Fruits and vegetables are vital for healthy diets, but intake remains low for a majority of the global population. This chapter reviews academic literature on food system issues, as well as opportunities for research and action, as an input into the 2021 UN Food Systems Summit in the context of the International Year of Fruits and Vegetables.

The chapter summarises evidence underpinning food system actions to make fruits and vegetables more available, accessible and desirable through push (production and supply), pull (demand and activism) and policy (legislation and governance) mechanisms, with action options at the macro (global and national), meso (institutional, city and community) and micro (household and individual) levels. It also suggests the need to recognise and address power disparities across food systems, and trade-offs among diet, livelihood and environmental food system outcomes.

We conclude that there is still a need to better understand the different ways that food systems can make fruits and vegetables available, affordable, accessible and desirable across places and over time, but also that we know enough to accelerate action in support of fruit- and vegetable-rich food systems that can drive healthy diets for all.

1. Why Fruits and Vegetables? Why Now?

Fruits and vegetables are vital for healthy diets, and there is broad consensus that a diverse diet containing a range of plant foods (and their associated nutrients, phytonutrients and fibre) is needed for health and wellbeing (FAO 2020). Studies have suggested intake ranges of 300–600 g per day (200–600 g of vegetables and 100–300 g of fruits) to meet different combinations of health and environmental goals (Willett et al. 2019; Loken et al. 2020; Afshin et al. 2019). The World Health Organisation (WHO) recommends that adults eat at least 400 g of fruits and vegetables per day (World Health Organisation 2003), with national food-based dietary guidelines translating these into recommendations to eat multiple portions of a variety of fruits and vegetables each day for health (Herforth et al. 2019).

Despite this clear message, intake of fruits and vegetables remains low for a majority of the global population (Afshin et al. 2019; Kalmpourtzidou et al. 2020). Low fruit and vegetable consumption is among the five main risk factors for poor health, with over 2 million deaths and 65 million Disability-Adjusted Life Years (DALYs) attributable to low intake of fruits, and 1.5 million deaths and 34 million DALYs attributable to low intake of vegetables globally each year, particularly in low- and middle-income countries (Afshin et al. 2019). Low consumption is a global problem, affecting high- and low-income countries: only 7% of countries in Africa, 7% in the Americas, and 11% in Europe reach 240 g/day of vegetables on average (Kalmpourtzidou et al. 2020), and only 20% of individuals in low- and middle-income countries reach the recommendation of five servings of fruits and vegetables a day (Frank et al. 2019). The mean global intake of vegetables is estimated to be around 190 g/day, and of fruits, 81 g/day. Studies generally agree that parts of Africa and the Pacific Islands have the lowest fruit and vegetable consumption, and East Asia has the highest vegetable (but not fruit) consumption (Afshin et al. 2019; Kalmpourtzidou et al. 2020; Micha et al. 2015).

Changes in fruit and vegetable consumption are happening against a backdrop of the ‘nutrition transition’ from traditional foods to processed and ultra-processed foods that are high in energy, fat, sugar and salt, but poor in other essential nutrients (Popkin et al. 2020). This transition also brings opportunities to diversify into healthy diets containing more fresh fruits and vegetables, although, for some populations, there is less opportunity than for others (Global Panel on Agriculture and Food Systems for Nutrition 2016). The available literature does not suggest systematic differences in fruit and vegetable consumption between men and women in many contexts (Frank et al. 2019; Micha et al. 2015), but it does highlight differences in consumption between rural and urban areas (Hall et al. 2009; Ruel et al. 2004; Mayen et al. 2014), and among populations with different levels of education and national income (Frank et al. 2019). These differences illustrate that there is an equity issue across populations in accessing fruits and vegetables (Harris et al. 2021a).

We now have good conceptual models for how food systems work to provide diets (HLPE 2017). These help us to describe the structural and social constraints to fruit and vegetable consumption and research how these play out in different contexts and for different populations. Below, we summarise what we know (and what we need to know) about how to address the issues above through a set of push (production and supply), pull (demand and activism) and policy (legislation and governance) actions. We conclude that there is still a need to better understand the different ways that food systems can make fruits and vegetables available, accessible, affordable and desirable for all people, across places and over time, so as to meet global recommendations, but also that we know enough to accelerate action in support of healthy diets. The year 2021 is the UN International Year of Fruits and Vegetables, embedded in the middle of the Decade of Action on Nutrition. Now is the time to prioritise understanding and addressing these issues to enable fruit- and vegetable-rich food systems that can drive healthy diets for all.

2. Policy Factors: Political Power

The Green Revolution in the latter part of the twentieth century transformed agriculture’s ability to produce sufficient calories to feed the world, but the focus on grain crops through funding, research, extension and technology development limited the supply of nutrient-dense fruits and vegetables, both through losses of wild sources with the promotion of monocultures and through policy and structural impediments that crowded out non-staple crops (Pingali 2012). Today, the combined international public research budget for maize, wheat, rice, and starchy tubers is 30 times greater than for vegetables, for instance (Herforth 2020), and these incentives skew many of the technology and infrastructure drivers of food systems. This has fed into national food policies, which are normally focused on the production or import of staple crops (as a source of cheap calories), rather than diet quality through diversity of fresh foods (as a source of other essential nutrients) (McDermott and De Brauw 2020). Following suit, food system data have focused largely on globally-tradable commodities, leading to a dearth of trustworthy and disaggregated data with which to track the production, price, trade or consumption of the diversity of fruits and vegetables (Masters et al. 2018), and global data are biased towards economically-relevant crops, often missing traditional fruits and vegetables and those produced non-commercially (Thar et al. 2020). Research on food systems and diets often treats fruits and vegetables as a single food group, rather than looking at diversity within fruit and vegetable species, or the amounts or variety consumed within the food group (Harris et al. 2021b), further limiting our knowledge on the specifics of issues or actions.

At the same time, large structural changes outside of the food system, such as the globalisation of supply chains and societies, and changing demographics and urbanisation have shaped food regimes to prioritise foods that are non-perishable and globally tradable (Magnan 2012; Lang and Heasman 2015), the very opposite of most fruits and vegetables, whose perishability requires shorter food chains from farm to fork. Modern trade rules improve regulation on the safety of imported fruits and vegetables and may protect domestic production or improve supply of highly-traded commodities, but they also limit the ability of governments to protect the public health policy space and the institutional purchase of fresh foods (Thow et al. 2015) and tend to prioritise staple foods over fruits and vegetables, while out-sourcing the environmental impacts of production to poor countries (FAO 2020). In many contexts, the concentration of inputs, distribution and retail of foods – including fruits and vegetables – in the hands of a few large companies, has shifted food system choices away from the livelihood interests of producers, the health interests of consumers, and the environmental interests of all (Howard 2016).

These broad and sweeping changes have not been without interruption: the COVID-19 pandemic and previous economic shocks and natural disasters have disrupted many aspects of food systems and diets over time (Savary et al. 2020; Block et al. 2004; Darnton-Hill and Cogill 2010). Such disruptions particularly affect fruits and vegetables because of their specific labour, storage and transport requirements (Harris 2020), with at least temporary impacts of different shocks having been documented on the livelihoods of fruit and vegetable producers and on fruit and vegetable prices and consumption (Block et al. 2004; Darnton-Hill and Cogill 2010; Harris et al. 2020; Hirvonen et al. 2020). These shocks have affected the diets and livelihoods of marginalised populations in ways different from those with economic or social power, further exacerbating inequity (Carducci et al. 2021; Kansiime et al. 2021; Goldin and Muggah 2020).

3. Push Factors: Production and Post-Harvest Power

By the data we have, global fruit and vegetable production is insufficient to meet the WHO dietary recommendations, and has been since global records began: in 1965, sufficient fruits and vegetables (≥400 g/day) were available for 17% of the global population, increasing to 55% in 2015 (Mason-D’Croz et al. 2019). Supply varies widely between contexts: in Africa, only 13% of countries have an adequate aggregate vegetable supply, while in Asia, 61% do (Kalmpourtzidou et al. 2020). This is despite the fact that fruits and vegetables are valuable: the annual farmgate value of global fruit and vegetable production is nearly $1 trillion and exceeds the farmgate value of all food grains combined (US$ 837 billion) (Schreinemachers et al. 2018). Most fruits and vegetables (about 92%) are not internationally traded, but the international trade in fruits and vegetables was still valued at US$ 138 billion in 2018.

Fruit and vegetable production needs to increase, particularly in regions with low consumption, together with accompanying measures to prevent losses, to provide enough for healthy diets (Mason-D’Croz et al. 2019). Scaling production is not straightforward, as fruits and vegetables have specific attributes – in terms of seasonal and agro-climatic differences, labour and input needs, knowledge and expertise, and storage and distribution – that mean there are particular trade-offs to consider. While we can, in theory, produce healthy diets within planetary boundaries (Willett et al. 2019), achieving national food-based dietary guidelines has been found to be incompatible with climate and environmental targets in a majority of the 85 countries studied (Springmann et al. 2020), and producing more fruits and vegetables may require more land, water and chemical inputs than producing staple foods in some contexts (Aleksandrowicz et al. 2016), with one-third of all greenhouse gas emissions being produced by the food system (Crippa et al. 2021). Various studies show widespread misuse of agricultural chemicals, particularly on high-value vegetables, creating hazards for farm workers, consumers and the environment (Schreinemachers et al. 2020a). Foodborne diseases caused by biological contamination of food are also an important threat to public health, particularly in low- and middle-income countries, and fruits and vegetables are among the riskiest foods for biological hazards (Grace 2015).

Seed or planting stock is a key input in fruit and vegetable production, although it is a contested area: some see the introduction of (often proprietary) improved varieties of fruits and vegetables as necessary to transform the fruit and vegetable sector to one with increased volumes of regularly available quality products (Schreinemachers et al. 2018; Dawson et al. 2019; Schreinemachers et al. 2021; Lillesø et al. 2018). Others stress the importance of local or cultural seed-saving and exchange of planting material for conserving farmers’ independence, agricultural diversity and food sovereignty (Howard 2016; Phillips 2016), and debates about the primacy of breeders’ rights or farmers’ rights are ongoing (Gupta and Negi 2019; Salazar et al. 2007; Dias 2011). Beyond inputs, labour requirements in fruit and vegetable production are considerably higher than in cereal production, with labour costs making up more than 50% of production costs, depending on the food grown, related to more skilled and intensive field operations (Weinberger and Lumpkin 2007; Herrero et al. 2017). This is a positive for food system worker incomes, but extension services are often geared towards staple crops, with little support for fruit and vegetable producers, limiting formal training opportunities (Pingali 2015). Beyond the farm, post-farmgate midstream employment in developing regions constitutes roughly 20% of rural employment (Dolislager et al. 2020; Reardon et al. 2014). It is assumed that many smallholders also engage in midstream fruit and vegetable chain operations, such as trade and processing, but fruit and vegetable value chains have not been a focus of this work, so more knowledge is needed in this area.

Of food produced for human consumption, around one-third by volume or one-quarter by calories is either lost (before retail) or wasted (after purchase) (HLPE 2014). Highly perishable fruits and vegetables have the highest rates of loss and waste, usually within the range of 40–50% (Global Panel 2018; FAO 2019). Local production is therefore central, and in many contexts, ultra-local home-based fruit and vegetable production and wild plant gathering are important strategies (Schreinemachers et al. 2015; Bharucha and Pretty 2010), as are ‘under-utilised’ species and many traditional fruits and vegetables that are often left out of data, policy and extension (Raihana et al. 2015; Hunter et al. 2019). Fruits and vegetables are particularly seasonal, which can be an advantage in diverse systems where different foods become available at different times, or a challenge where there are gluts and shortages that lead to price changes over the course of the year (Gilbert et al. 2017; McMullin et al. 2019).

4. Pull Factors: People Power

While availability of, and physical access to, sufficient fruits and vegetables is an important prerequisite, there are other factors at the socio-economic and personal levels that also impact their role in diets. Reviews of research suggest that, in low-income countries, similar determinants play a role in food choices as in high-income countries, at the individual level (income, employment, education level, food knowledge, lifestyle, time), in the social environment (family and peer influence, cultural factors), and in the physical environment (food expenditure, lifestyle) (Gissing et al. 2017).

Food prices interact with incomes to determine whether households can afford the components of a healthy diet, and fruits and vegetables, along with animal-source foods, are the most expensive element of a healthy diet, comprising, by many metrics (Maillot et al. 2007; Headey and Alderman 2019), around 40% of the cost of a healthy diet (Herforth et al. 2020), although these costs tend to vary with the season (Gilbert et al. 2017). Fruits and vegetables are unaffordable for many, with 3 billion people unable to afford diverse, healthy diets (Herforth et al. 2020). Fruits and vegetables appear more affordable when comparing prices per micronutrient, according to which they are likely to be a relatively low-cost source of varied vitamins, minerals, and phytonutrients (Drewnowski 2013), but this is not how most families choose their food.

Beyond a certain income level, affordability is not a driving factor for everyone everywhere: while an increase of fruit and vegetable consumption by income across geographical regions is confirmed in many studies, indicating that a low income is a barrier to fruit and vegetable consumption for some (Frank et al. 2019; Miller et al. 2016), there is only a weak association between incomes and fruit and vegetable consumption, showing that, on average (across 52 countries), 82% of the poorest quintile consume an insufficient amount of fruits and vegetables and 73% of the wealthiest quintile do the same (Hall et al. 2009). As incomes rise, the consumption of meat, dairy and ultra-processed foods rises much faster than that of vegetables; additionally, the purchase of vegetables in some contexts changes little across income groups, and hence vegetable consumption is relatively inelastic to income past a certain level (Ruel et al. 2004), although a greater amount of fruit may be consumed at higher incomes. With little change in the consumption of vegetables across income groups in some contexts (Morris and Haddad 2020), affordability is not the largest driver of consumption for all.

Even if vegetables are available, accessible and affordable, most people still do not consume large enough quantities (Hall et al. 2009), particularly if they are not considered an acceptable or desirable food choice, for instance, due to food safety or contamination concerns, taste preferences, or cultural appropriateness (Aggarwal et al. 2016; Ha et al. 2020; Hammelman and Hayes-Conroy 2014). Low desirability of fruits and vegetables is a particular problem among children and adolescents, with data across 73 countries showing that between 10% and 30% of students do not eat any vegetables at all in one-quarter of these countries (FAO, IFAD, UNICEF, WFP, WHO 2019).

5. Fruit and Vegetable Food Systems: What Next?

The brief review above has laid out evidence on the key food system issues for fruits and vegetables in healthy diets, and, where available, included evidence on actions to address these. From this summary, it is clear that we know, on a broad scale, the structural limitations to fruits and vegetables: global and national challenges of increasing production and accessing quality growing material shared equitably, local issues of ensuring affordability, addressing perishability and enabling everyone everywhere to access fruits and vegetables, and social issues of valuing vegetables for their role in cuisines and for health. It is also clear that the precise issues and solutions to these vary by population and according to the food system context, and that there are multiple potential routes towards solutions that sometimes clash on ideals. Food system actions to make fruits and vegetables more available, affordable, accessible and desirable through policy, push and pull mechanisms comprise various options working at the macro (global and national), meso (institutional, city and community) and micro (household and individual) levels. Examples of actions from the review above are laid out in the table below.

It is unlikely that these are all of the options available for orienting food systems towards fruit- and vegetable-rich diets, but these are the options that appear in the academic literature, albeit with varying levels of evidence. In addition, there are two important over-arching considerations when considering action options: (1) Acknowledging that power shapes food systems, from the concentration of economic and political power in a few global agri-food businesses to the marginalisation of certain groups in societies from accessing healthy diets, so this needs to be considered in terms of both facilitating inclusive processes for deciding policies and actions and assessing their equity impacts (Howard 2016; Harris and Nisbett 2018); and (2) there will be trade-offs among food system outcomes, so starting with a focus on healthy diets is important, but understanding how food system decisions then impact fair livelihoods and sustainable environments is key (Wiebe and Prager 2021). We do not yet know enough to formulate clear actions that will address these trade-offs, but they need to be acknowledged and openly debated by those making food system decisions.

These actions are likely to be foundational to creating change within food systems towards enabling fruit- and vegetable-rich diets. None of these actions will change diets when implemented alone, but rather packages of actions need to be assembled to address particular limitations for fruit and vegetable consumption. These need to be considered in context, in light of an understanding of food system issues and bottlenecks limiting healthy diets in different places and for different people. It is likely that the best way to start is to bring together diverse groups of people interested in these issues at the different levels, to understand the issues and options from different perspectives and to prioritise together which actions should be undertaken first in their own context. This is not easy, given inherent power disparities among interested parties, but with care and inclusion, a strategy, policy or plan can be crafted to move towards enabling fruit and vegetable-rich food systems.

To guide better action, we need more evidence and understanding. We know a lot about a small fraction of the fruit and vegetable species of which we are aware, and very little about the rest. We know that there are disparities in diets in different contexts, but not how to address the political, social and equity determinants of who gets to eat fruits and vegetables. We know much about the technical production and market aspects of fruits and vegetables, but less about bottlenecks in bringing these to low- and middle-income countries, and we do not know enough about how these things change with context or over time. Work drawing on different academic traditions, including valuing traditional and tacit knowledge, is needed to connect the dots. Food systems that enable fruits and vegetables in healthy diets are not only a technical issue, but bring up very real political, social and ethical questions that societies will have to address, alongside a reliance on evidence. Having these conversations through the lens of equity to address the needs of both winners and losers within changing food systems will be a vital part of the UNFSS process towards enabling fruit and vegetable-rich food systems for healthy diets for all.

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