Fruit and Vegetable Consumption in Later Life
Fruit and Vegetable Consumption in Later Life
Fruit and Vegetable Consumption in Later Life
Department of Health Care of the Elderly, The University of Nottingham, Queens Medical Centre, Nottingham
NG7 2UH, UK
1
Department of Health Care for Elderly People, The University of Sheffield, Northern General Hospital,
Sheffield S5 7AU, UK
department of Applied Biochemistry and Food Science, The University of Nottingham, Sutton Bonnington LEI 2 5RD,
UK
3
School of Social Studies, The University of Nottingham, University Park, Nottingham NG7 2RD, UK
Address correspondence to: A. E. Johnson, 48 Corisande Road, Selly Oak, Birmingham B29 6RH, UK
Abstract
Objective: to assess levels of fruit and vegetable consumption in elderly people, and to examine the socio-
economic, physical and psychological factors which influence this consumption.
Methods: a three-phase survey: face to face interviews; self-completed dietary diaries with a food frequency
questionnaire; and follow-up face-to-face interviews.
Participants: 445 elderly people (aged 65+) randomly selected from general practitioner lists in urban Nottingham
and rural Nottinghamshire, Lincolnshire and Leicestershire.
Results: the recommended target of five portions of fruit and vegetables a day was achieved by less than half the
respondents: 37% of those living in the urban area and 51% of those living in the rural area. Low fruit and vegetable
consumption was particularly associated with being male, smoking and having low levels of social engagement.
Conclusions: most elderly people consume less than the recommended levels of fruit and vegetables. Health
programmes promoting fruit and vegetable consumption may not be successfully reaching elderly people and need
to target those particularly at risk of low consumption.
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A. E. Johnson et al.
activities [21], a higher life satisfaction [24] and fewer headaches, urinary incontinence, arthritis, falls, long-
problematic life events [21] being associated with term disabilities and drug and walking aid use, and
more adequate diets, and lower mortality [25] in contact with (primary and secondary care) medical
elderly subjects. services [26]. Psychological well-being was measured
Previous research has looked at the possible using the 20-item Brief Assessment of Social Engage-
influences on fruit and vegetable consumption in ment scale, documenting the amount of contact with
isolation, or in combination with only a few other friends, relatives or interest groups, and satisfaction
influences. We have estimated the proportion of with this level of contact; the frequency of taking
elderly people who are meeting the 'five-a-day' target; holidays, reading the paper, voting and using the public
and assessed the levels of fruit and vegetable con- library; and ownership of a telephone, car, television
sumption in relation to socio-economic, physical and and radio [27].
psycho-social factors. On completion of phase I, a 50% sub-sample of
respondents participated in phase n, completing a
self-administered 4-day dietary diary and food fre-
Subjects and methods quency questionnaire from which fruit and vegetable
consumption was calculated.
A further 50% sub-sample of phase n respondents
Sample participated in phase III: a face-to-face follow-up
The study was conducted in two areas: an urban area interview examining influences on food choices as
(the city of Nottingham) and a rural area comprising well as nutritional and food safety knowledge.
parts of Nottinghamshire, Lincolnshire and Leicester-
shire. Of 159 general practitioners (GPs) with patients Fruit and vegetable intake
living in Nottingham, 127 (78%) agreed to support the
study. With the consent of these GPs, Nottinghamshire Foods that contributed at least 5% of any major nutrient
Family Health Services Authority age/sex lists were to the diet were included in the food frequency
used to identify all non-institutionalized individuals questionnaire completed by phase n respondents
aged 65 years and over living within the Nottingham [28, 29]. Respondents were asked to indicate how
area. From the resulting sample of 26055, 1584 many times per day, week or month they consumed
individuals were randomly selected. The target was to each item. The food frequency data and Ministry of
complete 800 interviews. The sample was stratified at Agriculture Fisheries and Food food portion size tables
age 75 with equal probability representation in the age [30] were used to calculate the portions of fruit and
groups 65-74 and 75+. vegetables consumed per person per day. The fruit and
vegetables which contributed to the recommended
Of 76 GPs with patients living in the rural area, 47
five portions a day were based on the advice of
(62%) agreed to support the study. With the consent of
Williams [9]. Frozen and canned fruit and vegetables,
these GPs, Family Health Services Authority age/sex
fruit juice, dried fruit, baked beans and other pulses
lists were used to identify all non-institutionali2ed
were included; potatoes and nuts were excluded.
individuals aged 55 and over. From the resulting sample
Composite or processed foods were included provided
of 4408, 669 individuals were randomly selected. The
they contained enough fruit or vegetables [31].
target was to complete 400 interviews. The sample was
Analysis was also conducted excluding beans and
stratified at ages 65 and 75 with equal probability of
pulses, as these foods could be considered as alternatives
representation in the age groups 55-64, 65-74 and
to meat rather than as vegetables (personal commu-
75+. Respondents aged 65+ were included in this
nication, Ministry of Agriculture Fisheries and Food).
analysis.
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Fruit and vegetable consumption in later life
Table I. Socio-economic characteristics (weighted) of food frequency questionnaire and 177 (49%) of these a
urban (n — 312) and rural (n = 133) phase II respon- phase HI follow-up interview. Respondents who were
dents aged 65 and over and completed a phase II food
frequency questionnaire were included in this analysis:
% of subjects 312 weighted respondents. In the rural area 401 (72%)
Urban Rural of the 555 respondents who were asked to take part in
the study completed the phase I interview. Of these, 211
Sex (53%) completed a phase n food frequency question-
Female 53.8 58.9 naire and 106 (50%) of these a phase m follow-up
Male 46.2 41.1 interview, giving 133 weighted respondents aged 65+.
Age (years) The socio-economic characteristics of the two samples
65-74 62.8 63.3 are shown in Table 1. While the refusal rate was
75+ 37.2 36.7 relatively high (37% in the urban area, 28% in the rural
Social class area), in terms of age, sex and the number of individuals
Professional living alone, the resulting sample closely matched the
2.5 7.3
host population as described in the 1991 census.
Managerial 16.5 39.7
Skilled non-manual 22.7 23.6 Fruit and vegetable consumption was dichotomized
Skilled manual 37.7 17.4 into S5 and <5 portions a day. Rural respondents were
Semi-skilled 15.1 6.0 more likely than urban respondents to eat at least five
Unskilled 5.5 6.0 portions a day: 115 (37%) of the urban respondents and
67 (51%) of the rural respondents achieved this goal.
The mean daily consumptions of fruit and vegetables
were 4.5 servings (SD 2.1) in the urban area and 4.8
all models the independent variables were socio- servings (SD 1.9) in the rural area. In the multiple
economic circumstances (sex, age, social class, urban regression analysis three variables were independent
or rural area of residence), physical health (health predictors of a higher fruit and vegetable consumption:
index, smoker—yes or no) and psychological well- not smoking (R2 = 0.1159), a higher social engagement
being (social engagement scale). All analyses were score ( ^ = 0.1770) and female sex ( ^ = 0.1913;
performed using SPSS v6.0 [32]. Table 2).
Figure 1 illustrates the types of fruits and vegetables
eaten in the two areas. Vegetables contributed just over
half of the daily consumption of fruit and vegetables.
Results
Most of the vegetables eaten were fresh or frozen, most
In the urban area, 1281 respondents were asked to take commonly carrots, fresh peas and onions. About one-
part in the study and 809 (63%) completed the phase I quarter of the vegetables eaten were salad vegetables,
interview. Of these, 361 (45%) completed a phase II most commonly tomatoes. Most of the fruit eaten was
"Independent variables: sex, age, urban or rural area of residence, health score, social engagement score and social class.
^ increase in variation explained.
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A. E. Johnson et al.
Fruit and vegetables fruit and vegetable consumption. This is consistent with
Mean 4.6 portions research in younger age groups [12, 15, 22, 23]. Female
100i% gender and a higher social class were independently
associated with a high fruit consumption, but no such
differences were observed in vegetable consumption.
1
Vegetables
1
Fruit
Fruit may be seen as a low-calorie food, and thus be
Mean 2.6 portions Mean 2.0 portions
eaten more by women. Fruit often has a higher cost per
55.7% 44.3% calorie than vegetables, which may explain why more
fruit is eaten by those of a higher social class. Age was
associated with vegetable consumption, with older
r r respondents eating fewer vegetables. This might be
Fresh and frozen Fresh fruit due to a reduction in appetite or a lower taste acuity
vegetables 77% with advancing age [33], or to a reduction in the
64%
physical ability to prepare vegetables (although this
Salad vegetables Fruit juice association was independent of physical health status).
22.7% 13.2%
Respondents who were more socially engaged ate
Canned Dried fruit more fruit, but not more vegetables, than those with
vegetables 4.4% less social engagement. The social engagement scale
7.6% measures the degree to which individuals engage
Baked beans Fruit canned in syrup
actively (going on holiday, attending religious meet-
and pulses 2.9% ings) or symbolically (reading the newspaper) in the
4.5% social milieu. It also includes questions about lone-
liness and satisfaction with levels of contact with
Homemade vegetable Fruit canned in juice
soup 2.5%
others. It can be seen as a proxy for healthy ageing,
1.2% with a higher score indicating a more socially, mentally,
physically and emotionally active lifestyle and higher
Figure I. Types of fruits and vegetables eaten. morale. There has been much research on the
importance of social support on health and mortality,
with individuals who have social support tending to be
fresh, apples, bananas and oranges being the most in better physical [34] and psychological [35] health
popular. Fruit juice was the second most popular way and having a lower mortality [36]. Fruit consumption
of consuming fruit. may be an intervening variable between low social
Baked beans and other pulses were removed from support and poor health.
the analysis, reducing the mean daily consumption of
These analyses have demonstrated that many elderly
fruit and vegetables by only 0.1 of a serving to 4.4
people are not eating enough fruit and vegetables.
servings (SD 2.09) in the urban area and by 0.1 of a
Health education programmes promoting fruit and
serving to 4.7 servings (SD 1.9) in the rural area.
vegetable consumption need to target those elderly
Finally, fruit and vegetables were separated, and two people who are particularly at risk of a low consump-
multiple regression analyses conducted (Table 2). Four tion: men who smoke and have a low level of social
variables were independent predictors of a higher fruit engagement.
consumption: not smoking (R2 = 0.0812), a higher
engagement score (Jt2 — 0.1329), female gender (tf2 =
0.1601) and a higher social class (jf = 0.1723). Two
variables were independent predictors of a higher Key points
vegetable consumption: not smoking (R* = 0.0460) • Less than half the elderly subjects were eating five
and a younger age (Z?2 = 0.0954). portions of fruit and vegetables a day: 37% of those
living in the urban area and 51% of those in the rural
area.
Discussion • Low fruit and vegetable consumption was particu-
larly associated with being male, smoking and
We examined the fruit and vegetable consumption of having low levels of social engagement.
445 elderly people and found that the recommended • Health education programmes should target those
target of five portions of fruit and vegetables a day was groups of elderly people who are particularly at risk
being achieved by less than half them: 37% of those of low consumption.
living in the urban area and 51% of those living in the
rural area. This level of consumption, whilst falling
short of the ideal, is higher than that reported in studies
of younger people [11, 12, 15]. Acknowledgements
Smoking was the most important predictor of a low This study was funded under the Economic and Social
726
Fruit and vegetable consumption in later life
Research Council programme: The Nation's Diet: the 16. Slesinger DP, McDivitt M, O'Donnell FM. Food patterns in
Social Science of Food Choice and the Ministry of an urban population: age and sociodemographic correlates.
Agriculture, Fisheries and Food programme: Food J Gerontol 1980; 35: 432-41.
Acceptability and Choice. Thanks are also due to S. 17. Florence TM. The role of free-radicals in disease. Aust NZ
Herne andj. Iilley for the design of the questionnaires. J Ophthalmol 1995; 23: 3-7.
18. Heseker H, Schneider R. Requirement and supply of
vitamin-C, vitamin-E and beta-carotene for elderly men and
women. EurJ Clin Nutr 1994; 48: 118-27.
References
19. Steele P, Dobson A, Alexander H, Russell A. Who eats
1. Key TJA, Thorogood M, Appleby PN, Burr ML. Dietary what—a comparison of dietary patterns among men and
habits and mortality of 11,000 vegetarians and health women in different occupational groups. Aust J Publ Health
conscious people: results of a 17 year follow up. Br Med J 1991; 15: 286-95.
1996;313:775-9. 20. Heimendinger J, Van Duyn MAS. Dietary behaviour
2. Block G, Patterson B, Subar A. Fruit, vegetables, and change: the challenge of recasting the role of fruit and
cancer prevention—a review of the epidemiologic evidence. vegetables in the American diet. Am J Clin Nutr 1995; 61
Nutr Cancer 1992; 18: 1-29. (suppl.): 1397S-4O1S.
3. Shibata A, Paganinihill A, Ross RK, Henderson BE. Intake 21. Horwath CC. Socio-economic and behavioural effects on
of vegetables, fruits, beta-carotene, vitamin-C and vitamin the dietary habits of elderly people. Int J Biosocial Med Res
supplements and cancer incidence among the elderly—a 1989; 11: 15-30.
prospective-study. BrJ Cancer 1992; 66: 673-9.
22. Serdula MK, Byers T, Mokdad AH, Simoes E, Mendlein JM,
4. WeisburgerJH. Nutritional approach to cancer prevention Coates RJ. The association between fruit and vegetable
with emphasis on vitamins, antioxidants, and carotenoids. intake and chronic disease risk-factors. Epidemiology 1996; 7:
Am J Clin Nutr 1991; 53: 226S-37S. 161-5.
5. World Health Organisation. Diet, nutrition and the 23. Fehily AM, Phillips KM, Yarnell JWG. Diet, smoking,
prevention of chronic diseases. Geneva: WHO, 1990. social class and body mass index in the Caerphilly Heart
6. Duthie GG, Wahle KWJ, James WPT. Oxidants, anti- Disease Study. Am J Clin Nutr 1984; 40: 827-33.
oxidants and cardiovascular disease. Nutr Res Rev 1989; 2: 24. Harrill I, Erbes C, Schwartz C. Observations of food
51-62. acceptance by elderly women. Gerontologist 1976; 16: 349-
7. Colditz GA, Branch LG, Lipnick RJ et al Increased green 55.
and yellow vegetable intake and lowered cancer deaths in an 25- Welin L, Tibblin G, Svardsudd K, Tibblin B, Ander-Peciva
elderly population. AmJ Clin Nutr 1985; 41: 32-6. S, Larsson B. Prospective study of social influences on
8. Havas S, HeimendingerJ, Damron Detal 5-a-day for better mortality: the study of men born in 1913 and 1923. Lancet
health—9 community research projects to increase fruit and 1985; 20: 915-8.
vegetable consumption. Publ Health Rep 1995; 110: 68-79. 26. Bassey EJ, Morgan K, Dallosso HM, Ebrahim SBJ.
9. Williams C. Healthy eating: clarifying advice about fruit Flexibility of the shoulder joint measured as a range of
abduction in a large representative sample of men and
and vegetables. Br Med J 1995; 310: 1453-5.
women over 65 years of age. Eur J Appl Physiol 1989; 58:
10. Subar AS, Heimendinger J, Krebs-Smith SM, Patterson 353-60.
BH, Kessler R, Pivonka E. Five-a-day for Better Health: a
baseline study of American's fruit and vegetables consump- 27. Morgan K, Dallosso HM, ArieT, Byrne EJ, Jones R, WaiteJ.
tion. Rockville, MD: National Cancer Institute, 1992. Mental health and psychological well-being among the old
and the very old living at home. BrJ Psychiatr 1987; 150:
11. Krebssmith SM, Cook DA, Subar AF, Cleveland L, Friday J. 801-7.
US adults' fruit and vegetable intakes, 1989 to 1991—a
28. Ministry of Agriculture Fisheries and Food. National Food
revised base-line for the heaIthy-people-2000 objective. Am J
Publ Health 1995; 85: 1623-9. Survey. London: HMSO, 1993.
29- Gregory J, Foster K, Typer H, Wiseman M. The dietary
12. Anderson AS, Hunt K, Ford G, Finnigan F. One apple a
and nutritional survey of British adults. London: HMSO, 1990.
day?— Fruit and vegetable intake in the west of Scotland.
Health Edu Res 1994; 9: 297-305. 30. Ministry of Agriculture Fisheries and Food. Food Portion
13. Bennett N, Dodd T, Flatley J, Freeth S, Boiling K. Eating Sizes, 2nd ed. London: HMSO, 1993.
habits. In: Bennett N, ed. Health Survey for England. London: 31. Holland B, Welch AA, Unwin ID, Buss DH, Paul AA,
HMSO, 1995: 118-39- Southgate DAT. McCance and Widdowson's The Composition
14. Ministry of Agriculture Fisheries and Food. National Food of Foods, 5th ed. London: Ministry of Agriculture Fisheries
and Food, 1991.
Survey. London:HMSO, 1995.
32. Norusis MJ. SPSS for Windows. 6.0 ed. Chicago: SPSS Inc,
15. Subar AF, HeimendingerJ, Patterson BH, Krebsmsith SM,
Pivonka E, Kessler R. Fruit and vegetable intake in the United- 1993.
States—the base-line survey of the 5 a day for better health- 33. Schiffman SS. Perception of taste and smell in elderly
program. AmJ Health Promotion 1995; 9: 352-60. persons. Crit Rev Food Sci Nutr 1993; 33: 17-26.
727
A. E. Johnson et al.
34. Cobb S. Social support as a moderator of life stress. and mortality: a nine-year follow-up study of Alameda county
J Psychosom Med 1976; 38: 300-14. residents. Am J Epidemiol 1979; 109: 186-204.
35. Lowenthal MF, Haven C. Interaction and adaptation:
intimacy as a critical variable. Am Sociol Rev 1968; 33: 20-30.
36. Berkman LF, Syme SL. Social networks, host resistance Received 28 August 1997; accepted 31 October 1997
728