Ann Nutr Metab 2013;63:131–138 DOI: 10.1159/000351987
Fruit and Vegetables: Intake and Sociodemographic Determinants among Portuguese Mothers
Bela Franchini a Rui Poínhos a Knut-Inge Klepp b Maria Daniel Vaz de Almeida a
a Faculty of Nutrition and Food Sciences, University of Porto, Porto , Portugal; b Department of Nutrition, Faculty of Medicine, University of Oslo, Oslo , Norway
among Portuguese mothers is far below international rec-ommendations. Effective strategies to promote fruit and vegetable intake are needed, especially for mothers belong-ing to lower social classes and educational levels.
Epidemiologic data show fruit and vegetable con-sumption to be one of several important protective fac-tors against noncommunicable diseases such as several cancers [1, 2] , cardiovascular diseases [3–5] , diabetes [6] and obesity [7–10] . International health agencies [1, 2] and European countries [11] have set recommendations for the desirable daily level of consumption of fruit and vegetables, which vary between 400 and 750 g.
Large discrepancies in fruit and vegetable intake have been associated with sociodemographic and psychosocial determinants (namely knowledge, attitudes, preferences and perceived barriers), but most studies took place in the USA or the UK [12–17] . Similar intake discrepancies have also been found across Europe [11, 18–21] . There-fore, a better understanding of the potential determinants of fruit and vegetable intake are vital to plan and develop more effective interventions aiming to promote their consumption.
Background: Fruit and vegetable intake is crucial in health promotion and disease prevention. Inadequate intake is found among adult populations worldwide. Aims: To assess fruit and vegetable intake among Portuguese mothers and to examine its association with sociodemographic determi-nants. Methods: A national cross-sectional survey was per-formed in Portugal as part of the Pro Children study. Data from self-administrated precoded 24-hour recall and food frequency questionnaires answered by 1,853 mothers of 11- to 13-year-old children were analyzed. Descriptive analysis of the data was followed by logistic regression to assess as-sociations between daily fruit and vegetable intake and so-ciodemographic determinants. Results: The mean fruit and vegetable intake was 221.2 and 170.0 g/day, respectively. Only 46% of the mothers met the WHO recommendations ( ≥ 400 g fruit and vegetables/day). Daily fruit intake was sig-nificantly higher among mothers who live with a spouse/partner, and who belong to a higher social class. For vegeta-bles, daily intake was significantly higher among mothers with a higher education and social class. Conclusions: This study shows that the mean intake of fruit and vegetables
Received: December 19, 2012 Accepted after revision: May 6, 2013 Published online: August 21, 2013
Bela FranchiniFaculty of Nutrition and Food Sciences, University of PortoRua Dr. Roberto FriasPT–4200-465 Porto (Portugal)E-Mail belafranchini @ fcna.up.pt
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A recent systematic review about associations between the family environment and young people’s fruit and veg-etable intake demonstrated that parental intake was con-sistently and positively associated with young people’s in-take [22] . Consequently, parents are a target group for interventions to promote fruit and vegetable intake. Moreover, mothers are of particular interest for chil-dren’s eating behavior, as they have been shown to spend more time than fathers in direct interactions with their children in several family situations, including mealtimes [23–25] .
The present study is part of the Pro Children cross-sectional survey, designed to assess fruit and vegetable consumption in 11- to 13-year-old European schoolchil-dren and their parents, to identify factors associated with the consumption patterns, and to develop and test effec-tive and culturally relevant intervention strategies for the promotion of adequate consumption levels among school-aged children and their parents [26] . The aims of the present paper are to assess fruit and vegetable intake patterns among Portuguese mothers of schoolchildren, and to examine the associations between sociodemo-graphic determinants and fruit and vegetable intake.
Methods
Design and Sample Collection The Pro Children cross-sectional survey was carried out in nine
European countries between October and December 2003. Ac-cording to the study protocol, schools should constitute the sam-pling unit, and from each country random samples of at least 20 schools and 1,300 children (aged between 11 and 13 years) and their parents should be recruited [26] . The study was approved by the research ethics committees within participating countries.
Self-administered questionnaires were developed for children and parents, and administered in all countries. Parental written consent was obtained through a question at the beginning of the questionnaire for both children and parents. The instruments were translated into national languages (and translated back to English) taking into account the cultural appropriateness for the subjects, and tested for reliability and validity in multiple pilot tests prior to final administration. More details about this are given elsewhere [27–29] .
Child data collection was performed directly in the classroom with the help of teachers, who received careful instructions prior to the investigation. The time required to complete the question-naire was about 35–40 min. All pupils received a closed envelope with an additional questionnaire to take home to be completed by one of their parents. The parent questionnaires were returned to the teachers by the children, who in turn sent them to each na-tional research center. Both questionnaires (child and parent) in-cluded three parts: the first part consisted of a dietary intake of fruit and vegetables; the second covered different issues of study poten-tial, including social and physical environmental factors of fruit
and vegetable intake, and the third part comprised information about socio-economic and demographic characteristics, and par-enting style. These questionnaires were applied on only 1 weekday, from Tuesday to Friday.
In order to achieve the protocol mentioned above and to obtain a national representative sample, a list of 1,050 state and private Portuguese schools, with fifth and sixth grade (11- to 13-year-old) pupils, was acquired from the Portuguese Ministry of Education. Ultimately, 60 schools were randomly selected for participation in the study. These schools were invited to participate by an initial letter sent to each head teacher. All schools agreed to participate but only 34 returned the questionnaires.
A total of 3,044 questionnaires were completed by schoolchil-dren and 2,375 questionnaires were filled in by one of their parents (1,853 by mothers and 522 by fathers or guardians). In the present article, only the data from the mothers’ questionnaires were taken into account. Therefore, the response rate from mothers was 78%.
Measurement of Fruit and Vegetable Intake The dietary part of the questionnaire included two sections: a
precoded 24-hour recall and food frequency. The precoded 24-hour recall section was included to give information on the type and quantity (group mean intake) of fruit and vegetables eaten. In this section participants were asked to write down what they had eaten the day before. This precoded section asked in detail for the consumption of fresh fruit juice, fresh fruit, salad, other raw veg-etables, cooked vegetables and vegetable soup, and referred to three different time intervals: (1) before school; (2) school time and lunch, and (3) after school, dinner and after dinner. Specific ques-tions on vegetables as part of composite dishes were not included. Amounts were indicated in terms of number of pieces, slices or portions eaten, and standard weights were attributed in order to quantify intake [28, 29] . The total vegetable intake was calculated by summarizing all of the answers about vegetables.
The food frequency section ranked subjects according to levels of usual intake. It included five questions about the usual intake of fresh fruit, salad, other raw vegetables, cooked vegetables and fresh fruit juice. Eight response categories were used, ranging from ‘nev-er’ to ‘every day, more than twice a day’ [28, 29] . In order to prevent participants from including potato in the cooked vegetables group, a separate question on potato intake was included. Fresh fruit juice was excluded from further analysis as respondents did not differ-entiate between natural fruit juice and soft drinks – once several participants referred a brand of soft drink as ‘fruit juice’. This mea-sure was applied to both methods (24-hour recall and food fre-quency).
Each question of the food frequency section was recoded into the mean number of times per day. Answers to the vegetable ques-tions were summed to obtain the mean number of times per day. In this paper the food frequency is dichotomized into daily intake (at least once a day) and nondaily intake (less than once a day).
Measurement of Sociodemographic Characteristics Household size and composition, education level, social class
and region of residence were registered to characterize the stud-ied sample. Educational level was measured by four categories: (1) less than 7 years; (2) 7–9 years; (3) 10–12 years, and (4) more than 12 years.
To code occupational social class three kinds of job character-istics were used: educational requirements; management skills re-
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quested, and control over economic assets (ownership/self-em-ployed). This model defines a common hierarchical structure, which categorizes all occupations into five social classes (I = high-er; V = lower) and three extra groups (group VI = economically active but insufficient information to code the occupation; VII = economically inactive; VIII = students) [30, 31] .
Based on the classification of the official Portuguese territorial division NUT II, the sample was assigned to one of the five regions of residence: North, Center, Lisbon area, Alentejo and Algarve [32] . The former two regions were analyzed as one region due to their low sample size and close geographical location.
Data Analysis The descriptive analysis consisted of the calculation of means,
standard errors and frequencies. Logistic regression analysis was applied, using the data from the food frequency part of the ques-tionnaires in order to estimate the association between fruit and vegetable intake and sociodemographic characteristics. Sociode-mographic variables were entered into three separate models, which used (1) daily consumption of fruit, (2) daily consumption of vegetables and (3) a combined fruit and vegetable consumption (at least three times a day) as dependent variables; all values were adjusted to all variables in each model. Analyses were conducted using SPSS (Statistical Package for Social Sciences) version 14.0 for Windows. A p value <0.05 was considered statistically signifi-cant.
Results
The distribution of the sample by sociodemographic characteristics is presented in table 1 . Due to incomplete-ness of data, the sample size varies across variables. Ap-proximately half of the mothers (48.5%) reported that the number of people in their household was 4. The majority of this sample ‘lived with spouse/partner’ (88.6%) and ‘lived with own child/children’ (83.9%).
Regarding the educational level, the highest percent-age (43.7%) was found for mothers with less than 7 years of education. Only 12.2% of the sample was classified into higher social classes (class I or II) and 29.6% were classi-fied into groups VII and VIII, which includes economi-cally inactive mothers; within this group 71.6% (n = 370) reported to be housewives.
Table 2 shows the intake of fruit and vegetables based on the 24-hour recall and food frequency questions. The mean intake of fruit was 221.2 g/day and of vegetables was 170 g/day. The main intake of vegetables came from veg-etable soup (75.5 g/day). A daily intake (at least once ev-ery day) of fruit and vegetables was reported by 73 and 70% of the mothers, respectively. For this analysis, only 1,620 Portuguese mothers were included, due to incom-plete filling in of the food frequency section of the ques-tionnaire.
Table 1. Sociodemographic characteristics of the sample (Portu-guese mothers of 11- to 13-year-old children participating in the Pro Children Project)
Characteristics Subjects, n %
Number of people in household (n = 1,811)<4 519 28.7
4 878 48.5>4 414 22.9
Live with spouse/partner (n = 1,809) 1,602 88.6Live with own child/children (n = 1,809) 1,518 83.9Education level (n = 1,806)
<7 years 789 43.77–9 years 343 19.010–12 years 326 18.1
>12 years 348 19.3Social class (n = 1,749)
Class I–II (high) 214 12.2III 281 16.1IV 288 16.5V (low) 334 19.1Group VI (economically active,
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Table 3 displays the associations between fruit and vegetable intake (separately and combined) and the so-ciodemographic characteristics. Mothers’ daily fruit in-take was positively associated with mothers who ‘lived with spouse/partner’ (p = 0.001). The social class showed a significant association with daily fruit intake of the Portuguese mothers (p = 0.018). Every class and group, excluding class V (low), was significantly associated with lower daily fruit intake when compared to the highest classes (I and II). The region of residence variable did not show significant association to mothers’ daily fruit intake. However, Portuguese mothers living in the ‘center’ re-gion showed higher daily fruit intake when compared to the ‘north’ (p = 0.048).
For vegetables, the daily intake demonstrated signifi-cant associations with the educational level (p = 0.008) and social class (p = 0.027) variables. Portuguese mothers belonging to a higher educational level demonstrated higher daily vegetable intake when compared to those with less than 7 years of education (p = 0.007 for both 10–12 years and more than 12 years of education). Re-garding the social class, mothers belonging to classes IV and V, and groups VI–VIII, showed significant associa-tions with lower daily vegetable intake in comparison with the highest classes (I and II).
For combined intake of fruit and vegetables ( table 3 ), the Portuguese mothers’ intake was positively associated with the following variables: ‘live with spouse/partner’
Table 3. Adjusted odds ratio and 95% confidence intervals for daily intake of fruit and vegetables, separated and combined by sociode-mographic characteristics (n = 1,620; Portuguese mothers of 11- to 13-year-old children participating in the Pro Children Project)
Fruit(at least once a day)
Vegetables(at least once a day)
Fruit and vegetables (at least 3 times a day)
OR 95% CI p value OR 95%CI p value O R 95% CI p value
People in household, n 0.242 0.651 0.4454 (n = 788) 1 (reference) 1 (reference) 1 (reference)
p values refer to the comparison with the reference group, except for those presented in the same line as the name of the variable, which refer to the overall effect for that variable.
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(p = 0.03) and ‘live with own children’ (p = 0.014). Over-all the educational level, social class and region of resi-dence variables did not show significant association with combined daily fruit and vegetable intake. However, edu-cation level demonstrated a positive and significant asso-ciation with combined daily fruit and vegetable intake among Portuguese mothers belonging to the higher edu-cational level category (10–12 years of education; p = 0.031) when compared to less than 7 years of education. In relation to the social class variable, a negative and sig-nificant association with combined daily fruit and vege-table intake was found among mothers belonging to classes III, IV, VII and VIII when compared to the highest classes (I and II).
Discussion
The present study shows, according to the 24-hour re-call method, that the mean intake levels of fruit and veg-etables among Portuguese mothers are below the WHO recommendations of ≥ 400 g/day. Only 46% of the moth-ers met this recommendation. Vegetable soup was the leading item that contributed to the main portion of veg-etable intake.
On the other hand, and taking into account the food frequency method, more than two thirds of the sample reported to be daily consumers of these groups of foods. The Epi Porto study, developed among Portuguese adults living in Porto, which used semiquantitative food fre-quency questionnaires, showed a similar trend concern-ing the daily intake frequency of fruit and vegetables [33] .
Also, in line with other studies, namely among women [34–36] , we found that Portuguese mothers belonging to higher social classes were more likely to eat fruit and veg-etables daily. However, we observed that mothers belong-ing to the lowest social class (class V) showed a tendency toward a higher frequency of daily fruit intake when com-pared to their higher social class counterparts (classes III and IV). This may be due to social desirability.
Previous studies have shown the belief in ‘fruit and vegetables’ as the main characteristic of healthy eating to be more common among those belonging to lower socio-economic and educational levels [37, 38] . This contradic-tory result was only observed for fruit, not for vegetable intake and, therefore, further analysis is required to iden-tify possible confounding factors involved.
When intake of fruit and vegetables were combined, no differences among social classes were found. More in-vestigation is needed to understand this finding.
A systematic review on determinants of fruit and veg-etable consumption among adults revealed higher house-hold income and marital status to be the most important positive associations of fruit and vegetable intake [12] . Our results also showed a positive association of marital status (‘live with spouse/partner’) with daily intake of fruit and combined intake of fruit and vegetables, in line with other authors [36–39] .
The number of household inhabitants and the group ‘living with own child/children’ were not separately as-sociated with daily fruit and vegetable intake. A few stud-ies that have evaluated this showed a mixed association [36, 39–41] . ‘Living with spouse/partner’ had a positive association with the combined intake of fruit and vegeta-bles, a result which is supported by an earlier study ap-plied to women [36] .
Educational level was positively associated with daily vegetable intake – Portuguese mothers belonging to higher educational levels were more likely to have a dai-ly vegetable intake. This association has also been ob-served by others, with similar results [36, 42–45] . More-over, a nationally representative Portuguese cross-sec-tional survey showed that highly educated women consumed more vegetables and more fruit [46] . How-ever, we did not find fruit intake to be associated to edu-cational level. A review of selected European studies, car-ried out by Gun Roos et al. [47] , showed similar results, as no clear association between educational level and fruit and vegetable intake in southern and eastern European countries could be established. For fruit and vegetables combined, a positive association was found in Portuguese mothers belonging to higher educational lev-els (10–12 years of education) that showed higher intakes when compared to lower educational levels (7 or less years of education). Previously, similar associations with significance among adults, especially women, were ob-served [36, 48–51] .
Concerning the regions, there were no differences in the intake of fruit and vegetables. However, this was not the case with another study among the adult population in Britain, for which the opposite was observed [52] . Considering this, and taking into account the lack of in-formation about fruit and vegetable intake among the different regions, more investigation is needed in this area.
Other investigators have studied additional factors that can influence the intake of fruit and vegetables among adults. According to the review by Shaikh et al. [15] , self-efficacy, social support and knowledge about fruit and vegetable intake were the strongest psychosocial predic-
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tors of fruit and vegetable consumption . When Havas et al. [48] assessed to what extent sociodemographic and psychosocial determinants influence the intake of fruit and vegetables among women, the results showed that sociodemographic characteristics were not powerful de-terminants of consumption, but in relation to psychoso-cial determinants, self-efficacy, attitudes and perceived barriers emerged as the strong predictors. In the Pro Chil-dren Project, similar findings were found for children, in which a combination of personal and social factors, par-ticularly knowledge of the national recommendations and parental modeling, influenced fruit and vegetable in-take for every country [53] . As parental intake seems to be a strong predictor of fruit and vegetable intake among children, interventions should target the eating habits of parents, encouraging them to be positive role models for their youngsters [54–56] .
This research has some limitations that should be highlighted prior to further interpretation of the findings. Psychosocial determinants, such as self-efficacy and at-titudes, were not analyzed and may moderate some of the reported relationships. The 24-hour recall used to assess the mean intake of fruit and vegetables was applied only on a weekday and therefore cannot be seen as representa-tive for usual intake, including day-to-day variation as well as seasonal differences. All information given by 24-hour recall about pieces, slices or portions consumed had to be converted into standardized portion sizes in grams. The food frequency section of the questionnaire did not include a specific question about vegetable soup, which may have led to an underestimation of vegetable intake. This might have occurred because vegetable soup is tra-ditionally included in main meals in Portugal. However, these limitations were overcome because the question-naire applied in this study showed satisfactory validity [28, 29] .
Conclusions
This study reveals that the mean intake of fruit and vegetables among Portuguese mothers is below interna-tional recommendations. Social class and educational level appear to influence the intake of fruit and vegeta-bles, which was more likely to be high among mothers belonging to higher social classes, whereas the influ-ence of educational level was only observed for vegeta-ble intake.
These facts suggest that future intervention strategies to increase fruit and vegetable intake should be targeted at Portuguese mothers belonging to lower social classes and educational levels. The use of the mass media, health and nutrition campaigns stressing the health benefits of fruit and vegetable consumption may be useful not only to raise awareness and enhance motivation, but also to increase fruit and vegetable consumption in these groups. Further research should focus on the efficacy of such ap-proaches.
Acknowledgments
Special thanks to the parents who took the time to participate in this study. We also thank the people that were involved in the data collection (namely children, headmasters, teachers and staff).
This study was carried out with financial support from the Commission of the European Communities specific RTD pro-gramme, ‘Quality of Life and Management of Living Resources’, QLKI-2001–005472: ‘Promoting and Sustaining Health through Increased Vegetable and Fruit Consumption among European Schoolchildren’ (Pro Children).
Disclosure Statement
The authors declare that they have no conflict of interests.
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