Determinants of fruit consumption in adult women in Indonesia [version 1; peer review: 1 approved with reservations]

Background: Fruit consumption in Indonesia is low, while diet related diseases are climbing, including among adult women where obesity prevalence is the highest. This study aimed to analyze determinants of fruit consumption among adult women aged 19–49 years in the country. Methods: Analysis was done to secondary data on food consumption obtained from a cross sectional survey of the national Basic Health Research 2010. The potential determinants analyzed were nutritional status (body mass index, BMI), age, formal education, marital status, economic status (quintile), and region. The logistic regression model was applied. Results: The results showed that adult women in Indonesia had higher odds of consuming more fruits if they were with higher BMI (OR BMI > 25=1.093, CI:1.026–1.165), in the older age group (OR middle-aged adult=1.079, CI:1.013–1.150), had higher educational status (OR completed elementary School or higher=2.070, CI:1.909–2.244), from higher economic status (OR high=2.258, CI:2.112–2.413), and resided in urban regions (OR urban area=1.305, CI:1.230–1.385). Meanwhile, being married appeared to hinder fruit consumption (OR=0.915, CI:0.849–0.986). Conclusions: Fruit consumption among adult women in Indonesia showed disparities between socioeconomic and sociodemographic characteristics. Thus intervention to improve fruit consumption should involve improving nutritional knowledge, especially among those with lower level of consumption ( e.g married women), as well as improving access and availability of fruit for women from lower socioeconomic status and rural areas. This could include the use of locally available fruits that is less expensive and more accessible.


Introduction
Easy access and advanced information push modern society to lead a life that dominantly involves mild activities and consume fast food with high fat, sugar, salt, and low fiber (WHO, 2002). Based on WHO review (2021), such meal plans increase the risk of having obesity and non-infection diseases.
In Indonesia, the prevalence of obesity is considerably high, especially for adult women. In 2010, the prevalence percentage of adult women with obesity presented 15.4% (Ministry of Health, 2010) and considered higher numbers in 2013 with 32.9% (Ministry of Health, 2013). Obesity prevalence is higher in urban areas compared to rural areas, and the number of women affected by obesity is higher compared to their male counterparts (Ministry of Health, 2013). Based on the WHO report (2020), 73% of deaths in Indonesia happen due to non-infectious diseases. One of the non-infectious diseases that contribute to the highest numbers of death in Indonesia is diabetes mellitus (DM), according to the Ministry of Health of Indonesia (2020). Diabetes mellitus can happen to anyone, though the higher risk applies from adults to elders, and can reduce life expectancy (Magliano et al., 2018). Diabetes mellitus can also affect workers' productivity, as workers who have diabetes mellitus have lower productivity than those who do not (Tabano et al., 2018). Diabetes mellitus can consecutively decrease the productivity-adjusted life years (PALY) for 11.6% in men and 10.5% in women (Magliano et al., 2018). Also, based on the American Diabetes Association (2018), workers who have diabetes mellitus have higher cost burdens. Diabetes economic cost in the US based on the calculation from direct medical costs and reduced productivity costs, increased by 26% in 5 years (2012)(2013)(2014)(2015)(2016)(2017) due to the increased prevalence of diabetes mellitus.
According to WHO (2003) and Ministry of Health Republic Indonesia (2014), the advised balanced nutrition guide to consuming fruits and vegetables is 400 grams/person/day. Among those numbers, 150 grams are fruits. In general, fruits contain phytonutrients, potassium, and fibers that help fight against non-infectious chronic diseases (WHO, 2003). On the other hand, having less than five portions of fruits and vegetables per day affects a higher rate of deaths (Bellavia, 2013). In Indonesia, as much as 93.6% of the population aged 10 years old or more have fruits and vegetable consumption deficiency (Ministry of Health, 2007). There are many factors that determine a person's consumption of fruit, including: sensory factors, social interactions, fruit price, time, personal principles, media and health advertising (Pollard et al., 2003).
So far, there has been no national-scale research that analyzes determinants of fruit consumption in Indonesia for adult women, a socio-demographic with the highest prevalence of obesity in Indonesia. Thus, this research aims to analyze the determinants of fruit consumption for adult people aged from 19-49 years old. This research follows Basic Health Research 2010 method to collect sampling numbers and methods. The Basic Health Research data collected in 2010 comes from 441 regions/cities among 33 provinces. The numbers of households were 69,300, the number of household members were 251,388, and the number of women aged 19-49 years old were 54,178. The cleaning of data was conducted by eliminating subjects that have no height data (143 people), weight data (135 people), food consumption data (228 people), and pregnancy status data (466 people). We eliminated subjects with calorie intakes numbers of <0.3 and >0.3 times to basal energy (536 people), nutrients adequacy of >400% (635 people), body mass index (BMI) of <12.5 and BMI of >40 (123 people) and unusual consumption (1292 people). The total subjects were 50,620 adult women.

Data source and subject
The types of data and methods of data From the Basic Health Research e-file in 2010, the collected data consists of individual characteristics, economic status characteristics, anthropometric, and food consumption. The individual characteristic data consists of age, origin, education, and jobs. The anthropometric data uses weight and height. The food consumption data uses fruits types and numbers of consumed fruits.
The processing of data and analyses of data Data processing was conducted after data cleaning. The cleaned data was used to calculate the total grams of fruit consumption and to create new variables or derivatives. The bivariate analysis uses the chi-square test to see the correlations of food consumption level to nutritional status, education, region, jobs, and economic status. The overview of the variables and their descriptions are presented in Table 1, and t test used for calculating the average gram per capita per day in fruit consumption and the difference between groups.
The cutoff point used for fruits was 75 g/day or half of fruit consumption recommendation based on balanced nutrients guidelines (150 g/day). This was because the average number of fruit consumption in Indonesia only reaches up to 76.4 g/day (Ministry of Health, 2010). Thus, to analyze the cut-off point, the number of recommended consumptions should be lowered to half point. The multiple logistic regression analysis was used to know the determinant factors of fruit consumption in adult women. All data cleaning and statistical analysis were done using the IBM SPSS version 17. The multiple regression model applied in the research is shown below: π x ð Þ ¼ e β 0 þβ 1 x1þþβ 2 x2þþβ 3 x3þ…þβ n xn 1 þ e β 0 þβ 1 x1þþβ 2 x2þþβ 3 x3þ…þβ n xn

Results and discussion
The analysis results show that the number of adult women in Indonesia who consume less than half of the fruit consumption recommendation reaches 88%. Socioeconomic characteristic consists of nutritional status, age, education, marital status, jobs, economic status, and region type as shown in Table 2. Table 2 shows that women with BMI<25 tend to consume fruits less than 75 g/day (65.4% of all women). Both young adults (32.6% of all women) and middle-aged women (56.5% of all women) tend to consume fruits less than 75 g/day. This showed that fruits consumption in women in Indonesia is low. In addition, women who have elementary school education (82.7% of all women) and are married (72.5% of all women) tend to consume fruits less than 75 g/day. Higher percentage of women who are employed (6.4% of all women) consume more than 75 g/day of fruit compared to only 4.5% of all women among women who are unemployed. More women who are coming from the upper middle-income bracket and those living in urban areas consume fruits more than 75 g/day.
As it was mentioned earlier, the average number of fruit consumption in Indonesia only reaches up to 76.4 g/day (Ministry of Health, 2010). This average consumption per capita is even lower among adult women, which was only around 23 g/day. The t test results presented in Table 3 showed that all socio demographic characteristics significantly correlated to total average consumption of fruit per capita per day. Total average consumption of fruit among women with BMI>25 kg/m 2 , older women aged 30-49 years old, women with higher education of elementary school or higher, women who are single and employed, women coming from upper middle quintile of income bracket as well as women   living in urban areas all show significantly higher average of fruit consumption per capita per day. Sadly, despite fruit consumption being significantly higher among these sociodemographic groups, the total average was very low compared to the national recommendation of 150 g/day and only one third of the national average of fruit consumption which is around 76 g/day. In addition, the calculation also showed very high standard deviation. Thus, caution should be applied in reading the result which indicates low consumption and large disparities.
Multiple logistic regression results showed ( Our findings showed a similar picture in comparison to previous studies regarding the topic. In the USA, a study on consumption pattern among different socioeconomic groups and demographics showed that consumption of fruit and fruit juices are higher among more affluent communities and among those with active lifestyles (Deshmukh-Taskar et al., 2007). Regarding the correlation between education level and fruit consumption, it is assumed that people with higher education levels have better knowledge and awareness to consume healthier foods (Elfhag, 2008). Having a good understanding of nutrition significantly relates to fruit and vegetable consumption (Wardle, Parmenter & Waller, 2000). On the other hand, an individual with lower education may be less likely to consume fruit every day (Giskes et al., 2008) which affects low fruit and vegetable consumption (Darmon & Drewnowski, 2008). The research result of Dynesen et al. (2003) shows that adult women with higher education levels and those who live with two members at the house both have higher frequencies of consuming fruits.  In contrast to reviews from Ab Karim et al. (2012) which shows that marital status has a significant and positive impact on fruit and vegetable consumption, our study showed the opposite where being single was correlated with significantly higher fruit intake. Married people tend to have a higher income than those who are single or those who are unmarried (Friel et al., 2005). Research by Pollard et al. (2001) shows that being married and having smaller number of members living in one house share a positive impact on fruit consumption level, while the mixed result are shown with children. In our case, it is likely that importance of body image and higher agency of choosing better diet may contribute to the higher intake of fruits among unmarried adult women in Indonesia.
The multivariate test result shows that job status is not significant as fruit consumption determinants. The research result from Shohaimi (2004) shows there are strong and independent relations between a social class of work and education level to fruit consumption. Women from lower working social class and have less educational background have less fruit consumption. These findings link to higher awareness of the benefits of consuming fruits (McIntosh et al., 1990). The effect of peer pressure in the workplace are considered non-significant (Shohaimi, 2004).
Our findings show that in adult women with low economic status, the fruit consumption level is lower than upper-middleclass women. This is in line with research on adolescents (Riediger et al., 2007). Both populations in the USA (Rose & Richards, 2004) and Canada (Riediger et al., 2007) show that higher family economic status showed higher fruit and vegetable diet than those with lower economic status. People with lower economic status tend to spend their income for basic needs than for fruits and vegetables, as may be considered as non-beneficial products (Ab Karim et al., 2012).
Research in the UK also shows that fruit and vegetable consumption or healthy food in general are considered costly (Thompson, 2008). Based on research held by WHO (2005), the cost of fruits and vegetables had a negative impact on the consumption of fruits for both people with higher and lower incomes. In line with this, Indonesia has similar condition, as a case study from Hartini et al. (2003) shows that fruit consumption in women in urban areas are higher than in women in rural areas. Thus, systematic education and transformation in the food system to change this point of view is needed.
Residing area types also influence the consumption of fruits. Our study found that women who live in rural areas have lower levels of consumption than those who live in urban areas. Gustafson et al. (2007) reports that there are different numbers of fruit and vegetable consumption between people who live in rural areas to urban areas. This is also related to different job statues and workloads from both areas (Devine et al., 2003), despite the assumption that in urban areas, the probabilities of increased price impact to low demand, the availability and accessibility to various type of fruits may result in increased consumption (WHO, 2005).
This research used a cross-sectional study from the Basic Health Research 2010, collected by Health Research and Development Agency of the Ministry of Health of Indonesia, and has limited views to differentiate cause and effects in variables. Furthermore, it used 24 hours recall calculating data about food consumption, which gives less detailed food consumption habits. However, this research generally shows results that are in line with other previous works.

Conclusions and suggestions Conclusions
The study examined the determinants of fruit consumption among adult women in Indonesia. The finding revealed that fruit consumption among adult women in Indonesia remains low, with nutritional status, age, education level, and income as the determinants of adequate fruit consumption. Based on this research, fruit consumption can elevate in several ways. This includes upgrading information related to nutrition and improving the availability of fruits in each area at an affordable price. Health promotion interventions to scale up fruit consumption should pay attention to the factors identified in this study. The results of this study are expected to provide input to existing government policies. The Indonesian government so far has had guidelines for fruit consumption for the community, but it must continue to be socialized regarding this matter in increasing fruit consumption. Further research is necessary to analyze other determinant factors related to fruit consumption.

Data availability
The data of this study are from the Indonesian Ministry of Health. The data can be obtained trough the following process: 1. Submit an application and proposal to the Indonesian Ministry of Health Balitbangkes (https://www. badankebijakan.kemkes.go.id/) 2. Assessment of proposals by the data owner of the Indonesian Ministry of Health's Balitbangkes 3. If approved, raw data are given according to what is needed in the research 4. Authors are required to sign disclaimer which prohibits data sharing by data owner (Indonesian Ministry of Health Balitbangkes) and only allowed to share results of analysis