Deanna K. Olney

Objective: Household Consumption and Expenditure Surveys (HCES) are increasingly used to assess diets in low- and middle-income countries, but their validity compared to individual-level dietary data remains uncertain. We assessed the strengths and limitations of HCES data for informing strategies to improve diets and nutrition in Tanzania. Design: Exploratory analysis of food group consumption from HCES (individualised using the adult female equivalent approach) and 24-h dietary recall (24hR). We examined concordance and trends by socioeconomic characteristics between methods for 10 food groups and fortifiable food vehicles. Setting: Rural Arusha and Kilimanjaro regions, and national data from the Tanzania National Panel Survey Wave 5. Participants: The analysis included 2599 adult women who completed a 24hR and lived in 2604 households contributing to HCES data in Arusha and Kilimanjaro. Nationally, 4469 households were included, with a regional subsample of 370 households from Arusha and Kilimanjaro. Results: Dietary patterns were similar using HCES and 24hR data, including low consumption of nutrient-dense foods, while HCES were effective at capturing usual intake of food items eaten episodically. However, compared to 24hR data, energy intakes were substantially lower using HCES data, particularly in large households (42% difference), while there was poor concordance between methods for fruit and meat consumption and for wealth-related trends in cereal and vegetable intake. Conclusion: HCES data can provide valuable insights for nutrition policy and planning; however, careful communication and interpretation of evidence is required, given limitations such as assumptions on within-household allocation of foods. Methods development could reduce measurement error.

Globally, 75% of adolescents do not meet recommendations for fruits and vegetables (F&V) consumption. This study investigated drivers of F&V choices among adolescents in Benin and identified barriers and facilitators to modifying F&V consumption. We conducted 16 focus group discussions (FGDs) with 126 adolescents and 5 semi-structured school observations in December 2024. FGDs were purposively chosen to explore variation by region (north/south), school location (urban/rural), adolescent age (12–15 years/16-18 years) and gender (boys/girls). Inductive and deductive thematic content analysis was performed using Atlas.ti . Findings showed that adolescents perceived a healthy diet as one composed of meals providing nutrients and strength, and including F&V. At home, adolescents mentioned eating staples and other vegetables more than other food groups. The foods adolescents reported typically eating at school varied by age, gender, and location. The primary categories of factors that influenced adolescent F&V choices were: intrapersonal (knowledge related to healthy eating and the nutrition and health benefits of F&V, taste preferences, and health prioritisation), socio-cultural (family and peer influences), and food environment (low availability, low affordability, convenience, and desirability). DFC factors were consistent across adolescent age, gender, and location. Multiple, dynamic, and multilevel factors influence adolescent F&V choices. Interventions that simultaneously address multiple barriers and involve family and peers are likely to be more successful in promoting F&V consumption and healthy diets than interventions only addressing individual barriers. Key messages: According to adolescents in Benin, a healthy diet was one composed of meals providing nutrients and strength and including fruits and vegetables (F&V). Intrapersonal, socio-cultural, and food environment factors influenced adolescent F&V choices regardless of adolescent gender, age, and location. Adolescent F&V choices are influenced by a dynamic interplay of multiple factors. Thus, interventions to improve adolescent diets should likely address several critical barriers in an integrated and holistic manner.

Improving diets can improve nutrition and health outcomes. In this supplement, evidence from five low-and-middle-income countries on the country specific dietary (including F&V) intake patterns, nutrition issues and evaluated solutions to improve diets across population groups is presented. Based on this evidence, the final paper offers perspectives and future priorities.

Suboptimal diets, including low fruit and vegetable (F&V) intake, are major contributors to malnutrition and non‐communicable diseases (NCDs) in Sri Lanka. Understanding dietary patterns is essential for addressing these challenges. This scoping review synthesizes the literature on diet, F&V intake, and nutritional status across different population groups in Sri Lanka. Searches were conducted in PubMed in October 2023. In total, 30 publications on diet, 13 on F&V intake, and 26 on nutritional status met the inclusion criteria. Sri Lankan diets were found to be rice‐dominant with limited variety of nutrient‐dense foods such as animal‐source foods (ASF) and F&V. Trends in nutritional status varied across life stages. Among children < 5, undernutrition was prevalent, with stunting affecting 14%–21%, wasting 10%–15%, and underweight 17%–21%. Anemia was found in 8%–15% of children < 5 and 25%–30% of pregnant women. Micronutrient deficiencies, particularly vitamin D, iron, and zinc, affected more than one‐third of pregnant women. In adults, over one‐third were overweight/obese, 8%–12% had diabetes, and 20%–25% had hypertension. Diet, F&V intake and nutrition outcomes also differed by socioeconomic, demographic, and geographic characteristics, with estate sector residents, Indian Tamil populations, and low‐income groups disproportionately affected by poor diet quality, low F&V intake, insufficient nutrient intake and malnutrition, while women (vs. men) and urban (vs. rural/estate) residents exhibited higher prevalence of overweight/obesity and NCDs. This review revealed evidence gaps such as the lack of recent dietary intake data based on individual quantitative dietary assessments that limit understanding of current diet adequacy. Additionally, only one impact evaluation designed to improve diet was identified. More research is needed to understand how to effectively improve diet including increasing intake of F&V and ASF in Sri Lanka.

Adequate amounts of fruit and vegetables (F&V) are an important part of a healthy diet, yet intake is suboptimal in most population groups worldwide. To better understand the evidence of strategies aiming to improve F&V intake, we conducted a scoping review of interventions assessing the impact on F&V intake, including those aiming to improve F&V intake explicitly and those targeting diet, health, lifestyle, or food environment generally. Among all eligible interventions reviewed, most of which were implemented in high-income countries, about half reported a significant positive impact on fruit and/or vegetable intake. Interventions that used a multicomponent strategy (61%) and those that focused on F&V specifically (72%) were most likely to find a significant increase in fruit and/or vegetable intake. Detailed summaries are provided in 2 accompanying articles. In the present article, we put these findings into perspective. Specifically, we considered the evidence for 4 target countries of the Fruit and Vegetables for Sustainable Healthy Diets Initiative: Benin, the Philippines, Sri Lanka, and Tanzania. When considering available evidence at the national level, there is a paucity of information from intervention trials despite evidence of inadequate F&V intakes in each of these countries. When considering available evidence at the global level, and especially for low-and-middle income countries, there is a critical need to strengthen the evidence across various intervention strategies, particularly related to targeting, timing, intensity, duration, frequency, and other key characteristics, to better understand how to enhance their impact on F&V intake in various population groups and contexts.

Background: Despite well-documented health benefits, fruit and vegetable (F&V) intake remains below recommended levels globally. Objectives: This scoping review aimed to identify effective intervention strategies to increase F&V intake. Methods: We searched PubMed and Web of Science (February 2023) for intervention studies assessing impact on F&V intake. Eligibility criteria included studies published in English since 2012, a valid control group, ≥2 weeks duration, and ≥50 participants per intervention arm. Analysis was done by intervention comparison. Findings were described by summarizing proportion of intervention comparisons reporting statistically significant increases in fruit, vegetable and/or combined F&V intake across standalone (nutrition communication, social protection, agriculture or food environment restructuring) and multi-component strategies. Results: A total of 284 intervention comparisons (223 unique studies) were included. The majority of comparisons (191/284) came from high-income countries (HICs) and 93/284 from low- and middle-income countries (LMICs). Nutrition communication was the most common standalone strategy, with 121/218 comparisons reporting positive impacts on fruit, vegetable and/or combined F&V intake. Fewer studies evaluated standalone social protection (13/284), food environment restructuring (4/284), or agriculture strategies (3/284). Among the limited interventions, 7/13 social protection and 3/4 food environment restructuring comparisons reported positive impacts, while none of the 3 standalone agricultural interventions did. Multi-component interventions demonstrated potential with 28/46 comparisons having positive impacts. Conclusions: Some of the intervention strategies showed potential for increasing fruit and/or vegetable intake. However, given the heterogeneity of the interventions, small number of studies for some strategies and limited evidence from LMICs, more rigorous, context-specific research is needed.

Objective Household Consumption and Expenditure Surveys (HCES) are increasingly used to assess diets in low- and middle-income countries, but their validity compared to individual-level dietary data remains uncertain. We assessed the strengths and limitations of HCES data for informing strategies to improve diets and nutrition in Tanzania. Design Exploratory analysis of food group consumption estimated from HCES (individualized using the adult female equivalent approach) and 24-hour dietary recall (24hR). We examined concordance and trends by socioeconomic characteristics between methods for 10 food groups and fortifiable food vehicles. Setting and Participants Dietary 24hR of adult women (n=2,599) and HCES data (n=2,604) were collected from the same households in rural Arusha and Kilimanjaro regions in Tanzania. Additionally, food group consumption was estimated using HCES data from the Tanzania National Panel Survey Wave 5 at the national level (n=4,469 households) and for Arusha and Kilimanjaro regions (n=370). Results Dietary patterns were similar using HCES and 24hR data, including low consumption of nutrient-dense foods, while HCES were effective at capturing usual intake of food items eaten episodically. However, compared to 24hR data, energy intakes were substantially lower using HCES data, particularly in large households (42% difference), while there was poor concordance between methods for fruit and meat consumption and for wealth-related trends in cereal and vegetable intake. Conclusion HCES data can provide valuable insights for nutrition policy and planning, however, careful communication and interpretation of evidence is required, given limitations such as assumptions on within-household allocation of foods. Methods development could reduce measurement error.

Increasing fruit and vegetable (F&V) intake is essential for transitioning toward healthier, more sustainable diets. To design effective intervention programmes to promote F&V intake, it is crucial to understand intake levels and dietary patterns across different demographic groups as well as populations' nutritional status. We conducted a scoping review to summarise scientific evidence on the diet, F&V intake and nutritional status of the Fijian population. In January 2023, we searched PubMed for relevant literature. Studies were eligible if they were published in English since 2012 (for dietary intake and nutritional status) or since 2002 (for F&V) and met predefined inclusion criteria. We identified 163 articles reporting on diet, 47 on F&V intake and 95 on nutritional status. After further review and confirmation that articles met inclusion criteria, data were extracted from 16 articles on diet, 8 on F&V and 13 on nutritional status. The scoping review revealed a shift in Fiji from traditional foods to processed, unhealthy foods, high salt intake and poor dietary diversity. F&V intake was low, with only a quarter of adults and adolescents consuming the recommended daily servings. Approximately 7% of children under‐five were stunted, and 8% were overweight. At least 25% of adolescents were overweight or obese, whereas 10% were underweight. Over 30% of adults were obese, and at least 25% were overweight. Overweight/obesity was higher in females and Indigenous Fijians; underweight higher among Indo‐Fijian adolescents, especially males. Strengthening population‐wide efforts to promote healthy lifestyles and dietary habits is crucial to address these issues.

A healthy diet low in fat, sugars, and sodium and high in fruit and vegetables (F&V) is recommended to ensure overall health and reduce risk of noncommunicable diseases. However, despite the evidence of strong health benefits, dietary intake of both fruit and vegetables is inadequate in most populations worldwide. To better understand the state of the evidence of what has worked to improve F&V intake, we conducted a scoping review to summarize available evidence of interventions focusing on the impact on F&V intake, including those aiming to improve F&V intake specifically and those targeting diet, health, lifestyle or environment more broadly. We chose to take a global view as lessons learnt from studies in high-income countries may provide important insights for other contexts. The evidence summarized in this Food and Nutrition Bulletin supplement can be used to inform program and policy design as well as future research areas.

Background: Adequate fruit and vegetable (F&V) intake is important for health, yet populations globally are failing to meet recommendations. Objective: A scoping review to summarize available evidence of evaluations of interventions to increase F&V intake globally, focusing on target populations, intervention strategies, research methods, and summarizing their evaluated impacts. Methods: We searched PubMed and Web of Science in February 2023 for intervention studies in which dietary intake of fruit and/or vegetables were documented. Eligible studies included all age groups, excluding those targeting populations with specific disease-related conditions, such as cancer patients/survivors. Only articles published in English since 2012 were included in the review. Results: We identified 6338 articles, with 226 meeting inclusion criteria, comprising 223 unique studies and 284 intervention comparisons. Most comparisons occurred in high-income countries ( n = 192) compared to low- and middle-income countries ( n = 92). Randomized controlled trials (RCTs; 37.3%) and cluster RCTs (52.5%) were predominant. Interventions primarily targeted adults (31.7%), school-aged children (18.0%), children under-five (14.4%), and adolescents (13.7%), lasting an average of 24 weeks (range: 2 weeks to 20 years). Food-frequency questionnaires (59.2%) and 24-h recalls (26.8%) were the most used dietary assessment method. Health and nutrition communication (75.9%) was the most common intervention, utilizing interpersonal communication, mass media, and information-communication technology, often in combinations. Positive impacts on fruit (43.9%), vegetable (40.2%), and combined F&V intake (53.0%) were observed in nearly half the intervention comparisons. Conclusions: These findings highlight the predominance of health and nutrition communication interventions, predominantly in high-income countries, showing mixed success in improving F&V intake, emphasizing the need for context-specific strategies and standardized methodologies to design sustainable, cost-effective interventions for better diet quality and health outcomes. Plain language title: A literature review assessing what we know and do not know about efforts to improve fruit and vegetable intake across the world.