 16-24, peaking at 3.4 and 3.8, respectively in those aged 55-64 before falling slightly at older ages.

20% of men and 24% of women met the recommended daily intake of five or more portions of fruit and vegetables, whereas 10% of men and 7% of women had consumed none at all. The proportion consuming the recommended five or more portions was highest in men aged 65-74 (25%) and in women aged 45 to 64 (29%). Around 1 in 10 men aged under 65 and a similar proportion of women aged under 45 consumed no portions of fruit and vegetables. Men aged 75 and over and women aged 65 and over were the least likely to have consumed no portions at all on the previous day. However, consumption of five portions or more was also lower among those aged 75 and over (18% of men and 17% of women). This suggests that although a high proportion of older people eat some fruit and vegetables on a daily basis, their consumption levels are not sufficiently high to meet the recommended five portions. In contrast, some other age groups, most notably men under 65 and women aged under 45, contain a significant minority who currently eat no fruit and vegetables at all. This latter group would have to make bigger changes to their eating habits in order to meet the recommendations than people who already consume some portions of fruit and vegetables, but not as many as five. Table 5.1, Figure 5A

Figure 5A Proportion eating five or more portions of fruit and vegetables per day, and the mean portions consumed per day, by age and sex

There were no statistically significant changes in fruit and vegetable consumption between 2003 and 2008. The proportion eating five or more portions a day remained at 20% for men in both years. For women there was a small but insignificant increase from 22% to 24%. Men consumed an average of 3.0 portions in 2003 and 3.1 in 2008. The equivalent figures for women were 3.2 and 3.4. Table 5.1

5.3.2 Fruit and vegetable items consumed, by age and sex

Table 5.2 gives the proportions eating the different fruit and vegetable items (fresh fruit; fresh/raw/tinned/frozen vegetables; fruit juice; pulses; salad; frozen/tinned fruit; vegetables in composites; fruit in composites; and dried fruit) in the 24 hours prior to interview. The most popular of these were fresh fruit and fresh/raw/tinned/frozen vegetables.

Around three-quarters of men and women had eaten some vegetables or fruit, including those in composite form but excluding fruit juice, in the 24 hours prior to being interviewed. The difference between men and women's fruit and vegetable consumption patterns were statistically significant in most cases; the exceptions are noted below. 73% of men and 79% of women had eaten any vegetables or salad, the figures for any fruit (except fruit juice) were 73% for men and 80% for women. Over half of men and around two-thirds of women had consumed fresh fruit with similar, but slightly lower proportions having also eaten fresh, raw, tinned or frozen vegetables. More women (31%) than men (23%) had eaten salad and consumption of dried fruit was also significantly more common in women than men. The remaining items were consumed by similar proportions of men and women; around 40% consumed fruit juice, just under 30% had pulses and figures for frozen or tinned fruit and vegetables in composites were 6% for each item. Consumption of any vegetable or salad and consumption of fruit, except fruit juice, was lowest among those aged 16-24 and highest among men aged 75+ and women aged 65-74. Except for vegetables in composites, consumption of fruit and vegetable items varied significantly across age groups and tended to be lower among younger age groups, though fruit juice consumption was an exception to this. Table 5.2

The discussion above (in relation to Table 5.1) highlighted the fact that although older people were the least likely to have eaten no portions of fruit or vegetables on the previous day, the proportion of this age group eating five or more was comparably low. The consumption patterns illustrated in Table 5.2 confirm that high proportions of people in the older age groups had eaten most of the items asked about. Indeed, for the two summary measures - any vegetables or salad, and any fruit (excluding juice) - consumption levels were as high as (and in some instances higher than) those found among younger age groups that were more likely to have met the five a day recommendation. This suggests that older people consume a wide variety but not always a high volume of fruit and vegetables.

5.3.3 Fruit and vegetable consumption by socio-demographic factors

Tables 5.3 to 5.5 present the proportions who consumed the recommended five or more portions a day by socio-economic classification ( NS-SEC of the household reference person), equivalised household income and the Scottish Index of Multiple Deprivation (descriptions of each of these measures are available in the Glossary at the end of this volume). To ensure that the comparisons presented in this section are not confounded by the different age profiles of the sub-groups, the data have been age-standardised (for a description of age-standardisation please refer to the Glossary). On the whole the differences between observed and age-standardised percentages are small. Therefore, the percentages and means presented in the text below are standardised. The tables report both the observed and the age-standardised figures.

Socio-economic classification NS-SEC

Table 5.3 shows how the age-standardised prevalence of consuming the recommended five or more portions of fruit and vegetables varied significantly across the NS-SEC groups for both sexes. 26% of men and 31% of women in managerial and professional households had consumed five or more portions compared with 14% of men and 17% of women in semi-routine and routine households. The reverse was true for the consumption of no portions of fruit and vegetables, with the lowest proportions in managerial and professional households (6% of men and 4% of women) and the highest proportions in semi-routine and routine households (15% of men and 11% of women). The mean number of portions of fruit and vegetables consumed also varied significantly by NS-SEC, and were highest among managerial and professional men (3.6) and women (3.9) and lowest among semi-routine and routine men (2.6) and women (2.8). Table 5.3

Equivalised household income

There were statistically significant gradients in the consumption of fruit and vegetables by equivalised household income, for both sexes (see Table 5.4). 28% of men and 35% of women in the highest income quintile consumed five portions or more, dropping to just 12% of men and 18% of women in the lowest quintile. The proportion consuming no portions was 5% for men and women in the highest income quintile, rising to 16% of men and 12% of women in the lowest quintile. The mean number of portions dropped significantly from 3.8 in men and 4.3 in women in the highest quintile to just 2.5 in men and 2.8 in women in the lowest. Table 5.4

Scottish Index of Multiple Deprivation ( SIMD)

Two measures of SIMD are being used throughout this report. The first, which uses quintiles, enables comparisons to be drawn between the most and least deprived 20% of areas and the three intermediate quintiles, and helps to assess the extent of any inequalities in behaviours or outcomes. The second contrasts the most deprived 15% of areas with the rest of Scotland (described in the tables as the "85% least deprived areas"). The most deprived 15% of areas have been identified as of particular concern by Scottish Government and are the subject of a number of policy initiatives. The Scottish Health Survey is designed to provide robust data for detailed analysis of the SIMD 15% areas after four years.

As with income, gradients in fruit and vegetable consumption across SIMD quintiles were statistically significant and striking, especially for men, as shown in Table 5.5. While 25% of men in the least deprived quintile consumed the recommended five portions or more, just 9% of those in the most deprived quintile did so. The corresponding figures for women were 31% and 16%, respectively. 4% of men and women in the least deprived quintile consumed no fruit or vegetables compared with 18% of men and 13% of women in the most deprived quintile. The mean number of portions consumed dropped significantly from 3.5 for men and 4.0 for women in the least deprived areas to 2.2 for men and 2.7 for women in the most deprived.

Comparing the most deprived 15% of areas to the rest of Scotland also reveals clear and significant distinctions in fruit and vegetable consumption. Just 10% of men and 16% of women in the 15% most deprived areas consumed the recommended five or more portions per day compared with 22% of men and 25% of women in the rest of Scotland. The mean portions of 2.3 in men and 2.7 in women in the 15% most deprived areas in the country were significantly below the means of 3.2 in men and 3.5 in women found in the rest of Scotland. However, it is clear from the quintile analysis that significant differences exist between areas, not just between the most deprived areas and the rest of the country. Table 5.5

5.3.4 Factors associated with fruit and vegetable consumption

Logistic regression was applied to examine the association between the consumption of the recommended amount of fruit and vegetables (five or more portions a day) and socio-demographic, behavioural, and anthropometric factors. Analyses were run separately for men and women and the factors investigated were: age, NS-SEC, household income, SIMD quintile, parental NS-SEC (classified according to the highest occupation recorded for participants' parents when the participant was aged 14), body mass index, marital status, cigarette smoking status and physical activity. By controlling for factors simultaneously, the independent effect of each on the dependent variables of interest can be established. The dependent variable was the consumption of five or more portions of fruit and vegetables a day. Logistic regression compares the odds of a reference category (shown in the table with a value of 1) with that of the other categories. In this example, an odds ratio of greater than one indicates that the group in question has higher odds of having eaten five or more portions of fruit and vegetables per day than the chosen reference category; an odds ratio of less than 1 means they have lower odds. For more information about logistic regression models and how to interpret their results see the Glossary at the end of this volume.

The odds ratios for consumption of five or more portions of fruit and vegetables per day are presented in Table 5.6. Age was significantly associated with eating five or more portions a day for both men and women. Compared with those aged 16-24, men aged 55 to 74, and women aged 25-34 and 45 and over all had significantly higher odds of eating the recommended amount of fruit and vegetables. The odds were highest for men aged 65-74 and women aged 55-64 (odds ratios of 2.78 and 2.60 respectively).

The odds of eating five or more portions a day was significantly associated with SIMD quintile in both men and women. Men in the 2 ^nd and 1 ^st (most) deprived quintiles (odds ratios of 0.56 and 0.42 respectively) and women in the 3 ^rd and 1 ^st (most) deprived quintiles (odds ratios of 0.68 and 0.70 respectively) had significantly lower odds of eating the recommended amount of fruit and vegetables than those living in the 5 ^th (least) deprived quintile.

Parental NS-SEC was also significant; in general, men and women in all the other groups had lower odds of eating the recommended amount of fruit and vegetables than those who had grown up in professional and managerial households. The two exceptions were men from intermediate and lower supervisory and technical households.

Both male and female current smokers had significantly decreased odds of eating five or more portions a day (odds ratios of 0.62 and 0.53 respectively) compared with those who had never smoked. In addition, men who used to smoke cigarettes occasionally had higher odds (odds ratio of 1.82).

Three levels of physical activity were analysed: high (30 minutes or more at least 5 days a week); medium (30 minutes or more on 1 to 4 days a week); and low (fewer than 30 minutes of activity a week). Those with high activity levels were used as the reference category; compared with this group people with medium and low physical activity levels had significantly decreased odds of eating five or more portions a day (odds ratios of 0.56 and 0.39 respectively in men, and 0.63 and 0.40 respectively in women).

Household NS-SEC was independently associated with the odds of eating five or more portions of fruit and vegetables a day among women but not men. Women from lower supervisory and technical households and semi-routine and routine households had significantly lower odds of eating the recommended amount of fruit and vegetables (odds ratios of 0.60 and 0.65 respectively) than women in professional and managerial households.

Obesity, marital status and alcohol intake were also investigated but found not to be associated with fruit and vegetable consumption. Table 5.6