Description

• Proportion of the population, aged 12 and over, that have consumed vegetables and fruits five or more times daily.

Specific Indicators

• Proportion of population consuming vegetables and fruits five or more times per day

Ontario Public Health Standards (OPHS)

The Ontario Public Health Standards (OPHS) establish requirements for the fundamental public health programs and services carried out by boards of health, which include assessment and surveillance, health promotion and policy development, disease and injury prevention, and health protection. The OPHS consist of one Foundational Standard and 13 Program Standards that articulate broad societal goals that result from the activities undertaken by boards of health and many others, including community partners, non-governmental organizations, and governmental bodies. These results have been expressed in terms of two levels of outcomes: societal outcomes and board of health outcomes. Societal outcomes entail changes in health status, organizations, systems, norms, policies, environments, and practices and result from the work of many sectors of society, including boards of health, for the improvement of the overall health of the population. Board of health outcomes are the results of endeavours by boards of health and often focus on changes in awareness, knowledge, attitudes, skills, practices, environments, and policies. Boards of health are accountable for these outcomes. The standards also outline the requirements that boards of health must implement to achieve the stated results.  

Outcomes Related to this Indicator

• Societal Outcome (Chronic Disease Prevention): An increased proportion of the population lives, works, plays, and learns in healthy environments that contribute to chronic disease prevention.
• Societal Outcome (Chronic Disease Prevention): There is increased adoption of behaviours and skills associated with reducing the risk of chronic diseases of public health importance.
• Societal Outcome (Reproductive Health): An increased proportion of individuals in their reproductive years are physically, emotionally, and socially prepared for conception.
• Board of Health Outcome (Chronic Disease Prevention): Priority populations have food skills and adopt healthy eating behaviours.

Assessment and/or Surveillance Requirements Related to this Indicator

• The board of health shall conduct epidemiological analysis of surveillance data...in the area of healthy eating (Chronic Disease Prevention).

http://www.ontario.ca/publichealthstandards

Corresponding Health Indicator from Statistics Canada and CIHI

• Fruit and Vegetable Consumption (previously referred to as dietary practices)
  Population aged 12 and over, by the average number of times per day that they consume vegetables and fruits. Measure does not take into account serving sizes.
  Categories: 5 or more times per day.

http://www.statcan.gc.ca/

On the search box, select "Tables"

Type "Health Indicators" into search box
Scroll down and click on the html version of "Health Indicators"
Click on "Data tables, maps and fact sheets" and then "Fruit and Vegetable Consumption"

Data Sources

Numerator & Denominator: Canadian Community Health Survey (CCHS)
Original source: Statistics Canada
Distributed by:
1. Ontario Ministry of Health and Long-Term Care
2. Statistics Canada
Suggested citation (see Data Citation Notes):
1. Canadian Community Health Survey [year], Statistics Canada, Share File, Ontario Ministry of Health and Long-Term Care.
2. Canadian Community Health Survey [year], Statistics Canada, Public Use Microdata File, Statistics Canada.

Survey Questions

The CCHS has a Fruit and Vegetable Consumption module that consists of a series of questions that ask about the foods the respondent usually eats or drinks, including meals and snacks eaten at home and away from home. For each food grouping, the respondent is asked how often they usually eat or drink the food (for example, once a day, three times a week, twice a month). The interviewer enters the reporting unit (per day, week, month or year, or never) and the number of times per reporting unit. The following food and drinks are included in the module: 1) fruit juices such as orange, grapefruit or tomato; 2) fruit; 3) green salad; 4) potatoes, not including French fries, fried potatoes, or potato chips; 5) carrots; 6) other vegetables. The question about other vegetables is worded: "Not counting carrots, potatoes, or salad, how many servings of other vegetables do you usually eat? The goal of this question is to elicit other vegetables not cited before, not as a point of comparison between number of times and servings. According to the documentation, "Respondents are asked to report in 'servings' rather than 'times' so that all different fruits and vegetables eaten at the same meal are counted. Servings should not be interpreted as referring to a specific quantity." Responses to these questions are combined to give the number of times per day that a respondent eats vegetables and fruits. 

The CCHS has a derived variable that groups the daily consumption of vegetables and fruits into three categories: Respondent eats vegetables and fruits less than 5 times per day; between 5 and 10 times per day; more than 10 times per day.

Alternative Data Source

Rapid Risk Factor Surveillance System (RRFSS) - rotating core module
The RRFSS fruit and vegetable module is very similar to that in the CCHS asking about the same foods, with only slight differences in wording. RRFSS asks "How many times per day, week or month do you drink 100 percent fruit juices such as orange, grapefruit, or tomato juice?", whereas CCHS asks "How often do you usually drink fruit juices such as orange, grapefruit or tomato?" RRFSS asks "how many times" in all six questions, while the final question in the CCHS asks "how many servngs?"

A SPSS Syntax file exists to create the derived variable for years prior to 2007.
Note that the RRFSS sample includes adults aged 18 years and older.

Analysis Check List

CCHS

• It is recommended that public health units use the Share File provided by the Ministry of Health and Long-Term Care rather than the public use file (PUMF) provided by Statistics Canada. The Share File has a slightly smaller sample size because respondents must agree to share their information with the province to be included; however, the share file has more variables and fewer grouped categories within variables. The Share File is a cleaner dataset for Ontario analysis because all variables that were not common content, theme content or optional content for Ontario have been removed.
• There may be slight differences between results from the share file and data published on the Statistics Canada website for the Health Indicators because rates calculated for Health Indicators use the master CCHS data file.
• Not applicable respondents should be excluded; however, it is important to understand who these respondents are from the questionnaire skip patterns to be able to describe the relevant population.
• Users need to consider whether or not to exclude the ‘Refusal, 'Don't Know' and ‘Not Stated' response categories in the denominator. Rates published in most reports, including Statistics Canada's publication Health Reports generally exclude these response categories.  In removing not stated responses from the denominator, the assumption is that the missing values are random, and this is not always the case.  This is particularly important when the proportion in these response categories is high.
• Estimates must be appropriately weighted (generally the share weight for the CCHS) and rounded.
• Users of the CCHS Ontario Share File must adhere to Statistics Canada's release guidelines for the CCHS data when publishing or releasing data derived from the file in any form. Refer to the appropriate user guide for guidelines for tabulation, analysis and release of data from the CCHS. In general, when calculating the CV from the share file using the bootstrap weights, users should not use or release weighted estimates when the unweighted cell count is below 10. For ratios or proportions, this rule should be applied to the numerator of the ratio.  Statistics Canada uses this approach for the tabular data on their website. When using only the Approximate Sampling Variability (CV) lookup tables for the share file, data may not be released when the unweighted cell count is below 30. This rule should be applied to the numerator for ratios or proportions.  This provides a margin of safety in terms of data quality, given the CV being utilized is only approximate.
• 4.5% of Ontario respondents were "not stated" for total daily vegetable and fruit consumption (FVCEGTOT) in CCHS 2005. This percentage is larger than for most variables because the variable is derived and based on many other variables, and also because it is not included for proxy interviews (e.g. 1.7% of respondents in CCHS 2005).
• Before releasing and/or publishing data, users should determine the CV of the rounded weighted estimate and follow the guidelines below:
• Acceptable (CV of 0.0 - 16.5) Estimates can be considered for general unrestricted release. Requires no special notation.
• Marginal (CV of 16.6 - 33.3) Estimates can be considered for general unrestricted release but should be accompanied by a warning cautioning subsequent users of the high sampling variability associated with the estimates. Such estimates should be identified by the letter E (or in some other similar fashion). 
• Unacceptable (CV greater than 33.3) Statistics Canada recommends not to release estimates of unacceptable quality. However, if the user chooses to do so then estimates should be flagged with the letter F (or in some other fashion) and the following warning should accompany the estimates: "The user is advised that...(specify the data)...do not meet Statistics Canada's quality standards for this statistical program. Conclusions based on these data will be unreliable and most likely invalid". These data and any consequent findings should not be published. If the user chooses to publish these data or findings, then this disclaimer must be published with the data.
• Caution should be taken when comparing the results from 2000/01 (Cycle 1.1) to subsequent years of the survey, due to a change in the mode of data collection.  The sample in 2000/01 had a higher proportion of respondents interviewed in person, which affected the comparability of some key health indicators.  Please refer to http://www.statcan.gc.ca/imdb-bmdi/document/3226_D16_T9_V1-eng.pdf for a full text copy of the Statistics Canada article entitled "Mode effects in the Canadian Community Health Survey: a Comparison of CAPI and CATI".

Method of Calculation

Vegetable and Fruit Consumption:

Basic Categories

• Age groups for age-specific rates: 12-19, 20-44, 45-64, 65+
• Sex: male, female
• Geographic areas for: CCHS - all 36 Public Health Units in Ontario; RRFSS - participating health units that chose the fruit and vegetable module

Indicator Comments

• Increased vegetable and fruit consumption is associated with many health benefits including a reduced risk of cardiovascular disease, stroke, many functional declines associated with aging ¹, and probable reduced risk of cancer ². Some evidence suggests that diets rich in dietary fibre (e.g. whole grains, legumes, vegetables, fruits) are associated with a lower risk of Type 2 diabetes ³. 
• Dietary intake is difficult to measure because it is complex and varies greatly on a daily, weekly and seasonal basis.
• Food intake is systematically under-reported by adults. This may be related to eating less than usual on the days on which food intake is recorded, inaccurate recall of the amount of food that was consumed, and/or omitting or forgetting certain types of foods ⁴.  Personal characteristics associated with under-reporting are: high BMI, body dissatisfaction and not smoking. Social desirability is also a factor. For example, people tend to report lower intakes of foods perceived as being less healthful ⁴.
• There are three primary methods of estimating food intake: 24-hour recalls, food records (i.e. diet diary), and food frequency questionnaires.  Different methods used to estimate food intake provide different information.  For example, the times per day that fruit and vegetables are consumed is generally less than the number of servings found through 24-hour recall results ⁴.
• The CCHS Fruit and Vegetable Consumption Module, on which the APHEO Vegetable and Fruit Consumption Indicator is based, is a food frequency questionnaire. It is adapted from the Fruit and Vegetable Module in the Behavioural Risk Factor Surveillance System (BRFSS), which has been in use in the United States since 1984 ⁵.
• The 7-item CCHS fruit and vegetable module is simple and fast to administer compared to other methods of assessing dietary intake. It provides information about the frequency of consumption, not the quantity consumed. Thus, it does not translate to number of servings per day.  It is appropriate for monitoring changes in fruit and vegetable consumption over time. 
• The Fruit and Vegetable Consumption module was core content in CCHS 2000/01, 2003, 2007/08 and 2009/10. It was optional content in 2005, but was chosen by all Ontario public health units. CCHS 2004 (Cycle 2.2) had a nutrition focus, providing more detailed nutrition data at the national and provincial levels.
• Validation studies of the BRFSS fruit and vegetable consumption module have evaluated the degree to which the BRFSS questions capture “true” consumption of fruit and vegetables as measured through repeat 24-hour recalls, diet records and longer food frequency questionnaires. One study found that the BRFSS underestimated fruit and vegetable consumption compared to 24-hour food recalls ⁶. Another study reported that the mean daily frequency of fruit and vegetable intake was similar to the mean number of servings estimated by multiple diet records or recalls ⁷.
• A review of reliability and validity studies of measures on the BRFSS determined that the fruit and vegetable consumption module had “moderate” reliability and “moderate” validity ⁷.
• Short vegetable and fruit food frequency questionnaires in general have been found to overestimate ⁹, underestimate ^{10, 11,12}, and have similar estimates ^{13, 14} of vegetable and fruit intake relative to 24-hour dietary recalls.  One review suggests a greater validity for survey instruments with a moderate number of fruit and vegetable items and/or which included questions on portion sizes and consumption of mixed vegetable dishes ¹⁰.
• A validation study of the fruit and vegetable module in RRFSS demonstrated that vegetable and fruit consumption measured in terms of times per day was a proxy for commonly recognized portions of total vegetable and fruit intake at the population level ¹⁴.
• A Canadian study raised concerns about the cultural relevance of a more comprehensive food frequency questionnaire for respondents in ethno-cultural groups other than British and French. Some issues were: relevance of foods listed, multiple meaning of words, and the appropriateness of the telephone as a way to survey people ¹⁵.
• The results of population surveys cannot be used to assess the adequacy of the nutrient intakes of the population.  This is because more than one food group may provide nutrients, and nutrients may be provided by food fortification and/or by dietary supplements ⁴.
• The cut-offs of 5 and 10 times per day has been used historically in reporting results from CCHS and BRFSS.  Eating Well with Canada’s Food Guide, released in 2007, recommends between 4 and 10 servings of vegetables and fruits per day depending on age and sex ¹⁶.  As these guidelines refer to number of servings and serving sizes rather than frequency (i.e. times per day), it is not recommended to use the age and sex thresholds for vegetable and fruit consumption from the Food Guide with food frequency information from CCHS.
• This indicator prescribes using the cut-off of 5 or more times per day.  However, it may also be important to consider the distribution of times per day that individuals report consuming vegetables and fruits.  For example, consider a sample population where 70% of the group reports consuming vegetables and fruits less than 5 times per day.  Individuals may all be consuming just less than 5 times per day or, there could be a large proportion of the group who consume vegetables and fruits only one or two times per day ⁴. Another reason for continuing to use the cutoff of 5 or more times/day is that with higher thresholds it is more difficult to observe changes in the population because a large proportion is below the threshold.
• Based on the CCHS 2005 Share File, 43.4% of Ontarians aged 12 and older consumed vegetables and fruits 5 or more times daily. Not stated were excluded.
• Women generally consume more vegetables and fruits than men. Frequency of eating vegetables and fruits is positively related to being physically active, not smoking, not being overweight, and in women to not being alcohol-dependent ¹⁷.
• In 2011, Cancer Care Ontario started using a new definition for vegetable and fruit consumption to align with the most recent recommendations for cancer prevention.  The following definitions are now being employed:
  • Adult: Proportion of adults (aged 18+) who ate vegetables (excluding potatoes) and fruit 5 or more times daily.
  • Youth: Proportion of youth (aged 12 to 17) who ate vegetables (excluding potatoes) and fruit 5 or more times daily.

Cross-References to Other Indicators

• Food Insecurity (Section 2A. Social Environment and Health)
• Adult Body Mass Index (Section 5D. Nutrition and Healthy Weights)
• Adolescent Body Mass Index (Section 5D. Nutrition and Healthy Weights)

1. World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective. Washington DC: AICR, 2007.
2. Heber D. Vegetables, fruits and phytoestrogens in the prevention of diseases. J Postgrad Med 2004; 50:145-149. Available online at: http://www.jpgmonline.com/article.asp?issn=0022-3859;year=2004;volume=50;issue=2;spage=145;epage=149;aulast=Heber (Accessed April, 2008).
3. World Health Organization. Diet, Nutrition and the Prevention of Chronic Disease: Report of a joint WHO/FAO Expert Consultation, WHO Techincal Rport Series 916. 2003.
4. Office of Nutrition Policy and Promotion, Health Products and Food Branch. Canadian Community Health Survey Cycle 2.2, Nutrition (2004)-A Guide to Accessing and Interpreting the Data (Catalogue No. H164-20/2006E). Ottawa, ON: Health Canada, 2006.
5. Office of Nutrition Policy and Promotion, Health Canada. Fruit and Vegetables Frequency Questions - Canadian Community Health Survey Literature Review. December 2009 (unpublished).
6. Smith-Warner SA, Elmer PJ, Fosdick L, Tharp TM, Randall B. Reliability and comparability of three dietary assessment methods for estimating fruit and vegetable intakes. Epidemiology 1997; 8:196-201. 
7. Serdula M, Coates R, Byers T, Mokdad A, Jewell S, Chávez N, Mares-Perlman J, Newcomb P, Ritenbaugh C, Treiber F, Block G. Evaluation of a brief telephone questionnaire to estimate fruit and vegetable consumption in diverse study populations. Epidemiology 1993; 4:455-63.
8. Nelson DE, Holtzman D, Bolen J, Stanwyck CA, Mack KA. Reliability and validity of measures from the Behavioral Risk Factor Surveillance System (BRFSS). Sozial-und Praventivmedizin 2001;46 Suppl 1:S3-42.
9. Warneke CL, Davis M, De Moor C, Baranowski T. A 7-item versus 31-item food frequency questionnaire for measuring fruit, juice, and vegetable intake among a predominantly African-American population. J Am Diet Assoc 2001; 101(7):774-9. 
10. Kim DJ, Holowaty EJ. Brief, validated survey instruments for the measurement of fruit and vegetable intakes in adults: a review. Prev. Med. 2003 Apr. 36(4):440-7.
11. Thompson FE, Kipnis V, Subar AF, Krebs-Smith SM, Kahle LL, Midthune D, Potischman N, Schatzkin A. Evaluation of 2 brief instruments and a food frequency questionnaire to estimate daily number of servings of fruit and vegetables. Am J Clin Nutr 2000; 71:1503-10.
12. Field AE, Colditz GA, Fox MK, Byers T, Serdula M, Bosch RJ, Peterson KE. Comparison of 4 questionnaires for assessment of fruit and vegetable intake. Am J Public Health 1998; 88:1216-18.
13. Resnicow K, Odom E, Wang T, Dudley WN, Mitchell D, Vaughan R, Jackson A, Baranowski T. Validation of three food frequency questionnaires and 24-hour recalls with serum carotenoids levels in a sample of African American adults. Am J Epidemiol 2000; 152:1072-80.
14. Traynor MM, Holowaty PH, Reid DJ, Gray-Donald K. Vegetable and fruit food frequency questionnaire serves as a proxy for quantified intake. Can J Public Health 2006; 7(4):286-290. 
15. Paisley J, Greenbrg M, Hains J. Cultural relevance of a fruit and vegetable food frequency questionnaire. Canadian Journal of Dietetic Practice and Research 2005; 66(4):231-6.
16. Health Canada. Eating Well with Canada’s food Guide (Catalogue No. H164-38/1-2007E). Ottawa, ON: Health Canada, 2007.
17. Perez CE. Fruit and vegetable consumption. Health Rep 2002: 13(3):23-31.

Other References

• World Cancer Research Fund/American Institute for Cancer Research. Food, Nutrition, Physical Activity and the Prevention of Cancer: a Global Perspective: The Continuous Update Project. Available from: http://www.dietandcancerreport.org/cu/ (Accessed November 2008).

Changes Made

Acknowledgements