Abstracts

Introduction

Adequate fruits and vegetable consumption has an important protective effect on health ¹1. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014.^,22. Cena H, Calder PC. Defining a healthy diet: evidence for the role of contemporary dietary patterns in health and disease. Nutrients 2020; 12:334.. This benefit stems from their rich micronutrients, vitamins, minerals, fibers, and phytochemicals content, in addition to their low energy density ²2. Cena H, Calder PC. Defining a healthy diet: evidence for the role of contemporary dietary patterns in health and disease. Nutrients 2020; 12:334.^,33. Wallace TC, Bailey RL, Blumberg JB, Burton-Freeman B, Chen O, Crowe-White KM, et al. Fruits, vegetables, and health: a comprehensive narrative, umbrella review of the science and recommendations for enhanced public policy to improve intake. Crit Rev Food Sci Nutr 2020; 60:2174-211.. A consistent relation has been established between consuming enough fruit and vegetable and the prevention of noncommunicable diseases (NCD) such as cardiovascular diseases, different types of cancer, diabetes mellitus, and metabolic syndrome ³3. Wallace TC, Bailey RL, Blumberg JB, Burton-Freeman B, Chen O, Crowe-White KM, et al. Fruits, vegetables, and health: a comprehensive narrative, umbrella review of the science and recommendations for enhanced public policy to improve intake. Crit Rev Food Sci Nutr 2020; 60:2174-211.^,44. World Health Organization. Healthy diet. Update August 2018. http://www.who.int/mediacentre/factsheets/fs394/en/ (accessed on 09/Jul/2024).
http://www.who.int/mediacentre/factsheet... . The World Health Organization (WHO) recommends a minimum intake of five servings or 400g of fruit and vegetable per day ⁵5. World Health Organization. Diet nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert Consultation. Geneva: World Health Organization; 2003. (WHO Technical Report Series, 916)..

Specifically in Brazil, the Dietary Guidelines for the Brazilian Population, proposed by the Brazilian Ministry of Health, aligns with the WHO recommendation by advocating for a diet based on natural and minimally processed foods rather than ultra-processed foods ¹1. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014.. It represents a dietary intake made up of a wide diversity of plant- and animal-based foods that have undergone little or no change, such as grains, roots, vegetables, fruits, eggs and fresh meat ¹1. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014..

Despite the long-standing understanding of the benefits of fruit and vegetable consumption, several studies have reported a low prevalence of individuals meeting the recommendation, both in high-income countries and in low- and middle-income countries ⁶6. Frank SM, Webster J, McKenzie B, Geldsetzer P, Manne-Goehler J, Andall-Brereton G, et al. Consumption of fruits and vegetables among individuals 15 years and older in 28 low-and middle-income countries. J Nutr 2019; 7:1252-9.. A cross-sectional study showed that 80% of individuals residing in low- and middle-income countries fail to meet adequate amounts of fruit and vegetable as recommended by WHO guidelines ⁶6. Frank SM, Webster J, McKenzie B, Geldsetzer P, Manne-Goehler J, Andall-Brereton G, et al. Consumption of fruits and vegetables among individuals 15 years and older in 28 low-and middle-income countries. J Nutr 2019; 7:1252-9.. This finding is concerning as these countries are at risk of being disproportionately affected by NCD in the coming years ⁷7. Daniels Jr. ME, Donilon TM, Bollyky TJ. The emerging global health crisis. Noncommunicable diseases in low- and middle-income countries. New York: Council on Foreign Relations; 2014. (Independent Task Force Report, 72)..

In Brazil, between 2008 and 2016, there was an increase in the recommended consumption of fruit and vegetable with approximately 24.4% of the adult population meeting adequate consumption of these foods in 2016 ⁸8. Silva LES, Claro RM. Tendências temporais do consumo de frutas e hortaliças entre adultos nas capitais brasileiras e Distrito Federal, 2008-2016. Cad Saúde Pública 2019; 35:e00023618.. Although only a quarter of the population reached sufficient fruit and vegetable consumption, this proportion is higher than high-income countries such as the United States, in which only 9% of the population reached the recommendation in 2015 ⁹9. Lee-Kwan SH, Moore LV, Blanck HM, Harris DM, Galuska D. Disparities in state-specific adult fruit and vegetable consumption - United States, 2015. MMWR Morb Mortal Wkly Rep 2017, 45:1241-7.. This scenario results from efforts by the Brazilian government to promote healthy eating habits ¹⁰10. Brasil. Lei nº 10.696, de 2 de julho de 2003. Dispõe sobre a repactuação e o alongamento de dívidas oriundas de operação de crédito rural, e dá outras providências. Diário Oficial da União 2003; 3 jul., including fruit and vegetable consumption, as well as intensified actions targeting food and nutrition in primary health care (PHC) during this period ¹¹11. Bortolini GA, Pereira TN, Nilson EAF, Pires ACL, Moratori MF, Ramos MKP, et al. Evolution of nutrition actions in primary health care along the 20-year history of the Brazilian National Food and Nutrition Policy. Cad Saúde Pública 2021; 37:e00152620.. Furthermore, intersectoral strategies contributed to the economic growth of the country, leading to higher family income ¹²12. Brasil. Lei nº 10.836, de 9 de janeiro de 2004. Cria o Programa Bolsa Família e dá outras providências. Diário Oficial da União 2004; 12 jan. and more favorable food prices ¹⁰10. Brasil. Lei nº 10.696, de 2 de julho de 2003. Dispõe sobre a repactuação e o alongamento de dívidas oriundas de operação de crédito rural, e dá outras providências. Diário Oficial da União 2003; 3 jul., both of which are potential determinants of fruit and vegetable consumption.

However, a series of political and economic changes experienced in the country since 2015 ¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua (PNAD contínua): rendimento de todas as fontes. https://biblioteca.ibge.gov.br/visualizacao/livros/liv101950_informativo.pdf (accessed on 02/Aug/2023).
https://biblioteca.ibge.gov.br/visualiza... may have negatively influenced the food consumption patterns of the Brazilian population. Additionally, the COVID-19 pandemic exacerbated the situation by introducing a health emergency and intensifying economic challenges ¹⁴14. Rede Brasileira de Pesquisa em Soberania e Segurança Alimentar e Nutricional. Food insecurity and COVID-19 in Brazil. https://olheparaafome.com.br/VIGISAN_AF_National_Survey_of_Food_Insecurity.pdf (accessed on 16/Feb/2024).
https://olheparaafome.com.br/VIGISAN_AF_... . In this context, it becomes imperative to continue monitoring the temporal evolution of fruit and vegetable consumption to assess and strengthen public strategies and policies aimed at promoting the consumption of these foods. Thus, this study aimed to analyze the temporal trend of fruit and vegetable consumption among adults in Brazilian capitals and the Federal District from 2008 to 2023, comparing estimates from the initial period (2008-2014) and the most recent period (2015-2023).

Methods

Design

This is a time series study based on data collected by the Surveillance of Risk and Protective Factors for Chronic Diseases by Telephone Survey (Vigitel, acronym in Portuguese) from 2008 to 2023. Vigitel is a population-based health survey conducted annually with a probabilistic sample of adults (≥ 18 years) living in households in the 26 capitals and the Federal District, provided they have at least one telephone landline (n = 697,549) ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022..

Sample

The sampling process is conducted in two steps. The first step consists of a systematic gathering of 10,000 telephone lines (including landlines and mobile phones in 2023) in each city and identifying the eligible ones. For landline interviews, the second step involves selecting one adult resident from each household (via simple random sampling) to participate in the interview. In the case of mobile phones, the interview is conducted directly with the line user, provided they are adults (≥ 18 years old) ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022..

Until 2019, around 2,000 interviews were conducted annually in each city, which allowed an estimation of indicator prevalence with a maximum error of two percentage points and a 95% confidence interval (95%CI) ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.. During the COVID-19 pandemic in 2020 and 2021, a minimum sample size of 1,000 individuals in each city was established. This adjustment enabled estimating indicator prevalence with a maximum error of four percentage points and a 95%CI ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022.. However, due to issues in the bidding process of the survey, data collection was not possible in 2022, requiring a simplified operation in 2023. Consequently, further reduction in the sample size was necessary, with a minimum of 800 interviews per city. Despite the reduction, estimates with 95%CI and a maximum error of four percentage points were still achievable ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022..

Post-stratification factors are employed to correct the estimates, considering the probability of unequal selection of respondents, adjusting the sociodemographic distribution (sex, age, and schooling) of the sample to the distribution of the adult population of each city. More details about the sampling and weighting processes are provided in the annual reports ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022..

Measures

For this study, the indicators of regular and recommended fruit and vegetable consumption were analyzed. The construction of the variable was based on the fruit and vegetable consumption indicator from the main Brazilian health surveys ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022.^,1717. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019. Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020.. Regular fruit and vegetable consumption was estimated based on responses to the following questions: “How many days per week do you usually eat at least one type of vegetable (lettuce, tomato, cabbage, carrot, chayote, eggplant, zucchini - not including potatoes, cassava, or yams)?”; “How many days per week do you usually drink fresh fruit juice?”; and “How many days per week do you usually eat fruit?”. The response options for each of these questions ranged from: 1-2, 3-4, 5-6, every day, rarely, never ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.^,1616. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022.^,1717. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde 2019. Percepção do estado de saúde, estilos de vida, doenças crônicas e saúde bucal: Brasil e grandes regiões. Rio de Janeiro: Instituto Brasileiro de Geografia e Estatística; 2020.. Regular consumption was considered in cases in which fruits (including fresh juices) and vegetables (regardless of type) were consumed on five or more days of the week (≥ 5 days/week). It is necessary for individuals to consume both regularly, but the number of servings throughout the day is not considered.

The recommended fruit and vegetable consumption was estimated based on the responses to the following questions: “How many days of the week do you usually eat lettuce and tomato salad or any other raw vegetable salad?” (1-2, 3-4, 5-6, every day, rarely, never); “On an ordinary day, do you eat this type of salad” (at lunch, at dinner, both); “How many days of the week do you usually eat cooked vegetables in a meal or soup, for example, kale, carrot, chayote, eggplant, zucchini - not including potatoes, cassava or yam? (1-2, 3-4, 5-6, every day, rarely, never)”; “On an ordinary day, do you eat cooked vegetables” (at lunch, at dinner, both); “On an ordinary day, how many glasses do you drink of fresh fruit juice?” (1, 2, 3 or more); and “On an average day, how many times do you eat fruit?” (1, 2, 3 or more) ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.. Regarding fruit consumption, up to three daily servings were considered, with fruit juice consumption counting as one serving. Regarding the consumption of raw and cooked vegetables at lunch and/or dinner, up to four daily servings were considered. Recommended fruit and vegetable intake was achieved when the total servings consumed daily reached at least five servings on at least five days of the week (based on the regular fruit and vegetable consumption indicator, ≥ 5 servings/day on ≥ 5 days/week), following WHO ⁵5. World Health Organization. Diet nutrition and the prevention of chronic diseases. Report of a Joint WHO/FAO Expert Consultation. Geneva: World Health Organization; 2003. (WHO Technical Report Series, 916). and Brazilian ¹1. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014. dietary guidelines.

Sociodemographic variables such as sex (male, female), age group in years (18-24, 25-34, 35-44, 45-54, 55-64, ≥ 65) and schooling level in years of study (0-8, 9-11, ≥ 12) complement the analysis.

Analysis

The population was described according to sociodemographic characteristics. The prevalence of recommended and regular fruit and vegetable consumption was estimated for the entire population and sociodemographic groups across all years studied. The temporal trend of the indicators was estimated using linear regression models for the entire period (2008-2023), as well as for the initial (2008-2014) and most recent (2015-2023) periods. To assess the impact of political and economic changes in the country from 2015 onwards, the continuous fractional time series was analyzed in this study. From 2015, other studies have noted negative changes in the prevalence of risk factors ¹⁶16. Ministério da Saúde. Vigitel Brasil 2006-2021: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica do estado nutricional e consumo alimentar nas capitais dos 26 estados brasileiros e no Distrito Federal entre 2006 e 2021: estado nutricional e consumo alimentar. Brasília: Ministério da Saúde; 2022., identifying 2015 as a crucial cutoff point for our analysis. By conducting a comparative analysis of periods before and after that year, we aimed to better identify changes in indicators, as significant changes might be masked when analyzing the complete period. Linear regression models - preferably Prais-Winsten or simple linear regression when convergence was not achieved - were used to identify temporal trends for each indicator in the studied period. Prais-Winsten models are used to correct the effect of serial autocorrelation and are recommended in time trend studies ¹⁸18. Antunes JLF, Cardoso MRA. Uso da análise de séries temporais em estudos epidemiológicos. Epidemiol Serv Saúde 2015; 24:565-76.. A positive regression coefficient showed an increase in the indicators in percentual points per year (pp/year), while a negative coefficient indicated a decrease. Significant variation values were considered, p-values less than 0.05.

Stata software version 16.1 (https://www.stata.com) was used to organize and analyze the data. Vigitel databases are available for public access (http://svs.aids.gov.br/download/Vigitel/) and the survey was approved by the Brazilian National Ethics Committee for Research with Human Beings of the Brazilian Ministry of Health.

Results

Vigitel conducted 697,549 interviews with adult individuals (≥ 18 years) from 2008 to 2023. Over the entire period, a decrease was observed in the proportion of young adults (18-24 years), declining from 17.9% to 12.9% (-0.33pp/year), while an increase in the proportion of individuals aged 55-64 years was observed, rising from 10.4% to 13.9% (0.25pp/year). Regarding schooling level, there was a decrease in individuals with 0 to 8 years of schooling, from 43.7% to 25.8% (-1.28pp/year), and an increase in adults with 12 years of schooling or more, from 21.6% to 32.9% (0.78pp/year) (Table 1).

The prevalence of regular fruit and vegetable consumption (≥ 5 days/week) remained stable from 2008 to 2023, with an average of 34.1% for the entire population and among all sociodemographic groups. In the initial period (2008-2014), regular fruit and vegetable consumption increased from 33% to 36.5% (0.71pp/year) for the entire population and almost all sociodemographic groups, except for adults aged 25 to 34 years. The highest increase during this period was observed among women (0.75pp/year), individuals aged 65 and more (0.83pp/year), and adults with 0 to 8 years of schooling (0.69pp/year). Conversely, the analysis of the most recent period (2015-2023) showed a decrease in the prevalence of fruit and vegetable consumption for the entire population, from 37.6% to 31.9% (-0.56pp/year), particularly among men (-0.70pp/year), individuals aged 25-34 years (-0.84pp/year) and with more than 12 years of schooling (-0.96pp/year) (Table 2 and Supplementary Material - Table S1: https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00032424_6302.pdf).

Recommended fruit and vegetable consumption (≥ 5 servings/day on ≥ 5 days/week) also remained stable from 2008 to 2023, with an average of 22.5% for the entire population and across all sociodemographic groups. In the initial period (2008-2014), recommended fruit and vegetable consumption increased from 20% to 24.1% (0.81pp/year) for the entire population, with almost all sociodemographic groups showing an increase, particularly among women (0.90pp/year), individuals aged 55 to 64 years (0.96pp/year), and those with 12 years or more of schooling (0.77pp/year). The only exception was the group of individuals aged 65 and more, in which no increase was observed. However, from 2015 to 2023, the recommended fruit and vegetable consumption decreased from 25.2% to 21.4% (-0.52pp/year) for almost all sociodemographic groups, except for men, individuals aged 18-24 and aged 65 or more. The largest reductions were observed among women (-0.68pp/year), adults aged 25-34 years (-0.73pp/year) and with 12 years or more of schooling (-0.74pp/year) (Table 3 and Supplementary Material - Table S2: https://cadernos.ensp.fiocruz.br/static//arquivo/suppl-e00032424_6302.pdf).

Discussion

From 2008 to 2023, a stability in the prevalence of regular and recommended fruit and vegetable consumption among Brazilian adults was observed. However, when stratifying the period, significant changes in fruit and vegetable consumption were evident, with increased fruit and vegetable consumption in the initial period (2008-2014) followed by a sharp reduction in the most recent period (2015-2023). Among the sociodemographic groups, fruit and vegetable consumption increased in the initial period, especially among women and older adults. There was an increase in regular fruit and vegetable consumption, mainly among adults with lower schooling, and an increase in recommended fruit and vegetable consumption for adults with higher schooling. Conversely, there was a reduction in regular and recommended fruit and vegetable consumption in the most recent period for almost all sociodemographic groups, especially men (regarding regular consumption), individuals aged 25-34 years, and with higher schooling. Overall, the greater prevalence and a larger increase in fruit and vegetable consumption in the initial period among women, older individuals, and those with higher schooling, maintained these groups with the highest prevalence of consumption.

In recent decades, studies have evaluated fruit and vegetable consumption worldwide, including in Brazil. Nationally, population-based studies have used different Brazilian surveys for research, contributing to an increase in the body of evidence on fruit and vegetable consumption. For example, using data from Vigitel, the fruit and vegetable consumption trend was analyzed in the same population from 2008 to 2016 and an increase in the prevalence of these indicators was identified ⁸8. Silva LES, Claro RM. Tendências temporais do consumo de frutas e hortaliças entre adultos nas capitais brasileiras e Distrito Federal, 2008-2016. Cad Saúde Pública 2019; 35:e00023618.. Another study compared fruit and vegetable consumption for the entire adult population in 2013 and 2019 using data from the Brazilian National Health Survey. This study found little difference in overall fruit and vegetable consumption between those years, with a slight increase in fruit consumption but not in vegetable consumption ¹⁹19. Santin F, Gabe KT, Levy RB, Jaime PC. Food consumption markers and associated factors in Brazil: distribution and evolution, Brazilian National Health Survey, 2013 and 2019. Cad Saúde Pública 2022; 38 Suppl 1:e00118821.. And data from the Brazilian Household Budget Survey (POF, acronym in Portuguese) showed an increase in the availability of fruit and vegetable in Brazilian households during the 2002-2003, 2008-2009, and 2017-2018 periods, driven primarily by an increase in fruit availability ²⁰20. Levy RB, Andrade GC, Cruz GL, Rauber F, Louzada MLC, Claro RM, et al. Three decades of household food availability according to NOVA - Brazil, 1987-2018. Rev Saúde Pública 2022; 56:75.. Although these studies have different methodologies, scopes, and periods of analysis, they similarly indicate insufficient and unequal consumption among populations. Our results add to this evidence, uncovering the population’s updated consumption trends. We found an increase in fruit and vegetable consumption essentially from 2008 to 2014 but a reduction in the prevalence after 2015, confirming the initial hypothesis that the political, economic, and sanitary crisis in the country since 2015 could affect fruit and vegetable consumption.

Several initiatives by the Brazilian government that aim to address NCD have been implemented, including national plans with goals that encompass promoting fruit and vegetable consumption ¹. The Strategic Action Plan to Tackle Noncommunicable Chronic Diseases in Brazil, 2011-2022 was the first action plan of the country on this topic, proposing a 10% increase in the prevalence of recommended fruit and vegetable consumption among Brazilians ²¹21. Departamento de Análise de Situação de Saúde, Secretaria de Vigilância em Saúde, Ministério da Saúde. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas não Transmissíveis (DCNT) no Brasil 2011-2022. Brasília: Ministério da Saúde; 2011.. The goal was to achieve a 21.5% prevalence by 2022, but this target was already surpassed in 2011 (22%) ²²22. Malta DC, Silva AG, Teixeira RA, Machado IE, Coelho MRS, Hartz ZMA. Avaliação do alcance das metas do plano de enfrentamento das doenças crônicas não transmissíveis no Brasil, 2011-2022. An Inst Hig Med Trop (Lisb) 2019; 1:9-16.. The second and most current action plan, the Strategic Action Plan to Tackle Noncommunicable Chronic Diseases (NCD) in Brazil, 2021-2030, proposes a 30% increase in recommended fruit and vegetable consumption by 2030 ²³23. Departamento de Análise em Saúde e Vigilância de Doenças Não Transmissíveis, Secretaria de Vigilância em Saúde, Ministério da Saúde. Plano de Ações Estratégicas para o Enfrentamento das Doenças Crônicas e Agravos não Transmissíveis no Brasil 2021-2030. Brasília: Ministério da Saúde; 2021.. However, as observed in this study, the reduction trend in the recommended fruit and vegetable consumption will likely hinder meeting this goal.

Such events may be associated with structural changes in Brazil during the investigated periods. The increase in fruit and vegetable consumption in the initial period followed a remarkable period of economic, social, and health policies in the country ¹1. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014.^,1010. Brasil. Lei nº 10.696, de 2 de julho de 2003. Dispõe sobre a repactuação e o alongamento de dívidas oriundas de operação de crédito rural, e dá outras providências. Diário Oficial da União 2003; 3 jul.^,1111. Bortolini GA, Pereira TN, Nilson EAF, Pires ACL, Moratori MF, Ramos MKP, et al. Evolution of nutrition actions in primary health care along the 20-year history of the Brazilian National Food and Nutrition Policy. Cad Saúde Pública 2021; 37:e00152620.^,1212. Brasil. Lei nº 10.836, de 9 de janeiro de 2004. Cria o Programa Bolsa Família e dá outras providências. Diário Oficial da União 2004; 12 jan.^,2424. Brasil. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 sep.^,2525. Ministério da Saúde. Portaria nº 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família. Diário Oficial da União 2008; 25 jan.^,2626. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2013.. The population adhered to healthier behaviors, including fruit and vegetable consumption, as well as greater engagement in physical activity and a reduction in smoking rates ²⁷27. Silva AG, Teixeira RA, Prates EJS, Malta DC. Monitoring and projection of targets for risk and protection factors for coping with noncommunicable diseases in Brazilian capitals. Ciênc Saúde Colet 2021; 26:1193-206.. Notably, actions during this time included the presence of the Brazilian National Food and Nutritional Security Council (CONSEA, acronym in Portuguese), a presidential advisory council with an important role in promoting the agenda of family farming ²⁴24. Brasil. Lei nº 11.346, de 15 de setembro de 2006. Cria o Sistema Nacional de Segurança Alimentar e Nutricional - SISAN com vistas em assegurar o direito humano à alimentação adequada e dá outras providências. Diário Oficial da União 2006; 18 sep.^,2828. Castro IRR. The dissolution of the Brazilian National Food and Nutritional Security Council and the food and nutrition agenda. Cad Saúde Pública 2019; 35:e00009919., particularly via initiatives like the Food Acquisition Program (PAA, acronym in Portuguese). This program facilitated the purchase of products from family farmers and distributed them to those facing food insecurity ¹⁰10. Brasil. Lei nº 10.696, de 2 de julho de 2003. Dispõe sobre a repactuação e o alongamento de dívidas oriundas de operação de crédito rural, e dá outras providências. Diário Oficial da União 2003; 3 jul.. Income increases, associated with initiatives like the Brazilian Family Income Program [Programa Bolsa Família] ¹²12. Brasil. Lei nº 10.836, de 9 de janeiro de 2004. Cria o Programa Bolsa Família e dá outras providências. Diário Oficial da União 2004; 12 jan., played a decisive role in reducing food insecurity among beneficiary families, with a positive impact on food consumption ²⁹29. Martins APB, Monteiro CA. Impact of the Bolsa Família program on food availability of low-income Brazilian families: a quasi experimental study. BMC Public Health 2016; 16:827.. Additionally, the expansion of PHC, along with the inclusion of nutritionists in these settings ²⁵25. Ministério da Saúde. Portaria nº 154, de 24 de janeiro de 2008. Cria os Núcleos de Apoio à Saúde da Família. Diário Oficial da União 2008; 25 jan., facilitated nutritional attention and multidisciplinary care for individuals ¹¹11. Bortolini GA, Pereira TN, Nilson EAF, Pires ACL, Moratori MF, Ramos MKP, et al. Evolution of nutrition actions in primary health care along the 20-year history of the Brazilian National Food and Nutrition Policy. Cad Saúde Pública 2021; 37:e00152620.. Moreover, the reformulation of the Dietary Guidelines for the Brazilian Population¹1. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Guia alimentar para a população brasileira. Brasília: Ministério da Saúde; 2014. positioned it as a key tool in food and nutrition actions, especially in the PHC ²⁶26. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2013..

However, recent years have been characterized by political instability and the worsening of the economic crisis ¹³13. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional por Amostra de Domicílios Contínua (PNAD contínua): rendimento de todas as fontes. https://biblioteca.ibge.gov.br/visualizacao/livros/liv101950_informativo.pdf (accessed on 02/Aug/2023).
https://biblioteca.ibge.gov.br/visualiza... , exacerbated by fiscal adjustments that lowered State expenditures, especially in health and social sectors ³⁰30. Menezes APR, Moretti B, Reis AAC. The future of the SUS: impacts of neoliberal reforms on public health - austerity versus universality. Saúde Debate 2019; 43:58-70., since its implementation in 2016 ³¹31. Brasil. Emenda Constitucional nº 95, de 15 de dezembro de 2016. Altera o Ato das Disposições Constitucionais Transitórias, para instituir o Novo Regime Fiscal, e dá outras providências. Diário Oficial da União 2016; 16 dec.. This has been compounded by a reduction in social participation in the formulation and monitoring of food and nutrition policies ²⁸28. Castro IRR. The dissolution of the Brazilian National Food and Nutritional Security Council and the food and nutrition agenda. Cad Saúde Pública 2019; 35:e00009919.^,2929. Martins APB, Monteiro CA. Impact of the Bolsa Família program on food availability of low-income Brazilian families: a quasi experimental study. BMC Public Health 2016; 16:827., as well as in important health programs in the PHC ³²32. Mattos MP, Gutiérrez AC, Campos GWS. Construction of the historical-regulatory standard of the Expanded Family Health Center. Ciênc Saúde Colet 2022; 27:3503-16.. Considering that the purchase of natural and minimally processed foods typically entails a higher financial cost, families still face obstacles in accessing them during this period, mainly for lower income populations ³³33. Maia EG, Passos CM, Levy RB, Martins APB, Mais LA, Claro RM. What to expect from the price of healthy and unhealthy foods over time? The case from Brazil. Public Health Nutr 2020; 23:579-88..

Since 2023, some of the programs and actions aforementioned are once again returning to the political agenda, however no significant changes have yet been observed. The reduction in fruit and vegetable consumption among the same groups reinforces the stagnation in overcoming social differences. This study, along with many others, contributes to the growing body of evidence on entrenched disparities in demand for and use of health services related to lifestyle and illness. Studies conducted in developed and developing countries have consistently shown that being a woman ²⁰20. Levy RB, Andrade GC, Cruz GL, Rauber F, Louzada MLC, Claro RM, et al. Three decades of household food availability according to NOVA - Brazil, 1987-2018. Rev Saúde Pública 2022; 56:75.^,3434. Silva ZP, Ribeira MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Colet 2011; 16:3807-16., younger individual ⁸8. Silva LES, Claro RM. Tendências temporais do consumo de frutas e hortaliças entre adultos nas capitais brasileiras e Distrito Federal, 2008-2016. Cad Saúde Pública 2019; 35:e00023618.^,3535. Costa CS, Sattamini IF, Steele EM, Louzada MLC, Claro RM, Monteiro CA. Consumption of ultra-processed foods and its association with sociodemographic factors in the adult population of the 27 Brazilian state capitals (2019). Rev Saúde Pública 2021; 55:47., and having higher schooling levels ⁶6. Frank SM, Webster J, McKenzie B, Geldsetzer P, Manne-Goehler J, Andall-Brereton G, et al. Consumption of fruits and vegetables among individuals 15 years and older in 28 low-and middle-income countries. J Nutr 2019; 7:1252-9.^,3636. Barros MBA, Medina LPB, Lima MG, Sousa NFS, Malta DC. Changes in prevalence and in educational inequalities in Brazilian health behaviors between 2013 and 2019. Cad Saúde Pública 2022; 38:e00122221. can be considered protective factors.

Women typically presents greater concern about their health and well-being ³⁴34. Silva ZP, Ribeira MCSA, Barata RB, Almeida MF. Perfil sociodemográfico e padrão de utilização dos serviços de saúde do Sistema Único de Saúde (SUS), 2003-2008. Ciênc Saúde Colet 2011; 16:3807-16.. This heightened awareness can be attributed to sociocultural norms that emphasize care and self-care among women. They tend to seek more health information and medical advice, leading to greater adoption of health recommendations and lifestyle changes ³⁷37. Grzymislawska M, Puck EA, Zawada A, Grzymislawski M. Do nutritional behaviors depend on biological sex and cultural gender? Adv Clin Exp Med 2020; 29:165-72.. The individual’s aging process can often serve as a catalyst for behavior change, as part of recommendations for disease treatment ³⁸38. Barros MBA, Francisco PMSB, Zanchetta LM, César CLG. Tendências das desigualdades sociais e demográficas na prevalência de doenças crônicas no Brasil, PNAD: 2003-2008. Ciênc Saúde Colet 2011; 16:3755-68., while younger individuals tend to have higher ultra-processed food consumption ³⁵35. Costa CS, Sattamini IF, Steele EM, Louzada MLC, Claro RM, Monteiro CA. Consumption of ultra-processed foods and its association with sociodemographic factors in the adult population of the 27 Brazilian state capitals (2019). Rev Saúde Pública 2021; 55:47.. A greater consumption of fruit and vegetable among women and older adults was also described in a study carried out with data from the Behavioral Risk Factor Surveillance System (BRFSS), the largest telephone survey on NCD carried out in the United States ⁹9. Lee-Kwan SH, Moore LV, Blanck HM, Harris DM, Galuska D. Disparities in state-specific adult fruit and vegetable consumption - United States, 2015. MMWR Morb Mortal Wkly Rep 2017, 45:1241-7..

Regarding schooling, individuals with a higher schooling generally tend to prioritize their health ³⁹39. Pampel FC, Krueger PM, Denney JT. Socioeconomic disparities in health behaviors. Annu Rev Sociol 2010, 36:349-70. and consequently adopt healthier behaviors ⁶6. Frank SM, Webster J, McKenzie B, Geldsetzer P, Manne-Goehler J, Andall-Brereton G, et al. Consumption of fruits and vegetables among individuals 15 years and older in 28 low-and middle-income countries. J Nutr 2019; 7:1252-9.^,3636. Barros MBA, Medina LPB, Lima MG, Sousa NFS, Malta DC. Changes in prevalence and in educational inequalities in Brazilian health behaviors between 2013 and 2019. Cad Saúde Pública 2022; 38:e00122221.. This happens because education contributes to a better understanding of health-related information and an increased awareness of one’s health status. Education can also be seen as a proxy for individual income. This would facilitate access to purchasing these foods ³⁹39. Pampel FC, Krueger PM, Denney JT. Socioeconomic disparities in health behaviors. Annu Rev Sociol 2010, 36:349-70.. Despite this, our findings indicate a reduction in the regular and recommended fruit and vegetable consumption in the population, even among those with higher schooling. This suggests that economic changes in the country may have affected individuals with higher incomes as well. Data from the latest POFs (2002-2003, 2008-2009, and 2017-2018) showed an increase in fruit acquisition among the poorest strata, while it remained unchanged among the richest ²⁰20. Levy RB, Andrade GC, Cruz GL, Rauber F, Louzada MLC, Claro RM, et al. Three decades of household food availability according to NOVA - Brazil, 1987-2018. Rev Saúde Pública 2022; 56:75.. Furthermore, the acquisition of ultra-processed foods has grown across all strata over the years ²⁰20. Levy RB, Andrade GC, Cruz GL, Rauber F, Louzada MLC, Claro RM, et al. Three decades of household food availability according to NOVA - Brazil, 1987-2018. Rev Saúde Pública 2022; 56:75.. A recent study highlighted that during the COVID-19 pandemic, ultra-processed foods became cheaper than fresh and minimally processed foods, impacting the purchase of fruit and vegetable, especially among the poorest social classes ⁴⁰40. Andrade GC, Caldeira TCM, Mais LA, Martins APB, Claro RM. Food prince trends during the COVID-19 pandemic in Brazil. PLoS One 2024; 19:e0303777..

The decrease in fruit and vegetable consumption represents a deterioration in dietary quality and diversity among the Brazilian population, impacting not only the profile of micronutrients and fiber intake in the diet but also contributing to worsening populations’ health, and a weakening in the food culture of the country ^{1 ,2,3}. A set of actions and policies can strategically improve the population’s food intake by discouraging the consumption of ultra-processed foods and encouraging fruit and vegetable consumption. Simple advances have been made, such as changes in food labeling, with an emphasis on front labeling indicating specific critical nutrients present mainly in ultra-processed foods ⁴¹41. Agência Nacional de Vigilância Sanitária. Resolução de Diretoria Colegiada nº 429, 8 de outubro de 2020. Dispõe sobre a rotulagem nutricional dos alimentos embalados. Diário Oficial da União 2020; 9 oct.. Considering the experience of other countries, it is expected that front labeling will enable more informed food choices, consequently reducing ultra-processed food consumption. Furthermore, an indirect effect of healthy food consumption, such as fruit and vegetable, can be expected by shifting consumption. Economic tools, such as the taxation of unhealthy foods concomitant with the subsidy of healthy foods, have been recommended, recognizing that price plays a significant role in food choice ⁴²42. World Health Organization. 'Best buys' and others recommended interventions for the prevention and control of noncommunicable diseases. https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf (accessed on 01/Feb/2023).
https://apps.who.int/iris/bitstream/hand... . Reducing the price of healthy foods, such as fruit and vegetable, has been found to be more effective than just increasing the price of unhealthy foods. In fact, even a modest decrease of about 10% in the price of fruit and vegetable can lead to a significant increase of up to 12% in their consumption. On the other hand, a 10% increase in the price of unhealthy foods, such as fast foods, typically results in a modest decrease of about 6% in their consumption ⁴³43. Afshin A, Peñalvo JL, Gobbo LD, Silva J, Michaelson M, O'Flaherty M, et al. The prospective impact of food pricing on improving dietary consumption: a systematic review and meta-analysis. PLoS One 2017; 12:e0172277..

Therefore, efforts to increase the direct consumption of fruit and vegetable must be prioritized with strategies that focus on supporting the production, supply, and access to these foods ^{21 ,22,23}. A previous study evaluated different intervention scenarios to increase fruit and vegetable consumption in New York City neighborhoods (United States), revealing that two strategies were associated with increased fruit and vegetable consumption: increasing the number of stores in low-income neighborhoods with limited access to healthy foods ⁴⁴44. Li Y, Zhang D, Thapa JR, Madondo K, Yi S, Fisher E, et al. Assessing the role of access and price on the consumption of fruits and vegetables across New York City using agent-based modeling. Prev Med 2017; 106:73-8. and reducing fruit and vegetable prices through tax subsidies or direct financial incentives ⁴³43. Afshin A, Peñalvo JL, Gobbo LD, Silva J, Michaelson M, O'Flaherty M, et al. The prospective impact of food pricing on improving dietary consumption: a systematic review and meta-analysis. PLoS One 2017; 12:e0172277.^,4444. Li Y, Zhang D, Thapa JR, Madondo K, Yi S, Fisher E, et al. Assessing the role of access and price on the consumption of fruits and vegetables across New York City using agent-based modeling. Prev Med 2017; 106:73-8..

In Brazil, policies aimed at offering low-cost meals and purchasing food from local family farmers to provide school meals have proven to be successful in providing indirect access to healthy foods ⁴⁵45. Ministério do Desenvolvimento Social e Combate à Fome. Manual do Programa Restaurante Popular. https://bvsms.saude.gov.br/bvs/publicacoes/projeto_logico_restaurante_popular.pdf (accessed on 09/Jul/2024).
https://bvsms.saude.gov.br/bvs/publicaco... ^,4646. Brasil. Lei nº 11.947, de 16 de junho de 2009. Dispõe sobre o atendimento da alimentação escolar e do Programa Dinheiro Direto na Escola aos alunos da educação básica; altera as Leis nº 10.880, de 9 de junho de 2004, 11.273, de 6 de fevereiro de 2006, 11.507, de 20 de julho de 2007; revoga dispositivos da Medida Provisória nº 2.178-36, de 24 de agosto de 2001, e a Lei nº 8.913, de 12 de julho de 1994; e dá outras providências. Diário Oficial da União 2009; 16 jun.. Additionally, it is crucial to ensure comprehensive care practices for individuals within the scope of PHC and promote adequate and healthy nutrition ²⁶26. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2013.. Given the scenario of increasing NCD, promotion actions should target both users and healthcare teams by providing professional training and implementing care protocols that involve multidisciplinary teams ²⁶26. Departamento de Atenção Básica, Secretaria de Atenção à Saúde, Ministério da Saúde. Política Nacional de Alimentação e Nutrição. Brasília: Ministério da Saúde; 2013..

We must point out issues and recognize the limitations of the study. Firstly, regarding the inclusion of fruit juices in the calculation of daily fruit consumption. Fruit juices have a historical precedent, with these beverages becoming a staple in many cultures as an alternative to water. Although fruit juices can be nutritious, they have different nutritional properties compared to whole fruits. For these reasons, the international “at least five per day” campaign recommends that juices should account as only one portion per day, regardless of the amount consumed ⁴⁷47. World Cancer Research Foundation; American Institute for Cancer Research. Food nutrition, physical activity, and the prevention of cancer: a global perspective. Washington DC: American Institute for Cancer Research; 2007.. This guideline ensures that people benefit from the full spectrum of nutrients and fiber that whole fruit and vegetable provide, promoting overall health and well-being. The World Cancer Research Foundation also recognizes that “natural fruit juice is a source of healthy nutrients, but it also contains a lot of sugar and loses most of the fiber obtained from eating the whole fruit. Therefore, it is best not to drink more than one glass (150 mL) per day” ⁴⁷47. World Cancer Research Foundation; American Institute for Cancer Research. Food nutrition, physical activity, and the prevention of cancer: a global perspective. Washington DC: American Institute for Cancer Research; 2007. (p. 151). To ensure the adequacy of the analyses performed, we carried out additional ones excluding juices from the estimates, yielding similar results (data not shown). Furthermore, it is also important to explain the absence of data collection in 2022 and the simplified collection in 2023. In the Vigitel 2023, the report indicates that interviews were concentrated in a few months of the year, there was a reduction in sample size, and interviews via mobile phone were introduced, requiring careful analysis and comparison of estimates ¹⁵15. Ministério da Saúde. Vigitel Brasil 2023: Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico. Estimativas sobre frequência e distribuição sociodemográfica de fatores de risco e proteção para doenças crônicas nas capitais dos 26 estados brasileiros e no Distrito Federal em 2023. Brasília: Ministério da Saúde; 2023.. Likewise, it is important to consider Vigitel’s type of data collection, a telephone survey with self-reported information. While self-reported information is frequently used in health surveys due to ease and low-cost administration in large population samples ⁴⁸48. Riley L, Guthold R, Cowan M, Savin S, Bhatti L, Armstrong T, et al. The World Health Organization STEPwise Approach to Noncommunicable Disease Risk-Factor Surveillance: methods, challenges, and opportunities. Am J Public Health 2016; 106:74-8., they may produce biased estimations. However, it is plausible to assume that such limitations remain consistent over time, thereby minimizing their impact on the identified trends or annual variations. Regarding Vigitel, a study comparing results from the system with a survey that used a gold standard methodology (household) showed similar outcomes ⁴⁹49. Caldeira TCM, Soares MM, Silva LES, Veiga IPA, Claro RM. Chronic disease risk and protective behaviors in Brazilian state capitals and the Federal District, according to the National Health Survey and the Chronic Disease Risk and Protective Factors Telephone Survey Surveillance System, 2019. Epidemiol Serv Saúde 2022; 31(spe l):e2021367.. Additionally, the Vigitel sample was limited to individuals with at least a landline in Brazilian capitals, an inherent characteristic of the research methodology. However, Vigitel employs appropriate weighting factors to adjust estimates and correct differences between populations with and without a landline. Therefore, it is possible to extrapolate the results to the whole Brazilian population.

Conclusion

The prevalence of fruit and vegetable consumption showed unfavorable evolution over the 15 editions studied. While there were significant changes in fruit and vegetable consumption in the country, characterized by an increase from 2008 to 2014, there was a substantial reduction in consumption from 2015 to 2023. Men, young adults, and adults with higher schooling levels were the most affected by the reduction in fruit and vegetable consumption. These results highlight the importance of expanding and strengthening public health actions aimed at improving food consumption and conducting continuous surveillance to develop and enhance effective health policies.

References

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