Obesity, type 2 diabetes mellitus, CVD (e.g. hypertension, stroke) and several types of cancer are becoming increasingly important causes of early mortality or permanent morbidity(1). The influence and importance of a varied and wholesome diet on health and thus also on the prevention of chronic diseases is now widely accepted(Reference Pomerleau, Mc Kee, Lobstein and Knai2). Epidemiological studies have indicated that fruit and vegetable intake has a major influence on cancer risk(Reference Steinmetz and Potter3). Contrary to initial results from case–control studies, however, results from cohort studies show that while an effect is possible, it is restricted to certain types of cancer(Reference Riboli and Norat4, Reference Gonzalez, Navarro and Martinez5). Both fruit and vegetables probably reduce the likelihood of developing mouth, laryngeal, oesophageal and stomach cancer(6). Concerning the relative risk of developing cancer, it was shown that even an increment of five servings of fruit and vegetables per day apparently does not decrease the risk(Reference Hung, Joshipura, Jiang, Hu, Hunter, Smith-Warner, Colditz, Rosner, Spiegelman and Willett7, Reference Takachi, Inoue, Ishihara, Kurahashi, Iwasaki, Sasazuki, Iso, Tsubono and Tsugane8). In contrast, the positive effects of sufficient fruit and vegetable consumption on the cardiovascular system are now largely validated(Reference Dauchet, Amouyel, Hercberg and Dallongeville9, Reference He, Nowson, Lucas and MacGregor10). Meta-analyses also showed that increased fruit and vegetable intake is associated with a reduced risk of stroke(Reference Dauchet, Amouyel and Dallongeville11, Reference He, Nowson and MacGragor12). However, the intake of three or more daily servings of fruit or vegetables was not associated with a substantial reduction in the risk of type 2 diabetes according to meta-analysis(Reference Hamer and Chida13). The effect of fruit and vegetable intake on body weight should not be underrated. As people tend to consume similar weights of food every day, total energy intake decreases with decreasing energy content of the foodstuffs. In this context, a positive effect of sufficient fruit and vegetable intake has been demonstrated(Reference Tohill14).
The most important initiative worldwide to increase vegetable and fruit consumption is ‘5 a day’. In Austria, the campaign ‘5 a day – fruit and vegetables’ was presented to the public by the Austrian Cancer League (in cooperation with the Institute of Nutritional Sciences of the University of Vienna) in autumn 2000 and has been widely advertised since 2001. ‘5 a day’ is a rather important message to increase intake(Reference Ashfield-Watt15), especially as different individual barriers prohibit a higher consumption. Reasons, besides cost(Reference Yeh, Ickes, Lowenstein, Shuval, Ammerman, Farris and Katz16), could be availability(Reference Kamphuis, Giskes, De Bruijn, Wendel-Vos, Brug and Van Lenthe17), impractical if not at home(Reference John and Ziebland18) or preparation effort(Reference Maclellan, Gottschall-Pass and Larsen19).
The present paper describes fruit and vegetable intake in Austrian adults, barriers to increased intake, and the current potential for increasing consumption.
Methods
The study design was cross-sectional. Four independent sub-samples (one for each season) of a total of 5130 adults (aged 19–64 years) from throughout Austria were surveyed over the course of one year in 2006, in order to measure seasonal fluctuations. The sample was stratified by sex and occupation. Occupation was chosen as a criterion because it gives information on further sociodemographic characteristics(Reference Kromrey20). Sample size was calculated based on the occupational distribution. We excluded people older than 65 years from the analysis. In order to access the chosen occupational groups effectively, companies, public and private institutions were chosen randomly. Following initial contact by telephone, which served to acquire a competent contact person, an appropriate number of questionnaires according to the stratification sampling design were mailed to each contact. It was attempted to keep the selection bias as low as possible with this method. The response rate was 52·7 % (2704 adults). Representativeness of the data regarding current employment status, age structure, sex, the highest level of education and household income was verified using data provided by Statistik Austria. The characteristics of the study sample are shown in Table 1.
Table 1 Major characteristics of the study sample according to season: Austrian adults participating in a nationwide postal questionnaire survey, 2006
Questionnaire design
A self-administered questionnaire with questions on different topics regarding fruit and vegetables was used. The complete questionnaire contained thirty-nine closed questions. Questions on reasons for consumption (‘because it tastes good’, ‘because it is healthy’, ‘because it is available’) and barriers for consumption (‘intake is already sufficient’, ‘I often forget to eat fruit/vegetables’, ‘I often don’t feel like it’, ‘too much preparation effort’, ‘inconvenient if not at home’, ‘too expensive’, ‘does not suit my lifestyle’, ‘function of higher consumption is unknown’) were dichotomous questions but allowed multiple answers. FFQ were used for a qualitative assessment (‘How often do you eat…’) of the intake of different types of fruit and vegetables. A single self-administered 24 h recall survey was used to obtain quantitative information (g/d) on fruit and vegetable intake(Reference Beer-Borst and Amado21). The intake was measured by household measures. The questionnaire was developed during two pre-test phases and its reliability was evaluated by the test–retest method. For eighty-five out of eighty-six ordinal questions, the test–retest reliability was rated ‘good’ or ‘very good’ (intra-class correlation >0·6). Only for one parameter was the test–retest reliability ‘acceptable’ (intra-class correlation >0·50 to 0·59). For sixty-two out of seventy-five dichotomous variables, concordance was over 80 %; for thirteen variables, concordance was between 71 % and 80 %.
Analysis
The SPSS for Windows statistical software package version 12·0 (SPSS Inc., Chicago, IL, USA) was used to analyse the data. All questions were analysed with respect to sex, age, season and geographical region. Data for fruit and vegetable intake were ‘raw data’ and were not adjusted for energy. We used the χ 2 test (standard residuals were used to determine significant differences) for dichotomous data and the Mann–Whitney U test for ordinal data. P values were adjusted for multiplicity according to the Bonferroni–Holm procedure.
The data from the 24 h recalls were entered into the ‘Ernährungswissenschaftliche Programm’. This software is based on the German Food Database Version II.3 but was adapted for Austrian eating habits through the addition of typical Austrian recipes(Reference Dehne, Klemm, Henseker and Hermann-Kunz22).
To adjust for under-reporting as well as for over-reporting, the quotient of the recorded energy intake and the individually calculated BMR, after Schofield, was used(Reference Schofield23). Based on cut-off points, participants with an extremely high or extremely low energy intake could subsequently be identified(Reference Goldberg, Black, Jebb, Cole, Murgatroyd, Coward and Prentice24–Reference Black26). The cut-off points used were 2·4 for over-reporting and 0·92 for under-reporting(Reference Ferrari, Slimani and Ciampi27).
Results
Consumption of fruit
The qualitative assessment showed that the intake frequency of fruits in Austria is too low. According to their own accounts, 22·7 % of the respondents consumed fruit several times a day, 34·4 % once a day, 11·7 % ate fruit four to six times per week and 21·9 % between one and three times per week. Some 10·3 % of the participants consumed fruit only every second week or less often.
Women reported a significantly higher (P < 0·001) intake frequency of fruit than men, with 65·6 % of participating women reporting consumption of fruit at least once a day compared with 44·2 % of men. Thus, women consumed fruit on average once a day, men only four to six times a week.
A significant increase in intake frequency was found with increasing age (19–24-year-olds v. 25–50-year-olds, P < 0·001; 19–24-year-olds v. 51–64-year-olds, P < 0·001; 25–50-year-olds v. 51–64-year-olds, P < 0·001). While women over 25 years old consumed fruit significantly more frequently than younger women, in men the same applied only to participants aged 51 years and over. No significant difference in the intake frequency of fruit was found between eastern and western Austria or between seasons.
According to the data from the 24 h recalls, the participants ate on average 250 (sd 225) g of fruit (not including fruit juices) per day. This is a greater amount than described in the second Austrian nutrition report 2003 (183 (sd 227) g/d)(Reference Elmadfa, Freisling and Koenig28). Assuming a serving size of 120 g (according to the recommendation of 600 g per person per day to reach public health goals)(29), the participants consumed on average 2·1 (sd 1·9) servings of fruit per day.
The proportion of people consuming less than one serving of fruit per day was 29·0 %, 26·6 % consumed one serving a day and nearly half of the respondents (44·5 %) estimated their consumption as two servings of fruit per day.
On average, men ate 2·0 (sd 2·0) servings (237 (sd 262) g) and women ate 2·1 (sd 1·7) servings (256 (sd 206) g) of fruit per day. Still, 47·4 % of the women reached the recommended daily amount of two servings of fruit per day, whereas only 38·3 % of men did.
Regarding age, it was shown that only 29·6 % of 19–24-year-olds, 44·9 % of 25–50-year-olds and 53·0 % of 51–64-year-olds met the recommended two daily fruit servings.
According to overall intake frequency, there were no significant differences in average serving sizes between eastern and western Austria and between the different seasons.
Consumption of vegetables
Vegetables were consumed less frequently than fruit: 7·7 % of the respondents reported consuming vegetables several times a day, 28·5 % ate vegetables once a day, 22·2 % ate vegetables four to six times per week and 34·2 % one to three times per week. Some 7·3 % of all participants reported consuming vegetables only every second week or less frequently.
Women reported a significantly (P < 0·001) higher intake frequency of vegetables than men. Of female participants, 42·0 % indicated that they ate vegetables at least once a day, compared with 27·5 % of participating men. For both women and men, the average intake frequency was four to six times a week.
Regarding the effect of age, the results showed that women aged 19–24 years ate vegetables significantly (P = 0·03) less frequently than women aged 25–50 years. In men, intake frequency was approximately the same for all ages. People from western Austria consumed vegetables significantly (P < 0·001) more frequently than participants from the east of the country.
Concerning intake frequency during the different seasons, the data showed that the participants consumed vegetables significantly (P < 0·001) less frequently in winter than in the summer season.
According to the data from the 24 h recalls, the participants ate on average 198 (sd 159) g of vegetables per day. As found for fruit, this amount is greater than that published in the second Austrian nutrition report 2003 (148 (sd 134) g/d)(Reference Elmadfa, Freisling and Koenig28). Assuming a serving size of 120 g, the participants ate on average 1·7 (sd 1·3) servings of vegetables per day.
Of the participants, 37·2 % consumed less than one serving per day, almost one-third (31·0 %) consumed one serving per day and nearly one-sixth (17·1 %) consumed two servings of vegetables per day. The recommendation of eating three servings of vegetables daily was met by only 14·7 % of the respondents.
Men ate significantly (P < 0·001) fewer servings of vegetables than women. On average, men ate 1·5 (sd 1·2) servings (180 (sd 149) g) and women ate 1·7 (sd 1·4) servings (208 (sd 164) g) of vegetables per day. Only 11·2 % of men and 16·6 % of women met the recommendation to consume three servings of vegetables per day. Regarding age, it was shown that only 9·1 % of 19–24-year-olds, 15·6 % of 25–50-year-olds and 15·6 % of 51–64-year-olds consumed the recommended three daily servings. Again, there was no significant difference between western and eastern Austria or between the seasons.
Reasons for consumption
Regarding reasons for the consumption of fruit and vegetables, the respondents could choose between three response options (‘because it tastes good’, ‘because it is healthy’ and ‘because it is available’).
The results showed that taste was the most important factor for the intake of both fruit and vegetables (Tables 2 and 3). In addition to the health aspect, availability also played an important role. This was especially the case for men in general and for the age group 19–24 years.
Table 2 Motives for the intake of fruit according to sex, age and intake frequency: Austrian adults participating in a nationwide postal questionnaire survey, 2006
Table 3 Motives for the intake of vegetables according to sex, age and intake frequency: Austrian adults participating in a nationwide postal questionnaire survey, 2006
With increasing intake frequency, it was found that taste and the health aspect became more important motives for the intake of both fruit and vegetables, whereas the importance of availability decreased.
Barriers to consumption
To evaluate consumption barriers, eight relevant response options were provided that were based on internal and external barriers according to John and Zeibland(Reference John and Ziebland18). The five most important barriers to consumption of fruit or vegetables were: ‘intake is already sufficient’, ‘I often forget to eat fruit/vegetables’, ‘I often don’t feel like it’, ‘too much preparation effort’, and ‘inconvenient if not at home’. In contrast to other studies(Reference Yeh, Ickes, Lowenstein, Shuval, Ammerman, Farris and Katz16, Reference Anderson and Cox30–Reference Claro, Esvael do Carmo, Sarti Machado and Monteiro33), price constituted only a minor barrier to a higher intake of fruit or vegetables. In addition to price, the association between fruit and vegetable intake and one’s lifestyle (‘does not suit my lifestyle’) and lack of knowledge why a higher consumption is better (‘function of higher consumption is unknown’) were not barriers for a higher intake in Austria.
Additionally, the eight consumption barriers were considered in relation to intake groups (fruit intake: ‘less than one serving per day’, ‘one serving per day’, ‘two or more servings per day’; vegetable intake: ‘less than one serving per day’, ‘one to two servings per day’, ‘three or more servings per day’; Tables 4 and 5).
Table 4 The eight evaluated barriers to consumption of fruit in relation to intake groups: Austrian adults participating in a nationwide postal questionnaire survey, 2006
Table 5 The eight evaluated barriers to consumption of vegetables in relation to the intake groups: Austrian adults participating in a nationwide postal questionnaire survey, 2006
The percentage of people stating that their intake was sufficient increased with increasing intake of both fruit and vegetables. There is some reason for concern given that, in the groups consuming less than one serving of fruit or vegetables per day, respectively 31·3 % and 54·0 % nevertheless considered their intake sufficient. This response was given especially often by people over 50 years of age. Regarding fruit intake, the results showed that in the group consuming less than one serving per day, a lack of liking was particularly prevalent (33·8 %). Moreover, 50·4 % in this intake group simply forget to consume fruit.
While preparation effort played only a minor role in hindering consumption of fruit, it posed a significant barrier to consumption of vegetables in all three intake groups (less than one serving per day: 23·0 %, one to two servings per day: 21·4 %, three or more servings per day: 19·4 %).
Increasing consumption
Regarding intake of fruit, 20·8 % of the participants indicated they did not want to increase their intake. Over half of the respondents (55·0 %) could imagine increasing consumption by one serving per day, 20·3 % felt they would be able to increase intake by two servings and 3·9 % by three or more servings per day. No differences were found between men and women or between the different age groups. On average, the increase potential is one serving of fruit per day.
Concerning intake of vegetables, 40·1 % of the participants indicated they did not wish to increase their intake. Half of the respondents (50·1 %) could imagine eating an additional serving of vegetables per day. Only 8·2 % of the participants would be willing to eat two more servings per day and merely 1·5 % would increase their intake by three or more servings. While the different age groups did not differ significantly in their willingness to increase intake, there was a significant difference between men and women (P < 0·001): 43·6 % of male respondents could not presently imagine consuming one or more additional servings of vegetables per day; for women, this figure was 37·8 %. The average increase potential is one serving of vegetables per day.
At present, the average potential for increasing fruit and vegetable consumption can be estimated at one serving for fruit as well as vegetables per day. Thus, on average, daily serving amounts could be increased to 5·9 (sd 1·7) servings in women and to 5·6 (sd 1·7) servings in men.
Discussion
The chosen study design facilitated a very efficient implementation and a high response rate. Due to representativeness of the data the results are representative for the adult Austrian population. The major selection bias we had to deal with was the well-known fact that women are more-health conscious and therefore are more interested in nutritional surveys. The 24 h recall was, as expected, the greatest source for bias. It would have been better to instruct participants on portion sizes by using picture examples to further increase the quality of data.
The results clearly show that Austrian adults consume insufficient amounts of fruit and vegetables evaluated by FFQ and 24 h recall. Despite the low intake, it is notable that fruit intake has increased by 67 g/d and vegetable intake by 50 g/d since 2003(Reference Elmadfa, Freisling and Koenig28). Still, the consumption frequency is an important reason for the insufficient intake: 43·0 % of all respondents do not consume fruit daily and 63·7 % do not consume vegetables daily. The fact that women eat more servings of fruit and vegetables than men reflects typical sex-specific differences in health behaviour in Austria(Reference Kiefer, Rathmanner and Kunze34). Given that availability of fruit and vegetables plays an important role in consumption behaviour particularly of men, as reported in various studies(Reference Kratt, Reynolds and Shewchuk35–Reference Jago, Baranowski and Baranowski37), attempts to increase intake should address this issue more. It can be speculated whether it would be a suitable strategy, besides promoting employee health schemes, to encourage women in their role as spouses and partners to facilitate availability of fruit and vegetables to men, as the results of the questionnaire showed that women are significantly (P < 0·001) more often responsible for grocery shopping.
Regarding vegetable intake, the results reflect the well-known west–east gradient in health-conscious nutrition(Reference Birner, Fülöp, Hlava, Sax and Winkler38). One major reason for this could be the relationship between nutrition and lifestyle factors such as physical activity and smoking behaviour(Reference Friel, Newell and Kelleher39–Reference Thompson, Margetts, Speller and McVey42). People in eastern Austria not only eat less vegetables but also smoke significantly (P < 0·001) more and get significantly (P = 0·001) less exercise than people in the west.
The constant level of intake of fruit over the course of the year can be regarded as very positive. One reason for the difference in vegetable intake between the winter and summer seasons could be the change from winter vegetables to the richer, more varied and fresher choice of seasonal products in spring. In contrast to vegetables, a constant range of fruit is available throughout the year.
The present investigation shows that a majority of the respondents choose to consume fruit and vegetables because of the taste. As the health aspect plays a much smaller role in comparison, efforts to increase intake should increasingly consider the aspect of taste in addition to the health advantages. At the same time, the importance of availability should not be underestimated. Availability is regarded as a major reason for, as well as an important barrier to, consumption. Especially availability of fruit and vegetables at the place of work (also at canteens) plays an important role(Reference Anderson, Cox, McKellar, Reynolds, Lean and Mela43, Reference Oppen, Sugarman and Foerster44).
In contrast to other studies, price was found to be only a minor barrier to consumption of fruit and vegetables. The importance of availability is affirmed by the fact that people often forget to eat fruit and vegetables, as well as naming preparation effort and inconvenience if not at home as barriers to consumption. Thus, it is advisable to improve availability in the future, while at the same time further emphasizing the ease of preparing and eating fruit and vegetables.
As most respondents stated that they consider their present intake sufficient, there is a question to what extent people are aware of daily requirements and whether there has been a lack of promoting an adequate desire for fruit and vegetables. Especially in this respect, the main objective should not be to draw attention to the well-known benefits of fruit and vegetables for human health(Reference Blanck, Galuska, Gillespie, Khan, Serdula, Solera, Mokdad and Cohen45), but to emphasize the taste aspect more.
To conclude, Austrian adults eat considerably too little fruit and vegetables. An increase in intake is possible if the existing potentials are utilized.
Acknowledgements
No funding was received for the present study. The authors have no conflicts of interest. M.S. was responsible for study design and data analysis, and contributed to the drafting of the paper. P.R. was responsible for study design and data discussion, and contributed to the drafting of the paper. I.E. was responsible for study design and proof reading of the paper.
