ca n a d i a n j o u r n a l o f public health

Understanding the Forces That Influence

Our Eating Habits

What We Know and Need to Know

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

P U B L I CH E A L T HV O L U M E 9 6 , S U P P L E M E N T 3 �� J U L Y / A U G U S T 2 0 0 5

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

S A N T ÉP U B L I Q U EV O L U M E 9 6 , S U P P L É M E N T 3 �� J U I L L E T / A O Û T 2 0 0 5

Acknowledgements

The development of this supplement was coordinated by Michelle Hooper and Ann Ellis inHealth Canada’s Office of Nutrition Policy and Promotion (ONPP), Health Products andFood 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* wasinstrumental 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 seriesof synthesis papers on the determinants of healthy eating produced for Health Canada. The effort andexpertise 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, RyersonUniversity; “Children and Youth”, Susan Evers, University of Guelph, Mary McKenna, Universityof New Brunswick; “Seniors”, Shanthi Johnson, Acadia University, Heather Keller, University ofGuelph; “Low Income Populations”, Anne-Marie Hamelin, Université Laval, Lynn McIntyre,Dalhousie University, Patricia Williams, Mount Saint Vincent University; “AboriginalPopulations”, 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 BritishColumbia, Patty Pliner, University of Toronto.

• Individuals who provided additional advice and feedback: Helen Brown, Ontario Ministry ofHealth and Long-Term Care; Karen Cooper, Saskatchewan Health; Catherine Freeze, PrinceEdward Island Department of Health and Social Services; Susan Crawford, formerly of theInstitute of Nutrition, Metabolism and Diabetes, Canadian Institutes of Health Research; Erica DiRuggiero, 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 ofthe original papers did not review the summary articles presented in this supplement. All of theauthors are responsible for final content of their article, including errors of fact or interpretation. Theopinions expressed in this publication are those of the authors and do not necessarily reflect the viewsof Health Canada.

This supplement is available on the Canadian Public Health Association’s website at www.cpha.caand 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.

JULY – AUGUST 2005 CANADIAN JOURNAL OF PUBLIC HEALTH S1

CANADIAN JOURNAL OF PUBLIC HEALTH

Table of Contents

Information for Authors

Style requirements for submission ofmanuscripts to the Canadian Journal ofPublic Health can be found at www.cpha.ca

Interested in subscribing to the CJPH?Have you moved or changed your name?

For information on subscribing to the CJPHor to make changes to your membership orsubscription information, please contact theMembership and Subscription Office,[email protected], or 613-725-3769, ext. 118.

www.cpha.ca

Understanding the Forces ThatInfluence Our Eating Habits

What We Know and Need to Know

S4 Foreword from Health CanadaM. Bush

S5 Foreword from the Canadian Institutes of Health ResearchJ. Frank, D. Finegood

S6 PrefaceM. Hooper, S. Kirkpatrick, A. Ellis, B. McIntyre

ORIGINAL ARTICLES

S8 Determinants of Healthy Eating in Canada: An Overview and SynthesisK.D. Raine

S15 Perceptions of Healthy Eating: State of Knowledge and Research GapsM-C. Paquette

S20 Determinants of Healthy Eating in Children and YouthJ.P. Taylor, S. Evers, M. McKenna

S27 Determinants of Healthy Eating in Community-dwelling Elderly PeopleH. Payette, B. Shatenstein

S32 Determinants of Healthy Eating in Aboriginal Peoples in Canada: The CurrentState of Knowledge and Research GapsN.D. Willows

S37 Determinants of Healthy Eating Among Low-income CanadiansE.M. Power

S43 Mental Health and Eating Behaviours: A Bi-directional RelationJ. Polivy, C.P. Herman

S2 CANADIAN JOURNAL OF PUBLIC HEALTH VOLUME 96, SUPPLEMENT 3

EXECUTIVE BOARD

President:Sheilah Sommer, MSc, BScN

Past President:Christina Mills, MD, FRCPC

President-Elect:Ron de Burger, BA, CPH, CPHI(C)

Honorary Secretary:Mary Martin-Smith, RN, BScN

Treasurer:Paul Hanvey, BA, CA

Honorary Legal Counsel:David L.E. Charles, BSc, LLB

Ex officio:PTBA RepresentativeJoan Riemer, BScN

Chief Executive OfficerElinor Wilson, RN, PhD

Honorary Scientific Editor:Patricia Huston, MD, MPH

MEMBERS-AT-LARGE

Ms. Elaine BertheletInternational Health

Dr. Brian BrodieAdministration of Health Services

Dr. Ian GemmillHealth Promotion

Ms. Heather Ann PattulloDisease Surveillance and Control

Dr. Harvey SkinnerEquity and Social Justice

PROVINCIAL/TERRITORIAL BRANCH/ASSOCIATION REPRESENTATIVES

Dr. Minnie WasmeierPresident, Newfoundland and Labrador Public Health Association

Ms. Florence TarrantPresident, Public Health Association of NovaScotia

Ms. Sharon LawlorPresident, New Brunswick/Prince EdwardIsland Branch - CPHA

Dr. Renald BujoldPrésident sortant, Association pour la santépublique du Québec

Ms. Connie UetrechtExecutive Director, Ontario Public HealthAssociation

Mrs. Sue HicksPresident, Manitoba Public Health Association

Ms. Joan ReimerPast President, Saskatchewan Public HealthAssociation

Mr. Robert CampbellPresident, Alberta Public Health Association

Ms. Shannon TurnerPresident, Public Health Association of BritishColumbia

Ms. Jill ChristensenPresident, Northwest Territories/NunavutBranch - CPHA

Ms. Jody Butler WalkerPresident, Yukon Public Health Association

PATRON

Her Excellency the Right HonourableAdrienne Clarkson, CC, CMM, CD

Governor General of Canada

PATRON

His ExcellencyJohn Ralston Saul, CC

CPHA MISSION STATEMENT

The Canadian Public Health Association(CPHA) is a national, independent, not-for-profit, voluntary association representing publichealth in Canada, with links to the internation-al public health community. CPHA’s membersbelieve in universal and equitable access to thebasic conditions which are necessary to achievehealth for all Canadians.

CPHA’s mission is to constitute a specialnational resource in Canada that advocates forthe improvement and maintenance of personaland community health according to the publichealth principles of disease prevention, healthpromotion and protection and healthy publicpolicy.

The Canadian Journal of Public Health con-tributes to CPHA’s mission through the pub-lishing of original articles, reviews and corre-spondence on related aspects of public health.

CANADIAN PUBLIC HEALTH ASSOCIATION

Board of Directors


CANADIAN JOURNAL OF PUBLIC HEALTH

Editorial Offices

All articles published in this journal, including editorials, represent the opinions of the authors and do not necessarily reflect the official policy of theCanadian Public Health Association or the institution with which the author is affiliated, unless this is clearly specified.

The Canadian Journal of Public Health is published every two months by the Canadian Public Health Association. A subscription to theCJPH is included in the Association’s membership fee.

Publications Mail Agreement #40062779. Registration #09853. Return undeliverable Canadian addresses to: CirculationDepartment, Canadian Public Health Association, 1565 Carling Avenue, Suite 400, Ottawa, Ontario, K1Z 8R1, E-mail: [email protected].

Subscription rate: Canada $103.79 per year, including 7% GST ($111.55 per year, including 15% HST), payable in advance; United States$125.00 per year and other countries $161.00 per year payable in advance in Canadian funds. Single copies $21.40 Canadian, including 7%GST ($23.00 Canadian, including 15% HST), $26.00 U.S.A. and $31.00 International. Reprints: Reprints of articles, minimum 50, are avail-able from the business office of the Journal (price on request). Contents may be reproduced only with the prior permission of the EditorialBoard. A maximum of 30 photocopies of articles are permitted with acknowledgement of CJPH.

Changes of address and requests for subscription information should be forwarded to the business office.CJPH is available in microform from University Microfilms International, Ann Arbor, Michigan and is abstracted by ProQuest and EBSCO.Indexed in the Canadian Periodical Index, Index Medicus, and Social Science Citation Index.

SCIENTIFIC EDITORS

Scientific Editor:Patricia Huston, MD, MPH

Associate Editors:Denise Aubé, MD, FRCPClément Beaucage, MD, FRCPReg Warren, MA

STAFF

Executive Managing Editor:Elinor Wilson, RN, PhD

Assistant Editor:Karen Craven

Editorial Assistant:Debbie Buchanan

Designer:Ian Culbert

Circulation:Joan Barbier [email protected]

ISSN 0008-4263

EDITORIAL BOARD

Patricia Huston, MD, MPHScientific Editor

Denise Aubé, MD, FRCP

Clément Beaucage, MD, FRCPAssociate Co-Editors

Elinor Wilson, RN, PhDExecutive Managing Editor

Sheilah Sommer, MSc, BScNChair

Heather Maclean, MDMember-at-Large

Reg Warren, MAMember-at-Large

COVER ILLUSTRATION

Andrew Young

TRANSLATION

Louise Desmarais, MAIsabelle Sirois, MSc, RD

BUSINESS OFFICE / SUBMISSION OF ARTICLES

Canadian Journal of Public Health400-1565 Carling AvenueOttawa, Ontario, Canada K1Z 8R1Telephone: 613-725-3769Fax: 613-725-9826E-mail : [email protected]

All material intended for publication should beaddressed to the Scientific Editor.

ADVERTISING

Karen Craven400-1565 Carling AvenueOttawa, Ontario, Canada K1Z 8R1Telephone: 613-725-3769Fax: 613-725-9826E-mail: [email protected]

Foreword from Health CanadaMary Bush, MSc, RD

The Office of Nutrition Policy andPromotion is pleased to haveenabled the development of this

special supplement. The collection of sevenarticles is the culmination of significanteffort by more than 20 Canadianresearchers in applied nutrition, healthpromotion and population health.

What people eat is influenced by manyfactors, such as economic and social fac-tors, the physical environment, the capaci-ty to make healthy eating choices, time andskills to prepare food, and personal buyingpower. Appropriate action for the promo-tion and support of healthy eating requiresa comprehensive evidence base.

Stakeholders identified the need to syn-thesize the existing evidence regarding thepromotion and support of healthy eatingbefore setting research priorities.1 The orig-inal synthesis papers developed in 2003-2004 and the summary articles in this jour-nal supplement highlight “what we know”and identify knowledge gaps about thedeterminants of eating. This work offers astep forward in enhancing the evidencebase. As the authors point out, the avail-able literature does not support an exami-nation of the complex interactions acrossdeterminants, and there is still much tounderstand. Knowledge developmentefforts in this area need to be supported so

that our policy and program decisions bet-ter address the complexity of factors thatinfluence eating behaviour. Understandingwhich strategies and interventions are mosteffective in promoting and supportinghealthy eating is also an essential compo-nent of a comprehensive evidence base forprogram and policy decisions. However, areview of the effectiveness of interventionswas beyond the scope of the synthesis workundertaken.

The articles in this supplement will beavailable for use by academics, policy-makers and community health profession-als. They provide not only a synthesis ofexisting literature and recommendationsfor research but also a basis for involve-ment in advocating for, or participating in,appropriate research to fill the evidencegaps. Continuing efforts will require part-nerships among policy and program deci-sion makers, practitioners and researchers.It is clear that understanding the under-lying issues that determine eating behaviourwill also require the involvement of otherdisciplines. Efforts by the CanadianInstitutes of Health Research to encourageinterdisciplinary and cross-sector researchprovide hope that research on healthy eat-ing in the context of population health willbe enhanced and will supply a strong plat-form for filling our evidence gaps.

We are at an important moment in timewhen significant efforts are under way,both internationally and across our coun-try, to support healthy living and preventchronic diseases. In many cases, practice isahead of the evidence base as a result of thepressures to take action. There is a need tolearn from practice through appropriateresearch, evaluation and surveillance, andthereby strengthen the evidence base forfuture decisions.

This supplement offers a call to action.In our search for answers, we need to becreative in our approaches. As we look atthe issue of healthy eating within a broadpopulation health framework, we need tochallenge ourselves to consider alternativeand new frameworks, to work across sec-tors and with other disciplines. With acoherent approach and collaborative effortsto strengthen our knowledge base, we willcontribute to improved nutritional healthof Canadians.

REFERENCES

1. Diane McAmmond and Associates. 2001.Promotion and Support of Healthy Eating: AnInitial Overview of Knowledge and Research Needs:Summary Report, March 2001. Available on-lineat http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/promotion_support_healthy_eating_e.html

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



Foreword from the CanadianInstitutes of Health Research*

John Frank, MD, CCFP, MSc, FRCPC1

Diane Finegood, PhD2

Given the worldwide attention tothe dramatic increases in over-weight and obesity, this special

supplement on healthy eating comes at avery opportune time. Healthy eating notonly plays a role in the prevention andcontrol of chronic disease but is also a keydeterminant of human health and develop-ment throughout the life course. A com-prehensive research agenda on healthy eat-ing and mechanisms to facilitate collabora-tive problem solving across disciplines andsectors are urgently needed in Canada toadvance our knowledge base on the deter-minants of healthy eating. While the focushas largely been at the individual level(e.g., knowledge of Canada’s Food Guide toHealthy Eating), we need also to furtherunderstand the social, cultural and envi-ronmental determinants of healthy eatingthat operate at the community/neighbour-hood, regional, national/provincial/territo-rial levels and in whole societies. Theseinclude, for example, the impact of global-ization and how it affects our food supply,and barriers to accessing affordable andpersonally acceptable food. This evidencebase is also needed to inform the policiesand programs that have a significant effecton the health and lives of all Canadians,regardless of their income, education orethnicity, or of the places in which theywork, live, play and learn.

The Institute of Population and PublicHealth (IPPH) of the Canadian Institutesof Health Research (CIHR) supportsresearch to further our understanding ofthe determinants of human health at theindividual and population levels on thebasis of the bio-psycho-social factors thatinfluence health and well-being over the

life course.1 As the pre-eminent epidemiol-ogist of our time, Geoffrey Rose, pointedout some 15 years ago, it is only by directlyunderstanding and tackling the “upstreamforces” that are shifting entire populations’distributions of risk factors in anunfavourable way that we can expect tomake a significant impact on these healthproblems,2 through a strengthened publichealth infrastructure working in concertwith other sectors. IPPH is most concernedwith population-level and community-level intervention research to understandand effectively address the underlying drivers affecting the health of populations.

The CIHR Institute of Nutrition,Metabolism and Diabetes (INMD) hasidentified obesity and maintenance ofhealthy body weight as its number onestrategic priority.3 Obesity and overweighthave been called the fastest growing epi-demic of our time, but the good news isthat they are potentially reversible. Manylevels of government and non-governmentalorganizations, such as the Chronic DiseasePrevention Alliance of Canada, have calledfor multi-sectoral approaches to combatthis significant health problem, its under-lying risk factors and their determinants.However, in some instances, the evidencebase for intervention effectiveness is weak.In other words, we cannot yet point to amenu of proven, cost-effective policy andprogram interventions that can be readilyimplemented in the Canadian context tochange or modify the socio-cultural andenvironmental factors that truly influencethis critical aspect of our health.4 At thecore of this challenge is the need to under-stand the relative contribution ofunhealthy eating habits versus that of other

risk factors, such as physical inactivity,and, more important, which strategic mixof interventions can make a difference topreventing and controlling overweight, aswell as other common risk factors forchronic diseases. In collaboration withpartners, including the Heart and StrokeFoundation of Canada, the CanadianDiabetes Association, the Public HealthAgency of Canada and Health Canada,INMD is increasing our capacity and seek-ing solutions to this complex problem.

In summary, the insights gained fromthis supplement are intended to contributetowards advancing a relevant researchagenda on healthy eating, a key foundationto support evidence-based community pro-grams and healthy public policies. CIHRlooks forward to continuing our work withHealth Canada’s Office of NutritionPolicy and Promotion, the new PublicHealth Agency of Canada, and other keyactors, towards this end.

REFERENCES

1. Canadian Institutes of Health Research –Institute of Population and Public Health(CIHR-IPPH). Mapping and Tapping theWellsprings of Health: Strategic Plan 2002-2007,August 2002.

2. Rose GA. The Strategy of Preventive Medicine.New York: Oxford University Press, 1992.

3. Canadian Institutes of Health Research –Institute of Nutrition, Metabolism and Diabetes(CIHR-INMD). Strategic Plan 2004-06: TheWay Forward, 2004.

4. Smedley BD, Syme SL. Promoting Health:Intervention Strategies from Social and BehavioralResearch. Washington, DC: Institute ofMedicine, National Academy Press, 2000.

1. Scientific Director, Institute of Population and Public Health2. 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.


PrefaceMichelle Hooper, MSc1

Sharon Kirkpatrick, MHSc, RD2

Ann Ellis, MSc, RD1

Brenda McIntyre, MHSc3

Healthy eating is a critical contributor to overall health at every stage of develop-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. Promotinghealthy eating for all Canadians requires a better understanding of these factors and theirinteractions. Currently, significant knowledge gaps exist in our evidence base to supportpolicy and program development. This supplement of the Canadian Journal of PublicHealth provides a collection of summary articles highlighting key findings from a series ofsynthesis papers on the determinants of healthy eating recently completed for HealthCanada’s Office of Nutrition Policy and Promotion (ONPP).

BackgroundIn 2003-2004, a project was undertaken to synthesize the literature on determinants ofhealthy eating. This project grew out of recommendations from an overview of key knowl-edge gaps for promotion and support of healthy eating undertaken in 2001. Through thesynthesis of information provided by more than 50 key informants, important knowledgegaps and research needs with respect to determinants of healthy eating and the effectivenessof interventions to promote healthy eating were identified.1 Key informants specificallypointed to the need to consolidate, synthesize and disseminate what is already known inthese areas. This was considered necessary for the development of research agendas, to pro-vide a base of information to help inform policy and funding decisions, and to supportapplication and evaluation of best practices.

Scope of the synthesis papersNutrition for Health: An Agenda for Action, Canada’s national plan of action on nutrition,considers the multiple factors that influence healthy eating and nutritional health withinthe Framework for Population Health.2 This Framework, which recognizes that both indi-vidual and collective factors affect health and that these factors interact, provided the foun-dation for the synthesis papers (see Figure 1). “Healthy eating” was defined as “eating prac-tices and behaviours that are consistent with improving, maintaining, and/or enhancinghealth”. The original papers i) summarize the published literature on individual and collec-tive determinants of healthy eating, ii) highlight gaps in knowledge about the determinantsand iii) recommend areas for research to address the identified gaps. While it is essential tounderstand that policies and programs are the foundations for action in promoting andsupporting healthy eating, critically reviewing the available evidence on their role wasbeyond the scope of this project.

Various approaches were considered for the selection of topics for the synthesis papers.The goal was to select a feasible approach that would have the greatest potential foradvancing knowledge of the determinants of healthy eating. Ultimately, the papers wereoriented by life stage and/or sub-population in an effort to facilitate identification of inter-relations between determinants – a key principle of population health. This approach wasconsistent with the findings from the key informant survey, which concluded that knowl-

edge gaps are probably best addressedthrough research directed to specific popu-lations. In addition to children and adoles-cents, seniors, and Aboriginal peoples, theissues of food insecurity and healthyweights were considered priorities regard-ing the promotion and support of healthyeating.

Building on these priority areas, as wellas specific program needs, the synthesispapers focussed on the following topics:children and youth; seniors; Aboriginalpopulations;* low-income populations;perceptions of healthy eating; and the bi-directional relation between mental healthand eating behaviours. At the time thiswork was initiated, a synthesis of the litera-ture related to healthy weights was underway through a process led by the CanadianPopulation Health Initiative (CPHI) ofthe Canadian Institute for HealthInformation (CIHI).† This topic was not,therefore, pursued in this series of synthe-sis papers.

The original synthesis papers were writ-ten by Canadian researchers in appliednutrition, health promotion, and/or popu-lation health, with particular expertise inthe chosen topic areas. Outlines and draftversions of each of the papers were critical-ly reviewed by two to three peer reviewers,as well as the Health Canada project man-agers. In total, 22 Canadian researcherswere involved as authors or reviewers ofthe original synthesis papers.

The synthesisThe methods employed to select and criti-cally review the literature are described ineach of the papers. Generally, the authorssearched relevant electronic databases andhand-searched key journals, covering liter-ature published in the 10 to 15 years pre-ceding 2004. The literature in English andFrench was reviewed. Literature fromcountries other than Canada was included,but the authors were asked to consider theapplicability of the findings from interna-tional sources to the Canadian context. Onthe basis of the literature synthesis, knowl-

1. Office of Nutrition Policy and Promotion, Health Products and Food Branch, Health Canada2. PhD Candidate, Department of Nutritional Sciences, Faculty of Medicine, University of Toronto3. Community Programs Directorate, First Nations and Inuit Health Branch, Health Canada

* Development of the synthesis paper on determi-nants of healthy eating among AboriginalCanadians was undertaken in collaboration withCommunity Programs Directorate, First Nationsand Inuit Health Branch, Health Canada.

† Overweight and Obesity in Canada: APopulation Health Perspective (CanadianInstitute for Health Information, 2004) is a prin-cipal product of this work.


PREFACE

edge gaps and directions for furtherresearch were identified.

OverviewWith the exception of the first article byDr. Kim Raine, the articles in this supple-ment represent summaries of the originalsynthesis papers completed for the ONPP.The article by Dr. Raine provides anoverview of the complex set of interactionsamong the determinants of healthy eating.Dr. Raine synthesizes key findings fromthe original synthesis papers and considersimplications for healthy public policy.

The next article focusses on the percep-tions of healthy eating. Dr. Marie-ClaudePaquette builds on theoretical models sug-gesting that individuals’ ideals and assump-tions about food are key determinants offood choice.

The third and fourth articles considerdeterminants of healthy eating of particularrelevance to two life-stage groups. Drs.Jennifer Taylor, Susan Evers and MaryMcKenna look at the factors that influencehealthy eating in children and youth, andDrs. Hélène Payette and Bryna Shatensteinsynthesize the key determinants of healthyeating among community-dwelling elderlypeople.

Dr. Noreen Willows’ paper follows, witha focus on Canada’s Aboriginal popula-tions.

Building on sociological theory, Dr.Elaine Power considers the determinants ofhealthy eating among low-incomeCanadians, including factors related tosocio-economic gradients in eating patterns,food insecurity and inequalities in diet.

The final paper in the supplement, byDrs. Janet Polivy and C. Peter Herman,focusses on the bi-directional relationbetween mental health and eating behav-iours.

Each of the papers summarizes the exist-ing literature, identifies gaps in knowledgeand offers recommendations for research toenhance the evidence base on the determi-nants of healthy eating relative to the par-ticular topic discussed. Collectively, theresearch recommendations presented inthis supplement will be an important com-ponent of further efforts to build andimplement a broader strategy for enhanc-ing the evidence base for promoting andsupporting healthy eating in Canada.

REFERENCES

1. McAmmond D and Associates. Promotion andSupport of Healthy Eating: An Initial Overview ofKnowledge and Research Needs: Summary Report.March 2001. Available on-line at http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/promotion_support_healthy_eating_e.html.

2. Joint Steering Committee Responsible forDevelopment of a National Nutrition Plan forCanada. Nutrition for Health: An Agenda forAction. 1996.

3. Federal/Provincial/Territorial AdvisoryCommittee on Population Health. Strategies forPopulation Health: Investing in the Health ofCanadians. Prepared for the Meeting of Ministersof Health in Halifax, Nova Scotia, September 14-15, 1994.

Figure 1. Framework for Population Health3

Individualfactors

and

Collectivefactors

Foundations for actionTools and supports

Research, information and public policy

Populationhealth status

Determinants of health

Personalhealth practices

Individualcapacity andcoping skills

Social and economicenvironment

Physicalenvironment

Health services


Determinants of Healthy Eatingin CanadaAn Overview and Synthesis

Kim D. Raine, PhD, RD

ABSTRACT

This article uses a population health perspective to examine the complex set ofinteractions among the determinants of healthy eating. An overview of current knowledgeon determinants of healthy eating was organized as follows: 1) individual determinants ofpersonal food choices and 2) collective determinants, including a) environmentaldeterminants as the context for eating behaviours and b) public policies as creatingsupportive environments for healthy eating. A conceptual synthesis of the literaturerevealed that individual determinants of personal food choice (physiological state, foodpreferences, nutritional knowledge, perceptions of healthy eating and psychologicalfactors) are necessary, but not sufficient, to explain eating behaviour, which is highlycontextual. Collective determinants of eating behaviour include a wide range of contextualfactors, such as the interpersonal environment created by family and peers, the physicalenvironment, which determines food availability and accessibility, the economicenvironment, in which food is a commodity to be marketed for profit, and the socialenvironment, in which social status (income, education and gender) and cultural milieuare determinants of healthy eating that may be working “invisibly” to structure foodchoice. Policy is a powerful means of mediating multiple environments. There are gaps inour understanding of the process of intervening in macro-level environments and theimpact of such interventions on the promotion of healthy eating. Collective determinantsof food choice and policy contexts for promoting healthy eating, therefore, requireinvestment in research. Applying a population health promotion lens to understanding themultiple contexts influencing healthy eating provides insight into prioritizing research andaction strategies for the promotion of healthy eating.

MeSH terms: Nutrition; health promotion; public health; social environment; populationpolicy

The promotion of healthy eating inCanada has significant implicationsfor improving the health of popula-

tions, locally and globally. For example,the current epidemic of obesity, in Canadaand worldwide, is associated with changingeating (and activity) patterns and has sig-nificant public health implications.1

Promoting and supporting healthy eatingamong Canadians, however, requires acomprehensive understanding of the mul-tiple influences on eating behaviour andthe interactions among these determinants.

This paper will provide 1) an overviewof determinants of healthy eating by syn-thesizing the current state of knowledgehighlighted in the six individual articles onthe determinants of healthy eating in thissupplement, and 2) recommendations forresearch to promote healthy eating basedupon identified gaps in knowledge. Thesynthesis and recommendations will beplaced within the context of populationhealth promotion (PHP). “The PHPmodel draws on a population healthapproach by showing that, in order toimprove the health of the people, actionmust be taken on the full range of healthdeterminants. The model draws on healthpromotion by showing that comprehen-sive action strategies are needed to influ-ence the underlying factors and conditionsthat determine health.”2

A population health perspective examinesthe complex set of interactions among therange of individual (biological, behavioural)and collective (social, cultural, physical, eco-nomic and political) determinants of health.Applying a population health promotionlens to understanding the multiple contextsinfluencing healthy eating provides insightinto potential means of promoting healthyeating through a wide variety of actionstrategies that focus on entire populations.Population health promotion is consistentwith ecological approaches for multilevelpublic health strategies to promote healthylifestyles.3,4 Ecological approaches can helpto organize strategies that work both to helpindividuals adopt healthy lifestyles and toinfluence policy in order to create opportu-nities for social and cultural change.Strategies can be categorized by their pre-dominant focus at the following ecologicallevels: individual or intrapersonal (individ-ual knowledge, attitudes and behaviour);interpersonal (family and peers); institu-tional (schools, worksites); community

Centre for Health Promotion Studies, University of AlbertaCorrespondence and reprint requests: Kim D. Raine, 5-10 University Extension Centre, 8303 112Street, University of Alberta, Edmonton, AB T5G 2T4, Tel: 780-492-9415, Fax: 780-492-9579, E-mail:[email protected]


OVERVIEW AND SYNTHESIS

(interagency and intersectoral) and publicpolicy.3 Ecological levels are not discrete butare interconnected.

For the purpose of this overview, deter-minants of healthy eating and their impli-cations for health promotion action strate-gies will be organized as follows: 1) indi-vidual determinants of personal foodchoices and 2) collective determinants,including a) environmental determinantsas the context for eating behaviours, and b) public policies as promoting environ-ments for healthy eating. This organizingstrategy is not meant to artificially separatethose determinants of healthy eating thatare intimately connected but, rather, toassist the reader in understanding the cur-rent state of knowledge of determinants ofhealthy eating and to assist in prioritizingaction strategies for the promotion ofhealthy eating, as well as to identify gapsfor further research.

Personal food choices: Individualdeterminants of eating behaviourAt first blush, what determines one’s eatingbehaviour, healthy or otherwise, appears tobe purely a matter of personal choice. Afterall, for the majority of the free-living popu-lation, the act of putting food into one’smouth is an individual act. Yet, personalfood choices are structured by a variety ofindividual and collective determinants ofbehaviour. This section focusses on indi-vidual determinants, ranging from one’sphysiological state, food preferences, nutri-tional knowledge, perceptions of healthyeating and psychological factors.

Physiological InfluencesAt both ends of life, physiological develop-ment5 or deterioration with aging6 influ-ence eating behaviour. Throughout child-hood, dietary quality appears to decreasewith age. This is perhaps a function ofemotional and social development thatprovides children with more control overfood choice and thus is influenced by otherindividual determinants, such as food pref-erences and nutritional knowledge.5 Withaging, health status and functional abilitiesinfluence food-related behaviours.7-9 Yet,changes to physiological health status arenot beyond intervention, as communityresources that provide assistance canenhance seniors’ abilities to procure andprepare an adequate diet.10-12

Food PreferencesAlthough food preferences are highly indi-vidual and may indeed have physiologicalorigins (such as innate preferences forsweet and aversions for bitter tastes), socialand cultural norms also determine rangesof food preferences. For example,Aboriginal peoples report preferences fortraditional foods.14-20 In children, foodpreferences are more likely guided by tastealone,13 whereas external factors (such asenvironmental cues) contribute more toadult preferences. From a health perspec-tive, preferences for sweet foods are com-mon in children but diminish with age,and preferences for high-fat foodsendure.13 The physiological “anorexia ofaging”21,22 is associated with impaired tasteand smell as well as metabolic changesaccompanying aging.

Nutritional KnowledgeChildren and adolescents have been shownto demonstrate a general understanding ofthe connections between food choice andhealth.23,24 However, Taylor’s review of theresearch does not consistently show thatknowledge influences food choices in theseage groups.5 Among seniors, high aware-ness of nutrition and health is associatedwith better food and nutrient intakes.25-29

In the adult population, nutritional knowl-edge is intertwined with perceptions ofhealthy eating.

Perceptions of Healthy Eating“Perceptions of healthy eating” are definedby Paquette30 as the “public’s … meanings,understandings, views, attitudes and beliefsabout healthy eating, eating for health, andhealthy foods.” (pg. S15) Theoretical mod-els suggest that key determinants of foodchoice are individuals’ ideals and theirassumptions about food,31,32 which wouldinclude perceptions of healthy eating.

The public’s perceptions of healthy eat-ing include consumption of vegetables,fruits and meat; limitations of sugar, fatand salt; and variety and moderation.30

These elements seem to be influenced bycurrent dietary guidance aimed to improvenutritional knowledge and eating habits.However, other important elements ofdietary guidance not generally included inpeople’s perceptions of healthy eatinginclude consumption of grain productsand milk products. Non-nutritional ele-

ments that seem central to people’s percep-tions of healthy eating include the impor-tance of freshness, unprocessed and home-made foods, and the concept of balance.30

Perceptions of healthy eating are embed-ded within cultural meanings of food andhealth. For example, Willows’ review33

reveals that “food choices based onAboriginal cultural values may not be con-gruent with Western scientific constructsregarding the nutritional value of food.”(pg. S34) If traditional food is necessaryfor survival, it is by its very nature health-promoting. The concept that any food,including “store food”, may not contributeto health is, therefore, culturally foreignand difficult to grasp.33

Psychological FactorsPolivy and Herman’s review34 highlightsthat “individual psychological factors thataffect eating include personality traits suchas self-esteem, body image and restrainedeating (chronic dieting), as well as moodand focus of attention.” (pg. S44) Theauthors appropriately point out that thereis a bi-directional relation between eatingand psychological states, in that not onlydo psychological factors affect our foodchoices, but our food choices affect ourpsychological well-being.34

Despite a significant level of researchinto psychosocial influences on healthyeating for both children and adults overthe past decade, the ability of various mod-els of psychosocial variables (e.g., theTheory of Planned Behaviour, SocialCognitive Theory, TranstheoreticalModel) to predict individual dietary intakeremains low.35 Increasingly, these modelsare being refined and expanded to captureaspects of environmental influences onbehaviour, including healthy eating.

Summary of Individual Determinantsof Healthy EatingPersonal food choices are structured by avariety of individual determinants ofbehaviour, ranging from one’s physiologi-cal state, food preferences, nutritionalknowledge, perceptions of healthy eatingand psychological factors. However, indi-vidual determinants are necessary, but notsufficient, to explain eating behaviour.Healthy eating is much more complicatedthan personal choice, as eating behaviour ishighly contextual.



Collective determinants, Part 1:Environmental determinants ofhealthy eating as context for individual behaviourThe term “environment” will be used hereto describe a wide range of contextual fac-tors influencing eating behaviour.Environment may be intimate and local,such as the interpersonal environment cre-ated by family and peers. Alternately, envi-ronment may be further removed fromone’s immediate awareness and control,such as the physical environment thatdetermines food availability and accessibili-ty; the economic environment, in whichfood is a commodity to be marketed forprofit; and the social environment, inwhich social status and cultural milieu aredeterminants of healthy eating that may beworking “invisibly” to structure foodchoice. This section will attempt to makemore visible what is known about environ-mental determinants of healthy eating andthe interactions among these environ-ments.

Interpersonal Influences on HealthyEatingFamily provides an important context forchildren’s food choices, as family providesthe first and immediate social environmentin which children learn and practise dietarypatterns.36,37 Family can have both positiveand negative effects on eating patterns forall ages of family members. For example,Polivy and Herman’s review34 revealed that“family…contributes to disturbed eatingbehaviours and eating disorders, increasedconsumption in overweight children, andamounts of fruit and vegetables consumed.”(pg. S45) Family food provisioning, or howthe available food is distributed within afamily, is often influenced by gender, withmothers sacrificing their own food intaketo protect their children from hunger whenfood supplies are scarce.38 As children age,familial effects take less precedence associal encounters outside the familyincrease.39 Throughout life, the effect ofpeers and others on eating behaviour, par-ticularly the presence of others during aneating episode, may function through aninfluence on perceived consumptionnorms.34 In seniors, social isolation appearsto have a negative impact on food intake,particularly among men.6 Family food pro-visioning strategies, gender differences in

eating patterns in response to social isola-tion, and influences of social contacts out-side of the family are indications of fami-lies’ embeddedness in the broader socialenvironment. This will be explored inmore detail in a subsequent section.

Physical Environment as aDeterminant of Healthy EatingThe physical environment refers to thatwhich determines what food is available forconsumption and access to that food.Obviously, if healthy food is neither avail-able nor accessible, the potential forhealthy eating is compromised. Althoughthe Canadian food supply is plentiful, asevidenced by ecological food disappearancedata,40 the nutritional quality of the avail-able food supply is unknown. Do the foodsin Canada, in the quantities available, con-stitute a national food “basket” that is con-sistent with dietary guidance and nutri-tional recommendations? The ways inwhich food is produced, transported, dis-tributed (to markets or through charitableorganizations), procured from the land ormarkets, and purchased from food servicelocations in communities, worksites andschools vary significantly in a country asgeographically and culturally diverse asCanada.

The role of the physical environment ismost profound and evident in remote ornorthern communities, primarily occupiedby Aboriginal peoples. As Willowsreviews,33 changes in the physical environ-ment associated with technological devel-opment (e.g., hydroelectric dams, defor-estation), including environmental conta-mination, have reduced the availability oftraditional foods. Substitution of marketfoods has not necessarily enhanced theavailability of nutritious foods, as hightransport cost and spoilage have often ledto ready availability of less nutritious, non-perishable foods (e.g., soda, potato chips).The interconnection of the physical envi-ronment with the economic environmentis evident, since store managers’ stockmanagement practices may be determi-nants of food availability.33

The role of the physical environment indetermining healthy eating is less immedi-ately apparent in urban populations.However, the role of the built physicalenvironment becomes more obvious if oneconsiders that the supermarkets offering

inexpensive healthy foods may be lessaccessible in low-income communities38

and near seniors’ housing.6 Most largesupermarkets are located near major trans-portation routes that assume automobileaccess. Also, food service operations offer-ing less healthy alternatives are ubiquitousin most urban areas, with particularly highaccessibility in lower-income neighbour-hoods.41 As low income appears to be acommon denominator in physical access,the interconnection of the physical envi-ronment with the economic environmentis clear.

Even in unique “bounded” physicalenvironments, such as schools, the avail-ability of food low in nutrient density ver-sus healthier food is likely to influencefood choice.5 Promoting healthy food poli-cies in schools, including approved menusfor school meals and student stores, guide-lines for bag lunches and healthier choicesfor fundraising, has implications for thepromotion of healthy eating through thecreation of supportive environments.42

Herein lies an example of the complexitiesof the interconnections among determi-nants, as school food policies to promotehealthy eating may be in conflict with theneed to generate revenue, as will be dis-cussed further in the economic environ-ment section.

Another area in which social, economicand physical environments intersect explic-itly is in the charitable food distributionsystem in Canada, primarily through foodbanks. Given that food banks have becomeinstitutionalized in Canada,43 they havebecome one channel through which low-income Canadians access food regularly, atleast for a portion of their total diet, andtherefore constitute a “physical environ-ment”. One Canadian study on the nutri-tional quality of foods available from foodbanks suggests that access and availabilityof healthy food may be compromised forthis population.44

Economic Environment as aDeterminant of Healthy EatingThe economic environment, in which foodis a commodity to be marketed for profit,has major implications for eating practicesin a market-based economy such asCanada. Increasingly, the food industrytargets marketing messages at young chil-dren, perhaps in recognition of their vul-

nerability to such messages associated withan underdeveloped critical consumer con-science. As well as children’s reduced criti-cal thinking abilities, marketers recognizethe strong influence children and youthhave on the purchasing patterns of care-givers and the large disposable income ofcurrent children and youth.45 As Taylorreviews,5 from a very young age, childrenare bombarded with media messagesthrough television advertisements, the bulkof which promote a diet high in fat andsugar, and lower in fruits and vegetables.Exposure to advertisements influencesindividual determinants of healthy eatingsuch as food preferences and perceptions ofhealthy eating that give priority to distort-ed nutritional messages designed to sellindividual products, not promote a totaldiet.5 Adults are not immune to influencefrom media.34

Marketing food, however, transcendspersuasive advertising to include the pro-motion of less healthy foods in physicalenvironments (school, worksites). The pro-liferation of soft-drink vending in schoolsis a prime example of this interconnectionof the physical and economic environ-ments. Although soft-drink vending is notcommonplace in Canadian elementaryschools, it is almost universal in highschools, and many university campuseshave entered into exclusive contracts withsoft drink manufacturers for exclusive“pouring rights” assumed to engenderbrand loyalty.46 As Power eloquentlyargues in her review,38 the food industry’sprimary logic is to make profit, which isoften in conflict with the promotion ofhealthy eating.47,48 The food industry,through its marketing practices, has a sig-nificant influence on the ways in whichsocial norms around eating are shaped. Assuch, the economic environment intersectswith the social environment as a determi-nant of healthy eating.

Point-of-choice nutrition education infood retail and service operations has beenused extensively, in partnership with thefood industry, with variable success rates inmotivating healthy choices.49 Pricingstrategies have also been used to promotehealthy food choices. Evaluation of com-bined nutrition messages with price reduc-tions suggests that price decreases may be amore powerful means than health messagesof increasing consumption of healthy

foods.50 Thus, this is a strong point forsubsidization strategies. Examined critical-ly, however, one must recognize that suchprograms are likely to be accepted by thefood industry only if they prove to be prof-itable. Public policy, to be discussed in alater section, is a potential means of medi-ating corporate-driven economic intereststo create a social environment more sup-portive of healthy food choices.

Within Canada, research consistentlydemonstrates that “the most importantbarrier to healthy eating is inadequateincome.”38 (pg. S39) Income is a determi-nant of healthy eating that transcends sev-eral social groups, notably children,5 seniorsand Aboriginal peoples. In a market-based economy, those with inadequateincome to purchase a healthy diet for myri-ad reasons, including inadequate welfarerates, minimum wage, or higher costs ofhealthier foods and diets, are unable tofully participate as consumers. Enhancingindividual determinants, such as nutrition-al knowledge, may provide some copingskills, but as Power’s review clearly demon-strates,38 most low-income Canadiansdemonstrate significant resourcefulnessand “buy more nutrients for their fooddollar than higher income households.”(pg. S39)

Community initiatives to promotehealthy eating, such as food policy coun-cils, have been developed as models forinfluencing the physical and economicdeterminants of healthy eating by provid-ing ready access to a variety of nutritious,affordable foods. For example, originallydeveloped in response to the need of low-income city dwellers, the Toronto FoodPolicy Council (TFPC) of the TorontoBoard of Health was developed in 1990.The TFPC is a unique organization withmembership from large food corporations,conventional and organic farms, coopera-tives, unions, social justice and faithgroups, and City Council. As such, there isa commitment to a common goal by avariety of stakeholders at the communitylevel and beyond. The Council supportsprograms, such as Field to Table, that con-nect low-income inner city residents withfarmers in need of a market for their pro-duce, as well as rooftop and communitygardens. The TFPC’s local action is “bal-anced by longer-term efforts to developpolicies at the municipal and provincial

level that will support Ontario farmers andprovide quality, environmentally-sound,nutritious food to the people ofToronto”.51 There is a need for research todetermine whether community approachesto address economic determinants ofhealthy eating are workable in a variety ofCanadian contexts, have an impact onfood and eating practices at the populationlevel, influence population-level policiesthat promote supportive environments forhealthy eating, and ultimately influencepopulation health status.

Social Environment as a Determinantof Healthy EatingThe previous sections make clear that foodand eating have meaning far beyond physi-cal and emotional nourishment. Eating is asocially constructed act that is embeddednot only in individual perspectives ofhealthy eating drawn from dietary guid-ance and marketing of products but also inphysical and economic environments thatdetermine what food is available to us andat what cost. Food and eating also havesocial, cultural and symbolic functions;food and feeding can signify a sense ofbelonging, caring and community.52,53 Oursocial context and culture is often “invisi-ble” to us, as our immersion in our socio-cultural context assures a “taken-for-grantedness” of our day-to-day experiences.Increasingly, we live in a social environ-ment that disconnects us from the sourceof our food: food comes from supermar-kets and restaurants, not farms and theland or sea. Our social context devalues thepreparation of food in the home and pro-motes quick and easy meals from the freez-er. The time investment in sharing meals isless significant than the time saved bydrive-through or take-out.45 Yet, we con-tinue to celebrate life and traditionsthrough sharing food, since food and eat-ing have strong social dimensions.

Our understanding of culture isenhanced by examining that which is cul-turally foreign to us. For example, asWillows33 states, “Of importance to under-standing the role that culture plays indetermining food choice in Aboriginalcommunities is that the activities requiredto procure traditional food are not merelya way of obtaining food but, rather, amode of production that sustains socialrelationships and distinctive cultural char-



acteristics.” (pg. S33) Juxtaposed againstmainstream Canadian culture, which, aspreviously described, includes a strongsocial dimension to food and eating, thevalue of food in sustaining social relation-ships and cultural characteristics is not for-eign at all.

The question that we face is, have wefreely chosen our cultural destiny or havewe allowed our “choices” to be dictated byinterests inconsistent with the promotionof health? If, as Power argues,38 “one of theconditions for improving the food prac-tices of… Canadians is an improvement inthe dominant food culture and foodnorms, then it will be important to charac-terize food cultures and food norms in thiscountry, plus the most effective means ofshifting them.” (pg. S40) Examining foodpractices through a broad policy lens is onemeans of assessing the potential for creat-ing a cultural context and supportive socialenvironment for the promotion of healthyeating.

Collective determinants, Part 2:Creating supportive environments for healthy eating through healthypublic policyPolicies define what is considered impor-tant and guide our choices. Individualsmay have implicit personal food policiesand make choices according to family pref-erences, nutritional value, cost, environ-mental sustainability, religious or numer-ous other reasons. Policies at the local,regional and national level can have a sig-nificant impact on our collective foodchoices and thus act as determinants ofhealthy eating. The capacity to make large-scale macrosystem changes in the socialenvironment to promote healthy eating is,in part, dependent upon political will.

Some of the less controversial and well-established policy approaches to the pro-motion of healthy eating deal with dietaryguidance and attempt to work throughimproving nutritional knowledge and per-ceptions of healthy eating. Health Canadapromotes the health and well-being ofCanadians by collaboratively defining, pro-moting and implementing evidence-basednutrition policies and standards in docu-ments such as Canada’s Food Guide toHealthy Eating54 and Canada’s Guidelinesfor Healthy Eating.55 These documentsunderpin nutrition and health policies, and

standards and programs across the country,and they serve as a basis for a wide varietyof healthy living initiatives. The nationalplan of action on nutrition, Nutrition forHealth: An Agenda for Action (1996)56

builds on the population health model andsets out strategic directions to encouragepolicy and program development that iscoordinated, intersectoral, supports newand existing partnerships, promotes theefficient use of limited resources andencourages relevant research to improvethe nutritional health of Canadians.

In a physical environment context, poli-cies that protect the food supply throughprotection of the natural environment,such as preventing industrial contamina-tion of food and water, have potentialmacro-level impacts on opportunities forhealthy eating. Agricultural policies inter-sect with economic policies in influencingthe availability of a safe, nutritious andaffordable food supply.

Given the evidence linking lower socio-economic status and social inequity topoorer diet and nutritional status, policiesthat redistribute income and provide asocial safety net (income taxes, provincialhealth care taxes) act to promote health.Protecting and rebuilding Canada’s socialsafety net may hold promise for promotinghealthy eating. Specific policies, such asmonitoring income support to ensure thatit is adequate to purchase the componentsof a healthy diet, as recommended inNutrition for Health: An Agenda for Action(1996),56 may also influence healthy eat-ing.

In the context of a “consumer culture”,policies provide protection to consumersby counterbalancing prevailing marketingmotivated by profit, not health. For exam-ple, taxation policies could subsidize thecost of low-energy, nutrient-dense foodwith taxes of sufficient magnitude to affectsales of high-energy, low-nutrient densefoods.57 These potential policy levers pro-mote healthy eating through a changedprice structure for food that favours pur-chase of more nutritious choices.58

Taxation has been successfully used insome jurisdictions as a disincentive forsnack food purchase59 or a means to gener-ate revenue for health promotion.60 It hasbeen noted that Canada’s GST/HST sys-tem provides a potential model for achanged price structure for food.41 There

remains much research to be done on thepublic acceptability of such policies, andon the level of taxation or subsidizationnecessary to motivate changes in consumerbehaviour.

Similarly, given the extent of exposure tofood advertising, the majority of which isfor foods of lower nutritional quality,restrictions on advertising may holdpromise as a policy lever. Given the poten-tial opposition to restrictive advertising bycorporations and civil libertarians, it isimportant to recognize that public supportfor such policy change is essential for suc-cess.59 Research is needed to evaluate theimpact on healthy eating of current adver-tising restrictions, such as Quebec’s restric-tions on advertising to children.61 The roleof media literacy training to promote resis-tance to advertisements also requires inves-tigation. For both taxation and advertising,learning from successes in tobacco reduc-tion is recommended, including takinginto account the differences betweentobacco and food products. Again, theprocess of intervening in macro-level envi-ronments and the impact of such interven-tions on the promotion of healthy eatingrequire significant investment in research.

Policy is a powerful means of mediatingmultiple environments. Dietary guidancemediates an environment of multiple, con-flicting food and nutritional messages tocreate an environment for informed indi-vidual choice. Environmental protectionpolicies can mediate the effects of industryon the physical environment by protectingthe food supply. Economic policies canmediate food affordability. Social policycan mediate corporate-driven economicinterests, support disadvantaged Canadiansto become self-sufficient, and can mediatea culture of food consumerism to create acultural context and supportive social envi-ronment for the promotion of healthy eat-ing.

SUMMARY AND CONCLUSIONS

This paper used a population health per-spective to examine the complex set ofinteractions among the determinants ofhealthy eating. Although determinants ofhealthy eating are intimately connected,for clarity of understanding the synthesisof current knowledge on determinants ofhealthy eating was organized as follows:





1) individual determinants of personalfood choices, 2) collective determinants,including a) environmental determinantsas the context for eating behaviours and b) public policies as creating supportiveenvironments for healthy eating.Individual determinants of personal foodchoice, including physiological state, foodpreferences, nutritional knowledge, percep-tions of healthy eating and psychologicalfactors, are not sufficient to explain eatingbehaviour, which is highly contextual.Collective determinants of eating behav-iour include a wide range of contextual fac-tors, such as the interpersonal environmentcreated by family and peers, the physicalenvironment, which determines food avail-ability and accessibility, the economicenvironment, in which food is a commodi-ty to be marketed for profit, and the socialenvironment. Within the social environ-ment, social status (income, education andgender) and cultural milieu are determi-nants of healthy eating that may be work-ing “invisibly” to structure food choice.Policy is a powerful means of mediatingmultiple environments.

This overview and synthesis of determi-nants of healthy eating reveals basic infor-mation gaps, partially associated with limi-tations of food, nutrition and health sur-veillance, that pose a barrier to understand-ing the determinants of healthy eating.Development of a comprehensive, integrat-ed food, nutrition and health surveillancesystem for Canada would create an infor-mation base for understanding the deter-minants of healthy eating at all levels. Inaddition, ongoing surveillance would facili-tate tracking the impacts of interventions.

Applying a population health promotionlens to understanding the determinants ofhealthy eating provides insight into identi-fying gaps for further research, which mayhelp prioritize action strategies for the pro-motion of healthy eating. Although thereare some gaps in knowledge regardingindividual determinants of healthy eating,there are significant gaps in knowledgeregarding collective determinants.Understanding the complex interactionsamong multiple environments and policycontexts for individual food choice isessential to guide efforts to promote andsupport healthy eating in Canada. In addi-tion, there are huge gaps in our under-standing of the process of intervening in

macro-level environments, including policy-related initiatives, and the impact of suchinterventions on the promotion of healthyeating. Environmental determinants offood choice and policy contexts for pro-moting healthy eating, therefore, requiresignificant investment in research.

REFERENCES

1. World Health Organization. WHO TechnicalReport Series No 894. Obesity: Preventing andManaging the Global Epidemic. Geneva,Switzerland: WHO, 2000.

2. Hamilton N, Bhatti T. Population health promo-tion: An integrated model of population health andhealth promotion. Available on-line athttp://www.phac-aspc.gc.ca/ph-sp/phdd/php/php.htm (updated Nov. 29, 2002; accessed Sept. 9, 2004).

3. McLeroy KR, Bibeau D, Steckler A, Glanz K. Anecological perspective on health promotion pro-grams. Health Educ Q 1988;15(4):351-77.

4. Green LW, Richard L, Potvin L. Ecological foun-dations of health promotion. Am J Health Promot1996;10(4):270-81.

5. Taylor J. Determinants of healthy eating amongCanadian children and youth. Can J PublicHealth 2005;96 (Suppl. 3):S20-S26.

6. Payette H, Shatenstein B. Determinants ofhealthy eating in community-dwelling elderlypeople. Can J Public Health 2005;96 (Suppl.3):S27-S31.

7. Payette H, Gray-Donald K, Cyr R, Boutier V.Predictors of dietary intake in a functionallydependent elderly population in the community.Am J Public Health 1995;85(5):677-83.

8. Gray-Donald K. The frail elderly: Meeting thenutritional challenges. J Am Diet Assoc1995;95(5):538-40.

9. Keller HH, Østbye T, Bright-See E. Predictors ofdietary intake in Ontario seniors. Can J PublicHealth 1997;88(5):305-9.

10. Finley B. Nutritional needs of the person withAlzheimer’s disease: Practical approaches to quali-ty care. J Am Diet Assoc 1997;97(10 Suppl.2):S177-80.

11. Payette H, Ferland G. La malnutrition chez lespersonnes âgées démentes : étiologie, évolution etefficacité des interventions. In: La collectionl’année gérontologique. Paris, France : MaisonSerdi, 1999;131-45.

12. Shatenstein B, Ferland G. Absence of nutritionalor clinical consequences of decentralised bulkfood portioning in elderly nursing home residentswith dementia in Montreal. J Am Diet Assoc2000;100(11):1354-60.

13. Drewnowski A. Taste preferences and foodintake. Annu Rev Nutr 1997;17(1):237-53.

14. Brody H. Living Arctic: Hunters of the CanadianNorth. Vancouver/Toronto: Douglas &McIntyre, 1987.

15. Wein EE, Freeman MM. Inuvialuit food use andfood preferences in Aklavik, NorthwestTerritories, Canada. Arctic Med Res 1992;51(4):159-72.

16. Kuhnlein HV. Factors influencing use of tradi-tional foods among the Nuxalk people. J CanDiet Assoc 1989;50:102-8.

17. Kuhnlein HV. Change in the use of traditionalfoods by the Nuxalk native people of BritishColumbia. Ecol Food Nutr 1992;27 (3-4):259-82.

18. Trifonopoulos M. Anthropometry and diet ofMohawk schoolchildren in Kahnawake [Mastersthesis]. Montreal, QC: McGill University, 1995.

19. Bernard L, Lavallee C, Gray-Donald K, DelisleH. Overweight in Cree schoolchildren and ado-

lescents associated with diet, low physical activity,and high television viewing. J Am Diet Assoc1995;95(7):800-2.

20. Bernard L, Lavallee C. Eating Habits of CreeSchool Children: A Pilot Study. Montreal, QC:Community Health Department, MontrealGeneral Hospital, 1993.

21. Morley JE, Thomas DR. Anorexia and aging:Pathophysiology. Nutrition 1999;15(6):499-503.

22. Morley JE. Decreased food intake with aging. J Gerontol A Biol Sci Med Sci 2001;56(Spec No2):81-88.

23. Pirouznia M. The correlation between nutritionknowledge and eating behavior in an Americanschool: The role of ethnicity. Nutr Health2000;14(2):89-107.

24. Birch LL. Children’s preferences for high fatfoods. Nutr Rev 1992;50(9):249-55.

25. Murphy SP, Davis MA, Neuhaus JM, Lein D.Factors influencing the dietary adequacy andenergy intake of older Americans. J Nutr Educ1990;22(6):284-91.

26. McIntosh WA, Kubena KS, Walker J, Smith D,Landmann WA. The relationship between beliefsabout nutrition and dietary practices of the elder-ly. J Am Diet Assoc 1990;90(5):671-76.

27. Toner HM, Morris JD. A social-psychologicalperspective of dietary quality in later adulthood. J Nutr Elderly 1992;11(4):35-53.

28. Lahmann PH, Kumanyika SK. Attitudes abouthealth and nutrition are more indicative ofdietary quality in 50- to 75-year-old women thanweight and appearance concerns. J Am Diet Assoc1999;99(4):475-78.

29. Shatenstein B, Nadon S, Ferland G.Determinants of diet quality among Quebecersaged 55-74. J Nutr Health Aging 2004;8(2):83-91.

30. Paquette M-C. Perceptions of healthy eating:State of knowledge and research gaps. Can JPublic Health 2005;96 (Suppl.3):S15-S19.

31. Falk LW, Bisogni CA, Sobal J. Food choiceprocesses of older adults: A qualitative investiga-tion. J Nutr Educ 1996;28(5):257-65.

32. Furst T, Connors M, Bisogni CA, Sobal J, FalkLW. Food choice: A conceptual model of theprocess. Appetite 1996;26(3):247-65.

33. Willows N. Determinants of healthy eating inAboriginal peoples in Canada: The current stateof knowledge and research gaps. Can J PublicHealth 2005;96 (Suppl.3):S32-S36.

34. Polivy J, Herman CP. Mental health and eatingbehaviours: A bi-directional relation. Can JPublic Health 2005;96 (Suppl.3):S43-S46.

35. Baranowski T, Cullen KW, Baranowski J.Psychosocial correlates of dietary intake:Advancing dietary intervention. Annu Rev Nutr1999;19:17-40.

36. Davison KK, Birch LL. Childhood overweight: Acontextual model and recommendations forfuture research. Obes Rev 2001;2(3):159-71.

37. Baranowski T, Smith M, Hearn MD, Lin LS,Baranowski J, Doyle C, et al. Patterns in children’sfruit and vegetable consumption by meal and dayof the week. J Am Coll Nutr 1997;16(3):216-23.

38. Power EM. The determinants of healthy eatingamong low-income Canadians. Can J PublicHealth 2005;96 (Suppl.3):S37-S42.

39. Rozin P, Vollmecke TA. Food likes and dislikes.Annu Rev Nutr 1986;6:433-56.

40. Statistics Canada. Food Statistics 2001. Ottawa,ON: Minister of Industry, 2003.

41. Raine K. Overweight and Obesity in Canada: APopulation Health Perspective. Ottawa, ON:Canadian Institute for Health Information,2004.

42. Booth SL, Sallis JF, Ritenbaugh C, Hill JO,Birch LL, Frank LD, et al. Environmental andsocietal factors affect food choice and physicalactivity: Rationale, influences, and leveragepoints. Nutr Rev 2001;59 (Suppl.3):57-65.



43. Tarasuk VS, Maclean H. The institutionalizationof food banks in Canada: A public health con-cern. Can J Public Health 1990;81(4):331-32.

44. Jacobs Starkey L, Kuhnlein HV. Montreal foodbank users’ intakes compared with recommenda-tions of Canada’s Food Guide to Healthy Eating.Can J Dietet Pract Res 2000;61(2):73-75.

45. Schlosser E. Fast Food Nation: The Dark Side ofthe All-American Meal. New York, NY: Perennial,2002.

46. Nestle M. Soft drink “pouring rights”: Marketingempty calories. Public Health Rep 2000;115(4):308-19.

47. Drewnowski A, Specter SE. Poverty and obesity:The role of energy density and energy costs. Am JClin Nutr 2004;79(1):6-16.

48. Nestle M. Food Politics: How the Food IndustryInfluences Nutrition and Health. Berkeley, CA:University of California Press, 2002.

49. Schmitz KH, Jeffery RW. Prevention of obesity.In: Wadden TA, Stunkard AJ, (Eds.), Handbookof Obesity Treatment. New York, NY: TheGuilford Press, 2002;556-93.

50. Battle Horgen K, Brownell KD. Comparison ofprice change and health message interventions inpromoting healthy food choices. Health Psychol2002;21(5):505-12.

51. Toronto Food Policy Council (Web Page).Available on-line at http://www.ryerson.ca/~foodsec/food-policy/ (accessed Dec 2002).

52. Stone DA. Policy Paradox and Political Reason.Glenview, IL: Scott, Foresman, 1988.

53. DeVault M. Feeding the Family: The SocialOrganization of Caring as Gendered Work.Chicago, IL: University of Chicago Press, 1991.

54. Health Canada. Canada’s Food Guide to HealthyEating. Available on-line from http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/food_guide_rainbow_e.html (updated Oct 1, 2002; accessedMar 3, 2003).

55. Health and Welfare Canada. Action Towards HealthyEating: Canada’s Guidelines for Healthy Eating andRecommended Strategies for Implementation. Ottawa,ON: Minister of Supply and Services Canada, 1990.

56. Office of Nutrition Policy and Promotion.Nutrition for Health: An Agenda for Action.

Ottawa, ON: Health Canada, 1996. Availableon-line from http://www.hc-sc.gc.ca/hpfb-dgpsa/onpp-bppn/nutrition_health_agenda_e.html

57. Nestle M, Jacobson MF. Halting the obesity epi-demic: A public health policy approach. PublicHealth Rep 2000;115(1):12-24.

58. Jeffery RW. Public health strategies for obesitytreatment and prevention. Am J Health Behav2001;25(3):252-59.

59. Battle Horgen K, Brownell KD. Policy change asa means for reducing the prevalence and impactof alcoholism, smoking and obesity. In: MillerWR, Heather N (Eds.), Treating AddictiveBehaviors . New York, NY: Plenum Press,1998;105-18.

60. Jacobson MF, Brownell KD. Small taxes on softdrinks and snack foods to promote health. Am JPublic Health 2000;90(6):854-57.

61. Advertising Standards Canada. Canadian Code ofAdvertising Standards. Toronto, ON: ASC, 2004.

Perceptions of Healthy EatingState of Knowledge and Research Gaps

Marie-Claude Paquette, PhD

ABSTRACT

To effectively promote and support healthy eating among Canadians, there needs to be abetter understanding of the factors that influence eating behaviours. Perceptions of healthyeating can be considered as one of the many factors influencing people’s eating habits. Forthis review, “perceptions of healthy eating” are defined as the public’s and healthprofessionals’ meanings, understandings, views, attitudes and beliefs about healthy eating,eating for health, and healthy foods.

This article’s aim is to review and summarize the literature on the perceptions of healthyeating and to identify the current state of knowledge and key knowledge gaps. Databases,the worldwide web, selected journals and reference lists were searched for relevant papersfrom the last 20 years.

Reviewed articles suggest relative homogeneity in the perceptions of healthy eating despitethe studies being conducted in different countries and involving different age groups, sexesand socio-economic status. Perceptions of healthy eating were generally based on foodchoice. Fruits and vegetables were consistently recognized as part of healthy eating.Characteristics of food such as naturalness, and fat, sugar and salt contents were alsoimportant in people’s perceptions of healthy eating. Concepts related to healthy eating,such as balance, variety and moderation, were often mentioned, but they were found to bepolysemous, conveying multiple meanings.

The main gap identified in this review concerns the lack of knowledge available onperceptions of healthy eating. More data are needed on the perceptions of healthy eatingin general, on the influence on perceptions of messages from diverse sources such as foodcompanies, and, most important, on the role of perceptions of healthy eating as adeterminant of food choice.

MeSH terms: Eating; perceptions; diet; attitude; food habits

To successfully promote and supporthealthy eating among Canadians, abetter understanding of the factors

that influence eating behaviour is needed.Theoretical models of food choice suggestthat individuals’ ideals and their consciousor tacit assumptions about food are keydeterminants of food choice.1,2 The per-ceptions of healthy eating can be viewed asinfluential on nutritional health within itsbroad conceptualization, based on theFramework for Population Health.3

Over the last century, evolution ofnutritional science has increased the com-plexity of the definition of healthy foods.4

Many elements of foods must now betaken into consideration to determine theirhealthiness, e.g., type of fat. Additionally,consumers must combine foods intohealthy food patterns and ways of eating.Within this context of complexity, peoplegather information on food and nutritionfrom multiple sources, such as television,food labels, food manufacturers and healthprofessionals.5,6 These sources presentnutritional information each in theirunique way.7 People must then give mean-ing to this information and decide on itsusefulness and applicability in their dailylife.

Greater understanding of the public’sperceptions of healthy eating is essentialto assess how current health promotionmessages are interpreted and put intopractice in daily life in order to developsuccessful healthy eating messages andinterventions.

The objectives of this review are two-fold: 1) to examine and summarize theexisting literature on perceptions ofhealthy eating in children, adolescents,adults and health professionals; and 2) toidentify research gaps and future avenuesfor research in the area of perceptions ofhealthy eating. For the purpose of thisreview, “perceptions of healthy eating” aredefined as the public’s (children, adoles-cents and adults) and health professionals’meanings, understandings, views, attitudesand beliefs about healthy eating, eating forhealth, and healthy foods.

Because of the multiple perceptions andmeanings of healthy eating, this reviewrests on a constructivist perspective.8-10

Within this perspective, healthy eating isunderstood as constructed within manyrealities, to have numerous meanings, andto be dynamic and changing over time.

Institut national de santé publique du QuébecCorrespondence and reprint requests: Marie-Claude Paquette, Institut national de santé public duQuébec, Bureau 9.100, 500 René-Lévesque Ouest, Montréal, PQ H2M 1W7, E-mail:[email protected]


LITERATURE SEARCH METHODS

Database and web searches, hand review ofselected journals, and reference lists ofpapers were used to find information onthe perception of healthy eating. Referencedatabases covering the topics of nutrition,medicine, sociology, psychology, aging,nursing, and education (MEDLINE,PubMed, Sociological Abstracts, ERIC,CAB abstracts, PsycINFO, AgeLine,FRANCIS, CINAHL) were searched forCanadian and international scientific liter-ature from 1980 to 2004. Findings of keywords were put under two broader terms,an “eating” term (key words: healthy eat-ing, food choice, food habit, food, andfood selection) and a “perceptions” term(key words: perception, lay conceptualiza-tion, conception, meaning, belief, attitude,interpretation, conceptualization, andmeaning), which were intersected; result-ing findings were reviewed on screen orprinted.

Additional information sources weresought to complement the more traditionalchannels of the scientific literature,through e-mails sent to personal contactsand consultation of websites of profession-al associations and health-related organiza-tions. Additional unpublished reports wereobtained from the Office of NutritionPolicy and Promotion at Health Canada.While materials collected through thesealternative sources are not typically peer-reviewed, they are an essential complementto the paucity of peer-reviewed articles onthe topic of healthy eating perceptions.

All articles and reports were examinedfor inclusion in this review. The inclusioncriteria included the following: 1) theobjectives of the study were stated asexploring the perceptions of healthy eating,or findings and results explored aspects ofhealthy eating; and 2) studies were deemedmethodologically sound. Methodologicalsoundness was evaluated by examininginternal validity, reliability and the objec-tivity of quantitative studies; and transfer-ability, dependability, confirmability andcredibility10 of qualitative studies. In theend, 38 studies were included in thisreview.

Since perceptions are likely influencedby culture, it was not assumed at the outsetthat perceptions of healthy eating in a pop-ulation group of another country were sim-

ilar to those of Canadians, or that percep-tions across Canada are homogenous.These differences limit the transferabilityof findings and point to the need to repli-cate studies from other regions or coun-tries. However, international studies areincluded in this review because of the lackof Canadian data.

The public’s perceptions of healthyeatingIn the review of the literature, fundamentalelements of the perceptions of healthy eat-ing were found to be 1) vegetables andfruits, 2) meat, 3) low levels of fat, salt andsugar, 4) quality aspects, such as fresh,unprocessed and homemade foods, and 5) concepts of balance, variety and moder-ation.

While the majority of studies foundexplored adults’ perceptions of healthy eat-ing, studies that focussed on specific agegroups, such as persons over 65 year of age,children and adolescents, did not reportmajor differences from adults’ perceptions.For that reason, studies from all age groupsare included in this section, and differencesin perceptions are highlighted in the text.Because of the small number of studiesthat focussed on variations in perceptionsaccording to socio-economic status (SES),results from these studies have also beenincluded in this section.

Not all studies included in the reviewwere from Canada, but review of the litera-ture strongly suggested that perceptionswere relatively homogenous regardless ofcountry, and thus it is appropriate to con-trast the perceptions of healthy eating withCanadian dietary guidance. In general, thepublic’s perceptions of healthy eating seemto be heavily influenced by dietary guid-ance, which recommends vegetables andfruits,11,12 meat,11,12 limitations of fat andsalt,11 variety11,12 and moderation.12

However, other elements that seem centralto people’s perceptions of healthy eatingare not found in current dietary guidance,such as the importance of freshness,unprocessed and homemade foods, limit-ing sugar intake and the concept of bal-ance.

Vegetables and fruitsA good number of the studies involvingchildren, adolescents and adults6,8,13-27

found that fruits and vegetables were most

often mentioned by participants as healthyfoods, as part of a healthy diet or as mostimportant for healthy eating.

Studies that included older respondents,persons over 65 years of age, did not findthat the importance of vegetables and fruitsto healthy eating varied according toage.13,28 In addition, the importance of veg-etables and fruits does not seem to havechanged much with time, as a few olderstudies, published 20 years ago, alsoreported that vegetables and fruits wereperceived to be an essential part of ahealthy diet.29,30

However, a few studies15,28,31 suggestedthat gender influenced the perception ofvegetables and fruits. Women mentionedvegetables and fruits more often as part of ahealthy diet,15 and these foods were per-ceived to be more suited to women.28,31

These findings support the notion of genderdifferences in attitudes to vegetables andfruits.4,32 In her book, Lupton4 suggests thatlight, sweet, soft-textured foods and foodsthat are easy to digest are associated withwomen, whereas meat and foods that areharder to digest are associated with men.

In addition, a Canadian study33 reportedon the emergence of a fruit and vegetablemorality: “the should syndrome”. In thisstudy, some participants felt obligated toeat vegetables and fruits. The researchersattributed this attitude to current healthmessages that promote eating vegetablesand fruits for their health value, and thestatus of vegetables as an essential part ofan “ideal” diet.

MeatIn adults, meat was mentioned in thegreatest number of studies after vegetablesand fruits.8,15,17,18,34 It was also mentionedas part of healthy eating by children andadolescents.21,23,26 However, the role ofmeat in healthy eating is not clear. In mostcases the perceptions of healthy eatingincluded avoiding or limiting meat con-sumption.13,15 Indeed, a Canadian studyreported that participants perceivedhealthy eating as trying to limit meatintake, specifically red meat, and replacingit with chicken or fish.18 On the otherhand, some studies have reported that peo-ple perceive eating more meat as part ofhealthy eating.18,19,35 One of these studies18

reported the confusion surrounding thequantities of meat to eat, several partici-

PERCEPTIONS OF HEALTHY EATING


pants believing that eating a lot of meat isimportant to healthy eating. Older andrecent studies also support the notion thatmeat is an essential component of “tradi-tional” meals.29,30,36 Finally, a few stud-ies19,34 suggested that SES may influenceperceptions regarding meat. In one study,34

red meat was more frequently mentionedas healthy by women of lower SES. Part ofthe inconsistency in perceptions of meatmay be attributable to the term itself,which can encompass many varieties ofmeat and meat cuts.

Low levels of fat, salt and sugarFat, salt and sugar were the three most fre-quently mentioned components of food tobe avoided for a diet to be perceived ashealthy in all age groups.6,7,16,19,20,22-24,26,27,31,37

A telephone survey35 representative of theCanadian population reported that peopleavoided foods with cholesterol (60%), salt(56%) and sugar (48%) to make their dietshealthier. Another Canadian study18 foundthat when asked what advice they wouldgive on healthy eating, participants recom-mended avoiding fat and high-fat foods,sugar and fried foods. Similar findingswere found in studies conducted in theUK17 and European Union (EU).15

The latter also reported that womenwere more likely than men to mention eat-ing less fat in their definition of healthyeating.15 However, the influence of SES onthe perceptions of fat, salt and sugar is notclear. While the results of a UK study34

suggested that women of higher SES weremore concerned than women of lower SESabout eating low-fat foods, both socialclasses perceived sweet foods andfatty/fried foods to be unhealthy.

Studies also suggested a heightenedawareness of fat, sugar and salt among olderrespondents.6,13,38 A Canadian telephonesurvey16 suggested that restricting fat, sugarand salt was more common in adults overage 55 than in younger age groups. Olderadults’ heightened apprehension of the fat,sugar and salt content of food, found inthese studies, is understandable in light ofthe link with chronic diseases.

Qualities: Fresh, unprocessed andhomemade foodsOther characteristics of food not associatedwith food composition, such as freshness,were influential on people’s perceptions of

healthy eating.6,8,14,15,28,34,37 In many studies,fresh foods and the freshness of food wasconsidered in opposition to canned, frozenand processed foods. For the latter therewas a perception that such foods wereunhealthy or not as healthy as freshfoods.17,18,30

Fresh foods may also be important tosome older respondents. In a pan-EUstudy,13 10% of seniors included naturalfoods and no processed foods in theirdescription of healthy eating. Somestudies28,34,39 described not only the impor-tance of freshness but also the freshness ofspecific categories of foods, such as vegeta-bles and fruits, and meat products.

Studies have also suggested that the wayfood is prepared influences perceptions ofhealthiness. A Canadian opinion survey40

found that meals considered to be the mosthealthy were home-cooked meals. In addi-tion, studies in children and adoles-cents20,21,41 have suggested that the situa-tion, location and context surrounding eat-ing influence perceptions. Foods eaten athome were viewed as healthy comparedwith foods eaten outside the home or withfriends. This distinction was not clearlyreported in studies of adults’ perceptions.

Concepts of balance, variety and moderationIn all age groups, the concepts of balance,variety and moderation were often report-ed as part of the perceptions of healthy eat-ing.14-18,21-23,26,33,34,40,42,43

A Canadian study18 showed that abouthalf of the respondents spontaneouslymentioned eating a balanced diet or a vari-ety of foods as part of healthy eating.Balance was discussed in terms of eatingmore one day to balance eating less thenext day and varying the emphasis on dif-ferent food groups from day to day.Another Canadian study33 found balanceto be a polysemous concept, expressingvariety in meal composition, balancinghealthy foods with less healthy ones, bal-ancing a healthier diet with occasionallapses, and balancing enjoyment withnutritional or health concerns.

A UK study39 supports these findingsand reports that participants had difficultyin explaining the meaning of the term bal-ance. It was associated with notions ofright and good, and was often contrastedwith the concept of ”excess”. Confusion in

the meaning of the term “balance” was alsosuggested in a study of children,22 in whichone child described healthy eating as “tohave a balanced diet such as pasta, choco-late and eggs.”

The concept of balance was often men-tioned by study participants in combina-tion with the concepts of variety and mod-eration.15,18,39An Australian study7 reportedthat the concept of moderation was used asa response to confusion and inconsistenciesperceived about healthy eating. By usingthe concept of moderation, people couldjustify any food choices. Confusion andpolysemy were also reported in a lay jour-nal article44 in which both lay people andhealth professionals “struggle with the defi-nition of a ’moderate’ diet”44 and questionthe usefulness of the concept. Some healthprofessionals were also quite critical of theterm, believing that it contributed to weakening dietary recommendations.Moderation was also mentioned in a quali-tative study of British seniors.36 Theserespondents believed it was important toeat with moderation to avoid weight gainbut also to avoid overindulgence as a moralvalue. Finally, a study of women34 reportedthat middle-class women placed greaterimportance on balance and moderation intheir perceptions of healthy foods thanworking-class women.

The studies reviewed in this sectionreveal the numerous meanings associatedwith the terms “balance” and “modera-tion”. Findings also suggest that whilethere exists wide diversity of meanings forthe term “balance”, nutrition messages andhealth professionals may not be aware of ortake into account this diversity of mean-ings; rather, they tend to assume a morespecific, single definition.

Overlap in perceptions of healthy eating and of weight loss dietingA few studies included in this review havesuggested that overlap between perceptionsof healthy eating and perceptions of diet-ing for weight loss exists.25,28,36,39,42,45,46 Aqualitative study in the UK39 suggestedthat participants consciously used conceptsof moderation and healthy eating to con-ceal and make more socially acceptabletheir weight loss attempts. In their study ofolder adults, McKie et al.36 also reportedthat participants’ conceptualization ofhealthy eating included concerns about



weight gain that emerged under the themeof moderation. One study42 of childrenreported that for some the concepts ofthinness and fatness were spontaneouslyassociated with concepts of healthy eating.Finally, a study conducted with boys andgirls45 also reported that dieting for weightloss was described as healthful eatingbehaviours, such as “eating more salads orfruits or vegetables”, “I think it has moreto do with healthy eating.”

The consequences of the overlapbetween healthy eating and weight lossdieting are not known. While someauthors propose that these findings suggestwe need not be so concerned about dietingfor weight loss in adolescents, as it mayactually reflect healthy eating behaviour,45

others caution that healthy eating messagescould reinforce unhealthy eating practicesand excessive weight preoccupation.47

More research needs to be conducted onthe origins and effects of the overlapbetween people’s perceptions of healthyeating and dieting for weight loss.

The public’s perceptions of healthy eat-ing are most often conceptualized throughfood choice; fruits, vegetables and meatwere the most mentioned. Food character-istics and components were also importantelements in people’s perceptions of healthyeating. The concepts of balance, variety andmoderation were often part of respondents’perceptions of healthy eating. However,few studies examined the meaning of theseterms for respondents, and most did notdescribe the researcher’s interpretations andcoding scheme for recognizing thesenotions in participants’ narratives. Whencoding schemes were reported, meaningswere numerous rather than uniform.

The public’s perceptions of healthy eat-ing seem to be heavily influenced bydietary guidance, (which is relatively simi-lar across the countries of studies discussedin this review), which also recommendsvegetables and fruits,11,12 meat,11,12 limita-tions of fat and salt,11 variety11,12 and mod-eration.12 However, other elements thatseem central to people’s perceptions ofhealthy eating, such as the importance offreshness, unprocessed and home-madefoods, limiting sugar intake and the con-cept of balance, are not found in currentdietary guidance.

Other important elements of dietaryguidance, such as the grain products and

milk products groups, were not includedin people’s perceptions of healthy eating toany major extent. A few studies reportedthat carbohydrate-rich foods such asbreads, grains, pastas, pulses and potatoeswere part of healthy eating defini-tions.15,17,18,20,21,23,27,31,39 Canadian data alsosuggested that the grain products group israrely mentioned.18 The milk productsgroup is even more rarely mentioned aspart of healthy eating. Except in onestudy,21 in which adolescents rarely men-tioned dairy products, studies focussing onchildren and adolescents found that milkwas more often included in their definitionof healthy eating than it was in adults’ defi-nitions.20,23 In adults, milk products werementioned most often within the contextof decreasing fat intake by consuming low-fat dairy products.15,38

In addition, most studies did not assessmore precise aspects of perceptions, such asquantities, serving sizes and portion sizes.While people perceive vegetables and fruitsto be important to healthy eating, theymay not know how much they need to eatto be healthy. Such notions themselvescould be the subject of multiple meaningsand interpretations, and should constitutefuture research avenues. More research alsoneeds to be initiated into how people puttheir definitions of moderation, variety andbalance into effect in their lives.

Health professionals’ perceptions ofhealthy eatingOnly one study was found that briefly dis-cussed health professionals’ perceptions ofhealthy eating, conducted in London, UK.39

The findings suggested that health profes-sionals recommend that clients opt forhealthy eating rather than for dieting. Theyalso alluded to notions of “good” and “bad”foods, but the way in which “bad” foodswere part of a healthy diet was not clear. Theauthors concluded that even health profes-sionals seemed to have a difficult time com-municating the message that healthy eatingis not the same as dieting for weight loss.

KNOWLEDGE GAPS AND DISCUSSION

The perceptions of healthy eating remain arelatively unexplored issue, as suggested bythe small number of studies (38) includedin this review. This may be because the

polysemy of “healthy eating” has not beenrecognized in the past and because of thecomplexity of the issue. Even if perceptionswere found to be relatively homogenousacross studies in different developed coun-tries, age groups, sexes and SES, moreresearch needs to be conducted to validatethis finding.

This review has identified many gaps inknowledge. Overall, three aspects of per-ceptions need to be further investigated:most importantly, the influence of the per-ceptions of healthy eating on food choiceand eating behaviour; how messages frominformation sources (e.g., media, healthprofessionals, food industry) shape percep-tions of healthy eating, and the need forresearch on perceptions themselves.

Indeed, while the link between percep-tions and behaviour can be inferred, it isnot clearly supported in the literature. Thisaspect of perceptions could be studiedwithin the context of research into the dif-ferent factors that influence food choice oras an exploration of the two-way relationbetween perceptions and behaviour. Suchstudies are central to asserting that the per-ceptions of healthy eating are truly a deter-minant of healthy eating.

The process by which informationsources shape people’s perceptions ofhealthy eating by contributing meaning tonutritional messages also needs to be betterunderstood. Such research is essentialinformation to direct the development andwording of future dietary guidance andhealth promotion efforts for healthy eat-ing. These findings could also potentiallycontribute to developing regulations aimedat controlling food advertising and claims,as well as critical appraisal techniques ofmedia literacy.

Perceptions of healthy eating themselvesalso need to be further explored. Indeed,no study was found that specificallyexplored health professionals’ perceptionsof healthy eating. Research is first neededon dietitians’ perceptions of healthy eating,as they are considered the nutrition expertsand are often called upon to inform andeducate about healthy eating. Variations inthe perceptions of healthy eating also needto be investigated in other health profes-sionals, such as physicians, nurses and pub-lic health professionals.

In order to better tailor interventions, tomake them more salient and successful for



specific groups, research on perceptionsshould explore variations in perceptions byindividual or group characteristics, such asgender, age, SES, cultural heritage andgeographic area of residence. Theseresearch initiatives would also providemuch needed Canadian data.

Finally, more detailed research is neededon the perceptions of healthy eating suchas quantities and serving sizes of food andfood groups, on the meat group and itspart in healthy eating, on largely ignoredgroups such as grain and dairy products,and on the way people’s perceptions deter-mine their daily food choices.

REFERENCES

1. Falk LW, Bisogni CA, Sobal J. Food choiceprocesses of older adults: A qualitative investiga-tion. J Nutr Educ 1996;28:257-65.

2. Furst T, Connors M, Bisogni CA, Sobal J, FalkLW. Food choice: A conceptual model of theprocess. Appetite 1996;26:247-65.

3. Joint Steering Committee Responsible forDevelopment of a National Nutrition Plan forCanada. Nutrition for Health: An Agenda forAction. Ottawa, ON: Health Canada, 1996.

4. Lupton D. Food, the Body and the Self. London,England: Sage, 1996.

5. Nestle M. Food Politics: How the Food IndustryInfluences Nutrition and Health. Berkeley, CA:University of California Press, 2002.

6. van Dillen SM, Hiddink GJ, Koelen MA, deGraaf C, van Woerkum CM. Understandingnutrition communication between health profes-sionals and consumers: Development of a modelfor nutrition awareness based on qualitative con-sumer research. Am J Clin Nutr 2003;77:1065S-1072S.

7. Lupton D, Chapman S. “A healthy lifestylemight be the death of you”: Discourses on diet,cholesterol control and heart disease in the pressand among the lay public. Sociol Health Illness1995;17:477-94.

8. Chapman G, Beagan B. Women’s perspectiveson nutrition, health and breast cancer. J NutrEduc Behav 2003;35:135-41.

9. Lincoln YS, Guba EG. Paradigmatic controver-sies, contradictions and emerging confluences. In:Denzin NK, Lincoln YS (Eds.), Handbook ofQualitative Research. Thousand Oaks, CA: Sage,2000;163-88.

10. Lincoln YS, Guba EG. Naturalistic Inquiry.Beverly Hills, CA: Sage, 1985.

11. Health Canada. Action Towards Healthy Eating:The Report of the Communications/ImplementationCommittee. Ottawa, ON: Health Canada, 1990.

12. Health Canada. Canada’s Food Guide to HealthyEating. Ottawa, ON: Health Canada, HealthProducts and Food Branch, 1992.

13. de Almeida MD, Graca P, Afonso C, KearneyJM, Gibney MJ. Healthy eating in Europeanelderly: Concepts, barriers and benefits. J NutrHealth Aging 2001;5:217-19.

14. Falk LW, Sobal J, Bisogni CA, Connors M,Devine CM. Managing healthy eating:Definitions, classifications, and strategies. HealthEduc Behav 2001;28:425-39.

15. Margetts BM, Martinez JA, Saba A, Holm L,Kearney M, Moles A. Definitions of ‘healthy’ eat-ing: A pan-EU survey of consumer attitudes tofood, nutrition and health. Eur J Clin Nutr1997;51 (Suppl. 2):S23-S29.

16. National Institute of Nutrition. TrackingNutrition Trends. IV: An Update on Canadian’sNutrition-related Attitudes, Knowledge andActions, 2001. Ottawa, ON, 2002.

17. Povey R, Conner M, Sparks P, James R,Shepherd R. Interpretations of healthy andunhealthy eating, and implications for dietarychange. Health Educ Res 1998;13:171-83.

18. Sage Research Corporation. QualitativeInvestigation of Canadians’ Understanding of andAttitudes Towards Nutrition and Healthy Eating.Draft report, 2003.

19. Santich B. Good for you: Beliefs about food andtheir relation to eating habits. Aust J Nutr Diet1994;51:68-73.

20. Chapman G, Maclean H. “Junk food” and“healthy food”: Meanings of food in adolescentwomen’s culture. J Nutr Educ 1993;25:108-13.

21. Croll JK, Neumark-Sztainer D, Story M.Healthy eating: What does it mean to adoles-cents? J Nutr Educ 2001;33:193-98.

22. Edwards JSA, Hartwell HH. Fruit and vegetables– attitudes and knowledge in primary school chil-dren. J Hum Nutr Diet 2002;15:365-74.

23. Le Bigot MA. Eat to live or live to eat? Do par-ents and children agree? Public Health Nutr2001;4:141-46.

24. Lytle LA, Eldridge AL, Kotz K, Piper J, WilliamsS, Kalina B. Children’s interpretation of nutri-tion messages. J Nutr Educ 1997;29:128-36.

25. Roberts SJ, Maxwell SM, Bagnall G, Bilton R.The incidence of dieting amongst adolescentgirls: A question of interpretation? J Hum NutrDiet 2001;14:103-9.

26. Story M, Resnick MD. Adolescent’s views onfood and nutrition. J Nutr Educ 1986;18:188-92.

27. Eikenberry N, Smith C. Healthful eating:Perceptions, motivations, barriers, and promotersin low-income Minnesota communities. J AmDiet Assoc 2004;104:1158-61.

28. McKie LJ, Wood RC, Gregory S. Women defin-ing health: Food, diet and body image. HealthEduc Res 1993;8:35-41.

29. Blaxter M, Paterson E. The goodness is out of it:The meaning of food to two generations. In:Murcott A (Ed.), The Sociology of Food andEating. Aldershot, Hants, England: Gower,1983;95-105.

30. Pill R. An apple a day ... some reflections onworking class mothers’ views on food and health.In: Murcott A (Ed.), The Sociology of Food andEating. Aldershot, Hants, England: Gower,1983;117-27.

31. Roos G, Prattala R, Koski K. Men, masculinityand food: Interviews with Finnish carpenters andengineers. Appetite 2001;37:47-56.

32. Bourdieu P. La distinction : critique sociale dujugement. Paris, France : Éditions de Minuit,1979.

33. Paisley J, Sheeshka J, Daly K. Qualitative investi-gation of the meanings of eating fruits and veg-etables for adult couples. J Nutr Educ2001;33:199-207.

34. Calnan M. Food and health: A comparison ofbeliefs and practices in middle-class and working-class households. In: Cunningham-Buley S,McKeganey N (Eds.), Readings in MedicalSociology. London, England: Routledge, 1990;9-36.

35. Ipsos-Reid. A Profile of Canada’s Eating and FoodPurchasing Habits. 2002.

36. McKie L, MacInnes A, Hendry J, Donald S,Peace H. The food consumption patterns andperceptions of dietary advice of older people. J Hum Nutr Diet 2000;13:173-83.

37. Fagerli RA, Wandel M. Gender differences inopinions and practices with regard to a “healthydiet”. Appetite 1999;32:171-90.

38. Gustafsson K, Sidenvall B. Food-related healthperceptions and food habits among older women.J Adv Nurs 2002;39:164-73.

39. Keane A, Willetts A. Concepts of Healthy Eating:An Anthropological Investigation in South EastLondon. London, England: GoldsmithsUniversity of London, 1996.

40. Time, health and shopping: The balancing act.Canadian Living 1999.

41. Ross S. ‘Do I really have to eat that?’: A qualita-tive study of schoolchildren’s food choices andpreferences. Health Educ J 1995;54:312-21.

42. Dixey R, Sahota P, Atwal S, Turner A. Childrentalking about healthy eating: Data from focusgroups with 300 9-11-year-olds. Nutr Bull2001;26:71-79.

43. Fuller TL, Backett-Milburn K, Hopton JL.Healthy eating: The views of general practitionersand patients in Scotland. Am J Clin Nutr2003;77:1043S-1047S.

44. Havala S. Deciphering those dietary recommen-dations – How do you define moderation?Vegetarian J 1992;July/August:8-13.

45. Neumark-Sztainer D, Story M. Dieting andbinge eating among adolescents: What do theyreally mean? J Am Diet Assoc 1998;98:446-50.

46. Saltonstall R. Healthy bodies, social bodies:Men’s and women’s concepts and practices ofhealth in everyday life. Soc Sci Med 1993;36:7-14.

47. Dixey R. Healthy eating in schools and “eatingdisorders” – Are “healthy eating” messages part ofthe problem or part of the solution? Nutr Health1996;11:49-58.




Determinants of Healthy Eatingin Children and YouthJennifer P. Taylor, PhD, RD1

Susan Evers, PhD, RD2

Mary McKenna, PhD, RD3

ABSTRACT

This review outlines the state of knowledge and research gaps in the area of determinantsof healthy eating among children and youth. The article is structured around individualand collective determinants that affect healthy eating in children and youth. We definedhealthy eating as “eating practices and behaviours that are consistent with improving,maintaining and/or enhancing health.” Relevant databases were searched for paperspublished between January 1992 and March 2003 that focussed on children or youth andreported at least one factor relevant to healthy eating. Among collective factors, familialfactors and the nature of foods available in the physical environment, including at home,schools and in fast-food establishments, stand out as significant influences on healthyeating in children and youth. The media, particularly television, also have an enormouspotential influence and can overshadow familial influences. Individual factors identifiedinclude knowledge, attitudes and food preferences; only the latter have been identified asa strong determinant of healthy eating in both children and adolescents. The results of thereview identified a significant body of literature in the area of determinants of healthyeating in children and youth; however, very little of this research has taken place inCanada. Only a few determinants, such as economic factors and food security, the contentof media nutritional messages, and the issue of flavours, neophobia and food preferences,have undergone some examination by Canadian researchers. Research priorities forCanada in the area of determinants of healthy eating and surveillance of eating behavioursare identified.

MeSH terms: Eating; child; adolescent; factors

There is mounting evidence thatCanadian children may be makingunhealthy food choices, leading to

both dietary excesses and inadequacies.Most information comes from nutritionalsurveillance in the United States (US),which suggests that few children meetdietary recommendations. They have lowintakes of fruits, vegetables and milk prod-ucts; high intakes of less healthy choices,such as soft drinks and high-fat, high-sugarsnack foods; and consumption of toomuch fat and saturated fat, and too littlefolate and calcium.1-7 Overall dietary quali-ty declines with age, and the rate of break-fast skipping increases. Although there areno comparable national data available onchildren’s eating behaviours in Canada,limited information from a nationalstudy,8 and some provincial data,9,10 sug-gest that similar concerns exist aboutCanadian children, including low fruit andvegetable consumption and high consump-tion of candy, chocolate bars and softdrinks.

Unhealthy eating habits during child-hood may interfere with optimal growthand development while setting the stagefor poor eating habits during adolescenceand adulthood.11,12 Moreover, poor dietand inactivity during childhood have beenimplicated in the worrisome increase inchildhood overweight,13 which is consid-ered to be at epidemic proportions inCanada and in other developed nations.14-16

Increases in other nutrition-related riskfactors for chronic disease in children suchas hypertension, hypercholesterolemia andType 2 diabetes have also beenobserved.17,18

A range of health promotion strategiesare required in order to support healthyeating during childhood and adolescenceand promote optimal growth and develop-ment while reducing risk for obesity aswell as chronic disease rates in the adultpopulation.11,19 However, in order todesign effective interventions, an under-standing of the complexity of factors thatinfluence the eating behaviours of childrenand adolescents is needed.

This review outlines the state of knowl-edge and research gaps in the area of deter-minants of healthy eating among childrenand youth. The paper is structured aroundindividual and collective determinants, asdescribed in the Framework for PopulationHealth,20 that affect healthy eating in chil-

1. Associate Professor, Department of Family and Nutritional Sciences, University of Prince EdwardIsland, Charlottetown, PE

2. Professor, Department of Family Relations and Applied Nutrition, University of Guelph, Guelph,ON

3. Associate Professor, Faculty of Education, University of New Brunswick, Fredericton, NBCorrespondence and reprint requests: Jennifer P. Taylor, Department of Family and NutritionalSciences, University of Prince Edward Island, 550 University Avenue, Charlottetown, PEI, C1A 4P3.Tel: (902) 566-0475; Fax: (902) 628-4367; E-mail: [email protected]: Thank you to Rose Peacock, MHSc, RD, for her assistance with compiling refer-ence lists for the paper, and to Michelle Hooper for her patience, wise advice and support.


HEALTHY EATING IN CHILDREN AND YOUTH

dren and youth. Individual determinantsinclude biological factors (sex, age), foodpreferences, knowledge and attitudes per-taining to health and food, and skill level orcapacities. Collective determinants includethe economic, social and physical environ-ments. We defined healthy eating, as “eat-ing practices and behaviours that are consis-tent with improving maintaining and/orenhancing health.”

METHODS AND LITERATURE SEARCH

All primary data-based papers and reviewpapers published between January 1992and March 2003 that focussed on childrenand/or youth (age 2-18 years) and reportedat least one behaviour or determinant rele-vant to healthy eating were included.Databases searched included MEDLINE,CINAHL, PsycINFO, ERIC and SocialScience Index, and the key words usedwere: children, toddlers, youth, adolescents,school children, factors/influences, eating,diet, food, eating behaviours and nutrition.Six journals were also hand searched from1997 to 2003 inclusive (Appetite, CanadianJournal of Dietetic Practice and Research,Canadian Journal of Public Health, Journalof the American Dietetic Association, Journalof Nutrition Education and Behaviour andObesity Research). Key sources in Frenchwere also identified and translated.

RESULTS

Individual determinantsThese include biological factors (age, sex),food preferences, nutrition knowledge andattitudes. Most studies focussed on differ-ences in eating behaviours, such as snack-ing or breakfast consumption, rather thandifferences in determinants of eatingbehaviours such as age and sex.

American surveys indicate that there isa decline in diet quality and breakfastconsumption with age and an increase insnacking from elementary to highergrades.1,3,7 Smaller Canadian studiesconfirm these trends.9,10 This is a con-cern, since children who eat breakfastregularly are more likely to have morenutr i t ious diets than those who donot.9,21 Females, particularly adolescents,tend to be at greater nutritional riskthan males.7

Children’s food preferences are oftenguided by taste or liking alone.22,23

Preference for specific food items (e.g.,fruits and vegetables) is a strong positiveindicator of the consumption of that foodin both children and adolescents.24-30 Tastecan lead to poor choices: for example, “dis-like for vegetables” is one of the three mostimportant predictors of fruit and vegetableintake in children.30,31 Personal preferencesfor eating fast food32 or vending machinesnacks 33 have also been identified as a bar-rier to healthy eating in adolescents.

Nutrition knowledge levels are generallylow among children and adolescents, whohave a weak understanding of the connec-tion between food choice, physical activity,and health.23,34-36 While knowledge doesnot consistently influence dietary behav-iour,37-44 inconsistent findings may reflectpast methodological problems43 or theinter-relation between knowledge andother determinants, which may make inde-pendent effects difficult to assess.Relatively few studies have described atti-tudes toward food and the role of food inhealth.28,45,46 Intervention47,48 studies utiliz-ing models such as Social CognitiveTheory49-53 have been unable to explain alarge variation in children’s eating behav-iours. Those using a qualitative approachto examine attitudes and meanings associ-ated with foods suggest that determinantsvary by sex and age.30,37,54,55 Even fewerstudies have examined the effect of foodpreparation skill level (perceived or actual)among children and adolescents.30,31

Collective determinants

Economic DeterminantsThese include income/socio-economic status,food pricing, education and employment.Income and socio-economic factors are dis-cussed more thoroughly elsewhere in thissupplement. Food price becomes the mostimportant consideration in food choicewhen income is restricted,56 often leading tothe selection of foods that are higher in sugarand fat because they are among the leastexpensive sources of dietary energy.57

Further, reducing the price of foods and bev-erages that are high in sugar and/or fatincreases the consumption of these foods.58,59

Lower educational status of parents has beenassociated with lower dietary quality, includ-ing higher fat and lower micronutrient

intakes in children.60-63 Finally, maternalemployment has been found to be negativelyassociated with the frequency of familymeals, which are, in turn, positively associat-ed with diet quality.64

Social DeterminantsThese include cultural factors, familial fac-tors, peers and product marketing/massmedia. Although culture is considered oneof the most important influences onhealthy eating, increasing “globalization” offood habits65 has led to a reduction in inter-cultural differences in food practices withinsociety.66 In Canada, there has been clearevidence of nutritional concerns aboutAboriginal children.67-70 However, there is apaucity of data comparing dietary behav-iours of Canadian children and youth withthose from other countries and cultures.

Children’s dietary patterns evolve withinthe context of the family.71 The intakes ofparents and children are correlated formost nutrients,72 with stronger correlationsbetween mothers and children than fathersand children. According to Nicklas andcoworkers,11,73 familial factors include foodexposure and availability, parental model-ling, meal structure and family meals, parenting style, and food socializationpractices. A strong positive associationbetween the availability of fruits and veg-etables in the home and consumption hasbeen reported.27,30,31,45,73-75 While the avail-ability of healthy foods is necessary, it isnot always a sufficient enabler of healthyeating: qualitative research indicates thatalthough parents provide youth withhealthy homemade foods, the youth do notalways like them.32 Few studies have exam-ined the role of parental modelling as a pre-dictor of healthy eating in children andyouth.45,50,75,76 Family meals have a positiveinfluence on diet quality of children andyouth,77-79 with higher consumption ofvegetables and fruit, milk products andimproved nutrient intakes.

An authoritarian parenting style, charac-terized by controlling child feeding prac-tices (using high-fat/high-sugar foods asrewards, restriction of “junk foods”)increases childrens’ preferences for andintake of restricted foods once the restric-tion is removed.73,80-85 Further, encouragingthe consumption of a healthy food on thebasis of its health benefits decreases chil-dren’s preference for the food.86,87



Permissive parenting can lead to inappro-priate snacking and consumption of inap-propriate portions of energy-dense foods.88

Parental attitudes and knowledge aboutnutrition, termed “food socialization prac-tices” 73, 89, have also been correlated withnutrient intakes of children.90 Parents’nutritional knowledge may affect the nutri-tional quality of foods purchased, andtherefore their availability, as well as thesize of portions served to the child.71,90-92

Positive nutritional attitudes in parents ofpre-schoolers have been found to be associ-ated with more pleasant mealtime experi-ences, fewer suboptimal mealtime practicesand fewer eating problems.93 Some earlyresearch94 suggested that peers are an impor-tant and lasting influence on the food pref-erences of pre-schoolers (age 2-5).Enthusiastic peer modelling has been foundto be the strongest predictor of youngerchildren’s willingness to try new foods.95

The effects of product marketing andmass media on dietary behaviour are inter-related and include influences on foodpreferences, food purchases and children’sfood requests, or they may affect knowl-edge and attitudes, and the development ofdieting behaviours and body image prob-lems. The media, particularly television,have an enormous potential influence onhealthy eating in children and youth, and,in many instances, can overshadow familialinfluences. Food advertising promotesmore frequent consumption of less healthyfoods, including higher-fat, energy-densesnacks96,97 and rarely features healthychoices such as fruits and vegetables.98-100

This is a concern, since children are morelikely to request, purchase and consumefoods that they have seen advertised ontelevision.96,101 In addition to their effectson food consumption, food or beverageadvertisements are persuasive and havebeen shown to often contain misleadinginformation or incomplete disclosure,which can contribute to confusion amongchildren.39 Finally, mass media have beenidentified as important factors in the devel-opment of both overweight102,103 and diet-ing behaviours,104 particularly in youngwomen.

Physical EnvironmentThis includes foods available/portion sizesand the school environment. The negativeinfluence of increased availability and

effective mass marketing of fast food, con-venience foods and expanding portion sizeson healthy eating in children and youthhas received considerable attention inrecent years.105 This is a concern, sincechildren as young as five years eat morewhen they are served large portions.106

Further, changes have been associated witha decline in dietary quality, including areduction in the consumption of nutrient-dense foods and a concomitant increase infoods that are low in nutrients yet high inenergy, fat, sugar and sodium.59,86,89,106,107

The school environment may influencehealthy eating in children and youththrough the foods that are available, nutri-tional policies, school nutrition and healthcurricula, and teacher and peer modelling.Schools are the ideal settings to establishand promote healthy eating practices inchildren and adolescents.108,109 Recent sur-veys of food programs in Canadian schoolshave identified a number of concernsregarding the nutritional quality of foodsin schools, including the ready availabilityof high-fat, high-sugar, low nutrient-densefoods and beverages, particularly in vend-ing machines.110-114 A national scan indicat-ed that there are very few school nutrition-al policies in Canada,115 which are criticalin order to provide guidelines for the plan-ning, development and implementation ofcomprehensive nutrition programs,12 andwhich are associated with changes in stu-dents’ nutritional knowledge and behav-iours.41,43,116

KNOWLEDGE GAPS

Although there is now a significant body ofliterature in the area of determinants ofhealthy eating in children and youth, verylittle of this research has taken place inCanada. Only a few determinants, such aseconomic factors and food security,117-121

the issue of flavours, neophobia and foodpreferences122,123 and the content of medianutritional messages96,99,100 have undergonesome examination by Canadian researchers.It may seem reasonable to build on researchconducted elsewhere, given the commonexposure to powerful forces such as themass media and technology, an increasinglyglobally homogenous food supply, andcommon health problems, such as over-weight. This is not appropriate, however,where there are significant national differ-

ences, for example, the role of the schoolenvironment or the effect of nationaldietary guidelines on healthy eating in chil-dren and youth. The following key researchpriorities have been identified:

1. Research examining the nature of familialinfluences on healthy eating in childrenand youth, including family food practices,the frequency of family meals and the rela-tive influence of peers and siblings onhealthy eating.Among collective factors, familial factors

and the nature of foods available in thephysical environment, including at home,schools and in fast-food establishments,stand out as particularly significant influ-ences on healthy eating in children andyouth. Given the positive associationbetween family meals and diet quality,future research should attempt to increaseour understanding of how families withworking parents living in a time crunch domanage to have family meals.64 Becausechildren have, in turn, influenced familyfood habits by pressuring food preparers topurchase and prepare food they like,research on the interaction between chil-dren and parents, which examines thecomplexity of this relationship, is needed.Although mothers are more motivated tochange their children’s eating behavioursthan fathers and are more knowledgeableabout the nutrient content of foods, theyare relatively unsuccessful in changing theirchildren’s food habits on their own.124 Thereported incongruence between reportedmaternal motivations and the foods theyselect for their children125 reflects the com-plex context in which eating takes placeand the influence of other cognitions relat-ing to mothers’ concerns about their ownweight. The observed inter-relationsamong cultural, familial and societal influ-ences in the formation of children’s eatinghabits serve to decrease the impact of fami-ly culture on food behaviours in childrenand youth. This, in addition to the cleardecline in familial influences with age,including a decline in the frequency offamily meals, underscores the importanceof supporting healthy food socializationpractices in parents. Since it is food use,portion sizes and food preparation meth-ods that are often targeted in interventions,it would be useful to examine the influenceof familial factors on these food-related

practices more closely and whether theypredict eating behaviours and bodyweight.61,126 Although the problem of esca-lating portion sizes in the fast-food indus-try and the grocery retail sector (muffins,bagels, soft drinks and confections) is wellknown, there has been little research onthis phenomenon in the home environ-ment. Research to clarify and confirm thepotential influence of peers and siblings ondietary behaviour is needed.

2. Research regarding the impact of the schoolenvironment on healthy eating, particular-ly nutritional policy and modelling.Evidence suggests that, while school

environmental change is occurring inCanada, many schools are failing to pro-vide adequate environments to supporthealthy eating.110-114 Thus, while studentsmay be receiving some nutritional educa-tion in the classroom, confusing and coun-terproductive messages appear to be pro-vided in cafeterias and other school set-tings.12,109 It is encouraging that enthusias-tic teacher and peer modelling has beenfound to increase acceptance of healthyfood choices in pre-schoolers; this suggestsimportant opportunities for day care cen-tres and kindergarten settings to promotehealthy eating. The characteristics of mod-elling activities, environments and childrenfor whom modelling is effective89 need tobe documented. This would facilitate thedesign of effective interventions in bothschool and home settings. Recent findingsthat changing the economics of foodchoice in schools and other environments,such as grocery stores, can have positiveeffects on healthy eating58 must be con-firmed in a broader range of foods, settingsand age groups. Finally, it is important tomonitor the impact of school nutritionalpolicies on improving the school foodenvironment and eating behaviours. Thepossible effects of such policies on timeallotted for physical activity in schoolshould be assessed as part of this monitor-ing.

3. Effects of mass media on healthy eating.Much of the evidence of the effective-

ness of television food commercials inchanging dietary behaviour comes frommarketing research, which is not accessibleto researchers or the public. Although theamount of money invested in food com-

mercials seems to provide clear testimonyto the perceived effectiveness of influenc-ing behaviours,98,127 the effects of televisionon nutritional knowledge, children’s per-ceptions and views, and, most important,food intake in children and youth, afterexposure to food commercials128 needs tobe further investigated.

4. Research regarding food preferences andnutritional knowledge/skills in childrenand youth and their impact on behaviourchange.Among individual determinants, only

food preferences or liking was consistentlyidentified in both young children and ado-lescents as an important predictor ofhealthy eating.22-30 Since food preferencesare often not consistent with children’sknowledge, educators should go beyondteaching children what to eat, and assistthem in choosing healthy foods that arealso seen as good tasting.129 While there isevidence of an association between knowl-edge and behaviour, particularly in olderchildren,32,34,35,44 the ability of children toidentify appropriate foods needed to meetdietary recommendations should beassessed. It is not sufficient to be able to“parrot” nutritional recommendations;children need to be able to identify andrequest healthy choices (e.g., lower-fatfoods).129 Longitudinal studies of the effectsof knowledge on dietary behaviour andstudies of children from diverse culturesand socio-economic backgrounds are neces-sary. Qualitative methods appear to havepromise in terms of studies examining theeffect of knowledge on healthy eating.129

The relation between food-related skills(including food selection and preparation)and healthy eating in both children andtheir parents should also be examined.Given the decrease in emphasis on thedevelopment of food-related skills in schoolsystems across Canada, changes in coursesoffering Home Economics/FamilyStudies,130 and the increase in prepared andconvenience foods in the home, it is impor-tant to identify means by which childrenwill consistently acquire food-related skillsand use them to make healthy choices.

5. Methodological issues in the examinationof multiple determinants of healthy eatingin children and youth, and their inter-actions.

Much of the research has been limited toan examination of bivariate relations71 andthe use of non-experimental designs, pre-cluding the identification of causal rela-tions between determinants and eatingbehaviours of children and youth. Manyinterventions have focussed on fruit andvegetable intake.131-133 Although determi-nants of healthy eating appear to vary byfood, it is impractical to develop predictivemodels for individual foods.45 Examininggroups of foods that are homogenous interms of determinants of consumption issuggested as a possible approach.

The low predictability of psychosocialmodels to predict food intake in childrenand youth may be improved by consider-ing the relatively stronger influence of fac-tors such as food availability and accessibil-ity, and their interactions.133

Quantitative methods predominate inthe literature, and there is a paucity ofCanadian studies exploring the determi-nants of healthy eating in children using aqualitative approach. The latter approachcould help identify the reasons why chil-dren and youth make positive choices, sothat supports for healthy eating can bestrengthened.

6. Monitoring eating behaviours and weightin children and youth.Canada must have its own nutritional

monitoring system to identify uniquenational and regional dietary behavioursand nutritional concerns. Clearly, in orderto choose interventions wisely and tailorthem to specific regions, to evaluate themeffectively and make sound dietary recom-mendations, accurate and current data onthe eating behaviours of Canadian childrenand youth are essential. To date, Canadiannutritionists have not had adequate dataupon which to base any of these importantactivities. Although smaller studies haveidentified some dietary concerns, thisreview confirms the lack of national nutri-tional assessment data on dietary behav-iours in Canadian children. This was alsoidentified as a gap in knowledge in a recentHealth Canada report.134

Difficulties in assessing dietary behav-iours in children and youth contribute tothe challenge of identifying key determi-nants and in assessing the impact of inter-ventions targeting them. It is encouragingthat Canada is currently gathering dietary





intake data through the CanadaCommunity Health Survey (CCHS),Cycle 2.2, Nutrition Focus.135 Pre-schooland school-age children and adolescentsare included in the sample.135 It is hopedthat the collection of nutritional indicatorswill continue as part of the CCHS or othernational surveys. Since there is increasingrecognition that food intake and eatingpatterns, rather than specific nutrients,play important roles in health and in dis-ease prevention, monitoring systemsshould focus more on foods and overalleating patterns and develop further dietquality measures in children136 in order todevelop appropriate dietary guidelines forthem.

CONCLUSIONS

Currently, the lack of Canadian data onboth the determinants of healthy eatingand dietary behaviours in children andyouth are significant barriers to the devel-opment of effective policies and programsin Canada. Recognition of the importanceof research into the determinants ofhealthy eating in children and youth,through sustained significant researchfunding and identification of mentoringopportunities for researchers, are twomeans by which we can ensure that thereare sufficient Canadian researchers inapplied nutrition to conduct this impor-tant work.

It is intended that this review willbecome part of the foundation for furtherexamination of the determinants of healthyeating, and inform a broader dialogueamong researchers, practitioners and policymakers on research-related priorities inCanada.

REFERENCES

1. Lino M, Basiotis PP, Gerrior SA, Carlson A.The quality of young children’s diets. Fam EconNutr Rev 2002;14;52-60.

2. Suitor CW, Gleason PM. Using dietary refer-ence intake-based methods to estimate theprevalence of inadequate nutrient intake amongschool aged children. J Am Diet Assoc2002;102:530-36.

3. Wilkinson Enns C, Mickle SJ, Goldman JD.Trends in food and nutrient intakes by childrenin the United States. Fam Econ Nutr Rev2002;14:56-68.

4. Neumark-Sztainer D, Story M, Resnick MD,Blum RW. Correlates of inadequate fruit andvegetable consumption among adolescents. PrevMed 1996;25:497-505.

5. Muñoz CA, Krebs-Smith SM, Ballard-BarbashR, Cleveland LE. Food intakes of US children

and adolescents compared with recommenda-tions. Pediatrics 1997;100:323-29.

6. Muñoz CA, Krebs-Smith SM, Ballard-BarbashR, Cleveland LE. Errors in food intake article.Pediatrics 1998;101:952-53.

7. Levine EL, Guthrie JF. Nutrient intakes andeating patterns of teenagers. Fam Econ Nutr Rev1997;10:20-35.

8. King AJC, Boyce WF, King MA. Trends in theHealth of Canadian Youth. Ottawa, ON:Minister of Health Canada, 1999.

9. Evers S, Taylor J, Manske S, Midgett C. Eatingand smoking behaviours of school children inSouthwestern Ontario and Charlottetown, PEI.Can J Public Health 2001;92:433-36.

10. Taylor J, Bradley D, Peacock R. Food HabitsSurvey of Students in Grades 4 to 9 in theWestern School Board. Final Report submittedto the PEI Health Research Program. March2003.

11. Johnson RK, Nicklas TA. Position of theAmerican Dietetic Association: Dietary guid-ance for healthy children aged 2 to 11 years. J Am Diet Assoc 1999;99:93-101.

12. Centers for Disease Control and Prevention.Guidelines for school health programs to pro-mote lifelong healthy eating. J Sch Health1997;67:9-26.

13. Bronner YL. Nutritional status outcomes forchildren: Ethnic, cultural, and environmentalcontexts. J Am Diet Assoc 1996;96:891-903.

14. Tremblay MS, Willms JD. Secular trends in thebody mass index of Canadian children. CanMed Assoc J 2000;63:1429-33. Erratum2001;164(7):970.

15. Troiano RP, Flegal KM. Overweight childrenand adolescents: Description, epidemiology,and demographics. Pediatrics 1998;101:497-504.

16. Chinn S, Rona RJ. Prevalence and trends inoverweight and obesity in three cross sectionalstudies of British children, 1974-94. BMJ2001;322:24-26.

17. Morrison JA, James FW, Sprecher DL, KhouryPR, Daniels SR. Sex and race differences in car-diovascular disease risk factor changes in schoolchildren, 1975-1990: The Princeton SchoolStudy. Am J Public Health 1999;89(11):1708-14.

18. Nicklas TA, Webber, L, Srinivasan SR,Berenson GS. Secular trends in dietary intakesand cardiovascular risk factors of 10 year oldchildren: The Bogalusa Heart Study (1973-1988). Am J Clin Nutr 1993;57:930-37.

19. Ernst ND, Obarzanek E. Child health andnutrition: Obesity and high blood cholesterol.Prev Med 1994;23(4):427-36.

20. Health Canada. Population Health Promotion:An Integrated Model of Population Health andHealth Promotion. February 1996. Availableon-line at: http://www.hc-sc.gc.ca/hppb/phdd/php/php2.htm#Healthy (Accessed onJune 27, 2003).

21. Nicklas T, Bao W, Webber L, Berenson G.Breakfast consumption affects adequacy of totaldaily intake in children. J Am Diet Assoc1993a;93:886-91.

22. Drewnowski A. Taste preferences and foodintake. Annu Rev Nutr 1997a;17:237-53.

23. Birch LL. Children’s preferences for high fatfoods. Nutr Rev 1992;50:249-55.

24. Skinner JD, Carruth BR, Bounds W, ZieglerPJ, Reidy K. Do food related experiences in thefirst 2 years of life predict dietary variety inschool aged children? J Nutr Educ Behav2002;34:310-15.

25. Krebs-Smith SM, Heimendinger J, PattersonBH, Subar AF, Kessler R, Pivouka E.Psychosocial factors associated with fruit andvegetable consumption. Am J Health Promot1995;10:98-104.

26. Drewnowski A, Henderson SA, Levine A, HannC. Taste and food preferences as predictors ofdietary practices in young women. PublicHealth Nutr 1999;2:513-19.

27. Resnicow K, Davis-Hearn M, Smith M,Baranowski T, Lin LS, Baronowski J, et al.Social-cognitive predictors of fruit and vegetableintake in children. Health Psychol 1997;16:272-76.

28. Ross S. ‘Do I really have to eat that?’: A qualita-tive study of schoolchildren’s food choices andpreferences. Health Educ J 1995; 54:312-21.

29. Watt RG, Sheiham A. Towards an understand-ing of young people’s conceptualisation of foodand eating. Health Educ J 1997;56:340-49.

30. Baranowski T, Domel S, Gould R, BaranowskiJ, Leonard S, et al. Increasing fruit and veg-etable consumption among 4th and 5th gradestudents: Results from focus groups using recip-rocal determinism. J Nutr Educ 1993;25:114-20.

31. Kirby S, Baranowski T, Reynolds K, Taylor G,Binkley D. Children’s fruit and vegetableintake: Socioeconomic, adult child, regional andurban-rural influences. J Nutr Educ1995;27:261-71.

32. Shepherd J, Harden A, Rees R, Brunton G,Garcia J, Oliver S, Oakley A. Young people andhealthy eating: A systematic review of researchon barriers and facilitators. London, England:Evidence for Policy and Practice (EPPI-Centre),2001.

33. French SA, Story M, Hannan P, Breitlow KK,Jeffery RW, Baxter JS, Snyder MP. Cognitiveand demographic correlates of low-fat vendingsnack choices among adolescents and adults. J Am Diet Assoc 1999;99:471-75.

34. Pirouznia M. The correlation between nutritionknowledge and eating behavior in an Americanschool: The role of ethnicity. Nutr Health2000;14:89-107.

35. Pirouznia M. The association between nutritionknowledge and eating behavior in male andfemale adolescents in the US. Int J Food SciNutr 2001;52:127-32.

36. Edwards JS, Hartwell HH. Fruit and vegetables- attitudes and knowledge of primary schoolchildren. J Hum Nutr Diet 2002;15:365-74.

37. Croll JK, Neumark-Sztainer D, Story M.Healthy eating: What does it mean to adoles-cents? J Nutr Educ 2001;33:193-98.

38. Harrell JS, McMurray RG, Bangdiwala SI,Frauman AC, Gansky SA, Bradley CB. Effectsof a school-based intervention to reduce cardio-vascular disease risk factors in elementary-schoolchildren: The Cardiovascular Health inChildren (CHIC) study. J Pediatr1996;128:797-805.

39. Hart KH, Bishop JA, Truby H. An investiga-tion into school children’s knowledge andawareness of food and nutrition. J Hum NutrDiet 2002;15:129-40.

40. Hern MJ, Gates D. Linking learning withhealth behaviours of high school adolescents.Pediatr Nurs 1998;24:127-32.

41. Keirle K, Thomas M. The influence of schoolhealth education programmes on the knowledgeand behaviour of school children towards nutri-tion and health. Res Sci Technol Educ2000;18:173-90.

42. Vandongen RV, Jenner DA, Thompson C,Taggart AC, Spickett EE, Burke V, et al. A con-trolled evaluation of a fitness and nutritionintervention program on cardiovascular healthin 10- to 12-year-old children. Prev Med1995;24:9-22.

43. Wardle J, Parmenter K, Waller J. Nutritionknowledge and food intake. Appetite 2000;34:269-75.

44. Berg MC, Goeteborg U, Jonsson I, ConnerMT, Lissner L. Relation between breakfast food



choices and knowledge of dietary fat and fiberamong Swedish schoolchildren. J Adolesc Health2002;31:199-207.

45. Baranowski T, Cullen KW, Baranowski J.Psychosocial correlates of dietary intake:Advancing dietary intervention. Annu Rev Nutr1999;19:17-40.

46. Noble C, Corney M, Eves A, Kipps M,Lumbers M. School meals: Primary schoolchild-ren’s perceptions of the healthiness of foodsserved at school and their preferences for thesefoods. Health Educ J 2001;60:102-19.

47. Perry CL, Stone E, Parcel GS, Ellison RC,Nader PR, Webber LS, Luepker RV. School-based cardiovascular health promotion: TheChild and Adolescent Trial for CardiovascularHealth (CATCH). J Sch Health 1990;60:406-13.

48. Reynolds KD, Franklin FA, Binkley D,Raczynski JM, Harrington KF, Kirk KA, PersonS. Increasing the fruit and vegetable consump-tion of fourth-graders: Results from the High 5Project. Prev Med 2000;20:309-19.

49. O’Dea JA. Why do kids eat healthful food?Perceived benefits of and barriers to healthfuleating and physical activity among children andadolescents. J Am Diet Assoc 2003;103:497-501.

50. Reynolds KD, Hinton AW, Shewchuk RM,Hickey CA. Social cognitive model of fruit andvegetable consumption in elementary children. J Nutr Educ 1999a;31:23-30.

51. Berg C, Jonsson I, Conner M. Understandingchoice of milk and bread for breakfast amongSwedish children aged 11-15 years: An applica-tion of the Theory of Planned Behaviour.Appetite 2000;34:5-19.

52. Baranowski T, Cullen KW, Nicklas T,Thompson D, Baranowski J. School-based obe-sity prevention: A blueprint for taming the epi-demic. Am J Health Behav 2002;26:486-93.

53. Lytle LA, Varnell S, Murray DM, Story M,Perry C, Nirnbaum AS, Kubik MY. Predictingadolescents’ intake of fruits and vegetables. J Nutr Educ Behav 2003;35:170-78.

54. Chapman G, MacLean H. “Junk food” and“healthy food”: Meanings of food in adolescentwomen’s culture. J Nutr Educ 1993;25:108-13.

55. Novotny R, Han JS, Biernacke I. Motivatorsand barriers to consuming calcium-rich foodsamong Asian adolescents in Hawaii. J NutrEduc 1999;31:99-104.

56. Basiotis PP, Kramer-LeBlanc CS, Kennedy ET.Maintaining nutrition security and diet quality:The role of the Food Stamp program and WIC.Fam Econ Nutr Rev 1998;11:4-16.

57. Drewnowski A. Fat and sugar: An economicanalysis. J Nutr 2003;133:838S-840S.

58. French SA. Pricing effects on food choices. J Nutr 2003;133;841S-843S.

59. Guthrie JF, Lin B-H, Frazao E. Role of foodprepared away from home in the American diet,1977-78 versus 1994-96: Changes and conse-quences. J Nutr Educ Behav 2002;34:140-50.

60. Pelto GH, Backstrand JR. Interrelationshipsbetween power related and belief-related factorsdetermine nutrition in populations. J Nutr2003;133:297S-300S.

61. Cullen KW, Lara KM, de Moor C. Children’sdietary fat intake and fat practices vary by mealand day. J Am Diet Assoc 2002b;102:1773-78.

62. Guillaume M, Lapidus L, Lambert A. Obesityand nutrition in children. The BelgianLuxemburg Child Study IV. Eur J Clin Nutr1998;52:323-28.

63. Crawford PB, Obarzanek E, Schreiber GB,Barrier P, Goldman S, Frederick MM, SabryZI. The effects of race, household income andparental education on nutrient intakes of 9 and10 year old girls. Ann Epidemiol 1995;5:360-68.

64. Neumark-Sztainer D, Hannan PJ, Story M,Croll J, Perry C. Family meal patterns:

Associations with sociodemographic characteris-tics and improved dietary intake among adoles-cents. J Am Diet Assoc 2003;103:317-22.

65. Mennell S. The globalization of eating. Appetite2000;35:191-92.

66. Krondl M, Lau D. Acculturation of food habits.In: Masi R, Mensah LL, MacLeod K (Eds),Health and Cultures, Vol. I. Oakville, ON:Mosaic Press Publishers, 1993;185-94.

67. Kuhnlein HV, Soueida R, Receveur O. BaffinInuit food use by age, gender and season. J CanDiet Assoc 1995;56:175-83.

68. Evers S. Dietary intake and nutritional status ofCanadian Indians: A review. Arctic Med Res1991;50(Suppl 5):731-34.

69. Trifonopoulos M, Kuhnlein H, Receveur O.Analysis of 24-hour recalls of 164 fourth- tosixth-grade Mohawk children in Kahnawake. J Am Diet Assoc 1998;98:814-16.

70. Morrison NE, Receveur O, Kuhnlein HV,Appavoo DM, Soueida R, Pierrot P.Contemporary Sahtu Dene/Metis use of tradi-tional and market food. Ecol Food Nutr1995;34:197-210.

71. Davison KK, Birch LL. Childhood overweight:A contextual model and recommendations forfuture research. Obes Rev 2001;2:159-71.

72. Oliveria SA, Ellison RC, Moore LL, GillmanMW, Garrahie EJ, Singer MR. Parent-childrelationships in nutrient intake: TheFramingham Children’s Study. Am J Clin Nutr1992;56:593-98.

73. Nicklas TA, Baranowski T, Cullen KW,Berenson G. Eating patterns, dietary qualityand obesity. J Am Coll Nutr 2001a;20:599-608.

74. Hearn MD, Baranowski T, Baranowski J,Doyle C, Smith M, Lin L, Resnicow K.Environmental influences on dietary behaviouramong children: Availability and accessibility offruits and vegetables enable consumption. J Health Educ 1998;29:26-32.

75. Backman DR, Haddad EH, Lee JW, JohnstonPK, Hodgkin GE. Psychosocial predictors ofhealthful dietary behavior in adolescents. J NutrEduc Behav 2002;34:184-93.

76. Promoting Healthy Eating and Active Living inChildren Project. Barriers and enablers to healthyeating and active living in children: Key findingsin six Nova Scotia communities. CanadianDiabetes Association, December 2002.

77. Tibbs T, Haire-Joshu D, Schechtman KB,Brownson RC, Nanney MS, Houston C,Auslander W. The relationship betweenparental modeling, eating patterns, and dietaryintake among African-American parents. J AmDiet Assoc 2001;101:535-41.

78. Skinner JD, Carruth BR, Moran III J, HouckK, Schmidhammer J, Reed A, Coletta F.Toddlers’ food preferences: Concordance withfamily members’ preferences. J Nutr Educ1998;30:17-22.

79. Neumark-Sztainer D. The social environmentsof adolescents: Associations between socioenvi-ronmental factors and health behaviors duringadolescence. Adolesc Med 1999a;10:41-55.

80. Gillman MW, Rifas-Shiman SL, Frazier AL,Rockett HRH, Camargo CA, Field AE, et al.Family dinner and diet quality among olderchildren and adolescents. Arch Fam Med2000;9:235-40.

81. Videon TM, Manning CK. Influence on ado-lescent eating patterns; The importance of fami-ly meals. J Adolesc Health 2003;32:365-73.

82. Fisher JO, Birch LL. Restricting access to foodsand children’s eating. Appetite 1999a;32:405-19.

83. Birch LL . Psychological influences on thechildhood diet. J Nutr 1998;128:407S-410S.

84. Fisher JO, Birch LL. Restricting access to apalatable food affects children’s behavioralresponse, food selection, and intake. Am J ClinNutr 1999b;69:1264-72.

85. Birch LL. Development of food acceptance pat-terns in the first years of life. Proc Nutr Soc1998;57:617-24.

86. Birch LL, Fisher JO. Development of eatingbehaviors among children and adolescents.Pediatrics 1998;101:539-49.

87. Fisher JO, Mitchell DC, Smiciklas-Wright H,Birch LL. Parental influences on young girls’fruit and vegetable, micronutrient and fatintakes. J Am Diet Assoc 2002;102:58-64.

88. De Bourdeaudhuij I. Family food rules andhealthy eating in adolescents. J Health Psychol1997;2:45-56.

89. Nicklas TA, Baranowski T, Baranowski J,Cullen K, Rittenberry L, Olivera N. Family andchild-care provider influences on preschool chil-dren’s fruit, juice and vegetable consumption.Nutr Rev 2001b;59:224-35.

90. Contento IR, Basch C, Shea S, Guting B,Zybert P, Michela JL, Rips J. Relationship ofmothers’ food choice criteria to food intake ofpreschool children: Identification of family sub-groups. Health Educ Q 1993;20:243-59.

91. Zive MM, Berry CC, Sallis JF, Frank GC,Nader PR. Tracking dietary intake in white andMexican-American children from age 4 to 12years. J Am Diet Assoc 2002a;102:683-89.

92. Gibson EL, Wardle J, Watts CJ. Fruit and veg-etable consumption, nutritional knowledge andbeliefs in mothers and children. Appetite1998;31:205-28.

93. Gable S, Lutz S. Nutrition socialization experi-ences of children in the Head Start program. J Am Diet Assoc 2001;101:572-77.

94. Birch LL. Effects of peer models’ food choicesand eating behaviors on preschoolers’ food pref-erences. Child Dev 1980;51:489-96.

95. Hendy HM, Raudenbush B. Effectiveness ofteacher modelling to encourage food acceptancein preschool children. Appetite 2000;34:61-76.

96. Marquis M, Dagenais F, Filion YP. The habitof eating while watching television, the frequen-cy of consumption of specific foods and foodpreferences, as reported by Quebec children.Can J Diet Pract Res 2002;63:S104.

97. Francis LA, Lee Y, Birch LL. Parental weightstatus and girls’ television viewing, snacking, andbody mass indexes. Obes Res 2003;11:143-51.

98. Byrd-Bredbenner C, Grasso D. What is televi-sion trying to make children swallow?: Contentanalysis of the nutrition information in primetime advertisements. J Nutr Educ 2000;32:187-95.

99. Wadsworth LA, MacQuarrie A. Nutrition mes-sages on Saturday morning children’s television:1989-1998. Can J Diet Pract Res 2002;63Supp:105.

100. Østbye T, Pomerleau J, White M, Coolich M,McWhinney J. Food and nutrition in Canadian“prime time” television commercials. Can JPublic Health 1993;84:370-74.

101. Borzekowski DL, Robinson TN. The 30-sec-ond effect: An experiment revealing the impactof television commercials on food preferences ofpreschoolers. J Am Diet Assoc 2001;101:42-46.

102. Hanley AJG, Harris SB, Gittelsohn J, WoleverTMS, Saksvig B, Zinman B. Overweightamong children and adolescents in a NativeCanadian community: Prevalence and associat-ed factors. Am J Clin Nutr 2000;71:693-700.

103. Berkey CS, Rockett HRH, Field AE, GillmanMW, Frazier AL, Camargo Jr CA, Colditz GA.Activity, dietary intake, and weight changes in alongitudinal study of preadolescent and adoles-cent boys and girls. Pediatrics 2000;105:56.

104. Field AE, Camargo Jr CA, Barr Taylor C,Berkey CS, Roberts SB, Colditz GA. Peer, par-ent, and media influences on the developmentof weight concerns and frequent dieting amongpreadolescent and adolescent girls and boys.Pediatrics 2001;107:54-60.



105. Young LR, Nestle M. Expanding portion sizesin the US marketplace: Implications for nutri-tion counseling. J Am Diet Assoc 2003;103:231-34.

106. Rolls BJ, Engell D, Birch LL. Serving portionsize influences 5-year-old but not 3-year-oldchildren’s food intake. J Am Diet Assoc2000;100:232-34.

107. Hill JO, Peters JC. Environmental contribu-tions to the obesity epidemic. Science 1998;280:1371-74.

108. Neumark-Sztainer D, Martin SL, Story M.School-based programs for obesity prevention:What do adolescents recommend? Am J HealthPromot 2000a;14:232-35.

109. Briggs M, Safaii S, Beall DL. Position of theAmerican Dietetic Association, Society forNutrition Education and American School FoodService Association-Nutrition Services: An essen-tial component of comprehensive school healthprograms. J Am Diet Assoc 2003;103:505-14.

110. Rankine D. Foods Available in New BrunswickSchools. Survey Report 1989-1990. HealthPromotion and Disease Prevention Unit, PublicHealth/Medical Services Division, Departmentof Health and Community Services. November1990.

111. Nova Scotia Department of Health, NovaScotia Nutrition Council. Foods Offered inSchools. Report of a survey of school food pro-vision practices in Nova Scotia. Halifax 1993.

112. Manitoba Council on Child Nutrition. Foodand nutrition in Manitoba schools. SurveyReport 2001. Available on-line at:http://www.mast.mb.ca/communications/poverty/MCCN.pdf (Accessed on July 5, 2002).

113. Taylor JP, Mather SE, McBride TL. Food andnutrition policies and programs in PrinceEdward Island schools. Presented at the SecondConference of the International Society forBehavioral Nutrition and Physical Activity(ISBNPA). Quebec City, July 2003.

114. Coalition for School Nutrition. Survey of foodand nutrition policies and services inNewfoundland and Labrador. 2001. Availableon-line at: http://www.nlta.nf.c/a/html_files/

coalition/survey.html (Accessed on July 5,2002).

115. Health Canada. Scan of Canadian NutritionPrograms for School-Aged Children. Ottawa,ON: Childhood and Youth Division, HealthCanada, 1998.

116. Luepker R, Perry C, McKinlay SM, Nader PR,Parcel GS, Stone EJ, et al. Outcomes of a fieldtrial to improve children’s dietary patterns andphysical activity: The Child and AdolescentTrial for Cardiovascular Health (CATCH).JAMA 1996;275:768-76.

117. Tarasuk V, Beaton G. Household food insecuri-ty and hunger among families using food banks.Can J Public Health 1999a;90:109-13.

118. Tarasuk VS, Beaton GH. Women’s dietaryintake in the context of household food insecu-rity. J Nutr 1999b;129:672-79.

119. McIntyre L, Glanville NT, Raine KD, DayleJB, Anderson B. Do low-income lone motherscompromise their nutrition to feed their chil-dren? CMAJ 2003;168:686-91.

120. Hamelin AM, Habicht JP, Beaudry M. Food inse-curity: Consequences for the household and broad-er social implications. J Nutr 1999;129:525S-528S.

121. Badun C, Evers S, Hooper M. Food securityand nutritional concerns of parents in an eco-nomically disadvantaged community. J CanDiet Assoc 1995;56:75-80.

122. Pliner P. Development of measures of food neo-phobia in children. Appetite 1994;23:147-63.

123. Pliner P, Stallberg-White C. “Pass the ketchup,please.”: Familiar flavours increase children’swillingness to try novel foods. Appetite2000;34:95-103.

124. De Bourdeaudhuij I, Van Oost P. Family mem-bers’ influence on decision making about food:Differences in perception and relationship withhealthy eating. Am J Health Promot 1998;13:73-81.

125. Alderson TSJ, Ogden J. What do mothers feedtheir children and why? Health Educ Res1999;14:717-27.

126. Cullen KW, Lara KM, de Moor C. Familialconcordance of dietary fat practice and intake.Fam Community Health 2002c;25:65-75.

127. Fried EJ, Nestle M. The growing politicalmovement against soft drinks in schools. JAMA2002;288:2181.

128. Kuribayashi A, Roberts MC, Johnson RJ.Actual nutritional information of productsadvertised to children and adults on Saturday.Child Health Care 2001;30:309-22.

129. Lytle LA, Eldredge AL, Kotz K, Piper J,Williams S, Kalina B. Children’s interpretationof nutrition messages. J Nutr Educ1997;29:128-36.

130. McQuaid S, Allen T, Smith N. A review of thelabor market status of home economists in PEI.A report prepared for the PEI Home EconomicsAssociation and the University of PrinceEdward Island. November 2001.

131. Reynolds KD, Franklin FA, Binkley D,Raczynski JM, Harrington KF, Kirk KA, PersonS. Increasing the fruit and vegetable consump-tion of fourth-graders: Results from the High 5Project. Prev Med 2000;20:309-19.

132. Domel SB, Baranowski T, Davis H, ThompsonWO, Leonard SB, Riley P, et al. Developmentand evaluation of a school intervention toincrease fruit and vegetable consumptionamong 4th and 5th grade students. J Nutr Educ1993;25:345-49.

133. Lytle LA, Fulkerson JA. Assessing the dietaryenvironment: Examples from school basedinterventions. Public Health Nutr 2002;5:893-99.

134. McAmmond D. Promotion and support ofhealthy eating. An initial overview of knowledgegaps and research needs. Final report preparedfor the Office of Nutrition Policy andPromotion, Health Canada, March 2001.

135. Statistics Canada. The Canadian CommunityHealth Survey. Cycle 2.1. Available on-line at:http://www.statcan.ca/english/concepts/health/cycle2_1/cchsinfo.htm (Accessed on March 30,2003).

136. Contento IR, Randell JS, Basch CE. Reviewand analysis of evaluation measures used innutrition education intervention research. J Nutr Educ Behav 2002;34:2-25.

Determinants of Healthy Eatingin Community-dwelling ElderlyPeopleHélène Payette, PhD1

Bryna Shatenstein, PhD, PDt2

ABSTRACT

Among seniors, food choice and related activities are affected by health status, biologicalchanges wrought by aging and functional abilities, which are mediated in the larger arenaby familial, social and economic factors. Determinants of healthy eating stem fromindividual and collective factors. Individual components include age, sex, education,physiological and health issues, psychological attributes, lifestyle practices, andknowledge, attitudes, beliefs and behaviours, in addition to other universal dietarydeterminants such as income, social status and culture. Collective determinants of healthyeating, such as accessible food labels, an appropriate food shopping environment, themarketing of the “healthy eating” message, adequate social support and provision ofeffective, community-based meal delivery services have the potential to mediate dietaryhabits and thus foster healthy eating. However, there is a startling paucity of research inthis area, and this is particularly so in Canada. Using search and inclusion criteria and keysearch strings to guide the research, this article outlines the state of knowledge andresearch gaps in the area of determinants of healthy eating among Canadian seniors. Inconclusion, dietary self-management persists in well, independent seniors withoutfinancial constraints, whatever their living arrangements, whereas nutritional risk is highamong those in poor health and lacking in resources. Further study is necessary to clarifycontributors to healthy eating in order to permit the development and evaluation ofprograms and services designed to encourage and facilitate healthy eating in olderCanadians.

MeSH terms: Elderly; nutrition; determinants; eating habits; healthy eating

People aged 65 or over account for13% of the nation’s population.1

Those aged 80 or over are increasingat the fastest pace, and this segment isexpected to increase by 43% in the next 10years. Most seniors aged 65 or over live athome (93%) and report that their health isgenerally good.1 However, 41% of Canadianseniors report having disabilities. Theseinclude problems with vision, memory,hearing, speech, mobility and agility, as wellas pain and learning, developmental, andpsychological difficulties.2 Those who agesuccessfully live independently and show lit-tle or almost no loss in functioning. Thoseaging in a typical fashion live independentlyand have a variety of medical conditions.Finally, those in whom the aging process isaccelerated carry a heavy burden of chronicdisease and disabilities, which generallyobliges them to live in institutions.3,4

Aging is generally believed to alter nutri-ent requirements for energy, protein andother nutrients because of changes in leanbody mass, physical activity and intestinalabsorption. Energy needs decline with agebecause of decreased basal metabolism,5

reduction in lean body mass or sarcopenia6

and a more sedentary lifestyle.7,8 Energyneeds could be even higher than levels setout in the current recommendations9-11

considering that regulation of food intakeis impaired in old age.12 However, totalenergy intake generally decreases with ageand results in concomitant declines inmost nutrients, the distribution of manymicronutrients indicating intakes belowrecommended levels.13-18

Among elderly persons, food-relatedactivities are greatly affected by health sta-tus and functional abilities.19-21 Forinstance, the ability to procure and preparenutritious food and eat independently, theavailability of dietary assistance whenneeded, and appropriate meal environmentand food presentation will contribute to anadequate diet.22-24 On the other hand, apoor diet can contribute to frailty, compli-cating functional limitations25,26 and lead-ing to loss of muscle mass, metabolicabnormalities and diminished immunity.Malnutrition occurs on a continuum andis most often characterized as poorappetite, insufficient dietary intake, faultyor inadequate nutritional status, weightloss and muscle wasting.27

However, these results should be inter-preted with caution, since many con-

1. Research Centre on Aging, Sherbrooke Geriatric University Institute, Sherbrooke, and Faculté demédecine et des sciences de la santé, Université de Sherbrooke, Québec

2. Département de nutrition, Université de Montréal, and Centre de recherche, Institut universitairede gériatrie de Montréal, Québec

Correspondence and reprint requests: Hélène Payette, Director, Research Centre on Aging,Sherbrooke Geriatric University Institute, 1036 Belvédère Street South, Sherbrooke, QC J1H 4C4, Tel:819-829-7131, Ext. 2631, Fax: 819-829-7141, E-mail: [email protected]: The authors would like to express special thanks to Céline Lapointe and SandraBérubé for their assistance in searching and reviewing the literature.


founding factors, such as the cohort orperiod effect and selective mortality, can-not be clearly separated from the agingeffect per se, particularly in cross-sectionalstudies. The few nutritional surveys of free-living elderly subjects with functional dis-abilities or in poor health suggest dietaryintakes leading to insufficient levels ofenergy, protein and most micronutrients.28-35

This paper was written to outline thestate of knowledge and research gaps in thearea of determinants of healthy eatingamong Canadian seniors.


Search and inclusion criteria and keysearch strings were established and used toguide the research. Published literaturefrom 1990 to 2003 was examined as wellas several older, classic sources. The searchstrategy targeted sources of information onthe determinants of healthy eating amongseniors, using web-based search enginessuch as MEDLINE, Ageline, PsycINFOand others, along with position papers andwebsites of numerous national and interna-tional governmental, public health- andnutrition-oriented organizations, as well aselectronic newsletters. Search tools avail-able through universal web browsers suchas Google and Alta Vista were also used,and the relevant “grey literature” wasaccessed through a bilingual (French,English) catalogue developed by theBibliothèque de gériatrie et de gérontologieof the Institut universitaire de gériatrie deMontréal. Key words included healthy eat-ing in seniors, determinants of diet inelderly, factors influencing diet in elderly,determinants of nutrition status in elderly,determinants of food choice (intake/con-sumption/habits/practices) in older people,nutritional health promotion in the elder-ly, and targeted specific issues, such associal support and healthy eating.

Peer-reviewed scientific journals werethe main sources of publications of recentresearch, and the proceedings of scientificconferences were also used to keep track ofongoing research in Canada, the US andinternationally. Specific searches were car-ried out to locate and access research con-ducted by Canadian researchers, and anattempt was made to query gerontologicalnutritionists on their work. Studies were

included in the review if they met the following criteria: study subjects were65+ years of age, the dependent variablewas “healthy eating”, or the study wascross-sectional or longitudinal. Studieswere excluded from the review if the lan-guage of publication was other thanEnglish or French, or the methodologywas not described or was unreliable.Decisions on the relevance of the materialwere made by both authors on the basis ofthe abstracts and, where necessary, thecomplete articles. Papers reporting on veryspecific population subgroups were dis-cussed and put into context at the discre-tion of the authors.

Determinants of healthy eating inolder people

Individual Determinants of HealthyEatingIndividual components motivating dietarypractices include age, sex, education, othersocio-economic factors, physiological andhealth issues, psychological attributes,lifestyle practices, and knowledge, atti-tudes, beliefs and behaviours. As peopleage, these factors often lead to alterationsin food selection and decreases in foodintake.25,36-39 Such modifications may bemediated by marital status, smoking,health status and physical activity level,physiological and functional attributes, anddiverse biological changes wrought byaging, in addition to universal dietarydeterminants such as sex, education,income, social status and culture. Whilehigher education and income levels are fre-quently strongly associated with betternutrition, disease prevention knowledgeand behaviour in US, European40-48 andCanadian studies,21 this is not a universalfinding.49,50 These conflicting results mayreflect not only the great heterogeneity inolder populations but also the impact ofconfounding factors. For instance, foodaccess is more difficult and health prob-lems are more frequent in disadvantagedelderly subjects.51 This controversy is fur-ther highlighted when comparing cross-sectional and longitudinal survey findings.Indeed, over a six-year period, age emergedas a positive predictor of diet quality, par-ticularly among women.52

Food intake and appetite can also benegatively influenced by impaired visual13

auditory and olfactory stimuli.53-56 Manydrugs can also alter taste.57 A decline insalivary flow and masticatory impairmentdue to poor dentition (loss of teeth, inade-quate dental and gingival care) contributeto insufficient mechanical crushing andinitial enzymatic digestion in the mouth.58-60

These processes, along with mechanismsgoverning satiation and energy metabo-lism,61,62 have been shown to be disruptedin older adults, leading to the developmentof a physiological “anorexia of aging”.63,64

Loneliness can contribute to inadequatenutrient intakes.40,65 Indeed, it has beenshown that simply having the Meals-on-Wheels delivery volunteer stay with themeal recipient can improve dietaryintakes.66 Food and nutrient intakes maybe better among those with high nutritionand health awareness40,67-70 and pooreramong those with a negative self-perceptionof physical health.21,65 In secondary analy-ses of dietary data collected fromQuebecers aged 65 to 74 years,71 regressionanalyses showed that the strongest corre-lates of diet quality were the degree ofattention paid to keeping a healthy diet,along with higher education, being a city-dweller, being a non-smoker and regularexercise.70 The issue of supplement use isalso of interest in older individuals, as thismay signal a healthier lifestyle and highernutrient intake72 or, on the other hand,provide evidence that supplements are usedto compensate for a poor diet.70 Finally,alcohol intake in seniors tends to be mod-erate,73 and light to moderate drinking isassociated with a better nutrient profile inolder people.47,73

Collective Determinants of HealthyEatingFood choice in seniors is motivated byindividual attributes that are mediated inthe larger arena by familial, social and eco-nomic factors. In older people, collectivedeterminants of healthy eating, such asaccessible food labels, an appropriate foodshopping environment,74,75 the marketingof the “healthy eating” message,75,76 ade-quate social support70 and provision ofeffective community-based meal deliveryservices,31,77 have the potential to mediatedietary habits and thus foster healthy eat-ing. However, there is a startling paucity ofresearch in this area, and this is particularlyevident in Canada.

HEALTHY EATING IN COMMUNITY-DWELLING ELDERLY PEOPLE


In community-dwelling elders, the rela-tion between dietary quality, social supportand living arrangements is controversial.Some studies have found positiverelations,21,65,68,70,78-80 whereas others havefound diet quality to be unaffected by apoor social network.81 It has been suggest-ed that geographical isolation has anadverse effect on nutritional status amongthe elderly.82 For instance, an urban-ruraldifference in meal structure was observedin Poland,83 with lower consumption ofcertain food groups (meat, fish and eggs,fruit and their products, and fats and oils)in rural-dwelling seniors. It was suggestedthat food distribution systems anddecreased buying power among ruralinhabitants profoundly affect food habits.In contrast, other comparative studies ofurban and rural-dwelling seniors in theUS84,85 showed that nutrient intakes werenot related to geographical setting. Theseobservations demonstrate the difficultiesinherent in drawing conclusions from age,sex, socio-economic and health factorswhen comparing urban and rural seniors,but they could also be due to specific char-acteristics within the populations studied.The local food environment has an impacton food choice beyond the urban-ruralissue.

Food consumption research suggeststhat widowhood confers potentially nega-tive effects on food intake through weightchange, increased adverse health outcomes,including depression, and diminished“nutritional self-management”, leading tochanges in dietary behaviour and foodintakes.86,87 This is particularly evidentamong men over the age of 7540,65,78,88 withlow incomes.89 Indeed, there is a strongrelation between living alone and dietaryintakes among men,80,88-90 but these find-ings have not been consistent91,92 and areeven less so among women.88 Informationon the influence of living arrangements ondietary intake in seniors appears to beinconclusive and may depend on culturalor other differences in the samples studied.

In conclusion, research in this area hasclearly identified two poles: widowed indi-viduals (men or women) in good healthand without financial constraints who con-tinued to drive and remained independentin their dietary self-management; andthose in poor health with no informal sup-port, who experienced difficulties obtain-

ing formal support services, had few socialcontacts and were at great nutritional risk,since their food preparation abilities anddietary intakes could become extremelylimited. These qualitative observations aresupported by secondary analyses of Quebecnutrition survey data.70

The heterogeneity and interactionbetween needs and adaptive dietary strate-gies often cloud the issue, and only longi-tudinal studies will permit clarification ofthese differential influences on healthy eat-ing. Given the complexity of these inter-actions and the fact that most research todate has been cross-sectional, it is virtuallyimpossible to tease apart the specific influ-ence of individual or collective determi-nants.

KNOWLEDGE GAPS AND DIRECTIONS FOR FURTHER RESEARCH

Gaps in knowledge were detected in thecourse of this review. These are summa-rized in the following section, which alsosuggests directions for further investiga-tion. Further study and regular dietarymonitoring are needed in order to knowmore about food consumption habits inseniors. These investigations must beadapted to the reality of targeted agingpopulations using precise measurements,diverse approaches, appropriate methodsand accurate dietary assessment tools toreflect the great heterogeneity typical ofolder populations.

The research agenda should be focussedon interactions between individual andcollective determinants of healthy eatingthat are unique to the elderly in Canada.To achieve this goal, longitudinal studiesshould be conducted to examine the epi-demiological and social aspects of aging;describe the chronology of events and thedirection of causal relations; determine andtrack seniors’ food intakes, their food-relatedneeds, variability over time in dietary needsand resources; the interactions that existbetween age- and gender-related changesin socio-demographic factors and eating;and how healthy eating could interfacewith disease prevention and health mainte-nance.

Further study is necessary in order tounderstand which foods favour healthyaging. Patterns of use, long-term effective-

ness and the safety of dietary supplements,probiotics and functional foods in agingpopulations must be further investigated.Indeed, more needs to be known aboutwhat constitutes “healthy eating” in seniorsto permit the modification of our foodguidance system and provide Canadianseniors with targeted dietary guidance.

More specifically, we must further exam-ine health beliefs, and food beliefs andpractices that have symbolic or traditionalimportance to determine how knowledge,beliefs and attitudes translate into eatingbehaviour in older adults, especially atadvanced ages. More research is needed toclarify the relative contribution of income,ethnic background and other personal pre-dictors of healthy eating – self-control,emotions, resistance to change, time con-straints, lack of knowledge – and environ-mental factors governing food availabilityand cost. Information is needed linkingnutritional services, health, psychological,cognitive and social characteristics, as wellas financial constraints to procuringhealthy foods. More information is neededon barriers, both real and perceived, thatdiscourage healthy eating. For instance, theimpact of therapeutic or self-imposedrestrictive diets on dietary adequacy is notknown. Investigations must simultaneouslyaddress interdependent attributes, such asbiological parameters, clinical factors andthe psychosocial dimension, together withdietary and psychosocial variables.

To encourage and facilitate healthy eat-ing in older people, a broad range ofimproved and expanded services must beoffered to seniors as an adjunct to thehealthy eating message. The availability,acceptability, utilization and effectivenessof nutritional interventions and communi-ty programs should be rigorously exam-ined, evaluated and refined in order to fos-ter independence in community-dwellingseniors living in urban or rural communi-ties.

Other issues that require further study tofacilitate healthy eating in older Canadiansshould be clarified by academics, clini-cians, public health authorities, the foodindustry and decision-makers at both theregional and national level. These mayinclude evaluation of the effectiveness ofprovision and marketing of appropriate,affordable nutrient-dense foods andupgrading the food market and transporta-



tion (food products, packaging, shelf pre-sentation, supermarket organization andlocation, delivery). These efforts mustinvolve concerted action by dietitians,manufacturers, retailers and foodserviceproviders to offer a nutritious and accessi-ble food supply for the seniors’ market. Itis essential that healthy nutritional mes-sages be coupled with adequate physicalactivity to produce a broad-based healthpromoting lifestyle in older Canadians, andthat the effectiveness of these population-based programs be documented.

REFERENCES

1. Statistics Canada. 2001 Census Analysis Series –Profile of the Canadian Population by Age and Sex:Canada Ages. Catalogue: 96F0030XIE2001002,Ottawa. Available on-line at http://www12.stat-can.ca/english/census01/Products/Analytic/com-panion/age/contents.cfm (accessed Jan 27, 2003).

2. Statistics Canada. Participation and ActivityLimitation Survey, 2001. A Profile of Disability inCanada, 2001 – Tables. Catalogue no. 89-579-XIE, Ottawa, ON, December 2002.

3. Rowe JW, Kahn RL. Successful Aging. Toronto,ON: Random House, 1998.

4. Bates CJ, Benton D, Biesalski HK, Staehelin HB,van Staveren W, Stehle P, et al. Nutrition andaging: A consensus statement. J Nutr HealthAging 2002;6(2):103-16.

5. Forbes GB. Human Body Composition. Growth,Aging, Nutrition, and Activity. New York, NY:Springer-Verlag, 1987.

6. Rosenberg IH. Sarcopenia: Origins and clinicalrelevance. J Nutr 1997;127:990S-991S.

7. Garry PJ, Vellas BJ. Aging and nutrition. In:Ziegler EE, Filer LJ, Jr. (Eds.), Present Knowledgein Nutrition, 7th ed. Washington, DC: ILSI Press,1996;414-19.

8. Ausman LM, Russell RM. Nutrition in the elder-ly. In: Shils ME, Olson JA, Shike M, Ross AC(Eds.), Modern Nutrition in Health and Disease,9th ed. Baltimore, MD: Williams & Wilkins,1999;869-81.

9. Campbell WW, Cyr-Campbell DWJA, EvansWJ. Energy requirement for long-term bodyweight maintenance in older women. Metabolism1997;46(8):884-89.

10. Roberts SB, Dallal G. Effects of age on energybalance. Am J Clin Nutr 1998;68S:975S-979S.

11. Poehlman ET. Energy expenditure and require-ments in aging humans. J Nutr 1992;122:2057-65.

12. Roberts SB. Energy regulation and aging: Recentfindings and their implications. Nutr Rev2000;58(4):91-97.

13. Moreiras O, van Staveren WA, Amorim Cruz JA,Nes M, Lund-Larsen K. Euronut-SENECA studyon nutrition and the elderly in Europe. Intake ofenergy and nutrients. Eur J Clin Nutr1991;45(Suppl.3):105-19.

14. Payette H, Gray-Donald K. Dietary intake andbiochemical indices of nutritional status in anelderly population with estimates of the precisionof the 7-d food record. Am J Clin Nutr1991;54(3):478-88.

15. Ryan AS, Craig LD, Finn SC. Nutrient intakesand dietary patterns of older Americans: Anational study. J Gerontol A Biol Sci Med Sci1992;47(5):M145-M150.

16. Wakimoto P, Block G. Dietary intake, dietarypatterns, and changes with age: An epidemiologi-cal perspective. J Gerontol A Biol Sci Med Sci2001;56 Spec No 2(2):65-80.

17. DeWolfe J, Millan K. Dietary intake of olderadults in the Kingston area. Can J Diet Pract Res2003;64(1):16-24.

18. Shatenstein B, Nadon S, Ferland G. Diet qualityamong older Quebecers as assessed by simpleindicators. Can J Diet Prac Res 2003;64(4):174-80.

19. Payette H, Gray-Donald K, Cyr R, Boutier V.Predictors of dietary intakes in a functionallydependent elderly population in the community.Am J Public Health 1995;85(5):677-83.

20. Gray-Donald K. The frail elderly: Meeting thenutritional challenges. J Am Diet Assoc1995;95(5):538-40.

21. Keller HH, Østbye T, Bright-See E. Predictors ofdietary intake in Ontario seniors. Can J PublicHealth 1997;88:305-9.

22. Finley B. Nutritional needs of the person withAlzheimer’s disease: Practical approaches to qualitycare. J Am Diet Assoc 1997;97(Suppl.2):S177-80.

23. Payette H, Ferland G. La malnutrition chez lespersonnes âgées démentes : étiologie, évolutionet efficacité des interventions. L’Année géron-tologique 1999;(Suppl « Nutrition et vieillisse-ment »):131-45.

24. Shatenstein B, Ferland G. Absence of nutritionalor clinical consequences of decentralised bulkfood portioning in elderly nursing home residentswith dementia in Montreal. J Am Diet Assoc2000;100(11):1354-60.

25. Lebel P, Leduc N, Kergoat M-J, Latour J, LeclercC, Beland F, et al. Un modèle dynamique de lafragilité. L’Année gérontologique 1999;13:89-94.

26. Nourhashémi F, Andrieu S, Gillette-Guyonnet S,Vellas B, Albarede JL, Grandjean H.Instrumental activities of daily living as a poten-tial marker of frailty: A study of 7364 communi-ty-dwelling elderly women (the EPIDOS study).J Gerontol A Biol Sci Med Sci 2001;56(7):M448-M453.

27. Chen CC, Schilling LS, Lyder CH. A conceptanalysis of malnutrition in the elderly. J AdvNurs 2001;36(1):131-42.

28. Owen R, Krondl M, Csima A. Contribution ofconsumed home-delivered meals to dietary intakeof elderly women. J Can Diet Assoc 1992;52:24-29.

29. Stevens DA, Grivetti LE, McDonald RB.Nutrient intake of urban and rural elderly receiv-ing home-delivered meals. J Am Diet Assoc1992;92(6):714-18.

30. Smiciklas-Wright H, Lago DJ, Bernardo V,Beard JL. Nutritional assessment of homeboundrural elderly. J Nutr 1990;120:1535-37.

31. Payette H, Gray-Donald K. Risk of malnutrition in anelderly population receiving home care services. FactsRes Gerontol 1994;(supplement:Nutrition):71-85.

32. Ritchie CS, Burgio KL, Locher JL, Cornwell A,Thomas D, Hardin M, et al. Nutritional status ofurban homebound older adults. Am J Clin Nutr1997;66:815-18.

33. Hoogenboom MS, Spangler AA, Crose R.Functional status and nutrient intake from theCouncil on Aging meal and total daily intake ofcongregate, adult day care and homebound pro-gram participants. J Nutr Elder 1998;17(3):1-18.

34. Coulston AM, Craig L, Voss AC. Meals-on-wheelsapplicants are a population at risk for poor nutri-tional status. J Am Diet Assoc 1996;96(6):570-73.

35. Gloth FM, Jordan DT, Smith CE, Meyer JN.Nutrient intakes in a frail homebound elderlypopulation in the community vs a nursing homepopulation. J Am Diet Assoc 1996;96(6):605-7.

36. Rappaport L, Peters GR. Aging and psychosocialproblematics of food. Am Behav Sci 1988;32:31-40.

37. Seoane NA. Les habitudes alimentaires des aînésquébécois. Ministère de l’Agriculture, desPêcheries et de l’Alimentation du Québec, 1989.

38. de Groot CP, van Staveren WA, de Graaf C.Determinants of macronutrient intake in elderlypeople. Eur J Clin Nutr 2000;54(Suppl.3):S70-76.

39. Drewnowski A, Shultz JM. Impact of aging oneating behaviors, food choices, nutrition, andhealth status. J Nutr Health Aging 2001;5(2):75-79.

40. Murphy SP, Davis MA, Neuhaus JM, Lein D.Factors influencing the dietary adequacy andenergy intake of older Americans. J Nutr Educ1990;22:284-91.

41. Fischer CA, Crockett SJ, Heller KE, Skauge LH.Nutrition knowledge, attitudes, and practices ofolder and younger elderly in rural areas. J AmDiet Assoc 1991;91(11):1398-401.

42. Toner HM, Morris JD. A social-psychologicalperspective of dietary quality in later adulthood. J Nutr Elder 1992;11(4):35-53.

43. Lee CJ, Godwin SL, Tsui J, Kumelachew M,McWhinney SL, Idris R, et al. Associationbetween diet knowledge and quality of diets insouthern rural elderly. J Nutr Elder 1997;17(1):5-17.

44. Howard JH, Gates GE, Ellersieck MR, DowdyRP. Investigating relationships between nutri-tional knowledge, attitudes and beliefs, anddietary adequacy of the elderly. J Nutr Elder1998;17(4):35-52.

45. Donkin AJ, Johnson AE, Morgan K, Neale RJ,Page RM, Silburn RL. Gender and living alone asdeterminants of fruit and vegetable consumptionamong the elderly living at home in urbanNottingham. Appetite 1998;30(1):39-51.

46. Weimer JP. Factors affecting nutrient intake ofthe elderly. Fam Econ Nutr Rev 1999;12(3&4):101-3.

47. McKie L, MacInnes A, Hendry J, Donald S,Peace H. The food consumption patterns andperceptions of dietary advice of older people. J Hum Nutr Diet 2000;13(3):173-83.

48. Guthrie JF, Lin BH. Overview of the diets oflower- and higher-income elderly and their foodassistance options. J Nutr Educ Behav2002;34(Suppl.1):S31-41.

49. Tucker KL, Dallal GE, Rush D. Dietary patternsof elderly Boston-area residents defined by clusteranalysis. J Am Diet Assoc 1992;92:1487-91.

50. Heimendinger J, Chapelsky D. The national 5-A-Day for Better Health Program. Adv ExpMed Biol 1996;401:199-206.

51. Schlettwein-Gsell D, Barclay D. Dietary habitsand attitudes in healthy elderly. In: Adaptationsin Aging. The 1994 Sandoz Lectures inGerontology. London, England: Academic Press,Harcourt Brace & Company, Publishers,1995;253-64.

52. Fernyhough LK, Horwath CC, Campbell AJ,Robertson MC, Busby WJ. Changes in dietaryintake during a 6-year follow-up of an older pop-ulation. Eur J Clin Nutr 1999;53(3):216-25.

53. Griep MI, Verleye G, Franck AH, Collys K,Mets TF, Massart DL. Variation in nutrientintake with dental status, age and odour percep-tion. Eur J Clin Nutr 1996;50:816-25.

54. de Jong N, Mulder I, de Graaf C, van StaverenWA. Impaired sensory functioning in elders: Therelation with its potential determinants andnutritional intake. J Gerontol A Biol Sci Med Sci1999;54(8):B324-31.

55. Bray GA. Afferent signals regulating food intake.Proc Nutr Soc 2000;59:373-84.

56. Schiffman SS, Graham BG. Taste and smell per-ception affect appetite and immunity in theelderly. Eur J Clin Nutr 2000;54(3S):S54-S63.

57. Winkler S, Garg AK, Mekayarajjananonth T,Bakaeen LG, Khan E. Depressed taste and smellin geriatric patients. J Am Dent Assoc1999;130(12):1759-65.

58. Brodeur JM, Laurin D, Vallée R, Lachapelle D.Nutrient intake and gastrointestinal disordersrelated to masticatory performance in the enden-tulous elderly. J Prosthet Dent 1993;70:468-73.

59. Sheiham A, Steele J. Does the condition of themouth and teeth affect the ability to eat certain



foods, nutrient and dietary intake and nutritionalstatus amongst older people? Pub Health Nutr2001;4(3):797-803.

60. Marshall TA, Warren JJ, Hand JS, Xie XJ,Stumbo PJ. Oral health, nutrient intake anddietary quality in the very old. J Am Dent Assoc2002;133(10):1369-79.

61. Poehlman ET, Toth MJ. Energy dysregulation inmenopause. Menopause Management 1996;5:18-21.

62. Poehlman ET. Effect of exercise on daily energyneeds in older individuals. Am J Clin Nutr1998;68:997-98.

63. Morley JE, Thomas DR. Anorexia and aging:Pathophysiology. Nutrition 1999;15(6):499-503.

64. Morley J. Decreased food intake with aging. J Gerontol A Biol Sci Med Sci 2001;56A(SpecialIssue II):81-88.

65. Walker D, Beauchene RE. The relationship ofloneliness, social isolation, and physical health todietary adequacy of independently living elderly.J Am Diet Assoc 1991;91(3):300-4.

66. Suda Y, Marske CE, Flaherty JH, Zdrodowski K,Morley JE. Examining the effect of interventionto nutritional problems of the elderly living in aninner city area: A pilot project. J Nutr HealthAging 2001;5(2):118-23.

67. McIntosh WA, Kubena KS, Walker J, Smith D,Landmann WA. The relationship between beliefsabout nutrition and dietary practices of the elder-ly. J Am Diet Assoc 1990;90:671-76.

68. Toner HM, Morris JD. A social-psychologicalperspective of dietary quality in later adulthood. J Nutr Elder 1992;11(4):35-53.

69. Lahmann PH, Kumanyika SK. Attitudes abouthealth and nutrition are more indicative ofdietary quality in 50- to 75-year-old women thanweight and appearance concerns. J Am Diet Assoc1999; 99(4):475-78.

70. Shatenstein B, Nadon S, Ferland G.Determinants of diet quality among Quebecersaged 55-74. J Nutr Health Aging 2004;8(2):83-91.

71. Bertrand L. Les Québécoises et les Québécois mangent-ils mieux? Rapport de l’Enquête québécoisesur la nutrition, 1990. Montreal, QC : ministèrede la Santé et des Services sociaux,Gouvernement du Québec, 1995.

72. Houston DK, Johnson MA, Daniel TD, PoonLW. Health and dietary characteristics of supple-ment users in an elderly population. Int J VitNutr Res 1997;67:183-91.

73. Walmsley CM, Bates CJ, Prentice A, Cole TJ.Relationship between alcohol and nutrientintakes and blood status indices of older peopleliving in the UK: Further analysis of data fromthe National Diet and Nutrition Survey of peo-ple aged 65 years and over, 1994/5. Public HealthNutr 1998;1(3):157-67.

74. Schlettwein-Gsell D, Barclay D, Osler M,Trichopoulou A. Euronut-SENECA study onnutrition and the elderly. Dietary habits and atti-tudes. Eur J Clin Nutr 1991;45(Suppl.3):83-95.

75. Sidenvall B, Nydahl M, Fjellström C. Managingfood shopping and cooking: The experiences ofolder Swedish women. Ageing Soc 2001;21:151-68.

76. Laing MM, Reid D. Food and NutritionOpportunities in the Seniors’ Market: A SituationAnalysis. Ottawa, ON: National Institute ofNutrition, 1996.

77. Krassie J, Smart C, Roberts DCK. A review ofthe nutritional needs of Meals on Wheels con-sumers and factors associated with the provisionof an effective Meals on Wheels service – anAustralian perspective. Eur J Clin Nutr2000;54:275-80.

78. Davis MA, Murphy SP, Neuhaus JM, Lein D.Living arrangements and dietary quality of olderU.S. adults. J Am Diet Assoc 1990;90:1667-72.

79. McIntosh WA, Shifflett PA, Picou JS. Social sup-port, stressful events, strain, dietary intake, andthe elderly. Med Care 1989;27:140-53.

80. Prothro JW, Rosenbloom CA. Description of amixed ethnic, elderly population. II. Food groupbehavior and related nonfood characteristics. J Gerontol A Biol Sci Med Sci 1999;54A(6):M325-M328.

81. Rothenberg E, Bosaeus I, Steen B. Intake of ener-gy, nutrients and food items in an urban elderlypopulation. Aging Clin Exp Res 1993;5(2):105-16.

82. Fogarty J, Nolan G. Assessment of the nutritionalstatus of rural and urban elderly living at home.Ir Med J 1992;85(1):14-16.

83. Kozlowska K, Wierzbicka E, Brzozowska A,Roszkowski W. Consumption of food productsby the elderly living in different environments ofthe Warsaw region, Poland. J Nutr Health Aging2002;6(1):27-30.

84. Stevens DA, Grivetti LE, McDonald RB.Nutrient intake of urban and rural elderly receiv-ing home-delivered meals. J Am Diet Assoc1992;92(6):714-18.

85. Holcomb CA. Positive influence of age and edu-cation on food consumption and nutrient intakesof older women living alone. J Am Diet Assoc1995;95:1381-86.

86. Quandt SA, McDonald J, Arcury TA, Bell RA,Vitolins MZ. Nutritional self-management ofelderly widows in rural communities.Gerontologist 2000;40(1):86-96.

87. Shahar DR, Schultz R, Shahar A, Wing RR. Theeffect of widowhood on weight change, dietaryintake, and eating behavior in the elderly popula-tion. J Aging Health 2001;13(2):189-99.

88. Donkin AJ, Johnson AE, Morgan K, Neale RJ,Page RM, Silburn RL, Gender and living alone asdeterminants of fruit and vegetable consumptionamong the elderly living at home in urbanNottingham. Appetite 1998;30(1):39-51.

89. Charlton KE. Elderly men living alone: Are theyat high nutritional risk? J Nutr Health Aging1999;3(1):42-47.

90. Campbell CC, Horton SE. Apparent nutrientintakes of Canadians: Continuing nutritionalchallenges for public health professionals. Can JPublic Health 1991;82:374-80.

91. Lee CJ, Tsui J, Glover E, Glover LB,Kumelachew M, Warren AP, et al. Evaluation ofnutrient intakes of rural elders in eleven southernstates based on sociodemographic and life styleindicators. Nutr Research 1991;11:1383-96.

92. Pearson JM, Schlettwein-Gsell D, Van StaverenW, de Groot L. Living alone does not adverselyaffect nutrient intake and nutritional status of70- to 75-year-old men and women in smalltowns across Europe. Int J Food Sci Nutr1998;49:131-39.




Determinants of Healthy Eatingin Aboriginal Peoples in CanadaThe Current State of Knowledge and Research Gaps

Noreen D. Willows, PhD

ABSTRACT

Aboriginal peoples are the original inhabitants of Canada. These many diverse peopleshave distinct languages, cultures, religious beliefs and political systems. The currentdietary practices of Aboriginal peoples pose significant health risks. Interventions toimprove the nutritional status of Aboriginal peoples must reflect the realities of how peoplemake food choices and therefore should be informed by an understanding ofcontemporary patterns of food procurement, preparation and distribution. Most of theliterature documenting the health of Aboriginal peoples is primarily epidemiologic, andthere is limited discussion of the determinants that contribute to health status. The majorityof studies examining dietary intake in Aboriginal communities do not aim to study thedeterminants of food intake per se even though many describe differences in food intakeacross sex, age groups, seasons and sometimes communities, and may describe factorsthat could have an effect on food consumption (e.g., employment status, level ofeducation, household size, presence of a hunter/trapper/fisher, occupation, main source ofincome). For these reasons, there are many gaps in knowledge pertaining to thedeterminants of healthy eating in Aboriginal peoples that must be filled. Given thediversity of Aboriginal peoples, research to address the gaps should take place at both thenational level and at a more local level. Research would be important for each of Inuit,Métis and First Nations.

MeSH terms: Canada; diet; food habits; Indians, North American; Inuit; nutrition

Aboriginal peoples occupied the areanow called Canada before thearrival of Europeans, and they have

cultures and histories that make them dis-tinctive within Canadian society. In thepast, they subsisted by extracting and pro-cessing foods from the land and waterusing hunting, trapping, fishing, gatheringand agriculture in different combinations.The tremendously diverse diet was, in gen-eral, high in animal protein and low in fatand carbohydrates, and provided adequateamounts of energy and micronutrients forhealth.1-3 The contemporary diet has, tovarying degrees, replaced traditional foodswith market foods, many of which are oflow nutritional quality. Traditional foodsare those culturally accepted foods avail-able from local natural resources that con-stitute the food systems of Aboriginal peo-ples. The concept of food system includessociocultural meanings, acquisition andprocessing techniques, use, compositionand nutritional consequences for the peo-ple using the food. Positive nutritional sta-tus might be possible to maintain whentraditional food use is diminished if eco-nomic circumstances are favourable, a vari-ety of high-quality, non-traditional foodsis available, and education in the use ofgood-quality traditional food alternatives ison hand.4,5

The three groups of Aboriginal peoplesdefined in the Canadian Constitution areIndian, Métis and Inuit (the term FirstNation now commonly replaces the wordIndian).6 Inuit live predominantly inNunavut, the coastline areas of theNorthwest Territories, Northern Quebec(Nunavik) and Labrador. They are cultur-ally and linguistically distinct from FirstNations and Métis. Métis is used broadlyto describe people with mixed FirstNations and European ancestry.6

The health of Aboriginal peoples isworse than that of Canadians, in general,for almost every health status measure andcondition.7 There is considerable evidencethat many health problems experienced byAboriginal peoples are related to diet; theyinclude anemia, dental caries, obesity,heart disease and diabetes.2-4 Althoughmany health issues appear related to poordiet, dietary intake data in Aboriginal pop-ulations are limited in scope, with a nar-row geographic and subject focus andincluding only a few Aboriginal communi-ties. Most of the literature documenting

Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, ABCorrespondence and reprint requests: Noreen D. Willows, 4-10 Agriculture/Forestry Centre,Department of Agricultural, Food and Nutritional Science, University of Alberta, Edmonton, AB T6G2P5Acknowledgements and source of support: The author appreciated the comments and editorial sug-gestions of Valerie Tarasuk, Olivier Receveur, and Brenda McIntyre, which benefitted the paperimmensely. Noreen Willows is an Alberta Heritage Foundation for Medical Research PopulationHealth Investigator.


HEALTHY EATING IN ABORIGINAL PEOPLES IN CANADA

the health of Aboriginal peoples is primari-ly epidemiologic, and there is limited dis-cussion of the determinants that contributeto health status. Urban-living Aboriginalpeople are under-represented in manystudies, as are First Nations living off-reserve, Métis, and women and children.8,9

To effectively promote and supporthealthy eating in Aboriginal peoples, thereis a need for a more comprehensive under-standing of the many factors that influenceeating behaviour, including deeper under-standing of their interactions. This articleis intended to provide an overview of thestate of knowledge and research gaps in thedeterminants of healthy eating, includingconsumption of traditional food as relatedto Aboriginal peoples. For manyAboriginal groups, healthy eating is basedon the premise of the consumption of tra-ditional food, which, in addition to con-tributing to nutrition, is an importantindicator of cultural expression, an anchorto culture and personal well-being, anessential agent to promote holistic healthand culture, and the direct link betweenthe environment and human health.10 Thefocus of the article will be predominantlyInuit and First Nations living on-reserveand in remote or northern communities,although the literature pertaining to othergroups will also be included.


A literature search was completed using theterm “aboriginal” and MeSH synonyms forthat term (Inuit, Indians North American)combined with the term “Canada” andwith “food” or “nutrition”. The strategywas repeated in medical and sociologicaldatabases (PubMed, MEDLINE,HealthSTAR, CINAHL, SociologicalAbstracts; Bibliography of Native NorthAmericans; International Bibliography ofthe Social Sciences; Proquest DigitalDissertations). For international compar-isons, the same strategy and search engineswere used but the terms United States,Australia and New Zealand were used inplace of Canada. The search strategy wasrestricted to literature written in theEnglish language and published fromJanuary 1990 to December 2003, and keypublications published January to April2004, although pertinent older material

was included. Website searches (e.g.,National Aboriginal Health Organization,Indian and Northern Affairs Canada) pro-vided grey literature, as did citations in arti-cles, grey literature and books. The mostsalient information relating to understand-ing the determinants of healthy eating andgaps in knowledge are presented herein.

Summary of the literature on thedeterminants of healthy eatingPartly because of the substitution of tradi-tional foods with market foods, the currentdiet of Aboriginal peoples is often low iniron, folacin, calcium, vitamin D, vitaminA, fibre, fruit and vegetables; high fat andsugar intakes are commonly reported.11-18

A better understanding of the determi-nants of traditional food use in relation tomarket food use is required to know howto modify the determinants in a way thatwould result in better dietary patterns forAboriginal peoples. The transition fromtraditional to market food has been a mul-tidimensional, dynamic and complexcourse, and the decision-making processabout consuming traditional or marketfood, as discussed later, is made at multiplelevels of influence: societal, individual,socio-economic (food insecurity) and envi-ronmental, all which may overlap andinteract. In the discussion that follows,environmental influence refers to the phys-ical environment.

Societal Level InfluenceCulture is broadly defined as the values,beliefs, attitudes and practices accepted bymembers of a group or community. Itdetermines, in part, what foods are accept-able and preferable, the amount and com-binations of foods to eat, when and how toeat, and the foods considered ideal orimproper.19 Aboriginal people maydescribe their traditional food quite specifi-cally, for example, as Inuit or Dene food,as the case may be, demonstrating itsstrong link to cultural identity.20 Ofimportance to understanding the role thatculture plays in determining food choice inAboriginal communities is that the activi-ties required to procure traditional food arenot merely a way of obtaining food but,rather, a mode of production that sustainssocial relationships and distinctive culturalcharacteristics. This is because the con-sumption of traditional foods is more than

just about eating; it is the endpoint of aseries of culturally meaningful processesinvolved in the harvesting, processing, dis-tribution and preparation of these foods.For many Aboriginal peoples, theseprocesses require the continued enactmentof culturally important ways of behaving,which emphasize cooperation, sharing andgenerosity.20-25

In some Aboriginal communities, thecultural preference for body size may influ-ence eating behaviour and food choice. Astudy in Ojibway-Cree in northernOntario showed a preference for large bodysize, particularly among older adults whoperhaps had memories of the associationbetween thinness and infectious diseases,such as tuberculosis.26 In Cree communi-ties in northern Quebec, having extraweight is considered a sign of robustnessand strength.27 In contrast, First Nationsand Métis girls and women living in ornear to urban centres in Manitoba preferthin body sizes and may use dieting to loseweight.28 Urban American Indian womenin the United States engage in unhealthyweight-control practices, such as binge eat-ing, skipping meals, fasting and purging.29

Many American Indian children have bodydissatisfaction, concerns about highweight, unhealthy weight control practicesand eating disorders.30-33 The varying pref-erences for body size among Aboriginalpeoples may be based in traditional cultur-al values; alternatively, as culture is not sta-tic but changes over time in response tosocial dynamics, one cannot ignore theadoption of non-Aboriginal perspectives ofbody size.

IndividualFood selection is often governed by sensorycharacteristics.34 Although taste preferenceis personal, it is influenced by the culturalgroup to which one belongs. Taste prefer-ence for traditional food has been docu-mented for Aboriginal peoples. Inuit con-sume igunaaq (fermented seal meat), whichhas a distinctive and strong flavour; appre-ciation of igunaaq is considered an impor-tant and sophisticated feature of Inuittaste.35 Inuvialuit, Inuit who live in theWestern Arctic, mention the good tasteand texture of traditional foods, such ascaribou, as reasons for eating it.36 Amongthe Nuxalk First Nation, the frequency ofconsumption of many traditional foods is



associated with taste appreciation; how-ever, the relation between taste preferenceand food choice is not always evident. Lackof species availability and time for harvest-ing may explain why not all traditionalfoods with highly desired tastes are con-sumed frequently.37 In Mohawk children,food preference ratings do not alwaystranslate into consumption of those pre-ferred foods: although children may prefercertain traditional foods, they seldom eatthem.38 A study of the eating habits ofCree children found that even though chil-dren consumed a preponderance of store-bought food, the majority expressed a pref-erence for traditional food.39

For many Aboriginal peoples, culturalidentity will inform personal knowledge,attitudes and beliefs about food and foodchoice. The eating of traditional food isoften associated with feelings of goodhealth, whereas the eating of “non-traditional food” is considered by someAboriginal peoples as polluting or weaken-ing.21,24,25,40 Food choices based onAboriginal cultural values may not be con-gruent with Western scientific constructsregarding the nutritional value of food.24,25

The cultural worldview held by someAboriginal peoples that traditional food byits very nature is health-promoting makesit difficult for them to understand whythey must avoid certain store-bought foodsto maintain health. Among the Inuit ofnorthern Labrador, for example, all tradi-tional foods are considered “good”, and“nutritional balance” is perceived as con-suming different parts of an animal, andalternating the diet between fish, landmammals, seal and birds. Perhaps becauseof this ideology it is puzzling to these Inuitthat store food may not contribute tohealth.25 The Cree of northern Quebecalso find the categories of healthy andunhealthy as related to store-bought foodto be confusing because Cree food, by itsvery nature, is good to eat.24

In northern and remote communities,age and sex differences in food consump-tion have been noted.15,17,37,41-45 Sex differ-ences in the amount of traditional foodconsumed may be due, in part, to differ-ences in body size and energy expenditurebetween men and women. Children tendto consume less traditional food thanadults, and young adults consume less tra-ditional food than middle-aged adults, who

in turn consume less traditional food thanelders. The age disparity in traditional foodconsumption implies inter-generational differences in taste preference and suggeststhat younger generations are losing theknowledge of harvesting and preparingtheir traditional foods.

Food InsecurityAboriginal families are over-representedamong those experiencing hunger inCanada.46 As a result of the pervasivenessof poverty in many Aboriginal communi-ties, income and food costs may be morepotent determinants of food selection thanconsiderations of the healthfulness, socialdesirability and taste of food.34 Food inse-curity is commonplace, meaning that theavailability of nutritionally adequate andsafe foods or the ability to acquire accept-able foods in socially acceptable ways islimited or uncertain.47 In the 1998/1999National Population Health Survey, theprevalence of food insecurity amongAboriginal respondents living off reservewas 27.0%, and 24.1% had a compro-mised diet, meaning that they did not haveenough food to eat or that they could noteat the quality or variety of foods theywanted to because of lack of money.48 Ithas been documented that low-incomeFirst Nations women in Winnipeg are notable to choose food on the basis of itshealth attributes because of the constraintsof food insecurity.49 Differing degrees offood insecurity, from anxiety to hunger,exist among Inuit, including hunger inchildren.18

Some Aboriginal communities use food-sharing networks as a strategy against foodinsecurity. Community freezers and otherforms of community sharing enable food-insecure individuals living on reserves or inremote regions to consume traditionalfoods.50,51 These systems of food reciproci-ty and obligation do not always bufferagainst food insecurity in urban centres.49

In remote and northern communities,the high cost, poor quality, lack of varietyand lack of availability of perishable foodsare barriers to the purchase of fresh fruitsand vegetables.18,52 The cost of market foodis high as a result of transport costs, andthe limited availability of nutritious foodsis due, in part, to spoilage.52,53 In remoteregions, where a single store may serve thecommunity, the individual store manager’s

stock management practices, and personalbeliefs and attitudes about stocking health-ful foods may be major determinants ofthe availability of nutritious foods.54

Physical EnvironmentalModification of the physical environment(e.g., hydroelectric dams, deforestation, cli-mate change) and contamination of thephysical environment have resulted inreduced availability of traditional animaland plant species.40,55,56 When speciesdecline or become contaminated, recom-mendations are often made to limit orcease their consumption. In response toadvisories, Aboriginal peoples may switchto hunting or fishing different species,reduce intake or maintain the status quo.57

Concern over food contamination orspecies diminishment may be insufficient,in and of itself, to cause reduced intake ofa food species given the pragmatic consid-eration that market food, in many cases, isan expensive or unpalatable substitute fortraditional food. Identifiable local sourcesof contamination may cause greater disrup-tion of normal dietary patterns than conta-mination from distant sources. The com-munication style for conveying risk infor-mation about contaminants and the cul-tural context within which risk is interpret-ed may also be decisive factors in howcommunity members respond to advi-sories.20,58

KNOWLEDGE GAPS IN THE LITERATURE

To effectively promote and support healthyeating, there is a need for a more comprehen-sive understanding of the many factors influ-encing eating behaviours, and their complex-ity and interactions. Some important gaps inunderstanding are described below.

Beliefs about foodMore study is required of the relationbetween individual beliefs about food andfood intake. Most studies in Aboriginalcommunities that examine the health ratingsof traditional and store-bought food do notevaluate whether the health rating of a foodcorresponds to its frequency in the diet.

Hedonic qualitiesThe sensory properties of food consumedby Aboriginal peoples have seldom been

studied as a determinant of food intake,despite evidence that sensory properties areimportant reasons why traditional food isculturally palatable and why market food isconsumed. The hedonic quality of tradi-tional and market food as it relates to foodchoice needs further investigation.

Food insecurityThere are many issues relating to foodinsecurity that have not been studied.Scales for measuring food insecurity havenot been validated in Aboriginal popula-tions in Canada, therefore, commonly usedfood insecurity questions may need to beadapted to accommodate First Nations,Métis and Inuit languages, cultural percep-tions and unique life experiences.47 Insmall communities, it is not clear howmuch influence store policies or store man-agers have in determining the types of foodavailable for sale, or how food pricinginfluences food choice. Information isrequired about how food insecurity affectsfood selection, given traditions of obliga-tion, sharing and reciprocity that are inher-ent to many Aboriginal peoples’ cultures.

Body imageConsidering that there are few studiesabout body image, weight concerns anddieting practices in Aboriginal adults andchildren, community-based studies of bodyimage concepts would be valuable fordeveloping dietary interventions. Thisinformation is relevant because initiativesto prevent obesity may not be effective ifobesity is viewed as a positive physicalattribute. On the other hand, if thinness isdesired, care must be taken to avoidincreasing concerns about weight, bodydissatisfaction and the adoption ofunhealthy eating patterns. For a givencommunity, it would be important toknow whether obesity is viewed as a posi-tive or negative physical attribute, self-perception of body size, and whether diet-ing or food intake behaviours are related tobody size perception.59

Physical environment health discourseConcern about the safety of traditionalfood or the diminishment of food speciesmay result in a change in diet; however, lit-tle has been reported about how knowl-edge of the existence of contaminants inlocal food or discourse about species

decline alters dietary intake. To ensure thatdietary modifications are counterbalancedby selection of healthy food alternatives, abetter understanding of how environmen-tal health discourse influences food choiceis required, as well as quantification of anyresulting dietary changes. The healthimpacts of such dietary changes could besignificant, given that traditional foodscontribute to both nutritional benefits andcontaminant exposure.4

Interactions among determinantsIndividual, social, physical environmentaland socio-economic factors interact incomplex and changing ways to influencefood choice. For example, individuals mayuse knowledge about the health propertiesof foods when they make choices, butknowledge alone is insufficient to affectfood choices unless it can overcome coun-teracting psychosocial, behavioral andenvironmental barriers.60,61 The issue of theinteraction of the determinants of healthyeating at different levels of influenceshould be examined to see how that inter-action modifies food access and choice.

CONCLUSION

Current dietary practices of some Aboriginalpeoples pose significant health risks anddiminish the quality of life. It is thereforecritical to obtain information on the factorsthat relate to determinants of food choiceand food access. There are few comprehen-sive studies documenting the determinantsof healthy eating in Aboriginal communities;therefore, there are many gaps in knowledgepertaining to them. In view of the enormousdiversity of Aboriginal peoples, research toaddress the gaps should take place at boththe national level and a more local level.Research would be important for each ofInuit, Métis and First Nations.

REFERENCES

1. Health Canada. Native Foods and Nutrition: AnIllustrated Reference Manual. Ottawa: MedicalServices Branch. Minister of Supply and ServicesCanada, Government of Canada, 1995.

2. Schaefer O. Changing dietary patterns in theCanadian north: Health, social and economicconsequences. J Can Diet Assoc 1977;38:17-25.

3. Sinclair H. The diet of Canadian Indians andEskimos. Proc Nutr Soc 1953;13:69-82.

4. Kuhnlein HV, Receveur O, Chan HM.Traditional food systems research with Canadianindigenous peoples. Int J Circumpolar Health2001;60:112-22.

5. Kuhnlein HV, Receveur O. Dietary change andtraditional food systems of indigenous peoples.Annu Rev Nutr 1996;16:417-42.

6. Indian and Northern Affairs Canada. Words First:An Evolving Terminology Relating to AboriginalPeoples in Canada. Ottawa: Government ofCanada, 2002.

7. Health Canada. A Statistical Profile on the Healthof First Nations in Canada. Ottawa, 2003.

8. Young TK. Review of research on aboriginal pop-ulations in Canada: Relevance to their healthneeds. BMJ 2003;327:419-22.

9. MacMillan HL, MacMillan AB, Offord DR,Dingle JL. Aboriginal health. Can Med Assoc J1996;155:1569-78.

10. Kuhnlein HV. Global Nutrition and the HolisticEnvironment of Indigenous Peoples. The Path toHealing. Royal Commission on AboriginalPeoples. Ottawa, 1993.

11. Wein EE, Gee MI, Hawrysh ZJ. Nutrient intakesof native mothers and school children in north-ern Alberta. J Can Diet Assoc 1993;54:42-47.

12. Wein EE. Nutrient intakes of a sample of FirstNations adults with and without diabetes melli-tus in central Alberta. J Can Diet Assoc1996;57:153-61.

13. Berti PR, Hamilton SE, Receveur O, KuhnleinHV. Food use and nutrient adequacy in BaffinInuit children and adolescents. Can J Diet PractRes 1999;60:63-70.

14. Delormier T, Kuhnlein HV. Dietary characteris-tics of eastern James Bay Cree women. Arctic1999;52:182-87.

15. Kuhnlein HV, Soueida R, Receveur O. BaffinInuit food use by age, gender and season. J CanDiet Assoc 1995;56:175-83.

16. Trifonopoulos M, Kuhnlein HV, Receveur O.Analysis of 24-hour recalls of 164 fourth- tosixth-grade Mohawk children in Kahnawake. J Am Diet Assoc 1998;98:814-16.

17. Campbell ML, Diamant RMF, Mapherson BD,Grunau M, Halladay J. Energy and nutrientintakes of men (56-74 years) and women (16-74years) in three northern Manitoba Cree commu-nities. J Can Diet Assoc 1994;55:167-74.

18. Lawn J, Harvey D. Nutrition and Food Securityin Kugaaruk, Nunavut: Baseline Survey for theFood Mail Project. Ottawa: Minister of PublicWorks and Government Services, 2003.

19. Kittler PG, Sucher KP. Food and Culture, 4th ed.Toronto: Thomson Wadsworth, 2004.

20. Van Oostdam J, Gilman A, Dewailly E, Usher P,Wheatley B, Kuhnlein HV, et al. Human healthimplications of environmental contaminants inArctic Canada: A review. Sci Total Environ1999;230:1-82.

21. Borre K. The healing power of the seal: Themeaning of Inuit health practice and belief. ArcticAnthropol 1994;31:1-15.

22. Stairs A, Wenzel G. “I am I and theEnvironment”: Inuit hunting, community, andidentity. J Indigenous Studies 1992;3:1-12.

23. Ohmagari K, Berkes F. Transmission of indige-nous knowledge and bush skills among the west-ern James Bay Cree women of subarctic Canada.Hum Ecol 1997;25:197-222.

24. Adelson N. Being Alive Well: Health and thePolitics of Cree Well-being. Toronto: University ofToronto Press, 2000.

25. Mackey MGA. The impact of imported foods onthe traditional Inuit diet. Arctic Med Res 1988;47Suppl 1:128-33.

26. Gittelsohn J, Harris SB, Thorne-Lyman AL,Hanley AJ, Barnie A, Zinman B. Body imageconcepts differ by age and sex in an Ojibway-Cree community in Canada. J Nutr1996;126:2990-3000.

27. Boston P, Jordan S, MacNamara E, KozolankaK, Bobbish-Rondeau E, Iserhoff H, et al. Usingparticipatory action research to understand themeanings aboriginal Canadians attribute to the





rising incidence of diabetes. Chron Dis Can1997;18:5-12.

28. Marchessault GDM. Far from Ideal: Talkingabout Weight with Mothers and Daughters fromWinnipeg, Southern Manitoba and a First NationsCommunity. Dissertation. University ofManitoba, Winnipeg, 2001.

29. Sherwood NE, Harnack L, Story M. Weight-losspractices, nutrition beliefs, and weight-loss pro-gram preferences of urban American Indianwomen. J Am Diet Assoc 2000;100:442-46.

30. Davis SM, Lambert LC. Body image and weightconcerns among Southwestern American Indianpreadolescent schoolchildren. Ethn Dis2000;10:184-94.

31. Rinderknecht K, Smith C. Body-image percep-tions among urban Native American youth. ObesRes 2002;10:315-27.

32. Story M, Hauck FR, Broussard BA, White LL,Resnick MD, Blum RW. Weight perceptionsand weight control practices in American Indianand Alaska Native adolescents. A national survey.Arch Pediatr Adolesc Med 1994;148:567-71.

33. Neumark-Sztainer D, Story M, Resnick MD,Blum RW. Psychosocial concerns and weightcontrol behaviors among overweight andnonoverweight Native American adolescents. J Am Diet Assoc 1997;97:598-604.

34. Messer E. Methods for studying determinants offood intake. Food Nutr Bull 1989;11(suppl):1-33.

35. Brody H. Meat. In: Living Arctic: Hunters of theCanadian North. Vancouver/Toronto: Douglas& McIntyre, 1987;51-67.

36. Wein EE, Freeman MM. Inuvialuit food use andfood preferences in Aklavik, Northwest Territories,Canada. Arctic Med Res 1992;51:159-72.

37. Kuhnlein HV. Change in the use of traditionalfoods by the Nuxalk native people of BritishColumbia. Ecol Food Nutr 1992;27:259-82.

38. Trifonopoulos M. Anthropometry and Diet ofMohawk Schoolchildren in Kahnawake. Thesis.Montreal, QC: McGill University, 1995.

39. Bernard L, Lavallee C, Gray-Donald K, DelisleH. Overweight in Cree schoolchildren and ado-

lescents associated with diet, low physical activity,and high television viewing. J Am Diet Assoc1995;95:800-2.

40. O’Neil JD, Elias B, Yassi A. Poisoned food:Cultural resistance to the contaminants discoursein Nunavik. Arctic Anthropol 1997;34:29-40.

41. Kuhnlein HV, Soueida R, Receveur O. Dietarynutrient profiles of Canadian Baffin Island Inuitdiffer by food source, season, and age. J Am DietAssoc 1996;96:155-62.

42. Kuhnlein HV, Receveur O, Morrison NE,Appavoo D, Soueida R, Pierrot P. Dietary nutri-ents of Sathu Dene/Metis vary by food source,season and age. Ecol Food Nutr 1996;34:183-95.

43. Kuhnlein HV, Receveur O, Soueida R, EgelandGM. Arctic indigenous peoples experience thenutrition transition with changing dietary pat-terns and obesity. J Nutr 2004;134:1447-53.

44. Wolever TM, Hamad S, Gittelsohn J, HanleyAJG, Logan A, Harris SB, et al. Nutrient intakeand food use in an Ojibwa-Cree community inNorthern Ontario assessed by 24h dietary recall.Nutr Res 1997;17:603-18.

45. Morrison NE, Receveur O, Kuhnlein HV,Appavoo DM, Soueida R, Pierrot P.Contemporary Sahtu Dene/Metis use of tradi-tional and market food. Ecol Food Nutr1995;34:197-210.

46. McIntyre L, Connor SK, Warren J. Child hungerin Canada: Results of the 1994 NationalLongitudinal Survey of Children and Youth. CanMed Assoc J 2000;163:961-65.

47. Tarasuk V. Discussion Paper on Household andIndividual Food Insecurity. Health Canada, 2001.

48. Che J, Chen J. Food insecurity in Canadianhouseholds. Health Rep 2003;12:11-22.

49. Sinclaire M. Barriers to Food Procurement: TheExperience of Urban Aboriginal Women inWinnipeg. Dissertation. Winnipeg, MB:University of Winnipeg, 1997.

50. Condon RG, Collings P, Wenzel G. The bestpart of life: Subsistence hunting, ethnicity, andeconomic adaptation among young adult Inuitmales. Arctic 1995;48:31-46.

51. Duhaime G, Chabot M, Gaudreault M. Foodconsumption patterns and socioeconomic factorsamong the Inuit of Nunavik. Ecol Food Nutr2002;41:91-118.

52. Wein EE. The high cost of a nutritionally ade-quate diet in four Yukon communities. Can JPublic Health 1994;85:310-12.

53. Lawn J, Langner N, Brule D, Thompson N, HillF. The effect of a federal transportation subsidyon nutritional status of Inuit in Canada’s Arctic.Arctic Med Res 1994;53(Suppl 2):289-95.

54. Lee A, Bonson AP, Powers JR. The effect of retailstore managers on aboriginal diet in remote com-munities. Aust N Z J Public Health 1996;20:212-14.

55. Canadian Institute for Health Information.Improving the Health of Canadians. Ottawa,2003.

56. Wheatley MA. Social and cultural impacts ofenvironmental change on aboriginal peoples inCanada. Int J Circumpolar Health 1998;57(Suppl1):537-42.

57. Collings P. Subsistence hunting and wildlifemanagement in the central Canadian Arctic.Arctic Anthropol 1997;34:41-56.

58. Usher PJ, Baikie M, Demmer M, Nakashima D,Stevenson MG, Stiles M. Communicating aboutContaminants in Country Food: The Experience inAboriginal Communities. Ottawa: ResearchDepartment, Inuit Tapirisat of Canada, 1995.

59. Marchessault G. Weight perceptions and prac-tices in native youth. Healthy Weight J1999;13:71-73, 79.

60. Wetter AC, Goldberg JP, King AC, Sigman-Grant M, Baer R, Crayton E, et al. How andwhy do individuals make food and physical activ-ity choices? Nutr Rev 2001;59(3 Pt 2):S11-S20.

61. Booth SL, Sallis JF, Ritenbaugh C, Hill JO,Birch LL, Frank LD, et al. Environmental andsocietal factors affect food choice and physicalactivity: Rationale, influences, and leveragepoints. Nutr Rev 2001;59(3 Pt 2):S21-S39.

Determinants of Healthy EatingAmong Low-income CanadiansElaine M. Power, PhD

ABSTRACT

This paper draws on four bodies of literature to consider the determinants of healthy eatingfor low-income Canadians: a) the social determinants of health; b) socio-economicgradients in diet; c) food security; and d) the sociology of food. Though there is a paucityof data for Canada, it is very likely that, as in other industrialized countries, there aresocio-economic gradients in diet such that those who are better off consume healthierdiets than those less well-to-do. The available evidence suggests that income affects foodintake both directly and indirectly through the dispositions associated with particularsocial class locations. Thus, there may be both economic and cultural thresholds for somefood groups or particular foods in food groups. Understanding these thresholds isespecially important in addressing the issues facing those who are the most vulnerableamong Canadians with low incomes: the food insecure. The literature reviewed suggeststhat improved nutrition for low-income Canadians may be difficult to achieve a) inisolation from other changes to improve their lives; b) without improvement in thenutrition of the general population of Canadians; and c) without some combination ofthese two changes. Four major areas of research need were identified: a) national data onsocio-economic gradients in diet; b) sociological research on the interaction of incomeand class with other factors affecting food practices; c) sociological research on Canadianfood norms and cultures; and d) research on the costs of healthy eating.

MeSH terms: Diet; public health; poverty; medical sociology; social class

The purpose of this article is to out-line the state of knowledge regard-ing the determinants of healthy eat-

ing* among low-income Canadians,† aswell as the gaps in that knowledge. Thefocus is income, the first of 12 determi-nants of health identified in HealthCanada’s model of population health,1 as akey determinant of healthy eating. Incomehas direct effects on healthy eating as wellas indirect effects, mediated through socialclass. Income affects and interacts withother important individual and collectivefactors affecting healthy eating practices.These include individual factors, such asfood skills and preferences; social factors,such as gender and social support; culturalfactors, such as traditions, norms and val-ues; physical factors, such as housing andaccess to healthy food; and policy factors,such as food labeling, and school andworkplace food policies.2,3

A further factor is the type and strengthof dominant political discourse (e.g., neo-liberalism, welfare liberalism, democraticsocialism), which affects the role the stateplays vis-à-vis the private sector, civil soci-ety and the family in providing goods andservices, as well as the ability of the state todevelop healthy public policy and createthe conditions that facilitate populationhealth.4-7 The dominant political discoursein a society has effects on factors influenc-ing healthy eating that range from theamount of time working parents haveavailable to feed their families, to the abili-ty of a society to regulate food advertisingto children, to the breadth and adequacyof income support programs.

Low-income Canadians are consideredto be nutritionally vulnerable for a numberof reasons. First, analysis from the 2000-01 Canadian Community Health Survey(CCHS)8 suggests that 14.7% of Canadianhouseholds are food insecure. Food insecu-rity refers to “limited or uncertain avail-ability of nutritionally adequate and safefoods or limited or uncertain ability toacquire acceptable foods in socially accept-able ways.”9 There is a growing body of lit-erature on the extent, nature and manage-

Health Studies Program, School of Physical and Health Education, Queen’s University, Kingston, ONCorrespondence and reprint requests: Elaine M. Power, Health Studies Program, School of Physicaland Health Education, Queen’s University, Kingston, ON K7L 3N6, Tel: 613-533-6283, E-mail:[email protected]: I thank Susan Anstice and Sandra Morency for their capable assistance with thisproject, and Michelle Hooper and Sharon Kirkpatrick of Health Canada’s Office of Nutrition Policyand Promotion for their expert guidance and unending patience.


* “Healthy eating” refers to eating practices andbehaviours that are consistent with improving,maintaining and/or enhancing health.

† “Low income” is defined according to StatisticsCanada’s low income cut-offs, i.e., it refers tothose for whom spending on food, clothing andshelter takes up 20% more of their income thanthe relative amount spent by the averageCanadian family for those necessities.

ment of food insecurity amongCanadians,9-30 showing that inadequateincome plays a pivotal role.

Second, there is evidence from Western,industrialized countries that those in high-er socio-economic groups have healthierdiets (eating more fruit, vegetables andlow-fat or skimmed milk, as well as fewerfats and oils, and less meat) than those inlower socio-economic groups.31-52

Third, there is considerable evidencethat early life circumstances, includingnutrition, have a significant impact onhealth in adulthood.53-58 As a result, thereis great interest in improving the nourish-ment of infants and children, starting in utero and continuing throughout child-hood, particularly those living in poverty,in order to offset potential future healthproblems.

Fourth, there is at least the perception ofa socio-economic gradient in obesityamong Canadians. There is evidence thatrates of obesity follow a socio-economicgradient in the US, at least amongwomen;59-61 however, until data from the2004 CCHS (Cycle 2.2) are analyzed, wewill not have strong Canadian data on obe-sity rates in relation to socio-economicposition.

Finally, it is well established that thereare social inequalities in health, such thatas economic and social circumstancesdecline, people have shorter, sicker lives.62-64

It has been hypothesized that healthier eat-ing and improvements in other lifestylefactors could reduce morbidity and prema-ture mortality in low-income groups.39,65-75

However, the evidence suggests that therole of nutrition and other lifestyle risk fac-tors, including smoking, in social inequali-ties in health are less important than thesocial determinants of health, particularlypoverty itself.47,56,76-83


Searches were conducted on the electroniccomputerized databases CINAHL, MED-LINE, and Sociological Abstracts over thetime period of December 2002 to March2003. ERIC was searched in July 2003.Citations from 1975 onward were includ-ed. The following key words were used:food insecurity; inequalities and nutrition;hunger; poverty and food; poverty and

diet; food poverty; health inequalities anddiet; healthy eating and low-income; foodbehaviour; food choice; dietary patterns;lay knowledge and health; health behav-iour; health beliefs.

The search strategy included careful read-ing of references for materials not indexedin the databases, such as books, book chap-ters and “grey” literature. Books were alsoidentified by a search of the University ofToronto library system, and additional greyliterature was identified through Googlesearches. References suggested by thereviewers of the original scoping paper werealso included. Relevant key articles pub-lished in French were identified using simi-lar search strategies and summarized by abilingual research assistant.

The minimum methodological criteriafor inclusion were as follows:• a clear statement of methods, including

study population and selection of sam-ple; identification of data collectionmethods; a discussion of data collectionbiases;

• elaboration of the details of data analy-sis; appropriate statistical tests or analyti-cal approach used;

• interpretation of the findings that wasappropriate for the data collected andthe analytical framework.

Summary of the literature

Socio-economic Gradients in Eating PatternsEuropean studies have consistently shownthat those of higher social class (generallydefined using education as an indicator,rather than income or occupation) havehealthier diets (eating more fruit, vegeta-bles and low-fat or skimmed milk, as wellas fewer fats and oils, and less meat).32-40

Socio-economic gradients have also beennoted in studies in the US31,41-46 andAustralia,47-49 with higher socio-economicgroups consuming diets that are closer tothe dietary recommendations than lowersocio-economic groups. However, studiesthat have measured nutrient intake, ratherthan food consumption,33,47,84,85 havefound the differences among socio-economic groups to be small and “appearto be of limited importance when consid-ering the relatively low degree of compli-ance of all social groups with dietary guide-lines.”47

In Canada, there is some historical evi-dence of socio-economic gradients indiet.86-89 More recent studies have also sug-gested the existence of socio-economic gra-dients51,52,90-92 and the likelihood of incomethresholds for some food groups, includingfruit, vegetables and dairy products.51,52,93

An income threshold refers to the likeli-hood that, beneath the threshold, incomeis the most important determinant of con-sumption; a socio-economic gradient sug-gests that other determinants, especiallyeducation, are also likely to be important.Thus it seems very likely that socio-economic gradients in diet exist in thiscountry, as well as income thresholds forsome food groups. Nationally representa-tive data, collected on an ongoing basis, arefundamental to understanding nutritionalinequalities in this country and to formu-lating strategies to address them.

Food Insecurity and Inequalities in DietThere is considerably more research on aparticularly vulnerable component of theCanadian low-income population: thosewho are food insecure. Income is the mostimportant determinant of food insecurityand hunger, but there is not a linear rela-tion between income and measures of foodsecurity.94,95 Analysis of available Canadiandata shows that the odds of reporting foodinsecurity or food insufficiency* increaseswith declining income,10,11,22,97 one nation-ally representative survey showing thathouseholds in the lowest third of standard-ized household incomes were 10.2 timesmore likely to be food insecure than thosein the highest third.26 Analysis of the 1998-1999 National Population Health Survey(NPHS) shows that 10.2% of Canadianhouseholds, or approximately 3 millionpeople, reported food insecurity in the pre-vious year.10,26 More recent analysis sug-gests that the number of food insecureCanadians has increased dramatically, to14.7% in 2000-2001.8

While food insecurity is measured at thehousehold level, dietary intakes are mea-sured at the individual level,95 and individ-uals in food insecure households show dif-fering patterns of intake. Research on the

HEALTHY EATING AMONG LOW-INCOME CANADIANS


* Food insufficiency is a narrower, simpler con-struct than food insecurity. Food insufficiency ismeasured by a single survey question about thequantity and quality of food eaten in the house-hold, and is seen as a measure of fairly severehousehold food insecurity.96

nutrient intakes of children in food insecurehouseholds,15,95,98-101 the management ofhousehold food insecurity12-15,18,20,27,28,99,102-112

and the gender aspects of feeding thefamily113-116 suggests that food is not evenlydistributed among family members. Thisresearch shows that mothers protect theirchildren as much as possible from overtfood deprivation or hunger (though thequality of food fed to children suffers dur-ing times of constraint). Mothers employnumerous management strategies, includ-ing the reduction of their own food qualityand quantity, to avoid the catastrophe ofhaving their children go hungry. Tworecent studies of the diets of high-riskCanadian households14,15,18 have focussedon mothers’ intakes, the most sensitiveindicators of potential nutritional risk.These have demonstrated estimated preva-lences of inadequacy for several nutrients.

The research on food insecure Canadiansdemonstrates that, for the populationsstudied to date, the most important barrierto healthy eating is inadequate income.This conclusion is supported by the factthat mothers do protect their children’senergy and nutrient intakes,15 and thatenergy and nutrient intakes decline system-atically as food security status deteriorates.18

It is also supported by research establishingthat incomes for those receiving welfare andthose working at minimum wage jobs areinadequate to purchase the food for ahealthy diet.21,117 Higher levels of educationdo not protect households from food inse-curity,14,19,26,97,118 nor does education appearto mitigate the dietary effects of inadequateincome.51,93 Neither nutritional knowl-edge27,66,119-122 nor food skills25,123 appear tobe significant factors affecting healthy eat-ing in these populations. Those in low-income households have been shown tobuy more nutrients for their food dollarthan higher income households.124,125

Indeed, it can be concluded that those wholive in poverty are particularly adept andcreative in juggling and managing theirfinancial and food resources to ensure thattheir most important needs are metfirst.9,12,13,23,69,102-105,108-110,112,115,120,126-135

Using Sociology to Understand Food PracticesSociological research on health and foodpractices that compares different classes136-140

suggests that there are two opposing, class-

based relations to food: substance (food asmaterial reality, sustaining the body andgiving strength) and form (food as self-discipline to an aesthetic idea). These differ-ent relations to food are divided by the “dis-tance from necessity”,136 which is an indirectway in which income and class positionaffect eating practices. This research suggeststhat apart from income thresholds for theconsumption of different food groups, theremay also be cultural thresholds related toclass (including educational attainment) andclass trajectory over time.

Social science research also suggests thatthe concept of “belonging” may be impor-tant for understanding food practices. Aspolitical scientist Deborah Stone has putit,141 what we eat is “a sign of membership,social status and spiritual worth. Eating thesame food as others is a basic mark ofbelonging” (p. 71). The practice of feedingthe family involves, in part, meeting whatStone141 calls “communal needs”, whichinclude “community, solidarity, a sense ofbelonging; dignity, respect, self-esteem,and honor; friendship and love” (p. 77).The desire of low-income people to belongto the dominant culture through food hasbeen well documented by those examiningthe social aspects of food insecuri-ty.13,108,142,143

This body of research highlights theimportant social, cultural and symbolicfunctions of food, eating and “feeding thefamily”,115 and suggests that there are differ-ent cultural “logics” underlying these every-day practices for different social classes.

KNOWLEDGE GAPS IN THE LITERATURE

National data on socio-economic gradients in dietA robust research program on the determi-nants of healthy eating among low-incomeCanadians must be founded on quantitativedata examining dietary intakes and patterns inCanadians; therefore, the lack of national dataon socio-economic gradients in diet is perhapsthe most significant gap in the Canadianresearch literature. Fortunately, that gap willbegin to be filled in the near future, with theresults of the CCHS, Cycle 2.2, NutritionFocus, which was scheduled to conclude datacollection in December 2004.

Ideally, a nutrition monitoring and sur-veillance system would provide data over

time. To provide data that would help usunderstand socio-economic gradients indiet and the determinants of healthy eatingamong low-income Canadians, the designof a nutrition survey would have to incor-porate multiple measures of class, includ-ing income, level of education, occupationand the social trajectory of both therespondent and spouse/partner (if applica-ble).144 Other known influences on eatinghabits should also be included in the sur-vey, such as family structure, family rolesand responsibilities, ethnicity, length oftime in Canada, hours of employment,food availability at work and so on. Ideally,such a survey would also include measure-ment of individual food insecurity96 andfood costs.145 A longitudinal study designcould provide data on how changes in cul-tural capital, income and food security sta-tus, as well as in factors such as age, familycomposition and children’s ages, affectfood practices.

National nutrition data, provided overtime, could help us fill the gaps about howsignificant the dietary differences areamong socio-economic groups; how thegradients are different using different mea-sures of socio-economic position; the rela-tion between socio-economic gradients andincome thresholds for different foodgroups; whether the relation is different fordifferent food groups or for food groupsrather than nutrient intake; how socio-economic differences in diet are distributedamong rural, rural remote, suburban andurban localities, between the sexes, acrossage groups, and among different ethnicgroups; the relation between the expectedgradients in food groups and adherence tothe dietary guidelines and other measuresof dietary quality; and how these relationschange over time.

Sociological research on the interaction of income and class withother factors affecting food practicesThere is little research on the interaction ofincome with other factors affecting foodpractices, such as housing status, socialsupport, family roles and responsibilities,time constraints, the stage of the lifecourse, ethnicity, length of time inCanada, etc. Sociologically informed, qual-itative research could help develop addi-tional indicators of food insecurity thatassess qualitative and social dimensions of



food insecurity, as well as measures of indi-vidual (rather than household) food securi-ty status, as suggested by Tarasuk.96 Suchresearch could, for example, help elucidatethe dynamics of intra-familial food distrib-ution in low-income two-parent hetero-sexual families, and how the desire tobelong, when there is social exclusion,affects food practices. A longitudinal studydesign could help us understand howchanges in individual and household fac-tors affect food practices.

Sociological research on Canadianfood norms and culturesThere is little written about Canadian foodnorms and cultures. If, as suggested by thisreview of the literature, one of the condi-tions for improving the food practices oflow-income Canadians is an improvementin the dominant food culture and foodnorms, then it will be important to charac-terize food cultures and food norms in thiscountry, plus the most effective means ofshifting them. This has become particular-ly salient with the awareness of increases inthe prevalence of obesity and a growingsense of urgency to undertake interven-tions to combat the problem.

For example, one important influenceon the ways in which food norms areshaped and developed in contemporaryNorth America is the food industry and itsmarketing practices. The food industry hasits own logic, that of making profit, whichis often in conflict with the promotion ofhealthy eating.146,147 It is important toexplore how the food industry shapes socialnorms around eating in Canada; how thosein different positions in social space (e.g.,class, sex, ethnicity, age, etc.) are targetedby food marketers; and how people take upand act on those marketing messages andthus produce and reproduce food normsand culture. Such research could be useful,for example, in understanding how socialmarketing campaigns to promote healthierdiets can be more effective.

Research on the costs of healthy dietsIdeally, food costs would be included in anational nutrition survey, so that dietaryand economic variables can be linked. Inthe meantime, smaller research projectscould begin to fill the gap, with studiescomparing prices of healthier options with-in food groups (e.g., lower-fat products),

comparing food baskets,148 and comparingfood prices and energy density.145 If it isthe case that healthier diets are moreexpensive than less healthy diets, this hasimportant implications for public policy.At the individual level, changes in pricinghave a strong effect on food choices,149-152

and pricing strategies have been suggestedas potentially effective population-basedstrategies to improve eating practices.146

Understanding the costs of healthier dietswould be a first step towards assessing thepotential of community-based food pricinginterventions to affect food practices inCanada.

REFERENCES

1. Health Canada. Population Health Website,2004. Available on-line at http://www.hc-sc.gc.ca/hppb/phdd/approach/index.html(Accessed on January 24, 2004).

2. Joint Steering Committee. Nutrition for Health:An Agenda for Action. Ottawa, ON, 1996.

3. McAmmond D, and Associates. Promotion andSupport of Healthy Eating: An Initial Overview ofKnowledge Gaps and Research Needs. Ottawa,ON: Office of Nutrition Policy and Promotion,Health Canada, 2001.

4. Coburn D. Income inequality, social cohesion,and the health status of populations: The role ofneo-liberalism. Soc Sci Med 2000;51:135-46.

5. Coburn D. Beyond the income inequalityhypothesis: Class, neo-liberalism and healthinequalities. Soc Sci Med 2004;58:41-56.

6. Lynch J. Income inequality and health:Expanding the debate. Soc Sci Med2000;51:1001-5.

7. Navarro V, Borrell C, Benach J, Muntaner C,Quiroga A, Rodriguez-Sanz M, et al. Theimportance of the political and the social inexplaining mortality differentials among thecountries of the OECD, 1950-1998. Int JHealth Serv 2003;33(3):419-94.

8. Kirkpatrick S. Analysis of the 2000-01 CCHSFood Security Indicator Questions. Departmentof Nutritional Sciences, University of Toronto,unpublished.

9. Tarasuk V. Household food insecurity withhunger is associated with women’s food intakes,health and household circumstances. J Nutr2001;131(10):2670-76.

10. Che J, Chen J. Food insecurity in Canadianhouseholds. Health Rep 2001;12(4):11-22.

11. Hamelin A-M, Beaudry M, Habicht J-P. Lavulnérabilité des ménages à l’insécurité alimen-taire. Rev can d’études du dévelop 1998;14:277-306.

12. Hamelin A-M, Habicht J-P, Beaudry M. Foodinsecurity: Consequences for the household andbroader social implications. J Nutr1999;129:525S-528S.

13. Hamelin AM, Beaudry M, Habicht JP.Characterization of household food insecurityin Quebec: Food and feelings. Soc Sci Med2002;54(1):119-32.

14. McIntyre L, Glanville NT, Officer S, AndersonB, Raine KD, Dayle JB. Food insecurity of low-income lone mothers and their children inAtlantic Canada. Can J Public Health2002;93(6):411-15.

15. McIntyre L, Glanville NT, Raine KD, DayleJB, Anderson B, Battaglia N. Do low-incomelone mothers compromise their nutrition to

feed their children? Can Med Assoc J2003;168(3):686-91.

16. McIntyre L, Walsh G, Connor S. A Follow-upStudy of Child Hunger in Canada. Ottawa, ON:Human Resources Development Canada,Applied Research Branch Strategic Policy,2001.

17. Tarasuk V. Low income, welfare and nutritionalvulnerability. Can Med Assoc J 2003;168(6):709-10.

18. Tarasuk V, Beaton G. Women’s dietary intakesin the context of household food insecurity. J Nutr 1999;129:672-79.

19. Tarasuk V, Beaton G. Household food insecuri-ty and hunger among families using food banks.Can J Public Health 1999;90:109-13.

20. Tarasuk V, Maclean H. The food problems oflow-income single mothers: An ethnographicstudy. Can Home Econ J 1990;40(2):76-82.

21. Vozoris N, Davis B, Tarasuk V. The affordabil-ity of a nutritious diet for households on welfarein Toronto. Can J Public Health 2002;93(1):36-40.

22. Vozoris N, Tarasuk V. Household food insuffi-ciency is associated with poorer health. J Nutr2003;133(1):120-26.

23. Dachner N, Tarasuk V. Homeless “squeegeekids”: Food insecurity and daily survival. Soc SciMed 2002;54:1039-49.

24. Antoniades M, Tarasuk V. A survey of foodproblems experienced by Toronto street youth.Can J Public Health 1998;89(6):371-75.

25. McLaughlin C, Tarasuk V, Kreiger N. Anexamination of at-home food preparation activi-ty among low-income, food insecure women. J Am Diet Assoc 2003;103:1506-12.

26. Rainville B, Brink S. Food insecurity in Canada,1998-1999. Ottawa, ON: Human ResourcesDevelopment Canada, Applied ResearchBranch of Strategic Policy, 2001.

27. Badun C, Evers S, Hooper M. Food securityand nutritional concerns of parents in an eco-nomically disadvantaged community. J CanDiet Assoc 1995;56(2):75-80.

28. Travers KD. The social organization of nutri-tional inequities. Soc Sci Med 1996;43(4):543-53.

29. Jacobs Starkey L, Gray-Donald K, Kuhnlein H.Nutrient intake of food bank users is related tofrequency of food bank use, household size,smoking, education, and country of birth. J Nutr 1999;129:883-89.

30. Jacobs Starkey L, Kuhnlein H. Montreal foodbank users’ intakes compared with recommen-dations of Canada’s Food Guide to HealthyLiving. Can J Diet Pract Res 2000;61(2):73-75.

31. Morris DH, Sorensen G, Stoddard AM,Fitzgerald G. Comparison between food choicesof working adults and dietary patterns recom-mended by the National Cancer Institute. J AmDiet Assoc 1992;92:1272-74.

32. Roos G, Prättälä R, FAIR-97-3096 DisparitiesGroup (tasks 4 and 5). Disparities in FoodHabits: Review of Research in 15 EuropeanCountries. Helsinki, Finland: National PublicHealth Institute, 1999.

33. Galobardes B, Morabia A, Bernstein M. Dietand socioeconomic position: Does the use ofdifferent indicators matter? Int J Epidemiol2001;30:334-40.

34. Groth MV, Fagt S, Brøndsted L. Social deter-minants of dietary habits in Denmark. Eur JClin Nutr 2001;55:959-66.

35. Martikainen P, Brunner E, Marmot M.Socioeconomic differences in dietary patternsamong middle-aged men and women. N Engl JMed 2003;56:1397-410.

36. Perrin AE, Simon C, Hedelin G, Arveiler D,Schaffer P, Schlienger JL. Ten-year trends ofdietary intake in a middle-aged French popula-tion: Relationship with educational level. Eur JClin Nutr 2002;56:393-401.



37. Pryer JA, Nichols R, Elliot P, Thakrar B,Brunner E, Marmot M. Dietary patterns amonga national random survey sample of Britishadults. J Epidemiol Community Health2001;55:29-37.

38. Roos E, Lahelma E, Virtane M, Prattala R,Pietinen P. Gender, socioeconomic status andfamily status as determinants of food behaviour.Soc Sci Med 1998;46(12):1519-29.

39. Laitinen S, Räsuanen L, Viikari J, ÅkerblomHK. Diet of Finnish children in relation to thefamily’s socio-economic status. Scand J Soc Med1995;23:88-94.

40. Ruxton C, Kirk T. Relationship between socialclass, nutrient intake and dietary patterns inEdinburgh schoolchildren. Int J Food Sci Nutr1996;47:341-49.

41. Basiotis PP, Carlson A, Gerrior SA, Juan WY,Lino M. The Healthy Eating Index: 1999-2000.Washington, DC: US Department ofAgriculture, 2002.

42. Bowman SA, Linn M, Gerrior SA, Basiotis PP.The Healthy Eating Index 1994-96. Washington,DC: US Department of Agriculture, 1998.

43. Center for Nutrition Policy and Promotion.The Healthy Eating Index. Washington, DC: USDepartment of Agriculture, 1995.

44. Kushi LH, Folsom AR, Jacobs DR, LuepkerRV, Elmer PJ, Blackburn H. Educationalattainment and nutrient consumption patterns:The Minnesota Heart Survey. J Am Diet Assoc1988;88:1230-36.

45. Popkin BM, Haines PS, Reidy KC. Food con-sumption trends of US women: Patterns anddeterminants between 1977 and 1985. Am JClin Nutr 1989;49:1307-19.

46. Popkin BM, Siega-Riz AM, Haines PS. A com-parison of dietary trends among racial andsocioeconomic groups in the United States. N Engl J Med 1996;335:716-20.

47. Smith AM, Baghurst K. Public health implica-tions of dietary differences between social statusand occupational category groups. J EpidemiolCommunity Health 1992;46:409-16.

48. Turrell G. Socioeconomic differences in foodpreference and their influence on healthy foodpurchasing choices. J Hum Nutr Diet1998;11:135-49.

49. Turrell G, Hewitt B, Patterson C, OldenburgB, Gould T. Socioeconomic differences in foodpurchasing behaviour and suggested implica-tions for diet-related health promotion. J HumNutr Diet 2002;15:355-64.

50. Leather S. The Making of Modern Malnutrition:An Overview of Food Poverty in the UK. TheCaroline Walker Lecture, 1996. London,England: The Caroline Walker Trust, 1996.

51. Kirkpatrick S, Tarasuk V. The relation betweenlow income and household food expenditurepatterns in Canada. Public Health Nutr2003;6(6):589-97.

52. Ricciuto L. Characterization of Canadian FoodExpenditure Patterns in Relation to Income, andImplications for Food Policy. Toronto, ON:Department of Nutritional Sciences, Universityof Toronto, 2003.

53. Nyström Peck M. The importance of childhoodsocio-economic group for adult health. Soc SciMed 1994;39(4):553-62.

54. Barker DJP, Forsén T, Uutela A, Osmond C,Eriksson JG. Size at birth and resilience toeffects of poor living conditions in adult life:Longitudinal study. BMJ 2001;323:1273-76.

55. Barker DJP, Winter PD, Osmond C, MargettsB, Simmonds SJ. Weight in infancy and deathfrom ischaemic heart disease. Lancet1989;334:577-80.

56. Davey Smith G, Hart C, Blane D, Hole D.Adverse socioeconomic conditions in childhoodand cause specific adult mortality: Prospectiveobservational study. BMJ 1998;316:1631-35.

57. Gunnell D, Davey Smith G, Frankel S,Nanchahal K, Braddon FEM, Pemberton J, etal. Childhood leg length and adult mortality—follow up of the Carnegie (Boyd Orr) Survey ofdiet and growth in pre-war Britain. J EpidemiolCommunity Health 1998;52:142-52.

58. Hertzman C. The biological embedding of earlyexperience and its effects on health in adult-hood. Ann N Y Acad Sci 1999;89:85-95.

59. Flegal KM, Carroll MD, Ogden CL, JohnsonCI. Prevalence and trends in obesity among USadults 1999-2000. JAMA 2002;288:1723-27.

60. Paeratakul S, Lovejoy JC, Ryan DH, Bray GA.The relation of gender, race, and socioeconomicstatus to obesity and obesity comorbidities in asample of U.S. adults. Int J Obes Relat MetabDisord 2002;26:1205-10.

61. Wardle J, Waller J, Jarvis M. Sex difference inthe association of socioeconomic status withobesity. Am J Public Health 2002;92(8):1299-304.

62. Wilkinson R, Marmot ME (Eds.). The SocialDeterminants of Health: The Solid Facts, 2nd Ed.Copenhagen, Denmark: World HealthOrganization, 2003.

63. Raphael D. Social Determinants of Health:Canadian Perspectives. Toronto, ON: CanadianScholars’ Press Inc., 2004.

64. Marmot M, Wilkinson R (Eds.). SocialDeterminants of Health. Oxford, UK: OxfordUniversity Press, 1999.

65. Carlisle S. Inequalities in health: Contestedexplanations, shifting discourses and ambiguouspolicies. Crit Public Health 2001;11(3):267-81.

66. Blaxter M. Health & Lifestyles. London & NewYork: Tavistock/Routledge, 1990.

67. D’Arcy C. Social distribution of health amongCanadians. In: Coburn D, D’Arcy C, TorranceGM (Eds.), Health and Canadian Society:Sociological Perspectives, 2nd ed. Toronto, ON:University of Toronto Press, 1998;73-101.

68. Davey Smith G, Brunner E. Socio-economicdifferentials in health: The role of nutrition.Proc Nutr Soc 1997;56:75-90.

69. Dowler E. Inequalities in diet and physicalactivity in Europe. Public Health Nutr2001;4(2B):701-9.

70. Hupkens C. Social Class Differences in Eatingand Drinking Behaviour. Delft, TheNetherlands: Martijn Geerdes, 1998.

71. Lee P. Nutrient intakes in socially disadvan-taged groups in Ireland. Proc Nutr Soc1990;49:307-21.

72. Lynch JW, Kaplan GA, Salonen JT. Why dopoor people behave poorly? Variation in adulthealth behaviours and psychosocial characteris-tics by stages of the socioeconomic lifecourse.Soc Sci Med 1997;44(6):809-19.

73. Macintyre S. The Black Report and beyond:What are the issues? Soc Sci Med 1997;44:934-42.

74. Pill R, Peters TJ, Robling MR. Social class andpreventive health behaviour: A British example.J Epidemiol Community Health 1995;49:28-32.

75. Robertson A. Social inequalities and the burdenof food-related ill-health. Public Health Nutr2001;4(6A):1371-73.

76. Kaplan GA, Keil JE. Socioeconomic factors andcardiovascular disease: A review of the literature.Circulation 1993;88:1973-98.

77. Diez Roux AV, Stein Merkin S, Arnett D,Chambless L, Massing M, Nieto FJ, et al.Neighbourhood of residence and incidences ofcoronary heart disease. N Engl J Med2001;345(2):99-106.

78. Fuhrer R, Hipley MJ, Chastang JF, Schmaus A,Niedhammer I, Stansfeld SA, et al.Socioeconomic position, health, and possibleexplanations: A tale of two cohorts. Am J PublicHealth 2002;92:1290-94.

79. Lantz P, Lynch JW, House JS, Lepkowski JM,Mero RP, Musick MA, et al. Socioeconomic

disparities in health change in a longitudinalstudy of US adults: The role of health-riskbehaviors. Soc Sci Med 2001;53:29-40.

80. Marmot MG, Davey Smith G, Stansfeld S,Patel C, North F, Head J, et al. Health inequal-ities among British civil servants: The WhitehallII study. Lancet 1991;337:1387-93.

81. Pill R, Peters TJ, Robling MR. Factors associat-ed with health behaviour among mothers oflower socio-economic status: A British example.Soc Sci Med 1993;36:1137-44.

82. Whichelow M, Prevost AT. Dietary patternsand their associations with demographic,lifestyle and health variables in a random sampleof British adults. Br J Nutr 1996;76:17-30.

83. Marmot MG, Shipley MJ, Rose G. Inequalitiesin death—specific explanations of a general pat-tern? Lancet 1984;1:1003-6.

84. Hulshof K, Lowik M, Kok F, Wedel M, BrantsH, Hermus R, et al. Diet and other lifestyle fac-tors in high and low socio-economic groups(Dutch Nutrition Surveillance System). Eur JClin Nutr 1991;45:441-50.

85. Roos E, Prattala R, Lahelma E, Kleemola P,Pietinen P. Modern and healthy?:Socioeconomic differences in the quality of diet.Eur J Clin Nutr 1996;50(11):753-60.

86. McHenry EW. Nutrition in Toronto. Can JPublic Health 1939;30(1):4-13.

87. Patterson JM, McHenry EW. A dietary investi-gation in Toronto families having annualincomes between $1,500 and $2,400. Can JPublic Health 1941;32(5):251-58.

88. Hunter G, Pett LB. A dietary survey inEdmonton. Can J Public Health1941;32(5):259-65.

89. Myres A, Kroetsch D. The influence of familyincome on food consumption patterns andnutrient intake in Canada. Can J Public Health1978;69:208-21.

90. Dubois L, Girard M. Social position and nutri-tion: A gradient relationship in Canada and theUSA. Eur J Clin Nutr 2001;55:366-73.

91. Pérez CE. Fruit and vegetable consumption.Health Rep 2001;13(3):23-31.

92. Marrett L, Roberts M, Innes M. Insight onCancer: News and Information on Nutrition andCancer Prevention. Toronto, ON: Cancer CareOntario and Canadian Cancer Society (OntarioDivision), 2003.

93. Ricciuto L. The Effect of Household Income onthe Purchase of ‘Healthy Foods’. SocialDeterminants of Health Across the Life-Span.York University, Toronto, 2002.

94. Nord M, Brent CP. Food Insecurity in HigherIncome Households. Washington, DC: USDAEconomic Research Service, 2002.

95. Rose D. Economic determinants and dietaryconsequences of food insecurity in the UnitedStates. J Nutr 1999;129:517S-520S.

96. Tarasuk V. Discussion Paper on Household andIndividual Food Insecurity. Ottawa, ON: HealthCanada Office of Nutrition Policy andPromotion, 2001.

97. McIntyre L, Connor SK, Warren J. Childhunger in Canada: Results of the 1994 NationalLongitudinal Survey of Children and Youth.Can Med Assoc J 2000;163(8):961-65.

98. Shatenstein B, Ghadirian P. Nutrient patternsand nutritional adequacy among French-Canadian children in Montreal. J Am Coll Nutr1996;15:264-72.

99. Dowler E, Calvert C. Nutrition and Diet inLone-Parent Families in London. London,England: Family Policy Studies Centre, 1995.

100. Casey P, Szeto K, Lensing S, Bogle M, Weber J.Children in food insufficient, low-income fami-lies: Prevalence, health, and nutrition status.Arch Pediatr Adolesc Med 2001;155:508-14.

101. Cristofar SP, Basiotis PP. Dietary intakes andselected characteristics of women ages 19-50



years and their children ages 1-5 years byreported perception of food sufficiency. J NutrEduc 1992;24(1):53-58.

102. Radimer KL, Olson CM, Greene JC, CampbellCC, Habicht J-P. Understanding hunger anddeveloping indicators to assess it in women andchildren. J Nutr Educ 1992;24:36S-45S.

103. Ahluwalia I, Dodds J, Baligh M. Social supportand coping behaviors of low-income familiesexperiencing food insufficiency in NorthCarolina. Health Educ Behav 1998;25(5):599-612.

104. Campbell C, Desjardins E. A model andresearch approach for studying the managementof limited food resources by low-income fami-lies. J Nutr Educ 1989;21(4):162-71.

105. Dobson B, Beardsworth A, Keil T, Walker R.Diet, Choice and Poverty: Social, Cultural andNutritional Aspects of Food Consumption amongLow-income Families. London, England: FamilyPolicy Studies Centre and the Joseph RowntreeFoundation, 1994.

106. Dowler E, Turner S, Dobson B. Poverty Bites:Food, Health and Poor Families. London,England: CPAG, 2001.

107. Durand-Gasselin S, Luquet F-M. La vie quoti-dienne autour de l’alimentation : les modes devie, les représentations socio-culturelles et lescomportements alimentaires de 55 familles àfaibles revenus en banlieue parisienne. MédNutr2000;1:40-52.

108. Fitchen J. Hunger, malnutrition, and poverty inthe contemporary United States: Some observa-tions on their social and cultural context. In:Counihan C, van Esterik P (Eds.), Food andCulture: A Reader. New York, NY: Routledge,1997;384-401.

109. Hitchman C, Christie I, Harrison M, Lang T.Inconvenience Food: The Struggle to Eat Well ona Low Income. London, England: Demos, 2002.

110. Radimer KL, Olson CM, Campbell CC.Development of indicators to assess hunger. J Nutr 1990;120:1544-48.

111. Tarasuk V. A critical examination of communi-ty-based responses to household food insecurityin Canada. Health Educ Behav 2001;28(4):487-99.

112. Wehler CA, Scott RI, Anderson JJ. TheCommunity Childhood Hunger IdentificationProject: A model of domestic hunger-demonstration project in Seattle, Washington. J Nutr Educ 1992;24(1):29S-35S.

113. Jansson S. Food practices and division ofdomestic labour. A comparison between Britishand Swedish households. Sociol Rev1995;43(3):462-77.

114. Charles N, Kerr M. Women, Food and Families.Manchester, England: Manchester UniversityPress, 1988.

115. DeVault M. Feeding the Family: The SocialOrganization of Caring as Gendered Work.Women in Culture and Society. Chicago, IL:University of Chicago Press, 1991.

116. Ellis R. The way to a man’s heart: Food in theviolent home. In: Murcott A (Ed.), TheSociology of Food and Eating: Essays on theSociological Significance of Food. Aldershot,England: Gower Publishing Company Limited,1983;164-71.

117. Dietitians of Canada BC Region, CommunityNutritionists Council of BC. The Cost of Eating

in BC: The Challenge of Feeding a Family on aLow-Income. Vancouver, 2002.

118. Wilson B, Tsoa E. HungerCount 2002. Eatingtheir Words: Government Failure on FoodSecurity. Toronto, ON: Canadian Association ofFood Banks, 2002.

119. Travers KD. “Do you teach them how to bud-get?” Professional discourse in the constructionof nutritional inequities. In: Maurer D, Sobal J(Eds.), Eating Agendas: Food and Nutrition asSocial Problems. Social Problems and Social Issues.Hawthorne, NY: Aldine de Gruyter, 1995;213-40.

120. Bradbard S, Michaels E, Fleming K, CampbellM. Understanding the Food Choices of Low-income Families. Washington, DC: USDepartment of Agriculture, Food andConsumer Services, 1997.

121. Blaxter M. Why do victims blame themselves?In: Radley A (Ed.), Worlds of Illness:Biographical and Cultural Perspectives of Healthand Disease. London, England: Routledge,1993.

122. Lang T. Dividing up the cake: Food as socialexclusion. In: Walker A, Walker C (Eds.),Britain Divided: The Growth of Social Exclusionin the 1980s and 1990s. London, England:CPAG Ltd., 1997.

123. Lang T, Caraher M, Dixon P, Carr-Hill R.Cooking Skills and Health. London, England:Health Education Authority, 1999.

124. Philip W, James T, Nelson M, Ralph A,Leather S. Socioeconomic determinants ofhealth: The contribution of nutrition toinequalities in health. BMJ 1997;314:1545-49.

125. Horton S, Campbell C. Do the poor pay morefor food? Food Market Commentary1990;11(4):33-39.

126. Edin K, Lein L. Making Ends Meet: How SingleMothers Survive Welfare and Low-wage Work.New York, NY: Russell Sage Foundation, 1997.

127. Ehrenreich B. Nickel and Dimed: On (Not)Getting By in America. New York, NY:Metropolitan Books, 2001.

128. Graham H. Being poor: Perceptions and copingstrategies of lone mothers. In: Brannen J,Wilson G (Eds.), Give and Take in Families:Studies in Resource Distribution. London,England: Allen & Unwin, 1987;56-74.

129. Kempson E. Life on a Low Income. York, UK:Joseph Rowntree Foundation, 1996.

130. MacGregor S. Feeding families in Harris’Ontario: Women, the Tsubouchi Diet, and thepolitics of restructuring. Atlantis 1997;21(2):93-110.

131. Polakow V. Lives on the Edge: Single Mothersand their Children in the Other America.Chicago, IL: University of Chicago Press, 1993.

132. Schein V. Working from the Margins: Voices ofMothers in Poverty. Ithaca and London: CornellUniversity Press, 1995.

133. Swanson J. Poor-Bashing: The Politics ofExclusion. Toronto, ON: Between the Lines,2001.

134. Toynbee P. Hard Work: Life in Low-PayBritain. London, England: BloomsburyPublishing, 2003.

135. Quandt SA, Argury TA, Early J, Tapia J, DavisJD. Household food security among migrantand seasonal Latino farmworkers in NorthCarolina. Public Health Rep 2004;119:568-76.

136. Bourdieu P. Distinction: A Social Critique of theJudgement of Taste. Cambridge, MA: HarvardUniversity Press, 1984 (originally published inFrench in 1979).

137. Prout A. Families, Cultural Bias and HealthPromotion: Implications of an EthnographicStudy. London, England: Health EducationAuthority, 1996.

138. Coveney J. A qualitative study of socio-economicdifferences in parental lay knowledge of foodand health: Implications for public health nutri-tion practice. Public Health Nutr (In press).

139. Calnan M. Food and health: A comparison ofbeliefs and practices in middle-class and work-ing-class households. In: Cunningham-BurleyS, McKegney NP (Eds.), Readings in MedicalSociology . London, England: Tavistock/Routledge, 1990;9-36.

140. Calnan M, Cant S. The social organization offood consumption: A comparison of middleclass and working class households. Int J SociolSoc Policy 1990;10(2):53-59.

141. Stone D. Policy Paradox and Political Reason.Glenview, IL: Scott, Foresman and Company,1988.

142. Power EM. The unfreedom of being Other:Canadian lone mothers’ experiences of povertyand ‘life on the cheque’. Sociology (In press; 39(4)).

143. Nova Scotia Nutrition Council, Atlantic HealthPromotion Research Centre. Participatory FoodSecurity Projects, Phases I and II. Building FoodSecurity in Nova Scotia: Using a ParticipatoryProcess to Collect the Evidence and Enhance theCapacity of Community Groups to InfluencePolicy. Halifax, NS: Authors, 2004.

144. Krieger N, Williams DR, Moss NE. Measuringsocial class in US public health research:Concepts, methodologies and guidelines. AnnuRev Public Health 1997;18:341-78.

145. Drewnowski A, Specter SE. Poverty and obesi-ty: The role of energy density and energy costs.Am J Clin Nutr 2004;79:6-16.

146. French S, Story M, Jeffrey R. Environmentalinfluences on eating and physical activity. AnnuRev Public Health 2001;22:309-35.

147. Nestle M. Food Politics: How the Food IndustryInfluences Nutrition and Health. CaliforniaStudies in Food and Culture. Berkeley, CA:University of California Press, 2002.

148. Travers KD, Cogdon A, McDonald W, WrightC, Anderson B, MacLean DR. Availability andcost of heart healthy dietary changes in NovaScotia. J Can Diet Assoc 1997;58(4):176-83.

149. French SA, Jeffrey RW, Story M, Hannan P,Snyder MP. A pricing strategy to promote low-fat snack choices through vending machines.Am J Public Health 1997;87:849-51.

150. French SA, Story M, Jeffrey RW, Snyder P,Eisenberg M, Sidebottom A, et al. Pricing strat-egy to promote fruit and vegetable purchase inhigh school cafeterias. J Am Diet Assoc1997;97(9):1008-10.

151. Hannan P, French SA, Story M, Fulkerson JA.A pricing strategy to promote sales of lower fatfoods in high school cafeterias: Acceptabilityand sensitivity analysis. Am J Health Promot2002;17(1):1-6.

152. Jeffrey RW, French SA, Raether C, Baxter JE.An environmental intervention to increase fruitand salad purchases in a cafeteria. Prev Med1994;23:788-92.



Mental Health and EatingBehavioursA Bi-directional Relation

Janet Polivy, PhD

C. Peter Herman, PhD

ABSTRACT

Background: Variations in mental health may contribute to or impair healthy eating. Therelation between eating and mental health is bi-directional: one’s mood or psychologicalstate can affect what and how much one eats, and eating affects one’s mood andpsychological well-being. Thus, if we want to promote and develop strategies toencourage healthy eating, it is important to understand the connections between mentalhealth and healthy eating.

Methods: To contribute to this understanding, we examine the research on individualdifferences in how people respond to food, as well as mood, and emotional, social andcollective influences on what and how much is eaten; we then examine the implicationsof these connections for mental health, with a focus on adolescents and adults. Looking atthe relation between eating and mental health from the other direction, we reviewresearch investigating whether the amount that one eats or particular foods one ingests canmake one feel good or bad about oneself.

Conclusions: Overeating and undereating have complex effects, sometimes contributing toimproved feelings of well-being and at other times leaving the individual feeling guilty,deprived, depressed and anxious. We attempt to identify both what we know and the gapsin our knowledge.

MeSH terms: Mental health; eating behaviour; overeating; mood; undereating

Why do we need to know aboutthe connections between eatingbehaviour and mental health?

Variations in mental health may con-tribute to or impair healthy eating. Forinstance, disturbances in mental health,such as depression, unhappiness or anxiety,may cause people to eat unhealthyamounts or types of food.1,2 Conversely,eating behaviour influences mental health.When we eat too much, we feel uncom-fortable (socially, we do not want to look“piggish” to others, and, even alone, weprefer not to feel that we are eating “toomuch” or “more than normal”), and if wehappen to be dieting to lose weight wemay also feel guilty and anxious.3 Negativeemotions, in their turn, can make usovereat in an attempt to feel better.Certain foods may be comforting or helpto alleviate negative moods.4 If, on theother hand, we eat too little, we may feelirritable, tired or deprived, especially ifothers around us are eating more and seemto be enjoying their food. This may bepartly a physiological reaction to hunger,but it may also reflect a psychologicalresentment that one is not having whatothers have. The resentment may becaused by a self-imposed diet or by livingin a society in which food is so abundantfor most, but some have too little. Therelation between eating and mental healthis thus bi-directional: one’s psychologicalstate can affect what and how much oneeats, and eating affects one’s mood andpsychological well-being.

The consequences of eating on mentalhealth may reinforce healthy or unhealthyeating patterns (i.e., it is possible that eat-ing in a healthy manner makes people feelbetter psychologically, but it is also possi-ble that eating in an unhealthy way makespeople feel better emotionally). If we wantto promote healthy eating and developstrategies to encourage it, we need tounderstand the connections between men-tal health and healthy eating. At the sametime, we must remain alert to the possibili-ty that healthy eating may occasionallyexact a mental-health cost. Indeed, wemight even be forced to the conclusionthat in some rare circumstances a strictadherence to healthy eating might beexcessively costly in term of psychologicalwell-being.5

In this article, we will use “healthy eat-ing” to refer to eating practices and behav-

Department of Psychology, University of Toronto, Toronto, ONCorrespondence and reprint requests: Janet Polivy, Department of Psychology, University of Torontoat Mississauga, Mississauga, ON L5L 1C6, Tel: 905-828-3959, Fax: 905-569-4326, E-mail:[email protected]


iours that are consistent with improving,maintaining and/or enhancing health, bothphysical and psychological. Mental healthwill be used in the context of the normal(as opposed to clinical) population, andwill thus refer to mood, mental state, feel-ings about the self, and general psychologi-cal well-being. The focus of this article isthe psychological or mental health-relateddeterminants of healthy eating in adoles-cents and adults, and the impact of healthyand unhealthy eating on mental health, asdefined. It should be recognized that men-tal health issues may often interfere withhealthy eating, rather than promote it. Inaddition, what is healthy eating may bedifferent in a person who is overweightfrom one who is of normal weight orunderweight. Thus, an overweight personwho eats less than his or her body needsand loses excess weight may be engaged inhealthy eating, whereas a normal or under-weight person doing the same thing maybe eating in an unhealthy manner, particu-larly if that person is a teenager who hasnot yet reached full growth and needsmore energy to do so healthily. These dis-tinctions must be borne in mind whenreading about research on the influence ofeating on mental health and of mentalhealth on eating.

METHODS

The present article is based on a reviewthat encompassed searches of the literaturethrough PsycINFO and MEDLINE forthe last 10 years (1994-2004). Relevantwords, such as obesity, mental health,depression, self-esteem, overweight, foodintake, restraint, restrained eating, mealsize, carbohydrate, protein, fat, meal com-position, diet, food, eating patterns andeating habits were searched and examinedto determine whether they were relevant tothe topic of “eating and mental health.”The term “eat” was also paired with rele-vant terms (affect, emotion, anxiety,depression, stress, alcohol, intoxication,drink, social influence, social norms,matching, insecurity, self-awareness, feed-back) and searched. Finally, reference listsin the most relevant articles were examinedfor citations that did not appear in the lit-erature searches. We could not possiblyreview all of the relevant studies identifiedin this manner, so we chose methodologi-

cally sound studies that represent the find-ings in the area. We thus included repre-sentative studies that had control groups,reasonable sample sizes and, when possible,were theoretically based or even experi-mentally manipulated. In addition, weconcentrated our investigation on adoles-cents and adults, in order to keep the scopemanageable.

Summary of the literatureSimply focussing on what is eaten or howmuch is consumed sidesteps the importantquestion of why people eat the amountsand types of food that they do. Healthyand unhealthy eating are both influencedby a variety of individual and collective(social and environmental) factors, manyof which interact with each other in com-plex fashions. We must understand thesefactors and their interactions to understandhow to promote and support healthy eat-ing, and how to maximize the physical andmental/emotional benefits of healthy eat-ing. Individual psychological factors thataffect eating include personality traits suchas self-esteem, body image and restrainedeating (chronic dieting), as well as moodand focus of attention.

Self-esteem seems to be strongly con-nected to eating both directly (as shown byexperimental demonstrations that loweringself-esteem produces excessive eating)1,6

and indirectly, through the association oflow self-esteem with body or weight dissat-isfaction and a corresponding tendency tobinge eat or diet in an unhealthy manner.7

Negative body image predicts excessivefood restriction followed by bouts ofovereating and even binge eating in adoles-cent and adult women.8 Some programs toimprove body image have been successfulat teaching adolescents to resist mediapressure to attain an unrealistic body, pre-venting the development of less healthyattitudes and behaviours, and helping topromote healthy eating and body weightmaintenance.9-11

Chronic on-again, off-again dieting(often called “restrained eating” in the lit-erature) can reflect a constellation ofbehaviours and attitudes that represent apersonality trait and have a strong influ-ence on eating. Restrained eaters are char-acterized not only by concern about theireating, weight and appearance but also bya variety of cognitive and affective attribut-

es, including low self-esteem and negativebody image.12,13 Successful dieting (i.e.,avoiding weight gain or maintaining one’scurrent weight) and weight loss, whileapparently much less common than unsuc-cessful attempts, produce improved psy-chosocial functioning and mood.14

Furthermore, restrained eating that is notaccompanied by disinhibited eating orbingeing is less likely to be related topathological eating and eating disorders.15

Conversely, however, for the many dieterswho are prone to disinhibition of their eat-ing and who seem to be unable to loseweight, and especially for females,restrained eating or chronic dieting is cor-related with negative mood and psycholog-ical functioning, overeating or even eatingbinges in many situations, weight gain orfailure to lose weight over time, and a ten-dency to overeat when stressed or upset inany way.3,5,16-18

More transient factors, such as moodand focus of attention, also affect eating.Celebratory feasts often entail overeating,which is unhealthy if it represents frequentbehaviour. Stress and negative affect canadversely influence the kinds of foodseaten, either through suppressing eating, aswith grief or loneliness, or increasing notonly eating but consumption of unhealthy“comfort” foods.2,4 Restrained eaters oftenbinge eat when they experience negativeaffect.1 Negative affect seems to promoteingestion of high-fat and/or high-sugarfoods.1,4 A shift in temporal focus from along-term desire for good health to a focuson the immediate pleasures of theunhealthy but good-tasting food impairsone’s ability to continue striving for thedistant goal of being healthy.19 Conversely,being aware of one’s eating or self-monitoring intake can prevent overeatingand help to change intake of specific nutri-ents (i.e., reducing fat or increasing fibre),but may also lead to perceptions that“reduced fat” foods are less tasty.20-22

It is evident that everyone is influenceddramatically by physical environmentalcues concerning eating. For example,increased portion sizes and marketing ofhigh-fat, high-sugar foods have both beenidentified as contributors to the increasingprevalence of overweight and obesity inNorth America.23 Similarly, the eating situ-ation affects what and how much getseaten: people who eat while distracted by

MENTAL HEALTH AND EATING BEHAVIOURS


television or movies may eat more food,and the food they select is less likely to below energy or low fat.24 Moreover, peoplerecognize the influence of environmentalfactors on other people, but do notacknowledge a similar influence on them-selves, even though those effects may beprofound.25 If the role of the environmentin the development of unhealthy eating isto be diminished, we must a) explore andsystematically articulate these influences, b) make people more aware of the impactthat such influences are having on them,and c) create helpful social and physicalenvironments. Many environmental influ-ences gain power from the fact that theyoperate below the level of the individual’sawareness.25 If we remain oblivious to theinfluence of collective factors, those factorswill continue to exert their perniciousinfluence by allowing us to feel psychologi-cally comfortable with intakes that areactually physically excessive.26

The presence of other people during aneating episode is also a collective factor.Extensive research indicates that the pres-ence of others has profound effects on foodintake, often distorting intake away fromwhat would be judged a healthy amount orhealthy types of food.26 The effect of thepresence of others on eating may best beunderstood in terms of three separate socialsituations – modeling, social facilitation(increased eating with others) and impres-sion management (using eating to make animpression on others) – although all ofthem probably operate through their influ-ence on perceived consumption norms.People use social cues to decide how muchthey can eat without attracting negativesocial judgments from others.26 The familymay be regarded as a special source ofsocial influence and has a strong impact onfood selection and eating patterns. Forexample, studies show that one way toreduce dietary fat in people’s diets is tochange what other family members are eat-ing.27 The family also contributes to dis-turbed eating behaviours and eating disor-ders,28 increased consumption in over-weight children,29 and amounts of fruitand vegetables consumed.30

The amount that one eats can make onefeel good or bad about oneself (good foreating only a small amount of anunhealthy food or bad for eating a lot ofthe unhealthy food).4,31 Similarly, people

are influenced in several ways by whichparticular foods they choose to eat (e.g.,being pleased with oneself for eatinghealthier foods and avoiding unhealthyones, or seeking relief from distress by eat-ing a particular comfort food).4 Restrictingone’s eating, commonly referred to as“dieting”, actually causes overeating, evenin animals.32 Binge eating is a consequenceof semi-starvation in victims of war andfamine, and in volunteers in starvationexperiments.33 Starvation-induced behav-iours, in addition to binge eating, includebizarre mixing of ingredients and adulter-ation of food; eating inappropriate, soiledor discarded food; secrecy, deception anddefensiveness.33 Even normal dieting canproduce depression and anxiety of mild tosevere proportions,34,35 or happiness whendieting is successful and perceived excessweight is lost.31 There is also a correlationbetween healthy eating and positive mood,though it is not clear which causes which.36

For example, eating breakfast improvesmood.37 People often use eating specificallyto alter their emotional state.38 They alsouse their eating to influence how otherpeople view them, and other people’s eat-ing can affect their own mood and self-image if they deviate from the behaviour ofthe group.36

GAPS IN THE LITERATURE

Why does distress or negative emotioncause some people to overeat (especiallyto overeat unhealthy foods) and others toundereat? We know that distress increas-es consumption of high-sugar and high-fat foods and snacks, and unhealthy“comfort” foods (often consisting ofsweet or salty-fat foods such as mashedpotatoes, rich cakes or chocolate in anyform), but we know little about why theconnect ion between distress andunhealthy eating exists, or whether itholds for all types of negative affect.Conversely, severe depression or anxietyreduces some people’s intake to a mini-mum, putting them at risk of caloricinsufficiency. The question of how emo-tion and stress affect eating in differentpeople at different times needs clarifica-tion. Healthy eating must be achieved asa sustainable lifestyle rather than as ashort-term corrective that may dissipatein the face of negative affect.

What factors promote dysfunctional eat-ing, particularly in young women? Eatingdisorders may not be as prevalent a prob-lem as obesity is, but subclinical variantsdo affect large numbers of young women.From a population perspective, then, men-tal health issues that contribute to eatingdisorders also pose a serious health risk.Does focussing on healthy eating andweight help to prevent disordered eatingand eating disorders, or does it exacerbatethe problem? Although we have identifieda connection between some factors, such asa negative body image, low self-esteem andchronic dieting, and the development ofeating disorders, we do not yet know howthese associations work or whether otherfactors are involved.

What impact do low self-esteem andpoor body image have on food selectionand eating behaviour? Higher self-esteem isassociated with healthy eating and lowerself-esteem with overconsumption and thedevelopment of disordered eating. Thesame seems to be true for body image,which is itself connected to self-esteem.Are these two factors independently relatedto eating, or do they interact? Given thefrequency of problems with self-esteemand body image, could these be contribut-ing to overeating and obesity, as well aseating disorders? To date, attention hasbeen directed primarily at the eating dis-orders connection, ignoring the impact ofnegative self-image on overeating andweight.

To what extent do personality, moodand collective factors interact to controleating? Making sense of the informationwe have about what promotes or interfereswith healthy eating is necessary before wecan move forward on a large scale. Somestudies have begun to explore the inter-active effects of personality, mood andenvironmental influences, but more sys-tematic investigation of these interactiveeffects is required before we can designprograms appropriate for different peoplein different milieus.

We still do not understand what deter-mines healthy eating or how to inducepeople to undertake these behaviours. Theliterature indicates that when people feelbetter about themselves, they eat in ahealthier manner than when they feel badabout themselves. Conversely, eating wellcan help us to feel better, which should



encourage healthy eating. Paying attentionto our own eating (self-monitoring) orchanging our temporal focus seem to beways to help us to achieve healthy eating,but what other sorts of behaviours pro-mote healthy eating?

How do dieting and weight loss affectmental health and eating? The literature onthe effects of restricting energy intake onmental health (and vice versa) is volumi-nous but full of contradictions. More workis needed to separate the effects of actualenergy restriction and weight loss fromthose of psychological deprivation andresentment. Does restriction cause over-eating, or does the psychological feeling ofbeing deprived of desired foods result inovereating when those foods become avail-able? Additional research is also needed inorder to determine the extent to whichdieting-induced weight loss versus unin-tentional weight loss is associated with dif-ferential (mental and physical) health out-comes.

How does portion size exert its effects oneating behaviour? Some phenomenaappear to be well established, but a com-pelling explanation for them has not beenprovided or empirically supported. Forinstance, we know that portion size power-fully affects food intake, often in a detri-mental way. It is not clear how portion sizeexerts its effects, however. Testing the pro-posal that portion size controls intake bydefining the limit beyond which eatingwould be excessive requires disconnectingthe linkage between portion size and judg-ments of appropriateness.

In conclusion, we are beginning to gainsome understanding of the bi-directionalrelation between mental health and eatingbehaviours, but further knowledge is nec-essary to allow us to apply what we arelearning in order to promote healthy eatingwhile supporting psychological well-being.

REFERENCES

1. Heatherton TF, Herman CP, Polivy J. Effects ofphysical threat and ego threat on eating behavior.J Pers Soc Psychol 1991;60:138-43.

2. Polivy J, Herman CP. Distress and eating: Whydo dieters overeat? Int J Eat Disord 1999;26:153-64.

3. Polivy J. Psychological consequences of foodrestriction. J Am Diet Assoc 1996;96:589-94.

4. Wansink B, Cheney MM, Chan N. Exploringcomfort food preferences across age and gender.Physiol Behav 2003;79:739-47.

5. Polivy J, Herman CP. Etiology of binge eating:Psychological mechanisms. In: Fairburn C (Ed.),Binge Eating. London, England: Guilford Press,1993;173-205.

6. McFarlane T, Polivy J, Herman CP. The effectsof false feedback about weight on restrained andunrestrained eaters. J Abnorm Psychol1988;107:312-18.

7. Fairburn CG, Cooper Z, Shafran R. Cognitivebehaviour therapy for eating disorders: A “trans-diagnostic’’ theory and treatment. Behav Res Ther2003;14:509-28.

8. VandenBerg P, Thompson JK, Obremski-Brandon K, Coovert M. The Tripartite InfluenceModel of body image and eating disturbance – acovariance structure modeling investigation test-ing the mediational role of appearance compari-son. J Psychosom Res 2002;53:1007-20.

9. Springer EA, Winzelberg AJ, Perkins R, TaylorCB. Effects of a body image curriculum for col-lege students on improved body image. Int J EatDisord 1999;26:13-20.

10. Stice E, Chase A, Stormer S, Appel A. A random-ized trial of a dissonance-based eating disorderprevention program. Int J Eat Disord2001;29:247-62.

11. Stice E, Mazotti L, Weibel D, Agras WS.Dissonance prevention program decreases thin-ideal internalization, body dissatisfaction, dieting,negative affect, and bulimic symptoms: A prelim-inary experiment. Int J Eat Disord 2000;27:206-17.

12. Heatherton TF, Polivy J. Chronic dieting andeating disorders: A spiral model. In: CrowtherJH, Hobfall SE, Stephens MAP, TennenbaumDL (Eds.), The Etiology of Bulimia: TheIndividual and Familial Context. Washington,DC: Hemisphere Publishers, 1992;133-55.

13. Pesa J. Psychosocial factors associated with diet-ing behaviors among female adolescents. J SchHealth 1999;69:196-201.

14. Wilson GT. Relation of dieting and voluntaryweight loss to psychological functioning andbinge eating. Ann Intern Med 1993;119:727-30.

15. Van Strien T. The concurrent validity of a classi-fication of dieters with low versus high suscepti-bility toward failure of restraint. Addict Behav1997;22:587-97.

16. Carels RA, Hoffman J, Collins A, Raber AC,Cacciapaglia H, O’Brien WH. Ecologicalmomentary assessment of temptation and lapse indieting. Eat Behav 2001;2:307-21.

17. Herman CP, Polivy J. Self-regulatory failure andeating. In: Baumeister RF, Vohs KD (Eds.),Handbook of Self-regulation Research. New York,NY: Guilford Press, 2004;492-508.

18. Stice E, Presnell K, Spangler D. Risk factors forbinge eating onset in adolescent girls: A 2-yearprospective investigation. Health Psychol2002;21:131-38.

19. Herman CP, Polivy J. Dieting as an exercise inbehavioral economics. In: Loewenstein G, Read

D, Baumeister R (Eds), Time and Decision:Economic and Psychological Perspectives onIntertemporal Choice. New York, NY: RussellSage Foundation, 2002;459-90.

20. Allen HN, Craighead LW. Appetite monitoringin the treatment of Binge Eating Disorder. BehavTher 1999;30:253-72.

21. Schnoll R, Zimmerman BJ. Self-regulation train-ing enhances dietary self-efficacy and dietary fiberconsumption. J Am Diet Assoc 2001;101:1006-11.

22. Wansink B, Painter JM, van Ittersum K.Descriptive menu labels’ effect on sales. CornellHotel Restaurant Admin Q 2001;42:68-72.

23. Young LR, Nestle M. The contribution ofexpanding portion sizes to the US obesity epi-demic. Am J Public Health 2002;92:246-49.

24. Gore SA, Foster JA, DiLillo VG, Kirk K, WestDS. Television viewing and snacking. Eat Behav2003;4:399-405.

25. Wansink B. Environmental factors that unknow-ingly increase food consumption by consumers.Annu Rev Nutr (in press).

26. Herman CP, Roth DA, Polivy J. Effects of thepresence of others on food intake: A normativeinterpretation. Psychol Bull 2003;129:873-86.

27. Shattuck AL, White E, Kristal AR. Howwomen’s adopted low-fat diets affect their hus-bands. Am J Public Health 1992;82:1244-50.

28. Polivy J, Herman CP. Causes of eating disorders.Annu Rev Psychol 2002;53:187-213.

29. Laessle RG, Uhl H, Lindel B. Parental influenceson eating behavior in obese and nonobese pread-olescents. Int J Eat Disord 2001;30:447-53.

30. Videon TM, Manning CK. Influences on adoles-cent eating patterns: The importance of familymeals. J Adolesc Health 2003;32:365-73.

31. Miller-Kovach K, Hermann M, Winick M. Thepsychological ramifications of weight manage-ment. J Womens Health Gend Based Med1999;8:477-82.

32. Hagan MM, Moss DE. Persistence of binge-eating patterns after a history of restriction withintermittent bouts of refeeding on palatable foodin rats: Implications for bulimia nervosa. Int J EatDisord 1997;22:411-20.

33. Hagan MM, Whitworth RH, Moss DE.Semistarvation-associated eating behaviors amongcollege binge eaters: A preliminary descriptionand assessment scale. Behav Med 1999;25:125-33.

34. Ross CE. Overweight and depression. J HealthSoc Behav 1994;35:63-78.

35. Wadden TA, Stunkard AJ, Smoller JW. Dietingand depression: A methodological study. J Consult Clin Psychol 1986;54:869-71.

36. Weidner G, Connor SL, Hollis JF, Connor WE.Improvements in hostility and depression in rela-tion to dietary change and cholesterol lowering.Ann Intern Med 1992;117:820-23.

37. Benton D, Slater O, Donohoe RT. The influenceof breakfast and a snack on psychological func-tioning. Physiol Behav 2001;74:559-71.

38. Soliah L, Walter JM, Erickson JS. Physical activi-ty and affinity for food of high school and collegestudents. Am J Health Behav 2000;24:444-57.



ca n a d i a n j o u r n a l o f public health

Documents