Feature
An apple a day...
A good diet may be essential to health – but how much can really be achieved by schemes such as free fruit in schools and food co-ops? Martin Caraher and Annie Anderson examine the evidence
There is growing evidence for the protective effect of fruit and vegetables against chronic diseases such as chronic heart disease and cancer (see box below). The World Health Organisation (WHO) recommends that people should eat at least 400g (about five portions) of fruit and vegetables a day, which could reduce overall deaths from chronic diseases (such as heart disease, stroke and cancer) by up to 20 per cent.
While the scientific evidence of the benefits of consuming fruit and vegetables are convincing the challenge remains one of translating policy into action, particularly for those groups who have problems accessing fruit and vegetables or accepting the cultural challenge to current eating habits.
One attempt to address these challenges is set out in The NHS Plan for England that endorses the need to eat more fruit and vegetables, and sets out plans for both a national school fruit scheme and a five-a-day programme to help increase fruit and vegetable consumption. The purpose of the National School Fruit Scheme is to provide, free of charge, a piece of fruit on each school day to over two million children aged four to six from 2004.
The first phase began in November 2000 with the provision of free fruit in 33 schools in three health action zones. The scheme was extended to over 500 schools (covering 80,000 children) in 25 HAZs across England in 2001. In the run-up to 2004, £42m is being made available to extend the scheme to over one million children from 2002. The funding will come through the New Opportunities Fund and areas of high deprivation will be given priority. The scheme is not simply aimed at increasing access to fresh fruit but also educating children through good practice and fostering an eating pattern that it is hoped will be maintained into adulthood.
“One in five children in the UK eat no fruit in a week”
The Five-a-Day programme currently has five pilot sites: in Hastings, Airedale and Craven, Sandwell, Somerset and County Durham. These are research-based community initiatives that aim to increase fruit and vegetable consumption in deprived areas. The five sites, which cover a million people, aim to address what are known as the five As: awareness, acceptability, affordability, availability and accessibility of fruit and vegetables. An additional £10m is being made available the New Opportunities Fund to develop the initiatives.
Current understanding and consumption in the UK
A survey for the Food Standards Authority widespread recognition of the need to consume more fruit and vegetable but less of what constitutes a portion or recommended amount. Only one-third of respondents knew the correct number of portions recommended for daily consumption, far more thought it was less than five a day. There was confusion over portion size: 71 per cent correctly identified an apple as one portion, while only 33 per cent correctly identified two plums, with even fewer (25 per cent) knowing that two tablespoons of vegetables was equal one portion.
In the UK, average consumption is three to four portions a day, although there are marked regional and social differences: unskilled groups tend to eat around 50 per cent less than professional groups. The National Diet and Nutrition Survey, published in July 2000, found:
- Children ate only two portions of fruit and vegetable a day, compared with expert recommendations for five;
- One in five children ate no fruit in a week and three in five ate no leafy green vegetables;
- Children in low income groups were 50 per cent less likely to eat fruit and vegetables;
- In Scotland, 46 per cent of boys did not eat fresh fruit daily.
A report from the Office for National Statistics paints a complicated picture which belies the simple belief that those on low incomes eat less fruit and vegetables. It found that families where the head of household earned in excess of £640 a week ate twice as much fruit as those where income was less than £160 a week. This is not surprising and seems to be in line with general opinion, but the figures for vegetable consumption show a more complex picture.
Low-earning households, pensioners and those with no earner ate more fresh potatoes and fresh green vegetables than high-income households. Those with one or more earners ate the same amount of vegetables regardless of whether the head of household earned more than £640 a week or less than £160 a week.
Low consumption of fruit among low-income groups may be the result of cultural and financial restraints. The short shelf life of fruit and storage problems in the home put constraints on those on low incomes.
Policy implications
The establishment of fruit and vegetable co-operatives in the community has been popular in the context of pilot initiatives such as health action zones and healthy living centres. Community development initiatives can help address problems of physical and economic access to food and can offer work experience, transferable skills and provide wider social benefits for the community.
Community projects have been promoted in the WHO Urban Food and Nutrition Action Plan, which encourages the growing of food in urban environments and the setting up of local means of distribution. It should be stressed, however, that many studies of community food initiatives conclude that ‘food projects are clearly not the only way to answer health inequalities, but they can be part of a wider strategy’. It is important to be aware of the small-scale operations of many projects, making them unlikely candidates for alleviating food insecurities in the UK.
“There is also a need to address the commercial and ecological aspects of food policy”
The benefits of increasing fruit and vegetable intake among young children are to be encouraged, but the current policy initiatives based on primary school children and community development interventions raise wider public health concerns (see box below).
Food culture – as a part of our recent heritage – is in many parts of the UK nutritionally unimpressive but that does not stop poor food choice being viewed as desirable, normal, familiar, comfortable and, indeed, seen as an example of social inclusion.
Changing what is deemed acceptable is only partially about what parents have set out for us to learn. Eating habits are maintained by what society deems acceptable, a view acquired by observing what your peers do and what the media tells us our peers do through advertising.
Fruit and vegetable-based schemes need to be encouraged and supported, but there is also a need to place them within broader public health agendas that address the commercial and ecological aspects of food policy. Making a start that is visible and measurable is welcome, but let us look forward to genuine progress in the next few decades.
Martin Caraher is reader in food and social policy at the centre for food policy, Thames Valley University, and Annie Anderson is professor of food choice at the centre for public health nutrition research, University of DundeeThe preventive effects of diet
Evidence of a contribution to cancer prevention
Diet is estimated to contribute to the development of one-third of all cancers. COMA’s Working Group on Diet and Cancer concluded that, overall, the evidence was moderately consistent with higher vegetable consumption reducing the risk of colorectal cancer, and higher fruit and vegetable consumption reducing the risk of gastric cancer.
There is weak but consistent evidence, based on fewer data, that higher fruit and vegetable consumption would reduce the risk of breast cancer. In addition, there is moderately consistent evidence that higher consumption of fruit is associated with a lower risk of lung cancer (although the effect of smoking is the major environmental consideration).
These cancers represent a significant proportion of cancers in men and women. Even a small reduction in relative risk would have important public health benefits in terms of the absolute numbers affected. The World Cancer Research Fund estimated that increasing fruit and vegetable consumption could prevent 20 per cent or more of all cases of cancer.
Evidence of a contribution to cardiovascular disease prevention
The results of a 1997 systematic review were consistent with a strong protective effect of fruit and vegetables for stroke and a weaker protective effect for coronary heart disease.
Studies published since this review have also found a protective effect. For example, a study among US health professionals found that an increase of just one portion of fruit and vegetables a day lowered the risk of coronary heart disease by 4 per cent lower risk and the risk of stroke by 6 per cent, after controlling for other risk factors.
Pilot school and community interventions
One part of the evaluation of the fruit in schools initiative carried out by the National Foundation for Education Research and ADAS Consulting Ltd involved 80,000 children in over 500 schools, with free fruit provided mainly in the HAZ areas. It found that:
- 80 per cent of children took the fruit provided
- Consumption levels in most schools were maintained or increased
- 99 per cent of schools saw the scheme as a way of improving children’s health
- 97 per cent of schools felt the scheme supported learning about healthy eating
The Five-a-Day projects in the community have centred on five sites in England and have involved activities such as:
- Mapping access to and increasing availability of fruit and vegetables
- Establishing local co-ops to improve the affordability and accessibility of fruits and vegetables
- Working with local food retailers to improve availability and delivery services for those most in need
- Developing skills in growing and preparing fruit and vegetable dishes to help acceptability and awareness
These projects are due to report later this year, with the results available soon after.
Community development approaches have been used to bridge the gap between knowledge, access and affordability of a healthy, balanced diet.
Fruit and veg in schools: some issues to chew on
Is targeting primary school children too late or too early? Although it hard to present a better case for any other age group, cynics will ask whether these learnt eating habits can be maintained in later years
The free fruit scheme partially addresses access and affordability of fruit for children – but how best to target the rest of the family, whether in school, community, workplace (or unemployment) remains a challenge
The advantage of school programmes is that peer behaviour can have a large effect because fruit is provided to everyone (not just those who want and can afford it). So school schemes are a good context for research into fruit consumption – not something that can be observed in every household in the country
One possible disadvantage is that the schemes diminish the parent/guardian’s responsibility for nourishing children – so it may be less likely that the remaining balance of the diet will be provided. But it may be easier to provide the remaining balance than the whole day’s nutrition requirements. Whether school fruit and vegetable initiatives support or undermine household food security is still unknown
School feeding programmes have many critics (often economic) but they can set standards that reflect nutritionally desirable goals. Some critics argue that school food provides nourishment only on school days, and that nutirition on non-school days get ignored
There may be worthwhile educational as well as nutritional outcomes. The benefits of fruit and vegetable schemes in a school, whether in breakfast clubs or as part of tuck shops, include positive effects on involvement in school activities, educational achievement and behaviour
Providing fruit in schools and the use of community development initiatives such as fruit and vegetable co-ops, delivery schemes and so on are no substitute for ‘upstream’ issues addressing access and affordability of fruit and vegetables. Local food projects cannot replace – and should not be seen as substitutes for – local, accessible shops offering a range of food, including fruit and vegetables. Retailers at all levels will remain the major providers of fruits and vegetables
Ecological and sustainability issues seem to be neglected but clearly need to be addressed: for example, where do the fruit and vegetables come from – and is there an increase in ‘food miles’ and a consequent increase in pollution? This need not be the case: the North Karelia project demonstrates how it is possible to work with local growers and retailers to change the fruit and vegetable habits of a community
But such change takes a decade to achieve and requires an emphasis on food policy at local, regional and global levels. A scheme in Somerset has shown how it is possible to change supply systems to encourage the delivery of apples from a local orchard to three schools – and has plans to supply a further four
A public health approach is needed that addresses practical barriers, such as limited availability of fruit and vegetables in certain areas, or places such as work canteens. Anderson et al evaluated an education intervention to increase fruit and vegetable intake and found that support of family and friends, food costs, time constraints and shopping practicalities were barriers to greater consumption
Multidisciplinary approaches are also needed. In work with schools, Anderson and Bell found no significant improvement in overall dietary intake as a result of a breakfast club. So it is important not to expect single-issue programmes to tackle the bigger cultural issues related to fruit and vegetable consumption. Increasing access and affordability can help, but may not achieve any appreciable change in diet unless acceptability is also considered
