State-Specific Trends in Fruit and Vegetable Consumption Among Adults --- United States, 2000--2009

A diet high in fruits and vegetables can reduce the risk for many leading causes of death (1--3) and can play an important role in weight management (4). Healthy People 2010 objectives for fruits and vegetables include targets of increasing to 75% the proportion of persons aged ≥2 years who consume two or more servings of fruit daily and to 50% those who consume three or more servings of vegetables daily.* To assess states' progress over the past decade in meeting these targets among adults and to provide an update of the 2005 subgroup estimates (5), CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS). This report describes the results of that analysis, which indicated that, in 2009, an estimated 32.5% of adults consumed fruit two or more times per day and 26.3% consumed vegetables three or more times per day, far short of the national targets. Overall, the proportion of adults who met the fruit target declined slightly, but significantly, from 34.4% in 2000 to 32.5% in 2009; no significant change was observed in meeting the vegetable target. No state met either target, and substantial variability occurred among states. Only one state had statistically significant increases in the percentages of adults meeting each target. These findings underscore the need for interventions at national, state, and community levels, across multiple settings (e.g., worksites, community venues, and restaurants) to improve fruit and vegetable access, availability, and affordability, as a means of increasing individual consumption.

BRFSS is an ongoing, state-based, telephone survey of the noninstitutionalized U.S. civilian population aged ≥18 years. Data are used to monitor the prevalence of health behaviors and progress toward national and state-specific health objectives. BRFSS uses a multistage design based on random-digit dialing methods to gather a representative sample from each state. Data were included from all 50 states and the District of Columbia (DC) for years in which the fruit and vegetable module was included in the core survey: 2000 (N = 179,139), 2002 (N = 238,852), 2003 (N = 255,657), 2005 (N = 347,278), 2007 (N = 420,217), and 2009 (N = 420,968). Median survey response rates by state, calculated using Council of American Survey Research Organizations (CASRO) guidelines,† were 48.9% (range: 28.8%--71.8%) for 2000 and 52.5% (range: 37.9--66.9%) for 2009. Median cooperation rates were 53.2% (range: 35.5%--77.7%) for 2000 and 75.0% (range: 55.5%-- 88.0%) for 2009.

For each survey year, prevalence estimates were weighted to the respondent's probability of being selected for the age-, race-, and sex-specific distributions for the state based on U.S. Census data. Logistic regression analysis was used to assess temporal changes in consumption during 2000--2009, including year as a continuous variable and controlling for changes in state distributions of age through standardization to the 2000 U.S. standard population; a p-value of <0.05 was used to assess statistical significance.

Six BRFSS questions assess fruit and vegetable intake and are the only diet intake questions on the core survey: "These next questions are about the foods you usually eat or drink. Please tell me how often you eat or drink each one, for example, twice a week, three times a month, and so forth. How often do you..." 1) "...drink fruit juices such as orange, grapefruit, or tomato?" 2) "Not counting juice, how often do you eat fruit?" 3) "...eat green salad?" 4) "...eat potatoes, not including French fries, fried potatoes, or potato chips?" 5) "...eat carrots?" 6) "Not counting carrots, potatoes, or salad, how many servings of vegetables do you usually eat?" Consumption was divided by 7 for weekly frequencies, 30 for monthly frequencies, and 365 for yearly frequencies to calculate daily consumption. Total daily consumption of fruit was the sum of responses to questions 1--2 and vegetables the sum of responses to questions 3--6. Participants were not given a definition of serving size. To be consistent with previous reports, respondents who did not answer all six questions and those who reported consuming fruits and vegetables 25 or more times per day were excluded (n = 24,652 for 2009) from the final sample.

In 2009, an estimated 32.5% of U.S. adults consumed fruit two or more times per day (Table 1), with the highest percentage in DC (40.2%) and the lowest in Oklahoma (18.1%). The percentage of adults who consumed vegetables three or more times per day was 26.3%, with the highest percentage in Tennessee (33.0%) and the lowest in South Dakota (19.6%). Thus, no state met either of the Healthy People 2010 targets related to fruit and vegetable consumption among adults. Twelve states and DC had 35%--45% of adults who consumed fruit two or more times per day, compared with no states that had 35%--45% of adults who consumed vegetables three or more times per day (Figure).

From 2000 to 2009, the overall prevalence of consuming fruit two or more times per day decreased slightly, but significantly, from 34.4% to 32.5% (Table 1). Slight but significant increasing linear trends for fruit consumption were observed in four states, decreasing trends in 22 states and DC, and no significant change in 24 states. The prevalence of consuming vegetables three or more times per day did not change significantly during this period (26.7% in 2000 and 26.3% in 2009). Slight but significant increasing trends were observed in 11 states and DC, decreasing trends in 14 states, and no significant change in 25 states. Idaho was the only state that had significant, although slight, increases in both fruit and vegetable consumption, whereas 10 states had slight but significant decreases in both proportions.

Overall in 2009, the prevalence of consuming fruit two or more times per day or vegetables three or more times per day varied substantially by selected characteristics (Table 2), with the greatest prevalences observed among women (36.1% for fruit two or more times per day and 30.9% for vegetables three or more times per day), persons aged ≥65 years (41.3% and 29.0%), college graduates (36.9% and 32.2%), persons with annual household income ≥$50,000 (32.9% and 29.4%), and persons with a body mass index (weight [kg] / height [m2]) <25.0 (36.6% and 28.3%). Consumption by race/ethnicity varied by the type of produce; for example, Hispanics had the highest prevalence of fruit consumption (37.2%) but the lowest prevalence of vegetable consumption (19.7%).

Reported by

KA Grimm, MPH, HM Blanck, PhD, KS Scanlon, PhD, LV Moore, PhD, LM Grummer-Strawn, PhD, Div of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion; JL Foltz, MD, EIS Officer, CDC.

Editorial Note

The findings in this report indicate that 2009 overall and state-specific estimates of the proportions of U.S. adults consuming fruit two or more times per day or vegetables three or more times per day were far short of the targets set by Healthy People 2010; furthermore, trends in fruit and vegetable consumption during the past decade were relatively flat. The prevalence of fruit and vegetable consumption varied by demographic characteristics and body mass index; nonetheless, neither the fruit nor vegetable consumption target was met by any of the subgroups analyzed.

In 2009, no state met the Healthy People 2010 targets for fruit or vegetable consumption, and substantial variability occurred among states. These variations might be attributed to a number of factors, including differences in population demographics and access, availability, and affordability of produce. In addition to monitoring progress toward Healthy People 2010 behavioral targets, CDC monitors policy and environmental measures. In 2009, the first state-specific data were released on policy and environmental supports that increase fruit and vegetable consumption. The findings in this report indicate that 20 states had a state-level food policy advisory council, but only eight had enacted healthy food retail policies (e.g., tax incentives, low-interest business loans, and zoning for stores, markets, and stands) (6), and states having farmers markets that accept electronic benefit transfers (the system delivering benefits in the federal Supplemental Nutrition Assistance Program) ranged from zero to 50%.§

To improve access, availability, and affordability of fruits and vegetables through retail stores, farmers markets, farm-to-institution, worksite food standards, and other policy and environmental interventions, CDC provides guidance and funding to 25 states.¶ To assist these efforts, CDC recently released a guidance document on policy and environmental strategies to improve fruit and vegetable consumption.** Other new federal efforts include the First Lady's Let's Move! Campaign,†† the U.S. Department of Agriculture's Know Your Farmer, Know Your Food program§§ and CDC's Communities Putting Prevention to Work¶¶ program, which help support private and public partners, connect consumers to growers, and prioritize interventions at the state and community levels.

Data from the BRFSS dietary screener are used to monitor state progress among adults because other national surveys do not provide state-specific estimates. Estimates of fruit and vegetable consumption obtained from a short food frequency module, such as the six-item BRFSS dietary screener described in this report, generally are lower than estimates from more detailed methods of dietary assessment that record all foods (e.g., mixed dishes, soups, and sauces) consumed in a 24-hour period or from longer food frequency questionnaires (e.g., those with 60--120 items) (7,8). However, fruit and vegetable intake estimates derived with more detailed dietary instruments, such as the National Health and Nutrition Examination Survey, also reveal flat trends and consumption below national targets.***

The findings in this report are subject to at least four limitations. First, these results might not be generalizable. BRFSS excludes certain populations, including persons residing in institutions and without landline telephones. Certain subpopulations are more likely to be represented in wireless-only households (e.g., younger, Hispanic, and lower-income adults) (9). Second, dietary history was self-reported and subject to social-desirability response bias and recall bias. This might have led to overestimates or underestimates of prevalence of fruit and vegetable consumption. Third, BRFSS has a low median response rate; however, BRFSS weighting procedure partially corrects for nonresponse. Finally, only trends in overall consumption were examined; trends might vary by subpopulation within a state

A number of previous initiatives to promote consumption of fruits and vegetables in the United States have included individual approaches, such as the Fruits and Veggies -- More Matters campaign††† and single-setting interventions, such as community gardens or farmers market voucher programs. Despite these initiatives, fruit and vegetable consumption is lower than recommended. Thus, intensified, multisector (e.g., agriculture, business, food industry, and health care) and multisetting (e.g., worksite, school, child care, and community) approaches are necessary to facilitate healthier choices among all persons in the United States.

References

1. US Department of Health and Human Services, US Department of Agriculture. Dietary guidelines for Americans 2005. 6th ed. Washington, DC: US Government Printing Office; 2005.
2. He FJ, Nowson CA, Lucas M, MacGregor GA. Increased consumption of fruit and vegetables is related to a reduced risk of coronary heart disease: meta-analysis of cohort studies. J Hum Hypertens 2007;21:717--28.
3. CDC. Deaths: preliminary data for 2004. Natl Vital Stat Rep 2006;54(19).
4. Rolls BJ, Ello-Martin JA, Tohill BC. What can intervention studies tell us about the relationship between fruit and vegetable consumption and weight management? Nutr Rev 2004;62:1--17.
5. CDC. Fruit and vegetable consumption among adults---United States, 2005. MMWR 2007;56:213--7.
6. CDC. State indicator report on fruits and vegetables, 2009. US Department of Health and Human Services, CDC; 2009. Available at http://www.fruitsandveggiesmatter.gov/indicatorreport. Accessed August 31, 2010.
7. Thompson FE, Kipnis V, Subar AF, et al. Evaluation of 2 brief instruments and a food-frequency questionnaire to estimate daily number of servings of fruit and vegetables. Am J Clin Nutr 2000;71:1503--10.
8. Thompson FE, Subar AF. Dietary assessment methodology. In: Coulston AM, Rock CL, Monsen ER, eds. Nutrition in the prevention and treatment of disease. San Diego, CA: Academic Press; 2001:3--30.
9. CDC. Wireless substitution: early release of estimates from the National Health Interview Survey, January--June 2009. US Department of Health and Human Services, CDC, National Center for Health Statistics; 2009. Available at http://www.cdc.gov/nchs/data/nhis/earlyrelease/wireless201005.pdf. Accessed August 31, 2010.

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