title: Availability, affordability, and consumption of fruits and vegetables in 18 countries across income levels: findings from the Prospective Urban Rural Epidemiology (PURE) study.
abstract: Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability.
  
  
  
  We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost.
  
  
  
  Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040).
  
  
  
  The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.
  
  
  
  Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
authors: Victoria
authors: V
authors: Miller
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
authors: Salim
authors: S
authors: Yusuf
authors: Westmead Hospital and the George Institute for Global Health, Sydney University, Sydney, NSW, Australia.
authors: Clara K
authors: CK
authors: Chow
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
authors: Mahshid
authors: M
authors: Dehghan
authors: Ottawa Hospital Research Institute, Ottawa, ON, Canada.
authors: Daniel J
authors: DJ
authors: Corsi
authors: Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.
authors: Karen
authors: K
authors: Lock
authors: Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors: Barry
authors: B
authors: Popkin
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
authors: Sumathy
authors: S
authors: Rangarajan
authors: Stritch School of Medicine, Loyola University Chicago, Maywood, IL, USA; Institute of Community and Public Health, Birzeit University, Ramallah, Occupied Palestinian Territory.
authors: Rasha
authors: R
authors: Khatib
authors: Faculty of Health Sciences, Simon Fraser University, Burnaby, BC, Canada.
authors: Scott A
authors: SA
authors: Lear
authors: St John's Medical College & Research Institute, Bangalore, India.
authors: Prem
authors: P
authors: Mony
authors: School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
authors: Manmeet
authors: M
authors: Kaur
authors: Madras Diabetes Research Foundation, Chennai, India.
authors: Viswanathan
authors: V
authors: Mohan
authors: Community Medicine, Health Action By People, Thiruvananthapuram, Kerala, India.
authors: Krishnapillai
authors: K
authors: Vijayakumar
authors: Department of Medicine, Fortis Escorts Hospital, Jaipur, India.
authors: Rajeev
authors: R
authors: Gupta
authors: Faculty of Health Science North-West University, Potchefstroom Campus, Potchefstroom, South Africa.
authors: Annamarie
authors: A
authors: Kruger
authors: University of the Western Cape, Bellville, South Africa.
authors: Lungiswa
authors: L
authors: Tsolekile
authors: Isfahan Cardiovascular Research Center, Cardiovascular Research Institute, Isfahan University of Medical Sciences, Isfahan, Iran.
authors: Noushin
authors: N
authors: Mohammadifard
authors: Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh.
authors: Omar
authors: O
authors: Rahman
authors: Sahlgrenska Academy and Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden.
authors: Annika
authors: A
authors: Rosengren
authors: Research Division, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil.
authors: Alvaro
authors: A
authors: Avezum
authors: Estudios Clinicos Latino America, Rosario, Argentina.
authors: Andrés
authors: A
authors: Orlandini
authors: Department of Community Health, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur Malaysia.
authors: Noorhassim
authors: N
authors: Ismail
authors: Grupo Investigaciones FOSCAL, Fundacion Oftalmologica de Santander and Medical School, Universidad de Santander, Bucaramanga, Colombia.
authors: Patricio
authors: P
authors: Lopez-Jaramillo
authors: Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates.
authors: Afzalhussein
authors: A
authors: Yusufali
authors: Department of Internal Medicine, Istanbul University, Istanbul, Turkey.
authors: Kubilay
authors: K
authors: Karsidag
authors: Department of Community Health Sciences and Department of Medicine, Aga Khan University, Karachi, Pakistan.
authors: Romaina
authors: R
authors: Iqbal
authors: Physiology Department, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe.
authors: Jephat
authors: J
authors: Chifamba
authors: Facultad de Medicina, Universidad de La Frontera, Temuco, Chile.
authors: Solange Martinez
authors: SM
authors: Oakley
authors: Faculty of Medicine, UiTM Sungai Buloh Campus, Selangor, Malaysia.
authors: Farnaza
authors: F
authors: Ariffin
authors: Department of Social Medicine, Medical University in Wroclaw, Wroclaw, Poland.
authors: Katarzyna
authors: K
authors: Zatonska
authors: Laval University Heart and Lungs Institute, Quebec City, QC, Canada.
authors: Paul
authors: P
authors: Poirier
authors: National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China.
authors: Li
authors: L
authors: Wei
authors: National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China.
authors: Bo
authors: B
authors: Jian
authors: National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China.
authors: Chen
authors: C
authors: Hui
authors: National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China.
authors: Liu
authors: L
authors: Xu
authors: National Center for Cardiovascular Diseases, Fuwai Hospital, Beijing, China.
authors: Bai
authors: B
authors: Xiulin
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
authors: Koon
authors: K
authors: Teo
authors: Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada. Electronic address: andrew.mente@phri.ca.
authors: Andrew
authors: A
authors: Mente
mesh_terms: D000328:Adult; D000368:Aged; D003365:Costs and Cost Analysis; D019049:Developed Countries; D003906:Developing Countries; D004032:Diet / Q000191:economics*; D004034:Diet Surveys; D005191:Family Characteristics; D005247:Feeding Behavior; D005260:Female; D005523:Food Supply / Q000191:economics*; D005638:Fruit; D006801:Humans; D007182:Income; D008297:Male; D008875:Middle Aged; D018673:Nutrition Policy / Q000191:economics; D011203:Poverty; D011446:Prospective Studies; D012424:Rural Population; D012923:Social Class; D014505:Urban Population; D014675:Vegetables