Age and Ageing 1998; 27: 723-728 © 1998, British Geriatrics Society

Fruit and vegetable consumption in

later life
ANGELA E. JOHNSON, ANGEU\ J. M. DONKIN, KEVIN MORGAN 1 , ROGER J. NEALE2, ROBERT M. PAGE3,
RICHARD L SILBURN3

Department of Health Care of the Elderly, The University of Nottingham, Queens Medical Centre, Nottingham
NG7 2UH, UK
1
Department of Health Care for Elderly People, The University of Sheffield, Northern General Hospital,
Sheffield S5 7AU, UK
department of Applied Biochemistry and Food Science, The University of Nottingham, Sutton Bonnington LEI 2 5RD,
UK
3
School of Social Studies, The University of Nottingham, University Park, Nottingham NG7 2RD, UK

Address correspondence to: A. E. Johnson, 48 Corisande Road, Selly Oak, Birmingham B29 6RH, UK

Abstract
Objective: to assess levels of fruit and vegetable consumption in elderly people, and to examine the socio-
economic, physical and psychological factors which influence this consumption.
Methods: a three-phase survey: face to face interviews; self-completed dietary diaries with a food frequency
questionnaire; and follow-up face-to-face interviews.
Participants: 445 elderly people (aged 65+) randomly selected from general practitioner lists in urban Nottingham
and rural Nottinghamshire, Lincolnshire and Leicestershire.
Results: the recommended target of five portions of fruit and vegetables a day was achieved by less than half the
respondents: 37% of those living in the urban area and 51% of those living in the rural area. Low fruit and vegetable
consumption was particularly associated with being male, smoking and having low levels of social engagement.
Conclusions: most elderly people consume less than the recommended levels of fruit and vegetables. Health
programmes promoting fruit and vegetable consumption may not be successfully reaching elderly people and need
to target those particularly at risk of low consumption.

Keywords: dietary recommendations, fruit and vegetables

Introduction consumption of vegetables in old age has been found to

Fruit and vegetable consumption may reduce the risk of
several chronic diseases, including cancers, cardiovas-
cular disease, coronary heart disease, hypertension and
stroke [1-7]. The World Health Organisation therefore
recommends the consumption of at least 400 g, or five
portions, of fruit and vegetables a day [5, 8-10]. Most
adults' consumption falls short of this recommenda-
tion, with only 32% of American respondents [11] and
4% of Scottish respondents [12] meeting the 'five a day'
targets. Fruit and vegetable intake has been found to be
higher in older, as opposed to younger, adults [12-16],
but little is known about the typical fruit and vegetable
intake of elderly people in the UK. The benefits of fruit
and vegetable consumption continue into old age: the
be associated with a reduction in cancer mortality [7].
With advancing age, the requirements for some
antioxidants may be increased [17, 18].
The factors which may affect fruit and vegetable
consumption are: socio-economic circumstances, phy-
sical factors and psychological wellbeing. Being male
[12, 15, 19], having a lower income, lower educational
attainment and lower occupational status have been
associated with eating less fruit and vegetables [12, 13,
15, 19-21]. Physical health may play a role in fruit and
vegetable consumption, reducing appetite and the
ability to shop and cook; and smokers eat less fruit and
vegetables than non-smokers [12, 15, 22, 23]. Psycho-
logical well being also plays a role in diet, with
participation in a greater variety of social and physical

723
A. E. Johnson et al.
activities [21], a higher life satisfaction [24] and fewer
problematic life events [21] being associated with
more adequate diets, and lower mortality [25] in
elderly subjects.
Previous research has looked at the possible
influences on fruit and vegetable consumption in
isolation, or in combination with only a few other
influences. We have estimated the proportion of
elderly people who are meeting the 'five-a-day' target;
and assessed the levels of fruit and vegetable con-
sumption in relation to socio-economic, physical and
psycho-social factors.
Subjects and methods
Sample
The study was conducted in two areas: an urban area
(the city of Nottingham) and a rural area comprising
parts of Nottinghamshire, Lincolnshire and Leicester-
shire. Of 159 general practitioners (GPs) with patients
living in Nottingham, 127 (78%) agreed to support the
study. With the consent of these GPs, Nottinghamshire
Family Health Services Authority age/sex lists were
used to identify all non-institutionalized individuals
aged 65 years and over living within the Nottingham
area. From the resulting sample of 26055, 1584
individuals were randomly selected. The target was to
complete 800 interviews. The sample was stratified at
age 75 with equal probability representation in the age
groups 65-74 and 75+.
Of 76 GPs with patients living in the rural area, 47
(62%) agreed to support the study. With the consent of
these GPs, Family Health Services Authority age/sex
lists were used to identify all non-institutionali2ed
individuals aged 55 and over. From the resulting sample
of 4408, 669 individuals were randomly selected. The
target was to complete 400 interviews. The sample was
stratified at ages 65 and 75 with equal probability of
representation in the age groups 55-64, 65-74 and
75+. Respondents aged 65+ were included in this
analysis.
Data collection
The study comprised three phases of data collection.
In phase I, face-to-face interviews were conducted
•with the whole sample using a structured question-
naire on diet, shopping behaviour, household and
socio-economic circumstances, physical health and
psychological well-being. All interviews were con-
ducted on a laptop computer in the respondents'
own homes. Data collection took place over 17 months
(January 1994-May 1995).
Physical health was measured using a 14-item health
index covering the presence or absence of: heart,
stomach, eyesight, sleep or foot problems; giddiness,
724
headaches, urinary incontinence, arthritis, falls, long-
term disabilities and drug and walking aid use, and
contact with (primary and secondary care) medical
services [26]. Psychological well-being was measured
using the 20-item Brief Assessment of Social Engage-
ment scale, documenting the amount of contact with
friends, relatives or interest groups, and satisfaction
with this level of contact; the frequency of taking
holidays, reading the paper, voting and using the public
library; and ownership of a telephone, car, television
and radio [27].
On completion of phase I, a 50% sub-sample of
respondents participated in phase n, completing a
self-administered 4-day dietary diary and food fre-
quency questionnaire from which fruit and vegetable
consumption was calculated.
A further 50% sub-sample of phase n respondents
participated in phase III: a face-to-face follow-up
interview examining influences on food choices as
well as nutritional and food safety knowledge.
Fruit and vegetable intake
Foods that contributed at least 5% of any major nutrient
to the diet were included in the food frequency
questionnaire completed by phase n respondents
[28, 29]. Respondents were asked to indicate how
many times per day, week or month they consumed
each item. The food frequency data and Ministry of
Agriculture Fisheries and Food food portion size tables
[30] were used to calculate the portions of fruit and
vegetables consumed per person per day. The fruit and
vegetables which contributed to the recommended
five portions a day were based on the advice of
Williams [9]. Frozen and canned fruit and vegetables,
fruit juice, dried fruit, baked beans and other pulses
were included; potatoes and nuts were excluded.
Composite or processed foods were included provided
they contained enough fruit or vegetables [31].
Analysis was also conducted excluding beans and
pulses, as these foods could be considered as alternatives
to meat rather than as vegetables (personal commu-
nication, Ministry of Agriculture Fisheries and Food).
Statistical analysis
To compensate for the intentional over-sampling of
those aged 75+, the sample was weighted back to the
expected frequency of individuals as indicated by the
1991 census. The present analyses use weighted data
except in the three multiple regression analyses.
Stepwise multiple regression was used to identify the
independent contribution of socio-economic circum-
stances, physical health and psychological well-being
to the consumption of fruit and vegetables. Three
multiple regression analyses were conducted with fruit
and vegetable consumption, fruit consumption and
vegetable consumption as the dependent variables. In
 Fruit and vegetable consumption in later life

Table I. Socio-economic characteristics (weighted) of food frequency questionnaire and 177 (49%) of these a
urban (n — 312) and rural (n = 133) phase II respon- phase HI follow-up interview. Respondents who were
dents aged 65 and over and completed a phase II food
frequency questionnaire were included in this analysis:
% of subjects 312 weighted respondents. In the rural area 401 (72%)
Urban Rural of the 555 respondents who were asked to take part in
the study completed the phase I interview. Of these, 211
Sex (53%) completed a phase n food frequency question-
Female 53.8 58.9 naire and 106 (50%) of these a phase m follow-up
Male 46.2 41.1 interview, giving 133 weighted respondents aged 65+.
Age (years) The socio-economic characteristics of the two samples
65-74 62.8 63.3 are shown in Table 1. While the refusal rate was
75+ 37.2 36.7 relatively high (37% in the urban area, 28% in the rural
Social class area), in terms of age, sex and the number of individuals
Professional living alone, the resulting sample closely matched the
2.5 7.3
host population as described in the 1991 census.
Managerial 16.5 39.7
Skilled non-manual 22.7 23.6 Fruit and vegetable consumption was dichotomized
Skilled manual 37.7 17.4 into S5 and <5 portions a day. Rural respondents were
Semi-skilled 15.1 6.0 more likely than urban respondents to eat at least five
Unskilled 5.5 6.0 portions a day: 115 (37%) of the urban respondents and
67 (51%) of the rural respondents achieved this goal.
The mean daily consumptions of fruit and vegetables
were 4.5 servings (SD 2.1) in the urban area and 4.8
all models the independent variables were socio- servings (SD 1.9) in the rural area. In the multiple
economic circumstances (sex, age, social class, urban regression analysis three variables were independent
or rural area of residence), physical health (health predictors of a higher fruit and vegetable consumption:
index, smoker—yes or no) and psychological well- not smoking (R2 = 0.1159), a higher social engagement
being (social engagement scale). All analyses were score ( ^ = 0.1770) and female sex ( ^ = 0.1913;
performed using SPSS v6.0 [32]. Table 2).
Figure 1 illustrates the types of fruits and vegetables
eaten in the two areas. Vegetables contributed just over
half of the daily consumption of fruit and vegetables.
Results
Most of the vegetables eaten were fresh or frozen, most
In the urban area, 1281 respondents were asked to take commonly carrots, fresh peas and onions. About one-
part in the study and 809 (63%) completed the phase I quarter of the vegetables eaten were salad vegetables,
interview. Of these, 361 (45%) completed a phase II most commonly tomatoes. Most of the fruit eaten was

Table 2. Multiple regression results

R2
Variable/independent
predictor3 Value Changeb P value
Fruit and vegetable consumption
Smoking 0.1159 11.6 -0.3404 <0.00001
Social engagement score 0.1770 6.1 0.2513 <0.00001
Sex 0.1913 1.4 0.1206 <0.03
Fruit consumption
Smoking 0.0812 8.1 -0.2850 <0.00001
Social engagement score 0.1329 5.2 0.2310 <0.00001
Sex 0.1601 2.7 0.1662 <0.001
Social class 0.1723 1.2 -0.1207 <0.03
Vegetable consumption
Smoking 0.0460 4.6 -0.2143 <0.0002
Age 0.0954 4.9 -0.2235 <0.0001

"Independent variables: sex, age, urban or rural area of residence, health score, social engagement score and social class.
^ increase in variation explained.

725
A. E. Johnson et al.

Fruit and vegetables fruit and vegetable consumption. This is consistent with
Mean 4.6 portions research in younger age groups [12, 15, 22, 23]. Female
100i% gender and a higher social class were independently
associated with a high fruit consumption, but no such
differences were observed in vegetable consumption.
1
Vegetables
1
Fruit
Fruit may be seen as a low-calorie food, and thus be
Mean 2.6 portions Mean 2.0 portions
eaten more by women. Fruit often has a higher cost per
55.7% 44.3% calorie than vegetables, which may explain why more
fruit is eaten by those of a higher social class. Age was
associated with vegetable consumption, with older
r r respondents eating fewer vegetables. This might be
Fresh and frozen Fresh fruit due to a reduction in appetite or a lower taste acuity
vegetables 77% with advancing age [33], or to a reduction in the
64%
physical ability to prepare vegetables (although this
Salad vegetables Fruit juice association was independent of physical health status).
22.7% 13.2%
Respondents who were more socially engaged ate
Canned Dried fruit more fruit, but not more vegetables, than those with
vegetables 4.4% less social engagement. The social engagement scale
7.6% measures the degree to which individuals engage
Baked beans Fruit canned in syrup
actively (going on holiday, attending religious meet-
and pulses 2.9% ings) or symbolically (reading the newspaper) in the
4.5% social milieu. It also includes questions about lone-
liness and satisfaction with levels of contact with
Homemade vegetable Fruit canned in juice
soup 2.5%
others. It can be seen as a proxy for healthy ageing,
1.2% with a higher score indicating a more socially, mentally,
physically and emotionally active lifestyle and higher
Figure I. Types of fruits and vegetables eaten. morale. There has been much research on the
importance of social support on health and mortality,
with individuals who have social support tending to be
fresh, apples, bananas and oranges being the most in better physical [34] and psychological [35] health
popular. Fruit juice was the second most popular way and having a lower mortality [36]. Fruit consumption
of consuming fruit. may be an intervening variable between low social
Baked beans and other pulses were removed from support and poor health.
the analysis, reducing the mean daily consumption of
These analyses have demonstrated that many elderly
fruit and vegetables by only 0.1 of a serving to 4.4
people are not eating enough fruit and vegetables.
servings (SD 2.09) in the urban area and by 0.1 of a
Health education programmes promoting fruit and
serving to 4.7 servings (SD 1.9) in the rural area.
vegetable consumption need to target those elderly
Finally, fruit and vegetables were separated, and two people who are particularly at risk of a low consump-
multiple regression analyses conducted (Table 2). Four tion: men who smoke and have a low level of social
variables were independent predictors of a higher fruit engagement.
consumption: not smoking (R2 = 0.0812), a higher
engagement score (Jt2 — 0.1329), female gender (tf2 =
0.1601) and a higher social class (jf = 0.1723). Two
variables were independent predictors of a higher Key points
vegetable consumption: not smoking (R* = 0.0460) • Less than half the elderly subjects were eating five
and a younger age (Z?2 = 0.0954). portions of fruit and vegetables a day: 37% of those
living in the urban area and 51% of those in the rural
area.
Discussion • Low fruit and vegetable consumption was particu-
larly associated with being male, smoking and
We examined the fruit and vegetable consumption of having low levels of social engagement.
445 elderly people and found that the recommended • Health education programmes should target those
target of five portions of fruit and vegetables a day was groups of elderly people who are particularly at risk
being achieved by less than half them: 37% of those of low consumption.
living in the urban area and 51% of those living in the
rural area. This level of consumption, whilst falling
short of the ideal, is higher than that reported in studies
of younger people [11, 12, 15]. Acknowledgements
Smoking was the most important predictor of a low This study was funded under the Economic and Social

726

Research Council programme: The Nation's Diet: the
Social Science of Food Choice and the Ministry of
Agriculture, Fisheries and Food programme: Food
Acceptability and Choice. Thanks are also due to S.
Herne andj. Iilley for the design of the questionnaires.
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Received 28 August 1997; accepted 31 October 1997

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