By House, Jennifer; Su, Jenny; Levy-Milne, Ryna
Abstract
Purpose: To identify definitions of healthy eating in terms of food characteristics, eating behaviours, barriers, and benefits in university students.
Methods: Four focus groups were conducted; verbatim transcripts were analyzed and coded using qualitative methods. Participants were nine students of dietetics and six students of other subjects. All were females in their third or fourth year at the University of British Columbia (UBC).
Results: Participants often described healthy eating as consuming all food groups of Canada’s Food Guide to Healthy Eating, with the associated notions of moderation and balance. Benefits of healthy eating were cited as a healthy weight, good physical appearance, feeling better, preventing disease, and achieving personal satisfaction. Barriers to healthy eating included lack of time, choice, taste preferences, and finances. There was some discrepancy between what the dietetics students perceived as barriers for clients (e.g., lack of information), and barriers the potential clients (other students) perceived for themselves.
Conclusions: As dietitians, we must try to understand our clients’ definitions of healthy eating and their barriers to achieving it, which likely differ from our own.
(Can J Diet Prac Res 2006;67:14-18)
Rsum
Objectif. Connatre les dfinitions d’une alimentation saine en termes de caractristiques des aliments, comportements alimentaires, obstacles et avantages chez des tudiants d’universit.
Mthodes. Quatre groupes de discussion ont t constitus; les transcriptions des discussions ont t analyses et codes l’aide de mthodes qualitatives. Neuf tudiantes en dittique et six tudiantes d’autres disciplines ont particip l’tude; elles taient en troisime ou quatrime anne l’Universit de Colombie-Britannique (UBC).
Rsultats. Plusieurs participantes ont dcrit l’alimentation saine comme tant la consommation de tous les groupes d’aliments du Guide alimentaire canadien pour manger sainement, en tenant compte des notions associes de modration et d’quilibre. Parmi les avantages d’une alimentation saine, elles ont mentionn un poids sant, une belle apparence physique, une sensation de mieux-tre, la prvention des maladies et la satisfaction personnelle. Le manque de temps, le choix, les gots et la situation financire ont t cits comme obstacles l’alimentation saine. On a not des diffrences entre ce que les tudiantes en dittique percevaient comme obstacles pour leurs futurs clients (par exemple, le manque d’information) et les obstacles que les clients potentiels (les autres tudiantes) percevaient eux-mmes.
Conclusions. titre de dittistes, nous devons essayer de comprendre les dfinitions de l’alimentation saine de nos clients et les obstacles qu’ils peroivent, car leurs points de vue semblent diffrer des ntres.
(Rev can prat rech ditt 2006;67:14-18)
INTRODUCTION
Many countries, including Canada, have developed guidelines to promote a healthy diet, including Canada’s Food Guide to Healthy Eating (CFGHE) and Canada’s Guidelines for Healthy Eating ( 1,2). Studies show that while people define healthy eating in accordance with dietary guidelines (3-5), they may perceive healthy eating messages as personally irrelevant (4). Few Canadian studies have examined what consumers understand by healthy eating, or their definitions of healthy eating. Quantitative comparison of students has been conducted in the United States (6), but not in Canada. The purpose of this research was to identify students’ definitions of healthy eating in terms of food characteristics, eating behaviours, barriers and benefits. In addition, these definitions of healthy eating were compared among students of dietetics and students of other subjects.
METHODS
This study used qualitative research methods to gather data through focus group interviews. Focus groups have been defined as “a group of individuals selected and assembled by researchers to discuss and comment on, from personal experience, the topic that is the subject of the research” (7). Compared to individual interviews, focus groups provide a more natural environment because participants are influenced by each other as they are in real life (8).
Participants
Participants included nine dietetics students and six students of other subjects from the University of British Columbia. All were females in their third or fourth year of study. The students of subjects other than dietetics were enrolled in various faculties, including agriculture and arts. Potential participants were recruited through announcements before lectures, and posters placed in different faculty buildings. Convenience sampling was used to recruit and all volunteers were accepted as participants.
The UBC Behavioural Research Ethics Board provided ethical approval for this project. Each participant signed an informed consent form before participating in a focus group.
Focus groups
Four focus groups, each with three to five participants, were conducted on the topic of what defines healthy eating. Two groups contained dietetics students and two groups contained students of other subjects, run separately so that participants would feel more comfortable sharing their knowledge and opinions. Each focus group was held at UBC and lasted approximately 45 minutes. A moderator (UBC graduate student) and comoderator (UBC undergraduate student) conducted each focus group. The moderator facilitated the discussion and the comoderator operated the tape recorder and took notes.
Participants were initially asked to build a collage (8) as a pictorial representation of what healthy eating meant to them, using poster board, magazine clippings and crayons. Each participant was then asked to explain their collage. After discussion, each focus group was asked the same set of questions, including:
“What foods do you see as unhealthy?”
“What influences the way you choose food?”
“Where do you get your nutrition information from?”
“What are the benefits of healthy eating?”
“What are the barriers to healthy eating?”
The moderator probed for additional information, based on the responses. For example, if organic food was described as healthy, the moderator asked the participant why they considered organic food healthier than nonorganic food.
To ensure trustworthiness in the research process, member checks (9) were conducted. At the end of each focus group session, the comoderator verbally summarized the main points made by participants to ensure that their interpretations of statements and ideas were accurate. One investigator was a dietitian, and the other was a dietetics student. To minimize the effect of the researchers’ background on the focus groups, the moderator kept verbal and non- verbal cues to a minimum.
Data analysis
Each focus group was tape-recorded and transcribed. The transcripts were coded and summarized by the student investigators using a constant comparative method of coding (8). Six general codes were developed, based on the questions asked during the focus groups: definitions of healthy eating, definitions of unhealthy eating, sources of nutrition information, influences on food choices, barriers to healthy eating, and benefits of healthy eating. The long table approach (8) was used to divide the focus group transcript dialogue into the six codes, to organize the responses by content. Within each general code, specific codes were further developed to identify major themes. A memo (8) was then constructed to describe common themes seen in each code.
RESULTS
Healthy eating collages
Participants in all focus groups centered their collage on the four food groups and nutrition messages seen in CFGHE. All focus groups mentioned another key message from CFGHE: moderation and variety. “That sums it up far healthy eating right there. Moderation.” Participants often mentioned that healthy eating should be individualized, which is another theme from CFGHE: “7 do what is right for me. “Other eating patterns not included in CFGHE were also considered healthy, such as small frequent meals, eating before hunger pains, and eating breakfast.
Other elements of healthy eating described only by dietetics students included emotional enjoyment: “A main point is that healthy eating, I consider it to be enjoyable. It makes you feel good about yourself. “Another idea unique to the dietetics groups was the general importance of meal planning, preparation, and the enjoyment of eating with others: “When I’m cooking with someone, we talk verbally about what we’re going to make and then we go and shop for the food… you cook it together and enjoy it. “Furthermore, some dietetics students also brought up a concern about being overly obsessive with healthy eating, and feeling good about themselves based on how they eat during the day: “Being interested in it [nutrition], or even obsessive about the topic, it changes how you eat.”
Students of other subjects were more concerned with the nutritional value of food, as opposed to the emotions attached to eating. Preparing food yourself so you know “what’s inside what you’re eating” was an idea unique to the other students. Organic foods were also mentioned as a part of healthy eating by this group: “[Organic food is] closer to how it was, I don’t know, originally brought up in nature. ” Consuming functional foods was also conside\red healthy eating by one member of these focus groups, when describing her collage: “/ also put broccoli here because broccoli’s supposed to be good for preventing cancer or something. And I have fish here as well for omega-3 fatty acids. “
Unhealthy eating
All participants associated unhealthy eating with specific foods, such as foods high in fat and saturated fat, deep fried foods, and processed foods: “It’s just foods that have really gone the distance from what their original form was. “High calorie foods with little nutritional value, such as “a lot of fast foods, meals on-the-go type of thing” were considered unhealthy, as were meals lacking variety. Most groups described fad diets as unhealthy, particularly the present trend of high protein, low carbohydrate diets. One dietetics student said: “Idon’t think it’s a sustainable way and it does have negative impacts on your body.”
Dietetics students often considered the use of supplements as unhealthy because they felt that: “people will become skewed in their judgment and start to rely on them [supplements]” instead of eating real foods. Dietetics students also believed that not following eating guidelines for disease prevention or management was unhealthy. Only dietetics students discussed the focus on weight loss as an ultimate goal, instead of overall health, as an unhealthy practice: “When I go to the bookstore… [the nutrition section] focuses on just weight loss and not health per se… implying that by losing weight you are healthier, which may not be the case.”
Other students thought that eating too much or too little was unhealthy, such as hinging and skipping meals. Eating at the right time was important to other participants because: “If you ‘re deprived of it you ‘re probably going to be like… 7 need that big piece of chocolate cake.'” This group defined snacking and late night eating as unhealthy.
Influences on food choices
A common theme for influence on food choices throughout all focus groups was family, upbringing, and culture: “If you grow up eating healthy foods, then you’re going to keep going with that. ” Taste preferences and cravings influenced what the participants choose to eat. Body image, such as preventing weight gain or maintaining a slim figure, was another factor that influenced participants’ food choices.
In addition, dietetics students felt that they were a biased group because they: “have so much more knowledge of food compared to the regular population.”Dietetics students felt that the public was more susceptible to follow “trends, fad diets, and new products, “and are influenced by “marketing and how they [stores] display the food. ” Food choices were also made to promote health, depending on individual lifestyle choices. For example, a vegetarian dietetics student mentioned that she chose food to ensure adequate amounts of iron in her diet. Dietetics students also mentioned that health scares have influenced their family members to choose ‘healthier’ foods: “There’s a history of heart disease in my family… once people start dying you pay attention and you make changes. “
A student of another subject stated that how she physically feels after eating certain food influences her choices: “/ think it [fast food] is really fattening… my stomach doesn ‘tfeel too well afterwards.” Only other students mentioned dial price and affbrdability of food products influenced their food choices.
Sources of nutrition information
An important source of nutrition information for participants was family members, particularly mothers and peers. School courses were mentioned as the main source of nutrition knowledge, especially by dietetics students. Government initiatives and programs, such as food labelling and CFGHE, as well as professionals such as dietitians, were sources of nutrition information. One student also obtained nutrition information from seminars and trainers at her gym.
All focus groups cited media, in the form of magazines, newspapers and television, as a source of nutrition information. Dietetics students conducted independent research from journals and the Internet, but placed strong emphasis on the reliability of sources. They agreed that the media were generally a poor source for reliable nutrition information, despite their strong influence on the public.
Barriers to healthy eating
Lack of time was described as a principal barrier to healthy eating among both dietetics students and other students. Participants felt that meal preparation for healthy eating was often too time consuming: “You’ll go to a vending machine and grab a candy bar or chips to satisfy you because you don’t have time to prepare yourself a proper lunch. ” Also, lack of choice on campus was a barrier: “There’s not a huge choice of healthy places to eat. ” Some other students described bad taste as a barrier to consuming healthy foods: “[brawn bread] tastes really bad and I’m willing to forfeit. “Other students also agreed that money was a barrier to eating healthy: “It’s expensive to eat healthy.”
Dietetics students perceived few barriers to healthy eating for themselves, but believed that lack of time, information, shopping and cooking skills were barriers for the general public: “They don’t have the time to do it [eat healthy], or the education to make the good choices. They just don’t know how to make their money go that far. “Another barrier dietetics students saw for the average consumer was the media’s influence to buy unhealthy products. They also agreed that although there are many long-term benefits of a healthy eating plan, lack of short-term effects (i.e., quick weight loss) creates another barrier for the public to eat healthy: “It’s hard to get people excited about that when you don’t see the results fast.”
Benefits of healthy eating
Both groups described appearance, such as a healthy weight, glowing skin, and physical physique, as a benefit of healthy eating. Also, feeling better physically and having “more energy from day to day “was considered a benefit of healthy eating.
One dietetics group thought that the good taste of healthy foods was a benefit to healthy eating, in contrast to some other students who viewed taste as a barrier to healthy eating. Dietetics students listed additional benefits of healthy eating not mentioned by the other students, such as health maintenance, disease prevention and personal satisfaction: “I’m much more satisfied if I’ve had a good day where I ate good meals and exercised and at the end of the day, you ‘re just really pleased with yourself. “
DISCUSSION
The results of this study show that participants defined healthy eating in accordance with Canadian dietary guidelines. All participants seemed knowledgeable about the messages disseminated through CFGHE, including the four food groups, moderation and variety. Overall, our results are consistent with die literature. Most studies have found that consumers define healthy eating as moderation, balance and variety (3,4,10). More specifically, consumers have defined healthy eating as low fat, natural, eating for disease prevention/management, and weight control (11). Additional definitions of healthy eating from our research participants included organic food, eating with others, and functional foods.
Our participants placed an emphasis on their upbringing and education as influences on eating and sources of nutrition information. Sources of nutrition information appear to be similar when comparing our participants’ results with those from Health Canada studies (5,10). In general, Canadians cite product labels as their most frequently used nutrition information source, followed by radio and TV, friends and relatives, and magazines or books (5). The dietetics students in our study were concerned with the reliability of nutrition information from media sources. This concern is likely justified, as a large European study found that 61% of the population trusted radio and television information to be accurate (4).
While most participants had a good understanding of healthy eating, barriers to achieving it still exist, particularly for the other participants. Barriers included expense and perceived poor taste of healthy foods, which is consistent with the literature (4,10). The dietetics groups did not mention expense as a barrier towards achieving healthy eating for themselves, but believed that it may be an obstacle for the general public, who may not be educated on how to shop for healthy foods on a budget. While dietetics students viewed lack of information, shopping and cooking skills as barriers to healthy eating for the general public (their future clients), the other students did not discuss these factors as barriers. Insufficient knowledge is generally not viewed as a major barrier to healthy eating (4,6). The dietetics students also described taste as a benefit to healthy eating, rather than a barrier as described by some other students. The dietetics students thought that lack of shortterm effects which may be seen with fad diets (i.e., quick weight loss) deterred the public from following healthy eating plans. Yet the other students described fad diets as unhealthy, and did not discuss lack of quick weight loss as a barrier to healthy eating. The dietetics students did not seem to understand some real barriers to healthy eating, potentially impacting their ability to counsel their clients successfully in the future.
Many Canadian consumer beliefs about the benefits of healthy eating were similar to our results, such as long-term health, more energy, and weight control (6,10). A unique benefit of healthy eating mentioned only by the dietetics students was personal satisfaction gained from eating well. This finding may be unique in comparison to studies with the average consumer, as dietetics students likely place a greater emphasis on what they eat.
The sample used in this study represented young womenwith university education. The demographic characteristics of age (18- 24), sex, and education have been correlated with having more knowledge about nutrition than do consumers over age 24, males, or those without a university education (5,12). There are likely healthy eating definitions that are not represented by this sample, so caution should be used when generalizing these findings to other groups. A factor limiting the generalizability of these findings is the small sample size. Generally, focus groups have six to eight participants (8). While our smaller focus group sizes were advantageous for participants’ comfort, it may have limited the range of experiences voiced. Because participants volunteered for this study, there is a possibility of self-selection bias in that the other participants may have been more interested in healthy eating than is the average university student.
Further study exploring the definitions of healthy eating with participants different from those in this sample would add to our knowledge. Possible participants could include males, different cultural groups, and perhaps registered dietitians compared to naturopaths or unregistered nutritionists. There has been little research on determining how people make food choices and how to overcome barriers to healthy eating. This study further solidifies the concept that healthy eating involves more than choosing just ‘healthy’ foods, but is also influenced by people’s backgrounds and feelings towards food.
RELEVANCE TO PRACTICE
How people choose food is an experience with psychological, social, and cultural influences (11). In creating successful nutrition goals for clients, dietitians can benefit from understanding the belief systems people have for healthy eating.
The sources of information and perceived barriers to healthy eating found in this study exposed challenges for nutrition professionals. For example, one common source of nutrition information for the participants was the media. As dietitians, it is important for our credible messages of healthy eating to make it into the media as often as possible. There was some discrepancy between what the dietetic students perceived as barriers for clients, and barriers the potential clients (the other students) perceived for themselves. As dietitians, we must try to understand our clients’ definitions of healthy eating and their barriers to achieving it, which likely differ from our own.
“That suras it up for healthy eating right there. Moderation.”
“It’s expensive to eat healthy.”
The dietetics groups did not mention expense as a barrier
References
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2. Health & Welfare Canada. Canada’s Guidelines for Healthy Eating. Ottawa: Office of Nutrition Policy and Promotion; 1992. Available from: http:/ywww.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/ food_guide_guidelines_e.html; accessed December 7, 2004.
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10. Health & Welfare Canada. Healthy eating – consumer perspectives summary of qualitative research. Ottawa: Office of Nutrition Policy and Promotion; 2003. Available from: www.hc- sc.gc.ca/hpfb-dgpsa/ onpp-bppn/ healthy_eating_consumer_persp_e.html; acccessed July 5, 2004.
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JENNIFER HOUSE, MSc, RD; JENNY SU, BSc, RD; RYNA LEVY-MILNE, PhD, RD, Division of Human Nutrition, University of British Columbia, Vancouver, BC
Copyright Dietitians of Canada Spring 2006
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