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Abstract

Background

Despite well-documented health benefits, fruit and vegetable (F&V) intake remains below recommended levels globally.

Objectives

This scoping review aimed to identify effective intervention strategies to increase F&V intake.

Methods

We searched PubMed and Web of Science (February 2023) for intervention studies assessing impact on F&V intake. Eligibility criteria included studies published in English since 2012, a valid control group, ≥2 weeks duration, and ≥50 participants per intervention arm. Analysis was done by intervention comparison. Findings were described by summarizing proportion of intervention comparisons reporting statistically significant increases in fruit, vegetable and/or combined F&V intake across standalone (nutrition communication, social protection, agriculture or food environment restructuring) and multi-component strategies.

Results

A total of 284 intervention comparisons (223 unique studies) were included. The majority of comparisons (191/284) came from high-income countries (HICs) and 93/284 from low- and middle-income countries (LMICs). Nutrition communication was the most common standalone strategy, with 121/218 comparisons reporting positive impacts on fruit, vegetable and/or combined F&V intake. Fewer studies evaluated standalone social protection (13/284), food environment restructuring (4/284), or agriculture strategies (3/284). Among the limited interventions, 7/13 social protection and 3/4 food environment restructuring comparisons reported positive impacts, while none of the 3 standalone agricultural interventions did. Multi-component interventions demonstrated potential with 28/46 comparisons having positive impacts.

Conclusions

Some of the intervention strategies showed potential for increasing fruit and/or vegetable intake. However, given the heterogeneity of the interventions, small number of studies for some strategies and limited evidence from LMICs, more rigorous, context-specific research is needed.

Plain language title

What works to increase fruit and vegetable intake? A global review of intervention strategies.

Plain language summary

Background

Eating enough fruit and vegetables is important for maintaining good health, but most people do not eat the recommended amounts. Many strategies have been tested to encourage fruit and vegetable intake, but it is unclear how successful they have been.

Objective

This study reviewed the success of different types of strategies to understand which ones were most likely to increase fruit and/or vegetable intake.

Methods

We analyzed 284 comparisons from 223 unique studies that tested interventions to increase fruit and/or vegetable intake. These included nutrition communication (e.g. education, cooking skills, diet counselling), social protection programs (e.g. food assistance or financial incentives), agricultural programs (e.g. school or home gardens), and food environment changes (e.g. making fruits and vegetables more available in schools or workplaces).

Findings

The majority of interventions included in this review were conducted in high-income countries (191/284) and the rest came from low- and middle-income countries (93/284).

Nutrition communication was the most common standalone strategy. Of the 218 interventions, 56% increased fruit and/or vegetable intake.

The other standalone strategies were less common, although 7 of 13 social protection and 3 of 4 food environment interventions reported positive impacts, whereas none of the 3 agriculture interventions did.

Of the 46 multi-component interventions that combined 2 or more strategies, such as pairing nutrition communication with cash or home garden, about 61% reported positive impacts on fruit and/or vegetable intake.

Conclusions

Although some strategies showed promise, the variability of the interventions, small number of studies in some cases, and limited evidence from LMICs indicate a need for additional research to help us better understand successful interventions for increasing fruit and/or vegetable intake.

Keywords

fruit vegetables diet nutrition communication food environment social protection agriculture

Introduction

Increasing fruit and vegetable (F&V) intake is critical for adopting healthier and more sustainable diets.¹ Inadequate intake of F&V is a significant risk factor for non-communicable diseases (NCDs) and is estimated to be a leading cause of preventable deaths globally.^2–4 Fruit and vegetables are important sources of essential micronutrients and dietary fiber across all age groups,⁵ enhancing immunity and maternal-fetal health during pregnancy, supporting growth and cognitive development in children and adolescents, and reducing the risk of NCDs in adults and the elderly.^2,5,6 Despite well-established health benefits, F&V intake remains below recommendations worldwide, particularly in low- and middle-income countries (LMICs),² where food insecurity and resource constraints exacerbate the challenge of intake adequacy.⁷ Addressing this gap is essential to reducing the global burden of nutrition-related diseases and conditions, including undernutrition, micronutrient deficiencies and NCDs, while supporting healthy development across the life course.

Efforts to improve diet quality and increase F&V intake have drawn on a wide range of strategies, such as nutrition education, social protection programs, agriculture programs, and food environment restructuring.⁸ Despite this diversity, many interventions remain siloed, focusing on a single entry point rather than addressing the full spectrum of factors that shape dietary intake such as economic barriers, knowledge, attitudes, social and cultural norms, physical access and individual preferences. Emerging evidence points to the greater promise of multi-component strategies,⁹ i.e., those that attempt to tackle different types of barriers to F&V intake simultaneously.

Frameworks like the NOURISHING Framework¹⁰ and the Nuffield Ladder¹¹ reinforce a systems perspective, calling for coordinated action across individual, community, environmental and policy levels. These principles align closely with social and behavior change communication (SBCC), which can integrate various approaches such as education, media, social mobilization and structural changes to support healthier behaviors.¹² By simultaneously addressing multiple determinants of F&V intake, these integrated approaches can help create an enabling environment to make healthier choices more feasible.^13,14 To design effective interventions to increase F&V intake in diverse settings, a better understanding is needed of which strategies work best, where and for whom.

This scoping review examined the evidence of the impact of intervention strategies to increase F&V intake across high-income countries (HICs) and LMICs. It was undertaken as part of the Fruit and Vegetables for Sustainable Healthy Diets (FRESH) Initiative, a multidisciplinary, multi-partner research program aimed at designing and evaluating end-to-end approaches to increasing F&V intake for healthy diets from consumer demand to supply to food environment.¹³ In an accompanying paper,⁸ we summarized available evidence of interventions on F&V intake with a focus on the methods used. This review article builds on that work and aims to identify the most effective approaches and highlight potential entry points for impact on F&V intake.

Methods

Scoping Review Design

Both this and our preceding paper,⁸ used the same protocol,¹⁵ and the same search strategy, eligibility criteria, full-text article selection, and data extraction process. This current analysis leverages the same database (Supplementary Table 1) to explore intervention strategies that were used in studies to increase F&V intake across various population groups in both HICs and LMICs.

Eligibility Criteria

As previously described in more detail,⁸ intervention studies, published since 2012, with a valid control or counterfactual group were included, such as randomized controlled trials (RCTs), cluster-RCTs, controlled before-after studies and feasibility or pilot studies. Interventions with a duration of less than 2 weeks were not eligible for inclusion. Additionally, only studies in which at least 1 intervention or comparison arm included 50 or more participants per arm were considered eligible. All age groups, life stages and groups from any country worldwide were eligible. The population groups included were children aged 6 months to 4.9 years (referred to as children under 5 years), school-aged children (5-9.9 years), adolescents (10-19.9 years), adults (20-59.9 years), and older adults (60 years and older). Studies targeting populations with health conditions or pre-existing comorbidities were excluded.

Outcomes Assessed

The outcomes of interest for this review were fruit intake, vegetable intake, total F&V intake, intake of specific fruits or vegetables, and intake of fruit or vegetable food groups, such as vitamin A-rich F&V, green leafy vegetables, and orange-fleshed F&V. F&V groupings were based on study-specific definitions, as reported in each included study. Outcomes referring to specific fruits, vegetables or F&V groups were aggregated into the broader fruit, vegetable, or combined F&V categories. Throughout this manuscript, we consistently use the term ‘intake’ to refer to individual-level dietary intake, including types, quantities, and frequency of specific foods or food groups consumed, as reported in the primary studies.

Intervention Strategies

When using the term ‘intervention strategy,’ we refer to the combination of an intervention component and the intervention approach.¹⁶ The ‘intervention component’ includes the specific element(s) designed to drive change (here, increased F&V intake). The ‘intervention approach’ involves the method(s) used to deliver the intervention component. Intervention components identified in this scoping review were grouped into 4 categories: nutrition/health communication, social protection, agriculture, and food environment restructuring. The intervention approaches were classified as interpersonal communication (IPC), group-based, mass communication, information and communication technology (ICT), community or social mobilization, and cash transfers, in-kind transfers, or other financial incentives. Intervention components and approaches are defined with examples in Table 1. Interventions utilizing more than 1 component and/or approach were classified as multi-component and multi-approach, respectively, and were not double counted under individual categories.

Table 1:

Definition of Intervention Strategies Used in Interventions Targetting Dietary Changes.

Intervention strategy	Definition
Intervention component: Specific elements or tactics that are part of an intervention designed to effect change
Nutrition communication	This encompasses a range of approaches designed to inform and engage individuals, households, and communities about health, nutrition, and the importance of balanced diets. These programs aim to empower people with knowledge, skills, and tools to make healthier food choices and adopt positive lifestyle changes.
Social protection	This encompasses a range of policies and programs aimed at reducing poverty and enhancing access to food, healthcare, and income security e.g., cash transfers, livelihood enhancement, women empowerment, school meals, etc.
Agriculture	In the context of nutrition interventions, this approach focuses on agricultural practices and policies that ensure food security and improve access to diverse and nutritious foods. This could involve diversifying crop cultivation, improving agricultural productivity, and supporting small-scale farmers to grow more nutritious foods.
Food environment restructuring	This approach involves modifying the physical or organizational environment to make healthier choices more accessible, convenient, and normative. This could mean redesigning food environments in schools, workplaces, or communities to promote the consumption of healthier foods.
Intervention approach: Ways in which intervention components are implemented and delivered to the target audience
Community/ Social mobilization	This method entails engaging and motivating a wide range of actos, partners, and stakeholders at the community level to effect change or contribute to a specific cause. It might involve launching awareness campaigns, mobilizing local leaders and influencers, etc.
Mass communication	This refers to utilizing media and communication technologies to disseminate messages to large audiences. This might include public service announcements, educational campaigns, or social media campaigns aimed at promoting healthy dietary behaviors.
Information and communication technology	This may include leveraging digital tools and platforms (e.g., mobile apps, online platforms, SMS services) to deliver nutritional information, support behavior change, or facilitate access to nutrition services.
Interpersonal communication	This involves direct, face-to-face communication that allows for personal interaction and feedback, e.g. counseling sessions with dietitians or nutritionists.
Group-based approaches	This method involves conducting interventions or educational programs in group settings. It leverages the dynamics of group learning and support to foster behavior change. Examples include nutrition workshops, cooking classes, school classroom education, or support groups for individuals.
In-kind/ Cash transfers	Provision of food or cash directly to individuals or households to ensure that specific needs are met.

Intervention Types

Interventions were also classified based on their design intent and framing as reported in study materials. These were grouped into 3 mutually exclusive categories: 1) F&V-specific interventions, which were designed and implemented with targeted messaging or activities related to fruit and/or vegetables; 2) other dietary interventions, aimed at improving food security, dietary diversity and/or diet quality without specific emphasis on F&V messaging; and 3) lifestyle interventions, which provided general nutrition information and promoted healthy behaviors such as physical activity and smoking cessation. Where interventions could fit multiple categories, classification was based on the primary objective of the study and dominant framing in study materials. F&V-specific interventions were prioritized in cases of overlap.

Impact Assessment

A statistically significant increase in dietary fruit, vegetable and/or combined F&V intake in an intervention arm compared to a valid control arm was recorded as a positive impact. Intervention comparisons were reported as having either a positive impact (yes) or no positive impact (no); null or negative effects (if any) were captured within the no category. If an intervention assessed more than 1 relevant outcome, each was treated separately and counted individually. Studies with multiple intervention arms contributed multiple outcomes, each summarized separately. Therefore, throughout this review, the analysis was based on each intervention comparison, defined as an intervention arm compared to a valid control arm within a study.

Data Summary

Findings were summarized as the number and proportion of intervention comparisons reporting a positive impact on fruit intake, vegetable intake, combined F&V intake or any impact across the 3 indicators. We summarized this data by intervention strategy, population group and by HIC and LMIC (classified according to the World Bank at the time of data extraction). In line with recommendations for scoping reviews¹⁷ and due to the heterogeneity of included studies, no formal statistical tests were conducted for comparison of intervention strategies, intervention types, or by country context.

Reporting

While we extracted data on fruit intake, vegetable intake, combined F&V intake, and any impact across the 3 indicators separately, we primarily give examples of intervention comparisons reporting on combined F&V intake, as this aligns with WHO recommendations that emphasize total daily F&V intake. For intervention strategies with few comparisons or no assessment of combined F&V intake, we report on any positive impact across the 3 indicators.

Results

Characteristics of Intervention Strategies

This scoping review identified 6338 articles, with 226 meeting the inclusion criteria, comprising 223 unique studies, which included a total of 284 intervention comparisons. Of the intervention comparisons, over 60% were conducted in HICs (191/284). Intervention strategies were classified as either standalone or multi-component (Table 2). The most common standalone strategy was nutrition communication (218/284), which encompassed a range of approaches to improve knowledge, attitudes, beliefs, social norms, skills, and behaviors related to F&V, diet, and health. Some of these interventions explicitly applied SBCC theories, while others used more traditional, information-focused education methods. Other standalone strategies included social protection (13/284), food environment restructuring (4/284), and agricultural interventions (3/284). Two-component interventions were the second most common strategy (41/284), frequently combining nutrition communication with social protection (23/284), agricultural interventions (15/284), or food environment restructuring (3/284).

Table 2:

Strategic Approaches to Increase Dietary Intake of Fruit and/or Vegetable.

Intervention strategies/ Setting	HICs(n=191)	LMICs(n=93)	Total(n=284)
Standalone intervention strategies	169	69	238
Nutrition communication	155	63	218
Community/ Social mobilization	0	3	3
Mass communication	10	1	11
Group-based approaches	42	28	70
Interpersonal communication	13	5	18
Information and communication technology	9	1	10
2 methods of delivery	66	15	81
More than 2 methods of delivery	15	10	25
Social protection	8	5	13
Cash	1	3	4
In-kind	3	1	4
Cash + In-kind	1	0	1
Financial incentives	3	1	4
Agriculture	2	1	3
Food environment restructuring	4	0	4
Multi-component intervention strategies	22	24	46
Two components	18	23	41
Social protection plus nutrition communication	12	11	23
Agriculture plus nutrition communication	3	12	15
Food environment restructuring plus nutrition communication	3	0	3
More than 2 components	4	1	5

Abbreviations: HICs: High-income countries; LMICs: Low- and middle-income countries.

The intervention strategies varied by type, with most being F&V-specific (115/284) or lifestyle-focused (112/284) and the remaining diet-focused (57/284) (Supplementary Table 2). About two-thirds of the intervention comparisons focusing on F&V specifically found a positive impact on combined F&V intake (39/60), whereas about half of the diet-focused (15/27) and about a third of the lifestyle focused interventions (17/47) reported such an impact (Figure 1; Supplementary Figure 1). Similar results were observed when considering any impact across fruit, vegetable and/or combined F&V. These findings were also consistent when stratified by HICs/LMICs (Supplementary Table 3).

Figure 1.

Significant positive impact of intervention types on dietary intake of fruit and/or vegetable.

Impact on intakes of fruit, vegetable and/or combined F&V differed by intervention strategy (Table 3; Supplementary Table 4). Below, we provide further details on the reported impacts in HICs (Supplementary Table 5) and in LMICs (Supplementary Table 6). We also provide an overall summary of the number of intervention comparisons for each intervention strategy (Supplementary Table 7) and their proportional impact (Supplementary Table 8) by population group.

Table 3:

Significant Positive Impact of Intervention Strategies on Dietary Intake of Fruit and/or Vegetable.

Country setting	HICs		LMICs		Total
Outcome	Combined F&V intake (n=77)	Any positive impact (n=191)	Combined F&V intake (n=57)	Any positive impact (n=93)	Combined F&V intake (n=134)	Any positive impact (n=284)
Standalone intervention strategies
Nutrition communication	30/60	86/155	23/43	36/63	53/103	121/218
Community/ Social mobilization	0/0	0/0	0/0	0/3	0/0	0/3
Mass communication	3/5	8/10	0/1	1/1	2/5	9/11
Group-based approaches	6/11	24/42	7/16	17/28	13/27	41/70
Interpersonal communication	2/6	6/13	3/5	3/5	5/11	9/18
Information and Communication Technology	3/7	5/10	1/1	1/1	4/8	6/11
2 methods of delivery	13/22	36/66	9/13	9/15	22/35	45/81
More than 2 methods of delivery	3/9	7/15	3/8	5/10	6/17	12/25
Social protection	3/5	4/8	1/3	3/5	4/8	7/13
Agriculture	0/2	0/2	0/0	0/1	0/2	0/3
Food environment restructuring	0/0	3/4	0/0	0/0	0/0	3/4
Multi-component intervention strategies
Two components	5/7	13/18	7/11	12/23	12/18	25/41
Social protection plus nutrition communication	4/6	7/12	5/8	6/11	9/14	13/23
Agriculture plus nutrition communication	0/0	3/3	2/3	5/12	2/3	8/15
Food environment restructuring plus nutrition communication	1/1	3/3	0/0	0/0	1/1	3/3
More than 2 components	2/3	2/4	0/0	1/1	2/3	3/5

Statistics in cells represent n/N where n= number of intervention comparisons showing positive increase in outcome for each intervention strategy and N= total number of intervention comparisons using the intervention strategy for that outcome; HICs: High-income countries; LMICs: Low- and middle-income countries; F&V: Fruit and Vegetable; Any positive impact refers to increase observed in either fruit intake, vegetable intake, and/or combined fruit and vegetable intake.

Standalone Nutrition Communication Strategies

The majority of standalone nutrition communication interventions were conducted in HICs (155/218), and less than one-third were implemented in LMICs (63/218) (Table 2). In HICs, nutrition communication comparisons primarily targeted adults (71/155), followed by school-aged children (22/155) and children <5 years (18/155) (Supplementary Table 7). Conversely, in LMICs, intervention comparisons were evenly distributed between adults (16/63) and adolescents (15/63), followed closely by children <5 years (13/63) and school-aged children (11/63). Among standalone nutrition communication intervention comparisons, 30/60 in HICs and 23/43 in LMICs reported a positive impact on combined F&V intake, while 86/155 in HICs and 36/63 in LMICs reported any positive impact across either fruit, vegetable and/or combined F&V intake (Table 3).

The majority of standalone nutrition communication interventions utilized a single intervention delivery approach (112/218), with group-based approaches being the most common of these (70/112) (Table 2). Of the 218 intervention comparisons, 81 combined 2 delivery methods, and an additional 25 used more than 2, including 15 in HICs and 10 in LMICs. We next examined nutrition communication strategies by delivery approach to explore their effectiveness.

Nutrition communication through group-based approaches: Six of 11 intervention comparisons in HICs and 7/16 in LMICs reported a positive impact on combined F&V intake (Table 3). Interventions reporting increased intake had a median duration of approximately 6 months and were primarily school-based programs (8/13).^18–24 These interventions often targeted adolescents (6/13) and school-aged children (4/13), and incorporated interactive and experiential elements. Examples included in-school cooking demonstrations,²² use of tools like a “fruitometer” poster to track student intake, field visits to markets and farms, and goal-setting diaries to support self-monitoring of F&V intake.¹⁹

Nutrition communication through interpersonal communication (IPC): IPC was used in 13/155 standalone nutrition communication intervention comparisons in HICs and 5/63 in LMICs (Table 3). In HICs, IPC was primarily implemented in lifestyle-focused interventions (9/13), whereas in LMICs, interventions were mostly F&V-specific (3/5) or diet-focused (2/5). Most IPC typically involved one-on-one counselling by healthcare workers, dietitians or nutritionists.^25–35 Of the 5 interventions reporting positive impacts on combined F&V intake, 2/6 were from HICs,^25,29 and 3/5 were from LMICs.^26,28,36 All but 1 of these effective interventions were F&V-specific.²⁵

Nutrition communication through mass communication: All 10 intervention comparisons in HICs that used mass communication were F&V-specific (Table 3); and primarily targeted adults (8/10).^37–43 Three of the 5 comparisons that reported on combined F&V intake showed a positive impact. These included interventions using tailored written information, with or without accompanying videos, delivered monthly over 4 months,⁴¹ and a healthy eating guide delivered monthly over a 12-month period for adults.⁴³ Only 1 mass communication intervention was identified in LMICs, where adults received daily and twice-weekly text messages over a 6-month period in India; this study reported increased intake in combined F&V in the intervention arm compared to the control group.⁴⁴

Nutrition communication through information communication technology (ICT): ICT-based approaches were more frequently used in HICs (9/155) compared to LMICs (1/63) (Table 2). Among the 7 HIC-based intervention comparisons that reported on combined F&V intake, 3 showed a positive impact,^45–47 as did the only ICT intervention conducted in LMICs.^48,49 Websites, mobile Apps, video clips and interactive games were channels for information transfer used in these interventions.

Nutrition communication with 2 delivery approaches : Thirteen out of 22 comparisons in HICs and 9 out of 13 in LMICs reported a positive impact on combined F&V intake (Table 3). In HICs, most of the effective interventions were F&V-specific, with 2 exceptions: 1 lifestyle-focused intervention combined nutrition communication with social marketing to promote F&V intake and physical activity among school-aged children,⁵⁰ and another targeted mother-daughter pairs through nutrition education and development of personalized healthy eating plans in the USA.⁵¹ In LMICs, 4/9 effective nutrition communication interventions were F&V-specific, often delivered through group-based education sessions paired with cooking demonstrations⁵² or counselling.⁵³

Of the 13 intervention comparisons using 2-delivery approaches in HICs, ICT combined with IPC was the most frequently tested and effective combination (6/13),^54–57 with tailored websites or mobile Apps offering personalized feedback as a key feature. Other effective combinations included group-based education sessions with ICT (2/13)^51,58 and group-based education with mass media (2/13).^59,60 In LMICs, effective multi-approach delivery methods involved group-based education with IPC (4/9),^54,61–63 group-based education with mass media (2/9),^52,64 ICT with IPC (2/9),^65,66 and group-based education with community mobilization (1/9).⁶⁷

Nutrition communication with 3 or more delivery approaches : Three out of 9 intervention comparisons in HICs and 3 out of 8 in LMICs demonstrated positive impacts on combined F&V intake (Table 3). In HICs, effective interventions primarily targeted adults,^60,68 whereas, in LMICs, they targeted adolescents^48,49,69 and children <5 years.⁷⁰ In HICs and LMICs, 1 of each of the 3 intervention comparisons with a positive impact was F&V-specific, conducted in France and China, respectively. In France, a 6-month program combining group-based education with barrier identification, practice prompts, and ongoing encouragement was found to improve F&V intake among adults relative to comparison groups that received fewer or less interactive components.⁶⁰ The intervention in China was a 2-month web-based program for adolescents integrating social mobilization, mass communication, and ICT relative to a no-intervention control.^48,49

Standalone and Multi-Component Social Protection Programs

Social protection interventions as a standalone component were less common (13/38) than as part of multi-component strategies (25/38). Overall, 21/38 intervention comparisons were conducted in HICs and 17/38 in LMICs (Table 2). In both settings, the most common target populations after adults, were caregiver-child dyads, children <5 years, and school-aged children.

Among standalone social protection comparisons 7/13 reported any positive impact across either fruit, vegetable and/or combined F&V intake, with 4/8 in HICs and 3/5 in LMICs (Table 3). When considering only combined F&V intake, 3/5 intervention comparisons in HICs^54,71,72 and 1/3 in LMICs⁷³ were effective. Thirteen of 23 comparisons combining social protection with nutrition communication reported any positive impact across either fruit, vegetable and/ or combined F&V intake. Similarly, 9/14 of social protection comparisons assessing combined F&V intake reported an increase.^74–80 This included 4/6 successful intervention comparisons conducted in HICs and 5/8 in LMICs.

Social protection components were delivered through in-kind food transfers (18/38), other financial incentives (11/38), cash-only (8/38) and combined cash and in-kind transfers (1/38) (Supplementary Table 9).

Social protection through cash-only transfers: There were 4 standalone cash-only interventions; 3 conducted in LMICs^73,81,82 and 1 in HICs.⁷¹ None of the 4 standalone cash-only interventions were F&V-specific, and of those 2 resulted in a positive impact on combined F&V.^71,73 Overall, the amounts and timing of cash transfers varied across studies, ranging from $16 in Burkina-Faso to $60 in the US and from monthly disbursements to disbursements at specific times of the year. The 1 cash-only intervention that did not result in an increase in F&V intake took place in Burkina Faso, where households with children <5 years received $16 monthly during the lean season.⁸²

There were 4 multi-component cash-only interventions, all conducted in LMICs.⁸¹^,^83–85 None showed impact on combined F&V intake, although 1 increased vegetable intake among adolescents in Nepal who received cash combined with nutrition communication and seeds for home and school gardens compared to a no-intervention control group.⁸⁵

Social protection through in-kind food transfers: In-kind transfers included the provision of fruit and/or vegetables (10/18), non-F&V fortified foods, supplements, or general ‘healthy’ meals (8/18). Among the intervention comparisons that assessed combined F&V intake, 5/10 of the F&V-specific^54,76,77 and 1/8 of the non-F&V specific⁷⁸ comparisons reported a positive impact. Ten intervention comparisons using standalone or multi-component in-kind strategy were conducted in HICs and 8 in LMICs. Five of 8 multi-component in-kind transfer intervention comparisons increased combined F&V intake, with 1/2 in HICs⁷⁶ and 4/6 in LMICs.^77,78

Social protection through both cash and in-kind transfers: One US-based study provided both nutritious food boxes and a $15 F&V voucher, leading to increased intake among school-aged children and adolescents compared to non-recipient households.⁷²

Social protection through financial incentives: Examples of standalone and multi-component financial incentives included discounts (4/11), vouchers (2/11), reimbursement (1/11), cost-offset (2/11), or participation incentives (2/11). Among the 7 multi-component interventions, 5 reported any positive impact across either fruit, vegetable and/or combined F&V intake,^74,75,80 while none of the 4 standalone financial incentive interventions did. All but 1 study was conducted in an HIC; the exception was a study in Ethiopia, which included both a voucher-only and a voucher plus nutrition communication arm compared to a control arm.⁷⁵ Only the latter showed an increase in combined F&V intake.

Standalone and Multi-Component Agriculture Interventions

We identified more multi-component (16/19) than standalone (3/19) agricultural intervention comparisons. The majority of these studies were conducted in LMICs, with 6 in Africa^86–90 and 5 in Asia,^91–95 while 4 were conducted in the US^96–99 and 1 in the UK.¹⁰⁰ All studies reported nutrition-sensitive objectives and most were F&V-specific (14/19) (Supplementary Table 3). None of the standalone agricultural interventions increased fruit, vegetable or combined F&V intake.^95,98,100

Eight of the 15 agriculture interventions combined with nutrition communication were found to have any positive impact across either fruit, vegetable, and/or combined F&V intake (Table 3; Supplementary Table 4). This 2-component strategy was particularly successful at increasing either fruit intake and/or vegetable intake among school-aged children over a period of 9,⁹⁶ 12⁹⁷ and 20⁹⁹ months in studies conducted in HICs. All 3 interventions included hands-on school gardening activities combined with nutrition communication. Conversely, in LMICs, this strategy showed any positive impact across either fruit, vegetable and/or combined F&V intake in 5/12 intervention comparisons.^{86,87,89,91,92,94} Agricultural interventions typically lasted 8 months^90,93 to 2 years,^88,90 but the duration of the intervention alone did not determine intervention impact.^86–88

Standalone and Multi-Component Food Environment Restructuring

Food environment restructuring interventions included changes to the physical food environment, such as offering healthier options in school cafeterias, modifying food placement or presentation of F&V, and creating local markets. All intervention comparisons were conducted in HICs (Table 3), and most were among school-aged children or adolescents in school settings (Supplementary Table 7), with an equal number being either standalone (4/8)^101–104 or part of a multi-component strategy (4/8).^{101,103,105,106} Three of the 4 standalone interventions^101,103,104 and all 4 of the multi-component interventions^{101,103,105,106} reported any positive impact across either fruit, vegetable and/or combined F&V intake.

Overall Multi-Component Strategies

Multi-component strategies were implemented almost equally in HICs (22/46) and LMICs (24/46) (Table 2). The most frequent strategies included nutrition communication with social protection (23/46), nutrition communication with agriculture (15/46), and nutrition communication with food environment restructuring (3/46). Among the multi-component interventions that reported combined F&V intake, a similar proportion reportedly increased intake in HICs (7/10) and LMICs (7/11) (Table 3).

Discussion

This scoping review aimed to identify effective intervention strategies to increase F&V intake in HICs and LMICs. Our review included 284 intervention comparisons classified into 4 broad intervention strategies – nutrition communication, social protection, agricultural approaches, and food environment restructuring – of which nutrition communication was the most widely implemented. Nutrition communication and multi-component strategies showed potential with more than half increasing fruit and/or vegetable intake. Similarly, social protection and food environment strategies show promise although there were few studies. Considerable variation in study design, delivery methods, and outcome measurement across studies limited our ability to draw firm conclusions on the most effective strategy for increasing F&V intake.

Nutrition communication: Overall, nutrition communication interventions showed modest and inconsistent impact on F&V intake. An umbrella review by Wolfenden et al. also concluded with similarly inconsistent effects of nutrition communication strategies on F&V intake.¹⁰⁷ Such variability reflects the complex nature of dietary behaviors which are shaped by multiple determinants according to socio-ecological models of behavior change, ranging from individual knowledge and beliefs, to social norms, economic constraints, food environments, and personal preferences.^108–111 Effective behavior change likely requires strategies that address these multiple layers of influence.¹¹²

The similar success rates of standalone nutrition communication interventions in HICs and LMICs suggest that the choice of intervention delivery method is a key determinant of impact for F&V intake. Among interventions using a single delivery method, reported impact varied. Mass communication, though widely promoted for population-level outreach,¹¹³ has been associated with modest increases in F&V intake in the broader literature.^114,115 Social mobilization approaches were infrequently used in included studies, and these generally require long-term investment and enabling environments to drive meaningful behavioral changes.^116,117 Group-based approaches and IPC were designed to support behavior change through tailored feedback, social support, and participatory learning. These approaches were common in school-based interventions that incorporated experiential elements – such as cooking, tasting, field visits, and peer or caregiver engagement – which have been highlighted in prior reviews as promising channels for dietary behavior change.^118–121 However, we found inconsistent impact on F&V intake, possibly due to differences in program intensity, duration, reach, fidelity, and implementation quality. ICT-based approaches also produced mixed results, which may have been influenced by factors such as type of digital tool,^121,122 technology access, user literacy, and participant engagement,^123,124 particularly across income settings.

Building on this diversity of single delivery approaches, some interventions integrated multiple methods, a practice often encouraged by communication theory which suggests that reinforcing messages through multiple, context-relevant channels may enhance their effectiveness by improving reach, salience, and retention.^125,126 While nearly half of nutrition communication interventions in this review used more than 1 delivery method, outcomes remained inconsistent overall and across HICs and LMICs. This evidence on both single-delivery and multi-delivery approaches provides an indication that the delivery approach alone is not sufficient in nutrition communication interventions for F&V intake – design, content, and context also matter. However, due to the diversity in study design, population group, communication strategy, study duration, and outcome measured we were unable to identify which communication strategy would work best in which setting.

Social protection: The evidence on the impact of standalone social protection strategies on F&V intake appears promising but remains inconclusive due to the limited number of studies reviewed (n = 13). This reflects a broader pattern: many nutrition-sensitive social protection programs focus on food security or health outcomes, and do not commonly report changes in specific dietary components or food groups. As a result, evidence on their direct contribution to F&V intake remains limited, even when relevant dietary shifts may have occurred.

While cash transfers enhance purchasing power and could improve F&V affordability, evidence from our review and previous meta-analyses suggests inconsistent results on diet behaviors,^127–129 with some regional variations.¹³⁰ These differences may reflect variation in program design, coverage, and/or implementation, in addition to setting. In contrast, direct provision strategies such as school-based or community-based F&V distributions consistently increase intake of fruit and/or vegetables, particularly when produce is freely available rather than subsidized.¹³¹ Such interventions, however, are resource-intensive, face sustainability challenges, and may be culturally inappropriate in certain contexts.

Several multi-component interventions that combined social protection with other strategies reported improvements in F&V intake, though findings remained inconsistent. Prior impact evaluations have noted that the effectiveness of social protection programs depends on factors such as transfer modality, duration, targeting, and the broader food environment including food availability, market access, and cultural acceptability.¹³² For example, financial incentives, such as discounts and vouchers, increase F&V purchases;^115,133 but their effectiveness remains limited unless paired with other interventions, particularly nutrition communication and/or food environment restructuring.^133,134

Agricultural interventions: Most agricultural programs prioritize production goals and often, impacts on diet or nutrition may not be documented.¹³⁵ This likely contributed to the small number of agricultural intervention studies meeting our inclusion criteria, as studies without relevant dietary intake outcomes were excluded. This makes it difficult to assess whether and how agriculture influences consumption patterns of fruit and/or vegetables. Despite the limited number of standalone agriculture interventions (n=3), the absence of impact on F&V intake challenges the assumption that increasing production alone improves diets. While agriculture can enhance food availability and household income, additional behavioral and structural modifications may be necessary to translate these gains into dietary improvements.^9,136–138 For example, school garden programs combining gardening education and/or skills with nutrition communication have been shown to increase children’s knowledge, acceptability, and intake of F&V.¹³⁹

There were more multi-component agriculture interventions than standalone ones, but the impact on F&V intake remained inconsistent. Given the small number of studies and variation in context, geography, seasonality, design and implementation, firm conclusions cannot be made. Instead, these findings underscore the need for understanding the pathways through which agricultural interventions are expected to influence diets, and for targeted measurement of dietary outcomes when the intervention is nutrition-sensitive.

Food environment restructuring: Although few studies included in our review evaluated food environment restructuring (n = 8), most of these interventions increased fruit and/or vegetable intake, particularly when combined with complementary strategies. Modifying food environments — such as improving produce availability or altering choice architecture — can effectively nudge individuals toward healthier selections, with consistent impacts observed in structured settings like schools.^140,141 However, inconsistent effects on vegetable intake suggest that additional strategies may be needed to address taste preferences, particularly among children.¹⁵² The broader literature suggests that combining food environment modifications with nutrition communication results in the most consistent improvements in F&V intake.^142,143

Among the few studies that were included in the present review, the exclusive implementation of these interventions in HICs highlights a research gap in addressing food environment barriers in LMICs. This disparity may reflect differences in public health priorities, infrastructure, or policy focus, but it does not imply a lack of relevance or feasibility in LMICs.¹⁴⁴ Given the ongoing nutrition transition in many LMICs, where shifts in food environments contribute to rising diet-related diseases,¹⁴⁵ scalable and cost-effective food environment interventions warrant greater attention.

Multi-component interventions: Multi-component interventions in this review most commonly combined nutrition communication with social protection, agriculture, or food environment restructuring. However, although such interventions showed potential, outcomes were inconsistent and no one combination demonstrated uniformly positive results on F&V intake. Only a few interventions included more than 2 strategies. This suggests that existing interventions have addressed a limited subset of the behavioral, structural, and environmental factors that shape dietary intake. Our review does not indicate that more components necessarily lead to greater impact but rather point to the importance of alignment between intervention strategy, context, and implementation. For example, combining nutrition communication with a voucher scheme may have limited dietary impact if supply or access barriers remain unresolved. Understanding how different intervention components interact in practice, whether they are delivered with sufficient intensity and coherence, and whether they are taken up by participants, is critical for designing effective and scalable programs to increase F&V intake and improve diets.

Strengths and limitations: This scoping review has several strengths, including its comprehensive scope and inclusion of all age groups and settings. However, we were limited by the heterogeneity of methodological approaches and dietary outcomes reported in the primary studies, which made direct comparisons challenging. As such, we were unable to explore the overall magnitude of impact of intervention strategies on F&V intake, further limiting our ability to identify the most effective option. Additionally, by focusing only on studies that reported fruit and/or vegetable intake as a specific outcome, we may have excluded valuable insights from broader nutrition programs that prioritize dietary diversity, where F&V intake may be embedded but not disaggregated. The review was also limited to 2 English-language peer-reviewed databases and excluded region-specific databases, which may have led to underrepresentation of programs and findings from non-English-speaking countries.

Areas for further research: First, there is a clear need for more research in LMICs – not only to test the effectiveness of F&V interventions, but also to better understand how local food environments, affordability, access, and policies shape intervention outcomes. Second, certain population groups such as adolescents, pregnant and/or lactating women, and older adults, remain understudied in the available evidence. Future studies should prioritize populations with the highest diet-related disease risk, lowest F&V intake, or with the most potential to benefit, to guide targeted programming. Third, for interventions with demonstrated effectiveness, further research is needed to assess their long-term sustainability, cost-effectiveness, and scalability. Fourth, future studies should test the additive and synergistic effects of different intervention strategies and approaches on F&V intake. Such information derived from interventions with multiple arms would be valuable for program planning by identifying any added value of additional components or alternative approaches. Finally, since our review did not clearly identify the best strategy for increasing F&V intake, detailed analysis of intervention characteristics such as design, delivery, message, implementation, adoption, frequency, duration and intensity is needed to fully evaluate what drives the success or failure of each strategy.

Conclusion

There was inconsistent evidence on the impact of different intervention strategies on fruit and/or vegetable intake. Multicomponent strategies and nutrition communication indicated potential to increase intake with more than half of the intervention comparisons being successful. Social protection and food environment restructuring approaches also showed promise, although these were less frequently evaluated. Generating more evidence, particularly in LMICs, and aligning strategies across all relevant sectors will be essential to designing coherent, systems-based responses that lead to lasting improvements in F&V intake and healthier diets for all.

Supplemental Material

sj-docx-1-fnb-10.1177_03795721251350208 - Supplemental material for Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-, Middle- and High-Income Countries: A Scoping Review

Supplemental material, sj-docx-1-fnb-10.1177_03795721251350208 for Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-, Middle- and High-Income Countries: A Scoping Review by Nadia Koyratty, PhD, Fusta Azupogo, PhD, Taryn J. Smith, PhD, Guy-Marino Hinnouho, PhD, Manisha Tharaney, PhD, Lilia Bliznashka, PhD, Deanna K. Olney, PhD, and Sonja Y. Hess, PhD in Food and Nutrition Bulletin

Supplemental Material

sj-xlsx-2-fnb-10.1177_03795721251350208 - Supplemental material for Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-, Middle- and High-Income Countries: A Scoping Review

Supplemental material, sj-xlsx-2-fnb-10.1177_03795721251350208 for Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-, Middle- and High-Income Countries: A Scoping Review by Nadia Koyratty, PhD, Fusta Azupogo, PhD, Taryn J. Smith, PhD, Guy-Marino Hinnouho, PhD, Manisha Tharaney, PhD, Lilia Bliznashka, PhD, Deanna K. Olney, PhD, and Sonja Y. Hess, PhD in Food and Nutrition Bulletin

Footnotes

Acknowledgements

We appreciate the valuable feedback on the draft manuscript provided by Kenda Cunningham (IFPRI-UK).

Author Contributions

Conceived and designed the study: TJS, NK, FA, LB, GMH, DKO, and SYH; Literature search: TJS and FA; Screening and data extraction: FA, TJS, NK, GMH, SYH, and LB; Writing the first draft of the manuscript: NK, FA, TJS, GMH and SYH; Contributed to the editing of the manuscript: MT, LB, and DKO. All authors read and approved the final manuscript.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The FRESH Initiative is being implemented by CGIAR researchers from IFPRI, CIMMYT, The Alliance of Bioversity International and CIAT, IWMI, and CIP in close partnership with the World Vegetable Center, Applied Horticultural Research, the University of Sydney, the Institute of Development Studies, Wageningen University & Research, the University of California, Davis, Sokoine University of Agriculture, Wayamba University of Sri Lanka, and the Philippines Department of Science and Technology-Food and Nutrition Research Institute, along with other partners.

We would like to thank all funders who support this research through their contributions to the CGIAR Trust Fund: .

ORCID iDs

Nadia Koyratty

Fusta Azupogo

Taryn J. Smith

Guy-Marino Hinnouho

Manisha Tharaney

Lilia Bliznashka

Deanna K. Olney

Sonja Y. Hess

Supplemental Material

Supplemental material for this article is available online.

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Supplementary Material

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Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-,Middle- and High-Income Countries: A Scoping Review

Abstract

Background

Objectives

Methods

Results

Conclusions

Plain language title

Plain language summary

Background

Objective

Methods

Findings

Conclusions

Keywords

Introduction

Methods

Scoping Review Design

Eligibility Criteria

Outcomes Assessed

Intervention Strategies

Intervention Types

Impact Assessment

Data Summary

Reporting

Results

Characteristics of Intervention Strategies

Standalone Nutrition Communication Strategies

Standalone and Multi-Component Social Protection Programs

Standalone and Multi-Component Agriculture Interventions

Standalone and Multi-Component Food Environment Restructuring

Overall Multi-Component Strategies

Discussion

Conclusion

Supplemental Material

sj-docx-1-fnb-10.1177_03795721251350208 - Supplemental material for Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-, Middle- and High-Income Countries: A Scoping Review

Supplemental Material

sj-xlsx-2-fnb-10.1177_03795721251350208 - Supplemental material for Impact of Intervention Strategies on Fruit and Vegetable Intake in Low-, Middle- and High-Income Countries: A Scoping Review

Footnotes

Acknowledgements

Author Contributions

Declaration of Conflicting Interests

Funding

ORCID iDs

Supplemental Material

References

Supplementary Material