Is there a relationship between health care coverage and consuming 5 or more fruit and vegetable

servings a day?
Abstract
The purpose of this secondary data analysis was to examine the relationship between
having or not having healthcare coverage and consuming 5 or more fruit and vegetable servings
per day. Data was collected by the Behavior Risk Factor Surveillance System (BRFSS) survey,
which was given by telephone to collect self-reported data on a number of health related factors.
The data was analyzed using the CDCs Web Enabled Analysis Tool to identify any relationships
between health care coverage and fruit and vegetable consumption. The data did indicate a
relationship between health care coverage and consuming five or more servings of fruit and
vegetables per day, with an odds ratio of 1.28 (CI 1.21-1.35) (p=0.001). A positive relationship
can be seen between having health care coverage (health insurance, HMO, HAS) and consuming
5 or more servings of fruits/vegetables per day.
Introduction
Access to health insurance is a major problem in the United States.1 The United States is
one of the few industrialized nations that does not provide some type of health coverage for all of
its citizens, resulting in many American having to forgo health coverage.1 There are several
factors that can lead to an individuals uninsured status, such as unemployment or problems with
cost of insurance. For example some individuals have incomes too high to qualify for Medicaid
but still too low income to afford private insurance.2,3 This can result in many uninsured
individuals receiving medical treatment from the emergency department rather than from a
primary care provider.1,3 Individuals who do not have health insurance are not as likely as insured
individuals to get regular quality care leading to an overall decrease quality of overall health.1,3

The uninsured population in America are also at an increased risk for chronic diseases because
insured Americans are more likely to participate in screenings that can promote earlier
interventions.1,4 Due to the fact that uninsured Americans have less access to primary care and
quality of care this could lead to an increased risk of mortality in this population1,4. A study
conducted by Wilper et al. 1 used The Centers for National Statistics NHANES III data with a
follow up of participants in this survey through the year 2000.1 Data from NHANES III was
included in the analysis only if an individuals baseline data had been completed. 1 A cox
proportional survival analysis was used to analyze the data and controlled for age and gender.1 A
secondary analysis controlled for age, gender, race, income, education, employment status,
smoking, alcohol consumption, BMI, self-rated and physician rated health.1 It was found that
16.2% of individuals included in the analysis were uninsured and 3.1% of the participants had
died.1 Overall they found that uninsured individuals were more likely to die compared to insured
individuals.1 It was initially calculated, in the year 2000, that 27,424 American ages 18-64 die
each year because they do not have health insurance.1 This information was updated using the
NHANES data from 2005 and the number of deaths per year increased to 44,789 in individuals
18-64.1
McDonald, et al. examined heath needs and health behaviors of individuals given an
alternative health plan (The Healthy Howard Health Plan).3 Health behaviors and health status
was observed over a 18 months period of time. The Healthy Howard Health Plan helps
individuals, who do not have an insurance plan, find affordable primary health care,
prescriptions, labs test, mental health treatment, urgent care, inpatient care, and health coaching.
Participants in the study were between the ages of 19-64, without health insurance for 6 months,
ineligible for government assistance, and have a household income no more than 300% of the

poverty level. Participants that qualified paid a small fee based on their income, which could
range from $50-$85 for an individual and $80-$130 for a couple. Once the participants were
enrolled they were required to meet with a health coach every three months to talk about health
related goals. They also filled out a health risk assessment questionnaire and a patient activation
measure. The results found that when the participants did the health risk assessment again after
18 months there was a significant improvement in physical activity and fruit and vegetable
consumption with improved access to health care. Also when participants Patient Activation
Score was reevaluated it was found that 60% of participants scored higher and participants that
scored higher were more likely to have better self-management and maintain healthy behaviors.3

Dietary quality can also have a profound effect on overall health. Fruit and vegetable
intake has been researched extensively for it health benefits.5 Increased fruit and vegetable
consumption has been found to have an inverse relationship with chronic disease and mortality.5
Fruit and vegetable consumption has been shown to have a positive effect on chronic disease
such as heart disease, hypertension and stroke.5, 6 Heart disease is the leading cause of death
worldwide.6 In 2013, 23.5% of deaths in United States could be attributed to heart disease
making it the leading cause of death in the United States.7 A meta- analysis by He et al.8
reviewed the effect fruit and vegetable consumption has on heart disease.8 The analysis found
that individuals who eat 3-5 servings a day can reduce the risk of CHD by 7%.8 While
individuals who increased intake from less than 3 serving per day to more than 5 servings of fruit
and vegetables per day showed a reduced risks of 17%.8 They concluded with recommending
that individuals consume 5 or more fruits and vegetables a day to reduce the risk of heart
diseases.8

A study conducted by Adams, Katz and Shensone created a healthy lifestyle measure
based off of the Healthy People 2020.9 A healthy lifestyle is a combination of behaviors that can
be done to decrease risk of chronic disease and mortality.9 This study used adequate sleep,
physical activity, 5 or more serving fruit and vegetable a day, limited alcohol consumption and
no smoking as indicators for a healthy lifestyle. BRFSS data from 2013 was used for data
analysis. The results found that there was a small number of Americans actually living a heathy
lifestyle, with only 7.7% of Americans doing all five of the behaviors.9 Increasing fruit and
vegetable consumption was found to be the best for improving healthy lifestyle among
different regions and demographic groups.9 Overall they found that 28% of Americans could
meet guidelines for a healthy lifestyle if they increased their fruit and vegetable intake to 5 or
more serving per day.9 The results also found that there was an association between following all
five of the healthy lifestyle factors and a decrease in chronic diseases.9 Following all five
factors was also associated improved access to health care.9
In summary, health care coverage is a problem that persists in the United States.1
Individuals who do not have health insurance have less access to primary care.1, 3 They are also
are less likely to be screened for chronic disease, which can lead to earlier interventions and a
decreased risk mortality.1, 4 Fruit and vegetable consumption has been recommended for reducing
risk of various chronic diseases such as heart disease.5,6 More specifically, consuming 5 or more
servings fruits and vegetables a day can lead to improved health outcomes.8,9 The objective of
this analysis was to determine if there is an association between having or not having health
insurance and consuming 5 or more servings of vegetables a day.

Methodology

The Behavior Risk Factor Surveillance System (BRFSS) is a national survey conducted each
year by the Centers for Disease Control and Prevention (CDC). The telephone survey collects
data on individuals health status and health related behaviors. The dataset utilized in this study
was from2009. The data was obtained from the CDC website and analyzed using the Web
Enabled Analysis Tool (WEAT). The participants included in the BRFSS data were from all 50
states in United States and were between the ages of 18 and 64 years old (n = 280,880). The data
set included all races/ethnicities and both males and females.
Variables
The variables used in the data analysis were health care coverage, and self- reported daily
fruit and vegetable consumption. In order to obtain information on health care coverage the
individuals were asked Do you have any kind of health care coverage, including health
insurance, prepaid plans such as HMOs, or government plans such as Medicare? The
individuals could respond with four different responses: yes, no, not sure or refuse. The
individuals that responded with yes or no are included in the data set. Individuals were also
asked about their fruit and vegetable intake in this survey. The data set categorized daily of fruit
and vegetable intake in several different categories based on the number of daily servings (0 to
<1, 1 to <3, 3 to <5, or 5). This data was collected by using several different questions from the
survey such as Not counting juice, how often do you eat fruit?, How often do you eat green
salad? and Not counting carrots, potatoes, or salad, how many servings of vegetables do you
usually eat? (Example: A serving of vegetables at both lunch and dinner would be two
servings.) and then computing a total fruit and vegetable servings variable. The participants
responded to this question by stating the number of servings they consumed per day during a
week and during a year on average.

Statistical Analysis
The data was analyzed using the WEAT tool on the CDC website. For the data analysis,
Chi-square and logistic regression were used to determine if there was a significant association
between health care coverage, and fruit and vegetable consumption. In order for the results to be
considered significant, the alpha value was set at 0.05 (p<0.05).
Results
Out of the 288,880 individuals included in the analysis, 240,399 (83.2%) of them had
some form of health coverage and 40,481 (14.0%) did not have health coverage. This analysis
found that 23.9% of individuals who do have health insurance consumed 5 or more fruit and
vegetable servings daily. Individuals who have health insurance, but consumed less than 5
servings of fruits and vegetables per day accounted for76.1% of the sample. Uninsured
individuals who consumed 5 or more serving a day accounted for 19.7% of the uninsured
population. Uninsured individuals who consumed less than 5 servings of fruits and vegetables
per day accounted for 80.3% of the population (Fig.1). When running the logistic regression, the
odds ratio showed that insured individuals were more likely to consume 5 or more servings of
fruits and vegetables daily compared to uninsured individuals (OR 1.28; CI (1.21-1.35);
p<0.001) (Fig.2).
Discussion
Americans who have health insurance were found to be more likely to consume 5 or
more servings of fruits and vegetables per day, compared to Americans without health insurance.
Previous research has also shown that Americans with health insurance are more likely to

participate in disease prevention practices, such as getting screened for common chronic
diseases.1,4 People who have no health insurance are less likely to be screened for chronic
disease, which could lead to a decrease in overall health and an increase in mortality. Fruits and
vegetables contain vital vitamins, minerals, and phytochemicals that help humans achieve good
health. This study found that only 23.9% of insured Americans consumed 5 or more servings a
day, which is line with Hughes et al., who found that 50% or less of insured and employed
Americans consumed a similar amount of fruits and vegetables.10 Similarly in the study
conducted by McDonald et al., insuring previously uninsured Americans increases this
populations fruit and vegetable intake with the increased healthcare coverage.3 Strengths in this
study include the use of the BRFSS data, which is an established method of data collection and
the large sample size. Limitations faced in this study were that some of the data was collected
before the Affordable Care Act was implemented, so the data may no longer be relevant. With
the Affordable Care Act, which was implemented on March 23rd, 2010, health care became easier
to access, better protection for Americans with preexisting conditions, and coverage became
more affordable. 2 Additionally, all data was self-reported so there is room for reporter bias.
Future research should be focused on understanding why fruit and vegetable consumption is
lower among Americans without health care, and how fruit and vegetable intake could impact the
health of this population.

Figure 1
Cross tabulation
Row: Fruit/vegetables: Summary index for fruits and vegetables consumption per day
Column: Health Care Access: Any health care coverage
Controlling For: Demographic information: Reported age (18-64, 65+) = Age 18-64

0 <= Daily servings < 1

1 <= Daily servings < 3

3 <= Daily servings <1

Daily servings >= 5

Column Total

Chi-Square Value
91.42

Yes

No

Row Total

Sample Size

11,308

3,280

14,588

Row %

72.4

27.6

100.0

Column %

5.0

8.8

5.7

Sample Size

85,654

16,875

102,529

Row %

80.1

19.9

100.0

Column %

36.3

41.4

37.2

Sample Size

86,039

12,363

98,402

Row %

84.4

15.6

100.0

Column %

35.1

29.8

34.1

Sample Size

57,398

7,963

65,361

Row %

84.4

15.6

100.0

Column %

23.6

20.1

23.0

Sample Size

240,399

40,481

280,880

Row %

82.1

17.9

100.0

Column %

100.0

100.0

100.0

Degrees of
Freedom
3

p-value
<0.0001

Figure 2

Logistic Regression
Dependent variable: Fruits/vegetables: consumed five or more serving of fruits and vegetables a day
Independent variable: health Care Access: Any health care coverage

Modeling the dependent variable category: yes

Variable
Name

Variable
Level

Sampl
e size

Beta
coefficie
nt

Standar
d Error

tstatistic

p-value
for tstatistic

Odds
Ratio

95%CIfor Odds
Ratio

Intercept

N/A
(interce
pt)
Yes

414,3
59

-1.38

0.03

-52.25

<0.0001

0.25

(0.24 0.26)

371,4
58

0.25

0.03

8.96

<0.0001

1.28

(1.21 1.35)

No (REF)

42,90
1

0.00

0.00

1.00

(1.00 -1.00)

Health
care
Access:
Any
health
care
coverage

Contrast

Degrees of freedom

Wald chi-square

Overall model
Model minus intercept
Intercept
Health Care Access:
Any health care
coverage

2
1

22974.0
80.35

P- value for wald chi

square
<0.0001
<0.0001

80.35

<0.001

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