Food choice is complex and is heavily influenced by the environment one lives in(1). Pacific Island food environments, including those in Tonga, have changed considerably in recent years, making healthier food choice more challenging(2). A widespread nutrition transition across the region has contributed to an increase in the availability of, and accessibility to, highly-processed foods, and high rates of diet-related non-communicable diseases(3). While system change is needed to support the availability, accessibility and affordability of healthy foods, nutrition education plays an important role in supporting individuals, communities, and populations to navigate their rapidly changing food environments, and to encourage healthy food choice and behaviour change. Approaches to nutrition education in the Pacific Islands region vary and do not always consider the socio-cultural aspects of the food environment, especially when focusing on fruit and vegetable consumption. This work was driven by an intent to develop contextually appropriate nutrition education plans using a structured process, Design Online(4). However, to develop a nutrition education plan a critical analysis of the current motivators and facilitators for the behaviour are required. When reviewing the scientific literature there is limited information on determinants of food choice within Tonga, and more broadly within the Pacific Islands context. Therefore, the aim of this cohort study was to qualitatively explore and document the motivating and facilitating determinants of fruit and vegetable consumption in Tonga. Data collection took place during August and September 2023 on the main island of Tongatapu. Semi-structured interviews (n = 5 men, 3 women) and a focus group (n = 4 women) based on the most appropriate method of engaging with participants, were conducted in Tongan. Guiding questions were derived from Design Online and proposed within the following categories: motivating determinants and facilitating determinants. Interview responses were qualitatively analysed using an inductive content analysis model. Key categories for motivating determinants included health and nutrition knowledge, normal consumption patterns, availability and access, production, financial considerations and preferences, perceptions and practices. Key categories for facilitating determinants included education, community engagement, environmental factors, food preference, finance, and accessibility. While this work has explored motivating and facilitating determinants for fruit and vegetable consumption in Tonga with a small sample, it makes an important contribution to the limited literature. The findings of this study can be used to underpin activities, such as the design of nutrition education plans. The findings also provide a foundation for further exploration of determinants of food choice. This study was undertaken on the main island of Tongatapu, but it is of interest to explore determinants with communities who live in the outer islands, and at different time points during the year to reflect seasonality.

Associations between fruit and vegetable (FV) consumption and mental health are suggested, largely from observational studies. This systematic review aimed to identify and summarise all published controlled intervention studies investigating the effects of FV consumption on mental health in adults. Four academic databases (Medline, PsycINFO, PubMed, Web of Science) were searched on 16 September 2022, over all years, for studies that used an intervention design; included FV consumption; included an appropriate non-FV-consumption control; used a validated measure of mental health and were conducted in healthy adults or adults with solely a depressive or anxiety-related condition. Study details were tabulated and combined using meta-analyses. Risk of bias was assessed using the domains of the Cochrane Collaboration. Six studies, enrolling 691 healthy adults and reporting on one or more mental health outcomes, were found. Meta-analyses found small and imprecise effects of FV consumption for: psychological well-being (4 studies, 289 participants) standardised mean difference (SMD) = 0·07 (95 % CI −0·17, 0·30), P = 0·58, I2 = 0 %; depressive symptomology (3 studies, 271 participants) SMD = –0·15 (95 % CI −0·40, 0·10), P = 0·23, I2 = 47 % and anxiety-related symptomology (4 studies, 298 participants) SMD = –0·15 (95 % CI −0·39, 0·08), P = 0·20, I2 = 71 %. Some benefit for psychological well-being was found in change-from-baseline data: SMD = 0·28 (95 % CI 0·05, 0·52), P = 0·02, I2 = 0 %. Risk of bias was high in many studies. Limitations include the consideration only of published studies and stem from the studies found. Given the few, limited studies available and the small size of effects, stronger evidence is needed before recommending FV consumption for mental health.

Modifiable lifestyle factors, such as improved nutrition, are crucial in maintaining cognitive health in older age. Fruit and vegetables represent healthy and sustainable sources of nutrients with the potential to prevent age-related cognitive decline. The aim of this review is to synthesise the available evidence, from epidemiological and randomised controlled trials (RCT), regarding the role of fruit and vegetables in sustaining healthy cognitive function. Epidemiological studies of combined fruit and vegetable intake suggest that increased consumption may sustain cognition in later life. The evidence appears to be stronger for an association between vegetables and cognition, particularly for green leafy and cruciferous vegetables. Specific benefits shown for berries, citrus fruits, avocado and nuts suggest fruit is worthy of further investigation in relation to cognition. Data from RCT indicate benefits to differing aspects of cognition following citrus and berry fruits, cocoa and peanuts, but the data are limited and there are a lack of studies exploring effects of vegetables. There is growing evidence for an association between fruit and vegetable intake and cognitive function, but this is not always consistent and the data from RCT are limited. Issues in previous research are highlighted, such as strict exclusion criteria, absence of baseline nutritional status data and lack of consideration of individual differences, which may explain the weaker findings from RCT. Inclusion of those most at risk for cognitive decline is recommended in future nutrition and cognition research.

A high intake of fruit and vegetables (FV) has consistently been associated with a reduced risk of a number of non-communicable diseases. This evidence base is largely from prospective cohort studies, with meta-analyses demonstrating an association between increased FV intake and reduced risk of both CHD and stroke, although the evidence is less certain for cancer and diabetes. Controlled intervention trials examining either clinical or intermediate risk factor endpoints are more scarce. Therefore, evidence that FV consumption reduces the risk of disease is so far largely confined to observational epidemiology, which is hampered by some methodological uncertainties. Although increased FV intake is promoted across all dietary guidelines, national surveys confirm that dietary intakes are suboptimal and are not increasing over time. A range of barriers to increasing FV intake exist, including economic, physical and behavioural barriers that must be considered when exploring potential opportunities to change this, considering the feasibility of different approaches to encourage increased FV consumption. Such interventions must include consideration of context, for example, challenges and uncertainties which exist with the whole food system.

Xerostomia and salivary gland hypofunction are prevalent conditions in older people and may adversely influence the intake of certain foods, notably fruit and vegetables. Here, we aimed to investigate whether xerostomia and salivary gland hypofunction were associated with a lower intake of fruit and vegetables. The study included 621 community-dwelling adults, mean age 75⋅2 ± 6⋅4 years, 58⋅9 % female, who had participated in the Copenhagen City Heart Study follow-up, and undergone interviews regarding food intake (preceding month), oral and general health (xerostomia, taste alterations, diseases, medication, alcohol consumption and smoking), clinical oral examination and measurements of unstimulated and chewing-stimulated whole saliva flow rates. The average total energy intake (8⋅4 ± 2⋅7 MJ) and protein energy percentage (14⋅8 ± 3⋅1 %) were slightly below recommendations. The average fruit (234⋅7 ± 201⋅2 g/d) and vegetables (317⋅3 ± 157⋅4 g/d) intakes were within recommendations. Xerostomia and hyposalivation were more prevalent in women than in men (16⋅4 v. 7⋅1 %, P < 0⋅001 and 40⋅7 v. 27⋅5 %, P < 0⋅001). Multiple linear regression analyses revealed that older age (β −0⋅009, se 0⋅003, P = 0⋅005), smoking (β −0⋅212, se 0⋅060, P = 0⋅0005) and wearing complete dentures/being partially or fully edentulous (β −0⋅141, se 0⋅048, P = 0⋅003), but neither xerostomia nor salivary flow rates were associated with an inadequate fruit and vegetable intake, after adjustment for covariates. Older age, smoking, tooth loss and denture-wearing were stronger determinants of low fruit and vegetable intakes than xerostomia and salivary hypofunction supporting the importance of dietary counselling and maintenance of oral health and an adequate masticatory performance.

Previous research into the effectiveness of healthy eating programmes has shown increases in healthful eating behaviour in primary schools; however, data collection methods have not been sufficiently sensitive to detect micronutrient changes. The present study extends the literature by measuring individual children's intake of macro- and micronutrients at lunchtime, before and after a programme targeting children's consumption of fruit and vegetables, to identify evidence-based health benefits of programme participation. Baseline data were collected over 4 d at lunchtime in two primary schools. The Food Dudes programme was then implemented in the intervention school. Follow-up data were collected over 4 d in each school 2 months after baseline. We employed a validated and sensitive photographic method to estimate individual children's (N 112) consumption of fruit, vegetables, and their intake of calories, macro- and selected micronutrients. Significant changes were observed in the intervention school but not in the control school: Children's consumption of fruit, vegetables, vitamin C and E intake increased, while their total energy consumption, fat, saturated fat, and sodium intake decreased. The present results show that the Food Dudes programme produced a positive nutritional change, with implications for its application as a healthy eating and obesity prevention intervention. These optimistic conclusions should be tested by further research to establish the longevity of the positive effects presented here.

The consumer food environment is changing: an extensive variety of foods are now available in most markets, offering palatability, convenience and novelty. However, little is known about the availability and advertising of food items within food outlets, especially among developing countries. The present study examined these dimensions in 281 food outlets located around eighteen primary healthcare services in Belo Horizonte, Brazil, in 2013. These establishments were classified as large-chain supermarkets; specialised fruits and vegetable (F&V) markets; and local grocery stores, convenience stores or bakeries. Availability of F&V, availability of ultra-processed foods (UPF) and food advertising were compared across the food outlet categories by applying the χ2 test. Almost 60 % of the food outlets were specialised F&V markets, 21⋅4 % were large-chain supermarkets and 19⋅2 % were local grocery stores, convenience stores or bakeries. Almost 80 % contained at least eight types of fruits and vegetables, and 60 % contained UPF. Food advertisement was absent in 59⋅8 % of the food outlets, 19⋅6 % were advertising only F&V and 17⋅4 % were advertising only UPF. Higher F&V availability was noted inside specialised F&V markets and large-chain supermarkets than local grocery stores, convenience stores or bakeries. Advertising of F&V was more common within specialised F&V markets. However, large-chain supermarkets and local grocery stores, convenience stores or bakeries contained more frequent UPF food advertising isolated: 38⋅3 and 35⋅2 %, respectively. Therefore, the availability and advertising of food items within food outlets around primary healthcare services are different according to the type of food outlet.

Children’s vegetable consumption is generally below national recommendations in the UK. This study examined predictors of vegetable intake by children aged 1·5–18 years using counts and portion sizes derived from 4-d UK National Diet and Nutrition Survey food diaries. Data from 6548 children were examined using linear and logit multilevel models. Specifically, we examined whether demographic variables predicted vegetable consumption, whether environmental context influenced portion sizes of vegetables consumed and which food groups predicted the presence (or absence) of vegetables at an eating occasion (EO). Larger average daily intake of vegetables (g) was predicted by age, ethnicity, equivalised income, variety of vegetables eaten and average energy intake per d (R2 0·549). At a single EO, vegetables were consumed in larger portion sizes at home, with family members and at evening mealtimes (Conditional R2 0·308). Within EO, certain configurations of food groups such as carbohydrates and protein predicted higher odds of vegetables being present (OR 12·85, 95 % CI 9·42, 17·54), whereas foods high in fats, sugars and salt predicted a lower likelihood of vegetable presence (OR 0·03, 95 % CI 0·02, 0·04). Vegetables were rarely eaten alone without other food groups. These findings demonstrate that only one portion of vegetables was eaten per d (median) and this was consumed at a single EO, therefore falling below recommendations. Future research should investigate ways to encourage vegetable intake at times when vegetables are not regularly eaten, such as for breakfast and as snacks, whilst considering which other, potentially competing, foods are presented alongside vegetables.

Fruit and vegetables (F&V) play an important role in the prevention of obesity and other chronic diseases and low intakes have been highlighted as one of the risk factors attributing to global mortality in adults. The childhood years are a critical period during which eating behaviours and food preferences evolve, providing an opportunity to develop and foster healthy eating practices, which carry into adulthood. This review aimed to summarise dietary guidelines relating to F&V, intakes of F&V and the contribution of F&V to energy and nutrient intakes in school-aged children in Europe. The current review showed a paucity of data in relation to guidelines specific for children for F&V consumption. Where guidelines were available, they ranged from 100 to 500 g or one to three portions of F&V daily (with variations in the categorisations). A key finding was the lack of data on estimates of F&V intakes in school-aged children across Europe. Where data were available, intakes ranged from 221 to 404 g/d and were generally below the WHO recommendation of at least 400 g/d. F&V contributed low proportions of energy intake (6–9%) but made significant contributions to intakes of dietary fibre (19–37%), vitamin A (26–46%), vitamin C (32–83%) and potassium (16–27%); however, they also contributed to intakes of total (25–50%) and free sugar (7–11%). This review has highlighted the need for more data on estimates of F&V intakes in school-aged children in Europe and a need for continued promotion of F&V consumption to increase intakes in this age group.

Increased fruit and vegetable (FV) intake is associated with reduced blood pressure (BP). However, it is not clear whether the effect of FV on BP depends on the type of FV consumed. Furthermore, there is limited research regarding the comparative effect of juices or whole FV on BP. Baseline data from a prospective cohort study of 10 660 men aged 50–59 years examined not only the cross-sectional association between total FV intake but also specific types of FV and BP in France and Northern Ireland. BP was measured, and dietary intake assessed using FFQ. After adjusting for confounders, both systolic BP (SBP) and diastolic BP (DBP) were significantly inversely associated with total fruit, vegetable and fruit juice intake; however, when examined according to fruit or vegetable sub-type (citrus fruit, other fruit, fruit juices, cooked vegetables and raw vegetables), only the other fruit and raw vegetable categories were consistently associated with reduced SBP and DBP. In relation to the risk of hypertension based on SBP >140 mmHg, the OR for total fruit, vegetable and fruit juice intake (per fourth) was 0·95 (95 % CI 0·91, 1·00), with the same estimates being 0·98 (95 % CI 0·94, 1·02) for citrus fruit (per fourth), 1·02 (95 % CI 0·98, 1·06) for fruit juice (per fourth), 0·93 (95 % CI 0·89, 0·98) for other fruit (per fourth), 1·05 (95 % CI 0·99, 1·10) for cooked vegetable (per fourth) and 0·86 (95 % CI 0·80, 0·91) for raw vegetable intakes (per fourth). Similar results were obtained for DBP. In conclusion, a high overall intake of fruit, vegetables and fruit juice was inversely associated with SBP, DBP and risk of hypertension, but this differed by FV sub-type, suggesting that the strength of the association between FV sub-types and BP might be related to the type consumed, or to processing or cooking-related factors.

The Supplemental Nutrition Assistance Program Education (SNAP-Ed) aims to prevent obesity and chronic disease among SNAP-eligible families by facilitating healthy eating and active living. This study aimed to capture the voices of California SNAP-Ed eligible parents to inform program planners of their challenges in feeding their families, their available supports and priorities for intervention. We conducted eight focus groups with 55 participants across five counties in California from May through August 2017. Trained researchers used Dedoose to code and analyze data for substantive themes and overarching findings.Ten key findings and 4 additional findings were identified. Participants experience multiple challenges, primarily inadequate income and limited access to high quality, affordable healthy food contrasted with easy access to affordable unhealthy food. Despite efforts to manage food resources, most struggle to afford adequate diets. Employed parents confront a particularly challenging dual poverty of money and time. Many parents report feeling guilt related to feeding their children. Participants appreciate available programs and services and suggest increasing community input; providing sustainable programs; lowering the cost of and improving access to healthy food; reducing access to unhealthy food; modifying food assistance efforts; and improving nutrition education and promotion. Overall, low-income parents in California struggle to feed their families the way they would like. Participants generally understand what to feed their children, but struggle with how to do it, perceiving their circumstances and environments as inhospitable to healthy eating. Participants' suggestions can help SNAP-Ed programs and other efforts better support families' needs.

A high intake of fruit and vegetables (FV) has been associated with reduced risk of a number of chronic diseases, including CVD. The aim of this review is to describe the potential use of biomarkers to assess FV intake. Traditional methods of assessing FV intake have limitations, and this is likely to impact on observed associations with disease outcomes and markers of disease risk. Nutritional biomarkers may offer a more objective and reliable method of assessing dietary FV intake. Some single blood biomarkers, such as plasma vitamin C and serum carotenoids, are well established as indicators of FV intake. Combining potential biomarkers of intake may more accurately predict overall FV intake within intervention studies than the use of any single biomarker. Another promising approach is metabolomic analysis of biological fluids using untargeted approaches to identify potential new biomarkers of FV intake. Using biomarkers to measure FV intake may improve the accuracy of dietary assessment.

Evidence suggests that diets meeting recommendations for fruit and vegetable (F&V) intake are more costly. Dietary costs may be a greater constraint on the diet quality of people of lower socioeconomic position (SEP). The aim of this study was to examine whether dietary costs are more strongly associated with F&V intake in lower-SEP groups than in higher-SEP groups. Data on individual participants’ education and income were available from a population-based, cross-sectional study of 10 020 British adults. F&V intake and dietary costs (GBP/d) were derived from a semi-quantitative FFQ. Dietary cost estimates were based on UK food prices. General linear models were used to assess associations between SEP, quartiles of dietary costs and F&V intake. Effect modification of SEP gradients by dietary costs was examined with interaction terms. Analysis demonstrated that individuals with lowest quartile dietary costs, low income and low education consumed less F&V than individuals with higher dietary costs, high income and high education. Significant interaction between SEP and dietary costs indicated that the association between dietary costs and F&V intake was stronger for less-educated and lower-income groups. That is, socioeconomic differences in F&V intake were magnified among individuals who consumed lowest-cost diets. Such amplification of socioeconomic inequalities in diet among those consuming low-cost diets indicates the need to address food costs in strategies to promote healthy diets. In addition, the absence of socioeconomic inequalities for individuals with high dietary costs suggests that high dietary costs can compensate for lack of other material, or psychosocial resources.

Problematic eating behaviours during early childhood could be mediators of poor dietary habits. This study aims to prospectively relate early eating behaviours with fruit and vegetable (F&V) intake and a healthy diet variety score of children aged between 4 and 5 years. Eating behaviours were assessed in three European birth cohorts (Generation XXI from Portugal, ALSPAC from the UK and EDEN from France) at 4–6, 12–15, 24 and 48–54 months of age, based on the child’s feeding difficulties, mother’s perception of child’s poor eating (eating small quantities at each meal, not eating enough or needing to be stimulated to eat), food refusal and difficulties in the establishment of daily food routines. Daily servings of F&V (>1 v. ≤1 serving/d, except in Generation XXI: >3 v. ≤3) and the Healthy Plate Variety Score (categorised by the median score of each sample) were calculated using FFQ. Associations were tested by logistic regressions adjusted for maternal age, education, smoking during pregnancy, any breast-feeding and the child’s z-score BMI at 4–5 years of age. Children with more feeding difficulties, poor eating, food refusal/neophobia and difficulties in establishing a daily routine at 12–15, 24 and 48–54 months of age had in general lower F&V intake at 4–5 years of age. The association with vegetables was slightly stronger than with fruits. These early feeding problems were also inversely associated with the variety score at 4–5 years of age, particularly when eating behaviours were reported after 12–15 months of age. A better understanding of these early feeding difficulties may help define strategies to increase the dietary quality in children.