Is education or income associated with insufficient fruit and vegetable intake among cancer survivors? A cross-sectional analysis of 2017 BRFSS data

Abstract

ObjectivesPrevious studies found that low education or income level was associated with insufficient fruit and vegetable consumption (IFVC) among the general population. However, cancer survivors can be heterogeneous from the general population in many aspects. Our objective was to disentangle their association among cancer survivors.DesignNationwide cross-sectional survey in the USA.Setting2017 Behaviour Risk Factor Surveillance System.Participants5409 cancer survivors.Exposure and outcomeEducational level (graduated from college/technical school, attended college/technical school and high school or less) and annual household income (≥US$75 000, US$35 000 to <US$75 000 and <US$35 000) were exposures of interest. IFVC, which was defined as <5 servings/day according to the American Cancer Society recommendation, was treated as the outcome.Data analysisMultivariable logistic regression corrected for sampling weight was performed to estimate the association. Subgroup analyses and interaction tests were performed by age, gender, obesity and physical activity.ResultsOverall, 4750 survivors (weighted percentage: 88.5%) had IFVC. Participants with lower education had a significantly higher rate of IFVC (high school or less vs college graduates: adjusted OR=2.17, 95% CI 1.45 to 3.25, p trend <0.01). The association between income and IFVC was almost null. Associations did not differ in most subgroups; however, the association of lower education appeared to be more substantial among physically inactive survivors (p interaction <0.01).ConclusionLow educational background, not low income, was associated with IFVC among cancer survivors. Prospective cohort studies are needed to verify the conclusion.

Prevalence of health behaviors among cancer survivors in the United States

“…We did not have data on type of cancer to be able to estimate weighted percentages among breast cancer survivors solely. Another more recent study using the 2017 BRFSS found that 11.5% of cancer survivors ate 5 or more servings of fruits and vegetables per day [16], a slightly lower weighted percentage than we found in the 2019 BRFSS (15.1% for all cancer survivors). Differences in fruit and vegetable intake reported across different years of BRFSS may reflect actual differences in intake across years, but also may be partially due to differences in wording of survey questions or the different choices by investigators of which fruits and vegetables to include in the total fruit and vegetable variable.…”

“…As mentioned, we did not have information on time since cancer diagnosis, but observed a similar higher prevalence of adhering to multiple behaviors among older cancer survivors (≥ 65 years) compared to younger. We also noted higher prevalence of adhering to multiple behaviors among males, non-Hispanic White and Other race and ethnicity respondents, and those with higher income or education (at least some college) which also have been reported for individual health behaviors in previous studies [15][16][17].…”

“…For example, the 2017 and 2019 BRFSS inquired about frequency of intake of 100% fruit juice with no added sugar, while the 2009 BRFSS asked frequency of intake of any fruit drink. Fruit juice was not included in the total fruit and vegetable intake in the Zhu et al publication on the 2017 BRFSS [16] but was included in the Zhao et al publication from 2009 [15] and in our analyses. Regardless, the prevalence in the range of 11-34% of cancer survivors meeting the fruit and vegetable guideline across different studies is low and The weighted percentage of obesity among cancer survivors increased slightly from the 2009 BRFSS in which 28% had obesity [19] compared to 33% in 2019.…”

“…A systematic review and meta-analyses of 51 studies published prior to 2019 concluded that adherence to diet, physical activity, or multiple health behavior guidelines as recommended by the World Cancer Research Fund/American Institute for Cancer Research was low among cancer survivors [ 12 ], which was corroborated in two more recent papers reporting on Health Information National Trends Survey (HINTS) data [ 13 , 14 ]. Additionally, disparities in adherence to health behaviors by age [ 15 ], sex [ 16 ], race and ethnicity [ 17 ], and socioeconomic status [ 15 , 16 ] have been reported among cancer survivors and those living in areas of high cancer mortality rates.…”

“…Previous literature has reported on the prevalence of health behaviors among cancer survivors in the United States using data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) [ 15 , 18 , 19 ], and a more recent report from the 2017 BRFSS was limited to dietary intake data only [ 16 ]. Thus, we aimed to examine prevalence of multiple health behaviors among cancer survivors in the US with more recent data from the 2019 BRFSS and include the five health behavior guidelines: consuming fruits or vegetables at least five times per day; maintaining a BMI < 30 kg/m 2 ; engaging in at least 150 min of physical activity weekly; not currently smoking; and not drinking alcohol excessively [ 4 , 9 ].…”