Background
The prevalence of consumption of fruits and vegetables below the recommended daily intake is a persistent phenomenon in many developing countries [
1‐
3]. Nearly 3.0% (approximately 1.7 million) of global deaths are attributable to low fruits and vegetable consumption. Insufficient intake of fruits and vegetables results in about 14% of gastrointestinal cancer deaths, 11% of ischaemic heart disease deaths and 9% of stroke deaths [
4,
5]. In South Africa, a comparative burden of disease study reported that low fruits and vegetable intake accounted for 3.2% (1,667) of 521,000 deaths and a 1.1% disability-adjusted life years (DALY) [
6].
Adequate intake of fruits and vegetables is considered an essential option for disease prevention and maintaining optimal health [
7,
8]. Increasing evidence shows that the consumption of fruits and vegetables prevent weight gain, and reduces the incidence of type 2 diabetes, and the risk of cancer, certain eye diseases, dementia and osteoporosis [
9,
10]. In a recent multi-country Prospective Urban and Rural Epidemiology (PURE) study involving low-, middle-, and high-income countries, consumption of higher portions of fruits and vegetables (seven portions and above) indicated a reduced risk for cancer (0.75 (0.59–0.96) and cardiovascular mortality (0.69 (95% CI: 0.53–0.88)) [
3]. An increased proportion of fruits and vegetable consumption is also linked to a decrease in all-cause mortality [
11].
According to the World Health Organization reports, eating at least five portions of fruits and vegetables (a recommended minimum of 400 g) per day reduces the risk of non-communicable diseases (NCDs) and also ensures an adequate daily intake of dietary fibre [
4,
5]. However, studies showed that consumption of these foods in the recommended amounts is very low in poor populations unlike in Europe and the USA [
12]. The ‘at-least-five-portions’ recommendation for fruits and vegetables intake is largely based on observational data from Europe and the USA, and therefore, has not been feasible in many resource-poor and economically disadvantaged settings [
12,
13]. A multi-country study by Hall et al. reported that 77.6% of men and 78.4% of women (based on findings from 52 low- and middle-income countries) consumed less than the minimum recommended five daily servings of fruits and vegetables [
14]. The South African National Health and Nutrition Survey 2013 (SANHANES-1), for an example, reported a very low intake of fruits and vegetables among South Africans [
15]. This situation is probably due in part to the socioeconomic deprivation resulting high proportion of unemployment, and lack of income and limiting choice of diet in the population [
3].
Studies on food prices and diet cost had pointed to the socio-economic disparity in dietary intake and health [
16]. A systematic review and meta-analysis have also reported that consumption of acceptable healthier food (example, fruits and vegetables) in many studies are commonly associated with higher costs, disproportionally high in low-income settings [
16,
17]
. In many developing countries, inadequate consumption of fruits and vegetables have been documented with substantial variability by country and socioeconomic status [
14,
18]
,.
In a study conducted in seven African countries in 2010, a considerable proportion of school boys and girls consumed less than one fruit (36 and 33%) and vegetable (23 and 22%) per day [
19]. A large multi-country study involving South African cohorts recently reported a low consumption of healthy food particularly, fruits and vegetables, and that this decreased with increasing cost [
3]. There is generally a disproportionately high level of sugar-sweetened beverages (SSBs) intake reported among the poor food insecure adults, which is believed to result (perhaps, in part) in a decline in intake of fruits and vegetables in the poor settings of South Africa [
20‐
22].
Although South Africa is undergoing nutrition and epidemiological transitions, research relating to the food environment, access, purchase and consumption patterns of healthy diets, particularly, fruits and vegetables in resource-poor settings is limited. Moreover, the findings from the food-based dietary surveys in South Africa have shown that the recommended 5-servings guideline (i.e. 2 servings of fruits and 3-servings of vegetables/day) has not been a norm in economically disadvantaged communities [
23,
24]. The national survey (SANHANES-1, 2014 version) further showed that only 4.6% of the adults consumed four or more fruits per day while the majority (52.2%) reported consuming one to three fruits per day (irrespective of portion size) [
25]. This situation is similar in other low-middle income settings, as a recent study in Tanzaina, reported that 82% of the participants aged ≥15 years did not meet the recommended daily fruits and vegetables intake, and only 16 and 44% had consumed fruits and vegetables daily, respectively [
26].
Furthermore, the SANHANES-1 study, reported that 25.6% of South Africans had low score (i.e.0–2 fruits/day) for daily fruits and vegetables intake. This low intake has been linked to the high cost and unavailability in poor communities [
15]. In the present study, we assessed the frequency and pattern of intake of commonly available fruits and vegetables in resource-poor South African communities, and the possible factors associated with daily intake of at least two portions.
Discussion
Adequate intake of fruits and vegetables is considered an essential option for disease prevention and maintaining optimal health, our study points to low purchase and inadequate daily intake in these communities. There were disparities in the purchases and consumption patterns of fruits and vegetables by rural-urban location. There were variations in the commonly purchased fruits and vegetables by location. Daily consumption of fruits and vegetables were also low particularly in the rural community compared to the urban.
The analysis also showed that those who had spent R1 000 (USD71.4) or more per month on groceries were mostly like to consume a portion of fruits and vegetables daily. In contrast, those who consumed SSBs daily/weekly were significantly less likely to consume fruits and vegetables daily. These results are discussed in details.
Low purchase and daily intake of fruits and vegetables.
This study has shown that the amount spent on monthly grocery purchases and transport was highest in the township zones/hostels with the least socio-economic status confirming previous studies in the general population of South Africa [
1]. In addition, patterns of purchase and daily consumption of fruits and vegetables were lowest in the rural and poor urban area, even though this setting seems to be producing the fruits and vegetables for the urban population. These findings point to the challenge of equity and food insecurity in disadvantaged settings and may inform sustainable intervention on food security.
In addition, the urban community purchased fruits and vegetables most often on a weekly basis, whereas in the rural community a substantial proportion (~ 40%) purchased fruits and vegetables monthly or seldomly. This underlying pattern of fruits and vegetable purchases may be linked to their high cost often reported in poor South African settings [
1,
21,
32]. This study confirms the previous reports that indicated a low intake of fruits and vegetables reported in many South African settings, particularly in the rural and urban poor communities
([
1,
3,
23]
).
The national survey (SANHANES-1) conducted in 2012 also reported a low intake of fruit and vegetables of two or fewer portions per day in about a third of South Africans
([
15]
). Spending more than R1000/month and having personal transport to purchase groceries were key determinants of intake of daily fruits and vegetables. However, a study of non-African populations had shown that determinants of low consumption of fruits and vegetables were: perception on affordability, and absence of financial means to buy fruits and vegetables daily, younger age (< 55 years), and education level lower than tertiary [
33]. The inverse association of daily/weekly SSBs intake with daily consumption of fruits and vegetables reported in this study is of considerable importance. The increasing access to readily available and cheaper SSBs can lead to substitution of fruits and vegetables (which are often costly) with SSBs for in economically disadvantaged communities [
34]. Although inadequate fruits and vegetable consumption is a problem worldwide [
35], the situation in South Africa is of critical concern, as most people in the disadvantaged communities do not have access to farmland to produce their fruits and vegetables. Also, poor access to land has made farming and gardening difficult in the disadvantaged communities, compounding the problem of food insecurity in this setting [
36]. The impact of the increasing access to cheap SSBs on fruits and vegetables intake was reported in a previous study [
21]. Also, a recent study by Okop et al. [
22] had reported that persons from food-insecure South African households in two selected communities had consumed more SSBs servings per week than the food-secure ones, and this was also associated with weight gain. Notably, vegetable consumption among South Africans, for instance, had decreased by about 8.0% between 1999 and 2012 [
21]. Moreover, in these impoverished communities with high unemployment, the income level of the study participants had no significant association on the daily intake of fruits and vegetables. Having no income, being unemployed with limited social agencies, place many in a situation with no choice for healthy nutrition, as striving to survival (‘striving to eat anything to fill the stomach’) will be the ultimate goal.
Our findings also show that there was no significant association between owning a functional refrigerator and daily intake of fruit and vegetables. This could likely mean that even though people may have refrigerators to store fruits and vegetables, they may not have enough to last longer for sustained daily consumption. Besides storage, the effect of seasonality on the intake of fruits and vegetables could also affect the pattern of purchase and consumption. Improving purchase by reducing prices (through subsidies), increasing access to fresh fruits and vegetables (through incentivising with coupons system) [
37] could probably increase purchase and invariably, daily intake considerably according to Temple et al. [
34]. Communal or shared-refrigeration at the community level can be supported to enhance preservation of fruits and vegetables for a longer period, and to avoid daily purchase. Institutional policies on fruits and vegetables for health reasons should include strategic school and worksite feeding programmes that support adequate nutritious food.
Summarily, this study had shown that the amount spent on monthly grocery purchases and transport was highest in the township zones/hostels with the least socio-economic status confirming previous studies in the general population of South Africa. In addition, patterns of purchase and daily consumption of fruits and vegetables were lowest in the rural and poor urban area. These findings point to the challenge of equity and food insecurity in disadvantaged settings and may inform sustainable intervention on food security.
Impact of affordability and purchase of SSBs and snacks
This study showed that substantially high proportions of those living in socio-economically disadvantaged communities (based on our sampled population), particularly, the urban township had purchased sugary drinks daily/weekly and had spent a substantial amount of their monthly household income on groceries, utilities and transport. Moreover, the average monthly household expenditure on groceries (including fruits and vegetables) was significantly higher than the expenditure on other household items and utilities put together, even though less than 3% of households earned US$357 (R5000)/month. Moreover, in the two study communities, only very few households (17.8%) own gardens where they could produce fruits and vegetables for their consumption. The urban informal low SES areas had no one who owns a garden or is growing fruits or vegetables for personal consumption. These findings point to economic deprivation due to lack of jobs, employment, and access to land for cultivation by the disadvantaged black South Africans.
In addition, purchasing and consuming fruits and vegetables daily or weekly tended to be lowest in the rural and poor urban areas, as previously reported in poor South African settings, perhaps, due to poverty and food insecurity [
21,
38]. It could be implied that, although the study participants had access to the commonly available fruits and vegetables, purchasing and consuming these needed some agencies to be actualized. Findings from recent study in Cape Town collaborated this assertion, as it showed that persons living in poor-resource areas (usually the food insecure persons) have poor purchasing power and purchased fruits and vegetables less frequently [
18]. Also, these persons purchased more of less expensive SSBs and snack items more frequently than those in high-income areas. Moreover, the formative evidence from a 4.5 year longitudinal cohort, including 800 adults in South Africa (SA), from the harmonised STOP-SA study indicated that: i) the socio-economically disadvantaged (mainly the food-insecure) persons are more likely to purchase SSBs and salty snacks, and less likely to purchase vegetables/fruits, than those that are food secure, and ii) high intake of SSBs, and low intake of vegetables/fruits predicts weight gain over this period [
16,
17].
In summary, these findings could imply that due to very low and competing needs for utilities and transport, and with the little means for choice, dietary preference for sugary beverages and snacks food might be one main choice. This assertion is collaborated by previous studies which have shown that access to cheap sugary drinks can impact negatively on the daily intake of fruits and vegetables in this setting [
16,
39]. In contrast, a study conducted in 7 Asian countries has shown that the use of substances such as alcohol had no significant influence on the poor intake of vegetables and fruits [
40].
Furthermore, our study showed that a higher proportion of those who reported having diabetes mellitus did not consume a portion of two fruits and vegetables daily. This finding has implications for the management of patients with diabetes in poor communities. Moreover, the intake of a diet deficient in fruits and vegetables and other nutrients is linked with increasing NCD [
41].
The issues of cost, availability and access to healthy food are considered key factors that influence the purchase and consumption of these foods. In this study, those living in economically disadvantaged areas (with low income and high unemployment) spent more on groceries - mainly fruits and vegetables. This finding confirms the findings from recent and previous studies indicating that persons living in low-income households or settings spend more on fruits and vegetables [
3,
16]. In addition, those who could afford R1 000 groceries per month were about two times more likely to consume at least two portions of fruits and vegetables. According to Temple et al., a healthier diet is largely unaffordable for most South Africans, as this can cost as much as 69% more than a typical South African diet [
34]. Taste, health, nutrient content, safety and quality, and ease of preparation are considered after the price of food [
42].
The challenging food environments and the increasing retail supermarkets in economically disadvantaged communities, unfortunately, provide easy access to available and relatively cheaper, high-calorie ‘obesogenic’ food and SSBs [
43,
44]. The above challenge and the high level of inequality, poverty and unemployment might be responsible for the low intake of fruits and vegetables among those living in poor settings. These have been reported to often purchase cheaper and affordable high calorie unhealthy (obesogenic) foods perhaps due to cost and access [
21]. Intake of these obesogenic foods, particularly, SSBs and snacks were recently linked to relative weight gain in this same study population [
22]. As indicated by our study, affordability and access to SSBs are considered important factors that can affect adequate fruits and vegetables intake patterns among the poor. Interventions that can promote sustainable production and access to affordable varieties of fruit and vegetables should, therefore, be implemented in resource-poor communities.
Strategic interventions are needed
Strategic interventions that promote sustainable access to affordable fruits and vegetables and discourages the aggressive promotion of SSBs in the communities is therefore critical to addressing the problem of low intake. It is envisaged that this will mitigate the health impact of low intake of fruits and vegetables in the resource-poor populations. There is the need to build the capacities of Stokvel (an example of rotating savings and credit associations – ROCSA) highly prevalent in South African communities to create demand for healthy food in the communities. This can be achieved, if Stokvels, such as grocery or saving stokvel groups harness their resources to buy bulk at the source and deliver to their members, and create awareness on universal accesses to healthy food. Furthermore, awareness campaigns on the health benefits of fruits and vegetables consumption should be undertaken and target meso-level actors in the food environment such as community leaders, consumers in the households and schools, and food producers and handlers. These set of actors can be reached through community-based health promotion programmes targeting specific food players in the communities. In addition, a combining subsidies on healthy foods and taxes on unhealthy foods which has been shown to be cost-effective in improving diet and population-health should be commissioned by the government [
45]. Finally, policies that seek to promote subsidies on healthy food should be implemented in the Provinces to bring about sustainable access to affordable fruits and vegetables particularly.
Strengths and limitations of the study
We obtained our data from two South African economically disadvantaged communities which allows comparison of food purchasing and consumption patterns among poor communities in two settings. Generally, the two communities had low monthly household income and high (77%) unemployment rates which might have impacted on the purchasing power. Many of the types of fruits and vegetables were also purchased on a monthly or weekly basis, leading to a higher weekly/monthly consumption but low daily consumption as suggested in the food-based dietary guidelines.
This study has some limitations. The quantified dietary data were not collected making it impossible to report on the average daily amount of fruits and vegetables consumed per person. Also, in our multivariate logistic model, we did not totally control for all expected confounders such as price of and access to fruits and vegetables, food insecurity, smoking status, and number of children in the household which could influence intake of fruits and vegetables. However, we had controlled for sociodemographic factors (income, gender, age, and location), monthly expenditure on groceries, consumption of other foods (SSBs), travel to buy food, and attitudes (or preference) of fruits and vegetables as healthy food. In addition, the study participants were predominantly women, most of them unemployed, with no minimal household income, which therefore could contribute some possible bias. The skewed gender proportion could contribute a bias to the study; however, this was controlled for in our final model. Furthermore, this is a cross-sectional study, and can only allow us to determine the associations between outcome variable and explanatory variables. The findings can be applied to the poor-resource settings in South Africa and other African populations. Future studies should use larger more representative populations to determine and compare the impact of socioeconomic status (low, medium, high) on fruits and vegetables consumption in the entire population of South Africa. Future research should also consider the effect of seasonality, food insecurity on daily intake of fruits and vegetables in resource-poor settings.
Acknowledgements
The authors acknowledge the following: The PURE study research teams in South Africa, research participants, the School of Public Health and the University of the Western Cape. We also acknowledge the DST-NRF Centre of Excellence (COE) in Food Security and National Research Foundation of South Africa (NRF) for the support. Opinions, findings, conclusions and recommendations expressed in this paper are those of the authors, and the funders accept no liability whatsoever in this regard.
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