FRUIT AND VEGETABLE CONSUMPTION AND PREVALENCE OF RISK FACTORS FOR NON-COMMUNICABLE DISEASES AMONG ADULTS IN OYIGBO LOCAL GOVERNMENT AREA, RIVERS STATE

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ABSTRACT

The aim of the study was to assess fruit and vegetable consumption pattern and the association with prevalence of selected NCDs among adults in Oyigbo LGA, Rivers State. This cross-sectional study was conducted among 379 randomly selected adults (18 -60 years). Food frequency questionnaire and 24 hour dietary recall were used to assess fruit and vegetable consumption. Average daily intake of  5 serving of fruits and vegetable was considered adequate intake. Anthropometric methods of height, weight, waist and hip circumference as well as blood pressure were measured following standard procedures. Body Mass Index (BMI) was calculated from height and weight measurements. Fasting blood glucose level was used to assess diabetes. Blood pressure measurement was done to assess hypertension. Physical activity levels were assessed using the Physical Activity Questionnaire for Adults (PAQ). Categorical variables were presented using frequency distribution, tables and graphs. Independent T-test was used to compare variables based on sex. The association of adequate fruits and vegetables with prevalence of NCDs was determined using Chi square and logistic regression. Result of the study showed that 57.5% of participants were civil servants, had attained tertiary education level (75.1%), and earned above ₦100,000 (34.1%). Slightly more than half (55.6%) of the participants had fair knowledge of the importance of FVs consumption. Availability (32%) and health reasons (20.9%) were the dominant reasons for choice of FVs consumed. Physical activity level of 66.7% participants did not meet WHO recommendation (> 600 MET-minutes/week) especially for adults older than 50 years. Men were significantly more physically active than women (p=0.028). Many of the adults did not smoke (87.8%) or consume alcohol (64.3%). The prevalence of overweight and obesity were 46% and 24.6%, respectively. Females had significantly higher WHR compared to men (p<0.05). The prevalence of hypertension and diabetes were 58.7% and 6.7%, respectively. The prevalence of adequate consumption of fruits and vegetables in this study was 21.2% and 16.7% respectively. Nutrient intake was generally below FAO/WHO/UNU recommendations. Mean Adequacy Ratio (MAR) was 58.52% and 56.72% for men and women, respectively. A significant association was found between BMI and adequate fruit and vegetable consumption. The study participants had low fruit and vegetable consumption, physical activity level, and diabetes. However, the prevalence of hypertension, obesity and overweight were high. Therefore, promotion of fruit and vegetable consumption and increased availability of FVs varieties by relevant sectors in Rivers State are recommended.    





TABLE OF CONTENTS             

Title Page                                                                                                                                i

Declaration                                                                                                                                 ii

Dedication                                                                                                                              iii

Certification                                                                                                                           iv

Acknowledgment                                                                                                                   v                            

Table of content                                                                                                                vi   

List of Tables                                                                                                                          vii       

List of Figures                                                                                                                        viii

Abstract                                                                                                                                    ix                                                                                                                     

CHAPTER 1: INTRODUCTION

1.1           Background of the Study                                                                                                    1

1.2           Statement of Problems                                                                                                        6

1.3           Objectives of the Study                                                                                                      10
1.4           Significant of the Study                                                                                                      11

CHAPTER 2: LITERATURE REVIEW

 

2.1          Definition of Fruits and Vegetable (FVs)                                                                            12

 

2.2          Global prevalence of Fruit and Vegetable Intake                                                               14

                           

2.3          Health Benefits of Consumption of Fruits and Vegetable                                                  16

 2.4         Factors Influencing FVs Consumption Among Adults                                                       20

                 

2.5          Dietary Intake Assessment                                                                                                  22

                                                                  

2.5.1        Dietary assessment                                                                                                             22

                                                                               

2.6           Measuring Fruit and Vegetable Intake                                                                               26

 

2.7           Definition of Non-communicable Diseases                                                                      27

      

2.7.1         Populations of risk of NCDs                                                                      28

 

2.7.2        Socio-economic impacts of NCDs                                                                                     29

 

2.8           Global Prevalence of NCDs                                                                                               29

 

2.9           Reviews of the Relationship between NCDs and FV Consumption                                   31

 

2.9.1        Relationship between cardiovascular disease and FVs intake                                         32

 

2.9.2        Relationship between blood pressure and FV intake                                                         33

 

2.9.3        Relationship between cancer and FV intake                                                                      33

 

2.9.4        Relationship between diabetes and FV intake                                                                   35

 

2.9.5        Relationship between obesity and FV intake                                                                                 35

 

CHAPTER 3: MATERIALS AND METHODS

                                                                                 

 

3.1          Study Design                                                                                                                       36

 

3.2           Area of Study                                                                                                                     36

 

3.3           Population                                                                                                                          37

 

3.4           Sampling and Sampling Techniques                                                                                       37

 

3.4.1         Sample size                                                                                                                             37

 

3.4.2        Sampling technique                                                                                                                 38

 

3.5           Preliminary Activities                                                                                                              40

 

3.5.1        Preliminary visits                                                                                                                     40

 

3.5.2       Inclusion/exclusion criteria                                                                                                 40

                                            

3.5.3      Training of research assistants                                                                                                   41

   

3.5.4      Pre-test of questionnaire                                                                                                            41

 

3.6         Data Collection Technique                                                                                                       41

 

3.6.1      Data collection                                                                                                                     41

 

3.6.2      Anthropometric measurement                                                                                                   42

  

3.6.3       Dietary assessment                                                                                                                   47

 

3.7         Lifestyle Factors Assessment                                                                                                     48

 

3.8         Data Analysis                                                                                                                            50

 

3.9        Statistical Analysis                                                                                                                     50

 

3.10      Ethical Approval                                                                                                                       51

 

CHAPTER 4:   RESULT AND DISCUSSION      

 

4.1a      Socio-Demographic Characteristics of the Participants                                                                    52                             

 

4.1b      Socio- Economic characteristics of the participants                                                                         54

 

4.2        Knowledge of Fruits and Vegetable Consumption                                                                           56

 

4. 3       Reason for Choice of Fruits and Vegetable Consumed                                                               61

 

4.4        Behaviour and Lifestyle Characteristics of Participants                                                              62                      

 

 4.5       Nutrient Intake of Participants                                                                                                    66

 

 4.6       Anthropometric Indices of the Participants                                                                                70

 

 4.7       Blood Pressure Classification of the Participants                                                                        72

 

4.8       Mean, Anthropometric, Blood Pressure and Blood Glucose

             Classification According to Sex                                                                                                    74

 

4.9      Consumption Pattern of Fruits and Vegetables                                                                            75                                                                                                                     

 

4.10      Prevalence of Participants Meeting WHO Recommended

              Fruit and Vegetable                                                                                                              79

                                                                 

4.11      Relationship between Non communicable Disease Risk

             Factors and Adequate Fruit and Vegetable Consumption                                       81

 

CHAPTER 5: CONCLUSION AND RECOMMENDATION

 

5.1     Conclusion                                                                                                                  85

5.2    Recommendation                                                                                                         87                             

         References                                                                                                                   88

          Appendices                                                                                                                     106                 







 

LIST OF TABLES

            


3.1    Selected number of communities                                                                                  39

3.2    Selected number of respondents from each communities                                            39

3.3    BMI categories                                                                                                              43

3.4    Waist- Hip ratio categories                                                                                                     45

3.5    Blood pressure categories                                                                                             46

4.1a   Socio-demographic characteristics of the participants                                                           53 

4.1b   Socio-economic characteristics of the participants                                                                55 

4.2a   Knowledge of fruit and vegetable consumption                                                                     57      

4.2b   Knowledge score of fruit and vegetable consumption                                                         60                            

 4.3    Reason for choice of fruits and vegetables consumed                                                 61  

4.4a   Behaviour and  lifestyle characteristics of participants                                                            62

4.4b   Physical activity classification according to sex and age of adults                                     66             

4.5 a   Nutrient Intake of participants                                                                                     67

4.5b   Nutrient adequacy ratio of participants                                                                                  69

4.6      Anthropometric indices of the participants                                                                 70                                         

4.7a    Blood pressure indices of the participants                                                                   72           

4.7b    Blood glucose level of the participants                                                                       73  

4.8      Mean anthropometric, blood and blood glucose measurement                                    74 

4.10      Prevalence of participant meeting recommended fruit and vegetable

           consumption per day                                                                                                   80                        

4.11    Relationship between NCD, risk Factors and Adequate Fruit and

           Vegetable Consumption                                                                                              81

 

 

                                                              







 

LIST OF FIGURES

 

4.1      Frequency of fruits and vegetable consumption of participants                                  77

 

 

 

                                                                                                


 

 

 


 

CHAPTER 1

INTRODUCTION


1.1    BACKGROUND OF THE STUDY                      

Dietary factors contribute to a large percentage of the global burden of diseases. It was estimated that 10% of all deaths (12.5 million) were attributable to dietary factors (Lim et al., 2010). Adequate consumption of fruits and vegetables (FAVs) has protective benefits against the development of NCDs (Kabwama et al., 2019). Fruits and vegetables are important components of a healthy diet due to their low energy density, micronutrients, fiber, and other functional properties (Lim et al., 2010). Reduced fruit and vegetable consumption is linked to poor health and increased risk of non-communicable diseases (NCDs) (Kabwama et al., 2019).

Non-communicable diseases (NCDs) are the leading cause of morbidity and mortality in developed and developing countries. An FAO/WHO joint report showed low consumption of fruits and vegetables to be associated with NCDs (Kabwama et al., 2019). An estimated 6.7 million deaths worldwide were attributed to inadequate fruit and vegetable consumption in 2010 (Lim et al., 2010).

WHO recommended a daily intake of ≥5 portions (400g) of fruits and vegetable, but people generally have low intakes both in developing and developed countries (WHO, 2005). World Health Organization (WHO) (2003) estimated that low intake of fruits and vegetables caused about 19% gastro- intestinal cancers, about 31% of ischemic heart disease and 11% of stroke. (WHO, 2003) of the global burden attributable to low fruit and vegetable consumption, about 585% was from Cardiovascular Diseases (CVD) and 15% from cancers.

NCD are now seen to affect the poor of the poorest countries in the world. The impact is greatest on the poor countries of sub-Saharan Africa of which Nigeria occupy a significant position. This is because they are often unable to access the education and services required to prevent and treat NCDs. The little health resources remained focused on reducing the already overwhelmed burden of communicable diseases and preventable causes of infant and maternal mortality. Thus, it is not an exaggeration to describe the situation in developing countries as an impending disaster; a disaster for health, for society and most of all for national economies.

The shift towards NCDs in developing countries dispelled the popular myth that NCDs afflict mostly the affluence (high income) population. However, the developed countries are equally sharing in the scourge, but while the developing countries are facing a double burden, the developed and the high income countries are experiencing a shift in the health trend from communicable to non-communicable diseases.

Non-communicable diseases are the number one world’s killer, causing 60% of all deaths globally (Healthy Caribbean Coalition  (HCC)  NCD Alliance, 2011) and a staggering 35 million people die every year from these silence killers, of which 18 million are women. In 2008, this figure rose to 36.1million (i.e. about 63% of global deaths), and nearly 80% of those NCD deaths-equivalent of 29 million people occurred in low and middle income countries with the projection of about 52 million deaths annually by 2030 (WHO, 2011).  Globally, around 2.8% of deaths are attributable to low fruit and vegetable (FAV) consumption, and these deaths are 30mainly from these NCDs like gastrointestinal cancer, coronary heart disease, and stroke (WHO, 2016). Low FAV consumption contributes to 1.8% of the global burden of disease (Lock et al., 2005). Regular, adequate consumption of FAVs has been reported to improve survival (Nicklette et al., 2015) and may confer protection against chronic diseases (Wu y et al., 2015). When consumed in adequate amounts on a regular basis, FAVs can play an important role in management of weight, (Roll et al., 2004), lowering the risk of obesity, and can ward off many oxidative stress related chronic diseases. One report shows that higher FAV intake is associated with better overall nutritional intake from other food sources as well (Bermejo et al., 2002). Also, NCDs will be responsible for three times as many disability adjusted life years (WHO, 2004), and nearly 5 times as many deaths as communicable diseases, maternal, perinatal, and nutritional conditions combined (WHO, 2008). About one-fourth of the global NCDs related deaths take place before the age of 60 years (WHO, 2010). These clusters of diseases represent the biggest threat to global health care and economy, especially as it concerns women (HCC-NCD Alliance, 2011), since prior studies have shown a higher prevalence of some of the predisposing factors in women than men (Khuwaja et al. 2010).

In a study carried out in the south-south region in Nigeria to determine the age and sex specific prevalence and associated risk factors for non-communicable diseases in adult population, it was found that the overall prevalence of NCDs is 32.8% (Ekpenyong et al.,2012). In United States, 750 billion dollars is spent annually on cardiovascular disease and diabetes mellitus (Venkat-Narayan et al. 2010) and about 87% of all deaths in US are due to NCDs (WHO, 2011). Globally, cardiovascular disease account for most death (about 17 million people annually) followed by cancer (7.6 million), respiratory diseases (4.2 million) and diabetes (1.3 million) (WHO, 2016). These cluster of diseases account for 80% of disease related deaths (Shukla, 2011). In Africa, most countries have not conducted risk factor surveys to establish the national based line prevalence rates and accurately quantify the magnitude of the problem (Mufunda et al.,2006)

In Nigeria, the impact of NCD is enormous and glaring. It was reported that about 5 million Nigerians may die of NCDs by the year 2015, and diabetes alone was projected to have caused about 52% of the mortality in 2015. Also, the economic cost of NCDs in Nigeria in 2005 was about 400 million dollars from premature death due to NCDs. By 2015, it was estimated to rise to about 8 billion dollars (Health Reform Foundation of Nigeria (HERFON), 2011). At present, about 8 million Nigerians suffer from hypertension and 4 million has diabetes; 100, 000 new cases of cancers are diagnosed each year in Nigeria (Baba et al., 2014). Researchers have empirically identified the link between NCDs and globalization, urbanization, demographics, life style transition, socio-cultural factors, poverty, poor maternal, fetal and infant nutrition (Ekpenyong et al.,2014). For example, in 2012, NCD mortality rate for the African region alone was 28 million (Health Reform Foundation of Nigeria (HERFON, 2011). African countries are undergoing an epidemiological transition indicating that sicknesses they suffer are no longer infectious diseases but now chronic diseases or non-communicable diseases (Anue et al., 2017). This is as a result of urbanization, industrialization, increased life expectancy and the adoption of western lifestyle characterized by reduced physical activity and dietary changes from foods rich in fruits and vegetables to refined, energy-dense and fatty foods (Anue et al., 2017).  Though previous studies have evaluated the existence of factors that influence the consumption of fruits and vegetables. Some of the factors are knowledge, beliefs, cost, convenience and the sensory characteristics of vegetables (Anue et al., 2017).  

Evidence shows that four major groups of diseases namely cardiovascular diseases, cancers, respiratory diseases and diabetes mellitus account for 82% of all NCD deaths (Lim et al., 2010). These diseases share four common behavioural risk factors (tobacco use, excess alcohol consumption, unhealthy diet and physical inactivity) and four metabolic risk factors (elevated blood pressure, overweight and obesity, hyperglycaemia and hyperlipidaemia) (WHO, 2011).

According to the WHO/FAO (2003), the set population nutrient goals and recommended intake was put at a minimum of 400g for fruits and vegetables per day for the prevention and reduction of the risk of chronic heart diseases, cancer, diabetes and obesity.

In a study conducted in the south-south part of Nigeria, including Rivers-State. It was observed that fruits and vegetable consumption is a commonly recommended element in a balanced and healthy eating pattern (Anune et al., 2017). In another study carried out to determine the heterogenous consumption patterns of fruit and vegetables in Nigeria, it was found out that while fruit consumption increased dramatically in both the North and the South over the past decade, vegetable consumption declined in both regions, albeit marginally in the south, yet fruit and vegetable combined consumption levels are well below the per capita daily recommended level by WHO of 400grams across Nigeria and especially lower in rural areas and among the poorest (Parkhi et al., 2023).

An adequate consumption of fruits and vegetables could lead to significant improvements in public health, as it reduces the risk of the development of chronic diseases (e.g., heart diseases, high blood pressure, diabetes and obesity), several cancers and prevents or alleviates several micronutrient deficiencies (Anune et al.,2017). Despite all the recommendation, the consumption is still insufficient in Nigeria as a whole (Chubike, 2013). A study conducted in Oyigbo Rivers state, showed that the prevalence of hypertension, obesity, and diabetics were linked with lifestyle factors such as dietary, smoking, harmful use of alcohol, and even time factors as respondents barely have time to go for check-ups in the hospitals. Similarly, the high occurrence of overweight in the same study which itself could have led to high prevalence of hypertension may be due to life style (poor diet and drinking alcohol), lack of proper dietary advice, diet consumption of high calorie food and lack of knowledge about the possible etiology of essential hypertension and its consequences to human health (Akinlua et al, 2015).

The World Health Organization (WHO) has come up with the surveillance of NCDs and their risk factors to facilitate the implementation of appropriate public health strategies. This surveillance known as ‘WHO STEPWISE’ approach is a standardized methodology for the surveillance of non-communicable diseases (STEPS) (WHO, 2015) although; studies using this approach have just begun to emerge (Choi et al., 2015). Therefore, it is crucial to pay close attention to NCDs among the working population, different business men and women, farmers or adults as a whole because these health challenges can perhaps lead to economic losses, household poverty and reduction in productivity (Lock et al., 2004). The World Health Organization (WHO) has also recommended FAV as central to a healthy diet and has long advocated for increased consumption through targeted campaigns. Despite the growing body of evidence and promotion of consumption in guidelines and by other means, FAV intake is far less than the recommended amount in many low and middle-income countries (LMICs).   This study is therefore aimed at providing information on fruits and vegetable consumption pattern and magnitude of NCDs risk factors among adults in Oyigbo L.G.A to form the baseline for monitoring the trends, guiding decision making, and implementing appropriate interventions.

1.2   STATEMENT OF PROBLEM

Non-communicable diseases (NCD) have become a global health problem which threatens Sub-Sahara Africa (SSA) including Nigeria. Adults which include business men and women, civil servants, farmers etc are all affected in these conditions. This could be as the result of stress encountered in the pursuit of money, lifestyle, dietary pattern or sedentary nature of their occupation (Ekpenyong et al., 2014). It is also known that low consumption of plant-based foods, including fruits and vegetables, is associated with an increased risk of several chronic non-communicable diseases including hypertension, cardiovascular disease (CVD), stroke, obesity, diabetes, osteoporosis and certain cancers and with high all-cause mortality (Slavin et al., 2012). In 2009, it was estimated that excess of 2 million deaths and 26 million disability-adjusted-life-years (DALYs; 1.8%) could be attributable to suboptimal fruit and vegetable consumption worldwide (Hall et al., 2009). Data suggest that these figures may be considerably higher, with nearly 8 million premature deaths attributable to fruit and vegetable intake below 800 g per day (Aune et al.,2017). Modelling data also suggest that 31% of ischemic heart disease, 19% stroke, 20% oesophageal cancer, 19% gastric cancer and 12% lung cancer cases globally could be avoided by increasing the daily intake of fruits and vegetables to at least 400 g per day (Lock et al., 2004), while 15 000 deaths each year could be avoided if similar dietary guidelines were followed in the UK (Scarboroughh et al., 2012). In the UK National Diet and Nutrition Survey (NDNS), 70% of all men and women sampled reported eating less than the recommended minimum 5 daily portions (400 g), with 62% of both sexes consuming fewer than 3 portions of fruits and vegetables each day (Scarboroughh et al., 2012).

Low fruit and vegetables consumption is not confined to high-income countries but is prevalent across many nations. In a study, 77.6% of men and 78.4% of women sampled from 52 low- and middle-income countries reported consuming less than 400 g of fruit and vegetables per day, the minimum recommended by the World Health Organisation (WHO) Panel on Diet, Nutrition and Prevention of Chronic Disease (Hall et al., 2009). The consumption in Africa is lower than the recommended daily guidelines prescribed by the World Health Organization (Hall et al., 2009). In sub-Saharan Africa, estimates of fruit and vegetable consumption range from 70-312g per person per day, which is far lower than the WHO recommendation of at least 400g per person per day (Ruel and Minot, 2005). The steady rise in the burden of non-communicable diseases (NCDs)in Sub-Saharan Africa over the past 20 years, driven by an increase in risk factors such as unhealthy diets, (Bigna and Noubiap, 2019) coupled with the concurrent challenges of infectious diseases, makes it imperative to seek cost-effective interventions to address the low consumption of FV in these settings.

There are a number of other reasons why the intake of fruits and vegetables are low in developing country of which Nigeria is one of. Some of these reasons are limited year-round availability, affordability, need for convenience, food safety issues and the attraction to modern or Western lifestyles which are reported as constraints for healthy food choices by urban middle class consumers in Lagos (Hollinger et al., 2015). Cultural beliefs and taboos, as well as religious beliefs are found to influence the food choices of consumers (Ijewere et al., 2012). Religious environments serve as potential avenues for health promotion and have become increasingly relevant because of the existing social networks and support (Bigna and Noubiap, 2019). It has been established that health programmes focusing on behaviours that can be reinforced by social support are effective in religious settings.

 Regarding the FV availability, this is region- and season-dependent, and products are mostly eaten fresh, since storage possibilities are few and substantial losses occur due to inadequate preservation and transport. Also at the national level, the availability of fruits and vegetables is insufficient to meet the recommended levels of intake (FAO, 2017). For lower social economic classes (SEC), the affordability of fruits and vegetables is problematic due to low purchasing power of households, and necessities to prioritize energy-dense foods which are generally cheaper (FAO, 2017). Across all urban consumers, including the lower SEC, constraints in the time available for shopping and preparation of food appears to drive consumers towards increased consumption outside the home (Hollinger et al., 2015). Convenience foods are typically high in fat and carbohydrates, and low in vegetables and other nutrient-dense foods. Those seeking to shift to healthier, but convenient alternatives, such as fish, fresh fruits and vegetables are faced with the increasingly expensive costs of nutritious foods relative to the fast-food alternatives (Hollinger et al., 2015).

Another problem is that in developing countries, majority of the population are involved in agriculture, yet availability and accessibility of FV is low leading to low consumption. This is seen in a study carried out in Bangladeshi where the majority of the populations are engaged in agriculture, which confounds the availability and accessibility hypothesis of FAV consumption (Brunt et al., 2012).

In a study carried out by (Dauchet et al., 2008), they investigated the correlation of low FAV consumption in different populations and identified several socio-demographic, psychosocial, and behavioral factors. They found associations of FAV consumption with place of residence, socioeconomic status, educational attainment, occupational category, household income, and television viewing along with non-modifiable factors such as age, gender and ethnicity (Dauchet et al., 2008). 

Another factor is that most studies on relationships between fruit and vegetable consumption and NCDs were conducted in developed countries and so little is known about the relationship in developing countries (Dauchet et al., 2008). For instance, studies carried out in countries like Asia revealed that a higher intake of FAV is associated with an improved NCD risk profiles such as a lowered systolic BP, waist circumference and low- density lipoprotein cholesterol in southern India (Radhika et al.,2008) and lower risk of obesity in Iran (Radhika et al.,2008). Based on the fact that some studies have shown that increasing FV could potentially be a way to reduce the NCDs, it is then worthy to carry out a research in this area, since more knowledge is needed in this area in Nigeria and other developing countries. This study is therefore aimed at determining fruit and vegetable consumption and relating it to selected NCDs among adults in Rivers State

1.3           OBJECTIVES OF THE STUDY

The general objective of this study is to assess fruit and vegetable consumption pattern and         risk factors of NCDs among adults (18-60 years) in Oyigbo L.G.A in Rivers-State.

The specific objectives are to:

1.     determine socio-demographic and socio-economic characteristics of the adults

2.     determine the knowledge of fruits and vegetable consumption.

3.     assess the commonly consumed fruits and vegetables by these adults using the food frequency questionnaire

4.      assess prevalence of fruit and vegetable consumption (> 5 serving per day) among the adults daily

5.     assess the nutritional status of adults using anthropometric indices

6.     determine the behavioural and lifestyle habits of the adults

7.     to assess the prevalence of established selected risk factors for NCDs (obesity and overweight, blood glucose and blood pressure)

8.     determine the relationship between, NCDs risk factors and adequate fruit and vegetable consumption.

1.4             SIGNIFICANCE OF THE STUDY

The findings of this study will:

·       help in developing effective policies, programmes, and initiatives to promote adequate consumption of variety of both fruits and vegetables in the population who are in urgent need, given the high attention to population who consume less than the minimum recommended five daily servings/400g of fruits and vegetables.

·       help health care professionals to disseminate Information on health benefits of sufficient fruit and vegetable consumption.

·       Behavioral changes and dietary guideline programs will help to promote fruit and vegetable consumption and it should be based on local knowledge regarding the demographic, cultural, and psychosocial factors that affect consumer choices. These should focus on translating accurate and useful information to consumers about the health benefits of sufficient fruit and vegetable consumption.

·        Government policies are urgently required to support availability, affordability, and accessibility of these fruits and vegetables.

·       The findings of this study will also provide insight for nutrition/ health educators when developing family based interventions for weight management.

 

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    It agree, a useful piece

  • Anonymous

    3 months ago

    Good work and satisfactory

  • Anonymous

    3 months ago

    Good job

  • Anonymous

    3 months ago

    Fast response and reliable

  • Anonymous

    3 months ago

    Projects would've alot easier if everyone have an idea of excellence work going on here.

  • Anonymous

    3 months ago

    Very good 👍👍

  • Anonymous

    3 months ago

    Honestly, the material is top notch and precise. I love the work and I'll recommend project shelve anyday anytime

  • Anonymous

    3 months ago

    Well and quickly delivered

  • Anonymous

    3 months ago

    I am thoroughly impressed with Projectshelve.com! The project material was of outstanding quality, well-researched, and highly detailed. What amazed me most was their instant delivery to both my email and WhatsApp, ensuring I got what I needed immediately. Highly reliable and professional—I'll definitely recommend them to anyone seeking quality project materials!

  • Anonymous

    3 months ago

    Its amazing transacting with Projectshelve. They are sincere, got material delivered within few minutes in my email and whatsApp.

  • TJ

    5 months ago

    ProjectShelve is highly reliable. Got the project delivered instantly after payment. Quality of the work.also excellent. Thank you