Academic journal article Bulletin of the World Health Organization

The Global Burden of Disease Attributable to Low Consumption of Fruit and Vegetables: Implications for the Global Strategy on diet./Charge De Morbidite Attribuable a la Faible Consommation De Fruits et De Legumes Dans le Monde : Consequences Pour la Strategie Mondiale En Matiere De nutrition/Carga Mundial De Morbilidad Atribuible Al Bajo Consumo De Frutas Y

Academic journal article Bulletin of the World Health Organization

The Global Burden of Disease Attributable to Low Consumption of Fruit and Vegetables: Implications for the Global Strategy on diet./Charge De Morbidite Attribuable a la Faible Consommation De Fruits et De Legumes Dans le Monde : Consequences Pour la Strategie Mondiale En Matiere De nutrition/Carga Mundial De Morbilidad Atribuible Al Bajo Consumo De Frutas Y

Article excerpt

Introduction

Chronic noncommunicable diseases are the leading causes of death and disability worldwide and are increasing rapidly in most regions of the world (1). The world health report 2003 (2) estimated that cardiovascular disease accounted for 16.7 million deaths globally (29.2% of the total), while cancer contributed to 7.1 million deaths (12.5% of the total). Policies aimed at reducing these diseases have typically emphasized selected risk factors such as smoking, and, where diet is included, attention has focused on fat consumption. Less attention has been given to other dietary risk factors, specifically consumption of fruit and vegetables. This is of growing importance as the nutrition transition, occurring in all but the poorest countries of the world, is resulting in the replacement of traditional plant-based diets that are rich in fruit and vegetables with diets that are rich in calories provided by animal fats and sugar and are low in complex carbohydrates (3).

Although there is now increasingly good evidence that fruit and vegetables protect against cardiovascular diseases and some cancers (4-6), their precise contribution has been unclear. It may be considerable: earlier national studies estimated that low consumption of fruit and vegetables was responsible for 2.4%, 2.8% and 3.5% of the burden of disease in New Zealand (7), Australia (8) and the European Union (9), respectively. Until now, however, there has been no attempt to estimate this contribution globally, particularly in developing countries.

The original global burden of disease (GBD) project (10) was the first study to calculate the worldwide burden of disability and mortality and the contribution of different diseases and risk factors in 1990. In the initial study, the number of risk factors examined was limited. Although it identified protein--energy malnutrition as the single greatest contributor to the overall disease burden, it did not look explicitly at the impact of dietary intake (11). In the updated analysis for 2000, WHO has expanded the study to include 26 risk factors assessed using a unified framework called comparative risk assessment (CRA) (1, 12). For the first time this included "fruit and vegetable consumption" as a risk factor. This paper reports the research undertaken to estimate the global burden of disease attributable to low consumption of fruit and vegetables, and discusses its implications for policy development.

Methods

Two sources of information were combined to derive the burden of disease attributable to low intake of fruit and vegetables; first, information on the level and distribution of consumption in the population and a baseline level of intake that would yield the lowest overall population risk; and second, estimates of the association, in terms of relative risks (RR) between fruit and vegetable intake and selected health outcomes. Data on risk factor levels and relative risks were obtained for both sexes, eight age groups, and 14 geographical regions (Table 1). The detailed methods have been published elsewhere (12-14).

Estimates of fruit and vegetable consumption

In this study, the risk factor was an aggregate measure called "fruit and vegetable intake", which we defined as being total consumption of fruit and vegetables, excluding potatoes (4, 5, 15). Intake was treated as a continuous variable and expressed in grams (g) per person per day. Estimates were based primarily on national representative surveys of individual dietary intake identified through a comprehensive search of the literature and contact with experts worldwide. Surveys with individual-level dietary data provide information on intakes and their variability (standard deviations) in population subgroups (age and sex strata). Data were obtained for 26 countries (highlighted in bold in Table 1) within 9 regions (16, 17). These included nationally representative surveys from some of the most populated countries in the world, including China, India, the Russian Federation and the United States of America (USA). …

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