Suboptimal Intake of Fruits and Vegetables in Nine Selected Countries of the World Health Organization European Region
RESEARCH BRIEF — Volume 20 — November 16, 2023
Holly L. Rippin, PhD1; Katerina Maximova, PhD2,3; Enrique Loyola, MD, MSc1; Joao Breda, PhD4; Kremlin Wickramasinghe, MBBS, PhD1; Carina Ferreira-Borges, PhD1; Nino Berdzuli, MD5; Morteza Hajihosseini, PhD6; Irina Novik7; Vital Pisaryk7; Lela Sturua8; Ainura Akmatova9; Galina Obreja10; Saodat Azimzoda Mustafo11; Banu Ekinci12; Toker Erguder13; Shukhrat Shukurov14; Gahraman Hagverdiyev15; Diana Andreasyan16; Sergei Bychkov1; Ivo Rakovac, PhD1 (View author affiliations)
Suggested citation for this article: Rippin HL, Maximova K, Loyola E, Breda J, Wickramasinghe K, Ferreira-Borges C, et al. Suboptimal Intake of Fruits and Vegetables in Nine Selected Countries of the World Health Organization European Region. Prev Chronic Dis 2023;20:230159. DOI: http://dx.doi.org/10.5888/pcd20.230159.
PEER REVIEWED
What is already known on this topic?
Low rates of fruit and vegetable intake are associated with increased risk of noncommunicable diseases (NCDs). Although the disease burden due to inadequate fruit and vegetable consumption appears highest in Eastern Europe and Central Asia among countries in the World Health Organization (WHO) European Region, little systematic evidence exists.
What is added by this report?
Higher NCD death rates in Eastern Europe and Central Asia may be partly explained by differences in diet quality, particularly low rates of fruit and vegetable intake. Most populations in our study did not meet the WHO-recommended daily intake of at least 5 servings (400 g).
What are the implications for public health practice?
Evidence-based policies are needed to increase fruit and vegetable consumption and reduce the burden of and disparities in NCDs. Our findings can inform further research and policy development.
Abstract
The objective of this study was to characterize fruit and vegetable consumption in 9 selected countries of the World Health Organization (WHO) European Region. We analyzed data on fruit and vegetable intake and participant sociodemographic characteristics for 30,455 adults in 9 Eastern European and Central Asian countries via standardized STEPS survey methodology. Fruit and vegetable consumption across all countries was suboptimal, with a high percentage of populations not meeting the WHO-recommended intake of at least 5 servings (400 g) per day. Strengthened implementation of evidence-based policies to increase intake of fruit and vegetables is needed to reduce the burden of and disparities in NCDs.
Objective
Noncommunicable diseases (NCDs) account for 74% of deaths globally (1). Of all World Health Organization (WHO) regions, the European Region has the highest rates of NCD-related illness and death; almost 90% of deaths in this region are related to NCDs (2). Overweight and obesity affect more than 59% of adults in the European Region (2,3). Surveillance and monitoring are key to preventing and controlling NCDs (1). The WHO STEPwise approach to Surveillance (STEPS) is a standardized tool for collecting, analyzing, and disseminating data on NCD risk factors to guide and inform NCD policy makers on prevention policies (4).
WHO recommends daily consumption of at least 400 g (equivalent to 5 servings) of fruit and vegetables (5). Low consumption rates are associated with increased NCD risk (6). Increasing fruit and vegetable intake would, therefore, help achieve healthier diets and improve NCD outcomes (7,8).
Although the disease burden due to inadequate fruit and vegetable consumption appears highest in Eastern Europe and Central Asia among countries in the WHO European Region, little systematic evidence is available (9). Using STEPS data, we assessed fruit and vegetable consumption in 9 Eastern European and Central Asian countries. This evidence will help provide information for evidence-based policies to increase fruit and vegetable intake and reduce the effect of NCDs.
Methods
The WHO STEPS surveyed 37,311 adults in Armenia, Azerbaijan, Belarus, Georgia, Kyrgyzstan, the Republic of Moldova, Tajikistan, Turkey, and Uzbekistan. The survey used a multistage clustered sampling design to collect population-based, cross-sectional, nationally representative household survey data from 2013 through 2018. Sampling procedures are detailed elsewhere (10,11). Informed consent was obtained by using country-specific language forms; ethical approval was obtained in each country before survey administration.
Face-to-face interviews and a standardized questionnaire assessed sociodemographic characteristics and NCD risk factors (11). Participants reported their age, sex, education level, marital status, and work status. Participants used visual aids to record the number of days per typical week and number of servings on each of those days that they consumed fruits and vegetables, from which the daily number of 80g servings was derived. Participants reported (yes/no) whether they received advice from a health care professional in the previous 3 years to eat at least 5 daily servings of fruits or vegetables. Trained interviewers measured height and weight at the participant’s home after the interview.
To enable comparisons across countries, we restricted our sample to adults aged 25 to 65 years. We considered participants who reported consuming 20 or more daily servings of fruit or vegetables to be outliers and excluded them from analyses. Our analytic sample size consisted of 30,455 participants. To estimate a nationally representative prevalence of fruit and vegetable consumption for each country, we calculated percentages derived in R version 3.5.0 survey package (R Foundation for Statistical Computing), which used survey design weights developed by WHO to account for multistage cluster design and nonresponse while considering the population age and sex distribution. We assessed differences in these percentages by using weighted multinomial mixed-effects regression adjusted for age, sex, marital status, and weight status (underweight, normal weight, overweight, obese), in lme4 and broom packages in R version 3.5.0 (R Foundation for Statistical Computing). Analyses were stratified by country to facilitate comparisons and acknowledge country-specific contexts and cultural factors related to food intake. Significance was set at P < .05.
Results
The average age of the study population was 42 years, and most participants were married or cohabiting (Table 1). In all countries, most participants had completed high school. Employment rates ranged from 37% to 80%. More than half were overweight or obese in all countries. The proportion of people not meeting the WHO recommendation to consume at least 5 daily servings of fruit or vegetables ranged from 60% in Tajikistan and 62% in Georgia to 88% in Turkey (Table 2). The average number of servings of fruit or vegetables per day was below the 5 recommended servings in all countries, except Tajikistan (5.1 servings/day).
Fruit and vegetable intake varied substantially by education, particularly in Armenia, Azerbaijan, Belarus, Kyrgyzstan, Republic of Moldova, and Tajikistan. Broadly, participants with more than a high school education consumed more servings of fruit and vegetables daily (Figure).
Figure.
National prevalence of daily servings of fruit and vegetables (0, 1-2, 3-4, ≥5), by education (A) and by receipt of advice from a health care professional to eat at least 5 daily servings of fruits or vegetables (B). Education level was determined by using national education categories mapped to UNESCO’s (United Nations Educational, Scientific and Cultural Organization’s) International Standard Classification of Education (ISCED) (12). ISCED provides a comprehensive framework of uniform and internationally agreed definitions to facilitate comparisons of education systems across countries. Value in parentheses after country name is P value. [A tabular version of this figure is available.]
Rates of fruit and vegetable consumption were higher among participants who had received advice from a health care professional to eat at least 5 daily servings of fruits or vegetables, particularly in the Republic of Moldova, Tajikistan, Turkey, and Uzbekistan (Figure). Rates of fruit and vegetable consumption were also higher among those who were overweight or obese, older participants, and among women.
Although fruit and vegetable consumption varied by work status, particularly in Armenia, Azerbaijan, Republic of Moldova, and Tajikistan, we found no clear pattern between or within countries. Similarly, consumption varied by marital status, particularly in the Republic of Moldova and Tajikistan, but no clear pattern emerged.
Discussion
This study used WHO STEPS data to assess fruit and vegetable consumption in 9 Eastern European and Central Asian countries in the WHO European Region. National consumption varied, but no country met WHO’s recommendation of at least 5 servings (400 g) per day, except for Tajikistan (5.1 servings/day). Participants with more education generally consumed more daily servings, mirroring regional trends (13) and suggesting that education interventions could improve fruit and vegetable intake and, therefore, population health. Availability, affordability, and national income and development level may influence this complex relationship. Further research is needed into the relationship between fruit and vegetable consumption and education, availability, and affordability.
In some countries, participants receiving advice from health care professionals to consume at least 5 daily servings of fruit or vegetables had higher intakes than participants not receiving this advice. Health care provider–patient consultation time could be used more effectively to improve fruit and vegetable intake; for example, brief interventions are a WHO “Best Buys” intervention (14). A suite of policy options and public health strategies, such as procurement policies, in-store promotions, and subsidies, is needed to increase population-level fruit and vegetable consumption (14,15). More research on the relationship between those receiving advice and fruit and vegetable intake would help prioritize policy development.
Our study has strengths and limitations. The STEPS survey has an extensive infrastructure and a standardized methodology. Our study is the first to systematically assess fruit and vegetable consumption by using comparable indicators in Eastern European and Central Asian countries in the WHO European Region. The data are nationally representative with a high response rate, but the survey design is cross-sectional, which precludes causal inference. The data are self-reported, so they rely on participants’ understanding and accurate reporting of their fruit and vegetable intake. The data are also dated (2013–2017) and do not show trends over time.
Higher NCD-related death rates in Eastern Europe and Central Asia may be partly explained by differences in diet quality, particularly rates of low fruit and vegetable consumption. Our study found that fruit and vegetable consumption in all countries was suboptimal. Survey participants with higher education who had received advice from a health care professional to eat at least 5 daily servings of fruit or vegetables generally consumed more fruits and vegetables in some countries. Awareness of the 5-a-day recommendation and the ability to operationalize awareness could lead to higher intakes, possibly especially in populations that are overweight. Evidence-based policies are needed to increase fruit and vegetable consumption and reduce the burden of and disparities in NCDs. Policy makers can use our findings to initiate further research and policy development.
Acknowledgments
This research was funded by the WHO Regional Office for Europe. Funding for the publication was received from Member States in the context of the WHO European Office for the Prevention and Control of Noncommunicable Diseases (NCD Office). The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions, or policies of the institutions with which they are affiliated. No copyrighted materials were used.
Author Information
Corresponding Author: Holly L. Rippin, PhD, World Health Organization European Office for the Prevention and Control of Non-Communicable Diseases, Division of Country Health Programmes, World Health Organization Regional Office for Europe, Marmovej, Copenhagen, Denmark (rippinh@who.int).
Author Affiliations: 1World Health Organization European Office for the Prevention and Control of Non-Communicable Diseases, Division of Country Health Programmes, World Health Organization Regional Office for Europe, Copenhagen, Denmark. 2MAP Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada. 3Dalla Lana School of Public Health, University of Toronto, Ontario, Canada. 4Division of Country Health Policies and Systems, World Health Organization Greece, Athens, Greece. 5World Health Organization Regional Office for Europe, Copenhagen, Denmark. 6School of Public Health, University of Alberta, Edmonton, Alberta, Canada. 7Republican Scientific and Practical Center of Medical Technologies, Informatization, Management and Economics of Public Health, Minsk, Belarus. 8National Center for Disease Control and Public Health of Georgia, Tbilisi, Georgia. 9Department of Public Health, Ministry of Health, Bishkek, Kyrgyzstan. 10Department of Social Medicine and Management, Nicolae Testemitanu State University of Medicine and Pharmacy, Chisinau, Republic of Moldova. 11State Research Institute of Gastroenterology, Ministry of Health and Social Protection of Population, Dushanbe, Republic of Tajikistan. 12Department of Chronic Disease and Elderly Health, General Directorate of Public Health of Ministry of Health of Turkey, Ankara, Turkey. 13World Health Organization Country Office in Turkey, Ankara, Turkey. 14Central Project Implementation Bureau of the Health-3 Project, Tashkent, Uzbekistan. 15Public Health and Reforms Center, Ministry of Health, Baku, Azerbaijan. 16National Institute of Health, Ministry of Health, Yerevan, Armenia.
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Tables
| Characteristic | Armenia (n = 1,878) | Azerbaijan (n = 4,700) | Belarus (n = 4,224) | Georgia (n = 3,399) | Kyrgyzstan (n = 2,623) | Republic of Moldova (n = 3,983) | Tajikistan (n = 2,237) | Turkey (n = 4,208) | Uzbekistan (n = 3,203) |
|---|---|---|---|---|---|---|---|---|---|
| Survey year | 2016 | 2017 | 2016 | 2016 | 2013 | 2013 | 2016 | 2017 | 2014 |
| Response rate, % | 82 | 97 | 87 | 76 | 100 | 84 | 99 | 70 | 89 |
| Mean age, y | 42 | 42 | 42 | 42 | 42 | 42 | 42 | 42 | 42 |
| Female, % | 47 | 51 | 51 | 52 | 50 | 49 | 45 | 51 | 49 |
| Marital status, % | |||||||||
| Never married | 12 | 10 | 15 | 15 | 5 | 8 | 3 | 12 | 5 |
| Currently married or cohabiting | 80 | 82 | 63 | 77 | 80 | 77 | 92 | 83 | 81 |
| Other | 8 | 8 | 22 | 8 | 15 | 15 | 5 | 5 | 14 |
| Highest level of education, %b | |||||||||
| Less than high school | 46 | 12 | 18 | 20 | 10 | 20 | 21 | 35 | 48 |
| High school | 28 | 43 | 53 | 22 | 66 | 58 | 63 | 46 | 39 |
| College/university/postgraduate | 25 | 44 | 28 | 58 | 23 | 23 | 16 | 19 | 13 |
| Work status, % | |||||||||
| Employed | 45 | 50 | 80 | 44 | 49 | 59 | 37 | 46 | 46 |
| Nonpaid/homemaker/student | 28 | 26 | 5 | 0.2 | 29 | 18 | 34 | 39 | 25 |
| Retired | 3 | 6 | 9 | 56 | 12 | 9 | 7 | 10 | 13 |
| Unemployed | 24 | 18 | 5 | —c | 10 | 14 | 23 | 5 | 15 |
| Weight status, %d | |||||||||
| Underweight | 5 | 4 | 2 | 3 | 2 | 2 | 2 | 0.9 | 2 |
| Normal weight | 43 | 34 | 37 | 31 | 39 | 36 | 36 | 27 | 36 |
| Overweight | 30 | 39 | 36 | 33 | 34 | 35 | 40 | 40 | 34 |
| Obese | 22 | 23 | 25 | 33 | 25 | 27 | 22 | 32 | 28 |
Abbreviation: WHO, World Health Organization.
a The WHO STEPwise approach to Surveillance (STEPS) is a standardized tool for collecting, analyzing, and disseminating data on NCD risk factors to inform NCD prevention policies (4); 37,311 adults participated in this survey during 2013–2018 in these 9 countries in WHO’s European Region; after exclusions, the analytic sample consisted of 30,455 adults aged 25 to 65 years. Percentages may not add to 100 because of rounding.
b Determined by using national education categories mapped to UNESCO’s (United Nations Educational, Scientific and Cultural Organization’s) International Standard Classification of Education (ISCED) (12). ISCED provides a comprehensive framework of uniform and internationally agreed definitions to facilitate comparisons of education systems across countries.
c Data not available.
d Weight status based on body mass index (BMI), derived from measured height and weight and calculated as weight in kg divided by height in m2: underweight, BMI <18.5, normal weight; BMI 18.5 to <25.0; overweight, BMI 25.0 to <30.0; obese, BMI ≥30.0.
| Measure | Armenia | Azerbaijan | Belarus | Georgia | Kyrgyzstan | Republic of Moldova | Tajikistan | Turkey | Uzbekistan |
|---|---|---|---|---|---|---|---|---|---|
| Mean no. of days fruit consumed/week | 5.4 | 5.1 | 5.1 | 5.3 | 4.9 | 5.6 | 4.9 | 4.6 | 4.4 |
| Mean no. of days vegetables consumed/week | 5.0 | 5.9 | 5.6 | 6.0 | 5.3 | 5.9 | 6.6 | 5.1 | 6.2 |
| Mean no. of servings of fruit consumed/day | 2.2 | 2.1 | 2.2 | 2.5 | 2.3 | 2.3 | 2.5 | 2.0 | 2.4 |
| Mean no. of servings of vegetables consumed/day | 2.1 | 2.2 | 2.3 | 2.7 | 2.0 | 2.3 | 3.3 | 2.0 | 3.2 |
| Mean no. of servings fruits and vegetables consumed/day | 3.6 | 3.5 | 3.7 | 4.5 | 3.4 | 4.1 | 5.1 | 3.1 | 4.6 |
| % Consuming <5 portions fruit and vegetables/day | 76 | 76 | 73 | 62 | 74 | 65 | 60 | 88 | 67 |
Abbreviation: WHO, World Health Organization.
a The WHO STEPwise approach to Surveillance (STEPS) is a standardized tool for collecting, analyzing, and disseminating data on non-communicable disease (NCD) risk factors to inform NCD prevention policies (4); 37,311 adults participated in this survey during 2013–2018 in these 9 countries in WHO’s European Region; after exclusions, the analytic sample consisted of 30,455 adults aged 25 to 65 years.
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