Intake of Vegetables, Fruits and Berries and Compliance to “Five-a-Day” in a General Norwegian Population—The Tromsø Study 2015–2016

Vegetables, fruits and berries are associated with reduced disease risk, and recommended intake is “five-a-day”. We studied the intake of vegetables, fruits and berries and compliance with “five-a-day” in 11,425 adults (40–96 years) who completed a food frequency questionnaire in the seventh wave of the Tromsø Study (2015–2016). Intake and proportion above/below recommended intake (250 g/day of vegetables and 250 g/day of fruits/berries, combined and separately) were analyzed. Logistic regression was used to examine compliance with recommendations in 10-year age-groups, and level of education, body mass index (BMI) and physical activity, in strata of sex and adjusted for total energy. Median intake of vegetables was 228 and 168 g/day, and fruits/berries 292 and 268 g/day, in women and men, respectively. In total, 31% of women and 17% of men met the five-a-day recommendation, and 44% and 60% of women, and 25% and 54% of men, met the recommendation for vegetables and fruits/berries, respectively. Odds of compliance with recommendation for both vegetables and fruits/berries were positively associated with age, education and physical activity (p trend < 0.001). The intake of vegetables, fruits and berries was suboptimal, in particular for vegetables. More women than men met the recommendation, and intake varied by education, physical activity level, age and BMI.


Introduction
Non-communicable diseases (NCDs), such as cardiovascular diseases, diabetes and cancer, are the leading cause of death globally and contributed to 73% of deaths in 2017. This number has increased by 23% from 2007 to 2017 and raises an urgent need to address the underlying causes [1]. Unhealthy diet is one out of three main risk factors for obesity and NCDs [2], and a low intake of vegetables and fruits, a high intake of added sugar, a high intake of saturated fat and a high intake of sodium are among the leading dietary risk factors for deaths and disability-adjusted-life years [3]. There is strong evidence that intake of vegetables, fruits and berries reduces the risk of, among others, obesity, coronary heart diseases and cancer in the digestive system [4].
In order to fight the epidemic of obesity and NCDs, an increased intake of vegetables, fruits and berries is advised. The World Health Organization (WHO) [5] recommends an intake of at least five servings-or 400 grams (g)-of fruits and vegetables a day. Food-based dietary guidelines are found in 90 countries worldwide, of which 84 of them have a keymessage about fruit and vegetable intake [6], of which 30 are in accordance with the WHO recommendation [6]. The Norwegian food-based dietary guidelines recommend an intake of at least five servings a day (each equal 100 g), of which half (250 g) should be vegetables [7]. The recommendation includes fresh, hermetic, frozen and heat-treated vegetables, fruits and berries, and it is encouraged to vary between different types. Potatoes, legumes, grains, spices and herbs are not included in the Norwegian "five-a-day" recommendation.
Dietary surveys conducted among adults in the Nordic countries between 2010 and 2013 all found a suboptimal intake of vegetables, fruits and berries in the adult population [8][9][10][11]. The Norwegian national dietary survey NORKOST 3 (2010NORKOST 3 ( -2011 was conducted in 1787 adults 18-70 years, and found the mean intake of vegetables and fruits/berries to be 155 and 178 g/day, respectively [8]. Norwegian food-supply statistics found that the consumption of vegetables increased between 2010 and 2019, and the consumption of fruits and berries increased until 2015, and then had a slight decrease [12]. There is a need for more recent information on reported intake rather than food-supply statistics, including a large sample of adult and elderly participants [8]. This study presents data from one of the most recent surveys mapping diet in a general Norwegian population and may serve as an important foundation for comparison with both past and future studies presenting the intake of vegetables, fruits and berries.
The objective of this study was to present the intake of vegetables, fruits and berries; to investigate the association between sex, age, education, BMI and physical activity and intake; and, finally, to present the compliance with the Norwegian "five-a-day" recommendation in a general Norwegian population of adults and elderly.

Study Population
The Tromsø Study is a population-based ongoing cohort study consisting of seven completed surveys (Tromsø 1-Tromsø 7 1974-2016) [13] conducted in Tromsø municipality, consisting of both urban and rural populations. In Tromsø 7 (2015-2016), invitations were sent to all inhabitants aged 40 years or older in Tromsø municipality (n = 32,591). A total of 21,083 women and men (40-99 years) participated (65%) between March 2015 and October 2016. The data collection included biological sampling, clinical examinations including anthropometric measures and questionnaires, including a separate food frequency questionnaire (FFQ).
A total of 15,146 women and men completed the FFQ (72% of all Tromsø 7 participants). Participants with low completion rate (<90%) of the FFQ (n = 3489), and participants with unrealistic energy intakes (the 1% highest and lowest energy intake (above 21,267 or below 3948 kJ/da y, n = 232) were excluded (Figure 1), in accordance with Lundblad et al. [14]. Thus, the final sample in the present study included 11,425 persons aged 40-96 years (54% of all Tromsø 7 participants and 75% of those who completed the FFQ) ( Table 1). intake of at least five servings a day (each equal 100 g), of which half (250 g) should be vegetables [7]. The recommendation includes fresh, hermetic, frozen and heat-treated vegetables, fruits and berries, and it is encouraged to vary between different types. Potatoes, legumes, grains, spices and herbs are not included in the Norwegian "five-a-day" recommendation.
Dietary surveys conducted among adults in the Nordic countries between 2010 and 2013 all found a suboptimal intake of vegetables, fruits and berries in the adult population [8][9][10][11]. The Norwegian national dietary survey NORKOST 3 (2010-2011) was conducted in 1787 adults 18-70 years, and found the mean intake of vegetables and fruits/berries to be 155 and 178 g/day, respectively [8]. Norwegian food-supply statistics found that the consumption of vegetables increased between 2010 and 2019, and the consumption of fruits and berries increased until 2015, and then had a slight decrease [12]. There is a need for more recent information on reported intake rather than food-supply statistics, including a large sample of adult and elderly participants [8]. This study presents data from one of the most recent surveys mapping diet in a general Norwegian population and may serve as an important foundation for comparison with both past and future studies presenting the intake of vegetables, fruits and berries.
The objective of this study was to present the intake of vegetables, fruits and berries; to investigate the association between sex, age, education, BMI and physical activity and intake; and, finally, to present the compliance with the Norwegian "five-a-day" recommendation in a general Norwegian population of adults and elderly.

Study Population
The Tromsø Study is a population-based ongoing cohort study consisting of seven completed surveys (Tromsø 1-Tromsø 7 1974-2016) [13] conducted in Tromsø municipality, consisting of both urban and rural populations. In Tromsø 7 (2015-2016), invitations were sent to all inhabitants aged 40 years or older in Tromsø municipality (n = 32,591). A total of 21,083 women and men (40-99 years) participated (65%) between March 2015 and October 2016. The data collection included biological sampling, clinical examinations including anthropometric measures and questionnaires, including a separate food frequency questionnaire (FFQ).
A total of 15,146 women and men completed the FFQ (72% of all Tromsø 7 participants). Participants with low completion rate (<90%) of the FFQ (n = 3489), and participants with unrealistic energy intakes (the 1% highest and lowest energy intake (above 21,267 or below 3948 kJ/da y, n =232) were excluded (Figure 1), in accordance with Lundblad et al. [14]. Thus, the final sample in the present study included 11,425 persons aged 40-96 years (54% of all Tromsø 7 participants and 75% of those who completed the FFQ) ( Table 1).  Numbers are mean (standard deviations) or percentages (total number). a Primary (up to 10 years of schooling); secondary education (a minimum of 3 years); tertiary short (college/university less than 4 years); tertiary long (college/university 4 years or more). b Exercise and physical activity in leisure time over the last year: sedentary (reading, watching TV/screen or other sedentary activity); light (walking, cycling or other forms of exercise at least 4 h a week); moderate-to-vigorous (participation in recreational sports, heavy gardening, snow shoveling, etc., at least 4 h a week or participation in hard training or sports competitions, regularly, several times a week).

Sociodemographic and Anthropometric Information
Information on educational level (primary, secondary, tertiary short and tertiary long) and leisure-time physical-activity level (sedentary, light and moderate-to-vigorous) were included from a questionnaire. BMI (weight in kilograms (kg) divided by height in meters (m) squared) was calculated based on body weight and height measured by trained personnel and divided into three groups: normal (<25.0 kg/m 2 ), overweight (25.0-29.9 kg/m 2 ) and obese (≥30.0 kg/m 2 ). Participants with underweight were merged with the normal-group because of few participants (n = 52).

Food Intake Measurements
An extensive previously validated [15] FFQ was used to collect information about diet during the past year. The FFQ consisted of 13 pages with questions about 261 different food items, dietary supplements, drinks (including alcoholic beverages) and meals (available in full version on the Tromsø Study website [16]). Intake of a variety of vegetables, fruits and berries was mapped by using questions on frequency and amount of intake: carrot, cabbage, turnip, cauliflower, broccoli, Brussel sprouts, onion (raw and fried), salad, paprika, avocado, tomato, corn, mix of frozen vegetables, mixed salad apple, pear, banana, orange, clementine, grapefruit, peach, nectarine, kiwi, grapes, melon, strawberries (fresh/frozen), raspberries, blueberries, cloudberries, raisins, dried fruit (e.g., apricot or figs), and fruitand-nut mix. In addition, questions on numbers of daily servings of vegetables, fruits and berries were included. The food-and-nutrient calculation system Kostberegningssystemet (KBS), database AE14 (based on the Norwegian food composition tables 2014 and 2015), in software version 7.3, was used to calculate the intake of food, macro-and micronutrients at the University of Oslo. FFQ data collection and processing for Tromsø 7 have been described in detail elsewhere [14].

Data Analyses
Intake of vegetables, fruits and berries was investigated by calculating median (25th-75th percentile) intake and presenting the proportion of participants compliant with the "five-a-day" recommendation (Tables 2 and 3). In addition, the participants were considered compliant or not with the recommendations for daily intakes of fruits/berries (at least 250 g) and vegetables (at least 250 g), respectively. We present median (25th-75th percentile) values rather than mean (standard deviation) values because the data were skewed to the right and thus were not normally distributed. We used multivariable linear regression to present the association between intake of vegetables, fruits and berries (g/day) and sociodemographic factors (Table 4). Logistic regression analyses were used to investigate the odds (odds ratio, OR) of compliance with recommendations ( Table 5). All analyses were performed in strata of sex and in groups of 10-year age groups (40-49 years, 50-59 years, 60-69 years, 70-79 years or 80+years), education (primary, secondary, or low or high tertiary), BMI (normal < 25.0, overweight 25.0-29.9 or obese ≥ 30.0 kg/m 2 ) and selfreported leisure-time physical activity (sedentary, light or moderate-to-vigorous), with the lowest group as reference group and mutually adjusted for 10-year age groups, education, BMI and self-reported leisure-time physical activity, respectively. The linear and logistic regression analyses were adjusted for total energy intake (kJ/day), and linear trends were investigated by including age, education, BMI and physical activity, respectively, as continuous variables in an identical analysis (Tables 4 and 5      Results are adjusted for total energy intake and given as odds ratio (95% confidence interval). A separate analysis was performed for age groups, education level, body mass index and physical-activity level, respectively, with adjustment for all other covariates. * Statistically significant (p <0.05). ** Statistically significant (p <0.001). a Highest level of educational attainment: primary, up to 10 years of schooling; secondary education, a minimum of 3 years; tertiary short, college/university less than 4 years; tertiary long, college/university 4 years or more. b Exercise and physical activity in leisure time over the last year: sedentary = reading, watching TV/screen or other sedentary activity; light = walking, cycling or other forms of exercise at least 4 h a week; moderate-to-vigorous = participation in recreational sports, heavy gardening, snow shoveling, etc., at least 4 h a week or participation in hard training or sports competitions, regularly, several times a week.

Ethical Considerations
The Tromsø Study was performed in accordance with the 1964 Helsinki declaration and its later amendments. Tromsø 7 was approved by the Regional Committee for Medical Research Ethics (REF North ref. 2014/940) and the Norwegian Data Protection Authority. All participants gave informed written consent.

Study Population
A total of 11,425 persons were included in the analysis (53.4% women) ( Table 1). About 50% of the participants had tertiary education. A total of 59.3% of women and 73.9% of men were overweight or obese, and about 13% reported doing sedentary activities during leisure time (Table 1).

Five-a-Day
In total, 30.8% of women and 17.0% of men were compliant with the five-a-day recommendation (Tables 2 and 3). The odds of being compliant with the five-a-day recommendation were positively associated with age, education, BMI and physical-activity level in both women and men (p linear trend < 0.001) ( Table 5).

Intake of Vegetables
Median intake of vegetables was 228 and 168 g/day in women and men, respectively (Tables 2 and 3). In total, 44.0% of women and 25.2% men were compliant with the recommendation (Tables 2 and 3). Age, education, BMI and physical-activity level were positively associated with reported intake of vegetables in both women and men (p linear trend < 0.001) ( Table 4). The odds of being compliant with the recommendation for vegetables increased with age, education, BMI and physical-activity level in both women and men (p linear trend < 0.001) ( Table 5).

Intake of Fruits and Berries
Median intake of fruits/berries was 292 and 268 g/day in women and men, respectively, and 59.6% and 53.8% were compliant with the recommendation (Tables 2 and 3). Age and education were positively associated with the intake of fruits/berries in both women and men (p linear trend < 0.001) ( Table 4). The odds of being compliant with the recommendation for fruits/berries were positively associated with age, education and physical-activity level in both women and men (p linear trend < 0.001) ( Table 5)

Discussion
We found suboptimal intakes of vegetables, fruits and berries in the present study. Only 30.8% of women and 17.0% of men met the five-a-day recommendation; 44.0% of women and 25.2% of men met the recommended intake of 250 g vegetables per day; and 59.6% of women and 53.8% of men met the recommended intake of 250 g fruits/berries per day.
Overall, the reported intake of both vegetables, fruits and berries found in this study, conducted in 2015-2016, was higher than that found in women and men in national dietary surveys, conducted in 2010-2013, among adults in the Nordic countries Norway [8], Denmark [9] and Finland [11], and higher for women, but similar for men, in Sweden [10]. The higher reported intake found in this study, especially compared to the findings from the Norwegian survey NORKOST 3 conducted in 2010-2011 [8], can indicate that the intake in the population has increased during the period 2010-2011 to 2015-2016. This is supported by the annual report on the development in the Norwegian Diet from 2017, based on food supply statistics [17]. In the most recent report from 2019, however, the consume of vegetables, fruits and berries had decreased slightly from 2017 to 2018 [12].
A low proportion (30.8% of women and 17.0% of men) met the five-a-day recommendation. A study among persons aged 15 years and older in all member states of the European Union (EU) (The European Health Interview Survey (EHIS) 2013-2015) found that, on average, 14.1% reported a daily consumption of at least five fruits and vegetables [18]. This proportion did, however, vary across the EU, from around 25% in Denmark, the Netherlands, the United Kingdom and Ireland to less than 10% in Romania, Bulgaria, Croatia and Turkey [18].
In general, women reported higher intakes and were more compliant with the recommendation for both vegetables and fruits/berries, as compared to men. A similar higher reported intake among women than men were found in both the national dietary surveys from Nordic countries [8][9][10][11], in other population-based studies in Norway [16,17] and in the large survey from the EU (EHIS) [18].
We found age to be positively associated with reported fruit and vegetable intake in women and men. A similar gradient (although weak) was found in other Norwegian population-based studies [19,20]. Education was positively associated with the reported intake of vegetables, fruits and berries in both women and men. This corresponds to findings from previous Nordic national dietary surveys, Nordic population-based studies and the large survey from the EU [8,10,[18][19][20][21]. Obesity was positively associated with reported vegetable intake in both women and men. This is supported by similar findings from the SAMINOR2 study [22], but it contrasts with the findings from the Swedish national dietary survey [10]. Physical activity was positively associated with the reported intake of vegetables, fruits and berries in both women and men, corresponding to similar findings in the Swedish national dietary survey [10] and in population-based surveys from Norway and Sweden [19,21].
Education is frequently used as an appropriate indicator for socioeconomic status [23,24], and the association between education and intake of fruit and vegetables found in this study may serve as a measure of social inequality in health. An educational gradient in favor of those with higher education was also found for intake of fiber, proteins and added sugar in a previous study of the same population [25].
These results are important for future studies investigating total intake and trends in fruit and vegetable intake in general populations and for researchers interested in comparing results across different populations. Future studies are warranted for observing potential changes in fruit and vegetable intake, and further to explain why differences in subgroups occur. It would also be useful to explore those with a low intake of fruit and vegetables further to attain a deeper understanding of the mechanisms behind the low intake, and to investigate whether they have other dietary characteristics that are unfavorable for the health.

Strengths and Limitations
This study had a large and population-based sample of adult and elderly women and men from both urban and rural living areas, representative of the general Norwegian population as for the distribution of sex, age, educational attainment, BMI and moderate-to vigorous activity level [26][27][28]. However, although the overall participation was high (65%), selection bias is possible. Previous studies from health surveys in Norway have indicated that participants in health surveys tend to have higher educational attainment and better health than non-responders [29][30][31]. However, Lundblad et al. [14], using the same sample as in the present study, concluded that Tromsø 7 attenders were similar to the non-attenders. Thus, the external validity in this study is probably high.
Another strength is that the FFQ used for data collection is previously validated for several dietary factors in studies of Norwegian adults [15,32,33]. However, a general limitation of the use of a FFQ is the risk of misclassification due to inaccurate memory or for instance social desirability bias. Social desirability bias would imply that some participants might over-report their intake of healthy food items, such as vegetables, fruits and berries [34]. The inclusion/exclusion criteria of ≥90% completeness of the FFQ and the exclusion of highly unrealistic energy intakes ensured that some of the cases with high risk of uncertainty in the dietary assessment were removed.

Conclusions
In this Norwegian population-based sample of adults and elderly, the median intake of vegetables, fruits and berries was suboptimal. This applies especially to the intake of vegetables. More women (31%) than men (17%) met the five-a-day recommendation. Furthermore, 44% of women and 25% of men met the recommended intake of 250 g vegetables per day and approximately 57% met the recommended intake of 250 g/day of fruits/berries per day. Odds of compliance with recommendation for both vegetables and fruits/berries were positively associated with age, education and physical-activity level.