Computer-assisted health impact assessment for intersectoral health policy.

Intersectoral health policy implies negotiations with politicians outside the health sector. Health politicians have a stronger position if they can quantify health impact. In this Dutch case-study we used a computer simulation approach to answer the following questions: Which anti-tobacco intervention has the largest health gain? Will a commuter cycling policy result in any substantial health gain? What is the relative health gain of promoting higher consumption of vegetables and fruit? We concluded that substantial health gain can be achieved if cigarette packet price were to increase by 2 Dutch guilders. A commitment of all general practitioners to implement a smoking cessation intervention will result in a similar health gain. Stimulating commuter cycling could be a promising example of intersectoral health policy. Interventions to promote higher vegetable and fruit consumption will result in a relatively small health gain. Pros and cons of simulation models to support intersectoral health policy are discussed.     

Plasma carotenoid levels in Dutch men and women, and the relation with vegetable and fruit consumption

OBJECTIVE: Fruit and vegetable intake is inversely associated with cancer risk in many epidemiological studies. Accurate assessment of consumption of these foods is difficult, and biomarkers of intake would overcome several drawbacks of currently used dietary assessment methods. Therefore, we investigated the relation between plasma carotenoids and usual vegetable and fruit intake. DESIGN: Plasma carotenoid concentrations were measured and vegetable, fruit and juice consumption was assessed by a food frequency questionnaire (FFQ) in a random sample of 591 Dutch men and women aged 20-59 y from the MORGEN-project, one of the contributions to the European Prospective Investigation into Cancer and Nutrition (EPIC)-study. RESULTS: In this sample of the general Dutch population, in both genders, relative to the other carotenoids, plasma beta-cryptoxanthin was the best indicator for fruit intake, and for the sum of vegetable, fruit and juice intake, while lutein concentrations best reflected intake of vegetables, although quartiles of intake were not consistently separated. Since levels of lycopene were not associated with any of the main food groups examined, associations with total carotenoids improved when excluding lycopene, and monotonously increasing plasma levels were seen for intakes of vegetables, of fruits, and of the sum of vegetables, fruits and juices. Several vegetable types and orange/grapefruit juice were associated with plasma levels of one of the carotenoids. CONCLUSION: Plasma carotenoids were only crude indicators of vegetable and fruit intake as assessed by a FFQ; beta-cryptoxanthin for fruit intake and lutein for vegetable intake. None of the plasma carotenoids could distinguish all four quartiles of vegetables, fruit and/or juice intake.     

Health status and the challenges for prevention in The Netherlands

In 2002, the third Public Health Status and Forecasts report was published, containing up-to-date information about Dutch public health and health care. A striking finding was that although life expectancy (LE) in The Netherlands increased between 1980 and 2000, the LE of men is rising less rapidly than the European Union (EU) average. The LE of Dutch women is stagnating and has now fallen below the EU average. These and many other unfavourable trends in the health status of the Dutch population were found to be largely due to unhealthy behaviour. One of the policy recommendations therefore was to strengthen the investments in prevention in order to reverse the stagnation in health status. In response to the findings, the Ministry of Health, Welfare and Sport published the National Prevention Paper. This Paper states that the Ministry, within the existing prevention policy, will pay more attention to healthy behaviour, stressing the responsibility of citizens as well as the societal responsibility of other parties, such as business communities, schools, health insurers and care suppliers. The prevention of specific diseases (diabetes, psychosocial problems, heart diseases, cancer, musculosceletal disorders, asthma and chronic obstructive pulmonary disease) has been given priority status. In this article, we present the major findings regarding the health status of the Dutch population and discuss the implications for prevention policy.     

Consumption of plant foods and stomach cancer mortality in the seven countries study. Is grain consumption a risk factor? Seven Countries Study Research Group.

Plant foods are generally considered to be beneficial for health. A higher consumption of fruits, and to a lesser extent vegetables, is consistently associated with a lower risk of stomach cancer. Results on the association between stomach cancer and grain consumption are less clear. We associated plant food consumption with 25-year stomach cancer mortality at population level in the Seven Countries Study. Around 1960, > 12,000 men aged 40-59 years from 7 countries and 16 cohorts were enrolled. In each cohort, dietary information was collected in small random samples. Crude and adjusted associations were calculated for a change of 10% of mean intake. Results differed for the plant foods studied: an inverse association was observed for fruits (adjusted rate ratio = 0.96, 95% confidence interval = 0.91-0.99), a positive relation for refined grains (adjusted rate ratio = 1.07, 95% confidence interval = 1.03-1.12), and no association for total plant foods, vegetables, whole grains, and potatoes. A high intake of refined grains was correlated with a low consumption of fruits. In conclusion, high intake of refined grains may increase stomach cancer risk. However, because adjustment could only be limited in this study, high intake of refined grains may just reflect the deleterious effect of a diet low in fruits or other characteristics associated with low fruit consumption.     

Using financial incentives to increase fruit and vegetable consumption in the UK

Encouraging the consumption of fruits and vegetables can help people increase their intake of micronutrients, dietary fibre and non‐nutrient substances, which together have benefits for health. A high intake of fruits and vegetables is associated with a lower risk of a number of diseases including heart disease, stroke, type 2 diabetes and some cancers. Among the numerous barriers to purchasing fruits and vegetables, price is still cited as a common factor. Therefore, more needs to be done to incentivise consumers to pick up more of these foods during their weekly shop. The UK Public Health Responsibility Deal seeks to reshape the food environment through behaviour change interventions; however, evidence to support the effectiveness of altering environments to change behaviour as a means to improve population health is weak. In particular, reducing price is a frequently considered policy to improve dietary habits. However, few studies to date have evaluated the effectiveness of such interventions on encouraging fruit and vegetable consumption. Our goal (The Co‐operative Group), in line with the Public Health Responsibility Deal, is to do more to create a positive environment that supports and enables people to increase their fruit and vegetable consumption. In light of this, we piloted a coupon incentive scheme in July 2012 for low fruit and vegetable spenders to see if making these items more affordable would encourage purchases and facilitate increased consumption. Results showed that sales of fruits and vegetables increased by 23.2% during the four‐week campaign, with 132 000 redemptions of the coupon by 90 000 members.     

Overview of the health benefits of fruit and vegetable consumption for the dietetics professional: selected literature

Epidemiologic evidence of a protective role for fruits and vegetables in cancer prevention is substantial. The strength of this scientific base guides US national policymaking in diet and health issues and facilitates community and local programs that address national dietary goals to increase fruit and vegetable consumption. Current scientific evidence also suggests a protective role for fruits and vegetables in prevention of coronary heart disease, and evidence is accumulating for a protective role in stroke. In addition, a new scientific base is emerging to support a protective role for fruits and vegetables in prevention of cataract formation, chronic obstructive pulmonary disease, diverticulosis, and possibly, hypertension. This article provides an overview of the health benefits associated with fruit and vegetable consumption for each of these conditions, including brief discussions of underlying protective mechanisms, identifies key scientific findings regarding the health benefits of fruit and vegetable consumption, and outlines applications of these findings for dietetics professionals. The evidence reviewed provides additional support for increased consumption of a wide variety of vegetables, in particular, dark-green leafy, cruciferous, and deep-yellow-orange ones, and a wide variety of fruits, in particular, citrus and deep-yellow-orange ones. Continued attention to increasing fruit and vegetable consumption is a practical and important way to optimize nutrition to reduce disease risk and maximize good health. J Am Diet Assoc. 2000; 100:1511-1521.     

More Americans are eating "5 a day" but intakes of dark green and cruciferous vegetables remain low

Epidemiological investigations repeatedly show that the regular consumption of dark green and cruciferous vegetables, tomatoes and citrus fruits in particular is related to reduced cancer risk. We used the 1994-1996 Continuing Survey of Food Intakes by Individuals to examine the types of fruits and vegetables consumed by Americans. The analytic sample population, which consisted of 4806 men and women (25-75 y old) who completed two nonconsecutive 24-h recalls, consumed 3.6 +/- 2.3 servings of vegetables and 1.6 +/- 2.0 servings of fruit daily. Iceberg lettuce, tomatoes, French fried potatoes, bananas and orange juice were the most commonly consumed fruits and vegetables, accounting for nearly 30% of all fruits and vegetables consumed. The most popular items, lettuce and tomatoes, were consumed by 39-42% of the sample population during the reporting period. Fewer respondents (16-24%) consumed French fried potatoes, bananas or orange juice. Only 3% of the sample consumed broccoli during the reporting period. White potato consumption averaged 1.1 servings daily, with French fried potatoes representing 0.4 serving. Tomato product consumption averaged 0.5 serving daily, dark green vegetable consumption averaged 0.2 serving daily and citrus, berries or melon consumption amounted to nearly 0.8 serving daily. These data indicate that Americans are consuming more fruits and vegetables but that dark green and cruciferous vegetable intake is low.     

Vegetable and fruit consumption in relation to prostate cancer risk in Hawaii: a reevaluation of the effect of dietary beta-carotene

This is a further analysis of a case-control study of 452 prostate cancer cases and 899 population controls that was conducted in 1970-1983 among the multiethnic population of Hawaii. Because a previous analysis had shown a positive association with intake of beta-carotene, a nutrient presently being tested for chemoprevention, the authors reexamined the data for consistency among the main food sources of beta-carotene. Vegetables and fruits containing other phytochemicals suspected to be cancer inhibitors were also examined. With the exception of papaya, which was positively associated with risk among men aged 70 years and older, consumption of other yellow-orange fruits and vegetables, tomatoes, dark green vegetables, and cruciferous vegetables was not associated with prostate cancer risk. These results suggest that: 1) the positive association with beta-carotene intake among older men that the authors previously reported was essentially due to the greater papaya consumption of cases compared with controls; and 2) intake of beta-carotene, lycopene, lutein, indoles, phenols, or other phytochemicals is not associated with prostate cancer risk.     

Increasing antioxidant intake from fruits and vegetables: practical strategies for the Scottish population

Background Increasing intakes of dietary antioxidants may help to reduce oxidative damage caused by free radicals and provide protection against the progression of a number of chronic diseases. The present study aimed to estimate the antioxidant intake from fruits and vegetables in the UK and Scottish population and to examine consumption models to identify potential strategies to optimize antioxidant intake from these foods. Methods This was a retrospective study of cross‐sectional data on fruit and vegetable intake in relation to antioxidant intake. Antioxidant capacity of individual fruits and vegetables was determined by the ferric reducing antioxidant power assay and data on quantity and frequency of consumption of fruits and vegetables determined from National Diet and Nutrition Survey 2000–2001. Results Mean antioxidant intake in UK population from fruits and vegetables varied by region. In the Scottish sample (n = 123), mean antioxidant intake was estimated at 680 ± 689 μmol day^?1 with 92% subjects consuming <400 g of fruits and vegetables per day. Consumption data showed that strawberries, apples, orange citrus fruits, purple broccoli and cauliflower were the top five sources of antioxidants from fruits and vegetables in the Scottish population. Conclusions Appropriate selection of fruits and vegetables would help to achieve a higher antioxidant intake with the potential to produce significant health benefits.     

Population-based cancer control: where is the greatest benefit from proven strategies to ‘Regain’ years of life lost prematurely?

OBJECTIVE: To apply a 'health gain' approach to population-based cancer control. METHOD: We calculated the potential years of life otherwise lost prematurely which could be 'regained' through implementation of cancer control programs for which Level I or Level II evidence already exists for population outcomes. RESULTS: More potential years of life lost (PYLLs) would be 'regained' by enforcing a 'smoke-free' Australia than by any other possible scenario based on proven effectiveness. Even achievable scenarios for tobacco control (17% or 20% prevalence) would 'regain' more PYLL than either mammographic screening according to national policy or faecal occult blood testing (FOBT) of both men and women over 50 years for colorectal cancer. CONCLUSIONS: As few commentators remain optimistic that more money will be allocated to health, strategic thinking for health gain needs to re-appraise resource allocation for population-based cancer control in Australia. IMPLICATIONS: We recommend wider debate in response to our finding that, on the basis of best available evidence, the greatest potential for health gain lies less in cancer screening than fully funded tobacco control.     

Fruit and vegetables in cancer prevention

Our aim was to review the epidemiological literature on possible cancer-preventive effects of the consumption of fruits and vegetables in humans, to quantify the effect of high versus low consumption of fruits and vegetables, and to give an overall assessment of the existing evidence. We based our work on an expert meeting conducted by the International Agency for Research on Cancer in 2003. A qualitative reading and evaluation of relevant articles on the cancer-preventive effect of the consumption of fruits and vegetables was made followed by the calculation of the mean relative risk and range for cohort and case-control studies separately. The possible population-preventable fraction for modifying diet in relation to fruit and vegetable consumption was calculated as well as an overall statement about the degree of evidence for the cancer-preventive effect of fruit and vegetable consumption for each cancer site. There is limited evidence for a cancer-preventive effect of the consumption of fruits and vegetables for cancer of the mouth and pharynx, esophagus, stomach, colon-rectum, larynx, lung, ovary (vegetables only), bladder (fruit only), and kidney. There is inadequate evidence for a cancer-preventive effect of the consumption of fruits and vegetables for all other sites. Applying this range of risk difference to the range of prevalence of low intake, the preventable fraction for low fruit and vegetable intake would fall into the range of 5-12%. It is important to recognize that this is only a crude range of estimates and that the proportion of cancers that might be preventable by increasing fruit and vegetable intake may vary beyond this range for specific cancer sites and across different regions of the world.     

Reported adoption of dietary fat and fiber recommendations among consumers

OBJECTIVE: To identify constraints in adopting dietary fat and fiber recommendations. DESIGN: A questionnaire was mailed to a sample of the general population, a convenience sample of persons with heart disease and cancer in 11 states, and registered dietitians in 5 states. The survey included questions on demographic and attitudinal factors that were correlated with specific practices to reduce fat intake and increase fiber intake. SETTING: From the general population sample of 6,206 eligible respondents (return rate of 51.5%), those selected were respondents who indicated that they would adopt a dietary recommendation if it were good for them (n = 2,682). Subsamples from the general population were matched to 362 registered dietitians and 147 persons with cancer or heart disease on selected demographic variables. Factors associated with adoption of specific behaviors were identified. STATISTICAL ANALYSIS PERFORMED: Statistical analysis included chi 2, factor analysis, and analysis of variance. RESULTS: The majority of persons who said they would adopt a fat-reducing behavior if it were good for their health reported practicing that behavior often or usually. More than 60% reported consuming whole grains; however, only 15% reported eating fruits and vegetables frequently. Among the general population sample, those more likely to practice a behavior had the following characteristics: female, college educated, older than 60 years, white, higher income, no children younger than 18 years, perceived health status as excellent, and absence of chronic disease. Registered dietitians and those with chronic disease were also more likely to follow dietary fat and fiber recommendations. APPLICATIONS: Nutrition education messages that lead to increased consumption of dietary fiber need to be developed. Nutrition educators should provide strategies for consumers for increasing use of fruits and vegetables in all meals. Good taste and convenience are critical components. The food industry may assist by providing a wider array of convenience entrees or side dishes that feature produce and whole grains.     

Effect of increased vegetable and fruit consumption on plasma folate and homocysteine concentrations

OBJECTIVE: We assessed the effects of an intervention aimed at increasing the consumption of fruits and vegetables on plasma folate and homocysteine concentrations. METHODS: Seventy-one healthy non-smoking women (mean +/- SD 41 +/- 4 y of age) were randomized to an intervention or a control group. Participants in the intervention group (n = 36) received weekly packets containing fruits and vegetables free of charge and were asked to consume a daily amount of >or=200 g of vegetables and two pieces of fruit (the Dutch recommended intake level) over a period of 1 mo. Control subjects did not receive any intervention. RESULTS: Compared with the control group, reported fruit and vegetable intakes in the intervention group increased by 133 g/d (95% confidence interval [CI] 87-179, P < 0.001) for fruits and juice and 64 g/d (95% CI 37-91, P < 0.001) for vegetables and estimated folate intake from fruits and vegetables increased by 40 microg/d (95% CI 22-58, P < 0.001). However, no effect was observed on plasma folate concentrations (intervention effect 0.3 nmol/L, 95% CI -1.8 to 2.8, P = 0.77) or homocysteine concentrations (intervention effect 0.26 micromol/L, 95% CI -0.34 to 0.87, P = 0.39). CONCLUSION: The results suggest that 4 wk of increased fruit and vegetable consumption to the recommended amounts may be insufficient to change plasma folate and homocysteine concentrations.     

Fruits and Vegetables in Relation to Prostate Cancer in Japanese Men: The Japan Public Health Center-Based Prospective Study

Although dietary risk factors may differ between localized and advanced prostate cancer, data on associations between the consumption of fruits and vegetables and risk of localized and advanced cancers are limited. We examined associations between fruit and vegetable consumption and risk of prostate cancer in a Japanese population. During 1995–1998, a validated food frequency questionnaire was administered to 43,475 men aged 45–74 yr. During 321,061 person-years of follow-up until the end of 2004, 339 cases of prostate cancer were identified. Consumption of fruits or total vegetables was not associated with a decreased risk of total prostate cancer, with corresponding multivariate hazard ratios of the highest vs. lowest quartiles of 1.09 (95% CI = 0.77–1.53; trend P = 0.39) for fruits and 1.33 (95% CI = 0.93–1.91; trend P = 0.52) for total vegetables. Also, no association was observed for intake of either fruits or vegetables (total or any subtype) with localized or advanced prostate cancer. This prospective cohort study suggests that consumption of fruits or vegetables may not be associated with the risk of either localized or advanced prostate cancer in Japanese men. However, the possibility of confounding by detection bias on the risk of localized cancer could not be totally ruled out.     

Gender differences in the consumption of meat, fruit and vegetables are similar in Finland and the Baltic countries

BACKGROUND: Women's diets are healthier than men's. Finnish women eat more fruits and vegetables but less meat than men. Gender differences may be larger in the Baltic countries, which represent Eastern European transition societies than in Finland, a society characterized by the Scandinavian welfare ideology and a high degree of gender equality. METHODS: The data are based on questionnaires to random samples of adults in Finland, Estonia, Latvia and Lithuania. The data provide a way of addressing gender differences at the turn of the century in the economically and culturally different countries. The purpose is to explore whether the consumption of foods classified as masculine or feminine-meat, fruits and vegetables-follow a similar gender pattern in Finland and the Baltic countries. RESULTS: Men ate meat more often while women ate fruits and vegetables. A high educational level was associated with frequent consumption of fruits and vegetables. Educational differences in the consumption of meat were few and inconsistent. The consumption of fruits and vegetables was more common in urban areas except in Finland. Gender differences were similar in all countries throughout age and educational groups and in rural and urban areas. CONCLUSION: The consistent association of gender and food and the similarity of gender patterning in population subgroups point to the stability of masculine versus feminine food habits. The similarity suggests that food habits contribute equally to the gender gap in health in the Baltic countries as they do in Finland.     

Vegetable and fruit consumption and risks of colon and rectal cancer in a prospective cohort study: The Netherlands Cohort Study on Diet and Cancer

The relation between vegetable and fruit consumption and colorectal cancer risk was comprehensively assessed in the Netherlands Cohort Study on Diet and Cancer using a validated 150-item food frequency questionnaire. After 6.3 years of follow-up (1986-1992), over 1,000 incident cases of colorectal cancer were registered. Using case-cohort analysis, the authors calculated rate ratios and 95% confidence intervals adjusted for age, alcohol intake, and family history of colorectal cancer. For colon cancer, no statistically significant associations with total vegetable intake or total fruit intake were found. However, among women, an inverse association was observed with vegetables and fruits combined (for the highest quintile vs. the lowest, the rate ratio was 0.66 (95% confidence interval: 0.44, 1.01)). Brassica vegetables and cooked leafy vegetables showed inverse associations for both men and women. Among women and, to a lesser extent, among men, inverse associations were stronger for distal colonic tumors than for proximal colonic tumors. For rectal cancer, no statistically significant associations were found for vegetable consumption or fruit consumption or for specific groups of vegetables and fruits; only Brassica vegetables showed a positive association in women. As in other cohort studies, the observed inverse relation between vegetable and fruit consumption and occurrence of colorectal cancer was less strong than relations reported in case-control studies.     

How does the business cycle affect eating habits?

As economic expansions raise employment and wages, associated shifts in income and time constraints would be expected to also impact individuals' health. This study utilizes information from the US Behavioral Risk Factor Surveillance System (1990-2009) to explore the relationship between the state unemployment rate and the consumption of various healthy and unhealthy foods in the United States. Estimates, based on fixed effects methodologies, indicate that unemployment is associated with reduced consumption of fruits and vegetables and increased consumption of "unhealthy" foods such as snacks and fast food. Heterogeneous responses are also identified through detailed sample stratifications and by isolating the effect for those predicted to be at highest risk of unemployment based on their socioeconomic characteristics. Among individuals predicted to be at highest risk of being unemployed, a one percentage point increase in the resident state's unemployment rate is associated with a 3-6% reduction in the consumption of fruits and vegetables. The impact is somewhat higher among younger, low-educated, and married adults. Supplementary analyses also explore specific mediating pathways, and point to reduced family income and adverse mental health as significant channels underlying the procyclical nature of healthy food consumption.     

Differences in the Prevalence of Fruit and Vegetable Consumption in Spanish Workers

The present study aims to examine the differences in daily fruit and vegetable consumption in the working population in Spain. A cross-sectional study was conducted, using data from the 2017 National Health Survey (n = 10,700 workers aged between 18 and 65 years). The daily consumption of fruit and vegetables was evaluated using two items included in a food frequency questionnaire. Occupations were classified into the 17 main groups of the National Classification of Occupations of 2011 (CNO-11). The prevalence (P) of daily fruit and vegetable consumption was calculated in relation to sociodemographic characteristics, health behaviors, work-related characteristics and occupations. Logistic regression analysis was performed to examine the association, with simple and adjusted Odds Ratio (aOR). The P of daily consumption of fruit and vegetables in workers was 60% for fruit and 40% for vegetables. After adjusting for sociodemographic characteristics and health behaviors, workers working night or rotating shifts had a lower consumption of fruits (aOR:0.9; p < 0.05), and those working on temporary contracts had a lower consumption of vegetables (aOR:0.8; p < 0.05). Engineers, scientists, health care workers and teachers had the highest fruit consumption (74.5%) and the highest vegetable consumption (55.1%). The lowest consumption of fruits was presented by the military (42.3%) and unskilled workers in the service sector (45.8%), and the lowest consumption of vegetables was presented by skilled construction workers (25.5%). These findings could aid in workplace health promotion and could be used in future studies to evaluate the impact of the activities adopted.     

Diet and stomach cancer risk in Warsaw, Poland

Some of the world's highest rates of stomach cancer are found in Poland. Reasons for the increased incidence are not known, but high intake of sausages and other preserved foods and low intake of fresh fruits and vegetables may be involved. A case-control study comprising residents newly diagnosed with stomach cancer during 1994-96 and controls randomly selected from the general population was conducted in Warsaw, Poland. Standardized interviews were conducted to ascertain usual consumption of 118 common foods and beverages and other exposures. Using data from direct interviews with 274 cases and 463 controls, odds ratios of stomach cancer were calculated as estimates of risks associated with dietary factors, adjusting for age, sex, education, smoking, and caloric intake. Risk of stomach cancer was inversely related to intake of total fruits and dark green-yellow vegetables and to indices of vitamins C and E and alpha- and beta-carotenes. However, risk was not significantly increased among those with high intake of pickled/salted vegetables and sausages. Risks were positively associated with increased intake of breads/cereals/rice/pasta and other refined grains, as well as a high carbohydrate index. Our findings add to the evidence of a protective effect of fruits and certain vegetables on stomach cancer risk, but do not indicate that high intake of sausage and other preserved foods typical in the Polish diet has contributed to the country's elevated stomach cancer incidence. Our data also suggest that high carbohydrate consumption may influence risk, but further confirmation is needed.     

The relationship between self-efficacy, attitudes, intake compared to others, consumption, and stages of change related to fruit and vegetables

PURPOSE: This study examined whether eating practices and psychosocial factors differed across stages of change for fruit and vegetables. DESIGN: Data were collected using a self-administered written survey among a convenience sample of 739 Dutch adults. Response rate was 92%. SETTING: Data were collected as part of the baseline assessment for a nutrition intervention study. MEASURES: Fruit and vegetable intake was measured as self-reported consumption with a validated eight-item food frequency questionnaire. Psychosocial variables were measured with six items on bipolar seven-point scales and stage-of-change classifications were based on separate four-item algorithms for fruits and vegetables. Differences in psychosocial factors and consumption were analyzed using one-way analysis of variance with Scheffé's multiple-comparison test. RESULTS: Significant differences were found between stages of change in dietary intake, attitudes, self-efficacy, and judgment of one's own intake compared to others. Attitudes were most positive in preparation and action and least positive in precontemplation. Intake and self-efficacy were more positive in action/maintenance than in pre-action stages. CONCLUSIONS: The findings suggest that nutrition education aimed at encouraging higher intake of fruits and vegetables might be most effective if it is stage-tailored. Messages to influence attitudes about fruits and vegetables are likely to affect people in precontemplation, and self-efficacy information to increase confidence in overcoming barriers to consumption is likely to be effective with persons in contemplation and preparation stages.