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BMJ 1995;310:1453-1455 (3 June)
Education and debate
Healthy eating: clarifying advice about fruit and vegetables
Carol Williams,
visiting lecturer a
a Human Nutrition Unit, Department of Public Health and Policy, London School of Hygiene and Tropical
Medicine, London WC1H 0BT
Consumers need health information which is clear and unambiguous. Advice to "eat more
fruit and vegetables"
gives consumers no guidance on the quantities involved. Popular advice is to eat "five portions a day." This paper
provides a rationale for determining which foods are included within this advice--for example, processed foods such
as baked beans are but potatoes and nuts should not be. It also describes how much of the most commonly consumed
fruit and vegetables constitutes a "portion." A bowlful of salad, for example, is needed to make up a portion but an
apple or banana on its own will count.
The government's nutrition task force recently decided that it wanted to provide consumers with information on the
amounts of
fruit and vegetables, bread and cereals, and fish recommended for a healthy diet. It set up a subgroup to
advise on simple and practical messages on the consumption of these foods. This paper reflects the conclusions of
that subgroup on
fruit and vegetables.
Until recently health advice about
fruit and vegetables from government organisations has tended simply to
recommend eating "more." This advice is open to different interpretations concerning which
fruit and vegetables are
included (does it include potatoes or
fruit juice?) and the amounts.
No universally accepted convention exists on which foods should be included in health advice on
fruit and
vegetabl
es.1 When different definitions are used misleading conclusions can be drawn about current levels of
fruit and vegetable consumption, and the interpretation of diretary surveys can be conflicting. Lack of clarity over the
status of the more controversial foods such as dried
fruit or pulses can lead to confusion and uncertainty among
consumers. Disagreement among academics and health professionals over these issues lends further weight to the
public perception that nutrition experts "never agree."
Advice which simply recommends eating "more" gives consumers no indication of how much is reasonable and
allows complacency about present levels of consumption. A study of
fruit and vegetable consumption in Scotland
found that among respondents whose intake of
fruit and vegetables was low (less than two portions a day) 55%
thought that they were eating enough and already eating "more."
2 In England, the nutrition task force noted that
"even where consumers are aware of the main healthy eating messages they are often unsure how to translate these
into appropriate
food choices."3 Providing practical quantified advice onhealthy intakes of foods may help to solve
this problem.
National quantified targets
Before the Committee on the Medical Aspects of Food Policy's cardiovascular review group published its report in
November 1
9944 there were no national numerical goals for
fruit and vegetable consumption for England, Wales,
and Northern Ireland. The Scottish diet report in 1993 recommended that Scotland's population should eat an average
of at least 400 g of
fruit and vegetables (excluding potatoes) a day.
5 This is consistent with the lower limit
population goal for
fruit and vegetable consumption contained in the World Health Organisation's report Diet,
Nutrition and the Prevention of Chronic
Diseases.6 The cardiovascular review group recommends a 50% increase in
the mean population intake of
fruit and vegetables.
Estimates of current intakes of
fruit and vegetables in Britain vary. The National Food Survey estimated mean
consumption of
fruit and vegetables to be around 275 g per person a day,
7 but this excludes foods eaten outside the
home and was based on households so that the average includes the amounts eaten by small children. It also uses the
weight of foods bought, not eaten so includes the weight of peel, core, and discarded outer leaves etc. I have adjusted
the figures from the National Food Survey to take account of this using factors for edible proportions,
8 and my
estimate is that the mean weight of
fruit and vegetables consumed is around 240 g/day. Data from the Dietary and
Nutritional Survey of British Adults (which recorded amounts actually consumed and includes food eaten outside the
home) indicate a mean adult consumption of
fruit and vegetables of around 250 g a day. On these figures, a 50%
increase in consumption would raise mean intakes to around 375 g and purchases to around 435 g a day. These
figures are lower, but similar to the 400 g target of the Scottish diet report and the World Health Organisation report.
Practical advice for consumers
What then is the practical interpretation of this 400 g target? Popular health magazines have advised consumers to
eat "at least five portions of
fruit and vegetables a day" based on "decent sized" portions of around 80 g
.10 11 12 13
Public awareness of the "at least five" message is growing in Britain and it is now widely used in the popular media.
It has been used by the Europe Against Cancer programm
e14 and is the basis of several commercial promotio
ns.15 16
The concept of "five a day for health" is also well established in the United States.
17 18 But is five correct? There are currently no accurate figures available on the number of servings of
fruit and
vegetables consumed in Britain. Comparison of mean intakes from the adult's survey
19 with data on average portion
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sizes as published by the Ministry of Agriculture, Fisheries, and Food (tab
le I)20 suggests that most people,
particularly those in lower socioeconomic groups, are eating fewer than five portions a day. Even if there was
agreement on what amounts constitute a portion, we do not know whether the "eat five" message is effective at
achieving the desired dietary changes.
TABLE I--Average serving sizes20
taken from weights recorded in
recent dietary surveys
----------------------------------
Average
serving
Food size (g)
----------------------------------
Medium apple (without
core) 100
Medium banana
(without skin) 100
Average serving of
brussels sprouts 90
Medium portion of boiled
carrots 80
Medium portion of peas 70
Medium tomato 85
In the absence of research into the effectiveness of particular quantified advice on
fruit and vegetable consumption,
any recommendation should encourage greater consumption but not be so ambitious that it puts people off.
Consistency is also important in fostering confidence. Eating five portions a day clearly represents an increase in
consumption for most of the population, and there is currently no evidence to suggest that it is either inappropriate or
ineffective in achieving levels of desired dietary change. On the basis of these considerations the nutrition task force
subgroup advises people to aim to eat at least five portions/servings of
fruit and vegetables a day.
Which foods are included?
Different types of
fruit and vegetables have differing nutritional attributes--for example, avocado pear is an
excellent source of vitamin E but is also high in fat. Ideally, consumers need to be encouraged to eat
fruits and
vegetables with a range of nutritional characteristics. This can be achieved by emphasising variety--for example, "try
to eat five different
fruits and vegetables." This avoids the need to complicate advice further and should help to
maximise levels of intake. Agreement is also needed on the place of more controversial foods. The subgroup
believes that
fruit juice, baked beans and other pulses, dried
fruit, and
fruit and vegetables which are frozen,
canned, or used as a main ingredient in recipes or composite foods should be included but that potatoes and nuts
should be excluded (table II).
TABLE II--Controversial foods and advice on
fruit and vegetables
--------------------------------------------------------------------------------------------
Conclusion Rationale
------------------------------------------------------------------------------------------
Exclude potatoes Biologically potatoes are a vegetable, but
Exclude other starchy dietetically they are a "starchy staple"
staples such as yams, cassava, (major source of complex carbohydrate).
plantain when eaten as a They are used in place of other starchy
starchy staple staples and main carbohydrate sources
Include root crops such as such as bread, pasta, or rice. They are
carrots, swedes, turnips not used interchangeably with other vegetables.
eaten in addition to main This is in keeping with Balance of
starchy staple Good Health food selection guide for the
UK.
21
Include
fruit juice
Fruit juice can provide most of the
Fruit juice should count only vitamins and minerals of fresh
fruit, but
once towards the "at least the structure of the food is disrupted and
five a day" recommendation, most of the fibre is lost. Most of the
so that consumers do not intrinsic
fruit sugars in the
fruit will have
think they can achieve five become extrinsic during extraction and
by drinking litres of
fruit more carcinogenic
juice Most
fruit drinks, squashes, and cordials
Exclude
fruit drinks, do not contain sufficient
fruit juice
squashes, and cordials
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Include baked beans and Pulses are rich in fibre, virtually free of
other pulses fat, and a useful source of iron and
protein, but they do not provide much
vitamin A, C, or E. Dietary advice is
that pulses are an alternative to meat,
but also count towards
fruit and
vegetables
For many who consume low amounts of
fruit and vegetable, particularly children,
baked beans are one of the few they
currently eat. Encouraging people to eat
"at least five" is less off putting when they
start from a base of one or two portions
currently consumed, rather than zero
Exclude nuts Nuts are usually consumed in small
quantities as a snack item and contribute
little to the average UK diet.
Include dried
fruit. Although dried
fruit is a source of dietary
Use portions based on fibre and various vitamins and minerals,
equivalent wet weight. the drying process converts much of the
Supporting advice needs to intrinsic sugar to extrinsic and destroys
emphasise the need for most labile vitamins such as vitamin C;
variety and getting the rest of and the dried
fruit is highly energy dense.
the five portions from other (Including dried
fruit in "at least five"
fruit and vegetables advice could encourage consumption of
dried
fruit outside a meal.) But dried
fruit
clearly is a
fruit.
Include frozen and canned Frozen
fruit and vegetables have similar,
fruit and vegetables and sometimes better, nutritional profiles
than fresh
fruit and vegetables.
Consumers should be encouraged to
choose produce tinned without sugar or
salt.
Include composite (recipe) The
fruit in a
fruit pie, or the vegetables in
or processed foods provided a ready meal, can contribute towards the
they contain enough
fruit or "at least five" advice irrespective of the fat
vegetables or sugar content of the other ingredients.
Some processed foods are To count as a portion, the
fruit or
unlikely to contain sufficient vegetable needs to be present in sufficient
fruit or vegetable ingredient quantity. For example, if the amount of
and are excluded--for apple in a serving of apple pie is equivalent
example, ketchup, to a whole apple, it counts as a portion
processed vegetable soups, Some processed foods--for example,
fruit
fruit cakes, and yoghurts jam and
fruit drinks--retain relatively
little of the nutritional quality of the
ingredients. Others contain very small
amounts of
fruit or vegetables.
How much in a portion?
Whether advice to "eat five a day" should refer to the number of occasions of eating
fruit and vegetables or the
number of portions is uncertain. To achieve the kind of dietary changes proposed in health strategies such as the
Health of the Nation and The Scottish Diet advice needs to promote consumption of five "decent sized" servings or
portions. A couple of slices of tomato in a sandwich or a few mushrooms in a chicken and mushroom pie should not
count.
Nutrition information which uses a mean portion size of around 80 g as a decent sized portion ties in well with
average serving sizes used by households in Britain.
20 The main area of discrepancy is with salad foods: consumers
and caterers should be told that it is necessary to eat a "bowlful" of salad to count as one portion.
Table III uses this approach to show amounts which constitute a "portion" of
fruit and vegetables. Supporting advice
should explain that serving size should reflect age, sex, and activity and that active young men would be expected to
eat larger portions. Similarly, small children can still aim to "eat at least five" but their portions may be smaller.
TABLE III--Advice on portions for consumers on "eating five portions of
fruit and vegetables a day." (The term "serving spoonful" has been used
to emphasise that the amounts of
fruit and vegetables are as served on to
the plate, rather than raw ingredients)
--------------------------------------------------------------------------------
Food type Practical description of
portion (approx 80 g) Examples
--------------------------------------------------------------------------------
Fruit:
Very large
fruit One large slice Melon, pineapple
Large
fruit One whole Apple, banana
Medium
fruit Two whole Plum, kiwi
Berries Cupful Raspberries, grapes
Stewed and Three serving spoonfuls Stewed apple, canned
canned
fruit peaches
Dried
fruit Half serving spoonful Apricots, raisins
Fruit juice Full wine glass Orange juice, fresh and
from concentrate
Vegetables:
Green vegetables Two serving Broccoli, spinach
spoonfuls
Root vegetables Two serving spoonfuls Carrots, parsnip
Very small Three serving spoonfuls Peas, sweetcorn
vegetables
Pulses and beans Two serving spoonfuls Baked beans, kidney
beans
Salad Bowlful Lettuce, tomato
I thank the policy unit of the Consumers' Association for supporting initial development work for this paper and for
comments received from interested parties, particularly the Department of Health.
A more detailed list is available on request for use in preparing photographs and illustrations of portion sizes and for
interpreting dietary surveys.
1. Domel SB, Leonard SB, Baranowski T, Baranowski J. "To be or not to be."
Fruits and vegetables. J Nutr
Ed 1993 25:6:352-8.
2. Anderson A, Marshall D, Lean MEJ, Foster A. Ripe for change:
Fruit and vegetable consumption in
Scotland--current patterns and potential for change. Edinburgh: Department of Business Studies, University
of Edinburgh, 1993 (Working paper series 93/1).
3. Department of Health. Eat well, an action plan from the Nutrition Task Force to achieve the Health of the
Nation targets on diet and nutrition. In: The health of the nation. London: DoH, 1994.
4. Department of Health. Nutritional aspects of cardiovascular disease: report of the cardiovascular review
group, committee of medical aspects of food policy. London: HMSO, 1994 (Report on health and social
subjects; 46).
5. Working Party to the Chief Medical Officer for Scotland. The Scottish diet, Scotland's Health--a challenge
to us all. Edinburgh: Scottish Office, 1993.
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HMSO, 1994.
8. McCance and Widdowson's The composition of foods. 5th ed. Cambridge: Royal Society of Chemistry,
Ministry of Agriculture, Fisheries, and Food, 1992.
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the dietary behaviour, nutritional status and blood pressure of adults aged 16 to 64 living in Great Britain.
London: Office of Population Census and Surveys. Social Survey Division, HMSO, 1990.
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11. Marshall J, Heughan A. Eat for life diet. London: Vermilion, 1992.
12. Eating for health WHO style. Which way to health? 1991; April:48-9.
13. Eating for health. Inside story. Which? May 1991:224.
14. Europe Against Cancer. A key to health: eat five
fruit and vegetables every day.? Brussels: Cancer
Education Coordinating Group, European Union Against Cancer Programme, Europe against Cancer, 1994.
15. Fresh
Fruit and Vegetable Information Bureau. Fresh is beautiful. London: Fresh
Fruit and Vegetable
Information Bureau, 1994.
16. Take 5! Healthy eating with
fruit and vegetables. London: J Sainsbury's, 1994.
17. National Cancer Institute and Produce for Better Health. '5' a day' for better health. Bethesda, Maryland:
NCI, 1994.
18. USA Department of Agriculture. The food guide pyramid ... beyond the basic. USAD: Human Nutrition
Service, 1992.
19. Ministry of Agriculture, Fisheries and Food. The dietary and nutritional survey of British adults--further
analysis. London: HMSO, 1994.
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21. Health Education Authority. The balance of good health. Introducing the national food guide. London:
HEA, 1994.
(Accepted 7 March 1995)
