Fruit and Vegetables for Health

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Fruit and Vegetables
for Health
Report of a Joint FAO/WHO Workshop,
1–3 September 2004, Kobe, Japan

WHO Library Cataloguing-in-Publication Data
Joint FAO/WHO Workshop on Fruit and Vegetables for Health (2004 : Kobe, Japan)
Fruit and vegetables for health : Report of a Joint FAO/WHO Workshop,
1-3 September, 2004, Kobe, Japan.
1.Fruit 2.Vegetables 3.Public health 4.Nutrition policy I.Title.
ISBN: 92 4 159281 8
(NLM Classification: WB 430)
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Photo credits
Cover: UNECE, WHO/P. Virot
Fruit and Vegetables for Health
Interior Pages: p. 3 UNECE, p. 4 WHO/P. Virot, WHO/A. Waxman, p. 33 UNECE, p. 35 PAHO. Baudoin,
Report of a joint FAO/WHO workshop
p. 6 WHO/P. Virot, p. 7 FAO/W.O. Baudoin, p. 8, 9,
p. 37 UNECE, p. 41 WHO/P. Virot, p. 43 WHO/P. Virot,
1-3 Sept 2004, Kobe, Japan
11, 12 UNECE, p. 15, 16 WHO/P. Virot, p. 18 FAO/W.O.
p. 45 UNECE.
Baudoin, p. 19, 20 UNECE, p. 22 FAO/W.O. Baudoin,
p.26 FAO/W. Baudoin, p. 27 FAO/W. Baudoin, p. 31
Cover design and layout:
Printed in the Philippines.

Content
Background
7
1
Welcome address
8
2
Presentations
9
3 3.1 Overview of health effects of fruit and vegetables-regarding cancer, CVD, obesity and diabetes
9
3.2 Trends in fruit and vegetable consumption and effects as part of the nutrition transition
10
3.3 Worldwide production of fruit and vegetables
10
3.4 Measuring intake of fruit and vegetables
11
3.5 Effectiveness of interventions and programmes promoting fruit and vegetable intake
12
3.6 Production interventions to improve the availability of and access to fruit and vegetables for all
13
3.7 A global initiative on fruit and vegetables: FAO’s interdisciplinary approach to the promotion of fruit and vegetables
14
3.8 Meeting consumers’ needs and preferences for fruit and vegetables
15
3.9 Food safety aspects in fruit and vegetables
16
3.10 Patterns and determinants of fruit and vegetable demand in developing countries: a multi-country comparison
17
3.11 Country case study presentations
18
3.11.1 Brazil
3.11.2 Ethiopia
3.11.3 Iran
3.11.4 Thailand
4 Workshop Conclusions
21
A framework for promoting fruit and vegetables at national level
23
5 5.1 Guiding principles for a fruit and vegetable programme
23
5.2 Consumer domains and fruit and vegetable supply networks
24
5.2.1 Characteristics of consumer domains and fruit and vegetable supply networks
5.2.2 Entry points for fruit and vegetable promotion programmes
5.2.3 Barriers to fruit and vegetable promotion/consumption
5.3 Identification of stakeholders
28
5.4 National coordinating team
29
5.4.1 Constitution of national coordinating team
5.4.2 Roles of national coordinating team
5.5 Identification of national goals and objectives
30
5.5.1 Considerations regarding goal-setting
5.6 Activities at national level
31
5.6.1 Existing national policies and action plans
5.6.2 Possible interventions at national level
5.7 Sources of data and data collection
37
5.8 Monitoring and evaluation
38
Annex 1
40
Participants
Annex 2
44
Workshop agenda
5

WHO and FAO held their first joint workshop –
Fruit and Vegetables for Health – at the WHO
Centre for Health Development in Kobe, Japan,
on 1-3 September 2004. Participants included
nutrition, health and agricultural scientists,
representatives from ministries of health and
agriculture, advisers on nutrition from WHO
1 Background
Regional Offices, experts from the World Food
Programme, the United Nations Economic
Commission for Europe, the Secretariat of the
Noncommunicable diseases (NCDs), especially cardiovascular
Pacific Community, the International Food
diseases (CVDs), cancer, obesity and type 2 diabetes mellitus,
Policy Research Institute, and the global "5 A
currently kill more people every year than any other cause of death.
Day" community, which promotes fruit and
Four factors in the epidemiology of these diseases – poor diet, physical
vegetable consumption (see Annex 1 for the
inactivity, tobacco and alcohol use – are of overwhelming importance
list of participants and Annex 2 for the
to public health.
workshop programme).
Fruit and vegetables are an important component of a healthy diet and,
The overall goal of the workshop was to
if consumed daily in sufficient amounts, could help prevent major
develop a draft framework to guide the
diseases such as CVDs and certain cancers. According to The World
development of cost-efficient and effective
Health Report 2002, low fruit and vegetable intake is estimated to
interventions to promote adequate
cause about 31% of ischaemic heart disease and 11% of stroke
consumption of fruit and vegetables in
worldwide.1 Overall it is estimated that up to 2.7 million lives could
Member States. The expected outcomes of the
potentially be saved each year if fruit and vegetable consumption was
workshop were a series of background papers
sufficiently increased. Recommendations in this direction tend to
prepared by experts (and published in
complement and reinforce other valid messages based on the long-
separate documents, available under:
known health benefits of consuming vegetables and fruit as dietary
www.who.int/dietphysicalactivity/fruit/en, and
sources of fibre, vegetable proteins and protective micronutrients. The
the elaboration and endorsement by
recent Joint FAO/WHO Expert Consultation on diet, nutrition and the
participants of a draft framework to guide
prevention of chronic diseases, recommended the intake of a
effective fruit and vegetable promotion
minimum of 400g of fruit and vegetables per day (excluding potatoes
interventions at national level, taking the whole
and other starchy tubers) for the prevention of chronic diseases such
chain from production to consumption into
as heart disease, cancer, diabetes and obesity, as well as for the
account (i.e. production, trade, post-harvest
prevention and alleviation of several micronutrient deficiencies,
handling, processing, distribution, marketing,
especially in less developed countries.2 The recommendation thus
procurement, preparation and consumption of
adds to the already strong case for the health benefits to be gained
fruit and vegetables).
from the consumption of fruit and vegetables and paves the way for
concrete action advocating increased consumption of these
Presentations of the background papers and
commodities.
case studies from selected countries are
summarized in section 3 of this report. The
WHO has responded to the global rise in NCDs by giving increasing
points and arguments raised by participants
attention to their prevention and control, most recently through the
Global Strategy on Diet, Physical Activity and Health endorsed at the
Fifty-seventh World Health Assembly on 22 May 2004.3 Within the
framework of this Global Strategy, WHO aims to actively promote an
increase in fruit and vegetable intake worldwide. To reach this goal,
1
The World Health Report, Reducing risks, promoting
health.
Geneva, World Health Organization, 2002.
WHO and FAO have formed a partnership around the theme of fruit
2
Diet, nutrition and the prevention of chronic diseases.
and vegetables for health.
Report of a Joint FAO/WHO Expert Consultation. Geneva,
World Health Organization, 2003 (WHO Technical Report
Series, No. 916).
WHO and FAO announced their joint effort at the Third Global Forum
3
Available from: http://www.who.int/dietphysicalactivity/en/
on NCD Prevention and Control held in Rio de Janeiro, Brazil, in
November 2003, emphasizing that worldwide awareness of the health
benefits of fruit and vegetable consumption needs to be increased. In
addition, accelerated national initiatives are required to produce and
efficiently market more affordable horticultural products, while
ensuring that they are safe and that fewer losses occur along the post-
harvest handling chain.
7

during the discussion are included in text boxes in Section 3. While
these do not reflect the opinion of WHO or FAO, nor the workshop
participants overall, they are included to reflect the rich discussion
and different points of view raised during the workshop. The
conclusions of the workshop are summarized in Section 4 and Section
5 contains the draft framework.
The workshop was financially supported by the WHO Kobe Centre for
Health Development. FAO's support for the participation of a number
of agriculture and horticulture experts from Africa, Asia and Latin
America was supplemented by contributions from ongoing national
programmes - Special Programme on Food Security and others - in
Ghana, Nigeria, Thailand, and Venezuela, from the P.N. Agricultural
Science Foundation, India and also from programmes funded by
Belgium, DANIDA (Denmark) and Norway.
2 Welcome address
The Director of the WHO Centre for Health Development (WKC), Dr
Wilfried Kreisel opened the workshop. He stressed that the workshop
was an excellent opportunity for the two UN agencies to join hands and
consequently to have a stronger impact on the health outcomes of
corresponding policies, programmes and activities of the Member
States. He reminded the participants that WHO had identified low fruit
and vegetable intake as one of the top 10 risk factors contributing to
mortality, and that adequate fruit and vegetable consumption could
help prevent major chronic NCDs. In addition, low consumption of
fruit and vegetables also contributes to hunger and to malnutrition
through micronutrient deficiencies, which increase the risk of
mortality and morbidity throughout the life course.
Dr Kreisel explained that WKC forms an integral part of the Secretariat
of WHO. Established in 1996, it is one of the newest WHO research-
oriented centres. Its mandate is to carry out innovative,
interdisciplinary research into the health consequences of social,
economic, environmental and technological change at global and local
levels. He acknowledged this joint workshop as an important
opportunity for both WHO and FAO to share scientific knowledge and
experience in both health and agriculture and called on participants to
consider how to incorporate fruit and vegetable promotion initiatives
into their countries’ existing programmes and policies.
After Dr Kreisel had concluded his opening remarks, Professor Hester
H Vorster (South Africa) was elected as chairperson and Mr Chavalvut
Chainuvati (Thailand) as co-chair. Rapporteurs were Dr Prem Nath
(India) and Ms Christine Quested (Samoa).
8

3
Presentations
Points raised in the
discussion
3.1 Overview of health effects of fruit and vegetables-
>>>
regarding cancer, CVD, obesity and diabetes
• There is a need for policies to
promote/support fruit and vegetable
Dr Lydia Bazzano 4, Beth Israel Deaconess Hospital, Boston, USA, Dr
consumption.
Anna Ferro-Luzzi, WHO Collaborating Centre for Nutrition, National
• Adding fruit and vegetables to the diet
Institute of Research on Food and Nutrition, Rome, Italy, Dr Beth
does not necessarily decrease the
Tohill 5, Nutrition and Physical Activity Division, Centers for Disease
energy density of the diet. There is a
Control, Atlanta, USA
need to consider how people are
preparing and eating them. Fruit and
NCDs are the main cause of death in most regions of the world.
vegetables need to replace other high
Research findings reviewed for this paper are strongly suggestive of a
energy foods in the diet to effectively
potential for fruit and vegetables to reduce the risk of type 2 diabetes
decrease its energy density.
mellitus. Several short-term, carefully-conducted clinical trials show
• With regard to health benefits, it is
that the consumption of fruit and vegetables can help achieve or
better to consider fruit and vegetables
maintain a healthy body weight. However, longer-term intervention
as a broad food group rather than
studies and epidemiological studies have given inconsistent results.
splitting them into individual fruits or
The findings show that diets rich in fruit and vegetables significantly
vegetables. This is more useful
reduce the risks of ischaemic heart disease and stroke.
because it is not known which
components in fruit and vegetables are
The following recommendations can be made: for weight
beneficial. There is a need to increase
management, longer-term and carefully-designed clinical studies are
consumption of fruit and vegetables in
still needed to determine whether the consumption of fruit and
general and also increase variety to
vegetables can help with weight management. With regard to type 2
ensure the best possible benefits.
diabetes mellitus and CVDs, further research is needed to evaluate
• There is a need to look at the total diet
separately specific fruits and vegetables. Also, research needs to be
and different dietary components, not
conducted in developing countries, since most of the evidence to date
just consider fruit and vegetables on
comes from industrialized countries.
their own.
4 5 Fuller details can be found in the related background
papers at www.who.int/dietphysicalactivity/fruit/en
9

3.2 Trends in fruit and vegetable consumption and effects as
>>>
part of the nutrition transition
Dr Carlos Monteiro, University of Sao Paulo, Brazil
In the last four decades the relative availability of staple foods (cereals,
pulses and starchy roots) has decreased in almost all geographic
regions. There are indications of partial shifts from staple foods
towards vegetable oils and sugar in low and lower-middle income
countries; towards vegetable oils, sugar and meat in upper-middle
income countries, and towards vegetable oils and meat in higher-
income countries. The relative availability of fruit and vegetables has
Between 1980 and 2001, consumption rose
only increased slightly in most countries and is still well below the
substantially for all 15 vegetables. On a per
recommended level in both developed and the developing countries.
capita basis worldwide, consumption of all 15
categories rose by double digits, with cabbage
the lowest (21%), and eggplant the highest
The impact of food availability changes on nutritional parameters of
(148%).
the diet are shown in the following table:
Of the 15 vegetables, 12 had export growth
since 1980 of over 100% in volume and five
Likely impacts
exceeded 200%. Garlic enjoyed the highest
• increase in total fat content and decrease in total carbohydrate
absolute rate of export growth; 11.4% per year
content everywhere
(much of the growth has been in the most
• increase in energy density everywhere
recent years). The export values of garlic and
• decrease in fibre content everywhere
frozen vegetables have had very strong growth.
• decrease in protein content in less developed countries
Vegetable imports were valued at US$ 7.3
billion in 1980 and reached US$ 21.6 billion in
2002.
Possible impacts
• increase in saturated fats
Only five of the 15 fruits studied showed
• decrease in some vitamins and minerals
production increases greater than 100%
• increase in the glycaemic index
between 1980 and 2003. These include
• decrease in bioactive compounds (flavonoids, etc)
watermelons, cantaloupes and other melons,
lemons and limes, and other fresh fruit not
otherwise specified (which covers a wide
The food availability changes in the last four decades are therefore
range of minor fruits). Annual growth rates in
consistent with the transition of human diets particularly in relation to
production of some fruits have been
the incidence of obesity, CVD, diabetes, certain types of cancer, and
substantial.
other nutrition-related NCDs. A higher replacement of staple foods by
fruit and vegetables, instead of meats, fats and sugar, would have
Solid consumption growth was revealed for all
avoided most of this deterioration. An increase in the availability (and
15 fruits between 1980 and 2001. On a per
consumption) of fruit and vegetables, particularly if these replace
capita basis, growth has been somewhat more
meats, fats and sugar where these are being consumed to excess, has
restrained; only two fruits, watermelons and
the potential to revert the deterioration seen over the last decades.
cantaloupes/melons, have experienced triple
digit growth. However, all 15 categories of
fruit had double digit consumption growth,
3.3 Worldwide production of fruit and vegetables
>>>
apart from plantains (0.66%) and pineapples
(-21%).
Ms Alison Hodder6, Horticultural Crops Group, Food and
Agriculture Organization, Rome, Italy

Fruit export volumes have grown enormously
in the 24-year period. For example, increases
The fruits and vegetables most widely produced and consumed in the
on 1980 figures have been 310% for
world have been examined using FAOSTAT data from 1980 to the
cantaloupes/melons, 357% for orange juice,
present. Current production of the 15 vegetables studied has risen
and 280% for pineapples. Orange juice
above 1980 levels e.g. by 74% for green (sweet) corn (maize) to
exports have expanded at a rate of 7.2% per
259% for spinach and eggplant. For 11 of the 15, production has risen
year, while melons/cantaloupes, pineapples
over 100%. The rise in production has been relatively steady for
and lemons and limes have enjoyed rates
almost all the vegetables studied.
above 6% per year. In many instances trade
1 0

has been from developing country exporters, adding to their
purchasing power and capacity to import other foods. The value was
Points raised in the
substantial for all fruits, but greatest for grapes, orange juice,
discussion
cantaloupes/melons, pineapples and watermelons.
• There is a need to collect additional
Imports of a few categories of fruits have surged. In the past few years
data to reflect appropriately the
import volumes of concentrated apple juice have increased by 1944%,
consumption of fruit and vegetables in
with a yearly growth of 14.7%. Pineapple import growth has been
the context of health.
399%, or 7.6% per year.
• To increase the usefulness of data on
production, consumption, and trade,
While this study analysed trends in the 15 major fruits and vegetables,
consideration needs to be given to the
it omitted many other horticultural products for which there is a lack
type of data needed: fruit and
of data due to the small volumes traded. However, some of these
vegetables are not all equally good for
products are very important for the local economy and food security
health, there is variability among
of some developing countries and further research is needed to
vegetable types in health benefits (not
quantify their significance in this respect.
all of which are fully understood), and
macro-pictures of production and
As several fruits and vegetables are in oversupply, many developing
consumption do not reveal localized
countries have diversified into the production and export of organically-
deficits or patterns within the informal
grown fruit and vegetables. Sales of these products have expanded
sector.
considerably in the last decade, with growth rates estimated at 25% per
year in some instances. Consumer concerns for the safety and healthiness
of foods, and perceptions that organic foods are better for health, have
6
fuelled this growth. Retail sales of organic fruit and vegetables were
A statistical overview prepared by the Horticultural
Products Group, FAO Commodities and Trade Division : full
estimated at US$ 1.7 billion in the European Union in 2002.
text available under : www.who.int/dietphysicalactivity/fruit.
7
Fuller details can be found in the related background paper
at www.who.int/dietphysicalactivity/fruit/en
3.4 Measuring intake of fruit and vegetables
>>>
Dr Antonio Agudo7, Catalan Institute of Oncology, Barcelona, Spain
The accurate measurement of fruit and vegetable intake is essential to
provide valid messages about fruit and vegetables and health. When
defining or grouping fruit and vegetables, botanical and culinary
classifications, as well as nutritional properties and potential health
effects, should be taken into account. The inclusion of composite
foods in fruit and vegetable assessment may be important depending
on dietary patterns in each country. The error of omitting such foods
seems to affect measurements of intake of vegetables more than fruit.
In dietary assessment methods, the completeness, structure and
wording of the questionnaire must be considered. A short list of fruit
and vegetables has less validity than a longer one and validity is
improved when questions on portion size are included.
In dietary guidelines it should be emphasized that the frequently-
recommended five servings-per-day should be considered as a
minimum. Separate advice should be given for fruit and for vegetables.
1 1

A standard portion size is assumed to be 80g and the studies reviewed
showed that, on average, this is appropriate. However, actual portions
tend to be lower for vegetables and higher for fruit. It is advisable to
provide the consumer with detailed lists of the usual portion sizes of
fruit and vegetables commonly eaten, together with overall broad
recommendations for fruit and vegetable intake.
All public health recommendations on fruit and vegetable intake
should be flexible and adapted to local circumstances because of the
wide variability of dietary patterns, food availability, food preferences
and cultural considerations of food.
In April 2004, the following databases were
searched from the earliest record: PUBMED,
Points raised in the discussion
CAB Abstracts (including nutritional abstracts
• There is a need to decide which data should be collected to
and reviews), The Cochrane Library (including
measure fruit and vegetable production, supply, and
DARE: Database of Abstracts and Reviews of
consumption. Appropriate indicators are needed to ensure
Effects), Web of Knowledge (including Web of
that what is measured provides the necessary information.
Science and ISI database), IBSS (International
• There is a need to decide on the definition of fruit and
Bibliography of the Social Sciences), Psychinfo
vegetables to avoid confusion.
(BIDS), EMBASE, AGRICOLA, LILACS, ID21,
• There is a need to take into account inter alia cultural and
ERIC, SIGLE and INGENTA.
socioeconomic differences between countries when
considering the promotion of fruit and vegetables.
The search strategy was designed to be used in
• The amount of fruit and vegetables required by an individual
PUBMED and adapted to the other databases.
per day is at least 400g; this is a minimum, not the target.
Papers published in Danish, English, French,
• It was suggested that some countries have such a low intake at
Norwegian, Portuguese, Russian, Spanish and
present that 400g may not be an appropriate minimum target;
Swedish were considered. The reference lists
they may never reach this goal. However, the consensus of the
of articles found were also examined and
meeting was that the 400g minimum should be the ultimate
experts in the field in all regions of the world
goal for all countries, but that each country could set
contacted. All individual- and population-
intermediate objectives to reach the 400g goal according to
based interventions and promotion
their own situation.
programmes which encouraged consumption
• Along with the 400g minimum goal the ideas that “variety is
of a diet rich in fruit and/or vegetables in
important” and “fresh is better” should be incorporated into
unsupervised (i.e. free-living) children and
promotional messages.
adults of both sexes who were not acutely ill
were included, providing individuals were
followed for at least three months and changes
in fruit and/or vegetable intake were
3.5 Effectiveness of interventions and programmes promoting
estimated.
>>>
fruit and vegetable intake
The results of this review showed that a wide
Dr Karen Lock8, London School of Hygiene and Tropical Medicine,
range of interventions and programmes
London, United Kingdom
promoting fruit and vegetable intake in
children and adults around the world have
In some developed countries, including Australia, the United Kingdom
already been performed and assessed.
of Great Britain and Northern Ireland and the United States of America,
Interventions aimed at children achieved an
fruit and vegetable promotion initiatives have been established for
increased intake of 0.14–0.9 servings of fruit
several years. Various groups of researchers have also performed
and vegetables per day, and in adults intake
food-based intervention studies for primary and secondary prevention
increased by up to 1.2 servings per day. None
of chronic conditions. An up-to-date systematic review of the literature
of the studies showed a detrimental effect of
on promotion programmes and interventions promoting fruit and
the interventions on fruit and vegetable
vegetable consumption was carried out to examine the effectiveness of
consumption.
such interventions in promoting fruit and/or vegetable intake.
8 Fuller details can be found in the related background paper
at www.who.int/dietphysicalactivity/fruit/en
1 2

Points raised in the discussion
• Initiatives to promote intake of fruit and vegetables must be
based on scientific evidence. Evaluating projects is essential to
learn what works and what does not. Without evaluation,
much time and money may be wasted repeating things that do
not work. Simple acceptable evaluation tools need to be
developed so that projects can be evaluated easily.
• Messages concerning fruit and vegetables need to be
integrated into guidelines with other healthy-diet messages
and into different healthy-diet programmes, e.g. cancer
prevention.
• Messages need to be country-specific and culturally-relevant.
For example, bananas can be classified as a fruit, but where
they are eaten as a staple in a country, they should be classified
differently to ensure sufficient diversity of fruit and vegetables
in the diet.
• There is a lack of data from developing countries; a lot of the
current information is from Europe and the United States.
3.6 Production interventions to improve the availability of
Increasingly, in addition to ministries of
>>>
and access to fruit and vegetables for all
agriculture, other actors and stakeholders are
involved, including civil society and
Mr Wilfried Baudoin9, Horticultural Crops Group, Food and
decentralized authorities, in order to ensure
Agriculture Organization, Rome, Italy
effective linkages with the market as well as
integration with social, educational and
A variety of strategies can be employed to improve the long term
economic development programmes.
productivity, diversity and quality of fruit and vegetable production. In
Examples include school gardens, promoting
order to direct these strategies more precisely, the various target
the adoption of Good Agricultural Practices
groups should be differentiated, i.e:
(GAP) for product quality and safety, and
monitoring and impact assessment.
• the rural poor, through the promotion of homestead gardens and
small-scale commercial production;
• the urban poor, through the promotion of urban and peri-urban
Points raised in
intensified horticulture for home consumption and neighbourhood
marketing;
the discussion
• commercial farmers, through market-oriented fruit and vegetable
For the implementation of production
production responding to national, intra-regional and international
interventions, it is important to:
market opportunities.
• provide clear messages and guidelines
with regard to quality and safety of
In general, production interventions are planned and implemented
fruits and vegetables;
with the growers’ community in cooperation with national
• pay special attention to fruit and
horticultural research and development centres under the ministries
vegetable species and cultivars that
of agriculture. The sustainability and further expansion of pilot
have a comparative advantage for their
production interventions depend on a series of key elements of the
nutrient density or market value;
supply chain that need to be addressed. These include micro-credit
• adapt the intervention strategy to focus
facilities, input of items that meet local requirements (e.g. tools),
on the target beneficiaries;
marketing to reduce transport costs and post-harvest losses, and
• consider South-South cooperations to
storage and small-scale food processing to improve prices for
gain benefit from other countries’
perishable produce (e.g. onions) or to add value for selected markets
experience.
(e.g. street food).
9 Fuller details can be found in the related background paper
at www.who.int/dietphysicalactivity/fruit/en
1 3