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Addressing the low consumption of fruit and vegetables in England: a cost-effectiveness analysis of public policies
  1. Ana-Catarina Pinho-Gomes1,
  2. Alec Knight1,
  3. Julia Critchley2,
  4. Mark Pennington3
  1. 1 School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King’s College London, London, UK
  2. 2 Population Health Research Institute, St George’s University of London, London, UK
  3. 3 King’s Health Economics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
  1. Correspondence to Mark Pennington, Institute of Psychiatry,Psychology & Neuroscience at King’s College London, Box 24, David Goldberg Centre, De Crespigny Park, Denmark Hill, London SE5 8AF, UK; mark.w.pennington{at}


Background Most adults do not meet the recommended intake of five portions per day of fruit and vegetables (F&V) in England, but economic analyses of structural policies to change diet are sparse.

Methods Using published data from official statistics and meta-epidemiological studies, we estimated the deaths, years-of-life lost (YLL) and the healthcare costs attributable to consumption of F&V below the recommended five portions per day by English adults. Then, we estimated the cost-effectiveness from governmental and societal perspectives of three policies: a universal 10% subsidy on F&V, a targeted 30% subsidy for low-income households and a social marketing campaign (SMC).

Findings Consumption of F&V below the recommended five portions a day accounted for 16 321 [10 091–23 516] deaths and 238 767 [170 350–311 651] YLL in England in 2017, alongside £705 951 [398 761–1 061 559] million in healthcare costs. All policies would increase consumption and reduce the disease burden attributable to low intake of F&V. From a societal perspective, the incremental cost-effectiveness ratios were £22 891 [22 300–25 079], £16 860 [15 589–19 763] and £25 683 [25 237–28 671] per life-year saved for the universal subsidy, targeted subsidy and SMC, respectively. At a threshold of £20 000 per life-year saved, the likelihood that the universal subsidy, the targeted subsidy and the SMC were cost-effective was 84%, 19% and 5%, respectively. The targeted subsidy would additionally reduce inequalities.

Conclusions Low intake of F&V represents a heavy health and care burden in England. All dietary policies can improve consumption of F&V, but only a targeted subsidy to low-income households would most likely be cost-effective.

  • Economic evaluation
  • Diet
  • Public health policy

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  • Contributors ACPG and MP conceived the study design, did the statistical analysis and wrote the manuscript. All authors provided critical revisions of the draft and approved the submitted draft. The corresponding author attests that all listed authors meet authorship criteria and that no others meeting the criteria have been omitted. MP is the guarantor.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None to be declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the study are included in the article or uploaded as supplemental information.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.