VEGETABLE & FRUIT CONSUMPTION

AND HEART POSITION

DISEASE AND
STATEMENT
STROKE

VEGETABLE & FRUIT

CONSUMPTION
AND HEART DISEASE
AND STROKE
FACTS
• The Vegetables and Fruit category is the most prominent
food group in Eating Well with Canada’s Food Guide.
It makes up the largest proportion of the Food Guide
servings, emphasizing the important role these foods play
in a healthy diet.1
• The Vegetables and Fruit category of Canada’s Food
Guide includes vegetables and fruit in many forms such as
fresh, frozen, as juice, canned and dried. The Food Guide
recommends that Canadians have vegetables and fruit
more often than juice and choose vegetables and fruit with
no added fat, sugar or salt.1
• A diet rich in vegetables and fruit can reduce the risk of
heart disease, stroke and some types of cancer.1-6
• Insufficient consumption of vegetables and fruit is one
of the major causes of chronic or non-communicable
diseases (diseases that are not contagious) including
heart disease, stroke, cancers, respiratory diseases,
diabetes and obesity.7-11
• Worldwide, 1.7 million deaths (2.8% of all deaths) can be • Barriers to accessing fresh vegetables and fruit are complex
attributed to inadequate vegetable and fruit consumption. and include income, education, age, geographic location,
Inadequate intake is estimated to cause approximately affordability, availability, quality, insufficient transportation,
14% of gastrointestinal cancer deaths, 11% of heart disease and gaps in food skills including preparation, handling
deaths and 9% of stroke deaths globally each year.7 and storage.14-17
• According to Canadian surveys, seven out of 10 children • Low consumption of vegetables and fruit (less than 5
aged 4 to 812, and over half of adults (59.6%) eat fewer servings per day) is associated with lower income, and
than five servings of vegetables and fruit each day, an unhealthy behaviours such as cigarette smoking, a diet high
increase for the second year in a row.13 Canada’s Food in fat, and high levels of television viewing.17,18
Guide recommends 5 servings per day of vegetables and
• Canadian adults in the lowest income households are
fruit for children aged 4 to 8 years and 7 to 10 servings/day
more likely than those in the highest income households to
for adults.
consume less than five daily servings of vegetables and fruit
• Men (33.5%) are less likely than women (47.2%) to consume (58% versus 41%).12
five servings of vegetables and fruit each day.13
• Canadians living in rural and remote centres are less likely
to consume at least 5 daily servings of vegetables and fruit
than people living in urban settings.18

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RECOMMENDATIONS
The Heart and Stroke Foundation recommends that:
CANADIANS
1. Follow Canada's Food Guide which recommends Canadians:
a. Aim to eat the appropriate number of servings of
vegetables and fruit each day (See Table 1).
b. Eat at least one dark green and one orange vegetable
each day.
c. Choose vegetables and fruit prepared with little or no
added fat, sugar or salt.
d. Benefit from eating vegetables and fruit at all meals
and snacks.
e. Have vegetables and fruit more often than juice.
2. Identify opportunities to increase fruit and vegetable
access in your community. Look for opportunities in
schools, daycare centres, workplaces, retail locations and
other settings to support policies and programs that make
vegetable and fruit consumption an easier option.*
FEDERAL GOVERNMENT
1. In cooperation with provincial/territorial governments,
develop agricultural policies and subsidies that provide
incentives for enhancing the production, distribution and
consumption of vegetables and fruit in order to make
vegetables and fruit more affordable to consumers.
For example:
• Establish direct commodity subsidies for the production
of vegetables and fruit.
• Develop subsidized transportation and revenue
insurance policies for fruit and vegetable farmers.
• Restructure agricultural research and development
funding to promote increased fruit and vegetable
production.
• Investigate the feasibility of fruit and vegetable subsidies
specifically targeted for low-income people and
families, for example, through grocery and debit cards
directly connected with the Canada Revenue Agency
for monitoring and reimbursement. Ensure that these
subsidies apply to fresh, frozen and canned vegetables
and fruit.
* Programs can include farm to school or farm to venue programs, farmer’s
markets, community and school gardens, and edible landscaping.
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VEGETABLE & FRUIT CONSUMPTION
AND HEART DISEASE AND STROKE
2. Continue to support and improve the Nutrition North
Canada program to help ensure access and affordability of
fresh vegetables and fruit in remote northern communities.
3. Provide financial, research and policy support to
foster growth of food procurement initiatives and the
improvement of food distribution networks that increase
access to vegetables and fruit on First Nations’ reserves.
4. Ensure that trade barriers that could affect the trade of
fresh vegetables and fruit are not introduced, in order to
provide Canadians with adequate access to a wide range
of products.
5. Conduct public awareness campaigns with allied partners
targeting a variety of populations and cultural groups
concerning the benefits of fruit and vegetable consumption
and how to prepare them.
6. Give consideration to providing a tax credit to growers and
producers for donations of fresh produce (vegetables and
fruit) to food banks.
PROVINCIAL/TERRITORIAL
GOVERNMENTS
1. Provide subsidies and other support for the distribution
of vegetables and fruit from farms to venues such as
farmer’s markets, cooperatives, schools, community/
recreational centres, worksites, and hospitals in order to
make vegetables and fruit more affordable to consumers.
In particular, address areas with low access such as remote
northern communities and low-income neighbourhoods.
Where feasible, work with existing compatible programs
such as those of Farms to Cafeteria Canada.
2. In cooperation with school boards, develop school
food policies that provide students with easy access to
vegetables and fruit. In particular, subsidize the provision
of vegetables and fruit in schools and, where possible,
provide vegetables and fruit free of charge to students. In
part, this could be accomplished through cooperating with
and supporting programs such as the Farms to Schools
salad bar program.

3. In cooperation with school boards, ensure that programs
within school curricula teach students about the benefits of
consuming vegetables and fruit and how to prepare them.
4. In cooperation with municipal governments and school
boards, provide resources and support for the establishment
of school and community gardens.
5. Conduct public awareness campaigns concerning the
benefits of fruit and vegetable consumption, sources of
affordable fruit and vegetable access, and how to prepare
and grow them.
MUNICIPAL GOVERNMENTS AND
REGIONAL HEALTH AUTHORITIES
1. Promote the establishment of Food Policy Councils that
develop local policies, programs and strategies related
to year round food access including vegetable and fruit
consumption.†
2. Support the use of community food assessment tools to more
effectively determine the availability of vegetables and fruit in
individual communities.
3. Consider the implementation of incentives (e.g.,
tax incentives, grants, and low interest loans) for the
establishment of stores selling vegetables and fruit, and
for existing stores to increase the availability of vegetables
and fruit in areas with low availability (e.g., low income
neighbourhoods and near schools).
4. Establish zoning by-laws and policies designed to facilitate
the establishment of farmer’s markets and stores selling
vegetables and fruit in areas with low availability (e.g., low
income neighbourhoods and near schools).
5. Support community programs that provide education
concerning the benefits of consuming vegetables and fruit
and how to grow, handle and prepare them.
6. Provide resources and support for the establishment of
school and community gardens.
† For examples see: Toronto Food Policy Council: toronto.ca/health/tfpc/
index.htm, Vancouver Food Policy Council: vancouverfoodpolicycouncil.
ca, or Kamloops Food Policy Council: kamloopsfoodpolicycouncil.com
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VEGETABLE & FRUIT CONSUMPTION
AND HEART DISEASE AND STROKE
RESEARCHERS
1. Conduct studies to evaluate the impact of vegetable and
fruit consumption on health including the role of vegetables
and fruit in reducing rates of cardiovascular disease,
cardiovascular disease risk, blood pressure, and preventing
weight gain.
2. Design and conduct studies to evaluate fruit and vegetable
policies and programs including their impact on affordability,
availability, access, sustainability and consumption in various
settings (e.g., in workplaces, schools, communities, or northern,
rural and remote areas) and among various populations (e.g.,
low-income individuals, ethnic populations, aboriginal, elderly,
children and youth).
FOOD MANUFACTURERS
Lower the sodium and/or sugar content of canned vegetables
and fruit, vegetable and fruit juices and cocktails to the lowest
level possible, taking into consideration microbial food safety,
quality and consumer acceptance.
BACKGROUND INFORMATION
WHAT IS A HEALTHY DIET?
There has been much debate about the definition of a ‘healthy’
diet. In Canada, a healthy diet is defined as one that includes a
variety of foods from each of the four food groups – Vegetables
and Fruit, Grain Products, Milk and Alternatives and Meat and
Alternatives – per Canada's Food Guide.1 The Food Guide
describes the number of servings to eat from each food group
and guidance on the appropriate portion size. The recommended
number of servings is based on age and gender.
VEGETABLES AND FRUIT
The Vegetables and Fruit category is the most prominent food
group in Canada’s Food Guide, emphasizing the important role
these foods play in a healthy diet. This food group makes up the
largest proportion of the Food Guide servings in a healthy diet
and includes vegetables and fruit in many forms: fresh, frozen,
as juice, canned and dried. The Food Guide recommends that
Canadians have vegetables and fruit more often than juice and
choose vegetables and fruit with no added fat, sugar or salt.
Health Canada further suggests that individuals divide their
dinner plate and fill half the plate with vegetables, a quarter with
grain products and a quarter with meat or alternatives.19

TABLE 1: RECOMMENDED NUMBER OF SERVINGS OF VEGETABLES AND FRUIT PER
DAY IN EATING WELL WITH CANADA’S FOOD GUIDE
CHILDREN TEENS
Age 2-3 4-8 9-13 14-18
Sex Girls and Boys Females
Servings 4 5 6 7
What is one Food Guide Serving of vegetables or fruit?
• ½ cup of fresh frozen or canned vegetables
• ½ cup cooked leafy vegetables
• 1 cup raw leafy vegetables
• 1 fruit (banana, apple, orange)
• ½ cup frozen or canned fruit
• ½ cup 100% juice
Vegetables and fruit have important nutrients including
vitamins, minerals and fibre.1 In particular, vegetables and fruit
provide vitamins A and C, potassium, magnesium and some
B vitamins such as folate. These nutrients provide a number
of health benefits. A diet rich in vegetables and fruit may
help reduce the risk of heart disease, stroke and some types
of cancer.1-6 Evidence also suggests that vegetables and fruit
play a role in reducing the risk of obesity, diabetes, respiratory
diseases and can contribute to weight loss.7-11
EFFECTS OF VEGETABLE AND FRUIT
CONSUMPTION
A review of evidence investigating the relationship between
vegetable and fruit intake on cardiovascular disease
concluded that there is a moderate inverse relationship
between vegetable and fruit consumption on heart attack
and stroke risk, with significantly larger, positive effects noted
above five servings of vegetables and fruits per day.20 As the
number of servings of vegetables and fruit increases, the risk
of heart attack and stroke is reduced.
The InterHEART study found that an unhealthy diet (including
low intake of vegetables and fruit) was one of 9 modifiable risk
factors that account for 90% of heart attack risk.8 The study
concluded that an unhealthy diet increases the risk of heart
attack and accounts for approximately 30% of the population-
attributable risk. Similarly, the InterSTROKE study found that an
unhealthy diet (including low fruit and vegetable consumption)
was one of 10 modifiable risk factors accounting for 90% of
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VEGETABLE & FRUIT CONSUMPTION
AND HEART DISEASE AND STROKE
ADULTS
19-50 51+
Males Females Males Females Males
8 7-8 8-10 7 7
stroke risk.9 Studies have shown an overall risk reduction of
heart attack or stroke by as much as 11% for each serving of
vegetables and fruit added per day.2,3
The European Investigation into Cancer and Nutrition (EPIC)-
Heart Study followed over 300,000 men and women without
heart disease or stroke for more than 8 years. Individuals
who ate at least eight servings of vegetables and fruit a day
had a 22% lower risk of dying from heart disease than those
who consumed fewer than three servings a day. The results
were adjusted for smoking, alcohol intake, body-mass index,
physical activity, marital status, education, employment, high
blood pressure, angina, diabetes and total energy intake.6
Other large studies confirm this inverse relationship between
vegetable and fruit consumption for cardiovascular death.3-5
While scientific evidence may be lacking to describe the
precise pathway in which vegetables and fruit help reduce
the risk of developing heart disease or stroke, it is clear that
the more vegetables and fruit an individual consumes, the
lower the risk of heart disease or stroke.
An evidence review published by the World Health
Organization found that there is convincing evidence that
vegetables and fruit decrease the risk for obesity.10 Research
also indicates that replacing foods of high energy density
(high calories per weight of food) with foods of lower energy
density, such as vegetables and fruit, are an important part
of a weight management strategy. Fruit and vegetable
consumption contribute to increased feelings of satiety
(fullness), which can help in reducing overall energy intake.21
A study of risk behaviours found that inadequate fruit and
vegetable consumption had an impact of 2.0 fewer years of
life expectancy. The study further found that reducing this
unhealthy behavior would add years to life (life expectancy)
and even more life to years (health-adjusted
life expectancy).22

In addition to the health benefits, an increase in population
levels of vegetable and fruit consumption would have
a positive impact on health care costs. Reductions in
diet-related disease and health care costs would be
achieved if vegetable and fruit consumption were raised
to recommended levels.23,24
VEGETABLE AND FRUIT COST, SALES
AND CONSUMPTION IN CANADA
Statistics Canada reports that in 2012 sales of fruits and
vegetables by Canadian farmers reached $1.7 billion in
2012, up 9.2% from 2011. Fruit sales increased 13.1% to $872
million, while vegetable sales rose 5.4% to $847 million.25
In 2013 Nielsen reported that fresh vegetables and fruit
represent 10.4% of all food sales in Canada at major retail
outlets.26 This represents a total of $8.8 billion in food sales
and is up 3% in 2013. Fresh vegetables represented 51% of
the dollars spent on fresh produce.27
Despite the sales statistics, surveys reveal that less than half
of Canadians aged 12 years and older (40.4%) consume
servings of vegetables and fruit five or more times each day,
down for a second year since 2009. Men (33.5%) are less
likely than women (47.2%) to consume five servings a day,13
and when it comes to children, seven out of 10 children aged
4 to 8 years eat fewer than 5 servings each day.12
Common reasons for not consuming vegetables and fruit
are ‘it takes too much time to prepare vegetables and
fruit’, ‘vegetables and fruit are not readily available at
home/school/work’, ‘vegetables and fruit spoil too quickly’,
‘vegetables and fruit cost too much’, ‘it is too difficult to eat
the recommended amount’, and individuals ‘don’t like the
taste of many vegetables and fruit’.28 Children who report
a greater liking to vegetables and fruit are more likely to
consume higher intake levels than children who do not like
vegetables and fruit. Increasing taste preference through
introducing a variety of vegetables and fruit in the home
and taste testing may be effective and practical approaches
to improving vegetable and fruit consumption.29
Price and affordability of vegetables and fruit is a growing
concern as food prices rise in Canada, and around the
world. Researchers forecast that in 2013 the expenditures
for vegetables and fruit (fresh, preserved and prepared) will
increase in the range of 1 to 3%.30 The increase in reported
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VEGETABLE & FRUIT CONSUMPTION
AND HEART DISEASE AND STROKE
sales of vegetables and fruit could be attributed to increased
price as opposed to increased volume.
Studies have found that vegetable and fruit consumption
is lower among males, middle-aged, singles, smokers,
individuals with weak social interaction, and households with
no children. Low income-education groups are less likely to
consume vegetables and fruit than high income-education
groups. There are significant differences in fruit and vegetable
consumption between provinces, where the Atlantic, Western,
British Columbia and Ontario provinces consume vegetables
and fruit less often than residents of Quebec.21 Surveys
indicate that Canadians living in rural centres are less likely to
consume at least 5 servings of vegetables and fruit each day
than those living in urban settings.18
STRATEGIES TO IMPROVE VEGETABLE
AND FRUIT CONSUMPTION IN CANADA
Adequate food preparation skills are needed to prepare
healthy meals. Individuals who lack basic food selection and
preparation skills may be more likely to rely on convenience
and fast foods. Increased consumption of pre-packaged
and processed foods may also be contributing to fewer
individuals cooking at home. Families with single parents
or with both parents working outside the home may be less
likely to pass on food preparation skills to children and may
lack basic preparation skills themselves. Involving children
in meal preparation in the home is associated with higher
fruit and vegetable preferences and greater ability to choose
healthier foods.31 In addition, precut, prewashed, frozen and
canned vegetables and fruit can provide options for those
who don’t like to cook, have limited cooking skills or ability,
or have poor or no kitchen facilities.
Strategies to improve vegetable and fruit consumption need
to recognize the complex food environment and address the
socio-cultural, economic, education and technical challenges
that exist in the vegetable and fruit supply chain.32 The
complexity of purchasing and consuming vegetables and
fruit relies on geographic food access which includes:
availability, affordability, and quality. To support this complex
model, a strategy that includes both domestic and imported
products is necessary.
Canadians consume over 50 billion servings of fresh produce
annually. Variety, quality, price and access are important
and therefore local Canadian production, though an integral

part of the domestic marketplace, cannot meet this demand
alone. Canadians are able to enjoy over 400 different
types of fresh fruits and vegetables from over 150 different
countries throughout the year.
Canadians demand variety, best quality, best price, all year
round. Canadians have come to expect the same selection
of affordable, quality fresh produce throughout the year at
their supermarkets and grocery stores, regardless of season
or weather patterns in Canada.
Improved opportunities for consumption of fruit and
vegetables in various settings, partnered with a better
understanding of individual eating behaviours and consumer
awareness and education may further influence vegetable
and fruit consumption.
Increasing the number of locations where vegetables and
fruit are sold in communities can help to improve their
accessibility. Making produce available in supermarkets,
grocery stores, convenience stores, corner stores and
specialty food stores (e.g., vegetable and fruit markets) at
affordable prices will help increase consumption among
individuals within the communities. Financial incentives to
attract food stores to underserved areas, improved public
transportation, improved facilities in existing stores and
increased supply of and shelf space dedicated to affordable
vegetables and fruit in existing stores are suggested
methods to improve access within communities.32
The home, community, workplace and school environments
influence the food choices that Canadians make. Some
neighbourhoods do not have stores that sell healthy foods,
and not all families have transportation to travel to stores
where vegetables and fruit are available. Food is at the
core of a highly complex system that includes the way it is
produced, processed, distributed, priced, marketed, and
consumed. Each stage is influenced by various levels of
government and by businesses from local to multinational
levels. Access and affordability of vegetables and fruit can
be altered through agriculture, building sustainable
community food systems, and by exploring multi-level
food policies, such as incentives to bring grocery stores
or farmer’s markets to underserviced neighbourhoods.
Increased access to vegetables and fruit can be achieved
through a number of policy and program options.33
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VEGETABLE & FRUIT CONSUMPTION
AND HEART DISEASE AND STROKE
Food-to-Family programs such as Food Share in Toronto,
Ontario are positive community tools, which apply a wide
range of programs. These programs take a unique long-term
approach to hunger and food issues. They aim to empower
individuals, families and communities through food-based
initiatives, while advocating for broader public policies
needed to ensure that everyone has adequate access to
sustainably produced, good healthy food.34
The term ‘edible landscaping’ refers to the use of edible
plants such as fruit and nut trees, berry bushes, vegetables,
herbs and edible flowers instead of ornamental or traditional
plants in various settings. Benefits of edible landscaping
include increased food security, reduced food costs,
convenience and sustainability at personal, community
and global levels. Policies and programs that promote and
support edible landscaping can contribute to improved
vegetable and fruit consumption.
Farm-to-location programs allow local farms to sell
vegetables and fruit directly to local establishments (e.g.,
schools, hospitals, worksites, or daycares). These programs
provide groups and organizations with locally grown, healthy,
and nutritious foods and contribute to the health of a
community in season. Local produce is made available for
use in cafeterias, restaurants, and catering services and at
meetings, conferences and special events. These programs
are often subsidized through government subsidies, local
organizations or individuals. The goal of these programs is
to help ensure regular access to fresh produce and promote
consumption of vegetables and fruit. Farm-to-location
programs can also incorporate education about vegetables
and fruit, food preparation, or agriculture. For example,
many farm-to-school programs include activities that provide
students with hands-on learning opportunities, such as
food preparation and cooking classes, school gardening,
composting, and farm visits. Farm to Cafeteria Canada is an
emerging national network that promotes, supports and links
farm to cafeteria programs, policy and practice from coast
to coast to coast. Their website (www.farmtocafeteriacanada.
ca) provides information about projects and programs across
Canada and is a valuable resource for policies and available
funding opportunities.

Nutrition North Canada is a food subsidy program in isolated
northern locations that is funded by the Federal government.
It was launched in April 2011 to replace the former Food Mail
Program, and seeks to improve access to perishable healthy
foods. Perishable foods can be fresh, frozen, refrigerated, or
have a shelf life of less than one year and must be shipped
by air. A higher subsidy applies to the most nutritious
options such as fresh fruit, frozen vegetables, bread, meat,
milk, and eggs. A lower subsidy applies to other eligible
foods such as flour, crackers, ice cream and combination
foods (e.g. pizza, lasagna). To be eligible for the program
a community must lack year-round surface transportation
or have used the previous Food Mail program. Registered
retailers are subsidized to enable them to reduce food
prices for consumers. Although Nutrition North Canada is an
improvement over the former Food Mail program, a report
of the United Nations Special Rapporteur on the Right to
Food highlighted limitations to the current program including
community and food eligibility criteria. The report further
emphasized the need for improved program monitoring to
determine whether desired outcomes are being achieved.35
A tax credit for growers and producers who donate fresh
vegetables and fruit to food banks has been introduced
in several US States. Food banks distribute perishable and
non-perishable food to those who have difficulty purchasing
enough food to avoid hunger. Food banks in Canada have
served over 700,000 individuals every month for the better
part of the last twelve years.36 Introduction of a similar tax
credit in Canada for producers and growers to donate
unused fresh produce to food banks could help increase
consumption of vegetables and fruit among low-income
Canadians and families in need.
Evidence of strategies to improve vegetable and fruit
consumption among Canadians continues to grow. Evidence
from the tobacco control field suggests that multiple,
interrelated strategies that create an environment and
culture where healthier choices are normalized, are effective.
To increase vegetable and fruit consumption among
Canadians, a comprehensive approach that addresses
multiple levels including intrapersonal factors (knowledge
and skills), interpersonal processes (social supports),
organizational and community factors (local rules and
norms), and public policy (voluntary and/or regulatory
measures, tax incentives) is required.37,38
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AND HEART DISEASE AND STROKE
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foodbankscanada.ca/getmedia/a5361057-b6c4-4fab-a82c-
6bc5a8e96e3f/Agricultural-Tax-Credit_Food-Banks-Canada_
Jan2012.pdf.aspx?ext=.pdf
37. Centers for Disease Control and Prevention. . Atlanta: U.S.
Department of Health and Human Services; 2011.
38. Raine KD. Addressing poor nutrition to promote heart health:
Moving upstream. Canadian Journal of Cardiology 2010;26(Suppl
C):21C-24C.
The information in this Position Statement is
current as of AUGUST 2013

28. Region of Peel. Overcoming barriers to eating vegetables &

fruit. Colour your world with vegetables and fruit. Adapted with
permission from the Community Food Advisor Program of the
Ontario Public Health Association, 2008. www.peelregion.ca/
health/shp/nutrition-month/educator/pdfs/barriers-eat-v-f.pdf
29. Chu YL, Farmer A, Fung C, Kuhle S, Veugelers P. Fruit and
vegetable preferences and intake among children in Alberta.
Canadian Journal of Dietetic Practice and Research 2013;74(1):21-7.

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