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

BMJ Open. 2020 Dec 1;10(12):e041285. doi: 10.1136/bmjopen-2020-041285.


Objectives: Previous 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.

Design: Nationwide cross-sectional survey in the USA.

Setting: 2017 Behaviour Risk Factor Surveillance System.

Participants: 5409 cancer survivors.

Exposure and outcome: Educational 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 analysis: Multivariable 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.

Results: Overall, 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).

Conclusion: Low educational background, not low income, was associated with IFVC among cancer survivors. Prospective cohort studies are needed to verify the conclusion.

Keywords: epidemiology; medical education & training; nutrition & dietetics; oncology.