Fruits and Vegetables Versus Vegetables and Fruits: Rhyme and Reason for Word Order in Health Messages (2024)

Abstract

Both vegetable and fruit consumption contribute to wellness and diseaseprevention. Most dietary health messages promote both together and position theword “fruits” before “vegetables.” We examined the word order of the commonlyused phrase “fruits and vegetables” through linguistics, psychology, botany,nutrition, health outcomes, and current US intake to determine if the commonword order best presents these two foods in health messaging. By comparing the10 most commonly consumed vegetables versus fruits, we found that vegetablesscored higher on the Aggregate Nutrient Density Index and contained fewercalories and more fiber than fruits. Among the “nutrients of public concern”listed in the 2015 Dietary Guidelines for Americans, we determined thatvegetables are better sources of these nutrients than fruits, although fruitsscored higher in antioxidant content. In observational cohort studies, vegetableand fruit consumption was found to be associated with decreased mortality.Finally, daily intakes of both vegetables and fruits are lower than recommended,but the discrepancy is larger for vegetables—especially amongchildren—suggesting a greater imperative to promote vegetables. For thesereasons, future health messages promoting both together should intentionally put“vegetables” first to promote intake and emphasize their importance regardingcontribution to health.

Keywords: word order, health messages, fruit and vegetable, vegetable and fruit, nutrition

‘Is there a return to vegetable rapture in health messaging, or is it just randomword choice to put vegetables first in these situations?’

Introduction

Intake of vegetables and fruits is promoted by several US government and nationalhealth agencies to support optimal health.1,2 Versions of US food guidespublished between 1940 and 1970 referred to the “vegetable and fruit group” as partof the daily diet recommendations. The US Department of Agriculture (USDA) createdseparate vegetable and fruit groups in 1984 for the Food Wheel: A Patternfor Daily Food Choices prepared for the Red Cross.3 The original USDA Food Pyramid,4 MyPyramid.gov,5 and the most recent, MyPlate.gov,6 all have separate vegetable and fruit groups.3 However, many other public health messages still combine the two and list“fruits” first. Examples include the Centers for Disease Control and Prevention(CDC) Five-a-Day7 program and its successor, Fruit and Veggies: More Matters.8 Similarly, in a search of scientific literature indexed in MEDLINE usingPubMed.gov we found six to eight times more English language articles published overthe past 10 years with “fruits and vegetables” in their titles versus “vegetablesand fruits.”

However, a trend of listing “vegetables” first appears to have emerged recently insome public health messaging. The Nutrition Source, Harvard T. H.Chan School of Public Health’s nutrition information website, refers to “vegetablesand fruits” as part of a healthy diet.9 The 2015 Dietary Guidelines for Americans emphasize that Americans shouldincrease their intake of “vegetables and fruits.”2 One of Healthy Canada’s public health messages is to eat more “vegetables and fruits.”10 Is there a return to vegetable rapture in health messaging, or is it justrandom word choice to put vegetables first in these situations? The aim of thisproject was to explore rationales for word order, including linguistics, psychology,botany, nutrition, health outcomes, and the alignment of current US intake with USrecommendations for intake, to determine whether there were compelling reasons tothink that vegetables squash fruits and should be put first in the word order ofhealth messages.

The Linguistics of Food

In many languages, the order of words can change the meaning of the sentence, or justshow the importance of one over the other. “Fruits and vegetables” is a commonbinomial in the English language, where the word order is predictable. A binomial isa sequence of two words from the same word class that are linked by a conjunctionand are usually said in the same order.11 The word order of binomial expressions typically follows set linguisticstandards, although these rules are debated by linguists.12,13 The order of some commonbinomials in the English language can be predicted from rhythm (eg, “peas andcarrots”), length of the words (eg, “oil and vinegar”), or both the combination oflength and position of the stressed syllable (eg, “salt and pepper”). Word orderthat utilizes alternating rhythm between the stress syllables of binaries is morecommon than word order with an irregular pattern of syllable stressing.14 In this example, “fruits and vegetables” has a shorter space between thestressed syllables of the words than “vegetables and fruits.” Mollin12 and Malkiel15 both suggest that the reason for the order of binomials in language can besimply that the first word has fewer syllables than the second as in “rich andfamous,” and “time and money.” From a linguistics perspective, binomial word orderis partially dependent on metrics, rhythm, and count of syllables; therefore, theword order “fruits and vegetables” simply sounds better when “fruits” is saidfirst.

Psychology of Word Order

Psychologists have found the predictability of word order in multiword phrasesinfluences their persistence in memory and that by processing an unfamiliar phrase,the reader must think about it for more time.16 Similarly, unfamiliar bionomial phrases and garden path statements (eg, “Timeflies like an arrow; fruit flies like a banana”) often need to be read more thanonce in order to understand their meaning.17 This additional processing time, measured as an event-related potential inthe brain known as P600, is elicited when the brain requires more thought resourcesto understand the inconsistency in the actual versus the expected word order in a phrase.18 The cognitive load of processing an unfamiliar phrase can also be explainedby Levy’s Surprisal Theory,19 where a flipped binomial like “vegetables and fruits” may provide enough of asurprise to the reader to require more processing time and, therefore, may becomemore entrenched in memory. Could this change in the familiar order of words in acommonly heard public health message be the proverbial carrot that entices Americanconsumers to think twice about their food intake preferences?

Botany of Vegetables Versus Fruits

An issue of relevance to add to this discussion is the confusion regarding thedistinction between what constitutes a vegetable versus a fruit in the United States.20 The confusion typically arises from differences between culinary versusbotanical classifications. Foods that fall into the culinary classification ofvegetable include both botanical vegetables as well as somebotanical fruits (eg, bell peppers, tomatoes, and eggplant). To clarify thisdistinction, it is informative to look through the lens of plant anatomy.

Botanically, a fruit is the reproductive outcome of floral pollination and is theripened ovary of flowering plants. The term fruit defines thosefoods humans use as food and recognize as fruits, such as an apple, butscientifically is the result of a plant’s resources to ensure the proliferation oftheir particular plant species. Plants create the fruits we eat as a means todisseminate seeds using animals. Frugivore animals will smell the ripe fruit, ingestit, and then travel around and deposit the seeds elsewhere after the flesh of thefruit is digested.

The word vegetable originates from the growth of the vegetativeparts of the plant that are of the plant’s body and are not the result of floralpollination. For example, the potato is actually a stem tuber that grows undergroundand is a source of nutrition for the plant; it is, thus, considered a storage organ.A carrot is the taproot of the entire plant, and onions are bulbs or short stemswith fleshy leaves—both of which are also storage organs. Lettuce is the entireplant, and celery includes the stalks of the entire plant body. Broccoli, Brusselssprouts, and kale are all the same species but different cultivars or breeds ofBrassica oleracea that were selected for their specificvegetable offerings: Brussels sprouts are small, densely leaved buds; broccoli hasthick stems with abundant stalks holding many little flowers; kale has large edibleleaves; and all have the beneficial phytochemicals found in cruciferous vegetables.21 All vegetables are from parts of the plant body itself and not the result ofplant reproduction efforts that result in a seed-dispersal organ or a fruit.

A classic example illustrating the public confusion of vegetables and fruits is thetomato. Tomatoes—the second most consumed vegetable in the United States22—are botanically fruit, yet most people consider them a vegetable. In 1883,the tomato was the center of a court decision involving taxes—vegetables were taxed,whereas fruits were not. The plaintiff from the West Indies was selling tomatoes asfruit to avoid this tax. It was legally decided that tomatoes are, in fact,vegetables in the light of tariffs and common speech23: law 1, botany 0?! Therefore, tomatoes are legally categorized as vegetables,whereas other botanical fruits (eg, peppers, cucumbers, eggplant, and olives) areclassified as vegetables because of their culinary uses and savory flavors.

The botanical guidelines for characterizing produce as vegetable, fruit, or other(eg, grains, tubers, or stems) can be confusing to nonbotanists. However, forbotanists, it is clear which are true vegetables and fruits. Given that the averageconsumer of vegetables and fruits is not a botanist, we will use culinaryclassifications rather than botanical guidelines to distinguish between the two.

Contrasting Commonly Consumed Vegetables and Fruits

Consideration of the nutrients that people receive when consuming their favoritevegetables and fruits is one way to rationalize which of these botanicalwonders—vegetables or fruits—should come first in public health messages. Table 1 lists the top 10vegetables and fruits consumed by weight in the United States each year as reportedby the USDA.24

Table 1.

The 10 Most Commonly Consumed Vegetables and Fruits in the United States.

Vegetables/FruitsPounds/Capita/Year (Loss Adjusted)
Vegetables
 Potatoes26.8
 Tomatoes12.7
 Onions7.9
 Iceberg lettuce7.3
 Green bell pepper4.3
 Carrots4.0
 Cabbage3.1
 Cucumbers2.7
 Celery2.6
 Broccoli2.5
Fruits
 Banana10.3
 Apples9.9
 Watermelon4.3
 Grapes4.2
 Strawberries3.8
 Oranges3.4
 Avocado1.9
 Peaches1.7
 Pears1.6
 Mangoes1.1

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For the purpose of comparison, we considered serving size and energy content (ie,Calories, or kilocalories [kcals]). Serving sizes vary depending on which USgovernmental agency you ask. We used Nutrition Labeling and Education Act (NLEA)servings as set by the US Food and Drug Administration25 because these represent commonly eaten food portions. Some foods included inthe analysis did not have NLEA serving sizes established, so the authors estimatedserving size based on USDA serving sizes.26 There are different serving sizes for each type of food. Given that servingsizes vary, we also analyzed the nutrient content of 100 kcal portions of eachvegetable and fruit to make sure that we were comparing broccoli to broccoli andapples to apples. Table2 presents the specific serving sizes used in the analyses. Additionally,we compared the nutrients per serving, 100 kcal, and 100 g for the top 15 and top 25consumed vegetables and fruits (by weight) as well as all vegetables and fruits forwhich at least 1 pound per capita per year was eaten in the United States. We founda similar pattern when examining per serving, 100 kcal, or 100 g whether we lookedat the top 10, 15, or 25 most commonly consumed vegetables and fruits. Therefore,for ease of presentation we chose to display the analysis for only the top 10 inTable 2.

Table 2.

Nutrient Levels in the 10 Most Commonly Consumed Vegetables and Fruits Per100 Calories.

Serving Size (g)Serving Size (Approximate)Total Sugar (g)Total Fiber (g)Vitamin A (IU)Vitamin C (mg)Folate (µg)Iron (mg)Magnesium (mg)Calcium (mg)Potassium (mg)ANDI Index
Vegetable
 Potatoes116.001 Small baked0.992.383.008.5810.000.3623.009.00380.0043.00
 Tomatoes554.503 Large14.586.654619.0075.9783.001.5061.0055.001314.00186.00
 Onions251.002 Medium10.643.675.0018.5748.000.5325.0058.00366.00109.00
 Iceberg lettuce711.501½ Heads14.028.543572.0019.92206.002.9250.00128.001003.00110.00
 Green bell pepper500.003 Large12.008.501850.00402.0050.001.7050.0050.00875.00371.00
 Carrots243.004 Medium11.526.8040 ;596.0014.3446.000.7329.0080.00778.00458.00
 Cabbage399.00Half medium head12.778.94391.00146.03172.001.8848.00160.00678.00434.00
 Cucumbers664.002 Large11.097.57697.0018.5946.001.8686.00106.00976.0087.00
 Celery624.5010 Large stalks11.439.992804.0019.36225.001.2569.00250.001624.00135.00
 Broccoli293.002 Stalks4.987.621825.00261.36185.002.1462.00138.00926.00340.00
Mean435.6510.407.105636.2098.50107.101.4950.30103.40892.00227.30
SEM64.701.300.803915.4042.4025.400.306.4021.90121.7049.50
Fruit
 Banana112.501 Medium13.762.9372.009.7923.000.2930.006.00403.0030.00
 Apple192.001 Medium19.954.61104.008.836.000.2310.0012.00205.0053.00
 Watermelon333.302¼ Cups diced20.671.331896.0027.0010.000.8033.0023.00373.0071.00
 Grapes145.001½ Cups22.451.3196.004.643.000.5210.0015.00277.00119.00
 Strawberries313.001 Pint15.316.2638.00184.0475.001.2841.0050.00479.00182.00
 Orange212.001½ Oranges19.824.98477.00112.7864.000.2121.0085.00384.0098.00
 Avocado60.00Half avocado0.184.0888.005.2853.000.3717.008.00304.0028.00
 Peach256.002 Small21.483.84835.0016.9010.000.6423.0015.00486.0065.00
 Pear175.001 Medium17.065.5344.007.5312.000.3212.0016.00203.0046.00
 Mango166.701 Cup pieces22.772.671804.0060.6872.000.2717.0018.00280.0053.00
Mean196.6017.303.75545.4043.8032.800.4921.4024.80339.4074.50
SEM27.002.100.53231.8019.009.400.103.307.7032.2014.90
t Valuea−3.412.76−3.60−1.30−1.18−2.74−3.65−4.00−3.38−4.39−2.95
P valueb0.010.01<0.010.230.260.02<0.01<0.010.01<0.010.01

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Abbreviations: ANDI, Aggregate Nutrient Density Index; SEM, standarderror of the mean.

a

Positive t values indicate higher mean difference valuefor fruit compared with vegetables; negative t valuesindicate higher mean difference for vegetables compared with fruit.

b

P values from t-test; they are boldedif <.05.

Another option considered for analysis was to exclude white potatoes from vegetables(because they are classified as a starch in USDA’s MyPlate and often eaten as afried food), iceberg lettuce from vegetables (because they are widely recognized forlack of significant nutritional content), and avocados from fruits (because they arenot considered a fruit by culinary classification). However, we did not want to beaccused of cherry-picking, so all three remained in our final analyses.

Nutrient Density of Vegetables and Fruits

Increasing both vegetable and fruit intake is a nearly universal dietaryrecommendation. Prioritizing one over the other to optimize health could bebased on nutrient density or other nutrient quality scores. These scores can bea useful way to distinguish which foods pack the most nutritional punch.

Two scores that have been used to rank foods are the Aggregate Nutrient DensityIndex (ANDI) and NuVal scores. The ANDI score divides the total nutrients in thefood by the number of calories per serving; it includes 35 vitamins and mineralsas well as other nutrients such as fiber, antioxidants, phytosterols,angiogenesis inhibitors, and resistant starches in its algorithm.27 The ANDI score ranges from 1 to 1000, with 1000 being the mostnutritious. The NuVal Score is based on an algorithm of the OverallNutritional Quality Index to measure 30 different nutrients(including vitamins, minerals, bioflavonoids, and carotenoids), protein quality,fat quality, glycemic load, and energy density. The NuVal score rates foods from1 to 100, with 100 being the most nutritious.28 Unlike the ANDI score, the NuVal score also detracts for trans fat,cholesterol, saturated fat, sodium, and sugar.

Comparison of the ANDI scores for the top 10 consumed vegetables and fruits areshown in Table 2.Carrots rooted out the most nutrients of the vegetables at 458, whereasstrawberries topped the fruits at a juicy 182. Overall, vegetables significantlyoutperformed fruits: 227 ± 50 versus 74 ± 15 (mean ± SEM); P =0.014. The NuVal scoring system gives all whole plant foods near perfect scores.Therefore, all the vegetables and fruits included in the analyses had nearlyidentical NuVal scores (all >90) and are not shown in the table.

Selected Nutrients in Vegetables and Fruits

Daily intake of vegetables and fruits provides vital vitamins and minerals. The2015 Dietary Guidelines for Americans recommends vegetables as a source ofnutrients such as potassium, vitamin A, vitamin C, vitamin K, copper, magnesium,vitamin E, vitamin B6, folate, iron, manganese, thiamin, niacin, andcholine. It recommends fruit as a source of dietary fiber, potassium, andvitamin C.2 Some nutrients currently considered more important and challenging to getin the American diet include vitamins A and C, folate, calcium, iron, magnesium,and potassium.1 Eating both vegetables and fruits provide these specific nutrients ofconcern.

The amounts of these specific nutrients in each of the 10 most commonly consumedvegetables and fruits are presented in Table 2. Per 100 kcal, vegetablescontained significantly more folate, iron, magnesium, calcium, and potassiumthan fruit. However, when compared per serving, no statistically significantdifferences between vegetables and fruits were found for any of these nutrients.Table 2 presentsonly the 100-kcal data in the table to show these differences, wherepresent.

Fiber in Vegetables Versus Fruits

As presented in Figure 1,there are differences in the total fiber content of the vegetables and fruitsanalyzed. By 100-kcal portions, the vegetables had nearly double the fiber (7.8g) of the fruits (3.8 g); however, per serving, there was no statisticallysignificant difference in fiber between vegetables and fruits. Notably, 100 kcalof vegetables is, on average, a larger serving than 100 kcal of fruit. Thisdifference is primarily a result of the higher sugar, and therefore highercalorie, content of fruit (15.0 g) compared with vegetables (2.8 g) per standardserving.

Figure 1.

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Antioxidant Content of Vegetables Versus Fruits

Both vegetables and fruits are good sources of antioxidants but vary in thestrength of their antioxidant activity. Two common tests of total antioxidantactivity of plants are the oxygen radical absorption capacity (ORAC) assay29 and the measurement of total phenolics (a specific type of antioxidant).The ORAC score is shown in micromoles of Trolox Equivalence per 100 g (µmolTE/100 g) where Trolox is the standard for measurement of antioxidant power.Total phenolics are measured against Gallic Acid Equivalents (GAE), which usesgallic acid as the standard phenol.29,30 Published values for bothmeasurements are available for 100-g portions.30 For the top 10 addressed in these analyses, fruits have, on average, morethan double the ORAC score of vegetables30: 1875 ± 375 TE/100 g (mean ± SEM) for fruits compared with 733 ± 124TE/100 g for vegetables. However, scores for total phenolic content are not asdivergent (158 ± 26 [mean ± SEM] for fruits vs 109 ± 31 GAE/100 g forvegetables). For fruits, strawberries had the most of phenolics (332 mg GAE/100g) and the highest ORAC score of 4302 µmol TE/100 g. Broccoli was at the head ofthe vegetable list with an ORAC score of 1510 µmol TE/100 g and 316 mg GAE/100 gof phenolics.30

Associations of Vegetable and Fruit Intake With Mortality in CohortStudies

A literature review was conducted to search for studies that reported all-causemortality as well as mortality findings related to cardiovascular disease (CVD),diabetes, or cancer and their associations with vegetable and fruit consumption.Relevant publications were identified by conducting a PubMed search for thefollowing terms in the title and abstract fields “(fruit intake[Title/Abstract] ORfruit consumption[Title/Abstract]) AND (vegetable intake[Title/Abstract] ORvegetable consumption[Title/Abstract]) AND (cancer[Title/Abstract] ORdiabetes[Title/Abstract] OR cardiovascular[Title/Abstract] OR heart[Title/Abstract])AND (morbidity[Title/Abstract] OR mortality[Title/Abstract]),” and by reviewing thereference sections of the identified studies as well as relevant reviews andmeta-analyses. To be included, studies had to be prospective cohort studies with>1000 participants and present associations for total mortality and mortalityrelated to each condition separately for vegetable and fruit intake.3143 Of 30 publications initiallyidentified by the search protocol, 13 publications comprising 15 internationalcohorts met the inclusion criteria. Excluded were review studies (n = 2), cohortstudies with fewer than 1000 participants (n = 1), duplicative studies (n = 1), andstudies that either did not report results for total mortality or disease-relatedmortality or did not report these results separately for vegetable and fruit intake(n = 11).

Overall, both vegetable and fruit intakes were linked to lower all-cause, CVD,stroke, and cancer mortality; however, the studies reported significant inverseassociations of mortality with vegetable consumption more frequently than with fruitconsumption. In Table 3,a significant association between vegetable or fruit intake and mortality was notedonly when researchers reported a continuous statistically significant associationbetween mortality and portions or servings of vegetable or fruit consumption.

Table 3.

Associations of Vegetable and Fruit Intakes With Mortality in CohortStudies.

AuthorsSample SizeCohortMethodFollow-up (Years)Mortality OutcomesVegetable Consumption and ProtectiveAssociationsFruit Consumption and ProtectiveAssociationsSummary
Bellavia et al, 20133171 706The Cohort of Swedish Men and the Swedish Mammography Cohortwere combinedFFQMean 13● All-cause (n = 11 439)All-causeNone● Vegetables, yes
● Fruit, very limited
Buil-Cosiales et al, 2014327216Prevención con Dieta Mediterránea (PREDIMED), SpainFFQMean 5.9● All-cause (n = 425)
● Cancer (n = 169)
● CVD (n= 103)
NoneAll-cause● Vegetables, no
● Fruit, yes
Cox et al, 2000 333389British Health and Lifestyle Survey (HALS1, 1984-1985) (HALS2,1991-1992)FFQ6-8● CVD (n =161)
● Cancer (n = 126)
● Men, CVD and cancer
● Women, CVD
● Men, no
● Women, CVD
● Vegetables, yes
● Fruit, yes
Women only
Choi et al, 2015 3414 198Seoul Male Cohort StudyFFQMean 15.6● Cancer (n = 507)Men, cancerNone● Vegetables, yes
● Fruit, no
Hertog et al, 1996352112The Caerphilly Study, WalesFFQMean 13.8● Cancer (n = 114)NoneMen, cancer● Fruit, yes
● Vegetables, no
Hung et al, 20043671 910Nurses’ Health StudyFFQMean 13● CVD (n = 1964)
● Cancer (n = 6584)
● Other (n =781)
NoneNone● Fruit, no
● Vegetables, no
Hung et al, 20043637 725Health Professionals’ Follow-Up StudyFFQMean 13● CVD (n = 1670)
● Cancer (n = 2500)
● Other (n =787)
NoneNone● Fruit, no
● Vegetables, no
Leenders et al, 201437451 151European Prospective Investigation into Cancer and Nutritionstudy (EPIC)Country-specific dietary questionnaireMean 13● All-cause (n = 25 682)
● CVD (n = 5125)
● Cancer(n = 10 627)
● CVD
● Cancer
Nonea● Vegetables, yes
● Fruit, limited
Nagura et al, 20093859 485Japan Collaborative Cohort Study for Evaluation of CancerRiskFFQMean 12.7● All-cause (n = 7543)
● CVD (n = 2513)
● Stroke(n = 1053)
● CHD (n = 452)
● All-cause
● CVD
● CHD
● All-cause
● CVD
● Stroke
● CHD
● Vegetables, yes
● Fruits, yes
Nakamura et al, 20083929 079Takayama Study, JapanFFQMean 7.3● CVD (n = 384)● CVD
● Women, yes
● Men, no
None● Vegetables, women only
● Fruits, no
Okuda et al, 2015409112National Nutrition Survey Japan (1980)3-day weighed recordsMean 24● CVD (n = 823)
● Stroke (n = 385)
● CHD (n =165)
● CVD
● CHD
● CVD
● Stroke
● Vegetables, yes
● Fruits, yes
Oyebode et al, 20144165, 226Health Surveys for EnglandFFQ and 24-hour diet recallMedian 7.7● All-cause (n = 4399)
● CVD (n = 1554)
● Cancer(n = 1398)
● All-cause
● CVD
● Cancer
● All-cause
● CVD
● Cancer
● Vegetables, yes
● Fruits, yes
Zhang et al, 20114274 942Shanghai Women’s Health Study, ChinaFFQMean 10.2● All-cause(n = 3442)
● CVD (n = 1023)
● Cancer (n= 1485)
● All-cause● All-cause
● CVD
● Vegetables, yes
● Fruits, yes
Zhang et al, 20114261 500Shanghai Men’s Health Study, ChinaFFQMean 4.6● All-causes (n = 1951)
● CVD (n = 635)
● Cancer(n = 853)
● All-cause
● CVD
● All-cause
● CVD
● Vegetables, yes
● Fruits, yes
Sharma et al, 201443164 617Multiethnic Cohort Study, United StatesFFQ and three 24-hour diet recalls5-8● CHD (n = 1951)● CHD (among men), inconsistent among womenNone● Vegetables, yes
● Fruits, no

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Abbreviations: FFQ, Food Frequency Questionnaire; CVD, cardiovasculardisease; CHD, coronary heart disease.

a

Fruits were associated with unknown causes of mortality.

In all, 10 studies found a statistically significant inverse association withmortality for vegetable intake.31,33,34,37-43 One of the studies observed asignificant, but nonlinear, trend.34 Specifically, vegetable intake was associated with lower all-cause, cancer,stroke, ischemic heart disease, and CVD mortality. Among these studies, four did notfind an association between fruit intake and mortality.31,34,39,43 In contrast, eight studiesfound a statistically significant inverse association of mortality with fruitintake.32,33,35,37,38,40-42 Specifically,fruit intake was associated with lower all-cause, cancer, stroke, ischemic heartdisease, and CVD mortality. Among these studies, 2 did not find an associationbetween vegetable intake and mortality.32,35 One study did not find astatistically significant association between mortality and either vegetable orfruit intake.36

Among the five studies reporting on vegetable subgroups, two studies found a benefitfor “salad vegetables” (eg, leafy salads, cucumbers, and tomatoes).33,41 One study eachfound a benefit for “green leafy vegetables,”36 cooked and raw vegetables,37 and “cruciferous vegetables” (eg, bok choy, cabbage, cauliflower, and turnip42). Of the three studies reporting on fruit subgroups, none reportedassociations with specific fruits or types of fruits.35,36,41 Results presented here werelimited by the individual food categories investigated by researchers in thesearticles.

Overall, the studies identified in this literature review reported more significantinverse associations between total and disease-related mortality for vegetableversus fruit consumption. However, most studies found intake of both vegetables andfruits to be beneficial, suggesting that both are associated with a mortalitybenefit.

Gap Between Current Recommendations and Current Intake of Vegetables andFruits

A final factor to consider in choosing whether to prioritize vegetables over fruitsin public health messages is the size of the gap between current consumption andcurrent recommendations. According to the National Cancer Institute, from 2007 to2010, 87% of the US population did not meet daily recommendations for vegetableintake, whereas 76% did not meet daily recommendations for fruit intake.44 In a more recent comparison of vegetable and fruit intake by state conductedby the CDC, 13% of Americans were meeting daily recommendations for fruit intake,whereas only 9% were eating the recommended amount of vegetables.45 The extents of both deficits are disturbing, but there is a larger gapbetween current intake and recommendation for vegetable consumption.

Conclusion

Currently, there appears to be a shift in public health messages around vegetable andfruit consumption. Whereas the normative ordering of this pair of food groups fordecades has been “fruits and vegetables,” there are now many examples of healthmessages referring to “vegetables and fruits.” We have asked the question as to whatrhyme or reason might justify one order versus the other, and many possibleperspectives were considered.

Linguistically there are general principles of ordering binomials that suggestreasons of sound and syllable to support starting with fruits. But, as healthprofessionals and scientists, we feel that other factors are relevant and should beapplied. We dove into the botanical weeds to acknowledge the bounty of anatomicalconfusion between the two. This would surely incline one to use them together in anyhealth message for the practical purpose of grounding reason in science. Using thecognitive psychology of word order, a phrase that is less familiar increases thecognitive load needed to process the anomalous word order, and it tends to becomemore deeply embedded into the memory; this could argue for switching to vegetablesfirst to promote more people to think about both vegetables and fruits and keep themin mind. Nutritionally, when considering energy density and nutrient density,whereas both food groups beat all packaged processed junk foods to a pulp, there wasa trend for vegetables to edge out fruits. Summarizing available observationalcohort studies that reported on associations between vegetable or fruit intakes andmortality, the strength of the evidence was slightly more consistent in supportingvegetable intake. Finally, citing current data on American consumption patternsrelative to national recommendations, we found a larger gap in vegetable versusfruit intake, which adds greater urgency to emphasizing vegetables first.

Overall, we do find that there are several rationales for referring to this duo as“vegetables and fruits,” rather than “fruits and vegetables.” However, we would notbe so bold as to suggest that reversing the trajectory of diet-related chronicdiseases depends on getting this order correct. In fact, we strongly believe thatmeaningful health impacts from dietary changes will require large increases in bothvegetable and fruit intake—larger than have been accomplished in recent decades. Itis hoped that messaging strategies, such as the USDA transition from the FoodPyramid to MyPlate, will affect behavior change by simply framing half the plate asideally coming from these two important food groups. Given the disparities betweencurrent intakes and recommendations, public health professionals will need to domore to close the gaps for both food groups. But when it comes to vegetables andfruits, we conclude that there is good reason to use “vegetables and fruits” as theword order of choice in public health messaging.

Acknowledgments

The authors would like to acknowledge Katherine Preston for her expertise in botany,Dan Jurafsky and Cati Brown-Johnson for their expertise in linguistics, SarahFarzinkhou for her expertise in NDS-R, and Peter Bayley for his guidance. The NIHIRACDA Postdoctoral Fellowship (1 K12 GM088033) supported Dr Offringa at StanfordUniversity. Dr Stanton was supported by the War-Related Injury and Illness StudyCenter and VA Palo Alto Health Care System. Dr Hauser is supported by training grant5T32HL007034-39 from the National Institutes of Health.

Footnotes

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to theresearch, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/orpublication of this article.

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References

  • 1.Guenther PM, Casavale KO, Reedy J, et al. Update of the Healthy Eating Index:HEI-2010. J Acad Nutr Diet.2013;113:569-580. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 2.US Department of Agriculture, US Department of Health and HumanServices. Dietary Guidelines for Americans.7th edWashington,DC:Government PrintingOffice; 2015. [Google Scholar]
  • 3.Welsh S, Davis C, Shaw A.A brief history of food guides in the UnitedStates. Nutr Today.1992;27:6-11. [Google Scholar]
  • 4.Welsh S, Davis C, Shaw A.Development of the food guide pyramid.Nutr Today.1992;27:12-23. [Google Scholar]
  • 5.Haven J, Burns A, Britten P, Davis C.Developing the consumer interface for the MyPyramid Food GuidanceSystem. J Nutr Educ Behav.2006;38:S124-S135. [DOI] [PubMed] [Google Scholar]
  • 6.US Department of Agriculture.MyPlate/MiPlato. https://www.cnpp.usda.gov/MyPlate.Accessed November 11,2017.
  • 7.Centers for Disease and Control and Prevention. 5 A DayWorks!Atlanta, GA: US Department ofHealth and Human Services;2005. [Google Scholar]
  • 8.Fruit and Veggies More Matters. Home page.https://www.fruitsandveggiesmorematters.org/. AccessedNovember 11, 2017.
  • 9.Harvard T H Chan. The nutrition source:vegetables and fruits. http://www.hsph.harvard.edu/nutritionsource/what-should-you-eat/vegetables-and-fruits/.Accessed June 28, 2015.
  • 10.Government of Canada. Vegetables andfruit. https://www.canada.ca/en/health-canada/services/food-nutrition/canada-food-guide/choosing-foods/vegetables-fruit.html.Accessed March 22, 2018.
  • 11.Gustafsson M.The syntactic features of binomial expressions in legalEnglish. Text Interdiscip J StudyDiscourse.1984;4:123-142. [Google Scholar]
  • 12.Mollin S.Revisiting binomial order in English: ordering constraints andreversibility. English Lang Linguistics.2012;16:81-103. [Google Scholar]
  • 13.Benor SB, Levy R.The chicken or the egg? A probabilistic analysis of Englishbinomials. Language.2006;82:233-278. [Google Scholar]
  • 14.Shih SSY.Towards Optimal Rhythm.Stanford, CA: StanfordUniversity; 2014. [Google Scholar]
  • 15.Malkiel Y.Studies in irreversible binomials.Lingua.1959;8:113-160. [Google Scholar]
  • 16.Anna Siyanova-Chanturia A, Conklin K, van Heuven WJ.Seeing a phrase “time and again” matters: therole of phrasal frequency in the processing of multiwordsequences. J Exp Psychol Learn Mem Cogn.2011;37:776-784. [DOI] [PubMed] [Google Scholar]
  • 17.Meseguer E, Carreiras M, Clifton C.Overt reanalysis strategies and eye movements during the readingof mild garden path sentences. Mem Cognit.2002;30:551-561. [DOI] [PubMed] [Google Scholar]
  • 18.Osterhout L, Holcomb PJ.Event-related brain potentials elicited by syntacticanomaly. J Mem Lang.1992;31:785-806. [Google Scholar]
  • 19.Smith NJ, Levy R.The effect of word predictability on reading time islogarithmic. Cognition.2013;128:302-319. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 20.Thompson FE, Willis GB, Thompson OM, Yaroch AL.The meaning of “fruits” and“vegetables.” Public Health Nutr.2011;14:1222-1228. [DOI] [PubMed] [Google Scholar]
  • 21.Nienhuis J, Slocum MK, DeVos DA, Muren R.Genetic similarity among Brassica oleracea L.genotypes as measured by restriction fragment lengthpolymorphisms. J Am Soc Hortic Sci.1993;118:298-303. [Google Scholar]
  • 22.Kantor LS.A Dietary Assessment of the US Food Supply: Comparing Per Capita FoodConsumption With Food Guide Pyramid Serving Recommendations. Vol772Beltsville, MD:US Department of Agriculture, Economic ResearchService; 1998. [Google Scholar]
  • 23.Nix v Hedden, 149 US 304, 137(1893). [Google Scholar]
  • 24.US Department of Agriculture. Nutrient DataLaboratory, release 27. https://www.ars.usda.gov/northeast-area/beltsville-md-bhnrc/beltsville-human-nutrition-research-center/nutrient-data-laboratory/docs/sr27-home-page/.Accessed March 22, 2018.
  • 25.US Food and Drug Administration. NutritionalLabeling and Education Act (NLEA) Requirements (8/94-2/95).http://www.fda.gov/ICECI/Inspections/InspectionGuides/ucm074948.htm.Accessed May 10, 2016.
  • 26.Kimmons J, Gillespie C, Seymour J, Serdula M, Blanck HM.Fruit and vegetable intake among adolescents and adults in theUnited States: percentage meeting individualizedrecommendations. Medscape J Med.2009;11:26. [PMC free article] [PubMed] [Google Scholar]
  • 27.Furman J.Nutritarian Handbook and ANDI Food Scoring Guide.Flemington, NJ: Gift ofHealth Press; 2012. [Google Scholar]
  • 28.Katz DL, Njike VY, Kennedy D, Faridi Z, Treu J, Rhee LQ.Overall Nutrition Quality Index: Reference Manual.Derby, CT: Yale UniversitySchool of Medicine; 2007. [Google Scholar]
  • 29.Cao G, Prior RL.Measurement of oxygen radical absorbance capacity in biologicalsamples. Methods Enzymol.1999;299:50-62. [DOI] [PubMed] [Google Scholar]
  • 30.Haytowitz DB, Bhagwat S.USDA Database for the Oxygen Radical Absorbance Capacity (ORAC) ofSelected Foods, Release 2. Beltsville,MD: US Department ofAgriculture; 2010. [Google Scholar]
  • 31.Bellavia A, Larsson SC, Bottai M, Wolk A, Orsini N.Fruit and vegetable consumption and all-cause mortality: adose-response analysis. Am J Clin Nutr.2013;98:454-459. [DOI] [PubMed] [Google Scholar]
  • 32.Buil-Cosiales P, Zazpe I, Toledo E, et al. Fiber intake and all-cause mortality in thePrevencion con Dieta Mediterranea (PREDIMED) study.Am J Clin Nutr.2014;100:1498-1507. [DOI] [PubMed] [Google Scholar]
  • 33.Cox BD, Whichelow MJ, Prevost AT.Seasonal consumption of salad vegetables and fresh fruit inrelation to the development of cardiovascular disease andcancer. Public Health Nutr.2000;3:19-29. [DOI] [PubMed] [Google Scholar]
  • 34.Choi Y, Lee JE, Bae JM, et al. Vegetable intake, but not fruit intake, isassociated with a reduction in the risk of cancer incidence and mortality inmiddle-aged Korean men. J Nutr.2015;145:1249-1255. [DOI] [PubMed] [Google Scholar]
  • 35.Hertog MG, Bueno-de-Mesquita HB, Fehily AM, Sweetnam PM, Elwood PC, Kromhout D.Fruit and vegetable consumption and cancer mortality in theCaerphilly Study. Cancer Epidemiol BiomarkersPrev.1996;5:673-677. [PubMed] [Google Scholar]
  • 36.Hung HC, Joshipura KJ, Jiang R, et al. Fruit and vegetable intake and risk of majorchronic disease. J Natl Cancer Inst.2004;96:1577-1584. [DOI] [PubMed] [Google Scholar]
  • 37.Leenders M, Boshuizen HC, Ferrari P, et al. Fruit and vegetable intake and cause-specificmortality in the EPIC study. Eur JEpidemiol.2014;29:639-652. [DOI] [PubMed] [Google Scholar]
  • 38.Nagura J, Iso H, Watanabe Y, et al. Fruit, vegetable and bean intake and mortalityfrom cardiovascular disease among Japanese men and women: the JACCStudy. Br J Nutr.2009;102:285-292. [DOI] [PubMed] [Google Scholar]
  • 39.Nakamura K, Nagata C, Oba S, Takatsuka N, Shimizu H.Fruit and vegetable intake and mortality from cardiovasculardisease are inversely associated in Japanese women but not inmen. J Nutr.2008;138:1129-1134. [DOI] [PubMed] [Google Scholar]
  • 40.Okuda N, Miura K, Okayama A, et al. Fruit and vegetable intake and mortality fromcardiovascular disease in Japan: a 24-year follow-up of the NIPPON DATA80Study. Eur J Clin Nutr.2015;69:482-488. [DOI] [PubMed] [Google Scholar]
  • 41.Oyebode O, Gordon-Dseagu V, Walker A, Mindell JS.Fruit and vegetable consumption and all-cause, cancer and CVDmortality: analysis of Health Survey for England data.J Epidemiol Community Health.2014;68:856-862. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 42.Zhang X, Shu XO, Xiang YB, et al. Cruciferous vegetable consumption is associatedwith a reduced risk of total and cardiovascular diseasemortality. Am J Clin Nutr.2011;94:240-246. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 43.Sharma S, Vik S, Kolonel LN.Fruit and vegetable consumption, ethnicity and risk of fatalischemic heart disease. J Nutr HealthAging.2014;18:573-578. [DOI] [PMC free article] [PubMed] [Google Scholar]
  • 44.National Cancer Institute. Epidemiology and Genomics ResearchProgram. Usual dietary intakes: food intakes, USpopulation, 2007-2010. http://epi.grants.cancer.gov/diet/usualintakes/pop/2007-10/.Accessed June 1, 2016.
  • 45.Moore LV, Thompson FE.Adults meeting fruit and vegetable intake recommendations—UnitedStates, 2013. MMWR Morb Mortal Wkly Rep.2015;64:709-713. [PMC free article] [PubMed] [Google Scholar]
Fruits and Vegetables Versus Vegetables and Fruits: Rhyme and Reason for Word Order in Health Messages (2024)
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