The Author 2008. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oxfordjournals.org.

doi:10.1093/fampra/cmn063 Family Practice Advance Access published on 30 September 2008

Determinants of healthy eating: motivation, abilities and environmental opportunities

Johannes Brug
Brug J. Determinants of healthy eating: motivation, abilities and environmental opportunities. Family Practice 2008; 25: i50i55. Background. In order to promote healthful nutrition, insight is needed in the behavioural deter-minants of nutrition behaviours. Most research on behavioural determinants has been restricted to individual-level motivational factors. However, health behaviour is influenced by individual motivation and abilities, as well as environmental opportunities. Objective. To provide an overview of motivation, ability and opportunity-related potential de-terminants of nutrition behaviours and of the evidence for associations of potential environmen-tal determinants with nutrition behaviour. Method. A narrative review informed by a series of six systematic reviews including more than 400 original studies and recent original studies on associations of environmental factors with nu-trition behaviours. Results. Although the number of studies on potential environmental determinants of nutrition as well as physical activity behaviour has increased steeply over the last decades, these include only few well-designed studies with validated measures. Preliminary evidence from the avail-able systematic reviews indicates that social support and modelling, availability and accessibility of healthy and less healthy foods as well as socioeconomic status are important for nutrition behaviours; schools and worksites offer good settings for improving healthful nutrition opportunities. Conclusion. Although the evidence to date is inconclusive due to lack of well-designed studies, specific socialcultural, physical and economical environmental factors appear of importance for healthful nutrition. Keywords. Behaviour, behavioural determinants, environment, nutrition.

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sp id ec e Diet and nutrition are major determinants of popula-tion health. Dietary behaviours and nutrition are asso-ciated with four of the ifi nt c if top-five burdens of disease (high blood pressure, high cholesterol, obesity and low fruit and vegetable consumption). 1 Acrossdi y Europe and beyond, majorities of populations do not comply to recommendations regarding, for example, intakes of energy,et w saturated fat, sodium and fruits and vege-tables. Public health interventions have been, are and should be designed and ar h y y implemented to pro-mote that more people engage in healthful eating habits. 2 bep hae For planned promotion of population health, it is not enough to identify the risk behaviours, i.e. the vi o o pl ur e s e th n at g ca a us g e e ill in hesu al c th h . ri Wsk e b al e so h nea edvi to o

Introduction

urs. These behavioural determinants should be identified so that we can target and tailor health promotion interventions. 3 2 The present paper describes and discusses the evi-dence for different categories of potential determinants of eating behaviours, 9, with a specific focus on environ-mental factors. First, different categories of determinants of eating behaviours and different 2 categories of potential environmental determinants will be introduced. Sub-sequently, the evidence from six systematic reviews 0 the author was involved in of the different categories of po-tential environmental determinants will be summarized and 1 2 consequences for interventions to promote healthy nutrition behaviours will be briefly discussed.

Received 4 June 2008; Revised 31 July 2008; Accepted 26 August 2008. EMGO Institute, VU University Medical Center, Amsterdam, The Netherlands. Correspondence to Johannes Brug, EMGO In-stitute, VU University Medical Center, Van der Boechorststraat 7, 1081 BT Amsterdam, The Netherlands; Email: j.brug@vumc.nl i50

i51 will argue that it is the interplay be-tween individual-level andT Determinants of health h behaviours: motivation, ability environmental factors thate determine food choices and and opportunity eating habits. A frame-worko r by Rothschild 5y With the overabundant range of food items proposed on offer, people in market-economy provides a simple and easy to6 countries can, to a large extent, choose understand point of departure tor what, when and how much they eat. Tocategorize the large and diversee induce dietary change, one needs to change number of potential determi-c peoples food choices. To be able to donants at these two levels.o identifies three that, insight in to why people choose to eat Rothschild g categories of determinants: what they eat is necessary. n ability and Studies on determinants of eating motivation, i behaviours have primarily focused onopportunity. z individual-level factors, such as taste e preferences, nutrition knowledge, attitudes b Motivation: attitude and and intentions and insight in to such e personal norms h motivational determi-nants have informed theories ofa health education interventions to promote Important more healthful eating habits, including determinants of human healthv behaviour, such as the Theory of nutri-tion advice and counselling by GPs. 3Planned Behaviour, Protectioni Such nutrition education approaches Motivation Theory and Socialo u attempt to urge people to con-sciously Cognitive r adopt healthier eating habits by providing a in-formation about unhealthful eating and l more healthful alternatives. However, such d nutrition educa-tion interventions have had e limited and mostly short-lived effects at c best. More recently, it has been argued that i the environment we live in may be the s driving force behind many of our less i healthful eating habits as well as lack of o physical activity.4 It has, for example, been n posited that the present-day food o environment in market-economy countries r i is characterized by abun-dantalmost n anywhere and anytimeavailability and t accessibility of energy-dense and energye rich foods that strongly appeal to our n innate and early acquired preferences for t 3 This, combined with sweet, fat and salty. i a natural human tendency to eat when food o is available and eat more when more is on n offer, may lead to overeating and a consequently to weight gain, overweight s and obesity, as well as high intakes of satut rated fat, refined sugars and salt. This more h recent fo-cus on environmental e determinants of eating habits asks for a p health protection approach to promotion of r healthful eating, i.e. changing the i environment to pro-tect the population m against exposure to foods and eat-ing a patterns that contribute to chronic disease r risk. y m o The present paper builds on a series of s reviews on environmental correlates of t health behaviours I was involved in, and I
Determinants of healthy eating

proximal determinant of behav-iour. dicated rarely or never to Intentions can be regarded as thecompromise on taste to improve consequence of motivation. Each theory the healthfulness of their diets. 10 proposes different but sim-ilarFurther-more, in practice, health determinants of intentions. Based on anexpectations may only influintegra-tion of insights from theence food choices significantly aforementioned theories, four groups offor most people when the health determinants that predict intention haveconsequences are expected to be been recognized: attitudes, self-soon, se-vere and easy to representation, self-efficacy and social recognize.7 People may influences.6 therefore quickly develop Of these, attitudes and self-negative attitudes towards foods representation are most directly related tofor which they are allergic or motivation; self-efficacy is related tointolerant, i.e. foods that litability, and social influences will beerally make them sick. But since further dis-cussed in the paragraph onenergy-dense foods provide a comfortable feeling of satiety, opportunities. Attitudes are based on a subjective beliefs about the potentially weighing of ex-pected positive and negative health consequences ofD eating such foods often do not negative consequences or out-comes of the o have a strong impact on food behaviour. Closely related constructs are w decisional balance, outcome expectations nl and per-ceived threat. Beliefs or o expectations about short-term outcomes a are more important than longer term outd comes.7,8 Taste, satiety and pleasure are e short-term outcomes of major importance d for most people. First of all, people tend to fr eat what they like and avoid foods they o m dislike.7 Certain taste preferences are inht nate, such as a liking for sweet and salt and a dislike for bitter. However, taste tp :/ preferences can be learned and unlearned, 8 /f and the fact that many people like the taste a of coffee and beer illustrates that we can m even unlearn our innate dislike of bitter p tastes. Learn-ing to like and dislike certain ra tastes are basic classical and operant .o conditioning processes, and we quickly x learn to like the taste of foods that are reinforced by the pleasant feeling of satiety f (taste-nutrient learning), that are eaten in o pleasant surroundings or with pleas-ant r company (taste-environment learning) and dj of foods that are combined with a taste that o we already have a strong liking for (taste u taste learning).7,8 We therefore quickly r n learn to like foods high in fat and sugar (taste-nutrient learning), foods offered as al re-wards, at parties or encountered during s. holidays or other pleasant circumstances o (taste-environment learning) and foods r with added sugar or salt (taste taste g/ learning). b
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Health is a second category of outcome expectations of major importance for peoples food choice. 9 Never-theless, 40% of Americans and 57% of Europeans in-

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acts, from choosing foods, choice.8 Convenience is a third important portion sizes and preparation o f factor that may shape food-related attitudes. 11methods, to transportation, workm leisure time physicalo In Europe, 42% of consumers indicated thatand convenience comes before health in makingactivities, it takes a great deal oft food choices, compared to 24% in US andfood knowledge and goodi Australia.10 arithmetic skills to monitor onesv Self-representations or self-identity reflectcalorie intake or day-to-daya bal-ance. If thet what a person thinks of as important and stableenergy characteris-tics of the self, i.e. the values andopportunities for objective self-i o norms people adhere to.6 Less research hasassessment are lacking, peoplen been conducted on self-representation than ontend to compare their intakes tot attitudes related to food choice, but somewhat they perceive others do.o personal values have been shown to be related Such social compari-sons arec h to nutrition behaviours. People may seeliable to so-called optimistica 14,15 resulting in peoplen themselves, for example, as health conscious, bias environ-mental conscious or animal friendly.thinking that they already comply g Such personal norms may induce specificwith die-tary recommendations e . dietary habits such as healthy eating, choosing while they are not and to lack 1 organically grown foods or adopting a 5 12 vegetarian diet.
, 1

From motivation to ability: selfefficacy, skills, knowledge and awareness Self-efficacy, or perceived behavioural control, refers to the perception of, or confidence in, ones abilities and skills to engage in certain behaviour. A person who is confident that he can cut back on saturated fat intake will be more motivated to do so even when faced with certain barriers. Self-efficacy is behaviour and context specific. A person can, for example, have high confidence to be able to eat less fat, but not to in-crease vegetable intake; and confidence to cut back on fat may be high for regular meals prepared at home, but not for eating out. Self-efficacy is strongly related to abilities and skills. If self-efficacy is based on true personal abilities and skills, people are more likely to be able to translate their motivation into action. 6 Skills and abilities are to some extent dependent on practical knowledge. For example, knowledge of recommended intake levels and healthy alternatives for unhealthy choices help to enable voluntary dietary change. Nevertheless, earlier research has shown13 that knowledge is often not a di-rect determinant of eating behaviours; some nutrition knowledge appears to be a necessary but insufficient prerequisite for health behaviour change. Awareness of personal intake levels is another im-portant ability-related factor. Caloric intake and ex-penditure are determined by complex collections of different specific

S t u d i e s h a v e s h o w n t h a t a w a r e n e s s o f u n h e a l t h y

eating habits is a strong positive correlate of intentions to make dietary changes.1416

in worksites and institutions and also family food rules are examples of political environmental factors. The socio-cultural environment refers to the social and cultural subjective and Opportunities and support: physical and descriptive norms and other social cultural food environments Defining the environment: the ANGELOsocial in-fluences such as social framework. The environment can be definedsupport for adoption of health as ev-erything and anything outside thebehaviour and social pressure to person. 17 Environ-ments may make healthierengage in unhealthy habits. choices easier choices or may even reduce the number of options or possibilities for unhealthy choices. Just as personal factors have been further subdivided in more specific determinant constructs and proposed pathways of mediation, so can and should the environment be further defined by means of distinguishing D various environmental factors. o 17 was specifically The ANGELO framework w devel-oped to conceptualize health behaviour nl environments related to obesity. It is a grid o with two axes. On the first axis, two sizes of a environment (micro and macro) are d distinguished. Micro-environments are defined e as envi-ronmental settings where groups of d people meet and gather. Such settings are often fr geographically distinct and there is often room o for direct mutual influence be-tween m individuals and the environment. Examples of ht micro-environments are homes, schools, tp workplaces, supermarkets, bars and restaurants, :/ other recreational facilities and also include /f neighbourhoods. a Macro-environments, on the other hand, m include the broader, more anonymous p infrastructure that may sup-port or hinder ra health behaviours. Examples of macro.o environments are how food products are x marketed, taxed and distributed; the media may f also be included in the macro-environment. o On the second axis, four types of r environments are distinguished: physical, dj economic, political and socio-cultural. The o physical environment refers to availabil-ity of u opportunities for healthy and unhealthy r choices, such as points-of-purchase for fruits n and vegetables, soft drink vending machines, al availability of low satu-rated fat spreads in s. worksite cafeterias, etc. The eco-nomic o environment refers to the costs related to healthy and unhealthy behaviours, such as the r costs of soft drinks, fruits and vegetables or g/ energy-dense snacks. The political b environment refers to the rules and regulations y that may influence food choice and eating g behaviour. Bans on soft drink vending mau chines in schools, rules on what treats can and e cannot be brought to school, nutrition policies st

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i53 Although outnumbered by observational studies, the a Conclusions from recent intervention studies that weren systematic reviews of the reviewed provide more d literature consistent evidence regarding a c Most publications arguing thatrelevant environ-mental factors, c but the range of environmental environmental factors drive unhealthy e eating habits are position papers orfactors studied was small. s narrative reviews and do therefore not Based on an integration of the s provide sys-tematic evidence in favour of afindings from the dif-ferent i causal association be-tween environmental reviews, we have drawn theb factors and unhealthy eating habits or its following conclu-sions related to i consequences. 18 Most of these position nutrition behaviours: (i) social l papers focus primarily on the presumedsupport and modelling appear to i importance of the physical environment, be important for different nu- t i.e. the availability and accessibility of trition behaviours especially iny foods that contribute to unhealthful eating youth; (ii) parents have a crucial o role in the nutrition behaviours f patterns. of their chil-dren. They should h not only provide a good example e Recently, six systematic reviews of the by eating right themselves but a scientific lit-erature up to 2005 were also by using parenting practices l conducted under my supervi-sion initiated t and supported by the Netherlands and styles that encourage and support healthy eating habits inh Organization for Health Research and y Development on environmental correlates their offspring; (iii) availability a (297 papers included in the reviews) and n interventions (112 papers included) for d nutrition behaviours and physical activity, l for chil-dren, adolescents and adults in e established market economy countries. s These reviews of more than 400 original s papers were published as a report in print h and electronic form and in a series of e a papers in different scientific journals. 16,19 l 22 t h First, these systematic reviews reveal y that research on potential environmental f correlates of nutrition be-haviours is o becoming more and more popular, given o the sharply increasing number of d publications on this issue in the last s decades. 19 The reviews also indicate that a micro-size environmental factors were r more often studied than macro-level e factors. Socio-cultural and physical i environmental factors were most often inm cluded in the studies that were reviewed.19 p o More importantly, the reviews of r observational studies do not yet strongly t support the recent claims that the a environment strongly influences nutrition n be-haviours. For none of the categories of t environmental factors have a majority of f studies reported significant associations o between environmental factors and the r nutrition behaviours investigated. n
Determinants of healthy eating

utrition behaviours in youth and adult- Most studies applied weak study and non-validated hood; schools and worksites offer good designs opportunities to improve availability of measurement instruments. 19 healthful foods; (iv) children and Nearly all the available adolescents from more deprived observational studies used crossfamilies are likely to have unhealthier sectional de-signs. They evidence for diets, and lower household income is provided associations, but not for associated with less healthy diets in adults.19 So the reviews indicate that social prediction or causation. cultural environ-mental factors may have Most studies only presented a more consistent influence on nutrition simple associations be-tween a behaviours than the physical environ- presumed correlate and the ment. Recent studies in The Netherlands behaviour; few studies used further sup-port this. Wind et al.23 and De multivariate analyses, adjusting for other potential personal or Bourdeaudhuij et al.24 studied environmental correlates of nuassociations between a range of trition or physical activity potential physical and socialcultural behaviours. Many interven-tion environmental factors with fruit and studies did not include a control vegetable intakes. Their results indicate group. Only some recent studiesD o that family social cultural factors such as used multi-level analyses to take w parental en-couragement and modelling nl were stronger correlates of intakes than o availability of fruits and vegetables. This a finding is supported by a further systematic re-view of the literature d focussing specifically on fruits e d and vegetables. 25 fr The number of conclusions we could o draw from re-viewing the more than 400 m original studies was not very impressive. ht The relatively weak evidence found thus tp far should not be interpreted as absence of :/ a rela-tionship between the environment /f and nutrition be-haviour. Despite the large a number of studies, there is still a lack of m high-quality studies and of study replicap tions. Furthermore, many potentially ra relevant environ-mental factors have not been studied at all. The available research .o was focussed on only a part of the x environment, especially micro-level factors f in the socialcultural and the physical o environmental. These were typically r home-environmental social factors and dj schoolphysical environmental factors o (parental influ-ences and school u availability) for youngsters, and so-cial r support, home and worksite availability n and accessibility factors in adults, with few al studies on neighbourhood environmental s. factors. Studies on macro-size o environmental factors were almost comr g/ pletely absent. 19
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Limitations of the studies reviewed

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think this is appropriate and/or into account potential environmental correlateswhen protocols require them toe that are studied in non-independent samples,do so. Research indicates,n such as indi-viduals clustered withinhowever, that large majorities ofv neighbourhoods, schools or school classes.19 populations are already motivatedi Exposure to environmental factors andto eat healthfully and to ber nutrition behaviour was mostly measured withphysically active,29 but that nutri- o non-validated self-report measures. One of thetion education often has minorn issues that need fur-ther exploration is theand short-lived effects at best. Itm difference between objectively assessedhas been argued that this is thee environmental factors and subjective,case because the so-calledn perceived environments. In research focussingobesogenic environment preventst on pre-sumed environmental determinants ofpeople acting on their positive i s health behav-iours, there is an urge to useintentions. This obesogenic c objective measures of the environment, for h example, based on observations or audits. a However, our reviews indicate that associar tions between environments and behaviour a were stronger when subjective, self-report c measures of envi-ronments were used, and t recent research by Giskes et al.26 also indicates e that perceptions of availability and price of r healthful foods are more strongly associ-ated i with food choice than objective availability and z price data. e d b Our reviews also showed that studies that y explored mediating and moderating pathways h between poten-tial motivational, ability-related i and environmental determinants were largely g lacking. Kremers et al.27 posited and presented h preliminary evidence that envi-ronmental a factors may have a direct impact on health v behaviours, but these environmental influences a are likely to be mediated by individual-level i factors, i.e. motivation and ability. For l example, an environment that offers plenty of a opportunities for healthy food choices may b improve motivation to eat a healthy diet and i may improve perceived abilities to eat l i healthily. Kremers et al.27 suggest that the t causal pathway be-tween environments and y health behaviour may be moderated by such a factors as personality, habit strengths and level n of awareness of personal health be-haviours. d For example, habitual behaviours were found a to be triggered by environmental cues without c conscious deliberations.28 c e s s i b i l i t y

Discussion and implications

Promoting healthy nutrition behaviours still relies mostly on health education techniques that try to mo-tivate people to adopt more healthy lifestyles. GPs may importantly contribute to nutrition education dis-cussing nutrition issues with their patients when they

of palatable energy-dense foods, as well as great opportunities to avoid almost any work, trans-port or leisure-time physical activities. Declaration It has therefore been argued that Funding: Financial support from interventions to promote more healthfulthe EC, SP5A-CT-2006-044128 nutrition and physical activity practices shouldHealth-promotion through adopt a health protection paradigm instead ofObesity Pre-vention across the present-day focus on health education. AEurope (HOPE): an integrated health protection approach means a focus onanalysis envi-ronmental changes that help to protect the popula-tion against unhealthy nutrition and lack of physical activity, i.e. environmental changes that would make healthy nutrition and sufficient physical activity more likely or even unavoidable. Interventions to promote healthy eating should ad-dress the most important and changeable determinants of healthy eating. To D promote healthy eating, people should be o motivated to do so, should be confident about w their abilities and should preferably be exposed nl to environments that offer them easy o opportunities. a This health promotion and protection d approach creating environmental e opportunities for healthful be-haviours but also d protecting the population against opportunities fr for unhealthful behaviourshas been o successful in the great achievements in public m health such as the reduction of infectious ht diseases, promotion of traffic safety and tp reducing smoking. In recent years, especially :/ school-based interventions to promote more /f healthful nutrition and/or physical activity a behaviours among children and adolescents have been conducted in which such a more m integral health education and health protection p approach was used, where changes in the ra school or neighbourhood environments were an .o integral part of the intervention approach. x Examples such as the Dutch Do-IT study and f the cross Euro-pean Pro Children study show o that such an integral approach can make r significant changes in health bedj o haviours and contribute to better body 30,31 u composition among young people. r In conclusion, the evidence for the n importance of environmental opportunities for al healthful eating is rather strong for social s. environmental factors but not for physical o environmental influences. This lack of r evidence should not be interpreted as evidence g/ that the physical environment is not important. b Bet-ter designed and focussed studies using more objec-tive and validated measurement y instruments should be conducted to explore the g true associations be-tween environmental u opportunities and nutrition behaviours. e
st

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Am J Public Health 1996; 86: 13941400. 14 Lechner L, Brug J, de Vries H. Misconception of fruit and vegeta-ble consumption: differences between objective and subjective estimation of intake. J Nutr Educ 1997; 29: 313320. 15 Bogers RP, Brug J, van Assema P, Dagnelie PC. Explaining fruit and vegetable consumption: the theory of planned behaviour and misconception of personal intake levels. Appetite 2004; 42: 157166. 16 Giskes K, Kamphuis CB, van Lenthe FJ, Kremers SPJ, Droomers M, Brug J. A systematic review of associations between enviro nment al factor s, energ y and fat intake s amon g adults : is there evide nce for enviro nment s that encou rage obeso genic dietar y intake s? Publi c Healt h Nutr 2007; 10: 1005 1017.
S w i n b u r n B , E g g e r G , R a z a F . D i s s e c ti n g o b e s o g e

to support European health policy. The paper does not necessarily reflect the ECs views and in no way anticipates the future policy of the EC in this area. Ethical approval: None. Conflicts of interest: None.

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