Abstract
At the national and state levels, data on changes over time in fruit and vegetable intake among young children are limited. Using nationally representative data from the National Survey of Children’s Health during 2021-2023, we examined trends in daily fruit and vegetable intake among children aged 1 to 5 years. We conducted trend analyses nationally, by age, and by state. We found no significant linear trends in daily fruit or vegetable intake at the national level or by age. At the state level, fruit intake increased significantly from 2021 to 2023 in Connecticut (from 65.8% to 77.2%; P = .049), Illinois (from 68.5% to 77.8%; P = .03), and Montana (from 66.1% to 81.0%; P = .01) and decreased significantly in Massachusetts (from 82.2% to 65.0%; P = .001); no state had significant changes in daily vegetable intake. Lack of improvement in daily fruit and vegetable intake among young children emphasizes the continued need for monitoring and evidence-based interventions.
Keywords: public health, nutrition, child health
The 2020-2025 US Dietary Guidelines for Americans (DGAs) recommend that people in the United States, including children aged 1 to 5 years, consume nutrient-dense foods such as fruit and vegetables. 1 A nutrient-dense dietary pattern supports child development, growth, and health, and suboptimal intake patterns can adversely influence childhood overweight and obesity and the risk of other chronic diseases. 1 Dietary patterns begin to form during early childhood, and establishing healthy dietary patterns and food preferences can influence food choices later in life. 1 However, previous national data have shown that early childhood dietary intake of fruit and vegetable food groups is low, and many children aged 1 to 5 years are not consuming any fruit or vegetables daily.1-3 In addition, fruit and vegetable intake varies by state 2 and by child, caregiver, and household 3 characteristics. At the national and state levels, data on changes over time in fruit and vegetable intake among young children are limited. We examined national- and state-level (50 states and the District of Columbia) trends in daily fruit and vegetable intake from 2021 through 2023 for all children aged 1 to 5 years.
Methods
The National Survey of Children’s Health (NSCH) is an annual, nationally representative survey of children and adolescents aged 0 to 17 years living in the United States; an oversample of children aged 0 to 5 years was implemented during 2021-2023.4-6 From surveyed households, an age-specific topical questionnaire for 1 selected child is completed by a parent or caregiver. Our analysis focused on children aged 1 to 5 years from the 2021, 2022, and 2023 surveys (n = 18 830; n = 17 811; n = 19 579, respectively), excluding children with missing values for fruit or vegetable intake (2021: n = 412; 2022: n = 403; and 2023: n = 436). For our analyses, the sample sizes were 18 418 in 2021, 17 408 in 2022, and 19 143 in 2023. The overall weighted response rates for the NSCH were 40.3% in 2021, 39.1% in 2022, and 35.8% in 2023.4-6 No strong or consistent evidence of nonresponse bias has been found.7-9
Beginning in 2021, for children aged 1 to 5 years, respondents were asked the following 2 questions: (1) “During the past week, how many times did this child eat fruit? Include any that were fresh, frozen, canned, or dried. Do not include juice.” and (2) “During the past week, how many times did this child eat vegetables? Include any that were fresh, frozen, canned, or dried. Do not include French fries, fried potatoes, or potato chips.” Response options were dichotomized to reflect daily or less-than-daily consumption of fruit and vegetables.
For each survey year, we calculated national and state weighted estimates and SEs for fruit and vegetable intake, separately. We stratified the national estimates by child’s age. To determine whether changes in daily intake were significant, we evaluated linear and quadratic trends over time by using orthogonal polynomial contrasts. 10 If the quadratic contrast did not indicate a nonlinear trend, then we evaluated a linear contrast for significance. We considered P < .05 to be significant. We conducted analyses in SAS-callable SUDAAN version 11.0 (RTI International) to account for the complex sample design and weights. This activity was reviewed by the Centers for Disease Control and Prevention (CDC), deemed research not involving human subjects, and was conducted consistent with applicable federal law and CDC policy (see, eg, 45 CFR part 46, 21 CFR part 56; 42 USC §241[d]; 5 USC §552a; 44 USC §3501 et seq).
Results
Nationally, among children aged 1 to 5 years, the prevalence of children eating a daily fruit in 2021, 2022, and 2023 was 67.9%, 66.0%, and 67.4%, respectively, and the prevalence of eating a daily vegetable was 50.6%, 48.5%, and 49.7%, respectively (Table). From 2021 to 2023, we found no significant change in the prevalence of children eating a daily fruit nor a daily vegetable nationally. Similarly, from 2021 to 2023, we found no significant change in the prevalence of children eating a daily fruit nor a daily vegetable when stratified by age.
Table.
Trends in the prevalence of daily fruit and daily vegetable intake among children aged 1 to 5 years, nationally, by age, and by state, National Survey of Children’s Health, United States, 2021-2023 a
| Variable | No. | Daily fruit intake (≥1 time per day), % (SE) |
Daily vegetable intake (≥1 time per day), % (SE) |
||||
|---|---|---|---|---|---|---|---|
| 2021 (N = 18 418) | 2022 (N = 17 408) | 2023 (N = 19 143) | 2021 (N = 18 418) | 2022 (N = 17 408) | 2023 (N = 19 143) | ||
| United States overall | 54 969 | 67.9 (0.8) | 66.0 (0.8) | 67.4 (0.8) | 50.6 (0.9) | 48.5 (0.8) | 49.7 (0.8) |
| Child’s age, y | |||||||
| 1 | 7651 | 74.9 (2.0) | 65.2 (2.2) | 72.9 (1.9) | 55.2 (2.3) | 54.3 (2.1) | 56.9 (2.0) |
| 2 | 12 909 | 68.7 (1.7) | 68.4 (1.6) | 69.9 (1.6) | 51.5 (1.7) | 49.4 (1.8) | 51.3 (1.9) |
| 3 | 11 404 | 67.2 (1.9) | 67.6 (1.8) | 68.2 (1.6) | 49.9 (2.0) | 45.8 (1.8) | 47.2 (1.6) |
| 4 | 11 409 | 65.2 (1.9) | 64.9 (1.7) | 63.9 (1.9) | 49.5 (2.0) | 46.1 (1.7) | 47.5 (1.8) |
| 5 | 11 596 | 63.7 (1.8) | 64.0 (1.6) | 62.9 (1.6) | 47.2 (1.9) | 47.4 (1.6) | 46.6 (1.6) |
| State | |||||||
| Alabama | 921 | 60.6 (3.8) | 62.3 (4.3) | 57.4 (4.0) | 42.7 (3.8) | 47.3 (4.5) | 41.6 (3.8) |
| Alaska | 930 | 79.5 (3.4) | 71.3 (4.1) | 69.3 (4.5) | 52.9 (4.5) | 62.3 (4.4) | 56.1 (4.7) |
| Arizona | 841 | 69.7 (4.3) | 65.8 (4.8) | 75.8 (3.3) | 49.0 (4.5) | 45.2 (5.0) | 49.2 (4.6) |
| Arkansas | 937 | 64.4 (4.2) | 59.6 (4.3) | 58.6 (4.0) | 49.7 (4.4) | 51.5 (4.3) | 41.2 (4.1) |
| California | 2632 | 67.5 (4.1) | 69.4 (2.4) | 71.9 (1.9) | 48.4 (3.9) | 54.0 (2.6) | 52.7 (2.0) |
| Colorado | 1495 | 74.5 (2.9) | 71.9 (3.6) | 71.4 (3.5) | 53.2 (3.3) | 50.6 (3.5) | 52.7 (3.5) |
| Connecticut b | 1003 | 65.8 (4.3) | 73.6 (3.9) | 77.2 (3.8) b | 49.5 (4.0) | 55.8 (4.1) | 55.4 (4.4) |
| Delaware | 875 | 71.0 (3.6) | 59.7 (4.9) | 63.9 (4.3) | 46.5 (4.0) | 44.2 (4.7) | 45.0 (4.5) |
| District of Columbia | 1104 | 63.6 (5.2) | 69.3 (5.0) | 70.9 (4.8) | 56.6 (5.0) | 57.2 (4.8) | 50.9 (4.8) |
| Florida | 854 | 65.3 (4.2) | 58.0 (4.5) | 55.3 (4.4) | 47.5 (4.4) | 34.3 (4.3) | 42.8 (4.3) |
| Georgia | 1219 | 63.0 (3.4) | 67.6 (3.5) | 68.2 (3.7) | 51.2 (3.4) | 55.0 (3.6) | 54.0 (3.9) |
| Hawaii | 998 | 61.5 (3.7) | 67.2 (4.5) | 53.6 (5.0) | 44.9 (3.7) | 53.4 (4.8) | 36.0 (4.5) |
| Idaho | 894 | 62.4 (4.2) | 67.4 (3.9) | 61.5 (4.9) | 49.4 (4.3) | 48.0 (4.1) | 52.1 (4.6) |
| Illinois c | 1131 | 68.5 (3.6) | 67.6 (4.0) | 77.8 (2.5) c | 49.4 (3.8) | 41.2 (4.1) | 54.7 (3.0) |
| Indiana | 923 | 56.7 (3.8) | 66.0 (3.8) | 63.7 (3.8) | 47.4 (3.8) | 45.1 (4.0) | 45.2 (3.8) |
| Iowa | 969 | 68.3 (3.6) | 68.5 (4.1) | 71.9 (3.9) | 50.1 (3.8) | 52.6 (4.3) | 53.7 (4.2) |
| Kansas | 1453 | 67.8 (3.5) | 68.7 (4.4) | 68.3 (2.3) | 57.7 (3.6) | 44.9 (4.3) | 52.1 (2.4) |
| Kentucky | 915 | 57.9 (4.0) | 63.2 (4.2) | 60.2 (4.2) | 45.9 (4.0) | 50.4 (4.3) | 49.5 (4.2) |
| Louisiana | 1210 | 50.4 (4.1) | 48.5 (4.7) | 55.0 (2.7) | 35.6 (4.0) | 37.2 (4.5) | 42.4 (2.7) |
| Maine | 1007 | 79.9 (2.9) | 79.2 (3.5) | 79.8 (3.2) | 65.9 (3.5) | 64.3 (3.8) | 60.0 (3.9) |
| Maryland | 892 | 74.4 (3.7) | 65.8 (4.4) | 68.0 (4.2) | 54.5 (4.6) | 50.6 (4.4) | 44.1 (4.2) |
| Massachusetts d | 883 | 82.2 (2.6) | 72.5 (3.8) | 65.0 (4.6) d | 54.2 (4.3) | 49.5 (4.3) | 50.3 (4.3) |
| Michigan | 947 | 69.7 (3.6) | 69.2 (3.9) | 74.8 (3.1) | 56.4 (3.9) | 56.0 (4.0) | 50.6 (3.9) |
| Minnesota | 1301 | 76.7 (4.0) | 74.6 (3.6) | 75.7 (2.3) | 58.3 (4.3) | 55.1 (4.0) | 57.9 (2.5) |
| Mississippi | 810 | 52.7 (4.2) | 48.2 (4.9) | 52.2 (4.7) | 43.6 (4.3) | 33.4 (4.5) | 43.8 (4.6) |
| Missouri | 943 | 63.0 (4.0) | 69.8 (4.0) | 71.5 (3.6) | 55.6 (4.0) | 62.6 (4.1) | 52.1 (4.2) |
| Montana e | 952 | 66.1 (4.4) | 76.9 (3.7) | 81.0 (3.3) e | 54.2 (4.3) | 53.9 (4.3) | 55.7 (4.4) |
| Nebraska | 1082 | 65.7 (3.9) | 65.3 (3.8) | 70.1 (3.6) | 48.0 (3.9) | 50.0 (3.8) | 51.3 (3.8) |
| Nevada | 808 | 65.5 (4.3) | 66.2 (4.4) | 62.6 (4.6) | 52.2 (4.4) | 51.2 (4.7) | 46.9 (4.6) |
| New Hampshire | 930 | 77.3 (3.4) | 78.3 (3.2) | 79.3 (3.1) | 60.6 (3.8) | 57.8 (3.8) | 56.8 (4.2) |
| New Jersey | 905 | 67.5 (3.8) | 71.1 (4.1) | 66.5 (4.0) | 42.3 (3.8) | 53.4 (4.4) | 40.8 (4.0) |
| New Mexico | 988 | 59.6 (4.8) | 70.1 (4.0) | 62.6 (3.8) | 51.7 (4.8) | 56.5 (4.1) | 48.4 (3.8) |
| New York | 1872 | 61.9 (4.0) | 65.0 (1.9) | 59.8 (4.5) | 45.3 (4.0) | 50.2 (2.0) | 39.8 (4.1) |
| North Carolina | 839 | 74.6 (3.6) | 66.7 (5.0) | 66.9 (4.3) | 50.8 (4.5) | 57.3 (4.9) | 46.3 (4.5) |
| North Dakota | 903 | 68.8 (3.5) | 70.5 (4.0) | 69.9 (3.8) | 55.4 (3.7) | 52.5 (4.2) | 54.1 (4.0) |
| Ohio | 1421 | 72.3 (2.9) | 69.0 (3.2) | 65.2 (2.8) | 53.3 (3.2) | 48.0 (3.2) | 50.3 (2.8) |
| Oklahoma | 911 | 62.5 (4.1) | 60.6 (4.7) | 65.0 (3.9) | 41.8 (4.2) | 43.8 (4.6) | 44.8 (4.0) |
| Oregon | 1904 | 73.8 (2.2) | 79.7 (2.3) | 73.6 (4.8) | 57.2 (2.4) | 54.7 (2.8) | 53.7 (4.6) |
| Pennsylvania | 1217 | 71.8 (3.8) | 64.5 (3.5) | 74.7 (2.9) | 53.7 (4.2) | 49.9 (3.4) | 48.7 (3.2) |
| Rhode Island | 932 | 69.1 (4.1) | 76.6 (3.9) | 66.3 (4.3) | 45.0 (4.2) | 53.9 (4.4) | 47.1 (4.4) |
| South Carolina | 886 | 64.8 (4.1) | 66.7 (3.7) | 65.4 (4.1) | 52.2 (4.3) | 48.8 (4.0) | 45.4 (4.3) |
| South Dakota | 993 | 63.9 (3.6) | 71.5 (4.0) | 67.0 (4.4) | 49.8 (3.6) | 52.8 (4.5) | 48.0 (4.6) |
| Tennessee | 1244 | 64.3 (4.2) | 68.1 (2.8) | 64.1 (3.4) | 58.5 (4.1) | 47.9 (3.0) | 48.0 (3.5) |
| Texas | 882 | 69.4 (3.8) | 55.3 (4.7) | 62.8 (4.7) | 51.9 (4.3) | 35.4 (4.1) | 53.1 (4.7) |
| Utah | 981 | 72.2 (2.7) | 67.6 (3.6) | 71.4 (3.4) | 48.2 (3.3) | 44.1 (4.0) | 51.1 (3.9) |
| Vermont | 920 | 83.7 (2.7) | 72.6 (4.2) | 78.4 (3.8) | 69.4 (3.7) | 60.7 (4.4) | 64.1 (3.9) |
| Virginia | 918 | 68.2 (4.3) | 71.5 (3.9) | 68.7 (3.8) | 46.9 (4.3) | 52.9 (4.1) | 55.5 (4.1) |
| Washington State | 978 | 81.3 (2.8) | 76.3 (3.2) | 85.2 (3.2) | 64.0 (3.5) | 52.8 (4.4) | 65.3 (4.1) |
| West Virginia | 958 | 59.8 (4.0) | 60.5 (4.3) | 66.0 (3.9) | 50.4 (4.1) | 54.2 (4.2) | 54.7 (4.1) |
| Wisconsin | 1366 | 73.4 (2.5) | 73.0 (4.2) | 74.7 (3.0) | 56.0 (2.7) | 61.0 (4.3) | 55.6 (3.3) |
| Wyoming | 1092 | 74.5 (3.5) | 67.0 (3.2) | 71.4 (3.3) | 54.8 (4.2) | 50.6 (3.6) | 52.8 (3.5) |
Data source: National Survey of Children’s Health, United States, 2021-2023.11-13 Weighted prevalence estimates and SEs are presented.
A significant increasing linear trend in daily fruit intake occurred from 2021 to 2023 (P = .049) using orthogonal polynomial contrasts for linear trend, with P < .05 considered significant.
A significant increasing linear trend in daily fruit intake occurred from 2021 to 2023 (P = .03) using orthogonal polynomial contrasts for linear trend, with P < .05 considered significant.
A significant decreasing linear trend in daily fruit intake occurred from 2021 to 2023 (P = .001) using orthogonal polynomial contrasts for linear trend, with P < .05 considered significant.
A significant increasing linear trend in daily fruit intake occurred from 2021 to 2023 (P = .01) using orthogonal polynomial contrasts for linear trend, with P < .05 considered significant.
Estimates of daily fruit consumption in 2021 ranged from 50.4% in Louisiana to 83.7% in Vermont, in 2022 ranged from 48.2% in Mississippi to 79.7% in Oregon, and in 2023 ranged from 52.2% in Mississippi to 85.2% in Washington State (Figure, Table). From 2021 to 2023, the prevalence of daily fruit consumption increased significantly in Connecticut (from 65.8% to 77.2%; P = .049), in Illinois (from 68.5% to 77.8%; P = .03), and in Montana (from 66.1% to 81.0%; P = .01) and decreased significantly in Massachusetts (from 82.2% to 65.0%; P = .001). The prevalence of children consuming vegetables daily in 2021 ranged from 35.6% in Louisiana to 69.4% in Vermont, in 2022 ranged from 33.4% in Mississippi to 64.3% in Maine, and in 2023 ranged from 36.0% in Hawaii to 65.3% in Washington State. The prevalence of daily vegetable consumption remained stable across all states from 2021 to 2023.
Figure.
State prevalence estimates and trends for (A) daily fruit intake and (B) daily vegetable intake among children aged 1 to 5 years, National Survey of Children’s Health, United States, 2021-2023. An upward-facing arrow indicates a significant increasing linear trend in daily fruit intake from 2021 to 2023: in Connecticut, from 65.8% to 77.2% (P = .049); in Illinois, from 68.5% to 77.8% (P = .03); and in Montana, from 66.1% to 81.0% (P = .01). A downward-facing arrow indicates a significant decreasing linear trend: in Massachusetts, from 82.2% to 65.0% (P = .001). No significant trends were found for daily vegetable intake. Data source: National Survey of Children’s Health.11-13
Discussion
Using data from 2021-2023, we analyzed trends in daily fruit and vegetable intake among children aged 1 to 5 years at the national and state levels. We found that intake remained unchanged nationally, with about one-third of children not eating fruit daily and about one-half not eating vegetables daily. Many children are not meeting dietary recommendations 1 by not consuming fruit and vegetables even once per day. The lower prevalence of young children eating vegetables versus fruit daily indicates greater room for improvement in addressing vegetable intake.
State-level trends in fruit and vegetable intake have also largely remained stable, although a few states—Connecticut, Illinois, and Montana—saw an increase in the prevalence of fruit intake, and Massachusetts saw a decrease in fruit intake. Trends in fruit and vegetable intake might not be attributed to a single factor and instead could be affected by a combination of factors across a socioecological framework. Efforts to improve fruit and vegetable intake could take a multicomponent approach by coordinating programs and policies at the federal, state, and local levels to improve consumption behavior14,15 and by promoting healthy food options where food is provided through food service and nutrition guidelines. 16 Existing strategies that could be used to increase fruit and vegetable consumption include federal programs that include or incentivize fruit and vegetable consumption,17-19 state early care and education licensing regulations for serving fruit and vegetables, 20 and school-based nutrition education and parent-focused social marketing interventions. 21
This study had several strengths. First, the NSCH is an annual, nationally representative survey, and during 2021-2023, it oversampled children aged 0 to 5 years. Second, the increase in sample size provided an opportunity to assess fruit and vegetable intake estimates in each state for this age group. This study also had several limitations. First, we did not assess factors that affect state-level trends; future research could further explore state-level factors that may influence fruit and vegetable intake in this young population. Second, this analysis was limited to 3 time points, because these questions were asked starting only in 2021. Third, questions asked what a child ate during the previous week and might not reflect the child’s usual intake. Fourth, intake was reported by a child’s caregiver, who might not be aware of everything a child consumed; potential recall or social desirability bias22,23 might have led to under- or overreporting of intake. Fifth, in this study, reported intake represents the frequency of intake, not the amount, and cannot be directly compared with DGA recommendations. Lastly, the prevalence of fruit and vegetable intake from the survey may have been affected by changes brought about by the COVID-19 pandemic. However, we were unable to assess this effect. Other studies have indicated that the effects of the pandemic on dietary practices might have varied.24,25
Nationally, daily fruit and daily vegetable intake among young children did not change from 2021 to 2023, and only a few states saw significant changes in fruit intake. Lack of improvement in daily fruit and vegetable intake among young children emphasizes the continued need for monitoring and evidence-based interventions. State decision-makers can use their data on current estimates and recent changes in consumption to help identify needs and guide strategies for improving the diets of young children.
Acknowledgments
The authors thank Kathleen Watson, PhD, Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, for statistical expertise and review of methodology.
Footnotes
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Sofia Awan and Mary Ellen Grap were supported in part by an appointment to the Research Participation Program at the Centers for Disease Control and Prevention administered by the Oak Ridge Institute for Science and Education through an interagency agreement between the US Department of Energy and the Centers for Disease Control and Prevention.
ORCID iDs: Sofia Awan, MPH 
https://orcid.org/0000-0003-0328-7214
Kristin J. Marks, PhD, MPH
https://orcid.org/0000-0002-0261-9443
Disclaimer: The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.
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