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C A N A D I A N J O U R N A L O F

P U B L I C
H E A LT H
VOLUME 96, SUPPLEMENT 3  JULY/AUGUST 2005

Understanding the
Forces That Influence
Our Eating Habits
What We Know
and Need to Know

R E V U E C A N A D I E N N E D E

S A N T É
PUBLIQUE
VOLUME 96, SUPPLÉMENT 3  JUILLET/AOÛT 2005
Acknowledgements
he development of this supplement was coordinated by Michelle Hooper and Ann Ellis in

T Health Canada’s Office of Nutrition Policy and Promotion (ONPP), Health Products and
Food Branch, and Brenda McIntyre in the Community Programs Directorate, First Nations
and Inuit Health Branch. Until her departure from ONPP in August 2003, Sharon Kirkpatrick* was
instrumental in the early stages of the original work that led to the development of this supplement.
With the exception of the article by Kim Raine, the articles in this supplement are based on a series
of synthesis papers on the determinants of healthy eating produced for Health Canada. The effort and
expertise of many individuals, whose contributions made the original papers and the subsequent sup-
plement articles possible, are gratefully acknowledged:
• Reviewers of the original synthesis papers: “Perceptions of Healthy Eating”, Gwen Chapman,
University of British Columbia, Linda McCargar, University of Alberta, Judy Paisley, Ryerson
University; “Children and Youth”, Susan Evers, University of Guelph, Mary McKenna, University
of New Brunswick; “Seniors”, Shanthi Johnson, Acadia University, Heather Keller, University of
Guelph; “Low Income Populations”, Anne-Marie Hamelin, Université Laval, Lynn McIntyre,
Dalhousie University, Patricia Williams, Mount Saint Vincent University; “Aboriginal
Populations”, Olivier Receveur, Université de Montréal, Valerie Tarasuk, University of Toronto,
Mary Trifonopoulos, Community Programs Directorate, First Nations and Inuit Health Branch;
“Bidirectional Relation Between Mental Health and Eating”, Susan Barr, University of British
Columbia, Patty Pliner, University of Toronto.
• Individuals who provided additional advice and feedback: Helen Brown, Ontario Ministry of
Health and Long-Term Care; Karen Cooper, Saskatchewan Health; Catherine Freeze, Prince
Edward Island Department of Health and Social Services; Susan Crawford, formerly of the
Institute of Nutrition, Metabolism and Diabetes, Canadian Institutes of Health Research; Erica Di
Ruggiero, Institute of Population and Public Health, Canadian Institutes of Health Research;
Danielle Brulé, ONPP; Suzanne Hendricks, ONPP; Isabelle Sirois, ONPP.
Although the individuals listed provided many constructive comments and suggestions, they were
not asked to endorse the conclusions or recommendations presented by the authors. The reviewers of
the original papers did not review the summary articles presented in this supplement. All of the
authors are responsible for final content of their article, including errors of fact or interpretation. The
opinions expressed in this publication are those of the authors and do not necessarily reflect the views
of Health Canada.
This supplement is available on the Canadian Public Health Association’s website at www.cpha.ca
and the Health Canada website at www.healthcanada.ca/nutrition.

* Sharon Kirkpatrick is currently a Ph.D. candidate in the Department of Nutritional Sciences, Faculty of Medicine,
University of Toronto.
CANADIAN JOURNAL OF PUBLIC HEALTH

Table of Contents

Understanding the Forces That


Influence Our Eating Habits
What We Know and Need to Know

S4 Foreword from Health Canada


M. Bush

S5 Foreword from the Canadian Institutes of Health Research


Information for Authors J. Frank, D. Finegood
Style requirements for submission of
manuscripts to the Canadian Journal of S6 Preface
Public Health can be found at www.cpha.ca
M. Hooper, S. Kirkpatrick, A. Ellis, B. McIntyre

Interested in subscribing to the CJPH? ORIGINAL ARTICLES


Have you moved or changed your name?
For information on subscribing to the CJPH
S8 Determinants of Healthy Eating in Canada: An Overview and Synthesis
or to make changes to your membership or K.D. Raine
subscription information, please contact the
Membership and Subscription Office,
info@cpha.ca, or 613-725-3769, ext. 118. S15 Perceptions of Healthy Eating: State of Knowledge and Research Gaps
M-C. Paquette

www.cpha.ca S20 Determinants of Healthy Eating in Children and Youth


J.P. Taylor, S. Evers, M. McKenna

S27 Determinants of Healthy Eating in Community-dwelling Elderly People


H. Payette, B. Shatenstein

S32 Determinants of Healthy Eating in Aboriginal Peoples in Canada: The Current


State of Knowledge and Research Gaps
N.D. Willows

S37 Determinants of Healthy Eating Among Low-income Canadians


E.M. Power

S43 Mental Health and Eating Behaviours: A Bi-directional Relation


J. Polivy, C.P. Herman

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S1


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Scotia
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Honorary Scientific Editor: Ms. Joan Reimer promotion and protection and healthy public
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MEMBERS-AT-LARGE tributes to CPHA’s mission through the pub-
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International Health
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Branch - CPHA
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Disease Surveillance and Control Ms. Jody Butler Walker
President, Yukon Public Health Association
Dr. Harvey Skinner
Equity and Social Justice

S2 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


CANADIAN JOURNAL OF PUBLIC HEALTH

Editorial Offices

SCIENTIFIC EDITORS EDITORIAL BOARD BUSINESS OFFICE /


SUBMISSION OF ARTICLES
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Patricia Huston, MD, MPH Scientific Editor Canadian Journal of Public Health
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TRANSLATION

ISSN 0008-4263 Louise Desmarais, MA


Isabelle Sirois, MSc, RD

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JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S3


Foreword from Health Canada
Mary Bush, MSc, RD

he Office of Nutrition Policy and that our policy and program decisions bet- We are at an important moment in time

T Promotion is pleased to have


enabled the development of this
special supplement. The collection of seven
ter address the complexity of factors that
influence eating behaviour. Understanding
which strategies and interventions are most
when significant efforts are under way,
both internationally and across our coun-
try, to support healthy living and prevent
articles is the culmination of significant effective in promoting and supporting chronic diseases. In many cases, practice is
effort by more than 20 Canadian healthy eating is also an essential compo- ahead of the evidence base as a result of the
researchers in applied nutrition, health nent of a comprehensive evidence base for pressures to take action. There is a need to
promotion and population health. program and policy decisions. However, a learn from practice through appropriate
What people eat is influenced by many review of the effectiveness of interventions research, evaluation and surveillance, and
factors, such as economic and social fac- was beyond the scope of the synthesis work thereby strengthen the evidence base for
tors, the physical environment, the capaci- undertaken. future decisions.
ty to make healthy eating choices, time and The articles in this supplement will be This supplement offers a call to action.
skills to prepare food, and personal buying available for use by academics, policy- In our search for answers, we need to be
power. Appropriate action for the promo- makers and community health profession- creative in our approaches. As we look at
tion and support of healthy eating requires als. They provide not only a synthesis of the issue of healthy eating within a broad
a comprehensive evidence base. existing literature and recommendations population health framework, we need to
Stakeholders identified the need to syn- for research but also a basis for involve- challenge ourselves to consider alternative
thesize the existing evidence regarding the ment in advocating for, or participating in, and new frameworks, to work across sec-
promotion and support of healthy eating appropriate research to fill the evidence tors and with other disciplines. With a
before setting research priorities.1 The orig- gaps. Continuing efforts will require part- coherent approach and collaborative efforts
inal synthesis papers developed in 2003- nerships among policy and program deci- to strengthen our knowledge base, we will
2004 and the summary articles in this jour- sion makers, practitioners and researchers. contribute to improved nutritional health
nal supplement highlight “what we know” It is clear that understanding the under- of Canadians.
and identify knowledge gaps about the lying issues that determine eating behaviour
determinants of eating. This work offers a will also require the involvement of other REFERENCES
step forward in enhancing the evidence disciplines. Efforts by the Canadian
1. Diane McAmmond and Associates. 2001.
base. As the authors point out, the avail- Institutes of Health Research to encourage Promotion and Support of Healthy Eating: An
able literature does not support an exami- interdisciplinary and cross-sector research Initial Overview of Knowledge and Research Needs:
Summary Report, March 2001. Available on-line
nation of the complex interactions across provide hope that research on healthy eat- at http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-
determinants, and there is still much to ing in the context of population health will bppn/promotion_support_healthy_eating_e.html
understand. Knowledge development be enhanced and will supply a strong plat-
efforts in this area need to be supported so form for filling our evidence gaps.

Director General, Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health
Canada

S4 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


Foreword from the Canadian
Institutes of Health Research*
John Frank, MD, CCFP, MSc, FRCPC1
Diane Finegood, PhD2

iven the worldwide attention to life course.1 As the pre-eminent epidemiol- risk factors, such as physical inactivity,

G the dramatic increases in over-


weight and obesity, this special
supplement on healthy eating comes at a
ogist of our time, Geoffrey Rose, pointed
out some 15 years ago, it is only by directly
understanding and tackling the “upstream
and, more important, which strategic mix
of interventions can make a difference to
preventing and controlling overweight, as
very opportune time. Healthy eating not forces” that are shifting entire populations’ well as other common risk factors for
only plays a role in the prevention and distributions of risk factors in an chronic diseases. In collaboration with
control of chronic disease but is also a key unfavourable way that we can expect to partners, including the Heart and Stroke
determinant of human health and develop- make a significant impact on these health Foundation of Canada, the Canadian
ment throughout the life course. A com- problems,2 through a strengthened public Diabetes Association, the Public Health
prehensive research agenda on healthy eat- health infrastructure working in concert Agency of Canada and Health Canada,
ing and mechanisms to facilitate collabora- with other sectors. IPPH is most concerned INMD is increasing our capacity and seek-
tive problem solving across disciplines and with population-level and community- ing solutions to this complex problem.
sectors are urgently needed in Canada to level intervention research to understand In summary, the insights gained from
advance our knowledge base on the deter- and effectively address the underlying this supplement are intended to contribute
minants of healthy eating. While the focus drivers affecting the health of populations. towards advancing a relevant research
has largely been at the individual level The CIHR Institute of Nutrition, agenda on healthy eating, a key foundation
(e.g., knowledge of Canada’s Food Guide to Metabolism and Diabetes (INMD) has to support evidence-based community pro-
Healthy Eating), we need also to further identified obesity and maintenance of grams and healthy public policies. CIHR
understand the social, cultural and envi- healthy body weight as its number one looks forward to continuing our work with
ronmental determinants of healthy eating strategic priority.3 Obesity and overweight Health Canada’s Office of Nutrition
that operate at the community/neighbour- have been called the fastest growing epi- Policy and Promotion, the new Public
hood, regional, national/provincial/territo- demic of our time, but the good news is Health Agency of Canada, and other key
rial levels and in whole societies. These that they are potentially reversible. Many actors, towards this end.
include, for example, the impact of global- levels of government and non-governmental
ization and how it affects our food supply, organizations, such as the Chronic Disease REFERENCES
and barriers to accessing affordable and Prevention Alliance of Canada, have called 1. Canadian Institutes of Health Research –
personally acceptable food. This evidence for multi-sectoral approaches to combat Institute of Population and Public Health
base is also needed to inform the policies this significant health problem, its under- (CIHR-IPPH). Mapping and Tapping the
Wellsprings of Health: Strategic Plan 2002-2007,
and programs that have a significant effect lying risk factors and their determinants. August 2002.
on the health and lives of all Canadians, However, in some instances, the evidence 2. Rose GA. The Strategy of Preventive Medicine.
New York: Oxford University Press, 1992.
regardless of their income, education or base for intervention effectiveness is weak. 3. Canadian Institutes of Health Research –
ethnicity, or of the places in which they In other words, we cannot yet point to a Institute of Nutrition, Metabolism and Diabetes
work, live, play and learn. menu of proven, cost-effective policy and (CIHR-INMD). Strategic Plan 2004-06: The
Way Forward, 2004.
The Institute of Population and Public program interventions that can be readily 4. Smedley BD, Syme SL. Promoting Health:
Health (IPPH) of the Canadian Institutes implemented in the Canadian context to Intervention Strategies from Social and Behavioral
Research. Washington, DC: Institute of
of Health Research (CIHR) supports change or modify the socio-cultural and Medicine, National Academy Press, 2000.
research to further our understanding of environmental factors that truly influence
the determinants of human health at the this critical aspect of our health.4 At the
individual and population levels on the core of this challenge is the need to under-
basis of the bio-psycho-social factors that stand the relative contribution of
influence health and well-being over the unhealthy eating habits versus that of other

1. Scientific Director, Institute of Population and Public Health


2. Scientific Director, Institute of Nutrition, Metabolism and Diabetes
* The authors acknowledge the contributions of Erica Di Ruggiero, Associate Director, CIHR-
Institute of Population and Public Health, in the preparation of this foreword.

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S5


Preface edge gaps are probably best addressed
through research directed to specific popu-
lations. In addition to children and adoles-
Michelle Hooper, MSc1 cents, seniors, and Aboriginal peoples, the
Sharon Kirkpatrick, MHSc, RD2 issues of food insecurity and healthy
weights were considered priorities regard-
Ann Ellis, MSc, RD1 ing the promotion and support of healthy
Brenda McIntyre, MHSc3 eating.
Building on these priority areas, as well
as specific program needs, the synthesis
papers focussed on the following topics:
children and youth; seniors; Aboriginal
ealthy eating is a critical contributor to overall health at every stage of develop- populations;* low-income populations;

H ment and is equally important in reducing the risk of many chronic diseases.
Food choices are complex decisions that are influenced by the relation between
individual and collective factors, including social and physical environments. Promoting
perceptions of healthy eating; and the bi-
directional relation between mental health
and eating behaviours. At the time this
healthy eating for all Canadians requires a better understanding of these factors and their work was initiated, a synthesis of the litera-
interactions. Currently, significant knowledge gaps exist in our evidence base to support ture related to healthy weights was under
policy and program development. This supplement of the Canadian Journal of Public way through a process led by the Canadian
Health provides a collection of summary articles highlighting key findings from a series of Population Health Initiative (CPHI) of
synthesis papers on the determinants of healthy eating recently completed for Health the Canadian Institute for Health
Canada’s Office of Nutrition Policy and Promotion (ONPP). Information (CIHI).† This topic was not,
therefore, pursued in this series of synthe-
Background sis papers.
In 2003-2004, a project was undertaken to synthesize the literature on determinants of The original synthesis papers were writ-
healthy eating. This project grew out of recommendations from an overview of key knowl- ten by Canadian researchers in applied
edge gaps for promotion and support of healthy eating undertaken in 2001. Through the nutrition, health promotion, and/or popu-
synthesis of information provided by more than 50 key informants, important knowledge lation health, with particular expertise in
gaps and research needs with respect to determinants of healthy eating and the effectiveness the chosen topic areas. Outlines and draft
of interventions to promote healthy eating were identified.1 Key informants specifically versions of each of the papers were critical-
pointed to the need to consolidate, synthesize and disseminate what is already known in ly reviewed by two to three peer reviewers,
these areas. This was considered necessary for the development of research agendas, to pro- as well as the Health Canada project man-
vide a base of information to help inform policy and funding decisions, and to support agers. In total, 22 Canadian researchers
application and evaluation of best practices. were involved as authors or reviewers of
the original synthesis papers.
Scope of the synthesis papers
Nutrition for Health: An Agenda for Action, Canada’s national plan of action on nutrition, The synthesis
considers the multiple factors that influence healthy eating and nutritional health within The methods employed to select and criti-
the Framework for Population Health.2 This Framework, which recognizes that both indi- cally review the literature are described in
vidual and collective factors affect health and that these factors interact, provided the foun- each of the papers. Generally, the authors
dation for the synthesis papers (see Figure 1). “Healthy eating” was defined as “eating prac- searched relevant electronic databases and
tices and behaviours that are consistent with improving, maintaining, and/or enhancing hand-searched key journals, covering liter-
health”. The original papers i) summarize the published literature on individual and collec- ature published in the 10 to 15 years pre-
tive determinants of healthy eating, ii) highlight gaps in knowledge about the determinants ceding 2004. The literature in English and
and iii) recommend areas for research to address the identified gaps. While it is essential to French was reviewed. Literature from
understand that policies and programs are the foundations for action in promoting and countries other than Canada was included,
supporting healthy eating, critically reviewing the available evidence on their role was but the authors were asked to consider the
beyond the scope of this project. applicability of the findings from interna-
Various approaches were considered for the selection of topics for the synthesis papers. tional sources to the Canadian context. On
The goal was to select a feasible approach that would have the greatest potential for the basis of the literature synthesis, knowl-
advancing knowledge of the determinants of healthy eating. Ultimately, the papers were
oriented by life stage and/or sub-population in an effort to facilitate identification of inter-
* Development of the synthesis paper on determi-
relations between determinants – a key principle of population health. This approach was nants of healthy eating among Aboriginal
consistent with the findings from the key informant survey, which concluded that knowl- Canadians was undertaken in collaboration with
Community Programs Directorate, First Nations
and Inuit Health Branch, Health Canada.
† Overweight and Obesity in Canada: A
1. Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada Population Health Perspective (Canadian
2. PhD Candidate, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto Institute for Health Information, 2004) is a prin-
3. Community Programs Directorate, First Nations and Inuit Health Branch, Health Canada cipal product of this work.

S6 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


PREFACE

edge gaps and directions for further


research were identified.

Overview
With the exception of the first article by
Dr. Kim Raine, the articles in this supple- Population
health status
ment represent summaries of the original
synthesis papers completed for the ONPP.
The article by Dr. Raine provides an Individual
overview of the complex set of interactions Determinants of health
factors
among the determinants of healthy eating.
Personal Individual
Dr. Raine synthesizes key findings from and
health practices capacity and
the original synthesis papers and considers coping skills
implications for healthy public policy. Collective
Social and economic Physical Health factors
The next article focusses on the percep-
environment environment services
tions of healthy eating. Dr. Marie-Claude Foundations
Paquette builds on theoretical models sug- Tools and supports for action
gesting that individuals’ ideals and assump- Research, information and public policy
tions about food are key determinants of
food choice.
Figure 1. Framework for Population Health3
The third and fourth articles consider
determinants of healthy eating of particular
relevance to two life-stage groups. Drs. The final paper in the supplement, by REFERENCES
Jennifer Taylor, Susan Evers and Mary Drs. Janet Polivy and C. Peter Herman, 1. McAmmond D and Associates. Promotion and
McKenna look at the factors that influence focusses on the bi-directional relation Support of Healthy Eating: An Initial Overview of
healthy eating in children and youth, and between mental health and eating behav- Knowledge and Research Needs: Summary Report.
March 2001. Available on-line at http://www.hc-
Drs. Hélène Payette and Bryna Shatenstein iours. sc.gc.ca/hpfb-dgpsa/onpp-bppn/promotion_
synthesize the key determinants of healthy Each of the papers summarizes the exist- support_healthy_eating_e.html.
eating among community-dwelling elderly 2. Joint Steering Committee Responsible for
ing literature, identifies gaps in knowledge Development of a National Nutrition Plan for
people. and offers recommendations for research to Canada. Nutrition for Health: An Agenda for
Dr. Noreen Willows’ paper follows, with enhance the evidence base on the determi- Action. 1996.
3. Federal/Provincial/Territorial Advisory
a focus on Canada’s Aboriginal popula- nants of healthy eating relative to the par- Committee on Population Health. Strategies for
tions. ticular topic discussed. Collectively, the Population Health: Investing in the Health of
Canadians. Prepared for the Meeting of Ministers
Building on sociological theory, Dr. research recommendations presented in of Health in Halifax, Nova Scotia, September 14-
Elaine Power considers the determinants of this supplement will be an important com- 15, 1994.
healthy eating among low-income ponent of further efforts to build and
Canadians, including factors related to implement a broader strategy for enhanc-
socio-economic gradients in eating patterns, ing the evidence base for promoting and
food insecurity and inequalities in diet. supporting healthy eating in Canada.

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S7


Determinants of Healthy Eating he promotion of healthy eating in

in Canada
T Canada has significant implications
for improving the health of popula-
tions, locally and globally. For example,
the current epidemic of obesity, in Canada
An Overview and Synthesis and worldwide, is associated with changing
eating (and activity) patterns and has sig-
nificant public health implications. 1
Kim D. Raine, PhD, RD
Promoting and supporting healthy eating
among Canadians, however, requires a
comprehensive understanding of the mul-
tiple influences on eating behaviour and
ABSTRACT the interactions among these determinants.
This paper will provide 1) an overview
This article uses a population health perspective to examine the complex set of of determinants of healthy eating by syn-
interactions among the determinants of healthy eating. An overview of current knowledge thesizing the current state of knowledge
on determinants of healthy eating was organized as follows: 1) individual determinants of highlighted in the six individual articles on
personal food choices and 2) collective determinants, including a) environmental the determinants of healthy eating in this
determinants as the context for eating behaviours and b) public policies as creating supplement, and 2) recommendations for
supportive environments for healthy eating. A conceptual synthesis of the literature research to promote healthy eating based
revealed that individual determinants of personal food choice (physiological state, food upon identified gaps in knowledge. The
preferences, nutritional knowledge, perceptions of healthy eating and psychological synthesis and recommendations will be
factors) are necessary, but not sufficient, to explain eating behaviour, which is highly placed within the context of population
contextual. Collective determinants of eating behaviour include a wide range of contextual health promotion (PHP). “The PHP
factors, such as the interpersonal environment created by family and peers, the physical model draws on a population health
environment, which determines food availability and accessibility, the economic approach by showing that, in order to
environment, in which food is a commodity to be marketed for profit, and the social improve the health of the people, action
environment, in which social status (income, education and gender) and cultural milieu must be taken on the full range of health
are determinants of healthy eating that may be working “invisibly” to structure food determinants. The model draws on health
choice. Policy is a powerful means of mediating multiple environments. There are gaps in promotion by showing that comprehen-
our understanding of the process of intervening in macro-level environments and the sive action strategies are needed to influ-
impact of such interventions on the promotion of healthy eating. Collective determinants ence the underlying factors and conditions
of food choice and policy contexts for promoting healthy eating, therefore, require that determine health.”2
investment in research. Applying a population health promotion lens to understanding the A population health perspective examines
multiple contexts influencing healthy eating provides insight into prioritizing research and the complex set of interactions among the
action strategies for the promotion of healthy eating. range of individual (biological, behavioural)
and collective (social, cultural, physical, eco-
MeSH terms: Nutrition; health promotion; public health; social environment; population nomic and political) determinants of health.
policy Applying a population health promotion
lens to understanding the multiple contexts
influencing healthy eating provides insight
into potential means of promoting healthy
eating through a wide variety of action
strategies that focus on entire populations.
Population health promotion is consistent
with ecological approaches for multilevel
public health strategies to promote healthy
lifestyles.3,4 Ecological approaches can help
to organize strategies that work both to help
individuals adopt healthy lifestyles and to
influence policy in order to create opportu-
nities for social and cultural change.
Strategies can be categorized by their pre-
dominant focus at the following ecological
levels: individual or intrapersonal (individ-
Centre for Health Promotion Studies, University of Alberta ual knowledge, attitudes and behaviour);
Correspondence and reprint requests: Kim D. Raine, 5-10 University Extension Centre, 8303 112
Street, University of Alberta, Edmonton, AB T5G 2T4, Tel: 780-492-9415, Fax: 780-492-9579, E-mail:
interpersonal (family and peers); institu-
kim.raine@ualberta.ca tional (schools, worksites); community

S8 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


OVERVIEW AND SYNTHESIS

(interagency and intersectoral) and public Food Preferences ments that seem central to people’s percep-
policy.3 Ecological levels are not discrete but Although food preferences are highly indi- tions of healthy eating include the impor-
are interconnected. vidual and may indeed have physiological tance of freshness, unprocessed and home-
For the purpose of this overview, deter- origins (such as innate preferences for made foods, and the concept of balance.30
minants of healthy eating and their impli- sweet and aversions for bitter tastes), social Perceptions of healthy eating are embed-
cations for health promotion action strate- and cultural norms also determine ranges ded within cultural meanings of food and
gies will be organized as follows: 1) indi- of food preferences. For example, health. For example, Willows’ review 33
vidual determinants of personal food Aboriginal peoples report preferences for reveals that “food choices based on
choices and 2) collective determinants, traditional foods. 14-20 In children, food Aboriginal cultural values may not be con-
including a) environmental determinants preferences are more likely guided by taste gruent with Western scientific constructs
as the context for eating behaviours, and alone,13 whereas external factors (such as regarding the nutritional value of food.”
b) public policies as promoting environ- environmental cues) contribute more to (pg. S34) If traditional food is necessary
ments for healthy eating. This organizing adult preferences. From a health perspec- for survival, it is by its very nature health-
strategy is not meant to artificially separate tive, preferences for sweet foods are com- promoting. The concept that any food,
those determinants of healthy eating that mon in children but diminish with age, including “store food”, may not contribute
are intimately connected but, rather, to and preferences for high-fat foods to health is, therefore, culturally foreign
assist the reader in understanding the cur- endure.13 The physiological “anorexia of and difficult to grasp.33
rent state of knowledge of determinants of aging”21,22 is associated with impaired taste
healthy eating and to assist in prioritizing and smell as well as metabolic changes Psychological Factors
action strategies for the promotion of accompanying aging. Polivy and Herman’s review34 highlights
healthy eating, as well as to identify gaps that “individual psychological factors that
for further research. Nutritional Knowledge affect eating include personality traits such
Children and adolescents have been shown as self-esteem, body image and restrained
Personal food choices: Individual to demonstrate a general understanding of eating (chronic dieting), as well as mood
determinants of eating behaviour the connections between food choice and and focus of attention.” (pg. S44) The
At first blush, what determines one’s eating health.23,24 However, Taylor’s review of the authors appropriately point out that there
behaviour, healthy or otherwise, appears to research does not consistently show that is a bi-directional relation between eating
be purely a matter of personal choice. After knowledge influences food choices in these and psychological states, in that not only
all, for the majority of the free-living popu- age groups.5 Among seniors, high aware- do psychological factors affect our food
lation, the act of putting food into one’s ness of nutrition and health is associated choices, but our food choices affect our
mouth is an individual act. Yet, personal with better food and nutrient intakes.25-29 psychological well-being.34
food choices are structured by a variety of In the adult population, nutritional knowl- Despite a significant level of research
individual and collective determinants of edge is intertwined with perceptions of into psychosocial influences on healthy
behaviour. This section focusses on indi- healthy eating. eating for both children and adults over
vidual determinants, ranging from one’s the past decade, the ability of various mod-
physiological state, food preferences, nutri- Perceptions of Healthy Eating els of psychosocial variables (e.g., the
tional knowledge, perceptions of healthy “Perceptions of healthy eating” are defined Theory of Planned Behaviour, Social
eating and psychological factors. by Paquette30 as the “public’s … meanings, Cognitive Theory, Transtheoretical
understandings, views, attitudes and beliefs Model) to predict individual dietary intake
Physiological Influences about healthy eating, eating for health, and remains low.35 Increasingly, these models
At both ends of life, physiological develop- healthy foods.” (pg. S15) Theoretical mod- are being refined and expanded to capture
ment5 or deterioration with aging6 influ- els suggest that key determinants of food aspects of environmental influences on
ence eating behaviour. Throughout child- choice are individuals’ ideals and their behaviour, including healthy eating.
hood, dietary quality appears to decrease assumptions about food,31,32 which would
with age. This is perhaps a function of include perceptions of healthy eating. Summary of Individual Determinants
emotional and social development that The public’s perceptions of healthy eat- of Healthy Eating
provides children with more control over ing include consumption of vegetables, Personal food choices are structured by a
food choice and thus is influenced by other fruits and meat; limitations of sugar, fat variety of individual determinants of
individual determinants, such as food pref- and salt; and variety and moderation. 30 behaviour, ranging from one’s physiologi-
erences and nutritional knowledge.5 With These elements seem to be influenced by cal state, food preferences, nutritional
aging, health status and functional abilities current dietary guidance aimed to improve knowledge, perceptions of healthy eating
influence food-related behaviours.7-9 Yet, nutritional knowledge and eating habits. and psychological factors. However, indi-
changes to physiological health status are However, other important elements of vidual determinants are necessary, but not
not beyond intervention, as community dietary guidance not generally included in sufficient, to explain eating behaviour.
resources that provide assistance can people’s perceptions of healthy eating Healthy eating is much more complicated
enhance seniors’ abilities to procure and include consumption of grain products than personal choice, as eating behaviour is
prepare an adequate diet.10-12 and milk products. Non-nutritional ele- highly contextual.

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OVERVIEW AND SYNTHESIS

Collective determinants, Part 1: eating patterns in response to social isola- inexpensive healthy foods may be less
Environmental determinants of tion, and influences of social contacts out- accessible in low-income communities38
healthy eating as context for side of the family are indications of fami- and near seniors’ housing. 6 Most large
individual behaviour lies’ embeddedness in the broader social supermarkets are located near major trans-
The term “environment” will be used here environment. This will be explored in portation routes that assume automobile
to describe a wide range of contextual fac- more detail in a subsequent section. access. Also, food service operations offer-
tors influencing eating behaviour. ing less healthy alternatives are ubiquitous
Environment may be intimate and local, Physical Environment as a in most urban areas, with particularly high
such as the interpersonal environment cre- Determinant of Healthy Eating accessibility in lower-income neighbour-
ated by family and peers. Alternately, envi- The physical environment refers to that hoods.41 As low income appears to be a
ronment may be further removed from which determines what food is available for common denominator in physical access,
one’s immediate awareness and control, consumption and access to that food. the interconnection of the physical envi-
such as the physical environment that Obviously, if healthy food is neither avail- ronment with the economic environment
determines food availability and accessibili- able nor accessible, the potential for is clear.
ty; the economic environment, in which healthy eating is compromised. Although Even in unique “bounded” physical
food is a commodity to be marketed for the Canadian food supply is plentiful, as environments, such as schools, the avail-
profit; and the social environment, in evidenced by ecological food disappearance ability of food low in nutrient density ver-
which social status and cultural milieu are data,40 the nutritional quality of the avail- sus healthier food is likely to influence
determinants of healthy eating that may be able food supply is unknown. Do the foods food choice.5 Promoting healthy food poli-
working “invisibly” to structure food in Canada, in the quantities available, con- cies in schools, including approved menus
choice. This section will attempt to make stitute a national food “basket” that is con- for school meals and student stores, guide-
more visible what is known about environ- sistent with dietary guidance and nutri- lines for bag lunches and healthier choices
mental determinants of healthy eating and tional recommendations? The ways in for fundraising, has implications for the
the interactions among these environ- which food is produced, transported, dis- promotion of healthy eating through the
ments. tributed (to markets or through charitable creation of supportive environments. 42
organizations), procured from the land or Herein lies an example of the complexities
Interpersonal Influences on Healthy markets, and purchased from food service of the interconnections among determi-
Eating locations in communities, worksites and nants, as school food policies to promote
Family provides an important context for schools vary significantly in a country as healthy eating may be in conflict with the
children’s food choices, as family provides geographically and culturally diverse as need to generate revenue, as will be dis-
the first and immediate social environment Canada. cussed further in the economic environ-
in which children learn and practise dietary The role of the physical environment is ment section.
patterns.36,37 Family can have both positive most profound and evident in remote or Another area in which social, economic
and negative effects on eating patterns for northern communities, primarily occupied and physical environments intersect explic-
all ages of family members. For example, by Aboriginal peoples. As Willows itly is in the charitable food distribution
Polivy and Herman’s review34 revealed that reviews,33 changes in the physical environ- system in Canada, primarily through food
“family…contributes to disturbed eating ment associated with technological devel- banks. Given that food banks have become
behaviours and eating disorders, increased opment (e.g., hydroelectric dams, defor- institutionalized in Canada,43 they have
consumption in overweight children, and estation), including environmental conta- become one channel through which low-
amounts of fruit and vegetables consumed.” mination, have reduced the availability of income Canadians access food regularly, at
(pg. S45) Family food provisioning, or how traditional foods. Substitution of market least for a portion of their total diet, and
the available food is distributed within a foods has not necessarily enhanced the therefore constitute a “physical environ-
family, is often influenced by gender, with availability of nutritious foods, as high ment”. One Canadian study on the nutri-
mothers sacrificing their own food intake transport cost and spoilage have often led tional quality of foods available from food
to protect their children from hunger when to ready availability of less nutritious, non- banks suggests that access and availability
food supplies are scarce.38 As children age, perishable foods (e.g., soda, potato chips). of healthy food may be compromised for
familial effects take less precedence as The interconnection of the physical envi- this population.44
social encounters outside the family ronment with the economic environment
increase.39 Throughout life, the effect of is evident, since store managers’ stock Economic Environment as a
peers and others on eating behaviour, par- management practices may be determi- Determinant of Healthy Eating
ticularly the presence of others during an nants of food availability.33 The economic environment, in which food
eating episode, may function through an The role of the physical environment in is a commodity to be marketed for profit,
influence on perceived consumption determining healthy eating is less immedi- has major implications for eating practices
norms.34 In seniors, social isolation appears ately apparent in urban populations. in a market-based economy such as
to have a negative impact on food intake, However, the role of the built physical Canada. Increasingly, the food industry
particularly among men.6 Family food pro- environment becomes more obvious if one targets marketing messages at young chil-
visioning strategies, gender differences in considers that the supermarkets offering dren, perhaps in recognition of their vul-

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OVERVIEW AND SYNTHESIS

nerability to such messages associated with foods.50 Thus, this is a strong point for level that will support Ontario farmers and
an underdeveloped critical consumer con- subsidization strategies. Examined critical- provide quality, environmentally-sound,
science. As well as children’s reduced criti- ly, however, one must recognize that such nutritious food to the people of
cal thinking abilities, marketers recognize programs are likely to be accepted by the Toronto”.51 There is a need for research to
the strong influence children and youth food industry only if they prove to be prof- determine whether community approaches
have on the purchasing patterns of care- itable. Public policy, to be discussed in a to address economic determinants of
givers and the large disposable income of later section, is a potential means of medi- healthy eating are workable in a variety of
current children and youth.45 As Taylor ating corporate-driven economic interests Canadian contexts, have an impact on
reviews,5 from a very young age, children to create a social environment more sup- food and eating practices at the population
are bombarded with media messages portive of healthy food choices. level, influence population-level policies
through television advertisements, the bulk Within Canada, research consistently that promote supportive environments for
of which promote a diet high in fat and demonstrates that “the most important healthy eating, and ultimately influence
sugar, and lower in fruits and vegetables. barrier to healthy eating is inadequate population health status.
Exposure to advertisements influences income.”38 (pg. S39) Income is a determi-
individual determinants of healthy eating nant of healthy eating that transcends sev- Social Environment as a Determinant
such as food preferences and perceptions of eral social groups, notably children,5 seniors of Healthy Eating
healthy eating that give priority to distort- and Aboriginal peoples. In a market- The previous sections make clear that food
ed nutritional messages designed to sell based economy, those with inadequate and eating have meaning far beyond physi-
individual products, not promote a total income to purchase a healthy diet for myri- cal and emotional nourishment. Eating is a
diet.5 Adults are not immune to influence ad reasons, including inadequate welfare socially constructed act that is embedded
from media.34 rates, minimum wage, or higher costs of not only in individual perspectives of
Marketing food, however, transcends healthier foods and diets, are unable to healthy eating drawn from dietary guid-
persuasive advertising to include the pro- fully participate as consumers. Enhancing ance and marketing of products but also in
motion of less healthy foods in physical individual determinants, such as nutrition- physical and economic environments that
environments (school, worksites). The pro- al knowledge, may provide some coping determine what food is available to us and
liferation of soft-drink vending in schools skills, but as Power’s review clearly demon- at what cost. Food and eating also have
is a prime example of this interconnection strates, 38 most low-income Canadians social, cultural and symbolic functions;
of the physical and economic environ- demonstrate significant resourcefulness food and feeding can signify a sense of
ments. Although soft-drink vending is not and “buy more nutrients for their food belonging, caring and community.52,53 Our
commonplace in Canadian elementary dollar than higher income households.” social context and culture is often “invisi-
schools, it is almost universal in high (pg. S39) ble” to us, as our immersion in our socio-
schools, and many university campuses Community initiatives to promote cultural context assures a “taken-for-
have entered into exclusive contracts with healthy eating, such as food policy coun- grantedness” of our day-to-day experiences.
soft drink manufacturers for exclusive cils, have been developed as models for Increasingly, we live in a social environ-
“pouring rights” assumed to engender influencing the physical and economic ment that disconnects us from the source
brand loyalty. 46 As Power eloquently determinants of healthy eating by provid- of our food: food comes from supermar-
argues in her review,38 the food industry’s ing ready access to a variety of nutritious, kets and restaurants, not farms and the
primary logic is to make profit, which is affordable foods. For example, originally land or sea. Our social context devalues the
often in conflict with the promotion of developed in response to the need of low- preparation of food in the home and pro-
healthy eating. 47,48 The food industry, income city dwellers, the Toronto Food motes quick and easy meals from the freez-
through its marketing practices, has a sig- Policy Council (TFPC) of the Toronto er. The time investment in sharing meals is
nificant influence on the ways in which Board of Health was developed in 1990. less significant than the time saved by
social norms around eating are shaped. As The TFPC is a unique organization with drive-through or take-out.45 Yet, we con-
such, the economic environment intersects membership from large food corporations, tinue to celebrate life and traditions
with the social environment as a determi- conventional and organic farms, coopera- through sharing food, since food and eat-
nant of healthy eating. tives, unions, social justice and faith ing have strong social dimensions.
Point-of-choice nutrition education in groups, and City Council. As such, there is Our understanding of culture is
food retail and service operations has been a commitment to a common goal by a enhanced by examining that which is cul-
used extensively, in partnership with the variety of stakeholders at the community turally foreign to us. For example, as
food industry, with variable success rates in level and beyond. The Council supports Willows33 states, “Of importance to under-
motivating healthy choices. 49 Pricing programs, such as Field to Table, that con- standing the role that culture plays in
strategies have also been used to promote nect low-income inner city residents with determining food choice in Aboriginal
healthy food choices. Evaluation of com- farmers in need of a market for their pro- communities is that the activities required
bined nutrition messages with price reduc- duce, as well as rooftop and community to procure traditional food are not merely
tions suggests that price decreases may be a gardens. The TFPC’s local action is “bal- a way of obtaining food but, rather, a
more powerful means than health messages anced by longer-term efforts to develop mode of production that sustains social
of increasing consumption of healthy policies at the municipal and provincial relationships and distinctive cultural char-

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OVERVIEW AND SYNTHESIS

acteristics.” (pg. S33) Juxtaposed against standards and programs across the country, remains much research to be done on the
mainstream Canadian culture, which, as and they serve as a basis for a wide variety public acceptability of such policies, and
previously described, includes a strong of healthy living initiatives. The national on the level of taxation or subsidization
social dimension to food and eating, the plan of action on nutrition, Nutrition for necessary to motivate changes in consumer
value of food in sustaining social relation- Health: An Agenda for Action (1996) 56 behaviour.
ships and cultural characteristics is not for- builds on the population health model and Similarly, given the extent of exposure to
eign at all. sets out strategic directions to encourage food advertising, the majority of which is
The question that we face is, have we policy and program development that is for foods of lower nutritional quality,
freely chosen our cultural destiny or have coordinated, intersectoral, supports new restrictions on advertising may hold
we allowed our “choices” to be dictated by and existing partnerships, promotes the promise as a policy lever. Given the poten-
interests inconsistent with the promotion efficient use of limited resources and tial opposition to restrictive advertising by
of health? If, as Power argues,38 “one of the encourages relevant research to improve corporations and civil libertarians, it is
conditions for improving the food prac- the nutritional health of Canadians. important to recognize that public support
tices of… Canadians is an improvement in In a physical environment context, poli- for such policy change is essential for suc-
the dominant food culture and food cies that protect the food supply through cess.59 Research is needed to evaluate the
norms, then it will be important to charac- protection of the natural environment, impact on healthy eating of current adver-
terize food cultures and food norms in this such as preventing industrial contamina- tising restrictions, such as Quebec’s restric-
country, plus the most effective means of tion of food and water, have potential tions on advertising to children.61 The role
shifting them.” (pg. S40) Examining food macro-level impacts on opportunities for of media literacy training to promote resis-
practices through a broad policy lens is one healthy eating. Agricultural policies inter- tance to advertisements also requires inves-
means of assessing the potential for creat- sect with economic policies in influencing tigation. For both taxation and advertising,
ing a cultural context and supportive social the availability of a safe, nutritious and learning from successes in tobacco reduc-
environment for the promotion of healthy affordable food supply. tion is recommended, including taking
eating. Given the evidence linking lower socio- into account the differences between
economic status and social inequity to tobacco and food products. Again, the
Collective determinants, Part 2: poorer diet and nutritional status, policies process of intervening in macro-level envi-
Creating supportive environments that redistribute income and provide a ronments and the impact of such interven-
for healthy eating through healthy social safety net (income taxes, provincial tions on the promotion of healthy eating
public policy health care taxes) act to promote health. require significant investment in research.
Policies define what is considered impor- Protecting and rebuilding Canada’s social Policy is a powerful means of mediating
tant and guide our choices. Individuals safety net may hold promise for promoting multiple environments. Dietary guidance
may have implicit personal food policies healthy eating. Specific policies, such as mediates an environment of multiple, con-
and make choices according to family pref- monitoring income support to ensure that flicting food and nutritional messages to
erences, nutritional value, cost, environ- it is adequate to purchase the components create an environment for informed indi-
mental sustainability, religious or numer- of a healthy diet, as recommended in vidual choice. Environmental protection
ous other reasons. Policies at the local, Nutrition for Health: An Agenda for Action policies can mediate the effects of industry
regional and national level can have a sig- (1996),56 may also influence healthy eat- on the physical environment by protecting
nificant impact on our collective food ing. the food supply. Economic policies can
choices and thus act as determinants of In the context of a “consumer culture”, mediate food affordability. Social policy
healthy eating. The capacity to make large- policies provide protection to consumers can mediate corporate-driven economic
scale macrosystem changes in the social by counterbalancing prevailing marketing interests, support disadvantaged Canadians
environment to promote healthy eating is, motivated by profit, not health. For exam- to become self-sufficient, and can mediate
in part, dependent upon political will. ple, taxation policies could subsidize the a culture of food consumerism to create a
Some of the less controversial and well- cost of low-energy, nutrient-dense food cultural context and supportive social envi-
established policy approaches to the pro- with taxes of sufficient magnitude to affect ronment for the promotion of healthy eat-
motion of healthy eating deal with dietary sales of high-energy, low-nutrient dense ing.
guidance and attempt to work through foods.57 These potential policy levers pro-
improving nutritional knowledge and per- mote healthy eating through a changed SUMMARY AND CONCLUSIONS
ceptions of healthy eating. Health Canada price structure for food that favours pur-
promotes the health and well-being of chase of more nutritious choices. 58 This paper used a population health per-
Canadians by collaboratively defining, pro- Taxation has been successfully used in spective to examine the complex set of
moting and implementing evidence-based some jurisdictions as a disincentive for interactions among the determinants of
nutrition policies and standards in docu- snack food purchase59 or a means to gener- healthy eating. Although determinants of
ments such as Canada’s Food Guide to ate revenue for health promotion.60 It has healthy eating are intimately connected,
Healthy Eating54 and Canada’s Guidelines been noted that Canada’s GST/HST sys- for clarity of understanding the synthesis
for Healthy Eating. 55 These documents tem provides a potential model for a of current knowledge on determinants of
underpin nutrition and health policies, and changed price structure for food.41 There healthy eating was organized as follows:

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OVERVIEW AND SYNTHESIS

lescents associated with diet, low physical activity,


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43. Tarasuk VS, Maclean H. The institutionalization 50. Battle Horgen K, Brownell KD. Comparison of Ottawa, ON: Health Canada, 1996. Available
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cern. Can J Public Health 1990;81(4):331-32. promoting healthy food choices. Health Psychol dgpsa/onpp-bppn/nutrition_health_agenda_
44. Jacobs Starkey L, Kuhnlein HV. Montreal food 2002;21(5):505-12. e.html
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Guilford Press, 2002;556-93. Nutrition for Health: An Agenda for Action.

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Perceptions of Healthy Eating o successfully promote and support

State of Knowledge and Research Gaps


T healthy eating among Canadians, a
better understanding of the factors
that influence eating behaviour is needed.
Theoretical models of food choice suggest
Marie-Claude Paquette, PhD that individuals’ ideals and their conscious
or tacit assumptions about food are key
determinants of food choice.1,2 The per-
ceptions of healthy eating can be viewed as
influential on nutritional health within its
broad conceptualization, based on the
Framework for Population Health.3
ABSTRACT Over the last century, evolution of
nutritional science has increased the com-
To effectively promote and support healthy eating among Canadians, there needs to be a plexity of the definition of healthy foods.4
better understanding of the factors that influence eating behaviours. Perceptions of healthy Many elements of foods must now be
eating can be considered as one of the many factors influencing people’s eating habits. For taken into consideration to determine their
this review, “perceptions of healthy eating” are defined as the public’s and health healthiness, e.g., type of fat. Additionally,
professionals’ meanings, understandings, views, attitudes and beliefs about healthy eating, consumers must combine foods into
eating for health, and healthy foods. healthy food patterns and ways of eating.
Within this context of complexity, people
This article’s aim is to review and summarize the literature on the perceptions of healthy gather information on food and nutrition
eating and to identify the current state of knowledge and key knowledge gaps. Databases, from multiple sources, such as television,
the worldwide web, selected journals and reference lists were searched for relevant papers food labels, food manufacturers and health
from the last 20 years. professionals. 5,6 These sources present
nutritional information each in their
Reviewed articles suggest relative homogeneity in the perceptions of healthy eating despite unique way.7 People must then give mean-
the studies being conducted in different countries and involving different age groups, sexes ing to this information and decide on its
and socio-economic status. Perceptions of healthy eating were generally based on food usefulness and applicability in their daily
choice. Fruits and vegetables were consistently recognized as part of healthy eating. life.
Characteristics of food such as naturalness, and fat, sugar and salt contents were also Greater understanding of the public’s
important in people’s perceptions of healthy eating. Concepts related to healthy eating, perceptions of healthy eating is essential
such as balance, variety and moderation, were often mentioned, but they were found to be to assess how current health promotion
polysemous, conveying multiple meanings. messages are interpreted and put into
practice in daily life in order to develop
The main gap identified in this review concerns the lack of knowledge available on successful healthy eating messages and
perceptions of healthy eating. More data are needed on the perceptions of healthy eating interventions.
in general, on the influence on perceptions of messages from diverse sources such as food The objectives of this review are two-
companies, and, most important, on the role of perceptions of healthy eating as a fold: 1) to examine and summarize the
determinant of food choice. existing literature on perceptions of
healthy eating in children, adolescents,
MeSH terms: Eating; perceptions; diet; attitude; food habits adults and health professionals; and 2) to
identify research gaps and future avenues
for research in the area of perceptions of
healthy eating. For the purpose of this
review, “perceptions of healthy eating” are
defined as the public’s (children, adoles-
cents and adults) and health professionals’
meanings, understandings, views, attitudes
and beliefs about healthy eating, eating for
health, and healthy foods.
Because of the multiple perceptions and
meanings of healthy eating, this review
rests on a constructivist perspective. 8-10
Within this perspective, healthy eating is
Institut national de santé publique du Québec understood as constructed within many
Correspondence and reprint requests: Marie-Claude Paquette, Institut national de santé public du
Québec, Bureau 9.100, 500 René-Lévesque Ouest, Montréal, PQ H2M 1W7, E-mail:
realities, to have numerous meanings, and
marie_claude027@yahoo.ca to be dynamic and changing over time.

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S15


PERCEPTIONS OF HEALTHY EATING

LITERATURE SEARCH METHODS ilar to those of Canadians, or that percep- often mentioned by participants as healthy
tions across Canada are homogenous. foods, as part of a healthy diet or as most
Database and web searches, hand review of These differences limit the transferability important for healthy eating.
selected journals, and reference lists of of findings and point to the need to repli- Studies that included older respondents,
papers were used to find information on cate studies from other regions or coun- persons over 65 years of age, did not find
the perception of healthy eating. Reference tries. However, international studies are that the importance of vegetables and fruits
databases covering the topics of nutrition, included in this review because of the lack to healthy eating varied according to
medicine, sociology, psychology, aging, of Canadian data. age.13,28 In addition, the importance of veg-
nursing, and education (MEDLINE, etables and fruits does not seem to have
PubMed, Sociological Abstracts, ERIC, The public’s perceptions of healthy changed much with time, as a few older
CAB abstracts, PsycINFO, AgeLine, eating studies, published 20 years ago, also
FRANCIS, CINAHL) were searched for In the review of the literature, fundamental reported that vegetables and fruits were
Canadian and international scientific liter- elements of the perceptions of healthy eat- perceived to be an essential part of a
ature from 1980 to 2004. Findings of key ing were found to be 1) vegetables and healthy diet.29,30
words were put under two broader terms, fruits, 2) meat, 3) low levels of fat, salt and However, a few studies15,28,31 suggested
an “eating” term (key words: healthy eat- sugar, 4) quality aspects, such as fresh, that gender influenced the perception of
ing, food choice, food habit, food, and unprocessed and homemade foods, and vegetables and fruits. Women mentioned
food selection) and a “perceptions” term 5) concepts of balance, variety and moder- vegetables and fruits more often as part of a
(key words: perception, lay conceptualiza- ation. healthy diet,15 and these foods were per-
tion, conception, meaning, belief, attitude, While the majority of studies found ceived to be more suited to women. 28,31
interpretation, conceptualization, and explored adults’ perceptions of healthy eat- These findings support the notion of gender
meaning), which were intersected; result- ing, studies that focussed on specific age differences in attitudes to vegetables and
ing findings were reviewed on screen or groups, such as persons over 65 year of age, fruits.4,32 In her book, Lupton4 suggests that
printed. children and adolescents, did not report light, sweet, soft-textured foods and foods
Additional information sources were major differences from adults’ perceptions. that are easy to digest are associated with
sought to complement the more traditional For that reason, studies from all age groups women, whereas meat and foods that are
channels of the scientific literature, are included in this section, and differences harder to digest are associated with men.
through e-mails sent to personal contacts in perceptions are highlighted in the text. In addition, a Canadian study33 reported
and consultation of websites of profession- Because of the small number of studies on the emergence of a fruit and vegetable
al associations and health-related organiza- that focussed on variations in perceptions morality: “the should syndrome”. In this
tions. Additional unpublished reports were according to socio-economic status (SES), study, some participants felt obligated to
obtained from the Office of Nutrition results from these studies have also been eat vegetables and fruits. The researchers
Policy and Promotion at Health Canada. included in this section. attributed this attitude to current health
While materials collected through these Not all studies included in the review messages that promote eating vegetables
alternative sources are not typically peer- were from Canada, but review of the litera- and fruits for their health value, and the
reviewed, they are an essential complement ture strongly suggested that perceptions status of vegetables as an essential part of
to the paucity of peer-reviewed articles on were relatively homogenous regardless of an “ideal” diet.
the topic of healthy eating perceptions. country, and thus it is appropriate to con-
All articles and reports were examined trast the perceptions of healthy eating with Meat
for inclusion in this review. The inclusion Canadian dietary guidance. In general, the In adults, meat was mentioned in the
criteria included the following: 1) the public’s perceptions of healthy eating seem greatest number of studies after vegetables
objectives of the study were stated as to be heavily influenced by dietary guid- and fruits.8,15,17,18,34 It was also mentioned
exploring the perceptions of healthy eating, ance, which recommends vegetables and as part of healthy eating by children and
or findings and results explored aspects of fruits,11,12 meat,11,12 limitations of fat and adolescents. 21,23,26 However, the role of
healthy eating; and 2) studies were deemed salt, 11 variety 11,12 and moderation. 12 meat in healthy eating is not clear. In most
methodologically sound. Methodological However, other elements that seem central cases the perceptions of healthy eating
soundness was evaluated by examining to people’s perceptions of healthy eating included avoiding or limiting meat con-
internal validity, reliability and the objec- are not found in current dietary guidance, sumption.13,15 Indeed, a Canadian study
tivity of quantitative studies; and transfer- such as the importance of freshness, reported that participants perceived
ability, dependability, confirmability and unprocessed and homemade foods, limit- healthy eating as trying to limit meat
credibility10 of qualitative studies. In the ing sugar intake and the concept of bal- intake, specifically red meat, and replacing
end, 38 studies were included in this ance. it with chicken or fish. 18 On the other
review. hand, some studies have reported that peo-
Since perceptions are likely influenced Vegetables and fruits ple perceive eating more meat as part of
by culture, it was not assumed at the outset A good number of the studies involving healthy eating.18,19,35 One of these studies18
that perceptions of healthy eating in a pop- children, adolescents and adults 6,8,13-27 reported the confusion surrounding the
ulation group of another country were sim- found that fruits and vegetables were most quantities of meat to eat, several partici-

S16 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


PERCEPTIONS OF HEALTHY EATING

pants believing that eating a lot of meat is healthy eating.6,8,14,15,28,34,37 In many studies, the meaning of the term “balance” was also
important to healthy eating. Older and fresh foods and the freshness of food was suggested in a study of children,22 in which
recent studies also support the notion that considered in opposition to canned, frozen one child described healthy eating as “to
meat is an essential component of “tradi- and processed foods. For the latter there have a balanced diet such as pasta, choco-
tional” meals. 29,30,36 Finally, a few stud- was a perception that such foods were late and eggs.”
ies19,34 suggested that SES may influence unhealthy or not as healthy as fresh The concept of balance was often men-
perceptions regarding meat. In one study,34 foods.17,18,30 tioned by study participants in combina-
red meat was more frequently mentioned Fresh foods may also be important to tion with the concepts of variety and mod-
as healthy by women of lower SES. Part of some older respondents. In a pan-EU eration.15,18,39An Australian study7 reported
the inconsistency in perceptions of meat study,13 10% of seniors included natural that the concept of moderation was used as
may be attributable to the term itself, foods and no processed foods in their a response to confusion and inconsistencies
which can encompass many varieties of description of healthy eating. Some perceived about healthy eating. By using
meat and meat cuts. studies28,34,39 described not only the impor- the concept of moderation, people could
tance of freshness but also the freshness of justify any food choices. Confusion and
Low levels of fat, salt and sugar specific categories of foods, such as vegeta- polysemy were also reported in a lay jour-
Fat, salt and sugar were the three most fre- bles and fruits, and meat products. nal article44 in which both lay people and
quently mentioned components of food to Studies have also suggested that the way health professionals “struggle with the defi-
be avoided for a diet to be perceived as food is prepared influences perceptions of nition of a ’moderate’ diet”44 and question
healthy in all age groups.6,7,16,19,20,22-24,26,27,31,37 healthiness. A Canadian opinion survey40 the usefulness of the concept. Some health
A telephone survey35 representative of the found that meals considered to be the most professionals were also quite critical of the
Canadian population reported that people healthy were home-cooked meals. In addi- term, believing that it contributed to
avoided foods with cholesterol (60%), salt tion, studies in children and adoles- weakening dietary recommendations.
(56%) and sugar (48%) to make their diets cents20,21,41 have suggested that the situa- Moderation was also mentioned in a quali-
healthier. Another Canadian study18 found tion, location and context surrounding eat- tative study of British seniors. 36 These
that when asked what advice they would ing influence perceptions. Foods eaten at respondents believed it was important to
give on healthy eating, participants recom- home were viewed as healthy compared eat with moderation to avoid weight gain
mended avoiding fat and high-fat foods, with foods eaten outside the home or with but also to avoid overindulgence as a moral
sugar and fried foods. Similar findings friends. This distinction was not clearly value. Finally, a study of women34 reported
were found in studies conducted in the reported in studies of adults’ perceptions. that middle-class women placed greater
UK17 and European Union (EU).15 importance on balance and moderation in
The latter also reported that women Concepts of balance, variety and their perceptions of healthy foods than
were more likely than men to mention eat- moderation working-class women.
ing less fat in their definition of healthy In all age groups, the concepts of balance, The studies reviewed in this section
eating.15 However, the influence of SES on variety and moderation were often report- reveal the numerous meanings associated
the perceptions of fat, salt and sugar is not ed as part of the perceptions of healthy eat- with the terms “balance” and “modera-
clear. While the results of a UK study34 ing.14-18,21-23,26,33,34,40,42,43 tion”. Findings also suggest that while
suggested that women of higher SES were A Canadian study18 showed that about there exists wide diversity of meanings for
more concerned than women of lower SES half of the respondents spontaneously the term “balance”, nutrition messages and
about eating low-fat foods, both social mentioned eating a balanced diet or a vari- health professionals may not be aware of or
classes perceived sweet foods and ety of foods as part of healthy eating. take into account this diversity of mean-
fatty/fried foods to be unhealthy. Balance was discussed in terms of eating ings; rather, they tend to assume a more
Studies also suggested a heightened more one day to balance eating less the specific, single definition.
awareness of fat, sugar and salt among older next day and varying the emphasis on dif-
respondents.6,13,38 A Canadian telephone ferent food groups from day to day. Overlap in perceptions of healthy
survey16 suggested that restricting fat, sugar Another Canadian study33 found balance eating and of weight loss dieting
and salt was more common in adults over to be a polysemous concept, expressing A few studies included in this review have
age 55 than in younger age groups. Older variety in meal composition, balancing suggested that overlap between perceptions
adults’ heightened apprehension of the fat, healthy foods with less healthy ones, bal- of healthy eating and perceptions of diet-
sugar and salt content of food, found in ancing a healthier diet with occasional ing for weight loss exists.25,28,36,39,42,45,46 A
these studies, is understandable in light of lapses, and balancing enjoyment with qualitative study in the UK 39 suggested
the link with chronic diseases. nutritional or health concerns. that participants consciously used concepts
A UK study 39 supports these findings of moderation and healthy eating to con-
Qualities: Fresh, unprocessed and and reports that participants had difficulty ceal and make more socially acceptable
homemade foods in explaining the meaning of the term bal- their weight loss attempts. In their study of
Other characteristics of food not associated ance. It was associated with notions of older adults, McKie et al.36 also reported
with food composition, such as freshness, right and good, and was often contrasted that participants’ conceptualization of
were influential on people’s perceptions of with the concept of ”excess”. Confusion in healthy eating included concerns about

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PERCEPTIONS OF HEALTHY EATING

weight gain that emerged under the theme milk products groups, were not included polysemy of “healthy eating” has not been
of moderation. One study 42 of children in people’s perceptions of healthy eating to recognized in the past and because of the
reported that for some the concepts of any major extent. A few studies reported complexity of the issue. Even if perceptions
thinness and fatness were spontaneously that carbohydrate-rich foods such as were found to be relatively homogenous
associated with concepts of healthy eating. breads, grains, pastas, pulses and potatoes across studies in different developed coun-
Finally, a study conducted with boys and were part of healthy eating defini- tries, age groups, sexes and SES, more
girls45 also reported that dieting for weight tions.15,17,18,20,21,23,27,31,39 Canadian data also research needs to be conducted to validate
loss was described as healthful eating suggested that the grain products group is this finding.
behaviours, such as “eating more salads or rarely mentioned. 18 The milk products This review has identified many gaps in
fruits or vegetables”, “I think it has more group is even more rarely mentioned as knowledge. Overall, three aspects of per-
to do with healthy eating.” part of healthy eating. Except in one ceptions need to be further investigated:
The consequences of the overlap study,21 in which adolescents rarely men- most importantly, the influence of the per-
between healthy eating and weight loss tioned dairy products, studies focussing on ceptions of healthy eating on food choice
dieting are not known. While some children and adolescents found that milk and eating behaviour; how messages from
authors propose that these findings suggest was more often included in their definition information sources (e.g., media, health
we need not be so concerned about dieting of healthy eating than it was in adults’ defi- professionals, food industry) shape percep-
for weight loss in adolescents, as it may nitions.20,23 In adults, milk products were tions of healthy eating, and the need for
actually reflect healthy eating behaviour,45 mentioned most often within the context research on perceptions themselves.
others caution that healthy eating messages of decreasing fat intake by consuming low- Indeed, while the link between percep-
could reinforce unhealthy eating practices fat dairy products.15,38 tions and behaviour can be inferred, it is
and excessive weight preoccupation. 47 In addition, most studies did not assess not clearly supported in the literature. This
More research needs to be conducted on more precise aspects of perceptions, such as aspect of perceptions could be studied
the origins and effects of the overlap quantities, serving sizes and portion sizes. within the context of research into the dif-
between people’s perceptions of healthy While people perceive vegetables and fruits ferent factors that influence food choice or
eating and dieting for weight loss. to be important to healthy eating, they as an exploration of the two-way relation
The public’s perceptions of healthy eat- may not know how much they need to eat between perceptions and behaviour. Such
ing are most often conceptualized through to be healthy. Such notions themselves studies are central to asserting that the per-
food choice; fruits, vegetables and meat could be the subject of multiple meanings ceptions of healthy eating are truly a deter-
were the most mentioned. Food character- and interpretations, and should constitute minant of healthy eating.
istics and components were also important future research avenues. More research also The process by which information
elements in people’s perceptions of healthy needs to be initiated into how people put sources shape people’s perceptions of
eating. The concepts of balance, variety and their definitions of moderation, variety and healthy eating by contributing meaning to
moderation were often part of respondents’ balance into effect in their lives. nutritional messages also needs to be better
perceptions of healthy eating. However, understood. Such research is essential
few studies examined the meaning of these Health professionals’ perceptions of information to direct the development and
terms for respondents, and most did not healthy eating wording of future dietary guidance and
describe the researcher’s interpretations and Only one study was found that briefly dis- health promotion efforts for healthy eat-
coding scheme for recognizing these cussed health professionals’ perceptions of ing. These findings could also potentially
notions in participants’ narratives. When healthy eating, conducted in London, UK.39 contribute to developing regulations aimed
coding schemes were reported, meanings The findings suggested that health profes- at controlling food advertising and claims,
were numerous rather than uniform. sionals recommend that clients opt for as well as critical appraisal techniques of
The public’s perceptions of healthy eat- healthy eating rather than for dieting. They media literacy.
ing seem to be heavily influenced by also alluded to notions of “good” and “bad” Perceptions of healthy eating themselves
dietary guidance, (which is relatively simi- foods, but the way in which “bad” foods also need to be further explored. Indeed,
lar across the countries of studies discussed were part of a healthy diet was not clear. The no study was found that specifically
in this review), which also recommends authors concluded that even health profes- explored health professionals’ perceptions
vegetables and fruits,11,12 meat,11,12 limita- sionals seemed to have a difficult time com- of healthy eating. Research is first needed
tions of fat and salt,11 variety11,12 and mod- municating the message that healthy eating on dietitians’ perceptions of healthy eating,
eration.12 However, other elements that is not the same as dieting for weight loss. as they are considered the nutrition experts
seem central to people’s perceptions of and are often called upon to inform and
healthy eating, such as the importance of KNOWLEDGE GAPS AND educate about healthy eating. Variations in
freshness, unprocessed and home-made DISCUSSION the perceptions of healthy eating also need
foods, limiting sugar intake and the con- to be investigated in other health profes-
cept of balance, are not found in current The perceptions of healthy eating remain a sionals, such as physicians, nurses and pub-
dietary guidance. relatively unexplored issue, as suggested by lic health professionals.
Other important elements of dietary the small number of studies (38) included In order to better tailor interventions, to
guidance, such as the grain products and in this review. This may be because the make them more salient and successful for

S18 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


PERCEPTIONS OF HEALTHY EATING

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7. Lupton D, Chapman S. “A healthy lifestyle The incidence of dieting amongst adolescent Healthy eating: The views of general practitioners
might be the death of you”: Discourses on diet, girls: A question of interpretation? J Hum Nutr and patients in Scotland. Am J Clin Nutr
cholesterol control and heart disease in the press Diet 2001;14:103-9. 2003;77:1043S-1047S.
and among the lay public. Sociol Health Illness 26. Story M, Resnick MD. Adolescent’s views on 44. Havala S. Deciphering those dietary recommen-
1995;17:477-94. food and nutrition. J Nutr Educ 1986;18:188-92. dations – How do you define moderation?
8. Chapman G, Beagan B. Women’s perspectives 27. Eikenberry N, Smith C. Healthful eating: Vegetarian J 1992;July/August:8-13.
on nutrition, health and breast cancer. J Nutr Perceptions, motivations, barriers, and promoters 45. Neumark-Sztainer D, Story M. Dieting and
Educ Behav 2003;35:135-41. in low-income Minnesota communities. J Am binge eating among adolescents: What do they
9. Lincoln YS, Guba EG. Paradigmatic controver- Diet Assoc 2004;104:1158-61. really mean? J Am Diet Assoc 1998;98:446-50.
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JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S19


Determinants of Healthy Eating here is mounting evidence that

in Children and Youth


T Canadian children may be making
unhealthy food choices, leading to
both dietary excesses and inadequacies.
Most information comes from nutritional
surveillance in the United States (US),
Jennifer P. Taylor, PhD, RD1 which suggests that few children meet
Susan Evers, PhD, RD2 dietary recommendations. They have low
Mary McKenna, PhD, RD3 intakes of fruits, vegetables and milk prod-
ucts; high intakes of less healthy choices,
such as soft drinks and high-fat, high-sugar
snack foods; and consumption of too
ABSTRACT much fat and saturated fat, and too little
folate and calcium.1-7 Overall dietary quali-
This review outlines the state of knowledge and research gaps in the area of determinants ty declines with age, and the rate of break-
of healthy eating among children and youth. The article is structured around individual fast skipping increases. Although there are
and collective determinants that affect healthy eating in children and youth. We defined no comparable national data available on
healthy eating as “eating practices and behaviours that are consistent with improving, children’s eating behaviours in Canada,
maintaining and/or enhancing health.” Relevant databases were searched for papers limited information from a national
published between January 1992 and March 2003 that focussed on children or youth and study,8 and some provincial data,9,10 sug-
reported at least one factor relevant to healthy eating. Among collective factors, familial gest that similar concerns exist about
factors and the nature of foods available in the physical environment, including at home, Canadian children, including low fruit and
schools and in fast-food establishments, stand out as significant influences on healthy vegetable consumption and high consump-
eating in children and youth. The media, particularly television, also have an enormous tion of candy, chocolate bars and soft
potential influence and can overshadow familial influences. Individual factors identified drinks.
include knowledge, attitudes and food preferences; only the latter have been identified as Unhealthy eating habits during child-
a strong determinant of healthy eating in both children and adolescents. The results of the hood may interfere with optimal growth
review identified a significant body of literature in the area of determinants of healthy and development while setting the stage
eating in children and youth; however, very little of this research has taken place in for poor eating habits during adolescence
Canada. Only a few determinants, such as economic factors and food security, the content and adulthood.11,12 Moreover, poor diet
of media nutritional messages, and the issue of flavours, neophobia and food preferences, and inactivity during childhood have been
have undergone some examination by Canadian researchers. Research priorities for implicated in the worrisome increase in
Canada in the area of determinants of healthy eating and surveillance of eating behaviours childhood overweight,13 which is consid-
are identified. ered to be at epidemic proportions in
Canada and in other developed nations.14-16
MeSH terms: Eating; child; adolescent; factors Increases in other nutrition-related risk
factors for chronic disease in children such
as hypertension, hypercholesterolemia and
Type 2 diabetes have also been
observed.17,18
A range of health promotion strategies
are required in order to support healthy
eating during childhood and adolescence
and promote optimal growth and develop-
ment while reducing risk for obesity as
well as chronic disease rates in the adult
population. 11,19 However, in order to
design effective interventions, an under-
standing of the complexity of factors that
influence the eating behaviours of children
and adolescents is needed.
1. Associate Professor, Department of Family and Nutritional Sciences, University of Prince Edward This review outlines the state of knowl-
Island, Charlottetown, PE
2. Professor, Department of Family Relations and Applied Nutrition, University of Guelph, Guelph, edge and research gaps in the area of deter-
ON minants of healthy eating among children
3. Associate Professor, Faculty of Education, University of New Brunswick, Fredericton, NB
Correspondence and reprint requests: Jennifer P. Taylor, Department of Family and Nutritional and youth. The paper is structured around
Sciences, University of Prince Edward Island, 550 University Avenue, Charlottetown, PEI, C1A 4P3. individual and collective determinants, as
Tel: (902) 566-0475; Fax: (902) 628-4367; E-mail: jtaylor@upei.ca
Acknowledgements: Thank you to Rose Peacock, MHSc, RD, for her assistance with compiling refer-
described in the Framework for Population
ence lists for the paper, and to Michelle Hooper for her patience, wise advice and support. Health,20 that affect healthy eating in chil-

S20 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


HEALTHY EATING IN CHILDREN AND YOUTH

dren and youth. Individual determinants Children’s food preferences are often intakes in children.60-63 Finally, maternal
include biological factors (sex, age), food guided by taste or liking alone. 22,23 employment has been found to be negatively
preferences, knowledge and attitudes per- Preference for specific food items (e.g., associated with the frequency of family
taining to health and food, and skill level or fruits and vegetables) is a strong positive meals, which are, in turn, positively associat-
capacities. Collective determinants include indicator of the consumption of that food ed with diet quality.64
the economic, social and physical environ- in both children and adolescents.24-30 Taste
ments. We defined healthy eating, as “eat- can lead to poor choices: for example, “dis- Social Determinants
ing practices and behaviours that are consis- like for vegetables” is one of the three most These include cultural factors, familial fac-
tent with improving maintaining and/or important predictors of fruit and vegetable tors, peers and product marketing/mass
enhancing health.” intake in children.30,31 Personal preferences media. Although culture is considered one
for eating fast food32 or vending machine of the most important influences on
METHODS AND snacks 33 have also been identified as a bar- healthy eating, increasing “globalization” of
LITERATURE SEARCH rier to healthy eating in adolescents. food habits65 has led to a reduction in inter-
Nutrition knowledge levels are generally cultural differences in food practices within
All primary data-based papers and review low among children and adolescents, who society.66 In Canada, there has been clear
papers published between January 1992 have a weak understanding of the connec- evidence of nutritional concerns about
and March 2003 that focussed on children tion between food choice, physical activity, Aboriginal children.67-70 However, there is a
and/or youth (age 2-18 years) and reported and health.23,34-36 While knowledge does paucity of data comparing dietary behav-
at least one behaviour or determinant rele- not consistently influence dietary behav- iours of Canadian children and youth with
vant to healthy eating were included. iour,37-44 inconsistent findings may reflect those from other countries and cultures.
Databases searched included MEDLINE, past methodological problems 43 or the Children’s dietary patterns evolve within
CINAHL, PsycINFO, ERIC and Social inter-relation between knowledge and the context of the family.71 The intakes of
Science Index, and the key words used other determinants, which may make inde- parents and children are correlated for
were: children, toddlers, youth, adolescents, pendent effects difficult to assess. most nutrients,72 with stronger correlations
school children, factors/influences, eating, Relatively few studies have described atti- between mothers and children than fathers
diet, food, eating behaviours and nutrition. tudes toward food and the role of food in and children. According to Nicklas and
Six journals were also hand searched from health.28,45,46 Intervention47,48 studies utiliz- coworkers,11,73 familial factors include food
1997 to 2003 inclusive (Appetite, Canadian ing models such as Social Cognitive exposure and availability, parental model-
Journal of Dietetic Practice and Research, Theory49-53 have been unable to explain a ling, meal structure and family meals,
Canadian Journal of Public Health, Journal large variation in children’s eating behav- parenting style, and food socialization
of the American Dietetic Association, Journal iours. Those using a qualitative approach practices. A strong positive association
of Nutrition Education and Behaviour and to examine attitudes and meanings associ- between the availability of fruits and veg-
Obesity Research). Key sources in French ated with foods suggest that determinants etables in the home and consumption has
were also identified and translated. vary by sex and age. 30,37,54,55 Even fewer been reported.27,30,31,45,73-75 While the avail-
studies have examined the effect of food ability of healthy foods is necessary, it is
RESULTS preparation skill level (perceived or actual) not always a sufficient enabler of healthy
among children and adolescents.30,31 eating: qualitative research indicates that
Individual determinants although parents provide youth with
These include biological factors (age, sex), Collective determinants healthy homemade foods, the youth do not
food preferences, nutrition knowledge and always like them.32 Few studies have exam-
attitudes. Most studies focussed on differ- Economic Determinants ined the role of parental modelling as a pre-
ences in eating behaviours, such as snack- These include income/socio-economic status, dictor of healthy eating in children and
ing or breakfast consumption, rather than food pricing, education and employment. youth.45,50,75,76 Family meals have a positive
differences in determinants of eating Income and socio-economic factors are dis- influence on diet quality of children and
behaviours such as age and sex. cussed more thoroughly elsewhere in this youth, 77-79 with higher consumption of
American surveys indicate that there is supplement. Food price becomes the most vegetables and fruit, milk products and
a decline in diet quality and breakfast important consideration in food choice improved nutrient intakes.
consumption with age and an increase in when income is restricted,56 often leading to An authoritarian parenting style, charac-
snacking from elementary to higher the selection of foods that are higher in sugar terized by controlling child feeding prac-
grades. 1,3,7 Smaller Canadian studies and fat because they are among the least tices (using high-fat/high-sugar foods as
confirm these trends. 9,10 This is a con- expensive sources of dietary energy. 57 rewards, restriction of “junk foods”)
cern, since children who eat breakfast Further, reducing the price of foods and bev- increases childrens’ preferences for and
regularly are more likely to have more erages that are high in sugar and/or fat intake of restricted foods once the restric-
nutritious diets than those who do increases the consumption of these foods.58,59 tion is removed.73,80-85 Further, encouraging
not.9,21 Females, particularly adolescents, Lower educational status of parents has been the consumption of a healthy food on the
tend to be at greater nutritional risk associated with lower dietary quality, includ- basis of its health benefits decreases chil-
than males.7 ing higher fat and lower micronutrient dren’s preference for the food. 86,87

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HEALTHY EATING IN CHILDREN AND YOUTH

Permissive parenting can lead to inappro- effective mass marketing of fast food, con- ences, for example, the role of the school
priate snacking and consumption of inap- venience foods and expanding portion sizes environment or the effect of national
propriate portions of energy-dense foods.88 on healthy eating in children and youth dietary guidelines on healthy eating in chil-
Parental attitudes and knowledge about has received considerable attention in dren and youth. The following key research
nutrition, termed “food socialization prac- recent years. 105 This is a concern, since priorities have been identified:
tices” 73, 89, have also been correlated with children as young as five years eat more
nutrient intakes of children. 90 Parents’ when they are served large portions. 106 1. Research examining the nature of familial
nutritional knowledge may affect the nutri- Further, changes have been associated with influences on healthy eating in children
tional quality of foods purchased, and a decline in dietary quality, including a and youth, including family food practices,
therefore their availability, as well as the reduction in the consumption of nutrient- the frequency of family meals and the rela-
size of portions served to the child.71,90-92 dense foods and a concomitant increase in tive influence of peers and siblings on
Positive nutritional attitudes in parents of foods that are low in nutrients yet high in healthy eating.
pre-schoolers have been found to be associ- energy, fat, sugar and sodium.59,86,89,106,107 Among collective factors, familial factors
ated with more pleasant mealtime experi- The school environment may influence and the nature of foods available in the
ences, fewer suboptimal mealtime practices healthy eating in children and youth physical environment, including at home,
and fewer eating problems.93 Some early through the foods that are available, nutri- schools and in fast-food establishments,
research94 suggested that peers are an impor- tional policies, school nutrition and health stand out as particularly significant influ-
tant and lasting influence on the food pref- curricula, and teacher and peer modelling. ences on healthy eating in children and
erences of pre-schoolers (age 2-5). Schools are the ideal settings to establish youth. Given the positive association
Enthusiastic peer modelling has been found and promote healthy eating practices in between family meals and diet quality,
to be the strongest predictor of younger children and adolescents.108,109 Recent sur- future research should attempt to increase
children’s willingness to try new foods.95 veys of food programs in Canadian schools our understanding of how families with
The effects of product marketing and have identified a number of concerns working parents living in a time crunch do
mass media on dietary behaviour are inter- regarding the nutritional quality of foods manage to have family meals.64 Because
related and include influences on food in schools, including the ready availability children have, in turn, influenced family
preferences, food purchases and children’s of high-fat, high-sugar, low nutrient-dense food habits by pressuring food preparers to
food requests, or they may affect knowl- foods and beverages, particularly in vend- purchase and prepare food they like,
edge and attitudes, and the development of ing machines.110-114 A national scan indicat- research on the interaction between chil-
dieting behaviours and body image prob- ed that there are very few school nutrition- dren and parents, which examines the
lems. The media, particularly television, al policies in Canada,115 which are critical complexity of this relationship, is needed.
have an enormous potential influence on in order to provide guidelines for the plan- Although mothers are more motivated to
healthy eating in children and youth, and, ning, development and implementation of change their children’s eating behaviours
in many instances, can overshadow familial comprehensive nutrition programs,12 and than fathers and are more knowledgeable
influences. Food advertising promotes which are associated with changes in stu- about the nutrient content of foods, they
more frequent consumption of less healthy dents’ nutritional knowledge and behav- are relatively unsuccessful in changing their
foods, including higher-fat, energy-dense iours.41,43,116 children’s food habits on their own.124 The
snacks 96,97 and rarely features healthy reported incongruence between reported
choices such as fruits and vegetables.98-100 KNOWLEDGE GAPS maternal motivations and the foods they
This is a concern, since children are more select for their children125 reflects the com-
likely to request, purchase and consume Although there is now a significant body of plex context in which eating takes place
foods that they have seen advertised on literature in the area of determinants of and the influence of other cognitions relat-
television.96,101 In addition to their effects healthy eating in children and youth, very ing to mothers’ concerns about their own
on food consumption, food or beverage little of this research has taken place in weight. The observed inter-relations
advertisements are persuasive and have Canada. Only a few determinants, such as among cultural, familial and societal influ-
been shown to often contain misleading economic factors and food security,117-121 ences in the formation of children’s eating
information or incomplete disclosure, the issue of flavours, neophobia and food habits serve to decrease the impact of fami-
which can contribute to confusion among preferences122,123 and the content of media ly culture on food behaviours in children
children.39 Finally, mass media have been nutritional messages96,99,100 have undergone and youth. This, in addition to the clear
identified as important factors in the devel- some examination by Canadian researchers. decline in familial influences with age,
opment of both overweight102,103 and diet- It may seem reasonable to build on research including a decline in the frequency of
ing behaviours, 104 particularly in young conducted elsewhere, given the common family meals, underscores the importance
women. exposure to powerful forces such as the of supporting healthy food socialization
mass media and technology, an increasingly practices in parents. Since it is food use,
Physical Environment globally homogenous food supply, and portion sizes and food preparation meth-
This includes foods available/portion sizes common health problems, such as over- ods that are often targeted in interventions,
and the school environment. The negative weight. This is not appropriate, however, it would be useful to examine the influence
influence of increased availability and where there are significant national differ- of familial factors on these food-related

S22 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


HEALTHY EATING IN CHILDREN AND YOUTH

practices more closely and whether they mercials seems to provide clear testimony Much of the research has been limited to
predict eating behaviours and body to the perceived effectiveness of influenc- an examination of bivariate relations71 and
weight.61,126 Although the problem of esca- ing behaviours,98,127 the effects of television the use of non-experimental designs, pre-
lating portion sizes in the fast-food indus- on nutritional knowledge, children’s per- cluding the identification of causal rela-
try and the grocery retail sector (muffins, ceptions and views, and, most important, tions between determinants and eating
bagels, soft drinks and confections) is well food intake in children and youth, after behaviours of children and youth. Many
known, there has been little research on exposure to food commercials128 needs to interventions have focussed on fruit and
this phenomenon in the home environ- be further investigated. vegetable intake.131-133 Although determi-
ment. Research to clarify and confirm the nants of healthy eating appear to vary by
potential influence of peers and siblings on 4. Research regarding food preferences and food, it is impractical to develop predictive
dietary behaviour is needed. nutritional knowledge/skills in children models for individual foods.45 Examining
and youth and their impact on behaviour groups of foods that are homogenous in
2. Research regarding the impact of the school change. terms of determinants of consumption is
environment on healthy eating, particular- Among individual determinants, only suggested as a possible approach.
ly nutritional policy and modelling. food preferences or liking was consistently The low predictability of psychosocial
Evidence suggests that, while school identified in both young children and ado- models to predict food intake in children
environmental change is occurring in lescents as an important predictor of and youth may be improved by consider-
Canada, many schools are failing to pro- healthy eating.22-30 Since food preferences ing the relatively stronger influence of fac-
vide adequate environments to support are often not consistent with children’s tors such as food availability and accessibil-
healthy eating.110-114 Thus, while students knowledge, educators should go beyond ity, and their interactions.133
may be receiving some nutritional educa- teaching children what to eat, and assist Quantitative methods predominate in
tion in the classroom, confusing and coun- them in choosing healthy foods that are the literature, and there is a paucity of
terproductive messages appear to be pro- also seen as good tasting.129 While there is Canadian studies exploring the determi-
vided in cafeterias and other school set- evidence of an association between knowl- nants of healthy eating in children using a
tings.12,109 It is encouraging that enthusias- edge and behaviour, particularly in older qualitative approach. The latter approach
tic teacher and peer modelling has been children,32,34,35,44 the ability of children to could help identify the reasons why chil-
found to increase acceptance of healthy identify appropriate foods needed to meet dren and youth make positive choices, so
food choices in pre-schoolers; this suggests dietary recommendations should be that supports for healthy eating can be
important opportunities for day care cen- assessed. It is not sufficient to be able to strengthened.
tres and kindergarten settings to promote “parrot” nutritional recommendations;
healthy eating. The characteristics of mod- children need to be able to identify and 6. Monitoring eating behaviours and weight
elling activities, environments and children request healthy choices (e.g., lower-fat in children and youth.
for whom modelling is effective89 need to foods).129 Longitudinal studies of the effects Canada must have its own nutritional
be documented. This would facilitate the of knowledge on dietary behaviour and monitoring system to identify unique
design of effective interventions in both studies of children from diverse cultures national and regional dietary behaviours
school and home settings. Recent findings and socio-economic backgrounds are neces- and nutritional concerns. Clearly, in order
that changing the economics of food sary. Qualitative methods appear to have to choose interventions wisely and tailor
choice in schools and other environments, promise in terms of studies examining the them to specific regions, to evaluate them
such as grocery stores, can have positive effect of knowledge on healthy eating.129 effectively and make sound dietary recom-
effects on healthy eating58 must be con- The relation between food-related skills mendations, accurate and current data on
firmed in a broader range of foods, settings (including food selection and preparation) the eating behaviours of Canadian children
and age groups. Finally, it is important to and healthy eating in both children and and youth are essential. To date, Canadian
monitor the impact of school nutritional their parents should also be examined. nutritionists have not had adequate data
policies on improving the school food Given the decrease in emphasis on the upon which to base any of these important
environment and eating behaviours. The development of food-related skills in school activities. Although smaller studies have
possible effects of such policies on time systems across Canada, changes in courses identified some dietary concerns, this
allotted for physical activity in school offering Home Economics/Family review confirms the lack of national nutri-
should be assessed as part of this monitor- Studies,130 and the increase in prepared and tional assessment data on dietary behav-
ing. convenience foods in the home, it is impor- iours in Canadian children. This was also
tant to identify means by which children identified as a gap in knowledge in a recent
3. Effects of mass media on healthy eating. will consistently acquire food-related skills Health Canada report.134
Much of the evidence of the effective- and use them to make healthy choices. Difficulties in assessing dietary behav-
ness of television food commercials in iours in children and youth contribute to
changing dietary behaviour comes from 5. Methodological issues in the examination the challenge of identifying key determi-
marketing research, which is not accessible of multiple determinants of healthy eating nants and in assessing the impact of inter-
to researchers or the public. Although the in children and youth, and their inter- ventions targeting them. It is encouraging
amount of money invested in food com- actions. that Canada is currently gathering dietary

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S23


HEALTHY EATING IN CHILDREN AND YOUTH

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S26 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


Determinants of Healthy Eating eople aged 65 or over account for

in Community-dwelling Elderly
P 13% of the nation’s population. 1
Those aged 80 or over are increasing
at the fastest pace, and this segment is
expected to increase by 43% in the next 10

People years. Most seniors aged 65 or over live at


home (93%) and report that their health is
generally good.1 However, 41% of Canadian
Hélène Payette, PhD1 seniors report having disabilities. These
Bryna Shatenstein, PhD, PDt2 include problems with vision, memory,
hearing, speech, mobility and agility, as well
as pain and learning, developmental, and
psychological difficulties.2 Those who age
ABSTRACT successfully live independently and show lit-
tle or almost no loss in functioning. Those
Among seniors, food choice and related activities are affected by health status, biological aging in a typical fashion live independently
changes wrought by aging and functional abilities, which are mediated in the larger arena and have a variety of medical conditions.
by familial, social and economic factors. Determinants of healthy eating stem from Finally, those in whom the aging process is
individual and collective factors. Individual components include age, sex, education, accelerated carry a heavy burden of chronic
physiological and health issues, psychological attributes, lifestyle practices, and disease and disabilities, which generally
knowledge, attitudes, beliefs and behaviours, in addition to other universal dietary obliges them to live in institutions.3,4
determinants such as income, social status and culture. Collective determinants of healthy Aging is generally believed to alter nutri-
eating, such as accessible food labels, an appropriate food shopping environment, the ent requirements for energy, protein and
marketing of the “healthy eating” message, adequate social support and provision of other nutrients because of changes in lean
effective, community-based meal delivery services have the potential to mediate dietary body mass, physical activity and intestinal
habits and thus foster healthy eating. However, there is a startling paucity of research in absorption. Energy needs decline with age
this area, and this is particularly so in Canada. Using search and inclusion criteria and key because of decreased basal metabolism,5
search strings to guide the research, this article outlines the state of knowledge and reduction in lean body mass or sarcopenia6
research gaps in the area of determinants of healthy eating among Canadian seniors. In and a more sedentary lifestyle.7,8 Energy
conclusion, dietary self-management persists in well, independent seniors without needs could be even higher than levels set
financial constraints, whatever their living arrangements, whereas nutritional risk is high out in the current recommendations 9-11
among those in poor health and lacking in resources. Further study is necessary to clarify considering that regulation of food intake
contributors to healthy eating in order to permit the development and evaluation of is impaired in old age.12 However, total
programs and services designed to encourage and facilitate healthy eating in older energy intake generally decreases with age
Canadians. and results in concomitant declines in
most nutrients, the distribution of many
MeSH terms: Elderly; nutrition; determinants; eating habits; healthy eating micronutrients indicating intakes below
recommended levels.13-18
Among elderly persons, food-related
activities are greatly affected by health sta-
tus and functional abilities. 19-21 For
instance, the ability to procure and prepare
nutritious food and eat independently, the
availability of dietary assistance when
needed, and appropriate meal environment
and food presentation will contribute to an
adequate diet.22-24 On the other hand, a
poor diet can contribute to frailty, compli-
cating functional limitations25,26 and lead-
ing to loss of muscle mass, metabolic
abnormalities and diminished immunity.
1. Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, and Faculté de
Malnutrition occurs on a continuum and
médecine et des sciences de la santé, Université de Sherbrooke, Québec is most often characterized as poor
2. Département de nutrition, Université de Montréal, and Centre de recherche, Institut universitaire appetite, insufficient dietary intake, faulty
de gériatrie de Montréal, Québec
Correspondence and reprint requests: Hélène Payette, Director, Research Centre on Aging, or inadequate nutritional status, weight
Sherbrooke Geriatric University Institute, 1036 Belvédère Street South, Sherbrooke, QC J1H 4C4, Tel: loss and muscle wasting.27
819-829-7131, Ext. 2631, Fax: 819-829-7141, E-mail: helene.payette@usherbrooke.ca
Acknowledgements: The authors would like to express special thanks to Céline Lapointe and Sandra
However, these results should be inter-
Bérubé for their assistance in searching and reviewing the literature. preted with caution, since many con-

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HEALTHY EATING IN COMMUNITY-DWELLING ELDERLY PEOPLE

founding factors, such as the cohort or included in the review if they met the auditory and olfactory stimuli.53-56 Many
period effect and selective mortality, can- following criteria: study subjects were drugs can also alter taste.57 A decline in
not be clearly separated from the aging 65+ years of age, the dependent variable salivary flow and masticatory impairment
effect per se, particularly in cross-sectional was “healthy eating”, or the study was due to poor dentition (loss of teeth, inade-
studies. The few nutritional surveys of free- cross-sectional or longitudinal. Studies quate dental and gingival care) contribute
living elderly subjects with functional dis- were excluded from the review if the lan- to insufficient mechanical crushing and
abilities or in poor health suggest dietary guage of publication was other than initial enzymatic digestion in the mouth.58-60
intakes leading to insufficient levels of English or French, or the methodology These processes, along with mechanisms
energy, protein and most micronutrients.28-35 was not described or was unreliable. governing satiation and energy metabo-
This paper was written to outline the Decisions on the relevance of the material lism,61,62 have been shown to be disrupted
state of knowledge and research gaps in the were made by both authors on the basis of in older adults, leading to the development
area of determinants of healthy eating the abstracts and, where necessary, the of a physiological “anorexia of aging”.63,64
among Canadian seniors. complete articles. Papers reporting on very Loneliness can contribute to inadequate
specific population subgroups were dis- nutrient intakes.40,65 Indeed, it has been
METHODS AND cussed and put into context at the discre- shown that simply having the Meals-on-
LITERATURE SEARCH tion of the authors. Wheels delivery volunteer stay with the
meal recipient can improve dietary
Search and inclusion criteria and key Determinants of healthy eating in intakes.66 Food and nutrient intakes may
search strings were established and used to older people be better among those with high nutrition
guide the research. Published literature and health awareness 40,67-70 and poorer
from 1990 to 2003 was examined as well Individual Determinants of Healthy among those with a negative self-perception
as several older, classic sources. The search Eating of physical health.21,65 In secondary analy-
strategy targeted sources of information on Individual components motivating dietary ses of dietary data collected from
the determinants of healthy eating among practices include age, sex, education, other Quebecers aged 65 to 74 years,71 regression
seniors, using web-based search engines socio-economic factors, physiological and analyses showed that the strongest corre-
such as MEDLINE, Ageline, PsycINFO health issues, psychological attributes, lates of diet quality were the degree of
and others, along with position papers and lifestyle practices, and knowledge, atti- attention paid to keeping a healthy diet,
websites of numerous national and interna- tudes, beliefs and behaviours. As people along with higher education, being a city-
tional governmental, public health- and age, these factors often lead to alterations dweller, being a non-smoker and regular
nutrition-oriented organizations, as well as in food selection and decreases in food exercise.70 The issue of supplement use is
electronic newsletters. Search tools avail- intake.25,36-39 Such modifications may be also of interest in older individuals, as this
able through universal web browsers such mediated by marital status, smoking, may signal a healthier lifestyle and higher
as Google and Alta Vista were also used, health status and physical activity level, nutrient intake72 or, on the other hand,
and the relevant “grey literature” was physiological and functional attributes, and provide evidence that supplements are used
accessed through a bilingual (French, diverse biological changes wrought by to compensate for a poor diet.70 Finally,
English) catalogue developed by the aging, in addition to universal dietary alcohol intake in seniors tends to be mod-
Bibliothèque de gériatrie et de gérontologie determinants such as sex, education, erate,73 and light to moderate drinking is
of the Institut universitaire de gériatrie de income, social status and culture. While associated with a better nutrient profile in
Montréal. Key words included healthy eat- higher education and income levels are fre- older people.47,73
ing in seniors, determinants of diet in quently strongly associated with better
elderly, factors influencing diet in elderly, nutrition, disease prevention knowledge Collective Determinants of Healthy
determinants of nutrition status in elderly, and behaviour in US, European40-48 and Eating
determinants of food choice (intake/con- Canadian studies,21 this is not a universal Food choice in seniors is motivated by
sumption/habits/practices) in older people, finding.49,50 These conflicting results may individual attributes that are mediated in
nutritional health promotion in the elder- reflect not only the great heterogeneity in the larger arena by familial, social and eco-
ly, and targeted specific issues, such as older populations but also the impact of nomic factors. In older people, collective
social support and healthy eating. confounding factors. For instance, food determinants of healthy eating, such as
Peer-reviewed scientific journals were access is more difficult and health prob- accessible food labels, an appropriate food
the main sources of publications of recent lems are more frequent in disadvantaged shopping environment,74,75 the marketing
research, and the proceedings of scientific elderly subjects.51 This controversy is fur- of the “healthy eating” message,75,76 ade-
conferences were also used to keep track of ther highlighted when comparing cross- quate social support 70 and provision of
ongoing research in Canada, the US and sectional and longitudinal survey findings. effective community-based meal delivery
internationally. Specific searches were car- Indeed, over a six-year period, age emerged services,31,77 have the potential to mediate
ried out to locate and access research con- as a positive predictor of diet quality, par- dietary habits and thus foster healthy eat-
ducted by Canadian researchers, and an ticularly among women.52 ing. However, there is a startling paucity of
attempt was made to query gerontological Food intake and appetite can also be research in this area, and this is particularly
nutritionists on their work. Studies were negatively influenced by impaired visual13 evident in Canada.

S28 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


HEALTHY EATING IN COMMUNITY-DWELLING ELDERLY PEOPLE

In community-dwelling elders, the rela- ing formal support services, had few social ness and the safety of dietary supplements,
tion between dietary quality, social support contacts and were at great nutritional risk, probiotics and functional foods in aging
and living arrangements is controversial. since their food preparation abilities and populations must be further investigated.
Some studies have found positive dietary intakes could become extremely Indeed, more needs to be known about
relations,21,65,68,70,78-80 whereas others have limited. These qualitative observations are what constitutes “healthy eating” in seniors
found diet quality to be unaffected by a supported by secondary analyses of Quebec to permit the modification of our food
poor social network.81 It has been suggest- nutrition survey data.70 guidance system and provide Canadian
ed that geographical isolation has an The heterogeneity and interaction seniors with targeted dietary guidance.
adverse effect on nutritional status among between needs and adaptive dietary strate- More specifically, we must further exam-
the elderly.82 For instance, an urban-rural gies often cloud the issue, and only longi- ine health beliefs, and food beliefs and
difference in meal structure was observed tudinal studies will permit clarification of practices that have symbolic or traditional
in Poland,83 with lower consumption of these differential influences on healthy eat- importance to determine how knowledge,
certain food groups (meat, fish and eggs, ing. Given the complexity of these inter- beliefs and attitudes translate into eating
fruit and their products, and fats and oils) actions and the fact that most research to behaviour in older adults, especially at
in rural-dwelling seniors. It was suggested date has been cross-sectional, it is virtually advanced ages. More research is needed to
that food distribution systems and impossible to tease apart the specific influ- clarify the relative contribution of income,
decreased buying power among rural ence of individual or collective determi- ethnic background and other personal pre-
inhabitants profoundly affect food habits. nants. dictors of healthy eating – self-control,
In contrast, other comparative studies of emotions, resistance to change, time con-
urban and rural-dwelling seniors in the KNOWLEDGE GAPS AND straints, lack of knowledge – and environ-
US84,85 showed that nutrient intakes were DIRECTIONS FOR mental factors governing food availability
not related to geographical setting. These FURTHER RESEARCH and cost. Information is needed linking
observations demonstrate the difficulties nutritional services, health, psychological,
inherent in drawing conclusions from age, Gaps in knowledge were detected in the cognitive and social characteristics, as well
sex, socio-economic and health factors course of this review. These are summa- as financial constraints to procuring
when comparing urban and rural seniors, rized in the following section, which also healthy foods. More information is needed
but they could also be due to specific char- suggests directions for further investiga- on barriers, both real and perceived, that
acteristics within the populations studied. tion. Further study and regular dietary discourage healthy eating. For instance, the
The local food environment has an impact monitoring are needed in order to know impact of therapeutic or self-imposed
on food choice beyond the urban-rural more about food consumption habits in restrictive diets on dietary adequacy is not
issue. seniors. These investigations must be known. Investigations must simultaneously
Food consumption research suggests adapted to the reality of targeted aging address interdependent attributes, such as
that widowhood confers potentially nega- populations using precise measurements, biological parameters, clinical factors and
tive effects on food intake through weight diverse approaches, appropriate methods the psychosocial dimension, together with
change, increased adverse health outcomes, and accurate dietary assessment tools to dietary and psychosocial variables.
including depression, and diminished reflect the great heterogeneity typical of To encourage and facilitate healthy eat-
“nutritional self-management”, leading to older populations. ing in older people, a broad range of
changes in dietary behaviour and food The research agenda should be focussed improved and expanded services must be
intakes. 86,87 This is particularly evident on interactions between individual and offered to seniors as an adjunct to the
among men over the age of 7540,65,78,88 with collective determinants of healthy eating healthy eating message. The availability,
low incomes.89 Indeed, there is a strong that are unique to the elderly in Canada. acceptability, utilization and effectiveness
relation between living alone and dietary To achieve this goal, longitudinal studies of nutritional interventions and communi-
intakes among men,80,88-90 but these find- should be conducted to examine the epi- ty programs should be rigorously exam-
ings have not been consistent91,92 and are demiological and social aspects of aging; ined, evaluated and refined in order to fos-
even less so among women.88 Information describe the chronology of events and the ter independence in community-dwelling
on the influence of living arrangements on direction of causal relations; determine and seniors living in urban or rural communi-
dietary intake in seniors appears to be track seniors’ food intakes, their food-related ties.
inconclusive and may depend on cultural needs, variability over time in dietary needs Other issues that require further study to
or other differences in the samples studied. and resources; the interactions that exist facilitate healthy eating in older Canadians
In conclusion, research in this area has between age- and gender-related changes should be clarified by academics, clini-
clearly identified two poles: widowed indi- in socio-demographic factors and eating; cians, public health authorities, the food
viduals (men or women) in good health and how healthy eating could interface industry and decision-makers at both the
and without financial constraints who con- with disease prevention and health mainte- regional and national level. These may
tinued to drive and remained independent nance. include evaluation of the effectiveness of
in their dietary self-management; and Further study is necessary in order to provision and marketing of appropriate,
those in poor health with no informal sup- understand which foods favour healthy affordable nutrient-dense foods and
port, who experienced difficulties obtain- aging. Patterns of use, long-term effective- upgrading the food market and transporta-

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S29


HEALTHY EATING IN COMMUNITY-DWELLING ELDERLY PEOPLE

17. DeWolfe J, Millan K. Dietary intake of older 39. Drewnowski A, Shultz JM. Impact of aging on
tion (food products, packaging, shelf pre- adults in the Kingston area. Can J Diet Pract Res eating behaviors, food choices, nutrition, and
sentation, supermarket organization and 2003;64(1):16-24. health status. J Nutr Health Aging 2001;5(2):75-
location, delivery). These efforts must 18. Shatenstein B, Nadon S, Ferland G. Diet quality 79.
among older Quebecers as assessed by simple 40. Murphy SP, Davis MA, Neuhaus JM, Lein D.
involve concerted action by dietitians, indicators. Can J Diet Prac Res 2003;64(4):174- Factors influencing the dietary adequacy and
manufacturers, retailers and foodservice 80. energy intake of older Americans. J Nutr Educ
19. Payette H, Gray-Donald K, Cyr R, Boutier V. 1990;22:284-91.
providers to offer a nutritious and accessi- Predictors of dietary intakes in a functionally 41. Fischer CA, Crockett SJ, Heller KE, Skauge LH.
ble food supply for the seniors’ market. It dependent elderly population in the community. Nutrition knowledge, attitudes, and practices of
Am J Public Health 1995;85(5):677-83. older and younger elderly in rural areas. J Am
is essential that healthy nutritional mes- 20. Gray-Donald K. The frail elderly: Meeting the Diet Assoc 1991;91(11):1398-401.
sages be coupled with adequate physical nutritional challenges. J Am Diet Assoc 42. Toner HM, Morris JD. A social-psychological
activity to produce a broad-based health 1995;95(5):538-40. perspective of dietary quality in later adulthood.
21. Keller HH, Østbye T, Bright-See E. Predictors of J Nutr Elder 1992;11(4):35-53.
promoting lifestyle in older Canadians, and dietary intake in Ontario seniors. Can J Public 43. Lee CJ, Godwin SL, Tsui J, Kumelachew M,
that the effectiveness of these population- Health 1997;88:305-9. McWhinney SL, Idris R, et al. Association
22. Finley B. Nutritional needs of the person with between diet knowledge and quality of diets in
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JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S31


Determinants of Healthy Eating boriginal peoples occupied the area

in Aboriginal Peoples in Canada


A now called Canada before the
arrival of Europeans, and they have
cultures and histories that make them dis-
tinctive within Canadian society. In the
The Current State of Knowledge and Research Gaps past, they subsisted by extracting and pro-
cessing foods from the land and water
using hunting, trapping, fishing, gathering
Noreen D. Willows, PhD
and agriculture in different combinations.
The tremendously diverse diet was, in gen-
eral, high in animal protein and low in fat
and carbohydrates, and provided adequate
ABSTRACT amounts of energy and micronutrients for
health.1-3 The contemporary diet has, to
Aboriginal peoples are the original inhabitants of Canada. These many diverse peoples varying degrees, replaced traditional foods
have distinct languages, cultures, religious beliefs and political systems. The current with market foods, many of which are of
dietary practices of Aboriginal peoples pose significant health risks. Interventions to low nutritional quality. Traditional foods
improve the nutritional status of Aboriginal peoples must reflect the realities of how people are those culturally accepted foods avail-
make food choices and therefore should be informed by an understanding of able from local natural resources that con-
contemporary patterns of food procurement, preparation and distribution. Most of the stitute the food systems of Aboriginal peo-
literature documenting the health of Aboriginal peoples is primarily epidemiologic, and ples. The concept of food system includes
there is limited discussion of the determinants that contribute to health status. The majority sociocultural meanings, acquisition and
of studies examining dietary intake in Aboriginal communities do not aim to study the processing techniques, use, composition
determinants of food intake per se even though many describe differences in food intake and nutritional consequences for the peo-
across sex, age groups, seasons and sometimes communities, and may describe factors ple using the food. Positive nutritional sta-
that could have an effect on food consumption (e.g., employment status, level of tus might be possible to maintain when
education, household size, presence of a hunter/trapper/fisher, occupation, main source of traditional food use is diminished if eco-
income). For these reasons, there are many gaps in knowledge pertaining to the nomic circumstances are favourable, a vari-
determinants of healthy eating in Aboriginal peoples that must be filled. Given the ety of high-quality, non-traditional foods
diversity of Aboriginal peoples, research to address the gaps should take place at both the is available, and education in the use of
national level and at a more local level. Research would be important for each of Inuit, good-quality traditional food alternatives is
Métis and First Nations. on hand.4,5
The three groups of Aboriginal peoples
MeSH terms: Canada; diet; food habits; Indians, North American; Inuit; nutrition defined in the Canadian Constitution are
Indian, Métis and Inuit (the term First
Nation now commonly replaces the word
Indian). 6 Inuit live predominantly in
Nunavut, the coastline areas of the
Northwest Territories, Northern Quebec
(Nunavik) and Labrador. They are cultur-
ally and linguistically distinct from First
Nations and Métis. Métis is used broadly
to describe people with mixed First
Nations and European ancestry.6
The health of Aboriginal peoples is
worse than that of Canadians, in general,
for almost every health status measure and
condition.7 There is considerable evidence
that many health problems experienced by
Aboriginal peoples are related to diet; they
include anemia, dental caries, obesity,
heart disease and diabetes. 2-4 Although
Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB many health issues appear related to poor
Correspondence and reprint requests: Noreen D. Willows, 4-10 Agriculture/Forestry Centre, diet, dietary intake data in Aboriginal pop-
Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB T6G
2P5 ulations are limited in scope, with a nar-
Acknowledgements and source of support: The author appreciated the comments and editorial sug- row geographic and subject focus and
gestions of Valerie Tarasuk, Olivier Receveur, and Brenda McIntyre, which benefitted the paper
immensely. Noreen Willows is an Alberta Heritage Foundation for Medical Research Population
including only a few Aboriginal communi-
Health Investigator. ties. Most of the literature documenting

S32 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


HEALTHY EATING IN ABORIGINAL PEOPLES IN CANADA

the health of Aboriginal peoples is primari- was included. Website searches (e.g., just about eating; it is the endpoint of a
ly epidemiologic, and there is limited dis- National Aboriginal Health Organization, series of culturally meaningful processes
cussion of the determinants that contribute Indian and Northern Affairs Canada) pro- involved in the harvesting, processing, dis-
to health status. Urban-living Aboriginal vided grey literature, as did citations in arti- tribution and preparation of these foods.
people are under-represented in many cles, grey literature and books. The most For many Aboriginal peoples, these
studies, as are First Nations living off- salient information relating to understand- processes require the continued enactment
reserve, Métis, and women and children.8,9 ing the determinants of healthy eating and of culturally important ways of behaving,
To effectively promote and support gaps in knowledge are presented herein. which emphasize cooperation, sharing and
healthy eating in Aboriginal peoples, there generosity.20-25
is a need for a more comprehensive under- Summary of the literature on the In some Aboriginal communities, the
standing of the many factors that influence determinants of healthy eating cultural preference for body size may influ-
eating behaviour, including deeper under- Partly because of the substitution of tradi- ence eating behaviour and food choice. A
standing of their interactions. This article tional foods with market foods, the current study in Ojibway-Cree in northern
is intended to provide an overview of the diet of Aboriginal peoples is often low in Ontario showed a preference for large body
state of knowledge and research gaps in the iron, folacin, calcium, vitamin D, vitamin size, particularly among older adults who
determinants of healthy eating, including A, fibre, fruit and vegetables; high fat and perhaps had memories of the association
consumption of traditional food as related sugar intakes are commonly reported.11-18 between thinness and infectious diseases,
to Aboriginal peoples. For many A better understanding of the determi- such as tuberculosis.26 In Cree communi-
Aboriginal groups, healthy eating is based nants of traditional food use in relation to ties in northern Quebec, having extra
on the premise of the consumption of tra- market food use is required to know how weight is considered a sign of robustness
ditional food, which, in addition to con- to modify the determinants in a way that and strength.27 In contrast, First Nations
tributing to nutrition, is an important would result in better dietary patterns for and Métis girls and women living in or
indicator of cultural expression, an anchor Aboriginal peoples. The transition from near to urban centres in Manitoba prefer
to culture and personal well-being, an traditional to market food has been a mul- thin body sizes and may use dieting to lose
essential agent to promote holistic health tidimensional, dynamic and complex weight.28 Urban American Indian women
and culture, and the direct link between course, and the decision-making process in the United States engage in unhealthy
the environment and human health.10 The about consuming traditional or market weight-control practices, such as binge eat-
focus of the article will be predominantly food, as discussed later, is made at multiple ing, skipping meals, fasting and purging.29
Inuit and First Nations living on-reserve levels of influence: societal, individual, Many American Indian children have body
and in remote or northern communities, socio-economic (food insecurity) and envi- dissatisfaction, concerns about high
although the literature pertaining to other ronmental, all which may overlap and weight, unhealthy weight control practices
groups will also be included. interact. In the discussion that follows, and eating disorders.30-33 The varying pref-
environmental influence refers to the phys- erences for body size among Aboriginal
METHODS AND ical environment. peoples may be based in traditional cultur-
LITERATURE SEARCH al values; alternatively, as culture is not sta-
Societal Level Influence tic but changes over time in response to
A literature search was completed using the Culture is broadly defined as the values, social dynamics, one cannot ignore the
term “aboriginal” and MeSH synonyms for beliefs, attitudes and practices accepted by adoption of non-Aboriginal perspectives of
that term (Inuit, Indians North American) members of a group or community. It body size.
combined with the term “Canada” and determines, in part, what foods are accept-
with “food” or “nutrition”. The strategy able and preferable, the amount and com- Individual
was repeated in medical and sociological binations of foods to eat, when and how to Food selection is often governed by sensory
databases (PubMed, MEDLINE, eat, and the foods considered ideal or characteristics.34 Although taste preference
HealthSTAR, CINAHL, Sociological improper. 19 Aboriginal people may is personal, it is influenced by the cultural
Abstracts; Bibliography of Native North describe their traditional food quite specifi- group to which one belongs. Taste prefer-
Americans; International Bibliography of cally, for example, as Inuit or Dene food, ence for traditional food has been docu-
the Social Sciences; Proquest Digital as the case may be, demonstrating its mented for Aboriginal peoples. Inuit con-
Dissertations). For international compar- strong link to cultural identity. 20 Of sume igunaaq (fermented seal meat), which
isons, the same strategy and search engines importance to understanding the role that has a distinctive and strong flavour; appre-
were used but the terms United States, culture plays in determining food choice in ciation of igunaaq is considered an impor-
Australia and New Zealand were used in Aboriginal communities is that the activi- tant and sophisticated feature of Inuit
place of Canada. The search strategy was ties required to procure traditional food are taste.35 Inuvialuit, Inuit who live in the
restricted to literature written in the not merely a way of obtaining food but, Western Arctic, mention the good taste
English language and published from rather, a mode of production that sustains and texture of traditional foods, such as
January 1990 to December 2003, and key social relationships and distinctive cultural caribou, as reasons for eating it.36 Among
publications published January to April characteristics. This is because the con- the Nuxalk First Nation, the frequency of
2004, although pertinent older material sumption of traditional foods is more than consumption of many traditional foods is

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S33


HEALTHY EATING IN ABORIGINAL PEOPLES IN CANADA

associated with taste appreciation; how- in turn consume less traditional food than stock management practices, and personal
ever, the relation between taste preference elders. The age disparity in traditional food beliefs and attitudes about stocking health-
and food choice is not always evident. Lack consumption implies inter-generational ful foods may be major determinants of
of species availability and time for harvest- differences in taste preference and suggests the availability of nutritious foods.54
ing may explain why not all traditional that younger generations are losing the
foods with highly desired tastes are con- knowledge of harvesting and preparing Physical Environmental
sumed frequently.37 In Mohawk children, their traditional foods. Modification of the physical environment
food preference ratings do not always (e.g., hydroelectric dams, deforestation, cli-
translate into consumption of those pre- Food Insecurity mate change) and contamination of the
ferred foods: although children may prefer Aboriginal families are over-represented physical environment have resulted in
certain traditional foods, they seldom eat among those experiencing hunger in reduced availability of traditional animal
them. 38 A study of the eating habits of Canada.46 As a result of the pervasiveness and plant species. 40,55,56 When species
Cree children found that even though chil- of poverty in many Aboriginal communi- decline or become contaminated, recom-
dren consumed a preponderance of store- ties, income and food costs may be more mendations are often made to limit or
bought food, the majority expressed a pref- potent determinants of food selection than cease their consumption. In response to
erence for traditional food.39 considerations of the healthfulness, social advisories, Aboriginal peoples may switch
For many Aboriginal peoples, cultural desirability and taste of food.34 Food inse- to hunting or fishing different species,
identity will inform personal knowledge, curity is commonplace, meaning that the reduce intake or maintain the status quo.57
attitudes and beliefs about food and food availability of nutritionally adequate and Concern over food contamination or
choice. The eating of traditional food is safe foods or the ability to acquire accept- species diminishment may be insufficient,
often associated with feelings of good able foods in socially acceptable ways is in and of itself, to cause reduced intake of
health, whereas the eating of “non- limited or uncertain.47 In the 1998/1999 a food species given the pragmatic consid-
traditional food” is considered by some National Population Health Survey, the eration that market food, in many cases, is
Aboriginal peoples as polluting or weaken- prevalence of food insecurity among an expensive or unpalatable substitute for
ing. 21,24,25,40 Food choices based on Aboriginal respondents living off reserve traditional food. Identifiable local sources
Aboriginal cultural values may not be con- was 27.0%, and 24.1% had a compro- of contamination may cause greater disrup-
gruent with Western scientific constructs mised diet, meaning that they did not have tion of normal dietary patterns than conta-
regarding the nutritional value of food.24,25 enough food to eat or that they could not mination from distant sources. The com-
The cultural worldview held by some eat the quality or variety of foods they munication style for conveying risk infor-
Aboriginal peoples that traditional food by wanted to because of lack of money.48 It mation about contaminants and the cul-
its very nature is health-promoting makes has been documented that low-income tural context within which risk is interpret-
it difficult for them to understand why First Nations women in Winnipeg are not ed may also be decisive factors in how
they must avoid certain store-bought foods able to choose food on the basis of its community members respond to advi-
to maintain health. Among the Inuit of health attributes because of the constraints sories.20,58
northern Labrador, for example, all tradi- of food insecurity.49 Differing degrees of
tional foods are considered “good”, and food insecurity, from anxiety to hunger, KNOWLEDGE GAPS IN THE
“nutritional balance” is perceived as con- exist among Inuit, including hunger in LITERATURE
suming different parts of an animal, and children.18
alternating the diet between fish, land Some Aboriginal communities use food- To effectively promote and support healthy
mammals, seal and birds. Perhaps because sharing networks as a strategy against food eating, there is a need for a more comprehen-
of this ideology it is puzzling to these Inuit insecurity. Community freezers and other sive understanding of the many factors influ-
that store food may not contribute to forms of community sharing enable food- encing eating behaviours, and their complex-
health. 25 The Cree of northern Quebec insecure individuals living on reserves or in ity and interactions. Some important gaps in
also find the categories of healthy and remote regions to consume traditional understanding are described below.
unhealthy as related to store-bought food foods.50,51 These systems of food reciproci-
to be confusing because Cree food, by its ty and obligation do not always buffer Beliefs about food
very nature, is good to eat.24 against food insecurity in urban centres.49 More study is required of the relation
In northern and remote communities, In remote and northern communities, between individual beliefs about food and
age and sex differences in food consump- the high cost, poor quality, lack of variety food intake. Most studies in Aboriginal
tion have been noted.15,17,37,41-45 Sex differ- and lack of availability of perishable foods communities that examine the health ratings
ences in the amount of traditional food are barriers to the purchase of fresh fruits of traditional and store-bought food do not
consumed may be due, in part, to differ- and vegetables.18,52 The cost of market food evaluate whether the health rating of a food
ences in body size and energy expenditure is high as a result of transport costs, and corresponds to its frequency in the diet.
between men and women. Children tend the limited availability of nutritious foods
to consume less traditional food than is due, in part, to spoilage.52,53 In remote Hedonic qualities
adults, and young adults consume less tra- regions, where a single store may serve the The sensory properties of food consumed
ditional food than middle-aged adults, who community, the individual store manager’s by Aboriginal peoples have seldom been

S34 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


HEALTHY EATING IN ABORIGINAL PEOPLES IN CANADA

5. Kuhnlein HV, Receveur O. Dietary change and


studied as a determinant of food intake, decline alters dietary intake. To ensure that traditional food systems of indigenous peoples.
despite evidence that sensory properties are dietary modifications are counterbalanced Annu Rev Nutr 1996;16:417-42.
important reasons why traditional food is by selection of healthy food alternatives, a 6. Indian and Northern Affairs Canada. Words First:
An Evolving Terminology Relating to Aboriginal
culturally palatable and why market food is better understanding of how environmen- Peoples in Canada. Ottawa: Government of
consumed. The hedonic quality of tradi- tal health discourse influences food choice Canada, 2002.
7. Health Canada. A Statistical Profile on the Health
tional and market food as it relates to food is required, as well as quantification of any of First Nations in Canada. Ottawa, 2003.
choice needs further investigation. resulting dietary changes. The health 8. Young TK. Review of research on aboriginal pop-
ulations in Canada: Relevance to their health
impacts of such dietary changes could be needs. BMJ 2003;327:419-22.
Food insecurity significant, given that traditional foods 9. MacMillan HL, MacMillan AB, Offord DR,
There are many issues relating to food contribute to both nutritional benefits and Dingle JL. Aboriginal health. Can Med Assoc J
1996;155:1569-78.
insecurity that have not been studied. contaminant exposure.4 10. Kuhnlein HV. Global Nutrition and the Holistic
Scales for measuring food insecurity have Environment of Indigenous Peoples. The Path to
Healing. Royal Commission on Aboriginal
not been validated in Aboriginal popula- Interactions among determinants Peoples. Ottawa, 1993.
tions in Canada, therefore, commonly used Individual, social, physical environmental 11. Wein EE, Gee MI, Hawrysh ZJ. Nutrient intakes
food insecurity questions may need to be and socio-economic factors interact in of native mothers and school children in north-
ern Alberta. J Can Diet Assoc 1993;54:42-47.
adapted to accommodate First Nations, complex and changing ways to influence 12. Wein EE. Nutrient intakes of a sample of First
Métis and Inuit languages, cultural percep- food choice. For example, individuals may Nations adults with and without diabetes melli-
tus in central Alberta. J Can Diet Assoc
tions and unique life experiences. 47 In use knowledge about the health properties 1996;57:153-61.
small communities, it is not clear how of foods when they make choices, but 13. Berti PR, Hamilton SE, Receveur O, Kuhnlein
much influence store policies or store man- knowledge alone is insufficient to affect HV. Food use and nutrient adequacy in Baffin
Inuit children and adolescents. Can J Diet Pract
agers have in determining the types of food food choices unless it can overcome coun- Res 1999;60:63-70.
available for sale, or how food pricing teracting psychosocial, behavioral and 14. Delormier T, Kuhnlein HV. Dietary characteris-
tics of eastern James Bay Cree women. Arctic
influences food choice. Information is environmental barriers.60,61 The issue of the 1999;52:182-87.
required about how food insecurity affects interaction of the determinants of healthy 15. Kuhnlein HV, Soueida R, Receveur O. Baffin
Inuit food use by age, gender and season. J Can
food selection, given traditions of obliga- eating at different levels of influence Diet Assoc 1995;56:175-83.
tion, sharing and reciprocity that are inher- should be examined to see how that inter- 16. Trifonopoulos M, Kuhnlein HV, Receveur O.
ent to many Aboriginal peoples’ cultures. action modifies food access and choice. Analysis of 24-hour recalls of 164 fourth- to
sixth-grade Mohawk children in Kahnawake.
J Am Diet Assoc 1998;98:814-16.
Body image CONCLUSION 17. Campbell ML, Diamant RMF, Mapherson BD,
Grunau M, Halladay J. Energy and nutrient
Considering that there are few studies intakes of men (56-74 years) and women (16-74
about body image, weight concerns and Current dietary practices of some Aboriginal years) in three northern Manitoba Cree commu-
dieting practices in Aboriginal adults and peoples pose significant health risks and nities. J Can Diet Assoc 1994;55:167-74.
18. Lawn J, Harvey D. Nutrition and Food Security
children, community-based studies of body diminish the quality of life. It is therefore in Kugaaruk, Nunavut: Baseline Survey for the
image concepts would be valuable for critical to obtain information on the factors Food Mail Project. Ottawa: Minister of Public
Works and Government Services, 2003.
developing dietary interventions. This that relate to determinants of food choice 19. Kittler PG, Sucher KP. Food and Culture, 4th ed.
information is relevant because initiatives and food access. There are few comprehen- Toronto: Thomson Wadsworth, 2004.
to prevent obesity may not be effective if sive studies documenting the determinants 20. Van Oostdam J, Gilman A, Dewailly E, Usher P,
Wheatley B, Kuhnlein HV, et al. Human health
obesity is viewed as a positive physical of healthy eating in Aboriginal communities; implications of environmental contaminants in
attribute. On the other hand, if thinness is therefore, there are many gaps in knowledge Arctic Canada: A review. Sci Total Environ
1999;230:1-82.
desired, care must be taken to avoid pertaining to them. In view of the enormous 21. Borre K. The healing power of the seal: The
increasing concerns about weight, body diversity of Aboriginal peoples, research to meaning of Inuit health practice and belief. Arctic
Anthropol 1994;31:1-15.
dissatisfaction and the adoption of address the gaps should take place at both 22. Stairs A, Wenzel G. “I am I and the
unhealthy eating patterns. For a given the national level and a more local level. Environment”: Inuit hunting, community, and
community, it would be important to Research would be important for each of identity. J Indigenous Studies 1992;3:1-12.
23. Ohmagari K, Berkes F. Transmission of indige-
know whether obesity is viewed as a posi- Inuit, Métis and First Nations. nous knowledge and bush skills among the west-
tive or negative physical attribute, self- ern James Bay Cree women of subarctic Canada.
Hum Ecol 1997;25:197-222.
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Community. Dissertation. University of in Nunavik. Arctic Anthropol 1997;34:29-40. quate diet in four Yukon communities. Can J
Manitoba, Winnipeg, 2001. 41. Kuhnlein HV, Soueida R, Receveur O. Dietary Public Health 1994;85:310-12.
29. Sherwood NE, Harnack L, Story M. Weight-loss nutrient profiles of Canadian Baffin Island Inuit 53. Lawn J, Langner N, Brule D, Thompson N, Hill
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H. Overweight in Cree schoolchildren and ado- males. Arctic 1995;48:31-46.

S36 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3


Determinants of Healthy Eating he purpose of this article is to out-

Among Low-income Canadians


T line the state of knowledge regard-
ing the determinants of healthy eat-
ing* among low-income Canadians, † as
well as the gaps in that knowledge. The
focus is income, the first of 12 determi-
Elaine M. Power, PhD nants of health identified in Health
Canada’s model of population health,1 as a
key determinant of healthy eating. Income
has direct effects on healthy eating as well
as indirect effects, mediated through social
class. Income affects and interacts with
ABSTRACT other important individual and collective
factors affecting healthy eating practices.
This paper draws on four bodies of literature to consider the determinants of healthy eating These include individual factors, such as
for low-income Canadians: a) the social determinants of health; b) socio-economic food skills and preferences; social factors,
gradients in diet; c) food security; and d) the sociology of food. Though there is a paucity such as gender and social support; cultural
of data for Canada, it is very likely that, as in other industrialized countries, there are factors, such as traditions, norms and val-
socio-economic gradients in diet such that those who are better off consume healthier ues; physical factors, such as housing and
diets than those less well-to-do. The available evidence suggests that income affects food access to healthy food; and policy factors,
intake both directly and indirectly through the dispositions associated with particular such as food labeling, and school and
social class locations. Thus, there may be both economic and cultural thresholds for some workplace food policies.2,3
food groups or particular foods in food groups. Understanding these thresholds is A further factor is the type and strength
especially important in addressing the issues facing those who are the most vulnerable of dominant political discourse (e.g., neo-
among Canadians with low incomes: the food insecure. The literature reviewed suggests liberalism, welfare liberalism, democratic
that improved nutrition for low-income Canadians may be difficult to achieve a) in socialism), which affects the role the state
isolation from other changes to improve their lives; b) without improvement in the plays vis-à-vis the private sector, civil soci-
nutrition of the general population of Canadians; and c) without some combination of ety and the family in providing goods and
these two changes. Four major areas of research need were identified: a) national data on services, as well as the ability of the state to
socio-economic gradients in diet; b) sociological research on the interaction of income develop healthy public policy and create
and class with other factors affecting food practices; c) sociological research on Canadian the conditions that facilitate population
food norms and cultures; and d) research on the costs of healthy eating. health.4-7 The dominant political discourse
in a society has effects on factors influenc-
MeSH terms: Diet; public health; poverty; medical sociology; social class ing healthy eating that range from the
amount of time working parents have
available to feed their families, to the abili-
ty of a society to regulate food advertising
to children, to the breadth and adequacy
of income support programs.
Low-income Canadians are considered
to be nutritionally vulnerable for a number
of reasons. First, analysis from the 2000-
01 Canadian Community Health Survey
(CCHS)8 suggests that 14.7% of Canadian
households are food insecure. Food insecu-
rity refers to “limited or uncertain avail-
ability of nutritionally adequate and safe
foods or limited or uncertain ability to
acquire acceptable foods in socially accept-
able ways.”9 There is a growing body of lit-
erature on the extent, nature and manage-
* “Healthy eating” refers to eating practices and
behaviours that are consistent with improving,
Health Studies Program, School of Physical and Health Education, Queen’s University, Kingston, ON maintaining and/or enhancing health.
Correspondence and reprint requests: Elaine M. Power, Health Studies Program, School of Physical † “Low income” is defined according to Statistics
and Health Education, Queen’s University, Kingston, ON K7L 3N6, Tel: 613-533-6283, E-mail: Canada’s low income cut-offs, i.e., it refers to
power@post.queensu.ca those for whom spending on food, clothing and
Acknowledgements: I thank Susan Anstice and Sandra Morency for their capable assistance with this shelter takes up 20% more of their income than
project, and Michelle Hooper and Sharon Kirkpatrick of Health Canada’s Office of Nutrition Policy the relative amount spent by the average
and Promotion for their expert guidance and unending patience. Canadian family for those necessities.

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HEALTHY EATING AMONG LOW-INCOME CANADIANS

ment of food insecurity among diet; food poverty; health inequalities and In Canada, there is some historical evi-
Canadians, 9-30 showing that inadequate diet; healthy eating and low-income; food dence of socio-economic gradients in
income plays a pivotal role. behaviour; food choice; dietary patterns; diet.86-89 More recent studies have also sug-
Second, there is evidence from Western, lay knowledge and health; health behav- gested the existence of socio-economic gra-
industrialized countries that those in high- iour; health beliefs. dients51,52,90-92 and the likelihood of income
er socio-economic groups have healthier The search strategy included careful read- thresholds for some food groups, including
diets (eating more fruit, vegetables and ing of references for materials not indexed fruit, vegetables and dairy products.51,52,93
low-fat or skimmed milk, as well as fewer in the databases, such as books, book chap- An income threshold refers to the likeli-
fats and oils, and less meat) than those in ters and “grey” literature. Books were also hood that, beneath the threshold, income
lower socio-economic groups.31-52 identified by a search of the University of is the most important determinant of con-
Third, there is considerable evidence Toronto library system, and additional grey sumption; a socio-economic gradient sug-
that early life circumstances, including literature was identified through Google gests that other determinants, especially
nutrition, have a significant impact on searches. References suggested by the education, are also likely to be important.
health in adulthood.53-58 As a result, there reviewers of the original scoping paper were Thus it seems very likely that socio-
is great interest in improving the nourish- also included. Relevant key articles pub- economic gradients in diet exist in this
ment of infants and children, starting lished in French were identified using simi- country, as well as income thresholds for
in utero and continuing throughout child- lar search strategies and summarized by a some food groups. Nationally representa-
hood, particularly those living in poverty, bilingual research assistant. tive data, collected on an ongoing basis, are
in order to offset potential future health The minimum methodological criteria fundamental to understanding nutritional
problems. for inclusion were as follows: inequalities in this country and to formu-
Fourth, there is at least the perception of • a clear statement of methods, including lating strategies to address them.
a socio-economic gradient in obesity study population and selection of sam-
among Canadians. There is evidence that ple; identification of data collection Food Insecurity and Inequalities in Diet
rates of obesity follow a socio-economic methods; a discussion of data collection There is considerably more research on a
gradient in the US, at least among biases; particularly vulnerable component of the
women;59-61 however, until data from the • elaboration of the details of data analy- Canadian low-income population: those
2004 CCHS (Cycle 2.2) are analyzed, we sis; appropriate statistical tests or analyti- who are food insecure. Income is the most
will not have strong Canadian data on obe- cal approach used; important determinant of food insecurity
sity rates in relation to socio-economic • interpretation of the findings that was and hunger, but there is not a linear rela-
position. appropriate for the data collected and tion between income and measures of food
Finally, it is well established that there the analytical framework. security.94,95 Analysis of available Canadian
are social inequalities in health, such that data shows that the odds of reporting food
as economic and social circumstances Summary of the literature insecurity or food insufficiency* increases
decline, people have shorter, sicker lives.62-64 with declining income,10,11,22,97 one nation-
It has been hypothesized that healthier eat- Socio-economic Gradients ally representative survey showing that
ing and improvements in other lifestyle in Eating Patterns households in the lowest third of standard-
factors could reduce morbidity and prema- European studies have consistently shown ized household incomes were 10.2 times
ture mortality in low-income groups.39,65-75 that those of higher social class (generally more likely to be food insecure than those
However, the evidence suggests that the defined using education as an indicator, in the highest third.26 Analysis of the 1998-
role of nutrition and other lifestyle risk fac- rather than income or occupation) have 1999 National Population Health Survey
tors, including smoking, in social inequali- healthier diets (eating more fruit, vegeta- (NPHS) shows that 10.2% of Canadian
ties in health are less important than the bles and low-fat or skimmed milk, as well households, or approximately 3 million
social determinants of health, particularly as fewer fats and oils, and less meat).32-40 people, reported food insecurity in the pre-
poverty itself.47,56,76-83 Socio-economic gradients have also been vious year.10,26 More recent analysis sug-
noted in studies in the US 31,41-46 and gests that the number of food insecure
METHODS AND Australia,47-49 with higher socio-economic Canadians has increased dramatically, to
LITERATURE SEARCH groups consuming diets that are closer to 14.7% in 2000-2001.8
the dietary recommendations than lower While food insecurity is measured at the
Searches were conducted on the electronic socio-economic groups. However, studies household level, dietary intakes are mea-
computerized databases CINAHL, MED- that have measured nutrient intake, rather sured at the individual level,95 and individ-
LINE, and Sociological Abstracts over the than food consumption, 33,47,84,85 have uals in food insecure households show dif-
time period of December 2002 to March found the differences among socio- fering patterns of intake. Research on the
2003. ERIC was searched in July 2003. economic groups to be small and “appear
* Food insufficiency is a narrower, simpler con-
Citations from 1975 onward were includ- to be of limited importance when consid- struct than food insecurity. Food insufficiency is
ed. The following key words were used: ering the relatively low degree of compli- measured by a single survey question about the
food insecurity; inequalities and nutrition; ance of all social groups with dietary guide- quantity and quality of food eaten in the house-
hold, and is seen as a measure of fairly severe
hunger; poverty and food; poverty and lines.”47 household food insecurity.96

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HEALTHY EATING AMONG LOW-INCOME CANADIANS

nutrient intakes of children in food insecure based relations to food: substance (food as time. To provide data that would help us
households, 15,95,98-101 the management of material reality, sustaining the body and understand socio-economic gradients in
household food insecurity12-15,18,20,27,28,99,102-112 giving strength) and form (food as self- diet and the determinants of healthy eating
and the gender aspects of feeding the discipline to an aesthetic idea). These differ- among low-income Canadians, the design
family113-116 suggests that food is not evenly ent relations to food are divided by the “dis- of a nutrition survey would have to incor-
distributed among family members. This tance from necessity”,136 which is an indirect porate multiple measures of class, includ-
research shows that mothers protect their way in which income and class position ing income, level of education, occupation
children as much as possible from overt affect eating practices. This research suggests and the social trajectory of both the
food deprivation or hunger (though the that apart from income thresholds for the respondent and spouse/partner (if applica-
quality of food fed to children suffers dur- consumption of different food groups, there ble).144 Other known influences on eating
ing times of constraint). Mothers employ may also be cultural thresholds related to habits should also be included in the sur-
numerous management strategies, includ- class (including educational attainment) and vey, such as family structure, family roles
ing the reduction of their own food quality class trajectory over time. and responsibilities, ethnicity, length of
and quantity, to avoid the catastrophe of Social science research also suggests that time in Canada, hours of employment,
having their children go hungry. Two the concept of “belonging” may be impor- food availability at work and so on. Ideally,
recent studies of the diets of high-risk tant for understanding food practices. As such a survey would also include measure-
Canadian households14,15,18 have focussed political scientist Deborah Stone has put ment of individual food insecurity96 and
on mothers’ intakes, the most sensitive it,141 what we eat is “a sign of membership, food costs.145 A longitudinal study design
indicators of potential nutritional risk. social status and spiritual worth. Eating the could provide data on how changes in cul-
These have demonstrated estimated preva- same food as others is a basic mark of tural capital, income and food security sta-
lences of inadequacy for several nutrients. belonging” (p. 71). The practice of feeding tus, as well as in factors such as age, family
The research on food insecure Canadians the family involves, in part, meeting what composition and children’s ages, affect
demonstrates that, for the populations Stone141 calls “communal needs”, which food practices.
studied to date, the most important barrier include “community, solidarity, a sense of National nutrition data, provided over
to healthy eating is inadequate income. belonging; dignity, respect, self-esteem, time, could help us fill the gaps about how
This conclusion is supported by the fact and honor; friendship and love” (p. 77). significant the dietary differences are
that mothers do protect their children’s The desire of low-income people to belong among socio-economic groups; how the
energy and nutrient intakes, 15 and that to the dominant culture through food has gradients are different using different mea-
energy and nutrient intakes decline system- been well documented by those examining sures of socio-economic position; the rela-
atically as food security status deteriorates.18 the social aspects of food insecuri- tion between socio-economic gradients and
It is also supported by research establishing ty.13,108,142,143 income thresholds for different food
that incomes for those receiving welfare and This body of research highlights the groups; whether the relation is different for
those working at minimum wage jobs are important social, cultural and symbolic different food groups or for food groups
inadequate to purchase the food for a functions of food, eating and “feeding the rather than nutrient intake; how socio-
healthy diet.21,117 Higher levels of education family”,115 and suggests that there are differ- economic differences in diet are distributed
do not protect households from food inse- ent cultural “logics” underlying these every- among rural, rural remote, suburban and
curity,14,19,26,97,118 nor does education appear day practices for different social classes. urban localities, between the sexes, across
to mitigate the dietary effects of inadequate age groups, and among different ethnic
income. 51,93 Neither nutritional knowl- KNOWLEDGE GAPS IN THE groups; the relation between the expected
edge27,66,119-122 nor food skills25,123 appear to LITERATURE gradients in food groups and adherence to
be significant factors affecting healthy eat- the dietary guidelines and other measures
ing in these populations. Those in low- National data on socio-economic of dietary quality; and how these relations
income households have been shown to gradients in diet change over time.
buy more nutrients for their food dollar A robust research program on the determi-
than higher income households. 124,125 nants of healthy eating among low-income Sociological research on the
Indeed, it can be concluded that those who Canadians must be founded on quantitative interaction of income and class with
live in poverty are particularly adept and data examining dietary intakes and patterns in other factors affecting food practices
creative in juggling and managing their Canadians; therefore, the lack of national data There is little research on the interaction of
financial and food resources to ensure that on socio-economic gradients in diet is perhaps income with other factors affecting food
their most important needs are met the most significant gap in the Canadian practices, such as housing status, social
first.9,12,13,23,69,102-105,108-110,112,115,120,126-135 research literature. Fortunately, that gap will support, family roles and responsibilities,
begin to be filled in the near future, with the time constraints, the stage of the life
Using Sociology to Understand results of the CCHS, Cycle 2.2, Nutrition course, ethnicity, length of time in
Food Practices Focus, which was scheduled to conclude data Canada, etc. Sociologically informed, qual-
Sociological research on health and food collection in December 2004. itative research could help develop addi-
practices that compares different classes136-140 Ideally, a nutrition monitoring and sur- tional indicators of food insecurity that
suggests that there are two opposing, class- veillance system would provide data over assess qualitative and social dimensions of

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HEALTHY EATING AMONG LOW-INCOME CANADIANS

feed their children? Can Med Assoc J


food insecurity, as well as measures of indi- comparing food baskets,148 and comparing 2003;168(3):686-91.
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ty status, as suggested by Tarasuk.96 Such the case that healthier diets are more Study of Child Hunger in Canada. Ottawa, ON:
Human Resources Development Canada,
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the dynamics of intra-familial food distrib- important implications for public policy. 2001.
17. Tarasuk V. Low income, welfare and nutritional
ution in low-income two-parent hetero- At the individual level, changes in pricing vulnerability. Can Med Assoc J 2003;168(6):709-10.
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Mental Health and Eating hy do we need to know about

Behaviours
W the connections between eating
behaviour and mental health?
Variations in mental health may con-
tribute to or impair healthy eating. For
A Bi-directional Relation instance, disturbances in mental health,
such as depression, unhappiness or anxiety,
may cause people to eat unhealthy
Janet Polivy, PhD
amounts or types of food.1,2 Conversely,
C. Peter Herman, PhD eating behaviour influences mental health.
When we eat too much, we feel uncom-
fortable (socially, we do not want to look
ABSTRACT “piggish” to others, and, even alone, we
prefer not to feel that we are eating “too
Background: Variations in mental health may contribute to or impair healthy eating. The much” or “more than normal”), and if we
relation between eating and mental health is bi-directional: one’s mood or psychological happen to be dieting to lose weight we
state can affect what and how much one eats, and eating affects one’s mood and may also feel guilty and anxious.3 Negative
psychological well-being. Thus, if we want to promote and develop strategies to emotions, in their turn, can make us
encourage healthy eating, it is important to understand the connections between mental overeat in an attempt to feel better.
health and healthy eating. Certain foods may be comforting or help
to alleviate negative moods. 4 If, on the
Methods: To contribute to this understanding, we examine the research on individual other hand, we eat too little, we may feel
differences in how people respond to food, as well as mood, and emotional, social and irritable, tired or deprived, especially if
collective influences on what and how much is eaten; we then examine the implications others around us are eating more and seem
of these connections for mental health, with a focus on adolescents and adults. Looking at to be enjoying their food. This may be
the relation between eating and mental health from the other direction, we review partly a physiological reaction to hunger,
research investigating whether the amount that one eats or particular foods one ingests can but it may also reflect a psychological
make one feel good or bad about oneself. resentment that one is not having what
others have. The resentment may be
Conclusions: Overeating and undereating have complex effects, sometimes contributing to caused by a self-imposed diet or by living
improved feelings of well-being and at other times leaving the individual feeling guilty, in a society in which food is so abundant
deprived, depressed and anxious. We attempt to identify both what we know and the gaps for most, but some have too little. The
in our knowledge. relation between eating and mental health
is thus bi-directional: one’s psychological
MeSH terms: Mental health; eating behaviour; overeating; mood; undereating state can affect what and how much one
eats, and eating affects one’s mood and
psychological well-being.
The consequences of eating on mental
health may reinforce healthy or unhealthy
eating patterns (i.e., it is possible that eat-
ing in a healthy manner makes people feel
better psychologically, but it is also possi-
ble that eating in an unhealthy way makes
people feel better emotionally). If we want
to promote healthy eating and develop
strategies to encourage it, we need to
understand the connections between men-
tal health and healthy eating. At the same
time, we must remain alert to the possibili-
ty that healthy eating may occasionally
exact a mental-health cost. Indeed, we
might even be forced to the conclusion
that in some rare circumstances a strict
adherence to healthy eating might be
excessively costly in term of psychological
Department of Psychology, University of Toronto, Toronto, ON well-being.5
Correspondence and reprint requests: Janet Polivy, Department of Psychology, University of Toronto
at Mississauga, Mississauga, ON L5L 1C6, Tel: 905-828-3959, Fax: 905-569-4326, E-mail:
In this article, we will use “healthy eat-
jpolivy@utm.utoronto.ca ing” to refer to eating practices and behav-

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MENTAL HEALTH AND EATING BEHAVIOURS

iours that are consistent with improving, cally sound studies that represent the find- es, including low self-esteem and negative
maintaining and/or enhancing health, both ings in the area. We thus included repre- body image. 12,13 Successful dieting (i.e.,
physical and psychological. Mental health sentative studies that had control groups, avoiding weight gain or maintaining one’s
will be used in the context of the normal reasonable sample sizes and, when possible, current weight) and weight loss, while
(as opposed to clinical) population, and were theoretically based or even experi- apparently much less common than unsuc-
will thus refer to mood, mental state, feel- mentally manipulated. In addition, we cessful attempts, produce improved psy-
ings about the self, and general psychologi- concentrated our investigation on adoles- chosocial functioning and mood. 14
cal well-being. The focus of this article is cents and adults, in order to keep the scope Furthermore, restrained eating that is not
the psychological or mental health-related manageable. accompanied by disinhibited eating or
determinants of healthy eating in adoles- bingeing is less likely to be related to
cents and adults, and the impact of healthy Summary of the literature pathological eating and eating disorders.15
and unhealthy eating on mental health, as Simply focussing on what is eaten or how Conversely, however, for the many dieters
defined. It should be recognized that men- much is consumed sidesteps the important who are prone to disinhibition of their eat-
tal health issues may often interfere with question of why people eat the amounts ing and who seem to be unable to lose
healthy eating, rather than promote it. In and types of food that they do. Healthy weight, and especially for females,
addition, what is healthy eating may be and unhealthy eating are both influenced restrained eating or chronic dieting is cor-
different in a person who is overweight by a variety of individual and collective related with negative mood and psycholog-
from one who is of normal weight or (social and environmental) factors, many ical functioning, overeating or even eating
underweight. Thus, an overweight person of which interact with each other in com- binges in many situations, weight gain or
who eats less than his or her body needs plex fashions. We must understand these failure to lose weight over time, and a ten-
and loses excess weight may be engaged in factors and their interactions to understand dency to overeat when stressed or upset in
healthy eating, whereas a normal or under- how to promote and support healthy eat- any way.3,5,16-18
weight person doing the same thing may ing, and how to maximize the physical and More transient factors, such as mood
be eating in an unhealthy manner, particu- mental/emotional benefits of healthy eat- and focus of attention, also affect eating.
larly if that person is a teenager who has ing. Individual psychological factors that Celebratory feasts often entail overeating,
not yet reached full growth and needs affect eating include personality traits such which is unhealthy if it represents frequent
more energy to do so healthily. These dis- as self-esteem, body image and restrained behaviour. Stress and negative affect can
tinctions must be borne in mind when eating (chronic dieting), as well as mood adversely influence the kinds of foods
reading about research on the influence of and focus of attention. eaten, either through suppressing eating, as
eating on mental health and of mental Self-esteem seems to be strongly con- with grief or loneliness, or increasing not
health on eating. nected to eating both directly (as shown by only eating but consumption of unhealthy
experimental demonstrations that lowering “comfort” foods.2,4 Restrained eaters often
METHODS self-esteem produces excessive eating) 1,6 binge eat when they experience negative
and indirectly, through the association of affect.1 Negative affect seems to promote
The present article is based on a review low self-esteem with body or weight dissat- ingestion of high-fat and/or high-sugar
that encompassed searches of the literature isfaction and a corresponding tendency to foods.1,4 A shift in temporal focus from a
through PsycINFO and MEDLINE for binge eat or diet in an unhealthy manner.7 long-term desire for good health to a focus
the last 10 years (1994-2004). Relevant Negative body image predicts excessive on the immediate pleasures of the
words, such as obesity, mental health, food restriction followed by bouts of unhealthy but good-tasting food impairs
depression, self-esteem, overweight, food overeating and even binge eating in adoles- one’s ability to continue striving for the
intake, restraint, restrained eating, meal cent and adult women.8 Some programs to distant goal of being healthy.19 Conversely,
size, carbohydrate, protein, fat, meal com- improve body image have been successful being aware of one’s eating or self-
position, diet, food, eating patterns and at teaching adolescents to resist media monitoring intake can prevent overeating
eating habits were searched and examined pressure to attain an unrealistic body, pre- and help to change intake of specific nutri-
to determine whether they were relevant to venting the development of less healthy ents (i.e., reducing fat or increasing fibre),
the topic of “eating and mental health.” attitudes and behaviours, and helping to but may also lead to perceptions that
The term “eat” was also paired with rele- promote healthy eating and body weight “reduced fat” foods are less tasty.20-22
vant terms (affect, emotion, anxiety, maintenance.9-11 It is evident that everyone is influenced
depression, stress, alcohol, intoxication, Chronic on-again, off-again dieting dramatically by physical environmental
drink, social influence, social norms, (often called “restrained eating” in the lit- cues concerning eating. For example,
matching, insecurity, self-awareness, feed- erature) can reflect a constellation of increased portion sizes and marketing of
back) and searched. Finally, reference lists behaviours and attitudes that represent a high-fat, high-sugar foods have both been
in the most relevant articles were examined personality trait and have a strong influ- identified as contributors to the increasing
for citations that did not appear in the lit- ence on eating. Restrained eaters are char- prevalence of overweight and obesity in
erature searches. We could not possibly acterized not only by concern about their North America.23 Similarly, the eating situ-
review all of the relevant studies identified eating, weight and appearance but also by ation affects what and how much gets
in this manner, so we chose methodologi- a variety of cognitive and affective attribut- eaten: people who eat while distracted by

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MENTAL HEALTH AND EATING BEHAVIOURS

television or movies may eat more food, are influenced in several ways by which What factors promote dysfunctional eat-
and the food they select is less likely to be particular foods they choose to eat (e.g., ing, particularly in young women? Eating
low energy or low fat.24 Moreover, people being pleased with oneself for eating disorders may not be as prevalent a prob-
recognize the influence of environmental healthier foods and avoiding unhealthy lem as obesity is, but subclinical variants
factors on other people, but do not ones, or seeking relief from distress by eat- do affect large numbers of young women.
acknowledge a similar influence on them- ing a particular comfort food).4 Restricting From a population perspective, then, men-
selves, even though those effects may be one’s eating, commonly referred to as tal health issues that contribute to eating
profound.25 If the role of the environment “dieting”, actually causes overeating, even disorders also pose a serious health risk.
in the development of unhealthy eating is in animals.32 Binge eating is a consequence Does focussing on healthy eating and
to be diminished, we must a) explore and of semi-starvation in victims of war and weight help to prevent disordered eating
systematically articulate these influences, famine, and in volunteers in starvation and eating disorders, or does it exacerbate
b) make people more aware of the impact experiments.33 Starvation-induced behav- the problem? Although we have identified
that such influences are having on them, iours, in addition to binge eating, include a connection between some factors, such as
and c) create helpful social and physical bizarre mixing of ingredients and adulter- a negative body image, low self-esteem and
environments. Many environmental influ- ation of food; eating inappropriate, soiled chronic dieting, and the development of
ences gain power from the fact that they or discarded food; secrecy, deception and eating disorders, we do not yet know how
operate below the level of the individual’s defensiveness.33 Even normal dieting can these associations work or whether other
awareness.25 If we remain oblivious to the produce depression and anxiety of mild to factors are involved.
influence of collective factors, those factors severe proportions,34,35 or happiness when What impact do low self-esteem and
will continue to exert their pernicious dieting is successful and perceived excess poor body image have on food selection
influence by allowing us to feel psychologi- weight is lost.31 There is also a correlation and eating behaviour? Higher self-esteem is
cally comfortable with intakes that are between healthy eating and positive mood, associated with healthy eating and lower
actually physically excessive.26 though it is not clear which causes which.36 self-esteem with overconsumption and the
The presence of other people during an For example, eating breakfast improves development of disordered eating. The
eating episode is also a collective factor. mood.37 People often use eating specifically same seems to be true for body image,
Extensive research indicates that the pres- to alter their emotional state.38 They also which is itself connected to self-esteem.
ence of others has profound effects on food use their eating to influence how other Are these two factors independently related
intake, often distorting intake away from people view them, and other people’s eat- to eating, or do they interact? Given the
what would be judged a healthy amount or ing can affect their own mood and self- frequency of problems with self-esteem
healthy types of food.26 The effect of the image if they deviate from the behaviour of and body image, could these be contribut-
presence of others on eating may best be the group.36 ing to overeating and obesity, as well as
understood in terms of three separate social eating disorders? To date, attention has
situations – modeling, social facilitation GAPS IN THE LITERATURE been directed primarily at the eating dis-
(increased eating with others) and impres- orders connection, ignoring the impact of
sion management (using eating to make an Why does distress or negative emotion negative self-image on overeating and
impression on others) – although all of cause some people to overeat (especially weight.
them probably operate through their influ- to overeat unhealthy foods) and others to To what extent do personality, mood
ence on perceived consumption norms. undereat? We know that distress increas- and collective factors interact to control
People use social cues to decide how much es consumption of high-sugar and high- eating? Making sense of the information
they can eat without attracting negative fat foods and snacks, and unhealthy we have about what promotes or interferes
social judgments from others.26 The family “comfort” foods (often consisting of with healthy eating is necessary before we
may be regarded as a special source of sweet or salty-fat foods such as mashed can move forward on a large scale. Some
social influence and has a strong impact on potatoes, rich cakes or chocolate in any studies have begun to explore the inter-
food selection and eating patterns. For form), but we know little about why the active effects of personality, mood and
example, studies show that one way to connection between distress and environmental influences, but more sys-
reduce dietary fat in people’s diets is to unhealthy eating exists, or whether it tematic investigation of these interactive
change what other family members are eat- holds for all types of negative affect. effects is required before we can design
ing.27 The family also contributes to dis- Conversely, severe depression or anxiety programs appropriate for different people
turbed eating behaviours and eating disor- reduces some people’s intake to a mini- in different milieus.
ders, 28 increased consumption in over- mum, putting them at risk of caloric We still do not understand what deter-
weight children, 29 and amounts of fruit insufficiency. The question of how emo- mines healthy eating or how to induce
and vegetables consumed.30 tion and stress affect eating in different people to undertake these behaviours. The
The amount that one eats can make one people at different times needs clarifica- literature indicates that when people feel
feel good or bad about oneself (good for tion. Healthy eating must be achieved as better about themselves, they eat in a
eating only a small amount of an a sustainable lifestyle rather than as a healthier manner than when they feel bad
unhealthy food or bad for eating a lot of short-term corrective that may dissipate about themselves. Conversely, eating well
the unhealthy food).4,31 Similarly, people in the face of negative affect. can help us to feel better, which should

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MENTAL HEALTH AND EATING BEHAVIOURS

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