The role of fruit and vegetables in the diets of children in Europe: current state of knowledge on dietary recommendations, intakes and contribution to energy and nutrient intakes

Abstract

Fruit and vegetables (F&V) play an important role in the prevention of obesity and other chronic diseases and low intakes have been highlighted as one of the risk factors attributing to global mortality in adults. The childhood years are a critical period during which eating behaviours and food preferences evolve, providing an opportunity to develop and foster healthy eating practices, which carry into adulthood. This review aimed to summarise dietary guidelines relating to F&V, intakes of F&V and the contribution of F&V to energy and nutrient intakes in school-aged children in Europe. The current review showed a paucity of data in relation to guidelines specific for children for F&V consumption. Where guidelines were available, they ranged from 100 to 500 g or one to three portions of F&V daily (with variations in the categorisations). A key finding was the lack of data on estimates of F&V intakes in school-aged children across Europe. Where data were available, intakes ranged from 221 to 404 g/d and were generally below the WHO recommendation of at least 400 g/d. F&V contributed low proportions of energy intake (6–9%) but made significant contributions to intakes of dietary fibre (19–37%), vitamin A (26–46%), vitamin C (32–83%) and potassium (16–27%); however, they also contributed to intakes of total (25–50%) and free sugar (7–11%). This review has highlighted the need for more data on estimates of F&V intakes in school-aged children in Europe and a need for continued promotion of F&V consumption to increase intakes in this age group.

On-going research suggests that changes in current dietary patterns including an increased consumption of plant-based foods will provide major health benefits and will support a more sustainable environment^(1–4). In particular, higher intakes of fruit and vegetables (F&V) has been associated with a lower risk of obesity and other chronic diseases and low intakes have been highlighted as one of the risk factors attributing to global mortality in adults (about 2⋅6 million deaths per year)^(5,6) . While most research on health outcomes of F&V intake is in adults, the childhood years are a critical period during which eating behaviours and food preferences evolve, providing an opportunity to develop and foster healthy eating practices, which carry into adulthood^(7,8) .

Vegetables have been defined as the edible parts of the plant which include stems and stalks, roots, tubers, bulbs, leaves, flowers and fruits⁽⁹⁾. Fruits are a subgroup of vegetables containing seeds and pulpy surrounding tissue and are generally consumed raw as a breakfast, snack or dessert while vegetables can be consumed raw or cooked with a main dish, in a mixed dish or in a salad⁽⁹⁾. Due to their low energy density and high concentration of dietary fibre, vitamins and minerals, F&V are often grouped together and hold an important place in food-based dietary guidelines (FBDG) worldwide^(10–12). The WHO recommends a minimum intake of 400 g (five portions) of F&V daily (excluding potatoes and other starchy tubers) for the general healthy population⁽⁵⁾. However, individual countries develop their own FBDG which have been compiled in a comprehensive database by the FAO⁽¹³⁾. There is a need to understand the role of F&V in the diet including compliance with guidelines and the contribution of F&V to nutrient intakes.

This review aimed to summarise dietary guidelines relating to F&V, intakes of F&V and the contribution of F&V to energy and nutrient intakes in school-aged children in Europe. In order to review the dietary guidelines across Europe, the FAO database was used to source the FBDG of all European countries and guidelines were included if they were accessible online, included F&V and were published in English. For F&V intake and contribution to nutrient intakes, data are included from nationally representative dietary surveys published as reports, online web pages or peer-reviewed journal articles. For inclusion in this review, the studies must be published in English, conducted post 2000 and have collected dietary intake data at an individual level via either food records or 24 h recalls.

Guidelines for fruit and vegetable consumption in Europe

The comprehensive database from the FAO was reviewed with regard to guidance on F&V consumption for children in European countries and the findings are presented in Table 1. A key finding of this review was that there is a lack of data in relation to guidelines specific for children for F&V consumption. Denmark, Finland, Greece, the Netherlands and Norway are the only countries that provide guidelines for F&V consumption specific for school-aged children (4–13 years) with recommendations ranging from 100 to 500 g or one to three portions of F&V daily^(14–18). Many countries in Europe (including Austria, Bulgaria, France, Georgia, Germany, Ireland, Italy, Sweden, the UK and Turkey) instead have adopted the WHO recommendation for F&V consumption which is aimed at the general population (including children) and recommends an intake of a minimum of 400 g of F&V (excluding potatoes and other starchy tubers)^(19–29).

Table 1. Fruit and vegetable consumption guidelines for children from the food-based dietary guidelines in European countries within the WHO region

Ministry of Food Agriculture & Fisheries 2013⁽¹⁴⁾, National Nutrition Council Finland 2019⁽¹⁵⁾, Institute of Preventive Environmental & Occupational Medicine, Prolepsis 2014⁽¹⁶⁾, Netherlands Nutrition Centre 2015⁽¹⁷⁾, Norwegian Directorate of Health⁽¹⁸⁾, Austrian Ministry of Health and the National Nutrition Commission 2010⁽¹⁹⁾, Bulgarian National Center of Public Health Protection 2006⁽²⁰⁾, Ministry of Solidarity and Health 2019⁽²¹⁾, Ministry of Labor Health and Social Affaires 2005⁽²²⁾, The German Nutrition Society 2013⁽²³⁾, Food Safety Authority of Ireland 2011⁽²⁴⁾, Department of Health 2017⁽²⁵⁾, WHO 2000⁽²⁶⁾, The Swedish National Food Agency 2015⁽²⁷⁾, Public Health England 2016⁽²⁸⁾, Republic of Turkey Ministry of Health 2016⁽²⁹⁾, WHO/FAO⁽⁵⁾.

Whilst there is some variation in the quantities recommended for F&V consumption, particularly for children, there are also differences with regard to the inclusion/exclusion of individual components such as fruit juice, potatoes, dried fruit, nuts, legumes, tinned/canned fruit or vegetables and mushrooms in country-specific guidelines (Table 2).

Table 2. Categorisation of fruit and vegetables in food-based dietary guidelines in European countries within the WHO region

– Data not available.

* excludes mushrooms as part of the guidelines for vegetable consumption.

Austrian Ministry of Health and the National Nutrition Commission 2010⁽¹⁹⁾, Bulgarian National Center of Public Health Protection 2006⁽²⁰⁾, Ministry of Food Agriculture & Fisheries 2013⁽¹⁴⁾, National Nutrition Council Finland 2019⁽¹⁵⁾, Ministry of Solidarity and HeElth 2019⁽²¹⁾, Ministry of Labor Health and Social Affaires 2005⁽²²⁾, The German Nutrition Society 2013⁽²³⁾, Institute of Preventive Environmental & Occupational Medicine, Prolepsis 2014⁽¹⁶⁾, Food Safety Authority of Ireland 2011⁽²⁴⁾, Department of Health 2017⁽²⁵⁾, Norwegian Directorate of Health⁽¹⁸⁾, The Swedish National Food Agency 2015⁽²⁷⁾, Netherlands Nutrition Centre 2015⁽¹⁷⁾, Public Health England 2016⁽²⁸⁾, Republic of Turkey Ministry of Health 2016⁽²⁹⁾, WHO/FAO⁽⁵⁾.

For fruit juice, the majority of countries in Europe (except for the Netherlands, Finland and Sweden) limit fruit juice to one portion of fruit with varying quantities (100, 125, 150, 200 ml and unlimited quantity)^{(14–25,27–29)} . Dried fruit is included as a portion of fruit with varying quantities (e.g. 25 g, 30 g, 1½ tablespoons, ½ cup, etc.) in Bulgaria, France, Germany, Greece, Ireland, the Netherlands and the UK^{(16,17,20,21,23–25,28)} . Nuts (25 g) are included as a portion of fruit in Germany, but not in any other country reviewed⁽²³⁾.

The majority of countries in Europe do not include pulses and legumes as part of their guideline for vegetable consumption with the exception of Austria and Germany where legumes are included in varying quantities (70–200 g/d)^(19,23) . Potatoes are included as a portion of vegetables in Turkey, but not in any other countries reviewed⁽²⁹⁾. Tinned/canned fruit or vegetables are included in the recommendations in Bulgaria, Denmark, Ireland, Norway and the Netherlands^{(14,17,18,20,24,25)} . Interestingly, Denmark does not include mushrooms as part of their guidelines for vegetable consumption due to the high content of natural toxins (phenylhydrazine derivatives), while all other countries do⁽¹⁴⁾.

Fruit and vegetable consumption in children in Europe

Comparison of studies

This review of national dietary surveys of school-aged children in Europe found that very few countries have data on F&V intakes. Data on F&V intakes and the contribution of F&V to energy and nutrient intakes were available only for Denmark, Ireland, Italy, Spain, the Netherlands and the UK^(30–41).

When comparing F&V intakes between countries, it is important to acknowledge the previously mentioned variation in the categorisation of F&V between countries. Additionally, as F&V (in particular vegetables) are often consumed as part of a composite dish, F&V components from composite dishes should be included to ensure best estimates. It has previously been shown that excluding the vegetable component of composite dishes may underestimate vegetable intakes by up to 52 % in children aged 1–12 years^(42,43) . To the best of the author's knowledge, F&V from composite dishes have been included in estimates of intakes in all countries included in this review.

Fruit and vegetable intakes and contribution to energy and nutrient intakes

Using data from national dietary surveys in Europe, the intakes of F&V in school-aged children (3–12 years) are presented in Table 3. Intakes of F&V for children in Ireland, the Netherlands and the UK ranged from 221 to 272 g/d, while intakes in Italy and Spain ranged from 341 to 350 g/d and intakes in Denmark were 404 g/d^(30–35). Despite the different classifications of F&V intakes between countries in Europe, intakes can be broadly compared with the WHO guideline to consume a minimum of 400 g F&V⁽⁵⁾. Intakes of F&V in children were below the WHO guideline for all countries apart from Denmark where children aged 4–9 years had intakes of 404 g/d⁽³⁰⁾. In light of changing food consumption patterns, it is important to continue to monitor intakes of F&V. Recent time-trend analyses from Ireland (2003/04–2017/18), the Netherlands (2007 to 2012) and the UK (2008/09–2016/17) have shown that while there was no change in overall F&V consumption among children, there was an increase in whole fruit and a decrease in fruit juice intakes in this age group which is in line with public health advice to limit fruit juice intake to reduce free sugar intake^{(31,34,44,45)} .

Table 3. Mean intake (g/d) of fruit and vegetables in school-aged children in Europe from National Dietary Surveys

Pedersen et al. 2014⁽³⁰⁾, IUNA, 2019⁽³¹⁾, Leclerq et al. 2009⁽³²⁾, Partearroyo et al. 2019⁽³³⁾, Van Rossum et al. 2016⁽³⁴⁾, Public Health England, 2018⁽³⁵⁾.

The contribution of F&V to energy and nutrient intakes in school-aged children is presented in Tables 4 and 5. It is important to note that Denmark, Spain and the Netherlands (for micronutrients) included adults in these estimations and hence findings are not specific to children for these countries.

Table 4. The contribution (%) of fruit and vegetables to energy and nutrient intakes in children in Europe from National Dietary Surveys

− Data not available.

* Does not include fruit juice.

† Macronutrient data is reported for 9–12 years old while micronutrient data is for 9–75 years old collectively.

Pedersen et al. 2014⁽³⁰⁾, IUNA, 2019⁽³¹⁾, Sette et al. 2013⁽³⁶⁾, Ruiz et al. 2016⁽³⁷⁾, Ruiz et al. 2017⁽³⁸⁾, Olza et al. 2017⁽³⁹⁾, Mielgo-Ayuso et al. 2018⁽⁴⁰⁾, Van Rossum et al. 2011⁽⁴¹⁾, Public Health England 2018⁽³⁵⁾.

Table 5. The contribution (%) of fruit, fruit juice (FJ) and vegetables (Veg) to energy and nutrient intakes in children in Europe from National Dietary Surveys

− Data not available.

* Does not include fruit juice.

† Macronutrient data are reported for 9–12 years old while micronutrient data are for 9–75 years old collectively.

Pedersen et al. 2014⁽³⁰⁾, IUNA, 2019⁽³¹⁾, Sette et al. 2013⁽³⁶⁾, Ruiz et al. 2016⁽³⁷⁾, Ruiz et al. 2017⁽³⁸⁾, Olza et al. 2017⁽³⁹⁾, Mielgo-Ayuso et al. 2018⁽⁴⁰⁾, Van Rossum et al. 2011⁽⁴¹⁾, Public Health England, 2018⁽³⁵⁾.

F&V contributed low proportions of energy intake (6–9 %) in all countries reviewed which may be partly explained by the low energy density and low consumption of this food group. F&V contributed relatively small proportions of fat (2–6 %) and protein (4–8 %) and 8–19 % of carbohydrate intakes^{(30,31,35–37,41)} . F&V contributed to significant proportions of dietary fibre intakes (32–37 %) in Denmark, Italy and Spain and contributed to significant but lower proportions in Ireland, the Netherlands and the UK (19–27 %) with fruit contributing to the majority of intakes in Italy (20 %) and vegetables contributing to the majority of intakes in the Netherlands, the UK and Spain (14–18 %) while both F&V contributed similar proportions of dietary fibre in Denmark and Ireland^{(30,31,35–37,41)} . F&V contributed 25–31 % of total sugar intake in Ireland and Italy and to 50 % of total sugar intakes in Spain with fruit contributing to the majority of this intake in Ireland and Italy (16 %) and both fruit (21 %) and, juices and nectars (23 %) contributing to the majority of intakes in Spain^(31,36–38) . Fruit juice accounted for 10–11 % of free sugar intake in children in Ireland and the UK and juices and nectars accounted for 7 % of free sugar intake in Spain^{(30,31,35,37,38)} .

In terms of vitamins, F&V contributed 50–83 % of vitamin C intakes in Denmark, Ireland, Italy and Spain with fruit contributing to the majority of intakes in Ireland (23 %) and vegetables contributing to the majority of intakes (34–51 %) in other countries^{(30,31,36,39,41)} . F&V contributed lower proportions of vitamin C intakes in the Netherlands (32 %) due to the exclusion of fruit juice when reporting the contribution of F&V to nutrient intakes⁽⁴¹⁾. For vitamin A, F&V contributed 26–46 % of intakes in Denmark, Ireland, Italy, Spain and the UK with vegetables contributing to the majority of vitamin A intakes (24–36 %)^{(30,31,35,36,39)} . F&V contributed to significant proportions of vitamin E intakes (38 %) in Denmark with relatively lower proportions (9–20 %) in Ireland, Italy, Spain and the Netherlands^{(30,31,36,39,41)} . F&V made significant contributions to intakes of thiamin (9–18 %), riboflavin (5–12 %), niacin (4–10 %), vitamin B₆ (10–25 %) and dietary folate equivalents (14–19 %) in children across Europe with the majority of these intakes coming from vegetables^{(30,31,35,36,40,41)} . As expected, due to vitamin B₁₂ being found in animal sources only, F&V did not contribute to vitamin B₁₂ intakes in children across Europe^(36,41) .

For mineral intakes, F&V contributed 16–27 % of potassium intakes in Denmark, Ireland, Italy, the Netherlands and the UK with vegetables contributing to the majority of these intakes in Denmark, Italy and the Netherlands (9–15 %) and fruit contributing the majority of intakes in Ireland and the UK (9 %)^{(30,31,35,36,41)} . F&V contributed to small proportions of iron (7–18 %), magnesium (12–19 %), calcium (4–9 %) and zinc (4–11 %) intakes in children across Europe^{(30,31,35,36,41)} .

Strategies to increase fruit and vegetable intakes

Given the importance of F&V in FBDG and with low intakes generally observed across European populations, public health strategies have been introduced to increase the intake of F&V in population groups including children^(11,12) . These include programmes such as educational and promotional campaigns and implementation of school policies for healthy eating^(46–50).

In line with the FBDG, ‘5 a day’ and similar campaigns have been set up in many countries to promote the consumption of F&V using communication and media events, and educational programmes⁽⁴⁶⁾. Across Europe, the EU school scheme supports the distribution of products, educational measures and information measures with regard to healthy eating including the consumption of F&V⁽⁴⁹⁾. In addition, some countries have implemented school food policies to promote F&V within the school setting such as provision of fruit at break times and in vending machines (at low cost) and promotional material for F&V within the school⁽⁴⁸⁾. Other EU projects such as EU FRUITS and Cultivating the Taste of Europe have been implemented to promote the production and consumption of F&V through education and promotional activities in European countries^(47,50) .

Conclusion

This review aimed to summarise dietary guidelines relating to F&V, intakes of F&V and the contribution of F&V to energy and nutrient intakes in school-aged children in Europe. Few countries provide guidelines specific for children for F&V consumption in Europe with recommendations ranging from 100 to 500 g or one to three portions of F&V daily. Most other countries have adopted the WHO guideline of at least 400 g/d for the general population including children. Differences were noted in the categorisation of F&V within FBDG for individual countries, for example, the inclusion/exclusion of fruit juice, potatoes, dried fruit, nuts, legumes, tinned/canned fruit or vegetables and mushrooms.

A key finding of this review was that only six European countries have data on F&V intakes in nationally representative samples of school-aged children. Where data were available, F&V intakes in European children are generally below the WHO recommendations with the exception of Denmark. F&V contributed low proportions of energy intake (6–9 %) but made significant contributions to intakes of dietary fibre (19–37 %), vitamins A (26–46 %), vitamin C (32–83 %) and potassium (16–27 %); however, they also contributed to intakes of total (25–50 %) and free sugar (7–11 %).

This review has highlighted the need for continued promotion of F&V consumption for school-aged children and more data on estimates of F&V intakes in this age group in European countries. The present review provides a comprehensive overview of the role of F&V in the diets of children in Europe and may be of use to stakeholders including researchers and policy makers.