Victoria Miller, McMaster University, Hamilton, ON, Canada
Salim Yusuf, McMaster University, Hamilton, ON, Canada
Clara K. Chow, Sydney University, Sydney, NSW, Australia
Mahshid Dehgha, McMaster University, Hamilton, ON, Canada
Daniel J. Corsi, Ottawa Hospital Research Institute, Ottawa, ON, Canada
Karen Lock, London School of Hygiene and Tropical Medicine, London, UK.
Barry Popkin, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
Sumathy Rangarajan, McMaster University, Hamilton, ON, Canada
Rasha Khatib, Loyola University Chicago, Maywood, IL, USA.
Scott A. Lear, Simon Fraser University, Burnaby, BC, Canada
Prem Mony, St John's Medical College & Research Institute, Bangalore, India
Manmeet Kaur, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Viswanathan Mohan, Madras Diabetes Research Foundation, Chennai, India
Krishnapillai Vijayakumar, Health Action By People, Thiruvananthapuram, Kerala, India
Rajeev Gupta, Fortis Escorts Hospital, Jaipur, India
Annamarie Kruger, North-West University, Potchefstroom Campus, Potchefstroom, South Africa
Lungiswa Tsolekile, University of the Western Cape, Bellville, South Africa
Noushin Mohammadifard, Isfahan University of Medical Sciences, Isfahan, Iran
Omar Rahman, Independent University, Bangladesh Bashundhara, Dhaka, Bangladesh
Annika Rosengren, University of Gothenburg, Gothenburg, Sweden
Alvaro Avezum, Dante Pazzanese Institute of Cardiology, São Paulo, Brazil
Andrés Orlandini, Estudios Clinicos Latino America, Rosario, Argentina
Noorhassim Ismail, University Kebangsaan Malaysia Medical Centre, Kuala Lumpur Malaysia
Patricio Lopez-Jaramillo, Universidad de Santander, Bucaramanga, Colombia
Afzalhussein Yusufali, Hatta Hospital, Dubai Health Authority, Dubai, United Arab Emirates
Kubilay Karsidag, Istanbul University, Istanbul, Turkey
Romaina Iqbal, Aga Khan UniversityFollow
Jephat Chifamba, University of Zimbabwe College of Health Sciences, Harare, Zimbabwe
Solange Martinez Oakley, Universidad de La Frontera, Temuco, Chile
Farnaza Ariffin, UiTM Sungai Buloh Campus, Selangor, Malaysia
Katarzyna Zatonska, Medical University in Wroclaw, Wroclaw, Poland
Paul Poirier, Laval University Heart and Lungs Institute, Quebec City, QC, Canada
Li Wei, Fuwai Hospital, Beijing, China
Bo Jian, Fuwai Hospital, Beijing, China
Chen Hui, Fuwai Hospital, Beijing, China
LiuXu Xu, Fuwai Hospital, Beijing, China
Bai Xiulin, Fuwai Hospital, Beijing, China
Koon Teo, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
Andrew Mente, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada

Document Type



Community Health Sciences



Several international guidelines recommend the consumption of two servings of fruits and three servings of vegetables per day, but their intake is thought to be low worldwide. We aimed to determine the extent to which such low intake is related to availability and affordability.


We assessed fruit and vegetable consumption using data from country-specific, validated semi-quantitative food frequency questionnaires in the Prospective Urban Rural Epidemiology (PURE) study, which enrolled participants from communities in 18 countries between Jan 1, 2003, and Dec 31, 2013. We documented household income data from participants in these communities; we also recorded the diversity and non-sale prices of fruits and vegetables from grocery stores and market places between Jan 1, 2009, and Dec 31, 2013. We determined the cost of fruits and vegetables relative to income per household member. Linear random effects models, adjusting for the clustering of households within communities, were used to assess mean fruit and vegetable intake by their relative cost.


Of 143 305 participants who reported plausible energy intake in the food frequency questionnaire, mean fruit and vegetable intake was 3·76 servings (95% CI 3·66-3·86) per day. Mean daily consumption was 2·14 servings (1·93-2·36) in low-income countries (LICs), 3·17 servings (2·99-3·35) in lower-middle-income countries (LMICs), 4·31 servings (4·09-4·53) in upper-middle-income countries (UMICs), and 5·42 servings (5·13-5·71) in high-income countries (HICs). In 130 402 participants who had household income data available, the cost of two servings of fruits and three servings of vegetables per day per individual accounted for 51·97% (95% CI 46·06-57·88) of household income in LICs, 18·10% (14·53-21·68) in LMICs, 15·87% (11·51-20·23) in UMICs, and 1·85% (-3·90 to 7·59) in HICs (ptrend=0·0001). In all regions, a higher percentage of income to meet the guidelines was required in rural areas than in urban areas (p<0·0001 for each pairwise comparison). Fruit and vegetable consumption among individuals decreased as the relative cost increased (ptrend=0·00040).


The consumption of fruit and vegetables is low worldwide, particularly in LICs, and this is associated with low affordability. Policies worldwide should enhance the availability and affordability of fruits and vegetables.


Population Health Research Institute, the Canadian Institutes of Health Research, Heart and Stroke Foundation of Ontario, AstraZeneca (Canada), Sanofi-Aventis (France and Canada), Boehringer Ingelheim (Germany and Canada), Servier, GlaxoSmithKline, Novartis, King Pharma, and national or local organisations in participating countries.

Publication (Name of Journal)

Lancet Global Health