Perceived influences of fruit and vegetable consumption among Indian adolescents – A qualitative inquiry

Abstract

Background

Fruits and vegetables are primary sources of vitamins and minerals that may alleviate the risk of chronic illnesses. However, Indian adolescents consume inadequate amounts of fruits and vegetables, with less than 10% meeting recommendations. Micronutrient deficiencies are a major public health problem in India. For example, the prevalence of iron-deficiency anemia and Vitamin A deficiency in adolescents is 28.5% and 14.4%, respectively. To promote fruit and vegetable consumption among Indian adolescents, we need to identify the factors which may influence the consumption. The aim of this qualitative inquiry was to explore perceived influences of fruit and vegetable consumption among Indian adolescents.

Methods

Using purposive sampling, adolescents aged 10–19 years were recruited from two public and two private (independent) schools in Varanasi, India. Face-to-face interviews along with the ‘draw and tell’ technique were used for data collection. Interviews were conducted in English as well as in Hindi depending on the preferences of the adolescents. The conversations were digitally recorded and transcribed verbatim. The transcribed data were subjected to thematic analysis. Data were coded inductively, and themes were extracted using NVivo software program.

Results

A total of 58 adolescents (53% female; 74% urban) with mean age 13.6 years completed the interviews. Nine major themes and associated sub-themes emerged, including: (i) Sensory properties (i.e., taste, color, flavor, texture); (ii) Health and immunity; (iii) Allergy; (iv) Home food environment (i.e., influence of mothers, availability and accessibility of fruits and vegetables); (v) Cost; (vi) Food preparation; (vii) Influence of peers; (viii) School food environment; (ix) Proclivity for energy-dense, nutrient-poor foods and beverages.

Conclusions

The emerging themes and sub-themes show that multiple factors are likely to affect fruit and vegetable consumption in adolescents, aligning with literature on adolescent fruit and vegetable consumption in international settings. Behavioral interventions should be designed to create enabling environments to encourage fruit and vegetable consumption in Indian adolescents by removing barriers at the individual, household, and community levels, thereby reducing the enduring prevalence of micronutrient deficiencies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-025-21408-0.

Background

Micronutrients are vital chemical compounds essential for normal growth and development [1]. Although required in small amounts, both vitamins and minerals are important throughout the lifespan, but the period of adolescence is more critical as it is characterized by rapid growth spurt [1]. Micronutrient deficiencies are a major public health problem in India [2]; with high prevalence among children and adolescents [1, 3–5]. According to a recent community-based cross-sectional survey in India - Comprehensive National Nutrition Survey (CNNS), the inflammation-adjusted prevalence of Vitamin A deficiency in adolescents (10–19 years, N = 9824) was 14.4% [6]. The same study also reported that 28.5% of adolescents (39.6% girls, 17.6% boys) had anemia and this prevalence of anemia translated to 72 million adolescents in 2018 [7]. Indian adolescents are highly prone to micronutrient deficiencies because of several factors including accelerated increase in requirements for micronutrients, poverty, unhygienic living condition, lack of access to health care services, early age marriage, illiteracy, and unhealthy dietary habits [8, 9]. Empirical evidence suggests that deficiency of micronutrients (iron, zinc, selenium, folate, Vitamin A, and Vitamin B12) during adolescence have adverse effects on overall health, neuropsychological behavior, cognitive and motor function, eye health, immune function, work capacity, language development, and scholastic achievement [10–13]. Considering these negative health consequences, it is important for Indian adolescents to consume a micronutrient-rich diet.

Fruits and vegetables are primary sources of vitamins and minerals that may alleviate the risk of chronic illnesses [14, 15]. Daily consumption of adequate amounts of fruits and vegetables may lower the risk of heart diseases [16], type 2 diabetes [17], and certain forms of carcinomas [18], and are critical in the prevention of micronutrient deficiencies. In addition, to these health benefits, fruits and vegetables are more sustainable than other micronutrient-dense flesh foods as they are associated with the lowest greenhouse gas emissions [19, 20]. Furthermore, dark green leafy vegetables are more accessible and affordable sources of several vital micronutrients than animal source foods in most populations [20–22]. Headey and Alderman (2019) have also reported that dark green leafy vegetables were relatively cheaper in India as well as in Western and Central Africa in comparison to other geographical regions [23].

Despite these numerous benefits, Indian adolescents consume inadequate amounts of fruits and vegetables [24–26]. CNNS found that only one out of 5 adolescents ate green leafy vegetables while less than one out of five adolescents (˂10%) consumed fruits daily [27]. Similarly, another cross-sectional study from Kolkata, India reported that 45% and 30% adolescents (N = 1026; aged 14–16 years) did not consume any servings of fruits and vegetables respectively [24]. While comparing the Indian diet with the EAT-Lancet reference diet, Sharma and coworkers highlighted than an even the richest households in India fail to consume adequate amounts of fruits and vegetables and an average Indian household consumes more calories from ultra-processed foods than fruits [28].

Longitudinal data indicates that lower fruit and vegetable intake during adolescence may predict risk for chronic disease in adulthood [29]. Thus, there is a need to inculcate healthy eating behaviors among Indian adolescents [29, 30]. Therefore, to facilitate the development of effective fruit and vegetable promotion programs for adolescents in India, it is essential to explore the various factors which may be related to the consumption of fruit and vegetables [31].

India is home to 253 million adolescents 10–19 years of age, among the largest cohorts globally [1]. Adolescence represents a sensitive period for developmental, physiological and behavioral changes [1]. Moreover, nearly all the government-led health programs in India designed for adolescents, encompass the 10–19 year old age group, further endorsing the selection of adolescents aged 10–19 years as the study sample.

A number of factors may be positively or negatively associated with the intake of fruit and vegetables among adolescents [32–34]. Two systematic reviews based on quantitative [35] and qualitative [31] studies, predominantly from the western countries, highlighted several likely determinants of fruit and vegetable intake among children and adolescents. These predictors included gender, age, taste, access to unhealthy food, time, cost, influence of peers, socioeconomic position, and home availability/accessibility. However, neither of the systematic reviews included any studies from India, and therefore there is a dearth of empirical evidence about factors related to fruit and vegetable consumption among Indian adolescents. Furthermore, evidence from developed countries may not be applicable to the Indian population because it is a developing country with a diverse dietary landscape (i.e., dietary habits differ from one Indian state to another) [36]. Moreover, if the enduring micronutrient deficiencies are to be tackled effectively, a strong understanding of fruit and vegetable consumption for adolescents at the individual, family, and household levels is necessary.

Behavior change interventions require a better understanding of beneficiaries’ perceptions of fruit and vegetables as well as the barriers and facilitators associated with the consumption of fruits and vegetables [37, 38]. Regrettably, there is little empirical evidence about Indian adolescents’ perceptions. Only one study has explored the barriers and facilitators of fruit and vegetable consumption experienced by rural women of reproductive age [39]. Therefore, the existing literature is devoid of novel, in-depth qualitative data for adolescents in India.

Qualitative methods can identify unknown barriers and facilitators to fruit and vegetable intake as they allow room for unprecedented responses as opposed to highly structured questionnaires administered during surveys [31, 40, 41]. Previously, school-based, community-based [42, 43] and, garden-based nutrition education interventions [44] have been successful in increasing adolescents’ fruit and vegetable intake in international settings, but again, no study to our knowledge has ever examined Indian adolescents’ views of fruit and vegetable consumption.

In this light, the present qualitative inquiry was designed to illuminate the factors related to fruit and vegetable consumption among Indian adolescents through in-depth interviews. Findings from this inquiry have the potential to inform interventions to promote fruit and vegetable consumption and prevent micronutrient deficiencies for adolescents in India.

Methods

Study design

The present inquiry adopted a qualitative research design [45, 46] informed by the social constructivist paradigm [47]. Through the social constructivist paradigm, the investigators aim to understand informants’ perspectives about the subject area which result from their interactions with the members of their society [47]. Adopting the social constructivist lens, the study investigators examined the adolescents’ responses to questions to capture key insights about the factors related to fruit and vegetable consumption. Qualitative research techniques are valuable tools to generate a more thorough understanding of the topic under study, reflecting the diversity of views within the framework of formative research aiming to design sustainable interventions tailored to a specific population’s needs and contextual conditions [31, 37, 38]. This inquiry received ethical approval from the Institutional Ethical Committee of Banaras Hindu University (Dean/2021/EC/2817). The Consolidated Criteria for Reporting Qualitative Research (COREQ) – a 32-item checklist [48] was used to report the research protocol of this study (Additional File 1).

Research team

Within the context of the present qualitative inquiry, the lead author (NR) is a mid-career researcher from India with expertise in adolescent nutrition and qualitative research. She conducted all the interviews in person and did not share any prior relationship with the study respondents. Other two members of the research team included a female Public Health Nutritionist (MB) from the United States and a male food psychologist (AW) from Australia. Both MB and AW being senior scientists, supervised data analysis and report writing. This involvement of authors from varied academic disciplines minimized the possibility of any personal or disciplinary biases during thematic analysis of the interview transcripts.

Study sample and setting

Adolescents aged 10–19 years in India formed the study sample. Data collection was carried out in Varanasi (Varanasi is a district in the state of Uttar Pradesh; Uttar Pradesh is the most populous state of India) between October 2023 and February 2024. As per 2011 census data, Varanasi had a population of 3,676,841 (52% males, 56% rural) with a literacy rate of 83.77% and 66.69% in males and females respectively [49]. Uttar Pradesh has the highest adolescent population in India which is badly affected by micronutrient deficiencies [6–8]. It is home to twice as many anaemic adolescents when compared to any other state in the country. According to the CNNS, 15% of the adolescent population is suffering from Vitamin A deficiency and this was greater than 20% in four Indian states including Uttar Pradesh [6]. The adolescent participants in the study were selected both from rural and urban Varanasi. Efforts were made to recruit relatively equal numbers of male and female adolescents since fruit and vegetable intake may be influenced by gender [35] as female adolescents tend to consume more fruits and vegetables compared to their male counterparts [24].

Sampling and recruitment

Purposive sampling was used for the recruitment of adolescents from eight schools in Varanasi. Two public and two private (independent) schools each were selected from rural and urban Varanasi respectively. School education system in India comprises four stages: Stage 1 – Foundational stage (3–8 years); Stage 2 – Preparatory stage (8–11 years) ; Stage 3 – Middle stage (11–14 years); and Stage 4 – Secondary stage (14–18 years) [50]. Private schools are more popular in urban settings while public schools are mostly attended by children from lower socio-economic strata (SES) because it provides free education until Grade Eight unlike fee-charging private schools [51]. In addition, the food environment in public schools varies from food environment in private schools. In public schools, free lunch is provided until 8th Grade whereas in private schools no free lunch is provided. The lead author (NR) sought the permission of school principals to carry out research in their respective schools. Adolescents were recruited by posting flyers on school billboards. School Principals provided organizational consent for the study to take place in their schools, wrote to parents requesting permission for their children to participate, and obtained informed consent from those who agreed. The investigators obtained assent from minor children who participated and written informed consent from older adolescents.

Data collection

Face-to-face interviews (i.e., one interview per adolescent) along with the ‘draw and tell’ technique [52] was used to collect data from the study sample. The draw and tell technique [53, 54] is an exploratory bottom-up approach to facilitate inductive reasoning in interpretive descriptive studies [52]. Traditionally, the drawing approach has been often used as a way to engage younger children in health and behavioural research [55–57]. However, in the recent past this technique has been shown to be effective with adolescents and adults [52]. The participants were asked to draw a picture in response to the following instruction: “Please draw your favourite fruit and vegetable.” The interviewer (NR) informed the participants that their drawing ability was not under scrutiny [52]. Participants were provided with crayons, sketch pens, pencils, eraser, and drawing sheets. Subsequently, the participants discussed their drawing with the interviewer and answered a list of open-ended questions.

The interview guide (Table 1) was developed to understand adolescents’ perceptions about impediments and enablers to fruit and vegetable consumption. The open-ended questions were derived from the literature [31, 39, 58, 59] and pre-tested with four adolescents (2 boys and 2 girls, ages 11–15, one boy and one girl from urban and rural area each) to verify the face validity of the questions. No modifications were made in the interview guide and consequently the pre-test data was merged with the final data set.

Table 1.

Interview guide

1. Draw your favorite fruit and vegetable. Why do you like them?

2. Are there any fruits and vegetables which you don’t like? If yes, may you please draw them. Why don’t you prefer eating them?

3. What do you believe is the main reason for adolescents consuming fruits and vegetables?

4. Are you more likely to eat fruits or vegetables at breakfast, lunch, dinner, or as a snack or dessert?

5. What would make it easier for you to eat fruits and vegetables on a daily basis?

6. If you could change one thing that would make you eat more fruits and vegetables, what would it be?

7. What do you believe is the main reason adolescents do not consume fruits and vegetables?

8. What makes it hard to eat more fruits and vegetables?

9. Think about when you are at home; is there anything that prevents you from eating fruits and vegetables?

10. Think about when you are at school; is there anything that prevents you from eating fruits and vegetables?

11. What do you think causes you to eat more or less vegetables when you dine in a restaurant?

12. When at home, what prevents you from reaching for an apple instead of the Oreo cookie?

The face-to-face interviews were conducted in English as well as in Hindi depending on the preferences of the adolescents (NR is fluent in both Hindi and English). The adolescents were provided with fresh seasonal fruits and yoghurt on completion of the interview. Saturation [60] was reached at the 54th interview. Nonetheless, NR conducted four more scheduled interviews and therefore data collection was completed at the 58th interview. All interviews were audio recorded and they ranged from 25 to 50 min. Out of 58 interviews, 48 interviews were carried out in a closed classroom where no teacher or class fellow known to the interviewee were present while remaining 10 interviews were conducted in the participants’ homes as the winter break was prolonged due to cold wave conditions in Varanasi. Permission to conduct interviews in participants’ homes was sought from parents over the phone. The home interviews were carried out in a closed room in the participant’s house when no parent or sibling was present. Basic socio-demographic information such as age, gender, and year level at school were recorded for each interviewee. All recordings were transcribed verbatim and translated to English where necessary.

Data analysis

A six-phase thematic analysis framework [61] was adopted by the study investigators which included: Phase I - the investigators acquainted themselves with the raw data through repeated reading of the transcripts; Phase II – Inductive coding was employed wherein preliminary codes were produced from the raw data; Phase III – Assembling the preliminary codes into potential themes; Phase IV – Critical evaluation and refinement of the themes; Phase V – Generating distinct definitions and narrative description for each theme; Phase VI – Developing the manuscript where themes were linked to illustrative quotes from the participants, allowing for a comprehensive analysis of the participant accounts [61–63]. The NVivo 12 software program (QSR International Pvt Ltd, 2010) was used to thematically analyze the transcribed data.

All data was primarily coded by NR while MB coded 50% of the interview transcripts to enhance reliability and minimize any possible bias associated with personal interpretation of data [64]. Any conflict between the two coders (NR, MB) was addressed through discussion and consultation with the third coder (AW). In addition to ensure fidelity, member checking [65] was performed whereby all the interviewees were invited to review their respective transcripts, but none expressed any interest in assessing them.

Results

Personal characteristics of the sample

Fifty-eight adolescents (53% female; 74% urban) with mean age 13.6 (SD = 1.9) years participated in the interviews (Table 2). Out of these 58 adolescents, 71% attended private school and a similar proportion (72%) were studying between 4th and 8th grades.

Table 2.

Personal characteristics of the study participants

ITEMS		N = 58 (%)
Gender	Male	27 (47)
	Female	31 (53)
Type of setting	Rural	15 (26)
	Urban	43 (74)
Type of school	Government	17 (29)
	Private	41 (71)
Grades	Primary (IV-VIII)	42 (72)
	Secondary (IX-X11)	16 (28)

Drawings

All the adolescents drew pictures (Additional File 2 - Figure S1, S2) of their most and least favorite fruits and vegetables. Mango emerged as the most popular fruit as 31 adolescents drew mango. The second favorite fruit was apple (N = 11). Among the vegetables, 17 adolescents drew okra making it the most liked vegetable among the sample. Other popular vegetables included potato (N = 10), carrot (N = 8), and cauliflower (N = 8). Bitter gourd (N = 20) and eggplant (N = 13) were the least popular vegetables as illustrated through the adolescents’ drawings. Pineapple (N = 8) and kiwifruit (N = 7) emerged as the least popular fruits.

Themes

Nine major themes along with sub-themes were identified through thematic analysis of the 58 interviews associated with the perceived influences of fruit and vegetable consumption among the adolescents: (i) Sensory properties (i.e., taste, texture, color, smell); (ii) Health and immunity; (iii) Allergy; (iv) Home food environment (i.e., influence of mothers, availability and accessibility of fruits and vegetables); (v) Cost; (vi) Food preparation; (vii) Influence of peers; (viii) School food environment; (ix) Proclivity for energy-dense, nutrient-poor foods and beverages (Table 3).

Table 3.

Themes and sub-themes associated with perceived influences of fruit and vegetable consumption

THEMES	SUB-THEMES	QUOTES
Sensory properties	Taste	“Among fruits, I like mango the most because it is sweet and very juicy.” (A3, 16 years, F, U) “I don’t like bitter gourd because it tastes bitter!” (A26, 12 years, F, U)
	Texture	“I don’t like kiwi because it tastes sour and contains seeds.” (A25, 15 years, M, R) “….Orange contains fiber which I don’t like.” (A2, 15 years, F, U)
	Color	“I don’t like pumpkin because of its taste and color.” (A43, 13 years, M, R) “I don’t like brinjal because I don’t like its color.” (A10, 14 years, F, U)
	Smell	“……I don’t like its (mango) taste and smell.” (A18, 18 years, F, R) “I don’t like its (mango) smell, that’s why I don’t eat it.” (A56, 12 years, M, U)
Health and immunity		“I like spinach because it is very good for our eyes.” (A23, 15 years, F, U) “……I eat an apple every morning. They say, ‘An apple keeps a doctor away’ so I eat an apple every morning.” (A24, 17 years, M, U) “I like mangoes because they are tasty and contain many vitamins and minerals.” (A32, 12 years, F, U)
Allergy		“I don’t like pomegranate as I have an allergy…. After eating I start vomiting……” (A38, 16 years, F, U) “Allergy occurs after eating mangoes and pimples start appearing. ” (A18, 18 years, F, R)
Home food environment	Influence of mothers	“Their (friends) mother gives fruits in tiffin, their mother even came to school to complain but still they do not eat fruits.” (A4, 11 years, M, U) “Whether anyone is at home or not, I will have my fruits because my mother feeds me fruits daily. ” (A39, 10 years, M, U)
	Availability and accessibility of fruits and vegetables	“….usually fruits are not available at my home.” (A4, 11 years, M, U) “There are not many fruits available in my house so when papa brings it, we eat it. We usually eat on Sunday afternoon.” (A28, 13 years, M, R)
Cost		“Fruits are very expensive, so poor people are not able to eat much.” (A28, 13 years, M, R) “…There are families who can’t afford to buy fruits.” (A45, 13 years, M, U)
Food preparation		“I don’t like any vegetable no matter how it is prepared” (A21, 14 years, F, R) “We can make juice and shakes out of fruits …I think everyone likes juices rather than having it raw…” (A48, 13 years, F, U)
Influence of peers		“There are certain friends of mine who don’t eat fruits.” (A51, 11 years, M, R) “My friends eat very little fruits and vegetables….They always had a habit of eating junk food since childhood. All my friends only eat momos (rice dumplings steamed/fried) and patties. So, I also eat momos, patties, and samosas in school.” (A27, 15 years, M, R)
School food environment		“Vegetables are provided as part of the mid-day meal program.” (A44, 15 years, F, U) “….chips, cold drinks are available in school.” (A54, 14 years, F, R)
Proclivity for energy-dense, nutrient-poor foods and beverages		“Nowadays our eating habits have become very different, and children like to eat outside food like pizza, burgers only according to their taste, which feels good.” (A23, 15 years, F, U) “I would like to have Oreo cookies because they taste better than vegetables and fruits.” (A29, 15 years, F, R) “Junk food (pause)…….Every child likes it, who doesn’t like it??” (A8, 15 years, F, U)

Theme 1 - Sensory properties

The most frequently discussed influences on fruit and vegetable intake were sensory properties including taste, color, texture, and smell.

Taste: The majority of the participants cited taste as a barrier to, and facilitator of, fruit and vegetable consumption. Sweet taste was most preferred while sour and bitter tastes were not favored by several participants.

“I don’t like to eat pineapple because of its sour taste. It causes irritation to my lips and tongue.” (A57, 11 years, F, U).

“I love to eat capsicum because it’s incredibly tasty and we can make so many different dishes with it.” (A43, 13 years, M, R).

Texture: Besides taste preferences, texture was often mentioned as a factor related to eating fruit and vegetables. Some participants did not enjoy eating certain fruits and vegetables because of the presence of seeds and fiber in them. A few participants disliked certain vegetables like bottle gourd and eggplants, which turned slimy on cooking.

“Yes, I don’t like to eat guava because when I eat it, it’s seeds get stuck in my teeth.” (A39, 10 years, M, U).

“I don’t like eating eggplant. Eating this leaves a peel in the mouth.” (A4, 11 years, M, U).

Color: The interviewees also reported that color also influenced their fruit and vegetable intake. Bright colored fruits like mangoes and strawberries were the most preferred fruits. On the other hand, they did not like vegetables such as eggplant and spinach which turned black/dull green in color during food preparation.

“I don’t like eggplant as it turns black on cooking.” (A27, 15 years, M, R).

“My favorite fruit is mango because its color and taste are very good, and it is also very juicy.” (A40, 13 years, F, U).

Smell: Another important sensory property reported by the participants was smell. Several participants noted that they enjoyed the flavor of bell peppers and how it can be blended with other vegetables to enhance their aroma. Smell could also be an inhibiting factor as noted by two participants who did not enjoy the smell of cooked cabbage and overripe mangoes.

“….Because it has a nice aroma, it is delicious and we can buy it in every season, also we can add it in every vegetable to enhance the flavour so that is why I like capsicum.” (A38, 16 years, F, U).

“I don’t like the smell of cooked cabbage.” (A28, 13 years, M, R).

Theme 2 - Health and immunity

All the adolescents claimed to consume fruits and vegetables as they were good sources of essential micronutrients like vitamins and minerals. Besides promoting good health, fruits and vegetables also provided protection from morbidities as noted by the participants.

“…Fruits will keep your health good and will not cause any disease.” (A35, 11 years, F, R).

“Although all fruits are good, my favourite fruit is mango….Because it tastes very good….Vitamin A and Vitamin C are also found in it which are good for our health.” (A24, 17 years, M, U).

“I like carrots because they are good for eyesight.” (A2, 15 years, F, U).

Theme 3 - Allergy

Fruit and vegetable allergies emerged as barriers to fruit and vegetable intake during the interviews. Nine adolescents noted that intakes of fruits and vegetables like mangoes, broccoli, pomegranate could trigger allergic reactions with symptoms ranging from itching, tingling sensation in the mouth, to nausea.

“Actually, I eat all green vegetables, but I have a problem with broccoli. Because I’m allergic. When I eat broccoli, it makes me feel sick.” (A39, 10 years, M, U).

Theme 4 - Home food environment

Influence of mothers: The adolescents also discussed the role of their mothers in determining their fruit and vegetable intake. They claimed that their mothers informed them about the benefits of eating fruits and vegetables and emphasized the need for regular consumption of these healthy foods thereby inculcating the habit of eating fruits and vegetables regularly among the participants. The mothers often packed fruits and cooked vegetables for school lunch as reported by the participants and if these healthy foods were not consumed then the participants faced severe punishment from their mothers.

“…Mummy repeatedly says that fruits are good and have high nutritional value….” (A51, 11 years, M, R).

“When Mummy cooks vegetables, I have to take them in tiffin.” (A9, 13 years, F, U).

“….In fact, my mother scolds me that’s why I eat more fruits and vegetables at home than in school.” (A48, 13 years, F, U).

Availability and accessibility of fruits and vegetables: The availability and accessibility of fruits and vegetables within the household was perceived to be an important determinant of adolescents’ fruit and vegetable intake. Adolescents predominantly from rural settings reported cultivating their fruits and vegetables in their fields and using them for their own consumption. Several adolescents noted that they did not consume fruits regularly because of limited availability of fruits in their homes as their fathers did not procure them daily from the market.

“Potato, tomatoes, peas, and radishes are grown. In fruits, we have papaya, mango, guava trees.” (A15, 13 years, F, R).

If it (fruits) is available at home, then I eat. I don’t know…………… when it is available in the market my father buys it and brings it home.” (A14, 11 years, M, U).

“We are not always able to eat fruits as we cannot afford them, so they are brought home sometimes.” (A41, 15 years, F, R).

Theme 5 - Cost

About two-fifths of the sample complained about the rising prices of fruits and vegetables. In particular, adolescents reported that fruits were quite expensive, and therefore, fruits were rarely consumed on a daily basis in lower SES households.

“Fruits and vegetables are quite expensive….Their price is increasing day by day.” (A58, 12 years, F,U).

To mitigate this cost barrier, one of the participants suggested generating more income through increased farming activities thus enhancing the frequency of fruit consumption:

“If I have to eat fruits every day, then we will have to do farming well and save money so that we can buy them.” (A13, 10 years, M, R).

Theme 6 – Food preparation

Food preparation was also reported to be a key determinant of fruit and vegetable consumption. Some adolescents reported that they did not enjoy eating whole fruits but liked consuming fresh fruit juices, milk shakes (e.g., banana shake, strawberry shake), fruit custard, fruit chaat (i.e., fruit salad seasoned with Indian spices). Some adolescents also commented on the type of food preparation used for cooking vegetables; they preferred grilled and fried vegetables over steamed and boiled vegetables.

“If you put fruits in custard then I will have them. I like fruit custard.” (A20, 16 years, F, U).

“As such I don’t like brinjal curry, but I like roasted brinjal very much.” (A25, 15 years, M, R).

Theme 7 - Influence of peers

The participants also talked about the influence of their peer group on their fruit and vegetable intake. These friends pressured them to bring junk food in their packed lunches from home. Ten participants also mentioned that they did not consume their own packed lunch of fruits and home cooked foods such as sautéed vegetables as they preferred to share junk food from their classmates’ lunchboxes. The participants reported that they relished junk food in the school canteen along with their classmates.

“Most of my friends like tasty food that is why they don’t eat fruits and vegetables.” (A22, 19 years, F, R).

“They (classmates) do not bring green leafy vegetables in tiffin (lunch box). They bring junk food. So, eat from their tiffin (packed lunch brought from home). They also ask me to get pizza, chips in tiffin….My mother packs fruits for me but I don’t have them.” (A4, 11 years, M, U).

Theme 8 - School food environment

The participants had mixed views about the influence of the school food environment on adolescents’ consumption of fruits and vegetables. Participants attending public schools noted the availability of fruits and vegetables in the mid-day meal (free school lunch program). However, some of the participants criticized their school’s lunch program. For example, one participant reported that fruit was provided only once a week, and it was mostly bananas and vegetables were not cooked properly making them less palatable. Several participants noted that secondary school students (i.e., Grades IX-XII) were not eligible for this government food assistance program.

“Mid-day meal is available…. Vegetable rice is served on Monday. Fruit is provided once a week only. We only get bananas.” (A53, 15 years, F, U).

“Earlier it (fruits and vegetables) was available in school, but now it has stopped.” (A33, 12 years, M, R).

On the other hand, private school attendees reported that energy-dense, nutrient-poor foods and drinks like chips, pizzas, carbonated beverages were mostly available in their school canteens with limited availability of fruits and vegetables. They further noted that they were often attracted to these energy-dense, nutrient-poor foods and beverages. Some of them (n = 12) also reported that fruits and vegetables and other food products were not available in their schools because of the absence of canteens.

“Chowmein (Hakka noodles), samosa, Maggi (a brand name for instant noodles) are available. They are so tempting!!!” (A22, 19 years, F, R).

“There is no canteen in school, so nothing is available. ” (A8, 15 years, F, U).

Theme 9 - Proclivity for energy-dense, nutrient-poor foods and beverages

Nearly all the interviewees claimed that they savored the taste of energy-dense, nutrient-poor foods much more than the taste of fruits and vegetables. They further noted that they were bored with eating fruits and vegetables as well as home cooked food regularly and therefore enjoyed eating pizza, chips, cookies, and burgers. Nearly one-fifth of the sample also reported that consumption of fruits and vegetables did not give a ‘cool vibe’ while consuming fast food and sugar-sweetened beverages was considered in vogue.

“…….We do not want to eat normal food, which is cooked at home, so we get attracted to junk food.” (A38, 16 years, F, U).

“Burger….eating all this feels good.” (A56, 12 years, M, U).

“Everyone is bored of fruits & vegetables. Instead, they (friends) like to eat snacks, cold drinks. To be cool, to make reels in Instagram…Eating fruits and vegetables does not make us look cool!” (A41, 15 years, F, R).

Discussion

The purpose of this study was to provide the first known assessment of perceived influence to the consumption of fruits and vegetables among Indian adolescents. This research inquiry identified nine factors that could influence the intake of fruits and vegetables among Indian adolescents. Health and immunity emerged as a key facilitator of fruit and vegetable consumption among the study participants. The adolescents cited peer influence, the higher cost of fruits and vegetables and widespread liking for unhealthy food as three of the main barriers to fruit and vegetable consumption during the interviews. Other perceived determinants of fruit and vegetable intake like home food environment, school food environment, sensory attributes of fruits and vegetables, and food preparation had both positive and negative influences on fruit and vegetable consumption. These factors complement existing empirical evidence on the determinants of fruit and vegetable intake in children and adolescents and provide a novel viewpoint from the global south [31, 32, 66–68].

Fruits and vegetables’ sensory attributes like taste, smell, texture, and color were identified as both promoters and barriers for fruit and vegetable consumption among our participants, a determinant that has been widely discussed in the literature [31, 68]. Many participants saw taste as the most important factor among the sensory attributes for liking fruits and not liking vegetables, a viewpoint also expressed by Iranian [69] and Malaysian [70] adolescents. In line with the Iranian [69] adolescents, our interviewees indicated that they appreciated the sweet taste of fruits like mangoes while showing aversion towards green vegetables like bitter gourd because of its bitter taste. This finding corresponds to other research [71, 72] that suggests that children and adolescents are more sensitive to bitter taste and prefer higher concentrations of sugar than adults [73, 74]. In addition, a systematic review reported that adolescents sensitive to bitter tastes often demonstrate reduced liking for bitter-tasting food and enhanced liking for sweet-tasting food [75].

Besides taste, the home food environment was perceived to have both negative and positive influences on the participants’ fruit and vegetable intake. The participants claimed that their mothers endorsed healthy eating through nutrition education and provision of fruits in their lunch box. If fruits were not consumed, then the adolescents were often reprimanded by their mothers. These maternal feeding practices appear to reflect both authoritative and authoritarian parenting styles [76, 77], which have been adopted by parents globally to facilitate healthy eating in adolescents [78–83].

Consistent with previous investigations [31, 68, 69, 84], the present study also showed that the availability and accessibility of fruits and vegetables inside the home environment were important determinants of adolescent fruit and vegetable consumption. Participants particularly from rural settings discussed growing their favorite fruits and vegetables on their own land, highlighting the easy availability and accessibility of fresh produce. In contrast, urban adolescents criticized the limited availability of fruits in their homes because their fathers were not frequent buyers of fruits. This criticism was also endorsed in previous research by Indian fathers from middle and lower socioeconomic strata who lamented their poor financial status which hindered them from purchasing fruits for their adolescents on a daily basis [85]. Also, unlike other countries [86, 87] where mothers are recognized as the primary food shoppers, the present study as well as a local study [85] suggested that Indian fathers were mostly engaged in food shopping for their households.

Apart from the home food environment, the study participants reported that the school food environment also played a major role in determining fruit and vegetable intake. The participants attending primary and upper primary public schools received fruits once a week and vegetables on a regular basis under the Mid-Day Meal (MDM) scheme. The MDM scheme is recognized as the world’s largest national free school lunch program, serving hot cooked and balanced meals to Indian public school children till eighth grade [88, 89]. However, some participants complained that they only received banana or sweet lime on Monday and the vegetable curry was not palatable as it had uncooked vegetables. The MDM scheme has received harsh criticism for its low-quality meals, half-cooked meals, and unhygienic cooking practices [90, 91]. Another shortcoming raised by public school attendees was that fruits and vegetables were not available in high school (i.e., Grades IX – XII). Perhaps, the MDM scheme could be extended to high schools thus enhancing access to fruits and vegetables in high school pupils.

In contrast, the study respondents attending private schools discussed the widespread availability of palatable energy-dense, nutrient-poor foods in their school canteens which frequently incited the adolescents to consume such foods, a finding consistently reported in the South Asian context [92–96]. The participants from private schools further noted that fresh fruits and vegetable salads were sparingly available in the private school canteens. This negative feedback regarding school canteens could be attributed to the lack of school food policies [97, 98]. To combat the burgeoning obesogenic school food environment, Indian schools could implement the recently introduced Food Safety and Standards Regulation 2020, which would ensure the availability of nutritious foods in school canteens thereby sustaining healthy dietary behaviors among pupils [99, 100].

The adolescents held positive beliefs about fruits and vegetables. Unanimously, they recognized fruits and vegetables as healthy food choices, a belief also shared by Dutch [101], Flemish [101], and Latino adolescents in the US [102]. The participants further noted that fruits and vegetables contain vitamins and minerals as well as strengthened immunity. In contrast to these positive views, most Indian adolescents fail to meet national dietary recommendations [24, 27]. This finding might be attributed to lack of procedural nutritional knowledge (i.e., how to do things – cooking skills) among Indian adolescents [103–105], as this wasn’t raised by the adolescents in the current study. Declarative nutrition knowledge (i.e., awareness about facts and things – e.g. carrots are a good source of β-Carotene) is essential but not adequate to change dietary behavior [106]. Therefore, a combination of both declarative and procedural nutritional knowledge could result in improved intakes of fruits and vegetables [106].

Adolescents’ proclivity for energy-dense, nutrient-poor foods including pizza, chips, burgers was perceived as a potential barrier to fruit and vegetable intake. Similar liking for unhealthy foods has also been observed among adolescents globally [107–109]. Recent studies in India have also highlighted adolescents’ excessive consumption of unhealthy foods and sugar-sweetened beverages and poor dietary intake of fruits and vegetables in Indian adolescents [24, 27, 103, 110]. This proclivity could be linked to the burgeoning fast food multinational companies in the Indian food market which in turn has triggered the replacement of traditional Indian dietary components with westernized diet in both urban and rural households [28, 36, 93, 111–113]. The changing dietary landscape, coupled with relatively inactive lifestyles [114], is associated with the increased risk of non-communicable diseases which are currently on rise in India [115–118]. Besides the food environment, this proclivity could also be attributed to adolescent autonomy and social acceptability [119].

The rising prices of fruits and vegetables were another consumption barrier cited by the adolescents. Some participants mentioned that they were unable to consume fruits daily because their parents could not afford to buy fruit and vegetables on a regular basis. Globally, cost has consistently been identified as a common barrier to meeting dietary recommendations of fruits and vegetables across different populations, more so in low-income settings [31, 39, 120–123].

High food prices have been associated with reduced access to fruits and vegetables and poor nutritional status among vulnerable groups including adolescents [124]. Fruits and vegetables have shown a higher degree of intra year volatility in their prices and have also been identified as one of the major contributors to overall food inflation in India [125]. This calls for increasing the shelf-life of perishable produce by improving the infrastructure required for their storage and transport [125, 126]. Making fruits and vegetables available at affordable prices is a global priority and this would require a multisectoral (e.g. agriculture, public health, economic) collaboration to develop innovative strategies and policies at the individual, society and national level [127–129]. Perhaps, policies should be implemented whereby subsidies are given to farmers for cultivating fruits and vegetables. Furthermore, greater investment in research and innovation aimed at enhancing efficiencies, reducing waste, and improving healthy competition for fruits and vegetables as high-value crops both nutritionally and economically is warranted for making fruits and vegetables more affordable [126, 130].

Some of the interviewees perceived their peers as major barriers to their fruit and vegetable intake. This was because their peers rarely consumed fruits and vegetables and were habitual consumers of unhealthy foods. This negative influence of peers has also been cited previously [109, 123, 131]. Echoing the views of Lithuanian adolescents [131], our participants also noted that their peers regarded eating fruits and vegetables as well as posting pictures of them on social media was not a ‘cool’ activity. In contrast, Stok and colleagues found in the TEMPEST study that peer influence can be positive. They found peer encouragement of healthy eating was significantly associated with adolescents’ healthy eating intentions and intake of fruits and vegetables [132].

In addition to these determinants, the present study also unveiled Indian adolescents’ preferred and non-preferred fruits and vegetables. Mangoes and apples emerged as the most popular fruits, again this is consistent with the liking of South Korean [133] and Bangladeshi adolescents [123]. Mango, ‘The King of Fruits’, is commercially the most important fruit crop of India [134]. India is the largest producer of mangoes in the world and within India, Uttar Pradesh ranks second in terms of mango production [135, 136]. The most popular variety is Alphonso which is known for its high content of Vitamin C, β-carotene, and minerals [134, 137, 138].

Interestingly, the most preferred vegetable was okra, however, this contradicts earlier evidence wherein Beninese [139] and Malaysian [140] adolescents showed aversion towards okra. One plausible reason for this discrepancy could be the type of food preparation used in Indian households as okra is often deep-fried and served as fritters. Furthermore, vegetable consumption data from the global north [141–144] highlights potato as the most preferred vegetable among adolescents whereas in the present context, potato was ranked second after okra. Like mango, India is the largest producer of okra in the world [145] and is a very good source of vitamins (i.e., vitamin K, vitamin C, vitamin B1, vitamin B6, folate), minerals (i.e., manganese, potassium magnesium), and dietary fiber [146].

Our adolescents disliked consuming bitter gourd which is in line with the views of Thai adolescents [147]. Peer modelling, reward and repeated exposure have been effective in increasing liking for fruits and vegetables in children [148]. In addition, fruits and vegetables can be incorporated in a variety of snacks, meals, and drinks (e.g., mango sandwich, cream of broccoli soup, corn and spinach sandwich, mango shake, carrot dip, spinach and carrot pilaf) acceptable to adolescents or by disguising their presence (e.g., green leafy vegetables can be kneaded into the dough of Indian breads and other vegetables like pumpkin, carrots, broccoli can be mashed/pureed and used as a stuffing or a base for Indian curries) [137].

Strengths and limitations

Against the backdrop of limited evidence on determinants of fruit and vegetable consumption among adolescents in the developing world, this is one of the foremost qualitative research investigations to explore the perceived influences of fruit and vegetable consumption among a group of Indian adolescents. These adolescents’ novel insights have the potential to inform future healthy eating interventions. Although this inquiry captured the first-hand views of both urban and rural Indian adolescents attending public/private schools, there are a few limitations. First, the adolescents could have provided socially desirable responses as 10 interviews were conducted in adolescents’ homes. However, they openly criticized the MDM scheme in public schools and the rampant availability of unhealthy foods in private school canteens, which suggests that socially desirable responses were minimal in this inquiry.

Second, the present findings may not be generalizable to the entire Indian adolescent population as it was conducted only in the Varanasi district and during winter season when schools were physically closed due to prolonged winter break. This highlights the need to extend this study to different geographical regions due to India’s diverse food landscape.

Third, our sample was dominated by adolescents studying in primary grades (IV-VIII) with a mean age 13.6 (SD = 1.9) years and this could affect the generalizability of our findings. One reason for this dominance could be that there is immense academic load in senior grades (IX-XII) because two national level competitive examinations are conducted in grades X and XII respectively every year. In addition, previous qualitative research conducted on Indian adolescents (n = 39; 10–19 years) in Varanasi showed similar age-wise distribution within the sample where the mean age of the participants was reported as 14.35 years (SD = 2.70) [149].

Fourth, there was more representation from the urban area as compared to rural area as a greater number of students from private schools than public schools expressed interest in participating in this research inquiry. This could be partially explained by the fact that public schools in rural areas were closed for a longer duration because of the prolonged cold wave conditions in January 2024 (i.e. data collection period) while private schools in urban areas were conducting online classes. Moreover, private schools and public schools are more popular in urban and rural areas respectively. This is clearly reflected in a recent study conducted in rural Varanasi where 37 adolescents out of 39 adolescents attended public schools, only one adolescent attended private school, and the remaining adolescent was an early school leaver [149].

Nonetheless, despite the predominance of urban adolescents in the present sample, no vivid discrepancies were observed in the perceptions of urban and rural participants regarding the factors influencing the intake of fruits and vegetables among them. Previous literature on healthy eating also suggests that both rural and urban adolescents in India share comparable views about their daily diets and its determinants [150, 151].

Recommendations for practice

The multiple factors highlighted during the interviews could inspire both school-based [152–154] and home-based behavioral nutrition interventions [31, 154] to boost fruit and vegetable intake among Indian adolescents. In the home, parents could serve as role models for healthy eating as parental role modelling of fruits and vegetables at meals and snacks has been associated with adolescents’ adequate consumption [155]. Parents could also engage their adolescents in food preparation skills like peeling and cutting of fruits and vegetables [31]. The home nutritional environment could be further enhanced by involving adolescents in cultivating their own fresh produce in kitchen gardens thus increasing their accessibility to fruits and vegetables.

Supportive school food environments could be created through implementation of effective school food policies [154] which prohibit or limit the sale of unhealthy foods and sugar-sweetened beverages in school canteens. Following the MDM scheme, private schools in India could also provide fruit and vegetables at subsidized rates or free of cost to their students. They should also make provision for a separate ‘fruit break’ to allow pupils to consume fruit and vegetables during school hours [31]. Classroom-based activities like culinary classes (i.e., preparing vegetable soup, fruit salad) could help to cultivate both declarative and procedural nutritional knowledge among Indian adolescents, subsequently empowering them to consume more fruits and vegetables. School-based gardening interventions [156] can also assist in healthy eating among adolescents. However, studies of Indian school curricula suggest that Indian schools lack basic resources (i.e., lack of learning-specific facilities such as library, laboratory; lack of teachers learning materials) and time (i.e., more class time is devoted to Mathematics and Physical Sciences when compared to Home Economics or Biological Sciences where food and nutrition is discussed) to implement skills-focused nutrition curricula [105, 157–159].

In addition, considering the significant influence of peers on adolescents’ dietary intake, it may be highly relevant for Indian schools to adopt peer-led, nutrition education programs for fostering healthy eating habits in adolescents [153, 160, 161]. Emerging findings could also inform policy innovations that provide subsidies that would remove financial impediments to fruit and vegetable consumption among adolescents and their families [120].

Conclusions

This qualitative inquiry contributes to the limited evidence exploring the perceived influences of fruit and vegetable consumption among a sample of Indian adolescents. Overall, both urban and rural adolescents shared similar views regarding the determinants of fruits and vegetables. This research showed that multiple factors such as health and immunity, home food environment, school food environment, cost, peers, and taste are likely to affect fruit and vegetable consumption in adolescents. These factors could inform the development and implementation of sustainable school-based and home-based behavioral nutrition interventions to promote fruit and vegetable intake among adolescents, thereby reducing the enduring prevalence of micronutrient deficiencies.

Electronic supplementary material

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Abbreviations

CNNS

Comprehensive National Nutrition Survey

MDM

Mid-Day Meal

COREQ

Consolidated Criteria for Reporting Qualitative Research

SES

Socio-economic strata

Author contributions

N.R., A.W. and M.G. conceived the study and its original design. N.R. collected the data. N.R., A.W. and M.G. analyzed the data. N.R. drafted the initial form and all revisions of this manuscript. N.R., A.W. and M.G. reviewed and approved the final manuscript.

Funding

NR is ISBNPA’s Pioneer 2023–2024 Scholarship Grant Awardee. The funder (ISBNPA) had no role in the conduct of the study. NR acknowledges the support of the Institution of Eminence program of the Ministry of Education as Malaviya Post Doctoral Fellow.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Declarations

Ethical approval and consent to participate

The study was conducted according to the guidelines of the Declaration of Helsinki and approved by the Institutional Ethical Committee of Banaras Hindu University (Dean/2021/EC/2817). The procedures performed were in accordance with the ethical standards of the committee. Written informed consent was obtained from all respondents before commencement of the study. The investigators obtained assent from minor children who participated and written informed consent from older adolescents.

Consent for publication

Not applicable.

Competing interests

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